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Change maintenance after therapeutic enactment : a critical incident study The show must go on 2002

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C H A N G E M A I N T E N A N C E A F T E R THERAPEUTIC E N A C T M E N T : A CRITICAL INCIDENT STUDY The show must go on By JODI L E E F O T H E R I N G H A M B. A . , The University of Manitoba, 1983 B.Ed., The University of Manitoba, 1989 A THESIS SUBMITTED IN P A R T I A L F U L F I L L M E N T OF THE REQUIREMENTS FOR THE D E G R E E OF M A S T E R OF ARTS In T H E F A C U L T Y OF G R A D U A T E STUDIES (Department of Educational and Counselling Psychology and Special Education) We accept this thesis as conforming tojhe-required standard THE UNIVERSITY OF BRITISH C O L U M B I A December 2002 © Jodi Lee Fotheringham, 2002 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of ^AxAAd^^Sh c W r f u ^ , fAC^^jj - . The University of British Columbia Vancouver, Canada Date DE-6 (2/88) ABSTRACT Peoples' efforts to change, grow, and heal take place under a variety of conditions. The goal of any therapeutic intervention is to provide exceptional conditions of safety and skill to strategically promote change. The majority of psychotherapeutic investigation has focused on its own outcome effectiveness to the detriment of a broader understanding of change (Karoly & Wheeler Anderson, 2000; Meichenbaum, 1997; Prochaska, 1999). The purpose of this study is to contribute to an understanding of how people continue their own change process after participating in therapy. The present study uses Flanagan's (1954) Critical Incident Method to investigate what factors facilitated participants' efforts to maintain the change they achieved through therapeutic enactment. Co-researchers in this study were individuals who reported significant change as a result of their experience as leads in their own enactments. These co-researchers were asked to engage in self-reflection, and to articulate their experience of critical incidents which helped or hindered them in the consolidation of their changes. They were interviewed once to collect the data, and again a second time in order to validate the data. Five additional procedures were used to establish validity and reliability of the data: independent raters, expert raters, exhaustiveness check, participation rate, and theoretical agreement. A total of 125 critical incidents were reported by eight co-researchers. Six facilitative action categories were developed from this data: (a) connecting with others, (b) practicing, (c) remembering, (d) connecting with emotional and physical aspects of self, (e) resolving, (f) contemplating. Strong theoretical agreement was established between these helpful activities and nine of the ten processes of change determined through the studies of Prochaska and colleagues (Prochaska, Johnson, & Lee, 1998). The source or contexts o f the incidents also proved to be significant in facilitating change maintenance. A taxonomy of action categories and context sub-categories was developed to provide some ideas to promote change maintenance. The taxonomy is based on a compilation of the results from this study and relevant literature. Special attention was paid to two of the most commonly and frequently used facilitative activities: connecting with others and practicing. Theoretical, practical, and research implications are discussed related to these facilitative action categories. iii T A B L E OF CONTENTS ABSTRACT .. ., • • • • • • • • - i i T A B L E OF C O N T E N T S . . . . . . . . . . : . . . . . . . . . . . . . . . . i \ LIST OF T A B L E S . . . . . vii LIST OF FIGURES • viii A C K N O W L E D G E M E N T S i> CHAPTER 1 INTRODUCTION • 1 Background - Problem • Purpose Significance • 2 LITERATURE REVIEW Introduction Theory & Practice: Psychodrama to Therapeutic Enactment Research: Psychodrama to Therapeutic Enactment Change: Theory & Research 3 M E T H O D O L O G Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction Critical Incident Technique iv Co-researchers 31 Interview 32 Analysis — . .34 4 RESULTS ........38 Introduction 38 Description of the Categories • 39 Connecting with others 39 Practicing 41 Remembering 43 Connecting with emotional & physical aspects of self 45 Resolving 46 Contemplating ; • 48 Validation Procedures 49 Co-researchers' Validation 50 Independent Raters 53 Exhaustiveness 55 Participation Rate 55 Expert Validation 56 Theoretical Agreement........ ....58 Connecting with others ......59 Practicing 60 Connecting with emotional & physical aspects of self 61 Contemplating 63 5 DISCUSSION 65 Summary of Results 65 Limitations 66 Theoretical Implications 69 Practical Implications • 78 Research Implications • 84 Voice of the Principal Researcher 87 REFERENCES 90 APPENDICES 95 A. Poster 95 B. Study Introduction Letter 96 C. Letter of Informed Consent 98 D. Orientation Statement 100 E. Interview Questions 101 F. Second Interview Protocol 103 G. Planned Happenstance Steps and Questions 105 vi LIST OF TABLES T A B L E Page 1. Categories and Frequencies of Critical Incidents .40 2. Categories, Frequencies, and Participation Rates 56 a 3. Ideas to Promote Change Maintenance: Action categories and their contexts 66 4. Ideas to Promote Change Maintenance: A compilation of research and literature based action categories and their contexts 85 vii LIST OF FIGURES FIGURE 1. Formation and revision of the action categories throughout the data analysi process... 2. Comparison of the change maintenance action categories to the processes ( change • 70 Page 52 viii ACKNOWLEDGEMENTS A special thanks goes to Dr. Marv Westwood and Dr. Victoria Alfonso who have provided the kind of guidance and encouragement that graduate students hope for and are sometimes lucky enough to receive. There were pitfalls along the way; you coaxed me out, and when necessary pulled me out! Thank you for your wisdom, as well as your down to earth support. Thanks also to Dr. Rod McCormick for your willingness to offer practical help through different points of the investigation process. Certainly the people at the heart of this venture are the eight co-researchers who were willing to take the time and the risk to share the details of their personal experience and change process. I appreciate and admire your courage to open yourselves up. Thank you for your contribution to a better understanding of how people change, as well as to the development of the practice of therapeutic enactment. It was an honour to get to know you and benefit from your wisdom. Like the co-researchers in this study, the facilitative activity that most aided me in my own endeavour to persist, adapt, and complete this research project was connecting with trusted and healthy others in my life. I am blessed to have too many valued family-friends to name here. You know who you are, and if you're not sure how you helped me get through this, I'll let you know! ix 1 CHAPTER 1 INTRODUCTION Background Change is at the heart of growing, learning, and healing. The practice of psychotherapy seeks to serve as a catalyst in these processes. Of course people attempt and achieve change in countless contexts, but more and more people are turning to professional helpers when they find themselves stuck and unable to make the changes they desire. The evolution of psychotherapy, while somewhat brief, has yielded hundreds of theories and techniques to help people change. Theoretical focus has ranged from behaviour to cognition to emotion, and at the dawn of the new millennium the focus has broadened to a more holistic and complex view of the human experience (Mahoney, 2000). Despite the proliferation of theories and practices, the field of psychotherapy still lacks a fundamental, comprehensive, and testable theory of change (Meichenbaum,T997; Prochaska, 1999). As of yet there is no widely accepted explanation for how people change and how therapy promotes that change. In search of an answer to this problem James Prochaska and his colleagues have devoted many years to the development of what they call a transtheoretical model of change (Grimley, Prochaska, Velicer, Blais, & DiClemente, 1994). The initial aim of their research was to understand how people change through therapy. However, when they took into account that such a small percentage of people ever participate in psychotherapy, along with the fact that clients spend less than 1% of their waking hours in therapy sessions, the focus expanded to a more basic inquiry of how people change, 2 period (Prochaska, 1999). Through their comparison studies of people in professional treatment versus people changing on their own, they eventually argued that "all change is self-change, and therapy is simply professionally coached self change" (Prochaska, Norcross, & DiClemente, 1994, p. 17). Self generated change and spontaneous recovery inevitably involves individuals accessing resources in their natural environments. The therapeutic relationship is one more "resource that facilitates, supports, or focuses clients' self-healing efforts" (Tallman & Bohart, 1999, p. 102). If self-change or self-healing is such a naturally occurring phenomenon, what need is there for therapy? In their overview of the literature on change and the client as a common factor in this process, Tallman and Bohart make note that an individual's natural environment often does not provide opportunities "to think about and explore their problems, gain distance, re-experience them (along with the accompanying emotion), and perhaps begin to find the threads of a way out" (p. 111). How does a person begin the search for a way out through therapeutic intervention? Based on an overview of the trends in psychotherapeutic research and practice, Snyder and Ingram (2000) pose a number of interesting questions for the evolving field of psychotherapy as it enters the 21st century. They predict that brief forms of psychotherapy are not only here to stay, but are a good match to the lifestyle of today's North American. They call for a move from a repair model to a broader growth model of change, whereby people are seeking to generalize, as well as to maintain changes made through therapeutic interventions. They envision people seeking brief booster sessions/interventions at different points in their lives in a kind of continuing education context. Research and practice indicates that there will be a growing focus on 3 interpersonal factors as being significant to positive outcomes. Subsequently, they foresee an increase in the popularity of different forms of group therapy; people drawn to shared experiences. In spite of some negative views among psychotherapy researchers toward the notion of self-help approaches, Snyder & Ingram assert that "self-help principles are at the heart of psychotherapy change and maintenance . . . psychotherapy researchers need to better understand how personal empowerment can be attained in the context of psychotherapy" (p. 724). Therapeutic Enactment is an intervention in alignment with many of the afore- mentioned features. It is a form of group therapy that has evolved out of psychodrama through the work of Westwood and Wilensky (M. Westwood, personal communication, August, 2000). Groups generally range from 8 to 25 participants, along with two to four therapists/directors. They usually meet over a period of 3 days. During this time a number of participants who have pre-arranged with the directors will be the leads in their own enactments. Group members/witnesses may be called on to play roles in the enactments, and will be coached by the directors. Content of enactments may range from re- experiencing past events to experiencing prospective, imagined or symbolic events. Enactments have three stages and typically last for 2 to 4 hours. First is the warm-up stage in which group safety and cohesion are developed, along with the group's introduction to the lead's story and goals. Second is the action phase where the roles are developed and the enactment plays out, culminating in resolution. Third is the integration phase where the group de-roles and de-briefs in order to make meaning from the experience. Follow-up consists of an open invitation to the leads to contact the directors 4 as needed, and a last de-brief meeting of the group is set for 6 to 8 weeks after the workshop. By many accounts (Baum, 1994; Brooks, 1998; Brown-Shaw, Westwood, & DeVries, 1999; Hirakata, 2002; Keats, 2000; Martens, 1990; Morley, 2000) therapeutic enactment is proving to be an effective, albeit brief, therapeutic intervention that provides a powerful opportunity for creative change and healing. Like psychodrama, its multi- modal approach sets it apart from traditional talk therapies. As a truly experiential therapy it activates not only the behavioural, cognitive, and emotional dimensions, but also the physical dimension through action. There is commonly a recognition of the spiritual dimension, in the content of some enactments, as well as in the dreams and experiences reported after the intervention (Brooks, 1998). Therapeutic enactment offers people a safe space to come together in an intensive and interpersonal context to explore, experiment and re-experience problems in a new and corrective way (Westwood, Keats & Wilensky, in press). As in the larger field of psychotherapy, the focus of exploratory research in relation to therapeutic enactment has focused mainly on what happens within the therapy session (Keats, 2000; Martens, 1990; Morley, 2000). Prochaska (1999) declares that in addition to focusing on this time frame, "the field needs to know how people change before therapy begins, after it ends, and when therapy never occurs" (pp. 228-229). Baum (1994) and Brooks (1998) do make some reference to the period of time after a therapeutic enactment, but the main aim of their exploration into change processes through therapeutic enactment still lay within the time frame of the intervention itself. Therapeutic enactment is a form of psychotherapy that is being supported by many personal testimonies, as well as by a growing body of research literature (Baum, 1994; Buell, 1995; Brooks, 1998; Hirakata, 2002; Keats, 2000; Martens, 1990; Morley, 2000). However, little is known about how participants continue or maintain the changes they experience and report as a result of this therapy. The need for post-intervention opportunities to process their change is a common theme developed by the co-researchers of three phenomenological studies conducted in the context of therapeutic enactment (Baum, 1994; Brooks, 1998; Martens, 1990). Prochaska (1995) challenges researchers and practitioners in the field: "As we become forced to practice time-effective psychotherapies, we had better come to grips with maximizing self-change processes lest we and our clients end up feeling demoralized and defeated" (p. 101). It is the desire for this study to extend the focus on change beyond the 1 % of time people spend in the therapy session. Problem Lacking in the field of psychotherapy at large, and in the smaller sphere of therapeutic enactment, is an empirical understanding of how to prepare and empower the client for independence and change maintenance post-treatment. This is of particular importance in the context of such a brief and intensive intervention as therapeutic enactment. It is the responsibility of researchers and practitioners to gain an understanding of how best to empower clients as they leave the therapeutic setting to live out the changes in the other 99% of their lives. Purpose The purpose of this study is to investigate and determine the factors which facilitate or hinder the maintenance of change achieved through a therapeutic enactment. This study seeks to learn directly from the clients themselves. Each client, being at the centre and the forefront of this investigation, is now cast in the role of co-researcher. The method for this inquiry is Flanagan's (1954) Critical Incident Technique. Co- researchers in this study will be those individuals who have reported significant change as a result of their experience as leads in their own enactments. These co-researchers will be asked to engage in self-reflection, and to articulate their experience of incidents which helped or hindered them in the consolidation of the changes they achieved through therapeutic enactment. These incidents will be drawn from the period of time between their enactments and their interviews for this study. Significance There is much to be learned from people who have reported a positive change experience through a brief therapeutic intervention. Rather than evaluating therapeutic outcome this study follows these people into the "trenches of life" as one of Mahoney's (1991) clients put it (p. 294). Through qualitative inquiry this study seeks to capture their experience of continued change, more aptly continued self-change. How might people capitalize on a change experience through a brief therapeutic intervention? How might they continue this change momentum beyond the intervention? This study offers a rare look at the post-therapeutic time frame. Rather than the typical focus on conditions created for change within therapy, this study will focus on the conditions that are useful 7 for change maintenance in the real world. While Karoly and Wheeler Anderson (2000) assert that most psychotherapy research is busy considering its own power to create change, this research will consider the power of the people to create their own change. This study provides a number of unique strands which may contribute to the current change and therapeutic enactment literature. First, it looks directly to the descriptive voices of the people themselves. Qualitative research is still novel in the context of most change related research (Karoly & Wheeler Anderson, 2000; Maione & Chenail, 1999; Prochaska, 2000; Tallman & Bohart, 1999). This kind of data offers naturalistic, descriptive, and interpretive information that may help to inform other qualitative or quantitative forms of inquiry. Second, the results of this study can very specifically be compared to the 10 change processes that have been developed through the work of Prochaska and colleagues (Prochaska, Johnson, & Lee, 1998). This study will also add to the growing body of research surrounding the practice of therapeutic enactment (Westwood et al., in press). It will extend the existing exploratory and descriptive focus from experiences within the context of the actual intervention to a unique perspective beyond the therapy session. The majority of related qualitative studies have taken a phenomenological approach to their research questions (Baum, 1994; Brooks, 1998; Keats, 2000; Martens, 1990; Morley, 2000). These have yielded common themes and interesting data as to the lived experience of participants. The critical incident method will produce data in the framework of a taxonomy. This classification of facilitative behaviours is a practical platform from which to suggest guidelines. Therapists can offer ideas and suggestions of behaviours and contexts that may be helpful for clients to maintain and continue change as they move on from therapy. 8 Based on this information therapists/directors will be able to proactively guide their clients as to what behaviours and events can be helpful or harmful in the continuation of change after therapeutic enactment. 