INTEGRATING EGO IDENTITY IN AN ADULT THIRD CULTURE KID WITH LIFESPAN INTEGRATION THERAPY: A REFLEXIVE HERMENEUTIC SINGLE CASE EFFICACY DESIGN by SHARON MACFARLANE Bachelor of Education, Brock University, 1997 Bachelor of Arts (Honours), University of Western Ontario, 1996 Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of MASTER OF ARTS IN COUNSELLING PSYCHOLOGY in the FACULTY OF GRADUATE STUDIES TRINITY WESTERN UNIVERSITY September 2019 © Sharon Macfarlane, 2019 INTEGRATING EGO IDENTITY WITH LI THERAPY ii ABSTRACT Research findings support the presence of psycho-social challenges for third culture kids (TCKs) given their lifestyle of high mobility and the acculturative stress of repatriation. I structured this study as a self-experimentation hermeneutic single-case efficacy design (auto-HSCED). Through HSCED I investigated the efficacy of lifespan integration (LI) therapy in addressing issues with self-structure and autobiographical narrative fragmentation. I proposed the use of an Eriksonian-based ego identity fragmentation model as an explanatory framework for conceptualizing these long-term self-identity issues among TCKs. Acting as both the study participant and primary investigator, I sought to answer: Can LI be efficacious in addressing ego identity fragmentation in an adult TCK? Initial outcomes did not meet HSCED standards for significant client change due to LI therapy, however, I noted significant discrepancies in the results which led to a secondary examination of the findings. My investigation revealed evidence of oppressive data interpretation and analysis processes that I corrected through a metasynthetic remediation process. This re-contextualization of the initial findings allowed me to reinterpret them within a broader intersectional framework. I concluded by arguing for outcomes having met HSCED’s threshold for significance and for demonstrating clear and compelling evidence of LI efficacy in producing client ego identity change. Finally, I offered a unique perspective on the therapeutic process through the inclusion of enhanced reflexivity processes in which I invite the reader into my personal therapeutic and academic journey of ego identity integration. Keywords: third culture kids (TCK); high mobility; repatriation; lifespan integration therapy; ego identity; fragmentation; hermeneutic single case efficacy design (HSCED); reflexive research INTEGRATING EGO IDENTITY WITH LI THERAPY iii TABLE OF CONTENTS ABSTRACT.......................................................................Error! Bookmark not defined. TABLE OF CONTENTS .................................................................................................... ii LIST OF FIGURES .......................................................................................................... xii LIST OF TABLES ........................................................................................................... xiv ACKNOWLEDGEMENTS .............................................................................................. xv CHAPTER 1: INTRODUCTION ....................................................................................... 1 My Story ................................................................................................................. 1 The Study ................................................................................................................ 2 CHAPTER 2: LITERATURE REVIEW ............................................................................ 8 Third Culture Kids .................................................................................................. 8 High mobility lifestyle. ............................................................................... 9 Repatriation. .............................................................................................. 10 High mobility, repatriation and identity.................................................... 12 Summary of third culture kids. ................................................................. 14 Ego Identity: A Framework for Understanding Fragmented Selves .................... 14 Ego identity, psychological well-being, and TCKs. ................................. 16 Summary of an Ego Identity Model.......................................................... 20 Lifespan Integration Therapy: TCKs, Ego Identity Cohesion and Therapy ......... 20 Tenets of LI therapy. ................................................................................. 21 INTEGRATING EGO IDENTITY WITH LI THERAPY iv Neurobiological underpinnings. ................................................................ 23 Processes of LI therapy. ............................................................................ 25 Dynamics of the therapeutic relationship. .................................... 28 Creation and use of LI Time Line. ................................................ 29 Neural integration. ........................................................................ 31 Distinctiveness of LI therapy. ....................................................... 31 LI and TCKs. ................................................................................ 32 Summary of Lifespan Integration. ................................................ 34 Enhanced Reflexivity ............................................................................................ 34 Rationale, Statement of Purpose, and Research Question .................................... 37 CHAPTER 3: METHODOLOGY .................................................................................... 40 Paradigmatic Considerations ................................................................................ 40 Personal positioning. ................................................................................. 40 Pragmatism. .............................................................................................. 42 Ontology ....................................................................................... 42 Epistemology. ............................................................................... 44 Axiology. ...................................................................................... 45 Feminist Influences. .................................................................................. 46 Divisions and power hierarchies. .................................................. 47 Voice for marginalized experiences.............................................. 47 INTEGRATING EGO IDENTITY WITH LI THERAPY v Intersectionality............................................................................. 47 Enhanced reflexivity. .................................................................... 48 Research Design.................................................................................................... 48 Hermeneutic Single Case Efficacy Design (HSCED). ............................. 49 Rationale for HSCED. .................................................................. 50 Overall structure of HSCED. .................................................................... 53 Adaptations. .............................................................................................. 54 Researcher-participant. ................................................................. 54 Enhanced reflexivity. .................................................................... 56 Data collection. ............................................................................. 59 Intersectional analysis. .................................................................. 60 Procedures ............................................................................................................. 62 Research Process Timeline. ...................................................................... 62 Research Participants. ............................................................................... 62 Inclusion and exclusion criteria. ................................................... 63 Participant recruitment. ................................................................. 63 Therapist recruitment. ................................................................... 64 Therapy and Data Collection Procedures. ................................................ 68 Therapy sessions. .......................................................................... 68 Data collection. ............................................................................. 69 INTEGRATING EGO IDENTITY WITH LI THERAPY vi Measures. .................................................................................................. 74 Simplified Personal Questionnaire (PQ) and PQ Duration Rating Form. ............................................................................................. 74 Helpful Aspects of Therapy (HAT). ............................................. 76 Therapist Session Notes Questionnaire (TSNQ). ......................... 77 Video and audio recordings. ......................................................... 77 Change Interview (CI). ................................................................. 78 Data Analysis, Case Development, and Adjudication. ............................. 79 Quantitative data analysis. ............................................................ 79 Change Interviews ........................................................................ 83 Rich Case Record (RCR). ............................................................. 84 Affirmative and skeptic cases. ...................................................... 85 Adjudication. ................................................................................. 89 Intersectional analysis. .................................................................. 90 Final Conclusions.......................................................................... 91 Methodological Rigour and Quality. .................................................................... 93 Case Study Research ................................................................................. 93 Qualitative Methods. ................................................................................. 94 Rigour for enhanced reflexivity. ............................................................... 94 Subjectivity. .................................................................................. 95 INTEGRATING EGO IDENTITY WITH LI THERAPY vii Self-reflexivity. ............................................................................. 95 Resonance. .................................................................................... 95 Credibility. .................................................................................... 96 CHAPTER 4: OUTCOMES ............................................................................................. 98 Rich Case Record .................................................................................................. 98 Contextual Factors. ................................................................................... 98 Participant. .................................................................................... 98 Therapist. .................................................................................... 100 Therapy. ...................................................................................... 101 Quantitative Outcome Data..................................................................... 101 Qualitative information about significant events. ................................... 108 Helpful aspects of therapy. ......................................................... 108 Therapist session notes questionnaire. ........................................ 110 Qualitative Outcome Assessment. .......................................................... 111 Adjudication Process .......................................................................................... 116 Case Development. ................................................................................. 116 Affirmative brief. ........................................................................ 117 Skeptic brief. ............................................................................... 118 Affirmative rebuttal. ................................................................... 120 Skeptic rebuttal. .......................................................................... 121 INTEGRATING EGO IDENTITY WITH LI THERAPY viii Adjudication Process. ............................................................................. 121 Summary opinions regarding client change. ............................... 125 Summary opinions regarding change due to therapy. ................. 128 Mediator factors. ......................................................................... 130 Moderator Factors. ...................................................................... 131 CHAPTER 5: DISCUSSION.......................................................................................... 132 Client Change, Therapy Attribution, and Therapy Processes ............................. 133 Client Change.......................................................................................... 133 Ego identity change..................................................................... 133 TCKs and ego identity change. ................................................... 134 Change Due to Therapy. ......................................................................... 135 Ego identity change due to LI therapy. ....................................... 135 Ego identity change due to overall therapy experience. ............. 135 Therapeutic Processes. ............................................................................ 136 Common factors. ......................................................................... 136 Ego identity processes................................................................. 136 LI attunement protocol. ............................................................... 137 HSCED and research processes during therapy.......................... 137 Intersectional Analysis. ........................................................................... 138 Metasynthesis of compartmentalization of experience. .............. 142 INTEGRATING EGO IDENTITY WITH LI THERAPY ix Metasynthesis of privileging of data sources. ............................. 146 Metasynthesis of fragmentation of therapy factors and experiences. ..................................................................................................... 148 Critiquing metasynthesis............................................................. 151 Mediating and moderating factors. ............................................. 152 Therapeutic Consideration and Future Directions of LI ..................................... 153 Future LI and TCK Research Directions ............................................................ 155 HSCED Implementation and Enhancement........................................................ 155 Auto-HSCED. ......................................................................................... 155 PQ Adaptations. ...................................................................................... 156 Data Analysis and Adjudication Process. ............................................... 157 Orientation meetings. .................................................................. 157 Case development guidelines. ..................................................... 157 Inclusion of intersectional analysis. ............................................ 157 Study Limitations ................................................................................................ 158 Implication for Counselling ................................................................................ 159 Conclusions ......................................................................................................... 159 CHAPTER 6: ENHANCED REFLEXIVITY ................................................................ 161 Prologue .............................................................................................................. 161 Part 1: “I can’t be! Can I be?” ............................................................................ 163 INTEGRATING EGO IDENTITY WITH LI THERAPY x “I can’t be!”............................................................................................. 163 “Can I be?” .............................................................................................. 166 Part 2: “Therapy is hard!” ................................................................................... 166 Part 3: “This is me, and I’m okay!” .................................................................... 174 Discovering My Voice and Taking Up Space. ....................................... 175 Growing Up. ........................................................................................... 177 Finding My Core Self. ............................................................................ 180 Encountering Me Equals Encountering Others....................................... 183 Part 4: “Me encanta quien soy yo!” / “I like to be me!” ..................................... 184 Epilogue .............................................................................................................. 187 REFERENCES ............................................................................................................... 190 APPENDIX A Definitions of Key Terms ...................................................................... 207 APPENDIX B Cross-Cultural Kids and Third Culture Kids ......................................... 209 APPENDIX C Lifespan Integration Therapy and Neural Integration ........................... 210 APPENDIX D Data Collection and Analysis Flow Charts ........................................... 211 APPENDIX E Simplified Personal Questionnaire (PQ) Procedure .............................. 214 APPENDIX F Daily PQ Tracking Form ....................................................................... 219 APPENDIX G Helpful Aspects of Therapy Form (HAT) ............................................. 221 APPENDIX H Therapist Session Notes Questionnaire (TSNQ) ................................... 223 APPENDIX I Change Interview (Elliott, 1999) ............................................................ 224 INTEGRATING EGO IDENTITY WITH LI THERAPY xi APPENDIX J Video Clips Ratings ................................................................................ 231 APPENDIX K Reflexive Primary Investigator Informed Consent .............................. 234 APPENDIX L Case Development Guidelines ............................................................... 239 APPENDIX M Adjudication Response Form ............................................................... 245 Appendix N Confidentiality Agreement ....................................................................... 248 Appendix O Third Party Informed Consent................................................................... 249 Appendix P HAT Helpful and Hindering Events .......................................................... 252 Appendix Q TSNQ Helpful and Hindering Events ....................................................... 269 APPENDIX R Enhanced Reflexivity Feedback ............................................................ 282 APPENDIX S Rich Case Record – Rose ............................................................... 285 APPENDIX T Affirmative Case Brief ......................................................................... 517 APPENDIX U Skeptic Case Brief ................................................................................. 525 APPENDIX V Affirmative Rebuttal ............................................................................ 532 APPENDIX W Skeptic Rebuttal ................................................................................... 538 APPENDIX X Adjudicator A Response Form .............................................................. 541 APPENDIX Y Adjudicator B Response Form .............................................................. 545 APPENDIX Z Adjudicator C Response Form............................................................... 548 APPENDIX AA Reflexive Researcher Adjudicator Response ..................................... 552 INTEGRATING EGO IDENTITY WITH LI THERAPY xii LIST OF FIGURES Figure 1. Lifespan Integration protocols categorized by primary therapeutic goals. ...... 27 Figure 2. Lifespan Integration Standard Protocol procedure outline. .............................. 30 Figure 3. Structure and stages of HSCED method .......................................................... 53 Figure 4. Flow chart of data collection processes. ........................................................... 70 Figure 5. Flow chart of quantitative data analysis processes. .......................................... 81 Figure 6. Flow chart of four-part adjudication results examination to arrive at final conclusions. ....................................................................................................................... 92 Figure 7. Tracking of intersession combined mean ratings for PQ items 1-8 over course of therapy. ....................................................................................................................... 105 Figure 8. Tracking of intersession combined mean ratings for PQ items 9-15 over course of therapy. ....................................................................................................................... 106 Figure 9. Daily PQ mean ratings across all items with outlier item 15. ........................ 107 Figure 10. Comparison of daily PQ mean ratings across all items (including outlier item #15) with daily PQ mean ratings of items 1-14 only ...................................................... 107 Figure 11. The imbalance of challenges versus resiliency resources that can lead to TCK ego identity fragmentation .............................................................................................. 127 Figure 12. Intersectional Analysis: Areas for remediation through metasynthesis ....... 141 Figure 13. Me wearing my ‘bad-ass tiara.’ .................................................................... 173 Figure 14. Embodied progression of discovering my voice. ......................................... 175 Figure 15. Toy timeline of my childhood. ..................................................................... 177 Figure 16. Sticker activity book for my 2-year-old self................................................. 178 Figure 17. Lego DeLorean and pirate ship built with my 7-year-old self. .................... 178 INTEGRATING EGO IDENTITY WITH LI THERAPY xiii Figure 18. Heart Book that I shared with my friends Kristin and Vanessa. .................. 179 Figure 19. Closure of childhood story and launch of new relationship with Mexico. ... 188 INTEGRATING EGO IDENTITY WITH LI THERAPY xiv LIST OF TABLES Table 1 Summary of research timeline from initial research focus to internal defence. . 62 Table 2 Summary of identity and life experience shifts experienced by Rose at repatriation. ..................................................................................................................... 100 Table 3 Rose’s individualized PQ items prepared before therapy began and tracked daily over the course of therapy. .............................................................................................. 103 Table 4 ............................................................................................................................ 104 Table 5 Change list and ratings at mid-therapy .............................................................. 113 Table 6 Change list and ratings at post-therapy .............................................................. 114 Table 7 Change list and ratings at follow-up .................................................................. 115 Table 8 Adjudicator’s judgments of client change ......................................................... 124 Table 9 Intersectional analysis of mediator and moderator therapy factors as identified by adjudicators. .................................................................................................................... 152 INTEGRATING EGO IDENTITY WITH LI THERAPY xv ACKNOWLEDGEMENTS As I sit to write this acknowledgement section my heart is full of thanks and appreciation for the multitude of people who have been a part of this journey in big and small ways. There are too many to mention all by name but some who cannot go without special recognition. To the 2017 thesis cohort I am honoured and privileged to have walked with each of you from thesis classes to research seminar and beyond. Your interest in and enthusiasm for my project have been a constant source of encouragement. Continued thanks to those who participated in this study as part of the case development teams and panel of judges, as well as Kristin, Trish, Ivy, Danica, Amy, Darcie, Vanessa, and Alex. I appreciate you taking time out of your busy lives and schedules to help with the logistical, analysis and rigour processes of this study. To Trish, who freely offered her amazing organizing, editing and academic services at a time of personal overwhelm to help me translate ideas into academic thesis language; and to my boss, Paul Dyck, a fellow MK and TCK, for his continued support, understanding and flexibility when thesis work took over my life – THANK-YOU! To Marvin McDonald, thank-you for your wisdom and insights, and your guidance regarding how to navigate some complex thesis processes. To my research lab and especially Janelle’s Fabulous Four – you know who you are you have all been a continued source of inspiration, cheerleading, and academic and emotional support. To Hillary, I have no words to express the depth of my gratitude and appreciation for journeying with me in therapy. Thank-you for your willingness to participate in this project. INTEGRATING EGO IDENTITY WITH LI THERAPY xvi It would not have been possible and would not have been the same without your involvement. Kristin and Vanessa, I can say without a doubt that I would not have made it through this process without the two of you. The emojis, Bitmojis, texts, emails, tears, laughs, even chicken noodle soup and ginger ale were lifesavers through the darkest times and a source of joy in times of victory and celebration. Thank-you my friends! And finally, to Janelle, what an incredible journey this has been. None of it would have been possible without your guidance, support, and care. Thank-you for your willingness to step outside the box and take risks in this project; and for believing in my abilities and always ensuring that I was proceeding with full inner consent. We made a pretty amazing team! INTEGRATING EGO IDENTITY WITH LI THERAPY 1 CHAPTER 1: INTRODUCTION “Having grown up in three cultures, none of them fully my own, I acquired very early the sense of being loosed [sic] from time as well as space,” (Pico Ayer as quoted in Killguss, 2008). My Story It was only for one year. I1 could do anything for one year. It was the summer of 1984. I was 10 and starting grade 6 while living with my family in Toronto, Ontario, but we were only going to be there for one year. Then we would be heading back to Mexico City, back to the people I knew, the friends I had made, the culture I had learned to love. Since the age of 4, my family and I had been living in Mexico City where my parents served as missionaries. Growing up in this world, as Canadian missionaries in a Latino country, had shaped the person that I was as well as how I understood the world and my place in it. But visiting Canada was only for one year, and I could survive anything for one year. Then, in February of 1985 came devastating news. Mom and Dad had made the decision that we would be staying in Canada permanently. We would never be returning to Mexico. I was devastated. 1 As both the researcher and participant in this case study, I will be referring to myself in the first person in these roles. The use of my personal voice within this study is consistent with feminist frameworks in which the rigid differentiation between researcher and subject and the nature of knowledge and knower are challenged. I position myself as an expert observer in this study, and borrow principles laid out in social and ethnographic first-person research or self-inquiry. (See section on Enhanced Reflexivity for further details.) INTEGRATING EGO IDENTITY WITH LI THERAPY 2 I knew how to survive in Canada, but I had no clue how to live here. Life as I knew it would not be changing and would not be going back to normal. Instead I had to find a way for this new life in Canada to become my new normal. And that is when it happened. That is when I shut a part of myself away. I took the part of myself that did not fit with Canadian culture, locked her away and left her behind. From that day forward, I understood my life to be divided in two halves – my life in Mexico before moving back to Canada, and my life since then. The Study Globalization is on the rise in the 21st century. According to Finaccord (2018), a market research and financial consultancy company, the global number of expatriates (people living outside of their home country; see also definition in Appendix A) could rise to as many as 87.5 million by the year 2021 demonstrating continued growth of this population. Included in this number are the children of expatriates, often referred to as Third Culture Kids2 (TCKs), upon whom this study is focused. Traditional TCKs are children who have spent a significant amount of time during their developmental years (0-18) living outside their passport country due to a parent’s work decision (Pollock, Van Reken, & Pollock, 2017; see also definition in Appendix A). As the number of global expatriates continues to grow, so also do the number of TCKs (Van Reken, 2009) and we 2 Other terms that have been used to refer to this population include global nomads and transculturals (Fail, et al., 2004). Within the research literature the most common term used is third culture kids and is therefore the most prominent and widely understood term for this population. The use of TCK for the purposes of this study reflects its predominance within the literature. INTEGRATING EGO IDENTITY WITH LI THERAPY 3 are seeing increasing numbers of TCKs becoming a visible influence within the public domain (Bell-Villada, 2016). According to Lambiri (2005) this rise in numbers and visibility has been accompanied by an increase in importance and prevalence of TCK research. Amid the body of literature on TCKs one prominent topic has been their psychological well-being given the challenges posed by being raised amid multiple cultural frameworks (e.g., BellVillada, 2016; Klemens & Bikos, 2009; Wrobbel & Plueddemann, 1990). While acknowledging the many benefits and advantages of the TCKs cross-cultural experiences, research findings also predominantly support the presence of social and emotional challenges for TCKs. TCK researchers have traced the source of these challenges to the TCK characteristic lifestyle of frequent moves and transitions (high mobility, see also definition in Appendix A; e.g., Fail, Thompson, & Walker, 2004; Gilbert, 2008; Lijadi & Van Schalkwyk, 2017; Walters, 2006) and the acculturative stress related to their eventual return to their passport country (repatriation, see also definition in Appendix A; e.g., Gilbert, 2008; Klemens & Bikos, 2009; Purnell & Hoban, 2014; Smith, 2011). Given the forecasted continued growth of the TCK population, I would suggest that the pursuit of a better understanding of the emotional and psychological adjustment of TCKs becomes even more salient. Of interest to the discipline of counselling psychology is a deeper understanding of TCK’s emotional and psychological needs related to their experience of living outside their passport country during a sensitive developmental period, and the need for evidence pertaining to effective psychotherapeutic interventions for addressing these needs. In this study I aim to address one aspect of this need by investigating the efficacy of a counselling treatment in a single INTEGRATING EGO IDENTITY WITH LI THERAPY case of a TCK, attending explicitly to issues of identity that arose from distress experienced as a result of the characteristic TCK lifestyle. Researchers have proposed several frameworks with which to conceptualize the properties and impact experienced by TCKs due to high mobility and repatriation. For example, Klemens and Bikos (2009) and Priest (2003) made use of conceptual frameworks centered on repatriation experiences of missionary kids and focused on the mastery of cultural adaptations skills and acquisition of cultural competencies respectively. The results of both studies supported the authors’ hypotheses that a lack of appropriate sociocultural adaptation skills and cultural competencies were positively correlated with decreased psychological well-being and increased life struggles in adulthood (Klemens & Bikos, 2009; Priest, 2003). A further example appears in Bennet’s (1993) work in which she proposes a model of encapsulated marginalization (i.e., the inability to manage shifts between different cultural selves) and constructive marginalization (i.e., effectively navigating and integrating cultural selves). Bennet’s (1993) model provided a theoretical framework to explain the commonality of identity and self-concept struggles among TCKs returning to their passport country while also accounting for the disparity between those TCKs who resolve these struggles (i.e., transition to being constructive marginals) and those who do not (i.e., those who remain encapsulated marginals). Smith (2011) likewise offers a framework centered on identity in which challenges and distress at repatriation are conceptualized as a lack of adequate resolution of Erikson’s identity versus confusion and intimacy versus isolation stages of psychosocial development. 4 INTEGRATING EGO IDENTITY WITH LI THERAPY 5 While these models have illuminated important elements of the TCK experience, such as cultural adaptation skills (Klemens & Bikos, 2009), cultural competency (Priest, 2003), marginalization (Bennet, 1993), and adolescent identity crisis (Smith, 2011), for the purposes of this study I use the construct of ego identity as an explanatory framework. Ego identity or a person’s sense of cohesion of self across time and space (Erikson, 1963, 1968, 1994) is a construct that I argue is able to encompass the complexity and multiplicity of factors involved in long-term emotional, social, and psychological adjustment of the TCK population upon repatriation. As a population that experiences frequent cultural and social transitions due to geographic relocation (Pollock et al., 2017), and that experiences significant losses (Gilbert, 2008; Smith, 2011) and social alienation (Killguss, 2008; Lijadi & Van Schalkwyk, 2014; Schaetti & Ramsey, 1999) when repatriating to their passport country, a common thread of TCK life narratives is the experience of fragmentation in their sense of self (e.g., leaving behind or suppressing a part of self; Ender, 2002; Killguss, 2008; Smith, 2011; Walters, 2006; Wrobbel & Plueddemann, 1990). I propose that these types of self-identity struggles can be conceptualized within a framework drawing on Eriksonian (Erikson, 1963, 1968, 1994) and neo-Eriksonian (Berzonsky, 1992; Côté & Levine, 2002) theories as a fragmentation of their ego identity in which their internal autobiographical sense of self has been segmented and is experienced as lacking coherence and cohesion. For those TCKs who experience a fragmented ego identity a preliminary research question guiding this study has been: Is there a specific therapeutic intervention that could be efficacious with TCKs who self-identity as experiencing a rupture in ego identity related to their high mobility and repatriation experiences as a child or adolescent? INTEGRATING EGO IDENTITY WITH LI THERAPY 6 In seeking an answer to this question, I discovered lifespan integration (LI) therapy which makes anecdotal claims to repairing ego identity fragmentation and the development of a strong core sense of self (Pace 2012). LI’s protocols and practices are designed to connect clients with younger parts of self that are trapped in unresolved memories and to integrate these parts with current self to establish a coherent sense of self across time and space (Pace 2012, 2018). To achieve this integration Pace (2012, 2018) designed a protocol of repeatedly guiding clients through memory cues of their life experiences to create new neurological connections between past selves and the present self. These characteristics of LI therapy would appear to match the needs of ego identity ruptures (Pace 2012, 2018). Additionally, I propose that LI therapy contains unique aspects that could be especially effective with TCKs due to lifestyle challenges (e.g., linguistic barriers, lack of social support systems). In this present study I, therefore, seek to evaluate the suitability of LI therapy for an adult TCK who self-identifies as having a fragmented sense of self. This study was guided by the following research question: Can LI be efficacious in addressing ego identity fragmentation and its correlates in an adult TCK? Specifically, this study sought to answer the following questions: 1. Did the client change substantially over the course of therapy? (Stephen & Elliott, 2011); Did the client experience change in ego identity (sense of coherent self across time and space)? 2. If change occurred, is this change substantially due to the effect of therapy? (Stephen & Elliott, 2011) INTEGRATING EGO IDENTITY WITH LI THERAPY 7 3. If change occurred, what factors may be responsible for that change? (Stephen & Elliott, 2011); Which factors specifically contributed to ego identity change? In conducting this study, I made use of Elliot’s (2002) hermeneutic single-case efficacy design (HSCED) with this writer as the only participant. Throughout initial preparation stages my role as a participant-researcher was carefully considered and was deemed an appropriate and natural decision. This decision was based on my status as a member of the TCK community who highly resonates with the TCK identity and my selfidentified experience of a fragmented ego identity specifically tied to TCK mobility and repatriation. Moreover, my knowledge of psychotherapy processes and therapeutic growth offered a unique perspective of the therapeutic process and further enabled me to effectively communicate my experiences in therapy. To account for the subjective nature of this dual role and further enhance the rigour of this study, I added reflexivity practices to the research process. INTEGRATING EGO IDENTITY WITH LI THERAPY 8 CHAPTER 2: LITERATURE REVIEW The purpose of this chapter is to provide a context for this study within the extant literature on TCKs, ego identity, and LI therapy. I will begin by reviewing the relevant literature on the psychological, emotional and social challenges presented by the high mobility lifestyle and repatriation experiences of TCKs and their subsequent identity issues. I will then link these identity issues with Eriksonian and neo-Eriksonian theories regarding ego identity and self-structure. Drawing on these theories I will propose an ego identity framework for conceptualizing the lack of a cohesive sense of self present among TCKs who experience long-term difficulties. Next, I will argue for the suitability of LI therapy for use with clients with fragmented ego identities and in particular TCKs. Finally, I will conclude with a rationale for this study and for the inclusion of reflexivity given my status as both researcher and participant within the study. Third Culture Kids Pollock, et al. (2017) defined TCKs as individuals who have spent a significant period of their developmental years (ages 0-18) living outside of their passport country or the passport country of at least one of their parent’s due to a parent’s work decision (see also definition in Appendix A). Housed within the broader construct of cross-cultural kids (CCKs), Pollock et al. (2017) suggested that the experiences of TCKs share much in common with kids who are bi-cultural, immigrants, and international adoptees (see Appendix B, Figure B1). However, Grimshaw and Sears (2008) and Pollock et al. (2017) added that there are two characteristics that unite TCKs and distinguish them from other CCKs: 1) a highly mobile lifestyle, and 2) their expected repatriation to their passport country. Given these parameters, the experiences of missionary children, military INTEGRATING EGO IDENTITY WITH LI THERAPY 9 children, children of parents who are in the foreign service and of international business personnel all fall within the narrower TCK category (see Appendix B, Figure B2). As may be expected from the inclusion criteria for TCKs, Cottrell (2007) pointed out that individual experiences also include a wide degree of variation in length of time abroad, ages spent abroad, and number of countries lived in. Considering this variability, what unites TCKs, therefore, are the shared parameters of high mobility and expected or experienced repatriation to a passport country. Researchers discovered that the inherent instability of these two distinctive characteristics of the TCK lifestyle can present significant challenges for the psychological and social well-being of TCKs, which will be further explored below. High mobility lifestyle. Useem and Downie (1976) and Pollock et al. (2017) defined a high mobility lifestyle as one that is characterized by frequent geographic moves and relocations and can take many different forms. For some TCKs, high mobility means moving every few years and living in several different countries (Bell-Villada, 2016; Cottrell, 2007; Schaetti & Ramsey, 1999). For others it can mean transitioning back and forth every few years between their host country (overseas country) and their passport country (Bell-Villada, 2016; Davis, Edwards, & Watson, 2015). Lijadi and Van Schalkwyk (2017) described a third scenario in which TCKs remain in the same country but move every few years to a different location within the country with a significantly different way of life (e.g., big city urban locale to a remote village). Moreover, Bell (1997) noted that some TCKs are born abroad or move abroad at a young age while others experience their first cross-cultural move in later childhood or during adolescence. INTEGRATING EGO IDENTITY WITH LI THERAPY 10 Despite the differences among individual experiences of high mobility, there are certain commonalities in the impact this lifestyle has upon TCK development. Due to its transitory nature, researchers have demonstrated that constant change (Schaetti & Ramsey, 1999), loss (Gilbert, 2008), and disconnection (Lijadi & Van Schalkwyk, 2014) characterize the highly mobile lifestyle. Schaetti and Ramsey (1999) noted that with every change in location comes an accompanying psychological adjustment; A phenomenon best described by Fail, Thompson, and Walker (2004) as the self being continually confronted with new values and social norms and being continually challenged to adapt one’s self to a new context. Gilbert (2008), in his study on loss and grief among TCKs, also reported that, “coping with loss became a constant in [the TCKs’] lives,” (p. 107). With each transition, TCKs reported losses of relationships, places, pets, and possessions, as well as deeper psychological losses such as “a place they can call home”, and the loss of “a safe and trustworthy world” (Gilbert, 2008). Within this environment of pervasive disruption and change, investigators revealed that the focus of life becomes one of continuous adaptation and, at least initially, survival (Fail et al., 2004; Lijadi & Van Schalkwyk, 2017; Walters, 2006). Thus, according to the research, TCKs learn to be cultural chameleons because, as they enter a new environment, they must leave behind a part of who they were, discover the rules that govern life within this new context, and become something different to fit in (Fail et al., 2004; Lijadi & Van Schalkwyk, 2017; Walters, 2006; Williams, 2013). Repatriation. Researcher’s findings identified the most challenging, and often distressing transitional move for TCKs as that of repatriating or returning long-term to their passport country (Bell-Villada, & Sichel, 2011; Cottrell, 2007; Klemens & Bikos, INTEGRATING EGO IDENTITY WITH LI THERAPY 11 2009). Cottrell (2007) pointed out that, although TCKs may have grown up identifying themselves as members of their passport culture, they may have spent little or no time living in their passport country. Pollock et al. (2017) defined the TCK’s ‘home culture’ as the culture belonging to “the country issuing the parents’ passports,” (p. 403) and recognize that the TCK’s sense of home is likely quite different from their parents’. In fact, investigators found that TCKs often experience culture shock upon returning to their passport country and do not usually experience repatriation as a sense of returning to the familiarity and comfort of home (Klemens & Bikos, 2009; Cottrell, 2007; Fail et al., 2004; Useem & Downie, 1976; Walters, 2006; Williams, 2013). Although, as discussed above, losses are experienced at every transition, Smith (2011) argued that for a TCK the most profound experience of loss occurs at repatriation. TCKs described the repatriation experience as follows: “Moving back … is like dying and being reborn,” (Eakin, 1998, p. 14); and, “My whole world was changed and put upside down. I lost everything and everyone,” (Smith, 2011, p.76). In addition to staggering personal, relational and cultural losses, TCKs interviewed for Smith’s (2011) study on repatriation also reported the loss of their way of life, their social and cultural statuses, and their reputations. Van Reken (2011) also described the immensity of the change and loss TCKs experience at repatriation: “With one airplane ride, they lose an entire world they may love and emotionally claim as home, but others don’t recognize the degree or impact of this loss because, officially, it is not the TCKs ‘home’,” (p. 41). Gilbert (2008) revealed that the disenfranchised grief accompanying these losses, unrecognized by those who see TCKs as having returned home, often remains unresolved. INTEGRATING EGO IDENTITY WITH LI THERAPY 12 High mobility, repatriation and identity. River and Hofman (2010) described identity formation as including both intrapsychic and interpersonal influences3. Given these influences on identity, in addition to the impact high mobility and repatriation have on TCKs’ sense of self (intrapsychic) and their experience of the world around them (interpersonal) as described above, it follows that high mobility, repatriation and identity may be closely linked. This section reviews evidence for this link amid the TCK literature. Difficulty with identity formation is a common theme within TCK literature and a key developmental problem faced by TCKs (e.g., Bennet, 1993; Killguss, 2008; Schaetti & Ramsey, 1999). In their study on “Belonging, Identity, and Third Culture Kids”, Fail et al. (2004), reported that a long-term effect of the pervasively transitional lifestyle of the TCK is difficulty in developing a strong and cohesive self-concept. According to their research, this difficulty emerges out of a childhood where the TCK’s, “identity and self-concept are constantly being challenged every time he or she moves,” (Fail et al., 2004, p. 323). Furthermore, Melles and Frey (2014) pointed out that the TCK pattern of adapting to blend-in with their environment, if carried over into adulthood, results in “[a] loss of a sense of authentic self” (p. 354). If left unresolved and unaddressed TCK researchers have suggested that these issues of identity can lead to identity conflict, 3 Definition: “People are able to express identity based on two primary sources of information: information from within and information beyond. Identity from within is based heavily on the component of the reflexive consciousness within the self. Here, people draw a sense of identity from information about their own beings through mood, self-knowledge, and expectations. Gaining identity from beyond is based heavily on the interpersonal aspect of self where information from others is used to gain information about the self.” (River & Hofman, 2010, p. 601) INTEGRATING EGO IDENTITY WITH LI THERAPY 13 confusion and fragmentation, all of which are key areas to be addressed in therapeutic work with TCK clients (Bell-Villada, 2016; Bennet, 1993; Davis, et al., 2015; Meneses, 2011). In this study I specifically focus on the TCK experience of identity fragmentation, as conceptualized through the lens of ego identity (further elaborated in the next section), and the efficacy of a specific therapy intervention, LI therapy, in addressing this fragmentation in an adult TCK. In addition to the effects of high mobility, I argue that for many TCKs repatriation precipitates an identity crisis that may be closely aligned to what Erikson (1968) described in the adolescent stage of Identity and Confusion. Researchers found that at repatriation the TCK’s identity, previously predicated on being different from the dominant culture and often accompanied by a special status, was no longer compatible as they entered their new context (Cottrell, 2007; Eakin, 1998; Killguss, 2008; Smith, 2011). In their passport country, TCKs looked like nationals, which masked their internal sense of living within a foreign culture. Pollock et al. (2017) used the term hidden immigrant to refer to this state of internally experiencing life through the eyes of a foreigner despite appearing to belong physically or externally as a national. In the words of TCKs themselves: “[home is] where I am foreign, I don’t especially care where, what I know is how to be foreign,” (Cottrell, 2007, p. 60); and “The notion of ‘home’ is foreign and the ‘state of foreignness’ [sic] is the closest thing I know to home,” (Pico Iyer as quoted in Killguss, 2008). TCKs know how to be different, a minority, a foreigner. What is unknown to them is living where they are considered normal, ordinary, a national (Killguss, 2008). In research studies, TCKs reported feeling as though they must abandon their international self in order to fit in as a national hence fragmenting their INTEGRATING EGO IDENTITY WITH LI THERAPY 14 experience of self, their identity (Ender, 2002; Killguss, 2008; Smith, 2011; Walters, 2006; Wrobbel & Plueddemann, 1990). In sum, these studies indicate that identity concerns are prevalent among TCKs and have been linked to the highly mobile lifestyle and repatriation experiences of this population. Summary of third culture kids. TCKs are defined here as individuals who have lived outside of their passport country for a significant period of time between birth and age 18. The TCK’s multicultural lifestyle is characterized by high mobility and expected repatriation to their passport country. Researchers have identified numerous social and emotional challenges that often accompany this highly transient upbringing including acculturation stress, losses, disenfranchised grief, marginalization and difficulties with identity formation. In the following section I will examine Eriksonian and neoEriksonian conceptualizations of ego-identity as an explanatory model for TCKs who experience long-term fragmentation of self connected with their childhood lifestyle. Ego Identity: A Framework for Understanding Fragmented Selves Erik Erikson (1963, 1968, 1994) conceptualized ego identity as a psychodynamic self-organizing mechanism underlying the eight stages of his theory of psychosocial development. Succinctly, his ego identity was the process of individuals shaping a coherent sense of self throughout the life span. Erikson (1994) believed this construct to develop in infancy with the child’s first encounter with another person as an experience of self-recognition and continue to change, adapt and transform throughout a person’s lifetime (Erikson, 1994). However, ego identity is not to be confused with personality. While Erikson (1963, 1994) recognized that many versions of self may emerge throughout a person’s lifespan (for example, selves that play various roles and respond to INTEGRATING EGO IDENTITY WITH LI THERAPY 15 different needs and expectations in the environment), ego identity reflects the mind’s ability to synthesize and integrate these varying selves into a sense of wholeness over time. Erikson (1994) defined ego identity as: The conscious feeling of having a personal identity is based on two simultaneous observations: the immediate perception of one’s selfsameness and continuity in time; and the simultaneous perception of the fact that others recognize one's sameness and continuity. (p. 22, original emphasis) To this Erikson (1994, p. 22) added that ego identity is a subjective awareness of selfsameness and continuity. Erikson further theorized that ego identity serves both a personal and social function (Erikson, 1994). At the personal level, its purpose is to establish a sense of internal coherence across a lifetime (Côté & Levine, 2002; Erikson, 1968, 1994). Within the social sphere, the purpose of ego identity is to establish a contextually appropriate and understandable social presence within the larger group, ensuring integration, group belonging, and enabling effective interactions with others (Côté & Levine, 2002; Erikson, 1968, 1994). As such, Erikson (1968, 1994) understood ego identity to be the shaped by intra- and inter-individual processes continuously intersecting over the lifespan. According to Erikson (1974, 1994), a healthy and cohesive ego identity is one that is appropriately grounded in the past, present and future. Côté and Levine (2002) suggested that evidence of grounding can be seen in those who define themselves as a coherent extension of their past experiences, find meaning and significance in their present, and are oriented towards an anticipated future. Furthermore, Erikson (1968, 1994) theorized that a cohesive ego identity would feel at home within one’s own body, INTEGRATING EGO IDENTITY WITH LI THERAPY 16 would effectively integrate selves to develop a defined personality, and would develop confidence in role adoption and performance. Given the role of ego identity in developing a cohesive sense of self across time, we turn now to examine problems that may arise with ego identity development, how these problems are seen to impact psychological well-being, and how both can be seen at work in the TCK population. Ego identity, psychological well-being, and TCKs. The ego identity model I propose in this study is a combination of Eriksonian and neo-Eriksonian theoretical principles and my own conceptualization of ego identity within TCK populations. In this model I purport that, since a healthy and cohesive ego identity is one that is appropriately grounded in the past, present and future, then the inherent disorganization of a TCK lifestyle may be expected to lead to problems in the development of an integrated ego identity. This lack of ego identity integration would be due to the characteristic TCK high mobility and repatriation, in conjunction with other factors such as family dynamics, degree of cultural differences, number of transitions, age at time of transition, and personality. Erikson (1994) suggested that overwhelming, unfamiliar, and stressful circumstances can overload a person with too much incoming information resulting in a disruption of the self-organizing and environmental mastery processes of ego identity. Côté and Levine (2002) maintained that this disruption leads to the adoption of defense mechanisms to manage the self which distort perception of social and emotional information and disrupt the self’s ability to engage with experience and plan for the future. Berzonsky (1992) additionally argued that a further outcome of this state of INTEGRATING EGO IDENTITY WITH LI THERAPY 17 dissonance between outer environmental demands and internal resources is a fragmented self-structure (p. 772). Researchers have documented evidence of recurrent TCK experiences of being overwhelmed and experiencing stress related to the effects of a highly mobile lifestyle and of repatriation as noted previously. Meneses (2011) explained how these frequent geographic and cultural transitions can negatively impact TCKs ability to successfully integrate multiple identities to achieve a healthy psyche: while the ego is searching for integration and pattern [of life experiences], in an attempt to establish a unified identity, the child or adolescent has…entered one or more culture groups, each of which provides a social identity that the individual becomes attached to. This tension between the need for integration and the very real presence of different ‘identities’ can lead to what can be a stressful and confusing time of identity development in TCKs (p. 281-282). Drawing on Eriksonian and neo-Eriksonian theories of ego identity and selfstructure development, and my own understandings of TCK challenges, I suggest that a TCK’s ego may adopt defenses in order to cope with this tension as described above by Meneses (2011). Prevalent amid the TCK literature are defense mechanisms such as becoming the perpetual chameleon (Fail et al., 2004), denial of self (Lijadi & Van Schalkwyk, 2017), and cutting off emotions (Walters, 2006). In her study of female identity formation among adult TCKs, Walters (2006) observed several common themes amid the women’s descriptions of coping with transitions. Among these were the denial of self in order to fit in, the silencing of voice, and emotional blunting for protection against overwhelming emotions (Walters, 2006). Wrobbel and Plueddemann’s (1990) INTEGRATING EGO IDENTITY WITH LI THERAPY 18 study of the psychosocial development of adult missionary kids also observed a pattern of burying past experiences in order manage the demands of current circumstances during repatriation. The cumulative work of developing a healthy ego identity can be further stalled and disrupted by what Erikson (1968, 1994) termed as an identity crisis. Many commentators associate the term identity crisis with Erikson’s (1968, 1994) Identity vs Confusion adolescent stage of psychosocial development. Erikson (1994), however, did not limit identity crises to any one developmental stage. Instead an identity crisis could emerge at any time in a person’s lifespan (Côté & Levine, 2002; Erikson, 1994). According to Erikson (1968) this process is characterized by the shedding of a previous identity that is no longer appropriate in a changing environment while not yet taking on a new identity. This state of being in-between identities creates an identity void until the individual can integrate past selves into a new persona (Côté & Levine, 2002; Erikson, 1968). According to Erikson (1968) and Berzonsky (1992), the psychological implications of this type of identity crisis can range from identity confusion to identity fragmentation (respectively). This state of identity liminality or ‘inbetweeness’ is particularly salient amongst the TCK literature (Bennet, 1993; Gilbert, 2008; Hisano, 2015; Schaetti & Ramsey, 1999). I propose that for TCKs repatriation is often accompanied by some degree of identity crisis. Cottrell (2007) noted that repatriation is accompanied by significant identity losses such as loss of belonging to a community based on sponsor organization affiliation, loss of special status, and loss of uniqueness. These losses leave TCKs wondering, “Who am I?” and “Where do I belong?” (Gilbert, 2008; Pollock et al., 2017). INTEGRATING EGO IDENTITY WITH LI THERAPY 19 According to Killguss (2008), this identity crisis is compounded by the TCKs’ experience of marginalization or being rejected by a dominant culture that does not understand that which fits outside a local cultural norm of experience (p. 143). Killguss (2008) continued on to explain that when a TCK becomes stuck in this state of identity liminality – in between the person they were and who they choose to be – this can result in isolation, disconnection, feelings of inauthenticity of self, and becoming a perpetual chameleon (pp. 144-145). Bell-Villada (2016) also pointed to the potential psychological damage of this cultural and identity disorientation experienced by TCKs: “In the worst-case scenarios, a TCK’s confused and fractured self can lead to a fall through the cracks, a spiral into alcoholism, and other sorts of personal loss,” (p. 309). While, according to research studies, most TCKs learn to resolve these conflicts and problems in ego identity cohesion on their own over time, researchers revealed that a segment of the TCK population experiences prolonged psychological and emotional difficulties (Purnell & Hoban, 2014; Menses, 2011; Moore & Barker, 2012; Priest, 2003; Useem & Downie, 1976; Yoshida et al., 2009). Huff (2001) and Paige (1993) delineated additional factors such as family dynamics, level of experienced acceptance and support, degree of cultural differences, number of transitions, age and developmental stage at time of transition, and personality, among others, impacting the level of distress experienced during cross-cultural transitions. Based on the research and theory reviewed above, I suggest that it seems likely that the greater the experienced acculturative stress, the more likely it is that the TCK will be vulnerable to issues related to ego identity fragmentation. It is on this segment of the TCK population, those unable to resolve autobiographical disruptions in ego identity without help, that I have focused this study. INTEGRATING EGO IDENTITY WITH LI THERAPY 20 Summary of an Ego Identity Model. Drawing on the Erikson’s (1963, 1968, 1994) and neo-Eriksonian (Berzonsky, 1992; Côté & Levine, 2002) conceptualizations of self-structure development, I recommend a model of ego identity as a framework in which to conceptualize TCK struggles with their sense of self resulting from challenges presented by high mobility and repatriation. From this model, the TCK’s continual state of fluctuating self-identity along with acculturative stress would lead to the adoption of defense mechanisms and may result in an identity crisis. In turn these defense mechanisms and identity crisis, if persistent and unresolved, would give rise to a lack of cohesion in the sense of self across time and space (i.e., a fragmented ego identity). For the segment of TCKs who experience long-term difficulties with ego identity coherence, the question emerges as to what counselling professionals may offer in the way of therapy to these individuals seeking help in addressing on-going identity issues. One possible answer is LI therapy to which we now turn our attention. Lifespan Integration Therapy: TCKs, Ego Identity Cohesion and Therapy Melles and Frey (2014) and Williams (2013) observed that, within TCK research literature, there is limited information on addressing TCK needs in therapy. In my literature search, I only found two studies recommending the use of a specific therapeutic intervention with TCKs: Melles and Frey (2014) argued for the use of relational cultural therapy; and David, Edwards and Watson (2015) recommended the use of processexperiential emotion-focused therapy. While both therapies are well-suited for issues salient to the TCK experience, such as identity development, culture shock, grieving losses, and emotional blunting, I found that neither specifically address ego identity fragmentation needs. The remaining therapy related articles I found presented more INTEGRATING EGO IDENTITY WITH LI THERAPY 21 general observations and conclusions regarding the needs of TCKs from a counselling perspective such as addressing issues of rootlessness, alienation and unresolved grief (Barringer, 2001), closely examining the dynamics and impact of the parent-TCK relationship (Choi, 2004), and incorporating cultural sensitivity into therapy work with TCKs (Williams, 2013). The limited resources available to professionals seeking guidance in the treatment of TCK clients, and the absence of research specifically addressing ego identity issues in therapy, prompted my search for a therapy capable of addressing TCK experiences of ego identity discontinuity. I discovered Pace’s (2012) LI therapy to make anecdotal claims of effectiveness in re-integrating self-states and building a strong core sense of self and therefore it was chosen as the focus therapy for this study. As a relatively new approach to therapy, the available research literature on LI is limited. There are, however, several theses and dissertations showing promising results in the use of LI for repairing early childhood attachment ruptures (Lewis, 2017), and the processing of trauma with children (Rensch, 2015) and with adults (Balkus, 2012; Hu, 2014). Selecting LI therapy for use in this study represents an investigation into its use with a new subject matter (ego identity) as well as with a new population (TCKs). Tenets of LI therapy. Peggy Pace (2012) created LI therapy to address perceived gaps in effectiveness or appropriateness of other forms of therapy such as cognitive therapy, Jungian therapy, and EMDR in addressing dysfunctional patterns that are resistant to change or involving clients who dissociate. As such, LI therapy offers a distinctive approach to therapeutic work. According to Pace (2012), the goals and aims of LI therapy are to “integrate neural structures and firing patterns throughout the body- INTEGRATING EGO IDENTITY WITH LI THERAPY 22 mind, and across the lifespan… [and] can be used to clear trauma or build self structure or both….[to] build self structure, change attachment patterns, and improve regulation of emotion,” (p. 1). The influence of neuroscience in the construction of LI therapy can be seen in the centrality of neural integration in Pace’s (2012) conceptualization of normal and abnormal development. The underlying premise of LI therapy is that normal development involves the integration of early childhood states over time (Pace, 2012). Pace (2012) asserted that this process of integration occurs by connecting selves “across time and across contexts through the co-construction of autobiographical life narratives between parent and child,” (p. v.). Subsequently, emotional and psychological maladjustment is conceptualized as the result of insufficient neural organization or the reflection of self-states that are frozen in the past and have only partially been integrated into the whole self-organizing system (Pace, 2012). Moreover, according to Pace (2012), these frozen parts of self are the result of early trauma, neglect, or other circumstances where the child’s needs were not met and/or where their upbringing was chaotic, unpredictable, or otherwise unfavourable for the child’s development. She created LI therapy to specifically target these stuck and unresolved selves and integrate them into the system by bringing new information to bear on past experiences, reconstructing them, and repairing harm that was done (Pace, 2012). Pace (2012) further asserted that, “Reconstructing the past in this way can create positive and lasting change in the present,” (p. 12). The hypothesized result of LI is a cohesive autobiographical map of self across space and time (Pace, 2012); or what could be classified within Eriksonian theory as a cohesive ego identity. INTEGRATING EGO IDENTITY WITH LI THERAPY 23 Neurobiological underpinnings. The protocols and processes of LI therapy are best understood within the context of their neurobiological underpinnings. Much of what has been learned about neurobiological functioning, such as the role of body memory in accessing frozen, dissociated and disconnected parts of self, has emerged from trauma research (e.g., Levine, 2015; van der Kolk, 2014). Bessel van der Kolk (2014) concluded from his research and clinical experience that body-based therapy is far more effective than talk therapy in trauma cases as we experience our world through our bodies. He noted that language is often insufficient to express internal realities, emotions, and states because access to memories has been blocked due to the mind’s use of defense mechanisms such as dissociation, suppression or avoidance (van der Kolk, 2002). Instead, van der Kolk (2014) advocated for the use of body-based interventions which bypass linguistic communication and instead speak through “sensations, tone of voice, and body tensions," (p. 262). In this manner, as noted by Levine (2015), clinicians can tap into a person’s implicit memory system comprised of unconscious memories organized around emotions and intuitive behaviours such as fight, flight and freeze. Pace (2012, 2018) made use of this model in LI therapy by incorporating the use of affect bridges in which clients are guided to focus on present body sensations as a means of connecting to past memories with similar bodily sensations. In addition to this emphasis on implicit body-based memory, theoretical formulations regarding episodic memory are instrumental in LI’s processes of integration of self-states and the construction of autobiographical cohesion (Pace, 2012). Wheeler, Stuss, and Tulving’s (1997) theory of memory asserted that autonoetic consciousness (self-knowing) is required for a person to experience themselves as present within a INTEGRATING EGO IDENTITY WITH LI THERAPY 24 memory. Described by Wheeler and colleagues (1997) as mental time travel, “autonoetic consciousness is the capacity that allows adult humans to mentally represent and to become aware of their protracted existence across subjective time….[and allows] an individual [to] focus attention directly on his or her own subjective experiences,” (p. 335). Consequently, this mental time travel is what enables us to position ourselves as a first-person actor in a past memory and to re-experience, re-write and reconstruct these memories to fit within a broader autobiographical narrative (Wheeler et al., 2017). Autonoetic consciousness is therefore essential to those LI protocols in which memories are revisited and actively participated in through imagination. Furthermore, the effectiveness of LI protocols aimed at neural integration is predicated on the continued plasticity of the brain throughout the lifespan, specifically its ability to change and grow in response to stimuli and experience which enables continued learning (Cozolino, 2010; Siegel, 2014). While the brain’s ability to form new neural connections and pathways, one form of neural plasticity, has been an a recognized fact for decades (e.g., LeDoux, 2003), researchers formerly believed that neurogenesis, the brain’s ability to create new neurons, was no longer possible after the onset of puberty (Gross, 2000). Over the last two decades, researchers such as Eriksson et al. (1998), Gould (2007), Gross (2000), and Schwartz and Begley (2002) have demonstrated that humans retain the ability for neurogenesis and demonstrate neural plasticity across the entire lifespan. Without the brain’s ability for continued neural plasticity, the neural integration central to the effectiveness of LI therapy would be impossible to achieve within a psychotherapy environment. INTEGRATING EGO IDENTITY WITH LI THERAPY 25 Donald Hebb’s theory that neurons that “fire together wire together” (as cited in Siegel, 2014, Dec. 9 posting; & LeDoux, 2013, p. 79) is a second neurobiological principle underlying LI’s goal of neural integration is. Siegel (2014) explains that as energy passes along the neural networks in the brain, “links among simultaneously firing neurons are created or strengthened, making their firing together in the future more likely,” (paragraph 9; December 9, 2014 post). In purposefully structuring LI protocols to facilitate the formation of new linkages, Pace (2012) created space for various brain systems associated with past self-states and memories to work together in connecting these experiences together across time (p. 11). The desired outcome is to enable LI therapy work to modify and redirect neural connections leading to new mental representations and images which is essential for the reconstruction of memories and the reintegration of self-states into a cohesive ego identity (Pace , 2012; Siegel, 1999). Describing the above-mentioned neurobiological principles serves to frame LI processes and procedures, to which we turn our attention next, within the broader research on implicit body-based memory, autonoetic consciousness, neural plasticity and neural connectivity. Processes of LI therapy. Pace (2018) created several protocols that form the overarching structure of LI therapy (see Figure 1) and which align with the neurobiological principles outlined above. These protocols enable clinicians to effectively work with clients in resolving traumas and/or developing a cohesive selfstructure. While the core building protocols appear to be the best fit for use in ego identity repair, in populations such as TCKs trauma protocols may also be necessary as trauma can lead to disintegration of ego identity. For the purposes of this study, I have INTEGRATING EGO IDENTITY WITH LI THERAPY 26 not outlined specific procedures for each LI protocol, but instead have focused on delineating the three essential components shared by all protocols: a) the importance of the therapeutic relationship; b) the use of the client LI Time Line; and c) achieving neural integration. INTEGRATING EGO IDENTITY WITH LI THERAPY Figure 1. Lifespan Integration protocols categorized by primary therapeutic goals. Reprinted with permission from Lifespan Integration Level 1 training manual, by Pace. P. Copyright 2018, Lifespan Integration, LLC. 27 INTEGRATING EGO IDENTITY WITH LI THERAPY 28 Dynamics of the therapeutic relationship. According to Pace (2012), the quality of the therapist-client relationship is central to the effectiveness of LI interventions. She identified therapist attunement and grounding as the most important qualities of the therapist-client interaction within LI therapy (Pace, 2012). Given the focus on implicit and episodic memoires, most of the experiential work and processing occurs internally within the client and is not verbalized to maintain the client’s attention and immersion in the experience (Pace, 2012, 2018). Pace (2012) emphasized that the therapist must therefore be a stable, coherent and grounded presence for the client in order to make space for experiential learning. She asserted that the clinician’s ability to keep the client in the experience and not moving into cognitive processing enhances the effectiveness of bilateral integration processes central to the autobiographical reconstruction process (Pace, 2012). According to Pace (2012) the therapist also provides safety for the client to fully participate in the protocols by being attuned to the client’s levels of arousal and shifts in the client’s mental and emotional state during LI therapy. In this manner, clinicians can ensure that clients remain within their window of tolerance. Pace (2012) argued that, in modeling a safe, stable, and open presence for the client, the therapist-client interaction mimics the infant-caregiver attachment relationship and allows for dyadic sharing of emotion and energy between the client and therapist. This mutual sharing of emotion and energy enables the therapist to co-regulate emotion with the client thus maintaining client groundedness and managing client emotional activation (Pace, 2012). In doing so, Pace (2012) suggested that the therapeutic relationship creates safety for the co-construction of new narratives throughout LI therapy protocols. INTEGRATING EGO IDENTITY WITH LI THERAPY 29 Creation and use of LI Time Line. The LI Time Line is the central tool in LI therapy (Pace, 2012, 2018). Clients are asked to create a timeline of their life, starting as young as possible, and listing a cue for at least one important memory for each year of their life. According to Pace (2018), the best memories are those which elicit sensory information as these activate multiple areas across both hemispheres in the brain and thereby enhance neural integration. The LI Time Line is used to guide past selves through life experiences over time and integrate them into the present self (Pace, 2012, 2018). In Standard Protocol (Pace, 2012, 2018; see Figure 2), the client begins with their presenting problem in mind and notices any affective or somatic symptoms that may arise. This somatic and affective information is used to connect with a past memory (the source memory) accompanied by similar emotions and bodily sensations. Next the therapist coaches the client in using their imagination to enter the source memory, interact with their younger self and take them to a safe place. The client-created Time Line cues are read out loud by the therapist as the client, in their imagination, shows their younger self how their autobiographical narrative has continued to unfold up to the present day. Once the younger self has seen all the Time Line cues, he or she is introduced to the client’s present-day life. The client then takes a short break to check-in with the therapist and then the process is repeated with the same source memory. Timeline repetitions continue with this one memory until affective and somatic symptoms are cleared (Pace 2012, 2018). INTEGRATING EGO IDENTITY WITH LI THERAPY Figure 2. Lifespan Integration Standard Protocol procedure outline. 30 INTEGRATING EGO IDENTITY WITH LI THERAPY 31 Neural integration. According to Pace (2012), it is the repetition of multiple LI Time Lines with the same memory that is integral to resolving trauma and stuck emotions, as well as constructing a coherent sense of temporal and spatial self. Pace (2012) purports that as the therapist guides the client through multiple journeys of their Time Line the client is continually transitioning between self-states and creating new links between states and across time. These links not only result in a better organized and more stable self system but are also an essential component to achieving neural integration (Pace, 2012). In short, Pace (2012) believed that with each repetition clients can experience and link together more and more elements of memories across time and strengthen new neural connections (see Appendix C, Figure C1 & C2). She claimed that through this process a complete temporal and spatial map of self through the lifespan would begin to emerge and a coherent self structure would be in the process of being constructed (Pace, 2012). Distinctiveness of LI therapy. LI therapy is comprised of several distinctive and unique characteristics that set it apart from among other psychotherapeutic interventions. Pace (2012) distinguished LI therapy from talk therapies which mainly engage the left hemisphere of the brain. In contrast, she designed LI as a body-based intervention which engages the right hemisphere of the brain and comprises a sharing of energy (body) and information (mind) between the therapist and client (Pace, 2012). In addition, LI therapy marks a departure from therapies that emphasize emotional catharsis as a means of achieving healing. Pace (2012) argued that reexperiencing emotionally difficult memories in their fullness only serves to reinforce the neural networks that maintain the memories and their associated emotional states. Instead of INTEGRATING EGO IDENTITY WITH LI THERAPY 32 emotional immersion in memories, Pace (2012) created protocols that seek emotional activation in which memories are moved through quickly as clients only need to “hook” into the memories. Lastly, Pace (2012) advocates for the repetition of the visual and sensory Time Line as a unique feature of the LI therapeutic process which set it apart from other experiential interventions. The use of the LI Time Line is central to this therapeutic intervention as evidenced by the Standard Protocol procedure detailed above. LI and TCKs. There are numerous attributes of LI therapy that make it particularly well-suited for use with TCKs. For example, Pace (2012) recognized both the importance of and the often-lacking presence of familial and societal support systems in our modern-day society. Both support systems are frequently lacking in the lives of TCKs. While they are often very close to family members as noted by Gilbert (2008), Huff (2001), and Lijadi and Van Schalkwyk (2014), TCKs often do not have well established social support systems outside the family due to the constant mobility both of themselves and those around them (Lijadi & Van Schalkwyk, 2014; Melles & Frey, 2014). Given this context, LI’s focus on accessing and enhancing clients’ internal resources (Pace, 2012) becomes particularly pertinent for TCKs. LI therapy may also be useful in bypassing the difficulties TCKs may have in communicating occurrences connected with their international lifestyle. Meneses (2011) explained that experiences and emotions that have been encoded in the context of a specific language can be challenging to communicate with others outside of this primary encoding language. I propose that this challenge is greatly diminished within LI therapy as there is only minimal sharing of verbal information between the clinician and client. INTEGRATING EGO IDENTITY WITH LI THERAPY 33 Much of the work being done is within the imaginative constructions of the client and need not be shared with the clinician (Pace, 2012) therefore potentially freeing them from linguistic constraints. In addition, the memory cues utilised in the LI Time Line, apart from the clinician being able to read and pronounce them, need only be understood by the client (Pace, 2018). I argue that this also frees the client from needing to explain culturally specific memories and language laden constructs associated with these memories. As such, language is diminished if not potentially eliminated as a barrier to making use of cross-cultural experiences within therapy. Additionally, LI therapy offers TCKs a mode of restoring some sense of stability that has been characteristically lacking in their life story. Pace (2012) noted that our modern-day transient society is plagued by a lack of stability and permanency which impacts our psychological well-being. This discontinuity of time and place described by Pace is magnified in the highly mobile and cross-cultural lifestyle of TCKs (Bell-Villada, 2016; Cottrell, 2007; Davis, et al., 2015; Lijadi, & Van Schalkwyk, 2017; Schaetti & Ramsey, 1999). Pace (2012) argued that LI, through the use of the LI Time Line, offers the means by which a sense of inner stability can be restored (p. ix). Essentially she asserted that by using LI protocols in the presence of an attuned clinician, clients who have grown-up in an environment that lacks stability, can experience the co-construction of a cohesive autobiographical narrative of their life restoring a sense of continuity of self across the lifespan (Pace, 2012). The suitability of LI therapy for use within the TCK population is clear given its focus on bolstering internal client capacities, its likely ability to bypass linguistic barriers, and its offer of restoration to internal stability and continuity. INTEGRATING EGO IDENTITY WITH LI THERAPY 34 Summary of Lifespan Integration. LI therapy appears to be uniquely suited to address issues in ego identity coherence. The inclusion of underlying neurobiological principles supporting LI therapy’s focus on neural integration, its body-based structure eliciting right-hemispheric brain activation and facilitating access to implicit memory, its unique use of visual and sensory cues to bring past selves into the present, and its intentional minimization of emotional experiencing while maintaining emotional activation, are all elements which make LI an ideal therapeutic technique for use with ego identity fragmentation. Additionally, LI’s focus on building client internal resources, its potential to bypass communication issues caused by culturally laden and language specific content, and its intent to restore a sense of continuity and stability amidst a discontinuous life experience, are attributes of this therapy approach that make it particularly well-suited for use with TCKs. Thus, as a result of this review of the relevant literature, the conclusion was reached to further study the efficacy of LI therapy in addressing ego identity fragmentation experienced within the TCK population. For the purposes of this study the Hermeneutic Single Case Efficacy Design (HSCED; further elaborated in CHAPTER 3: Methodology) was used to investigate the efficaciousness of LI therapy for an adult TCK with self-reported ego identity fragmentation. Enhanced Reflexivity Given my status as an insider within the TCK community, my self-identification as having experienced a fragmented sense of self, and my knowledge of psychotherapy processes and therapeutic growth, it seemed especially relevant for me to take on a dualrole as researcher-participant within this study. My personal experience encompasses reflexive awareness in clinical training as a therapist as well as reflexive methodological INTEGRATING EGO IDENTITY WITH LI THERAPY 35 training as a researcher, both enriching and extending avenues of approach to personal experiences as a TCK, the subject matter for analysis. To provide additional rigour to the research process and make space for the privileging of client voice and subjective experience a form of enhanced reflexivity is being added to the structure of this study. Reflexivity is a process which makes the context and positionality of the researcher explicit within the study (Clancy, 2013; Finlay, 2002; Shaw, 2010). Hertz (1996) asserted that it makes room for the researcher to go beyond what they know to also question and make transparent how they arrived at this knowledge. Through reflexivity a researcher can make visible the social, historical, cultural and political factors that have influenced their decision-making throughout the research process (Etherington, 2017; Guillemin & Gillam, 2004; Mortari, 2015) and invite the reader to test out the trustworthiness of their findings (Etherington, 2017). To define enhanced reflexivity, I am pulling from the historical beginnings of research in psychology which made use of self-experimentation (Corti, Reddy, Choi, & Gillespie, 2015). Within this context, Corti, Reddy, Choi, and Gillespie (2015) described it as “akin to being an ethnographer within one’s own experiment [in which] the anthropological models of autoethnography and participant observation have much to offer,” (p. 303). Likewise, I offer an enriched form of reflexivity in which I pull back the curtain of therapeutic experience and offer the reader a more intimate look into my personal journey through psychotherapy. This is particularly well suited for use with LI therapy as processing of experience largely occurs internally for the client within therapy sessions and continues between sessions. As such, in LI therapy more so that in most INTEGRATING EGO IDENTITY WITH LI THERAPY 36 other therapies, the client is the only holder of the information and knowledge regarding personal experiences during and between sessions. By including this element of personally engaged reflexivity I am being informed by current practices in ethnographic methodologies such as autobiography, autoethnography and memoir and am positioning myself within a feminist theoretical framework. This feminist framework offers a tradition of pushing the boundaries of what can be known and who can be the knower. There is permission to be methodologically creative and challenge the traditional patriarchal control over knowledge and process and place myself at the very centre of this inquiry (Hesse-Biber, 2012). In so doing, it privileges experiential knowledge and provides space for sharing my process, selfawareness, tacit understanding, and intuition, a structure borrowing from Moustaka’s model of Heuristic Self-Search Inquiry (HSSI; Ozertugrul, 2017). Within the feminist umbrella my experience takes on the role of consciousnessraising like the aims of present-day feminist autobiographical practices in social psychology and ethnographic research (Corti et al., 2015; Crawford & Kimmel, 1999). In laying forth my personal experience, my awareness of social power dynamics such as marginalization and silencing of voice, and internal therapeutic processing become available to others. In positioning myself as an expert observer defined as someone who is “trained in methods of self-perception capable of carrying out [inquiry] on his or her own self” (Corti et al., 2015), I am not suggesting that this study is superior research to more traditional third-party research approaches. I advocate for viewing it as complementary; for viewing this study as a manner through which depth and richness of understanding of INTEGRATING EGO IDENTITY WITH LI THERAPY 37 self and others can be enhanced. I offer this type of knowledge with a dual purpose: a) to serve as an example of clinician self-experience in personal therapy work; and b) to promote self-reflection, self-understanding, greater care for struggling TCKs, greater care for individuals entering psychotherapy, and an increased awareness of client’s internal experience of therapeutic work. Rationale, Statement of Purpose, and Research Question This study emerged from my status as a member of the TCK community who self-identified as having a fragmented ego identity and who was keen to pursue healing and reparation in this area. For many years I have believed that my present-day anxiety and depression likely had roots reaching back to my repatriation experience. My return to Canada in middle childhood was accompanied by significant acculturative stress and distress which led me to lock a part of myself away in order to cope and survive. When years of counselling and talk therapy produced improvement but not resolution, I began to lose hope that restoring wholeness of self was even possible. Upon learning about LI therapy and witnessing its ability to transform a child’s conceptualization of self within a colleague’s research project (Lewis, 2017), I wondered if perhaps I had found a reason for restored hope. My curiosity was further peaked upon speaking to a fellow clinician who worked with TCKs and had recently been trained in LI therapy. She expressed seeing a very natural and organic fit between TCK presenting issues in therapy and the aims and goals of LI therapy. I began to wonder, could LI therapy help me rediscover the child-self I left behind and reintegrate her into my current understanding of self? Could this reintegration process result in a stronger and more INTEGRATING EGO IDENTITY WITH LI THERAPY 38 confident core self? Could this, in turn, reduce the level of fear of the world and anxiety in living life that I had experienced these past 35 years? As global numbers of TCKs and adult TCKs continues to grow and research reveals that some of the individuals may struggle with psychological and emotional adjustment issues uniquely connected to their distinct life experiences as TCKs, it becomes increasingly important for those within the mental health professions to better understand how they can best serve this population should they present with issues of or related to identity. It is evident from the literature that the highly mobile lifestyle and repatriation experiences of TCKs present specific challenges in identity formation and coherence of self-concept. According to research reviewed above, TCKs experience identity development difficulties due to the characteristic stressors, losses, and constant adjustments that accompany the high mobility lifestyle and repatriation experiences within this population. For those TCKs who, like myself, have experienced prolonged identity difficulties I offer a model of ego identity based on Eriksonian and neoEriksonian concepts of identity and self-structure. This model serves as a useful framework for understanding the long-term impact on identity of frequent childhood cross-cultural transitions. Ego identity, defined as achieving a stable and cohesive sense of self across time and space, can become fragmented when disrupted during development by experiences like those of TCKs facing highly transient and changing nature of their upbringing. Amongst the research literature on TCKs, investigations into effective therapeutic interventions in meeting TCK needs are limited. Among those found (Davis, et al., 2015; Melles & Frey, 2014), none address ego identity fragmentation. Pace (2012), however, INTEGRATING EGO IDENTITY WITH LI THERAPY 39 has claimed that LI therapy can be effective in integrating fragmented self-states and developing a strong core self. The present study, therefore, sought to evaluate the suitability of LI therapy for an adult TCK who self-identified as having a fragmented sense of self. This study was guided by the following research question: Can LI be efficacious in addressing ego identity fragmentation and its correlates in an adult TCK? Specifically, this study sought to answer the following questions: 1. Did the client change substantially over the course of therapy? (Stephen & Elliott, 2011); Did the client experience change in ego identity (sense of coherent self across time and space)? 