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A comprehensive discourse analysis of a successful case of experiential systemic couples therapy Newman, Jennifer Anne 1995

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A COMPREHENSIVE DISCOURSE ANALYSIS OF A SUCCESSFUL CASE OF EXPERIENTIAL SYSTEMIC COUPLES THERAPY by JENNIFER ANNE NEWMAN B.A., Carleton University, 1983 Diploma in Guidance Studies, The University of British Columbia, 1986 M.A., The University of British Columbia, 1989 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR.  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 June, 1995 © JENNIFER ANNE NEWMAN, 1995  for an advanced In presenting this thesis in partial fulfilment of the requirements Library shall make it degree at the University of Bntish Columbia, I agree that the permission for extensive freely available for reference and study. 1 further agree that by the head of my copying of this thesis for scholarly purposes may be granted tood that copying or department or by his or her representatives. It is unders d without my written publication of this thesis for financial gain shall not be allowe  permission.  Department of The University of British Columbia Vancouver, Canada  Date 9L4J  DE-6 (2/88)  ABSTRACT  This study investigated how a therapist and clients created couple change over the course of 15 sessions of Experiential Systemic Therapy (ExST) for the marital treatment of alcohol dependency. The aim of this research was to explore how change occurred during a single case of successful ExST and to refine and expand ExST theory. ExST has been shown to be an effective treatment for couple recovery from alcohol dependence yet little research has focused on how change occurs in ExST. The case selected for analysis was an exemplar of successful ExST couples therapy. The case met several criteria for success including therapist and client satisfaction with therapy, the cessation of alcoholic drinking, increased marital satisfaction at posttest and follow-up periods, and evidence of in-session couple change. Two therapy episodes containing relational novelty (couple change) were analyzed using the Comprehensive Discourse Analysis procedure. The results of this study highlighted the existence of a subtype of relational novelty called syncretic relational novelty. Syncretic change refers to the generation of intimacy by therapist and couple where initially there existed disparate beliefs and behaviour that isolated system members. The study found that the couple’s distance oriented beliefs and practices were reconciled and intimacy was enhanced through the employment of intense experiential activities and the provision of a collaborative therapeutic atmosphere. These two activities fostered increased couple intimacy by encouraging clients to engage one another through self disclosure, empathy, shared vulnerability, increased cooperation and greater personal awareness. Couple intimacy was fostered during experiential activity through a carefully  III  paced intensification of clients’ thoughts, feelings and physical sensations. In addition, intimacy was facilitated by the therapist when she accepted clients’ experiences and adopted clients’ language styles. As well as working collaboratively, the therapist acted as a therapeutic guide interceding during harmful spousal interactions, altering the therapy agenda at client request, promoting joint decision-making and valuing marginalized client experience. Recommendations based on these findings were made for the refinement and expansion of ExST theory.  iv TABLE OF CONTENTS  ABSTRACT  .  ii  TABLE OF CONTENTS  iv  LIST OF APPENDICES  vii  LIST OF FIGURES  vHi  ACKNOWLEDGEMENT  ix  CHAPTER I. PURPOSE OF THE STUDY  1  Research Aim  3  Research Question  3  Significance of the Study  3  Summary of the Method  6  Definition of Terms Relationally Novel Episodes Substantive Relational Themes Intensifying and Deepening Experience Therapeutic System: Therapist and Client Members Alcohol Dependence  9 10 10 10 11 11  Distressed Couple Functioning Successful Treatment  13  Experiential Systemic Therapy  14  Intrapersonal Level of the Therapeutic System Interpersonal Level of the Therapeutic System Symptomatic Level of the Therapeutic System Collaboration in Therapy Therapy Discourse  14  Organization of the Chapters  13  15 15 15 16 16  V  CHAPTER II. SURVEY OF THE LITERATURE Experiential Systemic Therapy  18 18  History of Experiential Systemic Therapy  18  Overview of Experiential Systemic Therapy Theory Relational Novelty as a Means to Individual and Couple Change  20 42  Experiential Systemic Therapy Empirical Status  61  Marital and Family Therapy Process Research  64  Quantitative Marital and Family Therapy Process Research Qualitative Marital and Family Therapy Process Research  65  Summary of the Literature Review  89  CHAPTER III. METHODOLOGY  74  95  Design Investigative Procedure Identification and Description of a Successful ExST Case of Couples Therapy Critical Case Selection Criteria Instruments Case Description Identification and Description of Relationally Novel Episodes  95 96 96 98 105 112  lnterjudge Agreement  113  Synopsis of Episode #1, Session #2 Synopsis of Episode #2, Session #10  115  Videotape and Audiotape Production Data Analysis Cross Sectional Analysis CHAPTER IV. RESULTS Results of the Comprehensive Discourse Analysis of Episode #1 and Episode #2 The Syncretic Change Process  116 117 118 120 128 128 129  vi Initial Disagreement and Conflicting Belief and Practice  130  Therapeutic System contributions to Convergence and Transformation  158  Summary of the Results of the Comprehensive Discourse Analysis of Episode #1 and Episode #2  302  The Syncretic Change Process Intense Experiential Activity The Provision of a Collaborative Therapeutic Environment CHAPTER V. DISCUSSION Implications of the Study Results to ExST Theory  302 303 305 309 309  Syncretic Relational Novelty  309  Tasks Associated with Syncretic Relational Novelty Gender issues in Heterosexual Couples Therapy  312 323  Summary  334  Study Links to the Literature  335  Intensification or Deepening Experience Therapist/Client Collaboration  336  Gender Issues in Heterosexual Couples Therapy Syncretic Relational Novelty  338 339  The Centrality of the Therapist Guide Role Qualities of the Intensification Process  340 341  Limits of the Study  337  342  Generalizability  342  Internal Validity  344  Analyst Interpretation versus Participant Report  344  Segmenting Therapy Process Proximal versus Large “0” Outcome Future Research Directions REFERENCES  346 347 348 350  vii LIST OF APPENDICES  Appendix A:  Intrapersonal Patterns of Relationship  360  Appendix B:  Interpersonal Patterns of Relationship  362  Appendix C:  Environmental Patterns of Relationship  364  Appendix D:  A Composite of the Three Patterns of Relationship  366  Appendix E:  Therapist Competency Form  368  Appendix F:  Relational Novelty Identification Form  371  Appendix G:  Jefferson’s Notation System  377  Appendix H:  Alcohol Dependence Data Questionnaire  380  Appendix I:  Symptom Checklist 90 Revised  382  Appendix J:  Beck Depression Inventory  384  Appendix K:  Dyadic Adjustment Scale  386  Appendix L:  Structural Analysis of Social Behaviour, Sam  388  Appendix M:  Structural Analysis of Social Behaviour, Jill  390  Appendix N:  Transcription of Episode #1: The Bottle is Shown The Door  392  Appendix 0:  Transcription of Episode #2: The Morning Fight  403  Appendix P:  Transcription of Sam’s View of Marital Decision Making  414  Transcription of Discussions Concerning Threats of Abandonment and Physical Intimidation  416  Transcription of Discussions Concerning Alcoholic Drinking and Sam’s Threats to Leave the Marriage  419  Transcription of Sam’s Remarks Concerning “Lone Male” Role Expectations  421  Transcription of Discussions Concerning Jill’s Childhood  423  The Alcohol Recovery Project Promotional Literature  425  Participant Family’s Consent Form  427  Appendix Q: Appendix R: Appendix 5: Appendix T: Appendix U: Appendix V:  VIII  LIST OF FIGURES Figure 1: Figure 2:  Therapeutic System and Component Subsystems  21  An Overview of the Therapeutic System Process  30  ix ACKNOWLEDGEMENT  I wish to express my gratitude to the many people who made the completion of this project possible. In particular, the staff at Surrey Alcohol and Drug Programs offered their time and expertise to this research. Thank you to Jean Matthews, Natacha Villasenor, Geoff Lyon, Dan Mitchell, Warren Weir, Cheryl Bate and Gillian Neumann. I would like to thank my committee including my supervisor, Dr. John D. Friesen for his consistent faith in me and his inspiring commitment to scholarship. I am appreciative of Dr. Bud Morris for his invaluable help and passion for discourse analysis. As well, many thanks to Dr. David Todtman whose attentive editing and thoughtful commentary helped polish this document. Also, thank you to Dr. Robert Tolsma and Dr. Larry Cochran for their engaging comments and efforts in the completion of this project. I wish to thank my mother, Louise Newman for her ideas in the writing of this document and for her inspiring courage, strength and love. Many thanks to my father, Ronald Newman and my brother, David Newman for their love, steadfast support and wholehearted acceptance. I am very grateful to Lorraine Centeno who looked after my son during the years it took to complete this study. In addition, I wish to acknowledge my husband, Dr. Darryl Grigg for his abiding love and encouragement. Lastly, to Robin with his small hands on my computer keyboard xxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxzzzxxxxxxxxxxxzxzxxxxxxx many kisses.  1 CHAPTER I PURPOSE OF THE STUDY  Increasingly, marital and family therapy process researchers are turning their attention to two streams of inquiry including the study of therapeutic process and the means by which therapy process is related to client change (Greenberg & Pinsof, 1986). Indeed, calls for therapy process studies that highlight the second stream, change process research, have been made since the 1970’s (Keisler, 1973). Investigator interest in conducting change process research emerges from a desire to increase our understanding of therapeutic change and insodoing elaborate change theory as it pertains to specifically delineated therapy models (Greenberg, 1986). Typically, marital and family therapy theories (i.e., efforts to understand, describe and explain observed therapy process) are based upon the clinical observations, discussions and the acquired knowledge of their developers (Newmark & Beels, 1994). Change process research offers marital and family therapy theoreticians and researchers the opportunity to test, challenge, confirm or expand theory via empirical means (Greenberg, 1986). The development of therapy theory via empirical theory building offers a rigorous and systematic means to continue the effort to produce ever-evolving explanatory systems. The purpose of this study is to further the development of experiential systemic marital therapy theory through the in-depth examination of therapy-in practice. Experiential Systemic Therapy (ExST) is an effective individual and marital treatment for alcohol abuse (Grigg, 1994). ExST was developed by this author, John Friesen, Darryl Grigg and Paul Peel in 1989 at the University of British Columbia in Vancouver, British Columbia, Canada (Friesen, Grigg, Peel,  2 & Newman, 1989). ExST was developed in response to the need for both a systemic and an integrative therapy model which could be employed to treat individuals, couples and families suffering from alcohol dependence and related problems. As an integrative therapy, ExST provides a theoretical framework that embraces a wide variety of therapist technique and practice. In addition, ExST can be applied to individual, couple and family treatment formats. The importance of ExST in the conduct of therapy for alcohol and drug abuse is that it offers clinicians an opportunity to apply an integrative therapy model to a variety of therapeutic contexts thereby providing an improved service to clients who may require treatment at the individual, couple and family levels of the system. This research project is concerned with exploring change as it occurs in the marital format of ExST. Buoyed by promising outcome evidence that testified to the overall efficacy of ExST for the treatment of individuals and couples suffering from alcohol dependency and its effects (Grigg, 1994), the present investigation was designed to explore how change occurred in sessions of successful experiential systemic marital therapy. This research represents an empirical theory building effort that seeks to contribute to the continued development of an efficacious form of marital therapy. The remainder of this chapter will be concerned with the articulation of the aim of this research investigation, the research question posed, and the significance of the study. Also, a brief description of the method employed to answer the research question will be provided followed by the definition of terms used in the conduct of this study. The organization of the chapters will be outlined after the definition of terms is complete.  3 Research Aim The goal of this study centers on an interest in the continued development of ExST change theory. This aim includes the exploration of how change occurs during a critical single case exemplar of successful ExST and the observation of the implications these findings have for ExST theory refinement and expansion. Thus, the research aim of this study is to contribute to the continuing development of the ExST theory of change through the in-depth exploration of the means by which change is co-created through interactions between therapist and clients.  Research Question The advent of videotaped recordings of therapy-theory-in-practice offered theoreticians and researchers an opportunity to base theory development on rigorous, contextually embedded empirical research. As a result, research questions that require the observation and analysis of therapy-in-progress for theory development purposes are more readily answered. The research question formulated to meet the aim of this study asked “How do members of the therapeutic system both explicitly and implicitly influence the creation of relationally novel episodes at the intrapersonal, interpersonal and symptomatic levels of the system over the course of 15 sessions of successful Experiential Systemic Therapy for the marital treatment of alcohol abuse?”  