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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 OFEXPERIENTIAL SYSTEMIC COUPLES THERAPYbyJENNIFER ANNE NEWMANB.A., Carleton University, 1983Diploma in Guidance Studies,The University of British Columbia, 1986M.A., The University of British Columbia, 1989A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFDOCTOR. OF PHILOSOPHYinTHE FACULTY OF GRADUATE STUDIES(Department of Counselling Psychology)We accept this dissertation as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAJune, 1995© JENNIFER ANNE NEWMAN, 1995In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of Bntish Columbia, I agree that the Library shall make itfreely available for reference and study. 1 further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.Department ofThe University of British ColumbiaVancouver, CanadaDate 9L4JDE-6 (2/88)ABSTRACTThis study investigated how a therapist and clients created couplechange over the course of 15 sessions of Experiential Systemic Therapy (ExST)for the marital treatment of alcohol dependency. The aim of this research wasto explore how change occurred during a single case of successful ExST and torefine and expand ExST theory. ExST has been shown to be an effectivetreatment for couple recovery from alcohol dependence yet little research hasfocused on how change occurs in ExST.The case selected for analysis was an exemplar of successful ExSTcouples therapy. The case met several criteria for success including therapistand client satisfaction with therapy, the cessation of alcoholic drinking,increased marital satisfaction at posttest and follow-up periods, and evidenceof in-session couple change. Two therapy episodes containing relationalnovelty (couple change) were analyzed using the Comprehensive DiscourseAnalysis procedure.The results of this study highlighted the existence of a subtype ofrelational novelty called syncretic relational novelty. Syncretic change refers tothe generation of intimacy by therapist and couple where initially there existeddisparate beliefs and behaviour that isolated system members.The study found that the couple’s distance oriented beliefs and practiceswere reconciled and intimacy was enhanced through the employment ofintense experiential activities and the provision of a collaborative therapeuticatmosphere. These two activities fostered increased couple intimacy byencouraging 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 carefullyIIIpaced intensification of clients’ thoughts, feelings and physical sensations. Inaddition, intimacy was facilitated by the therapist when she accepted clients’experiences and adopted clients’ language styles. As well as workingcollaboratively, the therapist acted as a therapeutic guide interceding duringharmful 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 andexpansion of ExST theory.ivTABLE OF CONTENTSABSTRACT.iiTABLE OF CONTENTS ivLIST OF APPENDICES viiLIST OF FIGURES vHiACKNOWLEDGEMENT ixCHAPTER I. PURPOSE OF THE STUDY 1Research Aim 3Research Question 3Significance of the Study 3Summary of the Method 6Definition of Terms 9Relationally Novel Episodes 10Substantive Relational Themes 10Intensifying and Deepening Experience 10Therapeutic System: Therapist and Client Members 11Alcohol Dependence 11Distressed Couple Functioning 13Successful Treatment 13Experiential Systemic Therapy 14Intrapersonal Level of the Therapeutic System 14Interpersonal Level of the Therapeutic System 15Symptomatic Level of the Therapeutic System 15Collaboration in Therapy 15Therapy Discourse 16Organization of the Chapters 16VCHAPTER II. SURVEY OF THE LITERATURE 18Experiential Systemic Therapy 18History of Experiential Systemic Therapy 18Overview of Experiential Systemic Therapy Theory 20Relational Novelty as a Means to Individual andCouple Change 42Experiential Systemic Therapy Empirical Status 61Marital and Family Therapy Process Research 64Quantitative Marital and Family Therapy Process Research 65Qualitative Marital and Family Therapy Process Research 74Summary of the Literature Review 89CHAPTER III. METHODOLOGY 95DesignInvestigative Procedure 95Identification and Description of aSuccessful ExST Case of Couples Therapy 96Critical Case Selection Criteria 96Instruments 98Case Description 105Identification and Description of RelationallyNovel Episodes 112lnterjudge Agreement 113Synopsis of Episode #1, Session #2 115Synopsis of Episode #2, Session #10 116Videotape and Audiotape Production 117Data Analysis 118Cross Sectional Analysis 120CHAPTER IV. RESULTS 128Results of the Comprehensive Discourse Analysis ofEpisode #1 and Episode #2 128The Syncretic Change Process 129viInitial Disagreement and Conflicting Beliefand Practice 130Therapeutic System contributions to Convergenceand Transformation 158Summary of the Results of the Comprehensive DiscourseAnalysis of Episode #1 and Episode #2 302The Syncretic Change Process 302Intense Experiential Activity 303The Provision of a CollaborativeTherapeutic Environment 305CHAPTER V. DISCUSSION 309Implications of the Study Results to ExST Theory 309Syncretic Relational Novelty 309Tasks Associated with Syncretic Relational Novelty 312Gender issues in Heterosexual Couples Therapy 323Summary 334Study Links to the Literature 335Intensification or Deepening Experience 336Therapist/Client Collaboration 337Gender Issues in Heterosexual Couples Therapy 338Syncretic Relational Novelty 339The Centrality of the Therapist Guide Role 340Qualities of the Intensification Process 341Limits of the Study 342Generalizability 342Internal Validity 344Analyst Interpretation versus ParticipantReport 344Segmenting Therapy Process 346Proximal versus Large “0” Outcome 347Future Research Directions 348REFERENCES 350viiLIST OF APPENDICESAppendix A: Intrapersonal Patterns of Relationship 360Appendix B: Interpersonal Patterns of Relationship 362Appendix C: Environmental Patterns of Relationship 364Appendix D: A Composite of the Three Patterns of Relationship 366Appendix E: Therapist Competency Form 368Appendix F: Relational Novelty Identification Form 371Appendix G: Jefferson’s Notation System 377Appendix H: Alcohol Dependence Data Questionnaire 380Appendix I: Symptom Checklist 90 Revised 382Appendix J: Beck Depression Inventory 384Appendix K: Dyadic Adjustment Scale 386Appendix L: Structural Analysis of Social Behaviour, Sam 388Appendix M: Structural Analysis of Social Behaviour, Jill 390Appendix N: Transcription of Episode #1: The Bottleis Shown The Door 392Appendix 0: Transcription of Episode #2: The Morning Fight 403Appendix P: Transcription of Sam’s View of MaritalDecision Making 414Appendix Q: Transcription of Discussions Concerning Threatsof Abandonment and Physical Intimidation 416Appendix R: Transcription of Discussions Concerning AlcoholicDrinking and Sam’s Threats to Leave the Marriage 419Appendix 5: Transcription of Sam’s Remarks Concerning“Lone Male” Role Expectations 421Appendix T: Transcription of Discussions ConcerningJill’s Childhood 423Appendix U: The Alcohol Recovery Project PromotionalLiterature 425Appendix V: Participant Family’s Consent Form 427VIIILIST OF FIGURESFigure 1: Therapeutic System and ComponentSubsystems 21Figure 2: An Overview of the Therapeutic SystemProcess 30ixACKNOWLEDGEMENTI wish to express my gratitude to the many people who made thecompletion of this project possible. In particular, the staff at Surrey Alcoholand Drug Programs offered their time and expertise to this research. Thankyou to Jean Matthews, Natacha Villasenor, Geoff Lyon, Dan Mitchell, WarrenWeir, 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 toscholarship. I am appreciative of Dr. Bud Morris for his invaluable help andpassion for discourse analysis. As well, many thanks to Dr. David Todtmanwhose attentive editing and thoughtful commentary helped polish thisdocument. Also, thank you to Dr. Robert Tolsma and Dr. Larry Cochran fortheir engaging comments and efforts in the completion of this project.I wish to thank my mother, Louise Newman for her ideas in the writingof this document and for her inspiring courage, strength and love. Manythanks to my father, Ronald Newman and my brother, David Newman for theirlove, steadfast support and wholehearted acceptance.I am very grateful to Lorraine Centeno who looked after my son duringthe years it took to complete this study. In addition, I wish to acknowledge myhusband, Dr. Darryl Grigg for his abiding love and encouragement. Lastly, toRobin with his small hands on my computer keyboard xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxzzzxxxxxxxxxxxzxzxxxxxxx many kisses.1CHAPTER IPURPOSE OF THE STUDYIncreasingly, marital and family therapy process researchers are turningtheir attention to two streams of inquiry including the study of therapeuticprocess and the means by which therapy process is related to client change(Greenberg & Pinsof, 1986). Indeed, calls for therapy process studies thathighlight the second stream, change process research, have been made sincethe 1970’s (Keisler, 1973). Investigator interest in conducting change processresearch emerges from a desire to increase our understanding of therapeuticchange and insodoing elaborate change theory as it pertains to specificallydelineated therapy models (Greenberg, 1986). Typically, marital and familytherapy theories (i.e., efforts to understand, describe and explain observedtherapy process) are based upon the clinical observations, discussions and theacquired knowledge of their developers (Newmark & Beels, 1994). Changeprocess research offers marital and family therapy theoreticians and researchersthe opportunity to test, challenge, confirm or expand theory via empiricalmeans (Greenberg, 1986). The development of therapy theory via empiricaltheory building offers a rigorous and systematic means to continue the effort toproduce ever-evolving explanatory systems.The purpose of this study is to further the development of experientialsystemic marital therapy theory through the in-depth examination of therapy-inpractice. Experiential Systemic Therapy (ExST) is an effective individual andmarital treatment for alcohol abuse (Grigg, 1994). ExST was developed by thisauthor, John Friesen, Darryl Grigg and Paul Peel in 1989 at the University ofBritish Columbia in Vancouver, British Columbia, Canada (Friesen, Grigg, Peel,2& Newman, 1989). ExST was developed in response to the need for both asystemic and an integrative therapy model which could be employed to treatindividuals, couples and families suffering from alcohol dependence and relatedproblems. As an integrative therapy, ExST provides a theoretical frameworkthat embraces a wide variety of therapist technique and practice. In addition,ExST can be applied to individual, couple and family treatment formats. Theimportance of ExST in the conduct of therapy for alcohol and drug abuse isthat it offers clinicians an opportunity to apply an integrative therapy model toa variety of therapeutic contexts thereby providing an improved service toclients who may require treatment at the individual, couple and family levels ofthe system.This research project is concerned with exploring change as it occurs inthe marital format of ExST. Buoyed by promising outcome evidence thattestified to the overall efficacy of ExST for the treatment of individuals andcouples suffering from alcohol dependency and its effects (Grigg, 1994), thepresent investigation was designed to explore how change occurred in sessionsof successful experiential systemic marital therapy. This research representsan empirical theory building effort that seeks to contribute to the continueddevelopment of an efficacious form of marital therapy.The remainder of this chapter will be concerned with the articulation ofthe aim of this research investigation, the research question posed, and thesignificance of the study. Also, a brief description of the method employed toanswer the research question will be provided followed by the definition ofterms used in the conduct of this study. The organization of the chapters willbe outlined after the definition of terms is complete.3Research AimThe goal of this study centers on an interest in the continueddevelopment of ExST change theory. This aim includes the exploration of howchange occurs during a critical single case exemplar of successful ExST and theobservation of the implications these findings have for ExST theory refinementand expansion. Thus, the research aim of this study is to contribute to thecontinuing development of the ExST theory of change through the in-depthexploration of the means by which change is co-created through interactionsbetween therapist and clients.Research QuestionThe advent of videotaped recordings of therapy-theory-in-practice offeredtheoreticians and researchers an opportunity to base theory development onrigorous, contextually embedded empirical research. As a result, researchquestions that require the observation and analysis of therapy-in-progress fortheory development purposes are more readily answered. The researchquestion formulated to meet the aim of this study asked “How do members ofthe therapeutic system both explicitly and implicitly influence the creation ofrelationally novel episodes at the intrapersonal, interpersonal and symptomaticlevels of the system over the course of 15 sessions of successful ExperientialSystemic Therapy for the marital treatment of alcohol abuse?”Significance of the StudyExST has been shown to be an effective treatment for marital recoveryfrom alcohol abuse (Grigg, 1994) yet little research has focussed on howchange occurs in ExST. Two studies to date have been conducted with4respect to experiential systemic couple’s therapy process and both havecentered on single case studies of experiential technique (Dubberley-Habich,1992; Wiebe, 1993). Dubberley-Habich concentrated on documenting theways in which an ExST therapist used conversation to guide a particulartherapy activity namel’, a ritual burning of an extra-marital affair. This researchendeavour is an example of the type of marital and family therapy processstudy that centers on the description of aspects of therapy process withoutrelating the technique or therapy activity of interest to client change.On the other hand, Wiebe (1993) was concerned more withunderstanding how change occurred through the employment of a particularexperiential activity. Wiebe (1993) studied how change was co-created bytherapist and clients when engaged in the externalization of alcoholdependency (a technique known as the symbolic externalization or evocation ofalcohol). Thus, Dubberley-Habich’s (1992) study is an example of a therapyprocess study designed solely to document therapist use of an experientialtechnique while Wiebe’s study represents an attempt to study an experientialtechnique in the context of in-session change.This dissertation is the third process research endeavour to be conductedconcerning ExST process. This effort expands upon the previous two studiesby moving beyond the description of technique alone or the study of how aparticular therapy technique was linked to in-session change. This studyexplored ExST change process irrespective of a particular experiential techniqueto illumine the ExST change construct (relational novelty) for theory buildingpurposes.As stated earlier, ExST is a recently articulated therapy and little workhas been conducted in the area of theory confirmation and refinement. Given5the demonstrated effectiveness of ExST (Grigg, 1994), the on-goingclarification and expansion of ExST may help foster its continued efficaciousconduct. That is, an enhanced understanding of how change is facilitatedthrough ExST will hone the theory offering experiential systemic therapistsincreased clinical guidance. In addition, this research will begin to provideExST with an empirically grounded theoretical base which is uncommon in thefield 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, ExSTsupervision practice and theory (Newman, Friesen & Grigg, 1991) and the ExSTtheory of change (Newman, 1991) have been detailed. However, ExSTcontinues to be a relatively new therapy and further effort is required tocapture the nuances of its various tenets and constructs.The current flurry of interest in ExST process notwithstanding, severalmarital and family therapy process researchers have engaged in attempts tounderstand aspects of therapy process and how clients change from withinparticular therapy paradigms with varying degrees of success (Pinsof, 1981).A lack of therapy theory articulation, inadequate measures and methods anddifficulties linking therapy process to therapy change have hampered efforts tounderstand 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 pastefforts by providing a clear articulation of ExST theory and the ExST changeconstruct (relational novelty) as well as employing standardized measures. Inaddition, this research effort adopted Comprehensive Discourse Analysis (CDA)(Labov & Fanshel, 1977) as a method of analysis suitable for capturing therapy6change process while maintaining a steady research focus on the manner inwhich change is created in ExST. The following section briefly describes CDAas the method employed in the provision of an answer to the researchquestion.Summary of the MethodThe answer to the research question posed in this study required theanalysis of therapy discourse as it occurred between the therapist and clients.The analysis of therapy discourse included not only what was said in therapyby the therapist and clients but also what was unsaid or conveyed throughparalinguistic and nonverbal cues. In addition, therapy discourse analysisrequired attention to the implicit meanings of the discourse, the assumptionsbeing made by the speakers, the social role obligations conveyed and the sociocultural influences on the speakers and the manner in which speakersattempted to influence each other (Labov & Fanshel, 1977). Given theimportance of therapy discourse in the creation of