“Will You Scream With Me?”

Perserverance

Overview of Chpt I

Purpose

Statement of Problem

Three Primary Purposes

Research Questions

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• Q1 What was the experience of an ASCSA in expressive therapy?
• Q2 What was the experience of a counselor working with an ASCSA using expressive therapy?

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• Q3 What was the experience of the counseling relationship for a counselor using expressive therapy with an ASCSA? Q4 What was the experience of the counseling relationship for a client with their counselor using expressive therapy?

Rationale and Significance

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• generated knowledge that informs the therapeutic work of counselors, counselors-in-training, other mental health professionals, counselor educators, and supervisors
• due to the prevalence of CSA (CDC, 2010), most mental health clinicians will work with ASCSA at some point in their careers

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• Through a deep understanding of one client’s perspective of components of expressive therapy for trauma, counselors and other mental health professionals may be able to navigate the therapeutic process and relationships more aptly with ASCSA clients

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• ASCSA clients may also benefit from the findings of this study by better understanding the benefits and challenges of integrating expressive aspects into therapy. By reading about the experience of another survivor in the survivor’s voice (as opposed to reading quantitative results), clients may find useful information they can apply to their own therapy or life

Overview of Chapter II

Prevalence

• 1 in 4 women and 1 in 7 men experience sexual abuse as children
• likely counselors will encounter a client (or many) who identifies as an ASCSA

Physiological Aspects of Trauma

• The body keeps the score: If the memory of trauma is encoded in the viscera, in heartbreaking and gut-wrenching emotions, in autoimmune disorders and skeletal/muscular problems, and if mind/brain/visceral communication is the royal road to emotion regulation, this demands a radical shift in our therapeutic assumptions. (p. 86)

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• a survivor experiences and remembers the trauma in nonverbal, visual, auditory, kinesthetic, visceral, and affective modalities (Bloom,2005)
• trauma is locked in the body and, therefore, the body must be accessed to heal (Levine, 2008)

Expressive Therapies

• Because trauma affects a person’s physiology and neurology, researchers have explored the value of nonverbal therapies for the treatment of trauma, especially with ASCSA
• Expressive therapies are considered mind-body interventions because of how the body is used during therapy, and many expressive therapies have somatic components intertwined (Malchiodi, 2005)

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• (Simonds, 1994) states survivors feel a loss of self and voice, and expressive therapies provide a tangible, here-and-now experience for survivors to look for their voice. ASCSA clients can feel ailenated from their body and the need for survivors to connect and integrate their body and mind experiences.

Overview of Chapter III

Methodology

• purpose of a case study is to develop a comprehensive, multilayered description and analysis of a bounded system
• describe the holistic and meaningful aspects of real-life events

Bounded System

• one counseling relationship, with the counselor being a licensed professional counselor who used expressive therapy and the client self-identifying as an ASCSA

Single-case study design

• The literature related to research theory acknowledges that a single-case study design results in a more careful and in-depth study of a unique case
• Benefit to the literature in richly and thoroughly describing one counseling relationship in the context of ASCSA

Trustworthiness and Rigor

• Credibility
• Dependability

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• Confirmability
• Transferability

Participants

Data Collection

Data Analysis

• Moustakas (1994) presented an analysis method that I used to analyze the data collected

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• "Play, like love, happiness, and other psychological constructs, is easier to recognize than to define"

How I arose at themes in my own words

• After the initial coding I looked for overlap and redundancy.
• Therapeutic relationship
• Expressive therapy
• Other

Collaboration

• Auditors: reviewed interviews and themes to audit what themes I combined and what themes I left as distinct/unique
• Lucy and Tumnus: to ensure themes were accurate and fitting
• Research Consultant: again reviewed the synthesization of themes

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• I did not want to compromise the richness of the data through combining/collapsing themes
• In order to capture such a complex and layered relationship, as well as the complexity of expressive therapy, I wanted to keep any theme that was distinct. Otherwise it would be a disservice to the participants and the data

Overview of Chapter IV

Participants
Tumnus and Lucy

Themes

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Complex Relationship

• Lucy: “I've tried to continually take the perspective that all relationships are a path towards growth, especially a relationship as complex, difficult, and beautiful as this one.”

Willingness

• The ability and desire for Lucy and Tumnus to move towards one another, which may include discomfort or not knowing, but having trust in oneself and the other person

Lucy:

• I think this has allowed me to be less reactive and more compassionate and gentle when Tumnus's depression and suicide ideation grow, or they are emotionally dysregulated, or where there is conflict between us. I think this came out in the sandtray (Appendix F), where we showed my efforts to meet the client's prickly protector monster with a gentler

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• cat side of me while I turn my lion fierceness into a protective force for the benefit of the client rather than trying to use it to force them into doing or being something other than who they are in that moment as many others in their life have done.

