Certificate for Approving the Dissertation

Home , Yeah Ya Know (Takers)

MIAMI UNIVERSITY The Graduate School

We hereby approve the Dissertation

Meredith Glick Brinegar

Candidate for the Degree:

Doctor of Philosophy

______Chair William B. Stiles, Ph.D.

______Reader Roger M. Knudson, Ph.D.

______Reader Larry M. Leitner, Ph.D.

______Graduate School Representative Paul V. Anderson, Ph.D. ABSTRACT

WHAT CLIENTS CAN TELL US ABOUT THE ASSIMILATION OF THEIR PROBLEMATIC EXPERIENCES: A MULTIPLE CASE STUDY

by Meredith Glick Brinegar

The assimilation model describes the process of change in psychotherapy. The model suggests that in successful therapy, clients’ problematic experiences progress through a series of developmental stages, referred to as the Assimilation of Problematic Experiences Sequence (APES). The model has been empirically supported and modified by a series of case studies, largely completed by observer-researchers. Relatively less attention has been paid to the client’s perspective on the process of assimilation. This study sought to incorporate clients’ phenomenological accounts about the assimilation of their problematic experiences and therapy, in general, into the model. The goals were to both honor clients’ experiences and inform a specific theory of change. Six client accounts were obtained using an interview strategy called Interpersonal Process Recall. Moments from recent therapy sessions that were related to assimilation constructs or which seemed salient to the client were identified and reflected on. Transcripts of these interviews were qualitatively analyzed by three co-investigators with the goal of creating a dialogue between clients and the assimilation model. They linked specific observations from the interviews with theoretical statements to elaborate the assimilation model, making it a richer account of psychotherapy. Primary areas of contact between the observations and the model were: client awareness of intrapersonal dialogue; secondary or derivative problems; client accounts of various APES stages, including somatic symptoms and behavioral changes; the role of the therapeutic relationship; the function of abrupt topic changes; and clients’ perception of progress. Modifications to general assimilation theory, the specific APES descriptions, and problems and questions raised by this study are discussed. WHAT CLIENTS CAN TELL US ABOUT THE ASSIMILATION OF THEIR PROBLEMATIC EXPERIENCES: A MULTIPLE CASE STUDY

A DISSERTATION

Submitted to the Faculty of

Miami University in partial

fulfillment of the requirements

for the degree of

Doctor of Philosophy

Department of Psychology

Meredith Glick Brinegar

Miami University

Oxford, Ohio

2006

Dissertation Chair: William B. Stiles, Ph.D.

Meredith Glick Brinegar

2006

List of Tables ...... vi List of Figures...... vii Acknowledgments...... viii Introduction...... 1 The Assimilation Model ...... 1 Assimilation is Largely a Researcher’s Account of Change ...... 7 Lessons from Rashomon: Point of View Matters...... 7 Creating a Dialectical Tension Among Multiple Frames of Reference...... 8 The Client’s Frame of Reference...... 11 Interpersonal Process Recall...... 17 Client Perspectives on Assimilation ...... 18 Method ...... 18 Participants...... 18 Investigators...... 19 Measures ...... 19 Procedure ...... 22 Organization of Results...... 26 Results: The Case of Sabrina ...... 26 Background Information...... 26 PQ ...... 27 AQ...... 27 Process of IPR...... 28 Analysis of IPR...... 28 Discussion: The Case of Sabrina ...... 46 Problems and Derivative Problems...... 46 A “Back and Forth” ...... 47 “Don’t Look a Gift Horse in the Mouth”...... 47 “A Little Therapist in My Head” ...... 48 Results: The Case of Kyle...... 48 Background Information...... 48 PQ ...... 49 AQ...... 49 Process of IPR...... 50 Analysis of IPR...... 51 Discussion: The Case of Kyle...... 66 Avoiding Contact with the Problem ...... 66 “Just Like Going Back in Time”...... 68 Socialization of Client Role...... 68 The Therapeutic Alliance...... 68 Results: The Case of Brian ...... 70 Background Information...... 70 PQ ...... 70 AQ...... 70 Process of IPR...... 71 Analysis of IPR...... 72

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Discussion: The Case of Brian...... 104 “Aren’t My Feelings Obvious?”: Implications for APES 1 and 2...... 104 Awareness of Defense Mechanisms ...... 105 Maintaining a Sense of Control ...... 105 Prelude to Insight ...... 106 Impatience for Change...... 107 Vocal Intrusions...... 107 “Feast or Famine…Where’s the Happy Medium?”...... 108 The Therapeutic Alliance...... 109 Results: The Case of Adam...... 110 Background Information...... 110 PQ ...... 110 AQ...... 111 Process of IPR...... 112 Analysis of IPR...... 113 Discussion: The Case of Adam...... 135 Who Defines the Problem...... 135 Fast Forwarding through Dysfluencies: Avoiding Negative Affect...... 136 Difficulty Reflecting on Highly Unassimilated Problems...... 137 Denial of Underlying Problem: A Marker of APES 0-1...... 137 Abruptly Changing the Topic: Marker of APES 1 ...... 138 Unwanted Thoughts: Marker of APES 1...... 138 Therapist’s Use of the Zone of Proximal Development...... 139 Voices and Intrapersonal Dialogue...... 140 Ruptures in the Therapeutic Alliance ...... 140 The Therapeutic Alliance and Termination Concerns...... 141 Helpful Aspects of Therapy...... 141 Results: The Case of Allison...... 141 Background Information...... 141 PQ ...... 142 AQ...... 142 Process of IPR...... 143 Analysis of IPR...... 143 Discussion: The Case of Allison...... 159 Client and Therapist Articulating Problem in Terms of Voices ...... 159 Voices As Active Traces of Experience ...... 160 Physical Characteristics of Voices...... 160 Abrupt Topic Shift ...... 160 Exploring Personal Historical Roots of Problem: A Marker of APES 4...... 161 Therapist’s Role in Promoting Assimilation...... 161 Fear of Being Judged for OCD: A Derivative Problem?...... 162 Results: The Case of Julie...... 163 Background Information...... 163 PQ ...... 163 AQ...... 163 Process of IPR...... 164

Analysis of IPR...... 165 Discussion: The Case of Julie...... 178 Assimilating Multiple Strands of a Problem...... 178 Bodily Symptoms: Not Limited to APES 0...... 179 Utility of Stating the Problem...... 179 Micro Moments of Insight ...... 180 Use of Silence and Meditation to Reach Insight...... 180 Feminist Perspective on Voices and Assimilation...... 181 Abrupt Topic Shift ...... 181 Collaborative Nature of Relationship ...... 182 General Discussion ...... 182 Voices and Intrapersonal Dialogue...... 182 APES...... 184 Secondary or Derivative Problems ...... 187 Therapeutic Alliance...... 189 Abrupt Topic Shifts...... 191 Perception of Progress ...... 192 Meditative Practices and Assimilation...... 194 Reflection on Participant and Researcher Characteristics ...... 194 Benefits of Research Participation...... 195 Problems and Issues Raised...... 197 Coda ...... 200 References...... 201 Appendices...... 215

List of Tables

Table 1 Assimilation of Problematic Experiences Sequence (APES)………..…………211 Table 2 Client Perspectives on the Assimilation of Problematic Experiences Sequence (APES)………………………………………………………………..………...212

List of Figures

Figure 1 Assimilation Curves……………………………………………………………214

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Acknowledgments I would first like to thank my participants, without whom this study would not have been possible. They generously provided their time and rich details about their intimate experiences in psychotherapy. I hope that this project honors their perspective. I am also indebted to the therapists involved in this project, for introducing the study to their clients and for being willing to have their work examined. I would also like to thank my co-investigators, Mike Gray and Rachel Hamilton, for their hard work and open minds. Their involvement reminded me that research can be fun! I also appreciated receiving input from the Assimilation Research Group, for their ideas and feedback during the planning stages of this dissertation. Thanks to D’Arcy Reynolds for serving as my mock participant and to Hani Henry for his help in transcribing the research interviews. I thank Julie Rubin and Kip Alishio for their support in completing this project. I am grateful to my committee members, Roger Knudson, Larry Leitner, and Paul Anderson for their input in shaping and evaluating this project. Thank you, Roger, for sharing your passion for qualitative research and for encouraging me to take your qualitative methods class during my first year of graduate school. You were right—it didn’t fulfill a course requirement, but it did impact my life. I owe a great deal of gratitude toward Bill Stiles, my advisor of seven years and chair of this dissertation. Your dedication to psychotherapy research has been an inspiration. You showed me that clinical research and practice don’t have to proceed on separate tracks. Thank you for believing in me and trusting me to create a project that was both theoretically interesting and personally meaningful. I have long valued your assertion that the assimilation model is our model. Finally, I would like to thank various loved ones for their emotional support in completing this project. To Amberly Panepinto, Jill Thomas, Lisa Salvi, Melissa Erickson, and Carol Humphreys—thank you for always listening and providing encouragement. Thanks, Carol and Steve, for hosting me before my defense! To my parents, Bonnie and David Glick, thank you for inspiring a love of learning from a very young age. And to my husband, Cornelius Brinegar, you have been my rock. Thanks for validating my questions and fears, for reading portions of this document, and for your enduring love and support.

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What Clients Can Tell Us About the Assimilation of Their Problematic Experiences: A Multiple Case Study

This study sought to enrich the assimilation model by incorporating clients’ perspectives of on-going therapy. The assimilation model (Stiles et al., 1990; Stiles, 1999a; 2002) is a theoretical account of how problematic experiences change over the course of psychotherapy. This model is empirically driven and is ever changing as it incorporates new observations. Most previous observations have been made from researchers’ perspectives on transcripts of completed therapy cases. I hoped that explicit consideration of clients’ perspectives would both honor their experiences and enrich the model's account of how change occurs in psychotherapy. To accomplish this, I focused on clients’ own words and stories and allowed clients to be active participants in the research. My goal was to continue refining the assimilation model so that it captures complex human exchanges in a more complete and vivid manner. Client accounts were obtained using an interview strategy called Interpersonal Process Recall (IPR). This method, a form of tape-assisted recall, allowed clients to identify and reflect on segments of recent therapy sessions that seemed relevant to core assimilation constructs. The client interviews were qualitatively analyzed to support, disconfirm, elaborate, and/or modify theoretical elements such as the proposed sequence of assimilation stages, the description of specific stages, and the experience of internal multiplicity. I begin with a description of the assimilation model, introducing major theoretical concepts and an overview of past research. I then explain why it is important to consider multiple perspectives, namely the client’s, when doing psychotherapy research. Then I review research on the client’s perspective that guided the goals and qualitative methodology for this study. The Assimilation Model The assimilation model (Stiles et al., 1990; Stiles, 1999a, 2002) describes how problematic experiences become assimilated. Over the course of successful therapy, problematic experiences appear to progress through a series of developmental stages, characterized by the Assimilation of Problematic Experiences Sequence (APES; Stiles, et al., 1991; Stiles, 2002). The assimilation model views the self as composed of multiple parts or voices (Honos-Webb & Stiles, 1998). Voices can be thought of as parts of the self that reflect traces of different

experiences. They are considered agentic in the sense that they strive for expression; when they are addressed or triggered, they can respond in words, behavior, and / or emotion. Other comparable terms for voices include subpersonalities (Rowan, 1990; Ross, 1999), “I-positions” (Hermans, Kemepen, & vanLoon, 1992), parts (Schwartz, 1999), and selves (Shotter, 1999), to name just a few. Assimilation theory suggests that voices get linked and form a community, wherein internal dialogue can occur. Voices are considered problematic when they are highly discrepant from the community or are traces of painful experiences such as trauma. They may remain separate and unassimilated from the community because awareness of and dialogue with such voices may cause great psychological pain. The degree to which voices are linked or assimilated within the community is described by the Assimilation of Problematic Experiences Sequence (APES). The APES (see Table 1) is an account of eight developmental stages through which problems seem to progress, ranging from being completely warded off, to being clearly stated, to being an integrated resource. Problematic voices reach higher levels of assimilation by first expressing their perspective and then developing shared understandings with other voices. These understandings are referred to as meaning bridges and are the links that hold a community of voices together. Voices undergo some changes in order to assimilate (cf. Piaget’s notion of accommodation) but still retain individual flavors and differences. The view of psychological health, according to the assimilation model, is an interconnected system of voices, wherein different experiences can be easily drawn upon to successfully navigate diverse situations. This model has been studied in a variety of psychotherapies including psychodynamic (Stiles, Meshot, Anderson, & Sloan, 1992; Varvin & Stiles, 1999), process-experiential psychotherapy (Honos-Webb, Stiles, Greenberg, & Goldman, 1998; Honos-Webb, Surko, Stiles, & Greenberg, 1999), client-centered therapy (Glick, 2002; Osatuke, Glick, et al., 2005), and cognitive-behavioral therapy (Osatuke, Glick, et al., 2005; Osatuke, Stiles, Shapiro, & Barkham, 2000). Although the techniques in each therapy modality are different, the assimilation model focuses on problematic or distressing experiences that are discussed in each therapy and traces their evolution over time. Successful therapy has been linked with higher levels of assimilation or integration of these problems. All assimilation constructs were potentially open to revision in this study. The majority of observations fell into five existing domains within assimilation theory: markers; rapid

crossfire in intrapersonal dialogue; emotion as contact between voices; physical characteristics of voices; and the therapeutic relationship, particularly the therapist’s use of the zone of proximal development. A sixth construct or domain was identified that had not been previously studied: secondary or derivative problems. Each of these domains will be reviewed, in turn, to provide a context for the study results. Markers of Assimilation In psychotherapy research, markers are considered easily recognizable signs of psychological events or client processes that “recur sufficiently often within and across clients to permit a systematic focus on their commonality” (Rice & Greenberg, 1984, p.19). Assimilation research has identified a number of markers for various APES stages that are potentially useful for both researchers and practitioners (Honos-Webb, Lani, & Stiles, 1999; Honos-Webb, Stiles, & Greenberg, 2003; Honos-Webb, Surko, & Stiles, 1998). Examples include the fear of losing control (APES 1); puzzlement (APES 2); understanding of personal historical roots (APES 4); and others notice change (APES 6). Intrapersonal Dialogue Intrapersonal dialogue is a term used to describe the dialogue that occurs between voices and which is spoken aloud, in therapy or other interpersonal settings. While some form of intrapersonal dialogue occurs at various APES stages, it becomes most pronounced between stages 3-4, when conflicting voices are equally in awareness. At a midway point (APES 3.2) voices engage in rapid crossfire, speaking in quick argumentative turns (Brinegar, Salvi, Stiles, & Greenberg, 2006). This substage is easily recognizable in client speech as a segment that is filled with back-and-forth, often contradictory statements. Clients seem to continually interrupt themselves mid-sentence. Rapid crossfire is one substage on the journey toward developing intrapersonal meaning bridges. Emotion as Contact between Voices Stiles, Osatuke, Glick, & Mackay (2004) suggested that emotional expression signals some kind of contact between voices, whether positive or negative. They outlined how emotional expression changes as clients progress through the APES and which is depicted by an S-shaped feelings curve (see Figure 1). The curve traces changes in the feeling level, the amount of positive or negative emotion a client is experiencing, at a given assimilation stage. The feeling level might be considered a function of the amount of attention paid to a problem

(salience) and the degree to which the problem is experienced as negative or positive (valence). Negative affect is most intense at APES 2 when encounters with problematic, unassimilated voices are negative in valence and sustained in awareness; this is often the time when clients seek therapy for their distress. The valence shifts from negative to positive once problems reach APES 4 and beyond, when clients take pride in understanding their problems and successfully implement solutions. Physical Characteristics of Voices: They Sound Different Previous research has shown that voices—in addition to having distinct content—actually sound different. Osatuke and colleagues (Osatuke, Gray, Glick, Stiles, Barkham, 2004; Osatuke, Humphreys, et al., 2005) have shown that internal voices can vary in terms of volume, rate, pitch, and intensity. In other words, voices can be identified based on what they say (content) and how they say it. Problematic voices that are at low levels of assimilation may speak in a more eruptive, volatile fashion. The Therapeutic Relationship and the Zone of Proximal Development The Zone of Proximal Development (ZPD) was a term coined by Vygotsky (1978) to explain the difference between what an individual can do with the help and collaboration of another individual and what he or she can do alone. Vygotsky noted that working in the ZPD allows “socially available skills and knowledge” (Vygotsky, 1978, p. 130) to become internalized. Vygotsky used the ZPD to describe children’s cognitive development, but the concept can be applied to clients’ progress in therapy. From an assimilation perspective, ZPD could be viewed as, “the segment of the APES continuum within which the client can proceed from one level to the next with the therapist's assistance" (Leiman & Stiles, 2001, p. 315). Clients who first work alongside their therapists to accept and develop an understanding of their problems may eventually be able to do the same for themselves. That is, they may be able to establish connections between the problematic voice and the dominant community after a connection has been made between the client and the therapist. Cooper (2004; 2003), also drawing on Vygotsky, made similar assertions about how the therapeutic relationship may promote acceptance between internal voices or what he refers to as I-positions. He suggested that if the therapist can model an I-Thou relationship to all of the client’s parts—including disowned parts that are rarely expressed—the client can start to do this for him or herself. “Through relating to these voices in a confirming, empathic way, there is the

possibility that the client may then, also, begin to acknowledge and accept these different voices” (Cooper, 2004, p. 70). And while he suggested that it is important to connect with and accept “subjugated I-positions” (i.e., unassimilated voices), it is also important to interact with the client as a whole, nonfragmented person (Cooper, 2003). Derivative Problems Although clients and therapists may focus on a primary problem in therapy, clients—and people, generally—often experience many problems at the same time. Sometimes, this means that clients are struggling with separate problematic experiences (e.g., the loss of a loved one and financial concerns). While these problems may remain distinct and can be worked on (assimilated) separately, they may also converge over the course of therapy (Knobloch, Endres, Stiles, & Silberschatz, 2001). Another possibility is that one problematic experience may be secondary to or a derivative of an earlier problem. Clients may find solutions to an existing problem without necessarily assimilating it. For example, in response to being rejected, one could avoid all intimate relationships to protect oneself from getting hurt again. That avoidance can, in turn, become problematic because it limits one’s ability to experience the joys of meaningful relationships and may foster a sense of loneliness. In this case, we could consider that there are two problematic experiences that could be addressed: the experience of being hurt and rejected (in the past) and the experience of being lonely (in the present). This observation is consistent with constructivist understandings of problems as creative solutions to past problems that are failing to work in the present (Leitner & Dill-Standiford, 1993; Leitner, Faidly, & Celentana, 2000; Mahoney, 2000). Clients and therapists may have differing views about which of these problems is primary, or more salient, or easier to discuss in therapy. The concept of derivative problems is discussed in most of the cases in this study. Participants often preferred to focus on derivative problems and reported great satisfaction in their progress. In summary, the idea that clients may be assimilating any number of separate or interrelated problems reminds us of the complexity of psychological distress and the need to pay close attention to what problem is being worked on in therapy or tracked by researchers. Personal Reflections on the Assimilation Model

I have found the assimilation model useful as both a clinician and a researcher. In the therapy room, it has helped me conceptualize cases and informed my intervention strategies. For example, the notion that people are composed of multiple parts or voices has helped explain the discrepancies and inconsistencies in clients’ thoughts, feelings, and behaviors. The assimilation model does not view multiplicity as unhealthy. Rather, multiple voices are viewed as resources so long as they are able to communicate with one another. The notion of problematic voices and the ways in which they are kept separate from other voices has helped me conceptualize clients’ problems. It has also informed strategies for facilitating dialogues between conflicting voices. As a researcher, the assimilation model has provided a theoretical account of the equivalence paradox by suggesting a common path for client change. Commonalities across clients are considered (as evidenced by the APES stages), but the model is also able to incorporate the individuality of the clients it seeks to explain. Although the theory suggests that clients’ problematic experiences move along similar paths over the course of therapy, the nature of these problems and specific ways they become integrated are unique. The particular path is influenced by both the client and the type of therapy (Barkham, Stiles, Hardy, & Field, 1996; Osatuke, Glick, et al., 2005). Another facet of the assimilation model that is appealing to me both as a clinician and as a researcher is that it places psychological health and pathology on a continuum. Psychological disorders are not viewed as discrete entities that individuals have or do not have. Rather, the assimilation model is an explanation of how any and all experiences get integrated, with or without therapy. Some individuals have more difficult experiences or have more difficulty integrating some of their experiences than others do; it is the degree of difficulty that differs. Many individuals are able to assimilate problematic experiences on their own, perhaps by journaling, or talking to friends, or setting up behavioral contingencies. I resonate with Art Bohart's view that clients—and presumably all individuals—are active agents of their own change (Bohart, 2000; Bohart & Tallman, 1999). He suggested that individuals often have a way of finding solutions that seem to work for them. Sometimes that solution may take the form of seeking psychotherapy for significant distress or difficulty in assimilating a particular problem. The therapist’s job, from this perspective, can be viewed as facilitating a normal process that has gotten stuck or slowed in some way.

Assimilation is Largely a Researcher’s Account of Change The assimilation model initially emerged in response to the way clients described helpful moments of therapy, such as insight (Elliott, et al., 1994). Stiles and colleagues noted some developmental regularity in the kinds of moments clients described, and the model was born (Stiles et al., 1990). Since then, most of the research has focused on studying assimilation from a researcher’s point of view. This has largely been done through intensive, qualitative case studies of completed psychotherapies (Barkham, Stiles, Hardy, & Field, 1996; Glick, 2002; Honos- Webb, Stiles, Greenberg & Goldman, 1998; Stiles, Meshot, Anderson, & Sloan, 1992;Varvin & Stiles, 1999). Following a procedure called assimilation analysis (Stiles & Angus, 2001), researchers immerse themselves in a case (using complete transcripts or audio recordings) to develop a conceptualization of the client’s problematic experiences. They then trace these experiences over time to see how they change (i.e., whether they become more or less assimilated). Both the identification of the problem and the tracking of its progression are performed by the researcher, an outside observer. The analyses and interpretations have been closely linked to the data (e.g., trying, when possible, to use clients’ own words to describe their problems). However, there has been little opportunity to involve the clients in the research process or to check the researchers’ findings with the clients’ explanations of therapy. A fundamental question, then, was how would clients describe concepts like voices, meanings bridges, APES stages, etc., as viewed from within? Lessons from Rashomon: Point of View Matters Kurosawa’s 1950 film, Rashomon, depicts two violent crimes as seen by four witnesses and thus from four different points of view. Each perspective is discrepant from the others, despite the commonality of the event. This film technique—used again in more recent times (e.g., Pulp Fiction, episodes of popular television shows such The West Wing and Dawson’s Creek)—demonstrates the importance of perspective. Every individual who views a particular event or situation does so from his or her own frame of reference. People make meaning of events in the context of their personal history (past experiences, values, expectations for the future, etc.). This concept fits well with constructivist perspectives in psychology (Kelly, 1955/1991) which appreciate the personal reality of all individuals. Constructivists and films like Rashomon remind us that point of view does, indeed, matter.

In studying psychotherapy, multiple perspectives may be necessary in order to more fully capture and describe the phenomenon at hand. With this in mind, Mintz, Auerbach, Luborsky, and Johnson (1973) set out to directly compare three different perspectives on psychotherapy: clients’, therapists’, and observers’. Their results partially supported a “Rashomon experience” in that individuals from different perspectives didn’t necessarily agree on what constituted effective treatment. Although there was some agreement on what good therapy should consist of, “our viewers of each hour did not agree as to when, in fact, effective treatment was happening” (p. 89). Evaluations are thus always embedded in a perspective. Differences in perspective are not necessarily to be looked down upon or fretted over as a source of diverging validity or unreliability. “Considering this issue as one having to choose the ‘best’ perspective unnecessarily restricts a researcher’s options…an ideal strategy would use multiple perspectives (client, observer, therapist) to take advantage of the strengths of each and to compensate for the limitations of each…” (Elliott & James, 1989, p. 446). Discrepancies in accounts represent different vantage points of a shared phenomenon, in this case, psychotherapy. This study focused on two perspectives (the client and assimilation theory) and creating a dialogue between them. Bridging these two worlds (the rich experience of clients and theoretical conceptualizations of change) has the potential to benefit both parties. Psychological theories that are multi-perspectival, incorporating clients’ own experiences, provide richer, more complex and true-to-life accounts. Such theories are better able to describe a portion of human experience and potentially, improve the quality of psychotherapy services. Clients may benefit by having a voice in the theories that describe their experience and by potentially learning something about themselves through participation in research. Creating a Dialectical Tension Among Multiple Frames of Reference Although clients, therapists, and researchers may tell a different story of therapy, each perspective is valuable. This study attempted to examine the relationship between two perspectives in more detail: the client and researcher/theory. Clients have privileged access to their inner experiences and can provide a wealth of information about psychotherapy. Their accounts, however, may lack the precise language to express their experiences. They may have notions about how change occurred, but may not be able to communicate it in a concise or coherent fashion. This is where researchers (and therapists) have an advantage. They have developed a theoretical language for understanding the process of change. Psychological

theories come equipped with an extensive set of concepts and language to describe experiences such as psychotherapy. The assimilation model is one such theory. This model describes a common sequence of changes that seems to occur in successful therapy. However, the model is also idiographic in the sense that unique facets of individual cases are emphasized. The kind of problems that change and the specific paths to progress may differ from client to client. The goal of this study was to create a dialogue between client perspectives and the assimilation model. Specifically, I was interested in enriching the model by incorporating observations from theoretically-informed interviews with clients, wherein clients were given freedom to explore their sense of change in therapy using their own words. In order to learn more about the client’s perspective, I first facilitated a dialogue between clients and me, as an interested observer. I then facilitated a second dialogue between the assimilation model—a theory of change I find useful—and me, as a researcher. In order to make sense of these two dialogues, the different frames of reference—the client’s phenomenology, the assimilation model, and the researcher—needed to be bridged. In this study, I attempted to establish some meaning bridges or shared understandings between these perspectives. The tension between clients’ phenomenological accounts of therapy and the theoretical account offered by the assimilation model in this study exemplifies a debate within qualitative research. There is an on-going tension between hermeneutic inquiry and theory-building (Stiles, 1993, 2003). Both can utilize qualitative methods, but typically serve different goals (generating thick, descriptive interpretations through empathy with the subject matter, and creating a cohesive set of constructs that accurately depicts some aspect of the world, respectively). This study incorporated elements of each research approach through dialogue, in a manner reminiscent of the hermeneutic circle outlined by Packer and Addison (1989). I hoped that increased empathy for clients’ lived experience in therapy could inform and enrich psychological theory by asking clients to review and comment on their on-going psychotherapy, with particular emphasis on assimilation constructs. I have chosen to focus on a dialogue between the client’s perspective and the assimilation model in this study. However, there are certainly other relevant perspectives in psychotherapy, and hence, other possible dialogues. The therapist’s frame of reference is certainly a valuable one. Although little research has focused on therapists’ subjective accounts of psychotherapy process, a few studies have examined similarities and differences among client, therapist, and

9 observer viewpoints (Caskey, Barker, & Elliott, 1984; Orlinksy & Howard, 1975; Rennie, 1994). A full review of therapist perspectives will not be attempted, given the focus of the current study. Instead, differences between therapist and client accounts will be considered, as an illustration of how two perspectives can differ and still be useful. Elliott and Shapiro (1992) emphasized the importance of obtaining both client and therapist perspectives in psychotherapy research. They used Interpersonal Process Recall (an interview strategy using tape-assisted recall) and Comprehensive Process Analysis (a method of qualitative analysis) to study significant events in therapy. “Clients and therapists have ‘privileged access’ to a large store of personal and shared background information. In addition, they have access to something that is often unavailable even on videotape—their own momentary private experiences” (Elliot & Shapiro, 1992, p. 165). Elliott and Shapiro considered clients’ and therapists’ views to be of primary importance, though did not exclude the observer- researcher perspective. Rather than viewing discrepancies between these views as sources of error or invalidity (as has been done by traditional, positivistic research), they viewed differences as interesting and rich sources of data that deserve exploration. In their 1992 study, Elliott and Shapiro found many similarities between client, therapist, and observer perspectives of therapy. The discrepancies were not drastic, but differed in terms of language and emphasis. Observers’ descriptions of significant events in therapy (as identified by the client) were more general, used professional jargon, and were grounded in psychological theory. The client’s descriptions were more specific, referring to particular life circumstances and details of lived experience. The therapist’s perspective was largely influenced by his or her professional identity as a therapist and the type of therapy implemented. Yalom, a well-known existential and group psychotherapist, provided one of the richest accounts of client and therapist perspectives (Yalom & Elkin, 1974). He and one of his clients wrote separate case notes of their therapy together, session by session. The result was a book wherein the session accounts and summaries were placed side-by-side, highlighting the similarities and differences, though without formal comparisons. An example of differing views on a particular session occurred mid-treatment. Yalom wrote, “For me, this was one of the least involved, least tangible meetings I have had with Ginny…And so we ended without really having said ‘hello’ today” (Yalom & Elkin, 1975, pp.87-88). Ginny reflected, “I expected to be disappointed with last Friday’s therapy. Instead when I left I felt better…I came away from the

session optimistic. Though I sensed that you did not enjoy it. But that didn’t detract from my pleasure” (pp. 88-89). Differences in client and therapist reviews of individual sessions have also been noted using the Session Evaluation Questionnaire (SEQ; Stiles, Gordon, & Lani, 2002). The SEQ includes 21 items listing bipolar adjectives (such as difficult-easy, rough-smooth, shallow-deep) that clients, therapists, or observers rate using a 7-point scale to describe the quality of a recent session. Client and therapist session ratings tend to be statistically independent of each other. These findings underline the importance of obtaining multiple perspectives on therapy sessions. Analysis of perspectival discrepancies (between any two or more points of view) can be illuminating. The Client’s Frame of Reference Psychotherapy researchers have, to a limited extent, considered the client’s frame of reference. Some of the existing studies will be reviewed here, which underscore the importance of obtaining the client’s perspective and using qualitative interview methods and results to do so. Further, the ways in which clients’ perspectives on topics such as the therapeutic alliance and the process of change inform the assimilation model will be considered. Collectively, the studies reviewed in the following sections helped guide the interview protocol (which centered on Interpersonal Process Recall) and qualitative analysis for the current study. Strupp, Fox, and Lessler (1969), in their book, Patients View Their Psychotherapy, described the results of two major studies asking clients to retrospectively reflect on completed therapies (mostly psychodynamic). They used questionnaires containing both quantitative and qualitative, open-ended items. A strength of this book is the presentation of direct, unedited commentary from the clients about the nature and effectiveness of their treatment. Strupp, Fox, and Lessler commented on the advantages and disadvantages of using clients’ own words: While they often reveal a high level of sensitivity, sophistication, and perceptiveness, these patients speak as laymen, not professionals. Their reports may be distorted by self- deceptions, biases, and wishful thinking; they may be inaccurate when judged against objective criteria…Yet they are better than statistics and percentages at revealing not only pain, disappointment, suffering, and despair but also gratitude for having received help, acknowledgment of change for the better, and, in many cases, a sense of new courage and strength in facing the problems of life. (Strupp, Fox, & Lessler, 1969, pp. 19-20)

The clients’ commentary on many different aspects of therapy revealed thoughts and feelings that are typically missed in more numerical, quantitative measures of process and outcome. Clients seemed less focused on reporting improvements in mood and anxiety symptoms (though they seemed to occur) and more intent on describing changes in self-esteem and interpersonal functioning. Although this finding is expected given the psychodynamic nature of the treatment, it underscores the point that clients often reported significant changes in areas they did not initially present as problematic. This is noteworthy since particular outcome measures are often selected to match specific presenting problems (e.g., The Beck Depression Inventory for initial complaints of depression). This study demonstrated the utility of asking clients open-ended questions about outcome and change. Elliott and James (1989) provided a comprehensive literature review of research considering clients’ experiences in psychotherapy. They defined client experience as “clients’ sensations, perceptions, thoughts, and feelings during, and with reference to, therapy sessions” (p. 444). This included experiences the clients were clearly aware of, as well as those that were on the edge or beyond their awareness. The authors qualitatively analyzed previous studies for themes; nine domains of client experience emerged. These domains seemed to fall into one of three types of experiences: (1) experiences of self (feelings, self-relatedness, style of relating to therapist), (2) experiences of what the therapist did (i.e., intentions) and who the therapist was as a person, and (3) experiences of change in therapy (i.e., helpful moments). Elliott and James suggested that an awareness of these categories could help sensitize therapists to the kinds of experiences their clients are likely to have. This will allow therapists to select therapeutic interventions in a more responsive manner. The authors also hoped that their analysis would remind therapists that much of client experience is covert. Therapists should not assume they know what their clients are thinking and feeling but should ask clients more frequently what they are experiencing while paying attention to nonverbal messages. Finally, the authors advocated close attention to client experiences to insure consumer satisfaction in therapy services. Elliott and James’ account of client experiences was meant to help therapists, though it is also provides a useful set of guidelines for researchers. For the purposes of the present study, what areas might clients be able to comment on that would not be transparent from studies of transcripts alone? For example, how are clients’ views of therapists related to assimilation?

Whereas Elliott and James (1989) reviewed both quantitative and qualitative studies that considered client perspectives in some way, Brian Rodgers conducted a review of purely qualitative studies, particularly those that viewed clients as active participants in psychotherapy (Rodgers, 2002). Rodgers described several such studies in detail, some of which will be commented on later. He used these studies to argue that clients are active agents of change. As such, clients and their accounts of psychotherapy need to be studied more intensely to understand how clients make therapy work. He argued that the studies able to capture this perspective are qualitative in nature, for they preserve clients’ own words. “Instead of trying to control ‘experimental variables’ and produce ‘statistically significant’ results, qualitative inquiry attempts to get as close to each participant’s experience as possible, and to allow the participant’s own voice to be heard in the research results” (Rodgers, 2002, p. 28). Following suit, the current study sought to honor clients’ words and experiences, giving them a voice in the findings. Clients as Active Agents of Change Art Bohart, too, has focused on clients as active agents of change (Bohart, 2000, 2002; Bohart & Tallman, 1999). Bohart argued that psychotherapies of different kinds have proven to be about equally effective (Smith, Glass, & Miller, 1980; Wampold et al., 1997) largely because of the clients themselves. “Our view is that the client is a creative, active being, capable of generating his or her own solutions to personal problems if given the proper learning climate. For us, therapy is the process of trying to create a better problem-solving climate rather than one of trying to fix the person” (Bohart & Tallman, 1999, p. xi). Clients are able to use therapist interventions (even poor ones) in a productive manner to make therapy work. This idea is in contrast to the medical approach, where the interventions themselves, rather than the clients or the therapist-client relationship, are thought to be of central importance. Although Bohart and colleagues view clients as self-healers, they did not deny the significance of the therapy relationship (Bohart, 2000, 2002; Bohart & Tallman, 1999). Empathic and supportive relationships allow clients to take risks and explore internally generated solutions for better living. From this perspective, research examining the effectiveness of psychotherapy should necessarily incorporate clients’ perspectives and the ways in which they make use of therapy. Duncan and Miller have also viewed clients as key players in psychotherapy effectiveness. They emphasized that clients undoubtedly have ideas about what makes psychotherapy effective, both generally and in terms of their specific problems. They suggested

that clients enter therapy with opinions about what caused their problems as well as expectations about how to change those problems (Duncan & Miller, 2000a; Duncan & Miller, 2000b). Perhaps clients feel the therapist, as a trained expert, will prescribe specific strategies for better living. Or perhaps they simply want someone to listen to them. Duncan and Miller referred to these attributions and expectations as the client’s theory of change. Although these theories may not be formally articulated or contain psychological principles, they exist and play a role in shaping clients’ experiences of therapy. Clients’ expectations have been shown to play a significant role in determining the outcome of therapy; clients whose theories of change aligned with their therapists’ views tended to fare better (Duncan & Miller, 2000a). This assertion fits well with the repeated finding that the therapy relationship—particularly clients’ evaluations of that relationship—is the strongest predictor of outcome (Asay & Lambert, 1999; Bachelor & Horvath, 1999). Given that clients have an understanding of and shape their therapy, it makes sense to include their accounts when studying psychotherapy process and outcome. Therapeutic Alliance The therapeutic alliance has consistently been one of the most robust predictors of outcome in the psychotherapy literature (Horvath, 2005; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). A widely used definition of the alliance stems from Bordin’s (1979) tripartite view that a strong alliance consists of (1) agreement on the goals of therapy, (2) agreement on the tasks for meeting those goals, and (3) and emotional bond between client and therapist. Two sorts of findings on the alliance seem particularly relevant for this study. First, client and therapist evaluations of the alliance do not always converge (Elliott & James, 1989; Fitzpatrick, Iwakabe, & Stalikas, 2005). Second, fluctuations in the alliance, or what has been referred to as “tears and repairs,” have been associated with positive outcome (Kivlighan & Shaughnessy, 2000; Kohut, 1984; Safran & Muran, 2000; Stiles, et al., 2004). Client perspectives on the alliance have been obtained using quantitative self-report measures. For example, the Working Alliance Inventory (WAI) was created to measure relationship factors, such as therapeutic bond, from the client’s perspective (Horvath, 1994; Horvath & Greenberg, 1986). The WAI and other alliance measures (e.g., the Agnew Relationship Measure, ARM; Stiles et al., 2002) have been adapted to assess the therapy relationship from other perspectives: namely therapists and observers. Some studies have shown that the client’s ratings seem to be one of the strongest predictors of outcome (Horvath &

Symonds, 1991; Asay & Lambert, 1999). And although most of the methods for assessing client perspectives on factors such as the alliance have been quantitative in nature, they illustrate potentially meaningful discrepancies among perspectives of psychotherapy process. Another important aspect of the alliance has to do with negotiating fluctuations in the alliance. “Bordin’s conceptualization of the alliance…assumes that there will be an ongoing negotiation between therapist and patient at both conscious and unconscious levels about the tasks and goals of therapy and that this process of negotiation both establishes the necessary conditions for change to take place and is an intrinsic part of the change process” (Safran & Muran, 2000, pp. 14-15). Safran and Muran (2000) elaborated on this concept and showed how alliance ruptures are both inevitable and if worked through, therapeutic. The studies to date examining the role of the relationship in terms of assimilation have suggested that interpersonal empathy between client and therapist facilitates intrapersonal empathy between internal voices, (Brinegar, Salvi, Stiles, & Greenberg, 2006; Leiman & Stiles, 2001; Stiles & Glick, 2002). Just as interpersonal empathy may serve as a template or model for intrapersonal empathy, so too may the process of resolving interpersonal conflict and ruptures. Clients who can successfully repair ruptures with their therapist—presumably by revising their understandings and making them more shared—may be better able to build internal meaning bridges, or shared understandings between voices. Hypotheses like this about the relationship between therapeutic alliance and assimilation will be examined in the case studies. Helpful and Hindering Aspects of Therapy Whether therapy is deemed a success or not, clients have opinions about what was helpful or hurtful (Elliott & James, 1989; Gershefski, Arnkoff, & Glass, 1996; Levy, Glass, Arnkoff, & Gershefski, 1996; Paulson, Truscott, & Stuart, 1999). They list variables such as unloading problems / client self-disclosure, therapist characteristics / interpersonal style, specific interventions, learning something new, and increased self-understanding as being helpful. Clients tend to be more reluctant to report unhelpful or hindering aspects of therapy (Elliott & Wexler, 1994; Lietaer, 1992; Stiles et al, 1994). And when clients do mention negative aspects of treatment, they tend to list general dissatisfactions with the therapy process rather than specific complaints about the therapist or therapy process (Levy, Glass, Arnkoff, & Gershefski, 1996). For the purposes of the current study, the moments that clients have reported on as helpful and hindering were useful in sharpening follow-up questions in the IPR. For example, I

inquired about participants’ reactions to therapists that, to me, seemed negative (following a misunderstanding, for example). Since clients have not been shown to report negative aspects about the therapist or the process on their own, I tried to be intentional about seeking this information and being open and accepting of negative evaluations. Hermeneutic Approaches to Studying Clients David Rennie was also interested in client perceptions of helpful and hurtful aspects of therapy. He was reluctant, however, to make the sorts of a prioi assumptions about client responses (e.g., pre-existing coding systems or theories to be tested) made in some of studies mentioned earlier. “An alternative to [the] confirmatory approach to research is the exploratory approach emphasized in the qualitative research paradigm. In exploratory categorization, the interest is in keeping theory at a low ebb in order to give a chance for the meanings of the data to come forward in their own right” (Rennie, 1996, p. 265). He has used qualitative, open-ended methods of inquiry to ask clients about their experiences and grounded theory to analyze their responses (Rennie, 1990, 1992). Rennie was frank about his research goals. He intended to provide rich, descriptive accounts of therapy, as experienced by clients. He was not interested in building or testing theories. He didn’t ascertain clients’ perspectives on theoretical constructs or use their responses to shape a theoretical account. Instead, he considered his account to be interpretive, and one which resulted in a taxonomy of types of client experiences. Rennie illustrated these categories with excerpts from client interviews (Rennie, 1990, 1992) and asserted that including clients’ verbatim responses in the research results is essential to convey their experiences (Rennie, 1996). Rennie suggested that the core category in his taxonomy was reflexivity, or the ability to be self-aware and agentic (Rennie, 1992). The idea of self-reflectiveness seemed important both during therapy (promoted change) and when describing it. Rennie asserted that studying client reflexivity is critical to understanding psychotherapy, for it taps covert client processes. Clients do not always share all that they are thinking and feeling, therefore, analysis of therapy texts alone is not sufficient. By facilitating client reflexivity in research interviews, we can gain a richer picture of how therapy is experienced by clients. A piece of work reminiscent of Rennie’s hermeneutical approach is Denise Gulledge’s doctoral dissertation (1987). Gulledge used unstructured interviews with clients who had completed at least 20 sessions of psychotherapy. She, too, was interested in obtaining a

phenomenological and theory-free account of clients’ experiences in therapy, and specifically, their perceptions of change. Gulledge developed a set of broad themes to characterize clients’ responses: exposure of repressive forces, psychotherapy as empowering, self-reconciliation, and the therapeutic alliance. She, too, illustrated these categories with verbatim client accounts. Interpersonal Process Recall A method for obtaining client perspectives on therapy that seems to capture the spirit of many of the studies previously reviewed is Interpersonal Process Recall (IPR). IPR is an interview strategy using tape-assisted recall to obtain detailed information about a person’s experience of a recent conversation. Participants listen to segments of a recording of that conversation and are asked to describe what they were thinking and feeling at the time. A central idea behind IPR is that people are always experiencing more than they can or choose to verbalize in a conversation. IPR can be used with any kind of conversation, though has been tailored for use in psychotherapy research and supervision (Kagan, 1980; Kagan & Kagan, 1997; Elliott, 1984, 1986; Rennie, 1990). This method has proven particularly useful for psychotherapy process researchers who are interested in understanding how the moment-to-moment interactions in therapy lead to particular outcomes (Elliott & Shapiro, 1992; Wiseman, 1992). It can be used to interview both clients and therapists about their experiences in specific therapy sessions. IPR provides a window into clients’ evolving perceptions and subjective impressions of therapy that may never get verbalized to therapists and do not appear in transcripts or recordings of therapy sessions alone. Wiseman (1992) used IPR to ask clients about recent experiences in therapy. She used their accounts to elaborate a theory of micro-change: the Problematic Reaction Point (PRP) model. She found support for a sequence of proposed stages for resolving problematic reactions points in therapy. Clients were unaware of the model but described experiences that were similar to those characterized by the PRP stages. A strength of this study was the attempt to incorporate the client’s perspective into an existing theory of change. This was done using a qualitative interview method that allowed clients to describe their experiences in their own words. However, the qualitative data did not seem to directly inform the theory. Support came from the numerical percentage of clients who appeared to identify with a particular PRP stage. The theory was not modified based on client accounts and no interview excerpts or traces of client language were present in the results or discussion.

Client Perspectives on Assimilation I shared Wiseman’s (1992) aspiration to build theory using client accounts and used the same interview strategy (IPR) in the present study. However, I wanted to improve upon the way that the qualitative data fed back into the theory. The goal was not just to find supportive evidence of theoretical claims, but also to change, modify, and generally improve theory in a manner congruent with the qualitative observations. This study focused on both client accounts of therapy and the assimilation model. It had the dual aims of honoring clients’ experiences and enriching a theory of change in therapy. This was accomplished by using the researchers as facilitators of a dialogue between the two perspectives. While clients’ perspectives at times differed from the theoretical account, discrepancies provided different vantage points of the same phenomenon. This allowed for triangulation in the qualitative tradition and potential correctives to the assimilation conceptualization. More specific goals included: (a) retaining clients’ words and nonverbal communications in the results; (b) linking observations (client descriptions) to assimilation constructs; and (c) refining the theory to incorporate these new observations while still making sense of information obtained from previous case studies. The end product, hopefully, is a richer, more vivid theory that describes psychotherapy in a way that resonates with clients’, therapists’, and observers’ experiences of it. Method Participants Six adult clients from a Midwestern university participated in this study. They were receiving services from a psychology clinic (a departmental training clinic for doctoral students in clinical psychology) and a university counseling center (staffed by professionals and trainees). Three participants were male and three were female. All were White and ranged in age from 19 to 31 (mean = 23.8). Five of the six participants were single undergraduate students and one was a partnered graduate student. The participants received psychotherapy services (typically weekly) from a variety of theoretical orientations, including experiential personal construct psychotherapy, developmental, interpersonal / archetypal, and postmodern feminist approaches. Differences in theoretical approach were considered in the analyses but were not a primary concern since the assimilation model aims to account for change in therapies of all kinds. The

18 therapists were either graduate student trainees or predoctoral psychology interns; all were supervised by licensed clinical psychologists. Investigators The primary investigator in this study was Meredith Glick Brinegar (me), a White woman in her late 20’s who was a doctoral student in clinical psychology. She had had several years of experience researching the assimilation model and valued qualitative methodology. She had over four years of experience as a therapist and described her theoretical orientation as humanistic/experiential. Her academic advisor, Bill Stiles, served as her chief consultant. He was a White male in his early 60’s and one of the originators of the assimilation model. He had conducted and supervised many qualitative studies examining the model. Stiles and Roger Knudson, both licensed psychologists in Ohio, had agreed to provide clinical supervision if any problems arose during the interview procedure. Two graduate students in clinical psychology helped analyze the interviews who, along with myself, I will refer to as co-investigators. Michael A. Gray was a White man in his late 20’s and Rachel Hamilton was a White woman in her mid 20’s. They both had a working knowledge of the assimilation model. Measures Personal Questionnaire (PQ) The PQ (Elliott, Mack, & Shapiro, 1999; Hobson & Shapiro, 1970; Shapiro, 1961) is a self-report questionnaire that measures the intensity of client-identified problems. Client- participants are asked to generate a list of the problems that prompted them to seek therapy and that they would like to work on. The problems are noted on the PQ Problem Description Form. The form was slightly modified for this study to ask participants about problems they were currently working on in therapy as well as those which had not been discussed (see appendix). PQ items are generated from this list and are phrased in the form of a problem or difficulty, “I have trouble speaking in public” rather than a goal, “I want to feel more comfortable around others.” The researcher administering the PQ collaborates with the participant to clarify the wording of the problems, which are written down on index cards. The cards are then given to the participant, who sorts them in terms of importance, with the most salient or important concern first, etc. After the participant has prioritized the cards, the problems are transferred by hand to a PQ form, which asks participants to rate how much they have been bothered by each problem in

19 the last week. The rating is done using a seven-point Likert scale, ranging from “Not at all” to “Moderately” to “Maximum Possible.” Higher numbers indicate greater levels of distress. The problem statements are then typed into the PQ form for use in later interviews. See the appendix for sample PQ forms. The purpose of the PQ, in this study, was to prompt participants to think about their particular problems, which were asked about in more detail by the Assimilation Questionnaire. Assimilation Questionnaire (AQ) The AQ is a self-report measure derived from the Therapy Session Topic Review (TSTR) form (Barkham, Stiles, Hardy, & Field, 1996). It was used to locate moments in therapy sessions that seemed to have particular relevance to the assimilation model (see appendix). The following is a sample item from the AQ, inquiring about APES stage 1: During your last session, were there any topics that came up that you didn’t feel like discussing? For example, you might have had a thought or feeling come into your head that you pushed away. Or, your therapist might have said something that made you feel uncomfortable (e.g., sad, anxious, embarrassed, angry, or afraid), and you chose to not talk about it or tried changing the subject.