marital change, a responseto the research question was sought through the use of CDA. A brief summaryof the CDA method will introduce the method by which the research questionwas answered in this study. The summary will include an outline of theresearch design, elements of the investigative procedure, and the method ofdata analysis using CDA.A critical single case study design was chosen for this research basedupon calls for the employment of single case studies to illumine the process ofclient change within a particular therapy paradigm (Wynne, 1988). This studysought to explore a successful case of ExST for the purposes of theorydevelopment. The critical or crucial case selected for analysis was an exemplarof a successful ExST case of marital treatment since it met the three criteria for7success outlined for the purposes of this study. First, these criteria includeddocumented client satisfaction with therapy, the cessation of alcoholic drinkingand increased marital satisfaction at posttest and follow-up periods. Second,the change construct of interest was evident in a number of therapy sessionsand third, the therapist expressed satisfaction with her work with the couple.The change construct (relational novelty) examined in this study andembedded in the successful marital therapy case was observed to haveoccurred in eight of the 15 therapy sessions completed by the couple. Threeepisodes identified as exemplars of the change construct were selected foranalysis based upon six criteria outlined in the ExST theory of relationalnovelty. Each episode contained all six criteria whereas the remainingrelationally novel episodes did not meet all the criteria outlined as important torelational novelty for the purpose of this study. While the remaining episodeswere not considered exemplars (i.e., containing all six criteria) they were,nonetheless, relationally novel.The three episodes were reviewed by three independent expert judgesselected for their knowledge and familiarity with ExST. High indexes ofinterjudge agreement were obtained for the episodes indicating that theconstruct of interest was identified as occurring in the episodes selected foranalysis.Once the successful critical case was secured and the change episodesexemplifying the construct under investigation were identified, thecomprehensive discourse analysis of the three episodes began. Following theanalysis of the first two episodes, the analysis was concluded. Due to thethematic commonalities evident in the first two episodes, it became clear thatthe analyses of the first two episodes of relational novelty were sufficient forthe provision of an answer to the research question.8The discourse analysis procedure employed in this study is based uponthe work of William Labov, a linguist with training in sociology and DavidFanshel, a professor of social work with an interest in the delivery and practiceof psychotherapy (Grimshaw, ‘1979). Labov and Fanshel’s (1977) researchefforts were motivated by an interest in what occurs in therapeutic discourseas well as a desire to expand the scope of linguistic analysis to conversation asa whole (Grimshaw, 1979). As a result, Labov and Fanshel’s (1977) workaddressed two issues namely the relationship between what is said and what ismeant and how social acts and organization are accomplished through talk.Thus, the social act of change in therapy can be carefully examined usingLabov and Fanshel’s (1977) methodology.CDA relies upon a six step process which includes the making of videoand 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 visualand auditory rendition of the therapy as possible. The clarity of the recordingwas important to the next phase of the CDA procedure namely the transcriptionof the recordings. The ability to hear and see the therapy discourse clearlyaided in the production of the text used in the analysis. The second step, thetranscription of the therapy discourse, was a painstaking process oftransferring auditory and visual information onto the written page. Thisprocess required repeated listening and viewing of the therapy segmentselected for analysis to obtain an utterance-by-utterance record of thediscourse including paralinguistic and nonverbal cues as well as the spokenword. The third step required by CDA was the expansion of the transcribedtext. Utterance expansion included additions to the utterance with what wasbeing implied in the speech act. For example, a question such as “How areyou?” may contain within it a genuine interest in the respondent or an9uninterested attempt to be polite depending upon the context. The expansionof the text is designed to articulate the implied meaning of an utterance incontext. The fourth step in the analysis was the generation of propositions orassumptions being made by the speaker. Thus, a proposition that fits theexpansion of “How are you?” might include the following statement: Thespeaker is genuinely concerned with the respondent’s well being. The texttranscription, expansions and propositions were employed in the fifth CDA stepwhich necessitated an interactional analysis. Interactional analyses areconcerned with exploring how discourse participants are attempting toinfluence each other through their speech acts. The interactional statementwas crucial in understanding how speakers influence one another and revealedhow therapeutic change was brought about. The sixth step in the analysisincluded an episode summary in which the utterance-by-utterance analysisincluding expansions, propositions and interaction statements for each speechact were synthesized into a coherent whole. Once the analysis was complete,the work of synthesizing the data to provide an answer to the researchquestion was begun.This survey of the method used to answer the research question ismeant to be an introduction and a further elaboration can be found in chapterthree. The introduction of the research aim, question and method in thischapter 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 TermsThe terms defined in this section are important to a completeunderstanding of this research effort. These terms will be defined in order toclarify their usage in this study.10Relationallv Novel EpisodesRelational novelty refers to the enactment of an atypical way of being intherapy which alters the substantive relational themes represented in rigidcognitive, emotive, and behavioural ways of being with self, others, and thepresenting problem. Relationally novel episodes follow a general pattern thatcan be identified as beginning with therapist attendance to clients’ narratives.The therapist begins to collaboratively delve into a salient aspect of thenarrative through a therapeutic transaction. If the client(s) consent, eitherimplicitly or explicitly, then the therapist guides them through a deep, intense,and novel encounter with self, other, or the presenting problem. Generally, thisencounter ends with a de-intensification during which the therapist may markclient change, congratulate the client(s), summarize the process or ask theclient(s) for their views of the experience. The therapist may encourageclient(s) to talk about the experience or the client(s) may do so withoutprompting.Substantive Relational ThemesSubstantive relational themes are recursive patterns of emotion,cognition, behaviour and physiological process that embody intrapersonal andinterpersonal themes such as unlovableness, abandonment, unworthiness,undeservedness and rejection. They can also transform into themes oflovableness, worthiness, deservedness and inclusion. Substantive relationalthemes are descriptive of peoples’ intrapersonal and interpersonal thematicexperiences of being in the world.Intensifying and Deepening ExperienceThe process of intensifying and deepening experience aids clients inevoking their substantive relational themes, problematic behaviours, feelings11and thoughts. Deepening experience is achieved via empathy, the repetition ofwords or actions, experiential activities that involve the whole body as well asmetaphors, art, sculpting, dream work, symbolic externalization and enactment.Intensifying and deepening experience is the means by which clients fullyembrace their process such that different ways of being with themselves andothers are made possible both in the deepened moment and after.Therapeutic System: Therapist and Client MembersA therapeutic system is created when therapist and client(s) enter into adynamic interactive relationship. As such, the therapist and client subsystemsinfluence and are influenced by the exchange. They bring a variety ofintrapsychic, interpersonal and socio-cultural elements to the relationship. Forexample, the therapist subsystem may include the influences of co-therapists,colleagues, supervisors, personal issues/values, and agency affiliation andattitudes towards the symptom in therapeutic interaction with the couplesubsystem. The couple subsystem may include the influences of personalvalues, families, extended families, friends, work associates, institutionalaffiliations, aspects ofself and attitudes towards the symptom in interactionwith the therapist and either spouse. Thus, therapist and client(s) subsystemscombine to form the therapeutic system in which all system members affectone another and share ownership of the therapeutic venture.Alcohol DependenceThe male alcoholic featured in this study satisfied the DSM-lll-R (1987)diagnostic criteria for severe Psychoactive Substance Dependence. The man’sspouse must not be abusing alcohol. The diagnostic criteria are listed below:12At least three of the following items are evident:1. The substance is used in larger amounts and for a longer length oftime than the person initially intended.2. There exists a persistent desire or one or more unsuccessfulattempts to control the substance abuse.3. The individual spends a great deal of time attempting to obtain thesubstance, ingest the substance or recover from its effects.4. The person is frequently intoxicated or experiencing withdrawalsymptoms when expected to fulfill role obligations including worktasks or child care or use of the substance is physically hazardous(e.g., driving while intoxicated).5. Important social, occupational or recreational activities are givenup or reduced due to the substance use.6. The individual continues to use the substance despite knowledgeof recurring social, psychological or physical problems that arecaused or worsened by the substance use. These difficultiesinclude problems such as ulcers due to drinking, job loss or familyfights concerning the use of the substance.7. The individual experiences tolerance characterized by the need forincreased amounts of the substance to achieve intoxication or thedesired effect (at least a 50% increase) or the person observesmarkedly diminished effects with ongoing use of the same amount.Items #8 and #9 may not apply to cannabis, hallucinogens orphencyclidine (PCP).8. The individual experiences withdrawal symptoms.9. Symptoms of the disturbance have persisted for at least onemonth or have occurred repeatedly over a longer period. The13severity of the Psychoactive Substance Dependence ranges frommild to moderate to severe.Mild: Few, if any, of the symptoms are in excess of those necessary forthe diagnosis. The symptoms result in no more than mild impairment inoccupational functioning or social activities or relationships with others.Moderate: Symptoms or impairment is between “mild” and “severe” indegreeSevere: The individual has many more symptoms than are required forthe diagnosis. The symptoms markedly disrupt occupational functioning, socialactivities or relationships with others.Distressed Counle FunctioningOne or both spouses must indicate marital distress as obtained by ascore of 100 or below on the Dyadic Adjustment Scale (Spanier, 1976) in orderto be considered maritally distressed.Successful TreatmentThere are several criteria defining successful treatment for couplescomplaining of the deleterious effects of alcohol abuse. These criteria includespousal satisfaction with therapy, the attainment of therapy goals including thecessation of alcohol and drug abuse at posttest and follow-up periods andtherapist satisfaction with the couple’s progress and her work with the dyad.In addition, the pretest, posttest and follow-up measures should indicate achange towards more personal and marital satisfaction and less personal andmarital distress. Finally, relationally novel episodes should be co-created by thetherapist and clients throughout the 15 sessions of therapy.14Experiential Systemic TherapyExST was created for the treatment of individuals, couples and familiescomplaining of drug and alcohol abuse issues. The theory is complex and aimsfor an integrative understanding of individual, couple and family functioning intherapy. It strives to access the cognitive, emotional, physiological andbehavioural aspects of experience in order to promote change. These aspectsof experience are tapped via experiential, symbolic and systemic means in acollaborative, present tense, goal oriented, spontaneous and creativetherapeutic atmosphere. Client issues are viewed from a developmentalperspective that highlights strengths and resources rather than pathology anddis-ease. ExST subscribes to the notion that human beings develop andmaintain their identities in a social or relational milieu from the day they areborn through early childhood, youth and adulthood. Experiences that span thelife cycle serve to maintain, sustain or perturb human beings sense of self andways 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), andexperiential (Whitaker & Keith, 1981), strategic (Haley, 1976; Madanes, 1981)and structural (Minuchin & Fishman, 1981) family therapy.Intranersonal Level of the Therapeutic SystemThe intrapersonal level of the system refers to the inner world of thespouses and the therapist including thoughts and emotions internal to theindividual. The inner environments of client and therapist may also includevarious aspects of self which engage in internal dialogue. For example, acritical aspect of self may berate a fearful aspect of self. Also, internal aspects15of self may engage in dialogue with the symptom or people in the individual’sworld (e.g., a hurt aspect of self may call out to alcohol for relief or a hurtaspect of self may reveal itself to a concerned spouse). The intrapersonaldomain is notable in therapy when the clients engage in a dialogue withaspects of self or disclose information about their inner thoughts and emotions.Interpersonal Level of the Therapeutic SystemRelationships between the spouses, the couple and the therapistconstitute the interpersonal level of the system. The interpersonal level of thesystem is evidenced in therapy when the spouses interact with one another.Another example occurs when the therapist interacts with either one or both ofthe spouses.Symptomatic Level of the Therapeutic SystemThis level refers to the relationship the therapist and clients have withthe presenting problem or symptom. One of the therapeutic tasks is to aidclients in bringing this relationship into awareness. The symptomatic level ofthe system is in evidence when the clients or therapist interact with thepresenting problem in its symbolic form.Collaboration in TherapyTherapist and client collaboration is an important principle of ExST inwhich therapy is understood as a shared venture involving mutual trust. Thetherapist is a guide to the therapeutic process and co-develops the therapy withthe client. Both the client and therapist own the therapy process and bothassume responsibility for the activities. Therapists endeavour to enter theclient’s world by adopting client language and accepting the client’s currentstate before encouraging clients to experiment with alternate ways of being,16thinking or feeling. The collaborative therapist is considered a part of thetherapeutic system rather than a neutral observer, an all knowing expert or amaster technician. A collaborative therapist does not understand therapy to bea battle or characterize clients as adversarial or resistant. Instead, clients andtherapist work together as co-creators and co-developers of the therapy.Therapy DiscourseTherapy discourse includes both the spoken word as well as that whichis left unsaid but still communicated. Discourse in therapy accounts for theimplicit meanings of speech acts and the meanings revealed in paralinguisticcues (e.g., sighs, laughter) and nonverbal activity (e.g., headnods,handshakes). In addition, therapy discourse incorporates the suppositionsmade by the participants in the discourse, their assumed social role obligations(e.g., expectations regarding a father role), the socio-cultural influences on thespeakers and the manner in which discourse participants attempt to influenceone another (Labov & Fanshel, 1977).Organization of the ChaptersThe remaining chapters of this dissertation will provide a review of theliterature, an encapsulation of the methodology, a description of the results anda discussion of the conclusions made as a result of this research. Chapter twowill incorporate a detailed articulation of ExST theory including the results of arecent outcome study testifying to ExST efficacy and a review of the history ofExST. Following the delineation of ExST theory, relevant quantitative andqualitative marital and family therapy process research will be reviewed.Chapter three describes the critical single case research design and relatedissues, the investigative procedure used in the conduct of the study and the17CDA method of data analysis employed to yield the results. Chapter four willdescribe the research results and their importance to ExST theory and chapterfive will be concerned with summarizing the results and outlining the proposedrefinements to ExST theory based on the findings. Also, limits to the study andfuture research directions will be discussed in chapter five.18CHAPTER IISURVEY OF