2. If change occurred, is this change substantially due to the effect of therapy? (Stephen & Elliott, 2011) 3. If change occurred, what factors may be responsible for that change? (Stephen & Elliott, 2011); Which factors specifically contributed to ego identity change? As a researcher-participant case study, enhanced reflexivity was included in the project to explicitly address researcher subjectivity and its influence on the research process and study findings. INTEGRATING EGO IDENTITY WITH LI THERAPY 40 CHAPTER 3: METHODOLOGY The goal of this research project is to evaluate the suitability of LI therapy in addressing ego identity fragmentation due to high mobility and repatriation among TCKs. As such, I conducted this study as an in-depth case study analysis of my personal journey through LI therapy as an adult TCK who self-reports as experiencing a fragmented sense of self. This study involved a personal element as this writer served as both researcher and participant with the primary purpose of evaluating the efficaciousness of LI therapy in addressing ego identity fragmentation and its correlates in an adult TCK. Paradigmatic Considerations The choice of pragmatism as the paradigm upon which to situate this study was due to the suitability of this philosophical framework given the study’s topic, research questions and subject matter under investigation. I adopted a pragmatic framework with feminist influences to guide the design of this research project as it was best suited to my personal position within this study and provided the best ontological, epistemological and axiological structure for this research endeavour. Personal positioning. As an adult TCK who moved back to Canada from Mexico at the age of 10, I understand the difficulties, challenges, and complexities that accompany the TCK repatriation experience. Ego identity fragmentation describes my understanding of how I learned to cope with the immense stressors that accompanied my personal repatriation experience. In leaving behind the parts of myself that were not acceptable within Canadian culture those aspects of self became frozen in time, essentially emotionally and psychological stuck at my repatriation age. While I have understood this conceptualization of myself and the effects of repatriation on my sense of INTEGRATING EGO IDENTITY WITH LI THERAPY 41 self for over a decade, and have experienced healing, growth and recovery in other areas through engagement in counselling and therapy during this time, my fragmented sense of self has remained untouched. What I have lacked and what I have sought is something or someone able to help me recover those parts I left behind and re-integrate them into a coherent sense of self in the present. It is from this place of woundedness, practical need, and academic curiosity that this study has emerged. Therefore, I approached this study and its subject matter from multiple perspectives and positions: as an insider member of the TCK community; as a long-term client of psychotherapy; as a therapist-in-training completing her MA in Counselling Psychology; and as a member of humanity seeking to live a congruent and authentic life. It is from within this context that my own personal data and process became the most efficient and purposeful choice as the subject matter for this research with some specific benefits. This decision was congruent with the pragmatic paradigm that advocates for making methodological choices in accordance with what best facilitates a rich and active engagement with and careful inquiry of experiential data towards answering of the research question (Biddle & Schafft, 2015; Johnson & Onwuegbuzie, 2004; Morgan, 2014; Tashakkori & Teddlie, 2010). My role as researcher-participant also aligned with pragmatism’s embracing of subjective experience as a source of knowledge and reflexive action as a method for inquiry (Biddle & Schafft, 2015; Hall, 2013; Johnson & Gray, 2010; Morgan, 2014), as pragmatism asserts that both objective and subjective knowledge can co-exist (Hall, 2013; Shannon-Baker, 2016). In eschewing the either-or approach to subjectivity and objectivity (Johnson & Onwuegbuzie, 2004), the pragmatist INTEGRATING EGO IDENTITY WITH LI THERAPY 42 approach provided a dialectical foundation for this research legitimizing and valuing both the subjective and objective sources of knowledge within this study. My dual role as researcher and study participant also spoke to feminist paradigmatic influences by challenging research-participant distancing and power dynamics (Campbell & Wasco, 2000; Etherington, 2017; Leckenby & Hesse-Biber, 2007). In this dual role I was intimately engaged and involved at all levels and in all processes of research: distance between researcher and participant was non-existent and power hierarchies were thus eliminated. The pragmatic decision to use personal experience as the subject matter of this study was congruent with the feminist approach in privileging participant voices, and subjective experiences and understandings within the research process (Brown & Gilligan, 1992; Campbell & Wasco, 2000; Gilligan, 2003; Mitchell, 2017). Pragmatism. As indicated above, pragmatism serves to provide an epistemological, ontological and axiological framework for this study regarding the nature of knowledge, the process of inquiry, the researcher-participant relationship, and the ethics and values that guided this research process. Ontology. Pragmatic ontology discards the metaphysical debates regarding truth and reality (Morgan, 2007, 2014; Johnson & Onwuegbuzie, 2004) and rejects all forms of dualism and as such can embrace a world in which objectivism and subjectivism can coexist (Johnson & Onwuegbuzie, 2004; Johnson & Gray, 2010; Morgan, 2007). This dialectical view of reality and existence opens doors for greater methodological variety and flexibility, adding to experiments the value of observation and experience as a means of producing valuable knowledge about people and the world (Johnson & Gray, 2010; INTEGRATING EGO IDENTITY WITH LI THERAPY 43 Johnson & Onwuegbuzie, 2004; Tashakkori & Teddlie, 2010). The truth we come to know in pragmatic research is not universal or absolute rather it is a provisional ‘truth’ that is instrumental in fostering beliefs and actions aimed at the good of all people (Creswell, 2003; McWilliams, 2016; Mertens, 2014; Morgan, 2014) but are subject to change, fallible and held tentatively (Greene & Hall, 2010; Johnson & Onwuegbuzie, 2004). As outlined by pragmatism, the ontological focus of this study is on the efficaciousness of LI therapy and its ability to produce results that work in generating change in ego identity fragmentation in a specific population. In congruence with pragmatic ontology, this research project does not aim to make universal or absolute claims regarding the efficacy of LI therapy amid the TCK population struggling with ego identity fragmentation. Rather, the goal of this study is to establish provisional truths that can further inform clinical practice and future research. In this study I also embrace the pragmatist dialectical view of reality in allowing for the co-existence of overarching principles and themes that demonstrate transferability to other cases while respecting and valuing knowledge attained from subjective experiential data in individual cases. An additional and highly pertinent pragmatic ontological principle for this study is Dewey’s transactional realism and intersubjectivity (Hall, 2013; Johnson & Gray, 2010; Morgan, 2007). Hall (2013) describes transactional realism in the following manner: …[it] suggests that the mind and world are in constant interaction with each other through transactions where by individuals actively engage, transform, or change INTEGRATING EGO IDENTITY WITH LI THERAPY 44 the environment. These transactional experiences also produce knowledge which has the ability to reconstruct reality continuously. (p. 17) In adopting this interactional, experience-based approach to being and becoming in the world, Dewey unapologetically advocates for the subjective nature of our individual perceptions of reality (Johnson & Gray, 2010). Critics of Dewey assert that such a highly subjective perception of the world negates the possibility of a joint or shared understanding of reality (Johnson & Gray, 2010). Dewey’s response was the introduction of intersubjectivity, a process of interpersonal interaction whereby we collectively communicate and coordinate our individual subjective experiences of the world with the subjective perspectives of others in order to collaboratively construct a communally understood reality (Johnson & Gray, 2010). Dewey’s transactional realism and intersubjectivity provide a framework for this study’s collaborative and interactional examination of subjective experience that expands knowledge and understanding beyond the emic towards communal knowledge constructions. Epistemology. The pragmatist approach adheres to an “antirepresentational stance of knowledge” (McWilliams, 2016, p. 21), that places experience at the heart of all knowledge and the beneficiaries of this knowledge at the centre of the research process (McWilliams, 2016; Mertens, 2014; Patton, 2002). According to Dewey, all experience and therefore all knowledge is context-dependent and cannot be examined nor interpreted apart from its cultural and historical situatedness (Morgan, 2014). Furthermore, in his theory of inquiry (Hall, 2013; Morgan, 2007, 2014) Dewey asserts that research knowledge is achieved by engaging with experience through the process of abduction which is, “reasoning that moves back and forth between induction INTEGRATING EGO IDENTITY WITH LI THERAPY 45 and deduction first converting observations into theories then assessing those theories through action,” (Morgan, 2007, p. 71). The results of this cyclical process of inquiry are what Dewey termed warranted assertions which are context dependent beliefs about what has worked in a particular situation (Hall, 2013; Johnson & Gray, 2010; Morgan, 2014). The value of these assertions is in their transferability to different contexts by providing guidance in one possible way forward, however, their applicability in a new context can only be determined through action (Johnson & Gray, 2010; Hall, 2013). The underlying research question in this study aligns with pragmatic epistemological considerations in focusing on experiential knowledge that is context dependent and results in probabilistic claims. The pragmatist epistemological focus on experience as a pathway to knowledge and Dewey’s abductive cyclical inquiry process are ideally suited for this study as it is centered on LI therapy processes which are by very nature experiential and that organically contain a cyclical process of theorizing, action, and reflection. Dewey’s inquiry process will be additionally advantageous as a structure or approach to the self-examination and self-analysis characteristic of this project’s reflexivity work. Furthermore, the context-dependent nature of knowledge according to pragmatic conceptualizations is particularly important in this research project as it includes cross-cultural dynamics which are a distinguishing characteristic of the TCK population. Axiology. At the foundation of pragmatism is an ethical view of research as a social endeavour aimed at bettering the lives of the targeted population, improving society and tasked with working for the social good (Biddle & Schafft, 2015; Hall, 2013). Within this context pragmatists place high value on the principles of action and reflection INTEGRATING EGO IDENTITY WITH LI THERAPY 46 throughout the research process (Biddle & Schafft, 2015; Hall, 2013; Johnson & Onwuegbuzie, 2004). Pragmatist researchers are aware that their own values influence and shape research goals and processes, what and how they study, and as such advocate for the inclusion of reflection within research projects (Hall, 2013). All these axiological considerations are particularly relevant to the analysis process of this study, as will be further substantiated below. In investigating the use of LI therapy in addressing experiences of fragmentation of self among TCKs, I aim to influence and inform therapeutic practices for this population. This goal is in alignment with pragmatic axiological considerations regarding social improvement. The high importance of reflection and reflexivity within the pragmatic approach is highly pertinent for this project in my taking on the role of both study participant and lead researcher. This dual role places greater importance on explicitly identifying and examining the influence of my positionality and biases on research decisions, procedures and processes. Feminist Influences. Pragmatism and feminism are compatible paradigms (Seigfried, 1996) that share several conceptual and theoretical principles such as the value of subjective experience as a source of credible knowledge (Biddle & Shaft, 2015; Campbell & Wasco, 2000; Mitchell, 2017; Morgan, 2014), valuing social change (Campbell & Wasco, 2000; Hall, 2013), and perceiving the process of knowledge acquisition as equally important to the knowledge itself (Campbell & Wasco, 2000; Morgan, 2014). While this study is primarily situated within the pragmatic paradigm, certain foci and values from feminism are adopted as they highlight unique aspects of the study. INTEGRATING EGO IDENTITY WITH LI THERAPY 47 Divisions and power hierarchies. In positioning myself in the dual role of researcher-participant I am aligning myself with the feminist call to challenge the divisions and power hierarchies present in traditional researcher-participant dynamics (Eagly & Riger, 2014; Etherington, 2017; Hesse-Biber, 2012). In being both the subject of study and the primary investigator, the researcher-participant divide and hierarchical structure are eliminated. In so doing, this project spotlights and prioritizes the subjective and emic experience within the research which is also congruent with feminist paradigmatic considerations (Mitchell, 2017). Voice for marginalized experiences. In utilizing a first-person narrative approach within this study, I am adopting the feminist value of giving voice to marginalized experiences (Brown & Gilligan, 1992; Gilligan, 2003). While TCKs are not a marginalized population due to oppression, the TCK literature clearly identifies social marginalization as characteristic of the TCK experience (Cottrell, 2007; Ender, 2002; Killguss, 2008; Pollock et al., 2017; Smith, 2011; Walters, 2006; Wrobbel & Plueddemann, 1990). In living between cultural worlds and amid structures in which they have no power or control (Davis, et al., 2015; Hoersting & Jenkins, 2011) their voices are silenced, and their experiences rendered invisible (Killguss, 2008; Melles & Frey, 2014; Walters, 2006). This study, then, takes up the feminist call to give voice to the silenced and make visible that which has been hidden. Intersectionality. Intersectionality is a feminist analytic tool that has earned wide-spread influence and application across disciplines and has been hailed by Kathy Davis as “the most important contribution women’s studies…has made so far” (as cited in Nash, 2019, p. 11). The addition of intersectional analysis within the methodology of INTEGRATING EGO IDENTITY WITH LI THERAPY 48 this study brings to the forefront feminist resistance to forms of oppression and rectification of inequalities in privilege and power (Cho, Crenshaw, & McCall, 2013; Grzanka, 2018; Nash, 2019). The pattern in research and psychology of privileging objective and quantitative forms of knowledge and compartmentalizing constructs and lived experience are examples of oppression and domination that can be addressed through intersectionality (Cho, Crenshaw, & McCall, 2013; Grzanka, 2018; Nash, 2019). Within this project, the intersectional response of resistance towards and remediation of these reductive and dismissive practices serves to synthesize discrepancies and conflictual information resulting from the inclusion of both third-party external analysis and reflexive researcher-participant determinations (see Research Design, p. 46 for further details). Intersectional analysis therefore serves as a tool for broadening the analytic lens through the examination of ideas and experiences in a wholistic and interconnected manner (Bowleg & Shields, 2008; Cho, Crenshaw, & McCall, 2013; Nash, 2019). Enhanced reflexivity. The inclusion of an additional methodological section of enhanced reflexivity is congruent with the feminist value of making researcher positionality and bias explicit within the research process (Campbell & Wasco, 2000; Mitchell, 2017). Its purpose is to mollify the impact of researcher-participant subjectivity within the study and to explore the implications of positionality and bias on the research process, findings and conclusions. Research Design Given the paradigmatic considerations outlined above and in alignment with the pragmatic paradigm and feminist theoretical influences, the research design best suited INTEGRATING EGO IDENTITY WITH LI THERAPY 49 for this study is the Hermeneutic Single Case Efficacy Design (HSCED; Elliott, 2002, 2015). The aim of this study has been to investigate the efficacy of an under-researched psychotherapy (LI therapy) with a new population (TCKs). With this aim in mind, HSCED was selected given its ability to effectively provide evidence for change in psychotherapy outcome research. Specifically, in utilizing HSCED this research has sought to demonstrate whether I, as the LI therapy client, experienced change over the course of therapy; whether this change could be attributed to therapy work; and whether there were any mediating or moderating factors that could better account for the experienced change. By compiling data from numerous quantitative and qualitative sources and recruiting external volunteers to assist with analysis and interpretation of the data, I sought to make probabilistic cause and effect assertions regarding the ability of LI therapy to address my self-reported ego identity fragmentation. The details of my research design are outlined in the following sections. Hermeneutic Single Case Efficacy Design (HSCED). Robert Elliot (2015) created the Hermeneutic Single Case Efficacy Design (HSCED) as “a convincing practical reasoning system for judging the influence of therapy on client change,” (p. 353), considering perceived contextual and causal weaknesses of Randomized Control Trials (RCT) when applied to investigations of psychotherapy techniques (Elliott, 2015). HSCED is a rigorous and systematic research methodology with the ability to incorporate the complexities of context and demonstrate a cause and effect relationship in research on therapeutic processes and client change (Elliott, 2015). More specifically, the structure and process of the HSCED method serves to answer three outcome-related psychotherapeutic questions: INTEGRATING EGO IDENTITY WITH LI THERAPY 50 1) Did the client change substantially over the course of therapy? 2) Is this change substantially due to the effect of therapy? 3) What factors may be responsible for that change? What mediating and moderating factors can be identified? (Stephen & Elliott, 2011, p. 231). The wording of these questions as well as the systematic nature of the HSCED structure have undergone substantial change and revision since the inception of the HSCED method to ensure the greatest accuracy between what is being asked and what can confidently be asserted based on study findings (Stephen & Elliott, 2011). Elliott (2015) labeled this method as hermeneutic, meaning interpretive, in that it is not experimental and does not make absolute claims (see also Wall, Kwee, Hu & McDonald, 2017). Instead, it “attempts to construct a plausible understanding of the influence processes in complex ambiguous sets of information about client’s therapy,” (Elliott, 2015, p.352). To establish causality between therapy processes and therapy outcomes in HSCED, the researcher examines the data collected in search of plausible and compelling narrative explanations for client change (Elliott, 2015). These narrative accounts are interpretive in being context-dependent and in attributing specific explanatory meanings to otherwise inconclusive data (Wall et al., 2017). Rationale for HSCED. In establishing a rationale for the use of HSCED within this research project we first need to examine other treatment outcome research designs, such as randomized control studies and traditional case studies, and understand why they are not an appropriate choice for this study. In determining treatment efficacy, the gold standard for evidence-based interventions has been the Randomized Control Trial (RCT; Elliott, 2015). While RCTs INTEGRATING EGO IDENTITY WITH LI THERAPY 51 have proved effective within the medical field, McLeod (2010) and McLeod and Elliott (2011) revealed that they have been demonstrated to be insufficient in clearly establishing a link between therapy processes and client change within psychology and psychotherapy research. Given the statistical focus on mean values amid a large number of participants, McLeod (2010) explained that RCTs have been unable to predict the efficacy of psychotherapy interventions or the likelihood of change for the single individual. Additionally, it has not been within the purview of RCTs to examine whether there were contextual factors outside of therapy contributing to client change or which specific therapeutic practices led to the observed change (McLeod & Elliott, 2011). As such, an RCT design would not be effective in answering the central research question of this study which means to examine the efficacy of LI therapy in producing client ego identity change. Since randomized control trials have been insufficient for effectively demonstrating a causal relationship between treatment and change within psychology and psychotherapy, researchers have instead proposed the use of case study research (McLeod & Elliott, 2011). This has been demonstrated to be highly effectual in determining the efficacy of therapeutic interventions and is therefore a particularly helpful tool for use in counselling and psychology research (Elliott & Zucconi, 2006; McLeod, 2010; McLeod & Elliott, 2011; Morrow, Castañeda-Sound, & Abrams, 2012). By focusing on a single case, McLeod (2012) noted that factors impacting change can be more thoroughly examined. In contrast to RCTs, researchers conducting case studies are enabled to access and observe the complex nature of the therapy process, collect data observations over time, track patterns of change over time, position therapy within the INTEGRATING EGO IDENTITY WITH LI THERAPY 52 broader contextual framework, and integrate narrative knowledge into the research process (McLeod & Elliott, 2011). This design appears to match the goals and aims of this research study, which are to examine the causal relationship between LI therapy and client change in ego identity fragmentation. Critics of case study research, however, have questioned its validity and value due to “reliance on anecdotal evidence, confirmatory bias, and narrative smoothing,” (Stephen & Elliott, 2011, p. 231). Alongside tackling weaknesses of RCTs within psychology research, Elliott (2015) also structured HSCED to specifically address these case study criticisms. To address over reliance on anecdotal evidence, Elliott (2002, 2015) added the collection of quantitative data (see also Benelli, De Carlo, Biffi, & McLeod, 2015; Stephen & Elliott, 2011). The systematic collection and presentation of both negative and positive evidence for client change, including input from outsider perspectives, and the presence of an external adjudication process addressed concerns regarding confirmatory bias and narrative smoothing (Benelli, et al., 2015; Elliott, 2002, 2015; Stephen & Elliott, 2011). Given the usefulness of case study research for investigations of therapy efficacy, the highly contextual nature of LI therapy, and my position as both the subject of the research and the principal investigator, integrative data sources and a systematic structure are qualities of HSCED that have made it the most reasonable choice in research design. This is congruent with paradigmatic consideration in which pragmatism has advocated for methodological choices based on best fit given the research question (Morgan, 2007; Johnson & Onwuegbuzie, 2004). Additionally, HSCED is congruent with pragmatism’s INTEGRATING EGO IDENTITY WITH LI THERAPY 53 focus on experiential learning while also requiring intersubjective input and making probabilistic rather than universal claims regarding outcomes (Elliott, 2002, 2015). Overall structure of HSCED. While specific processes and measures utilized in HSCED will be explained in greater depth in the upcoming section on Procedures (see pg. 58), here I present a brief look at the overarching structure of HSCED. HSCED follows a systematic and rigorous structure that can be divided into three stages (see Figure 3; Benelli, et al., 2015). The first stage is comprised of therapy sessions and data collection. The second stage involves data analysis through the compilation of the rich case record (RCR) and the development of the affirmative and skeptic case briefs. The final stage incorporates the adjudication process to arrive at answers to the three central questions, and the researcher’s final conclusions (Elliott, 2002, 2015; Stephen & Elliott, 2011; Wall et al., 2017). Figure 3. Structure and stages of HSCED method (adapted with permission from Wall, Kwee, Hu, & McDonald, 2017). INTEGRATING EGO IDENTITY WITH LI THERAPY 54 Adaptations. For the purposes of this study several adaptations were made to Elliott’s (2002, 2015) HSCED method to accommodate the unique contributions of this research to the study of therapeutic interventions and the study’s alignment with the paradigmatic considerations outlined above. These adaptations include this writer taking on the dual role of both researcher and study participant; the addition of a section on enhanced reflexivity; the absence of an objective quantitative measure; increasing the frequency and type of tracking of HSCED’s quantitative client measure (Personal Questionnaire); and the inclusion of intersectional analysis. Researcher-participant. The decision to take on the dual role of sole study participant and primary researcher within the project was a naturalistic choice. This project emerged out of my personal experience and a personal quest for answers in my own journey towards healing. As such, I not only fit the criteria for participation in this study but was primed for engagement in therapy making my data readily available and easily accessible. This is congruent with pragmatic and feminist theoretical views which blur the lines between subject and object in research (Hall, 2013; Johnson & Gray, 2010; Johnson & Onwuegbuzie, 2004; Morgan, 2007, 2014), and between researcher and participant (Brown & Gilligan, 1992; Campbell & Wasco, 2000; Etherington, 2017; Mitchell, 2017). One potential implication of taking on a dual role of researcher-participant was the production of a highly subjective and biased study with little value or validity beyond relaying a personal experience. Many of the concerns surrounding this adaptation were mitigated with the adoption of the HSCED method, which affords a level of rigour to the study by its very structure (Elliott, 2015; Stephen & Elliott, 2011; Wall et al., 2017). Of INTEGRATING EGO IDENTITY WITH LI THERAPY 55 note is the requirement to produce case documentation both for and against client change and change due to therapy which greatly reduces the possibility of confirmatory bias (Elliott, 2002, 2015; Stephen & Elliott, 2011; Morrow, 2005). Additionally, I made use of research team members and external volunteers during preparation of the RCR, case development and adjudication procedure to ensure that final conclusions were not solely or even primarily based on my personal viewpoints and observations. Rather, the input of outsider perspectives and judgments were integrated throughout the data analysis process. The effects of functioning within this highly subjective role were further mitigated by the inclusion of a section on enhanced reflexivity in which I explicitly present and explore the implications of power dynamics and my positionality within the study on both the process and findings of this research. Furthermore, this is consistent with feminist paradigmatic considerations (Eagly & Riger, 2014; Etherington, 2017; Hesse-Biber, 2012). Using my personal experience not only made logistical sense, it also offered the potential for greater richness of data in having full access to my first-person experience as the client. In making use of myself as the research subject, this study could be described as a type of auto-HSCED along the lines of other auto-methodologies such as autoethnographies, autobiographies, and memoirs. This innovative contribution to the HSCED literature is congruent with feminist theoretical influences in privileging the voice of the client and valuing knowledge gained through subjective and emic experiences (Brown & Gilligan, 1992; Gilligan, 2003; Mitchell, 2017). A further adaptation to HSCED implemented within this study was to invite the researcher-participant to participate in the adjudication process. In addition to the 3 INTEGRATING EGO IDENTITY WITH LI THERAPY 56 external judges that were recruited, I also conducted my own adjudication process of the study data and included my determinations in the project’s final conclusions. This is congruent with feminist theoretical influences in privileging the voice of the client and valuing knowledge gained through subjective and emic experiences (Brown & Gilligan, 1992; Gilligan, 2003; Mitchell, 2017) and with Stephen and Elliot’s (2011) desire to enhance the presence of client voice and knowledge within case study research. Enhanced reflexivity. While the inclusion of reflexivity is recommended for all qualitative research (Finlay, 2002; Guillemin & Gillam, 2004), it is not included as a standard element within the HSCED structure (see Figure 3). The inclusion of reflexivity within this study was viewed as a necessary adaptation due to my role as researcherparticipant. To begin, I will define what is meant by reflexivity and then proceed to discuss its purpose within the research project, its unique contributions to this study and briefly outline the process. Defining reflexivity. To fully understand what is meant by enhanced reflexivity one must first differentiate between reflection and reflexivity. Reflection is characterized by “thinking about something,” (Mann, 2016, p. 8). It involves thinking over one’s experience, assessing its quality, and arriving at a judgment or opinion about one’s sense of that experience (Mann, 2016). Reflexivity, on the other hand, is an “explicit evaluation of self…. reflecting your thinking back to yourself….turning your gaze to the self,” (Shaw, 2010, p. 234). Or, in the words of Clancy (2013), it is the, “ability to be introspective and to look at external forces that may shape the [experience] such as culture, history, politics…. social interactions,” (p. 15). Thus, reflexivity is an examination of power hierarchies at work INTEGRATING EGO IDENTITY WITH LI THERAPY 57 within the research process and the impact of researcher positionality upon the findings and outcomes of the study (Clancy, 2013; Finlay, 2002; Mann 2016) which is necessary for the inclusion of the researcher-participant adaptation. Purpose and contributions. Enhanced reflexivity is a combination of the practice of researcher reflexivity with the feminist construct of voice. This allows a rich personal description of subjective experiences alongside an in-depth analysis of the social and cultural forces at play within these experiences. Enhanced reflexivity not only serves to disclose and minimize the impact of researcher-participant bias, it also allows “the inner psychic world of feelings and thoughts out into the open air of relationship where it can be heard by oneself and by other people,” (Brown & Gilligan, 1992, p. 20). In enriching researcher reflexivity with the inclusion of first-person narrative description, readers are drawn into an encounter with the real-world experience of a person. The desired impact of this encounter is that: as the other’s words enter our psyche, a process of connection begins between [their] thoughts and feeling and our thoughts and feelings in response, so that [they] affect us and we begin to learn from [them] – about [the narrator], about ourselves, and about the world we share in common….We are affected, changed by that voice, by words that lead us to think or feel a variety of things – that may turn our thoughts in new directions and may cause us to feel, (Brown & Gilligan, 1992, p. 28).4 4 Original text made use of exclusively female pronouns. Here, these pronouns have been replaced with third person pronouns to reflect a modern shift in feminism to include all marginalized communities regardless of gender (Eagly & Riger, 2014; Mitchell, 2017). INTEGRATING EGO IDENTITY WITH LI THERAPY 58 The hope has been that in providing an opportunity for this type of encounter between the author and the readers, this study may act as a catalyst for change and transformation; revealing truths, fostering understanding, encouraging curiosity, and bolstering courage. Process. The primary tool in reflexivity is the research diary or journal that maintains a chronological record of the researcher’s thoughts, feelings, questions, challenges and other experiences throughout the research process (Ballinger, 2003; Gough, 2003). In adopting an enhanced form of reflexivity in this study the research journal was expanded to also include experiential data in my role as a therapy client. While at times it was easy to distinguish between material collected that is specific to my role as client or my role as researcher, at other times content served both purposes in being applicable both to therapy work and to my process as a researcher. This journal took many forms including paper journal entries, electronic journal entries, records of personal communications in the form of texts and emails, and photographs. Ballinger (2003) de-emphasized the systematization of journal keeping and instead advocated for entries that are voluntary and on an as-needed basis. In following this example, I mirror Ballinger’s (2003) desire for his research journal, “to represent a resource which [he] did not feel compelled to maintain, but rather where [he] could engage with intellectual (and personal) challenges connected with [his] research enterprise when [he] wished,” (p. 70). This perspective on the use of the research journal is congruent with pragmatic methodological considerations that prioritize functionality over systematization (Biddle & Schafft, 2015; Johnson & Onwuegbuzie, 2004; Morgan, 2014; Tasshakkori & Teddlie, 2010). INTEGRATING EGO IDENTITY WITH LI THERAPY 59 Data collection. Data collection adaptations present within this study included the absence of an objective measure of ego identity and the daily tracking of PQ ratings for both intensity and frequency of distress. Absence of objective measure. Elliott (2015) delineated within the HSCED structure, the use of at least one problem-specific or theoretically relevant quantitative measure alongside the HSCED-specific and client-generated quantitative measure called the Personal Questionnaire (PQ). This problem-specific or theoretically relevant quantitative measure was absent in this project and was instead replaced with extensive first-person experiential data including such items as journal entries, personal communications, and photographs. The absence of an objective measure and its replacement with experiential data is congruent with pragmatic and feminist paradigmatic considerations in privileging the client voice above statistical data and objective measures (Brown & Gilligan, 1992; Gilligan, 2003; Mitchell, 2017), in emphasizing experience as a source of knowledge (McWilliams, 2016; Mertens, 2014; Patton, 2002), and in spotlighting the value in research of subjective and emic experiences (Biddle & Shaft, 2015; Campbell & Wasco, 2000; Mitchell, 2017; Morgan, 2014). The richness of this data in portraying an in-depth perspective on therapeutic change is a unique contribution this study hopes to offer research on therapeutic treatment. Personal Questionnaire (PQ). A further adaptation is the introduction of daily PQ (Elliott, Mack, & Shapiro, 1999; see Appendix E & F) item tracking in addition to weekly tracking for increased accuracy in measuring levels of distress. Daily tracking utilized the same 7-point Likert scale and enhanced data collection in tracking both the intensity and frequency of each PQ item. Calculations of PQ item means for the period INTEGRATING EGO IDENTITY WITH LI THERAPY 60 in between counselling sessions was used in preparing the pre-session summative reports. At times I made use of subjective judgement in increasing or decreasing ratings on the summative reports if I felt the resulting mean scores did not accurately reflect the level of distress I experienced between sessions. These changes are readily identifiable when comparing mean daily item ratings with summative report ratings (see RCR Appendix B, pp. 416-423). Where scaling of a PQ item differed from the norm, such as PQ item 11 where intensity rating reflected occurrence of behaviour rather than level of distress, this has been clearly documented (see section on Measures for a more detailed explanation). Previously, PQ items were rated retrospectively by the client in completing a summative report at the beginning of each therapy session reflecting perceived levels of distress on PQ items over the past seven days (Elliott, et al., 1999; see Appendix E). In instituting daily tracking of PQ items data more accurately reflected actual levels of distress across time in being a summary of 24 hours versus a retrospective evaluation of a 7-day period. In addition, in instituting tracking of intensity and frequency of distress this data provided a less skewed portrayal of overall distress in not overinflating the significance of single episodes of high distress over and above general patterns of low distress. Mapping out this data across time afforded greater accuracy in tracking patterns and significant levels of change in PQ item scores. Intersectional analysis. In alignment with feminist paradigmatic influences adopted within this study, intersectional analysis is a novel procedural addition to the traditional HSCED data analysis process. The characteristic uncertainty that intersectional thinkers hold towards analytic processes in recognizing their ability to both enlighten and oppress knowledge (Nash, 2019), parallels Elliott’s (2002, 2015; Stephen INTEGRATING EGO IDENTITY WITH LI THERAPY 61 & Elliott, 2011) impetus and structural decisions in the creation of HSCED. Rooted in resistance to de-contextualizing psychotherapy research, HSCED was created as a response to processes that failed to recognize the wholeness of research participants (Elliott, 2015). To achieve credibility and comparability within the broader context of academia, however, Elliott (2002, 2015; Stephen & Elliott, 2011) included certain research elements that mirror the very problematic processes HSCED is meant to remediate. Notably is Elliott’s (Stephen & Elliott, 2011) use of a judicial framework as a metaphor for conducting case development and adjudication processes. In framing analysis in this manner there is risk for HSCED, even when conducted properly, to reproduce the oppressive compartmentalization and reductionist tendencies present in legal processes and marking a return to the de-contextualizing patterns of traditional psychotherapy research. To borrow from Elliott’s judicial metaphor, the emergent intersectional analytic process included in this study serves as a type of appeal process of the external adjudication findings. It is not a dismissal of the external adjudication results but a reexamination and re-contextualization of the data in order to reconcile discrepancies of findings with the reflexive adjudication determinations. This appeal process required an examination and comparison of all adjudicator responses (external and reflexive) through an intersectional lens focused on identifying instances where oppression, power and privilege produced differences in analytic processes and results. In resisting these influences by providing a broader contextual framework for data interpretation, intersectional analysis serves as a synthetic clarification or refinement of adjudication analytic results. INTEGRATING EGO IDENTITY WITH LI THERAPY 62 Procedures This research project followed a unique timeline due to personal, therapeutic, academic and research considerations. Procedures in this study are therefore best understood within the context of the overall research process timeline. Research Process Timeline. This study emerged from a series of key conversations and decision points as well as situational and contextual factors. Various personal, academic and research considerations led to this project following a unique timeline with regards to the order in which certain activities took place. Table 1 provides a summary outline of this project’s timeline from deciding on the study’s overall research focus up until the internal thesis defence 19 months later. Table 1 Summary of research timeline from initial research focus to internal defence. DATE(S) RESEARCH PROCESS/ACTIVITY September 2017-May 2018 Determination and refinement of research focus February 2018-April, 2018 REB approval process. May 2018 – April, 2019 May, 2018-February 2019 Thesis Proposal: from first draft to eventual defence. Determination and refinement of analysis method and theoretical foundation. LI counselling with Hillary McBride May 2018-April 2019 Data collection April-June, 2019 Data Analysis process. July 2019 Internal Thesis Defence Research Participants. The single-case research design for this study involved the participation of a single adult TCK who would benefit from therapeutic help in addressing a fragmented sense of self due to their TCK experience of repatriation. INTEGRATING EGO IDENTITY WITH LI THERAPY 63 Inclusion and exclusion criteria. More specifically, the participant selfidentified as and matched the descriptive criteria of a traditional TCK as someone who has spent a significant amount of time during their developmental years living outside of their passport country due to a parent’s work decision (Pollock et al., 2017). Furthermore, the candidate self-reported ego identity fragmentation, defined as a lack of cohesion in sense of self over time and space, that they attributed specifically to the dynamics of mobility and repatriation in their TCK experience. In addition, the participant had no previous experience with LI therapy and was willing and available to participate in LI therapy sessions over a minimum 4-6-month period. The participant was committed to participating in all aspects of the research project including completion of all necessary measures and paperwork as well as change and follow-up interviews. According to LI protocol, candidates who are regularly taking prescription benzodiazepine medication, pain-killers or marijuana would need to be excluded as use of these drugs interferes with body-based protocols integral to LI therapy and the candidate’s ability to be fully mentally and emotionally engaged with LI processes (Pace, 2018; Wall et al., 2017). Moreover, to prevent harm and facilitate full candidate participation both in therapy sessions and research processes, the participant was screened and deemed to be free from major mental health problems including, but not limited to, persistent thoughts of suicide, frequent and major panic attacks, and frequent episodes of dissociation from their body. Participant recruitment. Recruitment for this study followed a naturalistic selection process in choosing a candidate who fulfilled all inclusionary and exclusionary criteria, was already committed to the project, had unlimited availability and was already INTEGRATING EGO IDENTITY WITH LI THERAPY 64 seeking therapeutic help for the identified problem area. Given these parameters, I was the logical choice of participant. As a Canadian citizen who lived in Mexico City from the ages of 4 to 10 due to my parents’ roles as missionaries, I match the description of a TCK and self-identify as a member of this population. For many years now, I have conceptualized experiencing a fragmentation of my core self identity as a result of acculturative stresses related to repatriation to Canada at age 11 and, therefore, self-report ego identity fragmentation. Issues with regular use of painkillers or marijuana were nonexistent and, while I have been experiencing anxiety and symptoms of dissociation, neither were severe enough to interfere with therapy and exclude me from the study. Furthermore, the prescription medication I have been taking for anxiety does not exclude me from participation as it is serotonin-norepinephrine re-uptake inhibitor (SNRI) and not a benzodiazepine. Therapist recruitment. Recruitment of the LI therapist was conducted from among known therapists in the geographical vicinity of me (the participant). Therapists under consideration were required to be certified or registered (i.e., RCC - Registered Clinical Counsellor; CCC – Canadian Certified Counsellor; or R. Psych. - Registered Psychologist) indicating compliance with academic, clinical competence, and professionalism standards of the governing professional association including formal training in counselling and therapy as evidenced by a minimum MA in Counselling Psychology or equivalent degree, and with demonstrated overall competency in therapeutic work. In addition, the therapist was required to have successfully completed at least level 1 and 2 of LI therapy training and have prior experience with its use. At minimum the therapist had to commit to being available for weekly or bi-weekly therapy INTEGRATING EGO IDENTITY WITH LI THERAPY 65 sessions with myself and agree to participate in data collection by completing the postsession therapist measure designed for this study (see Appendix H). Upon consideration of all these criteria, Hillary McBride was recruited as the therapist of this research study. Her credentials included being a Registered Clinical Counsellor, having an MA in Counselling Psychology, current candidacy for a doctoral degree, beginning and advanced training in LI therapy (equivalent to Levels 1-2 in current LI training structure), and experience as an instructor for graduate-level advanced skills course. Her prior experience with research and her ongoing interest and commitment to furthering counselling psychology research made her an ideal candidate. It is important to note that prior relationships with Hillary McBride existed with some members of the research team who participated in this research project. As a former graduate student of the MA Counselling Psychology program at Trinity Western University (TWU) where this research was being conducted, Hillary was known by the two professors who participated in case development, as well as by my supervisory committee (Dr. Kwee and Dr. McDonald). Additionally, Dr. Kwee had supervised Hillary’s master’s thesis and together they had collaborated on research and academic publications over the years since her graduation from the program. I, as the client, research participant and primary investigator in this project, knew Hillary McBride only by name and reputation prior to beginning this project as she had taught a graduate course at TWU the previous academic year. She and I had never met in person nor communicated until the day Dr. Kwee and I met with her to discuss her participation in this thesis study. While such background information was not collected, given Hillary’s presence at TWU and the popularity of some of her counselling related INTEGRATING EGO IDENTITY WITH LI THERAPY 66 podcasts it is likely that many of the case development team members and external judges (besides the professors) had at least heard of her by name and were familiar with her reputation. It is, however, unclear if any had a more personal relationship with her. Research teams and judges. Data analysis within the HSCED structure lends itself to incorporating outside volunteers to assist in examining the study data and increasing the rigour and trustworthy of research findings and conclusions. To this end I made use of research team members, and case development and adjudication recruits during the data analysis process. Research team. Graduate students with graduate level experience and training with quantitative and qualitative research data were recruited to assist with analysis of quantitative measures and to provide an outsider perspective and input in the development of the RCR. All research team members were required to sign a confidentiality agreement (see Appendix N) with regards to research material. Gender of team members was not a consideration. Training regarding HSCED processes, data analysis criteria and purpose and structure of the RCR was provided to research team members as needed to ensure standards of rigour and trustworthiness of results and findings was maintained. Case development teams. Case development team creation entailed the recruitment of eight volunteers from among known clinicians, professionals, and graduate students with expertise in the areas of LI therapy, ego states and identity development, and TCKs (Lewis, 2017; Wall et al., 2017). Research team members were exempt from consideration for case development teams due to prior exposure to case study data. Each case development volunteer was assigned to either the affirmative or skeptic team INTEGRATING EGO IDENTITY WITH LI THERAPY 67 ensuring a balance in numbers (4 members per team) and areas of expertise and experience between the two teams was maintained (Stephen & Elliott, 2011; Wall et al., 2017). To allow team members to focus on argumentation, I recruited a fifth non-expert volunteer for each team from among graduate students to serve as a dedicated note-taker during the case development working session. All team members were required to sign a confidentiality agreement (see Appendix N) and to commit to reviewing the RCR document on their own prior to participating in a three-hour conjoint case development meeting. To ensure role competency and adherence to criteria for methodological rigour (see section on Methodological Rigour and Quality for a more detailed explanation, p. 84) team members attended either an individual or group orientation meeting that provided oral and written training and instruction with regards to tasks and responsibilities as laid out within HSCED (see section on Affirmative and Skeptic Cases for a more detailed description, p. 79). These were further reviewed at the start of the group working session. Adjudicators. The adjudication process entailed recruiting a panel of three judges (Elliott, 2015) from among expert clinicians and professionals with theoretical and practical knowledge in the areas of LI therapy, ego states and identity development, and TCKs (Stephen & Elliott, 2011; Wall et al., 2017). In recruitment, I prioritized candidates with demonstrated ability to make sound judgments and with prior experience with research in the humanities and/or experience in evaluating research data. Adjudicators were required to commit to: a) conducting a review of the RCR including both the affirmative and skeptic case development summaries; b) individually arriving at a decision or judgment regarding the presence or absence of client change, whether the INTEGRATING EGO IDENTITY WITH LI THERAPY 68 change was due to therapy, and their level of confidence in putting forward these assertions; and c) be available to fulfill these responsibilities within an appropriate timeframe. To ensure role competency and adherence to criteria for methodological rigour (see section on Methodological Rigour and Quality for a more detailed explanation, p. 84) all adjudicators attended a project orientation meeting during which they were provided with training and instruction orally and in writing with regards to tasks and responsibilities of adjudicators as laid out within HSCED (see section on Adjudication for a more detailed description, p. 82). Therapy and Data Collection Procedures. In this first stage of the HSCED structure, therapy sessions were conducted and data on quantitative measures as well as qualitative and experiential data was collected. Below I outline the processes followed in gathering research data including pre-therapy, during therapy and post-therapy collection of information. Furthermore, a description of each measurement tool used in this study is provided. Therapy sessions. LI therapy was pursued by me in my role as study participant and entailed a series of 32 weekly or bi-weekly sessions that began May 18, 2018 and ended on February 27, 2019. Hillary McBride conducted all sessions in her role as a clinical counsellor. The first 14 sessions (March – August 2018) were conducted in person at Hillary’s office. In September sessions transitioned to an online format using Zoom (an online remote conferencing service) due to the therapist moving out of area as a result of a change in her educational placement. As recommended by Elliot (2002) a change interview was conducted in August prior to the start of online sessions to highlight any possible impact a change in modality may have on the efficacy of the INTEGRATING EGO IDENTITY WITH LI THERAPY 69 therapy process. The change interview process is further detailed below in the therapy mid-point section of Data Collection (p. 64). Therapy session work focused on the use of LI protocols which targeted the autobiographical integration of ego identity and the establishment of a strong cohesive core self. Data collection. As illustrated by the flow chart in Figure 4, data collection within the HSCED model occurs at 4 different points in the research process: 1) pretherapy, 2) during therapy, 3) therapy mid-point, and 4) post-therapy. Detailed descriptions of the forms and assessments used in each stage of data collection is provided in the Measures section (p. 68). INTEGRATING EGO IDENTITY WITH LI THERAPY Figure 4. Flow chart of data collection processes. 70 INTEGRATING EGO IDENTITY WITH LI THERAPY 71 Pre-therapy. Pre-therapy work focused on establishing criteria to be measured and tracked in the PQ and establishing a baseline of beginning levels of distress and symptom prevalence/duration related to each PQ item (Elliott et al., 1999; see Appendix E). This process involved my meeting with my research supervisor on May 10, 2018 before the start of the first LI therapy session. During this meeting we identified key problem areas to be included on my PQ form and prioritized them based on level of personal significance and desired change I attributed to each item. Completing the PQ Duration form (see Appendix E) established the historical prevalence of symptoms. Lastly, I completed my first summative PQ form providing the initial baseline distress scores for each PQ item. During therapy. Data collection during therapy involved daily tracking of PQ items, completion of pre-session summative PQ reports, session audio and video recordings, and post-session Helpful Aspects of Therapy (HAT) and Therapist Session Note Questionnaire (TSNQ) forms. As previously mentioned in this study we adapted tracking of PQ scores to include daily tracking of both intensity and frequency of distress experienced over a 24hour period for each PQ item (see Appendix F). Daily tracking began after session 2 of therapy (May 25, 2018) and continued throughout therapy until the follow-up Change Interview on April 4, 2019. These scores were recorded in an Excel spreadsheet securely maintained on this writer’s personal computer. Before each LI therapy session, I also recorded distress levels on what I am calling a pre-session summative PQ report in order to differentiate it from the daily PQ item tracking. This report consisted in the standard PQ form typically used in HSCED INTEGRATING EGO IDENTITY WITH LI THERAPY 72 studies (see Appendix B). I am classifying it as a summative report as I used the mean scores of my daily PQ tracking to summarize the general trend in daily recorded levels of distress for the time period in between therapy sessions. All therapy sessions were recorded using my laptop (video) and iPhone (audio). When sessions transitioned to occurring online, I made use of the recording feature within the Zoom programing to produce audio and video recordings of the sessions. Separate audio and video recordings were taken to act as back-ups for each other should one format of recording fail. After each therapy session I, in my role as the study participant and therapy client, completed the Helpful Aspect of Therapy (HAT) form (Llewelyn, 1988; see Appendix G) and Hillary McBride, in her role as the therapist, filled out the Therapist Session Notes Questionnaire (TSNQ) (Hu, 2014; see Appendix H). Both data sources are part of the structured and systematic quantitative and qualitative data collection procedures inherent within the HSCED method. Over the course of therapy, I also collected what I am terming experiential data. By this I am referring to data that records, describes and explores my personal experience as a therapy client as well as my internal process as the primary researcher in this study. Sources of this data have included but are not limited to a paper journal, an online journal, records of personal communication such as emails and texting conversations, and photographs of projects or activities. Therapy mid-point. At the mid-point of therapy, after the 14th session, a Change Interview (CI; Elliott, 1999) was conducted in accordance with Elliott’s (2002) recommendation for the collection of periodic summative change data in longer-term INTEGRATING EGO IDENTITY WITH LI THERAPY 73 therapy investigations. Furthermore, due to the switch from in-person therapy to online therapy that occurred after session 14, I, in consultation with the research supervisor, perceived it to be prudent to have a record of changes experienced thus far in therapy to highlight any potential impact of therapy modality on degree of experienced change or efficacy of LI therapy in producing said change. This CI consisted of a 2-hour semistructured interview conducted by the research supervisor, Janelle Kwee, in accordance with procedures outlined within the HSCED method (Elliott, 1999; see Appendix I). Post-therapy and follow-up. In accordance with best practices when employing the HSCED method, Janelle Kwee, the research supervisor, conducted a second CI at the termination of LI therapy on February 28, 2019, and a third CI at the follow-up meeting approximately one month after the termination of therapy (April 4, 2019; Elliott, 2002). Data storage and confidentiality. All files and paperwork pertaining to this study and containing client information were anonymized with the use of a pseudonym of my choice. Access to electronic files maintained on my personal laptop were restricted through the institution of double level security including password protection access to the laptop and password protected encryption of files. In addition, these encrypted electronic files were backed up to my password protected cloud account. Paper copies of HAT and summative PQ reports were stored in a locked location and submitted to the research supervisor every few weeks for secure storage on campus. TSNQ files completed by the therapist were anonymized through use of client pseudonym and were securely stored by her until after therapy was complete at which time Hillary submitted them to the research supervisor to be stored in a locked location along with other project paperwork. INTEGRATING EGO IDENTITY WITH LI THERAPY 74 Measures. Simplified Personal Questionnaire (PQ) and PQ Duration Rating Form. The Simplified Personal Questionnaire (PQ; Elliott et al., 1999; see Appendix E) is a quantitative self-report measure comprising a list of approximately 10 key problem areas identified by the client. It is first completed pre-therapy to establish a baseline value for each PQ item and changes are tracked by subsequent rating of PQ items before the start of each therapy session. These PQ ratings provide data points over time for tracking shifts in behaviours and linking these to therapy events and external factors (Elliott, 2002). The PQ Duration Rating Form (Elliott et al., 1999; see Appendix E and PreTherapy in Figure 4) is also a quantitative self-report tool completed once before therapy begins and which measures the length of time the client has been experiencing the identified problems at approximately the same or higher level of current distress. This form is used in establishing the historical prevalence of symptoms or problem areas. Each PQ item is rated on a 7-point Likert scale ranging from less that 1 month (1) to more than 10 years (7). For the purposes of this study, my research supervisor and I met before the start of my first therapy session to identify and prioritize the key problem areas to be included on my PQ form (see Pre-Therapy in Figure 4). Collaboratively we identified 14 items that I hoped would evidence change over the course of LI therapy. Due to the emergence of another significant area of hoped for growth over the course of the first half of therapy, I added a fifteenth PQ item for tracking in August. The addition of this fifteenth item is consistent with Dewey’s pragmatic process of inquiry in which reflection (noticing a new INTEGRATING EGO IDENTITY WITH LI THERAPY 75 area of hoped for growth) leads to action (tracking change in this new area) (Morgan, 2014). Furthermore, the addition of a new PQ item is congruent with feminist practice in prioritizing the client perspective in research (Mitchell, 2017). Daily PQ scoring (see Appendix F) followed the 7-point Likert scale regarding levels of distress experienced ranging from not at all (1) to maximum possible (7). Levels of distress were termed intensity. In addition, daily tracking included frequency of distress symptoms for each item and utilized a similar 7-point Likert scale ranging from not at all (1) to all the time/all day (7). PQ items 6, 11, and 15 follow modified Likert scales. Item six, related to sleep patterns, retained the same scale for scoring level of experienced distress but the second rating measured level of sleep disturbance experienced followed a scale from none (1) to being awake for an extended period of time more than once through the night (7). A second PQ item, number 11, retained the same scale for frequency however, instead of measuring intensity of experienced distress I measured the degree or level of engagement in the specific identified behaviour. The third PQ item, number 15, was rated using the same intensity and frequency Likert scales however, as it measured the hoped-for emergence of a positive behaviour pattern, scores indicating positive change moved in the opposite direction meaning high scores reflected positive change and low scores reflected a lack of change. Data set for this PQ item was reverse scored at time of data analysis to ensure all positive changes were reflected by analogous patterns in the data. Daily PQ item ratings (see During Therapy in Figure 4) were tracked by me on an Excel spreadsheet which aided in the calculation of mean item scores for the period in between therapy sessions. In turn I used these mean values in completing each pre- INTEGRATING EGO IDENTITY WITH LI THERAPY 76 session summative PQ report (see During Therapy in Figure 4) summarizing the general trend in daily recorded levels of distress for the time period in between therapy sessions. The summative PQ report recorded mean values using the 7-point level of distress Likert scale ranging between none at all (1) to maximum possible (7). The PQ item rating modifications mentioned above applied to the three PQ item ratings (item 6, 11 and 15) on the summative report as well as the daily ratings. Helpful Aspects of Therapy (HAT). The HAT (Llewelyn, 1988; Elliott, 1993; see Appendix G) form consists of a 7-point questionnaire inquiring about helpful and hindering aspects of the therapy session. It is used to identify therapy session events that may have impacted weekly quantitative measures and so provides insight into therapy processes that bring about change (Elliott, 2015). Information from HAT forms was used in data analysis processes (see Appendix D, Figure D1 and D2) in identifying explanatory evidence for patterns and shifts in PQ ratings over time as further described in the Quantitative Data Analysis section (p. 74). I, in my role as the therapy client, completed a HAT form after each LI session identifying helpful and hindering events (actions or words) that I perceived having occurred during therapy (see During Therapy in Figure 4). Typically, the form is completed immediately at the end of the therapy session, however, due to the highly experiential nature of LI therapy and the neural processes at work during and after sessions, LI clients are given the opportunity to postpone their response for 24-48 hours (Lewis, 2017). Furthermore, the research supervisor, Janelle Kwee, made herself available for session debriefing if I needed assistance in processing my experience during session and INTEGRATING EGO IDENTITY WITH LI THERAPY 77 completing responses on the HAT questionnaire. In total, I utilized this resource twice over the course of therapy that consisted of me verbally answering the HAT form prompts and the research supervisor recording my responses in writing. Therapist Session Notes Questionnaire (TSNQ). The TSNQ (Hu, 2014; see Appendix H) was developed specifically for use in HSCED projects involving LI therapy. It is an adapted version of the Therapist Experiential Sessions Form (TESF; Elliott, 2003) that is traditionally used in HSCED projects, in combination with the HAT, and modified to also record LI protocol information, general session notes and other therapist observations (Hu, 2014). These notes are helpful in providing general information on therapy sessions and offer a second perspective on client change as well as helpful and hindering events (Wall et al., 2017). Elliott (2002) notes that therapist information can be helpful when needing to “pinpoint, corroborate, or clarify issues or contradictions elsewhere in the data,” (p. 5). As with the HAT form, information from TSNQ forms was used in data analysis processes (see Appendix D, Figure D1 and D2) in identifying explanatory evidence for patterns and shifts in PQ ratings over time as further described in the Quantitative Data Analysis section (p. 74). As the LI therapist for this study, Hillary McBride completed the TSNQ form for each of our therapy sessions. Video and audio recordings. Audio and video recordings of sessions are recommended as a primary data source that can be referred to in order to ensure clarity and accuracy of information being compiled in the RCR (Elliott, 2002, 2015). Recordings were collected for each therapy session and each CI, both those conducted in person and those conducted online via the online remote conferencing service Zoom (see During Therapy in Figure 4). INTEGRATING EGO IDENTITY WITH LI THERAPY 78 Separate files for audio and video recordings were created to act as back-up copies of sessions should one system or the other fail to properly record proceedings. Additionally, while audio files would be sufficient to understand verbal content of therapy sessions, video recordings are useful in capturing the subtleties of non-verbal communication. This was especially important in this study due to the nature of LI therapy which relies heavily on non-verbal signals and cues to inform therapist actions and communicate client experience. Change Interview (CI). The CI (Elliott, 1999; see Appendix I) is a minimum 3045-minute semi-structured interview conducted at least at the end of therapy but may also be conducted every 10 or so sessions and be used at follow-up (Elliott, 2002). All CIs were video, and audio recorded and were transcribed in full for inclusion in the RCR as described further ahead in the section on data analysis (see Therapy Mid-Point and PostTherapy in Figure 4, and Appendix D, Figure D3). The purpose of the CI is to record the client description of any changes experienced during therapy and the client attributions as to what brought about this change (Stephen & Elliott, 2011). Like the weekly HAT forms, the CI also includes prompts for identifying helpful and hindering factors in the LI therapy process. Since it may be difficult to discuss evaluations of therapy sessions with the therapist themselves, it is recommended that CIs be conducted by a third party (Elliott, 2015). In this study, a CI was conducted mid-therapy (August 8, 2018) after the fourteenth session, at the end of therapy (February 28, 2019) and at the one-month follow-up meeting (April 4, 2019; see Appendix D, Figure D3). These interviews were INTEGRATING EGO IDENTITY WITH LI THERAPY 79 conducted by the research supervisor, Janelle Kwee, who is familiar with the HSCED method, is fully trained in LI therapy, and was not my therapist. Data Analysis, Case Development, and Adjudication. Once therapy was terminated and all data was collected, I transitioned from primarily being a study participant and therapy client to taking on the role of lead researcher as the study entered the data analysis, case development and adjudication stages (see Figure 3). Having a very clear-cut transition point between serving as a client-participant and a researcher as marked by the termination of therapy and data collection was paramount to successfully navigating the dual role of researcher-participant. This distinct demarcation enabled me to switch focus and perspective from that of an individual experiencing therapy (clientparticipant role) to that of analyzing data, evaluating evidence and examining my positioning and process as a researcher. In this section I will outline the quantitative data analysis procedures, rich case compilation processes, case development practices, and adjudication systems as prescribed by the HSCED method while highlighting methodological adaptation and describing any unique features pertaining specifically to this study on the efficacy of LI therapy in addressing ego identity fragmentation in an adult TCK. Quantitative data analysis. Data analysis primarily involved compiling PQ ratings, graphing them over time, examining them for trends and patterns, and comparing them to baseline values to determine the presence of any statistically significant change in PQ item ratings over time. See Figure 5 for an overall picture of the quantitative data analysis processes as described below. For a more detailed overview of quantitative data analysis procedures see Figure D1 (Appendix D) that provides a flow chart for analysis of INTEGRATING EGO IDENTITY WITH LI THERAPY 80 daily PQ ratings, and Figure D2 (Appendix D) that provides a flow chart for analysis of pre-session summative PQ ratings. INTEGRATING EGO IDENTITY WITH LI THERAPY Figure 5. Flow chart of quantitative data analysis processes. 81 INTEGRATING EGO IDENTITY WITH LI THERAPY 82 Stage 1. The first stage in the quantitative data analysis process was the calculation of mean intensity, frequency and overall PQ ratings for the timeframes between LI therapy sessions based on daily PQ item tracking. I used Excel formulas to automatically perform these calculations on an on-going basis throughout the duration of therapy. Stage 2. In stage two I compared the daily PQ ratings collected throughout therapy and the mean ratings calculated in stage one with the mean ratings reported on the summative PQ reports. I examined these values for any discrepancies between calculated and reported mean values to identify where subjective judgment had impacted reported ratings on summative report. HAT, TSNQ and experiential data were examined for any explanatory evidence regarding these differences. To enable analogous comparison of PQ item ratings the meaning of high and low values must be synonymous. For this reason, reverse-scoring was performed for PQ item 15 on all daily tracking and summative reports (see Appendix D, Figures D1 and D2) and adjusting mean calculations from step 1 in order to mirror the meaning of other PQ item ratings where high values reflected poorer functioning and low values reflected improvement. Additionally, in stage two I calculated overall mean PQ values. First, I calculated an overall daily mean rating across all PQ items, including all intensity and frequency ratings for all PQ items for each day, using Excel software (see Appendix D, Figure D1). These values provided a summary of daily levels of distress and negative functioning. Secondly, I calculated an overall mean rating across all PQ items for each summative report providing an overall value for level of distress and negative functioning INTEGRATING EGO IDENTITY WITH LI THERAPY 83 experienced during each timeframe in-between therapy sessions (see Appendix D, Figure D2). Stage 3. Stage three of quantitative data analysis included the graphing of PQ ratings to facilitate analysis of trends, pattern and shifts in data values over time. The first set of data that I graphed were the daily PQ item ratings tracked over the course of therapy (see Appendix D, Figure D1). To do so intensity and frequency ratings for individual PQ items were averaged to produce a single daily value for each PQ item. The second graph I created compared daily overall to summative overall mean PQ ratings (see Appendix D, Figure D2). I made these graphs available to case development team members for a more detailed examination of PQ rating patterns, shifts and significant changes (see Appendix D, Figures D1 and D2). Stage 4. The final stage of quantitative data analysis involved an examination of data for evidence of significant change over the course of therapy (see Appendix D, Figures D1 and D2). Comparing summative and daily PQ mean item ratings and overall mean ratings from pre-therapy, post-therapy and follow-up provided key information regarding substantial and sustained change over time. A minimum 2-point decrease in mean score over time was required as evidence of substantial change (Elliott et al., 2016; see also Appendix I). Change Interviews. (see Appendix D, Figure D3) As previously mentioned, three separate CIs were conducted: mid-therapy, termination of therapy, and therapy follow-up. These interviews were transcribed in full by me and then audited by volunteers for accuracy of transcription. Transcripts were subsequently used in data analysis to extract explanatory evidence for significant changes in quantitative data from pre-therapy, to INTEGRATING EGO IDENTITY WITH LI THERAPY 84 post-therapy, and at follow-up (see Appendix D, Figures D1 and D2). Full transcripts5 of all CI interviews were included in the RCR that for use in case development and adjudication procedures. Rich Case Record (RCR). The RCR is a summative report of observations and information compiled by myself in my role as principal researcher with the assistance of research team members. This document included (Elliott, 2002; Stephen & Elliott, 2011):  background information on myself as the therapy client and research subject including pertinent demographic information (age, ethnicity, etc.), educational history, medical information, information on presenting problem (ego identity fragmentation) and previous therapy experience;  background information on Hillary McBride as the study therapist including counselling training and credentials, years of clinical experience, level of training in LI therapy, therapeutic experience in LI therapy, experience and training in research practices, and areas of expertise;  information regarding the specific goals of LI therapy as agreed upon by myself and my therapist at the beginning of our clinical work together;  pertinent family and personal history including current and past family dynamics, traumas, mental illness, etc. and highlighting applicable details regarding my TCK experience (ages and length of time spent outside of 5 The mid-therapy CI interview included some gaps in verbatim transcription due to time constraints in compiling the RCR for case development team members. Gaps are clearly indicated in the transcript and accompanied by a general description of the missing content. INTEGRATING EGO IDENTITY WITH LI THERAPY 85 passport country, locations lived, repatriation experience, acculturative stresses experienced, etc.);  a summary of daily PQ results;  a record of quantitative scores from all three CIs (mid-therapy, post-therapy, and follow-up) with accompanying explanatory evidence;  all qualitative and quantitative data from TSNQ and HAT forms as completed by me and Hillary McBride over the course of therapy; and  transcripts of the all three CIs (mid-therapy, post-therapy, and follow-up). While most of the RCR was compiled by me in my role as primary researcher, research team members were used in its compilation by assisting in reviewing PQ graphs for clarity of content and for determining best examples of experiential data to be included in the RCR. I also recruited a team member to review selected information contained in session notes, HAT and TSNQ data to provide feedback on potentially problematic third-party descriptions contained therein. Team members also reviewed video clips prepared by the researcher and rated each clip based on the clarity of the content and its ability to accurately demonstrate ego identity (see Appendix J for rating scale). Transcription of CIs was completed by me and audited by a research team member to ensure accuracy. Research team members were purposively included in the preparation of the rich case study in order to mitigate the potential for subjective bias in the presentation of materials for consideration during the case development and adjudication process due to my dual role as researcher-participant. Affirmative and skeptic cases. The compiled RCR was used during the case development process conducted by two teams: a) the affirmative team, and b) the skeptic INTEGRATING EGO IDENTITY WITH LI THERAPY 86 team. Teams were comprised of four individuals recruited from among known clinicians, graduate students and professionals with expertise in LI therapy, ego states and identity development, and TCKs, and had equal representation of these areas of expertise on each team (Lewis, 2017; Stephen & Elliott, 2011; Wall et al., 2017). Case development process. A case development working meeting (Wall et al., 2017) was held on May 24th. Prior to this meeting, case development team members for the affirmative and skeptic position attended an orientation conducted by me in which I acquainted them with the broader thesis project, supplied them with a hard copy of the RCR, and provided oral and written instructions on their role and task in case development. Between the orientation and the working session team members familiarized themselves with the RCR data and put together some preliminary thoughts on evidence for argumentation. At the case development meeting, teams worked collaboratively to prepare a case brief of evidence in support of their respective position: a) affirmation of evidence of my experiencing change in ego identity fragmentation and of these changes occurring due to LI therapy work (affirmative position); or b) against evidence of my experiencing change in ego identity fragmentation or of these changes being due to contextual matters apart from LI therapy work (skeptic position). Each team designated a spokesperson who presented their brief to the whole group, after which the opposing position presented their rebuttal, followed by a counter-argument from the presenting team (Stephen & Elliott, 2011). Teams provided a summary of their case brief, rebuttal, and counter argument that I then added to the RCR for use in the adjudication process (Lewis, 2017). INTEGRATING EGO IDENTITY WITH LI THERAPY 87 Affirmative case development. The job of the affirmative team was to build a case that change in ego identity fragmentation did occur and that the change was due to LI therapy work (Wall et al., 2017). According to Elliott (2015), the affirmative team must present at least 2 different kinds of evidence to support their claims. The kinds of evidence that are effective in supporting the affirmative claim include (Elliott, 2002, 2015):  experiencing change in an area of long-term difficulty;  researcher-participant’s explicit attribution of change to therapy processes;  a clear connection due to temporal proximity between a helpful therapy event and an on-going shift in a problematic area;  and, a demonstrable co-variant relationship between in-session therapy processes and weekly client changes. Skeptic case development. The job of the skeptic team was to compile an argument that client did no experience change and/or did not experience ego identity fragmentation change, and that change was not due to LI therapy (Wall et al., 2017). Types of evidence to support that no change or no change in ego identity fragmentation was experienced include (Elliott, 2002, 2015):  6 changes were negative 6or irrelevant7; Negative change is defined simply as clinical deterioration(Elliott, 2002). This could be demonstrated by a decline in healthy or positive functioning, or an increase in symptomology. 7 Irrelevant change, also termed trivial change, is defined as change that is not important (Elliott, 2002). It may be irrelevant due to client’s ambivalence or dubiousness at nature or significance of changes or may pertain to change in factors external to the client such as changes in others or in circumstances (Elliott, 2015). INTEGRATING EGO IDENTITY WITH LI THERAPY  88 change was due to statistical artifacts such as errors in measurement, regression to the mean, and experiment-wise error;  change reflected the researcher-participant’s desire to meet therapist expectations (people-please);  and, change was due to the researcher-participant’s positive beliefs about therapy and expectations of change. Evidence to support a claim that changes were not due to LI therapy processes include (Elliott, 2002, 2015; Stephen & Elliott, 2011):  change reflected the researcher-participant’s ability to help themselves and self-correct;  change was due to events and occurrences external to LI therapy sessions such as changes in employment, relationships, and recreational activities;  change was due to modification in medication or physical health changes;  and, change was due to the researcher-participant’s desire to produce positive results for use in this research project. Case development and researcher-participant role. The case development process described above is ideally suited for this research project in mitigating the impact of researcher-participant bias on final study conclusions regarding the efficacy of LI therapy in producing ego identity change in an adult TCK. In recruiting experts to analyze and evaluate the compiled data, objective external viewpoints of the evidence are included in the analysis process that enhances the credibility and validity of study findings. Credibility and validity are further enhanced by a shift in my role as principal researcher. In the case development process, my role was to provide organization, INTEGRATING EGO IDENTITY WITH LI THERAPY 89 instruction and training on the purpose and process of case development; to be available to answer questions or provide further information; and to assemble team findings for inclusion in the RCR. As such, my role in analysis at this stage in the HSCED process was more passive than active in being a step removed from direct evaluation of the data. Adjudication. The RCR, including the arguments and rebuttals presented by the affirmative and skeptic teams, was presented to a panel of three external judges. The responsibility of the adjudicators was to consider the evidence both for and against substantial client change in ego identity fragmentation, and client change substantially due to LI therapy, and render judgements regarding research questions (Stephen & Elliott, 2011; Wall et al., 2017; see Appendix M). Each judge independently provided their evaluation in the form of a percentage rating of probability and rated their level of confidence in their judgment as a percentage (Stephen & Elliott, 2011; Wall et al., 2017). According to Stephen and Elliott (2011), “clear and convincing evidence” for change and change due to therapy requires a rating of 80% or higher probability (p. 238). Lastly, the panel identified any factors beyond therapy, including mediating and moderating factors, that they believed may have been responsible for evidence of ego identity fragmentation change over the course of therapy (Elliott, 2015). Adjudication and researcher-participant role. The adjudication process, like the case development process, is a systematic component of HSCED that was highly advantageous for the current study in reducing the effects of researcher-participant subjectivity on the study findings and significance. The use of external experts as adjudicators once again removed me from direct, active engagement in the data evaluation process. This adjudication process enabled the judges to objectively evaluate INTEGRATING EGO IDENTITY WITH LI THERAPY 90 the case study evidence and make probabilistic claims regarding the efficacy of LI therapy in creating ego identity change in an adult TCK. As before, the primacy of objective perspectives in evaluation and judging processes bolsters the validity and credibility of research findings and conclusions. To balance the objective perspectives of the external adjudicators with feminist theoretical influences in valuing the subjective experience and knowledge of the participant (Brown & Gilligan, 1992; Gilligan, 2003; Mitchell, 2017), the researcherparticipant participated in the adjudication process as a 4th judge. I conducted my own independent adjudication process alongside the other external judges including all the same tasks, responsibilities and timeline. Intersectional analysis. As an emergent analytic process without standardized procedures (Cho, Crenshaw, & McCall, 2012) the following is a description of processes followed for conducting transactional analysis within this study. Broadly described this analytic process required an intersectional engagement with the data and the analytics being deployed in adjudication. This process was initiated by my intuitive response to the adjudication results in my role as a client that was responded to from within my researcher role. My client response led my researcher-self to an examination of the external and reflexive findings and analytic tools identifying points of discrepancy in use of data and meaning attributed to study information. To understand the source of these discrepancies they were examined for deviation from the wholistic ontology of HSCED: does this reflect the presence of compartmentalization? Does it reflect a reductionist stance or decontextualization of data? Is there evidence of privileging objective and quantitative data INTEGRATING EGO IDENTITY WITH LI THERAPY 91 above subjective ways of knowing? Oppressive elements identified in adjudication results and analytic processes were then addressed through re-contextualizing within a wholistic view of the study data in addition to the broader context of study literature. The end result of this analytic process was a refinement of adjudication results for consideration in the preparation of final conclusions. Final Conclusions. The last step in this process was to integrate the judges’ ratings and decisions and arrive at final research conclusions regarding the goals and purposes of the project being conducted (Wall et al., 2017). For the purposes of this study conclusions were drawn regarding the probability of change in ego identity having occurred, and the probability that said change was due to LI therapy work or other factors. To arrive at final conclusions, I engaged in a four-part process of examining determinations by external judges and researcher-participant as well as intersectional analysis results both separately and collectively (see Figure 6). The first part of this process involved separately examining each external judge’s adjudication conclusions, both the percentages they awarded for each research question as well as their reasoning and evidence for each result (see Part 1 in Figure 6). These were examined for clarity of thinking process and explanation of resulting conclusions. INTEGRATING EGO IDENTITY WITH LI THERAPY Figure 6. Flow chart of four-part adjudication results examination to arrive at final conclusions. 