A Comparison of Two Cases in Experiential Systemic Therapy: a Case Study Approach
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A COMPARISON OF TWO CASES IN EXPERIENTIAL SYSTEMIC THERAPY: A CASE STUDY APPROACH By Liz Prette B.A. University of Victoria, 1985 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of Counselling Psychology We accept this thesis as conforming to the required standard A THE UNIVERSITY OF BRITISH COLUMBIA March, 1997 ©Liz Prette, 1997 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada DE-6 (2/88) ii Abstract The problem of this study was to examine the variables that contributed to a successful case of Experiential Systemic Couples Therapy as compared to a non-successful case using a qualitative, exploratory case study. The main purposes were: (a) to generate concepts that may have led to or hindered therapeutic change, (b) to investigate the process of change in Experiential Systemic Couples Therapy, and (c) to contribute to the clinical understanding of how change occurs in ExST. The case data sources included documentation (objective measures, situation diaries and reviews of therapy) and video tapes (15 taped sessions from each of the cases). The two cases were chosen using Pinsof's (1988) techniques of Success-Failure Strategy from a larger pool in The Alcohol Recovery Project. A qualitative case study methodology was implemented to discover the major differences between the two cases. Along with these descriptive methods, three sessions from each case were also analyzed using the Vanderbilt Psychotherapeutic Process Scale. The researcher also used Pinsoff's small chunk strategy and analyzed the "best and worst" session of each of the cases. Again a qualitative analysis was done of the sessions, as well as using the Hill (1993) Category Systems. Key findings from each of the cases were identified and compared. The findings revealed nine major differences which occured between the two cases. The analysis of the cases revealed nine major findings associated with outcome. First, three pre-existing variables were discovered to be associated with the successful and unsuccesful case: client variables, stage of change and length of therapy. Second, three findings were delineated as to why change may have occurred: therapeutic alliance, addressing intimacy issues and practicing opportunities in therapy. Finally, three findings were discovered as to how greater change may have occurred: depth of experiencing, therapist techniques and the completion of a 'story' during a therapy session. These findings are integrated with current research. As well, implications for future research and clinical practice are discussed. The limitations of this study and it's methodology are also presented. iii TABLE OF CONTENTS ABSTRACT ii LIST OF FIGURES •••v LIST OF TABLES vi ACKNOWLEDGEMENTS vii A. CHAPTER ONE -Introduction 1 Background to the Research Problem 1 Research Problem 3 Purpose of the Study 3 Approach to the Research Problem 3 Definition of Terms 4 B. CHAPTER TWO- Literature Review 7 Experiential Systemic Therapy 7 Overview of ExST Theory 7 Key Dimensions of the Model 7 Phases of Therapy 8 Transactional Classes 9 Relational Novelty 10 Overview of ExST Research 11 Quantitative Studies 11 Qualitative Studies 12 Marital and Family Process Research 14 Case Study Research and Methodology 18 C. CHAPTER THREE - Methodology 27 Research Design ; 27 Case Study 28 Success/Failure Strategy 29 Episode or Small Chunk Strategy 30 Procedure 30 Project Description , , 30 Subjects 30 Therapist Selection 34 Selection of "best and worst" sessions 34 Origin of the Data Record 35 Measures 36 Outcome Measures 36 Process Measures 37 Data Collection and Data Analysis 39 Phase One- Holistic 40 Client Variables 40 Outcome Measures , 40 Process Measures 41 Qualitative Observation , 41 Vanderbilt Psychotherapy Process Scale 43 iv Phase Two- Embedded 44 Process Measures 44 D. CHAPTER FOUR - Results 47 Part One 47 Client Background 47 Pretest Results ....48 Presenting Problems 49 Part Two.; 52 Outcome Measures 52 Vanderbilt Psychotherapy . Process Scale ...66 Part Three Qualitative clinical analysis 73 The First Session 73 Pattern of Therapy 75 Use of Symbols 83 Experiential Techniques 92 Intimacy Creation 95 Major Issues 109 Issue of Alcohol 109 Issue of Co-dependency 134 Issue of Fear 149 Issue of Sexuality 169 Part Four 176 Qualitative Clinical Analysis 177 Counselor Verbal Response Category Stystem 187 Client Behaviour System 189 E. CHAPTER FIVE - Discussion 192 Findings 193 Limitations 212 Further Research 214 F. References ? 