THE LITERATUREThe purpose of this chapter is twofold. First, the aim is to outline whyExST change is worthy of process oriented investigation including a generaldescription of ExST and the change construct of interest namely relationalnovelty. The second aim of the chapter is to review previous marital and familytherapy process research. The literature review will focus on the manner inwhich marital and family therapy process has been studied and the resultsgarnered from these studies. Both quantitative and qualitative types ofinvestigations will be reviewed.Experiential Systemic TherapyThis section will offer a discussion of ExST history, theory and efficacywith a view to outlining the development of the therapy and the articulation ofthe theory including an overview of ExST and an in-depth description ofrelational novelty. Finally, a recent outcome study testing the efficacy of ExST(Grigg, 1994) will be reviewed to provide a context for this process researcheffort.History of Experiential Systemic TherapyExST was co-developed by John Friesen, Darryl Grigg, Paul Peel andJennifer Newman in 1989 at the University of British Columbia. While ExST, inmany ways, represents the accumulated experience and knowledge of all theseindividuals, it was in 1986 that ExST began to form in earnest.Extensive training sessions conducted by the ExST originators in the areaof marital and family therapy for substance abuse with alcohol and drug19counsellors led to the eventual inception of ExST. The training events anddiscussions with alcohol and drug clinicians across British Columbia, plus theneed to clearly explain concepts when imparting them, provided fertile groundfor the subsequent articulation of ExST.ExST developers sought to delineate an integrative theoretical frameworkcapable of embracing a variety of therapy technique and a wide spectrum ofhuman experience in the behavioural, the emotive and the cognitive domains.In addition, ExST was designed to integrate individual practice with a familysystems theoretical orientation. The articulation of ExST prompted a largescale research endeavour named The Alcohol Recovery Project (TARP) of whichthis research is a part.The general mission of TARP was to test the efficacy of ExST andconduct process research with respect to therapy-theory-in-practice. Also,TARP provided an umbrella for a variety of outcome, descriptive and processstudies related to ExST and alcohol dependency in general. Conducted over aperiod of five years, TARP has received funding from the British ColumbiaAlcohol and Drug Program (now part of the provincial Ministry of Health andformerly in the Ministry of Labour and Consumer Services) and from the BritishColumbia Health Research Foundation (Health Services Research Programme).Other assistance has been extended to TARP by the University of BritishColumbia and the Social Sciences and Humanities Research Council of Canada(SSHRC). These funds and other forms of assistance have enabled thecompletion of this study, as well as others resulting from TARP activities.SSHRC funding, awarded to the author, was important to the completion ofthis study. TARP has been conducted under the general direction of thePrincipal Investigator, John D. Friesen, Ph.D., co-investigator Robert F. Conry,Ph.D., and project coordinator, Darryl N. Grigg, Ed.D. Additional information20regarding TARP may be obtained from Professor John D. Friesen, Departmentof Counselling Psychology, University of British Columbia.Currently, ExST is practiced throughout British Columbia in a variety ofpublic agencies as well as private enterprises and research on ExST processand efficacy is ongoing at the University of British Columbia. Also, ExSTtheory and technique has been adapted to group counselling efforts with singleparents at risk for child maltreatment (Newman & Lovell, 1993) and applied totherapy with adolescent substance abusers (Selekman, 1993). The followingsection will outline ExST theory with reference to composite case examplesaltered to protect client confidentiality.Overview of Experiential Systemic Therapy TheoryThis section will provide an overview of ExST and an elaboration ofrelational 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 wasdesigned in response to a lack of integrated individual, couple and familytherapy models of treatment for alcoholism (Friesen, Grigg, Peel & Newman,1989; Friesen, Grigg & Newman, 1991). The current study represents anempirical effort to continue the ongoing process of theoretical refinement.ExST is an interpersonal process, the success of which is dependentupon the client’s experience. The observable manifestation of the therapeuticsystem arises out of the dynamic interaction of its two constituent parts, thetherapist and client subsystems. Therapists and clients influence one anotherthrough discourse and the ongoing therapeutic relationship is an interactiveprocess.21In some therapeutic models, clients are viewed as resistant or appearunreceptive to the therapist’s interventions (e.g., Madanes, 1981).Consequently, such techniques as paradox are used by therapists to out-witclients. In other approaches, clients are seen as opponents with whom thetherapist must struggle against and vanquish through a series of “battles”(Whitaker & Keith, 1981). Such notions can become self fulfilling therapistprophecies and are incompatible with the Experiential Systemic Therapy theory.Efforts are made to avoid militaristic language that references combativeways of construing clients and the process of change. Therapy is best seen assomething created with clients as opposed to something imposed upon them.Consequently, there is no need to conceive of the therapist/client relationshipusing metaphors of armed struggle and combat. Therapy is seen as acooperative venture shared by therapist and client.— — ——Therapeutic System/I, —— ——— —— —4________________________—. — — ——7 ,‘ “Therapist” “Client”I I subsystem may include: / subsystem may include \therapist, co—therapist, ‘ / individuals, couples, ‘team, colleagues, families, extended II supervisors, clinic staf families, friends, work)treatment community / associates, conunwuty //— — — — — ——. c..___________-_. —Figure 1. Therapeutic System and Component Subsystems22The unified view of the therapeutic system presented schematically inFigure 1, illustrates the interdependent collaborative relationship between thetherapist and client subsystems. It is recognized that both therapist and clientsubsystems are frequently comprised of a complex of constituents and theterms therapist and client will be employed throughout the remainder of thissection to denote the subsystems.The experiences clients bring to therapy are indicative of their struggleswith others, themselves and the presenting problem. These experiences arefrought with frustration, tension and stagnation. The therapeutic story initiallyincludes the client’s struggles as a starting point while simultaneouslyincorporating potential for change.ExST theory assumes therapy has an elevated status in the normal bustleof the client’s daily life. It is a weekly or bimonthly ritual that has as its explicitgoal, the transformation of the clients’ experience and stories. The story oftherapy is a story of transformation and as such it is imbued with the kind ofrespect reserved for the sacred in our culture, It is a special social occasionwherein all acts, thoughts, feelings and physical sensations have symbolicsignificance. Within this context, anything can happen, the most mundane canbecome the miraculous and that which was pained can become a joy.The Role of SvmDtomsSymptoms are considered indicators of relational difficulty and as suchare meaningful signs of distress. Rigid, restrictive and repetitive patterns ofinteraction characterize the symptom-bearer’s relationship to the symptom, selfand family members. Similarly, family members may experience a particularrelationship with the symptom and the symptom-bearer. Painful intrapsychic,interpersonal and social contexts can give rise to symptomatic behaviour. An23appreciation of the myriad of contexts from which symptomatic behaviour mayarise fosters a comprehensive view of symptomatology that includes anacknowledgement of the possible physiological, psychological and socialfactors that can determine symptom development and maintenance (Donovan,1988). For example, a comprehensive perspective regarding symptomdevelopment and maintenance is helpful when clinicians are required to treatalcoholism. Alcoholism can be understood as a multi-dimensional and systemicmanifestation of a physical addiction process interacting with psychological andsocial factors. Intervention at all three levels is required to interrupt thedevelopment and course of the syndrome (Kissin & Hanson, 1982).This multi-dimensional and systemic view of symptom development andmaintenance also offers clinicians a way of understanding the complexity ofsymptomatic distress (Schwartz, 1982). For example, while the presentingproblem may be expressed as depression, secondary relational disturbancessuch as unemployment or excessive fatigue may be related to the chronicity ofthe symptom. In addition, previous problematic relations such as childhoodsexual abuse may pre-date the emergence of the symptom and be revealedduring the course of therapy. Thus, the therapeutic task includes an adequateassessment of the symptom and related factors to help in understanding theproblem and its meaning in clients lives.To aid in both the assessment and amelioration of symptomaticbehaviour, ExST therapists remain curious about the symptom viewing it to beakin to a teacher or messenger. Symptoms are considered teachers ormessengers providing either learning opportunities for clients or giving clientsmessages regarding relationships in need of attention. Clients’ relationships toself 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 therapists24and clients grapple with symptom relief is found in the symbolic, experientialand systemic dimensions of ExST. These three dimensions are described in thefollowing section.Dimensions of the ModelThe therapeutic story has a beginning, a middle and an end and like allstories it is an expression of the authors’ talents, needs and limitations.Experiential systemic stories are centered on three domains including thesymbolic, experiential and systemic dimensions.Symbolic dimension.The symbolic dimension refers to the notion that therapy is a symbolicand culturally sanctioned change ritual. Acts in therapy are symbolic andconsidered an analogue to the story the clients enact in other life situations. Inaddition, actual symbolic objects are employed in therapy to represent parts ofself, interpersonal relationships and presenting problems. Where single wordsmay be insufficient, symbols provide a meaningful way to describe the totalityof client experience.Exneriential dimension.The experiential nature of the model is also important in facilitatingchange. Experiencing in therapy deepens and expands clients alternatives. Anexperience is helpful if it increases the clients awareness of their thoughts,feelings, perceptions and behaviours. New awareness and changedrelationships are achieved through intensified experiencing. Experiencingrepresents an integration of behaviour, cognition, affect and perception suchthat these constructs are synthesized into a whole.25Action oriented techniques are utilized to achieve the broadening ofexperience. These may include psychodrama, sculpting, enactment, emptychair work, and two chair techniques. These techniques offer clients anopportunity to experience different ways of being together rather than engagingin a didactic or content oriented discussions about what “should” be done.The rigid manner in which the clients behave begins to erode when theyexperience a visceral sense of the alternatives open to them. Experientialtechniques are not applied for their own sake. They are used to deepen clientsexperience of the patterns they have encountered with their spouses orchildren. For this reason, the experience provided must fit the therapist andclients’ perceptions of the difficulty at hand.The characteristics of therapeutic experiencing entail both theenhancement of emotions and cognitions as well as the bringing intoprominence the interactive essence of experience. In other words, clientsobtain understanding at both an intrapsychic and systemic level. They come to“know” the patterns and relationships they live at a deeper level. Thesepatterns and interactive postures may incorporate purser/distancer,attack/attack, withdraw/attack, withdraw/withdraw and dominate/subjugatedynamics.Another characteristic important to therapeutic experiencingencompasses the notion of relational novelty. That is, clients obtain a physical,affective, cognitive and behavioural sense of a new “way of being” in theworld. Relational novelty is the experiencing of new alternatives that grow outof the special status of the therapeutic context and the experiential nature ofthe 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 ofexperiencing converge to form a new coherent whole. Once this has occurred,26clients quite literally, can never be the same again. They see the world anewand they no longer maintain the same rigid patterns of behaviour to which theyhad previously become accustomed.These shifts occur through the use of pictorial language, metaphor,intensifying experience through repetition, identifying underlying emotions andthe use of symbols. These activities are most meaningful when the clients’metaphoric language is understood and spoken by the therapist and when thetherapist and client(s) have entered into a collaborative relationship.Systemic dimension.The ExST model is based upon a systemic perspective that viewsrelational patterns as malleable and subject to the experiential shifts of theobserver. ExST emphasizes the plastic, evolutionary nature of systems ratherthan a static, self regulatory concept of homeostatic functioning. Systemsinclude a wide of variety of relationships including interactions between partsof self, ideas, problems, people, cultures and nations. These relationships existin the social domain and are interdependent such that any movement in anygiven 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 theyinteract with the therapist, each other, themselves and their problems.Therapists are socially sanctioned “change agents” who bring the totality oftheir experiences to the therapy setting. These experiences includeprofessional 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 aspecific length, developing characters and roles, focussing on main dramatic27themes and delineating the role history plays in the present lives of thecharacters. The following discussion depicts the nature of the therapy story.Outline of PrinciplesExperiential Systemic Therapy is problem and pattern focussed in thatthe clients’ presenting problems are noted and relief of these problems isactively sought. Problematic patterns are tracked and various transactionsoccur between the therapist and clients which address the relational stagnationintrinsic to client complaints. ExST is a brief therapy in that the story rangesfrom four to 20 sessions in length. It is goal directed and an agreementregarding the focus of therapy is made at the outset.Developmental perspective.ExST maintains a developmental perspective which frames the client’sdifficulties in relation to various human experiences in the life cycle. Theseexperiences can include: a birth of a child, a death of a child, a child leavinghome, a parent dying, a marriage or engagement, a divorce or separation,career transitions, housing problems, difficulties with adolescents and caring foraging parents to name a few. The understanding of the developmental natureof life cycle experiences is important for two reasons. Firstly, our society isever changing and currently blended families, single parent families andextended families are common. As a result, ExST does not assume a “typical”course for family or couple events. The idea of stages of development islimited by the shifting nature of our increasingly cross-cultural and feminizedsociety. As a result, ExST theory considers human dilemmas in light of theiruniversal qualities such as loss, transition and reunion. Secondly, a focus onthe evolutionary nature of life events is important in that this frame providesvalidation for clients who are attempting to make changes in their living28arrangements. Rather than applying an outmoded yardstick to clientexperience, ExST strives to normalize struggles as valid, understandable andrational given the circumstances.Therapy is also viewed as a developmental process in which change isconstrued as an ongoing occurrence. Client regressions to previousproblematic states and patterns are understood to be opportunities rather thanfailures. Clients will revisit outmoded ways of being in order to learn moreabout 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 packedand told in the present tense. This is not to say that the model ignores thepotency of the past. Rather, it recognizes the influence of past events andfigures and actively offers these historical legacies a voice as they manifest inpresent interactive patterns. For example, constraints and problems in thepresent may indicate that a client’s deceased but once sexually abusive fatherstill 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. Thehaunting figure is not left in the attic but is brought into therapy and attendedto 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 anecological assessment of their difficulties. The story that unfolds isrepresentative of the characters’ lives and this entails the observance of alllevels of the system in which the characters are involved. This assessmentincludes gaining an understanding of the individual, couple, family andcommunity contexts (including work, school, medical services and