Clients' Experience of Exploring Pro-Symptom Positions In

Clients’ experience of exploring pro-symptom positions in integrative counselling

Jodie Hawkey Diploma for Professional Studies Counselling, University West of England, UK.

Abstract

Coherence therapy identifies three specific steps that need to occur in sequence for transformational change to occur in therapy. These steps coincide with the neurological processes involved in memory reconsolidation. The present study explores one of the techniques utilised in step one; through the eyes and experience of the client. Four counselling students took part in a skills practice setting where the technique of ‘symptom deprivation’ was employed. Experience was recorded through semi-structured questionnaires and the qualitative data was thematically analysed. Four themes emerged from the data. The most poignant was the effect of honing in to a specific element of the client’s symptom. Results suggest that this tight focus allows clients to drop into their unconscious and access more global constructs that are influencing multiple areas of their life. This is

explored with reference to the literature and implications regarding accessibility of the technique are considered.

Introduction

Coherence therapy is an approach in counselling that claims to have identified neurological processes that link with memory reconsolidation which are believed to accompany deep and lasting change in therapy as experienced by clients (Ecker et al., 2012). Coherence therapy sits within a framework of constructivism, believing that individuals each construct their own personal ‘knowings’ about the world through their own experiences and perceptions of those experiences. Although the majority of these knowings about the world are implicit and so not readily accessible to conscious thought, they actively guide an individual’s expectation of the world and so guide thoughts, emotional responses, somatic responses and behaviour (Held, et al. 2006 cited in Ecker et al. 2012). Coherence therapy suggests that these constructs, or knowings, once accessed, are potentially revisable (Ecker & Toomey, 2008). Coherence therapy identifies three specific steps that need to occur in sequence for memory reconsolidation to take place.

The first step is known as the discovery stage. Counsellors work with the client to identify specifically what the client feels is the presenting symptom and then to work

1 to uncover the ‘pro-symptom’ position; what personal implicit constructs have led the client to feel like they require this symptom; what coherent emotional need is being served by having the symptom. Toomey & Ecker (2007) cite various psychotherapeutic systems that entail the conscious retrieval of unconscious, unresolved emotional themes (implicit schemas); psychodynamic psychotherapy (Crits-Christoph, Luborsky, & Barber, 1990), psychoanalysis (Curtis & Hirsch, 2003), and existential– humanistic therapies (Schneider, 2003). However, Toomey & Ecker (2007) propose a concise method that appears to access the ‘pro-symptom’ position, the adaptive implicit knowledge behind the symptom, in a direct way. One technique involves guiding the client towards an embodied experience of their symptom, and then asking them to imagine that same experience but with the symptom removed. This can help access a greater fear that their symptom is in fact protecting them from. The principle of ‘symptom coherence’ maintains that an individual's seemingly irrational symptoms are actually meaningful, orderly expressions of the person's existing constructions of self and world, rather than a disorder or pathology. So a client's presenting symptoms are understood as an activation and enactment of specific constructs.

The second step needed for memory reconsolidation involves fully integrating the newly accessed implicit knowledge into conscious awareness. Part of this work in coherence therapy involves writing the new knowledge on a card that the client is invited to read several times a day between sessions. There is no attempt to counteract the new knowledge. This stage of the process resonates with Carl Rogers’ (1967) statement; “The curious paradox is that when I accept myself just as I am, then I can change” and is similarly aligned to the ‘paradoxical theory of change’ (Beisser, 1970).

The final step required for memory reconsolidation is the process by which retrieved schemas then undergo profound change or dissolution: the retrieved emotional construct must be experientially activated while concurrently the individual vividly experiences something that sharply contradicts it. Neuroscientists have confirmed that these same steps are precisely what unlocks and deletes the neural circuit in implicit memory that stores an emotional learning—the process of reconsolidation. “Reconsolidation is the only known neural mechanism capable of dissolving an existing emotional learning” (Ecker et al. 2012)

My initial interest in this approach came from an article I read in Therapy Today (Sibson & Ticic, March 2014). I have a clear memory of reading the article and a sense of excitement building; I felt like I was reading something that intuitively made sense. I was attracted by the depth of the work, and also by the potential of working in this way in brief therapy. I liked the need for a deep level of empathic attunement, alongside phenomenologically assisting a client to uncover their unconscious meaning making constructs. I also like the emphasis on validating rather than counteracting. In this way I feel that the approach de-pathologises constructs that might otherwise be seen as defences that need to be ‘got rid of’. I was also attracted

2 by the convergence between the findings of therapeutic transformation and neurological function (Toomey and Ecker, 2007).

Having attended a coherence therapy workshop and experienced, as a ‘client’, the process of uncovering implicit memories through experiential work, I have become familiar with the ‘tingle’ I experience when a piece of consciously unknown, and at the same time, implicitly known information is brought into conscious awareness. I had the experience of working briefly with one of the trainers and I was really struck by his approach. He was so inquisitive and I felt like there was an absolute belief that whatever came forth from my unconscious would be wholly acceptable, and somehow, objectively so. I feel that the expectation of there being a coherence to the discovery work, brings an added dimension and it was this that I became interested in. The question I asked myself was; what is it about this expectation that allowed me to access these previously unknown ‘knowings’?

The idea of personal constructs, or ‘inner working models’ were originally developed by Bowlby (1969) to explain how a child’s attachment relationship with their primary caregiver leads to a framework from which subsequent relationship expectations will be based. Maronne (1998) suggests that the term ‘working model’ can be used “to denote all the representations we have about the world around us that we have built out of our individual experience.” Maronne explains the importance of the earliest attachment models in that they are likely to influence the way the child subsequently experiences the world and so may influence the construction of later models.

Through accessing these inner working models using coherence therapy techniques, I have come more into contact with these hidden aspects of myself, recognising that they are originally rooted in either attachment and/or survival needs. I am therefore much more ready to accept and validate these parts of me. I feel like I’m much more willing to meet my unconscious.

