Well-being and optimal performance in psychotherapy practice: a phenomenological study

This qualitative study explored the personal experience of optimal performance of psychotherapy through personal well-being practices as described by 10 therapists. Psychotherapy is defined herein as a healing art in which the therapist is the instrument of healing. Based on the high level of interpersonal functioning required for therapists to perform their work, self-care is presented as an ethical imperative. Through stratified sampling, 10 participants, cisgender male and female psychotherapists - six psychologists, two social workers, and two mental health counselors - ranging in age from 30-64, with varied religious or spiritual affiliations, sexual orientations, and racial backgrounds, each of whom described themselves as committed to personal self-care practice, were recruited and interviewed and asked to describe their experiences of providing good therapy and the components of caring for themselves that were seen as necessary to provide good therapy. The data spoke less of distinct activities and more of a continual process of personal wellness. Phenomenological explicitation through an hermeneutic design as a "dance of interpretation" was used to explore and describe the continual process of self- and other-attunement, including acceptance, compassion, and self-regulation. The results are presented as a dynamic process consisting of five main elements: context, attunement, embodiment, responsiveness, and vulnerability. An exciting discovery is the synergistic flow experienced by participants while providing quality therapy. This may suggest that optimal performance in psychotherapy may be regenerative for therapists. The findings from this study contribute new data to the literature on the role of self-care in the provision of good psychotherapy.

WELL-BEING AND OPTIMAL PERFORMANCE IN PSYCHOTHERAPY PRACTICE: A PHENOMENOLOGICAL STUDY by Hope Andreason A dissertation submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Educational Psychology The University of Utah August 2019 Copyright © Hope Andreason 2019 All Rights Reserved The University of Utah Graduate School STATEMENT OF DISSERTATION APPROVAL The dissertation of Hope Andreason has been approved by the following supervisory committee members: Amy Jo Metz , Chair 04/9/2019 Susan L. Morrow , Member 04/9/2019 Karen W. Tao , Member 04/9/2019 Lauren M. Weitzman , Member 04/9/2019 Jonathan M. Ravarino , Member 04/9/2019 and by the Department/College/School of Anne Cook Date Approved Date Approved Date Approved Date Approved Date Approved , Chair/Dean of Educational Psychology and by David B. Kieda, Dean of The Graduate School. ABSTRACT This qualitative study explored the personal experience of optimal performance of psychotherapy through personal well-being practices as described by 10 therapists. Psychotherapy is defined herein as a healing art in which the therapist is the instrument of healing. Based on the high level of interpersonal functioning required for therapists to perform their work, self-care is presented as an ethical imperative. Through stratified sampling, 10 participants, cisgender male and female psychotherapists – six psychologists, two social workers, and two mental health counselors – ranging in age from 30-64, with varied religious or spiritual affiliations, sexual orientations, and racial backgrounds, each of whom described themselves as committed to personal self-care practice, were recruited and interviewed and asked to describe their experiences of providing good therapy and the components of caring for themselves that were seen as necessary to provide good therapy. The data spoke less of distinct activities and more of a continual process of personal wellness. Phenomenological explicitation through an hermeneutic design as a “dance of interpretation” was used to explore and describe the continual process of self- and other-attunement, including acceptance, compassion, and self-regulation. The results are presented as a dynamic process consisting of five main elements: context, attunement, embodiment, responsiveness, and vulnerability. An exciting discovery is the synergistic flow experienced by participants while providing quality therapy. This may suggest that optimal performance in psychotherapy may be regenerative for therapists. The findings from this study contribute new data to the literature on the role of self-care in the provision of good psychotherapy. iv This dissertation is lovingly dedicated to healers, and to the healing magic of all beings. “Please remember, it is what you are that heals, not what you know.” - C. G. Jung TABLE OF CONTENTS ABSTRACT .......................................................................................................................iii ACKNOWLEDGEMENTS ............................................................................................... ix Chapters I INTRODUCTION ...................................................................................................... 1 Review of Literature ............................................................................................. 2 Purpose of the Study ........................................................................................... 25 Questions Guiding the Research ........................................................................ 26 Rationale for Qualitative Research ..................................................................... 27 II METHOD ................................................................................................................. 28 Research Paradigm ............................................................................................. 28 Research Design ................................................................................................. 33 Researcher as Instrument .................................................................................... 34 Participants ......................................................................................................... 40 Sources of Data................................................................................................... 43 Data Analysis...................................................................................................... 49 III RESULTS ................................................................................................................. 56 Overview ............................................................................................................ 56 Summary of Participants .................................................................................... 60 Emerging Themes as Elements .......................................................................... 86 Discovery: A Dynamic Process of Attunement and Personal Wellness .......... 124 IV DISCUSSION......................................................................................................... 125 Summary of Findings ....................................................................................... 125 Interpretation of Data ....................................................................................... 128 Implications ...................................................................................................... 141 Limitations ........................................................................................................ 145 Future Directions .............................................................................................. 146 Conclusion ........................................................................................................ 147 Appendices A: RECRUITMENT LETTER ........................................................................................ 149 B: BRIEF PARTICIPANT SCREEN .............................................................................. 151 C: PERSONAL INFORMATION FORM ...................................................................... 153 D: INFORMED CONSENT ............................................................................................ 155 E: SELF-CARE LOG ...................................................................................................... 158 REFERENCES ................................................................................................................ 160 viii ACKNOWLEDGEMENTS As the culmination of my doctoral degree this work is an organizing force in understanding the human capacity to heal one self and one another. My journey to integrate layers of vulnerability has been supported by individuals who encouraged selfreflection, introspection, and humility. I thank each of you. I thank my parents, and their parents, who believed anything was possible and encouraged me to pursue wild dreams and nurtured tenacity and optimism, and gave me a calling in a name. I thank my four children, a unified force of unique and spirited cheerleaders; their sacrifices have not been small. I thank Olivia for steady wisdom and feminine feminism. I thank Jeremy for activating and accelerating with the energy of a thousand suns. I thank Joshua for deep roots and abiding belief in moments when I was ready to give up. Thank you Owen for loving connection, curiosity, patience, and trust that I had a plan. I thank each of you for making the journey possible and trusting in my unconventional mothering. I want to thank A.J. Metz, who was my first contact in the department of Counseling Psychology and became, all at once, a trusted advisor. She is a model of compassion and grit, as well as a believer in dreams. I want to thank Sue Morrow my friend and guide for her commitment and passion for the evolution of humankind, with a particular spark for individuals with identities that have been marginalized and oppressed. She modeled the absolute necessity for self care among healers. We cannot do this work without it. To all my beloveds, seen and unseen, named and unnamed, I express deepest gratitude. CHAPTER I INTRODUCTION The American Psychology Association ethics code emphasizes the responsibility of psychologists to be self-aware, such that they are cognizant of the way their personal experience influences their ability to perform their work (APA, 2002). For years, Western medicine – which emphasizes a reductionist, diagnostic medical approach to treating dysfunction—has provided a context for psychotherapy. Consistent with this model, training efforts in the field of psychotherapy have largely focused on self-awareness and the practice of self-care as a way to avoid low levels of functioning, such as burnout, which may lead to client harm. In this vein, some have referred to self-care as a competency and an ethical imperative to avoid maleficence (Barnett, 2007). Although positive psychological principles are incorporated into psychotherapy practices and interventions, they are not used to understand or describe how therapists can attain high levels of functioning and optimal performance. In this study, I suggest a paradigm shift in the way we think about therapist performance and functioning. As opposed to focusing on avoiding compassion fatigue and burnout, I am interested in exploring what therapists do to help them function at the top of their game. I propose that in order for therapists to provide quality care, they must operate from a state of high well-being herein described as attunement. As opposed to avoiding compassion fatigue and burnout, I set out to 2 explore the ways that therapists achieve attunement through principles of positive psychology such as cultivating higher levels of well-being, optimal performance, and vitality. Review of Literature The term psychotherapy has ancient Greek origins. Psyche was used to refer to the human soul, mind, or spirit, and Therapeia meant healing. Thus, psychotherapy can be literally translated as “healing of the soul.” More recently, psychotherapy has been defined as “the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable” (Norcross, 1990, p. 218). Psychotherapy is a dynamic, complex process that relies upon the therapeutic relationship or bond between therapist and client (Cuijpers et al., 2008). It is culturally informed and adaptive in that therapists may alter their treatment strategies and methods to address the unique needs, complaints, or problems of the client (Wampold & Imel, 2015). Research on the effectiveness of psychotherapy has demonstrated significant positive outcomes (Chorpita et al., 2011; Smith, Glass, & Miller, 1980; Wampold, 2001), and common factors of psychotherapy have been identified as having significant effects in treatment (Frank & Frank, 1991; Wampold & Imel, 2015). Among the common factors, an emphasis is placed on the therapeutic alliance and the therapist’s ability to build relationships with a wide variety of clients and adapt treatment strategies to unique client needs; to do so in real-time is the cognitively and personally demanding work of 3 the psychotherapist (Horvath, 2001). Consistent with the traditional approach of Western medicine to treat illness, psychotherapy has been viewed as remedial. “It is a treatment designed to remove or ameliorate some client distress, and therefore, the definition requires that the client have a disorder, problem, or complaint. Thus, prevention programs or interventions are not considered psychotherapy” (Wampold & Imel, 2015, p. 38). From this perspective, therapy is not a tool for self-exploration, growth, or wellness. Perhaps because of this approach to the work of psychotherapy, there is a tendency for psychotherapists to find themselves avoiding burnout or disease rather than striving to maintain an optimal performance. Said another way, if avoiding illness is the focus of the profession, a therapist may not see a need to engage in personal therapy or in self-care activities from a wellness mindset but may wait until they see signs of distress or impairment. To illustrate this point, the APA Board of Professional Affairs Advisory Committee on Colleague Assistance (BPACCA) developed a model referred to as the stress-distress continuum (Figure 1). As shown, items on this continuum move from stress, to distress, to impairment, to improper behavior, to interventions or sanctions. Although the BPACCA described this as a continuum, it is more descriptive of a bleak downward spiral of ineffective functioning when stress is not effectively managed, a limitation described by Wise et al. (2012). The stress-distress continuum represents what happens when therapists are not able to manage stress. Much has been written about how the work of psychotherapists can be stressful. The following describes professional and personal risk factors and how the APA has responded. 4 Stress Distress Impairment Improper Behavior Intervention/Sanction Figure 1. Stress-Distress Continuum. Professional Risk Factors Psychotherapy is a cognitively and emotionally demanding task. Based on their work, psychotherapists are in everyday contact with clients who engage in high-risk behaviors, demonstrate personality issues, experience chronic difficulties, and have a tendency to experience relapse, or exhibit suicidality (Barnett et al., 2007, p. 605). Therapists’ work may amplify their own distress and may expose them to a variety of issues associated with their personal and family history, trauma, and impairment in interpersonal relationships (Bearse, 2013; Elliott & Guy, 1993). Therapists may work long hours in an attempt to accommodate clients’ schedules and potentially be on call. Often they also have stressful office work, dealing with the complexity of paperwork for third party providers. Additional challenges include professional isolation, worries about malpractice, and attending to crisis (Barnett et al., 2007). Research has shown that higher levels of stress can “impact capacity for attention, concentration, and decision-making” (Shapiro, Shapiro, & Schwartz, 2000). This could be particularly troubling for psychotherapists as attention, concentration, and in-the-moment decision making define the practice. Personal Risk Factors Over and above the occupational risk factors, there is some evidence that therapists themselves have higher than normal rates of childhood trauma and a history of 5 family dysfunction (Elliott & Guy, 1993; Nikcevic, Kramolisova-Advani, & Spaca, 2007). They also may have higher than normal incidence of psychological distress than individuals in other professions (Elliott & Guy, 1993). For example, Elliott and Guy (1993) reported that 51% of the women therapists who responded to their survey reported the occurrence of one or more of the following before age 16: physical abuse, sexual molestation, parental alcoholism, hospitalization of a parent for mental illness, or the death of a parent or a sibling. In addition, mental health professionals also experience a high prevalence of clinical symptoms including depression (61-62%) and suicidal ideation (29 %; Gilroy, Carrol, & Murray, 2002; Pope & Tabachnick, 1994). Pope and Tabachnick (1994) reported that almost 4% of 474 psychologists who responded to a mailed survey had made a suicide attempt. In a study of more than 230 occupations analyzed through the National Institute of Occupational Safety and Health, Ukens (1995) found that male psychologists were the most likely to commit suicide, demonstrating an odds ratio of 3.5 greater than the general population. More recently, Gilroy et al. (2002) found that 42% of respondents indicated suicidality or suicide behaviors. Family and childhood risk factors may reflect the individuals drawn to this type of work. However, it is unclear whether clinical symptoms reported here are associated with the individual or the demands of the work on the individual. A variety of subclinical responses to a stressful working environment have been adopted into the nomenclature of mental health professionals, including burnout, compassion fatigue, and vicarious trauma (Bearse, 2013; Jenaro, Flores, & Arias, 2007; Phillips, 2011). Burnout is commonly recognized in multiple dimensions, which include emotional exhaustion, depersonalization, and a lessened sense of personal 6 accomplishment (Jenaro et al., 2007). The price of burnout is high among psychotherapists and their clients. Personal distress, turnover costs, and potential risk to clients are associated with psychotherapists who continue to work at a low capacity (Rupert & Morgan, 2005). According to Figley (2002), compassion fatigue refers to the compromised capacity to recognize pain in others, to be motivated to respond to it, and to experience the painful emotions of the client. Vicarious trauma is related to the direct exposure of therapists to their clients' emotional suffering and is compounded by a prolonged sense of responsibility for their clients’ care (Bearse, 2013). A far more frequent experience for psychotherapists is countertransference. Essentially, countertransference is an emotional reaction that reflects a therapist’s own inner needs and conflicts, but may be a reaction to a client’s behavior or the interpersonal relationship. Countertransference is defined in various ways: classical, totalistic, complementary, and relational (Hayes, Gelso, & Hummel, 2011). Briefly, countertransference impacts therapists on cognitive, affective, and behavioral dimensions, is related to the therapist’s own internal and external reactions to the client, and is shaped by therapist’s past and present emotional conflicts and vulnerabilities (Hayes et al., 2011). Although countertransference does not always negatively impact therapy, it may manifest through an unresolved issue, and it can surface as defensive, self-serving, sexualized, or hostile behaviors (Burwell-Pender & Halinski, 2008; Hayes, 2014). Guy (1987) found that some psychotherapists may see a career in mental health as a way of working through their own problems or a way to reduce loneliness; others may experience a sense of power and control in the psychotherapy setting. The above described personal and professional risk factors, if left unattended, have the potential to 7 negatively impact the therapeutic relationship. APA Response to Risk Factors The APA takes these risk factors seriously. The APA’s Board of Professional Affairs is charged with recommending and implementing APA policy, standards, and guidelines, maintaining relationships with other professional organizations, and with proposing ways to enhance the profession of psychology to promote public welfare (APA, n.d.). At the APA conference in 2010, the BPACCA presented the results of a study of psychologists, which suggested the following items as risk factors that may increase vulnerability to occupational stress: professional isolation, inadequate clinical case consultation, inadequate professional support, poor self-care, overwork, a paucity of leisure and nonwork activities, stigma within the profession for individuals who acknowledge stress or impairment, unrealistic self-expectations (rigidity), a tendency to focus on the needs of others while ignoring or minimizing their own, a tendency to neglect one’s own needs and personal problems, poor boundaries, and an imbalance in caseload/professional responsibilities (BPACCA, 2010). The BPACCA further identified the following signs that occupational stress is present: loss of pleasure in work, depression, including sleep or appetite disturbance, lethargy and negative mood, inability to focus or concentrate, anxiety, substance use or abuse or other compulsive behaviors to manage stress, frequent clinical errors, reduced contact with colleagues, workaholism, persistent thoughts about clients and clinical material during off-work hours, intrusive imagery from clients’ traumatic material, increased cynicism, overgeneralized negative beliefs, increased isolation from or conflict with intimates, chronic irritability, 8 impatience, increased reactivity, a loss of objectivity and perspective in work, and suicidal thoughts (BPACCA, 2010). As a response to the results of their study, the BPACCA (2010) suggested that therapists protect themselves from the consequences of occupational stress by engaging in the following: • Take risks seriously. Honestly assess your emotional, psychological, and spiritual well being on a regular basis. Seek personal psychotherapy and other resources for health as needed. • Make and maintain professional connections that include opportunities to discuss the specific nature and stresses of our work. Model openness in such discussions for students and colleagues. • Seek consultation with knowledgeable peers and experts concerning specific clinical and professional challenges. • Understand that all psychologists are vulnerable to vicarious traumatization and other role-related risks and consult, limit caseload or make other accommodations or adjustments accordingly. • Pay attention to balance in work, rest, and play. Make personal and professional self-care a priority. Attend to your physical and spiritual well being, as well as your emotional and psychological health. Pursue opportunities for intellectual stimulation, including those outside the profession. • Challenge assumptions that stigmatize or demonize psychologists who acknowledge current or past experiences of distress, impairment, or personal pain. • Develop reasonable and realistic expectations about workload, responsibilities, 9 and capabilities. • Become familiar with the literature on occupational risk for psychologists and pursue continuing education on these topics (e.g., burnout, vicarious traumatization, compassion fatigue, colleague assistance, and professionals in distress). • Identify sources of support for your work and use them. • Take regular vacations. • Incorporate topics of occupational vulnerability and professional well-being into graduate education, professional training, and continuing education. Ethical Imperative for Self-Care The APA has long seen a need for self-care. In fact, the ethics code charges therapists with maintaining high levels of self-awareness (APA, 2002). Therapists “should have the self-awareness to know when they are functioning poorly and then pursue the options to resolve the problem” (Haas & Hall, 1991, p.7). However, as described above, therapists are people exposed to occupational stress, and, based on professional mores, may not follow through on attention to self-care until they have reached a level of impairment unacceptable for a therapist who is treating clients (Bearse, 2013). Barnett and others (2007) described the pursuit of psychological wellness through ongoing self-care as an ethical imperative. The basis of this ethical imperative is found in Principle A, Beneficence and Nonmaleficence, of the APA “Ethical Principles of Psychologists and Code of Conduct” (APA, 2002), which states, in part, “Psychologists strive to be aware of the possible effect of their own physical and mental health on their 10 ability to help those with whom they work” (p. 1062). Furthermore, Standard 2.06 (Personal Problems and Conflicts) of the APA ethics code states the following: (a) Psychologists refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner. (b) When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related activities. (APA, 2002, p. 1063) The requirements described in the ethics code provide a course of action for times when difficulties arise. However, one might argue that self-care should be upheld as an ongoing preventive activity. Barnett and colleagues (2007) suggested an expanded reading of the ethics code as follows: Psychologists are aware of the possible impact of their own physical and mental health on their ability to help those with whom they work, and they engage in ongoing efforts to minimize the impact (p. 604). Therapist as the Instrument One reason to consider self-care as a competency requirement is that regardless of the psychotherapeutic approach, the task of the psychotherapist is cognitively demanding as well as interpersonally complex. It requires simultaneous self-awareness, presence with another, perspective taking of another, and personal insight (Hayes, 2014). Clinicians maintain awareness and attention to the client’s eye contact, body posture, paralinguistics, and capacity for self-regulation, in addition to tracking the client’s story, all while providing interpersonally appropriate responses and utilizing theoretically and empirically derived interventions. In addition to tracking the client, psychotherapy also requires the conscious awareness of self-perceptions and the management of 11 countertransference reactions (Grepmair et al., 2007; Hayes et al., 2011; Siegel, 2010). Barnett et al. (2007) describe the emotional, physical, and cognitive demands of psychotherapy as taxing to the person of the therapist. In the midst of a 1 hour exchange with a person in some degree of psychological distress, the psychotherapist strives for self-awareness and other awareness, to achieve attunement (Siegel, 2010), and finally, must also direct attention purposefully during therapy (Grepmair, 2007). The therapist works to build a therapeutic alliance that will support the goals and tasks associated with change for the client (Bordin, 1979; Horvath, 2001). Siegel refers to the interaction between the therapist and the client, wherein the client experiences a sense of being seen and heard, as resonance, and resonance is possible when the therapist achieves attunement (Siegel, 2007). Attunement According to Siegel (2007), presence is openness to unlimited possibilities and attunement is the manner in which “we focus our attention on others and take their essence into our own inner world.” By this definition, attunement refers to both selfawareness and other awareness, in conjunction with the in-the-moment attention and the clear perception necessary to connect with another person. Attunement is related to empathy in that it provides a way to enter the inner world of the other person while maintaining awareness of one’s own inner world (Hayes, 2014; Baldwin, 1987). Interpersonal attunement has physical elements that are witnessed and described through mirror neuron theory (Iacoboni, 2008) and subjective elements of feeling connection with another (Siegel, 2010). This specialized type of interpersonal attention lies at the heart of 12 the art of healing. Both social engagement and intentional self-engagement (Porges, 2009; Siegel, 2007) are prerequisite to the achievement of attunement and are described here. Social engagement is the other-oriented component of attunement: the capacity to be present and empathic with an-other. Porges (2011) describes a specific interpretation of social engagement based on Polyvagal theory. Polyvagal theory holds that there are two distinct branches of the vagus nerve serving distinct functions when a mammal is presented with stress or trauma. One function is to elicit immobilizing behaviors; the other is to elicit social communication and self-soothing behaviors (Porges, 2011). Polyvagal theory is organized around the autonomic nervous system as it relates to affect, emotions, and social communication. According to Porges (2011), “social engagement” serves to down regulate (calm) the sympathetic nervous system allowing a person to temper their responses to interpersonal threats and challenges. Porges (2009) suggests that building social engagement is particularly important for psychotherapists, who focus on social interactions to produce therapeutic levels of healing, as opposed to relying on pharmacological interventions. Self-engagement is a second component of attunement. Self-engagement is rooted in a compassionate and undefended relationship toward the self. A therapist must be able to hold space for self-compassion, self-love, self-kindness, and self-acceptance, in order to hold this space for clients. Presence, previously described as openness to unlimited possibilities, is necessary for self-engagement and presence depends upon a sense of safety (Siegel, 2010). If a therapist feels unsafe or is in a reactive state, she or he is more likely to be distracted if a client approaches a topic that is personally sensitive for the 13 therapist. Due to human factors, therapists cannot have all possible situations sorted through, but it is possible to have a practice of self-engagement when painful emotions arise. When therapists are able to tune in, without defensiveness, to their own responses to a variety of sensations, benign as well as activating, they will have greater capacity to use these inner responses to direct attention purposefully, and with clarity, in the present moment with their clients (Siegel, 2010). This is a practical approach to addressing countertransference. Self-engagement can be described as a way of being mindful in a therapeutic relationship. Promising research findings suggest that self-engagement is a skill that can be incorporated into the training of therapists through mindfulness and mindfulness based stress reduction (MBSR). Based on Zen Buddhist tradition, mindfulness has been integrated into a variety of psychotherapy treatment approaches since the 1980s (Christopher & Maris, 2010; Grepmair et al., 2007). Mindfulness has been used in psychotherapy, counseling, and behavioral medicine (Baer, 2006; Germer, Siegel, & Fulton, 2005). MBSR was developed by Jon Kabat-Zinn who over his career has taught and conducted research using MBSR for four decades. MBSR has been used in the training of medical students and nursing students with positive outcomes such as reduced psychological symptoms as well as increased empathy (Shapiro, Schwartz, & Bonner, 1998) and higher levels of quality of life (Bruce, Young, Turner, Van der Wal, & Linden, 2002). Shapiro, Brown, and Biegel (2007) conducted a study among counseling trainees and found that compared to a cohort control group, trainees in an MBSR program reported reductions in stress, negative affect, rumination, state and trait anxiety, and significant increases in positive affect and self-compassion. 14 Mindfulness practice has also been taught to therapists in training and has been shown to be effective in increasing self-regulation and the ability to be present with clients (Christopher & Maris, 2010). Christopher and Maris (2010) summarized several qualitative research projects conducted over a decade in which they found that training in mindfulness allowed trainees to be aware of how stress and tension manifested in their bodies so they had a means to monitor and change their stress response. These authors also provided a summary of comments from subjects “many students reported that they were much more at ease in sessions with periods of silence, even when the client was clearly ill-at-ease.” They also reported the following: When students did experience feelings of anxiety, irritation or confusion, for example, in session, they were better able to recognize the feelings and observe them with less internal pressure to enact them. Their own emotions were more consciously felt and known and, therefore, less threatening to them. Students reported that they were better able to relax the internal tension that is commonly experienced by beginning therapists. They recognized their fear of their clients, the fear of not knowing everything or anything, the fear of their own incompetence and the fear of inner emptiness. (Christopher & Maris, 2010, p.122) Therapists in training who participated in this study indicated, through their practice of being in contact with discomfort, an increase in their ability to respond mindfully when discomfort arises during sessions. Furthermore, they reported more ability to witness the experience so that it did not take over the interaction (Christopher & Maris, 2010). In addition to trainees feeling more comfortable with the process of therapy, in one study, positive outcomes of patients were correlated with trainees who practiced mindfulness (Grepmair, 2007). 15 Attunement and well-being The above paragraphs help to illustrate how mindful presence is related to attunement through self-engagement and self-regulation. Siegel (2010) suggests that presence requires a sense of safety. He further suggests that mindfulness exercises are “daily brain fitness practices that study after study suggest keep the brain healthy and the mind resilient,” and that one way therapists can work to “keep themselves well is through regularly exercising attunement through mindfulness practices” (Siegel, 2010, p. 30). It seems then that there is a connection between well-being and attunement. While attunement has been described as a way of focusing attention in a therapeutic relationship, well-being is more inherently related to the person of the therapist. It may be that in order for a therapist to experience attunement through self-engagement and social engagement, a minimum and necessary level of well-being must exist within the person. Therapist Well-Being Although therapist well-being has been studied in terms of therapist distress (Mahoney, 1997) and therapist mood (Gurman, 1972; Gurman, 1973), well-being is not equivalent to the absence of distress or the presence of happiness, or can it be tracked by mood fluctuations alone. Seligman (2011) suggests that well-being is a construct with five measureable elements: positive emotion, engagement, relationships, meaning, and achievement. Positive emotion is associated with mood and is the hedonic, pleasurable element of well-being that is experienced in-the-moment. Engagement is associated with being completely absorbed by the given task and is seen in retrospect. Positive psychology is largely about other people. Seligman (2011, p. 20) suggests that 16 relationships are key because “other people are the best antidote to the downs of life and the single most reliable up.” Meaning is associated with well-being in that life can have meaning even when it includes misery. For example, when committed to social justice or working with a client who is talking about a traumatic experience, while positive emotion is not present, meaning can be. Finally, achievement for its own sake is associated with paying attention to what people are doing when free of coercion. The goal of well-being theory is to increase flourishing by increasing these five elements. For the purpose of this research, a well-being continuum, shown in Figure 2, is suggested as a way to describe therapist performance, and an alternative to the stressdistress continuum. While the BPACCA focuses on a continuum that follows a downward spiral from stress toward impairment and sanctions, the well-being continuum covers a broad range of subjective well-being, from the undesirable experience of burnout to the experience of vitality and optimal performance, thus exploring the upward spiral. Attunement with clients is theorized as only being possible at the middle to upperlevels of well-being as by definition, it includes engagement, meaning, and relationship, three of the five elements associated with the construct of well-being. Burnout ATTUNEMENT Compassion Fatigue Sluggish Optimal Performance Vitality Radiant/Vibrant Figure 2. Well-being Continuum. 