As the sample item illustrates, the AQ is not like most other ratings scales where participants rate the degree to which they have had particular experiences. Instead, it gives anchor points on a scale of assimilation and asks participants to specify what experience they had during the session that might be given such a rating. To describe this reversed sort of responding, we refer to participants as “identifying” or “resonating” with an assimilation concept. That is, we use the terms identified with and resonated with interchangably to describe clients acknowledging having had an experience that could be rated at one of the anchor points described in the AQ. The identification of a personal experience that fit the rating description might also be viewed as a phenomenological fit. A few of the items were reworded after it was administered to the first two participants to try to better differentiate the constructs. Assimilation Constructs There are several core constructs that describe the process of assimilation, including voices, problematic experiences, meaning bridges, the role of emotion, and the Assimilation of Problematic Experiences Sequence (APES). Participants were asked to describe therapy experiences relevant to these concepts. Afterward, co-investigators compared the PQ, AQ, and IPR interviews (containing both segments from the therapy session recording and the IPR

20 recording) to these core constructs. Voices—agentic parts of a person—are perhaps most noticeable during transitions between voices. Co-investigators looked for distinct changes in content (what the voice was expressing), emotion, vocal quality (e.g., pitch, rate), and transitional phrases and conjunctions (e.g., but, or, on the other hand). Problematic experiences were expected to be present in the PQ, AQ, and the IPR interviews, however, the degree to which participants could articulate them was expected to vary. Negative affect was used as a strong indicator of an encounter with a problem. Meaning bridges are often indicated by moments of insight, when a new understanding is reached or solidified. At this point, conflicting voices reach common ground and are able to develop a shared understanding or perspective on what was previously a source of conflict. APES. The eight APES stages (see Table 1) are the other main constructs that the co- investigators used to compare client observations to assimilation theory. For evidence of APES 0 (Warded off / dissociated), when clients are unaware of the problem, somatic symptoms or periods of dissociation were anticipated to be strong indicators. During APES 1 (Unwanted thoughts / active avoidance), clients actively avoid talking about problematic experiences and may quickly change topics to safer ones. APES 2 (Vague awareness / emergence) is typically characterized by strong negative affect and confusion about the nature of the problem and the intensity of the emotion. At APES 3 (Problem statement / clarification), problematic experiences are clearer and often stated as something that can be worked on in therapy. This stage is also marked by a high degree of internal dialogue, with quick transitions between voices. Stage 4 (Insight / understanding) is often marked by moments of insight or a new perspective (e.g., “I never thought about it that way before”). There is an increased sense of optimism during APES 5 (Application / working through), when clients are deepening insights and trying out solutions to problems, which may only be partially successful. During APES 6 (Resourcefulness / problem solution), clients are likely to report on specific successes they have had. APES 7 (Integration / mastery) is a difficult stage to directly observe, and is most noticeable in the context of the entire therapy. What was once problematic is no longer something to worry about. Clients automatically apply successful strategies to help them navigate situations that were previously a source of distress. Interpersonal Process Recall (IPR)

Interpersonal Process Recall (IPR) is an interviewing technique in which participants listen to a recording of their conversation and are asked to remember and describe their experiences during the conversation. The recording is frequently stopped so that participants can articulate what they were thinking and feeling at specific moments during the original conversation. The researcher attempts to empathically understand the participant’s account. The researcher also encourages participants to elaborate on their experiences at the time of the recording while discouraging retrospective reflections and interpretations. The interview is conducted shortly after the conversation occurs so that participants can more easily access and report on their thoughts, feelings, and perceptions during the recorded conversation. “IPR makes it possible for participants to recapture fleeting impressions and reactions which would ordinarily be forgotten or merged into global perceptions” (Elliott, 1986, p. 503). Elliott (1986) suggested that IPR promotes vivid recall from participants for five reasons: (1) the recording acts as a cue for events in the conversation that might otherwise have been discarded or forgotten; (2) conducting IPR soon after the conversation also prevents participants from forgetting their experiences; (3) IPR slows down the conversation by letting participants stop the recording to describe their experience in great detail; (4) The participant is asked to take a “there-and-then” frame of mind. This decreases participants’ tendency to make inferences or generalizations about the past conversation and to distinguish between memories and current perceptions; (5) participants are made to feel safe. They are given control over the process, which helps them be more forthcoming. Procedure Recruiting Participants Participants were recruited through their therapists. Therapists verbally agreed to have their session recordings reviewed by the co-investigators. They provided a brief overview of the study to clients they deemed appropriate for the study (i.e., interested in participating and able to reflect on their therapy). If interested, clients agreed to be contacted by me. I provided more information about the purpose of the study and the ways in which the data gathering could potentially affect the therapy. Clients who chose to participate signed an initial consent form to conduct the research interviews during their treatment and to allow me to review relevant clinical materials in their file, namely contact information and audio or video recordings of their therapy sessions. After completion of the final interview, participants signed a second consent form,

22 indicating which portions, if any, of the interviews could be used for research purposes. This was implemented to insure that clients still agreed to have their information used in this study with the knowledge of what information they had shared. All participants gave permission for their interviews to be used in their entirety for research purposes. See the appendix for the consent forms. Conducting Interviews Clients were asked to participate in two or three research interviews, each occurring within 48 hours of a therapy session. Interviews took place in a departmental psychology clinic and university counseling center and lasted approximately 1 ½-2 hours each. The interviews were conducted approximately every other week, after every two therapy sessions. At the start of each interview, I administered the PQ and the AQ to identity relevant segments of the pervious therapy session. If participants answered affirmatively to any of the items in the AQ, they were asked to describe the experience(s) and the context in which it occurred. These segments were then located on a recording of the therapy session by the participant. Once found, these segments were played for both the participant and me using IPR. If the participant could not localize or remember a particular time when his or her assimilation experience(s) occurred, we cued the tape recording to the beginning of the session and proceeded from there. When introducing the IPR procedure, I instructed participants to re-immerse themselves into the session, remembering their thoughts, feelings, intentions, etc. Participants were asked to try to distinguish between what they were experiencing during the therapy session, and what they were experiencing while listening to the recording. The participants had control over the recording, stopping it as they saw fit, to expand on what they were experiencing. I also stopped and started the tape if I identified a theoretically salient portion that the participant did not select. While participants offered their explanations, I attempted to empathically reflect and summarize their comments. This served to check my understanding and to help the participants clarify their comments. I also asked questions, as needed, to probe for more complete accounts of the participants’ experiences. I asked questions in a responsive matter and relied on my clinical judgment and knowledge of assimilation theory. For sample questions and a more detailed description of the IPR directions given to participants, see the appendix. The IPR interviews were audio-recorded. No identifying information was placed on the tape label to preserve confidentiality. The interviews were transcribed, excluding any identifying

information. I recorded my experience of conducting the IPR in a subjectivity journal immediately following the interview, noting successes, challenges, frustrations, emerging conceptualizations, etc. Analysis of AQ and IPR Interviews The primary investigator (Brinegar) and two graduate student peers in clinical psychology (Gray and Hamilton) analyzed the AQ responses and the transcripts of the IPR interviews. They reviewed and discussed one case at a time, following the same three steps for each case. Their overarching goal was to identify client perspectives on assimilation constructs rather than doing a formal assimilation analysis (Stiles & Angus, 2001) of each case. Step 1. In the first step, the three co-investigators immersed themselves in the IPR transcripts, reading and re-reading them in an intensive fashion. This phase was done independently. They each compared therapy moments described in the AQ with those discussed during the interview (e.g., Were they the same or similar moments?). This was done to check that clients had described some aspect of assimilation during the IPR. Co-investigators then analyzed the content of these moments. They used open-ended rating sheets to note specific client passages that seem to do one of the following: (1) were congruent with and exemplified current statements in the theory, (2) were different than or in contradiction to current statements in the theory, (3) were only partially described by the theory, or (4) were not covered by the model, but were clinically and theoretically interesting and could make potentially relevant additions. Each co-investigator, who already had at least minimal experience with the assimilation model, had a list of central theoretical constructs—similar to those described in the Assimilation Constructs section—and a copy of the APES (Table 1) to help guide their analyses (see appendix for Rating Sheet and Assimilation Constructs). The co-investigators were also asked to pay attention to the way in which participants described their experiences (in addition to the content). For example, how adept was the participant in engaging in IPR? It was expected that participants would have varying ability to concisely articulate their experiences. Participants whose problems are at very low levels of assimilation may have little conscious awareness of them and have few words to describe them. In contrast, participants who have already clearly stated their problems and are working on specific solutions may be able to provide richer linguistic accounts. A lack of words, though, was not necessarily a hindrance to this study. Participants’ inability to clearly describe their

experiences may help elaborate certain aspects of the model, particularly lower APES stages. The goal was not to elicit client accounts that were in strict agreement with the theory. Though both clients and assimilation theory may be describing the same phenomena (i.e., they share common targets of depiction), their accounts were expected to be different. As in Rashomon, discrepancies in perspectives are potentially illuminating, and not to be forced into boxes of similarity. Co-investigators were also instructed to assign a global APES rating and rationale as a shorthand for comparing co-investigators’ conceptualizations. This instruction was provided after the first two cases had been analyzed. The co-investigators had given APES ratings spontaneously, even though they had not been asked to do so. Rather than ignore this information, I tried to systematize this analysis by asking for global APES ratings for subsequent cases. However, this task proved more challenging than anticipated in terms of reaching consensus on a single global rating. In struggling to make sense of discrepant ratings, we realized that most of our disagreement resulted from client progress within and across sessions (i.e., problematic experiences became more assimilated over time) and focusing on different problematic experiences or different threads of the same problem (discrepant APES ratings at a given point in time). Although the assimilation model is a stage model, people don’t move through the stages holistically as people (as they do in, e.g., Piaget’s model of cognitive development). Rather, experiences or voices may progress through the APES and may do so at different rates. Discrepancy in ratings of different problematic experiences will be elaborated in the case results, as will the current rater culture for making global APES ratings. Co-investigators were instructed to note any aspects of the case that seemed relevant to assimilation but which weren’t directly related to therapy, or the client’s view of therapy. For example, they were asked to identify interesting features of the participants’ psychopathology or defense strategies. Step 2. In the second step, the co-investigators convened to discuss their analyses from step one. They shared their global APES ratings, salient features of the case, and the participant’s ability to reflect on therapy. They also presented the moments from the interview they found theoretically most relevant and their rationale for categorizing them into one of the four categories listed earlier. The co-investigators engaged in a dialogue in an attempt to reach consensus about (a) the theoretical relevance of the particular client account and (b) the specific

25 ways in which the account either supported, disconfirmed, elaborated, or modified the assimilation model. Consensus was not forced, though. Unresolved disagreements about the classification of certain client passages were noted and kept. Step 3. In the third step, I compiled the co-investigators’ comments and developed a set of statements that (a) empathically described theoretically-relevant client statements, (b) were illustrated with excerpts from the IPR interviews to retain clients’ language, and (c) discussed proposed changes to the model that both incorporated the new data and were consistent with past data. This qualitative compilation was done in consultation with Bill Stiles. Organization of Results The results are presented case by case, in the order that they were conducted and analyzed. The results for each case are organized by assimilation construct into the following categories: voices / intrapersonal dialogue, APES stages, therapeutic alliance, and perception of progress. If multiple APES stages were present, they were arranged in ascending order to illuminate progress. In writing separate results sections for each case, I hoped to convey the participant-clients’ individual views. Verbatim passages are presented throughout to honor their unique experiences of therapy, to enrich our appreciation, and to use their experiences to build on assimilation theory. Results: The Case of Sabrina Background Information Sabrina, a pseudonym, was a 22-year-old White female. She was a senior at a Midwestern university, about to graduate and get married. She was finishing up a three-year, fairly intense therapy relationship with a graduate student therapist at a departmental psychology clinic. She sought therapy to help deal with depression and self-harm behaviors, and was initially vague about her problems. Sabrina had a history of long silences in therapy sessions, frequently said, “I don’t know,” and seemed cut-off from her emotions. Her therapist described her theoretical orientation as Experiential Personal Construct Psychotherapy, with a focus on relationships and emotions. Both the therapist and client reported making progress in improving depressive symptoms, getting more in touch with feelings, and decreasing the need to “zone out” as a coping mechanism. Sabrina met with me for three research interviews. During our second interview, the tape of her therapy session was inaudible. Since she had already filled out the questionnaires about

that session, we discussed her general impressions of the session. Sabrina elaborated on the moments she had described in the AQ. PQ Sabrina identified seven problems on the PQ. From most significant to least, she listed: 1) I have periods of depression—swings from slight to severe; 2) I’m anxious most of the time; 3) I have performance anxiety, especially on tests; 4) I have trouble communicating and explaining things to my fiancé; 5) My self-esteem isn’t as high as I would like; 6) I am too much of a perfectionist; 7) I have some disordered eating patterns. Sabrina said she had talked about most of these problems in therapy except for her eating patterns. AQ On the AQ in the first interview, Sabrina identified with (i.e., found a phenomenonological fit with) the moments describing APES stages 1 and 2 in relation to her problems with depression and anxiety. Related to having unwanted thoughts or actively avoiding a topic (APES 1), she reported that when she felt overwhelmed by what she was discussing in therapy or something her therapist brought up, she shut down; she said she “doesn’t go there.” She reported that there were a couple of sensitive topics that prompted her to feel overwhelmed. She said she became silent, though then felt anxious when no one was talking. Sabrina also identified with APES 2 (vague awareness/emergence). She said she often had trouble finding the right words to describe her experience. She said she had difficulty expressing any feelings of depression and that when she was feeling worse, it was even harder to describe. Sabrina said she ended up being silent and saying “I don’t know” much of the time. During the second interview, Sabrina identified with APES 3 (Problem Statement / Clarification) on the AQ. She said, “I have a tendency to be very disconnected with myself…I struggle with emotions in any sort of moderation (i.e., I either feel nothing or everything), and I discovered that a lot of that probably comes from my dissociating. I knew I did it in therapy sometimes, but didn’t realize how much I think I do it in life in general as well.” She also indicated that she felt stuck about where to start fixing this problem. She reported trying to be more aware in order to catch herself “zoning out” during a normal day and trying to think about why she does so. This suggests that she was actively struggling with her problem of dissociating and trying to understand the meaning behind it—perhaps moving from APES stage 3 to 4. During the third interview, Sabrina reported getting a clearer sense about another

problem during therapy. She said she was “more able to realize that leaning on others doesn’t make me a weak person—complete independence isn’t always what it’s cracked up to be.” She said she explored the conflict between relying on herself and relying on others and would like to talk more with her friends about things that bother her. Although she seemed to gain clarity on her problems during the three therapy sessions reviewed, she had been working on these issues for quite some time and, presumably, been making progress. It is possible that the significant progress she demonstrated in the sessions reviewed may have been affected by her impending termination. Process of IPR Sabrina seemed willing to participate in the research interviews, though like her presentation in therapy, she presented with a fair amount of sarcasm and some defensiveness. Although she acknowledged having experienced three moments described in the AQ (see below for details), she did not seem to think there were any specific spots of the session that were more salient than others. Instead, there seemed to be a collection of smaller moments scattered all through the tape. Because of this, we started listening to the tape at the beginning, with the general instruction to stop it when one of the assimilation moments was present or when she identified something as particularly salient. Sabrina seemed to become increasingly comfortable stopping the tape as time went on. Sabrina canceled our second scheduled interview due to the “sensitive” nature of her previous therapy session. She said she focused on a topic that she rarely discusses, and she did not feel comfortable sharing it with me. I told her that I respected her decision and wanted her to feel comfortable in her participation. She seemed appreciative, and we rescheduled the interview. What was perhaps most striking about this case was Sabrina’s ability to reflect on and articulate moments of therapy that were rated at low levels of assimilation. For instance, she was able to expand on her tendency to dissociate and to avoid negative affect. This was contrary to my expectation that clients at lower levels of assimilation would be less able to articulate their thoughts and feelings. Analysis of IPR Voices and Intrapersonal Dialogue All three co-investigators agreed that they identified distinct voices in Sabrina. They

heard them in both the therapy session and during the IPR and rated and commented on both. This is consistent with the theoretical suggestion that internal multiplicity is present in everyday life, not just in therapy and that there is some consistency across domains. One of the salient voices was a critic voice that harshly judged Sabrina’s thoughts, feelings, and behavior and is illustrated in the following passage where she was reflecting on the process of listening to portions of her therapy session. The critic voice may have contributed to Sabrina’s long silent periods in therapy, figuring that it was better to say nothing than to say something wrong. Sabrina: Okay, well. I’m big on things having to come out right. Um, which is why, like when I listen to myself and I’m stumbling over all my words, I think, “oh my gosh, I sound like such a moron.” (laughs)

Researcher: Yeah, hard to not judge yourself there.

Sabrina: Um, and, part of it is, I’m really bad at, I’m really bad at stating things verbally. I can write better, um, than I can say things. And that, I worry about what other people are going to think and so I generally just don’t say anything at all. So the combination of “oh my gosh, I don’t know what to say”; “oh my gosh, it’s not going to come out right”; “oh my gosh, what are they going to think about me?” is enough to keep me quiet most of the time. (laughs)

Sabrina’s conflicting internal voices often engaged in intrapersonal dialogue. Sabrina commented on this tendency in the following passage where she noted that it was a common occurrence for her to feel multiple and conflicting perspectives. In this and the next several passages, Sabrina talked about whether or not she should depend on others. Historically, she viewed herself as extremely independent and was reluctant to turn to others for help. In discussing the tension between being independent / competent and dependent / weak, it is notable that she used the term “back and forth” to describe her conflicting views—a phrase similar to the label rapid crossfire that assimilation researchers have used to describe the rapid exchanges between conflicting voices at APES 3. Her independent voice is in boldface and her dependent voice is in italics. The asterisks, here and throughout the results sections, indicate whether the participant or researcher stopped the therapy recording to speak. Excerpts from the therapy sessions are doubly indented; excerpts from the IPR sessions are singly indented.

Sabrina: I guess there’s a back and forth. I guess, I mean, there are times when I’m like, “oh you know, that’s okay, I can do this. And then there are

times when I’m like, “no I can’t!” (laughs) So, mean I’ve had both, so—

Therapist: So usually when you think about leaving, you think a lot about how you’re going to able to handle things on your own?

Sabrina: Yeah. [silence] ______*Researcher: So the back and forth. Can you say more about that?

Sabrina: Um, this is, this is sort of the where the whole like independence-dependence things started. Because I was like, sometimes I think, leaving won’t be that bad cause you know, it’s not a big deal--I can handle it. And then other times, it’s like, “oh no, no I can’t!” (laughs) So—

Researcher: So when you have, like, kind of, two different things at odds with each other, what is—what’s that like? To feel two different things, almost at the same time?

Sabrina: Gosh, it’s so common. I don’t even think about it, but, um, obviously, it’s a little confusing because—they seem to be sometimes so much on one end or so much on the other. Like, I’m—trying real hard to find the middle, but I end up in one end or the other. In some respects, um, but—and a little bit frustrating because I’m like, “well yeah, I can do it,” “no I can’t,” and—

Researcher: And you can see both at the same time, right? (Sabrina: right) But it’s—

Sabrina: Because I’ve been in both situations at the same time. Not at the same time, but at one time, um, so, like I can see where both could feasibly happen. So, you know, it’s sort of like, I don’t really know what’s going to happen. I—

Researcher: So part of it’s the not knowing how it’s going to turn out. Is it, feeling stuck? Or how would you describe that, when you can kind of see it going either way?

Sabrina: Um, I mean I suppose it s-sounds okay—I don’t like knowing what’s—I don’t like not knowing what’s going to happen. So, I mean if I’m—if I’m able to sort of predict it, I’ll feel a little bit better. But most of the time, I’m sort of like, “well, this could happen and this could also happen, so I don’t really know, and I’m just gonna have to go with it because I don’t really have any other choice.” Um, but

Researcher: Any emotions or feelings kind of surrounding that? When you’re in that position?

Sabrina: Um, more frustration than anything else.

Here is another example of the “back-and-forth” Sabrina referred to, which occurred shortly after the previous passage.

*Researcher: You say, “a little bit” [in response to therapist asking her if she felt guilty for relying more on others]. Sounds a little tentative there. Do you remember what you were thinking at that time?

Sabrina: Um, I think it’s probably going back and forth, like the logic in my head. Like, it’s unrealistic to expect me or anyone else to never lean on anybody. Um, but at the same time, I sometimes feel like I should just, never lean on anybody. So, I mean, there’s a certain amount—there’s a certain amount of guilt that goes with that. But then, there’s also a certain amount of “well, that’ just dumb—like nobody ever always does things on their own.

Researcher: Okay. So again, kind of this tension of—“yeah, some of it’s guilt” (Sabrina: yeah)—but then there’s this other side, “well but of course I should expect to lean on people.

Sabrina: Yeah

In the next passage, Sabrina reflected on the progress she had made in creating a balance between dependence and independence. The problematic voice (depending on others) seemed to have gotten stronger over the course of therapy, allowing for a somewhat more equal dialogue and understanding with the more dominant voice (relying on self).

Sabrina: Sometimes I still do view it [relying on others] as a weakness, but um, not to the same degree or as often. So, I’m heading in the right direction. At the very least (laughs).

Therapist: So perhaps now you can value both independence and dependence, or whatever [inaudible] Perhaps there’s room for both?

Sabrina: Yeah, I think I still value the independence a little bit more, but maybe I’m starting to feel like dependence is valuable as well (laughs). ______*Researcher: So here, some sense of—well, maybe one part of this conflict or this tension—the independence—seems like it’s still a little stronger at this point. Maybe?

Sabrina: I think I still—like I said—I still value my independence a little more bit more than I value leaning on other people. Like if—when all is said and done, if I’ve gotten through X situation by myself, I’ll feel better about it. Then if I had leaned on someone else in the process.

Researcher: Um, is it fair to say that sort of the other part—the dependence, leaning on other people—has, maybe not as strong as the independence, but gotten stronger?

Sabrina: Um, yeah. If, you know, talking about X situation again, if I were—if I had ended up leaning on someone else, I don’t think I would feel, um, nearly as bad about it as I once would have. Sort of like, well obviously I can’t expect to do everything on my own.

In the following passage, the researcher asked the participant to reflect on what it was like to have the therapist say she (Sabrina) was going to avoid avoiding talking about termination. It illustrates her mixed feelings as well as her awareness that she liked to avoid talking about painful issues. The part of her that wanted to avoid talking about termination (because it’s painful) is in boldface and the part that was relieved and wanted to discuss this is in italics. The purpose here is not explicate which voices are speaking (e.g., how they might differ from Sabrina’s other voices), but that they engaged in intrapersonal dialogue.

Sabrina: Um, a couple different things I think. I was—a little, shall I say, relieved that I wasn’t going to be allowed to get away with it. Because I know that, I mean initially, I would walk away and be like, “oh phew, I got away with it.” But then, you know a couple months or whatever down the road, I might be like, “well that wasn’t a very good idea.” You know, and then it’d be done, and I, there wouldn’t be anything I’d be able to do about it. Um, so, you know, if you stick me there, then I got to do it. Um, but then on the other hand, then it means I have to do it so. I guess a little nervous, because I’m not a big “talk about my feelings” kind of person, so—

Researcher: Right, so yeah, it’s kind of like other moments we talked about before. Where there’s—it’s mixed. You know, there’s both good and bad.

Sabrina: Yeah, it’s pretty common for—it’s a pretty common theme of mine, I think to have sort of mixed feelings about almost everything (laughs) so—

APES Overview Most of Sabrina’s problems were rated in the APES 0 to 1 range. She seemed to avoid contact with her problematic experiences by “zoning out.” The nature of these experiences, because they were at low levels of assimilation, remained largely unknown. On a few occasions, Sabrina’s problems emerged into awareness and were rated at APES 2. Several passages were given an APES rating of 3. Sabrina gained clarity on a secondary or derivative problem: the fact that she was zoning out and avoiding her problems. For Sabrina, and the cases that follow, the observations are grouped by APES stage rather than problematic experience. This was done to accumulate a sense of how a particular stage was experienced by the client. We tried to be as clear as possible about what problematic experience(s) was being rated within each stage.

APES 0 and APES 1 There was convincing evidence for problematic material at APES 0 (Warded off / Dissociation) and APES 1 (Unwanted Thoughts / Active Avoidance), though it seemed hard to disentangle these two stages for Sabrina. She used dissociation as a coping strategy, to use her words, “zoning out,” which often kept her from feeling any pain. We considered this as an indicator of APES stage 0. There were frequent several-minute pauses in the three therapy sessions we analyzed. At one point, the therapist commented that Sabrina looked as if she had checked out and wasn’t really there. Sabrina responded by saying that she’d gone to the beach and then made some sarcastic comments about the weather being warm there. The complicating factor surrounding this issue is that Sabrina was often aware of zoning out and did it (at times) intentionally to avoid talking/thinking/feeling about problems that were potentially painful and “overwhelming.” Intentionally avoiding is characteristic of APES stage 1. The next passage illustrates Sabrina’s tendency to not talk in order to avoid feeling any emotion—and her awareness that she does this. The therapist had asked Sabrina if there was a temptation to speak less than usual in the session since Sabrina would be reviewing it later for research.

Sabrina (during IPR): Um, the laughter there—just, it, I think I often go into, um, session, sort of like, “I don’t really feel like talking.” (laughs) So I think it’s just kind of funny that she [therapist] said that because, it’s sort of, a trend of a sort. Not a big, uh, not big on sharing feelings at all with anybody. Like this is different from any other time? [said sarcastically while laughing]

In the following example, Sabrina noted that she purposely didn’t ask her therapist to clarify her previous comment urging her to talk about her relationship concerns (which she hadn’t fully understood) because she suspected it involved expressing her worries and getting in touch with negative affect. She suggested that it’s better to not say anything than to feel.

Sabrina: I worry about it [relationship with fiancé], but I don’t know whether it’s really true. You know, I worry about everything, so--

Therapist: Well, let’s worry about it out loud, and see what comes of it. And we’ll leave deciding if it’s true for later.

[long pause] ______

*Researcher: I guess something that I’m a little curious about, is when she [therapist] says, “worrying about it out loud.” What was your reaction to that?

Sabrina: I didn’t really know what she meant. I didn’t ask either, because I knew what I was going to have to do (laughs).

Researcher: You’d have to do what?

Sabrina: Worry out loud. Or do what ever she was talking about.

Researcher: …So better to just sort of—

Sabrina: Not say anything.

The following passage is another illustration of Sabrina’s tendency to avoid talking about topics that will get her in touch with her emotions. She often used silence as a way of avoiding, and at times, dissociating.

[long pause]

Therapist: What’s going on?

Sabrina: I don’t know. ______* Researcher: So here’s a, kind of a silence. And kind of, I don’t know, one of those times where it’s hard to put into words what was going on for you at that time? I don’t know. Can you tell me about that?

Sabrina: Sort of a combination of that and a combination of me zoning out. And a combination of me just not feeling like saying anything.

Researcher: Even if you could, “I don’t want to.”

Sabrina: Yeah, sort of, yeah. Mostly because I think it would require me to like, be in touch with it. Which I really don’t want to do.

Researcher: Yeah, and be in touch with it—that’s the—

Sabrina: It’s a little overwhelming.

Researcher: The overwhelming part. Yeah, okay. So here, it’s like, I’m not going to say too much. [Sabrina laughs] I’m not going to go there. I’m going to sit here and—

At times, Sabrina’s active avoidance of potentially painful topics (characteristic of APES

1) led to moments of dissociation that are typical of APES 0. The next passage illustrates the client’s reluctance to discuss some distressing feelings that she had worked hard to avoid in the preceding days.

Sabrina: Yep. [pause] I think there was probably some self-anger that seems to be going on, but in general, I think I was just more, um, like generally depressed more than angry at myself. If that makes any sense. And then I think I spent the rest of the day trying to block it out of my mind and therefore ended up losing touch with (laughs) most of it I think. Because I—cause I think I tried to go back a couple days ago, and I was like, hmm, I don’t really remember (laughs) so—

Therapist: So it’s going to be hard for you sort of, bring it back to the present, here, now?

Sabrina: [pause] Yeah, I suppose. [said quietly]

Therapist: Those must have been some pretty powerful feelings to block them out that successfully.

Sabrina: Uh, uh, yeah! [said sarcastically] I’m not sure how successful I really was, but I tried. ______*Sabrina: I think that nice little silent moment in there was, um, one of those things, because she [therapist] had said that, “must be some pretty power feelings in order for you to block them so successfully.” And I was sort of like, oh, don’t bring me back into my head (laughs). I must push them back out again.

Researcher: Because that’s kind of the point—I’ve told you I’ve just done that. (Sabrina: yeah) And now it’s like, what’s the thought when she’s saying, talking about them [feelings] being really powerful?

Sabrina: That they are.

The following passage illustrates another moment where Sabrina started to zone out after the therapist had asked her about the panic she’d felt in the previous week. When Sabrina reflected on this moment in the IPR interview, she commented on the fluctuating nature of her dissociation.

Therapist: That panic that you felt last week. Do you feel any of that now?

Sabrina: Um—[inaudible]—not to the extent that I did at the time. [pause] Why do you ask?

Therapist: It’s hard to read you sometimes. I wonder if you’re thinking over there—you’re fading out.

Sabrina: A little. [pause] ______*Sabrina: It’s hard for me to concentrate on, I don’t know, [inaudible]

Researcher: Say that again.

Sabrina: It’s hard for me to concentrate.

Researcher: Yeah, when you’re listening to this you mean, or at the time?

Sabrina: At the time

Researcher: At the time, yeah.

Sabrina: Actually, I mean in general. I think my brain goes haywire most of the time. But, I think it’s a tendency now?

Researcher: Yeah, so maybe that’s part of the silence—is some sort of some sense of zoning out.

Sabrina: Yeah, part of it. Part of it is I’m thinking about something, and now I’m zoned out. And now I’m thinking about something (laughs) and—

Minimizing and Making Light of Problems. At a couple points during the IPR interviews, Sabrina commented on her frequent laughter in therapy. She noted that she tended to laugh to relieve anxiety and to minimize or lighten negative emotions. This is consistent with APES 1, when clients prefer not to think about their problems and will develop strategies to avoid or minimize them.

Sabrina: I think, that also I noticed I talk really fast, which I didn’t realize. I think that’s an anxiety thing. And I laugh a lot. Which I knew anyway. Um, there will be a lot of giggles in there probably.

Researcher: It really helps relieve some tension, or?

Sabrina: Laughter is a coping mechanism big time. (laughs) So, I’m always cracking little jokes and having a laugh at myself. That’s—I don’t really know what else to do other than that.

In the next passage, Sabrina commented on how much she laughed in therapy sessions—and at

36 moments that weren’t very funny.

Sabrina: I know that I have a gigantic tendency to laugh as a coping mechanism. That, gosh, I didn’t realize how often I do it! It was kind of interesting. And also annoying. (laughs) Some of the time, I was like, God, you should stop laughing. And like, it’s not really that funny. Um—

Researcher: Did you get a sense that the times when you were using it—when you were laughing—did it seem to—could you tell when you were using it?

Sabrina: I know—I know that I do it. But like I said, I just don’t think I realized the, the frequency. At least not, not in the front of my mind. It was, but then after listening to a couple of these, it’s like, “damn, I do it a lot!” But, I think—any, any sort of feeling that could be perceived as uncomfortable, my immediate reaction is to laugh. So, I guess I always figure, better to laugh than to cry.

Sabrina also tended to minimize intense, negative emotions by dismissing her problems or describing them in an understated fashion. In this passage, the therapist noted that Sabrina’s feelings must have been pretty powerful to avoid feeling them during the previous week, and Sabrina responded very sarcastically, saying “apparently.”

Therapist: It’s interesting, because it’s kind of a—the way you said it made me think that you’re kind of like dismissing it. Yeah, ya know—they’re big emotions. It’s almost a way of saying, “yeah, they’re not really big emotions.” You have ways of making them sound little when they’re not.

Sabrina: I think I hope that I’ll believe it.

Therapist: But you don’t.

Sabrina: In the long run, no. I’m working on that. [whispered]

APES 2: Vague Awareness / Emergence Although most of Sabrina’s problematic experiences were rated at APES 1, she also showed evidence of APES 2, where problems are no longer being avoided and are discussed in therapy for longer periods of time, albeit in a confused, vague, and emotion-filled way. The following passage illustrates Sabrina’s tendency to say, “I don’t know.” She reported saying “I don’t know” or saying nothing at all very often in her sessions. She reported having difficulty expressing feelings of depression and when the feelings were worse or more intense, they became even harder to describe.

[Sabrina and researcher start laughing after hearing Sabrina say, “I don’t know” on the therapy tape, something she had described in the AQ.]

*Sabrina: It’s one of those infamous “I don’t knows.” (laughs)

Researcher: So that’s infamous, huh? Yeah?

Sabrina: I say that all the time.

The following passage demonstrates an instance where Sabrina was worried about something but didn’t know why and didn’t try to figure it out. Being consumed by a feeling and having little perspective on that feeling is characteristic of APES 2. Sabrina’s reaction to it in the IPR added little insight, but this is also characteristic of the vague awareness at this stage.

Sabrina: I haven’t really—broken the idea apart much. Just sort of—either worried about it or not worried about. There isn’t a whole lot of thought process going on.

Therapist: Hmm. So it’s like you’re—you’re overwhelmed with feeling, but not quite sure what it is that’s behind that feeling. ______[Tape doesn’t get stopped.]

*Researcher: That sounds like something we talked about.

Sabrina: Yeah.

At times, it seemed as if Sabrina advanced into APES 2 (i.e., began to experience some negative and often overwhelming emotions), stayed with the feelings for a while, but then eventually retreated. The next passage describes an episode where Sabrina felt panicked and confused.

Sabrina: …I was so panicked about it, that I—my brain was completely kaput. (laughs) I tried journaling it, but I wasn’t getting anywhere so I just stopped and went to bed. So—

Therapist: Okay, so there’s so much anxiety surrounding that idea that you’re just—like, block it out, sort of—got all confused about it too?

Sabrina: Yeah. That’s probably pretty accurate. [whispered]

APES 3: Problem Statement / Clarification Sabrina’s tendency to avoid talking about her problems became a secondary or derivative problem itself. Sabrina was aware that she did this, could openly talk about it, and clearly saw the ways in which it interfered with her life, namely her relationships. For example, Sabrina stated in the IPR interview, “It sucks when that happens…when I’m not aware that I’m doing it [zoning out]. These factors all indicate that the problem of dissociating could be considered at APES 3. On the AQ, Sabrina commented, “I’ve tried to be more aware to catch myself ‘zoning out’ during a normal day and to think about why.” When asked to elaborate on this during the IPR, Sabrina discussed her growing awareness of this as a problem (APES 3) and began considering reasons for doing this (inching toward APES 4).

Sabrina (during IPR): It forces me to be conscious about it. At least when I realize (laughs) that I realize what’s going on. I mean, uh, it forces me to be more conscious about it and it forces me to at least try to figure out what’s going on.

Sabrina displayed evidence of APES 5 (working through) in the sense that she tried to be more aware and stop herself when she was dissociating because she saw the impact it had on her conversations and relationships. Interestingly, Sabrina seemed to achieve some success at doing so, without ever really understanding why she dissociated, in essence, moving from APES 3 to 5 without gaining the insight/understanding characteristic of APES 4. Perception of Progress Progress / Insight is a Mixed Bag. There were several instances where Sabrina was proud to report on progress she had made in therapy (e.g., gaining clarity about her problems, developing some insight and understanding about her problems). However, this feeling of pride was often accompanied by a sense of dread about how she was going to solve her problems (now that she was aware what they were) or if she had some ideas about ways to solve them, she worried that the struggle was going to be long and hard. Progress was often a mix of positive and negative emotions. The following passage illustrates the mixed reactions Sabrina had to discovering the degree to which she “zoned out” both in and out of therapy. She seemed pleased to become more aware of one of her struggles yet frustrated by the thought of figuring out how to change such a long-standing pattern.

Sabrina: Um, there was a little sense of relief. It’s always nice to know and (laughs) sort of figured out something. Um, but at the same time, I think I was sort of thinking about the extent that I do it and how long I feel like it’s going to take me to not do it anymore. So, there’s some relief and frustration and--

Researcher: So it was a mixed bag, right? (Sabrina: yeah) So partly it’s relief of, oh,

Sabrina: Sort of a weight off your shoulders cause in a sense. But in another sense it was sort of like, well gee! (laughs)

Researcher: Look at all this work ahead of me (Sabrina: yeah) to deal with this.

Sabrina: Basically, yeah. Like well, “yeah, kind of good to know what’s going on” but um, more in a sense of this one, like well, okay there’s X number of things that I/we just thought of. Well, that’s a lot! And (laughs) I don’t really know where would be a good place to start or how to start or—I mean there are some ideas floating around in my head, but I don’t know where to begin.

Sabrina made additional reflections on the notion of progress being a mixed bag. In the next passage, she expressed ambivalence about being more aware of her tendency to dissociate.

Sabrina: At least I know. (laughs) Better to know.

Researcher: Yeah, yeah. So it is, it is a mixed bag.

Sabrina: With knowing comes a certain amount of responsibility, too. Which is sort of a pain in the ass sometimes (laughing). Because when you don’t know, you can be like “oh I don’t know, whatever.”

Hesitancy to Reflect on Progress. When Sabrina and her therapist were reflecting on their work together, she noted that she seemed to feel better and as if therapy was working after returning from a summer break. She didn’t have an explanation for the change nor did she seem eager to come up with one. It is possible that Sabrina simply didn’t care why she was feeling better or that perhaps it was too dangerous to ask why—that she might lose the progress she had made.

Therapist: I remember you coming back that second year feeling, much different. And you were never really able to say what that was.

Sabrina: I never came up with a why either. [pause] It’s sort of like, don’t look a gift horse in the mouth, you know.

Therapist: Well yeah, you don’t have to psychoanalyze your life to death. But at the same time, it would be nice to know, if it was something that worked for you. If you know what it is, we could make it happen more often.

Sabrina: Unfortunately, I don’t know. ______Researcher: She’s asking you to sort of think about what that was? Or, the difference?

Sabrina: First, she asked when I started to notice that things were getting better. And I said, after the first summer. Um, and so there she was asking if I remembered what it was that changed. And I said no, I didn’t.

Researcher: Because you were unsure yourself, right?

Sabrina: Yeah. I said, I think I ended up saying it eventually, that I think it was just a bunch of little things that added up, that I didn’t really notice the process changing at the time.

Researcher: Mm hmm. Some sense of too much, like, psychoanalyzing yourself, like is there some sense of, aren’t you tired of that?

Sabrina: Don’t look a gift horse in the mouth. Sort of like, if I think about it too much, you know, it will come back to haunt me, or-or something like that. Like I’m just gonna take, take what I have.

Researcher: Just take it and run.

General Reflections on Progress. When reflecting on some of the changes she’d made in therapy, Sabrina noted that talking about some of the “little” coping strategies that had worked in the past and bringing them to the front of her mind was helpful. She also compared her journey in therapy to running a marathon (which she was actually hoping to complete some day). The metaphor, discussed in the following passage, was a powerful way for Sabrina (and others) to understand her progress. It shows where she had been, and what she still had left to accomplish.

Therapist: It actually—the marathon—kind of reminds me of, metaphorically, about what you’re saying about our work here. You’ve made a lot of progress. You’re not like, huffing and puffing after 2 blocks anymore. You can run half a mile, and you wish you could run whole—half marathon. You wish you could run a whole one. You can’t yet, but it feels good knowing that you can run a whole lot more than 2 blocks.

Sabrina: Yeah, it’s weird how that ended up happening. [pause] And I supposed I made it half-way to a marathon, but I, my instinct tells me that I’m a little more

than half-way. Um, I don’t know. It’s kind of interesting how that kind of ended up happening.

Therapist: Sort of parallels

Sabrina: Mm hmm. Kind of cool, but (Therapist: yeah) ______*Researcher: Here, it’s like feeling more than half-way? Sort of, you’re comparing—

Sabrina: I’m comparing myself to a marathon. There’s 26 miles in a marathon. I ran 13. And if there’s 26 miles in my progress in my emotional stability, I feel like I’m a little bit more than 13.

Researcher: More than 13, yeah, yeah.

Sabrina: But I was just, I was just saying how I think it was interesting how those two things ended up happening at the same time…um, or at least that I—you know—realized that they happened. Like, hey I came and I ran half a marathon. And hey, it’s almost the end of the year. And you know, I’m doing a whole lot better than I was at the beginning. Even though I can’t do the whole 26 miles. So—

When asked how she felt about being more than half way to her goals, Sabrina’s response was mixed. In the continuation of the passage below, she noted how she was both proud of her progress and fearful of how hard the rest of the journey was going to be—another instance of progress being mixed.

Researcher: Okay. And feeling more than half way—kind of realizing that, um, that you’re more than half way to where you want to be—in the metaphor of a marathon. What was your reaction to that?

Sabrina: Um, (laughs) a little bit of a mix, as usual! Because, I mean, more than half way is—I think, significant progress. Then I think of it in terms like—just as an example—if I’m at 18 miles or something like that. You know, and I have 8 more to go. How I was, um, when I was running the 13 and how hard the last—how much harder the last 3 were than I had anticipated. And so if you think of it in a metaphoric sense, you know, that I only had 8 more left out of 26, but, it probably. It was still going to be a really hard 8 miles left.

Toward the end of the final IPR interview, Sabrina was asked to reflect generally on therapy—what was meaningful, helpful, etc. The following passage highlights Sabrina’s sense of the progress she made and her gratitude for having developed a trusting relationship with her therapist that allowed her to feel more comfortable relying on others for help. Although not a

stated problem from the beginning, Sabrina improved her ability to trust others, which appeared to be one of the main benefits of therapy. This passage also illustrates how Sabrina learned how to become a client.

Sabrina: Um, I think—no matter how much I value you my independence, um, coming in to therapy has been way more helpful than I would have ever been on my own. Even though I like to think that (laughs) I coulda-I could have done it better. Um, I mean I was new at it three years ago. And so, I definitely went in with this sort of like, “ I have no idea what I’m supposed to do.” (laughs)

Researcher: What’s expected of me?

Sabrina: Um, you know. But, over—obviously over the years I’ve gotten more comfortable. And I think the process has been a little slower for me than maybe some other people. But I definitely think that—I mean I gained a lot out of it. So, I think, you know, I think it could be beneficial to anybody. I mean, it doesn’t really matter what the issue is, I don’t think. I mean I think I used to sort of have a, um, you have to be so, like, messed up to benefit, but I think even the little things that aren’t related at all to, “hey I’m having a shitty emotional day” have been helpful top, so, I feel like I’ve learned a lot about myself, but I also think that you need to find the right person to work with too. Because it’s obviously not going to work if you don’t get along.

Researcher: That’s seems important, yeah.

Sabrina: If your viewpoint is different, or whatever. So—

Researcher: So have you felt like it was a good match with [therapist]? You got along?

Sabrina: Um, I was back and forth with it for awhile, but I feel like at the end, it was. But I also think that I was really back and forth with it because, I was, one—really new at it; two—very not confident in myself at all, um, and you know, just things like that. Like, trust issues and things like that, I guess. So, I mean I don’t think it would have mattered who it was at the time.

Researcher: But feeling like that trust kind of grew over time.

Sabrina: Mm hmm. It was a little bit slower than I would have liked, I guess, but now like I said, I’ll take what I can get.

Therapeutic Alliance / Voice of the Therapist By the end of their three-year therapy relationship, Sabrina seemed to have internalized the perspective of her therapist, assimilating the voice of the therapist if you will.

Therapist: Some days when it’s hard, sure. And you probably have that little therapist in your head (Sabrina laughs) that talks to you, sometimes. Even when I’m not there. (Sabrina laughs) Am I right?

Sabrina: Yeah. (laughs) ______*Sabrina: Follow me around in my head!

Researcher: Is there a sense of having some kind of a little [therapist’s name] or a therapist inside of your head?

Sabrina: (laughing) Um, sort of. I mean, there will be times when I catch myself being, like, real self-critical and I think, “now Sabrina, you know, that’s not really how it is— you’re not really that bad” [said quietly as if in therapist’s voice]. It’s just funny. Because when she said that, I thought about it. Times when I caught myself doing that and it was just kind of funny, to think of it in that way. Like there’s a little therapist in my head.

Sabrina and her therapist appeared to have a solid working alliance. The following passage illustrates how, according to Sabrina, her therapist was able to offer her something different than most other people in her life provided. Specifically, her therapist did not ridicule Sabrina’s recent accomplishment of running 13 miles and her desire to one day run a marathon.

Sabrina: …that was a huge accomplishment for me. Just personally. So I was really excited about it.

Researcher: What was it like to share that, with [therapist]?

Sabrina: Oh gosh, I was telling everybody! Most people—I mean, I got a better reaction out of her than I did most people. Cause a lot of people are like—like I said— were like, why would you want to do that? And, I just want to be like, “give me a break!” (laughs) I can’t stand people—you know what I mean?

Researcher: Like it discredits it or something?

Sabrina: You know, whatever. But, yeah. Like my fiancé even was like, “why?” And I was like, “come on!” Seriously! (laughs)

Researcher: It’s a big deal!

Sabrina: Can’t you just say, “good job” and let it go? But yeah, so, most people were a little confused, I guess. But—anybody who was a runner understood. So, but it was nice to get some positive feedback too. Because a lot of what I’d been getting was sort of like, “okay, and why would you want to do that?”

Researcher: “Are you crazy?”

Sabrina: Yeah, “are you nuts?” Yeah, so--

Researcher: So it felt good to hear that. (Sabrina: mm hmm)

In the following example, Sabrina and her therapist were discussing their upcoming termination and ending of a meaningful relationship. They experienced a moment of truly being in-synch and which Sabrina commented on as being spooky—as if the therapist were reading her mind. This was especially notable since early in treatment, Sabrina often felt as if her therapist could and should read her mind so that she wouldn’t have to actually share her thoughts and feelings.

Therapist: …there’s a lot of different things to talk about when it comes to ending. One is, progress you’ve made and progress you expect to see in the future—things you didn’t see happen. Um, and sort of mourning that. And there’s also the piece of, um, there’s the personal relationship that we have and dealing with losing it. That may be one of the hard aspects.

Sabrina: Yes, I was thinking that as you said it. That was kind of strange!

Therapist: Oh, on the same [wave] length. Great! (whispered)

Sabrina: I’d hope so, after such a long time! (laughs) ______Researcher: [asks for clarification because client was laughing] What was that, did you say?

Sabrina: I said, “you’d hope so after such a long time.”

Researcher: But having the sense that you were, at the same place she was right then.

Sabrina: Yeah. Pretty much at the exact same moment. It was a little creepy.

Researcher: Weird, yeah.

Sabrina: (laughing) I was like, wow, I just finished thinking that. Were you like reading my mind at this point?

Researcher: But you’re in synch?

Sabrina: Yeah, mm hmm.

Discussion: The Case of Sabrina Problems and Derivative Problems One of the most striking features of this case was Sabrina’s tendency to avoid talking about (and thus feeling) problematic experiences. Sabrina’s behavior was characteristic of APES 1, where clients prefer not to think about their problems, which often emerge in response to external triggers. Clients typically suppress or actively avoid experiencing the problem and when they do, affect is intensely negative, but fleeting (due to successful suppression). The complicating factor for Sabrina, though, was that at times this avoidance seemed unconscious (little to no awareness that she was in a dissociative state, as in APES 0). At other times, though, the avoidance was a conscious strategy to avoid getting close to painful and potentially overwhelming emotions, indicative of APES 1. To further complicate this issue, the tendency to avoid, dissociate, or “zone out,” was a problem that Sabrina was aware of and attempting to understand and find solutions to (indicating APES 3). Said differently, Sabrina’s symptom was both a resource (way of coping with overwhelming negative emotions) and a problem (interfered with her relationships). A single APES rating would fail to capture this complexity. To make sense of this complexity, we considered that Sabrina was struggling to make sense of and assimilate multiple problems. From Sabrina’s perspective, the problematic experience was her tendency to “zone out.” She was aware of this and could speak openly about it (in the vein of APES 3). From the researchers’ perspective, it seemed that Sabrina’s dissociation and active avoidance was not the primary problem, but a derivative or secondary problem. It was a resource for dealing with a deeper, unspoken problem (presumably at APES 1). This resource, though, was also problematic. As one of the co-investigators phrased it, “Sabrina’s main problem is running away from the problem.” It is not fully clear what the underlying problem was since Sabrina did not, herself, seem aware of it. The problem could have been one specific and coherent trauma or, perhaps more likely, a series of diffuse, chronic invalidations. According to both Sabrina and her therapist, it was this lack of a concrete problem or trauma that made it difficult for her to understand and accept her pain. It is possible that Sabrina may have suffered a traumatic experience so painful or discrepant to warrant dissociation though we have no way of confirming or disconfirming this. What we do know is that Sabrina seemed to have several different, interrelated problems that were at different APES

stages in relation to her dominant community. In summary, Sabrina appeared to be making progress assimilating two problems: an unknown problem at a low APES level and the derivative problem of dissociating which was at a higher APES level. These two problems seemed related in the sense that while the unknown problem was still present—and at times prompted dissociative behavior—parts were gone (i.e., assimilated), explaining why Sabrina felt better. This may help explain another observation, notably, that Sabrina seemed to show a “working through” at each APES stage. For example, at a period when Sabrina was still dissociating, she was actively trying to catch herself doing this outside of the therapy relationship and trying to engage more fully in her relationships. She seemed to be applying this understanding to her daily life and in so doing, may have made inroads to advancing to APES 2 in terms of the primary problem. Said differently, the recognition and working through of her tendency to dissociate may have helped her to address whatever it was that she was avoiding. The progress on the zoning out may also have had practical benefits in her relations with other people. That is, progress on dealing with her zoning out had other benefits besides helping her confront bits of her dissociated problem or trauma. This could help explain Sabrina's sense that she had gained a good deal from therapy. A “Back and Forth” Sabrina’s account of a “back and forth” in her head between different parts of herself is consistent with the assimilation model’s account of internal multiplicity (people are composed of many different parts) and the notion of intrapersonal dialogue (voices engage in a spoken dialogue). Sabrina said she frequently felt torn, lived life at extremes, and was often confused because of this. These self-descriptions align with prior research accounts of APES 3, where conflicting voices are fully in awareness, of equal weight or strength, and are often engaging in rapid cross-fire (Brinegar, Salvi, Stiles, & Greenberg, 2006). Sabrina noted that feeling two different things at the same time was a familiar experience, occurring with great regularity. This observation underscores the idea that internal multiplicity or the presence of voices is not an uncommon experience. Further, the desire to find a “middle ground’ is consistent with the idea of creating shared understandings or meaning bridges between voices. “Don’t Look a Gift Horse in the Mouth” The assimilation model is predicated on the notion that successful outcomes in therapy are linked with acknowledging problems, gaining insight or understanding about those problems,

47 and working through them to generate real-world solutions. Along the way, psychological symptoms (e.g., depression, anxiety) tend to decrease. Sabrina and her therapist both commented on Sabrina’s progress (namely, feeling less depressed) but neither seemed able to explain what accounted for the change. In fact, Sabrina seemed disinterested in understanding the reason, as if knowing might jeopardize the gains she had made. As she said, “don’t look a gift horse in the mouth,” which might be interpreted as apathy for and even potential fear of examining the progress in greater detail. So while therapists and researchers are continually looking for the factors that facilitate change (i.e., linking process to outcome), clients may be less interested in doing so and may not have a theory of change, even a lay one. This does not necessarily discredit current theories of psychological change, but it does point out that they may be more useful to researchers and therapists than clients themselves. “A Little Therapist in My Head” Assimilation research to date has focused on voices internal to the client, with relatively less attention paid to the voice of the therapist. In one of the sessions we analyzed, Sabrina and her therapist co-constructed an image of a miniature therapist inside Sabrina, or in their words, “a little therapist in my head.” It seems clear that Sabrina had internalized some kind of representation of her therapist (after developing a trusting working relationship), which might be considered another internal voice that when triggered, could motivate thoughts, feelings, and behaviors. This observation led us to question what role the voice of the therapist plays in psychotherapy. It seems possible that in successful therapies, clients assimilate the voice of the therapist to some extent, giving them a different perspective or vantage point on their problems. In client-centered therapy, this might involve internalizing the acceptance and positive regard offered by the therapist. Or in cognitive therapy, it might involve adopting the therapist’s questioning of irrational thoughts. Future assimilation studies might examine this phenomenon, identifying and tracing the voice of the therapist across therapy sessions. One such study is underway, using a modified version of the APES to describe how clients assimilate the voice of the therapist (Mosher, Del Castillo, & Stiles, 2006). Results: The Case of Kyle Background Information Kyle (a pseudonym) was a 20-year-old single White male. He was a junior at a Midwestern university and worked part-time on campus. He was nearing the end of his therapy

with a graduate student therapist at a departmental psychology clinic (November-May) because it was the end of the school year. He had sought therapy to deal with depression and lack of motivation, which contributed to significant academic struggles. He had a 1.7 GPA and was on academic probation at the time of the interviews. Kyle’s therapist drew from interpersonal and archetypal theories in their work together. During therapy, Kyle’s depressive symptoms appeared to decrease, and he focused more on family dynamics and his tendency to please others instead of doing things for himself. Kyle met with me for three research interviews. PQ Kyle identified six problems on the PQ. From most significant to least, he listed: 1) I lack motivation; 2) I have trouble confronting people who are significantly older than me and in positions of authority; 3) My grades have slipped because of too much pressure; 4) I have trouble telling people about my problems due to guilt; 5) I tend to miss classes; 6) I have relationship problems with my ex-girlfriend. In therapy, Kyle said he talked less frequently or not at all about his problems with authority and his lack of motivation. AQ On the AQ in the first interview, Kyle did not identify with any of the moments described in the questionnaire in his most recent therapy session, but said he had experienced them in the past. We started listening to the recording of the session at the beginning of the tape, and I asked him to identify moments that seemed salient or important. He was able to elaborate on key moments even though he did not associate them with moments described on the AQ. On the AQ in the second IPR interview, Kyle reported that he felt a stomach ache during the middle of the therapy session, which he felt was connected to “going forward,” in his therapy work. He also seemed to identify with feeling “stuck,” In his words, “I definitely felt stuck—we both [he and therapist] thought something was wrong but couldn’t figure it out.” He also said that he felt totally lost and was unclear where they were going in therapy even though his therapist said they were “getting somewhere.” Kyle’s sense of being stuck seemed more theoretically consistent with APES 2—when clients often feel confused as problems are emerging—than APES 3, the stage this AQ item intended to reflect. When asked if he got a clearer sense of one of his problems, Kyle said he realized that he is always making excuses and that he eventually figured out why he does this. During the third interview, Kyle identified with several moments described in the AQ.