9 CHAPTER 2 LITERATURE REVIEW Introduction The goal of this chapter is to explore the landscape of theory, practice and research that is relevant to the study of change after the intervention of therapeutic enactment. An understanding of therapeutic enactment would be incomplete if not considered in the greater context of psychodrama. This evolving and innovative therapy has grown out of Westwood and Wilensky's original practice of psychodrama in its classic form (M. Westwood, personal communication, August, 2000). A number of significant studies have served as part of the fabric of this evolution, and are pertinent to this study as guides to some of the change processes at work within the bounds of this form of therapy. The larger context of what the field of psychotherapy is learning about change will also be explored as a means to understanding what the results of this study may yield. Theory and Practice: Psychodrama to Therapeutic Enactment Jacob Moreno is noted as the first thinker/practitioner in the field of psychotherapy to see the potential therapeutic effects of drama (Blatner, 1988; Holmes & Watson, 1994; Kedem-Tahar & Kellermann, 1996). Moreno, who had developed a wide range of interests in philosophy, the arts, and medicine, became aware of how professional actors and children playing make-believe benefited from the spontaneity and creativity of their active experiences. What started as a pursuit of theatrical 10 experimentation through spontaneous improvisations, with social development in mind, gradually developed into a model for group psychotherapy. Moreno (1946) found many aspects of enactment to have psychological healing effects on participants. Improvisation opened the way for spontaneity and insight, approaching challenging situations in new ways. Catharsis was a major curative factor, enabling a person to bring to consciousness and integrate previously repressed parts of self. Moreno's development of "role theory" laid the foundation of his significant contribution to social psychology (Blatner, 1995). The metaphor of role has been very powerful and provides people with some role distance, consequently they are freed to experiment, expand or alter their role repetoire. Moreno was devoted to refining the practice of psychodrama, some say at the expense of theoretical development (Blatner, 1997). In spite of others' subsequent contributions in this vein, Blatner concludes that "it is useful to uncouple the use of psychodramatic techniques from any single theory. These methods can be and have been used within many different general theoretical schools" (p. 25). Blatner, and Kellermann (1987), encourage therapists of varied theoretical persuasions to adapt and integrate the psychodramatic method to suit their eclectic needs. Westwood et al. (in press) have recently documented the alterations and the rationale for their re-development of psychodrama into a model they call "therapeutic enactment." The basic principles of creativity, spontaneity, catharsis, and role dynamics remain essential to this practice. Like psychodrama, its experiential nature continues to operationalize multiple modalities and reflect the complexities of life (Brooks, 1998; Moreno, 1971). Active experiencing in the therapeutic setting serves to elicit and enhance 11 a variety of modalities: cognition, affect, physical activity/senses, imagination, intuition, and interpersonal interaction. Beyond the backdrop of psychodramatic principles and praxis, Westwood et al. (in press) make reference to a number of additional and significant theoretical pillars upon which therapeutic enactment is built. First, they place great emphasis on the group theory factors laid out by Shutz (as cited in Westwood, in press): inclusion, control and trust. Second, they draw on the interpersonal theories of self-psychology and object relations. These theories offer guidance in the understanding of early developmental experiences which translate into internal representations of self and relationship. Schema and script theory are the third pillar. These are the mental framework by which people interpret and make sense of their interactions and relationships with others. Therapeutic enactment is an opportunity to re-activate and re-structure longstanding, obstructive schemas and scripts. And finally, gestalt theory emphasizes the critical relationship between one's context/environment, and the successful completion and integration of a meaningful experience. The goal of therapeutic enactment is to re-enact an experience in a new context/environment of trust, acceptance and support, whereby completion and integration are achieved by the client. Westwood et al. (in press) conclude that "therapeutic enactment, in contrast to classic psychodrama, is pre-planned, highly controlled enactments within a group setting used for the repair and restoration of the individual client's experience of self (p. 10). Alterations of the five elements of classic psychodrama have mainly been in relation to terminology, to reflect the viewpoint of Westwood and Wilensky's theoretical evolution. The director is the therapist who leads the group and works closely with the 12 lead, the client central to the enactment (formerly called the protagonist). The enactment takes place in a suitable space designated as the stage. While there may be some variation to this setting in psychodrama, in the context of therapeutic enactment the stage is always held within the circle of the group/witnesses (formerly referred to as the audience). Some group members, auxiliaries, are chosen by the lead to take on roles in the enactment. Many of the same techniques are employed by the director of a therapeutic enactment as by the director of a psychodrama: doubling, role reversal, mirroring, and a number of ways to incorporate surplus reality (transcending the boundaries of physical reality i.e. having a conversation with a dead parent). There are hundreds of techniques and even more variations to choose from in order to best meet the needs of the lead/client (Blatner, 1996). In spite of many of the powerful and healing aspects of psychodrama, Westwood and colleagues became concerned over time with problems they observed related to individual safety, the role of spontaneity, and the purpose of catharsis (Westwood et al., in press). Consistent findings and recommendations made through research (Baum, 1994; Brooks, 1998; Buell, 1995; Martens, 1990), in addition to their own integrative theoretical perspectives, led them to gradually adjust their practices. The more significant adaptations made by Westwood and Wilensky have been to the first and the last of the three traditional stages of a psychodrama: the warm-up, the action, and the integration (Westwood et al., in press). Much of the work around individual safety has been addressed by the extension of the warm-up stage from simply an initial opening of the group to include pre-session contact between the lead group member and the director. This serves the purpose of strengthening the therapeutic 13 alliance between the client and therapist, collaborative planning of the enactment and its goals, which in turn increases the client's sense of safety and control. The pre-planning and preparation for the enactment shifts the role of spontaneity from Moreno's focus on it as a key to transformative learning in the moment to Westwood and Wilensky's view of it as an outcome of successful psychological repair through enactment (Westwood et al., in press). They found Moreno's original goal for the use of spontaneity too often left the lead member feeling unsafe in the group setting. The safety created through preparation paves the way for a successful enactment, which in turn elicits the potential for greater creativity and spontaneity in the future. Similarly, in contrast to some approaches to psychodrama, Westwood et al. (in press) view catharsis as a beginning to healing rather than a targeted end to enactment. Blatner (1985) defines catharsis as a release of emotional energy and a shifting of attention when an individual experiences certain kinds of role transitions. In response to some psychodramatic practices Blatner too asserts that catharsis " is not in itself a goal, but rather an indicator of emotional expansion and integration. Great dramatic break- throughs should not become the end point of psychodramatist's work; small gentle catharses can also be very healing" (p. 164). The action stage, in which the enactment occurs and the roles are taken, has remained very much the same. The therapeutic enactment director, however, seldom works alone. There are generally two to four directors for a group that can range from 8 to 25 members. Experienced group members are often included in the group as soul catchers. Their role is to be aware of and attend to the needs of auxiliary and witness members of the group through the action stage. They may also offer guidance to the 14 director(s) whose intense focus may benefit from the broader lense through which the soul catcher is making observations. One of the key goals of the group is to become a safe and accepting community. Not only should this provide the lead with a new and supportive context in which to re-experience a significant event, but the witnesses are also greatly affected by the action (Buell, 1995). During the integration stage they will have the opportunity to share with the community their own experience as a result of witnessing the enactment. While the 3 day therapeutic enactment workshop model is the context under consideration in this study, it is also important to note that Westwood has adapted the use of therapeutic enactment in a program developed for Canadian peacekeeping soldiers (Westwood, Black, & McLean, 2002). Therapeutic enactment is utilized in the third phase of the Transition Program for Peacekeeping Soldiers. Small groups of 6 to 8 former peacekeeping soldiers meet weekly for 3 hour sessions over a period of 14 weeks. The first phase of the group involves developing effective communication skills as well as building group safety and cohesion. In the second phase the soldiers participate in life review activities. These activities provide the basis for therapeutic enactment in the next phase. The final phase of the group focuses on consolidation of the learning, and transferring this new understanding into future goals and career related strategies. Westwood et al. (2002) attend to pre-group screening to ensure the emotional intensity of therapeutic enactment is not contraindicated for potential participants. In addition to pre- intervention concerns they also interview the participants after the program has concluded in order to gain feedback regarding the effectiveness of the intervention. 15 Group member feedback gathered via research from the 3 day workshop model (Baum, 1994; Brooks, 1998; Buell 1995; Martens, 1990) has consistently indicated that participants desire further support and opportunity to process and integrate the results of the enactments after the group sessions finish. According to these researchers, this desire speaks to the fact that insight and integration continue in the weeks and months after the enactment experience. Consequently, it has become part of the practice to hold one post- workshop group meeting 6 weeks later. This follow-up is seen as an opportunity for all members to de-brief, however it is especially valuable for the lead members. Along with these findings, Kellermann (1988) also points to the continuation of the change process beyond the integration/termination phase. In his assessment of the closure concept in psychodrama he concludes that "the ultimate purpose of closure in psychodrama is to extend the drama beyond its natural end and induce a transition to a new beginning" (p. 28). Research: Psychodrama to Therapeutic Enactment Research in the field of psychodrama has been somewhat sketchy over the years (Brooks, 1998). Kipper (1978) was one of the first to provide an overview of the research scene in psychodrama. He called for a move away from therapeutic strategy reports and case illustrations to evaluative investigation using more reliable and valid tests and measurements. His emphasis on quantitative inquiry was certainly in keeping with the widely accepted mode of research of the day. In spite of the difficulties in applying quantitative methods to the practice of psychodrama, highlighted by D'Amato and Dean (1988), they maintain the call for more controlled studies in order to empirically examine and support psychodramatic theories and practices. Another 10 years, another overview of the field and Blatner (1997) lifts up the call yet again for more quantified outcome research. Echoing D'Amato and Dean's recognition of the challenges of controlling too many variables in psychodrama, Brooks (1998) uses the image of water to describe the research problem. The complex and dynamic flux at work in psychodrama "can create a situation where the more one tries to grab a handful of this river in order to get to know it the more one wonders what they have actually grasped" (p. 3). Walsh (as cited in Karp, 1998) on the other hand, suggests that research in psychodrama would benefit from a non-outcome orientation. Formulating other methods outside the positivistic paradigm may be more relevant to assess and understand the process of psychodrama and its effects. In this vein, Westwood et al. (2002) have drawn mainly on qualitative research to support their theoretical and practical developments of therapeutic enactment. Qualitative inquiry is discovery oriented and is concerned with description and interpretation, often seeking to give voice to the research participants themselves (Maione & Chenail, 1999). This way of knowing can contribute to theory building, and may also "help quantitative researchers concentrate their efforts on pheno- mena that have already been shown to have meaning for therapy participants" (Maione & Chenail, p. 79). A number of the descriptive studies which have informed the practices of therapeutic enactment have explored various aspects of the participants' experience through enactment. Martens (1990) investigated the meaning of the psychodramatic process as experienced by protagonists/leads. Baum (1994) explored the meaning of significant change for psychodrama participants. Brooks (1998) conducted a 17 comprehensive study of the meaning of change through therapeutic enactment in psychodrama. His goal was to build a bridge between theory and practice through the development of a model of change in the context of psychodrama. It is important to note that only participants who reported significant change as a result of their enactments were selected as co-researchers for each of these studies. A l l three of the principal researchers used a phenomenological approach to the analysis of the data they collected from in- depth interviews with their co-researchers. Consequently, they produced a number of themes, all in relation to the three stage timeline of psychodrama: before (warm-up), during (action), and after (integration). Of interest here are the results and themes related to the last stage of the intervention. Martens (1990) developed 8 themes associated with this last stage, Baum (1994) developed 5 themes, and Brooks (1998) produced 21 themes. There is strong agreement across the themes of the three studies. This agreement is highlighted in four core concepts: (a) sense of significant and positive change, (b) cognitive insights, integration and self-understanding continue long after the enactment, (c) conviction and desire to continue to act on these changes, and (d) need to continue to process and work through the experiences and changes from the enactment. Many of the themes Brooks (1998) and his co-researchers constructed provide further detail as to the positive change reported: ability to make life changing decisions; increased differentiation among feelings, meanings, as well as greater differentiation between self and others; new awareness and ability to dispute negative beliefs; increased openness and closeness to others; new awareness and values regarding interpersonal ethics; increased future orientation; others note change in presentation; changes often 18 reflected in dreams and imagery. The one theme specifically articulated by participants as a strategy to support their changed behaviour is their use of imagery as an enduring reference point (frequently associated with a cathartic moment in the enactment). As noted previously, the integration stage has been extended by Westwood et al. (in press) in an attempt to meet the need consistently expressed by the participants across these three studies: to continue to process and work through the experience and change resulting from the enactment. Beyond one post-group meeting 6 weeks after the enactment, are there other ways to empower these participants to continue their change and growth process outside the therapy session? If therapeutic enactment remains in its present form, a brief therapy, it is incumbent upon practitioners and researchers to establish some trustworthy guidance for clients as they make the transition back to their old-new lives. How can we prepare clients for the process of maintaining the changes they have achieved through therapeutic enactment? Change: Theory and Research . The field of psychotherapy offers limited understanding of the general processes of change (Meichenbaum, 1997; Prochaska, 2000; Snyder & Ingram, 2000). Mahoney (1991) speaks to the kind of change that has been unfolding in the field of psychotherapy itself. He points to the issue of prime movers or first causes in human experience. Cognition, affect and behaviour, being the three domains of human experience, have received differing emphases depending on one's theoretical foundation. Mahoney welcomes the dialogue that has been evolving among behaviourists, cognitivists and humanists over the past decade. There is more agreement and appreciation for the 19 complexity and individuality of human experience. One domain is not necessarily primary in people's experience and change processes. There is also a growing recognition of the agency of people in their own change. In their overview of psychotherapy literature, Tallman and Bohart (1999) conclude it is the client who is the common factor that leads to effective outcome through therapy. They propose a model of client generativity and self-healing: The ultimate change process, inside and outside of therapy, is one wherein clients actively explore their worlds, both in thought and in behaviour, try out new ways of being and behaving, engage in creative variations on old learning, and solve problems as they come up . . . The processes of change in therapy are the same as those outside of therapy. Prochaska and his colleagues have demonstrated that individuals who spontaneously solve major life problems use the same general change strategies used in therapy, (p. 110) Spontaneous recovery and non-specific factors are often referred to in psychotherapy research, but seldom explored or explained. Based on their research, Lambert and colleagues (as.cited in Tallman.& Bohart, 1999) have estimated the rate of spontaneous recovery for various disorders to be in the range of 40%. Given that the majority of people never use therapy as a resource for change, it is worth exploring how people change through using resources in their natural environments. Prochaska and colleagues conducted a study of coping strategies for self-change of psychological distress among laypersons versus psychologists (Norcross, Prochaska, & DiClemente, 1986). They used a questionnaire to measure the use of 12 intentional processes of change (previously identified through repeated factor analyses). The 2 most commonly used processes, by both groups, were helping relationships and self liberation (willpower strategies). Through comparative analyses they were also able to determine that psychologists employed a larger and more varied repertoire of coping strategies. 