17 Self-Care Practice Among Psychotherapists Previously, I described the need for self engagement, social engagement, attention and well-being in order to perform the actively attuned role of the therapist. I have also described the APA’s perspective on the ethical imperative to maintain at least minimal levels of well-being through self-care. As the rationale for self-care has been described above, this section will provide a working definition of self-care, describe some of the history of self-care in the healing arts, provide examples of some of the ways psychotherapists report engaging in self-care, and, reiterate the particular importance of the role of self-care in the field of psychotherapy. Defining self-care There are numerous definitions of self-care. In a review of evidence-based healthcare articles, Godfrey et al., (2011) found studies with 139 definitions of self-care between 1970 and 2009. Although an array of definitions exists, this paper will focus on selfcare in the helping professions, and most specifically in the field of mental health counseling and psychology. Beauchamp and Childress (2001) described self-care as one of six virtues upheld by the helping professions and defined it as “taking adequate care of ourselves and managing the stressors and challenges in our professional roles and personal [lives] to prevent the development of burnout and problems with professional competence.” Baker (2003) suggested that self-care is about maintaining balance between and within the personal and professional lives as well as promoting optimal mental, physical and spiritual well-being. Wise et al. (2012) suggested the inclusion of mindfulness practices, values-oriented acceptance-based therapies and positive psychology in a self-care model. Among the varied components that may be associated with self-care, there are three that seem consistent 18 and central to the task of therapist attunement: self-awareness, self-regulation, and selfcompassion (Baker, 2005; Norcross & Guy, 2007). Integration of self-care based on these elements may be dynamically sustainable, as proponents of self-care suggest that the practice of self-care reciprocally builds the capacity for self-awareness, self-regulation, and self-compassion. Self-awareness and self-monitoring Self-awareness and self-monitoring are valued and are taught as an important component in the training of psychotherapists across theoretical orientations (APA, 2002; Coster & Schwebel, 1997). Self-awareness includes the capacity to nondefensively experience the self and to see the truth of the self. It requires an advanced level of nondefensiveness. It is not easy to be self-aware. Inner experiences and the content of the inner world can bring up strong feelings, sometimes visceral responses, that surprise us and have the potential to overtake us. Baker (2005) includes in her definition of selfawareness the benign self-observation of our own physical and psychological experience to the degree possible without distortion or avoidance (p. 14). An undefended selfawareness allows us to be with our clients as they process their own difficult emotions and needs without unconsciously and unintentionally imposing our own needs upon them (Baker, 2005; Hayes, 2014). Self-regulation This ability involves regulation of the physiological system and includes the functional regulation of mood, affect, and emotional experiences in-the-moment. Many 19 types of self-care, such as an intentional mindful meditation practice, incorporate selfregulation as part of the practice. Self-regulation returns us to Polyvagal theory and the practice of soothing oneself in order to engage in movement toward challenges rather than a flight response (Porges, 2009; Siegel, 2010). Self-regulation is a process of maintaining stability of functioning while remaining adaptable to new circumstances. Practicing intentionally allows us to mobilize our most powerful inner resources to help us achieve greater health and well-being (Kabat-Zinn, 1990). This is an example of the way that effortful practice improves noneffortful performance (Csikszentmihalyi, 1990; Duckworth, 2016). Self-compassion The willing acceptance of the reality of one’s humanity is one definition of selfcompassion. Self-compassion is extending compassion to one’s self in instances of perceived inadequacy, failure, or general suffering. Kristin Neff (2003), a compassion researcher, described self-compassion as a construct of self-attitude having three elements: self-kindness, common humanity, and mindfulness. According to Neff (2003), self-compassion provides a more stable sense of self-worth than self-esteem because in contrast to self-esteem it is there especially when we fail (Dembling, 2015). In a recent study, Beaumont et al (2016) found an inverse relationship between compassion fatigue and self-compassion among student counselors. Loving kindness meditation (LKM) was taught to student therapists to increase self-compassion (Boellinghaus et al., 2013), with mixed results. Researchers found that LKM increased awareness of past experiences which brought discomfort to some and resulted in distancing from the self-critical 20 thinking, while others described an experience of “taking the pressure off” and feeling like a “good enough student” (Boellinghaus et all., 2013, p. 272). Self-care in the person of the therapist Similar to Seligman’s theory of well-being, authors Norcross and Guy (2007) suggest that self-care is holistic and involves attending to activity, awareness, personal growth and creativity, and engaging in personal therapy and cultivating spirituality or a mission. They also describe the importance of personal relationships and boundaries as well as healthy escapes. Norcross and Guy (2007) suggest that if self-care is seen as selfchange, then it is a fundamental attribution error, that, at times, it is the environment, rather than the individual, that needs changing. Self-care is a central element of being a therapist, is focused on process rather than outcome, and requires lifelong commitment (Barnett et al., 2007). Self-care is proactive and is critical in the development and maintenance of the meaningful personal and professional life of a psychotherapist (Norcross & Guy, 2007). Self-care creates potential for conscious self-monitoring. The following is provided as an example of self-awareness without self-compassion and a clear lack of self-monitoring: Suppose you were to come upon a man in the woods working feverishly to saw down a tree. “What are you doing?” You might ask. “Can’t you see?” Comes the impatient reply. “I’m sawing down this tree.” You exclaim: “You look exhausted!” How long have you been at it?” The man replies: “Over 5 hours, and I’m beat! This is hard work.” You inquire: “Well, why don’t you take a break for a few minutes and sharpen that saw? I’m sure it would go a lot faster.” The man emphatically replies: “I don’t have time to sharpen the saw. I’m too busy sawing!” (Norcross & Guy, 2007, p. 6) In the practice of psychotherapy, the person is, to a large degree, the tool of the work. Barnett et al. (2007) suggested that the therapist’s own relatedness, capacity for 21 reflection and clinical decision-making are the common factors that, associated with knowledge, science, and professional skills, lead to successful outcomes. There is evidence that self-care activities positively influence subjective well-being. In one study, self-care emphasis and utilization accounted for 50% of the variance in quality of life scores among graduate trainees (Goncher et al., 2013). Baehr (2004), as cited in Hayes et al. (2011) reported that therapists’ self-care practices between sessions, which included meditation, resting and exercising, and not over-scheduling patients, reduced the occurrence and intensity of in-session countertransference behaviors. Based on the broad definitions of self-care and the five elements of well-being theory, I started with a hunch that influences on personal self-care are derived from wellness as well as woundedness that comes from identities, which may include family, culture, religion and spirituality, values, activity or exercise, and are associated with professional meaning making. Personalized self-care methods In a 1997 study, 339 psychologists ranked seven items on the Well-Functioning Questionnaire (WFQ) highest with regard to personal importance. These items were self awareness/self-monitoring, personal values, preserving balance between personal and professional lives, relationships with spouse/partner/family, vacations, relationships with friends, and individual therapy (Coster & Schwebel, 1997). Self-care methods vary and, likely, are derived from the person of the therapist. Norcross and Guy (2007) suggest that self-care practice is a distinct entity that should be cultivated and will provide strategies that formalize physical and emotional boundaries and transitions. They further suggest that self-care practices should build a way of paying attention to and counting one’s blessings as an antidote to instances of the lack of therapeutic success. Broadly, self-care 22 might be a transition or decompression ritual, such as 12 minutes of meditation, to demarcate work and home. More narrowly, it might demarcate transitions between clients (Norcross & Guy, 2007). Spiritual practices, exercise and physical activity, mindfulness, time spent with family and loved ones, and time spent outdoors are examples of self-care activities. Christopher and Maris (2010) conducted a study where students were taught mindfulness practices. Students in their study reported that they were better able to be present with themselves during therapy sessions and that they had an increased awareness of how their mind, body, and emotions were all interconnected. Training in mindfulness practices is a promising way of addressing self-care and helping prevent burnout, compassion fatigue, and vicarious traumatization (Christopher & Maris, 2010). Role of self-care in therapeutic attunement In addition to providing therapists with a greater sense of well-being, in one unique study, Grepmair et al. (2007) found a relationship between mindfulness training and practice in psychotherapy trainees and the outcomes of patients. According to the researchers, at the end of 9 weeks, patients of meditating trainees reported higher levels of global functioning and subjective experience and lower scores on a symptom checklist (Grepmair et al., 2007). In this study, clients of meditating trainees were found to be more secure about socializing, reported less obsessiveness, anger, anxiety, and fewer phobias, and were more optimistic about their own progress in therapy. Finally, trainees reported that although they did experience anxiety, irritation or confusion, they recognized these feelings and observed them with less internal pressure to enact them. These trainees reported that having cultivated greater observing capacity in themselves, 23 they were able to be more attentive to the therapeutic process and less enchanted with the “story” of their clients (Grepmair et al., 2007). This study is promising in that it provides information about 1) the ability of the students who practice mindfulness to self-regulate during sessions and 2) the potential for therapists self-regulation to have a positive impact on the therapeutic experiences and the outcomes of their clients. Moving Toward a Culture of Optimal Performance Through Self-Care As described previously, “self-care is not a narcissistic luxury to be fulfilled as time permits; it is a human requisite, a clinical necessity, and an ethical imperative” (Norcross & Guy, 2014, p.14). While the avoidance of burnout and stress consider “what’s going wrong?” and reflect a deficit approach, resilience and engagement are positive approaches that look at “what’s going right?” (Howard & Johnson, 2004). Moving toward a culture that cultivates self-care as a consistent practice is a strategy for increasing effectiveness through well-being. Handelsman, Gottleib, and Knapp (2005) described a need for a change in the culture of self-care and called for an acculturation process or model for accomplishing this change. Others have suggested that it is a good time to enact change in the culture as the field moves toward a focus on competence (Nelson, 2007). Elman and Forest (2007) described that the field is moving away from conceptualization of impairment and toward professional competence. In the work of psychotherapists, there is a fine line between the personal and professional self (Pipes, Holstein, & Aguirre, 2005). For this reason, appropriate self-care shows up as competency. Appropriate self-care takes into consideration the changing 24 needs of the therapist over the personal and professional life span. It further considers the toll that professional and personal challenges have on the therapist. Appropriate self-care is a critical element in the prevention of harm to clients through iatrogenic effects caused by the psychotherapist or the psychotherapy (Baker, 2007). In 2007, Barnett and others identified self-care as an ethical imperative. These authors called upon the organization of the APA to create a professional culture that places value on self-care and promotes this as an ethical competence (p. 609). Specifically, the author stated: The leadership and imprimatur of major professional organizations like the APA are crucial in the allocation of financial and infrastructural support necessary for the promulgation of professional well-being…. ultimately it may be the relatively measurable realities of the legal, financial, and/or professional repercussions of professional distress and impairment that will have the greatest impact in influencing systemic change. For ourselves as psychologists and for the profession of psychology to thrive, we have little choice but to come to terms with the profound relationship between professional well-functioning and the imperative of self-care. (Barnett et al., 2007, p. 608) Martin Seligman crystallized the modern day notion of positive psychology in his 1998 Presidential Address to the APA. Today, well-being is the topic of positive psychology. The gold standard for measuring well-being is flourishing and the goal of positive psychology is to increase flourishing (Seligman, 2011). To my way of thinking, it is not enough to avoid impairment. It is not enough to avoid harm. Advisory Committee on Colleague Assistance A document, Advancing Colleague Assistance in Professional Psychology (APA BPACCA, 2005), was developed in collaboration with representatives of SPTPAs, the Association of State and Provincial Psychology Boards, and the American Psychological 25 Association of Graduate Students. The guiding principle of this document was to address problematic functioning and to promote self-care over the professional life span. The premise is proactive and ultimately could move the profession forward in the direction of wellness. The development of a Board of Professional Affairs’ Advisory Committee on Colleague Assistance to create a climate that supports well-being is a great approach, theoretically. However, many states either never have had or have discontinued their programs because psychologists do not take advantage of them. Confidentiality, fear of litigation, or licensing board interventions have been cited as reasons why individuals do not utilize the programs (BPACCA, 2010). For this reason, it seems that wellness and well-being may not be the present view of psychologists who may stand to benefit from colleague assistance programs. We know that a proactive approach is in order; what we do not know is how psychotherapists are already meeting these needs and until we ask what they are already doing, we will not know. Furthermore, we do not know whether a subjective experience between well-being and high performance of interpersonal attunement is assumed or realized because well-being and self-care are conflated in the literature. We need a better understanding of the individual approach to high performance through self-care. Instead of simply avoiding illness, we need a new approach. Purpose of the Study As described above, the work of the psychotherapist requires interpersonal attunement. To maintain attunement, psychologists must be aware of early signs of their own distress or burnout. As a professional community, we direct attention to the first principle of the APA code of ethics (Principle A: Beneficence and Nonmaleficence). 26 Still, therapists have higher exposure to emotional and interpersonal stress than the average person, they may have higher risk factors – risk factors that may be associated with the individual and may be established in the culture of the profession. There is wisdom in creating a professional atmosphere where personal well-being and the enhancement of professional well-being are a path of optimism and optimal performance, rather than the avoidance of ill health. A proactive and well grounded approach to personal wellness is in order. The purpose of this study is exploratory: to understand optimal performance of therapeutic functioning. This study aims to cast a wide net to gather an array of information related to the ways in which psychotherapists achieve this, whether through the practice of self-care, or through some other action. More specifically, this study intends to identify important themes, patterns, or categories of meaning for optimal performance among the participants and whether self-care and well-being are included. “The task of positive psychology is to describe rather than prescribe, what people actually do to get well-being” (Seligman, 2011, p. 20). Therefore, the questions guiding this research are aimed at understanding how practitioners experience and define their personal approaches to well-being and how it may relate to their work in therapy. Questions Guiding the Research Based on the experiences and perceptions of therapists, is there some connection between their own well-being and their ability to provide quality therapy? If there is a relationship between personal well-being and quality therapy, how do therapists a) track their level of well-being, and b) engage in activities that help them to maintain well- 27 being? Rationale for Qualitative Research Qualitative methods are commonly used to investigate topics for which there is little or no previous research (Marshall & Rossman, 2011). Given limited information on the relationship between personal self-care practice as a tool for creating attunement, as well as a more clear understanding of attunement, among psychotherapists, this exploratory study was well-suited to the qualitative methods employed. Qualitative studies are not limited to predetermined categories of meaning to gain knowledge, and rather seek to capture the complex processes that individuals undergo to create meaning from experience (Marshall & Rossman, 2011; Morrow, 2007). This study has been an exploration to understand the personal meaning that participants assign to their self-care practices. The rational for a qualitative study was to achieve results that were as openended as possible without an imposed etic, and to understand the meaning the participants spontaneously generate. Given the complex relationship between self-care practices, a self-reflective process, and therapeutic attunement, qualitative methods proved to be ideal for capturing inter-related themes among participants. The use of qualitative methods used in the present study may serve to facilitate a theory-building process (Creswell, 2007; Morrow, 2007). Limited and unexpected knowledge about well-being and therapeutic attunement provided space for serendipitous discovery of sometimes new and often unexpected knowledge about self-care and well-being and therapeutic attunement that was not previously conceptualized. CHAPTER II METHOD Research Paradigm Research was guided by constructivism and informed by feminist ideological theory. Specifically, this study served as an inquiry conducted with exquisite sensitivity to context, and with no expectation for discovery of an ultimate truth. It served rather to explore the experiences of individual therapist participants in the context of larger social forces, including a polarized political climate, which shape the ideas and expectations regarding the meaning and evolution of practices that promote therapists’ provision of high quality therapy. I set out to engage in the research as a process of cocreating understanding and to discover ideas therapist participants had about self-care practice and the ways they enact this wellness to meet their personal definition of good therapy. I used Crabtree and Miller’s (1999) conceptualization of Shiva’s Circle of Constructivist Inquiry as a guide for this research. My hope is to support the development of a “more empowered and emancipated consciousness that incorporates social justice issues and ecology by reducing the illusions” of therapists’ use of self-care and well-being practice as part of the process of sharpening themselves as the tool in their clinical work (p. 10). A positivist perspective recognizes the interpretations of diachronic social change, but this perspective does not see issues as solvable or resolvable. Instead, a positivist perspective 29 can be understood as being somewhat analogous to the metaphor of Shiva, the Hindu god of the dance. Shiva fully attends to the dance, yet stands apart from it sufficiently to interpret and provide an overarching explanation (Marshall & Rossman, 2011). My intent was to explore the unique and dynamic dance of self-care, and to weave together the shared stories of therapists to create a wider understanding of the possibility and potential for well-being and attunement in-the-moment through participants descriptions of engagement in self-care. I hoped to involve participants in conversations about the role of personal well-being as it related to attunement to their clients in psychotherapy. Ontology From the perspective of constructivism, entities are matters of definition and convention and only exist in the minds of the persons contemplating them: “They have ontological status only insofar as some group of persons grants them that status” (Lincoln & Guba, 2013, p. 40). Creswell (2003) suggests that ontology is the claim researchers make about what is known, epistemology is how researchers arrive at knowledge, and the methodology is the process of studying it. This study was an exploration of the lived experiences of participants and their unique and dynamic dance of self-care, which I believed was potentially performed to some degree, as a ritual practice that related to their provision of “good therapy.” Going into the study, I expected that each participant would have a dance that was uniquely organized and supported by their personal history, and that combined with their role in providing therapy within a social context would add to the complexity of what could be known. These ontological assumptions supported the exploration and are the foundation upon which multiple realities were discovered and are 30 herein described. Epistemology As social scientists we come to epistemology through transactional subjectivism. The relationship between the knower and that which is knowable is person and context specific. The transaction is highly subjective – the means by which we come to an understanding of ontology is contextual in that it is mediated by the knower’s prior experience and knowledge and interpretation of context, by political and social status, by gender, by race, by class, by sexual orientation, by nationality, by personal and cultural values (Lincoln & Guba, 2013). In constructivism, knowledge is created in the framework in which it is generated and the various levels of soul, discipline, and political system. This is important to my research because the individual participant is constructing the truth of how she or he defines quality therapy and how she or he provides quality therapy. Furthermore, many conversations led to a new exploration of attunement that was introduced as “doing your best work,” and was then influential in developing themes simultaneously discovered and cocreated through said conversations. Interactions between myself, as researcher, and individual therapist participants during interviews have informed the developing narrative and a thick description of attunement in therapy that is supported by self-care rituals and practices. Methodology Given the above, it follows that my methodology became a process of meaning making activities involving the participants and researcher. The processes required in the 31 exploration were the following: first, a thoughtful and expansive exploration of the constructions about attunement and self-care held by individual therapist participants; second, these conversations were reobserved, explored more deeply, and compared and contrasted to each other. Comparing and contrasting the experiences of my participants provided further understanding of the wide array of self-care activities as well as the meaning of attunement, or the active feeling of providing a therapeutic environment. My intent was to work with research participants in the pursuit of expanding the understanding of the topic in their lived experience (Lincoln & Guba, 2013). This research method mirrors development of awareness about and enactment of self-care, which evolves over time as therapists interact with their inner experiences, their experiences with clients, and their experiences in the work of psychotherapy. Axiology The values of the researcher and the participants have an integral role in the research of self-care practice development. The first value recognized is the value of attunement as well as an assumption that it exists and could be described by participants. Attunement is complex and requires significant commitment, self-awareness, and vulnerability. The second value, well-being, is intimately related to attunement. As described previously, a minimum level of well-being is necessary for attunement to exist. The value of self- and other-attunement is integral to the study. Without the assumption that attunement is a prerequisite to the provision of quality psychotherapy, the need for well-being achieved through self-care would be a moot point. The values of therapists are influenced by their individual cultures, backgrounds, and theoretical orientations. This 32 includes the value that therapists place on self-care and well-being. Therapists in turn have a direct impact on their clients, colleagues, and professional communities. In this study, the values of stakeholders such as the profession of psychology, the APA, and the community we serve also inform the research (Lincoln & Guba, 2013). I do not assume that my research will bring me closer to an objective truth about how a given therapist would develop or engage with self-care in an ideal scenario. Instead, this work has been an exploration of the practices in which therapists engage in an effort to organize their personal and professional experiences, sustain and enliven their personal well-being, and, if they described it, to attend to attunement as an essential component of practicing the art of healing. Rhetorical Structure The study is presented in subjective language. As a therapist in training, I have experienced a broad spectrum of well-being and states of attunement, from optimal performance, to fatigue, to exhaustion, and to experiences akin to burnout. I have a personal stake in expanding my awareness and understanding about how therapists engage in self-care to achieve optimal professional performance. Due to this personal interest, I have worked diligently to be clear about my lens of subjectivity and the positionality inherent in this research. I have engaged in frequent self-inquiry, reflexive journaling, and an active dialogue with “Tashen,” which is the name given to my dissertation. She has become a trusted partner, friend, ally, and a fervent accomplice. Conversations with “Tashen” have challenged both my research methods and reporting and have provided a strong rationale for my personal attendance to self-care as I strive to 33 maintain and sustain attunement in my daily interactions with clients. It has been an iterative process of self- and other- exploration that has provided steady grounding for growth in a rigorous program of study. Research Design The methodological approach for this study is phenomenology through hermeneutics. Hermeneutics, principally related to interpretation, may be derived from the Greek god Hermes, whose role was to interpret messages from the gods and make them understandable to humans. Phenomenology is a journey to understanding the lived experience of individuals. Indeed, it is seeking to describe the essence of phenomena from the perspective of the individuals living in the experience. In phenomenology, researchers bracket their experience to enter the lifeworld of the participants and use the self as an interpreter presenting results in a descriptive narrative (Miller & Crabtree, 1999). Hermeneutics moves beyond phenomenology with the expanded goal of these interpretations as a means to further understanding of the political, historical, and sociocultural contexts in which the phenomenon occurs. In hermeneutics the researcher, herself, enters the interpretive cycle, or the dance, in a “fusion of horizons” (Gadamer, 1976). Denzin (2001) describes hermeneutics as interpretive interactionism and fuses this methodology with feminist, postmodern, and critical-biographical thought. Hermeneutics as a methodology is also described by Packer and Addison (1989). Consistent with the constructivist paradigm which informs the study, the underpinnings of hermeneutics is sociological with the central task of recognizing, identifying, and interpreting complex phenomena. From this perspective, instead of an absolute standpoint 34 from which the researcher can determine the truth, there is “a ‘coconstitution’ of foreground and background, parts and whole, interpreter and interpreted, researcher and research participants, data and theory in a circular or spiral form.” (Crabtree & Miller, 1999, p. 148). The Gestalt nature of hermeneutics was flexibly combined with grounded theory to search for themes (Glaser & Strauss, 1967) and to employ a constant comparative method of analysis (Addison, 1999). Beyond the grounded methodology, the hermeneutic approach illuminates social, cultural, historical, political, economic, linguistic, and other background aspects that frame self-care, which is grounded in the everyday practices of individual participants (Kuzel, 1986). Researcher as Instrument In a qualitative study the researcher is the instrument (Marshall & Rossman, 2011). For this reason it has been important to have an honest and undefended understanding of myself. As part of my personal self-care, when I began the study, I was regularly engaging in contemplative practices that include meditation, yoga, and rhythmic movement such as walking and cycling. Over the course of the study, I added practices that my participants described, including gardening, the use of environmental enhancement including a diffuser and soft light, and I began a focus on my awareness whenever I went outdoors. I danced between sessions and played musical instruments (badly). I also wrote poetry and drew (badly). I have added regular and frequent “unfamiliar adventures”; I have also incorporated a clear separation between work and home life. I have reduced the number of different locations where I work, and I have implemented conscious practices associated with nourishing personal relationships. One 35 or more of the participants in the study informed each of these activities. I chose to actively practice what they considered to be key to well-being, and I kept a journal of changes that I noticed. Underlying Assumptions and Biases I highly value self-care and I believe that it is critical to creating a sense of wellbeing. In my own life and in my training experience, I have found that when I feel personally depleted it has an impact on my ability to provide an environment in which I am regulated and have the capacity to hold space for clients to describe a variety of experiences that are, for the most part, not colored by my perceptions of them. I accept that I have personal assumptions and biases about nearly all situations. My acceptance of this allows me to recognize the information that comes into each interaction based on my worldview. Rather than pretending that I do not make assumptions, I strive for an honest awareness of my inner experience and how it is reflected on interpersonal experiences. I have a belief that each interaction dynamically changes the individuals involved in the interaction. Because I have a background in mindful and contemplative practices and a bias that these constitute self-care, I determined not to name mindfulness as a self-care practice for participants in the study. I did enter the research with an assumption that mindfulness would be named and described by participants, because it is a common practice according to the current literature and popular psychology. This is one example of how social and historical context informs the results of this research. In light of this, I made efforts to explore with participants in such a way that they had space to self-define the practices that afford them a sense of well-being and, also, to describe wellness 36 differently than I had anticipated. Finally, attunement was not named by the researcher during interviews. Management of preconceptions and biases As the researcher, I view myself as an insider. I experience what I refer to as attunement as a result of well-being which requires active nurturing and often arises through rituals of self-care. To increase clarity of my descriptions and interpretations, I have kept a self-reflective journal throughout the duration of the study. I continued this practice in addition to discussing results, along with my responses to the results with my mentors and my research committee. These steps have supported what I believe to be a valid interpretation of the results. I also believe that my self-care practices have supported my ability to remain undefended and open to seeing my biases, which could otherwise have led to blind spots and missing results. Level of Revealedness I approached this study with the belief that I would be open to sharing my experiences. However, as I did not want to bias the statements of participants in the study, I began each new conversation with the questions as they are written and without guiding participants to name self-care in any particular way. I was honest and open, but I guided participants to talk about their own experiences rather than telling my story in any way. According to Marshall and Rossman (2011) “revealing exact purposes of a study can cue people to behave in unnatural ways.” For me this means that if I give too much of the story to the participants they may not tell me their authentic stories. While open and 37 authentic, I limited self-disclosure to the extent that participants knew why I was curious, but did not get caught up in my story. Intensiveness and Extensiveness Based on the literature reviewed, I entered this study with the belief that a minimum level of trust that needed to be established in each interview. There is a tendency for therapists to see themselves as competent and capable of providing care for others, while they are more defensive when it comes to admissions of vulnerability or personal struggles. According to some research, therapists tend to deny their need for self-care and to see it instead as a luxury or something that colleagues who have failed in some way require as an intervention or remediation. For this reason, I believed it was important to find an appropriate balance between providing adequate rationale and introduction to my research project while not leading them to a predetermined conclusion or theory of self-care. Efficiency In an effort to maximize the opportunities for data gathering it is important to set boundaries because questions and puzzles can mushroom out of control. Marshall and Rossman (2011) suggest that although a “researcher reserves the right to pursue them, she should remain mindful of the goals of the project” (p. 117). As described previously, I worked to adhere to the questions while allowing for an iterative process to inform the possibility of a wider scope than I anticipated. The utilization of specific questions proved to be effective in the management of time and to maintain the focus of the 38 interviews. Interpersonal Considerations As a counseling psychologist in training I have spent a reasonable amount of time developing listening and rapport building skills. I enjoy listening to the stories that people tell, and I have the ability to create a sense of safety and confidence in relationships that are new. Something I am aware of in myself is curiosity and tenacious intuitive thinking. Intuition is a helpful skill, but it can lead to the propagation of biases. One thing I have learned is that if I think I am onto something, or excited about a particular idea, I tend to pursue that direction. It was difficult for me to maintain mindful awareness and stay connected to the participant’s story as it unfolded rather than getting ahead of the story. There were a few circumstances in which intuition did lead away from the focus; however, it led to fortuitous opportunities to follow up in future interviews as well as to reconnect with those participants with whom I had previously met. The result was the addition of collecting demographics related with theoretical orientation. Challenges Interviewing therapists has unpredicted difficulties. Based on the literature and on my experience in training, therapists are simultaneously open, and somewhat guarded or defensive regarding descriptions of their well-being and their capacity to provide a quality therapeutic environment based on described well-being. I was concerned that I would find that some therapist participants would talk about practices that they understood theoretically, but in which they were not personally engaged. In these 39 situations, I had to consider ways to broaden my understanding about what keeps an individual from engaging in a practice that they understand theoretically, but do not practice. Although this was not the intent of the research project, there may be some usefulness associated with this unfolding understanding. Context An important aspect of qualitative inquiry is context. The ideal situation involves studying the phenomenon of interest in the setting where norms, traditions, roles, and values are present. For this reason, I asked participants whether they would like to be interviewed in the place where they provide therapy or in the place where they engaged in self-care. It was valuable to me to be able to diagram settings where self-care associated with therapeutic work is happening. Each of the participants wanted to meet where they provide therapy. It was critical to keep in mind that even brief interviews interrupt daily routines and a change in context occurred as soon as I made a request for intimacy in relationship to the self-care practices of participants (Marshall & Rossman, 2011). Therefore, I took time to describe the benefits of the research to therapists willing to engage in this research. There were four potential participants who were not able to accommodate an interview. Two of these individuals reported that they had too many demands on their time, and two reported that they did not qualify based on the screening – specifically, they did not have the required number of years in practice. 