Intensive short-term dynamic psychotherapy (ISTDP) therapists’
experiences of staying with clients’ intense emotional experiencing:
An interpretative phenomenological analysis
Alan Flynn
1426788
A thesis submitted in partial fulfilment of the requirements of the School of
Psychology, University of East London for the degree of Professional Doctorate
in Counselling Psychology
April, 2019
ii
Abstract
This study aimed to explore Intensive Short-Term Dynamic Psychotherapy
(ISTDP) therapists’ experiences of staying with their clients’ intense emotional
experiencing. Semi-structured interviews were conducted with five qualified
ISTDP therapists. Participants’ accounts were analysed using Interpretative
Phenomenological Analysis. The analysis generated three superordinate
themes: (1) “Opening that door”: striving for emotional closeness, (2)
Connection versus disconnection: what’s happening in the room, and (3)
“There’s more of myself now”: building one’s own capacity. These themes were
each supported by several subordinate themes that highlight the complexities
and ambiguities inherent in intensive, experientially-focused therapeutic work
from a psychodynamic perspective. The findings of the study reveal: (1) a
paradox of the moment-by-moment precision aimed for by therapists, whereby
effectiveness can be accompanied by a heightened focus on what gets missed;
(2) how therapists make sense of the therapeutic relationship as a place of
safety and risk; and (3) the importance of deliberate practice to help therapists
build their capacity to work effectively with their clients’ deep emotions.
Participants’ accounts also suggested that core features of the theory and
practice of ISTDP, such as its analytic stance and active, collaborative style,
aligns well with counselling psychology’s concern for integrative, evidenced-
based practice that prioritises the therapeutic relationship as the vehicle for
change. Applicability to clinical practice in counselling psychology is
highlighted. Future directions include research into the somatic experiences of
therapists involved in helping facilitate a therapeutic experience of emotion with
their clients.
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Table of Contents
Abstract ............................................................................................................. ii
Table of Contents ............................................................................................. iii
List of Tables ................................................................................................... vii
Abbreviations ................................................................................................. viii
Acknowledgements ......................................................................................... ix
Chapter One: Introduction ............................................................................... 1
1.1 Chapter One Overview ............................................................................... 1
1.2 Research Aims ............................................................................................ 1
1.3 The Research Origins: A Personal Context ............................................. 2
1.4 The Positioning of the Researcher ............................................................ 3
1.5 Introduction to ISTDP ................................................................................. 4
1.6 Terms of Reference: “Emotional Experiencing”, “Intensity” and
“Staying With” ................................................................................................... 5
1.6.1 Emotional experiencing. ............................................................................. 5
1.6.2 Intensity. ..................................................................................................... 6
1.6.3 Staying with. ............................................................................................... 6
1.7 Relevance of the Study and Contribution to Counselling Psychology . 6
1.8 Thesis Style and Structure ......................................................................... 7
1.9 Chapter One Summary ............................................................................... 7
Chapter Two: Literature Review ...................................................................... 9
2.1 Chapter Two Overview ............................................................................... 9
2.2 The Process of the Literature Review ....................................................... 9
2.3 Defining Emotions and Emotional Experiencing ................................... 10
2.4 Emotional Experiencing and the Therapeutic Endeavour .................... 11
2.5 Historical Overview of the Development of STDP ................................. 15
2.6 Development of ISTDP and Various EDT approaches .......................... 17
2.7 Researching In-session Emotional Experiencing in Psychotherapy
Process Research ........................................................................................... 20
2.8 Expert Therapists ..................................................................................... 21
2.9 Therapists Effects ..................................................................................... 22
2.10 The Practice of ISTDP and Implications for the Role of Therapist ..... 23
2.11 Therapists’ Capacity to Reflect On and Use Their Own Emotional
Experiences ..................................................................................................... 25
2.12 Researching Therapists’ Experiences .................................................. 26
2.13 Epistemological and Methodological Positioning in the Literature ... 28
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2.14 Rationale for the Current Study ............................................................. 29
2.15 The Current Study and Research Question ......................................... 30
2.16 Chapter Two Summary ........................................................................... 30
Chapter Three: Methodology ......................................................................... 32
3.1 Chapter Three Overview ........................................................................... 32
3.2 Purpose of My Research: Qualitative vs. Enriching Research ............. 32
3.3 Methodological Approach: Why Hermeneutic Phenomenology? ........ 33
3.4 Rationale for Using IPA ............................................................................ 34
3.5 IPA Method – The Research Process ...................................................... 37
3.5.1 Participant and recruitment procedures. .................................................. 37
3.5.1.1 Sampling method. ................................................................................. 37
3.5.1.2 Inclusion/exclusion criteria. ................................................................... 38
3.5.1.3 Recruitment strategy. ............................................................................ 38
3.5.1.4 Choosing the participants. .................................................................... 39
3.5.1.5 The five participants. ............................................................................. 39
3.5.2 Data collection. ........................................................................................ 40
3.5.2.1 Interviews. ............................................................................................. 40
3.5.2.2 Confidentiality, anonymity, and data security. ...................................... 42
3.5.3 Data analysis. .......................................................................................... 43
3.5.3.1 Step one: Reading and re-reading. ....................................................... 44
3.5.3.2 Step two: Initial noting – producing detailed annotations and comments.
............................................................................................................... 44
3.5.3.3 Step three: Annotating and developing emergent themes. ................... 45
3.5.3.4 Step four: Searching for connections across emergent themes within the
participant’s account. ........................................................................................ 46
3.5.3.5 Step five: Moving to the next case and repeating steps one to four. .... 46
3.5.3.6 Step six: Looking for patterns across cases. ........................................ 46
3.5.4 Enriching research and quality. ............................................................... 48
3.5.4.1 Sensitivity to context. ............................................................................ 48
3.5.4.2 Commitment and rigour. ....................................................................... 48
3.5.4.3 Transparency and coherence. .............................................................. 49
3.5.4.4 Impact and importance. ........................................................................ 49
3.5.5 Ethical considerations. ............................................................................. 49
3.6 Chapter Three Summary .......................................................................... 50
Chapter Four: Analysis .................................................................................. 51
4.1 Chapter Four Overview ............................................................................ 51
4.2 Overview of Themes ................................................................................. 51
4.3 Superordinate Theme One: “Opening That Door”: Striving for
Emotional Closeness ...................................................................................... 52
4.3.1 “It’s really rewarding”: the motivating power of seeing a person change. 53
4.3.2 “Not giving up on the route to getting there”: persevering through
resistance. ......................................................................................................... 56
4.3.3 “Trying to decide where to go next and how to proceed”: pressure and
focus on accuracy. ............................................................................................ 58
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4.4 Superordinate Theme Two: Connection vs Disconnection: What’s
Happening in the Room .................................................................................. 61
4.4.1 “A shared experience”: connection and intimacy in the therapeutic
encounter. ......................................................................................................... 62
4.4.2 “It's painful not to be able to reach a patient”: feelings of frustration and
inadequacy. ....................................................................................................... 65
4.4.3 “Talking to myself”: remaining calm and professional. ............................. 68
4.5 Superordinate Theme Three: “There’s More of Myself Now”: Building
One’s Own Capacity ....................................................................................... 71
4.5.1 “You get better…you get more emotion in the room”: building emotional
tolerance. .......................................................................................................... 71
4.5.2 “Those minute flickers”: observing and reflecting on inner emotional life. 74
4.5.3 “Knowing enough about myself”: using and protecting the self. .............. 75
4.6 Analytic Summary ..................................................................................... 77
4.7 Chapter Four Summary ............................................................................ 78
Chapter Five: Discussion ............................................................................... 80
5.1 Chapter Five Overview ............................................................................. 80
5.2 Situating the Research Findings Within the Wider Context of
Psychodynamic Practice in the UK ............................................................... 80
5.3 Summary of the Research ........................................................................ 82
5.3.1 Paradox of precision. ............................................................................... 83
5.3.2 The therapeutic relationship as safe and risky. ....................................... 87
5.3.3 The importance of deliberate practice. .................................................... 90
5.3.4 Summary of the discussion of superordinate themes .............................. 92
5.4 Working with the Therapeutic Relationship from an ISTDP Theory
Perspective ...................................................................................................... 92
5.5 Methodological Critique of the Study and Quality Issues .................... 93
5.5.1 Critique of IPA. ......................................................................................... 93
5.5.1.1 The role of language. ............................................................................ 93
5.5.1.2 The suitability of participants’ accounts. ............................................... 94
5.5.1.3 IPA’s descriptive nature. ....................................................................... 94
5.5.1.4 Cognition and phenomenology as discordant. ...................................... 95
5.5.1.5 Quality issues. ....................................................................................... 95
5.6 Reflexivity on the Research Process ...................................................... 96
5.7 Implications of Findings for Practice in Counselling Psychology ....... 98
5.8 Implications for Future Research ............................................................ 99
5.9 Summary of the Study ............................................................................ 101
References ..................................................................................................... 102
Appendix A: Participant Information Sheet ................................................ 118
Appendix B: Demographics Questionnaire ................................................ 120
Appendix C: Consent Form ......................................................................... 121
Appendix D: Interview Schedule ................................................................. 122
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Appendix E: Debrief Form ............................................................................ 123
Appendix F: Transcript Analysis: Initial Noting Extract ............................ 124
Appendix G: Clustered Themes For One Participant ................................ 125
Appendix H: Cross Reference to Theme Table .......................................... 126
Appendix I: Application for Research Ethics Approval ............................ 127
Appendix J: Notice of Ethics Review Decision .......................................... 134
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List of Tables
Table 1 Superordinate and subordinate themes ............................................... 52
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Abbreviations
ACT
BPS
Acceptance and Commitment Therapy
British Psychological Society
CBT
CFT
EDT
HCPC
Cognitive Behavioural Therapy
Compassion Focused Therapy
Experiential Dynamic Therapy
Health Care Professions Council
IPA
Interpretative Phenomenological Analysis
ISTDP
NICE
STDP
Intensive Short-Term Dynamic Psychotherapy
The National Institute for Health and Care Excellence
Short-Term Dynamic Psychotherapy
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Acknowledgements
I would like to express my sincere thanks to my supervisors Dr Melanie
Spragg and Dr Stelios Gkouskos for their encouragement and support with this
project and throughout the programme. I would also like to thank Dr Lisa Fellin
for inspiration and induction to the complexities and delights of
doctoral research in counselling psychology. Thanks also to Dr Lymarie
Rodriguez-Morales for her methodological support and for her dedication to
helping me accomplish this research. I am grateful for the support of Dr Sharon
Lewis who helped me develop this research idea and reach out to the ISTDP
community. I would like to thank my research participants for their courage and
generosity in agreeing to take part in this study and for the exceptional glimpse
into their therapeutic worlds. I am also very grateful for the support of my fellow
trainees for their good humour and steadfast companionship throughout the
research and training process. I am grateful for the input of my viva
examination team, Dr Catherine Athanasiadou-Lewis and Dr Jeeda Alhakim, for
insights that greatly boosted the quality of my final submission, and to Dr Claire
Marshall for her role as Chair and for support across the programme. My dear
friend Professor Walid Saleh has been my touchstone and guardian angel,
always there for me, and so I dedicate this research to him. Doctoral research
is a privilege for the researcher that involves frequent sacrifices for those
around them: a wholehearted thank you to my mother and family and friends for
their love and care and for the financial support that made this rewarding
experience possible.
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Chapter One: Introduction
In order to create profound moments of meeting with patients,
the therapist must be an emotionally engaged and available
presence, capable of intimacy and closeness…. it involves
exposing ourselves to our patient’s intense feelings and often
primitive unconscious material (not to mention our own!). We not
only deal with a patient’s feelings toward others, but encourage
the patient to face, experience, and express [their] intense mixed
feelings toward us directly. This requires a great deal of
emotional stability on the therapist’s part. The capacity to tolerate
intimacy and closeness with another, while regulating our own
emotions…. (Coughlin, 2017, p. 197)
1.1 Chapter One Overview
This introduction chapter first outlines the aims of the research. Next, I
situate this study in a personal context by providing a brief outline of my
professional journey that ignited my interest in carrying out a piece of doctoral
level research into therapists’ experiences of facilitating a therapeutic
experience of emotion. I continue by foregrounding my epistemological and
ontological position with the aim of introducing its philosophical foundations and
my methodological choices, topics that are more fully explored in Chapter
Three. This is followed by definitions of key terms of reference: “emotional
experiencing”, “intensity”, and “staying with”. The chapter concludes by
outlining the relevance of this topic to counselling psychology, and the structure
of the rest of the thesis followed by a chapter summary.
1.2 Research Aims
This study is the first of its kind that I know of to investigate therapists’
experiences of staying with their clients’ intense emotional experiencing. Its
primary aim is to examine this phenomenon from the perspective of five
Intensive Short-Term Dynamic Psychotherapy (ISTDP) therapists. This
therapeutic modality was specifically selected on the basis of its intensive,
emotion-focused approach. The research phenomenon is fundamental to
ISTDP therapists’ practice and therefore can be regarded as a focal point
around which narratives of experiences can be described. How these accounts
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differ and coincide is valuable in understanding therapists’ experiences of the
phenomena.
The description of the therapeutic task in the quote that introduced this
chapter will likely be familiar to any therapist who values the therapeutic
relationship and the therapist’s use of self in helping their client overcome
relational difficulties (Donati, 2016). My aim is to seek a better understanding of
therapists’ experiences of a process focused on feelings that are activated in
the therapeutic relationship and are due to the therapist’s efforts to bond with
the client. Research that investigates the lived experience of therapists whose
practice is based around the creation of “profound moments of meeting” with
their patients is intended to be of use to any therapist who relates to these
findings and apply them in their own practice (Kasket, 2017, p.231).
1.3 The Research Origins: A Personal Context
My personal interest in this question is in relation to my position as a
trainee Counselling Psychologist. Part of the distinctiveness in the counselling
psychologist’s professional identity is evidenced in their capacity to work both
with content and with interpersonal dynamics, referred to as “process”, as they
emerge throughout the therapeutic relationship (BPS, 2018a). In the second
year of my training, I encountered clinical challenges that were particular to
attending to unconscious processes and to the use of self that made staying
with the client’s deep emotions very challenging. I became interested in
learning more on how therapists manage to maintain their focus on the client’s
emotion in the therapeutic space, however, there was no one study in the
counselling and psychotherapy literature that focused on this aspect. As
Chapter Two: Literature Review illuminates, the psychotherapy literature does
provide examples of studies to related phenomena, such as therapists’
experiences of working with countertransference and clinical difficulties. There
is also a body of “wisdom” literature from experienced clinicians who highlight
the importance of the therapist’s capacity to bear their own emotions (Råbu &
McLeod, 2016). Yet, based on the comprehensive literature review, there is no
study that squarely explores what is like for therapists when they are working to
stay with their clients’ deep experience of emotion. I had attended an
introductory ISTDP training and was motivated by the intensity of this approach
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to focusing on clients’ emotions and that this was a new modality and approach
that was under researched. I had initially been researching third-wave cognitive
approaches to emotions-focused work but took seriously the recommendation
by Konstantinou (2014) of the need to advance the research knowledge base of
the field through engagement with alternative research. ISTDP is one such
alternative approach. This topic gave me the opportunity to conduct a critical
inquiry by examining the topic of emotions-focused work from a different angle
and offering possible alternatives to clinical practice (Feltham, 2010).
1.4 The Positioning of the Researcher
As all research begins with a set of assumptions that are based in
philosophical reflection (Willig, 2013) it is important to note how my positioning
aligns with the values that are made explicit in counselling psychology research
(Kasket, 2012; Lennie & West, 2010). I was motivated to adopt an
interpretative phenomenological approach and epistemology (Willig, 2012) for
several reasons. Firstly, psychotherapy research and the phenomena it studies
are socially constructed and based on the culturally shared values and beliefs
that are rooted in a specific community, time and place. From a science-
philosophical perspective, we encounter multiple “microworlds” out of which any
specific psychotherapeutic body of knowledge becomes conceivable. ISTDP
can be considered one such “microworld” of psychotherapy (Greiner, 2015, p.
104) and thus an idiographic approach that aims to illuminate particular aspects
of therapists’ experiences within their given context is valued and prioritised in
this study. Secondly, pluralism is a given of research-based accounts of
psychotherapy (McLeod, 2014). Critical reflection on research processes and
procedures helps account for the differentiated understandings of the
researcher’s psychotherapeutic ideas and practices they investigate. By
gaining deep insights into the complex phenomena that comprise
psychotherapeutic activities, various psychotherapeutic approaches can better
dialogue with each other. I have used basic principles and techniques of ISTDP
in my clinical practice and position myself as someone who believes this
modality has a great deal to offer the counselling and psychotherapy
community, and the field of counselling psychology. Thirdly, researchers do not
have direct access to participants’ accounts of their experience. Any
understanding is based on a process of intersubjective meaning-making (Larkin
4
& Thompson, 2012). It is imperative that I achieve and demonstrate awareness
of my actions and motivations through ongoing and reflexive engagement with
the key assumptions of research and the phenomena under study (Kasket,
2012). My position is both as an “insider” and “outsider” in the research. One
the one side, I am familiar with the basic techniques and theory of ISTDP which
means I can easily miss the taken for granted assumptions that other less
acquainted researchers might capture. On the other side, it is possible to
misunderstand aspects based on what is not known or experienced about the
specific and technical ways in which ISTDP is practice and evaluated. This
particular tension of my positioning and its impact on the research was
managed through a range of reflexivity practices (Kasket, 2013) that are
reflected on throughout the thesis.
1.5 Introduction to ISTDP
ISTDP is based on principles of psychodynamic and attachment theory
(Abbass, 2015). The therapy's main objective is to help the client in overcoming
their internal resistance to experiencing painful or unbearable feelings that are
linked to an early attachment trauma. The client’s unconscious avoidance of
such feelings generates and maintains their distress. The therapist addresses
this by engaging the client in innovative processes such as the monitoring of
unconscious bodily signals, rapid management of defences, and the somatic
experiencing of emotions (Malan & Coughlin Della Selva, 2006). Therefore, the
experiencing and processing of emotion is what helps the client heal. Although
there is a conscious therapeutic alliance, it is the unconscious therapeutic
alliance, an innovative construct of the model, that the therapist builds with the
client that reduces their symptoms and relational difficulties (Davanloo, 1987).
In the 1960s, Davanloo, the originator of the model, began recording and
reviewing his psychotherapy sessions on video. By studying the verbal and
non-verbal responses of his clients, he was able to verify the effectiveness of
and develop his interventions. This led to new psychodiagnostic tools for
assessing the client’s emotional capacity and the precise moment-by-moment
interventions to help facilitate a therapeutic experience of emotion. The ISTDP
therapists’ stance is not neutral yet holds the ground for the health of the client.
The intensive aspects and precision of the method arise from the therapist’s
5
attempts to intervene in the client’s protective avoidance and harmful
behaviours that undermine therapy and prolong suffering, as soon as they arise.
Specific techniques are used to motivate the patient, develop a collaborative
therapeutic alliance, robustly intervene in defences, foster the direct
experiencing of previously warded off feelings, and cultivate a context for
intimacy and trust between therapist and client (Coughlin & Katzman, 2013).
ISTDP employs key components that are salient in psychotherapy today,
including a high level of emotional engagement, use of video for quality
improvement, cognitive restructuring, and a here-and-now focus and evaluation.
Extensive research has shown the ISTDP approach is clinically effective for a
wide range of disorders, including depression, anxiety and psychosomatic and
personality disorders. There are now over 40 published research studies,
including radomised control trials, showing the benefits of ISTDP for clients hold
in long-term follow-up (Abbass, 2016). ISTDP also achieves good outcomes
with treatment-resistant and complex populations (see Abbass, 2015, for a list
of relevant studies and further information on the evidence base for the model.)
See Chapter 2 for further information on the development and practice of
ISTDP.
1.6 Terms of Reference: “Emotional Experiencing”, “Intensity” and
“Staying With”
1.6.1 Emotional experiencing. Frosh (2011) highlights the definitional
knot of “affect”, “feeling” and “emotion”. Definitions of these terms varied
according to their varied use in theory, research, and practice, and pertinent
usages are further referred to in Chapter Two: Literature Review. In this study,
all three terms are used interchangeably. “Experiencing” an emotion means
feeling it (Kuhn, 2014). This is in distinction to psychotherapy practice that
focuses on feelings by talking about emotions instead of actually experiencing
them. In this study, in order to overcome any confusion or ambiguities in
meaning, participants were asked to define their understanding of their client’s
emotional experiencing and also, as discussed next, their understanding of
intense emotional experiencing.
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1.6.2 Intensity. Intensity in the widest sense refers to a descriptive
quality of feeling. An intense experience of emotion in ISTDP, may include not
just the ability to label a subjective feeling state, but also a visceral,
physiological experience in the body and an awareness of the associated
impulse (for example, to cry, hug, hit). Patients may defend against any of these
aspects. Davanloo (1990) emphasised that in ISTDP, deep experience of
feeling — including murderous rage — “does not come with any explosive
outburst, but with a quiet, inner intensity” (1990, p. 7). Intensity may also have a
“non-linguistic” quality that is hard to name or directly perceive yet potent
(Frosh, 2011), which has implications for how the researcher elicits an
understanding of such phenomena from participants’ accounts. How this
challenge was addressed is discussed further in Chapter Three: Methodology.
1.6.3 Staying with. The “staying with” phrasing of the research question
was carefully considered in personal communication with an experienced
ISTDP trainer who stated that staying with their clients’ intense emotion is at the
heart of “what ISTDP therapists do” in the work. By implication, this suggests a
basic equivalence to adherence to the model. Staying with the client can thus
mean any number of eventualities, in terms of their process of experiencing
intense emotion. It can also reflect the attitude of the therapist who endeavours
to be an “emotionally engaged and available presence” (Coughlin, 2017, p.95).
ISTDP is thus a therapeutic approach with useful conceptualisations and
techniques with a high regard for the therapeutic relationship and its processes.
Likewise, in counselling psychology the therapeutic relationship is considered a
unique and relational encounter wherein the existences of two people unite to
produce a narrative that is co-created. As Parpottas (2012) asserts:
“[c]ounselling psychologists work towards what is thought to be therapeutic by
“staying with” the individual’s experience and also by paying attention to their
internal and external processes” (p.97).
1.7 Relevance of the Study and Contribution to Counselling Psychology
This study’s findings aim to provide a unique and original contribution to
the field of counselling psychology and therapists’ experiences research as
follows. It is hoped that a clearer picture emerges of the complex demands and
dynamics of what it is like for therapists to stay with client’s intense feelings.
7
Increasingly, affect focus and experiential aspects are important features of
current and new brief therapies (Parry, 2019) as are ways of making effective
use engaging emotions in therapy (Thoma & McKay). Therefore, the more we
know about the challenges, consequences and ways of coping with difficulties,
the better able the therapist is to be effective in their therapeutic work.
Technical aspects helpful to the therapist to consider in their own practice and
development will be highlighted.
1.8 Thesis Style and Structure
Many sections of the thesis are my first person account to foster the
readers’ involvement with my research process as it unfolded and to best
express my engagement with reflexivity. Also, the terms client and patient are
used interchangeably throughout this study, as they reflect the respective
preferences in counselling psychology and ISTDP. This thesis follows a
conventional structure. After this introduction, Chapter Two provides a review
of the literature associated with therapists’ experiences of working with clients
who are experiencing intense emotions, with critical reflection on the methods
used to gain their perspectives. Chapter Three details the methodology and
introduces the reader to the method of Interpretative Phenomenological
Analysis (IPA) used for data collection and how I approached the research
design, ethical considerations and how the stages of IPA were applied. In
Chapter Four I present the findings, and then showing the themes that emerged
from the data, supported by extracts from the transcripts. Chapter Five is a
discussion of the themes in relation to the research question and gives my
summary and conclusions of the research, with a review of outcomes set
against the research aims given above. Following identification of the original
research contributions made by this thesis, I conclude with a methodological
critique of this study and implications for further directions for counselling
psychology practice and future research.
1.9 Chapter One Summary
This study aims to explore the experiences of therapists engaged in
staying with their clients’ intense emotional experiencing. No published papers
address the area of eliciting therapists’ accounts of this phenomenon, which as
the literature in Chapter Two will aim to show, is underexplored. It is important
8
to address this gap in the research due to the acknowledged issues these
therapists face as they help clients heal from the effects of their early
attachment trauma (Abbass, 2015; Coughlin, 2017; Frederickson, 2013). It is
my intention that this research will facilitate an opportunity for a range of
therapists and mental health practitioners to learn from first-person accounts of
the experiences of ISTDP therapists. I therefore see this research project as
well suited to values and priorities of the field of counselling psychology that
regards subjective experience as essentially inherently dynamic, embodied, and
relational and seeks to develop phenomenological models of practice and
enquiry (BPS, 2018a). ISTDP and counselling psychology both share a belief in
the importance of the uniqueness of the human encounter between therapist
and client (BPS, 2018a; Coughlin, 2017). In producing knowledge that is
sensitive to context, committed and rigorous, it is my hope that an increased
understanding of therapists’ experiences in this area will aid the development of
research and practice in counselling psychology and inform the views of
practitioners who are interested in emotions-focused therapeutic work.
