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The differential effects of empathic reflection and empathic reflection plus the gestalt empty-chair… King, Sharron G. 1988

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THE DIFFERENTIAL EFFECTS OF EMPATHIC REFLECTION AND EMPATHIC REFLECTION PLUS THE GESTALT EMPTY-CHAIR DIALOGUE ON THE ISSUE OF UNFINISHED BUSINESS By SHARRON G. KING B.A., Lakehead U n i v e r s i t y , 1967 Diploma i n Education of the M e n t a l l y Retarded, U.B.C., 1977 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES THE DEPARTMENT OF COUNSELLING PSYCHOLOGY We accept t h i s Thesis as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1988 0 Sharron G. King, 1988 5 S 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 Counse l l ing Psychology The University of British Columbia Vancouver, Canada Date A p r i l 29, 1988. DE-6 (2/88) ABSTRACT The purpose of t h i s study was to explore the s p e c i f i c c l i e n t i s s u e of u n f i n i s h e d business by comparing the d i f f e r e n t i a l e f f e c t i v e n e s s of empathy p l u s the G e s t a l t empty-chair technique and empathic r e f l e c t i o n . The p o p u l a t i o n c o n s i s t e d of 28 s u b j e c t s drawn from students e n r o l l e d i n the f i r s t year of a Master's Degree program i n C o u n s e l l i n g Psychology at a major u n i v e r s i t y . The s u b j e c t s r e c e i v e d two c o u n s e l l i n g s e s s i o n s i n e i t h e r the empathy p l u s G e s t a l t c o n d i t i o n or the Empathic r e f l e c t i o n c o n d i t i o n . Two r e l a t i o n s h i p instruments, the Empathy Scale of the B a r r e t t -Lennard R e l a t i o n s h i p Inventory and the Task Dimension of the Working A l l i a n c e Inventory, were ad m i n i s t e r e d to assess the s u b j e c t ' s p e r c e p t i o n of t h e i r t h e r a p i s t ' s behaviour and to screen f o r s u b j e c t s who were not engaged i n the p r o c e s s . Two outcome measures, the Target Complaint Measure and the A f f e c t i v e Reactions Q u e s t i o n n a i r e , were used to assess the amount of r e s o l u t i o n s u b j e c t s f e l t i n t h e i r p r e s e n t i n g complaint and the amount of change i n t h e i r f e e l i n g s toward the s i g n i f i c a n t other. Two s e s s i o n measures, the Session E v a l u a t i o n Q u e s t i o n n a i r e and the Target Complaint Discomfort Box S c a l e , were used to assess the c u r r e n t amount of discomfort r e g a r d i n g the p r e s e n t i n g complaint and to evaluate the s u b j e c t ' s p e r c e p t i o n of the s e s s i o n s . The study showed that empathy p l u s the G e s t a l t empty-c h a i r d i a l o g u e produced s i g n i f i c a n t l y more t o l e r a n c e i n the s u b j e c t s ' f e e l i n g s toward a s i g n i f i c a n t other person as measured by the A f f e c t i v e Reactions Q u e s t i o n n a i r e on an i s s u e of u n f i n i s h e d business than those produced by empathic r e f l e c t i o n . The r e s u l t s f u r t h e r suggest that a g r e a t e r improvement i n i n i t i a l t a r g e t complaint as measured by the Target Complaint Measure was f e l t f o r the empathy p l u s G e s t a l t c o n d i t i o n than f o r the empathic r e f l e c t i o n c o n d i t i o n . T.he review of the l i t e r a t u r e suggests t h a t the i s s u e of u n f i n i s h e d b u s i n e s s i s an important one and the t e n t a t i v e r e s u l t s from t h i s study suggest the need f o r f u r t h e r i n v e s t i g a t i o n to determine i f the p r e l i m i n a r y r e s u l t s are upheld i n a c l i n i c a l s e t t i n g . The t e n t a t i v e r e s u l t s suggest t h a t the G e s t a l t empty-chair d i a l o g u e i n the context of an empathic r e l a t i o n s h i p may make a c o n t r i b u t i o n to the treatment of the i s s u e of u n f i n i s h e d b u s i n e s s . i v TABLE OF CONTENTS Page ABSTRACT i i TABLE OF CONTENTS i v LIST OF APPENDICES v i LIST OF TABLES v i i LIST OF FIGURES i x ACKNOWLEDGEMENTS x CHAPTER I INTRODUCTION . 1 Background of the Study 2 Purpose of t h i s Study 5 D e f i n i t i o n of Terms 6 Statement of Problem and Hypotheses 10 II REVIEW OF LITERATURE 14 U n f i n i s h e d Business i n Psychotherapy 14 Research on the Use of G e s t a l t Techniques ... 20 G e s t a l t Approach on the Issue of U n f i n i s h e d Business 23 Research of the Use of Empathic R e f l e c t i o n .. 31 Psychotherapy Research R e l a t i n g t o Outcome .. 35 I I I METHODOLOGY 4 9 P a r t i c i p a n t s i n the Study 49 Measuring Instruments 53 Overview 53 Subject D e s c r i p t i o n 54 R e l a t i o n s h i p Instruments 55 \ Outcome Measures 58 Session Measures 60 D e s c r i p t i o n of Treatments 62 Procedure 66 Design and A n a l y s i s 69 V IV RESULTS '71 Subject D e s c r i p t i o n Instruments 72 R e l a t i o n s h i p Instruments 73 Outcome Measures 75 Session Measures 84 V DISCUSSION 96 I n t e r p r e t a t i o n of F i n d i n g s 97 L i m i t a t i o n s of the Study 107 I m p l i c a t i o n s and Future Research D i r e c t i o n s 110 Co n c l u s i o n 112 REFERENCES 113 v i LIST OF APPENDICES Pacre A . Consent Form 120 B. C l i e n t I n f o r m a t i o n Form 121 C . A b b r e v i a t e d 16-PF I n t e r e s t Q u e s t i o n n a i r e 122 D. B a r r e t t - L e n n a r d R e l a t i o n s h i p Inventory Empathy S c a l e 127 E . Working A l l i a n c e Inventory - Task Dimension . . . . 129 F . T a r g e t Compla int Measure 132 G. A f f e c t i v e R e a c t i o n s Q u e s t i o n n a i r e 134 H . S e s s i o n E v a l u a t i o n Q u e s t i o n n a i r e 136 I . Q u e s t i o n n a i r e A 138 J . Q u e s t i o n n a i r e B 139 K. Q u e s t i o n n a i r e C 141 L . T h e r a p i s t Q u e s t i o n n a i r e 143 v i i LIST OF TABLES 1 Means and Standard D e v i a t i o n s of B a r r e t t - L e n n a r d R e l a t i o n s h i p Inventory 74 2 Means and Standard D e v i a t i o n s of Working A l l i a n c e Inventory 74 3 A n a l y s i s of Variance with Repeated Measures of Target Complaint Measure Scores 76 4 Means and Standard D e v i a t i o n s of Target Complaint Measure Scores 76 5 Item A n a l y s i s f o r A f f e c t i v e Reactions Q u e s t i o n n a i r e 80 6 Subtest I n t e r c o r r e l a t i o n s f o r A f f e c t i v e R eactions Q u e s t i o n n a i r e (Pre- and Post-) 80 7 Subtest I n t e r c o r r e l a t i o n s f o r A f f e c t i v e Reactions Q u e s t i o n n a i r e (Follow-up) 81 8 M u l t i v a r i a t e A n a l y s i s of Variance f o r A f f e c t i v e Reactions Q u e s t i o n n a i r e 81 9 U n i v a r i a t e R e s u l t s : Therapy I n t e r a c t i n g with Time A f f e c t i v e Reactions Q u e s t i o n n a i r e 82 10 Means - Confident Dimension A f f e c t i v e Reactions Q u e s t i o n n a i r e 82 11 Means - I n t o l e r a n t Dimension A f f e c t i v e Reactions Q u e s t i o n n a i r e 83 12 Means - Discouraged Dimension A f f e c t i v e Reactions Q u e s t i o n n a i r e 83 13 A n a l y s i s of Variance with Repeated Measures of Target Complaint Discomfort Box Scale 85 14 Means and Standard D e v i a t i o n s of Target Complaint Discomfort Box Scale 85 15 Item A n a l y s i s of Session E v a l u a t i o n Q u e s t i o n n a i r e - Subject Data 89 Subtest I n t e r c o r r e l a t i o n s - Session E v a l u a t i o n Q u e s t i o n n a i r e - Subject Data 89 M u l t i v a r i a t e A n a l y s i s of Variance f o r Session E v a l u a t i o n Q u e s t i o n n a i r e - Subject Data 90 U n i v a r i a t e R e s u l t s : Therapy Main E f f e c t S ession E v a l u a t i o n Q u e s t i o n n a i r e - Subjects ... 90 Means - Smoothness Dimension - Session E v a l u a t i o n Q u e s t i o n n a i r e - Subject Data 91 Means - Depth Dimension - Session E v a l u a t i o n Q u e s t i o n n a i r e - Subject Data 91 Means - P o s i t i v i t y Dimension - Session E v a l u a t i o n Q u e s t i o n n a i r e - Subject Data 92 Means - A r o u s a l Dimension - Session E v a l u a t i o n Q u e s t i o n n a i r e - Subject Data 92 Item A n a l y s i s f o r Session E v a l u a t i o n Q u e s t i o n n a i r e - T h e r a p i s t Data 93 Subtest I n t e r c o r r e l a t i o n s f o r Session E v a l u a t i o n Q u e s t i o n n a i r e - T h e r a p i s t Data 93 M u l t i v a r i a t e A n a l y s i s of Variance f o r S e s s s i o n E v a l u a t i o n Q u e s t i o n n a i r e - T h e r a p i s t s 94 U n i v a r i a t e R e s u l t s : Therapy Main E f f e c t - Session E v a l u a t i o n Q u e s t i o n n a i r e - T h e r a p i s t s 94 Means - Smoothness Dimension - Session E v a l u a t i o n Q u e s t i o n n a i r e - T h e r a p i s t Data 95 LIST OF FIGURES i x Page 1 P r e l i m i n a r y E m p i r i c a l Model of F i n i s h i n g Incomplete Experience 29 2 Order of A d m i n i s t r a t i o n of Measuring Instruments 67 ACKNOWLEDGEMENTS I would l i k e t o express my a p p r e c i a t i o n t o my A d v i s o r y Committee, Dr. Sharon Kahn, Dr. Robert Conry and Dr. L o r e t t Woolsey f o r t h e i r support and guidance. I would l i k e to thank Dr. Kahn, my committee c h a i r , f o r her a d v i c e and c o n s u l t a t i o n i n t h i s p r o j e c t . I am g r a t e f u l t o Dr. Conry f o r h i s t i r e l e s s support i n a s s i s t i n g with the s t a t i s t i c a l a n a l y s i s of my data. I wish t o express my s i n c e r e thanks to Dr. Les Greenberg f o r h i s c o n t i n u e d encouragement, understanding an p a t i e n c e . His ongoing support was i n v a l u a b l e t o me. To my c h i l d r e n , Kimberley and A l l i s o n , I am deeply g r a t e f u l f o r t h e i r c o n t i n u e d support and understanding d u r i n g t h i s major undertaking. 1 Chapter 1 INTRODUCTION The i s s u e of completing i n t e r r u p t e d emotional expr e s s i o n i s a common one i n therapy as c l i e n t s s t r u g g l e to f u l l y express and experience a v a r i e t y of b l o c k e d emotions and p a i n f u l f e e l i n g s . When these b l o c k e d emotions and unexpressed f e e l i n g s are i n r e l a t i o n to a s i g n i f i c a n t other person and when they i n t e r f e r e with the c l i e n t ' s c u r r e n t f u n c t i o n i n g , t h i s i s c o n s i d e r e d t o be u n f i n i s h e d b u s i n e s s . I t i s only by a l l o w i n g the f u l l e x p r e s s i o n and e x p e r i e n c i n g of these i n t e r r u p t e d f e e l i n g s that the c l i e n t i s r e l e a s e d t o develop a more balanced view of the s i t u a t i o n and l e t go of the a s s o c i a t e d negative f e e l i n g s (Greenberg & Safran, 1987). Many forms of therapy i n c l u d i n g c l i e n t - c e n t e r e d t h e r a p i e s and e x p e r i e n t i a l t h e r a p i e s encourage the process of ex p r e s s i n g p r e v i o u s l y suppressed or unexpressed emotions and of a c c e p t i n g the f e e l i n g s a s s o c i a t e d with these emotions. However, although a number of authors (Cohn, 1970; Daldrup, B e u t l e r & Greenberg, 1985; E n r i g h t , 1970; Greenberg & Safran, 1987; Latner, 1973; L e v i t s k y & P e r l s , 1970; P e r l s , 1979; P e r l s , H e f f e r l i n e & Goodman, 1951; and P o l s t e r & P o l s t e r , 1973) have w r i t t e n on the t h e o r e t i c a l s i g n i f i c a n c e of u n f i n i s h e d business as an important t h e r a p e u t i c i s s u e , t h e r e i s a p a u c i t y of r e s e a r c h i n v e s t i g a t i n g the s p e c i f i c i s s u e of u n f i n i s h e d business and 2 the techniques which may be h e l p f u l i n a c h i e v i n g r e s o l u t i o n . I t i s the i n t e n t of t h i s study to i n v e s t i g a t e the s p e c i f i c c l i e n t i s s u e of u n f i n i s h e d business by comparing the e f f e c t i v e n e s s at the end of treatment of two d i f f e r e n t t h e r a p e u t i c approaches, empathic r e f l e c t i o n and empathy p l u s G e s t a l t empty-chair d i a l o g u e , i n r e s o l v i n g the incomplete emotional experiences. Background of the Study Psychotherapy r e s e a r c h has been concerned with measuring "change i n the p e r s o n a l i t y s t r u c t u r e of the i n d i v i d u a l , at both s u r f a c e and deeper l e v e l s i n a d i r e c t i o n which c l i n i c i a n s would agree means g r e a t e r i n t e g r a t i o n , l e s s i n t e r n a l c o n f l i c t , more energy u t i l i z a b l e f o r e f f e c t i v e l i v i n g " as w e l l as change "towards behaviors regarded as mature" (Rogers, 1957, p.95). Both c l i e n t - c e n t e r e d therapy, as e x p l i c a t e d by Rogers (1957), and G e s t a l t therapy have s t u d i e d the components w i t h i n t h e i r approaches which l e a d to improvement i n c l i e n t f u n c t i o n i n g . Rogers (1957) f e l t t h a t c e r t a i n core c o n d i t i o n s of t h e r a p i s t genuineness, u n c o n d i t i o n a l p o s i t i v e regard, and empathy o f f e r e d to the c l i e n t i n the context of a t h e r a p e u t i c r e l a t i o n s h i p were necessary and s u f f i c i e n t f o r t h e r a p e u t i c change to occur. Many r e s e a r c h e r s (Gurman, 3 1977j Lambert, Shapiro & B e r g i n , 1986; M i t c h e l l , Bozarth & • K r a u f t , 1977; O r l i n s k y & Howard, 1978, 1986; and Truax & M i t c h e l l , 1971) agree t h a t a r e l a t i o n s h i p i s important to f a c i l i t a t e c l i e n t change and that these c o n d i t i o n s are necessary f o r the r e l a t i o n s h i p to develop, however few r e s e a r c h e r s are w i l l i n g to support Rogers' c l a i m of s u f f i c i e n c y (Carkhuff, 1969; P a t t e r s o n , 1984; Truax & Carkhuff, 1967; and Truax & Wargo, 1966). Therapeutic techniques or t e c h n i c a l c o n s i d e r a t i o n s are c o n s i d e r e d a necessary a d d i t i o n to a good r e l a t i o n s h i p (Bergin & Strupp, 1972; Greenberg, 1983; Greenberg & Kahn, 1979; and Strupp, 1978) . G e s t a l t therapy i s one approach that can be used to f a c i l i t a t e c l i e n t change by adding t h e r a p e u t i c techniques to the necessary r e l a t i o n s h i p c o n d i t i o n s as s t a t e d by Rogers (1957), Truax and Wargo (1966), Truax and Carkhuff (1967), and Carkhuff (1969). G e s t a l t therapy i s an e x p e r i e n t i a l therapy whose major goal i s the r e s t o r a t i o n of awareness. The main technique of the G e s t a l t approach i s the experiment which i s designed to promote awareness and c o n t a c t . However, the experiment must take p l a c e w i t h i n a t r u s t i n g r e l a t i o n s h i p and a good working a l l i a n c e (Greenberg, 1983) . One of the techniques used by G e s t a l t t h e r a p i s t s i s the two-chair experiment which was developed to work with c l i e n t - p r e s e n t e d i n t r a p s y c h i c c o n f l i c t s or s p l i t s . In a 4 number of s t u d i e s (Bohart, 1977; Greenberg & C l a r k e , 1979, 1984; Greenberg & Dompierre, 1981; Greenberg & H i g g i n s , 1980; Greenberg & R i c e , 1981; and Greenberg & Webster, 1982) G e s t a l t two-chair d i a l o g u e was shown to produce s i g n i f i c a n t l y g r e a t e r changes i n the v a r i a b l e b e i n g s t u d i e d when compared with a v a r i e t y of other approaches i n c l u d i n g empathic r e f l e c t i o n . A f u r t h e r refinement of t h i s technique i s the empty-c h a i r d i a l o g u e which has evolved as a means of d e a l i n g with c l i e n t - p r e s e n t e d i n t e r p e r s o n a l c o n f l i c t s . These c o n f l i c t s o f t e n emerge as i s s u e s of u n f i n i s h e d business with a s i g n i f i c a n t other person i n the c l i e n t ' s present l i f e or d i stant p a s t . U n f i n i s h e d business has been c o n c e p t u a l i z e d as the b l o c k i n g of unexpressed emotion i n r e l a t i o n to another person. To e v a l u a t e the importance of r e s o l v i n g incomplete experiences i t i s important to determine the r o l e that emotion p l a y s i n an i n d i v i d u a l ' s l i f e and to explore the e f f e c t s of i n h i b i t i n g emotional e x p r e s s i o n . Greenberg and Safran (1987) have i n v e s t i g a t e d the r o l e of emotion i n psychotherapy and c o n c e p t u a l i z e d emotion as p o t e n t i a l l y a d a p t i v e and t h e r e f o r e as an a l l y i n the change p r o c e s s . They f u r t h e r suggest that " p s y c h o l o g i c a l problems are o f t e n the r e s u l t of b l o c k i n g or a v o i d i n g p o t e n t i a l l y a d a p t i v e emotional experience" and that "the complete p r o c e s s i n g of a s p e c i f i c emotional experience leads to a s h i f t i n the nature of the emotional experience" (p.7) thus a l l o w i n g a new a d a p t i v e response to emerge. G e s t a l t therapy maintains that i t i s the b l o c k i n g of emotions, o f t e n b e f o r e they enter awareness, that leads to u n d e r l y i n g c o n f l i c t and u n f i n i s h e d b u s i n e s s . Therapy must "help the person enter the s i t u a t i o n s i n which they p r e v i o u s l y experienced the unwanted emotions or excitement" (Greenberg & Safran, 1987, p.52). These experiences are c a l l e d u n f i n i s h e d b u s i n e s s and prevent people from f u l l y e x p e r i e n c i n g s i m i l a r s i t u a t i o n s i n the p r e s e n t . Purpose of t h i s study The purpose of t h i s study was to explore the s p e c i f i c c l i e n t i s s u e of u n f i n i s h e d business through the use of c l e a r l y d e f i n e d t h e r a p e u t i c procedures. Empathic r e f l e c t i o n was chosen as one treatment as i t r e p r e s e n t s the core c o n d i t i o n s c o n s i d e r e d necessary to f a c i l i t a t e c l i e n t change. Empathy p l u s the G e s t a l t empty-chair d i a l o g u e was chosen as 0 the second treatment as t h i s i n t e r v e n t i o n employs an a c t i v e technique i n the context of a good working r e l a t i o n s h i p and t h e r a p e u t i c a l l i a n c e between c l i e n t and t h e r a p i s t . T h i s study i s not t e s t i n g the g e n e r a l e f f e c t i v e n e s s of G e s t a l t therapy versus c l i e n t - c e n t e r e d therapy but r a t h e r i t i s 6 i n v e s t i g a t i n g the u s e f u l l n e s s of p a r t i c u l a r i n t e r v e n t i o n s d e r i v i n g from these approaches on a s p e c i f i c c l i e n t i s s u e . D e f i n i t i o n of Terms Empathic R e f l e c t i o n Empathic r e f l e c t i o n i s a t h e r a p e u t i c technique through which a t h e r a p i s t expresses understanding of what the c l i e n t i s f e e l i n g and e x p e r i e n c i n g . Accurate empathy has been d e s c r i b e d by M i t c h e l l , Bozarth and K r a u f t (1977) as the extent to which the t h e r a p i s t 1. i s s e n s i t i v e t o the c u r r e n t f e e l i n g s and thoughts of the helpee (both i n and out of awareness), 2. has the a b i l i t y t o communicate h i s understanding of h i s c l i e n t ' s I f e e l i n g s and t h i n k i n g , and 3. has the a b i l i t y to use language attuned t o that of the c l i e n t . (p.483) In b e i n g empathic the t h e r a p i s t senses the c l i e n t ' s f e e l i n g s 'as i f they were h i s / h e r own while at the same time m a i n t a i n i n g an o b j e c t i v i t y which allows the c l i e n t t o f u l l y experience these f e e l i n g s . A f u r t h e r e s s e n t i a l i n g r e d i e n t i s that the c l i e n t must p e r c e i v e the t h e r a p i s t ' s empathic understanding f o r change to occur. Carkhuff (1969) d e v i s e d a f i v e - p o i n t s c a l e f o r measuring empathic understanding. L e v e l 1 and L e v e l 2 are 7 c o n s i d e r e d d e t r i m e n t a l i n t h a t they s u b t r a c t n o t i c e a b l y from the c l i e n t ' s statement. L e v e l 3 i s c o n s i d e r e d t o be n e u t r a l i n t h a t t h i s l e v e l allows the c l i e n t to maintain the same l e v e l of understanding but does not deepen a f f e c t or meaning. L e v e l 4 and 5 are c o n s i d e r e d a d d i t i v e i n that they help the c l i e n t ' s s e l f - e x p l o r a t i o n at deeper l e v e l s of a f f e c t and meaning. Carkhuff (1969) d e s c r i b e d these l e v e l s as f o l l o w s : L e v e l 3: The e x p r e s s i o n of the h e l p e r i n response to the expressions of the helpee(s) are e s s e n t i a l l y i n t e r -changeable with those of the helpee i n that they express e s e n t i a l l y the same a f f e c t and meaning. L e v e l 4: The responses of the h e l p e r add n o t i c e a b l y t o the expressions of the helpee (s) i n such a way as to express f e e l i n g s at a l e v e l deeper than the helpee was a b l e to express h i m s e l f . L e v e l 5: The h e l p e r ' s responses add s i g n i f i -c a n t l y to the f e e l i n g and meaning of the expressions of the heplee(s) i n such a way as to a c c u r a t e l y express f e e l i n g l e v e l s below what the helpee h i m s e l f was a b l e t o express or, i n the event of ongoing, deep s e l f - e x p l o r a t i o n on the helpee's p a r t , t o be f u l l y with him i n h i s deepest moments. (p. 174-5) In t h i s study t h e r a p i s t s were i n s t r u c t e d to respond with a L e v e l 3, 4 or 5 empathic r e f l e c t i o n when c l i e n t s p r e s e n t e d an i s s u e of u n f i n i s h e d b u s i n e s s . 8 G e s t a l t Empty-Chair Dialogue The G e s t a l t empty-chair d i a l o g u e i s a technique r e q u i r i n g the c l i e n t to express i n t e r r u p t e d f e e l i n g s to a s i g n i f i c a n t other person who i s imagined t o be present i n an empty c h a i r . The c l i e n t sometimes takes on the r o l e of t h i s other person. During the s e s s i o n a c l i e n t may say "I am angry at (a s i g n i f i c a n t other) f o r not h e l p i n g me enough" at which p o i n t the t h e r a p i s t w i l l a s s i s t the c l i e n t t o v i s u a l i z e t h i s person as b e i n g i n the empty c h a i r . The t h e r a p i s t w i l l then act as a guide i n a d i a l o g u e between the c l i e n t and the s i g n i f i c a n t other. The c l i e n t w i l l take on, from the s e l f c h a i r , the "I am angry ..." or "I am hurt ..." p o s i t i o n and w i l l speak to the empty c h a i r i n which he/she was asked t o v i s u a l i z e the s i g n i f i c a n t other. The m a j o r i t y of the d i a l o g u e p a r t i c u l a r l y i n the e a r l y p a r t of the work i s from the s e l f c h a i r with the empty c h a i r s e r v i n g p r i m a r i l y as a s t i m u l u s . As the work progresses the c l i e n t w i l l move to the empty c h a i r and respond to the statements made from the s e l f c h a i r . There i s some movement as the c l i e n t a l t e r n a t e s p o s i t i o n but t h i s work i s p r i m a r i l y focused on the c l i e n t i n the s e l f c h a i r . The empty-chair technique i s somewhat d i f f e r e n t from the work d e s c r i b e d by Greenberg (1979) i n t r a i n i n g t h e r a p i s t s i n the use of the two-chair technique i n that two-chair work i n v o l v e s an a c t i v e and a l t e r n a t i n g d i a l o g u e between two p a r t s of the c l i e n t i n an i n t r a p e r s o n a l c o n f 1 i c t . U n f i n i s h e d Business Greenberg and Safran (1987) have i d e n t i f i e d a c o l l e c t i o n of markers which taken together c o n s t i t u t e an i n d i c a t i o n of u n f i n i s h e d b u s i n e s s which needs to be completed. These components are: 1. C l i e n t s e x h i b i t a 'hanging onto' r e a c t i o n , a h o l d i n g on to o l d resentments, h u r t s , f r u s t r a t i o n s , g u i l t , g r i e f , or even unexpressed f e e l i n g s of love and a p p r e c i a t i o n . 2. T h i s o f t e n r e s u l t s i n a s e l f - p i t y i n g a t t i t u d e , or a blaming or complaining a t t i t u d e , or a f e e l i n g of h u r t , r e s i g n a t i o n and hopelessness. 3. The e x p r e s s i o n of t h i s l i n g e r i n g u n r e s o l v e d f e e l i n g i s r e l a t e d to a s i g n i f i c a n t other. 4. The experience and e x p r e s s i o n i s c u r r e n t l y b e i n g i n h i b i t e d . 