Significance of the Study ExST has been shown to be an effective treatment for marital recovery from alcohol abuse (Grigg, 1994) yet little research has focussed on how change occurs in ExST. Two studies to date have been conducted with  4 respect to experiential systemic couple’s therapy process and both have centered on single case studies of experiential technique (Dubberley-Habich, 1992; Wiebe, 1993). Dubberley-Habich concentrated on documenting the ways in which an ExST therapist used conversation to guide a particular therapy activity namel’, a ritual burning of an extra-marital affair. This research endeavour is an example of the type of marital and family therapy process study that centers on the description of aspects of therapy process without relating the technique or therapy activity of interest to client change. On the other hand, Wiebe (1993) was concerned more with understanding how change occurred through the employment of a particular experiential activity. Wiebe (1993) studied how change was co-created by therapist and clients when engaged in the externalization of alcohol dependency (a technique known as the symbolic externalization or evocation of alcohol). Thus, Dubberley-Habich’s (1992) study is an example of a therapy process study designed solely to document therapist use of an experiential technique while Wiebe’s study represents an attempt to study an experiential technique in the context of in-session change. This dissertation is the third process research endeavour to be conducted concerning ExST process. This effort expands upon the previous two studies by moving beyond the description of technique alone or the study of how a particular therapy technique was linked to in-session change. This study explored ExST change process irrespective of a particular experiential technique to illumine the ExST change construct (relational novelty) for theory building purposes. As stated earlier, ExST is a recently articulated therapy and little work has been conducted in the area of theory confirmation and refinement. Given  5 the demonstrated effectiveness of ExST (Grigg, 1994), the on-going clarification and expansion of ExST may help foster its continued efficacious conduct. That is, an enhanced understanding of how change is facilitated through ExST will hone the theory offering experiential systemic therapists increased clinical guidance. In addition, this research will begin to provide ExST with an empirically grounded theoretical base which is uncommon in the field of marital and family therapy (Newmark & Beels, 1994). ExST theory has been articulated in manual form (Friesen, et al., 1989) and in a more recent overview (Friesen, Grigg, & Newman, 1991). Also, ExST supervision practice and theory (Newman, Friesen & Grigg, 1991) and the ExST theory of change (Newman, 1991) have been detailed. However, ExST continues to be a relatively new therapy and further effort is required to capture the nuances of its various tenets and constructs. The current flurry of interest in ExST process notwithstanding, several marital and family therapy process researchers have engaged in attempts to understand aspects of therapy process and how clients change from within particular therapy paradigms with varying degrees of success (Pinsof, 1981). A lack of therapy theory articulation, inadequate measures and methods and difficulties linking therapy process to therapy change have hampered efforts to understand change process (Greenberg, 1986; Greenberg & Pinsof, 1986; Keisler, 1973; Pinsof, 1981; Rice & Greenberg, 1984; Safran, Greenberg, & Rice, 1988; Wynne, 1988). The present study sought to build upon past efforts by providing a clear articulation of ExST theory and the ExST change construct (relational novelty) as well as employing standardized measures. In addition, this research effort adopted Comprehensive Discourse Analysis (CDA) (Labov & Fanshel, 1977) as a method of analysis suitable for capturing therapy  6 change process while maintaining a steady research focus on the manner in which change is created in ExST. The following section briefly describes CDA as the method employed in the provision of an answer to the research question.  Summary of the Method The answer to the research question posed in this study required the analysis of therapy discourse as it occurred between the therapist and clients. The analysis of therapy discourse included not only what was said in therapy by the therapist and clients but also what was unsaid or conveyed through paralinguistic and nonverbal cues. In addition, therapy discourse analysis required attention to the implicit meanings of the discourse, the assumptions being made by the speakers, the social role obligations conveyed and the socio cultural influences on the speakers and the manner in which speakers attempted to influence each other (Labov & Fanshel, 1977). Given the importance of therapy discourse in the creation of marital change, a response to the research question was sought through the use of CDA. A brief summary of the CDA method will introduce the method by which the research question was answered in this study. The summary will include an outline of the research design, elements of the investigative procedure, and the method of data analysis using CDA. A critical single case study design was chosen for this research based upon calls for the employment of single case studies to illumine the process of client change within a particular therapy paradigm (Wynne, 1988). This study sought to explore a successful case of ExST for the purposes of theory development. The critical or crucial case selected for analysis was an exemplar of a successful ExST case of marital treatment since it met the three criteria for  7 success outlined for the purposes of this study. First, these criteria included documented client satisfaction with therapy, the cessation of alcoholic drinking and increased marital satisfaction at posttest and follow-up periods. Second, the change construct of interest was evident in a number of therapy sessions and third, the therapist expressed satisfaction with her work with the couple. The change construct (relational novelty) examined in this study and embedded in the successful marital therapy case was observed to have occurred in eight of the 15 therapy sessions completed by the couple. Three episodes identified as exemplars of the change construct were selected for analysis based upon six criteria outlined in the ExST theory of relational novelty. Each episode contained all six criteria whereas the remaining relationally novel episodes did not meet all the criteria outlined as important to relational novelty for the purpose of this study. While the remaining episodes were not considered exemplars (i.e., containing all six criteria) they were, nonetheless, relationally novel. The three episodes were reviewed by three independent expert judges selected for their knowledge and familiarity with ExST. High indexes of interjudge agreement were obtained for the episodes indicating that the construct of interest was identified as occurring in the episodes selected for analysis. Once the successful critical case was secured and the change episodes exemplifying the construct under investigation were identified, the comprehensive discourse analysis of the three episodes began. Following the analysis of the first two episodes, the analysis was concluded. Due to the thematic commonalities evident in the first two episodes, it became clear that the analyses of the first two episodes of relational novelty were sufficient for the provision of an answer to the research question.  8 The discourse analysis procedure employed in this study is based upon the work of William Labov, a linguist with training in sociology and David Fanshel, a professor of social work with an interest in the delivery and practice of psychotherapy (Grimshaw, ‘1979). Labov and Fanshel’s (1977) research efforts were motivated by an interest in what occurs in therapeutic discourse as well as a desire to expand the scope of linguistic analysis to conversation as a whole (Grimshaw, 1979). As a result, Labov and Fanshel’s (1977) work addressed two issues namely the relationship between what is said and what is meant and how social acts and organization are accomplished through talk. Thus, the social act of change in therapy can be carefully examined using Labov and Fanshel’s (1977) methodology. CDA relies upon a six step process which includes the making of video and audio recordings of therapy as a first step. Therapy sessions, in this study, were recorded with sensitive equipment to provide as clear and crisp a visual and auditory rendition of the therapy as possible. The clarity of the recording was important to the next phase of the CDA procedure namely the transcription of the recordings. The ability to hear and see the therapy discourse clearly aided in the production of the text used in the analysis. The second step, the transcription of the therapy discourse, was a painstaking process of transferring auditory and visual information onto the written page. This process required repeated listening and viewing of the therapy segment selected for analysis to obtain an utterance-by-utterance record of the discourse including paralinguistic and nonverbal cues as well as the spoken word. The third step required by CDA was the expansion of the transcribed text. Utterance expansion included additions to the utterance with what was being implied in the speech act. For example, a question such as “How are you?” may contain within it a genuine interest in the respondent or an  9 uninterested attempt to be polite depending upon the context. The expansion of the text is designed to articulate the implied meaning of an utterance in context. The fourth step in the analysis was the generation of propositions or assumptions being made by the speaker. Thus, a proposition that fits the expansion of “How are you?” might include the following statement: The speaker is genuinely concerned with the respondent’s well being. The text transcription, expansions and propositions were employed in the fifth CDA step which necessitated an interactional analysis. Interactional analyses are concerned with exploring how discourse participants are attempting to influence each other through their speech acts. The interactional statement was crucial in understanding how speakers influence one another and revealed how therapeutic change was brought about. The sixth step in the analysis included an episode summary in which the utterance-by-utterance analysis including expansions, propositions and interaction statements for each speech act were synthesized into a coherent whole. Once the analysis was complete, the work of synthesizing the data to provide an answer to the research question was begun. This survey of the method used to answer the research question is meant to be an introduction and a further elaboration can be found in chapter three. The introduction of the research aim, question and method in this chapter has required the use of many terms with which familiarity is important. The following section will define the terms used in this study.  Definition of Terms The terms defined in this section are important to a complete understanding of this research effort. These terms will be defined in order to clarify their usage in this study.  10 Relationallv Novel Episodes Relational novelty refers to the enactment of an atypical way of being in therapy which alters the substantive relational themes represented in rigid cognitive, emotive, and behavioural ways of being with self, others, and the presenting problem. Relationally novel episodes follow a general pattern that can be identified as beginning with therapist attendance to clients’ narratives. The therapist begins to collaboratively delve into a salient aspect of the narrative through a therapeutic transaction. If the client(s) consent, either implicitly or explicitly, then the therapist guides them through a deep, intense, and novel encounter with self, other, or the presenting problem. Generally, this encounter ends with a de-intensification during which the therapist may mark client change, congratulate the client(s), summarize the process or ask the client(s) for their views of the experience. The therapist may encourage client(s) to talk about the experience or the client(s) may do so without prompting. Substantive Relational Themes Substantive relational themes are recursive patterns of emotion, cognition, behaviour and physiological process that embody intrapersonal and interpersonal themes such as unlovableness, abandonment, unworthiness, undeservedness and rejection. They can also transform into themes of lovableness, worthiness, deservedness and inclusion. Substantive relational themes are descriptive of peoples’ intrapersonal and interpersonal thematic experiences of being in the world. Intensifying and Deepening Experience The process of intensifying and deepening experience aids clients in evoking their substantive relational themes, problematic behaviours, feelings  11 and thoughts. Deepening experience is achieved via empathy, the repetition of words or actions, experiential activities that involve the whole body as well as metaphors, art, sculpting, dream work, symbolic externalization and enactment. Intensifying and deepening experience is the means by which clients fully embrace their process such that different ways of being with themselves and others are made possible both in the deepened moment and after. Therapeutic System: Therapist and Client Members A therapeutic system is created when therapist and client(s) enter into a dynamic interactive relationship. As such, the therapist and client subsystems influence and are influenced by the exchange. They bring a variety of intrapsychic, interpersonal and socio-cultural elements to the relationship. For example, the therapist subsystem may include the influences of co-therapists, colleagues, supervisors, personal issues/values, and agency affiliation and attitudes towards the symptom in therapeutic interaction with the couple subsystem. The couple subsystem may include the influences of personal values, families, extended families, friends, work associates, institutional affiliations, aspects ofself and attitudes towards the symptom in interaction with the therapist and either spouse. Thus, therapist and client(s) subsystems combine to form the therapeutic system in which all system members affect one another and share ownership of the therapeutic venture. Alcohol Dependence The male alcoholic featured in this study satisfied the DSM-lll-R (1987) diagnostic criteria for severe Psychoactive Substance Dependence. The man’s spouse must not be abusing alcohol. The diagnostic criteria are listed below:  12 At least three of the following items are evident: 1.  The substance is used in larger amounts and for a longer length of time than the person initially intended.  2.  There exists a persistent desire or one or more unsuccessful attempts to control the substance abuse.  3.  The individual spends a great deal of time attempting to obtain the substance, ingest the substance or recover from its effects.  4.  The person is frequently intoxicated or experiencing withdrawal symptoms when expected to fulfill role obligations including work tasks or child care or use of the substance is physically hazardous (e.g., driving while intoxicated).  5.  Important social, occupational or recreational activities are given up or reduced due to the substance use.  6.  The individual continues to use the substance despite knowledge of recurring social, psychological or physical problems that are caused or worsened by the substance use. These difficulties include problems such as ulcers due to drinking, job loss or family fights concerning the use of the substance.  7.  The individual experiences tolerance characterized by the need for increased amounts of the substance to achieve intoxication or the desired effect (at least a 50% increase) or the person observes markedly diminished effects with ongoing use of the same amount.  Items #8 and #9 may not apply to cannabis, hallucinogens or phencyclidine (PCP). 8.  The individual experiences withdrawal symptoms.  9.  Symptoms of the disturbance have persisted for at least one month or have occurred repeatedly over a longer period. The  13 severity of the Psychoactive Substance Dependence ranges from mild to moderate to severe. Mild: Few, if any, of the symptoms are in excess of those necessary for the diagnosis. The symptoms result in no more than mild impairment in occupational functioning or social activities or relationships with others. Moderate: Symptoms or impairment is between “mild” and “severe” in degree Severe: The individual has many more symptoms than are required for the diagnosis. The symptoms markedly disrupt occupational functioning, social activities or relationships with others. Distressed Counle Functioning One or both spouses must indicate marital distress as obtained by a score of 100 or below on the Dyadic Adjustment Scale (Spanier, 1976) in order to be considered maritally distressed. Successful Treatment There are several criteria defining successful treatment for couples complaining of the deleterious effects of alcohol abuse. These criteria include spousal satisfaction with therapy, the attainment of therapy goals including the cessation of alcohol and drug abuse at posttest and follow-up periods and therapist satisfaction with the couple’s progress and her work with the dyad. In addition, the pretest, posttest and follow-up measures should indicate a change towards more personal and marital satisfaction and less personal and marital distress. Finally, relationally novel episodes should be co-created by the therapist and clients throughout the 15 sessions of therapy.  