Education, Faculty of
Educational and Counselling Psychology, and Special Education (ECPS), Department of
DSpace
UBCV
Westwood, Dianne Kathleen
Doctor of Philosophy - PhD
University of British Columbia
There are few studies in the literature that examine in-session emotional processes from the perspective of both client and therapist in psychotherapy. The aim of this project was to provide a rich and empathic understanding of the processes clients and therapists engaged in while working with clients’ positive emotional experience. The research question that guided the study was, “How do clients and therapists utilize positive emotion when they perceive it has arisen for the client in psychotherapy sessions.” A multiple case study approach (Stake, 2006) with a philosophical hermeneutic theoretical framework (Gadamer, 1975/2004) was used to examine the therapeutic conversations of three psychotherapy dyads. Interpersonal process recall interviewing (IPR, Bloom, 1954; Kagan, 1984) was conducted with individual therapy partners while they watched a video recording of their therapy session. The therapy sessions and interviews were transcribed, coded, and analyzed by adapting Braun and Clarke’s (2006) method of thematic analysis within a hermeneutic interpretivist lens. The analysis found that the therapeutic relationship and conversations formed the container within which therapy work, and its co-created meaning occurred. Considerable value and care was afforded to this connection by dyad partners. The therapeutic conversations revealed that therapy dyad partners had a significant impact on one another, across emotional, aesthetic, cultural, and moral domains. It also revealed that the privileging of positive emotional processes steered the direction of both the therapy sessions and research interviews. In addition, six common themes emerged across the three cases as follows: a) paying attention to safety; b) fueling the tank of togetherness; c) trusting the process and seeing where it leads; d) making implicit experience explicit and experiential to expand awareness and increase understanding; e) undoing aloneness; and f) affirming, anchoring, and appreciating the work done together. The implications for counselling practice and future research are discussed.
HOW DO CLIENTS AND THERAPISTS UTILIZE POSITIVE EMOTION IN PSYCHOTHERAPY SESSIONS by Dianne Kathleen Westwood B.N., McGill University, 1974 M.Ed., McGill University, 1979 M.A., The University of British Columbia, 2008 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Counselling Psychology) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) August 2016 © Dianne Kathleen Westwood, 2016 ii Abstract There are few studies in the literature that examine in-session emotional processes from the perspective of both client and therapist in psychotherapy. The aim of this project was to provide a rich and empathic understanding of the processes clients and therapists engaged in while working with clients’ positive emotional experience. The research question that guided the study was, “How do clients and therapists utilize positive emotion when they perceive it has arisen for the client in psychotherapy sessions.” A multiple case study approach (Stake, 2006) with a philosophical hermeneutic theoretical framework (Gadamer, 1975/2004) was used to examine the therapeutic conversations of three psychotherapy dyads. Interpersonal process recall interviewing (IPR, Bloom, 1954; Kagan, 1984) was conducted with individual therapy partners while they watched a video recording of their therapy session. The therapy sessions and interviews were transcribed, coded, and analyzed by adapting Braun and Clarke’s (2006) method of thematic analysis within a hermeneutic interpretivist lens. The analysis found that the therapeutic relationship and conversations formed the container within which therapy work, and its co-created meaning occurred. Considerable value and care was afforded to this connection by dyad partners. The therapeutic conversations revealed that therapy dyad partners had a significant impact on one another, across emotional, aesthetic, cultural, and moral domains. It also revealed that the privileging of positive emotional processes steered the direction of both the therapy sessions and research interviews. In addition, six common themes emerged across the three cases as follows: a) paying attention to safety; b) fueling the tank of togetherness; c) trusting the process and seeing where it leads; d) making implicit experience explicit and experiential to expand awareness and increase understanding; e) undoing aloneness; and f) affirming, anchoring, and appreciating the work done together. The implications for counselling practice and future research are discussed. iii Preface This dissertation is the original work of the author, D. Westwood. This research project was conducted with the approval of the University of British Columbia (UBC) Office of Research Services Ethics Behavioural Research Ethics Board (BREB), certificate number H11—03288. Participant interviews and data analysis were carried out by the author. During the data analysis three expert peer co-researchers reviewed, validated and provided feedback on the analysis at several key points during the process. They were: Yaari (Brenda) Dyer (Ph.D., Lecturer, Counselling Psychology, University of British Columbia), Emily Kristina Koert (Ph.D., Counselling Psychology, University of British Columbia), and Hilary Mary Pearson, (Ph.D. Curriculum and Instruction, University of British Columbia). iv Table of Contents Abstract ............................................................................................................................................ ii Preface ............................................................................................................................................ iii Table of Contents ............................................................................................................................ iv List of Tables .................................................................................................................................. ix Acknowledgements .......................................................................................................................... x Chapter 1: Introduction ...................................................................................................................1 Statement of the Problem .....................................................................................................1 Approaching the Research Question....................................................................................2 Purpose of the Study ............................................................................................................3 Rationale ..............................................................................................................................3 Psychotherapy Process and Outcome ..................................................................................4 Emotion Defined ..................................................................................................................6 Positive Emotion Defined ........................................................................................9 Benefits of Positive Emotion .............................................................................................10 Emotion in Psychotherapy .................................................................................................11 Chapter 2: Literature Review .........................................................................................................13 Psychotherapy Process Research .......................................................................................13 Emotion Theory and Foundational Research.....................................................................17 Terms and Definitions............................................................................................17 Feeling Component ................................................................................................21 Motivation Component ..........................................................................................28 Benefits of Positive Emotion .............................................................................................34 The Broaden and Build Theory..............................................................................34 Undoing Hypothesis...................................................................................35 Broadening Hypothesis ..............................................................................36 Build Hypothesis........................................................................................38 Upward Spiral Effect .................................................................................40 Positive Emotion and Success ...............................................................................44 Positive Emotion and Health .................................................................................46 Emotion in Psychotherapy .................................................................................................47 Assumptions about Positive and Negative Emotion in Psychotherapy .................47 Principles of Working with Emotion in Psychotherapy ........................................50 Arousal and Experiencing ..........................................................................52 Awareness, Expression, and Reflection .....................................................55 Emotional Regulation ................................................................................59 Changing Emotion with Emotion ..............................................................64 Conclusion .........................................................................................................................67 Chapter 3: Methodology ................................................................................................................69 Rationale for the Methodology and Procedures.................................................................69 Situating the Inquiry: Conceptual Framework...................................................................70 Interpretivism .........................................................................................................70 v Phenomenology......................................................................................................71 Hermeneutics .........................................................................................................72 Gadamerian Hermeneutics .........................................................................73 Situating Myself as an Inquirer in the Research ................................................................75 Theoretical Pre-understandings..............................................................................75 Personal Experiential and Professional Pre-understandings ..................................78 Research Methods ..............................................................................................................80 Multiple Case Study Approach ..............................................................................80 Interpersonal Process Recall Interviewing.............................................................81 Thematic Analysis..................................................................................................82 Participants.........................................................................................................................83 Screening................................................................................................................84 Selection of Psychotherapy Sessions for the Research ..........................................85 Research Team .......................................................................................................85 Data Collection Procedures................................................................................................86 Data Analysis .....................................................................................................................92 Within-Case Analysis ............................................................................................93 Cross-Case Analysis ..............................................................................................95 Ethical Considerations .......................................................................................................96 Criteria for Evaluating the Rigor and Worth of the Study .................................................98 Consensual Validation ...........................................................................................99 Resonance ..............................................................................................................99 Trustworthiness ....................................................................................................100 Chapter 4: Findings ......................................................................................................................101 Within-Dyad Analysis......................................................................................................101 Dyad 1 ..................................................................................................................102 Background Information .................................................................................102 Context of the Therapy Session .................................................................102 Context of the Interviews ...........................................................................103 Summary of Themes and Processes................................................................104 Paying Attention to Safety .........................................................................104 How the Dyad Worked with Relief .....................................................106 How the Dyad Worked with the Relief of Letting Go .........................108 Summary of Paying Attention to Safety ..............................................109 Imagining More to Scaffold New Experience ...........................................110 How the Dyad Worked with Pleasure and Pride .................................111 How the Dyad Worked with Relief .....................................................113 Summary of Imagining More to Scaffold New Experience ................115 Making Implicit Experience Explicit and Experiential .............................115 How the Dyad Worked with Joy, Happiness, Gratitude ......................116 Summary of Making Implicit Experience Explicit and Experiential...118 Fueling the Tank of Togetherness..............................................................118 How the Dyad Worked with Joy and Surprise.....................................119 Summary of Fueling the Tank of Togetherness...................................122 Undoing Aloneness ....................................................................................122 How the Dyad Worked with the Pleasure of Relaxation, Strength......123 vi Summary of Undoing Aloneness .........................................................125 Affirming, Anchoring, and Appreciating the Work Done Together .........125 How the Dyad Worked with Relief .....................................................126 Summary of Affirming, Anchoring, Appreciating the Work ..............129 Assertions........................................................................................................129 Dyad 2 ..................................................................................................................130 Background Information .................................................................................130 Context of the Therapy Session. ................................................................130 Context of the Interviews ...........................................................................131 Summary of Themes and Processes................................................................131 Paying Attention to Safety. ........................................................................132 How the Dyad Worked with Pleasure and Excitement........................132 How the Dyad Worked with Pleasure, Joy and Relief.........................135 Summary of Paying Attention to Safety ..............................................136 Trusting the Process and Seeing Where It Leads.......................................137 How the Dyad Worked with Surprise, Joy, and Ease ..........................138 How the Dyad Worked with Emergent Pride ......................................140 Summary of Trusting the Process and Seeing Where It Leads............140 Making Implicit Experience Explicit and Experiential .............................141 How the Dyad Worked with Pride and Mastery ..................................142 Summary of Making Implicit Experience Explicit and Experiential...144 Fueling the Tank of Togetherness..............................................................144 How the Dyad Worked with Pleasure and Joy ....................................145 Summary of Fueling the Tank of Togetherness...................................146 Affirming, Anchoring, and Appreciating the Work...................................146 How the Dyad Worked with Surprise and Gratitude ...........................147 How the Dyad Worked with Relaxation and Pleasure.........................151 Summary of Affirming, Anchoring, and Appreciating the Work........151 Assertions........................................................................................................152 Dyad 3 ..................................................................................................................152 Background Information .................................................................................152 Context of the Therapy Session .................................................................152 Context of the Interviews ...........................................................................153 Summary of Themes and Processes................................................................153 Fueling the Tank of Togetherness..............................................................154 How the Dyad Worked with Happiness and Being Welcomed ...........155 Summary of Fueling the Tank of Togetherness...................................157 Trusting the Process and Seeing Where It Leads.......................................157 How the Dyad Worked with Relief .....................................................158 How the Dyad Worked with Relief .....................................................161 Summary of Trusting the Process and Seeing Where It Leads............161 Undoing Aloneness ....................................................................................161 How the Dyad Worked with Relief .....................................................163 Summary of Undoing Aloneness .........................................................163 Being Guided and Guiding Through a Hard Place ....................................163 How the Dyad Worked with the Sense of Vitality ..............................164 vii Summary of Being Guided and Guiding Through a Hard Place .........166 Making Implicit Experience Explicit and Experiential .............................166 How the Dyad Worked with Relief .....................................................168 Summary of Making Implicit Experience Explicit and Experiential...169 Affirming, Anchoring, and Appreciating the Work Done Together .........169 How the Dyad Worked with Relief .....................................................170 Summary of Affirming, Anchoring, and Appreciating the Work........171 Balancing Giving and Receiving ...............................................................172 Summary of Balancing Giving and Receiving ....................................174 Assertions........................................................................................................174 Cross-Dyad Analysis .......................................................................................................174 Common Process Themes ....................................................................................175 Paying Attention to Safety ..............................................................................175 Fueling the Tank of Togetherness...................................................................175 Trusting the Process and Seeing Where It Leads............................................176 Making Implicit Experience Explicit and Experiential ..................................176 Undoing Aloneness .........................................................................................177 Affirming, Anchoring, and Appreciating the Work Done Together ..............178 Unique Process Themes .......................................................................................178 Imagining More to Scaffold New Experience ................................................178 Balancing Giving and Receiving ....................................................................179 Being Guided and Guiding Through a Hard Place .........................................179 Key Assertions .....................................................................................................179 Key Assertion 1...............................................................................................180 Key Assertion 2...............................................................................................180 Key Assertion 3...............................................................................................180 Key Assertion 4...............................................................................................180 Key Assertion 5...............................................................................................181 Chapter 5: Discussion ..................................................................................................................182 Summary of Research Problem and Rationale ................................................................182 Summary of the Findings .................................................................................................182 Significance and Theoretical Implications.......................................................................183 Client Positive Emotions......................................................................................183 Therapeutic Relationship .....................................................................................185 Mutual Impact ......................................................................................................187 Engaged Understanding and Co-Created Meaning..............................................188 Privileging Positive Emotion ...............................................................................190 Cultural and Historical Influences .......................................................................191 Methodological Contributions .........................................................................................191 Clinical Contributions ......................................................................................................192 Limitations .......................................................................................................................195 Implications for Future Research .....................................................................................197 Conclusion .......................................................................................................................198 References ....................................................................................................................................199 Appendix A: Recruitment Advertisement for Professional Websites and Listservs ...................224 viii Appendix B: Recruitment Letter for Therapist ............................................................................225 Appendix C: Telephone Screening Interview for Therapists ......................................................226 Appendix D: Scripts for Therapists Recruiting Clients ...............................................................228 Appendix E: Recruitment Letter for Clients ...............................................................................229 Appendix F: Telephone Screening Interview for Clients ............................................................230 Appendix G: Script of Statements to Prospective Participants When Recruitment is Completed ..............................................................................................................232 Appendix H: Therapist Informed Consent...................................................................................233 Appendix I: Client Informed Consent..........................................................................................236 Appendix J: Interpersonal Process Recall (IPR) Interview Format .............................................239 Appendix K: Example of Organization and Initial Coding of Positive Episodes and Post Episode Dialogue ...........................................................................................240 Appendix L: Preliminary Theme Summaries ..............................................................................241 Appendix M: Final Distillation of Process Themes.....................................................................244 ix List of Tables Table 1. Demographic Information of Participants.......................................................................84 Table 2. Positive Emotion Episodes..............................................................................................89 Table 3. Themes and Processes Related to Working with Positive Emotion for Dyad 1............104 Table 4. Themes and Processes Related to Working with Positive Emotion for Dyad 2............131 Table 5. Themes and Processes Related to Working with Positive Emotion for Dyad 3............154 x Acknowledgments This dissertation would not have been completed without the encouragement, affection, and support of my my family and friends. For their generosity, interest and insights over the years of this process, I am grateful. Sincere thanks to my research committee, Dr. Norman Amundson, Dr. Marla Buchanan, and Dr. William Borgen, for providing invaluable guidance and feedback throughout this process, for being enthusiastic about the project, and for your patience and advocacy. I am very appreciative to my co-researchers Yaari, Hilary, and Emily, who generously gave their time to assist me in the analysis. Special thanks to Hilary and David for help with editing. I am deeply grateful to the research participants. They graciously opened themselves up, sharing their life story, and a very private therapy session, making this project literally come alive. Thank you each for your courage, generosity and authenticity. Without the trust you placed in me this research would not have been possible. Your willingness to stay involved over the study period helped me stay motivated to complete the research. We have learned a great deal from you. Thank you. 1 Chapter 1: Introduction Statement of the Problem There is widespread interest and acknowledgment of the importance of attending to emotions1/affect2 in psychotherapy, across virtually all psychotherapy approaches (Pascual-Leone & Greenberg, 2006). According to Greenberg (2008) and Samoilov and Goldfried (2007) there is agreement amongst psychotherapy schools that emotion is a primary adaptive system that alerts us to the importance of events in our environment. In addition, emotion shares higher order meaning function with cognition, and “these affective-cognitive or cognitive affective structures are important targets for treatment” (2008, p. 51). However, each tradition has different ways of understanding the role emotion plays in successful therapy, how it is worked with, and for what purpose (Fosha, 2000; Menin & Farach, 2007; Pascual-Leone & Greenberg, 2006; Samoilov & Goldfried, 2000; Whelton, 2004). Counselling and psychotherapy researchers have invested considerable effort over the past fifty years with the question of how therapeutic change occurs. This research agenda has provided broad outcome evidence that psychotherapy works, with approximately 50% of therapy clients showing improvement within 20 sessions, and 75% of clients showing improvement after 50 sessions (Lambert & Ogles, 2004). However, there are still many individuals who do not benefit, and in fact, 5-10% of clients actually deteriorate while in therapy (Lambert & Ogles, 2004). The research literature has also identified broad relationship factors and therapist interventions (Castonguay & Beutler, 2006) that contribute to good therapy outcomes, and yet there is not a significant difference in specific ingredients or different psychotherapy schools in producing psychotherapeutic change (Wampold, 2001). In other words, it is not clear if therapeutic change occurs according to our current theories (Kopta, Lueger, Saunders, & Howard, 1999), and this also holds true in our understanding of how and why attending to client positive emotion in psychotherapy contributes to change and/or good outcomes (Fitzpatrick & Stalikas, 2008; Greenberg, 2008; Moses & Barlow, 2006). 1 Affect is an umbrella term used to refer to valenced states (appraised as good, bad, pleasant or unpleasant, negative or positive, and that include emotions, moods and attitudes (Gross, 2010). 2 Emotion is a term used to refer to more specific responses or states that emerge as a result of appraisals about the significance of particular events in the environment, and that generate feeling, cognition and behavior. Emotion is usually considered to have a feeling tone associated with its experience. Feeling is a term used to refer to a bodily felt sense, complex, symbolic reactions that are experienced as motivational and that influence thought and action (Izard, 2009; Kennedy-Moore & Watson, 2002), or a “felt sense of meaning” (Greenberg & Safran, 1987, p.47). 2 Much of the clinical research related to emotional processes, as well as time in therapy sessions, is directed at distressing emotions, and these are often the source of what brings people to therapy. In addition, positive and negative emotion have emerged as superordinate factors in many disorders, especially anxiety and mood disorders (Brown, Chorpita & Barlow, 1998; Watson, 2005), and there is a high incidence of co-morbidity amongst the mood disorders (Moses & Barlow, 2006), suggesting a vulnerability or common diathesis, and lending weight to the movement across psychotherapy traditions to consider common principles of treatment (Castonguay & Beutler, 2006; Moses & Barlow, 2006). Given these factors, one might argue it makes sense that less attention has been focused on pleasant or positive emotions (Fitzpatrick & Stalikas, 2008; Fosha, 2000) in psychotherapy. There may be other reasons for this, and these will be discussed in the next chapter. The emergence of positive emotion has been seen as a marker or sign of therapeutic change (Greenberg & Paivio, 1997). However, Fitzpatrick and Stalikas (2008) suggest positive emotion may in fact be initiating change. Several other authors assert the value of working with positive emotion in therapy sessions. They emphasize the idea that exploring and even privileging aspects of positive phenomena shifts perspective to what is working and what is naturally built into secure relationships and our response systems for well-being and coping (Bridges, 2006; Fosha, 2000, Russell, 2015; Sandler, 2007). These authors believe such an approach has the potential to: (a) assist clients to work with parts of experience that are challenging, (b) create new experiences of the self, potentially shifting clients’ views about themselves and others, and (c) promote perspective taking and reflection, helping clients consolidate and integrate therapeutic gains, (d) build awareness and understanding of the change process itself, setting in motion the potential for more, similar experiences. Approaching the Research Question My interest in positive emotional experience began in my Masters education and therapy training. My Masters research involved the exploration of a client receiving positive emotional resourcing. During clinical training, I frequently began to notice that when some clients received affirmation or a simple kindness from their therapists, they often responded with vulnerability and pleasure, sometimes even deflecting or ignoring the gesture. Similarly, therapists seemed to dodge the gratitude of clients, sometimes responding with what might be considered false modesty. I wondered what therapists and clients might be thinking and feeling internally during 3 these exchanges, and what impact they were having on one another when one or both of them expressed and/or observed positive emotion in a session. As I read more, I discovered that there was growing evidence in the literature that positive emotion impacts problem-solving and decision making (for a review see Isen, 2008), appears to be involved in coping (Folkman, 2008), resilience (Fredrickson, Tugdale, Waugh, & Larkin, 2003; Tugdale & Fredrickson, 2004) as well as conferring other benefits, such as health (Pressman & Cohen, 2005). As a result, my research interests shifted slightly—towards an interest in the positive emotional experience of clients, how psychotherapy partners attend to these emotions, and how they might be harnessed therapeutically. Purpose of the Study The purpose of this inquiry was to study how psychotherapy clients and therapists attend to and work with emergent or expressed positive emotion when it occurs for clients in psychotherapy sessions. A qualitative inquiry, using a multiple case study approach (Stake, 2006) and Interpersonal Process Recall (IPR; Kagan, 1984) interviewing, guided by a philosophical hermeneutic theoretical framework, was undertaken to address the following research question. “How do clients and therapists utilize positive emotion when they perceive it has arisen for the client in psychotherapy sessions?” This interpretive hermeneutic approach conceptualizes human understanding as occurring in conversation (Gadamer (1975/2004). In addition, a hermeneutic approach offers a framework to both conceptualize and explore how clients and therapists negotiate and coordinate their interactions and understandings of positive emotional experience as it emerges and unfolds in sessions. Rationale This research project is located at the intersection of three needs in the psychotherapy process and positive emotion literatures. First, psychotherapy process researchers are increasingly being asked to turn their efforts toward understanding how change processes unfold in sessions and to address the micro processes of how clients are impacted by therapist interventions and techniques (Pachankis & Goldfried, 2007; Wampold, Hollon, & Hill, 2011). Second, although in social and experimental psychology there is a large foundational literature on positive emotion, especially, proposing and identifying its structures, manifestations, functions and benefits, only a few researchers have explored and articulated how it is attended to, worked with, and explored with clinical populations. Third, the literature on emotion in 4 psychotherapy has few examples of research on positive emotion processes and primarily addresses distressing emotion. Psychotherapy Process and Outcome Psychotherapy process refers to what actually happens inside a therapy session (Orlinsky, Rønnestad, & Willutzki, 2004), more specifically, the “overt and covert thoughts, feelings and behaviors of both clients and therapists during therapy sessions” (Hill & Williams, 2000, p.670); whereas psychotherapy outcome refers to all the changes that come about for a client as a result of therapy (Hill & Lambert, 2004). Historically, the domain of process research was what occurred inside the sessions, and the domain of outcome research was what happened outside the session. According to Orlinsky, Rønnestad, and Willutzki (2004) and Greenberg and Pinsof (1986) these distinctions have shifted, and it is widely acknowledged that within-session changes (such as new understandings, emotional awareness, feeling understood) contribute to the overall outcome of therapy. In this way outcome is not confined to what occurs outside or after therapy. Although the relationship between process and outcome is relatively fluid, it is largely determined by the goals and rationales of the researcher (Greenberg & Pinsof, 1986). In this exploratory study, for example, examining how clients and therapists utilize client positive emotion is seen to be a study of an in-session process. Stiles (2015) distinguishes the purposes between three different types of research employed in psychotherapy research—theory-building, enriching, and fact gathering research. He postulates that these purposes can be explored by any method. The aim of theory-building research in psychotherapy is to build an explanatory framework for how psychotherapy works, along with how different aspects of it work together. This type of research might also be aimed at improving existing theory. The explanation sought in theory building is a “unified and logically consistent account” (p. 163). Enriching research in Stiles’ view involves “deepen[ing] and enrich[ing] people’s appreciation or understanding of a phenomenon by considering alternate perspectives and unpacking the implicit and explicit meanings involved” (p.160). Researchers addressing enriching purposes do not attempt to resolve multiple perspectives into a unified account of the phenomenon under study. The researcher with enriching purposes embraces an interpretative framework rather than an explanatory one. It is also important to note that Stiles does not consider enriching research as a first step in theory-building research because enriching research has a different purpose than theory-building research. Fact gathering research is understood in this classification as pre- 5 paradigmatic or pre-theoretical. Researchers gather facts without embedding them in a theory. This type of research might be considered data-driven or atheoretical. Stiles (2015) raises the question about how much psychotherapy research is pre-paradigmatic in forwarding this discussion. This inquiry falls into the category of enriching research. The aim in this study was not necessarily to build theory, or provide a unified account of positive emotional experience. Rather, as enriching research (Stiles, 2015), the aim of this project was to advance a deep, textured, practical, and empathic appreciation of client positive emotional experience in psychotherapy sessions to amplify and elaborate what we currently know about positive emotion in psychotherapy. Because this study approached positive emotion from the perspective of the participants, and examined the phenomenon (episodes of client positive emotion) within a hermeneutic interpretive framework, no emotion or outcome measures were conducted prior to or after the therapy sessions and interviews. Retaining the meaning of emotional experience in natural, plain language and embracing multiple possible meanings is considered a strength in enriching research (Stiles, 2015). As such, emotional episodes were identified and described by the participants through the interpersonal process recall (IPR) method of interviewing (Bloom, 1954; Kagan, 1984). It was anticipated that the findings from these interviews represent examples of participants’ experience that underpin and guide in-session processes that have the potential to impact overall therapy outcome. As stated earlier, fifty years of vigorous research efforts, including more refined research methodologies, have helped to validate that psychotherapy confers benefits to most clients. Random controlled studies (RCT) begin to get at causal relationships, but most studies in the psychotherapy literature are aimed at broad outcome research, and have been concerned with validating the efficacy of various psychotherapy approaches in whole treatment courses (Pachankis & Goldfried, 2007; Wampold, 2001). This type of research has afforded credibility and direction for practitioners and the public in selecting efficacious approaches such as a cognitive behavioural therapy (CBT) approach for generalized anxiety disorder (Borkovec & Ruscio, 2006), interpersonal therapy for depression (IPT, Bleiberg & Markowitz 2008), and emotionally focused therapy (EFT) for couples (Johnson, 2004). Correlational studies have examined the factors that operate in successful and unsuccessful clinical work, suggesting probable relationships between factors that influence 6 psychotherapy outcome, but are unable to address causal relationships (Kazdin, 2008). These studies, for example, have helped us understand that the expression of emotion seems to be helpful for many clients, but not helpful for others (for a review see Littrell 1998); that individuals who can access [their] positive emotion when distressed may be more resilient than those who do not (Fredrickson, Mancuso, Branigan, & Tugdale, 2000). However, RCTs and correlational studies do not answer questions for practitioners about how to use the approaches within sessions, with whom, and under what circumstances. Nor has this research progressed our understanding of how and which specific ingredients contribute to change processes (Pachankis & Goldfried, 2007; Kazdin, 2008; Wampold, 2001). In fact, what has emerged from this research is a shift in the aims of psychotherapy research from “Does (this) therapy work?” towards “How does (this) therapy work?” While it is useful to know that therapy works, which factors influence outcome, and how strong the influence is, this type of research evidence is different from evidence validating a mechanism of action, or how change actually comes about (Kazdin, 2008). Broad therapeutic ingredients and principles of change that contribute to good outcomes have also been identified, such as the therapeutic relationship, warmth, and common factors in therapy approaches (Castonguay & Beutler, 2006; Lambert & Ogles, 2004). The identification of common factors has done much to bridge a conversation, and build a consensus about the need for integrative approaches to treatment (Lambert & Ogles, 2004; Moses & Barlow, 2006), as well as a combined research focus on process and outcome. This research study design offers a rich description of therapy dyad engagement with client positive emotional experience. The findings provide practitioners with a detailed account of client and therapist perspectives on how client positive emotion was attended to and worked with in psychotherapy sessions. It is hoped that readers will form their own ideas of how the findings might serve as a heuristic for their clinical practice, and have implications for in-session processes that may contribute to change and/or overall therapy outcome. Emotion Defined There is no unified definition of emotion (Burum & Goldfried, 2007; Izard, 2009). In fact, definitional plurality is the norm in the literature. Izard (2010) conducted an email survey of expert scientists in emotion theory and research posing questions about definition(s), function(s), activating factors, regulation, and whether or not there are “rapid, automatic, and 7 unconscious connections among emotion, cognition, and action” (p. 364). His aim was to remind consumers of literature on emotion that the term “emotion” carries multiple meanings and aspects, and to suggest that researchers, scientists, and others be specific and declarative about the terms they use in relation to emotion. Two sentences, based on an agreement score average of 8 or higher out of 10 for the first sentence, and 5 or higher out of 10 for the second sentence, attempt to encompass the structure and functions of emotion on which the scientists agreed. Emotion consists of neural circuits (that are at least partially-dedicated), response systems, and a feeling state/process that motivates and organizes cognition and action. Emotion also provides information to the person experiencing it, and may include antecedent cognitive appraisals and ongoing cognition including an interpretation of its feeling state, expressions or social-communicative signals, and may motivate approach or avoidant behavior, exercise control/regulation of responses, and be social or relational in nature. (p.367). One of the most enduring debates in the emotion theory literature has centered around the broad epistemological issue of nature versus nurture—whether or not emotions are natural “kinds” or are socially constructed. The above definition includes both. Emotions are affected and shaped within social contexts and also have clear biological and evolutionary bases. The naturalist approach considers emotion as a kind (basic emotion) that can be categorized by physical structure (Izard, 2007; Panksepp, 2009). Izard (2009), historically considered to take the naturalist position, currently identifies basic emotions and their attendant feelings, as evolutionarily given neurobiological activity that organizes and motivates action for survival and well-being. Basic emotions include categories such as happiness, sadness, fear, anger, and disgust/contempt and are manifested in observable facial expression and patterns of muscle tension (Ekman & Friesen, 1975). All human emotions are seen to be combinations of these basic emotions. For example, compassion is understood to be a mixture of care, or love and sadness. Izard further stated that the integration and interaction of basic emotions and cognitive processes result in emotional schemas, which are defined as “emotion-cognition interactions/structures that generate feeling-thought experiences and behavioral tendencies that range from momentary processes to trait-like phenomena…” (2009, p. 3). He uses the term emotional schema in reference to cognitive, contextually learned content, not to characterize 8 basic emotion or a basic emotional episode (2007). Emotion, as a term in this theory, encompasses both basic emotion, emotion feeling, and emotional schemas. Closely related to basic emotions are primary emotion processes identified by Panksepp (2009). These emotional systems, understood as early given emotional dispositions, are: seeking, fear, rage, lust, panic, and play. These emotional systems are considered to be the most elemental emotional dispositions from the naturalist perspective, and are automatically activated in response to environmental cues such as danger, separation, and aggression, to name a few. As development occurs, they inevitably become entangled with cognition, life experience and language (Panksepp, 2009). In the psychological constructionist view emotions are seen to be socially constructed and have little to do with any physical characteristics or categories (Barrett, 2006a). Emotion is not considered to be a kind or entity, such as anger or sadness, and is not believed to originate in specific inborn neural circuits. Rather, theorists in this view, assert that humans have an inborn capacity for core affect, which is similar in some ways to generalized, valenced arousal. Categorization of emotional experience is seen to be influenced by learning and culture. In addition, emotional knowledge is acquired through language, it is not inborn. Discrete emotions such as sadness and anger are not construed as universal mechanisms that motivate specific behavior, their occurrence is believed to be based on the use of normative, contextual information applied to core affective experience, and it is the motivating aspect of both affect and cognition that motivates behavior. As such there are considerable cultural differences in the experience of emotion that are dependent on cultural categories and concepts of emotion, rather than universal processes that have culturally different triggers or display rules (Barrett, 2006b). In fact, these views on the nature of emotion are not incompatible on every level. Each acknowledges the influence of culture and history on emotional experiences and responses. They concur on the fact that once language begins there are likely few instances of pure categories of emotion and emotion experience (affect) and, as the human child grows and develops emotional experiences also differentiate and become increasingly more idiosyncratic and complex as a result of the interaction of culture and experience with individual characteristics. One of the major differences between the the naturalistic view and the constructionist view centers around inborn starting points, or what is given through evolution—dedicated neural circuits for the primary processes of a small group of basic emotional response 9 systems such as seeking, fear, rage, lust, care, panic, and play (Panksepp, 2009), or core emotion—an ever present stream of neurophysiologic changes that represent how each human is responding to the environment (Russell & Barrett, 1999). As is evidenced in the above discussion, emotions are considered to have multiple components (Barrett, 2006a, 2006b; Izard, 2007, 2009). Soloman (2002) summarized these in his holistic model of emotion in which he states that “every emotion has five aspects: 1) behavioral (including expressions, elaborate plans for action and verbal behavior), 2) physiological (hormonal, neurological, neuromuscular), 3) phenomenological (sensations, ways of construing the objects of emotion), 4) cognitive (appraisals, perceptions, thoughts, and reflections about one’s emotions), and 5) the social context (the immediacy of the interpersonal interactions, pervasive cultural considerations). These aspects are often interwoven and they should not be construed (as they often are) as competing conceptions of emotion…” (pp. 131-132). Given this definitional plurality, I currently situate myself with the two descriptive sentences offered by Izard (2009) and outlined above. Positive emotion defined. Defining positive emotion is probably as challenging as defining emotion itself. While not attempting a unified definition, there are two characteristics of positive emotions that generally distinguish them from negative emotions—they usually involve approach or appetitive motivation, and they are usually associated with a good feeling or pleasant valence (Smith, Tong, & Ellsworth, 2014). The concepts of positivity or negativity, as they are applied to emotion theory, are sometimes referred to as valence. These concepts are used in several different ways in the literature, and this is largely based on appraisal. Colombetti (2005) distinguishes between a number of separate uses of these terms in the current emotion literature, and problematizes how utilizing such general categorizations oversimplifies our understanding of emotional experience, and creates a lack of clarity for both theory and research. The term valence is used to describe both the general category of emotion, and individual aspects of emotion. However, some emotions are atypical in relation to notions of valence, and this is related to ongoing appraisals by an individual. For example, in the anger category, righteous anger may feel good or positive to an individual who is learning to stand up and assert herself with a bullying friend and involves approach motivation rather than withdrawal or avoidance. Conversely, being angry with her mother may feel bad or negative, and may involve either approach or withdraw motivation. Fear 10 is another emotion that does not fit neatly into a typical category. For example, the pleasant fear of being on a roller coaster could be experienced as typical excitement (Condon, Wilson-Mendenhall, & Barrett, 2014). Similarly, pride in accomplishment may feel good to one person and may feel like bragging to another person. In relation to aspects of emotion, valence is most commonly used to describe hedonic tone, or the feeling experience of emotion on a continuum of pleasantness to unpleasantness. Other aspects of emotion that are valenced are: evaluatio ns such as goodness and badness; resultant approach and avoidance behaviours; and teleological aspects such as movement towards attaining goals or goals being thwarted (Colombetti, 2005). These examples highlight that while appraisal is associated with both cognition and the experience of conscious affective states, whether the appraisal, goal, behavior or hedonic tone is labeled or experienced as an urge to approach or withdraw, pleasant or unpleasant, good or bad, right or wrong, or as positive or negative, is highly individual and influenced by intrapersonal, interpersonal, and wider social contextual factors (Colombetti, 2005; Soloman & Stone, 2002). These factors highlight that an apriori dichotomous classifying of emotions and emotional experience into simple, bipolar groupings ignores the complexity and the possibility of mixed or atypical emotional states which result from socially and culturally mediated experience. Given that enriching research, as previously discussed, involves considering alternate meanings, and for reasons discussed above, positive emotion is defined in this manuscript as any emotion experienced and labeled by an individual as being positive for him or her within the context it is experienced. This may include, but not be restricted to, states such as awe, joy, contentment, love, gratitude, interest, pride, amusement, inspiration, and hope. It may also include the sense that things are proceeding satisfactorily towards an intended purpose or a felt sense of personal rightness. These states may be typical, atypical, occur alone, in combination, or be mixed with negative or unpleasant emotions. For example, compassion often includes both love or affection and sadness. Examples of emotional states that an individual client may label as negative might be intense anger directed toward a loved one, sadness due to a personal loss, and shame experienced after doing something contrary to one’s held beliefs. Benefits of Positive Emotion There is considerable foundational evidence for the beneficial effects of positive emotion, in problem solving and decision making (Isen, 2008), and on attention, cognition and behaviour (Fredrickson and Cohn, 2008). For example, the dopamine hypothesis (Asby, Isen & Turken, 11 1999) attempts to explain the neurophysiologic basis for positive emotion being associated with a shift in attention and improved ability to problem solve. This theory proposes that positive emotion is associated with the release of dopamine in areas of the anterior cortex of the brain associated with higher levels of thinking, which is what mediates the cognitive effects of positive emotion rather than the associated positive feelings. In another example, Fredrickson and Joiner’s research (2002) suggests that while negative emotion tends to narrow attention, positive emotion broadens focus improving perspective-taking and problem-solving. Positive emotion has been found to calm the body effects of negative emotion such as increased heart rate (Fredrickson & Branigan, 2005). In a study conducted by Fredrickson, Mancuso, Branigan and Tugdale (2000) participants’ heart rate was seen to return to baseline more quickly following positive emotion than a neutral state. In addition, heart rate recovery following negative emotion took longer than in both positive and neutral conditions. Findings such as these have heuristic value for therapists who can assist clients to move between focused attention on their problematic issues and associated negative emotion, and see themselves in a larger perspective by attending to their experience of positive emotion as it emerges. Conversely, the brief relief and deactivation experienced during or after positive affective experience may afford the resource of momentary physiological relief and perspective required to turn towards deeper and more difficult issues requiring attention. Furthermore, positive emotions, such as happiness have been shown to be linked with success (Lyubomirsky, King, & Diener, 2005), and to confer benefits on health (Pressman & Cohen, 2005). Emotion in Psychotherapy The study of emotion and emotional processes in psychotherapy is a challenging endeavour, complicated by its phenomenological and relational complexity and qualia3, theoretical diversity, definitional issues, and current limits in our methodologies. Greenberg (2002, 2012) and Watson (Greenberg & Watson, 2005) have outlined five broad, empirically derived clinical emotional processes that contribute to change in psychotherapy—emotional awareness, emotional arousal and expression, reflection on emotion, emotional regulation, and transformation of emotion. These principles are generally considered to be useful for working 3 “Qualia is a term used to refer to a quality that is not easily connected to a source, such as the experience of empathy or being emotionally moved, or features of our experience that are more or less ineffable” (Young & Valach, 2009, p. 287). 12 with clients’ emotions (Greenberg & Pascual Leone, 2006; Menin & Farach, 2007; Whelton, 2004), and considered by these authors to have important implications for practice. For example, emotional arousal and experiencing can be helpful if they are mediated by support and reflection, allowing exploration, understanding and articulation of experience (Greenberg, 2002; Greenberg, Auszra, & Hermann, 2007; Littrell, 1998); therapeutic outcome is enhanced when clients are engaged in emotional processing (Newman, Castonguay, Borkovec, Fisher, & Nordberg, 2008; Pascual-Leone & Greenberg, 2007); exposure to traumatic material in a safe, structured context reduces anxiety and changes expectations (Rauch & Foa, 2006). This research project explored how clients and therapists worked with and/or utilized client positive emotional experience, which involved arousal, experiencing, expression, reflection, and regulation. To summarize, this study responded to identified needs in the literature to explore how positive emotional processes are attended to and worked with in psychotherapy sessions. 13 Chapter 2: Literature Review Gadamer (1975/2004)) wrote about understanding as a dialogic process, one that unfolds within the circular and reciprocal nature of interactions with others, within ourselves, and even as inquirers with texts. The circularity of our understanding comes from the inevitable way we lean into our studying and questions with our prior understandings, biases, and theories. The hermeneut does not attempt to bracket or withhold these pre-conceptions, rather they are understood to guide the inquiry, be partial or incomplete, and contextual. If the inquirer remains open, she may discern the implications of her theories and understandings and where they need to be changed, and the next circle of inquiry begins again. As a way of articulating these pre-understandings and biases, this chapter provides a discussion of the themes and ideas that have informed the research question, and addresses and expands the rationales for an inquiry into how clients and therapists utilize positive emotion when they perceive it has arisen for clients in psychotherapy. Three areas of the psychology literature are summarized. First, the study is located within psychotherapy process research. Second, positive emotion is described in relation to emotion theory and foundational research. While much of the literature in this section provides indirect evidence and is not directly related to positive emotion in psychotherapy processes, it is included for its heuristic value. Third, relevant literature examining how emotion, including positive emotion, has been studied within psychotherapy is summarized. Psychotherapy Process Research The psychotherapy process literature spans more than half a decade, and is both wide in scope and depth. In order to situate my research in this literature, I draw on the historical reviews of counselling and psychotherapy process research by Hill and Corbett (1993), Orlinsky, Rønnestad, and Willutzki (2004), and Braakmann (2014). A brief overview of the major trends in psychotherapy process research will follow, as a full history is beyond the scope of this project. Hill and Corbett (1993) traced the development of process research starting with early influences of process research in counselling psychology before 1950. These authors chart the general history of overall research approaches and strategies, and theory development across the humanistic, cognitive-behavioural, and psychodynamic schools of psychotherapy. Orlinsky, Rønnestad, and Willutzki’s (2004) historical review is a shorter and mainly addresses process research trends from clinical psychology. 14 Four historical periods emerged from the Orlinsky et al. (2004) account. The early phase extended from the 1920s to the early1950s, just after the war. In this period there was a proliferation of clinical case studies described in the literature that were receiving criticism in favor of more systematic clinical surveys (Braakmann, 2014). As a result, the primary focus of this period shifted towards the general question of outcome. Interestingly, outcome studies at the Berlin Psychoanalytic Institute during this time revealed similar rates of improvement and deterioration, over shorter time periods (Lambert, 2011), in clients to those reported in more contemporary research (and noted in Chapter one of this document). Eysencks’ (1952) famous critique of psychotherapy also occurred during this period. His controversial claim that psychotherapy clients improve just as well as those who do not receive therapy, sparked enormous controversy and research efforts. Eysenck’s (1952) article is often cited as a major influence on the direction that psychotherapy research took—therapy outcome success needs to be established before exploring therapy processes (Hill & Corbett, 1993). Despite this dominant outcome focus, the study of in-session processes moved ahead significantly with the advent of audio recording. Audio recording and transcription allowed researchers to analyze actual session dialogue, rather than having to rely on detailed case notes and case histories. Rogers and his colleagues at Ohio State University began studying in-session processes, in one study finding that the acceptance and clarification of feelings resulted in more insight than questions and interpretation (Braakmann, 2014). As early as the 1930s, wax recording cylinders were used in Germany to record analytic sessions (Hill & Corbett, 1993). This early work was a considerable achievement, illustrating phenomena of private therapy sessions as the objects of rigorous research, and establishing the goal of process research to examine key therapy process variables that contribute to successful sessions and overall outcome. Orlinsky et al. (2004) located the second historical period of process research between 1955 and 1970. In this period client-centered researchers were prominent, and several notable innovations occurred. The systematic observation of client subjective experience and the creation of early measures and questionnaires for both therapy participants, and expert observers appeared (2004). In addition, Rogers’ seminal article (1957) on the necessary and suffic ient conditions for change stimulated an enormous research and therapy legacy (Goldfried, 2007). The focus of much of the process research at this time was centered on understanding the therapeutic relationship, client and therapist characteristics, and how they affect one another and 15 the outcome of therapy, revealing the complexity between process and outcome (Braakmann, 2014). Other notable counselling psychology contributions in this period were the training models for therapists by Carkhuff (1969) and Ivey (Ivey, Normington, Miller, Morrill, & Haase, 1968), and Norman Kagan’s interpersonal process recall (IPR) method of interviewing (Kagan, 1975; Kagan, Krathwohl, & Miller, 1963). IPR is particularly notable for accessing the internal processes (thoughts and emotions) of therapists, clients, or any other research participant of interest, such as counsellors or teachers in training. Privileging client experience, and IPR interviewing are both aspects of the methods used in this project. The IPR procedure, including its past uses and benefits will be discussed in detail in Chapter Three. The third period of process research (between 1970-1985) was characterized as “one of expansion, differentiation, and organization” (Orlinsky et al., 2004. p. 308), and as having a central organizing discourse of scientific rigor. Outcome studies and the movement towards empirically supported treatment approaches dominated this period, as the psychotherapy community attempted to validate its work and respond to the demands of the economy, shrinking health care monies, and the dominance in psychiatry of pharmaceuticals (Hill & Corbett, 1993). In addition, the development of meta-analytic procedures allowed researchers to respond more fully to Eysenck’s (1952) critique and a general consensus began to be built that psychotherapy is generally effective for most clients (Lambert & Ogles, 2004). Orlinsky et al. (2004) cite two major developments in the process research occurring during this period. First, research on the therapeutic alliance, using Bordin’s (1979) concept of goals, tasks and bonds, stimulated a vast literature (Horvath & Bedi, 2002), and revived the interest in the therapeutic relationship started by Rogers (1957). Second, the introduction of task analysis into the study of psychotherapeutic processes by Rice and Greenberg (1984) provided valuable research insights into psychotherapy process. Task analysis (Greenberg, 2007) is a complex, mixed method, programmatic approach to in-session processes, involving a series of steps. Significant events and their markers within therapy sessions are identified in order to systematically study the micro processes within the events, events within sessions and across sessions. It initially involves a discovery-oriented phase whereby a small number of cases are analyzed to develop a rational model of the micro processes. The rational model is subsequently tested with a larger number of cases. Task analysis has led to a number of important understandings about psychotherapy process, such as how global emotional arousal can be 16 differentiated through emotional processing (Pascual-Leone & Greenberg, 2007). While I do not employ task analysis in this research project, I do closely examine episodes of positive emotional experience and expression, which can be seen as therapy moments or events that may be important in the change process (Fitzpatrick & Stalikas, 2008). The fourth period of process research is identified by Orlinsky et al. (2004) after 1985, and reported as “more difficult to characterize because we are still so close to it, or are perhaps still in it” (p. 308). The authors describe this phase as one of “consolidation, standardization, elaboration, innovation, critique and controversy” (p. 309, 2004). Large programmatic projects and their outcomes were reported, such as the influential NIHM Treatment of Depression Collaborative Research Program (Shea, et al., 1992). Considerable process and outcome research has been conducted since 1985. Researchers have advocated for methodological plurality, and the inclusion of more sophisticated quantitative analysis methods that can connect processes and outcomes, and model change over time (Laurenceau, Hayes, & Feldman, 2007; Kazdin, 2008, 2009). Specific controversy during this time has centered around what therapeutic modalities are empirically supported, how much change is accounted for by common factors such as the relationship, hope, patient and therapist characteristics, and the alliance. In 1985 the American Psychological Association’s (APA) clinical psychology division (Division 12) established the Task Force on Promotion and Dissemination of Psychological Procedures and published the standards for judging the validation of psychotherapy interventions, which subsequently resulted in published lists of empirically validated/supported treatments (Chambless, 1996; Chambless & Ollendick, 2001). These standards were heavily critiqued and controversial because many APA members believed the task force overlooked the research on critical relationship variables, and “were seen to be too closely aligned with cognitive behavioural treatments to be objective” (Castonguay, & Beutler, 2006, p. 3). To address this controversy, the APA Division 29 Psychotherapy Task Force was commissioned to identify elements of effective therapy relationships and methods of tailoring therapy to meet individual client characteristics. The outcomes of this task force were published in a volume entitled Psychotherapy Relationships that Work (2002). These outcomes were also criticized, but in this case for placing all their emphasis on relationship and participant factors, at the expense of treatment interventions (Castonguay, & Beutler, 2006). The debate continues. As a means of integrating 17 all this work Castonguay and Beutler (2006) spearheaded another task force from APA Division 12 and the North American Society for Psychotherapy Research (NASPR), which eventually published 61 empirically derived, integrative principles of change that cut across psychotherapy schools, and that practitioners can use to guide their practice. These principles include treatment procedures as well as relationship, client, and therapist factors. The principles were derived from a review of the studies and recommendations from both Task Force 12 and 29. The research question of this study directly addresses one of these principles—“therapeutic change is likely if therapists help clients accept, tolerate, and at times fully experience their emotions” (Castonguay & Beutler, 2006, p. 364). This particular principle applies across all four problem areas covered in the review and recommendations (dysphoria, anxiety, personality, and substance use disorders). Braakmann (2014) characterized this fourth period as a transition from verification to discovery. Braakmann and Orlinsky et al.’s (2014) accounts both noted the growing acceptance and use of qualitative research. This shift has served to act as a critique and balance to the post-positivist focus on verification and generalization to a focus on phenomena and exploration. Two of the main roots of qualitative research are phenomenology and philosophical hermeneutics. In phenomenology, investigation of subjective experience comes about as a result of exploration of first person accounts of their lived experience. Understanding and meaning, within a philosophical hermeneutic paradigm, occur in conversation between individuals, and are perspectival, partial, and fallible (Orange, 2010). In many ways this “innovation” is more of a controversy because it speaks to the debate within the mainstream psychology research discourse about how research “should” be conducted and what counts as evidence. This qualitative, enriching study explores how clients and their therapists attend to and work with client positive emotion experience, a concept that has been researched primarily within quantitative, positivist and post-positivist paradigms. The interpretive findings of this study, through a philosophical hermeneutic lens, provide a perspective on client positive emotion experience that is of interest and practical value to practitioners, and has relevance for clinical theory and future research. Emotion Theory and Foundational Research Terms and definitions. The study of emotion has a rich and varied foundational literature in both theory and research. However, there are many unanswered questions about structure and function, how and where emotion arises, what brain mechanisms are involved, and 18 how these translate into affective experience, physiologic changes, and behavioural manifestations. This section will summarize some of the basic theory and research related to positive emotion to highlight the heuristic value of this inquiry for psychotherapy practitioners and researchers. As previously mentioned, definitional plurality is the norm, as well as definitional confusion resulting from theorists and researchers not being declarative enough about what they are referring to when using terms, and subsequently using terms such as affect, emotion, and mood interchangeably. Taking up the discussion in the previous chapter, emotion is defined as: [a multicomponent] response system that includes a feeling state that motivates and organizes cognition and action. [It also] provides information to the person experiencing it, and may include antecedent cognitive appraisals and ongoing cognition including an interpretation of its feeling state, expressions or social-communicative signals, and may motivate approach or avoidant behavior, exercise control/regulation of responses, and be social or relational in nature (Izard, 2010, p. 367). Since every event or thought in our lives does not trigger an emotional reaction, Ekman (2003) proposed nine common ways of turning on emotion: automatic, hard-wired appraisal of environmental concerns such as security and need; thinking about what is going on in the environment which then turns on the automatic appraisers; remembering past emotional experience; imagination; talking about past charged events; empathy; learned emotional responses; and violations of social rules such as personal boundary intrusions or distancing; intentionally mimicking the appearance of a specific emotion. Emotion helps us organize how we are in relation to our environment and this includes our relationships with people in our environment. Emotion is also part of a broader set of affective phenomena that includes feelings, moods, and attitudes. Emotion has a subjective feeling associated with it, and unfolds in response to some appraisal of a personally relevant event or change in the environment in a short time frame. The affective experience or feeling component of emotion is also present in other affective states such as moods, attitudes, sensation, and affective traits such as negativity. The appraisal process may not be conscious (Berridge & Winkielman, 2003), but will set in motion a cascade of possible responses which may include diffuse or specific subjective experience, actions, facial expressions, physiologic changes, and cognition. Emotions are always about 19 something (they have an object), and as they become increasingly more differentiated with development and experience, they are typically grouped into discrete categories like fear, anger, interest, pride, and awe, to name a few. There are a number of general distinctions that can be made about emotion structure. One of the oldest and most common is between trait and state emotions. State emotions refer to immediate responses such as anxiety when speaking in public, or the sudden feeling of joy you feel when you see a loved one after a long separation. Emotional states typically last only a few seconds and they can also arise from mental activity such as daydreaming or anticipating future activities. As mentioned above, a mood is a feeling that persists and is consistent over minutes, hours or even days. “She’s in a bad mood,” characterizes this variety of emotional episode. On the other hand, trait emotions characterize us over years. A general tendency to be nervous or negative that is usually present would indicate a trait emotion. In addition, emotional traits, such as chronic grumpiness or irritability, increase the chance of having a particular emotional state like rage, “because they lower the threshold needed to feel such an emotional state” (Davidson & Begley, 2012, p. xi). “A person’s trait emotions may be thought of as the summation of the states he or she experiences, ‘sadness’ being the consequence of many sad experiences over time” (Burum & Goldfried, 2007, p. 408). Trait emotions are also associated with the domains of Extraversion and Neuroticism in the Five-Factor Model of personality (Costa & McCrae, 1980). Extraversion has been consistently associated with positive affect, frequent positive affective states in daily life, and susceptibility to positive mood, whereas neuroticism has been associated with negative affect and susceptibility to negative mood (Costa McCrae, 1980, Harker & Keltner, 2001). Another useful way of classifying of emotion, is the distinction between primary, and secondary emotions. This distinction is grounded in emotion theory, and focuses on emotions as adaptive sources of information about the importance of what is occurring in our environment. It has proved to be helpful in highlighting different emotional structures, and guiding clinical work with emotions. It is one of the many significant contributions that the experiential school has made to research on emotional processes in psychotherapy. Greenberg (2002), labelled as primary those first gut reactions (appraised states of readiness) to events and situations, such as anger at violation, or sadness at loss, or gratitude at receiving a gift (p. 44). Secondary emotions are understood to emerge out of primary emotional or cognitive processes such as anger in 20 response to shame, or anxiety from ruminating. In essence they are feelings about feelings. They involve an interesting form of substitution in which emotional expression is used to avoid emotional awareness and block the underlying primary emotion (Kennedy-Moore & Watson, 1999). This substitution may be the result of thoughts such as being ashamed in response to an aggressive fantasy, or they may serve a defensive function such being angry to protect the self from feeling a more vulnerable state like sadness. Instrumental emotions, a sub-type of secondary emotion, are learned emotional responses and serve to achieve a goal, such as crying to get support, or being angry to get control. All emotional states have their adaptive purpose. However, in this classification, the term adaptive emotion refers to an emotion that is consistent with the context, preparing the individual for effective action, while the term maladaptive emotion refers to states that involve faulty learning such as shame about the self after being abused, fear of love and support. They interfere with healthy functioning because underlying issues are not addressed. The experience of an emotion involves a feeling of pleasantness or unpleasantness, and “contains additional experiential contents, such as felt arousal, and relational or situational meaning” (Barrett, Mesquita, Ochsner, & Gross, 2007, p. 381). The relational content has to do with the mental representation of the individual’s relationship to others, either present or imagined. The situational content refers to the actual situation, and usually what the individual perceives the emotion to be caused by. This situational content is likely tightly coupled with cultural meanings and practices (Barrett, 2006b). Being surprised and laughing, or being surprised and annoyed when splashed by water as a car drives by at a bus station are examples of emotions (surprise, annoyance) and emotional responses (laughing). Emotions are usually quick, wane within seconds or minutes, are tied to habitual and/or culturally appropriate ways of expression in public, and are accompanied by any number of individual thoughts based on past experience, expectations, thoughts, and other contextual information. Moods, on the other hand, are “more enduring, but diffuse forms of emotional experience that can color perception, judgment, memory retrieval, and information processing” (Kennedy-Moore & Watson, 1999, p. 65). Moods also differ from emotions in that they tend to last longer and do not occur in relation to an event or object. They are often interwoven with negative cognitions about the self that are associated with depressed affect, and tend be more in the background of awareness (Fredrickson & Cohn, 2008). For example, a 21 person who had recently been in a disagreement with a sibling and perhaps received feedback like: “You are just the same rigid thinker as you always were,” might find themselves feeling regret and sadness, and have persistent thoughts like: “Why do I always say the wrong thing?” This combination of affective response and cognition has the potential to create or exacerbate a depressed mood that may last hours, days or even weeks, and potentially affect enjoyment of and attitude towards work, and other activities during the duration of the mood. Feeling component. The feeling component of emotion is a basic, free-floating sense of pleasantness or unpleasantness, tension or relaxation. Barrett et al. (2007) characterizes this elemental mode of responding to an inborn knowledge that functions to help humans decipher whether events, objects, and/or relationships are rewarding or helpful or not. This claim is based on observations and theorizing that experiences of pleasantness and unpleasantness are present at birth (Sroufe, 1979), and that these experiences are also pancultural (Mesquita, 2001), in effect representing the simplest and most basic building blocks for more complex emotional experience. In addition, feeling experience tends to last longer than an emotion, which is short lasting, and may only be salient in terms of actual conscious subjective experience (Fredrickson, 2001; Gross, 2010). The feeling component of an emotional state is often modeled as varying across two dimensions—pleasantness or unpleasantness and high or low activation (Russell & Barrett, 1999), or pleasantness or unpleasantness and positive or negative activation (Watson & Tellegen, 1985). These dimensions form a valence-arousal circumplex, around which different emotions are categorized. Theoretically, the circumplex is regular but research data reveals that emotions cluster in similar groups (Watson, Wiese, Vaidya, & Tellegen, 1999). For example, contentment is a pleasant, low activation state, whereas excitement is a pleasant high activation state. Positive affects such as these will appear on the same side of the circumplex, but elation would be closer to excitement than contentment. Evidence reveals a shifting relationship between pleasantness and unpleasantness along bipolar lines (Green, Salovey, & Truax, 1999). At low levels of emotional arousal positive affect and negative affect often co-occur, and do not appear to directly affect one another, but as arousal increases to high levels of activation, positive and negative affect experience are seen to be inversely correlated (Diener & Iran-Nejad, 1986; Diener, 1999; Green et al., 1999; Reich, Zautra, & Davis, 2003; Watson et al., 1999). In other words, when arousal is low to moderate, 22 along the dimensions of pleasantness and unpleasantness, positive or negative dimensions are more independent of one another, whereas when activation or arousal is high they appear more as a single bipolar dimension. Another aspect of the relationship between positivity and negativity that has implications for the broad positive and negative categorizations of emotional experience is the research related to negativity bias and positivity offset. Rozin and Royzman (2001) consider the principle of the negativity bias to be: “in most situations, negative events are more salient, potent, dominant in combinations, and generally more efficacious than positive events” (p. 297), and the principle of positivity offset to be “a bias to treat relatively neutral entities [events] as positive” (p. 297). The negativity bias is considered to be an adaption built into the brain early in our evolution for survival, and operates like a “hair-trigger readiness to go negative to help [us] survive” (Hanson, p. 20, 2013). Hanson (2013) summarizes the negativity bias as: “Your brain is like Velcro for negative experiences but Teflon for positive experiences,” (p. 27). Several reviews about the relationship between the impact of negative events versus positive events and negativity versus positivity (Baumeister, Bratslavsky, Finkenauer, & Vohs, 2001; Rozin & Royzman, 2001; Taylor, 1991) conclude that there is evidence to support the idea that negative events, experiences, or perceived negatives objects and events are generally more potent than positive ones, especially when they are competing for attention. It appears that negative events elicit more physiological, cognitive, and emotional activation than positive or neutral events, and tend to tax personal resources and capacities more than do positive events (Taylor, 1991). In addition, once initiated, these cascading effects are only gradually reduced over time and then minimized. This research validates what we intuitively know—negative events and strong negative experiences pack a punch, and their effects linger. Intense or novel, positive events and experience seem to have little lasting effect on implicit memory in the brain because in part when we recognize something positive it must be kept in mind for at least several seconds and optimally longer in order for it to be transferred into long-term memory storage (Hanson, 2013). Gottman and colleagues (Gottman & Krokoff, 1989; Gottman & Levenson, 1986) conducted research on couples’ interactions that bears out the principles of negativity bias and positivity offset. Couples were videotaped while interacting in Gottman’s laboratory, and then were interviewed using videotape playback to get affect ratings. What Gottman and his colleagues found was that when one partner reciprocated with a negative emotional response or 23 actions to the other partner’s negative emotional expression or acts (negative reciprocity), it influenced overall satisfaction with the relationship much more than similar positive reciprocity. This pattern of interaction was also predictive of later relationship satisfaction decline and divorce. Gottman (1999) then turned to looking at how to overcome this negativity bias, eventually discovering that increasing the frequency of positive to negative reciprocity to a ratio of 5:1 seems to mitigate the negative effects of poor conflict resolution skills and predict better marriage outcomes. However, if a person experiences positive and negative emotion at different times during the day there is no reason to believe their effects cancel each other out, especially if situations invoking such emotions are not competing with one another, as is the case in many laboratory research settings (Cohn, Fredrickson, Brown, Mikels, & Conway, 2009). These authors examined the relationship between daily positive and negative affect, ego resilience and life satisfaction in 98 university students. Daily emotions were reported via the modified differential Emotions Scale: (mDES; Fredrickson et al., 2003). Ego resilience was defined according to J. Block and Cremen’s Ego-Resiliency Scale (1996) as “ability to flexibly respond to challenging and shifting circumstances,” (p. 363). Life satisfaction was measured by asking participants to respond to five selected items on the Satisfaction with Life Scale (SWLS; Diener, Emmons, Larsen, & Griffin, 1985). What they found was that that positive and negative emotions did not correlate on any day. However, daily positive emotion predicted the growth of ego resilience, but not life satisfaction; it was the increase in ego resilience that mediated increase in life satisfaction. This finding is significant. There are many studies that highlight how positive emotion predicts successful life outcomes (Lyubomirsky, King, & Diener, 2005), and this finding addresses one of the issues highlighted by Lyubomirsky et al. (2005)—when positive affect is disentangled from life satisfaction it is the short-term experience of positive emotion itself that predicted outcomes. It also supports Fredrickson’s (1998, 2001) broaden and build theory that states that mild to moderate positive emotion broadens attentional focus and perspective and, over time, these effects accrue resources and lead to a growth in positive life outcomes. Lyubomirsky et al., (2005) and Fredrickson’s (2013) work is discussed in more detail later in this chapter. Cohn et al. (2009) also found that moderately high levels of positive emotion protected against the decrease of ego resiliency, and this effect continued in the presence of negative emotions. 