5. The experience of the f e e l i n g and i t s i n t e r r u p t i o n i s p r o b l e m a t i c f o r the c l i e n t as i n d i c a t e d by d i r e c t v e r b a l statements such as " I f o n l y " statements or s e l f - s t a t e m e n t s such as " I f only I had been a n i c e r , b e t t e r mother, spouse, and so f o r t h . " Non-verbal signs of b o d i l y t e n s i o n may be p r e s e n t . (Greenberg & Safran, 1987) 10 Statement of Problem and Hypotheses The importance of therapy o c c u r r i n g i n the atmosphere of a p o s i t i v e r e l a t i o n s h i p and a good working a l l i a n c e has been e x t e n s i v e l y documented (B a r r e t t - L e n n a r d , 1962, 1982, 1986; Carkhuff, 1969; Greenberg, 1981, 1982; Gurman, 1977; Horvath & Greenberg, 1986; M i t c h e l l , Bozarth & K r a u f t , 1977; Truax & Carkhuff, 1967; Truax & Wargo, 1966; and O r l i n s k y & Howard, 1978, 1986). Barr e t t - L e n n a r d ' s R e l a t i o n s h i p Inventory (1964) was designed to measure the c l i e n t ' s p e r c e p t i o n of the t h e r a p i s t ' s warmth, congruence, empathy and p o s i t i v e r e g a r d . The empathy s c a l e of the R e l a t i o n s h i p Inventory was a d m i n i s t e r e d to the s u b j e c t s to assess t h e i r p e r c e p t i o n of t h e i r t h e r a p i s t s ' empathy. Horvath (1982) designed the Working A l l i a n c e Inventory to measure the working a l l i a n c e along three dimensions: task, goal and bond. The t a s k dimension of the Working A l l i a n c e Inventory was a d m i n i s t e r e d to assess the s u b j e c t s ' p e r c e p t i o n s of t h e i r t h e r a p i s t s ' a b i l i t y to stay focused on the t a s k presented. Both the R e l a t i o n s h i p Inventory and the Working A l l i a n c e Inventory are d e s c r i p t i v e measures which were used to determine i f the t h e r a p e u t i c i n t e r v e n t i o n s were conducted i n the context of an empathic r e l a t i o n s h i p and an 11 environment i n which the s u b j e c t s p e r c e i v e d t h e i r t h e r a p i s t s t o be engaged i n t a s k - r e l e v a n t a c t i v i t i e s . Hypothesis 1 In choosing an i s s u e of u n f i n i s h e d business to work on the s u b j e c t s focused on a s p e c i f i c i s s u e of importance i n r e g a r d to a s i g n i f i c a n t other person. B a t t l e et a l (1966) designed the Target Complaint Measure to measure changes on t a r g e t complaints as i d e n t i f i e d by the c l i e n t s . In t h i s study b e f o r e treatment began the s u b j e c t s were asked to i d e n t i f y only one complaint as opposed to the three complaints o r i g i n a l l y suggested by B a t t l e et a l . The s u b j e c t s r a t e d changes on t h i s complaint at t e r m i n a t i o n and again at follow-up. Hypothesis 1 s t a t e s : Empathy p l u s the G e s t a l t empty-chair d i a l o g u e , when used with an i s s u e of u n f i n i s h e d b u s i n e s s , w i l l r e s u l t i n s i g n i f i c a n t l y g r e a t e r improvement on the p r e s e n t i n g t a r g e t complaint as measured a f t e r treatment and at follow-up by the Target Complaint Measure, than that produced by the use of Empathic R e f l e c t i o n . Hypothesis 2 C l i e n t - c e n t e r e d t h e r a p i e s encourage c l i e n t s to be more aware of t h e i r f e e l i n g s both as these f e e l i n g s r e l a t e t o t h e i r own i n n e r world and as they r e l a t e to persons and s i t u a t i o n s they contact i n t h e i r l i f e . In t h i s study 12 c l i e n t s were asked to d i s c u s s an i s s u e of u n f i n i s h e d business r e l a t i n g to a s i g n i f i c a n t other person. I t i s important t h e r e f o r e to measure how these f e e l i n g s change over treatment. The A f f e c t i v e Reactions Q u e s t i o n n a i r e (1984) was designed to capture a person's f e e l i n g s towards a s i g n i f i c a n t other person and was used i n t h i s study to measure change i n the s u b j e c t ' s f e e l i n g s towards a s i g n i f i c a n t other person. Hypothesis 2 s t a t e s : Empathy p l u s the G e s t a l t empty-chair d i a l o g u e when used with an i s s u e of u n f i n i s h e d b u s i n e s s , w i l l produce s i g n i f i c a n t l y higher means on the Confident dimension and s i g n i f i c a n t l y lower means on the Su p e r i o r , I n t o l e r a n t and Discouraged dimensions as measured a f t e r treatment and at follow-up by the A f f e c t i v e Reactions Q u e s t i o n n a i r e than those produced by the use of Empathic R e f l e c t i o n . Hypothesis 3. The Target Complaint Measure was used t o measure g l o b a l changes i n the p r e s e n t i n g complaint. I t was a l s o important to measure s m a l l e r u n i t s of change over the course of treatment. The Target Complaint Discomfort Box Scale was adm i n i s t e r e d t o the s u b j e c t s b e f o r e and a f t e r each s e s s i o n to assess the amount of discomfort c u r r e n t l y b e i n g f e l t r e g a r d i n g the p r e s e n t i n g complaint. Hypothesis 3 s t a t e s : 13 Empathy p l u s the G e s t a l t empty-chair d i a l o g u e when used with an i s s u e of u n f i n i s h e d b u s i n e s s , w i l l produce s i g n i f i c a n t l y l e s s d i s c o m f o r t b e f o r e and a f t e r each s e s s i o n as measured by the Target Complaint Discomfort Box Scale than that produced by the use of Empathic R e f l e c t i o n . Hypothesis 4 S t i l e s and h i s c o l l e a g u e s ( S t i l e s , 1980; S t i l e s & Snow, 1984a, 1984b; and S t i l e s , T u pler & Carpenter, 1982) have d i s c u s s e d the importance of a s s e s s i n g the immediate impact of the s e s s i o n . The Session E v a l u a t i o n Q u e s t i o n n a i r e was designed t o assess t h i s impact from both the t h e r a p i s t ' s and su b j e c t ' s p e r s p e c t i v e . T h i s measure was ad m i n i s t e r e d t o the p a r t i c i p a n t s i n the study i n an attempt to capture the f e e l i n g s aroused i n the s e s s i o n and t h e i r f e e l i n g s immediately on c o n c l u d i n g the s e s s i o n . Hypothesis 4 s t a t e s : Empathy p l u s the G e s t a l t empty-chair d i a l o g u e when used with an i s s u e of u n f i n i s h e d b u s i n e s s , w i l l produce s i g n i f i c a n t l y higher means f o r the P o s i t i v i t y , Depth and A r o u s a l dimensions and s i g n i f i c a n t l y lower means f o r the Smoothness dimension f o r the s u b j e c t s at the end of the s e s s i o n s as measured by the Session E v a l u a t i o n Q u e s t i o n n a i r e than those produced by the use of Empathic R e f l e c t i o n . Chapter 11 LITERATURE REVIEW A review of the l i t e r a t u r e p e r t i n e n t to t h i s study w i l l focus on f i v e areas: d i s c u s s i o n of u n f i n i s h e d business i n psychotherapy; r e s e a r c h i n the use of G e s t a l t techniques i n therapy; r e s e a r c h on the G e s t a l t treatment approach with the i s s u e of u n f i n i s h e d b u s i n e s s ; r e s e a r c h i n the use of empathic r e f l e c t i o n i n psychotherapy; and psychotherapy r e s e a r c h r e l a t i n g to outcome. U n f i n i s h e d Business i n Psychotherapy U n f i n i s h e d business i s a term d e r i v e d from G e s t a l t theory which r e f e r s to the b l o c k i n g of emotional experience thus p r e v e n t i n g the f u l l awareness of our emotions and i n h i b i t i n g our responsiveness to the a c t i o n s towards which our emotions prompt us. At the core of the b l o c k i n g i s the d e s i r e not only to a v o i d the p a i n f u l f e e l i n g s a s s o c i a t e d with these emotions and but a l s o t o a v o i d e x p e r i e n c i n g the n e g a t i v e emotions themselves. Although the term u n f i n i s h e d business i s from G e s t a l t theory the i s s u e of u n f i n i s h e d s i t u a t i o n s i s common and one that a r i s e s r e p e a t e d l y i n t h e r a p e u t i c s i t u a t i o n s . Greenberg and Safran (1987) have suggested t h a t the g r i e v i n g process i s one form of 15 i n t e r r u p t e d emotional e x p r e s s i o n but s t a t e that the area of u n f i n i s h e d business extends w e l l beyond t h i s to a v a r i e t y of other b l o c k e d processes i n c l u d i n g b l o c k e d e x p r e s s i o n of anger, resentment, rage, hatred, p a i n , and f e a r of abandonment. The i n a b i l i t y of the person to complete these u n f i n i s h e d s i t u a t i o n s i n h i b i t s the f u l l i n t e g r a t i o n and r e s t r u c t u r i n g of these b l o c k e d emotions i n t o one's world view. The c u r r e n t d i s c u s s i o n of u n f i n i s h e d b u s i n e s s w i l l draw p r i m a r i l y from the w r i t i n g s of G e s t a l t t h e o r i s t s as u n f i n i s h e d b u s i n e s s i s one of the core concepts of G e s t a l t t heory. T h i s d i s c u s s i o n w i l l begin with a g e n e r a l i n t r o d u c t i o n t o G e s t a l t theory to p l a c e the d i s c u s s i o n of u n f i n i s h e d b u s i n e s s w i t h i n i t s t h e o r e t i c a l c o n t e x t . G e s t a l t therapy i s a form of e x i s t e n t i a l therapy based on the premise t h a t i n d i v i d u a l s are capable of e f f e c t i v e l y g u i d i n g t h e i r own course through l i f e and of a c c e p t i n g p e r s o n a l r e s p o n s i b i l i t y f o r t h e i r l i f e c h o i c e s . An u n d e r l y i n g assumption i s t h a t humans p e r c e i v e t h e i r e n v i r o n -ment as a u n i f i e d whole, r a t h e r than as a s e r i e s of u n r e l a t e d , i s o l a t e d events. In t h i s approach i n d i v i d u a l s are seen as o r g a n i z e r s of themselves, as organisms, v i s - a -v i s t h e i r environment, thereby forming a continuous s e r i e s of G e s t a l t s at the p o i n t where the organism c o n t a c t s the environment. 16 Greenberg and Safran (1987) suggest t h a t emotion p l a y s a major r o l e i n t h i s o r g a n i z a t i o n a l process by c o n t i n u a l l y g u i d i n g the a d a p t i v e a c t i o n of the organism. They f u r t h e r s t a t e that emotions are what al l o w us to become aware of our concerns or needs and that emotions "need to be allowed to undergo n a t u r a l development and d i f f e r e n t i a t i o n i n order to act as c l e a r guides to a c t i o n . " (p. 51). The f i r s t step i n the process of G e s t a l t formation i s that a need or concern comes to awareness and both energizes and organizes behaviour. T h i s takes p l a c e on both the s u b j e c t i v e p e r c e p t u a l l e v e l and the o b j e c t i v e motor l e v e l . When t h i s need has been s a t i s f i e d the G e s t a l t i s complete and that need o r g a n i z a t i o n recedes i n t o the background thus a l l o w i n g a new G e s t a l t to form. However, a person o f t e n i n t e r f e r e s with t h i s process of s e q u e n t i a l G e s t a l t formation with the important r e s u l t t h a t "the needs of the organism are not f u l l y s a t i s f i e d and the G e s t a l t does not c l o s e " (Greenberg, 1983). T h i s need may recede i n t o the background but the G e s t a l t i s not complete. P e r l s , H e f f e r l i n e , and Goodman (1951) have l a b e l l e d t h i s r e s i d u e of t e n s i o n " u n f i n i s h e d b u s i n e s s " . P e r l s (1970) f e e l s t h a t we continue to be c o n t r o l l e d by t h i s need and t h a t the p r e s s u r e of u n f i n i s h e d business w i l l continue to i n t e r f e r e with our a b i l i t y t o respond to new s i t u a t i o n s and i n t e r f e r e with our a b i l i t y t o form new G e s t a l t s u n t i l these 17 u n f i n i s h e d s i t u a t i o n s are completed. These emotional r e a c t i o n s may remain incomplete or u n f i n i s h e d through r a t i o n a l i z a t i o n , i n t e l l e c t u a l i z e d judgments, a n a l y z i n g or d e n i a l (Daldrup et a l , 1985). Daldrup et a l (1985) f u r t h e r suggest t h a t these u n f i n i s h e d emotions u s u a l l y i n v o l v e anger and/or h u r t . L e v i t s k y and P e r l s (1970) contend t h a t resentments c o n s t i t u t e the most common and important form of u n f i n i s h e d b u s i n e s s . Cohn (1970) s t a t e s that the u n f i n i s h e d business may encompass any of the range of human emotions i n c l u d i n g p a i n , rage, a n x i e t y , mourning, e t c . E n r i g h t (1970) and Greenberg and Safran (1987) support t h i s view of u n f i n i s h e d b u s i n e s s as a major consequence of b l o c k e d awareness where experience remains incomplete and excitement i s unchanneled. Greenberg and Safran (1987) go beyond Cohn i n s t a t i n g t h a t the core of the b l o c k i n g of these emotions i s the avoidance of p a i n f u l f e e l i n g s and the f e a r of unwanted emotion. The i n d i v i d u a l becomes stuck on the unexpressed, slowing l i f e i n t o boredom and d e s p a i r with a l a c k of s p o n t a n e i t y , autonomy and intimacy ( E n r i g h t , 1970). The concept of u n f i n i s h e d business i s one of the c o r n e r s t o n e s of G e s t a l t theory and p r a c t i c e . Cohn (1970) views u n f i n i s h e d b u s i n e s s and avoidance as P e r l s ' core concepts. She c h a r a c t e r i z e d u n f i n i s h e d b u s i n e s s as the emotions, events and memories which l i n g e r unexpressed and avoidance as the mechanism whereby the i n d i v i d u a l keeps away from completing these u n f i n i s h e d s i t u a t i o n s . These 18 u n f i n i s h e d s i t u a t i o n s must be completed ( P e r l s , 1978) and i f powerful enough w i l l continue to present themselves u n t i l r e s o l u t i o n i s achieved ( P o l s t e r & P o l s t e r , 1973). When they become powerful enough "the i n d i v i d u a l i s beset with p r e o c c u p a t i o n , compulsive b e h a v i o r , wariness, oppressive energy and much s e l f - d e f e a t i n g energy" ( P o l s t e r & P o l s t e r , 1973, p.36). P e r l s et a l (1951) t a l k about t h i s c y c l i c a l p r e s s u r e as a n e u r o t i c compulsion to repeat u n t i l the u n f i n i s h e d s i t u a t i o n i s completed. This may take the form of r e t u r n i n g t o the o l d b u s i n e s s or it. may r e l a t e t.<& p a r a l l e l circumstances i n the p r e s e n t . Latner (1973) suggests that the urges f o r completion cannot be r e p r e s s e d , only t h e i r e x p r e s s i o n can. In G e s t a l t therapy these b l o c k e d expressions emerge as symptoms which are viewed as attempts by the i n d i v i d u a l t o s a t i s f y the need to b r i n g c l o s u r e to u n f i n i s h e d s i t u a t i o n s . Without t h i s completion the i n d i v i d u a l can not move on to c r e a t e new G e s t a l t s i n new s i t u a t i o n s but r a t h e r compulsively repeats o l d s o l u t i o n s i n an attempt to complete the past b e f o r e a f u l l awareness of the present can be enjoyed. Greenberg and Safran (1987) have i d e n t i f i e d f i n i s h i n g incomplete experiences as one of the a f f e c t i v e change events t h a t r e c u r i n therapy across a v a r i e t y of s i t u a t i o n s and a v a r i e t y of c l i e n t s . An event begins with a marker which a c t s as a guide to the t h e r a p i s t t o i n d i c a t e the type of i n t e r v e n t i o n l i k e l y t o be most e f f e c t i v e i n i n d u c i n g a 19 p a r t i c u l a r c l i e n t p r o b l e m - s o l v i n g approach. The markers f o r u n f i n i s h e d b u s i n e s s have been d e s c r i b e d above and p r i m a r i l y r e f e r to a l i n g e r i n g bad f e e l i n g towards a s i g n i f i c a n t other person which i s p r e s e n t l y a l i v e f o r the c l i e n t and which i s i n t e r f e r i n g with the c l i e n t ' s c u r r e n t f u n c t i o n i n g . When the unexpressed f e e l i n g s of anger, resentment, rage, hatred, p a i n or f e a r of abandonment are allowed f u l l e x p r e s s i o n the person seems t o be r e l i e v e d of an i n t e r n a l burden and i s f r e e d t o f u l l y d i f f e r e n t i a t e a l l the f e e l i n g s i n v o l v e d i n the o r i g i n a l s i t u a t i o n . Anger i s one of the most common unexpressed emotions and i s o f t e n one of the most damaging. The f e e l i n g s a s s o c i a t e d with the inc o m p l e t e l y processed'' emotions are o f t e n c a r r i e d around as b o d i l y s t a t e s of t e n s i o n of which the person may be unaware. T h i s t e n s i o n can be r e l e a s e d through a r o u s a l and exp r e s s i o n and t h i s r e l e a s e allows new meanings t o emerge. The important change mechanism i s "the exp r e s s i o n of emotions t o t h e i r n a t u r a l completion and the r e p r o c e s s i n g of the experience i n order to b r i n g about a c o g n i t i v e r e o r g a n i z a t i o n or r e e v a l u a t i o n of the experience" (Greenberg & Safran, 1987, p. 222). I f t h i s change mechanism doesn't take p l a c e the memories and f a n t a s i e s a s s o c i a t e d with the o r i g i n a l i n t e r r u p t e d f e e l i n g continue t o a f f e c t c u r r e n t f u n c t i o n i n g and t o i n f l u e n c e and i n h i b i t c u r r e n t behaviour. 20 Research on the Use of G e s t a l t Techniques i n Therapy A number of r e s e a r c h s t u d i e s have been conducted over the l a s t t en years on the e f f i c a c y of G e s t a l t therapy with a p a r t i c u l a r emphasis on the two-chair d i a l o g u e technique. T h i s technique i s used p r i m a r i l y when working with s p l i t s , i n which "two p a r t s of the s e l f are p r e s e n t e d as being i n o p p o s i t i o n i n a l i v e or poignant manner" (Greenberg, 1980a, P.143) . Greenberg (1980a) d e s c r i b e d an i n t e n s i v e a n a l y s i s of nine events i n which t h r e e c l i e n t s were working on r e s o l v i n g s p l i t s u s i n g the G e s t a l t two-chair method. In t h i s study Greenberg d e l i n e a t e d the process by which r e s o l u t i o n occurs i n two-chair work and i n d i c a t e d ways i n which t h e r a p i s t s can u t i l i z e t h i s i n f o r m a t i o n . Greenberg (1983) performed an in-depth a n a l y s i s of the process of c o n f l i c t r e s o l u t i o n performances compared with f o u r t e e n n o n - r e s o l u t i o n performances. From t h i s a n a l y s i s Greenberg p r e s e n t e d a t h r e e - s t a g e s e q u e n t i a l model of c o n f l i c t r e s o l u t i o n . Greenberg (1980a, 1983) adds immeasurably to our understanding of the process f a c i l i t a t i n g change when the G e s t a l t two-chair d i a l o g u e i s performed. 21 Bohart (1977) r e p o r t e d the r e s u l t s of an analogue study with 80 s u b j e c t s who were attempting to r e s o l v e p e r s o n a l anger c o n f l i c t s . G e s t a l t two-chair r o l e p l a y was more e f f e c t i v e i n r e d u c i n g anger, h o s t i l e a t t i t u d e s and b e h a v i o u r a l a g g r e s s i o n than were i n t e l l e c t u a l a n a l y s i s or emotional d i s c h a r g e t e c h n i q u e s . C l a r k e (1977) and Greenberg and C l a r k e (1979) r e p o r t e d on an analogue study u s i n g 16 s u b j e c t s comparing the d i f f e r e n t i a l e f f e c t s of a G e s t a l t two-chair i n t e r v e n t i o n and empathic r e f l e c t i o n . Depth of e x p e r i e n c i n g and change i n awareness were s i g n i f i c a n t l y g r e a t e r f o l l o w i n g the G e s t a l t o p e r a t i o n when the c l i e n t s were working on a s p l i t . In an analogue study of 28 s u b j e c t s Greenberg and Higgins (1980) extended the Greenberg and C l a r k e (1979) study by examining the e f f e c t of the d i a l o g u e component of the G e s t a l t two-chair method with the f o c u s i n g technique at a s u b j e c t p r e s e n t e d s p l i t . Two-chair d i a l o g u e produced s i g n i f i c a n t l y more depth of e x p e r i e n c i n g than d i d f o c u s i n g p l u s empathic r e f l e c t i o n . Dompierre (1979) and Greenberg and Dompierre (1981) s t u d i e d 16 c l i e n t s i n ongoing c o u n s e l l i n g . R e s u l t s showed that depth of e x p e r i e n c i n g , s h i f t s i n awareness and r e p o r t e d c o n f l i c t r e s o l u t i o n were g r e a t e r f o l l o w i n g the G e s t a l t two-c h a i r d i a l o g u e than with empathic r e f l e c t i o n . 22 Greenberg and R i c e (1981) r e p o r t e d on an in-depth study of three c l i e n t s i n which the G e s t a l t two-chair o p e r a t i o n was compared with an a c t i v e empathy o p e r a t i o n . Depth of e x p e r i e n c i n g was s i g n i f i c a n t l y higher f o l l o w i n g the G e s t a l t two-chair o p e r a t i o n . C l a r k e (1981) and C l a r k e and Greenberg (1984) r e p o r t e d on a study i n v o l v i n g f o r t y - e i g h t s u b j e c t s i n which G e s t a l t two-chair d i a l o g u e was compared with a c o g n i t i v e problem-s o l v i n g i n t e r v e n t i o n when s u b j e c t s were attempting to r e s o l v e i n t e r p e r s o n a l c o n f l i c t r e l a t e d to a d e c i s i o n . G e s t a l t two-chair d i a l o g u e was found to be more e f f e c t i v e on r e d u c i n g i n d e c i s i o n than a c o g n i t i v e i n t e r v e n t i o n . Rogers (1983) examined the f u n c t i o n of r e t r o f 1 e c t i o n i n the emergence of psychogenic p a i n from a G e s t a l t therapy p e r s p e c t i v e which i n c l u d e d two-chair work as w e l l as a v a r i e t y of other G e s t a l t methods. In a s i n g l e case study r e p o r t , the p a t i e n t ' s p a i n ceased a f t e r four weeks and d i d not r e t u r n throughout the course of an a d d i t i o n a l ten month therapy designed to r e i n t e g r a t e p o l a r i t i e s and enhance a g r e a t e r c a p a c i t y f o r s e l f - s u f f i c i e n c y . Serok and Zemet (1983) d e s c r i b e an experimental study of group therapy u s i n g G e s t a l t p r i n c i p l e s and methods with s c h i z o p h r e n i c p a t i e n t s . R e s u l t s show a s i g n i f i c a n t i n c r e a s e 23 i n r e a l i t y p e r c e p t i o n and d i f f e r e n t i a t i o n i n the G e s t a l t experimental group. It would appear t h a t the G e s t a l t method and i n p a r t i c u l a r the two-chair d i a l o g u e i s e f f e c t i v e i n f a c i l i t a t i n g c l i e n t change both i n d i v i d u a l l y and i n group s e t t i n g s when compared with a number of other t h e r a p e u t i c i n t e r v e n t i o n s on a v a r i e t y of c l i e n t i s s u e s . However i t i s a l s o apparent that the r e s e a r c h i n t h i s area i s sparse and that more i n v e s t i g a t i o n needs to be conducted t o determine the e f f e c t i v e n e s s of p a r t i c u l a r G e s t a l t techniques with s p e c i f i c c l i e n t i s s u e s . I t i s a l s o apparent that no re s e a r c h has been r e p o r t e d which i n d i c a t e s r e s u l t s u s i n g the empty-chair technique. F u r t h e r r e s e a r c h i s t h e r e f o r e needed i n a l l areas of G e s t a l t r e s e a r c h . G e s t a l t Treatment Approach on the Issue of  U n f i n i s h e d Business In r e s o l v i n g i s s u e s of u n f i n i s h e d business the c l i e n t i s working on i s s u e s r e l a t i n g t o i n t e r p e r s o n a l r e l a t i o n s h i p s and i t i s t h e r e f o r e necessary t o evoke not only the memory of p a r t i c u l a r episodes but a l s o to a c t i v a t e the memory s t r u c t u r e of the r e l a t i o n s h i p with the s i g n i f i c a n t other person. Once t h i s memory s t r u c t u r e i s a c t i v a t e d i t becomes necessary i n therapy t o d e s t r u c t u r e t h i s memory and reform 24 i t . What seems to happen i n t h i s process i s "that by b r e a k i n g the emotional s t r u c t u r e i n t o components and b r i n g i n g a l l the components to awareness, one can prevent them from a u t o m a t i c a l l y r e i n t e g r a t i n g i n t o the same network" (Greenberg & Safran, 1987, p. 281). Greenberg and Safran (1987) f u r t h e r suggest that a c t i v a t i o n of these emotional memories i n the t h e r a p e u t i c environment g r e a t l y f a c i l i t a t e s the formation of new emotional schema. They s p e c u l a t e that t h i s r e f o r m u l a t i o n i s p o s s i b l e i n t h i s s i t u a t i o n because the c l i e n t i s no longer i n v o l v e d i n the o r i g i n a l s i t u a t i o n and because the c l i e n t has a c q u i r e d other experiences with t h i s s i g n i f i c a n t person and p o t e n t i a l l y has a g r e a t e r range of support c u r r e n t l y a v a i l a b l e than was o r i g i n a l l y a v a i l a b l e . U n f i n i s h e d business work becomes the focus of therapy because i t i s o f t e n the only r o u t e back to the o r i g i n a l s i t u a t i o n . The person i n v o l v e d may simply no longer be a v a i l a b l e through death, a move or a l i e n a t i o n . Or i f time and space are not p r o b l e m a t i c , a c o n f r o n t a t i o n with the s i g n i f i c a n t other person may be too f r i g h t e n i n g t o engage i n or the time may l o n g s i n c e have passed to d i s c u s s e a r l i e r events ( P o l s t e r & P o l s t e r , 1973). In u n f i n i s h e d business work the t h e r a p i s t makes a number of assumptions r e g a r d i n g how the c l i e n t changes d u r i n g t h i s p r o c e s s . The f i r s t of these i s that the t h e r a p i s t assumes t h a t the c l i e n t i s o f t e n unaware of the 25 s p e c i f i c i n f l u e n c e of past u n f i n i s h e d s i t u a t i o n s on h e r / h i s c u r r e n t f u n c t i o n n i n g (Daldrup et a l , 1985; and Greenberg & Safran, 1987). I t i s because of t h i s assumption that G e s t a l t therapy p l a c e s a c e n t r a l focus on the process of awareness - awareness of what i s o c c u r r i n g now and more imp o r t a n t l y how t h i s c e n s o r i n g process occurs as the organism i n t e r a c t s with the environment at what G e s t a l t i s t s c a l l the c o n t a c t boundary. Awareness of emotion then i s an important t h e r a p e u t i c t o o l s i n c e "renewed awareness of momentary experience leads not only to the e x p r e s s i o n of o l d h u r t s , but a l s o to f r e s h and s u r p r i s i n g p e r s p e c t i v e s and enhanced p e r c e p t i o n " (Greenberg & Safran, 1987, p. 53). Because primary emotions are viewed as a d a p t i v e responses to s p e c i f i c s i t u a t i o n s v a l u e i s p l a c e d on what i s done with emotions and the u l t i m a t e goal i s not to be r i d of emotions but to "undo the i n t e r r u p t i v e process and to become aware of and r e s p o n s i v e t o the a c t i o n s toward which f e e l i n g s prompt us" (Greenberg & Safran, 1987, p. 53). Anger i s o f t e n one of the primary emotions i n v o l v e d i n u n f i n i s h e d b u s i n e s s . Daldrup et a l (1985) suggest that once anger i s aroused and expressed " t h e r e i s r e l e a s e of p h y s i c a l t e n s i o n and the o p p o r t u n i t y f o r a r e p r o c e s s i n g of experience" (p. 4 ) . I f the anger remains unexpressed, i t not only i n h i b i t s the flow of other emotions but a l s o i s r e -a c t i v a t e d i n s i t u a t i o n s where i t i s not a p p r o p r i a t e or c l e a r l y unproductive. I t i s f u r t h e r assumed by G e s t a l t t h e r a p i s t s that c l i e n t s can best r e d i s c o v e r t h e i r emotional experience by b e i n g a c t i v e l y i n v o l v e d i n the r e l e a r n i n g p r o c e s s . I t i s through the 'experiment' that the c l i e n t i s a b l e t o experience i n the present the denied or disowned emotions and thus a l l o w a r e i n t e g r a t i o n of these emotions i n t o h i s / h e r i n t e r n a l s t r u c t u r i n g schema. Daldrup et a l (1985) have suggested a s e r i e s of phases of experience that a c l i e n t may go through i n the process of u n f i n i s h e d b u s i n e s s work. The phases c o i n c i d e with what P e r l s (1970) has c a l l e d the f i v e l a y e r s of n e u r o s i s . 