Interest in the unconscious has expanded significantly in recent years as it has come to be explored within neuroscience with much interest generated in uncovering the areas of the brain responsible for our unconscious. Schore (2003) asserts that “the right hemisphere is the biological substrate of the human unconscious and it is it’s homeostatic-survival and affect regulation functions that are truly dominant in human existence”. He states however that because the left hemisphere has the capacity for explicit language, this hemisphere is often seen as dominant.

Schore (2005) has shown that early emotional experiences are stored in our right hemisphere, pre-verbal implicit memory systems. He suggests that these implicit or unconscious systems must be reached in psychotherapy in order for any lasting change to take place. He also cites Bowlby (1988) who asserted that; restoring into consciousness, and the reassessment of internal working models, is the essential task of therapy.

3 Toomey & Ecker (2007) argue that the mechanism of change in coherence therapy is centred around the brain's built-in capacities for change. They have mapped out the processes that they have observed across hundreds of therapeutic sessions where transformative change has been observed, and found that these converge with the steps needed for the brain to undergo memory reconsolidation; a recently discovered neural process that can actually unwire and delete longstanding emotional conditioning held in implicit memory (Schiller et al. 2010, Xue et al. 2012) The assertions that coherence therapy achieves implicit memory deletion are unproven but Ecker et al. (2012) assert that the process aligns with the growing body of evidence supporting memory reconsolidation. (Duvarci and Nader, 2004).

In all of the literature I have read about coherence therapy, I have not found any inquiry into the experience of the client going through the process and feel there may be interesting insights to be had here.

My own experience of coherence therapy was a powerful experience. The technique that was used is one of the most common and is called symptom deprivation. In this way, I was invited to describe the symptom that I wanted to explore through a recent experience where I encountered it in a powerful way. I was asked to really go into the experience; to imagine I was there and to describe what was happening in the present tense. I was invited to explore the physical experience and asked ‘what would I need to know to understand how you were experiencing this?’ I was then asked to imagine that the symptom with all of the associated bodily sensations and had somehow completely disappeared, and to describe the experience of this. My immediate sensation was relief, to be free of the dreaded symptom. This is a common initial reaction. But when the therapist then asked me gently ‘Is there any part of you that is not completely comfortable with this…’ I immediately made contact with a deep sense of fear and panic. As I explored what this was, I came to see how the symptom I was so keen to get rid of, was in fact protecting me from a far scarier (if imagined) fear, that was linked in to fear about survival.

As I came into contact with this new emotional learning, I could really feel it through my body; the feeling that I already ‘knew’ this, but had not previously had words for it. I could also see clearly how this underlying fear was making the symptom that I had been so keen to get rid of, necessary. The therapist made no attempt to counteract this link I had made, even though I could start to see how it was quite a global ‘rule’ that was governing my reaction.

My experience of this process felt decidedly different from my own therapy where I know that I have regularly come into contact with unconscious material. My instinct was that it was linked to the expectation of coherence that the therapist had, and how this somehow communicated an additional layer of empathy. Ecker et al. (2012) refer to this briefly as ‘coherence empathy’ but I have not found any further research or explanation of what this is. My idea for this research was to explore clients’ experience of having their symptom explored from a position of ‘symptom coherence’.

Method

Design

In designing this study, a qualitative approach was chosen as this is more suited to a research question concerned with understanding an experience rather than an outcome (Smith, 1996). The question for this paper was about the experience of a client when a counsellor is using a particular tool in a therapeutic setting.

The therapeutic setting was a 1:1 skills practice session, a format familiar to all participants. The researcher had dual roles and was also the counsellor in the ‘skills session’. For this reason a questionnaire was chosen to capture the participants experience. This was selected so that there was a clear distinction between the session and experience of the session. A semi structured questionnaire was used and the data was analysed using thematic analysis. McLeod (2011) cites various important investigations in counselling and psychotherapy where thematic analysis has been used and although there are limitations to this form of analysis, it was selected as the best fit methodology for this research.

An inductive approach was used to determine the themes (Braun and Clarke, 2006); the themes were identified from the material rather than from the research question. However I am aware that I have my own interest in the subject, so I wish to acknowledge that as Braun and Clarke (2006) suggest, the data is not coded in an epistemological vacuum.

The data was analysed at a semantic level (Braun and Clarke, 2006) because the questions were designed to access the participants’ experience of the process.

Method of data collection and analysis

A questionnaire was designed and tested in a pilot study to ascertain if it gave enough breadth to collect a variety of experience.

Table 1. Post session questionnaire

1. How do you feel about the session?

2. How was the experience of looking for the coherence/meaning behind the issue that you brought?

3. What was your experience of the counsellor whilst they were using this technique in the session?

5 4. Can you tell me about any differences or similarities you noticed to other therapeutic techniques you have experienced before?

5. Have you used this sort of approach in your own therapy or as a counsellor?

6. Is there anything further that you would like to add?

A follow up questionnaire was designed to send to participants who reached a point in the session where it felt appropriate to write an index card with their new learnings.

Table 2. Follow up questionnaire

1. Reflecting back on the session, how did you feel it went?

2. Can you remember what was written on your index card?

3. Have you read the card over the past 2 weeks? If so, how often approximately?

4. How true does the statement on the card feel for you today?

5. Can you describe any feelings in your body that you notice when you read the statement?

6. Could you give a score out of 10, for how much of an issue in your life you feel your presenting issue currently is? (With 10 being the most distressing)

7. Reflecting back to before the session, how much of an issue did you feel the issue was then? Please give a score out of 10 (as above), and anything you would like to add about the issue you chose to bring; why you chose to bring it? Perhaps the level of stuck-ness you had previously felt about the issue?

8. Do you notice right now, any difference in how you are thinking about the issue you brought?

9. Is there anything further that you would like to add?

6 Recruitment procedure

Participants were selected from within students studying on a professional counselling diploma program. Participants selected were all known to the researcher and considered to be robust enough to manage a session such as this, where the technique can involve going quite deeply. Time was spent with each participants explaining the need for them to consider carefully beforehand what issue they chose to bring. Before the session started, participants were asked for a brief outline of the presenting issue so that both participant and counsellor were comfortable that the issue was not too ‘weighty’ for the session.