the police)29as well as the societal, political and cultural systems within which thesubsystem members operate.Collaborative therapist stance.A collaborative therapeutic system is essential to the ExST model since itis within this relationship that the opportunity for client change and the ultimatere-writing of the clients’ tale is made possible. Relational novelty occurs withinthis collaborative setting. The therapist is considered to be a collaborator orco-author with the clients rather than an expert doling out therapeutic advice.This role is flexible and can accommodate many different modes dependingupon what is triggered spontaneously in the therapist. The therapist may takeon the aspect of a dramatic coach, a dance and movement choreographer, aorchestral conductor, a sculptor or the village idiot given what is “pulled” fromher or him during therapy.Therapist spontaneity.The therapist obtains permission through the therapeutic mandate to bespontaneous with clients as a direct result of maintaining a collaborative stancefrom the outset. A key element in ExST is the therapist’s ability to bespontaneous. Therapist creativity is essential to the model and the fear ofmaking mistakes with clients is a natural concern for any responsible therapist.However, once rapport has been established, the relationship between theclients and therapist can withstand the jostling that sometimes occurs on theway to health. As partners in collaboration, the therapist and the clients candiscuss the developing therapeutic subsystem and are encouraged to do so onan ongoing basis throughout the course of therapy. It is at these times thatany misunderstandings or differences in viewpoints can be addressed on thepart of all therapeutic system members.30Phases of TheranvA story of literary worth incorporates a certain structure which “movesthe 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 areintroduced and the principle problem or human theme is outlined. After theintroduction has been made, the stage is set for the dramatic action whichculminates in the story’s climax. The climax is reached and is quickly followedby the denouement and story resolution. These narrative elements arereflected in the therapeutic change story by way of the four phases of therapywhich may span, for example, 15 chapters or sessions.The four phases of the therapeutic story include: a) Forming thetherapeutic system: Establishing a context for change (introduction);b) Perturbing patterns and sequences and expanding alternatives; c) Integratingexperiences of change: Reorientation (action and climax) and finally;d) Disbanding the therapeutic system: Termination and acknowledgingaccomplishments (denouement and resolution). These phases take place withinthe sessions or chapters of the tale and are presented in Figure 2.—> > > > > > > Post—therapyPhase 1 Phase 2Forming PerturbingPhase 3 Phase 4IntegratingPre—therapyFigure 2. An overview of the therapeutic system process31Figure 2 depicts the time before therapy begins, the formation of thetherapeutic system, the perturbation of the system, the integration of changesand finally the eventual conclusion of therapy followed by post-therapyseparation. It portrays the therapeutic system developing over time andillustrates the four phases of therapy as they might occur over the course of 15sessions. The phases overlap and different elements of each phase may bepresent in any given session. At the outset of therapy, clients are invited toexpress their desires regarding the outcome of therapy. This task offers thetherapist and the clients a goal around which therapy is organized. While eachsession has an integrity all its own, the story achieves continuity through thegoals agreed upon in the first phase of therapy. In addition, each session endswith an invitation to clients to complete such tasks as experiments with novelbehaviour, the completion of a journey or the discovery of a symbol, as ameans to the desired goal. The next session begins with a review of theinvitation made in the previous one. The story maintains its focus, coherenceand continuity in this manner. The therapeutic activities engaged by thetherapist and clients during the four phases of therapy have been divided intobroad categories or transactional classes. These transactional classes aredescribed below.Transactional Class TaxonomyThere are seven transactional classes used to describe the activities ofthe therapeutic system. The term transaction is used instead of interactionsince it denotes the complexity of the process of accommodation and influenceengaged in by members of the therapeutic system. Each class is designed toreflect the mutually interdependent relationships that form what is called thetherapeutic system.32Therapist-Client relationship enabling.The focus of this class is on the creation and maintenance of thetherapeutic alliance. This occurs throughout the duration of therapy andensures that clients feel understood and safe with the therapist. The intentionbehind these transactions is to form a working alliance wherein there is a trustand commitment to the therapeutic process on the part of both the therapistand the client. These transactions can include empathy, self disclosure andimmediacy to name a few.Process facilitation transactional class.The relational patterns observed by the therapist and clients are thefocus of this transactional class. Clients are encouraged to become directlyinvolved with one another during the session. The therapist is interested in therecursive nature of client patterns as well as the cognitions, emotions andphysiological states that underlie these interactions. The clients cooperate withthe therapist in experiencing new patterns of behaviour. They engage inspontaneous dialogues while the therapist utilizes their immediacy to shiftotherwise static patterns of interaction. The techniques classified under thisclass include: blocking, coaching, marking boundaries, framing and encouragingthe expression of underlying feelings.Expressive transactional class.What has previously been private is made public through the process ofexploration, naming and owning of experience through verbal and nonverbalmeans of expression. These are creative transactions that obtain their powerthrough their metaphorical properties and the resources brought to bear on themoment by all members of the therapeutic system. These transactions caninclude art activities, dance, storytelling, baking and metaphor.33Symbolic externalizing transactional class.A symbolic representation of some aspect of the clients’ world is madeand brought to life in therapy. An alcoholic’s relationship to the bottle isexternalized so that the clients may relate to it from a distance. In this activitya beer bottle is put on.a chair and the alcoholic and his spouse are invited toaddress the bottle. In short, any dilemma, idea, feeling, person or thing can beexternalized and brought into therapy. These transactions include empty chairwork and two chair work.Meaning shifting transctional class.Clients make sense of their worlds in ways that leave little room forflexibility. The therapist can help clients expand their alternatives by aidingthem in developing an experience of the problem that implies a solution or thatenhances the clients’ ability to be compassionate towards one another andthemselves. Meaning shifts are important to therapy since they sometimesmark 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 areinvitations to engage in some form of between session homework and allow forcontinuity between meetings. They provide feedback as to how well clientsare maintaining their changes and developing alternatives. Therapeutic tasksmay perturb new behaviours and therein promote client self confidence. Thesetransactions include: homework, quests, rituals, journal writing and selfmonitoring.34Ceremonial transactional class.These transactions focus on formal acknowledgements of progress andchange in clients. These are memorable occasions and are enacted with all duereverence. Ceremonies can demarcate endings from new beginnings, shifts instatus and changes in role. They are highly ritualized and jointly planned.These transactions include: closing celebrations, burials, penance, confessionsand burnings.The following example of one client’s story of change describes thephases of therapy and the employment of various transactional classes. Thedetails of “Sue’s” therapy have been changed to protect her anonymity. Sue (afictitious name), 30 years old and mother to an infant, came to therapy havingjust ended her marriage of five years. She realized through the painful processof separation that she now wanted to use the opportunity to review some ofthe 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 transactionsemployed in therapy will be delineated during the case example. Thetherapeutic activity employed and the category to which it belongs will bebracketed in the text.Phase 1 - Forming the therapeutic system: Establishing a context forchange.One of the major tasks of this phase of therapy entails setting the stagefor the action to occur. This necessitates the establishment of a bond betweenclient and therapist, an assessment of the nature of the troublesome humandilemma brought to therapy and the development of a commitment to the goalsagreed upon by all members of the therapeutic system. This implies thecreation of a therapeutic mandate. The mandate is jointly accepted by35therapist and client and is connected to client goals. The therapist requestsclients to identify symbols that represent their therapeutic goals. Thesesymbols (which are brought into therapy) may represent a wide range ofpossibilities including cutouts from magazines, photographs, plant matter,visions, television personalities or families or prized possessions. The therapystory obtains its direction and navigates the troubled client waters throughthese symbols of desired outcome.The bond formed between the co-authors of the therapy tale is facilitatedthrough the collaborative stance adopted by the therapist. He or she alsoemploys a host of relationship enabling techniques in order to facilitate thetherapeutic relationship. These techniques include empathy, listening andattendingAn ecological assessment is conducted during this phase in order tounderstand the clients’ backgrounds and present roles more fully. The firstchapters of the therapeutic story center on the promotion of understanding,respect and trust between the therapist and clients in order to ready the scenefor change.For example, during the first session, the therapist listened closely to Sueas she told of seeing her sorrow contained in “jars of sadness”. These jars ofsadness were shut in a room (Metaphor: Expressive Transactional Class). Suewas afraid to trust others including the therapist. The therapist commendedher for her bravery which propelled her into therapy (Positive Connotation andValidation: Meaning Shift Transactional Class) and added that she would notask her to go anywhere she was not ready to go.As part of the ecological assessment, the therapist discovered that Suehad a previously difficult experience in therapy. Sue believed that her previoustherapist had not been honest with her. The present therapist said that36honesty was very important to her as well (Self disclosure: RelationshipEnabling Transactional Class) and that if Sue ever has any concerns thetherapist would like to hear them. The therapist also promised to bring herconcerns forward if need be (Immediacy: Relationship Enabling TransactionalClass).Sue is a single mother working in an drafting office and the demands toperform and be “one of the guys” sometimes left her feeling alienated from heroffice mates. She valued therapy as a place where she could “be herself”.Sue is an Anglo-Saxon Canadian and she said that the cultural differencesbetween herself and her husband (who was from Asia) caused a strain on theirmarriage.Sue was abandoned as an infant and lived with her father and a series ofstepmothers who were more or less accepting of her over the years. Thethemes of Sue’s story were ones of abandonment, alienation and loss. Shewas afraid to trust others and her career choice offered her healthyremuneration but very little emotional support. However, she valued her abilityto survive and the strength of her independence.Sue was happy to work with the therapist and the therapist echoed thisdesire. The therapist requested that Sue gather together jars and place thedifferent forms of sadness she experienced into each jar and bring them totherapy the following week (Homework: Invitational Transactional Class). Thetherapist also asked Sue to reflect upon what she envisioned as the idealoutcome of therapy. Her answer was immediate. She saw an empty room thatneeded redecorating. The room contained no jars of sadness but was a placeof refuge that was in dire need of interior design.37Phase 2 - Perturbing patterns and sequences and expanding alternatives.During this phase of therapy, the therapist strives to perturb relationalnovelty and therein directly affect clients’ static sequences of behaviour andexpand alternatives. The techniques used by the therapist must reflect thecollaborative nature of the therapeutic endeavour. The therapist remainsflexible and sensitive to the clients’ needs at this tender time. The symbolic,experiential, and systemic nature of the model is also evidenced during thisphase through the utilization of change skills encompassed in the transactionalclasses. The therapist’s spontaneity is important during this phase andthroughout the whole therapeutic process since he or she is required to engagein various forms of psychodrama, symbolic externalization, process facilitationand other metaphorical and intuitive activities. The purpose of this creativity isto trigger shifts in the clients’ experience of a rigid and stereotypic world.The following example illustrates two sessions that occurred duringphase two of therapy. In one session, Sue’s jars of sadness (Symbolicexternalization: Externalization Transactional Classes) were sitting on a chair.After being requested to place the jars in relation to how close or distant shefelt from them, Sue put them within arms reach and sat beside them. Whenthe therapist asked her to imagine opening one of the jars (Fantasy:Externalizing Transactional Class), she said, “I’m afraid when I think aboutdoing that. I can go into the room where the jars are but opening them isanother matter altogether.“For so long you have stored these jars and opening them and looking inis a terrifying thought right now, It may be today, may be next week, nextmonth or next year but some day you’ll be ready to look” replied the therapist(Empathy: Relationship Enabling Transactional Class).38This led to an exploration of Sue’s fear of crying and her belief that shedid not get anything accomplished that way. The therapist asked her whereher tears lived and Sue pointed to “a third lung in the middle of her chest”(Enactment: Process Facilitation Transactional Class). The therapist remarkedthat 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 tosave 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 toexplore. The jar contained her father’s death. She pulled a symbol of him fromthe jar and stared at it (Externalization: Externalizing Transactional Class) andcommented that what made her most sad was the fact that her father nevergot to see or play with his granddaughter. Tears trickled down her cheeks atthis thought. She let out a tremendous sigh and smiled through her tears atthe therapist. The therapist remarked how much courage Sue had to be able tolook into this jar and that she was crying healing tears. Sue nodded andanother 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, intothe room. The therapist asked Sue to place the symbol of her father in thetherapy 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 shewas crying because the “tears get in the way”. Rather than inviting Sue to talkdirectly to the symbol of her father (Externalization: Externalizing TransactionalClass), the therapist suggested that she close her eyes and imagine him in hermind’s eye (Guided Fantasy: Expressive Transactional Class). The fantasy wasabout a playtime between Sue, her daughter and her father. The therapist39guided Sue through the fantasy and she silently and freely cried as shewatched her daughter and father play together.Sue remarked that this was a precious fantasy for her since she couldnow visit her father whenever she wished and that she actually witnessed herdaughter and her Grandad playing together. She got to say “Goodbye” to herDad and she felt better than she ever had since his death many years ago. “Iguess I never really gave myself a chance to grieve and now I’ve mourned a bitand feel better,” said Sue.The next sessions in Sue’s transformational journey included visiting herfather in the therapy room and telling him how much she loved him and alsohow she felt abandoned by him. She also explored the jars of sadness thatcontained her aloneness, her marriage, her mentally abusive biological motherand her estranged husband. All these forms of sadness were externalized anddiscussions were held between Sue, her ex-husband and the mother whoabandoned her.Phase 3 - Integrating experiences of change.The rigidity with which clients once viewed their worlds gives way torelational flexibility. Where once there was hopelessness, anger and hurt therenow exists compassion, tolerance, acceptance and forgiveness. The therapistaids clients in generating novel experiences that validate their changes andsimultaneously helps them to release, albeit sadly, old patterns of relating.Grieving lost ways of being is also important during this phase of the changestory. This can be achieved through the creation of rituals or transformationalmarkers designed to ensure that the changes made can be absorbed into theclients’ lives. Once again, the techniques used in this phase are found in thetransactional classes and are triggered in response to the client’s needs.40The action of the story and the beginning of the end are written in thesessions or chapters that correspond to the two phases previously described.A climax has been reached. This may be embodied in a pivotal moment or itmay be the result of an imperceptible twist in the usual course of events. Theclient and therapist have been party to a transformational journey which is bothhumbling and invigorating.During Phase Three, Sue was light and happy. She saw herself as acookie and felt rich, sweet and complete. All the ingredients were present andnothing was missing (Metaphor: Expressive Transactional Class). She wasfeeling closer to her friends and less tense at work. The jars of sadnessseemed like sad memories or facts rather than raw wounds. Sue was no longeroverwhelmed by her sorrow and she began to deal with sad things in her dailylife without the added weight of her past sorrows. She felt sad to leave thejars and wanted to refurnish the empty room soon. Sue was reluctant to leavetherapy since she wanted to “make sure this is really happening.” She couldbarely believe that what had hurt for so long was no longer as painful. Shewanted to ensure that her changes would be lasting. The therapist asked Suehow she would know if she could trust her changes? Sue answered that shehad to test them by scanning the jars again and allowing herself to feel any ofthe feelings this elicited. Sue began the process of sorting the sadness intoenvelopes that were entitled “sad memories”. Those items that seemed to bebittersweet memories or thoughts were filed while those forms of sadness thatwere still painful were retained. Over the course of this sorting, Sue filed allher past sadness except for the ongoing divorce proceedings.As these sessions unfolded, the therapist spoke more frequently of theend of the therapy and Sue agreed that this appeared imminent. With that,41both the therapist and the client recognized that the time was right to begin theresolution of the story.Phase 4 - Disbanding the therapeutic system: Termination andacknowledging accomplishments in therany.The clients and the therapist begin to experience their meetings asunnecessary during the last few sessions. The purpose of this phase oftherapy is to dissolve the therapeutic system in order to bolster clientindependence. The clients review their journey together sharing pivotalmoments and congratulating each other on their changes. A final closing ritualis performed, an evaluation of the process is undergone and therapy isconcluded. This ceremony marks the end of therapy and the beginning of lifewithout 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 (CeremonialTransactional Class). Sue baked cookies (Baking: Expressive TransactionalClass) symbolizing her completion and wrote down a list of the changes shemade as well as her plans for refurnishing the room that the jars oncedominated. The therapist brought a “Goodbye” card for Sue, gingerale for atoast and balloons for the therapy room.A summary and review of therapy was conducted and Sue told thetherapist of her most memorable therapeutic moments. The last session wastouching for both the therapist and the client. Sue left knowing that thistherapeutic 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 thefile.42In conclusion, this overview has endeavoured to describe the dimensionsof the Experiential Systemic Therapy theory, the principles of its conduct, thephases of therapy and finally a brief description of the transactions undertakenby the members of the therapeutic system. In addition, the therapeutic journeyhas been illustrated through the use of a case example. The model is anintegrative one which seeks to bridge individual and systemic paradigms as wellas encourage therapist spontaneity over theoretical and practice dogma.The following section provides a detailed description of the conceptsimportant to the ExST theory of change. These concepts were touched uponin the previous overview but are elaborated in the following section.Relational Novelty as a Means to Individual and Counle ChanoeThe concepts integral to the ExST theory of change center on the utilityof a relational paradigm to understand human experience and the importance ofsubstantive relational themes and the intensification process in the creation ofrelational novelty (Newman, 1991). The following section will expand uponthese notions.The therapeutic journey is a story of courage and transformation and thistale has been retold since millennium through human myth and literature. Mythrepresents a culture’s conceptualization of a Larger Truth and exists in relationto that society’s psyche, structure and mores (Lerner, 1986). The consistenttheme found in Myths of Transformation can be best expressed metaphoricallyas Campbell (1988) wrote:At the bottom of the abyss comes the voice of salvation. Theblack moment is the moment when the real message oftransformation is going to come. At the darkest moment comesthe light. (p. 37)43The content of transformational stories stems from the diversity of situations inwhich couples and individuals find themselves. The content of the story isimportant and embedded in the culture and/or subculture to which clientsbelong. A couple’s visit to the campus marriage counsellor is different from aNative Canadian’s visit to a trusted Elder. However, while the narratives maybe dissimilar these heroic journeys contain the common theme oftransformation. This transformation can occur in the individual, the couple, thefamily and perhaps, in larger fields of socially constructed experience (Hoffman,1990).The tale of the means to Experiential Systemic change exists within acurrent Western conceptualization of healing; notably an intimate relationshipbetween clients and trained professional therapists. The means by which theintrapsychic and relational abyss is explored, the nature of the abyss, and theproducts of the darkest moment and the return to light will be discussed withinthe Experiential Systemic Therapy theory from intrapersonal, interpersonal andenvironmental viewpoints. In effect, this work represents an effort to combineindividual and systems thinking in order to explain the means by whichrelational beings change.The Imnortance of a Relational ParadigmSullivan (1953) maintained that interpersonal relationships represent apowerful human need and human life is characterized by continuous patterns ofinterpersonal interactions which occur over a life time. The infant’s relationshipwith a valued attachment figure is important to the formation of his or hermental models of self and others. These cognitive frames or representationalmodels influence later adult intrapsychic and interpersonal functioning.Representational models of self and attachment figures integrated in the mind44during childhood, reflect the treatment children receive at the hands of theirparents and the observations they make of the relationship between theircaregivers (Bowlby, 1988). The experiences children have with their caregiversin the past and the present, form the basis of the representational models theyuse in adulthood. Adults who have matured in unfortunate circumstances,tend to have little faith that the person to whom they have attached is eitheravailable 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 maygrow up to be not only confident of his (sic) parent’s affection butconfident that everyone else will find him (sic) lovable too. (pp.204-205)The stability of these relational patterns is not just a product of thechild’s innate temperament. As children grow older they absorb dailyinteractions with their parents as part of their ontological realities or ways ofbeing and these facilitate the generation of similar relational patterns betweenthe 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 modelsof self through cognitive means. This is an outgrowth of his notion thatworking or representational models are internal blueprints of the world “outthere”. However, the child’s experiences are of the child’s ontology and forthis reason cognitive, emotional, behavioural and physiological aspects ofhuman functioning are intertwined to offer us a view of the child’s patternedexperience. In other words, there is a lack of separation between the child’sexperience of the world and the world in which he or she lives. How the childrelates in the world is how the world is to that child until new experiences alterthis relationship. Thus, while the individual’s being in the world may have45thematic undercurrents of unlovableness, these themes are not prescriptivemaps of the world. These themes are the observer’s description of themesunderlying an individual’s being in the world based upon all four aspects ofongoing experience namely cognition, emotion, behaviour and physiology.Childhood and later-life experiences combine to influence the development ofemotional, cognitive, behavioural and physiological relational patterns that haveas an undercurrent themes such as lovableness, security or unlovableness andabandonment.ExST focuses on perturbing patterns of relationship between parts ofself, self and important others and self and the larger socio-cultural context.Perturbing these intrapsychic, interpersonal and socio-cultural patterns entailsthe generation of new experiences in each of these domains such that noveltyand change occur at the cognitive, emotional, behavioural and physiologicallevels of functioning. Human patterns of interaction are subject to theinfluence of life events (e.g., births and deaths, cultural events, societal forces,transitions and good fortune) and as such they are amenable to modificationand change in therapy. Since relationally novel intrapsychic, interpersonal andenvironmental experiences can elicit change in these three systems, it isimportant to note that early and ongoing traumas do not guarantee unrelentingsystemic distress in the future (e.g., West & Prinz, 1987).Ecosystemic Thought and the Process of RelationshiD FormationThe experiences that result from the interactive process between thechild and his or her caregivers are influential in the child’s way of being in theworld. Childhood experiences of self and others play an important role in theconstruction of relationships in adulthood. These relationships include internalrelations between aspects of self, relations with others and the environment46(e.g., work place, culture, community). The processes whereby we are bothbeing and becoming are manifest intrapsychically and interpersonally and assuch the work of individual, couple and family theorists (Bateson, 1972;Bogdan, 1984; Carson, 1982; Kiesler, 1982) combine to explain both one’srelationship to different aspects of self and one’s relationship to others and thelarger context.Maturana (1978) maintained that the conduct of two or more interactivesystems, over time, establishes the individuals in some form of being-in-the-world as well as creating an interlocking mutuality termed the “consensualdomain”. He uses the concept of “structural coupling” to describe how two ormore 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, mutuallyselecting, mutually triggering domain of state trajectories” (p. 36). Maturana(1978) is referring to interpersonal relationships in his work. However, thesenotions may be applied to intrapersonal functioning as well as interpersonalrelations. If one substitutes the words “aspect of self” for “system” in thequote above, it becomes theoretically possible that the process of structuralcoupling could occur at both the interpersonal and the intrapsychic levels. Themyriad of internalized aspects of self garnered from and evident duringinterpersonal interactions relate within the individual through the process ofstructural coupling.As human beings we are inseparable from our environment. We rely onthe earth and the air we breath to sustain us. According to Sullivan (1944) weexperience a similar need for protection and affiliation. He likens our culturalenvironments to oxygen and food and maintains that our society is necessaryto us as are food, air and water. If Sullivan (1944) and Maturana (1978) are47correct then it may be conceivable that the same patterns of relationship thatcharacterize our interpersonal and cultural existences may also characterize ourintrapsychic existence.The similarity between intrapsychic and interpersonal functioning hasimportant ramifications for the systemic treatment of both individuals andcouples in therapy. In the case of the systemic treatment of individuals, wecan broaden our notions of what constitutes a system to include not only whoand what exists in the clients’ outer worlds (e.g., presenting problems, RacistAttitudes, Homophobia, Bottles of Beer, Cancerous Cheese, family members,spouses, workmates, neighbours, etc.) but “who” and “what” exists in theirinner worlds (e.g., different aspects of self including unloved aspects, painedaspects, hopeful aspects, presenting problems, fear of gays, jars of sadness,little boys and little girls and nests of terror protected by little birds). Theseinner and outer worlds are intimately connected and are often indiscerniblefrom one another. It is for purposes of explanation that these somewhatartificial boundaries are made by clients, therapists and society. However,these distinctions can be exceptionally useful in therapy as representations ofthe whole. The use of metaphor and symbol in ExST (Bateson, 1979; Friesenet al., 1991) provides a kind of shorthand that encapsulates both the individualand couple’s issues and offers a means by which changes in intrapsychic andinterpersonal patterns may be perturbed. Thus, changes in one part of theintrapsychic, interpersonal and/or environmental system have an influence ateach level and may serve to perturb new patterns of interaction or relationalnovelty in the system as a whole.48Recursive patterns of relating.Past painful attachments (Black, 1979; Herman, 1981); presentdifficulties with intimacy (e.g., Carey, 1986); life transitions (e.g., Finkelstein,1988) and the anticipation of continued alienation (Carson, 1982) combine tocreate years of patterned isolation from self and others. Consistently rigid andsequential patterns of relationship between aspects of self and others areobservable phenomena (Breunlin & Schwartz, 1986) that occur within thetherapeutic context. ExST therapists are interested in identifying the recursiverelational 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 beheld accountable for their actions. Informational recursivity refers to a causeand effect chain such that behaviour of one spouse serves as information toinfluence the behaviour of the other in a temporal sequence. Taken in thecontext of violence being the responsibility of the perpetrator, informationalrecursivity allows for the description of abusive sequences of behaviourwithout blaming the battered woman or excusing the abusive man.For example, Joe and Sue decided to obtain couple’s therapy in order toimprove their marriage. This case example is a composite of several cases ofcouple’s therapy and identifying details of the “case” are omitted or changed toprotect confidentiality. Joe completed an intensive residential treatmentprogram for alcoholism one year ago. The couple hoped that Joe’s sobrietywould be the answer to their marital problems. Unfortunately, certain patternsof interaction which characterized the marriage while Joe drank continued to beproblematic after he was sober. Previously, a cycle of binge drinking followedby verbal and physical abuse ended in a honeymoon period of guilty49attentiveness on the part of Joe. This phase was later followed by more bingedrinking and abuse. The same pattern continued after Joe’s sobriety exceptthat alcoholic drinking was no longer involved in the cycle.Following a year of sobriety, the couple’s fights continued to be markedby Joe attacking Sue verbally and physically while she defended herself andretaliated by verbally abusing Joe and throwing things at him. Afterwards, Suewent to a Women’s Shelter or a friend’s house and Joe courted her withremorse and attentiveness until she returned home a few days later. Afterreturning home, Sue remained distrustful of the “new and improved Joe” andkept him at arms length. The uneasy truce would end several months laterwhen fighting escalated and Joe became abusive again. Although Joe obtainedresidential treatment and was able to maintain his sobriety through AA, thepattern of abuse remained and both partners were doubtful that their marriagecould be salvaged. Sue saw marital therapy as a last resort before divorce.This repetitive pattern of violence can be understood at threeinterconnected levels of the system: the environmental, the interpersonal andthe intrapsychic levels. At the environmental level, the struggle between Joeand Sue has socio-cultural significance. That is, certain socio-culturalmessages impinged upon both Joe and Sue promoting a rigid understanding ofappropriate male/female behaviour. For example, societally based warnings torefrain from vulnerable self disclosure, keep control and “got it alone” mayhave affected Joe’s ability to maintain an intimate relationship (Miedzian,1991). In addition, socio-cultural messages regarding Sue’s responsibility inthe relationship for caregiving and loyalty may affect her ability to experiencepersonal agency (Lawler, 1990). In this way, both spouses found their rolesand ways of being together increasingly detrimental.50Interpersonally, both Joe and Sue noticed how incredibly angry theywere with one another. They experienced little trust and anticipated the worstin the relationship. Sue experienced herself as constantly fearful around Joeand Joe experienced something akin to walking on eggshells around Sue.Neither spouse felt loved or supported by the other. They reported that