217 G. Appendix 229 Appendix A 229 Appendix B 230 Appendix C 232 LIST OF FIGURES Figure 1. Dyadic Adjustment Scale Scores 55 Figure 2. Tesch Intimacy Questionaire Scores 56 Figure 3. Symptom Checklist-90-Revised Scores 57 Figure 4. Alcohol Dependency Data Questionaire Scores 58 Figure 5. Z-Scores for Females on all Instruments 59 Figure 6. Z-Scores for Males on all Insturments 60 vi LIST OF TABLES Table 1. Patient Participation Scores 67 Table 2. Patient Hostility Scores 68 Table 3. Patient Exploration Scores 69 Table 4. Patient Psychic Distress Scores 70 Table 5. Therapist Warmth and Friendliness Scores 71 Table 6. Therapist Exploration Scores 72 Table 7. Pattern of Therapy Sessions- Case A 77 Table 8. Pattern of Therapy Sessions- Case B 80 Table 9. Counselor Verbal Responses 189 Table 10. Client Behaviours 190 VII ACKNOWLEDGEMENTS This research project was an learning process that was supported by numerous people along the journey. I would like to express my appreciation to John Friesen for his patience and commitment to process research. It is with gratitude and pleasure that I have been part of the TARP project and the wealth of data available for research purposes. I would like to thank all the therapists and clients who were willing to make their sessions available. I am very grateful to my own family of origin for their support and help throughout this project. It is also with appreciation that I thank my in-law family for their constant encouragement. As well, I thank numerous friends who sustained me though much of this project by believing in my capacity to finish. Finally, and most importantly I want to thank my family. I am indebted to my children, Anna and Rebekah, for their patience and understanding. My deepest appreciation goes to my husband, James, whose love, support, sense of humor and compassion made the journey endurable. 1 CHAPTER 1 INTRODUCTION Background to the Research Problem Understanding what constitutes successful marital therapy has been the focus of many research studies. Most of the research has been overshadowed by the demand for outcome studies to discover which of the therapeutic theories would show statistically significant effects relative to control groups or to other therapies ( Baucom & Hoffman, 1986; Goldman, 1987; Grigg, 1994; Hahlewegf & Markman, 1988; Halford, Saunders & Behrens, 1993; Johnson & Greenberg, 1985). This inquiry over the years has demonstrated that most psychotherapies can be shown to have efficacy but there are no reliable differences on the therapeutic outcomes between different theoretical models (Jacobson & Addis, 1993). Even the success these investigators have established has come under debate. Jacobson and Addis (1993), in their literature review, point out that in the absence of treatment the improvement rate is so low, that statistical significance is easy to obtain when comparing control groups with treatment groups. In conclusion, Jacobson and Addis (1993) point out that "all treatments are helping some couples, all treatments are leaving substantial numbers of couples unchanged or still distressed by the end of therapy, and all tested treatments appear to have about the same success rates". Until the past decade, empirical inquires into the subject of how and why therapy succeeds were rare. Recently, the trend in research has been to look at specific factors that are involved in the process of successful treatment. This new research endeavour has been labelled process research, and is still in its infancy, especially in the field of marital and family therapy (Pinsof, 1989). Process research is a critical area of study which seeks to understand the inner workings of therapy and helps link treatment to outcome. As researchers seek to identify, describe, and explain the processes that bring about therapeutic change, change theory can be elaborated and verified as it relates to specific models of therapy (Greenberg, 1986). As the process of therapy is explored, researchers take an in depth look at therapist, techniques and client variables, both during therapy and outside of therapy. Recently, with the methodological improvements of process research, 2 more studies are also exploring the interaction of the therapist, technique and client variables (Waring, Schaefer, & Fry, 1994). Process research is ail ever growing field that marriage and family therapy researchers are using to understand the therapeutic process and how the therapeutic process is related to client change