The session

The session utilised coherence therapy techniques. Participants were asked to come prepared to talk about a specific issue or symptom where they would like to see a change. Time was taken to clearly define which aspect of the issue they wished to change. The technique involves firstly asking the participant to recall a specific time where they experienced the symptom they wish to explore. It is intentionally an experiential process, as the counsellor is guiding the client towards the felt experience with the intention of ‘dropping into the limbic system’, the subcortical area of the brain where implicit emotional memories and knowledge are stored (Toomey & Ecker, 2007). The counsellor then used the coherence technique of symptom deprivation (see Ecker et al. (2012) for an in depth description of this and other techniques) alongside other coherence techniques designed to access implicit schemas.

Each client was asked at the beginning of the session whether they wished to stick to a clear 30 minutes, or whether they would like to have the potential to extend up to 50 minutes if it felt like they were getting close to a pro-symptom position. All participants asked for flexibility. At the end of the sessions where a pro-symptom position was identified, the counsellor worked with the client to identify the exact language that fit for their new learning, and wrote this out on an index card for them to take away. The participant was invited to read the card several times a day. It was then agreed that they would be sent a follow up questionnaire by email in 2 weeks time.

At the end of the session, the participant was asked to fill out the post session questionnaire and the counsellor wrote their own process notes.

Participants were then debriefed and any questions about the process were answered. The counsellor took time to ensure that the participant felt ready to leave the room and to check what support they had in place. All participants stated that they would take the issue to their therapist if they needed to.

7 Reflexivity

As the researcher and counsellor in this study, I feel it is important to note my interest in the methodology of coherence therapy and expectation that the technique can facilitate deep work and potentially transformative change. Interestingly, each of the participants chose to bring one of their big issues, even though I had spent considerable time explaining the need to bring a ‘smaller’ issue. I have wondered whether there is something significant in the invitation to bring something that they would like to change, almost like the ‘offer’ was too great to not bring the thing they felt most stuck with.

It is noteworthy that in the pre-session discussion, I also did not dissuade any of the clients from bringing the issue they felt they wanted to bring. I wonder if something of my belief in the approach was being communicated. I also feel on reflection that the offer to extend the session communicated some of my expectation or hope that we would reach a pro-symptom position.

The follow up questionnaire is more focussed on the effectiveness of the tool and I wonder whether my sub-research question is: How effective is the first step of coherence therapy?

Method of analysis

The post session questionnaires and the follow up questionnaires were read and re- read until they became as familiar as possible and any initial ideas were noted. (Braun and Clarke, 2006). The responses were then coded using a piece of software called NVivo and a hierarchical structure of themes was produced. There was no attempt to fit participant accounts into any predetermined framework

These themes were then viewed in clusters using word trees and the themes were reviewed and analysed into sub themes. On going reflection and analysis was carried out to refine the specifics of each theme and to view the overall story of the analysis. A similar process of reading and re-reading and highlighting themes was then carried out on the counsellors process notes, although these were not included in the software analysis. Finally, particularly vivid extracts were selected and the analysis was related back to the research question and the literature.

Ethical considerations.

Ethical approval was gained from the University West of England Ethics Committee who had authorised final approval to the head of the counselling program. Participants were informed that the content of the session and the questionnaire responses were confidential, and that if any material was used, it would be anonymised. They were also informed that and that they had the right to withdraw from the study at any time without giving a reason.

8 Demographics.

All 4 participants were female and known to the researcher. They were each selected partly for their interest in working at depth and willingness to reflect in this way. They each knew my interest in coherence therapy and had shown an interest in the techniques even though they had limited experience of the process.

Results

Main themes

Four main themes emerged from the data; (1) specificity/honing in of the technique, (2) clarity (3) potential for change and (4) effectiveness of the technique.

(1) Specificity/honing in of the technique

All 4 participants referred to the experience of honing in or focusing in on a very specific aspect of the symptom that they wanted to change. It came up across the 8 questionnaires on 24 separate occasions. There was some resistance experienced initially as participants described finding it unusually directive. I also noted this initial frustration in my process notes.

“Being asked to focus so tightly into one situation was novel – and initially felt possibly a bit restrictive – however, actually………I felt like this intense honing in on one area had in fact uncovered a feeling in me which affects all areas of my life.” (Participant 2, see appendix 2.1)

Here, the client identified some initial frustration but then stated that she felt that it was the process of being so specific that allowed her to get in touch with a feeling that permeates her life in many ways.

(2) Clarity

The second theme that emerged across all 4 participants and came up 17 times, is related to clarity. Linked to this, 3 of the 4 participants described a feeling of relief that they finally understood why their issue had held such a tight grip on them previously.

“I was apprehensive as it is a problem I have struggled with for years but also keen to look at it in other ways. If anything, great to know that taking away my coping strategy (as I now know it is) "cold turkey" with nothing else in place will just remove one problem and replace it with another, it helps me to understand myself (and hopefully be kinder).” (Participant 4, see appendix 4.2)

(3) Potential for change

This also came up across all 4 participants responses. There was a sense of feeling more in control; through understanding how their implicit knowings influence them. In two cases, it seemed to present a seed of potential for change.

“I expect this will have long standing, if not permanent impact on the way I view future workloads and relaxation periods..” (Participant 3, see appendix 3.1)

Two participants described how the issue that they previously thought was isolated to one area, was actually impacting many areas of their life, and this led to a sense that change may be on the horizon.

“It has been really helpful in getting me to look at it (the issue) more in other areas too, so it was a real catalyst for moving forward with this issue.” (Participant 1, see appendix 1.2)

But also noteworthy, was the actual shift each participant reported in how distressing the issue was for them. The level of distress caused by the issue was scored by each participant out of 10. The mean score before the session was 9.25, and 2 weeks after the session, the mean score was 4.75.