1. Disowning - i n i t i a l l y the c l i e n t enters therapy disowning the s t r o n g p r o b l e m a t i c emotions, such as anger or h u r t , or at l e a s t denying the impact these emotions are c u r r e n t l y having on the c l i e n t . This may i n v o l v e m i n i m i z i n g , d e n i a l or a t t r i b u t i n g one's anger to another. 2. Phobic R e a c t i o n - As the c l i e n t r e c o g n i z e s the a v a i l a b i l i t y and s i g n i f i c a n c e of the l e f t o v e r emotions th e r e i s o f t e n a phobic r e a c t i o n where c a t a s t r o p h i c r e s u l t s are p r e d i c t e d i f t h i s emotion i s allowed e x p r e s s i o n . 3. Implosiye Stage - At t h i s p o i n t the c l i e n t appears to reach an impasse and he/she f e e l s numb, dead and without awareness of emotion. 4. E x p l o s i v e Stage - C l i e n t s here begin to express spontaneously a l l thoughts, f e e l i n g s and s e n s a t i o n s a s s o c i a t e d with the i n t e r r u p t e d experience. P e r l s (1970) has i d e n t i f i e d four types of e x p l o s i o n : e x p l o s i o n i n t o j o y , i n t o g r i e f , i n t o orgasm, and i n t o anger. 5. Completion Stage - Spontaneous expre s s i o n takes a more i n t e g r a t e d form and t h e r e i s a marked d i m i n u t i o n of h o s t i l e f e e l i n g s . 27 The process of G e s t a l t therapy with the i s s u e of u n f i n i s h e d b u s i n e s s c o n s i s t s of f i v e stages (Daldrup et a l , 1985). F i r s t a focus f o r the work must be e s t a b l i s h e d f o l l o w e d by a commitment to work. The work stage i n v o l v e s the use of the empty-chair technique. In t h i s process the bu l k of the work takes p l a c e i n the " s e l f c h a i r " . I t i s i n t h i s p o s i t i o n t h a t the c l i e n t begins t o express the denied and disowned emotions. The empty c h a i r i s only used as a stimulus object so that the emotions may be heightened i n the s e l f c h a i r . E x p r e s s i o n i s c l o s e t o completion when th e r e i s a l e t t i n g go; a r e a l i z a t i o n that the c l i e n t d i d not get what he/she wanted f o l l o w e d by a gradual l e t t i n g go of t h i s e x p e c t a t i o n . I f r e s o l u t i o n occurs t h e r e i s a s o f t e n i n g of f e e l i n g towards the s i g n i f i c a n t other accompanied by f o r g i v e n e s s . Often, however, an impasse i s reached with no r e s o l u t i o n or s o f t e n i n g of f e e l i n g . In e i t h e r case i t i s important t o say goodbye (O'Connell, 1970) e i t h e r l i t e r a l l y as the c o n c l u d i n g p a r t of the work or by con n e c t i n g the work w i t h i n the s e s s i o n to p o t e n t i a l f u t u r e work. The f o u r t h stage i s an assessment phase i n which the goal i s t o i n t e g r a t e and assess the r e s u l t s of the work j u s t completed. T h i s i s a c o g n i t i v e stage which focuses on r e i n t e g r a t i o n of the c u r r e n t experience. Out of t h i s stage the f i n a l stage emerges i n which f u t u r e p l a n s are made. Although i s i s not yet c l e a r l y understood how r e s o l u t i o n occurs, Greenberg and Safran (1987) have 28 developed a p r e l i m i n a r y e m p i r i c a l model of the process of f i n i s h i n g incomplete experience. F i g u r e 1 shows t h i s model. T h i s model suggests that the event begins with the c l i e n t i d e n t i f y i n g an i s s u e of u n f i n i s h e d business with a s i g n i f i c a n t other person accompanied by the a s s o c i a t e d l i n g e r i n g n e g a t i v e f e e l i n g s . T h i s i s f o l l o w e d by i n t e n s i f i e d e x p r e s s i o n by the c l i e n t and a request by the t h e r a p i s t t h a t the c l i e n t v i s u a l i z e the s i g n i f i c a n t other person i n the empty c h a i r . These two a c t i v i t i e s b r i n g about an aroused a f f e c t i v e s t a t e . In t h i s s t a t e the c l i e n t i s o f t e n aware of a v a r i e t y of f e e l i n g s s i m u l t a n e o u s l y . The two t h a t are o f t e n most a l i v e are hurt and anger which may a l t e r n a t e or may appear u n d i f f e r e n t i a t e d as a complaint. I t i s important i n u n f i n i s h e d b u s i n e s s work to separate the complaint i n t o i t s component p a r t s of hurt and anger and a l l o w the f u l l e x p r e s s i o n of each emotion s e p a r a t e l y . When these emotions of hurt and anger have been d i f f e r e n t i a t e d and each allowed t h e i r f u l l e x p r e s s i o n , the c l i e n t i s then a b l e t o work towards r e s o l u t i o n . Part of t h i s r e s o l u t i o n process seems to be i n a c t i v a t i n g the harsh, r e j e c t i n g person (ofte n a parent) f o l l o w e d by the a c t i v a t i o n of the more human, compassionate person. These two components seem to be e s s e n t i a l t o r e s o l u t i o n i n which the c l i e n t i s a b l e to understand the s i g n i f i c a n t other's p o i n t of view and to accept that view. I t seems that "the e x p r e s s i o n of i n t e n s e negative a f f e c t toward the r e j e c t i n g o b j e c t and the subsequent i d e n t i f i c a t i o n with the r e j e c t i n g o bject produce 29 FIGURE 1 PRELIMINARY EMPIRICAL MODEL OF FINISHING INCOMPLETE EXPERIENCE L i n g e r i n g bad f e e l i n g toward s i g n i f i c a n t other I n t e n s i f i e d e x p r e s s i o n D i f f e r e n t i a t i o n of hurt and anger \!/ A r o u s a l and exp r e s s i o n of hurt and anger Understanding of s i g n i f i c a n t other's p o i n t of view w Imagining of the other Taking the r o l e of the other E v o c a t i o n of a l t e r n a t e schema of good, l o v i n g , i n t e r n a l r e p r e s e n t a t i o n S h i f t to e x p r e s s s i n g d i f f i c u l t i e s i n be i n g n u r t u r i n g / Emotional r e s t r u c t u r i n g , e x p r e s s i o n of love and f o r g i v e n e s s Note. From Emotion i n Psychotherapy (p. 289) by L.S. Greenberg and J.D. Safran, 1987, N.Y.: G u i l f o r d P r e s s . 30 s u f f i c i e n t cues to a c t i v a t e an a l t e r n a t e schema of the more compassionate other" (Greenberg & Safran, 1987, p. 290). T h i s leads t o an emotional r e s t r u c t u r i n g which may be marked by f e e l i n g s of acceptance or of f o r g i v e n e s s . Greenberg and Safran (1987) f u r t h e r suggest that what seems to take p l a c e i n t h i s process i s that "by b r e a k i n g the emotional s t r u c t u r e i n t o components and b r i n g i n g a l l the components to awareness" (p. 281) the c l i e n t i s able to r e i n t e g r a t e the emotional memories i n t o a new schema. They p o s t u l a t e that the c u r r e n t l a c k of t h r e a t inherent i n the t h e r a p e u t i c environment combined with the d i f f e r e n t f e e l i n g s and p e r s p e c t i v e s the c l i e n t b r i n g s to the c u r r e n t experience f a c i l i t a t e r e s t r u c t u r i n g on t h r e e l e v e l s : e x p r e s s i v e motor components; schematic memory s t r u c t u r e ; and conceptual and symbolic a s p e c t s . Greenberg and Safran (1987) f u r t h e r suggest that ''the a c t i v a t i o n of an a l t e r n a t e , more p o s i t i v e i n t e r n a l object schema and/or the a c t i v a t i o n  of a more p o s i t i v e self-schema and a sense  of s e l f - w o r t h i s brought about by the a r o u s a l of the negative a f f e c t i n v o l v e d i n the u n f i n i s h e d experience and the c a r r y i n g forward to completion of t h i s p r e v i o u s l y i n t e r r u p t e d e x p r e s s i o n . " (p. 290). Because G e s t a l t techniques can be very powerful, the importance of the t h e r a p i s t - c l i e n t r e l a t i o n s h i p i s becoming of i n c r e a s i n g prominence (Greenberg, 1983). I t i s e s s e n t i a l t h a t the techniques emerge out of the ongoing d i a l o g u e of the t h e r a p e u t i c encounter. A good r e l a t i o n s h i p i s not seen 31 as s u f f i c i e n t f o r t h e r a p e u t i c change but a t r u s t i n g r e l a t i o n s h i p and good working a l l i a n c e are assumed to be p r e c o n d i t i o n s f o r e f f e c t i v e G e s t a l t work. Research on the Use of Empathic R e f l e c t i o n i n Therapy Rogers (1957) i n a landmark paper o u t l i n e d what he c o n s i d e r e d to be the necessary and s u f f i c i e n t c o n d i t i o n s f o r c o n s t r u c t i v e p e r s o n a l i t y change to occur. One of these c o n d i t i o n s he d e f i n e d as empathic understanding which must be at l e a s t m i n imally communicated t o the c l i e n t . Empathic understanding i n v o l v e d s e n s i n g the c l i e n t s world "as i f " i t were your own without becoming p a r t of t h i s world. Truax and M i t c h e l l (1971) and G l a d s t e i n (1983) a l s o s t r e s s e d the f i n e balance between o v e r - i d e n t i f i c a t i o n with the c l i e n t and m a i n t a i n i n g o b j e c t i v i t y as a t h e r a p i s t . Rogers (1957) f u r t h e r s t r e s s e d that the c l i e n t must p e r c e i v e the t h e r a p i s t ' s understanding of the c l i e n t ' s world f o r empathy to be deemed to occur. T h i s p o s i t i o n has i n i t i a t e d t h r e e decades of r e s e a r c h designed to i n v e s t i g a t e Rogers' c l a i m s . Truax and Carkhuff (1967) f u r t h e r s p e c i f i e d the concept of empathy and s t a t e d that " a c c u r a t e empathy i n v o l v e s both the t h e r a p i s t s s e n s i t i v i t y t o c u r r e n t f e e l i n g s and h i s v e r b a l f a c i l i t y t o communicate t h i s understanding i n a language attuned to the c l i e n t s c u r r e n t f e e l i n g s " (p. 46). 32 T h i s p o s i t i o n i s supported by Gurman (1977). Truax and Carkhuff (1967) f e l t t h a t empathy grew out of a warmth and r e s p e c t f o r the c l i e n t and p r o v i d e d the f u n c t i o n of an emotional m i r r o r t o r e f l e c t the f e e l i n g s of the c l i e n t r a t h e r than the content expressed. They developed a t e n t a t i v e n i n e - s t a g e s c a l e f o r the measurement of a c c u r a t e empathy which Carkhuff (1969) subsequently r e v i s e d i n h i s t r a i n i n g model f o r t h e r a p i s t s to the f i v e - p o i n t s c a l e used i n t h i s study. A f u r t h e r c o n d i t i o n i n communicating ac c u r a t e empathy i n v o l v e s u s i n g language attuned to the c l i e n t s f e e l i n g s and which r e f l e c t s the c l i e n t s own language ( M i t c h e l l , Bozarth & K r a u f t , 1977; Truax & C a r k h u f f , 1967; and Truax & Wargo, 1966). As a r e s u l t of Rogers' (1957) work, B a r r e t t - L e n n a r d (1962) designed the R e l a t i o n s h i p Inventory to assess the c l i e n t ' s experience of the c o n d i t i o n s p o s t u l a t e d by Rogers as b e i n g necessary and s u f f i c i e n t f o r c l i e n t change. Bar r e t t - L e n n a r d ' s (1962) b a s i c assumption was that the " c l i e n t ' s experience of h i s t h e r a p i s t s ' response i s the primary locus of t h e r a p e u t i c i n f l u e n c e i n t h e i r r e l a t i o n s h i p " (p. 2 ) . T h i s viewpoint i s supported by Gurman (1977), O r l i n s k y and Howard (1978, 1986), B a r r e t t - L e n n a r d (1981, 1986) and Greenberg (1982). B a r r e t t - L e n n a r d (1962) i n i t i a l l y c o n c e p t u a l i z e d empathic understanding as encompassing two a s p e c t s : empathic r e c o g n i t i o n of the p e r c e p t i o n s and f e e l i n g s d i r e c t l y communicated by the c l i e n t 33 and empathic i n f e r e n c e which i n v o l v e s s e n s i n g that which i s merely i m p l i e d or i n d i r e c t l y expressed. In h i s most recent w r i t i n g s , B a r r e t t - L e n n a r d (1981, 1986) has expanded h i s c o n c e p t u a l i z a t i o n of empathic understanding to a t h r e e - s t a g e c y c l i c a l p r o c e s s . These t h r e e phases are: Phase 1 -empathic r e s o n a t i o n by the t h e r a p i s t to expressed or i m p l i e d experience of the c l i e n t (thus i n c o r p o r a t i n g the two stages of h i s e a r l i e r work); Phase 2 - communicative e x p r e s s i o n of t h i s understanding by the t h e r a p i s t ; and Phase 3 - r e c e i v e d empathy which i n c o r p o r a t e s the c l i e n t ' s p e r c e p t i o n of the t h e r a p i s t ' s p o s i t i o n . T h i s t h i r d stage and the r e s u l t s generated from the form measuring r e c e i v e d empathy "should be most s t r o n g l y r e l a t e d to c l i e n t change" (p. 448). Carkhuff (1969) has suggested that the f u n c t i o n of empathic understanding i s to a s s i s t the c l i e n t t o "expand and c l a r i f y h i s own s e l f - u n d e r s t a n d i n g as w e l l as h i s understanding of o t h e r s " (p. 202). He f u r t h e r s t a t e s that empathy i s the key i n g r e d i e n t of h e l p i n g and i s c r i t i c a l l y important e s p e c i a l l y d u r i n g the e a r l y phases of h e l p i n g . The q u e s t i o n remains, however, i f these c o n d i t i o n s , i n c l u d i n g empathic r e f l e c t i o n are s u f f i c i e n t f o r c l i e n t change. An e x t e n s i v e q u a n t i t y of r e s e a r c h has been conducted i n an attempt to answer t h i s q u e s t i o n . This r e s e a r c h has been reviewed and summarized by a number of authors i n c l u d i n g Truax and M i t c h e l l (1971); Gurman (1977); O r l i n s k y and Howard (1978, 1986); P a t t e r s o n (1984); and 34 Lambert, Shapiro and Bergin (1986). Truax and M i t c h e l l (1971) f e e l that the evidence i s c o n v i n c i n g that empathic responses p l a y an important r o l e . O r l i n s k y and Howard (1978) suggest that empathy i s a h i g h l y d e s i r a b l e q u a l i t y but stop short of s t a t i n g that warmth and empathy are necessary and s u f f i c i e n t c o n d i t i o n s of good outcome. Gurman (1977) goes so f a r as to s t a t e t h a t these c o n d i t i o n s are necessary as p r e c o n d i t i o n s f o r t h e r a p e u t i c change but are r a r e l y s u f f i c i e n t f o r c o n s t r u c t i v e p e r s o n a l i t y or behaviour change. O r l i n s k y and Howard (1986) concluded that t h e r e was s t r o n g evidence s u p p o r t i n g t h e r a p i s t empathy as making an important c o n t r i b u t i o n when empathy was measured as p e r c e i v e d by the c l i e n t . Lambert, Shapiro and Berg i n (1986) s t r e s s t hat r e l a t i o n s h i p f a c t o r s are important but q u e s t i o n how these f a c t o r s r e l a t e t o t h e r a p i s t technique. P a t t e r s o n (1984) i n a s t r o n g l y worded c r i t i c i s m of the l i t e r a t u r e which he reviewed suggests these reviewers were b i a s e d i n a number of ways. He reaches f a r d i f f e r e n t c o n c l u s i o n s and s t a t e s "the evidence f o r the n e c e s s i t y , i f not s u f f i c i e n c y , of the t h e r a p i s t c o n d i t i o n s of accurate empathy, r e s p e c t , or warmth, and genuineness i s i n c o n t r o v e r t i b l e " (p. 437). He f u r t h e r s t a t e s that the " e f f e c t i v e n e s s of a l l methods of c o u n s e l i n g or psychotherapy may be due to the presence of a t h e r a p e u t i c r e l a t i o n s h i p " (p. 4 37). The evidence s t r o n g l y supports the c o n c l u s i o n that empathic understanding i s a necessary component of 35 t h e r a p e u t i c change yet i s mixed i n s t a t i n g whether empathy p l u s Rogers' (1957) other core c o n d i t i o n s are s u f f i c i e n t f o r t h e r a p e u t i c change. Psychotherapy Research R e l a t i n g to Outcome O r l i n s k y and Howard (1978) have d e f i n e d psychotherapy as "a r e l a t i o n among persons, engaged i n by one or more i n d i v i d u a l s d e f i n e d as needing s p e c i a l a s s i s t a n c e to improve t h e i r f u n c t i o n i n g as persons, together with one or more i n d i v i d u a l s d e f i n e d as a b l e to render such s p e c i a l h e l p " (p.285). T h i s d e f i n i t i o n i m p l i e s that to i n v e s t i g a t e the e f f e c t i v e n e s s of psychotherapy the r e s e a r c h e r must determine that demonstrably b e t t e r changes have occured i n the l i f e of the c l i e n t . These changes are a l s o c o n s i d e r e d to take p l a c e w i t h i n a t h e r a p e u t i c r e l a t i o n s h i p ( O r l i n s k y & Howard, 1978, 1986). However to c o n s i d e r only outcome without a l s o s p e c i f y i n g what i t was that worked and how i t worked undermines the r e p l i c a b i 1 i t y of s c i e n t i f i c r e s e a r c h and i s u l t i m a t e l y of l i m i t e d v a l u e (Bergin & Lambert, 1978; Greenberg & P i n s o f , 1986). The study of change must l i n k process t o outcome i n psychotherapy r e s e a r c h , should e x p l a i n how the change came about and should r e s u l t i n p r a c t i c a l l y important improvements i n the l i f e of the c l i e n t (Greenberg, 1986; Lambert, Shapiro & B e r g i n , 1986). Strupp and Bergin (1969) have s t a t e d the b a s i c q u e s t i o n of psychotherapy 36 r e s e a r c h as "What s p e c i f i c i n t e r v e n t i o n s produce s p e c i f i c changes i n s p e c i f i c p a t i e n t s under s p e c i f i c c o n d i t i o n s ? " (p.20). Strupp and Bergin (1969) a l s o suggest that the " i s o l a t i o n and m a n i p u l a t i o n of s i n g l e v a r i a b l e s i s e s s e n t i a l f o r advancing knowledge concerning the process of t h e r a p e u t i c change" (p.25). The study of change thus becomes a focused i n v e s t i g a t i o n of a s i n g l e t h e r a p e u t i c i s s u e and the problem becomes t h a t of choosing the most e f f e c t i v e r e s e a r c h design to e x p l o r e t h i s i s o l a t e d v a r i a b l e . Kazdin (1986) i n h i s review of r e s e a r c h design and methodology supports the p o s i t i o n t h a t the e f f e c t s of therapy need to be e v a l u a t e d i n r e l a t i o n t o s p e c i f i c c l i n i c a l problems and d i s c u s s e s a v a r i e t y of treatment e v a l u a t i o n s t a t e g i e s . One approach i s the comparative treatment s t r a t e g y which i s f a m i l i a r to r e s e a r c h e r s because of the d e s i r e to determine which s p e c i f i c treatment approaches are most s u c c e s s f u l with p a r t i c u l a r c l i e n t s and p a r t i c u l a r i s s u e s so that outcome may be p r e d i c t e d . Two of these approaches are G e s t a l t therapy and empathic r e f l e c t i o n which has evolved out of Rogers' (1957) work and r e p r e s e n t s the c l i e n t - c e n t e r e d approach. D i f f e r e n t i a l treatment s t u d i e s have been used i n i n v e s t i g a t i n g both G e s t a l t therapy (Bohart, 1977; C l a r k e , 1977, 1981; C l a r k e & Greenberg, 1984; Dompierre, 1979; Greenberg & C l a r k e , 1979; Greenberg & Dompierre, 1981; Greenberg & H i g g i n s , 1980; Greenberg & Webster, 1982; and Webster, 1981) and the r o l e of empathy i n f a c i l i t a t i n g c l P a t t e r s o n 1984; 1966) . i e n t change ( O r l i n s k y & Howard 1978, 1986; Truax & M i t c h e l l , 1971; and Truax St Wargo, Although comparative r e s e a r c h p r e s e n t s a number of unique problems i n keeping the techniques d i s t i n c t Kazdin (1986) s t r e s s e s that "comparisons are e s s e n t i a l t o determine which technique should be a p p l i e d to a given problem" (p.29). Kazdin (1986) f u r t h e r s t a t e s that comparative r e s e a r c h makes an important c o n t r i b u t i o n i n c h a r a c t e r i z i n g a l t e r n a t i v e approaches e m p i r i c a l l y . R i c e and Greenberg (1984) p o i n t out that o f t e n r e s e a r c h on d i f f e r e n t i a l treatment e f f e c t s has f a i l e d t o y i e l d c o n c l u s i v e r e s u l t s and suggest t h a t the l a c k of demonstrated d i f f e r e n t i a l e f f e c t s may be due to an imprecise understanding of the a c t i v e components i n the techniques b e i n g compared. To help c o n t r o l f o r t h i s d i f f i c u l t y Greenberg (1986b) suggests examining s m a l l e r r e s e a r c h u n i t s . I t i s a l s o important t h a t the techniques under study should be s y s t e m a t i c a l l y a l t e r e d t o p r o v i d e evidence on what techniques are e f f e c t i v e with s p e c i f i c problem s t a t e s r e s u l t i n g i n s p e c i f i c r a t h e r than g l o b a l improvement i n d i c e s (Bergin, 1971; B e r g i n & Lambert, 1978; and Lambert, Shapiro, & B e r g i n , 1986). The r e s e a r c h supports the comparative use of s p e c i f i c , c l e a r l y d e l i n e a t e d techniques as they apply to s p e c i f i c t h e r a p e u t i c i s s u e s . R i c e and Greenberg (1984), Gottman and Markman (1978) and Kazdin (1986) s t a t e the importance of e n s u r i n g that the 38 treatments were adm i n i s t e r e d , i n c l u d i n g s p e c i f y i n g t h e r a p i s t behaviours and checking to ensure they oc c u r r e d . This strengthens the d i f f e r e n t i a l e f f e c t s d e s i g n . A f u r t h e r i s s u e i n the use of d i f f e r e n t i a l design s t u d i e s i s whether or not t o i n c l u d e the use of a c o n t r o l group as a comparison with the treatments b e i n g s t u d i e d or as a s u b s t i t u t e f o r the use of a second treatment group. C o n t r o l groups have f r e q u e n t l y been c o n s i d e r e d as an a l t e r n a t i v e to d i f f e r e n t i a l e f f e c t s s t u d i e s . However, Bergin (1971), Gottman and Markman (1978), and Lambert, Shapiro and B e r g i n (1986) s t a t e that t r u e no-treatment c o n t r o l groups are i m p o s s i b l e t o set up. They s t a t e that d i s t r e s s e d persons act t o r e l i e v e t h e i r d i s t r e s s and i f t h i s r e l i e f i s not forthcoming i n a t h e r a p e u t i c environment then help w i l l be sought elsewhere, such as through s e l f - h e l p groups or n o n - p r o f e s s i o n a l a s s i s t a n c e i n the form of f r i e n d s , c l e r g y or r e l a t i v e s or through other p r o f e s s i o n a l s e r v i c e s . Lambert, Shapiro and Bergin (1986) s t a t e that " i t appears that the v a r i o u s c o n t r o l group methods that have been designed are inadequate, t h a t they do not p r o v i d e f a i r t e s t s of therapy e f f e c t s , and that o f t e n e f f e c t s i z e s f o r therapy would be l a r g e r i f they were not reduced i n magnitude by s u b t r a c t i n g the e f f e c t s i z e s of s o - c a l l e d c o n t r o l groups" (p. 181). 