40 Participants At the time the study was proposed, it was my intention to meet with approximately 13 therapists. This number was an initial goal; however, therapists were interviewed with the goal of understanding each individual’s experience, rather than trying to understand a particular “population.” Participants were licensed mental health professionals (LCSW, CMHC, PhD, etc.) who provide psychotherapy or counseling every week, for at least 48 weeks a year, and have been providing therapy for at least 5 years. To qualify to participate, individuals also self-identified as placing importance on personal well-being or wellness. Prior to the interview, I did not ask for more specific information about their “self-care” based on my goal to understand the broad meaning of self-care within the professional community of mental health providers. Selection Procedures I used a stratified combination of sampling strategies for my study. The reason for this stratified sampling was to identify whether different themes associated with the development and enactment of self-care practices would emerge. Initially therapists were selected based on the previously described criteria. This may shift as the research informs the direction of the study (Glaser & Strauss, 1967; Guba & Lincoln, 1989). I followed Kuzel (1999) in utilizing purposeful variation to challenge my own preconceived understandings of the phenomenon and to allow for the messiness of reality to be explored. 41 Recruitment The recruitment of therapists representing a range of backgrounds was intended based on the constructivist nature of the study. The research team, which is made up of professionals at the university from the field of counseling psychology who are engaged in feminism and social justice were an initial source for recruiting therapists that are engaged in self-care. After screening these therapists, an expanding circle of therapists from different geographic locations, representing different racial and ethnic identities and sexual orientations, as well as orientation to treatment, were purposefully recruited. In the early stages, I predicted that themes would emerge that would guide my steps and direction for both expanding and narrowing the study sample. It was not the intent of the study to achieve saturation, but rather to describe the unique experiences of the participants and their interactions with political, historical and sociocultural contexts, to a limited degree. Evolution of the Sample Once the original interviews were conducted, these individuals were asked if they would be willing to refer friends and colleagues to incorporate a snowball sample (Marshall & Rossman, 2011). This method was helpful because therapists engaged in self-care were connected with other therapists with a similar value for self-care. The risk in this type of sampling was the potential for bias. Therefore, it is important to be clear that this study is not an attempt to describe a universal theory of self-care or attunement, but rather to understand these ideas for the individual participants. 42 Researcher Roles and Relationships with Participants Interviewing therapists about their well-being and attunement, as well as their personal practice of self-care required establishing a basic relationship of trust with the researcher. I anticipated that gaining entry would require sharing the intent of the research with potential participants through personal contact. Therefore, I built rapport through personal email contact and brief phone calls to set the stage for the interview. I was surprised by the number of therapists with schedules that were so full that they were not able to meet to discuss self-care. The reality of my experience was that many therapists, particularly therapists in private practice, do not have time open in their calendars. This seemed important considering the exploration of well-being and self-care, and I wondered about their experiences of being overwhelmed with their work as well as about their time being well-boundaried. I contacted more than 35 individual therapists before meeting with four. Four additional therapists responded to my recruitment, but they did not meet the screening requirements (two), or we were unable, after multiple attempts, to schedule a time for the interview (two). This turned me back to my curiosity about time affluence; I frequently provided 4-6 weeks worth of time options to look for an opening for interview. Unfortunately, I was not able to explore further what was in the way of the meeting. When I did make connections, I made it a priority to find a balance between clarity and generality to reassure therapists that I was interested in the genuine lived experience with attunement through self-care, whatever it looks like for them. It was consistently my intent to be affirming of the strengths that therapists bring to this phenomenon (Bogdewic, 1992). 43 Taking Leave Therapists who were willing to participate seemed to see value in understanding well-being and self-care practices and had rationale about why it was important. They shared important parts of their experiences with me, and often talked about learning something about themselves through their participation in the interview. Given the similar values and the positive feelings shared during the interviews, informal leavetaking was sufficient. I view leave taking with some tenderness. I felt real connections with participants and so was clear in taking an opportunity to express gratitude for what was shared and for their time and thoughtfulness during the interview (Marshall & Rossman, 2011). I offered each participant the opportunity to review the transcript and to follow up with me if they had questions or concerns, or if there was any clarification they wanted to provide. At the conclusion of the study, I will provide a summary of findings to the participants. Sources of Data The complex capacity for therapeutic attunement and optimal performance in therapy seems to be embedded in well-being and the process of self-care. The ways that therapists recognize and engage in a genuine and thoughtful self-awareness practice is at the heart of this research. In order to gain a depth of understanding of how therapists engage in this process, I hoped to utilize three styles of data collection: live observation and video recording of semistructured interviews of therapists exploring lived experience, semistaged enactments of personal practice, and brief self-reflections regarding the practice and personal attunement that is gained through the practice (Marshall & 44 Rossman, 2011). Few participants were willing to enact personal practice during interviews, although they did describe their practices, and only two completed the selfreflection of their practice. I hoped to gain clarity and broader understanding of how attunement was achieved and sustained through triangulation of multiple sources of data (Morrow & Smith, 2000). The sources of data I used included observation, interviews, participant self-reflections, participant review and feedback of transcribed interviews, and field notes including analytic memos and drawings. I was able to complete field notes, with memos and drawings, observation, interviews. Individual Interviews In-depth, semistructured interviews formed the bulk of the research. A hybrid of phenomenological interviewing provided the basis of the interview. In phase one, the participants were asked to reflect on ways that they would describe feeling effective during therapy in order to develop an understanding of their unique description of attunement; in phase two, participants were asked to talk about things they did that allowed them to be able to provide this effective therapy; in phase three, participants were asked to describe whether self-care was a part of this, if it had not already been named (Marshall & Rossman, 2011; Patton, 2015). As previously described, 35 therapists were personally referred and contacted by email with an invitation to participate in the study. I was able to interview four therapists and analyze this data to inform the need for and the continuing process of data collection. At this stage, themes began to emerge that guided the direction for completing the study. After the four initial interviews, I used snowball sampling to recruit and interview an additional six participants. I followed an 45 iterative process moving from data collection to analysis and back, keeping notes in a reflexive way until a thoughtful description and support for an interpretation was reached (Crabtree & Miller, 1999). In order to gain a deeper understanding of the various realities and lived experiences of attunement achieved through self-care, rather than the idealized scenario, the interview began with an exploration of effective therapy according to the participant. This was followed up questions regarding whether personal well-being influences a therapist’s ability to be present in the moment with their clients. Although I proposed a label for this, attunement, I wanted to be flexible and open to the naming and identifying of this experience as described by the participants. The participants narrative description set the stage for a semistructured interview that opened further exploration of self-care and personal awareness of attunement, including explorations of when it is present and when it is not, as well as how it is sustained. Interview protocol Initial interviews were scheduled for 90 minutes. The protocol for interviews is presented in a series of broad questions. Follow-up questions were asked based on the need for prompting. Some participants required stimulus, while others required refinement. The protocol shifted based on the results of the first interviews as well as on the difficulty getting participants. I was and continue to be specifically interested in the early markers and indicators that therapists are moving out of attunement –a level of selfengagement and social engagement that allows therapists to connect – which would limit their capacity to be truly present with their clients. I was curious about how open 46 participants would be to reflect on these experiences honestly and authentically. I began with a biased belief that if individuals are able to detect changes early – general cues of personal fatigue or a reduction in their ability to connect with their clients – then they would be less likely to experience shame or other affect that resulted in defensiveness regarding these changes. Further, my belief is that the smaller the shift away from attunement, at the point of detection, the easier it is to return to the path. For example, participants may just need to stand and stretch in between sessions or give themselves a brief foot massage. Because I want to understand the ability to sustain optimal performance rather than avoid burnout, I was particularly interested in these early cues. The following introduction and questions formed the basic structure of the interviews: In your therapeutic work, there are likely times when you feel your work is going well and that you are engaged in a way that seems to be conducive to therapy. 1. What’s it like for you when you are the most in touch with yourself and your client….. tell me about that? 2. What in your life contributes to your being able to be in that place? 3. I’m really interested in people who focus on their own health and wellness outside of work…. Can you talk about what you do to promote your own wellness? 4. How does that play into your ability to be in touch with your clients? Yourself? Interviews were conducted with participants on video. Video was the medium of choice because while interacting and discussing topics that involve self-care, it was expected that body language, voice tone, and over-talking would occur. I hoped that participants would naturally embody self-care enactment in the moment, and the video would provide rich data about the individual self-care and self-tuning practices of therapists. I also used video to capture nonverbal responses that would not have been available through audio-recording. 47 Follow-up interviews Thirty minute follow-up interviews were anticipated, but were not necessary. Brief phone contact and emails to two of the participants were sufficient to clarify questions that came up during analysis. I was sensitive to the possibility that follow-up interviews would be too much of an intrusion into the busy schedules of participants, and so I did not engage in superfluous follow up interactions. Enactments of self-care practice When participants talked about specific self-care activities during the interviews, I gathered details about those practices and took time to engage those practices on my own. This provided me with the opportunity to enact the self-care practices and to reflect upon my own experiences rather than ask participants to practice them while with me as I had initially intended. This opened me up to a different interaction with data provided by the participants and was also sensitive to maintaining boundaries with participants. A concern about maintaining this boundary was expressed during the proposal. My decision to engage with the practices as a follow up to the interviews proved to be a powerful expansion of my experience with the data. Participant review of transcript Participants were invited to review written summaries of our interviews. This gave participants the opportunity to provide feedback about the interview and to provide clarification regarding the narrative of their combined stories. When participants made notes or adjustments to my notes, if they believed a misunderstanding or 48 misrepresentation of meaning occurred, I made adjustments and followed up with them to make sure that my understanding was as accurate as possible. Self reflections Participants were asked whether they would be willing to engage in their individual self-care practices for 1 week, and provide a brief reflection of their experience. This reflection was to include a brief description of the personal well-being activity they performed and things they noticed about their level of presence or attunement with their clients, if they saw clients that day, as well as their thoughts about the effects of these activities and reflections on them and their therapy sessions. Only two participants provided this reflection. I reviewed these self-reflections in conjunction with the individual interview. Field notes I used field notes to record details associated with my impressions of observations during the interview process. In these notes, I recorded possible interpretations of statements and emotions related to these observations as well so that I could bracket them from the data (Morrow & Smith, 2000). As part of my field notes, I created drawings and analytic memos following each interview and interaction. These drawings included the arrangement of individuals in the space as well as any self-care objects that were visible and present during the interactions. The reason for this was to deepen my awareness and enhance my memory of the experiences. I remember through a variety of senses and drawing provides an important filter for my experiences and interpretations. Drawings 49 and analytic memos also served to support triangulation through clarifying potential variation in memory recall. These are included as part of the data corpus although drawings will not likely be presented in the final written product. Drawings were reflections of the emotional experience and occurred both following interviews and following review of the video during data analysis. Data Management As principal investigator, I conducted all of the interviews. Interviews and observations were video recorded. All videos are recorded on a secure device to which only the PI has access. Transcriptions include descriptions of what is seen and heard and are stored on a secure server. I transcribed all of the interviews verbatim, not correcting for language errors and including minimal communication (uh, um, etc.) and pauses and describing significant body language. Analytic memos were kept throughout the transcription process and included in the data analysis. Data Analysis Analysis of the data followed a theme-based hermeneutic design (Addison, 1999; Marshall & Rossman, 2011). Hermeneutics is related to phenomenological analysis. However, it goes beyond describing the essence of phenomena from the perspective of participants’ experience. This hermeneutic analysis, described by Miller and Crabtree (1999) as a “dance of interpretation,” includes the researcher’s interpretation of phenomena in the context of political, historical and social backgrounds. To provide an interpretation of attunement through self-care practice, development, and enactment, data 50 were collected and a constant comparative analysis of themes took place from the first interaction. I have immersed myself in the literature as well as the lived experiences shared by participants through the primary data collection strategies: observation, enactments of activities, and interviews (Brown, 1999; Marshall & Rossman, 2011; Miller & Crabtree, 1999). The “dance of interpretation” involves nonlinear, repeating patterns and overlapping circles. I have engaged in a variety of self-care practices and tracked my own experience throughout the research process, tracking my own personal well-being as well as my capacity to be attuned with clients throughout the process. During this process, I have engaged with several phases of data analysis concurrently: organization of and immersion in the data, generation of categories and themes, interpretations of themes, seeking out alternative understandings, and clear writing to present the results (Marshall & Rossman, 2011). Organization and Immersion in the Data Initial participants were contacted through referrals from the research team, and professionals in counseling psychology. Interviews were conducted with therapists and video recorded. As previously described video was the medium of choice to facilitate a rich data set from the participants and the researcher as they interact and share information about the self-care activities. Videos were transcribed and transcriptions include what is seen as well as what is heard. The principal investigator transcribed each video. Personal enactments of self-care activities described by participants by the principal investigator occurred within four weeks of recordings. This provided a complex process of immersion in the lived experience and provided data that clarified the 51 participants’ descriptions of their self-care patterns. Generation of Categories and Elemental Themes From the literature review forward, I engaged in the ongoing process of thematic explicitation. Elemental themes emerged directly from the data. As these themes emerged, I recorded them on large note cards to facilitate my visual and kinesthetic style of learning. I dedicated the walls, and often the floor, of my office to the organization of themes that surfaced during the process of analysis. I used large sticky notes and posters to facilitate mobility and flexibility of themes into patterns that gradually evolved into a credible interpretive description of the phenomenon during the process of crystallization (Crabtree & Miller, 1992). Intimacy with the data has evolved as I engaged with this physical organization of the themes I have described as elements. They remained on my walls throughout the project to hold it at the forefront of my mind, making an organic and authentic experience of the phenomenon. Because I anticipated this process would be fluid and that things would shift in a nonlinear fashion, I took photographs during different organizational phases of analysis prior to making changes in order to guard against the loss of serendipitous findings (Marshall & Rossman, 2011). Interpretation of Themes I kept analytic memos throughout the iterative process: each interaction through interview, observation, self-reflection, this investigator’s personal enactment of self-care activity, and research team meetings provided potential and opportunity to build on and refine the focus of the research. The process of organizing and interpreting the data has 52 been nonlinear and ambiguous at times, and it has evolved into a broadly supported interpretive description of the phenomenon of attunement as it relates to well-being and as it is sustained or enhanced through self-care practices (Marshall & Rossman, 2011). Beyond this, the data suggest that attunement during therapy is reciprocally healing and sustaining for the therapist. Seeking Disconfirming Evidence After each interview, I reflected on the variations as well as the consistencies to assist me in the exploration and refinement of the themes as well as the need for additional unanticipated theme development. Following each interview, observation, and analytic session an analytic memo was written as a means of tracking the unfolding patterns of understanding related to the phenomenon. These memos were included in the thematic analysis. This process supported the discovery of disconfirming evidence. Through this, I pursued an ongoing reflection with open curiosity, inviting questions about what was not known, and at times introduced tension into the evolving hypothesis, providing greater breadth of discovery. Writing to Present Results I see analysis and writing as overlapping circles from which a conceptual model of the phenomenon could emerge. As described previously, the rhetorical structure of the research is subjective. I wanted to provide a narrative of the experiences of individuals in the context of culture, history, and politics. It is my hope that my voice served to interpret a story that is relevant for individuals who are living and sharing a variety of personal 53 self-care practices in the present context in relationship to therapeutic attunement. It is impossible to capture all of these elements with any one individual participant, but interacting with these individuals as well as with the data over the course of the year has provided a rich explanation of layers of the phenomena. Trustworthiness The criteria associated with trustworthiness have been described as parallel to, yet distinct from, traditional quantitative research criteria. Specifically, credibility, transferability, dependability, and confirmability are related to internal validity, external validity, reliability, and objectivity (Lincoln & Guba, 2000). In a constructivist/ interpretivist paradigm, fairness, authenticity, and meaning provide support for trustworthiness in a qualitative study (Morrow, 2005). In this study, I have incorporated authenticity criteria suggested by Guba and Lincoln (1989). Strategies used to ensure credibility include triangulation, participant checking, peer debriefing, intercoder reliability, audit trails, and theoretical sufficiency (Marshall & Rossman, 2011). In an effort to reflect subjectivity, dependability, triangulation, and researcher reflexivity, a self-reflective journal has been kept throughout the study. This provides a record of intentional reflection on personal biases and observed change in my analytical processes over time. Efforts were made to share the authentic voices of the participants through providing them with an opportunity to review transcripts and summaries to ensure details of the experience were reflected in the final research product. Interviews have been conducted and integrated until themes demonstrated saturation and redundancy (Marshall & Rossman, 2011). An audit trail was kept to describe the steps taken during the study 54 and to reflect the evolving interpretation of the phenomenon. Ethical Considerations The ethical codes outlined by the APA (2002) have provided a guide for standards of procedure in this research. I obtained approval from the University of Utah Institutional Review Board before beginning data collection for my study. I obtained informed consent from participants prior to observations, interviews, and self-reflections. I took time to describe the purpose, duration, and procedures involved in the study, and I provided time for participants to ask questions regarding the study. I informed participants of their right to decline to answer questions or withdraw from the study at any time and discussed any foreseeable consequences of declining or withdrawing. I also attempted to attend to foreseeable factors that may have influenced their willingness to participate such as potential risks, discomfort, and adverse effects, with particular attention to the intention of the study to explore and interpret phenomenon associated with therapeutic attunement. I also described potential benefits and incentives for participation that included deeper understanding of themselves and their attunement as well as the potential of creating more robust self-care rituals and the possibility of becoming involved in a supportive community with a sense that they are engaged in a common goal. I provided participants with the name of my advisor(s) and those could contact if they had questions about the research. I provided them with a means to contact me and to get support with any concerns that came up during the course of the study, such as therapy for therapists, yoga and personal wellness support systems, and consultative groups. 55 The benefits of participation were expected to exceed any discomfort that participants experienced, although some participants are more vulnerable to harm than others. For example, individuals who have experienced burn-out, compassion fatigue, or vicarious trauma may have come into contact with difficult emotions and unresolved issues pertaining to personal history. I worked to insure that participants had an opportunity to be supported in the event that any of these potentialities occurred. Without exception, participants reported that the interview provided them with enhanced awareness of their access to personal wellness and the availability of resources they enlisted during and between sessions with clients. Video recordings of observations, interviews, and focus groups were maintained on a secure hard drive for the duration of the study. This hard drive was erased at the conclusion of the study. CHAPTER III RESULTS Overview The purpose of the study was exploratory: to look for optimal performance of therapeutic functioning. Specifically, I entered the study with an intent to explore and connect with this phenomenon, sufficiently to describe therapists’ own experience with the phenomenological elements deemed necessary for their provision of quality therapy. Participants were psychologists, social workers, and licensed professional counselors, all of whom identified as being committed to personal wellness, which they attributed to some form of self-care practice. Ages of participants ranged from mid-30s to early 60s. Participants were recruited through purposeful snowball sampling. During semistructured interviews participants described their experiences of being engaged with clients in a way that is conducive to therapy. Participants also described processes that made it possible for them to be engaged in this way, both with clients and with themselves. To deepen the phenomenological understanding, participants were invited to share their experiences as well as their beliefs about how these experiences played into their provision of quality therapy. The phenomena explored and described in the research was personal well-being within the experience of optimal performance in psychotherapy. In phenomenological 57 research the key operative is to describe the experiences of the people involved (Giorgi, 2012). In the current study the phenomena were explored from the perspectives of the participants. From that position, my exploration of this assumption was bracketed based on my interview introduction. I stated, “In your therapeutic work, there are likely times when you feel your work is going well and that you are engaged in a way that seems to be conducive to therapy.” At this point, each participant was asked to “describe, in your own words, what this is like for you.” Based on participant responses, a few characteristics seem to be present in therapy among participants. Quality therapy requires some degree of presence and connection. It requires that the therapist be self-aware and have self-connection as well as connection with the client. The therapist also needed to be able to differentiate their feelings from the client’s feelings. However, there are widely differing ways that participants describe this differentiation. Participants spoke about how they used self-knowledge and selfawareness as well as awareness of their clients to describe their interpretation of what was happening in the room. Most talked about how they needed both self- and otherawareness to provide quality therapy no matter how they defined it. From here, I moved into the questions about what was required for participants to be able to provide this quality therapy, which they described in various ways. Explicitation Pure phenomenology seeks to describe data but not to explain or interpret that data (Giorgi, 2012). However, most phenomenological research adds an interpretive element that allows the data to be used as a basis for theory and to challenge structural or 58 normative assumptions. It may also be used to challenge or support policies or actions related to a particular phenomenon (Giorgi, 2012; Groenwald, 2004). As I approached the data, I engaged in organizing through immersion or crystallization, incorporating extensive reflexivity (Miller & Crabtree, 1999). I conducted each interview, then listened to each interview, and then transcribed it. Following the transcription, I listened to the audio while reading the transcription, scanning for things that seemed to be highlighted by the participant. The rationale for this was to capture the essence of the phenomenon, holistically, and to recall the felt experience of sitting with the participant as they described the phenomenon. I did this to get a deeper feeling for the data in order to organize the information and to focus on understanding participants experiences. I consciously allowed the direction to change course following a nonlinear exploration, which spiraled and danced. I attempted to describe the data in reflexive journals, to research advisors, and my qualitative research team, while paying attention to all aspects of experience. I took care to maintain awareness of preconceived suppositions and to look for disconfirming evidence. Throughout the process of organizing and writing the results, I have avoided “data analysis” because Hycner (1999) suggests that analysis usually means breaking into parts, which Groenwald (2004) suggests has dangerous connotations for phenomenology. Crabtree and Miller (1999) suggest that a common error in qualitative research is to switch from a constructivist paradigm back to a positivist paradigm, as “cultural forces pushing and pulling toward universal, reliable, and valid “truths” with generalizable, predictable, and controllable outcomes are subtle, persistent, and powerful” (p. 132). My intention was explicitation, which involves an investigation of “constituents of the 59 phenomenon while keeping the context of the whole” (Hycner, 1999). It was my goal to follow steps for explicitation of the data, getting closer and more intimate with the data, until fully immersed and capable of describing the essential experience. Understanding which aspects were essential came through checking back with participants, as well as exploring aspects from various directions. If an aspect could be changed and meaning not lost, then the aspect was not considered essential (Giorgi, 2012). As previously stated, I bracketed preconceived ideas where possible, and considered collective and individual themes separately. From these data, I have described a dynamic, multilayered interactive process that participants engage with to achieve and sustain personal and interpersonal attunement, which may enhance their capacity for optimal performance in providing their unique version of quality therapy. From conceptualization of the study, I have used the Dance of Shiva as a metaphor to describe the constructivist, phenomenological research model (Crabtree & Miller, 1999). I acknowledge that my attempts to describe the complexity of the dynamic may distort or diminish the dynamic I am attempting to describe (Bell, H.R. date unknown). I have immersed myself in the data and throughout the iterative process, as information has surfaced and images evolved, I have kept redescribing and adjusting. I have continually leaned into trusting my capacity to describe the felt experience and released the impulse to discover “truth” (Crabtree & Miller, 1999). Because my research is focused on therapists and their well-being, the phenomenon I explored is their use of processes associated with self-care to provide a therapeutic space. It should not be overinterpreted to mean that therapists’ self-care does in fact produce client outcomes. In this 60 study, good therapy, and the elements necessary for providing good therapy, is described subjectively by participants. From the data, interrelated thematic elements of a dynamic process of balance emerged. They include context, attunement, embodiment, vulnerability, and responsiveness. I will provide a summary of five participant narratives illustrating interactions with these themes. A deeper exploration of the themes including subthemes from the full corpus of the data will be provided following the narrative summaries. Summary of Participants The results of this phenomenological study were developed through 10 face-to face interviews with therapists in two states: Utah (four) and New York (six). Purposeful snowball sampling was used to recruit these participants with the intent to interview participants who had interaction with the phenomenon of interest. Strategically, I only included participants who (a) had 5 or more years of experience providing face to face therapy, (b) saw at least five clients per week, 45 weeks per year, and (c) described themselves as engaging in personal self-care. The sample consisted of three men and seven women, all cisgender, ranging in age from 31to 61, and years of experience providing therapy ranging from 8 to 25+ years. One participant identified as Black, one identified as Vietnamese, eight identified as White. Three participants identified as LGBTQ, the remaining seven identified as heterosexual. All ten identified as being in committed monogamous partnerships. Orientation to treatment style varied among participants. Four provided therapy in private practice, two provided therapy in an agency, and four provided therapy in both an agency 61 and in private practice. Each of the participants chose a pseudonym to be used to identify them in the study. More detailed demographics are in Table 1. Participant Narratives In the narratives that follow, each participant attempts to put into words the ineffable essence of their experience during moments of providing good therapy. In each interview, I witnessed the challenge of naming the experience of providing good therapy. I was not asking about the theoretical orientation, I asked, “What is it like for you to be in that place?” and this serendipitously led to the discovery of the healer within each participant. Each healer is unique – as is the self-care of each healer. For