14 Experiential Systemic Therapy ExST was created for the treatment of individuals, couples and families complaining of drug and alcohol abuse issues. The theory is complex and aims for an integrative understanding of individual, couple and family functioning in therapy. It strives to access the cognitive, emotional, physiological and behavioural aspects of experience in order to promote change. These aspects of experience are tapped via experiential, symbolic and systemic means in a collaborative, present tense, goal oriented, spontaneous and creative therapeutic atmosphere. Client issues are viewed from a developmental perspective that highlights strengths and resources rather than pathology and dis-ease. ExST subscribes to the notion that human beings develop and maintain their identities in a social or relational milieu from the day they are born through early childhood, youth and adulthood. Experiences that span the life cycle serve to maintain, sustain or perturb human beings sense of self and ways of being in the world. ExST has roots in attachment theory (Bowiby, 1988), interpersonal and existential theory (Kiesler, 1982; May, 1969; Sullivan, 1944; Yalom, 1980), ecosystemic thought (Auerswald 1985; Bateson, 1972, 1979; Bronfenbrenner, 1979), client-centered theory (Rogers, 1961), and experiential (Whitaker & Keith, 1981), strategic (Haley, 1976; Madanes, 1981) and structural (Minuchin & Fishman, 1981) family therapy. Intranersonal Level of the Therapeutic System The intrapersonal level of the system refers to the inner world of the spouses and the therapist including thoughts and emotions internal to the individual. The inner environments of client and therapist may also include various aspects of self which engage in internal dialogue. For example, a critical aspect of self may berate a fearful aspect of self. Also, internal aspects  15 of self may engage in dialogue with the symptom or people in the individual’s world (e.g., a hurt aspect of self may call out to alcohol for relief or a hurt aspect of self may reveal itself to a concerned spouse). The intrapersonal domain is notable in therapy when the clients engage in a dialogue with aspects of self or disclose information about their inner thoughts and emotions. Interpersonal Level of the Therapeutic System Relationships between the spouses, the couple and the therapist constitute the interpersonal level of the system. The interpersonal level of the system is evidenced in therapy when the spouses interact with one another. Another example occurs when the therapist interacts with either one or both of the spouses. Symptomatic Level of the Therapeutic System This level refers to the relationship the therapist and clients have with the presenting problem or symptom. One of the therapeutic tasks is to aid clients in bringing this relationship into awareness. The symptomatic level of the system is in evidence when the clients or therapist interact with the presenting problem in its symbolic form. Collaboration in Therapy Therapist and client collaboration is an important principle of ExST in which therapy is understood as a shared venture involving mutual trust. The therapist is a guide to the therapeutic process and co-develops the therapy with the client. Both the client and therapist own the therapy process and both assume responsibility for the activities. Therapists endeavour to enter the client’s world by adopting client language and accepting the client’s current state before encouraging clients to experiment with alternate ways of being,  16 thinking or feeling. The collaborative therapist is considered a part of the therapeutic system rather than a neutral observer, an all knowing expert or a master technician. A collaborative therapist does not understand therapy to be a battle or characterize clients as adversarial or resistant. Instead, clients and therapist work together as co-creators and co-developers of the therapy. Therapy Discourse Therapy discourse includes both the spoken word as well as that which is left unsaid but still communicated. Discourse in therapy accounts for the implicit meanings of speech acts and the meanings revealed in paralinguistic cues (e.g., sighs, laughter) and nonverbal activity (e.g., headnods, handshakes). In addition, therapy discourse incorporates the suppositions made by the participants in the discourse, their assumed social role obligations (e.g., expectations regarding a father role), the socio-cultural influences on the speakers and the manner in which discourse participants attempt to influence one another (Labov & Fanshel, 1977).  Organization of the Chapters The remaining chapters of this dissertation will provide a review of the literature, an encapsulation of the methodology, a description of the results and a discussion of the conclusions made as a result of this research. Chapter two will incorporate a detailed articulation of ExST theory including the results of a recent outcome study testifying to ExST efficacy and a review of the history of ExST. Following the delineation of ExST theory, relevant quantitative and qualitative marital and family therapy process research will be reviewed. Chapter three describes the critical single case research design and related issues, the investigative procedure used in the conduct of the study and the  17 CDA method of data analysis employed to yield the results. Chapter four will describe the research results and their importance to ExST theory and chapter five will be concerned with summarizing the results and outlining the proposed refinements to ExST theory based on the findings. Also, limits to the study and future research directions will be discussed in chapter five.  18 CHAPTER II SURVEY OF THE LITERATURE  The purpose of this chapter is twofold. First, the aim is to outline why ExST change is worthy of process oriented investigation including a general description of ExST and the change construct of interest namely relational novelty. The second aim of the chapter is to review previous marital and family therapy process research. The literature review will focus on the manner in which marital and family therapy process has been studied and the results garnered from these studies. Both quantitative and qualitative types of investigations will be reviewed.  Experiential Systemic Therapy This section will offer a discussion of ExST history, theory and efficacy with a view to outlining the development of the therapy and the articulation of the theory including an overview of ExST and an in-depth description of relational novelty. Finally, a recent outcome study testing the efficacy of ExST (Grigg, 1994) will be reviewed to provide a context for this process research effort. History of Experiential Systemic Therapy ExST was co-developed by John Friesen, Darryl Grigg, Paul Peel and Jennifer Newman in 1989 at the University of British Columbia. While ExST, in many ways, represents the accumulated experience and knowledge of all these individuals, it was in 1986 that ExST began to form in earnest. Extensive training sessions conducted by the ExST originators in the area of marital and family therapy for substance abuse with alcohol and drug  19 counsellors led to the eventual inception of ExST. The training events and discussions with alcohol and drug clinicians across British Columbia, plus the need to clearly explain concepts when imparting them, provided fertile ground for the subsequent articulation of ExST. ExST developers sought to delineate an integrative theoretical framework capable of embracing a variety of therapy technique and a wide spectrum of human experience in the behavioural, the emotive and the cognitive domains. In addition, ExST was designed to integrate individual practice with a family systems theoretical orientation. The articulation of ExST prompted a large scale research endeavour named The Alcohol Recovery Project (TARP) of which this research is a part. The general mission of TARP was to test the efficacy of ExST and conduct process research with respect to therapy-theory-in-practice. Also, TARP provided an umbrella for a variety of outcome, descriptive and process studies related to ExST and alcohol dependency in general. Conducted over a period of five years, TARP has received funding from the British Columbia Alcohol and Drug Program (now part of the provincial Ministry of Health and formerly in the Ministry of Labour and Consumer Services) and from the British Columbia Health Research Foundation (Health Services Research Programme). Other assistance has been extended to TARP by the University of British Columbia and the Social Sciences and Humanities Research Council of Canada (SSHRC). These funds and other forms of assistance have enabled the completion of this study, as well as others resulting from TARP activities. SSHRC funding, awarded to the author, was important to the completion of this study. TARP has been conducted under the general direction of the Principal Investigator, John D. Friesen, Ph.D., co-investigator Robert F. Conry, Ph.D., and project coordinator, Darryl N. Grigg, Ed.D. Additional information  20 regarding TARP may be obtained from Professor John D. Friesen, Department of Counselling Psychology, University of British Columbia. Currently, ExST is practiced throughout British Columbia in a variety of public agencies as well as private enterprises and research on ExST process and efficacy is ongoing at the University of British Columbia. Also, ExST theory and technique has been adapted to group counselling efforts with single parents at risk for child maltreatment (Newman & Lovell, 1993) and applied to therapy with adolescent substance abusers (Selekman, 1993). The following section will outline ExST theory with reference to composite case examples altered to protect client confidentiality. Overview of Experiential Systemic Therapy Theory This section will provide an overview of ExST and an elaboration of relational novelty, the change construct under investigation. Experiential Systemic Therapy (ExST) originated with John Friesen, Darryl Grigg, Paul Peel and Jennifer Newman in 1989. The model was designed in response to a lack of integrated individual, couple and family therapy models of treatment for alcoholism (Friesen, Grigg, Peel & Newman, 1989; Friesen, Grigg & Newman, 1991). The current study represents an empirical effort to continue the ongoing process of theoretical refinement. ExST is an interpersonal process, the success of which is dependent upon the client’s experience. The observable manifestation of the therapeutic system arises out of the dynamic interaction of its two constituent parts, the therapist and client subsystems. Therapists and clients influence one another through discourse and the ongoing therapeutic relationship is an interactive process.  21 In some therapeutic models, clients are viewed as resistant or appear unreceptive to the therapist’s interventions (e.g., Madanes, 1981). Consequently, such techniques as paradox are used by therapists to out-wit clients. In other approaches, clients are seen as opponents with whom the therapist must struggle against and vanquish through a series of “battles” (Whitaker & Keith, 1981). Such notions can become self fulfilling therapist prophecies and are incompatible with the Experiential Systemic Therapy theory. Efforts are made to avoid militaristic language that references combative ways of construing clients and the process of change. Therapy is best seen as something created with clients as opposed to something imposed upon them. Consequently, there is no need to conceive of the therapist/client relationship using metaphors of armed struggle and combat. Therapy is seen as a cooperative venture shared by therapist and client.  — — —  —  Therapeutic System  I,  / ——  ——— —— —  4________________________—.  7  I  I  ,‘  I  “Therapist” subsystem may include: therapist, co—therapist, ‘ team, colleagues, supervisors, clinic staf treatment community / —  — — — — — —.  —  / /  —  ——  “Client” subsystem may include \ individuals, couples, ‘ I families, extended families, friends, work) associates, conunwuty /  c..___________-_.  Figure 1. Therapeutic System and Component Subsystems  —  /  22 The unified view of the therapeutic system presented schematically in Figure 1, illustrates the interdependent collaborative relationship between the therapist and client subsystems. It is recognized that both therapist and client subsystems are frequently comprised of a complex of constituents and the terms therapist and client will be employed throughout the remainder of this section to denote the subsystems. The experiences clients bring to therapy are indicative of their struggles with others, themselves and the presenting problem. These experiences are frought with frustration, tension and stagnation. The therapeutic story initially includes the client’s struggles as a starting point while simultaneously incorporating potential for change. ExST theory assumes therapy has an elevated status in the normal bustle of the client’s daily life. It is a weekly or bimonthly ritual that has as its explicit goal, the transformation of the clients’ experience and stories. The story of therapy is a story of transformation and as such it is imbued with the kind of respect reserved for the sacred in our culture, It is a special social occasion wherein all acts, thoughts, feelings and physical sensations have symbolic significance. Within this context, anything can happen, the most mundane can become the miraculous and that which was pained can become a joy. The Role of SvmDtoms Symptoms are considered indicators of relational difficulty and as such are meaningful signs of distress. Rigid, restrictive and repetitive patterns of interaction characterize the symptom-bearer’s relationship to the symptom, self and family members. Similarly, family members may experience a particular relationship with the symptom and the symptom-bearer. Painful intrapsychic, interpersonal and social contexts can give rise to symptomatic behaviour. An  23 appreciation of the myriad of contexts from which symptomatic behaviour may arise fosters a comprehensive view of symptomatology that includes an acknowledgement of the possible physiological, psychological and social factors that can determine symptom development and maintenance (Donovan, 1988). For example, a comprehensive perspective regarding symptom development and maintenance is helpful when clinicians are required to treat alcoholism. Alcoholism can be understood as a multi-dimensional and systemic manifestation of a physical addiction process interacting with psychological and social factors. Intervention at all three levels is required to interrupt the development and course of the syndrome (Kissin & Hanson, 1982). This multi-dimensional and systemic view of symptom development and maintenance also offers clinicians a way of understanding the complexity of symptomatic distress (Schwartz, 1982). For example, while the presenting problem may be expressed as depression, secondary relational disturbances such as unemployment or excessive fatigue may be related to the chronicity of the symptom. In addition, previous problematic relations such as childhood sexual abuse may pre-date the emergence of the symptom and be revealed during the course of therapy. Thus, the therapeutic task includes an adequate assessment of the symptom and related factors to help in understanding the problem and its meaning in clients lives. To aid in both the assessment and amelioration of symptomatic behaviour, ExST therapists remain curious about the symptom viewing it to be akin to a teacher or messenger. Symptoms are considered teachers or messengers providing either learning opportunities for clients or giving clients messages regarding relationships in need of attention. Clients’ relationships to self or others may be in need of care and the symptom or “bearer-of-bad-news” is to be heeded and relieved of its sad duties. The means by which therapists  24 and clients grapple with symptom relief is found in the symbolic, experiential and systemic dimensions of ExST. These three dimensions are described in the following section. Dimensions of the Model The therapeutic story has a beginning, a middle and an end and like all stories it is an expression of the authors’ talents, needs and limitations. Experiential systemic stories are centered on three domains including the symbolic, experiential and systemic dimensions. Symbolic dimension. The symbolic dimension refers to the notion that therapy is a symbolic and culturally sanctioned change ritual. Acts in therapy are symbolic and considered an analogue to the story the clients enact in other life situations. In addition, actual symbolic objects are employed in therapy to represent parts of self, interpersonal relationships and presenting problems. Where single words may be insufficient, symbols provide a meaningful way to describe the totality of client experience. Exneriential dimension. The experiential nature of the model is also important in facilitating change. Experiencing in therapy deepens and expands clients alternatives. An experience is helpful if it increases the clients awareness of their thoughts, feelings, perceptions and behaviours. New awareness and changed relationships are achieved through intensified experiencing. Experiencing represents an integration of behaviour, cognition, affect and perception such that these constructs are synthesized into a whole.  