39 Treatment s t r a t e g y i s but one aspect of psychotherapy r e s e a r c h . Another important component of the r e s e a r c h design i n v o l v e s the s e t t i n g i n which the study w i l l be conducted and the degree to which t h a t s e t t i n g w i l l approximate those c o n d i t i o n s found i n a c l i n i c a l environment. Analogue s t u d i e s conduct r e s e a r c h i n s i t u a t i o n s and under circumstances analogous to those found i n the c l i n i c a l s e t t i n g and are used to begin i n v e s t i g a t i o n of techniques and to begin t e s t i n g t h e i r e f f e c t i v e n e s s i n s p e c i f i c s i t u a t i o n s . The analogue study has been found to be a way of c l a r i f y i n g complex and s t i m u l a t i n g ideas f o r f u r t h e r r e s e a r c h (Bergin, 1971) . Bohart (1977) and B e r g i n and Strupp (1972) suggest a s i n g l e v a r i a b l e may be p r o d u c t i v e l y i n v e s t i g a t e d i n an analogue s i t u a t i o n as a way t o f u r t h e r our understanding of the change p r o c e s s . Kazdin (1986) suggests that the major advantage of the analogue study i s i t s " c a p a c i t y to surmount many of the m e t h o d o l o g i c a l , p r a c t i c a l and e t h i c a l i s s u e s a s s o c i a t e d with conducting r e s e a r c h i n c l i n i c a l s e t t i n g s " (p.33). The p r i o r i t y i s the experimental q u e s t i o n and the analogue study p r o v i d e s the o p p o r t u n i t y to look at the b a s i c elements of treatment and the c o n t r i b u t i o n s of these elements to t h e r a p e u t i c change and to c o n t r o l m u l t i p l e c o n d i t i o n s thereby m i n i m i z i n g t h e i r v a r i a b i l i t y . Analogue r e s e a r c h r e p r e s e n t s one end p o i n t of the continuum of r e s e a r c h designs with c l i n i c a l t r i a l s r e p r e s e n t i n g the other end. The obvious concern of t h i s design i s the a b i l i t y t o 40 g e n e r a l i z e from t h i s c o n t r o l l e d s i t u a t i o n to the c l i n i c a l s e t t i n g . A l a r g e body of psychotherapy r e s e a r c h has been conducted u s i n g a v a r i e t y of treatment s t r a t e g i e s and r e s e a r c h d e s i g n s . For the purposes of the c u r r e n t study r e s e a r c h r e l a t i n g process to outcome w i l l be d i s c u s s e d . O r l i n s k y and Howard (1986) r e p o r t e d on t h e i r e x t e n s i v e review of the l i t e r a t u r e r e l a t i n g process to outcome i n psychotherapy r e s e a r c h . They organized t h i s review i n t o f i v e conceptual elements: (1) Therapeutic c o n t r a c t which d e f i n e s the purpose, format, terms and l i m i t s of the encounter and forms the p l a n not the substance of therapy; (2) Therapeutic i n t e r v e n t i o n s which are g e n e r a l l y c o n s i d e r e d t o be the techniques used by the t h e r a p i s t i n response to the c l i e n t ' s p r e s e n t i n g d i f f i c u l t y ; (3) Therapeutic bond which r e f e r s t o the r e l a t i o n s h i p t h a t forms between the c l i e n t and t h e r a p i s t ; (4) P a t i e n t s e l f - r e l a t e d n e s s which r e f e r s t o aspects of the c l i e n t ' s f u n c t i o n i n g and i s o f t e n formulated i n terms of "openness" versus " d e f e n s i v e n e s s " ; (5) T h e r a p e u t i c r e a l i z a t i o n s which r e f e r s t o the e f f e c t of the t h e r a p e u t i c i n t e r v e n t i o n s and bond and should be demonstrable i n the c l i e n t ' s l i f e o u t s i d e therapy. These f i v e c a t e g o r i e s may i n c l u d e n o n - p a r t i c i p a n t o b s e r v a t i o n s or p a r t i c i p a n t o b s e r v a t i o n s by e i t h e r the t h e r a p i s t or the c l i e n t . T h i s framework o u t l i n e d by O r l i n s k y and Howard 41 (1986) w i l l be used to organize and summarize the psychotherapy r e s e a r c h l i t e r a t u r e r e l a t i n g t o outcome. The f i r s t element d e s c r i b e d by O r l i n s k y and Howard (1986) i s the t h e r a p e u t i c c o n t r a c t which c o n s i s t s of d e f i n i n g the l i m i t s of the therapy experience i n c l u d i n g the t i m i n g of the s e s s i o n s and the l e n g t h of the c o n t r a c t . O r l i n s k y and Howard (1986) found "good evidence to b e l i e v e that number of s e s s i o n s i s s t r o n g l y r e l a t e d to outcome" (p.315). They a l s o concluded that p r e p a r i n g c l i e n t s f o r the t h e r a p e u t i c r o l e of c l i e n t had a p o s i t i v e and s i g n i f i c a n t r e s u l t on t h e r a p e u t i c outcome. These components of the c o n t r a c t have r e l e v e n c e to the present study however the t h e r a p e u t i c c o n t r a c t r e l a t e s ^ p r i m a r i l y to c l i n i c a l s e t t i n g s r a t h e r than to analogue s t u d i e s and i s t h e r e f o r e of minimal importance t o the c u r r e n t r e s e a r c h . The second element d i s c u s s e d by O r l i n s k y and Howard (1986) i s t h a t of the t h e r a p e u t i c i n t e r v e n t i o n s which d e l i n e a t e the major d i f f e r e n c e s between t h e r a p i e s and determine the course of the therapy. Of p a r t i c u l a r importance i s the n e c e s s i t y of b e i n g s p e c i f i c about the techniques used. Strupp (1978) s t r e s s e s the growing emphasis on d e v e l o p i n g "more c l e a r l y d e f i n e a b l e techniques geared t o the treatment of p a r t i c u l a r p a t i e n t problems" (p.17). The r a p e u t i c techniques r e l a t i n g t o s p e c i f i c c l i e n t problems have been d e l i n e a t e d r e g a r d i n g a v a r i e t y of c l i e n t 42 i s s u e s i n c l u d i n g d e a l i n g with suppressed, u n f i n i s h e d emotional r e a c t i o n s (Daldrup, B e u t l e r , & Greenberg, 1985); r e s o l v i n g s p l i t s (Greenberg, 1979, 1980a); r e s o l v i n g c o n f l i c t s (Greenberg, 1983b); and t r a i n i n g c o u n s e l l o r s i n G e s t a l t methods (Greenberg, 1980b). Kazdin (1986) a l s o s t r e s s e s the importance of s p e c i f y i n g c o n c r e t e procedures and of s p e c i f y i n g the connection between treatment techniques and the s p e c i f i c d y s f u n c t i o n t o be t r e a t e d . The s p e c i f i c treatment techniques used i n t h i s study w i l l be d e s c r i b e d i n Chapter Three. As has been p o i n t e d out (Kazdin, 1986; O r l i n s k y & Howard, 1986; and Strupp, 1978) these techniques must be r e l a t e d t o a s p e c i f i c c l i e n t problem. B a t t l e et a l (1966) have developed a means of i d e n t i f y i n g the s p e c i f i c problem or problems and measuring change i n these complaints. The Target Complaint Measure ( B a t t l e et a l , 1966) allows c l i e n t s t o i d e n t i f y t h e i r core concerns and to eva l u a t e t h e i r improvement at the completion of treatment. B e r g i n and Lambert (1978) and Lambert, Shapiro and Berg i n (1986) support the i n c l u s i o n of t h i s k i n d of g l o b a l measure of c l i e n t change i n a s s e s s i n g t h e r a p e u t i c outcome. Thera p e u t i c i n t e r v e n t i o n s which add to the c l i e n t ' s a r o u s a l are important to f a c i l i t a t e t h e r a p e u t i c change. Outcome i s t h e r e f o r e o p t i m i z e d when c l i e n t s are a c t i v e l y i n v o l v e d i n the t h e r a p e u t i c p r o c e s s . A f f e c t i v e immediacy or 43 a r o u s a l seems t o be s i g n i f i c a n t l y important i n a t t a i n i n g b e n e f i t s from the t h e r a p e u t i c involvement and those c l i e n t s who experience a f f e c t i v e d i s c h a r g e and " g r e a t e r immediacy of a f f e c t i v e e x p r e s s i o n tended q u i t e c o n s i s t e n t l y t o experience b e t t e r outcomes" ( O r l i n s k y & Howard, 1986, p. 365). S t i l e s (1980, 1986), S t i l e s and Snow (1984a, 1984b) and S t i l e s , T u p ler and Carpenter (1982) have exp l o r e d the i s s u e of c l i e n t a r o u s a l and have developed the Session E v a l u a t i o n Q u e s t i o n n a i r e ( S t i l e s , 1984) to i d e n t i f y the c l i e n t ' s p e r c e p t i o n s of the s e s s i o n . The c l i e n t s r a t e the smoothness and depth of the s e s s i o n and they a l s o r a t e t h e i r mood along the dimensions of p o s i t i v i t y and a r o u s a l . T h i s measure allows c l i e n t s t o q u a n t i f y t h e i r l e v e l of a r o u s a l and taps the i s s u e of c l i e n t a r o u s a l as an important element i n f a c i l i t a t i n g c l i e n t change. Another component of t h e r a p e u t i c i n t e r v e n t i o n s i d e n t i f i e d by O r l i n s k y and Howard (1986) i s that of treatment i n t e g r i t y , or the extent t o which treatment has been c a r r i e d out as intended. T h i s needs t o be d i s t i n g u i s h e d from d i f f e r e n t i a t i o n of one treatment from another (Kazdin, 1986) . Once the treatment techniques have been c l e a r l y d e l i n e a t e d i t i s important t o be ab l e t o determine not only that they o c c u r r e d but a l s o t o measure t o what extent they were c a r r i e d out. In t h i s study two i n t e r v e n t i o n s were used and were measured with s c a l e s s p e c i f i c a l l y designed f o r t h i s purpose. Carkhuff (1969) 44 d e v i s e d a f i v e - p o i n t s c a l e to measure the extent to which empathic r e f l e c t i o n was c a r r i e d out. A f i v e - p o i n t s c a l e has a l s o been d e v i s e d to r a t e the occurrence of the G e s t a l t empty-chair d i a l o g u e . Both were used to e s t a b l i s h treatment i n t e g r i t y . The t h i r d element i d e n t i f i e d by O r l i n s k y and Howard (1986) i s t h a t of the t h e r a p e u t i c bond. The importance of the t h e r a p e u t i c r e l a t i o n s h i p or bond has been e x t e n s i v e l y documented (Barr e t t - L e n n a r d , 1962, 1982, 1986; Carkhuff, 1969; Greenberg, 1981, 1982; Gurman, 1977; Horvath & Greenberg, 1986; M i t c h e l l , Bozarth & K r a u f t , 1977; Truax & C arkhuff, 1967; Truax & Wargo, 1966) . O r l i n s k y and Howard (1986) d e s c r i b e t h i s bond as f e e l i n g s o l i d , resonant and warm to both t h e r a p i s t and c l i e n t and conclude that the q u a l i t y of t h i s bond i s an extremely important f a c t o r i n c l i e n t outcome. One of the most important aspects of t h i s bond i s t h e r a p i s t empathy which has been d i s c u s s e d i n d e t a i l elsewhere i n t h i s review. I t i s important to note that t h e r e i s "very s t r o n g evidence i n d i c a t i n g that t h e r a p i s t empathy makes an important c o n t r i b u t i o n to p a t i e n t b e n e f i t when empathy i s measured as p e r c e i v e d by p a t i e n t s " ( O r l i n s k y & Howard, 1986, p.344). T h i s p o s i t i o n i s a l s o supported by B a r r e t t - L e n n a r d (1962, 1982, 1986), Greenberg and P i n s o f (1986) , and O r l i n s k y and Howard (1978) . B a r r e t t - L e n n a r d (1964) designed the R e l a t i o n s h i p Inventory to assess the v a r i o u s components of the c l i e n t - t h e r a p i s t r e l a t i o n s h i p 45 i n c l u d i n g t h e r a p i s t empathy as p e r c e i v e d by the c l i e n t . Support f o r the importance of the t h e r a p e u t i c r e l a t i o n s h i p i s r e p o r t e d by Lambert, Shapiro and Bergin (1986) to apply to b e h a v i o u r a l t h e r a p i s t s as w e l l . In a d d i t i o n t o the importance of the r e l a t i o n s h i p i s the i s s u e of the working a l l i a n c e that e x i s t s between c l i e n t and t h e r a p i s t . Bordin (1979) i d e n t i f i e d the t h r e e components of t h i s a l l i a n c e as t ask, bond and g o a l . Horvath and Greenberg (1986) d e s c r i b e the development of a measure, the Working A l l i a n c e Inventory, which was designed to assess these components of the t h e r a p e u t i c r e l a t i o n s h i p and they s t a t e d that the t a s k dimension seems to be most p r e d i c t i v e of outcome. The concept of the working a l l i a n c e i s one which adds to our understanding of the t h e r a p e u t i c r e l a t i o n s h i p and one which i s seen to enhance the c l i e n t -t h e r a p i s t bond. The p o s i t i v e q u a l i t y of the bond between t h e r a p i s t and c l i e n t i s c o n s i d e r e d to be an "extremely important f a c t o r i n p a t i e n t outcome" ( O r l i n s k y & Howard, 1986, p. 357). The f o u r t h element d e s c r i b e d by O r l i n s k y and Howard (1986) which has an important b e a r i n g on t h e r a p e u t i c outcome i s the concept of p a t i e n t s e l f - r e l a t e d n e s s or the a b i l i t y of c l i e n t s t o be open to t h e i r f e e l i n g s . C l i e n t - c e n t e r e d t h e r a p i e s encourage c l i e n t s to be more open to t h e i r f e e l i n g s and t o be more aware of t h e i r thoughts and wishes. 46 From the viewpoint of c l i e n t - c e n t e r e d t h e r a p i e s "experience and acceptance of p r e v i o u s l y denied f e e l i n g s ... appears to be the major mechanism of change" (Greenberg & Safran, 1987, p. 46). G e s t a l t theory views emotion as a b i o l o g i c a l l y a d a p t i v e o r i e n t a t i o n system that c o n t i n u a l l y informs us of our experience i n the world (Greenberg & Safran, 1987). Awareness of emotions i s e s s e n t i a l and the G e s t a l t approach s t a t e s that i t i s o f t e n the b l o c k i n g of emotions b e f o r e they enter awareness t h a t leads t o incomplete experience and u n f i n i s h e d b u s i n e s s . I t . i s by r e - e n t e r i n g the p a i n f u l f e e l i n g s and r e - e x p e r i e n c i n g the b l o c k e d emotions that c l i e n t s change. Greenberg (1979, 1980a, 1982, 1983b) concluded i n h i s w r i t i n g s on the r e s o l u t i o n f o l l o w i n g two-c h a i r G e s t a l t work that a c r i t i c a l aspect of r e s o l u t i o n and c l i e n t change was the " s o f t e n i n g " of the harsh e x t e r n a l c r i t i c and the adoption of a more i n t e r n a l l y focused stance. F e e l i n g s are a v a l u e d p a r t of our experience and i t i s important to become aware of and r e s p o n s i v e toward the a c t i o n s inherent i n these f e e l i n g s . Often these f e e l i n g s are i n r e l a t i o n s h i p t o a s i g n i f i c a n t person i n our l i v e s and i t i s by acknowledging these f e e l i n g s and a l l o w i n g t h e i r e x p r e s s i o n t h a t change may occur. Although t h i s e x p r e s s i o n does not n e c e s s a r i l y need to occur i n the presence of the other person, i t may be necessary to be a b l e to assess the change i n these f e e l i n g s . Wiggins (1979, 1980, 1982) and Wiggins and Broughton (1985) have i n v e s t i g a t e d the realm of 47 i n t e r p e r s o n a l behaviour and have exp l o r e d ways to de t e c t changes i n f e e l i n g s toward another person. Wiggins (1982) reviewed the development of circumplex models of i n t e r p e r s o n a l behaviour which have been designed to d e s c r i b e the u n i v e r s e of content of i n t e r p e r s o n a l behaviour. Wiggins (1980) suggests that the circumplex model i s " p a r t i c u l a r l y w e l l - s u i t e d f o r r e p r e s e n t i n g the fuzzy boundaries and continuous ... c l a s s membership of a d j e c t i v e s d e s c r i b i n g i n t e r p e r s o n a l q u a l i t i e s " (p. 269). Wiggins (1979, 1982) and Wiggins and Broughton (1985) a l s o f e e l t h a t t h i s format would prove u s e f u l i n the study of i n t e r p e r s o n a l p e r c e p t i o n and p e r s o n a l i t y r e s e a r c h and they have developed two a d j e c t i v e s c a l e s u s i n g t h i s format. One such s c a l e i s the A f f e c t i v e Reactions Q u e s t i o n n a i r e (1984) which i s designed to capture an i n d i v i d u a l s ' f e e l i n g s towards a s i g n i f i c a n t or t a r g e t person. T h i s s c a l e f a c i l i t a t e s the sampling of these s p e c i f i c f e e l i n g s at v a r y i n g p o i n t s i n the t h e r a p e u t i c process and p r o v i d e s a measurement of change i n these f e e l i n g s at the c o n c l u s i o n of therapy. The l a s t element d i s c u s s e d by O r l i n s k y and Howard (1986) i s t h a t of t h e r a p e u t i c r e a l i z a t i o n which they l i m i t t o those s i g n s w i t h i n the t h e r a p e u t i c process that i n d i c a t e t h at therapy i s making a p o s i t i v e impact. S t i l e s (1980), S t i l e s and Snow (1984a, 1984b), and S t i l e s , T u pler and Carpenter (1982) i n t h e i r r e s e a r c h have focused on the immediate impact of therapy as r a t e d by both the c l i e n t and 48 the t h e r a p i s t . The mood dimension of the Session E v a l u a t i o n Q u e s t i o n n a i r e measures p o s t - s e s s i o n mood and p r o v i d e s a method of c a p t u r i n g the immediate impact of each s e s s i o n . Greenberg's (1979, 1980a, 1982, 1983b) d e s c r i p t i o n of the " s o f t e n i n g " of the harsh c r i t i c i s a f u r t h e r i n d i c a t i o n of t h e r a p e u t i c impact. This s o f t e n i n g may a l s o r e f l e c t a s h i f t i n f e e l i n g towards a s i g n i f i c a n t other person i n the c l i e n t ' s l i f e . T h i s overview of outcome r e s e a r c h h i g h l i g h t s the m u l t i p l i c i t y of f a c t o r s that need t o be c o n s i d e r e d when conducting psychotherapy r e s e a r c h . A c o n s i s t e n t f i n d i n g i s the importance of c l e a r l y d e l i n e a t i n g the d i f f e r e n t i a l treatments t o be used and of s p e c i f i y i n g the c l i e n t i s s u e t o be examined. I t i s a l s o apparent that these treatments must take p l a c e w i t h i n an empathic r e l a t i o n s h i p and that the i n t e r v e n t i o n s used are a d d i t i v e to that r e l a t i o n s h i p . In the c u r r e n t study two treatments were used: empathic r e f l e c t i o n and empathy p l u s the G e s t a l t empty-chair technique. The c l i e n t i s s u e t h a t was i n v e s t i g a t e d was th a t of u n f i n i s h e d b u s i n e s s . 49 Chapter I I I METHODOLOGY This chapter w i l l present the instruments used i n the study and b r i e f l y d i s c u s s t h e i r composition and r e l i a b i l i t y . The design, p o p u l a t i o n , sampling and data c o l l e c t i o n and a n a l y s i s w i l l be d e s c r i b e d and the t h e r a p i s t s and r a t e r s w i l l be c h a r a c t e r i z e d . A d e s c r i p t i o n of the treatments used w i l l be i n c l u d e d . P a r t i c i p a n t s i n the Study Subj ects Subjects were s o l i c i t e d from students e n r o l l e d i n the f i r s t year of a Master's Degree program i n C o u n s e l l i n g Psychology at the U n i v e r s i t y of B r i t i s h Columbia. They were t o l d t h a t the study was an i n v e s t i g a t i o n of u n f i n i s h e d b u s i n e s s and were asked to t h i n k of a p e r s o n a l l y meaningful i s s u e to d i s c u s s . The s u b j e c t s were not informed of any of the v a r i a b l e s under c o n s i d e r a t i o n . The amount of time and the a c t i v i t i e s were d e s c r i b e d i n s u p e r f i c i a l terms ( i e . complete a number of p e n c i l and paper measures, p a r t i c i p a t e i n two c o u n s e l l i n g s e s s i o n s as a c l i e n t , e t c . ) . A pool of 41 v o l u n t e e r s was s o l i c i t e d from ei g h t d i f f e r e n t c l a s s e s c o n t a i n i n g between 10 and 20 students each. Twenty-eight 50 s u b j e c t s were randomly s e l e c t e d from t h i s p o o l of vo l u n t eers. The s u b j e c t s ranged i n age from 24 to 52 years and i n c l u d e d 7 men and 21 women. Some of the s u b j e c t s had taken only one i n t r o d u c t o r y course i n the program and others had completed seven courses. The s u b j e c t s were asked to r a t e the amount of change they f e l t they had experienced d u r i n g the past year on a r a t i n g s c a l e r a n g i n g from "1" - "no change"; through "3" - "somewhat"; t o "5" - "maximum". The scores i n both groups ranged from "2" to "5" with the mean f o r the G e s t a l t group b e i n g 3.6 and the mean f o r the Empathy b e i n g 3.5. Both groups, t h e r e f o r e , showed d i v e r s i t y i n the experience they brought t o the study and i n t h e i r s e l f -p e r c e p t i o n s of change throughout the past year. The s e l e c t e d v o l u n t e e r s were randomly a s s i g n e d t o e i t h e r the G e s t a l t empty-chair c o n d i t i o n or the empathic r e f l e c t i o n group. A f t e r the s u b j e c t s were randomly a s s i g n e d each s u b j e c t was i n d i v i d u a l l y given a b r i e f i n t r o d u c t i o n to the i s s u e of u n f i n i s h e d business and then p r e s e n t e d with a r a t i o n a l e f o r the use of the form of therapy each was to experience. 51 T h e r a p i s t s Seven t h e r a p i s t s , 3 men and 4 women, were used i n the study. A l l t h e r a p i s t s had at l e a s t 96 hours of t r a i n i n g i n G e s t a l t therapy c o n s i s t i n g of a minimum of 32 weekly t h r e e -hour s e s s i o n s . In a d d i t i o n a l l t h e r a p i s t s r e c e i v e d approximately 20 hours of i n t e n s i v e t r a i n i n g i n empty-chair work as i t a p p l i e s t o the i s s u e of u n f i n i s h e d b u s i n e s s . A l l t h e r a p i s t s had a minimum of 100 hours of i n t e r p e r s o n a l s k i l l t r a i n i n g a c c o r d i n g t o the Egan model or other p e r s o n a l model. A l l t h e r a p i s t s had working experience u s i n g these s k i l l s of at l e a s t two y e a r s . Each t h e r a p i s t saw fo u r c l i e n t s , two u s i n g the G e s t a l t empty-chair technique and two u s i n g Empathic r e f l e c t i o n . T h e r a p i s t s were randomly a s s i g n e d treatment m o d a l i t i e s i n s u r i n g t h a t h a l f the t h e r a p i s t s used G e s t a l t empty-chair technique with t h e i r f i r s t s u b j e c t and h a l f used empathic r e f l e c t i o n with t h e i r f i r s t s u b j e c t . Raters. Two r a t e r s were used t o ensure t h a t the t h e r a p i s t s used the a s s i g n e d o p e r a t i o n i n both the empathic r e f l e c t i o n s e s s i o n s and the s e s s i o n s i n which the G e s t a l t empty-chair technique was used. The r a t e r s were g r a d u a t i n g students i n the Masters program i n C o u n s e l l i n g Psychology at the U n i v e r s i t y of B r i t i s h Columbia. The r a t e r s had a minimum of 100 hours of t r a i n i n g i n the Egan model and at l e a s t 100 52 hours of t r a i n i n g i n G e s t a l t therapy i n c l u d i n g t r a i n i n g i n the G e s t a l t empty-chair procedure. The videotapes from the empathic r e f l e c t i o n s e s s i o n s were submitted to two r a t e r s who r a t e d t h e r a p i s t responses from L e v e l 1 to L e v e l 5 on the Carkhuff Scale (Carkhuff, 1969) i n which L e v e l 3 i s c o n s i d e r e d to be minimally f a c i l i t a t i v e . The r a t e r s l i s t e n e d t o two f i v e - m i n u t e segments taken at approximately the 15 minute mark and the 35 minute mark i n each s e s s i o n and determined whether each segment was at l e a s t m i n imally f a c i l i t a t i v e on the Carkhuff s c a l e . None of the segments warranted a r a t i n g of l e s s than 3.0. T h e r e f o r e a l l s e s s i o n s were r e t a i n e d . Videotapes of the G e s t a l t empty-chair s e s s i o n s were submitted to two r a t e r s to ensure that the G e s t a l t empty-c h a i r d i a l o g u e o c c u r r e d . A f i v e p o i n t s c a l e r a n g i n g from "Not at a l l " , through "A l i t t l e " , "Somewhat" and "Mostly" t o " A l l the time" was used. The r a t e r s used c l i n i c a l judgement to determine where on the s c a l e the segments were p l a c e d . The r a t e r s were to determine that at l e a s t the middle r a t i n g of "Somewhat" occu r r e d . A ten-minute segment was s e l e c t e d and given a combined r a t i n g . The r a t i n g s c a l e d e s c r i b e d above was used to determine to what extent the G e s t a l t empty-chair technique o c c u r r e d . C l i n i c a l judgement was used to determine that the 53 o p e r a t i o n was performed adequately. Both r a t e r s confirmed the occurrence of the G e s t a l t empty-chair d i a l o g u e i n a l l G e s t a l t s e s s i o n s . Both r a t e r s a l s o confirmed that a minimum r a t i n g of "Somewhat" occu r r e d i n a l l G e s t a l t s e s s i o n s . T h e r e f o r e , a l l s e s s i o n s were r e t a i n e d . Measuring Instruments Qverview The measuring instruments i n t h i s study served a number of purposes. Subject d e s c r i p t i o n instruments were used to d e s c r i b e the s u b j e c t s and to g a i n c l i e n t i n f o r m a t i o n . R e l a t i o n s h i p instruments were used t o determine those c l i e n t s who were engaged i n the t h e r a p e u t i c process and those who were not. Outcome instruments were used to measure the dependent v a r i a b l e s of t a r g e t complaints and emotional r e a c t i o n t o the s i g n i f i c a n t other. Session instruments were used t o measure the amount of discomfort a s s o c i a t e d with the p r e s e n t i n g complaint and to measure the c l i e n t ' s p e r c e p t i o n of the s e s s i o n and p o s t - s e s s i o n mood. 54 Subject D e s c r i p t i o n Instruments The S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e (16-PF) The S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e ( C a t t e l l , Eber, & Taksuoka, 1970) was chosen to d e s c r i b e the s u b j e c t s . Two f a c t o r s , F a c t o r C and F a c t o r Q4, were ad m i n i s t e r e d t o a l l the s u b j e c t s p r i o r to the f i r s t experimental s e s s i o n . F a c t o r C, a measure of ego s t r e n g t h , was the f i r s t primary source t r a i t s e l e c t e d as i t was f e l t t h a t a low score on t h i s f a c t o r would n e g a t i v e l y impact on the c o u n s e l l i n g s e s s i o n s . F a c t o r Q4, c o n s i d e r e d a measure of g e n e r a l f r u s t r a t i o n , and r a n g i n g from r e l a x e d , t r a n q u i l , t o r p i d , and u n f r u s t r a t e d to tense, f r u s t r a t e d , d r i v e n and overwrought was the second primary source t r a i t s e l e c t e d . The 16-PF i s a s t a n d a r d i z e d o b j e c t i v e l y scored p e r s o n a l i t y t e s t which independently measures s i x t e e n f a c t o r - a n a l y t i c a l l y determined p e r s o n a l i t y v a r i a b l e s and four secondary dimensions e n c o r p o r a t i n g broader p e r s o n a l i t y t r a i t s . These f a c t o r s r e s t w i t h i n the context of a g e n e r a l theory of p e r s o n a l i t y and are based on a p o p u l a t i o n of normal and c l i n i c a l s u b j e c t s . A comprehensive review of the 16-PF i s a v a i l a b l e i n the Handbook f o r the 16-PF ( C a t t e l l , Eber, & Taksuoka, 1970).' The v a l i d i t y and r e l i a b i l i t y of the 16-PF have been e x t e n s i v e l y r e s e a r c h e d . T e s t - r e t e s t r e l i a b i l i t y are from (.58) to (.92) f o r each source t r a i t on the t e s t with a 2 7 day i n t e r v a l and from (.36) to (.88) with a 2 to 48 mont i n t e r v a l . D i r e c t v a l i d i t i e s range from (.44) to (.92) and i n d i r e c t v a l i d i t i e s from (.63) to (.96). S u b j e c t i v e C l i e n t