each participant unique elements surfaced that helped to provide a framework for the participant’s “good therapy.” The personal narratives pointed toward the differentiation of the self in that moment in the room and led to the phenomenological discovery, which incorporates the vulnerability of the individual in the on-going journeys toward self-understanding and necessary self-nourishment for each participant. As I interviewed my participants in an effort to understand the things they do for themselves in order to engage in quality therapy, my data spoke less of distinct activities than of the processes that created wellness among participants. Furthermore, each participant’s development toward the ability to be an engaged, connected, attuned therapist seemed to have arisen from a personal process of discovery. These personal processes were often born out of vulnerability – periods of personal struggle, burnout, or 62 Table 1. Participant Demographics. Pseudonym Race/Ethnicity Birth Country State/Residence Gender & Age Sexual Orientation Religious Affiliation SES – child/adult Licensure Type of practice Years in practice Direct Client Hours Mental Health Hours Hoa Asian/Chinese Vietnam Utah Jasmine Black U.S.A. New York Kirk Caucasian United States New York Mike Caucasian United States New York Female - 44 Heterosexual/Married None Working/Middle Class Female - 48 Lesbian/Married (left blank) Poor/Middle Class Male - 42 Heterosexual/Married Atheist Middle/Middle Class Male - 64 Heterosexual/Married “The Beloved” LowMiddle/Middle Class Female - 30 Gay/Partnered Agnostic LowMiddle/Middle Class Female - 52 Heterosexual/Married Unitarian Church Middle/Middle Class Female - 58 Heterosexual/Married Unknown Middle/Middle Class Male - 49 Heterosexual/Married Atheist Upper Middle/Upper Middle Class Female - 53 Bisexual/Partnered Spiritual w/o religion or dogma Poor/Middle Class Female – 48 Heterosexual/Married None Upper Lower/Upper Middle Class PhD Psychologist Private Practice 10+ years 30 clients/week 40 hours/week Licensed Social Worker Center & Private Practice PhD Psychologist Group specialist Private Practice 15+ years 15-20 clients/week 40-50 hours/week Licensed Social Worker Center & Private Practice 25 years 24-28 clients/week 48 hours/week PsyD Psychologist Center 8+ years 15-20 clients/week 40-45 hours/week PhD Psychologist Private Practice 15+ years 15 clients/week 25-30 hours/week LMHC Private Practice 15+ years 5 clients/week 10 hours/week PhD Psychologist Hospital – Provider Wellness 15+ years 5 clients/week 40 hours/week PhD Psychologist Private Practice 20+ years 16 clients/week 24 hours/week CMHC Private Practice 8+ years 20 clients/week 30 hours/week Lynn Caucasian United States New York Michelle Caucasian United States Utah Kerrie Caucasian United States Utah Jack Caucasian Canada Utah Lisa Caucasian United States New York Amy Caucasian United States Utah 15+ years 30 clients 45 hours/week 63 crisis in which they realized that what they had been doing was either ineffective, or that it was working less well than necessary, in order to facilitate the work they deeply wanted to perform. What arose from data across interviews was a phenomenon of personal process, in which the clinicians’ personal struggles resulted in growth that occurred from the inside out as they learned to know themselves as people, gained a deeper understanding of what led them to personal fulfillment, and became attuned to themselves. This attunement eventually led to an ability to attune to others in a way that, relationally, elicited from clients their own needs, self-knowledge, and personal development. Participants shared their spontaneous definitions of good therapy and what it is like for them to share space with their clients as they provide good therapy. They then talked about variations on how they learned to provide it and what they did to care for themselves so that they could provide a therapeutic interaction in a healing environment. Without exception, participants talked about the healing interactions being personally reinforcing for them in some way, saying things such as, “I get excited!” and “I love it when it’s like that!” or “They like me and I like them!” In the pages ahead, you will read narrative summaries of the experiences of five therapists. These narratives provide some insight into levels of awareness of personal and interpersonal attunement, as well as awareness of what is necessary to activate, refine, and maintain levels of attunement that allow therapists to provide what they consider to be quality therapy. The process of qualitative inquiry allowed me to interact intimately with layered identities of participants. For this reason, a more holistic summary of each participant is provided immediately preceding each narrative. I present a summary of 64 each participant along with the interview narrative, by design, so as to capture the phenomenon in context with the person of the therapist. This design was supported by the themes that evolved during the explicitation of the data and derived from a model demonstrated in Schueman’s (2014) phenomenological study. Following each brief description is a summary of the interview, which captures the essence of each participant’s definition of quality therapy, as well as the essential elements deemed necessary for the provision of quality therapy. Consistently, the summaries include, in no particular sequence, a description of quality therapy and the felt experience of providing therapy, a description of various self-care activities, a personal vulnerability, and awareness of the need for self-care as a process. This often concludes with a selfexploration of the dynamic dance of self-care and therapeutic work. Hoa is a 42-year-old Vietnamese American who has been in private practice for 10 years. Family roles that came through during our interview included wife, mother of two children, and sister. She describes her therapeutic approach as informed by interpersonal process. Additionally, Hoa shared that she immigrated to the United States with her family when she was a small child, which influences her self-care, her therapeutic work, and other professional practices. Sitting with Hoa, I experienced joy, sweetness, and fresh earth. Hoa’s narrative highlights therapeutic presence and the importance and value she places on boundaries between work and home. She talks about vulnerability, the importance of differentiation of herself, ways that she cares for herself, and regeneration or fulfillment that comes through her provision of therapy. Additionally, through Hoa’s narrative, the interaction between vulnerability and fulfillment are present as she talks 65 about her personal history as a refugee and her desire to help people with a similar background. In contrast, she talked about her limited work with children and refugees, because she is not able to separate her work from her home life. Hoa’s therapeutic process is centered on presence. She emphasized her ability to be present in the room with her client as the primary goal and described augmenting presence through a process of consciously separating personal and professional life experiences. She explained moments when she is doing her best work as follows, “I’m not thinking too much… and it just feels…good…. I guess when I’m not worried about things… things just feel natural to me.” For Hoa, it’s about the process. “What’s going on in the room?” “How do they feel?” “How do I feel?” “How do we feel about each other?” Hoa noticed that “I like them and they like me, … and there is an understanding in this room… and they know that I care about them.” A sense of presence seems to be what Hoa attributes her ability to connect with her clients in a meaningful, healing way. “I’m in tune with myself,” she said, which she explains allows her to be truly present with her clients, their experiences, and their healing. As Hoa explored things she does to care for herself in order to be present, she seemed to remember and to explain, “I have never felt that therapy is depleting for me… I’ve never really experienced that.” Here Hoa shared elements of vulnerability associated with regeneration as she talked about her own history, stating, Doing something for somebody else … in particular with the immigrant… because it’s such a part of …like my, history it is a part of who I (pointing to her chest) …I am… and I think it’s part of like, a reason why I went into psychology… to help a population … and in some ways it’s like, helping me, you know it’s like giving back to those, and helping those, because I know …how it was to be a new immigrant (holding hand over heart) I know… (nodding)… so for me… it is rewarding to be able to give and help somebody who is like me (nodding). 66 This led to her description of the fulfillment she experiences in her work: It does help… and I think maybe helping students is also helping… because … I had really good supervisors and I think they really… shaped me in a way that I think, really, I’m grateful for, and so I hope to give… I hope to give that to someone else… it fulfills (rubbing her heart space) I don’t know… it just fills something up there… you know? She demonstrated this with a physical gesture: “It is… that… for me (lifting hand from heart and moving it outward)… so… I’m sure there’s this, too (hands scooping and pouring it back into the heart) there is a lot of this,” which was followed by a pregnant pause, at which point, Hoa’s eyes lifted and she said, “I don’t want to toot my own horn, but I also feel like I find it… it’s rewarding for me because I think … I’m pretty good at what I do… (Hoa smiled) you know what I mean” and she continued, I’m like getting teary by saying that I think I’m good at what I do (while laughing, rubbing her heart, and leaning her head back in the chair) I guess maybe I’ve never said that (full laugh followed by a big breath). I really do, love what I do … maybe that’s what it is… I don’t find it… umm… draining… and ya-ahh. As Hoa talked about self-care, she described with great clarity delineating work and home life: You know a lot of people ask … how do you do this? Listen to people’s stories all the time…right? … I just don’t take it home… if I took it home I’d just be a basket case… I leave it here. Hoa’s presence at work is a mirror of her presence in her personal relationships, “I have to … work on my relationships at home… being in a happy marriage and … being a good mother (looks away) and I’m not… always a good mother.” Although Hoa trained as a child and family psychologist, she explained, I don’t see children… Number one; it’s the schedule, because I want to be done by 4:00. Number two, I have children that drive me crazy at home sometimes, and so I, I think it would be too hard for me to see kids… and not that I have … problematic relationships with my children, but just… they take a big chunk of my emotional…. ‘well’… you know … and so I… if I only have that much… 67 ‘emotional well’ for kids… I’m giving that to my kids. Hoa further described protecting time for various physical activities that are selfnurturing, which, according to Hoa, enhances her ability to be present in therapy. She described, “I protect that time for me… because it allows me to take care of… the other parts of me,” and she continued, I do a lot of gardening … that is where I get to be present… I feel the dirt (with hands churning in front of her), I smell, I smell the dirt, and I feel the pulling of the weeds (as her hands make the action), so that is where I am able to take care of myself and be present. I smell the flowers and the vegetables (as her hands move toward her face)…. So … that is, for me, I do things like that that allow me to … take care of myself… which then allows me not to take work (her hands delineating an invisible box in front of her) home with me.” Hoa described a clear connection, “so I can be very present with my clients, because I have taken care of myself outside of that. Here, vulnerability highlights a subtle indicator of the difference between and the impediment to presence with clients, which is described as herself: “I know if things are not going well… umm.. for me … I can’t be present with my clients, so,” when things are going well, “I know that I’ve taken care of myself because, I am there with them, and it’s all about them… it’s not about me… I’m just here, I’m just present. I’m not anywhere but here.” This opened an exploration of therapeutic presence, which is similar, yet distinct from self-presence. She spoke about the evolution of knowing herself as a therapist. It’s been 10 years since I’ve been licensed… It took 5 years or so to get to understand that I don’t want to see kids … I used to see people later… and… it’s not worth it. It is what I described earlier, I wasn’t able to be present. Instead she described a lack of presence, saying, I wonder what the kids are doing? I want to be at whatever it is that they’re at… or I was like rushing home. You know… like, being done with the session even before the session’s done, because I need to be at this… it’s not fair… to whoever I’m seeing, you know… and it just wasn’t working for me. 68 Summarizing Hoa’s narrative, there is clarity with regard to boundaries between work and home, which mirrored subtle indicators of differentiated presence with her self and her clients. Hoa’s descriptions of gradually coming to understand herself as a therapist highlighted the inference of awareness that comes through losing and regaining balance and gradually making thoughtful choices about her provision of therapy and meeting her personal and family needs. Jasmine is a 48-year-old Black woman. She works in an agency and has a moderate private practice on the side. Intersecting roles, beliefs, and identities that were described during her interview included her shifting spiritual or religious practice, her marriage, and her sexual identity as a lesbian. Jasmine describes her orientation to therapy as integrated. She uses elements of dialectical behavior therapy (DBT) as well as psychodynamic therapy and interpersonal process. Sitting with Jasmine, I experienced reverence, compassion, and humility. As Jasmine described the energetic and ephemeral experience of providing therapy, she frequently breathed “mmmmm” through softly closed lips. It was resonant and calming. As she talked about her ways of knowing she is engaged in a therapeutic interaction, she said, “I experience excitement… Breathing deeper… Relaxed.” After a long pause she said, “Mmmmm…yeah…. mmmm… I have less of a half smile. I don’t know how to explain that… I always have a half smile… sometimes when I’m irritated with the person… but in that moment, I’m more relaxed.” As if on cue, Jasmine visibly relaxed, sank into the moment, both her breathing and mine slowed, and her voice dropped to a whisper as she said, Yah, I’m more in tune… to …. More in tune to my feelings… and my client’s feelings at the time. I just have this ‘a-ha.’ I wish I could explain… it’s not my a- 69 ha… it’s their a-ha…. I’m just voicing it… Sitting with Jasmine, the room was like a charged space and I wondered aloud about the expansiveness I experienced in that moment. She continued, “I don’t know… mmmm…. feels connected… feels spiritual…. there’s awareness… there’s not just one word.” Jasmine talked about the times when this deeply connected interaction is most likely to happen saying, Mmmmm…. I think it depends on the client [long pause]. Yah – it depends on the client and what we’re working on… I know… some of my best work with some of my most traumatic clients happens early in the day… and that’s probably most likely because… I did my own meditation… I ran…. I did some kind of work out. I’m not feeling bogged down with other people’s stuff… that I wasn’t able to discharge prior to seeing someone that has a trauma history. Jasmine explained that after sessions “I take a moment… take a minute… just to let go… and discharge myself… I say a prayer… give it to the angels… take a walk or a run.” In between sessions, “I know who I need to go to here (at the clinic)… when I need to discharge… when I need to laugh… or… the opposite feeling of whatever it was that I was feeling in the room.” At the end of the day, I go home… I go home to C (wife)… my dogs. I don’t turn on the computer. I don’t do any notes. If they didn’t get done, they don’t get done. I don’t answer any emails that’s not… [laughs] I don’t answer any emails… until the next morning…. I talk to C. I mostly talk to her. I read… I read something that has nothing to do with the profession. As Jasmine talked about her evening discharge and renewal she spontaneously included, “I don’t watch the news. I don’t watch the news for me …. I don’t want to hear about the news for the most part.” She talked about asking her wife about the news instead: I say, ‘Ok, so what do I need to know about what happened today?’ So then when my clients do come in and they’re all stirred up about it, I do have some knowledge of what’s going on… but for me… I can’t watch it… I can’t hold it… 70 she just tells me what’s going on… in the government… ummm… that’s all I need to know… so when I say, ‘What’s going on?’ she knows it’s about the federal government… that’s what I want to know… and then if I’m more specific… I’m like, ‘C, I heard that there was a shooting of another black kid… did you read up on it?’ And she’ll tell me… or if she hasn’t, then she’ll go read up on it and she’ll just give me the information I need… and then I go from there… if I need to read about it… then I’ll go… which is wrong… because I won’t read about it… I’ll ask other people … so I’ll talk about it… I’ll go about getting my information…. I don’t know… reading about it seems too… it can seem scary or hurtful… I mean, it scares me… like I’ll… bringing it inside of me… inside of my space… and I don’t like watching… it… cause you can watch it over and over and over again, right? When Jasmine said, “Bringing it inside of me,” there was a visible shift in the living, breathing nature of providing therapy. The energy in the room changed when she talked about watching the news and about bringing fear into her body, which I experienced in my own body as severe restriction, or a shutting down. She continued, I can’t (with emphasis)… it’s ummm… it’s harmful for me it’s … it’ll… eventually it would kill me… and I choose not to die, before I experience what I need to or want to experience with C and my friends and my family. She described this, specifically, saying, Eventually it would kill me… I think ummm… being a black woman… being a black person… I have my own, intergenerational traumas. Part of that trauma is being susceptible to certain diseases: heart disease, high cholesterol, I already have controlled type 2 diabetes, ummm… I already know that I struggle with anxiety and depression… if I allow all that negativity inside of me, it takes… it takes away my days. I just choose not to… not to be filled with hate… with anger – like that … I choose not to be… I think at one time I was just living to …. Get through life… ummm.. now I’m living to experience life which is funny because … my body is my instrument… and my therapy is my art in order to keep your art “good” you gotta continue to… nurture it and hold it and… that’s what I do I think… yah… that’s what I do … I listen… I listen to my body… I know my triggers… but most of all, I just, I listen to my body. She closed her lips together and made the now familiar sound, “Mmhmmm.” I wondered, and asked, what happened if Jasmine did not listen to her body and how that might impact her therapy. 71 I’m overwhelmed. Mmmm… yah… in the room… I make mistakes… ummm… I can be … more directive… with a client… and less patient…. Sometimes in the moment I notice it… and sometimes… I’ll take a deep breath… I’ll drink some water… I might even mention it… I’ll say, ‘You know it feels like I’m being really directive right now and I don’t want to be that way… so… what’s it feel like to you?’ She also talked about noticing after the client leaves, and said that at those times: I probably go home and talk to C about it… ‘I had this client today and I’m really irritated with them… I felt like I was somebody’s mother today’ and I don’t want to be anyone’s mother… or.. you know… ummm.. or I’ll just tell myself… it’s time for me to do some reflection… it’s time for me to step back… and think, what’s going on in my life. At these times, she talked about noticing that she feels disconnected with herself and said, “That’s when I start to clean… or rearrange… like in here… or I’ll rearrange at home… like… my space isn’t right… [as she moved things around].” She explained that when she “de-clutters… it allows for the energy to flow.” She can tell when I’m more overwhelmed… I notice that… I’ll notice things… like, ‘Oh shit, there’s too much dust on my table’…. and I’ll notice that I have to make myself pay more attention to the client or it will distract me. She further explained, “I spend a lot of time here… so my office is an extension of my body… it is distracting.” Similarly, sometimes when sitting with clients, her body is distracting. “My stomach clenches… my shoulders…but when I ask my body… when I’m asking myself what’s going on in the moment… again, I might bring it up…” During sessions, in order to check her attunement in the room, she might bring it up to the client and say, ‘Hey, I’m noticing this right now… and I’m wondering if it’s mine or if it’s yours’… so… it’s helpful to open the conversation… because, it’s not all mine and I’m opening it up for the client to talk about it. Jasmine went on to provide an example of a time when she noticed something that was hers rather than her client’s. In her example, she talked about feeling judgmental and 72 how that was an indicator of her stuff. She said, And it could be judgment… when I’m working with a male…. I’m working with this young man and his room just got raided by the FBI and I’m thinking… is it drugs? Is it child porn? And I had to… take a deep breath… and remind myself… I’m being judgmental… which wasn’t easy…. And then I connect to the child… and I was able to go deeper and see the child part of him …I was able to help that part of it [the client]. She noticed the judgment was in the way of her providing therapy, and she said, I turn it over (to the angels)… I don’t turn things over in the session. It’s after. But sometimes I have clients turn it over in the session… or I have them turn it over to the room. I just invite them to leave it here. In addition to turning it over, Jasmine talked about discharge. She said, “Laughter, tears, running, that’s discharge.” And relationships do something else: I can’t have one without the other… in that way… So if I leave [it] here and I go to someone’s office… I’m looking for a relationship to do whatever I need to do… When I talk with someone else or go home or talk with C… or when I run… it’s my relationship with nature. Lisa is a 53-year-old White woman. She works from home in a small private practice. Intersecting roles, values, beliefs, and identities that were described during her interview included her passion for equine therapy and continued learning of depth models, her partnership, and her physical restrictions, due to chronic illness. Lisa describes her therapy as an embodied practice. She has two therapy dogs and sits supported by a wing-back chair. Sitting with Lisa, I experienced wordlessness, deep knowing, and a simmering, yet full breadth of emotion, from controlled rage to primal fear. Lisa describes that part of her capacity to therapeutically connect with her clients is by “bringing an embodied self as therapist to an embodied psychotherapy.” This embodied presence provides for healing connections. When I entered Lisa’s therapeutic 73 space, a felt sense of warm electric energy enveloped me. She talked about good therapy as follows: One of the things I am really present to is my own capacity to focus … I will notice affect in my body … that’s kind of one of the main things that will happen when I think someone is doing some really powerful work. She further described: “One very primary aim for years… decades… has been, bringing myself as an embodied therapist.” After reviewing her narrative for validation purposes, Lisa provided the following “loose definition of embodiment,” as “staying present to what is happening in the moment within the somatic, including sensations, body inhabitation, biological needs, and the physical and visceral experiences of emotion.” She explained, With this in place, we have a firmer foundation for being more fully in any moment at myriad levels, including somatic, sensate, emotional, intellectual, and spiritual. Somatic psychotherapy can provide a good deal more raw data, including how the body holds mixed emotions and emotional conflict, where and how trauma is stored at the cellular level, and allowing space for the unspoken or disowned parts of self to come to consciousness, to name just a few. She further explained, I also find it helpful in understanding transference and countertransference patterns and projective identifications. Beyond that, my own personal work in the soma and perception has opened me up to a fuller awareness of myself and of my relationships with others, including my clients. Lisa emphatically described the importance of “bringing myself as an embodied therapist to the hour … I would say that’s absolutely key within the therapeutic domain.” According to Lisa, I do so many things to take care of myself in terms of how my body is doing and working… you know, that go really just beyond good fitness … Like my own happiness is absolutely essential to me… and it’s not even happiness per se… it’s like, what things do I do regularly that feel like an intrinsic reach for my heart, you know… What am I passionate about? 74 And further, I think the more I have aged the more absolutely key that is in my life … and it helps me within a therapeutic domain because, not only am I looking for that in my clients… or helping them kind of find that eros, I will call that eros, within them but… keeping myself alive outside of … you know… just being a psychotherapist. She described that this includes “postgraduate training in whatever the heck I wanted to do,” and she stated, “I literally … like traveled the world … and worked in kind of bizarro realms at times… with people who were interested in the soma and perception.” Lisa talked about a health crisis several years ago when she became very ill. She talked about the interaction of the crisis and her passion. “I moved from a very busy practice that I ran… I actually had to close that… I had to… make my work very small… I stopped teaching, I stopped supervising, and I moved my practice home.” At the time of this crisis, I needed to be doing things that would keep my body moving… to the best extent that it could… even though I was having a lot of difficulty… and so the horses came in there… It was really my sickest moment and before diagnosis that I … [knew I] needed to do something that at least feeds me and nourishes me… and I started grooming a friend of mine’s horse… you know when I could… I couldn’t lift my arms really well at that point … then that turned into … ‘I’m going to try and take a lesson’… even though that’s kind of crazy…And then… the movement of the horse… even at a walk… was enough to start to loosen the muscle contraction … move my lymphatic system and… I was like… ok… it may be insane but this is what I am going to do … And so, I went from there. In addition to riding, Lisa described other activities: I also walk my dogs every day… to the extent that I can… Sometimes it’s 10 minutes, sometimes it’s an hour… I start my day with various… modalities… yoga, stretching… a little bit of dance if I can … because I have a harder time with my muscles in the morning… And that remains true as I am kind of working a very, very slow recovery. I was never the kind of person to hang out on the couch… So at my worst I have had to hang out on the couch and I haven’t liked it so much… But what I’ve done is to really kind of call in… creative things … I 75 have access to… and those I think feed me as much as a lot of the physical activities. So I engage with a lot of my own creativity to whatever extent I can… so I can’t draw… but I have a comic strip… about chronic illness called ‘Chronic City’…. And literally, I can’t draw… like I don’t care. And at the other end of the spectrum, she said, “I’m very much engaged into literary writing, poetry and fiction and that… I work on and send stuff out.” As Lisa continued to elucidate on caring for herself, she returned to describing the health crisis that served as a catalyst: I changed the location in 2014 because I was very ill… and I couldn’t do all that I had been doing. So, I had muscular issues… the reason I have a wing back chair is because I can only hold my head neck and spine for so long… so that’s kind of the ‘raw data’… I had to change my whole set up… I had to eliminate my commute… and I cut my practice into a third… stopped supervising and teaching… and, I didn’t have the diagnosis, for two more years… I couldn’t walk… some mornings… There are many symptoms I just won’t go into… I was very clearly ill… and …I was thinking maybe … should I apply for disability… but you know… there is something so tenacious in me… that, I was like, I just don’t want to give up … to being completely marginalized and disabled…So if I can continue to do this and make sure that I am really honest with ‘How present am I?’ for this very pared down practice…. then, I’m going to try that first. But I pared my practice down, like a said to a third…. I cut it into a third. Can you imagine …telling two-thirds of your clients … I’m sorry I can’t see you anymore… and some of them know one another… It was awful… It was so, so, so hard… and I think, I mean… I can make some meaning out of that, for me and who I am and all that jazz, but, it was just sheer… It was horrible. Consistent with her descriptions: I also knew in my body… if I don’t really provide a lot more space and time for whatever this disease process is…I couldn’t in good conscience… see people when I’m that sick and … I mean I just couldn’t handle the load… So I had to really listen then too... but I probably went a bit beyond you know, maybe normative limits around that because I just kept thinking… I’m just going to keep going… and it just didn’t work out so much. Lisa’s therapeutic embodiment incorporates the physical realities. She stated, Presence is key, and if I’m riddled with pain… and I’m super tired… you know… one of the realities of my disease… The last thing to go was actually my energy… At that point it was sheer mitochondrial dysfunction…. you know… Your mitochondria are making energy for you that is burned whether you are 76 burning mental energy, emotional energy, physical energy. It’s all the same to your mitochondria so… you know… they’re not like… oh well, you can sit and see… clients in a row… and that… you’re sitting… no… You get done with that and you’re like ‘How depleted am I from that?’… Whether you’re ill or not… you know… what is optimal… for the human creature that you are…A lot of therapists will do that… you know… They’ll have financial goals or aspirations for success… that are really fine… but they’ll end up going past what those limits are and… you know, I did that to some extent because of my fire… as it were… the eros… And you know I would say yes to some other project… because it was like… it seemed cool and fun… whatever… but then I’d be like … oh my goodness, I haven’t like… done these other things… these other parts of self are being neglected… And then of course the illness came in … so. In the course of her descriptions, I wondered if Lisa was more attuned because of the illness she was addressing. She responded, Gosh… I don’t know if I know like the answer to that… Like has my presence been a correlate… in some way… like a growth of presence…in the therapeutic hour…I’m certain that it must have been… It must be something that is variable… But if I think back to my 2014 self or my 2004 self … I think that… it wouldn’t be terribly different. I’ve always had this kind of fiery aspect… but I will reflect upon it too and if I come up with something else, I … I will send it to you because it might be quality… And certainly because I’m intrinsically interested in presence and what that is and how that not only works for me as a professional, but how, what I bring to my other relationships, and the world you know…. all my relationships… including… you probably have some sense of this… what you bring to the relationship with horse… because their limbic system’s are bigger than ours… They’re very resonant beings … that when you… if you have your experience of riding….You have to be present… you have to be embodied, fully, or you know… or why? So maybe that’s our metaphor for life here. Kirk is a 41year old White male who is engaged in private practice as well as working in an agency. Important roles that he discussed during the interview were fatherhood and being a husband. He talked about wanting to be healthy and active, and he also talked about his dysfunctional relationship with his mother, which informed his approach to therapy and to self-care. Sitting with Kirk, I experienced excitement, an almost perseverative focus, with intermittent distractibility, and the disruption that comes with the surprise of a fire drill, literally. 77 Kirk talked about how when he was really in touch with his clients he felt more confident about his ability to be in the moment, connected, and able to capture what was going on for his clients, and that beyond that, he cherished those moments. He stated, I am one of those therapists that has a notepad out. I have ADHD, and it helps me track. I’ve kind of conditioned myself to stay in the game, attention-wise, by like, taking notes … When I am in that moment – connected with the client – I just want to throw the clipboard … I don’t need it, I’m totally zoned in… it almost requires no effort … It’s kind of that flow state… I really feel like, in a synergy with the client, and… the content of what they’re saying, but also the process and the relationship and my own feelings and bodily sensations and all the rest and I love that place. I cherish it so much. He continued to describe this connection that creates an experience of flow where less effort is required, although attention is necessary. I don’t get it all the time, but the feeling I would describe is just a synergy … where things kind of flow naturally… but, I wouldn’t fully say … effortlessly, because there’s, you know, whether it’s conscious or unconscious, there is some sort of thought that’s going into, at least the delivery of how I say something… or what do I feel is most important … or, you know, pick the direction, or if it’s more person -centered in that moment… it requires a little bit of thought, because I need to reign it in. This taps into Kirk’s unique awareness of his need to care for himself. I can get excited and … lose inhibitions… and so I have to like, check myself, ground myself, breathe… I can generally sense when that’s happening though… It usually happens when I get that synergistic feeling, when that sort of comes together. At this point, Kirk more specifically defined his internal awareness as a therapist. He described it as “The extent that I’m trying to like stay in it and stay controlled and stay focused.” Kirk went on to describe three pillars that are part of his in-the-moment process. He said, I guess it’s empathy, but… There’s three … there’s like, what I would feel if I was in their situation as me; what I am feeling as me in this present… listening to 78 them; and then what I would feel if I was them, knowing what I know of them… based on background information and what they’re presenting in the here and now. Kirk described emotional connections as his most natural connection to therapy: I remember feelings really well … I just feel very connected to that person and I feel connected to their story and their, their heart, their emotion… Umm, where I start to feel disconnected is when I start to like perseverate or try to remember the content. And he talked about his therapeutic nature, saying, “It’s a lot more instinctual when the emotion is coming from the client.” At this point, I inquired about how Kirk was able to engage in this therapeutic process, and he described a self-understanding that informed his process of differentiation from clients, saying, Yah… uh… it’s gonna get personal… but, I was raised pretty much by a single mother… Only child, single mother… ummmm… I do have siblings, but my parents divorced when I was 2… and… I was pretty cut off from my dad… until my thirties… I saw him, but I didn’t have much of a relationship … and I had my mom in my ear, triangulating, and pretty enmeshed … pretty significantly… I don’t know where I wanna say it started, but there was a point where I started to really differentiate and individuate from the enmeshed relationship with my mom and… even more so… once I got married… and … Three years ago, once I moved away from Chicago… the more that I saw the enmeshment, the more I wanted the differentiation… and then… when I moved here to start a family of my own… distance and all of that other sort of psychological momentum… kinda came together and …that was probably single-handedly the biggest influence, the biggest factor in yah... being able to know myself and what I am feeling … Before that I used to just take on what others were feeling, like right away, like a sponge. He talked about how he thinks the difference of knowing this has led to a lot better therapy, and … it’s not that I don’t feel… it’s just I’m not emotionally swept away… and um… out of control with it… for lack of a better term… I used to just get swept away by the emotion… and, as a result I thought, ok, … I can’t work with axis II, … I can’t do a whole lot of trauma work, … I felt more limited in the kind of work I could do, because I felt like I was… I don’t know… it was going to affect me too much, and I experienced things too intensely and it blurred my objectivity. 