92 INTEGRATING EGO IDENTITY WITH LI THERAPY 93 Following this individual examination, the conclusions of all 3 external judges were considered as a collective group (see Part 2 in Figure 6). This involved calculating a median percentile determination and comparing and contrasting judgements, degree of confidence, explanatory data and contextual factors such as level of experience generally with research and specifically with HSCED as a method. Next, I considered the reflexive researcher adjudication process and results alongside those of the external adjudicators and observations gleaned from part one and two of this process as discussed above (see Part 3 in Figure 6). The median percentile determination across all 4 adjudication processes was calculated and explanatory evidence were compared and contrasted for similarities and differences in research question conclusions, level of confidence, and nature of case study data used as evidence supporting judgments. The fourth and final stage of this process (see Part 4 in Figure 6), was to apply principles of intersectional analysis and research metasynthesis (further explained in the Discussion chapter) to remediate reductionist and de-contextualizing professional research practices observed in external adjudicator conclusions and explanatory evidence. Through this process the evaluative context for arriving at final conclusions was broadened and an alternative interpretation of case study data was proposed from a more holistic framework. Methodological Rigour and Quality. Case Study Research. Morrow (2005) delineates several criteria for rigour and quality in case study research all of which are embedded within the structure of the HSCED method. First, the analysis and evaluation processes should consider alternative INTEGRATING EGO IDENTITY WITH LI THERAPY 94 explanations for any change (Morrow, 2005). This was met with the development of affirmative and skeptic case argumentation within the case development process. Second, the study must involve a systematic review of the data (Morrow, 2005). HSCED provides three different phases of data analysis procedures including quantitative data analysis, preparation of the RCR, and case development procedures. Lastly, quality case studies must include an external audit by an independent body (Morrow, 2005) which was fulfilled through the procedures and parameters of the HSCED adjudication process. Qualitative Methods. Triangulation is a key factor of rigour in qualitative methods (Morrow, 2005). Morrow, Castañeda, and Abrams (2012) define triangulation as “using multiple sources of data, multiple investigators, various theories, or multiple methods,” (p. 105). The HSCED method along with the outlined methodological adaptations for this study meet more than one of these criteria of triangulation. In this study data was collected from several different qualitative sources (e.g., HAT, TSNQ, CIs, audio and video recordings), while also collecting quantitative data (PQ, CI), and utilizing experiential sources of information such as personal communications, journals, and photographs. Use of research team members to assist in analysis as well as outside experts to serve on case development teams and as adjudicators meets the criteria for involving multiple investigators. Rigour for enhanced reflexivity. In terms of enhanced reflexivity, literature on quality and trustworthiness in narrative case-studies recommend borrowing from principles delineated for autoethnographies (McLeod, 2010). Le Roux (2017) proposed several criteria for ensuring rigour in autoethnographic research, four of which are INTEGRATING EGO IDENTITY WITH LI THERAPY 95 suitable for use with the definition of enhanced reflexivity as described above. Below is a description of these four criteria and how they were met within the current study. Subjectivity. This is evidenced by a clear representation of self as narrator of the text seeking self-understanding (Le Roux, 2017). Clarity regarding self as narrator will be reflected in the use of the personal pronoun ‘I’ and with the inclusion of personal experiential data including journal entry excerpts, personal communication excerpts, photographs of experiences, etc. Evidence of seeking self-understanding will be demonstrated by including narratives featuring self-inquiry; curiosity about thoughts, feelings and experiences beliefs and values; and episodes of personal insight. Self-reflexivity. This is defined as, “evidence of the researcher’s intense awareness of his or her role in and relationship to research…. [and] points to selfawareness, self-exposure, and self-conscious introspection,” (Le Roux, 2017, p. 204). Meeting criteria for self-reflexivity was particularly significant in this study given my dual role as both study subject and lead researcher. It necessitated intentionally encountering self through journals and personal communication with members of my support community and explicitly questioning my process and decision-making throughout all stages of the research process. I featured in the reflexivity chapter those moments of self-awareness and self-analysis with the greatest potential impact on the process, findings and conclusions of this study to reflect personal transparency within my roles. Resonance. Le Roux (2017) describes resonance as, “the audience [being] able to enter into, engage with, experience or connect with the writer’s story on an intellectual and emotional level…a sense of commonality between the researcher and the audience,” INTEGRATING EGO IDENTITY WITH LI THERAPY 96 (p. 204). Resonance was primarily achieved using a narrative voice in the reflexivity chapter as narrative can be used to establish a sense of commonality with the audience, connecting them with the narrator’s story, and engaging them in dialogue with the text (Brown & Gilligan, 1992; McLeod, 2010). As such, I wrote this chapter as though I was telling my audience a story. I focused this narrative on underlying universal themes present in my personal experience so that readers can identify with the text even when contextual elements significantly vary from typical life experiences. Furthermore, I used provocative imagery to engage the reader in personally encountering and dialoguing with the text. Three volunteers, including one with no previous study experience, were recruited from among counselling-psychology graduate students to read through this chapter on enhanced reflexivity and provide feedback and recommendations on the strength of resonance within the narrative (see Appendix R). I used feedback from these research team members to revise chapter content in order to improve audience connection with the text. Credibility. Credibility is demonstrated by an audience’s sense of “verisimilitude, plausibility, trustworthiness,” as they encounter the narrator through the text. The use of research team members for a type of member-check was pivotal for establishing credibility. To ensure that content being presented was plausible and trustworthy, I recruited three volunteers to read through the enhanced reflexivity chapter and provide feedback and recommendations specifically targeting credibility. Among these volunteers one individual had no previous involvement in the research project to better reflect the experience of a typical audience member. I provided volunteers with criteria and a rating system (see Appendix R) to address questions such as: Did the narrative INTEGRATING EGO IDENTITY WITH LI THERAPY 97 follow a logical sequence of events and ideas? Was the narrative coherent? Did it appear honest? Did it mirror reality or appear fantastical? Changes and revisions were made to chapter content and structure based on the feedback and recommendations provided to increase text credibility. INTEGRATING EGO IDENTITY WITH LI THERAPY 98 CHAPTER 4: OUTCOMES With therapy and data analysis completed, this chapter turns our attention to the results attained from the HSCED research process. Below is a summary of the outcomes evidenced through the rich case record (RCR), affirmative team (AT) and skeptic team (ST) case briefs and rebuttals, and adjudication process. Full copies of each of these documents can be found in the appendices: the RCR in Appendix S; AT and ST briefs and rebuttals in Appendices T, U, V and W; and Adjudicator response forms in Appendices X, Y, Z and AA. Rich Case Record The following is a summary of the data contained within the RCR with a focus on highlighting the most important or salient elements contained therein. A full record of the RCR as was presented to the case development teams and judges can be found in Appendix S. Contextual Factors. Participant. At the start of therapy in May 2018, Rose (pseudonym8) was 44 years-old, heading into her final year of studies towards an MA in Counselling Psychology and working part-time as an administrative assistant for a non-profit organization. When therapy ended almost 10 months later (February 2019), Rose was 45 8 The decision to make use of a pseudonym within the data set was to distinguish the role of therapy client/research participant (roles designated to Rose) from the roles of primary investigator/reflexive researcher (roles relegated to Sharon). Using the name Rose to refer to the client/participant also created some relational distance for the case development teams and adjudicators and afforded more space for clinical and objective decision-making in their respective roles. INTEGRATING EGO IDENTITY WITH LI THERAPY 99 have recently celebrated her birthday, was finishing up her final semester of course work in her program, and still working part-time. Rose was born in Canada and moved to Mexico at the age of 4 where her family went to serve as missionaries. Rose spent most of the next 6 years (1978-1984) living in and around Mexico City while also experiencing frequent transitions back and forth between Mexico, Canada and the USA (see Appendix S, p. 257, for further details). This cross-cultural childhood experience includes Rose within the TCK community. It is important to note that Rose’s maternal grandparents also served cross-culturally as missionaries in Paraguay and Argentina and therefore her mother is also a TCK. In May of 1984 Rose and her family returned to Canada for a one-year home service assignment, however, in February of 1985 her parents announced that the move to Canada was permanent. As such, Rose’s repatriation experience was unanticipated and lacking in preparation for this significant transition. Rose reported a drastic shift in identity, sense of self and life experience between Mexico and Canada as summarized in Table 1 below. Alongside these identity challenges Rose also reported significant losses including physical possessions and friendships, as well as a diminishing social support network. INTEGRATING EGO IDENTITY WITH LI THERAPY 100 Table 2 Summary of identity and life experience shifts experienced by Rose at repatriation. IN MEXICO IN CANADA Beautiful Not attractive (‘less than average’) Special status Outsider Important Did not belong anywhere Adventurous and exciting Quickly became routine 2 best friends Didn’t understand Canadian friendships Starting to discover boys Canadian kids were more advanced Safe and familiar Scary and unfamiliar At time of therapy start Rose had been involved in personal counselling for over 10 years with five different clinicians. In 2011 Rose was required by insurance to see a psychologist for treatment while on a mental health leave from teaching. A more detailed timeline of counselling history can be found in the RCR (Appendix S, p. 257). Therapist. The therapist, Hillary McBride, was a Registered Clinical Counsellor with an MA in Counselling Psychology degree and was studying towards a Ph. D. in Counselling Psychology at the time of therapy. While Hillary had previously received both beginning and advanced training in LI therapy (equivalent to Levels 1-2 in current LI training structure), and had both received personal LI therapy herself and consistently made use of LI protocols on a weekly basis in her clinical practice, it is to be noted that she was not certified in LI therapy. Pertinent areas of expertise developed throughout her INTEGRATING EGO IDENTITY WITH LI THERAPY 101 studies and seven years of clinical experience included developmental transitions throughout the lifespan, trauma, shame, and healing one’s relationship with self. Therapy. Therapy took place over 10 months constituting 32 sessions between May 18, 2018 (session 1) and February 27, 2019 (session 32). The first 14 sessions were conducted in-person at the therapist’s office with the remaining 18 sessions (sessions 1532) occurring online via a web-based video conferencing system (Zoom). This change in modality was necessary in order to continue therapy as the therapist was required to make a geographic move in order to continue her PhD studies. The broad goal of therapy, established between the Rose and Hillary at the start of treatment, was to restore a sense of core self that Rose reported having been present before repatriating to Canada but disappearing when she cut parts of herself off in order to cope with challenges of living in Canada. In short, to reconnect little Rose and big Rose. Additionally, Rose expressed a desire to decrease the presence and influence of shame and fear in her life. More specific goals were identified through the PQ which is further explored below. Quantitative Outcome Data. As shown in Table 2, Rose initially identified 14 PQ items she hoped would demonstrate change over the course of therapy. All but one of these PQ items (#8 – I cannot make decisions) demonstrated the minimum necessary 2point decrease in ratings (see Table 3) to indicate significant change over the course of therapy as determined by Elliott et al. (2016). The 15th item on the list was added as a target behaviour at the mid-therapy point. Unlike the other 14 PQ items which demonstrated a consistent pattern of decrease, #15 (‘I authentically and voluntarily INTEGRATING EGO IDENTITY WITH LI THERAPY 102 connect with God.’9) demonstrated a trend towards increased ratings signifying a decline in success over the course of therapy (see Figures 6 and 7). For this reason, and due to its ability to skew calculation results, item 15 was considered an outlier data point and was treated as a separate data set in the calculation of daily mean ratings (see Figures 8 and 9). 9 As PQ item 15 was the only positive behaviour being tracked ratings were reverse scored for use in analysis so that the direction of change had the same meaning for all 15 PQ items: decrease in ratings indicated improvement; increase in ratings indicated decline in functioning. INTEGRATING EGO IDENTITY WITH LI THERAPY 103 Table 3 Rose’s individualized PQ items prepared before therapy began and tracked daily over the course of therapy. #1 I feel shame about who I am and who I've been #2 I'm not enough ('should-ing') #3 I feel I don't belong #4 I have a fear of failing at life #5 I have trouble feeling present in the moment 1 #6 My sleep is interrupted 1 #7 I self-sabotage my own goals (NOT FOOD) #8 I cannot make decisions1 #9 I am stuck in an avoidant pattern1 #10 I use food to cope with stress #11 I self-medicate my own pain with poor strategies (not level of distress) #12 I don't accept my limitations/weakness #13 I have a tendency to think in "all-or-nothing" #14 I don't feel confident in my own opinions/viewpoints #15 I authentically and voluntarily connect with God 2 Note: Most items changed over more than 10 years duration. 1Items changed over 6-10 years duration. 2 PQ Item was added after mid-therapy Change Interview. INTEGRATING EGO IDENTITY WITH LI THERAPY 104 Table 4 PQ items change list and ratings at follow-up. Change Daily Summative 1. I feel shame about who I am and who I've been. 4.8 5 2. I'm not enough ('should-ing'). 4.2 4 3. I feel I don't belong. 3.6 4 4. I have a fear of failing at life. 3.1 3.5 5. I have trouble feeling present in the moment. 2.2 3 6. My sleep is interrupted – improved sleep patterns. 2.6 3 7. I self-sabotage my own goals. 3.6 4 8. I cannot make decisions.* 1.7 2 9. I am stuck in an avoidant pattern. 2.4 3 10. I use food to cope with stress – eating less about coping. 3.7 4 2.6 3 12. I don't accept my limitations/ weakness. 3.4 4 13. I have a tendency to think in "all-or-nothing". 3.1 3.5 14. I don't feel confident in my own opinions/viewpoints. 3.3 3.5 PQ Item 11. I self-medicate my own pain with poor strategies (not level of distress). Note: * Did not experience significant change (minimum 2-point decrease). INTEGRATING EGO IDENTITY WITH LI THERAPY 105 Figure 7. Tracking of intersession combined mean ratings for PQ items 1-8 over course of therapy. INTEGRATING EGO IDENTITY WITH LI THERAPY 106 Figure 8. Tracking of intersession combined mean ratings for PQ items 9-15 over course of therapy. INTEGRATING EGO IDENTITY WITH LI THERAPY 107 Figure 9. Daily PQ mean ratings across all items with outlier item 15. Figure 10. Comparison of daily PQ mean ratings across all items (including outlier item #15) with daily PQ mean ratings of items 1-14 only INTEGRATING EGO IDENTITY WITH LI THERAPY 108 Qualitative information about significant events. Qualitative information about important, helpful and hindering events during therapy was gathered from the HAT form and the TSNQ. Below is a summary of general themes found within this data. For a complete listing of all reported helpful and hindering events on the HAT and TSNQ forms see Appendices P and Q respectively, or the session summaries in the RCR (Appendix S). Helpful aspects of therapy. Rose consistently reported a minimum of one significantly helpful or important event over the course of therapy, often reporting a second additionally helpful event as well. Ratings of most important or helpful events as well as additional helpful events ranged from 7.5 (between moderately and greatly helpful) to 9 (extremely helpful) with a substantial number of the most important or helpful events having been rated at 9 (extremely helpful) and a large number of additional events receiving a rating of 8 (greatly helpful). Several patterns can be seen within the events chosen by Rose as most important or helpful. Rose reports as significant those moments during therapy when she recognized herself in younger states being encountered imaginally such as: seeing herself as a baby (session 2); finding a ‘kindred spirit’ in her 7-year-old self (session 6); and discovering sadness in the midst of reunion with her 11-year-old self (session 25). Rose also reported as helpful when interactions with younger selves taught her adult self something new, such as learning the difference between being okay and learning to be okay (session 7), and coming to grips with the reality that the sexual assault was over (session 12). INTEGRATING EGO IDENTITY WITH LI THERAPY 109 Rose rated moments of therapist attunement and a caring response to her needs as being highly important and helpful. Some examples include noticing swells of emotion in Rose (session 1), noting when Rose was stuck or frozen and addressing this therapeutically (session 5), providing a secure presence by repeating “I am here with you” (session 15), and taking time to introduce herself to Rose’s 4-year-old self (session 22). A third area that Rose rated as important and helpful were elements of body work that were brought into session. This included being anchored in her somatic experience (e.g., session 1); physically acting out emotions or experiences (e.g., embodying experience of voice in session 14); and the use of body movement for grounding (e.g., walking through the timeline in session 5; butterfly taps in session 10). Lastly, Rose often chose events in session where she felt seen, known and understood and moments of taking up space in the world and developing her personal voice as important and helpful. Some prime examples of these types of significant therapy events include: having the therapist reflect back what she hear Rose say (session 1); Rose ‘taking charge’ and letting the therapist know that she needed a break (session 22); and bringing in the terror and panic of the 11-year-old self (session 27). Rose included hindering events for approximately half of the sessions (17 out of 32) which were most often rated as either moderately (3) or slightly (4) hindering. Identified hindering events were focused largely on Rose’s frustration with her internal experience including uncertainty in her own thoughts, intuition, and needs, and difficulties engaging with memories and therapeutic experiences. Other identified hindering moments included problems with technologies (e.g., poor internet connection) INTEGRATING EGO IDENTITY WITH LI THERAPY 110 and struggles with protocol strictness (e.g., nodding at every memory cue in Time Line through every repetition) and protocol deviation (e.g., not taking a break between Time Line repetitions). Therapist session notes questionnaire. Ratings for the most important or helpful events on the TSNQ ranged from greatly hindering (2) to extremely helpful (9) with most falling between greatly (8) and extremely (9) helpful. Additional helpful event ratings ranged from slightly helpful (6) to extremely helpful (9) with the most common rating being greatly helpful (8). The most important and helpful events reported on the TSNQ demonstrated trends in therapist’s conceptualization of the Rose’s internal experience of self and her interpretation of shifts and changes occurring in session. The therapist specifically made note of moments of integration occurring evidenced by changes in Rose’s interactions between older and younger selves, Rose arriving at new understandings and responses to self, an increase in Rose’s attunement and care for self, an increased ability for emotional self-regulation, and the development of a positive perception of self. It is interesting to note that the therapist included two hindering events as important events during therapy: 1) in session 12 Rose’s younger self was trying to distract the adult-self in the timeline which the therapist rated as moderately hindering (3); and in session 16 again Rose reported resistance of her younger self to integrating with her present-day which she rated as greatly hindering (2). The therapist interpreted both events as important as they were evidence of barriers to integration. The therapist also included hindering events for approximately two-thirds of the sessions (21 out of 32 sessions). Of the recorded hindering events 5 were not rated. INTEGRATING EGO IDENTITY WITH LI THERAPY 111 Remaining event ratings ranged from greatly hindering (2) to between slightly hindering and slightly helpful (4.5) with most falling between 3 (moderately hindering) and 4.5 (between slightly hindering and slightly helpful). Hindering events were focused on moments of client distress, emotional discomfort, dissociation and state of immobility or ‘stuckness’. Qualitative Outcome Assessment. Client qualitative assessments on the outcomes of therapy were collected during the change interviews administered at three points during therapy (mid-therapy, post-therapy and 5-week follow-up). Below is a summary of the findings that emerged from these interviews. For a detailed presentation of the outcome assessment data from the change interviews see the RCR (Appendix S, pp. 359-378), as well the change interviews transcripts (RCR Appendices C to E, pp. 424-521). While significant changes in PQ item ratings evidenced by a decrease of 2 or more points were identified and discussed at each change interview, additional general changes were also named and explored. At mid-therapy Rose identified 15 observed changes of which 12 demonstrated improvement and 3 reflected a negative change (see Table 4). Ten areas of improvement were named at post-therapy (see Table 5) and 5 items at the follow-up change interview (see Table 6). Of those listed, an increase in experience of self as being grounded and anchored and of a more continuous self across time were mentioned both at the mid-therapy and post-therapy point. The most consistent general change identified both during and after therapy was a decrease in emotional activation that was mentioned in all three interviews. Other changes exemplified a greater sense of personal capability, improvement in attention and INTEGRATING EGO IDENTITY WITH LI THERAPY 112 attunement to self, finding her voice and taking back agency of her life, greater love for self and attachment to others. INTEGRATING EGO IDENTITY WITH LI THERAPY 113 Table 5 Change list and ratings at mid-therapy 1. 2. Change: Negative thoughts no longer directly correlate to level of distress. Self-medicating poor choices no longer resulted in shame and self-blame Swell of anxiety emerges with an increasingly powerful sense of anchor in ‘ME.’ Duration of negative emotions has decreased. Experientially allowing younger ego states to play intentionally and organically. Becoming aware of the role shame has played in life. Seeing self as more continuous throughout life. Show up with more voice. Likelihood Expected / without Important / surprising therapy unimportant VMS SU VI SS VU EI VMS VU EI N N EI SE SL VI SS VU VI VMS VU EI SS VU EI SS VU EI 10. Awareness that there is a ‘ME’ to encounter and express. I love me, truly and authentically. VMS VU EI 11. Close friend has noticed changes. SS VU VI 12. Greater spiritual connection. VMS SU EI 13. Emotions are more raw.* VME SU EI 14. Relationship with parents is changing; becoming more strained.* Uncertainty and fear about reaching goals (angst).* VMS VU EI to VI N VU VI 3. 4. 5. 6. 7. 8. 9. 15. Note: * Items got worse over the course of therapy. VME = very much expected, SE = somewhat expected, N = neutral, SS = somewhat surprising, VMS = very much surprising, VU = very unlikely, SU = somewhat unlikely, N = neutral, SL = somewhat likely, EI = extremely important, VI = very important. INTEGRATING EGO IDENTITY WITH LI THERAPY 114 Table 6 Change list and ratings at post-therapy Change: 1. Not experiencing triggers related to abusive relationship (in 2009). 2. Not as activated by potentially negative feedback. 3. Feel my own age and feel capable. 4. Loss of childhood fear base. Sees life as a capable adult and not fearful child. 5. Improved attention and care for self. 6. Increased attunement to self in therapy sessions and other places. 7. Able to release responsibility for others and to tell own truth. 8. Taking back agency of own life. 9. There’s a continuous “me” in what I do. 10. I have a more positive relationship to my sexuality. Expected / surprising SE Likelihood without therapy VU Important /unimportant EI VMS VU EI VMS VU EI SS VU EI N VU EI to VI VMS VU VI VMS VU EI N VU EI VMS VU VI VMS VU EI Note: SE = somewhat expected, N = neutral, SS = somewhat surprising, VMS = very much surprising, VU = very unlikely, EI = extremely important, VI = very important. INTEGRATING EGO IDENTITY WITH LI THERAPY 115 Table 7 Change list and ratings at follow-up Change: 15. Change in relationship to body – realization of being in full control 16. Improvement in ability to follow through with a desire. Being me and allowing me to be me. 17. Receiving feedback and not being thrown or panicked and recover more quickly. 18. Ability to experience positive and real attachment. 19. TV watching habits have shifted organically. Less need for TV. Expected or surprising VMS Likelihood without therapy VU Important or unimportant VI VMS VU EI N VU EI VMS VU EI VMS VU EI Note: N = neutral, VMS = very much surprising, VU = very unlikely, EI = extremely important, VI = very important. Rose was asked to rate each of these identified changes on three scales: 1) how surprising or expected the change was; 2) how likely or unlikely without therapy; 3) the level of importance of the change. She struggled with determining her responses to the first set of ratings; In particular, she struggled to understand the difference between hoping and wishing that something would occur and expecting it to happen. Many of the areas of change that she identified in her PQ items and named as general changes (e.g., decrease in shame and fear, core sense of self, emotional regulation, attachment), had been areas of growth that she had longed for and sought after for years. Up until this point, however, no amount of personal growth or therapy had produced any significant change or shift in these areas. Therefore, though Rose admitted to greatly desiring LI therapy to produce many of these changes, she was very much surprised to discover that shifts and changes did occur. INTEGRATING EGO IDENTITY WITH LI THERAPY 116 Tables 4, 5, and 6 also show Rose’s ratings for each of the 30 general change items she named during her change interviews. At mid-therapy (Table 4) most items were rated between somewhat and very much surprising, very unlikely without therapy and extremely important. This trend continued at the post-therapy interview (see Table 5) in which items were mostly rated as very much surprising and extremely important with all 10 items being described as very unlikely without therapy. The five changes named at the 5-week follow-up interview (see Table 6) followed suit in being very much surprising (apart from one neutral item), very unlikely without therapy and extremely important. Adjudication Process Case Development. Teams of four experts were recruited from among known graduate students, new clinicians, experienced clinicians and doctoral level practitioners to participate in case development. Experts were distributed between the two teams (affirmative and skeptic) so that the teams were balanced in representation regarding familiarity and experience with LI therapy, familiarity with the research method (HSCED), knowledge and experience with TCKs, and expertise in identity formation and development. Each team was also assigned a fifth member who served as a dedicated note-taker and did not participate in case development. Case briefs and rebuttals for both the affirmative and skeptic teams are summarized below. For a full account of arguments made by both teams see Appendices T, U, V and W. As data in the study appeared to provide ample evidence that the client did experience change over the course of therapy, the case development teams were instructed to place a greater focus on the nature of this change. In particular, the teams INTEGRATING EGO IDENTITY WITH LI THERAPY 117 were instructed to argue for (affirmative) or against (skeptic) ego identity change. The ST was also given the task of providing evidence that client change was trivial, unimportant, or irrelevant to the research question under investigation. Conversely, the AT was tasked with providing evidence to the contrary; that client change was significant, important, and relevant. Affirmative brief. To answer whether the client experienced change the AT began by focusing on the client’s experience of ego identity change. The team pointed to 3 PQ items (#1, 3 and 5) they judged to be evidence of shifts in ego identity that demonstrated a significant decrease in level of distress over the course of therapy with mean decreases ranging form 2.2 (#5) to 4.8 (#1). Journal entries, session notes (including HAT and TSNQ forms) and video clips were also utilized to bolster the affirmative argument for ego identity change and centered around client descriptions of a new sense of anchoring of self, the formation of a core ‘ME’, discovering and using her voice, and integration of self across the timeline. Beyond ego identity change, the AT found evidence of client improvement in other areas of long-standing difficulty as evidenced by significant changes in PQ ratings primarily for 13 out of 15 problem areas, ten of which had been areas of client distress for longer than 10 years. To build their argument for client change due to LI therapy the AT made use of all four types of evidence including client attribution, process-outcome mapping, dataevent relationship, and event-shift sequences. The team focused the client attribution evidence on client ratings of change as both surprising and unlikely without therapy in change interviews, and bolstered their argument with client reports of others seeing INTEGRATING EGO IDENTITY WITH LI THERAPY 118 change in her, and client recognition of sameness in younger selves gleaned from therapist session notes and HAT/TSNQ forms. Process-outcome mapping arguments were based on session notes, HAT and TSNQ forms, journals and post-therapy itemized changes and client ratings, focusing primarily on shifts in relationship with younger selves, finding voice and discovering agency with resulting post-therapy decrease in degree of shame and fear experienced, increased view of self as capable, and a greater sense of voice, belonging, agency and presence in own life. Further evidence of shifts in relationship to self, embracing voice and integration of selves found amid session notes, HAT forms and PQ ratings was used for data-event relationship and event-shift sequence arguments. Processes of change identified by the affirmative case development team included the attunement protocol, meeting needs of younger selves through imagination (standard protocol), therapist coaching of ego state dialogue, LI Time Line repetition for getting around blocks and dealing with unresolved material, helping past selves get ‘unstuck’ and to integrate by bringing them into present day context, and therapist attuned and grounded presence with client. Skeptic brief. The ST made use of all four types of evidence for client change including nonimprovement, statistical artefacts, relational artefacts, and expectancy artefacts. As mentioned previously, the ST did not contest the fact that change did happen for the client, however they did argue that the change was irrelevant to the research question as it more accurately reflected post-traumatic growth and acceptance of self and life change as opposed to ego identity integration. Additionally, they argued that the case lacked sufficient repatriation specific data concerning 11-year-old self and INTEGRATING EGO IDENTITY WITH LI THERAPY 119 Mexican self and did not specifically address cultural identity integration elements that are unique to TCK further proving its lack of connection to the aims of this project. The prominence of self-report data with little to no external viewpoints or objective measures provided supported the team’s doubts regarding the validity of the data set presented. The potential influence of the client’s dual role as both client and primary researcher, in so much as data collected impacted the success of their thesis project and academic success, and their role as an LI clinician in training having already invested many hours and funds in this intervention technique, bolstered the team’s skepticism regarding the authenticity of client change and rendered suspect client self-reported ratings and shifts. In building their case for change not being attributable to therapy the team produced all four types of arguments including self correction, extra therapy events, psychobiological causes, and reactive effects of research. The team argued for evidence in journals and change interviews indicating the presence of a narrative of self-help and inner commitment to continuing change within the client. Additionally, it was argued that the most significant shifts appeared to occur outside of the therapy room in between appointments. These were presented as further evidence that change was not due to therapy but instead to client’s use of therapeutic tools outside of session; the TCK ‘do it yourself’ pattern of behaviour. Extra-therapy events the team mentioned included a significant increase in involvement within the TCK community leading to resolution of TCK issues; being immersed in a psychologically minded graduate studies community accounting for significant shifts outside of therapy sessions; and having physical distance from family of origin accounting for decrease in levels of distress. The ST also included the client’s thesis work as a means of priming the client for change that would not have INTEGRATING EGO IDENTITY WITH LI THERAPY 120 occurred otherwise. Additionally, the team argued that the reflexive nature of this study, the client’s role as primary investigator and as an LI clinician-in-training, created a conflict of interest with the propensity on the part of the client/researcher/clinician to overestimate the positive outcomes of therapy casting suspicion on all attributions of change to therapy processes and events. Affirmative rebuttal. The AT addressed skeptic claims of absence of ego identity change, irrelevant change, statistical, relational and expectancy artefacts as well as skeptic arguments of self-correction, extra-therapy events, and reactive effects of research as evidence of non-therapy sources of change in their rebuttal. They contested the STs dismissal of all between session changes being attributable to therapy arguing these types of significant shifts and changes are a realistic impact of the implicit nature of LI therapy wherein the processes of brain reorganization and neural integration take time to work themselves out over time. This foundation allowed the researcher to submit additional evidence of cultural identity integration found primarily in journals into the affirmative rebuttal for the consideration of the judges. Regarding the primarily self-reported nature of the project data the AT argued that this fits within the structure and parameters of HSCED studies that privilege the client’s authority in making judgments regarding extent of change and attribution of change. In an HSCED study, therefore, self-reporting does not undermine the validity of the data presented. The conflicting roles of client, researcher and LI clinician-in-training were viewed as further complicating client engagement in therapy processes due to obstructive insider knowledge of protocol, purposes and potential impacts. Additionally, extra therapy events identified by the ST had been in place for 2 years already at the time of therapy start (TCK community, INTEGRATING EGO IDENTITY WITH LI THERAPY 121 psychologically minded community, distance from family) with no perceivable effect on problem areas on their own. In fact, the AT argued that extra-therapy events such as confronting family rules and failing to meet thesis deadlines would increase client levels of distress as opposed to decreasing them as evidenced in PQ ratings. Skeptic rebuttal. The ST responded to the affirmative case brief primarily by questioning the sufficiency of evidence in making any definitive claims regarding ego identity change and change due to LI therapy. If there is a lack of cultural integration of selves, is ego identity even possible? Was it really ego identity change or self-acceptance and post-traumatic growth or a combination of all three? The ST argued that the change interview process was overly focused on therapy attribution and did not adequately account for contextual or situational factors. They questioned if there was enough evidence to attribute change to a unique aspect of LI therapy that distinguishes it from other attunement therapies. The inclusion of additional therapeutic intervention strategies – the AEDP triangle, embodiment, bilateral stimulation – further complicated the process of distinguishing what could and could not be attributed to LI therapy processes. Adjudication Process. The adjudication process consisted in recruiting three external expert judges from among known experienced clinician pool. Two of the three adjudicators, judge A and C, had received training in LI therapy and were actively using this technique in their clinical practice. While Judge A was new to LI, Judge C had extensive experience in its use and was working towards a higher level of certification. Judge C also brought to the table her extensive knowledge of neurotherapy and judge A brought years of clinical experience regarding cross-cultural transitions and working with adult TCKs. The third adjudicator, Judge B, brought years of experience working with INTEGRATING EGO IDENTITY WITH LI THERAPY 122 children, especially teens and pre-teens, and was the only adjudicator with previous methodological experience and with doctoral level education. I, in my role as the reflexive researcher, also conducted my own adjudication process offering a 4th set of judgments alongside those submitted by these three external judges. The adjudicators, including myself, had a little under 2 weeks (12 days) to examine the evidence presented by the affirmative and skeptic case briefs and rebuttals (see Appendices T, U, V and W) and submit our determinations through the use of the Adjudicator Response Form (see Appendix M). Each adjudicator, like the case development teams, had both a hard copy and an electronic copy of the full rich case record including links to all video clips to which they could also refer. To align with the focus of this study adjudicators were asked to focus their reasoning regarding extent of client change specifically on ego identity as is noted in section A of their form. In this same section adjudicators were asked to judge the extent to which therapy was responsible for the ego identity change experienced by Rose. It became apparent during the adjudication process that, for those familiar with LI therapy, there were 2 questions: 1) general – to what extent is ego identity change due to overall therapy experience?; and 2) specific – to what extent is ego identity change due to LI therapy processes and protocols? Judges A and C and the reflexive researcher were asked to provide quantitative responses (percentages) to both questions. Table 7 presents a summary of the quantitative judgments made by all four adjudicators along with mean and median values for the three external judges alone and then adding in the reflexive researcher’s determinations. Stephen, Elliott and MacLeod INTEGRATING EGO IDENTITY WITH LI THERAPY 123 (2011) demonstrated the use of the median score as an appropriate measure to ascertain the majority ruling amid three adjudicators. The mean and median including the reflexive researcher are also listed. While an innovation to the adjudication process, the median will also be used to establish the majority ruling. A copy of the full responses from each adjudicator are included in the appendices (see Appendix X - Judge A; Appendix Y - Judge B; Appendix Z - Judge C; Appendix AA - Reflexive Researcher). INTEGRATING EGO IDENTITY WITH LI THERAPY 124 Table 8 Adjudicator’s judgments of client change 3 External Adjudicators Jdg. A Jdg. B Jdg. C M 1a. To what extent did the client experience ego 60% 80% 60% 67% identity change over the course of therapy? 1b. How certain are 60% 80% 60% 67% you? 2a. General - To what extent is this ego identity change due to 60% 80% 80% 73% overall therapy experience? 2a. Specific - To what extent is this ego identity change due to 40% N/A 60% 50% specific LI therapy processes? 2b. How certain are 60% 80% 60% 67% you? 3a. To what extent did the client experience general 80% 80% 80% 80% change over the course of therapy? 3b. How certain are 80% 80% 80% 80% you? 4a. To what extent is this general change 60% 80% 80% 73% due to therapy? 4b. How certain are 80% 80% 80% 80% you? Note: Jdg. = Judge, Refl. R. = reflexive Researcher Mdn All 4 Adjudicators Refl.R. M Mdn 60% 80% 70% 70% 60% 100% 75% 70% 80% 100% 80% 80% 50% 80% 60%. 60% 60% 100% 75% 70% 80% 80% 80% 80% 80% 100% 85% 80% 80% 100% 80% 80% 80% 100% 85% 80% INTEGRATING EGO IDENTITY WITH LI THERAPY 125 Summary opinions regarding client change. As mentioned above, adjudicator opinions were generally focused on ego identity change, however, judges were also to provide determination for general client change beyond ego identity shifts. Judge B and the reflexive researcher’s judgements of substantial (80%) change remained the same for general change or ego identity specific client change. Determinations for the other 2 adjudicators demonstrated and increase from ego identity change (Judge A and C – 60%) to general change (Judge A and C – 80%). Ego identity change. Judge A primarily focused on significant changes demonstrated in PQ items 1, 2, 3 and 5 which appeared to relate to ego identity change. Journal entries and sessions reports (HAT and TSNQ) that spoke of the development of a core identity, the emergence of a ME in the client, and the integration of parts of self, as well as the client experience of embodiment were also key to their determination of considerable ego identity change. While Judge A agreed that ego identity change for a TCK may differ from a non-TCK in necessitating the inclusion of cultural integration, they thought this was outside of the parameters of this study to determine. Ego identity change was judged to be considerable (60%) and not substantial (80%) as only 4 out 15 PQ items appeared to have any connection to ego identity. Judge A also expressed uncertainty as to whether these items accurately measured change in the construct of ego identity or if they were measuring something completely different. Judge B’s opinion regarding ego identity change made use of descriptive and quantitative evidence of the client being less triggered by known stimulus and feeling more grounded and confident in self and self in interaction with the world. Additionally, client reports of an emerging ME from journals and HAT forms, and therapist INTEGRATING EGO IDENTITY WITH LI THERAPY 126 observation of client integration and the development of voice influenced their decision. Judge B also referenced evidence of client separation of self from symptoms as an indication of ego identity change. Judge C referenced changes in long-standing problem areas and a decrease in emotional arousal and dissociation as evidenced in PQ item ratings, therapist session notes and client journals. Additional evidence from HAT, TSNQ and client journals of an emergence of self (“ME”), integration of self, and client change in relationship to self and anxiety were also used in arriving at a determination. Skeptic arguments that Judge C found persuasive included the influence of the client/researcher dual relationship on data collection, the TCK pattern of self-determination and self-help, and uncertainty as to the degree of cultural ego identity integration experienced by the client. As the reflexive researcher I made use of PQ data for items 1, 3 and 5, the HAT and TSNQ forms, journal entries, and adjudicator orientation information in arriving at my determination of ego identity change. Accounts of an emerging self I found were further bolstered by descriptions of being centered, grounded, discovering personal voice, and a change in relationship to fear and anxiety. Comments relating to the client ‘growing up’, feeling more their age and seeing them selves as more capable also appeared to be evidence of ego identity integration. In response to the ST’s argument that limited time was spent specifically with the 11-year-old (repatriation) self to make claims regarding ego identity integration as part of TCK healing, I referenced the adjudication orientation information indicating that family dynamics, defense mechanisms and attachment relationships had the ability to significantly impact the formation of ego identity fragmentation amid TCKs (i.e., ego identity fragmentation can INTEGRATING EGO IDENTITY WITH LI THERAPY 127 result from an imbalance between cultural adjustment challenges and available resiliency resources; see Figure 10). As such, I determined the repair of these elements (i.e., the creation of a positive attachment relationship, working with younger Mexican selves, addressing voicelessness and silencing within family dynamics) as addressing ego identity fragmentation in therapy. In conclusion, in agreement with the ST’s argument that ego identity change is unfinished, change was judged as substantial (80%) but not complete (100%). Figure 11. The imbalance of challenges versus resiliency resources that can lead to TCK ego identity fragmentation General change. It is significant to note that judges A and B who determined ego identity change was considerable (60%), determined there to be greater evidence for general client change which they rated as substantial (80%). Both judges also demonstrated greater confidence in their determinations of general change (significantly confident – 80%) than their judgment of ego identity change (considerably confident – 60%). Judge A noted that, although only 4 PQ items could be tentatively associated with INTEGRATING EGO IDENTITY WITH LI THERAPY 128 ego identity, many of the 15 PQ items demonstrated significant change over the course of therapy as evidenced in the change interview data. While Judge B also made mention of the significant shifts in PQ item scores in her determination of ego identity change, the reasoning for judging general change as more pronounced than ego identity change was unclear. Percentage ratings from Judge C and reflexive researcher did not change for general change in comparison to ego identity change; general change was also determined to be substantial (80%). Summary opinions regarding change due to therapy. Adjudicator determinations in this section fall into three categories: 1) ego identity change due to overall therapy experience; 2) ego identity change due to LI specific processes; 3) general change due to therapy. As Judge B did not have any training with LI processes and protocols, they did not provide a separate judgment for section 2 mentioned above. Ego identity change due to overall therapy experience. Judge A based their determination on client CI ratings of change as surprising, the richness of the PQ data that would be difficult to fake over a long period of time, and the absence of sufficiently convincing extra therapy events. Judge B likewise made use of client CI ratings in arriving at their judgment along with making use of client and therapist reports of coinciding helpful therapy events. Evidence of changes occurring in long-standing problem areas, of an increase in tolerance of triggers, and a decrease in symptoms despite continued contextual stressors, were also helpful in making their final decision. Judge B agreed with the skeptic argument that change did not address repatriation issue and TCK identity consolidation. INTEGRATING EGO IDENTITY WITH LI THERAPY 129 Judge C referenced the significance of the attuned therapist-client attachment relationship, client and therapist reports of connections with younger selves, and evidence from session six of a direct relationship between a meaningful therapy event and a decrease in PQ ratings. In contrast, the dual role of client/researcher created difficulty for Judge C in trusting or determining that accuracy of the client CI attributions of change. In making my determination I referenced the long-standing nature of problem areas and the lack of change and positive outcomes in these areas over the last 10+ years of therapy. The surprising nature of the changes that occurred negates the ability for manipulation or control of outcomes. I agreed with the AT’s rebuttal indicating that the client/researcher role was handled with diligence in order to minimize researcher impact on client experience of therapy. Ego identity change due to LI therapy. Both Judge A and Judge C, based on their training in LI therapy processes and protocols, clearly differentiated between change due to the overall therapy experience and those due to specific LI processes. Judge A explained that although change could be considerably attributed to therapy it could not be reliably attributed to LI specific processes utilized during therapy determining LI therapy to only be moderately (40%) due to LI therapy. Judge C identified the client connection to baby self and connection to 11-year-old self in the present-day context (session 27) to be evidence of change occurring due to unique LI specific therapeutic practices. In contrast, Judge C questioned the presence of neurological shifts and integrative processes due to the lack of Time Line repetitions necessary to produce these outcomes in 22 out of 26 LI specific sessions. INTEGRATING EGO IDENTITY WITH LI THERAPY 130 I determined change to be substantially due to LI therapy due to the many LI protocols and processes utilized that Rose reported as significant including the presence of a grounded and attuned therapist, encountering baby self in attunement protocol, use of the LI Time Line, bringing past selves into the present-day, encountering younger parts of self, engaging client inner resources in interactions, and therapist coaching. While not all these processes are unique to LI, they are all present and prominent within LI therapy practice. Those that are uniquely LI include encountering baby self during attunement protocol, use of LI Time Line, and bringing past selves into the present-day. I agree with AT’s attribution to therapy processes of between sessions changes and shifts due to the implicit nature to LI therapy. The ‘impure’ practice of LI therapy as evidenced by the inclusion of other therapy techniques as mentioned by the ST led to a determination of substantially due to LI therapy (80%) as opposed to completely (100%). General change due to therapy. While Judge A’s determination of degree of general change due to therapy remained considerable (60%; same as rating for ego identity change) their confidence level increased from considerable (60%) to substantial (80%). Judge B, Judge C and the reflexive researcher’s ratings for general change in comparison to ego identity change due to therapy remained substantial (80%) for both adjudicators and complete (100%) for the reflexive researcher. Mediator factors. All adjudicators identified the client-therapist relationship and experiential processing (i.e., connection to baby self, younger selves, and embodiment INTEGRATING EGO IDENTITY WITH LI THERAPY 131 session) as significant mediating factors. Judge A10 also identified PQ tracking, dialogue between ego states, reflecting on change (e.g., journal entries, texting), and participating in research process as capable of mediating client change. Additional mediating factors identified by Judge B included expectancy, trust in quality of therapist care due to referral source, and medication. The PTSD protocol used in therapy and client’s work on integration between sessions were named by Judge C as mediating factors. I identified five significant mediating factors within my therapy experience: 1) the use of the attunement protocol with baby self; 2) ego state dialogues and coaching from therapist in standard protocol; 3) the LI Time Line; 4) the presence of an attuned therapist for co-regulation of emotions; and 5) the therapist as witness to client’s life and cocreator of client autobiographical narrative . Moderator Factors. Rose’s high motivation to change and commitment to therapy as well as her training and experience with LI therapy were identified as moderating factors by all three adjudicators and the reflexive researcher. To this the adjudicators also named the Rose’s dual role as researcher as likely impacting therapy outcomes. Judge A and Judge B proposed the Rose’s current educational pursuits and context and Judge A11 also named timing (i.e., client life stage, age, and circumstance) as further moderating factors. 10 Judge A also identified “watching videos of self in therapy” as a mediating factor. This appears to be a misunderstanding of the order of events as they occurred during the research process as no videos were viewed by the client/researcher during the data collection phase of research and therefore was not occurring over the course of therapy. 11 Judge A also named extra therapy events as identified by the ST as moderating factors, however, they previously had described these specific elements as unconvincing and not persuasive. Due to this conflicting information I have chosen to not include extra therapy events in this summary. INTEGRATING EGO IDENTITY WITH LI THERAPY 132 CHAPTER 5: DISCUSSION This study has been constructed to evaluate the suitability of LI therapy in addressing ego identity fragmentation and its correlates in an adult TCK. As such, the central research questions of this study pertain to client change (i.e., did the client change substantially over the course of therapy and did the client experience change in ego identity) and the role of therapy in producing this change (i.e., was any of the change substantially due to the effect of therapy). A further aim of this project is to identify specific therapy processes contributing to general client change and to specific ego identity change. As evidenced in the outcomes presented in the previous chapter, the answers to these questions were complex and nuanced. In broad terms, when examining general client change, the adjudicators unanimously determined there to be substantial client change (median = 80%) with 80% confidence. Moreover, these changes were substantially (median = 80%) attributed to Rose’s overall experience of therapy, again with 80% confidence. At this level of investigation, therefore, adjudication results provide clear and convincing evidence of client change and client change due to therapy in meeting the 80% standard of proof established for HSCED studies by Stephen and Elliot (2011). When examining the data for more specific and detailed determinations of efficacy (i.e., extent of ego identity change, ego identity change due to LI therapy, ego identity change due to overall therapy experience, and change due to LI therapy) the results were not as clear. Pragmatic and feminist paradigmatic considerations support a multi-layered analytical approach to examining the complexities of these findings in INTEGRATING EGO IDENTITY WITH LI THERAPY 133 which authority of data interpretation and drawing conclusions is intentionally shared between the reflexive researcher and external adjudicators. This strategy converges elements of self-experimentation research practices, reflexive researcher positionality, and meta-synthesis principles under the broader umbrella of intersectional analysis and is epistemologically crucial to bridge the reflexive researcher positions with the HSCED method. I implemented intersectional analysis within this study not as a means of eclipsing the power of the adjudicators with my own reflexive researcher authority, but as an invitation into explicit dialogue with each of these perspectives as well as with the reader. In doing so, this approach allows the research to highlight insights into both the therapy process and into the reflexive research process. Client Change, Therapy Attribution, and Therapy Processes It is easily noted, upon examination of the adjudication determinations, that the judgments made by the reflexive researcher vary significantly from most of the external adjudicators. For this reason, the reflexive researcher results will not be addressed alongside of the external adjudicator outcomes but will be discussed separately at the end of this section. Client Change. Besides the general change mentioned above, the case development teams and adjudicators focused specifically on evidence for ego identity change. Amid this discussion the skeptic team brought up questions regarding the nature of ego identity for the TCK population. Both types of client change and the adjudicator results for each are further discussed below. Ego identity change. Determinations of client ego identity change did not meet the standard of proof for clear evidence of client change with a majority decision of INTEGRATING EGO IDENTITY WITH LI THERAPY 134 considerable (median = 60%) change with a 60% certainty. In contrast to general client change where the adjudicators were unanimously substantially confident of Rose’s change, 2 of the 3 judges (Judge A and Judge C) were less confident in their ability to identify and judge the level of ego identity change occurring for Rose. This is likely due to the complexity of and an unfamiliarity with the construct of ego identity; a multifaceted and dynamic construct. It is notable, that neither Judge A nor Judge C referred to the skeptic team’s alternative interpretation of client acceptance of self and life circumstances in arriving at their determination nor did they provide an alternative explanation for evidenced change. An argument was made by the skeptic team for the inclusion of an objective ego identity measure and/or external sources of evidence of client ego identity integration to bolster the validity of findings in client self-report measures and qualitative data. Inclusion of such data may have increased the adjudicator’s level of confidence in their responses if not also their determinations of the extent of ego identity change. TCKs and ego identity change. One of the most curious and unexpected findings was the skeptic development team’s presentation of cultural integration as a necessary element of TCK ego identity change. While one adjudicator (Judge A) felt this was outside of the scope of this project to determine, the other two (Judge B and Judge C) were in agreement with the skeptic team that cultural integration was both a necessary element of TCK ego identity change, and that there was very limited explicit evidence of this process occurring for Rose. These findings reveal cultural integration and its role in ego identity integration among TCKs as an important area that, while outside the scope of this project, merits further exploration and investigation. INTEGRATING EGO IDENTITY WITH LI THERAPY 135 Change Due to Therapy. The complexity of the determination of change due to therapy that became clear early in the adjudication process was a surprising dynamic within this study. I had anticipated a more direct understanding of therapy processes and had not anticipated the distinction the LI trained clinicians made between change due to overall therapy experience and change due to LI therapy processes. The counselling agreement between Rose and Hillary McBride was clearly delineated as LI therapy, however it appeared that the influence of LI specific protocols and processes was not self-evident. Consistent with professional and academic understandings of therapeutic factors, Judge A and Judge C distinguished between LI specific processes and Rose’s overall counselling experience. Ego identity change due to LI therapy. Adjudicator opinions on degree of client change due to LI therapy varied. While Judge A considered the influence of LI therapy to be moderate (40%), Judge C rated it as considerable (60%). As Judge B was not specifically trained in LI therapy, she was not asked to provide a determination in this category. While Judge A did not provide explicit details regarding why change could not be reliably attributed to LI therapy, Judge C relied heavily on the lack of LI Time Line repetitions in sessions as evidence that LI therapy was not substantially at work in this case study. This judgement was based on a central premise in LI protocol training indicating a required number of LI Time Line repetitions per session in order to begin to affect neural pathways and produce integration. Ego identity change due to overall therapy experience. In contrast, all adjudicator ratings increased when attributing ego identity change to the overall therapy experience including all of LI, non-LI and common factor elements of therapy work. The INTEGRATING EGO IDENTITY WITH LI THERAPY 136 majority decision was that change was substantially due to overall therapy (median = 80%) thereby meeting the standard of proof for a clear connection between therapy experiences and ego identity change. Therapeutic Processes. The case development teams and adjudicators identified numerous therapy processes which aided in producing change within the client. Judge A and Judge C clearly differentiated between processes uniquely evident in LI therapy and those evident in other attunement and ego state based forms of therapy, as well as factors common to most therapy modalities. Of those that were named the most prominent are discussed below. Common factors. A major proportion of therapy impact is shared with other modalities due to characteristics common to diverse therapy interventions and encounters. It is unsurprising therefore that adjudicators primarily identified common therapy factors as significantly impacting client change over the course of therapy within this study. Common factors named by the judges included the therapeutic alliance, client expectancy, client motivation and commitment to therapy, and client’s previous exposure and experience with the therapy modality. As such, the significant influence of these common factors indicates that the LI therapy was effective in ways that are shared with other therapy techniques. Ego identity processes. The adjudicators also judged experiential processing as specifically impacting client ego identity change. Included here were client imaginal encounters with younger selves and ego state dialogues. These experiences enabled Rose to access previously frozen and stuck parts of self and to engage in corrective emotional experiences with the younger ego states. While these experiential aspects are present and INTEGRATING EGO IDENTITY WITH LI THERAPY 137 central to many of the LI therapy protocols, Judge A and Judge C determined that these were not unique to LI and present in other ego state therapies therefore were not judged to be evidence of LI therapy specific sources of change. Embodiment exercises, such as physically acting out emotional states, were additional experiential elements of therapy reported by the client and therapist as being significant and helpful events in therapy. While embodiment - understanding our existence through our bodies and being informed through somatic experiences - is central to LI therapy, making use of our bodies to physically act out internal experiences is not explicitly required in LI protocols. Adjudicators determined that these corporeal manifestations significantly impacted ego identity change within Rose by enabling her to physically demonstrate internal emotional states and to communicate states of being for which she had no words. This was empowering and gave voice to previously silenced client experiences. Moreover, it visually exemplified Rose’s ego identity journey and became a symbol for change as ego identity grew. LI attunement protocol. All the external adjudicators made note of the Rose’s connection with baby self as a therapeutically significant event for her. Judge C also noted that this connection would not have occurred without the use of the LI attunement protocol. HSCED and research processes during therapy. It is significant to note that Judge A also identified elements of the HSCED research process and client qualitative data collection as enhancing Rose’s experience of change throughout the therapy process. Tracking of changes using the HSCED PQ and engaging in the practice of reflecting on INTEGRATING EGO IDENTITY WITH LI THERAPY 138 changes experienced through journaling and communication with personal support community were judged to be significant factors in creating positive change for Rose. In summary, while external adjudicator determinations clearly indicated substantial client change attributable to overall therapy experience, adjudicator interpretations of ego identity and LI therapy outcomes was not as clear. Adjudicator formulations of the ego identity construct, conceptualizations of cultural factors of integration, and professional understandings of therapy processes revealed layers of complexity in judging level of ego identity integration experienced by the client and degree of change attributable to LI therapy processes. Judges determined the data to be evidence of considerable ego identity change that was only considerably to moderately due to LI therapy processes; determinations that fell below the standard of proof for significant client change and change due to therapy. On the other hand, the judges unanimously determined client ego identity change to be substantially due to overall therapy experience which met the standard of proof as a significant research finding. Adjudicators identified common factors impacting client change including the therapeutic alliance, client expectancy, and client motivation and commitment. They also noted ego identity processes including experiential processing and embodiment, and other factor including the LI attunement protocol, and research processes such as client tracking of PQ items and researcher reflective practices. Next, we turn to discuss the reflexive researcher determinations and offer a means by which discrepancies in concluding judgments between external and reflexive adjudicators can be understood. Intersectional Analysis. An examination of the external adjudicator determinations and reflexive researcher judgments highlighted evident discrepancies INTEGRATING EGO IDENTITY WITH LI THERAPY 139 between these sets of adjudication results. In my role as a client, my experience of substantial change due almost exclusively to LI therapy processes appeared to be a foregone conclusion. I was therefore surprised by the general trend of the external adjudicator determinations. I felt unseen and misunderstood. As a client experiential marker this felt sense of being unseen and misunderstood is epistemologically relevant within this study in providing insight into the therapy and research processes. This experience presented an opportunity for further examination of the study data and represented an invitation to an open dialogue between myself as the reflexive researcher, the external adjudicators and research teams, the broader LI and research community, and the reader and expanding the scope of potential interpretations emerging from the study outcomes. In employing intersectional analysis this dialogue is not meant to challenge the professional analytic processes and legitimate determinations made by the external adjudicators. Instead it is intended to bring to the forefront our communal potential in research to apply professional formulations emerging from therapy research in such a manner as to unintentionally reify theoretical constructs at the expense of a wholistic and inclusionary perspective. To this end, in my role as primary investigator, I returned to re-examine the study data for explanatory evidence focusing primarily on the apparent incongruity of external and reflexive adjudication results. Upon a closer examination of the adjudication results through an intersectional analytic lens I came to understand these discrepancies as evidence of professional polarities in therapy formulations and analytic processes. Specifically, amid the external adjudicator data, I identified a highly detailed analytic stance towards the data resulting in fragmentation of the psychotherapy process and INTEGRATING EGO IDENTITY WITH LI THERAPY 140 experiences and a simplification of the interlocking variables and dynamics at play within this study. To remedy this de-contextualizing and reductionist treatment of the data, results were re-interpreted through a broader intersectional lens re-establishing a balance between analytic and synthetic processes in congruence with HSCED purposes and values (Elliott, 2015). To accomplish this re-balancing of analytic and synthetic processes I borrowed principles from research metasynthesis. Traditionally used to collectively analyze and integrate a series of qualitative or mixed-method studies centered around a common topic or theme (Lachal, Revah-Levy, Orri, & Moro, 2017), in this study metasynthesis was utilized to analyze and integrate information across various complex and dynamic data sources. As such, metasynthetic processes within this study serve to provide “a richer, more complete understanding of the phenomenon” (Erwin, Brotherson, & Summers, 2011, p. 188) under investigation. Metasynthetic principles of analysis, integration and interpretation were utilized to mediate the de-contextualizing and reductionist effects of three areas of professional practice: compartmentalization of experience, privileging of data sources, and fragmentation of therapy processes. See Figure 11 for an overview of the above described intersectional analysis process. INTEGRATING EGO IDENTITY WITH LI THERAPY Figure 12. Intersectional Analysis: Areas for remediation through metasynthesis 141 INTEGRATING EGO IDENTITY WITH LI THERAPY 142 Metasynthesis of compartmentalization of experience. Amid the adjudicator responses and rationales there was evidence of compartmentalizing Rose’s therapeutic experience into isolated categorical elements. This was evident in two primary areas: compartmentalization of TCK ego identity, and compartmentalization of TCK cultural identity. Using intersectional analysis and metasynthetic principles I sought to broaden the conceptual framework for analysis of these constructs and re-interpret and integrate a wider base of related therapy results and experiences. Compartmentalization of TCK ego identity integration. Proof of repair of TCK ego identity fragmentation due to repatriation was limited in adjudication processes to therapy events which directly addressed Rose’s repatriation experience (11-year-old self). This compartmentalized perspective disregarded the broader causes of ego identity fragmentation evidenced in TCK and ego identity literature (e.g., Erikson, 1963, 1968; Meneses, 2011; etc.). During adjudicator orientation these broader contextual causes were presented as an imbalance of cultural and transitional challenges and available resiliency factors (see Figure 10). Included in possible resiliency factors are family dynamics such as patterns of interaction and attachment relationships which are established early on in parent-child connection and are reinforced over time. When these patterns are dysfunctional they no longer serve the purpose of aiding in the resiliency of the TCK when faced with the psycho-socio-cultural challenges of repatriation hence tipping the balance towards the adoption of unhealthy coping mechanisms and ego identity fragmentation (Berzonsky, 1992; Côté & Levine, 2002; Erikson, 1994; see also Fail et al., 2014; Lijadi & Van Schalkwyk, 2017; Walters, 2006). INTEGRATING EGO IDENTITY WITH LI THERAPY 143 Within this framework of ego identity fragmentation any aspects of therapy that address family interactions, patterns of connection, and attachment relationships work to rebalance the scale and aid in the healing of ego identity fragmentation. As such, therapy work focused on repairing ego identity fragmentation is no longer limited to experiences explicitly related to repatriation and 11-year-old self. In contrast, from this perspective, therapy work focused on attachment, attunement, restoration of agency, taking up space and having a voice with younger and older parts of self, all of which are evident in this study’s data, also speak to repairing ego identity fragmentation. Compartmentalization of TCK cultural identity integration. In a similar fashion cultural identity was conceptualized by adjudicators as a distinct construct separate from ego identity and necessitating explicit attention during therapy work in order to produce integration. While legitimate, this formulation would seem to be an over-simplification of the complexities of culture and ego identity. I would argue, as is implied in Sussman’s (2000) review of self-concept and cultural identity dynamics, that an encounter with self is an intrinsically culturally embedded experience; it is an encounter with “a mental framework through which individuals define their ontology, motivate and select their behaviours, and judge and evaluate the actions of other,” (p. 356). Additionally, social scientists’ adoption of a nuanced, dynamic and agentic view of culture that is determined by communal and individual influences (García, 2019), suggests that cultural identity is inseparable from a holistic and contextualized understanding of an individual. It is exactly for this broader, more flexible, open and inclusive stance towards defining the complexities ‘culture’ that Williams (2013) advocates in her dissertation in which she INTEGRATING EGO IDENTITY WITH LI THERAPY 144 redefines TCKs as Third Route Kids de-centralizing culture as the defining aspect of their identity. From this intersectional clarification of cultural identity, the study data suggests that, although cultural elements were not explicitly addressed in therapy, my (Rose’s) interactions with younger selves existing with a Mexican cultural context implicitly addressed cultural identity. I offer as direct evidence of the process of embracing my Mexican self its apparent presence in post therapy journals and experiences. Prior to LI therapy my Mexican identity was as a memory of something that existed at one time but no longer was; a faded reflection of self I remembered when eating Mexican candies or foods. Post-therapy I experienced a reclaiming of these childhood memories as belonging to me, being mine (see journal from March 19, 2019, p. 385). This reclaiming of memories revived in me a Mexican identity that was no longer childlike and in the past, but present within my 45-year-old self. While not part of the study data set, I believe it is important to note that this reclaiming of Mexican identity also manifested itself in my binge-watching Spanishlanguage TV shows and movies, a phenomenon I had not experienced before. While I have enjoyed being immersed in the Spanish language of shows based both in Spain and Latin America, I have observed a greater experience of joy and recognition of self in the developing nation cultural context of shows in Latin America (Colombia, Mexico) than those based in first world Spain. INTEGRATING EGO IDENTITY WITH LI THERAPY 12 145 En ellos me encontré disfrutando de comprender no solo el lenguaje de la gente, pero sino también su manera de ser, de hablar y de vivir. Sumergiéndome en la lengua hispánica salió muy claramente una identidad latina madura. Esta identidad fue tan poderosa que hasta yo me salía de casa y me parecía que yo estaba en un país latinohablante. Me dio pena darme cuenta de que estaba en Canadá y que aquí la gente no me iba a comprender al hablarles en español. Incluso me encontré soñando por la noche en español, algo que yo no creía ser posible y que yo no tengo memoria de que había pasada antes, ni siquiera cuando estudiaba las lenguas en la universidad. A mi juicio, estas experiencias son pruebas concretas de la integración cultural y lingüística. [In these shows, I found myself enjoying not only understanding the language, but also the people’s way of being, their mannerisms and their lifestyle. While immersing myself in the Spanish language a mature Hispanic identity clearly emerged. This identity was powerful enough to cause me to envision myself in a Latin American country when out in the community. It was disappointing to realize that I was instead in Canada and that the people around me were not Spanish speakers. I even found myself dreaming in Spanish, something I thought was impossible and that I have no memory of every occurring before even when I studied French and Spanish in University. It is my judgment that these experiences are concrete examples of cultural and linguistic integration.] 12 In composing this section on cultural integration it became difficult to express my ideas in English and instead they organically emerged in Spanish. It is less empirically accurate to take out the Spanish when translating this portion into English as the bilingual nature of this phenomenon reflects the cultural identity topic being discussed. As such, a decision was made to include both the original Spanish followed by the English translation. INTEGRATING EGO IDENTITY WITH LI THERAPY 146 Metasynthesis of privileging of data sources. Within the adjudication determinations there was evidence of privileging certain data sources as being more reliable and credible than others; in-session data was privileged as was quantitative data. Intersectional analysis provided the framework for balancing the power and authority of all types of data and metasynthesis was utilized to more completely integrate all sources of data. Privileging in-session experiences. In both above examples of fragmentation of lived experience, adjudicators privileged in-session therapy experiences above descriptions of growth and change experienced between and post-therapy. In doing so, the influence and resultant developments emerging from the matrix of therapy became isolated from the broader context of life and constrained to changes which could be explicitly linked to in-session interventions and events. Examples of this are the between session journal entries that reflect upon and describe the emergence of a new sense of self (see journal entries in RCR, pp.349-359). The adjudicators determined the influence of therapy on these subjective descriptions of ego identity integration to be suspect as these descriptions could not be logically linked to explicit in-session therapy work. Additionally, Rose’s qualitative claims to cultural integration work that, as already mentioned, appeared post-therapy were not considered causally connected to therapy work which had already ended. According to Pace (2012) LI protocols are designed to re-organize neural firing networks with the aim of creating change at the synaptic level. Pace (2012) delineates post-therapy outcomes of this process include:  A newfound sense of a competent, capable, lovable and solid self. INTEGRATING EGO IDENTITY WITH LI THERAPY  The ability to let go of archaic defensive strategies.  An enhanced ability to enjoy life and intimate relationships.  A much improved ability to regulate affect.  An expanded emotional repertoire. (Pace, 2012, p. 15) 147 Given the focus of LI therapy on working with implicit and episodic memories (Pace 2012), the above outcomes cannot directly be linked exclusively with in-session therapeutic work. Rather these are indicative of neural changes occurring as a result of session work that become evident through changes in behaviours, thought processes and emotional states experienced outside of session in the context of real life. Accordingly, I purport that between session and post-therapy client journals, personal communications, and change interview reports present within this study that describe the types of changes listed above are, within the above described LI outcomes framework, conceptually and causally linked to in-session LI therapy work. Privileging of quantitative data. Among adjudicator responses I discovered evidence of privileging quantitative data as more credible proof of ego identity change in the client over and above any qualitative descriptions. Grzanka (2018) highlights that, “intersectionality challenges dominant, postpositivist psychology …. [demanding] a reconsideration of what counts as knowledge” (p. 589) resisting the dominance of postpositivist privileging of quantitative sources of knowledge that creates power differentials and oppressive structures. In contrast, Grzanka (2018) proposes that intersectionality centralize the subjective voice and felt intuition as valuable means of psychological knowing. Consequently, in conducting an intersectional re-analysis of this study’s data I equally considered both types of data (quantitative and qualitative) and INTEGRATING EGO IDENTITY WITH LI THERAPY 148 allocated the greatest power and influence based on the persuasiveness of the data source and the magnitude of the reported change. Based on these criteria, I judged that the subjective client reports evidencing ego identity change held more weight as they contain more clear descriptions of ego identity change (more persuasive). The quantitative PQ items related to ego identity change (#1, 2, 3, and 5) were among those that experienced the greatest rating change over the course of therapy, while qualitative data also demonstrated a in-depth change in core self, and therefore I determined magnitude of change to be shared between both qualitative and quantitative evidence. In fact, I would argue that the magnitude of change present in qualitative reports served to bolster the credibility of ego identity related quantitative PQ items. In considering both types of data collectively I deemed the presence of substantial ego identity change to be readily evident. Metasynthesis of fragmentation of therapy factors and experiences. Further evidence of compartmentalization was found in uncertainty among adjudicators regarding what constituted LI therapy which led to consequent fragmentation and highly detailed analysis of the therapy experience. In broadening the analytic framework to a holistic examination of the counselling experience I made use of metasynthesis to re-integrate individual therapy factors into the collective therapeutic experience and re-interpret study results from this perspective. Common factors. There was evidence among adjudicator rationales of treating common therapy factors in counselling as wholly separate elements detached from LI specific protocols. Therapist attunement was one dynamic specifically addressed by adjudicators as distinct from LI therapy processes and protocols dismissing the attribution INTEGRATING EGO IDENTITY WITH LI THERAPY 149 to LI therapy of any change linked to the influence of this relational dynamic. However, within the LI training literature, Pace (2012, 2018) emphasized therapist attunement as an essential and integral element of the effectiveness of LI interventions. This would seem to imply that the two are inseparable; LI therapy relies on a highly attuned therapeutic alliance between client and therapist. Contextually it is notable that this attuned therapeutic relationship was not unique to Rose’s work with Hillary McBride in this research project. All her relationships with former therapists had been positive and all her therapists had encountered her in an attuned and meaningful manner. Those that did not encounter her in such a manner did not last beyond the first session; she had dismissed as many therapists as she had kept. What may not have been explicitly evident within the data set was the unique nature of the attachment dynamic that emerged between Hillary and Rose that she had not previously experienced with other therapists. This dynamic I directly attribute to the use of the LI attunement protocol at the beginning of therapy. Using this protocol Hillary met a core need for care and attunement in Rose’s most vulnerable state. While an attuned therapeutic relationship is a common factor that transcends therapeutic modalities, I propose that the attachment attributes of Rose’s therapeutic relationship with Hillary are shared features of common factors and LI therapy processes and thus inseparable one from the other. Client factors. Another common factor cited by adjudicators as diminishing the impact and influence of therapy on client change was Rose’s high degree of motivation and commitment to the therapy process. While these characteristics were most certainly present and can act as moderators of client change, within the broader context of her INTEGRATING EGO IDENTITY WITH LI THERAPY 150 overall therapy experience I argue that their influence diminishes significantly in comparison to therapy interventions. Having been in therapy for over 10 years this high level of motivation and commitment was not a new development. They were dynamics that had been present in every therapy experience to date, and yet, as evidenced by Rose’s responses on the PQ duration form, their presence alone had not created change in the areas under investigation in this study. Rose advised that the one dynamic that had changed was switching from talk therapy to LI therapy. I do not contest the importance of client motivation as a significant factor in producing clinical change. I do, however, contend that in this case taking a broader perspective of overall clinical experience demonstrates that this was not unique to this particular therapy journey and therefore cannot account for degree of new changes experienced. LI factors. Among adjudicator determinations I also discovered evidence of a hyper-focus on the number of Time Line repetitions as the most significant proof of fidelity to LI therapy interventions. As an emergent therapy intervention, many elements of LI protocols are in process currently being based on clinical observation and informal therapeutic experimentation; There continues to be significant internal dialogue within the LI community regarding appropriate clinical standards for effective implementation of therapy protocols. One such feature is the recommended number of Time Line repetitions during sessions in which current formulations are a relatively new addition (within the past 5-8 years). It is important to state that it is not the specific number repetitions that is the key distinguishing feature of LI in comparison to other therapies, rather it is the use of repetition combined with the client-generated visual and sensory Time Line (Pace, 2012). Since the threshold of the minimum number of repetitions INTEGRATING EGO IDENTITY WITH LI THERAPY 151 currently recommended for specific LI protocols were not consistently met in Rose’s LI therapy, it may be surmised that changes occurred slower and over a longer period of time. This represent an important area for further research. Refined results. While the original results of the adjudication process stand, I set forth this appeal for a refinement of the determinations as meeting the standard of proof (80%) for the degree of ego identity change experienced by Rose and the extent of ego identity change due to LI therapy. The following appeal is based on the argumentation and explanatory evidence of the above intersectional analysis of the discrepancies found between external and reflexive adjudication results and analytic processes. I would argue that, having remediated the de-contextualization and reductionist treatment of data evident in the adjudication process, and having re-interpreted the data within a broader intersectional and re-contextualized lens, I have provided a sound rationale for adjusting the final conclusions of this study to reflect substantial (80%) rather than considerable (60%) client ego identity change due to LI therapy. Critiquing metasynthesis. The above intersectional analysis and metasynthesis of study results is an interpretive approach to interacting with the initial study findings. As such, I acknowledge that there is space for constructive debate and discussion regarding these processes and the proposed refinement of study conclusions. It is not the intent of this intersectional analysis and metasynthetic process to suggest any error or failure on the part of the external adjudicators. In contrast, the external judges performed their role with utmost professionalism and integrity. It is for this very reason that the refined results do not replace the original adjudicator determinations but instead are presented as an appeal for a re-consideration of study findings and conclusions within an alternative INTEGRATING EGO IDENTITY WITH LI THERAPY 152 broader interpretive framework. The persuasiveness of this appeal argument is left up to the reader to determine and to arrive at their own conclusion whether to accept the refined results, remain with the original adjudicator determinations, or set forth an additional appeal process. Mediating and moderating factors. Prominent moderating and mediating factors impacting therapy change identified by the external adjudicators and myself as the reflexive adjudicator, as summarized in Table 8, at first glance also appeared to be conflictual. While all parties agreed on the primary moderating factors as being client motivation and LI clinical training, identified mediating factors appeared to vary between external judges and the reflexive researcher. Table 9 Intersectional analysis of mediator and moderator therapy factors as identified by adjudicators. Adjudicators Reflexive Researcher Mediators Experiential processing Dialogue with younger selves Client-therapist relationship Ego-state dialogue LI Time Line Attunement protocol Attuned therapist Moderators Client motivation LI therapy training Client motivation LI therapy training INTEGRATING EGO IDENTITY WITH LI THERAPY 153 On closer inspection I noted that findings were linked. The experiential processing and dialogue with younger selves identified by the external adjudicators mirrored (in the sense of sharing many common qualities and characteristics) the mediating factors of ego state dialogue and LI Time Line named by me. Moreover, the intersectional analysis already performed as described above provided a rationale for clearly linking the client-therapist attuned relationship with LI attunement protocol work. The importance of LI protocols in helping the client experience change becomes apparent in concurrently examining mediating factors identified by external and reflexive adjudicators. Therapeutic Consideration and Future Directions of LI Rose, a 45-year-old woman, identified as an adult TCK. She reported experiencing ego-identity fragmentation due to the trauma she experienced at the time of repatriation. Moreover, she came with a long history of previous clinical work with no significant shifts in integrating these fragmented parts of self. Along with her therapist, Rose identified her primary therapy goals as developing an integrated core self and decreasing symptoms of fear and shame. The work into which Rose and her therapist were entering was difficult, painful and vulnerable work. For this reason, it is especially notable that the clinician chose to begin therapy with the attunement protocol. Through its use a strong, attuned attachment therapeutic relationship was built in which Rose, in her most vulnerable state as a baby, understood the therapist to be fully present and capable of caring and protecting her. Taking into consideration the TCK propensity for extreme self-sufficiency and selfdependency in order to avoid burdening others, the attunement protocol may present an INTEGRATING EGO IDENTITY WITH LI THERAPY 154 effective clinical tool in curtailing these patterns in TCKs. Additionally, it may be beneficial to make use of this protocol to establish a strong attachment relationship with TCK clients early on therapy. Moreover, in mimicking the infant-caregiver dyadic relationship, the attunement protocol also creates the platform for emotional coregulation (Pace, 2018), an important element of therapy for TCKs who often cope with challenges through the muting and blunting of emotions (Walters, 2006). With regards to ego identity work, the attunement protocol also increases client self-love, begins processes of establishing a sense of core self, and sets the stage for neural re-structuring (Pace, 2018). Additionally, the joint decision of the client and therapist to address lingering symptoms relating to the secondary trauma of sexual assault was essential to Rose’s growth process. While contextually unrelated to Rose’s repatriation trauma and ego identity fragmentation, thematically the two had significant common ground: voicelessness, silencing, abandonment, lack of agency and choice. In so doing, the effects of this secondary trauma did not interfere with accessing earlier experience and younger parts of self. Considerations of future directions of LI emerged primarily from the confusion and uncertainty amid the LI trained adjudicators (Judge A, Judge C and Reflexive Researcher). While the therapist and client believed they were engaging in LI therapy throughout the course of treatment, this was apparently not as clear among the adjudicators. What constitutes LI therapy? Is it comprised strictly in the use of uniquely LI processes? Or, within LI is there a mix of common factors, ego state practices and unique processes? To what extent can clinician intuition and creativity be welcomed in INTEGRATING EGO IDENTITY WITH LI THERAPY 155 LI before it ceases to function as LI therapy? In other words, what are the essential elements of LI therapy? Further clarification regarding what constitutes ‘LI therapy’ would be beneficial. Future LI and TCK Research Directions While the present study offers probabilistic claims of LI therapy effectively producing considerable ego identity integration within a middle-aged adult TCK who self-identified as experiencing ego identity fragmentation, the results are far from conclusive. Further studies among different TCK demographics and utilizing purer forms of LI therapy interventions are necessary to verify these tentative findings. Additionally, this study brought to light the need for further research into cultural elements of ego identity integration for TCKs. TCK clinicians would benefit from studies specifically focused on whether ego identity for TCKs is unique in necessitating the explicit inclusion of cultural and linguistic elements of younger selves. Additionally, studies of whether LI therapy is capable of effecting integration of these cultural and linguistic elements of TCK selves would significantly contribute to the literature on therapeutic interventions for TCKs. HSCED Implementation and Enhancement Auto-HSCED. To our knowledge there have not been any other HSCED studies conducted in which the primary investigator was also the study participant. This methodological innovation provided in-depth access to client data that otherwise would not have been available and enhanced the richness of the projects data set. It is noted, however, that two of the three adjudicators mentioned the dual role of the participantresearcher as considerably impacting the results of this study. The inclusion of objective INTEGRATING EGO IDENTITY WITH LI THERAPY 156 measures and outside data sources would have mitigated, at least in part, the appearance of bias in study data set. PQ Adaptations. The daily tracking of PQ items, including tracking both the intensity and frequency of PQ item distress, was a study innovation initiated by myself in my role as study participant. I began using the summary pre-session PQ tracking form but found it difficult to accurately rate levels of distress retrospectively over a 7-day period. Undoubtedly this was reflective in part to symptoms in difficulty making decisions and in experiencing high levels of anxiety. In response and in consultation with my research supervisor, we made the decision to daily track both the frequency and intensity of levels of distress for PQ items. Consistent daily tracking was instituted after session 2 of therapy. While at the time an onerous task, the daily tracking of PQ items was helpful in increasing my self-awareness of symptoms and in greatly increasing the accuracy of ratings in this study. Instituting daily tracking of PQ items would benefit future HSCED studies, however, may necessitate the creation of a user-friendly method of electronic reminders and tracking for participants to facilitate this adaptation. The tracking of both level of intensity and frequency of distress did appear to counteract the potential for infrequent but highly distressing events to skew overall data patterns. However, this dual tracking system was not as useful in preparing the rich case record as originally anticipated and necessitates a more complex system of data analysis to determine significance and provide meaning. INTEGRATING EGO IDENTITY WITH LI THERAPY 157 Data Analysis and Adjudication Process. Orientation meetings. To further enable the expert case development teams and adjudicators to effectively perform their roles a separate orientation meeting was held for each set of research assistants. At this meeting, team members and adjudicators were introduced to the principal factors of the study (i.e., TCKs, ego identity, and LI therapy) in addition to an overview of the HSCED method and the requirements of their role. Orientation meetings were held by the reflexive researcher and attendees were given hard copies of the presentation slides to use as reference in their role. Judge B positively remarked on the helpfulness of the orientation having previously participated in HSCED studies on a case development team and as an adjudicator without the benefit of an orientation. Flexibility in location, timing and modality was necessary in scheduling the orientation meetings including holding 2 official case development orientations and 2 additional individual sessions and having one adjudicator join the orientation virtually. Case development guidelines. Case development team members were also provided with guidelines specific to their respective teams – skeptic or affirmative teams (see Appendix L). These guidelines included a definition of ego identity, an overview of the project’s research questions, and the types of evidence each team was charged with providing in their case argumentation. Note-taking templates with focused questions and evidence categories already listed were provided for use during the case development working sessions. The focused nature of the affirmative and skeptic team arguments would appear to evidence the usefulness of these tools. Inclusion of intersectional analysis. The inclusion of intersectional analysis within this study is a novel contribution to the HSCED psychotherapy research. Its INTEGRATING EGO IDENTITY WITH LI THERAPY 158 necessity not only points to the continued limitations of research to fully capture human experience, but also points to the potential to distort data through the privileging of types of data and through hyper-analytic compartmentalization to which