Information Three c l i e n t r e p o r t forms (Questionnaire A, Q u e s t i o n n a i r e B and Q u e s t i o n n a i r e C) were a d m i n i s t e r e d to a l l s u b j e c t s t o g a i n s u b j e c t i v e i n f o r m a t i o n about the s u b j e c t ' s involvement i n therapy and to assess t h e i r p e r c e p t i o n of change i n t h e i r r e a c t i o n to the s i g n i f i c a n t other. I t was a l s o important to determine i f any unusual occurences had taken p l a c e between the two experimental s e s s i o n s which may have had an impact on the outcome of these s e s s i o n s and which might have been more r e s p o n s i b l e f o r change than the treatment s e s s i o n s . Bfllit-lamhip ImtEumanfei B a r r e t t - L e n n a r d R e l a t i o n s h i p Inventory (RI) The B a r r e t t - L e n n a r d R e l a t i o n s h i p Inventory ( B a r r e t t -Lennard, 1964) was designed to measure the c l i e n t ' s p e r c e p t i o n of the c o u n s e l l o r ' s warmth, congruence, empathy and p o s i t i v e r e g a r d . The RI i s based on Roger's statement that " i t i s the q u a l i t y of the i n t e r p e r s o n a l encounter wit the c l i e n t which i s the most s i g n i f i c a n t element i n 56 d etermining e f f e c t i v e n e s s " (Rogers, 1971, p. 85) and on Rogers' b e l i e f t h a t the c l i e n t must p e r c e i v e these q u a l i t i e s f o r change i n behaviour to occur. For the purposes of t h i s r e s e a r c h only the s i x t e e n items comprising the empathy sub-s c a l e were used to measure the s u b j e c t ' s p e r c e p t i o n of the t h e r a p i s t ' s understanding. The items range from "Yes, I s t r o n g l y f e e l t h a t i t i s t r u e " through four i n t e r m e d i a t e stages to "No, I s t r o n g l y f e e l that i t i s not t r u e " . There i s no n e u t r a l or midpoint category to ensure that s u b j e c t s make a s e l e c t i o n i n the "yes" or "no" d i r e c t i o n , however t e n t a t i v e t h i s c h o i c e may be. The empathy s c a l e of the RI was a d m i n i s t e r e d a f t e r the completion of the second experimental s e s s i o n . B a r r e t t - L e n n a r d (1962) r e p o r t e d s p l i t - h a l f r e l i a b i l i t y c o e f f i c i e n t s f o r empathic understanding of (.86). Gurman (1977) confirmed the s t a b i l i t y of these f i n d i n g s i n a review of f o u r t e e n s t u d i e s of i n t e r n a l r e l i a b i l i t y and ten s t u d i e s of t e s t - r e t e s t r e l i a b i l i t y . He found i n t e r n a l r e l i a b i l i t i e s a c r o s s the 24 s t u d i e s f o r empathy t o be (.84) and t e s t -r e t e s t r e l i a b i l i t i e s f o r empathy of (.85). B a r r e t t - L e n n a r d (1986) s t a t e d t h a t t h e r e was evidence of content v a l i d i t y and " e x t e n s i v e and s t r o n g evidence of ( p r e d i c t i v e ) c o n s t r u c t v a l i d a t i o n " (p. 459) . B a r r e t t - L e n n a r d (1981) d e l i n e a t e d a sequence of t h r e e d i s t i n c t stages i n v o l v e d i n the process of empathic 57 i n t e r a c t i o n : empathic r e s o n a t i o n by the t h e r a p i s t to the e x p r e s s i o n of the c l i e n t ; the t h e r a p i s t ' s communicative e x p r e s s i o n or expressed empathy; and r e c e i v e d empathy as p e r c e i v e d by the c l i e n t . In 1986 he reviewed the theory, method and uses of the RI over i t s 25 year h i s t o r y . In both a r t i c l e s he s t r e s s e d that the OS form of the RI taps the r e c e i v i n g person's d e s c r i p t i o n of the other's response w i t h i n the r e l a t i o n s h i p or Phase 3 empathy. In t h i s study the OS Form of the RI was used to assess the s u b j e c t ' s p e r c e p t i o n of r e c e i v e d empathy. Working A l l i a n c e Inventory (WAI) The Working A l l i a n c e Inventory (Horvath, 1982) i s a 36-item s e l f - r e p o r t instrument designed to assess the r e l a t i o n s h i p of the working a l l i a n c e t o outcome along t h r e e dimensions: Task, Bond and Goal. T h i s instrument was designed to sample the t h e r a p e u t i c a l l i a n c e i n the e a r l y stages of the r e l a t i o n s h i p . For each item the s u b j e c t s r a t e t h e i r p e r c e p t i o n s of t h e i r t h e r a p i s t along a f u l l y anchored seven-point L i k e r t s c a l e r a n g i n g from "never" through "sometimes" to "always". Horvath and Greenberg (1986) r e p o r t e d r e s e a r c h on the R e v i s e d WAI which y i e l d e d the f o l l o w i n g c o e f f i c i e n t s of r e l i a b i l i t y : Goal (.89), Task (.92), and Bond (.92). They suggest that the Task dimension of the WAI seems to be the most u s e f u l p r e d i c t o r of a l l aspects of therapy outcome and 58 t h a t t h i s dimension "may be a c r i t i c a l component i n psychotherapy p r o c e s s . a c r o s s a v a r i e t y of i n t e r v e n t i o n s t r a t e g i e s " (p. 553). In the present study only the Task dimension of the WAI was a d m i n i s t e r e d i n order to measure the s u b j e c t ' s engagement i n therapy i n both experimental s i t u a t i o n s . T h i s dimension was a d m i n i s t e r e d a f t e r the completion of the second experimental s e s s i o n . Outcome Measures Target Complaints Measure (TC) The Target Complaints Measure ( B a t t l e , Imber, Hoehn-S a r i c , Stone, Nash, & Frank, 1966) i s an instrument designed to enable the c l i e n t t o i d e n t i f y the primary problems c a u s i n g d i s t r e s s b e f o r e b e g i n n i n g treatment. F o l l o w i n g treatment the c l i e n t i s asked to r a t e changes i n each complaint on a f i v e - p o i n t s c a l e r a n g i n g from "Worse" to "No change" to "A l i t t l e b e t t e r " to "Somewhat b e t t e r " to "A l o t b e t t e r " . B a t t l e et a l (1966) r e p o r t e d h i g h l y r e l i a b l e s e v e r i t y r a t i n g s of p r e - s e s s i o n and p o s t - s e s s i o n complaints. They developed the Target Complaint Discomfort Box Scale to assess the degree of d i s c o m f o r t caused by each complaint and to gauge the r e l i a b i l i t y of t a r g e t complaint s e v e r i t y . T h i s instrument i s d e t a i l e d i n the s e c t i o n d e s c r i b i n g s e s s i o n measures. 59 B a t t l e et a l (1966) c i t e evidence f o r the v a l i d i t y of the TC measure by a n a l y z i n g and comparing i t s mean t a r g e t complaint improvement scores with the r e s u l t s of four other outcome measures. The TC c o r r e l a t e d t o a s i g n i f i c a n t degree with a l l four measures. In t h i s study s u b j e c t s were asked t o i d e n t i f y t h e i r one core complaint r e g a r d i n g the s i g n i f i c a n t other b e f o r e the experimental s e s s i o n s began and to r a t e changes i n t h i s complaint f o l l o w i n g the second experimental s e s s i o n and again one week l a t e r . A f f e c t i v e Reactions Q u e s t i o n n a i r e (ARQ) The A f f e c t i v e Reactions Q u e s t i o n n a i r e was designed by Wiggins (1984) t o measure an i n d i v i d u a l s emotional r e a c t i o n t o another person. The ARQ i s a two-dimensional circumplex model of i n t e r p e r s o n a l f e e l i n g s c o n s i s t i n g of eig h t f o u r -item s i n g l e a d j e c t i v e s c a l e s with each end r e p r e s e n t i n g s e m a n t i c a l l y b i p o l a r opposite v a r i a b l e s . The eig h t dimensions were c o l l a p s e d i n t o four s c a l e s by r e v e r s i n g the w e i g h t i n g on one end of the b i p o l a r p a i r s and combining the s c o r e s . The r e s u l t i n g s c a l e s were t i t l e d C o n f i d e n t , S u p e r i o r , I n t o l e r a n t and Discouraged. Subjects are asked t o i n d i c a t e how a c c u r a t e l y an a d j e c t i v e d e s c r i b e d t h e i r c u r r e n t f e e l i n g s towards a s i g n i f i c a n t other on an e i g h t - p l a c e L i k e r t s c a l e r anging 60 from "1" - extremely i n a c c u r a t e , through "4" - s l i g h t l y i n a c c u r a t e , t o "8" - extremely a c c u r a t e . The ARQ was ad m i n i s t e r e d t h r e e times; b e f o r e the f i r s t and a f t e r the second experimental s e s s i o n and one week a f t e r the second s e s s i o n . S e s s i o n Measures Session E v a l u a t i o n Q u e s t i o n n a i r e (SEQ) S t i l e s ' S ession E v a l u a t i o n Q u e s t i o n n a i r e (1984) c o n s i s t s of twenty-four b i p o l a r a d j e c t i v e s c a l e s p r e s e n t e d i n a seven-point semantic d i f f e r e n t i a l format and i s designed to measure s e s s i o n impact. The s u b j e c t s were asked t o p l a c e an "X" on the l i n e f o r each of twelve a d j e c t i v e p a i r s responding t o the phrase "This s e s s i o n was " and f o r each of twelve d i f f e r e n t a d j e c t i v e p a i r s responding to the phrase "Right now I f e e l ". The SEQ y i e l d s r e s u l t s a long two dimensions of p a r t i c i p a n t s ' p e r c e p t i o n s of therapy s e s s i o n s ; Smoothness and Depth: and along two dimensions of p o s t - s e s s i o n mood; P o s i t i v i t y and A r o u s a l . S t i l e s and Snow (1984b) r e p o r t e d i n t e r - c o r r e l a t i o n s f o r c l i e n t l e v e l comparisons with t h e r a p i s t v a r i a n c e removed as f o l l o w s : Depth (.84 to .89); Smoothness (.79 to .91); P o s i t i v i t y (.76 to .92); and A r o u s a l (.61 to .84) and i n t e r - c o r r e l a t i o n s across s e s s i o n s with the e f f e c t s of t h e r a p i s t - c l i e n t p a i r s removed as f o l l o w s : Depth (.74 to 61 .82); Smoothness (.77 to .87); P o s i t i v i t y (.76 to .85); and A r o u s a l (.54 to .79). S t i l e s and Snow (1984a) estimated t h a t t h r e e t o s i x s e s s i o n s would be needed t o a t t a i n a t e s t -r e t e s t r e l i a b i l i t y of (.80) to o b t a i n a r e l i a b l e d i f f e r e n t i a t i o n among dyads on each index. The SEQ was a d m i n i s t e r e d a f t e r each experimental s e s s i o n t o both the s u b j e c t s and the t h e r a p i s t s independently. Target Complaints Discomfort Box Scale (TCDBS) The s u b j e c t s used the Target Complaints Discomfort Box Sca l e t o r a t e the amount of di s c o m f o r t a s s o c i a t e d with the p r e s e n t i n g t a r g e t complaint as i d e n t i f i e d by the Target Complaint Measure d e s c r i b e d above. B a t t l e et a l (1966) d e v i s e d the TCDBS as a v e r t i c a l column d i v i d e d i n t o t h i r t e e n boxes. The words "not at a l l " are p r i n t e d b e s i d e the bottom box; "a l i t t l e " by the f o u r t h box from the bottom; " p r e t t y much" by the seventh box; and "couldn't be worse" by the top or t h i r t e e n t h box. In a r e l i a b i l i t y study B a t t l e et a l (1966) found the c o r r e l a t i o n between the p r e - s e s s i o n ranks f o r the o r i g i n a l p r i o r complaints was (.68). The s e v e r i t y r a t i n g s of the t a r g e t complaints d i d not change t o a s i g n i f i c a n t degree l e a d i n g the authors to conclude that the TCDBS produced r e l i a b l e r e s u l t s . The instrument was used t o r a t e the s u b j e c t s ' discomfort r e g a r d i n g the t a r g e t complaint b e f o r e and a f t e r each experimental s e s s i o n f o r a t o t a l of four r a t i n g s . T h e r a p i s t Q u e s t i o n n a i r e (TQ) The TQ was a d m i n i s t e r e d a f t e r each s e s s i o n to determine the t h e r a p i s t ' s p e r c e p t i o n of the i n t e r v e n t i o n performed and to assess the t h e r a p i s t ' s view of the r e s o l u t i o n a c h ieved by the s u b j e c t . D e s c r i p t i o n of Treatments G e s t a l t Empty-Chair Dialogue The G e s t a l t empty-chair d i a l o g u e i s an a c t i v e technique designed t o access unexpressed emotions and f a c i l i t a t e t h e i r f u l l e x p r e s s i o n and i n t e g r a t i o n i n t o the i n d i v i d u a l ' s emotional schema. Three processes seem to be i n v o l v e d i n t h i s work: a r o u s a l ; e x p r e s s i o n ; and recovery and completion (Greenberg, 1986a). In the a r o u s a l stage the c l i e n t i s asked t o imagine the s i g n i f i c a n t other person i n the empty c h a i r and to make c o n t a c t . T h i s w i l l i n v o l v e the c l i e n t ' s p r e f e r r e d sense modality - perhaps v i s u a l i z i n g t h i s person or imagining h e a r i n g the person's v o i c e . The focus i s on i n t e n s i f y i n g the image so that emotional a r o u s a l i s experienced by the c l i e n t . The c e n t r a l p a r t of the process i s e x p r e s s i o n . Once the c l i e n t has imagined the other person i n the empty c h a i r the c l i e n t i s then asked what he/she i s e x p e r i e n c i n g . I n i t i a l l y t h i s experience may be expressed as a complaint which i s viewed as c o n f l u e n t anger and hurt which must be separated and allowed independent e x p r e s s i o n . This e x p r e s s i o n i s i n t e n s i f i e d through the use of a v a r i e t y of techniques i n c l u d i n g r e p e t i t i o n of phrases or a c t i o n s ; f e e d i n g sentences; h i g h l i g h t i n g non-verbal a c t i v i t y ; and th use of r e v e r s a l s , such as s u p p o r t i n g a c l i e n t ' s r e s i s t a n c e t o c r y i n g by having them say "I don't want to c r y " . The m a j o r i t y of the time i s spent i n the s e l f c h a i r with the empty-chair s e r v i n g as a stimulus object t o i n t e n s i f y the experience of the c l i e n t . The i n t e n t i s not to develop a d i a l o g u e which would decrease the a f f e c t i v e e x p r e s s i o n . The process i n v o l v e d seems t o i n v o l v e a r e g r e s s i o n of the c l i e n t back t o c h i l d h o o d when the o r i g i n a l b l o c k i n g of emotional e x p r e s s i o n f i r s t o c c u r r e d . I t i s important t o all o w the resentments about what was not a v a i l a b l e to be c l e a r l y s t a t e d . F o l l o w i n g the statement of resentments i t i s c r u c i a l t o express the demand f o r what was r e a l l y needed With t h i s demand and e x p r e s s i o n of need the g r i e v i n g c y c l e can be i n i t i a t e d and the sadness at the l o s s can be expressed. There are two components to the l o s s : what was needed as a c h i l d and not r e c e i v e d ; and what i s l o s t by g i v i n g up the resentments. 64 E x p r e s s i o n i s c l o s e to completion when t h e r e i s a l e t t i n g go from the c l i e n t . T h i s u s u a l l y i n v o l v e s a r e c o g n i t i o n that what was d e s i r e d w i l l not take p l a c e accompanied by a l e t t i n g go of the e x p e c t a t i o n of having t h i s need f u l f i l l e d . There i s a sense of no longer t r y i n g t o make i t d i f f e r e n t . Completion may take a number of forms: f o r g i v e n e s s - a s i g n a l of s o f t e n i n g and a s i g n that the c l i e n t has completed the u n f i n i s h e d b u s i n e s s ; an a c t i o n tendency may emerge - a d e c i s i o n may be made to t a l k t o the s i g n i f i c a n t other; a temporary goodbye - the c l i e n t may not yet f e e l f i n i s h e d or the c l i e n t may not want t o l e t go of an emerging p o s i t i v e f e e l i n g towards the s i g n i f i c a n t other; or an impasse may emerge - t h i s may i n v o l v e r e s i g n a t i o n that the s i t u a t i o n hasn't changed or may i n v o l v e a statement that f o r g i v e n e s s i s i m p o s s i b l e . R e s o l u t i o n i n v o l v e s a sense of c l o s u r e , of s a y i n g what had not been p r e v i o u s l y expressed by both the c l i e n t and the s i g n i f i c a n t other. T h i s o f t e n i n v o l v e s a statement of needs f o l l o w e d by a statement of c a r i n g . A f i n a l step i n completing u n f i n i s h e d business work i n v o l v e s c r e a t i n g a meaning b r i d g e by l i n k i n g the work t o the c l i e n t ' s • c u r r e n t l i f e e xperience. 65 Empathic R e f l e c t i o n Carkhuff (1969) developed e i g h t t r a i n i n g g u i d e l i n e s f o r the communication of empathy. These are designed to communicate t o the c l i e n t a depth of understanding of h i s / h e r d i f f i c u l t i e s so that the c l i e n t may c l a r i f y s e l f -understanding and the understanding of o t h e r s . Carkhuff (1969) s t a t e s that the h e l p e r w i l l f i n d most e f f e c t i v e n e s s i n communicating empathic understanding when 1. c o n c e n t r a t i n g i n t e n s e l y upon the helpee's e x p r e s s i o n s , both v e r b a l and nonverbal, 2. c o n c e n t r a t i n g upon responses that are in t e r c h a n g e a b l e with those of the helpee, 3. f o r m u l a t i n g responses i n language that i s most attuned t o the helpee, 4. responding i n a f e e l i n g tone s i m i l a r t o that communicated by the helpee, 5. communicating empathic understanding when he (the helpee) i s most r e s p o n s i v e , 6. moving t e n t a t i v e l y toward expanding and c l a r i f y i n g the helpee's experiences at higher l e v e l s , 7. c o n c e n t r a t i n g upon what i s not b e i n g expressed by the helpee, 8. employing the helpee's behavior as the best g u i d e l i n e t o assess the e f f e c t i v e n e s s of h i s (the h e l p e r ' s ) responses. (p. 202-204) Procedure Before the f i r s t s e s s i o n s u b j e c t s were asked t o complete the a b b r e v i a t e d form of the 16-PF, and the A f f e c t i v e Reactions Q u e s t i o n n a i r e (ARQ) and they were asked to i d e n t i f y t h e i r core complaint u s i n g the Target Complaint (TC) Measure. F o l l o w i n g a short break the s u b j e c t s p a r t i c i p a t e d i n an i n d i v i d u a l i n d u c t i o n s e s s i o n . They were b r i e f e d on the form of therapy they were to r e c e i v e and a r a t i o n a l e was pres e n t e d f o r i t s use i n the r e s o l u t i o n of u n f i n i s h e d b u s i n e s s . The s u b j e c t s then completed Q u e s t i o n n a i r e A b e f o r e b e g i n n i n g t h e i r f i r s t c o u n s e l l i n g s e s s i o n . F o l l o w i n g the s e s s i o n the s u b j e c t s completed the Session E v a l u a t i o n Q u e s t i o n n a i r e (SEQ) and Q u e s t i o n n a i r e B. A week l a t e r the s u b j e c t s r e t u r n e d f o r t h e i r second s e s s i o n . Before t h i s s e s s i o n s u b j e c t s completed Q u e s t i o n n a i r e C. A f t e r the s e s s i o n the s u b j e c t s completed the SEQ, Q u e s t i o n n a i r e B, the Task dimension of the Working A l l i a n c e Inventory and the Empathy s c a l e of the B a r r e t t -Lennard R e l a t i o n s h i p Inventory. The s u b j e c t s then completei the ARQ and the TC Measure. The s u b j e c t s took home a packet c o n t a i n i n g the ARQ and the TC Measure to be completed one week f o l l o w i n g the second s e s s i o n and to be r e t u r n e d i n an enclosed addressed 67 FIGURE 2 ORDER OF ADMINISTRATION OF MEASURING INSTRUMENTS I I 1 ! 1 week ! ! R l 1 week TI . s i : EI : s i s i : E2 :SI . R2 TI T2 : :s2 : :s2 TI T2 ~~~ T2 II 16-PF; F a c t o r C a A d F a « t w TI Target Complaint Measure (TO T2 A f f e c t i v e Reactions Q u e s t i o n n a i r e (ARQ) 51 Target Complaint Discomfort Box Scale (TCDBS) 52 Session E v a l u a t i o n Q u e s t i o n n a i r e (SEQ) R l B a r r e t t - L e n n a r d R e l a t i o n s h i p Inventory (RI) - Empathy Scale R2 Working A l l i a n c e Inventory (WAI) - Task Dimension E l E2 F i r s t Experimental Session Second Experimental Session 68 stamped envelope. F i g u r e 2 shows a summary of the measures adm i n i s t e r e d . Follow-up phone c a l l s were made to the s u b j e c t s on the day the take-home measures were t o be completed. Two su b j e c t s f a i l e d t o r e t u r n the forms. T h e i r data were t r e a t e d as i f t h e i r follow-up responses were i d e n t i c a l t o those made f o l l o w i n g the second s e s s i o n . P r i o r t o a d m i n i s t e r i n g any of the measures signed p e r m i s s i o n was obtained from each su b j e c t t o audiotape and vide o t a p e the s e s s i o n s . A l l c o u n s e l l i n g s e s s i o n s were audiotaped and vid e o t a p e d with the exception of one subj e c t who w i t h h e l d p e r m i s s i o n to vid e o t a p e the s e s s i o n s . In the case of t h i s s u b j e c t the audiotapes were used by the r a t e r s to determine i f the t h e r a p e u t i c i n t e r v e n t i o n had occurred. F o l l o w i n g each s e s s i o n the t h e r a p i s t s completed the T h e r a p i s t Q u e s t i o n n a i r e and the SEQ. Scoring S c o r i n g o c c u r r e d i n two stages. A check was f i r s t made u s i n g the Empathy s c a l e of the R e l a t i o n s h i p Inventory t o ensure t h a t a l l c l i e n t s p e r c e i v e d t h e i r t h e r a p i s t as mini m a l l y empathic. The r a t e r s then r a t e d the tapes t o ensure that the t h e r a p i s t s were c o r r e c t l y c o n ducting both t h e r a p e u t i c operations as d e s c r i b e d above. 69 Design and A n a l y s i s The design employed i n t h i s study was a m o d i f i c a t i o n of the P r e t e s t - P o s t t e s t - C o n t r o l Group Design (Borg and G a l l , 1982) employing two d i f f e r e n t experimental treatments r a t h e r than an experimental and a c o n t r o l group. A counterbalanced design was used i n which a l l t h e r a p i s t s used both treatment techniques and the order of a d m i n i s t e r i n g was v a r i e d so that h a l f the t h e r a p i s t s began with empathic r e f l e c t i o n and h a l f began with empathy p l u s the G e s t a l t empty-chair technique. This design was used to e l i m i n a t e the p o t e n t i a l confounding e f f e c t s between the t h e r a p i s t s c h a r a c t e r i s t i c s and treatment d i f f e r e n c e s . The major a n a l y s i s used t o measure treatment e f f e c t was a m u l t i v a r i a t e a n a l y s i s of v a r i a n c e with repeated measures on the A f f e c t i v e Reactions Q u e s t i o n n a i r e . An a n a l y s i s of v a r i a n c e with repeated measures was used to analyze the Target Complaint Measure which measured s e l f - r e p o r t e d change as a r e s u l t of treatment. The s e s s i o n data were was analyzed u s i n g an a n a l y s i s of v a r i a n c e with repeated measures on the Target Complaint Discomfort Box Scale which measured s e s s i o n change and a m u l t i v a r i a t e a n a l y s i s of v a r i a n c e with repeated measures was used to analyze the Session E v a l u a t i o n Q u e s t i o n n a i r e which measured s e s s i o n e f f e c t and p o s t - s e s s i o n mood. 70 The Working A l l i a n c e Inventory and the B a r r e t t - L e n n a r d R e l a t i o n s h i p Inventory were analyzed u s i n g a t - t e s t t o assess the s u b j e c t - t h e r a p i s t r e l a t i o n s h i p and to c o n t r o l f o r the e f f e c t of non-engagement on the treatment outcome. Chapter IV 71 RESULTS This chapter presents the r e s u l t s of the s t a t i s t i c a l a nalyses performed on the treatment and s e s s i o n outcome measures. The r e s u l t s of a n a l y s i s of v a r i a n c e with repeated measures were used to determine the d i f f e r e n t i a l e f f e c t s of empathic r e f l e c t i o n and empathy p l u s the G e s t a l t empty-chair d i a l o g u e on one outcome measure - the Target Complaint Measure ( B a t t l e et a l , 1966) and one s e s s i o n measure - the Target Complaint Discomfort Box Scale ( B a t t l e et a l , 1966). A m u l t i v a r i a t e a n a l y s i s of v a r i a n c e with repeated measures was performed on the second outcome measure - the A f f e c t i v e R eactions Q u e s t i o n n a i r e (Wiggins, 1984) and the second s e s s i o n measure - the Session E v a l u a t i o n Q u e s t i o n n a i r e ( S t i l e s , 1984). T - t e s t s were used t o analyze the r e l a t i o n s h i p instruments; the Empathy s c a l e of the B a r r e t t -Lennard R e l a t i o n s h i p Inventory ( B a r r e t t - L e n n a r d , 1964) and the Task dimension of the Working A l l i a n c e Inventory (Horvath, 1982). 72 Subject D e s c r i p t i o n Instruments The S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e A t - t e s t was used to determine i f t h e r e was a d i f f e r e n c e between the two groups on F a c t o r C, the measure of ego s t r e n g t h . A t - v a l u e of 1.07 was found which i n d i c a t e d t h a t no s i g n i f i c a n t d i f f e r e n c e (p_=.295) e x i s t e d between the two c o n d i t i o n s at the cX=.05 co n f i d e n c e l e v e l . Both groups score d sten 4 or above on F a c t o r C with the means f o r each group f a l l i n g w i t h i n the 'average' range as d e f i n e d by C a t t e l l , Eber, and Taksuoka (1970). A t - t e s t was used to determine i f t h e r e was a d i f f e r e n c e between the two groups on F a c t o r Q4, a measure of g e n e r a l f r u s t r a t i o n . A t - v a l u e of -0.32 was found which i n d i c a t e d t h at no s i g n i f i c a n t d i f f e r e n c e (p_=.750) e x i s t e d between the two c o n d i t i o n s at the cx=.05 c o n f i d e n c e l e v e l . The scores f o r both groups f e l l between sten 3 and sten 8 with the mean f o r each group f a l l i n g w i t h i n the 'average' range as d e f i n e d by C a t t e l l , Eber, and Taksuoka (1970). S u b j e c t i v e C l i e n t Information The s u b j e c t i v e measures i n d i c a t e d that a l l s u b j e c t s f e l t they were i n v o l v e d i n the t h e r a p e u t i c p r o c e s s . No s i g n i f i c a n t events oc c u r r e d f o r any of the s u b j e c t s d u r i n g the p e r i o d between the two s e s s i o n s which were c o n s i d e r e d to have had a s i g n i f i c a n t e f f e c t on the therapy. 