24 In fact, bereaved spouses who are able to experience and express positive emotion six months after initial bereavement in a narrative interview, as measured by Duchenne smiles and self-reported emotion, experienced less grief over a period of two years (Bonnano & Keltner, 1997) than those bereaved spouses who expressed and experienced more negative emotion, especially anger. The Duchenne smile, also known as a “natural” smile, takes its name from the French anatomist Duchenne de Boulogne, to whom Darwin (1872/1955) attributed the credit for first observing that the the muscle around the eyes crinkles when authentic joy is felt and expressed. The Duchenne smile is characterized by the contraction of the zygomatic major muscle that draws the corners of the mouth up, and the orbicularis oculis muscle that surrounds the eye and manifests as wrinkles or “crows’ feet” around the eyes. There is no contraction of the orbicularis muscle, only contraction of the zygomatic major muscle during a non-natural or polite smile. Similarly, bereaved spouses who draw on positive experiences during periods of high negative and distressing emotion, especially expressing laughter and Duchenne smiles, experience less distress (Keltner & Bonnano, 1997). Taken together these findings suggest that assisting people who are experiencing high levels of distress to access positive emotion may prove to be important. For psychotherapists this does not mean that doing so would be at the expense of addressing distress and problems that often bring people into therapy. Rather, it suggests that interventions and exercises that bolster positive affect without sidelining important issues or being contraindicated, may well be helpful and protective. There are several such resources online and many people access these interventions and use them. Two examples include: Martin Seligman’s Authentic Happiness at http://www.authentic_happiness.com, and Rick Hanson’s The Foundations of Well-being at http://www.fwb.rickhanson.net. Seligman, Rashid, and Parks (2006) examined the impact of web-based positive psychology interventions that are part of their approach called Positive Psychotherapy (PPT) with people who were depressed. The goal of such interventions is to increase positive emotion, and build character strengths and sense of meaning in life. One example of a series of uncontrolled tests these authors carried out using web-based interventions with online website subscribers occurred on a pilot website, www.reflectivehappiness.com. It offered a book club, newsletter, monthly discussion forum, and they posted one positive psychology intervention per month. The three blessings exercise in which participants are asked to write down three things that went well in their day and why they think this was so was the first. The first month the site 25 was operational, 50 participants were scored and deemed depressed on a Center for Epidemiological Studies-Depression Scale (CES-D; Radloff, 1977). Two weeks after completing the three blessings exercise 94% of the subscribers were less depressed with their scores falling from a mean of 33.90 (deemed extremely depressed level) to a mean score of 16.90 (deemed mild to moderate depressed level). These are impressive results for a single, uncontrolled web administered intervention. It may be that the intentional effort of signing onto a web-based intervention, combined with the act of remembering positive experience and reflecting on it served to interrupt the usual negative focus and negative framing of situations and experiences so typical in depression. In addition, the introduction of positive experience into the struggle with depression may have served to open up perspective and provide a differentiated view of the day by speculating on why some things went well. These same authors went on to study a group of positive interventions administered face-to-face in a 6-week group format of university students with mild to moderate depression. The format was not tailored to the 40 individual participants. Participants were assigned to either one of two Positive Psychotherapy (PPT) groups of 8-11 members or no treatment control groups. Each of six interventions (signature strengths, three blessings, writing a positive obituary, going on a gratitude visit, active-constructive responding, and savoring) were introduced weekly. Sessions were two hours in duration and consisted of didactic explanations of the upcoming exercises as well as discussion of the previous weeks homework exercise. The interventions were the homework. Outcome measures were The Beck Depression Inventory-II (BDI; Beck & Steer, 1992), and Satisfaction with Life Scale (SWLS; Diener, Emmons, Larsen, & Griffin, 1985) to assess changes in well-being. The participants were assessed pre, during and post interventions at three-month, six-month, and one-year follow up using the outcome measures online. Those participants who received PTT reported significant improvements in depression symptoms and life satisfaction. These outcomes increased throughout the six-week intervention and were maintained through one year of follow-up. The no treatment group participants showed no improvement from baseline. Extending this study, Seligman, Rashid and Parks (2006) studied individual PPT sessions with 32 clients seeking treatment for unipolar depression at a university based counselling centre. Twenty participants were randomly assigned to either individual PPT or treatment as usual (TAU), and they were compared to a non-randomized group receiving either TAU or TAU plus medication (TAUMED). PPT was provided for twelve weeks 26 with up to twelve individualized sessions. The sessions were tailored to build therapeutic rapport, keep the clients focused on positive symptoms, lessen negative symptoms of depression. In addition, therapists steered the process by requesting clients to access their self at best, identify strengths and how they used them in work, relationships, and parenting if appropriate. Rather than exploring and reframing negative thoughts, beliefs and affects, the key goal of the approach is to assist clients to forward the positive aspects of their lives in their awareness, building and reinforcing these positive traits, behaviours, thoughts and feelings. PPT participants fared better than the TAU or TAUMED groups, with 64% of PPT over 11% of TAU group and 8% of TAUMED group remitting at the end of the intervention. These authors postulate that PPT interventions serve to turn attention away from negative biases, improve awareness of strengths, and sustain engagement in positive, purposeful activity. They further suggest that these interventions be combined with addressing clients’ concerns and distress. When clinical populations under stress, and in particular the stress of chronic pain, were studied, the complexity of the relationship between positive and negative affect began to emerge. Zautra and colleagues (Zautra, Smith, Affleck, & Tennen, 2001; Zautra, Johnson, & Davis, 2005) using their dynamic affect model have studied large groups of individua ls suffering with chronic pain. Their model posits that the relationship between positive and negative emotions is directly affected by individual differences and ongoing experiences and events in a person’s life (Zautra et al., 2001). As stress increases people are less able to detect the subtlety and differences in their emotional experience. The reduction in ability to accurately differentiate emotional states is explained as responsible for the inverse relationship seen between positive and negative emotion when negative emotion is high. This means that during times of high distress, people are less able to attend to the complexity of their experience, and they are more vulnerable to the negativity bias, in essence ensuring that they have less access to their positive experience. In a study of 175 women with rheumatoid arthritis over 12-20 weeks, Zautra et al., (2001) measured mood clarity (TMMS; Trait Meta-Mood Scale, Salovey et al., 1995), pain (self-report intensity scale of 1-100), and positive and negative affect (PANAS; Positive and Negative Affect Schedule, Watson, Clark, & Tellegen, 1988). The awareness of and ability to understand one’s emotions is referred to as mood clarity. Preliminary findings were obtained using descriptive statistics and correlations among the three variables of mood clarity, pain, and valenced affect. The initial results, not surprisingly, revealed that as pain increased, positive 27 emotion decreased, negative emotion increased, and positive and negative emotion were inversely related, as suggested by several researchers (Diener & Iran-Nejad, 1986; Diener, 1999; Green et al., 1999; Reich, Zautra, and Davis, 2003; and Watson et al., 1999). These findings were further elaborated by Zautra, Johnson, and Davis (2005) in a study of 124 women with osteoarthritis or fibromyalgia. In the first study (Zautra et al., 2001), mood clarity was also correlated with positive affect, but was unrelated to negative affect, suggesting that participants who were aware of their emotional states were able to detect a range of emotions, not just the most salient negative ones. When the interactions between positive emotion and pain, and positive emotion and mood clarity were tested, a weaker link between pain and negative affect was found when positive emotion was present. In addition, negative affect did not increase when positive affect was high, even when pain was high. Similarly, the relationship between mood clarity and negative emotion was weak. When mood clarity was high negative affect changes were not linked to positive affect changes. However, when mood clarity was low a strong inverse relationship between negative and positive mood occurred. At these times, when negative emotion is high and mood clarity is low people are more likely to engage in simpler explanations and types of thinking. We see examples of this in people with depression using black and white thinking. Given that the underlying mechanisms of how these relationships operate is unknown, we do not know if: a) positive affect acts as a buffer against stress; b) if the effects seen here are related to the fact that at high levels of activation, it is harder to have two opposing or related affective states; c) if the salience of high negative affect outweighs the salience of positive affect. Nevertheless, there are two implications of these findings for psychotherapy. First, as pain or distress increases, a corresponding increase in positive affect and/or the ability to sustain positive affect seems to play a role in regulating it, although when average levels of positive affect were present there was no salutary effect. For clinical practice, this means that when positive emotion is experienced by clients, deliberately up regulating it by attending to it, heightening it, and elaborating on it in sessions, when it is experienced by clients, could have the same effect as if it spontaneously occurred, and may serve to offset the impact of negative emotion. Second, the ability to differentiate between affective states is reduced at times of stress, potentially accentuating the inverse relationship between positive and negative emotions. This highlights the potential value of assisting individuals to access and differentiate emotional states, since being able to identify, 28 label and understand the meaning of all aspects of emotional experience has a protective effect. In addition, appreciation of the complexity of one’s emotional experience(s) is important for meaning making and decision making. These findings have important implications for understanding and building coping skills. Although the experience of pleasantness or unpleasantness or high or low arousal or activation is ubiquitous, it is by no means consistently communicated as such by everyone. In fact, Japanese students reported experiencing no emotion at all more frequently than did their American counterparts, suggesting that their emotional feelings may be in the background of their experience rather than in the foreground (Mesquita & Karasaw, 2002). General feelings of arousal or activation are also variously felt and/or reported. It seems that individuals who are sensitive to subtle visceral or physiological shifts, such as being aware of their heartbeat, notice and report arousal as part of their emotional reactions more frequently (Pollatos, 2005). These findings suggest that while valence and arousal may be consistent, basic aspects of emotional experience, they are highly individual and contextual in how they are experienced, noticed, and reported. The difference between emotion and feeling experience is one of the factors at the heart of the debate discussed in the previous chapter—is emotion inborn or is it socially constructed? Some emotion scholars and researchers postulate the core feeling of arousal and valenced experience (i.e., pleasantness or positiveness vs. unpleasantness or negativity) is the building block of emotional life, and eventually gives rise to emotion categories by virtue of experience mediated by culturally learned language and norms (Russell & Barrett, 1999). Others hold the view that a small group of discrete emotional categories such as seeking, fear, rage, lust, care, panic; and play, are inborn neural packages, and are the building blocks of emotional life that differentiate and change under the influences of socially mediated experience (Panksepp, 2009). However, both views have much to offer our understanding of emotional processes. Motivation component. Positive emotion is often seen to be associated with approach motivational direction, and negative emotion with withdraw or avoidance motivation (Watson & Tellegen, 1985). In other words, positive emotions are often associated with motivation to approach desired outcomes, rewards, and to seek out novel (Izard, 1997), and fun experiences (Carver &White, 1994). 29 Cacioppo and colleagues (Cacioppo & Bernston, 1994; Cacioppo, Gardner, & Bernston, 1999) theorize that in relation to approach and avoidance behaviours in humans, there seems to be a stronger motivation to approach and explore in the environment when appraised [emotional] arousal is at low levels. Furthermore, when emotional arousal is at low levels or perceived to be approximately neutral, it is appraised as positive. Cacioppo et al., (1999) infer from this that the evolutionary advantage of the positivity offset is the motivation to approach novel objects and contexts when things are going well, and the adaptive advantage of the negativity bias is to avoid or conserve energy and resources in stressful or dangerous circumstances. Carver (2001) further elaborated the motivation of approach or avoidance from a theoretical functional perspective by drawing on two theoretical ideas. First is the general view, partially stated above, that behavior and concomitant affective states such as positive emotion and negative emotion, emerge from either a behavioural activation system that manages approach motivation, or a behavioural inhibition system that manages withdrawal motivation. Second is Carver and Scheier’s (1990) view that affect arises from the effectiveness of goal directed action monitored by these systems. Carver postulates that positive affect arises when we are doing better at something than we need to, and negative feelings arise when we are doing worse than we need to. In other words, positive affect arises when we are achieving or very close to achieving our goals, whereas negative affect arises when we are farther away from achieving our goals or not achieving them at all. Given this, Carver and Scheier (1990) theorize that any action may involve positive, neutral, or negative affect along two bipolar dimensions. In the approach dimension sadness or depression arise when progress is very low, and eagerness, happiness or elation arise when progress is very good. Similarly, in the avoidance dimension when progress is very low (avoidance is unsuccessful), anxiety or fear arise, and when avoidance progress is high (successful) relief, calmness, or contentment may emerge. This model delineates different types of positive and negative affect and their relationship to one another, and is helpful when considering atypical emotional categories such as anger and fear. For example, the joy and satisfaction felt successfully pursuing (approaching) the goal of standing up for oneself in righteous anger is quite different than the positive affect of relief, calmness, and tranquility that may arise as a result of avoiding being on the receiving end of an aggressive act (avoiding threat). Extending this argument, Carver suggests positive and negative emotion may function as signals about the priority of the goal being enacted in the moment. For example, if 30 an individual successfully expresses righteous anger and is heard, the priority to continue with this goal is reduced. Similarly, if the fear signaling threat dissipates when the threat is successfully avoided, the priority to dedicate additional attention or resources to this goal is also reduced. While Carver does not suggest that openness to a new direction or interest in new goals is an absolute, the opportunity exists for a change of focus to occur. Several sources of evidence support this idea that positive emotions engender openness to different activities, and/or goals, especially self-relevant ones. Trope and Neter (1994) tested participants on a social sensitivity task, telling them that the test predicted social adjustment and success in relationships. In one experiment, prior success rather than failure bolstered participants’ interest in receiving negative feedback on an unrelated task. In a second experiment, participants were asked to recall and write a description of three positive or three negative events in the previous 3 months, after which mood was measured using a five-face scale schematic ranging from negative to positive mood, and five-point scale rating form very bad to very good. The control group was given a judgment test. After the mood rating was completed participants were offered their results. The feedback assessed three skills—empathic ability, ability to accurately assess other’s personality, and ability to avoid stereotyping. Each participant was given positive feedback on two of the dimensions and negative feedback on a third dimension. When asked if they would like additional detailed feedback, and that time would not permit detailed feedback on all three domains, participants in the positive mood group showed greater interest overall in negative feedback, whereas participants in the negative and neutral affect groups had a preference for positive feedback. In a third test, participants were found to actively seek positive experiences prior to deciding to accept negative feedback. Trope and Neter (1994) were studying these effects to look at the motivational conflict inherent in receiving feedback about personal challenges, and interpreted these results as positive affect buffering participants against the effects of receiving negative feedback, as well as serving as a resource for making changes in areas where personal skills need strengthening, such as being more empathic. These findings do seem to support Carver’s position, that positive affect arises when one is moving successfully towards a desired goal, and that this may set the stage for looking at alternate goals, where progress is not satisfactory. In another set of studies, Trope and Pomerantz (1998) replicated these findings. Specifically, they examined how prior success or failure affects willingness to seek feedback. 31 The authors hypothesized that with regard to the competing interests of self-assessment (learning what skills and abilities need improvement for achievement of life goals and occupational goals) and defensive goals (preserving self-esteem from the impact of negative feedback) positive experiences would increase interest in self relevant feedback whether it is positive or negative. In the first two experiments, these authors asked participants to rate their interest in and ability to achieve life goals, and their interest and abilities to fulfill occupational goals while in a neutral state. No emotional inductions were utilized. These experiments revealed that participants were interested in both positive and negative feedback as self-relevance of the life goal or occupation goal increased. In their third experiment, success or failure experience was induced via providing an anagram test, and participants were given either success or failure feedback. This mood induction was followed by a separate session in which participants were asked to indicate and rate their interest in receiving both positive and negative feedback related to their suitability in each of 26 occupations in an occupational suitability test they completed upon university entrance. The findings revealed that overall participants wanted both positive and negative feedback in occupations that interested them. Trope and Pomerantz (1998) interpreted these findings to suggest that while receiving negative feedback about suitability for a desired profession would be stressful and unflattering, participants wanted this feedback as much as they wanted positive feedback, in self relevant occupations. While these findings provide indirect evidence for the relationship between positive emotion and willingness to pay attention to negative information about the self, and do not relate to clinical populations, they have important implications for psychotherapy. The very nature of the therapeutic endeavor requires clients to soften their defenses and open themselves to vulnerability. Frequently this requires clients and therapists to work with fears and anxieties about approaching difficult, unwanted emotional states or hidden aspects of the self, such as blind spots, or shame-inducing experiences and narratives in order to make wanted changes. Accessing positive affect in a therapeutic session has the potential to resource and buffer clients from the stressful effects of negative emotional arousal. In addition, recruiting positive affect, successes, or even positive memories appears to open up perspective and set the stage for receiving feedback, and for new self-relevant goals to take precedence. Such interventions have the potential to accelerate and deepen therapeutic process. 32 In another line of research, E. Harmon-Jones, C. Harmon-Jones, Amodio and Gable (2011) expanded on the complexity of motivational aspects of positive and negative emotion. These authors provided evidence for the suggestion that Ekman (2003) made: “Just as there is a set of distinctive emotions that we usually don’t enjoy feeling, there is a set of distinctive emotions that we do enjoy feeling” (p. 190). E. Harmon-Jones et al. conducted a series of studies in which they examined the relationships between attitudes about five emotions (joy, anger, fear, disgust and sadness) and approach-avoidance, trait emotions, emotional reactivity, and emotional regulation efforts. These studies revealed that participants had distinct attitudes towards these emotions that predicted interest (measured as willingness to view stimuli that would evoke that emotion). As intuition would predict, joy was consistently evaluated as more positive than anger, and the other four emotions were evaluated as negative. However, there were differences in the degree to which these emotions were evaluated as positive or negative, differences that were associated with trait emotions. The direction of the association between positive affect was found to be related to whether or not the emotion was approach-oriented or withdraw-oriented. Those participants with high approach trait emotion of joy and anger liked and experienced these states more in response to stimuli that evoked them. Those that had high withdraw trait emotions such as fear and disgust disliked these states more and had less of these emotions in relation to stimuli that evoked them, suggesting they may have been actively avoiding these states (E. Harmon-Jones, C. Harmon-Jones, Amodio, & Gable 2011). These findings suggest that attitudes towards certain emotions, are more related to their regulation than the emotions themselves, tying into Greenberg’s (2002) notion of secondary emotions, and the value of helping clients to understand the reasons for preferring some emotional states, and wanting to avoid others. In a related line of research Gable and E. Harmon Jones (2008, 2010a, 2010b) studied the effects of motivational intensity on attention. These authors hypothesized that the broadening effect attributed to positive affect may be related to emotional intensity rather than purely the feeling experience or affective valence. Gable and E. Harmon-Jones (2008) reasoned that in previous research in which positive affect was induced using films, candy or small gifts, the emotion induced and responsible for broadened attention was likely of moderate or low intensity such as contentment, happy feeling, amusement. They further hypothesized that high intensity positive affect such as desire or enthusiasm would have the opposite effect of narrowing 33 attention related to the goal oriented or appetitive motivation associated with higher intensity affects. In a series of studies these authors found that low-intensity positive affects such as amusement, broadened the scope of attention while high- intensity positive affects such as desire narrowed the focus of attention onto specific goal pursuits. In addition, these authors (2010b) found this same relationship between motivational intensity and attention held when negative emotional intensity was examined between sadness and disgust. It has been suggested by Fredrickson (1998, 2001) that negative emotions narrow the scope of attention, while mild positive emotions broaden the scope of attention. These findings suggest that emotional intensity has different effects on different emotions, even within same valence categories. These findings have interesting implications for psychotherapists. For example, therapists can help their clients understand how their own past experiences, cultural practices, dispositional preferences, and appraisal biases work in their emotional responses, and how this may affect their relationships with themselves and with others, as well as why certain emotions are avoided, down-regulated or suppressed. Both positive responses and negative responses have their adaptive aspects. For example, a culturally relevant and ideal positive emotion such as expressed contentment or satisfaction expressed at a family gathering, as well as an individual, actual positive affective experience such as gratitude for being recognized by a colleague can serve as signals that things are going well, that the status quo and current activity or efforts do not require any changes. On the other hand, culturally relevant, appropriate negative emotion such as hidden fear at being required by an employer to speak before a large unknown audience, and actual, individual negative experience, such as anger about being required to speak in public may signal goals are not being attained, that challenge is too great, that the status quo requires a change in response. It has been suggested by Izard (2007) that the discrete emotion and dimensional approaches are complementary rather than contradictory. In psychotherapy practice helping clients to regulate high arousal feelings is as helpful as assisting clients to be able to differentiate and label feelings, using categories such as deep sadness, intense fear or emergent gratitude. Izard (2007) makes two further important points. First, both conceptions are required to explain why discrete emotions seem to be related (happy and pleasant, unhappy and unpleasant), and occur in patterns (Diener & Iran-Nejad, Diener, 1999; Green et al., 1999; Reich, Zautra, & Davis, 2003; Watson et al., 1999). Second, dimensional aspects such as pleasant/unpleasant or 34 positive/negative suggest approach and avoidance motivations, and discrete emotions provide particulars about how to approach or avoid, and why we are approaching or avoiding (Izard, 2007, p. 269). Benefits of Positive Emotion There is a wide spectrum of research inquiry that addresses the adaptive nature and multiple, interrelated benefits of positive emotion. These include cognitive, social, health, and psychological benefits. This section will start with Barbara Fredrickson’s work, because her broaden and build theory has been widely taken up as a central explanatory framework to explain the function of positive emotion, how positive emotion works in relation to negative emotion, psychological health, and resource building. A brief summary of some of this research follows. The Broaden and Build theory. The broaden and build theory of positive emotion (Fredrickson, 1998, 2001) has provided a useful theoretical framework to stimulate research. It also provides a functional explanation for atheoretical research conducted on the relationship of positive emotion to other aspects of human functioning, such as coping with stress, health, and life outcomes. The theory postulates that the function of positive emotion is to momentarily broaden a person’s scope of awareness, making the way for novel ideas, interest in new experiences and relationships. These repeated episodes of broadening provide the opportunity to practice and incrementally build personal resources, such as supportive relationships, skills, knowledge, and resilience over time. Furthermore, these resources will provide more experiences of positive emotion and create an upward [self-perpetuating] spiral (Fredrickson & Cohn, 2008). This theory has significant implications for psychotherapy theory and practice, that has traditionally seen positive emotion as an outcome of change for the better (Greenberg & Paivio, 1997). In proposing this theory, Fredrickson rejected the assumption that all emotions are characterized by distinct action tendencies, or states of readiness to act in a specific way. For example, fear elicits the urge to pull away and withdraw from a threatening stimulus, whereas contentment may induce sitting back and savoring, there is no real action required. Rather than using the term action tendency, which implies an urge for specific action related to the cause or trigger of the emotion, Fredrickson (1998, 2001) proposed the term thought-action tendency to more accurately capture the broad range of cognitive and action possibility that seems to be evoked by positive emotion. The theory holds that functionally, positive emotion signals that 35 things are going well enough that attention can be directed outwards into the environment towards novelty and possibilities for building resources, such as relationships and physical reserves (Gervais & Wilson, 2005). Thus, the theoretical link is made between broadening attention and building resources. Undoing hypothesis: the beginnings of the broaden and build hypotheses. While working with Robert Levenson in the 1990s, Fredrickson began to formulate her ideas. Levenson had speculated an undoing hypothesis in which positive emotions might be evolved to undo the psychological and autonomic nervous system (ANS) arousal associated with negative emotional states such as anger. This did not imply that all positive emotions would effect such a change, but rather suggested that those that follow negative emotion temporally may play such a role. Fredrickson and Levenson (1998) tested this hypothesis, and found that when subjects were shown a fear-inducing film, followed by a film that elicited contentment, amusement or sadness, those that viewed positive films recovered their baseline heart rate more quickly than those shown sad or neutral films. In another study, Fredrickson and Levenson (1998) tested subjects by showing a sad film, videotaped each participant and noted that those whose mouth revealed upturned edges (Duchenne’s smile) during the film also recovered baseline heart rate more quickly than those who did not smile. Both studies provided early validation of the undoing hypothesis, although they had several limitations: sympathetic nervous system arousal differed between participants—some showed heart deceleration which is not typical; heart rate was the sole indicator of autonomic arousal; the studies over relied on female subjects despite the cultural diversity in the sample. In addition, there was no neutral emotion condition, which leaves open the possibility of an alternate explanation—that positive emotion simply replaces the cardiovascular response of negative emotion because it slows heart rate (1998). In two further studies Fredrickson, Mancuso, Branigan and Tugdale (2000) addressed these limitations and replicated Fredrickson and Levenson’s (1998) work revealing that heart rate returns to baseline more quickly following a positive emotional state than a neutral state, and that heart rate recovery, following negative emotion, takes longer than in both positive and neutral conditions. What these studies illustrate is not so much about how positive and neutral emotional states differ in what they do to the cardiovascular system, but in what they undo within that system (Fredrickson, 2008, p. 788). Practically, these findings reveal that positive 36 emotion can affect the course and duration of negative emotions. For clinicians, it implies that working with positive emotion has the potential to both mobilize physical resources to move forward (for example, approach, renewed interest) in sessions during challenging, more distressing moments, and to provide necessary relief from the arousal of negative emotion experiencing. Eventually Fredrickson came to hypothesize that this undoing effect was the by-product, rather than the function of positive emotion (Fredrickson, 2003). Broadening hypothesis. Fredrickson still had doubts. “Is this the evolved purpose of positive emotions — that they are a reset button?” … “That would suggest that most of our positive emotions would occur in the context of negative emotions.” (Roberson, 2008, para. 8). In more closely examining the theoretical literature on joy, interest, love and contentment Fredrickson noted that each of these emotions did not result in distinct and direct action. In fact, these emotions seemed to bring about a change in cognition and only sometimes did this spark physical action (Fredrickson, 1998). For example, Frijda (1986) described joy: “… the action tendency of joy, is in part aimless, unmasked for readiness to engage in whatever interaction presents itself and in part readiness to engage in enjoyments [and] … is characterized by its particular activity monitoring features (mastery, freedom), as well as by its particular aims for sustaining coping endeavours” (p.89). Fredrickson (1998) hypothesized that this readiness and openness to engage was better understood as a thought-action tendency. She then made a considerable inferential leap by connecting readiness to engage with openness to play and explore in social, intellectual and creative activity: “to my mind, then, the urge to play represents a quite generic, non-specific thought-action repertoire” (p. 305). Seeking foundational research support for her ideas Fredrickson (1998, 2001) turned to the work of Alice Isen and her colleagues. Isen (2004, 2008) had been researching positive emotion and its impact on problem solving and decision making for two decades. Fredrickson believed Isen’s work complimented hers, in particular because Isen utilized neutral control groups in her research, which opens up the possibility for the independent effects of positive emotion to emerge for analysis. This operationalized their shared assumption that positive and negative emotions were not opposites on a continuum (Russell & Barrett, 1999; Watson & Tellegen, 1985), but rather separate dimensions (Cacioppo, Gardner, & Bernston, 1999). Isen also utilized a variety of methods to induce positive emotion, such as giving a small gift of candy, having subjects read cartoons, watch comedy films, or read multiple positive words, thus improving the 37 generalizability of the findings. Isen found that, generally, mild positive emotion facilitates flexible thinking (Isen, Johnson, Mertz, & Robinson, 1985) and creative thought (Isen, Daubman & Nowicki, 1987), improves memory via cognitive organization (Isen & Daubman, 1984) and facilitates openness to information (Estrada, Isen, & Young, 1997). In two early studies Fredrickson found evidence for the broaden hypothesis in momentary broadening of visual attention (Fredrickson & Branigan, 2005). Using short film clips they induced distinct positive (amusement and contentment) and negative (anger and anxiety) emotion, and these were each compared to a neutral state. Participants were given a visual processing task and then assessed on whether they focused on global configuration or detailed elements, validating that subjects in a positive emotional state (joy and contentment) show more visual preference for a global configuration than do those in a neutral or negative emotional state (fear and anger). In their second study, Fredrickson and Branigan (2005) asked participants to step away from the films inducing emotion, and imagine and list what they would like to do in that moment. Participants in the positive emotion conditions listed more items than did those in either of the neutral or negative emotion conditions. In addition, those in the negative condition listed less things they wanted to do than participants in the neutral condition. These findings provided evidence that the distinct, high activation positive emotion of joy and the mild positive affect of contentment both produce wider attentional focus and thought-action repertoire than does a neutral affective state (2005). Two further examples of support for broadened attention come from Isaacowitz, Wadlinger, Goren, and Rowe (2006), and Rowe, Hirsch, and Anderson (2007). Isaacowitz et al. used eye tracking to measure visual preference to photographs after receiving a gift of candy. They found that participants in positive emotion broaden their visual attention by looking at peripheral images longer while they are attending to other positive or neutral peripheral images. Rowe, Hirsch, and Anderson measured participants’ ability to link words via the Remote Associations Task (RAT) after being exposed to music that induced neutral, positive or sad emotion. They also measured ability to attend to a central target and ignore flanker distractions via the Ericksen Flanker Test. These results validated Isen, Daubman and Nowicki’s 1987 findings of improved ability to attend to a central cue and ignore peripheral cues. In addition, the dopamine hypothesis (Asby, Isen & Turken, 1999) attempts to explain the neurophysiologic basis for positive emotion being associated with a shift in attention and 38 improved ability to problem solve. As stated earlier, this theory forwards the idea that positive emotion is associated with the release of dopamine in areas of the anterior cortex of the brain associated with higher levels of thinking. It also states that dopamine mediates the cognitive effects of positive emotion rather than the associated positive feelings (1999). Although beyond the scope of this paper, this hypothesis lends physiologic and theoretical support for Fredrickson’s broaden and build theory. The theoretical and research findings described above provided Fredrickson with direct and indirect support for her first hypothesis—broadening. Build hypothesis. The build part of Fredrickson’s theory was initially undergirded by research on play and laughter. The human, inherited ability to laugh, Duchenne’s laughter, is associated with rough and tumble play and has been linked to the positive emotions of mirth, amusement and joy (Gervais & Wilson, 2005). Laughter also occurs occurs under conditions of satiety and safe surprise. Gervais and Wilson (2005) summarized research and theory that acknowledges the important links between laughter and play in relieving stress, stimulating the same response in others, and increasing group cohesion by building social links and associations between individuals. These benefits accrue to both the individual and the group in that individuals develop physically, learn through signaling from one another in rough and tumble play, and benefit physically from both the activity of play and the positive effects of recovery from autonomic arousal associated with distress or negative emotion that occurs as a result of positive emotion (2005). Panksepp’s (2009) research in animal models supported similar conclusions of rough and tumble play conferring physical and social benefits in rats and dogs. In the first study to directly test the build hypothesis, Fredrickson, Cohn, Coffey, Pek, and Finkel (2008) randomly assigned 139 adult employees who agreed to participate in a study on mindfulness meditation. Sixty-seven participants were in the treatment group, the remaining 72 were assigned to a waitlist control group. The intervention chosen was a 7-week long loving kindness meditation (LKM) workshop. LKM was chosen because it specifically aims to cultivate the experience of the positive emotion of loving kindness during the meditation and in life more generally. Participants in both groups kept daily reports of their emotional experience and meditation practice and received a final survey two weeks after the end of the workshop. The number of measures used in the study was considerable. Participants were asked to complete the Mindfulness and Awareness Scale (Brown & Ryan, 2003), the Trait Hope Scale (Snyder, Rand, 39 & Sigmon, 2002) and the Savoring Benefits Inventory (Bryant, 2003) to assess Cognitive resources; the Life Orientation Test—Revised (Scheier, Carver, & Bridges, 1994), the ego resilience measure (Block & Kremen, 1996), and a subscale of Ryff’s psychological well-being measure (1989) to assess psychological resources; the Dyadic Adjustments Scale (Spanier, 1976) and another subscale of Ryff’s psychological well-being measure (1989) to assess social resources; the Illness Symptoms Self-report (Elliot & Sheldon, 1998) and the Sleep Quality Index (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) to assess physical resources; and finally the Satisfaction With Life Scale (Diener, Emmons, Larse, & Griffin, 1985) and the Depression Measure (Radloff, 1977). This was a huge commitment for participants and generated a large data set for analysis. The results revealed an increase in people’s daily experience of positive emotions such as gratitude, joy, love, awe and interest. These shifts built gradually over the test period and were not large. They were, however, linked to increases in a variety of personal resources such as ability to savor positive experiences and relationships, motivation for self-relevant goals, self-acceptance, positive relationships with others, good physical health and resulted in participants feeling more satisfied with their life and having fewer depressive symptoms. These findings provided promising support for the build hypothesis that states positive emotions allow people to build resources for themselves and that these are associated with life satisfaction and general functioning (Fredrickson, 2013). To the extent that resilient individuals recruit positive affect into coping strategies and buffer themselves against the negative effects of stress, Ong, Bergeman, Bisconti, and Wallace (2006) conducted a series of studies with 27 participants, half women and men, ages 62-80 years, over 45 days in which they set out to examine the relationship between positive emotions, stress, and resilience. What they found was that on days when stress was high, negative emotion was also high, but that individuals who were resilient were able to recruit positive emotion to loosen the effects of negative emotion and reduce the stress and negative emotion experienced on subsequent days. Non resilient individuals who recruited less positive emotion experienced more stress and negative emotion on subsequent days, meaning that the stress we have today, becomes the negative emotion we have tomorrow (Russell, 2015). Ong, Zautra, and Reid (2010) conducted another study to examine the relationship between positive emotion and broadened thinking. To do so they studied if resilient individuals 40 proactively evoke positive emotions to reduce the narrowed, catastrophic thinking (ruminating, magnification, and helplessness) that is associated with chronic pain. In their sample of 72 women and 23 men, aged 52 years to 95 years, they found that that resilient individuals regularly experienced more positive emotion than did non-resilient individuals, and that increased positive emotion was associated with less catastrophizing thinking. In other words, positive emotion recruited by resilient individuals appears to counteract the habitual, narrow thinking patterns associated with pain catastrophizing. In addition, women demonstrated markedly more pain catastrophizing than did men in the study, emphasizing the importance of attending to sources of positive emotion for women who have chronic pain. These findings collectively support the broaden hypothesis and suggest that psychological interventions that bolster positive emotion have the potential to provide not only immediate relief from the effects of distress and stress, but contribute to improvements in daily mood, reduced stress, narrow and limited thinking styles, and coping ability. Upward spiral effect. An important extension to the correlational research cited above was to study whether the mutual influence of incremental positive emotion and increased personal resources results in an upward spiral of well-being over time. Fredrickson and Joiner (2002) conducted a preliminary study to test the link between positive emotion, broad-minded thinking, coping, and the incremental building of resources. Noting the finding that people in bereavement find positive meaning in incidental events and the bereavement experience itself (Folkman & Moskowitz, 2000; Moskowitz, Folkman, Colette, & Vittinghoff 1996), they reasoned that repeated cycles of coping, positive affect and broad thinking would initiate upward spirals toward resilience and well-being. One hundred and thirty-eight undergraduate students were given credit for an introductory psychology course for participating in two study sessions, five weeks apart, in which they completed both the Positive and Negative Affect Schedule (PANAS; Watson, Clark, & Tellegen, 1998) and the Coping Responses Inventory (CRI; Moos, 1988). The PANAS asks respondents to rate 20 items for the extent to which they felt certain emotions over the previous two weeks. The CRI asks respondents to identify “the most important problem they faced in the previous year and how often they used various strategies to deal with it” (Fredrickson & Joiner, 2002, p. 173). Results revealed that positive emotion led to improved coping, negative emotion did not; improved coping predicted positive emotion, but was not related to changes in negative emotion. The results support the theory that “positive 41 emotions—through their effects on broadened thinking—predict future increases in positive emotions” (p. 174). The same did not hold true for the reduction of negative feelings (i.e. predicting broadened thinking). The results of this study were replicated by Burns, Brown, Sachs-Ericsson, Ashby-Plant, Curtis, Fredrickson, and Joiner (2007) in a study of 185 undergraduates who were tested for positive and negative emotion, positive and negative coping, trust and social support. Burns et al. used the same measures and added the Interpersonal Distrust subscale from the Eating Disorder Inventory (EDI; Garner, Olmstead, & Polivy, 1983) to measure interpersonal trust, and an abbreviated version of the Social support questionnaire (SSQ; Sarason, Levine, & Sarason, 1983) to measure social support. The findings validated the previous study. Positive emotion and positive coping mutually built on one another, positive emotion and interpersonal trust also built upon one another, but the same did not bear out for positive affect and social trust (Burns et al., 2007). In a third project, Fredrickson, Tugdale, Waugh, and Larkin (2003) studied 18 men and 28 women, several weeks after the 2001 terrorist attacks in the United States. The researchers used the broaden and build theory to hypothesize that resilient individuals recruit positive emotions to buffer themselves from crisis, and that they build their resources and thrive in the process. From an initial group of 133 respondents they obtained the above sample. The measures used were: Block and Kremens Ego Resiliency Scale (1996) to identify trait resilience; a short version of Costa and McCrae’s (1992) NEO Five Factor Inventory (NEO-FFI) to measure trait affectivity; Satisfaction with Life Scale (SWLS; Diener, Emmons, Larsen, & Griffin, 1985) to rate life satisfaction as a measure of well-being; and a modified version of Russell, Weiss, and Mendelsohn’s (1989) Affect Grid for post crisis mood assessment. All participants experienced high levels of stress following the 2001 New York attacks. Participants had a mix of positive and negative emotions. Concurrent with distress and sympathy, some of the other positive emotions they recruited into their experiences included gratitude, love, and interest, seeming to indicate they had a range of emotional experience, were stressed by the events, but were not overwhelmed by them. Those participants who experienced positive emotions more than others were those with higher trait resilience, suggesting that “positive emotions were critical active ingredients that helped resilient people to thrive despite the emotional blows delivered by the September 11th attacks (Burns et al., 2003, p. 373). These findings are consistent with other 42 studies (Bonnano & Keltner, 1997; Folkman & Moskowitz, 2000; Moskowitz, Folkman, Colette, & Vittinghoff, 1996,) that have demonstrated that resilient people can access coping resources such as positive emotions of enjoyment and amusement, finding meaning in events and even in bereavement itself which evokes positive emotion when they are under stress. While the above studies provided a research foundation for the broaden and build theory, Fredrickson’ research program continues to expand into experimental, and longitudinal studies accumulating evidence for the upward spiral. Fredrickson and her students and colleagues have also extended their work into clinical populations and examined the effects of loving kindness mediation as an adjunct to medication, on the symptoms of people with schizophrenia (Johnson Penn, Fredrickson, Kring, Meyer, & Brantley, 2009; Johnson, Penn, Fredrickson, Kring, Meyer, Catalino, & Brantley, & 2011). They are exploring offshoots of the broaden and build theory into lifestyle change (Hogan, Catalino, Mata, & Fredrickson, 2015), and how positive spirals may interact with downward spirals in people with depression and anxiety (Garland & Fredrickson 2010). One point of view in the literature on positive emotion and cognition that differs from Fredrickson (1998, 2001) and Isen (2004, 2008) is stated by the mood-as-information theorists (Clore & Huntsinger, 2007, 2009). Consistent with the broaden-and-build theory, research on these theories has also revealed that positive emotion promotes a wider cognitive focus than negative emotion (Gasper & Clore, 2002). Where these theories differ is that some mood-as-information theorists have found that participants in positive moods may have a broadened focus, but at a cost. They rely more on stereotypes, heuristics, dominant responses and schema-guided memory than participants in negative mood (Clore & Huntsinger, 2007). These ways of thinking, although broad, do not necessarily serve to build something as Fredrickson’s model suggests, and in part may be affected by the affective immediacy principle, that “affective reactions are always experienced as being about whatever is in mind at the time” (2009, p.39). Because moods and emotions are part of associative networks in the brain, when they are experienced the entire network of previously associated experience will be available to guide judgment. This means that a sad person is primed to more readily recall and attend to sad or unhappy aspects in a situation, and it means that a happy person is more primed to remember and pay attention to positive aspects in a situation. Similarly, a happy feeling person will tend to utilize dominant cognitive structures (such as stereotyping when encountering a member of a 43 stereotyped group), and heuristics because positive emotion relaxes people and signals that the environment is benign, which results in less systematic thinking and less effort exerted on goals (Clore & Huntsinger, 2009). The mood-as-information perspective hypothesizes that because many of our judgments require complex thoughts, we tend to rely on our emotions to help us access information rapidly. These rapid evaluations based on current feelings serve well in complex situations where an immediate response is required, but may incur a cost in situations where the stakes are high and require systematic thought and decision making. Sad individuals, on the other hand, may expend considerable detailed effort on tasks, resulting in less use of heuristics and more accuracy. According to Isen (2008), this contrary evidence suggests that these ways of thinking (relying on heuristics, less attention to detail and negative feedback) happens when the task is not relevant to the individual or when no feedback is forthcoming. For example, Bodenhausen, Kramer, and Süsser (1994) found that when people were accountable for their decisions, those in positive emotion employed less stereotyping than controls. As previously discussed, when tasks have important self-relevance, positive emotion sets the stage for broadened perspective and productive attention to new goals and information, even when it is negative (Trope & Neter, 1994; Trope & Pomerantz 1998). As Carver (2003) suggests, it may be that positive emotion signals that the goal of focus is attained at a satisfactory enough level, allowing attention to shift and open to alternate unrelated, and self-relevant goals. Isen (2008) does not believe that this controversy is easily solved. Rather, she believes the term flexibility better describes the effect positive affect has on cognition and that future research needs to be directed at understanding how affect influences decisions, and the factors underlying the influences, such as cognitive organization, flexibility and motivation. Similar to Carver (2003), Isen (2008) states that: “some of the reasons for the discrepancy among the studies … may lie in these and other effects of positive feelings, such as motivation and sense of freedom to behave as one thinks appropriate or to pursue one’s goals” (p. 550). Isen (2008) has also stated that there is sufficient evidence (Estrada, Isen, & Young, 1997; Johnson & Fredrickson, 2005) to believe that the idea that positive emotion results in over reliance on existing cognitive processes is not an adequate conclusion (2008). Rather, evidence illustrates that positive emotion produces flexible thinking—the ability to utilize new information and existing schemas and cognitive structures (Isen, 2004). Flexible, open thinking is an important aspect of the effects of positive emotion on 44 thinking. Whether these effects are beneficial or unhelpful will be largely determined by the situational meanings and current or unconscious appraisals that are made when the emotion is experienced, as well as resultant behaviours, decisions or activities. The broaden and build theory has generated a great deal of research, and has provided a framework within which to consider questions such the function of positive emotion, whether or not it is the feeling experience or the motivation that concur benefits, or which benefits accrue as a result of the feeling aspect of positive emotion or the motivational aspects. From a therapeutic point of view the evidence suggests that both positive and negative affect are important targets for treatment. Positive emotion and success. Lyubomirsky, King and Deiner (2005) conducted a meta-analysis summarizing the links between positive affect, happiness, and life outcomes. Employing the logic coming out of studies showing that happy people flourish, these authors generated a conceptual model to rationalize bringing together a large body of growing research that suggests happy people are more successful across domains of marriage, friendship, income, work performance, and health than their unhappy counterparts. The authors defined happiness as “the frequent experience of (mild to moderate) positive emotions over time, (p. 806).” The conceptual model draws on three bodies of work related to positive emotion. First, is Fredrickson’s broaden-and-build theory (1998, 2001) which suggests that people in positive emotion are in the position to broaden and build, and that when they are in a positive state and free from danger they take advantage of this position “to seek new goals that they have not yet obtained” (Lyubomirsky et al., 2005, p. 804). Second, Isen’s (2004) work on problem solving and decision making is included—work that suggests positive emotion facilitates flexible thinking and problem solving, is creative, careful, thorough and purposeful, when the tasks at hand are relevant to the individual. Third, the model also includes the positivity offset and work from approach-related effects of positive emotion (Carver & Scheier, 1998; Carver, 2003; Ito & Cacioppo, 1999). The model posits that happy people have had past experiences with positive moods and success, and that these happy moods promote flexible thinking, and openness to new information. In addition, because happy people frequently experience happy moods, and approach new opportunities, they work actively to explore new goals and build on previous successes and resources. 45 The meta-analysis included 225 papers: 11 were unpublished or dissertations examined to establish a link between positive affect and happiness; longitudinal studies that suggest the causal link; experimental studies to validate the causal link; experimental long-term intervention studies to offer more support for the causal link. Within these studies, 293 samples were examined, including a total of 275,000 participants. Cross-sectional analyses indicated that positive affect is associated with resources and skills such as: sociability and activity (mean r =.51); altruism (mean r = .43); liking of self and others (mean r = .36); strong bodies and immune system (mean r = .38); and effective conflict resolution skills (mean r = .33). The link between pleasant mood and original thinking was weaker (mean r = .25). It was also acknowledged that the link between problem-solving and positive emotion was inconsistent depending on the situation despite a consistent, but low, effect size for complex mental tasks (mean r = .25). While the evidence is correlational, not causal, it does make an important link between frequent and/or sustained positive emotion over time and behaviours that are associated with success. The longitudinal evidence suggests that happiness and short-term positive affect precede success. However, the number of studies supporting this relationship is limited and therefore caution is necessary in making the directional link or any causal inference. In addition, being happy is more adaptive in some situations than others, including in non-westernized cultures where pursuing positive goals such as success is less important than avoiding negative situations or preventing disruptions to social harmony. Similarly, the characteristics of confidence, sociability, and creative thinking may not be valued in some cultures; nor the life domains of work, relationships and health be prioritized in the same way as the studies within this meta-analysis were. This often cited study and carefully executed analysis is included to illustrate the widespread interest in positive emotion and the accumulation and convergence of evidence that long-term happiness, and frequent experiencing of positive affect have many benefits associated with them. There is also some evidence to indicate that positive emotions and moods appear to contribute to certain outcomes, such as success, rather than only being caused by them. Many questions remain. These authors suggest that future research needs to disentangle mediating factors such as dispositional attitudes and personality characteristics such as extraversion, optimism, and sociability in order to test whether dispositionally happy people create successful outcomes even when they are not in a positive mood. For example, the social benefits of 46 positive affect may have important effects on life outcomes not directly related to relationship success, work or health. Positive emotion and health. A newer area of study investigates the effects of positive emotion on physiology and health. Pressman and Cohen (2005) conducted a rigorous literature review on how positive emotional experience or positive affect (PA), which they defined as “the feelings that reflect a level of pleasurable engagement with the environment” (p. 925) and which included happiness, joy, excitement, enthusiasm, and contentment, affects health. They also distinguished between state PA and trait PA in their conclusions. No studies were included in the review that did not directly assess PA. Most measures were based on self-report such as the PANAS (Watson, Clark, & Tellegen, 1998), Profile of Mood States Scale (POMS; McNair, Lorr, & Droppleman, 1971), the Centre for Epidemiological Studies Depression Scale (CES-D; Radloff, 1977). Studies using other scales were included only if they cautioned readers about how the instruments they used measured PA and its relation to negative affect (NA). Pressman and Cohen also carefully outlined the methods used to induce PA, as well as samples sizes of the studies they used in their discussion and conclusions. In addition, the authors only included prospective and experimental studies of health. They only briefly considered cross sectional correlation studies because health changes themselves may affect PA, and there are so many other possible variables that may affect PA and health together. The findings revealed that trait PA positively affects morbidity, pain and symptoms, as well as mortality in community samples of adults over age 60. State PA increased heart rate and blood pressure, epinephrine and nore-epinephrine, markers for physiological arousal, as well as increases in immune cells, more colonic motility for persons with irritable bowel syndrome and poorer pulmonary function. This evidence suggests that activated emotions act on the sympathetic nervous system and the HPA axis (hypothalamic-pituitary-adrenal axis) and have the potential to influence health outcomes (McEwen, 1998). The direction of these changes was the same for NA, but the effects were greater with NA. Overall, the authors conclude that the findings are “provocative, but not definitive” (p. 963), and give a general picture of when PA may be helpful, unhelpful or have no effect. Taken together, the theory and evidence presented thus far reveal that positive emotion, mood, and affect have important effects on thinking, motivation, behavior, physiological regulation, health, and life outcomes, such as success. The convergence in these lines of 47 thinking and research is noteworthy, further supporting the idea that there are separate, basic, elemental, and valenced emotional subsystems that serve as, or affect, core ordering principles in human functioning (Mahoney, 1991). These findings have enormous implications for therapists. Accessing, working with, and nurturing positive affective experience has the potential to bolster resources, buffer clients from the effects of pain, and strong negative affective experiences, and may fuel resilience, and progress in the therapeutic endeavor. However, a focus on positive emotion is not meant to signify that depth and complexity, suffering, and/or dysfunction need to be downplayed. Baumeister, Bratslavsky, Finkenauer, and Vohs (2001), and Rozin and Royzman’s, (2001) negativity bias provides us with knowledge that the natural preference to pay attention to negativity and distress far outweighs our preference to remember or even notice positive aspects of experience. Rather intentional focus on all aspects of positive and negative affective experience is important. Emotion in Psychotherapy This section will discuss reasons that negative emotion dominates the psychotherapy literature. In addition, it will discuss principles of working with emotion that are common across the three major schools of psychotherapy—cognitive behavioural, humanistic-experiential, and psychodynamic. A selective review of research related to these principles is included, as well as relevant process studies on positive emotion in psychotherapy. Assumptions about positive and negative emotion in psychotherapy. In the past two decades there has been a resurgence of interest in positive emotion, its benefits, functions, and how both systems of positive and negative emotional experience work together (Reich, Zautra, & Davis, 2003). These authors attribute this to the positive psychology movement’s emphasis on balancing our theory, practice and research efforts by attending to the positive. There is considerable epistemological debate and critique in the literature about the overemphasis of positivity by the positive psychology movement. These critiques were to some extent fuelled by positive psychology’s claim (Seligman & Csikszentmihalyi, 2000) to be a new and innovative movement in psychology. Several journals have devoted entire issues and special sections to highlight all sides of the debate from within their particular research, theory and practice domains—Clinical Psychology Review, 2010, Volume 30; Issue 7; Journal of Psychotherapy Integration, 2008, Volume 18, No. 2; Psychological Inquiry, 2003, Volume 14, No. 2; The Counseling Psychologist 2006, Volume 34, No. 2, to name a few. 48 This is a rich and dynamic discussion which seems to point the way to an emergent consensus that the research task now is to attend to how both emotion systems, positive and negative, work together. And while the positive psychology movement has served as a valuable reminder and stimulus to look at all types of emotion, it is not a unique approach. Humanistic psychology and counselling psychology have always brought a strengths-based approach to research, theory and practice endeavours (Mollon, Ethington, & Ridley, 2006; Wood, & Tarrier, 2010; Taylor, 2001), and the work of several other researchers, has paralleled positive psychology (Seligman & Csikszentmihalyi, 2000) in this convergence of thinking in psychology. Examples of these contributions include: the work of Alice Isen (2004, 2008), Russell and Carroll (1999), Watson and Tellegen (1999), Diener and Iran-Nejad (1986), and Cacioppo, Gardner, and Bernston (1999). The past two decades have seen counselling psychologists increasingly practicing with clients who have chronic and severe emotional distress (Heesacker & Bradley, 1997). Clients often come to counselling and psychotherapy because of distress, and in many cases because of troubling emotional experiences. In addition, as was mentioned earlier, little psychotherapy process research has been conducted on positive emotion processes, and until recently, clinical attention has been focused more on distressing emotion than on pleasant or positive emotions (Fitzpatrick & Stalikas, 2008; Fosha, 2000). There are many reasons for this. Stalikas and Fitzpatrick (2008) have suggested that several assumptions inherent in Judeo-Christian values, the legacy of psychoanalysis and the zeitgeist from which western psychotherapy has emerged have played a role in this. Notions such as: 1) privileging certain types of positive emotion as being genuine when they emerge from focused, intentional, hard won change processes over emotion that arises such as laughter or gratitude shown towards a therapist; 2) meaningful change necessitates the processing and integration of suffering; 3) healing of psychological wounds as a goal in psychotherapy; and 4) wellness or healing being defined by a reduction or absence of pain. Such beliefs arising from clinical theory, social values and practices, all suggest a certain caution about the experience of positive states. For example, traditional psychodynamic approaches cautioned against interventions that shifted session focus away from the concerns and distress that marked why the client came to therapy, and were suspicious of any sign of client overreliance on expressing pleasant emotions defensively to avoid approaching difficult or warded off affect (deRoten, Drapeau, & Michel, 2008). In 49 contrast, the research emerging about the salutary effects of positive emotion, such as its deactivating effects on the sympathetic nervous system (lowering heart rate, smiling and authentic laughter shared within the dyad, as examples) may be utilized by a therapist who interprets relieving laughter in the midst of emotional work as a needed and welcome break, preparing the client for further deepening and retrieving of important memories or affects for continued work. Historically, psychology and psychotherapy have been devoted to understanding and trying to ameliorate psychological distress. When positive psychology declared its agenda to consider strengths, virtues and positive emotion (Seligman & Csikszentmihalyi, 2000), there were many reactions and objections to their proposal based on the epistemological grounds outlined above by Stalikas and Fitzpatrick (2008). In many ways this debate highlights a deeper paradigmatic issue within the dominant discourse of psychology and its research. Sugarman (2007) took up one side of this debate and argued that the advance of western technology and scientific method has solidified scientific rationality, and that psychology has taken up methodological rigor and “quantitative calculation over [at the expense] qualitative discernment” (p. 181). Sugarman further argued that positive psychology, like mainstream psychology, while promising a new approach has taken up the same methodologies and attempted to study virtues and other moral aspects of human life as if they were natural phenomena, ignoring their historical, contingent and particular nature. This has the potential to result in oversimplification of positive emotion as good, desirable, useful and negative emotion as undesirable, pathological, or to reduce emotional experience to categories that can be definitively measured, observed, quantified. Even the idiosyncratic meaning attached to valenced emotion does not imply that this understanding is completely an individual endeavour. In fact, from an interpretive, hermeneutic point of view, understanding occurs in relationship and in conversation. Historical and wider contextual influences are considered to shape experience, and, by extension, emotional experience, labeling and expression (Martin & Sugarman, 1999). It is “what one does and what one says and others say about what one does that forms…[understanding] across time” (Young & Valach, 2004, p. 512). Helpful distinctions for psychotherapeutic work, or for supporting wisdom in living depend on nuanced, critical reflection about and with individual subjectivity in context. In other words, understanding of 50 emotional experience is negotiated between clients and therapists, and each bring with them their history, their theories, and their hopes and goals. Fitzpatrick and Stalikas (2008) highlight the fact that inherent subjectivity in no way means that emotional experience, and its personal idiosyncratic [and valenced] meaning, is hard to access, or even always private. In fact, perceiving, understanding, communicating, and facilitating these processes are core skills therapists possess. What this subjectivity does imply is that for understanding a client’s emotional experience, a priori categorization of emotion or affective states represent a set of biases and pre-understandings that therapists bring into the therapeutic endeavor, and if held with certainty are limited at best. The challenge for process researchers is to explore the usefulness and limitations of attending to and utilizing positive emotions in psychotherapy, especially with clients who have difficulty approaching and regulating negative emotion, and who do not easily recruit positive states in their coping strategies. As suggested by Ehrenreich (2007), how to investigate positive emotion within psychotherapy depends on the goals of the interventions. Principles of working with emotions in psychotherapy. Emotional experience and processes are fundamental aspects of human life and functioning, and therefore of central interest to counselling and psychotherapy, along with cognitive processes, interpersonal processes, and behavior. Despite the centrality of emotion, there has been disagreement about how emotion is involved in psychopathology and client problems, how to work with it, and how working with it contributes to change (Mennin & Farach, 2007; Greenberg, 2002). In order to understand the various ways in which therapists differentially target emotional processes in their work with clients, Greenberg (2002, 2008), Menin and Farach (2007), and Watson (Greenberg & Watson, 2005) highlight principles or intervention strategies that therapists employ in working with emotion: a) facilitation of emotional arousal and experiencing; b) assisting clients to become aware of, express, and reflect on their emotions; c) facilitating and teaching clients to regulate and modulate their emotions; and d) facilitating the transformation of prolonged, unproductive emotion by recruiting other emotion(s). While these principles and interventions are common across therapy schools, it is important for me to declare that I concur with Young, Valach and Collin’s (2002) view that both partners in the therapy dyad—the client and the therapist—are persons acting with intention, and actively, even if somewhat out of awareness, pursue their shared and individual beliefs, hopes 51 and expectations through agreed upon goals and tasks. In this sense client and therapist intentionality may also be considered to be oriented toward, or even entrained by the personal theories, therapeutic tasks and processes involved in achieving individual and joint goals. Richardson (2002) suggests that new intentions emerge in subjective experience and are symbolized according to culture. This has enormous implications in the therapeutic context where both client and therapist bring their intentions and goals into an intersubjective field where they become embodied in manifest behavior, where internal processes intermingle and mutually influence one another, and where understanding is co-constituted and mutually created. It is important to emphasize here that the therapeutic intersubjective field is in no way an isolated or local field. It is embedded in a larger context of personal, professional, social, cultural and political worldviews. These contexts infuse the therapeutic dyad rather than act upon it (Graham et al., 2008). For instance, a therapist whose orientation is emotionally-focused has an explicit and implicit theory with which to conceptualize and intervene with client problems and issues. One explicit goal may be to privilege, attend to and facilitate the complete processing of positive emotions, essentially steering the therapist to respond to any positive emotional expression of the client. Similarly, a cognitive behaviourally oriented therapist may enter the client’s world by attending to expressions of beliefs, noting the arousal associated with these beliefs. At specific times in a session a therapist may also implicitly attempt to suspend her therapeutic goals and agendas in the service of being fully present with the client, choosing to trust the process, follow the client’s lead, and wait to see where things go in the session. From the vantage point of the client, an individual client may have explicitly planned not to express her emotions in a session, preferring to remain in control while explaining her situation to the therapist. However, it may happen that in the presence of an attuned therapist, the client relaxes and spontaneously expresses her pleasure when remembering how sensitive her father was when she was younger, for example. This expression may lead to a new and unexpected focus for the session. Under the best circumstances, this mutual coordination proceeds over time creating a field of possibility or an arc of potential (Iwakabe, Rogan, & Stalikas, 2000, p. 398). This process of responding back and forth is not formally planned, although it may be steered by the goals and theories and tasks of the dyad partners. This directionality emerges in the therapeutic conversation and effectively stimulates forward movement in the therapeutic work. This mutual 52 coordination is central to productive therapeutic work, and also recursively deepens the sense of connection and safety between the therapy dyad partners. When the therapeutic alliance is strong, interactions between therapist and client often take the form of spontaneous authentic moments of connection that are infused with positive emotions such as delight, gratitude, and fondness between therapist and client. Arousal and experiencing. Working with the principle of emotional arousal and experiencing involves assisting clients to overcome their fears of experiencing emotions and memories that they have previously contained or defended against. What has been encapsulated and/or avoided may need to be experienced in awareness so that the individual can have access to the embedded meaning and action tendency, motivation or goal associated with the emotion, as well as to reflect on the experience, to make sense of it (Fosha, 2000; Greenberg, 2002). The benefits of such arousal, experiencing, and reflection on emotional experience is well substantiated in the literature (Greenberg, 2002; Littrell, 1998; Whelton, 2004). This is accomplished by careful attention to alliance building, and by helping the client learn to relax her/his defenses using the principle of emotional regulation and/or dyadic attunement (Iwakabe, Rogan, & Stalikas, 2000; McCluskey, 2005). It must be said that arousal and experiencing of emotion may not always be desirable, and therapists work differentially with clients, facilitating some emotional arousal and expression, and not others. For example, unregulated anger that is not mediated by careful exploration of its antecedents and meaning, can be unproductive, and even detrimental, leading to aggression (Bohart, 1977, 1980). It may well be as challenging for clients and therapists to work with positive emotions as distressing ones. This is especially true for those emotions that are interpersonally generated within the psychotherapy dyad—false modesty and intense vulnerability often emerge in both clients and therapists in the face of expressed gratitude and recognition (Fosha, 2000). Similarly, too much positive affect may result in missing the nuances of mixed emotional states and areas of vulnerability and distress, or might indicate a dysregulation problem such as is seen in some manic states, in which clients may be over focused on goal attainment and feeling good, seemingly gating out other aspects of experience. In a quasi-experimental exploratory study, Greenberg, Auszra, and Herrmann (2007) analyzed the sessions of eight participants, half undergoing client centered therapy (CC; Greenberg, et al., 1994; Rogers, 1951, 1975;) for depression and half undergoing process 53 experiential therapy (PE) for depression (PE; Greenberg, et al., 1993) to explore the relationship between productivity of emotional expression in sessions and the productivity of aroused emotional expressions and outcome. Productivity was tied to: the expression of primary emotion; the experiencing of emotion in the present; the owning of the emotion by the client (not being a victim of the emotion); the emotion not being overwhelming; and the emotion expressed being related to a clinically relevant theme. Results indicated that clients who had better outcomes expressed more productive high and low arousal emotions and more productive emotions overall. Interestingly, expressed arousal was not found to predict outcome. Although the sample size was very small, the authors proposed that results may refine previous findings that expressed emotional arousal at midpoint in a course of therapy was a unique predictor of outcome (Misserilian, Toukmanian, Warwar, & Greenberg, 2005). The study findings suggest that it is the arousal of primary emotions that makes the difference. In addition, the authors hypothesized that arousing primary emotion activates relevant adaptive meaning structures as opposed to maladaptive structures that are inhibiting or unhelpful. In one of the few studies in the literature that directly examine positive emotion in psychotherapy sessions, Bridges (2006) described preliminary data from an ongoing research study exploring Fredrickson’s undoing hypothesis and whether or not positive emotions contribute to the processing of negative emotions. The undoing hypothesis proposes that positive emotion reduces the cardiovascular effects of negative emotion, specifically heart rate. He examined the moment-to-moment processes in the sessions of three clients attempting to resolve attachment injuries from the past. The author presented transcribed videotaped sections of the three cases that demonstrated how arousal, experiencing, expression, and processing of emotion bring about in-session change. Emotional arousal was linked to cardiovascular activity and measured by a wristwatch cardiac monitor, emotional experiencing was measured at the end of the sessions through client responses on the Derogatis Affect Balance Scale (DABS; Derogatis, 1975), emotional expression and emotional processing were rated by trained observers watching the videotapes and using the Specific Affects Coding Scale (SPAFF; Gottman et al., 1996) and the Experiencing Scale (EXP; Klein et al., 1969) respectively. The study findings were differential. Two clients were able to engage in a relational dialogue, become emotionally aroused, demonstrate emotional experiencing, express their emotions and process them with subsequent resolution. These same two clients displayed higher 54 and more variable heart rates when crying and expressing sadness. One of these clients showed rapid recovery of heart rate from a peak of 129 beats/minute(BPM) back to 53 BPM after crying for two minutes and moving into a larger perspective of hope and self-compassion. When these clients expressed strong, prolonged emotion it was accompanied by a rapid increase in heart rate, and was subsequently followed by deeper emotional processing with resultant insight, a return to baseline heart rate, and a sense of resolution. Neither client reported feeling overwhelmed. The third client, in contrast, vented her feelings throughout the session excerpts, displaying stable levels of emotion with minimal processing. This client’s heart rate was initially high and gradually decreased over the course of the session. This was consistent with expectations about emotional venting resulting in immediate relief (and subsequent reduction in emotional arousal). That is, venting brings relief but it is not lasting change. It was found that in two clients where emotional processing was at a deep level and emotional arousal was moderate to high, the emergence of positive emotions seemed to not only enhance a return to homeostasis (lower heart rate) but also to reciprocally deepen emotional processing and result in a broadened perspective. These findings provide a clinical picture that practitioners can use to see how Fredrickson’s ideas of undoing and broadening might work in a psychotherapy session. The findings have several implications. First, related to emotional regulation, is that titrating a client’s emotional arousal to keep within a tight window of tolerance (Siegel, 1999) may not be necessary or even productive, especially when high emotional arousal is accompanied by deep emotional processing on relevant core themes; and positive emotion loosened the cardiovascular arousal effects of strong negative emotion. Second, the positive emotion that emerged after significant processing of negative affect on a self-relevant theme seemed to be part of a recursive process in which depth of processing and positive emotion mutually influence one another and as a result new, wider perspective emerges. This hypothesis is consistent with findings of Fredrickson and Joiner (2002) where positive emotions were found to increase broad-minded thinking, thereby expanding clinical understanding of the (therapeutic) function of positive emotion. Some caution is appropriate given that only three client sessions were examined. In addition, the perspectives are somewhat pre-determined and limited by the use of researcher-chosen rating scales and only expert perspectives are considered. No feedback was sought. In this current project multiple perspectives from clients, therapists, researcher and expert peer reviewers are incorporated. 