25 Action oriented techniques are utilized to achieve the broadening of experience. These may include psychodrama, sculpting, enactment, empty chair work, and two chair techniques. These techniques offer clients an opportunity to experience different ways of being together rather than engaging in a didactic or content oriented discussions about what “should” be done. The rigid manner in which the clients behave begins to erode when they experience a visceral sense of the alternatives open to them. Experiential techniques are not applied for their own sake. They are used to deepen clients experience of the patterns they have encountered with their spouses or children. For this reason, the experience provided must fit the therapist and clients’ perceptions of the difficulty at hand. The characteristics of therapeutic experiencing entail both the enhancement of emotions and cognitions as well as the bringing into prominence the interactive essence of experience. In other words, clients obtain understanding at both an intrapsychic and systemic level. They come to “know” the patterns and relationships they live at a deeper level. These patterns and interactive postures may incorporate purser/distancer, attack/attack, withdraw/attack, withdraw/withdraw and dominate/subjugate dynamics. Another characteristic important to therapeutic experiencing encompasses the notion of relational novelty. That is, clients obtain a physical, affective, cognitive and behavioural sense of a new “way of being” in the world. Relational novelty is the experiencing of new alternatives that grow out of the special status of the therapeutic context and the experiential nature of the therapy itself. New patterns of interaction are not just felt, talked about, thought or designed, they are born in a moment when all the elements of experiencing converge to form a new coherent whole. Once this has occurred,  26 clients quite literally, can never be the same again. They see the world anew and they no longer maintain the same rigid patterns of behaviour to which they had previously become accustomed. These shifts occur through the use of pictorial language, metaphor, intensifying experience through repetition, identifying underlying emotions and the use of symbols. These activities are most meaningful when the clients’ metaphoric language is understood and spoken by the therapist and when the therapist and client(s) have entered into a collaborative relationship. Systemic dimension. The ExST model is based upon a systemic perspective that views relational patterns as malleable and subject to the experiential shifts of the observer. ExST emphasizes the plastic, evolutionary nature of systems rather than a static, self regulatory concept of homeostatic functioning. Systems include a wide of variety of relationships including interactions between parts of self, ideas, problems, people, cultures and nations. These relationships exist in the social domain and are interdependent such that any movement in any given system influences other systems. The therapist is considered an integral part of the therapeutic system. He or she attends to patterns encountered and enacted by the clients as they interact with the therapist, each other, themselves and their problems. Therapists are socially sanctioned “change agents” who bring the totality of their experiences to the therapy setting. These experiences include professional training and affiliations, personal values and influential life events. It is within this dimensional framework that the therapeutic story unfolds. Many stories are concerned with creating a consistent style, maintaining a specific length, developing characters and roles, focussing on main dramatic  27 themes and delineating the role history plays in the present lives of the characters. The following discussion depicts the nature of the therapy story. Outline of Principles Experiential Systemic Therapy is problem and pattern focussed in that the clients’ presenting problems are noted and relief of these problems is actively sought. Problematic patterns are tracked and various transactions occur between the therapist and clients which address the relational stagnation intrinsic to client complaints. ExST is a brief therapy in that the story ranges from four to 20 sessions in length. It is goal directed and an agreement regarding the focus of therapy is made at the outset. Developmental perspective. ExST maintains a developmental perspective which frames the client’s difficulties in relation to various human experiences in the life cycle. These experiences can include: a birth of a child, a death of a child, a child leaving home, a parent dying, a marriage or engagement, a divorce or separation, career transitions, housing problems, difficulties with adolescents and caring for aging parents to name a few. The understanding of the developmental nature of life cycle experiences is important for two reasons. Firstly, our society is ever changing and currently blended families, single parent families and extended families are common. As a result, ExST does not assume a “typical” course for family or couple events. The idea of stages of development is limited by the shifting nature of our increasingly cross-cultural and feminized society. As a result, ExST theory considers human dilemmas in light of their universal qualities such as loss, transition and reunion. Secondly, a focus on the evolutionary nature of life events is important in that this frame provides validation for clients who are attempting to make changes in their living  28 arrangements. Rather than applying an outmoded yardstick to client experience, ExST strives to normalize struggles as valid, understandable and rational given the circumstances. Therapy is also viewed as a developmental process in which change is construed as an ongoing occurrence. Client regressions to previous problematic states and patterns are understood to be opportunities rather than failures. Clients will revisit outmoded ways of being in order to learn more about themselves, consolidate change and face the loss of familiar states. Present tense therapeutic focus. ExST adopts an active here-and-now focus. The story is action packed and told in the present tense. This is not to say that the model ignores the potency of the past. Rather, it recognizes the influence of past events and figures and actively offers these historical legacies a voice as they manifest in present interactive patterns. For example, constraints and problems in the present may indicate that a client’s deceased but once sexually abusive father still maintains a stranglehold on his adult daughter’s life. If this is the case, the “ghost” of the father is a current reality for the client and her spouse. The haunting figure is not left in the attic but is brought into therapy and attended to by the clients and the therapist as a present tense phenomenon. Ecological assessment. In order to engage clients it is essential that the therapist develop an ecological assessment of their difficulties. The story that unfolds is representative of the characters’ lives and this entails the observance of all levels of the system in which the characters are involved. This assessment includes gaining an understanding of the individual, couple, family and community contexts (including work, school, medical services and the police)  29 as well as the societal, political and cultural systems within which the subsystem members operate. Collaborative therapist stance. A collaborative therapeutic system is essential to the ExST model since it is within this relationship that the opportunity for client change and the ultimate re-writing of the clients’ tale is made possible. Relational novelty occurs within this collaborative setting. The therapist is considered to be a collaborator or co-author with the clients rather than an expert doling out therapeutic advice. This role is flexible and can accommodate many different modes depending upon what is triggered spontaneously in the therapist. The therapist may take on the aspect of a dramatic coach, a dance and movement choreographer, a orchestral conductor, a sculptor or the village idiot given what is “pulled” from her or him during therapy. Therapist spontaneity. The therapist obtains permission through the therapeutic mandate to be spontaneous with clients as a direct result of maintaining a collaborative stance from the outset. A key element in ExST is the therapist’s ability to be spontaneous. Therapist creativity is essential to the model and the fear of making mistakes with clients is a natural concern for any responsible therapist. However, once rapport has been established, the relationship between the clients and therapist can withstand the jostling that sometimes occurs on the way to health. As partners in collaboration, the therapist and the clients can discuss the developing therapeutic subsystem and are encouraged to do so on an ongoing basis throughout the course of therapy. It is at these times that any misunderstandings or differences in viewpoints can be addressed on the part of all therapeutic system members.  30 Phases of Theranv A story of literary worth incorporates a certain structure which “moves the action along” at a steady pace so that the reader’s attention is sustained. A story begins with an introduction wherein the setting and main characters are introduced and the principle problem or human theme is outlined. After the introduction has been made, the stage is set for the dramatic action which culminates in the story’s climax. The climax is reached and is quickly followed by the denouement and story resolution. These narrative elements are reflected in the therapeutic change story by way of the four phases of therapy which may span, for example, 15 chapters or sessions. The four phases of the therapeutic story include: a) Forming the therapeutic system: Establishing a context for change (introduction); b) Perturbing patterns and sequences and expanding alternatives; c) Integrating experiences of change: Reorientation (action and climax) and finally; d) Disbanding the therapeutic system: Termination and acknowledging accomplishments (denouement and resolution). These phases take place within the sessions or chapters of the tale and are presented in Figure 2.  Phase 1 Forming  Pre— therapy  —>  Phase 2 Perturbing  >  >  Phase 4  Phase 3 Integrating  >  >  >  Figure 2. An overview of the therapeutic system process  > Post—  therapy  31 Figure 2 depicts the time before therapy begins, the formation of the therapeutic system, the perturbation of the system, the integration of changes and finally the eventual conclusion of therapy followed by post-therapy separation. It portrays the therapeutic system developing over time and illustrates the four phases of therapy as they might occur over the course of 15 sessions. The phases overlap and different elements of each phase may be present in any given session. At the outset of therapy, clients are invited to express their desires regarding the outcome of therapy. This task offers the therapist and the clients a goal around which therapy is organized. While each session has an integrity all its own, the story achieves continuity through the goals agreed upon in the first phase of therapy. In addition, each session ends with an invitation to clients to complete such tasks as experiments with novel behaviour, the completion of a journey or the discovery of a symbol, as a means to the desired goal. The next session begins with a review of the invitation made in the previous one. The story maintains its focus, coherence and continuity in this manner. The therapeutic activities engaged by the therapist and clients during the four phases of therapy have been divided into broad categories or transactional classes. These transactional classes are described below. Transactional Class Taxonomy There are seven transactional classes used to describe the activities of the therapeutic system. The term transaction is used instead of interaction since it denotes the complexity of the process of accommodation and influence engaged in by members of the therapeutic system. Each class is designed to reflect the mutually interdependent relationships that form what is called the therapeutic system.  32 Therapist-Client relationship enabling. The focus of this class is on the creation and maintenance of the therapeutic alliance. This occurs throughout the duration of therapy and ensures that clients feel understood and safe with the therapist. The intention behind these transactions is to form a working alliance wherein there is a trust and commitment to the therapeutic process on the part of both the therapist and the client. These transactions can include empathy, self disclosure and immediacy to name a few. Process facilitation transactional class. The relational patterns observed by the therapist and clients are the focus of this transactional class. Clients are encouraged to become directly involved with one another during the session. The therapist is interested in the recursive nature of client patterns as well as the cognitions, emotions and physiological states that underlie these interactions. The clients cooperate with the therapist in experiencing new patterns of behaviour. They engage in spontaneous dialogues while the therapist utilizes their immediacy to shift otherwise static patterns of interaction. The techniques classified under this class include: blocking, coaching, marking boundaries, framing and encouraging the expression of underlying feelings. Expressive transactional class. What has previously been private is made public through the process of exploration, naming and owning of experience through verbal and nonverbal means of expression. These are creative transactions that obtain their power through their metaphorical properties and the resources brought to bear on the moment by all members of the therapeutic system. These transactions can include art activities, dance, storytelling, baking and metaphor.  33 Symbolic externalizing transactional class. A symbolic representation of some aspect of the clients’ world is made and brought to life in therapy. An alcoholic’s relationship to the bottle is externalized so that the clients may relate to it from a distance. In this activity a beer bottle is put on.a chair and the alcoholic and his spouse are invited to address the bottle. In short, any dilemma, idea, feeling, person or thing can be externalized and brought into therapy. These transactions include empty chair work and two chair work. Meaning shifting transctional class. Clients make sense of their worlds in ways that leave little room for flexibility. The therapist can help clients expand their alternatives by aiding them in developing an experience of the problem that implies a solution or that enhances the clients’ ability to be compassionate towards one another and themselves. Meaning shifts are important to therapy since they sometimes mark moments of irreversible progress. These transactions include: reframing, normalizing, circular questioning and positive connotation. Invitational transactional class. These transactions typically occur at the end of the session. They are invitations to engage in some form of between session homework and allow for continuity between meetings. They provide feedback as to how well clients are maintaining their changes and developing alternatives. Therapeutic tasks may perturb new behaviours and therein promote client self confidence. These transactions include: homework, quests, rituals, journal writing and self monitoring.  