“I arrived at a resolution which felt very powerful and gave me a clear mental picture of a change that I wanted to make that felt totally possible. I found the process engaging and exciting as I found a profound sense of clarity about a difficult situation which I have been struggling with for quite some time.” (Participant 2, see appendix 2.2 )

Asked to rate the current level of distress: “It changes from day to day, so this morning, writing this its about a 5, but later it could go to a 7… Before it felt like it was engulfing my life, so about a 10 when tuned into it, and a 5 if I was ignoring it. I brought it as I felt my level of stuckness was about 100 - I felt entirely helpless.” (Participant 4, see appendix 4.2)

(4) Powerful

This theme came up in 3 out of the 4 participants, the word ‘powerful’ was used 6 times.

10 “It was powerful in helping me to focus at first – the counsellor’s insistence on finding the essence of what I wanted to look at really helped with this – once I had identified the specific part that I wanted to change, she helped me to focus in on specific feelings and bodily sensations which brought me back to the moment really well. From there, considering those feelings and thinking about how I would have responded to them, I found the session quite transformative – and realised how I could move forward.” (Participant 2, see appendix 2.1)

There were two sessions that felt particularly significant.

Participant 2 chose to work on changing her response to her teenage son when he comes in late as this had been causing huge distress. We spent quite a bit of time focusing in to understand which aspect of it she wanted to change. This was initially quite difficult to reach. However, we stuck with the process and she identified that the key part for her was in the moment when she realised that she had to step into the role of being an authoritarian parent, where she felt a real reluctance to move into that position which triggered a huge stress reaction in her. As we explored this precise moment in detail and then imagined it again with the symptom (the stress caused by the reluctance) removed; the emotional learning that she made contact with led to the following statement:

“If I step into the authoritarian role, I claim all the responsibility and then if something goes wrong, it’s all my fault and I have failed my son and everything my family said about me leaving his father has come true and I am a complete failure.”

As she came into contact with this statement in her conscious thought, there was a significant moment where it felt as if something shifted. I noted in my process notes a tingly feeling all over as she realised that taking full responsibility hasn’t ever been what she wanted, and that for her relationship with her son it was far more appropriate for them to share the responsibility - this was much more in line with the way that she wants to parents. She realised that the pressure to step into this authoritarian role came from pressure from her partner and other outside influences but was completely at odds with her own instinct. She expressed that she wasn’t surprised that her son doesn’t find her credible when she steps into that role, and that it makes complete sense that he mocks her when she is standing there telling him off. She described how he has always been really independent and that she has previously given him much more responsibility than other people might agree with.

It was if by being able examine the driving emotional learning in her conscious mind, she had the clarity to see why she felt so stressed being pushed into that position; where she felt like she had to take on all the responsibility, and thus the blame. On top of that, it wasn’t even a parental position that she felt comfortable with in any way. By sharing the responsibility, she explained, this will “fit for my son and it fits with my parenting approach”.

11 She went on to state that this feeling of overwhelming responsibility is something that she knows influences many other areas of her life but she had never realised why it felt so uncomfortable.

The session with Participant 4 also felt significant because the issue that she brought turned out to be a vital coping strategy. Trying to hone in on the specific aspect of the symptom that she wanted to change, brought us up against a real resistance to imagine being without it. We then tried changing the focus to the resistance and how she experienced that. She got in touch with a physical feeling of pressure, of fear and anger pressing down on her. When asked what it would be like to be without that, she met with a feeling of paralysis, the fear that if she is asked to imagine being without the original symptom, she would be losing a coping strategy that feels completely tied up with her actual survival. When it was reflected back; the vital need for this coping strategy, it was if it unlocked a knowing that she had always had, but held out of awareness. She stated that she didn’t have any other coping strategies to replace it and so no wonder there has historically been a sense of absolute panic when she had been to see professionals intent on finding ways to ‘get rid’ of her symptom; her one and only coping strategy. It was as if there was then a cascade of realisations, as she mapped this new knowing on to past experiences that had not made sense, and frustrations that she had had at herself, for not being able to ‘solve’ this previously. She described a sense of relief to finally understand it and said that she felt comforted that it made so much sense to her.

Also, by coming into contact with the very real need to keep her symptom, she added that she needed to keep it “currently”, but that she could begin to see the possibility of developing new coping strategies. So although there was a sense of sadness as she realised how needed her symptom was currently, there was a sense of hope too.

Discussion

Analysis of findings

The themes that emerge potentially fit together to describe how the power of the technique may be linked to the specificity: how by honing in to a specific aspect in an experiential way, seems to allow the client to drop down into the limbic experience. By then giving language and conscious left hemisphere thought to these implicit right hemisphere constructs, gives clarity as clients are better able to make sense of themselves. The need to better integrate the two sides has been suggested as one of the goals of therapy (Siegel, 2012). It also seems to give clients a sense of having more control as they are no longer being driven by unknown forces. Without any attempt to change or counteract these discovered knowings, deeply accepting the ‘pro-symptom’ position can be a source of comfort.

Interestingly, my experience of being a client and working with a coherence therapist was that his expectation of coherence in whatever emerged from my

12 unconscious, felt deeply accepting and I experienced it as a slightly different form of empathy. My expectation in this study was that others would also experience the power of this ‘coherence empathy’ (Ecker et al. (2012)). However in my process notes, I experienced a sense of almost ‘chasing the coherence’, having such a deep curiosity about what was behind the presenting symptom that it gave me a sense of stepping away from the emotional content in some way. It was almost as if I was more objectively trying to understand the deeply subjective ‘limbic language’ (Joseph, 1982).

The participants in this study barely referred to empathy, the focus was much more on the effectiveness of the tool, with particular reference to the impact of honing in so tightly. This pinpoint focus feels like it has an essence of what Daniel Stern (2004) describes when therapy is being viewed ‘micro-analytically’. Although, he is taking the present moment as the focus, my suggestion is that by focusing so tightly into any one aspect of an experience, in a similar way “a world in a grain of sand” (Blake, 1803) is revealed.