all analysis is vulnerable and to which the adjudication process can lead. As such, by including client adjudication and intersectional analytic processes within this study I present HSCED researchers with an opportunity to recognize a new capacity for the adjudication process to further resist the oppressive structures of traditional psychotherapy research and foreground the synthetic capacity and intention of HSCED. Study Limitations The complexity demanded by the research process engaged in within this study is a challenge that may limit this study’s influence within the broader research community. The high demand on flexibility, commitment, resources, personnel, and time evident within this study may make it difficult for subsequent adoption by clinicians and researchers desiring to conduct similar research studies. Even within the HSCED community, the complexity evident in adaptations to the adjudication process alone may present a barrier to their implementation within an already highly demanding research structure. While the complexity has added nuance, richness and depth to the findings, conclusions and processes of this study, not everyone will have the ability to replicate its structure and procedures precisely because of the barrier presented by the high demands of this same complexity. The highly personal nature of this study in the researcher also being the client leads to high levels of vulnerability that may also present a barrier for study replication and adoption of certain study processes. The contextual appropriateness and possible INTEGRATING EGO IDENTITY WITH LI THERAPY 159 personal and professional implications of serving in the dual role of researcherparticipant were factors frequently under consideration within this research process. While it remained feasible for me to remain in the reflexive researcher role while also protecting personal interests, these decisions are highly personal and dependent on the nature of the research topic, therapy process, as well as other individual factors. Implication for Counselling In determining (post intersectional analysis) that Rose experienced substantial change and substantial change due to LI therapy there is evidence of the potential for LI therapy to both effect ego identity change and to be useful with adult TCKs. Adjudicator responses also indicate the importance of clinicians’ understanding the reasoning and theoretical underpinning of therapy techniques being used with clients. The effectiveness of a therapy intervention depends entirely on the inclusion of all fundamental elements. Highlighted here is also the importance of remaining clinically informed on current practices of therapeutic interventions being implemented with clients. Conclusions The case of Rose provided ample evidence of the long-term difficulties that can result for TCKs due to unresolved repatriation challenges and a lack of balance with resiliency resources. With limited literature regarding therapeutic interventions best suited to address TCK psycho-socio-cultural needs, LI therapy was selected for use in this study due to its anecdotal claims of effecting integration of separate self-states and developing a strong core self. The results from this research study seem to support these claims; when client data was examined from a holistic and contextualized intersectional INTEGRATING EGO IDENTITY WITH LI THERAPY 160 framework there emerged a clear rationale for claiming that Rose experienced substantial ego identity change due to LI therapy processes. The highly contextualized nature of this examination and of HSCED case studies in general means that these study claims are probabilistic and represent, as termed by Dewey, warranted assertions of what has worked in this particular circumstance and setting (Hall, 2013; Johnson & Gray, 2010; Morgan, 2014). While not generalizable, they offer guidance for clinicians of what may be possible and opportunity for continued research in broadening the scope of these claims to include more diverse TCK experiences and studies of other populations who experience ego identity fragmentation. To the counselling community this project will be beneficial in presenting research-based evidence for the use of LI in building and strengthening client sense of core self and in providing an in-depth view into a client’s therapeutic experience. To the LI community this project continues to expand the current LI therapy efficacy literature in its use with a new population (TCKs) and new clinical focus (ego identity fragmentation). Client and therapeutic factors impacting change included therapeutic processes (client-therapist relationship, experiential processing, work with younger selves) and client factors (highly motivated, clinically trained, researcher role). To the HSCED research community this project offers several innovative adaptions that increase the accuracy of quantitative measures and strengthen the HSCED value of examining psychotherapeutic data holistically and taking contextual elements into consideration by thinking intersectionally. INTEGRATING EGO IDENTITY WITH LI THERAPY 161 CHAPTER 6: ENHANCED REFLEXIVITY Once upon a time, in a land far, far, away…. Does not every good story begin like this? And yet it seems to fit. That is in fact where this story; where this project began. It began in the life of an 11-year-old girl who, in the midst of losing her whole world, felt abandoned, overwhelmed, confused, and terrified. ---------------------------Prologue Imagine this. It’s, 1984. I am 10 years-old and have lived in Mexico City since I was 4. I love it here. But it’s time to visit family in Toronto for a year. In Toronto I don’t settle in – soon enough I’ll be returning home. But plans change. After six months comes devastating news. My parents declare we are staying in Canada permanently. We are never going back to Mexico. In that moment I lost my whole world. I was familiar with how to survive short-term in Canada but had no idea how to plant roots here. To cope with this drastic change, I shut out my Mexican self and left her behind. This became my great identity divide – the me before and the me after. ---------------------------The experience described above marks the foundational event of this project. Over the next 35 years many events occurred to bring this project to where it is now, but it is here where it has its origins. The identity divide I describe above served me well to cope with life in Canada…until it no longer did. For more than 3 decades it kept me INTEGRATING EGO IDENTITY WITH LI THERAPY 162 alive, moving forward, doing life and looking normal even while inwardly being ruled by fear, depression, isolation, loneliness and guardedness. As I entered the MA in Counselling Psychology program, I knew that I was most interested in doing research regarding TCKs. Within the TCK literature I discovered I was not alone in this identity divide. A certain proportion of TCKs also manage the stress and instability of this lifestyle by leaving parts of themselves behind experiencing what I would come to describe as ego identity fragmentation. Through involvement in the graduate research program I was excited to discover Lifespan Integration therapy as an intervention that targets recovering younger parts of self and integrating them with present-day identity. In this same context I had the privilege of witnessing LI at work in repairing ego state attachment wounds. I began to wonder if this therapy whose processes are designed to create new brain connections between past memories and present-day experiences could be useful in working with TCKs like myself who left parts of their identity behind. So began this reflexive single case research study – the first auto-HSCED of its kind – that you are currently reading. When I began this thesis journey, I had little idea what I was getting myself into and what this project would require of me. Little did I know how many hats I would wear during this project – a researcher, a TCK, a client, a participant, a student, a clinician, an observer, a woman, a child, a daughter, a sister, a friend. It’s strange to think that it was in the midst of all of these roles that I discovered the presence of ME that interwove each part and bound them together. ---------------------------- INTEGRATING EGO IDENTITY WITH LI THERAPY 163 Part 1: “I can’t be! Can I be?” “Let your hopes, not your hurts, shape your future.” ~ Robert H. Schuller (n.d.) ~ This project has followed its own unique timeline since its inception. Most theses follow a typical pattern beginning with a thesis proposal and defense necessary for official approval as a thesis student, followed by application for study approval from the Research Ethics Board (REB), that leads to recruitment, data collection, data analysis, internal and then external defenses. Out of necessity this study followed a completely different route. “I can’t be!” By the new year of 2018 I found myself between a rock and a hard place: a long way from starting my thesis project but desperate to begin therapy. While the skeleton ideas of this study were in place – TCKs, fragmented parts of self, LI therapy, and auto-methodology – I was still months away from even beginning to put a thesis proposal together. However, my 8-month internship at Child and Youth Mental Health services which had ended in December had stirred up younger parts of self that would no longer be ignored. The excerpts below from my morning pages13 exemplify the anguish felt by this very present inner childlike self. January 10, 2018 I felt quite overwhelmed after Stats class….I was pretty proud of how much I participated in Stats class. I took some pretty big risks being first at sharing, offering my thesis project as an example, throwing out thoughts/ideas. I wonder if that is connected 13 Morning pages refers to a variation on the practice laid out by Julia Cameron, in her book The Artist’s Way, in which the first thing you do each morning is write 3-pages of whatever comes to mind (stream-of-consciousness writing). INTEGRATING EGO IDENTITY WITH LI THERAPY 164 to the panic I felt afterwards. Like a vulnerability hangover….no that doesn’t quite fit – or it’s not the whole picture….Wait! Could it have anything to do with my child self?? Hmm, emotions and tears come with that statement. And there’s some of that panic. That starts to make some sense. Of course, Little Sharon would be terrified by everything about yesterday afternoon – the concepts, the sharing, the vulnerability, the risk, the workload, the intensity. Little Sharon loves to play and this class – everything about it – is the complete opposite of play. It seems much was related to the ‘Life is over’ idea – it’s all school and work all the time. January 17, 2018 Little Sharon: I’m scared. Everything is so big, so complex. It’s scary. I don’t feel safe. I feel small and lost and overwhelmed by choices, decisions, responsibilities – notaries, $, scholarships, thesis, counselling… With the growing presence of this child part of self it was becoming very clear that the time to begin LI therapy had come and could not wait for months for the thesis process to catch up. If I was going to use my own data for this thesis project, it felt like it was truly a case of now or never. This represented quite a dilemma. Waiting did not feel like an option, but if I started therapy right then, no official data collection could be done and the plans for a study of my therapy journey were going to be invalid. In problem-solving with my research supervisor, we resolved for me to go through therapy as a participant in her ongoing LI research program. This would allow me to begin therapy as soon as possible without waiting for my thesis proposal to be approved and also allow for full data collection procedures which I could later use towards my thesis. It truly was the best of both worlds: thesis and therapy. All that was needed was to receive re-approval of Dr. Kwee’s research program form the REB and the support of Hillary McBride as the therapist and I could begin. Hillary’s support came quickly but REB approval took eleven long and painful weeks of INTEGRATING EGO IDENTITY WITH LI THERAPY 165 waiting before it came through. Throughout this waiting period, I continued my morning pages practice and it was revealing to read these once again in retrospect. Amid my writings I witnessed my own growth in my ability to understand areas of personal difficulty while also watching myself repeatedly try and fail to fix these problems on my own. I would set goals for myself such as determining to get my eating back on track, or spending time playing and connecting with Little Sharon, only to witness my efforts end in futility as I sabotaged my own efforts and failed to follow through. These constant failure in self-discipline and will-power were accompanied by waves of frustration, aggravation and anger towards self. I was discovering (once again?) that understanding was not enough. To change - in order for these problem areas to change - I needed something more. “I can’t be!” was my cry of desperation. Re-structuring my thesis process and initiating therapy and data collection in advance of formal thesis acceptance was a crash course in the systematization of academia. While philosophically appropriate and necessary, it was frustrating to have the naturalistic progression of this study stalled by the constraints of institutional and ethical checks and balances. I was ready. The time was now. But, as I had made the choice to use my data towards my thesis, politics and structures ultimately trumped my personal therapeutic needs. While the waiting was agonizing – with no exaggeration – and while I wish I had not had to wait at all, in the end I am glad for the decision to prioritize using my therapy data for my thesis and waiting for REB approval. I have found myself exhilarated by the richness of this case study, fascinated by the analysis process, and captivated by the INTEGRATING EGO IDENTITY WITH LI THERAPY 166 uniqueness of living out my researcher-participant role throughout this project. I cannot imagine having done any other project nor doing this particular study any other way. “Can I be?” What a relief it was when REB approval was finally granted in May (2018) and I was able to begin therapy sessions with Hillary. Finally, I could start to get the help I so desperately needed. Relief, however, was also accompanied by apprehension and healthy skepticism. It did not matter that I was voluntarily choosing therapy nor that I was a clinician-intraining who highly valued therapy, I was still nervous and scared. Based on what I had witnessed in a previous research project (Lewis, 2017), I had high hopes for LI and it’s potential to provide healing, but was also full of doubt and uncertainty: Is the healing I am seeking even possible? Can the problematic thoughts, emotions and behaviours change? Will they change for me? ---------------------------Part 2: “Therapy is hard!” “In the depth of winter, I finally learned that within me there lay an invincible summer.” ~ Albert Camus (n.d.) ~ And so, the journey began. On May 18, 2018 I had my first LI therapy session. I was surprised at how challenging that first introductory session was. Not only had I been in therapy for years and, having switched therapists more than a few times, had many first session experiences under my belt, I had also been trained on how to conduct an intake session such as this one and knew what to expect. I believe what made it so surprising was the degree to which I was present in the room not as a researcher, nor a clinician, nor even as student, but purely as a client. INTEGRATING EGO IDENTITY WITH LI THERAPY 167 As I sat in front of Hillary, my therapist, that first day none of my training or experience served to take away my nerves and anxiety. I laughed nervously as I shared parts of my story, using laughter to minimize vulnerability and keep other emotions hidden. I found myself paralyzed when asked, “What do you want out of therapy?” While I know I eventually gave a coherent reply of some sort, my initial internal response was, “I don’t know! You’re the expert. You tell me!” Moreover, despite my understanding of the importance of authenticity in therapy, I found myself fighting against inner scripts demanding that I ‘get it right’ to instead respond genuinely and authentically as best as I could. While it wasn’t a conscious decision to set aside other roles and interact simply as a client in session on that first day, it was an explicit decision that became necessary early on in therapy. This was precipitated by concerns regarding progress being made in session work: Saturday, July 21, 2018 HI Hillary, Just had some thoughts on the way home yesterday and wondered about a couple of things. It feels weird to speak to you about session stuff like this but thought I would throw this out there just in case it makes sense or is helpful or .... Don’t know if it’s problematic that we’ve spent 2 sessions just working on the PTSD protocol - I guess I’m concerned that it is but I don’t know that it is - but if it is... if it should be working faster (again...I have NO idea if that’s true, just a wondering that I had) I wondered - do we need to take out some of the other triggering events…that happened over the summer? Is it too many triggering events in a row? I don’t want to, I’d prefer to leave them in, unless it is interfering somehow. ….It feels really strange to put on my non-client/therapist/researcher hat in this email. I don’t normally ever do that so it’s really weird. Obviously, this is something you and I don’t need to discuss - I trust that you connect with Janelle if you have questions, etc. If you do connect with her with regards to this, please feel free to share in as much detail as INTEGRATING EGO IDENTITY WITH LI THERAPY 168 you feel is necessary. I hope I haven’t offended or intruded in sending this your way. Tentatively, Sharon In addressing this directly with Hillary I was able to consciously set aside my roles as a researcher and clinician-in training and fully engage in therapy solely as a client. This enabled me to let go of incongruencies I noted between LI protocols as implemented in our sessions in comparison to how I had been trained, even while acknowledging the potential for these differences to negatively impact the results of my thesis project. Above all else, I needed my therapy work to be centered on my personal journey of healing and not the research study, even at the expense of my thesis plans. As you can probably imagine, immersing myself in counselling as a client came with its own set of challenges. May 21, 2018 I am terrified of starting LI therapy because I know without a doubt that this will hurt, it will be painful. It means facing the well of emotions I’ve been stuffing and burying for decades. It means bringing out into the open the needs and desire for care that have been there, but I squashed and trampled down; [mean] giving them space and voice. That is terrifying. Why? Because grieving hurts, aches, and everything in me says not to go there – stay strong, handle it, survive. Yet my adult mind, my nurturing parent, know that this is both necessary and, in the end, will be good. It’s not a feeling, just a knowledge. It’s to that that I cling and move forward. As it does for most people, participating authentically in therapy work required vulnerability, knowing and trusting myself, and having confidence in Hillary, among other things. One especially unexpected dynamic that arose early on in counselling was the need to defend my choice to engage in therapy. INTEGRATING EGO IDENTITY WITH LI THERAPY 169 June 3, 2018 I know [some] people think that I’d be better off not doing therapy right now. I suppose there might be truth to that BUT it would also mean living longer without hope of these destructive patterns changing. It’s not like all my symptoms would disappear, or stop disrupting my life, or even become more manageable if I wasn’t in therapy. They might be [less] confusing to me but they’d all still be there….They don’t understand that I NEED HELP NOW!! Not because I’m in thesis, not because I’m anything other than because I’m alive, living in the world and my pain, my fractured-ness, my trauma is wholly unavoidable – it’s staring me in the face, won’t be put away or silenced anymore. I probably should not have been as surprised as I was given the independent, capable, empowered persona that best describes expectations of success in the Canadian academic context in which I was immersed. Nonetheless, this lack of understanding and comprehension from within the counselling psychology community shocked me. Resisting, standing my ground and defending my decision to engage with therapy required courage, strength and resolve. In the beginning, session work required a lot of energy and it often took a whole day to recover my energy reserves. The emotions were big, raw and so close to the surface they erupted out of me almost on their own. June 17 texts with Vanessa and Kristin ME: Hello friends - reaching out as I’ve had a tough weekend and I’m beside myself with how to handle where I’m at right now. Had a very powerful session with Hillary Friday night but have been a bit of a mess since then. Barely slept Friday night or last night. Am not resting well even when I take naps during the day. And there is a big gaping hole of emotion that’s been opened up that has me constantly close to tears (best way I can describe it). Yesterday was dedicated to job stuff which I managed well as it’s essentially data management, but today I’m supposed to be focused on my thesis proposal INTEGRATING EGO IDENTITY WITH LI THERAPY 170 work (which is really far behind) and am really struggling to conjure up the mental power to engage with it. I am really struggling with being kind to myself and allowing myself room to just be in the midst of BIG therapy work…  I hear your words, and my heart feels the tenderness and rawness K: Sharon  of all that you are engaging with right now. The various personal mountains to climb, and the more explicit roles and deadlines that are in the horizon... V: Sharon, I’m so sorry to hear how you’re struggling…. ME: …. I’ve been sobbing in tears since sending out the text and that feels goodwell it doesn’t feel good as the tears hurt but it feels good to let some emotion out. V: Of course, it does! I can feel how overwhelming this this…. K: Good but hard, eh? Does not that last phrase, ‘good but hard,’ so well describe the experience that is therapy? Good for us, but often so difficult along the way. The physical responses to LI therapy that I experienced were a second surprising dynamic of counselling work. While I knew well the emotional tiredness of therapy, and was familiar with the mental fatigue, the body sensations that at times emerged postsession were alarming, especially at first. July 20, 2018 I have been having these spasms - like the movement I can imagine happening when you get hit by a defibrillator. It starts with my lips feeling a bit numb, then there’s this feeling of impending emotional overwhelm, and then the spasm. Sometimes the spasm is small, but sometimes it’s a full body mega spasm. Never before had therapy had this type of physical manifestation. I came to interpret these symptoms as evidence of an electrolyte imbalance mainly because Hillary had mentioned electrolyte depletion as a possible side effect of LI therapy and because INTEGRATING EGO IDENTITY WITH LI THERAPY 171 drinking Gatorade seemed to help alleviate the spasms. However, the truth of the matter is that I have no idea why my body was responding the way that it was. A pivotal contextual element at this point in the narrative is that, throughout the course of LI therapy I was also simultaneously involved in composing my thesis proposal. As I reflect back on this period of time it is fascinating to note how my thesis journey and my therapy journey mirrored one another; a phenomenon that was completely unexpected. I could not have foreseen that the very act of preparing my thesis project would bring me face-to-face with the core issues we were addressing in therapy: silencing, voicelessness, and taking up space in the world. June 3, 2018 – texts with Vanessa and Kristin Me: I am really struggling with being kind to myself and allowing myself room to just be in the midst of BIG therapy work and being a responsible student working to minimize the extension I already know I’ll need for my Lit Review. I feel like if I choose to be kind to myself then I am choosing not to do a thesis because I won’t get a proposal done in time for July 31st - that is NOT a choice I want to make. But then if I choose to push my needs aside and power through then I’m choosing to stunt the growth and progress being made in therapy - another choice I DON’T want to make. Rock and a hard place!!.... K:I feel drawn to wanting to give you as much time and space you need to be with what you are going through. Even if that means delaying a deadline or two…. V: I completely agree with Kristin. It seems to me—correct me if I’m wrong— that therapy has opened a bit of a Pandora’s box. So even if you quenched it to do your INTEGRATING EGO IDENTITY WITH LI THERAPY 172 work instead, could you really? Box is open. You gotta go with it. That’s how it feels to me…. K: I see such courage in you Sharon. Engaging, reaching out to us, you are doing it! Asserting your “I am here” voice. Me: Me too! [I agree with giving me time and space.] I’m just not sure what that means - what that says about me. I don’t know if I’m allowed to put me first. I’m afraid of the questions regarding my decision to engage in this therapy process at this time and having to defend my choices - to defend being me, being real, being human. (Written between sobs an in the midst of reading your comments). V: But you already are. You have already been courageous enough to do things out of sequence and on your terms. There’s already the spark in you…. Me: …I am SO glad to have friends here in BC that I know I can share these things with - you two mean a WHOLE lot to me and I feel VERY safe sharing me in all my rawness with you both. Thanks for being AMAZING friends, supporters, cheerleaders, etc. Love you both loads!! K: Love you too Sharon! V: Love you too, Sharon!! Unlike any other academic project, I have ever done before, putting together this thesis project placed me in the spotlight. Every part of this project, from its conception to its completion, was based on my ideas, my conceptualization, my reasoning and INTEGRATING EGO IDENTITY WITH LI THERAPY 173 rationale. It required that I take a position, that I stand my ground, and that I speak and make myself understood. As I sit here in my living room typing out this chapter and recall the experience of writing the very first draft of my thesis proposal the comparison is shocking. At the start of this thesis journey, the mere thought of sitting and typing out a starting proposal draft of so definitively taking a stance and giving it voice and space – filled me with paralyzing fear. I could have given up and, truthfully, not being certain that I was actually capable of this level of academic work, came close to admitting defeat more than once. But, much to my own dismay, somewhere within me was a certainty, an inner resolve, to nurture my love of research and fully consent to engaging in the thesis project. Watering these seeds of resistance and rebellion against inner scripts of silencing required creativity and self-compassion. It meant finding my way forward by creating and brandishing what I call ‘my bad-ass tiara’ (see Figure 12) and handwriting my entire first draft with paper and pencil, behind closed doors and in the comfort and safety of my bedroom. Figure 13. Me wearing my ‘bad-ass tiara.’ INTEGRATING EGO IDENTITY WITH LI THERAPY 174 This was a puzzling phenomenon at the time, but I believe I understand it better now. The tiara crowning me queen and conqueror of this project, was a symbol of empowerment beating down scripts and messages of silencing, inadequacy and incompetence. The use of paper and pencil meant that nothing was permanent, as though it acted as a transitional stage before my thoughts and ideas were given concrete space in an electronic document. The closed room contained the space I was taking up; my presence in the world was contained within the 4 walls of my bedroom. Essentially this could be summed up in one word: control. Out of these experiences was born the title to this section: “Therapy is hard!” Even when you know the theory, purpose and goodness of what you are engaging in as I did, healing and growth are still difficult and challenging. Likely the most difficult part were the times, especially in those first few weeks, where I wondered if all this hard word was making any difference and if any change was actually occurring. But it was. It did. I changed. ---------------------------Part 3: “This is me, and I’m okay!” “I’m not scared to be seen I make no apologies, this is me” (emphasis added) “This is me” (Paul & Pasek, 2017, track 7) “This is me,” this became my theme song for this process I was experiencing of emerging out of hiding and shame to unapologetically declare who I am before the world. With increasing intensity throughout therapy, a desire grew within me to sing them unashamedly for all to hear - “I’m not scared to be seen / I make no apologies” - and to INTEGRATING EGO IDENTITY WITH LI THERAPY 175 shout from the mountaintops, “this is ME” (Paul & Pasek, 2017, track 7, emphasis added). Where and how did I show up? I discovered my voice and learned to take up space, I grew-up, and a new core sense of self was born. Discovering My Voice and Taking Up Space. Learning to speak, be heard, be seen and understood within the world was a profoundly visceral experience. It was something birthed from within that emerged outwardly in startling and unexpected ways. I describe this journey well in a set of text messages to my friend Kirstin. August 2018 Me: Normally [figure 13, image A] is how I’ve gone through life. Totally hidden - out of sight. Where I want to be is [figure 13, image C]. Standing confident - strong - visible seen - known - unashamed and enjoying who I am. Where I find myself, especially in therapy and in doing my thesis is [figure 13, image B]: Exposed - vulnerable - terrified uncertain - insecure - ready to fight….That’s what I discovered today. Somehow, it’s this in-between state of not being invisible and hidden any more, of emerging and being seen that elicits this incredible panic. It’s still not quite clear to me yet, but there’s an inkling of something that makes sense in these thoughts. A B C Figure 14. Embodied progression of discovering my voice. Kristin: Thank you for sharing about this. So beautiful, so open, so courageous to dialogue with yourself in it all. I   it all…. you are probably learning to navigate a “new Sharon” under new conditions. And therefore, new boundaries and relational rules etc. But it strikes me as a place of strength too...even though it might not feel that way. You are being seen and asserting something of yourself. This engagement is really cool, and inspiring actually. INTEGRATING EGO IDENTITY WITH LI THERAPY 176 Me: It is indeed SO GOOD to not be alone in the journey. It’s hard, grueling, takes everything you have and then some...but it WILL be worth it. In retrospect, I don’t think I started therapy fully hidden or invisible. I had already spent a number of years exposing who I was and telling my story both in therapy and in relationships with a few individuals. I can see how I likely started therapy closer to image B in Figure 13, and, after 3-months of therapy (August 2018) was probably closer to an embodied pose somewhere between images B and C. As things continued to move and shift within me over the course of therapy the strength and presence of my voice continued to grow and develop. After 10 months of therapy, I had begun to experience the strength and stability of a life not hidden away but being lived to its fullest (as depicted in image C, Figure 13). In my follow-up interview I spoke of this emergence of voice and taking up space with regards to a growing ability to accept constructive feedback regarding my thesis: holding onto my voice…. because I think that this is particular, like I don't feel [panicked and terrified] every time I get feedback on an assignment. Right, like this particular project has been very different because it's me speaking. It's me being in the world, right? And so, that ability to kind of navigate that and say, "No, I have a voice and it's a good voice and it's a strong voice and we can be there." And like allow myself to have space in the world, um, has - that transition from like full panic to like, "No, it's okay if I have a voice in the world" has been much shorter and almost stronger on the, on the other, on the flip side, right? Um, which is cool. (laughs) (RCR Appendix E, p. 500). This was not unique to my thesis work, but also made itself known in clinical interactions, personal relationships, and social contexts. This inner transformation even INTEGRATING EGO IDENTITY WITH LI THERAPY 177 impacted how I interacted with myself in allowing myself to hear and pay heed to my own voice and not letting it be drowned out by ‘shoulds’ or scripts of other’s expectations. Through this healing journey I have learned that there is room for me - for all my thoughts, opinions, beliefs and experiences - in the world. And, not only are they allowed to be heard, but they are a necessary and a positive contribution in the world. They, like me, have intrinsic value and worth. Growing Up. This process was magical to watch. Unlike previous planned experiences of inner child work, what arose from LI therapy was organic, spontaneous, experiential play. From my encounters with my baby self during the attunement protocol at the start of therapy emerged the creation of a timeline of my childhood depicted through images of toys I recall from my toddler years, early childhood, middle childhood and into my pre-teens (see Figure 14). Figure 15. Toy timeline of my childhood. The BIG Sticker for Little Hands book (see Figure 15) caught the eye of my 4year-old self as I browsed through the aisles of Shopper’s Drug Mart one day after an LI INTEGRATING EGO IDENTITY WITH LI THERAPY 178 session focused on a 4-year-old memory. While I initially tried to ignore the impulse to buy the book, my 4-year-old self was pretty insistent that this book was exactly what she needed and eventually I gave in. Figure 16. Sticker activity book for my 2-year-old self. After an LI session with my 7-year-old self, she and I spent about half an hour in the Lego aisle at Walmart picking out a Lego set that was both economical (for my adult self) as well as interesting and challenging (my 7-year-old self). Many hours were spent building Lego creations with the 3-in-1 pack that we purchased (see Figure 16). My heart book (see Figure 17), as I like to call it, was the perfect book for my 11-yearold tween self. Currently still a work in process, this book has been passed around between me and my friends Kristin and Vanessa as we slowly fill the pages with interesting and intriguing information about ourselves. Figure 17. Lego DeLorean and pirate ship built with my 7-year-old self. INTEGRATING EGO IDENTITY WITH LI THERAPY 179 Figure 18. Heart Book that I shared with my friends Kristin and Vanessa. Each of these experiential activities worked toward integrating these younger parts of self with my present-day identity. They became an organic extension of the therapy work being done in sessions with Hillary. As you read in the prologue, I had tried many times pre-therapy to connect to my inner child but to no avail. I made promises to younger selves, set guidelines, planned what and when we would connect, but I failed to keep my promises and rarely did those plans come to fruition. By contrast, the experiential play that transpired during LI therapy was unforced, unplanned and emerged not as rules to be followed or things I should do but were a response to inner yearnings; an opportunity to acknowledge, interact with and care for these younger parts of self. It is true that conceptually it felt a bit ridiculous. Strange to think of a 45-year-old graduate student choosing to colour in a sticker book designed for 3-year-olds, and who spent hours creating simple Lego machines for their own pleasure. But experientially it felt absolutely perfect, genuine, authentic and healing. It took courage and was a risk to engage with these parts of myself in such an overt manner, but the journey was well worth it. This process of growing up I summarized well in my post-therapy Change Interview: INTEGRATING EGO IDENTITY WITH LI THERAPY 180 I would also say I am 45. And that's important because I feel like I grew up a lot (laughs) over the last 6 months…. I've lived 45 years. And I've been through a lot of experiences and handled a lot of things in life…. it wasn't something I didn't know but there was this change in perception in being like - it was evidence of my capability not just evidence of like, well, you happen to fly through life and land on your feet, but that I[‘ve] actually been capable of doing 45 years and it that is going to keep me capable for the next 45, (see RCR Appendix D, p. 473). Finding My Core Self. The most fundamental and dynamic change I experienced over therapy was establishing a grounded core sense of self that had been absent in me since repatriating to Canada in my pre-teen years. Over the course of over a decade of therapy work I had come to describe what did exist at the core of my being, the overwhelming emotions of paralyzing fear and anxiety, as a chaotic, swirling black hurricane. Over those years, as I learned to be aware of my emotional state and stopped numbing and stuffing my feelings, I came to recognize triggering contexts and experiences which elicited this panic and paralysis. Then suddenly, in the midst of engaging in LI therapy work, I found myself meeting with familiar triggers of this hurricane but with a new grounded and anchored sense of self. Notice this new evolution of self as exemplified in the following three journal entries: October 11, 2018 So, I presented one of my clients in group supervision today… In the midst of receiving feedback I noticed several times when I started to dissociate and/or defend tune out of comments, fuzzy brain, pain in chest, retreat inward….So, noticing that this was happening just as it was starting to emerge is quite different for me. Normally I am right in the midst of it before I notice that it is there. What really surprised me was my ability to then coach myself through it - to remind myself that the comments are there to INTEGRATING EGO IDENTITY WITH LI THERAPY 181 help me, that there is no danger in hearing people out and listening, that there was no danger in staying engaged in the discussion, that I can then take their suggestions and make my own decisions as to what I want to do with them. It was sort of an on-going internal dialogue with myself. And I did it! I accepted all the comments, wrote down the suggestions for further thoughts and consideration later, and stayed present in the room and engaged in the discussion. Totally shocked me! I don’t think I’ve congratulated myself for doing that- congratulating myself now as I write - well done, Rose! Way to talk yourself through it and not let anxiety take control! You were able to recognize the triggers, acknowledge that there was actually no reason for panic, and coach yourself through it. Pretty amazing!! Who would have ever thought we’d get to this point and being able to do what we just did!! Yahoo!! November 9, 2018 So, in Couples class on Tuesday we had a special speaker who spoke about EFFT. At one point in the presentation she began speaking about trauma victims and relaying some information about a client of hers. As has been typical, when someone starts talking trauma my mind immediately goes to the abusive relationship…and the sexual assault. But this time was different - unlike so many times before. My thoughts went there... and then I waited and waited. I waited for the foggy brain, the difficulty breathing, the sense of disconnecting from the world around me...BUT it never came. The black hurricane did not come. There was little discernible difference between my state of being before the discussion on trauma began and as my thoughts moved towards the relationship…My response? A bit shocked and definitely surprised! I kept probing within to make sure I wasn't just masking or not paying enough attention to notice the hurricane, but it was really not there…. January 23, 2019 So, what’s different or changed? …. I don’t have this inner craving or drive …. this inner craving and drive to run away and hide. It still feels like there are remnants just below the surface … but it’s not a NEED, a crushing terrifying drive. It’s not in control…WOW!!...It’s not in control. There’s a ME who is in control instead – WOW!! A ME!! Even as I write that I don’t really understand that – intuitively I know it to be true, but it feels foreign, strange, unknown. …. Could my dream, my heart’s desire, my healing actually be happening?? Right before my eyes?? Is it really possible that I may emerge from all of this works as a whole integrated person? One who is aware, alive, purposeful , intentional, authentic, and at peace?? WOW! WOW! ….after decades living under the tyranny of fear, no matter how desirable it is to be free of it, it means reorganizing and restructuring life according to a new regime which is scary. But not terrifying. Just uncertain, unsure. …. Let’s see if I can diagram what the difference is: INTEGRATING EGO IDENTITY WITH LI THERAPY 182 The implications of this new relationship with self were far reaching. My conceptual understanding of my own inherent value and worth became an experiential reality for me. I no longer felt the desperation to have others bestow value and meaning on my life or to seek external approval for who I am and what I do. I saw myself not as young, fragile and vulnerable, but as capable, strong, courageous and mature. I understood that I had already and still could handle life and face what it was asking of me. Each of these areas of growth were crucial in enabling me to manage my role as researcher during the case development and adjudication process of data analysis. It would have been impossible, in my opinion, for the woman who entered therapy in May 2018 to have emerged unscathed from that experience. Lacking a core sense of self, the skeptic team arguments and critical adjudicator responses would have crushed and overwhelmed her. Instead, this new me was able not only to stay present during the case development working meeting, but also engage with the skeptic case development team discussion and make suggestions for arguments that might enhance their case. While it was still difficult and upsetting to receive some of the adjudicator’s responses, in conversation with my friend Vanessa I came to realize that my level of distress was a 3 out of 10 where previously it would have been a 9 or 10. INTEGRATING EGO IDENTITY WITH LI THERAPY 183 Encountering Me Equals Encountering Others. You have probably already noted just how many roles I took on over the course of all this learning and growing. While I may have set aside my researcher and clinician responsibilities to fully engage in counselling, in and out of session I encountered myself as a client, a study participant, a child, an adult, a daughter, a sister, a student and a friend. As I brought the contextual and situational realities of each of these roles into the therapy and research framework other third-party people also became implicated in this project, especially those who were closely connected with me and easily identifiable such as family and friends. In making myself fully identifiable within this research project I was turning the tables on the established research and therapy principles of privacy, confidentiality and anonymity. In my role as a client I was able to defer these considerations until I resumed my role as primary investigator post-therapy, but that is when things became difficult. I was confident of abating any personal, academic or professional harm through my decisions regarding how information would be presented for public consumption. The potential relational and personal third-party consequences of publishing my therapy data were more difficult to ascertain, especially with immediate family. To mitigate these effects, third-party informed consent (see Appendix O) was sought and attained from my friends (Vanessa and Kristin) and from my immediate family (Mom, Dad and sister). I will not easily forget the day I presented the informed consent to my family. It was a moment of intense cross-over of roles as I was coming before them as a researcher, a client, a daughter, a sister, a child and an adult all at once. While there was no means by which they could completely remove themselves from the study, they were being offered the chance to audit the data pertaining to themselves and provide feedback on its INTEGRATING EGO IDENTITY WITH LI THERAPY 184 presentation and wording within the study. After the conservation, once all my nervousness had calmed down, it was intriguing to note the conflicting responses I had to the conversation. A part of me of me was happy that my family had so easily trusted me and agreed to give their full consent, while another part was strangely troubled by the ease of their trust in me and disappointed that they had not requested to audit their information. This is perhaps reflective once again of the success of LI therapy. My former family role as the peacemaker, the good girl, the obedient child coming into conflict with my new empowered, unapologetic, ‘take me as I am’ sense of core self. ---------------------------Part 4: “Me encanta quien soy yo!” / “I like to be me!” “I’m the only one of me…. And you can’t spell ‘awesome’ without ‘me’,” “Me!” (Swift, Little & Urie, 2019, track 1) 14 Los cambios no se detuvieron cuando terminaron las sesiones de terapia. Ni si quiera cuando se suspendió de recoger información para este proyecto. Al contrario. La transformación personal siguió por adelante y continuó a solidificarse. Sin duda fue a una parte por asumir el puesto de un observador mientras me reintegraba en los datos de la investigación en mi oficio de investigadora principal. Al preparar el reportaje acerca de los acontecimientos de terapía para los asistentes del desarrollo del caso me ponía otra vez frente a mis experiencias terapéuticas. Y al enfrentarme a mí mismo - lo que yo pensaba y lo que yo aprendí entre ellas - vinieron aún 14 English translation is included at the end of this section. INTEGRATING EGO IDENTITY WITH LI THERAPY 185 más cambios. Y no solo al producir el reportaje sino también al recibir las resoluciones de los jueces y al escribir los resultados y la discusión. Reclamando mi cultura mexicana, mi cultura latina, fue el cambio más asombroso. Es la razón por la cual me parecía apropiado escribir esta sección en español – con mis faltas de gramática y de vocabulario - para situarme culturalmente justo en medio de dos culturas, dos idiomas, y dos identidades. Me parece que a usted le tocó un poco extraño que yo hubiera cambiado de lengua. Quizás tendrá razón, pero a mí me parecía la manera más lógica y arreglada de concluir este ensayo de la integración del ego identidad por un TCK. Solo unos dos o tres meses después de que yo estuve en terapía, me encuentro mirando programas de tele y películas en español, pensando en español, y aún soñando en español. Al punto de que, leyendo no se si lo estoy haciendo en inglés o español, pensando me falta poder traducir palabras o ideas españolas al inglés, y conduciendo se me olvida que estoy en Canadá y no en un país hispanohablante. Me encuentro siempre teniendo que recordarme cuando me voy de visitas que la gente aquí no habla español. Me parece que se haya nacido en mí una identidad verdaderamente bicultural. Ya no me siento una impostora; una chica canadiense imaginándose o fingiendo ser latina. Sino me siento como únicamente yo - ni canadiense ni latina pero mi propia mezcla de las dos culturas. Si se elimina cualquier parte, no sigo siendo yo. Y aquí estamos. Hasta aquí hemos llegado - hoy, en este momento en que estoy escribiendo. Me siento muy diferente frente a la vida de lo que antes sentía. Me siento más mujer, más madura, más segura, y más latina. Pero todavía me reconozco. ¿Entiende lo que le digo? No es fácil explicarlo, pero me parece como si yo volviera a encontrarme INTEGRATING EGO IDENTITY WITH LI THERAPY 186 con una muy buena amiga que no he visto desde hace muchos años. La veo y sé que, aunque ha pasado mucho tiempo y es cierto que ha cambiado, todavía la conozco y la conozco muy bien. Ella no es una desconocida. Y, pues, ella soy yo. Y me encanta quien soy yo. [Change did not end when therapy sessions were terminated. Not even once I had stopped collecting data for this thesis. In fact, the opposite is true. The personal transformation I was experiencing continued and changes continued to take root. Without a doubt this was in part due to taking on the role of an observer as I re-immersed myself in the project data as the primary investigator. As I was preparing the rich case record, I came face-to-face once again with what I experienced in therapy sessions. Encountering myself – my thoughts about and what I learned from these experiences – produced new shifts and transformations within me. The same process occurred at receiving the determinations from the adjudicators and as I was writing the outcome and discussion sections of this thesis. The most surprising change was evidence of reclaiming my Mexican and Latina culture. It was because of this change that it seemed appropriate to write this section in Spanish – with all my error in grammar and vocabulary mistakes – in order to situate myself in between two cultures , two languages, and two identities. The fact that I changed language probably seemed a bit strange to you. And, maybe you are right, but it seemed the most logical and reasonable way to conclude this thesis on ego identity integration in a TCK. Now, only two or three months after therapy, I find myself watching Spanishlanguage TV shows and movies, thinking in Spanish, and even dreaming in Spanish. I’m INTEGRATING EGO IDENTITY WITH LI THERAPY 187 so immersed in the language that I find myself reading and getting confused as to which language I’m reading in, not being able to translate Spanish words or ideas into English and driving around forgetting I’m in Canada and not a Spanish-speaking country. When out visiting others, I’ve had to consciously remind myself that they do not speak Spanish. It is my impression, based on these experiences, that a truly bi-cultural identity has been born within me. I no longer feel like an imposter; like a Canadian who is imagining or pretending she has some Latina in her. Instead I feel like the unique mixture that I am; neither Canadian nor Latina but my own mix of the two cultures. If either culture disappears, I cease to really be me. And now here we are. In this story we have arrived in the present to the moment in which I am writing. I feel as though I have a very different presence in life than what I had before. I feel more mature, more like a woman, more secure in myself, and more culturally Hispanic. And yet, I still recognize myself. Does that make sense? It is not easy to explain, but it is like finding myself with a really good friend that I have not seen in many years. The moment I see her, even though much time has passed, and she has changed, I know that I still know her intimately. She is not a stranger to me because she is me. And I like to be me!] ---------------------------- Epilogue February 27, 2019 I can’t even bring myself to write it down. Today is the day. Today is my last day of LI therapy with Hillary. The end of an era. [Ten] months of working together… [I’ve came to realize that] missing Mexico will always be a part of my experience. It’s not something I’ll ever package up and put away. But I can learn to have a different INTEGRATING EGO IDENTITY WITH LI THERAPY 188 relationship to it. I have come to accept that it ended, that there is no turning back time…Returning to Mexico may not bring ‘closure’ in the sense of wrapping it all up neatly but it will provide ‘closure’ in the sense of meeting the need to ‘go back home’ [to Mexico City in November]…It may also [as some friends have suggested] be the beginning of something brand new. Closing that loop that got left open [when we left Mexico] and starting or launching into something completely new; a new relationship to Mexico. Figure 19. Closure of childhood story and launch of new relationship with Mexico. --------------------------Looking retrospectively, do I regret deciding to engage in this project? My first response is, “Not at all!” and there is definite truth to that statement. However, there is also a part of me that remembers the struggle, the challenge, and the pain of battling my own demons along the journey. 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Retrieved from INTEGRATING EGO IDENTITY WITH LI THERAPY 203 https://ezproxy.student.twu.ca/login?url=http://search.ebscohost.com/login.aspx?d irect=true&db=nlebk&AN=474345&site=ehost-live Robert H. Schuller Quotes. (n.d.). Retrieved August 1, 2019, from https://www.brainyquote.com/quotes/robert_h_schuller_156006 Schaetti, B. F., & Ramsey, S. J. (1999) The global nomad experience: living in liminality. Available at: https://transitiondynamics.wordpress.com/resources-andproducts/articles-and-publications/198-2/Html (accessed June 20, 2018). Schwartz, J. M., & Begley, S. (2002). The mind and the brain: Neuroplasticity and the power of the mental force. [Adobe Digital Edition version]. Retrieved from https://b-ok.cc/book/1238897/656efb Seigfried, C. (1996). Pragmatism and feminism : Reweaving the social fabric. Chicago, IL: The University of Chicago Press. https://books.google.ca/books?id=26nNFoG5wH8C&printsec=frontcover#v=one page&q&f=false Shannon-Baker, P. (2016). 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H., & Downie, R. D. (1976). Third Culture Kids. In G. H. BellVillada, N. Sichel, F. Eidse & E. N. Orr (Eds), Writing out of limbo international childhoods, global nomads and third culture kids (pp. 18-24). Retrieved from https://ezproxy.student.twu.ca:3649/login.aspx?direct=true&db=nlebk&AN=5323 55&site=eds-live van der Kolk, B. A. (2002). Beyond the talking cure: Somatic experience and subcortical imprints in the treatment of trauma. In F. Shapiro, (Ed.). EMDR as an integrative psychotherapy approach: Experts of diverse orientations explore the paradigm prism (pp. 57-83). Washington, DC: American Psychological Association. doi:10.1037/10512-003 van der Kolk, B. (2014). The body keeps the score : Brain, mind, and body in the healing of trauma . [Adobe Digital Edition version]. Retrieved from http://bok.xyz/book/2457801/70cb10 Van Reken, R. E. (2009, November 13) Third culture kids. Telegraph. Retrieved from https://www.telegraph.co.uk/education/expateducation/6545869/Third-culturekids.html Van Reken, R. E. (2011) Crosscultural kids: The new prototype. In G. H. BellVillada, N. Sichel, F. Eidse & E. N. Orr (Eds), Writing out of limbo international childhoods, global nomads and third culture kids (pp. 25-44). Retrieved from https://ezproxy.student.twu.ca:3649/login.aspx?direct=true&db=nlebk&AN=5323 55&site=eds-live INTEGRATING EGO IDENTITY WITH LI THERAPY 206 Wall, J., Kwee, J., Hu, M., & Mcdonald, M. (2017). Enhancing the hermeneutic singlecase efficacy design: Bridging the research–practice gap. Psychotherapy Research, 27, 539-548. doi:10.1080/10503307.2015.1136441 Walters, K. A. (2006) A story to tell: The identity development of women growing up as third culture kids (Master's thesis). Retrieved from https://www.twu.ca/academics/school-graduate-studies/counselling-psychologyma/theses-online Williams, T. L. (2013). Third route kids : a new way of conceptualizing the adult third culture kid experience. (Unpublished doctoral dissertation). University of British Columbia, Vancouver, BC Wheeler, M. A., Stuss, D. T., & Tulving, E. (1997). Toward a theory of episodic memory: The frontal lobes and autonoetic consciousness. Psychological Bulletin, 121, 331–354. doi:10.1037/0033-2909.121.3.331 Wrobbel, K., & Plueddemann, J. (1990). Psychosocial Development in Adult Missionary Kids. Journal of Psychology and Theology, 18, 363-374. doi:10.1177/009164719001800406 Yoshida, Y., Matsumoto, D., Akashi, S. Akiyama, T. Furuiye, A., Ishii, C., & Moriyoshi, N. (2009). Contrasting experiences in Japanese returnee adjustment: Those who adjust easily and those who do not. International Journal of Intercultural Relations, 33, 265-276. doi:10.1016/j.ijintrel.2009.04.003 INTEGRATING EGO IDENTITY WITH LI THERAPY 207 APPENDIX A Definitions of Key Terms Expatriate Merriam-Webster (n.d.) defines expatriate as “a person who lives in a foreign country”. This is differentiated from immigrants who plan from the start to gain citizenship in their new country (Cottrell, 2007). Third Culture Kids (TCK) A term first coined by Ruth Hill Useem in the 1990’s, Pollock, Van Reken, and Pollock (2017) define Third Culture Kids (TCKs) as individuals who have spent a significant period of their developmental years (ages 0 to 18) living outside of their passport country or the passport country of at least one of their parent’s due to a parent’s work decision. The use of the term ‘third culture’ reflects the child’s lack of ownership and identification in either their passport culture or their host culture, but instead amongst the organically present sub-culture found amidst other TCKs (Pollock et al., 2017). Within the category of TCK fall the experiences of missionary children, military children, children of parents who are in the foreign service, and children of international business personnel (Pollock et al., 2017; see Appendix B, Figure B2). When TCKs reach adulthood, they are generally referred to as Adult Third Culture Kids or ATCKs (Van Reken, 2009). Ego Identity In its simplest definition, a healthy ego identity is defined as a coherent sense of self across time and space (Côté & Levine, 2002; Erikson, 1994). INTEGRATING EGO IDENTITY WITH LI THERAPY 208 Repatriation In the Merriam-Webster15dictionary repatriation is defined as the time of return to one’s country of origin or citizenship. In the case of TCKs this definition is further refined as the long-term transition back to their passport country. High Mobility In the context of this study, high mobility is used to refer to frequent international relocations experienced by TCKs (Useem & Downie, 1976) and/or frequent transitions between their host country and their passport country (Davis, Edwards, & Watson, 2015). According to an informal online survey of 200 TCKs conducted by the online magazine Denizen, most TCKs had lived in an average of 4 different countries (Natario, 2011) 15 Repatriate. (n.d.). In Merriam-Webster online dictionary, Retrieved October 20, 2018, from https://www.merriam-webster.com/dictionary/repatriate INTEGRATING EGO IDENTITY WITH LI THERAPY 209 APPENDIX B Cross-Cultural Kids and Third Culture Kids Figure B1 . The Cross-Cultural Kid (CCK) Model. Reprinted with permission from Third Culture Kids – Growing Up Among Worlds (3rd ed.), by Pollock, D. C., Van Reken, R. E. and Pollock, M. V., p. 44. Copyright 2002, Ruth E. Van Reken (updated in 2017). Figure B2. Types of third culture kids and their potential commonalities and differences. Reprinted with permission from Third Culture Kids – Growing Up Among Worlds (3rd ed.), by Pollock, D. C., Van Reken, R. E. and Pollock, M. V., p. 47. Copyright 1996, Ruth E. Van Reken (updated in 2017). INTEGRATING EGO IDENTITY WITH LI THERAPY 210 APPENDIX C Lifespan Integration Therapy and Neural Integration Figure C1. Model of disconnected neural nets before Lifespan Integration. Reprinted with permission from Lifespan Integration: Connecting ego states through time, by Pace, P., p. 31. Copyright 2009, Lifespan Integration, LLC. Figure C2. Model of a more coherent self-system after Lifespan Integration. Reprinted with permission from Lifespan Integration: Connecting ego states through time, by Pace, P., p. 31. Copyright 2009, Lifespan Integration, LLC. Figure C1. Model of disconnected neural nets before Lifespan Integration. Reprinted with permission from Lifespan Integration: Connecting ego states through time, by Pace, P., p. 31. Copyright 2009, Lifespan Integration, LLC. INTEGRATING EGO IDENTITY WITH LI THERAPY APPENDIX D Data Collection and Analysis Flow Charts Figure D1. Daily PQ data collection and analysis flow chart. 211 INTEGRATING EGO IDENTITY WITH LI THERAPY Figure D2. Pre-session summative PQ data collection and analysis flow chart. 212 INTEGRATING EGO IDENTITY WITH LI THERAPY Figure D3. Change Interview data collection and analysis flow chart. 213 INTEGRATING EGO IDENTITY WITH LI THERAPY 214 APPENDIX E Simplified Personal Questionnaire (PQ) Procedure Generating Items. The items generated for the PQ should be the most important in the client’s view. However, an attempt should be made to include one or two problems from each of the following areas: symptoms, mood, specific performance/activity (e.g., work), relationships, self-esteem. This means that if the client does not list a problem in a particular area, the interviewer should ask the client if s/he has any difficulties in that area that s/he wants to work on in therapy. This part of the procedure should be thought of as a brainstorming session, generating as many potential items as possible (around 15 is preferable). If helpful and the client has completed the CORE-OM, the interviewer can ask the client about items with higher ratings. Refining the PQ items. Next, the interviewer helps the client to clarify his/her items and, if necessary, to rephrase the goals into problems. If necessary, the number of items is reduced to around 10. In this part of the procedure, the interviewer begins by writing each problem onto a separate index card, revising it in the process. Refining PQ items is not a mechanical procedure, but requires discussion with the client to make sure that the PQ reflects his/her chief concerns. It takes careful, patient communication to make sure that the PQ items truly reflect the client’s experience of what is problematic. PQ items should be present problems or difficulties, and should be worded “I feel,” “I am,” “I can’t,” “My thinking,” and so on. It is useful to think of the list as things the client wants to change through therapy. After the interviewer writes down the items, s/he then asks the client if anything has been left out, adding, revising, deleting items as needed, until the client feels that the list is complete. The interview should not force the client to generate exactly 10 items; but try to obtain 8-12 items where possible. Prioritizing the items. Next, the interviewer asks the client to sort the index cards into order, with the most important concern first, the next most important second, etc. The rank order of the item is written on the card. Rating the PQ. After prioritizing, the interviewer gives the client a blank PQ form and the rank-ordered index cards, and asks the client to use the blank form to rate how much each problem has bothered him/her during the past week. These ratings become the client’s initial baseline score for the PQ. Optional: Duration ratings. In addition, at this first administration of the PQ, the interviewer may want to find out how long each problem has bothered the client at roughly the same level or higher as it does now, using the Personal Questionnaire Duration Form. This can be useful for establishing a retrospective baseline for the PQ. INTEGRATING EGO IDENTITY WITH LI THERAPY 215 Prepare the PQ. Finally, the interviewer types or writes the PQ items onto a blank PQ form, making at least 10 copies for future use. In doing so, it is a good idea to leave 2 spaces blank for the client to add more items later, in case his/her problems shift over time. INTEGRATING EGO IDENTITY WITH LI THERAPY 216 Personal Questionnaire - Problem Description Form Name (pseudonym) ______________________________ Date ____________________ Read Script: “As you are familiar from your knowledge about the study so far, I want to remind you that when we develop the Personal Questionnaire together, you have the right to choose not to answer any questions you prefer not to answer, to ask questions of the researcher, and to withdraw your participation at any time.” 1. Please describe the main problems you are having right now that led you to seek treatment. 2. If you are seeking psychotherapy, please list the specific problems or difficulties that would like assistance with. Please feel free to add to your list as you fill out other forms. INTEGRATING EGO IDENTITY WITH LI THERAPY 217 Simplified Personal Questionnaire Form Pseudonym: _____________________________ Date:_______________________ Instructions: Please complete before each session. Rate each of the following problems according to how much it has bothered you during the past seven days, including today. Maxim Very um Not At Very Modera Conside Conside Possibl All Little Little tely rably rably e 1. 1 2 3 4 5 6 7 2. 1 2 3 4 5 6 7 3. 1 2 3 4 5 6 7 4. 1 2 3 4 5 6 7 5. 1 2 3 4 5 6 7 6. 1 2 3 4 5 6 7 7. 1 2 3 4 5 6 7 8. 1 2 3 4 5 6 7 9. 1 2 3 4 5 6 7 10. 1 2 3 4 5 6 7 Additional Items: 11. 1 2 3 4 5 6 7 12. 1 2 3 4 5 6 7 13. 1 2 3 4 5 6 7 INTEGRATING EGO IDENTITY WITH LI THERAPY 218 PQ Duration Rating Form Pseudonym: _____________________________ Date:_______________________ Instructions: Please rate how long each of your problems have bothered you at roughly the same level (or higher) as it does now. Less More than 1 1-5 6-11 1-2 3-5 6-10 than 10 month months months years years years years 1. 1 2 3 4 5 6 7 2. 1 2 3 4 5 6 7 3. 1 2 3 4 5 6 7 4. 1 2 3 4 5 6 7 5. 1 2 3 4 5 6 7 6. 1 2 3 4 5 6 7 7. 1 2 3 4 5 6 7 8. 1 2 3 4 5 6 7 9. 1 2 3 4 5 6 7 10. 1 2 3 4 5 6 7 Additional Items: 11. 1 2 3 4 5 6 7 12. 1 2 3 4 5 6 7 13. 1 2 3 4 5 6 7 INTEGRATING EGO IDENTITY WITH LI THERAPY 219 APPENDIX F Daily PQ Tracking Form Dates: __________________________________________________ Date Date MEAN PQ item FRE FRE FRE # PQ item INT Q INT Q INT Q 1 I feel shame about who I am and who I've been (NOT BODY) 2 I'm not enough ('shoulding') 3 I feel I don't belong 4 I have fear of failing at life 5 I have trouble feeling present in the moment (chest tightness, brain feeling fuzzy, not feeling connected to others) 6 My sleep is interrupted 7 I self-sabotage my own goals (NOT FOOD) 8 I cannot make decisions 9 I am stuck in an avoidant pattern 10 I use food to cope with stress 11 I self-medicate my own pain with poor strategies (not level of distress) 12 I don't accept my limitations/weakness 13 I have a tendency to think in "all-or-nothing" 14 I don't feel confident in my own opinions/viewpoints 15 I authentically and voluntarily connect with God ALL INTEGRATING EGO IDENTITY WITH LI THERAPY Legend: Rating 1 2 3 4 5 6 7 Intensity Not at all Very little Little Moderately Considerably Very considerably Maximum possible Frequency Not at all One or two distinct occasions or rarely Less than half the day or occasionally About half the day or some of the time More than half the day Most of the time, most of the day All the time, all day Legend for item 6 frequency: Rating Sleep frequency 1 None 2 Trouble falling asleep 3 Awakened once during the night 4 Awakened twice during the night 5 Awakened 3+ times during the night 6 Awake for an extended period of time once during the night 7 Awake for an extended period of time more than once during the night 220 INTEGRATING EGO IDENTITY WITH LI THERAPY 221 APPENDIX G Helpful Aspects of Therapy Form (HAT) Name (pseudonym) _________________________ Date _________________________ Thank you for taking the time to fill in the information requested on this form. Please note that you have the right to choose not to share any information that you choose not to share, and the right to withdraw your participation from this study. 1. Of the events that occurred in this session, which one do you feel was the most helpful or important for you personally? (By "event" we mean something that happened in the session. It might be something you said or did, or something your therapist said or did.) 2. Please describe what made this event helpful/important and what you got out of it. 3. How helpful was this particular event? Rate it on the following scale. (Put an "X" at the appropriate point; half-point ratings are OK; e.g., 7.5.) HINDERING <----------Neutral -------------> HELPFUL 1 2 3 4 5 6 7 8 9 |---+--|---+--|---+--|---+--|---+--|---+--|---+--|---+---| E G M S S M G E X R O L L O R X T E D I I D E T R A E G G E A R E T R H H R T E M L A T T A L M E Y T L L T Y E L E Y Y E L Y L L Y Y Y 4. About where in the session did this event occur? INTEGRATING EGO IDENTITY WITH LI THERAPY 5. About how long did the event last? 6. Did anything else particularly helpful happen during this session?  Yes  No a) If yes, please rate how helpful this event was:  Slightly helpful  Moderately helpful  Greatly helpful  Extremely helpful b) Please describe the event briefly: 7. Did anything happen during the session that might have been hindering?  Yes  No a) If yes, please rate how hindering the event was:  Extremely hindering  Greatly hindering  Moderately hindering  Slightly hindering b) Please describe this event briefly: 222 INTEGRATING EGO IDENTITY WITH LI THERAPY 223 APPENDIX H Therapist Session Notes Questionnaire (TSNQ) Therapist Initials _______ Client (pseudonym) _____________ Date Session Notes Protocol(s) used (# repetitions): _______ Length of session:__________________ Most Helpful and/or Important Event/Experience (can be positive or negative): Description of why this event/experience was helpful and/or important. Rating of how helpful and/or important this was (put an “X” at the appropriate point; half-points are ok, e.g. 7.5) HINDERING <----------Neutral -------------> HELPFUL 1 2 3 4 5 6 7 8 9 |---+--|---+--|---+--|---+--|---+--|---+--|---+--|---+---| E G M S S M G E X R O L L O R X T E D I I D E T R A E G G E A R E T R H H R T E M L A T T A L M E Y T L L T Y E L E Y Y E L Y L L Y Y Y At what point in the session did this event occur? Number of protocol repetitions/other? Did anything else particularly helpful happen during this session? Please describe and give a rating between five and nine as per the scale above. Did anything else particularly hindering happen during this session? Please describe and give a rating between one and five as per the scale above. Therapeutic impressions at exit. Other notes or observations regarding coherence/integration, other progress/change. INTEGRATING EGO IDENTITY WITH LI THERAPY 224 APPENDIX I Change Interview (Elliott, 1999) After each phase of treatment, clients are asked to come in for an hour-long semistructured interview. The major topics of this interview are any changes you have noticed since therapy began, what you believe may have brought about these changes, and helpful and unhelpful aspects of the therapy. The main purpose of this interview is to allow you to tell us about the therapy and the research in your own words. This information will help us to understand better how the therapy works; it will also help us to improve the therapy. This interview is tape-recorded for later transcription. Please provide as much detail as possible. 1. General Questions: 1a. What medication on [sic] you currently on? 1b. What has therapy been like for you so far? How has it felt to be in therapy? 1c. How are you doing now in general? 2. Self-Description: 2a. How would you describe yourself? (If role, describe what kind of ____? If brief/general, can you give me an example? For more: How else would you describe yourself?) 2b. How would others who know you well describe you? (How else?) 2c. If you could change something about yourself, what would it be? 3. Changes: 3a. What changes, if any, have you noticed in yourself since therapy started? (For example, Are you doing, feeling, or thinking differently from the way you did before? What specific ideas, if any, have you gotten from therapy so far, including ideas about yourself or other people? Have any changes been brought to your attention by other people?) [Interviewer: Jot changes down for later.] 3b. Has anything changed for the worse for you since therapy started? 3c. Is there anything that you wanted to change that hasn’t since since therapy started? INTEGRATING EGO IDENTITY WITH LI THERAPY 225 4. Change Ratings: (Go through each change and rate it on the following three three scales:) 4a. For each change, please rate how much you expected it vs. were surprised by it? (Use this rating scale:) (1) Very much expected it (2) Somewhat expected it (3) Neither expected nor surprised by the change (4) Somewhat surprised by it (5) Very much surprised by it 4b. For each change, please rate how likely you think it would have been if you hadn’t been in therapy? (Use this rating scale:) (1) Very unlikely without therapy (clearly would not have happened) (2) Somewhat unlikely without therapy (probably would not have happened) (3) Neither likely nor unlikely (no way of telling) (4) Somewhat likely without therapy (probably would have happened) (5) Very likely without therapy (clearly would have happened anyway) 4c. How important or significant to you personally do you consider this change to be? (Use this rating scale:) (1) Not at all important (2) Slightly important (3) Moderately important (4) Very important (5) Extremely important INTEGRATING EGO IDENTITY WITH LI THERAPY 226 5. Attributions: In general, what do you think has caused these various changes? In other words, what do you think might have brought them about? (Including things both outside of therapy and in therapy) 6. Helpful Aspects: Can you sum up what has been helpful about your therapy so far? Please give examples. (For example, general aspects, specific events) 7. Problematic Aspects: 7a. What kinds of things about the therapy have been hindering, unhelpful, negative or disappointing for you? (For example, general aspects. specific events) 7b. Were there things in the therapy which were difficult or painful but still OK or perhaps helpful? What were they? 7c. Has anything been missing from your treatment? (What would make/have made your therapy more effective or helpful?) 8. Suggestions. Do you have any suggestions for us, regarding the research or the therapy? Do you have anything else that you want to tell me? 9. Review Personal Questionnaire (PQ) Instructions: Compare pre-therapy (screening) and post-therapy to current PQ ratings with client, noting number of points changed for each problem. Tell client: We are trying to understand how clients use the PQ, and what their ratings mean. 9a. In general, do you think that your ratings mean the same thing now that they did before therapy? If not, how has their meaning changed? (Sometimes clients change how they use the PQ rating scale; did that happen for you?) 9b. Identify each problem that has changed 2+ points: INTEGRATING EGO IDENTITY WITH LI THERAPY 227 (1) Compare each PQ problem change (2+ points) to the changes listed earlier in the interview. (2) If the PQ problem change is not covered on the change list, ask: Do you want to add this change to the list that you gave me earlier? •If yes -> go back to question 5 and obtain change ratings for this change. •If no -> go on: (3) For each PQ problem change (2+ points), ask: Tell me about this change: What do you think it means? Do you feel that this change in PQ ratings is accurate? INTEGRATING EGO IDENTITY WITH LI THERAPY 228 1. General Questions: 1a. What medication on [sic] you currently on? 1b. What has therapy been like for you so far? How has it felt to be in therapy? 1c. How are you doing now in general? 2. Self-Description: 2a. How would you describe yourself? (If role, describe what kind of ____? If brief/general, can you give me an example? For more: How else would you describe yourself?) 2b. How would others who know you well describe you? (How else?) 2c. If you could change something about yourself, what would it be? 3. Changes: 3a. What changes, if any, have you noticed in yourself since therapy started? (For example, Are you doing, feeling, or thinking differently from the way you did before? What specific ideas, if any, have you gotten from therapy so far, including ideas about yourself or other people? Have any changes been brought to your attention by other people?) [Interviewer: Jot changes down for later.] 3b. Has anything changed for the worse for you since therapy started? 3c. Is there anything that you wanted to change that hasn’t since since therapy started? 4. Change Ratings: (Go through each change and rate it on the following three three scales:) 4a. For each change, please rate how much you expected it vs. were surprised by it? (Use this rating scale:) (1) Very much expected it (2) Somewhat expected it (3) Neither expected nor surprised by the change (4) Somewhat surprised by it (5) Very much surprised by it 4b. For each change, please rate how likely you think it would have been if you hadn’t been in therapy? (Use this rating scale:) (1) Very unlikely without therapy (clearly would not have happened) (2) Somewhat unlikely without therapy (probably would not have happened) (3) Neither likely nor unlikely (no way of telling) (4) Somewhat likely without therapy (probably would have happened) (5) Very likely without therapy (clearly would have happened anyway) 4c. How important or significant to you personally do you consider this change to be? (Use this rating scale:) (1) Not at all important (2) Slightly important (3) Moderately important (4) Very important (5) Extremely important 5. Attributions: INTEGRATING EGO IDENTITY WITH LI THERAPY 229 In general, what do you think has caused these various changes? In other words, what do you think might have brought them about? (Including things both outside of therapy and in therapy) 6. Helpful Aspects: Can you sum up what has been helpful about your therapy so far? Please give examples. (For example, general aspects, specific events) 7. Problematic Aspects: 7a. What kinds of things about the therapy have been hindering, unhelpful, negative or disappointing for you? (For example, general aspects. specific events) 7b. Were there things in the therapy which were difficult or painful but still OK or perhaps helpful? What were they? 7c. Has anything been missing from your treatment? (What would make/have made your therapy more effective or helpful?) 8. Suggestions. Do you have any suggestions for us, regarding the research or the therapy? Do you have anything else that you want to tell me? 9. Review Personal Questionnaire (PQ) Instructions: Compare pre-therapy (screening) and post-therapy to current PQ ratings with client, noting number of points changed for each problem. Tell client: We are trying to understand how clients use the PQ, and what their ratings mean. 9a. In general, do you think that your ratings mean the same thing now that they did before therapy? If not, how has their meaning changed? (Sometimes clients change how they use the PQ rating scale; did that happen for you?) 9b. Identify each problem that has changed 2+ points: (1) Compare each PQ problem change (2+ points) to the changes listed earlier in the interview. (2) If the PQ problem change is not covered on the change list, ask: Do you want to add this change to the list that you gave me earlier? •If yes -> go back to question 5 and obtain change ratings for this change. •If no -> go on: (3) For each PQ problem change (2+ points), ask: Tell me about this change: What do you think it means? Do you feel that this change in PQ ratings is accurate? INTEGRATING EGO IDENTITY WITH LI THERAPY 230 Change Interview Record (Elliott, 1999) Client (pseudonym) ___________________________________________ Date __________________________  Post-therapy  Follow-up Read Script: “As we have talked about at other times, I want to remind you that, during this interview, you have the right to choose not to answer any questions you prefer not to answer, to ask questions of the researcher, and to withdraw your participation at any time.” Psychopharmacological Medication/Drug/Herbal Remedies Record Medication Name Change List Change For what symptom? Dose/Frequency How long? Last Adjustment? Change was: 1 – expected 3 – neither 4 – surprised by Without therapy: 1 – unlikely 2 – neither 5 – likely Importance: 1 – not at all 2 – slightly 3 – moderately 4 – very 5 - extremely 1. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 2. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 3. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 4. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 5. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 6. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 7. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 8. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 9. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 10. Additional Items 11. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 12. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 13 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 INTEGRATING EGO IDENTITY WITH LI THERAPY 231 APPENDIX J Video Clips Ratings Ego Identity:      Self-organizing mechanism Personal: A sense of internal coherence across a lifetime. Social: A contextually appropriate and understandable social presence within the social sphere which enables group belonging and effective interactions with others. “feeling of being at home in one’s body, a sense of ‘knowing where one is going’, and an inner assuredness of anticipated recognition from those who count,” (Erikson, 1968) “the sense of one’s self as a continuous entity or agent, in a variety of contexts, and over the passage of time” (Côté and Levine, 2002) Ratings for Feedback Rating Clarity of Content Scale Very clear 1 – no confusion regarding what this clip is about Somewhat clear 2 – could use a bit more explanation of context Somewhat unclear 3 – some parts were clear, other parts were not; OR it was difficult to see how segments fit together Example of Ego Identity Change Scale Very clear example – it is obvious that there has been some integration of your autobiographical sense of self Somewhat clear example – change describe does appear to be related to ego identity but some details of this change are unclear (Somewhat) Unclear example – uncertainty as to whether it does or does not demonstrate change in ego identity; too hard to tell. Very unclear OR unrelated example Very unclear 4 – it was confusing and difficult to follow what was going on – it is not clear in the clip that there has been a change in your sense of self; OR the change described in the video does not appear to be related to ego identity INTEGRATING EGO IDENTITY WITH LI THERAPY 232 Feedback CONTENT Clip & Length SESSION 3&4 June 12 & 15 4m 25s Context & Link Client and baby self (45-year-old and 2-weekold self). LINK SESSION 6 June 22 4m 55s Memory of 7-year-old in Mexico regarding a gift Dad didn’t like and returned. LINK Post-repatriation 11-yearold memory of anger outburst after my sister was blocking my ability to complete my vacuuming chore LINK Sharing my 5-year-olds Big Book of Stickers. LINK Meeting post-repatriation 11-year-old in family home in Toronto where she was ‘left behind’. LINK Remembering 11-year-old self around time of repatriation. LINK SESSION 19 Oct. 11 3m 58s SESSION 22 Nov. 29 #1 1m 38s SESSION 22 Nov. 29 #2 4m 20s SESSION 27 Jan. 16 3m 23s EGO IDENTITY OTHER (length, segments to take out, audio, video, etc.) INTEGRATING EGO IDENTITY WITH LI THERAPY SESSION 31 Feb. 21 #1 5m 48s Noticing changes in understanding of family of origin rules and scripts. In previous session had come to understand that I can acknowledge my pain my parents didn’t meet my needs and the hurt and pain that came with that, and still love them; both can be true at the same time. LINK SESSION 31 Feb. 21 #2 1m 40s Total Time: Rose (2-year-old self) and present-day self. LINK 29m 12s 233 INTEGRATING EGO IDENTITY WITH LI THERAPY 234 APPENDIX K Reflexive Primary Investigator Informed Consent Research Study Title: Integrating ego identity in an adult third culture kid with lifespan integration therapy: A reflexive hermeneutic single case efficacy design. Principal Investigator: Sharon Macfarlane, MA Student Counselling Psychology Department, Trinity Western University Email: Sharon.Macfarlane@mytwu.ca Phone: 778-991-7954 Co-Investigator: Hillary McBride, Ph. D. Candidate Educational and Counselling Psychology, and Special Education University of British Columbia Email: hillarylmcbride@gmail.com Phone: 604-833-4574 Project Supervisor: Dr. Janelle Kwee, Program Director & Associate Professor Counselling Psychology Department, Trinity Western University Email: janelle.kwee@twu.ca Phone: 604-513-2121 ext. 3870 Purpose: The purpose of this research project is to evaluate the suitability of LI therapy for an adult TCK who self-identifies as having a fragmented sense of self. This study will be guided by the following research question: Is LI efficacious in addressing ego identity fragmentation and its correlates in an adult TCK? My unique role as a reflexive researcher-participant within this study allows for the collection of an extensive and mutli-sourced data set permitting an in-depth perspective of the therapy process and permitting for continuous access to client data and perspective. Procedures: This reflexive project will follow the structure set out in Elliot’s (cite) Hermeneutic Single Case Efficacy Design (HSCED). HSCED follows a systematic and rigorous structure that can be divided into three stages (see Figure 1). The first stage is comprised of therapy sessions and data collection. The second stage involves data analysis through the compilation of the rich case record and the development of the affirmative and skeptic case briefs. The final stage incorporates the adjudication process to arrive at answers to the three central questions, and the researcher’s final conclusions. The rich case record is a summative report of observations and information contained within the data set and includes: background information on the client and therapist, the goals of LI therapy, pertinent client family or personal history, a summary of all quantitative measures, INTEGRATING EGO IDENTITY WITH LI THERAPY 235 Figure 1: Structure of HSCED copies of all qualitative post-therapy forms completed by the client and therapist, and full transcripts of the mid-therapy, post-therapy and follow-up change interviews. The compiled rich case record is used during the case development process conducted by two teams: a) the affirmative team, and b) the skeptic team. Teams are comprised of three to fours members with expertise in areas pertinent to the research process (for this project this includes LI therapy, ego states and identity development, and TCKs). During the case development meeting teams work collaboratively to prepare a case brief of evidence in support of their respective position: a) affirmation of evidence of the client experiencing change and change due to therapy (affirmative position); or b) against evidence of the client experiencing change or change due to therapy (skeptic position). Briefs are then presented to the whole group, the opposing position is given an opportunity to rebuttal, followed by a counterargument from the presenting team. A summary of each team’s position, rebuttal, and counter argument is then added to the rich case record for use in the adjudication process. My role in the case development process is to provide organization, instruction and training on the purpose and process of case development; to be available to answer questions or provide further information; and to assemble team findings for inclusion in the rich case record. As such, my role in analysis at this stage in the HSCED process is more passive than active in being a step removed from direct evaluation of the data. For adjudication, the rich case record, including the arguments and rebuttals presented by the affirmative and skeptic teams, is presented to a panel of three external judges again comprised of professionals with expertise in pertinent areas of the research project. The responsibility of the adjudicators is to independently consider the evidence both for and against substantial client change and client change substantially due to therapy and render a judgement in the form of a percentage rating of probability and their level of confidence in their judgment. INTEGRATING EGO IDENTITY WITH LI THERAPY 236 The panel is then asked to identify any factors beyond therapy, including mediating and moderating factors, that they believe may be responsible for evidence of change over the course of therapy. In proposing the use of external experts as adjudicators I am once again removed from direct, active engagement in the data evaluation process. This adjudication process enables the judges to objectively evaluate the case study evidence and make probabilistic claims regarding the efficacy of LI therapy in creating ego identity change in an adult TCK. The last step in this process is to integrate the judges’ ratings and decisions and arrive at final research conclusions regarding the goals and purposes of the project being conducted. For the purposes of this study conclusions would be drawn regarding the probability of change in ego identity having occurred, and the probability that said change was due to LI therapy work or other factors. Potential Risks and Discomforts: I have carefully considered the following personal and professional potential risks and discomforts of engaging in a reflexive research project as the primary investigator and sole study participant:     the emotional and/or psychological impact of sharing my personal story publicly and in a manner where it is subject to the scrutiny and evaluation of others the ethical principal of do no harm to my personal and professional reputation, especially regarding how information is presented for public consumption. my status as a future clinical counsellor and therapy practitioner and as a potential doctoral candidate will continue to be given special consideration in this decisionmaking process. balance of consideration in upholding the values of dignity and respect, while also pursuing authenticity, transparency, and quality in research. Continuous informed consent is integral to this process. My role as researcher-participant is fully voluntary it is never to be taken for granted. I will continually evaluate my consent for how my personal data is included in this study on my own and in consultation with my research supervisor. Potential Benefits: My participation as a reflexive primary investigator in this HSCED project further centralizes the important priority of privileging perspectives (e.g., client) in psychotherapy process and outcome research. This is congruent with a personal desire I have to systematically explore this aspect of my experience and as the reflexive researcher and my choice to engage in this approach aligns with my personal values. The anticipated outcomes in this study are: a) to provide probabilistic claims regarding the efficacy of LI therapy in addressing issues of ego identity integration among the TCK population, and b) to provide narrative evidence of an inferred causal relationship between client change and therapy events and practices. Additionally, I hope it this study will serve: a) as a role model for clinician therapeutic work; and b) to promote self-reflection, self-understanding, greater care for struggling TCKs, greater care for individuals entering psychotherapy, and an increased awareness of client’s internal experience of therapeutic work. Personal benefits also include INTEGRATING EGO IDENTITY WITH LI THERAPY 237 being empowered to take up space with my story in the world and have a voice within the academic community. Confidentiality: As the raw data from this study contains personal information not appropriate for inclusion in the summary report or for publication, both paper and electronic documentation have been anonymized via the use of a pseudonym. Furthermore, this data set is being stored securely either in a locked location (paper) or via encryption (electronic) and will be retained indefinitely in the research archives of Dr. Janelle Kwee’s ongoing LI therapy research project at Trinity Western University. The summary data (rich case record), however, is explicitly expected to be public, therefore confidentiality only pertains to aspects of the data that will not be included in this record. Within this study’s research design I have been given final authority to decide what will and will not be included in the public record of the research data and will seek consultation from research team members regarding this decision in order to maintain a full representative dataset according to HSCED parameters. Moreover, when possible, consent will be sought when data contains information that may identify other individuals in close relationship to myself (e.g., family members). When consent is not possible or appropriate the information will be closely examined and a collaborative decision regarding its inclusion in the project will be arrived at in consultation with the research supervisor. As all data being analyzed was collected under Dr. Janelle Kwee’s ongoing Lifespan Integration research program, the legal limitations of confidentiality are not applicable to the analysis of the raw data collected. Responsibility for abiding by the legal exceptions to confidentiality (i.e., danger to self or others, reports of abuse or neglect of a child or vulnerable adult, or a court order to release of records) rests with the therapist who conducted the LI therapy sessions which occurred previous to the start of the proposed data analysis. It has been and continues to be my understanding that if I have any questions or a desire for further information or clarification on any aspect of this project I may contact Dr. Janelle Kwee (Email: janelle.kwee@twu.ca or Phone: 604-513-2121 ext. 3870) at any time. Additionally, if any third party should have any questions or desire further information that cannot be satisfied by the primary investigator’s provision of answers and knowledge, such parties are welcome to contact Dr. Janelle Kwee (Email: janelle.kwee@twu.ca or Phone: 604513-2121 ext. 3870) in her role as research project supervisor. Withdrawal: As the reflexive primary investigator, I understand that I reserve the right to withdraw from participation in this research study at any time. I also understand the implications of not completing the proposed project on my academic program including the potential delay of graduation in order to fulfill the program requirements of switching to the non-thesis track of the Master’s in Counselling Psychology program (e.g., course requirements, writing the MANTCE exam, etc.). Participant Consent: INTEGRATING EGO IDENTITY WITH LI THERAPY 238 My signature on this form indicates that I voluntarily participated in Dr. Janelle Kwee’s Lifespan Integration research program and further desired to voluntarily engage with the data collected as a reflexive researcher. Furthermore, it indicates my understanding of the implications to anonymity and confidentiality of being personally identifiable within this research study and accept all personal and professional consequences of such participation. Additionally, my signature demonstrates that I understand my right to withdraw from this study at any time and that I understand and accept any academic repercussions of any such withdrawal. It is also my understanding that the data collected data will remain in Dr. Janelle Kwee’s LI research files regardless of my withdrawal. Signatures: My signature below indicates that I voluntarily consent to participate in this study and for my data to be kept for further use after the completion of the study. April 12, 2019 Research participant signature Sharon Macfarlane Printed Name Date INTEGRATING EGO IDENTITY WITH LI THERAPY 239 APPENDIX L Case Development Guidelines General Guidelines Ego Identity:      Self-organizing mechanism Personal: A sense of internal coherence across a lifetime. Social: A contextually appropriate and understandable social presence within the social sphere which enables group belonging and effective interactions with others. “feeling of being at home in one’s body, a sense of ‘knowing where one is going’, and an inner assuredness of anticipated recognition from those who count,” (Erikson, 1968) “the sense of one’s self as a continuous entity or agent, in a variety of contexts, and over the passage of time” (Côté and Levine, 2002) Research Question: Is LI efficacious in addressing ego identity fragmentation and its correlates in an adult TCK? More specifically:       Did the client change over the course of LI therapy? Did the client experience change in ego identity? If so, what general or ego identity changes are evident in the data? If change occurred: o can these changes be reliably attributed to the therapy? Skeptic – why not? Affirmative – why yes? If ego identity change occurred: o can these changes be reliably attributed to the therapy? Skeptic – why not? Affirmative – why yes? What specific event/processes (quantitative or qualitative data or other theory/ conceptualization) can be identified to support your arguments for (affirmative) or against (skeptic) change and change due to therapy? INTEGRATING EGO IDENTITY WITH LI THERAPY 240 Case Development Guidelines – Affirmative Team POSITION: Affirmation of evidence of client experiencing change in ego identity fragmentation and of these changes occurring due to LI therapy work. Must provide AT LEAST TWO of the following types of evidence: EVIDENCE FOR CHANGE (improvement): (Elliot, 2002, 2015; Stephen & Elliot, 2011)  Changes are in long-standing/stable problem areas: a. Changes are significant and important. b. Evidenced by an increase in functioning or decrease in symptoms. EVIDENCE FOR CHANGE DUE TO LI THERAPY PROCESSES: (Elliot, 2002, 2015; Stephen & Elliot, 2011)     Client specifically attributes change to the therapy process. Client describes helpful aspect in therapy clearly linked to the post-therapy changes. Evidence of a relationship between in-session therapy processes and weekly client changes as demonstrated in daily PQ data and in-therapy processes. Change occurs in close temporal proximity to a helpful therapy event demonstrating a clear connection between shifts in problematic areas and therapy processes. Nontherapy Process Improvement Examples Look for: Change happens in long-term problem areas Positive: improvement Important: significant and substantial       Attributional Change X is explained by therapy process Y Change X would clearly not have   Duration of problem area Increase in client functioning. Decrease in symptoms. Positive changes. Change that is significant or substantial. Client evaluates change as significant or important. Client referencing therapy events/processes in explanations of changes Client describes change as unlikely without therapy INTEGRATING EGO IDENTITY WITH LI THERAPY happened without therapy   Process-outcome Mapping Client explanation of change High client helpful event rating and linked post-therapy change  Data-event Relationship Helpful therapeutic exploration of a difficulty followed by change in that difficulty the following week  Event-shift Sequences Important therapy  events are followed by a shift in thoughts, feelings, behaviours  241 Client describes other people spontaneously commenting on changes which she attributes as having emerged from therapy Client description of changes as surprising. High client ratings of helpful followed by a significant shift  Shifts in PQ ratings that can be directly linked to a therapy event. High helpful event ratings from client or therapist followed by a described significant change Client narrative and descriptions of reasons and meanings of change INTEGRATING EGO IDENTITY WITH LI THERAPY 242 Case Development Guidelines – Skeptic Team POSITION: Against evidence of client experiencing change in ego identity fragmentation or of these changes being due to contextual matters apart from LI therapy work. EVIDENCE FOR NO CHANGE (nonimprovement): (Elliot, 2002, 2015; Stephen & Elliot, 2011)      Changes are negative: a. demonstrate a decline in healthy or positive functioning b. demonstrate an increase in symptoms. Changes are irrelevant or trivial due to: a. client’s ambivalence b. dubiousness at nature c. significance of changes d. may pertain to change in factors external to the client such as changes in others or in circumstances. Change is due to statistical artifacts such as: a. errors in measurement, b. regression to the mean, c. experiment-wise error. Change reflects relational artifacts: the client’s desire to meet therapist expectations (people-please) or due to other interpersonal dynamics between therapist and client. Change is due to expectancy artifacts: the client’s wishful thinking and expectations of change. EVIDENCE FOR CHANGE NOT DUE TO LI THERAPY PROCESSES: (Elliot, 2002, 2015; Stephen & Elliot, 2011)     Change reflects the client’s ability to help themselves and self-correct. Change is due to extra-therapy (or outside therapy) life events, e.g., changes in employment, relationships, recreational activities, etc. Change is due to adjustments in medication or physical health changes. Change is due to reactive effects of research: the client’s desire to produce positive results for use in this research project. INTEGRATING EGO IDENTITY WITH LI THERAPY Nontherapy Process Nonimprovement Examples Look for: Negative: deterioration  Irrelevant:  unimportant or trivial    Statistical artifact Measurement error Regression to the mean Relational artifact “Hello-goodbye effect:  emphasize distress at the beginning, positive  functioning at the end.      