55 Awareness, expression and reflection. Emotional awareness is the ability to notice emotions in oneself and in others (Lane & Schwartz, 1987; Mayer & Salovey, 1997). Recent theory suggests that the subjective or phenomenal awareness of an emotion is more than just an epiphenomenon, but is in fact a powerful signal that is motivational, informational and serves to help us engage in adaptive and meaningful action (Izard, 2009). Clinically, most psychotherapy approaches rely on clients being aware of their emotions for varying reasons. For example, it is considered a desirable clinical goal in some psychotherapy traditions, such as process experiential, in which emotional awareness is seen as a first step in approaching distressing or warded-off emotional experience (Greenberg, 2002, 2008) and subsequently exploring it and reflecting on it. In cognitive-behavioral approaches clients are often asked to attend to and rate the intensity of their emotions as they examine their thoughts. It is also seen as one of four aspects of emotional intelligence, the other three being: using emotions to facilitate thinking; understanding emotions, emotional language and the signals conveyed by emotions; and managing emotion to attain specific goals (Mayer & Salovey, 1997; Mayer, Salovey, & Caruso, 2008). These competencies help individuals navigate the complex layers of both internal and external worlds, and respond more effectively to life’s demands (Mayer & Salovey, 1997; Mayer, Salovey, & Caruso, 2008). Most individuals learn how to attend to their emotional experience as they develop, through acquiring language and formulating cognitive representations of emotional states, from learning to associate somatovisceral experience with emotion, and through discerning and recognizing facial expressions and feedback from others (Ekman, 1975). Since awareness also involves approaching, attending, and accepting emotion, often the first step of clinical work with emotions involves approaching and accepting emotional experience (Greenberg & Pascual-Leone, 2006). Lambie and Marcel (2002) distinguish between two different types of awareness. First order awareness is about “what this is like,” and second order awareness involves “how we feel,” “why we feel as we do,” and “what we can do about it.” In a study of 53 individuals who kept written diaries of their regulation of positive and negative emotions over a two-week period, Feldman Barrett, Gross, Christensen, and Benvenuto (2001) found that it was this second order awareness (differentiation of emotion) that was related to emotional regulation of negative affect but not positive affect. This clarity of emotional awareness, or differentiation, is important 56 because it highlights that individuals who experience their emotions globally, rather than with clarity or differentiation, have a harder time regulating their distress. Global distress is a frequent target for therapeutic intervention, the goal being to help clients identify, label, and explore underlying primary emotion, and its association with secondary, maladaptive emotional expression (Pascual-Leone & Greenberg, 2007). In an elegant task analytic study Pascual-Leone and Greenberg (2007) describe and test an emotional processing model of assisting clients in transforming states of global distress, a state of high distressing arousal with low meaning and understanding, to states characterized by clarity, personal agency, acceptance and understanding. There are four stages in this processing model that do not necessarily proceed in a linear fashion. First, the client in global distress may appear distant and emotionally unexpressive, and inside be feeling “I am worthless,” “I feel weak and hopeless.” The client’s feelings are undifferentiated and lack the understanding and expression of the underlying complexity of such a state. At this stage clients are encouraged to elaborate details of this experience and articulate their state through narrative details such as: “when I grew up, I had to be on guard all the time, watching whatever I said and doing everything perfectly.” This elaboration leads into the second stage of expressing specific distressing emotions inherent in the global distress such as fear of being alone, hurt at being mistreated. Third, as exploration and narrative elaboration unfold clients typically, with assistance or sometimes not, move towards the expression of deep existential need such as “despite feeling so unworthy, I really need a loving connection and recognition for my efforts and achievements.” Holding together the opposing sides of this dilemma (having present awareness and access to the complexity of their experience) within a safe, attuned, and supportive therapeutic relationship allows for a shift of focus from the other as judge of worth to self as judge of worth, and a shift from “I need and want to be worthy and lovable” to “I am worth loving.” A positive reframe and self-evaluation often emerges into awareness. Similarly, the fourth stage involves clients allowing themselves to experience the hurt or fear related to their losses without dropping back into a state of shame or self-pity. At this point emotional arousal is high but not overwhelming. Clients must again hold together their hurt and sadness of missing what they did not have and what they needed. What occurs is that clients will typically express self-righteous anger and assert themselves or meet their own existential needs through self-soothing. Recursive rounds of these stages result in 57 momentary resolution involving self-acceptance and being able to act on the behalf of themselves, another positive self-evaluation. In a subsequent study (2009) Pascual-Leone examined how successful and unsuccessful emotional processing within psychotherapy sessions contribute to overall session gains. He found that repeated rounds of successful processing were characterized by an uneven movement forward and towards resolution and a repetition of returning to undifferentiated states of global distress. Over time this repetition resulted in more frequent cycles of the four-stage process described above, and these sequences were characterized by greater emotional variation and shorter periods of falling back into global distress. These studies suggest that the elaboration of undifferentiated states to include both distress and more positive aspects of self-experience lead to in-session change events. In particular holding opposing states or dilemmas together was seen to result in new positive self-evaluations which serves to guide clients towards self-acceptance and agency. In addition, practice through repeated rounds of such processes seems to strengthen and widen emotional range and the ability to bounce back from overwhelming and undifferentiated distress. In this research project, episodes of positive emotion will be examined to include the perspective of both client and therapist to determine the meaning both dyad partners attribute to working with client positive emotional experience. Vandenberghe and Silvestre (2014) examined the role of therapists’ positive emotions in psychotherapy sessions. Turning the lens onto the awareness of therapists’ internal experiences, these authors interviewed twenty-six psychologists asking them to recall a short list of recent episodes from a therapeutic session in which they themselves experienced positive emotion. In addition, the participants were requested to describe their inner experiences of these episodes, along with the influence they believed the episodes had on their behavior in session and the outcome of the session. Using a grounded theory approach participants’ responses were grouped into two themes: sources of positive emotion and effects of positive emotion. The sources of therapists’ positive emotion were found to be related to both direct client input and their own direct input. For example, client input that triggered positive affects such as admiration, pleasure, compassion, and caring were related to how well clients connected with the therapist, how much effort and initiative the client expended in sessions, as well as signs that clients were showing improvement in areas such as mood, clear thinking, and improved responding skills. 58 Therapists’ input included: being proud and deriving pleasure from their own efficacy in use and improvement of their technical skills; interventions when they were helpful for clients; and personal involvement, such as enjoying feeling genuine liking and admiration for clients’ characteristics of courage, strength of moral conviction, and good intentions. They were even inspired to work on their own personal issues when client issues resonated with their own personal experiences. The effects these emotions had on therapists’ behaviour in sessions and session outcome are noteworthy. Again, these fell into three categories: client process, technical input, personal involvement and an additional category, therapist personal thriving. Therapist positive emotion seemed to fuel the therapeutic process. Positive emotion evoked in the therapist by client process sometimes fed back into the process and demonstrated the emotional availability of the therapist “he saw that I was moved and that meant that he was important to me” (p. 122). Some therapists inquired how their positive emotional expression impacted their client when they saw that their client was affected, and this opened up intense interpersonal metaprocessing. Metaprocessing refers to the explicit processing of emotional or other positive changes that are occurring within the session., including changes within the therapeutic relationship. Its goal is to facilitate and reflect the experience further. This type of intervention can have a powerful effect on the therapeutic relationship, as well as client relationship capacity, and understanding how change processes work (Fosha, 2000, Russell & Fosha, 2008; Russell, 2015). In terms of therapist technical input, therapist positive emotions served to heighten therapist awareness of in-session processes; bolstered therapists’ therapeutic imagination and courage, stimulating therapists to trust the process more, be more spontaneous, and break from routine interventions; helped therapists to recognize their own limitations and to put more effort into case conceptualization outside of sessions and to continue their professional development and learning. One negative effect was that some therapists were over focused on their positive experiences within sessions, they noticed that they were sometimes getting off track and even diverting attention away from treatment goals, and/or inadvertently invalidating client goals. In the category of personal involvement, it was reported that positive affective experiences of the therapists generated intimacy with and compassion for the client, in addition to enhancing safety and subsequently improving tolerance for intimacy in the client. Finally, and interestingly, frequent experiences of positive emotion in sessions 59 promoted their own thriving through increased interest in leisure, being more open, and being better able to self-regulate during emotionally straining situations in and out of session. While the study does not illuminate the actual dynamics of the therapist internal experience in any detail, it does highlight their thinking about such experiences, and their hypotheses about how positive emotion impacts clients and therapy sessions in general. The findings have significant implications for therapists. Therapist expressed positive emotion that does not dominate the therapeutic space or tasks has the potential to signal clients about how they are viewed by their therapist, and how the process is going from the perspective of the therapist. These types of communication can serve to regulate client fears, and validate for clients that their strengths, progress, and efforts impact the therapist and and are recognized. Furthermore, therapist positive emotions have a salutary effect on the therapists themselves bolstering their confidence and willingness to reflect on their work and effectiveness and to continue their own personal and professional development. These findings provide the current study with a point of comparison and validation for examining clients’ positive emotional experience in psychotherapy sessions. A unique strength of the current project is its detailed exploration of the meaning both therapy dyad partners make of client positive emotional experience. Emotional regulation. Emotional regulation refers to the processes of determining which emotions we have, and how and when we experience and express them (Sloan & Kring, 2007). In effect, the first three of the principles for working with emotions, identified previously, are encompassed by the concept of emotional regulation. According to Greenberg (2007), this idea of emotion as regulator and regulating means that emotion steers cognition and behaviour, and is influenced by cognition. The implication for psychotherapy is a shift in focus from trying to control unwanted emotional responses to understanding how emotional responses are created and regulated by other emotions, and relational interactions, as well as by cognition. Greenberg (2007) goes on to say that a crucial theory and research task is to distinguish between when explicit processes such as skill building, and practice of emotional regulation strategies such as self-soothing, relaxation, and grounding are needed, as opposed to more implicit, relational, corrective experiences involving affect attunement and new self-experience (p. 416). Achieving adequate emotional regulation in clinical work can be challenging, especially with individuals who have been repeatedly traumatized or neglected, and struggle with ingrained 60 trait-like emotional sensitivity, deep fears of vulnerability, pervasive trust issues, emotional lability and/or reactivity. Several clinical experts, theorists and researchers acknowledge that emotional regulation interventions that rely solely on cognitive strategies are frequently not adequate to help clients feel safe, and reduce the intensity of their emotional experience so that they can productively engage in therapeutic work (Campos et al., 2004; Fosha, 2000; Hunt, 1998; Linehan, Schmidt, Dimeff, Craft, Kanter, & Comtois, 1999). Deliberate cognitive and behavioural interventions and emotional regulation skills such as re-appraisal, reframing, relaxation, imagery, depend on left hemisphere processes, whereas being soothed and regulated dyadically, in a supportive, empathically attuned relationship seems to be very helpful for building the capacity to soothe the self and eventually be able to feel self-empathy and compassion (Bohart & Greenberg, 1997; Fosha, 2000; McCluskey, 2005). Savoring (Bryant & Veroff, 2007), one of the interventions in PPT discussed previously, refers to a set of processes that undergird the regulation of positive emotions, involving “generating, maintaining, or enhancing positive affect by attending to positive experiences in the past, present and future” (Bryant, Chadwick, & Kluwe, 2011). These processes are sometimes more colloquially referred to as taking in the good (Hanson, 2011), and involve four interrelated elements: savoring experiences, savoring processes, savoring strategies, and savoring beliefs. Savoring experiences can be differentiated by attentional focus on self, such as in pride in doing something well, or by attentional focus outside the self (world-focused) such as being awestruck by seeing a beautiful painting. Similarly, a savoring experience may occur as a result of being absorbed in cognitive reflection or subjective experience. An important distinction to make is that savoring is not the same as pleasure. When we are savoring we are consciously attentive to and appreciatively aware of the feeling of pleasure, whereas the experience of pleasure may include the experiencing and/or awareness only of the pleasure. Bryant and Veroff (2007) postulate that savoring processes regulate emotional states and propose a classification model in which four savoring processes regulate four emotional states. First, the world-focused, reflective savoring process of thanksgiving regulates gratitude. Second, the world-focused, experiential savoring process of marveling regulates awe. Third, the self-focused reflection of basking regulates pride. Fourth, the self-focused, experiential savoring process of luxuriating regulates physical pleasure. The strategies we employ to savor our positive experiences include: sharing with others, honing sensory perception, comparison, 61 behavioral expression, time awareness, building memories, counting blessings, self-congratulation, and kill-joy thinking. According to Bryant and Veroff (2007) cognitive appraisal predicts what savoring strategies we use, just as they influence what coping strategies we employ. Interestingly, some authors report that heightening of positive feelings through savoring versus dampening of positive feelings through strategies such as kill-joy thinking differs between women and men and in some cultural groups. For example, Bryant and Veroff (2007) have noted that women report greater capacity than men in savoring by self-reflection to enhance their perspectives and self-awareness, whereas men engage more frequently in savoring to escape their present reality. This seems to translate into greater capacity for women to savor with positive outcome, and for men to return to their present situation with little positive impact from savoring to escape. In addition, kill-joy thinking is not only more common in people with mood disorders, it is also employed in culturally normative ways by East Asians to reduce positive emotion, and regulate the balance between positive and negative emotions, both of which are considered to be socially desirable (Lindberg, 2004). We can heighten our positive emotions by savoring beliefs from different time orientations—past, present and future. However, an important distinction to be made is that savoring regulates positive affect in the here and now, regardless of whether we are focusing on past or future (2007). This means that upregulating past pleasurable experiences has the potential to create positive emotions in the present, explaining one aspect of the benefits of reminiscing for older persons, and providing opportunities for individuals to expand their self-reflective capacity and perspective by attending to and experiencing what it is about past positive experiences that is pleasurable, meaningful. Comparing savoring beliefs of individuals from the United States, Canada, Australia, and Japan, Bryant and Veroff (2007) found that people rate their capacity to savor as easiest to do retrospectively, followed by moderately easy to savor in the present, and most difficult to savor in anticipation. Furthermore, these authors speculate that the principles of rosy prospection (a positive event being less positive than expected) and rosy retrospection (a positive event being less positive than remembered) may be related to the challenges we sometimes have in capturing the joy in the moment, because in certain circumstances it seems we are more aware of our joy and pleasure before and after rather than during the experience. The implication here is that assisting clients to learn to savor in the moment may have beneficial effects and lessen the rosy effects. 62 There is some recent evidence that the ability to savor may matter most to those who have few daily positive events (Hurley & Kwon, 2013). These authors found that individuals with high daily positive events (uplifts) and higher levels of savoring in the moment had higher levels of positive emotion and life satisfaction than those who did not. However, combining the uplifts and savoring in the moment had no advantage over having high uplifts or other high savoring in the moment. For people who had high ability to savor in the moment, the number of uplifts was unrelated to life satisfaction. They reported positive outcomes regardless of number of uplifts if they savored in the moment. However, in those participants who had low capacity to savor the number of uplifts was related to their life satisfaction. These results suggest that facilitating savoring with clients may enable them to access the rewards from their positive experiences. Fitzpatrick, Janzen, Chamodraka, and Park (2006) interviewed 20 clients to investigate how they understood specific events that contributed to alliance development with their therapists. Clients were asked to describe elements important to them about a therapeutic relationship, expectations they had of the relationship before starting therapy and how they would characterize their current therapy relationship. They were then asked to describe a critical event that exemplified how they knew the relationship was on track or not. Responses were analyzed using the Qualitative Consensual Model (Hill, Thompson, & Nutt, 1997) and arranged in five domains–—descriptors of the event, meaning of the event, client contribution, impact on the relationship, and outcomes of the event. Nineteen of the twenty cases were used in the analysis, as one participant described a negative incident. Descriptors of the event included: therapist helped me think in a new way; therapist encouraged me to take space; therapist shared something meaningful; therapist responded to client wish; and therapist gave tools or assignment. The domain of meaning captured clients’ feelings that they were accepted and understood, they were important and at the center of the process, could/would be helped by this therapist, they knew how to be a client, and had contributed their own abilities to the process and could apply them outside sessions. The domain of client contribution to the incidents revealed two types of openness: a) openness to disclosure of personal narratives and experiences; and b) openness to receiving feedback. In the domain of impact on the relationship, all participants who described a positive incident (17 of 19) described positive feelings. The most common impact cited was trust or confidence in the therapist’s ability to help them or in the process being helpful. Acceptance, validation, comfort and safety were also reported within the context of the 63 relationship. Finally, in the domain of incident outcome, three outcomes were cited—increase in client productivity described as willingness to further and deepen exploration of issues; disclosure and openness explained as willingness to disclose and expand more experiences; and positive emotion expectation characterized as aspiring and aiming for more in the therapeutic relationship. These authors interpret their findings as validating Fredrickson’s broaden and build theory of positive emotion (Fredrickson, 2001; Fredrickson & Joiner, 2002). The relationship between the domains was then described in a framework which concluded that positive events served to create a forward momentum in the therapeutic process and were associated with positive emotion, whereas a negative event evoked a negative feeling and seemed to reduce productivity. This study demonstrates how moment-to-moment events and positive emotion impact both the forward momentum of the therapy process, by bolstering clients’ courage and willingness to increase and deepen exploration of their issues, as well as their valuing and investment in the therapy relationship. On a very basic level, emotional regulation may involve helping over regulated clients allow their emotions to emerge, or helping under regulated clients calm overwhelming, flooding emotion. In fact, some clients, such as those with unregulated emotion may need to master these types of emotional regulation/distress tolerance skills in order to benefit from productive arousal and experiencing (Linehan, et al.,1999; Paivio & Laurent, 2001). Working with emotions necessitates working within a window of tolerance (Siegel, 1999). In order for change to occur, the client must be aroused enough to experience previously warded off experience, but regulated enough to be able to be aware and reflect on what is happening. This means that working at the edges of the window of tolerance is most productive (Ogden, Minton, & Pain, 2006). Carryer and Greenberg (2010) found that in depressed individuals, moderate emotional arousal for short periods in a session was associated with good outcome, suggesting that high, prolonged arousal may not always be helpful. Two studies examining the effects of mutual smiling episodes (MSEs) in psychotherapy sessions validate the interpersonal regulating effect of mild positive emotion. These studies are included because of the obvious link between genuine Duchenne smiles as manifestations of positive emotion, and to illustrating how positive social cues such as smiling have a regulating effect both on interactions and emotional regulation and coordination. Adapting Vanger and Czogalik’s (as cited in de Roten, Gilliéron, Despland & Stigler, 2002) typology of MSEs these 64 authors explored the relationship between emotional coordination and MSEs as well as how different types of smiling episodes affect early alliance building in 12 psychotherapy dyads over four sessions each. Four types of smiling episodes were hypothesized and studied. First, social cooperation or agreement MSEs serve as social signals that help partners coordinate their behavior and and communicate that they agree to cooperate. Second, binding or intersubjective communication MSEs are direct expressions of emotional engagement and congruence. Third, negotiation or social confrontation MSEs signify that the relationship has not been broken despite disagreement related to an unresolved question or misunderstanding. Four, gentle fight or intersubjective conflict MSEs function to decrease the negative impacts of what is being discussed and to protect the ongoing integrity of the relationship. The findings of the study revealed that high alliance dyads demonstrated more binding and cooperation smiles than confronation MSEs and a higher degree of emotional coordination that was maintained throughout the four sessions. On the other hand, the low alliance dyads showed a pattern of equally distributed MSEs of all four types, which these authors interpreted as indicating less intersubjective engagement and coordination, persisting over the four sessions. Darwiche de Roten, Stern, Crettaz von Roten, Corboz-Warnery, and Fivaz-Depeursinge (2008) conducted a similar experiment in couples counselling between marriage dyads and therapists. They examined the relation of MSEs to relationship regulation and level of working alliance in 16 therapy triads. The findings in this study validated de Roten et al.’s (2002) findings. Coordination and positivity, defined as high number of binding MSEs and less confronting MSEs, are expressions of and indicators of the bond inherent in a strong therapeutic alliance, and they were more frequently expressed and reinforced through mutual smiling episodes. In short, mutual smiling episodes seem to play a role in regulating interactions and emotional engagement in the therapeutic relationship. Changing emotion with emotion. Changing emotion with emotion refers to a change process involving one emotion undoing or transforming another emotional response (Greenberg 2008). For example, positive emotion was found to broaden perspective (Fredrickson and Joiner, 2002), changing how a person thinks about their situation, and to undo the lingering physiologic effects of negative or distressing emotion (Fredrickson & Levenson, 1998). Fredrickson, Mancuso, Branigan, and Tugdale’s (2000) study revealed that resilient individuals recruit positive affect into their distressing experiences and reduce the impact of the negative event and 65 the way they understand the event. This finding is also supported by the finding that positive appraisal is associated with positive emotion, and it can be recruited by resilient individuals in very stressful situations, such as caregiving persons who are dying (Moskowitz, Folkman, Collette, & Vittinghoff, 1996). Another way emotion is transformed is when primary emotion, transforms secondary or maladaptive emotion. For example, a sense of hopelessness may be transformed by accessing primary adaptive anger, or disgust may be transformed by compassion. When an incompatible emotion is accessed the other emotion is transformed. This is then reflected on, and often a new understanding or wider perspective is achieved. This process was described earlier in this document, and in more detail through Pascual Leone’s (2007) work on emotional processing. Undifferentiated and highly aroused states such as global distress were changed by exploration into primary emotion, and further changed into a positive self-evaluation when paired with an opposite emotional experience. In addition, related memories, and/or situational details may enter awareness, releasing important readiness or information about what to do (Bridges, 2006; Greenberg & Pascual Leone, 2006). Diana Fosha, the founder of Accelerated Experiential Dynamic Psychotherapy (2000), is one of the few clinical masters who specifically focus on positive emotion and the phenomenological aspects of how it emerges, is processed, and is integrated. AEDP is a model of psychotherapy grounded in relational psychodynamics, assimilating experiential elements. Historically AEDP has its roots in the experiential short-term dynamic psychotherapies (STDPs: Alpert, 1992; Coughlin Della Selva, 1996; Davanloo, 1990; Malan, 1963; McCullough Vaillant, 1997). The approach is an integrative one, drawing on five bodies of theory, research and practice: 1) emotion studies and affective neuroscience, 2) attachment and developmental theory, 3) experiential, empathic based approaches, 4) somatic focusing and 5) transformational processes. AEDP therapists assume an intentionally empathic, emotionally engaged relationship with clients that provides a safe, supportive relational base within which clients’ defenses may soften as they explore, experience, and reflect on their own processes and the issues that bring them to therapy. The practice and rationales of AEDP privilege and tilt into the change processes of healing rather than pathology. Fosha herself would say that a therapist tracks positive affective phenomena in order to harness their transformance potential (2010). Transformance is a term Fosha (2008) defines as an “overarching motivational force, operating both in development and therapy, that strives toward maximal vitality, authenticity, and genuine 66 contact (p. 292).” A felt sense of vitality and energy characterizes transformance-based emergent phenomena. Fosha (2010) believes that positive affects always present when change is occurring. This does not mean happy affect. Rather, as mentioned earlier, it may be about a sense of personal rightness or a sense that one is proceeding in a satisfactory way towards desired goals. Fredrickson (2001) might infer that this momentary positive emotional experience is part of a recursive process involving broadened perspective and building resilience. This effect would theoretically reduce stress, facilitate emotional regulation, widen perspective, and set the stage for further emotional exploration or reflection and consolidation of experience (Fredrickson & Cohn, 2008; Greenberg, 2008). One particular class of intervention unique to AEDP is metatherapeutic processing. It will be discussed below in the context of a recent research study. In a carefully executed study Iwakabe and Conceicao, (2015) elucidate another way emotion changes emotion. These authors employed the discovery phase of task analysis to construct a rational empirical model of therapeutic metaprocessing events, finding that emotional transformation resulted from instances of attention and focus on positive emotion, in particular on positive emotions associated with positive change events within the session as well as aspects within the therapeutic relationship that are working well. The sample in this study comprised four exemplar session tapes of psychotherapy sessions facilitated by one therapist practicing Accelerated Experiential Dynamic Psychotherapy (AEDP; Fosha, 2000). The empirical model included both client and therapist processes. Therapist action was described as encompassing four main interventions: 1) affirmation through honoring, affirming, and valuing client experience, behavior, personal characteristics, efforts and changes; 2) assisting clients to focus on and stay with somatic experience; 3) attunement involving tracking and remaining in close connection with the client; and 4) restructuring involving assisting clients to examine beliefs about self or other or situations taking the recent therapy experience into consideration. The client process followed two intertwining tracks—affective and reflective. Clients worked back and forth between these tracks recursively, while the therapist facilitated this process utilizing the four clinical intervention processes described above. A typical client enactment during a metatherapeutic processing episode would follow a seven-part sequence: 1) expression of relief (affective track) following an invitation by the therapist to metaprocess what had just occurred (e.g. “What was is it like for you to have the courage to stand up to her and protect yourself?”); 67 2) affirmation of self (reflective track) following the sense of relief (e.g. “I feel strong, kind of powerful, and proud that I was able to show that I deserve to be treated better.”); 3) sense of enlivenment (affective track) that followed the self-reflection (e.g. “I find myself wondering about how her own background contributes to her acting this way.”); 4) becoming aware of self-limiting beliefs and patterns (reflective track) that followed the enlivened feeling (e.g. “ What I learned from my past is to keep my head down and not make waves, but I can see that limits me and I get treated poorly or overlooked.”); 5) grief following the realization of what has been lost, how the self has suffered (affective track) (e.g. “I think I can risk being myself and not let myself get put down.”); 6) engaging in new ways of coping (reflective track) exemplified by new intentions and hopes based on the new learning (e.g. “I have an awareness now that I am worth it, and that I can ask for what I need.”); 7) peacefulness (affective track) expressed as a sense of calm and well-being, and manifested in verbal fluidity, and congruence. This coordinated sequence exemplifies integration of both emotional and cognitive aspects of client experience, and appears to anchor and solidify change experiences within sessions. Interestingly the focus was almost uniquely on the positive aspects of the clients’ experiences. The model has considerable practical utility for practitioners as a vehicle for consolidating therapeutic gains and helping clients expand and differentiate their experiences to increase awareness and understanding and increase chances of applying what is learned in psychotherapy outside sessions. In addition, the model can be validated and compared to other successful and unsuccessful therapeutic metaprocessing episodes. Conclusion This chapter reviewed selected theory and research related to positive emotion in three main literature domains: historical and current psychotherapy process research; foundational theory and research on positive emotion; and emotion in psychotherapy theory and research. There has been a growing interest in positive emotion, its components, functions, and benefits in the past two decades. The theory and research summarized here demonstrates a growing convergence that positive emotion serves many important functions, and that its feeling components, motivational components, effects on decision making, creativity, successful life outcomes, and health are significant. It also highlights the need to examine how positive emotions can be and are worked with in psychotherapy, as well as how positive emotion can be utilized for therapeutic gain. The aim of this study was to add to our current clinical 68 understanding about how clients and therapists attend to, work with, and understand positive affective experiences when they arise for clients in psychotherapy sessions. The next chapter outlines and describes the methodology and procedures used to carry out the investigation. 69 Chapter 3: Methodology This chapter describes the methodological approach and procedures used to address the research question: How do clients and therapists utilize positive emotion when they perceive it has arisen for the client in psychotherapy sessions. This exploratory inquiry is situated in an interpretive epistemology (Crotty, 1998) using philosophical hermeneutics as a conceptual framework to guide the research procedures and analysis. The methods included Stake’s (2006) multiple case study approach, interpersonal process recall (IPR) interviewing (Bloom, 1954; Kagan, 1984), and thematic analysis (Braun & Clarke, 2006). A brief discussion of the interpretivist epistemology and philosophical hermeneutic conceptual lens follows. In addition, the methods and procedures I used to ensure the rigor and trustworthiness of the study findings are described in detail. Rationale for the Methodology and Procedures A philosophical hermeneutic conceptual framework is highly compatible with the research question, a multiple case study approach, IPR interviewing, and thematic analysis. The research question is a qualitative question, and is posed to expand and enrich understanding of personal, lived experience in the context of psychotherapy dyads, specifically that of client positive emotional experience and how it is attended to and worked with by clients and therapists in psychotherapy sessions. In a qualitative, hermeneutic study the researcher, in pursuing understanding, relies more on interpretation than on description and reporting (Haverkamp & Young, 2007). This study explored how clients and therapists worked with, negotiated and attributed meaning to expressions of positive emotion by clients in therapeutic sessions. A multiple case study approach and thematic analysis are flexible, yet atheoretical research procedures. A philosophical hermeneutic approach to understanding will provide a theoretical framework within which to articulate the scope of inquiry, as well as to interpret and evaluate the significance and worth of the findings. Stake’s (2006) multiple case study approach was employed to organize and focus the data and analysis. Cases were conceptualized as therapist-client dyads. A case is a “specific, unique bounded system” (Stake, 2005, p. 445) that is descriptive, particularistic, and heuristic (Merriam, 1998; Stake, 2005). Particularity refers to the uniqueness of each participant’s experience. Vivid details and quotations are described from video recordings of actual psychotherapy dialogue, allowing readers to get a sense of each participant’s actual experience. The cases are 70 heuristic, and were chosen and utilized in the service of expanding our understanding of the phenomenon of how positive emotion is worked with in psychotherapy sessions. In this way, the cases are also instrumental. Their primary significance is that they provided a bounded relational context in which the particulars of client positive emotion experience, as understood by each member of each dyad, were described, and thus have the potential to expand a reader’s understanding of how positive emotion is worked with in psychotherapy (Stake, 2006). The IPR method of interviewing generated rich, detailed data sources, such as video recordings of actual therapy sessions, video recordings of individual interviews with clients and therapists that resulted in personal accounts of overt and covert client and therapist thoughts and emotions during the sessions, as well as their reflections, and emotional responses after the sessions. Thematic analysis (Braun & Clarke, 2006) provided an atheoretical set of steps for further organizing and analyzing the data. Situating the Inquiry: Conceptual Framework Interpretivism. According to Schwandt (2000), interpretivism arose in reaction to late 19th and early 20th century debate about differences between the natural and human sciences. Proponents of interpretivism suggest that the aim of human science is to seek contextual understandings or interpretations of human action. On the positivist side of the debate, the aim of a human science is, like natural science, to offer causal explanations of social, behavioural and physical phenomena. The action or phenomenon under study is characterized by discrete essences which can be known, and are fixed, universal and ahistorical. From a positivist perspective, knowledge is generated from theory, and hypothesis testing. Data is derived by attempting to control environmental factors and manipulate variables in such a way that the object of study and/or its properties or essences reveal themselves, and are classified or measured. However, from a broad interpretivist view of the debate, human actions are seen as different from natural phenomena because human action is intentional, inherently meaningful, and has significance to the actor (Schwandt, 2000). Humans have the potential to recognize and understand how they are classified within their contexts. Furthermore, humans may respond to this information and act in ways that impact on and influence their contexts, subsequently changing their classifications and environments, including their relationships (Martin & Sugarman, 2001). 71 Interpretivists seek understanding, rather than explanation. This understanding generally encompasses: a commitment to studying human behavior within the everyday, intersubjective life world, and, with the exception of philosophical hermeneutics, shares with positivism and post-positivism a belief that it is possible for the interpreter to be an uninvolved observer, by suspending her own subjectivity (Schwandt, 2000). Both Crotty (1998) and Schwandt (2000) locate hermeneutics within the interpretive tradition of epistemologies. While the current project is located within the interpretivist tradition, as a hermeneutic inquirer, I have not held myself up as an objective observer. Rather, I have incorporated the perspectives of many: participants; myself; expert peer reviewers; and my supervisory committee in the final interpretation. Phenomenology. Phenomenology originated in the early 20th century with philosophy of Edmund Husserl (Langdridge, 2007). In this line of thinking things in the world present themselves to us, we are aware of them. Husserl rejected the positivist view that objects are separate in meaning from our view of them, forwarding the idea that only when we perceive an object does it come into our consciousness. What this means is that human activity is meaningful, objects encountered have meaning for individuals, and by extension, human action, as meaningful, is intentional. Husserl believed that “…all of consciousness is intentional, involves being directed towards something, being open to the world” (in Depraz, 2001, p.170). As humans, we cannot be seen or understood apart from the world, and consequently “return to the things themselves” (Langdridge, 2007). This phrase is attributed to Husserl, and is a central idea of phenomenology. Foundational to how this philosophy influences inquiry is a focus on: experience as it is lived, meaning and how it arises in experience, and understanding experience in context (Langdridge, 2007, p. 9). Husserl, in his descriptive phenomenological approach, suggested two methods by which human experience could be described and understood—epoche, and phenomenological reduction. Epoche, more contemporarily known as bracketing, is how an inquirer can attempt to suspend her preconceptions and usual ways of thinking that may obscure her understanding. There is considerable debate whether this is possible or even desirable from proponents of other philosophies, even within the phenomenologies (McLeod, 2001). The phenomenological reduction involves seeing the phenomenon from many different angles and instances in order to be able to see its properties, effectively reducing it to its essential essence(s). In a research inquiry, these essences are elaborated in a description of the phenomenon. 72 This study has phenomenological features in that its main focus was the lived experience of clients and therapists attending to and working with client positive emotional experience in vivo. The participants, as well as myself as researcher, had implicit and explicit goals, theories, assumptions, biases, and questions that we brought to our respective roles and actions within the project. Rather than attempting to bracket our intentions or theories, as a descriptive phenomenological approach suggests, we actively leaned into them seeking to question them, expand our understanding of them, test them, and in some cases transform them. This practice is at the very heart of the psychotherapeutic endeavor, was a primary aim of the study, and guided the research design. It is also consistent with interpretivism and hermeneutic phenomenology (Langdridge, 2007), rather than with descriptive phenomenology. Hermeneutics. The word hermeneutics derives from the Greek word from hermeneuein, which means to interpret (Online etymology dictionary). Historically, hermeneutics, as a discipline of interpretation, has been associated with ancient Greek literary study, and in more modern times, Talmudic and Christian biblical exegesis (Crotty, 1998). As previously stated, interpretivists place meaning at the center of inquiry. However, where meaning actually resides is a matter of opinion. Hermeneutic phenomenological thinking, like phenomenological thinking turns to human experience as it is lived. The goal is understanding what is below the surface of the everyday aspects of lived experience that may be forgotten or go unnoticed (Laverty, 2003). Heidegger, a contemporary of Husserl’s, was an existentialist. He had an enormous influence on the phenomenological movement, and introduced interpretation to phenomenology (Langdridge, 2007). Husserl’s main focus was on epistemology, what the knower knows, and how the knower’s mind or consciousness understands the world. Heidegger extended Husserl’s work into ontology, towards the notion that understanding it is a characteristic of being human, rather than a way of knowing the world (Koch, 1995; Osborne, 1994). The question for study for Heidegger was “... in what way [is] understanding being” (Koch, 1995, p.831)? Heidegger believed that it was not possible to separate a person from their life world. The notions of historicity and the hermeneutic circle are central to Heidegger’s approach to phenomenology. Historicity encompasses the idea that our background (including our social and cultural traditions and experiences) are an inextricable part of our being in the world and our understanding of the world. These pre-understandings, as Heidegger referred to them, cannot be 73 bracketed off. He asserted that a person and their life-world are not separable; they co-constitute one another. This means that we are shaped and made who we are by our life-world, and we continue to shape and re-shape our personal, social world through our life experiences and background or pre-understandings (Koch, 1995). By extension, we do not encounter anything in our world without interpreting it through our pre-understandings. The hermeneutic circle is a concept forwarded by Heidegger to explain the inevitable circularity of understanding. Ontologically, the circle is a form of dialogue between what an individual wants to understand and that individual’s past and current personal experiences with what she wants to understand. Methodologically, the circle represents a dialogue between a researcher’s preunderstandings and present experience. This will be expanded in the discussion that follows (Freeman, 2008). Smith (1993) makes a helpful distinction between three contemporary approaches to hermeneutics, based on their purpose and where meaning resides. First, with validation hermeneutics, based on the work of Dilthey (1926/1985), meaning resides in the author or the actor, and as a result, the purpose of interpretation is about accuracy and getting the author’s version right. Methods such as testing and consensus seeking are employed to actively seek falsification and disconfirmation. Second, with critical hermeneutics, based on the work of Habermas (1962), the researcher actively questions the perspective of the knower or actor, because of the distorting impact of social, cultural and historical influences. In fact, the critical hermeneutic inquirer is sometimes seen as having a better chance of accessing an accurate understanding. The goals of inquiry are emancipation and change. Participatory action methods are employed to expose participants to interpretations that explain how socio-cultural and political influences have created their understandings. Third, philosophical hermeneutics, based largely in the work of Gadamer (1975/2004) does not locate meaning with the knower nor within a set of objective historical influences. Meaning is “brought into being, and is constantly shaped and reshaped, as a result of the continuing dialogical encounter between and among people—inquirers included” (Smith, 1993, p. 186). The researcher pursues a deeper, more explicit understanding rather than an accurate one by allowing her perspective to be influenced and expanded by the perspective of the participants. This is known as a fusion of horizons. Gadamerian hermeneutics. Gadamer believed understanding was a dialogic process, and what emerges from conversation can be new and unexpected (Orange 2011). In this way, 74 dialogue has the potential to be critical, in that it can disturb and unsettle our taken-for-granted positions and beliefs. For Gadamer, understanding arises within the spoken language of conversation and dialogue, and as such we cannot separate ourselves from language (Lawn, 2006). For both Heidegger and Gadamer language is primarily expressive as opposed to representational. What this means is that language meaning is tied to how it is regularly used in conversation, and to that which is common amongst us. It allows us to understand one another and our life-world (Lawn, 2006). Language is not just one man’s possessions in the world; rather, on it depends the fact that man has a world at all. The world as world exists for man as for no other creature that is in the world. But this world is verbal in nature. ... But the ground of this statement is more important, namely that language has no independent life apart from the world that comes to language within it. Not only is the world world only insofar as it comes into language, but language, too, has its real being only in the fact that the world is presented in it. (Gadamer 1975/2004, p. 440) Understanding occurs through our own situated, cultural histories, traditions and theories. The extent or horizon of understanding is always from a certain vantage point, that of our prejudices (Gadamer, 1975/2004, p.301). We bring these pre-understandings or prejudices into all our experiences, including our therapeutics and our inquiry. Gadamer saw these intersecting pre-understandings as enabling and constraining our understanding. When we encounter another we do not abandon our vantage point for that of the other, we expand it through a dialectical process of question and answer, there is a fusion of horizons (Smith, 1993). Some commentators might say that with Gadamer understanding is negotiated more than it is constructed (Schwandt, 2000). Gadamer was criticized for his overreliance on tradition, but this view of tradition was not a static one: … Horizons change for a person who is moving. Thus the horizon of the past, out of which all human life lives and which exists in the form of tradition, is always in motion. The surrounding horizon is not set in motion by historical consciousness. But in it this motion becomes aware of itself (1975/2004, p. 303). The hermeneutic circle, as for Heidegger, remained important for Gadamer (Packer & Addison, 1989). The circle is not purely methodological or epistemological, it is primarily ontological. Understanding and interpretation are seen to be part of the way we are as beings in 75 the world. The circularity of understanding comes from our tendency to tilt into what we are studying and project our pre-understandings into the task. We live into the future. Our possibilities are both created and limited by the present and the past (Packer & Addison, 1989, p. 34). Understanding to both Gadamer and Heidegger is a reciprocal activity, represented in the circle as a recursive projecting of our prejudices and a pulling back into understanding how our preconceptions need to change. The circularity of understanding, then, is that we understand in terms of what we already know. But the circularity is not, Heidegger argues, a “vicious” one where we simply confirm our prejudices, it is an essential one without which there would be no understanding at all. And the circle is complete; there is accommodation as well as assimilation. If we are persevering and open, our attention will be drawn to the projective character of our understanding and—in the backward arc, the movement of return—we gain an increased appreciation of what the fore-structure involves, and where it might best be changed. (Packer & Addison, 1989, p. 34) The circle is the dialogical interplay between the reader and the text, whereby the reader does not grasp the whole of the text at once, but goes back and forth between the parts of it and the whole, learning more and more about her pre-understandings and what the text has to say. Theoretically, the circle does necessarily have an endpoint. In fact, some researchers assert that recursive reading and dialogue is sometimes more like a spiral, because with each reading understanding potentially expands and deepens (Conroy, 2003; Dowling, 2007). According to Lawn (2006), Gadamer viewed interpretation and re-interpretation as ceaseless tasks (p. 74), “the horizon of the present is continually in the process of being formed because we are continually having to test all our prejudices” (Gadamer 1975/2004; p. 305). Situating Myself as an Inquirer in the Research Theoretical pre-understandings. The choice of philosophical hermeneutics as a guiding theoretical framework within interpretive epistemology was influenced by my own epistemological and ontological beliefs about how psychotherapy works. I have been influenced by modern American relational theory (Gurman & Messer, 2003), and Accelerated Experiential Dynamic Psychotherpy (AEDP; Fosha, 2000), the hermeneutics of Hans-Georg Gadamer (1975/2004), and the writing of Donna Orange (1995, 2010, 2011). Generally, these perspectives can be considered to stand between post-positivist and postmodern paradigms, 76 acknowledging that reality is not a singular, objective universal that is external to the knower. Reality in these accounts is perspectival, and therefore multiple valid and apprehendable realities exist. In addition, understanding is seen as socially constructed by the knower in her historical/cultural milieu, and as a result is contextual, fallible and partial. These assumptions represent a move away from modernism’s unchanging, objective reality, and a move towards notions of co-constituted or co-created knowledge and a contextual understanding of the nature of phenomena (Ponterotto, 2005). Orange (2010), as a relational psychoanalyst and philosophical scholar, considers her psychotherapy practice as related to a humanistic paradigm. Philosophically, she considers herself a hermeneut. She summarizes her recent formulation of the link between how she understands humanism and relational self psychology as: What self psychology—both original and contemporary—brings to psychoanalysis and to the humanistically-oriented psychotherapies, I believe, is a sense of empathy as a way of being-with the other, an attitude that Kohut taught us to value in place of what he called “tool-and-method pride.” To those who, even today, disparage self psychology as “making nice” and ignoring the darker sides of human nature, we proclaim with Terentius [Roman poet and playwright] that we are human and nothing human is alien to us. We believe that our involvement in humankind means that all human experience is in principle understandable through empathic dialogue, including its nonverbal or embodied forms. This means that although you or I may not be able to understand every patient, no patient, no psychosis, no cultural difference, no form of otherness lies outside the possibility of understanding by someone. Daily we psychotherapists are called to be someone who makes the empathic stretch to include in our horizons of understanding that someone whom we find challenging, that is, difficult to understand. (p. 9) I concur with Orange (2010) that hermeneutic thinking fits naturally with relational psychoanalysis and helps clinicians stay close to their clients’ experience through its attention to prior understandings and biases. Before we label the patient, she says: … we can ask ourselves why we need to use such labels, and attempt to understand with the patient whatever experience is in question—yours, mine, ours—past, present, and future. In a fallibilistic spirit, we may be slow to foreclose possibilities of understanding; ready to hold our own perceptions, opinions, and theoretical language lightly; and 77 prepared to allow the inquiry to rest when the patient says the understanding is good enough for now. In other words, we work as partners in the search for understanding, but not as authority who says that bedrock … has been reached. We hermeneuts, acknowledging our own understanding as severely limited, refuse to insist on our own point of view. (p. 111) Relational psychodynamics is considered to be a two-person psychology in which relationship is seen as central to human psychological development. According to Mitchell (1988) the individual is … portrayed not as a conglomerate of physically based urges, but as being shaped by and inevitably embedded within a matrix of relationships with other people, struggling both to maintain our ties to others and to differentiate ourselves from them. In this vision, the basic unit of study is not the individual as a separate entity whose desires clash with an external reality, but an interactional field within which the individual arises and struggles to make contact and to articulate himself. Desire is experienced always in the context of relatedness, and it is that context which defines its meaning. Mind is composed of relational configurations. The person is comprehensible only within this tapestry of relationships, past and present. (as cited in Wachtel, 2008, p. 68) AEDP and relational psychoanalysis are practices of understanding together (Fosha, 2000, Orange, 1995). As previously mentioned, AEDP has its roots in the experiential short-term dynamic psychotherapies (STDPs: Alpert, 1992; Coughlin Della Selva, 1996; Davanloo, 1990; Malan, 1963; McCullough Vaillant, 1997). Fosha, with some of her colleagues established AEDP in an effort to move away from more traditional psychoanalytic approaches in which the therapist assumes a neutral stance, towards a more empathic, dialogic practice. The practice and rationales of AEDP privilege and tilt into the change processes of healing rather than pathology. Theoretically, the AEDP approach integrates aspects of: emotion studies and affective neuroscience; attachment and developmental theory; humanistic-experiential, and empathic-based approaches; somatic focusing; and transformational processes. The method of AEDP is described and practiced from a phenomenological stance. In-session client process is articulated as a flow of embodied, expressive experience. The therapist stance in AEDP and relational psychodynamics, like that of the hermeneut, is present, engaged, open, and responsive. From both perspectives, it is assumed that the participants in the dialogue come to the endeavour with 78 their own subjectivities, impacting what is explored and understood, and are changed by the work together, especially if it is productive. Central to the relational school and AEDP, and resonant with Gadamerian hermeneutics (1975/2004), the voice of the other is invited and included. To let what seems to be far and alienated speak again. But in all the effort to bring the far near … we should never forget that the ultimate justification or end is to bring it near so that it speaks in a new voice. Moreover, it should speak not only in a new voice but in a clearer voice. (in Orange, 2011, p. 40) Further considering how relational psychodynamics, AEDP, and hermeneutic philosophy come together in this project, I offer the following thoughts of Martin and Sugarman (1999). These authors postulate that psychological phenomena can be seen to reside in a nested set of biological and sociocultural realities that both enable and constrain our psychological reality. In other words, psychological reality comes into being in sociocultura l contexts, sociocultural contexts are dependent on human activities, our biology as humans is dependent on physical environmental realities, and so on. They further argue that “to say that something exists and/or exerts influence outside of human perception does not mean that the thing posited is fixed essentially, knowable with certainty, or that it is natural and without contingency” (p. 183). The implication of this for psychotherapy practice and research, as Orange (2010) stated so well above, is that the therapeutic conversation and process of understanding the reality of another always involves our situated humanness, and our limited understandings. However, there is always the priority and possibility for mutual understanding, even if not always fully achieved (Orange, 2011). Personal experiential and professional pre-understandings. My interest in positive emotional experience began in my Masters education and therapy training. I began to notice that when therapists facilitated an experience that felt “good” or “right” to a client, clients often appeared to savor the moment, slow down their personal and overall interpersonal process momentarily, sometimes even seeming vulnerable and pleased at the same time. I started wondering about what was going on for them. I began to read the work of Frederickson (2001) and Isen (2008) that suggests the impact of positive emotion on thinking and perspective-taking. As the literature review in Chapter Two indicated, negative emotion has emerged as a super ordinate factor in many mood disorders (Brown, Chorpita & Barlow, 1998; Moses & Barlow, 79 2006), and is a major focus of psychotherapy sessions. My own personal and professional experience bears this out. I have experienced both anxiety and depression in the past and I have been in long term psychotherapy as a client. Much of this work has been focused, necessarily, on my negative affect and “troubles.” I also believe that I have unquestioningly held protestant work ethics and other beliefs such as pain and meaning can come from suffering, going deep inside means facing difficult things, joy erupts after sorrow. And, I have personal narratives that illustrate these values. During my therapy training I have had the impression that positive emotion is not seen as being as important as negative emotion. This was never explicitly talked about, but I cannot remember anyone directing me to specifically focus on and explore emergent or expressed positive emotion, until I began training in AEDP. I am aware this may have been my own history, beliefs, and biases blocking me from taking up the idea. However, the therapeutic heuristic I absorbed is that positive emotion is a marker of psychotherapy change, rather than an ingredient of change (Greenberg, 2008; Fitzpatrick & Stalikas 2008). Embarking on this research has been both personally and professionally interesting to me. I concur with Stalikas and Fitzpatrick (2008) that negative emotion has been privileged in psychology. This makes sense given that it is what brings most people to counselling and psychotherapy—things are not going well and it doesn’t feel good. My research question was posed to learn more about positive emotion in psychotherapy sessions. I am not interested in bypassing negative emotion, or even in soliciting positive emotion. I am interested in knowing more about how to work with and utilize expressed and emergent positive emotion. Philosophical hermeneutics offers a theoretical framework that can accommodate the theories and concepts of psychotherapy, relational psychodynamics, AEDP, and the study of positive emotion. Specifically, the notion of the fusion of horizons and the hermeneutic circle helped me, as a researcher, to become increasingly more conscious of how my inquiry and interpretations were shaped by my theoretical and clinical perspectives, my views of human nature, human emotion, and human behavior, as well as my personal history, experiences and sociocultural background. Understanding and paying close attention to my prejudices allowed me to both pursue the research question, and to be aware of how my questions, listening, observing and interpreting were negotiated with the participants and emergent from our horizons. This approach also had the benefits of encouraging me to utilize my pre-understandings as starting points, hold my theories lightly, be open to being influenced, and to risk changing my 80 understandings. One significant shift that has occurred for me during this research project is my stance towards positive psychology. At the outset, I held a significant bias against some aspects of positive psychology. My background of stoicism, and entrenched protestant work ethic influenced some of my suspicious, even cynical views of interventions such as counting blessings, keeping a gratitude journal, and what I perceived to be an over focus on positivity. I can now see the value and place this approach has, and how these types of interventions can be helpful, without sacrificing depth, or bypassing distress and doubts. Research Methods Multiple case study approach. In Stake’s (2006) multiple case approach the phenomenon under study is called the quintain. In this project, the quintain was client positive emotion that clients and therapists attended to and worked with. Stake explained that “qualitative research is based on a view that social phenomena, human dilemmas, and the nature of cases are situational. The study of situations reveals experiential knowledge, which is important to understanding the quintain” (Stake, p. 12). In this way interest in the cases is instrumental, the purpose of the study being to go beyond the cases to my primary interest, the quintain. This differs from an intrinsic case study wherein the strongest interest is in the case itself. An example of an intrinsic case might be elaborating and exploring one person’s unique experience of their psychotherapy. Stake suggests three criteria for selecting cases: relevance to the quintain; diversity across contexts; and opportunity to learn about the context and complexity of the quintain. Acknowledging exceptions, Stake also suggests a minimum of four to five cases to demonstrate commonalty and uniqueness but less than 10 so that the amount of interactivity between the cases is not more than can be realistically handled by the researcher. In order to maximize the chance of the quintain being prominent, purposive sampling (Patton, 2002) was utilized in this study. Cases were relevant to the quintain, there was some diversity in the client profiles, and because the therapist participants practiced from a depth perspective, there was ample opportunity to tap complexity and micro contextual features of the cases. Stake’s multiple case study approach organizes the data analysis into within-case analysis and cross-case analysis. The within-case analysis includes a detailed account of participants’ experiences as they relate to the research question. In this inquiry that included identification and distillation of process themes, followed by initial assertions that summarized the important findings in each case (dyad). The cross-case analysis describes the similarities and differences between the cases (dyads) by 81 identifying common and unique themes. This discussion is then followed by a set of final assertions that represent the researchers best attempt to highlight the bindings between the cases. In short, the researcher’s interpretation of the findings. Both the common and unique themes, as well as the final assertions make up the cross-case analysis. Interpersonal process recall interviewing. The Interpersonal Process Recall (IPR) method was used to conduct individual interviews with participants. According to Elliott (1986), the actual procedure was first used by Bloom (1954) to study how college students were thinking during certain classroom activities, and was later taken up, named IPR, and utilized in the training of counsellors by Norman Kagan (1984). The potential of the method as a research tool has more recently been actualized to study psychotherapeutic relational processes. Elliott (1986) specifies two broad advantages of IPR. First, it employs a phenomenological approach in which actual live psychotherapy episodes/events can be analyzed. Second, it elicits rich, relevant, “insider,” subjective self-reports from both client and therapist narratives that are not attainable in other methods of transcription or video recording. IPR is not a rating scale or a process measure, “it is an interview situation” (p. 505) in which other data gathering tools, such as open-ended questions, rating scales, and/or experiencing scales can be utilized. This method entailed interviewing the participants (clients and therapists) individually, while viewing playback of their therapy session. The interview was designed to allow participants to reflect upon and describe their in-session experiences, taking advantage of the vivid recall the interview enables. Vivid recall of internal thoughts and feelings is related to several factors that operate during the interview process: 1) the recency effect of conducting the interview as soon after the session as possible, in these cases between 24 hours and 4 days after the therapy session; 2) cueing or priming the participant with a visual memory from the video recording of their sessions; 3) slowing down the therapy interactions by stopping the video recording to discuss memories of thoughts and feelings from the session; 4) encouraging participants to move psychologically from the here and now to the then and there of the session; and, 5) participants are given as much control over the recall process as possible (Elliott, 1986; Larsen, Flesaker, & Stege, 2008). The IPR interviews revealed specific details about client positive emotional experience from the participants’ perspective and thereby provided answers to the research question. In addition, the interviews expanded the client participants’ experience, and generated new 82 understandings by providing a venue to bring forward what was unspoken in the sessions by both members of the dyad. This included unformed or partially formed ideas, emergent material, and in some cases hidden material. No standardized emotional measurements were utilized in the study. Although directed, the IPR interviews were relatively unstructured, providing participants with an opportunity for in-depth reflection and discussion of their therapy session experience. As the interviewer, I remained present and empathically engaged. My primary agenda was to keep the interview on track by asking participants to imagine or remember their internal thoughts and feelings from the then and there and not the here and now. The IPR interview protocol can be found in Appendix J. In the tension between practicality and rigor, was the issue of whether clients and therapists are interviewed by different interviewers. Larsen, Stege, and Flesaker (2008) suggest there be two interviewers—one assigned to the client participant interviews, and the other to the therapist participant interviews, to keep the interview process from being unduly influenced by the other dyad member’s interview. For practical reasons this was not possible or desirable in this project. As a doctoral dissertation inquiry, having two interviewers adds to many confounds about who the data and interpretation belong to. It also may be argued that a hermeneutic interviewer starts with her prior knowledge, and may be able to facilitate the expansion of reflection, and understanding without imposing her own assumptions or those of other participants. Leading questions can be and were useful in both participant and researcher interpretations and assumptions—“the decisive issue is then not whether to lead or not to lead, but where the interview questions should lead, and whether they will lead in important directions, producing new, trustworthy, and interesting knowledge “ (Kvale, 1996, p. 159). The IPR interviews were 2 to 2 hours 40 minutes in length. The video recorded psychotherapy sessions watched during the interviews were 52-69 minutes duration. Thematic analysis. Thematic analysis, informed by the work of Braun and Clarke (2006) and Conroy (2003), was used to identify, interpret, and report patterns of personal and interpersonal processes within each case (psychotherapy dyad), and across cases. Thematic analysis is a widely used generic “method for identifying, analyzing and reporting patterns [process themes] within data” (2006, p. 79). However, thematic analysis is an atheoretical method. In keeping with a Gadmerian hermeneutic philosophy, the process of selecting themes went beyond the descriptive, semantic level to interpretation. Participant and researcher 83 emergent reflections, ideas, assumptions, and theories informed the content of the data and the processes enacted in the psychotherapy sessions and interviews. As a result, the analysis is partially theorized. Specifically, the interpretations in the analysis included an understanding of many of the historical, theoretical, and situational influences that enabled the responses that the participants provided (2006, p. 85), as well as how these understandings were negotiated and co-created. Participants In a hermeneutic research project, the participants are seen to be co-researchers. The participants were actively engaged in watching a video recording of one of their own therapy sessions and asked to reflect upon and comment on their experience as they remembered it. They were encouraged to express whatever thoughts and feelings they remembered having at the time of the therapy session, even those they may not have expressed fully in the session, or even those they actively concealed from their therapist or client. Purposive sampling (Patton, 2002) was utilized to recruit therapy dyads in which emotion is privileged as a key ingredient for attention and exploration, and in which positive affective processes are also privileged and likely to be explored as part of the therapeutic strategy. Specifically, this included therapists whose practices incorporate Emotionally-Focused Therapy (EFT) or Accelerated Experiential Dynamic Psychotherapy (AEDP), or a combination of the two. This purposive sampling served to bring the phenomenon clearly into view, and enabled a full exploration of how clients and therapists enacted such explorations in their sessions together. Recruitment began with prospective therapist participants. I used several methods including online advertisements on professional websites, advertising at a professional workshop, listservs, and word of mouth. Copies of the recruitment advertisement and recruitment letters for interested therapist and client participants can be found in Appendices A, B, and E respectively. In total 5 prospective therapist participants discussed their interest in the study with me. All five met the inclusion criteria. Four prospective therapist participants responded to the advertisement at the professional workshop, and one responded to the listserv advertisement. After several discussions two decided not to participate for ongoing personal reasons at the time, and the fifth wanted further time to consult with colleagues within their practice. In the end, I chose not to pursue this fifth prospective participant because I was able to obtain the sample without doing so. The sample included three therapy dyads, two different therapists, and three 84 different clients. One therapist participant recruited two client participants from their practice. Table 1 describes the demographics of the participants. Participants were all from Vancouver, were all white, first-language English speakers. One participant identified as being born in a Western European country. Table 1 Participant Demographics Age (years) Dyad Client Therapist Occupation of Client No. of sessions Prior to IPR No. of Years Practicing as Therapist 1 41 55 Physician Approx. 