Exploring a finely honed moment of experience, considering how inner working models (Bowlby, 1969) or emotional implicit knowings (Ecker, 2012) might be driving reactions, brings to mind a complicated Venn diagram; each circle represents an emotional construct held out of awareness and there may be a great many at play at any one time. To reveal how an individual’s unconscious is influencing conscious thoughts, behaviour and feelings, it would be necessary to reveal every construct that a person has ever developed. My supposition would be that there are hundreds if not thousands in operation directing responses across the span of an individuals experiences, and that in any present moment, there would be a significant overlapping of these circles. So the more specific the emotional reaction is that is explored in therapy, perhaps the purer or more distilled the experience is, so that there are fewer constructs at play and it is more possible to dip into the sea of unconsciousness and come into contact with just one circle at a time. As noted by participants, as one construct is revealed, it is likely that this construct will be influencing many other areas of experience, especially if it is a formative construct developed early in life that others may have been built upon.

My personal experience of the expectation of coherence, communicated to me that there would be complete acceptance of whatever surfaced from my unconscious constructs, because there was an understanding that these constructs are physiologically and psychologically necessary for the brain to develop a meaning making frame of reference and meet fundamental needs. I received from the experience the message that the contents of my unconscious were unconditionally or objectively acceptable.

Reflecting on this, I wondered whether this was largely an enactment of my own personal constructs; the deep need to feel acceptable, unconscious and all. However, through a conversation I had with a manager of a large counselling organisation, I have further reflected on this. He was enquiring about the nature of coherence therapy and I jokingly referred to it as a ‘hotline to the unconscious’. His

13 response was “That sounds terrifying!” I feel like this may somehow be at the heart of the issue. There is so much fear of the unconscious and what it will reveal. Freud’s model of the unconscious as ‘the primary guiding influence over every day life’ is as relevant today (Bargh & Morsella, 2008) however as Cortina & Liotti (2007) suggest there is currently a paradigm shift occurring; with a shift from ‘conceptualising the unconscious as serving primarily a defensive and regressive function, to seeing unconscious processes as serving much broader adaptive functions.’ Also highlighting the vital role of the unconscious, Wilson & Bar-Anan (2008) state that ‘without such an efficient, powerful and fast means of understanding and acting on the world, it would be difficult to survive.”

It’s almost as if the function of the unconscious needs to be normalised and the contents needs to de-pathologised. Perhaps then, clients will be more willing to do the discovery work of coherence therapy, to delve into the unknown and so open up the potential for deep transformative work through memory reconsolidation.

Limitations of the current study

The participant size is very small, and as a clinically based project, the study suffers from difficulties with replication and bias. Thematic analysis also has drawbacks, for example, there is no noting of contradiction and continuity within one account (Braun & Clarke, 2006). The researcher was also the counsellor and this may have impacted on participants giving completely candid responses. Also, all participants were counselling students, currently in therapy. Results suggesting the effectiveness of the technique must therefore be considered in the context that participants were very willing to engage in such deep work.

Suggestions for future studies

As with many modes of therapy, there is a lack of robust effectiveness research. A study comparing other short-term therapies, focussed on short and long term effectiveness would provide a good reflection on how permanent the changes are utilising memory consolidation.

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17 Appendix

Contents

1.1 Participant questionnaire…………………………………………………..……Participant 1 1.2 Follow up questionnaire……………………………………………....…………Participant 1 2.1 Participant questionnaire……………………………………………..…………Participant 2 2.2 Follow up questionnaire……………………………….……………...…………Participant 2 3.1 Participant questionnaire……………………………………………..…………Participant 3 3.2 Follow up questionnaire……………………………….……………...…………Participant 3 4.1 Participant questionnaire…………………………………………..……………Participant 4 4.2 Follow up questionnaire……………………………………………....…………Participant 4

18 Appendix 1.1

Questionnaire responses - Client one

How do you feel about the session?

I feel like I got some real insight into my issue and got to the core belief about why I’m struggling with it. It was deep and powerful and was held well. It took some time to get to the crux of the issue and that was more because I feel that it was such a deep and personal one that it was complex to unravel. I feel that you were really able to finely tune what was going on for me (honing down) and that was helpful but I like that kind of directive process.

How was the experience of looking for the coherence/meaning behind the issue that you brought?

A little frustrating in parts but again that was because it was a complex but when I actually got to the feeling it was liberating because I was able to see how if I didn’t have my issue there then that would be destabilising for me.

What was your experience of the counsellor whilst they were using this technique in the session?

It was really good to have her hone down the questions and focus me and keep me on track. She gave me really useful feedback and reflections during the process. There definitely feels like there’s an agenda though which my put some off! – I felt really supported and not judged and guided gently to an outcome.

Can you tell me about any differences or similarities you noticed to other therapeutic techniques you have experienced before?

Similarities – Empathy, UPR listening and really getting in to my shoes. Reframing questions.

Differences – More directive You have a piece of paper at the end Issue led (focused)

Have you used this sort of approach in your own therapy or as a counsellor?

No, but I would like to, but I feel it would really depend on the client and I would need some more background into how useful it could be. I would also need a ‘crib’ sheet on phrases that could be useful to use to hone down the issue or when writing

19 it up what kind of thing the sentence needs to say in order for it to be helpful to the client. Also feel that there’s a danger of the client feeling left with unfinished business.

Is there anything further that you would like to add?

Thank you. It has helped me to get clearer on this issue and I hope that there is a shift for me on the horizon. I already feel a bit calmer about it knowing where the meaning of why I do this comes from.

20 Appendix 1.2

Follow up Questionnaire - Client 1

1. Reflecting back on the session, how did you feel it went?

I felt it was very useful, and I felt that it started me on my process to consider this issue on a much deeper level. I felt I was held well and was able to go deep.

2. Can you remember what was written on your index card?

Honestly, no, I did look at it a few times but can’t remember the detail of what’s on there.

3. Have you read the card over the past 2 weeks? If so, how often approximately?

Probably about 4 times.

4. How true does the statement on the card feel for you today?

It feels that something has shifted slightly, I feel that I can see that It makes sense to me, and even though I wouldn’t change the statement completely, it feels that something has shifted.