20 They concluded that an important lesson from this study is, because most distressed people grapple with their problems outside of therapy, "theories of behavioural change must account for both naturally occurring self-change and professionally facilitated therapy change. We need to search for generic mechanisms of change without resorting to mystical explanations, such as spontaneous recovery" (p. 839). James Prochaska has been at the head of the pack of researchers and authors questing after a better understanding of change (Hubble, Duncan, & Miller, 1999). He has won numerous awards for his work in the field of health and change psychology (i.e. Top Five Most Cited Authors in Psychology from the American Psychological Society). He and his colleagues have been testing and refining their transtheoretical model of change for well over a decade (Grimley et al., 1994; Norcross et al., 1986; Prochaska et al., 1994; Prochaska, 2000), The development of this model has been based on their ; studies of people's self-change behaviour. They have focused mainly on people struggling with a variety of addictive behaviours such as smoking, substance abuse, and eating disorders. While they have also attended to emotional distress, Prochaska (1995) notes that their work is having "more impact in health psychology and the addictions than in the traditional mental health arena" (p. 101). These people have revealed to the researchers that behaviour change unfolds . through a series of six stages: 1. Precontemplation is the stage in which people have no intention of changing in the forseeable future. Denial of the problem and resistance to change is typical at this stage. Other people around the pre-contemplator will usually see his/her behaviour as a problem, however the individual doesn't want to think, read or talk about the issue. i 21 2. Contemplation is the stage in which people are intending to take action in the next 6 months. The contemplator acknowledges s/he has a problem, struggles to understand it, and begins to think about solving it. 3. Preparation is the stage in which people are intending to take action in the near future, usually 1 month. The individual who is preparing for change is finalizing his/her commitment and making adjustments before embarking on significant behaviour change. 4. Action is the stage in which people are presently making modifications in their lifestyles. The individual is not only in the process of changing visible behaviour, but also levels of awareness, emotions, self-image, thought processes, etc. 5. Maintenance is the stage in which people are working to prevent relapse. The efforts made at this stage to consolidate the gains made during the previous stages can last from 6 months to a lifetime. 6. Termination is the stage in which people are symptom free, have zero temptation, and 100% self efficacy. Whereas termination may be the ideal goal, Prochaska (2000) notes that the best people can generally hope for is a lifetime of maintenance. Evidence from their studies (Prochaska et al., 1994) indicates that the majority of relapses occur during times of emotional distress. Prochaska (2000) asserts that it is possible to prevent relapse if therapists attend to client preparation to cope with distress. He points to three avenues for managing mood and coping with distress: talking about one's distress with supportive others, physical exercise/activity, and some form of deep relaxation (i.e. yoga, massage, meditation, prayer). 22 Their studies (Prochaska, 2000) have also revealed a number of change processes that provide the momentum for people to progress through the stages of change. As their research has evolved Prochaska and colleagues have at times identified 12 processes (Norcross et al., 1986), 10 processes (Prochaska, Johnson, & Lee, 1998) and most recently 9 processes (Prochaska, 2000). Some of the names have changed but the substance of 10 of the processes have remained stable: 1. Consciousness-raising is the act of increasing information, awareness, and understanding of self, the problem and the environment. 2. Dramatic relief is about experiencing significant emotional arousal that results in increased awareness and motivation to take action. 3. Self-reevaluation is a cognitive and affective assessment of self image in view of the problem, and a view of self without the problem. 4. Environmental reevaluation is also a cognitive and affective assessment. This is a view of the problem in the context of one's social environment. 5. Self-liberation involves the mental act of commitment, private or public. The individual accepts responsibility for changing, believes that s/he can change, commits and re-commits to act on this belief. 6. Social liberation involves taking advantage of new alternatives that the environment provides. 7. Counterconditioning is the act of substituting healthy responses for unhealthy ones. 8. Stimulus control is about restructuring one's environment to increase healthy prompts and decrease potential problems. 23 9. Contingency management is a way to provide rewards in order to reinforce the positive behaviour. 10. Helping relationships involve seeking support from trusted friends, family, clergy, acquaintances in support groups, and professional therapists. Many others have presented successful strategies employed by people in their self-change efforts that correspond to Prochaska's findings. The prime importance of supportive relationships, and in particular those other than with a helping professional, are also highlighted by other theorists and researchers (Mahoney, 1991; Tallman & Bohart, 1999). While many people report finding satisfactory assistance from people other than mental health professionals, just as many reports are made of the lack of such support. Many friends and family members do not offer the time, the patience, or the skill necessary to be of help. Consequently, there is a place for the professional helper, as well as for the basic training of non-professionals in listening, reflecting and helping skills. Opportunities for self expression are also identified as significant in a person's process to change. There is certainly overlap here with helping relationships, as talking and telling are part of relating. However, there are other forms of expression which are helpful. Mahoney (1991) outlines the practicalities and benefits of therapeutic writing in journals and correspondence, as well as expression through art and music. In addition to the act of writing, Tallman and Bohart (1999) cite studies which demonstrate the power of people telling their stories into tape recorders and processing their thoughts in interviews. It is worth noting Rennie's findings (as cited in Maione & Chenail, 1999; also cited in Tallman & Bohart, 1999). Rennie used interpersonal process recall (IPR) in his 24 investigations of clients' perceptions of the therapy process. He replayed audio or video tapes for clients soon after therapy sessions. He then asked them to recall thoughts, images or emotions they experienced at particular moments during the session. He also audiotaped these interviews and later analyzed them. He offers his findings as evidence for people's high degree of reflexivity and agency during therapy. Clients are very covertly active during their therapy sessions, thinking about experiences in ways they wanted, regardless of what therapists might suggest. Tallman and Bohart also cite Rychlak who has shown that when people learn a fact, they also learn the opposite of the fact. People are creative; they can think oppositionally and generate the alternative. Tallman and Bohart make the summative argument that a self-healing cycle of thinking- exploring-experiencing-behaving is played out in similar ways whether in therapy or in vivo. They note that experiencing involves what Gendlin (as cited in Tallman & Bohart, 1999) refers to as bodily felt shifts. These can be achieved through behavioural practice and rehearsal. They conclude that "the individual must go through the process of making new decisions, setting new goals, developing new strategies, and then pursuing them" (p. 112). The benefit of self-help literature seems obvious based on the premise that helping people change is about helping them to help themselves. However, there is a general disdain toward self-help approaches or pop-psychology among psychotherapy researchers. Practitioners in large numbers, on the other hand, have acknowledged that they supplement their treatments with self-help books (Snyder & Ingram, 2000). Of course the professionals prefer to call it bibliotherapy. It makes sense that people who are the authors of their own lasting change would seek out other authors of change and 25 inspiration. Snyder and Ingram suggest that autobiographies are a particular form of literature that may prove beneficial to people who seek to change. They also propose that psychotherapists build a scientifically based self-help literature collection. In addition to the benefits derived from self-help books, Tallman and Bohart (1999) highlight studies that have demonstrated effective outcomes from classes where self-help procedures are taught, as well as computer programs that offer self-guided cognitive behaviour therapy. The authors do qualify that these sources of self-help are created by professional therapists. However, they conclude that these choices are yet another demonstration of people, as primary change agents, making use of resources in their environments. The preceding generic mechanisms of change meet Norcross et al.'s (1986) call for better explanations of change than vague references to spontaneous recovery. These mechanisms also imply there is a conscious effort on the part of people to create change. In addition to people power, is there still room for the mystical? Krumboltz (1999) offers a compromise to the pre-meditated and the spontaneous in his theory "planned happenstance." While Krumboltz (1999) is well established in the domain of career counselling his theoretical ideas have broader application. He provides an overview of a number of studies related to the role played by serendipity in the career paths of people. He concludes that "no one can legitimately claim that his or her life is self-managed in its entirety" (Krumboltz, 1998, p. 392). On the one hand, Krumboltz (1999) emphasizes that the field of counselling overlooks the element of serendipity or chance; on the other hand he contends that people too often attribute certain outcomes to chance, when they are in 26 fact, indirect outcomes of effective behaviour. He attempts to strike a balance through his theory of planned happenstance. Krumboltz intentionally unites these two words as an oxymoron, because he proposes that people must plan to generate and be receptive to chance opportunities. His theory encompasses two concepts: (a) exploration generates chance opportunities which can increase the quality of life, and (b) five skills enable people to seize and capitalize on these chance opportunities (i.e. curiosity, persistence, flexibility, optimism, and risk taking). Krumboltz highlights the unexpected event as an inevitable and desirable opportunity for learning and changing. These many change processes and coping strategies should serve to enlighten the results of this study. The purpose of this study is to develop a taxonomy of helpful and hindering behaviours and events which can aid therapeutic enactment directors and clients to better prepare for their maintenance of change beyond the therapeutic setting. The starting point for this investigation is to learn from the self-changers directly. As in their therapeutic enactments, these leads will once again be active participants in another aspect of their quest to change. More than participants in this endeavour they are co- researchers. Together we will answer the question: What factors help or hinder the maintenance of change achieved through therapeutic enactment? 27 CHAPTER 3 METHODOLOGY Introduction There were a number of considerations in the determination of an appropriate research design for the present study. First, a review of the research literature in psychodrama and therapeutic enactment revealed the many attempts and difficulties with applying traditional quantitative methods to the study of such a dynamic process as an enactment in psychodrama (Baum, 1994; D'Amato & Dean, 1988; Kipper, 1978). Qualitative inquiry offers the opportunity to provide more descriptive findings which are especially helpful in an exploratory study such as this (Maione & Chenail, 1999). The research goal here is to identify factors which facilitate the maintenance of change in participants after therapeutic enactments. Second, and in the same vein, this investigator preferred a method which would give voice to the participants more directly than in a quantitative, measurement study. Such an approach also acknowledges and draws upon the expertise of the people who are most invested in their own process of change. Prochaska (1993) argues that self report is the best methodology available to the field of psychology. Based on his experience as an avid researcher he concludes that "self reports simply yield more data on more difficult to study subjects in more reliable and valid ways than any other psychological or biochemical measures of behaviour" (p. 250). In keeping with the therapeutic goal to see people heal and change, and to carry that on into the rest of their lives, the method used here must recognize the value of the co-researchers' views on how they manage their own change independent of the formal counselling context (Prochaska, 1999). And finally, this investigator is interested in a practical application to the field of therapeutic enactment in order to help the therapist/director to empower clients beyond the therapeutic setting. The aim of the study is to develop a taxonomy of specific behaviours or incidents which either facilitate or hinder the maintenance of change once people are on their own again, independent of therapeutic support and guidance. The critical incident technique is a very suitable method of inquiry in order to create such a guide. Critical Incident Technique The Critical Incident Technique was first developed by John Flanagan (1954) and his colleagues in the 1940's. Their work started in the Aviation Psychology Program of the United States Army Air Forces. It led them to design a research method that would enable them to "collect direct observations of human behavior in such a way as to facilitate their potential usefuleness in solving practical problems and developing broad psychological principles" (p. 327). The use of this research method has been especially pertinent in generating descriptive data for exploratory purposes in the area of uncharted experiences (Alfonso, 1997; Woolsey, 1986). This method has been chosen here to investigate what factors facilitate the maintenance of change achieved through therapeutic enactment. Flanagan's original studies using this technique were aimed at developing procedures for the selection and classification of air crews. Later studies based on his work at the University of Pittsburgh focused on the critical requirements of a variety of 29 vocations. Since then the technique has been used by many others. Some examples are studies which have been conducted to determine the critical features of: work motivation (Herzberg, Manseur, & Snyderman, 1959), group process (Cohen & Smith, 1976), the quality of life of Americans (Flanagan, 1978), the connection between emotions and cognitions in achievement related contexts (Weiner, Russell, & Lerman, 1979), and the experience of unemployment (Borgen & Amundson, 1984). Counselling/psychotherapy was one of nine categories Flanagan (1954) outlined for the application of this research method. Lorette Woolsey (1986) considered the merit of this assertion and concluded "that the critical incident technique should contribute significantly to the development of a unique methodology for the discipline of counselling" (p. 242). Since Woolsey's (1985) study of same-sex social bonds, many others have applied this technique to studies in the field of counselling. Easton (1986) explored helpful behaviours for assisting the widow in bereavement, Proulx (1991) studied the decision-making process after divorce, McCormick (1997) analyzed the process of healing in a First Nations community, and Alfonso (1997) investigated overcoming depressive moods among HIV+ males. The critical incident technique is a set of procedures for gathering important information concerning incidents that contribute to a specified outcome. These incidents are behaviours or events which are directly observed or experienced. These observations can be made of one's own experiences or that of another person. The incidents are critical by virtue of significantly affecting an aim or outcome. Observers are selected based on their expertise in the subject to be studied. They have an understanding of the factors which either facilitate or hinder the process toward the aim in question. 30 There are five basic steps to the critical incident method. First, the researcher must determine the general aim of the activity to be studied. What is the goal? What does . success look like? In the case of the present study, the principal researcher together with each co-researcher, developed a clear and simple statement of aim. Each co-researcher established exactly what was the significant change that resulted from his/her enactment. The maintenance of this change formed the aim statement. In the context of this study the aim statements were unique to each co-researcher. This first step lays the foundation for the subsequent identification of relevant critical incidents. The second step is to set plans and to determine criteria for the incidents to be observed. Who will make the observations? Which individuals or activities will be observed? Incidents are selected based on their relevance and effect on the aim. Collecting data is the third step. Questionnaires or interviews are the typical instruments used. Analysis of the data is step four. This involves an inductive study and categorization of the thematic nature of the incidents collected. This step is explained in more detail in the last section of this chapter. Finally, the researcher arrives at the last step: reporting the findings. "In summary, the critical incident technique, rather than collecting opinions, hunches, and estimates, obtains a record of specific behaviors from those in the best position to make the necessary observations and evaluations" (Flanagan, 1954, p. 355). For the purposes of this study, the people in the best position to observe the behaviors or events that help or hinder maintenance of change after a therapeutic enactment are the clients/leads themselves. Together with the principal researcher, they each established their own statement of aim which guided their reflective observations of past critical 31 incidents. They provided their own accounts as to what they found to be helpful or harmful in their pursuit of change beyond the therapeutic setting. Co-researchers Sample size in a critical incident study is established by the redundancy of incidents rather than by the number of co-researchers interviewed (Flanagan, 1954; Woolsey, 1986). Once the incidents no longer lead to the creation of new categories, the principal researcher can stop interviewing co-researchers. Therefore, there were as many co-researchers recruited as was necessary to develop a list of incidents which composed unique thematic categories. Interviews stopped once repetitive patterns clearly required no new categories. This was established after the eighth co-researcher was interviewed and the exhaustiveness test was successfully completed. Exhaustiveness is a measure of validation which will be explained in more detail in the last section of this chapter. Co-researchers recruited were those volunteers who have been the lead in their own enactment in one of the 3 day therapeutic enactment workshops. An important aspect of the selection criteria involved confirmation from potential co-researchers that they experienced significant change as a result of their enactments. In other words, they found the intervention to be very helpful. Flanagan (1954) and Woolsey (1986) both speak to the permissibility of retrospective data, but do recommend the more recent the event the better. At the same time they both note that reporting on events which hold great value for the participants