thesefeelings of fear, anger, distrust and hurt exploded into physical and emotionalabuse. Joe broke Sue’s nose on one occasion and she told the emergencydoctor that she fell down the stairs. On another occasion, while escaping, Suepushed Joe down the stairs and threw a plate at him. Both spouses claimedthat although the physical damage had healed, the emotional scars remained.Intrapsychically, both Joe and Sue experienced self invalidation ofunloved and pained aspects of self (Miedzian, 1991). Neither spouseexperienced him or herself as lovable or deserving of love or care. Theirexperiences of one another and their families of origin maintained and sustainedthis relationship to these unloved and undeserving aspects of self.Patterns of relating with self, others and the environment areinterconnected. Cultural prescriptions for rigid gender roles combine to ensurethat interpersonally abusive interactions are reflected intrapsychically asinvalidated aspects of self. The invalidation of suffering aspects of selfconstitutes a form of intrapsychic violence and in this way abusive interactionsare found at each level of the system in the form of cultural, interpersonal andintrapsychic violence.Substantive relational themes.Client stories of emotional, cognitive, physiological and behaviouralpatterns provide cues about the underlying substantive relational themes(Friesen et al., 1991). The notion of substantive relational themes is used to51describe the underlying essence of the clients’ stories. Substantive relationalthemes are descriptive rather than prescriptive since they describe the child’sand the adult’s experience of being in the world. Clients’ recursive patterns ofemotion, cognition, and behaviour embody relational themes such asunlovableness, abandonment, unworthiness, undeservedness and rejection.Substantive relational themes underlie the client’s intrapsychic,interpersonal and environmental experiences in the world. The themes ofunlovableness and abandonment, for example, may be similar to a streamrunning through the client’s experience at each level of the system.Appendices A, B and C depict how the interconnected recursive patterns ofrelating, described earlier, manifest themselves at each level of the system.The three systems depicted in Appendices A, B and C have been divided forthe purposes of detailed explanation. Appendix D depicts a composite view ofthe three recursive patterns and their underlying substantive relational themes.These patterns and their underlying relational themes are maintained viastructural coupling (Maturana, 1978) and socially constructed experience(Gergen, 1985; Hoffman, 1990) such that once a pattern has been set in placeit is sustained until a new experience perturbs it. These new experiences aretermed relational novelty and they constitute change in therapy.Relational NoveltyRelational novelty refers to the enactment of a new way of being inrelationship which alters the thematic undercurrent represented in thesubstantive relational theme. It is within the intrapsychic, interpersonal andenvironmental domains that relational patterns are enacted and relationalnovelty occurs. This section provides a description of the intrapsychic,52interpersonal and environmental systems and how relational novelty isintroduced into each of them through therapy.Presenting problems.Clients have a special relationship with the dilemmas they bring totherapy. One of the tasks of the Experiential Systemic therapist is to helpclients 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 emotionalviolence that continued to occur despite Joe’s sobriety. Relational novelty intherapy can occur most effectively in a safe context and this is of paramountimportance when physical and/or verbal abuse is part of the couple’s pattern ofinteraction. In the case of verbal and/or physical abuse, the safe context iscreated and maintained when the couple continue both individually andcollectively to reiterate their explicit commitment to end the violence in theirrelationship. The establishment of this goal occurs at the outset of therapy andis explicitly agreed to by both spouses before therapy progresses. A frank,open atmosphere facilitates the discussion of this topic from the outset. Inaddition, a safety plan is created between the couple that may include leavingthe house and walking before a fight escalates into violence, phoning thepolice, visiting a shelter, phoning a supportive friend or taking time-outs withrelatives. This plan is developed collaboratively between the therapist and theclients. The therapist must remain sensitive and ready to bring concernsregarding client safety before, during and after sessions to the fore. ExSTmakes the explicit assumption that physical and verbal violence is under thecontrol of the perpetrator and is therefore a matter of choice. Because violence53is controllable and a matter of choice it can end and be replaced byconstructive ways of being.Violence and the threat of violence divided the couple from one anotherand made intimacy impossible. The therapist explored the violence by askingeach for a description of the abuse they endured and the violent acts theycommitted. 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 feettall. Sue said when Joe punched her, she felt like a rag doll and when sheswore and threw things at him, she felt like a frightened avenger. At thisjuncture, the couple may be requested to bring symbols into therapy thatrepresent these aspects of the violence. Joe’s pressure cooker andrepresentation of himself as two feet tall and Sue’s rag doll and frightenedavenger metaphors can be brought to life in therapy. The therapist can exploreeach symbol and track the patterns that occur with respect to them.The intensified experience of relating to concrete symbols such as bottlesof beer, pressure cookers and ragdolls is relationally novel in that the dilemmapresented is framed as something that divides the couple and is thereforeamenable to change. The couple is invited to band together to explore andchange their relationship to violence and remove it from their partnership. Fullyexperiencing their respective relationships to violence at the physiological,emotional, behavioural and cognitive levels also enables the couple to gain anexpanded understanding of the problem and each other. For example, Joe’spressure cooker has a distinct relationship to Sue’s ragdoll and her frightenedavenger while Sue’s frightened avenger has a particular relationship to Joe’spressure cooker and Little Joe. Similarly, Little Joe has an importantrelationship with the pressure cooker while the frightened avenger has a potent54relationship with the ragdoll. These relationships can be intensified in therapyand this exploration is extremely important in the creation of an atmosphere ofexperimentation and collaboration.In sum, relational novelty occurs with respect to the presenting problemwhen, through experiencing their relationship to the dilemma, the clientsengage the problem rather than minimizing it; explore their own and theirpartner’s pain and experience the deleterious effects of violence on theirrelationship in a safe therapeutic context.Intrapsychic system.This system refers to how aspects of self (e.g., unloved) and the individualinterrelate with other aspects of self (e.g., sad). Clients often have a particularrelationship with aspects of themselves which are manifest in the presentingproblem, interpersonal and environmental domains. Relational novelty occursat the intrapsychic level when the client experiences abandoned or unlovedaspects of self while simultaneously experiencing new loving and committedaspects of self in therapy. In addition, the act of entering into a “dialogue”with previously avoided or little understood aspects of self constitutes arelationally novel experience.The bringing of substantive relational themes into individual awarenessthrough therapeutic experiencing is in and of itself novel since many clientstend to stave off deep pain in an effort to cope with it and survive. The bodyand mind are capable of putting the experience and themes underlying traumaon hold just as severe wounds may be anesthetized with ether. Threats ofpunishment or death (Bowlby, 1988); the phenomenon of splitting (Masterson,1981); loyalty and shame can create a situation wherein traumatic occurrencesremain out of client awareness for long periods of time. Traumatic experiences55such as physical, sexual, and psychological abuse, neglect, parental death andloss embody substantive relational themes which may be out of clientawareness but are reflected in their pained ways of being in the world and withthemselves.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 selfblaming aspects of self. Powerless and helpless parts of self further invalidatethese pained aspects and anger, self hatred and hopelessness result (seeAppendix A). The process of experiencing and intensifying these powerlessand helpless parts of self is a relationally novel experience for the couple sinceeach individual gives her or his pain a forum. Hurt, powerless, guilty and/orself blaming aspects of self are transformed into loving, compassionate andhopeful aspects of self as therapy progresses.For example, in a sculpt of their relationship as it appeared in thepresent, both spouses depicted themselves as reaching out while keeping theirguards up. Joe placed himself sideways with one arm extended to Sue whomhe saw as turning away from him. Sue saw herself as reaching out with herright arm while holding the left one in a stop sign position. She positioned Joeto 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 feltdistrustful of Joe, helpless in the marriage and that she blamed herself for theproblems they shared. When the reaching hand was given a voice, Sue criedsaying she wanted Joe to love her but she wondered if he ever would and ifshe really deserved love at all. Joe stood sideways to Sue and from thisposition he experienced extreme frustrations guilt and powerlessness. With hisextended arm, Joe experienced frightening vulnerability and a sense of beingunloved and unworthy of love from Sue and others.56The clients were able to experience their mutual themes of unlovablenessand abandonment together. The experiencing and sharing of the substantiverelational themes that underlay attacking, defending, withdrawing andretaliatory interactions was a novel experience for the clients who until thispoint had characterized each other as spiteful, frightening, deceitful andmanipulative. This intimate exchange marked a shift in the clients usual patternof interaction and represents how the intrapsychic system of functioning isclosely connected to the interpersonal system of functioning.Internersonal system.The client’s relationship to important others can take the form of aspectsof self relating with aspects of the other as presented in the previous sculptingexample. Relations between individuals, family members and the therapistconstitute interpersonal interactions during which presenting problems,intrapsychic aspects of self and environmental influences overlap. Relationalnovelty occurs when spouses, through the process of intensification,experience commonalties in their substantive relational themes and engage in adifferent way of being with one another. The experience of being vulnerablewith one another in a safe context represents a departure from a formerlyabusive cycle. Rigid symmetrically escalating battles or caregiver/caretakercomplementary relationships can be transformed into flexible parallel unions(Lederer and Jackson, 1968) characterized by the latitude to engage in eithersymmetrical or complementary interactions dependent upon the couple’scircumstances and desires.For example, Sue and Joe’s experience in therapy of being vulnerableand unloved while being affirmed by one another constituted a relationallynovel experience in both the intra and interpersonal domains. Intrapersonally,57both Sue and Joe related more lovingly to hurt aspects of self whileinterpersonally they experienced confirmation of their worthiness andlovableness from a validating other. This more compassionate, commonalityseeking experience was radically different from the couple’s usual experienceof one another.Environmental system.The role of environmental influences is worthy of consideration wheneverwe seek to explore human dilemmas. The relationship between aspects of self,one’s interpersonal and familial relationships and the larger socio-culturalcontext is of great importance if we are to understand how it is thatsubstantive relational themes come to be observed and how human beingsshape and are shaped by the world in which they live. The existence of sexist,racist (Ng, 1982), classist and homophobic (Pharr, 1988) events andrelationships come into play at this level. Clients are often involved as victims,perpetrators, interveners or bystanders in sexist, racist, classist or homophobicsocio-cultural acts.Joe’s father was alcoholic. In drunken rages he beat his children andtheir mother. Joe remembered being very angry at his father and betrayed byhis mother when she would not leave the marriage. He described himself, hisbrother and his mother as “sitting ducks.” Sue’s mother was a binge drinkerwho 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 alternatelysuggested visiting child care workers, parenting programs, drug and alcoholcounselling and threatened to apprehend the children.58The themes of unlovableness and abandonment can be observed in boththese family stories. But where do we look for answers or ways to understandthis kind of pain? We may move quickly to blame Joe’s mother for notprotecting her children or herself from her husband or we may blame Sue’smother for abandoning her children. Or we may view the Social Services lackof success with the families and reluctance to apprehend the children as childabuse. We may wish to view Joe’s father and Sue’s mother as abusiveoffenders or as individuals badly in need of treatment. We may choose not towonder about Sue’s father at all or we may ask about his responsibility to thefamily. 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 atlarge.One socio-cultural lens through which to view the plight of Joe and Sueand their families of origin is that of gender socialization, It has beenhypothesized that violence towards women and children has been madeincreasingly possible by outmoded and rigid views of appropriate male andfemale behaviour (Barry, 1979; Brownmiller, 1975; Lerner, 1986; Luxton,1982; Martin, 1983). The difficulties Joe and Sue encounter reflect thispertinent concern. If Joe has adopted the socio-cultural message that “menshouldn’t need anyone,” this would have profound effects on Joe’s ability tobe in an intimate relationship which necessitates both care-giving and carereceiving behaviour. The message that a committed focus on being in anintimate relationship is a sign of “dependency and symbiosis” reflects a similarcultural bias against the value of relatedness (Lawler, 1990) and hasramifications for Sue’s ability to give and receive care. It is in the realm ofrelatedness that we can gain both competence in caring for others and a59healthy sense of self (Lawler, 1990) and it is also in this realm that peopleexperience both trauma and healing. Perhaps the means to our physicalsurvival and our psychological health is the acceptance of our interdependenceand the development of ways to facilitate relational healing. Relational noveltyin cultural terms would provide for the experiencing of new possibilities offeeling, thought and action and open the way for people to continue findingnew solutions to their problems (Friesen, et al., 1991). These solutions mayinvolve the jettisoning of rigid socio-cultural role expectations in favour of moreflexible ways of relating. The experiencing of new ways of being as a culturewill involve the interconnection of the three levels of the human system namelythe intrapersonal, interpersonal and environmental domains.The process of intensification.An important means by which clients therapeutically experience theirrelationships with the presenting problem, different aspects of self and others;the therapist; and the environment is through intensification, Intensification isthe process with which the therapist aids clients in evoking, enhancing anddeepening their substantive relational themes and introducing relational noveltyinto the system. This method of amplification of experience is similar tofocussing (Gendlin, 1978; Mathieu-Coughlan & Klein, 1984) or intensifying(Greenberg & Safran, 1987). Through experiential and symbolic meanstherapists tap the four aspects of human functioning (behaviour, cognition,emotion and physiology) and intensify the client’s experience. Therapists useexpressive means such as art, storytelling, sculpting, enactment and guidedfantasy to heighten client themes (Friesen et al., 1991). Therapists alsoemploy symbolic externalizing transactions (Friesen et al.) to bring symptoms,aspects of self, and dreams to life. In addition, meaning shift transactions60(Friesen et al.) are utilized to expand clients’ alternatives through reframing,questions and positive connotation. Finally, ceremonial transactions (Friesen etal.) are created to mark client and therapist changes through celebration andritual. The experiential techniques used to intensify experience are drawn andmodified from Symbolic-Experiential Family Therapy (Whitaker & Keith, 1981);Gestalt Therapy (Pens, 1973); Psychodrama (Fine, 1979); Family of Originwork (Bowen, 1978) and Structural Strategic Therapy (Andolfi, Angelo, Menghiand Nicolo-Lorigliano, 1983; Madanes, 1981)The therapist’s collaborative (Friesen et al., 1991) or relationalparticipant stance (Chrzanowski, 1982) is essential to the process of clientexperiencing. Therapists must be experientially involved with their clients inorder to be adequate guides to the experiencing