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Chapter Two: Literature Review
2.1 Chapter Two Overview
The aim of this chapter is to present the comprehensive literature review
that I conducted prior to starting the study. The intention here is to provide a
description of the findings of previous research that may support understanding
of current issues and establish what is already known; provide a critical
appraisal of relevant research and consider methodological implications both for
the research findings and for my own study; and provide the rationale, research
aims, and research question for this study. In conducting this literature review,
I intended to create a clear understanding of what we know about the value of
emotional experiencing in the therapeutic endeavour and what is already known
about how therapists work to help clients experience deep emotion. Lastly, the
research topic is further contextualised within clinical practice and counselling
psychology more broadly. This review was then used to shape the research
question in line with the most suitable methodological approach.
2.2 The Process of the Literature Review
This chapter is in part a summary of the process I have followed, in line
with Kasket’s (2012) guidance, in progressing from my research area to my
research question. As detailed in the introduction chapter, I have engaged
reflexively with my research question, to understand my positioning and the
influence this may have on my project. Reflecting on how this has influenced
my literature review process was done so that I could better bracket my
preconceptions that may bias an otherwise open and curious engagement with
the literature. Below I offer a definition of key terms and then go on to provide a
critical evaluation of relevant frameworks, namely the psychodynamic
understanding of emotional experiencing, explaining how these led to a focus
on ISTDP. I then critically engage with the empirical literature of ISTDP and
how this highlights a gap in the literature and to the rationale for the research
question. Consequently, this literature review thus functions as my empirical,
theoretical, methodological and personal rationale for my study (Finlay, 2011).
Strategies employed in the critical review of qualitative research adhered
to Morse’s (2015) criteria to help determine the rigour, validity, reliability, and
10
generalizability of the works in question. The data extraction strategy of Kasket
(2012) that covers purpose of reading, relevance to my research,
persuasiveness of author's argument, and what I make of the conclusion, was
followed. Analysis of papers and other pertinent materials is in line with a
distinguishing feature of counselling psychology that differentiates the field from
the other applied psychologies, namely, its therapeutic undertaking and "explicit
use of a phenomenological and hermeneutic inquiry" that emphasizes its
reflexive and critical position when dealing with "medical,
psychopharmacological, and classification literature as well as use of
nomothetic (psychometric and neurological) testing" (BPS, 2018a, pp. 6-7).
Evaluation of all research should include an appreciation of its philosophical
assumptions and researcher positioning (Ponterotto, 2005; Willig, 2013). The
co-creation of meaning and awareness of researcher-participant
intersubjectivity is fundamental to the interpretation of the data (Morrow, 2005;
Kasket & Gil-Rodriguez, 2011). Here, the intention of the quality evaluation is to
examine, from within an interpretative phenomenological framework, how the
research may be used to inform my understanding of the research area.
2.3 Defining Emotions and Emotional Experiencing
The emotions science literature is vast and detailing the various
conceptualisations and definitions of emotions is beyond the confines of this
study. However, as a useful starting point for this study, Hofmann (2016), who
considers emotion in the therapeutic context, offers the following multi-modal
definition of emotion (p. 2):
An emotion is (1) a multidimensional experience that is (2)
characterized by different levels of arousal and degrees of
pleasure–displeasure; (3) associated with subjective
experiences, somatic sensations, and motivational tendencies;
(4) colored by contextual and cultural factors; and that (5) can be
regulated to some degree through intra- and interpersonal
processes.
This quote highlights that to speak about emotions is to speak about
many areas of psychology (Hayes, 2016): experience and the valence of
experience, bodily arousal and sensation, culture and context, and social and
self-regulation.
11
Emotional experiencing is therefore at the heart of human experience
and is of fundamental importance in all therapeutic frameworks, even if of
primary or more peripheral concerns. This study is interested in therapists
whose work focused on this aspect and how the therapist experiences the
complexities of these intersubjective processes.
2.4 Emotional Experiencing and the Therapeutic Endeavour
This section begins a critical examination of the studies previously
completed to help in understanding the importance in psychotherapy of the
therapists’ attending to the client’s intense emotions. The therapist’s efforts to
help a client experience their emotions has been a key theme throughout the
history of psychotherapy, encompassing foundational ideas from
psychoanalysis (Freud, 1923), to other more recent schools of thought,
including short-term dynamic therapy (STDP) and third wave cognitive
approaches (Hayes & Hoffman, 2017). Freud developed his ideas from
believing in a cathartic model, where “making the unconscious conscious” was
the essential curative factor in the therapeutic process, to the view that insight
based on emotional experiencing was essential for bringing about enduring
change (Schafer, 2018). Today, a key integrative principle is that both cognitive
and affective aspects are important for producing therapeutic change (Whelton,
2004). The multifaceted and complex feature of emotion, described in the
above cited definition, means that therapists are inevitably involved in making
decisions about which element of emotional experience to prioritise in therapy,
in relation to the presenting difficulty, and select techniques to use accordingly
(Leahy, Tirch, & Napolitano, 2011).
This integrative principle and varying clinical focus is reflected in a
number of emotions-focused approaches, including STDP, humanistic emotions
focused therapies (Greenberg, 2010), and third wave cognitive-behavioural
approaches, such as Schema Therapy (Young, Klosko & Weishaar, 2003) ,
Compassion Focused Therapy (CFT; Gilbert, 2009), and Acceptance and
Commitment Therapy (ACT; Hayes, Strosahl & Wilson, 1999). These
modalities each draw on a research base that helps build the rationale for the
value of attending to emotions in psychotherapy. ACT for example, considers,
though its theory of contextual functionalism, the role of experiential avoidance
12
(Hayes, Strosahl & Wilson, 1999), whereby arbitrary associations the person
develops through language and cognition creates feelings and other
experiential aspects that are avoided and often self-defeating. CFT (Gilbert,
2009), to offer a further example, adopts an evolutionary science-based view of
people’s difficulties in accessing their emotional regulation system as related to
self-conscious processes, such as high shame and self-criticism (Gilbert &
Proctor, 2006), and considers how clients organize around emotions in terms of
attention, behaviour, thought, motivation, feelings, and physiology. These
process-oriented approaches aim work within a contextual understanding of the
experiential and emotional aspects of clients’ difficulties.
Affective neuroscience has contributed to an understanding of emotions,
personally and interpersonally, as experienced in the therapeutic space
(Schore, 2007). A person’s subjective experience of emotion occurs through
what Damasio (1994) refers to “somatic markers’, the signals that tell the
person what is of importance to focus on. Abstract reasoning, the has been the
central focus of a cognitive paradigm in research (Gilbert, 2009) emerges out of
embodied experience that Barrett (2017) suggests is based in our affective
experience rather than separate to it, as has been traditionally regarded
(Griswold, 2010). Emotions offer the person a rapid, preverbal method of
assessing danger (LeDoux, 1998) and the noting of salient features when
encoding memories (Panksepp, 1988). They also effect interpersonal
signposting and communication (Mayer & Salovey, 1997), help with the pursuit
of life goals (Tomkins, 1962), assist social competency, and together with
conscious thought brings about the narration of the self in context and across
time (Angus & Greenberg, 2011). Emotions are then regarded as fundamental,
yet difficulties arise with the identification of emotions, their modulation (i.e.
dysregulated or under- or overregulated) and the expression and
communication of emotions socially (Jurist, 2018).
A range of evidence now supports the approach of therapists’ attention
on encouraging affect (Thoma & McKay, 2015). For example, Foa and Kozak’s
(1986) emotional-processing theory suggested that enabling the modification of
excessive fear responses requires activation of the underlying fear system.
Activating emotion to boost the modification of fundamental cognitive-affective
13
structures provides a strong rationale for a range of interventions covering a
diverse range of emotional difficulties. Furthermore, arousal and expression are
correlated to a positive outcome in a range of psychotherapies. Emotional
arousal reported as high at the beginning of therapy along with between-
session habituation has been linked to positive outcomes in exposure therapy
for anxiety disorders (Borkovec & Sides, 1979; Jaycox, Foa & Morral, 1998). A
meta-analysis of 10 STDP studies demonstrated a positive association between
therapist’s facilitation affect and treatment improvement (Diener, Hilsenroth &
Weinberger, 2007). Studies reporting observer-rated arousal of emotion in
important phases of therapeutic episode was predictive of positive outcome in
therapy (Missirlian, Toukmanian, Warwar & Greenberg, 2005). Lastly,
neuroscientific research into the unconscious affective-relational functioning of
the right brain (Schore, 2007), requires therapists to comprehend and utilise
such processes with their clients, to foster enduring change. Deficiencies in
emotional awareness and regulation are regarded as central aspect to most
psychiatric disorders (Barlow et al., 2011). Increased attention to emotional
activation and regulation in treatment is consistent with the emerging data on
the nature of the underlying factors responsible for clients’ distress (Barlow et
al., 2011).
So to generate the type of emotionally-charged tenor required in the
therapy room, therapeutic interventions are designed to activate and intensify
the cognitive-affective and psycho-physiological aspects of emotional
experiencing. Recent studies on what helps diminish unhelpful responses in
exposure therapy have emphasised the importance of developing distress
tolerance and the acceptance of emotional experience (Arch, Wolitzky-Taylor,
Eifert & Craske, 2012; Bluet, Zoellner & Feeney, 2014; Craske et al., 2008);
accommodation of new meanings derived though the experience of emotional
also appears to be important in exposure therapy (Sobel, Resick & Rabalais,
2009). In emotion-focused therapy for depression, clients’ meaning making of
their emotional arousal enhanced outcome compared to that during treatment
(Missirlian et al., 2005). Furthermore, the quality of emotional awareness
experienced, coupled with the client’s attitude toward it, is shown to have a
strong correlation to outcome (Auszra, Greenberg & Herrman, 2013). Helping
14
clients to experience avoided emotions, therefore, is substantiated as a
worthwhile endeavor for the therapist.
Measures of in-session affective experiencing that focus on attention to,
acceptance, and differentiation of emotional experience, are linked to outcome
in many therapies (Castonguay, Goldfried, Wiser, Raue & Hayes, 1996;
Goldman, Greenberg, & Pos, 2005; Pos, Greenberg & Warwar, 2009, Watson &
Bedard, 2006). Emotion-Focused Therapy (Greenberg, 2015), a process-
experiential approach, is conceivably the most developed modality for working
with emotions in psychotherapy, where the expressed aim of the approach is to
“give words to moment by moment process of working with emotions” (p. 7). Yet
the role of therapist is as a coach to help client with “differentiating underlying
meanings and feelings and manifestation of primary emotional states” (p. 133).
Town, Salvadori, Falkenström, Bradley and Hardy’s (2017) review of those
measures more widely used and to help gather insights on the construct of
affect experience in their study, which demonstrated that the in-session
exercise of emotional experiencing can help to strengthen the therapeutic
alliance. Thus, the therapies discussed centre on some aspect of emotion,
whether talking “about” emotions, attention to somatic experiencing of emotions
or on developing skills to communicate emotions to valued others.
Though these psychotherapeutic models may have different and
contrasting theoretical bases, they nevertheless share a conception of
emotional experiencing as a phenomenon that assumes shape in the context of
human interrelatedness. These models acknowledge developmental
processes, whereby repeated patterns of emotional interaction within the child-
caregiver system produce ways of relating – object relations in psychodynamic
therapies; meaning-structures in humanistic/existential therapies; distorted
thinking in cognitive-behavioural therapies – that shape subsequent emotional
experiences. These experiences recur in the significant relationship with the
therapist who fosters an engagement with previously avoided feelings (Abbass,
2015). Dynamic approaches that attend to this will be the focus of the following
two sections in this chapter. Where interests in emotion span all schools of
psychotherapy, it has been more pertinent in recent psychotherapy research to
seek to analyse the phenomenological bases rather than the theoretical or
15
technical conceptualisations (Moltu & Binder, 2014). Phenomenological
enquiries are thus one way to produce convergence in how therapists from
different therapeutic modalities facilitate emotional change processes. The
above literature is produced from mostly quantitative research or process
studies and reveals the paucity of research in investigation into qualitative
research that may give a more contextual, subjective understanding of the
therapist’s experience. Qualitive research that helps us further understand the
importance of focusing on client’s deep emotional experiencing will be the focus
of section 2.7 Researching In-session Emotional Experiencing in Psychotherapy
Process Research onwards, and evaluated further in section 2.14 Rationale for
the Current Study.
2.5 Historical Overview of the Development of STDP
As mentioned in the section immediately above, Freud’s theories and
approach, are at the root of psychoanalysis. At the heart of all psychodynamic
practice is the interpreting of transference that brings inner conflicts to life in
therapy. It was this focus on patient defenses and resistances in therapy,
together with Freud’s own engagement in short episodes of treatment, gave
birth to brief dynamic psychotherapy (Davanloo, 1990). Nonetheless, as the
theories of psychoanalysis to explain transference neurosis proliferated,
analysis became longer, the sessions unfocused the and therapist passive. As
a counter to this, Sandor Ferenczi, through his psychoanalytic approach,
investigated innovations in technique, suggesting the necessity of active
methods for particular neuroses. This arose out of his clinical observation that
often an analysand will only be able to experience a positive connection to the
analyst after the anger is first experienced. Otto Rank was also a proponent of
the “active technique” (Meyers & Hoffer, 1994). His theoretical contribution
regarding birth trauma included seeing the issue of separation and individuation
as primary to the therapeutic work, which entailed a mobilizing of the patient’s
will to help motivate the patient towards dynamic change. Ferenczi and Rank
(1986) in their 1925 publication highlighted the significance of using moment-by-
moment transference interpretations of patients’ early conflicts as repeated in
the therapeutic relationship.
16
STDP, as it came later on to be known, had its origins in the 1940s
whereby psychoanalytically-informed thinkers began developing models that
formed into distinctive approaches. Alexander and French (1949) made vital
contributions, by conducting the first clinical trial with the expressed focus of
making psychoanalysis “briefer and more effective” (p.7). Whereas Freud
regarded cathartic expression of emotion as the basis to overcoming early
trauma, Alexander and French posited the “corrective emotional experience” as
a further step in this process. It was not recovered memories, once repressed,
which brought about therapeutic progress but rather the reverse: the intense
reexperiencing of repressed memories in the actual relationship was the
curative factor, whereby the patient learns a sense of autonomy through safe
re-exposure. Here the patient's experiencing of their relationship with an
emotional responsive therapist is seen as necessary and beyond the
insufficiency of mere intellectual insight. Prioritising experiential aspects meant
analysis could be achieved with shorter treatments that could, the authors
claimed, achieve depth and overcome the patient’s resistance. Alexander and
French aimed to heighten the emotional intensity of sessions and focus on
emotionally charged experiences, paved the way for in-session experiencing of
intense emotions that were shared by patient and therapist.
Yet Alexander’s (1953) view perhaps unintentionally retains the view of
the analyst as all-powerful in their ability to inform patients about what they may
be feeling. Balint and Malan took forward the idea of time limited therapy in
ways that further challenged psychoanalysis’ belief of the incompatibility of
shortness with relationship. Balint’s (1973) “focal therapy” was a three-stage
view that the therapist must accept, understand and interpret unconscious
material and discovered that patients could benefit from ‘deep’ interpretations in
short term work. Sifneos’s (1972) Short-Term Anxiety-Provoking Psychotherapy
was an alternative focal and brief therapy that emphasised on the central role of
anxiety in moderating access to primitive unconscious material. Yet attempts to
develop effective tools for regulating anxiety were unsuccessful. Malan (1979)
saw that such interventions were most helpful when linking patient’s past and
their current interactions with the therapist (triangle of persons), along with
linking the patient’s impulses, resulting defense and anxiety (triangle of conflict).
17
Thus, his model could help understand dynamic conflicts in the here and now,
and their origin.
2.6 Development of ISTDP and Experiential Dynamic Approaches
In the 1960s, Davanloo’s (1990) efforts to accelerate dynamic therapy
led him to create a model with two key distinctive features that made his ISTDP
the prototype for STDP approaches that followed (Osimo & Stein, 2012). First,
he developed new ways of working with defences and conceptualising defences
and resistance in therapy. Second, he employed highly specific techniques,
such as Malan’s trial interpretations, leading to rapid uncovering and
experiencing of primitive aspects of emotion and illuminating aspects of human
conflict, through a process of “unlocking of the unconscious”. Key to this was
the acknowledgement and confrontation of the patient’s resistance. Davanloo
used vivid, emotionally loaded language to speak to the unconscious of the
patient and believed that only once the unconscious therapeutic alliance – an
aspect of the alliance he was the first to label and emphasise – exceeded the
resistance of the patient, could such resistance be undone. Davanloo (2001)
theorised that the “twin factors of resistance the [complex] transference
feelings” rise in the patient when they feel pressured from the therapist’s
attempts to bond (p.30). This informs the therapist’s formulation in relation to
Malan’s triangles (slightly adapted by Davanloo). In the transference, “the
client’s powerful emotions, particularly towards the therapist, are defended
against, but the therapist’s constant interpretation of these leads to their
expression in therapy” (Coren, 2010, p. 290). The therapist can then help the
client override avoidance and feel their complex feelings, helping them heal
their past trauma (Abbass, 2015).
What ISTDP preserves from classical psychoanalysis is its focus on
transference and the value of insight, and to some extent, interpretation, though
the latter Davanloo saw as possible only post-breakthroughs to the
unconscious. The model draws from a Freud’s (1923) structural theory of the
mind – id, ego and superego – yet it is arguable more concerned with the
functioning of the ego, rather than its structure, and the mechanical aspects of
the triangle of conflict (impulse/feelings, anxiety and defense). Though ISTDP
regards itself within the psychoanalytic tradition, whether such brief approaches
18
are ‘different’ is debatable but nonetheless are drawing on psychoanalytic
ideas. From the 1960s onwards cultural and postmordernist aspects of emotion
receive attention in the shift from “one-person psychology” (Wachtel, 2008) to
two-person relational view (Aron, 1991), which brings intersubjectivity and the
therapist’s mutuality and involvement to the fore. This has led to number of
contemporary psychological approaches that seek to integrate attachment
theory and developmental psychology, and psychoanalytic concepts. These
include, for example, Psychodynamic Interpersonal Therapy, Cognitive Analytic
Therapy, Solutions-Focused Therapy, and Transactional Analysis (see Coren,
2010, for further details; Parry, 2019).
During the past thirty years, various approaches, stemming from
Davanloo’s application of scientific method to developing specific techniques
that accelerate psychotherapeutic process, have been established and
researched. Past students of Davanloo have elaborated on his theories within
ISTDP (Abbass, 2015; Coughlin Della Selva, 2017), Others have elaborated on
how the significance Davanloo gives to the attachment bond of child and
caregiver relates to mental health, referred to as Attachment Based ISTDP (ten
Have-de Labije & Neborsky, 2012). Modifications of Davanloo’s principles,
referred to often as experiential dynamic approaches (EDTs), whereby the titles
indicate distinctive rather than similar aspects include Accelerated Empathic
Therapy, Accelerated Experiential-Dynamic Psychotherapy, Intensive
Experiential-Dynamic Psychotherapy, Mindfulness Informed Experiential
Dynamic Therapy, Personality-Guided Relational Psychotherapy, and Affect
Phobia Therapy (see Osimo, 2012, for details of the authors of these
approaches).
Davanloo (1990) has across his career, still ongoing, built a large
evidence base for ISTDP based on case-series research methodology that
entailed him video recording all sessions, moment-to-moment analysis of the
recordings, and successful interventions tried out with the successive clients.
Then following termination, recordings were reviewed with clients to understand
which interventions worked, and lastly long term follow up was performed. This
methodology is successfully employed since then to generate the evidence
base for the key clinical processes in ISTDP practice (Abbass, 2015). However,
19
the focus is on patients’ response and outcome, whereas aspects of the
therapists’ experiences are less often reported. As stated by Davanloo (1990,
p. 2): “I believe that dynamic psychotherapy can be not merely effective but
uniquely effective, that therapeutic effects are produced by specific factors
rather than nonspecific factors, and that the essential factor is the patient’s
actual experience of their true feelings about the present and the past.” This is
now less of an “uncompromising stance” (p. 2) today than it was, due to
subsequent research in psychodynamic and experiential approaches and the
established evidence base for the efficiency and effectiveness of ISTDP, as
referred to in section 1.5 Introduction to ISTDP.
Despite a strong evidence base for the efficacy and cost-effectiveness of
ISTDP, which far outweighs that of its EDT siblings, it has yet to receive
government support in the UK context. Town and Abbass (2018) highlight in
their paper on epistemological deficiencies in The National Institute for Health
and Care Excellence (NICE) review methodology and its influence on
recommendations that have served to limit options for psychodynamic therapies
for complex and persistent depression, despite compelling evidence from recent
randomised control trials (Fonagy et al., 2015; Town, Abbass, Stride, & Bernier,
2017). Currently, the brief psychodynamic psychotherapy most widely available
in the UK is Dynamic Interpersonal Therapy (Lemma, Fonagy, & Target, 2012),
a 16-session model for depression. The current political climate in the NHS and
the overall position of psychodynamic therapy in public health is further
addressed in Chapter 5: Discussion, section 5.2 Situating the research findings
within the wider context of psychodynamic practice in the UK.
This section has outlined the development of psychoanalytically-informed
STDPs, from Freud to EDTs that are based on analytically-informed practices,
including the current brief dynamic UK context. In relation to the therapists’
task, psychodynamic and experiential approaches can nonetheless be set apart
from cognitive-behavioural therapies through their considerable attention to the
client’s gaining of emotional insight (Salvadori, 2010). Raised into
consciousness via somatic experience of emotion, the client is thought to be
able to better manage their previously avoided material. Malan (1979)
highlights the experiential and dynamic tenor of this theory: “The aim of every
20
moment of every session is to put the patient in touch with as much of his true
feelings as he can bear” (p. 74).The primacy of emotional experiencing in these
dynamic approaches, of which ISTDP is one, are of interest to counselling
psychology. Though at base a psychodynamic model, ISTDP is presented by
some leading authors (Coughlin, 2017; Frederickson, 2013) as an integrative
model of therapy. That is to say, theoretical integration as a model of
intervention that is grounded in the moment-by-moment assessment of the
client’s needs. See section 2.10 The Practice of ISTDP and Implications for the
Role of Therapist for further discussion of the practice of ISTDP.
2.7 Researching In-session Emotional Experiencing in Psychotherapy
Process Research
To my knowledge, there is paucity of qualitative research that has
specific focused on working with client’s intense emotions. Yet the several
studies that are concerned with this phenomena will receive attention in the
remaining sections of the literature review. Psychotherapy research and
developments in the theories of a wide range of therapy schools suggests that
increased client in-session affect experiencing is linked to therapeutic change
(Wiser & Arnow, 2001). Moreover, Coughlin (2017) highlights that sessions that
are regarded by clients as intensely emotional are most often those labelled as
“significant” (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Goldfried,
Raue, & Castonguay, 1998; Harnett, O’Donovan, & Lambert, 2010), and appear
to have the most influence on outcome. This therefore has relevance for
therapists in the development of specific skills in this clinical process. What
continues to be investigated and developed are the features that show where a
facilitation of emotional experiencing can be clinically useful.
In ISTDP, researchers have explored the process of clients’ in-session
emotional experiencing (Town, Hardy, McCullough & Stride, 2012; Town,
Salvadori, Falkenström, Bradley, & Hardy, 2017; Salvadori, 2010). The
experiencing of emotions as foundational to change have a strong outcome
factor in the process empirical data, from studies that measures the rise in
feelings in relation to its influence on outcomes. These studies utilise video-
material in case-series design to observe the affect peaks of the patient, and
attempt to link this to therapist intervention. Town and colleagues (2017, p.
21
148) describes “affect experiencing” as: “[t]he in-session bodily arousal of
emotions....[which] reflects the degree to which patients viscerally experience
then express their feelings.” This construct of affect experiencing is detailed in
metapsychological theory, yet the term “emotional processing” tends to be used
as an all-embracing construct in referencing how emotions are widely attended
to in psychotherapy (Frederickon, Messina & Grecucci, 2018). Such studies
provide insight into patient variables but do not inform us about what this is like
for the therapist or specifically, their emotional experiencing, which are
significantly harder to capture in experimental studies.
2.8 Expert Therapists
An expert psychotherapy practice is one that consistently helps clients
achieve their goals. (Hill, Spiegel, Hoffman, Kivlighan, & Gelso, 2017; Wampold
& Imel, 2015). Research into the nature of therapist expertise brings our
awareness to ideas and information across the natural and humanistic
sciences, which can help to enhance therapeutic practice and add to our
understanding of the therapist’s skill and expertise. Moreover, research
suggests that experienced therapists show greater flexibility, are better at
coping with complexity and severity of client difficulties, and are able to build
better quality formulations of their clients than less experienced therapists
(Oddli, Halvorsen, & Rønnestad, 2014).