can often extend the time frame. In such a case, they found their reporters maintained clear and detailed recall. Based on the assumption that co-researchers in this study would 32 be reporting on personally profound and significant events, the time frame chosen was a maximum period of 2 years between the individual's enactment and their initial interview for this study. "The criterion for accuracy of reporting is the quality of the incidents themselves. If the details are full and precise, the information can be taken as accurate, whereas i f the reports are vague, some of the data may be incorrect" (Woolsey, 1986, p. 246). Potential co-researchers were informed of this study by poster (Appendix A) and word of mouth through the therapists who have run the groups or by the coordinators who have organized the groups. Those participants who indicated an interest in the study • were given an introduction letter (Appendix B) by the therapist or coordinator describing the researcher's background and more detail regarding the purpose of the study. Through this letter anyone interested in volunteering for the study was invited to phone the principal researcher. Ensuring confidentiality, confirming the selection criteria, and arranging the first interview meeting was done through the initial phone contact. The principal researcher also explained the concept of informed consent and took this letter (Appendix C) to the first interview. Interview Co-researchers met with the principal researcher for two interviews. Each meeting was approximately one and a half hours in length. The first interview conducted was audio-taped and later transcribed, then number coded. In order to establish uniformity in the interview process, as well as to orient the co-researcher to the study, an orientation statement was read at the beginning of the first interview (Appendix D). The orientation 33 concluded with directions that helped to set the stage for the development of each co- researcher's statement of aim. The aim statement provided the focal point for the remainder of the interview. Each individual determined exactly what the significant change was which resulted from his or her enactment. This information was elicited by asking the co-researcher to describe "one or two of the important changes that came about for you as a result of your enactment." After some discussion and clarification, the key change was written down and used at times through the interview as a visual reminder and focal point. Understandably, the statements of aim were unique to each co- researcher. The change identified by the co-researchers guided them in their identification of relevant incidents. Once the aim was clear in their minds we moved on to the interview questions (Appendix E). These questions were designed to elicit the critical incidents that pertain to this study. Co-researchers were able to think about subsequent activities in the time since their enactment that were facilitative of the change for which they aimed. While there were a number of sub-questions used to probe and draw out more detail, the base question used was: Now that we've identified the key change(s) these will be our focus . . . the change you've desired to maintain since the enactment. I want you to reflect on the time that has passed since the enactment. Think about a situation when something happened that helped you to maintain/reinforce this change. The intention was to phrase questions in such a way as to invite co-researchers to speak freely about what was meaningful and pertinent to their experience of the critical incident. This process continued until the co-researchers were unable to think of any new facilitative critical incidents. At this point, the focus shifted to the consideration of critical incidents which they felt hindered their efforts to maintain change. Finally, the 34 co-researchers were left with the invitation to recall more critical incidents which could be shared during the second interview. The second interview can still be considered as innovative to the critical incident method since Alfonso (1997) first used it. It introduces a phenomenological component to the study by having co-researchers speak to the meaning of the categories developed. The second interview also serves as a very significant procedure for validation of the incidents, as well as of the categories. This interview was held within 3 months of the first meeting. Seven out of the eight co-researchers were able to make the second meeting. One individual was unable to do so, and this is discussed further in the Limitations section of the last chapter of this study. In an effort to maintain uniformity, a protocol was developed for the second interview. It consisted of an agenda and a re-orientation to the study (Appendix F). Data was partially analyzed by this time and co-researchers had the opportunity to add, change, and comment on the accuracy of the incidents, as well as that of the categories constructed for the variety of incidents. It was determined during this initial stage of analysis that repetitive patterns began to develop after the fourth interview. No new categories were developed after the eighth interview, and the principal researcher concluded that sufficient incidents had been collected. Analysis Flanagan (1954) outlined three fundamental steps in the process of data analysis. These steps are: extraction of the incidents, formation of the categories, and validation of the results. He acknowledged that this research method was evolving and encouraged 35 others to modify or adapt it to suit their needs. Similarly Alfonso (1997) developed and adapted the analysis procedure in order to guide her study both conceptually and practically. Her approach is very applicable to this study and was followed, and adapted as necessary. The fundamental three steps still serve as the guidelines. First involved the extraction of the incidents. The transcriptions from the interview audio-tapes were carefully studied in order to understand the full meaning intended by the co-researchers (Alfonso, 1997; McCormick, 1994). A l l incidents were recorded and written out in the words of the co-researchers as much as possible. In some cases the words were paraphrased in order to join thoughts and provide fluidity. The principal researcher examined this initial list according to the following criteria: (a) Was the co-researcher's account complete? (How and when did s/he notice the change was maintained or lost to relapse?), (b) Was the event clearly identified? (What was helpful/hindering to maintaining the change?), (c) Was the outcome related to the aim? (What did the co- researcher do that helped/hindered the process of maintaining change?). Incidents that did not meet the criteria were set aside to be clarified with the co-researchers at the second meeting. The second step was the formation of categories. Each incident was also divided into three components in order to sort them according to similarity: (a) source of the incident, which indicates the context of the event (i.e. " A professional family photo was being taken"); (b) action taken which explains what happened (i.e. "I was the last one placed in the group by the photographer, it flashed me back to almost the exact same scene during my enactment. I recalled the insight and feeling I had gained back then, that 36 we were more separate than I had realized); and (c) outcome which describes the effect resulting from the incident (i.e. "I felt that same peaceful detachment from my family I'd felt during my enactment; it reinforced my separateness from them and I could look at them more objectively, without all the guilt, obligation, anxiety, etc."). Emphasis was placed on the action taken. This served the purpose of developing categories based on behaviour or happenings to which co-researchers paid particular attention. The action could consist of what the co-researcher did (thought, felt or acted), what someone else did, or what happened. As the incidents were clustered and given descriptive headings, there was a process of re-definition and re-classification until all the incidents were satisfactorily grouped. In keeping with Alfonso's (1997) suggestion, the clearest incidents were categorized first and then used as prototypes to guide in the grouping of more complicated incidents (ones which resembled more than one category theme). All researchers using this method agree it is an inductive process. Consequently, corrections, revisions and re-naming of categories was to be expected. Co-researchers participated in this part of the process during the second interview. The third step was the validation of the results. More recent studies using the critical incident technique are making significant efforts to establish trustworthiness and validity. Alfonso (1997) and McCormick (1994) used five of the six validation procedures conducted in this study. Alfonsos used an additional validation procedure more typically employed in phenomenological studies. She conducted a second interview with each of her co-researchers. This not only strengthened their role and contribution as co-researchers, it also provided a valuable validity check for the critical incidents extracted. In addition, they were also able to speak to the validity of the categories 3 7 formed. This procedure was the first to be employed during the analysis stage of this research. The six validation procedures used for this study were as follows: 1. A second follow-up interview was conducted with the co-researchers. 2. Independent raters sorted the critical incidents in order to test reliability. The results of their sorts were compared to the results from the sort conducted by the principal researcher. 3. An exhaustiveness exercise was conducted by withholding 10% of the incidents after the categories were formed in order to assess the completeness of the categories. 4. Participation rates were calculated for each category which contributed to the notion of the trustworthiness of the categories. 5. Expert judges provided feedback as to the content validity of the category headings and their definitions. Are the categories relevant and useful guidelines in their practice and experience? 6. Examination was made of previous research in order to determine whether or not there is established theoretical agreement with the categories developed. Each avenue of validation for the results of this study will be explained in more detail in the next chapter. 38 CHAPTER 4 RESULTS Introduction A total of 125 critical incidents were identified by eight co-researchers (four women, four men). All individuals, having been leads in their own therapeutic enactments, described incidents that have facilitated their efforts to maintain change over the time since their enactments. Four of the co-researchers identified an additional 11 critical incidents which presented as hindrances to their efforts to maintain change. Nine of these incidents had exact opposite accounts. The co-researchers reported a positive incident which countered the effects of the hindrance. These individuals described assertive and constructive ways in which they dealt with the negative experiences. These positive countering incidents were classified in one of two categories: resolving or practicing. These categories infer that the individual puts some conscious thought and intention into avoiding old habits or situations. The fact that nine of these negative incidents have positive counterparts lend support to the validity of these two categories. This leaves only two hindering incidents unaccounted for by one co-researcher. Given the small number and the isolated nature of these incidents, it was decided to focus on the helpful incidents for the purposes of this study. The goal of this research project is to help prepare and empower people as they leave the therapeutic setting to live out the change process in their real worlds. What are the helpful factors that may facilitate their maintenance of change? 39 The 125 facilitative critical incidents were classified into six categories. This chapter is divided into two major sections. The first will cover the description of the categories. The second will outline and detail the validation procedures used in this study. Description of the Categories The heading and definition of each of the six categories is followed by three examples of critical incidents identified by various co-researchers. An attempt was made to quote the co-researcher as directly as possible. In some instances their words were paraphrased to provide a more fluid account of their meaning. The phrasing was confirmed or revised at the second interview. The examples selected are representative of the range or variation of the types of incidents in each category. Possible sub-categories will also be presented. The source or contexts of the critical incidents emerged as natural sub-categories. The eight co-researchers were assigned numbers one to eight in the order they were interviewed (for the first interview). Table 1 presents a summary of the six categories and their frequency rates (number of incidents for each category). The six categories are presented in order of descending frequency rates. Connecting with Others (41 incidents; 100%participation rate) This category denotes finding strength through relationships. Being with other people is a way in which the individual is able to facilitate the maintenance of their own change. Communication with others is most often at the heart of this activity. 40 Table 1 Categories and Frequencies of Critical Incidents Category Frequency Connecting with others 41 Practicing 34 Remembering 17 Connecting with emotional and physical aspects of self j 2 Resolving 13 Contemplating 7 Total number of incidents 125 It usually involves giving and/or receiving in some way. Co-researchers describe receiving: advice, feedback, questions, challenges, encouragement, affirmation, comfort, etc. They describe giving through telling or sharing their thoughts and feelings. They also speak of helping or supporting others as being beneficial in .their own change process. The context or the source of these critical incidents naturally lend themselves to sub-categories of connecting with others. Who are these others? There were three general groups of people with whom the co-researchers connected: (a) friends/family (sixteen incidents); (b) group members from therapeutic enactment (nine incidents); (c) a therapist (fifteeen incidents; ten incidents referred specifically to the director-therapist from the therapeutic enactment, and five incidents referred to other therapists). One incident involved talking to the researcher for this study. 41 The outcome of these incidents typically involves feeling known, understood, affirmed, as well as an increased sense of belonging. Example (Co-researcher #5) "The six week follow-up meeting of the group was important. It was a place to hold me, receive me after experiencing the shock of re-entry to the real world. Just the fact that they came to listen and respond was comforting. I felt cared for and validated. I knew I was connected to people and not alone." Example (Co-researcher #4) "Talking about my enactment experience with my sister-in-law helped to cement my learning. Explaining things to someone I 'm close to is important to me. I gained clarity and I was affirmed by her." Example (Co-researcher #1) "He (director-therapist) initiated contact with me. He would call and ask me what was going on, probing. But he'd always check first and ask i f it was O.K. to talk. I felt supported, not left hanging. His contact caused me to pause, reflect, and have ideas to try." Practicing (34 incidents; 100% participation rate) This category includes taking risks or opportunities to apply what has been learned or decided. Co-researchers follow through on their plans, decisions, values and convictions. They take opportunities to practice new or more assertive behaviours. The source or contexts of these incidents are too various to list. The outcome is, however, more common. The co-researchers reported feeling stronger, encouraged, more confident. Two natural sub-categories seemed to emerge here and then just as quickly seemed to fade. One was the pre-meditated application or practice of new behaviour. The second involved responding to the spontaneous, unplanned opportunity that presents itself to the individual. Although there is a sense of distinction between the pre-planned practice and the spontaneous practice, the line between these two experiences tends to blur. Two attempts were made by the principal researcher to sort these incidents into the two sub-categories. Half of the incidents originally designated as pre-planned ended up going into the spontaneous sub-category on the second sorting. It is often difficult to distinguish experiences that are out of our control and spontaneous from those which are consciously entered into or contrived. If a particular opportunity does not present itself to us spontaneously, who's to say we aren't going to seek it out somewhere else? One co- researcher seized the opportunity to demonstrate his forgiveness and love for his father by helping him in practical ways during an unexpected medical crisis. It is very likely that this individual would have found or created other opportunities to demonstrate his love and forgiveness had this circumstance not arisen. It could be concluded that people who are resolved to practice new behaviour will create or find opportunities for themselves. This is an interesting area for inquiry. 43 Example (Co-researcher #7) "I moderate myself when I drink now. I usually drink only wine, and I stay sober. Consequently, I am more in touch with myself. I prefer to be more aware of myself, others, and the situation." Example (Co-researcher #5) "Challenging events arose at my workplace (a legal process) that gave me the opportunity to deal with conflict differently - not to give in, but to lay claim to some things, to speak up, and to disagree. I became stronger, more autonomous, and I felt good." Example (Co-researcher #2) "I got together with my father. He made some hurtful comments. I had the opportunity to suck it in or to stand up for myself and tell him what I thought. And so I told him, and I did it in a very respectful way. I felt good, strong and free to be my own man. I didn't need his approval anymore." Remembering (17 incidents; 63%participation rate) This category is about reflecting on past experiences in a way that proves helpful. Co-researchers speak of recalling empowering images, voices, moments from their enactments. All memories in this category are directly related to personal enactments. There are two natural sub-categories which emerged as a result of the contexts surrounding this behaviour. One group of reflections is simply related to flashbacks 44 triggered by circumstance (twelve incidents). A situation triggers reflection for the individual. In some cases they recall specific images from past enactments. Two people recalled the voice of the director-therapist, having given them specific questions or reminders in the past. The individual's memory is triggered, s/he pays attention, pauses, reflects, incorporates the past into the present, takes encouragement, and moves forward. The second sub-category of reflections (five incidents) came about through the use of materials which facilitated the act of remembering i.e. journals, videos of the enactments, photographs, momentos used in the enactment. The typical outcome of these incidents involves gaining a sense of progress, encouragement, and motivation to keep moving forward. Example (Co-researcher #6) "The support of the group (from the therapeutic enactment weekend) remains fresh in my memory. I recall the circle they formed for me after my enactment. I feel honoured, supported, accepted, understood, loved. When I remember that, it makes me more able to take risks, to reach out in other relationships in my life." Example (Co-researcher #4) "I would recall the director-therapist's voice, his words — in important moments. During my first phone call with my ex-husband (after the enactment), I could hear the director's voice with reminders, questions, support (how I did it in the enactment and how I can do it now). I felt encouraged and understood. It gave me the courage to act, to do the more difficult thing." 