12 17 2 26 55 Health Coach Approx. 5 17 3 60 61 Accountant 2 30 Screening. Within each case, therapists were screened and selected first. A brief screening interview was conducted to ensure that interested, prospective therapists met the inclusion criteria: 1) psychotherapy practice is based on the models of Emotionally-Focused Therapy (EFT) or Accelerated Experiential Dynamic Psychotherapy (AEDP), or a combination of the two; 2) psychotherapy practice includes experience in video-recording sessions with clients, and the capacity for a physical set-up such that therapist and client faces are clearly visible on a video recording of a therapy session; 3) expert practice, as peer nominated, and/or as having completed certification in the above models of psychotherapy; 4) willingness to video tape sessions from the commencement of the study until an appropriate session is identified where positive emotion expressed by a client is explored; 5) being available for a 3-hour interview to discuss the therapeutic session within 1 week of the video recorded session; 6) being available for a one-hour member check following completion of the data analysis. The telephone screening interview protocol for therapists can be found in Appendix C. Once prospective therapist participants confirmed their willingness to participate. I provided further details of the study including: intended purpose; time commitment; and data collection procedures. Therapist participants were then asked to help with recruiting clients participants from their own practice. Suggestions for how to introduce the study and explain the study to interested clients were discussed (see Appendix D: Scripts for Therapists Recruiting Clients), and they were asked to circulate a written description of the research, in the form of a recruitment letter (see Appendix E) to their current clients who fit the inclusion criteria. The recruitment letter invited interested 85 clients to contact me, the researcher, directly about their interest in the study. Similarly, I conducted a telephone selection interview (see Appendix F: Telephone Screening Interview for Clients) to establish client eligibility for the study, explain the purpose of the research, benefits and risks of participation, data collection procedures, and time commitments. Contacting the therapists and clients separately, was a strategy employed to mitigate perceived pressure or influence which might occur if the therapists were to recruit their clients themselves. Clients were selected based on the following inclusion criteria: 1) being 21 years or older; 2) being a client in psychotherapy with a therapist who practices Emotionally-Focused Therapy (EFT) or Accelerated Experiential Dynamic Psychotherapy (AEDP), or a combination of the two; 3) being available for a 3-hour interview to discuss the therapeutic session within one week of the video recorded session, identified by the therapist; 4) being available for a one-hour member check following completion of the data analysis. The following were exclusion criteria for client participants: 1) not meeting inclusion criteria; 2) anyone who indicated they would need to withdraw during or after the IPR interview; 3) anyone who wishes to withdraw from the study before completion. Selection of psychotherapy sessions for the research. Once dyads had been selected, therapists contacted me when they and their client believed they had completed a psychotherapy session that would be suitable for the study. I collected and viewed a DVD of each video recorded session from the therapist participants the same day the session was held to determine instances where the quintain was present. Once a therapy session was selected I scheduled interviews to be conducted at a location of preference for the participants. This included participants’ homes or professional offices, at an office I rented from a colleague, and at my own home office. Research team. The interviews were all conducted by myself, the primary researcher. The research team during data analysis included myself as the primary researcher, and three other expert, peer co-researchers, in addition to my supervisory committee. All three co-researchers are doctorate prepared clinicians who have conducted their own qualitative studies, and in one case has supervised resident physicians in the planning of their research projects. These expert peer researchers acted in the capacity of verifiers and validators in the audit trail. They read over sections of the original transcripts, initial coding, and discussed with me whether or not they 86 could see clear links between actual dialogue in the transcripts, codes, patterns and how process themes emerged and were finalized. Data Collection Procedures Analysis and interpretation began as soon as data collection began. The interpersonal process recall (IPR) interview and the video recordings of the psychotherapy sessions were the primary tools used to generate the data. Prior to conducting the interviews I participated in a small group practice session in which I practiced utilizing the IPR with several colleagues. This practice helped me refine my ability to carry out the interviews and to use the video recording equipment effectively. The interviews were in-depth and semi-structured with two goals: 1) identification of episodes of client positive emotional experience and/or expression by participants; 2) elicitation of participants’ understandings of what was occurring for the client during the therapy session while they were experiencing and/or expressing positive emotion, as well as what occurred immediately following these positive emotional episodes. Identification of positive emotion episodes included what the emotion experienced was, and what appeared to trigger or generate the emotion. The experience of participants and dialogue between them following positive emotion episodes, as well as participants’ understandings of these experiences and dialogue, was particularly important because they directly answer the research question: how do clients and therapists utilize positive emotion when they perceive it has arisen for the client in psychotherapy sessions? As the interviewer I endeavoured to be fully present and engaged, and to create an environment that was comfortable for the participants. By using my counselling skills of active listening, empathic responding, questioning, and redirecting I kept the interview moving, and on track. This was a very pleasurable task for me. I was so honored and touched by the willingness, generosity, openness, and courage of the participants to share the intimacy of their therapeutic work with me that it was easy to join them in building our rapport together. Interestingly, there was considerable trust conferred to me by the therapists’ participation, in a sense by joining the study they vouched for me. This was exemplified by one client participant describing being primed to feel comfortable with me by her therapist, and our collective connection as being like three sides of a triangle. The following is an excerpt from the interview with this participant. “C” identifies the client participant, “R” identifies, me, the researcher. At the outset of her interview with me, she said: 87 C: There, I had a good feeling too because talking to you on the phone I had, for me, it went very well. R: Uh hm. Uh hm. C: And I felt attuned to you and I was predisposed to feel that way because of the connection with [therapist name]. R: [therapist name] C: And talking to you had reinforced that. And this was the third side of the triangle I was telling him …. R: Ahhhhh. C: I had made a good connection with you and he was, then, reinforcing that, again. R: Right. That makes so much sense. Because I felt the same thing. As soon as I heard your voice on the phone, I just had a sense of being attuned. I’m thinking, “Oh, this just feels nice.” C: Yeah. Yeah. R: It just feels good inside. C: Yeah, and it, and we were able to take each other and trust because of it really is a triangle, yeah. In order to obtain informed consent, I re-explained the study, its purpose, the study procedures, and explained to participants they could stop the interview at any time, either for a rest, or to exit the study entirely if they wished. Once informed consent was given, I began the interviewing process with an orienting statement, instructions about selecting positive emotion episodes, and gave the participant the remote control to start and stop the video recording of their psychotherapy session at each point on the video recording that they saw or remembered they were experiencing positive emotion. When the client was ready we started the interview process. To encourage as full an exploration as possible of these experiences within the session they were watching, I used several types of open-ended questions both to access detailed descriptions of personal experience and thoughts as well as to encourage the client to focus on what they were thinking and feeling then and there in the session, rather than here and now in the interview. A copy of the Interpersonal Process Recall (IPR) Interview Format is found in Appendix J. At the same time, I tried to be sensitive in providing my presence, space and time for emergent experience in the interview, mindful that watching a video recording of a private, intimate therapy session of our own is a vulnerable and powerful situation to put oneself into. When participants completed identifying and discussing episodes of client positive emotion experience I took the opportunity to return to the video recording and asked about specific episodes that I had seen on the video recording when I reviewed it prior to the interviews, if they had not already been examined by one or both of the participants. There were 88 two such episodes. One of these episodes was identified by the therapist and probed in the client interview by the researcher. The client considered this to be an example of a mixed state, both positive and negative and therefore it was included in the analysis. The other episode was identified in the client interview and probed by the researcher in the therapist interview, and was likewise included in the analysis. A total of 29 episodes of client positive emotion were identified. All episodes identified by client and therapist participants were included. This decision was made for two reasons. First, as was discussed earlier, the therapeutic endeavor is relational, co-constituted, and to some degree each partner in the dyad leans into and entrains their experiences, understandings, and intentions from moment-to-moment. In addition, these intentions, experiences and understandings—manifest, emergent or more latent— intermingle in the intersubjective field between them influencing and contributing to new co-created understandings. Second, in two instances in which an episode was identified by a client participant as an example of a positive emotion they experienced, that same episode was identified by the therapist participant and discussed because they either did not think the emotion was positive or were uncertain if it was expressed as a secondary emotion or as a primary emotion. For example, in one episode, the client identified her sense of a “lift” of relief after her therapist acknowledged her usual strength, something he knew and remembered about her from previous sessions. The therapist participant identified the episode and initially commented that he believed she was experiencing pain in that moment, but that he chose to comment on her strength to help her access her resource of strength. He later commented that he was unsure if her enjoyment of his compliment was defense or primary enjoyment. This example highlights the different vantage points of the dyad partners, who engage with the same material while bringing their respective theories, feeling experience, and intentions to the dialogue between them. Table 2 below summarizes the episodes identified. 89 Table 2 Positive Emotion Episodes Who Identified the Episode 1 Dyads 2 3 Total Both Client & Therapist 7 8 6 21 (72%) Client Only 0 1 5 6 (21%) Therapist Only 2 0 0 2 (7%) Researcher probed in client IPR 1* 0 0 0 Researcher probed in Therapist IPR 0 0 2 ** 2 Total 9 9 11 29 Note. * = 9th episode in session, therapist identified, and identified by researcher prior to interviews. **= 3rd and 9th episodes in session, client identified, and identified by researcher prior to interviews. When the interview was completed, each participant was given an honorarium in the amount of $150.00 as an expression of appreciation and acknowledgement of the personal commitment, time and effort involved in the research interview. I also asked the participants if I could contact them once the data analysis was completed to follow up with them, to share a summary of the findings from their dyad, and to have a brief discussion about whether the findings were complete and resonated with their experience. My intention was to contact the participants within three months of the interview. However, recruitment lasted until the beginning of a one-year internship I completed in another province. The therapy sessions and interviews were transcribed during that internship year. In addition, due to personal and health reasons the data analysis and follow-up member checks for trustworthiness were not completed until 36 months after the interviews. When the findings were completed I contacted the participants. All were willing to continue their participation and agreed to read the findings relevant to their dyad, including cross-dyad observations and assertions, a document of approximately 25 pages for each participant. This was done via email for three of the five participants, and via email and telephone for two of the five participants. These follow-up contacts varied in their length of exchange. In two of the five follow-up member checks by email, the participants responded with brief responses only to each follow-up question. In the third follow-up by email the participant made several detailed descriptions of their feedback, and responded fully to the follow-up questions. In the two member checks involving both email and telephone, there was a telephone conversation that lasted between 45 and 60 minutes, as well as several subsequent emails of clarification. 90 The purpose of the follow-up member checks was to validate the trustworthiness and resonance of the findings. Participants were asked whether any details in their biography synopses needed changing. Two participants requested a few details to be changed for accuracy. After discussion with all the participants, and in consultation with one participant and my supervisory committee, it was decided that some changes needed to be made to a description of an identity, to protect a relationship with a third party mentioned in one of the therapy sessions. As a result, changes have been made to one participant’s age, occupation and cultural background. After careful consideration, I also decided not to identify which dyad this participant belonged to, and to use no pseudonyms in the findings chapter to add another layer of anonymity. Generally, the participants confirmed that the findings were an accurate representation of their participation as they remembered it. The two therapist participants expressed the opinion that the process of metatherapeutic processing did not receive enough importance in the interpretation. Interestingly, this feedback highlighted a conflict I myself was grappling with at the time. Specifically, I had initially identified both metatherapeutic processing and making implicit experience explicit and experiential to expand awareness and increase understanding as separate final theme processes. However, by the time I provided the findings to participants, I had collapsed metatherapeutic processing under making implicit experience explicit and experiential to expand awareness and increase understanding. As a result of their feedback I returned to the within-dyad analysis and highlighted the use of metatherapeutic processing under several themes in Tables 3, 4, and 5. In addition, an explanation was provided in the cross-case analysis about why metatherapeutic processing was subsumed under the process theme making implicit experience explicit and experiential to expand awareness and increase understanding. One of the therapists expressed that he did not agree with one part of a process theme balancing giving and receiving to reduce power differential and affirm and build strength. He stated that he does not think this theme is about balancing power, but that perhaps balancing power is an outcome of the theme. I returned to the section and upon further reflection decided to shorten the theme process title to balancing giving and receiving. In addition, I included his comments as an explanation of his goal in initiating his disclosure. One of the therapists asked for the wording of an expression he used to be changed. This involved substituting the word validation in the place of a colloquial synonym he had used in the 91 interview. He requested this substitution for the sake of professional clarity about his intervention. This same participant questioned the piece of dialogue I had chosen to represent one theme. I returned to this segment of the chapter, re-checked the dialogue excerpt, and included a greater portion of the dialogue. I believe this addition improved the clarity of the section. One client participant asked for clarification about what one of my interpretations meant. I had written: “The client’s reflections [in the IPR interview] focused on the bond between her and her therapist, how their age allowed them to accept gratitude mutually, without false modesty. The actual dialogue suggests she deflected the intimacy and complimented her therapist.” When I explained my observation and interpretation, she responded: “so true … I do that … with humor, too.” This finding will be discussed further in the final chapter as it is an example of how the research processes extended the psychotherapy sessions. Other comments made about the themes and findings, including their completeness and accuracy, were: “it’s very strong, like a manual (for students, therapists) for how two people can be to be together,” “reading it over by myself, it seemed like you had taken the important meanings from me and [therapist’s name], nothing extraneous, you got all the essentials, all the most pertinent parts,” “I've taken the time to read through the document. It was a while ago, but it does appear to reflect my memory of the appointments, both with you and [therapist’s name],” “it certainly represents what I remember sharing in the interview, and to my weak memory now, seems very accurate. I definitely didn't read anything that I thought sounded unlike me, or that I wish were removed. It was all very positive of an experience, and I think you've successfully captured that sentiment (and process) here as well.” Participants also commented on how the findings resonated with their experience, still had an emotional impact after three years, and had practical utility for others. Examples of these comments are: “The summary is very much on-point with what I remember the experience being. It was really interesting to have the opportunity to first create the bond/safe space to explore with Dr. [therapist], and then to have the double-neat experience of getting to review and see my own experience & thought processes as they were unfolding. This summary was very much on-point!” “I have read the first document you sent. Very impressive. I’m moved by the detailed way that you captured the themes of the work. I’ve made about a page of notes which I will send after I review it again.” “I think you should share this with Diana [Fosha] and AEDP 92 faculty when you have completed it. Also I’m going to suggest that we list these publications on our web site as it demonstrates the impact of these approaches to therapy.” “I feel so moved in re-reading this with you (in the member check telephone conversation).” “Beautiful (as we read a section of his own reflections over together during the telephone interview).” “Despite reading a script without non verbals, it’s complete and it’s excellent and meaningful. It has enhanced vitality, the verbatim kept it vital.” “Reading this helped me see my growth edge.” “It’s congruent to me, helped me recognize how easy it is to mistake anxiety for emergent experience.” “It tells people the things we can do to work with positive emotion.” Lastly, one participant stated that the summary of findings highlighted and brought to mind a significant point in her session with her therapist. She shared with me her recollection of a poem entitled “A Memory of William Barnes” by Thomas Hardy (1886). I include it here to highlight how much resonance and re-engagement occurred for several participants during the member check process. A Memory of William Barnes Silently I footed by an uphill road That led from my abode to a spot yew-boughed; Yellowly the sun sloped low down to westward, And dark was the east with cloud. Then, amid the shadow of that livid sad east, Where the light was least, and a gate stood wide, Something flashed the fire of the sun that was facing it, Like a brief blaze on that side. Looking hard and harder I knew what it meant - The sudden shine sent from the livid east scene; It meant the west mirrored by the coffin of my friend there, Turning to the road from his green, To take his last journey forth—he who in his prime Trudged so many a time from that gate athwart the land! Thus a farewell to me he signalled on his grave-way, As with a wave of his hand. Data Analysis The overarching organizing strategy for this project was Stake’s (2006) multiple case study approach, guided by a philosophical hermeneutic framework (Gadamer, 1975/2004). Data analysis for each dyad (case) proceeded in steps and involved intensive, prolonged engagement 93 with the data from each case. In Stake’s approach this is known as the within-case analysis. This was followed by cross-dyad (cross-case) analysis in order to understand how each case, and the three cases taken together answer the research question. Braun and Clarke’s (2006) thematic analysis was utilized to give direction to the steps and levels involved “in identifying, analyzing and reporting patterns (themes) within the data” (p. 79). The data set included transcribed psychotherapy sessions, transcribed IPR interviews and transcribed verbal and written follow-up member check comments. Within-case analysis. The within-case analysis was guided by three concepts from hermeneutics: co-constitutionality, fusion of horizons, and the hermeneutic circle, as well as the first five of six phases of thematic analysis suggested by Braun and Clarke (2006). These phases are: 1) becoming familiar with the data; 2) generating initial codes; 3) searching for themes and patterns of meaning; 4) reviewing themes; 5) defining and naming themes; 6) producing a report. Despite how valuable transcribing is as the first immersion in the data, I elected to have the therapy sessions as well as the IPR interviews transcribed by a professional transcriptionist. Working dyad by dyad (case by case) to familiarize myself with the data, I initially listened to the entire transcribed psychotherapy session, with the express goal of correcting the transcription and adding in codes and notes for non-verbal cues, silences, voice tone, pace and other impressions. This was followed by reading the transcript of the therapy session while watching the video recording of the session, in its entirety, several times to get a sense of the whole session without altering its meaning. After several readings of a session, I repeated this process with the matching IPR interviews from both client and therapist participants. I then went through the IPR interviews line by line and identified where positive emotion episodes that each participant identified were located in the therapy transcripts. I compiled a list of episodes in three columns, representing those identified by myself, client and therapist participants. These were identified by numbered lines in the transcripts. As suggested by Levitt (2010) being maximally inclusive was a principle used to delineate each episode, in order to provide greater contextual information rather than leaving out potentially relevant dialogue. Dialogue segments that followed each positive emotion episode and that illustrated how clients and therapists attended to and worked with these positive emotion episodes were next selected. These excerpts were laid out on 45 large, 22-inch by 35-inch paper sheets enabling organization of all the data into manageable 94 segments. An example of this organization is found in Appendix K: Example of Organization and Initial Coding of Positive Episodes and Post Episode Dialogue. The dialogue from the entire psychotherapy session in each dyad was initially coded using in vivo and process coding (using gerunds) to represent the actual words and actions of participants, as suggested by Saldana (2013). Once this step was completed, I watched the video recordings again and began to compile a coding manual while completing a second round of coding, looking for patterns and themes, and beginning to group these together. The coding manual was structured by dyad, number of episode or post episode dialogue. The emotion(s) experienced and/or expressed and subsequently identified, were described, along with the interactional and/or situational factors that triggered the emotion. A summary of codes was completed in three columns underneath the emotion and trigger notations: 1) my coding of the psychotherapy session; 2) my coding of the client’s reflections from their IPR interview with me; 3) my coding of the therapist’s reflections from their IPR interview with me. This was followed by a précis of my reflections and ideas about the overall meaning of the episode and post episode, including my own questions and notes for further follow-up. Many of these notes contained my thoughts and theories about the therapeutic dialogue, as I began to interpret and decipher “what mattered” in each episode. Some of these notes were highly theorized. An example of one of these précis follows. The codes of the client’s reflections in our interview highlight her cultural beliefs about bearing pain, storing pain, dealing with pain—stoicism, fatalism. [In the interview] the client is aware she is being seen by her therapist as she watches herself. There’s coherence here (mirroring from attachment theory), that she feels good. It is a relief to make sense enough that someone sees you, feels with you. You are not alone. They are in it together. She can breathe again. There’s room to exchange air, she can make sense and talk about how it makes sense. See the post episode. The client’s “lift” has allowed her to see a bigger picture and from it she can see it leads onto her intensely painful past. It shows her the road ahead and behind. She has come into a clearing, like an open moor. This is also consistent with Mergenthaler’s work, a “lift” opening the way for deepening and retrieval of memories. (excerpted from notes on Dyad 3, episode/post episode 3). The next step of the analysis involved summarizing and reviewing codes and précis to identify overall themes for each episode. I created a spreadsheet that summarized each episode, 95 grouped by dyad, and included: a) a description of the emotion, and its trigger(s), and an excerpt from the therapy session that demonstrated this clearly; b) a description of what the dyad partners did with the emotion, and a representative excerpt of dialogue; c) a description of the overall theme of the episode. An example from this 40-page spreadsheet is found in Appendix L: Preliminary Theme Summaries. This step was followed by a long process of refining the specifics of each theme, finding related processes and themes that explained and expanded an understanding of how these dyad partners worked together to explore and understand these positive emotion experiences. This long engagement with the data enabled implicit meanings to be made more explicit, and permitted many versions to be “tried on” in the process of compiling and defining the final theme processes. I eventually settled on theme processes because theme seemed too static a term for what was being described. The final three steps of defining and naming the final theme processes are summarized in Appendix M: Final Distillation of Themes as Processes. At each of the five steps of the analysis described above, my supervisory committee and my expert peer co-researchers were consulted. In addition to participants’ input via member checks, the hermeneutic frame was respected by co-researchers having access to parts of the original transcripts, development of codes, patterns and themes. Allowing myself and my interpretations to be influenced by the meanings others attributed to the transcripts, codes, précis, and process themes highlights how multiple perspectives have infused the findings. While I tried to be aware of and hold my pre-understandings lightly, and those of my co-researchers, I also endeavoured to privilege the participants’ perspectives, understanding and sometimes choosing the position that my understandings were partial, perspectival, and fallible. In this way I believe the findings represent a “fusion of horizons.” Each within-case (dyad) analysis ended with a set of assertions that summarized the key aspects of how the dyad partners worked with and attended to positive emotion when it arose for the clients in their psychotherapy sessions. According to Stake (2006), assertions are a form of generalization made to better understand the quintain within its context. As an interpretive study the final assertions summarize the findings from the perspective of philosophical hermeneutics. I fully recognize that my understanding of the findings may not be the only interpretation. Cross-case analysis. As enriching, hermeneutic research, rather than theory-building research, the primary aim of the study was to expand and deepen reader, participant, and inquirer 96 experiences and understanding of the quintain, working with client positive emotion. The within-case analysis provided rich, thick descriptions of the phenomenon. Whereas in the cross-case analysis, comparisons were drawn between the cases setting up a tension between the binding of the cases and the particularity of each case. Stake (2006) refers to this tension as the case-quintain dilemma, “is it the quintain with loose ties to the cases or the quinta in with vital ties to the cases” (p. 7) that best describes the quintain? Stake describes the multiple case study researcher as: “start[ing] with the quintain, arrang[ing] to study cases in terms of their own situational issues, interpret[ing] patterns within each case, and then analyz[ing] cross-case findings to make assertions about the binding” (2006, p. 10). Drawing assertions in Stake’s multiple case study method is a “bigger” research strategy, attempting to knit together patterns (in this project theme processes) that emerged in the within-case analysis. According to Stake, “the assertions in a cross-case report are the researcher’s findings about the quintain” (p. 41). As such they are likely to be interpretive, less complex and contextual than the within-case findings, and yet still true to the particular in the within-case findings. The cases were selected instrumentally to highlight and understand the quintain. However, the phenomenon of dyad partners working with client positive emotion within three cases of psychotherapy sessions is common to the three cases, legitimizing a cross-case analysis. The cross-case analysis began informally quite soon after the first within-case analysis was undertaken. This naturally happened as I became aware of similarities and repeated processes I had read and heard in the other case video recordings and transcripts. The actual steps involved in the cross-case analysis were: comparing how each dyad answered the research question; identifying similarities and differences between the dyadic processes; compiling a distilled list of theme processes; and finally making assertions about the most important findings between the dyads. The three dyads in this inquiry were bound together by the research question and psychotherapy process. The assertions drawn are my best attempt to summarize aspects of therapeutic process that encompass the within-case themes, bind the dyad cases together, and answer the research question through the lens of a philosophical hermeneutic framework. As a result, the assertions from this study are highly conceptualized. Ethical Considerations The study was approved by the University of British Columbia Behavioural Research Ethics Board (BREB). Five ethical issues emerged as being important—informed consent, 97 respecting the boundaries of the participant-researcher relationship, confidentiality, well-being of the participants, and safety and privacy of the data. Informed consent is an ongoing process, not an act. Given that the participants were volunteers, and that informed consent is contractual, the participants were advised that they were free to exit the study at any time, without prejudice. A copy of the informed consent for therapists can be found in Appendix H, and a copy of the informed consent for clients in Appendix I. Confidentiality and privacy for participants was maintained by not identifying participants, even with a pseudonym. This decision has been previously discussed and was taken primarily to make it more difficult for readers of the final manuscript to identify participants (Hadjistavropoulos & Smythe, 2001). Interviews were conducted separately. No information from the IPR interviews was shared with participants within dyads or across dyads until they gave their permission. The summaries clients received during the member checks contained only the analysis of their dyad and only dialogue segments from their own particular interview. The data is stored in a locked filing cabinet and in encrypted files on the hard drive of my own personal computer, both in my home. I am the sole user of that computer. Only the researcher, myself, had access to the transcripts. Sections of the transcripts were read by three expert peer researchers, and my research committee during the data analysis process. I was the only person who had access to the video recordings of the psychotherapy sessions and IPR interviews. While the interview was not a counselling session, client and therapist participants did express emotion, and reflect silently and with me while watching and discussing a video playback of their therapy session. I was mindful of the intersection between my counselling training and researcher role (Haverkamp, 2005). In counselling and psychotherapy research, as with any therapeutic intervention, both benefits and risks to participants need to be articulated and measured to mitigate any harm to the participants. The IPR interview format suggests that the interviewer stay attuned to the participants. I assumed an engaged empathic stance, offering support and validation for responses and felt experience in the moment, while redirecting participants back to thoughts and feelings in the then and there of the session, rather than the here and now of the interview (Larsen, Flesaker, & Stege, 2008). This general approach to the interview process may have helped participants to feel both supported and encouraged to engage fully in the interview process. It is also designed to refocus participants back to the research 98 question(s). In doing so, it may also have created some distance from the session, and served to reduce some of the stress of impactful emotional responses or re-experiencing that arose as a result of watching and reflecting on playback of their session. In some approaches to psychotherapy (AEDP; Fosha, 2000), supervision (Safran & Muran, 2000) and research (Young, Valach & Domene, 2005), session or interview review, or metaprocessing in sessions are interventions utilized to enhance understanding, anchor and integrate insight and learning, and defuse and/or repair relationship misattunements and ruptures, resulting in a strengthened therapeutic alliance. For these reasons, the IPR interviews had the potential to benefit client and therapist participants (Butterfield, Borgen, & Amundson, 2009). I did not provide counselling or therapeutic interventions to the participants, although the questioning and exploration of the therapy session conversation and interactions had a therapizing effect in some instances. This will be further discussed in chapter 5. Within each dyad, participants were free to consult each other as part of their own usual session schedules about the impact of the IPR interview and viewing their therapy session. Criteria for Evaluating the Rigor and Worth of the Study Findings The epistemological position of interpretivism, and the philosophical hermeneutic framework of the research study have implications for how the study’s credibility can be considered (Crotty, 1998). As exploratory, hermeneutic research this study aimed at enriching and deepening practitioner, researcher, and participant experience and understanding of the phenomenon working with client positive emotional experience (Stiles, 2015). To this end multiple theories and different understandings were sought and considered, and although the findings are presented, they are not meant to be a final account. It is expected that other equally valid accounts are possible. In order to build rigor into this project I took up up Morrow’s (2005) suggestions. Rigor in qualitative research is associated with the quality of the research process and trustworthiness. This involves being able to communicate transparently to colleagues what and how procedures were used, being reflexive, keeping a thorough audit trail, involving expert peer co-researchers, and my supervisory committee to validate findings at each step of the analytic process (Saumere & Given, 2008). I endeavoured to carefully plan the research design. I grounded the project in an appropriate paradigm, interpretivist in this case, and extant literature, and I carefully selected the research question. Three other, more transcendent criteria of rigor that are consistent with the conceptual framework and that test rigor 99 and worth of the study have been chosen. These are consensual validation, resonance, and trustworthiness. Consensual Validation. Rather than examining the truth value of a hermeneutic study, more consistent with its methodological aims is consensual validation, which Lieblich, Tuval-Mashiach, and Zilber (1998) define as “sharing one’s views and conclusions and making sense in the eyes of a community of researchers and interested and informed individuals…” (p. 173). The expert peer co-researchers, as well as my research supervisory committee (expert researchers) read over sections of the original therapy transcripts once they were organized by episodes. They discussed their ideas of what they understood was occurring in the episodes and gave me feedback about my coding. A member of my supervisory committee and two expert peer co-researchers read through sections of my coding manual containing summarized codes, and précis of how I was beginning to interpret the episodes. They validated my interpretations and offered their thoughts, reflections, and feedback on the work. At later stages my research supervisor and one other committee member ensured that the descriptions of theme processes were detailed and vivid enough to closely represent the experience of the participants. When the final theme processes were completed and the findings chapter written up, the participants validated that the themes accurately captured their experiences of how they worked with client positive emotion in their sessions. Two of these participants were expert psychotherapy practitioners. Resonance. This criterion refers to whether or not the interpretive findings of the research reverberate sufficiently with readers to be meaningful (Tracy, 2010). That is, do the readers find the interpretation impactful and convincing enough to get a glimpse into aspects of their own world or the world of another? In a sense good writing and a resonant text takes the reader inside another’s world rather than explaining it (Neilson, 2008). The participants all reported that the IPR interviews themselves were engaging. During the member checks participants were asked the following questions. First, is the summary meaningful to you? Does it capture or resonate in some way with your experience of your therapy session and interview with me, as you remember them at this time? Second, does the summary represent what you shared in your interview? Is it complete and accurate? Is there anything missing? Is there anything that needs changing? Four of the five participants specifically stated that the summary resonated with them. Several of these statements were quoted earlier in this chapter. In addition, 100 the expert peer co-researchers and my research committee commented on the richness and vividness of the within-case (dyad) findings. Trustworthiness. Morrow (2005) suggests that trustworthiness is created through careful attention to issues of fairness, researcher reflexivity, praxis, and particularity, to name a few aspects of trustworthiness. Fairness involves involving the understandings of others and can be extended to include the depth of understanding reached about participants’ meanings and the degree to which meaning is co-constructed by participants, researchers and co-researchers. I endeavoured to keep an open dialogue with the participants during the interviews as well as the member checks. I also invited co-researchers several times into the analysis for validation and for discussion. I included many ideas from co-researchers as well as from participants into my interpretation. I believe that the detailed representation of the therapy session and interview dialogues, interspersed with my reflections, and the participants’ reflections provides a rich, resonant and deep engagement with the experience of the participants, and fulfills the criterion of particularity—respecting and honoring the integrity of each individual and dyad (Morrow, 2005). In addition, my own prolonged, personal engagement with the data, and my understanding of the literature emphasizes the centrality of praxis. I kept a detailed record of my process, thoughts and analysis (all described earlier in this chapter), including member checks. These records collectively represent a close audit trail of my process of analyzing data, summarizing, and presenting the study findings. The audit trail speaks to the quality of the process rather than its accuracy. Philosophical hermeneutics is not focused on the accuracy of meaning as much as it is interested in the engaged, co-created nature of understanding, along with its provisional and fallible nature. The relationship between theory and practice, praxis, will be evaluated by the research committee and external examiner during the final defense process. Researcher reflexivity was addressed by keeping track of my own theoretical, historical, personal, and cultural pre-understandings, as well as how my thinking and decisions were evolving and transforming, as I proceeded through carrying out the study. An example of how my attitudes and bias about positive psychology shifted during the research process was discussed in Chapter Two. 101 Chapter 4: Findings This chapter summarizes the findings of the research project that set out to answer the question: “How do clients and therapists utilize positive emotion when they perceive it has arisen for the client in psychotherapy sessions?” The findings are presented in three sections: within-dyad (case) analysis, cross-dyad (case) analysis, and key assertions. In the first section, the within-dyad analysis, the dyads are presented in detail to retain the unique complexity and co-created nature of the therapeutic endeavour, as well as the dialogic process involved in the interviews themselves. Many direct quotes from both the original therapy session transcripts and research interview transcripts are presented to provide the reader with a rich, contextualized picture of how clients and therapists worked together in exploring episodes of positive emotion in the therapy sessions. In addition, the detailed analysis allows the reader enough exposure to this textured and absorbing data to understand the researcher’s path to the overall findings, as well as to form their own interpretation and conclusions. The second section, the cross-dyad analysis, presents the researcher’s understanding of the common and distinct ways these dyads worked with and utilized client positive emotion. Section three, the final assertions, provides a summary of what binds the dyads (cases) together, and what was learned from the three therapy dyads through the lens of the hermeneutic framework described in Chapter Three. Within-Dyad Analysis This section presents detailed descriptions of the interactions between clients and therapists from the therapy session transcripts, and the corresponding reflections and exploration of these interactions by participants and researcher from the research interview transcripts. They are organized according to dyad and to the process themes that emerged from identified positive emotion episodes. In total, 19 process themes were identified—six each for Dyads 1 and 2, and seven for Dyad 3. Excerpts from the therapy and interview dialogue transcripts are labeled by source (S = therapy session; CIPR = client interview; TIPR = therapist interview) and line. For example, S (therapy session), 45-51 (lines from the respective transcript). In addition, each speaker in the transcript excerpts is identified (C = client; T = therapist; R = researcher). The process themes, while presented separately, are contextually related to each other and to some extent are emergent from previous processes, events and emotional states. As a result, 102 the many detailed excerpts from the therapy session and research interview transcripts also serve to illustrate the uniqueness of each process theme. In these rich descriptions the reader can begin to understand that meaning occurred within the conversations of these dyad partners, and in particular, how these dyads worked with spontaneous, emergent client positive emotion. Although the themes are presented sequentially, and as distinct processes, they did not necessarily follow one another in sequence, and in fact oftentimes overlapped experientially. The process themes paying attention to safety and making implicit experience explicit, and explicit experience experiential to make connections and build awareness are two in particular that emerged over and over in conversations between the dyad partners. In addition, one related process theme, metatherapeutic processing, was enacted over and over. This process theme was subsumed under making implicit experience explicit, and explicit experience experiential to make connections and build awareness. The reason for this decision will be discussed in the cross-dyad analysis section. Dyad 1. Background Information. This dyad included a 41 year old white, English speaking woman, the client, and a 55 year old white male therapist. The client is a full-time practicing physician and clinical teacher of medicine. The therapist is a doctoral level prepared Registered Psychologist with 17 years of experience. The therapist described his approach to psychotherapy as attachment-based, and he is trained in both Emotionally Focused Therapy (EFT) and Accelerated Experiential Dynamic Psychotherapy (AEDP). The client reported that she had been seeing her therapist monthly for approximately one year about issues related to the breakup of her previous relationship, and that she had seen this same therapist for couples work with her former partner prior to the relationship break up. Context of the therapy session. At the outset of the therapy session the client and therapist discussed video recording the session, and checked in with one another about their participation in the research project. The session was 69 minutes in duration. The major therapeutic focus of the therapy session was the issue the client opened the session work with—her emerging sense that she was beginning to “let go” of her worry for her former partner’s well-being, and her feeling of guilt about leaving the relationship and being in a new relationship. A second and implicit therapeutic focus held by both the therapist and the client was a core relational theme for the client: “Can I be in relationship and be myself without having to essentially change?” This 103 theme emerged in the first positive emotion episode identified by both participants in their respective interviews. Consistent with this therapist’s training and stated theoretical model, Accelerated Experiential Dynamic Psychotherapy (AEDP), many of the therapist’s responses and interventions were aimed at helping the client increase awareness, experiencing, regulation, and processing of her somatic and emotional experience as it occurred in the session. In addition, there are many exchanges in which the therapist invited the client to share her thoughts and feelings about how they were working together, including the impact of his presence, responses and interventions. From an attachment perspective, this type of intervention is intended to reveal the state of safety and security of the working relationship, as well as to assess and strengthen the client’s relational capacity. In AEDP terms, these interventions are known as metatherapeutic processing, a type of immediacy intervention (Fosha, 2000, Russell, 2015; Iwakabe & Conceicao, 2015). For example, “Can I be myself with you?” and “What is it like for me to feel what I feel, say what I think, and do this with you (as an other)?” In this way, the therapeutic relationship serves as a safe container, a safe base for therapeutic work, and as a real relationship from which relational capacity is built, expanded, and transferred to other relationships. As the therapy session progressed the dyad worked at: titrating the intensity of the client’s emotional experiencing; staying with her emotion(s) long enough to recognize their significance; resourcing privation imaginally to expand her experience; pendulating between eliciting experience and reflecting on it; labeling her somatic and emotional experience; allowing the therapist to accompany her in noticing and commenting how her work with him, and her presence was impacting him. Context of the interviews. The therapist interview was conducted first. We met at the home of the therapist participant, at his request, the evening after (approximately 30-36 hours) the therapy session under study was completed. The duration of this interview was 134 minutes. The client interview was conducted at an office I rented from one of my colleagues, approximately 48 hours after the therapy session. The office was selected as a venue that was conveniently located, comfortable, and private for the client participant. The duration of the interview was 131 minutes. 104 Summary of themes and processes. The dyad engaged in several different interpersonal and therapeutic processes in the context of specific personal and relational themes when they worked with the client’s positive emotion. These are summarized in Table 3. Table 3 Themes and Processes Related to Working with Positive Emotion for Dyad 1 Major Process Themes Related Themes and Processes Paying attention to safety - Negotiating comfort levels, proximity, authenticity and genuineness with one another - Repairing relationship rupture Imagining more to scaffold new experience - Experiencing being in relationship without having to change self in context of exploring a wished for, better outcome; savoring good feelings and being resourced by them Making implicit experience explicit and experiential to make connections and build awareness - Privileging exploration of gratitude in the context of exploring the complexity of experiencing mixed emotions (relief, joy, sadness, guilt) Fueling the tank of togetherness - Feeling and expressing good feelings in presence of another; expanding relational capacity - Metatherapeutic processing: mutual sharing of delight and making in-session changes explicit Undoing aloneness - Validating reality of client’s previous relationship struggle; discovering I am not alone in thinking this; experiencing “I am okay, I make sense” in context of being seen and understood by therapist - Metatherapeutic processing: exploring what it is like to do the work together Affirming, anchoring, and appreciating the work done together - Valuing and validating decision making - Noticing feeling better - Affirming the session work The following section explains the process themes summarized in Table 3 in more depth. Paying attention to safety. Both participants identified the following episode in the therapy session in which the client expressed relief in response to being asked how she was doing since the previous session. She recalled that she felt better since clearing up some legal issues related to the break up of her previous relationship. S 28-39 C: I’m feeling good. Like it’s a sort of funny combination of things. Ah, … Um, I think I’ve been feeling good. Like, I’ve been feeling pretty happy and, and, and calm, and T: (pause) Calm. That sounds, that sounds good. 105 C: Yeah. Yeah, it’s good … I think, I think it really did, it really did make a difference for me to get that whole legal thing out of the way. S40-53 T: Yeah. So, as you say, are you also aware, right now, as we speak of feeling some of the difference it makes having it over? Or is it more like reflecting on that’s how it’s been, and not feeling so much right [now] that’s (unclear). C: Yeah, I guess so. I feel it, in my, in my head … It’s more of a thought though, than … T: Okay. So, you have an awareness right now that it’s made a big difference and that has felt good. Am I getting that part right? C: Yeah. Yeah. The client identified and contextualized her feelings in the research interview. She described how she usually has her feelings in her head, and that when her therapist asks her to locate them in her body and label them, it sets up a tension for her—“it’s not how I operate.” She laughed as she described how this goes in sessions, and at the same time acknowledged she chose her therapist based on his emphasis on emotional processes. CIPR 65-79 C: And so, so we’re sort of getting to that part now where he’s like, and then we’ll spend a few minutes talking about that, about how I just, I don't know it’s not, it’s not there. I don’t have a feeling. … But it’s, it’s, it’s thoughts are, my thoughts are positive. R: Your thoughts are positive. You have a sense that things are moving in a direction that is going to be a positive. C: Yeah, a sense of optimism, a sense of relief, a sense of well-being. CIPR 99-115 R: and remember[ing] back, you don’t see anything shifting, your body or your breathing changing, or that he might have tuned into, from your perspective. C: No. (laughing) Only that, that I know he’s going to, that that’s part of what our therapy is. … Is that he sort of stops, stops me and says: “What’s your feelings?” And so because it’s not natural for me, that’s not my, that’s not how I operate. … the only thing I think that changes for me is that when he says, “Okay, let’s stop for a second and talk about your feelings.” I’m kinda like going, “Oh, not this again!” (laughing) The client was fully aware of what she called her “twofold reaction” (CIPR 125), a wariness about the therapist eliciting her internal experience, which does not come naturally to her, and being willing to continue to participate because she knew this was part of her work. The therapist was also aware of her reaction and proceeded with caution, inviting the client into paying attention to her internal experience of relief. TIPR 71-74 T: Maybe this is a little early to do it. “Just notice what that feels like in your body.” But I’ve been told by her that she only feels things in her head. And that it’s okay to ask her “Do you feel something?” But not to try and elicit what she feels, so that’s constraining. (laughing) 106 TIPR 89-90 T: Um, I’ve been told to – that there are very, I have to lean in, in very cautious ways. TIPR 156-157 T: we’re just at the little emerging, fleeting … yeah, I’m experiencing embodied relief. It’s mirror neuron, relief, it’s empathic relief. How the dyad worked with relief. Following the identification of the client’s experience of an emerging sense of relief, the dyad partners continued to pay attention to and get curious about more aspects of the client’s positive feeling. The therapist followed the client, noticed her experience and expressions, paraphrased her words and expressions, asked her where she was noticing her experience, and let her know he was noticing too, and trying to understand. In turn, the client responded, laughed, expressed her uncertainty, and then noticed the “hard bits” [about the relationship break up], that hinted at the other side of the break up coming into her awareness. S 57-72 C: Yeah, like right at this moment, it’s more like an awareness than a, than an actual sort of feeling of something. T: Yeah. I think that’s an important, that’s a good distinction, that we’re, that you have been feeling it. And in this moment as we talk about it, you have an awareness, which is more like a thought that you … C: Yeah. Yeah. I think, um …yeah. T: It’s like you’re in touch with something other than how, what a difference it makes. It’s like you’re in touch with some, something else, right now, is that right? C: Oh, no, just. Yeah. T: Yeah. Something shifts a tiny bit, is that so? C: Well, I just, you know it still, it still, there’s still some, there’s still some hard little bits. T: Yeah. Yeah. C: And I guess, hopefully those will, will become, will become less. There were no participant reflections on the above excerpt from the therapy session. Taken together the interactions excerpted above highlight the theme of paying attention to safety and comfort in the therapeutic relationship and the work itself. The client reported things were generally good in her life and in her in-session awareness, but communicated close attention to her internal, and/or affective experience being somewhat uncomfortable and “not natural” (CIPR 110) for her. As she and her therapist continued to explore her affective experience, specifically the part that felt positive, more challenging parts of her relationship break up experience started to emerge. 107 In another example of the dyad negotiating safety, the client and therapist explored the client’s tolerance for exploring her positive emotional experience of letting go of her previous relationship. S 182-204 C: Well, I didn’t just say, “Fuck you. I’ll see you in court.” T: Exactly. Exactly. Did you … C: That fact that I still kind of steered it. Like I still sort of said, “Oh, let’s go to mediation. Oh what could we do to make this better?” T: Yeah. Yeah, yeah. That I’ve actually had kept – that you, [client’s name], have kept [partner’s name] best interests. C: Yeah. T: At heart. Through all of these – in some way, through all of this, is that right? C: I think – yeah. Yeah (laughing) and I think it’s like oh it’s the same shit as before, like when we were still together, that was the way it was (laughing) … and it’s still that way … and … you know T: You laugh, while you sigh? C: I laugh … and people are like, “Oh, you know, now that it’s all over, did you tell her about [new partner], yet?” And I was like, “Oh, no, I think, I’m still part of me is like, oh, no, she’s going to be really upset.” And, and I’m like it’s almost time for that part to be over. In the interview, the client described what was occuring for her. CIPR 235-241 C: I’m, I can slowly feel myself kind of letting … go of that… dynamic a bit. Like I’m, where I, where I worry about her and I care what she’s going to think and I don’t want her to be hurt. And then I can, I can feel myself in this, in this, in that moment of just a little bit, letting that go. R: So, that letting go, feeling that, can you say what’s positive about the letting go? C: Again, it’s the same, it’s the same stuff that I, that I’m feeling less, less paralyzed. Like I’m feeling like actually like feeling outside of my head … CIPR 272-282 R: Yeah. Is there any other, like if you remember back to there and watching it yourself, um and sometimes it’s hard to separate what might be the experience and watching yourself, but, but like something that was felt good here, did it have any other qualities to it? Like was there a temperature to it or pressure to it or color to it or idea to it, or I mean you said it’s positive, but … I get the feeling you’ve got lots of like you’re really able to describe images and thoughts around …? C: It might feel like a, like a window opening up. R: Okay, so that’s a nice image. C: And ah, and ah, and ah breeze be here. [points at chest] The client and therapist talked about this episode from different vantage points. In the excerpts above the client reported feeling a sense of letting go, and opening up, and the therapist reported he thought she felt both caring for her partner and pain in letting go. 108 TIPR 317-320 T: So, I’m saying let’s notice this. Let’s see what it feels like to care. That’s what I’m wanting to do. R: Do you think you might be, are you thinking anything else there? T: Well, probably and is that okay to do with[client’s name]? TIPR 333-337 T: At the same time as the sadness and the pain. I am, [researcher’s name], so much about maximum complexity as opposed to complication. Trying to embrace as much of our experience as we can. And Daniel Siegel says it so clearly. That that’s the place of maximum flexibility and maximum adaptability. TIPR 352-356 T: No, I’m thinking let’s invite her caring and her pain all at once. That she cares and it’s painful to care because I believe that that’s going to allow her to stand, not on half of her experience, but on all of it. In a way that’s going, in a way that’s going to allow her maximum mobility and flexibility … How dyad worked with the relief of letting go. As the dyad continued to process the positive emotion, the therapist was too close, was not fully attuned, and the client reacted. However, she responded to his request for feedback, and she was candid in telling him her reaction. This resulted in their covert reactions being brought to the surface and articulated. In addition, the therapist apologized. S 247-257, 261-262 C: Well, I do feel like um – I do feel like a softening, kind of. Feeling. Like um … Yeah, so me kind of softening, kind of feeling. T: Uh hm. Now just breathe out. Okay. Because I feel some warmth. You know some warmth in my heart right by you saying part of the reason I care is because of whether I’m right or wrong. I think she’s [client’s partner] fragile right now. Right? Yeah. What happened? What is like to hear me say I feel supported; I feel sad? C: I don't know. T: I’m just curious, what is, maybe it feels like a distraction to you that I, that I feel warmth? S 267-274 T: Right? And I care to know if it’s a distraction or if it kind of happens how it lands with you. C: (laughing) Ah, it, it, it jars me out a little bit. (arms crossed) T: Okay, I’m glad I asked? I’m sorry. C: No, it’s… I’m just saying it’s not – it’s not super nice, just … T: It jars you out of your own experience. C: Yeah, a little bit. T: Yeah, so that’s important for both of us to know, to be mindful of. C: Okay. Good. Based on subsequent interactions in the session going well and deepening, this would be considered a repair of a mini relationship rupture, which has the potential to strengthen the 109 therapeutic relationship (Safran & Muran, 2000). Both client and therapist reflected on this dynamic and mis-attunement in the research interviews. CIPR 371-379 R: He uses the word softening and you say, “Yeah, I think maybe I was softening.” But it doesn’t feel complete. C: Right. R: So, you’re not describing it as a positive. C: No … He picks up on it being a positive. CIPR 387-395 C: And how sometimes he’ll communicate that as either well are you – are you feeling this? Or he’ll say “well I’m feeling that way … do you? What do you think about that?” … And then I kind of sort of feel like I need to respond to that. And then but that, but that, and, and often it’s and often it’s not. … And so this is sort of one of those times. TIPR 433-443 R: Yeah. Do you know what you might have been aware of? T: No. R: At the time? T: Ah yeah… well probably some wow, this is good. Look at that. Go[client’s name]. You actually are dropping down into your body a little bit. Taking some of these um [other experiences] that aren’t just in your [thoughts] inform you of your experience, I don't know. I’m probably pleased. R: Uh hm. T: Might be moved. And I’m probably also wanting to be gentle cause to not muck it up. TIPR 444-451, 478-480 R: So, a sense of carefulness a little bit. T: Yeah. Yeah, yeah. yeah, and not wanting to scare the deer. Uh hm. Uh hm. (laughing) The deer comes out of the clearing for connection … and I don’t want to be the clumsy human who startles her. … Well, so again, it looks like she bounces between softening as she touches [in] and then she tenses up as she says it. That’s what I think is … so again it’s between anxiety and defense and core categorical [emotion of love, sadness]… Summary of process theme paying attention to safety. This dyad utilized positive affective experience as a focus to pay attention to safety in the context of the therapeutic relationship as the safe container in which therapeutic work occurs. Specifically, they negotiated proximity; comfort levels; honesty and authenticity between themselves. In addition, the positive affect was used as a content focus for early session work. The therapist’s mixed metaphor of the deer coming out into the clearing or woods for connection is so powerful. It captures the dilemma faced by participants in therapy—coming into a clear space to be seen with all the vulnerability and fear it involves to let our tender, natural side be seen and known. 110 Imagining more to scaffold new experience. Both participants identified the following episode in which the client experienced pleasure and pride as a result of expressing her self-righteous anger in the presence of her therapist, and feeling she was understood. Having the “hard bits” emerge previously in the session, the client experiences self-righteous anger related to thinking she has not been respected and trusted by her ex-partner. Her speech flowed in this segment of the session, her words and tone of voice matched what she was feeling, she was congruent. S 102-116 C: Really. Like in the big picture, that’s good enough. Right. Right. … So, of course, that morning it was the day after [partner] sends me this stupid email. And it’s – even though I’ve spoken to her on the phone a couple of times, it’s all been normal. She sent me this stupid email. And it’s all like, “Oh, as per our separation agreement, I thought you know the date – the deadline of this and that and you failed to blah, blah, blah and ah please ah please advise as soon as possible.” And like the email is cc’d to her lawyer. And I emailed back and I’m like, “You know what? You can quit with this kind of email. You can quit speaking to me like this. … Like my patience with this whole landscape and its characters … and they’re populating it, is very, very thin at this point. T: Yeah. Wow. In the interview the client participant reported feeling “empowered” by expressing her anger to her partner in an email, telling her side of the story, and saying it out loud to her therapist. She also commented that it felt good and positive to her to experience her anger again in the session, especially since she had often deferred to her partner’s anger in the past. CIPR 138-151 C: And through the whole time with my separation from my partner, I was really subjected to a lot of her anger. Like I was subjected to a lot of her anger for, for many years. And then um so I know I’m, I was starting to becoming a storyteller in this video, here, like there was some of a story and I was sort of getting into the storytelling; I was a storyteller. But this is actually quite positive for me, cause I’m like “Finally, I’m going to say how angry I am.” And I’m just going to tell you how angry I was and then I told her that I was angry.” And so it might not like seem like a positive story, but it actually was a positive story. It was and it felt good to me too. R: To get angry and to actually fully express it. C: To get angry … yeah. And to express it to her even though it was in an email it was like, and to tell [therapist] about that, I felt like kind of empowered. I felt like “Oh, this is good.” CIPR 171-178 C: Well, I think there was like a little bit, a lot of the time I, in the past, I deferred to my ex-partner’s anger. … And I didn’t really, it, I felt, I felt quite paralyzed by it. And, so I think this was one time where I was like “Wow, we’re not even together and I’m still 111 kind of subjected to your anger and I’m kind of going to change that dynamic. I’m going to say this isn’t actually okay. And so that was, that was a really good feeling, when, when I was telling [therapist] about that. During the research interview, she reported another new awareness—she had begun to change the dynamic with her former partner, an awareness that was implicitly communicated to her therapist during the expression of her self-righteous anger. The therapist recognized how good it felt for the client to feel this self-righteous anger and to be understood. TIPR 183-188, R: So, what emotion would you say she’s having? T: Oh gosh. What’s it feel like to be seen and gotten? Um, what emotion would that be? … let’s see… um I do think there’s some element of happiness or … it’s not happy, hm … it’s not excitement exactly, there’s something, well there’s some version of … security. I don't know what emotion it is? R: Hm. Uh hm. Uh hm. Okay. TIPR 197-200, 270-271 T: Pleasure, some version of pleasure, … pleasure to be gotten, even when she’s talking about something painful (197-200) … well, anger, justified anger is also an emotion, right? … to have space for your anger, feels good. How the dyad worked with pleasure and pride. Immediately following the identified positive emotion episode the client stated she wished her former partner could have acknowledged her fairness in the legal procedures. Rather than focus on this painful client experience, the therapist piggybacked on the energy of the client’s pride and empowerment as a platform he called “the imaginal positive.” He invited the client to imagine a better outcome, the “good” outcome in which she receives an apology and/or a thank you or a recognition for all she did. This was an intentional scaffolding or approximation of having what she didn’t get that was so painful, possibly too painful to explore at this point. The therapist stated he did not believe the client was resourced enough or resilient enough at this point in time to move too quickly or deeply into the pain of not being fully seen and recognized by her partner. His reasons for saying this were related to his conceptualization that this client has a relational history of not being seen, understood, and acknowledged, and it is early in the session. This relational theme threads through most of the episodes in this session and is a therapeutic target that is worked with alongside all other session foci. S 140-142 C: I just, I just and you know it would have been nice at one point, at one point in this whole thing that you would have said something that resembled, “I’m sorry.” Or, or - or thank you or something. 112 S 148-154 T: Yeah.[client], what would it have been like to have gotten that, “I’m sorry.” Or “thank you.” that you [client] have been, what would you hear in that “thank you” or “I’m sorry?” It’s a recognition of something, right? C: Some kind of, acknowledgment T: an affirmation or something… C: acknowledgement that this was way more crazy than it needed to be. S 161-168 C: And then, and then T: What would it … C: And then it would have been nice for her to say you know thanks for sort of coming along on the ride. I realize it was pretty hard on both of us and I’m sure it was hard on you and, and I just appreciate you sticking with it. T: Yes. Thanks for still being there for me after this. Is that some of it? C: Yeah. Thanks for still being there. There are no client reflections for his segment of the session. The therapist provided his rationale for this intervention. In the follow-up member check the therapist expanded on the rationale of using an intervention like “imagining more.” He talked about how it is easier to have a positive experience that has already happened. By imagining how good it would have been to receive recognition or appreciation from her partner, the client is imagining something positive, something other than what happened. The therapist stated that type of experience expands the client’s model of self and the world. In short, he said: “she said it would be nice to have. So, okay, let’s give it to her.” He also mused: “the best intervention is the one already starting to happen.” He reported he could not remember the source of that quote. His explanation is related to a suggestion from Solution-Focused Therapy (de Shazer and Dolan, 2007) of “if it works, do more of it.” By doing doing more of what is already starting to happen, or starting to work, even in small steps, larger changes often begin to happen in interactional and systemic domains. Indeed, imagining more to expand one’s model of self and world! TIPR 281-285 T: .... I’m veering a little bit away from the pain of it because I think once she’s more resourced she’s going to be able to be in touch with the pain more and that that will also end up feeling better. So, that’s a little bit of my raison d’être right in this moment TIPR 295-298, 304-305 R: Uh hm. So, then you’re leaning toward eliciting something positive from her. T: That’s right. Exactly. I’m inviting it, I’m inviting it, a point choice for me … in this moment. I’m going to go to those places, but not in this moment. 