5. Can you describe any feelings in your body that you notice when you read the statement?

I feel a bit sad and there is anxiety in my tummy.

6. Could you give a score out of 10, for how much of an issue in your life you feel your presenting issue currently is? (With 10 being the most distressing)

7. Reflecting back to before the session, how much of an issue did you feel the issue was then? Please give a score out of 10 (10 being the most distressing), and anything you would like to add about the issue you chose to bring; why you chose to bring it? Perhaps the level of stuck-ness you had previously felt about the issue?

I chose to bring this issue as that is my pattern to go for the most difficult thing! I have to say, that it has been really helpful in getting me to look at it more in other areas too, so it was a real catalyst for moving forward with this issue. thank you!

8. Do you notice right now, any difference in how you are thinking about the issue you brought?

Yes, I have been having dreams around this issues which have brought it to the front of my mind and so it doesn’t seem so odd that I would be thinking this.

9. Is there anything further that you would like to add?

I met with my therapist the day after the session and read the card to her, and had a really strong physical body reaction where I was feeling dizzy and then had a strong emotional release, (it was an incredibly powerful session) since then I’ve been having strong dreams and brought it as an issue for a workshop that I wanted to look at.

Thank you for all of your thoughts and input. It is very much appreciated. Thank you !

22 Appendix 2.1

Questionnaire responses - Client two

How do you feel about the session?

It was powerful in helping me to focus at first – Jodie’s insistence on finding the essence of what I wanted to look at really helped with this – once I had identified the specific part that I wanted to change, Jodie helped me to focus in on specific feelings and bodily sensations which brought me back to the moment really well. From there, considering those feelings and thinking about how I would have responded to them, I found the session quite transformative – and realised how I could move forward.

How was the experience of looking for the coherence/meaning behind the issue that you brought?

Considering the meaning behind the feelings was somewhat painful, but as I worked through it I started to feel excitement at discovering that I could find, and did find I think, a new way to be in the situation.

What was your experience of the counsellor whilst they were using this technique in the session?

Jodie reflected thoroughly and sensitively my words, and also the meanings of the words – her summings up were succinct and incisive. I really felt accompanied by Jodie and felt real empathy from her – seeing that my feelings were received an understood by her.

Can you tell me about any differences or similarities you noticed to other therapeutic techniques you have experienced before?

Being asked to focus so tightly into one situation was novel – and initially felt possibly a bit restrictive – however, actually, I found it extremely useful to do this and stay with it, and once I had realised how I wanted to change, and how that could be possible, I felt like this intense honing in on one area had in fact uncovered a feeling in me which affects all areas of my life. I enjoyed the frequent reflections – with less interpretation!

Have you used this sort of approach in your own therapy or as a counsellor?

No.

Is there anything further that you would like to add?

This was a transformative experience, exciting and hopeful too. Thank you Jodie.

23 Appendix 2.2 Follow up Questionnaire - client 2

1. Reflecting back on the session, how did you feel it went?

I had not planned what I was going to talk about in the session, and went into it with an open mind. Jodie spent time settling me into the session and making sure I felt comfortable and relaxed and as she did this, what I wanted to talk about came to me. When I started to talk about what I wanted to look at, because I hadn’t had a preconceived idea of what that was going to be but had been given the space for it to emerge, it felt really natural and I found I was quickly engaged with the topic. Jodie allowed me space and time, and skilfully guided me with gentle questions, picking up on the things that felt important as they came up, and encouraging me to go further with those feelings towards a clear understanding. This way, I got to the crux of what I wanted to explore, and experienced some powerful feelings about the situation, and had time to consider what they meant to me. I was able to reach some clear points about my situation which Jodie helped me put into words which she wrote on the card. She checked very carefully exactly what I wanted to have written on my card, and spent plenty of time making sure that the feelings I had uncovered were accurately described by the words on the card. I felt that I had been on a clear journey towards a very specific conclusion by exploring my feelings about the situation, and realising what they meant to me. I arrived at a resolution which felt very powerful and gave me a clear mental picture of a change that I wanted to make that felt totally possible. I found the process engaging and exciting as I found a profound sense of clarity about a difficult situation which I have been struggling with for quite some time.

2. Can you remember what was written on your index card?

Yes, I have a clear impression in my mind of what was said on the card.

3. Have you read the card over the past 2 weeks? If so, how often approximately?

Yes, I have looked at it approximately 3 times in the past 2 weeks.

4. How true does the statement on the card feel for you today?

It was profound and still feels real. I have incorporated it into my way of managing the situation I was seeking resolution on. I has been really helpful.

5. Can you describe any feelings in your body that you notice when you read the statement?

Calm in my body, and also some excitement in my breathing. Happy sensation.

6. Could you give a score out of 10, for how much of an issue in your life you feel your presenting issue currently is? (With 10 being the most distressing)

4/10

9/10. I had been struggling with this issue for about 8 years, in varying degrees, and the way I brought the issue was around a specific example of it flaring up for me. I feel that I pinpointed what the issue exactly was during this session, and gave it words, by really honing in on a time when the issue had surfaced for me. It was an enormous relief to gain clarity and to realise that I could adjust my thinking and behaviour, and feel so much better.

8. Do you notice right now, any difference in how you are thinking about the issue you brought?

I have a much clearer understanding of what it is that I have been struggling with in regard to this part of my life, and why it has been so difficult for me. I feel greatly relieved that I have been able to identify how I feel, and also to realise what I can do to change my thinking about it and make some simple yet profound changes to my attitude.

8. Is there anything further that you would like to add?

Thank you for your help Jodie.

Thank you for all of your thoughts and input. It is very much appreciated.

25 Appendix 3.1

Questionnaire responses - Client three

How do you feel about the session?

It was very powerful. I ended up going into areas much deeper and more profound than I’d anticipated. I’d seen shorter examples of this type of practice before so I suppose I knew it has the potential to do that, but to actually find myself delving into topics that are of fundamental importance to me and are about my whole life-vision and purpose, took me by surprise. At the same time it felt completely natural and appropriate. I expect this will have long standing, if not permanent impact on the way I view future workloads and relaxation periods.