79 He, at first, stumbled and then clarified: I was so …deficient, I think, at leaving work at home, or leaving the office … at leaving my work at the office. I would carry things home with me. And it would stick with me in my dreams, and … and to some degree, that’s cool… I’m ok with that… you’re going to get affected in this line of work, the way I see it, but … It was… an unhealthy amount… It was consuming. And sometimes in a moment of clarity, I would look at it and think… ‘This isn’t even about me. This isn’t my life. I’m not them.’ … But I would be acting and thinking and feeling and consumed as if it was. As if it was like a continuation of the hour I just spent with somebody. And through Kirk’s growing awareness, he said, “So, I was taking things in in a way that overloaded, that overwhelmed my capacity for self-care.” Upon further inquiry about the evolution toward his self-care, Kirk shared this statement: I’ve always journaled. I just journaled a ton more… to almost, an infinite level with no bounds … and it influenced how I go about things now… but now there’s like… a beginning and an end to it. There’s a restful breaking point… that I can put the pad down and say, ‘I’m good for now.’ During the stage of his life Kirk described as enmeshed, he described journaling in the following way: It was like, I was doing it as if there was an addiction, or a need… that like if I wasn’t gonna journal, I was gonna sink… I was gonna free fall, and ummm, be too consumed and distracted in life, so I needed to purge it, but there was no end to the purge… It was like a… bionic purge… perpetual purge. Now, Kirk describes that he still uses journaling to assist his differentiation, “but now the concept of enough has really come into play … so journaling has changed its form over the years for me.” In this way, journaling may have been a differentiation process that Kirk now distinguishes from himself and toward which he feels more comfortable and less compelled. Based on his descriptions, Kirk’s differentiation process has also informed his 80 social relationships over the past ten years. He said, I’m a real social person… like being with others… having fun, laughing, seeing music, is huge for me… and so… that kind of stuff… socializing can rejuvenate me, rather than suck the energy from me… and in my 20s, it sucked the energy totally from me, and when people would go away, I’d be there with my journal just regurgitating or replaying scenarios, purging the emotions that I was feeling… so I just felt depleted – I just felt constantly depleted because I was taking on everything in my environment. Other ways that Kirk attunes himself as a therapist is through movement. He stated that “physical activity has helped me get in touch with my body… has helped me understand, like, what my reactions are ummm from a physical standpoint.” Kirk demonstrated this as he talked about his “makeshift yoga.” He said, Makeshift yoga, I don’t do actual yoga, but I stretch and I do pushups and … like, I do weird exercises… (laughing) … I do it all the time… I do it in between sessions. I’ll sit here and I’ll do (demonstrating some of the movements/stretching as he narrates the movement) arm circles… and I go backwards… and I reach as high to the sky as I can (stretching hands above his head) and I like, let it go as low as I can (bending forward and touching the ground --dangling a bit)… and I sort of like… I use some of the dance moves that I go through…like from concerts that I go to and I like… I try to capture… the most free-flowing … arm and leg movements that I could possibly do… and I can tell how free I’m flowing and I can feel how free I’m feeling, or how loose my body is based on like, the way that my body is operating when I do those things. He described that there are some times when he needs the stretching more or when he feels less free flowing, such as in his work with “trauma clients. Yah… ummm (ten+ second pause)… I think I tense up… with trauma.” At this point, Kirk reflected, Yah, you know, it started, instinctually… I didn’t… and it still is kind of instinctual… I don’t have a real, theory-based reason for this…It just feels right… it feels good… and ummm... and it helps me… see how much tension I have. And, I could go into all sorts of reasons why that became important to me, but the short of it is, I recognized … I started having physical ailments… that were due to being ‘locked up’ and that wasn’t cool. And I felt like, I was, … a 60 year old in a 30 something body for a while. And that just was not cool with me… especially having a kid … 18 months ago… you know… it’s like… am I going to be able to roll around on the floor with them? And play and be active and be, you know, an active dad? That’s very important to me… But, I was inhibited. I had …neck 81 problems, back problems, and rib problems… due to different things and so, yah, I don’t know I started paying attention to that stuff, for the first time in my life. Kirk explained seeing a chiropractor last year for 3 sessions… it’s not my favorite thing in the world… but whatever he cracked and loosened up… it didn’t do the trick permanently, but it drew my attention to posture… to body… and now, I’m… I’m pretty active in that way. And, before, I was pretty naturally active, a… play outside active… like go kayaking and go running… and I still do that stuff, but now, I’m like… aware of how everyday… like, simply sitting… and the posture that I use… factors into that… and so, so… I just stay limber, I stay loose… and I just sort of pay attention to … tension… there’s a difference between… that loose, relaxed state… that I can get into… and the greater the difference … the more, I’m able to see … oh wow, you’re tense, especially if it’s an unconscious posture that I was holding, when I was really honed in on a client. Jack is a 49-year-old White male who works at a hospital, in a short-term crisis model, using a wellness model to support physicians. Important roles that surfaced during the interview were husband and father. Jack also talked about his value for continued learning, generally, and specifically of his value for meditation. He is currently working toward certification in Mindfulness Based Stress Reduction (MBSR) and devotes 20-30 minutes a day to meditation. Sitting with Jack, I experienced focus, calm conscientiousness, and patience. As Jack reflected on times when therapy is going well, he described feeling excitement associated with being involved with something that heals or helps clients in various ways, from gaining insight, to having space for different parts of themselves. In his words, I feel excited … that my client is… gaining some insight to what it happening for them… in a way that feels like… they’re gonna be healed in some way… or that they have a new perspective … that’s going to allow them to move forward or even just feel like they have a space where they can express themselves fully… be themselves fully… [long pause]… I’m not sure honestly… other than… [these moments] feel exciting for me because it feels like… this is gonna be helpful for this person … I guess that’s what I’m feeling the most… it is the most rewarding 82 thing about the work that I do… when it feels like… this is actually going to help this person. I was curious about how Jack knew healing was happening for his clients and he described tuning in, saying, “I’m just paying attention to the microexpressions… or the emotion that is… coming up for them.” He clarified, It’s not like I’m tuning in to how I feel (pointing to self) about that… as much as I’m tuning into… the impact that this is having, so I guess I’m really focused and in touch with what’s happening… and that’s probably part of the excitement… because it’s like, ‘Oh this is … moving forward.’ I guess those are the times when it feels like… oh… they’re getting some new insight… they’ve made some kind of progress. And with further reflection: “But sometimes,” he said, It’s just… holding the sadness that they’re going through… or the… ummmm… the trauma that they’ve been through… the tragedy that they’ve been through… and just creating space for that… how it’s going to be held and…. I don’t know. For each participant, it is difficult to describe what they are doing to promote healing. For Jack, there was a pause at this point, as he reflected, There’s a little bit of metacognition (open hand up beside his head)… like awareness of… what’s happening … at least… some of the time… thinking about ok… how do we make sure that this kind of sticks… or goes in productive direction… but … umm.. mostly it’s just being tuned in. Jack spent time working toward the idea of the quality of being tuned in: I think that the reason that that statement came up for me is… the question of … what am I experiencing (hand to chest) and… mostly it’s the feeling of being tuned in … and a little bit (hand up beside head) of thinking… thinking about… where do we go next with this? And how do we give enough time to the emotion? Sort of deepen the emotion and just that kind of process thinking about … ummm… what’s going to be helpful … next… but mostly… it’s that… tuned in… and certainly the moments that… get you to that space… for me feel like… everything else (taking his hands wide) is tuned out… and I’m just… present with the client… and thinking about them (as he pointed toward a chair to the side) … I keep motioning this way because usually I sit with my client over here. Jack was so “tuned in” as he talked about the experience that he pointed to the 83 chair even though no one was sitting in the chair. Similar to other participants, when asked about how he engages with healing, Jack described a parallel process or a mirror. He explained that a primary way he tunes into patients is the same way he tunes into himself through his mindfulness practice. He said, I do think that formal practice in mindfulness helps in that… I can notice when I’m being distracted from clients and I then bring myself back, too. I’m here… those… other things that are coming can be handled or solved at another time… and for this moment I’m sitting here with this… person… this client… so … I think that it helps me, one, notice that quicker when I am distracted and, two, … bring myself, in the moment, back with the client. Based on this description, it seems that tuning in is the key to healing for Jack, and practicing tuning in helps him in his own life and is also the tool he uses to provide a space for healing. Vulnerability shows up for Jack as distraction. He said, “And the times when I notice it… are the times when I notice that something intense has happened just before… so if something intense… like leaks into my session… I know that I’m thinking about another patient.” He continued, So it’s not the most common experience for me but I notice it… and there’s some other type of intensity going on in my life… so… it’s the formal practice… like … mindfulness… that I think is helpful with that actually… I notice I’m distracted… and I will bring myself back to the patient … and it feels so similar. It’s like they are … it feels like the exact same thing I notice that my thoughts are over here… and I want them to be in the present. In addition to mindfulness, as Jack described his care for himself he spoke a great deal about balance. He stated, “Mindfulness practice is one piece of that, but I think the more my life is in balance, probably, the better I am at coming here, and like having energy with clients.” Jack talked about finding the middle ground in many ways, one of which is related to the number of clients seen during the week: 84 I cannot even imagine having a clinical case load of 25 clients … for me, that would be way too much, and I don’t think I could be present for clients in that way. With that said, I am seeing, probably 5 or 6 clients a week, which honestly feels like too few, for me, to like, be, really sharp with my, therapy skills … I don’t know if that’s true or not, but it feels like there’s some kind of balance. For me… about ten clients a week… feels like, ‘Oh, I’m a therapist, doing therapy’… And it’s not too much… it’s not exhausting… it’s not too much trauma… but it’s not too few either… and I think keeping everything in balance for me feels like really important. And here he cleared his throat and talked about more of the things in the balance, “Exercise, that my relationships are intact, that, you know, things are as calm as life allows it to be without it being dramatic.” Jack went on to talk about various elements and activities that he associates with self-care: Exercise during the week feels important… weekends I’ll do a long trip… that feels important… that’s usually by myself. If I can find someone that wants to do weird, crazy stuff, then I’ll do that, but often, it’s just kinda, on my own … My kids are grown… so it feels like… I have the luxury of doing some of those things … Because, I’m not… taking time away from family responsibilities. Jack consistently returned to frequency, flexibility, and balance. It all feels like this kind of puzzle that you have to kind of (hands held out to the sides moving up and down alternately – like scales balancing) pay attention to… family needs this much, work needs this much, relationship needs this much, I need this much, my body needs this much, and you know… you just kind of fit the pieces together … So, yah, I’m pretty consistent with what I do, but I don’t feel regimented …like oh, I have to do this… or things are going to fall apart. Flexibility was equally important to Jack. He said, All those wellness activities can become, you know, if they become a checklist… then they don’t enhance my wellness. They become a task that I have to get done… and it actually takes the enjoyment away… So I think probably another way in which my mindfulness practice kind of helps me to … just be present with what is… rather than thinking about … you know I have to get this task done in order to be happy… noticing… I’ve not slept well and so, I’m not going to go work out today because I’m going to sleep… and that’s ok… and I don’t have to punish myself for that or feel like I didn’t ‘do what I was supposed to do’…. that kind of trap that takes the wellness out of it. 85 Here, Jack talked about his realization and awareness of rigidity as a vulnerability: … Of course, the reason I know that making it into a task list isn’t healthy for me, is because I’ve done that, and do that sometimes… and that’s when I notice… oh… this is like another thing to get done, but I’m actually stressed out trying to get all my wellness in versus actually being well. And here, Jack circled back to balance, saying, I’m sometimes surprised… how much actual time goes into that ‘outside wellness’ for me… and it… it really also means… that I have had to think about and balance… How much ambition do I want to have in work and job stuff… and how much time (again using hands as the scales of balance) do I want to spend on … my own wellness? I easily could have a 20 hour a week job … you know… doing something else… if I said, yah, I don’t care about meditating or exercise or trying to prepare a healthy meal, or whatever it is. He continued, There’s a lot of time that goes into that as well … and it means ‘I’m not going to write that research paper… because I’m going for a run’ … it’s gonna take time… I mean I frame it as … I said a half time job… because it feels like 20 hours a week is a lot to spend on that … I don’t actually think about it as a job… I think about it as the things that make my life calm and worthwhile. This vulnerability also seems connected to accomplishment for Jack. He said, I think it’s when I notice… that I’m not present with the activity that I’m doing. [Instead] I’m actually thinking about ‘how do I get the most out of this?’… You know it’s like when you sit down to meditate and you’re thinking (eyes closed, whispering) ‘Ok, so after I finish meditating I need to get this thing done.’ Here Jack started laughing midsentence, opening his eyes and saying, It’s like… ‘What am I doing?’ … I’m not even doing the activity that I’m doing… I’m thinking about … how to fit everything… and it’s becoming a … a checklist for me… Because even if I’m going for a run, which feeds me… and I’m thinking …ok I gotta hurry and get this done so that I can get the next activity done…well, then either be with this activity and get something out of it, or stop… and if you’re gonna choose to do the next activity then stop and do the next activity and be present with that… but don’t try to be doing two things at once, I guess [mmhmmmm] yah… I don’t know if that … makes sense… but for me, it’s that felt sense of stressing about being efficient…and I’m just not present where I am anymore. Jack’s final comments about balance were: 86 When my life is out of balance in some way it is definitely … harder to be present with clients... I think probably there is less room to be curious about clients, or to be concerned about them… or just thinking through what they’re going through and be able to come to sort of insight about it… If I have stuff that’s happening in my own life… or if it’s out of balance in some way… I don’t have the space to let that client… percolate in my consciousness a little bit… The more I can take care of myself and be in balance, the more space there is to be in ‘wonder’ about clients… read something… and be thinking about my client… how it relates … and what might be helpful. In the end, Jack expressed concern that his interview would be taken out of context, and stated, I would just say… the danger for me of talking about this… is … it sounds like [there are] little nuggets of wisdom in what I’m saying… and I don’t think that. I think the danger is … the assumption is that ‘because they’re talking about balance they have balance or because they’re talking about mindfulness they have mindfulness.’ I don’t know… and I always… am hesitant to say that the way that I’m doing it is the best way, or the wise way… It’s not… I’m just doing it the best I can… … and so much my experience is thinking, ‘I’ve got this,’ and then realizing, ‘I don’t got this’ … [laughing] there’s another 12 levels to this that I didn’t even know existed… and … I’m scratching the surface. Emerging Themes as Elements As I interviewed my participants in an effort to understand the things they do for themselves in order to engage in quality therapy, my data spoke less of distinct activities than of the processes that created wellness among participants. Furthermore, each participant’s development toward the ability to be an engaged, connected, attuned therapist seemed to have arisen from a personal process of discovery. These personal processes were often born out of vulnerability – periods of personal struggle, burnout, or crisis, in which they realized that what they had been doing was either ineffective entirely, or that it was working less well than necessary in order to facilitate the work they deeply wanted to perform. What arose from data across interviews was a 87 phenomenon of personal process, in which the clinicians’ personal struggles resulted in growth that occurred from the inside out, as they learned to know themselves as people, gained a deeper understanding of what led them to personal fulfillment, and enabled them to attune to themselves. This attunement eventually led to an ability to attune to others in a way that, relationally, elicited from clients their own needs, self-knowledge, and personal development. From the data, I provide an illustration, shown in Figure 2, of the elements in a multilayered process, which enhances their capacity for providing their unique version of quality therapy. Due to the nature of written language, the elements are described one at a time. However, they are not distinct, or separate, and the descriptions are most accurate when considered holistically. Overview of Thematic Elements The thematic elements include context, attunement, embodiment, responsiveness, and vulnerability. These elements are depicted in Figure 3 as if balancing upon one another. They will be described in greater detail here. In order to provide a fuller, richer description of each element, I have included excerpts from the interviews in which participants describe the elements in their own words. These excerpts are drawn from the narratives above and as well as from the five participant interviews whose narratives are not included in their entirety. 88 CONTEXT: Therapeu/c Environment EMBODIMENT: A,unement to Embodied Self RESPONSIVENESS: Appraisal and AcAon VULNERABILITY: Unique History Figure 3. Presentation of Thematic Elements. Theme 1: “Context: Therapeutic Environment” Therapists operate within a variety of contexts. Some are engaged in private practice, some small group practice, or a more structured clinical environment such as a counseling center, community mental health or a hospital. Although there are many forms that a practice might take, context determines certain aspects of therapy and provides structure and a backdrop for the therapist. Context incorporates boundaries, including hours of operation and the setting for therapy, and establishes opportunities for consultation, or, sometimes the inhibition of consultation. Therapists frequently included context in their descriptions of self-care and self-management, specifically with regard to 89 distinguishing boundaries. Some participants set clear distinctions between work and home life. Others described thinking about their clients while on a run or while meditating – allowing clients to be a part of their distilling down thoughts and ideas. Politics, social context Participants talked about news, politics, and public opinion in relationship to providing therapy. One participant described the importance of filtering the news through her partner in order to prepare to respond to her client’s concerns in sessions. Another participant talked about discussing politics with friends at her church. Descriptions from participants suggest that there are a variety of ways that politics and social context enter therapy. It seems that participants recognize the outer and the inner world as part of the context of therapy that is included in their consideration of self-care. In her narrative, Jasmine talked about her partner watching the news and telling her about what was going on so she would be prepared to talk with her clients. I know I have to know some… but… [my wife] watches the news… and I say, ‘Ok, so what do I need to know about what happened today?’ So then when my clients do come in and they’re all stirred up about it, I do have some knowledge of what’s going on… but for me… I can’t watch it… I can’t hold it… … So when I say, ‘C I heard that there was a shooting of another black kid… did you read up on it?’ And she’ll tell me… or if she hasn’t, then she’ll go read up on it and she’ll just give me the information I need… and then I go from there. Michelle, another of the participants, talked about politics as well. What is happening politically… in this country, in the … political climate definitely is effecting us. We’re more fatigued and burned out because of the stress of all of that… it’s definitely affecting our clients… There’s an intensity level…. last January, when all of those executive orders came out….. oh my gosh… my clients… and everybody’s…. other therapists… and articles I’ve read…. The intensity level … and when he got elected… and all of it…. It’s more to deal with… it’s more to deal with internally. 90 It’s more to deal with, with our clients… you know… for so many traumatized women, you know, the sexual assault, and all of that…. WOW…so much came up…. For female clients that have been traumatized by men… oh my gosh. And I actually, I will bring it up if it seems relevant… I’ll just say, how are you doing with it, or just, acknowledge you know, the current political climate…. Or what’s happening in this country… is very stressful…. Most of my clients tend to be on the liberal end… and so I’m quite certain… that it’s affecting them… and it’s important to acknowledge that …there’s this added level of stress and anxiety…. So it sort of normalizes…. So clients aren’t thinking it’s just them. Sometimes they don’t even realize that it is a factor in their own anxiety, etc., and depression… I mean so many people are so discouraged… and then I feel it too. So they know they’re not alone… and because I work from a multicultural feminist perspective…. I often bring in the social, cultural, political, yeah… I don’t just ignore it… so it’s like… some people bring it up… but also, if it fits, I’ll just gently bring that in…. and just what’s going on in the country… it depends on the client…. How specific I get. It could be just as general as that… you know… What’s going on in our culture right now that has an impact… I think that’s gonna come up…. Because you know…. Those outside factors… the noise… whether it’s the space you’re in and what’s happening there… Whether it’s what’s happening politically…. and socioculturally… in the country and in the world… has an impact on how we do our work. Setting Some providers put a great deal of consideration into the office space and the therapeutic environment, while others were subleasing offices that were furnished by other people and made the best of the situation. Most participants described that the space provided support for them in the provision of therapy – as if it were an extension of themselves, allowing them to be comfortable and supported, and bringing parts of themselves into the room. In regard to his personal office at the clinic where we met, Mike stated, “I think there is something about the setting that matters a lot… I feel connected to myself here… more than anyplace else. I have to work really hard to be connected with myself at the 91 hospital.” Jasmine considers her office an extension of herself and engages with her office for self-care. “I spend a lot of time here, so the office is an extension of my body.” She further described, “It has an influence on therapy [because it has] an influence on me… when I’m more overwhelmed… I notice that … I’ll notice things like, ‘Oh shit, there’s too much dust on my table.’” Jasmine also talked about noticing when there was too much going on in her life outside of therapy, saying, “I will start to clean… or rearrange… like, my space isn’t right.” And Michelle said, I’ve been very thoughtful about how I decorated the space… they are all things that feel good to me… it’s very similar to the style of my house… and so it just makes me feel at home… and comfortable … and to me it matters. To some people, I don’t think it matters so much, but for me it had to be beautiful, and warm, and welcoming. Like who I am… so everything is congruent as a therapist. Hoa described her furniture selection: I’m short so I needed chairs that were short. They had to be comfortable… so I…can sit in these chairs and be comfortable and I love it… and I let the client choose, whichever chair that they want to sit in… and then I fill whichever one… so the colors … they just have to be calming… I’m here seven hours a day… so for me, it had to be comfortable… so I found things that were comfortable for me. Kerrie, another participant, sublets her office space so another therapist chose the décor. Still, she said, I sublet… but yet, I couldn’t just… like, I’m comfortable in the space… so for me… I need things like neatness or tidiness… umm cause just in my life in general… if things were all over the place in here… or were just… a wreck… that would just distract me… again, it’s about being grounded… and not distracted…. So I didn’t know… because I used to have my own office…. in New Jersey… So I didn’t know what it would be like to sublet… but I’m comfortable here … and really comfortable with the person that I sublet from… so it just feels… good. 92 Boundaries Amy and Hoa both talked about having very clear boundaries that differentiated their work and their lives at home. The boundaries that Amy and Hoa described allowed them to leave their work at the office and to focus on their family relationships while they were away from the office, which was a core value for each of them. Amy talked about boundaries allowing her to be really present during session because she is not thinking of clients outside of session. So some of it is just how I draw boundaries. I work really hard to hold really good boundaries … that for the most part… I don’t carry my clients with me when I am not with them… I mean… there are times when I will read something and I will think, ‘Oh, what would it be like to introduce that in with so and so…’ But I believe that the people that I see, because I only see adults… that I am there for them in as full a way as I can be for those 50 minutes and then they go into the world… when I am in my best state… and there is that sense of connection… and full seeing of each other… I can have the energy to do that because I am not… like doing it in small ways the other 6 days and 23 hours… because I am fully there then, but I am not holding them in other ways and in other places… I also choose to not see clients that would need that kind of holding either…I don’t ever think that I would see a client more than once a week and I certainly think that that is another thing that I do, and I think that my ability to have it be very clear… like when they walk out of my office… I put that out… and I don’t think about them again until they come back the next week… It’s like I put them out of my head… and I think that some of that is my age… and some of it is like how I organize my life, which is, the rest of my life is important… and that there is not a lot of bleed over… I do not go over time… almost ever… again, I am very boundaried with clients and I think that that is part of it too. Hoa talked about boundaries in a variety of ways, one of which was in relationship to having a private practice, which she believed allowed for the boundaries that are so important for her. I think part of a private practice that is so good for me is… my family is very important… ummm… so I am able to set my hours… not that I wasn’t able to set my hours before… I was walking out the other day and I asked myself… why do I like this work?… and it’s partly because… it’s what I said… what I told you 93 earlier… I get to leave… I don’t have to take it home… when I was doing research… the papers were never done, never ever [louder and turning her head for emphasis] … ever… ever done… right? The grants are never done [eye rolling and head turning]… you know… once that one is done you write another one… part of it is that I …am one who likes to just leave it here …and I go home, and I don’t think about it until I’m here again. Theme 2: “Attunement: Therapeutic Presence” During each interview, the participant was asked about times when they feel that therapy is going well. Consistently, participants reported the ability to be present with clients’ emotions was critical to good therapy. They talked about finding a relaxed, in the zone, type of a feeling where they maintained a focused awareness but experienced ease or flow in the therapeutic interaction. Some participants described being totally tuned in with clients and tuned out with everything outside the room. Finally, participants often described a surreal type of interaction that felt spiritual or energetically charged. Present with clients’ emotions Participants described having high awareness of what was happening with the other person. This idea is particularly intriguing. I was curious to know how participants could know what was happening within their clients. In particular, when the other person is a client in therapy who may have trouble describing emotions, needs, wants, hopes, and fears. This ineffable experience was a point that was circumambulated frequently during the interviews as participants attempted to describe this knowing what was happening for the other person. One participant, Kirk, described this in what he referred to as pillars. He stated, There are three parts to this specific type of empathy – what I would feel if 94 I was in their situation as me; what I am feeling as me in this present… listening to them; and what I would feel if I was them, knowing what I know of them… based on background information and what they’re presenting in the here and now. Other participants described a sense that their own inner experiences were taking up very little space when they were providing good therapy. Hoa, suggested that she does not notice herself in the room at all but instead is paying attention only to the interaction between herself and the client. In Hoa’s description the contrast between her experience and her client’s experience seemed murky or blended. She stated, Having them feel like they are cared about… I guess, I’m feeling… well I’m not…. I guess I’m not thinking too much about it. I like them and they like me and we are understanding – there is an understanding in this room… and they know that I care about them. And they know that I understand them and that they, so it’s more about them than it is about me, I guess, when I feel that things are going well, because that’s the approach that I take. It’s about the process that we have so it’s much less… I mean, I’m in tune with myself. I am there with them, and it’s all about them… it’s not about me… that’s why when you asked about me, it’s like, huuuh, really? I’m just here, I’m just present. I’m not anywhere but here. Notably, Hoa’s self-care was centered on delineating clear boundaries between work and home. She described that her relationships with her husband and her children were important and she did not overlap contexts. It was important to Hoa to be centered in those relationships when she was not at work. This is likely an indication of Hoa’s personal relational style and her orientation as an interpersonal therapist. Amy said, When I am in my best state… and there is that sense of connection… and full seeing of each other…[and I am consistently meditating] like 30 -40 minutes almost daily… there is a part of me that is a lot quieter…. Then… it’s amazing then, what I can notice… and in terms of that felt connection… I can feel the subtle parts of that more… and I notice more about changes in people’s faces as they’re talking that I can then bring into the room… Like there’s just… the awareness is greater… And I think a lot of it is, I just take up less space… and, I’m a better therapist 95 when I’m taking up less space… So when that part of me is really quiet and I am just there and I can really trust the process… the connection is gonna be more likely. Jack also talked about being able to have a sense of what is going on for clients as something that he feels or is aware of based on his observation. I’m just paying attention to the microexpressions that they have… or the emotion that is… coming up for them… yah… I’m not… it’s not like I’m tuning in to how I feel (pointing to self) about that… as much as I’m tuning into… the impact that this is having… So I guess I’m really focused… and in touch with… what’s happening… and that’s probably part of the excitement… because it’s like… oh this is … it’s that forward… moving forward. Metacognitions direct therapeutic focus Therapeutic presence included the capacity to be fully focused on the client in the room, and went beyond this to include the awareness of where to direct the therapy. It was described as an “easy” and “relaxed” focus with awareness of little metacognitions that might provide direction for where to go next with the client. Participants suggested that it “just felt right,” or it was just happening. Kerrie said, The words that come to mind quickly are ease… it’s more easeful… It’s not work… it just feels….right…. Like it’s two-fold… firstly, what I’m getting from the client and then I’m feeling engagement, or good eye contact… if they’re struggling with something … they could be sitting there crying or whatever, but if there’s a feeling of connection… I don’t know if I can put into words exactly, what that is… the feeling in me is…. I’m not even thinking about it… it’s just this natural thing that happens. There’s not effort (with emphasis). I’m not getting sidetracked by any thoughts like, ‘Oh gosh, this isn’t going anywhere’…or … ‘I don’t know where to go next.’ It just is happening. This focus was reflexive and responsive and increased the sense of aliveness, excitement, and meaning fulfillment of the therapist in the moment. One participant, 96 Kirk, said, “I’m not going to say it’s without effort, because I do have to make choices, but it is almost effortless.” It seems that during these moments of high attunement, the relationship with the client is supporting the work. Kirk said, I’m totally zoned in… there is no… it almost requires no effort to… it’s kind of that flow state… and so, ummm… I don’t always use the clipboard because I’ve gotten to a point where I really feel like, in a synergy with the clients. And, in that regard… the content of what they’re saying, but also the process and the relationship and my own feelings and bodily sensations and all the rest … and I love that place. I cherish it so much. And I don’t get it all the time, but the feeling I would describe is just a synergy …. The flow… it aalllmost (stretching out the word) feels effortless…. Where things kind of flow naturally… but, I wouldn’t fully say that… effortlessly, because there’s, you know, whether it’s conscious or unconscious, there is some sort of thought that’s going into, at least the delivery of how I say something… or sometimes, like, if the client talks about like four things in one disclosure… I have to pick and choose like where to go with that. Jack and Lynn also described feeling excitement during these moments. It seemed that therapy during these moments felt like an interaction in which both the client and the therapist was working and moving in a desired direction. Jack said, I feel excited that things are going well… in a way that feels like… umm… that they’re gonna be healed in some way… or that they have a new perspective on … that’s going to allow them to move forward… or even… that they… just… feel like they have a space where they can express themselves fully… be themselves fully… those moments … they feel exciting for me because it feels like… this is gonna be helpful for this person. And, Lynn described it as follows: I try to gauge like the different level of effectiveness or if I think like good therapy is happening – I think there’s more excitement… because I think in general I don’t consider myself to be a super active therapist in the room, but I notice whenever I have a really strong connection with a client, I think we’re both more active…. Ummm and present… and I feel more attuned to what they’re sharing, vs. clients who… interpersonally are difficult to connect with or they’re sort of absent, or they’re not really in the room. I think too there is an element of curiosity ummmm…. Wherein I think as a therapist I bring curiosity into most of my sessions, but I don’t 97 always find that clients bring in like a similar level of curiosity… so, don’t know, I think a lot of it is matching… like sitting with people who … yah can bring in a similar level of curiosity and can… show up…. and be engaged …And I think those sessions go a lot faster and um yah… I notice myself feeling more excited for those sessions and less depleted afterwards… I think those sessions tend to feel more energizing. In these moments, the therapist, the client, and the relationship seem to all be working together to create a synergistic flow that is experienced as “good therapy.” For example, Jasmine described, Yah, in that moment, I’m just more relaxed… yah… I’m more in tune… to …. More in tune to my feelings… and my client’s feelings at the time I just have this ‘a-ha’ I wish I could explain… it’s not my a-ha… it’s their a-ha…. I’m just voicing it I don’t know… mmmm…. feels connected… feels spiritual…. There’s awareness… There’s not just one word. Therapeutic engagement feels spiritual, or energetically charged Participants frequently referred to a surreal feeling when they were providing quality therapy. This synergetic connection with clients was described as magic, energetic, etc. Mike also tried to describe something ineffable in the room. He said, With some people it feels like there is a thickness in the room… and I believe there is some kind of energy, and I am leaning more and more toward saying that it’s love or god or angels, and I don’t mean any of those literally, by those words, other than there is something in the room other than me and the person… and it’s not magical. I can’t… I wish I had a word. It feels pretty profound and it’s just very spiritual. It’s a spiritual connection and there’s the stuff… you know I feel honored… and I might go to those places where, it feels like that… and I feel very respectful… and I don’t think I do therapy like a lot of people – I immerse myself very deeply – I’m not just a listen and nod guy. I, I will do that, if that’s what the person wants… but I think more happens if we connect more deeply… and it’s not through… me talking about myself. It’s more me inserting myself into the experience with the person…. Like noticing their body… do they squinch their face up? Do they breathe differently? I will notice that and name it … so that they experience, ‘I am really with you… noticing everything that’s going on with you’… and with more… more than just the two of us. It sounds shamanistic 98 sometimes… especially group stuff. Kerrie’s description was closer to trying to describe emotions, It is ummm, I guess it’s almost a spiritual piece if you will, when you say to somebody, ‘Well, what’s your gut feeling?’ or I always say it as, ‘How do you know you love somebody?’ Yah, there are things they do for you, and that you do for them, but it’s something bigger than that… it’s a sense, it’s a feeling, it’s an energy… so I don’t think there are exact words, but when it happens you know it. Therapeutic attunement is connected to embodiment. As described previously, each element is connected to the others. Still, there are some that are so interwoven that they are difficult at times to differentiate. The following excerpts from Jack, Amy, and Lisa’s interviews provide examples of connections between attunement and embodiment. Jack said, What am I experiencing (hand to chest) and… mostly it’s the feeling of being tuned in … and a little bit (hand up beside head) of thinking… thinking about… where do we go next with this? And how do we give enough time to the emotion? Sort of deepen the emotion (using hands together in a rhythm) and just that kind of process thinking about … ummm… what’s going to be helpful … next… but mostly… it’s that… tuned in [yah] yah… and certainly the moments that… get you to that space… for me feel like… everything else is tuned out… and I’m just… present with the client. With a similar gesture, Amy said, It’s almost like I feel a connection in the center of my chest… (placing finger tips on sternum) So, it’s like there is the sense that something that is between my client and myself that is right here (5 fingertips gathered on sternum) and ummm… I don’t have a ton of awareness about what is going on, like outside the door. I sit down… they’re in front of me and there’s this… shared sense feeling or feltness between us and ummm… It almost feels separate from the world like the World with a big W and it feels very intimate…. And words are coming like… it feels like alignment… there’s probably mirroring… I’ll have the sense of emotion… like if they are tearful, I will find myself tearful too. And Lisa said, 99 I would say that one of the things I am really present to is my own capacity to focus … I think that would tell me that something’s going on, but, in terms of when therapy is happening… there are many body cues too… that occur… so… for example… I will notice affect in my body … I will notice even, physical reactions… particularly, like if tears come to my eyes… you know…that’s kind of one of the main things that will happen when I think someone is doing some really powerful work and… or having an a-ha moment, or something like that ummm… yah. Theme 3: “Embodiment: Contextual Self” Therapeutic presence is associated with embodiment. Where attunement as therapeutic presence might be connected to the little metacognitions that are happening during therapy, the body is the tool or the refined instrument through which all of the information is gathered and forms another facet of attunement. Although it is an oversimplification, the brain is part of the body. Therefore, therapeutic attunement might be described as the mind of an embodied therapy. This brings us to the element most closely associated to the physical body of the therapist. Lisa described, “I bring myself as an embodied therapist to the hour. Staying present to what is happening in the moment within the somatic, including sensations, body inhabitation, biological needs, and the physical and visceral experiences of emotion.” Body cues Many other participants described interactions of the body that afforded them information about client affect. Many participants talked about following cues within their body to tune into themselves and their clients. During the interview, Lisa described, Body cues too, can occur, I will notice affect in my body, physical reactions. The deeper I can embody myself and really stay in tune with what’s happening … ummm breath, affect, sensations that go along with 100 affect … how my vision is working – am I more in a widened peripheral field vs. a very elliptical field or a focused one – those can be clues… But I’ve spent so many years really committing myself to my own embodiment and I’m bringing myself as an embodied therapist to the hour that I would say that’s absolutely key within the therapeutic domain. In terms of when therapy is happening… there are many body cues too.. [that] can occur… so… for example… I will notice affect in my body … I will notice even physical reactions… particularly, like if tears come to my eyes… you know…that’s kind of one of the main things that will happen when I think someone is doing some really powerful work. Lisa specializes in somatic therapy and so describes much of her attunement as embodiment. Other participants, such as Jasmine, described her body cue as a subtle indicator as well. For example, Jasmine said that when she relaxed into her therapeutic presence, “I have less of a half smile.” This was differentiated, she said, from other times. “I always have a half-smile… sometimes when I’m irritated with the person… I don’t know how to explain that.” Jasmine’s smile cued her into times when she felt a client was experiencing healing. She said, “Yah, in that moment, I’m just more relaxed yah.” Jack summarized the interaction between his feeling body, his mental activities, and the connection with the client that contained the experience and differentiated the rest of the world, when he said, … what am I experiencing (bringing his hand to his chest)… mostly it’s the feeling of being tuned in … and a little bit (moving hand up beside his head) of thinking… thinking about… where do we go next with this? And how do we give enough time to the emotion… to sort of deepen the emotion (sweeping hands together in a rhythm) and just that kind of process thinking about … ummm… what’s going to be helpful … next… but mostly… it’s that… tuned in [yah] yah… and certainly the moments that… get you to that space… for me feel like… everything else (made space with his hands – spread out to the room) is tuned out… and I’m just… present with the client. 101 Authentic presence through body The body is perhaps the most constant informant of the capacity for the provision of therapy and a critical tool for therapeutic work. The embodied self is the element of connection to the genuine self during the provision of therapy and cues therapists into attuned, therapeutic presence. The body is connected to therapeutic presence as the body is not able to go into the future or the past, as the imagination can. The body also remains authentic – holds its shape – and keeps therapists connected to their authentic selves. Kerrie, Amy, and Lynn all described this as being an important element of caring for themselves during sessions while tuning into their clients. Kerrie talked about bringing her authentic self into the room as an aspect of caring for herself while caring for her clients. She said, Another thing that I do that I think is self-care… um… it’s the way I have always done it and there are probably people who would disagree, but I definitely bring my genuine self into the moment… Like … I’m … if this makes sense… I’m not playing a role… like this right here… I’m not playing a role… what you see is what you get…When I show up, I’m a person. Putting myself first. I’m not playing a role. I bring my genuine self to the moment. This brings me right into whatever needs to happen. I can’t help without bringing myself. Amy said simply, One of the things that I do… (long pause)… and I think that some of it is how … how I sit, and how I am open… and… I don’t know… I bring who I am into the room and I am not trying to be something else other than … than me. Lynn talked about the incorporation of herself into therapy: Not even necessarily about personal details or facts… but like, bringing my own feelings or thoughts into the moment and sharing them in a way that is intentional, but also, similarly vulnerable like on my side… it feels like, risky… in a place where… Yah, we ask clients to show up and be vulnerable and open and raw and …having like a social justice perspective in my work … I think the power differential is inevitable, but I think as a human, I can show up in a way that is inviting and kind of meets them in this place where we can do good work…Typically it’s just 102 a cognitive like check in… like just really checking cognitively and with my body. Lisa described her authentic self-interaction as follows, I deeply embody myself and really stay in tune with what’s happening. Really listening to my own body… paying attention to my own body… paying attention to the feelings that I’m having as I’m sitting with a person… But then there’s all these things that you’re doing outside the therapeutic interaction that help make it possible so you can do the listening while you are in it. And delightedly, Mike said, “Yah, yah, yah – I’m always having my own experience,” as he talked about bringing his authentic self into his sessions. Embodied therapy A powerful element that surfaced during the interviews was the self as the healer. Participants described this in a variety of ways. Descriptions that were provided by Mike in relationship to his therapy were particularly opaque and intriguing. He said, [It’s] like there’s something moving through me… like sometimes you hear a musician talk about something moving through them… it doesn’t come from them but it moves through them…. That’s what it feels like to me sometimes… I have a real spiritual bent to how I experience the world… and I’ve had some pretty intense experiences that you can’t measure or explain real well… so I don’t share it too often… but some of that kind of stuff happens … sounds shamanistic sometimes. Mike went on to describe, I connect to this, guy, who came to me in a vision… I can see him right now… I can picture his face and his body and his lumpy oldness… There’s a wolf that sits on top of my head and its chin is on my head… and they’re just in my body now. Kirk described his experience of engaging with healing in a way that almost overwhelms him as follows, It requires a little bit of thought, because I need to reign it in… I can get 103 excited and lose, sort of… inhibitions… and so I have to like, check myself, ground myself, breathe…and uh… I can generally sense when that’s happening, though… It usually happens when I get that synergistic feeling, when that sort of comes together… so I guess in a way I get excitable… and I guess I can lose sort of this… this like superego… or this ummm… I don’t know. The extent that I’m trying to like stay in it and stay controlled and stay focused. Sometimes I—I don’t know… Sometimes I lose that and I need to like, reign it in. Consistently, Jasmine used the fewest words to describe the profundity of therapy. My body is my instrument… and my therapy is my art… in order to keep your art “good” you gotta continue to… nurture it and hold it and… that’s what I do I think… yah… that’s what I do, I listen… I listen to my body. Body as the contextual microcosm Therapists’ bodies hold boundaries parallel to the way their offices and practices hold boundaries. As therapeutic context creates boundaries around the therapeutic environment, it seems that embodiment, or therapist’s awareness of their physical experience, helps to create boundaries with regard to attunement. In this way, the body is the contextual microcosm, within the contextual macrocosm of therapist’s office or practice. The therapist’s body functions to provide boundaries, differentiations, clarification of transference, etc. As previously referenced, Jasmine’s illustration of the parallel was stated concisely, “My office is an extension of my body.” Differentiation Kirk also described taking care of his body between sessions through repetitive movements such as dancing and “makeshift yoga,” which helps him differentiate through physical awareness and through moving his body. He said, 104 I can feel how free I am, or how loose my body is based on, like, the way my body is operating when I do those things… Being able to know myself and what I am feeling and having ownership of that and know that is and can be different than what others are feeling – I used to take it on. I would carry things home with me and it would stick with me in my dreams. Kirk described, Physical activity has helped me get in touch with my body and has helped me understand what my reactions are from a human standpoint…That ownership… and that self-awareness that leads to the ownership, really helps me. It really helps me. Kerrie described, Being… ummm . … grounded and present in my body…. And having the ability to … [be present]. This is something that I had to learn to be… how can I be ummm… here for a client… right… so… sometimes we have to be an extension for them – holding things (hands in cup shape) at least in the moment of the session… How can I do that and also… be present in my own body… noticing what I might need in that moment. She further explained differentiating statements for herself: I found the space to … do that like um, ‘Ok… that’s not mine to take with me… I can leave it here.’ Or ummm… and this sounds a little more flippant… and I don’t mean it that way but it works in my head, ‘It’s not my problem’ you know like, Whatever is happening here, that I’m assisting with, isn’t mine. Lynn talked about noticing that when she is chronically stressed at the agency she experiences neck and back spasms. Through her own therapy, she has become aware that her body gives her cues about her own processes during therapy. Lynn reported the belief that countertransference exists in every interaction. Therapy helps her to remember, “This is the thing that comes up for me sometimes,” and this embodied response helps her to differentiate from her client’s experience. 105 Clarifications Clear perception of the self through body cues helped participants to incorporate internal sensations to understand transference. The body is the instrument that measures connection, empathy, and can at times be over-identified with client material. The body is vulnerable. Our visceral responses to old wounds are held in our bodies (Van der Kolk, 2014; Levine, 2007). Mike described an experience with countertransference: You feel it in your body and you just say something… like it comes out before there’s any kind of [thought] and it’s jarring… but leaving my body … the spirituality stuff… those things have impacted me a lot… because I see stuff more than those just sitting in front of me. Mike talked about using LSD and working with shaman to engage with experiences of leaving his body. These processes have allowed him to heal so that he is less likely to have experiences such as that described above. Kerrie elaborated on her inner inquiry with regard to her body’s intense reactions as follows: Where am I feeling that… when the trigger comes up… I don’t know exactly, but there’s pretty certainly somewhere that I’m feeling. It’s not just a thinking thing, it’s like a visceral, physical, sensation, and I do believe that tuning into physical sensations, sometimes gives us way more information than tuning into the thinking brain… what does it feel like to feel grounded? Like some people wouldn’t even know what that meant and it really is physical… like it’s really a solid feeling… that happens here (touches her sternum and moves hand up and down) vs. swimming up in my head (swirling her hand, index finger pointing around her head) so right now I am way more physically grounded than all that’s happening from the neck up (uses hands to emphasize the cutoff) like in my thinking brain… in my emotion center …. The amygdala is firing and firing away and not being able to be … to just, settle down (uses hands in a downward wave motion) and that’s part of self-care for me too. It’s having that awareness, being able to breathe. There were so many times in my younger life when I was doing what I needed to do… you know what I was supposed to do… yet, dealing with the anxiety in my body… like heart racing or… and just brushing it aside. 106 Body reflects vulnerability When the needs of the body are consistently ignored, the body will gradually experience disease or discomfort, and eventually chronic problems that may significantly impact one’s capacity to provide quality therapy. Two participants who experience chronic illness spoke to this specifically. Kerri stated her belief as follows: We can’t connect if we are not taking care of ourselves because our body is an amazing thing that’s going to make sure that we’re paying attention to things, at least when things get serious. If we could learn to be more in touch with our bodies prior to things having to get… you know… to big levels… then even our relationships are gonna be better. And Lisa said, I couldn’t do all that I had been doing. So, I had muscular issues… so the reason I have a wing back chair is because I can only hold my head neck and spine for so long… so that’s kind of the ‘raw data’… so I had to change my whole set up… I had to eliminate my commute… and I cut my practice into a third…and the last thing to go was actually my energy… But your mitochondria are making energy for you that is burned whether you are burning mental energy, emotional energy, physical energy…. It’s all the same… to your mitochondria at that point it was sheer mitochondrial dysfunction…. That is not… you know. She further described that the body gives clues. “Whether you are ill or not paying attention to what is optimal for the human creature that you are.” Kirk described a recent growing awareness of the impact of providing therapy on his body, specifically when working with clients who have experienced trauma. Kirk said, I could go into all sorts of reasons why that became important to me, but the short of it is, I recognized … I started having physical ailments… that were due to being ‘locked up’ and that wasn’t cool. And I felt like… I was a 60 year old in a 30 something body for a while. And that just was not cool with me… especially having a kid … 18 months ago. Michelle explained that as her body ages, therapy is harder on her body, sitting for 107 long periods of time while holding intense emotions and stories of her clients has led to aching shoulders. She goes to physical therapy and practices yoga, and she reports that movement helps her to reset. You start to get tired and fatigued, and it’s too much. You don’t want to be sitting around… too much…. But ideally…. Especially as I’m getting older… like I’m having some issues with my neck and shoulder … and so … sitting… for that many hours in a row… I actually have gone to physical therapy and that is one of the things she has said, it would be better… say … if I would see three, if I would have a break… it would be like...I’m starting fresh ... it’s like being able to take a break… and do other things and… like I said, especially if I can leave….. like here, there is [a] park and like, if it’s decent weather you know, sometimes I’ll go and walk around outside…. And I’m like… ok. Ok… it’s sort of like, I let go of the energy of the people I’ve already seen… and like…reconnect with myself. Kirk talked about addressing interpersonal vulnerability through journaling: I’ve always journaled. I just journaled a ton more… to almost, an infinite level with no bounds, I don’t know … in my 20s… it was great… I have all the journals, like hand-written, like, I love them… it’s, it’s me… It’s cool, and I love it … and it influenced how I go about things now… But now there’s like… It feels like, there’s a beginning and an end to it. There’s a restful breaking point… that I can put the pad down and say, ‘I’m good for now’… uhhhmmmm, before it was like, I was doing it as if there was an addiction, or a need… that like if I wasn’t gonna journal, I was gonna sink… I was gonna free fall, and ummm, be too consumed and distracted in life, so I needed to purge it, but there was no end to the purge… It was like uhh… bionic purge… perpetual purge… but now the concept of enough has really come into play … so journaling has changed it’s form over the years for me… Physical activity has helped me get in touch with my body… has helped me understand, like, what my reactions are ummm from a physical standpoint. Body interacts with responsiveness Finally, the body reflects vulnerability and interacts with responsiveness – alerting therapists to needs. The body has the capacity to distract and is also the path to ease and a sense of being grounded. Participants described that when they were 108 disconnected from their bodies, either unconsciously or through a misappraisal of needs, their bodies would give them feedback. Kerrie described wondering what her early experiences would have been like: I think if I had really paid attention to it… maybe I really needed four deep breaths… and the whole thing would have just felt way different… then I could have been way more present. She continued to describe her belief, saying, “We can’t connect if we are not taking care of ourselves because our body is an amazing thing that’s going to make sure that we’re paying attention to things, at least when things get serious, right? Like it’s gonna distract you if you have to pee… Like it’s gonna keep doing it…. and you know if we could learn to be more in touch with our bodies, prior to things having to get… you know… to big levels…. Then even our relationships … are gonna be better. Lisa reported that even at the worst times before diagnosis, she needed to move as much as possible. She reported that being with the equines was powerfully healing for her body. During this time, she described that she had to move as much, or little, as she could, and that being close to horses, with limbic systems that are much larger than ours, was incredibly therapeutic for her. She described the equine as the facilitator of her healing. She reported deep awareness and connection with her body, which increased her capacity to focus. She described that movement was great for her body. Michelle talked about her experiences, saying, Releasing something that is maybe set on your shoulders, by your clients or something -- yesssss (long audible sigh) that’s it… and I ….. one way I can describe it is…. That a yoga teacher that I’ve gone to has talked about….when she does… uh …. Yoga with trauma survivors …. Or has facilitated a retreat where there’s been a lot of emotion… and then she’ll actually do physical movement…and kinda…like… shake it off... yah… like stomp her feet… and shake her arms… and kinda [moving her hands and shaking them with a very expressive face] And I have done that sometimes… and it’s…. that’s …it’s embodied … shifts… physically like, move …. and I need …I’m gonna do that … and then….see if that makes a difference. Hoa takes care of her body throughout the day: 109 Because I’m here… I’m in here 7 hours a day… so for me, it had to be comfortable, so I found things that were comfortable for me… I also… I have snacks in here. I have lots of snacks, like nuts, I have nuts, pistachios, I have wasabi beans, I have walnuts. So these are all mine. This is my personal stash …um… so this is just, fuel, right, I need fuel. I’m here… 7 hours. Body interacts with responsiveness through being receptive to self-care Hoa described engaging with her body through working in her garden. She explained, I garden… I do a ton of gardening… that is where I get to be present… I feel (hands churning in front of her) the dirt, I smell, I smell the dirt,(lifting her hands to her face) and I feel the pulling of the weeds (hands make the action) so that is where I am able to take care of myself and be present. It allows me to (hand on her heart) ummm… be who I want to be… it allows me to take care of things that I want to take care of… Ummm the other parts of me are allowed to be… I, I guess (smiling and looking up). Lynn talked about care for herself in the following ways: Like the very literal things of just like taking care of your body… like taking a bath or using essential oils or face masks or digging out a sweater that’s super cozy and just comforting… like I think … I don’t know…. I think I’m really activated by like… all of my senses… and incorporate that into soothing myself or like re-energizing myself… to some degree… I think …so… I tend to wear more colors if I feel depleted… or if I’m feeling… like… I’m in jeans right now and it’s not Friday so sometimes I just feel like rebellious… and it’s very intentional if I wear jeans and it’s not Friday … it usually … I think today I was opposing having to come back to work after the holiday and being off for several days… and so sometimes I act out my feelings through my clothing choices too. 110 Theme 4: “Vulnerability: Unique History” Participants described a variety of self-care activities in which they engaged on a regular basis as preventive or prophylactic to keep them at their best. They described a variety of contexts in which they learned, through trial and error and sometimes through supervision, to access self-care in order to create space for vulnerable parts of themselves that are consistently exposed while providing therapy. Frequently participants described, to varying degrees, learning to engage in their specific activities due to difficult life experiences that indicated a need. Many described their self-care activities as absolutely necessary to providing good therapy. Wound that attracts therapists to profession In the literature review, I described that therapists are often people who have higher than normal rates of childhood trauma and history of family dysfunction and may have higher than normal incidence of psychological distress than individuals in other professions (Elliott & Guy, 1993; Nikcevic, Kramolisova-Advani, & Spaca, 2007). Some research suggests that these types of life experiences may draw individuals to work in this field (Guy, 1987). During interviews and during the explicitation of the data, it became clear that vulnerability was connected to providing therapy among participants. Although this study was not set up to explore this relationship, participants described an inexplicable draw to engage in therapy that exposed vulnerability, and lead to insatiable curiosity. Frequently, participants would describe that the boundaries they had to draw in therapy were associated with vulnerability based on their unique history. In relationship to this, Hoa 111 described, I still do some, but not many… psychological evaluations. I used to do some … but what I found is that, that’s when I take it home … and I can’t leave it. I have learned, another way to take care of myself, is don’t take any work that I can’t leave here.” Hoa explained, “that is… (pause)… work that is… umm… meaningful in terms of… I’m an emigrant… and some of them are about refugees and I was a refugee… and so, these things … they’re important to me... and so, in some ways… it’s like…giving back… and it’s also about helping me and so I will do that kind of work but… I still won’t do very many of them because its… because I take it home. For Hoa, this vulnerability prevents her from maintaining the boundaries that she sees as integral for her self-care. Kirk described being raised by a single mother and feeling that he was triangulated in the relationship between his mother and his absent father. He described that as he began to engage in therapeutic work it overwhelmed his ability to engage in self-care. He described that individuating and differentiating from his mom cleared things in such a way that he was able to differentiate from clients as well. Kirk said, My survival… now…. [is] not contingent on me sharing the same views, feelings, etc. as my mom… That was probably single-handedly the biggest influence, the biggest factor in yah.. being able to know myself and what I am feeling and having ownership of that … and know that that is and can be… different than what others are feeling … before that I used to just take on what others were feeling, like right away, (flicks his fingers) like right away, like a sponge.… I used to just get swept away by the emotion and, as a result … I felt more limited in the kind of work I could do, because I felt like I was… I don’t know … it was going to affect me too much, and I experienced things too intensely and it blurred my objectivity. Through his work to heal his unique vulnerability, Kirk saw In a moment of clarity... this isn’t even about me. This isn’t my life. I’m not them… but I was taking things in in a way that overloaded, that overwhelmed my capacity for self-care. Another participant, Mike, described a history of drug abuse. He talked about how 112 his unique history opened him up to being better able to sit with people in therapy and to really connect in ways that he described as spiritual. He explained, I think that I was tremendously impacted by taking LSD, actually, and … people have said that I’m different … and I lost myself in it… but, I…something changed in me, too. And there is this like psychic experience that you have…. That uh… there’s something to it… it wasn’t just a drug experience… there’s more that happened and I … have left my body with a healer a few times… I found my dad dead… I was with my mom when she breathed her last breath… and with [my wife’s] mom when she breathed her last breath… I was sexually abused…. I was a great athlete…. A pretty good guitar player…. So all those things, kind of ummm… impact my human-ness and ummm… they’ve all made me very wise… aaaagh…. I feel like I’m pretty wise at this point. Concerns about competency Several participants talked broadly regarding worry about competency at different stages in their development. Some talked about times when they had too many or too few clients and felt that they were not “real therapists.” Amy described, A lot of it …is… the things that I would do that support me…and umm… of… like owning my legitimacy as a therapist because that is something that I always struggle with … am I just a fraud?