113 Another example of imagining more occurred in the session when the client experiences relief and joy triggered by imagining herself in a relationship where she can be herself, no changes required. S 290-294, 299 C: Well, I’d like to be, I’d like to be able to, to care about her. Like to feel, to feel for her and, and to, and to, and to, and to want to be there. And know, know her. But not have to, not have to change my own behaviour or modify what I’m saying or doing … I should be able to do both S 313-321 T: Yeah. What would it be like to be able to be in that place? C: I think it would feel really good … I think it would feel really good. I think I would feel relief. I think I would feel relief. … In fact, I feel relief just thinking about it. Even though (laughing) I haven’t even gone there yet. (laughing) The client and therapist reflected on this powerful intervention in their interviews. The client stated she actually felt relief by simply imagining her goal of having a relationship in which she can be herself without being required to change. CIPR 419-425 C: I am feeling quite positive because I think, I think it is, it’s, it’s, it is a one-line encapsulation of, of probably, if I could have articulated what I would have wanted to get out of about who my therapy would be is exactly that. Would be like oh I want to be able to, to, to care about you know whatever my ex or people or … whatever. But that I don’t have to feel like I need to change who I am. TIPR 538 T: Okay, so she identifies it. She actually has the experience of relief, right? How the dyad worked with relief. The dyad partners stayed with the client’s relief and imagined more, again. The therapist invited the client to stay at the edge of this new experience—the opening to, remembering, and taking in of her relief. Relief is an emotion that is often experienced at the intersection of something unpleasant or challenging being completed, or let go. This is a mixed emotional experience, similar to her feeling caring and sadness about her previous partner, and it is another example of her therapist choosing to focus on the positive affect in her mixed emotional experience. He gently invited the client to notice that something painful was also present in part of her experience. This resulted in the client inviting relief, release, joy, and guilt into her awareness. She was beginning to hold the complexity and opposites of all that was currently happening to her in her life. S 322-326 T: Wow, look at that. Uh hm. Just noticed what it really feels like in this moment for you. I don’t want any report on it; I just want you to observe your experience right 114 now. Because having the experience actually facilitates our awareness of a preferred experience. It facilitates it recurring. C: (laughing) Like it might happen again for real? S 337-345 T: Just really kind of imagine. You. Caring and not having inner caring, not having to sacrifice other aspects of your authenticity [whispering] and who you are and what you do. What would that be like? Does some of the relief feel like relief? Is it still believing what it would be like? C: I think so. T: And what might that relief make space for? Because relief is sort of a releasing. Well tell me more about it? C: Well, I think relief would be release. It would feel like a release of something. S 353-354 C: I don't know what it would make room for? I think it would just make room for joy, I think. T: And it looks like there’s some, some pain or some sadness associated with it, right now. Is that possible? C: Well, I think - I think that the pain is ... I think it’s still some residual guilt. S 388-390 C: And like gratitude for, for my, for my new relationship. … A lot of gratitude. Reflecting on this in the interview, the client stated that recalling the positives had helped her to realize: “I am okay, and I know why I know I am okay, there are markers …” In a sense this might be considered a self-recognition experience: “I see me. I am okay. Things are okay, and remembering and feeling it lets me know it.” CIPR 567-568 C: Yeah. Yeah. It felt good to, to sort of recall those recent experiences of, of release CIPR 579-581 C: To think about those positive things that, and of positive feelings that I’ve had over the past number of weeks does pull up, for me, a sense of, of gratefulness. CIPR 583-588 C: And so, and so it changed my thinking about that, like oh wow I’m, I’m really, I’m okay like things are okay. I’m, I’m grateful that they’re okay. R: And here’s some markers of why. C: And here’s some, some markers of, of, of things that are of why I would think that they are, that things are okay. This appeared to be a new place for the client, a place of recognizing something different in herself. She was feeling better, experiencing feeling better, and not just as thought feelings in her head. As well, she was able to discuss her experience with her therapist. The therapist commented on this in the interview. TIPR 724-738 115 T: Finally. It took us 25 minutes of the session to, to get to I’ve been feeling good. I wished I’d asked her “What are you experiencing right now as you tell me?” Just a really open question. … Because she was so in touch. And it looked to me like mourning the self or when I think it’s really a very lynch, a really, ah, kind of the arch stone in an arch, whatever the really crucial point of therapeutic change I think is when people get to: “wow I’m not hurting it like I’ve hurt.” Hurt. “I feel better.” Or “I’m well, I’m different. And wow has it been a long time in the desert.” “It feels so good to be out of the desert and it puts me in touch with how painful it was to be in the desert. “That I think is – to me that’s the kind of fulcrum or the, um, that’s the, to me the sign that we’re really doing therapy. Summary of process theme imagining more to scaffold new experience. The dyad utilized positive emotion to imagine and approximate a desired outcome; to resource the client by savoring the good feelings of relief, release, and joy in order to prepare for later exploration of the more painful aspects of her experience. The therapist stated he thought that imagining more is a type of imaginal exposure, resourcing a deprivation. Another stated rationale for the intervention was to invite an approximation of having a preferred experience in order to facilitate it recurring, and to expand the client’s model of self and the world. For example, “I can have what I need, the world can offer me what I need and want.” The client grasped this immediately and in the process had an experience that approximated being in a relationship where her fuller emotional self was expressed and welcomed. Making implicit experience explicit, and experiential to make connections and build awareness. This episode was identified by both client and therapist in the research interviews for reflection and discussion. The client reported joy, happiness, and gratitude in response to thinking about how her life has been since the break-up of her previous relationship. S 384-390 C: (laughing) Um, no, it’s not that either. It’s more like that I, that, I that I have this have this sense of feeling grateful. That, that, that my, that my life is how it is. T: Uh hm. Hm. Uh hm. C: And like gratitude for, for my, for my new relationship. T: Yeah. C: A lot of gratitude. CIPR 620-634 C: and it’s happy. And it’s joy. And it’s, but I think, I think tied into lucky is a sense of like I didn’t see this coming. … Or I, I didn’t know it was, I didn’t know it was going to happen or I didn’t know it was possible. Some sense of that. That … R: Some unexpected delightful surprise ... C: I think when I say lucky, the fact is that’s part of it. Some element of like surprise and, and good fortune and happiness. I think those sorts of feelings. R: And so you’re contacting kind of all of that there, in there? 116 C: Yeah. CIPR 605-607 C: Like just happiness and gratitude and I and I think I get into it in a minute about, there’s bewilderment mixed into the, the word lucky. However, the therapist did not think the client was experiencing positive emotion, only naming it. This may be an example of a quiet, emergent experiencing of positive emotion, undetected by the therapist and the researcher. It is important to note that the therapist was cued to something more in her experience and very quickly followed up on it in the post episode dialogue. The client also expressed some bewilderment in noticing how suddenly things in her life changed for the better, alongside her guilt. This appeared to be new for her, and it was somewhat confusing and disrupting. TIPR 758, 764-766 T: Positive emotion T: So, here, I think I’m doing, I’m wanting to disentangle compassion or sadness that someone I care about is hurting. From, wow, gratitude. My life has changed. … That’s what I’m trying to do in that moment. And in a kind of slightly cognitive way. But we’re not really at the positive emotion. She’s naming it, but not experiencing it. How the dyad worked with the joy, happiness and gratitude. Up to this point in the session the therapist had been privileging, leading explorations and assisting the client to process her positive emotion in order to resource her, expand her models of self and the world, help build her capacity to look at and hold the complexity of her situation together. While the therapist did not specifically utilize the gratitude the client had just experienced, it is likely that the gratitude described above was a further resource for the client herself, allowing her to hold a larger perspective (with more complexity), and thus increase her general awareness and ability to make new connections. The therapist invited and guided the client into clarifying and experiencing aspects of her complex experience: compassion and caring, guilt and shame, self preservation, deciding when personal costs are too high, letting go of caretaking, and being compassionate. He led with the positive aspects of the client’s compassion. What occurred was integration—the client expressed what was true for her, but it was new for her to do this, and she experienced some anxiety S 392-394 C: And then and then and then this little edge of, of guilt comes in because … T: Yeah, right. Is there a difference between compassion and guilt? S 398-407 117 T: Right. Because that sounds like there’s compassion there. [she, partner] doesn’t have that caring [from someone else]. And then also what I sometimes think of as crossed wires. … And I caused that. Is that the guilt? Because guilt is usually “I’ve done something….wrong.” C: Yeah, maybe, maybe partly I wouldn’t have sort of … I wouldn’t have connected those dots, but I guess like if we were still together, she would still have some of that. S 455-466 C: Because I really cared and she was, I don't know what she thinks about when she goes home and she’s like: “okay I don’t have that anymore.” T: Yeah. Right. So, while I really get that. You don’t want to think about that because you’re sad. That’s what I call crossed wires, is that all of a sudden it goes to some version of I’m, I’m bad. Which isn’t guilt; it’s shame, actually. But I’m bad. I’ve done some, or I’ve done something wrong. Right, okay. C: It’s not that. It’s just more like I, I could, I could, I could fix that if I wanted to. T: Yes, exactly. At what cost? Right? C: It’s not like I’m bad or I did something wrong, but … T: I chose myself over … S 499- 505 C: Yeah. I picked – I picked me. T: Yeah. You didn’t pick for her to stay. Like if there was wreckage, you used to talk about the train going off the rails…? C: Yeah. T: If there was wreckage, you didn’t choo[se], pick for her to be where she is. You picked for yourself to have a better life than you two were able to make together. And part of you says some version of I deserved that. And another part of you says you’re, another part of you feels fucked up. C: Well, just, because I could, I could just do what I was, what I did for a long time was just say well … S 517-526 T: Just notice your experience of this. Notice the richness and complexity of your experience, of caring about [partner’s name], feeling some relief that you’re not caught up in extra sacrificing, somebody you’re not enjoying … As well as the guilt. The sense that somehow you’ve done wrong by choosing you over you and her. Am I getting it right? Is there more there also? C: Uh hm. Yeah. No. Well, that’s um that’s… T: [whispering] Just to be with all of that, now, [client’s name]. How comfortable or uncomfortable does it feel as we speak of it? C: No, it’s okay, Um, not so good. There are no client interview reflections for this segment. The therapist identified this as an example of balancing mixed, complex experience in the presence of another—her relief, new relationship freedom, right alongside beginning to let go of her old relationship. She reported making new connections, and as a result it appeared that something was beginning to re-organize, and it created anxiety in her. The therapist’s metaphor of a “balance beam has a little 118 more latitude” captured the leading edge of the client’s experience and her growing relational capacity. TIPR 783-883 T: gratitude. Right. I’m trying to access the gratitude and the sadness. Trying to tease apart all the stuff that’s going on and the complexity there. And the, yeah, and make space for as much of it as we can in an experiential and embodied way. Yeah. And feeling good about the work because I mean cause she’s, cause we’re with each other. R: Yes, yes. She’s really working. T: And she’s closer to her experience. Which, if she’s tense a lot of the time and on guard and vigilant, then there’s some ease in even naming their hard stuff. But I think all of this is productive. So, I feel like, again, it’s a, the tight wire I mentioned earlier. A balance beam has a little more latitude. But I’m, I think that we’re working at the cusp of, of experience. It’s a frontier for her. Especially to have this and be seen. I think she knows how to pull away from other people and be in touch with her experience. To do this and be with me is a lot. And she keeps coming back. Summary of process theme making implicit experience explicit, and experiential to make connections and build awareness. The dyad partners utilized the positive emotion of gratitude and compassion as an entry point to explore the complexity of the client’s experiencing. They heightened her experience of the relief and joy in her mixed emotions (relief, joy, sadness, guilt) by paying attention to it, exploring it and getting the subtleties of meaning right. This resulted in her emergent and implicit feeling of guilt, shame, and issues of self preservation and limit setting becoming explicit, spoken of and felt in the presence of a trusted other, her therapist. Russell (2015) reminds therapists that emergent experience is the expression of the self in transition. It is sometimes manifest in mixed states, confusing and contradictory behaviours. By facilitating implicit experience to become explicit, the therapist assists clients to better know these aspects of self that are coming to the surface for expression, understanding, and possibly action. Further, to help bring reflection and experiencing together begins to structure and facilitate new learning or to scaffold it until it can be utilized by the client. Russell (p. 121) compares this to Vygotsky’s (1978) “zone of proximal development.” Fueling the tank of togetherness. The client expressed relief, gratitude, and joy, mixed with a bit of anxiety—“can I trust this happy surprise?’ This was triggered by the previous episode in which she and her therapist explored the complexity of her experience, and her therapist asked her to pay attention to and describe her gratitude in more depth. S 541-546 T: Tell me about the gratitude. Your gratitude. 119 C: Just like that I feel like we’re lucky. Somehow it’s a strong word, but it’s the word that I keep saying. It’s just like god, I just feel lucky. I feel, I feel lucky. T: Like luck has smiled on you. C: (laughing) Like how did this happen? Like my life is so good. And I’m just, I just feel just feel grateful that it’s, that I have what I have S 550-552, 566-570 C: that it’s, that it is what it is. Like um I can’t I can’t believe it. T: Okay, so notice like that, that kind of disbelief and why you feel it. C: (laughing) Um, the um I’m in touch a little bit with the bewilderment. T: Yeah. How could this have befallen me? Is that …? C: How could this … T: Happen to me. C: … happen to me. How could this have happened? … Um, the um I’m in touch a little bit with the bewilderment, happen to me. How could this have happened? Yeah. It’s a pleasant surprise Both the client and therapist validated the client’s feelings of relief, gratitude, joy, and anxiety in their respective interviews. CIPR 646-648, 678-679 C: (laughing) So I think that’s more of the same like more of just sort of like the, the surprise, like the - the happiness. And just – I was just in at the point just thinking about it, about it. R: Do you think there was, like I’m curious that there’s something more … C: … Maybe a sense of space. Like a, yeah, maybe something, something big and, and joyful noisy. TIPR 917-920 T: So, actually that uh, hm, was positive emotion. It was the green light. Right? Because I made a choice. I said “Yeah, I am curious about the guilt, but let’s again lean into the positive first. And she goes there with me … which she wouldn’t do earlier in the session TIPR 931-932 T: I almost said “Luck just kissed you hello.” I mean, that’s so, that’s yeah. Luck, luck smiled on you. TIPR 962-964 T: And the intellectual play, there, that we both can do about these words. But it was, yeah it was shared delight. Yeah. And then she goes into the kind of the laugh, which is more like State 1 anxiety defense… How the dyad worked with the happiness, joy and surprise. The dyad used the positive emotion of gratitude, happiness to move forward generally in the work—the client was fully experiencing her feelings and allowed the therapist to help her process them. There did not appear to be any of her “twofold reaction” present. The client was doing something she had found hard earlier in the session and in the past—experiencing and expressing her feelings in the presence of another. In a form of metatherapeutic processing—mutual sharing of feelings, and 120 explicitly exploring change events within the session in this case, “hanging out with” her success in experiencing her feelings with her therapist, the dyad heightened her feelings of gratitude. There was ease and flow in the dialogue. This led to a validation of her decision to leave her relationship, and had an enormous positive impact on the client at two levels: the client felt seen and understood for decisions she made; for allowing herself to feel good in the presence of her therapist. The client may have been less aware of the change in her relational capacity and openness at this point of the session. This is a wonderful example of working at a developmental edge—expanding the client’s relational capacity. Her relational capacity at this point included being able to feel her feelings outside her head, and not be jarred by her therapist reflecting them back to her or asking her to let him know more about them. She seemed to be able to do this in this segment without feeling she was being asked to be a different way, or do something that was unnatural for her. S 604-618, 637-641 T: So, let’s just breathe together into that for a moment. And celebrate that. Is that okay to celebrate? C: (laughing) Yeah, (laughing) Yeah. T: You’re sure? (laughing) … Okay. I mean I want to give you a high five. … I do. I want to say “You go!” … “You go.” C: (laughing) I know. Everybody’s really happy for me. T: What’s that like? Hard to receive. C: A little bit. T: Yeah. Yeah. Now just notice … it looks like a little bit of embarrassment, but maybe I’m wrong … C: Yeah. A little bit. … Yeah, not so much attention. … Yeah, I don’t like attention. T: Yeah. Un, unaccustomed to getting attention for the good stuff. C: Yeah. Yeah. S 672-684 C: Yeah, no, it’s okay. T: Okay, good. So, I said we’d go to the other part. …That we’d hang out for a while in gratitude. … When you say, when you say it’s okay, you’re saying you can receive it from me that I’m happy for you, that that’s okay. C: Yeah. T: But there’s a message like, is there something kind of like I’m doing well. [my ex is] hurting. I’m bad. And I know I’m making this really bald when I say it that way. S 774-792 C: It’s just what you do when you’re an adult. Is you just, you suck it up and things aren’t going 100%, well that’s too bad. You just have to, that’s what you do. You look after somebody; you, and you stay and take care of them and even if they’re, even if your relationships sucks. T: … I’m glad I was your couples’ therapist. 121 C: I can see like a real insight into (laughing) T: I think you probably do. … Because yeah things weren’t 100% … Yeah, they weren’t. C: No, they weren’t. In the interview, the client primarily spoke about having her reality validated by her therapist as a significant experience and integration point. Interestingly, the therapist reflected mainly about the interaction between them as the new developmental point in his interview. These may be parallel processes (within client and between client and therapist) about: “I am okay to be me, to make my decisions, to have my feelings, and be okay with others and myself.” The client appeared to be largely unaware of her expanding relational capacity with the therapist in this session. She also appeared somewhat bewildered, at that point, about how her life had recently transformed. Things were re-organizing in the client, and it felt both good and was anxiety-provoking. CIPR 736-757 C: And so at this point I do have positive feelings and I do have this sense of relief. R: Anything else? C: Just … R: You said validation. Can you say more about that? C: Well, a sense of like “It’s okay, like I’m okay. I’m, I’m okay that I, that I made the decision that I made. And that I’m not, that I’m not. That he, that, that I don’t need to feel like I’m judged for , or that.” And that ah so validation in that sense. R: Somebody else saw the same thing. C: Somebody else saw the same thing and says, “No, it’s okay that you’re not there anymore.” … Like, and that he offers that very spontaneously. Like I don’t have to say you know “Do you think that it was okay that we split up?” … Like I don’t solicit that at all. And so I don’t have, that he volunteers that. Um, I have, have quite a lot of positive feelings in the next couple of minutes. R: Can you say a little more about that? Like he offers it spontaneously. What does that mean for you that he does that spontaneously. C: Well, that it must be real. The therapist commented that he was hoping to enhance or heighten her sense of happiness in order to solidify this relational experience of feeling good and being seen feeling good. TIPR 985-992, 995-997, 1001-1005, 1007 T: She’s not, and I say it to her explicitly two minutes later. She’s not used to being seen when she’s happy. She hasn’t had goodness of fit. So I’m also making case formulation for myself. … Attachments. Style … So, when she has the positive, she doesn’t know what to do with it. 122 T: … she knows how to have her experience by herself. (laughing) So that that is part of what I’m doing with her positive emotion and fitting it into a framework that helps me and maybe her understand her experience T: … Well, yeah, I mean I’m definitely, like I said a moment ago, I’m mirroring it. I’m actually kind of trying to invite her to deepen, to experience it more. To see if it actually um cascades into more … But I’m also seeing that she interrupts herself. T: … And I’m kind of wanting to make sense of that for her and for me. TIPR 1013 -1019 T: I just think of it in terms of understanding how a person came to their habitual ways. Things that work, seem to work best at an earlier time anyway … Yeah, just sense making creates relaxation and relaxation allows for more fullness of experience. So, that’s sort of what I’m doing in a way as well. Summary of process theme fueling the tank of togetherness. The dyad utilized the client’s positive emotion of happiness and surprise as a platform for the therapist to use metatherapeutic processing—to acknowledge and disclose his own good feelings and celebrate her new circumstances, the changes she made. This cascaded into the therapist validating the client’s decision to leave her relationship. What occurred as a result of the dyad partners celebrating together was the client had an experience of self recognition—she recognized her action, her version of reality was also seen by someone she trusts. She was able to trust herself and her decision—in a sense: “I am me, what I see and understand makes sense, and to my therapist, too. And it feels great!” Undoing aloneness. The client is beginning to resolve an internal conflict—“Am I a jerk?” “Am I an adult?” She expressed a pleasurable feeling of relaxation, strength, and clarity emerging, and she stated it felt positive. This experience was triggered by having her therapist validate her decision to leave her previous relationship (in the previous episode), tell her that he also saw her previous relationship was very distressed. S 829-854 C: But there is, there is a, I am very, I am very, I am fairly clear about it. T: What is it? C: That it was, that, that, that this stark contrast that I have now. It, it really does it make clear, I think if I didn’t have my current relationship I might be sort of, I might have some kind of weird rose-colored glasses about that whole thing. Or I might be ease, more easily be sucked into some sort of, form of guilt or whatever. T: Okay. So just notice what clear-eyed feels like right now. What it feels like to be clear eyed, right? I know those, I know those are hard questions sometimes. I’m not asking you to articulate; I’m just asking you to, to take a moment to be with clear eyed. For me, there’s something calling about added clarity. C: Yeah. 123 T: There’s something settling, and reassuring, for me, about clarity. It’s almost, um, it shores me up. (laughing) … Clarity. It does that. C: (laughing) I think clarity also, I think you have to feel, to some extent, I have to feel, there’s some strength in clarity. … Like clarity feels certain. … Clarity feels sure. T: Yes, absolutely. Do you feel a little bit of that there now? C: I do feel a little bit of that. … I do feel that. I do feel that. Some certainty and … CIPR 820-825 C: And I think this is, I think it’s true, like when I was, when I was talking there, I did feel like a, that that I have, that I was feeling a, a sense of clarity and of clearness and that I was feeling like, and it was a positive. It was a positive feeling. Like a positive feeling of feeling sure. And a positive feeling of strength; of like, yeah. Strength and, and, and clear and sure and some sort of feelings of certainty. While watching this segment of the therapy session (S 829-854) the therapist reflected: TIPR 1068-1073, 1082-1084 T: … but, but she, it’s almost like she did her own ‘two chair’ [therapy work] and now she’s come to what she’s talking about, which is – she’s about to call it clarity and clear eyed. … And strong. She comes up with all that stuff, so she’s got some resolution here. … Right, because she just told me “When I compare my other relationships and all that stuff, the shame stuff falls away and it’s just really, it becomes clearer to her.” How the dyad worked with the pleasure of feeling relaxation, strength. The therapist invited the client to metaprocess the session work—they explored how it felt to do the work together. By doing this the implicit experience of being seen and understood, not being alone in her perceptions of her distressed long-term relationship, was made explicit. In addition, the client was feeling her experience while talking about it. This solidified her experience of clarity, and was integrating. She said it felt resonant. S 870-883, 909-910, 922 T: We’ll have to wrap up in a couple of minutes. What’s it been like to have this conversation today? C: Hm, it’s been good. It’s been good. T: Can you say just a little more of that? How so? What’s been good about it for you? Can you say a little more about it? C: … That just that you were somewhat of a witness to it. T: I saw an extremely escalated negative cycle between you and [former partner]. Absolutely. Where I did and it was really clear. You said you felt like you were always digging out. That it was all about [partner] in some ways. That you wanted help doing the emotional lifting. I think that was your term. That it didn’t seem like there was a lot for, there wasn’t enough of what you wanted and needed. S 935-945 C: There is, no, no one has particularly wanted to sit in front of me and say “I saw a lot of negativity going on there. And ah you know I could see very clearly that and I could 124 see fairly clearly where you are now. And it’s very different.” Like it’s just not something, and so while I know intellectually that there’s a great difference. T: It helps to have it mirrored. To have it seen… C: To have somebody else say this is how I see it. And it’s kind of the way you see it. T: Yeah. I know. C: Like it’s… T: I do get the way you see it and I really, it fits with C: Yeah, and it resonates. The client reflected on how important and meaningful it was for her to have her therapist say that he saw what she experienced—how distressed her previous relationship was. CIPR 863-867 C: I mean he knows her and he knows the stuff that we went through, so um, but this was the first time that he’d ever, he’d ever said this. Like… the escalating, the extremely escalating negative cycle that was going on between you. … But that I don’t, you know I don’t, I don’t, I think guilt is the wrong word. I don’t. But I have, there’s some negative, there’s some negative feelings about the fact, the fact that I left [partner], but, but I think, so I think for someone to say, for him to say, I saw it. It was very negative. And you guys tried hard. But you’re in a much better place right now. For someone to have to have seen it in the intimacy that he did, is meaningful for, for me because it’s, because it’s, I, I place a lot of truth in that. Like I place, it’s meaningful for me. It’s truthful … It’s true. It’s it holds a lot of meaning and, and so it was, it was, this was really, really important for me. CIPR 960-961 C: This last couple of minutes, here, were really, really important for me to hear him say that. … So this was, this was a good, this was a good part. A good experience. The therapist reflected on what they were doing together, from his perspective. He explained how he used meta processing to invite the client to articulate her thoughts and emotions while she was experiencing them with him. Given that this client’s central goal for her therapy was to be able to be herself in relationship and not to have to essentially change, this was an important part of the session. TIPR 1128-1143 T: Okay, let’s go back because she is really, really integrating. This is metaprocessing. She is experiencing it as she talks about it, in a way. So, she’s integrating her experience, actually reflects on her experience, it deepens her experience. It’s weird because for her; she’s so cognitive that that’s the way into it. I mean it’s funny. Because it sounds like she’s just answering back by rote what I just said to her, except it looks more embodied than anything in the whole session ever has. So she’s actually, and she is having the experience of the relief right now in this moment. She’s having integration right here. Let’s go back, yeah. Whoops, it’s going slow. There’s her sweet, little smile. Let’s just see, is that it that you saw back there? Yeah. So it is the meta- processing. The invitation to meta process is exactly where it happens. 125 TIPR 1231-1234 T: Know myself and be known, which I think is what she wh, wants. Okay, so that’s my reason for doing all that. Summary of process theme undoing aloneness. Undoing aloneness in this dyad is a process theme describing how the dyad utilized the pleasurable feelings of relaxation, strength, and clarity as a platform and as a focus for checking in with the one another about how the session had gone, and what was helpful about what they did together. The client was more fully in relationship with herself and the therapist. She was not struggling by herself. This metatherapeutic processing facilitated expanding the client’s relational capacity by attending to and articulating how the dyad partners were impacting one another for the better, and by bringing implicit changes into awareness and making them explicit. They also confirmed that seeing the same thing together made a big difference for the client. In this case, it strengthened the client’s feeling that while her decision to leave her previous relationship was difficult, it made sense for her, she was not a jerk, she tried her best, and a trusted, respected other understood what and why she did what she did. Affirming, anchoring, and appreciating the work done together. The therapist identified this segment near the end of the session for comment. The client experienced relief in response to her therapist understanding her experience and affirming her decision to leave her previous relationship. There was no input from the client participant for this segment. S 968-983 T: Okay, so it feels good. It feels good to be, to know that I know some of your experience. C: Yeah, I think so. T: Yeah. C: I think so. T: I kind of putting a different spin on it from what you first said. C: (laughing) Yeah. T: And I guess you’re getting what I’m saying. I get it. I get why you … C: Uh hm. And it’s okay. T: It is ok… you know what? It is okay. To choose yourself. When, if joy’s, a possibility of fullness and, well, feeling well. Is it a possibility and you’re trying really hard. And you’re not there and the person you’re trying so hard isn’t there either? I, personally, my own morality thinks it’s okay to say we’ve tried really hard and this isn’t working for me. C: Right. Right. T: I do think it’s okay to choose yourself, actually C: Yeah. T: Some of us have to. Sometimes. Right? 126 C: Yeah. Well aware that it is not his role to to give permission to the client’s decision, the therapist explained that he was intentionally affirming her decision to choose herself because of her mixed feelings about having left her former partner. This affirmation also served to reinforce the work she had done in session. TIPR 1256-1266 T: Um, what am I doing with positive emotion. I’m trying to …. R: Or what are you responding to her? Is she experiencing positive emotion? T: I think, she’s again, she’s experiencing some relief. And she said it. It feels good. It feels good to know. And so I’m – I mean in some ways I’m saying yeah; I’m giving permission … R: Uh hm. T: to feel good. To say you’re not, it’s okay to feel good. Um, what… that yeah that we can choose; we know how to fix it. Some of us, she and I, both, know how to “fix it” – to make, to prop the other up. But at what expense? And is that relationship? … TIPR 1274-1275 T: Um, have to, if we want to live authentically and fully… TIPR 1280-1283 T: So, in some ways, I’m just, I guess I mean I’m validating her; I’m giving her, it does feel like I’m affirming, I’m affirming it. How the dyad worked with the relief. The dyad continued to pay attention to her complex experience of relief, the experience of moving from a difficult relationship into something new, while acknowledging the challenging stance of choosing for herself. The dyad also moves back to an earlier part of the session to tease out another nuance of why imagining getting a thank you or acknowledgement would have been nice. This kind of exploration and repetition in therapy has the potential to help the client expand their self experience, refine their understanding of what is going on for them, as well as remember and retain what occurred in the session. Oftentimes many iterations of experiencing and processing a new understanding or awareness are required in order for “the good enough” understanding to occur and for integration to begin. S 1002-1015 T: So, just as we finish up, I’m just going to loop really far back to the beginning of the session. There was something, I felt like part of what would be so validating about [partner’s name] saying thank you, or acknowledging, for you, that you, if you’re, you talk, it’s kind of what we’ve been talking about that you’re sort of, you’re trying to hold your relationship with [partner’s name]and let it be something separate of all this lawyery stuff. C: Uh hm. T: And so when you get that email and stuff like that it seems to violate that. 127 C: Yeah. T: Yeah. C: Yeah. I think so. T: Right. C: Like, aw, I have been really trying. T: Yeah. S 1046-1061 C: I think I’m really not, you know what occurred to me that it would be nice if she gave acknowledgement of that, but not, I, I have no way to expect that because that was not something she would, she would never did when we were together, so … T: Right. C: she would never sort of go to a place of hmm sorry or oh that wasn’t so great. T: Right. So that’s not a tree to go barking at now. C: No, it’s not. T: No. C: It’s not worth it. T: And that’s part of, right it’s not worth it. See what that feels like. C: (laughing) T: It’s not worth it. C: It’s not worth it. T: Yeah. C: It’s not. The therapist explained why he returned to earlier session material—to pick up a thread of the session that had deeper, historical roots. TIPR 1308-1328 T: There’s probably a sense of, again, mastery, that maybe even some beyond relief. If we really got to it, there might be joy that I’m not barking up that tree anymore. She can’t quite go there, yet, but I think that’s, I think, I think this is success for her; she said at the beginning of the session some version of “I don’t want to care.” R: Uh hm. T: Wouldn’t it be good, if I could stop caring? And she says, “It’s not worth it.” R: And she’s puzzled by it. She’s quite confused by it. T: Well, it doesn’t fit with her attachment history at all. She basically there wasn’t goodness of fit with her mom and her version, I mean, you know, … I don't know much about her mom. I just know there wasn’t goodness of fit. So she’s not, she’s not, she isn’t used to being celebrated or embraced. A further example of this theme is taken from one of the last segments of the session. The therapist identified this part of the session as an example of positive emotion, but the client participant did not. The researcher probed the client to comment on this segment at the end of the research interview. The therapist focused on the client’s experience of relief. Whereas the 128 client reflected on her mixed experience of a “weird positive,” which was triggered by the therapist saying “you are worth it.” S 1062-1088 T: And the corollary that I want to assert is that you are worth it. You’re worth happiness; you’re worth recognition and acknowledgement. As is [partner] and the fact that she’s that you and she wouldn’t do it mutually, doesn’t make you a bad person. In my eyes. C: Uh hm. T: Yeah. So anyway, we can revisit this stuff another time if, if you want. Okay. C: Okay. T: Yeah. I’m glad that you have been feeling relief and the kind of bewilderment and gratitude. C: (laughing) Yeah. Now it’s ah I was thinking about it like just a couple of days ago as I was just falling asleep that in that past year, I partly, I partly use them because of, of my shift work to reorient myself but um last spring when things were really really bad, I, I got a prescription for some sleeping pills from my family doctor and I would split them in half and I would use them every once in a while, you know, to fall asleep. And it’s like maybe half a tablet twice a week. And ah I was thinking as I was falling asleep last night, I was thinking I haven’t taken one in a month. T: Yeah. C: And I still work the same shift work. T: Yeah. So, something’s changed. Something’s changed. C: Yeah, I think it … T: Yeah. C: I sleep better. T: Yeah, just again, as we finish up, just notice what you feel. How you that is for you. What it’s like to be with the awareness that you sleep better and to be C: Just relief. The client reported that she was not going to identify this as an episode, despite watching herself say she was relieved. The client was at the edge of her relational receptivity in this example. She was able to accept some of the idea that she is worthy, but not her perception that the therapist was implying she deserved to be happy. CIPR 990-1003, 1005-1015 R: … there’s one little piece in there, right near the end, and that I’m curious about and that is um you didn’t press it. So, I am assuming it didn’t feel good, but I am interested to know what was going on for you when [therapist] said, “You’re worth it.” C: Yeah, I thought about stopping it then. … I thought about stopping it then, but I didn’t ah cause it’s, because, it’s, it, it, it is positive, but it’s ah, it’s a, it’s a, it’s, it’s a weird positive. … Well, I was sort of the same, “Oh, well I’m, I don’t want to necessarily be seen all that much.” R: Okay, so it’s that vulnerability, again, or? C: Yeah. So like when he’s like, “Oh, I think, you know, you deserve to be happy, like you’re worth it.” It feels like a little bit much. 129 C: … Like I can recognize it as, I can recognize it as it is something that should be positive. R: But it doesn’t feel positive with you. C: Well, it … It’s mixed. … And so when we came, when that part came up, I thought, “Oh, should I stop it now?” And I was like ... maybe I should have just stopped it to qualify and say this is probably something that most people might think would be positive, but it’s mixed for me CIPR 1052-1056 C: … for someone to say to me well so and so deserves X, … I would never use that phrase. So when he says that at the end, if he’d left that part out. … But when he says, “Oh, you deserve to feel happy.” It jars me slightly. And then I’m like okay, that’s, that’s funny because it always makes me feel weird. And so then I, then it becomes a mixed experience. The therapist appeared to be unaware of her mixed reaction, a signal that he was mis-attuned, and just ahead of her relational capacity to receive such affirmation, or to consider the suggestion of entitlement to happiness for herself. TIPR 1340 T: Just relief. Yeah. She’s beyond it now. Okay, it’s a wrap. Summary of process theme affirming, anchoring, and appreciating the work done together. The dyad utilized the client’s experience of relief to: reinforce and validate her decision to leave her previous relationship; to notice, even in that moment, that she was feeling better; and that she is feeling better, and to affirm the work she did in the session. Assertions. First, the safety and security of the therapeutic relationship, along with the therapist’s care/full/ness, and following the client’s lead created a relational space in which dyad partners were able to relax and be more fully themselves. Second, as a result, the client risked her own vulnerability to access, notice and experience her feelings while she was in conversation and in relationship with her therapist. This was a mixed blessing, at times pleasurable, and at other times more challenging. The therapist was also able to risk and be less careful as they successfully negotiated safety between them. He was able to move in closer to the client, be more spontaneous, trust the process with her, and disclose his responses and reactions to her. Third, the client was genuinely touched and impacted for the better by her therapist validating that he had seen how distressed her previous relationship was. This validation seemed to go beyond the realm of intervention and be impactful person-to-person—“he saw what I saw, it was real.” In turn, the therapist was genuinely touched by the client as a person, working hard, being open, and trusting him with her thoughts and her feelings. 130 Dyad 2 Background Information. This dyad included a 26 year old white, English speaking man, the client, and a 55 year old white male therapist. The client completed a Bachelors degree in psychology, and was working as a fitness and nutrition coach at the time of the therapy session and research interview. Since that time the client has entered medical school. The therapist is a doctoral level prepared Registered Psychologist with 17 years of experience. The therapist described his approach to psychotherapy as attachment-based, and he is trained in both Emotionally Focused Therapy (EFT) and Accelerated Experiential Dynamic Psychotherapy (AEDP). The client reported that he had seen his therapist approximately 5 times in the previous 2-3 months for issues related to work—responsibilities, stress, and questioning the meaning of his work and its “fit” for him. In addition, he stated that he had seen his therapist approximately 5-7 years previously, and had benefitted enormously. He also reported that he was “tending to leftovers” in his life in pursuing therapy again with this therapist. Context of the therapy session. The session was 52 minutes in duration. The major therapeutic focus of the therapy session was a relational issue that emerged during the first several minutes of the interaction between the client and therapist—a self-interrupting split. The client became aware that it was difficult for him to show his positive feelings and maintain eye contact with his therapist. A second and personally relevant content focus of the session was his new relationship with a woman and her recent pregnancy. As stated previously, and in keeping with this therapist’s training and stated theoretical model, Accelerated Experiential Dynamic Psychotherapy (AEDP), many of the therapist’s responses and interventions were chosen to assist the client to increase his awareness, experiencing, regulation, and processing of his somatic and emotional experience as it occurred in the session. In addition, there were many exchanges in which the therapist invited the client to share his thoughts and feelings about how they were working together. From an attachment perspective, these interventions are intended to reveal (make explicit) the state of safety and security of the working relationship, highlight and process change events and work done in the session, as well as to assess and strengthen the client’s relational capacity. In AEDP terms, these interventions are known as metatherapeutic processing, a type of immediacy intervention (Fosha, 2000, Russell, 2015; Iwakabe & Conceicao, 2015). For example, “Can I feel good and remain in contact with you?” “What is it like for me to feel my whole experience and still remain in direct relationship to you?” The 131 therapeutic relationship, in this theoretical approach is seen as a safe and secure base for therapeutic work, and as a real relationship from which relational capacity is built, expanded, and transferred to other relationships. As the therapy session progressed the dyad worked at: titrating the intensity of the client’s emotional experiencing; staying in contact with one another while the client was experiencing his emotion(s), pendulating between eliciting experience and reflecting on it, labeling his somatic and emotional experience; allowing the therapist to accompany him in noticing and commenting on how their work together impacted him. Context of the interviews. The therapist interview was conducted first. We met at the home of the therapist participant, at his request, the evening after (approximately 32-33hours) the therapy session under study was completed. The duration of this interview was 120 minutes. The client interview was conducted at my home office approximately 45 hours after the therapy session. The office was selected as a venue that was conveniently located, comfortable, and private for the client participant. The duration of the interview was 133 minutes. Summary of themes and processes. The dyad engaged in several different interpersonal processes in the context of specific personal and relational themes when they worked with the client’s positive emotion. These are summarized in Table 4. Table 4 Dyad 2: Themes and Processes Related to Working with Positive Emotion Major Process Themes Positive Emotion and Related Interpersonal Themes and Processes Paying attention to safety to create a secure base for therapeutic work - Enjoying and exploring the pleasure of being in session together; noticing how the pleasure gets stopped in context of the relationship, practicing being in close connection Trusting the process and seeing where it leads - Trusting the client’s lead into narrative; sharing reactions together; leading and following Making implicit experience explicit and experiential to make connections and build awareness - Paying close attention to emergent somatic experience; inviting more of the new experience; naming and reflecting on new experience; meta-therapeutic processing; heightening experience Fueling the tank of togetherness - Inviting more of the experience by meta processing what it was like to feel good together; heightening experience to enhance self recognition, awareness of being in relationahip, and meaning of experience Affirming, anchoring, and appreciating the work done together - Accompanying client through a long, challenging narrative and new self experience; appreciating the gift of listening; metaprocessing what it was like to do the work together 132 The following section presents detailed descriptions of the identified process themes. Paying attention to safety. The client expressed pleasure and excitement in response to being in the session, the place of the therapy, and noticing how attuned his therapist was to him. This segment speaks to the containment experienced by the client in his session, how the relationship created a safe relational container for the therapeutic work. In his research interview the client commented that meeting with his therapist provided him with a safe base for him to be able to focus on himself and his life. S 1-11 T: Hi. So take a moment to settle in. C: I like coming here. T: Yeah. What sensation inside tells you that you like coming here? C: It feels like the things we’re doing here, I’m very much taking and, and ah they’re not compartmentalized just here. …You know, they’re very much flowing into the background of my, of my, the way I’m approaching the rest of … the week. C: And then just arriving here, I just felt more of the same. You know and it just feels nice to have that continue, continuity of being able to check in, in my life … S 23-30 C: … and knowing kind of where I am and how I’m doing and, and, and having that base I feel like to give other people love and support. Because I don’t have my own things that I’m struggling with. I’m more in my heart than in my head CIPR 91-92 C: (laughing) It’s like ah just really, really, ah, excited by somebody being that attuned to me. … um, how there’s this continuity between what I’m learning with [therapist] and what’s going on in the rest of my life. CIPR 103-104) C: It’s kind of like stepping back for a minute and just looking at what I’d created with him in the first two minutes of sitting down. CIPR 143-144 C: … I’m not sure how to put it. Um, that feels like, that feels and looks like my natural state of what human beings should look and feel like. The client’s positive emotion was validated by the therapist in the research interview. The dyad partners are settling into the session together and checking in on how they are doing together. TIPR 22-25 T: That’s a positive attitude there … So, obviously there’s positive affect. He sits down and says I like coming here and smiles and it seems really genuine How the dyad worked with the pleasure and excitement. The dyad partners started to pay attention to what it was like to feel pleasure in being in the session. What emerged was the client’s relational capacity, (it’s good and difficult) to feel good in the presence of another. They 133 worked at the edge of client’s receptive capacity. As this unfolded, further building of trust and relationship strengthening occurred. This was evidenced in the responsiveness and availability of the therapist (attunement), and the client being touched by being seen so accurately, gently, and “in a very playful way” (CIPR 227). S 32-43 T: Wow, that’s a lot. Notice, what, as you um as you realize that what we’re doing here together is actually … What just … something just shifted for you, just now… C: Yeah. (laughing) It’s just nice. T: Stay with nice. (client laughing) … I want to get a sense of what nice looks like. Stay with nice and stay with me together. C: (laughing) Yeah. Exactly, yeah. T: It’s something. Yeah. What sensation inside tells you that it’s nice to be here with me, doing this work? C: It feels just kind of like a, a welling up from my chest, you know. And it feels like there is this kind of spring, like, like every spring you don’t really know … S 53-59 T: Yeah. Great. So. Well, what’s it like to tell, to tell me about it. … How is that for you? Right now. C: It’s difficult. It’s difficult ah I mean it’s easy, it’s nice. But at the same time it’s difficult … T: Uh hm. Okay, it’s both. S 76-79 C: In, in the sense that when I feel that way, I feel almost embarrassed. You know, … You know and it’s, it’s interesting because it feel so nice. And I think people like kind of being there and being and seeing it and being in the presence of it. But at the same time, it feels like one of those things that should be in private. The client reflected on how they began to work at negotiating how much he could maintain his connection to his own self experience and be in contact with his therapist. CIPR 191-197 C: but it seems that with me there’s a difficulty between being in this blissful state [feeling pleasure] um and still being checked in with people. … And so to have someone immediately in front of me, while I’m in this meditative state [feeling good], makes me think that you know I have to look down, I have to look away to maintain it, um, because the other person would just be a distraction. The nuances in their face or the you know um it’s almost like a vulnerability being in this … CIPR 205-217 C: Looking at someone in the eyes. Um, because it, I, I, I feel like it would be very easy to be judged in that state when you’re so exposed and so kind of like feeling that, you know it’s, it’s sort of a new state for me over the last year or two. Um and it’s taken a lot of work to get to it, so I’m afraid of losing it or afraid of someone injuring it or hurting it or whatever. But ah not to go on negative emotions for a little bit, but um that that’s kind of my reason for the difficulty ah, there, why I look down. And then I think of the positive emotion I came up is when he recognized that, again, and then, 134 and then you know sort of challenged me gently to say, okay, you have this state, but you look away when you have this state. Try to look up a little bit. Connect with me while you’re in that state. And then that made me laugh. I think he went like this. Because it was almost like, “Oh, you got me.” (laughing) … The therapist reflected on this same self-interrupting split in the client. TIPR 143-144 T: Can you be in your experience and be in relationship? It’s that simple. For me, my theory has always been [whisper]. So let’s see what happens. TIPR 162-164 T: … And staying with me, all of that came out of “stay with me.” But all of that came out of how hard it was to feel good and be seen when you feel good. Earlier the client used the metaphor of a spring to describe his experience of joy in being in session. The metaphor hinted at why careful attention to safety is so important as the session begins and as the dyad quickly moved into therapeutic work. The flow of a spring in his heart served as a signal of a spontaneous flow of good feeling felt inside. When extended the metaphor captures the client’s self-interrupting split so well: “when the waters of the spring flow, things get stirred up.” And, as a result, it’s hard to stay in connection. In a further example of paying attention to safety to create a secure base for therapeutic work the client experienced a mixture pleasure, joy, and relief, and also some embarrassment in response to being so closely tracked and seen by the therapist. S 117-135 C: It’s attracting. It’s attractive. It’s really awesome. At the same time it’s new for me, so I’m still very, not sure how to handle the, those feelings when they come up in public. (sighs here) T: Yeah. Yeah, that makes sense. So, let’s kind of go back. Let’s notice both now. Yeah, just again what happens just as you being like that? C: Just ah don’t know. Don’t really catch anything T: It’s okay to, to not know. Until (unclear) let your feelings emerge. Yeah, yeah. So, it looks like if we go back to the welling up, your heart, I can’t remember the words, like a spring. T: Yeah. Yeah. A spring. You’re not sure of the source and it feels really good. Yeah. C: (laughing) Yeah. T: And there’s another, when does it shift. See if you can notice a shifting or notice both. It feels good. And then the embarrassment, right. C: Yeah. Yeah. And in my head feels a little bit like, it’s still difficult to maintain eye contact when I feel this good. Yeah, you know T: Let me tell you that it doesn’t, you don’t feel too big or too expansive to me at all. The client identified this episode as positive but was unable to say why. This is likely because he was working at the edge of his capacity and new relational development, and was as 135 yet unable to language his experience clearly. He appeared to be quite emotionally activated in the interview watching himself on the videotape. He was focused on the video recording, his body was still, and his face was flushed. CIPR 349-360 C: I don’t remember anything about that. So, (laughing) I don’t remember, any, any reason for that positive ah emotion, but that was a positive emotion of some kind. R: You think so, hey? C: Yeah. R: Okay C: I don’t remember anything I was thinking, yeah. R: So, just, um how do you know it was positive? C: The laugh and I would say the eyes. The therapist considered the episode to be an example of mixed positive affect—relief and the pleasure of being in connection. TIPR 221-228 T: He’s got feeling nice and feeling that he’s too much and he’s too exuberant, so I’m, now I come back to let’s see both. Let’s notice that it feels nice and good and the other comes up, which is I’m too much. So, I am working with the positive. … But I’m working with it in tandem with what inhibits it. R: Uh hm. T: So, I’m looking at the self-interrupting split…. TIPR 238-240 R: What did you think was going on for him, as in nice, right? T: There was a fleeting moment, we didn’t get to find out very much about it. R: Yeah. Did you have a hunch about it? At the time? T: Um, that it felt good to be in connection? I don't know … How the dyad worked with the pleasure, joy and relief of being connected. First the dyad partners focused on the pleasure, and then on how the pleasure was interrupted. The therapist invited the client to notice what he was experiencing in the moment as his joy, exuberance and embarassment emerged together. This began the work of expanding his relational capacity, the first step being to understand more about what it felt like, and how it manifested. This is a form of exposure or strengthening of his capacity to experience his good feelings, be in connection, and tolerate his anxiety. This engendered the emergence of shame. S136-149 C: Maybe it’s my own kind of internal check that … T: Yeah. Sure, there’s an internal check. So if you can just, noticing it’s already a lot. What, how do you feel in this moment as we talk about how both are there the joy and the internal check? That really touches you deeper. C: Uh hm. 136 T: Stay with it. Just breathe. Just breathe and internalize. So, what’s happening right now? C: Just ah sitting with the difficulty of trying to maintain eye contact while, while trying to allow that that spring to, to, to, you know, not to stifle it while maintaining eye contact. T: Yeah. Okay. So, there’s some difficulty. It’s okay to kind of break eye contact, too. Yeah. Yeah. Yeah, so … C: (big sigh) (laughing) The client identified this part of the session for comment because he had a new understanding as he was watching himself on the video recording. He used a metaphor to capture his new insight, the silo. This silo represented how he isolated himself emotionally in order to have his authentic feelings, especially his pleasure. The emergence of a new insight in the research interview represented an additional finding, unrelated to the research question. This will be discussed further in chapter five. CIPR 363-393 C: It’s not positive emotion; I just wanted to comment on it. … Um, but I noticed there’s a bit of fear there. Around, around um [throat clearing] a bit of fear there around, um, not allowing other people affect me or not allowing other people to influence who I become or who I am becoming um or what my life trajectory is kind of thing. Um and I hadn’t noticed that before. Ah but ah from that last sort of story it seemed really apparent using that friend as a … an example. … Um, how much of this sort of almost like the silo-like mentality there is with me sometimes that says like I don’t want to let anybody in. I don’t want, like here, here is my space and nobody should come in here because I have to, I’ve worked hard to cultivate this area, this space and I’m scared of losing it or somebody coming in and changing it and I’ve done all this work. Even if they change it for the better, it’s still very scary for me. … Um, so, it’s not necessarily a positive emotion, but I just wanted to bring out that reflection. The therapist commented on a core belief he thought to be underlying the client’s need to break eye contact when he is feeling good. TIPR 290-297 T: Joy. … I must have thought it was joy. … I maybe should have let him go longer. … I’m moved at this point because that was so honest and genuine. Maybe the most contact he and I had ever made, right there. … His eyebrows recoil because he expresses all this stuff about these people. ... It’s not for him. Okay, so this is the genesis of shame—is my exuberance too much for people? Summary of process theme paying attention to safety. The dyad utilized the positive emotion of pleasure, joy and relief as a content focus to explore the safety of the therapeutic relationship, and to facilitate the client to continue to practice expanding his relational capacity. In particular, they enjoyed and explored the pleasure of being in session together; they noticed 137 how the pleasure stopped in the context of the relationship; and they practiced being in close connection while still having authentic self experience. Trusting the process and seeing where it leads. The client felt surprise, joy, and ease in response to his therapist disclosing he felt something similar (ease) as the client spoke of his sense of opening and expansion in his chest. S 216-225 T: You don’t…? And so I get that, I think, I get both parts of that. So how was that for you to, for us to be looking at this together? And that I get it C: It feels good. Feels good. T: What happens? Again, what, what sensation, what does it feel like in this moment? C: Sort of like an, like a, an opening and a lengthening of the chest. T: That sounds pretty spacious. I feel some increased ease myself as you say it. C: (laughing) T: And so thank you for that. The client described what a good feeling it was to know his therapist was feeling the same ease as he was. Having these good feelings together contributed to building more trust and safety in their relationship. CIPR 395-397 C: I think ah it was really neat, there, how, how the state that I was feeling is something that he could relate to, so well that he could physically sort of feel it. And he put a word on it. CIPR 443-457 C: … if I could use almost a, almost a, um, an analogy of me living in a silo. One of those big, tall you know cylinder things, ah without any windows and being in there alone and that’s kind of me figuring out my thoughts. … It feels like, you know, he just kind of opened a window. And just kind of like you know poked his head in … and waved or something and I was like “Oh, I didn’t know that I could have a window.” You know? Um, so that’s kind of the way it felt with, here I was kind of trying to figure out, okay, what am I feeling? What am I thinking? And then he brought up, “I feel spacious.” I was like, “Oh, there’s somebody else here.” And I’m like , the energy is bigger than just this silo and that’s cool because I like the, you know I like the way it was feeling. The therapist also commented on feeling ease with the client and reported that he was following the client’s lead. TIPR 320-323 T: Okay, I remember this actually. I decided not to pursue it. Because he comes up with something. So, I start to, I do a self-disclosure. R: Yeah. And he responds to that. T: But it actually takes him into something important TIPR 337-339, 341-343 138 T: I get the defense, I get your anxiety, I get the self-interrupting. We’re building safety for him to do whatever piece of work he needs to do in here. … So, we’re accessing a little bit of self, at best, maybe. Or, Or a good enough other, me as a good enough other to create a safe dyad to do maybe do whatever he’s wary about doing in here TIPR 344-352 R: And so what makes you say that this episode started off as positive affect? T: Right now. This little bit. Um, he … That he told me spaciousness here. He said spaciousness. He actually could tell, give more information about his experience. … That sounds positive to me. TIPR 359-374 T: It was good to hear about; I felt better when he told me about it. Then I shared that with him, but I didn’t meta process it because he went somewhere else with it. And I need to lead by following. R: So your feelings at the time, then there were you felt open. T: Increased ease. … I think so, spaciousness, yeah. I felt open. R: Yeah and what were – where were your thoughts taking you at that time? Do you remember? T: Um, I like being transparent in the therapeutic relationship. … Let’s share with him that it feels good on this end, to see where he takes it. R: Right. And did you have any thoughts or judgments about what he was giving to you and what you were receiving? At this point? T: Um, my thought was this looked real. How the dyad worked with the client’s surprise, joy and ease. The therapist and client do not comment on the session segments after this episode of surprise, joy, and ease (window in the silo opening). However, we hear early on what the strategy of the therapist is: let’s just follow this and “see where he takes it.” What occurs next is that the client discloses a major life event to the therapist—his partner’s pregnancy. The therapist clarified with the client that he thought until recently the client had been celibate. The client went on to describe how he and his partner were managing together, while the therapist listened and followed. S 226-229 C: There’s been something on my mind the last couple of days. Um, there’s been, there’s been a lot of thoughts, actually, that have come up the last couple of days. Um, I found out a couple of days ago, that [partner] pregnant. S 232-235 T: Okay, well actually, so actually that’s big. C: (unclear) T: And last time [last session] you had been celibate, so this is… C: Yeah, that was, um, until about ah a couple of weeks ago. A further example of trusting the process and seeing where it leads occurred when the client expressed what appeared to be emergent pride. The therapist did not believe this was an expression of positive affect. Privileging the client’s reflections, this example represents another 139 example of quiet, undetected emergent positive affect, mixed with anxiety that the therapist did notice. The client himself could not identify the feeling in typical emotional language, and there was some sense of self-consciousness in how he expressed his thinking about what was going on for him. This self-consciousness points to pride as it is considered one of the “self-conscious emotions.” In addition, it felt good to him. The feeling arose in response to feeling good about being able to say to another adult (his therapist) that he thinks he is doing pretty well in this adult situation. It is not clear if he was trying to say he was on the edge of his own agency, mastery. He in a sense is taking himself into adulthood. S 314-329 C: Um, and both of us have a very similar, long term you know vision of, of where our lives, what we want them to look like and the things we want to accomplish and this doesn’t factor in at all with our lives. Um, it really feels like an adult problem. You know I feel like a child, still, in a lot of ways. Um, and I think that if I ever do have a kid it’d be like maybe mid to late 30s. … Um, but it’s just surprising that it happened at 26 to have this issue in my life. Although I think it’s, I think it’s being handled as easily as it could be handled. We both feel the same way. We’re in love. We’re going to still keep dating. So, we’ll keep building up a relationship and explore, you know, even further methods of, of, of controlling that, afterwards. But, ah, it’s just, it’s, it’s a very interesting you know thing to come into my life to teach me these things. From their unique vantage points, the client and therapist commented on different aspects of the client’s experience. The client focused on the reflective quality of his experience, whereas the therapist commented that he thought the client was feeling guilt, and was asking for help. The client’s feeling of pride was quietly emergent and was unrecognized and unnamed by both dyad partners. CIPR 476-491 C: Usually you think of positive emotions as um, um, very sort of boisterous or loud or, or very obviously, classically positive um, but I would classify that as a positive emotion. Very much reflective in nature. … Um, and um careful. But insightfully careful. Um, so it’s, it’s a really subtle positive emotion. But I feel like it does need to be recognized. R: Uh hm. So, in your experience of the insightful, reflective, carefulness, um do you have a sensation or like a feeling that goes along with your sense that you’re being careful? Is it, is it something about being carefully reflective that signals something positive for you? C: Um, yeah. R: Could you say something about that? C: It signals maturity to me. (looks down) R: Hm, Uh hm. 140 C: Um, having a sort of a, a gap and having sort of a um, … I don't know what the word is. TIPR 484, 495-501 T: So, this is guilt. I feel guilty is what … R: … Interesting his expression, though, hey? T: Yeah. It’s almost like an appeal. R: Uh hm. T: Yeah, underneath all of this asserting that everything is so good … Uh hm. help … How the dyad worked with the client’s emergent pride. The therapist stayed present, carefully listened, and encouraged the client to go on. The client led and the therapist followed. In this moment they were each present in the same interactions, following the same narrative and emotional storyline but from different vantage points and thinking about them differently. S 330-337 T: Wow. You’ve kind of got it figured out in some ways. C: Yeah. Yeah. T: [Whispering] a couple C: Yeah. We’ve joked around a little bit about how this kid must be the next Jesus’s coming because every precaution was there for him not to exist, you know. T: Yeah. Yeah. C: So, that kind of lightens the, you know having that, comedic sense a little bit. S 348-354 C: You know, and, and, ah , you know, this brings up a lot of philosophical stuff about what is life? And, and, um, and, you know, does this, does this life only have this one chance, through this one avenue? Or are there different life, you know, outlets for this life force to express itself? T: Uh hm. Right, right cause that would feel really different, in a way, right? There are no client or therapist interview reflections for this section of the therapy session. Summary of process theme trusting the process and seeing where it leads. This is an example of a quietly emergent positive affect that is not in the client’s full awareness and that goes undetected by the therapist. As a result it was missed in the session, and came into the client’s awareness during the interview. This may also be an example of how experience is elicited and meaning occurs within a relational conversation. The interview itself may have extended the meaning the client made of this experience. The dyad used the client’s expressed and emergent positive experience as a content focus in order to continue to build safety, trust the process, and follow where it was leading. In this case it led to a disclosure by the client of a significant life event, his partner’s pregnancy, and how he was managing the situation, and to more positive emotion. 141 Making implicit experience explicit, and experiential to make connections and build awareness. The client experienced self-reflective pride and mastery. This was triggered by his own reflections with the therapist that he has matured and changed. He started to be aware that he was not only in good connection with his partner and his therapist, he was managing to stay in connection with himself as well. He called it “Full Circle.” He implied that his experience was mixed because of the vulnerability he felt, and the newness of this way of being. From the perspective of the therapist and researcher he was also likely feeling the pleasure of being seen and understood. S 473-475 T: What do you sense inside as we talk about it? C: I guess as much as there is going on, I’m in a really, really good place to help, to help support her through this and to be there. S 488-493 C: In particular, you know, I imagine if this would have happened two or three years ago, fear would have been my number one emotion. And I would have panicked and I would have, I wouldn’t even have been able to listen … T: Uh hm. C: or be there for whoever the partner was. S 496-503 C: It’s a really different place, right T: Yeah, yeah. Just notice your smile C: It feels really gentle. It feels really good. It feels, it feels fantastic. It feels, you know, exactly what all this was for. What the meditation was for, what all the work that I’ve done over the years has been for is not anything obtuse and is not anything you know major and drastic and you know, not for me to stand on top of a tower and yell at the world. But for me to quietly and humbly feel this stable, you know this solid. The client explained that an aspect of his “full circle” was related to often leading with his faults rather than his strengths or what he is proud of. In relation to his experience in session he reflected that he was better able to feel his self-interrupting split inside, recognize it, and still be able to be in contact with his therapist. CIPR 793-798 C: In a lot of ways it felt like the same sort of positive emotion … It was all still very reflective and still very kind of um sobering kind of thing. R: And there’s something about being sober that feels good for you? C: Yeah. Yeah, it feels more clear. CIPR 840-845 C: … of the whole situation and saying, “Oh, man, I’m so proud of myself. I did so well.” And then bring it up with [partner] and her saying, “Well, yeah you did pretty well. Or you could have done this and this better.” And I’m like, “Oh, I thought I’d just killed it.” (laughing) You know 142 CIPR 864-867 C: I think there’s a big difference between my, my own experience of myself and other people’s experience of being around me. Sometimes I gauge myself as worse and sometimes as better as to what actually transpired. CIPR 880-889 C: So, but as far as my connection with [therapist], I feel, I feel like, again, like there’s a connection there … that, that he kinda brought to light. And I’m, it’s not as profound as as it was at the beginning because now I, I am more easily able to kind of feel it and recognize it and be reflective at the same time I was being with him. Um, so I think that was the positive event that just happened there for me, full circle. (laughing) The therapist explained that the client was on the edge of his development in this segment, and that he was inviting the client’s masterful self to come forward, the self that trusts himself to continue to do what he needs to do, be who he wants to be in relationship. TIPR 616-621 T: Because this is huge what he’s just said. … He said I’m actually able to trust myself and what I want. To have a little more clarity and I’m not pulled away. I’m able to be there for other people and that matters to me, especially for this woman who, who, she and I both want, along with our careers, which is fine, you know. TIPR 625-626 T: So, this is huge and I’m trying to invite him into it. So, I’m thinking he’s having it and he doesn’t even know it, yet. TIPR 672 T: Uh hm. So, I’m heralding it right here, I guess. TIPR 689-690 T: And is it preferred and if it’s preferred, notice what that feels like because my understanding is that neurobiology that it potentiates when we notice the preferred state it potentiates the preferred state recurring, is what I understand. How the dyad worked with the client’s pride and mastery. They used the client’s new experience of pride and mastery as a resource platform, a place of resilience, a place where things were already working well to expand his awareness of what is possible for him. He was in touch with his emergent new experience of self-trust in the presence of another. The client had some difficulty languaging what he was experiencing because it was so new. S 511-518 T: Hm. Stay with me, stay with nice [whispering] C: It feels not as heavy. (laughing) It feels like we’re kind of sharing it and as a result of sharing, it’s off both of our backs. You know. T: And in some ways we’re celebrating something together, too. Is that possible? C: Yes, yeah. Exactly. T: It feels being important to be able to. C: Yeah. I felt a little bit in a celebratory mood on the way here. S 540-553 143 C: (laughing) Yeah. It feels like, ah, it feels like this is ah the way life is supposed to be. T: Hm. C: You know. Not, not burning out, up and down and doing a million things all at once, but in a gentle, consistent wave like, kind of, … feeling good … T: Yeah. And not afraid and that soft, gentle wave. It’s really, that’s really … C: Yeah. Yeah, yeah. Yeah, yeah. T: I think you’re talking around big changes S 555-567 C: It’s almost hard to believe that this is me sitting here, today, actually. T: Uh hm. C: There’s part of me that is almost waiting for this dream to just end. … You know, I’ll wake up and I’ll be frantic and panicked and feeling like I’m you know I don’t have enough hours in the day. Like I’ll have 12 hours and everybody else has 24. T: It takes some getting used to. That this is you. C: Yeah. T: Yeah. But this is something that you, you could get used to. C: (laughing) T: Yeah. C: It’s a whole different dimension. You know, it’s a whole different S 584-595 C: It feels like I can, I can almost see it easier in front of me than I can feel it, just, yeah. You know. It still feels like it’s a foot in front of me. This kind of gentleness as I’m looking at it. It’s sort of in this sort of mental place, looking at it. It doesn’t really feel like it’s part of me yet. It still feels like it’s out there. T: Uh hm. C: And I’m just happen to be lucky to be in this cloud the past couple of days. T: Uh hm. … So… you kind of…[whisper] it’s you, almost, moved into it, but it doesn’t feel like it’s really you, does it? C: yeah … The client was enjoying being immersed in the flow of his present moment experience of himself in session with the therapist, even taking delight in the “simple movement of having my hand go back and forth in front of me.” (CIPR 1060-1061) CIPR 952-967 C: And then laughing when he’s pointed out that we’re really connected right now or I’m really feeling this or I’m really moved by this, while you’re saying it. And laughing and saying ‘Yeah.’ Kind of thinking that that’s, that’s um, that that’s a real gift. You know. A gift of an experience … R: To… C: to be there connecting with somebody. R: Okay. And that gift would you say, like if we, if you were to just push a bit on the gift idea, that you feel like you got given a gift or are you giving a gift? C: I feel like I got given a gift. R: Okay. C: Um, 144 R: So it feels like something is coming from [therapist] or is it coming from you, do you think? C: Coming from [therapist]. The therapist explained that he was inviting the client to resonate with his experience, not judge it, but instead to enjoy it, think about it, play with it, get to know it. He also commented that newness is awkward, so the newness to the client is gentle, and a little clumsy. TIPR Lines 769-770 T: What? And he’s able to just trust himself and stop doubting everything so much, I think. And that’s what I’m actually heralding, in a way. That he’s being gentle within himself. TIPR 789-793 T: So, that’s just a little marker for myself for this whole one I think. I say to myself I think “Okay, this looks like state three.” Is there a way that we can, then, make it, make the implicit, explicit and make the explicit, experiential? That’s what I’m doing a lot through the whole session. If you ask me what am I thinking? What am I trying to do? TIPR 815-817 T: I think this whole thing that he’s waking, he’s resonating with what I’m heralding. He’s seeing it and experiencing it a little bit more. So, yes, I think he is. TIPR 834-837, 863 T: So, it’s um core, it’s not core state. I don’t think. But it’s, or maybe it is. It’s close to, it’s congruence. It’s the truth sense or when something feels right. And not askew. I think that’s the gentleness. It’s totally, totally new for him. T: Okay, well, that seems to be what is – stumbling into gentleness Summary of process theme making implicit experience explicit, and experiential to make connections and build awareness. The dyad utilized the energy and strength of the client’s self-mastery and pride, a place where positive forces were already evident, to expand his awareness about what is possible. It was all lining up, having feelings with others, being his fuller self with others, staying in connection with himself and others at the same time, acting or being congruent with his values. It felt good to him and a little new. He was unsure of its full meaning and implications at this point. As the therapist so eloquently put it the client was stumbling into [his own] gentleness. Fueling the tank of togetherness. The client experienced a mixture of pleasure, joy and some mild anxiety in response to his own self experience of feeling he was in a pleasant cloud. In a sense he was floating in the ease of being able to feel his positive emotions in the presence of another, but not yet able to feel it solidly in himself. S 598-615 C: It’s like home, but home in a dream. Yeah. 145 T: Yeah. That’s so well put. It feels like home, but home in a dream. It’s unfamiliar. C: Yeah. … It’s really nice. It’s really comfortable. … Yeah. … It’s really like I could spend a lot of time here. … You know. T: Yeah. It fits. It’s just not where you’ve been. C: Yeah. And I really want it. T: Yeah. But it…[whispers] … Welcome. C: (laughing) Yeah. It’s nice to be here. (laughing) T: Yeah, what’s ... Well, how is it? C: Third try shy. (laughing) The client identified the segment as an example of positive affect but only briefly commented on it in the interview. “I really like that part. Home in a dream. I really like that term.” (CIPR 1067-1069) It appeared to be difficult for the client to language this emergent experience, even in the interview. The therapist also commented briefly. TIPR 869-874 T: So, again, I’ve been thinking ... It feels good, but it’s not where I’ve been dwelling. But it fits, it’s unfamiliar. I’m just trying to elaborate, make explicit what I think he’s experiencing and what he’s telling me. … And I welcome him to it How the dyad worked with pleasure and joy. They metaprocessed the positive emotion by inviting the client to explore what it was like to feel good with his therapist present. The therapist encouraged the client to communicate somatically to his deeper emotional side that was emerging. In addition, they heightened the client’s experience so he could feel it more and and understand its significance. S 615-623 C: Third try shy. (laughing) T: How do you feel right now as you share with me that it’s nice? C: It feels like if, like if, you know, actually I feel it in the shoulders in a good way. Whereas instead of before it was like a heaviness in the traps and now I feel like a strength in the shoulders. Like a, you know, like a lot of energy, a lot of, you know, maybe I wouldn’t say energy, but a lot of um, yeah maybe energy. Just not in sort of, a sporadic way. Like a very, like a stored up energy just hanging. I don’t know to do describe, I don’t know what the word is S 648-651 C: So, it’s rare, I don’t often touch my shoulders. T: Hm. Yeah. Yeah, just use your hand like that to let that place, that energy, maybe to hold it or support it and let it know that you know it’s there. Just like that. [breathing]. Just like this. There were no client interview reflections for this part of the session. The therapist reported that he believed the client was showing him something that was stronger than before, 146 and noticed how authentic the client’s experience appeared. He described how he understood this episode in the interview. TIPR 895-901 T: Meta processing. Because I think he’s attuned is what I … Stored up. I thought it was stored up. So, I get lost for a second because holding it like a backpack does not sound like (laughing) shoring him up. It sounds like oh now it feels like a burden. But I think he just gets mixed in his metaphor. Or when you wear a backpack, you feel your shoulder blades down your back. I don't know what. … But that’s okay. TIPR 905-908 T: I don’t need to know. He’s definitely showing me something that feels … Something that feels better than the way it felt before. … Absolutely. And it sounds like it’s strong … TIPR 917, 925-926, 942 T: Now, this is really important. Look how we’re mirroring each other T: To let that place know that you know that it’s there, yeah. And then observe what happens next, but anyway. This is so important, though T: … He’s really holding himself Summary of process theme fueling the tank of togetherness. The dyad utilized the client’s pleasure as a focus to invite more of the experience by metaprocessing what it was like to feel good together. This heightened the client’s experience, with the goal of enhancing recognition and meaning of the experience for the client. Affirming, anchoring, and appreciating the work done together. The client felt pleasure, surprise, and gratitude in response to being seen and heard by a trusted other, his therapist. This was triggered by touching his shoulders and noticing the pleasant surprise of something new. S 648-652 C: So, it’s rare, I don’t often touch my shoulders. T: Hm. Yeah. Yeah, just use your hand like that to let that place, that energy, maybe to hold it or support it and let it know that you know it’s there. Just like that. [breathing]. Just like this. C: It’s a new place for me. (laughing) S 659-670 C: I think maybe it’s because my parents have this like carpet back in Ontario. I mean there’s nothing special about this carpet. It’s just like carpet that’s always been there for 20, almost 30 years. Um and it just feels kinda like I’m lying on that, um, on that carpet. My shoulders are on that carpet. There’s nobody else home. There’s nobody else in that house except me. It feels like the whole house is just filled with my energy. You know. Not mine egotistically, but like this energy that I’ve been … S 679-687 C: Yeah, yeah. Yeah. Like stable, but there’s also a little bit of give to it, you know? You can move around. 147 T: Yeah and it can fit you well. C: Yeah. T: In some ways, you know? So, you’re swimming in this energy and there’s no one else home in the house. It’s yours in a way. C: Yeah. T: Wow. Yeah. It sounds really good. C: Yeah. The client reflected on how grateful he felt in having a therapist who was so attentive to him. Gratitude often emerges in response to helpfulness shown by another (Algoe, 2008). The gratitude that appeared to emerge for the client was in response to his therapist listening to him so carefully. The client spoke about self-containment, and having a new experience of strength. He was touching his shoulders, and it reminded him of lying on an old carpet at home. It conjures up a wonderful containment metaphor: snug as a bug in a rug. CIPR 1080-1089 C: … of just being kind of grateful that he’s that attentive. You know, in recapping the analogy um and kind of adding to it, adding his own kind of feeling of what carpet feels like … And I’m like yeah, that’s it. Um, so I think, I think there’s sort of a subtle gratitude there. In just that he’s still listening. You know? It’s been a long … session and he’s still listening CIPR 1113-1126 C: I think that ah with the, with um sort of the track that we’re on, still very much focused on tapping into my shoulders. … Um, but gratitude I especially feel in my chest. R: Uh hm. And what, can you say more about what that sensation’s like in your chest? C: Yeah, um. It feels expansive and it feels connective. You know. … And I - I think I explained a little about the connection with him like my heart with his heart. You know R: Right. That does come up. C: Uh hm. Um, so it just feels like I’m, I’m just under the surface. Kind of feeling that gratitude. And it might come up in a minute or two or five. I don't know when. The therapist commented in the interview TIPR 948-949, 952-953 T: He definitely said it because he said it would be very rare that I’d ever touch my own shoulders. Strong. Self-trust. (laughing), the yawning session. (laughing) I forgot about this (laughing) So, I think all of this is an episode of positive emotion. How the dyad worked with the pleasure, surprise, and gratitude. They continued the work of inviting the client to explore how he felt inside his body knowing he was able to go home and not get caught in old ways. In this particular instance, the client was able to stay fully present with the therapist while being in his emotional experience and telling his story of being at 148 his family home recently. This is an example of how early new relational capacity can be accompanied, practiced, and strengthened within the therapeutic relationship. S 692-695 C: The last time, when I was in Toronto a few weeks ago. … Yeah. It feels like ah, it feels very much like that same energy I brought home. C: Yeah, and it feels like this kind of energy, this kind of like space that I feel when I’m, picturing myself lying at home there on that carpet. It feels the whole house. And it’s very nice and anybody that walks and feels it, really enjoys it. It feels like when I’m not at, in the home, that’s not there. At least that’s what I picture. That’s what I got the sense of not, not came home. Was there was almost a desperation when I came home, for me to stay. S 706-712 T: Right. So, how do you feel about doing that? About going home and bringing this kind of feeling, overarching energy? C: It feels really good for, for a couple of reasons. The first one that comes to mind is just how ah … that … you know I can hold that energy. That I can go somewhere and I can hold that energy. … And not walk into a, for example, the old house and um you know become fragmented when I walk in the door. S 728-730 T: How do you feel about that? How does that feel inside to know that you did that? C: It’s a new; it’s definitely a new feeling. I don’t really have the words for it. The client specifically reflected on the genuineness and strength of the relationship he had with his therapist. CIPR 1223-1229 C: There’s positive emotion around there is just how different you know, how different we are. The typical, I think client, client-therapist, um, duo, you know. R: Can you say more about that? C: Um, you know I’ve had, I’ve had a bunch of therapy over the past, years ago and it always, it never seemed to be this sort of brotherly, the connection. CIPR 1243-1247, 1268-1269 C: Yawning and yeah … fully kind of, it’s, it’s the, it’s interesting because he’s not afraid of, of, of, you know, being real. You know, and especially I think, going towards psychology in a way that I was going, I was always kind of, um, ah, always sort of afraid of turning into a psychologist. [but here] yeah, he’s on the exact, same page as me. The therapist commented on this session being a “watershed.” A new relationship template was being constructed, a container in which the client’s trust in himself and trust in another make it possible to approach those “leftovers,” likely related to home, of the work he came to therapy to complete. TIPR 985-996 C: … I need to be left alone to be in touch. 149 R: Uh hm. I need to be alone, in the house, on the carpet, all by myself … T: To feel, to feel … and I have good stuff inside, but as soon as there are other people around … yeah ... I get pulled away from me or … And, really, this is all a precursor to the work we need to do cause he’s got a whole back, literally a whole backpack that he brought in, full of all the things that he’s consumed about. TIPR 1017-1024 T: Right, so we’re building the container. I love how he said he’s experiencing with me, he’s experiencing with me that he can be himself with me and have his experience. And that really, it’s that simple. R: He’s just starting to trust it. T: Yeah. And it, exactly, and that this session’s our watermark and he recognizes it. Not a watermark, a land, what’s it called? Um, not a watermark. That’s on paper. A watershed In another example of affirming, anchoring and appreciating the work done, the client was relaxed, and feeling the pleasure of connection with the therapist. This was triggered by yawning together and talking about it together. The client also experienced some pride about reflecting that he had come full circle with his family visit. S 736-746 T: That’s good. Sometimes that [yawning] can really actually deepen the experience C: Yeah. You know, it feels like ah, it feels like like, it feels like yawning. You know, because you can’t yawn and be afraid at the same time. T: Yeah. Yeah. Yeah. We’re really in our experience when we yawn, huh C: Yeah. Yeah. Yeah, yeah. Really, we have to feel like we’re comforted and really safe. And like there’s not a rush, there’s not some alarm or emergency. T: Uh hm. Uh hm. Yeah and it’s a big, open feeling of taking in oxygen. S 750-760 T: So, you’re doing something, here was more though. You said there was a number of feelings. One was that you went home and brought your own energy. Or you told me that and there was one thing that you felt C: Yeah. T: … that sense of accomplishment, I think. I’m thinking pride and mastery, but those aren’t the words you used, but um yeah. C: (laughing) T: Oh, that you had, you had, you were not afraid…. C: Yeah. T: … of your experiences, don’t have any words for. Yeah. C: I still … but it feels like full circle S 765-770 C: You know, like life is happening to or through me. … Um, and I’m just going along for the ride, sometimes not voluntarily. … Um, that it’s, it’s led me through a really beautiful circle as it relates to my family anyway. 150 The client reflected that when he was able to relax and fully be himself, he noticed himself stretching, expanding, in a sense making more room for or having more space for himself. CIPR 1355-1359 C: Yeah. This this, you know very much with the last couple of minutes, I was just being able to relax and be ourselves and you know it feels like that was kind of a gateway for me to make myself comfortable and fully stretching my arms over my head and just… CIPR 1371-1379 C: So, I wouldn’t be breaking the connection by going like this, which in in other circumstances would look almost like I’m pulled away like I’m bored, like I’m going into my own thoughts and leaving it behind, but I feel like this is very much me hanging out saying “We’re really, really connected right now. And I can hang out like this and be really, really connected with him.” You know. R: Right. C: Like I trust him, not having to be looking each other in the eye and knowing that we’re so connected right now CIPR 1397, 1402 C: Trust in myself and trust with him and trust between us. R: Yeah, okay. Hm, nice. C: I think the positive emotion there is is around his sigh that he sighed in a way that’s “Yeah, we did a good job. The therapist described his observations, noting how contagious the yawning was, how good it felt to do together and see his client in flow. He also commented how clearly the client was speaking, how poetic he sounded—both markers of being in full connection with his deeper unguarded self, while in the presence of another. TIPR 1075-1081 T: It’s like [yawning]. So, that’s part of what I’m doing here, too. Inviting him. R: It’s so contagious. T: Yeah. And it feels good. It does feel good. R: Yes, it does feel good. T: [yawning.] It’s open. I was just yeah Lines 1096, 1100-1103 T: Really [exaggerated laugh] and then self-trusting. spontaneity T: I wish I had said this is definitely something we’d come back to. Maybe I’ll make a little note to myself. I’ll be sure to go back to ‘full circle’ and his family. Hm, I have a pad. Right over there. I have a pad. TIPR 1105-1111 T: I guess my thought was maybe I was going to watch this tape anyway. Full circle. Beautiful circles in relationship to his family. Because this might be integrating coherent autobiographical … I mean it’s, sure, and that simple, clear statement. And poetic—is some of the markers of core state … 151 How the dyad worked with the client’s feelings of relaxation and pleasure. They enacted another round of metatherapeutic processing, checking in with one another about how the work they were doing together was going, and tying it to the present moment. The goal of this exploration was to anchor and solidify the session work, and help the client be able to remember and retain his gains. In addition, this served to practice expanding relational capacity, what is possible with another. S 791-795 T: We’re going to finish up with one more round. How is it for you as I’m telling you I’m moved? What do you sense? C: I feel really grateful. You know. I feel like, like, I’m just really, really grateful to have you in my life. Yeah. To have you, to have you, your heart here with me S 802-807 T: Okay, beautiful. What’s the quality here in your heart? C: It just feels there’s like a connection. T: Hm. C: Like directly. I even see a red heart there you know. Right in the middle. It’s not even a physical heart. It’s just a big shape. T: Uh hm. Uh hm. Right in the middle (laughing) yeah, yeah The client’s ease and delight was evident when he commented in the interview: “… and I was like, yeah, we did a good job. And just like me and him sighing and me laughing was kind of my, my laugh was recognition of like I feel the exact same …” (CIPR 1402-1403). The therapist explained the intention of his invitation to meta-process the experience with the client. TIPR 1129-1139 T: Yeah. And then I decide to, to do one more little bit. Because it’s so worth going over for. That’s what I thought in my head, right then. He’s touched. … Yeah. Yeah, he’s in contact. Yeah. Yeah, he says it right in between us. A red heart right in between us. Yeah. Now, he’s, he really does make contact – while feeling good. This is an extraordinary session in that way. He accomplishes something by the end that he couldn’t do at the beginning Summary of process theme affirming, anchoring, and and appreciating the work done together: The watershed metaphor, another water theme, captured the culmination of this session. The waters of self-experience flowed through the client in the form of ease. Energy, pleasure, joy, gratitude, and quiet self-experience that he could not easily name emerged. This was made possible by being in relationship with his available and responsive therapist. The watershed (“Watershed,” 2015) is a dividing line between two rivers. Siegel (2011) says that the river of well-being has two banks—chaos and rigidity. We have to move between the two and not get off and stay on one bank or another. In this session the client was moving off his rigid 152 silo bank and working at staying in the “mixed water of the spring” where he felt anxious, vulnerable and also all of the good feelings listed above. This foundation and the safe relationship with his therapist will help to allow him to approach his deeper issues in the future, if he chooses. In addition, the dyad utilized the client’s positive emotion to review what they had achieved in the session in the hopes that it would help to anchor the client’s new experience in his memory. Assertions. First, the safety of the therapeutic relationship and the therapist’s ability to be attuned, present, and follow the client’s lead created a relational space and place for the client to risk being himself. Second, the client and therapist were mutually impacted by one another. The therapist was delighted and touched by the client’s efforts and willingness to be in full contact with him, in a way he had not done in previous sessions. The client was deeply grateful and somewhat awed by his therapist’s willingness and capacity to be fully present for him, and to listen for such a long period of time. The ease and flow of sustained yawning together was a wonderful indicator of a “job well done” in a real relationship. Third, the privileging of the positive aspects of the client’s personal experience, and relational experience with his therapist allowed him to begin to access some of his challenges under the aegis of what was already working well, and the energy and motivation of his positive affect as a platform. Dyad 3 Background Information. This dyad included a 60 year old white, married, English speaking woman of north western European heritage, the client, and a 61 year old white male therapist. The client is a retired accountant. The therapist, also of the same north western European heritage, holds a Masters degree (M.A.) in Humanistic Psychology and is a Registered Clinical Counsellor with 35 years of experience as a psychotherapist. The therapist has advanced training in Emotionally Focused Therapy (EFT) and holds certification in Accelerated Experiential Dynamic Psychotherapy (AEDP). The client reported that she had seen her therapist twice over the past 2-3 months for issues related to her relationship with her adult daughter, and that she had seen this same therapist for couples work with her husband approximately 2-3 years previously. Context of the therapy session. The session was 64 minutes in duration. It was the third session. The major therapeutic focus of the therapy session was a relational issue between the client and her daughter, connected to her divorce from her first husband and her children not 153 living with her. As stated previously, and in keeping with this therapist’s training and stated theoretical model, Accelerated Experiential Dynamic Psychotherapy (AEDP), many of the therapist’s responses and interventions were targeted at assisting the client to increase her awareness, experiencing, regulation, and processing of somatic and emotional experience as it occurred in the session. The therapist invited the client to share her thoughts and feelings about how they were working together, including the impact of his presence, responses and interventions many times. From an attachment perspective, these interventions were intended to reveal the state of safety and security of the working relationship, as well as to assess and strengthen the client’s relational capacity. In AEDP terms, these interventions are known as metatherapeutic processing, a type of immediacy intervention (Fosha, 2000, Russell, 2015; Iwakabe & Conceicao, 2015). For example, “What is it like for me to show you more of myself, even the things I have done that I believe are unforgivable?” The therapeutic relationship, in this theoretical approach is seen as a safe and secure base for therapeutic work, and as a real relationship from which relational and other ego capacities are built, expanded, and transferred to other relationships. As the therapy session progressed the dyad worked at: titrating the intensity of the client’s emotional experiencing; staying in contact with one another while the client was experiencing her emotion(s); pendulating between eliciting experience and reflecting on it; labeling her implicit somatic and emotional experience; challenging an unexamined and long-held belief; allowing the therapist to accompany and guide her into and back out of a painful, dark place; sharing mutual stories and laughter to take a breather. Context of the interviews. The client interview was conducted first. We met in my home office, approximately 48 hours after the completion of the therapy session under study. The office was selected as a venue that was conveniently located, comfortable, and private for the client participant. The duration of the interview was 159 minutes. The therapist interview was conducted in his office, at his request, 4 days (approximately 96 hours) after the therapy session was completed. The duration of this interview was 138 minutes. Summary of themes and processes. The dyad engaged in several different interpersonal processes in the context of specific personal and relational themes when they worked with the client’s positive emotion. These are summarized in Table 5. 154 Table 5 Themes and Processes Related to Working with Positive Emotion for Dyad 3 Major Process Themes Related Themes and Processes Fueling the tank of togetherness - Appreciating being in session together; metatherapeutic processing of what it’s like to be in session together; laughing together about personal commonalities; recognizing capacity Trusting the process and seeing where it leads - Choosing a session focus; following the client’s lead; entraining the good connection between dyad partners Undoing aloneness - Validating strength; enabling courage to arise; facing pain together; seeing and being seen Being guided/guiding through a hard place - Looking at pain together; shifting understanding by questioning long held beliefs; considering new perspectives Making implicit experience explicit and experiential to make connections and build awareness - Understanding how old patterns and understandings were co-created; getting clear about the meaning of new experience Affirming, anchoring, and appreciating the work done together - Being grateful and receiving gratitude; offering and receiving of a physical marker to remember work done together Balancing giving and receiving - Inviting mutual strength, agency, and experience to emerge; responding with tenderness; being comfortable with intimacy Fueling the tank of togetherness. The client reported she felt happy and welcomed, and she said she trusted she was in good hands. This was triggered by the therapist stating he was happy to see her and sit with her. S 1-13 T: What? C: Here we are again (laughing). T: Yeah, we are. C: That’s wonderful (laughing). T: Oh good. That’s so nice to hear. C: Well, it’s so good to come here. T: Well. I’m happy to sit with you. C: Oh, thanks. T: Yeah. C: I always feel as if you are. (laughing) Yeah. The client’s reflections in the interview expanded the meaning of her experience, which included the idea of containment, being in a safe place for doing the work she came to do, with a person she felt confident would help her. CIPR 2-7 155 C: Like that was an enclosed space where I could just be. And anything I said wouldn’t be judged. I wouldn’t need to watch myself in any way or be guarded. That I would be really safe in that space. … CIPR 48-52 C: So, I know what I’m, I’m going for. And it was the sort of trust and knowing that he would help me … get out of being stuck. In his interview the therapist explained what he hoped to accomplish in joining with her at the beginning of the session. TIPR 5-6, 54-57 T: … I’m wanting to join with her appreciating our connection. So, it’s a, a sense of taking delight. Yeah, her taking delight in our being together. … Sure. Is just the, um, very consciously self disclosure around my experience that it’s important that she understands um well below gets/feels that I am happy to be with her. Um, and so that there’s a mutuality in our shared delight in being together. TIPR 76-77 T: … Now that I, through AEDP, I understand the um ah how that ah solidifies deepens and feels the, ah, safety um that’s why I really am leaning into that. How the dyad worked with the client’s happiness and sense of being welcomed. They metaprocessed the positive feelings between them—that is, what it is like for the client to see, hear, and know that her therapist is also happy to be in her presence? They entrained their good history together and utilized the good feelings and mutuality between them in the moment to reconnect and solidify their relationship bond, and increase trust and safety. S 11-28 T: Well, it’s true. What’s it like that it brings happiness to me as well? C: Well, it, it makes the mutuality. T: Yeah. Uh hm. C: You know, it’s, it’s part of our relationship. T: Yeah. Uh hm. C: We are here in harmony. And you know we’re like ... I never get the feeling you’re saying “Oh, Okay, (sigh), (laughing) what’s wrong with her now (laughing)?” T: (laughing) No, no. C: I am putting it in the negative, that’s very [cultural heritage name]. (laughing) T: Okay. (laughing) See, I learn more and more about my culture from you every day than from my own family. C: Yeah, yeah. T: Yeah. Of course they were generations removed, so C: Yeah, but when [cultural heritage name] people, when they came they don’t say, “No, no, no that’s right. It’s the weather” (laughing) T: (laughing) No, no, no, that’s right. I remember I was in a pub in[city name in Europe], I … guess, when would that be? About, oh more than 15 years ago 156 The client explained that she had extended the trust and good feelings between her and her therapist into the research interview. In her own way she was checking in with safety as she prepared to work in the therapy session and as she began the research interview. By naming it she set the tone and let us know that she needed her vulnerability respected and protected, and we confirmed our implicit covenant: “I give you my vulnerability and my my private self and you in turn give me your professional and personal selves providing containment and guidance.” CIPR 62-83, 97 C: And I felt attuned to you and I was predisposed to feel that way because of the connection with [therapist]. … C: And talking to you had reinforced that. And this was the third side of the triangle I was telling him …. C: I had made a good connection with you and he was, then, reinforcing that, again. R: Right. That makes so much sense. Because I felt the same thing. As soon as I heard your voice on the phone, I just had a sense of being attuned. I’m thinking, “Oh, this just feels nice.” C: Yeah. Yeah. … C: Yeah and it and we were able to take each other and trust because of it really is a triangle, yeah. R: Yeah, I know. Yeah, that’s nice. Yeah. And so what do you think you were experiencing there? C: I … R: Or sensing? Or if you have ... C: I felt reinforcement of … I was in good hands. … But with this vulnerable stuff you need to feel safe. From the perspective of the therapist, he intentionally let the client know about his pleasure in seeing her again, making the mutuality between them explicit to build their connection and to further the possibility that she would be able to move into the deeper, painful experiences that she came to therapy for help with. In addition, they extended the good feelings of welcome into some playful laughter about their shared heritage. The therapist offered his theoretical stance that if we can play together, we can work together. TIPR 107-111 T: … there’s a conscious level of which I’m um being her student. Or um equalizing the relationship, which is not equal. But which in a consciously make, ah honouring what she can give me. Um furthering our good connection. It’s more of the same. TIPR 123-125, 131-132 T: Right, well, I also know, I mean we’re going into, working more deeply with, um probably the second, you know what I mean by second behind, but the second major trauma in her life. Or third. Um, you know T: Um, but I’m also, knowing where we’re going, it’s kinda like put extra fuel in the tank of togetherness 157 TIPR 142-150 T: So, the other thing I’d say is that ah you know I’m mind – more mindful now that, ah um, play, which is what, we’re playing. … Um is just kind of deepens all the attachment, connection, dyadic, so we’re playing together. … So, we’re having fun together. … Which means we also work together. Summary of process theme of fueling the tank of togetherness. Fueling the tank of togetherness is a powerful metaphor that captures the complexity of building trust and safety within the working relationship bond in order for the client to be able to work therapeutically and relax defenses against exploring painful experience. Feeling good together and privileging this positive emotional experience resourced the relationship, and the sense of safety and trust between the dyad partners. Trusting the process and seeing where it leads. The therapist did not consider the emotion in this segment positive. He believed the client was experiencing pain. As a result, the client’s feelings of being understood by him were unnoticed or at least uncommented on by him. The client reported experiencing both pain and the relief of being seen, accepted and valued enough to be listened to and respected as a human being, despite what she had recounted to him, and the consequences of her actions. Her relief was expressed as an ability to breathe again, and as a sort of “lift.” It was triggered by the therapist acknowledging her usual strength, being able to cope with difficult things without compensating with food. S 122-133 C: And today I just suddenly started to feel like I could come out of it. T: Wow, … What told you that you could come out? I mean did you notice that, and there’s a big sigh there. C: Yeah, … Well, it’s my gut. … That always tells me. … And I think my gut is telling me that I faced the worst of it. T: Wow. How does your gut let you know that? C: It just kind of, my strength comes back S 146-154 T: And you’re, you generally don’t use food to deal with emotions that are … C: Exactly, you know. It’s like … I don’t need the compensation. T: Yeah. You’re so, you’re psychologically insightful about yourself. T: It’s one of your wonderful traits. C: Oh. … Thank you. (laughing) There were initially no reflections from the therapist on this segment of the session from the IPR interview. However, the therapist offered his reflections during the member check follow-up. He stated that: 158 I’m highlighting her “transformance strivings” (an AEDP term) which is bringing mindfulness in her and witnessing from me to her positive “self-at-best” [in] to order to work through her “self-at-worst.” Both are AEDP terms. By attending to her somatic experience of this, “gut” I help her to connect further to her felt sense of the good, thereby increasing access to self-at-best. … I first recall a characteristic of hers, “not using food to deal with emotions.” [This] shows her I remember her and a positive quality of hers. The next two lines by me are my admiration to which she responds with laughter after the thank you. I can’t tell from transcript whether that laughter is defense or enjoyment. … In the context of the beginning of the third session, and returning to therapy to work through a difficult relationship issue with her daughter, the client described that she felt reassured and relieved that her therapist saw, remembered, and recognized her and her unique ways of managing her pain. CIPR 271-278 C: That that felt good there because he was recognizing that I’m normally stronger than this. And it felt good at that time that I was saying I could deal with pain, not deal with it, but go through the pain, which is better than running around, not knowing what’s causing the pain. Because the pain goes into whichever part of my body. But then when I get to grips with what’s bothering me, then I can deal with the pain. In a real way I can deal with it intellectually and emotionally, rather than storing it wherever it might be CIPR 282-286 R: … when he said, was it, was it, were you responding to him saying, “Um, so you’re not using food to um manage emotion and ...” C: Yes, it was like he, he saw me. He recognized, oh yeah that’s one of [my] quirks, (laughing) one of [my] alternate diversions to depression is to, to go into pain. And I had just kind of recognized that CIPR 301-304 C: … he said that and I’m [sighing] ah I can breathe (laughing) slightly again. R: You can breathe again. So some relief in a way. C: Yeah. How the dyad worked with the client’s relief. Focusing on his belief that the client was experiencing pain, the therapist listened carefully. He patiently followed the client trusting that she was beginning to approach what she came to talk about. The relief and “lift” the client experienced in being seen and recognized allowed her to approach the issue she wanted to explore and she began to move into it. It might be said that the entrained implicit good experience together from the past and the explicit positive affect between the therapist and client strengthened their connection, fuelled the client’s courage, and provided the container in which she could proceed into something difficult. 159 S 277-280 C: And I can face that, I did something. T: Uh hm. C: That was at the expense of my children. That damaged them, that broke their hearts, that is not what a mother would normally do. S 293-296 C: Because I’m not stupid and insensitive. I don’t think I was ever able to face what I’ve just told you because… T: Yeah. What’s it like to face this? C: Intensely painful. S 315-318 C: But that doesn’t take away from her very real grievance and hurt. T: yeah, yeah, and the fact that you’re also are in pain as you have the courage, use the courage to face this. C: I don’t think I could have faced it any sooner and I don’t think I could have … The client described how touched she was by her therapist accompanying her, feeling with her, and providing a loving, respectful space for her to unfold her painful story at her own pace. He allowed her to lead. Her words were coherent and flowing. CIPR 318-319 C: … an eternal amount of time when I just told him exactly how I felt and how painful it was and he just sat and just sort of lovingly listened to it CIPR 331-338 C: (laughing) you know, uplifting, whatever. R: Uh hm. C: Self-affirming. It’s something more primal than that. R: Uh hm. C: It’s like being accepted as a human being in among all us other human beings, despite terrible outcome of your action. It’s like being respected in some way, the way he just sat and listened to that whole, long painful passage. CIPR 342-345 C: It was almost like a sense of being held up lovingly. R: Okay. Anything else? C: Well, just the respect of his listening because there was lots of places he, he could have interjected The therapist commented that he was aware of feeling connected to the client at this point in the session. He was following along with her, feeling the sting of pain with her, and paying attention to where they both were in their immediate experience of themselves and each other. TIPR 627-629 T: So. I figure it’s just my sting. It felt very connected in myself, feeling the pain with her at that time so it sort of stuck with me. 160 In a further example of trusting the process and seeing where it goes, the client experienced mild relief while at the same time feeling terrible about what she had done. This was triggered by being seen and accepted by her respected and trusted therapist. S 321-324 C: [couldn’t have] faced if I hadn’t met Dr. [former therapist name] and you. T: Right. What makes it possible from what you’ve done with Dr. [X] and me, what’s made it possible for you to face, to face this huge pain? C: That I am [client says her name]; I am everything that’s in me… and I did something that wasn’t deliberately bad. S 350-354 C: But, when I’m in here, I feel, seen as myself. T: I am so glad. What’s it like to be seen? C: It’s wonderful. It’s … It’s a relief. The client described coming back full circle to make sense of her past. She used the powerful metaphor of the scarlet letter to signify how her identity had been marked by her painful past by leaving her children behind when she left her violent ex-husband. She reported “pain’s okay, … pain’s better than not knowing.” (CIPR 444-446) CIPR 393-395 C: So, this is like the circle. … Coming back. CIPR 425-436 C: So, that’s a back story to tell…. just what that good feeling it was. R: Being seen. C: Like the opposite of what happened … at the time. R: So, kind of um would you say at this point that it’s beginning to feel like something’s getting knitted together here in a way for you, or …. C: Oh, absolutely. CIPR 408-412 C: But nobody could understand that at the time. You know, so … R: Yeah, so you were really utterly alone in that having broken some cardinal … C: Yeah, (laughing) like sort of the scarlet letter (laughing) The therapist described how and why he followed her lead, and importantly named how he saw his role as being the one who follows the person I am working for. TIPR 207, 211-214 T: … more, I’m just with her than generally. I’d be more directive than that. So, I’m just kind of really pacing, staying with um responding to what comes up in her naturally, without being conscious so you see my resonance here and there in terms of my affect, her distress and her in her distressing moments. So, that as I was watching it, the metaphor, it’s kind of like fishing. You know, I know we’re going somewhere. We don’t, in a sense, have a bite yet. But it’s not time to leave this place of fishing and go somewhere else. 161 TIPR 230-232, 278-280 T: So. … And following um one of the best cues I got in therapy was staying one step behind the person I’m working for. So, I’m endeavouring to do that for the most part knowing, trusting something. … But she’s, she’s in the experience of that story. In that experience as she’s saying it. Because of that there’s something significant happening even though there are no fireworks. How the dyad worked with the client’s relief. They followed her lead. The good feelings of relief at being seen and accepted provided a platform of safety from which the client could talk about her painful history, and the therapist could listen and follow her, trusting it was going somewhere productive, and somewhere she needed to go. S 451-459 T: So, [client’s name], I, I… C: So, it wasn’t me; it was what was going on. T: I know. I want to invite your guidance, in our work together, in particular is to where we should focus to you know help you recover. C: Well, my fear … has always been … T: Uh hm. C: that in some ghastly way, [daughter] will stop me from seeing the children [her grandchildren] There are no client reflections for this segment of the session. The therapist explained how he intentionally asked his client for guidance about where she wanted to focus her session, given the complexity of her painful history and the many themes within it. TIPR 354-357 T: I one thing, I, I, she knows herself so well and it makes a lot of sense for me to ask her, rather than by my theoretical places on her. … Ah, cause I trust her intuition well enough to know that … Summary of process theme of trusting the process and seeing where it leads. Both the client and therapist are well aware of where the work has been in the past and where it needs to go. They allowed the relief of being seen and understood to fuel the client’s courage to lead into her painful past with her therapist just one step behind her. Undoing aloneness. The client experienced a “glowing” feeling, joy, as a result of her therapist stopping her midsentence to express his admiration and acknowledge the worth (goodness), the wisdom, and the gift of what she said to her daughter. This caused her to pause, stop and say to herself: “Yes, it’s good.” This allowed her to move even closer to her painful past history and tell the therapist about it. S 511-515 162 C: And I said, just straight from the gut, I said, “Maybe what happened was unforgiveable.” T: Wow (therapist interjects) C: Well, and I have a feeling that that’s what’s going on, what I did was unforgiveable. S 528-539 T: So, I’m just, I really want to admire um your statement to her. Maybe what was done is unforgiveable. I mean that’s a wise and beautiful response from you. C: She missed it … I felt it was a wonderful thing to say, but she jus, she’s so hurt and angry… and dismissive. T: Yeah. What’s it like to, I admire that wisdom in you. C: It’s like you’re really seeing me. Like you understand. You get it. T: Yeah. So and, and what’s it like? That I see you and get you? C: It’s warm because I respect you. … It’s like you’re really seeing me. Like you understand. You get it. The client described how she chose to share her story with her therapist because she intuitively knew she would be tenderly received and held, and he would be genuine, fair, and realistic. CIPR 547 C: And I can live with that. … CIPR 552-554 C: So, [therapist] balanced my side. He didn’t, he didn’t take her side down, but balanced (laughing) my side of the scale up by reinforcing … CIPR 593-595 C: Well, I, I feel um I’m handing him myself or my, my understanding or, of what I’m thinking or feeling. It’s like I’m giving myself to him and he’s receiving. He’s not doing this in return, but he is in a way without the hand gestures. [I am in good hands] The therapist described his awareness that the client received his validation while he listened without judging or reassuring her. He also explained that his intervention was intentional and genuine in wanting to ensure she did not feel alone in her pain, that he was there with her. TIPR 723-725, T: And I also thought that her statement to her daughter, the only, the only word I wished I’d added was that it was an extraordinary gift. You know? Um, not only was it wise, but it was a tremendous gift to, to give her. … TIPR 736-738 T: So, she just you know there’s a, her eyes light up. Which is like she’s lighting up from having been seen. Right? So, it’s the undoing, I’m undoing the aloneness. TIPR 749-751, 756-760 T: … It’s the most beautiful thing to have a person feel seen that’s felt invisible. So. You could say that my ah you know joy virtually is, I that’s the epitome of therapy, is undoing aloneness. So. Yeah, that’s um, there’s, … 163 TIPR 756-760 T: there’s you know um I just mark that ah you know she’s got a distance between “I forgive myself” when she hasn’t. So, I know I’m going back there. So, knowing that I can put it on the shelf and stay with that. How the dyad worked with the relief of being seen and understood. In a challenging moment, the client received genuine respect and fondness, and experienced the “glow” of being recognized and even admired when she revealed and faced something she did that she believed was unforgivable. This appeared to bolster her to continue to approach a very difficult part of her past, trusting she would be accepted, respected, and helped. It helped to know she was not alone in facing her pain, responsibility and fear about the future. S 551-557 T: So, I think it would be important to examine this um fear that um, [your daughter’s] going to ex-communicate you from the lives of your grandchildren, which causes you to, to do what? How do you do the bad fear? How do you live differently or behave differently? Or …? C: Well, it’s what’s let me put up with … [verbal] abuse. S 630-631, 649 C: Because I couldn’t live with this fear of what damage it would do to me and the girls. C: And which is why I came to you. What followed in the session was an exploration of the fear the client chose as a focus. The dyad partners examined the details of what the client’s fear was about, when it came, what helped it, and what made it worse. There were no participant reflections on this part of the session. Both client and therapist, in their respective interviews, silently watched the video recording as the conversation between them unfolded. Summary of process theme of undoing aloneness. The dyad utilized the client’s good feelings of being seen, understood and admired as a platform of support and trust that the journey into difficult work and intense emotional experience was not a solo trip. She was “in [the] good hands” and presence of her therapist. Being guided and guiding through a hard place. The client identified this private, interior sense of vitality that was unnoticed by therapist and researcher. She reported that she experienced vitality as a result of sitting with a respected other who trusted, accepted and respected her while she looked at something important, painful and truthful. S 652-666 T: So, ah I’m thinking again about what you said, that’s, you know, with this, our third meeting, and you took some things away from our first meeting. C: Yeah. 164 T: And rearranged a lot. Your responses, in a sense, of how you saw things. And, and you said also today, now, that you know the pain you’re facing in some way that you hadn’t. Only got little glimpses before. C: yeah. T: The pain of the choice you made um to leave your [children] behind because your husband was such a bastard to you. C: Yeah. T: And the thought of staying there, you’d rather be literally dead, right? C: It wasn’t just him. It was the weight of my childhood, you know. … I was a certain person. The client explained her quiet sense of vitality, and her sense of a new awareness emerging about her therapist seeing and understanding the gains she had made in her work with him. There were no therapist reflections on this part of the session. CIPR 606-608, 619 C: I felt very warm there because [therapist] was acknowledging that after the first session, I capitalized on what had happened. I was capable of growing. And coming out from a stuck place. … Uh hm. Well, a feeling of being seen as worthy. CIPR 628-629, 638-643 C: There’s, it’s almost as if he’s interested in the valuable things you have to say. (laughing) You know, it’s just remarkable. … Of being seen is … Iris Murdoch writes, she hates vulgar psychotherapy because it tries to fit life into a neat little drama that we can understand. Maybe you’ve read (laughing) all that stuff. And this is the opposite. This is really sitting in a room, in a vital state, with another human being. CIPR 645, 658 C: This feeling of vitality. That something’s growing. He, just to reinforce what I just said, “we could look at together.” How the dyad worked with the client’s sense of vitality. With security of the therapist’s presence, support and expertise, and the client’s vitality entrained they continued to explore the client’s fear. The therapist decided to challenge the client’s belief that she would always have to pay for her action of leaving her children behind when she left her first marriage by suffering. This confrontation broke through the “spell” of the belief and the client began to try to understand a new perspective. S 669-681 T: So, what I want, I’m just um what we need to be able to look at together is how ah how we can, all the healing you’ve already done, how we are able to, maybe, open those doors together, with me, with you. C: Okay. T: Because I don’t, I don’t want you to be alone with this. You’ve needed those doors to close down the horror of that pain. C: I know. 165 T: Yeah. And I’m glad you’re able to do that. And now you’re not alone. You have the love of [husband] and you and I are connected. C: Yeah. T: So I, I want to together taking the right time be able to see and feel what has been too big to see and feel before. C: I just can’t believe I could cause that much pain. S 697-699 T: So, what are you, what are you noticing inside as you said, “She just wanted her mommy to come back.” C: It’s a pain that will never go away. S 707, 710-715 T: So… so I think I’d like to give you my opinion on that pain … Well, what I mean is that yes you’ll always be living with the fact that you made that choice. But I think a whole lot of healing can happen in you. And that I don’t think you have to carry this cross with the same weight your whole life. There may, in fact, be um a possibility to put it down and forgive. C: I can’t do that. S 722-723, 753-755 T: Yeah. I understand. Yeah. Would you be willing to consider something? T: So, is there a way in which holding this pain, apparently taking it and feeling it and bearing it, is what in a sense what you owe her [daughter]? C: I never thought about it that way, but that makes sense. S 799-800 C: That’s pretty primitive thinking, and that’s exactly what I’ve been doing (laughing) The client interview described how her therapist helped her challenge a long held and largely unexamined belief—carrying pain as a penance for unforgivable action on her part—and considering a new perspective. CIPR 662-670 C: Another thing he does that’s really good is because, at times, I’m getting almost sidetracked by talking about something that I’m on the subject of and I don't know how he does it, but he always senses that I’m getting a little diffuse and I kind of know it and he senses (laughing) it. And just very gently he says let’s, let’s go on. R: Uh hm. C: So, he’s a true guide, but a very gentle, like a shepherd. R: Hm, that’s a nice metaphor. C: You know, he shepherds us through that. CIPR 683-685 C: And it was like he let me go down into the very depths and then he said, “Here, I’ll make sure you’re out too.” And that was just ahhh [sigh] such a relief. (she sighed) The therapist described how he pressured the client’s belief by using empathy to invite her to think about her suffering in a new way. He reflected on how good feelings felt together resourced the client to face difficult things [with a trusted, skilled other]. Extending his idea, it 166 would also stand that a resourced client signaled to him that he could proceed with the challenge and know the client would be able to withstand it, take it in, and utilize it. TIPR 361-362 T: So, Henry Russo calls this, um, an AEDP faculty member, pressuring with empathy TIPR 387-390 T: Yeah and um … somehow you know, that was kind of a long piece, about ten minutes, with ten minutes prior to that. I don't know it’s almost like maybe like a dog circling its, around to sit down. It seemed to be necessary. TIPR 403-407 T: So, in terms of your study, take a moment of humour with each other in the context of facing the unfaceable. … Ah, you know it’s how positive that affect fuels courage that’s found together. And cannot be found alone in the face of something huge. Summary of process theme of being guided and guiding through a hard place. The dyad capitalized on the vitality of the client and the entrained good feelings between them to guide the client to look at her pain with him; assist her to shift her understanding by questioning an unexamined belief structure; and consider a new perspective. Making emergent implicit experience explicit and experiential to make connections and build awareness. The client experienced deep and momentary relief and release in response to her therapist carefully following her exploration of her fear, and gently confronting her belief with his opinion. This had the effect of breaking down an old belief structure. This was disorienting and there was just enough “light” in the relief to help her stay in her experience while things inside her began to shift and reorganize. She was then able to articulate a new insight. S 773-780 C: That ties in with when I started to have moments of happiness. I didn’t want my kids to know. T: Oh? That’s very interesting. C: Like if I won an award, oh, I don’t want them to know. T: They needed to see their mother as suffering. C: Yeah. T: Continuing. C: And I didn’t realize, I’ve never connected up all these things. S 784, 792 C: That makes so much sense. It’s like I’m agreeing with her. S 795-800 T: It’s kind of a deal is that you continue to feel terrible until the day you die, which is testimony ah to your acknowledging that you did this terrible thing. And if you do not continue to feel pain, then it’s like you’re saying it doesn’t matter, “I did what I had to do.” 167 C: Oh, that’s pretty primitive thinking, and that’s exactly what I’ve been doing (laughing). The client described the emergence of her relief and release, and her new understanding that she and her daughter were “in it together,” an implicit deal they had made together, and continued to enact. She began to see her part in the suffering contract. CIPR 694-696 C: I was kind of stunned because it just ah, I would never figured that either before. And I think when I went “ha” [sigh] it was positive just for an instant. CIPR 703, 715 C: Like the door opens. C: And something is opening or a release … CIPR 729, 731, 733 C: And then it just came down into my gut. R: And then your gut told you … C: Yeah. Oh, there’s a lot of little light in the tunnel. (laughing) R: Okay. Okay, great, thank you. C: It was very, very quick. The therapist described how he was understanding her mixed experience of relief and anxiety; signs that something was changing. His conceptualization of what was occurring for her was the crumbling of an old identity belief. The mantle with the scarlet letter was beginning to fall off her shoulders. TIPR 809-811 T: She’s still struggling on the edge here, right? So, it starts here and then it’s like a little bit of a mini cascade, I think. … Uh hm. I just thought we hit pay dirt. TIPR 819-823 T: And so there’s, there’s a kind of structure that she’d ah she assigned to her suffering is crumbling before her eyes. And it’s both ah on the one hand relieving and on the other hand a disarming and someone anx, somewhat anxiety producing. So it’s both kind of. It’s ah, what is it? In AEDP terms, it’s ah um well, it’s a kind of glimmering that comes to mind, right? TIPR 826, 830 T: Right. Heralding affect … Something is beginning to undo. TIPR 832-834 T: So, so in a sense these, the structure is, is collapsing, which is both a relief and frightening because she’s been hanging on that for 35 years. … Uh hm. A bit disorienting TIPR 912-914, 916 T: That’s being lit by the sun from different angles. So, new things. So I’m settling with her with that I was very happy she saw we’re in it together. … So, she’s seeing it as a co-created … 168 How the dyad worked with her momentary relief. They used the energy of the relief to begin to explore what it was like for her to have this new understanding. They directed their attention to each part of her experience, by asking about it, and languaging it. The client was invited to remain in full contact with her therapist and her emotional experience in order to expand her understanding of what was occurring in her. She described her relief as “taking the stone off the coffin,” being released from a painful spell, a suffering contract. This triggered more relief and delight. S 804-808 T: What’s it like? What’s happening? C: Well, it’s like the stone’s come off the top of the coffin…(laughing) T: (laughing) What are you noticing? C: Ah [sigh] Just a flood of relief or, cause that’s not doing any good, that kind of thinking. S 812-822 C: She’s [daughter] not seeing me. T: No. So what are you…? C: She’s prevented seeing me by … T: So, as you’re feeling this relief, listen to the breath there… C: It’s like I was stuck in my thinking. T: I know. C: You know you come along and … T: Yeah. C: you, you get to a little up … and you can’t get up there… T: Yeah. C: to the next bit and you need somebody, like you, to kind of (laughing) The client reflected on this segment, expanding on her previous metaphor of coming full circle—picking up tangled, dropped threads—as having relived something very hard and worthwhile because it represented a new opportunity. CIPR 738-750 C: It’s not just a relief, it’s a delight. T: Uh hm. Uh hm. C: It’s “For god’s sake I don’t want you to think that way anymore.” R: Uh hm. C: You know it was just beginning – that was there was one little crack and then it started to really flood in. R: Because you said something, “It’s like releasing something off of a coffin.” C: Taking the stone off … R: A stone off a coffin. C: off a coffin. You know there’s a sarcophagus … R: Yes. Exactly. C: I didn’t say sarcophagus, but that’s what I was thinking. 169 CIPR 754-756 C: It’s like second rising. You’re at a new stage of life because you’ve had an enlightenment. And something you’ve done for 35 years, you don’t need to do anymore. (hands up over her head) CIPR 783-787 C: Because it’s like getting a second chance at a really, big, important thing that’s happened in your thinking and your emotions. It’s, it’s wonderful. … It’s a pain that’s worth living again (laughing). The therapist described his conceptualization of what the client was experiencing. He noted that something new was emerging in her somatic experience, and that she was looking in a new direction, literally. TIPR 950-957 R: But before she’s this, how would you name that? I mean it’s more than relief that’s happening with her, right now. That’s my sense anyway. T: Uh hm. Well, I think with the relief, her energy comes up. Like rising from the dead. (laughing) She decided to die. You know. She had to hide her um her joy in a crypt. Ah from her daughters. R: Not allowed to live. T: Right. Yeah. And so this is hallelujah TIPR 961-964 T: Right. I don’t use the word spell until the end, but it was very much that she … You know, she entered into a trance or a spell … TIPR 967-972 T: … at that point, interesting the direction she looked right there, which is a new direction for her to look at. … I don't know if you saw that. It was like five seconds ago. She’s looking over here. Summary of process theme of making implicit experience explicit and experiential to make connections and build awareness. Making the implicit experience of relief and release explicit and experiential by continuing to stay in direct contact with her internal experience, assisted the client to re-articulate her emergent experience, an experience that was disorienting, anxiety-provoking, and “wonderful.” This allowed her to begin to look at her situation differently, literally from a new direction or vantage point. Anchoring, affirming and appreciating the work done together. The client was touched by the therapist’s protective and preventive counsel. She was feeling both relief and some anxiety. This was triggered by the therapist inviting her to live with her new understanding for a bit [before she acts]. The therapist commented only on the part of the session following the advice he gave. He perhaps did not notice her being touched by his counsel. S 1020-1032 170 C: It’s like I had manacles on and you’ve got a bolt cutter and taken them off. I’m, it’s just … T: (laughing) Beautiful image. Yeah. C: It’s unreal. And that’s what’s wrong between [daughter] and I. T: I know. C: From my point of view. … From my side. T: So, I really want to invite you to let this discovery, what we found together, to really be with this, and I know you will. But I want you to know that it’s my invitation to you as well. C: I think I need to think it through and realize all the ramifications because this is huge. The client described her appreciation for the timely and sanguine advice of her therapist about not acting too soon on her new understandings and perspective. She felt respected by his implied caution and protection. The therapist did not offer any comments or reflections on this segment of the session. CIPR 1076-1085 C: I think that was wonderful, him there, because I made that realization and then there was the relief of laughing and the mutuality and then he came back and said, “I want you to live with this.” Because I had said it was huge and he was reinforcing that it was huge and made me stop and say, “There’s a lot of ramifications to this.” So, he was very wise there in, in his timing. And it felt so supportive. … I felt really taken seriously. And at the same time given good advice. You know, don’t, don’t just carry on. Really think about it. How the dyad worked with the client’s relief. The therapist invited the client to accept a stone as a symbol to remember and anchor the experience of relief of being freed from her old belief structure. This was a very intimate place in the session. There was some relieving laughter from the client to titrate the closeness. They acknowledged the fullness of the work together. S 1037-1041 T: So, I would like to give you something if I, if you would accept it C: Sure. T: … It’s good to remember with an object given openly. I’d like you to choose. C: Oh, I’ll take the red one S 1047-1055 T: (laughing) So, that is a little stone to hold, to connect with, you’re having the shackles cut. And having broken the spell… C: Yeah. T: You’ve broken a spell. We found emotion together. C: I never even questioned it. T: Questioned what? C: That 35-year conviction… 171 T: I know. Right. So, when you hold this in your fingers, it reminds your body of what you [did, experienced]. Yeah S 1060-1071 C: God, you’ve got a good eye. (laughing) T: What do you mean? C: Oh, well, it’s like you can see the thing I can’t see. T: Uh hm. Hm. C: Like you can zero in through all the words I say. That they’re really important. … T: Yeah. Uh hm. C: Oh, thank you. T: wow, … Thank you. Ah [sigh] I’m going to treasure this. C: Me too. T: That makes two of us. The client’s reflections focused on the bond between her and her therapist, how their age allowed them to accept gratitude mutually, without false modesty. The actual dialogue suggests she deflected the intimacy and complimented her therapist. CIPR 1088-1092 C: I love the way when he pays me a compliment, I say yes that’s right. And when I pay him a compliment he says that’s true. That’s. Like we’re both at a certain stage in life where you’re passed all that angst and uncertainty when you’re young. And somehow that’s part of the bond between us. The therapist reflected more specifically on the intimacy of the moment and how he perceived her unease with it. This is interesting because in an earlier part of the session, it was he who pulled back from the intimacy of the client’s gratitude. TIPR 1126-1142 R: What do you think was going on from your perspective there? As you’re remembering? As you’re giving her the stone. T: Well, she’s being taken farther into anchoring this. R: Uh hm. T: Um, and the laughter is a defensive reaction to the intimacy of our work together. R: Uh hm. Uh hm. T: Ah, but not only that. Also mixed with kind of delight, so there’s, ah, ah, it’s almost like the ah, the ah, there’s something about it that’s just a little too close … for her … at this time. Summary of process theme of anchoring, affirming and appreciating the work done together. The dyad utilized the client’s relief and appreciation (being touched and grateful for his advice) to further express gratitude to one another and thereby affirm and solidify the work done together. This resulted in an increased intimacy between them. 172 Balancing giving and receiving. The client experienced reverence and tenderness in response to an intentional self-disclosure by therapist. This was at the end of the session and was not discussed by them together. S 1086-1092 T: I want to share something with you. C: Sure. T: Just before I came here, I left a friend at his bedside. And so I think that ah tonight he will die. … Or very soon. And ah the last thing he said to me was, “I’ll wave to you.” S 1102-1104 T: Yeah. And although we’ve not, we’ve known each other for many years, we haven’t explicitly talked about our friendship, we have a deep bond. S 1125-1135 T: I think it’s the Celtic understanding that these moments like I share with him and you and I shared are the thin places. C: I always think that’s so weird. It’s like something in a little glass ball that you can hold in your hand and look at. It’s complete … and you can take that out anytime in your life. T: Uh hm. … And it always be there because it’s more important than anything else S 1166-1171 T: Oh, that’s wonderful. Right. And I believe. The little red one that you chose is one that came from Nice. C: Oh really? Oh. Now, I’m not going to say that’s nice. (laughing) T: (laughing) Good. Good. Because I know you’re not a corny person. C: Not at all. (laughing) T: Thanks The client reflected on this segment in which she drew on her “good self,” and past experience to give the gift of her listening, compassion, and empathy to her therapist. She recognized the privilege conferred on her in this moment. CIPR 1143-1160 C: (laughing) Oh god. (laughing) That’s a really good movie when you laugh and then you cry. (laughing) That bit at the end when he talked about his friend, that was just amazing. R: Uh hm. Can you say more about that from your experience? What you experienced during that? … C: [sigh] Just like we’re one person … and just like, ahhh, the best gift I have is my compassion and empathy. And …. People used to go and sit with dying people. They didn’t used to die in hospital, so since I was a very tiny child I’m used to sitting … somebody dying and so I don’t have that fear of the unknown that people might have, who haven’t been around dying. So when somebody talks to me like that, I’m just totally feeling in my element. CIPR 1165-1167 173 C: So, I felt really privileged in the way that he was privileged to be with his friend and death. That he would share with me. I’m happy that that was my forte. That I felt like a good self. The therapist reflected on her capacity to be with the intimacy of her tenderness with him. Although he did not mention it during the interview when asked about it, it is similar to an earlier part in the session when he noted how he was letting her be his teacher about their shared cultural heritage, rather than refocusing her attention or commenting about [cultural heritage name] stoicism as a defense. During the member check follow-up, the therapist specifically mentioned to me that he did not do this to equalize power in the relationship, a phrase I had used to explain a possible intention for his action. Rather, he explained: I don’t hold the view that it’s about balancing of power. As a therapist I’m paid to be in the position of the older, wiser other. And she pays to see me. But by allowing the person I am working for to give to me, care about me and understand me I show that it’s human to have these struggles, thus normalizing hers. As I let her see that I’m touched by her care then our alliance is strengthened as it’s a two-way street. By showing her that her care impacts me her loving agency is validated, in contrast to what her daughter shows her. He did agree that balancing power is a possible outcome of this intervention, but it was not the aim. So, while he intentionally made his disclosure in the session, he appeared to do it intuitively at the time, and in the interview reflected on her expanding capacity for intimacy in that interaction. TIPR 1189-1194 T: It’s interesting watching it. We’re actually able to stay with the intimacy between her and I longer because it’s … explicitly about someone else, even though it’s actually about her and I. TIPR 1198-1205 R: What do you think her affect might be in that? T: Tenderness. Uh hm. R: And for you as well as herself? T: Uh hm. Yeah. R: Yeah. Yeah, okay. T: Gentle. Tender. What occurred here was the emergence of reverence and ego strength. With manacles set aside, the client stepped into and connected with her own self at best at the invitation of the therapist’s disclosure. This invitation was intentional, to ask the client “to stay longer with the newness with me.” He called forth her wisdom (and unbeknownst to him an area of experience for her) and shared something very personal that was touching him in his own life at that time. 174 She brought her full self to listening and holding what he told her. She was alive, awake, and responded spontaneously with depth of emotion. Summary of process theme of balancing giving and receiving. The dyad balanced the power in their relationship by switching roles. The client’s self at best responded to a bid from the therapist to equalize the power differential and call on her strength and experience. We are both human, we are both equal in this conversation called life. It was a mutual and self-differentiated state for the client and therapist to end on. Assertions. First, the strength of the relational bond of this dyad and the mutual trust between the partners was enacted and entrained in a way that created a synergy for enjoyment, mutual admiration, and productive work. Second, the social and cultural beliefs of the client, some shared and therefore well understood by the therapist, along with the therapeutic theories of the therapist created a powerful alchemy for challenging one of the client’s long-held beliefs about suffering. Third, this fusion of horizons enabled the client to come to a new understanding of an untenable contract she had been endorsing. Cross-Dyad Analysis This section presents a comparison of the dyads with one another, describing the similar and unique ways the dyads utilized positive emotion when they perceived it had emerged for clients. It is not surprising that common process themes emerged from the analyses, especially since the two therapist participants practiced from the same theoretical clinical model. However, there were demographic differences between participants, and different presenting issues brought to the therapeutic endeavor by the client participants. Despite these differences, the following six process themes were found to be common across the dyads: paying attention to safety; fueling the tank of togetherness; trusting the process and seeing where it leads; making implicit experience explicit and experiential to expand awareness and increase understanding; undoing aloneness; affirming, anchoring, and appreciating the work done together. Three unique process themes emerged from the analysis: imagining more to scaffold new emergent experience; being guided and guiding through a hard place; balancing giving and receiving. These process themes are unique in that they emerged in only one of the three dyads. Imagining more to scaffold new experience occurred in dyad 1, while being guided and guiding through a hard place and balancing giving and receiving were present only in dyad 3. 175 Common process themes. Paying attention to safety. All dyads worked directly and continuously at building and maintaining a safe relationship environment for the therapeutic work to occur. This theme was separated out because of its importance, but there is evidence of it being negotiated and enacted throughout the episodes and whole sessions in all three dyads. Each participant commented in varying ways about how different aspects of feeling safe was important to them both during the session and generally, depending on their vantage point and what stage of the session they were reflecting on. Related notions of closeness, comfort, responsiveness, trust, genuineness, helpfulness, and feeling important and valued emerged within the theme of safety. In dyad 1 and 2, for example, the issue of psychological and emotional proximity was primary. How emotionally close the therapist was required awareness and negotiating. In dyad 1 the client expressed her dis/ease with the therapist’s emotional closeness as a bid for something she was uncomfortable doing, in one instance expressing a feeling that she didn’t think she had. In dyad 2 the client had difficulty maintaining eye contact at times, and needed support and guidance to practice this and to understand its meaning. In dyad 3, the participants commented on safety and mutual affection being entrained from previous sessions and previous work done together. The dyad 3 therapist participant talked about sharing levity together as a resource for what is possible, being responsive and being fully present and emotionally available to ensure the client felt seen and understood. The client in dyad 3 emphasized the responsiveness, helpfulness and wisdom of the therapist. Genuineness was also highlighted, by participants in all three dyads, especially the client participants. The client in dyad 2 expressed surprise and gratitude for how natural his therapist was in being willing to yawn at the same time as him and enjoy it together. In dyad 1 the client was deeply touched by, and grateful for her therapist being honest with her about having seen how distressed her previous relationship had been. In dyad 3 the client commented on how her therapist had been very honest and genuine with her when he listened to her challenging past history and did not try to reassure her. Fueling the tank of togetherness. This metaphor was given by the therapist in dyad 3. It captures so well the sense of connection and solidarity that comes when we feel good things at the same time as others we are with. The therapists commented on this theme more specifically than the client participants, although it was evident that the feelings shared had similar impacts for clients and therapist participants. In dyad 1 sharing good feelings together had the immediate 176 impact of allowing the comfort levels within the relationship to increase. This entrained enough ease for the client to be able to experience her feelings fully and share what her experience was with her therapist, something that had been more challenging to do at the beginning of the session. This is an example of the client having a mini experience of building her relational capacity, being able to be fully herself while in relationship with another person, without having to essentially change, her stated goal for being in therapy. In dyad 2 sharing good feelings resourced the client in two ways: it increased his energy and he felt more in touch with himself and subsequently more closely in connection with his therapist. In dyad 3, laughter and delighting in shared cultural connections was a form of playing together that deepened the attachment already firmly in place between the client and therapist. The strengthened and resourced relationship provided a safe container for the client to be able to move towards deeper, more challenging issues that she wanted assistance with. Trusting the process and seeing where it leads. In all three dyads it was obvious that therapists were trusting the process and following the lead of their clients, and the clients commented on how patiently, and sometimes lovingly, their therapists listened for long periods, were present to them without interjecting or redirecting them. However, only in dyad 2 and 3 was this explicitly described within the context of the therapy session discussed in the interviews. In dyad 2 the therapist demonstrated his trust in the process several times by patiently listening to the client narrative and emotional story line, not knowing where it would lead and initially thinking it would not be productive, until the client made an important disclosure. The client expressed profound gratitude, especially in his interview that his therapist had listened to him and accompanied him for such a long period. In dyad 3 the therapist explicitly requested the client tell him what part of her history she wanted to explore together, trusting that she knew herself well enough to choose what was most important for her at that time. This exemplifies the idea that therapists lead by following. In this case the therapist explicitly stated his role as being “the one who follows the person I am working for.” Making implicit experience explicit and experiential to make connections and build awareness. All three dyads worked actively with this process throughout many of the episodes and across all therapy sessions. It may be said that therapy partners working together to bring implicit experience into explicit awareness, and facilitating clients full experiencing of what was happening for them in the moment, was the cornerstone of experientially oriented work done by 177 these two therapists with these three clients. This was achieved by pendulating between eliciting experience and reflecting on it. Specifically, this was done by heightening somatic and emotional experience, naming what was happening somatically and cognitively, and inviting more of the experience to emerge so that clients could have an experience that they felt, talked about, and understood. Repeating this process over and over in the course of the sessions provided clients with a new experience of themselves in the presence of their therapists, and resulted in significant clarity, new awarenesses, and fuller understandings about their own internal processes and ways of relating. In dyad 1, the client was able to get clarity about a decision she made and was able to begin to feel her emotions in her body, not just in her head. In dyad 2, the client was able to more easily feel his own excitement, good feelings, and exuberance in the presence of his therapist without feeling embarrassed or needing to look away. In dyad 3, the client was able to feel the weight of past pain lift, and understand her part in how she came to carry the pain. Also incorporated into this theme is metatherapeutic processing. The decision to subsume metatherapeutic processing under this theme was directly related to how it is defined by Fosha (2000), and her colleague Russell (2015)—the exploration of a specific instance of micro or macro change that has just occurred in session. In this way it has been described as a type of immediacy intervention (Iwakabe & Conceicao, 2015) or a savoring strategy (Russell, 2015). It encompasses both the exploration of change experience, eliciting what the experience was like, while reflecting on its meaning, as well as its relational context. For example, “what is it like to do this work together?” Undoing aloneness. Each dyad co-created an experience in which the client was able to feel accompanied and connected with a trusted, available, and responsive other while having an emotional experience or exploring an issue that in the past was either overwhelming, experienced alone, or misunderstood in some way. This had a powerful impact for the better for each client. In dyad 1, the client received validation that her therapist had seen and understood the distress she experienced in a previous relationship, as well as how her efforts to make things better had failed. No one had ever shared this perspective with her previously, and it was a very important event for her, literally validating her reality. In dyad 2, the client was invited to be his full emotional self in the session with his therapist, noticing how he struggled to stay in connection. This resulted in the client making an important disclosure to the therapist, and understanding that 178 he does not have to be alone to have some of his emotional experiences. In dyad 3, the client was held in care and respect, and received admiration for her wisdom during her disclosure of something she did in her past that she believed was unforgivable. This had the impact of helping her garner the courage to face a very painful part of her past and know that she was not alone. Affirming, anchoring, and appreciating the work done together. The dyads all enacted some form of explicitly affirming, anchoring and/or appreciating the work done together in order to facilitate the client being able to remember and hang on to gains made in the session. Although the dyads repeated many rounds of making implicit experience explicit, and repeated iterations also helped in this process of remembering and anchoring new experience, the therapists all took the lead to ensure that this occurred at the end of the sessions as a way of preparing clients to take their new experiences into their lives outside the therapy session. Each dyad did this in a slightly different way. In dyad 1 the therapist took the lead to intentionally reaffirm and validate the client’s decision to leave her former partner. He appeared to want to reinforce that her decision was something she had considered thoroughly and that choosing herself and her own welfare was a necessary step for her, despite her continued mixed feelings about it. This also appeared to support her to hold the complexity of her experience together. In dyad 2, this same therapist worked with a second client to invite “one more round” of connecting with one another about their internal emotional experience related to the work they had done together. The therapist’s disclosure of being moved by the client was met with the client’s gratitude for his relationship with his therapist. In dyad 3, the therapist offered the client a small stone for remembrance and acknowledgement of their shared emotion, and the client’s new found release from the pain she had carried for a considerable time. Unique process themes. Imagining more to scaffold new experience. This process theme emerged in dyad 1 only. The therapist made the decision to focus the client’s attention on imagining a better outcome to her recent relationship break up rather than to focus on the distressing feelings of not getting the appreciation or acknowledgment she hoped for. This was intended to approximate or scaffold having what the client wished for and didn’t get, something the therapist discerned was too painful to approach directly at that point in the session. The intervention was a way to resource a privation, an experience that was possible and attainable imaginally. As such it was imaginally near to what could have happened, but not a bull’s eye, and thus was less distressing 179 to process. It was a pleasurable entry into the complexity of the immediate issue, as well as having the potential to lay the groundwork for future exploration of more painful aspects of her relationship break-up, and make links to her past relational history. Balancing giving and receiving. In dyad 3, the therapist was intentional on two occasions to invite and encourage contributions to the session and their relationship coming out of the strength and experience of the client. He commented that he did this because the therapeutic relationship is inherently a real relationship. He stated he did this to normalize that it is human to struggle by showing her some of his. He specifically honoured the care the client gave to him, furthering their good connection, and countering what her daughter would not accept from her. The impact this had on the client was indeed to help her feel like herself at her best, as well as very connected to him “just like were one person.” Being her best self, and being seen at her best involved her using her past experience and compassion, and as such had the impact of facilitating the client to return to her strength as she prepared to leave the session. Being guided and guiding through a hard place. This process theme was clearly articulated by both participants in dyad 3. The client commented on how helpful it was for her therapist to listen so attentively, be honest with her, not take sides in her narrative, gently remind her to move on when she was being “diffuse,” and to reflect and take time with her new understandings before acting on them. In addition, this client discussed how important it was that her therapist knew both the route in and down into her deeper experience, and then helped her come back up and out of it. The therapist did not back away from the client’s gratitude on this process theme. In fact, he acknowledged it in a beautiful metaphor in which he imagined them both as two seals swimming under the ice, running out of air, and of him knowing where the air hole was, taking her flipper and swimming there with her. Key Assertions. The within-dyad and cross-dyad analyses provided a detailed account of the major process themes engaged in by the three dyads when positive emotion spontaneously arose for the clients during their psychotherapy sessions. The key assertions are derived from an examination of the within-dyad and cross-dyad analyses, and represent my best attempt to distill the bindings between the cases from the perspective of a philosophical hermeneutic framework. As previously described, the dyads are bound together by both the research question and 180 psychotherapy process. As a result, these assertions are highly theorized and represent the broadest aspects of my interpretation. Key Assertion 1. Working with clients’ positive emotion in psychotherapy sessions was a co-created relational endeavor. Participants came to these sessions open to the process and actively engaged in a therapeutic conversation. Close examination of these therapy sessions revealed that both partners in the dyads contributed to the process and outcome of each interaction and the overall session work and gains for the client. The therapeutic relationship formed the container within which the conversation and therapeutic work and its meaning occurred, and there was considerable care and importance attributed to this connection by all participants. Key assertion 2. Each partner in the dyad came to the therapeutic conversation bringing different perspectives (personal and professional theories, educational backgrounds, family cultural histories, age and gender differences), and participated in the session from a different vantage point, either as therapist or client. In the process each shared their worldview implicitly, or explicitly where possible and appropriate given the primacy of each client’s experience, by sharing the perspective of their respective vantage points. In the process, they were touched, moved, puzzled, delighted, supported, and ultimately were impacted and/or learned from one another in personal, cultural, emotional, aesthetic, and moral domains. Key assertion 3. The outcome of the therapy sessions represents an engaged and co-created understanding that occurred as a result of clients being courageous, open and questioning, and therapists holding their theories lightly, being compassionate, staying close to the experience they and clients were having in the moment. At the same time, participants leaned in to the therapeutic conversation with their commitment and their belief in the power and primacy of a safe relationship, and their trust in the process and each other as the ground required to work productively together. Key assertion 4. Privileging positive emotion as a focus for exploration and interest by the therapists highlighted their theoretical assumption that positive emotion is a signal that things are going well, a marker of where things are already working, has many benefits for therapeutic work, and may be a key ingredient of the change process. This assumption was a major driver of the direction of the therapeutic conversation and the study rationale and findings. 