Expectancy artifacts Client tries to convince self and others that change has occurred when it has not. 243     Decline in client functioning. Increase in symptoms. Negative changes. Change that is not significant or substantial. Client evaluates change as insignificant or unimportant. Duration of the identified problems Client reports inconsistency in PQ ratings Who conducted the Change interviews? Were negative comments encouraged? Reported? Client spontaneously expresses desire to please or fear of evaluation. Global or vague positive descriptions versus supporting on convincing detail. Presence of both positive and negative descriptors. Client description of changes as expected. Examine client descriptions for consistency with cultural stereotypes versus plausible detail. Client spontaneously trying to convince self or therapist that change has occurred. Client is the only person to notice change. INTEGRATING EGO IDENTITY WITH LI THERAPY Self-corrections: self-generated return to baseline Extra therapy events (positive life events) Psychobiological causes Reactive effects of research Temporary initial state of distress or dysfunction. Reversion to normal baseline through client’s own natural corrective or self-help processes. Change would have occurred with or without therapy. Improvements in relationships or work.      Medications Herbal remedies Changes in health status unrelated to therapy Effects of research activities (e.g., assessments, interviews, etc.). Relations with research staff. Sense of altruism.       244 Long-term duration of problems. Client evaluation that change was likely without therapy. Client narratives of self-help efforts begun before therapy. Client narratives of extra therapy events and changes. Evidence of extra therapy events impacting weekly changes. Changes in medication. Adjustments to medication dosage. Use of herbal remedies. Narratives of medical interventions. Client narrative regarding effects of research. Use of naturalistic clients rather than recruited clients. INTEGRATING EGO IDENTITY WITH LI THERAPY 245 APPENDIX M Adjudication Response Form The following form was provided to the Adjudicators as a locked electronic file to facilitate the reporting of judgements through the use of drop-down menus. The drop down menu scales are provided at the bottom of the form for reference only. *In answering these questions, please use whatever space is needed to give a full response. The document will automatically adjust spacing as you continue to write. DUE: midnight Sunday, June 9 A. EGO IDENTITY CHANGE: 1a.To what extent did the client experience ego identity change over the course of therapy? SELECT ONE a 1b. How certain are you? SELECT ONE b 1c. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? AND How did you make use of this evidence? *  2a.To what extent is this ego identity change due to therapy? SELECT ONE c 2b. How certain are you? SELECT ONE b 2c. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? AND How did you make use of this evidence? * INTEGRATING EGO IDENTITY WITH LI THERAPY 246  B. OTHER CHANGE: 3a. To what extent did the client experience general change over the course of therapy? SELECT ONE a 3b. How certain are you? SELECT ONE b 4a. To what extent is this general change due to therapy? SELECT ONE c 4b. How certain are you? SELECT ONE a C. MEDIATOR/MODERATOR FACTORS: 5. Which therapy processes (mediator factors) do you feel were helpful to the client? *  6. Which characteristics and/or personal resources of the client (moderator factors) do you feel enabled the client to make the best use of therapy? *  NOTE: Drop-down menus were used wherever it says “SELECT ONE” above. Below are the scales in use for each of the 3 types of drop drop-down menus. a Options to select from: No change 0% Slightly 20% Moderately 40% Considerably 60% Substantially 80% Completely 100% INTEGRATING EGO IDENTITY WITH LI THERAPY b Options to select from: Not at all certain 0% c 247 Slightly 20% Moderately 40% Considerably 60% Substantially 80% Completely 100% Moderately 40% Considerably 60% Substantially 80% Completely 100% Options to select from: Not at all due to therapy 0% Slightly 20% INTEGRATING EGO IDENTITY WITH LI THERAPY 248 Appendix N Confidentiality Agreement As a member of the research team for Integrating Ego Identity In An Adult Third Culture Kid With Lifespan Integration Therapy: An Auto-Hermeneutic Single Case Efficacy Design study, I acknowledge that I will be accessing confidential research participant information and identities. As such, I agree to:  maintain strict confidentiality protocols regarding any information I access or that is shared with me both during this project and afterwards.  not share any portion of this information with anyone outside of the research team involved in this project.  keep all copies of information stored securely in a locked location (paper format) and encrypted and password protected (electronic format).  return all research data in all formats to the principal researcher once my role in this study have been completed.  securely destroy (shred or delete) any additional research information in my possession if returning it to the principal researcher is not a feasible option. I have read and understood the above Confidentiality Agreement and agree to all the terms as described above both during my participation in this student and afterwards. ________________________ Assistant Name: ________________________ Witness: __________________ Signature: __________________ Signature _______________ Date: _______________ Date: INTEGRATING EGO IDENTITY WITH LI THERAPY 249 Appendix O Third Party Informed Consent Research Study Title: Integrating ego identity in an adult third culture kid with lifespan integration therapy: A reflexive hermeneutic single case efficacy design. Principal Investigator: Sharon Macfarlane, MA Student Counselling Psychology Department, Trinity Western University Email: Sharon.Macfarlane@mytwu.ca Phone: 778-991-7954 Co-Investigator: Hillary McBride, Ph. D. Candidate Educational and Counselling Psychology, and Special Education University of British Columbia Email: hillarylmcbride@gmail.com Phone: 604-833-4574 Project Supervisor: Dr. Janelle Kwee, Program Director & Associate Professor Counselling Psychology Department, Trinity Western University Email: janelle.kwee@twu.ca Phone: 604-513-2121 ext. 3870 Purpose: The purpose of this research project is to evaluate the suitability of LI therapy for an adult TCK who self-identifies as having a fragmented sense of self. This study will be guided by the following research question: Is LI efficacious in addressing ego identity fragmentation and its correlates in an adult TCK? My unique role as a reflexive researcher-participant within this study allows for the collection of an extensive and mutli-sourced data set permitting an in-depth perspective of the therapy process and permitting for continuous access to client data and perspective. Procedures: This reflexive project will follow the structure set out in Elliot’s (cite) Hermeneutic Single Case Efficacy Design (HSCED). HSCED follows a systematic and rigorous structure that can be divided into three stages (see Figure 1). The first stage is comprised of therapy sessions and data collection. The second stage involves data analysis through the compilation of the rich case record and the development of the affirmative and skeptic case briefs. The final stage incorporates the adjudication process to arrive at answers to the three central questions, and the researcher’s final conclusions. INTEGRATING EGO IDENTITY WITH LI THERAPY 250 Figure 1: Structure of HSCED Potential Risks and Discomforts: Consenting to being identified in this study entails acknowledging the potential for being identified within this course of research. Potential Benefits: While there are no specific personal benefits of being identified within this study inclusion contributes to the general body of reasearch. If you have any questions or desire further information, you may contact Sharon Macfarlane, (sharon.macfarlane@mytwu.ca or 778-991-7954) or Dr. Janelle Kwee (Email: janelle.kwee@twu.ca or Phone: 604-513-2121 ext. 3870). If you have any concerns about your rights in being identifiable within this project you may contact Elizabeth Kreiter in the Office of Research, Trinity Western University at 604-513-2167 or researchethicsboard@twu.ca. Withdrawal: Full withdrawal from this single case research study is not feasible, however, any identifiable third party within this research may request to audit what specific information is being included and give input towards its inclusion in the dataset. Participant Consent: Your signature on this form indicates that you understand:   that providing consent to be identified within this study is entirely voluntary. that you have the right to audit the way you are identified within the dataset at any time before the internal defense without repercussions. INTEGRATING EGO IDENTITY WITH LI THERAPY 251 that it is your responsibility to contact the principal researcher either verbally or in writing should you choose to audit your identifiable information or if you have any questions regarding the study. In addition, your signature indicates that:  You are aware of the possible risks and benefits of being identified within this study. You have been informed of and understand the processes that are in place for maintaining confidentiality.  You have been informed of and understand the limits to confidentiality. Signatures: Your signature below indicates that you have had your questions about the study answered to your satisfaction and have received a copy of this consent form for your own records.   Your signature indicates that you consent to be included in this study as an identifiable party. ____________________________________ Consenting party’s signature ____________________________________ Printed name ____________________ Date INTEGRATING EGO IDENTITY WITH LI THERAPY 252 Appendix P HAT Helpful and Hindering Events Table P1 Summary of Client Reported Most Helpful or Important Event on the HAT form16 Session Most Helpful/ Important Event Description Rating 1 9 extremely helpful When therapist noticed a swell of emotion in me and helped anchor that emotion in my body. It was important that she noticed the emotion – that she saw me in that moment of vulnerability. I was at a loss for how to describe the emotion, so she guided me to just point where it was. Eventually I was able to attach descriptive words to the emotion. 2 The second time through the attunement protocol, when we brought my baby self to my apartment and met my adult self, I suddenly realized there was indeed a time in my life when I was 2 weeks old. 8 greatly helpful It was quite a revelation! To envision a young, 2-week-old ME without the potential to be burdened, but merely the responsibility to BE was somehow heartbreaking and yet integral to seeing the whole me. 3 Sharing my observation of the baby being so defenseless the fear that accompanied it. 9 extremely helpful This tapped into a core emotion. Sharing that with another person, having them see/know that and care for me in that felt powerful. Even just the act of my trusting my experience/reality in the timeline enough to share my experience adds a bit more strength and stability to who I am. 4 Physically holding my baby-self. I burst into sobs as soon as I held her, and then remember bursting out with “She’s so beautiful!” I don’t even know exactly what happened but know something significant happened. Something deep within me was accessed and given space and voice in that moment. 16 For full client responses see rich case record (Appendix ____). 9 extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 5 At the end of a timeline I was stuck/frozen. The therapist noted this and immediately addressed it therapeutically. 253 9 extremely helpful This is the first time I’ve experienced the stuckness/paralysis being therapeutically addressed in a significant manner. Not just talked about, but we did something. 6 When I exclaimed, “She’s me!” Not just the declaration that my 7year-old self is me, but the process of discovering this, coming to this realization – through my interaction with her in the timeline. Seeing how much my 7-year-old self and I had in common - it was like discovering a ‘kindred spirit’ and realizing that person is YOU. Not odd, weird, bizarre but beautiful, full of life, joy, wonder. 7 When the therapist helped me answer my little girl’s question, “Are we okay?” - we are learning to be okay and that part of that process was coming back for my 7-year-old self. 8.5 greatly and extremely helpful 8 greatly helpful These were words very important for my child and adult self to hear. It was liberating to NOT hear the therapist say, “Yes, we’re okay.” Learning to be okay is different – recognizes current struggles (validates) while instilling hope for something better/different. 8 The therapist was very present with me as I tried to verbalize the scene (trauma). She said things like, “I’m right here with you. You’re safe.” As I continued to struggle, she encouraged me to start with telling where the scene was taking place. 9 extremely helpful Internally I was stuck/frozen, unable to speak but the therapist was attuned to this, recognized it, and was immediately there to support and help. At the same time, I never felt like she was judging me nor did I feel abnormal for freezing. (Note: some previous therapy experiences I have been left in freeze to get out on my own which was not only difficult but isolating and the opposite of normalizing.) 9 I was sharing some changes and shifts that I had noticed 8 happening and the therapist was quite excited to hear of all that greatly was happening. Then she asked me, “Are you able to take that helpful [her excitement] in?” As this discussion progressed, she mentioned that we were building an attachment relationship. INTEGRATING EGO IDENTITY WITH LI THERAPY 254 What I was not willing to admit in session was that I had no idea what she was asking. I understood her excitement, I tentatively believed it to be genuine but what did she mean by “take it in”? This is important because I’ve always felt there were certain interpersonal dynamics I didn’t comprehend, and this was one of them. I also had no clue what she meant by an attachment relationship. Further evidence of attachment void. 10 In the last timeline the therapist started by having me cross my arms and hold myself. I was imagining me holding Rose [my younger self] and letting her know we were OK because the therapist was holding us both. The therapist saw or sensed something and asked if I wanted to just stay in the embrace for a while longer. 9 extremely helpful She [the therapist] saw me. She saw a need to stay and didn’t just run with what I was consciously telling her with my nod but invited me to linger. I’ve always been afraid to linger, take up too much time/space. Here I was being invited to BE - be seen, known, felt, experienced. 11 When the therapist asked if I was ready to try standard protocol around the assault. Two things were important/helpful: 1) that I said YES; 2) her confidence in answering the question, “What if it goes disastrously?” – she simply states, “It can’t”. 9 extremely helpful This was important because I know that rescuing my younger self from the midst of the assault and showing my brain that its over is the only way I will ever be able to leave it behind. Also, despite all my knowledge of LI and my desire to do the work, I’m still scared that it will all go wrong, and I’ll just be stuck where I am. The therapist’s confidence that there is zero chance that it will end in disaster was very reassuring. 12 The therapist was coaching me to tell my younger self that the assault is over. As I spoke those words to my younger self, I was strong and confident in reassuring her of these truths while simultaneously shocked/surprised to discover my older self didn’t already know this. I heard the words with my whole self and there was relief, more than relief, release. For the first time I considered it to actually be true – it is done, finished; I survived and don’t ever have to go back there again. 9 extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 13 Switching my safe place form the lake at the cottage to the mountain top. 255 9– extremely helpful As I was interacting with my younger self it became clear that she didn’t want to go to the lake because we’d always only ever been there as a family and she wanted to be away from family – didn’t feel safe around them. So, the therapist said we could go somewhere new. 14 The therapist had me do some body work around my experience of 9 voice: physically show what it looks like when I feel silenced, extremely hidden, disappeared; what it looks like to be emerging; and what it helpful looks like to be free to speak, be seen, be heard. The therapist then performed the sequence for me to watch and see. It was such a vulnerable exercise to allow the therapist to see me as I’m trying to hide, disappear, survive; to have her witness my state of invisibility was very difficult to do. It also immediately surfaced deep emotions of fear, shame, sadness, trapped. The last stage was glorious. I felt so big, powerful, steady, joyful; an automatic smile came to my face. The uncertainty of the middle phase was curious – reflect my fear in exiting my survival zone, uncertainty of how to move from A to B, uncertainty in this last stage is just a dream or a possibility. 15 The therapist verbally saying, “I am here with you” as I focused on 8 my internal emotional experience in the moment. greatly helpful Until the therapist said those words, until I heard them, I was unaware of the loneliness I felt. With those words came a swell of emotion and tears and I realized that my inner self (inner child?) felt alone (abandoned?). 16 When I was able to verbalize out loud the connection, I see that my brain has made between sexual arousal and sexual violence/assault. To speak it out loud so bluntly and overtly was at first impossible as the shame took me out of my window of tolerance, but the therapist led me in tapping and pressing my limbs which grounded me, and I was able to speak. It’s important because it’s the reality of my current experience and something I want to see change, but if it remains locked in secrecy due to shame it won’t be able to change. It was also about being seen and known – having someone hear me speak my secret shame and not reject me, judge me, shame me, punish me, or disgust them – impact of that is freeing and beyond words. 9 extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 17 The therapist queried what goes on when I speak gibberish due to a state of wordlessness in expressing myself. 256 8 greatly helpful No one has ever asked before. It’s something that has always been a part of therapy, but no one has inquired why. I am being fully seen – every aspect of me is being experienced. 18 Sharing my 2-year-old memory of wanting my mom and instead getting the babysitter. Actually, being in the memory and speaking from a first-person perspective. Going back and getting her was SO important. 9 extremely helpful I’ve talked about the memory from an outsider perspective before but never as the one who experienced it and was blown away by the depth of fear that emerged. I was that little girl. Now she’s been seen, heard, and responded to. 19 During our second run through the memory, when I was with my younger self at 88 Ellerslie (home in Toronto), the therapist asked what my younger self might need to do. In response my younger self ran around the main floor smashing windows, slashing the kitchen cupboard doors with a knife and spray painting, “I want to go home” in black on the dining room wall. 9 extremely helpful Because this is the first time, I’ve acknowledged how angry I was – that I even was angry – and my intense desire to return to Mexico. The memory was about anger regarding a situation with my sister, but the out of control nature of the anger stems from being burdened and overwhelmed by the demands of life in Canada. Never before have I admitted that I wanted to go home – and that this was Mexico. 20 The therapist asked what little 4-5-year-old ME needs, and the answer was that she needed to meet the therapist. She doesn’t know her. So I sat on the floor with little ME on my lap [in my imagination] and the therapist spoke directly to little ME. It was such an intimate and precious time between the three of us [little ME, adult ME, the therapist]. The therapist was seeing and responding to a part of me that hasn’t been seen in a very long time and it was simply beautiful. It also took a lot of courage to tell the therapist what little ME needed – to meet her. It sounded ridiculous and yet I also knew it had value therapeutically – therapist ME vs logical ME in debate. 9 extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 257 21 This HAT was completed verbally with research supervisor. Talking about/ identifying personal changes/shifts - growing but 7.5 moderatel also hiding from the intensity). Being seen in the intensity. y and 1. Desire to give feedback to the therapist. greatly 2. Being able to put words to hesitancy of being seen and the other helpful person staying with – hindering/ uncomfortable part is not knowing what to do with this. 22 “Taking charge.” Letting the therapist know that I needed a break between timeline and that young ME and adult ME needed to go to the mountain top (peaceful place) before we told my story the second time. 8.5 greatly and extremely helpful Knowing and trusting what my instincts told me I needed and giving voice – empowering myself to ‘take charge’ and make that need known. Required a lot of strength, courage, determination and trust in myself to make my presence known in this way. 23 When I (my adult self) go into the memory, I am holding my younger self and keep repeating, “I’m here. I’m here.” 8 greatly helpful My younger self is being crushed by the weight of responsibility and pressure she feels to be able to handle all that comes with transitioning to Canada. In that moment she is all alone – nobody knows. But I know. I understand. And I’m stronger, bigger, have more resources. As I enter the scene, she needs to know she is no longer alone . I am there to care for her, help her, love her, protect her. She is not alone – “I am here.” 24 I shared that I knew what I wanted to do for 11-year-old ME but wasn’t sure if I was allowed. The therapist encouraged the adult ME to not worry whether or not I was allowed to do what I thought 11-year-old ME needed. 7.5 moderatel y and greatly helpful This helped get me out of the ‘shoulds’/’shouldn’ts’ to just listening to my gut instincts and getting out of my head. 25 The therapist was coaching me through merging my present self and younger self. This process brought up a ton of really strong emotions of missing my younger self – a deep ache, a longing being realized in the midst of reunion. Because, since she is me, she is not really lost – she is recoverable. I can bring her back again. Everything that she was is still within me and therefore can be a part of who I am once again. 9 extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 26 27 258 NO RECORDED HAT. Client was unable to remember the session, so no HAT data was collected.17 The therapist coaching me to switch back to my 11-year-old self from my adult self and then back again at the end of the first timeline. 9 extremely helpful It was important because it allowed the depth and breadth of the emotion of the terrified 11-year-old to be seen and heard. Also, it distinguished what belonged to the 11-year-old and what belongs to the adult me. I can now see how the terror, panic, anxiety isn't my adult self responding to the world around her but the is the response of a terrified, abandoned, lonely, isolated young girl. 28 NOTE: this HAT form was filled out verbally with research supervisor. 8 At the beginning, working on finding memory pertaining to greatly silencing of voice, trying to connect somatic to memory and felt room spinning. Helpful - therapist coaching around present helpful orientation and body grounding (open eyes, etc.) Helpful because client spoke up and it was responded to – this was an example of the opposite of theme of voicelessness. 29 When the therapist speaks of a new story and naming the hurt does not make me a bad person and I’m not wounding anyone. I realized that I could admit the hurt from Mom and Dad while also loving them. The therapist said that admitting it or naming the hurt doesn’t mean my parents are monsters, or that they didn’t do the best they could, or that I didn’t love them. 9 extremely helpful In what I said and what the therapist said we hit the core emotional center of the block, the resistance, the iron door that prevents me from allowing family hurts to be acknowledged and healed. 30 17 In timeline #2 the therapist prompted me to say to my child self whatever she needed to hear. I found myself telling her that we don’t have to take care of Mom. 9 extremely helpful This session centered around a memory that was complex and difficult to navigate due to dynamics of personal voice and family rules; a theme that runs throughout many of the therapy sessions and even to completing this thesis study and preparing this rich case record. This may explain the lack of memory of the session when attempting to complete the HAT form. INTEGRATING EGO IDENTITY WITH LI THERAPY 259 I had NO idea that was what I was trying to do – emotionally take care of Mom – or that this pattern might have started so young (age 2). It all started to make sense: why the memory had stuck with me, why the block was so strong, why things focused on my Mom. 31 When I shared with the therapist how, while showing the Timeline to little ME, I talked to her about the events as things she and I had done together - e.g.,"We taught line dancing at our 40th birthday party" 9 extremely helpful This is important because it is the first time through any timeline when there was a distinct recognition that my younger self IS me as we were going through the Timeline. We were travelling through the memories together and there was the knowledge that we BOTH experienced the events together. 32 The therapist reviewed the work we had done together since 9 August - she went week by week and mentioned what we had done extremely and significant changes that had occurred. helpful I was surprised that we had done so much work in such a short time frame. I had it in my mind that what she was describing was the scope of what we had done since May, not since August. Also, I had been worried that we really hadn't spent much time working on repatriation stuff but when she recapped our sessions I realized that we had in fact spent a significant number of sessions with my 11-year-old and that meaningful shifts had happened there. Table P2 Summary of Client Reported Additional Helpful Event on the HAT form Session Rating 1 There were at least 2 similar events where the therapist reflected back to me what she heard me saying and she was bang on! I can’t remember the specifics of what was said but remember feeling known, heard, seen, understood. 8 greatly helpful 2 When the therapist was holding my baby self and described looking/gazing into my eyes and holding my fingers as I watched her doing this, I was finally able to visualize myself as that little baby looking back at her and grasping her finger. It was the first real connection to my baby self. 9 extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 260 3 At the end I was confused because my adult-self wanted to hold my baby-self, but I also knew my baby-self did not want to be held by my adult-self. What was helpful is that the therapist took responsibility for worrying about and figuring out how to handle these conflicting desires. I didn’t have to figure it out. 8 greatly helpful 4 I noticed that the therapist took us back to the peaceful lake setting frequently, especially in the third timeline. This was so important as I finally breathed and relaxed when we went to the lake. I could feel how hard I was working in between, and the break was glorious! 9 extremely helpful 5 The therapist shared her hypothesis of what had [me] hyperaroused since our last session: AEDP explanation (defenses/anxiety/core affect triangle). Helped me understand what was happening over the weekend and perhaps also explain many of my life experiences. 8 greatly helpful 6 I had something I needed my Dad to hear in my timeline (#2) but couldn’t say it myself and was struggling to find someone to bring into the scene to say it for me (the therapist). It was so good to have the words spoken and not silenced. 8 greatly helpful 7 1. When the therapist essentially asked if my adult self knows I don’t need to be afraid of my Dad – my emotional answer was unfortunately, no. 8 greatly helpful 2. When I was with my 7-year-old self and told her “I see you. I know you. You are safe.” Spoke to the craving of my heart. 8 When we got to the break after the first timeline, I shared that my younger self did not want to leave. The therapist responded in two way: 1) We jumped right into another timeline so Rose wouldn’t be alone; 2) at the end of this 2nd timeline she invited my younger self to come with us to the office for the break. That felt much safer. 8 greatly helpful 9 While I was describing changes and shifts that had happened, I was 9 quite animated, and the therapist pointed out my excitement. I extremely hadn’t really recognized it up to that point but excitedly declared, helpful “I showed up!” It was a first conscious realization that a defined ME was emerging/had emerged. INTEGRATING EGO IDENTITY WITH LI THERAPY 261 10 Using the butterfly taps during the 3rd timeline (PTSD) was very grounding. The timeline was less overwhelming and more manageable. 8 greatly helpful 11 At the end of the last timeline I shared with the therapist that there was some resistance to the two of us merging together even though I knew they were both me. She asked if it was because of who my younger self was or because of the story. Hadn’t even thought of that distinction – very key. I thought/think it’s because of the story. 8 greatly helpful 12 During the 2nd and 3rd timelines I ran into some problems interacting with my younger self and entering the scene. The therapist took this all in stride, didn’t make a big deal of it or treat it as strange/abnormal. She just incorporated that information into her coaching, and we jumped back into standard protocol. Much to my surprise, we/I overcame the problems (her coaching me doing). 9– extremely helpful 13 I think it was the 3rd timeline when my younger self was so angry. 9 Hillary encouraged me to let her express her anger. So, she yelled extremely helpful and screamed, and beat up the trees on the mountaintop until she collapsed in tears and I rushed over to hold her. She would never have felt free to do all of that at the lake, but alone on the mountain there was no one to hear or see her while she raged. 14 Sharing a disturbing dream I’d had…and then speaking up very confidently in the dream that what was being suggested couldn’t happen due to the assault…Brought up the theme of confinement and having a voice with the family, setting appropriate boundaries, disobeying family rules – giving myself permission to have a voice and make my own decisions. 15 After a 3-week gap between sessions we began by catching up on 8 how I’ve been doing which led to addressing an immediate specific greatly need without the use of LI. It was beneficial to start where I was at helpful after such a long break and give an idea of what’s been happening /where we might need to restart/pick-up. 16 My younger self asked if we would ever be loved again. The therapist’s answer was not to promise or envision a future loving relationship for me but to coach me in letting my younger self know that I am lovable – right now, right here, just the way I am. 9– extremely helpful 9 extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 262 17 My younger self asked why we had to be so strong and courageous 8 – greatly and the therapist helped me answer her. Acknowledged the helpful difficulty and effort it has taken to get here. Permission to be tired, exhausted and in need of rest. 18 When we first tried the affect bridge to a memory, I felt blocked and couldn’t connect. The therapist zeroed in on feeling blocked and how/where I felt that. A memory did surface after acknowledging and making space for the block. 8 greatly helpful 19 The therapist had me physically act out my anger – show it with my body. It made my anger so accessible, in fact too accessible as I was hyperventilating at one point. It was so strong and led directly to the memory. 9 extremely helpful 20 I shared with the therapist, right near the beginning, how I’d been feeling disconnected or unsure of her investment…and also unsure of her understanding of what my repatriation experience had been – a process rather than an event. It was awkward and scary but very important as it was blocking my ability to fully engage in session with her. Talking it through eliminated the anxiety/confusion. 9 extremely helpful 21 This HAT was completed verbally with research supervisor. Being able to work with shame and be seen in it as therapeutic material (affect bridge to source memory). Explored difficulty internalizing other’s joy. Used feeling to link to source memory. 8 greatly helpful 22 Both the therapist and I together adapted our approach to 11-yearold ME based on her responses to adult ME appearing – hiding, scared. Really slowed down the encounter and gave space and time for younger ME to adjust – [imaginally] kept my distance, kept quiet, spoke tenderly, approached tentatively, waited for younger ME to make the first move. Coaching by the therapist + my own imaginative choices. 8 greatly helpful 23 When we first entered the memory, I described is as crushing me and I had difficulty separating from that 11-year-old ME to being my adult self into the scene. I shared this with the therapist who was able to coach me back into my adult self – ground me again in my 44-year-old self – and then return to the memory. 8 greatly helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 24 25 More than one distinct event but same theme of letting the therapist know how elusive it was to connect with my 11-year-old self – at the school yard, on the mountain top (hiding in the trees), showing her the timeline (projecting it onto a lake for us to watch together). I can’t remember if I also mentioned difficulty at my apartment. It was helpful that I spoke this out loud even thought I didn’t’ know how to interpret it. 263 7.5 moderately and greatly helpful 1. I was struggling to separate adult me from 11-year-old me even after the therapist brought me back into the room (the here-and-now) so we did some bi-lateral taping and did a timeline with my eyes open. Really helped ground me again in my 44-year-old body so we could continue. 9 extremely helpful 2. I told my younger self that I was sorry she had to try and cope with all this on her own. That she should never have had to do this on her own and that she and I could grieve what we lost in never going back to Mexico together. 9 extremely helpful 26 NO RECORDED HAT. Client was unable to remember the session, so no HAT data was collected. 27 We began the session by talking about closing up data collection at the end of February. There were a lot of emotions attached to the thoughts of things ending - fear & sadness in particular. This is unusual for me to feel so deeply about the end of a relationship. We talked about what those emotions said about our relationship the intimacy, connection, attachment and safety that has grown in our time together. We also discussed how the presence of a safe and intimate attachment relationship has spotlighted the years where this sort of connection and safety were missing, the opportunities that I missed for connection, and brought to the forefront that deep yearning and desire that has been there for so long. 9 extremely helpful Not sure this qualifies as an 'event' because it mostly happened in my imagination but at the end of the second timeline younger Rose found my make-up at my house. In such a caring and connected manner I let her know that I could show her how to use make-up. This is significant because no one showed me. 8 greatly helpful 28 NOTE: this HAT form was filled out verbally with research supervisor. None reported. See full session report in rich case record for more detailed information (Appendix S, p. 319) INTEGRATING EGO IDENTITY WITH LI THERAPY 264 29 The therapist, in sharing her thoughts, shared the paradox of this conflict wherein to heal and move past the block I must engage in the very activity this block will not allow to happen. I remember internally saying, “Yes, yes, YES!” I feel extraordinarily seen, known, understood. 9 extremely helpful 30 Me trusting the memory my body connected to. I couldn’t see any 9 connection with this paralysis of speaking that we were working on extremely – and yet I went with it. helpful 31 In the second Timeline little ME and I went to talk directly to 9 Mom. I explained how upset little ME was and how she was extremely confused by Mom's emotions. In that moment I was both little ME helpful and older ME. This was important and helpful because it is the first time I was able to speak directly to Mom about my hurt/pain even in my imagination. 32 8 As this was our final session the therapist reiterated her love and care for me and expressed being proud of me and the work that we greatly helpful had done together. As we celebrated this together again there was an internal pull towards and push against being seen and celebrated in this way. I shared that I thought this was difficult because it is not something I have experienced much in my life but it is something I crave and need so learning to recognize my response to it and learning to accept positive regard, trust it, and internalize it is very helpful. Table P3 Summary of Client Reported Hindering Event on the HAT form Session Rating 1 Being quite confused by the serious expression on the therapist’s face as I shared something ‘lighthearted’ or shared something as I laughed. The therapist brain in me figures she was probably demonstrating a more accurate reflection of the emotional content of what I was sharing….BUT the client /human me still is confused. My thoughts immediately went to, “I must be doing something wrong,” without having a clue what that might be. 3.5 between slightly to moderately hindering 2 Each time we went through the timeline I would nod to indicate 4 that I had captured the event. At times this was distracting – trying slightly to connect with events and remember to nod at the same time. I hindering also wonder if it slowed the process a bit. INTEGRATING EGO IDENTITY WITH LI THERAPY 265 3 I was late arriving for session, so we had less time. This mean we only got through the attunement protocol twice and things were just opened up when we had to shut down the session. 3 moderately hindering 4 None reported. - 5 Taking intermittent notes on her laptop (therapist) during break. It was both reaffirming that she was making note of significant factors for future reference, but the clacking of keys and the laptop screen between us was slightly unnerving. 4 slightly hindering 6 I noted struggling against myself, my own perfectionism, at times. I’m much better at recognizing this desire to be a good client in therapy and letting it go than I used to be, but it’s still there and was very present during this session (the last 2 actually). 3.5 moderately and slightly hindering 7 None reported. - 8 None reported. - 9 None reported. - 10 None reported. - 11 It was really hard to imagine myself in the scene because it was so complex, multifaceted and so I felt a bit disconnected from it – like watching myself in a movie vs actually being in the movie. 3 moderately hindering 12 1. When I ran into a disconnection with my younger self in the 2nd timeline…I refused to leave the scene or ask for help believing that I was failing at LI therapy – that I was doing something wrong. I’m sure I only struggled for a minute or two, but wish I’d been quicker to just admit I needed help. The therapist’s response made it much easier to quickly ask for help when I encountered difficulties in the 3rd timeline. 13 4 slightly hindering 2. Difficult to know how/where to jump into the scene to such 3 a complex, multi-step memory. moderately hindering In the 3rd timeline my younger self threw [the guy who assaulted 4 me] over the balcony after beating him up. My older self was slightly worried that this narrative was more damaging than helpful and hindering tried to change it (hindering). When I shared what had happened with the therapist, she was not shocked, nor concerned, but said something like “Good for her. Someone else can worry about [the guy]. He’s someone else’s problem.” With the caveat that this was okay and true because it was imaginary (helpful). INTEGRATING EGO IDENTITY WITH LI THERAPY 266 14 None reported. - 15 This was our first online therapy session (vs. in person) and I found myself, especially at the beginning, feeling hesitant to completely engage/connect – desire to hold back from being vulnerable and feeling somewhat disconnected. It was definitely helpful to close my eyes as then I could almost forget that the therapist was just on a computer screen and not in the room with me. 4 slightly hindering 16 The internet connection wasn’t very consistent so there was a time I said something that I don’t think the therapist heard as she didn’t respond and am pretty sure I missed some cues in my timeline. This was a bit distracting as we went through as I would wonder if a long pause was intentional or if I’d lost the connection with her (seeing as I had my eyes closed). 3 moderately hindering 17 None reported. - 18 I’m torn in responding to this question as my brain and self-debate whether it was hindering or helpful. When I was sharing the successes of the week, at the end the therapist asked me to “sit” in the emotion of celebrating. I went to share an observation of what it was like to think of coming to session and sharing the successes with her, but she stopped me and asked me to just BE in the moment. That was uncomfortable, scary – the actual being – but I also wonder if some of the discomfort/fear was at feeling silenced based on the childhood episode that I connected to with the affect bridge. Even as I write I feel tension and I think anger. But making me stop and feel is also a very good thing as I can more easily talk to avoid the discomfort of feeling – so I’m not sure what to think. Between 1 (extremely hindering) and 3 (moderately hindering) 19 None reported. - 20 None reported. - 21 This HAT was completed verbally with research supervisor. Lingering shame – unable to grasp memory clearly – felt 2 unresolved – felt elusive. greatly hindering Questioning the therapist’s investment in client – client has felt uncertain – feeling like a burden for a couple of weeks around this session. 1 extremely hindering INTEGRATING EGO IDENTITY WITH LI THERAPY 267 Questioning therapist’s understanding of client’s experience of repatriation as a process rather than event – therapist’s question implied different understanding. 2 greatly hindering 22 When the therapist went straight into suggesting a 2nd round through the timeline after our first round without a break there was some anger and frustration. Not the first time we’d not stuck to protocol this way but this time it really mattered. Had I not been able to speak up for myself and ask for a break this would have been significantly more hindering because I was starting to lose myself (maybe dissociate?) in the experience – was finding it exhausting and difficult to stay grounded. 3 or 4 – moderately or slightly hindering 23 There were very long pauses in between memory cues which at 3 times made it difficult to remain in the process of showing my moderately story to my younger self – worried the therapist hadn’t seen my hindering nod, or got too involved in the specific memory. Also, we never took a break form the process – remained in the memory the whole time. That actually made it more difficult to stay engaged as it’s just wearying. 24 None reported. - 25 None reported. - 26 None reported. - 27 Someone from my work organization logged into the Zoom software which brought up a distracting warning on my computer. The warning was easily dismissed, and I was able to set aside any worries about our session being further interrupted, terminated or not recorded and simply continue on, but it was definitely a small interruption in the session. 1 extremely hindering 28 NOTE: this HAT form was filled out verbally with research supervisor. None reported. See full session report in rich case record for more detailed information (Appendix S, p. 319) 29 None reported. - 30 None reported. - 31 While it was pretty clear that the memory of seeing my Mom cry was not yet resolved I had difficulty accessing my younger self within the memory when we first started the Timeline. It was only slightly hindering as the therapist helped me get back into the memory by first being my adult self in the memory and then my younger self. 4 slightly hindering INTEGRATING EGO IDENTITY WITH LI THERAPY 32 None reported. 268 - INTEGRATING EGO IDENTITY WITH LI THERAPY 269 Appendix Q TSNQ Helpful and Hindering Events Table Q1 Therapist Reported Most Helpful or Important Event on the TSNQ form Session Most Helpful/ Important Event Description Rating 1 Client shared about her negative beliefs about herself, disclosed 7.5 about her goals for therapy, and shared about some defensive between strategies to manage stress. moderately to greatly Helped me as the therapist begin to understand her internal helpful working models, and what may need to be explore in this work, also built trust in our relationship. 2 Client described sadness when seeing baby doll, even from first 8 moment. Client reported feeling a sense of urgency to have the greatly therapist care, come get her, and some fear in baby self-state helpful about parents being present. This event reveals some implicit sadness the client experiences about herself and the desire to be cared for and held as a baby. 3 Client described feeling herself as the baby in my arms and imagined reaching out to grab my face to say “see me”; she reported feeling like this was a part of her baby self, in part her more adult self. 7 moderately helpful This event represents the client’s deep implicit longing to be seen, and the sense of desperation about that. 4 Client took and held the baby self then exclaimed “She’s so beautiful!,” acknowledgment that “she is the baby”. 9 extremely helpful Client was able to feel love and admiration for younger self, demonstrated integration. 5 Client reported feeling more present in the room, less tension in 8 her body. greatly helpful After feeling dysregulated during the week, the client was able to experience some integration and regulation. INTEGRATING EGO IDENTITY WITH LI THERAPY 6 The client reported (after 4 repetitions) that she felt she was the same person as her 7-year-old self. Her stomach made a loud noise as if to release something. 270 8.5 greatly to extremely helpful The client reported feeling as if she has ‘merged’ her younger and present-day self. 7 Client reported at end of session that she could remember the memory without emotional intensity, instead it felt ‘fainter.’ Demonstration of an integration of a memory, and the settling of her nervous system related to that event. 8 Was able to reassure younger self that the assault was not her fault, and not because of her recent weight loss. 8.5 greatly to extremely helpful 9 extremely helpful Client had previously believed that the assault was her fault. 9 Client shared about feeling flooded with memories of the assault and what happened afterwards (reporting, etc.), and feeling tense but in a manageable way. 8 greatly helpful Remembering the event and going through the timeline seemed to stir up unprocessed traumatic content; client felt activated but “Ok.” 10 At the end of the session the client was able to remember the traumatic event (beginning July 2009) while feeling present in the room, (while tapping and hearing the story) with less peaks and dips in intensity. 8 greatly helpful Client appeared more settled, like she could hear the story without agitation/hyperarousal or hypo arousal. 11 Client reported younger self standing up to detective then saying to present day self when she arrived, “Come on. Let’s go.” Client described a sense of certainty in her position that previously she had doubted or had been made to doubt by detective. 8.5 greatly to extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 12 At one point during the third repetition the client reported that her 2009 self tried to distract her from completing the timeline. The client came back to the room to strategize with the therapist, then returned to the timeline to reassure her younger self, stepped into care-taker role to provide guidance and direction to younger self. 271 3 moderately hindering The client’s younger part appeared to have some difficulty coming forward into the present. 13 Client at end stated that she said to herself /felt “I love me” for the first time ever. This occurred after client reported merging of younger and present self. 9 extremely helpful This represents a new level of integration and connection with self, past and present. 14 Client reported learning to find her voice and her expression of that standing tall, holding arms open to symbolize taking up space. 9 extremely helpful The client had previously felt restricted in her capacity to engage in life as her “own person” and reported a change and increased desire to “take up space.” 15 During the past week, the client reported noticing emotions emerge and she decided she did not want to do that to her little girl self. Reflected on the care and attunement building within herself. Practiced in session remembering her 5-year-old self, fears/aloneness. When therapist said “I’m here with you” deep tears emerged. Client placed her hand on her chest in an effort to be with younger self. 9 extremely helpful Further development of self-care attunement to own pain, building skills of emotional regulation. 16 The client reported that she felt resistance (younger self) towards integrating with present-day self because her presentday self weighed too much compared to younger [2009] self. The client’s internalized body shame (both past and present) was identified as a barrier to present-day acceptance. 2 greatly hindering INTEGRATING EGO IDENTITY WITH LI THERAPY 17 Once collected from the past and in the present moment the client imagined being with her younger self and said “I would do it again because I love you. I am here to rescue you.” 272 9 extremely helpful Previously in the session the client had felt exhausted with the grief of what had happened, and this demonstrated a care and protective attunement continuing to develop for herself. 18 When bringing the 2-year-old through the timeline the little girl self was pleased (delighted) to know that as an adult she learned to ballroom dance. There were tears, and she felt herself as having fulfilled a childhood dream. 8.5 greatly to extremely helpful The client was able to view herself positively. 19 Client changed her ‘peaceful place’ to a mountain top not connected to any family or family members and helped her 11year-old “scream” out the anger from the top of the mountain. 9 extremely helpful Client gave herself permission to experience and express anger and spontaneously knew how she needed to change the imaginal environment to do that. 20 When encountering her 11-year-old self and the younger part’s anger, the adult self apologized to her saying, “I’m sorry” for silencing her and noted that “she had things that needed to be said”. 8.5 greatly to extremely helpful The client continued to connect with a part of herself that she felt she had silenced or not allowed to express itself following the return to Canada. 21 Showering her younger self in delight and noticing “She is really desperate for that”. Then younger self saying, “can we stay here a bit longer?” 8 greatly helpful Client was able to notice her need for attunement and direct that towards herself. She noticed that her younger self responded positively to that. 22 The client shared her concerns with the therapist and where she felt mis attuned to and insecure. This was important because it was an in vivo experience of using her voice (for the client) with a trusted other; something she had been working on imaginally. 9 extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 23 When connecting to 11-year-old self the child didn’t want to come into the present and return to the adult self’s home in present day. She agreed to go to the safe place. 273 6 slightly helpful Connecting in with the client’s voice/agency/resistance which seemed to have been thwarted when she returned to Canada. This also demonstrated some unreadiness to integrate with present self. 24 During the first timeline repetition while client and younger self were in the safe place, the client reported ‘losing’ her younger self and was unable to hold her younger self with her. Went back to the source memory to find her younger self. (None provided.) The more work done with 11-year-old part it becomes more clear how much fragmentation and unresolved emotion is connected to this age/stage/part. While it was unhelpful for the process of integration it was also meaningful or important to get a better sense of the depths of the challenge the client has with connecting to this part of her and the pain she must have been carrying at that time and state. 25 The client was initially unable to stay in her adult self while revisiting her younger self – shared that with the counsellor – the client did bilateral stimulation with her eyes open while therapist read the cues. 7.5 moderately to greatly helpful Client was able to stay more present and was able to identify she felt disconnected from present self. 26 The 6-year-old, when ‘back in the memory’ had a knowing – “I’m ok, Rose is coming” about older self. The memory changed and the younger self felt protected. 8.5 greatly to extremely helpful The younger self appeared to feel reassured, knowing implicitly without being prompted that she was not alone and someone was coming for her. 27 After the client ‘brought her 11-year-old self home’ integration began to occur, and the client was able to be both her adult self and child self. Reassured her child self “we are 45 now” and “we have choices now”. 8.5 greatly to extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 274 Client was able to reassure herself and connect to experience in the present that the pain was over, and life is different now. There was a big release of sadness/tears/grief at that point – body visibly let something go. 28 When back in source memory fear came up, [2-year-old feared that mom wasn’t able to come to help her because] “mom is dead” – client found it hard to stay with her child self. When going through timeline was shaking/tightening various point in her body intermittently. Seemed to access core fear/memory about aloneness. Client appeared to be activated but able to stay within her window of tolerance. 29 Client reported wanting to be “free” and heal her pain but realizing that she may have to acknowledge family wounds to do so – “to tell the truth about my pain is to break a family rule.” The fear appeared to be a 3 in the moment ultimately 7.5 because of the ability to integrate an early/core fear. 9 extremely helpful Client was able to identify a blocking belief/system from her family of origin which has impaired her ability to find/access her voice. Client is also expressing motivation/longing to move forward in her identity development and differentiation. 30 Bringing 2-year-old to present, was able to hold her and cuddle her on the couch. Said to child self, “We don’t have to take care of mom.” 8.5 greatly to extremely helpful Client and therapist hypothesized that this experience may have been connected to the belief, “I have to take care of mom, so I can’t tell her how I really feel about things,” or “there isn’t space for my feelings.” 31 Both parts (adult and child) were delighted about her timeline, specifically teaching line dancing at her 40th birthday. She noted that when merging she felt herself “fully bringing it all into herself.” Client demonstrated a delight/pride in her own story, appeared to integrate in a way which felt ‘deeper’ and more wholistic (including somatic). 8 greatly helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 32 Client appeared to have cathartic emotional release when hearing about what she had done. Really ‘took in’ her ability to heal, change rules around sexuality, emotions, voice, family rules, etc. Feels grown-up and her age. 275 8.5 greatly to extremely helpful Client appeared to realize in a new way the magnitude of the work she has done and feel the goodness of herself while also feeling some grief about how long she went without it. Table Q2 Therapist Reported Additional Helpful Event on the TSNQ form Session Rating 1 Client introduced me to ‘Rose,’ the ‘Rag Doll’ which she will bring to therapy. 8 greatly helpful 2 Client reported wanting to “stay there” in the therapist’s arms, describing how relaxed and at ease she felt being able to “just be.” Body appeared still and at ease. 8.5-9 extremely helpful 3 The client reported feeling that as a baby she did not want to be held by her adult self, even though her adult-self wanted to hold the baby. Although not an enjoyable sense, this is helpful for directing (indecipherable). 6 slightly helpful 4 Client reported feeling able to imagine, even sense, herself as the baby in my arms. Client reported having lots of unnamed emotion emerge when I used her name to speak to the baby. 9 extremely helpful 5 None reported. 6 The client asked the therapist to imaginally yell at her father for her, on her behalf, when going back in time. This occurred after the second repetition. Client expressed anger which has been difficult for her to feel in response to her parents. 8 greatly helpful 7 After the 3rd repetition collected her younger self from the past with attunement and said to her younger self, “I see you and know you.” 8.5 greatly to extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 276 8 After 3rd repetition, when remembering the event, she imagined her present-day self punched the man who assaulted her, accessing a protective part on her own behalf. 9 extremely helpful 9 The client was able to identify somatic markers at the end of each timeline – while the physical sensations seemed uncomfortable it was clear she was tuning into her body. 7.5 moderately to greatly helpful 10 The client reported having an insight at the end of session realizing in the past she had faked illness to receive care. This insight came after holding herself at the end of a timeline repetition. 8.5-9 greatly to extremely helpful 11 Client was able to know that present-day home has never been entered by the person who sexually assaulted her. 8 greatly helpful 12 At the end of the session the client shared that it seemed weird to experience integration as it meant the younger self was always with her, including her emotions, but stated that she was able to accept that because, “it’s me”. 8 greatly helpful 13 Client reported needing to change her safe place form a place where her parents would be (at lake) to a mountain top where it is just her and herself. 7.5 moderately to greatly helpful 14 None reported. 15 The client and therapist ended the session with a ‘celebration’ meditation to reflect on and savour experiences of care and attunement to self. 16 After the second timeline the client was able to spontaneously 7.5 reassure her younger self by saying “things will change, we’ll work moderately on it.” to greatly helpful 17 After the second timeline repetition the client expressed grief and 8 began crying heavily ad said, “why did we have to be so strong and greatly courageous?” helpful 7.5 moderately to greatly helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 277 18 Integration appeared to begin to happen on second time through timeline. Sometimes she was side by side with her younger self, sometimes she was her younger/adult self at the same time. 8.5 greatly to extremely helpful 19 The client imagined her younger self expressing her anger in their family home – without holding back – was surprised by the power of her 11-year-old self. The next repetition she expressed her feelings of anger as related to the experience of not being able to go back to Mexico. 8 greatly helpful 20 On the second time through the timeline the client reported that there 11-year-old self did not feel she needed more repair from her older self; that the younger self ‘knew’ the things she previously didn’t know. 8 greatly helpful 21 Client and younger self were in the present at her present-day home playing and singing together. Client reported feeling really present with her younger self. 6 slightly helpful 22 The client identified that the sense of insecurity she felt was connected [to] a 4- or 5- year-old part; was able to connect with that part. Little girl was hiding in a closet. / Little girl self wanted to connect with the therapist; this occurred after the client attuned and connect her younger self. 7 moderately helpful 23 At the end of the second timeline the adult self was able to stay attuned to 11-year-old self and provide her with physical affection. Client noted that that was lost upon returning to Canada. 7.5 moderately to greatly helpful 24 The client began to cry when the therapist reminded her and her younger self that any questions were ok at any time – it appeared from her body/breath/tears as if a release occurred when hearing that. 7.5 moderately to greatly helpful 25 Client was able to bring her 11-year-old self into her present-day home and sit next to each other on the couch, and in the end was able to experience integration. 8 greatly helpful 26 The client reported trying to support her younger self to speak up in response to her mom (in the memory). They appeared to both find that difficult. In the repetition process, younger self was eventually able to say something to mom. 8 greatly helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 278 27 The client noticed that when bringing her 11-year-old home the second time that she was more curious. Stated, “I’m sorry you lost mom and dad when we came back from Mexico, but we have friends now. You are not alone.” 7 moderately helpful 28 None reported. 29 The client was able to notice/identify/name for herself a new ‘rule’ moving forward = “I can tell the truth about my experiences AND love my mom and dad”. Realizing that those don’t need to be in conflict. 9 extremely helpful 30 Client demonstrated the ability to hold within herself the knowing that she both loved her parents and they loved her, and they weren’t perfect. Client was able to tolerate the pain of this. 8 greatly helpful 31 During second retrieval, 2-year-old spontaneously jumped into her mother’s arms and asked, “Did I do something wrong?” and mom said “No”, that her heart was just hurting. 8 greatly helpful 32 Client was able to stay with (to tolerate her delight and positive affect towards herself and from the therapist, while deepening it in mindfulness exercise. 7 moderately helpful Table Q3 Therapist Reported Hindering Event on the TSNQ form Session Rating 1 None reported. - 2 None reported. - 3 None reported. - 4 Client reported feeling some unknown reaction (a mix of a variety of feelings, some enjoyable, some not) when seeing me kiss the baby doll’s forehead. 3.5 slightly to moderately hindering. After the third repetition the client appeared dissociated and reported feeling physical distress. When supported to come ‘into the room’ demonstrated a ‘freeze response. 2 greatly hindering None reported. - 5 6 INTEGRATING EGO IDENTITY WITH LI THERAPY 279 7 After second repetition client realized a “fear of dad” which felt was both younger and older parts experiencing fear. Client seemed to want to focus on care for self but also like she had not voice when being in the imaginary version of the past. 2.5 moderately to greatly hindering 8 When remembering the event client appeared acutely distressed – shifting in seat, grasping arms of couch with white knuckles, short of breath, appeared to be re-experiencing some of the event. 2 greatly hindering 9 None reported. - 10 At the beginning of a timeline repetition the client’s body appeared 3 moderately to be extremely agitated, her hand contracting and flexing seemingly without voluntary control. hindering 11 Client reported some discomfort with merging; less about merging (None itself but experiencing some sadness to realizing that it is her story. provided.) 12 Client appeared to find it difficult at points to stay with the timeline and in it (may have been flooding or another distractor part inside). 4 slightly hindering 13 The client appeared to become stuck in the story and the affect of the trauma at the beginning, opening her eyes and stat that there is a “wall” going up, and her younger self won’t leave the environment. (None provided.) 14 Client described feeling as if she was “emerging” and not yet certain how to cully embody her voice and agency. 4.5 slightly hindering to neutral. 15 None reported. - 16 After the first timeline the client reported (and demonstrated para verbally and nonverbally) her inability to articulate a question. The therapist regulated her, and she was able to ask a question from younger self “will anyone love me?” While this could be identified as unhelpful, in a way her question (once regulated) proved to be an important question underlying her shame. (None provided.) 17 During the first timeline, the client reported ‘losing’ her younger self and having trouble connecting to herself. 3.5 moderately to slightly hindering INTEGRATING EGO IDENTITY WITH LI THERAPY 280 18 It was possible that the client was outside her window of tolerance during the first timeline repetition when connecting with her toddler self. 4 slightly hindering 19 None reported. - 20 None reported. - 21 Client reported feeling extremely uncomfortable with the therapist’s delight in her and the changes that are occurring. She commented that it felt too big for her when asked to meta process it. 3 moderately hindering 22 None reported. - 23 Client’s 11-year-old self was unready to come into the present moment and integrate. 4-4.5 slightly hindering to neutral 24 After the second timeline the client reported feeling as if things had integrated, however the way she described what was happening suggested she may have been ‘stuck’ in her adult self. (None provided.) 25 None reported. - 26 After saying things to her mom, younger self appeared afraid and concerned about having upset her mother; wanted to know if her mother would forgive her. Adult-self had to reassure child-self. 4 slightly hindering 27 The client was visibly concerned (afraid?) when talking about the upcoming ending. We queried how this might impact work moving forward. 4 slightly hindering 28 In the present with child self, client found it very difficult to use her voice or confront her parents imaginally. She appeared stuck and immobilized almost. 2.5 greatly to moderately hindering 29 Client described an overwhelming guilt about expressing her feelings, if they might be perceived as critical of her parents, almost self-silencing in session as if her parents were listening. 2.5 greatly to moderately hindering 30 During first timeline, client was unable to share the memory at first. Appeared to be speechless/immobilized. 3 moderately hindering INTEGRATING EGO IDENTITY WITH LI THERAPY 281 31 None reported. - 32 Client expressed fear of losing her new found groundedness – occurred near the beginning of the session. (None provided.) INTEGRATING EGO IDENTITY WITH LI THERAPY 282 APPENDIX R Enhanced Reflexivity Feedback Resonance: “the audience [being] able to enter into, engage with, experience or connect with the writer’s story on an intellectual and emotional level…a sense of commonality between the researcher and the audience,” (LeRoux, 2017, p. 204).  Use of narrative voice to establish a sense of commonality with the audience connecting them with the narrator’s story and engaging them in dialogue with the text (Brown & Gilligan, 1992; McLeod, 2013).  the use of provocative imagery and language and audience-directed questions18 to engage the reader in personally encountering the text and dialoguing with the text. Credibility.       18 audience’s sense of “verisimilitude, plausibility, trustworthiness,” as they encounter the narrator through the text. Did the narrative follow a logical sequence of events and ideas? Was the narrative coherent? Did it appear honest? Did it mirror reality or appear fantastical? Use of audience-directed questions were originally included in the first draft of the enhanced reflexivity chapter but were removed based on negative feedback regarding their purpose and effect received from volunteers filling out these forms. INTEGRATING EGO IDENTITY WITH LI THERAPY 283 Ratings for Feedback Rating Resonance Complete Resonance 4 – Clear narrative voice – clearly identifiable universal themes – effective use of provocative language19 and imagery – effective use of audience-directed questions Substantial Resonance 3 – clear narrative voice – identifiable universal themes – generally effective use of provocative language and imagery – generally effective use of audiencedirected questions Moderate Resonance 2 – unclear narrative voice – universal themes difficult to identify clearly – limited effective use of provocative language and imagery – limited effective use of audiencedirected questions Limited Resonance 1 19 – absence of clear narrative voice – limited identifiable universal themes – ineffective use of provocative language and imagery – ineffective use of audience-directed questions Credibiilty Complete Credibility – Highly logical sequence of events and ideas – Highly coherent narrative – High degree of honesty – Mirrors reality Substantial Credibility – Logical sequence of events and ideas – Coherent narrative – Honest – Mirrors reality Moderate Credibility – Somewhat logical sequence of events and ideas – Somewhat coherent narrative – Lacking in degree of honesty – Leaning towards fantastical versus mirroring of reality Limited Credibility – Limited logical sequence of events and ideas – Limited or incoherent narrative – Lacking honestly – Fantastical Similarly, the criteria of including provocative language was removed based on feedback on the effectiveness of the imagery. The overall sense was that further provocative language was not needed. INTEGRATING EGO IDENTITY WITH LI THERAPY 284 RATINGS: RESONANCE 4 3 2 1 3 2 1 Narrative voice: Universal themes: Provocative language and imagery: Audience-directed questions: OTHER COMMENTS: CREDIBILITY 4 Sequence of events and ideas: Coherent narrative: Honesty: Reality vs fantasy: OTHER COMMENTS: INTEGRATING EGO IDENTITY WITH LI THERAPY 285 APPENDIX S20 Rich Case Record – Rose Principal Reflexive Investigator: Sharon Macfarlane Thesis Supervisor: Dr. Janelle Kwee Trinity Western University 20 As an existing document compiled during data analysis, the Rich Case Record included here does not follow APA formatting but (unless otherwise noted) is presented exactly as was provided to case development teams and adjudicators. INTEGRATING EGO IDENTITY WITH LI THERAPY 286 TABLE OF CONTENTS Overview ..........................................................................................................................291 Outline of Data Collected During the Study ........................................................292 Background Information .................................................................................................293 Therapist ..............................................................................................................293 Clinical experience.......................................................................................293 Lifespan Integration Therapy training and experience ................................293 Research training and experience ................................................................293 Participant ............................................................................................................293 Demographics ..............................................................................................293 TCK Experience............................................................................................294 Repatriation stresses.....................................................................................295 Pertinent personal history ............................................................................296 Counselling history ......................................................................................297 Pertinent family history and dynamics ........................................................297 Current functioning at time of entry to therapy ...........................................298 Other social support .....................................................................................299 Personal Questionnaire (PQ) Results ...............................................................................299 Innovations ...........................................................................................................299 PQ items ...............................................................................................................301 Logistics of daily PQ data set ..............................................................................302 Daily PQ ratings ...................................................................................................302 PQ summary report ratings .................................................................................306 INTEGRATING EGO IDENTITY WITH LI THERAPY 287 Observations and comments about PQ ratings over course of therapy ...............308 Session Summaries ..........................................................................................................309 Overview .............................................................................................................309 Session 1 ......................................................................................................309 Session 2 ......................................................................................................310 Session 3 ......................................................................................................311 Session 4 ......................................................................................................313 Session 5 ......................................................................................................314 Session 6 ......................................................................................................315 Session 7 ......................................................................................................316 Session 8 ......................................................................................................317 Session 9 ......................................................................................................318 Session 10 ....................................................................................................320 Session 11 ....................................................................................................321 Session 12 ....................................................................................................322 Session 13 ....................................................................................................324 Session 14 ....................................................................................................325 Session 15 ....................................................................................................327 Session 16 ....................................................................................................328 Session 17 ....................................................................................................329 Session 18 ....................................................................................................330 Session 19 ....................................................................................................332 Session 20 ....................................................................................................333 INTEGRATING EGO IDENTITY WITH LI THERAPY 288 Session 21 ....................................................................................................335 Session 22 ....................................................................................................336 Session 23 ....................................................................................................338 Session 24 ....................................................................................................339 Session 25 ....................................................................................................341 Session 26 ....................................................................................................342 Session 27 ....................................................................................................343 Session 28 ....................................................................................................345 Session 29 ....................................................................................................347 Session 30 ....................................................................................................348 Session 31 ....................................................................................................349 Session 32 ....................................................................................................350 Life events during therapy ..................................................................................353 Change Interview .............................................................................................................354 Overview .............................................................................................................354 Summary of change interview qualitative responses ..........................................354 Summary of change interview quantitative and explanatory evidence ..............363 Mid-Therapy ................................................................................................363 Post-Therapy ................................................................................................368 Follow-up .....................................................................................................371 Ego Identity ......................................................................................................................374 Journal entries and personal communication ......................................................374 August 11, 2018 ...........................................................................................374 INTEGRATING EGO IDENTITY WITH LI THERAPY 289 August 20, 2018 ...........................................................................................374 September 22, 2018 .....................................................................................375 October 11, 2018 ..........................................................................................376 November 9, 2018 ........................................................................................376 December 8, 2018 ........................................................................................377 January 17, 2019 ..........................................................................................377 January 20, 2019 ..........................................................................................378 January 23, 2019 ..........................................................................................378 February 10, 2019 ........................................................................................379 February 13, 2019 ........................................................................................380 February 21, 2019 ........................................................................................380 February 27, 2019 ........................................................................................381 March 9, 2019 ..............................................................................................382 March 19, 2019 ............................................................................................383 Video clips ..........................................................................................................385 RCR APPENDIX A: Detailed PQ results graphs ............................................................387 RCR APPENDIX B: PQ ratings comparison graphs: daily vs pre-session summary .....411 RCR APPENDIX C: Mid-therapy change interview -full transcript...............................419 RCR APPENDIX D: Post-therapy change interview - full transcript .............................463 RCR APPENDIX E: Follow-up change interview - full transcript .................................486 INTEGRATING EGO IDENTITY WITH LI THERAPY 290 INTEGRATING EGO IDENTITY WITH LI THERAPY 291 Overview Therapy Client:  Rose (see details under Background Information below) Therapist:  Hillary McBride (see details under Background Information below) Clinical and Research  Dr. Janelle Kwee supervisor Length:  32 sessions  10 months (May 2018-February 2019) Format:  Sessions 1-14: in-person in Vancouver  Sessions 15-32: online via Zoom (web-based video conferencing system) Broad Goals:  Desire to connect parts: little Rose and big Rose to feel connected.  There was a core self before moving back to Canada. She felt like she had to “cut off parts of [herself] to be in Canada".  Desire to decrease shame and fear. Specific Goals: Specific goals were identified through the Personal Questionnaire measures as outlined below in the section Personal Questionnaire (PQ) Results, p. 270. INTEGRATING EGO IDENTITY WITH LI THERAPY Outline of Data Collected During the Study RCR Figure 1. Flow of data collection during study. 292 INTEGRATING EGO IDENTITY WITH LI THERAPY 293 Background Information Therapist Training and  credentials:   Clinical  experience: Lifespan  integration therapy training  and experience:   Research training  and experience:   Expertise:        MA in Counselling Psychology (TWU) PhD in Counselling Psychology student (UBC) Registered Clinical Counsellor 7 years of clinical experience Completed beginning and advanced training (now known as Level 1 & 2) Not certified Has received LI therapy in personal counselling Utilizes LI approximately 3-5 session/week since being trained Training in graduate level course work (MA and PhD level) in research methods, design and analysis (8 full courses) Conducted her own research-based thesis as part of her MA studies Currently working on her PhD research-based dissertation Developmental transitions throughout the lifespan (with a focus on women) Eating disorder and body image Embodiment Trauma (single incident and complex; historical and recent) Prenatal mental health Sexual functioning Shame and healing one’s relationship with self Participant Demographics: Birth year: 1974 Country of birth: Canada Ethnicity: White – Caucasian Spirituality: Christian - evangelical INTEGRATING EGO IDENTITY WITH LI THERAPY 294 Current age: 45 Age at time of participation in research: 44 at start of therapy and celebrated 45th birthday near the end of therapy. Current occupation: student (graduate school) and administrative assistant (non-profit). Previous occupation (s): Elementary school teacher (19972013); Administrative Assistant (2013-2016) TCK experience: Cross-cultural transitions with ages Aug. ’78-June ’79 (age 4-5): First move to Mexico. One-year in Guadalajara. Attended a small private international kindergarten. June ’79 (age 5): Move to an apartment complex in Mexico City. Begins attending Edron Academy, a British international school in the city. Dec. ’79 (age 5): One month in Canada (Toronto). Dec. ’80 - Aug.. ‘81 (age 6-7): Eight months living on site at Camp Kikoten (camp her father directed) about 1.5 hours outside of Mexico City. Rose was home schooled by her mother. Sept. ’81 – Jan. ’82 (age 7): Five months in Canada (Toronto) while her mother recovers from a medical procedure. Attends the first half of grade 2 in the Canadian school system before returning to Mexico City. May – Aug. ’82 (age 8): Four months in Canada and the USA with her mother and sister. Return to Mexico City to a new house, renting a suite from a lady at their church. Nov. ’83 (age 9): Family attends a camping conference in Wheaton, IL. Dec. ’83 (age 9): One month in Canada for the holidays. May ’84 (age 10): Rose and her family move to Toronto for a 1-year furlough or home service. Although grade 5 age Rose starts the school year in grade 6 due to differences between the Canadian and British school systems. INTEGRATING EGO IDENTITY WITH LI THERAPY 295 Feb. ’85 (age 11): Rose’s parents announce that family will not be returning to Mexico and are remaining in Canada permanently. Rose describes this announcement and the consequences of it as traumatic. NOTE: Not all of family trips to the US border to renew their missionary visas (only valid for 6 months) are indicated in the timeline above. While at times these trips coincided with events listed above, a few times they were separate trips, usually 1-2 weeks in length across the border in Texas. Repatriation stresses: Repatriation to Canada, especially once the announcement of never returning to Mexico was made, came with numerous losses – physical possessions that got left behind, people and places Rose never had a chance to say good-bye to, friendships she lost, as well as her identity, her sense of belonging, and her sense of safety. In Mexico, Rose was considered beautiful, had special status, and felt important. She had adventures both in the city, at camp and as her family travelled. At age 10 she was still playing superheroes, cops and robbers, and other childhood games with her friends. At this age she was also just starting to discover boys and was considered desirable as a girlfriend. Rose reports having 2 best friends: one at school and one at church. While she understood that Mexico was a dangerous place as a white ‘American’ girl, she felt safe and life was both exciting and familiar and known. In Canada, Rose no longer had special status but quickly found out she was looked upon as an outsider, less than average. While she could be friendly with people from different social groups, she belonged to none. She was ignorant of Canadian cultural references to movies, TV shows, music groups, etc. which again set her apart as an outsider. Canadian kids in grade 6 were very fashion conscious so wearing second-hand clothing further marginalized her from certain social circles. She also discovered that they were much more advanced in boy-girl relationships and she was no longer considered attractive/beautiful nor dating material. Kids also played differently in Canada and she found herself having to ‘grow-up’ quickly. Additionally, she discovered that Canadian friendships were connected with social status. She had several friends that first year who ‘un-friended’ her when they gained more social status. Life INTEGRATING EGO IDENTITY WITH LI THERAPY 296 in Toronto those first 4 years still had some elements of adventure and excitement but that all disappeared when her family moved to London, ON. With her mom struggling with burn-out and being emotionally unavailable, her dad on the road with a new job, and losing the previously close connection with her sister Rose reports feeling alone, on her own, helpless and terrified. She recalls crying herself to sleep many nights afraid to be awake while the rest of her family slept. In an effort to gain control of her circumstances and cling to elements of life that were familiar and known Rose threw herself into academic and spiritual pursuits. What she discovered is that it also wasn’t ‘cool’ to be smart or spiritual in Canadian society. Rose also learned the value of being extroverted and the use humour as coping mechanisms in interpersonal relationships. Pertinent Personal History: Continued transitions in Canada:  Sept. ’87 (age 13): Rose starts grade 9 at new school in Toronto.  