Lucy:

• I remember saying it felt like what it was like to be in a relationship with Tumnus, that it was a lot of work, that I had to try to find just the right way in, and all the while I wasn't even sure if they wanted me to come closer even when they said it was ok. I think that my patience and willingness to do that even though it wasn't easy and ability to put words to the process of it allowed that dynamic to shift

Lucy:

• I think that one of the things that has been so healing is our willingness to go outside the box, to take what works for us from feminist therapy, wilderness therapy, art therapy, experiential therapy, somatic therapy, EMDR

Vulnerability

• Lucy and Tumnus taking a relational risk in the hopes of further connection with the other, and the risk feels intense and scary

Lucy:

• It feels significant to me I think because I don’t cry with other clients and so it feels like a particularly vulnerable thing to do from the therapist seat. It feels like as the more I let myself be moved by things in a grounded way, it’s been really helpful

Tumnus:

• My love language is through food and when I care about people I like to make and give them food. Several sessions I tried to bring homemade cookies to Lucy, but I couldn’t, I was afraid that she might judge me, or she might reject my cookies and then I would be hurt, and then eventually I finally did. It’s been to me like this really sweet way of interacting or caring or whatever

Mutuality

• A relationship in which both Lucy and Tumnus get to be themselves and experience being important and influential within their relationship

Lucy:

• We’ve been working with stuff and what you’ve been saying has been really impactful and I’ve actually had tears in my eyes, and it feels like those moments have been really important and if you want to say anything about that. Kind of letting myself be touched by you, like that sense of belonging or mattering or knowing your impact

Tumnus:

• I would say what kept me coming back is that I would give a little and Lucy would give a little and that I’d ask for something and Lucy would give me something and that doesn’t necessarily mean that Lucy always gave me the things that I thought I wanted or anything like that but … it felt like she was consistently showing up and meeting me where I was at

Love

• Lucy and Tumnus experiencing a feeling of deep affection and care towards another

Tumnus:

• To me, that’s the word [love] that is missing [from our conversation]. It’s not about reciprocity or transparency as much as it’s been about being loved and loving, too.

Lucy:

• I feel like I love lots of my clients but it’s a different…like I think I love them from like one or two parts of me, it’s more one or two dimensional [the love with Tumnus is more dimensional]

Mattering

• For Lucy and Tumnus to know they are important and have significance in their relationship

Lucy:

• And this journal has quotes and poems and stuff in it and little messages from Tumnus in it and I used it on a trip while I was away for those 6 weeks. And when you [Tumnus] gave it to me, it was really touching, it made me cry. You were worried you had done something wrong, and it was because I wasn’t expecting you to make something that special for me

Tumnus:

• I think it's so important for me to spend that time reflecting on how far Lucy and I have come together, especially because this is the first time in my life where I've had a relationship like this ... where another person has fought as hard as Lucy has fought or showed up as consistently as Lucy has ... or made me feel important and special

Safety

• Tumnus's felt sense that Tumnus will not be harmed emotionally, physically, or mentally which leads to Tumnus being themselves because there is a felt sense of openness and nonjudgmental-ness from Lucy.
• Safety was further developed through competence and responsibility

Tumnus:

• These are microaggressions and this is the way it impacted me and the reason why I’m telling you this is not to make you feel shitty about having done these things so much as now you have more awareness around how that impacted me. I’m bringing these to your attention because

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• I need it to be your responsibility to learn these things that commonly happen as it relates to people from the communities I belong to and not expect me to teach you that along the way.

Corrective Emotional Experience

• Tumnus reexperiences a past pain or trauma in a new way that helps process and heal that pain

Tumnus:

• I think part of the magic in the relationship has been like this piece where Lucy has been able to show up from different parts of herself, at times … I have the need for Lucy to show up from this place of caring and nurturing and I’ve been met there and then have been other times where it’s been more playful,

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• and Lucy can let the younger parts of herself show up and there can be laughter and play and fun. And I think there has been so much healing for me in getting to have all of the missing experiences that I didn’t get to have when I was a kid now

Creating Opportunities

• Lucy: I just don’t feel we could’ve done any of this without doing expressive therapies

Tumnus:

• Through just experimenting and trying new things out, I’m beginning to understand not only is this needed but also what constitutes expressive therapy is so much more than I ever thought. And I think if it hadn’t been for the experiential pieces, we wouldn’t have gotten as far as we have

Awareness and Connection to Body

• For Tumnus to feel present in a given moment so that information from the body can be received

Tumnus:

• I was not accustomed to [people showing up for Tumnus] and I don’t know that I was this aware … I know I was not this aware then … but one of Lucy’s trainings is very body-based and like I’m even noticing now, like in this moment that I’m having this like rejection, this internal bracing away from being able to accept the care that it took for her to show up that way for me especially then

Attachment to Self

• Tumnus having a relationship that includes respect, honoring, and love with all of oneself

Tumnus:

• I think in the process of attaching to Lucy [it] has been possible [to attach to myself] and that has made it [coloring, onesies, significant therapeutic moments] more possible for me to attach to my younger parts in a way that’s healthy as opposed to shaming

Connection to My Experiences to Integrate Them

• Tumnus's ability to be present (not dissociated or only in Tumnus's head) to appreciate and recognize an experience and, therefore, be able to digest/process the impact of the experience

Tumnus:

• I use the metaphor with clients about titration from this perspective of if you have a 2-liter bottle of soda that was rolling around in the back of your car on the way home from the grocery store, when you open it you want to twist it a little bit and let some of the fizz out and then close it and open it a little bit and let some of the fizz out and then close it.