73 R e l a t i o n s h i p Instruments B a r r e t t - L e n n a r d R e l a t i o n s h i p Inventory (RI) The s u b j e c t s ' p e r c e p t i o n of t h e i r t h e r a p i s t ' s empathy was determined a c c o r d i n g t o the empathy s c a l e of the Ba r r e t t - L e n n a r d R e l a t i o n s h i p Inventory. In order t o be p e r c e i v e d as mi n i m a l l y f a c i l i t a t i v e , t h e r a p i s t s had to obt a i n a minimum score of 16 on the s c a l e , out of a p o s s i b l e maximum of 48. Four s u b j e c t s , two from the G e s t a l t c o n d i t i o n and two from the empathic c o n d i t i o n , r a t e d t h e i r t h e r a p i s t s lower than 16 on the empathy s c a l e of the RI. These s u b j e c t s were removed from the study because they d i d not p e r c e i v e t h e i r t h e r a p i s t s as b e i n g m i n i m a l l y empathic. As a r e s u l t 24 s u b j e c t s were c o n s i d e r e d to have p a r t i c i p a t e d i n the study, 12 i n the G e s t a l t c o n d i t i o n and 12 i n the empathic c o n d i t i o n . The mean score f o r the t h e r a p i s t s remaining i n the study was 34.26, with a standard d e v i a t i o n of 7.66. A t - t e s t was used t o determine i f th e r e was a d i f f e r e n c e between the two groups i n p e r c e i v e d empathy of the t h e r a p i s t s . A t - v a l u e of 1.23 was found which i n d i c a t e d t h a t no s i g n i f i c a n t d i f f e r e n c e (p_=.231) e x i s t e d between the two c o n d i t i o n s at the CX=.fJ5 c o n f i d e n c e l e v e l . The means and standard d e v i a t i o n s of the two groups may be found i n Table 1 and i n d i c a t e that the mean f o r the empathy p l u s G e s t a l t group (32.18) was lower t h a t that f o r the empathic r e f l e c t i o n group (36.17). 74 TABLE 1 MEANS AND STANDARD DEVIATIONS OF BARRETT-LENNARD RELATIONSHIP INVENTORY EMPATHY DIMENSION SCORES * TREATMENT GROUP MEAN STANDARD DEVIATION Empathy p l u s G e s t a l t 32.1818 7.653 Empty-Chair Dialogue Empathic R e f l e c t i o n 36.1667 7.826 * Administered a f t e r the second s e s s i o n TABLE 2 MEANS AND STANDARD DEVIATIONS OF THE WORKING ALLIANCE INVENTORY TASK DIMENSION SCORES * TREATMENT GROUP MEAN STANDARD DEVIATION Empathy p l u s G e s t a l t 49.4167 3.343 Empty-Chair Dialogue Empathic R e f l e c t i o n ; 47.4167 4.274 * Ad m i n i s t e r e d a f t e r the second s e s s i o n . 75 Working A l l i a n c e Inventory (WAI) A t - t e s t was used to analyze the Task dimension of the WAI to determine i f t h e r e was a d i f f e r e n c e i n the s u b j e c t s ' p e r c e p t i o n of t h e i r t h e r p i s t s ' a b i l i t y t o stay on t a s k . A t - v a l u e of -1.28 was found which was not s i g n i f i c a n t (E=.22) at the CX=.05 co n f i d e n c e l e v e l . The means and standard d e v i a t i o n s f o r the two groups may be found i n Table 2 and i n d i c a t e t h a t the mean (49.42) f o r the empathy p l u s G e s t a l t group was s l i g h t l y h igher than the mean (47.42) f o r the empathic r e f l e c t i o n group. Outcome Measures Target Complaint Measure (TC) An a n a l y s i s of v a r i a n c e with repeated measures was performed on the TC Measure because t h i s instrument was a d m i n i s t e r e d twice - immediately f o l l o w i n g the completion of the second experimental s e s s i o n (Score 1) and again one-week l a t e r (Score 2) . A n a l y s i s of v a r i a n c e of these r e s u l t s (Table 3) r e v e a l e d t h a t t h e r e was no s i g n i f i c a n t d i f f e r e n c e at the Ot =.05 c o n f i d e n c e l e v e l although there was s i g n i f i c a n c e at the CX=,10 c o n f i d e n c e l e v e l between the two groups when the e f f e c t of time and therapy were combined (p_=. 067). Those r e c e i v i n g the empathy p l u s G e s t a l t c o n d i t i o n showed more 76 TABLE 3 ANALYSIS OF VARIANCE WITH REPEATED MEASURES OF TARGET COMPLAINT MEASURE SCORES SOURCE SUM OF DEGREES MEAN F PROBABILITY SQUARES OF SQUARES RATIO FREEDOM Between 1.333 1 Therapies S-within 46.583 22 t h e r a p i es Between 0.750 1 Time S - i n t e r a c t i n g 7.917 22 with time Therapies 1.333 1 X Time 1.333 0.630 0.4.36 2 .117 0.750 2.084 0.163 0.360 1.333 3.705 0.067 TABLE 4 TARGET COMPLAINT MEASURE SCORES TIME MEANS GESTALT EMPATHY STANDARD DEVIATIONS GESTALT EMPATHY Post-Session 2 3.667 3.667 0.985 0.985 Follow-up 3.750 3.083 0.662 1 .621 77 change at follow-up on t h e i r p r e s e n t i n g t a r g e t complaint at the OC=.10 l e v e l than those r e c e i v i n g empathic r e f l e c t i o n . The means (Table 4) f o r Score 1 were the same (3.67) f o r both the empathy p l u s G e s t a l t empty-chair c o n d i t i o n and f o r the empathic r e f l e c t i o n group. This v a l u e r e s t s between "A l i t t l e b e t t e r " and "Somewhat b e t t e r " . The means f o r Score 2 d i f f e r e d with the emapthy p l u s G e s t a l t empty-chair group i n c r e a s i n g the amount of p e r c e i v e d change s l i g h t l y t o a mean of 3.75 and the empathic r e f l e c t i o n group d e c r e a s i n g the amount of f e l t change t o a mean of 3.08. A f f e c t i v e Reactions Q u e s t i o n n a i r e (ARQ) A m u l t i v a r i a t e a n a l y s i s of v a r i a n c e was performed on the A f f e c t i v e Reactions Q u e s t i o n n a i r e to take i n t o account the four combined dimensions of t h i s measure as w e l l as a c c o u n t i n g f o r i t b e i n g a d m i n i s t e r e d on t h r e e o c c a s i o n s : Time 1 - b e f o r e treatment; Time 2 - a f t e r treatment; Time 3 - one week a f t e r t e r m i n a t i o n . The A f f e c t i v e Reactions Q u e s t i o n n a i r e y i e l d s e i g h t s c a l e s measuring i n t e r p e r s o n a l f e e l i n g s toward a s i g n i f i c a n t other on the f o l l o w i n g dimensions: PA - C o n f i d e n t ; BC -S u p e r i o r ; DE - I n t o l e r a n t ; FG - Discouraged; HI -Insecure; JK - Humble; LM - Receptive; NO - E n t h u s i a s t i c . 78 The PA and HI dimensions were combined to form the Confident dimension: the BC and JK dimensions were combined to form the S u p e r i o r dimension: the DE and LM dimensions were combined to form the I n t o l e r a n t dimension: and the FG and NO dimensions were combined to form the Discouraged dimension. An item a n a l y s i s (Table 5) was conducted on the combined dimensions which y i e l d e d the f o l l o w i n g r e s u l t s . The i n t e r - i t e m i n t e r n a l c o n s i s t e n c y r e l i a b i l i t y c o e f f i c i e n t s were as f o l l o w s : scores f o r the Confident dimension averaged 0.73; scores f o r the Superior dimension averaged 0.59 with a low of 0.43 at post-therapy a d m i n i s t r a t i o n ; scores f o r the I n t o l e r a n t dimension averaged 0.82; and scores f o r the Discouraged dimension averaged 0.87. These r e s u l t s i n d i c a t e d t h a t the C o n f i d e n t , I n t o l e r a n t and Discouraged dimensions measure d i s c r e t e v a r i a b l e s . However the S u p e r i o r dimension does not d i s p l a y r e l i a b i l i t y over time and i t does not appear to measure a d i s c r e t e v a r i a b l e . It appears that the data generated i n t h i s study don't adequately measure the Superior dimension and i t was t h e r e f o r e e l i m i n a t e d from the m u l t i v a r i a t e a n a l y s i s of v a r i a n c e . The subtest i n t e r c o r r e l a t i o n s (Tables 6 and 7) are a l l low except f o r the c o r r e l a t i o n of .77 between I n t o l e r a n t and Discouraged on the pre-therapy a d m i n i s t r a t i o n ; a 79 c o r r e l a t i o n of .67 on post-therapy a d m i n i s t r a t i o n ; and a c o r r e l a t i o n of .61 between the same dimensions at follow-up. The r e s u l t s of the m u l t i v a r i a t e a n a l y s i s of v a r i a n c e are d i s p l a y e d i n Table 8 which summarizes the r e s u l t s of the H o t e l l i n g s m u l t i v a r i a t e a n a l y s i s of v a r i a n c e . Only the terms t e s t e d f o r s i g n i f i c a n c e are d i s p l a y e d . A s i g n i f i c a n t d i f f e r e n c e (p_=.045) was found at the cX = .05 c o n f i d e n c e l e v e l between the two groups when the e f f e c t of time and therapy were combined. The u n i v a r i a t e r e s u l t s (Table 9) show that t h e r e was a s i g n i f i c a n t d i f f e r e n c e at the £* = .05 c o n f i d e n c e l e v e l on the I n t o l e r a n t dimension (p_=.042) . An examination of the means of the I n t o l e r a n t dimension (Table 11) i n d i c a t e s t h at the empathy p l u s G e s t a l t group decreased t h e i r l e v e l of i n t o l e r a n c e from 40.25 at pre-therapy to 35.92 at follow-up and the empathic r e f l e c t i o n group i n c r e a s e d from 38.42 at pre-therapy to a high of 41.67 at post-therapy back t o 38.00 at follow-up. The u n i v a r i a t e r e s u l t s (Table 9) a l s o i n d i c a t e a s i g n i f i c a n t d i f f e r e n c e at the CX=. io c o n f i d e n c e l e v e l on the Confident dimension (pj=.064) . The means f o r the Confident dimension (Table 10) i n d i c a t e t h a t the empathy p l u s G e s t a l t group i n c r e a s e d t h e i r l e v e l of c o n f i d e n c e from 34.75 at pre-therapy to 40.08 at follow-up w h i l e the empathic r e f l e c t i o n group decreased from 38.25 at pre-therapy to a low of 35.83 at post-therapy to 37.33 at follow-up. The means f o r the Discouraged dimension are r e p o r t e d i n Table 12 and i n d i c a t e no TABLE 5 ITEM ANALYSIS FOR AFFECTIVE REACTIONS QUESTIONNAIRE * OCCASION PRE- POST- FOLLOW-UP DIMENSION TREATMENT TREATMENT MEANS Confident 0.51 0.81 0.88 0.73 Superior 0.60 0.43 0.74 0.59 I n t o l e r a n t 0.68 0.91 0.86 0.82 Discouraged 0.82 0.89 0.91 0.87 T o t a l s 0.75 0.80 0.87 * i n t e r n a l c o n s i s t e n c y r e l i a b i l i t y c o e f f i c i e n t s TABLE 6 SUBTEST INTERCORRELATIONS FOR AFFECTIVE REACTIONS QUESTIONNAIRE * Con Sup Int Dis Confident 0 .157 -0. 067 0. 006 Sup e r i o r 0 .286 -0. 029 -0. 02 8 I n t o l e r a n t -0 .370 0 .180 0. 774 Discouraged -0 .399 0 .195 0. 671 * E n t r i e s above d i a g o n a l are f o r pre-therapy a d m i n i s t r a t i Those below are f o r post-therapy a d m i n i s t r a t i o n . TABLE 7 SUBTEST INTERCORRELATIONS FOR AFFECTIVE REACTIONS QUESTIONNAIRE - FOLLOW-UP Con Sup Int Dis Confident 1 0.525 0.095 -0.222 Superi or 0.259 0.016 I n t o l e r a n t 0.614 Discouraged TABLE 8 MULTIVARIATE ANALYSIS OF VARIANCE * AFFECTIVE REACTIONS QUESTIONNAIRE SOURCE DEGREES OF F PROBABILITY FREEDOM RATIO Between Subjects Therapies 1, 22 0.173 0.914 Within Subjects Time 2, 22 0.962 0.456 Therapies X Time 2, 22 2 .264 0.045 * H o t e l l i n g s m u l t i v a r i a t e a n a l y s i s of v a r i a n c e TABLE 9 UNIVARIATE RESULTS: THERAPY INTERACTING WITH TIME AFFECTIVE REACTIONS QUESTIONNAIRE VARIABLE F RATIO PROBABILITY Confident 2.92082 0.064 I n t o l e r a n t 3.39897 0.042 Discouraged 2.10284 0.134 TABLE 10 MEANS - CONFIDENT DIMENSION  AFFECTIVE REACTIONS QUESTIONNAIRE OCCASION PRE POST FOLLOW-UP TREATMENT MEANS G e s t a l t 34.750 37.583 40.083 37.472 Empathy 38.250 35.833 37.333 37.139 Occasion Means 36.500 36.708 38.708 37.305 83 G e s t a l t Empathy Occasion Means TABLE 11 MEANS - INTOLERANT DIMENSION AFFECTIVE REACTIONS QUESTIONNAIRE OCCASION PRE POST FOLLOW-UP TREATMENT MEANS 40.250 35.917 35.917 37.361 38.417 41.667 38.000 39.361 39.334 38.792 36.956 38.361 TABLE 12 MEANS - DISCOURAGED DIMENSION AFFECTIVE REACTIONSQUESTIONNAIRE OCCASION G e s t a l t Empathy Occasion Means PRE POST FOLLOW-UP TREATMENT MEANS 44.833 41 .417 40.417 42 .222 42.333 42.667 45.167 43.389 43.583 42.042 42.792 42.806 84 s i g n i f i c a n t d i f f e r e n c e s between the two groups at the CX=.05 c o n f i d e n c e l e v e l . The empathy p l u s G e s t a l t group s i g n i f i c a n t l y decreased t h e i r f e e l i n g s of i n t o l e r a n c e and i n c r e a s e d t h e i r f e e l i n g s of co n f i d e n c e i n r e l a t i o n t o the s i g n i f i c a n t other as compared to the empathic r e f l e c t i o n group which showed l i t t l e change over the course of treatment i n t h e i r f e e l i n g s of i n t o l e r a n c e and t h e i r f e e l i n g s of c o n f i d e n c e towards the s i g n i f i c a n t other. Session Measures Target Complaint Discomfort Box Scale (TCDBS) An a n a l y s i s of v a r i a n c e with repeated measures was performed on the TCDBS because t h i s instrument was ad m i n i s t e r e d on fo u r o c c a s i o n s : Time 1 - b e f o r e the f i r s t experimental s e s s i o n ; Time 2 - a f t e r the f i r s t s e s s i o n ; Time 3 - b e f o r e the second experimental s e s s i o n ; Time 4 -a f t e r the second s e s s i o n . A n a l y s i s of v a r i a n c e of these r e s u l t s (Table 13) r e v e a l t h a t t h e r e was no s i g n i f i c a n t d i f f e r e n c e between the two groups at the c,t=.05 con f i d e n c e l e v e l due to therapy alone (p_=. 607) or the when the e f f e c t of therapy and time were combined (p_=.211) . A s i g n i f i c a n t d i f f e r e n c e (p_=.001) was found between the four measurement o c c a s i o n s . TABLE 13 ANALYSIS OF VARIANCE WITH REPEATED MEASURES OF TARGET COMPLAINT DISCOMFORT BOX SCALE SCORES SOURCE SUM OF DEGREES MEAN F PROBABILITY SQUARES OF SQUARES RATIO FREEDOM Between 3.762 1 3.762 0.273 0.607 Therapies S-within 303.148 22 13.779 t h e r a p i e s Between 133.617 3 44.539 11.888 0.001 Time S - i n t e r a c t i n g 247.270 66 3.747 with time Therapies 17.361 3 5.787 1.545 0.211 X Time TABLE 14 MEANS AND STANDARD DEVIATIONS OF TARGET COMPLAINT DISCOMFORT BOX SCALE ANALYSIS MEANS STANDARD DEVIATIONS TIME GESTALT EMPATHY COMBINED GESTALT EMPATHY 1 8.667 7.583 8.125 2.188 2.539 2 7.833 6.500 7.167 2.209 3.119 3 5.750 6.500 6.125 2.379 3.261 4 4.917 5.000 4.959 1.505 2.374 Occas i on Means 6.292 6.792 6.594 The means and standard d e v i a t i o n s of the TCDBS may be found i n Table 14. The means r e v e a l that both groups experienced a decrease i n the dis c o m f o r t caused by t h e i r t a r g e t complaint. The mean f o r the G e s t a l t empty-chair c o n d i t i o n dropped a t o t a l of 3.75 from 8.67 to 4.92 over the four o c c a s i o n s . The mean f o r the empathic r e f l e c t i o n c o n d i t i o n dropped a t o t a l of 2.58 from 7.58 to 5.00. Session E v a l u a t i o n Q u e s t i o n n a i r e (SEQ) An m u l t i v a r i a t e a n a l y s i s of v a r i a n c e was performed on the SEQ to account f o r the four dimensions of the instrumen which was ad m i n i s t e r e d on two o c c a s i o n s : a f t e r each experimental s e s s i o n . T h i s instrument was giv e n t o both t h su b j e c t s and the t h e r a p i s t s at each o c c a s i o n . The SEQ examines two dimensions of p a r t i c i p a n t s ' p e r c e p t i o n s of therapy s e s s i o n s : Smoothness and Depth; and two dimensions of p o s t - s e s s i o n mood: P o s i t i v i t y and A r o u s a l The s u b j e c t data w i l l be pres e n t e d f i r s t . An item a n a l y s i s (Table 15) was conducted which y i e l d e d i n t e r - i t e m i n t e r n a l c o n s i s t e n c y r e l i a b i l i t y c o e f f i c i e n t s r a n g i n g from 0.49 t o 0.82 f o r the four dimensions over the two s e s s i o n s . T o t a l r e l i a b i l i t y c o e f f i c i e n t f o r Session 1 was 0.81 and f o r Session 2 was 0.83. The subtest i n t e r c o r r e l a t i o n s (Table 16) were a l l below 0.60. These r e s u l t s suggest that the dimensions measure d i s c r e t e v a r i a b l e s and warrant the use o a m u l t i v a r i a t e a n a l y s i s of v a r i a n c e . 87 The r e s u l t s of the m u l t i v a r i a t e a n a l y s i s of v a r i a n c e are r e p o r t e d i n Table 17 which d i s p l a y s the H o t e l l i n g s m u l t i v a r i a t e a n a l y s i s of v a r i a n c e r e s u l t s . Only the items t e s t e d f o r s i g n i f i c a n c e are d i s p l a y e d . No s i g n i f i c a n t d i f f e r e n c e s were found between the two groups on any v a r i a b l e at the o t=.05 co n f i d e n c e l e v e l . The means f o r the Smoothness dimension are r e p o r t e d i n Table 19; f o r the Depth dimension i n Table 20; f o r the P o s i t i v i t y dimension i n Table 21; and f o r the A r o u s a l dimension i n Table 22. An item a n a l y s i s was a l s o conducted f o r the t h e r a p i s t r e s u l t s and the i n t e r - i t e m i n t e r n a l c o n s i s t e n c y r e l i a b i l i t y c o e f f i c i e n t s are r e p o r t e d i n Table 23. The i n t e r - i t e m r e l i a b i l i t y c o e f f i c i e n t s ranged from 0.61 to 0.92 f o r the four dimensions over the two s e s s i o n s . The t o t a l f o r S e s s i o n 1 was 0.86 and f o r Session 2 was 0.85. Subtest i n t e r c o r r e l a t i o n s (Table 24) show that a l l v a l u e s were below 0.60. The suggests that each s c a l e measures d i s c r e t e v a r i a b l e s and that the use of a m u l t i v a r i a t e a n a l y s i s of v a r i a n c e i s warranted. The m u l t i v a r i a t e a n a l y s i s of v a r i a n c e i s r e p o r t e d i n Table 25 which d i s p l a y s the H o t e l l i n g s m u l t i v a r i a t e a n a l y s i s of v a r i a n c e r e s u l t s . Only the items t e s t e d f o r s i g n i f i c a n c e are d i s p l a y e d . A s i g n i f i c a n t d i f f e r e n c e was found between the two groups at the c< =.05 c o n f i d e n c e l e v e l on the e f f e c t of therapy (p_=.044) . The u n i v a r i a t e r e s u l t s (Table 26) 88 i n d i c a t e t h at t h e r e i s a s i g n i f i c a n t d i f f e r e n c e (£=.008) between the two groups on the Smoothness dimension with the t h e r a p i s t s r a t i n g the empathic r e f l e c t i o n s e s s i o n s as smoother than the empathy p l u s G e s t a l t s e s s i o n s . The mean f o r the emapthy p l u s G e s t a l t group f o r the two s e s s i o n s was 21.25 and the mean f o r empathic r e f l e c t i o n group f o r the two s e s s i o n s was 25.83. The means f o r the two groups may be found i n Table 27. TABLE 15 ITEM ANALYSIS OF SESSION EVALUATION QUESTIONNAIRE - SUBJECT DATA * SUBTEST Smoothness Depth P o s i t i v i t y A r o u s a l T o t a l s OCCASION SESSION 1 SESSION 2 0.65 0 79 0.82 0 78 0.61 0 71 0.49 0 67 0.81 0 83 * i n t e r n a l c o n s i s t e n c y r e l i a b i l i t y c o e f f i c i e n t s TABLE 16 SUBTEST INTERCORRELATIONS SESSION EVALUATION QUESTIONNAIRE - SUBJECT DATA * Smoothness Depth P o s i t i v i t y A r o u s a l Smoothness 0.435 0.562 0.048 Depth 0.242 0.210 0.324 P o s i t i v i t y 0.547 0.472 0.354 A r o u s a l 0.025 0.168 0.300 * E n t r i e s above the d i a g o n a l are f o r Session 1. E n t r i e s below the di a g o n a l are f o r Session 2. 90 TABLE 17 MULTIVARIATE ANALYSIS OF VARIANCE* FOR SESSION EVALUATION QUESTIONNAIRE - SUBJECT DATA SOURCE DEGREES OF F PROBABILITY FREEDOM RATIO Between Subjects Therapies 1, 22 2 , .10295 •0 .120 Wit h i n Subjects Time 1, 22 0, .71086 0 .595 Therapi es X Time 1, 22 0, .59542 0 .670 * H o t e l l i n g s m u l t i v a r i a t e a n a l y s i s of v a r i a n c e TABLE 18 UNIVARIATE RESULTS: THERAPY MAIN EFFECT SESSION EVALUATION QUESTIONNAIRE - SUBJECT DATA VARIABLE F RATIO PROBABILITY Smoothness 3.99765 0.058 Depth 2.54752 0.125 P o s i t i v i t y 0.48063 0.495 A r o u s a l 1.36710 0.255 TABLE 19 MEANS - SMOOTHNESS DIMENSION SESSION EVALUATION QUESTIONNAIRE - SUBJECT DATA OCCASION G e s t a l t Empathy Occasion Means SESSION 1 SESSION 2 TREATMENT MEANS 23.167 21 .250 22 .209 23.167 24 .500 23.834 23.167 22.875 23.021 TABLE 20 MEANS - DEPTH DIMENSION SESSION EVALUATION QUESTIONNAIRE - SUBJECT DATA OCCASION SESSION 1 SESSION 2 TREATMENT MEANS G e s t a l t 29.083 29.667 29.375 Empathy 26.250 27.417 26.834 Occasion 27.667 28.542 28.104 Means TABLE 21 MEANS - POSITIVITY DIMENSION SESSION EVALUATION QUESTIONNAIRE - SUBJECT DATA G e s t a l t Empathy Occasion Means OCCASION SESSION 1 SESSION 2 TREATMENT MEANS 21.417 21.750 22.333 21.875 23.917 22.834 21 .584 23.125 22.354 TABLE 22 MEANS - AROUSAL DIMENSION SESSION EVALUATION QUESTIONNAIRE - SUBJECT DATA G e s t a l t Empathy Occasion Means OCCASION SESSION 1 SESSION 2 TREATMENT MEANS 15 .250 15 .583 15 .417 14.500 18.250 16.375 14.875 16.917 15.896 SUBTEST TABLE 23 ITEM ANALYSIS FOR SESSION EVALUATION QUESTIONNAIRE - THERAPIST DATA * OCCASION SESSION 1 SESSION 2 Smoothnes s Depth 0.73 0.81 0.92 0.85 P o s i t i v i t y 0.61 0.77 Ar o u s a l 0.65 0.61 T o t a l s 0.86 0.85 * i n t e r n a l c o n s i s t e n c y r e l i a b i l i t y c o e f f i c i e n t s TABLE 24 SUBTEST INTERCORRELATIONS FOR SESSION EVALUATION QUESTIONNAIRE - THERAPIST DATA * Smoothness Depth P o s i t i v i t y A r o u s a l Smoothness 0.498 0.407 0.089 Depth 0.061 0.550 0 .134 P o s i t i v i t y 0.313 0.503 0.334 A r o u s a l 0.079 0.368 0.566 * E n t r i e s above the d i a g o n a l are f o r Session 1. E n t r i e s below the d i a g o n a l are f o r Session 2. 94 TABLE 25 MULTIVARIATE ANALYSIS OF VARIANCE* FOR SESSION EVALUATION QUESTIONNAIRE - THERAPIST DATA SOURCE DEGREES OF F PROBABILITY FREEDOM RATIO Between Subjects Therapies 1, 22 3, .02121 0, ,044 Wit h i n Subjects Time 1, 22 1 , .15119 0. ,363 Therapies X Time 1, 22 1 , .14872 0. ,364 * H o t e l l i n g s m u l t i v a r i a t e a n a l y s i s of v a r i a n c e TABLE 26 UNIVARIATE RESULTS: THERAPY MAIN EFFECT SESSION EVALUATION QUESTIONNAIRE - THERAPIST DATA VARIABLE F RATIO PROBABILITY Smoothness 8.39218 0.008 Depth 0.85443 0.365 P o s i t i v i t y 1.96770 0.175 Ar o u s a l 0.02466 0.877 TABLE 27 MEANS - SMOOTHNESS DIMENSION SESSION EVALUATION QUESTIONNAIRE - THERAPIST DATA OCCASION G e s t a l t Empathy Occas i on Means SESSION 1 SESSION 2 TREATMENT MEANS 20.083 22 .417 21 .250 24.750 26.917 25.833 22 .417 24.667 23.542 96 Chapter V DISCUSSION The purpose of t h i s study was to i n v e s t i g a t e the s p e c i f i c c l i e n t i s s u e of u n f i n i s h e d b u s i n e s s , and to compare the e f f e c t i v e n e s s of empathic r e f l e c t i o n and empathic r e f l e c t i o n p l u s the G e s t a l t empty-chair technique on r e s o l u t i o n . The analogue format was chosen to assess the d i f f e r e n t i a l e f f e c t s of these two treatments on the s u b j e c t ' s f e e l i n g s toward the s i g n i f i c a n t other and t h e i r p e r c e p t i o n of f e l t change towards t h e i r i n i t i a l complaint. The i n v e s t i g a t o r measured the d i f f e r e n t i a l treatment e f f e c t s u s i n g two treatment outcome measures: the Target Complaint Measure and the A f f e c t i v e Reactions Q u e s t i o n n a i r e . D i f f e r e n t i a l s e s s i o n e f f e c t s were measured u s i n g the Target Complaint Discomfort Box S c a l e and the Session E v a l u a t i o n Q u e s t i o n n a i r e . Subject's p e r c e p t i o n of t h e i r t h e r a p i s t ' s empathy was measured u s i n g the B a r r e t t - L e n n a r d R e l a t i o n s h i p Inventory, and the Working A l l i a n c e Inventory was used to measure the s u b j e c t ' s p e r c e p t i o n of the t h e r a p i s t ' s on-task behavi our. 97 I n t e r p r e t a t i o n of F i n d i n g s The r e s e a r c h supports the importance of therapy t a k i n g p l a c e w i t h i n the context of a good working r e l a t i o n s h i p and s t r e s s e s the n e c e s s i t y of an empathic r e l a t i o n s h i p to f a c i l i t a t e c l i e n t change (Carkhuff, 1969; Greenberg, 1983; Gurman, 1977; Lambert, Shapiro & B e r g i n , 1986; M i t c h e l l , Bozarth & K r a u f t , 1977; O r l i n s k y & Howard, 1978, 1986; P a t t e r s o n , 1984; Rogers, 1957; Truax & Carkhuff, 1967; Truax & M i t c h e l l , 1971; and Truax & Wargo, 1966). The empathy s c a l e of the B a r r e t t - L e n n a r d R e l a t i o n s h i p Inventory was a d m i n i s t e r e d to assess the s u b j e c t s ' p e r c e p t i o n of t h e i r t h e r a p i s t s ' empathy. The r e s u l t s i n d i c a t e d t h e r e was not a s i g n i f i c a n t d i f f e r e n c e between the two groups and t h e r e f o r e that both groups p e r c e i v e d t h e i r t h e r a p i s t s to be empathic. T h i s then e s t a b l i s h e d the environment c o n s i d e r e d necessary f o r t h e r a p e u t i c change to occur. The empathic r e f l e c t i o n group however p e r c e i v e d t h e i r t h e r a p i s t s as somewhat more empathic than d i d the G e s t a l t group. This i s not s u r p r i s i n g s i n c e the G e s t a l t group added an a c t i v e technique to the core technique of empathic r e f l e c t i o n and s i n c e G e s t a l t t h e r a p i s t s t r a d i t i o n a l l y "deemphasize the r e l a t i o n s h i p with the t h e r a p i s t i n f a v o r of d e v e l o p i n g a c l o s e r r e l a t i o n s h i p between the person and b o d i l y f e e l i n g s , and between d i f f e r e n t p a r t s of the p e r s o n a l i t y " (Greenberg, 1983, p.135). However these 98 f i n d i n g s suggest t h a t G e s t a l t t h e r a p i s t s must c o n s i d e r the importance of the t h e r a p i s t - c l i e n t r e l a t i o n s h i p and must ensure t h a t G e s t a l t techniques take p l a c e w i t h i n the context of an empathic r e l a t i o n s h i p . Another component of the t h e r a p e u t i c environment found to p o s i t i v e l y i n f l u e n c e c l i e n t change i s the q u a l i t y of the t h e r a p e u t i c bond and the working a l l i a n c e e s t a b l i s h e d between the t h e r a p i s t and c l i e