181 Key assertion 5. While the analyses present only one session from each dyad, many instances hint at the longer history of the participants, especially that of the clients. The historical and cultural influences that shaped their troubles and personal theories are resonant beyond the particularity of each participant and dyad, and their responses to their troubles or how they extend their theories. Questions posed such as: What is it to be an adult, an adult man, a good mother, a good person, or a good partner in relationship and be myself are larger cultural and existential questions. This chapter summarized the study findings from three psychotherapy sessions, and individual interviews with the dyad partners in order to answer the study question: How do clients and therapists utilize positive emotion when they perceive it has arisen for the client in psychotherapy sessions? 182 Chapter 5: Discussion The purpose of this study was to examine how clients and therapists attend to, work with, and utilize clients’ positive emotional experience. The question that guided the research project was: How do clients and therapists utilize positive emotion when they perceive it has arisen for the client in psychotherapy sessions? The participants’ understanding of their experience occurred in their rich, complex therapeutic conversations, and their conversations with me during their respective research interviews. This chapter provides a discussion of the findings reported in the previous chapter. It begins with a description of factors for consideration in interpreting the study findings. This is followed by a brief summary of the study rationale and findings. Next, theoretical, methodological, and clinical implications of the findings will be considered. The chapter concludes with a brief discussion of implications for future research. Summary of the Research Problem and Rationale This study was situated between three needs in the literature. First, psychotherapy process researchers are increasingly asked to turn their efforts to understanding how change processes unfold in psychotherapy sessions, and how clients are impacted by the micro processes of therapists’ interventions. Second, there are only a few examples of how positive emotion is worked with in clinical populations. Third, the psychotherapy literature has primarily been focused on distressing emotion. This project addressed these issues by exploring how therapy dyad partners attended to and worked with client positive emotion through an interpretive lens. This lens illuminated the fusion of horizons as the privileged voices of clients and therapists, came together with my voice as the inquirer. Summary of the Findings The hermeneutic interpretation of how clients and therapists utilized client positive emotional experience when it arose in psychotherapy sessions was found to be a rich, mutually coordinated and relational endeavor. The five final assertions summarize my interpretation and represent the binding between the dyads (cases). First, the therapeutic relationship formed the container within which the conversation, therapeutic work, and its meaning took place. Considerable care and value of this connection was afforded by participants. Second, participants came to the therapeutic conversations from distinct vantage points and with a diversity of personal histories. In the process of sharing these differences and perspectives the participants were significantly impacted by one another across emotional, aesthetic, cultural and 183 moral domains. Third, the meaning participants made of their experiences, and in particular of the clients’ experience occurred as a result of engaged and co-created understandings. Fourth, the privileging of positive emotion influenced the understandings created by participants, as well as being a major driver of the direction of the therapeutic conversations and the research conversations. Fifth, while there was only a single therapy session examined for each therapy dyad, the therapeutic conversation revealed aspects of the participants, especially the client participants’ personal and cultural histories that shaped their troubles, their implicit theories about their troubles, as well their attitudes and preferences related to experiencing positive emotion. Significance and Theoretical Implications Client positive emotions. The within-case findings of this study extend the findings of foundational research by offering an amplification and elaboration of how attending to and working with client positive emotion actually works within psychotherapy dyads. The therapeutic conversations illustrated how elaborating client positive emotion provided several benefits for the work—needed breaks and renewed energy from the intensity of some parts of the session, building good feelings and strengthening the relationship between dyad partners, and providing a platform from which to approach and explore complex, challenging personal issues with their attendant mixed feelings. The positive emotions expressed by the clients in the therapy dyads arose in response to similar triggers within the therapy dyads as documented by Fitzpatrick, Janzen, Chamodraka and Park (2006), and as such validated their findings. Examples of these common triggers were: sensitively helping clients to think in new ways; providing space and time for clients to fully explain their perspective and/or narrative without interruptions; being invited to be an active part of the session and relationship; therapist self-disclosure; therapist validation; and positive feedback. Interestingly, the meaning attributed to these positive occurrences was also very similar between the two research projects. Clients in this research project as well as the Fitzpatrick et al. (2006) study attributed similar meaning to their positive emotions: “I am important and valued,” “my therapist can help me, [he] knows the way through this,” “I am doing okay!” “I know what I have to do now.” The findings of the current study provide an in-depth exploration of client positive emotion that complements the work of Vandenberghe and Silvestre (2015). These authors looked at how 184 therapist positive emotion arises in sessions and what impact these positive emotions had on the therapists and the session themselves. Similar to what was found about client positive emotions, therapists’ positive emotions arose when clients were: demonstrating openness; being actively engaged in the process and showing progress; making connections. Therapist positive emotion also arose: when they perceived themselves as being effective and making skilled interventions; when they noticed their own personal involvement with their clients in ways such as admiring the client and identifying with the client’s situation or needs. While not an exact bull’s eye, it is evident how therapist and client positive emotions arise in tandem, and in response to one another, and what is occurring between them and within them during sessions. This is an experientially overlapping, recursive process in which the activation or energy (feeling component), and the intention or urge to act (motivation component) create the forward movement in the interactions. The effects of the positive were also described in similar ways to Vandenberghe and Silvestre. For example, therapist and client positive emotion seemed to fuel the client’s process. When a therapist listens for an extended period, communica ting compassion and respect, sometimes even admiration and awe because the client is working so hard, being so honest, the client may respond by being touched, feeling relief because she realizes her mistakes are human and she is still accepted and valued as a person. These experiences feed back into the interpersonal space and have the potential for new awareness to emerge. For example: “she sees and feels I am moved and see her in her pain, and she knows she is important and valued and has worth;” “when he listened to me like that, I felt like I was worthwhile, that I am worthy, and I felt like I was sitting with another human being in a vital state.” Another finding emerged—clients themselves were resourced when they were aware of, experienced and reflected on their positive emotions. At times this fueling was energetic, creating levity and a needed and welcome break from hard work and energy expenditure. At other times, it lifted the client’s mood and openness to see things in a bigger perspective. At still other moments, it fuelled the courage and energy to move forward and look at hard things, things of personal concern and importance. These observations support findings that suggest that positive emotion helps to offset the impact of strong negative emotions that may include fear and anxiety about bringing difficult material into active awareness for exploration. (Bridges, 2006; deRoten, 2008; Zautra, Johnson, & Davis, 2005; Zautra, Smith, Affleck, &Tennen, 2001). 185 The current study adds two significant contributions beyond the Vandenberghe and Silvestre (2015) work. First is the wider perspective obtained by having both client and therapist reflections on the sessions. The richness of both vantage points extends the meaning made by participants because it includes how their behaviours, interactions, implicit and explicit goals and intentions worked together to steer the therapeutic processes. These dynamics are not accessible in the Vandenberghe and Silvestre study. Second, the IPR method allowed me to track the moment-to-moment emotional processes and ensuing work as they unfolded in sessions. This provided vital contextualization of how the emotions arose and how they were worked with, as well as how the mutually derived understandings and meanings occurred. One further implication of tapping into client perspectives alongside therapist perspectives is the the degree of convergence between client and therapist and researcher identification of client positive emotional experience, as well as what was helpful in the sessions. It has been noted that clients and therapists may have different perspectives on what in-session processes are significant (Fitzpatrick, Iwakabe, & Stalikas, 2005; Levitt, Piazza-Bonin, 2011), what in-session events clients find helpful (Levitt, Butler, & Hill, 2006; Timulak, 2007), and predict good outcome (Bachelor, 1995; Elliott & James, 1989; Gershefeski, Arnkoff, Glass, & Elkin, 1996), or what emotional reactions clients are having during sessions and their recall of them (Lundblad, Christiansson, & Engelberg, 2001). This study makes a contribution to this literature in linking specific episodes of positive emotion to helpful therapeutic action and conversations. In addition, other authors have commented that positive emotion is often subtle, semi-private, even hidden, and may go unnoticed in sessions (Stalikas, Fitzpatrick, Mistkidou, Boutri, & Seryianni, 2015). Clients in this study easily recognized and resonated with positive emotional experiences they were having or had while watching video recordings of their sessions, even if sometimes it was difficult to articulate. Similarly, we saw experienced, attuned therapists recognizing both actively expressed and emergent affect in their clients with a high degree of frequency and accuracy. This finding is likely related to the priming effect of participants watching video recordings of their sessions soon after the sessions, the experience of the therapists, and the level of attunement these dyad partners enacted. Therapeutic relationship. Previous research documents the centrality of the therapeutic relationship as a major contributor to therapeutic change (Castonguay & Beutler, 2006; Lambert & Ogles, 2004; Wampold, 2001). The therapeutic relationship is a real relationship. It has more 186 professional aspects such as roles, responsibilities, goals, and tasks, as well as more personal and intimate aspects (Gelso & Carter, 1985). The current study validated this research and theory. It was observed and reported that the relationship was considered a safe base, and container from within which the therapeutic conversations and initial work took place. The findings support authors who assert that the therapy relationship is more than the construct of the alliance—the sum of bonds, goals, and tasks (Gelso, 2009; Gelso & Carter, 1985; Safran & Muran, 2006). It was important to client participants that their therapists were genuine, attended to them non-judgmentally, were patient in their approach and listening, were responsive, trustworthy, helpful, competent, and real. Therapists were intentional, sensitive and self-reflective in their efforts to track the state of their relationship with their clients. They did this by directly checking in with their clients about how they were doing together; asking for direction; trusting the clients lead and the process at times and actively taking the lead at other times; noticing and taking responsibility when they were misattuned; making efforts to regain comfort, safety by adjusting proximity, emotional closeness, and allowing relieving moments of levity. From the within-dyad analysis common process themes emerged that directly relate to the significance and function of a strong therapeutic relationship. First was paying attention to safety. Safety was both an ingredient and condition of a strong relationship and was actively built, fuelled, negotiated, and repaired when ruptured. This attention to comfort and safety allowed clients to be open and tolerate the vulnerability inherent in approaching and deepening into working with sensitive and conflict-related material. Two other important process themes that emerged were fueling the tank of togetherness and undoing aloneness. The sense of connection and solidarity that comes from sharing good feelings can strengthen the therapeutic relationship itself, and literally undo the feeling of being alone in our troubles. These dyads demonstrated how that occurs, and that a good measure of positive emotion comes directly from the connection and engagement of dyad partners in their relationship. Greenberg and Paivio (1997) suggest that without these good feelings, the alliance would not be strong enough to sustain therapeutic work. Bordin (1979) describes the alliance as consisting of tasks and bond, and suggests that without the bond it is harder for clients and therapists to agree on goals and tasks and engage productively. These cases demonstrate this theory in action. 187 Mutual impact. To restate from Chapter Three, inviting the voice of the other is central to the AEDP school, and to the hermeneut. By inviting the voice of the other we inherently influence and invite being influenced. We risk changing our mind, reformulating our ideas and beliefs. We risk being moved and touched, and we risk being wrong. These cases and the findings that came from the analyses highlight the person-to-person impact of client to therapist and therapist to client. These impacts occurred within and as a result of the real relationships between therapy dyad partners, therapeutic conversations, emotional connection, and therapeutic action. As stated above, the therapeutic relationship is a real relationship (Gelso & Carter, 1995), one in which each partner’s characteristics, presence, and actions directly impact one another. There were multiple examples of how therapists were touched and moved to feeling admiration, affection, compassion in response to an expression of vulnerability, a smile or a joke, a gesture, an effort, to name a few. Similarly, clients were impacted by their therapist’s care, attention, skilled interventions, disclosure, willingness to be light hearted, serious, and genuine. In terms of interventions, validation of client reality had high positive impact even beyond what the therapist may have been aware of. In one dyad, patient listening, gentle curiosity, acceptance and reassurance that the client’s exuberance was not too much for the therapist was transforming, allowing the client to realize it might be possible to be his full self in the presence of another. The unique way in which dyad partners were emotionally attuned and interpersonally connected was stamped with the personal signature of the individuals involved. Clients benefitted from the relational capacity of their therapists, that literally supported and scaffolded them as they worked through challenging material. The expression of gratitude also signaled impact. Clients expressed profound gratitude for the help they received from their therapists. Algoe and colleagues (Algoe, Haidt, & Gable, 2008; Algoe, & Stanton, 2012) have postulated, in the find, remind, and bind theory of gratitude, that gratitude is an emotion that is highly specific to special instances in which we feel the beneficial responsiveness of another towards our needs and preferences. In this model gratitude is understood to promote connection back to the helpful one by recognizing their good qualities. This further promotes a bond. The findings in this study elaborate Algoe et al.’s theory by providing several examples of how expressing gratitude unfolds in psychotherapy sessions. This has enormous implications for therapists and clients. As suggested by Fosha (2000), therapists often squirm in the face of compliments and gratitude from clients. This is a lost opportunity 188 across a number of domains, including the therapy relationship, client agency, and re-moralizing clients through seeing examples of the good in themselves and others. Not insignificant is the spiritual benefit. Linking the work on savoring here, we remember that thanksgiving and gratitude are intimately linked, and the process of thanksgiving is postulated to regulate gratitude (Bryant & Veroff, 2007; Bryant, Chadwick, & Kluwe, 2011). Unaccepted gratitude is a lost offering or gift that therapy fees cannot cover. The client loses an opportunity to regulate their gratitude, as does the therapist (being able to accept it, and possibly feeling grateful for being thanked). When gratitude is not accepted the giver is denied the pleasure of gifting something of value from themselves and sharing the profound connection of seeing what is light and good in self and other. The receiver may be considered to be dis-regulated around receiving gratitude, a mirror of their helpfulness as another human being, not just as a therapist. In addition, they lose the gift of the esteeming and valuing of their person and intentions. Another aspect of impact occurred around disclosure. While the relationships in these cases are clearly real relationships, they are also therapeutic relationships and still have an imbalance despite a relatively flat hierarchy in terms of power. Slavin and Kreigman (1998) assert that one way this imbalance arises is in the fact of the client taking most of the risks to be influenced. Clients enter a relationship with a person who is not kin, friend, colleague or mentor where influence is usually reciprocal. These cases provide a small but important window into how clients and therapists influence one another through disclosure. Both therapists disclosed aspects of their personal selves. Sometimes this was couched in therapeutic language like validation, at other times a more transparent sharing of personal circumstance was offered. Engaged understanding and co-created meaning. Nielsen and Krasniak (2015) and Lambie and Marcel (2002) emphasize that there are clear limitations on the awareness we have of our emotional experience, particularly when we are in the midst of it. Furthermore, reporting on our experiences in any depth alters the experience itself. Walking the line between eliciting experience and reflecting on it in therapeutic work, we are inevitably working with a moving target. That said, one of the goals of therapy is to examine past and present experience in order to understand our relationship to it, to become aware of and understand how we manage our experience, interpret it, act within and on it. In short, we are often seeking to change unwanted aspects of our past experience and current ways of being. The analysis of cases revealed several ways in which clients and therapists actively engaged together in therapeutic conversations to re- 189 experience, elaborate and together understand the significance and meaning of client experience and the therapeutic relationship. Each of the therapists, through an AEDP lens and practice, utilized the principles for working with emotion described by Greenberg (2012) and Greenberg and Watson (2005). Making implicit experience explicit and experiential by pendulating between eliciting emotion and reflecting on it facilitated clients in this study to gain greater clarity, new awareness and new understandings. This involved guiding clients to feel and accept their emotions, heighten or temper the intensity of some emotions, explore the meaning of the emotions, including what motivations might be created by the emotion. This process validates both the work of Watson (1996) and Mergenthaler (1996, 2008) in which the value of simultaneous experiencing (emotional arousal) and reflection on self-relevant material is more effective in facilitating change than cognitive understanding by itself. In addition, the process itself is similar to Mergenthaler’s (1996, 2008) therapeutic cycles model in which session processes occur in cycles of emotional arousal and intensity, and abstraction. When session productivity is high, emotional experiencing and reflection on relevant personal themes or conflictual material occur simultaneously, resulting in moments of new awareness, insight, and change. Mergenthaler links the broadening aspects of positive emotion in these therapeutic cycles to being open to new ideas and perspectives, and “working through” issues. He suggests that the narrowing focus of negative emotions has a seeking and deepening function. He postulates that clients and therapists work together to create moments of shift or change. Therapy partners move recursively from low emotional activation, to heightening and or eliciting emotional experience, deepening and retrieving memories, then to reflecting on experience while experiencing, making connections and having new insights. Therapists guide clients and/or initiate either broadening or deepening phases depending on what is happening in the session. Metatherapeutic processing was another type of making implicit experience explicit and experiential. The dyad partners frequently engaged in metatherapeutic processing to bring clarity to the micro-changes that were occurring within the sessions, and to explore how each was impacting the other in their work together. It is apparent in these cases that new understandings occurred and were created collaboratively by the participation and assumptions, meanings and experiences each dyad partner brings to the therapy endeavor. On one part are the choice of material, the influence of 190 pre-understandings, and willingness to share emergent experience by clients. On the other part, are the actions of the therapists and the pre-understanding that steer the choice of which emotions to heighten, and explore, which to bypass, which thoughts and beliefs to validate, challenge or question. Taken together these influences steered the direction of the sessions, and speak to the social, and contingent way in which understanding is created between therapy partners. It also demonstrates the partial and fallible nature of understanding in psychotherapy. With each step a “good enough,” partial, or tentative meaning occurs. There is always more to understand. From a hermeneutic stance we may conceptualize new awareness and understanding as resulting from the prolonged interconnected and overlapping engagement of participants within the hermeneutic circle. Our very existence and being is only understood within its context. Each member of the dyad leaned into the conversation and therapeutic action with their pre-understandings, engaged with the other, and worked towards making their pre-understandings and experience explicit, resulting in a fusion of horizons. Similarly, I entered the circle repeatedly. The final interpretation represents active engagement with an enriching description of local therapeutic action and the larger frame of theory. I leaned in to the analysis with my questions, assumptions, and worldview, and was also impacted, hearing less familiar voices speak louder and clearer. Privileging positive emotion. In AEDP the therapist is encouraged to actively look for, attend to, heighten, and explore any aspect or glimmer of positive experience in the client or in the client’s narrative (Russell, 2015; Russell & Fosha, 2008). These types of experiences are considered to be markers of what is working well, such as resilience, capacity for relatedness and connection, love or care, friendship, interest. They are targets for clinical work because they are considered to be: a) points of strength from which to platform work with parts of self that are not working so well; b) part of normal social relatedness; c) part of the healing process as markers and ingredients of change. Greenberg (2012) and Fredrickson, Mancuso, Branigan, and Tugdale (2002) postulate that positive emotion can be accessed to undo distressing states or lessen their hold, opening the way for new states. This investigation provides an example for readers of how skilled AEDP therapists work with their clients’ positive emotions to bring about this type of transformation. Russell (2015) believes that when this type of experience is privileged and engaged it creates its own motivation to reproduce itself and build resilience (p. 100), a position consistent with Fredrickson’s (1998, 2001) broaden and build theory. 191 Cultural and historical influences. In line with E. Harmon-Jones, C. Harmon-Jones, Amodio, and Gable (2011) and Ekman (2003) there were several vivid examples of participants’ preferences for experiencing certain emotions. One example included a reluctance to express high intensity joy and exuberance in front of another. In addition, there were instances in which the participants expressed reluctance, uncertainty, and even active avoidance of expressions of success. The converse to this was also expressed as the need to “suck up” hardship, and suffer as a punishment. These preferences all seemed to express both individual preferences as well as learned collective attitudes such as being stoic, being an adult by suppressing needs and enduring hard things, paying back wrongs by suffering, and hiding success and good feelings. It was noteworthy that in choosing to privilege positive affect, these therapists assisted their clients to disrupt these taken-for-granted ways of being and examine these assumptions and biases, along with the impacts these positions and beliefs had on their clients’ lives. In addition, the therapists assisted their clients to hold the opposites of feeling good or being successful with the dis/ease of vulnerability and failure. These examples articulate and demonstrate the implications of our emotional preferences, as well as how these preferences can be explored in psychotherapeutic conversation. Methodological Contributions In responding to a call to better understand the impact on clients of therapists’ interventions and how micro processes unfold within psychotherapy sessions, this research project is innovative in two ways. First, the interpretive hermeneutic framework and case study approach are flexible enough and well suited to capture the interpersonal, conversational nature of how psychotherapy works in vivo. In addition, the voices of client, therapist, and researcher are brought forward as part of the overall interpretation and findings. Second, the IPR interviewing technique as it was carried out in this study is unique. This investigation demonstrates how effectively this technique captures the inner thoughts, feelings, motivations, intentions, and other less noticeable aspects of participants’ experiences during psychotherapy sessions. This highlighted how much convergence there was between these clients and therapists about what was occurring in the sessions. It also highlighted quieter, more hidden aspects of participants’ experience, sometimes revealing points of divergence, disagreement and even behaviour that was or had the potential to be at cross purposes. Accessing the private reflections 192 and observations of participants’ therapy experience by watching their therapy session with me, the researcher, enhanced the understanding of the phenomenon. Clinical Contributions As has been previously mentioned, this investigation provides practitioners with a vital, empathic, and contextual appreciation of how clients and therapists work with client positive emotional experience (Stiles, 2015). Multiple theories were presented to explain aspects of the phenomenon of positive emotional experience, as we understand it in the literature. This current study’s aim was to deepen and elaborate the understanding of the phenomenon of working with client positive emotional experience, and further, to encourage clinicians to come to their own conclusions about tracking and turning to positive emotion as a significant part of client experience and as fertile ground for therapy exploration. In addition, the rich detail within the cases provides a window and a local map for practitioners to better understand how this type of exploration proceeds in therapy sessions, as well as how some clients might respond. Reading actual therapy excerpts of how expert therapists worked with clients can be helpful for training and supervision of therapists, especially for those who are unfamiliar with how to implement such interventions. In this area one broad type of intervention stands out as important and useful for practice—making implicit experience explicit and experiential, and within this metatherapeutic processing. Making implicit experience explicit and experiential, is demonstrated many times in this research project, and speaks to two validated principles of therapeutic work. The first principle is granularity or differentiation of emotion. Assisting clients to recognize how they feel, why they feel the way they do, and what they can do or want to do with it or about it is a second order type of awareness that has been found to help with the regulation of negative emotion, and in particular with global distress (Feldman Barrett, Gross, Christensen, & Benvenuto, 2001; Pascual-Leone & Greenberg, 2007). Untangling this type of complexity is enormously helpful for clients in breaking cycles of undifferentiated, high intensity distress, building awareness, making new connections and understanding. The second principle is arousal and experiencing of emotion while reflecting. The benefits of pendulating between arousal, experiencing, and reflection is well established in the literature (Greenberg, 2002; Litrell, 1998; Whelton, 2004). Metatherapeutic processing, while unique to the AEDP school, has tremendous benefits. By working with the positive emotional experiences that often emerge when in-session gains and changes for the better occur, more positive emotions typically emerge 193 and may lead to a broadened perspective about the status of the therapeutic relationship, as well as clients’ own capacities and understandings. This type of intervention can be easily incorporated into any therapeutic approach. One additional implication for practice is directly related to the use of video recording in clinical practice across therapy approaches. The study findings suggest that the process of viewing a session videotape and/or interviewing a client afterwards had unintended beneficial effects. Two benefits stand out. First was a form of self-recognition experience that participants reported as surprising and delightful to them. One vivid example follows. C: (laughing) It is - It is weird that I’m laughing at exactly the same moments where I’m laughing in the video. R: Why is that? C: Well, it’s like I’m - I’m - I am who I am obviously cause like I’m having exact, I want to say exactly the same things as I’m saying in the video and I’m laughing at exactly the same points. R: Yeah. C: It’s quite, um, it’s quite funny actually. (laughing) R: You’re surprised. C: Well, it’s exactly me. R: Yeah. C: Like it’s so me. R: Hm. C: And … R: You recognize yourself. C: Yeah, I recognize myself. The minute I started laughing in the video, I’m like oh I start laughing, you know, like it’s - it’s quite um disarming actually. (laughing) R: Is disarming good or bad? C: In a good way, I think. R: In a good way. Yes. C: Yeah, in a good way because I think that I feel some sense of integrity. Like I look at that and I’m like “Yeah, that’s pretty much how I am.” (laughing) Obviously because I’m laughing at exactly the same moments as I am in the video. I almost feel like I’m about to have the same facial expressions as I’m just about to have in the video. So, anyways. Quite interesting. Offering this type of experience to a client has significant potential. What we hear here is a person recognizing herself as a whole, integral person with congruence. At that point in the interview she was watching herself celebrate with her therapist about her new relationship, how happy she was, and how happy he was for her. It validated her memory of what happened in the session and she recognizes herself laughing, having fun, in a sense savoring her positive 194 experience and newly found relationship success, one that is mirrored in her relationship with her therapist. The second benefit that appeared to accrue for client participants from watching the video recording of their sessions was deepening or possibly anchoring the work. In the example below, we can hear the client participant practicing with me, the researcher, what he had been working on in session. He appears to be having another experience of working at staying present with me, the researcher, while he is immersed in his own private emotional experience of watching himself talk about and feel pride about managing his current situation. C: that - that he kinda brought to light. And I’m, it’s not as profound as as it was at the beginning because now I - I am more easily able to kind of feel it and recognize it and be reflective at the same time I was being with him. R: Uh hm. C: Um, so I think that was the positive event that just happened there for me, full circle. (laughing) R: Uh hm. That’s great. Yeah, yeah. And how are you doing watching this? … C: Yeah. Uh hm. R: You know, how are you doing, so far, with the interview? C: Yeah, good. R: You’re good, okay. Good. C: I feel like it, it takes a lot of energy to share, though. R: Yeah. You’re feeling that? C: Yeah, it takes a lot of energy to be reflective, in the first place, with a camera. R: Yeah. C: And then to be reflective about my reflections with another camera is like, “Okay.” It’s just like, I really like it. It’s a cool experience, but at the same time it’s like one minute at a time. Just look at one minute at a time. (laughing) R: Okay. C: You know. R: Okay. C: Because it - it ah it’s definitely different, you know. It’s definitely different. R: Yeah. Yeah. C: It’s interesting. It - it would be really easy to just shut down. To be like, “There’s a camera.” You know? In one final example the client participant reported that reading the findings chapter after 36 months, had an impact on her. She said: I felt privileged to be able to visit a painful past experience with a sympathetic other, with respect. It was almost like a gentle inquiry, not quite like therapy. … It was wonderful to see again the start of my change in thinking, the beginning of strength building which continues. You and [therapist’s name] were co-conspirators. … I noticed again how 195 much it meant to me to be listened to. The way you and [my therapist] treated me made a big difference. The first two examples are taken from the interview transcripts, and the third example is a quote from the follow-up member check. These types of findings suggest that viewing video recordings of therapy sessions with clients may extend and consolidate therapeutic gains. Limitations In response to challenges during the recruitment and analysis phases, two changes occurred in the implementation of the design as it was originally planned. First, a change was made to recruitment. In the original proposal it was planned that three to five psychotherapy dyads would be recruited. Due to difficulty in recruiting therapist participants who believed they could also assist with recruiting clients from their practice, the criteria were relaxed somewhat, and one therapist participant recruited two clients from his practice. By making this change the study obtained its minimum required cases. There were three separate dyads, two of which had the same therapist participant. The implication of this change is that diversity of how the therapist participants interpreted and enacted their theoretical clinical orientations was sacrificed. The study sample was small and somewhat homogeneous from a social and cultural point of view. All participants were Caucasian, well educated, articulate, and relatively advantaged from a “white” socioeconomic perspective. The therapists were both men. As a result, it is acknowledged that the conversations, understandings and meanings other clients and therapists from diverse cultural, individual identity, social, educational, and economic backgrounds would hold about their experiences in psychotherapy may be very different from these participants. For situational, personal and health reasons the follow-up member checks were conducted 36 months after the interviews. While all participants agreed to continue in their participation in the study, and completed a follow-up member check, in two cases the member check was done through brief email check-in and response to the questions posed. The implication of this change was possibly losing more complete, and detailed feedback about the resonance, and meaningfulness of the findings. Self-selection is another issue to be considered in interpreting these findings. The sample was not an easy one to obtain, resulting in one therapist recruiting two clients. The participants each expressed their keen interest in the study, and were willing to share a private piece of their therapeutic work. It is interesting and noteworthy that two client participants explicitly stated 196 why they were inclined to participate. One expressed that the strong therapeutic relationship and trust in her therapist positively influenced her decision. In fact, she conferred that trust directly to me as previously discussed in Chapter Three by naming our connection as being the third part of a triangle. Another client participant reported that because she has conducted research herself, she likes to volunteer occasionally. In addition, she mentioned how challenging she thought it might be for me to recruit participants given what was required in terms of the time commitment to the interview and follow-up member check. Given these factors these participants may be considered to be ideal participants, aware of the purpose of the study, capable, willing, and motivated to carefully share and reflect on their experiences in as full a manner as possible. An interpretive hermeneutic approach was used to explore and highlight the phenomenon of clients and therapists working with client positive emotion in therapy sessions because few studies have focused on this previously. The aim of this inquiry was to provide an enriching exploration of the phenomenon for readers, in particular clinicians, rather than to build theory or explain causal relationships between positive emotion and therapy outcomes. As such, this project forwards my interpretation, co-created with the participants, knowing that other valid and different interpretations are possible. The findings of this study cannot be considered to represent therapeutic effects over time. The therapeutic conversations examined occurred in single sessions and represent a snapshot of what unfolds when therapeutic dyads engage in utilizing client positive affect. No conclusions may be drawn about how the perceived benefits for clients, that were described in the previous chapter, relate to overall therapy goals of the clients and therapists, or even how this one session contributed to overall therapy goals. It is hoped that this rich, vivid representation of the data allows readers to form their own conclusions about how the final interpretation was made, as well as encourages readers to make links from these findings to their own practice arena. While both therapist participants practiced from a similar theoretical background, AEDP and EFT, there was no attempt in the research design to ensure these therapists were fully certified in AEDP, or practiced in a consistent way. It is possible that other therapists, even other therapists who practice from an AEDP orientation, may have steered the process in a different way. This relaxed entry criterion was implemented in the service of obtaining the sample. 197 Implications for Future Research This study adds to the literature that is examining the role of positive emotion in psychotherapy, specifically, how clients and therapists work together to process positive emotion. The therapist participants both practiced from an attachment-based perspective. It would be useful to track how therapy dyads work with and utilize positive emotion in dyads where the therapists practice from different therapeutic modalities to explore if different processes and therapeutic gains are evident. In addition, both therapists were male and the therapy dyads were all quite homogeneous in terms of their socio-economic and ethnic characteristics. More diverse samples would perhaps reveal differences in how clients and therapists work with different positive emotions, as well as how therapists and clients are mutually impacting one another and the therapeutic processes. Given that most courses of psychotherapy span over weeks, months and sometimes years, it would be helpful for future research to track these processes over full courses of therapy, looking at how these processes affect the therapeutic relationship in early, middle and late stages of the therapy, when it is most productive to work with positive affect. In addition, two other avenues of inquiry would be greatly enhanced by longitudinal study—understanding how dyad partners impact one another over time, and how culture affects positive emotional experience and expression. This study was a preliminary exploration into how clients and therapists work together with client positive emotion. The aim of the study was to enrich readers’ sense of the participants’ experiences and the therapeutic processes rather than build a theory of how working with positive emotion contributes to change in a session. To extend this line of inquiry, employing an alternate research strategy such as task analysis would allow for a rational working model to be established and subsequently tested with a larger sample. The study could also be extended by analyzing the data to specifically address how working with positive emotion relates to in-session change processes, and how these processes contribute to session outcome and therapeutic gain. The unique process theme of imagining more to scaffold new experience, identified in the within-dyad analysis, is a fertile area for further research. Using imagination in psychotherapy is not a new idea. Other examples of using imagination in this way in therapy include: the miracle question in solution-focused therapy (de Shazer and Dolan, 2007); imaginal exposure; and 198 guided imagery. The utilization of imagination to specifically scaffold experience until the client is able to experience what they are imagining without assistance, as was done by one dyad in this inquiry, takes advantage of the hypothesis that remembering cannot be distinguished from imagining by the brain (Schacter, Addis, Hassabis, Martin, Spreng, & Szpunar, 2012). The intervention has interesting implications for psychotherapy because it begins to get at a way to create new experience and memory that may potentially compete with or mitigate the effects of other experience and memories. Exploring how clients and therapists use imagining more for therapeutic gain across psychotherapy schools from the perspective of both therapeutic dyad partners would be helpful for therapists in knowing how and when to use such interventions. Conclusion This investigation aimed to explore how clients and therapists work with and utilize client positive emotion in psychotherapy sessions. The hermeneutic interpretive framework and multiple case study approach brought three cases into sharp view and provided a rich, contextualized picture of how these therapy dyad partners worked productively with client positive emotions. The unique features of the IPR interviewing technique enabled first person accounts of both client and therapist to inform the reader about the benefits and potential of privileging client positive emotion. In addition, the research interview itself was found to be therapizing, suggesting that the revisiting of psychotherapy sessions through reviewing video recordings is not only beneficial and value-added for therapists in supervision, it has the potential to extend and deepen the therapeutic work. Finally, this research validated that the real relationship between these clients and therapists was responsible for much of the personal impact clients and therapists had on one another beyond what is usually expected with the construct of the alliance bond, tasks and goals. 199 References Algoe, S. B., Haidt, J., & Gable, S. L. (2008). Beyond reciprocity: Gratitude and relationships in everyday life. Emotion, 8, 425-429. doi:10.1037/1528-3542.8.3.425 Algoe, S. B., & Stanton, A. L. (2012). Gratitude when it is needed most: Social functions of gratitude in women with metastatic breast cancer. Emotion, 1, 1630168. doi:10.1037/a0024024 Asby, G. F., Isen, A.F., & Turkin, A. U. (1999). A neuropsychological theory of positive emotion and its influence on cognition. Psychological Review, 106, 529-550. doi: 10.1037/0033-295X.106.3.529 Bachelor A. (1995). Clients' perception of the therapeutic alliance: A qualitative analysis. Journal of Counseling Psychology, 42, 323-337. doi:10.1037/0022-0167.42.3.323 Barrett, L. F. (2006a). Solving the emotional paradox. Personality and Social Psychology Review, 10, 20-46. doi:10.1207/s15327957pspr1001_2 Barrett, L. F. (2006b). Are emotions natural kinds? Perspectives on Psychological Science, 1, 28-58. doi:10.1111/j.1745-6916.2006.00003.x Barratt, L. F., Mesquita, B., Ochsner, K. N., & Gross, J. J. (2007). The experience of emotion. Annual Review of Psychology, 58, 373-403. doi:10.1146/annualrev.psych.58.110405. 085709 Baumeister, R. F., Bratslavsky, E., Finkenauer, C., & Vohs, K. D. (2001). Bad is stronger than good. Review of General Psychology, 4, 323-370. doi:10.1037//1089-2680-5.4.323 Berridge, K. C., & Winkielman, P. (2003). What is an unconscious emotion: The case for unconscious 'liking'. Cognition and Emotion, 17, 181-211. doi:10.1080/ 02699930244000272 Bleiberg, K. L., & Markowitz, J. C: (2008). Interpersonal psychotherapy for depression. In D. Barlow (Ed.), Clinical handbook of psychological disorders (pp. 306-327). New York, NY: The Guilford Press. Bloom, B. S. (1954). The thought process of students in discussion. In S. J. French (Ed.), Accent on teaching: Experiments in general education.(pp. 23-46). New York, NY: Harper & Brothers. 200 Bodenhausen, G. V., Kramer, G., Süsser, K. (1994). Happiness and stereotypic thinking in social judgment. Journal of Personality and Social Psychology, 66, 621-632. doi:10.1037/ 0022-3514.66.4.621 Bohart, A. C. (1977). Role playing and interpersonal conflict reduction. Journal of Counseling Psychology, 24, 15-24. doi:10.1037/0022-0167.24.1.15 Bohart, A. C. (1980). Toward a cognitive theory of catharsis. Psychotherapy: Theory, Research and Practice, 17, 192-204. doi:10.1037/h0085911 Bohart, A. C., & Greenberg, L. S. (1997). Empathy reconsidered. Washington, DC: American Psychological Association. Bonnano, G. A., & Keltner, D. (1997). Facial expressions of emotion and the course of conjugal bereavement. Journal of Abnormal Psychology, 106, 126-137. doi:10.1037/0021 843X.106.1.126 Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16, 252-260. doi:10.1037/h0085885 Borkovec, T. D., Ruscio, A. M. (2001). Psychotherapy for generalized anxiety disorder. Journal of Clinical Psychiatry, 62(suppl 11), 37-42. Retrieved August 5, 2010 from: http://www.psychiatrist.com/default2.asp#. doi.org/10.1176/appi.books. 9781585625048.gg19 Braakmann, D. (2014). Historical paths in psychotherapy research. In O. C. G. Gelo, A. Pritz, & B. Rieken. (Eds.), Psychotherapy research: Foundations, process and outcome (pp.39- 65). New York, NY: Springer. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. doi:10.1191/1478088706qp063oa Bridges, M. R. (2006). Activating the corrective emotional experience. Journal of Clinical Psychology: In Session, 62, 551-568. doi:10.1002/jclp.20248 Brown, T.A., Chorpita, B. F., & Barlow, D. H. (1998). Structural relationships among dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect, and autonomic arousal. Journal of Abnormal Psychology,107, 179-192. doi:10.1037/0021-843X.107.2.179 Bridges, M. R. (2006). Activating the corrective emotional experience. Journal of Clinical Psychology: In Session, 62, 551-568. doi:10.1002/jclp.20248 201 Bryant, F. B. Veroff, J. (2007). Savoring: A new model of positive experience. Mahwah, NJ: Lawrence Erlbaum Associates, Inc. Bryant, F. B., Chadwick, E. D., & Kluwe, K. (2011). Understanding the processes that regulate positive emotional experience: Unsolved problems and future directions for theory and research on savoring. International Journal of Wellbeing, 1, 107-126. doi:10.5502/ ijw.v1i1.18 Burns, A. B., Brown, J. S., Sachs-Ericsson, N., Ashby Plant, E., Curtis, J. T., Fredrickson, B. L., & Joiner, T. (2007). Upward spirals of positive emotion and coping: Replication, extension, and initial exploration of neurochemical substrates. Personality and Individual Differences, 44, 360-370. doi:10.1016/j.paid.2007.08.015 Burum, B. A., & Goldfried, M. R. (2007). The centrality of emotion to psychological change. Clinical Psychology: Science and Practice, 14, 407-413. doi:10.1111/j.1468- 2850.2007.00100.x Butterfield, L., Borgen, W., & Amundson, N. (2009). Impact of a qualitative interview on workers' view of their situation. Canadian Journal of Counselling, 43, 120-130. Retrieved January 30, 2008 from: http://cjc-rcc.icaap.org/index-e.html. doi: 10.1002/j.2161- 0045.2005.tb00661.x Cacioppo, J. T., & Bernston, G. G. (1994). Relationship between attitudes and evaluative space: A critical review, with emphasis on the separability of positive and negative substrates. Psychological Bulletin, 115, 401-423. doi:10.1037/0033-2909.115.3.401 Cacopppo, J. T., Gardner, W. L., & Bernston, G. G. (1999). The affect system has parallel and integrative processing components: Forms follow function. Journal of Personality and Social Psychology, 5, 839-855. doi:10.1037/0022-3514.76.5.839 Campos, J. J., Frankel, C. B., & Camras, L. (2004). On the nature of emotion regulation. Child Development, 75, 377-394. doi:10.1111/j.1467-8624.2004.00681.x Carkhuff, R. R. (1969). Critical variables in effective counselor training. Journal of Counseling Psychology, 16, 238-245. doi:10.1037/h0027223 Carryer, J. R., & Greenberg, L. S. (2010). Optimal levels of emotional arousal in experiential therapy of depression. Journal of Consulting and Clinical Psychology, 78, 190-199. doi: 10.1037/aoo18401 202 Carver, C. S. (2001). Affect and the functional bases of behavior: On the dimensional structure of affective experience. Personality and Social Psychology Review, 5, 345-356. doi:10.1207/S15327957PSPR0504_4 Carver, C. S. (2003). Pleasure as a sign you can attend to something else: Placing positive feelings within a general model of affect. Cognition and Emotion, 17, 241-261. doi: 10.1080/02699930244000291 Carver, C. S., & Scheier, M. F. (1990). Origins and functions of positive and negative affect: A control-process view. Psychological Review, 97, 19-35. doi:10.1037/0033-295X.97.19 Castonguay, L. G., & Beutler, L. E. (Eds.). (2006). Principles of therapeutic change that work. New York: Oxford University Press. Chambless, D. L. (1996). In defense of dissemination of empirically supported psychological interventions. Clinical Psychology: Science and Practice, 3, 230-235. doi:10.1111/j.1468- 2850.1996.tb00074.x. Chambless, D. L. & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716. doi:10.1146/annurev.psych.52.1.685 Clore, G. L., & Huntsinger, J. R. (2007). How emotions inform judgment and regulate thought. Trends in Cognitive Science, 11(9), 393-399. doi:10.1016/j.tics.2007.08.005 Clore G. L., Huntsinger, J. R. (2009). How the object of affect guides its impact. Emotion Review, 1, 39-54. doi:10.1177/1754073908097185 Cohn, M. A., Fredrickson, B. L., Brown, S. l., Mikels, J. A., & Conway, A. M. (2009). Happiness unpacked: Positive emotions increase life satisfaction by building resilience. Emotion,9, 361-368. doi:10.1037/a0015952 Columbetti, G. (2005). Appraising valence. Journal of Consciousness Studies, 12, 105-126. Retrieved May 5, 2011 from: http://www.imprint.co.uk/jcs.html Condon, P., Wilson-Mendenhiall, C. D., & Feldman Barrett, L. (2014). What is positive emotion?: The psychological construction of pleasant fear and unpleasant happiness. In M. M. Tugdale, M. N. Shiota, & L. D. Kirby (Eds.), Handbook of positive emotions (pp. 60-81). New York, NY: The Guilford Press. 203 Conroy, S. A. (2003). A pathway for interpretive phenomenology. International Journal of Qualitative Methods, 2(3), 1-43. Retrieved March 27, 2006 from: http://www.ualberta.ca/ ~iiqm/ backissues/2_3final/ pdf/conroy.pdf Costa, P.T., McCrae, R.R. (1980). Journal of personality and Social Psychology, 38(1), 668-678. doi:10.1037/0022-3514.38.4.668 Crotty, M. (1998). The foundations of social research. Thousand Oaks, CA: Sage Publications. Darwiche, J., de Roten, Y., Stern, D. J., Crettaz von Roten, F., Corboz-Warnery, A., & Fivaz- Depeursinge, E. (2008). Mutual smiling episodes and therapeutic alliance in a therapist- couple discussion task. Swiss Journal of Psychology, 67, 231-239. doi:10.1024/1421- 0185.67.231 Darwin, C. (1872/1955). The expression of the emotions in man and animals. New York, NY: Philosophical Library. Davidson, R. J., & Begley, S. (2012). The emotional life of your brain: How its unique patterns affect the way you think, feel, and live—and how you can change them. New York, NY: Hudson Street Press. Depraz, N. (2001). The Husserlian theory of intersubjectivity as alterology. Journal of Consciousness Studies, 8(5-7), 169-178. Retrieved May 31, 2010 from: http://www.imprint.co.uk/jcs.html de Roten, Y., Drapeau, M., & Michel, L. (2008). Are there emotions in Short-term Dynamic Psychotherapy or is it all Freude-less? Journal of Psychotherapy Integration, 18, 207- 221. doi:10.1037/1053-0479.18.2.207 De Shazer, S., & Dolan, Y. (2007). More than miracles: The state of the art of solution-focused brief therapy. New York, NY: The Hawthorn Press. Diener, E. (1999). Introduction to the special issue on the structure of emotion. Journal of Personality and Social Psychology, 76, 803-804. doi:10.1037/0022-3514.76.5.803 Diener, E., & Iran-Nejad, A. (1986). The relationship in experience between various types of affect. Journal of Personality and Social Psychology, 50, 1031-1038. doi:10.1037/0022- 3514.50.5.1031 Dowling, M. (2007). From Husserl to van Manen. A review of different phenomenological approaches. International Journal of Nursing Science, 44, 131-142. doi:10.1016/ j.ijnurstu.2005.11.026 204 Ehrenreich, J. T. (2007). The role of emotion in psychological change. Clinical Psychology: Science and Practice, 14, 422-428. doi:10.1111/j.1468-2850.2007.00102.x Ekman, P. (2003). Emotions revealed: Recognizing faces and feelings to improve communication and emotional life. New York, NY: Henry Holt and Company. Ekman, P., & Friesen, W. V. (1975). Unmasking the face: A guide to recognizing the emotions from facial cues. Englewoods, NJ: Prentice Hall. Elliott, R. (1986). Interpersonal process recall (IPR) as a psychotherapy process research method. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp.503-527). New York, NY: The Guilford Press. Elliott, R., & James, E. (1989). Varieties of client experience in psychotherapy: An analysis of the literature. Clinical Psychology Review, 9, 443-467. doi:10.1016/0272- 7358(89)90003-2 Estrada, C. A., Isen, A. M., & Young, M. J. (1997). Positive affect facilitates integration of information and decreases anchoring in reasoning among physicians. Organizational behavior and Human Decision Processes, 72, 117-135. doi:10.1006/obhd.1997.2734 Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of Consulting and Clinical Psychology, 16, 319-324. doi:10.1037/h0063633 Feldman Barrett, L., Gross, J., Christensen, T. C., & Benvenuto, M. (2001). Knowing what you’re feeling: Mapping the relation between emotion differentiation and emotion regulation. Cognition and Emotion, 15, 713-724. doi:10.1080/02699930143000239 Fitzpatrick, M. R., Janzen, J., Chamodraka, M., & Park, J. (2006). Client critical incidents in the process of early alliance development: A positive emotion-exploration spiral. Psychotherapy Research, 16, 486-498. doi:10.1080/10503300500485391 Fitzpatrick, M. R., & Stalikas, A. (2008). Positive emotions as generators of therapeutic change. Journal of Psychotherapy Integration, 18, 137-154. doi:10.1037/1053-0479.18.2.137 Folkman, S. (2008). The case for positive emotions in the stress process. Anxiety, Stress & Coping, 21, 3-14. doi:10.1080/10615800701740457 Folkman, S., & Moskowitz, J. T. (2000). Stress, Positive Emotion, and Coping. Current Directions in Psychological Science, 9(4), 115-118. doi:10.1111/1467-8721.00073 Fosha, D. (2000). The transforming power of affect: A model for accelerated change. New York, NY: Basic Books. 205 Fosha, D, (2008). Transformance, recognition of self by self, and effective action. In K. J. Schneider (Ed.), Existential-integrative psychotherapy: Guideposts to the core of practice (pp. 290-320). New York, NY: Routledge. Fredrickson, B. L. (1998). What good are positive emotions? Review of General Psychology, 2, 300-319. doi:10.1037/0003-066X.56.3.218 Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden- and-build theory of positive emotions. American Psychologist, 56, 218-226. doi:10/1037//0003.066X.56.3.218 Fredrickson, B. L. (2013). In P. Levine & A. Plant(Eds.), Advances in social experimental psychology (Vol.47, pp.1-53). San Diego, CA: Academic Press. Fredrickson, B. L., & Branigan, C. (2005). Positive emotions broaden the scope of attention and thought–action repertoires. Cognition and Emotion, 19, 313-332. doi:10.1080/ 02699930441000238 Fredrickson, B. L. & Cohn, M. C. (2008). Positive emotions. In M. Lewis, J. M. Haviland-Jones, & L. Barrett (Eds.), Handbook of Emotions (3rd ed., pp. 777-796). New York, NY: The Guilford Press. Fredrickson, B. L., Cohn, M. C., Coffey, K. A., Pek, J., & Finkel, S. M. (2008). Open hearts build lives: Positive emotions, induced through loving-kindness meditation, build consequential personal resources. Journal of Personality and Social Psychology, 95, 1045-1062. doi:10.1037/a0013262 Fredrickson, B. L., & Joiner, T. (2002). Positive emotions trigger upward spirals toward emotional well-being. Psychological Science, 13, 172-175. Retrieved May 12, 2007 from: http://www.blackwellpublishing.com/journal.asp?ref=0956-7976 doi:10.1111/1467- 9280.00431 Fredrickson, B. L., Levenson, R. W. (1998). Positive emotions speed recovery from the cardiovascular sequelae of negative emotions. Cognition and Emotion, 12, 191-220. doi:10.1080/026999398379718 Fredrickson, B. L., Mancuso, R. A., Branigan, C, & Tugdale, M. M. (2000). The undoing effect of positive emotions. Motivation and Emotion, 24, 237-257. Retrieved November 4, 2008 from: http://www.springerlink.com/home/main.mpx. doi:10.1023/A: 1010796329158. 206 Fredrickson, B. L., Tugdale, M. M., Waugh, C. E., & Larkin, G. R. (2003). What good are positive emotions in crisis? A prospective study of resilience and emotions following the terrorist attacks on the United States on September 11th, 2001. Journal of Personality and Social Psychology, 84, 365-376. doi:10.1037/0022-3514.84.2.365 Freeman, S. (2008). Hermeneutics. In L. M. (Ed). The Sage encyclopedia of qualitative research methods (Vol. 1 & 2, pp. 385-388). Los Angeles, CA: Sage Publications, Inc. Frijda, N. H. (1986). The emotions: Studies in emotion and social interaction. New York, NY: Cambridge University Press. Gable, P. A., & Harmon-Jones, E. (2008) Approach-motivated positive affect reduces breadth of attention. Psychological Science, 19, 476-482. doi:10.1111/j.1467-9280.2008.02112.x. Gable, P. A., & Harmon-Jones, E. (2010b). The effect of low versus high approach-motivated positive affect on memory for peripherally versus centrally presented information. Emotion, 10,599-603. doi:10.1037/a0018426 Gable, P. A., & Harmon-Jones, E. (2010a). Late positive potential to appetitive stimuli and local attentional bias.. Emotion, 10,441-446. doi:10.1037/a0018425 Gadamer (2004). Truth and method. (2nd Rev. ed.), (J. Weinshaner & D. G. Marshall, Trans). London, United Kingdom: Sheed & Ward. (Original work published 1975). Gasper, K., & Clore, G. L. (2002). Attending to the big picture: Mood and global versus local processing of visual information. Psychological Science, 13(1), 34-40. Retrieved February 21, 2010 from: http://www.jstor.org/stable/40063692 Garland, E. L., Fredrickson, B., Kring, A. M., Johnson, D. P., Meyer, P. S., & Penn, D. l. (2010). Upward spirals of positive emotions counter downward spirals of negativity: Insights from the broaden-and-build theory and affective neuroscience on the treatment of emotion dysfunctions and deficits in psychopathology. Clinical Psychology Review, 30, 849-864. doi:10.1016/j.cpr.2010.03.002 Gelso, C. J. (2009). The real relationship in a postmodern world: Theoretical and empirical explorations. Psychotherapy Research, 19, 253-264. doi:10.1080/10503300802389242 Gelso, C. J., & Carter, J. A. (1985). The relationship in counseling and psychotherapy: Components, consequences, and theoretical antecedents. The Counselling Psychologist, 13, 155-243. doi:10.1177/0011000085132001 207 Gershefski, J. J., Arnkoff, D. B., Glass, C. R., & Elkin, I. (1996). Clients’ perceptions of treatment for depression: 1. Helpful aspects. Psychotherapy Research, 6, 233-247. doi:10.1080/10503309612331331768 Gervais, M., & Wilson, D. S. (2005). The evolution and functions of laughter and humor: A synthetic approach. The Quarterly Review of Biology, 80, 395-430. Retrieved from: http://www.journals.uchicago.edu/. doi:10.1086/498281 Goldfried, M. (2007). What has psychotherapy inherited from Carl Rogers? Psychotherapy: Theory, Research, Practice, Training, 44, 249-252. doi:10.1037/0033-3204.44.3.249 Goldman, R. N., Greenberg, L. S., & Angus, L. (2006). The effects of adding emotion-focused interventions to the client-centered relationship conditions in the treatment of depression. Psychotherapy Research, 15, 537-549. doi:10.1080/10503300600589456 Gottman, J. M. (1999). The marriage clinic: A scientifically-based marital therapy. New York, NY: W. W. Norton & Company. Gottman, J. M., and Krokoff, L.J., (1989). The relationship between marital interaction and marital satisfaction: A longitudinal view. Journal of Consulting and Clinical Psychology, 57, 47-52. doi:10.1037/0022-006X.57.1.47 Gottman, J. M., & Levenson, R.W., (1986). Assessing the role of emotion in marriage, Behavioral Assessment, 8, 31-48. Retrieved June 11, 2016 from: http://socrates. berkeley.edu/~ucbpl/ publications.html. doi.org/10.1037/0022-006X.57.1.47 Graham, M. D., Young, R. A., Valach, L., & Wood, R. A. (2008). Addiction as a complex social process: An action theoretical perspective. Addiction Research and Theory, 16(2), 121- 133. doi:10.1080/16066350701794543 Green, D. P., Salovey, P., & Truax, K. M. (1999). Static, Dynamic, and Causative Bipolarity of Affect. Journal of Personality and Social Psychology, 76, 856-867. doi:10.1037/0022- 3514.76.5.856 Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work through their feelings. Washington, DC: American Psychological Association. Greenberg, L. S. (2007). A guide to conducting a task analysis of psychotherapeutic change. Psychotherapy Research, 17, 15-30. doi: 10.1080/10503300600720390 Greenberg, L. (2008). Emotion and cognition in psychotherapy: The transforming power of affect. Canadian Psychology, 49(1), 49-59. doi:10.1037/0708-5591.49.1.49 208 Greenberg, L. (2012). Emotions, the great captains of our lives: Their role in the process of change in psychotherapy. American Psychologist, 67, 697-707. doi:10.1037/a0029858 Greenberg, L. S., Auszra, L., & Herrmann, I. R. (2007). The relationship among emotional productivity, emotional arousal and outcome in experiential therapy of depression. Psychotherapy Research, 17, 482-493. doi: 10.1080/10503300600977800 Greenberg, L. S., & Paivio, S. C. (1997). Working with emotions in psychotherapy. New York, NY: The Guilford Press. Greenberg, L. S., & Pascual-Leone, A. (2006). Emotion in psychotherapy: A practice-friendly research review. Journal of Clinical Psychology, In Session, 63, 611-630. doi:10.1002/ jclp.20252 Greenberg, L. S., & Pinsof, W. M. (1986). Process research: Current trends and perspectives. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 3-20). New York, NY: Guilford Press. Greenberg, L. S., & Safran, J. D. (1987). Emotion in psychotherapy: Affect, cognition, and the process of change. New York, NY: The Guilford Press. Greenberg, L. S., & Watson, J. (2005). Emotion-focused therapy of depression. Washington, DC: American Psychological Association. Gross, J. J. (Ed.). (2007). Handbook of emotional regulation. New York, NY: The Guilford Press. Gurman, A. S. & Messer, S. B. (2003). Essential psychotherapies: Theory and practice (2nd ed.). New York, NY: The Guilford Press. Hadjistavropoulos, T., & Smythe, W. E. (2001). Elements of risk in qualitative research. Ethics & Behavior, 11, 163-174. Retrieved September 15, 2011 from: http://collections.lib. uwm.edu/cipr/image/16.pdf. doi:10.1207/S15327019EB1102_4 Hanson, R. (2011). Just one thing. Oakland, CA: New Harbinger Publications, Inc. Hanson, R. (2013). Hardwiring happiness: The new brain science of contentment, calm, and confidence. New York, NY: Harmony. Hardy, T. (1886). A memory of William Barnes. In The Last Signal. Retrieved March 28, 2016 from: http://genius.com/Thomas-hardy-the- last-signal-annotated 209 Harmon-Jones, E., Harmon-Jones, C., Amodio, D. M., & Gable, P. (2011). Attitudes towards emotions. Journal of Personality and Social Psychology, 101, 1332-1350. doi:10.1037/ a0024951 Harker, & Keltner, D. (2001). Expressions of Positive Emotion in Women's College Yearbook Pictures and Their Relationship to Personality and Life Outcomes Across Adulthood. Journal of Personality and Social Psychology, 80, 112-124. doi:10.1037//0022- 3514.80.1.112 Haverkamp, B. E. (2005). Ethical perspectives on qualitative research in applied psychology. Journal of Counseling Psychology, 52, 146-155. doi:10.1037/0022-0167.52.2.146 Haverkamp, B. E., & Young, R. A. (2007). Paradigms, purpose, and the role of the literature: Formulating a rationale for qualitative investigations. The Counseling Psychologist, 35, 265-294. doi:10.1177/0011000006292597 Heesaker, M., Bradley, M. M. (1997) Beyond feelings: Psychotherapy and emotion. The Counseling Psychologist, 25, 201-219. doi:10.1177/0011000097252003 Hermeneutic. (n.d.). In Online etymology dictionary. Retrieved August 19, 2011 from: http://www.etymonline.com/index.php?search-hermeneut&searchmode-none Hill, C. E., & Corbett, M. M. (1993). A perspective on the history of process and outcome research in counseling psychology. Journal of Counseling Psychology, 40, 3-24. doi:10.1037/0022-0167.40.1.24 Hill, C. E., O'Grady, K. E. Balenger, V., Busse, W., Falk, D. R., Hill, M., Rios, P., & Taffe, R. (1994). Methodological examination of videotape-assisted reviews in brief therapy: helpfulness ratings, therapist intentions, client reactions, mood, and session evaluation. Journal of Counseling Psychology, 4, 236-247. doi:10.1037/0022-0167.41.2.236 Hill, C. E., & Lambert, M. J. (2004). Methodological issues in studying psychotherapy processes and outcomes. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behaviour change (5th ed., pp. 84-135). New York, NY: John Wiley & Sons, Inc. Hill, C. E., Thompson, B. J., & Williams, E. N. (1997). A guide to conducting consensual qualitative research. The Counseling Psychologist, 25, 517-572. doi: 10.1177/0011000097254001 210 Hill, C. E., & Williams, E. N. (2000). The process of individual therapy. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (3rd ed., pp. 670-710). New York, NY: John Wiley & Sons, Inc. Hogan, C. L., Catalino, L. I., Mata, J., & Fredrickson, B. L. (2015). Beyond emotional benefits: Physical activity and sedentary behavior affect psychosocial resources through emotions. Psychology and Health, 30, 344-369. doi:10.1080/08870446.2014.973410 Horvath, A. O. & Bedi, R. P. (2002). The Alliance. In Norcross, J. C. (Ed.), Therapeutic relationships that work: Therapist contributions and responsiveness to patients (pp. 37-69). New York: Oxford University Press. Hunt, M. G. (1998). The only way out is through: Emotional processing and recovery after a depressing life event. Behaviour Research and Therapy, 36, 361-384. Retrieved February 17, 2010 from: http://www.sciencedirect.com/science/journal/00057967. doi:10.1016 /S0005-7967(98)00017-5 Hurley, D. B., & Kwon, P. (2013). Savoring helps most when you have little: Interaction between savoring the moment and uplifts on positive affect and satisfaction with life. Journal of Happiness Studies, 14, 1261-1271. doi:10.1007/s10902-012-9377-8 Isaacowitz, D. M., Wadlinger, H. A., Goren, D., & Wilson, H. R. (2006). Selective preference in visual fixation away from negative images in old age? An eye-tracking study. Psychology and Aging, 21, 40-48. doi:10.1037/0882-7974.21.1.40. Isen, A. M. (2004). Some perspectives on positive feelings and emotions. In A. S. R. Manstead, N. Frijda, & A. Fischer (Eds.), Feelings and emotions: The Amsterdam symposium. (pp. 263-281). Cambridge, UK: Cambridge University Press. Isen, A. M. (2008). Some ways in which positive affect influences decision making and problem solving. In M. Lewis, J. M. Haviland-Jones, & L. Barrett (Eds.), Handbook of emotions (3rd ed., pp.548-573). New York: The Guilford Press. Isen, A. M., & Daubman, K. A. (1984). The influence of affect on categorization. Journal of Personality and Social Psychology, 47, 1206-1217. doi:10.1037/0022- 3514.47.6.1206 Isen, A. M., Daubman, K. A., & Nowicki, G. P. (1987). Positive affect facilitates creative problem solving. Journal of Personality and Social Psychology, 52, 1122-1131. doi:10.1037/0022-3514.52.6.1122 211 Isen, A. M., Johnson, M. M. S., Mertz, E., & Robinson, G. F. (1985). Journal of Personality and Social Psychology, 48, 1413-1426. doi: 10.1037/0022-3514.48.6.1413 Ito, T. A., & Cacioppo, J. T. (1999). The psychophysiology of utility appraisals. In D. Kahneman, E. Diener & N. Schwarz (Eds.), Well-being: The foundations of hedonic psychology (pp.470-488). New York, NY: Russell Sage Foundation. Ivey, A. E., Normington, C. J., Miller, C. D., Morrill, W. H., & Haase, R. F. (1968). Microcounseling and attending behavior: An approach to prepracticum counselor training [Part 2]. Journal of Counseling Psychology Monographs, 15(5, parts 2&3). doi: 10.1037/h0026129 Iwakabe, S., & Conceicao, N. (2015, October 12). Metatherapeutic processing as a change-based therapeutic immediacy task: Building an initial model using a task-analytic research strategy. Journal of Psychotherapy Integration. Advance online publication. doi: 10.1037/int0000016 Iwakabe, S., Rogan, K., & Stalikas, A. (2000). The relationship between client emotional expressions, therapist interventions and the working alliance: An exploration of eight emotional expression events. Journal of Psychotherapy Integration, 10, 375-401. Retrieved October 8, 2006 from: http://www.ingentaconnect.com/content/klu/jopi/2000/ Izard, C. E. (2007). Basic emotions, natural kinds, emotion schemas, and a new paradigm. Perspectives on Psychological Science, 2(3), 260-280. doi:10.1111/j.1745- 6916.2007.00044.x Izard, C. E. (2009). Emotion theory and research: Unanswered questions and emerging issues. Annual Review of Psychology, 60, 1-25. doi:10.1146/annurev.psych.58.110405.085709 Izard, C. E. (2010). The many meanings/aspects of emotion: Definitions, functions, activation and regulation. Emotion Review, 2, 363-370. doi:10.1177/1754073910374661 Johnson, K. J., & Fredrickson, B. L. (2005). “We all look the same to me:” Positive emotions eliminate the own-race bias in face recognition. Psychological Science, 16(11), 875-881. doi:10.1111/j.1467-9280.2005.01631.x Johnson, K. J., Penn, D. l., Fredrickson, B. L., Kring, A. M., Meyer, P. S., & Brantley. M. (2009). Loving-Kindness meditation to enhance recovery from negative symptoms of schizophrenia. Journal of Clinical Psychology: In Session, 65, 499-509. doi: 10.1002/jclp.20591 212 Johnson, K. J., Penn, D. l., Fredrickson, B. L., Kring, A. M., Meyer, P. S., Catalino, L. I., & Brantley. M. (2011). A pilot study of loving-kindness meditation to enhance recovery from negative symptoms of schizophrenia. Schizophrenia Research, 129, 137-140. doi: 10.1016/j.schres.2011.02.015 Johnson, S. M. (2004). The practice of emotionally focused couple therapy: Creating connection. (2nd ed.). New York, NY: Brunner-Routledge. Kagan, N. (1975). Influencing human interaction: Eleven years with IPR. Retrieved January 22, 2011 from: http://www.eric.ed.gov.pdfs.ED086918 Kagan, N. (1984). Interpersonal process recall: Basic methods and recent research. In D. Larsen (Ed.), Teaching psychological skills: Models for giving psychology away. (pp. 229-244). Monterey, CA: Brooks/Cole Publishing Company. Kagan, N., Krathwohl, D. R., & Miller, R. (1963). Stimulated recall in therapy using video tape: A case study. Journal of Counseling Psychology, 10, 237-243. doi:10.1037/h0045497 Kazdin, A. E. (2008). Evidence-based treatment and practice: new opportunities to bridge clinical research and practice, enhance knowledge base, and improve patient care. American Psychologist, 63, 146-159. doi:10.1037/0003-0066X.63.3.146 Kazdin, A. E. (2009). Understanding how and why psychotherapy leads to change. Psychotherapy Research, 19, 418-428. doi:10.1080/10503300802448899 Keltner, D., & Bonnano, G. A. (1997) A study of laughter and dissociation: Distinct correlates of laughter and smiling during bereavement. Journal of Personality and Social Psychology, 73, 687-702. doi:10.1037/0022- 3514.73.4.687 Kennedy-Moore, E., & Watson, J. C. (1999). Expressing emotion: Myths, realities, and therapeutic strategies. New York: The Guilford Press. Koch, T. (1995). Interpretive approaches in nursing research: The influence of Husserl and Heidegger. Journal of Advanced Nursing, 21, 827-836. doi:10.1046/j.1365-2648.1995. 