Studies in this area of the literature consulted tended to coalesce around
the area of clinical difficulties, but are without a direct focus on the therapist’s
engagement in emotional experiencing. Nonetheless, some valuable insights
can be drawn. Moltu and Binder (2014) found that skilled therapists experience
their own involvement in challenging therapies as maintaining a “double
awareness to create a relational space for growth” (p. 136). A key finding was
the use of embodied experiences to achieved intimacy with clients. This study is
helpful in offering a context of psychotherapeutic technique, yet seems
concerned with the meaning-making processes of the client over their affective
experiences.
The first examination of therapist wisdom by Levitt and Piazza-Bonin
(2016) recruited and interviewed therapists, who were peer-recommended as
22
possessing wisdom, on how they enact wisdom in therapeutic process. One
central category was: “Intelligence is not enough: Wise therapists have
emotional intelligence grounded in difficult life experiences to better understand
how to work through painful and powerful emotions” (p. 38). The authors found
that “wise therapists” were considered capable of tolerating threatening
emotions and also possessed interpersonal sensitivity to facilitate clients’
staying in contact. The counselling psychologist as researcher-practitioner,
values the importance of the practitioner knowing their limitations whilst
expanding their psychotherapeutic and professional knowledge, in the
acquisition of new clinical skills (BPS, 2005; Health Care Professions Council,
HCPC, 2015, 2016) and can draw from such studies to help guide their practice
and development.
2.9 Therapists Effects
Psychotherapy research appears to point towards a greater variability in
outcomes between therapists than therapies (Wampold & Imel, 2015). There is
a great deal of evidence to support the hypothesis that therapist effects
(differences in client outcomes between individual psychotherapists) are greater
than treatment effects (differences in client outcomes between treatment
modalities). Such findings suggest that there are therapist characteristics
associated with 18 better patient outcomes, yet there is no accepted model that
outlines what those characteristics might be. Of interest to the present study,
then, is how research that relates to therapist effects can inform therapists and
their real-world practice of providing a therapeutic experience of emotion.
Coughlin (2017) asserts that in contrast to their less effective colleagues,
“therapists who demonstrated a mix of cognitive and emotional speech content,
who conveyed warmth, and who were seen as actively listening to their clients,
had a better overall connection with patients” (Sexton, Littauer, Sexton, &
Tommeras, 2005, p. 110). As mentioned in the section 2.8 Expert Therapists
Literature, the best therapists possess of number of wide-ranging qualities: they
are confident but humble; lifelong learners with high levels of skill and expertise,
who are simultaneously open to feedback; and are flexible but systematic in
their approach (Wampold & Brown, 2005; Wampold & Budge, 2012). These
therapists are skilled at handling negative emotions and are courageous in
23
handling conflict directly and non-defensively. Finally, they are ambitious and
push themselves and their patients to work hard and endure discomfort in the
pursuit of exceptional results. Coughlin (2017) thus asserts that since an
enhanced sense of mastery and competence is a vital factor in healing, as well
as in preventing relapse (Weinberger, 1995), attending to the patient’s
expanding sense of self must be included in the therapists’ repertoire.
Research suggests that the therapist variable is the most significant factor in
creating this type of alliance. In other words, the most effective therapists are
interpersonally skilled and able to forge a relationship for change even with
patients with complex and long-standing difficulties (Frederickson, 2013). They
seem to do so by managing negative feelings in the transference, helping the
patient relinquish defenses, and actively encouraging clients to engage in a
collaborative effort. Thus the research in this section helps illuminate, when
considering therapist’ effects, the complex interactions between the relational
and technical aspects related to outcomes in psychotherapy.
2.10 The Practice of ISTDP and Implications for the Role of Therapist
One explanation for the effectiveness of ISTDP is that it incorporates
many of the factors outlined in the section above into a comprehensive system
of intervention (Coughlin, 2017). The process research highlights the
importance of focus to effective outcomes for patients and the importance of
defense work, whereby changes are predictive of improvement (Pennebaker,
1997). In light of the evidence base, the ISTDP therapist’s main task is to help
the client reach through their defenses to the experience of emotions. Once
there, the therapist facilitates cognitive reflection and understanding of the
emotional experience. ISTDP is thus not a cathartic therapy. Instead
conscious reflection on emotional experience is key distinguishing good from
poor outcome (Warwar & Greenberg, 2000). A deep and relational
understanding of self and other was seen to have enduring value, but only
clients who were emotionally involved in the process achieved that outcome
(Pennebaker, 1997).
Davanloo (1990) observed what he called a central dynamic sequence
whereby access to the unconscious is gained through persistence in the
therapist in effectively and efficiently helping patients overcome their resistance.
24
Therapists use response to intervention as their primary diagnostic tool and
their guide for intervention, leading to a tailor-made experience for the client.
Abbass and Town (2013) outline the phases of the therapy along with empirical
evidence supporting the main clinical processes. In the first two phases, the
therapist uses inquiry and pressure – encouraging the client towards
experiencing underlying emotion – to psychodiagnostically evaluate, through
the client’s response to intervention, suitability and plan for therapy. Monitoring
and assessing the client’s level pathway of anxiety may happen here, and
psychoeducation used to help client modulate anxiety within a window of
tolerance. In phases three and four, the therapist aims to help clarify and
challenge collaboratively resistances to experiencing their complex transference
feelings that have been mobilized as the result of a triggering event. Working
with defenses is, after anxiety, referred to as the second detour (Frederickson,
2013) to an effective focus on emotion. For example, observing whether the
patient resisting emotional closeness or their own internal experience, or
whether defenses are viewed as natural or necessary or unwanted and
excessive, and helping the patient with a cost-benefit analysis.
Once the client has seen and overcome their resistance and can directly
experience their feelings, the fifth phrase of unlocking the unconscious can
happen, whereby trauma-related memories surface and be reworked. This
entails a focus on the somatic pathways for core emotion, such as anger, guilt,
grief, sadness and love, so that these mixed feelings can be integrated. Being
“in touch” with feelings is reached through the client labelling the emotion,
observing and elaborating its physiological activation in the body and mobilizing
the resulting impulses and action tendencies that are fearfully avoided. The last
phase is supportive in helping recapitulate and consolidate the intrapsychic and
interpersonal patterns and processes experienced by the client, by making
sense of and thoroughly linking the client’s impulses/feelings, anxiety and
defenses with current and past figures. Such recapping of experience is seen
to aid the development of coherent life narrative (Nerborsky, 2001) and long-
term health and wellbeing.
Abbass (2016) highlights how working with transference leads to a
challenge to the ISTDP Therapist:
25
“... this same work will tend to mobilize intense, deep zones of
feeling in the therapist if [they] has not experienced these
feelings up to that point in time. If the therapist does not allow
[themselves] to feel the feelings [they] may end up with a burden
of increased guilt and neurosis transferred to his patients” (p.
277).
Whereas it is expected that if the therapist can meet the person through
their resistances, the therapist then has the ability to experience any of their
own unprocessed feelings. The ISTDP literature refers to this as a “double
unlocking of the unconscious” (p. 277), whereby a double therapeutic effect
happens for both therapist and client.
Overall, this section aimed to give some indication as to why ISTDP is
referred to as an advanced psychotherapy and offered as post-qualification
training. Interventions that propel the client through the treatment algorithm are
highly technical and specific, using video peer and self supervision to help
observe and refine technique that so that pacing and depth of dynamic
emotional experiencing can be optimised. The therapist must also sustain an
attitude of curiosity (Coughlin, 2017), develop skills that reduce therapist errors
that might give rise to resistance, and develop themselves personally, so they
can involve themselves in emotional closeness and attunement that can
facilitate change and growth in their clients.
2.11 Therapists’ Capacity to Reflect On and Use Their Own Emotional
Experiences
Counselling psychology regards the therapeutic therapist relationship as
the central means of change and thus sees the self of the therapist is as
involved in the therapeutic process, regardless of the approach (Orlans and Van
Scoyoc, 2009). The therapist’s capability to use their self effectively in the
therapy is impacted by their capacity to be aware of how their thinking,
emotions, needs and issues are brought about during their work. Training
components such as personal therapy, experiential work and supervision
become central activities through which a trainee’s understanding of the
interaction between their personal and professional identities, and their capacity
to apply themselves effectively in their work, is developed (Donati, 2016).
26
In ISTDP this means attending to one’s own inner life, in order to ensure
that the therapist can be emotionally present and open to connection with their
clients (Coughlin, 2017). This goes hand-in-hand with the development of
technical skills, through forms of deliberate practice, aimed at improving specific
clinical skills outside of the session and monitoring improvement and outcome
(Rousmaniere, 2016). Frederickson (2013) refers here to the ‘craft’ of
psychotherapy, as well as the art and science of the discipline. To help clients
in this mode thus requires skills and techniques that are integrated within a
theory of human development. In keeping with the values of counselling
psychology and its scientist-practitioner identity (Murphy, 2017), these skills
must be coherent with a theory of change that is bolstered by the research
base. Expertise is thus achieved through years of self-study, supervision,
further training, personal psychotherapy. The ISTDP therapist also achieves
this through the analysis of their own transcripts and videotapes (Abbass,
2004a).
2.12 Researching Therapists’ Experiences
Research on therapists’ experiences gives practitioners the opportunity
to engage with other subjectivities and associated clinical practices that can be
reflected on and transferred to the therapist’s own practice. One of the roles of
the counselling psychologist is the reflective-practitioner, which acknowledges
their need to understand the therapist’s experiences so they can continue to
learn and develop their practice and clinical skills (Donati, 2016). The
therapeutic relationship amounts to a complex matrix of intersubjective
processes (Mitchell and Aron, 1999) to which both therapist and client make
active contributions. This means that it is not necessarily easy for the therapist
to perceive, disentangle or attribute objectively what “belongs” to them from
what belongs to the client in any given interaction, though it may be important to
do so, particularly if working with clients who present with complex relational
difficulties. The importance of the issues noted here to counselling psychology
practice is reflected in the HCPC’s (2015) Standards of Proficiency, which state
that counselling psychologists need to learn to manage “the … emotional
impact of their practice” (p. 8), to understand “the dynamics present in
therapeutic and other relationships’ understand the dynamics present in
27
relationships between service users and practitioners (p. 11), and to be aware
of the “explicit and implicit communications in a therapeutic relationship” (p. 10).
Kenny (2014), in an attempt to understand such complex
intersubjectivity, as just described, interviewed eminent clinicians regarding their
psychoanalytically-informed practice. Kenny conducted a formal textual
analysis programme and a conceptual thematic extraction process in identifying
distinctions and commonalities in their accounts. Through an intensive dialogue
with Allan Abbass regarding his ISTDP practice, some important aspects of the
therapist’s experience are revealed. For example, Abbass reflects on his initial
difficulty with confusing the active nature of the therapist with an attack on the
patient, learning the importance of timing and clarifying interventions before
challenging the patient’s behaviour. He comments also on his own anxiety
response to the video case material as to linked to his own early attachment
feelings, the importance and value of emotion physiology, the therapeutic
effects and parallel experiences he experienced through the training, and the
mirroring process he encounters through his and his patient’s joint emotional
experiencing. These provide some coverage of only a few valuable glimpses
into aspects the therapist’s experiences of staying with his clients intense
emotional experiencing. The main authors and practitioners of ISTDP also
provide insights through their books and articles (for example, see Abbass,
2015; Coughlin, 2017; Frederickson, 2013; ten Have-de Labije & Neborsky,
2012).
Countertransference is often regarded as comprising the therapist’s
emotional responses to the client, and has been linked to negative outcomes in
therapy when ignored, but also as a phenomenon that can benefit therapeutic
work when reflected up and managed (Gait, 2017). Studies on this concept can
offer insight into therapists’ experiences of how they deal with their clients’
emotion. Gait (2017), using the grounded theory method on qualified therapists’
experiences of the countertransference awareness and development, found that
when experiences of feeling overwhelmed was managed in supervision and
personal therapy, and through aspects related the therapeutic modality and
context for the work, participants were capable of reflecting on their
countertransferential responses and to grasp an understanding of their
28
experiences. Thus, they were able to develop their awareness in ways that
benefited the therapeutic relationship. Yet when such aspects were not
managed, participants would act out on their countertransference and would
limit their availability in the therapeutic relationship. This study thus provided
useful reflections on intensity for the therapist, though where this might be
happening for the client also as less clearly delineated.
Athanasiadou and Halewood (2011) conducted a study drawing on
methodology of grounded theory, to explore therapists’ experiences of somatic
phenomena in the countertransference, a topic that has received little notice
despite evidence of its manifestation in therapy. They report that there was a
noticeable gap in counselling psychology literature of the therapist’s clinical use
of their somatic states. The results showed that therapists understood their
somatic experiences developmentally, as a “relating to the body” (p. 247) that
united stages of “defensive operations”, “intellectual reflections”, “attributions of
somatic ownership” and “recognitions of various working patterns in the
management of somatic experiences”. In addressing the aspects that comprise
therapists’ processing of their in-session experiences, the researchers found
that therapy may likely be impacted when somatic phenomena are neglected or
subverted. Athanasiadou and Halewood (2011) suggest replication studies with
a broader sample of therapists from various professional contexts. This study
provides interesting and novel insights into somatic experiences that convey a
sense of what the process of relating to body in the countertransference, that is
a related aspect to emotional experiencing of the therapist, though this is not
covered, nor is the focus of the study.
2.13 Epistemological and Methodological Positioning in the Literature
The research in this literature review spans a broad range of
methodological and epistemological stances, even if very few studies provide
acknowledgement or discussion of their paradigmatic assumptions and
positionings (Guba & Lincoln, 2005; Ponterotto, 2005). In counselling
psychology, a prevailing view for relational therapists, and one that reflects my
personal epistemological positioning, is that (Halewood, 2017): “…adopting a
critical constructivist position towards the “expert” objective analyst while
uncritically accepting the positivist findings of empirical research leads to
29
epistemological incoherence” (p. 99). The interpretative phenomenological
approach I adopt in this study acknowledges that reality is can only be
experienced through a process of intersubjective meaning-making, rather than
discovered. The case study methodology applied in many ISTDP studies aims
to overcome of the “privileged status” (Hoffman, 2009) afforded to
neuroscientific and experimental research by devoting its energies to the in-
depth case study approach as a way to progress psychotherapeutic knowledge
and process. The metapsychological concepts in psychoanalysis that help
determine the important clinical effects were developed through contextualized
clinical observations rather than through of systematic research that takes an
objectivist stance. Yet such an approach would apply a realist status to the
status of the analysis, which is in contrast with the epistemological stance opted
for in this study. Grounded theory methodology (Charmaz, 2013) employed in
investigating therapists’ experiences was theory forming, rather than focused on
the meaning-making of participant. Yet, in IPA studies, the purpose of
presenting an enriching, contextual view of therapists’ experiences appeared to
concentrate on related phenomena than emotional experiencing within a
specific context and therapeutic setting.
2.14 Rationale for the Current Study
This literature review has thus shown there are gaps in the literature in
terms of research focus and methodological approach. There are no studies
that investigate the phenomena of the therapists' experience of their clients'
deep experiencing of emotion. While some studies exist in other modalities,
ISTDP was selected over these for the following reasons. Emotion-focused
approaches share similarities in their attention to helping clients identify,
process and express their emotions. Yet these approaches vary in the extent
through which they either instruct clients on their feelings, use unconscious
processes that entail the therapist’s use of self, and the intensity and acuteness
of working with emotions. ISTDP, comparative to respective STDP and EDT
approaches, has the strongest evidence base for holding firm to its commitment
in ‘staying with’ clients intense emotional experiences. This makes this
approach a suitable choice for this study’s focus.
30
Furthermore, a review of the qualitative research on therapists’
experiences reveals that within ISTDP there appears to be a lack of research
into the experiences of ISTDP therapists and the phenomena of how they stay
with clients experiencing deep emotion. Observational studies undertaken have
tended to focus on their adherence-based responses to clients, to show efficacy
of ISTDP therapy. Wisdom literature and research on therapists’ effects reveals
the importance of the therapist’s tolerating emotion of the client though without
a direct focus on the phenomena of interest to this study. As the professional
and practical opportunities for the counselling psychologist are under constant
renegotiation as theory and praxis develops (BPS, 2018a), there is,
consequentially, an important gap in literature that needs to be addressed.
Developing our understanding of intensity of emotion that the ISTDP therapist
endeavours to facilitate therapeutically with their clients and experience with
them within the therapeutic relationship, seems relatively unique. The expert
therapist and therapists’ effects research supports the ISTDP assertion that this
is a valued skill of therapists who aim for a high degree of clinical effectiveness
in their practice. Further understanding what it is like will help offer counselling
psychologists and other therapists across modalities gain insight into their
clinical practice and professional identity, in view of this intensive, emotions-
focused approach. Rather than legislating differences, it is hoped that this can
add to the field’s preference to pluralism of multiple models, in the spirit of
learning from different practitioners and through the subtleties afforded through
an investigation of therapists’ subjective experience.
2.15 The Current Study and Research Question
The current study will address the following main research question: how
do ISTDP therapists experience their client’s intense experience of emotion? It
is hoped that this broader enquiry to the typical moment-by-moment manner in
which this group of therapists tend to reflect on the phenomena to be studied,
can help generate contextualised knowledge (McLeod, 2017) within the therapy
setting that can serve as a source of emergent and novel insights.
2.16 Chapter Two Summary
ISTDP has a very specific model of delivery, implying that the
experienced ISTDP will be in agreement on what exactly is meant by “staying
31
with” and “client’s intense emotional experience”. Yet, the epistemological
stance I adopt in this research means that I endeavour to elicit each
participant’s understanding of these terms, and so a subset is gaining an
understanding of how therapists understand these definitions, as well as their
role in therapy (therapeutic process and outcome). This is an exploratory study
that uses IPA to reach an understanding of this complex phenomena. What
becomes clear from the above literature on therapists’ experiences is that,
often, what people experience, and the way they understand that experience,
will not map on to theories of therapy in any straightforward manner.
Conducting this kind of research has the effect of inviting therapist-researchers
to examine their basic assumptions about therapy, and arrive at a deeper
understanding. The rationale for this approach will be further outlined in
following, Chapter Three: Methodology.
32
Chapter Three: Methodology
3.1 Chapter Three Overview
This chapter details the methodology I developed for this study. First, I
examine the development of qualitative methodologies and research in
counselling psychology. Then I explore the development and application of IPA
(Smith, Flowers & Larkin, 2009), involving in-depth, semi-structured interviews.
The subsequent sections in this chapter narrate my research process. Here I
describe participant recruitment procedures and sampling and the approach I
used in the analysis and interpretation of my empirical data, with a view to
highlighting the consideration I gave to quality issues in this study. Although my
personal reflections and ethical considerations are included in specific sections,
these important processes and research tools were drawn on throughout the
design and implementation of this study and are therefore emphasized
extensively in this chapter.
3.2 Purpose of My Research: Qualitative vs. Enriching Research
Counselling psychology has a long tradition of qualitative inquiry that
seeks, as one of its aims, to challenge the orientation toward mainstream
quantitative approaches in the field of psychology. These two different
methodologies are typically conceived of as based in “contrasting ways of
knowing” (McLeod, 2017, p. 395). Yet this distinction has been questioned, as
one that sets up a false sense of homogeneity and thus a false opposition
(Fasulo, 2015). I drew on Stiles’ (2015) classification of alternative purposes to
psychotherapy research, which aims to avoid conflating purpose with method.
These distinctions seemed to me valuable and desirable in understanding
differences in research approaches and how they are achieved differently.
My research aimed to understand how ISTDP therapists experience
staying with their client’s intense emotional experiencing. The purpose of my
study thus fits with Stiles’ (2015) category of enriching research as my study
likewise “seeks to deepen and enrich people’s appreciation or understanding of
a phenomenon” (p. 160). Instead of developing a theory or fact-gathering, the
purpose of my study is to promote an enriched and empathic understanding of
the experiences of therapists who are engaged in providing a therapeutic
33
experience of emotion. An enriching-based understanding is the point of the
study: one that seeks an aesthetic, empathic, and contextual appreciation of the
phenomena in question.
3.3 Methodological Approach: Why Hermeneutic Phenomenology?
Following Willig’s (2012) conceptual map of the possible epistemological
positions available to the qualitative researcher in psychology, my intended aim
of producing knowledge about my participants’ subjective experience squarely
positions my research within a phenomenological approach. Phenomenology
aims to study and comprehend lived experience through an awareness of how a
person involves themselves in the world. It is based on the hermeneutic
phenomenology of Heidegger (2010) that acknowledged the impossibility of
achieving direct access to a person’s experiences. Through the collection of
first-person accounts, it moves away from an interest in accurately capturing a
“real” world but instead focuses on how the researcher interprets the
participant’s own interpretation of their experiences (Langdridge, 2007). Willig
(2012) describes the role of the researcher here as like that of a counsellor.
Rather than question the external validity of what the participant says, the
researcher’s role is instead to listen empathically to the participant’s account of
their experience.
The phenomenological view assumes multiple worlds whereby the same
event (such as a therapeutic encounter) can be experienced differently and so
this perspective takes an interest in the lived experience of the participant and
what their world is like for them. It can give language to aspects of existence
we already know implicitly yet have not expressed in depth, or alternatively,
surprising insights can reveal themselves. As Finlay (2011) highlights,
phenomenological research can deepen an understanding of therapeutic
practice and processes and aid therapists in both their personal and
professional development. This methodological focus is therefore a good
starting place for a study on therapists’ experiences. This position recognises
the social-psychological and experiential world of the person as diverse. It also
echoes the value the field of counselling psychology places on the humanistic
and pluralistic attitude (Kasket, 2012) toward psychotherapy (Cooper &
McLeod, 2011) and research practice (McAteer, 2010; Rafalin, 2010).
34
More specifically, my study adopts an interpretative phenomenological
approach (Willig, 2013). Heidegger’s (2010) hermeneutic phenomenology
highlights the practice of interpretation as the key methodological task, based
on the centrality of interpretation to all human understanding. Interpretative
phenomenology shares a broadly realist ontology that does not deny the
presence of underlying psychological structures but asserts that the experience
of phenomenon can only be known through interpretation (Willig, 2013). Such
an approach is positioned ontologically between realism and relativism. Rather
than seek universal truths about phenomena, my inquiry rejects such realist,
positivist approaches that would aim for an objective account of phenomena
under study. Likewise, a totally relativistic, constructionist focus on the effect of
language, is also eschewed as this would also not fully address the main aim of
the study in exploring the meaning that therapists ascribe to the complex
phenomena of staying with their clients’ deep experiencing of emotion.
Interpretative phenomenology was thus considered aligned with my research
question and seen as a methodology that can attempt to apprehend and
highlight the essence of an intelligible experience through interpretative practice
(Langdridge, 2007).
3.4 Rationale for Using IPA
I have chosen IPA as the method most suited to address my research
question. This is primarily due to IPA’s epistemological underpinnings that
engender a methodological commitment to exploring how a unique
phenomenon is grasped and made sense of by particular people (Larkin &
Thompson, 2012). IPA is a pluralistic approach that aims to understand the
lived experience by incorporating the ideas of the key philosophers of
phenomenology: Husserl, Heidegger, Merleau-Ponty, and Sartre. Smith,
Flowers & Larkin (2009) provide detailed guidance on ways to investigate lived
experience in a systematic way that is valuable for psychologists. An
idiographic focus can best reveal the ISTDP therapist’s subjective lived
experience through an inductive process that centres on the participant’s
perceptions as opposed to other predefined categories. IPA can thus engage
me as the researcher in a detailed exploration of my participants’ lived
35
experience and locate the phenomenological account we generate together
within a co-created reality (Smith, 2011; Willig, 2013).
Hermeneutics is a method of interpretation that views meaning as a
socio-cultural product arising out of human action. The interpretation of a text is
thus influenced by the person doing the interpreting (Gadamer, 2013;
Heidegger, 2010). Understanding emerges through a practice of relating part of
a text to the whole in a back and forth, circular process. Consequently, any
interpretation a researcher offers will inevitably differ from the text’s original
meaning. Likewise, symbolic interactionism (Blumer, 1969; Mead, 1934) is
important for explaining the situated and relational aspects of human
understanding. Interactions between people and the sense people make of
their lived world through shared symbols and social life, place language at the
heart of the subjective meaning making processes of the person. It is through
people’s intersubjective and interpretative pursuits that they constitute their
worlds and through which their sense of themselves and others emerges.
IPA therefore views contextual processes as fundamental to
understanding our experiences, including the narratives participants give about
those experiences. Drawing further on Merleau-Ponty’s (2012) view that
humans regard themselves as different from all other things, means a sense of
self that is embodied, actively and holistically perceiving the world and others.