34 Ceremonial transactional class. These transactions focus on formal acknowledgements of progress and change in clients. These are memorable occasions and are enacted with all due reverence. Ceremonies can demarcate endings from new beginnings, shifts in status and changes in role. They are highly ritualized and jointly planned. These transactions include: closing celebrations, burials, penance, confessions and burnings. The following example of one client’s story of change describes the phases of therapy and the employment of various transactional classes. The details of “Sue’s” therapy have been changed to protect her anonymity. Sue (a fictitious name), 30 years old and mother to an infant, came to therapy having just ended her marriage of five years. She realized through the painful process of separation that she now wanted to use the opportunity to review some of the events of her pastand face that which she had buried along the way. Sue’s journey will be used to illustrate each phase of therapy. The transactions employed in therapy will be delineated during the case example. The therapeutic activity employed and the category to which it belongs will be bracketed in the text. Phase 1 change.  -  Forming the therapeutic system: Establishing a context for  One of the major tasks of this phase of therapy entails setting the stage for the action to occur. This necessitates the establishment of a bond between client and therapist, an assessment of the nature of the troublesome human dilemma brought to therapy and the development of a commitment to the goals agreed upon by all members of the therapeutic system. This implies the creation of a therapeutic mandate. The mandate is jointly accepted by  35 therapist and client and is connected to client goals. The therapist requests clients to identify symbols that represent their therapeutic goals. These symbols (which are brought into therapy) may represent a wide range of possibilities including cutouts from magazines, photographs, plant matter, visions, television personalities or families or prized possessions. The therapy story obtains its direction and navigates the troubled client waters through these symbols of desired outcome. The bond formed between the co-authors of the therapy tale is facilitated through the collaborative stance adopted by the therapist. He or she also employs a host of relationship enabling techniques in order to facilitate the therapeutic relationship. These techniques include empathy, listening and attending An ecological assessment is conducted during this phase in order to understand the clients’ backgrounds and present roles more fully. The first chapters of the therapeutic story center on the promotion of understanding, respect and trust between the therapist and clients in order to ready the scene for change. For example, during the first session, the therapist listened closely to Sue as she told of seeing her sorrow contained in “jars of sadness”. These jars of sadness were shut in a room (Metaphor: Expressive Transactional Class). Sue was afraid to trust others including the therapist. The therapist commended her for her bravery which propelled her into therapy (Positive Connotation and Validation: Meaning Shift Transactional Class) and added that she would not ask her to go anywhere she was not ready to go. As part of the ecological assessment, the therapist discovered that Sue had a previously difficult experience in therapy. Sue believed that her previous therapist had not been honest with her. The present therapist said that  36 honesty was very important to her as well (Self disclosure: Relationship Enabling Transactional Class) and that if Sue ever has any concerns the therapist would like to hear them. The therapist also promised to bring her concerns forward if need be (Immediacy: Relationship Enabling Transactional Class). Sue is a single mother working in an drafting office and the demands to perform and be “one of the guys” sometimes left her feeling alienated from her office mates. She valued therapy as a place where she could “be herself”. Sue is an Anglo-Saxon Canadian and she said that the cultural differences between herself and her husband (who was from Asia) caused a strain on their marriage. Sue was abandoned as an infant and lived with her father and a series of stepmothers who were more or less accepting of her over the years. The themes of Sue’s story were ones of abandonment, alienation and loss. She was afraid to trust others and her career choice offered her healthy remuneration but very little emotional support. However, she valued her ability to survive and the strength of her independence. Sue was happy to work with the therapist and the therapist echoed this desire. The therapist requested that Sue gather together jars and place the different forms of sadness she experienced into each jar and bring them to therapy the following week (Homework: Invitational Transactional Class). The therapist also asked Sue to reflect upon what she envisioned as the ideal outcome of therapy. Her answer was immediate. She saw an empty room that needed redecorating. The room contained no jars of sadness but was a place of refuge that was in dire need of interior design.  37 Phase 2  -  Perturbing patterns and sequences and expanding alternatives.  During this phase of therapy, the therapist strives to perturb relational novelty and therein directly affect clients’ static sequences of behaviour and expand alternatives. The techniques used by the therapist must reflect the collaborative nature of the therapeutic endeavour. The therapist remains flexible and sensitive to the clients’ needs at this tender time. The symbolic, experiential, and systemic nature of the model is also evidenced during this phase through the utilization of change skills encompassed in the transactional classes. The therapist’s spontaneity is important during this phase and throughout the whole therapeutic process since he or she is required to engage in various forms of psychodrama, symbolic externalization, process facilitation and other metaphorical and intuitive activities. The purpose of this creativity is to trigger shifts in the clients’ experience of a rigid and stereotypic world. The following example illustrates two sessions that occurred during phase two of therapy. In one session, Sue’s jars of sadness (Symbolic externalization: Externalization Transactional Classes) were sitting on a chair. After being requested to place the jars in relation to how close or distant she felt from them, Sue put them within arms reach and sat beside them. When the therapist asked her to imagine opening one of the jars (Fantasy: Externalizing Transactional Class), she said, “I’m afraid when I think about doing that. I can go into the room where the jars are but opening them is another matter altogether. “For so long you have stored these jars and opening them and looking in is a terrifying thought right now, It may be today, may be next week, next month or next year but some day you’ll be ready to look” replied the therapist (Empathy: Relationship Enabling Transactional Class).  38 This led to an exploration of Sue’s fear of crying and her belief that she did not get anything accomplished that way. The therapist asked her where her tears lived and Sue pointed to “a third lung in the middle of her chest” (Enactment: Process Facilitation Transactional Class). The therapist remarked that Sue may be afraid she might drown with so many tears in the lung. (Framing: Process Facilitation). Sue nodded adding, “I guess the only way to save myself is to shed the tears. I never thought of it that way.” A session later, Sue was ready to go to the jar she most wanted to explore. The jar contained her father’s death. She pulled a symbol of him from the jar and stared at it (Externalization: Externalizing Transactional Class) and commented that what made her most sad was the fact that her father never got to see or play with his granddaughter. Tears trickled down her cheeks at this thought. She let out a tremendous sigh and smiled through her tears at the therapist. The therapist remarked how much courage Sue had to be able to look into this jar and that she was crying healing tears. Sue nodded and another tear fell onto her hand. The therapist remarked that it was almost as if her father was here now. Sue agreed and the therapist invited Sue to bring her father, in the spirit, into the room. The therapist asked Sue to place the symbol of her father in the therapy room in relation to how close she felt to her father (Externalization: Externalizing Transactional Class). She brought it close to her heart. Sue had told the therapist that she did not like to try to talk while she was crying because the “tears get in the way”. Rather than inviting Sue to talk directly to the symbol of her father (Externalization: Externalizing Transactional Class), the therapist suggested that she close her eyes and imagine him in her mind’s eye (Guided Fantasy: Expressive Transactional Class). The fantasy was about a playtime between Sue, her daughter and her father. The therapist  39 guided Sue through the fantasy and she silently and freely cried as she watched her daughter and father play together. Sue remarked that this was a precious fantasy for her since she could now visit her father whenever she wished and that she actually witnessed her daughter and her Grandad playing together. She got to say “Goodbye” to her Dad and she felt better than she ever had since his death many years ago. “I guess I never really gave myself a chance to grieve and now I’ve mourned a bit and feel better,” said Sue. The next sessions in Sue’s transformational journey included visiting her father in the therapy room and telling him how much she loved him and also how she felt abandoned by him. She also explored the jars of sadness that contained her aloneness, her marriage, her mentally abusive biological mother and her estranged husband. All these forms of sadness were externalized and discussions were held between Sue, her ex-husband and the mother who abandoned her. Phase 3  -  Integrating experiences of change.  The rigidity with which clients once viewed their worlds gives way to relational flexibility. Where once there was hopelessness, anger and hurt there now exists compassion, tolerance, acceptance and forgiveness. The therapist aids clients in generating novel experiences that validate their changes and simultaneously helps them to release, albeit sadly, old patterns of relating. Grieving lost ways of being is also important during this phase of the change story. This can be achieved through the creation of rituals or transformational markers designed to ensure that the changes made can be absorbed into the clients’ lives. Once again, the techniques used in this phase are found in the transactional classes and are triggered in response to the client’s needs.  40 The action of the story and the beginning of the end are written in the sessions or chapters that correspond to the two phases previously described. A climax has been reached. This may be embodied in a pivotal moment or it may be the result of an imperceptible twist in the usual course of events. The client and therapist have been party to a transformational journey which is both humbling and invigorating. During Phase Three, Sue was light and happy. She saw herself as a cookie and felt rich, sweet and complete. All the ingredients were present and nothing was missing (Metaphor: Expressive Transactional Class). She was feeling closer to her friends and less tense at work. The jars of sadness seemed like sad memories or facts rather than raw wounds. Sue was no longer overwhelmed by her sorrow and she began to deal with sad things in her daily life without the added weight of her past sorrows. She felt sad to leave the jars and wanted to refurnish the empty room soon. Sue was reluctant to leave therapy since she wanted to “make sure this is really happening.” She could barely believe that what had hurt for so long was no longer as painful. She wanted to ensure that her changes would be lasting. The therapist asked Sue how she would know if she could trust her changes? Sue answered that she had to test them by scanning the jars again and allowing herself to feel any of the feelings this elicited. Sue began the process of sorting the sadness into envelopes that were entitled “sad memories”. Those items that seemed to be bittersweet memories or thoughts were filed while those forms of sadness that were still painful were retained. Over the course of this sorting, Sue filed all her past sadness except for the ongoing divorce proceedings. As these sessions unfolded, the therapist spoke more frequently of the end of the therapy and Sue agreed that this appeared imminent. With that,  41 both the therapist and the client recognized that the time was right to begin the resolution of the story. Phase 4 Disbanding the therapeutic system: Termination and acknowledging accomplishments in therany. -  The clients and the therapist begin to experience their meetings as unnecessary during the last few sessions. The purpose of this phase of therapy is to dissolve the therapeutic system in order to bolster client independence. The clients review their journey together sharing pivotal moments and congratulating each other on their changes. A final closing ritual is performed, an evaluation of the process is undergone and therapy is concluded. This ceremony marks the end of therapy and the beginning of life without it. The door is always open and another therapeutic story may be told, but for now the therapy has ended and another journey begun. For example, Sue and her therapist designed a closing ritual (Ceremonial Transactional Class). Sue baked cookies (Baking: Expressive Transactional Class) symbolizing her completion and wrote down a list of the changes she made as well as her plans for refurnishing the room that the jars once dominated. The therapist brought a “Goodbye” card for Sue, gingerale for a toast and balloons for the therapy room. A summary and review of therapy was conducted and Sue told the therapist of her most memorable therapeutic moments. The last session was touching for both the therapist and the client. Sue left knowing that this therapeutic story had ended and that she could rely on her new found peace. The therapist felt privileged having partaken in Sue’s transformational journey. She marvelled at the happiness Sue’s story engendered in her as she closed the file.  42 In conclusion, this overview has endeavoured to describe the dimensions of the Experiential Systemic Therapy theory, the principles of its conduct, the phases of therapy and finally a brief description of the transactions undertaken by the members of the therapeutic system. In addition, the therapeutic journey has been illustrated through the use of a case example. The model is an integrative one which seeks to bridge individual and systemic paradigms as well as encourage therapist spontaneity over theoretical and practice dogma. The following section provides a detailed description of the concepts important to the ExST theory of change. These concepts were touched upon in the previous overview but are elaborated in the following section. Relational Novelty as a Means to Individual and Counle Chanoe The concepts integral to the ExST theory of change center on the utility of a relational paradigm to understand human experience and the importance of substantive relational themes and the intensification process in the creation of relational novelty (Newman, 1991). The following section will expand upon these notions. The therapeutic journey is a story of courage and transformation and this tale has been retold since millennium through human myth and literature. Myth represents a culture’s conceptualization of a Larger Truth and exists in relation to that society’s psyche, structure and mores (Lerner, 1986). The consistent theme found in Myths of Transformation can be best expressed metaphorically as Campbell (1988) wrote: At the bottom of the abyss comes the voice of salvation. The black moment is the moment when the real message of transformation is going to come. At the darkest moment comes the light. (p. 37)  43 The content of transformational stories stems from the diversity of situations in which couples and individuals find themselves. The content of the story is important and embedded in the culture and/or subculture to which clients belong. A couple’s visit to the campus marriage counsellor