He seemed to identify with APES 1 (avoiding topics in therapy). He said he was thinking about his recent class absences but was afraid to tell his therapist because he feared she would judge him (she thought his attendance had improved and that he was attending class regularly). Kyle said he had been paranoid of judgment from a lot of people (not just his therapist) and feared that his classmates were laughing at him and talking about him behind his back when he went to one of his classes for the first time in over a week. He said he felt like an outcast but didn’t want to share this with her. Kyle also identified with the item asking if he had become clearer about one of his problems (APES 3). He said he realized that instead of living for everyone else, he should live for himself and make decisions that please him (and not his parents). He resonated with the other item assessing APES 3 (feeling openly conflicted about something) explaining that he felt as if his mind was saying, “don’t get back together with your ex-girlfriend because she betrayed you” while his heart was saying, “I love her and want to be with her.” Kyle also described his problem of living for others in three other AQ items, assessing higher APES levels. Most of his responses seemed to reflect gaining greater clarity on the problem and a renewed interest in solving it. Process of IPR Kyle seemed to readily engage with the IPR process. He had little trouble finding salient moments to elaborate on, both those identified in the AQ and others. He tended to elaborate on his experiences by sharing additional content (storytelling) rather than reflecting on his inner experiences at the time the moments had originally occurred. He did, however, make some interesting observations about himself while listening to his therapy recordings, notably that he tended to “swallow” his words when talking about something difficult. When asked to reflect on his research participation, he commented that the experience had been very helpful. He said he had initially agreed because it sounded interesting and because he wanted to be helpful. He said he hadn’t expected to benefit himself so directly. He said it had been easy in the past to not really think about his therapy sessions during the week, but that the research interviews helped him continue processing what had been going on in therapy. He said he learned a lot about himself and enjoyed the process. He seemed proud to liken his experience as a participant to the progress he had made in therapy in regards to doing things for himself instead of others. While his participation was initially to help someone else, he ended up completing it for personal satisfaction.

Analysis of IPR Voices and Intrapersonal Dialogue A full voice characterization was not completed (since that was beyond the scope of this study and because Kyle's problems appeared to be at lower APES levels where voices are less distinct), but there did seem to be two parts of Kyle. His dominant position or voice was termed the schemer. This was the part of Kyle that had a logical argument waiting for any opposition or challenge presented by others. It was also the part that seemed committed to getting by in life with the least possible amount of effort, be it at school or at work. The schemer voice seemed to rejoice in getting passable grades with little to no studying, had ample excuses for his tardiness at work, and seemed to delight in fooling others. The other less dominant and problematic voice traced to feelings of anger and hurt at the hands of his parents. This voice was just beginning to emerge in therapy and revealed a more vulnerable side of Kyle that did not feel as strong, competent, or in control. In the sessions we observed, Kyle seemed more in touch with feelings of anger (in response to poor treatment) than he did feelings of hurt or disappointment, though both were present to some degree. The strategies of defensive sparring and choking anger, described in detail in the APES sections that follow, seemed to be ways of warding off this hurt and angry voice. The following passage occurred just after the moment Kyle realized he had been “caught” by his therapist—he realized he’d been making a string of excuses and finally ran out of answers. A more vulnerable side of Kyle briefly emerged, and he contemplated doing something different (i.e., not responding with a defensive quip). This voice was quickly silenced, though, when Kyle decided that he could keep playing this “game” with his therapist. Therapist: You want to be a history teacher one day, right? (Kyle: mm hmm) So are you going to show up to class at 9:30 if class starts at 8:00?

Kyle: No, because that’s different. I have to be there on time for that.

Therapist: But you could probably teach them their lesson in half an hour. Tell ‘em what to read and send them on their way.

Kyle: Yeah, but teachers have to be at work by 6:30.

Therapist: You have to be at work at 8:30.

Kyle: (laughs) Yeah, but teaching is different.

Therapist: It’s a job.

Kyle: Yeah— ______*Kyle: Right here. Right there is when I realized that—cause I got quiet. And I--

Researcher: Yeah, I noticed that.

Kyle: Right then I’m like, she’s doing this on purpose! And I almost said something. I’m like, “no this is going to go somewhere.” And so eventually I was just--instead of trying to change right there, I was going ahead with what I would usually do before I realized it. Because, I could have changed that right there, but there was something coming. Yeah, because right now, it’s definitely—you can tell it’s just back and forth. It’s not anything specific, it’s just—her saying something and me defending it. And I’m like, okay. So, I’m back to kind of just jumping around now. Cause before it seemed like she was attacking me, and now I’m like, “uh okay” [said quietly].

Researcher: There was some laughter there. And then you said you noticed you got kind of quiet.

Kyle: Yeah. I mean I noticed that in the session too. Cause it kind of hit me and then I paused. And I’m like, “okay, I can do this.” (laughs) This is a good game—I can play this game. And then—well, we keep going [continue sparring].

In terms of dialogue, Kyle’s exchange with his therapist (interpersonal dialogue) was more pronounced than any conversation he had with himself (intrapersonal dialogue). Kyle did, however, show moments of an intrapersonal dialogue, where there appeared to be a back and forth between internal voices. The following passage is an example of a conversation between Kyle’s hurt and angry voice and the schemer voice. The hurt and angry voice (in italics) wanted to tell his parents that he’d been feeling depressed for awhile and that these feelings were associated with some of the hurtful ways they had acted toward him. The schemer voice (in boldface) didn’t like this idea, realizing that it had the potential to bring pain to both parties.

Kyle (in therapy): I don’t want us to get in a yelling fight. And I think that’s what will happen. Cause they won’t—if I go in and say, “look—last semester I was depressed. I really didn’t go to class.” They will freak out. I know they will— ______*Researcher: So what’s going on here, talking about this issue of, you know, potentially telling your parents?

Kyle: …I kind of think maybe I should tell them. Like they deserve to know sort of. But it’s sort of what they don’t know, won’t hurt them. And won’t hurt me! (laughs)

Reseracher: It won’t hurt you—cause I’ll—I’ll feel better! (Kyle: yeah) If we can just sort of keep this a secret.

Kyle: Yeah, and they’ll find out eventually. I know I’ll tell ‘em eventually. But right now, I don’t think it’s the best time just. Maybe over a cup of coffee in 10 years.

APES Overview We found evidence of multiple APES stages in analyzing Kyle’s therapy and interview sessions, though predominantly, the experience of being hurt by his parents seemed to be transitioning from APES 1 to 2. For much of the first two sessions, this problem appeared to be firmly in APES 1. This judgment was based on Kyle’s tendency to engage in defensive sparring with his therapist (and others) and his tendency to squelch any feelings of anger or resentment toward others. Passages illustrating these two strategies of avoidance are presented below, followed by evidence for Kyle’s transition into APES 2. In the final session, some of Kyle’s previously warded-off anger seemed to emerge, and he also appeared to gain clarity on the nature of this and other problems (indicative of APES 3). These passages are presented and analyzed in turn. APES 1: Strategy of Defensive Sparring At the start of one session, the therapist began questioning the veracity of Kyle’s concern about his problems (and desire for help in therapy) and began questioning his frequent rationalizations (e.g., excuses for missing class, showing up late to work). Kyle responded in a defensive fashion, and engaged the therapist in a heated, though logical, debate. The two sparred back and forth about whether missing class was a big deal (Kyle vehemently denied that it was a problem). The following passage illustrates this defensive sparring and Kyle’s large arsenal of excuses, this time, surrounding missing class for Good Friday.

Therapist: Um, have you not been wanting to go to classes lately?

Kyle: Yeah, I don’t know why. It’s just like—I mean I go, but well, this Friday is Good Friday so I’m going home to be with my family. And so--

Therapist: You always seem to have a reason to miss.

Kyle: (laughs) This Friday I do, but—

Therapist: But you say that every time. You always have a reason (Kyle: No, I don’t.) that makes it okay.

Kyle: Um, well sometimes I don’t—sometimes it’s just—

Therapist: I mean when you skip classes, uh, and you plan ahead to skip classes. You’ve already pre-justified it to yourself that it’s okay to skip class.

Kyle: Oh, I don’t think it’s all right to skip class, but I want to go home.

Therapist: Why can’t you go after class?

Kyle: Because then I wouldn’t get home till 9:00, 10:00.

Therapist: Well you’re going to be home all weekend.

Kyle: A day! [said defensively] I’ll be leaving Sunday afternoon-ish. At like 3. I don’t like driving in the dark, so it would make it more worthwhile to leave earlier tomorrow, but well—

This back-and-forth interpersonal sparring continued for several minutes, when in the next section, the therapist asked Kyle about the consequences of not participating in class discussions. Kyle had commented that he wouldn’t be missing anything in his discussion-based courses because he never participates, even when in attendance.

Therapist: And if there’s questions or things on the test about the discussion, you’ve been there to hear it.

Kyle: We don’t have tests. Just in the one class we have tests, and it’s straight out of the book—well books, and readings and movies.

Therapist: Why don’t you participate in the discussions? Don’t you get graded on that?

Kyle: I don’t know. I don’t participate any less than most people in the class. In all my classes, it’s usually 2 or 3 people that do all the talking. And once in awhile, I’ll have something important I throw in, I mean, and usually the professor is pretty pleased that somebody new is talking. But, then I feel like if I talk too much then I’m just one of those people that—

Therapist: Gets good grades for participation?

Kyle: Touché (laughs). Yeah, but I mean, I’ve never been dodged points for not

participating. I mean I guess there’s a first time for everything, but I don’t think it really matters.

Kyle continued debating with his therapist for several more minutes, discussing his reasons for frequently being late to work and the potential for getting fired. I eventually stopped the tape and asked Kyle what he was thinking and feeling at that point. His response is in the following passage.

Kyle: I think we’re almost to the point where I realize that I’m just making excuses. And I realize it; I’m just defending everything. Like defending myself in any way I can think of.

Researcher: So feeling like you have to somehow be on the defensive. How did you feel? What’s your sense of what it was like with [therapist] at this moment?

Kyle: Hmm, defensive. Like, I felt like almost like she was attacking me. Like, I mean I knew that, I’m like—okay, this has got to be getting us somewhere. Because, I—she said in a past session that I never bring any emotions to our session at all. And I, I was sort of trying to curve myself, like—

Researcher: Stop from feeling (Kyle: yeah) emotion?

Kyle: Yeah, I’m like, okay, “this is bad.” Okay, now—I was kind of getting angry. I’m like, nah, she’s—it’s no big deal.

A little while later, during the IPR, Kyle rolled his eyes and commented that the therapist started sounding like his mom. He noted how with his mom, he similarly defends himself when feeling attacked and vulnerable. And although this strategy usually works, Kyle realized that he was cornered or “stuck” in his discussion with his therapist, as illustrated in the following passage.

Kyle (during IPR): Yeah. It was just, and I was doing the same thing I was doing with my mom. If she gets on a subject that I really don’t want to talk about, it’s like—well, I’ll just defend myself. And so instead of trying to go to another subject, I’ll just defend myself because I know I can.

Researcher: Okay, so you could like change the topic or something. (Kyle: yeah) But here you’re saying, well I’ll defend myself and rebut whatever that person is saying.

Kyle: Yeah, it—eventually I talk myself into a circle, though. From here, I know I’m cornered and there’s no way out (laughs). And I think, around here, I’m realizing that I’m kind of stuck.

Researcher: I might be screwed.

Kyle: Yeah. Like I’m running out of answers. And I think—I kind of think she knew that the entire time. I mean, she really—like I said, today’s session she just impressed me. I was just like, whoah!

APES 1: A Façade of Happiness In the following passages, Kyle elaborated on his long-standing difficulty expressing anger, the first of which occurred right after Kyle realized he had run out of answers with his therapist. Kyle commented that he began feeling angry, but minimized it by saying, “it’s no big deal.”

Researcher: I wanted to see if you had anything more to say about the notion of, feeling a little bit of anger, but not really wanting to go there. Can you describe to me what that was like?

Kyle: Well, it was—I don’t know. I’ve never shown emotions around other people before. Um, my ex, obviously, 3 years—we had seen a lot of emotions between the two of us. And maybe my best friend who’s seen me upset. But no one’s ever seen me angry. Ever. I mean, I can get really angry, but I won’t—I won’t show anybody.

Researcher: You won’t convey it.

Kyle: Yeah. Or if I’m upset, I won’t show it. No one knows what I’m feeling because everybody knows me as somebody who’s perpetually happy. Of course, because I put on a façade—of happiness.

APES 2: Emergence of Anger Although Kyle often denied feeling angry both to himself and others, he eventually reached a point in therapy where some of this anger began to emerge into awareness. Although he didn’t yet feel comfortable expressing this to others (namely his mom and his boss at work), he could vividly talk about it in therapy and during the IPR. The following passage follows a segment of the therapy session where Kyle expressed anger at his mom for badgering him to change his major to computers, just like his older brother. In the IPR, Kyle explained that he felt angry but balked at the therapist’s suggestion that he might express this to his mom. He explained that he has difficulty displaying emotion (especially anger) in front of others, particularly those that are in a position of authority. Kyle was unable to directly answer my request to describe the experience of holding back his anger (as might be anticipated at a lower

APES stage) and instead, shared a story about how he recently had to hide his anger from a co- worker who worked under him. Portions of the passage that seemed especially indicative of APES 2 (emergence of anger) are in boldface.

Kyle (during IPR): …Last night, what happened was I was working at one of the lines [in a cafeteria] and this kid kept leaving. And my manager came up and she’s like, “where’s Aaron [a pseudonym]?” And I’m like, “he keeps disappearing. I have no idea. He always has a reason.” And she’s like, “cause I’ve caught him over at this other line and I’ve caught him in the dining rooms.” And I’m like, “oh.” And at that point, I can feel myself starting to boil. And we came back, and I’m like, “Aaron you’re not to leave the line again tonight.” And I’m like, “I’m going to get a drink.” Because I knew that if I stayed there, I would have started yelling at him. But I walked out of the dining room and…so I walked away at that point…but I mean, I’ve been doing it so long, that you know just again…I don’t want them to see that I have a mean side…

Researcher: Are there fears of having other people see that angry part?

Kyle: Yeah, it would ruin—at work I’m sort of like the nice guy. The nice manager that—you know, I’ll come over and tell you if you’re doing something wrong, but I won’t yell at you. I won’t write you up. But I’ve kind of had enough of it. I mean, it’s just like, every time I go into work, everybody expects something out of me. And it’s like, I’m a human. Okay, this is enough.

Kyle continued describing the situation that provoked him and said he did show some of his anger, but said he minimized it by only pretending to be mad. Clearly, though, anger that had been warded off for many years was emerging into awareness and beginning to be expressed to others (albeit in an indirect fashion).

Kyle: …or I would kind of play it off like I was jokingly mad, but I don’t know. One of these days. I—I have four shifts left. And I’m like, one of these shifts, it’s just going to be like, “shut up--just all of you.”

Researcher: Cause it’s been stifled for awhile, right? You’ve been sort of holding back.

Kyle: Yeah, well I’ve always—for 20 years—20 and a half years held in emotions. I’ve never shown—especially anger.

Although Kyle still seemed to think that showing anger was wrong and would cause others to judge him negatively, feelings of anger and resentment were bubbling up inside of him. Previous strategies for warding off the anger seemed to be failing. Because the problem inciting the anger was not yet clearly stated or understood, Kyle’s assumption that he might explode in

57 anger one day, as if the feelings were beyond his control, is understandable. Dysphoric feelings also emerged when Kyle told his therapist about how his dad had stopped being his Boy Scout leader and drama coach mid-way through his schooling. Kyle reflected on these feelings and talked about reliving the memories from his boyhood, as if he were going back in time.

Therapist: Were you upset that your dad wasn’t there for drama and Boy Scouts either?

Kyle: Well yeah, cause he had been there for my brother all the way through. My brother graduated, my dad was involved enough to be my—and my brother had gotten his Eagle—my dad dropped that shortly before my brother got his Eagle. So most of the time—

Therapist: He took your brother at least right up to the very end. (Kyle: mm hmm) How does that make you feel?

Kyle: It was upsetting back then. It’s upsetting now too. I don’t know, I didn’t really give it that much thought. But I was upset at the time. I understood that, it wasn’t his fault— ______*Researcher: What’s kind of going on for you right here?

Kyle: I don’t know, just—I really—it just brought back memories. I remember being so upset…I was just 15 when he dropped out of drama. I mean I didn’t understand that back then. And I tried to but--

Researcher: It didn’t make sense then.

Kyle: I mean all I knew was that I wanted my dad there. He had been there for my brother, why wasn’t he there for me? [Kyle continues talking about his hurt and disappointment.]

… Researcher: Sounds like a lot of these memories were kind of coming back at this point (Kyle: yeah) in the session. How—how did you feel sharing these things?

Kyle: It was—again, by now there’s no chance of me covering up anything [with therapist]. I mean, even now, I’m just—I just remember how it felt. I was just so upset.

Researcher: Like being back there.

Kyle: Yeah, and it was—right—just like going back in time.

Kyle continued elaborating on the ways in which he felt hurt or disappointed by both of

his parents. At the end of the IPR session, he commented that he felt like he’d made progress, but that it had been painful. He also described the phenomenon of unearthing memories and feelings that had been out of awareness for many years.

Kyle (during IPR): …she [therapist] was like, “well I know this was hard—the path to finding what’s wrong isn’t always easy.” Well now I know that… I haven’t thought about any of this really in awhile. I mean I must have buried these somewhere in between my freshman and sophomore years. Maybe I mean, it probably took a year— and I was probably—now I realize that I probably was depressed cause of depressed feelings. And now we’re getting to what those were—are.

APES 3: Stating the Problem As previously reported, Kyle had a tendency to engage in defensive sparring, which manifested with his therapist. After a long period of debate, Kyle not only recognized this tendency but came to see it as problematic. In the following passage, the therapist had asked Kyle if he’d always been able to make excuses. Instead of exploring this issue, Kyle continued defending himself, stating that his excuses usually worked and were therefore not a problem. He proceeded to share a story about how he had pleaded with a cop and a judge to reduce his sentence for a speeding ticket. What results is another debate about who was responsible for the ticket (Kyle blamed it on his friend who was a passenger).

Kyle: …and my friend, who I blamed the ticket on, paid for half the fine.

Therapist: You blamed the ticket on your friend!

Kyle: Indirectly, it was his fault (laughing).

Therapist: You were driving. ______Kyle: (laughs)

*Researcher: You’re laughing right now. So what were you thinking at that time?

Kyle: Well, (laughs) I was just thinking back to when the ticket happened. And, it was indirectly his fault. (laughs) And, it was just like, the fact that there was no reason he had to pay for anything, I was just kind of joking even when I said that to him. And one day, he’s like, here’s that money. Oh man. Like, this is when I realized, I just like—I talk myself out of everything.

Researcher: Out of everything—even this!

Kyle: Yeah. I mean, this is the law. Like, (laughs) so there’s something wrong with this here. Like even when the cop pulled me over, I had almost talked myself out of it.

Although Kyle seemed to recognize that his frequent excuse-making—even in important situations such as the law—was excessive, it is unclear if he truly believed this was a problem worth working on. Just after these statements (and also during the IPR), Kyle proceeded to brag about how smart he was to be able to evade the law with such ease and charm. Another problem in which Kyle seemed to gain some clarity was his tendency to live for others rather than himself. The following passage occurred in the context of talking about Kyle’s decision to stay a fifth year in college and to pursue a major that interested him but which was at odds with his parents’ wishes.

Kyle (during therapy): Well the thing I’ve been realizing the past probably week and a half is—I’m still working sort of for other people. I mean over the past week I’ve just started to figure out, I have to do this for me.

Kyle seemed to experience a kind of shift—a recognition that he hadn’t always done things to make himself happy, but to try to please others. He then expressed an interest in attending class and doing well academically for intrinsic reasons. However, he seemed unsure about how to accomplish this transition as well as whether to share his revelation with his parents. In his words, “I’ve been dealing with this my whole life, how am I supposed to fix it now?” Toward this end, Kyle expressed some regret that his therapy was ending (due to the end of the academic year) just as he was seeming to get to the heart of his problems. His therapist pointed out that articulating the problem alone could be considered a big step, as seen in the following passage, which occurred shortly after the problem statement in the previous passage.

Therapist: …the focus has kind of changed to…your family dynamics and your relationship with your parents and your brother… you were in your brother’s shadow, in her [mother’s] eyes. And that your father tended to just kind of quit on things…and then there was this newfound kind of issue that maybe was at the core of some of your other problems—that you had last year and last semester…and that came out just a couple weeks ago, really. And so now it’s like, wow this semester is over. We have to end. But…I feel like this is a good place to end. Like sometimes just realizing that that’s the issue helps a lot. And I think that in what you’ve just said, you’re illustrating how much that helps in that you’re starting to think, “you know, I’m going to do it for myself.” It’s not, my mom’s always going to wish that I did computers, but I’m never going to do

computers. So I’m going to do this for myself. And I think that it doesn’t mean it’s just, snap it’s all better and everything’s okay, and you don’t care anymore. But um, it will still be a hard thing to work through.

It is unclear, from a researcher’s perspective, how solidly Kyle had reached APES 3 regarding this problem, but Kyle clearly identified with understanding something in a new way, referring to this and similar statements regarding his parents as an epiphany and which seemed to hold great meaning for him. Perception of Progress At the end of the final IPR interview, Kyle described what it had been like doing the IPR, which allowed him a sense of perspective on where he’d been in therapy. He commented on the helpfulness of the 16 or 17 sessions of therapy he’d had to date in the next passage. He seemed especially struck by the sudden nature of his progress—which seemed to go from questioning why he was in therapy to the emergence of negative affect and a growing sense of the problem.

Kyle: And um, it was—nice over-viewing, seeing where I’d been. I don’t know, yesterday [previous therapy session] really helped like to see that the 16, 17 sessions were worth it. It was sort of—at the beginning I wasn’t sure. I was—

Researcher: Yeah, what did you think at the beginning?

Kyle: Like, for the first 5 weeks last semester and the first 7 or 8 sessions this semester even. Maybe even the first 8 or 9 sessions this semester, I was just like, “huh, so I’m just here talking.” (laughs)…But looking back even over those weeks, we were kind of getting somewhere. But it was kind of not getting to the core problem. So it was nice— and then seeing what I’d believed we’d made over the past couple 3 or 4 sessions. Man, we really got somewhere. But it was a little—little big. It wasn’t gradually getting into stuff. It was all of a sudden one week we kind of just hit a nerve.

Researcher: Yeah, it seemed like that was one of the sessions we reviewed. (Kyle: Yeah) Sort of that—all of a sudden it started to get more emotional and into something— like you said—more a core kind of thing about your family, right?

Kyle: Um hum. And I had never thought about it before…but it was kind of cool getting to learn all this stuff.

Therapeutic Alliance / Voice of the Therapist Kyle seemed to view his therapist as an expert who could guide him and fix all of his problems, ideally with little work from him. This view seems partially attributable to his lack of experience with therapy (he didn’t seem to understand what role he played as a client) but it also

61 fit with the worldview of the schemer voice, which tried to get away with doing as little work as possible. Kyle’s views of therapist as expert are present in the following passage, when his therapist suggested that there seemed to be more to Kyle’s problems than he was saying.

Therapist: Well I just think—I think there is something deeper there than, whether I should go to class. I feel like there’s something underlying all of this.

Kyle: Probably (laughs). I don’t know what it is though (laughs). ______*Researcher: What [therapist] said is pretty matter of fact. Feeling like there’s something deeper there. Um, and you’re saying, “I don’t know.” Tell me what was going on for you there.

Kyle: I was surprised that she was, like, I didn’t really know what to say, cause—I had no idea what it could be. I mean, a number of things—I was like, thinking typical consumer things like, you know, I’m paying you to figure this out (laughs). I have no clue! I wouldn’t be coming here if I had any idea of why I was coming… I was kind of embarrassed that I didn’t have anything to say. Like, at this point I was also going back to the thought, “well why am I here?”

In addition to not knowing how to proceed to “go deeper,” Kyle admitted to feeling embarrassed about his lack of knowledge. And while he did seem to feel put on the spot, the therapist’s question eventually prompted a deeper exploration of Kyle’s problems and seemed to facilitate the emergence of negative affect surrounding his family and the sense that he was living for others instead of himself. Later on in the same interview, the therapist said that she regretted writing Kyle a letter in support of a medical withdrawal from the previous semester, in light of Kyle’s acknowledged excuse-making to get out of all kinds of things. Her comment hurt Kyle and made him feel incredibly guilty for having used his therapist, albeit unknowingly. Although there was a moment of interpersonal pain, where Kyle felt as if her comment went “right to the heart,” it seemed to open up Kyle’s emotions and spur an awareness of how frequently he uses others, often without realizing it.

Therapist: Now I kind of regret writing you that letter. Just because you would have had the consequence. I—I was able—I fed ______*Kyle: Right there, like, that killed me. Like when she said, maybe I shouldn’t have written the letter. I’m like, huh that hurt. I mean, I didn’t say anything, but I mean, the mood had kind of loosened up, so and all of a sudden she said that and I was like, man.

And I almost—I almost felt guilty because I didn’t—I didn’t realize that I was doing it here. Like with her. I didn’t realize that last semester I was just making a big excuse for the semester…the only way to say it was that I used her, but I didn’t mean to. And it made me think that who knows how many other people I’ve used without knowing. Like how many excuses I’ve gotten written. How many teachers I would give some sob story to and they would write me a pass to go somewhere—go to the nurse to get me out of class or something. Who knows how many times I did that. I mean even getting myself to be allowed to hand a paper in late. Like, who knows how many times I’ve just done this. And I’m like, oh man, and then I did it. It was like it culminated right here.

Researcher: I hear you saying, wow—just sort of realizing how much I’ve done this in the past. Gotten out of things. But before you got there it seems like there was a moment, though, when [therapist] said, “I’m regretting writing that letter for you.” That it—it went right to the heart or something.

Kyle: I don’t think I’d ever felt so guilty and I don’t know if it showed up on my face or anything. Again, I try to cover everything so I’m just like, crud!…Again, I don’t think I’ve ever felt so bad because it wasn’t just her, it was when I realized how many times I’ve done it.

Researcher: Her and everybody else that you’ve used.

Kyle: Yeah, and I mean I could have been doing this to my best friend, and not even realized it. Doing this, undoubtedly at work and school, but I mean, who knows if I used my family or friends or something. And I’m like, oh man. Oh crap. At least, I think that moment there was just—right here—is where we broke through…It was a kind of a bad way to get there, because again, just like you said, it was like right—right to the heart…and it kind of just broke it up and like—

Researcher: So it got you somewhere, but the path was painful.

Kyle: I would much rather—I mean, I think it was right here on out that, I was trying to cover emotions, but I don’t think it was working anymore. I know I was visibly upset by now.

At the end of the session in which Kyle felt guilty for using his therapist to get a medical withdrawal from school, Kyle seemed really touched when his therapist asked if was okay. The following passage illustrates the relief and gratitude he felt from a simple question from his therapist—a question that conveyed, to him, that she still cared.

Kyle (during IPR): Yeah, I think this is just about the end. We talk about a little bit about my brother and then she asked me if I was okay. (laughs)

Researcher: When she asked you that--I mean, should we listen to that part or? Do you

remember it well enough?

Kyle: Well she asked me—she’s like, “Are you okay?” I’m like, “yeah, I’m fine.”

Researcher: Were you fine?

Kyle: Well I wasn’t—I wasn’t fine in the sense that I was happy or anything. But I mean I wasn’t suicidal (laughs)…But I was kind of surprised that, again cause I had felt so guilty earlier about the whole letter. And I was surprised that she asked if I was okay. And then—

Researcher: That struck something different in you then. (Kyle: yeah) How did you feel then?

Kyle: Well, I was kind of glad that she cared. It kind of showed that, “Are you okay, seriously?” [said tenderly] And I’d never thought of it. I’m like, “yeah.”

Researcher: But it was nice that she asked.

Kyle: Yeah, it was—made me feel better. I mean that alone made me feel better.

Kyle continued reflecting on his relationship with his therapist, lamenting their upcoming termination. He recognized that they had built a trusting relationship wherein he was just beginning to be able to share his intimate thoughts and feelings. He also seemed to fear opening up some of the problems connected to his family with just a few weeks left to sort through them in therapy.

Kyle (during IPR): …and then I was like—the only other thing that I had thought about—like when I was walking back to my room—was we only have 3 weeks left. And I’m like, how far are we going to get in 3 weeks? And I mean it’s taken a semester and a half to build a rapport with [therapist]--enough to where I trust her talk about just about anything.

Researcher: Even some of the more sensitive things.

Kyle: And I don’t really have to go through that. So I’m hoping that if we’re going somewhere, that she’ll be here over the summer too. At least for a couple weeks. Just to wrap things up.

The next passage illustrates the importance of language and phraseology in the dialogue between therapists and clients. Here, Kyle was bothered by the therapist’s use of the term “complaining of depression” to describe his initial presentation in therapy. Kyle was upset,

feeling as if she were criticizing him for either faking depression or whining about it.

Therapist: …you came in and you were complaining of depression, lack of motivation, not really able to like get into your schoolwork, not even really able to go to class. Um, and we spent the first 5 or 6 sessions before Christmas break kind of talking about—mostly about your— ______*Researcher: So [therapist’s] talking a bit here. What’s going through your mind as she’s sort of bringing up this issue of—

Kyle: She said “complaining.” (laughs)

Researcher: She said “complaining?”

Kyle: Yeah, that kind of bothered me. It’s true if that’s—I mean there’s no other good word for it. But it’s just--

Researcher: The way she phrased it, somehow.

Kyle: Yeah, it was just—it wasn’t really complaining. It was just stating the fact that I was depressed. It wasn’t like I came in and I was faking it. In a sense it kind of seemed like—I mean the depression wasn’t the core problem—but I mean, it wasn’t like, it was fake.

Researcher: Yeah, or somehow I get the sense that she made it sound like you were whining about it or something.

Kyle: Yeah. Yeah, there’s a big difference between having—actually having a problem or having a problem—and just complaining…but it kind of was like, okay, well there’s not really a good word for it, so I’ll just let it go.

Researcher: So it kind of bothered you, but you didn’t really say anything here.

Kyle: Yeah.

Kyle did not tell his therapist that he was bothered by her comment during the session. However, perhaps prompted by his exploration of his feelings during the IPR interview, he addressed it in therapy the following week. Both Kyle and his therapist reported that this led to a clarification of what she was trying to express (her words stemmed from the clinical terminology “presenting complaint”) and more importantly, led to a deeper connection and continued exploration as the result of resolving a rift in the therapeutic relationship. Although it seemed that Kyle had built up a trusting relationship with his therapist, he

hadn’t been completely honest with her, especially about his class attendance. She thought he had shown great progress from the prior semester in that he was attending classes regularly and would likely pass all four of his classes. In the following passage, Kyle doesn’t fully answer the therapist’s question about how he foresaw the completion of his semester.

Therapist: …How is your semester going to wrap up do you think?

Kyle: I’ll be here over the summer and next year. So, um— ______*Researcher: …when [therapist’s] sort of focusing on classes and finishing up the semester, what’s kind of going through your mind, I mean considering she knows some things but maybe not everything about how the semester’s going?

Kyle: Well I mean I sort of wanted to tell her that (laughs). I’m just like, “nothing” [said very sheepishly]. Not as well as you think it’s going to go. I mean the classes I’m in that I’ve been going to are going well, but this other class, it’s just—she [therapist] doesn’t know that, about the fourth class. That I’m dropping it. So, I—I was—that’s pretty much all I said.

Researcher: So it’s like, well you don’t know the whole story, right?

Kyle: Yeah (laughs)

Kyle seemed invested in presenting a positive image to his therapist, perhaps giving her the sense that he had progressed in therapy more than he really had. Although it does seem that Kyle was doing better academically, he had not disclosed his on-going struggles with attending class or his plan to drop one of his classes, the latter of which was reminiscent of his decision to take a medical withdrawal the previous semester. As he noted on the AQ, he hadn’t told his therapist that he’d been skipping classes all semester for fear that she would judge him. Discussion: The Case of Kyle Avoiding Contact with the Problem Defensive Sparring Kyle’s use of defensive sparring (with others) seemed to be an effective strategy to avoid contact with problematic experiences and to avoid feeling bad. Said differently, Kyle’s dominant community demonstrated a fairly effective tactic for not assimilating problematic parts of himself, namely the more vulnerable and weak aspects. This observation fits well with what has been described by APES 1: Unwanted Thoughts / Active Avoidance. The strategy used by

Kyle’s dominant community to avoid the problem might also be considered a defense mechanism and seems analogous to the psychodynamic notion of rationalization. What is interesting in this case, though, is Kyle’s growing awareness of this defensive strategy as a problem in its own right (aside from any underlying problems it may be protecting him from). The defensive sparring could be considered both a coping strategy and a problem, depending on which voice is the reference point. This is similar to Sabrina’s use of dissociation, described earlier. Both participants seemed to have a secondary problem (i.e., another problematic voice) that was a derivative of—and likely a dialogical response to—an earlier problem. These secondary problems seemed more assimilated and were rated at a higher APES level. Another interesting feature of this case was the intense back-and-forth interpersonal dialogue between client and therapist. Kyle’s sparring with his therapist seemed quite similar to the rapid crossfire substage (APES 3.2), where conflicting voices engage in intense intrapersonal dialogue, often rebutting each other mid-sentence. The parallel between the observations from this case (interpersonal sparring) and observations from previous cases (intrapersonal sparring or rapid crossfire)—led us to theorize that client-therapist sparring may be a useful step in creating shared understandings between individuals and between internal voices. At first glance it seemed as if Kyle’s defensive style inhibited the emergence of a problematic voice and thus prevented intrapersonal dialogue. Interestingly, though, the interpersonal sparring eventually reached a breaking point and Kyle recognized how much he relied on rationalizations and excuse-making. This process observation seemed to clear the way for the emergence of a problematic experience. It is possible that an increasingly open (and less defensive) dialogue between clients and therapists could lead to a more open and accepting intrapersonal dialogue. Stifling Anger Kyle also seemed to prevent contact with problematic parts of himself by denying or minimizing negative affect, anger in particular. Although Kyle seemed especially determined to hide his anger from others (for fear that they would no longer like him and think of him as a “nice guy”), he also seemed to be hiding his anger from himself. Negative affect, be it anger, sadness, or fear, is thought to be a sign of contact between conflicting voices (Stiles, Osatuke, Glick & Mackay, 2004). Kyle’s submergence of his anger thus would seem to be another strategy for avoiding contact with highly disparate and potentially painful parts of himself. Kyle seemed to fight the overwhelming feelings of emergence (APES 2) of a problematic voice,

similar to Sabrina’s tendency to use laughter, minimization, and “zoning out” to keep from feeling bad. Kyle did experience anger at times, allowing some to enter into his awareness, but then quickly stifling its full emergence. The stifling of anger seems well described by Kyle’s fear that he might one day explode with anger in an uncontrollable rage, having been boxed up for so long. “Just Like Going Back in Time” The moments when Kyle did allow problematic experiences to emerge into awareness (namely those associated with poor treatment from his parents), he spoke vividly about reliving the pain associated with old hurts, as if he were going back in time. This supports the notion that voices are active traces of experience. When voices are triggered or reactivated, so too are many of the thoughts and feelings that comprised the original experience or set of experiences. Kyle’s emotions may have felt so raw because they were never really experienced or processed at the time they occurred. A reliving of sorts seems to be a critical, though painful, part of the assimilation process that peaks at APES 2 when clients tend to feel at their worst. Socialization of Client Role Kyle admitted during the IPR interview that he had “no idea” what his therapist meant when she suggested that there was something “deeper” underlying his problems. He seemed unsure of how to proceed, feeling as if it was his therapist’s duty to fix him since she was the expert. Kyle initially seemed to have little understanding of how therapy worked and what was expected of him as a client (i.e., that he was expected to actively work alongside the therapist to address his problems). Over the course of therapy, he seemed to become socialized into his role as a client. Sabrina also expressed having little knowledge about how she was supposed to act in therapy, stating, “I mean I was new at it [therapy] three years ago. And so, I definitely went in with this sort of like, ‘I have no idea what I’m supposed to do.’” She, too, grew more comfortable talking in therapy as she realized what was expected of her. The Therapeutic Alliance Tears and Repairs In this case, several ruptures occurred, notably when the therapist disclosed that she felt as if Kyle had used her for a medical withdrawal. According to Kyle, her comment initially stung, and he felt incredibly guilty. The therapist’s use of transference and countertransference, whether intentional or not, seemed to allow Kyle’s primary problematic experience (feeling hurt)

to emerge into awareness. This enabled him to get some perspective on his schemer voice. Said differently, he could view this part of himself (from the vantage point of the hurt voice) rather than just be it. Kyle’s awareness of how he had treated his therapist seemed to promote internal empathy as well as empathy for other people in his life whom he may have hurt. In other words, a rupture in the client-therapist bond and the discussion that followed allowed Kyle to examine previous ruptures in other relationships and the ways in which he contributed to them. Another rupture seemed to occur when the therapist stated that Kyle had initially “complained” of depression. Kyle felt offended, as if his therapist thought he was either faking symptoms of depression or that the symptoms existed, but that he was whining about them. Kyle did not initially tell his therapist that he was upset by her comment. After talking about it in the IPR interview, though, Kyle felt comfortable broaching this topic in a later therapy session (with no prompting from the researcher). Kyle and his therapist both reported (independently) that this led to a fruitful discussion of what the therapist meant by “complaining,”—a word to describe his initial concern or “presenting complaint.” In assimilation terms, this might be thought of as creating an interpersonal meaning bridge, that is, reaching a mutual understanding of the word “complaining.” In addition to reaching a shared cognitive understanding of the term “complaining,” Kyle and his therapist addressed the emotional consequences of this misunderstanding. The therapist acknowledged Kyle’s hurt feelings and by working through the rupture, the two seemed to deepen and strengthen their relationship. The bond Kyle felt with his therapist was also salient when he reflected on their upcoming termination. He expressed concern over losing their trusting relationship before he finished working through his problems. It is hypothesized that Kyle’s success in sharing and working through hurt feelings with his therapist may help him do so in other relationships even if all of his problems were not “worked through” or solved by the end of therapy. The previous observations illustrated actual ruptures in the relationship. Imagined ruptures also seem to play a role in therapy. Kyle said he hid things from his therapist, namely that he wasn’t attending class regularly. He said he was afraid that she would judge him and potentially reject him (and create a rupture). Kyle seemed to long for acceptance and positive regard from his therapist, elements of the bond component of alliance, as well as one of the necessary and sufficient conditions of change that Rogers (1951, 1992) wrote about. Goldsmith,

Mosher, Stiles, & Greenberg (2006) have made some preliminary observations about the role of the therapist in terms of assimilation in client-centered therapy, suggesting the importance of making nonjudgmental, empathic reflections. Results: The Case of Brian Background Information Brian (a pseudonym) was a 31-year-old single White male. He was a nursing student at a branch campus of a Midwestern university and worked part-time at a fast-food restaurant. He had been working with a graduate student therapist at a departmental psychology clinic for the last year. The primary problems he dealt with in therapy were low self-esteem, feeling lonely/not having a girlfriend, feeling depressed, and anxiety/stress surrounding school. Brian had a solid academic record (3.9 GPA) but worried constantly about his grades and his potential for professional success. He said he hoped that many of his problems would be solved—namely his lack of a romantic relationship—if he could get a good job and earn a lot of money (during the interview, he was at a low SES level). Brian’s therapist described her theoretical orientation as interpersonal, and said her work was informed by archetypal psychology (e.g., using metaphors and imagery). Over the course of therapy, Brian’s therapist said it was often a struggle to focus on therapy process, since Brian was a very concrete, logical thinker. In terms of progress, she said that Brian no longer talked at her, leaving little room for her to speak, but was able to engage in more reciprocal conversations. At the time of the interviews, she said he had an outside group of friends that he didn’t have before. Brian met with me for 3 research interviews. PQ On the PQ, Brian identified 5 problems. From the most salient to the least, he listed: 1) I lack self self-esteem; 2) I am lonely / don’t have a girlfriend; 3) I have trouble talking to women I’m attracted to; 4) I feel depressed and hopeless; 5) I am anxious / stressed about school. He said that to the best of his knowledge, he shared anything he thought was a problem in therapy. He didn’t feel as if he were intentionally hiding anything from his therapist. AQ While filling out the AQ for the first time, Brian noted that his most recent session had been an “upbeat” one and that we’d have to go back about a month for more “drama.” He identified with one of the moments on the AQ meant to assess for a moment of insight or

understanding characteristic of APES 4. Brian said he realized that when he was speaking with his therapist, he used psychological terminology in order to demonstrate some knowledge of the field. Brian said she facilitated this new understanding by using an analogy that made sense to him. When asked to elaborate, he said his insight was “triggered” when his therapist asked him how he would feel (as a second-year nursing student) if a first-year nursing student told him how to give injections (a topic he was currently learning in school). Brian said he felt bad if he had ever made his therapist feel this way and apologized to her for trying to prove that he knew a lot about psychology. He explained that he had talked about defense mechanisms, for example, to prove that he wasn’t a “dumb Joe Blow” who didn’t know anything. On the second AQ, Brian did not identify with any of the moments on the questionnaire. We started listening to the beginning of the tape and Brian was instructed to stop the tape whenever he identified a significant or salient moment. On the third AQ, Brian identified with having trouble expressing something that was bothering him, an item meant to tap for the vague awareness and overwhelming emotion of APES 2. Brian said he couldn’t list any specific moments, but that he generally had times where “expressing myself is troubling.” He said this happened frequently and went on to clarify that perhaps “troubling” wasn’t the best word. He said he didn’t lack the courage to share things with his therapist (i.e., isn’t scared or consciously avoiding) but couldn’t seem to find the right words. He said he would say what was bothering him if he could. Brian also noted that stress may compound this difficulty. Process of IPR Brian seemed enthusiastic about participating. He seemed genuine about wanting to make a contribution toward my research, but also seemed appreciative of having social contact with an interested person (loneliness was something Brian had worked on in therapy). For example, I asked if he wanted to reschedule one of our planned meetings since it fell over a university holiday. Brian replied that he wasn’t going anywhere, didn’t have any plans, and was interested in meeting regardless of the holiday. Overall, Brian seemed adept at reflecting on his therapy, though perhaps less so on himself and his internal processes. He frequently stopped the recording of the therapy sessions to further explain what was going on and seemed to feel comfortable doing so. Frequently, this took the form of providing more context for his comments (often through engaging storytelling)

and/or clarifying what he meant in a didactic and, at times, pedantic manner. At other times, I was impressed by his ability to be aware of his defenses and certain patterns in therapy. And still at other times, he avoided answering my questions directly and would quickly resume the recording, presumably to avoid dwelling on a particular moment. On one occasion, when I asked him what he was thinking or feeling about a certain moment on the recording, he replied, “let’s see” and pressed the play button. During these moments, I don’t think he was necessarily avoiding reflecting, but perhaps due to his concrete thinking style, truly felt as if my questions would be answered by listening to more of what he had said in the session. Analysis of IPR Voices and Intrapersonal Dialogue Although we did not do a formal analysis of Brian’s voices, we identified two voices that were openly in conflict: the nice guy (a representative from the dominant community) and the destructive guy (an emerging problematic voice). The therapist identified a voice, which she termed “No bullshit-straight-up-guy” who wanted nothing less than straight answers. We think this voice is consistent with the destructive guy. We also identified an internalized critic voice that shamed Brian for feeling bad. Finally, we found evidence for sudden vocal intrusions— voices that seemed so unassimilated that they appeared out of nowhere in an eruptive fashion. Examples of these three observations will be presented in the following sections. “Feast or Famine…Where’s the Happy Medium?”. Brian reflected on his conflicting desires to be taken seriously / not considered weak versus not wanting to be so tough as to be destructive. The following passage represents a dialogue between these two conflicting parts, termed destructive guy, in boldtype, and nice guy, in italics (based on Brian’s words). The destructive guy appeared to be the problematic voice, in the sense that it was beginning to emerge into awareness, with some resistance from the more dominant nice guy voice.

Brian (in therapy): Sometimes it seems like I can come unwound. I try not to do that. Uh, I don’t feel that I’m a threat to society or anything like that or myself. I mean, ultimately. I mean like I said, I don’t—I—I don’t have the desire to reek massive destruction. You know, it’s not—ultimately, the fabric of who I am. You know, that’s not what I want to be about. But on the same token, you know, I want to be respected and taken seriously. Um…you know, I don’t want to be regarded as some pansy-ass wanna-be. You know, which may not have been the best of terms. But it’s probably the closest I can equate with that. I mean I do want to be respected. You know, I want to be regarded

well. ______Brian: That’s the first thing that popped into my head.

*Researcher: Yeah. So I’m gonna ask you a question about this. You’ve said, you know, it’s not—as your word—it’s not in your fabric of who you are to sort of be destructive.

Brian: Yeah, it’s not what I want to be

Researcher: And then you said, but on the other token, or a different token, that--

Brian: The other side, you know, I don’t want to—you know I don’t want to be destructive, but also, me not being destructive does not give people a license to take advantage of me.

Researcher: Right, so is there a sense that the two sides to the issue—maybe two sides to you—that they’re in conflict sometimes?

Brian: Oh yeah. Certainly.

Researcher: Can you say anything more about having conflicting parts?

Brian: Well, nothing jumps in my head at the moment. I mean I can’t say that I’m having any other conflicts like that. I mean that’s probably the biggest one. You know, you know I wanted to be a good guy. You know, a nice guy. But you know, in the same sense not wanting to be walked all over or taken advantage of.

Researcher: Right. So how do—how do I get both? How do I do both?

Brian: Yeah, where’s the happy medium?

Researcher: Happy medium, okay.

Brian: Which, you know, that’s probably a bad choice of terms, too, because life is not about a happy medium. It is often lived at extremes. So, I mean that’s—

Researcher: So if feels like it’s here [motions to one end] or over here [motions to other end].

Brian: Yeah. All or nothing. And that has a tendency to be my mentality, too. So, I can definitely relate to “feast or famine.”

As the previous passage indicates, Brian reported having significant difficulty making sense of two conflicting parts of himself that seemed diametrically opposed. The idea of getting

both needs met (being nice and being strong) seemed foreign. This tendency to view things in such black and white terms, or a “feast or famine” in Brian’s words, is characteristic of individuals at APES 3. At this stage, the problematic voice and dominant voice are equally in awareness and in direct conflict with one another, with short, alternating speaking turns. In reflecting on this experience, Brian was able to suggest that finding a “happy medium” would be desirable. In assimilation terms, a happy medium might be equated with finding a shared understanding or meaning bridge between the two voices to create a sense of inner peace. Internalized Critic. Brian also had a critic voice that told Brian he had nothing to complain about. He seemed to internalize this voice from others, in this case peers and teachers, who frequently gave him the message that he had no right to “bitch” about getting low A’s in classes. In the next passage, Brian had been telling his therapist how hard the last few weeks had been academically.

Brian (in therapy): From my perspective, yes, it’s been bad. Am I a spoiled little prick? I don’t know—but yes, from my perspective it has been bad. ______Researcher: What was that?

Brian: I’ll clarify that statement. [said matter-of-factly] In other words, and I’ve explained this earlier in this session, my lowest grade is like a 90%. Which maybe 50% of the class or something like that will be like, “well you don’t have a fuckin’ problem yet!”

Researcher: Ok, so it’s addressing those people that are like, “come on, quit your bitchin’!’’

Brian: Right. I mean that’s one way of puttin’ it.

Researcher: Ok, and I think you’re right because you had made an earlier comment, something to the effect of, “well some people might not say that’s right to complain.”

Brian: Yeah, they question my perspective…they ask me what the fuck I was bitching about. I mean I think I’ve even had a couple of professors say, what are you bitching about? Um, but you know what—[pushes play]

Brian pushed the play button without finishing his thought, perhaps a signal that he was finished talking about this problem. Although part of Brian seemed to refute criticism from others (I do have a right to complain), he had internalized a critic voice enough to question himself and cause uncertainty.

Hesitancy to Adopt Therapist’s Personified Voices Conceptualization. Toward the end of a session, Brian asked for specific feedback on how he related to others in a very demanding tone. The therapist commented that the tone of voice in which he was addressing her might be perceived by others as aggressive and might push them away. The following passage represents Brian’s explanation of this “voice” and the therapist’s personification of this voice.

Brian (in therapy): Well, [pause] that’s interesting. Um, basically uh, to translate it, basically if I had to put a name to that kind of voice, and that kind of demeanor, it’s just like, “no bull-shit, straight up, let’s have it, let’s have it now.” I mean that’s pretty much—I mean that’s how seriously I view it. Uh, and I don’t know how that will change. Or if that will change.