The implication for IPA is that as researchers we can observe and feel empathy
for our participants, but ultimately we only see phenomena from our
perspective, and can never share entirely the participant’s experience (Smith,
Flowers & Larkin, 2009). Sartre’s (1956) view of the self as an ongoing project
of always becoming ourselves, means he sees our being in the world as always
unfolding. Meaning-making is likewise unfolding for both the researcher and the
participant through a double hermeneutics of empathic understanding of the
participant’s perspective whilst also questioning aspects of their accounts that
they may be less aware of. Yet, IPA’s idiographic focus is on the participant as
the individual and entity to be understood in their own right (Smith, Flowers &
Larkin, 2009). The researcher may nevertheless endeavour to move beyond
the individual case to make more general statements about individuals.
36
Alternative methods, although of similar paradigmatic scope, were
disregarded due to a lesser correspondence with the research aims and my
epistemological position. These were grounded theory, discourse analysis,
narrative inquiry and thematic analysis. Grounded theory (Charmaz, 2013)
seeks convergences within a typically larger-sized sample to support broader
conceptual explanations, whereas IPA is interested with providing detailed and
rich accounts of the personal experiences of a smaller sample (Smith, 2004).
Discourse analysis is doubtful concerning the accessibility of cognitions, a key
aspect of IPA central to the sense-making process, and instead focuses on
language and how it acts to construct or constrain social reality (Smith, Flowers
& Larkin, 2009; Smith, Flowers & Osborn, 1997). Lastly, narrative inquiry
(Murray, 2008), though of a constructionist orientation that can match well with
the symbolic interactionism of IPA, and is concerned with sense-making,
delimits meaning to story form that can be adequately considered within IPA
without the story-form constraints (Smith, Flowers & Larkin, 2009). Additionally,
thematic analysis (Braun & Clarke, 2006) may have been appropriate for an
exploratory study of therapists’ experiences but was dismissed due to its
nomothetic, rather than idiographic focus.
Entering the lived experience of ISTDP therapists, and aiming to
understand the uniqueness of each therapist’s experiences within their context
may help sensitise other therapists to the potential ways that ISTDP therapists
might feel, think and respond, and in relation to their clients. Such studies are
not directly concerned with psychotherapeutic processes or outcomes (Gelo &
Manzo, 2015), but instead give therapists, what McLeod (2011) refers to as
“essential background information”. The purpose of such research aligns with
Stiles’ (2015) description of enriching research that is outlined above. Within
the qualitative research literature, and IPA literature more specifically (Smith,
2011), there exists a number of studies in which the experiences of people
living with health conditions and socio-cultural difficulties have been explored.
The therapist can find such studies and their implications to be a crucial
resource, as a way to attune to the uniqueness of the client’s experiences, and
transfer learning to their own clinical practice.
37
This section has considered the theory underpinning IPA and how this
method uses theoretical approaches – phenomenology, hermeneutics, symbolic
interactionism, and idiography – to guide its distinctive epistemological
framework. Doing so has enabled me to ensure I have chosen a methodology
that best reflects my personal and professional values and research objectives
(McLeod, 2011). Having outlined the major research paradigm and the
positioning of my own thesis within these paradigms, it can be concluded that
the epistemological positioning of my study is specifically suited to my research
question (Gelo, 2012). It is also aligned with the phenomenological roots of
counselling psychology, taking a subjective stance with a focus on the meaning-
making processes of individuals who participate in this study (McLeod, 2017).
3.5 IPA Method – The Research Process
The remainder of this chapter concentrates on steps I have taken to
gather rich and exhaustive data from participants that could successfully give
voice to their experiences through a sufficiently phenomenological and
interpretative account of their narratives. I offer reflections on my response to
the conceptual and practical difficulties I encountered, in order to provide a
transparent account of my research journey in executing the design of my study
and the collection and analysis of data (Tuffour, 2017).
3.5.1 Participant and recruitment procedures.
3.5.1.1 Sampling method. I used purposive sampling, the standard
basis for data collection for IPA studies (Smith, Flowers & Larkin, 2009), to
source participants. The suitability of the participant in being able to provide
insight into the phenomena under study was a core criterion of selection. A
consequence of this was a homogenous sampling that aimed for a rigorous
understanding of experiences shared by a particular group, as well as those of
the individual (Willig, 2013). ISTDP therapists are trained to work in an
intensive and experiential manner that is emotions-focused, thus making them
particularly useful participants for this study. The role and qualities of being an
ISTDP therapist, therefore, boosts the likelihood of their insight to the
experiences of staying with client’s experiencing deep emotion and what it is
like to work therapeutically in such instances.
38
3.5.1.2 Inclusion/exclusion criteria. To be invited to participate,
participants needed to have completed the ISTDP core training at a recognised
ISTDP institute and hold a minimum of 3 years’ professional experience as an
ISTDP practitioner. This decision was made in personal communication with an
experienced ISTDP trainer, with over 10 years ISTDP experience, who advised
on this criterion. A pragmatic balance was aimed for between securing the
required number of participants and ensuring a sufficient degree of experience
that could ensure adherence to the ISTDP model for the purposes of
adequately addressing the research question. Participants needed to possess
current membership/accreditation with a counselling or psychotherapy
professional body (for example, the BPC, BACP, BPS and UKCP). The
exclusion criteria were participants who were not currently practising ISTDP, or
who were not delivering ISTDP as their primary modality of treatment.
Participants who were for any reason unable to give informed consent or who
had complaints pending with their professional body would also have been
excluded. None of the exclusion criteria were encountered in the recruitment
process.
3.5.1.3 Recruitment strategy. There were at the time of recruitment
estimated to be around fifty ISTDP practitioners in the UK, including those
currently in training who may not yet have the requisite experience to participate
in the study. To ensure a purposively-selected, carefully-situated sample, I
contacted ISTDP-UK, the UK-based organization for ISTDP who hold a central
listings of registered ISTDP therapists. I provided this contact with the
participant information sheet, which outlined the purpose of the research (see
Appendix A) and a request to forward this information to the potential
participants. My contact details were included so that participants could contact
me for further information. Participants were also recruited via opportunities
through my own ISTDP contacts, who offered to distribute my advert through
their private contact listings of ISTDP therapists. Recruitment of participants via
the snowballing method was also permitted, where participants forwarded on
the research details to other potential participants, which happened in the
recruitment of three of my five participants. It would have been possible to
recruit from an international pool of ISTDP practitioners, and similar to the
39
process above, I distributed my advert through an ISTDP practitioner based in
California. However, there were no responses to the advert, and so due to time
constraints, I made the decision to concentrate my efforts on recruitment from
within the UK.
3.5.1.4 Choosing the participants. I received six responses from
current ISTDP practitioners who were suitably qualified and experienced to take
part in the study. I corresponded with all participants via email, forwarding the
recruitment advertisement and invitation letter, and inviting them to respond if
wishing to take part. Participants were offered choices of location and time for
the interview, where all venues chosen by the participants were their places of
work. One interview was conducted by Skype via a personal computer from a
private location. Skype interviews were offered as a substitute to face-to-face
meetings to help broaden the participant pool (Hanna, 2012; Sullivan, 2012).
Although six participants were interviewed, one participant requested post-
interview for their data to be withdrawn, and so their data were not included in
the study.
3.5.1.5 The five participants. Demographic details offered are
intentionally minimal so that the participant cannot be identified from any such
information or when considered together with the participant’s words. Of the
five participants included in the study, four described their gender as female and
one as male. All had a minimum of three years’ experience as an ISTDP
therapist and all had completed their training at the ISTDP-UK institute. All
were accredited psychotherapists who currently practiced ISTDP and classed
ISTDP as their core modality. Thus, these commonalities across participants
fulfilled Smith, Flowers and Larkin’s (2009) guidance for obtaining a moderately
homogenous sample that can produce a sufficient perspective that is suitably
contextualized.
The sample size of five participants was deemed suitable, according to
the guidance for doctoral studies of four to eight participants given by Smith,
Flowers and Larkin (2009). This lower sample size allowed for a faithful
adherence to idiographic focus of IPA and made it possible to present an
analysis of greater depth and interpretation that might be inhibited by larger
40
sample sizes. All participants were attentive and effective in expressing their
thoughts and feelings, in order to illuminate the particular research focus. This
idiographic presentation helped illuminate the complex thinking and emotional
processes these therapists faced in their moment-by-moment engagement with
clients’ intense emotional experiencing whilst also highlighting patterns across
these individual accounts. Thus the benefit of the specific sample was in being
able to capture detail on this group of psychotherapists who have shared
particular experiences with clients that are of interest to therapists who work in
an emotions-focused way and indeed any therapist hoping to understand further
what it is like to stay with their clients’ intense emotional experiencing.
3.5.2 Data collection. The standard method for IPA data collection,
drawn on in this study, is a semi-structured, one-to-one interview. IPA
researchers do not regard interviews as an objective and impartial method for
collecting data (Rapley, 2001). The interviewer aims to engage with the
participant flexibly and collaboratively, to identify and interpret the relevant
meanings employed in making sense of the subject matter. The interview can
aid the researcher in building a rapport with the participant that enables them to
voice their particular beliefs and ideas through personal and in-depth
discussion. ISTDP has a very specific model of delivery, implying that the
experienced ISTDP therapist will be in agreement on what exactly is meant by
“staying with” and “client’s intense emotional experiencing”. Yet, my
epistemological stance entailed that I endeavour to elicit each participant’s
understanding of these terms, and so a subset is gaining an understanding of
how they make sense of these definitions and apply them in their role in the
therapy they deliver.
3.5.2.1 Interviews. Before the interview commenced, the demographics
information form (see Appendix B) was given to and completed by the
participant. I then read aloud the consent form (see Appendix C) to the
participant to ensure a shared understanding of its contents before a signed
copy was obtained. This also ensured participants were clear about their
involvement and agreement with the study. All interviews were recorded
digitally. An initial warm up question of “what drew you to ISTDP?” and then
wider topics and areas of interest were introduced through open questioning,
41
such as how participants work as an ISTDP therapist. The interview schedule
(see Appendix D) covered three topic areas, including participants’
understanding of their focusing on clients’ intense emotional experiences (e.g.
how do you view intense emotional experience?), their experiences of staying
with such emotionally intense moments (e.g. what is it like when the emotions a
client experiences are particularly intense?), and their experience of their
capacity to facilitate a therapeutic experience of emotion (e.g. what enabled you
to stay with your patients’ deep experiencing of emotion?). Prompting
questions were used that followed participants’ responses, in order to help
highlight the key aspects of sense-making related to therapists’ endeavours with
a client experiencing deep emotion. At the close of the interview participants
were handed a debrief form (see Appendix E), which contained details of further
support should they need this. The same procedure was conducted via email
for the Skype participant.
During the interviews, I aimed to remain sensitive and aware of non-
verbal and non-behavioural communication (Pietkiewicz & Smith, 2014). All
interviews were later transcribed verbatim, where all grammatical and verbal
errata, laughter, significant pauses were retained to allow for full focus on the
semantic meaning (Smith, Flowers & Larkin, 2009). For the Skype interview,
though the guidance of Deakin and Wakefield (2014) on logistical and ethical
considerations, was easily met, I found building rapport online more challenging
than with face-to-face interviews. During the interview I had felt I was slightly
less emotionally connected to the participant. This, on reflection was perhaps
due to the lack of visual and sensory cues that might be available in an in-
person interaction and feeling concerned about the impact of this on the
participant. This meant I did not probe answers as fully as with the face-to-face
interviews. Two key differences therefore resulted in data collected. First, the
skype interview was the shortest in duration, at 40 minutes (whereas the
longest interview was 73 minutes). Second, though rich data (Smith, Flowers &
Larkin, 2009) was gathered, there was perhaps scope for a greater degree of
depth in terms of the phenomena under study. Based on the learning and
reflections from this interview, I believe that in the future I would be in a better
position to overcome these challenges with future Skype interviews, however,
for this study, no further online interviews were required.
42
Post-interview, I made reflections in my research diary regarding the
interview, in terms of any impressions or expectations, and also a brief
evaluation of my interview style, that I used as the basis to improve my
approach in subsequent interviews. I used Kasket’s (2016) reflexive list of
questions helpful for interrogating and reflecting on the research process, the
interviews and any pre-understandings about the participants that arose. For
example, I had noticed that my perception of the participants as experienced
and specialised practitioners had led to an erroneous assumption that they
would therefore be “zipped up” (as it appeared to my mind) emotionally-
speaking, in terms of having addressed their own early attachment traumas to
an extent that they no longer manifest in the work. Yet participants’ responses
often challenged my expectations and as I began noticing this, I was able to
explore this area more fully, including the contextual influences to such
moments in the work, which may otherwise have been missed. It also meant I
became more attentive to the sensitivity of the research by highlighting the
sensitive nature of the topic and reminding participants at the start that they
need only talk about what they would like, drawing on either personal or
professional material as they wished. Such reflexive activity was thus crucial for
identifying my positioning (Frost, 2016) and preconceptions that I was then able
to foreground and use to improve my interviewing practices and progress my
understanding of the phenomena under study.
3.5.2.2 Confidentiality, anonymity, and data security. Confidentiality
of the data and anonymity of participants was ensured by locking paper
transcripts and signed consent forms in a secure cabinet. Participants were
informed that after data has been analysed, supervisors and examiners would
also have access to sections from the anonymised transcriptions of interviews.
Audio-recordings were uploaded onto a laptop and destroyed from the digital
voice recorder and all electronic data, including audio recordings, were
password-protected. Real names and identifying references were omitted from
transcripts, and a pseudonym was assigned to each participant by the
researcher. Only the main researcher had access to the names and identities
of participants, which were stored separately from all transcripts. After the
completion of the study, audio recordings and transcripts would be kept
43
securely and anonymised. These data would be stored for a period of three
years, in the event that it is possible to publish the findings, and destroyed
thereafter.
3.5.3 Data analysis. The data were analysed using IPA. As a novice
researcher of IPA and qualitative research, I adhered closely but not
prescriptively to the six steps outlined for the analytic process (Smith, Flower, &
Larkin, 2009). Below, through description and reflexive commentary, I highlight
how the methods of my research aligned with the wider philosophical
commitments of IPA. I also highlight my efforts to draw on the six-step
guidelines in a flexible and creative manner, based on my own research
objectives and priorities. Some conceptual difficulties that I needed to
overcome are discussed. As well as reviewing past IPA studies (Smith, 2011)
and doctoral theses (for example Andersson, 2014; Spragg, 2013), I found the
work of Huff et al. (2014) and Gee (2011) useful in helping me build the
confidence to delve deeper into comprehending and conducting IPA in
enriching research.
In order to appreciate as fully as possible the influence of my
epistemological stance, it was important to consider my knowledge claims in
relation to the data collected and analysed. The distinct ways of knowing
reflected in the (psychodynamically-inclined) realist or constructivist position
that informs much of the ISTDP research described in the literature review
versus my interpretative phenomenological stance are also worth clarifying.
The researcher in the critical realist mode (Willig, 2012) may consider the status
of the data gathered as relativist (i.e. data does not necessarily accurately
reflect reality) and yet the status of the analysis as realist (where theoretical
explanations are used to accurately reflect what happens for the participant). In
IPA, the interview text is understood as a verbal utterance of the participant’s
psychological processes (Willig, 2013), and thus shares the empiricist concerns
of the critical realist stance. Yet in the same way that a concern for participant’s
meaning-making is not dependent on a truth value, my meaning-making
processes are implicated in any interpretation I offer. Therefore, in this study I
hold a relativist attitude towards the status of both the data and analysis (Willig,
44
2012), without any inclination to disavow the reality of those experiences for my
participants.
3.5.3.1 Step one: Reading and re-reading. In this first step I repeatedly
read the transcript in order to engage myself fully in the experiential world of the
participant. I listened to the audios alongside reading the transcript, considering
tone, volume and silences, as preparation for hearing the voice of the
participant. This also helped me to imagine the participant’s voice in later
stages of the analyses. I also made notes about my own role in the interview,
how I had handled the semi-structured format, particularly the open-ended
process of following the participant’s sense-making but keeping in mind key
questions relating to the phenomena under study. I found this a necessary
process in order to feel comfortable and confident to begin the next step of
initial noting.
3.5.3.2 Step two: Initial noting – producing detailed annotations and
comments. The transcript was presented in the first of three columns (see
example in Appendix F). In the second column, I made notes of initial
responses to anything interesting or significant in the transcript. Comments
were descriptive (meaning or content the participant talks about), linguistic (how
the participant uses language) and conceptual (arising questions or possibilities
relating to theory that can enhance understanding; Smith, Flowers & Larkin,
2009). The final column was left for the next step of noting emergent themes.
I found the early stages of the initial noting for the first participant to be
one of the most anxiety-provoking aspects of the analysis. It felt I had lost all
reference to any of the knowledge claims I was holding to in my epistemological
position and research approach. I reflected on this with peer researchers on my
programme of study and could begin to understand my fears as the “drift back
towards positivism”. This drift included the search for unambiguous answers
and objectivity rather than bringing my own perspective to the data and valuing
the intersubjectivity that is at the heart of good IPA and counselling psychology
research and practice (Kasket, 2012). This predicament could be explained by
my appreciating that my previous and first encounter in counselling psychology
was as a quantitative researcher. Once I could appreciate that my subjectivity
45
would be what makes rather than “corrupts” the research, I was able to begin
noting in a way that connected my pre-understandings with my emerging
understanding of the participant. One way I coped with the restrictiveness of
this was to write free text before and after the process of initial noting; before, to
free myself up to encountering the text, and after, to try and capture anything
from the participant’s account that I felt was not reflected in my initial noting. I
then was able to return to these statements at various later stages to check I
was speaking to the psychological concept as well as at the specific points of
the analysis.
3.5.3.3 Step three: Annotating and developing emergent themes.
This stage of the research was aimed at directing the analysis from the
annotations to apprehending a sense of the transcript in its entirety (Smith,
Flowers & Larkin, 2009). I noted in the third column any potential themes that
seemed to be suggested by what the participant had said and also any shared
features and attributes that surfaced in the transcript. These themes were then
transposed to another word document, along with line number and
corresponding verbatim quotes, so the articulation of these themes could be
easily evidenced and further examined for their phenomenological and
interpretative rigour. Once satisfied with the themes, I transposed the themes
to an online mapping tool, so they could be easily clustered by association and
commonalities (Huff et al., 2014). Many versions of the maps were generated
and re-arranged until all themes were clustered, retained separately or
discarded, or amalgamated with themes of significant overlap.
In this step I faced challenges with the task of reducing the whole text
and data set into parts, and in assuming the interpretive stance. I initially
perceived the shifting of my focus from the participant to the phenomena under
study as being unfaithful to their account. Consequently, in my first attempt at
generating emergent themes I had mostly elevated the participant’s words to
the level of theme. This generated themes that were phenomenologically
grounded in the participant’s experience but lacking focus and psychological
vigour. I reread Huff et al.’s (2014) example of adhering to the philosophical
commitments of IPA, which helped me gain confidence in including my own
understanding. I redid this stage over two days and was more at ease to
46
represent psychological themes that achieved more of an interpretative balance
and were more focused towards the research area.
3.5.3.4 Step four: Searching for connections across emergent
themes within the participant’s account. Once many of the emergent
themes were identified, it was possible to explore whether some of these
themes could be subsumed under other themes (see Appendix G for a table of
clustered emergent themes for one participant.) Here I used the research
question as my guide to help prioritise which themes were retained or
discarded, together with an overall sense of the participant’s account against
each theme. On my devised list of all the emergent themes that had been
identified in the participant’s account, I rearranged themes until all were
appropriately clustered. I looked for connections among clusters using
abstraction, subsumption, and polarization, as described by Smith, Flowers and
Larkin (2009).
3.5.3.5 Step five: Moving to the next case and repeating steps one
to four. Once the first four steps were completed for the first case, the same
steps were repeated individually for subsequent cases. Alongside the analysis,
I developed a preliminary version table of themes groupings until all three
superordinate themes were added. The table was instrumental for analysing
across cases where I trialed various arrangements of subordinate and
superordinate themes. Eventually, a clear and robust set of themes revealed
itself, producing a final version. Here I endeavoured to treat the next and
subsequent cases on their own terms, to adhere to the idiographic commitment
and focus on the individual. This entails, as Smith, Flowers and Larkin (2009)
suggest, “bracketing” any ideas that emerge from the previous case when
working on subsequent cases. I achieved this process of putting aside prior
concerns by noting down such “intrusions” in a separate document, and
dialogue with the current case by alternating the questions, “what have you told
me so far?” and “what are you trying to say here?” These practices helped me
develop the valuable skill in IPA of letting new themes emerge with each case.
3.5.3.6 Step six: Looking for patterns across cases. This final step
entailed searching for patterns across all five cases. This was achieved by
47
building a table that contains the final superordinate themes with extracts
illustrating each subordinate theme (Willig, 2013). To ensure researcher bias
did not over-intrude on the participants’ accounts through the generated
themes, I re-read the original transcripts a final time to check that interpretations
were rooted in the participant’s account. Having documented all steps in the
data analysis process, I now had a chain of evidence linking my decision-
making from the initial noting to the end of the analysis. Additionally, my
supervisors conducted small-scale audits of my work, performing their own brief
analysis and discussing my initial annotations and emergent themes through to
final themes. This way I could be sure my interpretations were valid in
connection to the case being examined. (See Appendix H for table showing
cross-reference to themes present in all cases).
Throughout, I found helpful Finlay’s (2011) four watch-words for
engaging with the analysis stage of the research. They are: dwelling, wonder,
evidencing and ambivalence. Dwelling refers to the immersion in the data that
happens throughout the analysis but contains its own inner rhythm of empathic
approaching and stepping back from the data to get a feel for the participant’s
experience and to consider how it appears for them. Adopting an attitude of
wonder involved attending to those parts of the transcript that were particularly
resonant – I aided this process by having my research question in plain sight at
all times during the analysis. Evidencing the analysis involved following an
empirical commitment and ensuring the creative and interpretative elements
were grounded in the data. This was an element of the analysis where I initially
had the least confidence but felt this grow throughout the process of analysis.
Lastly, capturing ambivalence, in order to illuminate the contradictions and
ambiguities of human experience, was initially difficult for me to attend to, based
on being overly committed to accuracy in wanting to “re-present” what the
participants have said. I could see the limitations of this fairly early on in
generating emergent themes, but also when looking for patterns across cases.
I considered the multi-layered aspect of human experience within and across
each case and ensured this had been properly captured in the emergent and
final themes. Altogether, these processes helped me to feel confident that my
interpretations of meaning and experience were “genuinely inductive” (Gee,
2011) and situated within the concerns and contexts of the participants.
48
3.5.4 Enriching research and quality. This study applied Yardley’s
(2000; 2008) evaluative criteria to assess the quality and validity of the
research, as they provide a set of principles that are established in the
phenomenological field for ensuring the rigour of the study (Finlay, 2011). This
helped address the ongoing challenge of ensuring my research evenly reflected
my interpretative phenomenological positioning (Willig, 2013) and was in tune
with the philosophical commitments of IPA methodology.
3.5.4.1 Sensitivity to context. Sensitivity to context was established
from the early stages of the research process. The literature review in Chapter
Two aims to convey how the current understanding of emotional experiencing
and the therapeutic endeavour is set within a combination of cultural tendencies
and ideological influences that are intensified by psychology’s focus on the
individual. This is a crucial precondition to the interpretative process of IPA,
that of the hermeneutic circle, that aims to achieve a more comprehensive
understanding of the “part” of the phenomena under study, in relation to the
“whole” socio-cultural context (Smith, Flowers & Larkin, 2009). Furthermore, I
adhered to IPA’s idiographic commitments by remaining sensitive to the
participant as an individual whose unique views and experiences are shaped by
their context. During the research process, I used reflexivity practices of
keeping a research diary and reflecting on my process through use of
supervision. This helped with recruiting and interviewing participants, and with
interpretations made during the analysis and discussion, and particularly with
recognising the contextual aspects of the researcher-participant relationship.
3.5.4.2 Commitment and rigour. I established commitment and rigour
through an ongoing engagement with the research focus, and careful and
rigorous data collection and analysis. Following Smith, Flowers and Larkin’s
(2009) advice for the researcher to develop their research competencies, I
attended a research consultation group comprised of fellow trainees, attended
IPA workshops and other research method lectures. The open-endedness of
the semi-structured interviews allowed me to rapidly build good rapport with
participants. Here I relied on my counselling psychology training and clinical
therapeutic skills to help forge sound relationships. As described above, the
49
detailed account of the methodological and analytic process illuminates the
vigorous and determined attempt to perform this research in a rigorous and
attentive manner in line with Yardley’s (2008) guidelines.