n t (Horvath & Greenberg, 1986; and O r l i n s k y & Howard, 1978, 1986). The ta s k dimension of the Working A l l i a n c e Inventory was a d m i n i s t e r e d t o assess the s u b j e c t s ' p e r c e p t i o n of t h e i r t h e r a p i s t s ' a b i l i t y to stay on t a s k . Horvath and Greenberg (1986) have suggested t h a t the t a s k dimension of the Working A l l i a n c e Inventory "may be a c r i t i c a l component i n psychotherapy process across a v a r i e t y of i n t e r v e n t i o n s t r a t e g i e s " (p.553). The r e s u l t s i n d i c a t e d t h a t t h e r e was not a s i g n i f i c a n t d i f f e r e n c e between the two groups and that the s u b j e c t s p e r c e i v e d t h e i r t h e r a p i s t t o be engaging i n on-task behaviour. The t h e r a p i s t s then may be c o n s i d e r e d t o have e s t a b l i s h e d at l e a s t minimal l e v e l s of on-task behaviour c o n s i d e r e d important t o f a c i l i t a t e c l i e n t change. The mean f o r the empathy p l u s G e s t a l t group was s l i g h t l y h igher than the mean f o r the empathic r e f l e c t i o n group. T h i s i s not s u r p r i s i n g because of the emphasis that the G e s t a l t t h e r a p i s t p l a c e s on the 'experiment' and the 99 emphasis on the r o l e of the t h e r a p i s t "as a c o l l a b o r a t o r who assumes the r e s p o n s i b i l i t y of guide" and who "provides a focus and d i r e c t i o n t o the p r o c e s s " (Daldrup et a l , 1985, p.8). T h i s more a c t i v e r o l e of G e s t a l t t h e r a p i s t s may be p e r c e i v e d to be more on t a s k than the l e s s a c t i v e , s u p p o r t i v e stance of c l i e n t - c e n t e r e d t h e r a p i s t s . The importance of c l i e n t p e r c e p t i o n of on-task behaviour needs to be c o n s i d e r e d however by c l i e n t - c e n t e r e d t h e r a p i s t s who may be viewed by t h e i r c l i e n t s as moving too slowly or, of not p r o v i d i n g a focus to the treatment. Taken together the r e s u l t s of the empathy dimension of the R e l a t i o n s h i p Inventory and the t a s k dimension of the Working A l l i a n c e Inventory suggest that r e g a r d l e s s of the c o n d i t i o n a l l therapy o c c u r r e d w i t h i n the context of an empathic r e l a t i o n s h i p and t a s k - o r i e n t e d environment. Hypothes i s 1. The Target Complaint Measure was a d m i n i s t e r e d to assess the change i n the p r e s e n t i n g complaint over the course of treatment and at follow-up. The a n a l y s i s of v a r i a n c e r e s u l t s showed no s i g n i f i c a n t d i f f e r e n c e between the groups at e i t h e r o c c a s i o n . T h i s does not support r e s e a r c h Hypothesis 1 t h a t s t a t e s : 100 Empathy p l u s the G e s t a l t empty-chair d i a l o g u e , when used with an i s s u e of u n f i n i s h e d b u s i n e s s , w i l l r e s u l t i n s i g n i f i c a n t l y g r e a t e r improvement on the p r e s e n t i n g t a r g e t complaint as measured a f t e r treatment and at follow-up by the Target Complaint Measure than that produced by the use of Empathic R e f l e c t i o n . Since the r e s u l t s of the data showed no s i g n i f i c a n t d i f f e r e n c e i n the means when c o n s i d e r i n g the e f f e c t of therapy i n t e r a c t i n g with time, the n u l l hypothesis was r e t a i n e d . T h i s suggests that when working with an i s s u e of u n f i n i s h e d b u s i n e s s n e i t h e r group y i e l d e d s i g n i f i c a n t l y g r e a t e r improvement on p r e s e n t i n g complaint over the course of two treatment s e s s i o n s and one week a f t e r . However on examination of the data an important d i f f e r e n c e between the two groups i s suggested. At t e r m i n a t i o n of treatment the means were i d e n t i c a l f o r both groups. However a f t e r one week the empathy p l u s G e s t a l t group had not only continued t o f e e l improvement on t h e i r p r e s e n t i n g complaint but had i n c r e a s e d s l i g h t l y i n t h e i r p o s i t i v e f e e l i n g s . The empathic r e f l e c t i o n group on the other hand, a f t e r only one week, had decreased t h e i r f e l t change. T h i s suggests that the improvement f e l t a f t e r the se s s i o n s d i d not h o l d as s t r o n g l y with those r e c e i v i n g the empathic r e f l e c t i o n treatment while the improvement not only h e l d but a l s o i n c r e a s e d s l i g h t l y f o r those r e c e i v i n g the empathy p l u s G e s t a l t empty-chair d i a l o g u e treatment. This 101 may present important i n f o r m a t i o n f o r p r a c t i c i n g t h e r a p i s t s who encounter i s s u e s of u n f i n i s h e d b u s i n e s s i n t h e i r p r a c t i c e s i n c e the present study suggests that the a d d i t i o n of the G e s t a l t empty-chair technique may f a c i l i t a t e more l a s t i n g change i n the c l i e n t ' s p r e s e n t i n g complaint than the use of empathic r e f l e c t i o n alone. I t must be remembered however t h a t the c u r r e n t study i s a p r e l i m i n a r y one and f u r t h e r r e s e a r c h i s needed to draw more d e f i n i t i v e c o n c l u s i o n s . Hypothesis 2 The A f f e c t i v e Reactions Q u e s t i o n n a i r e was a d m i n i s t e r e d to assess the s u b j e c t s ' f e e l i n g s toward the s i g n i f i c a n t other and to measure how these f e e l i n g s changed as a r e s u l t of treatment. The m u l t i v a r i a t e a n a l y s i s of v a r i a n c e r e s u l t e d i n a s i g n i f i c a n t d i f f e r e n c e between the two groups when the e f f e c t of time and therapy were combined. These r e s u l t s support r e s e a r c h Hypothesis 2 that s t a t e s : Empathy p l u s the G e s t a l t empty-chair d i a l o g u e when used with an i s s u e of u n f i n i s h e d b u s i n e s s , w i l l produce s i g n i f i c a n t l y higher means on the Confident dimension and s i g n i f i c a n t l y lower means on the S u p e r i o r , I n t o l e r a n t and Discouraged dimensions as measured a f t e r treatment and at follow-up by the A f f e c t i v e Reactions Q u e s t i o n n a i r e than those produced by the use of Empathic R e f l e c t i o n . 102 Since the r e s u l t s of the m u l t i v a r i a t e a n a l y s i s of v a r i a n c e showed a s i g n i f i c a n t d i f f e r e n c e between the two groups i n the main e f f e c t of treatment over time, the hypothesis was r e t a i n e d . The use of empathy p l u s the G e s t a l t empty-chair d i a l o g u e was found to be more e f f e c t i v e i n f a c i l i t a t i n g changes i n how s u b j e c t s f e l t about the s i g n i f i c a n t other than empathic r e f l e c t i o n alone. In p a r t i c u l a r , the G e s t a l t group f e l t s i g n i f i c a n t l y more t o l e r a n t and somewhat more c o n f i d e n t and somewhat l e s s d i s c o u r a g e d than the empathic r e f l e c t i o n group. It has been hypothesized by Greenberg and Safran (1987) th a t the r e s o l u t i o n of u n f i n i s h e d business w i l l l e a d t o enhanced understanding and t o l e r a n c e of the s i g n i f i c a n t other. In a d d i t i o n they have suggested that i n d i v i d u a l s w i l l develop a more balanced p e r s p e c t i v e not only of t h i s person but they a l s o w i l l have an enhanced s e l f - e s t e e m and a more p o s i t i v e sense of s e l f - w o r t h . Daldrup et a l (1985) and Greenberg and Safran (1986) have a l s o s t a t e d that r e s o l v i n g u n f i n i s h e d s i t u a t i o n s or r e l e a s i n g b l o c k e d emotional e x p r e s s i o n w i l l r e s u l t i n the i n d i v i d u a l f e e l i n g empowered and competent t o act i n the world. The r e s u l t s of the A f f e c t i v e R e actions Q u e s t i o n n a i r e l e n d support to t h i s h y p o t h e s i s . The empathy p l u s G e s t a l t group f e l t s i g n i f i c a n t l y more t o l e r a n t of the s i g n i f i c a n t other as a r e s u l t of the treatment than the empathic r e f l e c t i o n group. The G e s t a l t group f e l t more c o n f i d e n t i n r e l a t i o n t o the s i g n i f i c a n t other a f t e r treatment arid t h i s l e v e l of c o n f i d e n c e i n c r e a s e d over the ensuing week whereas the empathic r e f l e c t i o n group showed a decrease i n c o n f i d e n c e over the course of treatment. The empathy p l u s G e s t a l t group a l s o f e l t more encouraged whereas the empathic r e f l e c t i o n group f e l t more discou r a g e d . Taken together the f i n d i n g s t e n t a t i v e l y suggest that the G e s t a l t empty-chair d i a l o g u e i n the context of an empathic r e l a t i o n s h i p i s h e l p f u l i n f a c i l i t a t i n g c l i e n t change i n the d i r e c t i o n h y pothesized. T h i s r e s u l t supports Daldrup et a l (1985) wh suggest t h a t once a person has allowed the f u l l e x p r e s s i o n of h i s / h e r denied and disowned emotions the person w i l l c r e a t e a "schematic r e s t r u c t u r i n g and an o v e r a l l r e f o r m u l a t i o n of the assumptive stance" (p.7). I t i s f u r t h e r p o s t u l a t e d t h a t i n the change process i n d i v i d u a l s move to a more spontaneous and f l e x i b l e p o s t u r e i n d e a l i n g with the world and that they w i l l move "to experience themselves as a c t i v e c r e a t o r s of t h e i r own experiences" (p.11). Through t h i s process i n d i v i d u a l s f e e l more i n charge of themselves and i n c o n t r o l of t h e i r emotional r e a c t i o n s . The r e s u l t s of t h i s p r e l i m i n a r y study suggest that the s u b j e c t s may have achieved a g r e a t e r understanding of the s i g n i f i c a n t other which c o u l d l e a d t o an enhanced sense of c o n f i d e n c e i n themselves, a renewed sense of encouragement i n the a b i l i t y t o take charge, and more t o l e r a n c e of o t h e r s . T h i s r e s u l t may have s i g n i f i c a n c e t o t h e r a p i s t s o u t s i d e the experimental environment who may f i n 104 the G e s t a l t approach u s e f u l i n a s s i s t i n g c l i e n t s to r e s o l v e u n f i n i s h e d emotional experiences. A c o r r e l a t i o n was found between the I n t o l e r a n c e and Discouraged dimensions. T h i s f i n d i n g i s not s u r p r i s i n g as i t i s t o be expected that i f an i n d i v i d u a l f e l t i n t o l e r a n t of a s i g n i f i c a n t other person i n h i s / h e r l i f e t h i s would r e s u l t i n f e e l i n g d i s c o u r a g e d about the r e l a t i o n s h i p p a r t i c u l a r l y when th e r e were hopes f o r an improvement i n the f e e l i n g s toward the s i g n i f i c a n t other. Hypothesis 3 The Target Complaint Discomfort Box Scale was ad m i n i s t e r e d t o measure the amount of di s c o m f o r t f e l t by the su b j e c t s b e f o r e and a f t e r each s e s s i o n i n r e l a t i o n t o t h e i r p r e s e n t i n g complaint. An a n a l y s i s of v a r i a n c e with repeated measures r e s u l t e d i n a s i g n i f i c a n t d i f f e r e n c e between the two groups over the four measurement o c c a s i o n s . This r e s u l t however does not r e l a t e t o the combined e f f e c t of treatment i n t e r a c t i n g with time and t h e r e f o r e does not support r e s e a r c h Hypothesis 3 that s t a t e s : Empathy p l u s the G e s t a l t empty-chair d i a l o g u e when used with an i s s u e of u n f i n i s h e d b u s i n e s s , w i l l produce s i g n i f i c a n t l y l e s s d i s c o m f o r t b e f o r e and a f t e r each s e s s i o n as measured by the Target Complaint Discomfort Box Scale than that produced by the use of Empathic R e f l e c t i o n . 105 The r e s u l t s of the data showed a s i g n i f i c a n t d i f f e r e n c e i n the means of the scores f o r the two groups over time, thus i n d i c a t i n g t h a t when the groups were combined s i g n i f i c a n c e was found at d i f f e r e n t sampling o c c a s i o n s . T h i s however says nothing about the e f f e c t of s p e c i f i c treatments on each group or the e f f e c t of treatment over time and suggests that t h i s measure was not s e n s i t i v e enough to d e t e c t o v e r a l l treatment e f f e c t s . T h e r e f o r e the n u l l h ypothesis was r e t a i n e d and i t was concluded t h a t therapy made no d i f f e r e n c e i n the amount of di s c o m f o r t f e l t by the s u b j e c t s i n r e l a t i o n t o t h e i r p r e s e n t i n g complaint. Hypothesis 4 The Session E v a l u a t i o n Q u e s t i o n n a i r e was analyzed u s i n g a m u l t i v a r i a t e a n a l y s i s of v a r i a n c e . The r e s u l t s of the a n a l y s i s of the s u b j e c t data r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s between the two groups on any of the v a r i a b l e s . T h i s does not support r e s e a r c h Hypothesis 4 that s t a t e s : Empathy p l u s the G e s t a l t empty-chair d i a l o g u e when used with an i s s u e of u n f i n i s h e d b u s i n e s s , w i l l produce s i g n i f i c a n t l y higher means f o r the P o s i t i v i t y , Depth and A r o u s a l dimensions and s i g n i f i c a n t l y lower means f o r the Smoothness dimension f o r the s u b j e c t s at the end of the s e s s i o n s as measured by the Session E v a l u a t i o n Q u e s t i o n n a i r e than those produced by the use of Empathic R e f l e c t i o n . 106 Since the r e s u l t s of the m u l t i v a r i a t e a n a l y s i s of v a r i a n c e showed no s i g n i f i c a n t d i f f e r e n c e between the two treatment groups, the n u l l hypothesis was r e t a i n e d . T h i s i n d i c a t e s that both the empathic r e f l e c t i o n group and the empathy p l u s G e s t a l t group f e l t s i m i l a r r e a c t i o n s t o the s e s s i o n s , as i n d i c a t e d by the Smoothness and Depth dimensions, and had s i m i l a r moods f o l l o w i n g the s e s s i o n s , as i n d i c a t e d by the P o s i t i v i t y and A r o u s a l dimensions. An a n a l y s i s of the sub j e c t data r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s between the two groups on any of the v a r i a b l e s . However c l o s e r i n s p e c t i o n of the e f f e c t of therapy data r e v e a l e d a d i f f e r e n c e approaching s i g n i f i c a n c e between the two groups on the Smoothness dimension. Of i n t e r e s t here i s that the G e s t a l t group p e r c e i v e d the f i r s t s e s s i o n t o be smoother than the second s e s s i o n . The empathic group showed the o pposite s h i f t i n c o n s i d e r i n g the second s e s s i o n smoother than the f i r s t s e s s i o n . The r e s u l t s f o r the t h e r a p i s t s show the same d i s t i n c t i o n and i n d i c a t e that the t h e r a p i s t s f e l t t h a t the empathic r e f l e c t i o n s e s s i o n s were s i g n i f i c a n t l y smoother than the empathy p l u s G e s t a l t s e s s i o n s . For both s e s s i o n s the G e s t a l t s u b j e c t s f e l t the therapy t o be r e a c h i n g somewhat deeper l e v e l s of f e e l i n g than the empathy group. This t e n t a t i v e l y suggests that as G e s t a l t s u b j e c t s move more deeply i n t o the t h e r a p e u t i c process t h i s a c t i v e i n t e r v e n t i o n allows more v i v i d contact with unexpressed emotions and f a c i l i t a t i e s more dramatic 107 e x p r e s s i o n of these f e e l i n g s . The s u b j e c t s are l i k e l y to p e r c e i v e the work as more d i f f i c u l t whereas those i n the empathic r e f l e c t i o n group tend not t o reach such deep l e v e l s and tend to p e r c e i v e the work as smoother. This supports the p o s i t i o n of Daldrup et a l (1985) and Greenberg and Safran (1987) who suggest that magnifying and i n t e n s i f y i n g c u r r e n t f e e l i n g s w i l l f a c i l i t a t e a flow of emotion and a deeper e x p l o r a t i o n of b l o c k e d emotions i n r e s o l v i n g the u n f i n i s h e d s i t u a t i o n s . L i m i t a t i o n s of the Study A major l i m i t a t i o n of t h i s study i s t h a t i t was an analogue study and i s t h e r e f o r e only a b l e to approximate c o n d i t i o n s found i n a c l i n i c a l s e t t i n g . Kazdin (1986) compared these two s e t t i n g s on nine dimensions and suggested ways i n which the analogue study may vary i n the degree of resemblance to the c l i n i c a l s e t t i n g . The problems pr e s e n t e d i n an analogue study are viewed as s i m i l a r t o those observed i n the c l i n i c s e t t i n g but are probably l e s s severe. In t h i s study the s u b j e c t s d i d enter the study with a p r e - s e l e c t e d problem which was worked on i n a meaningful way however, t h i s u n f i n i s h e d b u s i n e s s had not reached the p o i n t where the s u b j e c t s were c h o s i n g to enter therapy and t h e r e f o r e the problem may have indeed been l e s s severe. The s u b j e c t s were randomly a s s i g n e d t o treatment groups to maintain the experimental design without r e g a r d to t h e i r p e r s o n a l p r e f e r e n c e s . On two occasions s u b j e c t s spontaneously i n d i c a t e d t h e i r disappointment about the group to which they had been a s s i g n e d . There may have been other s u b j e c t s who f e l t the same way who chose to remain s i l e n t . T h i s p r e f e r e n c e f o r treatment method and the subsequent r e a c t i o n t o the group a s s i g n e d may have i n f l u e n c e d the s u b j e c t s involvement i n the study. The s u b j e c t s were s o l i c i t e d from the f i r s t year of a masters program i n c o u n s e l l i n g psychology at a major u n i v e r s i t y i n a l a r g e urban area and v o l u n t e e r e d to p a r t i c i p a t e i n the study with minimal i n f o r m a t i o n r e g a r d i n g the nature of study. These students had a l l experienced some therapy experience as both a c l i e n t and a t h e r a p i s t . T h e r e f o r e , the r e s u l t s may be g e n e r a l i z a b l e only to people who have been i n c o u n s e l l i n g b e f o r e , who are knowledgeable about the c o u n s e l l i n g process and who are s u p p o r t i v e of the t h e r a p e u t i c p r o c e s s . The s u b j e c t s i n t h i s study may not r e p r e s e n t c l i e n t s who t y p i c a l l y chose to seek help i n a c l i n i c a l s e t t i n g and t h e r e f o r e the r e s u l t s of t h i s study may be c o n s i d e r e d to apply only to a s i m i l a r p o p u l a t i o n . The number of s e s s i o n s was minimal and does not represent what i s normal f o r a c l i n i c s e t t i n g . T h e r e f o r e , the r e s u l t s found i n t h i s study may be c o n s i d e r e d to apply only t o i n d i v i d u a l s i n the e a r l y stages of therapy and may not be a p p l i c a b l e to those who have been i n v o l v e d i n a longer course of therapy. The number of s u b j e c t s i n each experimental c o n d i t i o n (n=12) was small due to the e x p l o r a t o r y nature of the study. However t h i s i s a minimal requirement f o r s t a t i s t i c a l a n a l y s i s and g r e a t l y i n c r e a s e d the r i s k of making a Type 2 e r r o r ( i n c o r r e c t l y c o n c l u d i n g that the hypothesis i s t r u e when i t i s f a l s e ) and p r e s e n t e d a major l i m i t a t i o n i n a n a l y z i n g the data. A number of measures were adminstered to the s u b j e c t s which may have been t h e r a p e u t i c i n and of themselves and which may have i n c r e a s e d the p o s s i b i l i t y of i n c o r r e c t l y c o n c l u d i n g t h a t the hypotheses were f a l s e by a f f e c t i n g the r e s u l t s of treatment. This d i f f i c u l t y c o u l d have been reduced by d e c r e a s i n g the number of measures given and i n c r e a s i n g the number of s e s s i o n s . The t h e r a p i s t s were given a model of the G e s t a l t approach to completing u n f i n i s h e d b u s i n e s s . A comparable model was not a v a i l a b l e f o r the r e s o l u t i o n of incomplete experience u s i n g empathic r e f l e c t i o n . The l a c k of a c l e a r model f o r both forms of treatment may have i n f l u e n c e d the t h e r a p i s t s i n favour of the G e s t a l t treatment which had a c l e a r l y d e l i n e a t e d o u t l i n e of the r e s o l u t i o n p r o c e s s . 110 I m p l i c a t i o n s and Future Research Suggestions There are a number of i m p l i c a t i o n s f o r r e s e a r c h e r s i n t e r e s t e d i n p u r s u i n g e x p l o r a t i o n of the i s s u e of u n f i n i s h e d b u s i n e s s . The d i f f e r e n t i a l e f f e c t s design has r e l e v a n c e when s p e c i f i c techniques are a p p l i e d to the i n v e s t i g a t i o n of s p e c i f i c i s s u e s . In t h i s study the s u b j e c t s were a s s i g n e d to e i t h e r the empathic r e f l e c t i o n c o n d i t i o n or the empathy p l u s G e s t a l t c o n d i t i o n and r e c e i v e d t h i s form of therapy f o r both s e s s i o n s . A f u r t h e r study c o u l d devote the f i r s t s e s s i o n to the use of empathic r e f l e c t i o n only so as to b u i l d the necessary t h e r a p e u t i c r e l a t i o n s h i p b e f o r e the a p p l i c a t i o n of the s p e c i f i c t e c hniques. The s u b j e c t s would then be a s s i g n e d to e i t h e r the empathic r e f l e c t i o n or empathy p l u s G e s t a l t c o n d i t i o n . T h i s would prevent the s u b j e c t s from r e a c t i n g a g a i n s t the use of the empty-chair technique b e f o r e they f e l t a r e l a t i o n s h i p had been e s t a b l i s h e d with t h e i r t h e r a p i s t . The numbers i n each experimental c o n d i t i o n were low and f u r t h e r s t u d i e s would p o s s i b l y y i e l d s i g n i f i c a n t r e s u l t s i f there were at l e a s t 20 s u b j e c t s i n each group. This would a l s o e l i m i n a t e the p o s s i b l i l i t y of i n c o r r e c t l y r e t a i n i n g the n u l l h y p o t h e s i s . I l l The i s s u e of u n f i n i s h e d b u s i n e s s i s c o n s i d e r e d by G e s t a l t t h e r a p i s t s to be one of the core i s s u e s of therapy and t h e r e f o r e i s one which w i l l be expected to a r i s e i n the course of therapy i n other than the experimental environment. Although t h i s i s a p r e l i m i n a r y study the r e s u l t s l e n d t e n t a t i v e support to the use of the G e s t a l t empty-chair technique i n the context of an empathic r e l a t i o n s h i p when d e a l i n g with an i s s u e of u n f i n i s h e d b u s i n e s s . Although t h i s study i n no way concludes t h a t the use of G e s t a l t empty-chair d i a l o g u e i s more e f f e c t i v e than the use of empathic r e f l e c t i o n with the i s s u e of u n f i n i s h e d b u s i n e s s , i t does suggest that f u r t h e r r e s e a r c h c o u l d be conducted. T h i s r e s e a r c h c o u l d f u r t h e r i n v e s t i g a t e the p r e l i m i n a r y f i n d i n g s suggested here to determine i f t h e r a p i s t s c o u l d encorporate the use of t h i s technique i n t o t h e i r ongoing work with c l i e n t s whenever an i s s u e of u n f i n i s h e d business a r i s e s . Only two experimental s e s s i o n s were o f f e r e d t o the s u b j e c t s which i s l e s s than that normally encountered i n the c l i n i c a l s e t t i n g . A f u r t h e r study c o u l d o f f e r a course of 10 to 12 s e s s i o n s i n which t h e r a p i s t s would be i n s t r u c t e d t o deal with i s s u e s of u n f i n i s h e d b u s i n e s s as they n a t u r a l l y a r i s e with the G e s t a l t empty-chair technique and compare t h i s with another a c t i v e technique. These two c o n d i t i o n s would be o f f e r e d w i t h i n a c l i m a t e of an empathic 112 r e l a t i o n s h i p and a working a l l i a n c e p e r c e i v e d to be t a s k r e l a t e d . C o n c l u s i o n In c o n c l u s i o n , t h i s study has shown that empathy p l u s the G e s t a l t empty-chair d i a l o g u e produced s i g n i f i c a n t l y more t o l e r a n c e i n the s u b j e c t s ' f e e l i n g s toward a s i g n i f i c a n t other person as measured by the A f f e c t i v e Reactions Q u e s t i o n n a i r e on an i s s u e of u n f i n i s h e d business than those produced by empathic r e f l e c t i o n . The r e s u l t s f u r t h e r suggest t h a t a g r e a t e r improvement i n i n i t i a l t a r g e t complaint as measured by the Target Complaint Measure was f e l t f o r the empathy p l u s G e s t a l t c o n d i t i o n than f o r the empathic r e f l e c t i o n c o n d i t i o n . These are p r e l i m i n a r y r e s u l t s which suggest the need f o r f u r t h e r i n v e s t i g a t i o n i n the c l i n i c a l s e t t i n g to determine i f one form of treatment i s more h e l p f u l i n f a c i l i t a t i n g c l i e n t change when d e a l i n g with an i s s u e of u n f i n i s h e d b u s i n e s s . The r e s o l u t i o n of u n f i n i s h e d b u s i n e s s i s an important t h e r a p e u t i c i s s u e and one that m e r i t s f u r t h e r study. 