How was the experience of looking for the coherence/meaning behind the issue that you brought?

I have been trying to recognise the messages within my body more and more over the past 12-18 months, Before that I was quite the dualist and regarded my body as little more than a moving container for my thoughts. Back then, the idea of perceiving my issue within a physical, bodily domain would have seemed faintly ridiculous to me. This time though, I found I could readily conjure the images and sensations – and each one helped elucidate further the exact nature of my conflict. I don’t know how it was from Jodie’s perspective, but from mine it felt very natural, very fluid and not at all contrived. It achieved it’s purpose extremely well.

What was your experience of the counsellor whilst they were using this technique in the session?

I have always admired Jodie’s counselling qualities (along with many other aspects of her character) so I had total confidence in her ability to hold whatever I was going to bring. Indeed this was the case, even when the session moved into territory beyond where I’d initially expected it to go. I recognised the use of reflection and summary, which certainly helped to clarify my thoughts. The overall technique was largely new to me and I felt able to go on the journey that Jodie was inviting me on and ride with it. There was one point when I was worried the ‘final analysis’ writing wasn't entirely what I wanted to say but Jodie picked up on this even before I expressed it. She is an excellent counsellor and this technique suits her style beautifully.

Can you tell me about any differences or similarities you noticed to other therapeutic techniques you have experienced before?

I recognised body-work/imagery and, as stated, interpersonal techniques such as paraphrasing. The idea of expressly saying “what do I need to know to fully understand this from your perspective” was new to me though I found that a very

26 useful device for sharpening my thoughts and conveying them in such a way that they really put across my thoughts, feelings and personal conflicts about the issue. Writing a summarising statement at the end felt like an excellent way to finish. It gave it a tangibility and permanence that I can take with me into my life outside the session.

Have you used this sort of approach in your own therapy or as a counsellor?

No, this is new to me. Other than the Gestalt and interpersonal skills elements I've described, this is not an approach I've seen or heard of outside Jodie's descriptions in class and in the presentation she and Nic gave. I feel as though I would like to learn more about it though as I have benefited enormously from it and see the potential value for clients.

Is there anything further that you would like to add?

I'd like to commend Jodie on not just the session itself but on the time and care she took to make sure I was fully prepared for it. This included a good 10 minute chat before the session had even begun. Whilst I am aware this is for a research project, I never felt anything other than genuine guidance and support as we went through the process. It was very emotional for me to explore these particular issues and from a personal perspective I feel that we did some important work here today. I feel privileged to be one of Jodie's participants and indebted to her for the good work she did.

27 Appendix 3.2

Follow up Questionnaire - Client 3

1. Reflecting back on the session, how did you feel it went?

It went very well. Initially I’d planned to do something about my procrastination, but by the time the session came around I’d already overcome that. What I didn’t like though was my critical voice (which had dogged me throughout my stagnant period) and so I focussed on that instead. The session took me much further than I was expecting to go, although I was a willing traveller. The experience was intense and emotional and completely worthwhile.

2. Can you remember what was written on your index card?

Yes. Not the exact wording, but certainly the full gist of it. It was about my work (the plans I have for my future) being an absolute driving force for me – vocational really. It also addressed the fact that I would feel as though I’d wasted my life if I didn’t apply myself to make these things happen. In this way, my critical voice was could be regarded as quite useful and would help me achieve these goals until a better alternative came along.

3. Have you read the card over the past 2 weeks? If so, how often approximately?

I’ve read it quite a number of times – more frequently in the days following the session but not so much recently. I probably read it every day for the first four days, then maybe every few days and now only if I happen to come across it.

4. How true does the statement on the card feel for you today?

It feels true-ish. By the end of the session I had to reluctantly accept that my critical voice was quite good for me at times; quite motivating. But as I kept on reading it, I felt as though I was condemning myself to having this critical voice for a long stretch – and I really don’t like that idea. This is why it was important for me to have the ‘until something better comes along’ caveat. The affirmative nature of the card reminded me of the success I’ve had with affirmations before and so instead of focussing on my critical voice, I’ve instead being saying things like “I am diligent”, “I am focussed” or “I love my work” every day instead. It’s unlikely I’d be doing this were it not for the session though.

5. Can you describe any feelings in your body that you notice when you read the statement?

The bit about my critical voice always caused a sort of ‘clang’ in my head – like some gong or cymbal being struck in a slightly jarring key. The sensations are all upper body: head, shoulders, chest. The part about feeling as though my life would be

28 wasted if I didn’t follow through on my plans again leaves me with mixed feelings. On the one hand I feel as if it drives steel through my body, galvanising this determination I feel. At the same time I think, ‘No! I should be kinder to myself than that’. More “If I do this I will feel euphoric” than, “If I don’t do this I’ll feel wretched”. This is not Jodie’s fault – this is just where my head was at the time.

6. Could you give a score out of 10, for how much of an issue in your life you feel your presenting issue currently is? (With 10 being the most distressing)

Much less. Much, much less – I am forcing myself to repeat these positive affirmations daily and it really looks as though it’s paying off. Right now I’d say ‘4’, but I’m aware that’s also because I have been steadfast about doing at least an hour’s coursework every day. If I let that go, I’m not so sure how forgiving I’d be of myself.

It was probably around an 8 or 9 - and had been up to a 10 a couple of weeks prior to the session. I had felt very ‘stuck’ during that period but was starting to make a little headway. The session though, fully focussed my mind and body on to what I wanted (and didn’t want) in a way that felt very dramatic and intense. It felt a little exposing to discuss some of the things I discussed – there’s a lot of ego involved there and that’s a touchy subject for me. Jodie was remarkable though, and through a combination of this technique and her overall character, I felt able to immerse myself in the session and talk about the whole thing with depth and honesty.

8. Do you notice right now, any difference in how you are thinking about the issue you brought?

No, I’ve been thinking about it quite a lot, which is why I slightly altered my approach to what was written on the card. It’s still with me every day in that respect.