… is this just a waste of people’s time and money?” She talked about continually seeking training to satisfy her insecurity and the idea that her self-care activities serve to “reassure the part of me that worries that I am a fraud… as far as knowing what I’m doing… so in that way… that voice can be a little quiet … because… [another voice says], “You’ve done these things Amy… you’re not a fraud,”… So if that voice can be a little quieter… like if I can throw it a bone… then who I am innately as a person… is good at this. Jack said, I cannot even imagine having a clinical case load of 25 clients … For me, that would be, way too much, and I don’t think I could be present for clients in that way. With that said, I am seeing, probably 5 or 6 clients a week, which honestly feels like too few, for me, to like, be, really sharp with my therapy skills. I don’t know if that’s true or not, but it feels like there’s some kind of balance. For me… about ten clients a week… feels like, ‘Ok, I’m a therapist, doing therapy,’ you know… and it’s not too 113 much… it’s not exhausting… it’s not too much trauma… but it’s not too few either. Health, maintenance, and crisis Several participants described experiences related to burnout and health crises. Lisa explained, I started to have health difficulties about a decade ago and they went undiagnosed for about 7 years…. In those 7 years, ummm… I really… descended to a point where I didn’t have a great deal of functionality. Due to a combination of an immune disease and a tic bite, Lisa downsized her practice significantly, I had to like… make my work very small… and I … I was thinking maybe … should I apply for disability… but you know… there is something so tenacious in me… that, I was like, I just don’t want to give up … to being completely marginalized and disabled… so if I can continue to do this and make sure that I am really honest with ‘how present am I’ for this very pared down practice…. Then, I’m going to try that first. And, in relationship to making decisions about work, I couldn’t in good conscience…. See people when I’m that sick and … I mean I just couldn’t handle the load… so I had to really listen then too. One of the ways that Jasmine maintains her health is by avoiding the news and some awareness of social context. She described that her wife provides a filter for her with regard to information associated with politics and racism in the United States. Jasmine explained making choices to protect her health: It’s harmful for me … it’ll… eventually it would kill me… I think ummm… being a black woman… being a black person… I have my own, intergenerational traumas. Part of that trauma is being susceptible to certain diseases – heart disease, high cholesterol – I already have controlled type 2 diabetes. I just choose not to… not to be filled with hate… with anger like that. Kerrie also talked about a health crisis, although she provided fewer details. She 114 described that she found yoga after a health crisis and burnout after 5 years working in a women’s trauma program. Kerrie said, It was a very different schedule than I have now, but that’s purposeful… It was a full time job. You know, more than 40 hours a week… with paperwork…. And then I had family…. Well, I still have family… but there were more requirements with the children, yah, the children were younger… so I didn’t perceive that I had extra time, or I wouldn’t take that extra time for myself… I was working that much… I mean it was… during that time period I had started a private practice… while I was working a full time job… At that point in my life I wasn’t in a place where I could envision what [self-care] would look like … or even ask myself the question: what are you doing here? I don’t think it even occurred to me. She explained that during the time when she was just getting through supervision for licensure she did not have a vision of ways she could care for herself. That’s how a lot of people live life… we get tunnel vision… and we can’t see outside of the box… what anything could look like… so I was very much in that place… which I think was connected to the burnout… right, so like…. You can’t even see what you need… I was doing what I needed to do (hands marching)… and wasn’t saving anything for myself, because anything I had, I was giving to clients. The burnout that Kerrie described comes with a level of tunnel vision that prevents individuals from thinking flexibly and imagining possibilities of personal wellness. However, it is important to maintain awareness that this is part of an ongoing task in the work of therapy. Many participants explained, that being a therapist is difficult, isolative, trauma-exposed work. Amy said, There’s just so many parts of being a therapist that are… hard… because… I, you know, it’s only me… and the person…that are in the room… so I know… there are all sorts of parts of myself that I don’t know… that I’m not going to be aware of… that I need to be… that are likely … getting in the way and get in the way with some people and don’t get in the way with others… And there’s also all of this… how do I define the work that I do? … What is 115 my theoretical orientation? There’s all this almost, like… pressure to have that really well defined… I’m always like … that’s not me… am I still doing a good job? You know… so I think that’s just the nature of the work… and umm… the part that… when I’m not able to establish that sense of connection with clients… what should I do? And Michelle said, That is what we do… as therapists. I don’t… talk about my own experience and what that’s like… with other therapists… You can’t really know it, unless you do it… It’s a very unique kind of work ... and because, we’re primarily in session with just our clients… no one else… I mean, we don’t have peers that experience what we’re experiencing… Like say you’re in the medical profession… a nurse, a physician, what have you… I mean, that’s very hard work, in a different kind of way, and, you have people that are part of it with you.. on a daily basis typically… that you can… even if you don’t talk about … I mean ideally you would share some of your experiences, but you know you’re not alone…. I never really thought about that, until, we’re talking right now… how we do our work… for the most part… it’s us, and our clients… even if it’s a group…. I mean, sometimes you co-facilitate, but… I do my group by myself….. so nobody else shares my experience. And, I’m connected to myself…. Because in my work… I’m really not connected to anyone other…. Except my clients – I don’t have peers that are doing the work [I’m] doing …. And you know… not that exact work… they’re not seeing that client, in that moment, having that experience. Just like the body, relationships are both supportive to therapists, and they are distracting. Therapists who are parents talked about being distracted by worries about their children, and therapists in relationships talked both about being supported by their partners and the difficulty of being distracted when their relationships were out of balance. Amy explained that when she was present in therapy, There isn’t like a tug into those other parts of my life, like there’s, you know, a child who is taking the bus and so I’m wondering whether they made the bus and are they getting where they need to go? So there’s not that sense of those other things that I’m tied to in the world… like those 116 pieces are relatively quiet. Hoa said, when she worked later hours at her private practice, I wasn’t able to be present. I wonder what the kids are doing. I wonder… umm… you know…. I should… I want to be at whatever it is that they’re at… so… umm… or I was like rushing home. You know… yah… and like, being done with the session even before the session’s done, because I need to be at this… because it’s not fair… to whoever I’m seeing, you know… and it just wasn’t working for me. Kerrie also described that anytime something was going on with her kids it was distracting and Michelle described, Because I have my son, and my family…. I like to just come and … do my work… and then just go. Which ends up sometimes I’m seeing, more than five… I once, like, the most I saw was 10 in a row I do not know how I did that, and I do not recommend it…. But I did it (emphasis on did it). It would be better if I took a few minutes during sessions and did that … and this is making me reflect… That’s for… you know, the people that you’re interviewing (referring to our conversation of the benefit for participants)… even if I just took … you know 30 seconds and just you know but I tend to just… go… like crank people in and out. Theme 5: “Responsiveness: Appraisal and Action” Responsiveness as a theme overarches “all the things” a therapist does to attend to their unique needs for self-care and nourishment. An important interaction is suggested by the word responsiveness. Responsiveness implies input of some nature. It implies awareness, the capacity to receive information, as well as the capacity to accurately appraise needs and to act appropriately to meet needs. Furthermore, it requires the ability to connect with others to attract and manifest necessary support from others in order to regenerate and sustain. Finally, release or discharge of excess energy is part of the action. Therefore, this is a complex, multidimensional aspect. 117 Self - attunement - awareness It would be simple enough to say therapists meditate and practice yoga. They run and engage in other forms of exercise. Therapists rely on important others and build relationships that nourish them. Therapists also need to engage in novel activities and to spend time outside in order to connect with nature and feel as though they are supported based on the isolation of their work. The complexity of understanding therapists self-care is capturing and describing the internal attunement, compassion, and sensitivity to the self that cultivates the awareness that tells therapists “what” to do to and “how” to care for themselves in a given moment. One participant, Lynn, described this as follows: It’s just kind of like a needs appraisal and like sifting through different layers of like evidence… I think that it’s not always fool-proof and that’s because sometimes I mobilize certain coping skills that aren’t what I actually need in that moment … like… for example… sometimes I might mis-appraise and I might move away from something that I actually need to move towards… and so if there is incongruence between my needs and what I’m doing to cope then I usually don’t feel rejuvenated and like I’ve been replenished in some way… usually the feeling lingers and stays with me until I listen to myself and meet my needs. It’s just like the stubborn child in me that’s like.. ‘I know you need that, but I’m gonna withhold it because I wanna do this other thing…’ and yah…. I think it can be really effective if it’s congruent and aligns with what my needs actually are in the moment and less so when they don’t. Several participants reported that they engaged in meditation and mindfulness style practices. These participants reported that their practice helped them to be more attuned to their own needs as well as being more attuned in therapy sessions. Amy said, When I am meditating regularly, especially the longer meditations… I am quieter when I am with clients… so I take up less space… and there’s more space for them… ummm…. And I notice that every time… so if I am just doing 15 minutes of meditation three or four times a week… then, not so much… but if I am doing like 30-40 minutes almost daily… there is a part of me that is a lot quieter…. Then… it’s amazing then, what I can notice… and in terms of that felt connection… I can feel the subtle parts of that more… and I notice more. 118 And Jack described it this way, I for sure think my mindfulness practice… it seems so cliché… there’s so much pop culture going on right now about… mindfulness… but I do think that… formal practice in … mindfulness helps in that… I can notice when I’m being distracted from clients and I then bring myself back to… I’m here… those… whatever other things that are coming can be handled or solved at another… time… and for this moment I’m sitting here with this… person… this client… So, I think that it helps me, one, notice that quicker when I am distracted and, two, be able to bring myself… in the moment… back with the client. Participants struggled to describe self-care routines – sometimes using terms like “every time” but then clarified that self-care is not regimented. It is more consistent with “self-attunement,” which mirrors therapeutic presence and attunement. A therapist needs to first extend their antennae and to look for what is needed. Michelle said, I do all of these things as much as I can to prevent feeling exhaustion, burnout, whatever you want to call it, and then, if I start feeling that happening, then I scan and see, ok. What? What am I missing? And then I bring it in, to recover, and it also makes me feel really good. And they’re things I do anyway. But sometimes they’re out of balance, there’s not enough. Like maybe, I’m doing my yoga and meditation but I’m not having enough alone time, or, I haven’t gotten together with friends in a while, and I need to do that. So I’m like, ok – these are the pieces that are the cornerstones of my self-care, burnout prevention, and burnout recovery. Where am I out of balance? What am I… what do I need more of? The important consideration is that what is needed is not always the same. For example, Jack stated, emphatically, “I don’t have to punish myself for [not working out today] or feel like I didn’t ‘do what I was supposed to do’ [finger quotes]. That kind of trap that takes the wellness out of it.” Other participants, Hoa and Amy suggested that their routines were more predictable and that although there are subtle differences, they benefitted from having a set plan. With that said, although self-care cannot simply be established on the calendar 119 and then enforced, time does need to be set aside for self-care. Lisa explained balance as active responsiveness when she said I think what you are getting to is that balance actually is movement... because I would never use that word in this interview had you not brought it up… not even once… because it’s more kinetic… it’s more about flow… it’s more about… you know… actually being tuned in myself enough, to know … what do I need? Is it to go riding? Is it to talk on the phone with a friend… I don’t know… is it to write a poem about what is really… I don’t know angsting me… I don’t know…. I mean… that’s… I don’t use the word balance for that reason… but I like that… you think of it differently because honestly… that’s one of the things about being on a horse, in a saddle… truly … from a person who … has been on the ground many times…” She continued, “Balance is a concept and so like… if I’m living my life by a concept, like how many hours am I going to have for this or that… I’m not going to have any time … and it’s… it’s gonna be stressful… so it’s more like…oooohhh…. I feel like I’ve been doing one thing a lot and I want to do another thing… so, I’ve been riding a lot… and I’ve been working on my riding goals… but I really just need to like, hang out with my girlfriends…. We need to go do something or … you know, with my partner or something like that but… to me, like I said, it’s just about being in tune… it’s just about listening – you know there might be hungers… so, oh gosh I haven’t … I’ve been feeling well…. So I haven’t really sat down and read… like a really good Shakespeare play in a while… and so… I’m gonna hunker down and do that… and I’m not going to say that like – there are a lot of hungers… and not all of them go heeded. Different participants suggested different amounts of time. Some consider an hour walk with the dog daily their self-care. Some talked about running for an hour a day. One participant, Jack, suggested that self-care took as much time as a part-time job. I’m sometimes surprised… how much actual time goes into that (hands held in quotes) “outside wellness” for me… and it… it really also means… that I have had to think about and balance… how much ambition do I want to have in work and job stuff… and how much time (again using hands as the scales of balance) do I want to spend on kind of… my own wellness… and I (shrugging shoulders) easily could have a 20 hour a week job … you know… doing something else… If I said, yah, I don’t care about meditating or exercise (checking off his fingers) or trying to prepare a healthy meal, or whatever it is, so that’s… there’s a lot of time that goes into that as well [mmhmmm]… and it means ok that’s… I’m not going to write that research paper… because I’m going for a run. 120 A final and important consideration in self-attunement and awareness is associated with unique vulnerabilities of therapists, which was discussed previously. It is human to be vulnerable and therapists have vulnerabilities. Participants identified times when they were triggered during sessions. The triggers are rooted in therapists’ vulnerability. For example, Mike described, At one point I would say a provocative things that allowed movement to happen… and I really liked that… but really, I was just acting out … it was just a re-enactment of my family stuff… pushing against, you know, an abusive father… being the guy that would say ‘no’…. getting beat up… ‘not physically ever’ but…. You know, humiliated and shamed a lot. It wasn’t like I was thoughtful before I would say things, I just didn’t … you know you just feel your body… and you just say something … like it comes out before… there’s any kind of…. It came out as more jarring. When therapists are engaged in self-care, they are more able to appraise and respond to personal triggers in-the-moment and to “set them aside” in some way. Kerrie described noticing being triggered and responding as follows: I recognize that if someone says something in the session that is causing a reaction in me… I have to kind of look at it like… what was that… like is that something that is relevant to the session… like if it happens in their life all the time then it’s going to be therapeutic… or…. Is that mine? I think it’s a trigger… because I want to make sure is if it’s something that’s mine, then I’m being triggered… if it’s something that is my own issue, then again, I will note, in my head. Put aside to look at later – because it’s mine. At this point, I asked Kerrie if she could describe this process. She stated, I think it’s just awareness… I think it’s really important to me to always be doing my own work, right, to own, you know… um… for example, I, so, there is one client I can think of that I have been seeing for years. And there are times in session when I am frustrated because there’s this resistance to any kind of suggestion or change. And I can feel that frustration and, I have to remind myself, because I’m at…. I mean, I’ve checked in with this client and asked, ‘What are you getting out of therapy? What keeps you coming back?’ I’ve also gotten supervision about it. Because in my head I’m like, I don’t know why you keeping coming to see me because, what’s changing? Is anything changing? Is 121 anything working? Ummmm… and yet… she’s getting something out of it… She keeps coming back… But it’s what’s coming up for me…. It’s like …. It’s mine…. I’m not seeing what I want to see… but it’s not mine… it’s not my process… and so… in a moment like that I can…. You know…. What’s the frustration? Well, it’s not going how I want it to go…And then at a later time, I can look at my own stuff. In relation to differentiating between her own needs and her clients needs Kerrie said, I think because it helps me, um, to do all the things … for me to be healthier and happier and to be more in touch with my body and in touch with my feelings and my thoughts and …promoting my self-care and my wellness… gives me the tools I need to manage my stuff … and my distractions and my life… outside of my role as therapist – which is only one role of many in my life. Move my body In the quote from Kerrie above, she describes how getting in touch with her body helped her to get in touch with feelings, thoughts, and self-care. Part of responsiveness for most participants was being able to attend to their bodies and to be in relationship with their body through movement, exercise, nutrition, and sensorial soothing. Kerrie described, The things that I focus on first, …like….. getting sleep… 8 or 9 hours of sleep per night. I’m very particular about how I feed my body… like what am I feeding my body… like food… social engagements… I have a good support system. My children, my friends, I practice yoga regularly…. I knit…. It’s one of my favorite things mindfulness wise. Kirk described the importance of movement: Physical activity has helped me get in touch with my body… has helped me understand, like, what my reactions are ummm from a physical standpoint…I do it in between sessions… I try to capture… the most freeflowing … arm and leg movements that I could possibly do… and I can tell how free I’m flowing. Jasmine’s description of reconnecting with her body was clear and simple enough 122 to do during her session, “I’ll take a deep breath. I’ll drink some water.” Hoa described sensory nourishment during sessions: I have scents in here… so this is the diffuser… so I just have some oils here that… I just use like, what I’m in the mood for … what I think will be healing, maybe for me that day… and like, sometimes I think about which client will be in … and I will like… put… what will be helpful… but, I like the humidity that it gives… I just have very dry skin. So, even though it’s just a tiny bit… so throughout the day I am getting some humidity in here, and I also get some smells. Beyond therapy sessions, Lisa talked about listening to her body’s need for movement in conjunction with her heart’s desires: I just was… feeling not good… so, at that point… [these two] questions kind of merged… because I needed to be doing things that would keep my body moving… to the best extent that it could… so even though I was having a lot of difficulty… and so the horses came in there… so not just… that, that… intrinsic passion… and that’s where they came from, it was really my sickest moment and before diagnosis that I … needed to do something that at least feeds me and nourishes me… and I started grooming a friend of mine’s horse… and… you know when I could… I couldn’t really lift my arms really well at that point … but… ummm… and then that turned into … I’m going to try and take a lesson… even though that’s kind of crazy… and then this… the movement of the horse… even at a walk… was enough to start to loosen the muscle contraction or move my lymphatic system and… I was like… ok… it may be insane but this is what I am going to do … and so, I went from there…I also walk my dogs every day…. To the extent that I can… sometimes it’s 10 minutes, sometimes it’s an hour… ummmm I’m very… physically… I start my day with various.. modalities… yoga, stretching… a little bit of dance if I can …. Cause I have a harder time with my muscles in the morning… and that remains true as I am kind of working a very very slow recovery. Lisa, who through chronic illness has become intimately aware of the demands of her body, explained, You know… your mitochondria are making energy for you that is burned whether you are burning mental energy, emotional energy, physical energy… whether you’re ill or not… you know… what is optimal… for the human creature that you are…a lot of therapists … they’ll have financial goals or aspirations for success… that are really fine… but 123 they’ll end up going past what those [physical] limits are and… you know. Participants talked about the need to discharge, release, or set down the energy from difficult sessions. This was particularly relevant when therapists talked about their work with clients around trauma whether acute or chronic. Although this only touches upon evidence based research that suggests that healing from trauma comes through discharging it through physical activity (Levine, 2007), participants did talk about the need to set it down in some way. Lynn described learning to process and set things down in the moment: I think when I first started therapy as the therapist I was just holding… I would hold everything… and then I would go into the next session still holding what I had just picked up in the last one and by the end of the day I just felt totally wiped… and so the idea of thriving… with that … in the moment… in the present…. en vivo processing … that helps to diffuse… like I’ve learned how to do that like… in the moment. Jasmine needed to Take a moment… take a minute… just to let go… and discharge myself… I say a prayer… give it to the angels…” She talked about taking a walk or a run and knowing who to go to “… when I need to discharge… when I need to laugh… or… [to get] the opposite feeling of whatever it was that I was feeling in the room. She also describes discharging the room, saying, That’s when I start to clean… or rearrange… like in here… or I’ll rearrange at home… like… my space isn’t right… I don’t turn things over in the session, it’s after. But sometimes I have clients turn it over in the session… or I have them turn it over to the room. Hoa said, I leave it here and I know that I’m doing well when I don’t take home with me and I don’t bring home to work I need to contain it all. Because I, it’s exactly that. That’s how I handle it. Kerrie described that therapy can leave a residue, “like you’re carrying something 124 around that you know you don’t need to carry around but yet you can’t help but carry it around,” and Lynn used the metaphor of a dirty dish: Like what if you tried to bake like a sheet cake and then brownies and the accumulation of shit… of like… and it ends up tasting horrible and … you have to soak it for a week before you can…and I think as therapists we don’t have time to like… get some good… grease fighting soap and like let something soak. Discovery: A Dynamic Process of Attunement and Personal Wellness The relationship between care for the self and quality psychotherapy may be a dynamic process of self-attunement and personal wellness. The relationship between care for the self and quality psychotherapy came through the interviews as a synergistic flow that is experienced by participants as “good therapy.” This suggests regeneration and reciprocity is part of the lived experience of therapists while providing what they describe as good therapy. It is clear that all of the participants in the study experience an embodied fulfillment through providing therapy. They experienced the provision of good therapy as “easy” and “not work.” They stated, “I love these moments” and described the moments as times when: “I am in the flow”; “It’s natural”; and “It’s just happening.” Furthermore, therapists described themselves as experiencing “excitement” and having a sense of “being good at what I do.” CHAPTER IV DISCUSSION Summary of Findings This study was an exploration of ten therapists’ experiences of providing quality therapy and the things in their lives that make it possible for them to do so. The questions guiding this research were aimed at better understanding how therapists experience and describe personal well-being and the approaches taken to achieve well-being to support their provision of therapy. Results of this study suggest that psychotherapists are involved in a dynamic interactive dance of care for themselves and care for others. Based on their descriptions, these two forms of care often seem to mirror one another. In this discussion, I will provide a further exploration and a deeper interpretation of the data, including implications, limitations, and recommendations for future research. As described previously, true to the phenomenological models I followed (Giorgi, 2012; Groenewald, 2004; Schuemann, 2014). I have taken care primarily to describe rather than to interpret the data to this point. This was done to prevent my presuppositions, assumptions, and biases from over-informing the data while reporting. However, this discussion will incorporate interpretation, reintroducing biases, and will include some degree of meaning making. It is my intent to explicitly name biases where they are conscious and to acknowledge myself in the role of an intuitive participant and as the organizing system. 126 As described by Crabtree and Miller (1999), intuitions and reflexivity work as they are engaged with the data and are the primary source of interpreting. Reflexivity has been especially critical. Connection to the Literature In the literature review, I presented a translation of psychotherapy as “healing of the soul,” based on the roots psyche and therapeia, and described psychotherapy as a dynamic, complex process that is reliant on a therapeutic relationship between a therapist and a client (Cuijpers, et al., 2008). I described psychotherapy as cognitively and interpersonally demanding work, as it demands that therapists be able to build relationships with a wide variety of people and to adapt treatment to unique client needs in real-time (Horvath, 2001). Based on the literature, I suggested that the approach of Western medicine is to treat illness rather than wellness, and that psychotherapy, which is often consistent with this medical model, has been viewed as remedial in that therapists are seeking to reduce or ameliorate distress in contrast to encouraging growth or selfimprovement (Wampold & Imel, 2015). Based on this model, I provided references suggesting that therapists are generally interacting with interpersonally challenging clients (Barnett et al., 2007). In addition to their challenging work, I provided references to studies suggesting that therapists have higher than normal rates of childhood trauma, family dysfunction, and suicidal ideation and actions (Elliott & Guy, 1993; Gilroy, Carrol, & Murray, 2002; Pope & Tabachnick, 1994). Based on this, one older study suggested that psychotherapists may see a career in mental health as a way to work through their own problems, to avoid loneliness, and to get power and control (Guy, 127 1987). I provided reference to information consolidated by professional organizations (APA, BPACCA) regarding some of the challenges psychotherapists face within the following areas: professional isolation, inadequate clinical case consultation, inadequate professional support, poor self-care, overwork, a paucity of leisure and nonwork activities, stigma within the profession for individuals who acknowledge stress or impairment, unrealistic self-expectations (rigidity), a tendency to focus on the needs of others while ignoring or minimizing their own, a tendency to neglect one’s own needs and personal problems, poor boundaries, and an imbalance in caseload/professional responsibilities (BPACCA, 2010). Based on the personal risk factors and the nature and difficulty of the work, self-care is clearly an ethical imperative. The APA ethics code highlights the need for therapists to engage in self-care and to maintain self-awareness in order to avoid harm to clients (APA, 2002). From this challenging position, I introduced the therapist as the instrument of healing in psychotherapy and suggested that the process of healing requires simultaneous self-awareness, presence with another, perspective taking of another, and personal insight (Hayes, 2014). Therapists face the challenging task of connecting with another person who is in psychological distress, in a meaningful way. The therapist strives for selfawareness, and other awareness, and must also direct attention purposefully (Grepmair, 2007; Siegel, 2010). Sometimes called attunement, this capacity in psychotherapy practice has been described as a specific and refined type of empathy that requires therapists to enter the inner world of the client while maintaining awareness of their own inner world (Baldwin, 1987; Hayes, 2014). I further described interpersonal attunement 128 as having physical elements that can be witnessed and described (Iacoboni, 2008), as well as subjective elements of felt connection (Siegel, 2010). The current study was an exploration of these elements and, through participant narratives, provides a rich description and deeper understanding for the interrelatedness of unique vulnerability, caring for the self, and the ability to build connections to provide healing spaces for clients. This study helped to fill a gap between the challenges associated with creating an optimal therapeutic environment while being a unique human, with specific histories and worldviews, and maintaining the capacity to provide therapeutic presence over time. I have described five elements interwoven in the lives of the ten therapist participants as dynamic processes based on the phenomenological holism of the data. Based on participants’ own words, during times when they are providing what they consider good therapy they are also accurately and continually appraising themselves and responding to their own unique needs. I have come to interpret this as a Dynamic Process of Attunement. Interpretation of Data To further illustrate, and for the purpose of discussion, I have organized the elements into a dynamic, multilayered process described by participants in the results section as a way to achieve and sustain personal and interpersonal attunement. This personal attunement works to enhance each participant’s capacity to provide a unique version of quality therapy. In the discussion, I provide an illustration using the Shiva Nataraj, or the Lord of the Dance, as a dynamic image and a screen upon which to project the elemental themes that emerged from the data. The reader will recognize this as the 129 image referenced in describing the methodology. In this discussion, I will use aspects of the image to illustrate the dynamic dance of the elements. The ring of fire surrounding the dancing deity captures context. Shiva’s third eye, which is at the center of his forehead, captures attunement, therapeutic presence, or moment-to-moment awareness. Shiva’s torso captures embodiment, or the body’s direct connection to all of the elements. The legs and multiple arms of Shiva capture responsiveness, which includes the capacity to appraise the needs as well as the capacity to act to meet the needs of the therapist. The demon upon which Shiva’s dance is enacted captures the unique vulnerability of the participant. The holistic dance is symbolic of regeneration, and represents the fulfillment that therapists experience through their work and the meaning they make of the same. Based on the data, the therapist never truly finds balance, but is aware of vulnerability, through the integration of the mind and the body. An ongoing process of appraisal and action that includes, and values, a loss of balance, and a regaining of balance, is represented in this dance. In Figure 4, I have used the symbolism of the Dancing Shiva as an illustrative metaphor because it is holistic, regenerative, and interconnected. It is a mirror for the phenomena I have attempted to describe herein. Using the Dancing Shiva as a backdrop, I will now provide an interpretation of the elements that emerged. An important function of phenomenology is telling the story of participants within their context and within the systems in which they are operating; but when I first entered the study, I wondered if I was missing the forest for the trees. When I began the study, I anticipated that therapists would gain a clear understanding of how self-care practices 130 Dancing Shiva Ring of Fire : Context Shiva’s Third Eye : Attunement Shiva’s Body : Embodiment Legs and Arms : Responsiveness Demon : Vulnerability Figure 4. Dancing Shiva. influenced the provision of good therapy. I thought that self-care would be related to culture, context, and various identities. I imagined that it would be preventative and would reflect health and vitality. I believed I would gain a better understanding of how therapists care for themselves in order to return to center and to hone their skills. I learned early in the process that therapists have a fairly loose understanding of their own self-care, relying heavily on intuition and a felt-sense of well-being. Although I screened for participants who identified themselves as having a regular self-care practice, participants would stumble over descriptions of meditation, exercise, setting boundaries, and other predictable “self-care” activities that might be prescribed, but they did not have 131 a crystallized sense of how it influenced their provision of good therapy. In the process of deepening the conversation around these activities, the unique personalities, vulnerabilities, and challenges of therapists began to shine through. I realized that selfcare was not only preventative, but was often a part of their personal healing journey. Therapists are people first, and people live within contexts. The ring of fire captures context, or the context within which therapy is delivered. In the figure provided, there is but one ring. However, it is a dynamic ring of fire and represents multiple layers and intersections of identities that come to bear in decisionmaking with regard to practice and self-care. Just as clients operate within multiple ecological systems, so do therapists (Bronfenbrenner, 1977). Therapist participants’ unique backgrounds influenced their choices about where and how they practice and their intersecting identities played a role in where and how they engage in therapy as well as how they engage in self-care. Sometimes they are engaged in private practice, sometimes group or a more structured clinical environment. Although there are many forms that a practice might take, there are assumptions that are made about how therapy will go and there is a structure that is informed by the context. This might be described as the room where a therapist is working, but it expands beyond this to the type of practice, boundaries that a therapist creates such as separation between work and home, and the community within which the therapy is provided. Some participants, particularly those in private practice, put a great deal of consideration into the office space and the therapeutic environment; others were subleasing offices that were furnished by other people and made the best of their situations. These individuals talked about bringing parts of themselves into the room, but not relying quite so heavily on the therapeutic space. 