3.5.4.3 Transparency and coherence. Transparency and coherence in
the research process and write-up was achieved through clear delineation of
each stage of the research. The interpretative phenomenological stance I have
adopted meant that I aimed to recognise that any interpretation I offered was
rooted in my own experiences and “fore-understandings” (Heidegger, 2010) and
thus I have been transparent about these through use of reflexive practices.
Writing up of my research thus incorporates a sustained attention to my
positioning as researcher, including a focus on the influence of my epistemology
and psychotherapeutic perspective on my methodological choices. When
reflecting on how I collected and analysed the data, I aimed for rich descriptions
of my reflections on the data collection and analysis stages. Example
reflections are included across this methodology chapter and other chapters,
except the analysis chapter, which as an exception focuses solely on the
participants’ accounts.
3.5.4.4 Impact and importance. Yardley (2008) regards impact and
utility as the ultimate criterion by which to assess the quality of research. I hope
this study will broaden an understanding of what it is like for therapists when
working with clients who are experiencing intense emotion. There is currently
very little research highlighting therapists’ experiences in this area, particularly
from the modality of ISTDP. Moreover, I hope the application of the findings
can be extended, both to widen our understanding of the emotions-focused
work of ISTDP therapists, and in a small-scale way enable therapists to relate
more openly to their own capacity to engage with the deep emotions of their
clients. This fits with a key aim of enriching research that does not seek to give
a detailed account of broader populations but relies on its audience to discover
ways to transfer their observations and interpretations to their own contexts
(Stiles, 2015).
3.5.5 Ethical considerations. Ethical approval for the study was
granted by the University of East London’s Ethics Committee (see Appendices I
50
and J). I abided by the BPS (2018b) code of ethics and conduct and (2014)
code of human research ethics to help maintain an awareness of and guide the
approach to what was covered by the ethical approval. The information sheet
given to participants gave details and rationale for the study, including what
would be asked of participants, and how their data would be used and
anonymised. The consent form that participants signed emphasized that they
had read the information sheet relating to the research study, and that the
nature and purposes of the research had been explained to them. It also
confirmed that participants had had the opportunity to ask any questions, and
had an understanding of what was being proposed and the procedures in which
they would be involved. Due to the sensitive nature of the research topic, I
debriefed participants at the close of the interview. This was to check for any
distress that may have been present as a result of the interview. This included
the option to discuss and identify further support from a supervisor or personal
therapy. To ensure my personal safety when interviewing, I made contact with
a third-party prior to and after the interview.
3.6 Chapter Three Summary
This chapter detailed my chosen research methodology and positioning
for this study. It explained the processes of data collection and IPA analysis,
including my reflexive engagement. This “enriching research” study adopts an
interpretative phenomenological epistemology. My research process and
adherence to methodological commitments were described. Quality criteria and
ethical considerations for the study were presented. Chapter Four presents the
analysis that followed from the design of the research and the data collection
and analysis.
51
Chapter Four: Analysis
4.1 Chapter Four Overview
This chapter aims to provide an in-depth exploration of the three
superordinate themes which were constructed during the interview, transcription
and IPA process, supported and illuminated by extracts from the participants’
accounts.
4.2 Overview of Themes
In this section I describe in detail the three superordinate themes that
emerged from the data. They are: “opening that door”: striving for emotional
closeness; connection versus disconnection: what’s happening in the room; and
“there’s more of myself now”: building one’s own capacity. The themes connect
to areas of psychological relevance in relation to therapists’ experiences of
helping bring about a therapeutic and often intense experiencing of emotion for
clients. Table 1 presents the three superordinate themes, in which data from all
five participants have contributed. The table also shows the related subordinate
themes, in which three or more participants (around half the total number,
Smith, Flowers & Larkin, 2009) have made contributions. All subordinate
themes are based on at least three participants’ accounts. Where prevalence of
themes is highlighted, the following phrases are used consistently throughout
this chapter to indicate presence in cases: “all participants” = all five cases;
“nearly all” = at least four cases; and “most” = at least three cases. As indicated
by the exploration of the analysis throughout this chapter, the superordinate and
subordinate themes are interrelated, and their influence is multidirectional in
nature.
52
Table 1 Superordinate and subordinate themes
Superordinate themes
Subordinate themes
“Opening that door”:
striving for emotional
closeness
1. “It’s really rewarding”: the motivating
power of seeing a person change
2. “Not giving up on the route to getting
there”: persevering through resistance
3. “Trying to decide where to go next and
how to proceed”: pressure and focus on
accuracy
Connection vs
disconnection: what’s
happening in the room
1. “A shared experience”: connection and
intimacy in the therapeutic encounter
2. “It's painful not to be able to reach a
patient”: feelings of frustration and inadequacy
3. “Talking to myself”: remaining calm and
professional
“There’s more of myself
now”: building one’s own
capacity
1. “You get better…you get more emotion in
the room”: building emotional tolerance
2. “Those minute flickers”: observing and
reflecting on inner emotional life
3. “Knowing enough about myself”: using and
protecting the self
4.3 Superordinate Theme One: “Opening That Door”: Striving for
Emotional Closeness
This first superordinate theme clusters together subordinate themes that
recognise the contradictory features that arose from participants’ talk of their
striving for emotional closeness in their therapeutic work. The title of the theme
draws on the metaphor of the door to symbolize the challenging resistances in
the process of change that the therapist and client may face. The theme
presents the different ways in which participants spoke about how working with
patients’ defences against intimacy in the therapy room brings difficulty and
challenge for the therapist but also comfort and reward. This included noticing
patients’ immediate responses to having a caring other persevere through their
53
resistances to closeness. Similarly, therapists also face such exposure in
helping facilitate a therapeutic experience of emotion. The motivating aspects
of the work were therefore accompanied by challenges to help overcome
patients’ resistances. Striving to more accurate in delivering interventions,
therapists may face greater pressure and focus on avoiding misses or missteps
in their practice. This theme therefore captures the underlying tension between
the sense of achievement in effecting the reaching through to emotion but also
at times the sense of anxiety and attention to the pressures of achieving
intimacy. Three subordinate themes emerged: (1) “It’s really rewarding”: the
motivating power of seeing a person change; (2) Moment-to-moment precision
viewed as comfortable vs difficult to deliver; and (3) “Trying to decide where to
go next and how to proceed”: pressure and focus on accuracy.
4.3.1 “It’s really rewarding”: the motivating power of seeing a
person change. All five participants reflected on their initial experience of
being drawn to the precise nature of ISTDP as an effective way of working and
witnessing physical changes in the client in the room. Participants regarded the
video material of casework they viewed at conferences as a powerful influence
on their decision to train in the ISTDP model. This is illustrated by Raelyn’s
emphasis on effectiveness and the comparison with her then current way of
working:
… what really drew me was seeing um video material of ISTDP
in practice, so actually seeing the work, seeing the interventions,
and seeing the result … so effectiveness and I suppose, being
more active in the work, as a therapist, moving away from the
blank screen, and to being, you know, quite an active therapist.
(R, 14)
Raelyn’s repetition of “seeing” perhaps highlights the importance for her
of bearing witness to effective practice and also being able to notice the benefits
of this. Raelyn views the more active therapeutic stance in light of her own prior
experience, revealing her assumption of the neutral psychodynamic stance she
was feeling less close to as a more passive way of helping show patients their
unconscious inner world. Judith was, likewise, struck by seeing parallels with
what “rings true’ with her own clinical experience and that her response to the
theory, “Yes. That makes so much sense', was backed up by what she saw on
video. (J, 49). David (20) links the keenness of his emotional response to
54
witnessing the intensity that was reached through the work. Emma, too, was
impressed by the speed and efficiency of the work she witnessed in the time
sequence in the videotapes, seeing in hours what might have taken her years to
achieve in her way of working: “… So it just, it blew my head off, it really did” (E,
15). Emma uses a very powerful metaphor to recall an almost incredulous
response and the mode of questioning that followed seems emotionally
charged. That Emma, unlike Judith, could not yet see how effects were being
achieved, appears to have contributed to her “mind blown” reaction and the
extremely strong impression the tapes had on her. Beverly was impressed by
what was achieved in a single session:
… Um, I remember thinking that if psychotherapy is uh like going
to someone who massages a bit of you that's hurting - um gently
massages it - ISTDP seemed like a surgeon taking a very sharp
scalpel and very carefully cutting out, s- the thing that was
causing the problem, um, which was very effective but it's a
sharp scalpel and you have to know how to, how to use it. Or
you can, kind of, do some damage. That's, kind of, how I thought
about it, and I came away from that thinking, I want to learn how
to do this type of therapy. And if I can't do that of therapy, I don't
want to do the other type anymore…It had a very profound effect
on me. (B, 19)
Beverly’s interesting metaphor appears to highlight how in the same way
a surgical scalpel consists of two parts – a blade and a handle – the importance
of the practitioner who holds that handle and their discernment in the precise
application of ISTDP “tools”. It seems that part of this “profound” and revelatory
experience for Beverly, in terms of informing her future direction, was related to
a great sense of responsibility in approaching this way of working.
All participants reported the value of observing helpful change in the
being of the patient and how an appeal for the therapist is witnessing, in their
therapeutic work, signals of the healing for the patient. It also helps understand
the focus on the patient and their understanding and assessment of the patient
through how they present physically in the room. Raelyn highlights how when
helping the patient having that emotional experience she can “literally see a
person change” (R, 652):
they will be more better put together, more physical uh posture
and tension, but I don't mean tension in a bad way, I mean in a
good way like not slumping, like sitting up, they will somehow
55
look better. So you do see those very positive changes. You
see a massive drop in anxiety levels, right, so there's lots and
then you see improvement in symptoms, so there's lots of things
that encourage you, I think, just to know that you're doing a good
thing, and not harming the person. (R, 654)
Raelyn’s sense-making of a “good” or “bad” way of sitting is based on the
notion that various means that patients use to avoid emotion can reveal
themselves in the patient’s body positioning. Raelyn’s focus on the patient’s
emotional physicality is closely linked to her ability to assess their health and
progress. The encouragement she feels, when successfully helping the patient
forgo the use of emotionally avoidant responses that are generating their
symptoms, perhaps reveals how discouraging and uncertain this can be also for
the therapist before this point. Emma, likewise, is invigorated by the physical
changes she observed in patients in terms of how they relate to and “feel about
themselves” (280):
Uh that's exciting (eyes widen) - it's really rewarding. And again -
I can see in my mind the person I saw today, um started three
days ago with someone who looked very very different from the
way she ended up looking today, w-when we were going through
something which was highly charged. And she started to emerge
and just look. And give out a sense of a very different sort of
presence and strength. (E, 281)
Emma here emphasises how gratifying it is seeing true emotion
expressed through the body of the patient. There is sense of the “real” self of
the patient transpire which Emma regards as healthful. Emma lists physical
aspects in the way Raelyn does, but instead speaks of “presence and strength”
that are nonetheless seen by her as qualities that are somehow emanating out
of the patient. Whilst Raelyn and Emma identified patient examples in the
therapy room, Beverly also found reassurance and encouragement from seeing
changes in people in her personal relationships (B, 512/575). This presupposes
that reassurance from within the sessions may not always be enough for
Beverly, thus she experiences further validation for her approach as helpful. In
this subordinate theme, participants’ motivation in the work through the appeal
of seeing in-session changes in the patient. This is an aspect that connects
with the next subordinate theme where participants reflect on their views of their
work as easy versus difficult to deliver.
56
4.3.2 “Not giving up on the route to getting there”: persevering
through resistance. All participants made reference to the ease of working
with patients at the level of emotion in comparison to difficulty of helping them
reach beyond their resistances. Drawing on symbolism of the travel and the
journey helped participants convey a sense of the process and the vigorous
motion in continuing through the tough terrain of the emotional landscape
shared by patient and therapist.
Beverly here emphasises the opportunity and challenges early on in the
work:
what brings up emotions, particularly in the first session, is the
experience of being with someone, who, um, is really paying
attention, and is not put-off, is hopefully not put off, by their
manoeuvrings, to put you off the scent, and to avoid the
emotions which are painful to them. So the experience, I think, of
being with someone who's not frightened to um keep them
moving towards experiencing those emotions. I think that
touches a place of longing in most patients - to be really seen
and to be really attended to. And it may not be something they're
conscious of. (B, 120)
Beverly reveals here that it can be frightening to stay with clients who
might push her away. Participants also pointed to, as Beverly does here, to the
need to be compassionate in their approach and how this is understood within
the context of attachment trauma for the client and their need for care and
acceptance. Beverly’s description captures the dynamism and energy to this
process and also highlights aspects of intimacy that are likely experienced
unconsciously by the patient. The unconscious ways that patients protect
themselves in the therapy room can be challenging for the therapist. David
likewise refers to the challenge of unconscious aspects to patient motivation in
offering a distinction that helps him ascertain the degree of difficulty in the work:
But where a patient is, you know, I I don't wanna say, but you
know, honestly, earnestly, doing their best (laughs) uh and
obviously suffering, that's not difficult, no, and then, of course,
when they're in touch, most of the time, you know, with
themselves or even in defence, you know – put differently, is
where there's a good alliance, I guess, is another way to put it,
good working alliance – then it's not difficult. (D, 448)
57
David’s laughter here highlights his intentionally ironic use of the phrase
“obviously suffering”, which seems to indicate his understanding of such
patients as less challenging than a patient whose suffering is not obvious to
them. The latter might suggest a discord between what the therapist observes
versus what the patient observes, whereas David’s double mention of “alliance”
assumes there is greater consensus and contact between therapist and client
regarding the direction and task of therapy.
Most participants talked about how they can most often locate a sense of
ease in the work: “It's quite interesting and enjoyable. Yeah, I-I don't find it
difficult to stay with them” (R, 181). “I mean, most of the time I feel very very
comfortable in the therapist chair. I feel very very comfortable. It doesn't throw
me - but there are those moments where, you know, as I say” (E, 248).
Although Emma is most often comfortable, there are “those moments” of
difficulty in the work that she describes elsewhere as momentary confusion or
impairment in performance or concentration on where she is in the sequence of
interventions (489). Judith points to a difficulty that arises from sharing the
same defences as the patient:
…intellectualising - I mean, I can in- I-I that's one of my
defences. And if I'm not careful, instead of spotting it as a
defence in the patient, I I can just go along with them and
intellectualise and we can have and then I suddenly think,
'actually, hang on a minute, we've totally lost the focus here. This
isn't what we want to be doing'. And I'm actually meant to be
showing them what they're doing when they're using
intellectualising but cause it's something I do very naturally as
well, um, I can easily get drawn down that road. (J, 434)
Judith appreciates here that what she, as the person of the therapist,
does naturally and unknowingly to avoid feeling may obscure the work. “Going
along” here thus means cooperating or facilitating the patient’s avoidance. This
collusion is understood by Judith to be a co-creation between her and her
patient, but with an awareness that it is she who needs to be “careful” in getting
caught in dialoguing with patient’s resistance.
All participants point to some aspect of their own defences getting in the
way of the work and two participants highlighted intellectualising – talking about,
rather than doing therapy – when matched in the patient’s defences as raising
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an added difficulty in the work. This subordinate theme about not giving up on
the helping clients reach through their resistances highlights the perseverance
in navigating tough terrain with courage and compassionate stance. The
comfort versus difficulty of delivering moment-by-moment precision is reflective
of the tension in participants’ accounts related to their attempts to respond
accurately and immediately to patients’ responses, but sometimes without the
full awareness required to do so. The next subordinate theme connects this
sense of difficulty in relation to focusing the work with its implications for the
therapist, including feeling anxiety and the pressures of getting it right.
4.3.3 “Trying to decide where to go next and how to proceed”:
pressure and focus on accuracy. Nearly all participants highlighted feeling
pressured in maintaining their focus on the patient and on the accuracy of their
interventions. One of the effects of such pressure was anxiety as part of an
initial response to encountering particular difficulties in the work. Though the
following four excerpts could be included as examples in the following
superordinate theme of what might be “happening in the room”, they are instead
included under this theme due to their specific link with the pressure of time that
results from the moment-by-moment precision that the therapist strives for in
their practice. Beverly describes her bodily state that is particularly linked to
self-criticism that arises as a result of difficulties in the work:
… anxiety is what I'd be aware of - what I have been aware of in
that situation. So, it may be that there's anger underneath that -
that wouldn't surprise me. I haven't been in touch with anger at
the time, because I think I'm too busy, and, kind of, trying to
decide where to go next and how to proceed. (B, 428)
Beverly describes aspects that she has awareness of in those tough
situations, yet highlights that she has trouble ascertaining her emotional state
beyond the anxiety due to the pressure to respond to the patient. Her repetition
of “aware” seems intended to convey the great deal that is beyond her full
awareness. Emma, likewise, describes this as :the spike of anxiety, it is the sort
of coming out, uh and just reflect- uh responding in a more immediate way I
suppose” (E, 245), though for contrasts this experience as rare compared to her
usually more “comfortable“ position (E, 248) in the work.
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Judith, like Beverly, could identify a possible awareness of anger behind
the anxiety, but only on reflection, after the fact:
… I don't have time to process what I'm feeling about that level
of contempt towards me…and be effective with her
therapeutically. But but yeah what I was feeling was anxiety at
the time…. But maybe, I don't know, maybe it's more healthy. (J,
296)
Judith describes how the challenge of therapeutic effectiveness relies on
her not attending in this moment to her own internal experience of rage and
instead focusing on the patient and their feelings towards her. Judith’s
reflection of “maybe it’s more healthy” to have an anxiety response reveals here
her ambivalence of the value of anxiety. Judith may mean an anxiety response
is healthier than she supposes, and that it is better to respond in anxiety rather
than defend in other ways. Raelyn likewise reflects on anxiety she noticed as
an observer of herself when viewing her own session tapes: :I couldn't see it in
the moment, but I could see myself like moving away (leans back in seat), so
there must have been anxiety in me” (R, 136). Raelyn’s leaning back in her
seat seems to recreate the moment her own anxiety led to a “distancing“
between her and the patient.
Nearly all participants reflected on challenging therapeutic situations they
may handle differently in hindsight. David highlights (258) that the demand to
be present and engaged is something he expects of his own standards and also
what he knows is helpful. The personal and professional self meet for David in
this demand to be present:
I think the thing that makes it difficult to stay with, um, for me …
is the persecutory element, which is pretty much inherent in
anything that you're learning. But, particularly, I think, in ISTDP
unfortunately, this idea that … there's a, kind of, right way to do it
and the right question to ask - that you should be watching every
minute twitch of the patient's face that - or body, that you need to
be, you know, on the defences…. And of course, there's a truth
to it, but … the tone in which it's transmitted … makes it difficult
… to simply be present and sit with what's happening…. (D, 696)
David sees these “persecutory” pressures as inherent to the ISTDP
model and the way it is transmitted to therapists. He seems to suggest that if
the therapist is thinking all the time of what they should be doing, it leads to a
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disembodied state that interferes with the therapist’s capacity to be present and
close to the patient. The repetition of “right” here emphasises that when
presence is helpful for the patient, it may erroneously be experienced as
“wrong” by the therapist, whereby a pre-reflective quality of the therapist’s inner
experience is lost or not extended to the patient.
Most of the participants reflected on how such pressures led to missed
opportunities of interactions with patients where the feelings were directed
toward the therapist. Beverly reflected on how a patient’s reflective and active
engagement in identifying key therapeutic process has helped Beverly identify a
moment where focus is lost: “… by allowing myself to go into defence mode and
make myself the focus there, rather than just sticking with the patient's anger
(B, 234)”. Judith relates the experience of contempt directed towards her from
the patient: “.…but I guess I hadn't processed it. I mean, if I'd seen her again, I'd
have been a bit more ready, you know, to to look, you know, … with my
question, ‘what's just come up?” (J, 318). Raelyn, likewise, highlights a missed
opportunity of anger in the patient that was “pretended and ignored” by both her
and the patient “…that was there, on a gut level… it was never verbalised or
explicit” (R, 432):
So that can be a challenge for people and me included actually,
working with it directly to you – not that I mind, being killed or
being killed, raped, murdered and lots of things, but opening that
door and saying, ‘well, what is the feeling toward me as you're
sitting there?’ That can be one of the hardest places to go, I
think. Yeah. (R, 401)
Opening the door of bringing herself more fully into the relationship as
one of the most difficult aspects of the work for Raelyn. Raelyn’s striking
statement that she does not mind being “killed, raped, murdered”, in the client’s
portrayal of such an event, is positioned as something that is easier than the
experience of first inviting the client to notice the implicit, non-verbalised feeling
of rage that involves Raelyn.
This subordinate theme revealed the pressure and feelings of anxiety
that participants may experience when faced with difficulties in their attempts to
execute moment-by-moment precision. The immediacy of the situation
suggests there is not enough time to process other feelings that may be present
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and that participants may aim to respond to patients in a way that is
therapeutically beneficial. The predicament of “trying to decide where to go
next and how to proceed“ is beset by limitations that are not necessarily known
at the time but are yet accompanied by a pressure to move beyond them.
Together these three subordinate themes comprise the comforts and
hardships of the participants’ striving for emotional closeness, and in particular
the challenges of helping clients overcome their resistances. “Opening that
door” highlights the specificity of the work, as it represents the door that either
client or therapist would ordinarily prefer to keep closed. Participants spoke of
the perseverance and compassion required to reach the stage where client is
able to experience previously avoided feelings. The moment-by-moment
attention to this process raises immediate challenges in deciding where to focus
the work through the ISTDP model. The participants interpreted their anxiety in
such moments as evidence of not having enough time to process their feelings.
The underlying tension between achieving success versus feelings of anxiety
when about to potentially miss something important is further explored in the
superordinate theme two, which highlights participants’ accounts of their
responses and reflections of what happens in the therapeutic encounter.
4.4 Superordinate Theme Two: Connection vs Disconnection: What’s
Happening in the Room
This cluster of subordinate themes highlights what is happening in the
room for participants when staying with their clients’ intense emotional
experiencing. The polarity of connection vs disconnection in the title of this
superordinate theme aims to describe the underlying ways in which participants
tended to describe their experiences based on an assessment of their success
in the work. Therapy that is going well entails a sense of connection with the
patient, whereas therapy that is not going so well tended to be accompanied by
an assumed feeling of disconnection. The three subordinate themes capture
the various aspects of this polarity: (1) “A shared experience”: connection and
intimacy in the therapeutic encounter; (2) “It's painful not to be able to reach a
patient”: feelings of frustration and inadequacy; and (3) “Talking to myself”:
remaining calm and professional.
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4.4.1 “A shared experience”: connection and intimacy in the
therapeutic encounter. All participants refer to their understanding of the
therapeutic encounter as a shared experience that can be deeply intimate for
therapist and patient. Emma here describes the value of helping the client
experience their emotions:
What's best about it, what's good … is to be able to share with-
that experience with them, to see that anxiety diminish. So
someone who's very tormented and very tense and all over the
place - as you go through it and you stay with them, you see that
diminish. (E, 275)
Emma describes as meaningful the staying with the turbulence and
confusion of the client to a lessening of their severe physical and mental
suffering. Likewise, Raelyn views her “emotion focused” work as healing: “my
belief is that you need some form of emotional experiencing … in order to heal
… I think it's a it's an experience of intimacy isn't it, sharing emotional
experiences, it's a high level of intimacy. (R, 68) Raelyn clarifies that she
values this experience of intimacy as central to healing.
David further’s Raelyn’s sentiment to assert that it is “possibly the most
intimate that you get with anyone, even your partner… so it's a very unique uh
special uh experience” (D, 266). David’s description of this type of encounter as
perhaps “the most intimate” may be an acknowledgement of the private and
personal nature of exploring feelings that are never before expressed that is
individual to each patient. Whereas Beverly refers to the benefit to her from this
shared experience of expressed emotion:
… and then it just lifts. Cause it's it's come out - it's been shared,
it's been felt, it's been contained … the and the mood lifts and
one's then able to function again has an incredible effect. So in
that instance as well I think this work has helped me. Not be not
allow myself to be pushed out the door. (B, 585)
Beverly’s phrase of “pushed out the door” refers to being able to
withstand the feelings of the other who is perhaps resisting emotional
closeness. Part of connecting for Beverly entails perseverance in overcoming
these resistances. “Contained” for Beverly has an atmosphere to it of safety
that was perhaps not there moments before. All participants made distinctions
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between how they approach emotions, both negative and positive. Judith
describes what it is like helping a patient experiencing positive emotion:
… I have one patient here and just before he left, you know, he
just sort of reached out to touch me that's just, you know he just
really grateful and um had that impulse to, you know, touch, to
hold, I guess. That, that's the love impulse. (J, 163)
The gesture of touch by the patient towards Judith here seems to
indicate a level of intimacy that is shared by both herself and her patient. David
(272) draws from Buddhist concepts to help articulate the depth of intimacy:
There's uh a sense of, well uh difficult to describe, but um, a
sense of merger isn't right. It's really a connection. It's really a
kind of freedom of connection with, you know, your environment,
with the outside world, with other people, which is your very - is
is joyful um and releasing. So it is slightly like that … Letting go
of isolating boundary around the small self, the small sense of
self. And I'm sure patients must experience that too with me, in a
room. (D, 281)
The sense of connection that David attempts to convey here does not
seem limited to between people but seems to stretch beyond their “entrapped
separation” (279) to the “outside world”. David seems to describe “these two
people experiencing emotion” (274) as a shared form of meditation. “Letting go”
of an “isolating boundary” here suggests effecting a connection through which
the pain inherent to the “small self” – a term in Buddhism that refers to the
unique, individual and separate self – is released. Though David has been
tentative in his description here he nonetheless seems thoroughly convinced
about the shared aspect of this encounter, as something felt by his patients
also.