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Working A l l i a n c e Inventory (rev . ed . ) . Horvath, A.O., & Greenberg, L.S. (1986). The development of the Working A l l i a n c e Inventory. In Greenberg, L.S., & P i n s o f f , W.M. (Eds.). The Psychotherapeutic Process: A Research Handbook (pp. 529-556). N.Y.: The G u i l f o r d Press . Kazdin, A.E. (1986). The e v a l u a t i o n of psychotherapy: Research design and methodology. In G a r f i e l d , S.L., & B e r g i n , A.E (Eds.). Handbook of Psychotherapy and  Behavior Change (3rd ed. pp. 23-63). N.Y.: John Wiley & Sons. Lambert, M.J., Shapiro, D.A., & B e r g i n , A.E. (1986). The e f f e c t i v e n e s s of psychotherapy. In G a r f i e l d , S.L., & Be r g i n , A.E. (Eds.). Handbook of Psychotherapy and Behavior Change (3rd ed. pp. 157-206). N.Y.: John Wiley & Sons . La t n e r , J . (1973). The G e s t a l t Therapy Book. N.Y.: The J u l i a n Press, Inc. 117 L e v i t s k y , A., & P e r l s , F.S. (1970). The r u l e s and games of G e s t a l t therapy. In Fagan, J . , & Sheperd, I.L. (Eds.). G e s t a l t Therapy Now (pp. 140-149). N.Y.: Harper Colophon Books. M i t c h e l l , K.M., Bozarth, J.D., & K r a u f t , C C . (1977). A r e a p p r a i s a l of the t h e r a p e u t i c e f f e c t i v e n e s s of a c c u r a t e empathy, nonpossessive warmth, and genuineness. In Gurman, A.D., & Razin, A.M. (Eds.). E f f e c t i v e Psychotherapy: A Handbook Of Research (chap. 18). Oxford: Pergamon Press. O'Connell, V.F. (1970). C r i s i s psychotherapy: Person, d i a l o g u e , and the organismic event. In Fagan, J . , & Shepherd, I.L. (Eds.). G e s t a l t Therapy Now (pp. 243-256). N.Y.: Harper Colopohon Books. O r l i n s k y , D.E., & Howard, K.I. (1978). The r e l a t i o n of process to outcome i n psychotherapy. In G a r f i e l d S. L., & B e r g i n , A.E. (Eds.) Handbook of Psychotherapy and Behavior Change; An E m p i r i c a l A n a l y s i s (2nd ed. pp. 283-329). N.Y.: John Wiley & Sons. O r l i n s k y , D.E., & Howard, K.I. (1986). Process and outcome i n psychotherapy. In G a r f i e l d , S.L., & B e r g i n , A.E. (Eds.).Handbook of Psychotherapy and Behavior Change (3rd ed. pp. 311-378). N.Y.: John Wiley & Sons. P a t t e r s o n , C.H. (1984). Empathy, warmth, and genuineness i n psychotherpy: A review of reviews. Psychotherapy: Theory. Research and P r a c t i c e , 21(4), 431-438. P e r l s , F.S. (1970). Four l e c t u r e s . In Fagan, J . , & Shepherd, I.L. (Eds.). G e s t a l t Therapy Now (pp. 14-38). N.Y.: Harper Colophon Books. P e r l s , F.S. (1978) Cooper union forum - L e c t u r e s e r i e s . "The s e l f " . " F i n d i n g s e l f through G e s t a l t therapy". G e s t a l t J o u r n a l , 1(1), 54-73. P e r l s , J . , H e f f e r l i n e , R.E., & Goodman, P. (1951). G e s t a l t  Therapy. N.Y.: D e l l P u b l i s h i n g Co. P o l s t e r , E., & P o l s t e r , M. (1973). G e s t a l t Therapy I n t e g r a t ed. N.Y.: Brunner/Mazel. R i c e , L.N., & Greenberg, L.S. (1984). P a t t e r n s of Change: An I n t e n s i v e A n a l y s i s of Psychotherapy Process. N.Y.: The G u i l f o r d P r e s s . Rogers, C.R. (1957). The necessary and s u f f i c i e n t c o n d i t i o n s of t h e r a p e u t i c p e r s o n a l i t y change. J o u r n a l of C o n s u l t i n g Psychology, 21. 95-103. 118 Rogers, C.R. (1961). On Becoming a Person. Boston: Houghton M i f f l i n . Rogers, C., & Stevens, B. (1971) . Person to Pers on : The Problem of Being Human. N.Y.: Pocket Books. Rogers, R. (1983). Role of r e t r o f l e c t i o n i n psychogenic p a i n : A treatment p e r s p e c t i v e . Psychotherapy : Theory. Research and P r a c t i c e , 20(4), 4 35-440. Serok, S., & Zemet, R.M. (1983). An experiment of G e s t a l t group therapy with h o s p i t a l i z e d s c h i z o p h r e n i c s . Psychotherapy: Theory. Research and P r a c t i c e . 20(4), 417-424. Sh e r t z e r , B., & Linden, J.D. (1979). Fundamentals of I n d i v i d u a l A p p r a i s a l : Assessment Technigues f o r Counselors. Boston: Houghton M i f f l i n . S t i l e s , W.B. (1980). Measurement of the impact of psychotherapy s e s s i o n s . J o u r n a l of C o n s u l t i n g and and C l i n i c a l Psychology, 48(2), 176-185. S t i l e s , W.B. (1984). Session E v a l u a t i o n Q u e s t i o n n a i r e , Form 4. S t i l e s , W.B. (1986). Development of a taxonomy of v e r b a l response modes. In Greenberg, L.S., & P i n s o f , W.M. (Eds.). The Psychotherapeutic Process: A Research Handbook (pp. 161-199). N.Y.: The G u i l f o r d P r e s s . S t i l e s , W.B., T u p l e r , L.A., & Carpenter, J.C. (1982). P a r t i c i p a n t s ' p e r c e p t i o n s of s e l f - a n a l y t i c group s e s s i o n s . Small Group Behavior. 1.3(2), 237-254. S t i l e s , W.B., & Snow, J.S. (1984a). C o u n s e l i n g s e s s i o n impact as viewed by novice c o u n s e l o r s and t h e i r c l i e n t s . 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Truax, C.B., & M i t c h e l l , K.M. (1971). Research on c e r t a i n t h e r a p i s t i n t e r p e r s o n a l s k i l l s i n r e l a t i o n t o process and outcome. In B e r g i n , A.E., & G a r f i e l d , S.L. (Eds.). Handbook of Psychotherapy and Behavior Change (1st ed. pp. 299-344). N.Y.: John Wiley & Sons. Truax, C.B., & Wargo, D.G. (1966). Psychotherapeutic encounters that change b e h a v i o r : For b e t t e r or f o r worse. American J o u r n a l of Psychotherapy, 20, 499-520. Webster, M.C. (1981). The r e s o l u t i o n of d e c i s i o n a l c o n f l i c t : R e l a t i n g process to outcome. Unpublished D o c t o r a l D i s s e r t a t i o n , U n i v e r s i t y of B r i t i s h Columbia, Vancouver. Wiggins, J.S. (1979). A p s y c h o l o g i c a l taxonomy of t r a i t -d e s c r i p t i v e terms: The i n t e r p e r s o n a l domain. J o u r n a l  of P e r s o n a l i t y and S o c i a l Psychology, 37 (3), 395-412. Wiggins, J.S. (1980). Circumplex models of i n t e r p e r s o n a l b e h a v i o r . In Wheeler, L. (Ed.). Review of P e r s o n a l i t y  and S o c i a l Psychology ( V o l . 1 pp. 265-294). Beverly H i l l s : Sage. Wiggins, J.S. (1982). Circumplex models of i n t e r p e r s o n a l behaviour i n c l i n i c a l psychology. In K e n d a l l , P.C., & Butcher, J.N. (Eds.). Handbook of Research Methods i n C l i n i c a l Psychology (pp. 183-221). N.Y.: John Wiley & Sons . Wiggins, J.S. (1984). A f f e c t i v e Reactions Q u e s t i o n n a i r e . Wiggins, J.S., & Broughton, R. (1985). The i n t e r p e r s o n a l c i r c l e : A s t r u c t u r a l model f o r the i n t e g r a t i o n of p e r s o n a l i t y r e s e a r c h . P e r s p e c t i v e s i n P e r s o n a l i t y , 1, 1-47. APPENDIX A Consent Form Sharron King and Vera Maslove are conducting a study on U n f i n i s h e d Business under the s u p e r v i s i o n of Dr. Les Greenberg of the Department of C o u n s e l l i n g Psychology, U.B.C. Subjects w i l l be asked to be c l i e n t s i n 2 one-hour c o u n s e l l i n g s e s s i o n s . Subjects w i l l be asked t o b r i n g U n f i n i s h e d Business to work on i n the c o u n s e l l i n g s e s s i o n s . T o t a l time committment w i l l be approximately 4 hours. T h i s w i l l i n c l u d e an o r i e n t a t i o n , 2 c o u n s e l l i n g s e s s i o n s and q u e s t i o n n a i r e completion. Tapes w i l l be made of the c o u n s e l l i n g s e s s i o n s f o r r e s e a r c h purposes only. No one out s i d e of the r e s e a r c h team w i l l have access to the re s e a r c h m a t e r i a l s . Subjects w i l l be f r e e to withdraw at any time from the study f o r any reason without jeopardy to c l a s s s t a n d i n g . I f you have any questions r e g a r d i n g the study, p l e a s e co n t a c t Vera Maslove or Sharron King through the C o u n s e l l i n g Psychology Department. I have read and understood the above, and I agree to p a r t i c i p a t e i n the above study. Signature Date Courses taken 121 APPENDIX B C l i e n t Information Form Name: C l i e n t # Address: Age: Phone: Home: Work: How much change do you f e e l you've undergone t h i s year? 1 2 3 4 5 no change s omewhat maximum APPENDIX C A b b r e v i a t e d 16-PF I n t e r e s t Q u e s t i o n n a i r e On the f o l l o w i n g pages are some questions to see what i n t e r e s t s you have and how you f e e l about t h i n g s . On most items t h e r e are no " r i g h t " or "wrong" answers because people have the r i g h t t o t h e i r own views. A l l you have to do i s answer what i s t r u e f o r you. Don't spend too much time t h i n k i n g over each q u e s t i o n . Give the f i r s t , n a t u r a l answer as i t comes to you. Of course, the q u e s t i o n s are too short to g i v e you a l l the i n f o r m a t i o n you might l i k e , but g i v e the best answer you can under the circumstances. Please answer every q u e s t i o n one way or the other. You should mark the 'a' or 'c' answer most of the time. Mark the middle 'b' answer only when you f e e l you have t o , because n e i t h e r 'a' nor 'c' seems to be r i g h t f o r you. When I'm i n a sm a l l , cramped space (as on a crowded e l e v a t o r ) , I have an uncomfortable f e e l i n g of b e i n g "shut i n " . a. never, b. r a r e l y , c. o c c a s i o n a l l y . I f i n d myself t h i n k i n g over q u i t e t r i v i a l t r o u b l e s again and again and have to make a r e a l e f f o r t to put them out of my mind. a. yes (true) , b. o c c a s i o n a l l y , c . no (f a l s e ) . I f e e l r e s t l e s s as i f I want something but do not know what . a. very r a r e l y , b. o c c a s i o n a l l y , c. o f t e n . I f I had my l i f e t o l i v e over again, I would: a. p l a n i t d i f f e r e n t l y , b. unc e r t a i n , c. want i t much the same. In making d e c i s i o n s i n my l i f e and work, I was never t r o u b l e d by l a c k of understanding on the p a r t of my f a m i l y . a. t r u e , b. i n between, c. f a l s e . My nerves get on edge, so that c e r t a i n sounds, f o r example, a screechy hinge, are unbearable and g i v e me the " s h i v e r s " . a. o f t e n , b. sometimes, c. never. I o f t e n f e e l q u i t e t i r e d when I get up i n the morning, a. yes, b. i n between, c. no. Changes i n weather don't u s u a l l y a f f e c t my e f f i c i e n c y and mood. a. t r u e , b. i n between, c. f a l s e . 124 9. I sometimes f i n d q u i t e u s e l e s s thoughts and memories s t r a y i n g through my mind. a. yes, b. i n between, c. no. 10. I never f i n d myself so annoyed i n d i s c u s s i o n s that I can't c o n t r o l my v o i c e . a. t r u e , b. u n c e r t a i n , c. f a l s e . 11. I f i n d i t hard to "take 'no' f o r an answer," even when I know I'm a s k i n g the i m p o s s i b l e . a. t r u e , b. i n between, c. f a l s e . 12. I am o f t e n hurt more by the way people say t h i n g s than by what they say. a. t r u e , b. i n between, c. f a l s e . 13. In some moods I'm e a s i l y kept from working by d i s t r a c t i o n s amd daydreams. a. yes, b. i n between, c. no. 14. I don't form immediate l i k e s and d i s l i k e s f o r people I have j u s t met. a. t r u e , b. u n c e r t a i n , c. f a l s e . 15. I c r o s s the s t r e e t t o a v o i d meeting people I don't f e e l l i k e s e e i n g . a. never, b. seldom, c. sometimes. 16. In an average day, the number of problems I meet t h a t I can't s o l v e on my own i s : a . h a r d l y one, b . i n between, c. more than h a l f a dozen. 125 17. When pushed and overworked, I s u f f e r from i n d i g e s t i o n or c o n s t i p a t i o n . 18. I f someone annoys me, I: a. can keep i t to myself, b. i n between, c. must speak to someone e l s e "to l e t o f f steam". 19. Modern l i f e has too many annoying f r u s t r a t i o n s and r e s t r i c t i o n s . a. t r u e , b. i n between, c. f a l s e . 20. I f e e l ready f o r l i f e and i t s demands. a. always, b. sometimes, c. h a r d l y ever. 21. A n e a r - a c c i d e n t , or even a l i v e l y argument, sometimes leaves me shaky and exhausted, so that. I can't s e t t l e down to what I was doing. a. t r u e , b. i n between, c. f a l s e . 22. I f i n d my f e e l i n g s b o i l i n g up i n s i d e : a. r a r e l y , b. o c c a s i o n a l l y , c. q u i t e o f t e n . 23. I have d i f f i c u l t y i n f o l l o w i n g what some people are t r y i n g t o say because of t h e i r odd use of common a . o c c a s i o n a l l y , b. h a r d l y ever, c . never. words. a . yes , b. i n between, c . no. 24. On o c c a s i o n s , my emotions and f e e l i n g s "run away with me". a. t r u e , b. u n c e r t a i n , c . f a l s e . 126 25. I f e e l so f u r i o u s I want to slam a door, and maybe break a window: a. very r a r e l y , b. o c c a s i o n a l l y , c. f a i r l y f r e q u e n t l y . 26. I would p r e f e r to l e a d : a. the same k i n d of l i f e I now l e a d , b. u n c e r t a i n , c. a more s h e l t e r e d l i f e , with fewer d i f f i c u l t i e s t o f a c e . APPENDIX D (Barrett-Lennard) R e l a t i o n s h i p Inventory - Form OS - 64 Empathy Seale Date; Below are l i s t e d a v a r i e t y of ways that one person may f e e l or behave i n r e l a t i o n t o another person. Please c o n s i d e r each numbered statement with r e f e r e n c e to your present r e l a t i o n s h i p with your c o u n s e l l o r , mentally adding h i s or her name i n the space p r o v i d e d . For example, i f the other person's name was John, you would read statement #1, as 'John r e s p e c t s me as a person'. Mark each statement i n the answer column on the r i g h t , a c c o r d i n g to how s t r o n g l y you f e e l that i t i s t r u e , or not t r u e , i n t h i s r e l a t i o n s h i p . Please be sure to mark every  one. Write i n +3, +2, +1, -1, -2, -3, to stand f o r the f o l l o w i n g answers: +3: Yes, I s t r o n g l y f e e l -1: No, I f e e l t h a t i t i s that i t i s t r u e , probably untrue, or more untrue than t r u e . +2: Yes, I f e e l i t i s t r u e . -2: No, I f e e l i t i s not true, +1: Yes, I f e e l t h a t i t i s -3: No, I s t r o n g l y f e e l t h a t probably t r u e , or more i t i s not t r u e , t r u e than untrue. ANSWER 1. wants to understand how I see t h i n g s 2. may understand my words but he/she does not see the way I f e e l 3. n e a r l y always knows e x a c t l y what I mean.. 4. looks at what I do from h i s / h e r own p o i n t of view 5. u s u a l l y senses or r e a l i s e s what I am f e e l i n g 128 6. 's own a t t i t u d e s toward some of the t h i n g s I do or say prevent him/her from understanding me 7. Sometimes t h i n k s that I f e e l a c e r t a i n way, because t h a t ' s the way he/she f e e l s 8. r e a l i s e s what I mean even when I have d i f f i c u l t y i n s a y i n g i t 9. u s u a l l y understands the whole of what I mean 10. j u s t takes no n o t i c e of some t h i n g s that I t h i n k or f e e l 11. a p p r e c i a t e s e x a c t l y how the t h i n g s I experience f e e l t o me 12. At time t h i n k s that I f e e l a l o t more s t r o n g l y about a p a r t i c u l a r t h i n g than I r e a l l y do 13. does not r e a l i z e how s e n s i t i v e I am about some of the t h i n g s we d i s c u s s 14. understands me 15. 's response to me i s u s u a l l y so f i x e d and automatic that I don't r e a l l y get through to him/her 16. When I am hurt or upset can r e c o g n i z e my f e e l i n g s e x a c t l y , without becoming upset t o o . . . . 129 APPENDIX E Working A l l i a n c e Inventory - Task Dimension On the f o l l o w i n g pages t h e r e are sentences that d e s c r i b e some of the d i f f e r e n t ways a person might t h i n k or f e e l about h i s or her t h e r a p i s t ( c o u n s e l l o r ) . As you read the sentences, mentally i n s e r t the name of your t h e r a p i s t ( c o u n s e l l o r ) i n p l a c e of i n the t e x t . Below each statement i n s i d e , t h e r e i s a seven-point s c a l e : 1 2 3 4 5 6 7 Never R a r e l y O c c a s i o n a l l y Sometimes Often Very o f t e n Always I f the statement d e s c r i b e s the way you always f e e l (or t h i n k ) , c i r c l e the number '7'; i f i t never a p p l i e s t o you, c i r c l e the number '1'. Use the numbers i n between to d e s c r i b e the v a r i a t i o n s between these extremes. This q u e s t i o n n a i r e i s CONFIDENTIAL; n e i t h e r your t h e r a p i s t nor the agency w i l l see your answers Work f a s t ; your f i r s t impressions are the ones we would l i k e t o see. (PLEASE DON'T FORGET TO RESPOND TO EVERY ITEM). Thank you f o r your c o o p e r a t i o n Copyright A.O. Horvath, 1981, 1982. v 130 1 . and I agree about the t h i n g s I w i l l need to do i n therapy to help improve my s i t u a t i o n . 1 2 3 4 5 6 7 Never R a r e l y O c c a s i o n a l l y Sometimes Often Very o f t e n Always 2. What I am doing i n therapy gi v e s me new ways of l o o k i n g at my problem. 1 2 . 3 4 5 6 7 Never R a r e l y O c c a s i o n a l l y Sometimes Often Very o f t e n Always 3. I f i n d what I am doing i n therapy c o n f u s i n g . 1 2 3 4 5 6 7 Never R a r e l y O c c a s i o n a l l y Sometimes Often Very o f t e n Always 4. I b e l i e v e the time and I are spending together i s not spent e f f i c i e n t l y . 1 2 3 4 5 6 7 Never R a r e l y O c c a s i o n a l l y Sometimes Often Very o f t e n Always 5. I am c l e a r on what my r e s p o n s i b i l i t i e s are i n therapy. 1 2 3 4 5 6 7 Never R a r e l y O c c a s i o n a l l y Sometimes Often Very o f t e n Always 6. I f i n d what and I are doing i n therapy i s u n r e l a t e d to my concerns. 1 2 3 4 5 6 7 Never R a r e l y O c c a s i o n a l l y Sometimes Often Very o f t e n Always 7. I f e e l t h a t the t h i n g s I do i n therapy w i l l help me to accomplish the changes that I want. 1 2 3 4 5 6 7 Never R a r e l y O c c a s i o n a l l y Sometimes Often Very o f t e n Always 8. I am c l e a r as to what wants me to do i n these s e s s i o n s . 1 2 3 4 5 6 7 Never R a r e l y O c c a s i o n a l l y Sometimes Often Very o f t e n Always 131 9. We agree on what i s important f o r me to work on. 1 2 3 4 5 6 7 Never R a r e l y O c c a s i o n a l l y Sometimes Often Very o f t e n Always 10. I am f r u s t r a t e d by the t h i n g s I am doing i n therapy. 1 2 3 4 5 6 7 Never R a r e l y O c c a s i o n a l l y Sometimes Often Very o f t e n Always 11. The t h i n g s that i s a s k i n g me to do don't make sense. 1 2 3 4 5 6 7 Never R a r e l y O c c a s i o n a l l y Sometimes Often Very o f t e n Always 12. I b e l i e v e the way we are working with my problem i s c o r r e c t . 1 2 3 4 5 6 7 Never R a r e l y O c c a s i o n a l l y Sometimes Often Very o f t e n Always Name : Date : 132 APPENDIX F Target Complaint Measure Date: Name: Please name the main concern that you want t o work on i n t h i s c o u n s e l l i n g : 133 C l i e n t # _ Sex: F _ M Session # Date Target Complaints We are i n t e r e s t e d i n how much the f o l l o w i n g c o n f l i c t of yours has changed s i n c e the l a s t s e s s i o n . Please c i r c l e the words that d e s c r i b e your p o s i t i o n . worse same s l i g h t l y somewhat a l o t b e t t e r b e t t e r b e t t e r 134 APPENDIX G A f f e c t i v e Reactions Q u e s t i o n n a i r e Target Person Name Male Female Age On the next page you w i l l f i n d a l i s t of words that d e s c r i b e the f e e l i n g s or emotional r e a c t i o n s people experience when they i n t e r a c t with o t h e r s . Please imagine that you are i n the presence of the t a r g e t person and that you are i n t e r a c t i n g with him or her. Then, focus on the f e e l i n g s you experience while i n t e r a c t i n g with the t a r g e t person. For each word i n the l i s t , i n d i c a t e how a c c u r a t e l y the word d e s c r i b e s your f e e l i n g s . The accuracy with which a word d e s c r i b e s your f e e l i n g s i s t o be judged on the f o l l o w i n g s c a l e : 1 Extremetly i n a c c u r a t e 5 S l i g h t l y a c c u r a t e 2 Very i n a c c u r a t e 3 Qu i t e i n a c c u r a t e 4 S l i g h t l y i n a c c u r a t e 6 Qu i t e a c c u r a t e 7 Very accurate 8 Extremely a c c u r a t e Consider the word EXCITED. How a c c u r a t e l y does that word d e s c r i b e how you f e e l when i n t e r a c t i n g with the t a r g e t person? I f you t h i n k that t h i s word i s a q u i t e a c c u r a t e d e s c r i p t i o n of your f e e l i n g s , w r i t e the number "6" to the l e f t of the item: 6 EXCITED If you t h i n k that t h i s word i s a s l i g h t l y i n a c c u r a t e d e s c r i p t i o n of your f e e l i n g s , w r i t e the number "4" next t o i t , i f i t i s very i n a c c u r a t e , w r i t e the number "2", e t c . Copyright 1984 J e r r y S. Wiggins, Ph.D. Target Person makes me f e e l : Extremely i n a c c u r a t e Very i n a c c u r a t e Q u i t e i n a c c u r a t e S l i g h t l y i n a c c u r a t e 5 S l i g h t l y a c c u r a t e 6 Qui t e a c c u r a t e 7 Very a c c u r a t e 8 Extremely a c c u r a t e (01) Daring (17) A f r a i d (02) Confident (18) Timid (03) Adventurous (19) Weak (04) Strong (20) Insecure (05) Smug (21) Unaggressive (06) Arrogant (22) Modest (07) Cocky (23) Humble (08) Sup e r i o r (24) O b l i g i n g (09) A n t a g o n i s t i c (25) Rec ept i v e (10) I n t o l e r a n t (26) Cooperat i v e (11) A g g r e s s i v e (27) Agreeable (12) Demanding (28) T o l e r a n t (13) Discouraged (29) E n t h u s i a s t i c (14) D i s a p p o i n t e d (30) J o y f u l (15) D i s s a t i s f i e d (31) D e l i g h t e d (16) Resent f u l (32) Happy 136 APPENDIX H S p s s i o n E v a l u a t i o n Q u e s t i o n n a i r e - Form_4 C i r c l e one: T h e r a p i s t C l i e n t Today's date: / month day year T # C # D i r e c t i o n s : P l e a s e p l a c e an "X" on each l i n e t o show how you f e e l about t h i s s e s s i o n . T h i s s e s s i o n was: BAD SAFE DIFFICULT VALUABLE SHALLOW RELAXED UNPLEASANT FULL WEAK SPECIAL _ ROUGH COMFORTABLE. GOOD DANGEROUS EASY WORTHLESS DEEP TENSE PLEASANT EMPTY POWERFUL ORDINARY SMOOTH UNCOMFORTABLE Right now I f e e l : HAPPY ANGRY : -MOVING UNCERTAIN , CALM s-CONFIDENT WAKEFUL FRIENDLY :. SLOW '-. ENERGETIC :__ INVOLVED :__ QUIET 137 SAD PLEASED STILL DEFINITE EXCITED AFRAID SLEEPY UNFRIENDLY FAST PEACEFUL DETACHED AROUSED 138 APPENDIX I Q u e s t i o n n a i r e A Date: Name: 1. B r i e f l y d e s c r i b e the i s s u e that you wish t o work on. 2. Please i n d i c a t e , by checking one of the boxes below, how much t h i s i s s u e bothers you now. ! ! Couldn't be worse ! ! Very much ! ! P r e t t y much \~'< A l i t t l e ! ! Not at a l l APPENDIX J Q u e s t i o n n a i r e B Date: Name: Session #: Was the i s s u e t h a t you worked on d u r i n g the hour the same or s i m i l a r to the i s s u e that you brought in? ( C i r c l e one) Very d i f f e r e n t D i f f e r e n t R e l a t e d S i m i l a r Same 1 2 3 4 5 Please i n d i c a t e , by checking one of the boxes below, how much the i s s u e which you i d e n t i f i e d b e f o r e the hour bothers you now. Couldn't be worse Very much P r e t t y much A l i t t l e Not at a l l How do you f e e l about the hour which you have j u s t completed? ( C i r c l e one) 1. P e r f e c t 2. E x c e l l e n t 3. Very good 4. P r e t t y good 5. F a i r 6. P r e t t y poor 7. Very poor APPENDIX K Q u e s t i o n n a i r e C Date: Name : B r i e f l y d e s c r i b e the i s s u e that you i d e n t i f i e d b e f o r e the l a s t s e s s i o n . Please i n d i c a t e , by checking one of the boxes below, how much t h i s i s s u e bothers you now. ! ! Couldn't be worse ! ! Very much ! ! P r e t t y much ! ~ ! A l i t t l e ! ~ ! Not at a l l During the past week, have you experienced a change i n y o u r s e l f which you a t t r i b u t e to the c o u n s e l l i n g s e s s i o n ? ( C i r c l e one) 1 2 3 4 5 D e f i n i t e l y Don't t h i n k Unsure Think so D e f i n i t e l y no so yes 142 4. How much pro g r e s s do you f e e l you made i n d e a l i n g with your i s s u e s i n c e the l a s t hour? (Please c i r c l e the item which best a p p l i e s . ) 1. A great deal of p r o g r e s s . 2. C o n s i d e r a b l e p r o g r e s s . 3. Moderate p r o g r e s s . 4. Some p r o g r e s s . 5. Didn't get anywhere. 5. I f you answered p o s i t i v e l y t o questions 3 or 4 above, p l e a s e d e s c r i b e the changes or progress which you f e e l o c c u r r e d . 6. Has an y t h i n g unusual happened d u r i n g the week other than the s e s s i o n t o which you a t t r i b u t e any change you have reported? I f so, what? 143 APPENDIX L T h e r a p i s t Q u e s t i o n n a i r e Date: Name : C l i e n t 1. How many s e s s i o n s have you had with t h i s c l i e n t ? 2. Did the c l i e n t present an i s s u e of u n f i n i s h e d b u s i n e s s d u r i n g t h i s s e s s i o n ? ( C i r c l e one) D e f i n i t e l y Don't t h i n k Unsure Yes Very no so D e f i n i t e l y I f so, what was the u n f i n i s h e d business? 4. What i n t e r v e n t i o n were you p l a n n i n g to perform? 1 2 Empathy Empty~Chair 5. Were you a b l e t o perform the experimental i n t e r v e n t i o n ? 1 2 3 4 5 D e f i n i t e l y Yes Somewhat Don't t h i n k D e f i n i t e l y yes so no 144 6. During t h i s s e s s i o n , 1. I understood e x a c t l y how my c l i e n t thought and f e l t . 2. I understood very w e l l how my c l i e n t thought and f e l t . 3. I understood my c l i e n t p r e t t y w e l l , but t h e r e were c e r t a i n t h i n g s I d i d n ' t seem to grasp. 4. I d i d n ' t understand too w e l l how my c l i e n t thought and f e l t . 5. I misunderstood how my c l i e n t thought and f e l t . 7. D i d anything s i g n i f i c a n t happen i n t h i s s ession? 8. Is t here a n y t h i n g s p e c i a l about t h i s case know? (eg. An e x t e r n a l event i n f l u e n c i n g of the u n f i n i s h e d business.) that we should the r e s o l u t i o n 

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