9. Is there anything further that you would like to add?

Just that it was a terrific experience – enduringly helpful - and I’m grateful to have been offered the chance to take part. I’ve spoken to a couple of the other participants and it seems I’m not alone in feeling this way.

Thank you for all of your thoughts and input. It is very much appreciated.

29 Appendix 4.1

Questionnaire responses - Client four

How do you feel about the session?

Exhausted, but relieved. Like running a really long and hard race – glad at the end I saw it to the end and made the effort as it was worth it. Realising how sad my childhood was is still really hard, but unpicking what that did to me in things I still do now is entirely worth it. I learnt more about myself today and it felt very helpful. I would only do this with Jodie or someone else I would feel similarly safe with like my therapist.

How was the experience of looking for the coherence/meaning behind the issue that you brought?

Excruciating at times as I am very emotionally resistant to doing this, but practically I really wanted to do this and glad I did. I also felt frustration at trying to find the feeling- so the end part of realising I couldn't because a) it was too scary as I was potentially taking away a coping strategy and b) the whole coherence was based on making myself feel nothing – so I couldn't access them as that was the point!

What was your experience of the counsellor whilst they were using this technique in the session?

Really warm and understanding. I've known Jodie a while and trust her as a person and in a therapeutic setting so it felt very safe. I also liked how patient she was and the investment and genuine interest in helping me find out my coherence around my compulsion to eat.

Can you tell me about any differences or similarities you noticed to other therapeutic techniques you have experienced before?

I've done a lot of this with my therapist and as soon as I get to the subject of my mum I cry a lot and this happened too. I have also experienced this level of personal resistance in therapy when talking about this subject. In doctors surgeries and other medical interventions I've been near hysterical as the environment was unsafe and unsupportive as they just repeatedly suggested perhaps I didn't eat so much.

Have you used this sort of approach in your own therapy or as a counsellor?

30 I have wanted to but have not yet found an opportunity. Having experienced it first hand, I would like to try it as it is very helpful – especially when needing an understanding around a specific concern or behaviour etc.. Is there anything further that you would like to add?

This was great. I was apprehensive as it is a problem I have struggled with for years but also keen to look at it in other ways. If anything, great to know that taking away my coping strategy (as I now know it is) "cold turkey" with nothing else in place will just remove one problem and replace it with another helps me to understand myself (and hopefully be kinder) And look at safer, alternative ways to think about it in a moderate way.

31 Appendix 4.2

Follow up Questionnaire - Client 4

1. Reflecting back on the session, how did you feel it went?

I think it went well, I appreciated how much longer you took to stay with me to find out the real crux of what was going on - aware there’s so many more layers of resistance there to get through which helps me understand why its been so hard for me to address (so that takes the pressure off!) Although the board room was an odd venue (and I know unplanned!) I think being in an unfamiliar room helped me as it didn’t feel like a course activity.

2. Can you remember what was written on your index card?

Yes. I remember it as it took so long to get there, and actually I think I knew this but couldn’t make myself acknowledge it.

3. Have you read the card over the past 2 weeks? If so, how often approximately?

Physically taking it out and reading it, about 2/3 times, but I’ve actually read it perhaps 10/15 times each day in my head as I feel the words are stuck in there, it felt like its been burning a hole in my bag.

4. How true does the statement on the card feel for you today?

Very true, but the meaning has shifted in the last 2/3 days. So, to start it presented itself to me as a ‘get out of jail free’ card - Hey, I can’t cope without eating badly as I have no alternative coping strategy so I should go nuts and eat everything. This also made me feel guilty as well as defiantly justified , like a stroppy teen. This shifted in the last 2/3 says and now I think that I can accept what it is, it doesn’t mean I HAVE to binge or eat crap to make myself feel better (because in reality, it really doesn’t, it even has a converse effect with the feeling of badness afterwards) but if I do, that’s ok. Having dealing with clients who have recently been lapsing and feeling similar to myself, its really putting it all into perspective seeing it from the outside.

5. Can you describe any feelings in your body that you notice when you read the statement?

Not that I can think of, but essentially I really get into my head and ignore my body process when thinking about this. The only thing I think I can recognise is a weariness in my head. It’s like the card has always existed, but in my head only, I’m tired of it living there. In fact, physically I feel numb, as that’s what my body does.

6. Could you give a score out of 10, for how much of an issue in your life you feel your presenting issue currently is? (With 10 being the most distressing)

32 Not sure if this is going to help, but it changes from day to day, so this morning, writing this its about a 5, but later it could go to a 7. also I keep ignoring the distress so I’m not sure.

Before it felt like it was engulfing my life, so about a 10 when tuned into it, and a 5 if I was ignoring it. I bring it as I felt my level of stuckness was about 100 - I felt entirely helpless and as if I was kidding myself that I could actually change any of this, so I just wanted to test it. There’s obviously some level of hope or I wouldn’t keep bringing it to therapy and things like this. Also I thought it may go with what I’m doing in therapy which it is.

8. Do you notice right now, any difference in how you are thinking about the issue you brought?

I’m a little more accepting. before I slipped from victim (see, I have to be like this as I’m too helpless to change) to persecutor (I’m an idiot who is unable to change) to rescuer (its ok, maybe just eat now to feel better and change later on when you’re ready) daily and now I’m trying to sit with it more and just accept that’s how I am currently and that hating it, ignoring it or feeling its the only definition of me is not actually going to change anything. It’s still incredibly difficult but a bit less so.

8. Is there anything further that you would like to add? it keeps changing, I feel very sad reading this now. I’m doing work with my therapist at the moment with stuff that’s all linked into this as essentially my base subconscious emotional state is that I still feel I am not a good person who has the potential to ruin everything and I’ve shifted from just trying to rubbish it or just say I won’t feel like that as current evidence says otherwise and being angry or annoyed at myself to feeling more sympathy, so I’m more sad about this now, which although it sounds crazy is quite a positive shift - if I’m feeling able to show myself sadness then maybe I’ll allow myself to change rather than try and bully myself into it.

Thank you for all of your thoughts and input. It is very much appreciated.