is different from a Native Canadian’s visit to a trusted Elder. However, while the narratives may be dissimilar these heroic journeys contain the common theme of transformation. This transformation can occur in the individual, the couple, the family and perhaps, in larger fields of socially constructed experience (Hoffman, 1990). The tale of the means to Experiential Systemic change exists within a current Western conceptualization of healing; notably an intimate relationship between clients and trained professional therapists. The means by which the intrapsychic and relational abyss is explored, the nature of the abyss, and the products of the darkest moment and the return to light will be discussed within the Experiential Systemic Therapy theory from intrapersonal, interpersonal and environmental viewpoints. In effect, this work represents an effort to combine individual and systems thinking in order to explain the means by which relational beings change. The Imnortance of a Relational Paradigm Sullivan (1953) maintained that interpersonal relationships represent a powerful human need and human life is characterized by continuous patterns of interpersonal interactions which occur over a life time. The infant’s relationship with a valued attachment figure is important to the formation of his or her mental models of self and others. These cognitive frames or representational models influence later adult intrapsychic and interpersonal functioning. Representational models of self and attachment figures integrated in the mind  44 during childhood, reflect the treatment children receive at the hands of their parents and the observations they make of the relationship between their caregivers (Bowlby, 1988). The experiences children have with their caregivers in the past and the present, form the basis of the representational models they use in adulthood. Adults who have matured in unfortunate circumstances, tend to have little faith that the person to whom they have attached is either available to them or trustworthy. Bowlby (1973) wrote: Thus, an unwanted child is likely not only to feel unwanted by his (sic) parents but to believe that he (sic) is essentially unwantable, namely unwanted by anyone. Conversely, a much-loved child may grow up to be not only confident of his (sic) parent’s affection but confident that everyone else will find him (sic) lovable too. (pp. 204-205) The stability of these relational patterns is not just a product of the child’s innate temperament. As children grow older they absorb daily interactions with their parents as part of their ontological realities or ways of being and these facilitate the generation of similar relational patterns between the children, their friends and other adults (Stroufe, 1985). In Bowlby’s (1988) work with clients it is apparent that he favours the shifting of working models of self through cognitive means. This is an outgrowth of his notion that working or representational models are internal blueprints of the world “out there”. However, the child’s experiences are of the child’s ontology and for this reason cognitive, emotional, behavioural and physiological aspects of human functioning are intertwined to offer us a view of the child’s patterned experience. In other words, there is a lack of separation between the child’s experience of the world and the world in which he or she lives. How the child relates in the world is how the world is to that child until new experiences alter this relationship. Thus, while the individual’s being in the world may have  45 thematic undercurrents of unlovableness, these themes are not prescriptive maps of the world. These themes are the observer’s description of themes underlying an individual’s being in the world based upon all four aspects of ongoing experience namely cognition, emotion, behaviour and physiology. Childhood and later-life experiences combine to influence the development of emotional, cognitive, behavioural and physiological relational patterns that have as an undercurrent themes such as lovableness, security or unlovableness and abandonment. ExST focuses on perturbing patterns of relationship between parts of self, self and important others and self and the larger socio-cultural context. Perturbing these intrapsychic, interpersonal and socio-cultural patterns entails the generation of new experiences in each of these domains such that novelty and change occur at the cognitive, emotional, behavioural and physiological levels of functioning. Human patterns of interaction are subject to the influence of life events (e.g., births and deaths, cultural events, societal forces, transitions and good fortune) and as such they are amenable to modification and change in therapy. Since relationally novel intrapsychic, interpersonal and environmental experiences can elicit change in these three systems, it is important to note that early and ongoing traumas do not guarantee unrelenting systemic distress in the future (e.g., West & Prinz, 1987). Ecosystemic Thought and the Process of RelationshiD Formation The experiences that result from the interactive process between the child and his or her caregivers are influential in the child’s way of being in the world. Childhood experiences of self and others play an important role in the construction of relationships in adulthood. These relationships include internal relations between aspects of self, relations with others and the environment  46 (e.g., work place, culture, community). The processes whereby we are both being and becoming are manifest intrapsychically and interpersonally and as such the work of individual, couple and family theorists (Bateson, 1972; Bogdan, 1984; Carson, 1982; Kiesler, 1982) combine to explain both one’s relationship to different aspects of self and one’s relationship to others and the larger context. Maturana (1978) maintained that the conduct of two or more interactive systems, over time, establishes the individuals in some form of being-in-theworld as well as creating an interlocking mutuality termed the “consensual domain”. He uses the concept of “structural coupling” to describe how two or more subsystems “negotiate” their existence. Maturana (1978) notes that “changes of state of one system become the perturbations for the other [system] and vice versa in a manner that establishes an interlocked, mutually selecting, mutually triggering domain of state trajectories” (p. 36). Maturana (1978) is referring to interpersonal relationships in his work. However, these notions may be applied to intrapersonal functioning as well as interpersonal relations. If one substitutes the words “aspect of self” for “system” in the quote above, it becomes theoretically possible that the process of structural coupling could occur at both the interpersonal and the intrapsychic levels. The myriad of internalized aspects of self garnered from and evident during interpersonal interactions relate within the individual through the process of structural coupling. As human beings we are inseparable from our environment. We rely on the earth and the air we breath to sustain us. According to Sullivan (1944) we experience a similar need for protection and affiliation. He likens our cultural environments to oxygen and food and maintains that our society is necessary to us as are food, air and water. If Sullivan (1944) and Maturana (1978) are  47 correct then it may be conceivable that the same patterns of relationship that characterize our interpersonal and cultural existences may also characterize our intrapsychic existence. The similarity between intrapsychic and interpersonal functioning has important ramifications for the systemic treatment of both individuals and couples in therapy. In the case of the systemic treatment of individuals, we can broaden our notions of what constitutes a system to include not only who and what exists in the clients’ outer worlds (e.g., presenting problems, Racist Attitudes, Homophobia, Bottles of Beer, Cancerous Cheese, family members, spouses, workmates, neighbours, etc.) but “who” and “what” exists in their inner worlds (e.g., different aspects of self including unloved aspects, pained aspects, hopeful aspects, presenting problems, fear of gays, jars of sadness, little boys and little girls and nests of terror protected by little birds). These inner and outer worlds are intimately connected and are often indiscernible from one another. It is for purposes of explanation that these somewhat artificial boundaries are made by clients, therapists and society. However, these distinctions can be exceptionally useful in therapy as representations of the whole. The use of metaphor and symbol in ExST (Bateson, 1979; Friesen et al., 1991) provides a kind of shorthand that encapsulates both the individual and couple’s issues and offers a means by which changes in intrapsychic and interpersonal patterns may be perturbed. Thus, changes in one part of the intrapsychic, interpersonal and/or environmental system have an influence at each level and may serve to perturb new patterns of interaction or relational novelty in the system as a whole.  48 Recursive patterns of relating. Past painful attachments (Black, 1979; Herman, 1981); present difficulties with intimacy (e.g., Carey, 1986); life transitions (e.g., Finkelstein, 1988) and the anticipation of continued alienation (Carson, 1982) combine to create years of patterned isolation from self and others. Consistently rigid and sequential patterns of relationship between aspects of self and others are observable phenomena (Breunlin & Schwartz, 1986) that occur within the therapeutic context. ExST therapists are interested in identifying the recursive relational patterns and substantive relational themes underlying their clients’ problems. ExST draws upon the notion of informational recursivity (Cottone & Greenwell, 1992) to describe interaction patterns in which individuals can be held accountable for their actions. Informational recursivity refers to a cause and effect chain such that behaviour of one spouse serves as information to influence the behaviour of the other in a temporal sequence. Taken in the context of violence being the responsibility of the perpetrator, informational recursivity allows for the description of abusive sequences of behaviour without blaming the battered woman or excusing the abusive man. For example, Joe and Sue decided to obtain couple’s therapy in order to improve their marriage. This case example is a composite of several cases of couple’s therapy and identifying details of the “case” are omitted or changed to protect confidentiality. Joe completed an intensive residential treatment program for alcoholism one year ago. The couple hoped that Joe’s sobriety would be the answer to their marital problems. Unfortunately, certain patterns of interaction which characterized the marriage while Joe drank continued to be problematic after he was sober. Previously, a cycle of binge drinking followed by verbal and physical abuse ended in a honeymoon period of guilty  49 attentiveness on the part of Joe. This phase was later followed by more binge drinking and abuse. The same pattern continued after Joe’s sobriety except that alcoholic drinking was no longer involved in the cycle. Following a year of sobriety, the couple’s fights continued to be marked by Joe attacking Sue verbally and physically while she defended herself and retaliated by verbally abusing Joe and throwing things at him. Afterwards, Sue went to a Women’s Shelter or a friend’s house and Joe courted her with remorse and attentiveness until she returned home a few days later. After returning home, Sue remained distrustful of the “new and improved Joe” and kept him at arms length. The uneasy truce would end several months later when fighting escalated and Joe became abusive again. Although Joe obtained residential treatment and was able to maintain his sobriety through AA, the pattern of abuse remained and both partners were doubtful that their marriage could be salvaged. Sue saw marital therapy as a last resort before divorce. This repetitive pattern of violence can be understood at three interconnected levels of the system: the environmental, the interpersonal and the intrapsychic levels. At the environmental level, the struggle between Joe and Sue has socio-cultural significance. That is, certain socio-cultural messages impinged upon both Joe and Sue promoting a rigid understanding of appropriate male/female behaviour. For example, societally based warnings to refrain from vulnerable self disclosure, keep control and “got it alone” may have affected Joe’s ability to maintain an intimate relationship (Miedzian, 1991). In addition, socio-cultural messages regarding Sue’s responsibility in the relationship for caregiving and loyalty may affect her ability to experience personal agency (Lawler, 1990). In this way, both spouses found their roles and ways of being together increasingly detrimental.  50 Interpersonally, both Joe and Sue noticed how incredibly angry they were with one another. They experienced little trust and anticipated the worst in the relationship. Sue experienced herself as constantly fearful around Joe and Joe experienced something akin to walking on eggshells around Sue. Neither spouse felt loved or supported by the other. They reported that these feelings of fear, anger, distrust and hurt exploded into physical and emotional abuse. Joe broke Sue’s nose on one occasion and she told the emergency doctor that she fell down the stairs. On another occasion, while escaping, Sue pushed Joe down the stairs and threw a plate at him. Both spouses claimed that although the physical damage had healed, the emotional scars remained. Intrapsychically, both Joe and Sue experienced self invalidation of unloved and pained aspects of self (Miedzian, 1991). Neither spouse experienced him or herself as lovable or deserving of love or care. Their experiences of one another and their families of origin maintained and sustained this relationship to these unloved and undeserving aspects of self. Patterns of relating with self, others and the environment are interconnected. Cultural prescriptions for rigid gender roles combine to ensure that interpersonally abusive interactions are reflected intrapsychically as invalidated aspects of self. The invalidation of suffering aspects of self constitutes a form of intrapsychic violence and in this way abusive interactions are found at each level of the system in the form of cultural, interpersonal and intrapsychic violence. Substantive relational themes. Client stories of emotional, cognitive, physiological and behavioural patterns provide cues about the underlying substantive relational themes (Friesen et al., 1991). The notion of substantive relational themes is used to  51 describe the underlying essence of the clients’ stories. Substantive relational themes are descriptive rather than prescriptive since they describe the child’s and the adult’s experience of being in the world. Clients’ recursive patterns of emotion, cognition, and behaviour embody relational themes such as unlovableness, abandonment, unworthiness, undeservedness and rejection. Substantive relational themes underlie the client’s intrapsychic, interpersonal and environmental experiences in the world. The themes of unlovableness and abandonment, for example, may be similar to a stream running through the client’s experience at each level of the system. Appendices A, B and C depict how the interconnected recursive patterns of relating, described earlier, manifest themselves at each level of the system. The three systems depicted in Appendices A, B and C have been divided for the purposes of detailed explanation. Appendix D depicts a composite view of the three recursive patterns and their underlying substantive relational themes. These patterns and their underlying relational themes are maintained via structural coupling (Maturana, 1978) and socially constructed experience (Gergen, 1985; Hoffman, 1990) such that once a pattern has been set in place it is sustained until a new experience perturbs it. These new experiences are termed relational novelty and they constitute change in therapy. Relational Novelty Relational novelty refers to the enactment of a new way of being in relationship which alters the thematic undercurrent represented in the substantive relational theme. It is within the intrapsychic, interpersonal