The sharing of difficult emotions and intimacy, included for most
participants, a focus on emotional resonance through specific emotional states
or feelings. All participants talked about moments where they were feeling what
the patient feels. Beverly describes here how she notices the feeling in the
patient before they themselves have shown this visually or reported it:
You might see the, sort of, swallow or watery eyes or um a rise
in anxiety but there's also, particularly with grief, I quite often find
myself feeling it ... a strong grief response or an impulse to cry or
just a, kind of, feeling in my chest. But um, but, a sad feeling in
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my chest. And, often if I get that um, and I inquire, I'll find that the
client is feeling something similar. (B, 168)
Beverly here is relying on what is both seen and unseen, the visual
aspects of the patient’s physiology as it relates to their feeling but also her own
felt sense as a reflection of the patient’s feeling. Likewise, Judith talked about
feeling the feelings of the patient, even sometimes, as in this instance, before
she herself notices the feeling of sadness in the patient: “I could just feel it. And
then … I saw a little bit of fear in her and I said, 'what's coming up just now?'
and then the sadness came” (J, 175). Judith, like Beverly, here emphasises her
moment-by-moment attunement to the patient’s emotional state, where the
feeling of the therapist is still informed by observation of the client’s response.
David highlights how emotional resonance “if things are going well” (236)
with a patient can be “enlivening”:
… depending on the, on the particular emotion, uh you know, I'll
feel pain or I'll feel rage or I'll feel angry. I don't mind any of that.
That's … pretty good. As I said, it's part of feeling alive and also
… it's great to be so engaged with another human being. It's like
a moment of real connection, which is, you know, a beautiful
thing. (D, 237)
The context of being “engaged with another human being” has
significance for David, in terms of an openness to feeling what are typically
regarded as negative or unpleasant feelings. That this feels “pretty good”
speaks to the power of the connection he experiences with the patient as one
that is deeply satisfying, the beauty of which seems inextricably bound to the
lived space. Raelyn, too, highlights the energising aspect to experiencing an
emotional resonance with the patient: “whether I'm sitting with the patient or
whether I'm in a training watching videos” (R, 148). Raelyn’s experiencing of
similar energy through watching tapes highlights how such a process can
transcend space and time. Participants’ focus on the visual convey here in this
idea of shared emotional experience something that is unseen but very much
felt.
Each of the extracts in this superordinate theme presents the sense of
connection and intimacy that results from what participants considered to be a
shared emotional experience. A further aspect of connection that is
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experienced in the room, happens where the therapist is able to feel to what the
patient feels, in a way that is helpful and informative for the therapy. It seems
that achieving emotional resonance requires an openness of the therapist but
also the patient and so this links to the superordinate theme as an example of
connection that takes place in the therapeutic space. The next subordinate
theme begins to look at the other side of this polarity, the disconnection that can
occur between therapist and client when engaged in intense emotions-focused
work.
4.4.2 “It's painful not to be able to reach a patient”: feelings of
frustration and inadequacy. All participants described difficult encounters
they experienced whilst aiming to stay connected to clients who were
experiencing intense emotions. This subordinate theme captures the often-
resulting feelings of frustration and inadequacy that arise for the therapist during
difficult therapeutic encounters. David describes an example where he felt his
understanding of the patient who was chronically in tears had reached an
important limit: “I think liking a patient is important actually. I didn't really like
her” (D, 166). David seems to be recognizing the therapeutic relationship as
impacted by the ‘real’ person of the patient, beyond their defences, as important
in the therapist’s ability to express “sympathy” or “compassion”, which he views
as essential to good work. David also described “the most horrendous
experience” of his career that occurred recently with patient:
I got just totally - all I can say is - overwhelmed, uh, by, I think,
looking back, a mixture of fear and persecutory guilt. But I wasn't
experiencing that in a quite so defined way, as I now describe it,
it was just an overwhelming experience of being, kind of, like,
slightly losing boundary, in the worst sense, um of fear.… So I
really lost it. I mean, you know, my capacity to think was, like,
gone, my capacity to attend to my emotions was, kind of, not so
good. (D, 614)
David seems to be attempting to make sense of his emotional experiences that
were somewhat inexpressible. The isolation he describes seems existential
rather than merely relational, where not being able to look after his own
emotions means he has “lost” the ability to do the same for his patient. A
contradiction is revealed that though David elsewhere describes ways in which
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he has built his capacity to attend to his emotions yet he experiences this
encounter later on in his career.
Most participants described moments in the work where their
management of their expectations – of themselves or their patients – in
moments of disconnection were pronounced. Beverly highlights what she
describes elsewhere as her “self-critical mode” (374) that happens when
regarding herself as a “bad therapist” (375) as opposed to staying with the
patient’s feelings:
I hear it, I think, 'uh, is she right? Did I do that?’ Um, ‘I shouldn’t
have done that'. So that puts me slightly on the back foot. Uh,
then I'm thinking, 'do I apologise for doing that? Do I
acknowledge doing that? Apologise for doing that? But is she- is
it fair? Is that right? Did, did I do that? Or is she being unfair to
me?' And I get into that sort of thinking process um or I, I have
done in the past, which takes me completely away from the
focus on her anger and remembering that it may be related to
her experience of her mother and how, you know, how that is
being re-enacted. (B, 380)
Beverly recites here her self-questioning process rapidly and without
apparent effort, seeming to simulate a crowding effect that complicates her
decision-making processes and shifts her “focus” away from noticing the re-
enactment of the patient’s past relational dynamics.
Similarly, Judith highlights how for her that process of “self-doubt” (203)
can move quickly to a form of “self-attack” in some instances, with patients that
act toward her in a manner – for example, entitled or “contemptuous” – that
touches on her history of being devalued: “I um can very easily think, 'oh God,
I'm I'm absolute- I can start easily going into self-attack, I'm I'm clearly no good,
I really am rubbish, I must be doing something terribly wrong here'” (J, 209).
Although able to reflect on these thoughts beyond the moment, the ease and
certainty of the thoughts that beset Judith here is striking, whereby an
appreciation of her own attachment history that might help her separate from
these punitive thoughts is presently absent.
Emma also identifies a punitive element that arose in a pivotal moment of
having helped the patient express their sexual feelings towards her:
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I suppose a, sort of, a punitive thing came in that I was doing
something wrong that somehow I was encouraging this man to
… that I was leading him on in some way and that's the that's the
point I had to clarify in my head to be able to clarify it with him.
(E, 517)
Emma elsewhere (504) indicates there may be something to sexual
impulses that bring about an “inhibition” in her that is not there with the patient’s
“angry impulses”. Emma’s self-consciousness of “leading him on” and the
“punitive thing” is imbued with a worry of “doing something wrong”, which may
hamper the straightforwardness that she finds moments later to help the patient
deal with his sexual feelings. Raelyn highlights how feelings of frustration can
arise when the capacity of the patient to tolerate their emotion has been
misunderstood by the therapist: “because you're like, ‘why aren't we having the
big breakthroughs and the rage…’, but for that you have to stay where the
person is with emotional experiencing and how much can they actually tolerate”
(R, 505).
David elsewhere (315) highlights a sense of disconnection that he
describes as “two separate … scared individuals…trying to make some kind of
contact with each other”. Here, as he describes the consequence of such
feelings of frustration, that sense of loneliness is captured:
… I'm sitting here with, um, anger, pain, frustration, uh, on my
own - patient not experiencing, patient going off on their own
thing. Not in any state of conflict about what they're saying. You
know, just kind of gaily, like, defending or whatever else. So it's
it's painful to be left with that, it's painful not to be able to reach a
patient. (D, 505)
Frustration, here, for David, is borne out of the discrepancy in what the
therapist and patient are experiencing, where the patient is identified with their
defences. What is “beyond reach”, David seems to be suggesting, is the
unconscious, helpful part of the patient that seeks emotional health and
closeness to others. A consequence of this, repeated twice, is a “painful”
experience for David that seems tantamount to rejection, of the therapist’s input,
if not indeed the therapist’s self.
The excerpts in this subordinate theme capture the sense of painful
isolation and disconnection or withdrawal from connection that results from or is
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exacerbated by the feelings of frustration and inadequacy experienced by the
therapist. Participants’ accounts in this subordinate theme convey a sense of
the inevitability of the therapist’s deviation from staying with their patient’s
intense feelings but that this is knowledge that is achieved or remembered with
hindsight rather than accessed during their feelings of frustration. The next
subordinate theme moves on from these last two subordinate themes, which
relate moments of disconnection in the therapy room, by relating the ways in
which participants described their ways of coping when finding it difficult to stay
with their patients’ intense emotional experiencing.
4.4.3 “Talking to myself”: remaining calm and professional. This
subordinate theme described the ways participants coped with their difficult
therapeutic encounters. All participants described inner self-talk as their
moment-by-moment ways of coping with disconnection and their attempt to
reengage with their patient or to help assure themselves during their difficult
encounters. Emma described how she coped with the confusion and “shutting
down” (474) that arose when attempting to work more specifically with the
sexual feelings the patient had expressed towards her:
… I wasn't giving him a clear enough message about the reality
of what was possible and what isn't possible. The minute I
realised that, I was able to do something about it, and it was fine.
You know, it became very clear that that's what's inside him and
that he has feelings towards me, and then he also has feelings
that I'm not going to go along with what he wants. So we were
sort of back on track …. (E, 492)
This extract reveals the complicated processes at work simultaneously in
the therapeutic space. Emma is trying to ascertain what is real in the portrayal
with the client versus his “true” feelings for her and the “reality” of his
expectations and her own role in generating these. Here she seems to reason
or “realise” her way out of her confusion though clarifying for herself where she
is located in the process of staying with her patient. Emma elsewhere draws on
questions – “ok so what is going on?” (265) or “come on, stay with it – let’s see
where we’re going and get a handle on this – don’t shy away from it” (474) – to
help assist her with getting “back on track”. Raelyn also describes a process of
self-talk used to help her cope with her visceral reaction to her client’s sadistic
imagery that arises in their defence-work:
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I think in my head, I had to, I was just sort of talking to myself,
and saying just just sort of distance a bit, just stay with it, like
zone out a little bit, just kind of, so trying to get a bit of mental
distance, maybe not listen so closely, just sort of distance
internally (laughs) sort of not show your shock, of course, or your
discomfort and just thinking please let this be over soon (laughs)
before I throw up. (R, 281)
“I think in my head” is an interesting statement that makes it seem as if
that is where her total self is in that moment of trying to obtain some “mental
distance”. Raelyn understands her self-talk as an attempt to achieve this
“distance” from her state of fusion with the patient’s difficult feelings and
impulses. Perhaps her laugher at her recalling her attempts to “distance
internally” and wish to “please let this be over soon” is an acknowledgement of
her own internal conflict of wanting to stay with the patient yet be distanced from
them. Also, too, the disparity between what therapist and client may be thinking
in the moment. Rather than the form of a wish, David described a similar
sentiment to Raelyn’s self-talk, but in the form of a memory:
Um, so I think, I think maybe the, even when I was, you know
half-crazy with it, I think, just the memory that um things pass,
and I had things might help, and but that was that was helpful.
(D, 655)
David here experiences the truism of “things pass” – that every situation
ends – as helpful. Yet, this excerpt also conveys the sense of uncertainty that
David is experiencing in this moment. As well as relying on “cute couple of
deep breaths” (J, 317) Judith, when likewise faced with the unknown, relies on a
“layer of professionalism” (315):
…. I just relied on all my years of remaining calm, remaining
professional, keeping my anxiety under control, storing it for, I'm
gonna think of, you know, ‘look at this later myself’. Um eh yeah
and just keeping it, y-you know, keeping the therapy to, you
know, just keeping her in the room with me actually, cause I do
think she got up at one point. (J, 327)
Alongside regulating her anxiety, Judith also describes a deliberate
process of “storing” her responses for reflection later on. Beverly likewise
highlights how she attempts to keep connected with a patient who is
experiencing anger towards her:
…I recognize it. I remember it. I go, 'okay, I know this - focus on
the patient, focus on the feeling. Go through the questions -
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where is she experiencing it, et cetera, in the body?’ Keeping it,
keeping the-the - your, my and the patient's focus on the
patient's internal experience - being aware of mine, but not
making that the, you know, the thing that's leading my thinking.
Um, and that's helped a lot. That's helped a lot - that kind of
keeps you on the right, on the right path. (B, 450)
Beverly, here, conveys a sense of how she can reconnect with her
patient through a focus on the “patient’s internal experience”. Beverly also goes
on to describe how the “patient appreciates that” (457) also, which seems to
reinforce and justify her focus whilst also serving as a clear sign of maintaining
a connection to her patient that would otherwise be hard to keep. As well as
linking to the previous two subordinate themes in terms of the disconnection
participants experience, the current subordinate theme, in describing
participants’ accounts of their attempts to reconnect with clients, links almost
full-circle to the first subordinate theme of viewing what happens in the space as
“a shared experience”.
This subordinate theme has revealed some of the reactions that
therapists experience in difficult therapeutic encounters where the therapist’s
reaction itself seems to interrupt or disrupt their efforts to stay connected with
the patient and their intense emotional experiencing. Participants thus
described an emotional shutting down, a visceral response to patient’s sadistic
imagery, and the sense of feeling overwhelmed by feelings that are hard to
pinpoint.
These three subordinate themes are linked by what happens in the
therapeutic encounter when the therapist is aiming to stay with their patients’
intense emotional experiencing, and more specifically how this arises in
moments of connection versus disconnection between therapist and patient.
The background to this therapeutic enterprise is an appreciation of and aim for
a shared experience of intimacy and connection that is healthful for both patient
and therapist. In such moments, the therapist relies on their capacity to feel
what the patient is feeling, which is experienced as intimate and beneficial. The
last two subordinate themes evoke various aspects associated with
disconnection in the therapeutic encounter, in terms of therapist’s reactions to
difficulties, the resulting feelings of frustration and inadequacy and how they
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cope with such moments through self-talk to help regain or maintain connection
with their patients, in offering them a therapeutic experience of emotion. What
is revealed throughout this superordinate theme is the extent to which emotion
is something felt, both as something graspable or unknowable, versus what is
speakable between therapist and client.
4.5 Superordinate Theme Three: “There’s More of Myself Now”: Building
One’s Own Capacity
The final superordinate theme completes the analysis and consists of
three subordinate themes that describe the way participants talked about
technical aspects that relate to therapist’s practice and ongoing development.
All participants reflected on how with greater capacity comes assurance around
their very sense of self. Whereas the two previous superordinate themes have
described what therapists experience and encounter in their work of staying
with their clients’ intense feelings, this last superordinate theme concentrates
more on participants’ accounts of how they achieve this. This includes
participants’ reflections on how they have built their own emotional capacity.
Capacity here refers to the therapist’s or patient’s ability to bear, observe and
understand their feelings, as reflected in the final two subordinate themes of the
first superordinate theme and participants’ accounts more broadly. The three
subordinate themes are: (1) “More emotion in the room”: improving clinical
effectiveness; (2) “Those minute flickers”: observing and reflecting on inner
emotional life; and (3) “Knowing enough about myself”: attending to
unprocessed feelings.
4.5.1 “You get better…you get more emotion in the room”: building
emotional tolerance. This subordinate theme aims to capture what therapists
perceived as helpful for building their own capacity for bearing and holding their
own emotions. All participants discussed the value of supervision and training
as essential to building their sense of capacity. Raelyn described the value of
watching videotaped cases from the “countless conferences” (201) that have
helped her build up a tolerance for emotion:
so that builds your capacity to go to the emotional breakthroughs
and then of course I've sat with my own clients and as you get
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better at doing ISTDP so you get more emotion in the room. (R,
203)
Raelyn’s use of “breakthroughs” here refers to Davanloo’s term to
describe the emergence of previously warded off emotions into consciousness
(ten Have-de Labije & Neborsky, 2012). “Go to” here suggests breakthroughs
as a place the therapist helps the client to reach, and that Raelyn’s greater
effectiveness in this leads to “more emotion in the room”, where she believes
“the healing is gonna be” (210). David talks about his taking up of space rather
than emotions:
… it does feel like I've got a bigger space inside me. Um, and I
think I'm less embarrassed, as well, by it. Um, it's also very
linked with intimacy because if you're feeling something, you
know, more fully, you're more vulnerable, that you're more alive
and more open. So I think, yeah, I'm less embarrassed maybe,
by the presence that feeling an emotion brings, by the
connection that it brings, um, which is a massive shift to the way
I used to be …. (D, 591)
David here describes an expansiveness to his sense of self that feels
bodily but also psychic, even spiritual. He describes being in relationship to the
client on a profound level of closeness. The contradiction of greater
vulnerability with openness enabling David to be present and connected with
clients is transformative in terms of how he characterises himself in this moment
compared to an early version of himself: vibrant and forthcoming, rather than
emotionally aloof and solitary. In this later description, David seems to slip into a
personal rather than mere professional description showing a marriage between
the two aspects. Judith describes this learning process in practical terms:
…I guess the more times you encounter it, the more times you
see it, and the more times you see it in different patients…you
get quicker at spotting them and then you get quicker at seeing
what they're doing, and quicker at stopping yourself if you're
going down that route. (J, 444)
Judith goes on to illustrate this process through talking about the benefit
of recognising signals of defences in both herself and her patients. Using the
defence of “intellectualising” (449) as an example, Judith says she now hears
her “internal supervision” brining her back on track. Judith elaborates on what
was helpful about having her own tapes reviewed during her training as helping
her to “see exactly” (J, 67/73) the interventions she made and their impact on
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the patient through their responses. Judith thus felt she had “learned so much”
from this admittedly “exposing” (76) practice. Most of the participants also
reflected on the value of their engagement in ISTDP personal therapy.
Judith describes the self-knowledge she received from ISTDP
supervision, where how after a previous therapy that lasted many years, “I did
not know my defences”. Yet:
after five minutes with my supervisor, I could, she named all,
named 10 of my defences, and I’m like (gasps, laughs)…I
remember her going (clicks fingers) duh-duh-duh-duh, and I was
like, ‘there’s nowhere to hide’. (J, 464)
Words alone can do little to describe the astonishment Judith seems to
have experienced at the rate at which this self-knowledge was revealed to her,
and is perhaps more fully captured in the rapidity of her finger clicks and the
phrase “duh-duh-duh-duh”. That there was “nowhere to hide” suggests that
with previous supervisors, there may have been ways to not readily admit her
in-session use of defences with patients, whereas her ISTDP supervision
provided an opportunity to best honour her commitment to effective practice. All
participants highlighted the importance of contact with peers, through
supervision and attendance at conferences. Beverly highlights here how this
has helped her better attend to her self-critical processes:
being able to-to talk about what we’re doing, what we find
difficult….that’s helpful, knowing that others have similar
struggles. Um, that quietens the self-critical voice a bit (laughs).
(B, 636)
When difficulties are encountered in the work, her self-critical voice may
assume they apply only to her, whereas knowing that others encounter the
same difficulties, helps to minimize this. Overall in this subordinate theme,
participants value a range of activities that have helped them build their
emotional capacity, including review of own and other therapists’ video case
sessions, supervision and its therapeutic effects, personal therapy, and peer
contact that they experience currently and in their ISTDP training. The different
ways participants spoke about getting ‘more emotion in the room’ highlights how
this applies to both the therapist as well as the patient. The value of achieving
this is not just in greater achieving effectiveness in the work but also the impact
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of this on the person of the therapist. The personal and professional self
appear to unite when both patient and therapist can experience their feelings in
the therapeutic space.
4.5.2 “Those minute flickers”: observing and reflecting on inner
emotional life. This subordinate theme aims to capture the subtle experiences
that participants reported as significant evidence of their increased capacity to
bear and notice their client’s intense emotional experiencing. All participants
talked about language they use as important for helping the client focus on their
internal experiences. Beverly describes finding the “more robust challenging
therapist” role is “not easy” (326):
… finding the right words to deliver those interventions has been
difficult because you need to do it in a way that doesn't make
your patient feel told off or judged or coerced in any way. It's
gotta be delivered in a way that feels loving and that feels like
you're getting them - you're understanding something. (B, 327)
Beverly seems to highlight the importance of her role in its more
challenging mode to the patient is also inextricably tied to a commitment to
foster the patient’s self-compassionate engagement with their inner world. All
participants highlighted that their ability to be more present with the client
through their sense of improved observation of the client. David similarly
described his current practice as:
… a lot less persecutory. It's a lot less artificial and 'doing'. It's
more like 'being', uh so the therapy, kind of, more happens
through me….it feels much more like what I am and do
anyway….it's like playing the piano, it's um, you know, obviously
you use your reading notes. Right, but it's but it's kind of
happening through you. (D, 526)
David draws on the simile of the piano to communicate how he is now
better able to draw consciously on the techniques of ISTDP, as a “being” that is
“happening through” (531) as a “state of flow” that is “much more present”. All
participants commented on their improved ability to observe shifts in their
patient’s and own experiences that they may have been more likely to miss in
the earlier stages of their practice. Emma describes this in relation to her
overall goal of helping the patient to access their feelings:
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So I've always got that goal in mind, that we're trying to get at
those feelings. And, you-you know, at the beginning, it may just
be a tiny tiny little flicker of sadness. And I think in my old way of
working, you know, those minute flickers - I probably probably
wouldn't have even seen - whereas now I see them and I can
really make use of those and bring them to the-the other
person's attention. (E, 118)
Through a comparison of her current self with her less experienced self,
Emma here refers to her now being able to better observe the patient and
therefore start to “deepen the experience” (124). The phrase “minute flickers”
highlights the briefness and faintness of emotions that Emma might previously
have missed. Raelyn addresses the concerns of observing patients who may
pose a risk to themselves or others:
I feel like my basic training helped me with that [i.e. ‘risk and
harm’], I think there are people…again very few …have that
psychopathic anti-social trait, that are harming people, will harm
people, will misunderstand you…but I think you need your own
basic training, and understanding of anxiety pathways, to make
those distinctions, so that also makes it easier for me to go these
places. (R, 669)
Raelyn here is referring to a concern – rare and extreme in this example,
but a more general tension that exists in the work – that by inviting patients to
internally explore their hidden feelings and impulses, they may then
misunderstand this endeavour and go on to act out those impulses in their real
life. However, for Raelyn, her training and understanding of “anxiety pathways”
allows her to conduct a more complete and accurate assessment of the
patient’s psychopathology. Effectively handling this concern thus frees Raelyn
to go “to these places” with her patients that she believes can be part of a
healing experience for them. Overall, in this subordinate theme, participants
reflected on their learning and development of their ability to observe and reflect
back to their patient’s their emotional inner lives.
4.5.3 “Knowing enough about myself”: using and protecting the
self. In addition to learning specific skills to address the difficulties and
complexities of the clinical situations that therapists encounter, most
participants commented on the ways in which the work brought them in touch
with their own unprocessed feelings and how this entails a decision on how to
conduct themselves in such moments. Throughout participants’ accounts is
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emphasised the importance of being able to face their own emotions and
intimacy with their patients and how there are opportunities in supervision and
personal therapy to develop this. This subordinate theme aimed to capture the
differences in approach to this aspect, in terms of the extent to which the
therapist involves their own personal material in the work. Raelyn gives her
take on “how much you let yourself go” (315) in the work, where the therapist
might reach their own breakthroughs of unprocessed feelings alongside that of
the patient’s:
I don't go there, cause I think that would feel too difficult to
contain my own, what response might come up in me. So I I
stay very much just sort of cognitively with what the client is
saying with their experience…Yeah. Yeah I don't go there in my
own mind, I don't – what might come up for me, if it was my
mother or father or something like that, I don't. (R, 319/326)
Raelyn, preferring to keep a cognitive distance in the work, fearing the
involvement of her own personal material will lead to distraction away from the
focus of the client. Judith considers an example of a clinical case in which her
supervisor had her role-play the patient, whilst her supervisor role-played what
Judith “should have done” in the session under review:
…and then I, I had a huge amount of grief come up, I mean, like
I mean it was, it was in the group. It was like about half an hour
of grief. And um and then she, she said at the end of it, ‘now
you'll be able to help your patient’. And there's just something
about that that patient's, the the defences that were aligned,
some of the same sort of history that, like, because I, because it
was in-unresolved in me, I couldn't quite go there with her. (J,
356)
Judith here describes an experience where there were therapeutic
effects in supervision that were helpful to her reflection on a difficulty in practice
and healing, in the sense that she resolved a personal difficulty that would allow
her to “go there” with future patients. David (678) also considered a return to
ISTDP personal therapy for a difficulty the specifics of which touched on
“something I know I have a problem with”. Most participants talked about
having ISTDP therapy during own training:
And it's about knowing enough about myself - I can't always be
sure that I'm getting it right - but feeling comfortable enough with
myself and my reactions. I mean, that's the only thing I can go
on. I mean, if I if I can feel comfortable about my reactions, my
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responses, then I can help the other person do the same thing.