process. A more removedtherapeutic stance decreases the potential intensity inherent in therapeuticexperiencing and is based on the traditional assumption that it is possible forthe therapist to be solely an observer of the system (Sluzki, 1985; Varela,1989). Transformational experiencing in therapy is an wholistic here-and-nowencounter with ones own ontological reality and substantive relational themes.In conclusion, client’s stories of transformation are heroic tales thatrequire “the courage to face the trials and to bring a whole new body ofpossibilities into the field of interpreted experience” (Campbell, 1988, p. 41).Relational novelty is the creation of these new alternatives and thesimultaneous experiencing of them. Underlying these novel experiences arechanged substantive relational themes that describe compassionate interactionswith self, others and the world. Themes of relationship such as hope,forgiveness, caring and acceptance describe transformed ways of being forindividuals and couples whose prior experience has reflected pained ways ofbeing in the world.61ExST 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 StructuralStrategic family and individual therapy and as such embodies a relationalparadigm. This system of thought recognizes that as humans we cannot notbe attached. The process of individuation is achieved in relation to otherpeople, parts of self and the environment just as necessities of affiliation arecontextually and relationally based. Culturally, this notion defies the ideal of“personal individuality” (Sullivan, 1944) and maintains that this is an impossiblestate while arguing for individual commitment to the collective discourse. Italso includes the collective valuing of the individual’s contribution whileunderstanding the inseparable nature of our existence together. Thisunderstanding, when pared down, centers on what occurs “between” entities.The realm of relatedness exists between Me, Myself and I; I and Thou; Us andThem; and Me and It and ultimately, it is in relationship that we experienceboth the profane and the sacred (Berenson, 1990).Experiential Systemic Therapy Empirical StatusThis section will describe a recent outcome study testing the efficacy ofExST (Grigg, 1994). The goal of describing this outcome investigation is todetail the research context and rationale for the present process study of ExSTchange theory.Grigg (1994) conducted a differential treatment outcome studycomparing ExST to a behavioural monitoring treatment called SupportedFeedback Therapy (SFT). In addition, he compared ExST for the individualtreatment of alcohol dependency to experiential systemic marital therapy forthe same problem. One hundred and fourteen families were randomly assigned62to one of three treatment conditions including either ExST individual treatmentfocussed on the alcoholic drinker or ExST couple treatment focussed on thealcoholic and his spouse or SET. SFT was provided for the individual alcoholiconly. The participating families met the inclusion criteria requiring a maritallydistressed alcohol dependent father and a non-alcohol abusing mother residingtogether with at least one child living at home. Pretest, posttest and threemonth follow-up data were collected using questionnaires tapping alcohol use,intrapersonal well-being, couple satisfaction and adjustment and familysatisfaction. Therapy was conducted at two out-patient clinics in a rural andurban setting respectively. Participants engaged in up to 15 sessions oftherapy conducted over a 20 week period.While 114 families were screened into the study, 60 families completedtherapy and all the questionnaires at each measurement occasion as requiredby the data analysis. A multivariate analysis of the data indicated nosignificant differences between ExST and SET, however both treatments wereshown to have fostered highly significant and clinically relevant improvementson indices of drinking behaviour, intrapersonal symptomatology, maritaladjustment and family satisfaction. There were no significant differencesbetween ExST couples treatment and ExST individual treatment but bothspouses reported highly significant post-treatment changes which weresustained at follow-up.The clinical relevancy of these findings centered on the important clientchanges reported in this study. For example, as a group, the alcoholics scoredin the high end of the moderate alcohol dependency range and were found toscore in the psychiatrically symptomatic range at pretest. In addition, thealcoholics reported marital distress and low family satisfaction at pretest.However, these men reported mild alcohol dependency, psychiatric63symptomatology in the normal range, non-distressed marital adjustment andnormal levels of family satisfaction at posttest. Secondly, similar to the men,the non-alcoholic women experienced psychiatric symptomatology in thenormal range, reduced marital distress and normal levels of family satisfactionat 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 reasonssince participants may have been required to wait 20 weeks before beginningtherapy. In addition, clients who received SFT were not required to completefollow-up questionnaires therefore no data exists regarding the enduring qualityof SFT changes.Nevertheless, this outcome study indicated that ExST is an effectivetherapy for both the individual and couple treatment of alcohol dependency.The large sample size, varied clinical settings, and the ecological assessmentpackage employing a variety of standardized instruments made this studyunique. In addition, the multivariate approach to data analysis and the caretaken to monitor the delivery of the therapy rendered this study a significantcontribution to the field of marital and family therapy for substance abuseproblems.The empirically demonstrated effectiveness of ExST is important to thisstudy since a question could arise concerning the utility of delving into a singlecase of either an untested therapy or an ineffective one. Since ExST iseffective, with a large representative sample, exploration of a single successfulcase to understand how change occurred is both clinically and theoreticallyuseful. In the past, marital and family therapy outcome studies have beencritiqued for failing to provide information regarding how the therapy studiedwas effective (Pinsof, 1981; Safran et al., 1988). While this study is not64designed to account for the creation of successful change in a large sample ofExST cases (large “0” outcome), a single case study of in-session or proximalchange can shed light upon the change process as it occurs in xST.A review of previous marital and family therapy process studies centeringon therapy models including ExST will be undertaken in the next section. Thisliterature review will survey previous therapy process research results toexamine the findings for their utility with respect to theory building and theexpansion of knowledge regarding the therapy theory under investigation.Also, this examination will be employed to inform the conduct of this therapyprocess study.Marital and Family Therapy Process ResearchThe study of therapy-in-progress has been made possible with the adventof audio and video recordings of therapy practice. The examination of therapy-as-it-occurs provides for an enhanced understanding of therapy process andtherapy change. The probing of audio and videotapes of therapy has beentraditionally achieved through the use of coding systems that quantify aspectsof therapy process. More recently, efforts to explore therapy-as-it-occurs haveincluded the hermeneutical analysis of therapeutic discourse on an utterance-by-utterance basis providing a qualitative examination of therapy process andtherapy change. The following sections will offer a review of both quantitativeand qualitative research efforts designed to explore therapy-as-it-occurs for thepurpose of increasing knowledge concerning marital and family therapy processand change. This section will review the marital and family therapy processliterature based on various therapy models including ExST to situate this studyin the marital and family therapy process literature.65Quantitative Marital and Family Therapy Process ResearchThe following review will survey studies examining marital and familytherapy process using quantitative methods that inspect videotaped oraudiotaped 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 afamily with a schizophrenic daughter. The investigators believed that laughterwas the family’s means of disguising anxiety and was both a function ofintrapersonal and situational factors. Zuk et al. relied upon a laughterfrequency count based on the last 13 sessions of family psychotherapy. Theresearchers coded and summarized client laughter across sessions. Thelaughter measure reflected which family member laughed, at which point in thesession they laughed and whose comment triggered the laughter. Zuk et al.demonstrated that mother and father laughed most during the first 15 minutesof therapy and their daughter laughed most 30-45 minutes into the session.The investigators concluded that the schizophrenic’s anxiety increased as thesession intensified. Unfortunately, the study did not tap client anxiety. Also,the use of a frequency count precluded an understanding of what kinds ofstatements precipitated the laughter and how the laughter was associated withclient affect. This early quantitative family therapy study targeted generalprocess and did not relate therapy process to client change. In addition, themodel of treatment used in the study was not clearly articulated and thetherapist’s contribution to the family dynamics was not addressed.Winer (1971) improved upon Zuk et al.’s (1963) study by attempting toinvestigate client change as it occurred in couples group therapy. Four coupleswere engaged in therapy with therapist/theoretician Murray Bowen althoughnot every spouse attended every session. Winer was interested in verbal66markers of couple change captured on audio recordings of live sessionscovering a 3.5 year span. In particular, she was concerned with indicators ofchange with respect to increased statements of self-differentiation on the partof clients. The construct, self-differentiation, refers to the ability to speak foroneself, the ability to refrain from engaging in blaming behaviour as well asbeing goal directed and desirous of self change rather than change in others.Self-differentiation is an important construct and change marker in Boweniantherapy.Winer (1971) hypothesized that as clients became more differentiated,the number of “we”, “our” and “us” statements would decrease. Winerdeveloped a Change Ratio to quantify “differentiated” and “nondifferentiated”client statements. The Change Ratio was a qualified pronoun count based onthe 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, thegreater the degree of differentiation of self. The pronoun count change indexwas meant to reflect decreased symbiotic involvement between couples. Winercompared two early sessions in which all couples were present to a sessioncloser to the end of the course of therapy. The study findings indicated thatsix 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 latersessions. Unfortunately, Winer’s study was limited by the utilization of poorselection criteria for coded sessions; a lack of formal analysis of the datagenerated and an informal after-the-fact analysis of couple scores. Winer wasconcerned mainly with whether or not clients changed with regards to selfdifferentiation as opposed to how spouses came to use more “I” statements as67a result of therapy. Also, the therapist’s role in the client’s shift towards self-differentiation was unclear.In a similar vein, Postner, Guttman, Sigal, Epstein, and Rakoff (1971)coded familial affective expression and the quality and quantity of both familyand therapist participation and related these variables to final therapy outcome.Postner et al. studied family therapy with adolescents who were brought totherapy for a variety of issues including discipline problems, poor schoolattendance, attempted suicide and perversions. Eleven families participated inthe study receiving a treatment designed to bring reward and punishmentpatterns to the family’s attention, interpret family transactions and exploremotivation and transference phenomena as it related to family dynamics.Postner et al. sampled 20 minute sections of audiotaped therapy at six weekintervals obtaining a total of 49, 20 minute transcripts for the 11 participatingfamilies. Four coders recorded therapist behaviours and family affectiveexpression. The therapist behaviour measuring tool coded therapist “Drive”(e.g., stimulating family interaction, requesting information, giving support) andtherapist “Interpretation” (e.g., making process comments and identifying theunderlying meaning of family dynamics). The family measure recorded negativeor 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 goodoutcome and those who displayed a poor outcome as measured in an interviewand on a self report questionnaire. Although there were no significantdifferences between the families with respect to affective expression andtherapy outcome, the study demonstrated that, regardless of outcome, clientsspoke more to family members than they did to the therapist as therapyprogressed. The investigators also observed that the expression of pleasant or68Welfare emotions increased over time in therapy. Postner et al. accounted foran inability to demonstrate a relationship between family emotion and therapyoutcome by noting that the session sampling method employed reduced theopportunity for tapping subtle family changes. This investigation mappedcertain shifts in therapist and client speech over the course of therapy but wasnot intended to explore how these shifts were fostered by the treatment.However, Postner et al. focussed on both the therapists and the familiesverbalizations in their study which differed from earlier efforts.Dechenne (1973) also focussed on couples and therapists in a study ofhow spouses differed in their levels of experiencing when speaking to oneanother and the therapist. Dechenne pioneered the marital therapy applicationof a sophisticated verbal process measuring instrument called The ExperiencingScale (see Klein, Mathieu-Coughlan, & Keisler, 1986 for a recent version). Thescale is noted for its design and predictive and discriminant validity (Pinsof,1988). Ten couples were included in the study in which one hour of therapywas audiotaped and coded. Unfortunately, the couple’s presenting problemsand which session was coded was not revealed. The nine therapists whoparticipated in the study were said to have been eclectic but all engaged in thefacilitation of deepened client experiencing. Dechenne found that spouseswere more likely to engage in deep experiencing behaviour in response totherapists than in response to one another. He observed that when thetherapist spoke to a client, the client responded more expressively than whenspoken to by a spouse. Dechenne concluded that marital relationships in whichdeep experiencing occurred were more constructive and less structure boundthan relationships in which deep experiencing did not occur. Although therelationship between deep experiencing and subsequent couple change was not69addressed in this study, the notion that deep experiencing was related toincreased marital health was interesting from a theoretical viewpoint.To increase the clinical relevancy of therapy process research, someinvestigators turned their attention to the study of important clinicalphenomena. Patterson and Forgatch (1985) conducted two studies examiningtherapist impact on client resistance. In the first study, they explored sixmother-therapist dyads to observe the potential impact of therapist activities onthe mother’s behaviour. Other family members were present during thesessions but only data concerning mother-therapist interaction was analyzed.The families were in treatment for child management problems. The treatmentoffered was characterized by a parent training model drawn from social learningtheory in which the mothers were taught methods to alter a problem child’sbehaviour.Patterson and Forgatch (1985) hypothesized that “therapist efforts toteach and confront would be followed by increased likelihoods ofnoncompliance” (p. 847). The coded sessions averaged 47 minutes in lengthand the average number of sessions was 21. Cases were randomly assigned tothe coders by treatment session preventing coder bias with respect to eitherfamiliarity with the family or expectation based on sequence. Client andtherapist behaviour was scored separately by two groups of coders. Clientbehaviour was recorded on the Client Noncompliance Code which includedcategories such as interruption, negative attitude, confrontation, pursuing ownagenda and failure to track. Therapist behaviour was scored on the TherapistBehaviour Code which tapped support, teaching, questioning, confronting,facilitating and reframing behaviour. The investigators found that therapisteffort to teach and confront mothers was associated with noncompliance while70therapist use of facilitation and support decreased the likelihood ofnoncompliance.In a second study, Patterson and Forgatch (1985) sought to discovercausal links between therapist efforts to teach and confront clients and theirsubsequent noncompliance. The investigators used an ABAB design whereinthey instructed therapists to refrain from teaching and confronting in the Acondition and begin confronting and teaching in the B condition. Eachcondition lasted 8-12 minutes and a shift from the A condition to the Bcondition was signalled to the raters via the manipulation of a notebook. Thetherapist left the notebook on his or her lap during the A condition and placed iton the floor in the B condition.Patterson and Forgatch (1985) noted that it was difficult for thetherapists to return