Therapist: I’m not sure either. I like that name. No bull-shit-straight-up-guy. He’s the guy that usually comes up—you know I like to personify, I like to call him a little guy, whatever—I think that’s fun. He’s the guy that usually comes up five minutes before the end of the session and starts asking me questions real fast.

During the IPR, Brian reflected that the therapist’s label for this part of himself seemed accurate and elaborated on its intentions and attitude, “Don’t fuck with me. Just give me what I want here.” It seems likely that this is a slightly different manifestation of the destructive guy. Although Brian seemed to initially resonate with the idea behind this part of himself, he seemed hesitant to wholly adopt a personified view of his internal parts because he associated different personalities or voices with severe mental illness, which ran in his family. The next passage (which occurred a few minutes after the previous passage) illustrates Brian’s hesitancy.

Therapist: We only have a couple minutes—a minute. So here’s what I’m going to say. And I’m gonna—I like to speak in personified metaphors. So please don’t think that I think you’re crazy or whatever. But I would really like to spend time talking to Mr. Bullshit, no-nonsense guy. And the hard thing about that, is that he shows up now. And you know, I’ve got to go to lunch, right? So, what I’d like us to try to do—and this is going to be hard—and more your job than my job—is can we figure out a way that we can talk to him—earlier in the hour. He’s got a lot to say.

Brian: Yeah, but he does pick his shots. That’s interesting. That’s a really interesting perspective. Cause I mean, I mean it—I don’t know, I try to think of myself as all one person pretty much, but—

Therapist: I think—I’ll tell you this much—I like to think of people, actually, as all different types of people. (Brian: okay) So maybe you and I differ like that.

Brian: Well I guess everybody has different elements of their personality. ______*Brian: Let’s bear in mind, um, my family—particularly my maternal side—has a history of mental illness. So therefore, thinking of myself as different elements or different personalities is not necessarily a positive thing.

Researcher: Cause there’s a lot of baggage there (Brian: right) in what that means in your family.

Brian: It’s kind of like, yeah, it’s kind of like I never used the term grown-up. I use the term mature and adult. But you know, but being male and 5’3”, that’s not grown-up. So that’s—

Researcher: So here, it’s—you’re a little skeptical of her use of, “parts of you.”

Brian: I won’t say skeptical. I’m always skeptical. Uh, maybe skittish would be a better term.

Researcher: So it’s stronger than skeptical? There’s a negative tint to it.

Brian: Skittish, uneasy, yeah.

Sudden Vocal Intrusions. During both the therapy sessions and IPR interviews, Brian demonstrated several instances of a sudden vocal intrusion, where his manner of speaking rapidly changed, from his typical manner of speaking to a loud, fast, and often angry tone of voice that seemed to erupt out of nowhere. Brian noticed some of these vocal intrusions while listening to himself speak on the therapy recording. In the following example, Brian astutely observed how abruptly he went from “mellow to cokehead.” The vocal intrusion is in bold type.

Brian (in therapy): I mean, I don’t know, I don’t personally have a problem with the guy, but I mean that’s about it. You ain’t got nothing if you ain’t got love. The term love—the term love can be ambiguous at this point. That’s probably going to be my word of the day. But um--

Therapist: Love is going to be the word of the day?

Brian: No—ambiguous. That’s three times in the span of ten minutes.

Therapist: I bet it’s really hard for a guy like you, who likes concrete facts and doing things—um, in order to figure out how things work—to have to deal with this kind of ambiguous faith. And you have no proof.

Brian: Well, yeah. I mean, yeah, that’s—it does make it tough. Um, I mean I’m pretty much just a facts—just a facts-kind-of-guy. I mean, I can—every time I try to make inferences, it’s because my—when I make inferences, it’s because I have an experiential component based on observable things [said loudly and with hostility]. You know. ______*Brian: All right. Now, for whatever reason, uh, I just went from mellow to cokehead in the span of one sentence. So, I don’t—

Researcher: Do you remember what was going on then?

Brian: Uh, not—no not really.

Researcher: Okay. But something struck you—you went, “whoa.”

Brian: Yeah, something did, obviously. Uh, um, cause I—I’m not exactly going to say that you know, I felt like I had to spit this out very concisely. I can’t say it’s like that. Um, I mean if anything, uh, I don’t know. Maybe it’s just—I mean the closest thing I can try to pin to it, may be you know, frustration. Experiential com—because of my experiences, a lot of them haven’t been pleasant. Maybe that’s—maybe it’s something to do with that. I mean, that’s probably the closest thing that I can think of. But uh, yeah, yeah, it seems like I went from zero to cokehead within the span of one sentence.

A few other vocal intrusions were present in the therapy tape, similar to the previous example, though not always noticed or commented on by Brian. The following passage contains two such dramatic intrusions, characterized by sudden changes in volume (much louder) and emphasis (said with intense anger). Both intrusions occurred in the context of Brian discussing the high SES level of most students and parents at his university with a co-worker; they are represented by the text in boldface.

Brian (in therapy): …you know, and I told one of my mangers at work this, and I should have known better. I’m like, “is it just me—why is it that all these parents are well-dressed?” And she’s like, “well you know, you’re talking about [university]. You know, well, they’re [university].” It’s like, “wait a fuckin’ minute. So am I!” You know, “well you don’t go to the [main] campus.” “So fuckin’ what!” You know they’re not any more—well, I’m not gonna—[main campus] students do have more privileges. But, they also pay a much higher tuition. But um, you know and then one of my other managers who just so happens to be a [university] student—it’s like, well yeah from what he told me the median income of families that send their kids to [university] was around 90K a year. ______Brian: Now I’m not sure if he meant median or mean. I think he said median.

______Brian: …it’s like okay, you know, if you—if you duplicate my household situation about 8 times, maybe we got 90,000. Okay, we’re not even anywhere fuckin’ close to 90,000. Uh, if all goes well, give me about 10 years, and I’ll be above 90,000 on my own. That’s contingent on whether or not I get a master’s degree. You know, and you see—you see them kids—I’m sorry kids—I mean they’re children that happen to be students. You know, and it gets depressing because you’re walking around these damn streets looking at something that you wish you could have but you know you never will. That’s what makes it an absolute mother. That’s what hurts more than anything.

Although brief, these vocal intrusions were marked on the audio recording of the therapy session and seemed to come out of nowhere. Although the content did not change from the surrounding text, the intensity and emotion certainly did. We had trouble delineating which voice was intruding, mostly because of its short duration. It is consistent in vocal quality with the destructive guy (angry, demanding tone), though seemed to also have traces of an underlying hurt and vulnerability. Perhaps this portion of the destructive guy was less assimilated and came out in angry bursts. APES Overview All three co-investigators agreed that Brian’s problems hovered around APES 1 (Unwanted Thoughts / Active Avoidance). Brian seemed adept at storytelling and while this could be perceived as entertaining and a way of engaging both the therapist and interviewer, it was also viewed as a way of keeping himself distant from his problem. Stiles, Honos-Webb, & Lani (1999) described several functions of narrative in terms of assimilation, including using stories to “maintain distance from or to avoid direct expression of the problematic (e.g., anxiety provoking) material” (pp. 1217). Brian also used the strategies of intellectualizing and teaching others (most notably his therapist and the researcher) as a way to avoid contact with his distress. Interestingly, Brian was at times aware of his tendency to avoid distressing topics. We also found evidence for APES stages 2, 3, and 4, though these moments were more fleeting. Passages supporting each of these stages will be presented in turn. APES 1: The Entertainer Brian was fond of using metaphors and song lyrics to convey his experiences (some will be presented in the following sections). It seems fitting, then, to characterize Brian’s penchant for dramatic storytelling with lyrics from Billy Joel, “I am the entertainer, I come to do my show.” While this, at times, seemed to be Brian’s way of connecting to others, it often had the

78 effect of keeping both himself and others distant from his inner experiences, namely problematic ones. In the next passage, Brian told his therapist how one of his classmates had tried to console him about being single, comparing him to Paul from the Bible.

Brian (in therapy): And she’s [classmate] like, “well maybe you’re like Paul.” And I’m thinking, “okay, thanks but please stop.” ______*Brian: Alright. Um, like I said, you know, she was just trying to be conciliatory, here. Um, Paul basically, you know the Bible says—you know he was an apostle. In the beginning he mocked Jesus and then he finally came to his senses, you know, and then became one of Christ’s leading advocates. And you know, one of the things that he says is he knows if marriage will disrupt how you serve God, than it’s better that you don’t marry. So basically her point, you know Paul—he accepted being single and you know, accepted that that was his path. And you know, I guess you know, found—found that to be—well what’s the word I’m looking for—you know, he accepted it. Where, you know, I can appreciate—I can appreciate service to God. You know, I’m not questioning that. You know, but—

Researcher: So when she says, “maybe you’re like Paul,” and when you’re recounting that story of what she said, what was that like for you?

Brian: I mean, my first initial thought is basically like, well you know, I hope—I honestly hope you’re wrong. You know, I mean Paul—you know this is pretty far into the New Testament…in the Bible. Now if you go back to the Old Testament, you know, um Genesis—you know, the very beginning, right after God created man, you know. It’s—the Bible basically says, you know, it’s not good for man to be alone. Now, we can’t necessarily put all of our stock in the Old Testament, you know, because basically those events have been altered by the New Testament. I think that’s the more current teaching now. But I mean, still some people—you know even—they still have to go to Psalms and Proverbs. They’re still very popular even though they’re Old Testament scripture. I mean, she was trying to be nice.

The story of Paul seemed to hold meaning for Brian. In his second speaking turn (in italics) he was briefly able to state that he did not want to end up alone like Paul (after some questioning by the interviewer). Brian seemed unable to stay with this feeling, though and reverted back to telling and explaining less relevant information from the Bible. In the next example, Brian charismatically described a beer commercial during the IPR that seemed related to a moment he had just described in therapy about his desire for academic success and glory.

Brian (in therapy): Just the thought of having a degree with some kind of cum

laude stamp on it, you know, in a picture frame on the wall is a nice thing to look at. Uh, it’s a nice thing to show people. It gives them an indication of what I’m capable of. Again, a flash of brilliance. I don’t think I’m going to earn a higher rank pay on account of it, uh— ______*Brian: Oh damn, what’s that beer commercial? It’s not Beck’s. It’s not Killian’s, I don’t think. And it’s not Amstel is it? Uh, it’s the animated commercial. It’s kinda like a collage-type thing. I’m—it may just be on ESPN for the most part. But I cannot think of the name of the beer. But it’s got the two guys, and I guess they brew beers and stuff like, and it’s like, “I found an idea.” “What’s that?” “Beer in a bottle.” And the other guy goes, “beer in the bottle, BRILLIANT! [loudly]” Have you seen these commercials?

Researcher: No, I don’t think I have, but there’s something about that being a flash of brilliance.

Brian: Yeah, and so it—I mean that’s the most spoken word in that whole commercial is every time the one guy says something, the other guys says, “brilliant!”

Researcher: And that sort of—wanting somebody to acknowledge you, maybe, saying that that was brilliant, Brian. [Brian quickly pushed play before comment is finished.]

Brian: Uh huh, don’t we all want that? [said over top of tape]

So again, while the story Brian told (in this case about a beer commercial) wasn’t completely tangential from his experience, the narrative kept him distant from his stating his experiences more directly. Said differently, Brian seemed to find it easier to talk about his experiences in the third person, rather than the first. APES 1: Intellectualizing and Teaching Others Clearly, Brian was a bright young man with a history of academic success. It also seemed that Brian relied on his intellect (or “academic prowess” as he referred to it) as a defense when feeling vulnerable. His intellectualization often took the form of pedantically teaching those around him, including his therapist and myself. This seemed to be another strategy for avoiding contact with his problems and negative affect. The next passage illustrates Brian’s tendency to teach, first with me (definition of “subcutaneous”) and then with the therapist (giving an injection; what it means to “aspirate”).

Brian (in therapy): I mean it was just a subcutaneous injection because we were using insulin needles. I mean we weren’t using anything like— ______*Brian: Subcutaneous—that just means it goes—just—there’s a layer between, a layer

of fat basically, between the skin and the muscle and that’s where you put it in to— ______Brian: --you know, just a half-inch, probably a 28-guage needle. So, what you do, you just pinch the skin a little bit. So, I mean but I think I kind of ended up throwing it in there like a dart. So, I mean she didn’t say it hurt or anything like that. You know, and I had another professor tell me, “yeah, well it is kind of like throwing darts.” (laughs) So, they said, “well you gotta be quick about it” which is what I tried to do—just be quick. You know, I didn’t want to—you know, but I think it’s all good—

Therapist: You didn’t do it perfect, but it wasn’t terrible.

Brian: Well, I mean there was a pretty good bleed. Um, now, I mean that—there could be one of several factors related to that. Because when you put a needle in, normally you aspirate. Which that means you pull back on the plunger. Okay, and what that’s designed to do is see if you hit a blood vessel.

Brian relied on intellectualization in the following example as well, demonstrating his knowledge of anhedonia, a psychological term. It seemed to be a way of keeping him distant from a moment just reviewed in therapy, when the therapist had asked him what he found intrinsically rewarding about high academic achievement.

Therapist: Now, we’ve talked about the monetary and social rewards, and things like that, but what is it going to get you for you? Just—what else besides the house and possibly the wife and paycheck?

Brian: You mean as far as intrinsic measures? [sighs] Well, I don’t know, just the thought of having a degree with— ______*Brian: Ok, maybe that’s one of my weaknesses. I mean there are times in my life where I’m in an anhedonic state. And, you know, that’s—I haven’t been diag—well, I may have been diagnosed with depression actually. I think I saw that psychiatrist maybe twice. Uh, so yeah, anhedonic-- are you familiar with what that means? (Researcher: mm hmm) Some people aren’t.

Researcher: It’s a lack of pleasure.

Brian: Right! Not getting pleasure from a damn thing. And believe me, I myself, had to search the root of that term. Hedonism: pleasure-seeking behavior. Okay, an: anti pleasure. Got it. So anyway, um, now I consider that an achievement actually, but um, just you know, so I don’t think about intrinsic things all that much. And socially, I think a lot of us have been ingrained to seek the extrinsic stuff.

APES 1: Awareness of Avoiding Distressing Topics

One of the areas Brian struggled the most with in life, and also found the most difficult to talk about, was forming and maintaining relationships, particularly with women. The following passage illustrates Brian’s tendency to focus on the stresses of school as a way to avoid talking about his relationships in therapy. In this segment of therapy, Brian is explaining that he has been eating poorly, sleeping more, and smoking more cigarettes because he had been feeling stressed about school.

Brian: …Eat more, slept more, yeah. Yeah, I think I bought this pack [of cigarettes] last night man, and half of it’s gone already. So, but I don’t know—I don’t know. I’m still trying to fight the good fight. You know, just get it done. And maybe there’s a character lesson in all this. I don’t know.

Therapist: A character lesson? (Brian: Yeah) About your character?

Brian: Yeah, the whole—what doesn’t kill you, makes you stronger, bit is what I’m driving at. I don’t know. I guess maybe it’s comforting that I’m not thinking about some of my other issues so much. I don’t know, but then again, ______[Brian is laughing during IPR]

*Researcher: I’m pausing it because you’re laughing right now.

Brian: (still laughing) It just seems like a funny statement. Um, I mean with school, you know, it seems like things are diverted at this point. You know, I really don’t have time to focus on my lack of relationships. Wait a minute, that was “Freshman” by the Verve Pipe (laughs) But anyway—

Researcher: So it’s—you’ve been talking about how stressful school is, but on the other hand it’s comforting because you get to ignore the other problems in your life.

Brian: Yeah, in a manner of speaking. So—

Researcher: Some of the problems that were on that list? [Assimilation Questionnaire]

Brian: Right, I mean they haven’t gone away, but I mean they’ll—those demons will surface again when the time is right.

Researcher: Now it is not that time though.

Brian: Right, not at this point. Now, that doesn’t mean that I don’t have distractions, but, I mean still even though I know school is important, you know, it’s still kind of tough to focus.

Researcher: Okay, distractions from school—so school is both a distraction and you can get distracted from it. (Brian: Um hmm)

In the previous example, as well as the next, Brian seemed to be actively avoiding discussion of his relationships in therapy and was aware of doing so. The next passage illustrates that Brian didn’t always completely avoid talking about relationships, but often waited until the very end of session to do so, when there wasn’t much time to process his questions and concerns.

Therapist: And I think part of what happens, we get in this cycle where you wait till the very end of the session to ask me about something, and there’s not really time to deal with it. So I’m saying right now at the beginning of the session (Brian: alright) that I think you have some questions. ______*Researcher: You put—you did this [Brian had slapped his hands together in IPR; Researcher mimicked it]. That’s like, okay we’re getting to it now, early?

Brian: Well um, it was a slightly different approach.

Researcher: Different than normally happens?

Brian: Right. Usually I just spit some dialogue throughout the session, you know, and sometimes, you know, I have a tendency to bomb her with a question at the end of it when we only have like one—maybe a minute or 30 seconds to address this situation. You know, I don’t know. I looked over a list of defense mechanisms last night, and I don’t remember them right off hand, so.

Researcher: Oh that’s okay. I mean I’m not concerned about technical terms. But it— but so this was shaking things up a little bit.

Brian: Yeah, changing gears a little bit, which that’s cool.

And while Brian was aware of his tendency to wait until the end of sessions to bring up the topic of relationships (which was potentially very distressing), Brian also seemed willing to talk about it at the beginning of this session, with some prompting from the therapist. It seems like this provided a gateway from APES 1 to 2. Brian did, in fact, open up a little more about his relationship problems. APES 1: “Aren’t My Feelings Obvious?” There were multiple times during both the therapy sessions and IPR interviews when Brian seemed frustrated with the thought of articulating his emotions. He often seemed to feel that words weren’t necessary, as if his feelings were self-evident by the look on his face or based

on the content of his speech. In the following example, he expressed his frustration with his therapist during their first few sessions when she repeatedly asked him how he felt. His response in this, and other situations seemed to be, “aren’t my feelings obvious?”

Brian (in therapy): During the first—I mean our first initial sessions, I think I did most of the talking. Um, I think you asked me about five straight times after I stated something, “well how does that make you feel?” So I’d have to explain some more stuff again and then you say, “well how does that make you feel?” ______*Brian: That kind of got annoying.

Researcher: The “how does that feel?,” right?

Brian: (laughs) You know, I’m—well how does that make you feel? And you know, I think at first it was like, “well God damn it, can’t you figure it out?!” (laughs)

Researcher: Isn’t that your job?

Brian: Yeah, so it’s like, wait a minute. The—the—I mean I think I can understand you know, the purpose behind it. But yeah, I mean, it kind of got annoying. That was like our first session. And I’m thinking, “isn’t it obvious?” (laughs)

Researcher: Isn’t it written all over my face?

Brian: Yeah, isn’t it obvious how it makes me feel—geesh! You know, that type of thing.

In assimilation terms, it seemed as if Brian was avoiding full contact with his problematic experiences (often, feeling lonely). He seemed minimally aware of certain negative emotions (i.e., “aren’t my feelings obvious?”) but didn’t want to articulate them, perhaps because doing so would have made him feel worse. It is possible that Brian was at a midway point between APES 1 and 2. If problematic experiences were emerging, he may have had to be more active and creative to avoid them. Brian seemed to want to be understood by his therapist, though rarely expressed or communicated negative emotions in a direct fashion, making an empathic connection more challenging. Another example of Brian feeling that his therapist should be able to read his mind and/or automatically understand his emotions came when they were discussing how their relationship differed from other relationships. Brian was hinting that he wanted more of a connection with the therapist than was professionally appropriate (not necessarily sexual, but the kind of intimate

84 connection he longed for with a woman). In this instance, he appeared to be inching closer to APES 2 and accordingly, had trouble articulating his experiences, which resulted in frustration during both the therapy and IPR sessions.

Brian: I mean, I mean it’s a different value, it seems, than what I’m looking for. I mean yeah, that’s a tough—that’s a different type of value all in itself and I’m not necessarily speaking of that type of value.

Therapist: Can you tell me exactly what that type is? ______*Brian: It should be obvious, [therapist]! Come on.

Researcher: So maybe—so maybe she didn’t fully get it here. Or she’s asking just for more clarification. (Brian: Mm hmm) And you’re probably like, don’t make me say it. Or--?

Brian: Well, I mean I’ll say it in the best [way] I can considering the stress of the situation that that question puts me under.

A final example of Brian believing that his feelings were obvious (and there were more) came when his therapist noted that Brian didn’t seem too convinced that he would be able to improve his grade in a course from a B to an A, even though he stated that it was mathematically possible.

Brian: So like I said, mathematically, it’s still in within the reach—the realm of possibility.

Therapist: You don’t sound too convinced that it’s going to happen, though.

Brian: Well, again I just—as I just said—the reality and the pattern, so— ______Researcher: So when [therapist] said, “well you don’t sound so convinced”—

Brian: Right, oh yeah. Well I mean, you can—

Researcher: Did that fit for you?

Brian: Well, yeah of course. I mean, it’s obvious with the resonance of the tone of my voice that um, you know, and again, you know, my concern is—whereas ok—with me mentioning the mathematical part of it, that means it instills a little bit of hope. Ok, but again as I just explained to you, I am looking at the current pattern.

In this example, Brian seemed to think that his tone of voice should have made his feelings of

doubt clear to his therapist. Interestingly, Brian strayed from talking about his feelings by continuing his mathematical, logical prediction for his final grade which continued on in more detail than was presented here. APES 1 to 2: Emergence of a “Dark Side” At one point in therapy, Brian’s therapist asked him to imagine what it would be like to be really angry in session. Brian replied that he would just leave. When she asked what he would do if the door was locked, Brian stated that he would put his foot through the window to escape. She pressed him further and asked him to consider what it would be like if he absolutely couldn’t leave the room. The following passage reveals Brian’s response, which was initially a little vague during the therapy session, and which he elaborated on during the IPR. An undefined problematic experience involving anger—and described by Brian as a “dark side”— seemed to emerge.

Therapist: ...but if you couldn’t leave, if you were stuck here with me and were frustrated—really frustrated.

Brian: [pause] And I couldn’t leave? [pause] Then I could not honestly tell you what would happen. ______*Researcher: That moment, when you say “I could not honestly tell you what would happen”—what were you thinking?

Brian: Well it’s a little bit aggravating. Because, you know, I don’t want to talk to her like that. And you know, I don't want to come off to her as being a dangerous person.

Researcher: So were you thinking some of those things, but not necessarily wanting to tell her that?

Brian: I don’t believe—I may have been thinking something like, but you know, you know, again, you know, this kind of questioning is kind of exposing a dark side. You know, because I don’t—I don’t want to come off as threatening to her. You know, I mean I don’t want to—I mean I don’t want to feel like I have to threaten anybody. You know, I mean for one, I just, I mean I want to be respected. You know, not that I feel she’s disrespecting me with that, but she’s—she’s forcing my hand. And forcing me to talk about a situation that I really don’t want to see myself in.

Researcher: Right, right. And so this—it’s hard to even go there, to imagine that.

Brian: It’s not somewhere that I want to go. Exactly.

The prospect of letting his anger emerge seemed quite daunting, as if he would be revealing a “dark side.” He seemed reluctant to share this part of himself for fear that he would seem dangerous or threatening to his therapist and that she presumably would reject him. This passage nicely illustrates the role that therapists can play (intentionally or not) in nudging clients toward higher assimilation levels, in this case from APES 1 to 2. The therapist removed the roadblocks Brian had set up (I’d just leave, even if I had to break a window) that are characteristic of APES 1. Although he at first seemed hesitant to reveal his dark side, feeling like the therapist was “forcing his hand,” Brian stuck with the therapist’s question and was able to share how he might act in the room if really upset. APES 2: Emergence of Vulnerable Voice Though fleeting, Brian exhibited signs of APES 2, when he allowed a more vulnerable part of himself to emerge—the part that expressed pain of being alone and questioned why he was suffering. He didn’t seem to feel that his degree of suffering was deserved. The following passage was preceded by these comments from Brian in the IPR: “Now here we get into some of the good stuff. Here we go.” Brian seemed to realize that this portion of the therapy segment represented something significant, though interestingly, his commentary on it during the IPR was more tentative than normal. He seemed less comfortable reflecting on emotions and almost had to guess how he was feeling.

Brian (in therapy): I mean I still have faith in God. You know, that doesn’t change. Uh, there are sometimes I—I wonder what he’s got planned next. You know, I do that a lot. I accept that God works in mysterious ways, too. You know, but there—there are times I just have to look up and go, “why?” And yeah, I’ve been through that. And maybe that’s not—maybe that’s not necessarily the right thing to do. But you know, I’m human and I have my own set of emotions. ______*Brian: What I mean by not necessarily the right thing to do is questioning God.

Researcher: Okay. Also, during this time, I’ve—I’ve noticed it seems like you sound a little quieter through here. Did you feel any different when you were talking about this? It sounded like you were—you noticed that, “okay here, we’re getting into something.” (Brian: Um hmm) Did you feel a change in you at all?

Brian: Uh, yeah, probably emotionally. You know, I toned it down a little bit. I mean I know I don’t sound as upbeat. You know probably sounding a little more somber.

Researcher: Were you feeling more somber?

Brian: Yeah, I think so. Um, because I’m looking at—because I want—I want things— you know I want things a certain way. And I don’t entirely feel like I’m being unreasonable. You know, it’s not like I’m asking for everything. I don’t feel like I’m asking for a whole lot. And you know, there are times I wonder, you know, what have I done to deserve where I’m at?

Brian was able to notice, somewhat objectively, that his voice became quieter and he didn’t sound as upbeat, though it seemed difficult for him to directly communicate what he was feeling. While this observation seems specific to Brian (very intellectual), it is consistent with APES 2, when problems seem unclear and emotions are high. Brian may not have had the words to describe what he was feeling. Interplay Between APES 1 and 2: I’m In Control Brian seemed to suggest that he was always in control of the session, even if he might follow the therapist’s lead from time to time. For example, she encouraged Brian to talk about relationship problems at the start of a session, instead of waiting until the end like he normally did. This required a switch in topic from what Brian had originally brought up, presumably to a more difficult one.

Researcher: But she [therapist] was shifting you from what you were originally talking about.

Brian: Which that’s cool.

Researcher: And that was cool? Okay.

Brian: Yeah, I mean I had spoken my piece. I mean if anything, if it came down to it, like I said, you’ll learn a little more about it at the end here. You know, if I wanted to get back control, I would.

We hypothesized that Brian’s comment about taking back control implied that although he was letting the therapist guide him to a discussion about his relationship struggles—a painful topic he was at least partially interested in exploring—he could take over if necessary. He could regain control, for example, by changing the topic or finding some way to end the conversation and thereby avoid getting emotionally overwhelmed. Abruptly Pushing Play. Brian also seemed to exert control over the IPR sessions by pausing and playing the audio recording of the therapy sessions. On several occasions, Brian

88 abruptly pushed the play button and stopped talking. Although it is unclear exactly why Brian resumed the playing of the tape so quickly, about 6 of these instances followed the discussion of something problematic / emotional or when the researcher inquired about Brian’s feelings. In the following passage, Brian seemed uninterested in responding to the researcher’s reflection that a friend’s story (comparing him to the Apostle Paul) had hurt.

Researcher: And you said—you understand that she [friend] was coming from a good- intentioned place. But it, (Brian: sure) it still kind of stung a little.

Brian: Well, you know, I’ve also heard that the road to hell was paved with good intentions. So— [quickly pushes play]

In the next example, Brian reflected on what he was experiencing when his therapist had noted that there were times in the past when she felt like she couldn’t get a word in because Brian was talking so much or in Brian’s words, seemed “unapproachable.” In the IPR, Brian said he was trying to think of an example when this might have been true and came up with a session that had occurred about four weeks previously.

Brian: …that session I think was probably where she felt she couldn’t get a word in edge-wise.

Researcher: That you’re just sort of going and talking a lot about this.

Brian: Yeah, you know, what she’s saying isn’t registering. You know, in one ear and out the other. Whereas this session, you know, I carry a different—you know I seem to be more attentive and things like that.

Researcher: Okay, so you’re kind of understanding what she’s talking about and have an example in mind. Did this um—did you have a reaction to that though? The fact that you do that sometimes—you’re more approachable than others? [Brian immediately pushed play without answering the question.]

Although these previous two passages illustrated the phenomena of abruptly stopping the discussion of a topic or answering a question, the transcripts may not capture the unspoken essence of these moments. While sitting next to Brian during the IPR, I could feel Brian’s tenseness about these topics. His behavior (quickly and forcefully pushing play) seemed to communicate nonverbally that he did not wish to continue exploring this area; if we were listening to the therapy recording, he didn’t have to reflect and speak.

APES 3: Feeling Stuck: “Wound Tighter Than a Banjo String” After discussing some of his long-standing struggles in therapy, Brian said he (or part of himself) was going to keep plugging ahead, but another part questioned how much longer he could do this. Brian commented on this internal conflict during the IPR, using the metaphor of a stretched rubber band or a taut banjo string to describe his sense of feeling caught or stuck. An intrapersonal dialogue emerged in the following passage as Brian reflected further on his struggle; the persevering fighter voice is in bold and the tired, hopeless voice is in italics. These voices appeared to be observer or narrator voices in the sense that they commented on Brian’s ongoing problems (namely, feeling hurt and lonely).

Brian (in therapy): I’m still gonna fight the good fight regardless of what happens. But then there are times where I just say, “how much more of this am I supposed to take?” ______*Researcher: I’m gonna stop it because it sounds interesting. It’s like there’s—you say, “well your gonna keep fightin’ the good fight” and that’s the part that sort of—keep going, you’re on a path. There’s light at the end of the tunnel maybe.

Brian: Hopefully it’s not a train. [said sarcastically]

Researcher: Okay (slight laugh). But then this other part says something like, “but how much longer do I have to keep going?”

Brian: Yeah how—um, I mean at that point you know, I’m comparing myself like to a rubber band. You know: [pulls imaginary rubber band taut].

Researcher: Stretched real tight, huh?

Brian: Yeah, definitely. Wound tighter than a banjo string, defin—exactly. So you know, in one way I’m saying you know, I don’t know how much more of this I—I don’t know how much more I can deal with. You know, or maybe that—maybe it’s how much— how much longer am I going to have to deal with this? I mean regardless, I gotta deal with it. I can’t say—I can’t deal with it anymore, you know, because that’s not true. I still got to deal with it. You know, I got to get through this, because if I don’t get through this first part of it—meaning my school work—then yeah, hopeless will take on a new appreciation and meaning. (Researcher: okay) This is my hope. This is my lifeline. If I fuck this up, (laughs) then yeah, I’m toast.

The intrapersonal dialogue continued in the IPR interview, as illustrated in Brian’s last speaking turn in the previous example.

APES 3 to 4: Prelude to Insight During one of the sessions reviewed, Brian and his therapist were discussing his defenses early in therapy, namely his tendency to use psychological terminology in their sessions. Brian eventually reached a moment of insight about why he felt the need to this, though before this moment of insight crystallized, he seemed to be inching toward a new understanding. The following passage represents Brian’s active struggle to understand this problem.

Therapist: So um, I’m not going to take anything personally, because we’re talking about when you didn’t even know anything about me. But what was kind of the fear, of what—what I could do if you didn’t know anything about psychology?

Brian: Well um. I mean if there was, um— ______Brian: It would probably make me vulnerable. ______Brian: I guess if you wanted to you could still pull some tricks, you know. ______*Brian: I’m probably still vulnerable.

Researcher: Can you say more about that? The feeling vulnerable.

Brian: Okay, um I mean I’m a reasonably intelligent person but there are some things, you know especially if I don’t have any familiarity, you know where I can still be a little slow on the uptake. Um, you know, as far as people trying to pull a fast one over me and things of that nature. You know, I can still be susceptible to it. Um, maybe I have a little more defense, you know with some knowledge about certain things. Um—

Researcher: And that’s a way to sort of safeguard you, to protect you from being tricked or something?

Brian: Yeah. However, my background, you know—I took two classes. I took Intro [Psychology], and I took developmental psych. And neither one of those classes is going to, you know, give you a how-to list to keep from being screwed over. You know, those classes aren’t geared toward that. You know, maybe Cosmo could help me out with that. But you know, but still, I mean—I still wanted to make the point that, you know, I’m not some totally ignorant jack-ass.

Researcher: Okay, and to be—okay that helps. But to be vulnerable would just—is to put yourself at risk for getting hurt somehow. (Brian: Mm hmm)

[Tape starts to play and then Brian quickly stops it again.]

*Brian: Even then, there’s still a vulnerability. You know, it takes trust.

Brian was actively grappling with his tendency to use psychological terms in therapy, speculating that it kept him from feeling vulnerable, though he failed to grasp the full meaning of tendency and the impact it had on others. His insight about this behavior crystallized shortly thereafter (see next section). APES 4: “A Light Bulb Comes On” Brian and his therapist continued discussing Brian’s use of psychological theory until Brian felt as if something just “popped into my head” and a light bulb turned on. The following passage represents the moment of insight in therapy and his reflection on it during IPR.

Brian (in therapy): I knew—I knew a little about the game [of psychology]. I mean if you tried to throw some Freud or Erikson or Bandura at me, you know, you aren’t gonna throw it by me—you aren’t going to go over my head, so much. And alright, something just popped up into my head. Because when I talk to people, and talk about what they know, especially my co-workers and even some of my classmates, some of the things that I say I guess it’s just the way I am. Some of the things that I say to them goes: [Brian had motioned “over the head” with his hands, which he repeated in the IPR interview.] ______Brian: Right over their head.

*Researcher: Yeah, I’m interested in—not as much about the specifics of what you’re talking about, but this notion of “oh, this just popped into my head.” That somehow this seemed related…Say more about that moment of it popping into your head.

Brian: Well it’s just kind of like a light bulb comes on, you know. I mean, you know, like I said, you know sometimes I have to say something you know—something I’ll say will trigger—trigger a thought. I mean, I don’t know exactly why it’s like that or how it works. I mean, but it’s just part of—

Brian elaborated on this new understanding about his tendency to be pedantic and use intellectual terminology that may go over other people’s heads. As the conversation played out on the therapy tape, Brian commented during the IPR: “this is where it gets interesting,” indicating that this section of the session was fruitful or meaningful in some way. In the following passage, the therapist asked Brian what she might have been feeling when he was lecturing her about Freud and Bandura. Brian found this difficult to answer, presumably because it was hard to place himself in his therapist’s shoes. Brian eventually understood the therapist’s perspective when she posed the question differently, placing Brian (and not her) as the target of

92 such behavior. Therapist: I’m wondering how about if uh, you know some time next year, a first-year nursing student comes to you and starts telling you how to give injections, or all they know about injections. How would you feel about that?

Brian: [small pause] Alright! [said enthusiastically] I think—

Therapist: Yeah, you got something going on over there! ______Brian: [snaps his fingers]

*Researcher: You just stopped and you clicked [Brian literally snapped his fingers]. I mean that—boom, that was the moment. And sounds like she sensed it too. She saw you—something changed.

Brian: Oh yeah! Like—I was like, “got ya.” And the dialogue after this—

Researcher: Says a little more about that?

Brian: Well I become very apologetic really quick. ______Brian: I think I just figured out what you were driving at. And if that is how I made you feel, then I apologize. Because, like I said I

Therapist: Where am I [going?]

Brian: I can tell you from my perspective, you know, if some—yeah, next year, you know especially after I’ve been practicing, if some first-year rookie wants to tell me how to give injections. Yeah, I just might put ‘em in a gee-choke or something like that, you know (laughs). So, if I made you feel that way, I am terribly, terribly sorry. You know, I did not mean to. ______*Brian: Pretty much what that is, is I can—I mean a gee usually goes left over right and what you can do is you can place your thumb here and grab. And you can cut off the circulation to the neck and then you grab the other side and just kind of pull it down and what it does is it cuts off the oxygen supply to the brain, knocking the person out.

Researcher: Basically, saying—meaning that you’d be pretty pissed if they…first-years [were] trying to tell you what to do.

Brian: I’d be, “look you dumb son of a bitch. (laughs) You know, just who do you think you’re screwing with?” But yeah, pretty much, so—

Researcher: And then—then saying, “okay, maybe that’s how [therapist] might have felt.” If the metaphor holds up.

Brian: Well yeah, that’s what I’m thinking. It’s like—basically I’m saying, you know, I’m sorry if I make you feel that way. You know, I didn’t mean to insult your intelligence or do that to you.

Brian deepened this insight, realizing that this tendency, while self-protective, may be abrasive to others and turn them off. This led Brian to state, “I’m willing to accept that. Okay. My next question is, how do we fix that?” in effect, moving from APES 4 to APES 5 (Application / Working Through). APES 5: “How Do I Fix That?” Brian repeatedly asked his therapist for specific ways in which he might change his behavior so as to develop more relationships and feel less lonely. While Brian tended to ask these kinds of questions throughout the therapy sessions (regardless of where his problem might be rated in terms of assimilation), they often occurred following a moment of insight or understanding, as a problematic experience was moving toward APES 5, where new understandings are applied to problems. Following Brian’s insight about the ways in which his intellectual behavior might push others away, he wanted to know how this awareness could translate into action. In other words, he wanted to know what he could do to fix the problem. His desire for advice was noticeable during the session, but his impatience and frustration with the therapist were perhaps more pronounced during the IPR.

Brian (during IPR): Okay, we got this—we got this going [insight about abrasiveness]. Okay. It’s not a good thing. How do we get rid of it? And her response is usually, “well, I don’t really have a good answer for that.” ______Brian: Well uh, yeah. You know, I think people have even mentioned that [abrasiveness]. ______Brian: Okay, how did I fix it? ______Brian: And as far as trying to combat that and change that? For one, change is a slow process usually, even if it’s even possible. And at this point, you know, I don’t know what the hell I need to do to change that. ______[Brian is loudly laughing]

*Researcher: So are you hoping at this point that she may be clueing you in on how to do this?

Brian: [sighs] well, you know we’ve been through that process. We’ve been at this

point before. And you know, I think there’s some, “well are you looking for advice from me?” you know that type of thing—what are you wanting? It’s like, okay, yeah maybe some advice would be nice. But you know, I’m not sure if she sees herself in that capacity. Or if that’s the exact—

Researcher: So she may not be wanting to give suggestions, but you wouldn’t be turning ‘em down at this point. You’d be welcome to something.

Brian: Yeah, I’d be listening—definitely.

Therapeutic Alliance / Voice of the Therapist Brian appeared to have a solid working alliance with his therapist. Their relationship was salient throughout the IPR interviews and appeared to be a major contributor both in terms of making progress and feeling stuck and frustrated in therapy. Brian’s romantic attraction toward his therapist and moments of feeling understood and misunderstood are presented in turn. “It’s Not the Value I’m Lacking in My Life.” Early on in the IPR interviews, Brian noted that he admired her and that her opinion meant a lot to him. He also seemed to have romantic feelings toward his therapist, though he was clear that they could not pursue an outside relationship. These feelings surfaced when she asked Brian if he thought she valued his presence (he had suggested that his mom and a few professors were the only people in his life that valued him). The following set of passages reveals Brian’s reaction to this question, the first one highlighting Brian’s perception that this was a tricky question.

Therapist: Do you feel that I value your presence?

Brian: Well, alright if I want to be—I’ll be honest. Uh, you know, I don’t mean to be hurtful or anything, but—no offense to what I say, but, [sighs] our relationship, you know, is purely professional. ______*Brian: It’s a touchy question. That’s definitely going through my mind.

Researcher: That’s going through your mind, yeah, like how do I handle this?

Brian: Yeah. It’s one of those—I used to call them “poison” questions. Where, okay, there is no correct way to respond. There is a correct way and you’d better find it. It’s one of those.

Researcher: Or you’re screwed, right?

Brian: Oh yeah! That’s, you know, the initial reaction. Um, it’s kind of like, you know,

and I don’t mean to pick on women, but you know, when—when let’s say, you know, my significant other has on a dress and says, “does this make me look fat?” You know, it’s one of those questions. You’re damned if you do or don’t.

Researcher: So you felt here, I’m damned no matter what I say?

Brian: Yeah, my—my thinking is, okay, this can be trouble.

Brian further elaborated during the IPR that he was sure that she valued him professionally, but that it was not the value he was looking for: “the value that I feel like I’m void of in my life, is not the value that she is willing or able to provide.” Brian was honest with both his therapist and with me that one of his primary struggles was feeling lonely and not having a girlfriend. Knowing that his therapist could never be his girlfriend, Brian became defensive and suggested that he was of no more value to her than a class assignment. He was able to acknowledge and reflect on this defensiveness in the IPR.

Brian (in therapy): I don’t know that you can put that kind of value on a professional relationship. Okay. I mean, there’s a value in some way between boss and employee, you know, supervisor-employee, of course if the employee is productive then yeah, the supervisor’s going to value that person. You know, because of their productivity. You know, um, I really don’t know what you could call—how you would value me. Um, I mean yeah, maybe in some way you know, I contribute to a project and a grade that you receive on it for a class. I figure there’s that kind of value. ______*Brian: Maybe that was below the belt. Maybe that statement was kind of below the belt because I don’t necessarily think that—I think that [therapist] looks at me with more value than that.

Researcher: More than just a group class project or something.

Brian: You know, I’m not just some kind of experiment with no feelings. So maybe that was kind of below the belt.

Researcher: Okay. Feeling that at the time that maybe this was a—

Brian: I mean, again overall, this is a tough-ass question.

As the therapy recording continued, Brian acknowledged that he was appreciative that his therapist non-verbally conveyed that she was present during their sessions, and that her mind was not someplace else. In the following passage, the therapist pushed Brian to consider what further

value she might have for him. Brian again stated that he was looking for more than she could provide and agreed with my statement that she could not be the girlfriend that he was longing for. Although Brian might not have used the world “girlfriend” himself, he heartily endorsed this statement; vocally emphasized words are in bold.

Brian (in therapy): I’m grateful for that. So—

Therapist: But there’s something extra.

Brian: Mm hmm. Um, right. I mean, do I think that you value my well—do I think that you value my well-being? Yeah, I do. Um, I can’t exactly place a finger to what extent. But um, but the value that you ______*Brian: I don’t know, I just could not fig—spit it out at the time. You know, it’s like, okay the value that you have for me is, you know, there’s a different value that I’m lookin’ for kid. You know (laughs). I just wish I could have said it like that (still laughing).

Researcher: Said it like that, yeah. What—do you have any sense of what kept you from saying that? [Brian sighs] Worried about how she’d react or?

Brian: Purely physiological.

Researcher: Physiological?

Brian: Yeah, in other words my brain was just not working to just [snaps fingers]…I mean I just wish I could have simply said, “[therapist], the value that you have for me is not the value that—it’s not the value that I’m lacking in my life! (laughs) You know, so, you know how the hell do you broach that situation?

Researcher: Yeah, that you can’t be the girlfriend that I’m looking for.

Brian: Right! [takes a sip of water and kind of spills as he talks]

Researcher: That’s it, okay. [Brian and Researcher both laugh]

Brian: So it’s like, why the hell—so on that token, it’s like why the hell are you even askin’ me this question?

Researcher: Let’s not go there, because it can’t happen, right?

Brian: Yeah. [said quietly]

Brian’s desire to have a romantic, intimate relationship with his therapist was clearly

difficult to discuss, as manifested by his reluctance to answer the question and difficulty finding the right words when he did try to answer. And although Brian shared some of these thoughts with his therapist (he eventually told her that that the way she valued him was different than what he was looking for) he was not explicit about his feelings for her. Someone to Listen. Brian was aware that he often started his therapy sessions with some venting about the previous week’s stresses. When listening to the beginning of a session where Brain was talking about his desire to improve his grades in some of his classes, I asked Brian what it was like to talk about his stresses with his therapist, and what his expectations were. The following passage illustrates Brian’s view that the mere presence of a listening ear is useful.

Brian (during IPR): You know just talking things out has the tendency to be, you know, a little bit therapeutic. You know, I’m not—you know I can’t honestly expect [therapist] to say, here is what he needs to do, you know, with your school work.

Researcher: Does part of you want that?

Brian: Not necessarily from [therapist], no.

Researcher: Not really. Okay, it’s more--?

Brian: Someone to listen. I mean I think that’s, you know, I mean just having someone to listen, you know, is nice, although she probably questions my mechanisms for paying 15 dollars a week just for someone to listen. So I mean—but that’s—that’s part of it. I mean it alleviates a little bit of tension.

A Moment of Personal Connection. As already stated, Brian often began his sessions talking about his daily stresses, school in particular. While explaining some of these stressors to his therapist, he asked her if she understood what this was like. She offered an affirmative, personal answer, a response much appreciated by Brian (as evidenced in his commentary in the IPR).

Brian (in therapy): …you ever get that feeling as you go through a semester—I don’t know how familiar you are with exercise, but you know, like a pull-up for instance, or even just hanging from the bar. You start off—you got a hell of a grip on it. And then as the time goes by, you just kinda feel your grip is starting to—you see what I’m saying?

Therapist: That’s about every semester in graduate school.

Brian: Okay. Well, it’s like that as an undergrad too. ______Brian: She does, dumb-ass! (Brian and Researcher are laughing)

Researcher: Yeah, so when she said that, and right now we are laughing. Was that a connecting moment for you?

Brian: I mean I can understand it. I’m glad I wasn’t drinking something—I probably would have choked. Well, I mean me saying, “well you know that feeling?”—“yeah about every semester, man,” so—

Researcher: So that—is that unusual for her to just totally identify personally with something like that?

Brian: Yeah I think it’s kind of a first actually, um, I mean she usually says, well you know, I have kind of an understanding, so—

Researcher: Right, before she said, “well I don’t know—it’s been a while since I’ve taken a test.” But somehow this clicked. (Brian: Yeah.) And that felt how for you?

Brian: Uh well, I mean interesting, like I said. I mean, yeah, I feel like I finally reached some place you know on some level, um, you know—fully, deeply. Whereas you know, she is not always—I don’t really wanna get into talking about her, but she’s not—

Researcher: Well it’s ok. She’s a part of the therapy.

Brian: I means she’s not necessarily the most forthcoming with some things sometimes. So sometimes it seems like you gotta rip your layers, you know, to get certain responses out of her. Um, but then again you know, not that her personal life’s any of my business anyway—I mean that’s not what I am driving at.

Following this, Brian introduced the notion of transference—“people worry about the whole transference thing.” Although this seemed to be an example of Brian intellectualizing things and showing the researcher what he knew about psychology, it is clear that the therapist’s personal response to Brian’s question was a special moment of connection for him, a moment where he felt truly understood. Feeling Misunderstood. Brian seemed to feel heard and understood for much of the therapy (and noted this as “therapeutic,”) though this did not characterize every moment. There were times when Brian felt misunderstood by his therapist, resulting in frustration that he didn’t always express directly. In the following passage, Brian’s frustration came out in the IPR when reflecting on her seemingly critical comment that he had moved away from exploring his

99 motivations (intrinsic or otherwise) for academic achievement to focusing on definitions of words—a defense Brian often used and which they had previously discussed. Statements that Brian seemed to make directly to the tape recording (and presumably directed at his therapist) are noted in quotations; they are also in bold type because they were said with emphasis. The first speaking turn of this passage is repeated from a previous passage.

Brian (in therapy): …just the thought of having a degree with some kind of cum laude stamp on it, you know, in a picture frame on the wall is a nice thing to look at. Uh, it’s a nice thing to show people. It gives them an indication of what I’m capable of. Again, a flash of brilliance. I don’t think I’m going to earn a higher rank pay on account of it, uh—

Therapist: It sounds like what you’re gonna earn is for you and other people, to be able to say, “well Brian is worth something.”

Brian: That’s a good definition of intrinsic. Well maybe, maybe not. That might be an extrinsic motivation actually. Glory and recognition.

Therapist: Now we’re on—now we’re on definitions. I’ve got this—I’m thinking about this diploma— ______*Brian: “[therapist], definitions is how I work, ok?” [quickly pushes play]

*Researcher: Well wait, I’m gonna pause it again. You said that kinda like, “[therapist], come on!” [Brian laughs] What were you—what was going through your mind when she said that?

Brian: Well you know, definitions, that’s how I associate things. I mean I may not be able to totally ingrain the process, definitions is how I work through things. That is where—that to me is a critical component of putting things together.

Researcher: Okay, so in a sense, sounds like maybe she’s being a little—not necessarily sarcastic—but just now, if we’re gonna be defining things or something, like let’s—

Brian: Well I got the impression it’s like ok, you’re going back to definitions; we don’t need to go there. We need to break away from that. It’s like, “look, damn it!”

Researcher: She’s saying we don’t need to be focusing on definitions, right? (Brian: Right) But you’re saying, “well maybe, but come on, that’s me, Brian,” right?

Brian: Exactly. That’s what I am.

Another misunderstanding seemed to occur a few minutes later in the therapy session.

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Brian had been discussing his desire to graduate among the top of the class, to be one of the elite. His therapist asked him to consider what the opposite of being elite was for him.

Therapist: If you’re not the best, then what are you? What’s the opposite?

Brian: Well the polar opposite of the best?

Therapist: Well not the—I know what the dictionary would say, if I looked it up. But for you. If you’re not the best, what are you?

Brian: Just like everybody else. ______*Brian: “Don’t you understand that I don’t want to be like everybody else, especially in this angle?” [said into tape player]

Brian physically leaned into the tape player when he spoke the previous statement during the IPR, as if he was speaking directly to his therapist. Brian did not initially reflect on or articulate that he was feeling misunderstood by her, but his behavior spoke volumes. A few minutes later in the IPR, his frustration became a little more apparent after he had elaborated what the opposite of being the best was. In the next passage, Brian’s statements made directly to the tape player (and presumably to the therapist) are placed in quotations.

Brian (in therapy): Uh, [pause] just mediocrity— ______*Brian: I do not know why I said that, just that exact statement.

Researcher: What the mediocrity? Do you wish you would have--?

Brian: I wish I would have just said, “hey look, you know, don’t you understand that, you know, I don’t?—No, I wanna be the best in this.”

In this example, it seems that Brian was not feeling completely heard by his therapist, stating, “don’t you understand?” None of this frustration was expressed to her during therapy, though. They continued discussing the concept of mediocrity. In general, Brian seemed frustrated with his slow progress and with the therapist’s style. He wanted specific, concrete feedback about his behavior. Brian became frustrated when his therapist did not provide specific “how to” advice in order to improve. His desperation showed through during the IPR when he stated, “There’s gotta be a check-list someplace!” The following passage represents an example of Brian wanting to know what he was doing right and wrong in

101 terms of relating to other people.