and environmental domains that relational patterns are enacted and relational novelty occurs. This section provides a description of the intrapsychic,  52 interpersonal and environmental systems and how relational novelty is introduced into each of them through therapy. Presenting problems. Clients have a special relationship with the dilemmas they bring to therapy. One of the tasks of the Experiential Systemic therapist is to help clients bring this relationship into awareness through therapeutic experiencing. How the clients “are” with their dilemma is also reflected in how they “are” with themselves, each other and the world in which they live. For example, Sue and Joe entered therapy in order to end the physical and emotional violence that continued to occur despite Joe’s sobriety. Relational novelty in therapy can occur most effectively in a safe context and this is of paramount importance when physical and/or verbal abuse is part of the couple’s pattern of interaction. In the case of verbal and/or physical abuse, the safe context is created and maintained when the couple continue both individually and collectively to reiterate their explicit commitment to end the violence in their relationship. The establishment of this goal occurs at the outset of therapy and is explicitly agreed to by both spouses before therapy progresses. A frank, open atmosphere facilitates the discussion of this topic from the outset. In addition, a safety plan is created between the couple that may include leaving the house and walking before a fight escalates into violence, phoning the police, visiting a shelter, phoning a supportive friend or taking time-outs with relatives. This plan is developed collaboratively between the therapist and the clients. The therapist must remain sensitive and ready to bring concerns regarding client safety before, during and after sessions to the fore. ExST makes the explicit assumption that physical and verbal violence is under the control of the perpetrator and is therefore a matter of choice. Because violence  53 is controllable and a matter of choice it can end and be replaced by constructive ways of being. Violence and the threat of violence divided the couple from one another and made intimacy impossible. The therapist explored the violence by asking each for a description of the abuse they endured and the violent acts they committed. Joe said that when he broke Sue’s nose and called her a “whore”, he felt like a pressure cooker exploding. He said when Sue called him “dickless” or threw things at him, he felt like a “Little Joe” who was two feet tall. Sue said when Joe punched her, she felt like a rag doll and when she swore and threw things at him, she felt like a frightened avenger. At this juncture, the couple may be requested to bring symbols into therapy that represent these aspects of the violence. Joe’s pressure cooker and representation of himself as two feet tall and Sue’s rag doll and frightened avenger metaphors can be brought to life in therapy. The therapist can explore each symbol and track the patterns that occur with respect to them. The intensified experience of relating to concrete symbols such as bottles of beer, pressure cookers and ragdolls is relationally novel in that the dilemma presented is framed as something that divides the couple and is therefore amenable to change. The couple is invited to band together to explore and change their relationship to violence and remove it from their partnership. Fully experiencing their respective relationships to violence at the physiological, emotional, behavioural and cognitive levels also enables the couple to gain an expanded understanding of the problem and each other. For example, Joe’s pressure cooker has a distinct relationship to Sue’s ragdoll and her frightened avenger while Sue’s frightened avenger has a particular relationship to Joe’s pressure cooker and Little Joe. Similarly, Little Joe has an important relationship with the pressure cooker while the frightened avenger has a potent  54 relationship with the ragdoll. These relationships can be intensified in therapy and this exploration is extremely important in the creation of an atmosphere of experimentation and collaboration. In sum, relational novelty occurs with respect to the presenting problem when, through experiencing their relationship to the dilemma, the clients engage the problem rather than minimizing it; explore their own and their partner’s pain and experience the deleterious effects of violence on their relationship in a safe therapeutic context. Intrapsychic system. This system refers to how aspects of self (e.g., unloved) and the individual interrelate with other aspects of self (e.g., sad). Clients often have a particular relationship with aspects of themselves which are manifest in the presenting problem, interpersonal and environmental domains. Relational novelty occurs at the intrapsychic level when the client experiences abandoned or unloved aspects of self while simultaneously experiencing new loving and committed aspects of self in therapy. In addition, the act of entering into a “dialogue” with previously avoided or little understood aspects of self constitutes a relationally novel experience. The bringing of substantive relational themes into individual awareness through therapeutic experiencing is in and of itself novel since many clients tend to stave off deep pain in an effort to cope with it and survive. The body and mind are capable of putting the experience and themes underlying trauma on hold just as severe wounds may be anesthetized with ether. Threats of punishment or death (Bowlby, 1988); the phenomenon of splitting (Masterson, 1981); loyalty and shame can create a situation wherein traumatic occurrences remain out of client awareness for long periods of time. Traumatic experiences  55 such as physical, sexual, and psychological abuse, neglect, parental death and loss embody substantive relational themes which may be out of client awareness but are reflected in their pained ways of being in the world and with themselves. Through the story of Joe and Sue’s struggle, we may observe how hurt, unloved and frightened aspects of self are invalidated by guilty and/or self blaming aspects of self. Powerless and helpless parts of self further invalidate these pained aspects and anger, self hatred and hopelessness result (see Appendix A). The process of experiencing and intensifying these powerless and helpless parts of self is a relationally novel experience for the couple since each individual gives her or his pain a forum. Hurt, powerless, guilty and/or self blaming aspects of self are transformed into loving, compassionate and hopeful aspects of self as therapy progresses. For example, in a sculpt of their relationship as it appeared in the present, both spouses depicted themselves as reaching out while keeping their guards up. Joe placed himself sideways with one arm extended to Sue whom he saw as turning away from him. Sue saw herself as reaching out with her right arm while holding the left one in a stop sign position. She positioned Joe to face her but had him look off to the side with his arms across his chest. When asked to speak through her extended stop sign hand, Sue said she felt distrustful of Joe, helpless in the marriage and that she blamed herself for the problems they shared. When the reaching hand was given a voice, Sue cried saying she wanted Joe to love her but she wondered if he ever would and if she really deserved love at all. Joe stood sideways to Sue and from this position he experienced extreme frustrations guilt and powerlessness. With his extended arm, Joe experienced frightening vulnerability and a sense of being unloved and unworthy of love from Sue and others.  56 The clients were able to experience their mutual themes of unlovableness and abandonment together. The experiencing and sharing of the substantive relational themes that underlay attacking, defending, withdrawing and retaliatory interactions was a novel experience for the clients who until this point had characterized each other as spiteful, frightening, deceitful and manipulative. This intimate exchange marked a shift in the clients usual pattern of interaction and represents how the intrapsychic system of functioning is closely connected to the interpersonal system of functioning. Internersonal system. The client’s relationship to important others can take the form of aspects of self relating with aspects of the other as presented in the previous sculpting example. Relations between individuals, family members and the therapist constitute interpersonal interactions during which presenting problems, intrapsychic aspects of self and environmental influences overlap. Relational novelty occurs when spouses, through the process of intensification, experience commonalties in their substantive relational themes and engage in a different way of being with one another. The experience of being vulnerable with one another in a safe context represents a departure from a formerly abusive cycle. Rigid symmetrically escalating battles or caregiver/caretaker complementary relationships can be transformed into flexible parallel unions (Lederer and Jackson, 1968) characterized by the latitude to engage in either symmetrical or complementary interactions dependent upon the couple’s circumstances and desires. For example, Sue and Joe’s experience in therapy of being vulnerable and unloved while being affirmed by one another constituted a relationally novel experience in both the intra and interpersonal domains. Intrapersonally,  57 both Sue and Joe related more lovingly to hurt aspects of self while interpersonally they experienced confirmation of their worthiness and lovableness from a validating other. This more compassionate, commonality seeking experience was radically different from the couple’s usual experience of one another. Environmental system. The role of environmental influences is worthy of consideration whenever we seek to explore human dilemmas. The relationship between aspects of self, one’s interpersonal and familial relationships and the larger socio-cultural context is of great importance if we are to understand how it is that substantive relational themes come to be observed and how human beings shape and are shaped by the world in which they live. The existence of sexist, racist (Ng, 1982), classist and homophobic (Pharr, 1988) events and relationships come into play at this level. Clients are often involved as victims, perpetrators, interveners or bystanders in sexist, racist, classist or homophobic socio-cultural acts. Joe’s father was alcoholic. In drunken rages he beat his children and their mother. Joe remembered being very angry at his father and betrayed by his mother when she would not leave the marriage. He described himself, his brother and his mother as “sitting ducks.” Sue’s mother was a binge drinker who left Sue and her brother with a girlfriend for days while she “partied.” Sue’s father left the family when she was two and was never seen again. Social services was aware of the difficulties in both families and alternately suggested visiting child care workers, parenting programs, drug and alcohol counselling and threatened to apprehend the children.  58 The themes of unlovableness and abandonment can be observed in both these family stories. But where do we look for answers or ways to understand this kind of pain? We may move quickly to blame Joe’s mother for not protecting her children or herself from her husband or we may blame Sue’s mother for abandoning her children. Or we may view the Social Services lack of success with the families and reluctance to apprehend the children as child abuse. We may wish to view Joe’s father and Sue’s mother as abusive offenders or as individuals badly in need of treatment. We may choose not to wonder about Sue’s father at all or we may ask about his responsibility to the family. Each of these questions arise out of the larger socio-cultural domain. The socio-cultural context contributes to how these events are interpreted, construed and finally imbued with meaning by those involved and by society at large. One socio-cultural lens through which to view the plight of Joe and Sue and their families of origin is that of gender socialization, It has been hypothesized that violence towards women and children has been made increasingly possible by outmoded and rigid views of appropriate male and female behaviour (Barry, 1979; Brownmiller, 1975; Lerner, 1986; Luxton, 1982; Martin, 1983). The difficulties Joe and Sue encounter reflect this pertinent concern. If Joe has adopted the socio-cultural message that “men shouldn’t need anyone,” this would have profound effects on Joe’s ability to be in an intimate relationship which necessitates both care-giving and care receiving behaviour. The message that a committed focus on being in an intimate relationship is a sign of “dependency and symbiosis” reflects a similar cultural bias against the value of relatedness (Lawler, 1990) and has ramifications for Sue’s ability to give and receive care. It is in the realm of relatedness that we can gain both competence in caring for others and a  59 healthy sense of self (Lawler, 1990) and it is also in this realm that people experience both trauma and healing. Perhaps the means to our physical survival and our psychological health is the acceptance of our interdependence and the development of ways to facilitate relational healing. Relational novelty in cultural terms would provide for the experiencing of new possibilities of feeling, thought and action and open the way for people to continue finding new solutions to their problems (Friesen, et al., 1991). These solutions may involve the jettisoning of rigid socio-cultural role expectations in favour of more flexible ways of relating. The experiencing of new ways of being as a culture will involve the interconnection of the three levels of the human system namely the intrapersonal, interpersonal and environmental domains. The process of intensification. An important means by which clients therapeutically experience their relationships with the presenting problem, different aspects of self and others; the therapist; and the environment is through intensification, Intensification is the process with which the therapist aids clients in evoking, enhancing and deepening their substantive relational themes and introducing relational novelty into the system. This method of amplification of experience is similar to focussing (Gendlin, 1978; Mathieu-Coughlan & Klein, 1984) or intensifying (Greenberg & Safran, 1987). Through experiential and symbolic means therapists tap the four aspects of human functioning (behaviour, cognition, emotion and physiology) and intensify the client’s experience. Therapists use expressive means such as art, storytelling, sculpting, enactment and guided fantasy to heighten client themes (Friesen et al., 1991). Therapists also employ symbolic externalizing transactions (Friesen et al.) to bring symptoms, aspects of self, and dreams to life. In addition, meaning shift transactions  60 (Friesen et al.) are utilized to expand clients’ alternatives through reframing, questions and positive connotation. Finally, ceremonial transactions (Friesen et al.) are created to mark client and therapist changes through celebration and ritual. The experiential techniques used to intensify experience are drawn and modified from Symbolic-Experiential Family Therapy (Whitaker & Keith, 1981); Gestalt Therapy (Pens, 1973); Psychodrama (Fine, 1979); Family of Origin work (Bowen, 1978) and Structural Strategic Therapy (Andolfi, Angelo, Menghi and Nicolo-Lorigliano, 1983; Madanes, 1981) The therapist’s collaborative (Friesen et al., 1991) or relational participant stance (Chrzanowski, 1982) is essential to the process of client experiencing. Therapists must be experientially involved with their clients in order to be adequate guides to the experiencing process. A more removed therapeutic stance decreases the potential intensity inherent in therapeutic experiencing and is based on the traditional assumption that it is possible for the therapist to be solely an observer of the system (Sluzki, 1985; Varela, 1989). Transformational experiencing in therapy is an wholistic here-and-now encounter with ones own ontological reality and substantive relational themes. In conclusion, client’s stories of transformation are heroic tales that require “the courage to face the trials and to bring a whole new body of possibilities into the field of interpreted experience” (Campbell, 1988, p. 41). Relational novelty is the creation of these new alternatives and the simultaneous experiencing of them. Underlying these novel experiences are changed substantive relational themes that describe compassionate interactions with self, others and the world. Themes of relationship such as hope, forgiveness, caring and acceptance describe transformed ways of being for individuals and couples whose prior experience has reflected pained ways of being in the world.  