to baseline when required and the clinicians doubled theirteaching and confronting behaviours during the second nonteach/nonconfrontcondition. Nevertheless, the study indicated that therapist teaching andconfronting behaviours increased the likelihood of client resistance. Pattersonand Forgatch concluded that therapists employing social learning parenttraining models should learn skills and techniques that will ameliorate resistantbehaviours evoked when parent skill training is undertaken.While theoretically grounded units of analysis were studied and boththerapist and client behaviour was coded in this investigation, therapist impacton client noncompliance was not linked to proximal (in-session), intermediate(between session) or long-term therapy outcome. Despite the theoretical andclinical relevance of the results, the findings were not employed to commentupon the social learning parent training techniques that engendered resistance.Few marital and family therapy studies account for the relationshipbetween therapy process, therapy theory and client change. Yet, research that71leads to the delineation of models of change in specific in-session contexts isconsidered to be crucial to the growth of marital therapy (Beach & O’Leary,1986; Johnson & Greenberg, 1988). In an attempt to address therapy changeprocess and theory, Johnson and Greenberg (1988) focussed on clientperformance when resolving negative interaction cycles during an effectivemarital therapy called Emotionally Focussed Therapy (EFT). The investigatorswere interested in exploring the in-session processes that were associated withsuccessful EFT outcome. EFT emphasizes the role of affect, and intrapsychicexperience in therapeutic change. EFT follows a systemic approach thatfocuses on communication and interactional cycles in the maintenance ofmarital problems. EFT is designed to help clients access and explore keyemotional experiences so that new aspects of self are encountered therebyevoking new responses from the marital partner.EFT change theory identifies two process variables associated withpositive outcome including deep levels of experiencing and correspondingaffiliative and accepting interpersonal responses. These two change processvariables were measured using The Experiencing Scale (ES) (Klein, MathieuCoughlan, & Keisler, 1986) and the Structural Analysis of Social Behaviour(SASB) (Benjamin, 1974). The Experiencing Scale coded the level of clientemotional and experiential involvement in therapy. The SASB codedinterpersonal responses that constituted and elicited change includingautonomous rather than submissive or coercive interactions and affiliativerather than hostile or distancing transactions.Johnson and Greenberg (1988) hypothesized that couples who showedimprovement in therapy would exhibit high levels of experiencing, moreautonomous and affiliative responses and more instances of increasedvulnerability (softening). Six couples were selected for the study and divided72into two groups of three. The poor outcome group revealed the least amountof change in marital distress as measured by the Dyadic Adjustment Scale(DAS) (Spanier, 1976) and the good outcome group revealed the largestamount of marital change on the DAS.A best session of therapy was selected for each couple in each group. Abest session consisted of one in which the therapist rated the couple as makingthe most progress and the couple reported the session as being most useful inresolving their issues. All verbal statements in the last half of the best sessionswere transcribed and coded by independent raters blind to the researchhypotheses and the couple’s therapy outcome. The results of the studyshowed that couples who had successful therapy outcomes engaged in moreaffiliative and autonomous responses and deeper experiencing than did coupleswho did not improve. In addition, evidence of “softening” was found to occurin the best sessions of successful EFT while the “softening” change event wasabsent from the unsuccessful couples’ sessions.Johnson and Greenberg (1988) suggested that “successful couplesdisplayed less dominance and more affiliation in their interactions, with blamersreplacing hostile and coercive behavior towards their spouses with moreaffiliative and accepting behaviors” (p. 181). In addition, successful coupleshad deeper levels of disclosure and experiencing than did unsuccessful couples.The investigators suggested that therapists, who employ experientialapproaches to marital and family therapy such as EFT, focus on facilitatingdeeper levels of experiencing, self-disclosure and affective exploration. Thestudy is theoretically relevant in that the investigation supports some of theexplanations for change outlined in EFT theory.Johnson and Greenberg’s (1988) effort to explore in-session processesthat contributed to successful EFT outcome was an important contribution to73the field of marital and family therapy process research. By focussing on theprocess of change in EFT, the investigators hoped to explain how certaininterventions created change in a given therapeutic context. Johnson &Greenberg endeavoured to specify therapeutically helpful client behaviours andthe interventions that fostered them. However, questions arise regarding thetherapist role in the facilitation of deep experiencing and softening events. Inaddition, the means by which these change events were created throughinteractions between therapists and couples remained unaddressed. Finally,the contribution of the therapy sessions surrounding the “best” hours could notbe tapped when the “best” sessions were removed from the rest of treatmentfor coding purposes.A review of the quantitative marital and family therapy process literaturerevealed an evolving interest in how positive client change was fostered intherapy. However, the review of literature highlighted some of the clinical,theoretical and methodological limits encountered when attempts were made tocapture complex interactions between therapy participants using coding andrating systems. The review of literature showed that coding systems designedto quantify therapy process have difficulty tapping the complexity of therapyparticipant interaction and the subtleties of the therapeutic process. Indeed,previous researchers and reviewers have questioned the reliance onquantitative methods to pursue therapy process research goals (Wynne, 1988).In an overview of family therapy research, Wynne lamented the reduced clinicaland theoretical contributions made when quantitative methods were employedto understand therapy change process. As a result, Wynne recommended thatchange process research involve exploratory, discovery-oriented, single andmultiple case study approaches. Also, Yin (1989) suggested that researchquestions focussed on how an event, phenomenon, situation, state or process74came to exist be addressed through qualitative means using case study designmethods. The following section provides a survey of investigations answeringthe call for qualitative studies that contribute to knowledge regarding maritaland family therapy process and theory.Qualitative Marital and Family TheraDv Process ResearchThis section will review qualitative marital and family therapy processresearch studies that have applied discourse analysis methods to the study oftherapy as it occurs. However, a study centered on group therapy process hasbeen included in the review since it delved into interactions between a therapistand more than one client. Finally, two qualitative studies focussing on ExSTprocess and technique will be reviewed.Turner (1972) identified the socio-organizational properties of grouptherapy as a social structure. He asked the question: How is group therapysocially organized such that a therapist would be prompted to comment on thestart of the group? Turner noted that the group therapist repeatedly signaledthe formal start of the group via three different openers. They includedutterances such as “Look before we start . . .“, “Well, we might as well start.“, “Well, I think what we had better do is start.” Turner used discourseexcerpts to establish his findings and distilled five properties of pre-therapy andtherapy talk. Turner identified two pre-therapy talk properties which included:1. Pre-therapy talk is small talk done while waiting for therapy tobegin. All participants must be present or accounted for in orderto begin the session. Pre-therapy talk becomes irrelevant whenthe therapist or authorized “starter” enters.2. Small talk is generated via the embracing of a topic with which thebroadest number of participants can engage. Alternately, if the75topic is inaccessible, the excluded participant will relate the topicto another known party and therein gain access to theconversation. For example, two group members were discussingworking in a mill and logging camp. Another participant wasunable to join in the conversation with her own experience.However, she gained access to the discussion by introducing herbrother’s desire to work in these areas.Turner also identified three social organizing properties embedded intherapy talk. These included:1. The clients’ experiences of accountability to the group promptthem to formulate their presenting problems in such a way as toidentify commonalties between themselves and other groupmembers. In sum, clients’ attempt to construct accounts of theirconcerns with which other group members may resonate.2. Clients are responsible for delineating and meeting their own goalsin group therapy and sometimes do not understand that this taskis an integral part of their treatment. The therapist did notcomment on how well the clients were doing in therapy nor did heanswer questions as to why the client was attending therapy.3. There is no time-out in group therapy since the therapist gives a“theory governed hearing” to all participants during therapy. Thatis, all group member discussion is understood to be linked to clientissues during the therapy period. The therapist was considered tobe the session initiator and silence acted as a boundary markerbetween pre-therapy and therapy talk. References to the start oftherapy served to differentiate between the ordinary, face value76pre-therapy talk and the therapy oriented session talk in which allutterances were considered significant to treatment.In this study, Turner (1972) offered clinicians an understanding of howordinary conversation was different from therapy conversation. He alsoidentified clients struggles with creating and meeting their own goals in theabsence of therapist intervention. And lastly, Turner observed a similaritybetween pre-therapy and therapy talk in that group members construct speechacts in order to be included in the group discussion in either instance.A paucity of information about the therapy theory employed by thetherapist in Turner’s (1972) study, identified the importance of the articulationof theory in discourse analysis investigations. For example, Turner’sconclusions may have been augmented by a broader discussion of group theoryand a report of which sessions were used in the analysis. Unfortunately, it isdifficult to know how many times the group met and in which session thediscourse excerpted is situated. The result of these oversights was to preventan analysis of the discourse based on the developmental life of the group. Forexample, the group’s pursuit of identifying commonalties in their presentingproblems may be a function of the early life of the group during which timeinclusion issues come to the fore (Schutz, 1958).Turner’s (1972) study could have benefited from a further exposition ofthe theory that governed the therapist’s “theory-governed hearing” of thegroup members’ utterances. For example, the assumption behind the rule thattherapists must not answer questions about how the client is doing in therapyor why the client attends therapy in the first place is theory driven. Thetechnique of reflecting these concerns back to the client is also theory based.Turner refrained from explicitly delineating the therapist’s theory of change and77in so doing appeared to support the notion that this rule and technique aregeneric therapy maxims that transcend a particular theoretical orientation.Unlike Turner (1972), Gale (1991) provided a more detailed articulationof the therapy theory under investigation. Gale (1991) used conversationanalysis to answer two research questions. He was concerned withunderstanding theorist-clinician William O’Hanlon’s therapy skills and howchange was constructed in Solution Oriented therapy (Gale, 1989, 1991). Gale(1991) selectively quoted examples of transcript culled from a 45 minutetherapy session in which the presenting problem was the husband’s affair.This was the first and only session with the couple and was conducted beforea live audience.Gale (1991) utilized discourse examples to illustrate the wife’s,husband’s and therapist’s agendas in therapy and to compile a list of therapistinterventions. He noted the manner in which the therapist worked to changethe session topic from a problem oriented one to a solution oriented focus.According to Gale (1991), the wife pursued an agenda designed to blameher husband for an extra-marital affair, withhold forgiveness, punish him andrefuse to accept responsibility for (in the client’s words) “driving” him to theother woman. The husband’s agenda was to remain noncommittal about thestatus of the affair, refrain from accepting responsibility for it and appease bothhis wife and the therapist. The therapist’s agenda was to maintain a focus onhow the wife could put the affair behind her, regain trust in her husband andend dwelling on the affair. He also encouraged the couple to share theirfeelings with one another at scheduled times, engage in renewing theirwedding vows and burning the bill for the roses (a gift for the girlfriend).Gale (1991) documented nine procedures whereby the therapist pursuedthis agenda. These included pursuing solution oriented responses, overlapping78client talk and reformulation. Gale (1991) also documented interventions suchas ignoring the listener’s misunderstandings and rejections of the therapist’sassertions, modifying an assertion, clarifying unclear references and offering acandidate answer. Gale’s (1991) analysis also revealed O’Hanlon’s techniqueof posing rhetorical questions or problems and answering them and engaging inhumor designed to change the topic from a problem oriented focus to asolution oriented focus.The following example, illustrates Gale’s (1989) understandings of thefirst four procedures described above. The therapist suggested that thehusband believed he had paid his dues and admitted he was wrong and crazyto have had an affair. However, based on the passage selected for analysis, itis unclear as to whether or not the husband recognized any wrongdoing. Itappeared that O’Hanlon diminished the importance of a yet ongoing affair inpursuit of a solution. He attributed culpability and a statement that the affairhad ended to a noticeably silent husband (reformulation). The therapist thenturned to an exploration of a time when the relationship was more enjoyable(pursuing solution oriented responses). The husband immediately respondedwith a story about an enjoyable day trip with his wife to which the womancountered with an alternate view. She did not perceive the day trip to thegame park as enjoyable because the husband still maintained a relationshipwith his girlfriend. The woman then questioned her husband’s currentcommitment to the marriage until the therapist interrupted (overlapping clienttalk). O’Hanlon “ignores what the wife had just said about her concerns andinstead, returns to the topic of the (enjoyable) day trip . .. “(Gale, 1989,p. 89) (ignoring the listener). When the therapist requested more accounts ofgood times in the relationship (pursuing solution oriented responses), thewoman reiterated her inability to trust her husband.79Gale (1991) concluded that O’Hanlon’s therapy skills could beencapsulated in the nine procedures cited above and therapeutic change wasconstructed by the therapist and clients in an interactive system. That is, Gale(1991) observed that change was made possible when the therapistaccommodated the client’s therapeutic agendas through talk but maintained asolution oriented focus.Gale (1991) provided a strong description of the therapy theory behindthe treatment being analyzed. He also clearly articulated and answered his tworesearch questions. This study represents an influential process description ofsolution-oriented-therapy-in-practice conducted by one of its creators.However, an expansion upon the clinical implications of the study would havebeen helpful to practitioners.O’Hanlon’s theoretical orientation from the point of view of the impact ithad on the clients and particularly on the woman involved remainedunaddressed. Gale (personal communication, October, 1993) viewed this typeof analysis to be important but outside the scope of the study. Nevertheless, itwould have been clinically and theoretically interesting if Gale (1989) couldhave expanded upon his observation that “the wife would paint one picture ofthe husband, while O’Hanlon would try to describe another understanding ofthe husband’s behaviour” (p. 189). For example, during O’Hanlon’s attemptsto positively reformulate the husband’s behaviour, the husband remained silentand watchful. It appeared that the technique of reformulation may havecontributed to the underplaying of the woman’s distress while offering thehusband an opportunity to temporarily avoid owning his behaviour andunderstanding his wife’s pain. Gale’s observations of the couple’s reactions tothe downplaying of an ongoing affair as part of a solution oriented agenda wereinteresting from a theoretical point of view. In particular, it seems that ignoring80certain types of problem focussed concerns may sometimes delay resolutionand closure and hinder a solution oriente