Brian (in therapy): How I relate to people? Okay, yeah I guess that’s one of my biggest issues. [pause] [sighs] I mean just as a person, I mean citing specific examples in relating to people and I understand that you haven’t observed me naturalistically. You’ve only observed what we’ve done back and forth. What are my strong points? What are my weaknesses? [said very matter-of-factly]

Therapist: Sounds like—before we get to that—now there’s a different—you have a different tone going on, asking me questions now. (Brian: Mm hmm) I’m wondering what that’s about.

Brian: In other words…what do I do right? What do I do wrong?

Therapist: I got the question. (Brian: Okay) I’m gonna answer the question— ______*Brian: Then answer it, damn it! [said seriously, but while laughing] ______Therapist: and I’m just gonna tuck it away for a second. So if I don’t answer that question within two minutes— ______[Brian is grimacing]

*Researcher: So she gets it, but she’s gonna tuck it away.

Brian: Yeah, you’re about ready to see the duck.

The therapist proceeded to comment on Brian’s harsh tone of voice, referring to it as the hard- core-facts-speaking Brian that tended to emerge at the end of most sessions. She reflected that in this instance, it arrived with only five minutes left. The next passage shows Brian’s frustrated response.

Brian (in therapy): Well five minutes is constructive. I think we can work with that.

Therapist: Well, give me a second to think how I want to answer that question. ______*Brian: Pretty much I was thinking, five minutes, two minutes—I don’t give a shit! Let’s go!

Researcher: Don’t blow it off. (Brian: Yeah) ______Therapist: I don’t know if I would phrase it as strengths and weaknesses. I would want to phrase it as things we need to work on.

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______Brian: What’s the damn difference!!??

Perception of Progress The set of passages in the previous section focused on a particular incident where Brian felt frustrated that his therapist wasn’t giving him the specific feedback he desired, and seemed representative of a more general reaction toward therapy and his progress to date. Brian reflected on the process of therapy more generally at the end of our final IPR session. The following are some excerpts from those reflections.

Brian (during IPR): I mean there are times where I think the therapy is a slow process. There, I still would like some more concrete answers, and you know, it may not be the most concrete of things. There’s a lot of abstract principles it seems, and I don’t have the greatest understanding of abstract principles. So I think that’s one of my deficiencies. Again, you know, the biggest thing is, you know, at least it gets the ball rolling because there’s someone to talk to…

… again, it seems to be slow-going, and I don’t guess that there’s any easy answers. Sometimes I still feel like, ok what exactly do I need to be doing? You know, sometimes I feel like I’m still hanging….

…I mean she’s, [therapist]’s told me several times, you know, it’s like, well know I could tell you to go do X this, that, and the other, like a homework assignment, but she’s like, I don’t know that that’s necessarily what we need to go about. What she’s telling me is that there needs to be some kind of break in my habits. Ok, I can understand breaking habits, but in order to break those habits, usually new ones have to fall into place—to take their place. And I don’t know exactly what those habits are that need to come into effect just yet. So yeah, it still leaves me with a lot of questions, uh, and a lot of wonders and things like that.

Brian is left with a lot of questions, though as the next passage illustrates, he wonders whether this is to be expected from therapy.

Brian (in IPR): So yeah, in a lot of ways I’m still searching for answers, which may or may not be part of the process…at this point, you know, I’m—I’m still willing to participate with it. I feel that it’s a necessary—that it’s a necessary thing in order to gain a little bit of understanding. And I feel like I’m at the stage where I’m willing and ready to implement the changes, I just need to know what these changes are…that’s probably one of my biggest misunderstandings.

When asked if therapy had been helpful, despite the slowness, Brian answered affirmatively, as shown in the next passage. He also pointed out that if he really felt as if he were being misled in

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the process, he would say something. Whether or not this would actually happen, Brian seemed to have confidence that he wouldn’t be duped into doing something he didn’t believe in.

Brian: Well yeah, I think I’m better off now than before I started coming. I think there has been some progress made, um, you know and again, she’s the one with the training and things like that, so therefore I trust her judgment too. You know I don’t say a whole lot of, well why—you know I haven’t questioned exactly why we’re going in a certain way…I haven’t been to the point of saying, well exactly why are we doing this instead of this? You know, I haven’t asked those kinds of questions. I haven’t really felt the need to. If I did feel the need to, trust me,

Researcher: You would. (laughs)

Brian: Yes. I mean if something absolutely made no sense, I’d be like, alright why are we doing this? Believe me, I wouldn’t be the least bit bashful about doing that.

Discussion: The Case of Brian “Aren’t My Feelings Obvious?”: Implications for APES 1 and 2 Brian’s hesitancy to articulate his feelings in therapy appeared to be a manifestation of APES 1, where problematic experiences—and their accompanying pain—are actively avoided. Spelling out his feelings in detail may have been too overwhelming a prospect. This was not something that Brian necessarily avoided consciously; he truly seemed to think that his feelings were obvious and there was no need to articulate them. On the other hand, it is also possible that Brian’s sense that his feelings were obvious reflected APES 2, where problems are vague and difficult to express. Perhaps Brian—a male who historically had trouble accessing his emotions—simply didn’t have the words to describe his feelings when they did emerge. Sometimes, when intense emotions are bubbling up internally, individuals have the sense that their feelings are transparent. When encountering strong feelings of anger, for example, one might wonder, “How could someone not notice that I’m feeling this way?” Both interpretations of the statement “Aren’t my feelings obvious?” seem plausible and have potential implications for assimilation theory. For Brian, the hesitancy to articulate feelings primarily seemed to keep powerful negative emotions at bay (consistent with APES 1). Because emotions are intensely negative at this stage, client quickly stifle them when they emerge. The S-shaped feeling curve in Figure 1 shows that at APES 1, contact with unwanted thoughts results in significant distress (emotional valence is intensely negative), but because the contact is

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transient, the average feeling level is only mildly negative. Nevertheless, the overall amount of psychological pain at APES 1 is less than what individuals typically experience during APES 2 because problems are then sustained in awareness for longer periods of time. Clients would seem to have valid reasons for making a statement like, “Aren’t my feelings obvious?” at either of these stages. Brian did, however, show progress in moving from APES 1 to 2, and this statement might indicate a marker of a mid-way point (e.g., 1.5). Awareness of Defense Mechanisms Brian employed several strategies or defense mechanisms that kept his problems at bay: entertaining, intellectualizing/teaching, and focusing on other topics. These strategies appeared to be manifestations of APES 1, when clients prefer not to think about their problems. While Brian did not seem fully aware of these strategies (and probably would not characterize them as strategies or defense mechanisms), he was aware that he used humor to deflect emotional intensity and that he purposely avoided talking about relationships, his biggest problem. He was aware that talking about school stressors in therapy was a way to evade discussing his central problem: relationship difficulties and loneliness. Awareness of this tendency was not enough to change the behavior, presumably because it was an effective way to avoid feeling psychological pain. Avoiding his problem thus became a problem in its own right that was addressed in therapy. This is not unlike the previous two cases, where Sabrina was aware of her dissociation and Kyle was aware of his defensive sparring. In all three cases, the successful avoidance of an underlying problem came to be considered a secondary or derivative problem. Brian and his therapist attempted to address the derivative problem by talking about relationships early in the session, so that the time would not be filled with endless worries about school. Although this strategy did not guarantee that Brian would focus on the problem and progress toward APES 2 (other strategies could be and were applied), it was definitely an attempt to bring the problem front and center. Maintaining a Sense of Control Brian demonstrated—both in words and behavior—that he desired having control over his therapy. He was willing to follow the therapist, even when feeling unsure about her intentions or sensing that she was leading him toward contact with his problems, knowing that he could regain control at any moment. In his words, “If I wanted to get back control, I could.” Brian’s behavior suggested that taking control was not just an illusion or an empty threat.

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During the IPR, his control over the tape player—quickly starting and stopping as he saw fit— seemed to be one way in which he could monitor how much contact he had with a problematic experience. While this might be viewed as resistance, it might also be viewed as a way of appropriately self-monitoring and regulating emotion. Clients may know when they are reaching their emotional limits and take efforts to halt emotional exploration. This phenomenon, which will be explored in greater detail in the cases of Allison and Julie, has implications for how much (and when) therapists should actively push clients toward emotional exploration. Prelude to Insight Brian reached a moment of insight during therapy about his tendency to demonstrate his intellectual prowess in an abrasive fashion—and how this might turn people away. Although the understanding seemed to come in a flash of insight, or as if a light bulb was suddenly turned on—not atypical for APES 4—the moment did not appear out of thin air. A few minutes before the actual insight was reached, Brian noted during the IPR, “this is where it gets interesting.” Brian had actively been struggling with his need to show others his knowledge (e.g., demonstrating knowledge of psychology to therapist) as a way of protecting himself from being fooled or from being perceived as an “idiot.” Essentially, it had been a strategy to keep himself from feeling vulnerable. He first gained a sense of its personal utility (i.e., Why am I doing this?) before being able to consider its impact on others. Even then, the awareness of the interpersonal consequences was a slow process. He noted that something “popped into his head,” and he provided an example that his comments sometimes go over his co-workers’ heads. The insight didn’t crystallize, though, until the therapist asked him to consider what it would be like if a first-year nursing student told him, as a second-year student, how to give an injection. While the groundwork had been laid, it was not until this moment that the understanding became vividly clear. This gradual progression toward insight, notably Brian’s active struggle to understand his problem, illustrates one of the APES substages proposed by Brinegar, Salvi, Stiles, and Greenberg (2006): APES 3.8 – Active Search for Understanding. Brian’s perspective adds to our understanding of this substage. After reflecting on and understanding his personal reasons for being pedantic (actively grappling with “Why do I do this?”), Brian was then able to consider the impact his behavior had on others. This insight seemed related to Brian’s core problem of loneliness, in the sense that he better understood the way in which he may push others away.

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Impatience for Change Brian seemed eager, almost desperate to make changes in his life. He seemed to have little patience for letting his therapy unfold (as his therapist suggested) and wanted concrete advice from her about ways he could improve his functioning. Brian’s urgency for answers were present throughout but often intensified after understanding something in a new way (e.g., recognizing that his pedantic tendencies might be off-putting to others). This observation is congruent with clinical wisdom that insight is not enough. In assimilation terms, insight is just one (middle) stage in a developmental sequence (Stiles & Brinegar, 2007). After clients reach a new understanding (i.e., APES 4), there is still a lot of hard work left. Clients must generate and try out solutions in order to turn their insight into a reality. Although Brian had fleeting moments of insight, his eagerness to create change was intensely present throughout, including large portions of his therapy that seemed to be at APES 1. The harsh, demanding nature of his requests showed that Brian was presumably in a lot of pain and perhaps not surprisingly, wanted to jump into problem solving without having to go through the emotional journey associated with lower APES stages. Although therapists and researchers may have faith that things often have to get worse before getting better (Gray, 2003; Smith, 1993; Stiles, Osatuke, Glick, & Mackay, 2004), clients may struggle with this premise and either avoid contact with the problem, or desire a quick fix. Relatedly, clients may be eager to make observable changes in their lives no matter what APES stage they are at. They may also try out solutions at any stage. The current APES stage descriptions (Table 1) have not yet incorporated these observations (noted in this and other studies) and do not explicitly talk about implementing solutions (i.e., applying new understandings) until APES 5. A previously-analyzed case (Margaret) showed that changes outside therapy paralleled changes in therapy throughout treatment (Brinegar, Salvi, Stiles, & Greenberg, 2006). Clients do not experience therapy in a vacuum and are always wanting and trying new ways of being in the world. And although the model suggests that any progress in assimilation has implications for how one behaves, it may be useful to elaborate on the kinds of life changes that occur at each APES stage. Vocal Intrusions Brian appeared to have several vocal intrusions in his therapy—brief segments of speech that sounded dramatically different from surrounding statements. These self-interruptive

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segments are thought to represent a sudden shift in the voice or position from which an individual is speaking. Stiles (1999a) referred to this phenomenon as an intrusion of a problematic voice. “A client’s different internal voices are sometimes made salient by the intrusion of material that not only expresses distinct material but does so in a distinctive- sounding voice” (Stiles, 1999a, p. 14). Some of these vocal intrusions were so striking that Brian, himself, noticed them while listening to the recording of his therapy sessions during the IPR interviews. In his words, “I just went from mellow to cokehead in the span of one sentence.” Brian had vivid language to describe this phenomenon even though he was not really sure why it happened, other than it was associated with strong emotion, possibly frustration. From an assimilation perspective, the vocal intrusions seemed to represent the sudden emergence of a voice or part of Brian that was in desperate need of expression. While this voice is reminiscent of the angry destructive guy, we were hesitant to label it as such. The evidence suggests that something important was occurring, but something which we didn’t fully understand. Presumably, this voice was triggered by someone or something external to Brian. The eruptive nature of these intrusions is consistent with vocal presentations at early APES stages, when problematic voices may manifest as state switches (Osatuke & Stiles, 2006). Brian appeared to have little control over the switches, thereby going from “zero to cokehead” almost instantaneously. Because he may have had little to no awareness of the problematic experience that was bursting forth, it is not surprising that he could elaborate only minimally on his experience of the vocal intrusion in the IPR. Interestingly, Brian’s intrusions usually did not represent a drastic shift in content—in contrast to the well-studied case of Debbie (Stiles, 1999a; 1999b)—but did sound jarringly different “Feast or Famine…Where’s the Happy Medium?” One of the most pronounced intrapersonal dialogues observed in Brian’s therapy sessions was a conflict between the problematic destructive guy and dominant nice guy. This dialogue and Brian’s commentary on it, richly illustrates what the theoretical notions of intrapersonal dialogue, APES 3, and the struggle to create meaning bridges may feel like when they are happening. Brian’s two voices engaged in a clear back-and-forth manner, with neither voice speaking for too long without being interrupted by the other. The nice guy voice appeared to represent the dominant community and actively tried to keep the destructive guy in check. Brian noted that being destructive was not in the fabric of who he was (i.e., not part of his

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dominant way of being and acting). Brian commented on the extreme, contrasting positions, likening them to “feast or famine.” During the IPR, Brian articulated his desire to find a “happy medium” between these two positions. This desire seems to represent the concept of a meaning bridge from a client’s perspective. Brian’s words are different that the assimilation theory’s account (i.e., symbols that mean the same thing to both voices), but he nonetheless talks about wanting to find some common ground between these two positions so as to end their bickering and the accompanying internal conflict. The Therapeutic Alliance Moments of Understanding and Misunderstanding Brian appeared to have a solid working relationship with his therapist. The general properties of this relationship, according to Brian, included having someone listen to him and feeling understood. The latter, feeling understood, was important to Brian and is a well- established principle of many psychotherapies. However, the co-investigators also noted the importance of moments of misunderstanding. There were times when Brian felt less understood by his therapist, including when he felt as if his emotions were transparent and did not need to be articulated, or his tendency to use dictionary definitions. Other misunderstandings seemed connected to a disagreement on therapeutic tasks. For example, Brian repeatedly requested concrete advice, which his therapist was reluctant to give. Although not all tensions between Brian and his therapist were resolved at the time of the IPR interviews, Brian and his therapist appeared to be acknowledging and addressing moments of disconnection, or what might be considered minor tears in the relationship. As previously discussed, the act of repairing such ruptures or moments of empathic failure may be considered a primary healing component of psychotherapy (Kivlighan & Shaughnessy, 2000; Kohut, 1984; Rhodes, Hill, Thompson, & Elliott, 1994; Safran & Muran, 2000; Stiles, Glick, et al., 2004;). Romantic Attraction A distinctive aspect of Brian’s relationship with his therapist was his romantic attraction toward her. Brian acknowledged his strong desire for an intimate relationship with a woman, a domain in which he felt unsuccessful in the past and present. Brian’s feelings were not fully brought to light in his therapy sessions, but he commented on them during the IPR. He knew a non-professional relationship could never develop, but he still harbored a remote desire for her to fill the relationship void in his life. Brian and his therapist tended to dance around this topic and

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it was not openly discussed, at least in the sessions reviewed in this study. Brian—aware that she couldn’t provide the kind of relationship he desired—dealt with this unspoken rejection by minimizing their relationship and stating that she probably valued him solely because their work was a good training opportunity (a comment he later regretted). In what ways might the presence of romantic feelings toward the therapist either facilitate or inhibit the process of assimilation? If disclosed, the resulting dialogue with the therapist could bring to light relationship problems outside of therapy, allowing for a problematic voice or set of experiences to emerge more fully into awareness (e.g., “I’m lonely, and I want a girlfriend.”). If the client and therapist are able to openly talk about romantic and sexual feelings, it could potentially serve as a template for navigating relationships outside of therapy. Of course, the therapist needs to be willing to explore the romantic attraction (a potentially awkward topic) in the service of accessing and assimilating problematic voices. Therapists may also choose to collude with their client in avoiding a potentially awkward and painful topic. This may limit the assimilation of problematic voices expressing romantic needs. In summary, resolving interpersonal conflict (in this case, I want you to be my girlfriend and you can’t) may facilitate intrapersonal dialogue and assimilation. Results: The Case of Adam Background Information Adam (a pseudonym) was a 19-year-old single White male. He was a freshman at a Midwestern university studying business. He had been working with a graduate student therapist at a university counseling center. They had been meeting weekly for the preceding six months. The primary problems he dealt with were social anxiety, panic attacks (mostly connected to test anxiety), and adjusting to college (feeling homesick, depressed, and lonely). Adam’s therapist described his theoretical orientation as eclectic, combining elements of narrative, cognitive- behavioral, psychodynamic, and relational therapies. His therapist was also a co-facilitator of an interpersonal process group of which Adam was a member. In terms of progress, Adam seemed to have learned some cognitive and behavioral tools to help him cope with his anxiety. At the time of the interviews, he and his therapist were beginning to explore factors that may have been underlying his anxiety. Adam met with me for two research interviews, spaced two weeks apart. PQ On the PQ, Adam identified 6 problems. From the most significant to the least, he listed:

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1) I have trouble with anxiety, particularly social anxiety and test-taking anxiety; 2) I feel homesick, lonely, and depressed; 3) I struggle to enjoy all of life’s experiences; 4) I tend to think there’s something physically wrong with me; 5) maintaining and improving relationships; and 6) understanding the mind-body connection. When asked if there were any problems he had not talked about his therapy, Adam said they had not explored the causes or triggers of his anxiety in much detail. AQ On the first AQ, Adam identified with seven of the eight moments described in the questionnaire, some of which showed considerable overlap. It’s possible that Adam wanted to demonstrate that he was both a good client and research participant. He identified with the item assessing for APES 1 that asked if there were any topics that had come up which he didn’t feel like discussing. Adam reported that in many of his sessions, he didn’t feel like talking about a certain issue that was bothering him. In his previous session, the focus of the first interview, Adam noted, “we were talking about a panic attack I had taking a test, and I think I tried changing the subject after awhile because I didn’t want to talk about it anymore.” This reflected APES 1 and appeared to be a self-regulating strategy for dealing with emotions. The functionality of abruptly changing the topic will be explored in more detail in the cases of Julie and Allison and in the general discussion. On the AQ item tapping into APES 2 (vague awareness, difficulty describing something), Adam said he had trouble bringing up his belief that a physical problem may have caused his panic attack while taking a test. From a researcher’s perspective, this sounds more consistent with the active avoidance associated with APES 1. Adam had similar responses to the items assessing for APES 3 (getting a clearer sense about a problem) and APES 5 (applying a new understanding to a problem or trying something new). Adam said he started “conquering panic attacks and test-taking anxiety by relaxation, deep breathing, and not getting overwhelmed by tests and other stressors.” He also noted that he was trying to apply deep breathing as a routine in his daily life. For the AQ item assessing for awareness of internal multiplicity (or feeling openly conflicted about something), Adam reported, “on the one hand, I feel terrible about having the panic attack. On the other, I wanted to talk about it and prevent it from happening in the future.” This statement seemed to represent his ambivalence for talking about a recent panic attack with his therapist—he felt embarrassed but wanted to get help. From an assimilation perspective, this observation may represent the

111 internal conflict a client may experience about whether or not to share a problem. In a sense, this could represent conflicting positions at APES 1, before the problem has really been acknowledged or shared. On the AQ item assessing for APES 4 (understanding something in a new way), Adam said he realized that a lot of his anxiety was caused by a lack of “mental determination” to prevent it and letting the anxiety (which he and his therapist referred to as “the octopus”) get the best of him. Finally, Adam noted on the item assessing for APES 6 (something that used to be problematic but now seems manageable) that he now felt as if he had the tools to prevent and cope with his panic attacks. On the second AQ, Adam identified with five of the eight items. For the item assessing APES 2, Adam said he had trouble expressing his feelings about test-taking anxiety and what was causing it. For the item assessing APES 3, he said he was able to articulate that he gets anxious about meeting expectations, especially in a test setting. He said he also became aware that the need to do well made him anxious. For the item assessing for internal conflict, Adam responded, “I felt I needed to address my test-taking problem with the university (i.e., file for disability accommodations), but my parents felt that I should stick it out and get used to testing in the moment of the test.” Adam also identified with the item assessing for APES 4. He said he became more aware of where his test-taking anxiety came from (which overlapped with his AQ response about gaining clarity). Finally, Adam identified with the item tapping into APES 5. He said he felt optimistic about the possibility of using hypnotherapy and deep breathing for his test- taking anxiety. Process of IPR Adam seemed mildly anxious during the interview, though this was consistent with his presenting concern of social anxiety. Despite his anxiousness, he seemed willing to participate and appeared to give as open and honest of reflections about his therapy experience as he could. He was a very compliant participant, echoing his compliance in other relationships, including his therapist. Adam seemed less reluctant to pause the recording during the IPR interviews than other participants. Once the recording was stopped (either by him or me) his responses were not very reflective, and he seemed less introspective or psychologically minded than the other participants. Adam said, “I don’t know” throughout both his therapy and the research interviews. His lack of “knowing” seemed genuine, though. During the IPR, he focused more

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on content than process. For example, he frequently elaborated more on what he had said, rather than reflecting on what he was thinking and feeling at the time he said it. Analysis of IPR Voices and Intrapersonal Dialogue The External Critic Versus Kind and Compliant. One of Adam’s dominant voices characteristically took an accommodating position that we termed kind and compliant. This part of Adam talked favorably about others, often deferred to those around him so as to not disappoint them, and would go to great lengths to avoid interpersonal conflict. The kind and compliant voice appeared to be at odds with a non-dominant voice that we referred to as the external critic. The external critic offered negative evaluations and judgments of others, was considered contrary and problematic for the dominant community, and was typically silenced and kept in check by kind and compliant. Whenever Adam expressed anything negative toward others (i.e., spoke from the position of external critic), he would back pedal and water down his comments (i.e., switch to the kind and accommodating position). Adam self-censored his speech most of the time, continually modifying expressed emotion to be less negative or to decrease the negative impact on the listener. The co-investigators agreed that Adam’s dominant stance was to try to give others what they wanted to hear and to be as nice as possible. In the following passage, Adam said he felt connected to a fellow group therapy member with whom he’d eaten dinner. He also acknowledged feeling “weirded out” by this individual’s Bipolar diagnosis and unusual behavior but quickly apologized for being critical. Portions of speech attributed to the external critic are in boldface and portions attributed to kind and compliant are italicized in both the therapy session and IPR.

Therapist: …maybe there was a part of you that was lonely and you just kind of saw an opportunity—with M. [group member] feeling like he was lonely—I mean, there was a connection. A way of connecting with someone.

Adam: Yeah, that’s definitely true. Um, I mean, I’m a little bit—a little bit weirded out by him a little…

Therapist: Okay, what’s the weirded out part with respect to M.?

Adam: Um, I don’t know, just like—I guess this is kind of mean to say, but I could see how it would maybe be—I don’t know—I’m not a mean person. I don’t like to criticize people, but I know that he has sort of issues and— I’m

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just a little bit nervous around—because I feel like he might do something to me. Or just feeling not comfortable—not really comfortable. I guess is what I’m saying. And I know that’s a personal feeling, and maybe it’s wrong, [inaudible] I’m sure he’s a nice person inside just, I don’t feel totally comfortable, I guess. ______*Researcher: Were you sort of censoring yourself here? Like saying, (Adam: yeah) oh, I’m having a thought, but I’m not sure if I should share it.

Adam: Yeah, again, I didn’t put it on the sheet, but I did—sorry—I was afraid of M. Um, but um, because I’m a nice person, but also maybe felt like it would be a good thing to bring up or something.

Researcher: Okay, so sort of a little—

Adam: Conflict.

Researcher: Conflict in your head?

Adam: Yeah, and that was definitely one of the (laughs)—definitely one of the questions [on AQ]—I didn’t answer.

Researcher: No, no. That’s part of why we listen to the tape. You can’t remember everything…

Adam: But that was like a perfect example.

Two of Adam’s voices—external critic and kind and compliant—engaged each other in a back-and forth manner characteristic of rapid crossfire in the intrapersonal dialogue between conflicting positions. This crossfire continued on in the IPR. Adam seemed apologetic for making any negative statements against this group member. He was also very critical of himself for not having identified this moment on the AQ, an example of another key voice: internal critic. Internal Critic. Although Adam seemed to struggle to criticize others, he frequently criticized himself during both the therapy sessions and IPR interviews. In contrast to the problematic external critic (which was warded off by the dominant community), the internal conflict was a dominant voice (and a self-punitive one). On several occasions, Adam apologized to me for not having remembered and identified significant moments of therapy on the AQ, with comments like, “Again, I’m sorry I didn’t put it down on the yellow sheet.” He was also hard on himself for talking the way he did in therapy, noting that he sounded “dumb” and “stupid” when

114 describing his panic attacks. He was also critical of having had the panic in the first place and worried that others would judge him, as noted in the following passage.

Adam (in therapy): And I was just glad I came in [to see emergency therapist]. I had actually felt like crap through the weekend cause it had happened. And I was like, I’m not gonna be a total like loser—just feeling bad—like what if people saw me get up and leave the room and what were other people thinking?

Adam was also critical of his inability to control his panic and his struggle to master breathing techniques.

Adam: I mean if you’re thinking about maybe taking deep breaths then it’s not like—it’s not necessarily the right thing to do—just breathe normally.

Therapist: Yeah, that makes a lot of sense to me.

Adam: I know, I should have just picked up on it earlier or like—

APES Overview The co-investigators agreed that Adam’s primary problem appeared to be at APES 1 (Unwanted Thoughts / Active Avoidance). While the nature of the problematic experience causing distress was unclear, it tended to manifest itself in panic attacks. The limited assimilation research to date on social anxiety and social phobia indicates that the warded off problematic experience may be a vulnerable hurt voice (Gray, 2003). In the case of Adam, we saw evidence for a lonely voice emerging into awareness that may have been connected to his panic. Before the consensus on this problem was reached, rationale for ratings of APES = 0, 1, and 1.5 were discussed. Evidence supporting an APES 0 rating included Adam’s sense that his panic attacks appeared to emerge “out of the blue” and his denial that there was any problem underlying the attacks. A rating of 1.5 was suggested, given the intensity of his panic attacks, which could be considered mid-way between avoiding a problem and allowing it to emerge more fully into awareness. A rating of APES = 1 was agreed upon based on Adam’s lack of awareness about his problems, other than that he suffered from panic attacks, and his hesitancy to explore any psychological contributors or reactions to the panic. And the panic, itself, appeared like something foreign taking over control, similar to a flashback or a vocal intrusion, which have generally been considered manifestations of problems at early APES stages. When the problematic experience of the panic attacks themselves (i.e., the distress of

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having a panic attack) was considered, this problem was rated at a higher APES level. Raters agreed that the problem of panicking was at APES 5 (Application / Working Through). Adam had identified the problem, realized that it was the result of irrational thinking, and started to implement some cognitive and behavioral techniques for coping with it. The fact that Adam received multiple and highly discrepant APES ratings suggests that he was assimilating many problems, or aspects of a problem, at a time. APES 1: Avoidance and Criticism of Dysfluencies in Speech Adam showed dysfluencies in his speech, both in therapy and during the IPR. The following passage illustrates some of these dysfluencies while Adam was telling his therapist about a recent incident that had triggered a panic attack and after which, he had seen another therapist on an emergency basis. Adam seemed to be aware of his trouble explaining the situation and asked if he could fast forward the tape.

Adam (in therapy): I just, um, maybe I should tell you what happened when I kind of experienced it, cause maybe that would be helpful. Um, I don’t know, it’s just like, I was um, it was an architecture test. And like, I don’t know, I’m not very good at like architecture. It’s just sort of a class I’m taking for the art credit. And um, like I was pretty prepared for it, like I’d studied some of the—I’d studied the notes probably more than most people do cause it was an open-note test. And we could use those notes to write these essays. Um, we had to write four essays, so he puts ‘em up on the overhead and like they’re like—I don’t know—and each um like essay— ______*Adam: I think like, I kind of like, had trouble talking—like talking about it here. Maybe there’s—um, I think I kind of—we got—maybe talk about it better like a little bit ahead. Maybe like 10 minutes or?

Researcher: Do you want to fast forward? (Adam: yeah) Go for it. (Adam: Okay)

Adam seemed uncomfortable listening to the opening minutes of his therapy session. Recounting his recent experience of a panic attack seemed to have triggered some anxiety both in the therapy session and while listening to it during the IPR. Adam’s request to focus on a later segment of therapy may have reflected his desire to limit contact with the problematic experience and avoid the concomitant feelings of anxiety. An alternative hypothesis is that Adam, wanting to be a good participant, felt a more clearly-articulated passage might be more helpful to my research. Adam, aware of his difficulty talking about panic attacks, was highly critical of having

116 the panic attacks as well as his inability to talk about them. He elaborated on this struggle in the segment that he listened to after fast forwarding the therapy tape.

Adam (in therapy): After the second question it was maybe 20 minutes into the test, like, I just couldn’t handle it anymore. Like I didn’t want to write anymore, so I got up and, I don’t know, the teacher was like, um, can I go outside for a minute? So I just took my test—he was really understanding—um, I just took my test with me and kind of finished it in the hall. Cause I already had the questions written down, so, um, I sort of finished up out there and then, um, after that, I just started—and I wasn’t myself. I don’t know, I was just really shaken up by it because it hadn’t happened in awhile. ______*Researcher: So when you’re sort of going through this—explaining the experience step by step—what had happened—how were you feeling at the time when you were sharing this? Were you feeling any anxiety then? Or were you thinking back on it?

Adam: Yeah, um, just the part that I fast forwarded, like it was just hard to talk about it. Like, it sounded kind of—like it would have been really dumb for saying some of the stuff I said. Or I was just like, um, yeah but definitely feeling like, um, I mean I don’t know if the feelings of anxiety came back, but like, definitely just realizing that it was like really hard for me in the moment—on the test. And just feeling glad that I saw [emergency therapist] and like, um, cause I was talking about it again with [therapist] again.

Researcher: Okay, you were saying you were feeling a little dumb talking about it. (Adam: yeah) Was that at the time doing that or is that partly you looking back on it, listening, or maybe both?

Adam: Yeah, just looking back, like this is really stupid. Like why did I feel this way? Like, um, and just even getting like—not jammed up—like a little bit jammed up trying to describe like what happened and um, just kind of like—although it was a big deal in the moment, like it’s not such a big deal anymore, like yeah, kind of like those feelings…now it’s like it’s over. Like, I can’t really like—I can’t describe it any better anymore.

Adam seemed embarrassed at having had the panic attack, which may have contributed to his reluctance to share the story and the resulting dysfluencies. This is one of many examples where Adam passed harsh judgment on himself, or evidence of a critic voice speaking. As an aside, it was difficult for me, as the interviewer, to determine whether Adam was reflecting on his experience at the time of the panic attack, while recounting it in therapy, or while looking back on both situations during the IPR. The three experiences seemed somewhat melded together.

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APES 1: Abruptly Changing the Topic Adam, like several other participants in this study, seemed to reach a breaking point midway through the session when he felt he could no longer talk about his problem (panic attacks). He and his therapist had been discussing how Adam had gotten caught with his guard down and had an unexpected panic attack during the first big exam of the semester. Adam tried to downplay the importance of the attack and in the middle of a speaking turn, abruptly changed the topic. The switch is noted in italics.

Adam: …Maybe just getting it [first big exam] out of the way once wasn’t so bad.

Therapist: Also thinking about, you told me last semester, near the tail end, you had quite a few exams, I imagine. And you were able to kind of work with anxiety too. Like you said, you were getting anxious, but were able to work with your anxiety [inaudible] and get through that experience. (Adam: yeah) So you definitely have that kind of history of being able to kind of wrestle with this thing and make it go away.

Adam: Yeah, definitely.

Therapist: And you got caught with your guard down this time. (Adam: yeah) It happens.

Adam: It’s not so bad. I mean it wasn’t the worst thing in the world, like, I mean I thought it was like during the end moment, but—

Therapist: It felt like that.

Adam: Yeah, just when I tried that stuff, it’s helping me. Um, I don’t know, I’m trying to think of anything else we can talk about. [Adam made a comment about the time.] ______[Note: It’s unclear who stopped the tape, but we both recognized this segment as one of the moments Adam described on the AQ, indicating APES 1.]

Researcher: Cause I was thinking about the time (Adam: yeah)…What was going through your mind there?

Adam: Um yeah, just maybe wanting to transition into another topic. I wasn’t really sure what it was, but that’s what I—

Researcher: Is that what you were saying on that yellow sheet [AQ] (Adam: yeah)— maybe like, okay, we’ve talked about this for awhile—enough!

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Adam: Yeah, and I guess it was only 12:30, like it was about half-way through the session—I just didn’t want to talk—didn’t want to talk about it anymore. ______Adam: Um, I don’t have a lot else going on. Just kind of like going into spring break. Like, in a couple weeks I’ll be going home. Actually my buddy [name] is— ______*Researcher: So is that bringing a new topic—sort of like, spring break?

Adam: Yeah.

Researcher: Okay, this is—a safer topic? Or I don’t know—can you say more about why?

Adam: Yeah, I can say it was safer. Just wanting to talk about like, just like positive thoughts. Like what I’d been thinking about that makes me happy or something. Maybe I thought it would lead to another topic or something—I don’t know.

Although Adam was not able to elaborate on his desire for a topic change in great detail, it does appear that he had reached his fill of talking about the panic and was searching for a different, presumably safer, easier topic to discuss. Suddenly switching topics has been shown to be a marker of APES 1 (when clients prefer not to think about experiences and avoid doing so). Adam’s switch to a new topic seems to indicate that Adam had reached a psychological limit in discussing his panic attacks and possible solutions. This self-regulating aspect of avoidance will be explored in the discussion. APES 0/1: Denial of Problem Underlying Panic Toward the end of the first session we reviewed, Adam’s therapist shared his curiosity about what might be underlying Adam’s anxiety. This topic did not get explored in much depth (perhaps due to time), though it was apparent that Adam was uncomfortable talking about this. In the IPR, Adam seemed to feel that his therapist was poking for a deeper cause, which he didn’t feel existed. Interestingly, Adam wondered aloud whether this therapist suspected he had problems with his family or with his sexual orientation.

Therapist: …I’m noticing the time too. You know, Adam, one thing I’ve been wondering, too, is just with respect to this anxiety, and where it’s coming from and all of that, (Adam: yeah) you know, especially having this attack on Friday, I guess maybe just really curious about what it’s stemming from. ______

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*Adam: I think I listed this on the blue sheet or the yellow sheet, I’m not sure.

Researcher: The one about the causes of the problem?

Adam: Yeah. For something that we haven’t worked on. [on Problem Description Form]

Researcher: Trying to figure out what triggers the anxiety.

Adam: So I guess we start talking about it, but we don’t have a lot of time left, so we don’t really get into anything.

Researcher: So when he…brings up this idea—he’s sort of wondering about what’s sort of behind the anxiety, what was your reaction to that?

Adam: Um, yeah, I thought maybe he was thinking I had a family problem or something. Or that I was like—or that I had a problem with my sexual orientation or something. Um, which I told him I don’t.

Researcher: Okay, you’re thinking—he thinks you have some deeper problem. (Adam: yeah) And you’re saying—

Adam: I don’t.

It is possible that Adam may have had some underlying concerns connected to family and/or sexual orientation, though there is little direct evidence of this, other than Adam’s seemingly random and defensive mention of these topics. Alternatively, it is possible that Adam had been acculturated to think that therapists—in the spirit of Freud—attribute all problems to family relationships and sex. At the very least, Adam seemed resistant to considering a psychological explanation for his distress. APES 1: Unwanted Thoughts About Relationships In the second therapy session reviewed, Adam and his therapist discussed Adam’s experience in group therapy (of which the therapist was a co-facilitator). Adam had identified with one of the group member’s problems with romantic relationships and loneliness and the two had gone to dinner outside of group. As can be seen in the following passage, however, Adam seemed much less interested in talking about relationships than his therapist.

Adam: …I would imagine he [group member] doesn’t have as many friends as maybe other kids…I felt bad—maybe he needed to talk about other things— maybe he needed to get his mind off it for a little bit.

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Therapist: Okay, so it’s kind of like part of you felt like he was being excluded or not understood?

Adam: Yeah, maybe not understood, but like we went there too—sort of, I don’t know—rescue him or save him or, I don’t remember, but again—

Therapist: Feels like maybe there was a part of you that resonated with his experience. (Adam: yeah) It fits for you.

Adam: Yeah, sort of having the door shut on you. Maybe like being in a relationship, it seems like that was the case and also not being able to sort of pick up on the cues. Like not being able to see—I know one of the kids talked about it—um, not being able to see when a girl is telling you no. Or just—or girls are kind of sneaky or tricky. And I don’t know, but it’s like— ______*Researcher: What was going on for you here when you were talking about this? In some ways resonating with the ideas the group talked about.

Adam: Yeah, I don’t know, it seemed like he [therapist] was trying to get something out of me. Like, um, I don’t know, I think, yeah, whatever this kid in the group was talking about a story—he liked this girl and she wouldn’t like be with him because he was bipolar and he was freaking her out. So um, he asked me how I resonated with that, and I feel like in times past, I’ve had sort of the same thing, like sort of the same conflict. Like maybe the girl doesn’t want to be with him or want something more or isn’t ready for a relationship or something. So maybe it’s—I just felt like, I don’t know, he was asking me how I resonated with it, so I felt I did a little bit.

Researcher: So you did resonate—you could relate to some of the things he was talking about. But I’m struck by, you said, “he’s trying to pull something out of me.” (Adam: yeah) Was there a sense that he was digging for something?

Adam: I don’t know, I think he wanted me to talk about relationships more—just on a personal level.

Researcher: Were you wanting to talk about relationships?

Adam: Not really. This happens in group too. Like, I can’t really—I think I maybe don’t talk about things—I talk about things in a more general sense. And just with relationships, and maybe it would help if I talked about it more on a personal level cause I can relate my own experiences. But I wasn’t really wanting to at the moment—kind of thing.

Researcher: Here in this moment [pointing to the tape of session].

Adam: Yeah, in that moment.

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Both in group and individual therapy, Adam admitted to talking about his problems in generalities. Adam sensed that his therapist was “trying to get something out of me,” pushing him to speak about relationships with greater specificity and on a more “personal level.” While Adam had some awareness that doing so might be helpful, he was reluctant, presumably because talking about relationships in more concrete details would be more experience-near and painful. APES 2: Emergence of Loneliness Although Adam reported feeling reluctant to talk about relationships in more detail, he was able to expand on his general feelings of loneliness and that he didn’t feel like he fit in at college. The following passage was one of the few occasions on which Adam talked about any problems that might be underlying his panic attacks (which started the same time he transitioned to college) and which was a problem he had noted on the PQ. Adam described feeling lonely, awkward, and lost—consistent with the emergence of negative affect at APES 2. Interestingly, though, he didn’t get too near these experiences, framing his struggles as something he could bring up in the next group session. Some lines have been omitted from the following passage to save space (indicated by ellipses).

Adam: …I guess I agree with that at [university], I haven’t really connected with a lot of people, except for maybe a few like good friends that I’ve made. I don’t know, maybe I didn’t really connect with people a lot in high school either…it’s sort of a place where there are a lot of expectations and you had to be like perfect. And you had to be sort of a dynamic person and play sports and get good grades. And it seems like maybe friendliness or kindness to other people was forgotten. Or wasn’t emphasized as much. Maybe I could bring that up [in group].

Therapist: That sounds appropriate. Yeah, also too, getting a sense of other people’s experiences—what happened for them when they were in high school and you know, how they saw things in high school—this supposed [university] image and how people hold up to that and how it potentially gets in the way.

Adam: Yeah, it’s sort of strange just being—I mean—I feel like I’m in sort of in an awkward place at [university]. And maybe I should talk about this, because it doesn’t quite—maybe it’s, because it’s a bigger school—it doesn’t feel like home. Now I have like—you have to make your own little space and have it get smaller and make friends…

Therapist: And that strangeness comes up in the sense of—you know, trying to find your place.

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Adam: Yeah, feeling a little bit lost. Like, am I in the right place? Trying to do my own thing, like um, finding my own little niche…And sort of being lost— being a Freshman and not knowing where everything is yet—where all the hot spots are…Like, it’s a lonely campus sometimes. I just notice that all the time when I’m walking back to my dorm by myself. It’s really easy to sort of get lonely or think bad thoughts because you’re alone or you’re not with other people. ______*Researcher: I’m going to pause it here for a second. This makes me think it’s one of the problems on here [PQ]—sort of the “homesick, lonely, depressed.” (Adam: yeah) Is that kind of finding your place here? Does that speak to some of that right here?

Adam: Yeah, I feel like it happens maybe a little bit more when you’re back from a break [he had just returned from spring break]. Just sort of—I don’t know—thinking about, like, what am I doing here? (nervous laugh) I know that this is college—like I’m here to learn—like, but also thinking about the other people. And how do I fit in?

Researcher: The social part.

Adam: Yeah, the social part, yeah.

Researcher: So here, when you’re relaying some of these feelings of not fitting in or sometimes feeling lonely, um, what was going through your mind then when you were sharing this with [therapist]?

Adam: Um, I don’t know. I think I was thinking of things I could relate to the group maybe. A little bit. So I wanted to bring my own experience into the group. Um, not sure exactly what made me think of this. Again, I’m sorry I didn’t put it down on the yellow sheet [AQ].

Researcher: Oh no, that’s fine. We’re not limited to what’s on the yellow sheet by any means. It just struck me that that was one of the issues you’d been struggling with and you’re talking about it here. Um, maybe like you said, maybe connecting it to one of the more personal instances.

Adam: He just mentioned the [university] image and I was struck by that. Like exactly what is the [university] image? Is it kids walking around in Northfaces or (laughs) or is it like, everyone’s smart and athletic or something like that. I don’t know, just trying to figure out how I fit in and things like that.

Adam appeared to have difficulty reflecting on this therapy segment during the IPR. For the most part, he elaborated on the content of what he’d shared with his therapist. His compliant and self-critical voice also showed through with his apology for not initially identifying this problem (Problem #2 on the PQ: “I feel homesick, lonely, and depressed”) on the AQ. As the therapy segment proceeded, Adam seemed to gain some clarity on this problem,

123 notably his struggle to become independent while also being socially connected. Although Adam’s therapist may be slightly ahead of Adam in articulating this problem, the next passage illustrates some movement from APES 2 to APES 3 (Problem Statement / Clarification).

Adam: I definitely think a few good friends would help, because maybe—but you’re not going to be taking all the same classes together—you’re not going to be with them all the time. So, I guess it’s just really about sort of—you have to get used to being on—maybe I’m just not used to that. Just trying to—so I can rely on myself just so that—without other people to get to class by myself or do things by myself—study by myself and even exercise, go for a run by myself. I don’t know. I guess I don’t know—

Therapist: It sounds like what you’re wrestling with is just like, this thing between kind of being independent but also being connected to other people. And the tension between the two. (Adam: yeah) It feels like there’s times when you need to be independent and do things for yourself, but it also feels like there’s a part of you that wants to be connected and have other people that you can spend time with and talk with. (Adam: yeah) And it feels like you’re not so sure about that, but you’re moving toward the side of being more independent—probably more than you want to, which leaves you feeling kind of lonely…

Adam: Yeah, I was just thinking that it’s hard because there’s an emphasis by your parents and teachers on personal achievement or like self-worth. And I don’t know, maybe it becomes a little easier—you’re sort of fending for yourself in some ways. You’re competing for the best grades, the best job, like but there’s also sort of a need to be with other people. And I know that I definitely need like a setting with people—that’s where I do well.

Constructing a Meaning Bridge: The Octopus Adam and his therapist co-constructed a metaphor to describe his anxiety. They likened it to an octopus that snuck up on him from time to time, as mentioned in the following passage.

Therapist: The octopus has been silent for so long (Adam: I know)—months and months. And then finally when he thinks that your guard’s down, he starts playing with you. I kind of have to tip my hat to him. ______*Researcher: So this is interesting—is this octopus metaphor something you guys have used before?

Adam: Yeah, that’s true.

Researcher: So when he brings this up again—sort of this octopus sneaking back up on you—how’d that fit for you? Did it make sense?

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Adam: Yeah, it definitely seems like we’ve talked about it before. And um, like I’m good at like, that kind of metaphor—like, and um, and just like, it definitely fit for me because like we hadn’t talked about it in awhile. And like, it almost seems like my guard was down or whatever, and I wasn’t prepared for it.

In this instance, the octopus metaphor appeared to be a meaning bridge between Adam and his therapist—a sign that had the same meaning for each of them. It also may have been an internal meaning bridge—a way of linking Adam’s anxiety (i.e., the problematic experience) to the dominant community. By externalizing the anxiety (turning it into an object) it may have made it more tolerable to discuss and examine. Naming the problem moves it to APES 3 at a minimum, and perhaps APES 4 if the metaphor was an intrapersonal meaning bridge. Silencing the Octopus A focal point for addressing Adam’s struggle with panic attacks was building up an arsenal of cognitive and behavioral tools that could be used to both prevent and control panic. In terms of cognitions, Adam learned to minimize the impending threats from the octopus with comments like, “this isn’t a big deal.” Adam also used behavioral strategies—mostly deep breathing—to further keep the octopus at bay. These two coping tools are illustrated in the following passage.

Therapist: …So what makes sense for you and I as far as looking to—for the next time to feel like you’re more ready to tackle it? What feels like it would be helpful for you and I to do or talk about to put you in a better place if the octopus comes back?

Adam: Yeah, I don’t know. Just thinking of the tools that I have and the things I can do. Like, the things I can do like if it starts happening, or just taking a deep breath and just sort of saying, hey this isn’t a big deal…if I can just figure out those tools that I have and what I can do to just calm myself down.

Several minutes later in the same session, Adam elaborated on some of the cognitive- behavioral strategies he hoped to employ should the panic return. He also noted his tendency to avoid thoughts of panic was a way of keeping the anxiety at bay, even though he suspected it may make the problem worse. Portions of the following passage where Adam wanted to avoid the panic are italicized; portions attributed to wanting to acknowledge the panic as a part of himself are in boldface.

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Adam: …So, I mean next time—I’m just hoping that it wouldn’t happen again. But if it started happening, I would be able to control it with deep breathing.

Therapist: Deep breathing, but then it also feels like maybe thinking certain thoughts. (Adam: yeah) What’s your sense of those thoughts—just the kind of challenge [inaudible few words]

Adam: I mean—I’m totally like avoiding like the thoughts of panic because if I got—if I keep suppressing it, like maybe it will make it worse or—just maybe it’s saying, like hey, these feelings are a part of me and they’ll always be a part of me, but um, like in the moment, just trying to calm myself down. Maybe just make myself feel a little better.

Therapist: Yeah, it feels like part of it is saying hey, it’s like I’m anxious, and I know that sometimes the octopus is going to try to make me think that I’m having a heart attack or my head’s going to explode or whatever else. And I know that in times past, that you know, that I didn’t have a heart attack, my head didn’t explode (Adam laughs) and that I was able to kind of work to calm myself down. And it’s just [inaudible] other people don’t know what’s going on for me—it’s a part of the experience—so I can take care of myself and not have to worry about other people judging me or you know, what’s going—I can do my deep breathing and—

Adam: Um, deep breathing, um, sort of visualization, like I mean, visualizing myself being done with the test, or [nervous laughter] I don’t know. Like, “oh my God, this isn’t that bad…I’ll be done in 20 minutes.” …And it’s not getting too caught up in it that it takes away from my ability to think or focus on the test.

A part of Adam seemed to recognize that suppressing or avoiding thoughts of panic would not be helpful and might only make his problem with panic attacks worse. From a voices perspective, these thoughts might be attributed to the problematic experience striving to be heard by the dominant community. The community responded by stating that, during moments of panic, it is still best to try to control the anxiety so that the so-called octopus doesn’t get the best of him. In effect, the dominant community appeared to employ a strategy of silencing the octopus while strengthening Adam’s strong and competent voices. The notion of silencing the anxiety was mentioned again at the conclusion of the final IPR interview. Adam described his general approach toward addressing his problem: that the pressure or anxiety did not really exist but was irrational.

Adam (during IPR): Um, with the anxiety, just sort of working with it. Like, thinking about how I don’t have to feel rushed—I have more time than I actually think I do.

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There’s no real pressure. The pressure is sort of all-in-my-head-kind-of-thing. Yeah, I feel like that’s helped a lot.

Anxiety, in assimilation terms, is not a voice, but an indicator of contact with a problematic voice. Silencing the anxiety (as in previous passage) probably means silencing—or avoiding addressing—this problematic voice. Of course, the anxiety could also be viewed as an experience that was problematic and distressful and warranted a solution. The therapeutic strategy in this case was to learn enough about the experience of anxiety to avoid or suppress it without unpacking the source of the anxiety. This appears to be a form of a derivative problem, which will be elaborated on in the discussion. Therapeutic Alliance / Voice of the Therapist Two important aspects of the therapeutic alliance are agreement on the tasks and goals of therapy. Ruptures in the alliance may occur when therapists and clients disagree on the aims of therapy and the ways of achieving them. Adam and his therapist appeared to have a few such disagreements, which will be described in the following sections. The third critical aspect of alliance—emotional bond—will be discussed in light of Adam’s impending termination. Disagreement on goals. In general, it seems that Adam primarily wanted to feel better. While the therapist, too, seemed intent on providing some symptom relief, he also seemed interested in gaining a better understanding of the causes of the symptoms. Adam seemed less concerned about exploring the roots of his problems so long as he was able to manage his symptoms (i.e., panic). This discrepancy became apparent when the therapist probed for a deeper, underlying cause of Adam’s panic attacks. In the following example (a portion of an excerpt used above to illustrate APES stages 0-1), Adam did not think he had a deeper problem and therefore was not interested in establishing exploration of the causes or triggers of his anxiety as a goal.