45 Example (Co-researcher #5) "Using symbolic objects (i.e. scarf of my mother's, candle, bouquet, stones) during my enactment has helped to preserve the memories of the work I've done. They serve as concrete reminders of the connections I have to others and the progress I've made." Connecting with Emotional and Physical Aspects of Self (13 incidents; 88% participation rate) The incidents in this category have to do with gaining strength through increased self awareness. Co-researchers indicate that they understand themselves better through paying more attention to their emotions and to their bodies. They are able to include these senses more in their decision-making and behaviour. As a result they are feeling more balanced, genuine, and self accepting. One co-researcher explained it was a matter of "getting out of his head more." The sub-categories are apparent in the heading - emotional experience (ten incidents) and body experience (three incidents). Any number of events can trigger a beneficial emotional experience. Two co-researchers linked their emotional experiences with listening to music. Co-researchers also described expanding their physical awareness through: somatic therapy and training, yoga, relaxation techniques, and other forms of physical exercise. 46 Example (Co-researcher #2) "After a job interview I was upset. Over the weekend I was in touch with those feelings. I allowed those feelings to inform me about who I am. I felt angry with myself for selling out, and angry with the other guy for twisting things. I was able to be honest with myself, see my mistake, and plan a course of action." Example (Co-researcher #4) "A fight with my daughter before her big trip was another opportunity to act differently. In this case I was really able to recognize my physical signs and symptoms of tension and anxiety. This is what helped me to stop, think, and then act differently. We resolved our conflict much quicker, and I had my integrity and self respect intact." Example (Co-researcher #8) "The fact that I teared up, cried during our check-in (on the trip) was important. It put me more in touch with myself, how I was really feeling about certain events. I felt genuine and more comfortable with being genuine, in spite of my mother's discomfort with me crying. This experience also gave me some insight into my mother and our relationship." Resolving (13 incidents; 75%participation rate) The action in this category flows out of contemplating and remembering. It has to do with making decisions and plans. Having been informed by past experience, as well as 47 by new insights and guiding principles, co-researchers describe being strategic. Having anticipated problems they make plans for new alternatives. Consequently, they are able to avoid old patterns of behaviour that produced negative outcomes. Through their plans they feel more autonomous and are hopeful about developing new ways of living. This category was originally called planning and included additional incidents which are now placed in the contemplating category. Through the process of the co- researcher validation check (explained in further detail in the next section of this chapter) - the splitting of planning into two separate categories better reflects the distinction between different kinds of thought processes. The initial stage of creative thinking, preceding decision-making or planning, fits more aptly into the category of contemplating. The subsequent stage of thought that leads to action (deciding and strategizing) are incorporated in the resolving category. Similar to the category of practicing, attempts to form sub-categories here also led to a blurred line. It seemed there might be a distinction between a general decision and that of a more detailed plan. However, in almost every critical incident where a decision was described, so too were references to detailed strategies for the application of the core decision. Consequently, the category stands undivided. Example (Co-researcher #4) "I made a decision to be more generous toward others and myself, not to speak badly of them or myself, to try to catch myself before I speak. This decision has increased my acceptance of both others and of myself. I have more peace and patience." 48 Example (Co-researcher #6) "I realized that I needed to make up my mind about telling others when I'm having difficulties. So I decided to tell my husband when I'm struggling in my relationship with my parents. This helps me go against my tendency to keep things to myself, and get depressed and stuck in it. This means he can help me. We feel more connected to each other." Example (Co-researcher #7) "I made a conscious decision to be here more, not to travel as much. Recently I was here for 6 months straight (for the first time in 10 years). I wasn't running away from my history. Now it's very important to me to spend time with my parents and other people in my life. I feel more stable and confident." Contemplating (7 incidents;50%participation rate) This category deals with exploratory and creative thinking that precedes decision- making. It involves conscious or unconscious processes (i.e. dreaming). These thoughts are helpful as co-researchers formulate their beliefs, values, and plans. Sometimes these thoughts are in the form of guiding questions or principles. The outcome of these incidents generally involves fostering hope, understanding, and a sense of personal power. Once again the source or context for this behaviour provided a number of sub- categories: guiding questions (four incidents), night dreams (one incident), day dreams (one incident), reading (one incident). 49 Example (Co-researcher #3) "I'm reading more, exploring different beliefs, and my own beliefs are evolving. Right now I'm reading a book on Buddhism. I'm especially interested in what it says about lovingkindness. It's giving me hope, giving me ideas about how I can practice it, even with myself." Example (Co-researcher #4) "Changing beliefs is critical, recognizing some old ones are crap (i.e. 'endure the pain' from my mother). Developing new beliefs based on asking myself, 'What am I teaching my daughter? What do I want to teach her?' This process makes me feel more hopeful and genuine." Example (Co-researcher #5) "I had a vivid dream - of my beloved with arms wrapped around me from behind, our fingers linked. I see the dream as a symbol of connection. I see that I am able to receive love, to surrender without defensiveness. The dream has reinforced my sense of hope and potential in my relationships." Validation Procedures There are a number of questions related to the validity and reliability of the results of any study. In the case of a critical incident study, Anderson and Nilsson (1964) provide valuable guidelines. They recommend a number of checks in an effort to indicate a reasonable degree of soundness and trustworthiness in the development of the 50 categories. The goal is to ensure, as much as possible, that the categories formed are relevant, complete, and practical. They suggest the following procedures: an exhaustiveness check, the use of independent raters, independent judges or experts, and a check for theoretical agreement. Participation rate is another method to test the soundness of the categories. It has been used in a number of other critical incident studies (Alfonso, 1997; Borgen & Amundson, 1984; McCormick, 1994). Alfonso introduced the first validation procedure which is used in this study. She conducted a second interview with co-researchers which added a phenomenological component to the critical incident methodology. Co-researchers are able to speak to the meaning and the accuracy of the critical incidents, as well as to the meaning and relevance of the categories which are developed. Co-researchers' Validation A second interview was conducted with the co-researchers in order to clarify and verify the accuracy of the critical incidents extracted from the first interview. This interview was invaluable and speaks to the need for what Maxwell (1992) calls descriptive validity (accuracy of the account). The second meeting also provides the opportunity to establish interpretive validity (Maxwell, 1992). Co-researchers can respond to the principal researcher's findings by articulating and clarifying the meaning of the incident from their perspectives. The second interview also reinforces the premise that the co-researchers are the experts on their own change process (Prochaska, 1999). As a result of the second interview, some incidents were edited in order to reflect more accurately what was most salient to the co-researcher - what exactly was it within 51 the incident that was significant and helpful to them in their maintenance of change? For example, one co-researcher described the ongoing contact with group members through the "Soul Catcher" meetings as very helpful to her. She enjoyed feeling part of this group. Prior to the second interview, it seemed clear that this incident would be categorized under connecting with others. However, through the second interview she was able to clarify that thisact was more aptly slotted under practicing. She explained that the act of getting together with these people was more importantly a matter of risk taking and new assertive behaviour for her than simply deriving benefit through being with them and feeling a sense of belonging. Notes were also compiled through these second interviews in order to consider revisions to the headings and definitions of the categories. Figure 1 (phase two to phase three) reflects the changes made to the categories through the validation procedures (based on feedback from co-researchers, independent raters, and experts). In the case of the co-researcher feedback, planning was eventually divided into two categories: contemplating and resolving. This was done in order to respond to the concern that the word planning did not accurately encompass the wide range of incidents classified within. Contemplat-ing better reflects the initial stages of creative thinking (both conscious and unconscious) that precede decisions and plans. Resolving includes the act of deciding, as well as the more detailed act of planning and strategizing. Further explanation of the meaning of Figure 1 will be addressed at the end of the Expert Validation section in this chapter, and again in another section called Voice of the Principal Researcher in chapter 5.  53' Independent Raters Two independent raters were asked to sort the incidents into the six categories. These results were then compared to the results of the sorting done previously by this researcher. This method provides a measure of reliability and is based on the precedent set by Anderson and Nilsson (1964), since followed by many other researchers using the critical incident technique (Alfonso, 1997; McCormick 1994). Can different people use the categories in a consistent manner? The minimum standard deemed acceptable as a level of agreement between the researcher and independent raters is 75% (Alfonso, 1997; Anderson & Nilsson, 1964; Flanagan, 1954; McCormick, 1994). The two independent raters are both therapists with a master's degree in counselling psychology. Over the course of approximately 30 minutes, they were given an orientation to the study and a brief training trial with regard to the sorting process. The headings and definitions for each of the six categories were printed on the cover of manila envelopes. The researcher read these aloud and any clarification necessary was given. Critical incidents were written on index cards and were to be sorted and placed in the envelope deemed appropriate. Six randomly selected examples of critical incidents, for each category, were sorted as a trial run in order for the independent rater to become more familiar with the categories, as well as more familiar with the nature of sorting the incidents according to action, rather than context or outcome. Independent raters were then asked to sort the remaining 18 critical incidents on their own. This sample size represented 14.4% of the total number of incidents. These incidents were randomly selected (three for each category). No communication took place between the raters and the researcher during this process. The raters spent 54 approximately 30 minutes sorting these incidents into the categories. The level of agreement attained was the same in the case of both raters (83.3%). They both sorted 15/18 incidents in agreement with this researcher. An interview was conducted with each rater after the sorting to determine the possible reasons for the discrepancies. With regard to the first rater, it became apparent very quickly that she sorted two of these incidents according to context rather than action. Once this distinction was clarified, there was agreement as to the categorization based on the action within the critical incident. The wording of the third incident remained a stumbling block to agreement. It appeared to be able to fit into two possible categories. It was decided to leave this incident untouched in order to see what the second rater would do with it. The first rater recommended that the instructions to the second rater include an emphasis on the distinction between the action and the context of the incident. In the case of the second rater, de-briefing also quickly highlighted that two of the discrepant incidents were sorted according to outcome rather than action. Again the distinctions were reviewed, and there was subsequent agreement as to the categories based on the action within the incident. Interestingly, the third incident left was the same incident leftover with the first rater. Again, the second rater felt this incident could be classified into two possible categories. The conclusion of this researcher is that the incident is best left in the category determined by the co-researcher who is the expert and has the last word. However, it is also concluded that the wording of the incident is not concise enough to make it clear to others exactly what the co-researcher means. Overall, there is a satisfactory level of agreement to support the reliability of the category system. Exhaustiveness This test speaks to the question of saturation and comprehensiveness of the category system. By withholding approximately 10% of the incidents after the categories have been formed, and later sorting them, it can be determined whether or not the existing category system is relatively comprehensive and complete (Alfonso, 1997; Anderson & Nilsson, 1964; McCormick, 1994). Fourteen incidents provided by co- researcher #8 (11.2% of the total incidents) were held back until all the categories were formed. Subsequently, these incidents were classified. All of these incidents were easily placed within the existing category system, and it was therefore determined that the established categories were complete and comprehensive. Participation Rate Another measure of the soundness of the categories is to determine the level of agreement among the co-researchers with regard to their participation in each of the categories. The formation of a category is based on identifying a significant similarity among a number of critical incidents across a number of co-researchers. The higher the participation rate, the more valid the category. Borgen and Amundson (1984) suggest a participation rate of 25% is sufficient to establish validity of a category. The participation rate is determined by adding the number of co-researchers that participated in each category and calculating a percentage of participation. Table 2 provides a summary of these findings which outlines both the frequencies and the participation rates. The participation rates for this study ranged from 50% (contemplating) to 100% in two categories (connecting with others and practicing). The results of this measure provide 56 Table 2 Categories, Frequencies, and Participation Rates for Critical Incidents Category Frequency Percentage of . total incidents (N=125) Participation rate (N=8) Connecting with others 41 33 100% Practicing 34 27 100% Remembering 17 13.5 63% Connecting with emotional and physical aspects of self 13 10.5 88% Resolving 13 10.5 75% Contemplating 7 5.5 50% another means of establishing the validity of the categories for this study. Expert Validation Another important check as to the trustworthiness of the categories is to elicit feedback from a number of experts in the field. These experts are asked to judge the relevance and usefulness of the categories and their definitions in relation to their own practice and experience. Experts are in a position to survey the field at large and to speak to the content validity of the categories. Are the findings of this study consistent with their own experience? Do these categories have any bearing as guidelines for them and for their clients in the facilitation of maintaining change as a result of therapeutic intervention? Three therapists, with over 30 years of experience between them, provided commentary on the relevance and usefulness of the categories for this study. They were 57 simply asked to consider each category and to comment on its validity, in their own opinion. The first expert was approached on the basis of his practice as a therapist- director in therapeutic enactment. He found each of the six categories to be relevant to his own experience. In particular, he indicated that the act of connecting with others is especially powerful for his clients. His own research has highlighted the importance of group member connections with each other, even over connection with the therapist. The second expert has specialized as a therapist in the field of addictions. Her work with clients has focused on developing personal responsibility and building up personal resources outside of therapy. She too indicated all six categories to be extremely true to her own experience with clients. She commented that connecting with others through various types of groups has been especially significant for her clients. In addition : to more formal therapeutic groups, her clients have found support through self help groups, book clubs, and online interest groups. The third expert works as a school counsellor to a teen mother program. The nature of the school setting and its brief therapy opportunities mean that she works to help these young women establish supports and resources outside of the school setting as much as possible. She also takes opportunities to help them develop themselves more holistically. She has led them in yoga, meditation, nutrition, etc. Consequently, she found the categories of connecting with self and contemplating to be of special importance. She commented on the usefulness of each category and gave examples of similar critical incidents for both herself and her clients. In addition to unanimous support of the six categories by these experts, they each inquired about the dimension of fate, chance, synchronicity, divine intervention, spirit or 58 serendipity. Although they each had varying concepts, the common expectation was that the co-researchers would have identified critical incidents related to influences beyond their own control. These notions will be explored further in the last two chapters. Feedback from independent raters, as well as the experts, confirmed the need to alter the title of the categoryconnecting with self to connecting with emotional and physical aspects of self (see Figure 1, phase two to phase three). The initial heading was too broad, and therefore misleading. Although there was not an original intention to