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• And I think the experience of using expressive therapy has allowed me to let some of the fizz out and then close it back up and go through that process in a way that it’s actually manageable for my nervous system as opposed to so overwhelming that I’d just be flooded all the time or completely dissociated

Connection and Expressing Feelings

• Tumnus's awareness and ability to experience one’s internal world of emotion and having the ability to externalize those feelings through words or action (movement, writing, art)

Tumnus:

• Yeah and I think initially it was less about talking through it [feeling anger] and more about showing through the crunching of the pine cones like, “This is how I feel,” and I don’t necessarily know that I had words for it and I have a hard time letting myself be angry and feel anger and express anger

Tumnus:

• Lucy definitely has had many great ideas of how to express my anger. One time I came into session and she had a phone book ready for me to tear to shreds and at the end of it all, like the whole office was covered in phone book shreds and I didn’t have to clean it up and I got to throw my tantrum and not have to clean up after myself like a little kid with a healthy, regulated parent would be able to do. Beating logs with sticks have been another example. Lucy has been big on trying to get me to express it and move it physically

Safe Touch and Comfort

• Tumnus experiencing physical contact that is welcome and leads to feeling cared for and connected to Lucy

Lucy:

• In body-based therapy, touch is something that we're trained in. It can be used to evoke experiences or implicit memory from the past that has been held in the body or to provide missing experiences (usually of comfort or protection) that the client never received. During this session, the client asked me to follow my instincts

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• (which in this case are usually to lean in and offer missing experiences) and this started a phase of work with the client beginning to explore and disentangle safe touch from unsafe touch and to begin to experiment with taking in support from others both by physically leaning on my shoulder and working to stay present as I said supportive things or we looked jointly at something resourcing together

Crucial Moments

• A significant event in therapy that leads to a deeper relational connection between Lucy and Tumnus and/or personal insight for Tumnus that leads to awareness and growth

Lucy:

• I think there have been a lot of turning points. I think one of the big turning points was one of our first wilderness [trips]. We did a lot of EMDR, and that’s where you [Tumnus] started to make your altered book

Flexibility

• Lucy's ability to easily shift, change, or modify depending on what is occurring in a given moment

Tumnus:

• Yeah … being able to do things like that [forts, coloring, creating an altered book], like be that flexible and bring in play and nurturing … has allowed me to access those parts of me in a way that allows me to heal as opposed to me having to stuff it down and shame it

Playfulness

• An activity or experience that is not scheduled or predetermined; it happens when Lucy and Tumnus engage in something without purpose

Tumnus:

• [outdoor sessions] invited so much play, the session where we were at this outdoor, open space and this downed tree was … it was down in such a way like the branches were over it, it was almost like a fort and we both like … crawled in. We were really close together but it was like the experience of being a little kid and building a fort in the living room but in a tree, playing in the woods

Outside Experiences

Supervision

• Doubt
• Helpful

Tumnus Work as a Therapist

The Interview

• Tumnus- Processing
• Lucy- Scrutiny

Overview of Chapter V

Metaphor

Examples of the Greater Body of Literature

Theory that Describes Relational Themes

• Relational Cultural Theory describes the therapeutic relationship as being built on mutual respect, honesty, vulnerability, and empathy (Jordan, 2001). These RCT concepts are highlighted in the themes that arose from Tumnus and Lucy’s relationship, which include authenticity, vulnerability, mutuality, and understanding and care

Willingness

• Less literature
• Overlap with openness and humility
• Lucy "I think when we started to shift to doing outdoor sessions and started going to [location] more regularly that’s when it felt to me like you shifted to more willingness to being with stuff when we were doing it outside"

Relational Depth

• Clients and counselors report that relational depth is composed of the following deep relational experiences: love, connectedness, respect, transcendence, and mutuality
• Clients experiencing relational depth described their counselors as real, competent, caring, fully attentive, open and adaptable, unobtrusive, and capable of handling intense client material

Expressive Connections to Literature

• Van der Kolk (2014) described in depth the essential nature of connecting to one’s body to know safety and then to move towards healing from trauma. Similarly, Levine (2008) emphasized the importance of reestablishing a relationship with one’s body.
• Similarly, Levine (2008) emphasized the importance of reestablishing a relationship with one’s body.

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• A client works toward accepting the trauma and experiencing and expressing the emotions that come from the trauma (Courtois & Ford, 2012)
• To connect to feelings, we must live in our bodies and pay attention to the physical sensations that occur in our bodies (Bass et al., 1994)

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• The concept of playfulness is found in drama therapy (Versluys, 2017), sex therapy (Yadave et al., 2015), and attachment theory (Gordon, 2014)
• Playfulness is also tied to adult secure attachment and is a crucial factor in well-being (Gordon, 2014)

Implications related to Expressive Therapy

Added Implication to Expressive

• Counseling field trains counselors around ethics and boundaries which might limit opportunities, especially with trauma work

Limitations

Future Research