Summer of ’88 (age 14): The family moves to London, ON and Rose starts grade 10 at a new high school.  Sept. ’90 (age 16): Rose’s sister starts University in a different city (4hour drive away).  Sept. ’92 (age 18): Rose starts her University studies in London, ON.  Aug. ’96 (age 22): Rose moves to St. Catharines to complete her Bachelor of Education.  Jan. ’09 – June ’10 (age. 35-36): Rose serves as the ministry leader to pilot a 12-step recovery program for the youth in her church community. Secondary Trauma:  May – Aug. ’09 (age 35): Rose finds herself involved in a manipulative and abusive relationship (her first male-female relationship). Sexual assault.  Sept. ’10 – Aug. ’11 (age 36-37): Rose is off work and on disability for the school year due to anxiety and panic attacks. She is diagnosed with major depressive episode and general anxiety disorder with some agoraphobia by a psychiatrist and begins taking medication for the anxiety (Pristiq). INTEGRATING EGO IDENTITY WITH LI THERAPY  297 Sept. ’11 – June ’12 (age 37-38): Rose gradually returns to work as a volunteer. Other ‘milestone’ events:  May ’13 (age 39): Rose submits her official resignation from the board of education. She decides to pursue a career in counselling/psychotherapy and begins taking pre-requisite courses for application to the MA Counselling Psychology program at TWU.  Feb. ’14 (age 40): Rose throws a big party for herself to celebrate her 40th birthday (65 guests, fancy venue, catered, DJ, dancing, board games). Having not married she describes this as her ‘pseudo-wedding.’  July ’16 (age 42): Rose drives across Canada on her own from Ontario to BC.  Sept. ’16 (age 42): Rose begins her studies for the MA in Counselling Psychology program. Counselling history:      Fall ’04 – Spring ’12 (age 30-38): Rose attends a God-centered 12-step multi-issue recovery program at her church. 2006-2018: Rose attends weekly or bi-weekly individual counselling with 5 different clinicians (not including this study). Rose works for 6 years (summer ’09 – spring ’16) with the same therapist processing the trauma of the sexual assault and abusive relationship. Spring -Fall ’11: Rose is required by insurance to see a psychologist while on disability (about 10 months). Continues to engage in individual counselling at the same time. Winter/Spring ’13: Had several appointments with a counsellor from the sexual assault centre for assistance in reporting the assault to the police. Pertinent Family history and Dynamics:   Rose’s maternal grandparents worked as missionaries in South America which makes her mother also a TCK. Her mother was born in Argentina and lived between Canada, Argentina and Paraguay from ages 0-17. Rose has one sister who is 2.5 years older. They were very close when living in Mexico, but gradually became more distant upon moving to Canada, especially when her sister moved away for University. They reconnected about 18 years when they bought a home together and lived INTEGRATING EGO IDENTITY WITH LI THERAPY     298 together for 15 years. Neither herself nor her sister are married or have children. Rose’s mother has briefly described experiencing symptoms of burn-out or potentially undiagnosed anxiety and/or depression when the family returned to Canada in ’84. Rose’s father was born and raised in small town Ontario. When they moved to Canada and resigned from the mission organization, he attained a job as the Eastern Canada representative for another non-profit organization. This position, which he began when Rose was in grade 10 621, took him frequently on the road for weeks at a time. In Rose’s 3rd year of University her dad changed positions within the organization greatly reducing his need for travel and increasing his time at home with the family. Rose describes her family as close meaning that they keep in contact with each other, generally spend holidays together (Easter, Thanksgiving, Christmas) and also often vacation together. Rose’s move to BC has made sharing physical time together more difficult, but not impossible (Rose’s mother and sister came out to visit in April ’17, and her sister came out again for some vacation time together in Aug. ’18). Rose does not describe her family as emotionally close meaning they do not generally share or discuss personal (more private) thoughts, feelings and experiences with each other. Current functioning at time of entry to therapy:    21 Rose had no observable significant impairment in social and academic functioning at time of entry to therapy. She reported experiencing significant levels of anxiety and intermittent episodes of what she referred to as “panic attacks” – paralyzing fear and anxiety which often prevented her from handling life stressors. She also reported experiencing difficulties changing disruptive thoughts and behavioural patterns she desired to see changed at this time. Case development teams were given copies of the RCR indicating that this started when Rose was in grade 10, however this was an error. Rose’s Dad began this position when she was in grade 6. Adjudicators were notified of this correction via email communication in the event that it impacted their decisions. INTEGRATING EGO IDENTITY WITH LI THERAPY 299 Other social supports:     Rose lives on her own. Due to her recent relocation to BC and the demands of her master’s program Rose’s social support system is currently limited to friends she has met through school. Two important friendships Rose continues to foster are with classmates Kristin and Vanessa. They were a significant support for her before, during and after therapy. She attended a church community with a classmate for a couple of years but did not have time to get involved due to her studies and has not attended since her friend graduated almost 10 months ago. Personal Questionnaire (PQ) Results Innovations For this study we introduced daily tracking of Personal Questionnaire (PQ; Elliot, Mack, & Shapiro, 1999) items after session 222 (May 15th) in addition to pre-session summative reports of PQ items for increased accuracy in measuring levels of distress. Daily tracking tracked both the intensity and frequency of experienced distress for each PQ item. The mean ratings of daily PQ items over for the period in between counselling sessions was used in filling out the pre-session summative reports. One particular exception in rating is PQ item 11 where intensity rating reflects occurrence of behaviour rather than level of distress. PQ item 6 tracked a mix of both level of distress and occurrence of sleep interruptions. PQ items 15 was also unique in that positive change in original ratings was reflected in an increase in ratings, which was added to the list at the mid-therapy point, after the first Change Interview As daily ratings were found to more accurately and precisely reflect levels of distress and occurrences of behaviours, the data contained in this record has focused on this data set. Pre-session summative report PQ scores are also included for your reference and a comparison of daily and summative PQ scores included as an appendix. 22 Note: There is therefore no daily PQ data available between May 18th (start of therapy) and May 25th (session #2). Intersession mean values therefore begin at session 3 (June 12th). INTEGRATING EGO IDENTITY WITH LI THERAPY 300 Previously, PQ items were rated retrospectively by Rose in completing a summative report at the beginning of each therapy session reflecting perceived levels of distress on PQ items over the past seven days (Elliot, et al., 1999; see Appendix E). In instituting daily tracking of PQ items data will more accurately reflect actual levels of distress across time in being a summary of 24 hours versus a retrospective evaluation of a 7-day period. In addition, in instituting tracking of intensity and frequency of distress this data should provide a less skewed portrayal of overall distress in not overinflating the significance of single episodes of high distress over and above general patterns of low distress. Mapping out this data across time will also afford greater accuracy in tracking patterns and significant levels of change in PQ item scores. INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Items RCR Table 1. Rose’s individualized PQ items prepared before therapy began and tracked daily over the course of therapy. #1 I feel shame about who I am and who I've been #2 I'm not enough ('should-ing') #3 I feel I don't belong #4 I have a fear of failing at life #5 I have trouble feeling present in the moment #6 My sleep is interrupted #7 I self-sabotage my own goals (NOT FOOD) #8 I cannot make decisions #9 I am stuck in an avoidant pattern #10 I use food to cope with stress #11 I self-medicate my own pain with poor strategies (not level of distress) #12 I don't accept my limitations/weakness #13 I have a tendency to think in "all-or-nothing" #14 I don't feel confident in my own opinions/viewpoints #15 I authentically and voluntarily connect with God Legend More than 10 years duration. 6-10 years duration. 301 INTEGRATING EGO IDENTITY WITH LI THERAPY 302 Logistics of Daily PQ Data Set RCR Table 2. Summary of days missed and days with daily ratings for periods in between sessions. # of # days # of # days # of # days days with days with days with with missing with missing with missing Session data data Session data data Session data data 1 Summary only 14 4 0 26 12 2 2 Summary only 15 27 3 27 11 2 3 13 2 16 10 1 28 6 1 4 4 0 17 11 0 29 7 1 5 and 6 1 6 18 6 1 30 13 0 7 7 0 19 6 0 31 8 0 8 5 1 20 10 1 32 5 1 9 12 0 21 15 2 Post 1 6 1 10 3 0 22 7 4 Post 2 6 1 11 4 0 23 9 1 Post 3 7 0 12 3 0 24 11 4 Post 4 6 1 13 6 1 25 5 1 Post 5 6 1 Total days with 311 Total days with data 272 Total days without data 39 Daily PQ Ratings The first two figures below (RCR figures 2 and 3) graph out the mean rating of each PQ items for each intersession period. With 15 total PQ items it became too confusing to show them all on the same graph. For this reason, the items were split into two groups. RCR Figure 2 shows PQ items 1 to 8 and RCR figure 3 shows the results for PQ items 9-15. You’ll note that item 15 was added after the mid-therapy change interview so mean ratings aren’t available before session 15. The third graph provided below (RCR figure 4) shows the mean daily ratings for all PQ items together. Item 15 was not included in calculating these daily mean ratings as it was considered an outlier data set and significantly skewed the daily mean values. For this reason, it is presented separately. INTEGRATING EGO IDENTITY WITH LI THERAPY 303 RCR Figure 2. Tracking of intersession combined mean ratings for PQ items 1-8 over course of therapy. INTEGRATING EGO IDENTITY WITH LI THERAPY 304 RCR Figure 3. Tracking of intersession combined mean ratings for PQ items 9-15 over course of therapy. INTEGRATING EGO IDENTITY WITH LI THERAPY 305 RCR Figure 4. Tracking of daily PQ mean ratings across all items over course of therapy. RCR Figure 5. Daily PQ mean ratings across all items with outlier item 15 as a separate data set. INTEGRATING EGO IDENTITY WITH LI THERAPY 306 PQ Summary Report Ratings The following tables provide the PQ item ratings as recorded by Rose on the presession summary reports. To arrive at these ratings Rose used the intersession (days in between sessions) mean daily PQ rating as shown in example below. RCR Figure 6. Example of daily PQ ratings record showing mean values used for summary report. RCR Table 3. Tracking of pre-therapy summary report PQ ratings for each item over the course of therapy. PQ Items Session timeframe #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 1 6 5 5 5 4 6 5 3 4 5 4 5 5 5 2 6 6 5 5 4 5 5 4 5 4 6 5 5 6 3 6 6 5.5 5.5 5 5 4.5 4 5 4.5 6 4 5 6 4 4 4 3 2.5 1.5 6 4 2 3 4 3.5 2 4.5 3.5 5 and 6 6 6.5 6 5 6.5 5.5 5 4 4 5.5 3 4 5 5 7 4 3.5 3 2 4.5 4 2 2.5 1.5 3.5 5 2 2.5 3.5 8 3.5 3.5 1.5 2.5 4 4 3 3.5 3 4 5 1.5 3 4 9 3.5 4 3 3.5 3.5 4 3 2.5 3 4 1 3.5 4 4 10 2.5 2.5 1.5 1 3 7 1 1 1 5 3 2 1.5 1 11 4 3 2 2 3 6 1 1.5 1 3.5 6 2 1.5 2.5 12 2 2 1 2 1.5 3 5 2 4.5 3.5 5 2 2.5 4 13 2 2 1.5 2.5 1.5 3 2 1 2 4 3 2 2.5 2.5 14 3.5 3.5 3 3.5 3.5 4 2 2 1.5 2.5 1 3.5 3.5 4 15 2.5 3 1.5 2.5 1.5 4.5 1 2 1 1 4 2 2 1.5 6.5 16 3.5 4 2 3 1 5.5 4 1.5 3.5 3 6 2 2.5 2.5 6.5 17 2 3 1.5 2.5 2 4.5 2.5 2 2.5 1.5 4 1.5 2.5 2.5 7 18 2.5 2.5 1.5 1 1.5 5 1.5 1.5 1 2 1 2 1 2 6.5 19 2 3.5 1.5 1.5 2 4 2 1 2 1 2 2 2 2 7 #15 INTEGRATING EGO IDENTITY WITH LI THERAPY 307 Session timeframe 20 #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 #15 2.5 3.5 2.5 2.5 2 4.5 1 1 1 1 2 1.5 1.5 2.5 7 21 2.5 2.5 1.5 1 2 4 2 1 2 2 2 2 1 1 22 2.5 2 2 2.5 2 3.5 1 1 1 1.5 4 1.5 1 2 7 23 3 3.5 1.5 2.5 2.5 4 2 1.5 2 2 1 2.5 2.5 2.5 5.5 24 1.5 3 1 1.5 1 4 1 1 1 2 1 1 2 1.5 7 25 1.5 3 1 2.5 1.5 6 2 1 2 2 2.5 1 2 3 7 26 1.5 2 1.5 1.5 1 4 1 1.5 1 1 1 1 1 1 6.5 27 1.5 3 1.5 1 1 4 2 1 1 2 1 2 1.5 1 7 28 1 1 1 1 1 3 1 1 1 1 2 1 1 1 7 29 1 2 1 1.5 1 4 1 1.5 1 1 1 1 1 2 6 30 1 3 1.5 2.5 1.5 4 1.5 1 1.5 1 1 1 1 2.5 6.5 31 2.5 3 3 1 4 5 1.5 1 2 1 3.5 1 2 3.5 6.5 32 2.5 2 1.5 1 1 4.5 1 1 1 2 1.5 2.5 1 2.5 7 post 1 1 2 1 1 1 4 1 1 1 1 1.5 2.5 1.5 1 7 post 2 2 2 1 1.5 2 4 1 1 1 1 1 1.5 1 1 6.5 post 3 2 2 1 1.5 1 4 1 1 1.5 1 1 1.5 1 1 6.5 post 4 1.5 2.5 1 1 2 4 1 1.5 1.5 1 2 2 1 1.5 7 post 5 1 1 1 1.5 1 3 1 1 1 1 1 1 1.5 1.5 7 CHANGE: 5 4 4 3.5 3 3 4 2 3 4 3 4 3.5 3.5 0.5 INTEGRATING EGO IDENTITY WITH LI THERAPY 308 Observations and comments about PQ ratings over course of therapy.     23 PQ ratings demonstrated a pattern of significant decrease for almost all items with the exception of: o #823 which did decrease but not sufficiently to be significant (less than 2 points) o #15 which showed a pattern of increase over therapy. Patterns of change in ratings were realistic as they reflect the organic and naturalistic ups and downs of emotions and behaviours through the course of therapy, i.e., different areas of internal experience getting churned up at different points during therapy. Most items demonstrated a significant high point or peaking near the beginning of therapy which is consistent with being hyper-aroused as clinical work gets started. Item #15 was a target behaviour that was added at the mid-point of therapy. It is being considered an outlier data set as it did not demonstrate the same pattern of decrease as the remaining 14 items. Case development teams were given copies of the RCR indicating that PQ items #5 also did not decrease sufficiently to be significant. This was incorrect as it experienced a 2.2-point drop from pre-therapy to follow-up according to daily PQ ratings. Item #5 data was presented correctly in the case development briefs. Adjudicators were notified of this correction in the RCR via email communication to prevent any possible confusion. INTEGRATING EGO IDENTITY WITH LI THERAPY 309 Session Summaries In this section the data that is presented was collected from:  the post-session Helpful Aspect of Therapy (HAT) completed by Rose and recording important, helpful and hindering event from the session;  and the post-session Therapist Session Notes Questionnaire (TSNQ) filled out by Hillary McBride (therapist) documenting her session notes, LI protocol used, # of repetitions, and most important helpful and hindering events from the session. The session summaries are presented in chronological order from first (May 18th) to last (February 27th). SESSION 1 LI Protocol: None- intake session No. of TL repetitions: N/A May 18 Session Summary (with therapist session notes): 90 min. Intake session. Completed informed consent and got client history. Discussed client goals for therapy. Will start LI next session. [At exit:] Client seems willing, although nervous, about beginning this process. [Other:] Noticed client’s difficulty (sitting with) tolerating affect and using laughter to manage emotional distress. Client HAT form Most helpful/important event: When therapist noticed a swell of emotion in me and asked what was coming up for me and helped anchor that emotion in my body. Rationale for choice: It was important that she noticed the emotion – that she saw me in that moment of vulnerability. I was at a loss for how to describe the emotion, so she asked if it had body sensations that accompanied it. It did but I was at a loss for words to describe these, so she guided me to just point where it was, then describe if there was movement in these sensations. Eventually I was able to attach descriptive words to the emotion. Rating: 9 – extremely helpful Other helpful event: There were at least 2 similar events where the therapist reflected back to me what she heard me saying and she was bang on! I can’t remember the specifics of what was said but remember feeling known, heard, seen, understood. Rating: 8 – greatly helpful Anything hindering: Again, I don’t remember the specifics of what I was talking about but recall at least 2 times being quite confused by the serious expression on the therapist’s face as I shared something ‘lighthearted’ or shared something as I laughed. The therapist brain in me figures she was probably demonstrating a more accurate reflection of the emotional content of what I was sharing….BUT the client /human me still is confused. My thoughts immediately went to, “I must be doing something wrong,” without having a clue what that might be. INTEGRATING EGO IDENTITY WITH LI THERAPY 310 Rating: 3.5 – between slightly to moderately hindering Therapist TSNQ form Most helpful/important event: Client shared about her negative beliefs about herself, disclosed about her goals for therapy, and shared about some defensive strategies to manage stress. Rationale for choice: Helped me as the therapist begin to understand her internal working models, and what may need to be explored in this work, also built trust in our relationship. Rating: 7.5 – between moderately to greatly helpful Other helpful event: Client introduced me to ‘Rose,’ the ‘Rag Doll’ which she will bring to therapy. Rating: 8 – greatly helpful Anything hindering: None. SESSION 2 LI Protocol: Attunement protocol May 25 75 min. No. of TL repetitions: 3 Session Summary (therapist session notes): Began with a brief check in and a brief description of logistics. Client disclosed some fear about doing LI work, while also describing the feeling of “needing to.” Conducted attunement protocol … with use of baby. [Other:] Client appeared more settled affectively and somatically with less appearance of unsettledness or defensive humour or agitation. Session appeared to be helpful beginning to process of change. Client HAT form Most helpful/important event: The second time through the attunement protocol, when we brought my baby self to my apartment and met my adult self, I suddenly realized there was indeed a time in my life when I was 2 weeks old. I was once that young. There were tears, ache in chest, pressure behind my eyes at this realization (sadness?). Rationale for choice: I’m not sure I fully understand yet, but it was quite a revelation! I’ve internally conceptualized my life – at least from age 10 on – through the eyes of an adult – i.e., it feels like the 10-yearold ME is the same ME of today burdened by responsibilities. So, to envision a young, 2-week-old ME without the potential to be burdened, but merely the responsibility to BE was somehow heartbreaking and yet integral to seeing the whole me. Rating: 8 – greatly helpful Other helpful event: When the therapist was holding my baby self and described looking/gazing into my eyes and holding my fingers as I INTEGRATING EGO IDENTITY WITH LI THERAPY 311 watched her doing this, I was finally able to visualize myself as that little baby looking back at her and grasping her finger. It was the first real connection to my baby self. Rating: 9 – extremely helpful Anything hindering: Each time we went through the timeline I would nod to indicate that I had captured the event. At times this was distracting – trying to connect with events and remember to nod at the same time. I also wonder if it slowed the process a bit. Rating: 4 – slightly hindering Therapist TSNQ form Most helpful/important event: Client described sadness when seeing baby doll, even from first moment. Client reported feeling a sense of urgency to have the therapist care, come get her, and some fear in baby self-state about parents being present. Rationale for choice: This event reveals some implicit sadness the client experiences about herself and the desire to be cared for and held as a baby. Rating: 8 – greatly helpful Other helpful event: Client reported wanting to “stay there” in the therapist’s arms, describing how relaxed and at ease she felt being able to “just be.” Body appeared still and at ease. Rating: 8.5-9 – extremely helpful Anything hindering: None. SESSION 3 LI Protocol: Attunement protocol June 12 60 min. No. of TL repetitions: 2 Session Summary (therapist session notes): Client reported having a moment between the present session and the last session where she knew and felt the worth of her baby self as precious. Some sadness was reported when seeing baby as when client imagined me (therapist) holding her in the safe place. At the end, the client reported that her baby-self did not want to be to be held by her adult self in the present. [At exit:] Client reported feeling a sense of wordlessness about her experienced and displayed some relief at the suggestion that she spend time with her rag doll at home tonight. Appeared unresolved. [Other:] Some pieces may need to be resolved before integration can occur, including feelings about adult self; client also appears and reports having a difficult time believing the baby is her. INTEGRATING EGO IDENTITY WITH LI THERAPY Client HAT form 312 Most helpful/important event: Sharing my observation of the baby being so defenseless and how this came with a lot of somatic sensations and emotion. It was still difficult to put a label on the emotion, but fear seemed to fit. When the therapist asked if this fear was adult self or baby self it seemed to me to be both. Rationale for choice: This tapped into a core emotion – an emotional/ experiential pit (for lack of a better word) that sits at the very core of who I am or experience myself to be. Sharing that with another person, having them see/know that and care for me in that…well, I’m still not sure what that means but it felt powerful. Even just the act of my trusting my experience in the timeline enough to share my experience – trust my reality – adds a bit more strength and stability to who I am. Rating: 9 – extremely helpful Other helpful event: At the end I was confused because my adult-self wanted to hold my baby-self, but I also knew my baby-self did not want to be held by my adult-self. What was helpful is that the therapist took responsibility for worrying about and figuring out how to handle these conflicting desires. I didn’t have to figure it out. Rating: 8 – greatly helpful Anything hindering: I was late arriving for session, so we had less time. This mean we only got through the attunement protocol twice and things were just opened up when we had to shut down the session. A good reminder of the importance of being early/on-time.     Rating: 3 – moderately hindering Therapist TSNQ form Most helpful/important event: Client described feeling herself as the baby in my arms and imagined reaching out to grab my face to say “see me”; she reported feeling like this was a part of her baby self, in part her more adult self. Rationale for choice: This event represents the client’s deep implicit longing to be seen, and the sense of desperation about that. Rating: 7 – moderately helpful Other helpful event: The client reported feeling that as a baby she did not want to be held by her adult self, even though her adult-self wanted to hold the baby. Although not an enjoyable sense, this is helpful for directing ________. Rating: 6 – slightly helpful Anything hindering: None. INTEGRATING EGO IDENTITY WITH LI THERAPY 313 SESSION 4 LI Protocol: Attunement protocol June 15 75 min. No. of TL repetitions: 3 Session Summary (therapist session notes): Brief review of what has occurred since last session…attunement protocol, at the end the client held the baby. Lots of tears and emotion emerged. [At exit] Client appeared to experience some integration of baby self with adult self, and repair, love and warmth for self. [Other:] Client had a difficult time naming feelings between repetitions and at the end of the session. A milestone of integration occurred. Client HAT form Most helpful/important event: Holding my baby-self – I imagined holding my baby-self at the end of the timeline but then the therapist invited me to actually physically hold the baby doll. I burst into sobs as soon as I held her, and then remember bursting out with “She’s so beautiful!” Rationale for choice: I don’t even know exactly what happened or understand the tears, the emotions that came with that event but know something significant happened. Something deep within me was accessed and given space and voice in that moment. Rating: 9 – extremely helpful Other helpful event: I noticed that the therapist took us back to the peaceful lake setting frequently, especially in the third timeline. This was so important as I finally breathed and relaxed when we went to the lake. I could feel how hard I was working in between, and the break was glorious! Rating: 9 – extremely helpful Anything hindering: None. Therapist TSNQ form Most helpful/important event: Client took and held the baby self then exclaimed “She’s so beautiful!” acknowledgment that “she is the baby.” Rationale for choice: Client was able to feel love and admiration for younger self, demonstrated integration. Rating: 9 – extremely helpful Other helpful event: Client reported feeling able to imagine, even sense, herself as the baby in my arms. Client reported having lots of unnamed emotion emerge when I used her name to speak to the baby. Rating: 9 – extremely helpful Anything hindering: Client reported feeling some unknown reaction (a mix of a variety of feelings, some enjoyable, some not) when seeing me kiss the baby doll’s forehead. Rating: 3.5 – slightly to moderately hindering. INTEGRATING EGO IDENTITY WITH LI THERAPY 314 SESSION 5 LI Protocol: Basic protocol June 18 60 min. No. of TL repetitions: 6 Session Summary (therapist session notes): The focus of this session was on creating a baseline of integration. Client came in reporting feeling overwhelmed emotionally a mess. Baseline protocol was used…[with] no target. [At exit:] At the end of session, client appeared and reported feeling settled and present, however she also noted feeling slightly disconnected. Client HAT form Most helpful/important event: At the end of a timeline I was stuck/frozen, and it took me quite some effort to get back in the room. The therapist noted this and immediately addressed it therapeutically: 54-3-2-1 technique, exploring cause, next timeline was done walking around the room then progressively from sitting with eyes open for the next timeline, then sitting with eyes closed checking in on status of ‘stuckness’ at each timeline. (not sure if this description of what happened is 100% accurate). Rationale for choice: The stuckness/paralysis is not a new experience for me in therapy – happens frequently – but this is the first time I’ve experienced it as being normalized and therapeutically addressed in a significant manner. My reaction – stuckness – impacted how and what we did moving forward, not just talked about, but we did something. Rating: 9 – extremely helpful Other helpful event: The therapist shared her hypothesis of what had [me] hyper-aroused since our last session: AEDP explanation (defenses/anxiety/core affect triangle). This triangle not only helped me understand what was happening over the weekend but perhaps explain many of my life experiences. It fit really well and internally felt like a match. Rating: 8 – greatly helpful Anything hindering: Taking intermittent notes on her laptop (therapist) during break. It was both reaffirming that she was making note of significant factors for future reference, but the clacking of keys and the laptop screen between us was slightly unnerving. Rating: 4 – slightly hindering Therapist TSNQ form Most helpful/important event: Client reported feeling more present in the room, less tension in her body. Rationale for choice: After feeling dysregulated during the week, the client was able to experience some integration and regulation. Rating: 8 – greatly helpful Other helpful event: None. INTEGRATING EGO IDENTITY WITH LI THERAPY 315 Anything hindering: After the third repetition the client appeared dissociated and reported feeling physical distress. When supported to come ‘into the room’ demonstrated a ‘freeze response. Rating: 2 – greatly hindering SESSION 6 LI Protocol: Standard protocol June 22 60 min. No. of TL repetitions: 4 Session Summary (therapist session notes): The focus of the session was to use the standard protocol to return to a memory at 7 with her dad – the use of the affect bridge helped select the past memory connected to the present feeling of “dark swirling in the chest” and a feeling of shame. [At exit:] Client reported and appeared to be at ease. Was able to laugh about stomach noises [that happened during session]. Client HAT form Most helpful/important event: When I exclaimed, “She’s me!” Not just the declaration that my 7-year-old self is me, but the process of discovering this, coming to this realization – through my interaction with her in the timeline. Rationale for choice: Seeing how much my 7-year-old self and I had in common – she loves everything I do: jumping on beds, play-fighting, tickling, laughing, games, colouring. I can’t describe it well, but it was like discovering a ‘kindred spirit’ and realizing that person is YOU. Not odd, weird, bizarre but beautiful, full of life, joy, wonder. Rating: 8.5 – greatly and extremely helpful Other helpful event: I had something I needed my Dad to hear in my timeline (#2) but couldn’t say it myself and was struggling to find someone to bring into the scene to say it for me (therapist’s suggestion). Upon sharing this, the therapist suggested Jesus, but I’d already thought of Him and it didn’t work because Jesus doesn’t swear. So, the therapist wondered if it might work for me to bring her into the scene – and it did. It was so good to have the words spoken and not silenced. Rating: 8 – greatly helpful Anything hindering: I’m not sure if this count – fits the question – but I noted struggling against myself, my own perfectionism at time: Did I answer that question right? Can I trust my imagination? Do I admit I can’t speak? Desire to be a good client – something that has frequently been a battle in all my therapy – desire to ‘get it right,’ to ‘ follow the INTEGRATING EGO IDENTITY WITH LI THERAPY 316 rules.’ I’m much better at recognizing it and letting it go than I used to be – trusting my intuition, inner experience instead of silencing it – but it’s still there and was very present during this session (the last 2 actually). Rating: 3.5 – moderately and slightly hindering Therapist TSNQ form Most helpful/important event: The client reported (after 4 repetitions) that she felt she was the same person as her 7-year-old self. Her stomach made a loud noise as if to release something. Rationale for choice: The client reported feeling as if she has ‘merged’ her younger and present-day self. Rating: 8.5 – greatly to extremely helpful Other helpful event: The client asked the therapist to imaginally yell at her father for her, on her behalf, when going back in time. This occurred after the second repetition. Client expressed anger which has been difficult for her to feel in response to her parents. Rating: 8 – greatly helpful Anything hindering: None. SESSION 7 LI Protocol: Standard protocol June 30 60 min. No. of TL repetitions: 4 Session Summary (therapist session notes): Returned to the memory from the previous session (at 7 years-old – Holly Hobby gift) – completed repetitions. Fear of father came up. [At exit:] Client appeared present. Reflective. Client HAT form Most helpful/important event: When the therapist helped me answer my little girl’s question, “Are we okay?” I had no idea how to answer so the therapist prompted me to her [my little girl] know we are learning to be okay and that part of that process was coming back for her – my 7year-old self. Rationale for choice: The words the therapist said, and I spoke to my younger self were also very important for my adult self to hear. In a strange way it was liberating to NOT hear the therapist say, “Yes, we’re okay.” That’s what my mom would have said – or “You’re going to be okay.” But learning to be okay is different – recognizes current struggles (validates) while instilling hope for something better/different. Rating: 8 – greatly helpful Other helpful event: INTEGRATING EGO IDENTITY WITH LI THERAPY 317 1. When the therapist essentially asked if my adult self knows I don’t need to be afraid of my Dad – may emotional answer was unfortunately, no. 2. When I was with my 7-year-old self and told her “I see you. I know you. You are safe.” Spoke to the craving of my heart. Rating: 8 – greatly helpful Anything hindering: None Therapist TSNQ form Most helpful/important event: Client reported at end of session that she could remember the memory without emotional intensity, instead it felt ‘fainter.’ Rationale for choice: Demonstration of an integration of a memory, and the settling of her nervous system related to that event. Rating: 8.5 – greatly to extremely helpful Other helpful event: After the 3rd repetition collected her younger self from the past with attunement and said to her younger self, “I see you and know you.” Rating: 8.5 – greatly to extremely helpful Anything hindering: After second repetition client realized a “fear of dad” which felt was both younger and older parts experiencing fear. Client seemed to want to focus on care for self but also like she had not voice when being in the imaginary version of the past. Rating: 2.5 – moderately to greatly hindering SESSION 8 LI Protocol: Standard protocol July 5 60 min. No. of TL repetitions: 4 Session Summary (therapist session notes): After last session client reporting having bought Lego to connect with younger self. When anticipating dinner plans, she noticed sensation in her chest. Did affect bridge and revisited memory of being pushed against a car. [At exit:] Client reported that when thinking about dinner plans that evening, she no longer felt dysregulated, and that the memory of the assault felt more “flat.” [Other:] Client reporter that younger self “merged” with present self. Client made the connection between why memories which occurred after the assault also “stung” when reading timeline, because they were connected to the assault. After 2nd timeline the later memories also felt more neutral. Client HAT form Most helpful/important event: The therapist was very present with me as I tried to verbalize the scene (trauma). She said things like, “I’m right INTEGRATING EGO IDENTITY WITH LI THERAPY 318 here with you. You’re safe.” As I continued to struggle, she encouraged me to start with telling where the scene was taking place. Rationale for choice: Internally I was stuck/frozen, unable to speak but the therapist was attuned to this, recognized it, and was immediately there to support and help. At the same time, I never felt like she was judging me, nor did I feel abnormal for freezing – she was there for me in whatever way I showed up. We were in this together and she was right there with me. (Note: some previous therapy experiences I have been left in freeze to get out on my own which was not only difficult but isolating and the opposite of normalizing.) Rating: 9 – extremely helpful Other helpful event: When we got to the break after the first timeline, I shared that my younger self did not want to leave. The therapist responded in two way: 1) We jumped right into another timeline so Rose wouldn’t be alone; 2) at the end of this 2nd timeline she invited my younger self to come with us to the office for the break. The felt much safer. Rating: 8 – greatly helpful Anything hindering: None Therapist TSNQ form Most helpful/important event: Was able to reassure younger self that the assault was not her fault, and not because of her recent weight loss. Rationale for choice: Client had previously believed that the assault was her fault. Rating: 9 – extremely helpful Other helpful event: After 3rd repetition, when remembering the event, she imagined her present-day self punched the man who assaulted her, accessing a protective part on her own behalf. Rating: 9 – extremely helpful Anything hindering: When remembering the event client appeared acutely distresses – shifting in seat, grasping arms of couch with white knuckles, short of breath, appeared to be re-experiencing some of the event. Rating: 2 – greatly hindering SESSION 9 LI Protocol: Standard protocol July 17 60 min. No. of TL repetitions: 3 Session Summary (therapist session notes): INTEGRATING EGO IDENTITY WITH LI THERAPY 319 Since last appointment, client reported having a few panic attacks but noticed feeling more “grounded” and less “chaotic” than before. Began more work around integration of the assault(s) beginning 2009. [At exit:] Client reported feeling activated but described being able to manage and handle it. Client HAT form Most helpful/important event: I was sharing some changes and shifts that I had noticed happening and the therapist was quite excited to hear of all that was happening. Then she asked me, “Are you able to take that [her excitement] in?” As this discussion progressed, she mentioned that we were building an attachment relationship. Rationale for choice: While I gave some sort of answer in session, the truth I was not willing to admit was that I had no idea what she was asking. I understood her excitement, I tentatively believed it to be genuine (which I shared) but what did she mean by “take it in”? This is important because I’ve always felt there were certain interpersonal dynamics I didn’t comprehend, and this was one of them. I think she was asking if I could own her excitement as real, internalize her excitement for me. I also had no clue what she meant by an attachment relationship – conceptually, yes, but in reality, no. How was what we were building attachment? What did that mean? What does that look like? Further evidence of attachment void. Rating: 8 – greatly helpful Other helpful event: While I was describing changes and shifts that had happened, I was quite animated, and the therapist pointed out my excitement. I hadn’t really recognized it up to that point but excitedly declared, “I showed up!” It was a first conscious realization that a defined ME was emerging/had emerged. Rating: 9 – extremely helpful Anything hindering: None Therapist TSNQ form Most helpful/important event: Client shared about feeling flooded with memories of the assault and what happened afterwards (reporting, etc.), and feeling tense but in a manageable way. Rationale for choice: Remembering the event and going through the timeline seemed to stir up unprocessed traumatic content; client felt activated but “Ok.” Rating: 8 – greatly helpful Other helpful event: The client was able to identify somatic markers at the end of each timeline – while the physical sensations seemed uncomfortable it was clear she was tuning into her body. Rating: 7.5 – moderately to greatly helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 320 Anything hindering: None. SESSION 10 LI Protocol: PTSD protocol July 20 60 min. No. of TL repetitions: 5 Session Summary (therapist session notes): To continue on with trauma processing, the PTSD protocol was used. The client appeared somatically activated at session start, made an insight at end of session. [At exit:] Client appeared more present in her body, but tired or taxed, and tender emotionally. [Other:] Client was able to observe therapist holding her doll, ‘Rose’ and felt attached to the therapist. Client HAT form Most helpful/important event: In the last timeline the therapist started by having me cross my arms and hold myself. I was imagining me holding Rose [my younger self] and letting her know we were OK because the therapist was holding us both. The therapist asked to let her know if I was ready for the timeline to which I nodded but then she saw or sensed something and asked if I wanted to just stay in the embrace for a while longer. Rationale for choice: She [the therapist] saw me. She saw a need to stay and didn’t just run with what I was consciously telling her with my nod but invited me to linger. I’ve always been afraid to linger, take up too much time/space. I stay just long enough to be ‘appropriate’ and then push forward. Here I was being invited to BE, be ME in the midst of need and linger there – be seen, known, felt, experienced. Rating: 9 – extremely helpful Other helpful event: Using the butterfly taps during the 3rd timeline (PTSD) was very grounding. The timeline was less overwhelming and more manageable. Rating: 8 – greatly helpful Anything hindering: None. [It’s interesting. I really struggled to answer this question because this session felt less positive and so it seemed like something must have been wrong, but I couldn’t think of anything so couldn’t choose Yes. I think it was merely difficult, painful and focused on shameinducing events hence the less positive take-away. But this is to be expected or makes sense given the complex trauma we were processing.] INTEGRATING EGO IDENTITY WITH LI THERAPY Therapist TSNQ form 321 Most helpful/important event: At the end of the session the client was able to remember the traumatic event (beginning July 2009) while feeling present in the room, (while tapping and hearing the story) with less peaks and dips in intensity. Rationale for choice: Client appeared more settled, like she could hear the story without agitation/hyperarousal or hypo arousal. Rating: 8 – greatly helpful Other helpful event: The client reported having an insight at the end of session realizing in the past she had faked illness to receive care. This insight came after holding herself at the end of a timeline repetition. Rating: 8.5-9 – greatly to extremely helpful Anything hindering: At the beginning of a timeline repetition the client’s body appeared to be extremely agitated, her hand contracting and flexing seemingly without voluntary control. Rating: 3 – moderately hindering SESSION 11 LI Protocol: Standard protocol July 24 60 min. No. of TL repetitions: 4 Session Summary (therapist session notes): Client emailed during the week to ask a question about some concerns she has (she reported feeling afraid the traumas would not heal). Discussed her email. She reported the fear dissipating. Conducted standard protocol about memory of meeting with [police] detective. [At exit:] Client appeared energized at end of session. [Other:] Client had some sadness and tears when remembering and processing event but did not describe or appear to be dysregulated at any point. Client HAT form Most helpful/important event: When the therapist asked if I was ready to try standard protocol around the assault. Two things were important/helpful: 1) that I said YES; 2) her confidence in answer question, “What if it goes disastrously?” – she simply states, “it can’t”. Rationale for choice: This was important because I know that rescuing my younger self from the midst of the assault and showing my brain that its over is the only way I will ever be able to leave it behind. I’ve tried other ways and I’m still stuck there. And, despite all my knowledge of LI and my desire to do the work, I’m still scared that it will all go wrong, and I’ll just be stuck where I am. The therapist’s confidence that there is zero chance that it will end in INTEGRATING EGO IDENTITY WITH LI THERAPY 322 disaster was very reassuring. She didn’t promise results per se but was promising I’d be safe. Rating: 9 – extremely helpful Other helpful event: At the end of the last timeline I shared with the therapist that there was some resistance to the two of us merging together even though I knew they were both me. She asked if it was because of who my younger self was or because of the story. Hadn’t even thought of that distinction – very key. I thought/think it’s because of the story. Rating: 8 – greatly helpful Anything hindering: It was really hard to imagine myself in the scene because it was so complex, multifaceted and so I felt a bit disconnected from it – like watching myself in a movie vs actually being in the movie. Wonder if perhaps also because my memory of place and even what the detective looked is almost zero. Rating: 3 – moderately hindering Therapist TSNQ form Most helpful/important event: Client reported younger self standing up to detective then saying to present day self when she arrived, “Come on. Let’s go.” Rationale for choice: Client described a sense of certainty in her position that previously she had doubted or had been made to doubt by detective. Rating: 8.5 – greatly to extremely helpful Other helpful event: Client was able to know that present-day home has never been entered by the person who sexually assaulted her. Rating: 8 – greatly helpful Anything hindering: Client reported some discomfort with merging; less about merging itself but experiencing some sadness to realizing that it is her story. Rating: (None provided.) SESSION LI Protocol: PTSD protocol 12 July 27 60 min. No. of TL repetitions: 5 Session Summary (with therapist session notes): Client shared that some unwanted coping behaviour has increased since beginning the processing of sexual assault trauma. While doing the PTSD protocol, ‘younger self’ tries to distract the older self; needed to strategize about what to do. Client reported integrating with younger INTEGRATING EGO IDENTITY WITH LI THERAPY 323 self. [At exit:] Integration appeared to be tentative, like the client was experiencing something new. Client HAT form Most helpful/important event: The therapist was coaching me to tell my younger self that the assault is over, it’s done, I don’t ever have to go back there. As I spoke those words to my younger self, I was strong and confident in reassuring her of these truths while simultaneously shocked/surprised to discover I didn’t already know this – I had been living as though it was still happening. Rationale for choice: I heard the words with my whole self and there was relief, more than relief, release. I don’t quite know yet how to describe what happened in that moment, but for the first time I considered it to actually be true – it is done, finished; I survived and don’t ever have to go back there again. Freedom? I think somehow that fits. Like I’ve been chained to a heavy load and for the first time I was set free (didn’t even realize I was chained – wounded, yes, but not chained.) Rating: 9 – extremely helpful Other helpful event: During the 2nd and 3rd timelines I ran into some problems interacting with my younger self and entering the scene. The therapist took this all in stride, didn’t make a big deal of it or treat it as strange/abnormal. She just incorporated that information into her coaching, and we jumped back into standard protocol. Much to my surprise, we/I overcame the problems (her coaching me doing). Rating: 9 – extremely helpful Anything hindering: 1. When I ran into a disconnection with my younger self in the 2nd timeline…I refused to leave the scene or ask for help believing that I was failing at LI therapy – that I was doing something wrong. Eventually I had no choice but to open my eyes and “face the music.” I’m sure I only struggled for a minute or two, but wish I’d been quicker to just admit I needed help. The therapist’s response made it much easier to quickly ask for help when I encountered difficulties in the 3rd timeline. 2. Difficult to know how/where to jump into the scene to such a complex, multi-step memory. Rating: 4 – slightly hindering/ 3 – moderately hindering Therapist TSNQ form Most helpful/important event: At one point during the third repetition the client reported that her 2009 self tried to distract her from completing the timeline. The client came back to the room to strategize with the therapist, then returned to the timeline to reassure her younger self, stepped into care-taker role to provide guidance and direction to younger self. INTEGRATING EGO IDENTITY WITH LI THERAPY 324 Rationale for choice: The client’s younger part appeared to have some difficulty coming forward into the present. Rating: 3 – moderately hindering Other helpful event: At the end of the session the client shared that it seemed weird to experience integration as it meant the younger self was always with her, including her emotions, but stated that she was able to accept that because, “it’s me”. Rating: 8 – greatly helpful Anything hindering: Client appeared to find it difficult at points to stay with the timeline and in it (may have been flooding or another distractor part inside). Rating: 4 – slightly hindering SESSION LI Protocol: Standard protocol 13 Aug. 3 60 min. No. of TL repetitions: 4 Session Summary (therapist session notes): Discussed progress since last session. Continued doing timeline with 2009 incident. [At exit:] Client reported important experience of integration before leaving and appeared settled and grounded in her body. [Other:] Besides the above-mentioned integration, before session began client reported this past week feeling some groundedness even in a situation where she was self-critical. Client HAT form Most helpful/important event: Switching my safe place form the lake at the cottage to the mountain top. Rationale for choice: As I was interacting with my younger self it became clear that she didn’t want to go to the lake because we’d always only ever been there as a family and she wanted to be away from family – didn’t feel safe around them. So, the therapist said we could go somewhere new and as soon as she mentioned a mountain top my younger self and I were there – safe, at the top of the world, away from everyone. Rating: 9 – extremely helpful Other helpful event: I think it was the 3rd timeline when my younger self was so angry. Hillary encouraged me to let her express her anger. So, she yelled and screamed, and beat up the trees on the mountaintop until she collapsed in tears and I rushed over to hold her. She would never have felt free to do all of that at the lake, but alone on the mountain there was no one to hear or see her while she raged. INTEGRATING EGO IDENTITY WITH LI THERAPY 325 Rating: 9 – extremely helpful Anything hindering: In the 3rd timeline my younger self threw [the guy] over the balcony after beating him up. My older self was worried that this narrative was more damaging than helpful and tried to change it (hindering). When I shared what had happened with the therapist, she was not shocked, nor concerned, but said something like “Good for her. Someone else can worry about [the guy]. He’s someone else’s problem.” With the caveat that this was okay and true because it was imaginary (helpful). Rating: 4 – slightly hindering Therapist TSNQ form Most helpful/important event: Client at end stated that she said to herself /felt “I love me” for the first time ever. This occurred after client reported merging of younger and present self. Rationale for choice: This represent a new level of integration and connection with self, past and present. Rating: 9 – extremely helpful Other helpful event: Client reported needing to change her safe place form a place where her parents would be (at lake) to a mountain top where it is just her and herself. Rating: 7.5 – moderately to greatly helpful Anything hindering: The client appeared to become stuck in the story and the affect of the trauma at the beginning, opening her eyes and stat that there is a “wall” going up, and her younger self won’t leave the environment. Rating: (None provided.) SESSION LI Protocol: None – embodied work 14 Aug. 7 60 min. No. of TL repetitions: N/A Session Summary (therapist session notes): Client described inner conflict about continuing with thesis; shared a dream she had which involved the man who assaulted her and her parents. Together we embodied her experience of finding her voice; I performed her movements back to her and we reflected on it. [At exit:] Client reported feeling tired but described being excited about practicing the embodiment of her new emerging self/voice. [Other:] Client’s vulnerability and risk-taking with me was evident as well as her desire INTEGRATING EGO IDENTITY WITH LI THERAPY 326 to continue to “collect younger parts of self” to find her voice and inhabit her life. Client HAT form Most helpful/important event: The therapist had me do some body work around my experience of voice: physically show what it looks like when I feel silenced, hidden, disappeared; what it looks like to be emerging; and what it looks like to be free to speak, be seen, be heard. I knew exactly what the first stage looked like, and the last. The middle stage was more difficult. The therapist then performed the sequence for me to watch and see. Rationale for choice: It was such a vulnerable exercise to allow the therapist to see me as I’m trying to hide, disappear, survive; to have her witness my state of invisibility was very difficult to do. It also immediately surfaced deep emotions of fear, shame, sadness, trapped. The last stage was glorious. I felt so big, powerful, steady, joyful; an automatic smile came to my face. The uncertainty of the middle phase was curious – reflect my fear in exiting my survival zone, uncertainty of how to move from A to B, uncertainty in this last stage is just a dream or a possibility. This work was a physical representation of everything I am experiencing in LI therapy, thesis journey, family dynamics – FINDING ME – FINDING MY VOICE. Rating: 9 – extremely helpful Other helpful event: Sharing a disturbing dream I’d had…and then speaking up very confidently that this couldn’t happen due to the assault…Brought up the theme of confinement and having a voice with the family, setting appropriate boundaries, disobeying family rules – giving myself permission to have a voice and make my own decisions. Rating: 9 – extremely helpful Anything hindering: None. Therapist TSNQ form Most helpful/important event: Client reported learning to find her voice and her expression of that standing tall, holding arms open to symbolize taking up space. Rationale for choice: The client had previously felt restricted in her capacity to engage in life as her “own person” and reported a change and increased desire to “take up space.” Rating: 9 – extremely helpful Other helpful event: None. Anything hindering: Client described feeling as if she was “emerging” and not yet certain how to cully embody her voice and agency. Rating: 4.5 – slightly hindering to neutral. INTEGRATING EGO IDENTITY WITH LI THERAPY SESSION 327 LI Protocol: None – new online session format 15 Sept. 6 60 min. No. of TL repetitions: N/A Session Summary (therapist session notes): The first session together since therapist had moved. Took the session to become acquainted with adjustment to new format [Zoom online meeting] and connect after 1 month [with no sessions]. [At exit:] Client appeared tender emotionally, but present and connected to herself and therapist. Client HAT form Most helpful/important event: The therapist verbally saying, “I am here with you” as I focused on my internal emotional experience in the moment. Rationale for choice: Until the therapist said those words, until I heard them, I was unaware of the loneliness I felt. With those words came a swell of emotion and tears and I realized that my inner self (inner child?) felt alone (abandoned?). Rating: 8 – greatly helpful Other helpful event: After a 3-week gap between sessions we began by catching up on how I’ve been doing which led to addressing an immediate specific need without the use of LI. It was beneficial to start where I was at after such a long break and give an idea of what’s been happening /where we might need to restart/pick-up. Rating: 8 – greatly helpful Anything hindering: This was our first online therapy session (vs. in person) and I found myself, especially at the beginning, feeling hesitant to completely engage/connect – desire to hold back from being vulnerable and feeling somewhat disconnected. It was definitely helpful to close my eyes as then I could almost forget that the therapist was just on a computer screen and not in the room with me. Rating: 4 – slightly hindering Therapist TSNQ form Most helpful/important event: During the past week, the client reported noticing emotions emerge and she decided she did not want to do that to her little girl self. Reflected on the care and attunement building within herself. Practiced in session remembering her 5-yearold self, fears/aloneness. When therapist said “I’m here with you” deep tears emerged. Client placed her hand on her chest in an effort to be with younger self Rationale for choice: Further development of self-care attunement to own pain, building skills of emotional regulation. Rating: 9 – extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 328 Other helpful event: The client and therapist ended the session with a ‘celebration’ meditation to reflect on and savour experiences of care and attunement to self. Rating: 7.5 – moderately to greatly helpful Anything hindering: None. SESSION LI Protocol: Standard protocol 16 Sept. 17 60 min. No. of TL repetitions: 2 Session Summary (therapist session notes): The session began with the client sharing about her progress, noticing more the impact of the sexual assault on her life even now. The client reported some shame about that. Began timeline work. [At exit:] Client appeared stuck and unable to integrate due to body image concerns. Client HAT form Most helpful/important event: When I was able to verbalize out loud the connection, I see that my brain has made between sexual arousal and sexual violence/assault. To speak it out loud so bluntly and overtly was at first impossible as the shame took me out of my window of tolerance, but the therapist led me in tapping and pressing my limbs which grounded me, and I was able to speak. Rationale for choice: It’s important because it’s the reality of my current experience and something I want to see change, but if it remains locked in secrecy due to shame it won’t be able to change. It was also about being seen and known – having someone hear me speak my secret shame and not reject me, judge me, shame me, punish me, or disgust them – impact of that is freeing and beyond words. Rating: 9 – extremely helpful Other helpful event: My younger self asked if we would ever be loved again. The therapist’s answer was not to promise or envision a future loving relationship for me but to coach me in letting my younger self know that I am lovable – right now, right here, just the way I am. Need to know myself as lovable in my relationship with myself – not wait for someone else to make that real for me (if that’s even possible). Rating: 9 – extremely helpful Anything hindering: The internet connection wasn’t very consistent so there was a time I said something that I don’t think the therapist heard as she didn’t respond and am pretty sure I missed some cues in my INTEGRATING EGO IDENTITY WITH LI THERAPY 329 timeline. This was a bit distracting as we went through as I would wonder if a long pause was intentional or if I’d lost the connection with her (seeing as I had my eyes closed). Rating:3 – moderately hindering Therapist TSNQ form Most helpful/important event: The client reported that she felt resistance (younger self) towards integrating with present-day self because her present-day self weighed too much compared to younger [2009] self. Rationale for choice: The client’s internalized body shame (both past and present) was identified as a barrier to present-day acceptance Rating: 2 – greatly hindering Other helpful event: After the second timeline the client was able to spontaneously reassure her younger self by saying “things will change, we’ll work on it.” Rating: 7.5 – moderately to greatly helpful Anything hindering: After the first timeline the client reported (and demonstrated para verbally and nonverbally) her inability to articulate a question. The therapist regulated her, and she was able to ask a question from younger self “will anyone love me?” While this could be identified as unhelpful, in a way her question (once regulated) proved to be an important question underlying her shame. Rating: (None provided.) SESSION LI Protocol: Standard protocol 17 Sept. 28 60 min. No. of TL repetitions: 4 Session Summary (therapist session notes): The therapist remarked to the client upon beginning the session that she “looks older;” client reported she was struggling with the fundamental questions of existential analysis. Checked in about assault memory and client reporting noticing not much activation then began timeline repetitions again with the memory of the assault. [At exit] client appeared calm and settled. [Other:] Client reported feeling matter of fact when remembering the assault. She appeared at the beginning of the session to look more her age and not as child-like. Client HAT form Most helpful/important event: The therapist queried what goes on when I speak gibberish due to a state of wordlessness in expressing myself. She then went on to assure me that she is not expecting INTEGRATING EGO IDENTITY WITH LI THERAPY 330 perfection or even understanding or decision when she asks a question but is more an invitation to brainstorm. She assured me that there is nothing I could say that would scare, overwhelm her or change her opinion of me. Rationale for choice: No one has ever asked before. It’s something that has always been a part of therapy, but no one has inquired why. Why is asking it important? Fully seen – every aspect of me is being experienced. Bringing another internal rule, secret source of shame, out into the open (relational dynamics?). It was somehow difficult to hear her assurances – not sure I was able to believe them nor internalize them, but I heard them. Rating: 8 – greatly helpful Other helpful event: My younger self asked why we had to be so strong and courageous and the therapist helped me answer her. Acknowledge the difficulty and effort it has taken to get here. Permission to be tired, exhausted and in need of rest. Rating: 8 – greatly helpful Anything hindering: None. Therapist TSNQ form Most helpful/important event: Once collected from the past and in the present moment the client imagined being with her younger self and said “I would do it again because I love you. I am here to rescue you.” Rationale for choice: Previously in the session the client had felt exhausted with the grief of what had happened, and this demonstrated a care and protective attunement continuing to develop for herself. Rating: 9 – extremely helpful Other helpful event: After the second timeline repetition the client expressed grief and began crying heavily ad said, “why did we have to be so strong and courageous?” Rating: 8 – greatly helpful Anything hindering: During the first timeline, the client reported ‘losing’ her younger self and having trouble connecting to herself. Rating: 3.5 – moderately to slightly hindering SESSION LI Protocol: Standard protocol 18 Oct. 5 60 min. No. of TL repetitions: 3 Session Summary (therapist session notes): INTEGRATING EGO IDENTITY WITH LI THERAPY 331 The client shared that others have indicated to her noticing her joyfulness. She reported feeling grounded in a situation that previously would have left her feeling dysregulated. Asked the client to stay with feeling of goodness, she reported being uncomfortable and we decided to use an affect bridge to explore that back to [a] memory at 2-3 years old. [At exit:] Client appeared settled and calm. [Other:] After checking in on the source memory the client reported having trouble connected with the memory but that she felt no tension in her body when thinking of the memory. Client HAT form Most helpful/important event: Sharing my 2-year-old memory of wanting my mom and instead getting the babysitter. Actually, being in the memory and speaking from a first-person perspective. Going back and getting her was SO important. Rationale for choice: I’ve talked about the memory from an outsider perspective before but never as the one who experienced it and was blown away by the depth of fear that emerged. I was that little girl. I felt the desperation of needing my mommy. It’s always been there but never been seen or spoken. I don’t even know the level of accuracy of the memory, but it didn’t matter because it has been part of my reality for over 40 years. Now she’s been seen, heard, and responded to. Rating: 9 – extremely helpful Other helpful event: When we first tried the affect bridge to a memory, I felt blocked and couldn’t connect. The therapist zeroed in on feeling blocked and how/where I felt that. I can’t recall if she did something else as well but remember that a memory did surface after acknowledging and making space for the block. Rating: 8 – greatly helpful Anything hindering: I’m torn in responding to this question as my brain and self-debate whether it was hindering or helpful. When I was sharing the successes of the week, at the end the therapist asked me to “sit” in the emotion of celebrating. I went to share an observation of what it was like to think of coming to session and sharing the successes with her, but she stopped me and asked me to just BE in the moment. That was uncomfortable, scary – the actual being – but I also wonder if some of the discomfort/fear was at feeling silenced based on the childhood episode that I connected to with the affect bridge. Even as I write I feel tension and I think anger. But making me stop and feel is also a very good thing as I can more easily talk to avoid the discomfort of feeling – so I’m not sure what to think. Rating: between 1 – extremely hindering – and 3 – moderately hindering INTEGRATING EGO IDENTITY WITH LI THERAPY Therapist TSNQ form 332 Most helpful/important event: When bringing the 2-year-old through the timeline the little girl self was pleased (delighted) to know that as an adult she learned to ballroom dance. There were tears, and she felt herself as having fulfilled a childhood dream. Rationale for choice: The client was able to view herself positively. Rating: 8.5 – greatly to extremely helpful Other helpful event: Integration appeared to begin to happen on second time through timeline. Sometimes she was side by side with her younger self, sometimes she was her younger/adult self at the same time. Rating: 8.5 – greatly to extremely helpful Anything hindering: It was possible that the client was outside her window of tolerance during the first timeline repetition when connecting with her toddler self. Rating: 4 – slightly hindering SESSION LI Protocol: Standard protocol 19 Oct. 11 60 min. No. of TL repetitions: 2 Session Summary (therapist session notes): Client reported sitting with her anger after having a difficult dream about her mom. Client reflected that anger is “not allowed” and that there’s “no space for anger.” Did affect bridge to memory of answer with sister at 11, the promise to self to “never do that again”. [At exit:] Client reported and seemed to be connected positively to herself, younger and older self seemed to delight in each other saying ‘you’re fun’ and ‘we’re fun.’ Client HAT form Most helpful/important event: During our second run through the memory, when I was with my younger self at 88 Ellerslie (home in Toronto), the therapist asked what my younger self might need to do. In response my younger self ran around the main floor smashing windows, slashing the kitchen cupboard doors with a knife and spray painting, “I want to go home” in black on the dining room wall. Rationale for choice: Because this is the first time, I’ve acknowledged how angry I was – that I even was angry – and my intense desire to return to Mexico. The memory was about anger regarding a situation with my sister, but the out of control nature of the anger stems from being burdened and overwhelmed by the demands of life in Canada. Never before have I admitted that I wanted to go home – and that this was Mexico. Rating: 9 – extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 333 Other helpful event: The therapist had me physically act out my anger – show it with my body. It made my anger so accessible, in fact too accessible as I was hyperventilating at one point. It was so strong and led directly to the memory. Rating: 9 – extremely helpful Anything hindering: None. Therapist TSNQ form Most helpful/important event: Client changer her ‘peaceful place’ to a mountain top not connected to any family or family members and helped her 11-year-old “scream” out the anger from the top of the mountain. Rationale for choice: Client gave herself permission to experience and express anger and spontaneously knew how she needed to change the imaginal environment to do that. Rating: 9 – extremely helpful Other helpful event: The client imagined her younger self expressing her anger in their family home – without holding back – was surprised by the power of her 11-year-old self. The next repetition she expressed her feelings of anger as related to the experience of not being able to go back to Mexico. Rating: 8 – greatly helpful Anything hindering: None. Client HAT form reports from session 20, 22 and 23 had been mistakenly reported under the incorrect session date in rich case record presented to the case development teams. This significant oversite has since been corrected. SESSION LI Protocol: Standard protocol 20 Oct. 22 60 min. No. of TL repetitions: 2 Session Summary (therapist session notes): Client reported having some somatic symptoms which emerged after last session – when revisiting memory from last session (11-year-old) reported feeling “crushed”, then revisited memory to resume timeline work. [At exit:] Client reported feeling settled and like integration had happened on a much deeper level than before. INTEGRATING EGO IDENTITY WITH LI THERAPY Client HAT form 334 Most helpful/important event: When I (my adult self) go into the memory, I am holding my younger self and keep repeating, “I’m here. I’m here.” Rationale for choice: My younger self is being crushed by the weight of responsibility and pressure she feels to be able to handle all that comes with transitioning to Canada. In that moment she is all alone – nobody knows. But I know. I understand. And I’m stronger, bigger, have more resources. As I enter the scene, she needs to know she is no longer alone. I am there to care for her, help her, love her, protect her. She is not alone – “I am here.” Rating: 8 – greatly helpful Other helpful event: When we first entered the memory, I described is as crushing me and I had difficulty separating from that 11-year-old ME to being my adult self into the scene. I shared this with the therapist who was able to coach me back into my adult self – ground me again in my 44-year-old self – and then return to the memory. Rating: 8 – greatly helpful Anything hindering: There were very long pauses in between memory cues which at times made it difficult to remain in the process of showing my story to my younger self – worried the therapist hadn’t seen my nod, or got too involved in the specific memory. Also, we never took a break form the process – remained in the memory the whole time. That actually made it more difficult to stay engaged as it’s just wearying. Rating: 3 – moderately hindering Therapist TSNQ form Most helpful/important event: When encountering her 11-year-old self and the younger part’s anger, the adult self apologized to her saying, “I’m sorry” for silencing her and noted that “she had things that needed to be said”. Rationale for choice: The client continued to connect with a part of herself that she felt she had silenced or not allowed to express itself following the return to Canada. Rating: 8.5 – greatly to extremely helpful Other helpful event: On the second time through the timeline the client reported that there 11-year-old self did not feel she needed more repair from her older self; that the younger self ‘knew’ the things she previously didn’t know. Rating: 8 – greatly helpful Anything hindering: None. INTEGRATING EGO IDENTITY WITH LI THERAPY 335 SESSION 21 LI Protocol: Standard protocol Nov. 8 60 min. No. of TL repetitions: 2 Session Summary (therapist session notes): The client reported a change in her pattern of communication with her mom: setting boundaries. Celebrated that development. Client made the connection that anger was about coming back to Canada. Celebrated some changes together and client reported finding it extremely uncomfortable to take in the therapist’s delight in her. Did an affect bridge back to a memory at 11 when she felt dismissed and rejected … when her mom [didn’t spontaneously offer to] pray with her. [At exit:] Client reported feeling present and connected to younger self. [Other:] Therapist sensed the client’s discomfort with shared affection and difficulty with receptive affect; noticed the client’s inability to view herself as the therapist does, sensed the client withdrawal. Client HAT form NOTE: this HAT form was filled out verbally with Janelle Kwee. Most helpful/important event: Talking about/ identifying personal changes/shifts - growing but also hiding from the intensity). Being seen in the intensity. Rationale for choice: 1. Desire to give feedback to the therapist. 2. Being able to put words to hesitancy of being seen and the other person staying with – hindering/ uncomfortable part is not knowing what to do with this. Rating: 7.5 – moderately and greatly helpful Other helpful event: Being able to work with shame and be seen in it as therapeutic material (affect bridge to source memory). Explored difficulty internalizing other’s joy. Used feeling to link to source memory. Rating: 8 – greatly helpful Anything hindering: Lingering shame – unable to grasp memory clearly – felt unresolved – felt elusive. Questioning the therapist’s investment in client – client has felt uncertain – feeling like a burden for a couple of weeks around this session. Questioning therapist’s understanding of client’s experience of repatriation as a process rather than event – therapist’s question implied different understanding. Rating: 2 greatly hindering 1 extremely hindering 2 greatly hindering INTEGRATING EGO IDENTITY WITH LI THERAPY Therapist TSNQ form 336 Most helpful/important event: Showering her younger self in delight and noticing “She is really desperate for that.” Then younger self saying, “can we stay here a bit longer?” Rationale for choice: Client was able to notice her need for attunement and direct that towards herself. She noticed that her younger self responded positively to that. Rating: 8 – greatly helpful Other helpful event: Client and younger self were in the present at her present-day home playing and singing together. Client reported feeling really present with her younger self. Rating: 6 – moderately helpful Anything hindering: Client reported feeling extremely uncomfortable with the therapist’s delight in her and the changes that are occurring. She commented that it felt too big for her when asked to meta process it. Rating: 3 – moderately hindering SESSION LI Protocol: None – addressing client concerns 22 Nov. 19 60 min. No. of TL repetitions: N/A Session Summary (therapist session notes): Client reported having some concerns she wanted to discuss with the therapist – feeling disconnected from the therapist and concern the therapist viewed the repatriation as a singular event. The therapist normalized and validated the concerns and inquired about the process nature of the comments – and hypothesized together why these concerns might have been coming up. Client checked in with herself and noticed that part was confused who the therapist was and why she was involved – they hadn’t ‘met’. Discussed the possibility that technology or doing therapy by video conference can create experience of distance (time lags, or not being able to look in each other’s eyes). Therapist apologized for if she had made comments which made it appear that repatriation has a singular event, and therapist and client spoke about the possibility that last session (therapist sharing her delight) might have felt too much for the client and activated some defences. The therapist praised the client for using her voice during session – something that they had been working on in an imaginal way. [At exit] Client noted the magnitude of attunement during this session and stated that it felt like “a drop of water in a very dry bucket.” [Other:] It was a slow and thorough session and there was no time to complete a timeline. It also seemed as INTEGRATING EGO IDENTITY WITH LI THERAPY 337 if the client’s younger self was operating as more of a distinct self at the end of the session, and it appeared as though she felt attuned to but not integrated. Client HAT form Most helpful/important event: The therapist asked what little 4-5year-old ME needs, and the answer was that she needed to meet the therapist. She doesn’t know her. So, I sat on the floor with little ME on my lap [in my imagination] and the therapist spoke directly to little ME = it was like we were watching her on a big giant screen. Little ME asked me some questions as she was listening to the therapist like, “Does she really mean that? Will she dance with me?” Rationale for choice: It was such an intimate and precious time between the three of us [little ME, adult ME, the therapist]. For me to witness little ME’s responses questions, curiosity and tentativeness – her vulnerability, wonder, tenderness. Then for me to hear the therapist’s words to little ME – welcoming, kind, tender, loving – and her description of adult ME to little ME was ‘heart-expanding.’ The therapist was seeing and responding to a part of me that hasn’t been seen in a very long time and it was simply beautiful. It also took a lot of courage to tell the therapist what little ME needed – to meet her. It sounded ridiculous and yet I also knew it had value therapeutically – therapist ME vs logical ME in debate. Rating: 9 – extremely helpful Other helpful event: I shared with the therapist, right near the beginning, how I’d been feeling disconnected or unsure of her investment…and also unsure of her understanding of what my repatriation experience had been – a process rather than an event. It was awkward and scary but very important as it was blocking my ability to fully engage in session with her. Talking it through eliminated the anxiety/confusion. Rating: 9 – extremely helpful Therapist TSNQ form Anything hindering: None. Most helpful/important event: The client shared her concerns with the therapist and where she felt mis attuned to and insecure. Rationale for choice: This was important because it was an in vivo experience of using her voice (for the client) with a trusted other; something she had been working on imaginally. Rating: 9 – extremely helpful Other helpful event: The client identified that the sense of insecurity she felt was connected [to] a 4- or 5- year-old part; was able to connect with that part. INTEGRATING EGO IDENTITY WITH LI THERAPY 338 Little girl was hiding in a closet. / Little girl self wanted to connect with the therapist; this occurred after the client attuned and connect her younger self. Rating: 7 – moderately helpful Anything hindering: None. SESSION LI Protocol: Standard protocol 23 Nov. 29 60 min. No. of TL repetitions: 2 Session Summary (therapist session notes): Reflected on last session. Client reported that the challenges she was having may be related to 11-year-old self. Decided together to continue to work on integrating her 11-year-old self. [At exit:] Client seemed attuned to younger self but still seemed (like in past session) that parts had not come together. [Other:] Completing the timelines is taking longer and client is taking more time than before (before starting with memory cues) to connect with younger self. Client HAT form Most helpful/important event: “Taking charge.” Letting the therapist know that I needed a break between timeline and that young ME and adult ME needed to go to the mountain top (peaceful place) before we told my story the second time. Break: I was overwhelmed and exhausted – hardest timeline as of yet. Mountain: needed to get out of the house, somewhere neutral and safe. Rationale for choice: Knowing and trusting what my instincts told me I needed and giving voice – empowering myself to ‘take charge’ and make that need known. Required a lot of strength, courage, determination and trust in myself to make my presence known in this way. Rating: 8.5 – greatly and extremely helpful Other helpful event: Both the therapist and I together adapted our approach to 11-year-old ME based on her responses to adult ME appearing – hiding, scared. Really slowed down the encounter and gave space and time for younger ME to adjust – [imaginally] kept my distance, kept quiet, spoke tenderly, approached tentatively, waited for younger ME to make the first move. Coaching by the therapist + my own imaginative choices. Rating: 8 – greatly helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 339 Anything hindering: When the therapist went straight into suggesting a 2nd round through the timeline after our first round without a break there was some anger and frustration. Protocol dictates a break after every timeline. Not the first time we’d not stuck to protocol this way but this time it really mattered. Had I not been able to speak up for myself and ask for a break this would have been significantly more hindering because I was starting to lose myself (maybe dissociate?) in the experience – was finding it exhausting and difficult to stay grounded. Anger = “Why doesn’t she see how difficult this is and that I need a break? Doesn’t’ she get what’s going on?” I was reminded of the limitation of online therapy (which we talked about in last session) in being able to communicate nuances – the need for more verbal communication = courage to speak up. Rating: 3 or 4 – moderately or slightly hindering Therapist TSNQ form Most helpful/important event: When connecting to 11-year-old self the child didn’t wat to come into the present and return to the adult self’s home in present day. She agreed to go to the safe place. Rationale for choice: Connecting in with the client’s voice/agency/resistance which seemed to have been thwarted when she returned to Canada. This also demonstrated some unreadiness to integrate with present self. Rating: 6 – slightly helpful Other helpful event: At the end of the second timeline the adult self was able to stay attuned to 11-year-old self and provide her with physical affection. Client noted that that was lost upon returning to Canada. Rating: 7.5 – moderately to greatly helpful Anything hindering: Client’s 11-year-old self was unready to come into the present moment and integrate Rating: 4-4.5 – slightly hindering to neutral SESSION LI Protocol: Standard protocol 24 Dec. 14 60 min. No. of TL repetitions: 2 Session Summary (therapist session notes): Client shared about watching a show a lot about being rescued, thinks it is related to the timeline work. When connecting to somatic sensation client went back to being 11 on the playground. During timeline work the client reported being confused about if she was in her child or adult INTEGRATING EGO IDENTITY WITH LI THERAPY 340 ‘part.’ At the end she wanted to ask some question but felt unable to. The therapist provided reassurance that any and all questions are ok. [At exit:] The client reported feeling “shaky.” The therapist encouraged her to go towards it and notice the sensation, and it resolved. [Other:] Query the possibility of the merging being an experience of being in the felt sense of younger self? Client HAT form Most helpful/important event: I shared that I knew what I wanted to do for 11-year-old ME but wasn’t sure if I was allowed. The therapist encouraged the adult ME to not worry whether or not I was allowed to do what I thought 11-year-old ME needed when we were in the schoolyard in Toronto. Rationale for choice: This helped get me out of the ‘shoulds’/’shouldn’ts’ to just listening to my gut instincts and getting out of my head. Listening to needs and not stuck in morality or ‘good girl’ – it’s not real, it has no real consequences. Rating: 7.5 – moderately and greatly helpful Other helpful event: More than one distinct event but same theme of letting the therapist know how elusive it was to connect with my 11year-old self – at the school yard, on the mountain top (hiding in the trees), showing her the timeline (projecting it onto a lake for us to watch together). I can’t remember if I also mentioned difficulty at my apartment. It was helpful that I spoke this out loud even thought I didn’t’ know how to interpret it. Rating: 7.5 – moderately and greatly helpful Anything hindering: None Therapist TSNQ form Most helpful/important event: During the first timeline repetition while client and younger self were in the safe place, the client reported ‘losing’ her younger self and was unable to hold her younger self with her. Went back to the source memory to find her younger self. Rationale for choice: The more work done with 11-year-old part it becomes more clear how much fragmentation and unresolved emotion is connected to this age/stage/part. While it was it was unhelpful for the process of integration it was also meaningful or important to get a better sense of the depths of the challenged the client has with connecting to this part of her and the pain she must have been carrying at that time and state. Rating: None provided (see explanation above). Other helpful event: The client began to cry when the therapist reminded her and her younger self that any questions were ok at any time – it appeared from her body/breath/tears as if a release occurred when hearing that. INTEGRATING EGO IDENTITY WITH LI THERAPY 341 Rating: 7.5 – moderately to greatly helpful Anything hindering: After the second timeline the client reported feeling as if things had integrated, however the way she described what was happening suggested she may have been ‘stuck’ in her adult self. Rating: (None provided.) SESSION LI Protocol: Standard & Basic protocol 25 Dec. 20 60 min. No. of TL repetitions: SP = 3/BP = 1 Session Summary (therapist session notes): Client reported feeling “discombobulated” since working on her 11year-old self – “things feel messy”. Shared about believing there had been ‘2’ 11-year-olds, one who performed ‘ok’, one who disappeared. Began timeline work with 11-year-old self, but client reported being unable to stay in her adult self – old Basic protocol while tapping, then standard protocol 2 more times. [At exit:] Client appeared settled and present. [Other:] After the last 2 sessions in particular, when working with 11-year-old self, this was the first time when the client ‘felt’ integrated, as if parts had come together at the end instead of apart. Client HAT form Most helpful/important event: The therapist was coaching me through merging my present self and younger self. During this process I was engaging my imagination in which I was with my younger self at my apartment. At some point the therapist said, “You are her, and she is you” referring to myself and my 11-year-old self. This last phrase (bolded) is what brought up a ton of really strong emotions. We sat in those emotions for a time and she was curious as to what the emotions were. Eventually I came to understand that it was the emotion of missing my younger self – a deep ache, a longing being realized in the midst of reunion. Rationale for choice: Because, since she is me, she is not really lost – she is recoverable. I can bring her back again. Everything that she was is still within me and therefore can be a part of who I am once again. Rating: 9 – extremely helpful Other helpful event: 1. I was struggling to separate adult me from 11-year-old me even after the therapist brought me back into the room (the here-and-now) so we did some bi-lateral taping and did a timeline with my eyes open. Really helped ground me again in my 44-year-old body and person and we INTEGRATING EGO IDENTITY WITH LI THERAPY 342 were able to proceed with another timeline with me seeing my 11-yearold self while staying grounded in my 44-year-old self. 2. I told my younger self that I was sorry she had to try and cope with all this on her own. That she should never have had to do this on her own and that she and I could grieve what we lost in never going back to Mexico together. Rating: 9 – extremely helpful Anything hindering: None. Therapist TSNQ form Most helpful/important event: The client was initially unable to stay in her adult self while revisiting her younger self – shared that with the counsellor – the client did bilateral stimulation with her eyes open while therapist read the cues. Rationale for choice: Client was able to stay more present and was able to identify she felt disconnected from present self. Rating: 7.5 – moderately to greatly helpful Other helpful event: Client was able to bring her 11-year-old self int o her present-day home and sit next to each other on the couch, and in the end was able to experience integration. Rating: 8 – greatly helpful Anything hindering: None. SESSION LI Protocol: Standard protocol 26 Jan. 3 60 min. Client HAT form No. of TL repetitions: 3 Session Summary (therapist session notes): Client purchased and book and used pens that made her believe her 11year-old self “hadn’t gone away”. Used affect bridge in moment to connect experience of “alone” with memory at 6 of being stopped by police and asked to lie. Completed timelines until client reported feeling merged. [At exit:] Client reported that she believed her parts had “merged” and stated she neither felt numb or overwhelmed, but just in the middle. [Other:] Query client’s challenge using her voice with her mom in treatment and observe how that may be connected to difficulty with voice and may pose a challenge for future integration and releasing anger. NO RECORDED HAT. INTEGRATING EGO IDENTITY WITH LI THERAPY 343 Client was unable to remember the session, so no HAT data was collected.24 Therapist TSNQ form Most helpful/important event: The 6-year-old, when ‘back in the memory’ had a knowing – “I’m ok, Rose is coming” about older self. The memory changed and the younger self felt protected. Rationale for choice: The younger self appeared to feel reassured, knowing implicitly without being prompted that she was not alone, and someone was coming for her. Rating: 8.5 – greatly to extremely helpful Other helpful event: The client reported trying to support her younger self to speak up in response to her mom (in the memory). They appeared to both find that difficult. In the repetition process, younger self was eventually able to say something to mom. Rating: 8 – greatly helpful Anything hindering: After saying things to her mom, younger self appeared afraid and concerned about having upset her mother; wanted to know if her mother would forgive her. Adult-self had to reassure childself. Rating: 4 – slightly hindering SESSION LI Protocol: Standard protocol 27 Jan. 16 60 min. 24 No. of TL repetitions: 2 Session Summary (therapist session notes): Client celebrated 120 days without engaging in a certain coping behaviour. Spoke about the upcoming ending of our work together – possibly 6-8 sessions left, reflected on her challenges with endings as a TCK. Connected to aloneness – affect bridge to 11-year-old self and began timeline work. [At exit:] There was a deep sense of connectedness between client and present day and younger self. Client appeared tired but settled, present. [Other:] Although there may be This session centered around a memory that was complex and difficult to navigate due to dynamics of personal voice and family rules; a theme that runs throughout many of the therapy sessions and even to completing this thesis study and preparing this rich case record. This may explain the lack of memory of the session when attempting to complete the HAT form. INTEGRATING EGO IDENTITY WITH LI THERAPY 344 some challenges with ending, as endings are hard for the client, there may be enough time to continue to work on the challenges that make ending so hard. Integration appears to be continuing. Time Lines are moving quicker. Client HAT form Most helpful/important event: Hillary coaching me to switch back to my 11-year-old self from my adult self and then back again at the end of the first timeline when I had younger Rose at my home. I had just described how she was terrified and wouldn't open her eyes, so I was cradling her and comforting her. Rationale for choice: It was important because it allowed the depth and breadth of the emotion of the terrified 11-year-old to be seen and heard. Also, it distinguished what belonged to the 11-year-old and what belongs to the adult me. Sort of had to describe but somehow through this process I can now see how the terror, panic, anxiety isn't my adult self responding to the world around her but is the response of a terrified, abandoned, lonely, isolated young girl. Rating: 9 – extremely helpful Other helpful event: We began the session by talking about closing up data collection at the end of February. There were a lot of emotions attached to the thoughts of things ending - fear & sadness in particular. This is unusual for me to feel so deeply about the end of a relationship. Normally it just ends, and life goes on - even with past counsellors. And we talked about what those emotions said about our relationship - the intimacy, connection, attachment and safety that has grown in our time together. We also discussed how the presence of a safe and intimate attachment relationship has spotlighted the years where this sort of connection and safety were missing, the opportunities that I missed for connection, and brought to the forefront that deep yearning and desire that has been there for so long. Rating: 9 extremely helpful Not sure this qualifies as an 'event' because it mostly happened in my imagination but at the end of the second timeline younger Rose found my make-up at my house. In such a caring and connected manner, I let her know that I could show her how to use make-up. This is significant because no one showed me. In fact, in my 30s I payed for a session at a salon. So, for me to take that opportunity to celebrate, embrace and encourage my younger self's emerging womanhood - to help guide her on her way - was just beautiful. 