Researcher: So when he [therapist]…brings up this idea—he’s sort of wondering about what’s sort of behind the anxiety, what was your reaction to that?

Researcher: Okay, you’re thinking—he thinks you have some deeper problem. (Adam: yeah) And you’re saying—

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Adam: I don’t.

Disagreement on tasks. Disagreement on the goals of therapy often translates into disagreement on the tasks of therapy. Adam was not interested in engaging in a deeper exploration of his problems. He was hesitant to engage in the task of hypnotherapy, as suggested by his therapist. In the following passage, the therapist introduced the concept of hypnotherapy, to which Adam responded that he was a little “wigged out.”

Therapist: …One other thing that I was thinking about too that I wanted to throw out, just one of my thoughts, remember we were talking about trying to get at what’s underneath the anxiety. I don’t know if you remember talking about that?

Adam: Oh yeah.

Therapist: What was the root of it, what condition was causing it? Um, a thought I had—I’ll just throw it out to you and see what your sense is—um, one thought I was toying with, remember that person you met with when you had that attack during your architecture test? I was talking with her, and she’s someone that’s a licensed hypnotherapist. And she has been trained quite a bit in hypnotherapy. And I wonder if that might be something you’d be interested in exploring, maybe meeting with her for a few sessions and having her hypnotize you and maybe seeing if there’s some way of getting a sense of potentially what might be underlying the panic or maybe just kind of potentially learning more about it. (Adam: yeah)…[Therapist explains hypnotherapy in more detail]….And I just feel like with you and I, it might be one option that you want to explore? Do you have any thoughts?

Adam: Yeah, um, I think—I just remember when I was meeting with her, that I was sort of a little bit reluctant. I mean, I told her my head hurt and I didn’t really want to do this. Like, it’s just making it worse. But, I don’t know, um, um, like what was I going to say? I’m sorry. Um—

Therapist: What are you feeling right now, in this moment? It seems like you’re a little choked up. I don’t know if that fits or not?

Adam: Yeah, it does. Um, I’m just sort of balancing or weighing my options. Like, do I want to do this or am I going to get wigged out? ______*Researcher: Were you feeling at all choked up here?

Adam: Yeah, I kind of wanted to express sort of the reluctance about the hypnotherapy. Like, it kind of makes me a little bit wigged out, or—

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Researcher: Like, freaked out or “oohh, hypnosis.”

Adam: Yeah, like this sounds really strange. Is it really going to help? But I guess we kind of resolve it. A little bit.

Researcher: But that’s where you were initially.

Adam: That’s what I was initially thinking.

Adam’s therapist continued to explain procedures associated with hypnotherapy and how it might help Adam get more in touch with why he tends to panic during exams. The therapist seemed to present a convincing case and eventually, Adam agreed to try hypnotherapy, albeit somewhat reluctantly.

Therapist: Another thought I had, was maybe what we could do is alternate sessions. You could go for hypnosis one week in lieu of us meeting—and of course you’d have the group—and the next week we’d meet individually and we could just talk about your experience and what came up.

Adam: Yeah, that sounds like a good idea.

Therapist: Okay, that sounds like something that’s doable?

Adam: Yeah, I mean it doesn’t— ______*Researcher: So were you on board here?

Adam: Um, yeah, after he kind of convinced to—um, it was kind of a little bit weird about doing the alternate sessions or whatever. Cause I mean, if we only have six sessions left, we’d only have like three. Because we’d do the hypnotherapy one week and talk about it the next week.

Researcher: So worried that that might not be enough time or?

Adam: Yeah, also again, still thinking what I thought initially, that hypnotherapy isn’t a good idea. Like, it’s just gonna—it’s not going to do anything. But I don’t know. I think I start to be more like convinced.

Although Adam agreed to try the hypnotherapy (and from the outside there appeared to be an agreement on the tasks of therapy), he was still unsure about doing so. Perhaps because of Adam’s tendency to be compliant, he was unable to refuse his therapist’s request. Right after agreeing with his therapist’s statement about the potential usefulness of hypnotherapy, Adam

129 shared some of his doubts by relaying a story about his only previous contact with hypnosis.

Therapist: …Maybe it [hypnotherapy] would be helpful. I mean if it is, my sense is that it would definitely be worth pursuing.

Adam: Yeah, that sounds really good. The only hypnotherapy that I’ve experienced was at a party setting. Like they get hypnotized and they say whatever’s on their mind. It was at a graduation sort of thing. Um, for after high school, when we graduate, they sort of decorate the middle school and like we’d have this big extravagant party where there’s no alcohol and everyone plays games. And there’s card games, and everything. And a hypnotist came in and the kids in high school would be sitting up there and it was just funny because they were under sort of the hypnotherapy and they were acting out things would not normally be acted out. Yeah, but that’s what my experience is.

There were a few other instances where part of Adam appeared to disagree on the tasks of therapy. Adam seemed reluctant to engage in deep breathing tasks. He struggled to complete them during the week and he and his therapist had a detailed conversation about finding a better time of day to complete the daily recommended exercises. Adam also seemed somewhat disinterested in doing deep breathing during the sessions. He expressed contradictory thoughts in the next passage about whether the deep breathing exercises were helpful (noted in boldtype) or unhelpful (noted in italics).

Therapist: …I wanted to check too—I remember that last time when we were doing our deep breathing—um, one thing I had wanted to bring to your attention—I forgot to do it at the time— ______*Adam: I think he actually starts to do deep breathing in the session.

Researcher: Okay. Do you want to fast forward through that? Or you can tell me about doing the deep breathing—is that something you were wanting to use the time to do?

Adam: Um, yeah, I don’t know. Sometimes it’s like um, [therapist] will do things that maybe I’m not—maybe don’t really want to—maybe in the moment, like the deep breathing. But um, I don’t know, I think it helps in this case. I don’t know—I don’t know, at first, I wasn’t like a big fan of like just sitting and doing deep breathing. I didn’t think it really helped. Like, and I think he mentions right here that I’m not doing it right, so, maybe just listen to that?

This passage might represent an intrapersonal dialogue (contradictory positions spoken aloud), though it certainly represents Adam’s ambivalence about deep breathing. Adam

130 appeared to doubt its utility, but seemed afraid to voice such concerns to his therapist. The therapist proceeded to critique Adam’s deep breathing technique, suggesting that he was breathing too deeply at times. During the IPR, Adam said he had conflicting responses to this criticism. He said he recognized that perhaps he was trying too hard (and thus breathing too deeply) but that he also felt “annoyed that he’d say that” and “discouraged that I wasn’t doing it right or something.” The therapist then suggested that he model proper technique for Adam, as illustrated in the next passage.

Therapist: Would it make sense for us to just breathe a little bit—again—just kind of you can watch me and I’ll watch you.

Adam: Sure that’s fine.

Therapist: We can just see the depth of the breathing and just make sure we’re kind of on the same page. ______*Researcher: So at this point, were you on board with doing it? (Adam: Yeah) The deep breathing? I mean sometimes in the past you’ve been like, eehhh [wish-washy “yes”]—

Adam: Yeah, well like we’ve done it in sessions before so like, I wasn’t going to stop him from doing it this session. So maybe I should do it for me. I think we only do it for five minutes or something.

A few minutes after the previous passage, Adam made the following comment during the IPR, almost in passing: “I’m just going along with it and saying, ‘yeah’.” In response to the researcher’s query about this statement, Adam points out his agreeable nature in the face of conflict.

Researcher: Can I follow up on what you said? That sometimes, you’re like, well, I’m just kinda going along with it. Like, yeah, okay—that sort of—maybe part of you not really going along with it or?

Adam: Yeah, but I mean most of the stuff that he says, I do actually agree with. And like, then also like I’m kind of like a nice, agreeable person so [starts laughing]

Researcher: Hard to say “no” if you’re like that. So sometimes there are moments that are—

Adam: Don’t agree.

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At one point during their therapy, Adam’s therapist suggested that Adam share some of his concerns about dating and romantic relationships with his therapy group. Adam had indicated that he had resonated with another group member’s struggles, the individual he’d gone out to dinner with. Adam seemed uncomfortable at the thought of sharing his struggles and identification with this person with the group. He also seemed uncomfortable talking about it with his therapist in individual therapy, suggesting that they move on to a different topic. This passage lends support for avoiding topics that are painful (i.e., APES 1). Links between unwanted thoughts—in an assimilation sense—and disagreement on the tasks and goals of therapy will be addressed in the discussion of this case.

Therapist: I mean, to hear you kind of talk about this, it feels like this would be really great stuff to talk about in group as well. You know, it’s like perfect-made or custom-made.

Adam: I don’t know if you want to move on to any new topics or not, but—I don’t really want—[inaudible]. It sounds like he’s [M.] pretty emotional about it. And I think it would make the situation worse.

Therapist: Well, I mean I guess that’s a possibility. But also at the same time, too, if those are issues you feel you’re wrestling with, you’re definitely entitled to flag some time to discuss that. (Adam: uh huh) So you wouldn’t want your fear of M.’s feelings to get in the way of you talking about that. I mean, it might be further information for him. Maybe he could learn something from the resulting conversation.

Adam: Yeah, that’s true. [said hesitantly] ______*Researcher: Is this another instance of maybe some slight disagreement between him saying, “you should share this” and you saying, “well I don’t know”?

Adam: Yeah, I think so. (laughs) Definitely.

Researcher: Do you remember how you were feeling at the time? When he was urging you to talk about this in group.

Adam: Yeah, I just don’t think it—I didn’t feel like it would get anything accomplished in group. Just didn’t want to relate my own personal feelings toward it.

Impending Termination. Adam seemed to have mixed thoughts about his upcoming termination with his therapist. They were planning to end their relationship at the end of spring semester because the therapist would be completing his training at the center (and Adam would

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presumably be returning home for the summer). The therapist introduces their upcoming ending at the start of the session.

Therapist: …just kind of looking at the schedule, we have like six sessions left in the semester. And I think at that point we’ll have to make some kind of decision as far as, you know, closing. Because my sense is that for me, my term will come to an end here as far as being at the center.

Adam: Oh yeah. ______*Adam: It took us a while to start talking about the test-taking. I guess we’re just—

Researcher: Do you want to listen to this part or do you want to fast forward a little bit?

Adam: I think we start talking about it, I’m pretty sure. Like, within the next minute or two. So fast forwarding would probably not be worth it.

Researcher: Okay. Since we’re stopped here, (Adam: yeah) [therapist] brings up this issue of having six sessions left and ending—did you have a reaction to that?

Adam: Um yeah, I did because he said he was like leaving and it was kind of sad because it was the end of his term. Um, also, um, I don’t know, like I mean I feel like we could get a lot done in six sessions maybe. Also I feel like maybe it’s not enough time to talk about things or, I don’t know. I don’t know, just realizing it’s not a lot of time.

Researcher: So it’s mixed. On the one hand, you say, “we could do some good work.” (Adam: yeah) But then realizing, “well, I don’t know, there’s only six sessions.”

Adam: There’s only six sessions, yeah.

Although Adam appeared to have a sense of optimism for their remaining six sessions, overall, he appeared to be sad. Adam did not articulate any fears or concerns in great detail, though he expressed concern about not having enough time (both in the previous example and when the therapist suggested that Adam alternate his remaining sessions with hypnotherapy). In Adam’s words, “if we only have six sessions left, we’d only have like three [for psychotherapy with him]. Because we’d do the hypnotherapy one week and talk about it the next week.” Aside from not having enough time to complete his therapy goals, Adam likely felt some sadness at the thought of losing a meaningful relationship. Perception of Progress Advances and Setbacks. Like several other participants in this study, Adam viewed

133 progress as mixed. He seemed proud of all that he had accomplished, namely decreasing panic attacks during the previous semester and learning some coping skills when they did occur. However, at the time the IPR interviews were conducted, Adam had had a reoccurrence of the panic attacks and began questioning the gains he had made. Realizing there was more work to be done, he felt somewhat discouraged.

Adam (in therapy): …as like the first semester went on, it was less and less with test anxiety and maybe I got over it…I think maybe I was taking an Economics test, maybe, and just realizing that if I overcame it last semester, then it shouldn’t be too hard this semester. Even though maybe considering that Architecture was the first big exam, but so, I don’t know just kind of— ______*Researcher: I’m going to pause it here. Here, it seems like you’re reflecting on the past, where you are now, some of the changes. What were you feeling and thinking at the time?

Adam: I don’t know, just sort of thinking—kinda good that we were able to talk about it. I don’t know, maybe a little bit nervous that I might have it again or something and what would I do? And just feeling good that I was able to talk about it and realizing that like, I had fixed it last—like I got over it last semester. So that kind of thing.

Researcher: Okay. So a sense of accomplishment at all? Is that a good word to describe it?

Adam: Yeah, just um—definitely the first semester, but still realizing that there’s like work to be done. And to overcome the panic or whatever.

At the close of the last IPR interview, I asked Adam to reflect—in a general sense—on the helpful (and not so helpful) aspects of therapy. The first part of his answer seemed somewhat canned or artificial, as if Adam were trying to be a good research participant. He noted that it was helpful—on the part of the client—to be completely open and honest about one’s “real feelings” and to not feel as if there was a need to hide anything from the researcher. Interestingly, much of what Adam reflected on during the IPR had to do with (1) Adam avoiding his inner feelings and (2) censoring what he shared with his therapist.

Researcher: So if you had—words of wisdom—or your take on it, what would you want me to know as a psychotherapy researcher about things that are generally helpful or not so helpful as you think back on your therapy with [therapist].

Adam: Um, I think helpful, like, it’s helpful that you both put in your input—like both

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you and the therapist. Um, it’s helpful to be honest because it’s going to help you figure out what’s inside. Yeah, it’s helpful to think about what’s causing—what’s down deep, like what are your real feelings? Um, because then you can kind of work with them. Um, what else—I don’t know, it’s helpful to not feel like you need to be—not feel conflicted about anything. Like, don’t feel like you need to say something or you need to impress the other person, just sort of go—

Researcher: Like impressing the therapist?

Adam: Yeah, you don’t need to impress the therapist. Just sort of go in there and speak your mind—and talk about what’s on your—sort of, if you have problems, like express the problems.

When asked about ways in which therapists help (or hinder) therapy, Adam said he sometimes felt as if his therapist was more interested in a deeper, all-encompassing exploration of problems than he thought necessary.

Researcher: So yeah, that’s very useful—talking about your perspective and what you need to bring to it. Are there things that you found helpful or not helpful from the therapist’s end—things that they do?

Adam: I don’t know. I think maybe like they kind of tweak things a little too much. Like, um, looking into something too deeply maybe. There’s times, like, when I’ve talked about things and maybe I didn’t want to explore it further, and like, [therapist] would talk about it sort of like for hours (laughs). Or talk about it for longer than I wanted to. I feel like it dragged on too much.

Discussion: The Case of Adam Who Defines the Problem Perhaps the most puzzling aspect of this case was what constituted Adam’s problematic experience. He sought therapy to help deal with panic attacks. His therapist leaned heavily on cognitive-behavioral (CB) interventions to manage the symptoms. From a CB perspective, the problem might be viewed as the panic itself. The goal, then, is to reduce or eliminate the occurrence of panic attacks, or at least cope with them should they occur. In this view, labeling the anxiety as “the octopus” might map onto APES 3 (Problem Statement / Clarification). Gaining an understanding that the anxiety is irrational and that it (the octopus) could be defeated could be considered a sign of APES 4 (Insight / Understanding). From there, learning how to cope through a variety of behavioral exercises (deep breathing) and cognitive strategies (replacing irrational thoughts with rational ones) would represent APES stage 5. Silencing the

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octopus (i.e., denying the problematic voice) through downplaying its power and bolstering positive can-do voices appeared to be an effective way to cope with the anxiety. If the problem was the panic, Adam appeared to have reached APES 5, where he was able to implement partial solutions to improve his functioning and well-being. An alternative account, from a more psychodynamic or experiential perspective, might consider the core problematic experience lower along the assimilation continuum. The discrepancy could be attributed to a difference in how the problem is defined. Researchers and therapists from these traditions might consider Adam’s panic as a symptom of an underlying problem. Because the problem was warded off at some level, it spoke in an indirect manner through bodily sensations. And while it is unclear what the problematic experience was in this case (though it seemed connected to a sense of loneliness and harsh self-criticism), the degree to which the problem was integrated with Adam’s dominant community was low, indicating an APES rating of 1. Adam was not interested in exploring his relationships or sense of loneliness and actively avoided doing so. From this perspective, “silencing the octopus” might not be a lasting strategy. Adam’s anxiety could resurface since it was suppressed by the dominant community rather than allowed to emerge and become integrated with other aspects of Adam. Rather than prizing one explanation over the other, the assimilation model allows for both perspectives. Assimilation, in a general sense, describes the relationship between two particular voices. Specifying which voices are problematic in relation to each other is likely to be influenced by the therapist’s or researcher’s theoretical orientation (i.e., how he or she conceptualizes the problem). In this case, both the panic attacks (i.e., the experience of anxiety) and their mysterious underlying source were both problematic for different parts of Adam, but in different ways and to different degrees. This is similar to the notion of derivative problems, as described in the three previous cases. Both the original problem (unknown in this case but connected to loneliness) and the derivative or secondary problem (panic attacks) were a source of distress; each could have potentially been a focus in therapy. For the most part, Adam and his therapist paid attention to Adam’s relationship to the derivative problem, helping him to accept and come to terms with the symptom of panic attacks. Fast Forwarding through Dysfluencies: Avoiding Negative Affect Adam’s speech was halting during the therapy sessions and IPR interviews. His dysfluency and nervous laughter appeared to be signs of anxiety. Upon hearing significant

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dysfluencies, Adam opted to fast forward the therapy recording. It is unclear why he chose to skip over these sections, though two hypotheses seem viable: (1) given his degree of self- criticism, he felt embarrassed for having had a panic attack and was critical of his inability to talk about it. Similarly, he may not have felt as if those segments were worthy or useful for examination from a research perspective; (2) he did not want to relive the experience and the associated feelings of anxiety. Fast forwarding the tape may have been a way to avoid contact with a problematic voice that was triggered by an external source (the recording). These two hypotheses are not mutually exclusive and both may have played a role in his reluctance to focus on these segments. In general, fast forwarding through his dysfluencies appears to have been a way to avoid or minimize negative affect. Difficulty Reflecting on Highly Unassimilated Problems Adam had difficulty distinguishing between the experience of the panic attack (i.e., thoughts and feelings during his exam), talking about his panic in therapy, and reflecting (in hindsight) on his embarrassment and difficulty talking about the panic. During the IPR interviews, it was often difficult to determine which time frame he was referring to (panic attack, therapy, or present). While the blurring of these three experiences may reflect relatively poor introspective skills (and, hence, difficulty engaging in the IPR task), it may also indicate that Adam’s problematic experiences were not well integrated. The problem appears to have been activated and felt in all three situations at once. Adam was not able to step back and view these instances from an observer’s position, a skill that often doesn’t occur until later APES stages (APES 3 and beyond). Said differently, Adam experienced his thoughts and feelings without being able to reflect on them. This is consistent with the APES 1 interpretation offered earlier in the discussion. Something quite powerful was being avoided even in the IPR. Denial of Underlying Problem: A Marker of APES 0-1 Adam seemed adamant that there were no serious problems underlying his panic attacks. He seemed resentful that his therapist kept pushing him to explore the roots of his anxiety. The strength of his protest might indicate the presence of a problem at APES 0-1. Unyielding denial of an underlying problem might be considered a marker of this stage. During the IPR, Adam clarified the kind of problems he did not have. He randomly exclaimed that he did not have any underlying family problems or concerns about his sexual orientation. These two explanations seemed to appear out of nowhere. We tentatively speculate that Adam may have been projecting

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these concerns onto his therapist (who had made no mention of these two possibilities). Are family problems or sexual orientation concerns experiences that Adam was warding off, so successfully that he had little conscious awareness of them (e.g., in the spirit of APES=0 or 1)? While possible, it is also possible that individuals in this society are acculturated to believe that psychotherapy is the process of uncovering such dark secrets. Freud, the father of talk therapy, focused on early family relationships and sex as causes of psychological distress. Freud’s accounts—whether accurate or not—have become lodged into the collective psyche of Western thought. Adam may have felt the need to defend against two hypotheses he thought any therapist might suspect. Abruptly Changing the Topic: Marker of APES 1 When Adam abruptly changed the topic from coping with his panic to the upcoming spring break, it seemed to be a way of switching from a more painful experience to a safer one. This has been identified as a marker of APES 1 (Abrupt Change of Subject/Non Sequitur Marker). However, it is worth pointing out that Adam had already been talking about his panic attack for approximately 30 minutes. He may have reached his emotional limit discussing anxiety, and as a way to self-regulate his anxiety, turned his (and his therapist’s) attention to a more positive topic. Further, it was probably a gutsy move on Adam’s part to initiate a change in topic, given his strong compliancy. From this perspective, Adam could be viewed as asserting his own needs, even if it was to escape feeling bad. Unwanted Thoughts: Marker of APES 1 Adam revealed during the IPR that he didn’t really want to talk about relationships. Interestingly, he knew it would probably be helpful (intellectually), but remained reluctant, presumably because it would be difficult emotionally. This is consistent with APES stage 1 (and is built into the stage description), when clients prefer not to think about the problematic experience and may employ a variety of strategies to keep associated thoughts and feelings at bay (e.g., changing the topic as described previously). Although Adam noted at least a couple times (to either me or his therapist) that he didn’t want to talk about a particular topic (notably, relationships), there may have been many other times when Adam was experiencing unwanted thoughts. Because Adam was so compliant, it may not be obvious from the therapy recording or the IPR when and if Adam did not want to discuss topics introduced (or prolonged) by his therapist.

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Therapist’s Use of the Zone of Proximal Development. Therapeutic progress sometimes occurs when therapists work at the upper limit of the Zone of Proximal Development (ZPD), pushing clients as far as they can tolerate. At least two instances of this can be seen in the case of Adam. The first instance centered on the emergence of a sense of loneliness. Adam had reported identifying with the relationship problems and loneliness of a fellow group therapy member. The therapist encouraged Adam to explore his own loneliness during the next group. The therapist did not demand that he talk about this topic in greater detail, but over the course of discussing what he might share in group, Adam explored the problem in his individual therapy, allowing it to emerge more fully into awareness. Although fleeting, Adam showed moments of contact with a problem (loneliness) that was potentially contributing to his anxiety. These glimmers of APES 2 (Vague Awareness / Emergence) seemed prompted by the therapist’s active encouragement that Adam explore his own loneliness with the group. Adam’s therapist also appeared to be ahead of Adam in terms of formulating the problem, at times within the ZPD and at other times, beyond. Adam showed some progress moving from APES 2 to APES 3 (Problem Statement / Clarification). In a passage reported on in the results, Adam became clearer about an internal conflict that was related to his loneliness: making friends while also gaining independence. The therapist articulated the following conflict after a vague account from Adam about wanting to make friends but realizing he couldn’t depend on them for everything.

Therapist: It sounds like what you’re wrestling with is just like, this thing between kind of being independent but also being connected to other people. And the tension between the two.

The therapist then attempted to separate and clarify each of the conflicting parts—a feature of APES 3, when conflicting voices become clearer and equally weighted.

Therapist (continued): It feels like there’s times when you need to be independent and do things for yourself, but it also feels like there’s a part of you that wants to be connected and have other people that you can spend time with and talk with.

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Adam seemed to resonate with the therapist’s conceptualization and in his next speaking turn, elaborated on his struggles, albeit not as succinctly as the therapist. In this instance, Adam appeared to gain a clearer sense of his problem because his therapist—slightly ahead of him in terms of APES—was able to offer a more concise formulation of the problem, but without being too far ahead so as to leave Adam behind. Voices and Intrapersonal Dialogue Not very many instances of intrapersonal dialogue—or spoken conflict between two voices—were observed in the case of Adam. The lack of such an observation is consistent with problems that are below APES 3. One clear instance stood out, though: a dialogue between kind and compliant and the external critic. Any time Adam thought or felt something negative toward others (i.e., taking the position of the external critic), his dominant kind and compliant voice would reproach his criticism, thereby momentarily stifling the external critic. And in a few instances, like the one portrayed in the results section, the external critic would respond with a rebuttal, resulting in a back-and-forth intrapersonal dialogue. Ruptures in the Therapeutic Alliance In the two therapy sessions viewed in this case, there appeared to be several instances where the therapist and client disagreed on both the tasks and goals of treatment, two fundamental aspects of the alliance. Disagreement is not always negative, though. If ruptures in the alliance can be worked through, clients can learn a great deal about resolving conflict in relationships and healing can occur. However, if ruptures are not acknowledged by either the client or therapist, they cannot be addressed. This is relevant in the case of Adam, for there appeared to be at least a few instances where he disagreed with his therapist (e.g., deep breathing, exploring relationships) but did not share his disagreement or discomfort with his therapist. Adam was able to admit, albeit sheepishly, that he was skeptical of engaging in hypnotherapy. Through continued discussion, Adam agreed to try hypnotherapy and seemed at least somewhat convinced that it could be helpful. Alternatively, it is possible that Adam was simply afraid to strongly disagree with his therapist, given his tendency toward compliance and his therapist’s strong, persuasive stance. Adam may have also experienced a rift in the alliance due to a disconnection in the emotional bond when the therapist criticized Adam’s breathing technique. Adam reported feeling annoyed and discouraged because he had been trying really hard (at a task he was skeptical would help). This disruption went unspoken and was only

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noticeable during the IPR. The Therapeutic Alliance and Termination Concerns Adam expressed concern about his upcoming termination with his therapist on at least a couple occasions. He said he feared that they would not have enough time to complete their goals (they only had a handful of sessions left due to the end of the academic year). Adam also expressed sadness at the thought of ending their relationship. We inferred from this that Adam was concerned about losing a meaningful relationship that had been a source of personal connection as well as a resource in dealing with his anxiety. From an assimilation perspective, Adam may have wondered if he would be able to continue assimilating and working through his problems with panic attacks on his own after ending therapy. Further, he may have worried about handling new problems in the future without the help of his therapist. Helpful Aspects of Therapy When asked what was generally helpful (or not helpful) in his therapy, Adam’s response seemed to be a socially desirable one. He noted that it was important for clients to be open, honest, and not worried about impressing their therapists. And while it would be hard to disagree with these points, they seem somewhat ironic given Adam’s apparent struggles to do just that: speak openly and honestly about his problems and not censor his thoughts and feelings to his therapist. However, it is possible that Adam realized that these actions would be helpful even if he were not able to engage in them 100 percent. Results: The Case of Allison Background Information Allison (a pseudonym) was a 20-year-old White female. She was a sophomore education major at a Midwestern university. She had been meeting weekly with a graduate student therapist at a departmental psychology clinic for a little over a year. The primary problem she dealt with in therapy was her Obsessive-Compulsive Disorder (OCD), in particular her obsessive thoughts about getting pregnant. Allison coped with her obsessions by taking the “morning- after” pill, even when she realized she had not had sex, and rationally knew she was not pregnant. Allison also addressed her low self-esteem when not in a relationship with a man and body image issues. She was taking Celexa for her OCD concurrent with being in psychotherapy. Allison’s therapist described her theoretical orientation as a non-directive, developmental approach. The therapist noted that Allison was open and forthright in discussing her problems

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and at times wanted clear-cut answers. The therapist said that part of their work together involved Allison carving out her identity and creating her own understandings and solutions for her struggles. In terms of progress, Allison said she felt more in control of her obsessive thoughts though noted that they hadn’t disappeared. She also said she had learned more about herself and the historical origins of her problems. Allison met with me for two research interviews, spaced two weeks apart. PQ Allison identified six problems on the Personal Questionnaire. From most salient to least, she listed: 1) I have obsessive thoughts and behaviors about getting pregnant; 2) I have lower self-esteem when I don’t have a man in my life; 3) I have body image issues; 4) I struggle with hearing my dad’s voice/negative views of sex; 5) I have concerns (fears, anxieties) about sex in future relationships; and 6) I find it hard to accept compliments from people who are close to me. AQ During our first research interview, Allison identified with four of the moments described by the AQ. She resonated with becoming clearer about one her problems (an item assessing for APES 3). Allison said she became more aware that the sex education she received in school reinforced her parents’ beliefs about sex and contributed to her negative views of sex in the present. While it did seem that Allison became clearer about her struggles with sex, her response seemed more characteristic of APES 4, where clients often explore the historical roots of their problem to gain insight and understanding about it. Not surprisingly, Allison identified with the item tapping APES 4 and wrote, “see question #4”—the item assessing for problem clarity. It is possible that Allison did not distinguish between these two moments as described by the AQ, potentially due to a limitation of the questionnaire. For item 4 (assessing APES 3), Allison also said she became aware that her sexual relationship with her ex-boyfriend had ended on a positive note and was happy to have realized that. For the AQ item assessing for internal multiplicity, Allison said she often tends to feel conflict regarding her ex-boyfriend (T). She indicated that her therapist said there were “two Allisons.” In her words, “sometimes I justify T’s actions in the relationship and other times I’m angered by them.” Allison also identified with the item inquiring about APES 6, noticing that something that used to be problematic now seemed better or more manageable. She responded, “In regards to the morning after pill, sometimes I can talk

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myself out of taking it. Other times I can’t. I might go back on birth control because that seemed to be a good solution.” On the AQ from the second interview, Allison identified with three moments. She said there was a moment when a topic came up that she didn’t feel like discussing (indicating APES 1). She noted, “we were talking about taking the MA [morning-after] pill and after a while, I started to feel anxious and didn’t want to talk about it anymore…so I told her that.” She also described another moment when she felt openly conflicted about something (indicating APES 3 / internal multiplicity). She said part of her wanted to get back on birth control and part of her thought there was no reason to do this since she was not sexually active. “It would be an unnecessary ‘quick fix’.” The third moment Allison identified with was meant to tap APES 6. She said, “some of my obsessive thoughts bother me for awhile and then they just go away…I don’t really know why.” Process of IPR All three raters remarked on Allison’s excellent capacity to engage in self-reflection and the process of IPR. She was open about exploring her experiences in therapy and had a knack for articulating those experiences. She seemed aware of her emotions and physical changes in her speech in addition to reflecting on the content of her therapy. And as one rater phrased it, “she is characterologically predisposed to be reflective to the point of rumination, so she is good at critically examining her discourse and reflecting on its meaning.” Allison seemed to find the IPR interviews useful; she indicated that she was able to challenge her avoidance in therapy while listening to the recordings of her sessions. For example, she strongly connected to a moment in therapy where she abruptly switched topics to something less anxiety-provoking. Analysis of IPR Voices and Intrapersonal Dialogue Allison and her therapist identified different parts of herself, which Allison referred to as “two Allisons.” They labeled these parts as her rational self and her irrational self and were often a focus in therapy. The irrational self expressed extreme fears of getting pregnant, while her rational self often rebutted, in intrapersonal dialogue, that it was illogical to think she was pregnant if she had not had sex. I will describe these voices and their typical interactions in more detail in the following APES sections.

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APES Overview All three co-investigators agreed that Allison’s primary problem was at APES 3 (Problem Statement/Clarification). We, the co-investigators, and Allison identified this problem as the tendency to take the morning-after pill in order to relieve anxiety. Allison’s therapy and research interviews were filled with numerous examples of intrapersonal dialogue between her irrational and rational voices. Such dialogue is characteristic of APES 3 when internal voices are communicating in a back-and-forth manner. We all noted that an assimilation / voices conceptualization seemed especially fitting in this case. We also agreed that Allison showed some movement toward APES 4 (Insight/Understanding) with some prompting by her therapist. Finally, we also saw evidence for APES 1 and APES 2 (described below). APES 1: Strategy for Avoiding Anxiety Allison told her therapist about the audition process for a dance group she had belonged to last year and for which she was re-auditioning this year. She noted that keeping busy with activities such as this was a way to distract herself from anxiety.

Allison (in therapy): …I felt really confident when I did try out and you know, I was just really happy when I made it. And then, you know, I didn’t know how much fun it was gonna be and how much having something like that in my life really distracts me from my anxiety and keeps me busy so that I don’t focus and worry all the time. It keeps my mind on other things. And you know, keeps me somewhat in shape. And plus, like the friends. So when I realized all that, that I could like potentially lose that, that was very distressing for me.

And while some degree of distraction from everyday worries might be healthy, Allison’s avoidance of anxiety seemed to have made her problems with OCD more problematic in the past (i.e., before starting therapy). APES 2: The Push-Pull of Emergence There were several moments where Allison seemed to alternate between wanting her problems to emerge (and to share them with her therapist) and pushing them out of awareness. In the following passage, Allison described how she had struggled the previous week (in a session not reviewed with IPR) about whether to disclose her concerns about not getting her menstrual period.

Therapist: I wanted to ask you—at the end of last week’s session, it seemed like you felt like things were a little awkward because of what we’d talked about it.

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Allison: Yeah, it was.

Therapist: You had said something, and it kind of ran past me. But then I thought about it on the way out the door. I thought, I want to talk to Allison about that.

Allison: Yeah. ______*Allison: That was an instance where last week, at the end of the session, because I had told her at the end, that I was worried because I hadn’t got my period. And we were talking about something, and I had changed the subject. And I was like, I just kind of want to talk about this—I’ve kind of been not talking about it with you for awhile. And I was like, I kind of want to bring it up because I’m worried—it’s on my mind. So we talked about it and that was pretty much the last thing before I had to leave. And then I looked at the clock and I was like, well I should go. And then I was like, now this is kind of awkward. And I kind of made a comment like that, which probably made it a little bit more awkward. And so I think she thought I was kind of uncomfortable. And it was sort of uncomfortable because, you know, it was something of embarrassment and then I just go on to tell her that—even though I consciously brought up that issue and wanted to talk about it with her, it still made the issue more prevalent in my mind. Whereas I had been pushing it back kind of.

Researcher: The stuff related to the period and sex?

Allison: Yeah, yeah, exactly.

Researcher: Okay, so you had talked about it in the past, but it’s more like, more recently it had been shoved away or?

Allison: Right, right. And I had been shoving it away. And this was the first time I had like brought it up with her in a while. That I brought up—like I haven’t gotten a period in awhile. And even though I haven’t had sex, you know, some stuff did go down that I’m a little bit anxious about. And I think there’s maybe a little bit of embarrassment and it was just sort of awkward cause it was at the end of the session. I didn’t really know how to close it. And since it left me with a feeling of—that I was going to have to keep—since that was the last thing we talked about, it was on my mind and I wasn’t really crazy about the fact that that’s what I had to leave thinking about. And it wasn’t her fault. I mean, I was the one who brought it up, but—

In the end, Allison was able to tell her therapist about her period-related concerns, but not without an internal struggle. She admitted to pushing away these concerns for a time, but then realized she should probably acknowledge and talk about them. And even after she made the decision to share her concerns (at the end of the session), she had mixed feelings about whether it

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was a good idea. Allison seemed to both want to and not want to talk about her period at the same time. In a sense, she was experiencing a form of intrapersonal dialogue about whether to reflect on her problem. When asked what it was like for her therapist to revisit this topic the next session, Allison gave the following reply.

Researcher: So here [in most recent session], she brings it up. (Allison: yeah) What was your—when she was first says, okay last week we left kind of oddly. (Allison: right) What was going through your mind then?

Allison: Um, when she brought it up, I kind of felt a little bit awkward again. And I kind of felt a little embarrassed that I had made a comment. Like I literally said, wow this is kind of awkward now or something. And I felt a little embarrassed by that. But I just said, I just told her how I felt.

Despite the awkwardness of the situation, Allison plunged forward and shared her feelings with her therapist. The following passage illustrates a continuance of the push-pull or approach-avoidance Allison experienced in terms of allowing her problem to emerge into awareness and into a dialogue with her therapist. The boldtype portions represent Allison’s desire to talk about the problem (i.e., problematic voice speaking) and the italicized portions represent Allison’s desire to avoid the problem (i.e., dominant voice speaking).

Allison: …What if I had gotten to talk to you about it [at the end of last session]? While I wanted to talk about it [missed menstrual period] because it was on my mind and I kind of needed to talk about it, it also kind of made it—I couldn’t push it in my head anymore. So then I was thinking about it more and I think I was sort of feeling—not that, you know, like while I was happy we talked about it, it made the issue come up in my head again and I really kind of didn’t want it— didn’t want to be thinking about it and I was.

Therapist: So kind of like, it was sort of just in the back of your mind, and you kind of dealt with it and pushed it back. But by talking about it, it reminded you that you have to do something about this.

Allison: Yeah, yeah, exactly. And, so not that I was—you know, it wasn’t your fault. You didn’t make me talk about it all. I think I even completely changed the subject to talk about it. But, I think then I sort of felt like awkward—maybe even a little embarrassed. I’m not sure.

APES 3: Articulating the Problem in Terms of Voices or “Selves”

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Allison was aware that she struggled with anxiety around getting pregnant. But more than being aware, she was able to acknowledge that her compulsive behaviors were not rational but helped quell her anxieties. Allison described her problem in terms of a conflict between two different parts of herself: her so-called rational self (which reminded her that she could not be pregnant without having had sex) and her irrational self (which was obsessed with thoughts that she was pregnant). The following passage showcases a typical interaction between these two perspectives. Allison explained to the researcher why she had told her therapist that she had gotten her menstrual period. The voices speak in a back-and-forth manner, though they seem to be listening rather than interrupting or contradicting.

Allison (during IPR): I was kind of all nervous because I hadn’t gotten a period in awhile. And although I hadn’t had sex, there had been some like activity that made me worry. And so my rational self was trying to say, “You’re not pregnant, you’re not pregnant, you’re fine.” But I kept not getting a period and so I was worried. And that was what we had talked about last week.

Allison noted that talking about getting her period with her therapist had triggered some of the relief she had been feeling during the week. She also wondered aloud whether the doubts she had expressed in the previous session (i.e., irrational voice) had caused her therapist to doubt too. She said the resulting conflict between her self-doubt and rational self was an example of “the two Allison’s,” a concept she had mentioned while filling out the AQ.

Researcher: So here, when you say, “well I got my period,” what was going through your mind right then?

Allison: (sighs). Um, kind of like remembering how relieved I was when I got my period last week. It was kind of like feeling relieved all over again. And I kind of felt like maybe she was relieved for me because she knew I was worried and that I knew she was concerned. And even though I was rationalizing to her the way I had been rationalizing to myself, you know, my self-doubt gave her doubt too. And that gave me more doubt. So it was kind of just like—

Researcher: In this instance, was that—or maybe in the previous session—it was like, self-doubt versus rationalizing?

Allison: Yeah, exactly. Right. That was an instance of two Allison’s.

APES 3: Intrapersonal Dialogue

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Allison elaborated on the nature of her rational and irrational selves and their conflictual interaction. The constant tension between them resulted in uncomfortable anxiety. In the following passage, Allison shared with her therapist that her internal conflict about whether or not she was pregnant led to confusion about how to act (e.g., Should she take a pregnancy test? Should she not consume alcohol?)

Therapist: So you’re talking about these two different sides of anxiety and it’s like you’re on this narrow path. On one side, if you are pregnant, then you should know about it cause then the right thing to do is to know about it.

Allison: Yeah, cause you need to not be drinking!

Therapist: Right, that’s there. And then the other side, is the anxiety of like, am I pregnant, am I not pregnant?

Allison: Right, yeah.

Therapist: So you’re teeter-tottering.

Allison: Exactly. I was. I totally was. It’s sucks, but it’s the worst—the worst feeling. ______*Allison: I sound so dramatic sometimes…this is interesting. It really is.

Researcher: So here, when she—I was struck by the talking about the teeter-tottering. Is that another instance of feeling conflicted?

Allison: Yeah. That’s when—just a classic example of [therapist] being like, it seems like you have two kinds of anxiety going on. And she was talking about when I was not getting my period, there was this tension going on because there was rational me that’s saying, “you haven’t had sex. You haven’t had intercourse. And even though something did happen, but it wasn’t that big of a deal. You took a morning-after pill. So you really should be fine.” That’s like rational me. Irrational me is saying, “what if you are pregnant? You haven’t gotten a period in a while. Um, maybe you should just take a birth control test. To either make you feel better or to—so that you know. Because either way, if you God forbid are pregnant, you should not be drinking.”

Researcher: Oh, that was the drinking.

Allison: Yeah, cause I like partied like three nights last week. And that was sort of me, I think, not, like wanting to really believe that I was pregnant. Like I’m gonna go out, have a good time. And so I was putting off taking this pregnancy test because I was like, you’re terrified if it’s true. And as much—literally so much of me was like, I would be astonished if I really was pregnant. But I can’t shake the feeling that there’s still this

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possibility. I can’t shake the feeling, and so that was like the tension. The teeter-totter she was talking about.

APES 3: Awareness of Triggers Allison became increasingly aware that her irrational thoughts of getting pregnant were triggered by intimacy with men. In the following passage, she was able to link her anxiety episodes with being involved in a romantic relationship.

Allison (in therapy): And I also know like there was a long period, you know, between when J and I broke up and when I started up with K that I didn’t take the morning-after pill at all. And granted I hadn’t spent the night with any guys and I did not kiss any boy between J and K, which was like, a period of like 2 to 3 months. Which is like a pretty long time. And you know, at that point, I never worried about staying anywhere. And I never took—and being okay about this issue—this issue particularly was kind of at bay. So again, there were no guys involved. There was no—so it just seems that with me, it comes with the territory, if I’m getting involved guys, on some intimate level, like the issue kind of creeps back in.

Despite this awareness, Allison reported a sense of hopelessness that she would never be able to solve the problem. She did not believe her therapist’s suggestion that she might be able to overcome it.

Allison: And like I told you before, it’s just frustrating to know that I’m probably always going to have to deal with it.

Therapist: I guess I don’t—I don’t think that you will always have to deal with it.

Allison: You don’t?

Therapist: No.

Allison: Do you think at some point I’ll be able to just put it behind me?

Therapist: Um, I don’t know. I think it could—I think it could happen. ______*Allison: I think there, I actually said the word frustrated. Like I was frustrated that every time I get like intimate with somebody, this fear of pregnancy gets involved. Even if we don’t take pants off! Even—that’s not—it’s just like, I’m so used to worrying about it, with my ex-boyfriend and stuff. I guess that’s why it’s so wrong. But I don’t know. And it is just frustrating. And when [therapist] said, “I don’t think you’re always gonna worry about it,” like I doubted her. Like I don’t really that—

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Researcher: Like, yeah right. [sarcastically]

Allison: Yeah. I feel, at this point I feel like it will always—it probably won’t always bother me this much. I’m sure it won’t always bother me this much. But I—I have a hard time foreseeing that it will just go away…So those were like feelings of frustration and then like doubt when she was talking. With her comment, I felt doubt.

Physical Characteristics of Voices Allison was adept at reflecting on her inner experiences during therapy. She was also aware of and able to comment on the physical qualities of her presentation while listening to the recording. For example, she linked the hesitation in her voice to feelings of embarrassment about having had sex with her boyfriend before she was really ready.

Allison (in therapy): It’s sort of like, I didn’t want to lose him. I’m not saying I had sex with him to—whenever we fought about it, ______*Allison (during IPR): This part, I’m starting to sound a little bit anxious because we start talking about over-the-summer when J and I—we were having problems. And sex was one of the problems because he wanted a lot and I would not give it very much. And he never gave me an ultimatum, but kind of basically implied, if you don’t want to sleep with me, than I don’t really want to be in this relationship with you. And like, that was really like kind of scary for me to admit. And it’s like, it kind of makes me embarrassed that I let him have that kind of control over me. And even though he wasn’t like that for a very long time—it was only like two or three weeks that he was very harsh like that—it still, you know, makes me—hurts my feelings that he did have that kind of control over me and stuff. Again, there’s probably like hesitation in my voice, which is probably a little bit of the embarrassment and me being sad about it and stuff.

Allison also noticed a change in her volume and rate of speech while listening to a key moment in therapy. She identified this moment on the AQ as an instance of suddenly not wanting to talk about her primary problem anymore. During the start of the IPR interview reviewing this session, she described this moment as, “I’m tired of talking. Let’s stop.” The moment is presented below; boldface text indicates portions that were spoken quietly and quickly.

Allison (in therapy): But um, I feel like it could be a more fulfilling relationship. But I, you know, if I’ve been drinking and you know, did something with a guy that I’m still more likely to be like, oh don’t worry about this. I don’t know. Okay, I don’t really want to talk about it anymore. I feel like we’ve kind of

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talked about it to death. (Therapist: okay) If that’s okay? (Therapist: Yes) Well one thing I wanted to tell you was— ______*Researcher: Okay, so let’s maybe listen to this again, because it seemed like a striking moment to you. Um, initial impressions before we listen to it again?

Allison: It’s kind of weird because I sound really loud on the tape for the most part, and I could barely hear myself there.

Researcher: Yeah, I noticed that too.

Allison: I was like, well that’s weird. And I talked really, really fast. And it almost sounded like I was like embarrassed to say, “I don’t want to talk about this anymore.” Cause I don’t do it very often. I can remember only a couple times like specifically saying, “I don’t really want to talk about whatever topic anymore.”

Allison observed the physical changes that can occur when there is a change in voices. In switching from a problematic voice to a dominant one, Allison became noticeably quieter and spoke faster, as if she were rushing to talk about something different. Allison re-listened to this moment several times during the IPR; her commentary will be featured in the next section. Abruptly Changing the Topic Allison rewound the recording to listen more closely to the moment when she abruptly changed the topic. The moment is presented again below, with Allison’s reflections on becoming increasingly anxious and wanting to change the topic to manage that anxiety. The memory of having recently made out with a guy was, in her words, “replaying” in her head.

Allison (in therapy): I told you I feel like it’s sort of now it’s like, with—and there’s a guy and there’s that sort of like, when I started taking the morning-after pill. But um…I feel like it could be a more fulfilling relationship. But I, you know, if I’ve been drinking and you know, did something with a guy that I’m still more likely to be like, “oh don’t worry about this.” I don’t know. Okay, I don’t really want to talk about it anymore. I feel like we’ve kind of talked about it to death. (Therapist: okay) If that’s okay? ______*Researcher: Anything else that came up for you?

Allison: Well I know I was just feeling more—I remember the whole conversation I started getting distracted from it. Because I started thinking about Thursday night again when that guy came up to my room. Which brought on the morning-after pill from Friday. And talking about it, I hadn’t talked about it in awhile, and I kind of had forgotten about it. And um, wasn’t really worried about it anymore. And then I started worrying about it again, and I started to replay the situation in my head again—while

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talking to her. And kind of one part of me is talking to her about this, and the other part of me’s replaying the situation in my head. Like okay, we went upstairs, we started kissing, and he asked me if I was comfortable with this, and I said I’m comfortable with kissing. And then I don’t really remember how long we kissed and stuff. But I remember like taking off his shirt and I don’t remember if he took off mine. And then I remember like telling him, you know, you should probably go. Cause we don’t know each other very well. And I don’t want this to go much further—and stuff like that. And trying to rationalize to myself, like you didn’t have sex. You definitely didn’t have sex. Even if you did, you took the morning-after pill so that would take care of it. And um—

Researcher: So that’s kind of interesting. What I hear you saying is that, on the one hand, you’re sitting there in the room telling her these things, and that’s what we hear on the tape. (Allison: mm hmm) …But another part of you is sort of, gosh, replaying that scene (Allison: mm hmm) and what it was that exactly happened. (Allison: right, right) What should I have done? Just all the things associated with that, so that some of that was going on in the background (Allison: right) while you were talking.

Allison: Right, and um, but even the part of me that was talking to her, was just getting anxious in general, because I hadn’t talked about it in awhile. So kind of I guess, brought it back to me—brought back the initial worries of why I would get the morning-after pill in the first place. And stuff like that. And so then I think I was probably the most anxious at that point. And then I just kind of wanted to stop replaying the situation and I sort of thought, if I stop talking about it, it’ll kind of stop—and it did!

Researcher: It did? (Allison: yeah) So maybe we can just keep listening, but did you have a different topic in mind to talk about?

Allison: Yeah, I brought in this book that I read for class about a girl that has Obsessive- Compulsive Disorder. And I read her a section from it and I was telling her how I felt like I related to the character a lot.

And while Allison changed the topic away from her memory of a physical encounter with a guy, she did not completely avoid talking about her overarching problem with OCD. We speculate that she chose to focus on a less anxiety-provoking thread of the same problem and was not necessarily trying to avoid complete contact with the problem, as is typically the case in topic changes at APES 1. In addition, the topic change seems related to Allison’s agenda for her therapy session. She had brought in a book that had meaning for her struggle with OCD and wanted to discuss it. APES 4: Exploring Personal Historical Roots of Problem

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With some guidance from her therapist, Allison considered some of the historical antecedents of her fears around sex and getting pregnant. The following passage illustrates Allison’s consideration of the role her ex-boyfriend and dad played in her attitude toward sex.

Allison: It’s not like I’m afraid to get involved with somebody…

Therapist: Do you think it has more to do with being physical with somebody than it does being close with somebody emotionally?

Allison: Yeah, yeah. But if I get close with someone emotionally, then maybe I would end up being physical with them. I mean, if I were like dating somebody. I guess I’ve kind of accepted the fact that like, probably as I get in a relationship, I’m gonna have to deal with this again. I don’t think it was unique to me and J [ex-boyfriend]. Like while J and I certainly had our sexual issues—him pressuring me a few months before we had sex probably contributed to my negative ideas of sex. And my dad’s attitude toward it, definitely, for sure contributed to my like dire fear of pregnancy, and like, “must take morning-after pill.” But I don’t think it’s so much about J that it’s going to go away if I eventually do sleep with another guy. I really feel like it will still be there.

Therapist: So you just kind of made like a theory (Allison: yeah) of where the problem comes from. One, it was about J. Him pressuring you to do something that you’re not comfortable with. And another part of it is this voice from your dad that’s very loud.

Allison: It’s so loud.

Therapist: And it’s saying, if you have sex, you’re gonna get pregnant. Period. That’s the end of the story. (Allison: yeah, right)

A few minutes later in the session, Allison’s therapist asked her to consider how she learned about sex while growing up. Allison proceeded to talk about the influence sex-education in school had on her, and identified the following moment as a significant one in helping her better understand her problem.

Therapist: We’ve talked about sex a lot. But I don’t really have—the voice from your dad: if you have sex, you’re going to get pregnant. But what did you learn about sex growing up? So like middle school, high school, what are your images, thoughts, feelings? Like what was—like I know from last year on, kind of your ideas about sex, but that’s all built on a foundation that I don’t think I know about.

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Allison: Um well all the programs that we saw in middle school and high school were abstinence-based programs. So that was what they taught.

Therapist: So the schools are saying, just don’t have sex.