(E, 393)
The value of personal introspection is crucial for Emma in her capacity to
“feel comfortable” with her emotional responses in a way that allows her to help
her patients do likewise. This subordinate theme is characterised by a
commitment to deliberate forms of practice that are designed to maintain and
improve their own emotional capacity – and through their ability to observe
emotional shifts in their patients. These practices allow the therapist to maintain
their moment-by-moment precision to help their patients experience their
emotions and to help patients and themselves manage challenges to moments
of connection, and confidence in the approach of the therapist.
Superordinate Theme Three: Technical Aspects Related to Therapists’
Practice consolidates participants’ account of their experiences of the technical
aspects important to their practice and development. All participants
recognised the value of building their own capacity to bear emotion to help their
patients with this endeavour. All participants also talked about the value of
noticing minute shifts in their clients as helpful for staying with their patients’
intense emotional experiencing, as it enables them to recognise the value and
progress of their efforts to facilitate this. The participants spoke in different
ways about the degree to which they develop themselves as the person of the
therapist through work. This appears to be underpinned by important features
of the participant experiences in their professional contexts – for example, the
way in which the supervisor works – and their own personal histories and
contexts, which may provide opportunities or hindrances when trying to focus
on the patient.
4.6 Analytic Summary
This analysis explored the experiences of five ISTDP therapists working
with patients who are experiencing intense emotions. The superordinate
themes were presented in a specific order to elucidate and encapsulate the
distinctive and emergent nature in which participants narrated their in-session
experiences. Each superordinate theme captures a rich and textured portrait of
the essential aspects to understanding participants’ overall experiences, where
individually these themes would not convey the full account of the participants.
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In summary, superordinate theme one captures the different ways
participants talked about the ease and hardships of their striving toward
emotional closeness with their clients. Participants described how they were
motivated by seeing the physical changes in clients as confirmation of their
moment-by-moment approach to working with emotion. The importance of
perseverance in helping clients reach beyond their resistances to facing
previously unavoided emotion was emphasized, along with the compassionate
and collaborative stance to attend to client’s patterns of relating. The feelings of
anxiety and pressure to deliver consistently accurate and precise interventions,
forms a backdrop to what happens in the room – the focus of superordinate
theme two. Participants tended to describe what happens as experiences of
connection, where the work goes well, versus disconnection, where difficulties
are encountered in the room. Connection and a shared sense of intimacy are
the therapy’s raison d'être and are reached in part through an emotional
resonance between therapist and client. The moments of disconnection are
challenging for the therapist who must consider many layers of emotional
experience – their patients’ and their own – and technical aspects and
adherence to the ISTDP model. Difficult encounters were mostly characterised
as difficult feelings expressed towards the therapist that were difficult to bear
and engendered a reaction in the therapist that was deemed unhelpful, as it
shifted attention and focus away from the patient. The therapist’s feelings of
frustration and inadequacy provide further sources for disconnection, which are
overcome by ways of coping through internal self-talk that included self-
questioning and self-reassurance, figuring out where therapist and patient are in
the sequence of interventions, and using interventions aimed at regaining an
overall focus on the patient. Superordinate theme three captures the technical
aspects related to the development of the therapist and how they have
increased their capacity to tolerate their own feelings, and their capacity to
observe and reflect on both their patients’ and their own emotional
experiencing. Participants were all concerned with the development of the
person of the therapist but varied in their talk about where they saw the
opportunities for this in the work.
4.7 Chapter Four Summary
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In this chapter, I outlined the themes that emerged through the process
of IPA, together with supporting evidence of excerpts from the interview
transcripts. In Chapter Five I will apply and reflect on these findings in order to
answer the research question “what are ISTDP therapists’ experiences of
staying with clients’ intense emotional experiencing?”
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Chapter Five: Discussion
5.1 Chapter Five Overview
In this chapter I outline the key findings of this study and discuss both
how they relate to the research question and the research literature. The
relevance to counselling psychology practice and implications for therapists who
are likely to encounter intense feelings with their clients are discussed. A
methodological critique and quality issues of the study are examined. This is
followed by a reflexive section about the research process, implications for
future practice and research and a conclusion to the study.
5.2 Situating the Research Findings Within the Wider Context of
Psychodynamic Practice in the UK
IPA’s commitment to understanding the participants’ subjective views
and the psychological focus brought to bear on their personal meaning in
relation to the wider contexts (Smith, Flowers, & Larkin, 2013) entails that I
situate my interpretations within the broader literature, by engaging in dialogue
with my research and psychotherapy research and theory related to my topic. In
particular, I discuss the application of my findings with reference to the current
political climate in the NHS and the overall position of psychodynamic therapy in
public health. Equally, it is important to contextualise the findings within the
discipline of counselling psychology. The purpose of this study was to explore
how ISTDP therapists stay with their client’s deep emotion and thereby enrich
the way counselling psychologists can understand and reflect on this aspect of
their clinical practice. I drew on the IPA methodology and its inductive process
in conducting interviews and data analysis that are expected to guide the
researcher towards “new and unanticipated territory” (Smith, Flowers & Larking,
2013, p. 113). Consequently, the discussion draws in places on additional
literature to that covered in Chapter 2 Literature review. I highlight below how
the findings extend the current literature to offer a significant original
contribution to knowledge in the field (Kasket & Gil-Rodgriguez, 2011).
In the global context of evidence-based practice that holds RCTs as the
gold standard, psychodynamic therapy’s struggle to show itself as an
empirically supported has led to a decline in public provision (Fonagy, 2015).
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Yet in a recent research update, Fonagy (2015) found support for
psychodynamic therapy in a range of conditions, where nearly all studies
included were forms of STDP. This type of treatment has a good evidence base
with an efficacy comparable to CBT (Abbass et al., 2014). A growing body of
research supporting efficacy for STDPs and their technical attention to creating
more accelerating therapeutic outcomes, as compared to the classical long-
term psychoanalysis, have made, within the UK context of the NHS, briefer
forms of dynamic therapy an appealing option in for treating particular mental
health conditions. STDP has been seen as cost-effective whilst distinguishing
itself from CBT by preserving key elements of analytic therapy, for example, its
consideration of clients’ early life, unconscious feelings and defences, through
the therapist’s use of self in the therapeutic relationship (Shedler, 2010).
Despite this evidence some have argued that a focus on cost-
effectiveness has engendered an over-exclusion of approaches, such as
STDPs. McPherson, Rost, Town and Abbass (2018) argue that NICE
recommendations of psychological therapies is limited by their review methods
that leads to their evaluation of evidence for therapies, such as some STDPs,
as being of insufficient quality. NICE is charged with the responsibility to issue
guidelines that directly impact on access to treatments for patients with
depression through the NHS. For example, first treatment recommendations for
low level depression tend to be trialled in the following order, CBT self-help,
CBT, interpersonal therapy, CBT, counselling and STDP This means patients
can end up having to refuse a great number of treatments before learning about
the existence of or receiving STDP (McPherson & Beresford, 2019).
It is important to consider the impact of this political climate of narrow
evaluation of therapies, and the potential side-lining and innovation of STDPs,
in relation to the participants’ accounts. Accordingly, the participants’ accounts
can be understood in the context of their minority status, both within
psychodynamic practice and the wider psychotherapy world, given that there
were only around 50 ISTDP practitioners in the UK at the point of data
collection. As a minority group, practitioners may expect a potential lack of
understanding from those in other modalities and perhaps as a result exercise a
degree of carefulness in which they discuss their practice. Yet, at the same
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time, STDPs are examples of approaches that are at the cutting edge of
applying findings from affective neuroscience and evolutionary-based
understandings of the physiology of emotion (Coughlin, 2017; Frederickson,
2017). The excitement of being at the frontier of what is considered effective in
psychotherapeutic practice was something that was transmitted through how
participants discussed their therapeutic work. By elucidating this accelerated
way of working, with its affective, moment by moment focus on unconscious
processes, it is hoped that this presents counselling psychologists with the
opportunity to evaluate the value and positioning of short-term psychodynamic
approaches that are appealing but may currently not in full view.
5.3 Summary of the Research
This study of participants’ accounts of their experiences of staying with
their clients’ intense emotional experiencing has revealed three main findings.
Firstly, participants’ experiences of their motivations and the demands of their
intensive, experiential and emotion-focused work as ISTDP therapists, revealed
a paradox of precision. The satisfaction in participants’ experiences of how they
approach and achieve moment-by-moment precision can lead, paradoxically, in
other moments, to feelings of anxiety that relate to pressures of time and an
increased focus on what is missed. What appeared to be revealed for
participants is an assumption that precision can be achieved at all times, which
despite knowing this to be untrue, seems to be actively believed by participants
in such moments. Elements of this paradox may likely be familiar to all
therapists but talk of this by participants seemed heightened due to the precise
and intensive nature of their clinical approach. Secondly, participants talk
revealed an understanding of the therapeutic relationship and safe and risky.
The in-session experiences that participants described, broadly delineated by
the degree to which the work progresses successfully, were understood as an
intimate and shared experience when the work is going well versus the sense of
disconnection and frustration for the therapist when encountering challenges in
the therapeutic relationship. Also captured in participants’ accounts were how
little of the emotional contact between therapist and client could be made known
or rendered through words. Lastly, the many of forms of reflection and
development needed to help contain therapist’s reactions to difficult encounters
suggested the importance of deliberate practice in helping bear one’s own
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emotion and observe it in the room. Below I address each of the superordinate
themes in relation to the existing literature. The final structure of themes is
intended to be neither explanatory nor a model of what is “out there” but is a
representation of my analysis that captures properties of the participants, our
researcher-participant interactions, and the wider world (Smith, Flowers &
Larkin, 2009).
5.3.1 Paradox of precision. This finding underpins and links different
features of the participants’ experiences, where their accounts seemed to
encompass two diverse aspects of their moment-by-moment approach in the
work. Together these features comprise a paradox of precision, where the
more value that is placed on precision, the more this requires a level of
astuteness and responsiveness that are often beyond the immediate ability of
the therapist to deliver with an extremely high level of confidence. This
underlying tension is balanced by the effectiveness and gains achieved and an
appreciation of the difficulties in the work, together with reflection on their
anxiety and what is missed in the work. Subordinate theme 4.4.2 “It's painful not
to be able to reach a patient”: feelings of frustration and inadequacy, touches on
the hidden misconception of the paradox of precision of superordinate theme
one, that participants seemed to sometimes take on, that the therapist ought to
achieve precision with every intervention. Superordinate theme one “Opening
that door”: striving for emotional closeness, captures an inherent paradox where
the aim and achievement of moment-by-moment precision also entails greater
focus on where precision is missed or avoided. This reveals that perhaps in
certain moments the erroneous mythology that precision can be achieved every
time is hard at times for participants to shake off. Yet precision is at the same
time often reached by participants through the same deliberate practices that
engender the paradox.
The precise aspects that participants talked about were consistent with
those identified as key in the main ISTDP literature, in terms of the focus on
assessing patient variables, and in choosing and assessing the impact of their
interventions (ten Have-de Labije & Neborsky, 2012). All participants described
a sense of feeling invigorated when helping clients experience their avoided
emotions, which they found motivated them in the work to pursue this approach
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even in challenging moments. In particular, the power of seeing a client’s
physicality change, as a sign of therapeutic progress, was valued by all
participants. Yet, in contrast to these more appealing aspects, participants also
described the pressures and difficulties associated with staying on track and
accurately delivering the sequence of interventions. These moments were
accompanied by feelings of anxiety and the pressure to get it right, and the
focus on missed opportunities that may then lead to self-critical responses.
The paradox of precision was also talked about in relation to the
therapist’s role in helping bring avoided emotions into awareness to a degree of
intensity that can help healing to occur without the client feeling overwhelmed.
This way of working was seen as distinct from clients merely talking about
emotion rather than feeling it. The participants described how they often feel
comfortable in this role but also emphasised difficult aspects. The requirement
of empathic attunement in order to maximise healing, yet needing also to
withstand the client’s unconscious efforts to evade conscious experiencing of
emotion, is a further paradox of the therapist’s role that was highlighted. That
obtaining the “right” level of emotional experiencing was described as
challenging is consistent with the accounts of other ISTDP therapists (Abbass,
2015; Coughlin, 2017; Frederickson, 2013).
The resulting feeling of anxiety was a strong issue that was evidenced in
all participant accounts. The participants interpreted their anxiety as arising due
to the pressure of not having enough time to process their feelings at the same
time as maintaining a focus on the client. Although precision helped the
therapist achieve accuracy, participants also talked about feelings of
uncertainty, which were influenced by the patient, the therapist and what is co-
created between them in that particular moment. The feelings of anxiety were
experienced as helpful in moments where they felt there was no time to
consider their own emotions, yet, at other times, this was also thought to
interfere with their ability to focus on or stay with the patient’s emotional
experiencing. Here, this is not to suggest that the more precise the therapist is,
the more imprecise they become in moments of difficulty. A more nuanced
meaning, based on participants’ accounts, is intended. The paradox of
precision captures the contradictions that arise as a result of the greater
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emphasis placed on precision, which lead to clinical situations where
participants felt, either in the moment or on reflection, the required level of
intelligence and responsiveness was often beyond their immediate ability to
deliver with a high level of confidence or their desired competence.
The metaphor of the ISTDP therapist as surgeon, referred to by two
participants was intriguing, as it seemed to reveal participants’ concerns for the
care of the client, through awareness of the precision and potential harm that
can be caused if the tools of therapy are not used precisely. The drawing on
this analogy may have been influenced by the fact that Davanloo, originator of
the model, originally trained as a surgeon (Coughlin, 2017). Yet the focus on
missed opportunities and the pressure participants felt to “get it right”
highlighted a tension between their uncompromising focus on the details of the
patient’s internal experience but also a persistent sense of the larger vision that
relates to the person and their relational goals for therapy. Abbass (2016)
highlights this in relation to transference with the therapist, where “if these
transferred feelings are not experienced they result in repression of another
load of rage and guilt toward the therapist increasing his psychic burden of guilt
and need to self-destruct” (p. 277). Hence the importance and concern placed
on the therapist’s accurate intervening in a client’s anxiety and defences before
they develop, so that their dynamic unconscious impulses and feelings can
emerge, is not unfounded.
Together these multiple aspects reveal a contradiction that can be
interpreted as a paradox of the moment-by-moment precision that lies at the
heart of participants’ efforts to stay with their clients’ intense emotional
experiencing. One participant commented in relation to the origins of the model
and how a punitive aspect in the approach to precision had been transmitted
through the training in ways that were both regarded as helpful and unhelpful for
the participant. Abbass (2004b) has highlighted the poles of idealising and
devaluing behaviours as evident in therapeutic training programmes, and how
this may be heightened in approaches such as ISTDP where technical precision
is pronounced. Kuhn (2014), however, highlights that ISTDP is becoming
easier to learn as trainings get better at teaching it. He links the difficulties to
the origins of there being one therapist with one way of teaching that perhaps
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did not suit all students. He also points out that the teaching of skills is one
aspect, but the humanity of the approach has to found by each practitioner,
through infusing their training with their own humanity, to arrive at that
individuals’ “right way” of doing ISTDP. This aspect is captured in participant
accounts where there were concerns about the language and being empathic
and also ability to notice how to work within the anxiety thresholds of the patient
so the therapy is effective and compassionate, prioritising the clients’ worldview
and perceptions.
The participants talked about their emotional reaction and enthusiasm for
the power of the videotaped material of cases they initially viewed at
conferences, where they witnessed the process of therapists’ interventions and
somatic responses in helping clients access their avoided feelings in an
effective and efficient manner. The draw to the model for participants was in
witnessing an effective way of working which many participants found
appealing, linking this to a more “active” therapeutic stance that was in contrast
to their previous practice. Coughlin (2018) likewise supports a link for her
between passion for the work and her drive towards effectiveness: “Finding a
highly effective method that I was passionate about that really increased my
effectiveness. I was motivated to … do the best work I could possibly do” (p.27).
Participants talked about the value of witnessing the changes in the physicality
of the client as helpful for their ongoing motivation and confirmation of their
approach as helpful for the client. Part of the motivation for using moment-by-
moment precision to help clients access their emotions is thus the reward of
seeing its beneficial effects in the therapy room.
The findings in this section have identified many distinctive features that
are pertinent to counselling psychology’s tension between its scientist- and
reflective-practitioner identities. Together, these identities unite the scientific
need for “rigorous empirical enquiry” with a therapeutic and practice-based
relationship, rooted in the relational, which values empowerment of the client on
their own terms (BPS, 2005, p. 1). Counselling psychologists draw from both
identities and often work in a focused, precise, and active manner in their
cyclical approach to assessment, formulation, intervention and evaluation
(HCPC, 2015). They, too, share similar concerns for competent practice, both
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during and beyond training, whether model specific or linked to therapeutic
processes, such as facilitating clients’ emotional experiencing. As a result,
counselling psychologists are in a strong position to consider the tensions that
may arise from this key process in facilitating a therapeutic experiencing of
emotion.
5.3.2 The therapeutic relationship as safe and risky. Almost all
participants talked about their experience of the therapeutic relationship as safe
and risky in a number of ways. First, safety in terms of presence and emotional
resonance with the client in moments of connection. Second, moments of
feeling unable to feel or think or get emotional close to the client were
accompanied by a fear of losing boundary or intense loneliness and longing to
be seen. Third, in terms of feared consequences for the client when
immobilised in the work. A striking aspect was the way in which describing
emotions was often challenging and how the somatic aspects of experience that
were hard to put into words occurred instead through their body-to-body
communication with clients. Ogden and Fisher (2015) emphasise the inherent
tension that “[t]herapy is always a dance of safety and risk, not only for clients
but also for therapists” (p. 49). Similar to Odgen’s body oriented, trauma-
focused approach, participants’ talk tended to see, in part, risk and safety
through the lens of affective neurobiology (Schore, 2007), whereby an implicit
and intersubjective ‘being with’ the client, whereby residues of their memories
and past emerged in unbidden and unconscious manner. This finding links the
hardships and comforts for striving for emotional closeness, with the theme of
connection and disconnection that frames an understanding of what happens in
room, and the need to build capacity, discussed in the section just below (see
5.2.3. The importance of deliberate practice).
A key aspect in all participants’ accounts was of the therapeutic
relationship as a shared and intimate experience that is central to the patient’s
healing. Reminiscent of Buber’s (2013) “i-thou” relationship, whereby both
persons are accepting of and open to the other, holding each other in mutual
regard, both therapist and client are responding creatively in the moment rather
than the “i-it" relationship that is based on habit and instrumental ways of
responding, which instead may describe participants’ fears in-session when
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feeling disconnected from the client. Wampold (2015) refers to this as the “real
relationship” that is based on realistic perceptions and genuineness as an
aspect he sees as a necessary pathway in all effective psychotherapy. Yet,
additionally, participants spoke of the poignancy in their connection to clients
when they allow a “presence” to emerge. The context of a safe and empathic
connection experienced within the therapeutic relationship was understood by
participants to be active in disconfirming client’s fears of emotional closeness
and the bedrock to the healing of difficult emotions (Frederickson, 2013). All
participants expressed this understanding in terms of attachment theory
whereby the caregiver provides emotional regulation for the child as a blueprint
for the client’s future relationships. Relational psychoanalysis – also an
approach that has been argued to fit well the discipline of counselling
psychology (Gkouskos, 2017) – refers to this as “relational configurations”
(Perlman & Frankel, 2009, p.110). Such facilitation of the client’s experience of
healing by the agency of sharing feelings in a context of feeling safe and
connected is a central principle of counselling psychology practice (Sugarman,
2016).
Connection and a shared sense of intimacy are conceptualised as the
therapy’s key purpose (Frederickson, 2013) and participants talked about how
this is achieved in part through an emotional resonance between therapist and
client. The therapist’s emotional resonance whereby they feel the feelings of
the client describes the attunement of the therapist in a bodily sense, that can
allow for what one participant called the “unlocking” of the patient’s “life force”.
This aspect is something that is very important and particular to ISTDP and
other experiential dynamic approaches (Osimo & Stein, 2012) and the
sustained attention to this by participants is not as comprehensively
represented in counselling psychology’s interest in other affective processes,
such as emotional processing (Murphy, 2017). The bodily aspect, and very
much felt experience, however, may be similar to Eugene Gendlin’s (2010)
description of “felt sense” and the implicit aspect the therapist is trying to attend
to, as well as what is going on in the therapeutic relationship between two
persons.
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On the other side of the polarity drawn out in this subordinate theme,
participants described moments where they felt disconnected from their clients’
experiencing of emotion or issues arising in the work that resulted in reactions
in the therapist that lead to withdrawal from connection. Participants varied in
the reactions and situations they described, including distancing in the therapist
due to an aversive response to sadistic images, not liking the client and finding
it difficult to demonstrate empathy, and feeling overwhelmed by a patient with
similar defenses to the therapist. One participant’s response was to “shut
down” when sexual feelings were expressed towards them, which the therapist
felt was in part due to a feeling of confusion that arose over the how the
therapist’s intention to explore this in the work might be received by the client.
Therapists’ experiences of erotic transference and sexual feelings appear in a
number of studies in counselling psychology and psychotherapy (Kotaki, 2016;
Mann, 1997; Rodgers, 2011). These studies’ findings align with the
participants’ experience of feeling unprepared for such encounters. There are
differences in the literature over the degree to which sexual feelings are classed
as a different form of feeling. Yet in this study, the participant in this instance
felt the lack of clarity about how to proceed was not due to these feelings being
handled differently to other forms of feeling, but was based on her own
inhibitions in relation to sexual feelings that momentarily impeded clarity on how
to direct the therapy. It may therefore be that some feelings are experienced as
more intensely personal and the complexities of how they are understood could
benefit from further exploration in training and supervision.
All participants talked about feelings of frustration and inadequacy and
the origins of these feelings seemed influenced by a number of different factors.
Rizq (2012) has identified feelings of inadequacy as a primary experience for
therapists working with clients who experience particular relational difficulties
that lead therapists to doubt their effectiveness. One understanding in ISTDP’s
theory of frustration is “anger plus inhibition” (Kuhn, 2014, p. 109), which may
be drawn on further to help interpret the unexpressed feelings of participants
who talked about not having enough time to attend to their complex feelings.
An important consideration arises as to how it is, in an approach that is geared
towards “reaching through [the] resistance” of the client (Abbass, 2015), that
therapists inevitably manage to build often unconscious expectations of the
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client that go against an otherwise deeply informed understanding of the client’s
defensive structure. Research into therapists’ feelings of incompetence
(Thériault, 2003), perhaps an overlapping construct with inadequacy, similar to
the complexity of participants’ accounts, recognises such phenomena as
multiply determined, which in turn speaks to the complexity of the therapist-
client interaction and the therapist’s efforts to make sense of this and respond to
clients in the here and now.
Similarly, these complex processes in which therapists respond to
clients, particularly in difficult encounters, were conveyed in the ways in which
participants spoke about their ways of coping. All participants drew on an
internal process of self-talk in various ways to help move through their current
difficulty and to get back on track, including offering encouragement and
guidance to help with reconnecting with the client. Self-talk as a therapists’
strategy are used and described in Hill, Nutt-Williams, Heaton, Thompson, and
Rhodes (1996) study of therapists’ retrospective recall of impasses. The
literature drawn on in discussing this second superordinate theme affirms the
challenges participants talked about in relation to connection and disconnection
in the therapeutic relationship, whereby the complexity of processes related to
therapist’s reactions and feelings of frustration are highlighted. The in-depth,
psychologically and phenomenologically informed intimacy that participants
described is core to the counselling psychology identity (Fairfax, 2016) that
seeks psychosocial perspective that understands the individual in context.