create division between more cognitive activities (remembering, contemplating, and resolving) from emotional and physical activities, this is how the action categories evolved based on the nature of the incidents. The evolution of category development from phase one to phase two outlined in Figure 1 will be discussed in the final chapter under the heading Voice of the Principal Researcher. Theoretical Agreement The final check for reliability and validity of the category system in a critical incident study is sought through previous research. If agreement can be found, then the category can be considered to have strong merit. If agreement cannot be found then the soundness of the category must be questioned. The unsupported category would not necessarily be dismissed, particularly considering if it has received support as a result of other validation procedures. However, it would be noted that further research is needed to substantiate the value of those findings. Searching out related literature and research led to the support of five of the six categories, with the exception of remembering. Because this category received such a 59 significant degree of support from co-researchers (third highest frequency rate and 63% participation rate), as well as support from experts, it was decided to retain this category for future research to either confirm or disconfirm. The body of research most related to this study is that produced by Prochaska and colleagues. For over 20 years they have been developing, testing and refining their transtheoretical model of change. This model encompasses stages, principles and processes of change. The 10 processes represent the "covert and overt activities people use to progress through the stages" (Prochaska et al., 1998, p.62). Prochaska makes a distinction between a process and a technique. Each process is a broad strategy that may employ any number of techniques. Similarly in this study, each category represents a broad action that in turn involves a number of possible contexts, sources, or techniques. The processes from Prochaska's work provide a direct point of reference for comparison with the action-categories developed through this research. Relevant research and informed opinion for the five supported categories are as follows: Connecting with others. Studies conducted by Prochaska and colleagues over the past 20 years have consistently determined that helping relationships are the most commonly used process for change by individuals, whether they are engaged in therapy or not (DiClemete & Prochaska, 1982; Norcross et al., 1986; Prochaska et al., 1994). While he does acknowledge the significance of the relationship with a professional therapist, Prochaska emphasizes the importance of other supportive relationships. Self- changers report seeking help from friends, family, clergy, and acquaintances with similar problems. An important aspect of Prochaska's premise is that processes and techniques 60 should be appropriately matched to the individual's current stage of change. Helping relationships are so significant that it is the one process Prochaska proposes should be integrated at every stage of change. This conclusion highly resonates with the results of this study. Connecting with others was the category with the highest frequency rate (41/125 critical incidents) and the highest participation rate (100%). Practicing. Three of Prochaska's processes of change correspond to practicing new or more assertive behaviour: countering, social liberation, stimulus control (Prochaska, et al., 1994; Prochaska, 2000). Countering or counter-conditioning is the act of substituting healthy responses for unhealthy ones. This strategy is especially important during times of distress. An individual who typically resorts to overeating or drinking may choose to exercise. Social liberation involves taking advantage of new alternatives that the environment provides. This fits with incidents described in this study wherein co- researchers either followed through on pre-mediated plans for new alternatives or responded spontaneously and assertively to unplanned opportunities. Finally, environmental or stimulus control is about restructuring one's environment to increase healthy prompts and decrease potential problems. This process can actually line up with the act of resolving as well as the act of practicing. In some instances stimulus control is a cognitive activity in the context of planning or strategizing; in other instances it is action oriented as in this category of behaviour — practicing. This process involves either thinking about how to restructure the environment (resolving) or putting the plan into action (practicing). One co-researcher described planning and then following through on 61 a decision to avoid certain social situations that could lead to conflict. For him this meant playing basketball somewhere else and using the car versus taking the bus. Krumboltz (1999) also addresses the notion of practicing new behaviour in the midst of unexpected opportunities. His theory of planned happenstance includes utilizing the skills of optimism and risk taking in order to make the most of unexpected opportunities to learn, grow, and change. Connecting with emotional or physical aspects of self. Prochaska and colleagues have shifted their language of the emotional dimension of change from catharsis to emotional arousal to dramatic relief (Norcross et al., 1986; Prochaska et al., 1994; Prochaska, 2000). Overall they have described it as a powerful process in which people have a significant emotional experience. The results include increased awareness and : motivation to take action. The majority of critical incidents described by co-researchers in this category had to do with significant emotional experiences that provided valuable information, as well as a sense of relief. Prochaska refers to the benefits of physical exercise and relaxation activities within the process of countering (Prochaska et al., 1994). He points to a variety of research in the health field that spells out the benefits of what he considers to be active diversion or healthy alternatives to problem behaviour. The incidents in this study related to connecting with physical aspects of self (like yoga and somatic therapy) led not only to healthier alternative behaviour, but also to a sense of personal and holistic balance of head, heart and body. 62 Resolving. The significance of decision-making and strategizing is related.to two processes identified by Prochaska and colleagues: stimulus control and self liberation (Prochaska et al., 1994; Prochaska, 2000). Environmental or stimulus control involves restructuring one's environment in order to decrease unhealthy cues and increase healthy cues. It can be a matter of preventative planning or one of proactive planning. The aim of the former is to avoid anticipated problems, while the aim of the latter is to arrange for positive experiences. The second process related to the results of this study is that of self liberation, formerly called commitment. Like the act of resolving, the individual accepts responsibility for changing, believes that s/he can change, commits and re-commits to act on this belief. The importance of this activity is also highlighted by Karoly and Wheeler (2000) as they promote goal guided self-regulation. After a review of meta-analytic findings with regard to therapy outcomes and durability of treatment effects, they conclude that therapy needs to focus on strengthening people's goal-directedness. Although the co- researchers in this study did not speak directly of setting goals, the nature of their decisions, resolutions and plans imply the act of goal setting. One co-researcher decided he needed to stop travelling and moving so frequently. This decision tied into his expressed goal to spend more time with his parents. The significance of decision-making and strategizing is very apparent in Krumboltz's (1999) theory of planned happenstance. He emphasizes the importance of changing one's attitude through the skills of flexibility and optimism in order to capitalize on unplanned opportunities that will inevitably present themselves to people. 63 Contemplating. There are three processes identified through the transtheoretical model which correspond to the act of contemplating: consciousness raising, self re- evaluation, and environmental re-evaluation (Prochaska et al., 1994; Prochaska, 2000). Consciousness raising involves increasing information and awareness related to self, the problem, and the environment. All of this activity occurs in order to better inform the individual, as well as to improve the decision-making process and subsequent behaviour. This is especially significant given the manner in which the co-researchers in this study indicated that the contemplative type activities be separated from the planning or resolving type activities. They made a distinction between the kind of thought that precedes decision-making. Contemplative activity also included dreaming and imagining. Similarly, Prochaska et al. (1994) make note of dream interpretation and free association as techniques in the realm of consciousness raising. The other two processes hold similar implications for contemplating. They are self re-evaluation and environmental re- evaluation. Both involve cognitive and affective assessments of self-image and environment, respectively. The former involves more of a future focus as people imagine themselves free of their problem. The latter involves the individual considering the social impact of their behaviour with and without the problem. The initial step in Krumboltz's (1999) application of planned happenstance is the act of exploration and using the skill of curiosity. It is this open-mindedness, and willingness to ask questions that will help the individual to generate chance opportunities. As Krumboltz (1998) says, "Serendipity is ubiquitous" (p. 390). The individual needs to be prepared and be open to possibilities. 64 In summary, all validation procedures employed in this study provided a significant degree of support for the category system developed. The co-researchers not only validated every detail of the critical incidents, they contributed significantly to the development and revision of the category system. This was accomplished through the second interview. Agreement among co-researchers through measuring their participation rates in the categories also revealed a high degree of validity and soundness to the categories. Two categories maintained a 100% participation rate. The lowest participation rate was in one category, still sound at 50%. The exhaustiveness check, conducted after the interview with co-researcher #8, did not result in the need for developing any new categories, thus supporting the existing system. A high percentage of agreement, 83.3%, was obtained from each of the independent raters. They consistently sorted the incidents and thereby established the reliability of the categories. Expert validation of all categories was unanimous. Each expert spoke of the system of categories as relevant and applicable to their own practice and experience. Theoretical agreement and support was demonstrated for five of the six categories: connecting with others, connecting with emotional and physical aspects of self, contemplating, resolving, and practicing. It is reasonable to conclude that the category system established through this research is reliable, valid, and can be used to inform theory and practice related to therapeutic enactment, as well as to the process of change. 65 CHAPTER 5 DISCUSSION Summary of Results Interviews with eight co-researchers produced 125 critical incidents which facilitated their experience of change maintenance after therapeutic enactment. These incidents were sorted into six categories: connecting with others, connecting with emotional and physical aspects of self remembering, contemplating, resolving, and practicing. Each category represents the action dimension of the critical incidents identified by the co-researchers. Action involves the behaviour of the co-researcher. This behaviour can be of a physical, cognitive or emotional nature. Sub-categories emerged on the basis of the source or contexts of the various actions. The context is significant, because many times it serves to trigger or facilitate the helpful action. Table 3 provides an overview of the categories and sub-categories produced from the results of this study. This table is a taxonomy of ideas which could be used to foster change maintenance after therapeutic enactment. These ideas address the need, consistently expressed by co-researchers in previous studies, for further opportunities to continue to process the experience of change after a therapeutic enactment (Baum, 1994; Brooks, 1998; Martens, .1990). One of the goals of this study was to consider how therapists might empower clients as they leave the therapeutic setting. Six validation procedures were used in this investigation. Each one established reasonable soundness and validity for the categories that have been developed. 66 Table 3 Ideas to promote change maintenance: Action categories and their contexts Action categories Connecting with others Connecting with self (emotional & physical) Remembering Contemplating Resolving Practicing Friends Emotional Significant Guiding and/or experience circumstance questions family triggers memory Therapeutic Physical Materials Dreams enactment activities (i.e. journal, group (i.e. exercise, video, members relaxation photographs, techniques, momentos) somatic therapy) Therapist Daydreams, (i.e. imagination therapeutic enactment therapist, other therapist) Reading Limitations Before drawing any implications from the results of the study it is important to consider some of the limitations which affected the investigation. Two aspects of this research method pose some difficulty. First is the issue of self-report. Critical incidents obtained through self-reporting are limited to the events that people are able to remember, and are able or willing to articulate. It is possible that some critical incidents were 67 forgotten, overlooked or too private to share. It is also possible that the assumption made in the selection criteria played a role in limiting the kinds of incidents reported. Potential co-researchers had to confirm that they experienced significant and positive change as a result of their enactments in order to participate in this study. Consequently, there may have been a pre-established notion or inclination to focus on the positive. Flanagan (1954) addressed the limitation of self-report when he determined that people reporting on events which hold great value for them were able to provide clear and detailed recall. The data collected was considered valid and reliable when it was rich in descriptive detail. Prochaska (1993) has also concluded that "self-reports simply yield more data on more difficult to study subjects in more reliable and valid ways than any other psychological or biochemical measures of behaviour" (p. 250). He was able to demonstrate an invalid response rate of 2% based on a number of his smoking cessation studies. Prochaska also points to the manner in which many professions depend on self- report. He sums up by saying, "we would have a terrible time living socially if most self- reports were unreliable and invalid" (p. 251). Conducting a second interview with co-researchers was an important step taken in this study to curb problems associated with self-report. Lapses in memory, building trust and rapport with the interviewer, and clarifying previous reports were addressed as much as possible through this second opportunity to provide descriptive data. It should also be noted at this point that the principal researcher was unsuccessful in conducting a second interview with one of the co-researchers. This means that 10% of the total number of critical incidents collected for this study could not be validated by the reporter (co- researcher). Given that conducting a second interview is novel in this research method, 68 this principal researcher relied on the traditional strategies to compensate for possible misunderstanding. Careful study of the audio-tape and the transcript is the standard approach to gain as much clarification as possible. It is also important to note that the second interview was used to validate the content of the critical incidents and the relevance of the categories, not the relevance of the sub-categories. Although co-researchers did not speak directly to the relevance of the sub-categories, their verification of the accuracy of the incidents bolsters their validity. The sub-categories were developed on the basis of the source or context of the critical incidents in each category. Formation of the categories is a daunting task in this method. The vast amount of data collected, along with ample room for subjective interpretation, can be a problem. Two things helped to provide structure, and to help establish the reliability of the categories. First, the skeleton of a critical incident was extremely helpful in establishing valid incidents. Context, action and outcome form the skeleton. Action became the critical component for sorting the incidents into appropriate groups, and in turn helped to establish valid categories. Second, the validation interview with the co-researchers was essential in verifying the content of incidents, and subsequently providing feedback on the relevance of the categories. This led to the consistent and reliable sorting of incidents by the principal researcher and the independent raters. No demographic data was collected for this study. Therefore, only the following superficial observations can be noted from this group of co-researchers: (a) at least 85% of them have post secondary education and work as professionals, (b) at least 50% of 69 them are academics teaching in post secondary settings. This group appeared to be insightful and articulate. They represent a very limited cross-section of the population. Finally, qualitative investigation by its exploratory, naturalistic, descriptive nature is not intended for drawing conclusions about a specified population through statistical inference. Interviewing eight people provides deep data, not necessarily broad data. According to Maione and Chenail (1999) generalizability of results from a qualitative study is a two-fold process. First, researchers must be confident that how they describe a phenomenon is the best generalization they can make, that is, the most fitting among the variety of ways to discuss a given phenomenon. Second, the consumers of the research must judge whether the work is generalizable and consistent with their perceptual reality. In this way generalizability is an interactional process (p. 60). Making generalizations from the results of this study is a cautious venture. It requires careful comparison of the data to previous theoretical, practical and investigative work. Theoretical Implications The previous chapter contained important aspects of theoretical agreement between Prochaska et al.'s (1998) processes of change and the facilitative action categories developed through this research. An overview of these lines of agreement are presented in Figure 2. Prochaska and colleagues make a distinction between a process and a technique. Each process is a broad strategy that may employ any number of techniques. Each category in this study represents an action which can occur in a variety of contexts. While there is no need to repeat the details of theoretical agreement already discussed in chapter 4, it is worth noting some highlights and some discrepancies. Change Maintenance after Therapeutic Enactment Action Categories Prochaska's Change Processes Y Connecting v. with others J Helping relationships Figure 2. Comparison of the change maintenance action categories to the processes of change. 