Allison: Yeah, well I mean they did do sex education, but they said first and foremost, abstinence, abstinence, abstinence. And that’s what I got at home, got at church. But at school, I remember seeing the slide show of genitalia, STD’s, and a lot about—we had to memorize all the STD’s and the symptoms and which ones were deadly and which ones were curable and treatable and stuff. And, but we never learned about the morning-after pill or anything like that. I mean, that’s because it was an abstinence program, and some people thought the morning-after pill was like, an abortion pill, even though it’s not—it’s not at all. But, they didn’t teach you about emergency contraception, after-the-fact, um, I remember one time, my sex ed teacher was talking about how condoms don’t work. Cause they have, like, a percent, a rate—that they’re not that good. And I feel—I really feel like it wasn’t really about birth control methods. Cause I didn’t know there were all different kinds of birth control until I got older in high school and when I was in college. When I actually was having sex and was considering, do I want to be on the pill? Or do I want to take the shot? Or do I want to try the patch? Because realistically, most kids aren’t going to abstain.

Allison explained how her sex education classes taught her to fear being pregnant and her parents taught her that pre-marital sex was a sin. Her exploration of historical roots continues in the next passage as well as her commentary about the effect it had on her. Understanding the source of her problems seemed to make her feel less “crazy” and better able to work through them.

Allison (in therapy): And yeah, I totally got the scare tactic—scare you shitless. And giving me lots of apprehensive ideas about it, but it didn’t stop me. ______*Allison: That’s like the realization, right there.

Researcher: So when you’re…putting those things together, what was that like for you?

Allison: It kind of felt good! It felt like—well last year I think I kind of had the realization that—and I don’t want it to sound like I’m placing blame on my parents, but the way I was raised about sex, and the way my dad treats it now, like it’s the end-all, be- all, I think really contributes to why I’m so irrational when it comes to pregnancy. Because it’s almost like, sometimes I would have sex, and just be like, oh my god, I must be pregnant because it was just, go figure, it would happen to me. Even after all these— and the way my dad treats it, you know, that it’s the worst possible thing. It was the worst possible thing that would happen to me. And maybe, the way my school treated—and it wasn’t Catholic school or anything like that—but the way that they teach us, it sort of

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enforced my parents’ beliefs. And that could have contributed to the way I act toward it now. And it kind of—it sort of makes me feel better that I’m just not crazy.

Researcher: It’s not just me!

Allison: Yeah, it’s just not me, or maybe other people feel this way too. And maybe— I’m not gonna say people have to reroute their sex education because I’m mental about it, but like, I don’t know, it does seem more realistic to maybe teach a program that shows lots of different kinds of contraception, because like I said, the truth is that people—kids aren’t really abstaining from sex. And maybe it’s just safer all around. But anyhow, that’s the realization moment. I mean the realization moment is really, just pertains to me—like, oh, maybe my sex education in school is kind of combined with the way my parent and my dad treat sex—is one of the reasons why I’m so schiz’ed out about it now. I mean the realization did make me feel kind of good. Like one of those “aha” moments.

Therapeutic Alliance / Voice of the Therapist Allison appeared to have a solid working alliance with her therapist. Throughout the IPR interviews, she noted instances where she felt embarrassed revealing details of her problem, yet still managed to share them with her therapist. Allison was able to articulate some of the ways in which her therapist was especially helpful. For example, the next passage illustrates how her therapist’s interventions (which seemed to mostly be empathic reflections) were useful yet, at times, difficult to accept.

Allison: I also think if the doctor knew that I had started messing with the morning-after stuff again, she would probably say you should just get on birth control. Or if you even think you’re going to have sex, you should be on it. But I don’t—that’s not the point. It’s not sex, but it’s mental.

Therapist: So it’s almost like you’re taking a different kind of anxiety medication.

Allison: It really is! It really is. ______*Researcher: Did that fit for you, when she said that?

Allison: Yeah, she kind of hit the nail on the head…it was hard initially to wrap my mind around the fact that it’s going to be okay if you go off birth control because it [morning-after pill] was sort of like another anxiety medication.

Researcher: A way to just, whew, feel better if you take that.

Allison: Yeah, yeah. And she really did hit the nail on the head with that one, when she said that. [Therapist’s] good about—she definitely—she tries to sum up things that I say

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and then repeat them back to me. Like I know you can hear her do a lot. And that’s why she always comes up with, so there’s two Allison’s right now. Because she hears them. She hears two different voices of me coming out or something.

Researcher: So when she does make that summary, she sort of says back to you, what’s it like to hear some of those things you’ve just said?

Allison: Sometimes it’s scary cause she’ll say something that I don’t want to be true. And that maybe I don’t want to accept. And then sometimes it’s okay because she can articulate it better than I can say it. She can take all of it in and put it into two nice sentences. Whereas I have all these scattered thoughts that I’m just throwing at her. But sometimes it is scary for her to—to sit—cause she might come up with a theory or a summary or something that I’m like, no I really don’t want it to be that.

Allison’s reaction to the therapist’s suggestion that the morning-after pill was a form of anxiety medication (“she kind of hit the nail on the head”) seemed to mark a moment of insight or understanding. An interpersonal meaning bridge seemed to pave the way for an intrapersonal one. Seeing pill-taking as a form of anxiety management seemed appropriate (i.e., fit her experience) but difficult to accept because it was true. Despite the generally good working relationship between Allison and her therapist, Allison still experienced moments when she was worried about being judged or evaluated. This was present in some examples presented earlier when Allison felt embarrassed to discuss problems related to her period and sex (and which resulted in internal conflict about whether to mention it). Allison also reported some embarrassment and guilt about her risk-taking behavior (“hooking up” with guys after drinking alcohol) as illustrated in the following passage.

Therapist: I guess in my brain, I see the logic of—it seems like the two things don’t add up. Like the actions and the consequences. The consequences, you know, are taking the morning-after pill or eventually getting on the birth-control pill. But then like the actions of drinking and then going home with a guy that you don’t really know. And like being in a situation that could potentially be really dangerous. Like those are like risk-taking things. Where on this end, it’s like, the opposite direction or risk. I don’t know if that makes sense.

Allison: [pause] Well what’s the opposite of risk?

Therapist: Taking the morning-after pill.

Allison: Oh right, right, right, right. Exactly. Exactly.

Therapist: It’s like on two ends of a continuum. (Allison: yeah) So I wonder—

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Allison: I know. [said quietly…then a pause] ______*Researcher: What’s going on here? Little bit of a pause there. Do you remember?

Allison: Um, well I know I was starting to feel like sort of uncomfortable there because she brought up the fact that a lot of times when I do, um, either hook up with someone or hook up with someone and then go get the morning-after pill, there’s alcohol involved. And then I started to feel bad about that because like—she will never come out and say, “Allison I don’t think you should get so drunk.” But I almost feel like she wants to say that. Or maybe it’s internal and she’s not even—but that starts to make me feel a little bit guilty for drinking. And it makes—and that makes me start to feel a little bit anxious, like what could happen in a situation when I was really drunk. And I was home with a guy that I didn’t know. Which has happened a couple different times. And that—that does make me feel a little bit of anxiety. But then also like that if I was consuming alcohol beforehand, like that that was my decision. That makes me feel a little bit like guilty for—the actions that went down.

Researcher: So I hear you saying two things. There’s the guilt part. And even though [therapist]’s not judging or anything, it’s in the back of your mind—“what is she thinking?” And maybe I’m feeling bad—I shouldn’t have made this decision. (Allison: right) But then the other thing is just, aside from any feelings of guilt, is “oh goodness, what could have happened?”

Allison: Yeah, exactly.

Researcher: If I’m inviting this guy up and thinking up ahead—

Allison: Right, exactly.

Researcher: So that’s more the anxiety part of it?

Allison: Yeah, that’s what was creating the anxiety.

Allison’s sense of embarrassment continued as she talked more about her drinking behavior. The next passage illustrates her desire to rush through this anxiety-provoking topic and to make disclaimers that she knew her behavior was abnormal.

Allison (in therapy): So it’s almost like for the next two weeks until I get the pill, maybe I should either have to just be really strong and like really tell myself, “like don’t drink that much tonight that you’re going to worry.” Like, don’t get to the point where you’re gonna worry about every thing. And don’t stay the night with a guy or something. Or if you do go, like hang out with a guy, don’t be too drunk that you’re gonna worry about it the next day and want to get the pill…Like on a Saturday—I told you that one time—I went dancing one night. And one day

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I took the morning-after pill after that. Which is—that’s the most embarrassing thing I’ve done. And I’ve only done it that once. ______*Allison: That was like a feeling—like I rushed through saying that cause I hate talking—cause it’s so embarrassing and so like. Like if it was anyone besides like her or you, like I could never tell someone that. Or someone that knew that I have OCD. Like, I don’t—like it’s so embarrassing, you know.

Researcher: So with other people, you wouldn’t even say it. But with her, it’s okay to say it, but I’m gonna rush right through it.

Allison: Right, exactly…because it’s still embarrassing even though she understands me more than a lot of people. It’s just like—it’s like pain. Not pain, but can’t really describe the feeling I have when I have to say it, but it’s just like, “oohhh.” Like I’m gonna say it, but I don’t really want to.

Researcher: Like right now, you’re closing your eyes [squeezing them tight].

Allison: Yeah, it’s sort of like I clench up a little.

Researcher: Yeah, and it’s interesting, too, because before that it seemed like you were talking kind of slower, even more than normal. As you were talking about your mom and planned parenthood. So before you even got to that point of the clenched up, was it that stuff leading up to that? Do you remember when it was a little bit slower? Feeling generally--?

Allison: I think I was still—probably getting—probably feeling progressively a little bit more anxious. Maybe hence the slowing and maybe I was probably being a little more careful of how I was choosing my words and stuff…but then when I was like, really just wanting to get through that and just say it, to say—I just said it really fast. And then I qualified it by saying, “which is so embarrassing.” Because it’s like, I don’t just want to say that I took that morning-after pill and act like that’s a normal thing to do…I know it’s not normal. I know it’s very absurd. And maybe by saying “it’s embarrassing,” I’m showing that, yes, I know this is ridiculous. But I still do it. So it’s sort it’s like almost a disclaimer in a way. By saying that I am embarrassed by it, I’m not okay with the fact that I did it. But I did it. Does that make sense?

Researcher: Yeah, it’s a way of saying, “yeah I know I did a somewhat silly thing, but at least I’m aware—that I know it is.”

Allison: Yeah, right. I think it makes me sound like not completely crazy.

Allison noted some other instances where she felt as if she had to defend herself or qualify negative aspects of herself. In the following example, Allison said she made a disclaimer

158 after revealing that she didn’t follow her parents’ religious advice to abstain from pre-marital sex, to show that she was a good person at heart.

Allison (in therapy): Like I am, you know, a pretty—not a pretty religious person—but I am religious. I do believe in God. I think I act relatively Christian. And I pray— ______Allison: This is me being self-righteous. ______Allison: --and while I do do things that are sinful, like I think at the end of the day, I’m a good person. ______Researcher: You say, being self-righteous. Feeling a need to talk about that part of you?

Allison: Yeah, yeah. It’s like I’m going to justify—you know I’m going to make sure she knows I’m a good person. I don’t know. I do that. I preface what I’m going to say with something else. If I’m gonna feel guilty about something, I might say something good about myself.

Research: Yeah, to balance it?

Allison: Yeah, like a disclaimer or something.

Perception of Progress While the therapist’s interventions usually seemed to help clarify Allison’s problems and promote understanding (i.e., facilitating the assimilation process), the progress was not always welcomed. Allison clearly appreciated being understood “she [therapist] can articulate it better than I can say it. She can take all of it in and put it into two nice sentences.” However, Allison noted that she didn’t always want to accept what she knew was probably true about herself. A theme echoed again and again was that progress is a mixed bag. Moving forward can be a painful process, even with an awareness that one is advancing for the better. Discussion: The Case of Allison Client and Therapist Articulating Problem in Terms of Voices Allison’s primary problem (irrational self vs. rational self) was rated at APES 3, though instances of other stages were found, including APES 1, 2, and 4. One thing that stands out in this case, was Allison’s articulation of the problems in terms of voices or “selves.” She was able to state that her irrational self, who was characteristically fearful of getting pregnant, often

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doubted and contradicted her rational self, which realized she couldn’t be pregnant without having had sex. The interplay between these two voices (which might be parallel to the concept of obsessions) led Allison to engage in compulsive behavior (taking the morning-after pill) to reduce anxiety. The therapist, who had knowledge of the assimilation model but was not involved in assimilation research, seemed facile with the concept of internal multiplicity. She helped differentiate these two different parts of Allison and gave her a language to talk about them. Consistent with the model, Allison was holding conflicting parts of herself in awareness and engaging in intrapersonal dialogue. Voices As Active Traces of Experience Voices, which are thought to be traces of experiences, are not passive but active, according to the theory. When a voice gets triggered, the experience it traces gets activated and the person experiences some of the same sensations (images, smells, sounds), thoughts, and feelings that originally occurred. Allison’s re-experiencing of anxiety-provoking situations when talking about them in therapy confirms and elaborates this assumption. For example, she noted that when talking about a recent incident where she had felt anxious, she started replaying the scene in her mind separate from yet concurrent with the verbal retelling of the experience. In this replaying, Allison reported experiencing many of the same images and anxious feelings she had before. The reactivation was so strong in one instance, she abruptly changed the topic to self-regulate her negative affect. Similarly, Allison reported experiencing a sense of relief when retelling a situation that had been relieving, as if she were back in that moment. Physical Characteristics of Voices Voices, when communicating aloud, often sound different. This was noticeable to both Allison and me when reviewing her therapy recordings. Allison noted, just as Brian did, when her vocal presentation suddenly shifted. She not only commented on these changes (e.g., speaking quickly, quietly, or dramatically), but also reflected on her internal state of mind at the time and potential reasons for speaking in a different manner. Although she did not conceptualize the changes in terms of shifts between internal voices, she was struck by sharp contrasts and saw meaning in them. Abrupt Topic Shift Allison abruptly and intentionally changed the topic during one of her therapy sessions because she was feeling overwhelmed with anxiety. What is interesting about this shift, was that

160 it did not appear to be an indicator of APES 1 (Unwanted Thoughts / Active Avoidance), when clients prefer not to think about their problems and will only do so for fleeting moments. Rather, Allison had been discussing her problems related to OCD and her use of the morning-after pill openly and honestly for a good portion of the session. She appeared to reach a point, though, when she could no longer tolerate the anxiety it was evoking. And although she changed the topic to something more manageable, she did not completely avoid discussing her problem. Rather, she appeared to focus on a less intense strand of the same problem. In this instance, and in the case of Julie yet to come, abrupt topic shifts, seemed beneficial. While they did appear to be avoiding continued contact with a problematic experience, they seemed to be implementing an effective strategy for self-regulation and self- soothing. Clients may use a variety of strategies—avoidance being one of them—to stay within the zone of proximal development (ZPD), allowing them to work productively. In this instance, Allison may have changed the topic so as to not get too far ahead of the ZPD, where she could no longer make useful progress on her problem, at least on that particular strand. Exploring Personal Historical Roots of Problem: A Marker of APES 4 Allison spent a portion of one of her therapy sessions examining the roots of her problem. She considered the role that the sex education she received in school and from her parents played in her obsessive thoughts about being pregnant. Gaining a better understanding of her personal history led to an “aha” moment where she felt less “crazy.” She seemed to realize that she wasn’t internally defective for having irrational thoughts but had reasons to be afraid of sex and getting pregnant. Exploring the personal historical roots of a problem has been a documented marker of APES 4 (Understanding Personal Historical Roots; Honos-Webb, Lani, & Stiles, 1999; Honos-Webb, Stiles, & Greenberg, 2003; Honos-Webb, Surko & Stiles, 1998), where clients develop a greater understanding of their problem, thereby enabling them to start considering possible solutions. Therapist’s Role in Promoting Assimilation The therapist’s use of empathic reflections seemed to Allison to be quite helpful. As she put it, “[therapist] is good about—she definitely—she tries to sum up things that I say and then repeat them back to me…she can articulate it better than I can say it. She can take all of it in and put it into two nice sentences. Whereas I have all these scattered thoughts that I’m just throwing at her.” Allison indicated that her therapist’s ability to get at the heart of what she is saying in a

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pithy fashion helped her to clarify and understand her thoughts and feelings. From an assimilation perspective, the therapist’s interventions appeared to advance the integration of Allison’s problems, presumably because the therapist was working within the zone of proximal development. Allison seemed to get a clearer sense of her problems and was better able to articulate them, a characteristic of APES 3. And despite the fact that Allison, her therapist, and this researcher would likely say she was progressing by getting a clearer sense of her problems, Allison noted that she often found her therapist’s comments difficult to accept. Even though they seemed to ring true, she didn’t want to believe what she had heard, presumably because it prompted a response from an opposing voice, which is not uncommon at this stage. The therapist also actively encouraged Allison to explore the historical roots of her problem, namely the source of her early lessons about sex. This helped Allison inch toward APES 4, where clients cultivate a sense of insight and understanding about their problems. Above all else, it seems that Allison trusted her therapist. This trust seemed to enable Allison to share aspects of her problem that she said she couldn’t share with others. Although disclosing to her therapist was difficult, she was able to push forward and disclose embarrassing details. Fear of Being Judged for OCD: A Derivative Problem? Allison had a heightened awareness of her problem. This is consistent with one of the criteria for an official DSM-IV diagnosis of OCD: awareness that one’s thoughts and compulsions are irrational and excessive. However, Allison’s awareness was so intense that it seemed to become a problem in its own right. Allison repeatedly expressed her embarrassment about the nature of her problem. She seemed critical of herself for having OCD (and the irrational thoughts associated with it) as well as for the nature of her obsessions and compulsions (that they focused on sex, a socially uncomfortable topic). Allison’s self-criticism and fear of being judged for her problem became so strong, that it seemed to become a secondary problem to the OCD. In other words, the experience of having a problem was problematic itself. She spent considerable time and effort trying to conceal her problem so as to prevent negative judgment from others for her “crazy” behavior. Like Sabrina and Brian, Allison had a derivative problem that could be tracked using the APES.

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Results: The Case of Julie Background Information Julie (a pseudonym) was a 31-year-old White partnered female who was the mother of a young child. She was a graduate student in English at a Midwestern university. She had been seeing a pre-doctoral psychology intern at a university counseling center. They had been meeting weekly or every other week for the last six months, though Julie reported having had extensive prior therapy experience. Julie reported that her therapy focused on identifying and using spirituality to find balance, her future career choices, being a mother, writing her thesis (a personal memoir), and dealing with her past experiences with abuse, psychological disorders, and recovery. Julie’s therapist described her theoretical orientation as a postmodern feminist approach. Julie met with me for one research interview. We had intended to meet for a second interview, but Julie’s busy schedule delayed setting a date, and she eventually decided not to participate in another interview. PQ Julie identified five problems on the PQ. From most significant to the least, she listed: 1) struggling to identify and use spirituality to find balance; 2) future choices (e.g., What am I doing with my life?); 3) fears and choices associated with motherhood; 4) dealing with emotions that stem from writing my thesis (a personal memoir); and 5) dealing with my own experiences of depression, eating disorders, physical abuse, and recovery. Of note, Julie rated the last problem as bothering her “not at all” in the past 7 days. She appeared to have worked through much of her past experiences with abuse, depression, and eating disorders in prior therapy relationships. She denied having any problems (at present) that she did not talk about in therapy. AQ Julie identified with seven of the eight items on the AQ, though several moments she described appeared to have some overlap. In response to the item assessing for bodily sensations and physical pain (indicating APES 0), she reported feeling some “anxiety and depression” in her heart/chest region at the start of the therapy session. During the IPR, she elaborated on this physical sensation as a “tightness” in her chest. Julie also identified with the item tapping into APES 2. She said she felt overwhelmed by events in the last two weeks. She said she had difficulty explaining why she was having trouble with control in relation to her mother’s illness, spirituality, and the future.

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Julie also responded affirmatively to the item assessing for APES 3—gaining a clearer sense of her problems. She said she realized that the word “control” may be giving her trouble. Said she also realized that she doesn’t have to understand everything the she’s feeling or which happens immediately. She indicated that she needs to make time to simply sit in silence and process emotions and events or “just feel them.” Julie’s statement about the word “control” being problematic seemed consistent with APES 3. Her elaboration of the reason this word was difficult seemed more characteristic of APES stages 4 and beyond. It was not surprising, then, that Julie noted this same realization in the AQ items tapping into these later stages. For the APES 4 item, she said the word control was a problem and that she became convinced (in this session) that she needed to give herself permission and space to “let things sink in.” For the APES 6 item, Julie said that she was reminded, “(1) I move through difficult moments more quickly and (2) I need quiet time from the role of student, partner, mother, etc.” Julie said she already knew this, but that therapy reminded her of this. In response to the item assessing for internal multiplicity, Julie said she tended to think with her head and does not let her “intuition / gut / heart” do much of the work. She indicated having a battle between her brain and her heart (with her brain usually winning out). Finally, in response to the item tapping into APES 5 (applying a new understanding to a problem), she said that she’d recently found a more feminine aspect of spirituality and as a result, “felt like it opened something in me.” Process of IPR Julie was very adept at engaging in therapy- and self-reflection, perhaps due to her many years of prior therapy experience. As an illustration, Julie asked at the start of our interview whether she should reflect on “process,” new insights, or how she was feeling. She listed several meta-awareness alternatives, indicating a high degree of insight and ability to reflect on her internal process. Her self-reflexivity was also apparent throughout the interview. As one co- investigator noted, Julie “is introspective and verbal—she is a therapy ‘veteran’ and this was apparent in the text.” This co-investigator also noted that she was very adept at attending to her therapy and seemed “open to exploring her openness” in the session. Another co-investigator indicated that Julie had a solid understanding of her therapy, was able to compare/contrast it with other therapies, and seemed prepared for her therapy sessions.

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Analysis of IPR Voices and Intrapersonal Dialogue Silencing Parts of Ourselves. Both Julie and her therapist self-identified as feminists. In line with this, they had had several discussions about the pressure for women to silence their voices or not express certain parts of themselves. Julie remembered and commented on these conversations when talking about mourning the mother she never had. She noted that it didn’t feel right to “bury” her mom forever—as she had done in her memoir—and instead hoped to honor the weak parts of her mother (and herself) so as to accept both in their entirety.

Therapist: Perhaps this was letting that piece go—the book is up, it’s done…And so now perhaps this is the moment where you get to actually finally bury that mom that you didn’t like as you were growing up. The woman did not do for you what you wished she would have done. And now you get to go forward and be with this mom that you have.

Julie: Yeah. Cause I’ve been trying to rationalize—I’ve been trying to deal with that too. Remember when we talked about not wanting to—feeling strongly about not silencing the parts of ourselves that are weak or negative or whatever. Accepting the whole person. And maybe, I think she took up a lot of space. And so— ______*Researcher: I’m intrigued by that. Is that something you’ve talked about that in the past—about this sort of honoring all the parts of you? (Julie: yeah) And not silencing the bad ones?

Julie: Yeah, I was—it was something that I was sort of, I guess a few weeks ago, conflicted about. It was sort of a little epiphany that I had when I was finishing the book. That I didn’t want to bury my mother the way that I started out. That it—yes, that it feels really important to me, um, that we as women don’t silence the weak parts of our ourselves, in square quotes, or the things that we might call damaging or negative. Because I think that those things have a lot to say. Those pieces have a lot to say. So, when [therapist] was suggesting that maybe I was sort of burying that mom or putting her to rest, that’s why I brought up this thing that I had said in the past because it didn’t feel quite right to me.

Abrupt Topic Shift. Approximately two-thirds of the way into the therapy session, Julie abruptly changed the topic from mourning her mother to talking about her future and the status of her graduate school applications. This transition is noted in the following passage, which includes Julie’s explanation for the shift. She did not appear to be avoiding the original topic in the spirit of APES 1 (Unwanted thoughts / active avoidance), but rather, felt like she had

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discussed it enough and was ready to move on to the other topics she had planned on covering that session.

Julie: …I’m giving myself permission to cry, to be sad. To not feel like I have to be like some kind of—this is part of my humanity too. Just not getting stuck there is the key. To acknowledge these things and move through it seems to be really important as far as growing. Does that make sense?

Therapist: Absolutely. (Julie: yeah) Absolutely.

Julie: I think this whole week I’ve spent trying not to. Feeling like to really grow, I forgot that it would be okay—that this is part of who I am too. Grieving, being sad, or being a little afraid my mom might die. But just not getting bogged down by it. So, yeah. I think I learned that. Okay. [brief pause] Now what about college? Like we talked about— ______*Researcher: So there’s a transition here?

Julie: (laughs) Yeah. When I went in I had—well when I first started talking to her, there were like three pieces. There was the mom and the hospital and worrying about that. Well there was spirituality then the mom in the hospital. Then college. Um yeah, so, and that’s what I tend to do. If I’m done, if it feels like we’re done. I just—I’m really efficient.

Researcher: Yeah, so you have done some of your work before you come. In that, you know—these are the things I want to be talking about today.

Julie: Yeah, I think I generally—though I may not be thinking about them—it seems like when I come into the waiting room or even before that when I’m sitting in my car, my mind just transitions to, this is my time. And this is therapy time and talking time. And then I settle down and I do think I do some thinking right before I see [therapist]. So—

Researcher: Okay, so here, when you are making that transition, can you say a little more about—cause people can make transitions for different reasons. But what I heard you saying, was that it felt done. (Julie: yeah) Like you’d worked through kind of what you’d wanted to.

Julie: Yeah, exactly. That I didn’t have any more—I didn’t have anything else to say about mom—my mom. And I did have other things to say. About college and things like that.

Intrapersonal Dialogue. A few instances of rapid crossfire in intrapersonal dialogue were identified in Julie’s therapy. A striking example occurred when Julie explained the push-

166 pull or approach-avoidance she felt in relationship to publishing her manuscript and applying to another graduate program. At the time of the session, she was waiting to hear back from both editors and graduate programs about her manuscript and admission status, respectively. The part of her that felt vulnerable and bothered by submitting her manuscript and applying to grad school is in boldface and the part that was confident and encouraging of these processes is italicized.

Julie (in therapy): I know I’m putting myself in a very vulnerable situation by going to agents and publishers and then and having my applications out to universities. And just sort of being judged all the time. Like I really—every time I—this is what I asked for, sort of. I put myself in this position. So, I need to find a healthy way to manage it so it doesn’t hurt me. Um, because I feel like I want to do it. But it’s bothering me. It doesn’t feel good. So, not that I’ve been—I’ve gotten really positive feedback back about the book. I have gotten rejections, as far as, we’re not taking memoirs right now or things like that. But I keep getting agents asking for pages, so I know it’s a clear letter. So that’s a good thing. But it doesn’t feel good, combined with waiting for the applications. I’m still waiting to hear from Ph.D. programs.

APES Overview Although the co-investigators uniformly rated Julie’s ability to reflect on therapy as undeniably high, there was less consensus on the APES ratings of Julie’s various problematic experiences. We eventually made sense of our multiple ratings and lack of consensus by considering that Julie had multiple problems that we needed to define and rate independently. If we considered Julie’s progress on historical problems (e.g., her eating disorder and abusive childhood), Julie was rated at a much higher APES level. Julie had spent several years in therapy, working on many of the same problems listed in the PQ, and had reached a significant level of insight about them. Further, she had begun turning her problems into resources, namely the writing of a memoir as a way of assimilating her experiences of childhood abuse, a strategy consistent with APES 6. For the problems being dealt with in the session we analyzed, Julie was rated as moving from APES 2 to 3. Her problems focused on (1) unresolved issues with her mother, and (2) being open to her experiences and allowing herself to feel / “sit with” negative emotions. With respect to the first problem, Julie seemed to be at APES 2-3 due to the rawness of her hurt feelings regarding her mom but appeared to be gaining clarity on the ways their relationship was problematic and painful. Although she had made progress assimilating several strands of her

167 abusive relationship with her mom (i.e., consistent with the APES 6 rating discussed in the previous paragraph), Julie struggled to assimilate new experiences in the context of this relationship, namely, that mom’s health was in jeopardy again. Although Julie appeared to be transitioning from APES 2 to 3 in terms of her concerns for mom’s health in the present, there was were also moments when Julie avoided contact with this problem. She seemed to momentarily regress to APES 1 when this problem became too emotionally overwhelming. With respect to the second problem, Julie appeared to be at APES 3: she was aware of the problem (trouble “sitting” with painful emotions) and could state it as such. Julie, like several of the other participants, appeared to be struggling with a problem that was a solution to an earlier problem (i.e., a derivative problem). Julie’s old coping response to the problem of abuse (avoiding emotion in connection to her mom) became a problem in its own right (avoiding all negative emotion). This secondary or derivative problem was rated at APES 3; she had a clear awareness of this problem and a desire to change, yet she still avoided negative affect, a sign of APES 1 and an indicator of a more primary problem. APES 2: “Flopping Around in the Water” Julie and her therapist were talking about issues related to being in and out of control. Julie noted that control is a “loaded word…full of not just definitions, but memories and associations.” She went on to explain how uncertain she felt during moments when she was less in control, as if she were a fish “flopping around in the water.” Her description of this phenomenon is vividly articulated on the following passage and seems consistent with the vague awareness and confusion associated with APES 2.

Julie (in therapy): Yeah, and it’s…yeah, I don’t know. I feel like I’m—I’ve said this before—I’m back to this flopping around in the water. Not sure. I don’t have anything to hold onto right now. It felt great, but it’s all distorted. ______*Researcher: I’m going to pause. I’m intrigued by the metaphor of flopping around. I’m wondering if that’s linked to any of the moments you described [on AQ] about feeling a little overwhelmed or feeling uncertain. I mean I don’t know if you can unpack that a little bit. Not so much in terms of the content, but what it felt like to have that—to feel like you’re flopping around.

Julie: Um, yeah, I think I will unpack it later in the tape. But you mean the actual physical feeling?

Researcher: Physical or psychological.

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Julie: Yeah, it just feels like being in water and not, like I said, having a place to stand. Like having a lot of things going on emotionally and intellectually in my head. And not being able to manage it. Sort of, is what it feels like. Like I can physically feel in my head—well when I was in there and still there, trying to put these different little aspects in their place. And I don’t like it that they don’t just go there easily. And so I feel like— I guess that’s the flopping around in the water—sort of treading water, I guess, with all this stuff and not—and trying to manage it.

APES 2: Bodily Symptoms Julie identified some bodily symptoms before and at the start of her session that appeared to be connected to her psychological experience of anxiety and depression. She noted that she felt chest pains that seemed to dissipate later in the session once she shared some her concerns with her therapist. The following passage details her account of these pains, which seemed to signal the emergence of problematic experiences related to her mom.

Julie (in therapy): I’m really depressed. Like, I haven’t been this way in awhile. And I woke up this morning and my heart just felt like—[describes something about how her body feels.] Dark, and just not—yuck. And I think it’s all—not just my mom, but waiting for grad schools and waiting for people to respond, like editors and publishers. ______*Researcher: I’m going to pause it here. You had described waking up feeling some of that heart feeling. Was that similar to some of the sensations you were having during the session? [Julie had mentioned this on the AQ.]

Julie: Um, at the very beginning of the session. Yeah, I brought it with me. But as I talked about it, it like it’s not there now.

Researcher: Okay, it kind of went away then. (Julie: mm hmm) Okay. And more just sort of a tightness in this area?

Julie: Like a tightness or anxiety. Yeah, more than—depressed when I woke up and more tightness or anxiety going into [therapist’s] office. But yeah, that was the pain.

Researcher: Any other thoughts while it’s stopped?

Julie: Um, no (laughs). I’m just thinking that—I’m just trying to get my thoughts out— is my only thought. That it sounds random to me. Sort of connected, but random.

Julie described several elements of this moment: feeling a tightness in her chest, struggling to get her thoughts out, and that her words seemed somewhat random. The latter two

169 observations seem highly consistent with past observations about APES 2, while the first one (her bodily sensations) seem to provide a new aspect to this assimilation stage. A few minutes later in the session, Julie indicated a decrease in anxiety and tightness in her chest. The therapist’s response (which Julie perceived as being empathic) in the following passage appeared to help diminish the tension in her body. The therapist reflected Julie’s sense of confusion in trying to find a female alternative to spirituality.

Julie: Where do I start? It feels like it’s all melded together.

Therapist: I think that you have gotten the power from going back and finding the matriarchal piece of your spirituality. And you’ve taken back the power in your life. And that might be that feeling that you have. Because there’s a lot of energy devoted to it. And it’s powerful! And so that might be a little consuming and a little scary. But I think it’s letting it settle in. And seeing, wow, you’re in charge. This is what it’s all about. You’ve taken care of all these things in your past. You’ve taken charge. You have taken the power away from anorexia. You have taken the power away from a difficult childhood. You’ve taken the power away from your mother and father. You’ve taken the power away from a patriarchal god. And you’ve taken it back. That’s a lot of stuff to hold on to. It sounds—I mean just getting comfortable with it at this point.

Julie: Yeah, that sounds right. ______*Julie: I said yeah, that sounds right. But when she—I remember thinking or feeling like that anxiety—that’s the point where it stopped. When the anxiety really started to go…when [therapist] was talking about the things that I have done, and the things that— when she was sort of articulating in a much better way that I was doing, just what was going on in my head, then I started to be able to be less anxious. And the tightening sort of started to disappear.

Researcher: Okay. And this is—

Julie: That’s the point where it happened. So I think it was her saying it back to me. In a different way.

APES 2 to 3 Toward the end of the session, Julie’s therapist noted that she had been talking about the loss of her cat more cognitively than emotionally and encouraged her to share how she was feeling. As illustrated in the following passage, Julie was able to allow some of her sadness to emerge into awareness (APES 2) and in doing so, was able to recognize that her tendency to avoid emotions was a problem worth addressing (APES 3).

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Therapist: You talked about it [loss of cat] in a very intellectual tone—How do I address this to my son? How is it connected to my mom? But how did you feel about your cat?

Julie: You know, I haven’t had a lot of time to feel about it. I felt really sad. I know, I keep thinking, I’m so sad about my cat, but I haven’t let myself be sad about my cat. Because my mom’s in the hospital. But yes, I felt very sad. I mean I cried. And it was just—it was my baby and I was worried about it. He was my—like I had him in my only apartment that I’ve ever had all by myself. And I got him right before I got pregnant. And he was like my—he was really good practice for having children. Yeah, it was—Yeah, I am still sad about my cat…I’m sad about my cat. Yeah, I am in my head a lot.

Therapist: I think when you come up on some of the messier moments in your life, you tend to go to your head. And I’m wondering if it wouldn’t be helpful for you to go ahead and just feel some of the stuff. And not try to analyze it, write it out, anything else. Just get messy for awhile. (Julie: yeah) Just be there in it. And on the other side, think about it. Do something with it. Write about it. Do whatever you need to do to kind of clean up the messiness.

Julie: It was really huge. Like yesterday, I just got through the day. I couldn’t teach. I was a disaster in my class. I couldn’t even focus on anything. (Therapist: I’ll bet.) And my head wasn’t there—I couldn’t be with them. And as soon as I got in the car to come home, I was snapping at [partner] about something. And I just cried. So I know that I need to do that. And it was almost like forcing itself upon me. I just need some quiet. I haven’t had a day where I’m not trying to be a mom and a daughter. All spring break I was torn between me trying to be a daughter and a mother. And that was hard to do. So I keep thinking, I just want to get a hotel room and I just want to stay there all by myself and not have to do anything. And have some quiet. Because I don’t have that.

Therapist: Is there a way that you could get that for yourself?

Julie: I don’t know. I have been thinking that I just need to go do something all by myself for just a day.

APES 3: Helpfulness of Stating the Problem Julie addressed some of her lingering concerns about her future. She had submitted her memoir for publication, which while difficult facing potential rejection, seemed better than doing nothing with the memoir she had worked so hard on. She also shared with her therapist her uncertainties for the future and that she’d begun questioning herself. The following passage

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illustrates these concerns and Julie’s observation that even though her therapist couldn’t answer her questions and concerns, she felt the need to say them.

Julie (in therapy): For me, it’s something to do in the meantime…It feels really bad to stare at the manuscript after having worked so hard on it and do nothing with it. That doesn’t feel good either. So I think I choose this. I think this feels better. But it’s just not perfect. It’s not going to be perfect. [It’s a] process of questioning: what am I doing? What have I done? Why did I apply to these programs? Do I even want to go to a Ph.D. program? I’m tired of school. I’m sort of in the middle of finishing this. And then moving on to something else. And I started questioning myself again. What am I supposed to be doing? ______*Researcher: I’m going to pause it here because I’m reminded of the one card that had said, “what am I doing with my life and future?” and there’s this long litany of questions that you have. (Julie: yeah) As you were sitting there, as much as you can remember saying some of these things, what was the experience for you?

Julie: Um, I was thinking that—oh there was something [therapist] said—I was thinking—I guess what I was thinking, honestly, was that there nothing I could do about it. And there was nothing she was going to say that was going to help me feel any better. But that I needed to say it—anyway. But I didn’t feel like we were going to make a lot of—there’s really nothing she can do (laughs) for me, with this.

Researcher: Cause some of this is just the waiting.

Julie: It’s just the waiting, yeah. And she acknowledges that, like right up front. So, I think by saying that—that’s just kind of some of the stuff I just have to—it’s going to be uncomfortable. But it did feel—it does feel good to have somebody listen and to be able to just acknowledge that it doesn’t feel good to deal with that.

Researcher: Even if they can’t wave their wand and (Julie: [laughs] Right!) make it better.

Julie: Right, so I think that’s what I was thinking. I needed to say it—that I wasn’t going to get—I completely knew that I wasn’t going to get much out of it.

Julie’s observations seem to have strong implications for understanding clients' experiences at APES 3. She knew her therapist couldn’t magically solve her problems, yet she somehow felt the need to state them, and that the process of doing so was helpful, even if she left the session without any clear answers.

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APES 3 to 4: Using Silence and Meditation to Reach Insight Julie described wanting to find moments where she could be by herself and be silent. In these moments, she hoped to stop thinking about her problems so much in order to achieve some clarity and understanding about them. In the following passage, she is clear that doing so is not equivalent to avoiding or pushing her problems away.

Julie (in therapy): I mean, in my moments of peace, which have been really small, I have been trying to just keep quiet and not, not think about—not push it down—but try not to think so much about everything. Just trying to let it sort of—it feels like all this information, even the book that I’m reading, just I need to sort of sit. And if I’m quiet, something will click into place for me. But I haven’t been very quiet in my head.

Julie’s therapist later encouraged her to intentionally carve out down time in her schedule so she could have moments of quiet and solitude. Julie acknowledged that taking the time to be quiet had been productive in the past. It had helped her find clarity, sometimes through images, as illustrated in the next passage.

Julie: And I have this ability—I know I do. I’m really good at it when I get quiet. And it’s really weird, and I know [partner] thinks it’s bizarre. But I do. I do get—I do find clarity when I’m quiet. And I do get images. I do hear phrases in my head. But don’t feel necessarily like I’m the only person that owns them. And they’re really helpful. It happened once when I was driving—actually it was really weird. The image I got when I was driving home from the hospital, um, and it was just because it was quiet and I sort of asked for it. And got it. And I don’t know what it means, but it had a lot to do with a birth—the images I was getting. So, it was interesting. If nothing else, it’s interesting to see another part of my head or myself. But I don’t necessarily have to understand, but that it—I don’t get worried.

Therapist: And I think that that might be something—you just hit on something that I think is going to be very important for you. Is that you don’t have to understand. It may just be there. And it might just have to sit there and gestate there for a while before the understanding comes to fruition. And you might just always be with this—I have this insight, I have this intuition. Which for women, tends to have been buried over the years… ______*Julie: That’s sort of the end of what we were talking about. But yeah, she’s right. Like I was—it feels good to talk to her about things that um, don’t fit the norm. As far as definition of being a person, I guess. I like to be able to say that I would respond to meditation and that I do feel like I’m intuitive and um, and then for her to sort of put that idea that I don’t have to understand everything, is a good—just a good remainder

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overall—of just the way that I think about things. Um, when I’m working on different aspects of life, I’m always in a hurry to resolve things. And so for her to say that, was really good—a good reminder.

APES 4: Insight about Mom’s Current Condition Julie appeared to reach a moment of insight regarding her mom’s current medical condition. She recognized why she wasn’t falling apart at the thought of losing her mom. She realized, with the therapist’s help, that she had already mourned the loss of her mother—the mother she didn’t have as a child. The following passage contains this moment as well as Julie’s reflection that it was useful to have the therapist articulate what she was already thinking.

Julie: …I knew if she [mom] died I would grieve, but I think I would have worked through it. I think I would be happy for her now. Because I feel like there is something beyond this.

Therapist: I wonder if it’s because in your writing and your book, you’ve already mourned the mom that you wanted to have.

Julie: I have! I know, I was thinking that, yeah. I’ve done a lot of that. Yeah, I felt like—I think that’s what I was feeling a little bit angry about this week. Seeming so tired of—like I am tired of mourning my mother and this kind of brought that to the surface again. And it all came back again. ______*Julie: The whole, I think it’s the beginning of my book is talking about how I wanted to sort of bury—I play with the idea of holding a funeral for my mother. Um, this mother that I sort of had before I was—well from birth to seven. That I lost between seven and 18 when she was going through depression and suicide and the eating disorders. So um, the writing, the thesis, has been a lot about grieving for these different pieces of my mother. So, I think that what I’m trying to say is that, this just felt like another mini death or grieving process with my mom. Which [therapist] is sort of connecting.

Researcher: I was struck, too, when she made that connection, it seemed like yeah, that fit for you.

Julie: Mm hmm. Yeah it did. Could you hear it in my voice? (Researcher: yeah) It did, it felt really good to have her—to hear her say what I was thinking.

Therapeutic Alliance / Voice of the Therapist Safety and Acceptance. Julie appeared to have a trusting relationship with her therapist wherein she felt safe to disclose experiences and aspects of herself that were distressing. The therapeutic alliance allowed problems to emerge into awareness (and into the client-therapist

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dialogue). The therapist, at times, actively encouraged Julie to say things she was afraid of. In the following passage, the therapist seemed to identify the “elephant in the room”—the possibility that Julie attributed her mom’s recent health problems and hospitalization to the writing of her memoir. Julie agreed with the therapist’s assessment and commented on the therapist’s knack for bringing up things that she may not want to on her own.

Therapist: I’m wondering or curious, if there’s some piece of it that was like, “oh it’s my book.”

Julie: I was aware that that was a possibility. That I could definitely do that to myself. And I was trying not to do that. I was just trying to be aware that—that um, that would be an [il]logical connection in my brain. And that I was resisting that because I don’t want to own that…or like as if I’d brought it about.

Therapist: It’s one of those elephants in the room. If you can name it, then you can— ______*Julie: What I was thinking was how, talking to [therapist]…let’s see, what [therapist] does. [therapist] brings up—[therapist]’s good at calling—[therapist]’s good at bringing up things that I might be worried about. I’m very good at bringing up—I’m very honest. I’ve been doing this for a really long time. Therapy, I mean. Or um, and I should say that everything in the book started—the recovery started in ’95. And I’m 31 now so it has been about 10 years between the things I’m dealing with in therapy now and some therapy during those 10 years…So um, so I’m very—I’m trying to say that I’m very aware of myself when I’m in therapy and I try to be honest cause that’s my space to be really honest. But that [therapist] is good at bringing stuff up—what I was thinking was that she’s very good at bringing stuff up that I forget to say or maybe don’t even want to say. And so when she brought up the connection about my mom getting sick and the possibility of me connecting that to my book, and feeling guilty about it, it felt really good to know that she was paying attention. And that she knows me pretty well. Um, and that she’s comfortable enough to call me on things like that.

Researcher: Yeah, or somehow giving it—picking up on that from you, and giving voice to it?

Julie: Maybe yeah. Because I guess I did a little bit. I was sort of going in that direction, and she said it back to me in a more clear way. That’s what I was thinking with that—that’s something she does often and it’s really helpful.

This exchange, where the therapist asked Julie about the connection between her mom and her book, seemed to facilitate the emergence of a problematic experience (the idea of harming her mother) into awareness.

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Much later in the session, Julie commented on how appreciative she was that her therapist accepted her for who she was, without judgment. Her gratitude for being able to share herself without censorship is expressed in the following passage.

Julie (during IPR): …it was nice to have [therapist]—to be able to—I’m comfortable enough that I can—I can share parts of myself that I wouldn’t share with other people. That are really important parts of who I am. And I don’t feel like she judges me for it.

Researcher: Yeah, yeah. You’ve said that a lot. (Julie: yeah) It sounds like that’s really something special that you have from her.

Julie: Yeah, it is really—it’s important. Yeah, it’s really vital to me at this point in my life to have support in that way.

Collaboration: “It’s Not All on Her and It’s Not All on Me”. Julie and her therapist also appeared to have a collaborative relationship. They worked together to clarify and make sense of Julie’s problems. In the following passage, the two were discussing Julie’s issues with control (i.e., wanting to be in control even when not possible). The therapist suggested replacing the word control though admitted she didn’t have a clear alternative. She invited Julie to help her think of one.

Therapist: I’m curious about the word control. If that’s a word that you want to hang on to? If it’s fitting for what’s going on in your life. Sounds like there’s another transformation in the offing here. And I’m wondering if it’s the word control that is containing it at this point.

Julie: What other word would you use?

Therapist: I’m not sure. We may have to think of this one together. ______*Julie: Another thing that I was thinking of—I think I was thinking of this in therapy and now—is that how, how with [therapist], though this hasn’t been true for all [my] therapists in my past, but with [therapist], and in the place that I am now, I really feel like I get a lot out of the session because we—it’s not all on her and it’s not all on me. And we can have a conversation and go back and forth. So like me asking her—she suggesting something and I don’t know the answer. And I say, and I ask her what other word she would use. If control is the problem word, then what would she use? And then her inviting me to figure it out with her felt good. It felt really, like what I needed. I certainly didn’t need her to be in a power figure. Do you know what I mean?

Researcher: Yeah, I mean I get the sense that it’s very collaborative. Is that a good word?

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Julie: Yeah, yeah. I think it is.

Researcher: You’re working together, kind of side by side.

Julie: Yeah, so with this particular therapist, that it’s very helpful.

Researcher: And that’s really working for you.

Julie: Mm hmm. I don’t think I could—I wouldn’t be happy if it weren’t this way at this point in my life.

Therapist’s Use of Directiveness. Even though Julie seemed appreciative of the collaborative nature of her relationship with her therapist, she also valued the therapist giving her an occasional shove. The next passage shows the therapist taking a somewhat more directive approach, encouraging Julie to make time for solitude and quiet so that she could let herself feel her emotions.

Therapist: And is there a way that you can make that a part of your life? A part of your week?

Julie: …I do need it desperately. And I never make time for it. I don’t know. I think I could. I need to go someplace—I guess it would be [name of park]. I thought that it—sort of go to a hotel room and that’s not really where I want to be. But I do need to be away from people. And my house isn’t going to cut it because my house is full of other stuff. Yeah, I should make time to just go. Just be quiet for awhile. And that’s what happens. Like I’m doing all this work, and I’m trying to process it. And this really busy life too.

Therapist: So you have to [inaudible]. You’re still running? (Julie: mm hmm) Okay, so you make the time for that. So now it’s time for you to find the time to just be by yourself and be quiet.

Julie: Yeah, I think you’re right. ______*Julie: We’ve talked about how running for me is a good way for me to just have this— alone time. What it is, [therapist] said today, was just good. She was kind of firm about that I need to make this other time. That running isn’t cutting it. And that I need some other time. And she’s never—she’s never done that before. She’s suggested, but she’s never said, “okay now you need to do this.”

Researcher: And I’m being somewhat directive here.

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Julie: Yes. And so, that worked for me. I needed her to do that because this is really important.

Researcher: Something that you’ve been—for one reason or another, have sort of not found the time.

Julie: Yeah, we talk about it. And I’ll say, “yeah I need to” and I’ll do it a little bit, and then I don’t. So…it was really good that she—I was thinking, thank you for being just direct and not forceful, but sort of, you know, saying what needed to be said.

Researcher: Giving you a shove.

Julie: Yeah, giving me a shove! So that was a good thing to do.

Usefulness of IPR Use of IPR to investigate psychotherapy is not meant to be another form of therapy, but it may be therapeutic. Clients have the potential to learn a great deal about themselves as well as their therapy. Julie noted at the end of the IPR interview that she felt even better than at the end of her therapy session (which itself was an improvement from when she started the session). She reported that listening to key moments in the session helped her to feel less anxious.

Researcher: To wrap up for today’s meeting—thoughts or reflections on what it was like to do this? To hear yourself?

Julie: Um, actually I was thinking that I feel even better! (laughs) Now, then I did after I left. Hearing it again and sort of being able to key in on the important moments, um, I feel even less anxious now than I did when I left [therapist]’s office so—for me, um, it’s fine. It’s actually helpful.

Researcher: okay, good. I mean my hope is that you get something out of this too.

Julie: Yeah, it was interesting—it’s interesting. I think your study’s interesting too.