61 ExST is based on notions found in Attachment Theory (Bowlby, 1988), Interpersonal Theory (Sullivan, 1953), Ecosystemic Thought (Auerswald, 1985), Client-Centered theory (Rogers, 1961), and Experiential and Structural Strategic family and individual therapy and as such embodies a relational paradigm. This system of thought recognizes that as humans we cannot not be attached. The process of individuation is achieved in relation to other people, parts of self and the environment just as necessities of affiliation are contextually and relationally based. Culturally, this notion defies the ideal of “personal individuality” (Sullivan, 1944) and maintains that this is an impossible state while arguing for individual commitment to the collective discourse. It also includes the collective valuing of the individual’s contribution while understanding the inseparable nature of our existence together. This understanding, when pared down, centers on what occurs “between” entities. The realm of relatedness exists between Me, Myself and I; I and Thou; Us and Them; and Me and It and ultimately, it is in relationship that we experience both the profane and the sacred (Berenson, 1990). Experiential Systemic Therapy Empirical Status This section will describe a recent outcome study testing the efficacy of ExST (Grigg, 1994). The goal of describing this outcome investigation is to detail the research context and rationale for the present process study of ExST change theory. Grigg (1994) conducted a differential treatment outcome study comparing ExST to a behavioural monitoring treatment called Supported Feedback Therapy (SFT). In addition, he compared ExST for the individual treatment of alcohol dependency to experiential systemic marital therapy for the same problem. One hundred and fourteen families were randomly assigned  62 to one of three treatment conditions including either ExST individual treatment focussed on the alcoholic drinker or ExST couple treatment focussed on the alcoholic and his spouse or SET. SFT was provided for the individual alcoholic only. The participating families met the inclusion criteria requiring a maritally distressed alcohol dependent father and a non-alcohol abusing mother residing together with at least one child living at home. Pretest, posttest and three month follow-up data were collected using questionnaires tapping alcohol use, intrapersonal well-being, couple satisfaction and adjustment and family satisfaction. Therapy was conducted at two out-patient clinics in a rural and urban setting respectively. Participants engaged in up to 15 sessions of therapy conducted over a 20 week period. While 114 families were screened into the study, 60 families completed therapy and all the questionnaires at each measurement occasion as required by the data analysis. A multivariate analysis of the data indicated no significant differences between ExST and SET, however both treatments were shown to have fostered highly significant and clinically relevant improvements on indices of drinking behaviour, intrapersonal symptomatology, marital adjustment and family satisfaction. There were no significant differences between ExST couples treatment and ExST individual treatment but both spouses reported highly significant post-treatment changes which were sustained at follow-up. The clinical relevancy of these findings centered on the important client changes reported in this study. For example, as a group, the alcoholics scored in the high end of the moderate alcohol dependency range and were found to score in the psychiatrically symptomatic range at pretest. In addition, the alcoholics reported marital distress and low family satisfaction at pretest. However, these men reported mild alcohol dependency, psychiatric  63 symptomatology in the normal range, non-distressed marital adjustment and normal levels of family satisfaction at posttest. Secondly, similar to the men, the non-alcoholic women experienced psychiatric symptomatology in the normal range, reduced marital distress and normal levels of family satisfaction at posttest. The study was limited by the unavailability of a wait-list control group. A wait-list control group was not included by Grigg (1994) for ethical reasons since participants may have been required to wait 20 weeks before beginning therapy. In addition, clients who received SFT were not required to complete follow-up questionnaires therefore no data exists regarding the enduring quality of SFT changes. Nevertheless, this outcome study indicated that ExST is an effective therapy for both the individual and couple treatment of alcohol dependency. The large sample size, varied clinical settings, and the ecological assessment package employing a variety of standardized instruments made this study unique. In addition, the multivariate approach to data analysis and the care taken to monitor the delivery of the therapy rendered this study a significant contribution to the field of marital and family therapy for substance abuse problems. The empirically demonstrated effectiveness of ExST is important to this study since a question could arise concerning the utility of delving into a single case of either an untested therapy or an ineffective one. Since ExST is effective, with a large representative sample, exploration of a single successful case to understand how change occurred is both clinically and theoretically useful. In the past, marital and family therapy outcome studies have been critiqued for failing to provide information regarding how the therapy studied was effective (Pinsof, 1981; Safran et al., 1988). While this study is not  64 designed to account for the creation of successful change in a large sample of ExST cases (large “0” outcome), a single case study of in-session or proximal change can shed light upon the change process as it occurs in xST. A review of previous marital and family therapy process studies centering on therapy models including ExST will be undertaken in the next section. This literature review will survey previous therapy process research results to examine the findings for their utility with respect to theory building and the expansion of knowledge regarding the therapy theory under investigation. Also, this examination will be employed to inform the conduct of this therapy process study.  Marital and Family Therapy Process Research The study of therapy-in-progress has been made possible with the advent of audio and video recordings of therapy practice. The examination of therapyas-it-occurs provides for an enhanced understanding of therapy process and therapy change. The probing of audio and videotapes of therapy has been traditionally achieved through the use of coding systems that quantify aspects of therapy process. More recently, efforts to explore therapy-as-it-occurs have included the hermeneutical analysis of therapeutic discourse on an utteranceby-utterance basis providing a qualitative examination of therapy process and therapy change. The following sections will offer a review of both quantitative and qualitative research efforts designed to explore therapy-as-it-occurs for the purpose of increasing knowledge concerning marital and family therapy process and change. This section will review the marital and family therapy process literature based on various therapy models including ExST to situate this study in the marital and family therapy process literature.  65 Quantitative Marital and Family Therapy Process Research The following review will survey studies examining marital and family therapy process using quantitative methods that inspect videotaped or audiotaped segments of therapy process. Zuk, Boszormenyi-Nagy and Heiman (1963) studied the effect of time (session quarter) and person (who speaks) on the frequency of laughter in a family with a schizophrenic daughter. The investigators believed that laughter was the family’s means of disguising anxiety and was both a function of intrapersonal and situational factors. Zuk et al. relied upon a laughter frequency count based on the last 13 sessions of family psychotherapy. The researchers coded and summarized client laughter across sessions. The laughter measure reflected which family member laughed, at which point in the session they laughed and whose comment triggered the laughter. Zuk et al. demonstrated that mother and father laughed most during the first 15 minutes of therapy and their daughter laughed most 30-45 minutes into the session. The investigators concluded that the schizophrenic’s anxiety increased as the session intensified. Unfortunately, the study did not tap client anxiety. Also, the use of a frequency count precluded an understanding of what kinds of statements precipitated the laughter and how the laughter was associated with client affect. This early quantitative family therapy study targeted general process and did not relate therapy process to client change. In addition, the model of treatment used in the study was not clearly articulated and the therapist’s contribution to the family dynamics was not addressed. Winer (1971) improved upon Zuk et al.’s (1963) study by attempting to investigate client change as it occurred in couples group therapy. Four couples were engaged in therapy with therapist/theoretician Murray Bowen although not every spouse attended every session. Winer was interested in verbal  66 markers of couple change captured on audio recordings of live sessions covering a 3.5 year span. In particular, she was concerned with indicators of change with respect to increased statements of self-differentiation on the part of clients. The construct, self-differentiation, refers to the ability to speak for oneself, the ability to refrain from engaging in blaming behaviour as well as being goal directed and desirous of self change rather than change in others. Self-differentiation is an important construct and change marker in Bowenian therapy. Winer (1971) hypothesized that as clients became more differentiated, the number of “we”, “our” and “us” statements would decrease. Winer developed a Change Ratio to quantify “differentiated” and “nondifferentiated” client statements. The Change Ratio was a qualified pronoun count based on the number of “I” statements made by each client divided by the number of “we”, “our” and “us” statements. The higher an individual’s Change Ratio, the greater the degree of differentiation of self. The pronoun count change index was meant to reflect decreased symbiotic involvement between couples. Winer compared two early sessions in which all couples were present to a session closer to the end of the course of therapy. The study findings indicated that six out of eight clients used fewer “I” statements than the sum of “we”, “our” and “us” statements in early sessions. In addition, all eight clients used more “I” statements than the sum of “we”, “our” and “us” statements in later sessions. Unfortunately, Winer’s study was limited by the utilization of poor selection criteria for coded sessions; a lack of formal analysis of the data generated and an informal after-the-fact analysis of couple scores. Winer was concerned mainly with whether or not clients changed with regards to self differentiation as opposed to how spouses came to use more “I” statements as  67 a result of therapy. Also, the therapist’s role in the client’s shift towards selfdifferentiation was unclear. In a similar vein, Postner, Guttman, Sigal, Epstein, and Rakoff (1971) coded familial affective expression and the quality and quantity of both family and therapist participation and related these variables to final therapy outcome. Postner et al. studied family therapy with adolescents who were brought to therapy for a variety of issues including discipline problems, poor school attendance, attempted suicide and perversions. Eleven families participated in the study receiving a treatment designed to bring reward and punishment patterns to the family’s attention, interpret family transactions and explore motivation and transference phenomena as it related to family dynamics. Postner et al. sampled 20 minute sections of audiotaped therapy at six week intervals obtaining a total of 49, 20 minute transcripts for the 11 participating families. Four coders recorded therapist behaviours and family affective expression. The therapist behaviour measuring tool coded therapist “Drive” (e.g., stimulating family interaction, requesting information, giving support) and therapist “Interpretation” (e.g., making process comments and identifying the underlying meaning of family dynamics). The family measure recorded negative or Emergency emotions (e.g., anger and sadness), positive or Welfare emotions (e.g., happiness and joy) and Neutral emotions including information giving. The families were divided into two groups, those who experienced a good outcome and those who displayed a poor outcome as measured in an interview and on a self report questionnaire. Although there were no significant differences between the families with respect to affective expression and therapy outcome, the study demonstrated that, regardless of outcome, clients spoke more to family members than they did to the therapist as therapy progressed. The investigators also observed that the expression of pleasant or  68 Welfare emotions increased over time in therapy. Postner et al. accounted for an inability to demonstrate a relationship between family emotion and therapy outcome by noting that the session sampling method employed reduced the opportunity for tapping subtle family changes. This investigation mapped certain shifts in therapist and client speech over the course of therapy but was not intended to explore how these shifts were fostered by the treatment. However, Postner et al. focussed on both the therapists and the families verbalizations in their study which differed from earlier efforts. Dechenne (1973) also focussed on couples and therapists in a study of how spouses differed in their levels of experiencing when speaking to one another and the therapist. Dechenne pioneered the marital therapy application of a sophisticated verbal process measuring instrument called The Experiencing Scale (see Klein, Mathieu-Coughlan, & Keisler, 1986 for a recent version). The scale is noted for its design and predictive and discriminant validity (Pinsof, 1988). Ten couples were included in the study in which one hour of therapy was audiotaped and coded. Unfortunately, the couple’s presenting problems and which session was coded was not revealed. The nine therapists who participated in the study were said to have been eclectic but all engaged in the facilitation of deepened client experiencing. Dechenne found that spouses were more likely to engage in deep experiencing behaviour in response to therapists than in response to one another. He observed that when the therapist spoke to a client, the client responded more expressively than when spoken to by a spouse. Dechenne concluded that marital relationships in which deep experiencing occurred were more constructive and less structure bound than relationships in which deep experiencing did not occur. Although the relationship between deep experiencing and subsequent couple change was not  69 addressed in this study, the notion that deep experiencing was related to increased marital health was interesting from a theoretical viewpoint. To increase the clinical relevancy of therapy process research, some investigators turned their attention to the study of important clinical phenomena. Patterson and Forgatch (1985) conducted two studies examining therapist impact on client resistance. In the first study, they explored six mother-therapist dyads to observe the potential impact of therapist activities on the mother’s behaviour. Other