71 Connecting with others is a very significant category of action with a number of possible sources. This change maintenance strategy had the highest participation rate (100%) and the highest frequency rate (33%) of all the maintenance behaviours described by co-researchers. This is in complete.agreement with Prochaska's assessment that helping relationships are the most pervasive support at all stages of change (Prochaska et al., 1994). Comments from co-researchers in this study would qualify this statement with the descriptors "trusted" and "healthy" others. They also spoke of avoiding certain people in their lives who would have a negative impact on their efforts to change. Mahoney (1991) speaks to this incredible power in relationships - the power to significantly help or to significantly hurt. The source or context for the critical incidents in this category is important to consider. There were three natural sub-categories that emerged: (a) friends/family (sixteen incidents), (b) therapeutic enactment group members (nine incidents), and (c) therapists (fifteen incidents). Given that Prochaska et al. (1994) warn that a relationship with a therapist should only be one possible helping relationship among many others, the results of this study are encouraging. The majority of facilitation of change maintenance was found through supportive relationships with people other than a therapist. This speaks to the concern expressed by Mahoney (1991) as well as the group therapist expert who provided feedback for this study. Both men indicate that the dangers inherently found in the power dynamic between an individual and his therapist are often a non-issue in either group member to member relationships or with healthy others in a person's natural social network. That being said, the contribution a therapist can make toward promoting change maintenance is significant. In the context of a relationship with a 72 trusted and healthy therapist, co-researchers reported receiving valuable affirmation, encouragement, and advice. In addition to the fifteen therapist related incidents in this category, three incidents reported under remembering involved subsequent, vivid recollections of the therapist's voice and words from, significant moments during enactments. The trained professional helper is often able to provide a unique source of connection, communication and education that would be difficult to find in many regular relationships. It is also important to note the reports by co-researchers of the significance of duality in certain relationships - in some cases with the therapist-directors, and in other cases with group members from therapeutic enactment workshops. Five of the co- researchers made reference to the benefits they have derived from developing relationships with either the therapist-directors or group members across a number of other settings prior to and beyond the therapeutic enactment workshop (professional, educational, social, further informal therapeutic gatherings). They described a mutual understanding and trust that evolves which in turn enables them to take risks in sharing and behaving in new ways. In fact, every one of these co-researchers indicated that they had pre-established relationships with either the director or other group members before they did their enactments. These trustworthy relationships laid the foundation for their ability to risk doing an enactment, a very vulnerable venture. It seems what many of them are describing is the evolution of a community. This movement is in keeping with feedback from previous therapeutic enactment studies (Baum, 1994; Brooks, 1998; Martens, 1990). Co-researchers consistently reported the need for further support, as well as opportunities to process and integrate the results of 73 their enactment experiences. This informal community development is a broader and deeper extension of the 6 week follow-up meeting developed by Westwood et al. (in press). What's unique about this extension is that it is developed informally, in most cases, by individuals maintaining their connections with other group members. These supportive relationships have the added benefit of an unspoken identification and understanding based on a shared experience. This is typically what people are looking for when they search out self-help groups where there is a pre-established mutual interest i.e. Adult Children of Alcoholics, divorce support groups. In this case it is the intervention experience that is the common ground rather than the nature of the problem. Three of these co-researchers also make reference to their continued connection with their therapist-director in more of a mentoring relationship in an educational or professional context. This form of social, therapeutic, and professional networking can be considered as more evidence of people's efforts to use, even create resources in their environment (Tallman & Bohart, 1999). It is also evidence of the ground swell of self-help efforts made by people (Snyder & Ingram, 2000). It speaks to the question posed by one of the expert therapists who participated in this study. What about self-help and support groups? The drive to seek out like-minded others who are struggling with the same problems, and more importantly are motivated to change, is reflected in the proliferation of so many different types of self-help and growth groups (Forsyth & Corazzini, 2000). Researchers won't deny the power of these change promoting groups. In fact, this approach to change maintenance fits the growth model of change proposed by Snyder and Ingram (2000), as well as the goal guided self-regulation model proposed by Karoly and Wheeler Anderson 74 (2000). Some of the therapeutic enactment group members could be described as forming their own support groups. In most cases they had a head start, because they already had connections with some like-minded others who also chose to participate in the therapeutic enactment workshop. The significance of connecting with others is reinforced when the overlap between the categories for this study is considered. There were at least twelve incidents in the practicing category and two in the resolving category that had to do with the power of relationships. The fact that the connection with others had more to do with context or outcome rather than action is what placed these incidents in other action categories. Nonetheless, these incidents reinforce the critical role played by relationships when it comes to human development, change, and healing. Practicing was another very important category. It too garnered a 100% participation rate among the co-researchers, and had the second highest frequency rate (27%). This category posed the most difficulty in terms of overlap; it was easy to think a practicing incident could be just as suitably placed in another category. The majority of inconsistencies in the sorting process (between the principal researcher and the independent raters) were related to this category. The nature of practicing new behaviour means that this category can encompass any kind of behaviour or action. What makes these incidents distinct from those in other categories is that the co-researcher determines this action is critical because it is new for them to behave in this way. Novelty is what makes this category salient. Tallman and Bohart (1999) note people's capacities for creativity when it comes to behaviour. They cite Epstein (pp. 109-110) who concludes from his studies that "the behaviour of organisms has many firsts, so many in fact, that 75 it 's not clear there are any seconds. We continually do new things . . . When you look closely enough, behaviour that appears to have been repeated proves to be novel in some fashion." The word practicing was consciously chosen. It denotes a sense o f experimentation and never having quite perfected a behaviour. This certainly coincides with Prochaska's (2000) conclusion that the termination stage of change is never truly attained. Whi le the goal of this research effort was not to formulate a model of facilitative change activities, there seemed to be some relationship between certain actions. In particular, there seemed to be a natural flow from contemplating or remembering to resolving to practicing. Practicing behaviour seemed to be a culmination of contemplating and resolving behaviours. This fits with the model of client generativity and self-healing proposed by Tallman and Bohart (1999). They suggest the progression of change involves: people actively exploring their worlds through both thought and behaviour, trying out new ways of being and behaving, engaging in creative variations on old learning, and solving problems as they come up. Similarly, Krumboltz (1999) outlines the importance of exploration as the first step to people generating beneficial opportunities to learn and change. He emphasizes curiosity, open-mindedness, and the willingness to ask questions as keys to preparation for learning. This preparation, along with the skills of flexibility and optimism, then empowers people to take risks in the face of uncertain outcomes. There is also a significant dimension of spontaneity captured in the practicing category which speaks to the creativity of people accessing resources, even unexpected opportunities, in their environment (Tallman & Bohart, 1999). Whether an event is due to 76 chance or deliberation depends on the perception of the individual (Krumboltz, 1999). This perception was not always clarified with the co-researchers in this study, which explains why it was impossible to firmly establish the sub-categories: pre-meditated practice of new behaviour and spontaneous practice of new behaviour. The creative response to unexpected events corresponds to Krumboltz's (1999) theory of planned happenstance. On the one hand, Krumboltz emphasizes that the field of counselling overlooks the element of serendipity or chance; on the other hand he contends that people too often attribute certain outcomes to chance, when they are in fact, indirect outcomes of effective behaviour. He attempts to strike a balance by calling people to action in order to "create favorable circumstances, action to recognize opportunities when they arise, and action to capitalize on unplanned events in a timely manner" (Krumboltz, 1998, p. 392). He explains that these events are inevitable and ubitiquous, therefore people need to develop skills in order to take advantage of these opportunities. He quotes Pasteur's adage, "Chance favors only the prepared mind" (Krumboltz, 1999, p. 122). A number of Krumboltz's practical suggestions for counsellors and clients to foster these skills will be examined in the next section. As indicated in Figure 2 it is apparent that the issue of contingency management or positive reinforcement never arose in this study as a significant facilitative factor for change maintenance (Prochaska, 2000). Indirectly co-researchers spoke of receiving encouragement through connecting with others. Factors in this study related to positive reinforcement were more a matter of outcome than of action. Actions that were not necessarily considered to be rewards per se, resulted in positive reinforcement, 77 strengthening people's commitment to maintain change. It appears that people were intrinsically rewarded by some of their behaviours. Over half of the co-researchers (63%) contributed critical incidents to the category of remembering. This category also had the third highest frequency rate (13.5%) of incidents. In spite of this there was nothing of note in the literature reviewed regarding the role memories can play in the process of change maintenance. The cognitive kinds of activity noted by Prochaska et al. (1998) have more of a present and future orientation as revealed in the contemplating category in this study (exploring, inquiring, imagining, dreaming). There is some degree of reflecting back in time in the act of exploring, comparisons made to the past. The power of the images and the flashbacks reported by co-researchers here suggests that the act of remembering is distinct enough to stand on its own as a significant facilitator of change maintenance. All memories reported were directly related to critical moments from the co-researchers' enactments. Brooks (1998) also noted the significance of imagery as an enduring reference point for co-researchers who have been leads in therapeutic enactment. This was the one post-enactment theme specifically articulated by his co-researchers as a strategy to support their changed behaviour. They would refer back to powerful images derived from cathartic moments in their enactments. The results of this study provide further confirmation of the importance of enactment related imagery. This new memory created through re-enactment also speaks to the value Westwood et al. (in press) place on schema and script theory. The therapeutic enactment provides the opportunity to re-activate and re-structure longstanding, obstructive schemas 78 and scripts - to create a corrective mental memory, as well as a corrective emotional experience. The power of the emotion, the cathartic element of the moment in the enactment, might be considered to be the battery juice for the snapshot. A moment is captured and creates a new and critical memory that continues to serve the individual long after the enactment. The act of remembering that critical moment facilitates change maintenance once back in the real world. These kinds of results from such an experiential therapy also tie in with Tallman and Bohart's (1999) references to the power of bodily felt shifts gained through behavioural practice and rehearsal. There seems to be an important connection between emotion and memory as it pertains to creating useful flashbacks or reflections to promote change. A number of post-enactment themes from Brooks' (1998) study were confirmed through the results of this study. They are listed and matched to the corresponding categories in which similar critical activities occurred: (a) increased ability to make life changing, important decisions — resolving, (b) increased awareness and differentiation of feelings — connecting to emotional and physical aspects of self, (c) greater differentiation between self and others - connecting to emotional and physical aspects of self and practicing, (d) new awareness and ability to dispute negative beliefs - contemplating and practicing, and (e) increased openness and closeness to others - connecting with others, resolving, and practicing. Practical Implications Co-researchers have supported their own change through patterns of facilitative activities reflected in the six categories. The key action words are: remembering, 79 contemplating, resolving, practicing and connecting (in the context of self, as well as relationship). The question now is what can therapist-directors learn from these results in order to strategically prepare and empower their clients beyond the therapeutic setting? How can these facilitative activities or contexts for these activities be fostered? The top three categories in terms of frequency rate are: connecting with others, practicing, remembering. The top three categories in terms of participation rate are: connecting with others, practicing, connecting with emotional and physical aspects of self. This section will focus on practical implications related to the two most commonly and frequently used activities: connecting with others and practicing. Some overlap exists between practicing and the behaviours that typically precede it: remembering, contemplating, and resolving. Based on the results of this study, along with the conclusions of Prochaska et al. (1994), it seems that connecting with trusted and healthy others is the number one activity that proves helpful in change maintenance. What stood out as helpful for more than half of the co-researchers in the present study is that they had pre-established, trusting relationships with group members or leaders prior to their enactments. The continuity of these relationships remained an important factor after the enactments as well. Although two other co-researchers did not highlight the significance of having pre- established relationships with the therapist or other group members, they did indicate that they knew people at their enactments beforehand. Only one of the co-researchers for this study had no pre-established relationships. It seems significant that this co-researcher experienced the two outstanding hindering incidents mentioned at the beginning of chapter 4. It also seems significant that these incidents had to do with feeling 80 disconnected from others, in general and specifically upon later contact with group members. The words of this co-researcher echo the results of Stiles' study (as cited in Tallman & Bohart, 1999, p. 111): A person doesn't always self-heal in everyday life because for some reason, the natural environment has not provided the opportunities. For example, outside of therapy people rarely have a friend who wi l l truly listen to them for more than 20 minutes. This co-researcher says: I lack the type of support that you get in an intimate relationship. I have great friends, but you're always sucking it up, because you get them for 15 minutes every 2 weeks . . . and I just sound like a broken record i f I'm sad. They can't give me what I need. It makes me feel alone, no one to share my pain with. The question is what can be done to help therapeutic enactment clients foster the kinds of relationships that are important in the self-healing, self-changing process? It would seem a case may be made for stretching the therapeutic enactment workshop in ways in which people are provided opportunities to build trust with key support people (therapist-directors, group members or friends/family). A number of co- researchers have indicated this trust is necessary for taking risks, and also necessary for buffering them from the pain that comes about through their risk taking and self-healing efforts. This is especially true in cases where a lead plans to do an enactment based on a traumatic event in his/her life. As mentioned in chapter 2, Westwood et al. (in press) recognized the need to extend the warm-up stage of classical psychodrama by including pre-session contact between the therapist-director and the lead. In cases where a lead has no pre-established relationships with any group members or directors, this contact may need to be more extensive. A screening procedure, similar to that used with peacekeepers, may be useful. 