Discussion: The Case of Julie Assimilating Multiple Strands of a Problem Julie was the case that co-investigators struggled the most with in terms of APES ratings because she had so many different problematic experiences—and strands of the same experience—that appeared to be at different assimilation stages. Julie had assimilated different threads of the problem (i.e., her abusive relationship with mom) at different rates over time. She appeared to have made considerable progress integrating her past experiences with mom—she

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was able to mourn the mother she didn’t have growing up. However, Julie was still struggling to accept her current relationship with her mother (as triggered by her mom’s recent hospitalization). During the therapy session in question, she was dealing with overwhelming emotions and attempting to articulate her problems, hence the APES 2-3 ratings in terms of assimilating some aspects of her current relationship with her mom. Similarly, Julie was attempting to integrate secondary or derivative problems. Julie identified her tendency to avoid negative emotions as a problem to work on (which was rated at APES 3). The reason for avoiding, though, pointed toward an underlying problem (that may or may not have been disclosed) and which might be rated in the APES 0-1 range. When problems are in the low end of the assimilation continuum, clients may actively avoid them to prevent feeling pain (the precise behavior Julie had labeled as a problem). Bodily Symptoms: Not Limited to APES 0 Julie experienced some bodily symptoms before and at the start of her therapy session, namely tightness in the chest and a “dark heart.” These sensations seemed linked to the emergence of a problematic experience and occurred alongside feelings of depression and anxiety. This presentation is consistent with APES 2, when problems are emerging into awareness and clients typically feel overwhelmed by negative affect. In its present form, the assimilation model acknowledges the presence of somatic symptoms and links them primarily to APES 0. At this stage, problematic experiences are warded off and outside of one’s awareness. The problem may manifest itself through physical complaints that seem, to the individual experiencing them, unrelated to psychological distress. The observations from this case indicate that somatic symptoms are not limited to APES 0. Julie was aware that her bodily sensations were associated with psychological pain, even if she was unclear of the specific nature of the problem. This is often the case at APES 2, when problems are still fuzzy and unformulated. The description of APES stage 2 could be modified to include the possibility that psychological pain may be accompanied by physical pain (e.g., tightness in chest, stomach flutters, racing heartbeat). Physical sensations at this stage may be signs of autonomic arousal, and we could likely identify other sensations at other APES stages. Utility of Stating the Problem Julie elaborated on the usefulness of stating the problem aloud in therapy. Articulating the problem to herself and to her therapist seemed therapeutic. She was aware that this process

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was helpful, even if it did not automatically generate solutions. Although not all clients have the patience to sit with unresolved problems and inner conflicts, Julie seemed to appreciate the therapeusis of clarifying her problems. This is consistent with the idea that movement from any APES stage to the next, can feel like satisfying progress. Micro Moments of Insight Julie appeared to have a classic moment of insight, where the pieces came together and she realized that the reason she was not reeling at the thought of her mom dying was that she had already mourned her mother—the mother she didn’t have as a child. Although Julie appeared to understand something in a new way—consistent with APES 4—this problem (defining and accepting her current relationship with mom) did not appear to be solidly at this stage. It seems possible that clients can have moments of insight/understanding without a problematic experience being solidly at APES stage 4. This is evident when APES progress is tracked on a small scale; the ratings tend to jump around particular stages. Caro Gabalda’s (2005) graphical depiction of within-session APES ratings demonstrated that assimilation is not always a smooth, linear process. Her graphs showed up and down, jagged movement, around a central APES rating. In Julie’s case, there appear to have been moments at APES 4 followed by moments at other stages. She may have momentarily reached stage 4, but subsequent passages were at lower levels because other threads of the problem were less assimilated. This explanation, and others, about micro moments of insight will be elaborated on in the General Discussion. Use of Silence and Meditation to Reach Insight Both the therapist and the client in this case suggested that meditation or sitting alone in relative peace and quiet could facilitate insight. In this instance, creating a sense of internal quietude may enable the client to hear something else. For example, Julie noted that tuning into images (and not words) had facilitated a shift in understanding. From this perspective, there is no internal battle leading up to insight (as suggested by the model’s account of intrapersonal dialogue as clients move from APES 3 to 4). Silence and openness to experience seem to be more important than dialogue. This observation could be viewed as a disconfirming a major tenet of the model—that communication between problematic and dominant voices is essential for assimilation. However, an alternate explanation might view clearing one’s mind or sitting in solitude as creating room for a problematic, voice to emerge into awareness and no longer be silenced by the dominant community. Voices communicate using signs—often words—but also

180 images, gestures, etc. In either instance, though, the strategy seems less focused on interpersonal dialogue between the client and therapist and more focused on trying to clear one’s mind to open oneself up to understanding in the form of intuition and imagery. Feminist Perspective on Voices and Assimilation Julie and her therapist both identified with a feminist perspective; the therapist described her theoretical orientation as a postmodern feminist approach. To a limited degree in this session (and presumably more so in previous sessions), Julie and her therapist discussed how women in patriarchal societies often suppress parts of themselves. Julie expressed her desire to not silence the weak or negative aspects of herself. And while it could be argued that women also struggle to give voice to their strong, competent parts, the overarching idea is that women do not feel free to present themselves in their totality. Julie’s language for describing this—“it feels really important…that we as women don’t silence the weak parts of our ourselves…because I think that those things have a lot to say. Those pieces have a lot to say.”—is consistent with the use of the word voice in assimilation theory to depict internal parts that can speak and act. The feminist perspective on psychopathology is also consistent with the assimilation model’s assertion that voices can get squelched or silenced by dominant voices. Feminist theory might be more vocal about the idea that silencing occurs by the internalization of oppressive voices from the interpersonal community, though this does not conflict with, but is complementary to an assimilation conceptualization of pathology. Abrupt Topic Shift While talking about mourning the loss of her mother, Julie abruptly changed the topic to her concerns about her graduate school applications. Like several cases presented earlier, Julie’s abrupt shift was not necessarily a sign of avoidance (in the APES 1 sense) but a way of regulating how much she could and wanted to talk about a particular problematic experience. Julie seemed like she had talked enough about this topic—it felt done—and that she was ready to move on to the final topic she had hoped to discuss that session. This shift is perhaps also a sign of Julie’s extensive history with therapy. She was an active client who was planful about how she wanted to use her time in therapy. She typically prepared ahead of time and often walked in with an agenda.

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Collaborative Nature of Relationship Collaboration between client and therapist appeared to be a key factor in the success of this relationship. Although the therapist was quite active (and at times bordered on being a guru, according to the co-investigators), she did not appear to be too active or overbearing for the client. Julie appreciated that her therapist didn’t always have the answer and instead, invited her to figure things out with her. In Julie’s words, “I didn’t need her to be in a power figure.” An overactive therapist may have taken away Julie’s power, something she was trying to augment. Interestingly, the client noted that a collaborative style of therapy was what she needed at that point in her life, but perhaps not in the past. In previous therapy relationships, Julie may have needed more guidance and structure from her therapist. This speaks to the idea that level of activity and direction from the therapist should be tailored to the developmental needs of the client. General Discussion The goal of this study was to consider and integrate clients’ perspectives into the assimilation model. This was partly accomplished by asking clients about key therapeutic moments outlined in the model. Said differently, how were events that researchers would describe using assimilation concepts experienced by clients? The other key approach to reaching this goal was having clients identify and describe salient moments in therapy that were not explicitly asked about in the AQ. Clients repeatedly noted the importance of the client-therapist relationship and ways in which moments of connection and disconnection affected change and their perception of therapy. They also provided interesting commentary on how they perceived progress (or the lack thereof) in therapy. The following discussion is organized by constructs that were either elaborated on or which seem important to incorporate into the assimilation model. It will be followed by a discussion of participant and researcher characteristics, the benefits of research participation, and issues and problems raised by this study. Voices and Intrapersonal Dialogue Several participants noted that intrapersonal dialogue (or spoken dialogue between voices) was a common and often unpleasant experience. This finding is consistent with previous assimilation research focused on emotion, particularly the s-shaped feeling curve that describes the valence and intensity of emotions across the APES. Clients may interpret internal multiplicity as negative since they are most likely to be aware of multiplicity once both the

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problematic and dominant voices are equally in awareness and can articulate their positions. At APES 3—when internal conflict is heightened—the overall feeling is still largely negative. Participants did not use the term dialogue to describe their sense of internal multiplicity; instead, they described feeling torn, as if they went back and forth between different views or positions. They reported that the resulting sensation was one of being stuck and confused and which resulted in frustration. Several participants also noted hearing sudden shifts in the way they spoke. Although they were not able to offer detailed explanations for doing so, they were aware that these changes seemed significant. From a researcher’s perspective, we viewed these instances as evidence of the physical characteristics of voices (e.g., tone, rate, pitch) that are apparent when a person switches from speaking from one voice to another (see Osatuke, Gray, Glick, Stiles, & Barkham, 2004). When abrupt enough, these shifts seem to signal vocal intrusions of highly unassimilated voices. Three of the six therapists (Brian’s, Allison’s, and Julie’s) seemed to explicitly conceptualize their clients as being composed of parts and used interventions in line with this. These therapists used phrases like, “personified metaphor,” “parts of yourself,” “selves,” “the two Allison’s” and “voice” to explain parts of their clients they felt were being silenced or were expressing contradictory statements (in relation to other parts). None of the therapists were assimilation researchers, though a few had had limited exposure to the model. This suggests that therapists may routinely incorporate aspects of internal multiplicity into their work, regardless of research background or theoretical orientation. And perhaps even more noteworthy is that their clients, by and large, responded positively to this way of viewing themselves and their problems (in response to their therapists, the research questions, and me), presumably because it fit their lived experience. One participant (Brian), however, expressed discomfort at being characterized as a collage of personalities. Given his family history of severe mental illness, Brian thought this sounded too much like a serious disorder, perhaps Dissociative Identity Disorder (commonly referred to as Multiple Personality) or popular descriptions of schizophrenia as a split personality. Despite his hesitancy to label them as personalities, he agreed to having conflicting parts of himself that tended to express extreme viewpoints: “all or nothing;” “feast or famine.” So while he, the client-participant would not label this piece of his inner experience as a voice (as did I, an assimilation researcher), he and others identified as being complex and composed of

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parts. This discrepancy in perspective does not necessarily require a change in theory (i.e., how problems are construed) but it does caution researchers and therapists to take clients’ histories into consideration when discussing a voices conceptualization with them. Similarly, participants did not have the same language to talk about forming a meaning bridge or agreement between voices, though they did express interest in finding a “happy medium” between opposing parts, achieving peace and balance, and a desire to not feel internally torn. In terms of experiencing a moment of insight or solidifying a meaning bridge, participants used the following phrases: connecting, a light bulb came on, something just popped into my head, that was the realization moment, like an “a-ha” moment. APES Client Accounts of APES Stages The participants in this study provided a window into how various APES stages may be experienced by clients. Their descriptions, when viewed collectively, provide a complimentary account of the assimilation process. They used words and phrases like: zoning out, I don’t want to talk about it, it’s not no big deal, and it’s not somewhere I want to go, to describe APES 1. Participants explained APES 2 as: being overwhelmed with feeling, panicked, starting to boil, feeling lost and strange, flopping around in the water, trouble finding the right words, and experiencing a variety of autonomic arousal symptoms. To describe APES 3, they used the following language: frustrating, mixed feelings, two conflicting sides, teeter-tottering, and conflict. At APES 4, participants noted: a light bulb came on, having a realization, an “aha” moment, and connecting things. At APES 5, they reported a mix of frustration (How do I fix that?) and success (trying out new strategies). Few observations were made for APES stages 0, 6, and 7. For a more thorough summary of this complimentary view of the APES, see Client Perspectives on the APES (Table 2). Making Sense of Discrepancies in APES Ratings Assigning APES ratings to the cases in this study proved challenging for co-investigators. We found variability in ratings, both within raters (several APES ratings seemed appropriate for a given participant) and between raters (lack of consensus). We did not conduct any inter-rater reliability estimates to investigate these discrepancies. Instead, we used dialogue to understand the reason behind our different ratings (and different perspectives). What resulted, then, were

184 multiple agreed-upon APES ratings for each case where we tried to be as clear as possible what we were rating and why we had assigned a particular rating. When reflecting on the reasons for the discrepancies, in a broad sense, we identified three possibilities that are not mutually exclusive. First, problematic experiences become more (or less) assimilated as time progresses. APES ratings, if they accurately capture this progress, change over time too. A participant’s problems during the third IPR interview may have been further along the assimilation continuum than at the first interview. The second possibility is that clients often experience many problems at the same time. Whether the problems are distinct or interrelated, separate APES ratings are needed to capture their individual progression. Third, despite the model’s focus on the evolution of problematic experiences, raters in this and previous studies often considered that a client was at a given APES level at a particular time instead of a problematic experience (or thread of that experience). This led co-investigators to try to assign global APES ratings. In contrast to other stage models (e.g., Piaget’s model of cognitive development or Kohlberg’s stages of moral reasoning), the assimilation model traces the evolution of problematic experiences. A person, therefore, is not necessarily at one stage and a global APES rating does not have much meaning. However, the problematic experience or voice can be assigned an APES rating for a given period of time. Though the idea that problems, not people, progress through the APES is not a new development within the model, co-investigators across a number of recent assimilation studies have been asked to or ended up assigning global APES ratings. There seems to be a rater culture among assimilation researchers to express clients in terms of a single rating for simplicity of communication. Co-investigators were asked to make global APES ratings in this study as a short-hand for describing clients’ problems, providing a context for their observations. This tendency may also be influenced by the model’s use of the term voice to depict internal multiplicity. Voice, in contrast to the word experience (as in problematic experience), seems more holistic and personified, leading raters to try to track individual people’s progression through the APES rather than problematic experiences or voices. In summary, it is does not make theoretical or empirical sense to sort whole people into APES stages. Doing so will fail to capture their complexity.

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Somatic Symptoms at Multiple APES Stages Several participants in this study reported various somatic symptoms in relation to their problematic experiences. They indicated experiencing physical symptoms that are typically linked with anxiety: tightness in the chest, stomachache, difficulty breathing, and a racing heartbeat. Julie and Kyle reported such symptoms in response to “going forward” and having their problems emerge more into awareness (i.e., APES 2). Adam experienced classic signs of a panic attack, which seemed more reflective of APES 0-1 because he seemed to have little to no awareness about what was triggering his physical symptoms. Like many sufferers of panic, Adam had sought treatment at the emergency room because he thought he was having a heart attack and needed medical treatment. The assimilation model notes that somatic symptoms may indicate that a problematic experience is being warded off (i.e., the problem is at APES 0 and manifests in physical sensations that seem disconnected from psychological problems). And although the model does not preclude symptoms from occurring at other APES stages, the current APES descriptions do not state that symptoms may appear at other points in the assimilation continuum and what such symptoms might look like. Adam’s panic attacks seemed connected to the avoidance of a problematic experience (APES 0-1). At this stage, contact with negative affect is intense, but fleeting. This is consistent with the notion that panic attacks often seem to appear out of nowhere and are intensely distressful but do not last long. Other participants in this study reported physical symptoms in connection to problems hovering around APES 2. This is consistent with the theoretical account of this stage. As problematic material is increasingly held in awareness, clients experience greater psychological distress. Clients often feel their worst at APES 2 (see Figure 1). Negative affect is often accompanied by physiological arousal (e.g., shallow breathing due to sobbing or racing heartbeat due to anxiety). Unlike APES 0, clients at this stage are often aware—sometime acutely aware—that their physical distress is linked to their psychological distress. See Table 2 for the inclusion of physical symptoms in Client Perspectives on the APES. Outside Changes Occur Throughout Therapy Another observation from this study that is congruent with but not explicitly stated in the assimilation model is that clients are continually trying out new ways of acting and being in the world, regardless of APES stage. The APES table we used notes that clients actively generate

186 and test solutions to their problems in stages 5 and 6. Said differently, they apply the insight and understanding they have reached on their problems to their outer world. And while the model does not deny that clients are interacting with others (and themselves) outside of therapy, there is little explicit mention of the fact that psychotherapy occurs in a context wherein clients try out solutions to problems before they fully understand the what and the why of their distress. In light of the fact that assimilation progress of any size and at any level may lead to behavioral changes outside of therapy, future research might focus on the kinds of life changes that occur at each APES stage. This could build upon the work by Brinegar, Salvi, Stiles, and Greenberg (2006) which systematically described some of the changes that occurred outside of therapy as clients progressed from APES 3 to 4. All of the participants in the current study reported making observable changes prior to APES 5 (i.e., not just intrapsychic changes as described in the model). Even if the changes were small, clients seemed to be actively seeking out solutions and/or trying out new ways of being. Sabrina tried to be more aware of and limit her “zoning out;” Julie was attempting to find more time in her life for reflection and meditation; Adam was trying to implement breathing techniques (even though he was unsure of their usefulness); Allison read about OCD; Kyle expressed anger toward others for one of the first times; and Brian was desperately seeking advice on how to change his outside behavior in order to improve his relationships. And although his therapist and to some extent, the assimilation model, would suggest that relationship advice would not necessarily solve Brian’s problems, some attention to practical changes might have helped him acknowledge and assimilate painful past relationship experiences. Secondary or Derivative Problems Derivative problems (i.e., problems that were secondary or in response to primary or earlier problems) were noted in several cases. Sabrina seemed to use dissociation to ward off a problematic experience, though the strategy of dissociation (presumably to avoid pain) was considered a problem in its own right, by both Sabrina and the researchers. She appeared to make significant progress in stating, understanding, and working through the problem of dissociating (or “zoning out”). Kyle came to see his use of defensive sparring as both a solution and a problem. Similarly, Brian’s avoidance of talking about relationships became a problem he and his therapist explicitly named and worked on. Julie, too, had avoided negative emotions in the past (as a solution) though later labeled it as problematic. Adam’s identification of his panic

187 attacks as problematic (i.e., the experience of anxiety) also seemed to be a derivative of a problem initially prompting the panic. In all of these cases, the derivative problems were related to earlier ones. We speculate that clients found ways to manage the earlier problems without necessary assimilating the original problematic experience. Several of the participants found ways to avoid contact with the original problematic experience, through dissociating, minimizing negative emotions, or avoiding discussion of painful topics. These coping strategies—while creative and effective in the short-term—eventually became problematic in some way for the dominant community. Theoretically, the solution (e.g., dissociating, defensive sparring) appeased some portion of the dominant community, though eventually caused conflict with another community representative. In the case of Sabrina, for example, her dominant community kept an unknown but powerful problematic experience at bay by dissociating. This kept Sabrina from experiencing intense, painful affect. However, the act of dissociating also limited her ability to respond and connect to those around her. Warding off the initial problematic voice resulted in other needs of the community going unmet. Sabrina took steps to acknowledge when she was dissociating so as to improve her relationships with her therapist and her loved ones. Sabrina and other participants had multiple but related problematic experiences that could be identified and tracked separately using the APES. Therapists may focus more or less on derivative problems and may be guided by their theoretical orientations. Clients, too, appeared to have opinions about what constituted primary or secondary problems. Interestingly, several participants identified the derivative problem as the central focus or main point of therapy. They acknowledged it as problematic, worked toward understanding it, and took great pride in finding solutions to address it. The reason behind the focus on derivative problems may be connected to the impact secondary problems have on clients’ lives. They often interfere with interpersonal functioning, like Sabrina’s dissociation and Brian’s intellectualizing and pedantic tendencies. Clients may have more motivation to address these concerns so as to improve their daily functioning. Derivative problems were clearly important to clients, but because secondary in nature to earlier problems, may have been overlooked in previous assimilation analyses. This study highlights the variety of client problems and ways in which they can be dealt with.

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Therapeutic Alliance Every participant described some aspect of the therapeutic relationship as significant even though the AQ did not explicitly inquire about this. While I did, at times, facilitate participants’ exploration of their reactions to therapists during the IPR interviews, the relationship repeatedly emerged as a salient theme. Participants valued feeling understood and accepted by their therapists. The presence of a safe relationship and open dialogue between the client and therapist seems critical for the development of interpersonal meaning bridges. The research to date suggests that meaning bridges first form interpersonally, and then allow for the creation of intrapersonal meaning bridges, between internal voices (Brinegar, Salvi, Stiles, & Greenberg, 2006; Goldsmith, Mosher, Stiles, & Greenberg, 2006). Sabrina, for example, developed an interpersonal understanding that it was okay to rely on her therapist, which then translated into accepting her weaker parts and making it okay to ask for help. We might even suggest that interpersonal bridges between client and therapist foster intrapersonal bridges between conflicting voices, which then facilitate interpersonal bridges in clients’ personal lives. Observations about the relationship in this study are consistent with Vygotsky’s (1978) notion of the zone of proximal development (ZPD), or the distance between what an individual can accomplish alone and what he or she can accomplish with the help of someone else. Therapists who worked within this region (whether slightly ahead of their clients or at the same level), but not beyond, appeared to promote assimilate. Julie appreciated having her therapist walk by her side, helping her to articulate her problems but without offering a solution (facilitating problem clarification). Sabrina was able to reflect on the progress and loss associated with termination with some gentle pushing from her therapist (facilitating emergence). Allison’s therapist encouraged her to explore the historical roots of her problems with sex and pregnancy (facilitating insight). Brian’s therapist pressed him to discuss experiences related to anger and lack of relationships (facilitating emergence). The presence of the therapist—whether nudging or walking beside the client—appeared to help clients discuss and make progress in assimilating some portion of their problematic experiences. Therapists who go beyond the ZPD may lose clients, as happened on occasion in the case of Adam. In addition to empathy and acceptance, a sense of mutual caring between client and therapist seems important in promoting caring and understanding between internal voices.

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Sabrina’s words about the overall helpfulness of therapy nicely illustrate the importance of client-therapist match.

Sabrina (during IPR): I feel like I’ve learned a lot about myself, but I also think that you need to find the right person to work with too. Because it’s obviously not going to work if you don’t get along.

This is consistent with the bond element that has been described as central to the therapeutic alliance. When clients feel a sense of caring from their therapists, they may be in a position to assimilate the voice of the therapist (Mosher, Del Castillo, & Stiles, 2006). By incorporating a new perspective into their community, clients may be able to accept and integrate previously warded off voices. Said differently, they may be able to internalize the therapist’s caring and care for all parts of themselves. Participants also noted the challenges when they did not feel understood or disagreed about the tasks or goals of therapy. In light of the “tears and repairs” hypothesis offered by Muran and Safran (2000), the working through of alliance ruptures—or the failure to do so— seemed connected to therapeutic progress. Participants’ relationship with their therapists influenced what they said and how they said it. Adam, for example, was hesitant to state his disagreement over a few interventions, including the relaxation exercises and hypnotherapy. As in most domains, voicing disagreement seemed to be a struggle for Adam. Because he did not express his concerns directly—and because the therapist did not acknowledge any subtle forms of disagreement—a potential rift in the relationship was not acknowledged. Brian, too, struggled with his therapist’s interventions from time to time. He wanted concrete relationship advice; his therapist offered interpersonal exploration. I was not privy to any of the participants’ final outcomes, though working through or ignoring rifts such as these likely contributed to participants’ satisfaction with and progress in therapy. The resolution of interpersonal conflict (i.e., between client and therapist) may serve as a model or template for resolving intrapersonal conflict. Future assimilation research might use the IPR technique to examine therapeutic failures from both the client’s and therapist’s perspective. In the IPR, too, the creation of interpersonal meaning bridges was important. It helped participants feel safe and validated and provided some reassurance that my understanding of their experience was accurate. It is interesting that several of the participants seemed to find it

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easier to share uncomfortable things in the IPR than they did during therapy. Brian, for example, could discuss his romantic feelings for his therapist more easily with me than with her. Why was this the case? It is possible that it was easier for participants to share sensitive material with a relative stranger—someone they trusted enough to tell, but whom they didn’t have to worry about engaging in a long-term relationship with—and whose judgment did not matter as much. It could be quite intimidating to openly express disagreement with your therapist (as it seemed to be for Adam) and potentially much easier to comment on this to a third party (as Adam did during the IPR). Abrupt Topic Shifts Four participants had noticeable, abrupt topic shifts in their therapy sessions. These participants reported a reduction in distress by switching to a new topic and presumably did so as a way of protecting themselves from overwhelming emotional distress. While similar in their protective factor, the abrupt topic shifts differed among participants in terms of their specific function. Brian and Adam’s abrupt topic shifts seemed to signal the avoidance of painful material in the APES 1-2 range. They may not have clearly known what they were avoiding, only that it would have been emotionally distressing. This interpretation is consistent with a previously reported on marker of APES 1: Abrupt Change of Subject/Non Sequitur Marker (Honos-Webb, Stiles, & Greenberg, 2003; Honos-Webb, Surko, & Stiles, 1998). However, abruptly changing the topic may also signal later APES stages. Allison changed topics because didn’t want to continue discussing a known problem at a fairly intense level (a fully emerged problem in the APES 3 range). Clients may need moments during therapy when they can retreat. Julie abruptly changed topics because she felt like she was “done” and wanted to move on to a less-explored topic. Allison’s and Julie’s shifts to a new topic appeared to be less frantic and automatic and more purposeful. All kinds of abrupt topic shifts, though, appeared to be in the service of emotional regulation. The avoidance associated with abrupt topic shifts is perhaps a different way of talking about the notion of resistance in therapy. Resistance (the conscious or unconscious avoidance of topics) often has pejorative connotations, as in the “resistant client” or the “difficult-to-treat” client who struggles to make any change in therapy. Avoiding distress is not necessarily undesirable or an indication of hostility or moral weakness. Abrupt topic shifts may be viewed as a healthy form of avoidance. Participants who engaged in this behavior seemed to

191 be self-regulating how much exposure to an emotionally charged problem they could handle. This perspective is consistent with humanistic interpretations of resistance (Leitner & Dill- Standiford, 1993). Franella (1993), for example, suggested replacing the word resistance with persistence, with an eye toward understanding the “reasons why clients decide to persist in being as they are rather than to change” (p. 132-133). The subtle change in language honors the experience of avoiding rather than pathologizing it. Perception of Progress Participants reported feeling a sense of progress throughout their therapy. Their description of progress, or moving forward, was similar to typical accounts of insight. Clients may take pride in moving from one stage to the next, or in theory, making any progress along the assimilation continuum. Micro moments of “insight”—as clients referred to them—seemed to occur each time a client understood something in a new way, such as getting a clearer sense of one’s problems. Julie noted the usefulness of stating the problem to her therapist and the resulting relief she felt, even though she knew the problem was still there. Such moments of “insight” may or may not be markers of APES 4. Instead, they may be general indicators of therapeutic progress. Clients often experience a sense of progress at every stage of advancement in the model. Interestingly, clients may use the word insight to describe such progress but may not have established a meaning bridge between voices, as the word insight—in terms of assimilation language—would imply. This presents a theoretical puzzle, then, to theories—not limited to assimilation—which use the word insight. Many of these theories have a very specific meaning behind this term. Clients’ use of the word insight appears broader in scope, as a way of conveying some kind of new perspective or progress they’ve made in terms of their problems. They may have made some kind of connection—with insight-like features—but not necessarily a solid connection (i.e., a meaning bridge) between two conflicting voices. Progress, at any stage, in terms of understanding something in a new way may be marked by a sense of general satisfaction without necessarily reaching any kind of resolution on the problem. Julie, for example, took pleasure in being able to identify and state her problem. Although the problem was still present—two parts of herself were still in conflict—she rejoiced in understanding the nature of the problem a little better. To extend the metaphor of building a meaning bridge, clients may feel a sense of satisfaction at each stage of bridge construction. At

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APES 2, for example, clients recognize that something is wrong—that there may be a need for a bridge. At APES 3, they may see the two disconnected end-points more clearly. The process of building a meaning bridge between APES 3 and 4 has been previously studied (Brinegar, Salvi, Stiles, & Greenberg, 2006). Clearly, more work needs to be done to illuminate differences between clients’ and researchers’ understanding of insight. Future studies might examine the micro-processes of meaning bridge construction at other points along the assimilation continuum to better understand this puzzle. Participants in this study seemed especially proud to acknowledge and work through defenses and derivative problems. Although they continued to struggle with more primary problems, they rejoiced in the successes they were able to make. It is unclear exactly why clients focused more time and energy on derivative problems (and experienced a greater sense of progress) though it is likely connected to these problems being more accessible in awareness and less emotionally threatening. Another theme echoed by the participants was that progress was often experienced with some ambivalence. Clients celebrated moving forward but also lamented the rough journey still ahead. Dalton described similar moments in her chapter on choice and change in therapy (1993). “There are moments in therapy when the choice to change is especially highlighted. When a client emerges from a period of exploration with new clarity about where she is and where she wants to go, there is a sense of being on the threshold of something exciting and perhaps frightening” (p. 115). From an assimilation perspective, gaining clarity or insight about a problem can lead to frustration about how to work through or solve that problem, and ultimately, how one will have to change. Another explanation is that improvement in one area may lead to setbacks in another (Knobloch, Endres, Stiles & Silberschatz, 2001). In either case, it seems that while forward movement along any portion of the APES is considered progress, it may not always be a pleasurable experience for clients. This observation about the mixture of positive and negative affect associated with progress presents another theoretical puzzle. It tells us something about assimilation on a smaller scale. It reminds us that the feeling curve—which traces affect across the APES—is an idealized account. Finer-grained analysis of the assimilation process—zooming in on the curve, if you will—is likely to show a confluence of emotions and more jagged fluctuations.

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Meditative Practices and Assimilation One of the participants, Julie, highlighted the role that meditation and solitude can play in improving psychological well-being. She and her therapist described the helpfulness in creating a sense of inner and outer calm in order to be open to images or other perceptions that would facilitate insight and understanding. A question that emerges, then, is interpersonal or intrapersonal dialogue necessary to make sense of problems? Meditative practices seek to quiet inner dialogue in search of alternate states of consciousness. Another question might be, does meditation provide a different path to the assimilation of problematic experiences (i.e., a different method for allowing non-dominant voices to emerge into awareness)? Or, is the healing process altogether different, wherein the language of assimilation makes little sense? Although there are no clear answers to these questions, the combination of dialogue with a therapist and individual meditation seemed helpful to Julie. The two processes, while different, appear to be complimentary. Reflection on Participant and Researcher Characteristics Although we were not seeking a representative sample, it is important to note the following features of participants, to place our observations in context. First, participants were not paid for their participation and seemed giving of their time for intrinsic reasons. And although this selection factor lends credibility to the information participants shared, it excluded participants who may have been more reluctant to share their experiences without external compensation. It is possible that clients at particular APES stages, or with certain kinds of problems, or who were less interested in self-reflection may have been less inclined to participate. Secondly, all participants identified as being White/European American and were college students. Further, all therapists were White and were trainees (i.e., either graduate students or predoctoral interns). This was largely due to a pragmatic factor: trainees routinely record their sessions, making the IPR procedure much easier to implement. Future studies might try to solicit a broader range of ethnic, socioeconomic, and educational backgrounds among clients and therapists. Participants from minority populations might provide different perspectives on therapy process that could be informative for the assimilation model. Some participants were able to articulate their thoughts and feelings about the process of therapy in great detail and with ease. Others struggled with reflectiveness and focused more on content. What accounts for these differences? We speculate that some of these differences may

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be due to the assimilation level of the participants’ problematic experiences. Adam, for example, seemed to have especial trouble talking about his panic attacks and their source, presumably because the problematic experience to which they were connected was at a low level of assimilation. Adam’s speech was halting, and he focused much more on content than process. Another factor may be psychological-mindedness and the ability to reflect on one’s inner experiences. Allison and Julie seemed to feel at ease with the IPR procedure and provided richer accounts of their internal process. A final consideration is the quality of the participant- researcher relationship. Participants who felt more comfortable with me and trusted me to a greater extent may have disclosed more details about their therapy experiences. Finally, the researchers’ background with the assimilation model and commitment to enriching it inevitably influenced the data collection and analysis. Rather than attempt to bracket this part of our background, we openly acknowledged our investment in the model and tried to remain open to observations that would disconfirm or change the existing model in some way. Benefits of Research Participation Participants were quite generous with their time and what they shared. Because of them, we had rich data to make sense of—data that contained intimate and sensitive details of their experiences as psychotherapy clients. Further, participants seemed to benefit from the research; most noted that it was both enjoyable and informative, more so than anticipated. This observation is consistent with the idea of reciprocity in qualitative research, whereby researchers and participants benefit from the research. Though the interviews were not meant to mimic therapy, they often seemed to be therapeutic. Glesne (1999) stated that “the therapeutic dimension of good interviewing is part of what you can return to your participants” (p. 85). Brian, for example, stated that he wished he could have a recording of a portion of one of the interviews, since he had articulated an important aspect of his identity. Since I was planning to transcribe the interviews, I offered him a copy of this segment. He expressed interest in having this, which I provided after the interviews were conducted. The following passages represent other examples of ways in which participants found the research useful as well as my gratitude for their time and contributions.

Researcher: Okay, I thank you, and I think this takes some courage to do this. Both to be able to listen to yourself and then to talk about some of these sensitive issues. So, again, I appreciate it.

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Sabrina: You’re more than welcome. I’m glad that I could help, definitely.

______

Kyle: I find it interesting that you’re learning something else through this…I’ve found out a lot about myself—

Researcher: So have you found this to be helpful for you?

Kyle: Oh, very helpful. This second session, kind of listening, kind of thinking back through things. It brings up a lot of things that even yesterday I wasn’t thinking of. But now I have more things to think about. I mean, in between the time I’m doing my homework, I’ll [be] like, “so that session today…” So yeah, it’s kind of neat that—at first I was just—the first thought I was just like, “yeah this should be cool—see what this is and if I could help out”, cause I know you guys do all the different research and stuff. So I was like, well I’ll just help out and see what I can do. Again, I wasn’t thinking that it would help me at all…

Researcher: More for the other person?

Kyle: Yeah…I’m just like, “wait, this really helped a lot.” ______

Researcher: To wrap up for today’s meeting—thoughts or reflections on what I was like to do this? To hear yourself?

Julie: Um, actually I was thinking that I feel even better! (laughs) Now, then I did after I left. Hearing it again and sort of being able to key in on the important moments, um, I feel even less anxious now than I did when I left [therapist’s] office so—for me, um, it’s fine. It’s actually helpful.

Researcher: Okay, good. I mean my hope is that you get something out of this too.

Julie: Yeah, it was interesting—it’s interesting. I think your study’s interesting too, so—

Researcher: And for me, it’s—to use some of the language you used—it’s about giving clients a voice. (Julie: yeah) And oftentimes, it’s other people’s voices about [therapy]—[motions to books on shelves]—very little has been from clients’ points of view. And I feel like that’s really important to honor that. So I’m really glad you (Julie: yeah) were willing to share your thoughts.

Julie: It feels good, yeah. And I was thinking, too, that the—I don’t know—I wanted to be helpful. This has been a really helpful process for me and then you’re a student too, and trying to get your things done. So it feels good to participate.

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Most of the participants in this study seemed to benefit by learning more about themselves. Though reciprocity is sometimes achieved through monetary compensation, qualitative research participants more often benefit from the stories they share. Glesne (1999) noted that the interviewing process itself is often an occasion for reciprocity. “By providing the opportunity to reflect on and voice answers to your questions, you assist them [interviewees] to understand some aspects of themselves better. If your questions identify issues of importance to interviewees, then interviewees will invariably both enjoy and find useful their roles as information providers” (Glesne, 1999, p. 127). Glesne also pointed out the importance of actively acknowledging and showing gratitude for participants’ time, cooperation, and words, another form of reciprocity. Problems and Issues Raised A number of assimilation constructs were clarified in this study, namely how the APES stages and internal multiplicity were experienced by clients. The findings in this study also raised questions, puzzles, and problems for the assimilation model. Theoretical issues worthy of further investigation are presented in this section, including the definition of a problematic experience, the consequences of assimilating or not assimilating a problematic experience, assimilation conceptualizations of panic and obsessive-compulsive disorder, and the role of the client-therapist relationship in assimilation. What Constitutes a Problematic Experience? How a problematic experience gets defined is a question assimilation researchers continue to grapple with. Recent studies have focused on a voices conceptualization (i.e., identifying internal voices that are in conflict). Voices, which are thought to be traces of experience, can be difficult to clearly define. Although there are criteria to identify them (content, emotion, and vocal quality), the specific voices identified can vary depending on the level of analysis. How broadly or narrowly is the experience, or set of experiences, defined for a particular voice? In the case of Adam, for example, researchers grappled with alternate conceptualizations of Adam’s panic: was the problem in need of assimilation his fear of having a panic attack or the underlying experiences that prompted the panic? In this instance, panic was both a response to an experience and an experience in and of itself. Previous studies have dealt with similar questions and have identified voices within communities as well as sub-voices within sub-communities (Glick, Humphreys, & Stiles, 2003; Osatuke & Stiles, 2006). There is

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flexibility in the model to make such distinctions (given the open and evolving definition of a problematic experience and problematic voice), though it is a puzzle for researchers trying to systematically study the assimilation of problems. Consequences of Assimilating and Not Assimilating We found the concept of derivative problems to be useful in making sense of the multiple APES ratings found for each participant. It seemed that solutions to older problems later became problematic in their own right. Sometimes the derivative problems came by way of assimilation. Brian’s acceptance of his distancing others through intellectualization led to frustration about how to change this. Allison found her therapist’s reflections to be accurate and helpful in clarifying problems, though she sometimes noted, “I don’t want that to be true.” It seems that increased acknowledgment or assimilation of one voice, created a problem for another voice in the community. We could speculate that the competent voices in Brian and Allison felt threatened by the experience of not knowing how to proceed. At other times, the solutions to older problems (i.e., derivative problems) resulted from failure to assimilate a problematic experience. Sabrina’s dissociation (from an unknown problem which she avoided) later became problematic in the sense that it disrupted her interpersonal relationships. Observations about derivative problems prompted the following question: do we have to assimilate problematic experiences to insure psychological well-being? Julie seemed to suggest that, for her, it was important to give voice to negative or weak parts; she did not want to silence them because they had important things to say. Adam, too, suggested that ignoring or suppressing his panic might make things worse. These observations are consistent with assimilation theory, which suggests that unassimilated problems seek expression. If unable to communicate directly (due to suppression from the community), they may speak indirectly, through somatic symptoms, flashbacks, state switches, and presumably, panic attacks. While research has supported this claim (that psychological distress can result from avoiding contact with problems), it does not suggest that this is always the case. Might there be problematic experiences so horrendous that assimilating them would be undesirable for psychological health? Given that there are no clear answers to this question, future research might examine the benefits of maintaining distance from certain problematic experiences. Assimilation Conceptualizations of Specific Psychological Symptoms and Disorders

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The process of assimilation has been studied in a variety of psychological symptoms and disorders, including depression, borderline personality disorder, dissociative identity disorder, and social phobia. Two cases from this study stood out as being either new or difficult to conceptualize: obsessive-compulsive disorder (OCD) and panic attacks. Allison, who had been formally diagnosed with OCD, seemed to be an easy case to conceptualize from an assimilation perspective, even though the model had not examined this disorder to date. A bitter dialogue between her rational (I’m not pregnant) and irrational (I’m pregnant) parts fit well with a voices conceptualization. The case of Adam, who struggled with panic attacks, seemed much more complicated to understand. We sensed that his panic seemed related to loneliness and harsh self- criticism. This is consistent with the limited research done on social phobia, which found that anxiety was a way of warding off a vulnerable hurt voice (Gray, 2003). Studying assimilation in a variety of psychological disorders and presenting concerns will serve to broaden the scope of the assimilation model by identifying similarities and differences in the constellations of problematic voices and the process of assimilation. Role of Therapeutic Relationship The role of the client-therapist relationship in assimilating problematic experiences seems to be another fruitful area for further investigation. Participants repeatedly acknowledged the importance of their relationship with their therapist. A few studies have examined the therapist’s role in facilitating assimilation (Leiman & Stiles, 2001; Stiles & Glick, 2002). An area within this domain that warrants further study is how the creation of interpersonal meaning bridges (between clients and therapists) may facilitate meaning bridges between internal voices. Another area for future investigation is the way in which clients assimilate the voice of the therapist, or what Sabrina referred to as having a little therapist in her head. One such study is currently underway (Mosher, Del Castillo, & Stiles, 2006). Mosher and colleagues have developed a modified version of the APES to track this assimilation process. A third area related to the therapy relationship that deserves attention is the tears and repairs hypothesis. IPR could be a valuable method for studying both client and therapist perspectives on client-identified ruptures in the relationship. It would be informative to know whether therapists, too, identified those moments as ruptures. IPR could unpack the factors leading up to the rupture and examine the ways in which the relationship tear was either worked through or ignored.

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Coda This study focused on client perspectives on psychotherapy and the assimilation of problematic experiences. Clients generously provided rich narratives about the change process. Therapists, too, offer a valuable perspective. Future research might entail a similar method for asking clients to identify moments relevant to assimilation constructs and to elaborate on them using IPR. We could examine how therapists’ perspectives compare with those of researchers and clients. An ambitious project might try to assess all three perspectives on the same set of psychotherapy cases. With each added view, the phenomenon at hand becomes more complicated and messy, but hopefully richer and more well-defined, too. Like the parable of the blind men and the elephant, we might be able to see more than just a snake, a tree, and a spear. Rather than seeing isolated elements of therapy, we might catch a glimpse of the magic that transpires between clients and therapists.

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Table 1) Assimilation of Problematic Experiences Sequence (APES) ______0. Warded off/dissociated. Client is unaware of the problem; the problematic voice is silent or dissociated. Affect may be minimal, reflecting successful avoidance. Alternatively, problem may appear as somatic symptoms, acting out, or state switches. 1. Unwanted thoughts/active avoidance. Client prefers not to think about the experience. Problematic voices emerge in response to therapist interventions or external circumstances and are suppressed or avoided. Affect is intensely negative but episodic and unfocused; the connection with the content may be unclear. 2. Vague awareness/emergence. Client is aware of a problematic experience but cannot formulate the problem clearly. Problematic voice emerges into sustained awareness. Affect includes acute psychological pain or panic associated with the problematic material. 3. Problem statement/clarification. Content includes a clear statement of a problem--something that can be worked on. Opposing voices are differentiated and can talk about each other. Affect is negative but manageable, not panicky. 4. Understanding/insight. The problematic experience is formulated and understood in some way. Voices reach an understanding with each other (a meaning bridge). Affect may be mixed, with some unpleasant recognition but also some pleasant surprise. 5. Application/working through. The understanding is used to work on a problem. Voices work together to address problems of living. Affective tone is positive, optimistic. 6. Resourcefulness/problem solution. The formerly problematic experience has become a resource, used for solving problems. Voices can be used flexibly. Affect is positive, satisfied. 7. Integration/mastery. Client automatically generalizes solutions; voices are fully integrated, serving as resources in new situations. Affect is positive or neutral (i.e., this is no longer something to get excited about). ______Note. Assimilation is considered as a continuum, and intermediate levels are allowed, for example, 2.5 represents a level of assimilation half way between vague awareness/emergence (2.0) and problem statement/clarification (3.0).

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Table 2

Client Perspectives on the Assimilation of Problematic Experiences Sequence (APES) ______0. Warded off/dissociated. Clients may report experiencing bodily symptoms that do not seem related to psychological distress. Symptoms include, but are not limited to, headache, tension in neck and shoulders, backache, and stomach pains. Clients may be genuinely confused if a therapist suggests they have an underlying or deeper problem. 1. Unwanted thoughts/active avoidance. Clients may not want to talk about a particular topic and report difficulty if they try. They describe unwanted thoughts as: the brain going haywire, don’t make me say it, aggravating, the therapist was trying to get something out of me, I don’t want to talk about it, difficult to concentrate, and don’t bring me back into my head. They describe the experiencing of active avoidance as: zoning out, using laughter to cope (“better to laugh than to cry”), making emotions seem smaller than they are, “it’s no big deal”, putting on a façade of happiness, hiding emotions, and wanting to transition to another topic. These thoughts and feelings may or may not get expressed aloud in therapy. In terms of bodily symptoms, clients may report having panic attacks that seem to come out of the blue. 1.5. Transition from APES 1 to 2. Clients report feeling embarrassed and awkward, wanting to talk about it and not wanting to at the same time, shoving it away, pushing it back, and feeling forced to talk about a problem. 2. Vague awareness/emergence. As problems emerge into awareness, clients report: being overwhelmed with feeling, panicked, starting to boil, "I’ve had enough of it," going back in time, finding buried memories, coming unwound, exposing a dark side, feeling somber, feeling strange and lost, feeling like things are melded together, flopping around in the water, and treading water. They often feel confused and unsure, and as a result, have difficulty finding the right words and may say, “I don’t know.” Clients often experience a high degree of autonomic arousal associated with “moving forward,” including tightness in chest, stomach flutters, and a racing heartbeat. They may have a sense that these symptoms are connected to a psychological problem, even though that problem may be vague and unclear.

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3. Problem statement/clarification. Clients may describe a desire to state the problem even though they know it won’t automatically lead to a solution. Their accounts of this stage may focus on the experience of internal multiplicity: a back and forth, confused, frustrated, mixed feelings, two conflicting sides, Where’s the happy medium?, life lived at extremes, all or nothing, feast or famine, two me’s, and teeter-tottering. Some clients may report a continued sense of bodily tension and anxiety related to feeling internally conflicted or stuck. However, some clients may also report some initial relief of symptoms as they gain a clearer sense of their problem and the problem is expressed more directly. 3.5. Transition from APES 3 to 4. Clients who are transitioning from APES 3 to 4 may report things like: “I’ve been realizing…” and “I’ve just started to figure it out.” 4. Understanding/insight. Clients indicate feeling as if a light bulb came on, something just popped into my head, feeling good about a realization, having an “aha” moment, and connecting things. 5. Application/working through. Clients may report a mix of frustration (How do I fix that?) and pride (success in trying out new strategies). 6. Resourcefulness/problem solution. Clients are able to identify ways in which experiences that used to be problematic are no longer a source of distress but a resource (e.g., writing a memoir about childhood abuse). 7. Integration/mastery. [No observations from this study.] ______Note. The language used to describe clients’ experiences of APES are a mixture of verbatim accounts and close summaries using key words and phrases.

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Salience/ valence

+ I Salience of experience

Feeling level

Valence of experience

0 1 2 3 4 5 6 7 Assimilation level

Figure 1. Assimilation curves depicting the theoretical relationship between the valence and salience of a problematic experience. The characteristic feeling level at each stage of the Assimilation of Problematic Experiences Sequence (APES) may be considered the mathematical product of the valence and salience curves.

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Appendices

A. Informed Consent

B. Final Informed Consent

C. Problem Description Form

D. Personal Questionnaire

E. Assimilation Questionnaire

F. Interpersonal Process Recall Procedure Guidelines

G. Rating Sheet

H. Assimilation Constructs

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Appendix A

INFORMED CONSENT

Research has shown that psychotherapy is effective in treating a variety of psychological problems. The specific ways in which therapy is helpful are still being studied. The purpose of this study is to improve our understanding of how psychotherapy works from clients’ points of view.

The present study focuses on adult clients’ experiences of on-going psychotherapy. Clients who choose to participate will be asked about their experiences in a series of three interviews, each lasting about 1 ½-2 hours. During the interviews, participants will be asked to identify and listen to salient parts of a recent therapy session. They will be asked to reflect on their thoughts and feelings about what they were experiencing at the time of the therapy session. Participation in this study consists of three interviews, though we request permission to contact participants at a later date if necessary.

The research interviews will be audio-recorded. In order to ensure confidentiality, participants’ names will be not be labeled on the tape. Participants will be assigned a code number to identify audiotapes. All audiotapes will be stored in locked files within a University research lab, accessible only by members of the research team. Participants’ therapists will not have access to the audiotapes or any other information obtained during the interview. The principal investigator, Meredith J. Glick, will transcribe the research interviews, excluding any identifying information (names of people, places, etc.). The only other individuals to have access to the transcripts will be her faculty advisor, Bill Stiles, Ph.D., and members of their research team.

Participants will be discussing issues related to their psychotherapy. As such, it is possible that they may encounter some sensitive issues and/or distressing feelings. Participants may skip any portions of the interview that are found to be disturbing. They may discontinue the interview at any time without penalty or loss of psychological services. The research interviews are not intended to be therapy sessions. However, participants will be encouraged to talk with their therapists if they feel upset or disturbed as a result of a research interview.

Participation in this project is voluntary. Clients should not feel compelled to take part in this research in order to continue receiving psychological services. Should they choose to participate, they will have the opportunity to learn more about themselves and their therapy.

Should you have any questions about this study or the procedures involved, you can contact the principal investigator, Meredith J. Glick, M.A. at (513-529-2452) or [email protected]; or faculty advisor Bill Stiles, Ph.D. at (513) 529-2405 or [email protected].

For questions about your rights as a participant in this study, you may contact the Office for the Advancement of Research and Scholarship at (513-529-3734) or [email protected].

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Project Title: Clients’ Perceptions of Psychotherapy

Project Investigators: Meredith J. Glick, M.A. and William B. Stiles, Ph.D

I ______(print name) agree to participate in this study.

I am aware that:

(1) Participation is voluntary, and I may choose to withdraw from the study at any time without penalty.

(2) All interviews will be recorded by audiotape, and I understand that my name will not be used on the tape. The tape will be coded by numbers to ensure confidentiality.

(3) Audio recordings will be used to make written transcripts of the interview (excluding any identifying information other than a code number). The audiotapes and transcripts will be used through the duration of the research. My therapist will not have access to the interview tapes or transcripts.

(4) I give permission to be contacted by the researchers at a later date if necessary.

Signature: ______Date: ______

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Appendix B

FINAL INFORMED CONSENT

Project Title: Clients’ Perceptions of Psychotherapy

Project Investigators: Meredith J. Glick, M.A. and William B. Stiles, Ph.D

Participation in this study consisted of a series of interviews about your experiences in on-going psychotherapy. Now that you have completed these interviews, this form seeks permission to use the information shared during the interviews for research purposes.

If you agree, Glick’s dissertation committee and graduate student research assistants will have access to the interview transcripts (which will exclude names and other obvious identifying information). Small portions of these interviews may be quoted in Glick’s dissertation and future publications. Your name will not be used.

Please select and initial one of the options below.

______I give permission to use the interviews in their entirety for research purposes, as described above.

______I give permission to use only part of the interviews for research purposes, as described below. Please describe any restrictions. You may indicate which topics or parts of the interview to include or which to exclude : ______

______I do not give permission to use any portion of the interviews for research purposes.

For questions about your rights as a participant in this study, you may contact the Office for the Advancement of Research and Scholarship at (513-529-3734) or [email protected].

I ______(print name) agree to the terms I have selected above.

Signature: ______Date: ______

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Appendix C

Problem Description Form

Client ID: ______Today’s Date ______

1. What problems have you been focusing on in therapy?

2. Are there any problems you currently have that you have not talked about in therapy?

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Appendix D

PERSONAL QUESTIONNAIRE Client ID Today’s date:

Instructions: Please complete before each session. Rate each of the following problems according to how much it has bothered you during the past seven days, including today.

Not At Very Little Little Moderately Considerably Very Maximum All Considerably Possible 1. 1 2 3 4 5 6 7

2. 1 2 3 4 5 6 7

3. 1 2 3 4 5 6 7

4. 1 2 3 4 5 6 7

5. 1 2 3 4 5 6 7

6. 1 2 3 4 5 6 7

7. 1 2 3 4 5 6 7

8. 1 2 3 4 5 6 7

9. 1 2 3 4 5 6 7

Additional Problems: 1 2 3 4 5 6 7 10.

11. 1 2 3 4 5 6 7

Appendix E

Assimilation Questionnaire ______Please think about your last therapy session as you read the questions below. There are no right or wrong answers. I am interested in understanding your experiences of therapy and have described some situations that you may or may not have experienced. Your responses will help us select segments of the audiotape to listen to.

Please remember that your therapist will not see any of your answers. You are free to talk or not talk with your therapist about any thoughts or feelings you have as a result of answering these questions or listening to the audiotapes. ______1. During your last session, did you experience any physical pain? For example, you might have felt headaches, stomachaches, or muscle soreness during your session or reported on similar experiences you’ve had recently.