132 Context is also informed by the community where the therapist provides care. This includes the sociopolitical climate. Current events, including politics, election cycles, news, social media, and more were introduced as topics of personal concern and distraction during interviews. For example, Jasmine talked about creating a boundary around herself and limiting her interactions with the news. She specifically described multiple filters that she used to protect herself, physically, from painful information about police shootings of black men. She described having a filter, her partner, through which she gets her initial information. She recognized a need to have knowledge about current events in order to be responsive to her clients, but she also recognized a felt need to protect herself from “bringing all that anger and hate into her body.” Another participant talked about clients bringing news about sexual assault and misogynistic political views into therapy sessions. She talked about engaging in a community church that was more in line with her political views and created a sense of support for her in which she described “being connected to something bigger” that seemed to have her back when she was in therapy sessions. Each of these participants talked about the need to bring social context into their therapy sessions, even while recognizing a felt need to protect and support themselves and their clients from the painful reality of the circumstances. Based on these and other examples, it is clear that participants consider the inner world, the client’s inner world, and the outer – perhaps political – world as another means for understanding themselves and the interpersonal interactions between them. Included in therapeutic context and practice climate are time and boundaries. Participants described a range of time spent with clients, from 5 hours a week to 30 hours 133 a week. Some suggested minimum and maximum numbers of clients that they could see in a day or week and still feel like they were providing optimal therapy. One suggested that they thought six was a minimum for feeling like “I am a therapist, doing therapy.” Another suggested that six would be ideal, stating, “If I were independently wealthy, that is what I would do.” Due to the small number of participants, these numbers should not be over-interpreted as recommendations; rather they are recognized as parameters that individuals address when considering their own limits with regard to their provision of good therapy. Participants described boundaries differently. Some participants did not even discuss boundaries, the omission of which may indicate feeling comfortable. Two participants, Amy and Hoa, described, specifically, leaving things outside the room outside the room during therapy and distinguishing clear boundaries between work and home. Jasmine specifically stated that she does not check emails or take work home with her. She also described reading books that were not related to therapy when at home. Although they did not explicitly name differentiating work and home, both Kerrie and Michelle talked about how concerns for their children were some of the few things that were truly distracting during therapy. These had to be set down consciously before entering sessions, suggesting an implicit type of boundary. In contrast to these, other participants described thinking of their clients while on a run or while meditating – allowing clients to be a part of their distilling down of thoughts and ideas. Jack referred to this as “time to wonder” about his clients, and it was a clear interaction between personal self-care and client contact. Only one participant, Lisa, had a home practice. Her practice at home was an integral part of her self-care because she moved her practice into 134 her home when she became too ill to drive into the city to meet with her clients. Based on these participants, it is clear that boundaries are largely determined individually and serve both the therapist and the clients. “Presence is everything!” said Lisa. Shiva’s Third Eye – depicted between the eyebrows of many deities from Eastern traditions –is usually always open; it is relaxed, clear, and represents a high level of attunement, or therapeutic presence. For some therapists, this might include unconditional positive regard, but this is not necessary for presence. The capacity for being present, aware of the self and the other, and exhibiting nonjudgment, to the extent that one does not disconnect, is represented in the image of the Shiva Nataraj. The Third Eye suggests being unruffled, not distractible, and it suggests intelligence. Presence included the capacity to be fully focused on the client in the room. In the literature review, I described a specialized type of attention called attunement, which holds social engagement and self-engagement as prerequisites. Social engagement is described as a person being able to calm themselves to temper interpersonal challenges (Porges, 2009). Self-engagement is described as rooted in selfcompassion and an undefended relationship toward the self which depends upon a sense of safety (Siegel, 2010). As participants described attunement and therapeutic presence they talked clearly of ways they engage with clients using self and social engagement to regulate and engage in healing. Attunement as therapeutic presence was described as an “easy” and “relaxed” focus with awareness of metacognitions that might provide direction for where to go next with the client. This focus was reflexive and responsive and increased the sense of aliveness, excitement, and meaning fulfillment of the therapist in the moment. Kirk said, 135 “I’m not going to say it’s without effort, because I do have to make choices, but it is almost effortless.” It seems that during these moments of high attunement, the relationship with the client is carrying a great deal of the work. The “little metacognitions” described by Jack and Kirk during their interviews were clear indications of being present and tuned into their clients while also having the relaxed capacity to be thinking about the directions that needed to be taken for good therapy to be happening. As suggested by Grepmair (2007), a therapist must be both paying attention to the interaction and be directing therapy in a meaningful way. During each interview, the participant was asked to describe their experience of times when therapy was going well. This was a clear assumption that good therapy exists and that providers believe they know when it is happening. Participants gave descriptions of what they noticed about themselves and their clients during these moments. Consistently, participants reported being present as critical to this capacity. Some participants described being totally tuned in with clients and tuned out with everything outside the room. They also talked about having high awareness of what was happening with the other person. I was particularly intrigued by this concept, and I sought to understand how therapists described having awareness of the “inner world” of their clients. How does one know what is happening for another person? Particularly when the “other” is a client in therapy who may have trouble describing emotions, needs, wants, hopes, and fears. This was frequently a point upon which I would ask follow-up questions in an attempt to understand how the therapist could know what was happening for the other person. Hoa suggested that she does not notice herself in the room at all but instead is 136 paying attention only to the interaction between herself and the client. This was confusing, because I assumed that there had to be at least some limited self-awareness upon which to reflect. However, Hoa described, “I like them and they like me.” In her descriptions, her “self” in therapy existed only in the context of relationship. This turns us back to the person of the therapist. It is important to consider the culture, including communication styles and ways of interacting with others. Hoa is a Vietnamese American, and while her descriptions of therapy did contrast with other participants, my difficulty with understanding her description of knowing what her clients were feeling, with or without words to explain that knowing, is my struggle with regard to interpreting and understanding, but it was not a struggle for Hoa. Her confidence that she could know this and that it was integral to her provision of good therapy was clear. Of note, Hoa’s self-care was centered around her relationships with her husband and her children and she privileged boundaries between work and home life to a higher degree than most participants. Connected relationships were clearly core to her work and to her wellness. Shiva’s Torso captures the body as the connection and has also been described as the contextual microcosm. Within the ring of fire, which is the larger context, there is a body with its own boundaries, differentiations, clarities, etc. The body is perhaps the most constant informant of the capacity for the provision of therapy and, for many participants, is a critical tool for therapeutic work. However, even to participants who did not describe it as impactful in therapy, the body was an important access point for selfcare. Each participant described that the body could be very grounding and that it could also be completely distracting. When the needs of the body are attended to, then therapy is much easier. Kirk said, “If I know I am going to be hungry, or I am hungry, but I have 137 a plan in place for the need to be met, my body will relax and I can remain present.” Kerrie talked about how ignoring the needs of the body will gradually lead to disease, and even chronic illness. I thought of the body as an important connection point for the overall dance. The body must be attended to or it will distract the individual. If the body is attended to through appraisal and action via self-care activities on a regular basis – regular determined by vulnerability and imbalance – then the body will be most comfortable, present, and available for therapeutic attunement in the therapeutic context. When all of this is happening, we have the holistic dance, or flow and reciprocity. It is clear that in each of the themes there is interaction and interrelatedness. Although none of the themes is primary, embodiment does have the greatest emphasis, the most descriptiveness within the data, and has the greatest capacity to influence what participants described as wellbeing. The demon upon which the dance occurs captures the therapist’s vulnerability. The demon underfoot – vulnerability, woundedness, unique history – whatever way it is labeled is intriguing. I entered the study thinking that I could look at optimal performance without looking at burnout and compassion fatigue. I wanted to do this because this because research associated with well-being and optimal performance seemed to be missing, and because I was hopeful that a more optimistic view of the lived experience of providing therapy could be derived from looking through a lens of wellness. I came to more fully recognize that a bias of mine entering the study was that the focus on the disease model impedes our understanding of a wellness model. In my naïveté, I believed that this would, in fact, be more holistic. In hindsight, I see that I only wanted to see the 138 glass half full. Through the exploration of vulnerability with participants, I have learned that the glass is both half empty and half full, and it is not only because of perspective. Holistically speaking, vulnerability, or emptiness in the glass metaphor, is a critical element in the Dance. Vulnerability also seems to be a critical element in curiosity, which is essential in all forms of attunement. One must stay open, or empty, in order to provide space for new information as it comes. Participants described the importance of vulnerability in a variety of ways. Based on my screening of participants I expected to hear them name a variety of self-care strategies when I asked “What in your life allows you to provide good therapy?” I expected participants to say, “I do yoga three times a week”; “I meditate for 30 minutes every morning”; “I run”; “I spend time with friends”; “I cook”; “I shop”; etc. I did not expect therapists to describe life-changing crises. I did not expect that they would talk about difficult life experiences that both helped them understand how to provide good therapy and how to take care of themselves. This may suggest that the stress-distress continuum from the literature review could be reinterpreted as a feedback loop. When therapists are self-reflective and regularly engaging in self-care, vulnerability may function as a guide. The legs and multiple arms of Shiva captures responsiveness and can be visualized as the multiple ways that therapists attend to their unique needs for self-care and nourishment. An important interaction is suggested by the word “responsiveness.” Responsiveness implies input of some nature, in addition to the capacity to receive information and to act upon that information. Therefore, this is a multidimensional aspect. It would be simple enough to say therapists engage in physical exercise or 139 meditative practices, and they benefit from spending time with loved ones and engaging with healthy escapes. Therapists benefit from consultative groups, novel adventures and time outdoors. This may be due to the isolative nature of their work or their exposure to trauma. However, therapists have the unique experience of determining what needs to be done to renew them in a given moment. This may sometimes happen while in a session with a client and sometimes between sessions. It can be difficult to determine what is needed in these moments. Lynn explained that she does not always feel better after engaging in reliable forms of self-care. Sometimes she thinks this is due to the misappraisal of a need. Lynn described that she thinks there is a balance between escape and facing problems. Suggesting self-care is not just a regimen or a recipe. Jack explained that feeling like you have to do self-care takes the wellness out of experiences. Responsiveness, then, is more consistent with a “selfattunement” that mirrors therapeutic presence. A therapist needs to first extend antennae internally in order to look for what is needed. Michelle described this simply in the following statement: “I ask myself, ‘What am I missing?’ And then I bring that in.” Although self-care cannot simply be established on the calendar and then enforced, time does need to be set aside for self-care. Different participants suggested different amounts of time. Some consider an hour walk with the dog daily their self-care. Some talked about running for an hour a day. Jack suggested that his self-care took as much time as a part-time job. Finally, the life experiences that lead therapists to self-care are not one-time events. They include the simple awareness of hunger during a session, or the need to go to the bathroom. They also include moments of appraisal when a therapist sits in their office after a difficult session and realizes, “I have to find a way to 140 discharge.” Tuning the instrument of practice was key to good therapy. This was often described as addressing small imbalances or small problems in a thoughtful way. I came to think of this as dancing. Participants described recognizing fatigue, vulnerability or discomfort and then taking action to address that discomfort. This was directly connected to their ability to provide quality therapy. An important finding in this study is that the relationship between a therapist’s care for themself and the provision of quality psychotherapy is a dynamic process of attunement. An overarching illustration of the elemental themes suggests that the therapist never truly finds balance, but instead becomes aware of vulnerability, then assesses and responds to it in a process that includes, and values, a loss of balance, then regaining of balance, which could also be described as dancing. I chose to use Shiva’s Dance as an illustrative metaphor because it is holistic, regenerative, and interconnected. It is a mirror for the phenomena which I have attempted to describe herein. The therapist, the client, and the relationship seem to all be working together to create a synergistic flow that is experienced as “good therapy.” This was connected to moments that were regenerative for therapists. I felt similarly excited when therapists described this and then said things like “I am good at what I do” or “I am so happy to have a space to talk about this, because I never do.” Yet these moments seem to be what make their work so meaningful. I wondered about the parallel process I experienced as I witnessed their self-reflections, and I imagine this is something akin to their experiences of witnessing “a-ha” moments for their clients. 141 Implications Results from the present study indicate that participants’ experience of attunement to their own needs is connected with their capacity to provide quality therapy. To some degree, therapists achieve fulfillment through providing therapy, which provides a feeling of reciprocal well-being through their provision of therapy. Because therapy is personally fulfilling, therapists get some needs met through the provision of therapy. Consistent with the literature review, it is important to recognize this and for therapists to actively engage in activities that increase self-awareness and increase conscientious acknowledgement and therapeutic use of countertransference. This is particularly true during periods of fatigue or burnout. Although none of the participants were currently experiencing distress, when they talked about past experiences, they often reported the belief that they were providing good care even during periods of burnout. They reported the belief that they provided the same level of attention to their clients, but not to their families or themselves. It seems difficult to know whether clients are benefitting during these times. Although it is beyond the scope of this study to know whether outcomes are influenced by therapist self-care, it seemed difficult for participants to differentiate between the quality of the care and their periods of fatigue. I entered the study with the hope that optimal performance could be understood without understanding burnout; in hindsight, I have a better sense of the futility of looking at it this way for several reasons. First, the field of mental health operates within, and sometimes adjacent to, the medical system, and the medical system functions from the perspective of disease, trying to remove problems and discomfort. Second, the study was conducted with participants who have been working in this field for at least 8 years, 142 and some of them have been working in it for 20 years or more. Even those who identify themselves as coming from a wellness model have been immersed in this climate for a very long time. Thirdly, having completed the interviews and having immersed myself in the results and the experiences of participants, I have realized that the upward spiral suggested in the literature review is ungrounded and unsupported. It may be that rather than considering a continuum, a downward spiral or an upward spiral, what therapists are utilizing instead are feedback loops. This may suggest that at times during a therapist’s own personal or professional life, they reintegrate new information in a responsive way that then becomes part of the dance. These moments invited, or demanded, that participants focus on their care for themselves. Participants talked about this information coming into their field of experience in a number of ways. Whatever the method, the difficulty provided them with important information and what they did with that information was get more tuned into their wellness. This is consistent with the idea that integration of self-care supported by therapist attunement reciprocally builds the capacity for self-awareness, self-regulation, and self-compassion (Baker, 2005). Implications for Practice Based on the results of the study, participants strongly endorsed self-care as a means to increase their capacity to provide quality therapy. When I began the study, I anticipated that therapists would have a clear understanding of how self-care practices influenced the provision of good therapy. I thought that self-care would be related to culture, context, and various identities. I imagined that it would be preventative and would reflect health and vitality. I believed I would gain a better understanding of how 143 therapists care for themselves in order to return to center and to hone their skills. I screened for participants who identified themselves as having a regular self-care practice. Although these participants described a variety of self-care activities in which they engaged, they did not have a crystallized sense of how self-care influenced their provision of good therapy. It is important that more access to resources as well as information be made available for therapists generally. This may be of particular importance for therapists with working in underserved communities or those with marginalized personal identities that may serve to limit access to resources including adequate time away from their work and healthy escapes. Individuals who are work more hours in order to meet financial needs may have less opportunities to engage in these types of self-care and may not see this as possible, as described by one participant. When home and family demands are high, selfcare activities may not even seem possible. Clarity with regard to prioritizing self-attunement, specifically self-compassion, may be a next stage of understanding a rationale for self-care. Participants did not name self-compassion during their interviews, but they did embody self-compassion and modeled compassion as they spoke of clients. As described in the literature review, three components of self-care that are consistent and central to the task of therapist attunement are self-awareness, self-regulation, and self-compassion (Baker, 2005; Norcross & Guy, 2007). This may provide a guide for accurately appraising appropriate self-care. 144 Implications for Training There is a clear need for self-care to be addressed as an ethical imperative during the training of mental health providers. The three participants with the fewest number of years working in the field spoke specifically about intrusions associated with feeling unsure about their work as well as having difficulty differentiating their problems from their clients’ challenges. Each of these participants, and others, talked about developmental phases during which their self-care changed, and also during which they were better able to advocate for their self-care needs. Furthermore, participants reported that early in their training they were less likely to engage in self-care because they “did not have a vision.” Building self-compassion into the training model is equally important to building self-awareness and self-regulation. It is essential for training to include flexible and creative models of self-care that includes appraisal and responsiveness as well as awareness of personal vulnerabilities of therapists in training. Appraisal and responsiveness, in conjunction with self-awareness, should, ideally, be modeled while therapists are in training programs. Supervisors, mentors, and instructors have a specific opportunity and ethical responsibility to engage in adequate self-care to create a climate of personal wellness that is necessary for therapeutic presence. Implications for Continuing Education Self-care continuing education to meet the ethics requirement for CEUs would be an excellent way to increase therapists’ awareness of the need to self-assess and appraise needs, and it could potentially lead to less burnout and healthier lifestyles for students as 145 well as providers. The following recommendations from the BPACCA (2010) could provide an excellent foundation. • Honestly assess emotional, psychological, and spiritual well-being on regular basis • Seek personal psychotherapy and other resources for health as needed • Model openness • Acknowledge vulnerability • Seek consultation • Limit caseload • Balance work, rest, and play • Reasonable and realistic expectations Limitations Consistent with my interpretation with regard to balance and loss of balance, it is my belief that the gaps, or spaces, that allow for differences in interpretation, are equal in importance to the data that supports my attempt to describe the complexity of this dynamic. This is consistent with the constructivist paradigm. As the intuitive participant, I have made every effort toward explicitation of the data within my function as the organizing system (Crabtree & Miller, 1999). Given the iterative process, each interview built upon the prior interviews. For this reason, participants who were interviewed later were invited to talk about ideas such as balance if they used language that was similar to prior participants in their descriptions. Although six of the ten participants agreed to keep practice logs, these logs were 146 only kept by three of the participants. It was difficult to incorporate information from these logs, as the information that was provided was thin. Specifically, for each of these participants, the week that they were willing and able to participate in the interview they did not see any clients. For this reason, they only reported what they thought therapy might be like while they were engaging in their self-care activities. Although this might be a good direction for a future study, the data collected through the logs had little meaning or influence. It may be useful to consider an app to track self-care activities or a simple questionnaire in future research rather than the open-ended self-reflection. An important consideration with regard to participant recruitment is that the individuals who participated had adequate time to meet for an interview and reported commitment to personal self-care. A wider array of participants might demonstrate selfcare activities that are not realized herein. For example, participants with less disposable time or personal time wealth might have different responses with regard to appraisal and responsiveness as well as definitions of vulnerability including burnout. Future Directions Despite these limitations, this study contributes new data to the literature on the ethical requirement for therapists to maintain self through care and attention. It is clear that participants in this study are engaging in many of these recommendations. Future research may be able to explore how these strategies attenuate occupational stress and impact patient outcome. Future directions in research could expand upon the present study in numerous ways. A mixed methods study that includes client outcomes in connection with the 147 therapist’s descriptions of good therapy and self-care would expand our understanding of the impact of therapist well-being in relationship to client outcomes. It may also be useful to engage focus groups in an ongoing study of the impact of self-care and well-being in practice. This type of focus group could incorporate recommendations from the APA and the BPACCA for therapists to engage in consultation groups. A study that incorporated focus groups could both bring valuable data to the field of study and could also benefit the participants by creating a model for consultation, openness, and connection through a group. The literature recommends consultation to reduce feelings of isolation. Furthermore, participants frequently talked about consultation and interactions with other therapists as helpful in their engagement with wellness. Focus groups could be formed to support the well-being of therapists and to expand the understanding of the impact of well-being on client outcomes. In order to gain access to more therapists with less time flexibility due to socioeconomic status, family, and other time sensitive demands, future research may gain a wider array of participants in there is a monetary exchange for the time dedicated to the interview. Conclusion In conclusion, this study explored the experiences and perceptions of psychotherapists’ provision of good therapy in relationship to self-care and well-being. Based on the experience of interviewing 10 people I found elemental themes, but the illustration should not be interpreted as a model. Describing the illustration as a model would be presumptuous. What I have provided is a description – a screen upon which 148 narratives have been projected in order to facilitate the telling of their stories. Although some fit pretty well, the screen fits imperfectly, and to some degree, includes the interpreter’s intuition to fill in the gaps. In the brilliant words of Jack, The danger for me of talking about this… is … it sounds like [there are] little nuggets of wisdom in what I’m saying… and I don’t think that. I think the danger is … the assumption is that because they’re talking about balance they have balance or because they’re talking about mindfulness they have mindfulness. I don’t know… and I always… am hesitant to say that the way that I’m doing it is the best way, or the wise way… It’s not… I’m just doing it the best I can… … and so much of my experience is thinking, ‘I’ve got this,’ and then realizing, ‘I don’t got this’ … There’s another 12 levels to this that I didn’t even know existed… and … I’m scratching the surface. APPENDIX A RECRUITMENT LETTER 150 Research on Personal Wellness and Attunement in Providing Psychotherapy: Exploring the Experience of Wellness Among Psychotherapists Hello! I am writing to invite your participation in a research study about the personal activities therapists engage in to maintain a high level of attunement (presence & engagement) while providing therapy. My study is being conducted due to the overwhelming evidence that the provision of therapy is taxing to the therapist as a person. The purpose of this study is to learn from psychotherapists about their experiences of attending to personal well-being in real time – during therapy and during a typical work day. I hope to use this research to inform the counseling professions about the need to understand how therapists care for themselves while providing excellent therapy. If you choose to participate you will be asked to: • • Take part in an in-person interview of 60-90 minutes Take part in a follow-up phone or Skype interview of 30 minutes Criteria for Participation: • • • • A psychotherapist/counsel in the mental health field of o Counseling/ Clinical Psychology o Professional Counseling o Social Work o Marriage and Family Therapy Licensed with a minimum of 8 years counseling experience (including time prior to licensure) Providing face to face therapy for a minimum of 3 hours per week – at least 40 weeks each year Committed to and engaged in personal wellness activities I would be very interested in talking with you about taking part in this research. If you have questions or are interested in participating, please contact the researcher, Hope Andreason at 801-721-2731 or by email at [e-mail]. A request for more information does not obligate you to participate in the study. This study has been reviewed and approved by the University of Utah Institutional Review Board (IRB; 801-581-3655, [e-mail]). It is being supervised by, Dr. A.J. Metz (801-581-1719; [e-mail]). Thank you again for considering participating in this research opportunity. Hope Andreason Primary Investigator APPENDIX B BRIEF PARTICIPANT SCREEN 152 Brief Participant Screen & Professional Services These questions are to ensure that participants included in this study fit all inclusion criteria. Responses will be used only as composite data in the study. 1) Are you a psychotherapist in one of the following mental health fields: Clinical/Counseling/Professional Psychology, Marriage & Family Therapy or Social Work? (Please briefly describe or specify) 2) Are you a licensed professional? What is your license? 3) Are you currently providing psychotherapy/mental health counseling with a minimum of 5 years of counseling experience? (Please describe) 4) How many clients do you see during a typical week? 5) How many hours do you work in the mental health field during a typical week? 6) Please briefly describe your professional work setting. Some examples include: a. University Counseling Center, providing supervision, counseling, and teaching some courses. b. Private Practice, self-employed, managing billing, client scheduling, etc. c. Small Group Practice, working with several therapists, shared billing, shared front office/waiting area, shared reception, etc. d. Mental Health Organization, employed by agency, not responsible for billing or scheduling. e. Hospital setting, employed by hospital, providing crisis care, short term therapy, etc. APPENDIX C PERSONAL INFORMATION FORM 154 Personal Information Thank you for being a part of this research! The following will help me to better understand the information that you and other participants share with me: Date: __________________ Name: ________________________________ Name you would like to be identified by in the study: ___________________________ Please provide the following information: 1) Age: ________________ 2) Race(s)/ Ethnicity(ies): _______________________________________________ 3) Gender Identification: ______________________ 4) Sexual Orientation Identification: _____________________ 5) Religious/Spiritual Affiliation/Orientation:______________________________ 6) How do you identify your socioeconomic status (SES): a. Growing Up? ______________________________________ b. Currently? _______________________________________ 7) Highest Educational degree obtained: _______________________ 8) Country of Origin: _________________________ 9) Current Citizenship: _________________________ 10) Current geographic location (State if in U.S., otherwise country): ________________________________ Thank you! Please return to Hope Andreason via email: [e-mail] APPENDIX D INFORMED CONSENT 156 The purpose of this research study is to learn about the activities that therapists engage in to maintain a high level of attunement when working with their clients during therapy. This study is being conducted due to the overwhelming evidence that the provision of quality therapy is taxing to the person of the therapist. For example, therapists are at risk for burn out, compassion fatigue, and experience depression, anxiety, and suicidality at higher levels than individuals in other professions. In addition to the need for challenges to personal wellbeing, this also has implications for a therapist’s ability to provide good care to clients. This qualitative study will provide information about therapist’s individual approaches to wellbeing in real-time, and will help expand our understanding of the human side of attunement in therapy. Benefits of participation may include an increase in awareness of personal skills that are being used to increase attunement and may also include awareness of personal cues that self-nourishment is needed. At the conclusion of the study, participants will receive a summary of the information collected in the study for their personal reference and to expand their tools for therapeutic well-being enhancement. To participate in the study, you should be a provider of mental health counseling or psychotherapy for at least 3 clients, 40 or more weeks a year. Participants in the study will have been providing therapy for a minimum of eight years and have a commitment to personal wellness that matches behavior patterns. Participation in the study is voluntary; therefore, you may choose not to participate at any time in the process. There are no known risks associated with participation in this study. However, it is possible that you may feel uncomfortable answering some of the questions during the interview. You can choose not to finish the interview or refrain from answering any question you prefer not to answer without penalty. It is anticipated that the initial interview will last 1.5-2 hours. Following the interview, you will be asked to complete and submit a reflection of your daily personal wellness practices for one week. Completion of this reflection is optional and is not required to participate in the study. If necessary for clarification of the information provided in the interview and in the reflection, a follow up interview of 30 minutes may be requested. You will have the opportunity to review the transcript and provide clarification to any statements made during the interview and this may take an additional 30 minutes of your time. The interview will be video recorded. The primary investigator and/or professional transcribers will see the video to create the transcription. Personal information will be deidentified in the transcription and your responses will be kept strictly confidential and stored on a password-protected computer connected to a secure server. This data will be accessible only to the researchers working on this project. Anonymity is guaranteed in the reporting of the data. Any personal information will not be linked to your responses, and all research findings will be reported in aggregate or summary from. The results of this study will be used for scholarly purposes only. If you have any questions about the research study, please contact the principal investigator, Hope Andreason, Department of Educational Psychology, University of Utah at 157 [e-mail], or at 801-721-2731. Contact the Institutional Review Board (IRB) if you have questions regarding your rights as a research participant. Also, contact the IRB if you have questions, complaints, or concerns which you do not feel you can discuss with the investigator. The University of Utah IRB may be reached by phone at [phone] or by e-mail at [e-mail]. I sincerely thank you for your valuable time and willingness to participate in this important study. CONSENT: Your signature below indicates that: • you have read the above information • you voluntarily agree to participate • you are at least 18 years of age • you provide at least 5 hours of face-to-face therapy each week • you have been in practice for at least 8 years • you engage in regular activities that support your personal wellness __________________________________ Signature ______________________ Date __________________________________ Printed Name __________________________________ Witness ______________________ Date APPENDIX E SELF-CARE LOG 159 Participant Log: Please complete the following prompts each day this week. Today I engaged in (briefly describe wellness activity/ies): I noticed that today when I sat with clients I experienced: Or Although today I did not sit with clients, when I reflected on therapy with clients, I noticed that I experienced: REFERENCES Addison, R. B. (1999). A grounded hermeneutic editing approach. In B. F. Crabtree & W. L. 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