81 The screening procedure could be used not only to determine suitability for the intervention, but also to begin preparatory work for both the enactment and the post- enactment experience. The director could explore the nature of the lead's social support network that will eventually become key to their change maintenance and continued healing process once back in their real world. Together they could identify key people that the lead may strategically inform and request to be part of their healing process after the enactment. In cases where the lead is unable to identify key people who would be suitable and willing to provide support, the director may encourage the lead to take time to develop these relationships before embarking on an enactment. This pre-enactment contact also serves to develop trust and rapport between the lead and the therapist- director. If extending the therapeutic enactment workshop into a longer running group, as in the case of the peacekeepers, is not feasible there may be ways to provide opportunities for pre-enactment contact with soul catchers or more experienced group members. However, given that the lead may not have occasion to maintain these group member relationships after the enactment, it may be more useful to help them develop their natural social support network. If therapeutic intervention is like performing mental/emotional/spiritual surgery, then spending some time in intensive care after surgery may be necessary. Leads may need to consider the possibility of re-arranging their schedules in order to lighten the demands placed on them after their enactments. Preparing for this after-care by exploring and mapping out the individual's social support network is critical. Another way to help people discover and foster supportive relationships is to explore other kinds of self-help or psycho-educational groups which may exist in their communities. Finding other people 82 struggling with the same issues or at least finding a group of people striving for change can tie a whole new section of support into the individual's social network. It also creates the sense of community and belonging that is so critical in the healing process. Practicing new behaviour by following through on resolutions or taking advantage of opportunities which present themselves seem like reflexive behaviour that flows naturally out of. encouragement that has built up. In the case of following through on plans, Prochaska (2000) makes an important distinction between the private and the public nature of the resolution. He indicates that making one's decision public strengthens willpower. He also points to motivational research that suggests people are more motivated to follow through on decisions when they have two or three choices. If they see only one option in the change process, they are less motivated. According to Krumboltz (1999) there are a number of steps therapists can take to help their clients practice new behaviour in the context of unexpected opportunity. Whether one attributes these opportunities to chance, synchronicity or supernatural powers at work, Krumboltz aims to have therapists prepare clients for the unexpected. He speaks of planful serendiptiy or planned happenstance. Krumboltz (1998) offers a four step teaching method for therapists to enable clients to foster planned happenstance. While his focus is on people's career development, his approach can be adapted to focus on the change that the individual is attempting to consolidate and maintain. With the help of the therapist's direction the client deduces actions s/he can follow in the future based on his/her own past experience: 1. Ask clients to describe a situation in which some unplanned event affected their lives in general or the specified behaviour for change. 83 2. Ask clients what they did to enable this unplanned event to happen. What did they do to place themselves in the right place at the right time? 3. Ask clients to generalize about actions they could take in the future. 4. Contract with clients to try one of the actions by an agreed upon date. The key is to help people re-frame unexpected events. They need to consider the role they themselves play in creating or at least taking advantage of these opportunities. This will also likely lead to the consideration of missed opportunities. Krumboltz (1999) has gone on to offer more detailed lines of inquiry for therapists to follow with clients (Appendix G). Sensitizing people to the power of unexpected opportunities leads to preparation and strategy. These practical ideas for fostering planned happenstance invoke action in a number of the categories derived through this study: remembering, contemplating, resolving, as well as practicing. The power of enactment related imagery and its growing significance suggest that remembering is an activity worth exploring and fostering (Brooks, 1998). People may be very aware by the end of their enactment what are the especially significant moments, the natural mental snapshots with which they will walk away. However, this insight may not become apparent until some time has lapsed. There may be a natural opportunity at the 6 week follow-up meeting for leads to express what these snapshots are and what makes them so meaningful, as well as encouraging. Some of the contexts around the memories experienced by co-researchers might serve as material mechanisms to foster this activity (i.e. journals, symbolic momentos, photographs, videotapes). In the same way that Krumboltz (1999) has recommended people be aware and open to inevitable, unexpected 84 opportunities, people need to anticipate unexpected opportunities that trigger positive reflection, healing memories. Ultimately, it seems the most effective means of solidifying these memories is to verbally express them to others,, storytelling. Much.like Rennie's interpersonal process recall technique (IPR) (as cited in Tallman & Bohart, 1999) the interviews conducted for this study provided an opportunity to remember and to articulate the significance of those memories. This can serve to solidify the memories and help develop the habit of recollection. Half of the co-researchers identified these interviews as critical incidents in their change maintenance. Table 4 provides a taxonomy of ideas to promote change maintenance. It extends Table 3 by adding relevant ideas from the literature reviewed for this study. This framework of helpful activities, and the contexts in which these activities typically occur, may serve to foster change maintenance after therapeutic enactment. Research Implications The first point to make in this section is what an invaluable asset the second interview with co-researchers was to this research project. It contributed to many aspects of validation for the results. A l l aspects of validity were founded on the accuracy and completeness of the critical incidents. Many incidents needed to be re-sorted into different categories after clarifications were made in the second interview. It would be interesting to test the value of the second interview with co-researchers by calculating rater agreement between the principal researcher and the co-researchers. Just as comparison is currently made between the sorting of critical incidents into categories by the principal researcher and then by the independent raters (reliability check) - 85 Table 4 Ideas to promote change maintenance: A compilation of research and literature based action categories and their contexts Action categories Connecting with self Connecting (emotional & with others physical) Remembering Contemplating Resolving Practicing Friends and/or family Therapeutic enactment group members Therapist (i.e. therapeutic enactment therapist, other therapist) Self-help groups* Psycho- educational groups* Online groups* Emotional experience Physical activities (i.e. exercise, relaxation techniques, somatic therapy) Significant circumstance triggers memory (Appendix G) Materials (i.e. journal, video, photographs, momentos) Guiding questions (Appendix G) Dreams Private* Pre-meditated plans* Public* Unexpected opportunities* (Appendix G) Daydreams, imagination Reading Note. * refers to action contexts derived from literature. 86 comparison could also be made between the sorting of critical incidents into categories by the principal researcher and then by the co-researchers. If less than a 75% rate of agreement is reached, this would be a strong indicator that the second interview is a necessary step. Otherwise, the sorting of.incidents into categories is less than accurate, overlooking the voice of the co-researchers in such an important part of the data analysis. Further research in this regard may serve to confirm the significant degree of validity and reliability produced by the second interview. The results of this study further enhance the existing body of therapeutic enactment research by concentrating on the post-enactment time frame. The results also confirm many of the post-enactment themes developed by Martens (1990), Baum (1994), and especially the more comprehensive work done by Brooks (1998). These results also speak directly to the change processes developed through the research of Prochaska et al. (1998). While any number of future research questions could be pursued out of the literature reviewed for this investigation, there are some areas of inquiry highlighted by the results of this study. First, the act of remembering was considered critical and facilitative by over half of the co-researchers. It would be interesting to explore in more detail how the action and the context of remembering are helpful and how this facilitative activity could become more intentional. This exploration would also consider the significance of catharsis, emotion and enactment imagery as they relate to remembering. Second, a more in-depth investigation into the development of planned happenstance would be beneficial in an effort to empower people. Krumboltz (1999) asks the questions, "What skills can be confirmed as distinguishing those who generate and profit from chance events from those who do not? How can counsellors teach their clients to develop the skills that are most beneficial?" (p. 124). Finally, another significant area of investigation could involve the Canadian peacekeepers, a very different segment of the population that has been commonly served by therapeutic enactment. The practice of this intervention with this group has been delivered in a longer running context. They have typically met weekly over a period of 14 weeks and have incorporated life review activities in their meetings before moving on to the more risky sharing experienced in therapeutic enactment. There is time to build trust and develop relationships. The many differences in the set up of this group from the 3 day workshop model would provide an interesting contrast to the results of the majority of previous therapeutic enactment research. It would be beneficial to learn what facilitates change for this group of people. Many peacekeepers struggle to adapt to civilian life. They could teach researchers some important lessons about what helps them to change and to maintain change independent from therapeutic intervention. It would be especially interesting to note the similarities and differences between the action categories and context sub-categories developed here, with those which might be developed by the peacekeepers. Voice of the Principal Researcher This research adventure has been at times frustrating, perplexing, and at other times rewarding. The most perplexing part of the analysis process was definitely the formation of the categories. Having been an English literature major I felt quite confident about extrapolating themes from the stories told by co-researchers. The transition of 88 categories from phase one to phase two of Figure 1 (p. 52) in chapter 4 represents for me what was the most excruciating period of this research endeavour. I was stumped as I waded my way through the incidents and attempted to group them into categories. The initial headings (phase one) proved very confusing. There were two guidelines that pulled me through this confusion. First, I remembered that if there were too few incidents in a category, the validity of the category had to be suspect. This took me back to the principle that categorizing should start out broadly and then transition to detail. I realized I was attempting to be detailed too soon in the process. This revision led to the headings seen in phase two. The second aid in this arduous process involved remembering that the incidents were being classified according to action. Consequently, it seemed clear the headings should be verbs, action words. This simple approach helped me to focus on the overall intention of the study, as well as to sort the incidents more accurately. Certainly the most rewarding aspect of the study was meeting with the co- researchers. It was an honour to have them take the time and share intimate aspects of their lives and their personal growth process. Their stories were all the more meaningful to me because of my own therapeutic enactment experience. Like them, I have a personal investment in this experiential and effective therapeutic intervention. I considered integrating my own critical incidents into this study, however being a novice researcher I had my hands full as it was. This research project has met its goals. Six facilitative action categories were produced that encompass a variety of activities and relevant contexts in which these activities occur. These categories and sub-categories offer some ideas and suggestions as 89 to how therapists might foster their clients' change efforts as they move on from the insulated therapeutic setting. A number of validation procedures supported the validity and reliability of the results of this study. The important role played by relationships in facilitating the individual's change efforts emerged through the stories of the co- researchers. As Rychlak (cited in Tallman & Bohart, 1999) notes, there is an opposite lesson to be learned here too. Individuals who may lack this kind of intimate support are like patients being released from the hospital to their own care. Therapeutic enactment is such a provocative and powerful tool for healing that extra care must be taken to help participants coming in for this "surgery" to be planful for a successful recovery process once they return to their real world. 90 REFERENCES Alfonso, V. (1997). Overcoming depressed moods after an HIV+ diagnosis: A critical incident analysis. Unpublished doctoral dissertation, University of British Columbia. Anderson, B., & Nilsson, S. (1964). Studies in the reliability and validity of the critical incident technique. Journal of Applied Psychology, 48(6), 398-403. Baum, S. (1994). 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"Change maintenance after therapeutic enactment" Dear Participant, You may have been contacted by a therapist or coordinator of Therapeutic Enactment, or you may have seen some posters asking you to participate in this study. This research is being conducted as part of the requirements for a master's degree. My name is Jodi Fotheringham and I am a graduate student in counselling psychology. In addition to my interest in this study as a researcher, my own personal experience as a participant in therapeutic enactment has motivated me to explore factors which may help others once the enactment workshop is finished. The purpose of this study is to determine what factors help or hinder people as they seek to maintain the changes they have achieved as a result of their own therapeutic enactment. I would like to draw on the experience and expertise of people who have found therapeutic enactment to be beneficial. Participants in this study will be asked the following questions: "Think back to what you were hoping to change through your enactment. Now consider what did change as a result of your enactment. What has helped you in your process to maintain these changes? What has hindered you?" Page 1 of 2 100 APPENDIX D Orientation Statement Thank you very much for your time and participation. I would like to give you an orientation to this study, after which you may have some questions before we begin the interview. The purpose of this research is to find out what helps people to maintain the changes they experience through therapeutic enactment once they're back in their "real world." I plan to meet with people like you who have found therapeutic enactment to be beneficial in making change(s) — in order to draw on your experience and expertise. My goal is to develop a practical and general guide of helpful and harmful incidents/strategies that may serve to aid people with their growth/healing process after therapeutic enactment. We will focus mainly on your process to maintain change since the enactment, rather than focus on the enactment itself. First, we want to establish one or two of the most important changes that occurred for you as a result of your enactment. Then we will spend most of our time exploring significant incidents since your enactment which have either helped or hindered your ability to maintain these changes. We'll explore the helpful incidents first, and end with any harmful or hindering incidents. [Ifyou have had a number of enactments, we will target the time span since the enactment, within the past 2 years, that first produced this change.] 101 A P P E N D I X E Interview Questions A ) Can you describe one or two of the important changes that came about for you as a result of your enactment? [While you have had a number of enactments I'd like you to identify one or two of the most important changes that came about for you as a result of a particular enactment — an enactment within the past 2 years] B I ) N o w that we've identified the key change(s) these w i l l be our focus . . . the change you've desired to maintain since the enactment. I want you to reflect on the time that has passed since the enactment. Think about a situation when something happened that helped you to maintain/reinforce this change . . . something you did, someone else did or something that happened. B2) Think of a specific time since the enactment when you found yourself in a situation that helped you maintain these changes (you were tempted to slip back to your old way of responding, but you didn't). Take your time to think of a specific incident in as much detail as possible. Clarification: • What led up to the incident? • What did you see, hear, feel or think that might have brought on the incident? • Describe what happened? • What do you think it was about this incident that made it so helpful? • H o w did you know it was helpful? • What was the outcome? C) What are some other experiences that have helped you in the process to maintain /these changes? Page 1 of2 102 D l ) What has hindered you in the process of maintaining the change(s) you made through your therapeutic enactment? I want you to reflect on the time that has passed since the enactment. Think about a situation when something happened that hindered you in your process to maintain/reinforce this change. D2) Think of a time since the enactment when you found yourself in a situation where you slipped back to your old way of responding. Take your time to think of a specific incident in as much detail as possible. Clarification: • What led up to the incident? • What did you see, hear, feel or think that might have brought on the incident? • Describe what happened? • What do you think it was about this incident that made it so harmful? • How did you know it was harmful? • What was the outcome? Page 2 of 2 103 APPENDIX F Second Interview Protocol 1. Re-orientation 2. Critical Incidents (cards) 3. Categories (envelopes) 4. Sorting 5. De-brief Agenda Page 1 of2 104 Focus of Study What factors have helped you maintain change since your enactment? Critical Incidents • each card = an incident/factor • attempt made to quote you as directly as possible • you are invited to edit • you are invited to add any critical incidents overlooked Categories • definitions • you are invited to provide editorial comments after the sorting and de-brief is completed Sorting Source/Context Incident Action Outcome Page 2 of 2 105 APPENDIX G Planned Happenstance Steps and Questions Krumboltz (1999) 1. Normalize planned happenstance in the client's history. a) How have unplanned events influenced your life? b) How did you enable each event to influence you? c) How do you feel about unplanned events in your future? 2. Assist clients to transform curiosity into opportunities for learning and exploration. a) How is your curiosity excited? b) How have chance events contributed to your curiosity? c) How have you acted to heighten your curiosity? d) How could you explore the implications of curiosity on this change you want to sustain? Page 1 of 2 106 3. Teach clients to produce desirable chance events. a) Tell me a chance event you wish would happen to you. b) How can you act now to increase the likelihood of that desirable event? c) How would your life change if you acted? d) How would your life change if you did nothing? 4. Teach clients to overcome blocks to action. a) How have you been blocked from doing what you want to do? b) How could you find out how permanent that block is? c) How have other people overcome blocks like that? d) How would you begin overcoming that block? Page 2 of 2


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