21050827.x. Kopta, M.S., Lueger, R.J., Saunders, S. M., & Howard, K.I. (1999). Individual psychotherapy process and outcome research: Challenges leading to greater turmoil or positive transition? Annual Review of Psychology, 50, 441-469. doi:0084-6570/0201-0441$08.00 Kvale, S. (1996). InterViews: An introduction to qualitative research interviewing. Thousand Oaks, CA: Sage Publications. 213 Lambert, M. J. (2011). Psychotherapy research and its achievements. In J. C. Norcross, G. R. VandenBos, & D. K. Freedheim, (Eds.). History of psychotherapy: Continuity and change (2nd ed., pp. 299-232). Washington, DC: American Psychological Association Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behaviour change (5th ed., pp. 139-193). New York: John Wiley & Sons, Inc. Lambie, J. A., & Marcel, A. J. (2002). Consciousness and the Varieties of Emotion Experience: A Theoretical Framework. Psychological Review,109, 219–259. doi:10.1037//0033- 295X.109.2.219 Lane, R. D., Schwartz, G. E. (1987). Levels of emotional awareness: A cognitive-developmental theory and its implications to psychopathology. American Journal of \Psychiatry, 144, 133-143. Retrieved February 17, 2010 from: http://ajp.psychiatryonline.org/ archive/1987.dtl Langdridge, D. (2007). Phenomenological psychology: Theory, research and method. New York, NY: Prentice Hall. Larsen, D., Flesaker, K., & Stege, R. (2008). Qualitative interviewing using interpersonal process recall: Investigating internal experiences during professional-client conversations. International Journal of Qualitative Methods, 7(1), 18-37. Retrieved January 22, 2011 from: http://ejournals.library.ualberta.ca/index.php/IJQM/issue/archive Laurenceau, J. P, Hayes, A. M., & Feldman, G. C. (2007). Some methodological and statistical issues in the study of change processes in psychotherapy. Clinical Psychology Review, 27, 682-695. doi:10.1016/j.cpr.2007.01.007 Laverty, S. M. (2003). Hermeneutic phenomenology and phenomenology: A comparison of historical and methodological considerations. International Journal of Qualitative methods, 2(3). Article 3. Retrieved June 4, 2016 from: http://www.ualberta.ca~iiqm/ backissues/2_3final/pdf/laverty.pdf Lawn, C. (2006). Gadamer: A guide for the perplexed. London, UK: CONTINUUM International Publishing Group. Levitt, H. M., Butler, T., & Hill, T. (2006). What clients find helpful in psychotherapy: Developing principles for moment-to-moment change. Journal of Counseling Psychology, 53, 314-323. doi:10.1037/0022-0167.53.3.314 214 Levitt, H. M., & Piazza-Bonin, E. (2011). Therapists’ and clients’ significant experiences underlying psychotherapy discourse. Psychotherapy, Research, 21, 70-85. doi: 10.1080/10503307.2010.518634 Lieblich, A., Tuval-Mashiach, R., & Zilber, T. (1998). Narrative research: Reading, analysis, and interpretation. Thousand Oaks, CA: Sage Publications. Lindberg, T. L. (2004). Culture and savoring of positive experiences (Doctoral dissertation). Retrieved June 3, 2016 from: http://open.library.ubc.ca/cIRcle/collections/ubctheses /831/1.0092290 Linehan, M. M., Schmidt, M. A., Dimeff, L.A., Craft, J. C., Kanter, J., & Comtois, K. A. (1999). Dialectical behavior therapy for patients for patients with borderline personality disorder and drug-dependence. American Journal on Addictions, 8, 279-292. doi:10.1080/105504999305686 Littrell, J. (1998). Is the re-experience of painful emotional therapeutic? Clinical Psychology Review, 18, 71-102. doi:10.1016/S0272-7358(97)00046-9 Lundblad, S., Christiansson, SA., & Engelberg, E. (2001). Rememberng emotions experienced during psychotherapy treatment. International Journal of psychotherapy, 6, 37-46. doi:10.1080/13569080120042199 Lyubomirsky, S., King, L., & Diener, E. (2005). The benefits of frequent positive affect: Does happiness lead to success? Psychological Bulletin, 131, 803-855. doi:10.1037/0033- 2909.131.6.803 Mahoney, M. J. 1991). Human changes processes: The scientific foundations of psychotherapy. New York, NY: Basicbooks. Martin, J., & Sugarman, J. (1999). Psychology’s reality debate: A “levels” of reality” approach. Journal of Theoretical and Philosophical Psychology, 19(2), 177-194. doi:10.1037/h0091175 Martin, J., & Sugarman, J. (2001). Interpreting human kinds: Beginnings of a hermeneutic psychology. Theory & Psychology, 11(2), 193-207. doi:10.1177/0959354301112003 Mayer, J. D., & Salovey, P. (1997). What is emotional intelligence? In P. Salovey & D. Sluyter (Eds.), Emotional Development and Emotional Intelligence: Educational Implications (pp.3-31). New York, NY: Basic books. Retrieved February 18, 2010 from: http://www. 215 unh.edu/emotional_intelligence/EI%20Assets/Reprints...EI%20PropeEI1997MS WhatIsEI.pdf Mayer, J. D., Salovey, P., Caruso, P. R. (2008). Emotional intelligence: New ability or eclectic traits? American Psychologist, 63, 503-517. doi:10.1037/0003-066X.63.6.503 Menin, D., & Farach, F. (2007). Emotion and evolving treatments for adult psychopathology. Clinical Psychology: Science and Practice, 14(4), 329-352. doi: 10.1111/j.1468- 2850.2007.00094.x McCluskey, U. (2005). To be met as a person. London, UK: Karnac Books. McEwen, B. S. (1998). Stress, adaptation, and disease: Allostasis and allostatic load. Annals of the New York Academy of Sciences, 840, 33-44. doi:10.1111/j.1749-6632.1998.tb09546.x McLeod, J. (2001). Qualitative research in counselling and psychotherapy. Los Angeles, CA: Sage Publications. Mergenthaler, E. (1996). Emotion-abstraction patterns in verbatim protocols: A new way of describing psychotherapeutic processes. Journal of Consulting and Clinical Psychology, 64, 1306-1315. doi:10.1037/0022-006X.64.6.1306 Mergenthaler, E. (2008). Resonating minds: A school-independent theoretical conception and its empirical application to psychotherapeutic processes. Psychotherapy Research, 18, 109- 126. doi:10.1080/10503300701883741 Merriam, S. B. (1998). Qualitative research and case study applications in education: Revised and expanded from case study research in education. San Francisco: Jossey-Bass Publications. Mesquita, B. (2001). Emotions in collectivist and individualistic contexts. Journal of Personality and Social Psychology, 80, 68-74. doi: 10.1037//O022-3514.80.1.68 Mesquita, B., & Karasaw, M. (2002). Different emotional lives. Cognition and Emotion, 16, 127- 141. doi: 10.1080/0269993014000176 Missirlian, T. M., Toukmanian, S. G., Warwar, S. H., & Greenberg, L. s. (2005) Emotional arousal, client perceptual processing, and the working alliance in experiential psychotherapy for depression. Journal of Consulting and Clinical Psychology, 73, 861- 871. doi: 10.1037/0022006X.73.5.861 Mollen, D., Ethington, L., & Ridley, C.R. (2006). Positive psychology: Considerations and implication for counseling psychology. The Counseling Psychologist, 34, 304–312. 216 doi:10.1177/0011000005283522 Morrow, S. L. (2005). Quality and trustworthiness in qualitative research in counselling psychology. Journal of Counseling Psychology,52, 250-260. doi:10.1037/0022- 1067.52.2.250 Moskowitz, J. T., Folkman, S., Colette, L., & Vittinghoff, E. (1996). Coping and mood during AIDS-related caregiving and bereavement. Annals of Behavioral Medicine, 18, 49- 57. Retrieved September 26, 2011 from: http://www.springerlink.com/content/120893/. doi: 10.1007/BF02903939 Moses, E. B., & Barlow, D. H. (2006). A new unified treatment approach for emotional disorders based on emotion science. Current Directions in Psychological Science, 15, 146-150. doi:10.111/j.0963-7214.2006.00425.x Newman M, G., Castonguay, L.G., Borkovec, T.B., Fisher, A.J., & Nordberg, S.M. (2008). An open trial of integrative therapy for generalized anxiety disorder. Psychotherapy, Theory, Research, Practice, Training, 45(2), 135-147. doi:10.1037/0033-3204.45.2.135. Neilson, L. (2008). Lyric Inquiry. In G. Knowles & A. L. Cole (Eds.), Handbook of the arts in qualitative research: Perspectives, methodologies, examples, and issues (pp. 93-102). Thousand Oaks, CA: Sage Publications, Inc. Nielsen, L., & Krasniak, A. W. (2007). Conceptual, theoretical, and methodological issues in inferring subjective emotion experience. In J. A. Coan & J. B. Allen (Eds.), Handbook of emotion, Elicitation, and Assessment (pp.361-375). New York, NY: Oxford University Press. Norcross, J. C. (Ed.), Therapeutic relationships that work: Therapist contributions and responsiveness to patients New York, NY: Oxford University Press. Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. New York, NY: W. W. Norton & Company. Ong, A. D., Bergeman, C. C., Bisconti, T. L., & Wallace, K. A. (2006). Psychological Resilience, positive emotions, and successful adaptation to stress in later life. Journal of Personality and Social Psychology, 91, 730-749. doi:10.1037/0022-3514.91.4.730. Ong, A. D., Zautra, A. J., & Reid, M. C. (2010). Psychological resilience predicts decreases in pain catastrophizing through positive emotions. Psychology and Aging, 25, 516-523. doi:10.1037/a0019384 217 Orange, D. M. (1995). Emotional understanding: Studies in psychoanalytic epistemology. New York, NY: The Guilford Press. Orange, D. M. (2010). Thinking for clinicians: Philosophical resources for contemporary psychoanalysis and the humanistic psychotherapies. New York, NY: Routledge. Orange, D. M. (2011). The suffering stranger: Hermeneutics for everyday clinical practice. New York, NY: Routledge. Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years of psychotherapy process- outcome research: Continuity and change. In M. J. Lambert (Ed.), Bergin and Garfield's handbook of psychotherapy and behavior change (pp. 307-389). New York, NY: John Wiley & Sons, Inc. Osborne, J. W. (1994). Some similarities and differences among phenomenological and other methods of psychological qualitative research. Canadian Psychology, 35, 167-189. doi: 10.1037/0708-5591.35.2.167 Pachankis, J. E., & Goldfried, M. R. (2007). On the next generation of process research. Clinical Psychology Review, 27, 760-768. doi:10.1016/j.cpr.2007.01.009 Packer, M. J., & Addison, R. B. (1989). Introduction. In M. J. Packer & R. B. Addison (Eds.), Entering the circle: Hermeneutic investigation in psychology (pp.13-36). Albany, NY: Sate University of New York Press. Paivio, S.C., & Laurent, C. (2001). Empathy and emotion regulation: reprocessing memories of childhood abuse. Journal of Clinical Psychology, 57, 213–226. Retrieved October 24, 2006 from: http://www3.interscience.wiley.com/journal/31171/home. doi: 10.1002/1097- 4679(200102)57:213::AID-JCLP7>3.0CO;2-B Panksepp, J. (2009). Brain emotional systems and qualities of mental life: From animal models of affect to implications for psychotherapeutics. In D. Fosha, D. J. Siegel, & M. F. Solomon (Eds.), The healing power of emotion: Affective neuroscience, development & clinical practice. New York: W. W. Norton. Pascual-Leone, A., & Greenberg, L. S. (2007). Emotional processing in experiential psychotherapy: Why “the only way out is through.” Journal of Consulting and Clinical Psychology, 75, 875-887. doi:10.1037/0022-006X.75.6.875 Pascual-Leone, A., & Greenberg, L. S. (2006). Emotion in psychotherapy: A practice-friendly review. Journal of Clinical Psychology In Session, 62, 611-630. doi:10.1002/jclp.20252 218 Patton, M. Q. (2002). Qualitative research evaluation methods. (3rd ed.). Thousand Oaks, CA: Sage. Pollatos, O., Kirsch, V., & Schandry, R. (2005). On the relationship between interoceptive awareness, emotional experience, and brain processes. Cognitive Brain Research, 25, 948-962. doi:10.1016/j.cogbrainres.2005.09.019 Ponterotto, J. G. (2005). Qualitative research in counseling psychology: A primer on research paradigms and philosophy of science. Journal of Counseling Psychology, 52, 126-136. doi:10/1037/0022-0167.52.2.126 Pressman, S. D., & Cohen, S. (2005). Does positive affect influence health? Psychological Bulletin, 131, 925-971. doi:10.1037/0033-2909.131.6.926 Rauch, S., & Foa, E. 92006)). Emotional processing theory (EPT) and exposure therapy for PTSD. Journal of contemporary psychotherapy, 36,61-65. doi:10.1007/s10879-006- 9008-y. Reich, J. W., Zautra, A. L., & Davis, M. (2003). Dimensions of affect relationships: models and their integrative implications. Review of General Psychology, 7, 66-83. doi: 10.1037/1089-2680.7.1.66 Rice, L. N., & Greenberg, L. S. (Eds.). (1984). Patterns of change: Intensive analysis of psychotherapy process. New York, NY: Guilford Press. Richardson, M. S. (2002). An emergence of new intentions in subjective experience: A social/personal constructionist and relational understanding. Journal of Vocational Behavior, 64, 485-498. doi:10.1016/j.jvb.2003.12.011 Roberson, M. R. (2008). Why be Happy? Barbara Fredrickson is trying to find out if positive emotions do us any good. Endeavors (magazine): Research and Creative Activity. The University of North Carolina at Chapel Hill UNC -Chapel Hill Winter 24(2). Retrieved November 15, 2008 from: http://research.unc.edu/endeavors/win2008/fredrickson.php Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95-103. doi: 10.1037/h0045357 Rowe, G., Hirsh, J. B., Anderson, A. K. (2007) Positive Affect Increases the Breadth of Attentional Selection. Proceedings of the National Academy of Sciences of the United States of America, 104, 383-388. doi:10.1073/pnas.0605198104. 219 Rozin, P., & Royzman, E. B. (2001). Negativity bias, negativity dominance, and contagion. Personality and Social Psychology Review, 5, 296-320. Retrieved September 3, 2011 from: http://erlbaum.com/Journals/PSPR/pspr.htm. doi:10.1207/S15327957PSPR0504_2 Russell, E. (2015). Restoring resilience: Discovering your clients’s capacity for healing. New York, NY: W. W. Norton & Company, Inc. Russell, E., & Fosha, D. 92008). Transformational affects and core state in AEDP: The emergence and consolidation of joy, hope, gratitude, and confidence in (the solid goodness of) the self. Journal of psychotherapy Integration, 18, 167-190. doi:10.1037/1053-0479.18.2.167 Russell, J. A., & Barrett, L.F. (1999). Core affect, prototypical emotional episodes, and other things called emotion: Dissecting the elephant. Journal of personality and Social Psychology, 76, 805-819. doi: 10.1037/0022-3514.76.5.805 Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York, NY: The Guilford Press. Saldana, J. (2013). The coding manual for qualitative researchers. (2nd ed.). Los Angeles, CA: Sage. Samoilov, A., & Goldfried, M. R. (2000). Role of emotion in cognitive-behavior therapy. Clinical Psychology: Science and Practice, 7(4), 373-385. doi:10.1093/clipsy.7.4.373 Sandler, S. (2007). The reunion process: A new focus in short-term dynamic psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 44(2), 121-136. doi: 10.1037/0033- 3204.44.2.121 Saumere, K., & Given, L. M. (2008) Resonance. In L. M. (Ed). The Sage encyclopedia of qualitative research methods (Vol. 1 & 2, pp. 385-388). Los Angeles, CA: Sage Publications, Inc. Schacter, D. L., Addis, D. R., Hassabis, D., Martin, V. C., Spreng, N. R., & Szpunar, K. K. (2012). The future of memory: Remembering, imagining, and the brain. Neuron, 21(4), 1- 32. doi:10.1016/j.neuron.2012.11.001 Schwandt, T. A. (2000). Three epistemological stances for qualitative inquiry: Interpretivism, hermeneutics, and social constructionism. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (2nd ed., pp. 189-213). Thousand Oaks, CA: Sage. 220 Seligman, M., Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American Psychologist, 55, 5-14. doi:10.1037//0003-066x.55.1.5 Seligman, M. E., Rashid, T. & Parks, A. C. (2006). Positive psychotherapy. American Psychologist, 61(8), 774-788. doi.org/10.1037/0003-066X.61.8.774 Shea M. T, Elkin I, Imber S. D., Sotsky, S. M., Watkins, J.T., Collins, J. F., Pilkonis, P.A., Beckham, E., Glass, D. R., Dolan, R.T., & Parloff, M. B. (1992). Course of depressive symptoms over follow-up: Findings from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Archives of General Psychiatry, 49(10), 782-787. doi:10.1001/archpsyc.1992.01820100075013 Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to shape who we are. New York. NY: The Guilford Press. Slavin, M. O., & Kriegman, D. (1998). Why the analyst needs to change: Toward a theory of conflict, negotiation, and mutual influence in the therapeutic process. Psychoanalytic Dialogues, 8, 247-284. doi:10.1080/10481889809539246 Sloan, D. M., & Kring, A. M. (2007). Measuring changes in emotion during psychotherapy: Conceptual and methodological issues. Clinical Psychology: Science and Practice, 14(4), 307-322. doi:10.1111/j.1468.2850.2007.00092x Smith, J. K. (1993). Hermeneutics and qualitative inquiry. In D. J. Flinders & G. E. Mills (Eds.), Theory and concepts in qualitative research: Perspectives from the field (pp. 183-200). New York, NY: Teachers College Press. Smith, C. A., Tong, E. M. W., & Ellsworth, P. C. (2014). The differentiation of positive emotional experience as viewed through the lens of appraisal theory. In M. Tugade, L. Shiota, & L. Kirby, (Eds), Handbook of Positive Emotions (pp. 11-27). New York: Guilford. Snyder, C. R., & Lopez, S. J. (Eds.). (2002). Handbook of positive psychology. London, UK: Oxford University Press. Retrieved August 26, 2011 from: http://holismoplanetario.files. wordpress.com/2010/02/handbook-of-positive-psychology.pdf. Soloman, R. C. (2002). Back to basics: On the very idea of “basic emotions.” Journal for the Theory of Social Behavior, 32(2), 115-144. Retrieved August 27, 2011 from: http://www.wiley.com/Wiley.CDA/doi:10.1111/1468-5914.00180 221 Soloman, R. C., & Stone, L. D. (2002). On “positive” and “negative” emotions. Journal for the theory of social behavior, 32, 417-435. doi: 10.1111/1468-5914.00196 Sommers-Flanagan, J., & Sommers-Flanagan, R. (2004). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques. Hoboken, NJ: John Wiley & Sons, Inc. Sroufe, L. A. (1979). Socioemotional development . In J. Osofsky (Ed.), Handbook of infant development (pp.462-516). New York, NY: Wiley. Stake, R. E. (2005). Case studies. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (3rd ed., pp. 443-466). Thousand Oaks, CA: Sage. Stake, R. E. 92006). Multiple case study analysis. New York, MY: The Guilford Press. Stalikas, A. & Fitzpatrick, M. R. (2008). Positive emotions in psychotherapy theory, research and practice: New kid on the block? Journal of Psychotherapy Integration, 18, 155- 166. doi: 10.1037//1053-0479.18.2.155 Stalikas, A., Fitzpatrick, M., Mistkidou, P., Boutri, A., & Seryianni, C. (2015). In O. C. G. Gelo, A. Pritz, & B. Rieken. (Eds.), Psychotherapy research: Foundations, process and outcome (pp.331-349). New York, NY: Springer. Stiles, W. B. (2015). Theory building, enriching, and fact gathering: Alternative purposes of psychotherapy research. In O. C. G. Gelo, A. Pritz, & B. Rieken. (Eds.), Psychotherapy research: Foundations, process and outcome (pp.159-179). New York, NY: Springer. Sugarman, J. (2007). Practical rationality and the questionable promise of positive psychology. Journal of Humanistic Psychology, 47, 175-197. doi: 10.1177/0022167806297061 Task Force on Promotion and Dissemination of Psychological Procedures (1985). Training in and dissemination of the empirically validated therapies. The Clinical Psychologist, 6, 3- 23. Retrieved September 5, 2011 from: http://www.apa.org/divisions/div12/est/ chamble2.pdf Taylor, E. Positive psychology and humanistic psychology: A reply to Seligman. Journal of Humanistic Psychology, 41, 13-29. doi:10.1177/0022167801411003 Taylor, S. (1991). A symmetrical Effects of Positive and Negative Events: The Mobilization- Minimization Hypothesis. Psychological Bulletin,110, 67-85. doi.org/10.1037//0033- 2909.110.1.67 222 Timulak, L. (2009). Identifying core categories of client-identified impact of helpful events in psychotherapy: A qualitative meta-analysis. Psychotherapy Research, 17, 305-314. doi:10.1080/10503300600608116 Tracy, S. A. (2010). Qualitative quality: Eight “big tent” criteria for excellent qualitative research. Qualitative Inquiry 16, 837–851.doi:10.1177/1077800410383121 Trope, Y., & Pomerantz, E. M. (1998). Resolving conflicts among self-evaluative motives: Positive experiences as a resource for overcoming defensiveness. Motivation and Emotion, 22, 53-72. doi:10.1037/0022- 3514.22.1.53 Trope, Y. & Neter, E. (1994). Reconciling competing motives in self-evaluation: The role of self-control in feedback seeking. Journal of personality and Social Psychology, 66, 646- 657. doi:10.1037/0022- 3514.66.4.646 Tugdale, M. M., & Fredrickson, B. L. 92007). Regulation of positive emotions: Emotion regulation strategies that promote resilience. Journal of Happiness Studies, 8, 311-333. doi:10.1007/s10902-006-9015-4 Vandenberghe, L., & Silvestre, R. L. S. (2014). Therapists’ positive emotions in-session: Why they happen and what they are good for. Counselling and Psychotherapy Research, 14, 119-127. doi:10.1080/14733145.2013.790455 Wachtel, P. L. (2008). Relational theory and the practice of psychotherapy. New York: The Guilford Press. Wampold, B. (2001). The great psychotherapy debate: Models. methods, and findings. Mahwah, NJ: Lawrence Erlbaum Associates, Inc. Wampold, B. E., Hollon, S. D., & Hill, C. E. (2011). Unresolved questions and future directions in psychotherapy research. In J. C. Norcross, G. R. VandenBos, & D. K. Freedheim, (Eds.). History of psychotherapy: Continuity and change (2nd ed., pp. 333- 356). Washington, DC: American Psychological Association. Watershed. (2015). In Merriam-Webster:Dictionary and thesaurus. Retrieved September 11, 2015 from: http://www.merriam-webster.com. Watson, D., & Tellegen, A. (1985). Toward a consensual structure of mood. Psychological Bulletin, 98, 219-235. doi:10.1037/0033-2909.98.2.219 Watson, D., Wiese, D., Vaidya, J., & Tellegen, A. (1999). The two general activation systems of affect: Structural findings, evolutionary considerations, and psychobiological evidence. 223 Journal of Personality and Social Psychology, 76, 820-838. doi:10.1037/0022- 3514.76.5.820 Watson, D. (2005). Rethinking the mood and anxiety disorders: A quantitative hierarchical model for DSM–IV. Journal of Abnormal Psychology, 114, 522–536. doi:10.1037/0021- 843X.114.4.522 Whelton. W. J. (2004). Emotional processes in psychotherapy: Evidence across therapeutic modalities. Clinical Psychology and Psychotherapy, 11, 58-71. doi:10.1002/cpp.392 Wood. A. M., & Tarrier, N. (2010). Positive clinical psychology. A new vision and strategy for integrated research and practice. Clinical Psychology Review, 30, 819-829. doi:1.1016/j.cpr.2010.06.003 Young, R. A., & Valach, L. (2004). The construction of career through goal-directed action. Journal of Vocational Behavior, 64, 499-514. doi:10.1016/j.jvb.2003.12.012 Young, R. A., Valach, L., & Collin, A. (2002). A contextual explanation of career. In D. Brown & Associates (Eds.), Career choice and development (4th ed., pp. 206-250). San Francisco, CA: Jossey-Bass. Young, R. A., Valach, L., & Domene, J. F. (2005). The action-project method in counseling psychology. Journal of Counseling Psychology, 52, 215-223. doi: 10.1037/0022- 0167.52.2.21 Zautra, A., Smith, B., Affleck, G., & Tennen, H. (2001). Examinations of chronic pain and affects relationships: Applications of a dynamic model of affect. Journal of Consulting and Clinical Psychology, 69,786-795. doi:10.1037//0022-006X.69.5.786. Zautra, A. J., Johnson, L. M., & Davis, M. C. (2005). Positive affect as a source of resilience for women in chronic pain. Journal of Consulting and Clinical Psychology, 73, 212-220. doi: 10.1037//0022-006X.73.21 224 Appendix A: Recruitment Advertisement for Professional Website(s) and Listserv(s) I am a doctoral student in Counseling Psychology at The University of British Columbia (UBC) investigating how clients and therapists work with positive emotion in counselling and psychotherapy sessions. I am interested in the thoughts and feelings, expressed or unexpressed, by each member of the therapy dyad when positive emotion emerges for a client in a session, and is attended to and explored (or not). I am recruiting therapists who: 1) have been trained and/or supervised in either Emotionally-Focused Therapy (EFT) or Accelerated Experiential Dynamic Psychotherapy (AEDP), and 2) who have the capacity and consent of their clients to videotape their therapy sessions. The study will involve participation in a confidential interview with me during which we will review a videotaped therapy session in which you recognized, attended to and explored episodes of client emergent or expressed positive emotion. I will ask you describe your thoughts and feelings during these episodes. In a separate and confidential interview, your client will also be interviewed by me while reviewing the same therapy session you discussed with me. The client will be asked to identify episodes of his/her own emergent positive emotion expression, and speak about his/her thoughts and feelings at these times. If you practice EFT or AEDP, attend, explore/process emergent positive emotion as a usual practice of your approach with clients, videotape client therapy sessions, and think you might be willing to talk about your experience, please contact me at [researcher’s email address], or telephone me at [telephone number], my confidential voicemail. Recruitment Advertisement for Professional Website(s) and Listserv(s) Version March 27, 2012 Page 1 of 1 225 Appendix B: Recruitment Letter for Therapists I am a doctoral student in Counseling Psychology at The University of British Columbia (UBC) investigating how clients and therapists work with positive emotion in counselling and psychotherapy sessions. I am particularly interested in the thoughts and feelings, expressed or unexpressed, by each member of the therapy dyad when positive emotion emerges for a client in a session, and then is attended to and explored (or not) by the dyad. I am recruiting qualified and experienced therapists, to participate in my study. Specifically, I am recruiting therapists who: 1) have been trained and received at least one year of supervision in either Emotionally-Focused Therapy (EFT) or Accelerated Experiential Dynamic Psychotherapy (AEDP), and 2) who have the capacity and consent of their clients to videotape their therapy sessions. The study will involve your participation in a confidential interview with me during which we will review a videotaped therapy session in which you recognized, attended to and explored episodes of client emergent or expressed positive emotion. I will ask you describe your thoughts and feelings during these episodes. In a separate and confidential interview, your client will also be interviewed by me while reviewing the same therapy session you discussed with me. The client will be asked to identify episodes of his/her own emergent positive emotion expression, and speak about his/her thoughts and feelings at these times. If you practice EFT or AEDP, attend, explore/process emergent positive emotion as a usual practice of your approach with clients, videotape client therapy sessions, and think you might be willing to talk about your experience, please contact me or indicate your willingness to be contacted by me via telephone. Participants in the study will receive an honorarium of $150.00. If you are interested, please do not contact your client(s) yourself. After speaking with you and determining your eligibility for the study, I will ask you to distribute a recruitment letter to clients who you think may fit the criteria. Then, any of your clients that may be interested to join the study with you, will contact me directly themselves. Please send an email to my confidential address at [researcher’s email address]or telephone me at [telephone number], leaving a message on my confidential voicemail. If you prefer, please print your name and telephone number and sign below indicating I have your permission to contact you personally. I, ________________________________________ am interested in participating in this study, (Print Name) and I give my permission for Dianne Westwood to contact me at _________________________ (Telephone Number) to discuss the study. _________________________________________________ (Signature) Therapist Recruitment Letter Version Date: April 2, 2012 Page 1 of 1 226 Appendix C: Telephone Screening Interview for Therapists (adapted from Tavormina, 2011) Date of screening call: __________________________________________________________ Name/contact info: ____________________________________________________________________________________________________________________________________________________________ 1. Introduce myself and ask how he/she heard about the study. 2. Thank-you for your interest in this study. The purpose of this call is to explain the study and to determine whether your experience fits with the purpose of the project. There is potential for this phone call to take up to 45 minutes. Is it alright to proceed, or would another time be more suitable? 3. Description of the Study: The research study will investigate how clients and therapists notice and explore client positive emotion expression in sessions. For you, the study will consist of a) helping me identify and recruit one of your clients to be part of the study; b) having your sessions with this client videotaped; c) one 3-hour videotaped interview in which we will view a videotaped therapy session in which you noticed, attended to and/or explored your client’s positive emotion expression/emergence. Your client will also be asked to participate in a 3-hour videotaped interview in which your client and I will review the same videotaped therapy session. During your interview I will ask you open ended questions about your experience. Once I have read over the transcribed interviews and analyzed them for the themes they contain, I will meet with you again in a follow up interview so you can see the themes from your interview. This interview will be up to one hour, and its purpose is to seek your feedback about the themes I have identified and how they represent your experience. 4. Questions for Participant Selection: For you to be included in this study I first need to ask you a series of questions to determine if your experience with (name of therapist) fits with the purpose of the study. If you don’t meet the criteria, the information you have provided will be destroyed. Is it alright to proceed? a. Have you attended basic training in EFT or AEDP (5 day introduction or immersion), at least one year of supervision in the model of EFT or AEDP? Do you usually use an EFT or AEDP approach with clients? See next page Therapist Telephone Screening Interview Version Date: January 24, 2012 Page 1 of 2 227 b. Was this individual peer nominated as being an expert in this model? c. Do you have the capacity to videotape your therapy sessions? Your sessions will need to be video-recorded from the beginning of this research until you identify a session you consider representative of you having noticed, attended to, and explored client positive emotion expression. You will also need to identify current clients from your case load who might be interested in participating in this research. I will ask you not to discuss the study at any length with them. Instead, I will ask you to give these interested clients a recruitment letter from me, giving me permission to contact them. d. Are you available for a 3-hour interview and a 1-hour follow up interview? I will explain the procedure and purpose of these interviews. At this point, the determination is made to either proceed with the intake interview or to respectfully thank the potential participant and close the conversation. To conclude this intake interview I would like to explain to you your rights as a participant, the risks and benefits, and the limits of confidentiality to which I must abide. At this point I would proceed to discuss compensation, rights to withdraw at any time, and the limits of confidentiality etc. You meet the criteria for the study and I would like to invite you to participate. Please think over the time commitment carefully, and then contact me within two weeks (by email or phone) to let me know that you are definitely willing to participate. At that time we can determine the place, the details of how we will contact clients in your practice that may be interested in participating with you. Are there any final questions you would like to ask? Therapist Telephone Screening Interview Version Date: January 24, 2012 Page 2 of 2 228 Appendix D: Scripts for Therapists Recruiting Clients Script for introducing the study and responding to client inquiries: “I have agreed to participate/am participating in a UBC research study about positive emotion. The researcher is looking for/recruiting therapists and clients who would volunteer to talk about one of their sessions while they watch a video playback of it with her. She wants to talk to clients and therapists about positive emotion in the session. I have a one-page information letter you can read about it. I’ll leave it here and you can pick it up if you are interested. It’s all voluntary. Responding to questions from your client(s) if they express interest in the study, before s/he have agreed to participate in the study: Once you tell them something like the above statement, I suggest you give them the recruitment letter and say something like: “This letter explains it quite well. Why not read it over first, contact the researcher to see if it fits for you, and then we can speak about it together if you still think you want to participate.” I don’t want you to feel any pressure to participate with me. This is 100% voluntary. Scripts for Therapists Recruiting Clients Version January 24, 2012 Page 1 of 1 229 Appendix E: Recruitment Letter for Clients I am a doctoral student in counseling psychology at The University of British Columbia (UBC) investigating how clients and therapists work with positive emotion in counselling and psychotherapy sessions. I am particularly interested what it was like for you, as a client, to have your therapist pay attention to, and explore your expressions of positive emotion with you in your therapy sessions. I am recruiting qualified and experienced therapists, like yours, to pass on this invitation to participate in my study to clients with whom he/she pays attention to and explores positive emotions, and who regularly videotape their therapy sessions with clients. I hope to learn more about this type of exploration from hearing about your experience, and the experience of your therapist. The study will involve your participation in a confidential interview with me, during which we will review a videotaped therapy session in which you expressed positive emotion, and your therapist attended to it, and explored it with you. I will ask you to identify times in the session you thought you experienced positive emotion, and to describe your thoughts and feelings during these times. In a separate and confidential interview, your therapist will also be interviewed by me, while reviewing the same therapy session you discussed with me. Your therapist will be asked to identify times where he/she thought you expressed positive emotion, and explored it with you. I will also ask him/her what thoughts and feelings he/she was having at those times. Participants in the study will receive an honorarium of $150.00. If you and your therapist discuss and/or explore your expressions of positive emotion, videotape your sessions, think you might be willing to talk about your experience, and watch a videotape of your therapy session with me, please contact me or indicate on this form your willingness to be contacted by me via telephone. Please send an email to my confidential address at [researcher’s email address], or telephone me at [telephone number], leaving a message on my confidential voicemail. If you prefer, please print your name and telephone number and sign below indicating I have your permission to contact you personally. I, ________________________________________ am interested in participating in this study, (print name) and I give my permission for Dianne Westwood to contact me at _________________________ (telephone number) to discuss the study. _________________________________________________ (signature) Recruitment Letter for Clients Version Date: April 2, 2012 Page 1 of 1 230 Appendix F: Telephone Screening Interview for Clients (adapted from Tavormina, 2011) Date of screening call: __________________________________________________________ Name/contact info: ____________________________________________________________________________________________________________________________________________________________ Name of Therapist: ____________________________________________________________ 1. Introduce myself and explain I am calling about the study and the recruitment letter he/she signed for me to contact her/him. 2. Thank-you for your interest in this study. The purpose of this call is to explain the study and to determine whether your experience fits with the purpose of the project. There is potential for this phone call to take up to 45 minutes. Is it alright to proceed, or would another time be more suitable? 3. Description of the Study: The research study will investigate how clients and therapists notice and explore client positive emotion expression together in sessions. For you, the study will consist of a) having your sessions with your therapist videotaped; b) one 3-hour videotaped interview with me in which we will view a selected video-recorded therapy session. Your therapist will also be asked to participate in a 3-hour videotaped interview in which your therapist and I will review the same videotaped therapy session. During your interview I will ask you open ended questions about your experience. Once I have read over the transcribed interviews and analyzed them for the themes they contain, I will meet with you again in a follow up interview so you can see the themes from your interview. This interview will be up to one hour, and its purpose is to seek your feedback about the themes I have identified, and how they represent your experience. 4. Questions for Participant Selection: For you to be included in this study I first need to ask you a series of questions to determine if your experience with (name of therapist) fits with the purpose of the study. If you don’t meet the criteria, the information you have provided will be destroyed. Is it alright to proceed? See next page Client Telephone Screening Interview Version Date: January 24, 2012 Page 1 of 2 231 a. How old are you? _____________________________________________________ b. As mentioned, this study investigates the experience of attending to and exploring client expression of positive emotion. Your therapist will need to video-record all your therapy sessions from the beginning of this research until which time a session is identified by your therapist as representative of him/her having noticed, attended to, and explored with you your expression of positive emotion. c. Are you available for a 3-hour interview, and a one hour follow up interview? (At this point, the determination is made to either proceed with the intake interview or to respectfully thank the potential participant and close the conversation). 5. How long have you been seeing your therapist? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 6. What brought you to counselling? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ To conclude this intake interview I would like to explain to you your rights as a participant, risks and benefits, including support after the interview, how I will compensate participants, and the limits of confidentiality to which I must abide. At this point I would proceed to discuss compensation, rights to withdraw at any time, and the limits of confidentiality. You meet the criteria for the study and I would like to invite you to participate. Please think over the time commitment carefully, and then contact me within two weeks (by email or phone) to let me know that you are definitely willing to participate. At that time we can determine the place, the interviews will be conducted. Are there any final questions you would like to ask? Client Telephone Screening Interview Version Date: January 24, 2012 Page 2 of 2 232 Appendix G: Script of Statements to Prospective Participants When Recruitment is Completed Scenario 1: When a therapist and a client are recruited to complete a dyad, and prospective client participants (from the corresponding therapist’s practice) continue to inquire about participation, the following statements will be made to them. “Thank you for your interest in the study. At this point it looks like we have the participants we need for this part of the study. If, as we progress, we discover we need additional client participants, and your therapist also agrees to participate, would you be interested in being contacted by me?” “Do you have any questions about the study you would like me to address at this time?” (This might occur if a client participant withdrew from the study and the overall sample was not completed as a result). If he/she asks about why we might need more participants in the future, the following answer will be given. “It may be that some participants will withdraw from the study, and we will not have enough participant experiences to get a real sense of how clients and therapists are attending to positive emotion. Or, because we are interested in recognizing commonalities and patterns across sessions, as we analyze the interviews we may decide we need to conduct more interviews to access the experiences of more clients and therapists.” If he/she agrees to be contacted in the future, the following questions will be asked. “How do you prefer to be contacted? By telephone, or by email?” “Is there a time limit for me to contact you about this?” Scenario 2: When the purposive sample is completed, and prospective participants (therapist or client participants) continue to inquire about participation, the following statement will be made to them. “Thank you for your interest in the study. We have the participants we need for the study. “Do you have any questions about the study you would like me to address at this time?” Statements to Prospective Participants When Recruitment is Completed Version Date: April 19, 2012 Page 1 of 1 233 Appendix H: Therapist Informed Consent Consent Form An Inquiry into How Positive Emotion is Utilized by Clients and Therapists When They Perceive it has Arisen for the Client in Psychotherapy Sessions Principal Investigator: Dr. Norman Amundson, UBC Department of Educational and Counselling Psychology, and Special Education (Counselling Psychology Program, telephone number) Co-Investigator: Dianne Westwood, UBC Department of Educational and Counselling Psychology, and Special Education (Counselling Psychology Program, telephone number) The research conducted for this study will fulfill part of the dissertation requirement for a PhD degree for Dianne Westwood, under the direction of Dr. Norman Amundson. It will eventually be made available to the public. Purpose: The purpose of this study is to explore how clients and therapists understand their experiences when emergent or expressed positive emotion occurs for the client, and is attended to in counselling and psychotherapy sessions. Most of the research about emotional expression in counselling and psychotherapy sessions is about distressing emotions expressed by clients. Your participation will help us understand how clients and therapists work with positive emotion in therapy sessions. Expressing emotions in counselling and psychotherapy is usually considered helpful by clients, but we do not understand how this actually works in being helpful. Study Procedures: If you agree to participate in this study, you and your client will be asked to videotape all your counselling/psychotherapy sessions from the commencement of the study until such time as you identify a session in which you attended to and/or explored your client expressing positive emotion. You will also be asked to take part in a 2-3-hour interview in which you will review playback of the selected counselling/psychotherapy session and discuss your experiences during times you identify that you and your client were engaged in identifying, attending to and/or exploring client positive emotion. Therapist Informed Consent Version Date: February 7, 2012 Page 1 of 3 Department of Educational and Counselling Psychology, and Special Education The University of British Columbia Faculty of Education 2125 Main Mall Vancouver BC Canada V6T 1Z4 Tel 604-822-0242 Fax 604-822-3302 www.ecps.educ.ubc.ca 234 In addition, after the interviews are transcribed and analyzed, you will be asked to participate in a 1-hour interview to review the results, to provide your feedback to the researcher, and to discuss any remaining questions or comments you may have, including any positive or negative impacts of the study that you wish to share. The total amount of time required of you is approximately 4-5 hours. Any questions you have regarding the study procedures may be directed to the study co-investigator, Dianne Westwood at [telephone number]or [researcher’s email address] Potential Risks: Reviewing video playback and discussion of your counselling/psychotherapy session may be uncomfortable or even trigger distress for you. You may indicate this at any time and we will move on to other segments of the videotape, or if you prefer, take a break, or even stop the interview. Your participation in this study is completely voluntary. You may refuse to answer any questions or provide any information. You may also withdraw your participation at any time during the interview or after the interview. Your client will not be informed of your decision to withdraw, except with your permission. The interview is meant to be reflective, not therapeutic. If issues arise for you that you believe need attention, you are encouraged to discuss/consult about this with a colleague, in a consultation group, or with a supervisor/mentor if you have one. Potential Benefits: The potential benefits of talking about your counselling/psychotherapy experience include gaining new insight(s) into your experience that you did not previously have, and sharing your experience may be helpful to others. It may also affect your relationship with your client in a positive way. You will be compensated for your participation in this study. Confidentiality: All efforts will be made to ensure your identity remains confidential. Any information that is obtained in this study will remain confidential and will be disclosed only with your permission or as required by law. You will not be identified by name in any reports of the completed study. Direct quotes from the interview(s) may be reported in the findings of this study, but these quotes will not reveal any identifying information. All printed documents, audio and video-tapes will be kept in a locked file cabinet and all electronic files will be password protected on computer hard drives. Within five years all the data will be destroyed. The only individuals who will have access to the videotapes and transcripts are: my research dissertation committee members, and two expert peer reviewers during the analysis period. The expert peer reviewers will be a senior Counselling Psychology doctoral student at UBC, and a recent PhD graduate from Counselling Psychology at UBC. Both are knowledgeable in therapeutic and emotional processes. Their role is to validate that the findings of the research correspond directly to thoughts, and experiences described by participants like yourself. Therapist Informed Consent Version Date: February 7, 2012 Page 2 of 3 235 Remuneration/Compensation: You will be reimbursed for the cost of transportation to and from the interviews by the co-investigator. In addition, you will receive a $150.00 honorarium for the time spent in the two interviews. Contact Information About the Study: For further information about this study you may contact Dr. Norman Amundson, the Principal Investigator at [telephone number]. Contact for Concerns about being a Research Subject: If you have any concerns about your treatment or rights as a research subject, you may contact the Research Subject Information Line in the UBC Office of Research Studies at 604-822-8598. Consent: Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from the study at any time. Your signature below indicates that you have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study. __________________________________ __________________________ Subject Signature Date __________________________________ Subject name (printed) Therapist Informed Consent Version Date: February 7, 2012 Page 3 of 3 236 Appendix I: Client Informed Consent Consent Form An Inquiry into How Positive Emotion is Utilized by Clients and Therapists When They Perceive it has Arisen for the Client in Psychotherapy Sessions Principal Investigator: Dr. Norman Amundson, UBC Department of Educational and Counselling Psychology, and Special Education (Counselling Psychology Program, telephone munber) Co-Investigator: Dianne Westwood, UBC Department of Educational and Counselling Psychology, and Special Education (Counselling Psychology Program, telephone number) The research conducted for this study will fulfill part of the dissertation requirement for a PhD degree for Dianne Westwood under the direction of Dr. Norman Amundson. It will eventually be made available to the public. Purpose: The purpose of this study is to explore how clients and therapists understand their experiences when emergent or expressed positive emotion occurs for the client, and is attended to in counselling and psychotherapy sessions. Most of the research about emotional expression in counseling and psychotherapy sessions is about distressing emotions expressed by clients. Your participation will help us understand how clients and therapists work with positive emotion in therapy sessions. Expressing emotions in counselling and psychotherapy is usually considered helpful by clients, but we do not understand how this actually works in being helpful. Study Procedures: If you agree to participate in this study, you and your therapist will be asked to videotape all your counselling/psychotherapy sessions from the commencement of the study until such time as your therapist identifies a session in which you and your therapist attended to and/or explored your expression of positive emotion. You will also be asked to take part in a 2-3-hour interview in which you will review playback of the selected counselling/psychotherapy session and discuss your experiences during times you identify that you and your therapist were engaged in identifying, attending to and/or exploring positive emotion expressed by you. Client Informed Consent Version Date: February 7, 2012 Page 1 of 3 Department of Educational and Counselling Psychology, and Special Education The University of British Columbia Faculty of Education 2125 Main Mall Vancouver BC Canada V6T 1Z4 Tel 604-822-0242 Fax 604-822-3302 www.ecps.educ.ubc.ca 237 In addition, after the interviews are transcribed and analyzed, you will be asked to participate in a 1-hour interview to review the results, to provide your feedback to the researcher, and to discuss any remaining questions or comments you may have, including any positive or negative impacts of the study that you wish to share. The total amount of time required of you is approximately 4-5 hours. Any questions you have regarding the study procedures may be directed to the study co-investigator, Dianne Westwood at [telephone number]or [researcher’s email address] Potential Risks: Reviewing video playback and discussion of your counselling/psychotherapy session may be uncomfortable or even trigger distress for you. You may indicate this at any time and we will move on to other segments of the videotape, or if you prefer, take a break, or even stop the interview. Your participation in this study is completely voluntary. You may refuse to answer any questions or provide any information. You may also withdraw your participation at any time during the interview or after the interview. Your therapist will not be informed of your decision to withdraw, except with your permission. The interview is meant to be reflective, not therapeutic. If issues arise that need therapeutic attention, you are encouraged to discuss this with your therapist. A list of appropriate and affordable counselling services will be provided to you before the interview begins, in case you decide you would benefit from counselling support, and you do not wish to discuss this with your current therapist. Potential Benefits: The potential benefits of talking about your counselling/psychotherapy experience include gaining new insight(s) into your experience that you did not previously have, and sharing your experience may be helpful to others. It may also affect your relationship with your therapist in a positive way. You will be compensated for your participation in this study. Confidentiality: All efforts will be made to ensure your identity remains confidential. Any information that is obtained in this study will remain confidential and will be disclosed only with your permission or as required by law. You will not be identified by name in any reports of the completed study. Direct quotes from the interview(s) may be reported in the findings of this study, but these quotes will not reveal any identifying information. All printed documents, audio and video-tapes will be kept in a locked file cabinet, and all electronic files will be password protected on computer hard drives. Within five years all the data will be destroyed. The only individuals who will have access to the videotapes and transcripts are: my research dissertation committee members, and two expert peer reviewers during the analysis period. The expert peer reviewers will be a senior Counselling Psychology doctoral student at UBC, and a recent PhD graduate from Counselling Psychology at UBC. Both are knowledgeable in therapeutic and emotional processes. Their role is to validate that the findings of the research correspond directly to thoughts, and experiences described by participants like yourself. Client Informed Consent Version Date: February 7, 2012 Page 2 of 3 238 Remuneration/Compensation: You will be reimbursed for the cost of transportation to and from the interviews by the co-investigator. In addition, you will receive a $150.00 honorarium for the time spent in the two interviews. Contact Information About the Study: For further information about this study you may contact Dr. Norman Amundson, the Principal Investigator at [telephone number]. Contact for Concerns about being a Research Subject: If you have any concerns about your treatment or rights as a research subject, you may contact the Research Subject Information Line in the UBC Office of Research Studies at 604-822-8598. Consent: Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from the study at any time. Your signature below indicates that you have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study. __________________________________ __________________________ Subject Signature Date __________________________________ Subject name (printed) Client Informed Consent Version Date: February 7, 2012 Page 3 of 3 239 Appendix J: Interpersonal Process Recall (IPR) Interview Format Orienting Interview Statement: I am interested in hearing about your experience during this session. In particular, I am interested in talking to you about what you were experiencing at those points in your (the) session when you were experiencing and/or expressing positive emotion (you thought that your client was experiencing/expressing positive emotion). For this study, I am defining positive emotion as: “any emotion experienced and labeled by a person as being positive for her/him. This may include, but not be restricted to states such as awe, joy, contentment, love, gratitude, interest, pride, amusement, inspiration, hope, and a felt sense of personal rightness. It may also include the sense that things are proceeding satisfactorily towards an intended purpose.” However, you may define it in another way, and I would like to hear about how you may define it for yourself. The participant will then be asked to use the remote control to stop the videotape of the session at any and all points in the session that are related to positive emotional emergence, experiencing, or expression by the client. At every point we will watch the segment together and I will ask the participant two main guiding questions: “what were you thinking there, at that point?” “what were you feeling/experiencing/sensing, at that point?’ There may be other questions I will ask to facilitate the participants to re-orient to the “then and there” of the session rather than what they may be experiencing or thinking in the “here and now” of the interview. For example: “As you reflect on that moment . . .” or “Taking a step back from that moment . . .” In addition, I will ask facilitating questions to assist clients to elaborate on their thoughts and feelings. A list of examples follows. Possible facilitating questions:  What do you think you were experiencing?  I notice your eyes dropped (or other facial or bodily expression or movement), what do you think was going on for you there?  Tell me more about that, if you can… is there anything more?  I have a sense that you may be saying more than one thing. Can you tell me about that?  So you are feeling _____ now as you see yourself, what do you think you were feeling then?  What body sensations were you aware of? Once we have explored all the segments identified by the participants, I will identify segments of interest to me that have not been reviewed. I will follow the same interviewing guidelines. At the end of the interview, I may ask something like: “How do these segments contribute to the overall session, in your mind?” IPR Interview Protocol Version January 24, 2012 Page 1 of 1 240 Appendix K: Example of Organization and Initial Coding of Positive Episodes and Post Episode Dialogue Dyad 2 Episode 7 A B C A: Therapy Session Researcher Coding of A Researcher Notes on A B: Client Reflections on A Researcher Coding of B Researcher Notes on B C: Therapist Reflections Researcher Coding of C Researcher Notes on C Line 598.C: It’s like home, but home in a dream. Yeah. 599.T: Yeah. That’s so well put. It feels like home, but home in a dream. 600.T: It’s unfamiliar. 601. C: Yeah. 602. T : But, somehow 603. C: It’s really nice. It’s really comfortable. 604. T : Yeah. 605. C: It’s really like I could spend a lot of time here. 606. T : Uh hm. 607. C: You know. 608. T : Yeah. It fits. It’s just not where you’ve been. 609. C: Yeah. And I really want it . 610. T : Yeah. But it…[whispers] 611. C: (laughing) 612. T : Welcome. 613. C: Yeah. It’s nice to be here. (laughing) 614. T: Yeah, what’s .... Well, how is it? 615. C: Third try shy. (laughing) Line 616. T: How do you feel right now as you share that with me that it’s nice? 617. C: It feels like if – like if, you know, actually I feel it in the shoulders in a ... Recognizing something unfamiliar that feels familiar. Feeling good and comfortable Feeling the rightness or “fit” of it Connecting the feeling of rightness to his desire or preference for it Noting its goodness (of fit) Nearly there Feeling energy and strength Exploring what it’s like, this good feeling. Inviting client into metatherapeutic processing about feeling good. ... Like home in a dream Pleasure 3rd try shy! Making the implicit somatic experience explicit ... Line 1066 [VIEWING VIDEO lines 580-657] 1067. C: I really like that part. (610 interject) 1068 [VIEWING VIDEO, line 612 interject] 1069 C: Home in a dream. I really like that term. I really like this, liking his own metaphor! Delighting in own self experience Interesting, at edge of his own development here? State 3? In flow, ease, vitality, his own truth sense Line 869. T: So, again, I’ve been thinking state three – state three. It feels good, 870. T :but it’s not where I’ve been dwelling. But it fits, it’s unfamiliar. I’m just 871. T : trying to elaborate, make explicit what I think he’s experiencing and what 872. T : he’s telling me. 873. R: Uh hm. 874. T : And I welcome him to it . 875. R: Hm. Uh hm. 876. T : And I think he gets pulled out of it with all that, like extra stuff like 877. T : we were talking about before. That’s – that 878. T : might be shame based or it might be vulnerability based. I’m not quite sure, but I will explore it with 879. T : him at some point. I’ll invite him to see if a shift happens. If he has 880. T : experience and then he puts something on for me. I’ll find a way to talk with him about that stuff. ... Making implicit explicit Welcoming client to his new experience Hypothesizing and making mental note to return to this at a later time 241 Appendix L: Preliminary Theme Summaries Code Summaries A = emotion expressed/experienced + what triggered the emotion. Taken from codes of therapy session transcript and codes from interview with client and therapist. These emotional episodes were selected by either or both client and therapist during their interview. B = what did they do with the positive emotion (A)? Taken from codes of the therapy session transcript that followed the emotional episode i.e. what followed the expression or experiencing of positive affect (A) in the session transcript directly points to the research question: how do clients and therapists utilize positive emotion when it arises for the client? C = overall description of the episode and post episode (theme) T : Therapist C: Client R: Researcher Episode Dyad 1 Dyad 2 Dyad 3 1 Identified by both client and therapist A: Emotion and trigger: client expresses relief, triggered by being asked how she is doing since last session and recalling she feels better since clearing up some legal issues, comparing how she felt afterwards and realizing how the issues had been affecting her. Therapy session segment: Lines 28-39: C: I’m feeling good. Like it’s a sort of funny combination of things. Ah, … Um, I think I’ve been feeling good. Like, I’ve been feeling pretty happy and, and – and calm and… T : (pause) Calm. That sounds – that sounds good. C: Yeah. Yeah, it’s good. T : Uh hm. C: I think – I think it really did – it really did make a difference for me to get that whole legal thing out of the way. T : Yeah. C: With[partner]. Like… it… It did, um, it did make a big difference. Th yeah …and I knew that it would. I just don’t think that I really appreciated up until it - the time that it was over, is to how how much it had been affecting me. Client interview segment: Lines 68-79. 1. C: “I’m feeling feel sort of relief. But I don’t - like I don’t feel it . … R: Okay. 2. C: And so - so we’re sort of getting to that part now where he’s like – and then we’ll spend a few minutes talking about that – about how I just – I don't know it’s not – it’s not there. I don’t have a feeling. R: Okay. 3. C: But it’s - it’s - it’s thoughts are - my thoughts are positive. 4. R: Your thoughts are positive. You have a sense that things are moving in a direction that is going to be a positive. C: Yeah, a sense of optimism, a sense of relief, a sense of well-being. Lines 109-125 C: Is that he sort of stops, stops me and says “What’s your feelings?” And so because it’s not natural for me – that’s not my – that’s not how I operate. R: Uh hm. Identified by both client and therapist A: Emotion and trigger: Client expresses pleasure, excitement. Triggered by coming to the session, and to how attuned the therapist is to him, and that he considers the therapy space (I like coming here) as a safe base to connect in with himself and his life Therapy session segment: Lines 1-11 T : Hi. So take a moment to settle in. C: I like coming here. T : Yeah. What sensation inside tells you that you like coming here? C: It feels like the things we’re doing here, I’m very much taking and - and ah they’re not compartmentalized just here. … You know, they’re very much flowing into the background of my – of my – the way I’m approaching the rest of, the week. T : Oh, beautiful. Lines 23-30 C: And then just arriving here, I just felt more of the same. You know and it just feels nice to have that continue – continuity of being able to check in, in my life T : Yeah. C: and knowing kind of where I am and how I’m doing and - and - and having that base I feel like to give other people love and support. Because I don’t have my own things that I’m struggling with. I’m more in my heart than in my head. Client interview segment: Lines 91-92 C: (laughing) It’s like ah just really, really ah excited by somebody being that attuned to me. Lines 103-104 C: um how there’s this continuity between what I’m learning with [therapist]and what’s going on in the rest of my life. Lines 143-144 C: It’s kind of like stepping back for a minute and just looking at what I’d created with him in the first two minutes of sitting down. Lines 164-165 C: I’m not sure how to put it. Um, that feels like – that feels and looks like my natural state of what human beings should Identified by both client and therapist A: Emotion and trigger: Client feels happy, welcomed and she said she trusted she was in good hands. This was triggered by the therapist stating he was happy to see her and sit with her. Therapy session segments: Lines 1-13 T : What? C: Here we are again (laughing). T : Yeah, we are. C: That’s wonderful (laughing). T: Oh good. That’s so nice to hear. C: Well, it’s so good to come here. T: Well. I’m happy to sit with you. C: Oh, thanks. T : Yeah. C: I always feel as if you are. (laughing) Yeah. T: Well, it’s true. What’s it like that it brings happiness to me as well? C: Well, it - it makes the mutuality. T : Yeah. Uh hm. Client interview segments: Lines 2-7 C: Like that was an enclosed space where I could just be. And anything I said wouldn’t be judged. R: Oh, okay. C: I wouldn’t need to watch myself in any way or be guarded. That I would be really safe in that space. Lines 48-52 C: So, I know what I’m - I’m going for. And it was the sort of trust and knowing that he would help me … R: Uh hm. Uh hm. C: get out of being stuck. Therapist interview segments: Lines 5-6 T : … I’m wanting to join with her appreciating our connection. So, it’s a - a sense of taking delight. Yeah, , her taking delight in our being together. Lines 54-57 T : Sure. Is just the um very consciously self disclosure around my experience that it’s important that she understands, um. well below, gets/feels that I am happy to 242 Episode Dyad 1 Dyad 2 Dyad 3 C: The only thing I think that changes for me is that when he says, “Okay, let’s stop for a second and talk about your feelings.” I’m kinda like going, “Oh, not this again.” (laughing) R: So, not your feelings… you can actually feel yourself t ighten up again C: Not the feelings again. (laughing) R: Yeah, okay. (laughing) So, it’s kinda like um bracing or something. Is that …? C: Yeah. R: Yeah, a lit t le bit and that has felt good. Am I getting that part right? C: It’s like “Okay, here we go again.” Although, I mean that’s just my intellectual reaction or my – I don't know it’s some kind of reaction, but I know that that’s why I go … so it’s some – there’s a – there’s a twofold reaction to that, yes. Therapist interview segment: Lines 71-74 T: Maybe this is a lit t le early to do it . “Just notice what the feels like in your body.” But I’ve been told by her that she only feels things in her head. And that it’s okay to ask her “Do you feel something?” But not to try and elicit what she feels, so that’s constraining. (laughing) Lines 89-90 T: Um, I’ve been told to – that there are very – I have to lean in, in very cautious ways. Lines 156-157 T: we’re just at the little emerging, fleeting … yeah, I’m experiencing embodied relief. It’s mirror neuron – relief, it’s empathic relief. B: What did they do with A? They stayed with the awareness of the relief. The therapist gently paid attention to the client’s experience by asking her about it, client notes she has an awareness of something, cannot locate it somatically or describe it when attention is placed on it . As they did this her awareness of “ still some hard bits.” Therapy session segment: Lines 40-53. T : Yeah. So, as you say, are you also aware, right now, as we speak of feeling some of the difference it makes having it over? Or is it more like reflecting on that’s how it’s been, and not feeling so much right [now] that’s (unclear). C: Yeah, I guess so. I feel it … in my … in my head. T : Yeah. C: It’s more of a thought though … than… T: Okay. So, you have an awareness right now that it’s made a big difference C: Yeah. Yeah. Client interview segments: None for this part of the session Therapist interview segments: None for this part of the session. C: O verall Theme: “Evenly hovering attention.” Settling in together. Am I on the same page as you? Is it safe enough to go ahead? Can I have my feelings in my head without you look and feel like. Therapist interview segment: Lines 22-25 T: That’s a positive attitude there … So, obviously there’s positive affect. He sits down and says I like coming here and smiles and it seems really genuine B: What did they do with A? In “A” they enacted/ painted a picture of a secure base. Then they started to pay attention to what it’s like to be feeling this pleasure in being in the session. What emerges is the client’s relational capacity (it’s good and difficult) to feel good in the presence of another. Worked at edge of client’s receptive capacity. As this unfolds we see further fueling of the trust, and relationship strengthening through the responsiveness and availability of therapist (attunement). This manifests in client being touched by being seen so accurately, but gently and playfully (lines 224-227 in client interview). Therapy session segments: Lines 32-43 T: Wow, that’s a lot. Notice, what - as you um as you realize that what we’re doing here together is actually… What just … something just shifted for you, just now… C: Yeah. (laughing) It’s just nice. T: Stay with nice. (client laughing) … I want to get a sense of what nice looks like. Stay with nice and stay with me together. C: (laughing) Yeah. Exactly yeah. T: It’s something. Yeah. What sensation inside tells you that it’s nice to be here with me, doing this work? C: It feels just kind of like a - a welling up from my chest, you know. And it feels like there is this kind of spring – like - like every spring you don’t really know … Lines 53-59 T: Yeah. Great. So. Well, what’s it like to tell – to tell me about it . … How is that for you? Right now. C: It’s difficult. It’s difficult ah I mean it’s easy, it’s nice. But at the same time it’s difficult … T: Uh hm. Okay, it’s both. C: In - in the sense that when I feel that way – I feel almost embarrassed. You know, Lines 76-79 C: You know and it’s – it’s interesting because it feel so nice. And I think people like kind of being there and being and seeing it and being in the presence of it. But at the same time, it feels like one of those things that should be in private. Client interview segment: Lines 191-192 C: but it seems that with me there’s a difficulty between being in this blissful state [feeling pleasure] um and still being checked in with people. … You know because I’m – I’ve accustomed myself to this blissful state by way of meditation. Um, and so meditation, for me, has always been a really solitary practice. Um, with anyone else around, usually they’re a distraction. And so to have someone immediately in front of me, while I’m in this meditative state [feeling good], makes me think that you know I have to look down, I have to look be with her. Um, and so that there’s a mutuality in our shared delight in being together. Lines 76-77 T : now that I, through AEDP, I understand the um ah how that ah solidifies deepens and feels the - ah - safety um that’s why I really am leaning into that. B: What did they do with A?: They metaprocessed the positive feelings between them – that is what it is like for the client to see, hear, know that her therapist is[also] happy to be in her presence? From the perspective of the therapist he intentionally “leaned into” this to build their connection and to further the possibility that she would be able to move into her deeper, painful experiences which she came to therapy to process and understand better. In addition, they extended the good feelings of welcome into some playful laughter about their shared cultural heritage. The therapist says: “ if we can play together, we can work together.” used these good feelings and mutuality between them to “fuel the tank of togetherness.” Therapy session segments: Lines 11-28 T: Well, it’s true. What’s it like that it brings happiness to me as well? C: Well, it - it makes the mutuality. T : Yeah. Uh hm. C: You know, it’s - it’s part of our relationship. T : Yeah. Uh hm. C: We are here in harmony. And you know we’re like …. I never get the feeling you’re saying [yawning] “Oh, Okay, (sigh), (laughing) what’s wrong with her now (laughing)?” T : (laughing) No, no. C: I am putting it in the negative, that’s very [cultural heritage] (laughing) T : Okay. (laughing) See, I learn more and more about my culture from you every day than from my own family. C: Yeah, yeah. T : Yeah. Of course they were generations removed, so C: Yeah, but when [cultural group] people – when they came they don’t say, “No, no, no that’s right. It’s the weather” (laughing) T: (laughing) No, no, no, that’s right. I remember I was in a pub in[city name], I … guess, when would that be? About – oh more than 15 years ago Client interview segments: Lines 62-83, 97 C: And I felt attuned to you and I was predisposed to feel that way because of the connection with [therapist]. … C: And talking to you had reinforced that. And this was the third side of the triangle I was telling him …. C: I had made a good connection with you and he was, then, reinforcing that, again. R: Right. That makes so much sense. Because I felt the same thing. As soon as I heard your voice on the phone, I 243 Episode Dyad 1 Dyad 2 Dyad 3 expecting something else, something different? away to maintain it , um, because the other person would just be a distraction. The nuances in their face or the you know um it’s almost like a vulnerability being in this … Lines 205-217 C: Looking at someone in the eyes. Um, because it – I - I - I feel like it would be very easy to be judged in that state when you’re so exposed and so kind of like feeling that, you know it’s - it’s sort of a new state for me over the last year or two. Um and it’s taken a lot of work to get to it , so I’m afraid of losing it or afraid of someone injuring it or hurting it or whatever. But ah not to go on negative emotions for a lit tle bit, but um that that’s kind of my reason for the difficulty ah, there, why I look down. And then I think of the positive emotion I came up is when he recognized that, again, and then – and then you know sort of challenged me gently to say, okay, you have this state, but you look away when you have this state. Try to look up a lit tle bit . Connect with me while you’re in that state. And then that made me laugh. I think he went like this. Because it was almost like, “Oh, you got me.” (laughing) Therapist interview segment: Lines 143-144 T: Can you be in your experience and be in relationship? It’s that simple. For me – my theory has always been [whisper]. So let’s see what happens. Lines 162-164 T : And staying with me – all of that came out of stay with me. But all of that came out of how hard it was to feel good and be seen when you feel good. C: O verall theme: As the waters of the well spring flow, things get stirred up. It’s hard to be in relationship, can I feel good and be with you? just had a sense of being attuned. I’m thinking, “Oh, this just feels nice.” C: Yeah. Yeah. … C: Yeah and it and we were able to take each other and trust because of it really is a triangle, yeah. T: Yeah, I know. Yeah, that’s nice. Yeah. And so what do you think you were experiencing there? C: I …. R: Or sensing? Of if you have….? C: I felt reinforcement of … R: Okay. C: I was in good hands. … But with this vulnerable stuff you need to feel safe. Therapist interview segments: Lines 107-111 C: … there’s a conscious evel of which I’m um being her student. Or um equalizing the relationship, which is not equal. R: uh hm. T : But which in a consciously make – ah honouring what she can give me. Um furthering our good connection. It’s more of the same. Lines 123-125, 131-132 T : Right, well, I also know – I mean we’re going into – working more deeply with um probably the second – you know what I mean by second behind – but the second major trauma in her life. Or third. Um, you know T: Um, but I’m also, knowing where we’re going, it’s kinda like put extra fuel in the tank of togetherness Lines 142-150 T: So, the other thing I’d say is that ah you know I’m mind – more mindful now that ah um play, which is what – we’re playing. R: Uh hm. T : Um is just kind of deepens all the attachment, connection, dyadic, so we’re playing together. R: Okay. T : So, we’re having fun together. R: Yeah. T : Which means we also work together. C: O verall theme: Fueling the tank of togetherness” Feeling good together fuels the relationship, the sense of safety, trust . 244 Appendix M: Final Distillation of Process Themes Note: Numbered by dyad and episode. For example 1.1 = dyad 1, episode 1 Themes by Episode First Distillation of ProcessThemes Final Process Themes 1.1 using relief to pay attention to safety 1.1 using relief to pay attention to safety 1. paying attention to safety 1.2 imagining more pleasure 1.2 imagining more to scaffold new and/or emergent experience 2. fueling the tank of togetherness 1.3 exploring what it 's like feel relief, let go 3. trusting the process and seeing where it leads. 1.4 staying with it & imagining more relief and joy, feeling good together 1.3 feeling good together resources, expands self-experience and therapeutic relationship 4. making implicit experience explicit and experiential to make connections and build awareness 1.5 exploring & disentangling complexity 5. undoing aloneness 1.6 making implicit experience explicit, explicit experience experiential 1.4 making implicit experience explicit and experiential to expand awareness and increase understanding 6. affirming, anchoring and appreciating the work done together 1.8 affirming and validating the positive affect in mixed affective experience 1.6 affirming, validating , and acknowledging the work and gains 7. imagining more to scaffold new experience 1.9 affirming and acknowledging relief in mixed experience 8. being guided and guiding through a hard place 2.1 paying attention to safety and pleasure we have being here together 2.1 paying attention to safety to create a secure container or base for therapeutic work 9. balancing giving and receiving 2.2 invitation to notice pleasure in being together, notice how it stops 2 2 feeling good with another resources/expands self experience and deepens the working relationship 2.3 invitation to metaprocessing, what's it like to do this together. 2.3 invitation to metaprocessing, what's it like to do this together. 2.4 let 's just follow this and see where it goes. 2.4 trusting the process and seeing where it leads. 2.5 making implicit internal experience of ease, pleasure explicit, and experiential 2.5 making implicit experience explicit and experiential to make connections and build awareness 2.6 making implicit pride and mastery explicit, experiential, to expand awareness 2.7 invitation to metaprocessing, what is it like to do this together? Co-creation in action 2.8 making implicit gratitude, surprise, pleasure explicit , experiential, and relational 2.9 metaprocessing the shared pleasure, connection and we did a good job 2.6 affirming and appreciating the work done together 3.1 paying attention to to feeling good together 3.1 fueling the tank of togetherness and getting ready to work 3.2 client leads with hidden feelings of relief and "lift" and therapist follows client's lead 3.2 trusting the process and seeing where it leads 3.3 accompanying client into the hard bits acknowledging or having strength seen 3.4 being together in a hard place. 3.5 undoing aloneness. 3.3 undoing aloneness. 3.6 being guided or guiding through, therapist leads, clients follows. I know the way through. 3.4 being guided or guiding through a hard place 3.7 exploring new understandings with humor and mutual care 3.8 making emergent implicit relief, surprise explicit and experiential to expand understanding 3.5 making emergent implicit experience explicit and experiential to expand understanding 3.9 metaprocessing how new understandings were co-created after the emergence of gratitude 3.10 invitation to reflect and anchor the work by entraining gratitude 3.6 anchoring, affirming the work done together 3.11 balancing giving and receiving 3.7 balancing giving and receiving balances power differential, and affirms and builds strength
Thesis/Dissertation
eng
Counselling Psychology
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
How do clients and therapists utilize positive emotion in psychotherapy sessions?
Text