5.3.3 The importance of deliberate practice. All participants
connected their reflective practices with the key therapist competency of the
ability to cope with their own experiences while being at the same time available
to the encounter with client. The literature on the therapist’s development
shows the value of reflective process in learning therapy skills and practice
(Bennett-Levy, 2006; Bennett-Levy & Beedie, 2007; Stoltenberg, 2005), as well
as enhancing the therapist’s professional development (Schon, 1983;
Thompson & Thompson, 2008). In research by Chow et al. (2015) participants’
accounts identified, as a key factor in therapeutic competence, time spent in
“deliberate practice”, described by Blair (2016) as vigorous self-supervision and
reflection on practice (see Coughlin, 2017; Frederickson, 2013 and
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Rousmaniere, 2016 who are leading proponents of deliberate practice from
within ISTDP approach). Blair (2016) highlights a potential danger in
counselling psychology and psychotherapy whereby therapists’ effectiveness
plateaus out over time, once they reach a certain degree of comfort and
confidence (Nyman, Nafziger, & Smith, 2010). Thus, feedback-informed
approaches provide a useful way of maintaining and developing therapeutic
skills.
Participants also talked about particular technical aspects that relate to
their practice and development. The importance of supervision, including
videotape review and experiential practice, were emphasised, and also the
value of attending conferences, peer group support, and personal therapy as
helpful for building their capacity to experience and observe their own emotions
and responses in therapy. The value of reviewing video-case material – at
conferences, and in training and supervision – was highlighted by all
participants as helpful for building their capacity to bear their own emotions and
intimacy with their clients. One participant’s comment that “[t]here’s nowhere to
hide” when reviewing tapes in supervision was very powerful coming from a
therapist. This perhaps suggests there is less chance for exaggeration of skill
level and of outcomes in the session (Abbass, 2004a). Frosh (2011) highlights
an important aspect relevant to the professional self of the therapist: “Relational
integrity is an important life goal for people, and that depth of feeling – the
capacity to experience emotion without hiding from it – is an important marker of
such integrity” (p.25).
All participants talked about their improved capacity to observe and
reflect on the inner emotional life of their clients. Emotions expressed in the
client were referred to by one participant as “those minute flickers”, recognising
the fleeting and ephemeral nature of observing their clients. Abbass likewise
conceptualises this aspect as “…those flash moments [in which] you can pick
up the subtle passage of feeling that gets covered over really quickly—instantly
repressed or projected outward” (Kenny, 2014, p.220). Most participants
commented that to achieve this, they have to be comfortable and relaxed
enough to notice their own emotions and reactions and not fear and avoid them,
so they can be real in their relationships with clients. One participant points out
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the value of basic training, and then an understanding of anxiety pathways that
is provided with ISTDP training. This seems to imply a reliance on previous
psychotherapy training as something to be built on, through study of the
advance techniques (Abbass, 2015) of the ISTDP model. For participants,
building capacity was an ongoing learning process of developing expertise in
reading or working more with the implicit and non-verbalized aspects of
emotional experiencing as well as what is explicit, visually through the body and
in clients’ talk and behaviour.
5.3.4 Summary of the discussion of superordinate themesIn short,
the phenomenon explored is being studied in-depth for the first time, yet
findings of this study reflect those of prior literature, linking with the experience
of ISTDP therapists and other psychotherapists working in an experiential
manner. The tensions inherent in participants’ experiences of working with
moment-by-moment precision, staying connected with clients, and development
of their capacity and observation of the physiology of emotion, has offered a
richer understanding of therapist experiences of staying with clients’ intense
emotional experiencing. These tensions and paradoxes will be the focus of the
next section that considers these in relation to the interests of counselling
psychology.
5.4 Working with the Therapeutic Relationship from an ISTDP Theory
Perspective
Given that this is the first piece of research in counselling psychology
conducted solely on the modality of ISTDP, its relevance and use to the field in
light of participants’ accounts is worth highlighting. ISTDP is model focused on
the dynamic unconscious but with a “cognitive” frame – in terms of how
participants reported intervening in the client’s defences, the pragmatic
approach to helping clients regulate their anxiety, and the importance of
conscious reflection on their emotional states. It can be argued that due to its
pragmatic aspects, such as the active stance of the therapist, as outlined in the
above discussion of themes, ISTDP is a modality that has focused more on
technical aspects and “doing” therapy. However, participants have offered a
clear picture of how the therapeutic relationship operates in their practice of
staying with client’s intense emotions, and how the empirically supported
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metapsychology of ISTDP (Abbass, 2015), which draws innovatively on more
traditional concepts of psychodynamic psychotherapy, can inform the practice
of counselling psychologists who may wish to apply ISTDP in their clinical work.
Counselling psychology is seeing a move towards working in the
therapeutic relationship in an integrative manner that is increasingly
transtheoretical, whereby ‘schools’ of therapy are being eclipsed by
convergences in psychotherapy science. As Lambert and Norcross (2017)
highlight, therapies are complementary not contradictory when you start to
consider individual patients. As supported by participants’ accounts, in order to
build their conceptualisation of the individual the ISTDP therapist, in the context
of the therapeutic relationship, helps the client address their relational conflicts
that are the result of attachment trauma. To achieve this, they rely on a client-
informed understanding of transference, and countertransference and the
therapist’s use of self (HCPC, 2015; 2016). The relational focus at the heart of
counselling psychology is thus visible in many aspects of practice of ISTDP as it
has been related by participants in their accounts of their experientially-focused
work.
5.5 Methodological Critique of the Study and Quality Issues
Having outlined some of the original contributions to our knowledge of
how the ISTDP therapist experiences their clients’ intense emotional
experiencing, the following outlines considerations of the methodological
features of the study and quality issues.
5.5.1 Critique of IPA. As mentioned in Chapter Three: Methodology,
IPA was selected due to its ability to provide a rich and nuanced understanding
of the subjective lived experiences for a handful of participants (Smith, Flowers
& Larkin, 2009). A conceptual and practical critique (Brocki & Wearden, 2006;
Tuffour, 2017; Willig, 2013) of this choice of methodology and how it was
actioned and reflected on through this research is considered below.
5.5.1.1 The role of language. Firstly, IPA is assumed, in comparison to
more discursive approaches, to give insufficient attention to the integral role that
language plays in representing experience (Willig, 2013). Yet, in line with
94
Smith, Flowers and Larkin’s (2009) response to this criticism, this study accepts
that meaning-making happens in the context of the participants’ stories and how
they use language. Thus any insight gained into experience is always already
bound through language. This study, however, aimed to investigate therapists’
subjective experiences, where a comprehensive examination of individual
narratives suffices in assuring credibility of the study.
5.5.1.2 The suitability of participants’ accounts. A second criticism of
IPA relates to its reliance on participants accounts’ and researchers’
experiences, and the degree to which the method can apprehend the
experience and its meanings versus mere opinions (Willig, 2013). This being
the case, it is important to ascertain whether participant and researcher are
skilled enough and able to convey the nuances of experiences. All participants
in this study had the ability to articulate in a sophisticated manner their
experiences. Yet there are aspects that perhaps hindered participants’ abilities
here. For example, there is huge amount of sensitivity in discussing one’s own
professional conduct and experiences, and especially more so when being
asked to make comment on client work and their emotional and mental health.
So whilst participants had access to the requisite degree of fluency, there were
factors of sensitivity that perhaps limited their permission to describe their
experiences. My own skills in data collection are reflected on in the reflexivity
section below. Overall, the richness of the data and analysis detailed in this
study shows that this was not a key concern.
5.5.1.3 IPA’s descriptive nature. Thirdly, IPA’s focus on perceptions, it
is argued (Willig, 2013), limits understanding, where seeking to comprehend
lived experiences may not help to account for why they happen. Studies should
be robust by aiming to investigate the conditions that bring about the
experiences, which are situated historically or social-culturally beyond research
parameters. Yet, this study has aimed to avoid this criticism, through providing
an analysis in IPA that is interpretative, idiographic and contextual (Smith,
Flowers & Larkin, 2009), and thereby able to get close in understanding
something of the cultural positioning of the experiences participants talked
about.
95
5.5.1.4 Cognition and phenomenology as discordant. Lastly, the
claim that IPA is focused on mental action is perceived to be incompatible with
some aspects of phenomenology, and its role in IPA is not fully grasped (Willig,
2013). Smith, Flowers & Larkin (2009) reply that the method’s focus on sense-
and meaning-making encompasses forms of reflection that chime with the
cognitive paradigm.
5.5.1.5 Quality issues. This piece of research intended to study a
specific phenomenon with a particular therapist population within a particular
modality and UK context. In terms of the rigour (Yardley, 2008) of the study it is
worth noting the primarily subjective nature of IPA as an approach where the
researcher offers their interpretation of their participants’ interpretation of lived
experience (Smith, Flowers & Larkin, 2009). That my participants would have
given a different narrative to a different researcher is undoubtable and was a
question I reflected on throughout (McLeod, 2014). For example, how might
participants’ accounts have been modified if they were speaking to someone
fully immersed in the practice of ISTDP and also someone qualified rather than
someone in the midst of their primary clinical training? Overall, I felt my
researcher positionality (Frost, 2016), as someone who had received
introductory training and was using basic ISTDP principles in my
psychodynamic clinical practice, meant I had at various points an
“insider/outsider” status that allowed for a balance between empathic and
suspicious interpretation that is valued in IPA.
A second aspect, in terms of the rigour of the study, related to the
completeness of the analysis. The first superordinate theme draws from data
the was gathered around the question, ‘what drew you to ISTDP’? The rationale
for asking this question was to enable me to achieve a good degree of
closeness with participants early on in the interview and to direct the interviews
towards participants’ focus on their understanding of their work with their
clients. Initially, I considered that responses to this question would not be
central to phenomena, and that only data that spoke to in-session experiences
would be included in the analysis. This view was based on my understanding of
Smith’s (2011) quality criteria for good IPA where he highlights the importance
of providing “a clear focus…providing details of a particular aspect” of the
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phenomenon (p. 24). However, on reflection, and given the exploratory nature
of my research topic, I decided to include data at the broadest level of sense-
making possible, in order to reflect the contextual aspects that may help further
understand what motivates the participant in the room when working with their
client’s intense emotions. This made the analysis, in my view, more
interpretative rather than merely descriptive, and also more developed through
an elaborated account of the emerging themes. This approach thus also
represents an example of contextualising the interview through additional data,
as espoused by Smith, Flowers and Larkin (2009).
The transparency and coherence (Yardley, 2008) of this research, in
terms of how I can know whether the themes I have identified in the data are a
true reflection of participants' experience (McCleod, 2013), was a particularly
vivid concern in the data analysis. That IPA is fundamentally a relational
approach (Finlay, 2011) was most evident in my attempts to make meaning of
participants’ accounts. Regular support and guidance from my supervisory
team and contact with fellow IPA researchers in my cohort was invaluable to
gaining not only an understanding of participants’ words but in bringing to life
my own faithful translation and interpretation of their accounts. Furthermore,
the analysis was audited by an experienced IPA researcher, in order to track my
keeping to the methodological commitments in building a rich picture of
therapists’ experiences that is interpretative as well as descriptive, and thus
also trustworthy and credible (Hefferon & Gil-Rodriguez, 2011).
5.6 Reflexivity on the Research Process
Reflexivity is regarded as a further quality criteria that helps guarantee
the rigour of the research through the researcher’s reflection on their
assumptions and knowledge and the influence of this, as well as their role and
input, on the research process (Kasket, 2012).
Much of my personal reflexivity throughout the research centred on some
of my individual characteristics as a researcher and their influence on the study.
In particular, my reflections focused on the process of my engaging positionality
and owning my perspective as a researcher (Frost, 2016; Kasket & Gil-
Rodgriguez, 2011). A part of my personal motivation to undertake this research
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was to learn from experienced therapists about their way of working that would
speak to important clinical processes and their application to practice. My own
position as a trainee had led to me positioning the experienced therapists who
participated in my study as ‘experts’. This positioning showed up in a variety of
initially unconscious assumptions that were useful to have considered in order
to limit their undue influence on the study: initial drafts of my interview schedule
were highly technical and conceptual, rather than the everyday language that
IPA favours (Smith, Flowers & Larkin, 2009); my interviewing style was at times
timid on the basis of feeling anxious about “getting it right” from an ISTDP
perspective (which I realised was not a part of my role as interviewer) and that I
should be asking questions that were merely relevant to participants rather than
to the interests of the study; and in the data analysis and write up of the study, I
was initially tentative on the basis of feeling an allegiance to the participants’
experience rather than translating this experience in light of the phenomena
under study. Through these reflections, I was better placed to limit their
influence on the research. I was also able to better understand and articulate
their relationship to my research topic, my approach to the participants, and the
influence of the context in which I was conducting research in counselling
psychology.
Much of my epistemological and methodological reflexivity (Kasket,
2012; Willig, 2013) related to my attempts to adhere to the philosophical
commitments of IPA and grapple with the ontological and epistemological
stance of interpretative phenomenology. I chose this stance in relation to my
research aims and could appreciate ways in which my subjectivity, and indeed
the subjectivity of any other researcher, would shape and limit the research
accordingly. I could acknowledge how a shift in my epistemological positioning
would alter the knowledge gained. Two of the greatest dilemmas that I
engaged with, particularly at the initial noting stage, were: (1) how does an IPA
researcher begin to make sense of the experience of the other? I was unable to
locate useful guidance other than the general advice of ‘jumping in’ to the data
with initial observations, and felt throughout the research the ongoing tension of
the degree to which this is subjective and empirical; and (2) what counts as
“experience” in interpretation? A related question was, what is the frame of
reference for conceptual comments in IPA that the researcher draws on in
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interpreting participants’ accounts? I initially assumed a very limited view of
what counts as “experience” and “psychological concepts” and found that
bracketing these terms when facing this analysis and concentrating on
meaning-making, helped free me from these conceptual limitations.
5.7 Implications of Findings for Practice in Counselling Psychology
The findings of this research have relevant implications for the practices
of counselling psychologists and the broader practice of psychotherapy.
Counselling psychologists may benefit from developing an awareness of their
own motivations and responses to staying with their clients’ intense emotions
and of the benefit of this to the therapeutic relationship. The finding that
participants rely heavily on their theoretical framework suggests that counselling
psychologists may draw from this in helping them to identify and understand
and better observe their own emotional experiences.
The deliberate practices (Rousmaniere, 2016) that participants
discussed, such as videotaped supervision and peer review, indeed help focus
on the unique developmental path of each therapist, in terms of their capacity to
bear their emotions and stay with their clients’ intense feelings, but also provide
opportunity for further scrutiny and a focus on “getting it right”. Those
responsible for training and supervision may consider the benefits of such
practices but may also need to consider the punitive aspects raised in
participants’ account in the ongoing development and support of therapists. For
example, in the preparation and management of feelings of anxiety and
frustration and the self-critical responses that arise. Also, further to one
participant’s talk about drawing on their meditation practice to help cope in
times of difficulty, programmes that aim to comprehensively address these
burdens of training and therapeutic practice by improving trainees’ compassion
towards self and others may be a helpful starting point (Beaumont & Martin,
2016).
Participants’ accounts offer a view of ISTDP as an integrative, evidence-
based approach, incorporating clinical expertise, and attachment-based
understanding of dynamic unconscious processes that are helped into
conscious experience and processed within the therapeutic encounter. Other
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therapists can draw from this model and explore ways to incorporate its
techniques of intervening in clients’ defences and regulating anxiety, and in
helping clients experience their emotions. This study of ISTDP therapists’
experiences touches on the “tension of polarities” that exist in so-called natural
versus human sciences, that lead in practice to a balance of effective technique
and relational aspects that address the whole person (Murphy, 2017). The
counselling psychologist holds a firm commitment to evidence-based practice,
yet the value in an evidence base differs according to epistemological and
ontological standpoints. This research does not resolve this debate, but
hopefully will introduce counselling psychologists to ISTDP as a modality that is
evidence based, theoretically integrated and valuable to counselling psychology
and the science of psychotherapy.
It is important to reflect on the numerous ways this research has
impacted positively on my own clinical practice (Kasket, 2012; 2013).
Participants’ accounts have further alerted me to the value of attending to a
client’s emotional physiology, including an increased knowledge of anxiety and
emotional pathways, so I can better notice and gauge what is happening for the
client emotionally in the room. The participants’ accounts also elucidated their
phenomenological commitment to responding to the client through a focus on
their reactions and in seeking feedback from the client about those responses. I
too have found great benefit and creativity in this prioritising of the client’s
subjectivity and uniqueness, where adding this element to my practice. Thus, in
researching and writing my doctoral thesis, I have found that my own personal
definition of counselling psychology as it relates to me as a practitioner-
researcher has evolved to include greater belief in focused and pragmatic ways
to help empower clients, and in envisaging non-hierarchical relationships where
the therapist draws on their expertise to help the client address their relational
difficulties.
5.8 Implications for Future Research
The findings have revealed important aspects of the phenomenon that
could be further investigated, including therapists’ reactions to clients displaying
similar defensive structure to their own – an aspect common to participants’
difficult encounters – and the somatic phenomena in countertransference and
100
therapists’ way of relating to the body (Athanasiadou & Halewood, 2011), an
aspect which often eluded participants. As the development of the person of
the therapist was talked about in divergent ways, further phenomenological
study of therapists’ experiences of this could help elucidate this. Finlay (2006)
highlights how replicating research can broaden horizons by generating new
knowledge and interpretations. Exploring the experiences of other ISTDP
therapists based at other institutes or therapists working in similar modalities,
such as experiential dynamic therapies, may offer further understanding of
contextual aspects and their influences. Relatedly, it would be interesting to
see how therapists stay with their clients’ intense emotions in modalities where
emotional experiencing is not the primary focus.
The same phenomena could be explored from diverse paradigms
(Morrow, 2007). As participants’ accounts made reference to the fleeting and
ephemeral nature of emotional experience, “those minute flickers”, creative
methods could be employed to better apprehend emotional content. For
example, Grid Elaboration Method, a free association approach (Hollway &
Jefferson, 2000) that has been shown to fit well with a thematic analysis (Park,
2016) has been used to address features of thought and behaviour that arise
via emotionally laden, nonconscious processes. A critical realist approach
would allow for incorporation of ISTDP theoretical framework to aid
understanding or theory-building. Other methodological approaches, such as
the single case and video-case-series methodologies, used to good effect in
ISTDP to explore patient variables (Salvadori, 2010; Town et al, 2017), could be
employed to examine therapists’ emotional capacity in relation to key
therapeutic processes and outcomes.
The phenomenon studied here may also be worth exploring in other
emotions-focused or experiential modalities. As a cross-sectional view of one-
off interviews were used in this study, a longitudinal study exploring how
therapists manage within particular cases may highlight additional features.
Comparative studies may also highlight shared and divergent aspects between
approaches that share an experiential and dynamic focus. The nature and
extent of counselling psychology’s experiences of this phenomena could be
101
researched to better establish the relevance to the field of some of the
implications found in this study.
5.9 Summary of the Study
This exploratory study is the first of its kinds to present an in-depth look
at what it is like for ISTDP therapists to stay with their clients’ intense emotional
experiencing. It offers an interpretative phenomenological perspective on the
subtleties and complexities inherent in participants’ experiences of their in-
session experiences and the technical aspects of the development of their
capacity to endure intense emotions. The study illustrates how an important
issue for therapists and their ongoing development is attending to the paradox
of moment by moment precision, whereby the therapist achieves greater
effectiveness but at the cost of a greater focus on what they miss in the work.
The therapist’s experience of the therapeutic relationship as safe and risky also
revealed the sense of comfort in the work and also the sense of threat to the
self. Findings also suggested important ways of coping with difficult encounters
and helpful suggestions for building the capacity of the therapist through forms
of deliberate practice. Consideration of ISTDP as an integrative,
multidimensional approach that aligns to the values of counselling psychology
was presented. The findings can form the basis of future research into
therapists’ experiences of staying with their clients intense emotional
experiencing and other aspects of the therapists’ experience of providing an
emotions-focused, experiential approach that takes place within the context of a
healing and human relationship.
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Appendix A: Participant Information Sheet
119
120
Appendix B: Demographics Questionnaire
121
Appendix C: Consent Form
122
Appendix D: Interview Schedule
123
Appendix E: Debrief Form
124
Appendix F: Transcript Analysis: Initial Noting Extract
Extract from one participant’s (Raelyn) initial noting stage, illustrating
exploratory comments and emergent themes against the transcript.
Line
no.
Transcript
Exploratory Comments
Emergent
Themes
136
152
R: I mean, I actually, I think, I
think, if I looked at video tapes
earlier on, I couldn't see it in
the moment, but I could see
myself like moving away
(leans back in seat), so there
must have been anxiety in
me, so I think it comes
overtime, being com-, being
very comfortable with it,
comes and I'm not sure that
there's a short cut to that. So
it's like eh, you-you build up
your own tolerance, but I
actually um, I mean I think I
have sat with a lot of people
sobbing, I have sat with a lot
of people going to murderous,
torturous, primitive, sadistic
rage, so there, I guess in
some ways there's a
distancing in me as well, not
to say that I don't, you know, I
have that sort of, it doesn't – I
wouldn't say it affects me so
deeply. I mean sometimes
when people are grieving the
loss of a child, it's very hard
not to cry myself, um, but, uh,
but I enjoy it, I-I find it very, it's
like, I think it unlocks some
kind of life force in the patient
and I think it does to me as
well. I mean, whether I'm
sitting with the patient or
whether I'm in a training
watching videos, there's a
there's energy associated with
emotions which is very very,
yeah, energising. Yeah, so I
enjoy it, is the short answer.
‘I think’ repetition
perhaps highlights
distancing.
video tapes offer
reflection on in-session
responses
Assumption that the
moving away is due to
anxiety
Does not feel anxious
now in the same way
Acknowledgement that
this takes time.
distancing in second
tense? ‘but I actually’
separates herself from
other therapists?
Is anger the hardest
emotion for her/others
to tolerate?
Explanation entails
reflection on client
experiences
Underlying difficulty
articulating her
position? Does position
go against perceived
view of
therapists/person as
therapist?
The energy or life force
linked to emotions is
transmitted and is not
limited to time or space.
Shared experience of
emotion
Is it energising because
it has been previously
unfelt or because
merely it is being felt?
A distancing
in me
Building
emotional
tolerance
Levels of
rage
(emotion)
Enjoyment
A shared
experience
Emotions as
energizing
125
Appendix G: Clustered Themes For One Participant
A clustered themes table for one participant (Emma).
The appeal of the speed and
effectiveness
Physically seeing changes
I just accepted the cognitive
experience
Shared and intimate experience
A shared language
Sharing the experience
This is a collaborative effort
Using more of self in the work
Knowing enough about myself so I’m
comfortable with my reactions
I was able to use much more of myself
You have to be prepared to take a risk
Prepared to go to those places inside
yourself
What helps to stay with intensity
Therapist as really genuinely
interested in the other person
Support of colleagues/supervision
Seeing the benefits helps you stay
with it
Emotions as difficult to articulate
Emotional experiencing as fleeting
Different levels of intensity
I just go with it – intensity as difficult to
articulate?
The therapist’s role
We’re always trying to get back
to those early feelings
Watching the body
It’s a very lonely way of being
My job is just to give a little
nudge
We’re trying to get at those
feelings
Ways of coping
So active mentally on the patient
not therapist’s own body
All kinds of images came up
Talking myself down
Anxiety in the body
Challenge to not react to sadistic
images the client brings
Therapist’s reaction
A punitive thing came in
A conflict between the portrayed
and the real
I became quite sort of ‘uh uh’!
Inhibition around sexual feelings
Clarifying with the client
A shutting down when sexual
feelings are expressed
What it feels like
Comfortable but not pleasant
A very creative way of being
126
Appendix H: Cross Reference to Theme Table
A cross-reference to theme table indicating presence of theme in cases.
R
J
D
B
E
“Opening that door”:
striving for emotional
closeness
ü
ü
ü
ü
ü
“It’s really rewarding”: the
motivating power of seeing a
person change
14
654
49
20
19
512
575
15
281
404
5
“Not giving up on the route to
getting there: persevering
through resistance
27
181
434
448
39
248
5
“Trying to decide where to go
next and how to proceed:
pressure and focus on
accuracy
136
218
424
432
401
296
318
258
696
234
428
245
248
5
Connection vs
disconnection: what’s
happening in the room
ü
ü
ü
ü
ü
A shared experience:
connection and intimacy in the
therapeutic encounter
68
148
163
175
237
266
281
168
585
169
275
5
“It’s painful not being able to
reach a patient”: feelings of
frustration and inadequacy
171
505
209
166
315
505
614
374
380
200
474
517
3
“Talking to myself”: remaining
calm and professional
281
317
327
655
450
492
265
5
“There’s more of myself
now”: bulding one’s own
capacity
ü
ü
ü
ü
ü
“You get better…you get more
emotion in the room”: building
emotional tolerance
203
67
73
464
ü
636
ü
3
“Those minute flickers”:
observing and reflecting on
inner emotional life
669
444
526
327
118
5
“Knowing enough about
myself”: using and protecting
the self
319
326
356
ü
ü
393
3
Note: ‘All participants’ = 5, ‘Nearly all’ = 4, ‘Most’ = 3
127
Appendix I: Application for Research Ethics Approval
128
129
130
131
132
133
134
Appendix J: Notice of Ethics Review Decision
135
136