8 greatly helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 345 Anything hindering: Someone from my work organization logged into the Zoom software which brought up a distracting warning on my computer. The warning was easily dismissed, and I was able to set aside any worries about our session being further interrupted, terminated or not recorded and simply continue on, but it was definitely a small interruption in the session. Rating: extremely hindering Therapist TSNQ form Most helpful/important event: After the client ‘brought her 11-yearold self home’ integration began to occur, and the client was able to be both her adult self and child self. Reassured her child self “we are 45 now” and “we have choices now”. Rationale for choice: Client was able to reassure herself and connect to experience in the present that the pain was over, and life is different now. There was a big release of sadness/tears/grief at that point – body visibly let something go. Rating: 8.5 – greatly to extremely helpful Other helpful event: The client noticed that when bringing her 11year-old home the second time that she was more curious. Stated, “I’m sorry you lost mom and dad when we came back from Mexico, but we have friends now. You are not alone.” Rating: 7 – moderately helpful Anything hindering: The client was visibly concerned (afraid?) when talking about the upcoming ending. We queried how this might impact work moving forward. Rating: 4 – slightly hindering SESSION LI Protocol: Standard protocol 28 Jan. 23 60 min. No. of TL repetitions: 3 Session Summary (therapist session notes): Client shared that she was in a situation and was waiting to get anxious “freak out” as she has previously but it didn’t happen. Said, “I think I just grew-up” and “I have made it through 45 years of my life, that will get me through next 45”. Did an affect bridge back to memory at 2 or 3 – Focus to work on having a voice with family. [At exit:] Client appeared a little disorganized, or preoccupied, although she reported that this may have been related to the emerging piece of work related to learning how to hold herself firm when interacting with her parents even INTEGRATING EGO IDENTITY WITH LI THERAPY 346 imaginally. [Other:] During the last 3 timeline repetitions she reported having a hard time “hanging on to the child” self. Client HAT form NOTE: this HAT form was filled out verbally with Janelle Kwee. Most helpful/important event: At the beginning, working on finding memory pertaining to silencing of voice, trying to connect somatic to memory and felt room spinning. Helpful - therapist coaching around present orientation and body grounding (open eyes, etc.) Rationale for choice: Helpful because client spoke up and it was responded to – this was an example of the opposite of theme of voicelessness. Rating: 8 – greatly helpful Other notes: “Intense session” – hard to break down and analyze - Did not experience release from memory, question whether it can be released. - May feel a barrier to releasing because of family “rule” to be compliant - Physical sensation of constriction (voice) similar to memory but feels also like a different theme. 2-year-old self felt that she had a right to know parents would be away and that this right was violated. Therapist TSNQ form Most helpful/important event: When back in source memory fear came up, [2-year-old feared that mom wasn’t able to come to help her because] “mom is dead” – client found it hard to stay with her child self. When going through timeline was shaking/tightening various point in her body intermittently. Rationale for choice: Seemed to access core fear/memory about aloneness. Client appeared to be activated but able to stay within her window of tolerance. Rating: The fear appeared to be a 3 in the moment ultimately 7.5 because of the ability to integrate an early/core fear. Other helpful event: None. Anything hindering: In the present with child self, client found it very difficult to use her voice or confront her parents imaginally. She appeared stuck and immobilized almost. Rating: 2.5 – greatly to moderately hindering INTEGRATING EGO IDENTITY WITH LI THERAPY SESSION 347 LI Protocol: None – client reported challenges 29 Jan. 31 60 min. No. of TL repetitions: N/A Session Summary (therapist session notes): Client reported challenges filling out HAT form. Discussed family rules about logic/reason being what’s trusted and not able to think critically about family in a way that acknowledged her pain. [At exit:] Client’s nose started to bleed excessively after she said “I can tell the truth and love my mom and dad” – she was unable to stop the nosebleed, so session ended early. [Other:] It seems as if a significant shift occurred in the client today. Client HAT form Most helpful/important event: When the therapist speaks of a new story and naming the hurt does not make me a bad person and I’m not wounding anyone. I realized that I could admit the hurt from Mom and Dad while also loving them and the therapist had me say it out loud a second time which was hard to do but I did it. Then the therapist said that admitting it or naming the hurt doesn’t mean my parents are monsters, or didn’t do the best they could, or that I didn’t love them. Rationale for choice: In what I said and what the therapist said we hit the core emotional center of the block, the resistance, the iron door that prevents me from allowing family hurts to be acknowledged and healed. Hit the nail on the head and spoke out loud /made ‘real’ the secret fears of my heart – making healing a real possibility Rating: 9 – extremely helpful Other helpful event: The therapist, in sharing her thoughts, shared the paradox of this conflict wherein to heal and move past the block I must engage in the very activity this block will not allow to happen. I remember internally saying, “Yes, yes, YES!” I feel extraordinarily seen, known, understood. Rating: 9 – extremely helpful Anything hindering: None. Therapist TSNQ form Most helpful/important event: Client reported wanting to be “free” and heal her pain but realizing that she may have to acknowledge family wounds to do so – “to tell the truth about my pain is to break a family rule.” Rationale for choice: Client was able to identify a blocking belief/system from her family of origin which has impaired her ability to find/access her voice. Client is also expressing motivation/longing to move forward in her identity development and differentiation. Rating: 9 – extremely helpful INTEGRATING EGO IDENTITY WITH LI THERAPY 348 Other helpful event: The client was able to notice/identify/name for herself a new ‘rule’ moving forward = “I can tell the truth about my experiences AND love my mom and dad.” Realizing that those don’t need to be in conflict. Rating: 9 – extremely helpful Anything hindering: Client described an overwhelming guilt about expressing her feelings, if they might be perceived as critical of her parents, almost self-silencing in session as if her parents were listening. Rating: 2.5 – greatly to moderately hindering SESSION LI Protocol: Standard protocol 30 Feb. 13 60 min. No. of TL repetitions: 2 Session Summary (therapist session notes): Client’s birthday. Client reported feeling attached to God, and embodied (“my body is me, I am my body”). Colleague at class noted to her that she appeared to be glowing. Then transitioned to continue timeline work with belief “my parents love me and let me down.” Did an affect bridge with pain in chest to 2-years-old (mom crying but not sure why?). [At exit:] Integration is continuing, and client appeared to be well attuned to the younger self and was able to know in all parts of herself that she no longer needed to protect her mother, at least hypothetically from her feelings. Client HAT form A Most helpful/important event: Happened sort of in two part – the therapist hypothesizing and my enacting, but the enacting is the most important one. In timeline #2 the therapist prompted me to say to my child self whatever she needed to hear. I found myself telling her that we don’t have to take care of Mom. And then tearfully and with difficulty sharing this with the therapist. Rationale for choice: I had NO idea that was what I was trying to do – emotionally take care of Mom – or that this pattern might have started so young (age 2). But in putting 2 and 2 together it all started to make sense: why the memory had stuck with me, why the block was so strong, why things focused on my Mom. And I had no idea how heavy that burden was! Rating: 9 – extremely helpful Other helpful event: Me trusting the memory my body connected to. I couldn’t see any connection with this paralysis of speaking that we were working on – and yet I went with it. INTEGRATING EGO IDENTITY WITH LI THERAPY 349 Rating: 9 – extremely helpful Anything hindering: None. Therapist TSNQ form Most helpful/important event: Bringing 2-year-old to present, was able to hold her and cuddle her on the couch. Said to child self, “We don’t have to take care of mom.” Rationale for choice: Client and therapist hypothesized that this experience may have been connected to the belief, “I have to take care of mom, so I can’t tell her how I really feel about things,” or “there isn’t space for my feelings.” Rating: 8.5 – greatly to extremely helpful Other helpful event: Client demonstrated the ability to hold within herself the knowing that she both loved her parents and they loved her, and they weren’t perfect. Client was able to tolerate the pain of this. Rating: 8 – greatly helpful Anything hindering: During first timeline, client was unable to share the memory at first. Appeared to be speechless/immobilized. Rating: 3 – moderately hindering SESSION LI Protocol: Standard protocol 31 Feb. 21 60 min. No. of TL repetitions: 2 Session Summary (therapist session notes): Client learning about inner consent. The expressed fear about her mother reading her thesis but was able to know they are different people: “we can have our own reactions.” Continued timeline work with memory used in last session. [At exit:] Client appears to have internalized the knowing at a new level that her mom’s reactions are not about her. They are their own people. Client appeared ‘moved’ by the integration occurring. [Other:] Mentioned that next session is last session. Client HAT form Most helpful/important event: When I shared with the therapist how, while showing the Timeline to little ME, I talked to her about the events as things she and I had done together - e.g., “We taught line dancing at our 40th birthday party" Rationale for choice: This is important because it is the first time through any timeline when there was a distinct recognition that my younger self IS me as we were going through the Timeline. We were INTEGRATING EGO IDENTITY WITH LI THERAPY 350 travelling through the memories together and there was the knowledge that we BOTH experienced the events together. Rating: 9 – extremely helpful Other helpful event: In the second Timeline little ME and I went to talk directly to Mom. I explained how upset little ME was and how she was confused by Mom's emotions. In that moment I was both little ME and older ME. This was important and helpful because it is the first time, I was able to speak directly to Mom about my hurt/pain even in my imagination. Rating: 9 – extremely helpful Anything hindering: While it was pretty clear that the memory of seeing my mom cry was not yet resolved, I had difficulty accessing my younger self within the memory when we first started the Timeline. It was only slightly hindering as the therapist helped me get back into the memory by first being my adult self in the memory and then my younger self. Rating: 4 – slightly hindering Therapist TSNQ form Most helpful/important event: Both parts (adult and child) were delighted about her timeline, specifically teaching line dancing at her 40th birthday. She noted that when merging she felt herself “fully bringing it all into herself.” Rationale for choice: Client demonstrated a delight/pride in her own story, appeared to integrate in a way which felt ‘deeper’ and more wholistic (including somatic). Rating: 8.5 – greatly to extremely helpful Other helpful event: During second retrieval, 2-year-old spontaneously jumped into her mother’s arms and asked, “Did I do something wrong?” and mom said “No”, that her heart was just hurting. Rating: 8 – greatly helpful Anything hindering: None. SESSION LI Protocol: None -termination session 32 Feb. 27 60 min. No. of TL repetitions: N/A Session Summary (therapist session notes): Discussed the ending of the clinical work together. Reflected on the work/growth/change since September. Therapist provided a summary of key moments. Big release of emotion when hearing back all that has happened. Did a mindfulness exercise to ‘savor’ the goodness. Some INTEGRATING EGO IDENTITY WITH LI THERAPY 351 sadness that she went so long without feeling this way. [At exit:] Client appeared both sad, and grateful. Grounded and like she has some grief. [Other:] It was a great joy to see the client better able to take in the therapist’s feelings about her without as much defense against them – she was able to feel the sadness of how long she went without being able to take in others good feeling about her. Client HAT form Most helpful/important event: The therapist reviewed the work we had done together since August - she went week by week and mentioned what we had done and significant changes that had occurred. Rationale for choice: I was surprised that we had done so much work in such a short time frame. I had it in my mind that what she was describing was the scope of what we had done since May, not since August. I was doing my Change Interview the next day and was in a head space of wondering if anything had really changed since the last change interview in August, so this recap really helped to put things in perspective. Also, I had been worried that we really hadn't spent much time working on repatriation stuff and had spent most of our time working on other time frames, but when she recapped our sessions I realized that we had in fact spent a significant number of sessions with my 11-year-old and that meaningful shifts had happened there. Rating: 9 – extremely helpful Other helpful event: As this was our final session the therapist reiterated her love and care for me and expressed being proud of me and the work that we had done together. As we celebrated this together again there was an internal pull towards and push against being seen and celebrated in this way. It started off very positive and enjoyable but then I would feel myself trying to escape and hide away from being seen, as though too much of a good thing was something to fear and distrust. Sitting in that place of seeing the therapist celebrate me and trying to accept that celebration and positive regard and take that in was difficult but a good type of challenge. I shared that I thought this was difficult because it is not something I have experienced much in my life but it is something I crave and need so learning to recognize my response to it and learning to accept positive regard, trust it, and internalize it is very helpful. Rating: 8 – greatly helpful Anything hindering: None. Therapist TSNQ form Most helpful/important event: Client appeared to have cathartic emotional release when hearing about what she had done. Really ‘took in’ her ability to heal, change rules around sexuality, emotions, voice, family rules, etc. Feels grown-up and her age. INTEGRATING EGO IDENTITY WITH LI THERAPY 352 Rationale for choice: Client appeared to realize in a new way the magnitude of the work she has done and feel the goodness of herself while also feeling some grief about how long she went without it. Rating: 8.5 – greatly to extremely helpful Other helpful event: Client was able to stay with (to tolerate her delight and positive affect towards herself and from the therapist, while deepening it in mindfulness exercise. Rating: 7 – moderately helpful Anything hindering: Client expressed fear of losing her newfound groundedness – occurred near the beginning of the session. Rating: (None provided.) INTEGRATING EGO IDENTITY WITH LI THERAPY 353 Life Events During Therapy May-Aug. 2018: In May and the beginning of June Rose enjoyed a few week-end day trips exploring the beauty of BC with friends. She continued working part-time (10 hrs./week) at her administrative job and took one graduate course, research seminar, during this semester. She experienced significant levels of anxiety, avoidance, and dissociation while working through the stages of preparing and writing a first draft of her thesis proposal. In August she continued to work on thesis proposal assignments but was also able to take a week of vacation in BC with her sister as well as a second week off work and school before the beginning of the Fall semester. During May, June and part of July she continued to attend church on a weekly basis. Sept.- Dec. 2018: Course work from research seminar remained unfinished so Rose was granted an incomplete in the class with the understanding that all outstanding assignments would be submitted by December 31st. She completed the first section by early November and then spent her Christmas holiday time completing the second section. Her experience of working on her second draft was still challenging but significantly more positive and manageable than the first round. This was Rose’s first time in her life not spending Christmas with her family (Mom, Dad and sister). While continuing to work part-time (10 hrs./week) and taking 2 graduate courses, Rose also began a new internship on campus for half a day a week which she enjoyed. This Fall semester and the Spring semester in 2019 were Rose’s biggest course loads in her master’s program since beginning in September 2016. At the start of the Fall semester Rose is no longer attending weekly church services. Jan.–beginning of April. 2019: Rose continued her half day internship and continued moving forward with her thesis work (mainly therapy and data collection), as well as taking her final 2 graduate courses in her program. INTEGRATING EGO IDENTITY WITH LI THERAPY 354 Change Interviews Overview The Change Interview is a semi-structured interview that is conducted at minimum at the post-therapy and follow-up point. Each interview was conducted in person with Dr. Janelle Kwee at her office on campus. Further details (dates, length, etc.) are included below. Mid-therapy Change Interview Aug. 8 – between session 14 and 15 Change of interview format from in-person to virtually (online) with use of Zoom (web-based video conferencing system). 115 min. (1hr 55m) For full transcript see Appendix C. Post-therapy Change Interview Feb. 28 – day after final session (#32) 97 min. (1hr 37m) For full transcript see Appendix D. Follow-up Change Interview April 4 – 35 days after therapy ended 88 min. (1hr 28m) For full transcript see Appendix E. Summary of Change Interview Qualitative Responses    MT = mid-therapy PT = post-therapy FP = follow-up 1. General Questions: 1a. Any changes to relevant medications. For what Interview Medication symptoms MT Pristiq (SNRI) Anxiety PT Pristiq (SNRI) Anxiety FP Pristiq (SNRI) Anxiety For how long 8 years 8 years Dosage 100 mg 100 mg 8 years 100 mg Last adjustment 1.5 weeks ago None since MT. None since MT. 1c. What has therapy been like for you? How has it felt to be in therapy? Interview MT  Intense: accessed core base emotions, self-appraisals and worldview beliefs that have remained untouched to this point.  Surprising: changes just appeared accompanied with a reaction, “Woah! This is different. This is weird.” / Surprised by how difficult it was to follow her instincts and intuitions in the imaginal work of LI therapy. INTEGRATING EGO IDENTITY WITH LI THERAPY    355 Encouraging: “I see things emerging that I …have hoped for … a long time but wasn't getting through talk therapy or other kinds of therapy. We just weren't achieving…. And [also changing] things I didn't even really realize were there.” Vulnerable and exposing: “there's a whole lot that goes on that the therapist never really knows about…so [it’s] even [exposing] to yourself… encountering parts of yourself that are very vulnerable…or you maybe haven't been with for a very long time… Or even...episodes that I have not really allowed myself to recognize… I emotionally recognize them as being hurtful but haven't really allowed myself permission to-to let them be that.” Empowering: allowing her real experience to be what it has been without it being quantified and compared to some measure of adversity or to somebody else’s experience. / body stance standing up tall and strong with face turned upwards and arms stretched upwards. “I've been through a lot in my life. Even though on the outside it doesn't look like it, my internal experience of it has been quite enormous. And to just recognize that and allow myself … to let my life be what I have experienced it to be - regardless of what someone on the outside might evaluate it to…. And I've made it…. I had a really difficult time and I've crumbled but I also survived. And I'm here to thrive now….there's almost like a fighting…. like [a] gladiator sense behind it,” PT  Surprising: “something just appeared out of nowhere. Kind of like, "Where did this come from?" Where I can't like trace thought process that got me there,” Organic: Not forced. Not conjured. We went where I needed to go. Rollercoaster ride: “we had kind of touched on one issue and it felt like it settled, but then another thing would come up and I would feel like I was all - … discombobulated… I felt like all...confused and uncertain, again. And then we'd work through that and it would come down again.” Genuine: “a real encounter with self in the midst of it Free: “letting go of needing to, like, understand it and just be in it” Connection/attachment with the therapist.     Dedicated time to focus on self and growth. Positive attuned relational experience. Intimate: with Hillary and with self. Rediscovering and meeting ‘lost’ pieces of self.      FP INTEGRATING EGO IDENTITY WITH LI THERAPY  356 Intuitive: going with the flow and allowing inner intuition and not cognitive reasoning to lead the way. 1d. How are you doing in general? Interview MT  Feeling - ‘Stirred’/‘Evoked’/‘Raw-er’  Movement is happening. Things are shifting.  “So, in one sense it's like it's worse, but it's worse with help and change and potential for something different…. [T]his is actually something I've been feeling for really, really long time. It's just, all of the sudden now, I'm letting it be felt…And while that's like overwhelming and scary, there are changes happening that I feel like are moving that. And so, if those changes weren't happening then, yeah, I would say it was a disaster and I needed to run away…. [B]ut because those changes are happening, then…there’s a sense of…those two things are coexisting at the same time.” PT  Coming into new growth: Navigating a new relationship with her emotions and who she is in the world. Figuring out how to wear these new changes – how to wear the new me. FP     Sadness: grieving the end of therapy, the loss of the attuned relationship with her therapist, and the dedicated time to work towards further growth. Fearful: afraid that nothing had really changed and that she was heading right back to where she was pre-therapy. a return to post-therapy baseline. return to feeling more grounded and centered in herself. “…like, I kind of came out of it not sure whether I could handle life again…. And now it's kind of, ‘You know what? And I made it even through that, and through life. So, we're okay. We can, we can do this." 2. Description: 2a. How would you describe yourself? Interview MT Rose described herself as:  funny,  enjoy laughing,  resilient,  brave,  creative. PT Rose described herself as: INTEGRATING EGO IDENTITY WITH LI THERAPY           FP         357 a whole person: Recovering younger selves Recognizing self in childhood memories I am 45. And that's important because I feel like I grew up a lot (laughs) over the last 6 months. Joyful, positive, intelligent, funny, lively, sociable. Smart: Acknowledging it herself, “I am!” Not just academically smart but also creatively smart, technologically smart, socially smart. Emotionally smart. Culturally smart. Generous and applied ‘smarts.’ Brave. Strong: Determined. Beautiful: Reclaiming this word for herself after it’s dangerous use in the abusive relationship. Funny: although sometimes Rose recognizes this as more of a coping mechanism than an authentic expression of self. Not selfish. “I’m me.” Hardworking: “I’m not as lazy as I think myself to be.” and easy content 2b. How would others who know you well describe you? Interview MT  Introspective: “…they know I’m always thinking about - What is the meaning of that? ….Why did that happen?”  Smart  Lover of animals. Rose hopes other see her as:  caring and loving PT     Joyful. “Coming into yourself” Organized. Outspoken: “but I don't - like not the negative out-spoken but more like able to communicate what they're thinking, feeling kind of thing.” FP  ‘Gentle’ (opposite of aggressive or pushy) INTEGRATING EGO IDENTITY WITH LI THERAPY     358 Wise Generous Funny Fun to be with 2c. If you could change something about yourself, what would it be? Interview MT  How much fear has directed and controlled her life (less fear of the unknown)  Increase of inner confidence and inner knowing. PT    FP  Shape of her body. How much TV she watches. Her relationship with God: continued movement forward. Relationship she has with her body. “what that, what it means for me to exist in this body and to, not always like my body, but to understand that it's part of me. It is me.”  Anxiety to be gone for good. 3. Changes: 3a. What changes, if any, have you noticed in yourself since therapy started? For answers to this question see section on Summary of Change Interview Quantitative and Explanatory Evidence (starts of p. 338). 3b. Has anything changed for the worse for you since therapy started? Interview MT  Emotions are more raw.  Experiencing more tension in her relationship with her mother and father  While being ‘worse’ these factors also reflect growth in allowing emotional responses space to be, and in a “bursting out of constraints…[and] freedom.” PT   Healthy eating patterns. Feels less grounded and centered at end of therapy than midway through as new stuff (family rules) has been opened up. FP  Having experienced an attuned reparenting and attachment relationship in therapy brings to the surface feelings of grief for what wasn’t. 3c. Is there anything you wanted to change that hasn’t since therapy started? Interview MT  Angst of being in-process: o uncertainty and fear of where we are heading, INTEGRATING EGO IDENTITY WITH LI THERAPY 359 o wondering if change will continue, o what things will look like in the end. “I’m in the midst of discovering me and finding a voice and ... understanding how to speak out of that voice…in the midst of exposing shame and disempowering shame…. [M]y hope is that that those will increase and continue …. I mean my ultimate hope is that at the end I can get to that standing tall, feeling strong…. I don't even know what that feels…. Joy? …. taking up space and making myself known…. [T]hat's been my dream for a very long time and my hope is that I can get there.” PT  Spirituality: connection to God. FP   Improved sleep patterns. Relationship with God. 5. Attributions: In general, what do you think has caused these various changes? What do you think might have brought them about? (Including things both outside of therapy and in therapy.) Interview MT  Importance of authentic and attuned attachment relationship with Hillary (therapist).  Being coached in how to provide attunements to other younger parts of herself.  Working jointly with therapist to give attention to earlier needs that weren't met creates safety for self to emerge, be present, speak, be.  Rose describes this as transformative - something that she was hungry for. PT “Pretty much for all of them, like, I can't attribute it to anything except for therapy. 'Cause outside life` - outside of therapy life - was either largely remained the same or got more stressful and actually would have pulled me the other way.”  Taking agency: “in session I was taking agency of parts of my life [I: Yeah.] through memory.”  “Going back and meeting needs that weren't met through imagination.”  “Empowering younger memories to have agency in moments they didn't.”  “Or to speak out in moments that in real-life they hadn't.”  “the experience of, like, being seen and being known by my therapist….Being experienced by her” INTEGRATING EGO IDENTITY WITH LI THERAPY   FP  360 “really important to have each of those selves that I connected with come back to present day and... see where we are now, and see what life is now.” Comfort: for younger selves to become increasingly comfortable in the present-day home over multiple repetitions of the Time Line. Getting me connected to myself: "I have the capability of protecting and caring for myself in the midst of that, um, in the midst of life or whatever life brings." 6. Helpful Aspects: What has been helpful about your therapy? Interview MT  Client-therapist attunement  experiencing freedom within the therapy process – to go where it needs to go, including giving feedback as to what her needs were  therapist not being surprised or derailed even when needing to move outside of regular protocol processes  Flexibility of both Rose and therapist – adapting each session as needed. PT  Beginning with attunement protocol: establish “a different kind of care-giving relationship that I had previously known….There was greater safety.” FP     Beginning with attunement protocol Returning to specific memories Interacting with younger selves Client openness to the therapy process 7. Problematic Aspects: 7a. What kinds of things about therapy have been hindering, unhelpful, negative or disappointing for you? Interview MT  Need to nod after each memory cue: split her focus between connecting with the memory and remembering to nod. Eventually became more of a habit.  Getting in her own way: fighting her own intuition and trying to control and change what was emerging organically - inner struggle for freedom of experience. PT  Online therapy: not significantly hindering but had to make adjustments to online/virtual format. FP   Ending. Transition to online. INTEGRATING EGO IDENTITY WITH LI THERAPY 361 7b. Were there things in therapy which were difficult or painful but still OK or perhaps helpful? What were they? Interview MT  Rose reported that there have been painful yet still helpful aspects along every part of this therapy journey, and even in every LI therapy session. PT FP  Addressing family rules: “that we went and we actually addressed straight on the whole like, 'I need to be silent. I can't tell my mom. I can't tell my dad….And that was extremely difficult, like, paralyzingly silent….[but helpful]. … excited to see kind of where it rolls out.” “Every single session.”  Difficult memories  Big emotions 7c. Has anything been missing from your treatment? Interview MT  More time for debriefing and sharing of experiences happening between sessions. – need to get right down to work in session (fit in multiple Time Lines)  Occasional email contact between session helped mitigate the effects. . NOTE: Upon review of a number of video recordings of sessions it became evident that more debriefing occurred at the start of session than Rose was aware of. Often times LI Time Line repetitions did not start until hallway through the session. PT  Reconnection: One more in-person session with Hillary. FP  Reconnection: One more in-person session with Hillary. 8. Suggestions: 8a. Do you have any suggestions for us, regarding the research or the therapy? Interview MT None. PT   Make use of the daily tracking of PQ items for more accurate tracking of targeted behaviours. (Develop an app for ease of use.) Research what is going on in the body and mind that created these surprising and unexpected – even unconscious changes she experienced. INTEGRATING EGO IDENTITY WITH LI THERAPY FP  362 Recommend LI and research to everybody! 9. Review Personal Questionnaire (PQ): 9a. In general, do you think that your ratings mean the same thing now that they did before therapy? If not, how has their meaning changed? Interview MT  Generally, PQ ratings have remained the same.  Self-medicating: was consistently measured based on occurrence instead of distress level (different 7-point scale)  Sleep: a mix of both occurrence and distress level.  Self-sabotage: at first also included eating habits, however, was fine-tuned at some point during the first 14 session to no longer include them. . PT   FP Change in baseline/normal or range: Increased sensitivity to distress and ability to tolerate ratings at end of therapy may have reflected greater changes than are captured by the rating as a current rating of 4 may have previously been a 3. There was a change in how daily ratings were used to arrive at a summative rating for the pre-session report. Understanding of what the PQ items mean has changed over the course of therapy – more nuance. Less of a tolerance level – higher scores for less distress. INTEGRATING EGO IDENTITY WITH LI THERAPY 363 Summary of Change Interview Quantitative and Explanatory Evidence Mid-therapy RCR Table 4. General change list and ratings at mid-therapy Change Change: was: Without Where more explanatory information was 1 - expected therapy: 1 - unlikely provided regarding the rating of a change 3 – neither 3 – neither item this is provided as a footnote to the 5– table. surprised by 5 – likely IMPROVEMENTS 16. Negative thoughts no longer directly correlate to level of 5 2 distress. 17. Self-medicating poor choices no longer resulted in shame and self- 4 1 blame 18. Swell of anxiety emerges with an increasingly powerful sense of anchor in ‘ME.’ More detached 5a 1 from emotions and not as overwhelmed by them 19. Duration of negative emotions 3 3 has decreased. 20. Experientially (not cognitively) allowing and inviting younger ego states to play intentionally 2 4 and organically (e.g., buying and playing with Lego for 7-year-old self). 21. Becoming aware of the role 4 1 shame has played in life. 22. Seeing self – seeing ‘ME’ – as more continuous throughout life, and not just divided by pre- and post-repatriation. 23. Show up with more voice. Being less apologetic about being ME because of gathering pieces of self. Importance: 1 – not at all 2 – slightly 3 – moderately 4 – greatly 5 - extremely 4 5 5 5 4 4d 5 1 5 4 1 5 INTEGRATING EGO IDENTITY WITH LI THERAPY 24. Awareness that there is a ‘ME’ to encounter and express. Not a compilation of other people’s ‘shoulds’ but a ME that is core and unique. 25. I love me, truly and authentically (not just lip service) and I can speak and feel positively about me. 26. Close friend has noticed changes in ability to speak positively about self and changes in sense of groundedness/ centering/ finding footing. 27. Greater spiritual connection. 364 4b 1 5 5 1 5 4 1 4 5 2 5 WORSENED 28. Emotions are more raw. 1 2 5e 29. Relationship with parents is changing; becoming more 5 1c 4/5f strained. 30. Uncertainty and fear about 3 1 4g reaching goals (angst). a Before therapy Rose hoped for a change in core self strength but the way that it is happening is quite surprising to her. Previously she had an either/or mentality: either she was anxious/overwhelmed OR anchored in a core sense of self. This discovery that both are possible at the same time – being anxious and feeling anchored simultaneously – is quite surprising and seemingly incongruous. b Rose described this differently cognitively versus experientially; she wished for or hope for more, expected it cognitively, but experientially it was more surprising. The rating provided here is based on her experiential description. c Rose was divided with this rating as it was always possible for this to change and move towards greater tension, but the fact that it was occurring at this particular time she attributed to being a by-product of therapy (therapy could definitely be blamed for its appearance at this point and time). d This rating reflects the significance/importance of the insight regarding shame, not the importance/significance of shame itself. e This was a difficult one to rate but ultimately reflected the importance to Rose of connecting to her emotions: “from a life of having suppressed emotions and dismissed them…being able to give them space to be and to be heard and to be felt is very important.” f This rating reflects the importance Rose places on being able to be a separate entity within the family system and depends on whether she’s looking at the pain of separating self from family or the part that connects to her individuation. g This rating reflects Rose’s sense that she still hasn’t arrived and yet is also not resigned, but instead she is hopeful, living in the experience, and moving forward. INTEGRATING EGO IDENTITY WITH LI THERAPY 365 RCR Table 5. PQ items change list and ratings at mid-therapy Rating change Change: – pre-therapy Where more explanatory to midChange therapy was: information was Without provided regarding the daily (D) & 1 - expected therapy: rating of a change item summative 3 – neither 1 - unlikely this is provided as a (S) PQ ratings 5 – 3 – neither footnote to the table. D S surprised by 5 – likely IMPROVEMENTS 31. Decrease in feelings of shame about who 2.6 2.5 3 1 I am and who I've been. (PQ item #1) 5 32. I feel I don’t belong. (PQ item #3) 1.8 2 Despite 2-point change in ratings, Rose chose to not include this item in change list at this time.a 33. Less frequent interruptions in sleep patterns and less distress at interruptions. (PQ item #6) 1.9 2 4 3 Despite 2-point change in ratings, Rose chose to not include this item in change list at this time.b 2.3 2.5 4 2 5 2.6 2.5 5 1 4 3 3 4 3 3 34. I self-sabotage my own goals. (PQ item 3 #7) 35. Less time stuck in an avoidant pattern and less shame when it occurred. (PQ item #9) 36. More acceptance of using food to cope with stress. (PQ item #10) 37. More acceptance of self-medicating behaviours. (PQ item #11) a Importance: 1 – not at all 2 – slightly 3 – moderately 4 – greatly 5 - extremely 3 4 The reason for why this item was not included in the change list at this time is that Rose’s circumstances changed significantly since pre-therapy (i.e., spending a lot of time INTEGRATING EGO IDENTITY WITH LI THERAPY 366 alone getting thesis work done with no classes) and therefore it is unclear if the change is related to therapy at all. b Rose did not include this PQ item in the change list at this time due to having refined what was being tracked, no longer including eating habits and food choices, and therefore being unsure as to whether ratings accurately reflected a change. RCR Table 6. PQ items change meaning and rating accuracy at mid-therapy Change Change Rating Meaning Accuracy 16. Decrease in feelings of Rose reported that shame about who I am and Unsure. ratings accurately who I've been. (PQ item reflected change. #1) 17. I feel I don’t belong. (PQ item #3) Rose reported that ratings accurately 18. Less frequent interruptions Rose hopes that this means she is reflected change in sleep patterns and less experiencing less distress but advised being distress at interruptions. overall. unsure of whether it (PQ item #6) was truly significant 19. I self-sabotage my own goals. (PQ item #7) 20. Less time stuck in an avoidant pattern and less shame when it occurred. (PQ item #9) Rose advised that this item appeared to be closely related to shame, feeling overwhelmed by negative emotions and these feelings not lasting as long. Rose reported that ratings accurately reflected change. INTEGRATING EGO IDENTITY WITH LI THERAPY 367 21. More acceptance of using food to cope with stress. (PQ item #10) Rose advised that the change reflects an acceptance of what is; accepting that eating habits are also connected with selfprotective weight gain due to assault which is a common response to this sort of trauma. Rose also advised that in accepting what is, she found herself using food less for coping with stress. Rose reported that ratings accurately reflected change. 22. More acceptance of selfmedicating behaviours. (PQ item #11) Rose advised again that the change reflects an acceptance of what is; accepting that these self-medicating behaviours again connect with selfprotection due to the trauma of the experienced assault. Rose reported that ratings accurately reflected change. INTEGRATING EGO IDENTITY WITH LI THERAPY 368 Post-therapy Changes generally occurred between September 2018 and February 2019. RCR Table 7. General change list and ratings at post-therapy Importance: 1 – not at all Change: Change was: Without Where more explanatory information 1 - expected therapy: 2 – slightly 3 – neither was provided regarding the rating of a 1 - unlikely 3 – moderately change item this is provided as a 5 – surprised 3 – neither 4 – greatly footnote to the table. by 5 – likely 5 - extremely IMPROVEMENTS 11. Not experiencing triggers related to abusive relationship (in 2009). 2a 1 5 12. Not as activated by potentially negative feedback. 5 1 5 5 1 5 4 1 5 (+) 3 1 4.5 5 1 4 5 1 5 18. Taking back agency of own life. 3 1 5 19. There’s a continuous “me” in what I do. 5 1 4 20. I have a more positive relationship to my sexuality. 5 1 5 13. Realized I’ve lived 45 years and handled a lot of things in life. Feel my own age and feel capable. 14. Loss of childhood fear base. Sees life as a capable adult and not fearful child. 15. Taking self into consideration when planning activities, making decisions. Improved attention and care for self. 16. Spontaneous awareness of own boundaries and needs in therapy sessions. Increased attunement to self in other places as well. 17. Able to release responsibility for others and to tell own truth – own “what’s mine.” a Hoping vs. Expecting: While Rose hoped that this therapy could help with the triggers, past experience of therapy not resolving the triggers left her doubtful that it could actually happen. There was, however, something in her that drew her to believe with LI it might just be possible. INTEGRATING EGO IDENTITY WITH LI THERAPY 369 RCR Table 8. PQ items change list and ratings at post-therapy Change: Rating change – pre-therapy to Where more post-therapy explanatory information was summative (S) & daily (D) PQ Change was: Without provided regarding the rating of a ratings 1 - expected therapy: change item this is 3 – neither 1 - unlikely provided as a S D 5 – surprised 3 – neither footnote to the table. by 5 – likely IMPROVEMENTS 21. I feel less shame about myself (who I am and 3.5 3.5 4 1 who I’ve been). (PQ item #1) Importance: 1 – not at all 2 – slightly 3 – moderately 4 – greatly 5 - extremely 5 22. Not ‘should-ing’ as much. (PQ item #2) 3 2.5 4 1 4 23. Increased sense of belonging. (PQ item #3) 3.5 2.9 5 1 5 4 3.2 5 1 4 3 3 2 1 5 4 3.3 5 1 4 2 1.7 3 2 4 24. Increased ability to handle things that were fearful before. Decrease in fatalistic view of failure. (PQ item #4) 25. Feeling more present in the moment. (PQ item #5) 26. I have more freedom relative to pre-conceived goals. (PQ item #7) 27. Able to make decisions more confidently. (PQ item #8) INTEGRATING EGO IDENTITY WITH LI THERAPY 28. I avoid less. (PQ item #9) 29. I experience less distress around eating. (PQ item #10) 30. I no longer use some previous poor strategies for selfmedicating. (PQ item #11) 31. I have a greater acceptance of my limitations and weaknesses. (PQ items #12) 32. I think less in “all-or-nothing” ways. (PQ item #13) 33. I have a voice and can use it with confidence to express my opinions and viewpoints. (PQ item #14) 370 3 3 4 1 4 3 2.6 4 2 3 2.5 1.8 4 3 4 2.5 2.6 4 2 4 4 4 3 1 3 2.5 2.5 5 1 5 INTEGRATING EGO IDENTITY WITH LI THERAPY 371 Follow-up RCR Table 9. General change list and ratings at follow-up Change was: 1 - expected 3 – neither 5 – surprised by Without therapy: 1 - unlikely 3 – neither 5 – likely Importance: 1 – not at all 2 – slightly 3 – moderately 4 – greatly 5 - extremely 20. Change in relationship to body – realization of being in full control.a 5 1 4 21. Improvement in ability to follow through with a desire. Being me and allowing me to be me.b 5 1 5 3 1 5 5 1 5 5 1 5 Change: Where more explanatory information was provided regarding the rating of a change item this is provided as a footnote to the table. IMPROVEMENTS 22. Receiving feedback and not being thrown or panicked as much as previously, plus recover more quickly.c 23. Ability to experience positive and real attachment. Craving more of being held, cared for, accepted and loved. 24. watching habits have shifted organically. Less need for TV especially in morning and at bedtime. a “…my relationship to my body is changing and . . . even the discovery that . . the realization that I am in full control of my body. Um, I had no idea I had actually thought other people had control of my body … I read it in an article, which I know is something I've read before but this time it smacked me in the face. And I was like, "That's not true! My body is not my own." And I was like, "Whoa!" "Where did that come from?" b “… there has been a desire throughout my life to, like offer help to people when they're going through difficult times, but I've rarely every followed through with it. … now once in therapy and now once after therapy, I've actually done it. … "Hm. Never really done that before." … it was being me. Allowing me to be me….on the flip side of that is also like not feeling guilty that I don't want to do that for everybody.” c “…holding onto my voice because I think that this is particular, like I don't feel this way every time I get feedback on an assignment. Right, like this particular project [thesis] has been very different because it's me speaking. It's me being in the world, right? [I: yeah] And so, that ability to kind of navigate that and say, "No, I have a voice and it's a good voice and it's a strong voice and we can be there." And like allow myself to have space in INTEGRATING EGO IDENTITY WITH LI THERAPY 372 the world, um, has that transitioned from like full panic to like, "No, it's okay if I have a voice in the world" RCR Table 10. PQ items change list and ratings at follow-up. Rating change – pre-therapy to follow-up: Change summative was: Without (S) & daily 1 - expected therapy: (D) PQ 3 – neither 1 - unlikely ratings 3 – neither 5– Change S D surprised by 5 – likely 25. I feel shame about who I am and who 5 4.8 5 1 I've been. (PQ item #1) 26. I'm not enough ('should-ing'). (PQ 4 4.2 5 2 item #2) 27. I feel I don't belong. (PQ item 4 3.6 5 1 #3) 28. I have a fear of failing at life. (PQ 3.5 3.1 5 2 item #4) 29. I have trouble feeling present in 3 2.2 5 1 the moment. (PQ item #5) 30. My sleep is interrupted – improved sleep 3 2.6 5 1 patterns. (PQ item #6) 31. I self-sabotage my own goals. (PQ 4 3.6 5 1 item #7) 32. I cannot make decisions. (PQ 2 1.7 4 1 item #8) 33. I am stuck in an avoidant pattern. 3 2.4 4 1 (PQ item #9) Importance: 1 – not at all 2 – slightly 3 – moderately 4 – greatly 5 - extremely 4 5 5 5 5 5 4 5 5 INTEGRATING EGO IDENTITY WITH LI THERAPY 34. I use food to cope with stress – eating less about coping. (PQ item #10) 35. I self-medicate my own pain with poor strategies (not level of distress). (PQ item #11) 36. I don't accept my limitations/ weakness. (PQ item #12) 37. I have a tendency to think in "all-ornothing". (PQ item #13) 38. I don't feel confident in my own opinions/viewpoint s. (PQ item #14) 373 4 3.7 5 2 5 3 2.6 4 1 5 4 3.4 5 1 4 3.5 3.1 5 1 3 3.5 3.3 5 1 5 As you recollect, do you feel like a fair reflection of where you were and where you are.? “Yeah, I think what probably has changed . . . not so much my ratings, but…my experience of distress at the same behaviour has gone down. Like the behaviour may not have changed but I view it differently …like number 5 - I have trouble feeling present in the moment. That is a very- It's more objective. And that has gone from like …a 4 …. But there's was days where it was a 6 or a 7. And I haven't gotten to a 6 or a 7 for quite a while” INTEGRATING EGO IDENTITY WITH LI THERAPY 374 Ego-Identity Journal Entries and Personal Communication August 11, 2018 Personal communication – texts with Kristin and Vanessa ME: Okay well one question part of me knows the answer to but another part just needs to hear it again: will you ladies still love me if I don’t make it into thesis? If I don’t make the grade? (It’s one thing to choose not to do it - another to not make it in.) Kristin: Not even a hesitation in saying “of course! ” - a friendship not conditional on anything like grades or thesis or whatever pursuit.  ME: You won’t think less of me? (Man, the voice asking that question is SO young!! Crazy!) Vanessa: Puh-leeeeeez! Share Bare. Love you always!!! Always golden to me! Kristin: No, Rose, not at all. You could drop out of the program and build a log cabin in the middle of the woods and I would still respect and admire and love you! ...and would come visit :Vanessa: Man, I might even respect you more for that! … ME: Wow! I’m at a loss for words. Vanessa: Love it, ladies!! ME: Now I have to learn to love me the way you guys do. Vanessa: I recommend it—you’re pretty damn cool  ME: Okay - I think I’m done working for tonight. Just crying - that’s all I have left. No room for thinking. August 20, 2018 Living outside of fear: Personal journal entry I was…(just froze at the thought of writing down my next thought)…I was contemplating the reason for my intense emotional response to grades and feedback on my thesis and to postponing it for a semester. I’m intrigued that even the action of writing that down INTEGRATING EGO IDENTITY WITH LI THERAPY 375 produced a physical response: can’t breathe, catch my breath, jaw clenched and tense, swell of emotion…. ….When you’ve spent decades trying to control who you are and how you react/respond to the world, to actually authentically feel and respond/react is absolutely terrifying! Another observation that’s been intriguing – and vulnerable, authentic, sincere – is how young and tiny I feel in the midst of these emotions. It varies, of course but I do feel so young. Like when I was asking Vanessa and Kristin if they would still love me and not think less of me if I failed thesis and didn’t make it in. SO vulnerable, fragile, young, innocent, terrified was the part of me asking that question. And utterly surprised emotionally that their answers were ‘YES’ and ‘of course not’ respectively. Why such surprise? And why can I not extend the same love and acceptance to myself? September 22, 2018 Find me – fight for me: Personal journal entry GONE is about a woman who was abducted as a child and held captive for 5 years before being rescued by the FBI…. As I watched the episode, there were a number of times when something deep within me connected with the flashbacks of her as a little girl helpless, in need, being sought after, being rescued. There was a deep sense of grief, loss, longing, need accompanied by tears, tightness in my chest, constriction in my throat, pressured breathing. Questions of “Why not me? Who searches for me? Who rescues me? When do I get found?” would bubble to the surface. I have been trapped, locked away, forgotten, abandoned; why her and not me? I need someone to find me and rescue me; sadness that nobody ever has. Where is my champion????? The answer, my response amid tears and a mounting ache in my chest - “I will rescue you. I will find you. I’m looking for you. I’m coming for you.” That’s the whole purpose and role of LI therapy right now. To go back and find the abandoned, hidden, locked away, and trapped parts of me that need someone to find them and rescue them; lead them out into something new. When I started watching The Sinner… The main character ended up having a champion in a detective who never gave up searching for the truth of her situation - he fought for her. Again, I wondered what that would be like, and that deep desire to have someone who would fight for and champion for me surfaced. The underlying question, “Who fight for me?” As that question hangs in the air, I know that there is no external champion for me. There is no one who fights for me...except that I fight for myself. I have been my own best champion all along. And as I do LI therapy I continue to fight and champion for those INTEGRATING EGO IDENTITY WITH LI THERAPY 376 parts of me that cannot do so themselves. I, the me of 2018, and the one who will make room for their voices to be heard, their needs to be seen, acknowledged and met. I will FIGHT for their freedom, their healing, their restoration; for them to be seen and heard to be known. When no one else understands or comprehends, I DO. What no one else sees, hears, witnesses, I DO. With me these parts of me will find a place to belong (WOW! Powerful! That’s a whole new way of conceptualizing my world!! Blows the needs for external approval and validation of who I am right out of the water!!). October 11, 2018 Group supervision and internal grounding – Personal journal entry So, I presented one of my clients in group supervision today… In the midst of receiving feedback I noticed several times when I started to dissociate and/or defend - tune out of comments, fuzzy brain, pain in chest, retreat inward. This was especially true for any comments that had any hint of challenging the validity of what I have been doing or planned to do. So, noticing that this was happening just as it was starting to emerge is quite different for me. Normally I am right in the midst of it before I notice that it is there. What really surprised me was my ability to them coach myself through it - to remind myself that the comments are there to help me, that there is no danger in hearing people out and listening, that there was no danger in staying engaged in the discussion, that I can then take their suggestions and make my own decisions as to what I want to do with them. It was sort of an on-going internal dialogue with myself. And I did it! I accepted all the comments, wrote down the suggestions for further thoughts and consideration later, and stayed present in the room and engaged in the discussion. Totally shocked me! I don’t think I’ve congratulated myself for doing that- congratulating myself now as I write - well done, Rose! Way to talk yourself through it and not let anxiety take control! You were able to recognize the triggers, acknowledge that there was actually no reason for panic, and coach yourself through it. Pretty amazing!! Who would have ever thought we’d get to this point and being able to do what we just did!! Yahoo!! November 9, 2018 Recent observations: Personal journal entry So, in Couples class on Tuesday we had a special speaker who spoke about EFFT. At one point in the presentation she began speaking about trauma victims and relaying some information about a client of hers. As has been typical, when someone starts talking INTEGRATING EGO IDENTITY WITH LI THERAPY 377 trauma my mind immediately goes to the abusive relationship…and the sexual assault. But this time was different - unlike so many times before. My thoughts went there... and then I waited and waited. I waited for the foggy brain, the difficulty breathing, the sense of disconnecting from the world around me...BUT it never came. The black hurricane did not come. There was little discernible difference between my state of being before the discussion on trauma began and as my thoughts moved towards the relationship…My response? A bit shocked and definitely surprised! I kept probing within to make sure I wasn't just masking or not paying enough attention to notice the hurricane, but it was really not there. Is it gone? I don't know. I seem to recall there being subtler hints before this that something had changed - like not becoming emotionally overwhelmed at watching a couple passionately kiss on TV - but this was the most obvious and noticeable change. December 8, 2018 Trapped in the house: Personal journal entry [11-year-old at 88 Ellerslie – family home in Toronto, ON] …Alas I cannot go back and do it differently. I cannot go back and do any of it differently. I so desperately want to go back and start over. I want to go back and not be stuck in Canada. I want to go back and to return to Kikoten, to boys serenading at camp, to Independence Day celebrations, to tamales and chili powder candy, to cobblestone roads, and combis, to open marketplaces, and Edron Academy, and Timbiriche, She feels so distant and so near at the same time. But she IS me! Not a fairytale nor a dream or figment of my imagination. She is real. And it all really did happen. And it is all really part of MY story! It's not my whole story. It's not everything. But it is a part that still hasn't found a place to be - still somehow needs a voice, needs to be heard, seen, acknowledged. But perhaps it is not what is needed by other people, but instead what is needed within my own self. To reclaim this heritage. To reclaim the girl I was. January 17, 2019 Confidence is growing: Personal journal entry So today I had the opportunity to discuss my PhD research funding proposal idea with Melissa…. I was a bit nervous but was so proud of the way that I spoke my thoughts clearly - tentatively but clearly and without regret or anxiety. I also got to share my MA INTEGRATING EGO IDENTITY WITH LI THERAPY 378 thesis with John and Ed and again was much more confident than I have been in the past. I was filling out my PQ when I came to "I don't feel confident in my own viewpoints/opinions". That's when I realized that today I had been. I had spoken with confidence. Maybe not 100% confidence but from a much more centered, stable, solid place within me than what I've noticed before. I was partially nervous about messing up while at the same time knowing that I would be okay if I did mess up - I could handle it. So cool! January 20, 2019 Becoming more ME: Personal journal entry So, I’ve been waiting for a few days now for the panic and anxiety to set in as deadlines and responsibilities are approaching… but...it hasn’t come. In fact, I find myself quite calm and relaxed in the midst of a number of competing responsibilities and assignments. More centered or grounded. I can’t help but think this is significantly connected to the work I did with Hillary at our last session. Emerging from that session realizing that the panic and anxiety was that of my 11-year-old self and that the me of today has full control, autonomy, access to resources, abilities and capabilities that my 11-year-old self didn’t have really seems to have shifted something. I find myself actually engaging with my readings at a deeper level that I think I ever have ... even in the 2 years of this program. My brain has space to not just focus on understanding the words and concepts on the page, but also to reflect on what do they mean to me and how do they impact my life. …I’m not even worried. It will get done. That’s the simple truth. I am capable - I have 45 years of experience and proof of this. I have the resources I need. Even if I miss some sleep I will survive - I’ve done it before I can do it again. “I am kind. I am wise. I am safe. I am loved.” January 23, 2019 Changes: Personal journal entry So, what’s different or changed? Hmmm – I sense it but now to give it words. I don’t have this inner craving or drive – oh wow! Just got the words and here come the tears – this inner craving and drive to run away and hide. It still feels like there are remnants just below the surface – I feel it in my slightly clenched jaw and the sense of mild pressure in INTEGRATING EGO IDENTITY WITH LI THERAPY 379 my chest – but it’s not a NEED, a crushing terrifying drive. It’s not in control…WOW!!...It’s not in control. There’s a ME who is in control instead – WOW!! A ME!! Even as I write that I don’t really understand that – intuitively I know it to be true, but it feels foreign, strange, unknown. Could it be that I’m moving from just emerging from underneath my hiding place to actually standing tall, fee, and powerfully alive? Is that really possible? Of course, it is conceptually – but really? For me? Could my dream, my heart’s desire, my healing actually be happening?? Right before my eyes?? Is it really possible that I may emerge from all of this works as a whole integrated person? One who is aware, alive, purposeful , intentional, authentic, and at peace?? WOW! WOW! I wonder if part of the clenched jaw and pressure in my chest is also me waiting for the other shoe to drop? Wait for it all to disappear and for the panic, terror, hiding to return. Or even nervous and uncertain about accepting this new state – unsure of how to live here, scared of the implications and how to ensure everything gets done and I survive if I’m not being driven by fear….after decades living under the tyranny of fear, no matter how desirable it is to be free of it, it means reorganizing and restructuring life according to a new regime which is scary. But not terrifying. Just uncertain, unsure. Even this experience of fear is different. It’s not crushing, overwhelming fear. It’s anchored centered fear. Let’s see if I can diagram what the difference is: Wow! Just looking at the diagram - first I’m shocked how it just came – I just started drawing without thought or obsessively planning, stressing, etc. It just was and it was right. Then I’m also struck by the ‘accuracy’ – how well it reflects this change. And the shock – the unbelievability that this change or at least my conscious awareness and experience of it – has happened THIS WEEK!! It just sort of all of a sudden – WAS – and was surprising, unexpected, even unsettling in its appearance. February 10, 2019 Embodied: Personal communication – texts with Kristin and Vanessa ME: Okay - just had a pretty freaky moment. I’m calling it my first ever truly embodied experience….I was leaning up against the counter figuring out what to eat and wishing I had more chocolate pudding to make .... and some PB to eat with it. I was also noticing my big INTEGRATING EGO IDENTITY WITH LI THERAPY 380 stomach pressing up against the counter while also thinking that eating pudding and PB is part of why my stomach is so big. And then I thought... “But that’s okay. That’s just me.” I was actually thinking of my body as ME. Not as separate from ME but as a part of what makes me ME. Does that make any sense? Kristin: Wow, beautiful. So much sense. Vanessa: Yes! ME: It is fading already as I try to hang on to it. It was BEAUTIFUL! Got so excited I had to share! Kristin: So good!!! Vanessa: Thank you so much for sharing this with us February 13, 2019 Motivation: Personal journal entry I’ve definitely lost that external motivator – fear. It is what drove every action, word, thought. FEAR dictated bedtime, wake-time, punctuality, priorities, activities, everything. It’s jarring to see how much of what I thought were permanent personality traits shift as fear disappears – night owl instead of morning person; barely on-time or late instead of always early; challenge and speak plain instead of hide and bury; risk-taker and adventure-seeker instead of safety above all else. Very intriguing. February 21, 2019 Centered? Grounded? Personal journal entry Strangely even as I sit here there is both bubbling anxiety/fear and a sense of calm (groundedness? centeredness?). Even the clenched jaw is somehow softer than it would be normally. In fact, how do I even know there is anxiety/fear? I’m not somatically sensing if the way I normally would. But when I focus inward and listen there are tears that bubble out. This is the visual that came to mind. I’m not even sure I can explain it. The fire is still roaring – the water still boiling over but, because the lid is open, the pressure has somewhere to escape to and isn’t INTEGRATING EGO IDENTITY WITH LI THERAPY 381 just building up. But then there’s also this container that re-interprets the pressure into steams as it passes through. So, my emotions…are still there, they are still real, they are still intense, but instead of building up there’s room for them to escape – be seen, be known, be heard. But there is also this new viewpoint/perspective through which these emotions pass that somehow reinterprets them and changes their flavour or bursts them to let out even more intensity so that they are subdued as they interact with the world. It’s such a strange feeling as I expect the same crazy intensity of the past few days and yet it’s not there and I can’t even explain why or how. I still sense that fearful push – that scared distancing or avoiding of the fact that I have therapy today. But even this is subdued. It’s not panic. There’s a calm realization of its presence – acknowledgement and acceptance of its reality that is an undercurrent of living centered and grounded. Like I’m watching myself running away from therapy on a TV screen. I know what that push feels like . I can sense it and experience it, but I am also detached from it or not immersed in it completely. I can fully acknowledge and accept it while not being overwhelmed and controlled by it…I am not ignoring it or denying the feeling but also not controlled or defined by them. February 27, 2019 Ending therapy: Personal journal entry Boy I can’t even bring myself to write it down. Today is the day. Today is my last day of LI therapy with Hillary. The end of an era. 10 months of working together. My biggest fear? Nothing has changed…meaning there’s been no permanent change. There has been lots of change experiences along the way, but have they equaled lasting change? Core self, carry forward change? I hope so. I have my Change interview with Janelle tomorrow [February 28th – post therapy] and must admit that I have no idea what we are going to talk about. Unlike last time we did our interview [August – mid-therapy], this time I feel I’ve gone backwards, and lost ground not gained it. That is painful to admit (tears), and scary. All that hard work and I end up right where I started? But is that really true? The anxiety and dissociation and triggering over [relationships trauma stuff] hasn’t reappeared. There is some that has appeared at differentiation/family stuff but even that is more manageable. I think what I am noticing most/missing is that inner sense of a INTEGRATING EGO IDENTITY WITH LI THERAPY 382 confident, grounded, anchored core self. It ‘disappeared’ right around the time we started working on the paralyzing block around family. I miss that inner sense of calm and confidence. That sense that I am and will be okay. That sense that I am – that I am ME and that is good. Will it, can it return? Or is here where I live now? …I think I got used to this pattern of surprising changes that I expect it now as evidence of growth through LI. But change can and often is much more subtle. Do the results of my thesis work come to bear on this fear at all? Somewhat, but I feel it’s separate from a personal fear. I will be writing up the results regardless of the outcome, AND we’re not done yet! March 9, 2019 Teen Wolf and Stiles: Personal journal entry Yesterday was my first day in a long time that I didn’t watch Teen Wolf. I watched the entire series - all 6 seasons - 6 times in a row…always started and ended my day watching it. What’s really strange are the tears and deep sadness at letting go of the show. It’s actually painful. And the pain and sadness seems to centre around Stiles [one of the main characters] - like I’m trying to let go of a best friend. Why? Why? Why? Logically this makes absolutely no sense...so, it is hard to let it be and not deny it, suppress it, bury it. When I think of the show Stiles is the character that immediately comes to mind. He’s the character that elicits the ache and the tears. Clumsy, awkward, smart, non-supernatural Stiles. Loyal. Loved…. Yesterday was also the first day in a long time that I didn’t start and finish my day with TV. I worked without TV most of the day and then had to plug in my iPad at the end of the day but was still working at my desk. Is this change? Shifting? Or coincidence?... My last session with Hillary was 10 days ago. (Tears.) Maybe that’s all this is - grieving. Grieving the loss of a caring and loving relationship in which I felt seen, known, held, cherished, celebrated. It was a one-way relationship, but it was REAL, and it was DEEP from my end. She walked through some really dark places with me - like Stiles and the dark Kitsune [a plot line form Teen Wolf]. Hillary saw my pain, hurt, panic, fear, shame and neither stayed silent, nor ignored, nor dismissed, nor minimized it but held it, named it, sat with me in it, and helped me out of it. She saw tears and paralysis. She genuinely celebrated shifts and change. Do I fear being forgotten now like Stiles and the hunt [another Teen Wolf plot line]? Can I carry what Hillary gave me during our 32 sessions together? Do I have to let it go? Can I know that she carries me in her heart - can I believe that to be true? Can I believe that although we won’t be seeing each other regularly she still cares and has not forgotten INTEGRATING EGO IDENTITY WITH LI THERAPY 383 me? (Why? Why would she? She has other clients to care for and other people and activities to occupy her mind and heart. Why would she make any room to carry me with her? How can she do that? If she makes room for every former client that’s too much so what we make me at all special to have room in her heart?) Can I trust her at her word even though it doesn’t make sense to me? Can I let go of Stiles? Can I live and be in the reality of my world and not live and be through his? Can I face it? On my own? Just me? Just me. Just me. Can I know that I am enough - just me? Just me. Can I know that I can face life - just me? Just me. Can I be the person I discovered in therapy without the coping mechanisms? Can I be me? On my own? Is that safe? WOW! I had no idea there was all of this underneath watching a TV show. The tears and ache make sense - or their magnitude makes sense. So many questions. So much uncertainty. SO much change. Papa [God], even with You - just me, just me. I want to be - help me be - just me. I wonder what it would look like to be just me today. [In everything…] Just You [God]. Just me. Just real life. March 19, 2019 Longing for ‘home’: Personal journal entry LONGING: couldn’t take my eyes off that word. It speaks to the depths of my soul. But what does it mean? What am I ‘longing’ for or after? I think it’s a longing for things that were lost. So, in a way it is grieving but that word doesn’t resonate at all. It surfaces as I think of returning to Mexico – of going home (yep there it is). I know it won’t be home – at least my head know this – but my heart aches for the place I’ve longed to be these past 35 years. I’ve wandered the world trying to find it and have seen pieces in the cobblestone streets of Poland and the people of Central America, but my heart still aches for Mexico. For the places in my memories and for the little girl who lived there so long ago – the little girl in the family photographs: at Chapultepec, in Esperancita’s courtyard, painting desks, roller skating, helping mix cement, sch play, at the pyramids, in Acapulco, playing house with red berries, running all around Kikoten, The Little Princess in the chalet loft, TCK friends Patricia and Joel, fun with Mariana, earthquakes and eclipses, marriage beads, Sunday tamales, Independence Day celebrations, ‘boyfriends’, evangelism, Reino Aventura, VW bugs, Combi’s, Museo de antropologia, Ballet Folklorico…These memories are REAL! They are not made up or pretend. They really happened – they really happened to me! Not some distant ‘other’ but to me! I was standing in Chapultepec park. I was holding Xochit. I was helping mix concrete and INTEGRATING EGO IDENTITY WITH LI THERAPY 384 roller skating at the apartments. That. Was. Me! I went and saw Timbiriche con Vaselina and fell in love with the Johnny character. I loved visiting the library and Cuernavaca and I made spiral art at the fair in Guadalajara. I sang in the youth choir and ‘toured’ to churches. I played house and hide and seek at the church and superheroes at Kikoten. That was all ME! And while I can’t go back there – though I desperately wish that I could turn back time – I can return to Mexico and close that open loop that was left. INTEGRATING EGO IDENTITY WITH LI THERAPY 385 Video Clips NOTE: These links will cease to function after June 15, 2019. Clip & Length Context SESSION Client and baby self 3&4 (45-year-old and 2-week-old self). June 12 & 15 4m 25s SESSION Began with memory of 7-year-old in Mexico being 6 angry and upset by a gift Dad didn’t like and returned. June 22 4m 55s SESSION Post-repatriation 11-year-old memory of anger 19 outburst after my sister was blocking her ability to Oct. 11 complete my vacuuming chore. This precipitated an 3m 58s explosion of emotions unrelated to the immediate cause but reflective of the crushing fears, anxieties, pressures Rose was experiencing in surviving this new life in Canada. SESSION Rose shares the Big Book of Stickers she and her 522 year-old self are enjoying together. Nov. 29 #1 1m 38s SESSION Meeting post-repatriation 11-year-old in family home 22 in Toronto where she was ‘left behind’. Nov. 29 #2 4m 20s SESSION Remembering 11-year-old self around time of 27 repatriation. Jan. 16 3m 23s SESSION Noticing changes in understanding of family of origin 31 rules and scripts. In previous session Rose had come Feb. 21 to understand that she can acknowledge that her #1 parents did not always meet her needs and the hurt 5m 48s and pain that came with that AND is still able to love them; both could be true at the same time. LINK CLICK HERE to view video. CLICK HERE to view video. CLICK HERE to view video. CLICK HERE to view video. CLICK HERE to view video. CLICK HERE to view video. CLICK HERE to view video. INTEGRATING EGO IDENTITY WITH LI THERAPY SESSION Encountering the Time Line differently with her 2year-old self. 31 Feb. 21 #2 1m 40s Total Time: 29m 12s 386 CLICK HERE to view video. INTEGRATING EGO IDENTITY WITH LI THERAPY 387 RCR Appendix A Detailed PQ Results Graphs Graph A - Combined Mean Daily PQ These graphs are based on the mean rating of both intensity and frequency combined for all 272 days of collected data. Graph B – Daily PQ Intersession Mean These graphs provide the mean rating for intensity, frequency, and both combined for the intersession periods across therapy, (e.g., the mean intensity rating for all days between session 7 and 8; mean frequency rating for these same days; mean overall – combined intensity and frequency ratings – for this same time period). Provided here is also a trend line of all ratings and the rating difference between the first mean rating collected (pre-therapy) and the last rating collected (at follow-up). Graph C – Daily PQ – Pre/Mid/Post/Follow-up Intersession Mean These graphs provide the mean intersession ratings for intensity, frequency, and both combined at 5 different periods across therapy: 1. pre-therapy pre-session mean rating; 2. session 3 mean intersession intensity, frequency and combined ratings; 3. mid-therapy mean intersession intensity, frequency and combined ratings; 4. post-therapy mean intersession intensity, frequency and combined ratings; 5. follow-up mean intersession intensity, frequency and combined ratings. The second data set is provided as daily ratings, including tracking intensity and frequency ratings, were not collected until after session 2, and therefore the mean intersession ratings for session 3 offer a more accurate comparison point with midtherapy, post-therapy and follow-up ratings. INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #1 388 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #2 389 INTEGRATING EGO IDENTITY WITH LI THERAPY 390 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #3 391 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #4 392 INTEGRATING EGO IDENTITY WITH LI THERAPY 393 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #5 394 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #6 395 INTEGRATING EGO IDENTITY WITH LI THERAPY 396 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #7 397 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #8 398 INTEGRATING EGO IDENTITY WITH LI THERAPY 399 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #9 400 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #10 401 INTEGRATING EGO IDENTITY WITH LI THERAPY 402 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #11 403 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #12 404 INTEGRATING EGO IDENTITY WITH LI THERAPY 405 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #13 406 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #14 407 INTEGRATING EGO IDENTITY WITH LI THERAPY 408 INTEGRATING EGO IDENTITY WITH LI THERAPY PQ Item #15 409 INTEGRATING EGO IDENTITY WITH LI THERAPY 410 INTEGRATING EGO IDENTITY WITH LI THERAPY 411 RCR Appendix B PQ Ratings Comparison Graphs: Daily versus Pre-session Summary Report Score that differ by 1 or more points have been marked with a red box. Where a clear explanation is available for the difference in the scoring, this has been provided within the graph itself. The most significant reasons for other differences appearing between daily and pre-session ratings is due to a change in how decimal scores in daily mean values were translated to whole point and half point ratings on the pre-session summary reports. In the beginning Rose used a system in which a certain decimal value would indicate whether pre-session rating was recorded on the whole number or in between ratings, however this proved difficult due to their being 3 mean ratings (intensity, frequency and combined). Therefore Rose switched to a simpler system in which, if all ratings began with the same digit then this number was used on pre-session form, whereas if one rating differed than pre-session rating was recorded as in between (e.g., 2.3, 2.5, 2.4 = 2; 5.5, 6.3, 5.9 = 5.5; 4.3, 2.5, 3.4 = 3). INTEGRATING EGO IDENTITY WITH LI THERAPY 412 INTEGRATING EGO IDENTITY WITH LI THERAPY 413 INTEGRATING EGO IDENTITY WITH LI THERAPY 414 INTEGRATING EGO IDENTITY WITH LI THERAPY 415 INTEGRATING EGO IDENTITY WITH LI THERAPY 416 INTEGRATING EGO IDENTITY WITH LI THERAPY 417 INTEGRATING EGO IDENTITY WITH LI THERAPY 418 INTEGRATING EGO IDENTITY WITH LI THERAPY 419 RCR Appendix C Mid-Therapy Change Interview - Full Transcript Client: Rose (R) Interviewer: Janelle (I) TRANSCRIPT: I: Well welcome here. [R: (laughs)] We're not doing therapy we're just reviewing stuff, but I still want you to take a moment just to really be with yourself, [R: mmm] and to show up here, because this is about you and your journey so far, and research aside, and the questions aside, it's a chance for you to reflect and [R: Mm-hm.] -and just be aware of what going on for you. [R: mmm] and what this journey has done. So, whatever you do to do that - put your feet on the ground, your breath, just take up space. R: Mm-hm. Get comfortable. I: Yeah, get yourself comfortable. [R: (laughs)] Feel like I have extra pillows right now, but you never know when you want to hug a pillow. R: (laughs) Exactly. I: [unintelligible] and I'm supposed to say if this is post therapy or follow-up. I'm going to just click, um, mid-therapy or therapy transition. You said you've had - today it's been fourteen sessions? R: Yeah. [I: Okay.] And we're actually going to do one more next week, [I: Oh, okay.] which we didn't originally have planned but... I: Okay. And this is August… R: Eighth [I: Okay.] (laughs) I: I was going to figure it out. R: (laughs) I just had to write it a few times in the last 24 hours, [I: Yeah, yeah.] otherwise I would have no idea. (laughs) INTEGRATING EGO IDENTITY WITH LI THERAPY 420 I: Good. (laughs) Just like we've talked about other times, you have absolute right to not answer any questions, to quit at any time, um, to ask me questions, to withdraw your participation. So, this all belongs to you and I just want to remind you of that. Um, the first thing that-that we just check in about on this interview is any medications that you are on that could have any - just any medications, because they can have influence (on) [02:05] your psychological well-being and therapy impact. And I know we've talked about that, but I don't-I don't know if we have it written down. [R: Mm-hm.] So, what are you currently taking? R: So, um, I currently am taking Pristiq, [I: Mm-hm.] and… I: SNRI, right? R: Yes. I: And what symptoms would you say that is targeting? R: Primarily anxiety. I: Okay. [R: Yep.] And your dosage right now? R: Um, yeah, just switched to 100mg [I: ‘kay] a week and a half ago, I think? I: Okay, um, and how long have you been on Pristiq? R: Ah, since 2010, so… I: Long time. [R: yeah] So, eight years. R: Eight years. [R: (laughs)] It's like I can do the math. (laughs) I: [unintelligible]…eight years – eight years. R: Right. Since 2011. But anyways, somewhere in there. [I: ‘kay] Seven or eight years. I: Any other medications? R: Um, I have asthma medications, [I: ‘kay] um, and then I'm on Nexium for acid reflux. I: ‘kay-‘kay. Um, so that’s just the nitty-gritty and...the next thing I'm going to do is just ask you to describe changes you've experienced but I want to know if that feels - if you're INTEGRATING EGO IDENTITY WITH LI THERAPY 421 ready for that; if there's anything else you want to say as we get started and as you take up space [I: Mh-hm] and as you kind of show up here today? R: No (03:36), I don't think there's anything else. [I: Okay.] Yeah. I: Well then, let's just jump in. R: Alright. (laughs) I: So, I believe your first session was in May? R: Yeah, yeah. I: And we did the PQ items maybe May 15th or something around there? R: Yeah, something like that. I: Yeah, um, so if you can think back to this period of time, I'd like you to just name, um, and describe as much as you want - but name any changes that you've experienced. R: Mm-hm. Yeah, so I was even just thinking on my way here, like what are some of those changes? [I: Mm-hm] Um.....so, one of them that…is probably more recent, [I: Mm-hm] like more in the last couple of weeks, [I: Uh-huh] um, is being - like I've always kind of equated negative thoughts to level of distress, [I: Mm-hm] and in the last couple of weeks I've kind of realized that, “Hey! I just had that thought, but it didn't come with distress!” [I: Mm-hm] So, one of the things where I really noticed it is, um...since I've put on a lot of weight, um, there's been a lot of like…negative self-talk, like when I sit down, I see the like rolls and I'm like, I see the rolls and then I feel bad about myself. [I: Mmhm.] But in the last week and a half it's been more like, I see a roll and I'm like, “Okay. There's some extra fat there,” and there's no distress that comes with that. [I: Mm-hm. Mm-hm.] Which was very different like, and there's no [I: Mm-hm] like beating myself up about it. It's just kind of like - more like an observation [I: Mm-hm,] than like a judgement [I: Mm-hm] or an evaluation kind of statement and, yeah! It was kind of interesting ‘cause I think that had probably gone on for - for a little bit before I noticed it. I: Before you realized. R: Yeah. [I: Mm-hm] Before I realized that it didn't come with [I: Mm-hm] with this like [I: Yeah] emotional or-or even cognitive kind of judgment on myself. [I: Mm-hm] Um, and the same thing happened with, um, my poor choices on…like self-medicating poor choices. [I: Mm-hm. Mm-hm] It was I came to realize that it was happening, but I wasn't…placing a negative evaluation on it-it was [I: Mm-hm] just like, “Okay. That happened. Alright… [I: Mm-hm] um....we're....moving on. INTEGRATING EGO IDENTITY WITH LI THERAPY 422 I: So, like no longer resulting in as much distress and self-blame. R: Yeah. And even shame in it, right? [I: Mm-hm] Like, didn't have this connotation that I'm a bad person because of noticing that I'm fat or noticing that I've done that [I: Yeah, yeah.] kind of thing. [I: Yeah] Um, yeah. I: You've got to forgive me. I went out of order on something here. [R: (laughs)] Um, jumped to the-the records where I record this, but there’s a couple questions, so [R: Okay] speaking of shame and self-evaluation, um, there's-there's more general selfdescription questions that I want to get out before we continue [R: Okay, yeah.] with the changes, if that's Okay? R: Yeah. Totally. I: It's kind of abrupt for me. (laughs) By the way I did it completely wrong! Um, (laughs) missed that page. (both laugh) R: Aww! You're human??! Darn!! I: So, yeah. I know! So, we've got the medication part and we're just going-we're going to come right back to the list of changes. [R: Mm-hm.] But I want to check in with you and - This feels much more natural to start off the interview this way. [R: Mm-hm.] I think I was like, ‘What?! Where am I?’ ‘cause this didn't - Is what has therapy been like for you so far? [R: Mm-hm.] Just to - a-a general evaluation of it. R: Um...hmm. How do you put all of that in words? (laughs) I: Right? [R: (laughs)] R: It-it's been...intense…in that it has....it has finally gotten to what I knew was there which is this like core base of emotions and self-appraisals and... worldview…stuff that I knew was there but I just wasn't getting at. Um... and ... that's very intense 'cause it's just so... [I: Uh-huh] primal almost, kind of idea. [I: Uh-huh] Um, and it's been surprising, um, in noticing changes that I've like - that just happen, like I don't make them happen. I don't… I'm-I’m not working at them happening it's just sort of they appear. [I: Mm-hm] And I'm like, ‘Woah! This is different. This is weird.’ (laughs) Um and in that way... I: That's what we are going to come back to [R: Yeah] is those. That's awesome. [R: Yeah] R: And in that way encouraging, too, in that I see....I see things emerging that I had have hoped for-for a long time but wasn't…getting through talk therapy or other kinds of therapies. We just weren't…achieving. (phone rings) INTEGRATING EGO IDENTITY WITH LI THERAPY 423 I: We're just going to let that ring [R: yeah (laughs)] and ignore it completely. R: I'm so good at ignoring those things. (laughs) It was bad when I was a teacher and I ignored bells but...(laughs) I: We can ignore my phone today. [R: (laughs)] Yeah. So, you saw things emerging that you weren't getting to in talk therapy. [R: Yeah] Um… R: And things I didn't even really realize…were there. [I: Mm-hm] Um, like how... um...how far back feelings of shame go. [I: Uh-huh] Like they went way further back than I thought, um...Yeah, sort of giving ...putting in words things that I knew were there, but they've come out in a different way than I thought they were, kind of thing. It's like you-you know parts of it but now it's kind of emerging more - the entity in itself. [I: Mmhm. Mm-hm] And surprising. (laughs) Surprising two things: One - how difficult it can be for me to follow my instinct. Like [I: Mm-hm] ‘cause in LI therapy, you know, you're doing - you're meeting your younger self and you're using your imagination, and things come up, and you're like, ‘Woah! Where did that come from?!’ And having to kind of trust that intuition that this is the way it's supposed to go, while at the same time being surprised by, ‘That actually totally made sense that that's what happened. And that's what we did. And that's what [I: Mm-hm] occurred in that-that episode, [I: Yeah] kind of thing. [I: Yeah] Yeah. [I: Hmm] I: This is a twist on the same question. [R: Mm-hm] Um, I asked you, just, now what has therapy been like for you so far. So, for this question is, how has it felt to be in therapy. Would you describe that any differently? R: [long pause] [I: unintelligible]… here says, “Yes.” (points to body part) (laughs) [I: Mh-hm. Mh-hm.] but I’m not sure I know how to…it’s I: It's possible you've touched on it a little bit [R: Yeah] with the first question. R: I suppose it [11:43] felt very vulnerable. [I: Mm-hm. Mm-hm] Um, yeah. I think that's what kind of comes up in my chest, right. [I: Mm-hm] ‘Cause It's just that…it's very…exposing. [I: Mm-hm] Not just - I mean, there's a whole lot that goes on that the therapist never really knows about but - so even to yourself, right? And…and encountering parts of yourself that are very vulnerable, and [I: Yeah, yeah.] or you haven't maybe been with for a very long time, um. Or even...episodes that I have not really allowed myself to recognize, [I: Mm-hm] like I-I emotionally recognize them as being hurtful [I: yeah] but haven't really allowed myself permission to…to let them be that. I: And how has it been to let them be that? INTEGRATING EGO IDENTITY WITH LI THERAPY 424 R: Mmm [long pause] (laughs) Yeah, Oh, dear. Sorry, um, because we did body work yesterday (laughs) my automatic reaction is to, like, get up and show you. So, I'm going to do that. [I: Yeah!! That's fantastic!] So, this is my, like, voice – (stands up with face turned upwards and arms outstretched upwards) [I: Yeah] I have a voice stance [I: Yeah] and that's what it's like. [I: Mm-hm!] It's like - [I: Mm-hm] I: So, [R: Yeah] you describe vulnerable and exposing and then you just did this real strong, like, chest out, arms up - there is no-not a word that's as good as that. [R: Mmhm] But, having voice, [R: Mm-hm] you said. [R: Yeah] Um… R: I think it-it has been - doesn’t quite fit but it has been empowering in some sense. [I: Mm-hm] Like, I know in - one day in session I said to Hillary, I said, like, you know, “I've been-I've been through a lot in my life. Even though on the outside it doesn't look like it, my internal experience of it has been quite enormous. And to just recognize that, [I: Yeah] and allow myself to...to...not be that, but ... to let my life be what I have experienced it to be - [Mm-hm] regardless of what someone on the outside might [I: Yeah!] evaluate it to be - has been, like, has an empowering element to it, you know? [I: Yeah] I’ve, like, and I've made it. Like, it's not just -like I had a really difficult time and I've crumbled but I also survived. [I: Mm-hm] And I'm here to thrive now. [I: Mm-hm] So, that's kind of like - there's almost like a fighting. That's why I say empowering. Sometimes doesn't it-doesn't-there's like this, like, gladiator sense [I: Mm-hm] behind it almost. [I: Mm-hm] Yeah. I: And, it seems to me like you're describing that you are allowing your real experience to be what it has been, without it being quantified [R: Yep] and compared to some measure of the life adversity. R: yeah, or somebody else's experience [I: Yeah!] of the same event [I: Yeah] or whatever. [I: Yeah] It's like, [I: Yeah] ‘Alright. That's fine, but this was mine.’ I: I want to invite you to come back at any time to these general questions as things come to mind even though I'm moving on in the-in the protocol. So, if you want to reflect more on what it's been like for you and how you felt, just raise your hand. R: Okay. (laughs) I: Kidding. (laughs) [unintelligible] One, two, three. Eyes on me. R: (laughs) Give me five. I: Oh, my gosh! [R: Oh dear!] This next question [R: (Laughs) Sorry.] I...I find to be… R: That tickled my funny bone! INTEGRATING EGO IDENTITY WITH LI THERAPY 425 I: Yeah – uh, yeah - you're funny bone's good to play with. It's always ready. [R: Yep] [unintelligible] R: True enough! I: Right? Um, yeah, this next question is very general, and you get to choose how you answer it. How are you doing now in general? [R: Mm-hm] Whatever you want to start with in that you-you get to decide. R: Mmm. That’s a very good question... ‘cause I feel like, um - there's always two sides to it. Like in some ways I feel more, um... What's that called…emotionally? [gibberish] (laughs) [I: Mm-hm. Mm-hm...um] What's that called?? (laughs) I: Hmm...I see churning, but I don't think that's the word. Maybe 'stirred'? R: Yes. I: Evoked. R: Yeah, [I: Mm-hm] while at the same time [long pause] there's... I don't feel as stuck because I see movement happening. [I: Mm-hm] So, I don't feel like, ‘Okay, so this is just my reality for the next - for the rest of my life, because there is change happening. So, in one sense it's like it's worse [I: Mm-hm] but it's worse with help [I: Mm-hm] and change and potential for something different, if that makes sense? [I: Mm-hm] Okay, good. (laughs) I: It... you seem to believe that it is kind of worse with a purpose [R: Mm-hm] and you don't think it's just more raw... and just worse. [R: Yeah] You have to have the chance to say [R: Yeah] that maybe therapy has ruined things - things for you, I mean, (laughs) [R: Yeah] or made you decline ... R: I would say it-it is more raw, [I: Mm-hm] but I think it's more - I feel like it's more that, I'm just aware of it. Like, this is actually something I've been feeling for really, really long time. [I: Mm-hm] It's just, all of the sudden now, I'm letting it be felt. [I: Mm-hm. Mm-hm] Um. [long pause] And while that's like overwhelming and scary, there are changes happening that I feel like are moving that. [I: Mm-hm] And so, if those changes weren't happening then yeah, I would say it was a disaster and (laughs) I needed to run away. [I: Yeah-yeah-yeah. Yeah] Um, but because those changes are happening, then it's-there’s a sense of there’s - those two things are co-existing at the same time. [I: Yeah, Okay] I: And I'm going to come back to - when we talk about changes - to ask you to describe if anything has changed for the worse and you can describe - maybe they’re not either or INTEGRATING EGO IDENTITY WITH LI THERAPY 426 but, those pieces that are maybe more distressing. [R: Mm-hm] We can come back to, um, but before we do that, I want to just ask you to just take a moment to give me selfdescription. [R: (laughs)] It's part of this. [R: Oh, dear!] Um, how would you… R: I suck at this! I: …describe yourself? R: Um, funny. (laughs) [I: Mm-hm. Mm-hm] Or enjoy laughing that's for sure. [I: Mmhm] Um... huh?... The word resilient came to mind. And then I was like, ‘NO!’ And then I was like, ‘YES!’… [I: Mm-hm!] I: …after what you just said. R: Yeah, yeah. Um. Brave. [I: Mm-hm] Creative. I: Thinking of some crafts that you've showed me - [R: (laughs)] R: Actually, I made a Lego the other day. I have no idea what it was, but it was fun! (laughs) I: Do you have Legos? R: I bought Lego, yeah. [I: So good] After one of our sessions, my 7-year-old was like. ‘I want to play with Lego.’ So, [I: That's so good] we bought Lego. We've made it came with like 3 different things in the kit but then I found this website that makes other things with it. So, [I: Nice] we started out just making all these things that were step-bystep instructions, [I: Mm-hm] and now we’re into like what can I make out of it? [I: Cool!] So yeah, I made this creation. It's like [(laughs)] very bizarre, um....let's see, how else would I describe myself. I: Or how would others who know you well describe you? R: [long pause] Um ...what’s the word for that… Introspective maybe is the word I'm look- Like, just they know I’m always…thinking about - What is the meaning of that? What is - Why did that happen? Um...Okay, there's two words coming to mind and I'm like afraid to say them, (laughs) ‘cause I hope they're true. I don't know that I fully believe they are yet but, um, caring and loving would be two of them. Um, hard worker. Learning to believe myself is a hard worker...Smart. [I: Mm-hm] [long pause] Lover of animals. I love my animals! I: If you could change something about yourself what would it be? INTEGRATING EGO IDENTITY WITH LI THERAPY 427 R: I would change [unintelligible] Many things (22:22) are already changing but I would change how much fear...has...um, directed my life or controlled my life. . [I: Mm-hm] Umm. And I guess on that same vein, like yeah, I-I would change how much confidence - inner confidence - I have. Like being able to ... I don't know if it's confidence or not but, . [I: Mm-hm] yeah, just being sure of my decisions. [I: Mm-hm] Yeah. I: Makes sense. [R: Mm-hm] They're kind of two sides of the same coin. [R: Mm-hm] Less fear of the unknown and that inner knowing. Yeah. Um so, just like I said before, feel free to chime in and come back to these. But let's go back now to the changes [R: Mm-hm] which is really the heart, as you know, of this interview. [R: (chuckles)] Um and wh- you started describing that negative thoughts or observations don't correlate directly to the level of distress you feel. [R: Mm-hm!] And that you've noticed that happening after it probably started happening, [R: Mm-hm] and like, “Woah! This is different!” [R: Yeah] Um, and that when you use like self-medication and different behaviours that you don't, um, that you don't wish to use, you don't feel as much shame or self-blame. [R: Mm-hm] Um so, ... yeah, we'll go back, and I'll have you read these in terms of how much you expected them. But I just want to prompt you to think some more about different areas of change. Um, for example, are you doing, feeling or thinking differently [R: Mm-hm] than you did before? What you just described I think is an affective change, [R: Right] so that you're feeling differently when the same observations [ R: Right] go through your head. Um and then also, what specific ideas if any have you gotten from therapy so far? Including ideas about yourself or other people. Have any changes been brought to your attention by other people? And I'm just going to jot any more changes that you want to note down, um, in addition to the ones you started with. [R: Mm-hm] R: Wow! That was a lot of ideas! I: Mm-hm. And I'll come back - [R: (laughs)] and I'll come back [R: Okay] and give you prompts. But thinking, feeling, doing anything different? [R: Yeah] Things you've noticed about yourself or other things, others have noticed about you? [R: Mm-hm] R: Well, I'll go to one of the other ones that has definitely been key, um, has been in the last kind of three or four weeks, I think. [I: Mm-hm. Mm-hm] Um, when the swell of anxiety and - I'm about to die because of something - [I: Mm-hm] comes, it has emerged with a progressively or increasingly powerful sense of, like, I'm anchored in - there's a me anchored in solid ground alongside of that. [I: hmm] So, a bit of a - I feel these emotions, but the emotions don't completely overwhelm all of me. There's a part of me that's able to kind of step outside of them and be curious about them and, um, [I: hmm] wonder like or notice that, “Hey, that emotional response does not fit with the incident that provoked it.” [I: Mm-hm] And I am like, “Why is that like – like why are we feeling that?” [I: Mmhm] And um, so a bit like almost detached from -[I: Yeah] outside of the emotion a bit. [I: Mm-hm] Um, and-and I've noticed that those periods don't last as long as - I think anyways that's a very [I: Okay] (laugh) But, they feel like they don't last quite as long as, um, like the emotions aren't as heightened [I: Yeah] as long. INTEGRATING EGO IDENTITY WITH LI THERAPY 428 I: I'm tempted to note that as a separate change, [R: Mmm! Mm-hm!] but we can we can decide later maybe, [R: Yeah] whether they are. But, the first that you mentioned is that when you feel intense swell of anxiety that there's something that's also, has more weight and anchoring [R: Mm-hm] in you. And then I think they are separate. R: It does - yeah, I would say they are. I: And that the duration of intense negative emotions has decreased. [R: Mm-hm. Yeah] Or those episodes don't last as long I think is how you said it. [R: Mm-hm] Mm-hm R: I was trying to think of anything I'm doing differently. [I: Mm-hm] I think it's hard ‘cause it's been so focused on getting this thesis proposal done [I: Mm-hm. Mm-hm] done that... Like, I'm doing everything different (laughs) because it's just been like [I: Mm-hm] focus on getting writing done and [I: Mm-hm] that kind of thing. But ....I suppose, like, although I have done little bits and pieces like this in the past, like - I suppose even-even the, like, allowing my 7-year-old self to go and buy Lego, right? Like that's [I: Mmm, yeah!] sort of like it's - I've done creative things like that but never wh - it so specific to like listening to a part of myself [I: Mm-hm] and knowing that I'm doing that. Um, and even I, like, I-I stood in the aisle for like half an hour as my little kid and adult-self debated. ‘Cause it's like, ‘That's too expensive. Well, how about this? Well, that's a little too ex-’ Like they had to figure out, like, a medium ground of like, what they could afford and [I: Mm-hm] yet what would still be fun. (laughs) [I: Mm-hm. Mm-hm] Which was kind of funny ‘cause I felt really silly being in the aisle for half an hour. (laughs) [I: Mm-hm. Yeah] But it was, yeah, it was just a real special moment of that 7year-old self and me interacting with each other [I: Mm-hm] and me recognizing her need and allowing that to be [I: Mm-hm] kind of thing. I: And so, allowing, really intentionally inviting space for play [R: Mm-hm] in your life, kind of, connected to a younger ego state. [R: Mm-hm, yeah] Yeah, yeah. Other things that come to mind? Thinking, doing, feeling, beliefs about yourself; feelings about yourself, about others. R: There was something that I remember - gotta remember to mention this - and now it's flitted away. Um. [long pause] I: I think you started saying some of this stuff with my first questions, the general questions [R: Mmm] about what therapy has been like. So, I'd - so even though you've said it there [R: Right] feel free to bring them [R: Yeah] in here. [R: Yeah] Um. You had said that you have become more aware of some core things around self-appraisal. Um, you've said that…you've realized that your life has been what it has felt like [R: Mmm] and you can kind of validate that. [R: Mm-hm] And experience that that you've become aware that it's more difficult than you thought to follow your own instinct. [R: Mm-hm] Um, I don't know if those all fit for [R: Right] - if those are changes you've observed, [R: Mm-hm] but to me they strike me as observations that you may want to note here. [R: Yeah] Um. INTEGRATING EGO IDENTITY WITH LI THERAPY 429 R: I would say… I: You tell me. [R: Yeah] R: I would say, for sure, um, the coming to realize the role shame has played [I: Mm-hm] in my life’s definitely been a big one. Um, yeah. Like I, kind of - and its - there's been inklings of it before but now it's like, ‘Woah! Okay, I get it now!’ Where I've divided my life between like pre-Canada and post-Canada, [I: Mm-hm] but I see-I see snipped of – ‘post Canada’? Yeah. (laughs) being in Canada.[I: Mh-hm.] ME appearing even before that. [I: Mmm] Um, I guess the, yeah - and so then conceptualizing it different. Like, okay, there was obviously enough other grounding things present that I was able to manage them. [I: Mm-hm] And then when I came to Canada and those all were gone, that's when it was no longer manageable. [I: Yeah] Um, and so that's been-that's been interesting to kind of see myself as less - like I became a totally different person. [I: Mmhm] Um and gives more - makes more sense out of what happened [I: Mm-hm] when I came here, and why life became so much more difficult. [I: Mm-hm] Um, yeah. I: So, are you seeing yourself more as the same person now? R: Yeah. I: and that's in addition to the observation of the role that shame has played connected to that observation. R: Yeah, kind of. Yeah, so there's almost two things. I: Two sides to [R: Yeah] - like they come up in the same example for you, [R: Mm-hm] but one is this role of shame throughout your life, [R: Mm-hm] and the second is seeing yourself more continuous. R: Yeah. And I guess actually they are quite different [I: Mm-hm] ‘cause one is the role of shame throughout my life and the other one is recognizing that, Like, like when I was interacting with my 7-year-old self, one of my big one was like, “WOW! She's me!” [I: Mm-hm] like she came over to my place and we played pass the pigs and she wanted to colour and [I: Mm-hm] like, just recognizing. And so, that's where I haven't lost all the things that were me before I was ten. They're still me, [I: Mm-hm] um, and that's been Yeah, that part has been really [I: Mm-hm] - has been a big change. [I: Mm-hm] Like I’m-I’m still there, [I: Mm-hm] and I'm still me, and they are still part of me. [I: Mm-hm] Um. INTEGRATING EGO IDENTITY WITH LI THERAPY 430 I: Yeah, that's cool. That's different [R: Mm-hm] than just the observation about shame. [R: Mm-hm] For sure. [R: Yeah] Um, anything else from maybe those other things that you had said earlier around just changes, observations, [R: I think…] that you wanna kind of formerly note? [R: Yeah] R: I think - I'm not entirely sure how to like ???? (34:44) [I:???? Yeah. I know.] I: You can feel free to do more, [R: (laughs)] like, body posture demonstration. R: Um, I don't-have you seen The Greatest Showman by any chance? I: No. R: No? I: But it was - [R: Ugh] we tried to watch it the other day [R: Oh, did you?] actually. Yeah [R: Okay] I've heard it's really, really good. R: I-I mean the music is amazing, but [I: Yeah] there's this one song that sung by like all the circus performers, which are circus freaks, right? [I: Mm-hm] And they basically, they are singing about like, you know, ‘the world has told me we don't want your scars, we don't want your pain, um. But hey, I am here, and this is who I am.’ And that's been my like theme song. [I: Mm-hm] Um, with like - just like, I am not ashamed. I am - this is who I am, this is me, and I am here. Um...and it's - I guess it's got that component of voice in it. Like, this is my statement. [I: Mm-hm] This is my, yeah. I feel like rumph [sound effect with hand action bringing strong arms and fisted hands down powerfully from above head] (laughs) [I: Mm-hm] That kind of… I: I know. It's hard to - like it's this - I sense a willingness to just be, to show up, [R: Mmhm] to be you. And this has been your theme song. It sounds like you've connected to it not just through therapy but - Is there a way that you can say this is something that's emerging in you or that you're noticing that-that it belongs on the change list? [R: Mmhm] Like ‘I can,’ this ‘urgh!’; like stake my place [R: Yeah] or something. R: Because, I think like-like, I just think it's all like rmmm [sound effect with intertwining hands together] - melded together, but as I give, like, as I go back and I recover those pieces of myself [I: Mm-hm] and I give them voice, they are - I'm allowing them to say, “Hey, this is me!” [I: Mm-hm] Which gives me the chance to say, “Hey, this is us!” Um, [I: Mm-hm] and yeah, like even in session yesterday when we did all the body work [I: Mm-hm] was like, we talked about, like, how does this connect back to lifespan integration therapy? And it was very much like we're gathering the pieces of myself and giving them a voice throughout the story. [I: Mm-hm] Because there's things that need to be said but saying them today now, aren't as powerful as me going into those memories [I: Mm-hm] and saying them then. [I: Mm-hm] And giving myself power to say them, [I: INTEGRATING EGO IDENTITY WITH LI THERAPY 431 Mm-hm] um. And so, like even - it was a slightly different song - but even when we were doing the other session it was very much like, yeah, like it was just this idea that, like, in every session that we do, “This is me. This is who I am. This is my presence, my voice, [I: Mm-hm] my story, my…enveloped me, my package, my – Yeah. So, the whole - that whole process very much feels like I am - there is a me to encounter first. [I: Mmhm. Mm-hm] And that's been big. And the - that's been a realization, I think, definitely that has come out of therapy is, there is a me. [I: Mm-hm] Um. I: There is a me and the me can show up. [R: Yeah] Are those separate or are those the same? I feel like… R: Well... I: I don't have quite the right words. [R: Yeah] I say showing up with more voice, less apologetic about being me because of gathering the pieces of yourself, [R: Yeah] and there is a me to encounter, this sureness. [R: Yeah] How many items is that? Is that one that? R: (laughs) Many?! [I: yeah] I definitely think that ‘there is a me’ is separate. [I: Okay] For sure. [I: Okay] Um. I: So, this awareness of me. [R: Yeah] R: And that-that it's-it's not a me decided by other people's opinions [I: Mm-hm] but it's a core-a core me [I: Yeah] that's uniquely... Not a compilation of everybody else's ‘shoulds.’ [I: Mm-hm] That's a good way of putting it. [I: Mm-hm] Um, yeah. And then giving - and then, like, I-I still remember like talking with Kristin the one day and, even though it's about like handing in my Lit Review and just being like, “Wow! I'm amazing!!” And just being like. “I can't believe I said that!!” Right? (laughs) And just like again, it's that-that was me who did it! [I: Yeah-yeah] And I can be proud of something I accomplished and or even the like yester-like last session and I [I: Mm-hm]well maybe not last session, the session before that - and I said, “Wow! I love me!” And it was just like, “Woah!” [I: Mm-hm] Like that's-that's just language, and thoughts, and not even concepts ‘cause I definitely had the concepts there but applying those concepts to myself [I: Mm-hm] that I haven't really - I haven't done. I haven't given myself spoken positively about myself, or um I: Is that another one? R: Yep-yep. (laughs) I: I love me. [R: yep] I can speak freely and positively about me. [R: yeah] INTEGRATING EGO IDENTITY WITH LI THERAPY 432 R: And in a-in a...in a not giving lip-service , right? [I: Mm-hm] But from a like I: Truly and authentically. R: Yes! Yeah-yeah. I would say speak and feel positively. [I: Mm-hm] R: Throw my gum out here... I know you asked what would-what would other people… I: Or have [R: Yeah] -have any changes been brought to your attention by other people R: And....yeah. Yes, but I don't know how to.... I don't know how to put that in words, like, not so concretely. I: Yeah. Just describe- [R: Um..] describe what you-what, like, what - if it hasn't come up in words, like somebody said here's the itemization [R: Yeah] of changes, like what-what has come up in relationships, conversations, or even non-verbals [R: Yeah] that would suggest other people have noticed? R: Like, I would say probably the person who's noticed the most would be Kristin, um, [I: Okay] because her and I go for walks frequently. [I: Mm-hm. Mm-hm] Um, and... Yeah, like I remember when I said, like, “I'm amazing!” and she’s, like, “You sound surprised by saying that?” [I: Mm-hm. Mm-hm] right? Like, [I: (laugh)] she said, “Soulooks like you almost can't believe you said that about yourself.” And I was like, “I can't!” (laughs)] [I: Mm-hm] Um, and so, I think I-I would - if I was to put words to it, I would say she probably sees a change in how, like, a-a sense of like groundedness or centering of me. [I: Mm-hm. Mm-hm] Um, yeah. And the way that I-the way that I talk about myself; the way that I respond to things going on around me. [I: Mm-hm] Um, even...would that be a change? Mm? I was gonna say even in like being able to, like, share when bad things are going on. [I: Mm-hm] I'm not - I don't know if that's a change though. That might be more - that's just been the way I do things. (chuckle) [I: Mm-hm] Um, but, yeah. Definitely in-in the...the finding footing [I: Mm-hm] kind of idea. [I: Mm-hm] I: Any other changes that come to mind that you've noticed, um, in yourself since therapy started? R: [long pause] Not that I can think of off the top of my head. I: Yeah. And it's okay - just like any other item [R: Yep] we can come back to that. [R: Yep] Um, has anything changed for the worse since you started therapy? [R: Mmm] We kind of touched on it - this question was coming when you talked about raw emotions. [R: Mm-hm] Um, what do you want to say about that or anything else? INTEGRATING EGO IDENTITY WITH LI THERAPY 433 R: Yeah, um, yeah. Like I would say definitely, yeah, the emotions are definitely raw-er. Is that a word? (laughs) We'll make it a word. I: We can understand it. [R: laughs] I’m going to write ‘raw-er’ not ‘more raw.’ (laughs) R: (laughs) I like it! I: (laughs) And it's all being recorded, and you can transcribe it. R: Yeah. Exactly. (laughs) [I: laughs] I: Emotions are raw-er. [R: eh] Yes. R: Um, and something actually that's just kind of come up very recently, is relationship with mom and dad. Definitely right now is very - like my mom called yesterday and I was like, ‘I don’t have any desire to talk to you.’ Right? [I: hmm-hmm] Um, and there's, I mean, definitely reasons around that, but yeah, that was surprising. I: And unwanted? R: Um...yes and no...um...Why do I say yes and no? It's difficult and in that sense it's unwanted. But the no part is this like emotional reaction inside of me that goes, ‘NO! I don't want to talk!’ Like, (chuckle) I don't want to have anything to do with them kind of thing. [I: Mm-hm] So yeah. But it's never - it’s-it’s-it’s definitely against family rules for me to not want to - well I guess it's against anybody's family rules but, - to not want to talk to them or not wanna, um… And so, yeah. It’s like, even I texted my mom in response to something last night and I was like, “Can I put ‘Love you’? No, I don't think I can right now and that was -that's tough. [I: Mm-hm] ‘Cause that's not the way it's supposed to be. And [I: hmm] that's not easy to admit; that that's kind of the way you're feeling. [I: Yeah, yeah] I’m feeling. I: I really sense that...I'm struggling [R: Mmm] with like the interview part of me [R: Mmhm] and the more, like, wanting to engage with it from [R: Right] like a clinical standpoint- 'Cause I sense the conflictedness around this is something that maybe doesn't look good, it's not pleasant. But it may reflect also growth, [R: Mm-hm. Yeah] and a sense of boundary, and where you are and what you want [R: Yeah] emerging in your relationship. [R: Mm-hm] And so, I hear the yes and no really loudly. [R: Mm-hm] Like, it could be a sign of something that has an inner strength and a connectedness, but it’s also a relationship - apparent relationship - break-down [R: Mm-hm] of something. And [R: Yeah] I’m not sure how to name it exactly, except that as I hear you talking I sense that it's not just destruction but it's also coming from an emerging [R: Mm-hm] sense of who you are, and what you need, and where you are in relationship. [R: Yeah] INTEGRATING EGO IDENTITY WITH LI THERAPY 434 R: So, yeah. And that - I think that helps me put words to it a bit better. But the-the yes part is that - this is me bursting out of constraints, [I: Mm-hm] and that feels… I: More freedom. R:…freedom. [I: Mm-hm] It feels empowering. [I: Yeah] It feels positive while at the same time recognizing that that bursting out action is - will and is causing tension. [I: Mm-hm] And, and there will be [I: Mm-hm] negative or difficult things will come of that. [I: Yeah, yeah] And so there's that duality there. [I: Mm-hm] Yeah. [I: Yeah] I: Um... anything else you want to mention in terms of changes for the worse or maybe [R: Mm-hm] complicated? It's not [R: Yeah. (laughs)] necessarily worse, [R: Right] but it's pain [R: Yeah] in it that I think we can put there too. (laughs) [R: yeah] R: Um....Okay. How do I...there is, um...hmm...This is when I really wish I could like paint like Robert Bateman or something. (both laugh) I: If only! R: Um...well, at the, the - like there is an element of kind of (sigh) - Because I'm in the middle stage [I: Mm-hm] there's this sense of like uncertainty and fear. A combination of, like, what does it look like on the other end? [I: Mm-hm] Or, [I: Yeah] does what I'm hoping for - is that actually even a possibility? [I: Mm-hm] Um, am I going to just get stuck here in the middle? Uh, like, will this movement continue? [I: yeah] Like there's this kind of, like, eee- [I: Yeah] angst. There's a good word for it. I: Perfect. Yeah. So, that actually leads me exactly to the next question which is: Is there anything that you wanted to change that hasn't [R: mmm] since therapy started? [R: mmhmm] Because I think that's kind of what you're meaning. R: Yeah, yeah. Um, yeah. It's sort of ... like, I’m in the midst of discovering me and finding a voice and ... understanding how to speak out of that voice, um, in the midst of exposing shame and disempowering shame. (laughs) I'm, like, inventing words all over the place. (laughs) It's great! Um...and so, my hope is that that those will increase and continue. [I: Mm-hm] Um, I mean my ultimate hope is that at the end I can get to that, like, standing tall, [I: Mm-hm] um, feeling strong - I don't even know how to - I've never been there, so (laughs) it's like I don't even know what that feels like. But, [I: Yeah, yeah] um, joy. I know that, like, as soon as I got into that position and, actually Hillary replayed my positions for me while I watched, [I: Mm-hm] and that position always like – smile. [I: Hmm] Like, even though there was a lot of like sadness and stuff going on inside, like, my - [I: Yeah] automatic smile [I: Yeah] kind of thing. And then it's just, sense of like taking up space, [I: Mm-hm] and making myself known [I: Yeah] kind of thing. [I: Yeah] Um, and so my hope is that there is a-a way - (crying) I mean, that's INTEGRATING EGO IDENTITY WITH LI THERAPY 435 been my dream for a very long time. [I: Mm-hm] And my hope is that I can get there. [I: Yeah, yeah] I: So, you're in process [R: Yeah] and you don't feel like it's fully baked. [R: No! (chuckles)] Like this journey of, like, that grippingly powerful strong position, that's showing up. Just like, arms stretched. [R: Yeah, for sure] You're still working. [R: Yeah. (laughs)] Is it Okay for you now that we talk about ratings on these changes? [R: Mm-hm] 'kay. Um, I'm gonna ask you 3 questions [R: (laughs)] for each one and there's fourteen items that you've [R: O-kay! (laughs)] given me so, I'm just preparing you. Um. R: It's my lucky number. (laughs) I: I know. The questions are for each item. Um, I'm going to have you rate how much you expected it [R: Okay] versus were surprise by it where 1 is very much expected it and 5 is very much surprised by it. So, 1 is [R: Okay] like, “No. I knew that that would happen,” [R: Mm-hm] and 5 would be like, “No. I didn't think that that would happen.” [R: Right] And somewhere in the middle is, “Yeah. Little bit, you know.” Neither surprised or expected would be 3. Somewhat surprised – 4. And somewhat expected is 2. So, let's just stick with that one first [R: Okay] and then go through all the items and then you'll start to probably memorize the list of items [R: Yeah. (laughs)] as we go through the second and third times. So, this is expected. Um, the first item was that your negative thoughts no longer directly correlate to the level of distress you're feeling. Was that expected or surprising? R: Oh. I: 1 to 5. R: Definitely surprising. I: Give me a number: [R: Um…] somewhat or very much surprising? R: I'd give it a 5 actually. [I: ’kay] Yeah. I: Self-medicating, um, choices no longer resulted in shame and self-blame. Is that surprising or expected? R: Surprising. Um...probably more a 4 [I: Mm-hm] than a 5. Yeah. I: The next one is that: you described that while you have swells of anxiety that these emerge with an increasingly powerful sense of an anchoring in yourself, in ‘ME.’ And that the emotions are less overwhelming; you're more detached from that. [R: Mm- INTEGRATING EGO IDENTITY WITH LI THERAPY 436 hm] Those are all the descriptors of it. How expected or surprising is that change for you? R: Okay. Just wanna clarify, [I: Mm-hm] 'cause it's like, conceptually I expected to have a stronger sense of core self, [I: Mm-hm] but the way it's happening is completely surprising. [I: Hmm] So, not entirely sure how to - [I: Yeah] Like in the midst of… I: That makes sense. R: …like feeling and being anchored, [I: Uh-huh] that to me was absolutely a 5. I: So, I think that's what this item is describing [R: 'kay] because I think you're describing a mentality before [R: Right] that's very either/or; I can either be anxious or anchored. [R: Mm-hm. Yeah] And what you're describing has happened as you're able to experience anxiety while feeling anchored [R: Mm-hm] and that-that's incongruous. R: Very surprising. Yeah. I: But it also is true for you. R: Yeah. I: 'kay. So that's a 5. R: Yep. I: The next one is that the duration of negative emotions or the swell of anxiety has decreased; it doesn't last as long. R: I’d say that's a 3 - a little bit in between. [I: Mm-hm] I: Um. The next item is that you're allowing yourself space to play. Um, being intentional about giving your younger ego states, um, creative -[R: Yeah (laughs)] Like buying Legos was your example [R: Yeah] of that. R: I'd say that's a 2. I-It's not too surprising that I would do that [I: Mm-hm, yeah] (laughs) I: Um. The next one is insight that you've become more aware of the role that shame has played in your life, your entire life. R: I'd say that's a 4. INTEGRATING EGO IDENTITY WITH LI THERAPY 437 I: Yeah. And connected but separate from that, seeing yourself as more continuous throughout life - seeing ME - not just being divided by pre- and post-repatriation. R: [long pause] It's definitely either a 4 and-or a 5 but which one? I: What's your gut?... You said, [R: Yeah] ah, “My 7-year-old is me.” [R: Yeah] R: Based on how surprising that was in that episode I would say 5. [I: 'kay. Um.] Yeah and then every episode actually, 'cause even when we did our attunement baby self [I: mm-hm] I remember being surprised by that. [I: Yeah, yeah] I: Um. The next one’s showing up with more voice. Being less apologetic about being you because you've been gathering the pieces of yourself. And this is the - where you describe the Greatest Showman song {“This is me”}. [R: Mm-hm] R: Um. [long pause] Hmm...I'm going to give it a 4. [I: Mm-hm] I: 'kay. The next one is this core awareness that there is a ME to encounter, and that the ME is unique and core and not defined by other people's 'shoulds'. Belongs entirely to you. [R: Yeah] It's your essence, and it's there. [R: (laughs)] You're not created in other people's [R: Yeah] ideas but there is actually a YOU. R: So, again I feel a little torn [I: Mm-hm] 'cause... there's like I expected to encounter a ME. [I: Mm-hm. Mm-hm]... What’s the other side of that? Maybe I'm not so torn. (laughs) I: And you did [R: Yeah] encounter it, [R: Yeah] but you knew it was there, I think? R: I hoped it was there. I don't think I really knew, [I: huh] I hoped. SoI: So, let's go to experientially. [R: Mm-hm] That you live with an awareness - a felt awareness - that there is a ME. R: Okay, yeah. Experientially my gut is saying that's definitely not an expectation. (laughs) [I: Mm-hm] Yeah, that was - it was a hoped for but now that it's there [I: Mmhm] I'm [long pause] I: I just made a note in the margin [R: I was gonna say, yeah] that you had a more - Like, I still don't have a number, but that cognitively versus experientially it's different [R: Yeah] because you wished for, hoped for - More expected it cognitively but experientially it's more surprising. [R: Yeah] Um, I still want you to land, I think, more INTEGRATING EGO IDENTITY WITH LI THERAPY 438 experientially in how you rate it [R: Mm-hm] but I think it's important that we just kind of keep that note 'cause -[R: Mm-hm. For sure. Yeah] R: Um...yeah. I'm gonna give it a 4. I: 'kay. Next item: I love me [R: Mmm] truly and authentically, and I can speak and feel positively about me. Not just lip service. R: That's a 5. (both laugh.) I: You didn't hesitate on that one. R: Nope. (laughs) Which surprises me but... [I: chuckle] How expected was that you wouldn't have to, uh, debate on that one? 5! (laughs) I: So, this is: your friend Kristin has noticed changes in your ability to speak positively about yourself. Um, and it - her observation would be that you have greater groundedness, centering and finding your footing... It's kind of similar [R: yeah, Mm-hm] but it's through the eyes… I & R: (together - simultaneously) of someone else. R: Mm-hm. [I: Yeah.] I would - I would say I'm pretty surprised about that, so, I'm going to say a 4. I: ‘kay. Um. The next three items are the ones that are maybe worse, or ambiguous, [R: Mm-hm] or conflicted. Um, that your emotions are more raw. R: Excuse me. Um, yeah. That was pretty expected. That was 1. I: Okay. It's therapy after all. R: Exactly. (both laugh) I: Don’t know this gig. Your relationship with your parents is changing, um; is more strained. R: That's a 5 'cause I thought I was through that. I: 'kay. [long pause - writing] R: (referring to the dog in the room) Just had a bad dream (chuckle). INTEGRATING EGO IDENTITY WITH LI THERAPY 439 I: She still sleeping? R: As far as I can see-tell. I: 'kay. Um, and then the next one is the uncertainty and fear about reaching your goals. Angst that you feel about like where you want to get to. [R: Mm-hm'] R: Um...I’m going to say a 3 on that. [I: Mmm] Yeah. [I: 'kay] I: Okay. Now you know the list, um, and have kind of previewed the different questions. The next rating that we give is how likely you think it would’ve been for each change how likely it would have happened, um, if you hadn't been in therapy. So, um, 1 is very unlikely without therapy. Um, 5 is very likely without therapy, so it would have - it clearly would have happened anyways is a 5; 1 is it clearly would not have happened; 3 is there's no way of telling - its neither likely nor unlikely. More on the unlikely side, 2 is it probably would not have happened - somewhat unlikely without therapy; and 4 would be probably would have happened - but somewhat, so somewhat likely [R: Right] without therapy. [R: Yep] So, um, your negative thoughts no longer directly correlate to level of distress. Is that likely to have happened without therapy or unlikely to have happened without therapy? R: Unlikely. (laughs) I'm like getting stuck in the language in my head. Like so thisI: Yeah, so clearly would not have happened without therapy [R: Yeah] or probably would not have happened without therapy? [R: Um] Or without this therapy. You've done talk therapy, too. R: Yeah...I would say a 2. That's the probably would not have happened, right? I: Yeah, that's right. Self-medicating choices not resulting in shame and self-blame. R: I think that's a 1. I: 'kay. That your swell of anxiety can co-exist with this this more increasingly powerful sense of anchor in ME. That emotions don't overwhelm all of you. R: Oh, that's a 1 for sure. I: The duration of negative emotions decreasing, R: ...Mmm. Gonna give that a 3. INTEGRATING EGO IDENTITY WITH LI THERAPY 440 I: 'kay. Um, the allowing the younger ego-states to play intentionally. Like buying Legos, as an example. R: Yeah. Um... Yeah, I am going in the right direction. I think it's probably a 4. I: Yep. I'll just reiterate the anchors. The 4 means it probably would have happened… R: Mm-hm - without. I: but not clearly… R: Yep. I: …would have happened. 'kay. Um, becoming aware of the role that shame has played in your life, like, your entire life. [R: Mm-hm] The-the kind of - You keep saying, like, how-how pervasive or connected - [R: Mm-hm] I don't think those were your words, but it's like, “Woah! It's really [R: Yeah] it's really there! (laughs) R: Yeah, yeah. Ah, yeah. That's a 1 actually. I: Okay. Seeing ME. Seeing self as more continuous throughout life not divided by just pre- and post- repatriation. R: 1 I: Showing up with more voice. Being less apologetic about being ME. Gathering these pieces of yourself. R: 1 (laughs) I: Yeah. The awareness that there is a ME to encounter; this core self-self that’s unique and not connected to other people's shoulds. R: One I: Um, I love me. That one. [R: Mmm] Not just lip service R: One [I: um] Some of them are easy ‘cause it's like, I’ve been trying to do this for so long [I: Uh-huh!] so - (laughs) [I: Uh-huh] It's never [I: Yeah] happened before [I: Yeah] so - INTEGRATING EGO IDENTITY WITH LI THERAPY 441 I: Um. The next one is Kristin's observation of you, um, being more grounded and centered and finding your footing. R: Yeah, I'd say that's a 1. I: 'kay. Emotions more raw. R: (laughs) 1. I: (laughs) - so, um, in that… R: Um, well wait a second. I: Um. [R: yeah] Unlikely without therapy that it, is what you mean. R: Well, maybe a 2 actually. Yeah. I: Okay. Parents relationship strained; changing. R: ... Mh. I mean, it's possible I could have gotten there again cause I've-I sort of have gone through one... I: Worked through some of it. R: …state of it. [I: Yeah. Mm-hm] So, hard to tell, maybe? Like a 3? [I: Um] or or a 4. I: Or somewhat unlikely without therapy? [R: Yeah] Probably would not have happened or probably would have happened? ...You describe being relatively, actually quite surprised [R: Mm-hm, yeah] by this coming up. R: Okay. So, part of my, like, debate in my head is that I-I could probably say definitively it wouldn't have happened now [I: Yeah] if I wasn't in therapy. I: Sure, but it was always there to happen at some point. [R: Yeah, yeah] Yeah so, I think that means it's a more on the 1 or 2 side. R: Okay. Yeah. That makes sense. I: We can blame therapy for this. R: Yes. [I: Like] For sure. [I: Okay] Yes. Yeah. INTEGRATING EGO IDENTITY WITH LI THERAPY 442 I: So, the question would be, like, [R: absolutely] for sure, 1? Or probably which is 2. R: I’d say 1. [I: Yeah, 'kay] Like it wouldn't have come up without therapy, so I: Yeah. Um, angst, uncertainty, and fear about reaching your goals. Did, like - is this because [R: Ugh] of therapy or this, um, this likely to be something that you'd be feeling? R: Well, I wouldn't be trying [I: Yeah] to get to the goals if I wasn't in therapy, [I: True] (laughs) so - [I: Yeah, yeah] I know definitely I wouldn't be able to reach my goals. [I: Mm-hm] Um, yeah. I would say. Like, the level and it-the characteristic of it [I: Mmhm] is a 1. I: Okay. [R: Yeah] But like the angst has increased [R: Yeah] as you started this journey. R: Yep-yep. I: 'kay. Okay, the last rating [R: Alright. (laughs)] that we're doing on these items is the importance or significance to you personally, [R: Yep] um, of each change. So, 5 is extremely important to you. 1 is not at all important. 3 moderately. So, not at all goes to slightly, moderately, very, and extremely. [R: Okay] So, most important, 5. Least important/not at all important, 1. So, start at the beginning again, your negative thoughts are no longer directly correlated to your level of distress. How important is that to you? R: … 4 I: 'kay. That, um, your self-medicating choices don't result in the same level of shame and self-blame. R: 5 I: Swell of anxiety is occurring with increasingly powerful sense of your anchor in yourself. How important is that to you? R: 5 I: Duration of negative emotions is decreased. R: … That why I'm even debating this, 5. (laughs) I don't like [I: You] being in them so [I: Yeah, sure] I: Um, being able to intentionally play and nurture kind of younger parts of yourself. INTEGRATING EGO IDENTITY WITH LI THERAPY 443 R: Um... 4. Yeah. I: Becoming aware of the role of shame and that how it has - what it has played in your life. So, I think what we would - We're rating the importance of that insight not the importance of shame. R: Right. Yes. (laughs) I: Okay, yeah. Just to be clear. R: Yeah. (both laugh) [I: like] Good clarification. (laughs) I: Shame is really important to me or - (both laugh) Yeah. R: Yeah, that would not be good. Um. I: I mean it has a role. R: Yes. Exactly. Oh, this one's hard though. Um... I: You're going to hear more the laughing in the hall on that. [R: (laughs)] I don't think they can hear us though. R: That's right. Um, I’m gonna say a 4. I: Okay. Um. The next one is the seeing yourself as more continuous; seeing ME more continuous throughout life not divided by pre- and post-repatriation. R: That's a 5. I: Um. Showing up with more voice. Being less apologetic about being you because you've gathered pieces of yourself. R: 5. I: The awareness that there is your unique core essence ‘ME’ to encounter and express. R: That's 5 (whispered). (chuckle) I: No hesitation. ‘I love me.’ [R: Mmm] Not just lip service. INTEGRATING EGO IDENTITY WITH LI THERAPY 444 R: 5. I: You're kind of beaming as you describe that. R: (laughs) I know! I: That's really cool. Um, Kristin's observations of your groundedness and centeredness. R: Um, 4. I: That your emotions are more raw. R: ...How do I rate that? (laugh) I: I don't know. That's a good question. [R: (big sigh)] I mean, like, the - It's a negative experience in many ways [R: Mm-hm] and yet you're connecting it to a positive connection to self [R: Mm-hm] and authenticity. Um, so is connecting to your emotions important? Is it, maybe, neither here nor there? Maybe it's-it's- it is a harder one [R: Mm-hm] to rate the-the ones that are the kind of worse. R: So, hmm. Like a-from a life of having suppressed emotions [I: Mm-hm] and dismissed them, [I: Yeah] if I look at it that way then being able to give them space to be [I: Yeah] and to be heard and to be felt is very important. [I: Sure] So I'd give that a 5. [I: Okay] Does that make sense? [I: 'kay] I: That makes sense and you just qualified it. I didn't write that down, but it's all recorded. [R: Yeah] So, um, this is another one you're probably [R: Yep (laughs)] going to struggle with. The relationship with your parents. The fact that this is coming up now because of therapy. Um. [R: Um] I'll let you qualify how you want. R: I struggle with it a little less actually, [I: Okay] because, um, it has, like I said, it has come up in other [I: yeah] therapy. [I: yeah] Little bits in here and, um - Even li-like, even my coming to BC and starting, like, quitting teaching and starting [I: Mm-hm] this program was a bit of a fight with - not fight, [I: Yeah] but I had to very much kind of stand [I: Yeah] on my own ground, [I: Yeah] and kind of come against questions why I'm doing that [I: Mm-hm] kind of thing. So that theme of, like, being separate from my family and being able to be a separate entity [I: Mm-hm] is pretty important. So, um, is it a 4 or is it a 5? Uhh… I: And it probably, like you're qualifying it as it may depend on whether you’re looking at the ne-the pain of it [R: Yeah, exactly.] or the part that connects to your individuation. [R: Yeah] Um. I’m going to put 4 – 5 [R: Yeah] I don't know if that's allowed. INTEGRATING EGO IDENTITY WITH LI THERAPY 445 R: But we'll do it anyways. (laughs) I: But, um, but you've qualified it and it's there, [R: Yeah] with kind of the tension and then angst. I don't know how you're supposed to rate that, like [R: Mm-hm] that you're uncertain about the and maybe have fear about reaching your goals. I really don't know how it should be rated because is it saying that the goals are important to you? [R: Right] Or that the angst is communicating something? Um. You've said so far that it is neither; you're neither expected nor surprised by it. That it’s because of being in therapy that it's happening. [R: Mm-hm] It's unlikely that you'd feel this much angst about where you're going [R: Mm-hm] without therapy. Um. R: I'm gonna say it's a 4. I: 'kay. And then it's important. R: Because it-it's evidence that-that I still haven't arrived. It's evidence that I'm still hopeful as well; [I: Mm-hm] like it I haven't - I'm not resigned. [I: Yeah] I'm not, like, I'm still living in the experience [I: Yeah] of moving forward. I: Absolutely. That makes a lot of sense. Yeah. Okay. [R: Phew] In general - yeah, we did it! [R: (laughs)] Fourteen items. Three rating scales. (laughs) I mean this is - this is, like, not for the faint of heart! [R: laughs] Um, in general - this is now attributions - [R: yeah] what do you think has caused these various changes? What do you think might have brought them about? And I ask that not just ‘cause. You've said already whether they were surprising or because of therapy, so both things within therapy and outside of therapy. [R: Mm-hm] Are there specific connections that you can make that connect to these changes from your therapy journey? Or outside [R: Mm-hm] if you feel like, “No. That's totally an outside event.” R: Um. Yeah. One thought comes to mind. It probably, like, is a combination of a whole bunch of questions that are on there. [I: Mm-hm] But, um, very, like very early well within our first 3 sessions – um, Hillary very much focused on attunement protocol. [I: Mm-hm] And that... mmethiwhthwahah (gibberish) (Laughs) Ah! This is when Kristin and I just make sound effects (laughs). Um. That process of going through that made it, um, gave - I don't know if it's ‘gave voice.’ That's not what I really mean. But I have always kind of wondered whether I have ever really experienced attunement, [I: Mmm] and that process made it very clear, obvious to me, that-that no. [I: Hmm] I really haven't. Um. And so, the whole like - everything we've done in therapy so far has been not only her providing attunement for me but her helping me provide attunement for other parts of myself, [I: Mm-hm] right? [I: Mm-hm] And so going back to parts of, like experiences I've had, and meeting needs [I: Mm-hm] in those situations that weren't met, [I: Yeah] um [I: Yeah]...Yeah. It was again like-like one of the things I know that I, um, came to the realization of [I: Mm-hm] is I remember as a child and teen and whatever, um, [I: Mm-hm] often, uh, sort of faking illness or making a bigger deal out of an injury that [I: Mm-hm] maybe wasn't as big a deal. Um, and never - I think that's where I get INTEGRATING EGO IDENTITY WITH LI THERAPY 446 this sense that I’m an overly dramatic person. [I: Mm-hm] Um. And... I kind of realized that, “Oh! That was me looking for the attention that I felt I wasn't getting!” [I: Mm-hm] Um, and that was a new realization [I: Mm-hm] for me to kind of [I: Mm-hm, yeah] ... And so, ...yeah, just having – Gosh! It's so hard to put into words. (Laughs) Having another person, like my therapist [I: Mm-hm] and me together jointly work to giving attention to the needs that weren't met [I: Mm-hm] at different points in life [I: yeah] is creating safety for me to emerge, [I: Yeah, yeah] for me to be present, for me to speak, [I: Yeah] for me to be. [I: Mm-hm] That would be I: It's pretty big. [R: Yeah] So this theme of being seen and being attuned to is kind of your – like, it's a summary attribution that I think you're describing, [R: Mm-hm] as both from somebody else to you but then from you to yourself, [R: Mm-hm] is this has been a transformative element. Something that you were hungry for and [R: Yeah] confirmed in the process of therapy that you were missing pieces. [R: Yeah] You suspected it, but in experiencing attunement protocol, I don't know the - I see this, like, image of like a sponge. Like [R: Mm-hm] you were just ready to soak it in. [R: Mm-hm] R: And I think it -[I: Yeah] Part of what s-totally surprised me and made it quite like, “Woah!', um, is pretty much every time we did attunement protocol and I was like the two-week old baby, and Hillary would say, and “Watch me come in.” And I’d be like, “Hurry up! Hurry up get here!” Like there was this sense of urgency. [I: Mm-hm] Like, “You need to come!” Like, “You can't leave me here alone!” [I: Mmm] And that was right from the first time. [I: Yeah] And that was very surprising for me [I: Mmm] 'cause, you know, um - Actually I think the first time she didn’t mention that my parents were in the room and then the second time she mentioned my parents there [I: Mm-hm] and I was like, “No, no! No! You come!” (laughs) “I don't want my parents here.” Um...and I-I think within this relationship that - this therapy relationship that we have ... there's - And maybe within the structure of LI protocol too - exactly w-w the mechanisms, but, um, somehow I feel greater freedom to, um, break or shed family rules and just be. [I: Mmhm. Mm-hm] Um. And so, it was okay that I wanted Hillary there and not my parents when I was a 2-week-old baby, right? [I: Yep] And th-there's still sometimes inner conflict as I'm experiencing it but [I: Yeah!] I end up experiencing it anyways. [I: Yeah] So there just this - They're less confining or less - [I: Mm-hm] they have less say [I: Mmhm] in what happens. [I: Yeah] Um, yeah. I: That's, that's beautifully described.... Anything else you want to say about attributions? [R: Mmm] I don't - [R: No] I'm not saying that I think you should. R: No. I: ‘kay. The- it may be connected. The next question is can you sum up what has been helpful (laughs) about your therapy so far? Perhaps this is it. [R: Yeah] Um, are there specific events, general aspects of therapy? Shall we name attunement again here? Um. [R: Yeah] Is there anything else you want to say? INTEGRATING EGO IDENTITY WITH LI THERAPY 447 R: I would say like-like attunement's a huge part of it for sure. Um. And then I think, because like I've lived my life, like, here are the rules [I: Mm-hm] and this is what you do. [I: Mm-hm] Um. Sometimes I can get a bit stuck in there within protocol as well. [I: Mmm] Like “Okay. I’m supposed to go to the safe place now.” [I: Mm-hm] Um. And sometimes my younger self (laughs) doesn't want to do that and so it's been really When I finally get to, like, “Okay. We're just going to say something and admit that this isn't working,” [I: Mm-hm] um, it's very - it's okay. [I: Mm-hm] It's okay that, you know, [I: Mm-hm] we're changing things [I: Okay] or that things are going differently or I: Is that freedom to give feedback? But also, to, like, let the therapist be creative? Or is it more the therapist be creative? Or more you giving feedback? R: I think, um, it's almost more like freedom for the therapy process [I: Mm-hm] to go where [I: Mm-hm] it needs to. That includes me giving feedback as to-to what I’m experiencing and then her, like, not being surprised by it, and not being put-off by it and not being like-like - There's been a couple times where I was like, um, “I can't get into the scene” or “I can't, [I: Mm-hm. Mm-hm] like, I’m-I’m having difficulty. Like my-my person won't leave,” kind of thing. Or whatever. And as I finally get to the point where I say something, [I: Mm-hm] she's not derailed by that, right. [I: Mm-hm] It just becomes like, [I: Mm-hm] “Okay. Well, [I: Yeah] let's do this then.” [I: Mm-hm] You know? And so, it's just a kind of smooth, “Okay. Well, we'll do it a little differently,” [I: Mmhm] or we’ll, “Let's try doing it this way this time.” Um. [I: Yeah] And so even in that, there’s this sense of like, there's this little piece of my experience becomes validated [I: Mm-hm] in the space and my-and I-I give that experience voice. [I: Mm-hm. Mm-hm] Um. So, like a couple of weeks ago, um, we had to change my safe place [I: Mm-hm] and I was like, I-I, I mean in my imagination I was like, “No. We have to - this is where our safe place is,” [I: Right] right? [I: Right, yeah] And then I was like, “No. We can't go there 'cause mom and dad are there. [I: Mm-hm] So, I said something and she's like, “Okay. Well, let's pick a different safe place.” [I: yeah!] I was like, “Oh, okay.” (laughs) [I: (laughs)] You know? I: Can be flexible. R: Yeah. Exactly. I: Yeah, so flexible. [R: yeah] It has to do with attunement, too. [R: Mm-hm] It's really connecting to what your needs actually are. [R: Exactly] Yeah. R: And, and I think, yeah, in that sense it's not like it's... it's not so much like this like, ugh... um, clinical construct [I: Mm-hm] of like “well, you need to be flexible.” [I: Mmhm] It's, it's truly two people journeying together [I: Mm-hm] and so she's just with me wherever I need to go [I: Yeah] or wherever things need to move. [I: Yeah] Um, which is really cool. [I: Mm-hm] INTEGRATING EGO IDENTITY WITH LI THERAPY 448 I: Um. Those were helpful aspects. What about problematic aspects? What kinds of things about therapy have been hindering, unhelpful, negative or disappointing? General [R: Yeah] or specific. R: Um...generally that that part has been blank on most of forms. [I: 'kay] Um... Thethere's two things that kind of have come up. [I: 'kay. yeah] One is, um... kind of not, yeah, anyways. Um... The nodding to indicate where I've got. [I: Mm-hm] Uh, um. I’ve captured a memory. [I: Mm-hm] Um, especially I think more at the beginning. Now it's kind of more habit, but there have been times where I’ve almost, like, I've forgotten and then realize she was waiting for my nod (Laughs) and so sometimes it interferes a little bit [I: Mm-hm] with the experiencing part. [I: Yep, yep] Um, but yeah, so that was one that came up. [I: Mm-hm] And then the other one was more just how I can get in the way of my own self [I: Mm-hm] sometimes [I: Mm-hm] and, um. [I: Mm-hm] And almost fight my own intuition. Um. I know that a couple sessions ago, like I-I wanted like, I was like “no, we can't do that.” Like I want to change what just happened [I: Mmhm] in my imagination [I: Mm-hm] and my imagination wouldn't change (laughs). [I: Yeah. Right] I was just like “Okay, accept it Rose.” (both laugh) [I: Yeah, like let it be, yeah, yea., Mm-hm] Just let it be. [I: Mm-hm] Continue on. So [I: Yeah] sometimes it takes me a while to actually like move to the next part [I: Mm-hm] 'cause I'm like fighting [I: Yeah] with [I: Yeah] what’s going on, but. I: Have there been things in therapy that were difficult or painful but still perhaps helpful or Okay? R: Every session. (laughs) I: Like all of it?! [R: laughs] (laughs) Yeah, fair enough. [R: Oh dear] What about has anything been missing from your treatment? What would make or have made your therapy more effective or helpful? [R: Um] Besides the fact that we've already identified that this is a-a point in time [R: Mm-hm] and that this is on-going [R: Yeah] and that there's more work to be done. So, I think that's a given. [R: Yeah] R: Um. I think the only thing that sometimes I wish there was more time for. 'cause it, [I: Mm-hm] I mean in an hour when you're doing LI protocol, right, it's kind of like get down to business get going. [I: Yeah. It is] Um, is opportunities to kind of share some of what's going on. Um. I: For debriefing. R: Yeah. [I: Yeah] And so we have, I've on occasion like sent emails to her and just said, like, I've shared some photos of like my Lego, what’s going on or whatever. [I: Mm-hm] Um, and so that that would be one part [I: Mm-hm] that sometimes is-is more difficult. [I: Yeah] INTEGRATING EGO IDENTITY WITH LI THERAPY 449 I: In an ideal world we'd have more time. R: I know, yeah. (laughs) I: Yeah, yeah. Anything else that... R: Not that I can think of. I: ...you want to put words to missing or-or that moves to the next question, which is actually the last before we just compare PQ's. [R: Right] So if you're losing stamina [R: (laughs)] just want to - words of comfort. [R: Yes] Um, any suggestions for us regarding the research or therapy; anything else you want to tell me? R: [pause] Not that I can think of. I: Okay. So, the last thing we're supposed to do is compare. [R: Okay] Um, I have your file. Compare your first PQ, your baseline [R: Hmm] and present, and we're looking for items that have changes two or more points, [R: Mm-hm] um, so I believe. R: We have to do this week? (laughs) I: ... That would be your first one, May 18th. [R: Yeah] Um... and I believe this is your current one. [R: Okay] (paper shuffling) So let's just start with like go down and, um, the first item has that changed Two or more points or just go down and tell me the first one that has changed two or more points. [R: right] R: Uh yeah, the first one has gone down Two or more points. I: 'kay. Um. Wait actually before I ask you that, in general do you think your ratings mean the same thing now that they did before therapy? Or have they changed? Um, sometimes client's over time change how they use that scale, [R: Mm-hm] um, as things get more nuanced. R: I think generally they've stayed the same. [I: 'kay] There's a couple that have... well, no I guess I used it the same, I just realized [I: you just...] wasn't answering the question. [I: Yeah, Okay] Yeah. I: and that...um. I can just make a note here there's an item you rated based on occurrence not distress. [R: Yeah] 'Kay. Um, but you did it consistently. [R: Mm-hm] Yeah. So, I think now we can move on to the Two plus points changed. [R: yeah] So the first one is that problem change something that we already talked about? Today? R: Yeah, it's feel shame, so yeah. INTEGRATING EGO IDENTITY WITH LI THERAPY 450 I: It's shame. R: Yeah. Oh, I guess we didn't... I: No, we didn't... R: ...talk about it when we talked about change. I: ....we talked about the awareness of the role of shame. [R: Yeah] But, um, not just the experience of shame. [R: Mm-hm] Um. R: That's true. I: So. Do you want to add that change to the list you gave me earlier? Because it has changed significantly? R: Why am I stuck in the middle saying yes and no? (laughs) Um. I: Basically, this just gives us a chance to [R: Mm-hm] audit and edit [R: Right] the first list we came up with based on what you came in wanting to do. [R: Mm-hm] But if-if it doesn't feel important to do that, we-we won't. But I can just quickly-quickly add it... R: I think ... I: and get the ratings for it. R: I think part of the debate is like (hand gesture). And I don't know why. [I: Mm-hm] But there this sense of like, no, I don't want to add it yet. [I: Mm-hm] I don't know why. Um. I: Um, how much ... R: But does it make sense? I: ...did it change on your ratings? R: Um. Two and a half, so that's. I: It's considered significant, [R: Yeah] but it, I hear you also saying it's got ways to go. Like [R: Mm-hm] it's not at zero. INTEGRATING EGO IDENTITY WITH LI THERAPY 451 R: But it's still at, like, it started at very considerably and now it's in-between little and moderately. [I: 'kay] Which is pretty big. I: Yeah. But you're stuck [R: I am (laughs)] on this. R: I don't know why. I: I mean it-it has to be you that says whether we should include that as important now. Um, I have some thoughts about why. R: Yeah. Can I see the week before this one? Like the August 3rd ? Just... I: I think it should be towards the back. R: That might be why. That may be why, and my brain's saying “Oh this is just the week” but then I was like, actually this was one of the worst weeks so. [I: Mmm] (shuffling papers) Okay. Yeah, this is even lower, it's a two [I: Okay] and this was like an emotional week, so. [I: Yeah] Yeah, we should definitely add it (laughs). I: Okay. Um. So, based on PQ #15 shame. So, that is expected or surprising that that's gone down by Two or Two and a half or whatever? [R: yeah] Or? (both laugh) R: Um. Again, it was like I hoped for it. [I: Mm-hm. Mm-hm] Um... I’m gonna say a three 'cause I feel like it's right in the middle. I: Yeah. [R: yeah] For sure. Um. And how likely is this without therapy? R: (snort) zero?! (laughs) That's not... I: One is unlikely. R: Yeah, I know that's not an actual… I: Kay. How important is it to you? R: Five. I: Yeah. [R: Yeah] 'kay. So next, um. What's the next item that you see on there that has [R: what’s next?] decreased Two or more points? [R: unintelligible - speaking to self in the background - looking over PQ ratings] R: Man, it's a lot of math to do. Phew. (laughs) INTEGRATING EGO IDENTITY WITH LI THERAPY 452 I: Mm-hm yeah, I know. R: Um, I feel I don't belong went down by Two. [I: Mm-hm] That one I find because I've spent so much time [I: Mm-hm] alone. [I: Mm-hm] Um. Like that that one more comes up when I’m with other people and I’ve [I: Mm-hm] like I don't have class right now, [I: Mm-hm] I don't have, um, research sem. or anything like that so I find that one hard to. I: So that one it sounds like, um, we don't know if therapy has anything to do with it? [R: Mm-hm] Because your circumstances. Um. So, the question is-is it worth putting on the list or not? R: Yeah, I feel like right now it's not. I: Right now. Okay. What's the next one? R: (reviewing PQ's and whispering) I can do this (chuckle).... Huh, that was a bad week that one. Um, so my sleep is interrupted went down by two. I: 'kay. Does that go on this list? [R: Hmm] Based on your own ratings? [R: Yeah] R: Yeah, I’d say it probably does actually. I: 'kay. How expected or surprising? R: Um, pretty surprising actually. I would say a Four. I: 'kay. How, um. how likely without therapy? R: Hm, I'm going to say it's a three. It's hard to tell. I: Hard to tell, yeah. And how important? R: I'd say a four. I: 'kay. Any other items? Or multiple? R: (snort) There are. I: Great! R: Self-sabotage my own goals [I: Yep] went down by three. INTEGRATING EGO IDENTITY WITH LI THERAPY 453 I: Wow! R: Crazy. I: Um. How, how expected or surprising was that? R: Okay, so here's one that may have changed... Is this it or not? ...I'm just trying to think, like if this one has changed. Um. 'Cause I realize - I d-I do remember realizing that, like, my eating goals [I: Mh-hm] were - needed to be separate 'cause we have the like eating [I: Mmm] emotionally [I: Mm-hm] on there. And so, I actually put on my electronic one, I said “Not food” (laughs) [I: Mh-hm, yeah] on there so I could differentiate. [I: Yeah] Um. [I: Right] So, it may have changed how I rate it, [I: Mmm] um, from the first time we did it. [I: M-'kay] Um, where I was I: Maybe including food. R: ...including food in there. I: Okay. Um... So, it's a question mark. [R: Yeah] Like is your sense that there is change on that? Or do you wanna like maybe say leave that for now? R: I - I would like to leave that for now. I: Okay. [R: Yeah] I'm just putting in parentheses and like note, 'Not included this time,' [R: Yeah] even though the numbers are significant [R: Mh-hm] you're making the determination [R: Yeah] of it right now. Um. And the next one that you see 2 or more points. R: Well maybe this would work better? (switching pages around) (both laugh) It's like I keep track of where I am. [I: Yeah, yeah.] Um. Number eight. There we go... Oh yeah, this one has changed actually. Number 9: I'm stuck in an avoidant pattern [I: Mh-hm] has changed two and a half. And yeah, that one we should include, for sure. I: Okay. Um, how expected or surprising? R: (pause, tutting) Hmm. Good question! Um... I: Your gut, right? [R: Yeah] This is your evaluation of it. R: I'm going to say it's in-between. [I: Mh-hm] Yeah. 'Cause I didn't expect it to happen so quickly [I: Mh-hm. Mh-hm] and like the way - like it just happened. [I: Yeah, yeah.] And yet I kind of hoped that it would too. [I: Right] So, yeah. INTEGRATING EGO IDENTITY WITH LI THERAPY I: Yeah. So, what is that? Is that like a R: A three, right? Or is it a four? I: Um, well three is... R: I forget... I: Neither, um. R: Okay. I: um, [R: So...] Neither expected nor surprised. [R: Okay] Four would be somewhat surprised. R: Yeah. It's a four then. I: Okay. Um, and how likely... R: Without therapy? I:Yeah, without therapy. R: Somewhat unlikely. Is that at two? I: Yes! (both laugh) R: I know! I: Double check my anchors. How important? R: Uh, five. Yeah. I: Any others on there? R: I don’t know, let's see. (pause) (laughs) I: Math, I know. R: Ahhh. (big sigh) 454 INTEGRATING EGO IDENTITY WITH LI THERAPY I: Two or more. Two or more. R: Um. Okay so, 'I use food to cope with stress' has changed. I: 'Kay. Um. How many points different? R: Two and a half. I: Yep. And do you, do you want to have it on here? R: (pause) So part, like. I think probably has changed about this one, which is kind of what we've talked about [I: Mh-hm] in other areas is my level of distress I: About it R: In using food [I: Yeah!] to cope with the stress. Yeah. I: So, it's not necessarily the incidence of the behaviour [R: Mh-hm] but the distress. R: Yeah. [I: Yeah] Exactly. I: So that's what we're talking about... R: Yeah I: ... distress and R: So, definitely we need to include that. I: Yeah. Um and that is likely or unlikely? Like, I mean, sorryR: Yeah. Expected or surprised, right? I: Expected or surprised - oh my gosh! R: That's okay. I translated in my head. I: Yeah. You did, yeah. R: Um. Surprised. Five. [I: 'kay] Yeah. 455 INTEGRATING EGO IDENTITY WITH LI THERAPY 456 I: Now - (laughs) R: Both likely and unlikely. I: it is how-how likely without therapy? R: Very unlikely. So whichever one that is. I: One R: One? I: Yeah. And then how important to you? R: Mh-hm. I never considered it a - something that could happen (laughs) [I: Mh-hm] so, I was like, I don't even know. [I: Mh-hm] Um. but yeah as far as like it's a-it has definitely eased some angst [I: Mh-hm] so I would say definitely a four. I: 'kay. Yeah, and it be now how important is it to you [R: Yeah] not necessarily all along. [R: Yeah] Yeah. Any others? R: Um...Nope...Not that one... Nope, that's it. I: 'kay R: But they've all gone down. I: Good. [R: whoopee] And you know we obviously have additional ratings 'cause you've done the spreadsheet. [R: Mh-hm] And we can, um, we can average them and do, we can play with them. [R: Mh-hm] But at this point I just want to make sure this list captures [R: Yeah] the most important ones [R: Yeah] um... R: Yeah, and what's interesting is that this week like this represents the week where I got my feedback on my Lit Review [I: Mmm!] and I found out my mark [I: Yeah!] like so... I: Intensity! R: ...it's got intensity in it [I: Yeah. Absolutely.] As opposed to other weeks that were [I: Right, yeah] much more... I: Um. Oh, I'm supposed to ask you for each PQ change... INTEGRATING EGO IDENTITY WITH LI THERAPY 457 R: Oh, wait we did miss one. I: Oh, yeah? R: Yeah, we did. (laughs) I: Okay. Okay. R: Significantly. I: Oh, yeah. Then let's do it. R: It went down from a four to a one, so [I: Okay] that's three points. I: Which one is that? R: Um. Self-medicate, so. [I: Okay] And we kind of did - we talked about the differentiation... I: Yeah, but... R: ...in the change I: …you're doing this based on... R: Right, based on occurrence. I: Incidence not distress, [R: Yeah, yeah] but both changed [R: Yeah, yeah. For sure.] And so that can be another layer. Um, how expected or surprising is this one? 1:46:18 R: Um...I'd say a four I: 'kay. [R: Yeah] And how likely [R: Mmm] without therapy? R: That's hard to tell 'cause I have had times [I: Mh-hm] where it's happened. I: So, does that mean it's a three? R: Yeah. I: How important? INTEGRATING EGO IDENTITY WITH LI THERAPY 458 R: A five. [I: 'kay] Yeah. I: Um. Okay, so for each of these PQ items, um, they are shame, sleep, stuck in avoidant pattern, using food to cope, and self-medicating distress. Um, I'm supposed to ask you what do you think this change means, and do you think the change in PQ ratings is accurate. I'm just giving them [R: Mh-hm] in a summary so that you, kind of, are primed. So first of all, for shame. What does that mean, and do you think it's accurate? R: Yes, to the second question. "Huh??" to the first one. (laughs) I: Okay, okay. Fine. What about less interruptions in sleep? R: Um, what does it mean? Um. I hope it means that I'm experiencing less distress overall [I: Mh-hm. Sure.] so my sleep is moreI: Yeah. And do you think... R: ...able to sleep. I: ... that the rating actually reflects an accurate trend? I think that’s why we’re asking. R: Yeah. I: Kay. “Yeah” with hesitation. R: Yeah. I mean the way, the way I rated I think definitely because I basically rated on like, um, intensity and frequency, so. Like, did I consider it a night where it was really disrupted or not? [I: Mh-hm] And then frequency, I've got like from one to seven: one means I couldn't fall asleep [I: Mh-hm], two mean I woke up once [I: Yeah, yeah], that kind of thing. So, I think it definitely reflects a change. [I: Uh-huh] Whether it's significant is kind of [I: Yeah] where [I: Okay] I (unintelligible) I: Well, we have all the other ratings to look at, [R: Yeah] um. The avoidant pattern being stuck in the avoidant pattern. R: Definitely ratings reflect. [I: Yep] For sure. I: And do you have any more you want to say about what that means? R: Um...I think it's-I think it's connected to the shame piece as well? [I: Mh-hm. Mh-hm] Um, like I'm, and the feelings - that overwhelming feeling decreasing? [I: Mh-hm] So I INTEGRATING EGO IDENTITY WITH LI THERAPY 459 think all those [I: Yeah] are kinda connected [I: Yeah] and being able to get out of it faster. I: Using food to cope? The distress around using food to cope [R: Yes. Yeah.] not incidence. [R: Yes] This one you actually rated correctly. (laughs) [R: Yeah. (laughs) Um.] Based on the scale. R: What does it mean? I think it means an acceptance of what. Um, 'cause I-I think it came, like, right around the time where we talked about like often people who've experienced assault do gain weight as kind of a sense of protection [I: Mh-hm] and that kind of thing. And I think that's around [I: Mh-hm] the like just accepting it is what it is. And I actually found that I did it less [I: Mh-hm] by accepting it [I: Mh-hm] and just kind of letting it be. I: Yeah, yeah. [R: Yeah] So the ratings here you think are accurate. R: Yeah I: Yeah. Um, self-medicating behaviours. R: Yeah, again I think it came around that just kind of accepting it as a [I: Mh-hm] a response to [I: Yeah] something that had gone on and. I: And it rings true for you - the decrease? R: Yeah, yeah. I: Okay. I think this is - it's just, there SO much in this method. There's so much accountability to everything you say so that [R: Mh-hm] to avoid the things like of just narrative smoothing [R: Yeah] "yeah it all got better". [R: Yeah] So that's why we just, [I: For sure] we ask from every possible angle, [R: Yeah] um, what does it mean? Or is that actually true? [R: Yeah] And all of that. [R: Yeah, yeah] Not to, um, beat it to death [R: (laughs)] that - We do kind of - and that's it. [R: Mh-hm] That's all we need to go through, um. Unless there's any other lingering things that are general comments [R: Mhhm] or things we should know. Like we've done all the nitty-gritty and like (laughs) R: Yeah. (laughs) I don't think so. I: Marking things and - okay. R: Yeah. I think we... INTEGRATING EGO IDENTITY WITH LI THERAPY 460 I: It's pretty thorough [R: Yeah] It's really like. It's such a treat for me to glimpse with you [R: Mmm] into the process because it's like it's big. [R: Mh-hm] The stuff you're talking about is big [R: Mh-hm] and I feel like you're moving mountains [R: Yep] inside. And-and not just like not sugar-coated moving mountains R: Right. I: 'cause [R: Yeah] stuff's still happening and stuff's still stuck [R: Yeah] but it's really exciting to witness it in you [R: Yeah] so thank-youR: You're welcome. I: for that window. R: It was encouraging. Hillary kind of said yesterday like "you're engaging in a lot of like big [I: Mh-hm] emotional work [I: Yeah] while at the same time you're engaging in a lot of in-depth academic work" [I: yeah!] and it was just kind of like to have someone... I: That's exactly right! R: ... who's been in the process [I: Yeah, yeah] kind of say that I was like "okay... I: Yeah, you really are. R: Alright." I: Totally. So, you've recorded everything. [R: Mh-hm] You have that record, I'm gonna just stick this in your yellow file. [R: Yep] Um, and they're not - I didn't right things down verbatim I tried to just basically to have an anchor to go back to [R: Yep] but later when it gets transcribed I think it will take a neater form [R: Mh-hm] but I made notes in the margins when we had qualifying things that we talked about and-and we captured it in various ways so, that's where we're at. R: Excellent. Yeah, it’s-it’s, like, it’s fascinating even to go through and like, wow, I had, like, by the end maybe 16 items on my list? Or something. [I: Yeah, yeah] I was like wow that's cool. [I: Uh-huh!] Cause you feel it and you sense it. I: Yeah. But a lot of things are shifting for you [R: yeah] Yeah. R: To actually like [I: Yeah] list them or delineate them or- INTEGRATING EGO IDENTITY WITH LI THERAPY 461 I: So, one thing, um, that I guess like procedurally we should just consider is whether you want to change any of your PQ items [R: Mmm] going forward? Based on some of the changes you observed that you didn't note or things that have come up. So, I'll leave you with that. [R: Okay] Um, if you, if I don't hear from you, I'm just going to assume status quo and you have you have it electronically you just keep using it. But, um, if you're considering this a new phase of therapy? [R: Okay] It's fair to say like we could add things [R: Okay] or say certain things are irrelevant but R: Okay I: They're probably not based on what we saw just now [R: Mh-hm]it seems like there's still things - you haven't bottomed out [R: Mh-hm] on items [R: No] so R: Yeah, the only the one I know for sure I think I would like to add is like that spiritual connection... I: Yeah, yeah. R: ...we kind of talked about, but...yeah. I: Which you didn't mention as a change did you? R: No, I didn't. I actually just realized that. (laughs) I: But you've told me about it. [R: Yeah] Do you want to add it? R: Yeah. Let's do that. I: Let's just add one item. [R: yeah, yep] 'Cause it's significant enough that that's what you've brought up to me spontaneously just in conversation. [R: Mh-hm] Um and I think it you described it like as a desiring [R: Mh-hm] to...have spiritual disciplines or have spiritual connection. [R: Mh-hm] Um, I'm just gonna - it's number 22 but it's up here R: woo-hoo! (laughs) I: Um. I'll just write it spiritual connection. [I: Yeah] How expected or surprising? R: It was surprising. I would say a five. I: How likely without therapy? R: Mmm. Hmm. Um. Which way does it go again? (both laugh) INTEGRATING EGO IDENTITY WITH LI THERAPY 462 I: It would have happened without therapy is five R: Okay. I: Um, and it wouldn't have happened... R: So, I would say... I: ...without therapy is a one. R: I'm going to give it a two. I: And how important? R: Five. I: Okay. Yeah so, I-I've just added it there as actually something and then we've measured and [R: Yeah] let's - why you don't go ahead and add it [R: Okay] to your PQ and then send me the updated one so I have it. R: Sounds good. I: As like another thing that you're tracking. [R: Mh-hm] That you didn't even think of to name at the beginning. R: Yeah. Exactly. I: Which tells me it does make sense that it's surprising. R: Yeah. I: So that's that. R: Woo-hoo! (laughs) I: Thank-you. INTEGRATING EGO IDENTITY WITH LI THERAPY 463 RCR Appendix D Post-Therapy Change Interview- Full Transcript Client: Rose (R) Interviewer: Janelle (I) TRANSCRIPT: I: So, as you know (both laugh) but I'm going to be scripted [R: Yes.] a little bit. Um, after each phase of treatment clients are asked to come in for a semi-structured interview. And it's pretty simple, just like the last one we did. The major topics of the interview are any changes you've noticed since therapy began, what you may believe have brought about these changes, and helpful and unhelpful aspects of therapy. So, the really the main purpose is to allow you to tell us about the therapy in your own words, and the research experience in your own words, to help us better understand how therapy works and improve it. Um, there - the interview is recorded as you know [R: (laughs)] 'cause you set it up. Um, and because of that I'm not going to take a lot of notes, just basically the change ratings [R: Mh-hm] I'll take notes on 'cause it will give me an anchor to know what to come back to [R: Yep] but I trust everything is-is stored this way, [R: Yes (laughs)] so. Um we start off just with what medication you're currently on, um, and whether that's been adjusted recently or during the time in therapy. Could you tell me any medications that you're currently taking? R: Mh-hm. So, I'm on Pristiq [I: Mh-hm] and that was adjusted in the summer, I think, from 50 mg to 100 mg. [I: 'kay] I: And so, your currently take 100 [R: Yep] daily? R: Yes. Yep. I: And how long have you been on Pristiq? R: Um, pretty much since like 2011. [I: 'kay] I've tapered off a few times here and there, but I: Yeah, so 8 years. R: Yep. I: Okay. And what symptoms w-is it being prescribed for? R: For anxiety. [I: 'kay] Yep. I: Anything else? INTEGRATING EGO IDENTITY WITH LI THERAPY 464 R: Um, I'm on asthma inhalers. [I: 'kay] Couldn't even tell you the name of them. (laughs) The brown one and the red one. [I: 'kay] Um, and Nexium for acid reflux. I: Nexium? R: Yep. [I: 'kay] I: No adjustments in those... R: Nope. I: ...during the course of therapy. And those are long-term, like you've been on them since before the therapy. R: Yep. [I: 'kay. (long pause - writing)] 02:25 I: Okay. And as we've talked about at other times I want to remind you that during the interview you have the right to choose not to answer any questions you prefer not to answer, to ask me questions, and to withdraw your participation [R: Yep] at any time. So, general question: [R: (laughs)] what - and this is a fo-this is a post interview so we know that you're not, you've ended your therapy [R: Mh-hm] um, and you're looking back now - but the-the most general question is, what has therapy been like for you? [R: Hmmm] Or how has it felt to be in therapy? R: ...tsk...The first word that came to mind was surprising. [I: Mh-hm] Um...in that there were a lot of moments in between sessions mostly, [I: Mh-hm] but moments in between session where, like, I would notice something n-new within me or new response to life around me that were surprising because I didn't anticipate it or I didn't...Often therapy before has been, like, a thought got planted. It got seeded. It got watered. And it grew and I've kind of seen the progression [I: Mh-hm. Mh-hm.] from one to two to three and then it's like, "Oh, and now we get to here." Whereas this was more, like, something just appeared out of nowhere. [I: Hmm] Kind of like, [I: Hmm]"Where did this come from?" (laughs) kind of idea. And so that was been surprising. Where I can't like trace thought process [I: Yeah.] that got me there, um... I: Well said! [R: Yeah.] It just kind of creeps up sometimes. [R: Yeah, yeah.] And you realize something different is happening. [R: Mh-hm. Yeah.] R: Um, so that was the first [I: Mh-hm] kind of word [I: Mh-hm] that came to mind. Um... It's also been...hmm, what’s a way a way to describe that? Um...So, like in my last session with Hillary we actually kind of went over what we've done [I: Mh-hm] since August and I was surprised - Like my internal experience of what we did in that time slot felt like it should have been spanning three years [I: Mmm] versus 6 months. Um. It walike we covered a lot of ground. And actually, I was surprised we'd done all that since INTEGRATING EGO IDENTITY WITH LI THERAPY 465 September. I was like, "Oh, I thought that's what we did since May?!" (laughs) [I: Mhhm] Um. Yeah. I: As you say that and report that - this is not a scripted question [R: Mh-hm] - but I just want to unpack, does that feel like it's a positive thing? [R: Mh-hm] Or that maybe you were forced to work too fast. R: No, I would say it's a positive thing. [I: 'kay] Um... I didn't feel like we were going too fast while I was experiencing it [I: Mh-hm] I: Just... R: But looking... I: ...seems like three years of your life. R: Yeah! [I: Okay] Looking retrospectively it's like, [I: Yeah] Woah! We crammed a lot into six months. [I: Yeah. Yeah.] But it was - it came organically. It wasn't like we forced anything in there. [I: Yeah, yeah.] It just - it was time to do this [I: Mh-hm] and it was time to do this, and this was coming up [I: Oh, yeah.] so we went there, [I: Yeah] kind of thing. Yeah. I: Yeah. That makes sense. [R: Yeah.] There was another query on this [R: Mh-hm] that maybe you've touched on but another way of asking a general question: how has it felt to be in therapy? [R: Mh-hm] R: wee-ooh-wee-ooh (sound effect like a siren, hand motion like a roller coaster) (laughs) Um...tsk, oh there's so many feelings where do you - Uh... Sot-it-f-feeling it has been a bit of a roller coaster ride [I: Mh-hm] in the sense that, like, we had kind of touched on one issue and it felt like it settled [I: Mh-hm], but then another thing would come up and I would feel like I was all - I used the discombobulated a lot I guess. (chuckles) [I: Uh-huh. Mh-hm] I felt like all...confused and uncertain, again. [I: Mh-hm] And then we'd work through that [I: Mh-hm] and it would come down again. [I: Mh-hm] Um. So that's one feeling, um. Darn, what's the other one that I - it was like - I had like 5 in my head and now I can't remember any of them. Um. I: Well, you can also, um, in the course of the interview [R: Mh-hm] feel free to come back to general ones [R: Yeah.] later. [R: Right.] It's just kind of to get us warmed up [R: Mh-hm] so don't worry. [R: Yeah.] R: I think it was...Hmm, what's a good way to describe that... Maybe 'genuine' is a good way to describe that? Or, [I: Hmm] um...like it's got partly to do with a real encounter with self in the midst of it, but, um. You can't - or I couldn't, maybe I should say this 'cause maybe other people can but (chuckles) [I: Mh-hm] - I couldn't control it or predict it or make it do what I want it to do [I: Mh-hm] in that sense. Which was a good thing [I: Mh-hm] 'cause I just knew that what was there was real. [I: Mh-hm] It was made up, kind of thing. [I: Mh-hm] And in that way felt...And I guess there's this other element of, like, INTEGRATING EGO IDENTITY WITH LI THERAPY 466 letting go of needing to, like, understand it and just be in it [I: Mh-hm] kind of thing. So, [I: Mh-hm] which was challenging (laughs) I: Okay. Kinda in the moment. R: Yeah. [I: Mh-hm] Yeah. Uh-huh. I: Yeah. That's all good. [R: Yeah] And, you can always add stuff to it [R: Mh-hm] but you're - you're get-giving a sense of the flavour [R: Mh-hm] for you of really being with yourself [R: Mh-hm] as things came up and [R: Yeah.] Yeah. R: I would say the only other thing I-I wanted, before I forget it, [I: Mh-hm] um, is that there was a real sense of connection with my therapist. Like, [I: Mh-hm. Mh-hm] um, attachment [I: Mh-hm. Mh-hm] is what - the word I - [I: Mh-hm] Yeah. I: Um. The next general question is even more general: how are you doing now in general? R: How'm I doing now in general? Um. I: And if you want to just take [R: Yeah.] a breath and feel yourself now in this moment [R: Mh-hm] before you answer that. Close your eyes - whatever works for you. [R: Okay] Um. [R: Mmm.] Get some distance [R: Yeah. (laughs)] and do what you need. [long pause as Rose centers herself] R: Hmm. It's a kind of a strange... fight in my internal self (chuckles) [I: Mh-hm. Mhhm.] Um...I th-yeah,so there's (gibberish) (laughs) Uh, did you get that? No? (laughs) I: Oui, oui. (laughs) R: I love it! Um. I think currently I'm in this place of like - ah, there we go, now I've got words for it - [I: Hmm] of navigating a new relationship with my emotions. [I: Mmm] Navigating a new relationship with who I am in the world. And so, there's this internal debate of part of me knowing, "Yeah. We're much better now," like those - Like even looking at inside at my emotions and being like, "Okay, yeah. There's something there but remember when it was HUGE, and you'd be dissociating, and you would be like zoning out." [I: Mh-hm] And that's not, there. [I: Mh-hm] Um. While another part of me going, "Yeah, but there's still emotion there and I'm not sure what to think so it and what to - how to make sense of it now [I: Mh-hm] in this new dynamic," kind of. [I: Mh-hm. Mh-hm.] So, there's a little bit of, like, I'm...still trying out my sea legs, kind of. [I: Yeah.] Figuring out how to navigate this. I: I hear you describing, and I don't want to put my own words in it, [R: Mh-hm] but almost like coming into your growth. [R: Mh-hm] But there's been changes and you're figuring out how to wear it or something. R: Yeah, yeah. That very much feels like it. Yeah. INTEGRATING EGO IDENTITY WITH LI THERAPY 467 I: But for research it's bad if I say it. (both laugh) R: True enough. But I like that, like, how to wear this new me. [I: Mh-hm] Right? [I: Mh-hm] Like, and I mean, we'll get into changes, but some of the, like. things that have changed are so new [I: Yeah] that it's sort of like, hmmm, I'm not entirely sure, like These emotions don't feel the same as they did but they're -I- They're new so I-I'm kind of still reacting out of what they were [I: Mh-hm] without - And then kind of having to kind of find a new way to respond to those. [I: Mh-hm] So, yeah. I: Yeah. That's fair. (chuckles) [R: Yeah.] Okay, the next category [R: (chuckles)] of questions is self-description [R: Yeah.] and so it's perfect that you're thinking about [R: Mh-hm] relationship to self and - How would you describe yourself? R: (chuckles) It's such an open-ended question. (laughs) I: I know it is. So, and it's like R: Well, I'm 5'1" (both laugh) I: Right. 5'1". R: Um. I: What kind of [I: Yeah.] person are you? R: Huh. That's an interesting thought that just came to mind. It - huh. And I'm nervous to say it. [I: (chuckle)] That's really funny. Um. I: Say what's right for you to say. R: Yeah. It is right, it's just sort of like, it's almost one of those like nervousness of like a, if I say it out loud it makes it real, kind of thing. [I: Uh-huh] Um. So, part of my answer is that I'm a whole person. Yeah. I: That's kind of big. R: Yeah. Um. [I: Hmm] Yeah. I even like I: Did/Can you give me an example? R: Yeah. (laughs) Um. [long pause] Uh...There are...hmm...ah (gibberish) I hate it when this happens. Um. So, I describe it as a whole person because, um... there are parts of myself that I recovered in therapy and that I brought [I: Mmm. Mmm.] into the present with me, um, that I thought were lost but actually weren't. They were still there. [I: Mmm] Um, and so even sort of - Even to the point where like memories of Mexico are different now. They're more - I recognize myself in them. [I: Mh-hm] It's not just this INTEGRATING EGO IDENTITY WITH LI THERAPY 468 like, "Yeah, that's me," but it's this disconnected me. It's like, [I: Mh-hm] "No. That's me!" and that still me. That's still who I am. [I: Hmm] Um...15:34 Yeah. And then I would also say I am 45. And that's important because I feel like I grew up a lot (laughs) over the last 6 months. Um. I think I am...a joyful, positive person. Huh. That's interesting. (laughs) Um. Intelligent... Funny. Lively. Sociable. Hmm. I: Great. [R: Yep] I wasn't going to cut you off. (both laugh) It's all part of your wholeness [R: Yeah, yeah. For sure.] How would others who know you well describe you? R: Um...Hmm. One of my friends described me as a-a, uh, (in Spanish) arcoiris, uh - [I: Mh-hm] I & R: (simultaneously) Rainbow. (both laugh) I: Oh, you were R: What is that word? I: I was just going listen in Spanish. R: I know. I: (in Spanish) Que lindo el arcoiris. R: Si. (laughing) Um. And I had a friend comment actually that like my joy is showing through more [I: Hmm] which is interesting. Um. Yeah, it's been kind of interesting to wa- to like hear people reflect things back to me. [I: Hmm] 'Cause that's not [I: Hmm] often an experience I've had. [I: Yeah.] Um. Somebody else said, "You really - I really sense you coming into yourself." I was like, "Oh!" [I: Hmm] And I agreed. (laughs) Which is unusual for me. [I: Yeah.] But, um. Organized. Yes, the Google doc lady is organized. (laughs) [I: Mh-hm] Um. Funny. Um. Now what's a word for that? Um. Outspoken but I don't - like not the negative out-spoken but more like able to communicate what they're thinking, feeling kind of thing. [I: Mh-hm. Mh-hm.] I: Great. If you could change something about yourself what would it be? R: Hmm. My body. I think that's the main one at the moment. And probably how much TV I watch, but (laughs) I don't know if I definitely want to change that one or not. Um. Yeah. I: Anything more you want to say about changing yourself? R: Other than the fact that when I hear that question I think of, like, what are the negative things that I wanna make positive. [I: Mh-hm. Mh-hm] Like I'm always one - like I'veI've just always wanna continue growing and stuff, [I: Mh-hm] and so - [I: Mh-hm] Yeah INTEGRATING EGO IDENTITY WITH LI THERAPY 469 there's lots of things I'd like to learn about and those kind of changes. But I read it more as like what are things that I still feel unsettled with. [I: Mh-hm] Yeah. I: Um. I think that's a common read [R: Yeah.] of that question but you're right [R: And ] it could be framed... R: I think I would like my relationship with God and that whole spiritual element to keep moving forward. [I: Mh-hm] Yeah. I: And that's more of a continuation than a contrast. Like you were saying when you read it negatively [R: Mh-hm] you have one answer, [I: Yeah.] and this is something you want more of. [R: Yeah.] Yeah. So now the fun part - [R: Yay!] changes. [R: Yay!] (tsk)...so what changes, if any, have you noticed in yourself since therapy started, um...and I...I know we did this interview part way through your therapy [I: Mh-hm] um. My understanding of this interview is that everything is fair game. [R: Okay.] Not just post then, but it - [I: Mh-hm] I want to check that with you. Like what would be the reference - but we just wanna have a reference point. R: Yeah. Um. I would say probably primarily the things that I'll probably share [I: Mhhm] will have happened since September. [I: 'kay.] Um, but some things may come up as we talk that [I: Yeah.] are more recent. I: Yeah. So that's helpful just to say it. There's probably not a right and a wrong way, [I: Mh-hm] but if we're saying we're focusing on that and there-there may be that it's stuff from before [R: Yeah.] or since therapy first started [R: Yeah.] that's fine, too. [R: Yep. Yep.] and we can just make a note, so. Back to the question is: What changes have you noticed? And then just examples to make it more concrete. Are you doing, feeling or thinking differently from the way you did before? R: Yes. Yes. And yes. (both laugh) I: And, okay, what specific ideas have you gotten from therapy, including ideas about yourself or other people? [R: Mh-hm] Have changes been brought to your attention by other people? So, let's, yeah. So, doing, feeling, thinking differently from the way you did before - I'm actually - I have a little spot to keep a list [R: Mmm!] of what the changes are. And, what are - what are these changes? R: Yeah. Um. So, I'm really glad that I had this time with Hillary yesterday [I: Mh-hm. Mh-hm.] kind of go through - I did write some things down and I'll pull it up if I need to [I: If you need to. Yeah, yeah.] But, um. 'Cause I was like, Wow! Okay! So pretty much like major changes have happened in the last 6 months. (both laugh) I: Well, I'm glad we're talking! R: I know! INTEGRATING EGO IDENTITY WITH LI THERAPY 470 I: How perfect! R: Exactly. Um. I: It's like you almost knew what I was going to ask. R: Exactly. So, one of the ones that, um, yeah - they've all been significant - but, um, previous to counselling was still struggling with like major triggers from the abusive relationship I was in. [I: Mh-hm] And, um, a lot of anxiety and disoci - dissociative kind of behaviours. [I: Mh-hm] Umm and that has - it's gone. [I: Okay.] Um. In fact, I saw a car very similar to this the other day and I was like, "Huh. Nothing. Alright." [I: Mh-hm] (chuckles) Um. So that's huge 'cause I had been in other therapy for that before and that part had not disappeared. [I: 'kay.] Um....Yeah, no. I'm gonna have to pull out my notes. 'Cause it's just - it's like [I: Mh-hm] so big. I: Yeah. Doing, thinking and feeling. R: Yeah. Um. So, another one that's kind of on the doing list, I guess. Well, it's kind of all of them, but [I: Mh-hm] Um, had had several experiences in internship and even in thesis of like getting feedback and being very emotionally activated by that. Feeling like I was in danger in getting feedback. [I: Mh-hm. Mh-hm.] And, hasn't completely subsided since - in the thesis area [I: Mh-hm] but I have been able to coach myself through it and even noticed it not being there, um. Like even today my supervisor started talking about like something she needed to ask me. And (chuckles) I thought at first, I was like, "Oh, no. I'm in trouble." [I: Mh-hm. Mh-hm] Um. But it was so - it was such a quiet voice. [I: Mh-hm] It wasn't this overwhelming like, 'Oh, no. I'm in trouble. I need to panic. I need to leave.' Turned out I wasn't in trouble at all, but. Um. [I: Mh-hm] I: You just heard that question R: Yeah. Yeah. And it was a very sI: But it was a quiet hearing compared to the past. R: Exactly. [I: Mh-hm] It wasn't this, "Danger. Get out of here." [I: Mh-hm] Deer in the headlights. I: (with stern face and tone of voice) "Need a word with you!" R: Yeah. (both laugh) So, that was interesting to note today, kind of that that was still there, but it was much quieter [I: Mh-hm] and more kind of like, "I can still be present here. [I: Mh-hm] And wait and listen." [I: Yeah.] And even if I am in trouble, like that's okay. [I: Mh-hm] I can handle this. [I: Yeah.] So that was another - I guess that's a thinking one, that kind of came up, is coming to the realization that, hey, I've lived 45 years. [I: Hmm] And I've been through a lot of experiences and handle a lot of things in life. Um. Which, of course, it wasn't something I didn't know but there was this change INTEGRATING EGO IDENTITY WITH LI THERAPY 471 in perception in being like - it was evidence of my capability [I: Mh-hm] not just evidence of like well you happen to fly through life and land on your feet, but that I actually been capable of doing 45 years and it - that [I: Yeah!] is going to keep me capable for the next 45. [I: Mh-hm] Um. So that was a change in like perception of [I: Mh-hm] Which was really cool. It was like, phew, yeah. 45 years. That's a long time. (laughs) 25:27 I: Almost like capable proportionate to being a mature adult, [R: Mh-hm] being grownup. R: Yeah. Exactly. Yeah. [I: Yeah.] And it wasn't just all kid time and [I: Yeah.] it wasn't just like under somebody else's - [I: Mh-hm] being dependent. [I: Mh-hm] It was actually living life. [I: Mh-hm] Yeah. Huh. That was an interesting way for me to phrase that. (chuckles) 'Cause I've always characterized it [I: Mh-hm] as surviving, which I think there was an element of that, as well. [I: Mh-hm] But in surviving I was still also living. [I: Mh-hm] Um. Yeah. And so, there's this place of like, "Okay. Yeah. I've done 45 years. I can do another one. And another one after that. And, [I: Yeah] keep going. Yeah. [I: Hmm] So I guess that's also a change of like this scared child seeing life to an adult, grounded adult seeing life. I: I'm not sure if it's a separate or the same [R: Mh-hm] so I'm just writing it separately with one being, like, feels capable, like consistent with your own age. And then the next one I'm writing is: sees life as an adult [R: Mh-hm] instead of child. [R: Yeah. Yeah.] Um....Do you feel like they're a little bit nuanced, a little bit different, but... R: There is a little bit. I: ...kind of the same. [R: Yeah, yeah.] We' re both stuck a little bit. [I: Yeah, yeah.] R: There's this tiny little bit of like - [I: Yeah.] Yeah. It's like the... the capability meets the wholeness and they merge [I: Mh-hm. Mh-hm.]together. (laughs) Yeah. [I: Yeah. Yeah.] I: Feel free to note any changes that have brought to your attention by other people [R: Mh-hm] as well [R: Yeah.] whether a therapist or people in your life [R: Mh-hm] as you go through what R: Okay. [I: Yeah.] Yeah. Um...Nope, gone. (chuckles) It will come back. Um. So, one thing that my therapist did kind of point out [I: Uh-huh] and I was like, "Oh! That's very true." [I: Uh-huh] Um. Is this progression of like making - taking care of myself [I: Mhhm] throughout. So, things like, um, I took a week off of school; I postponed thesis, um, proposal. Um. And considering myself in them not just kind of what-what is expected, or what would other people want me to do, but really focusing in on what's best for me in that. [I: Mh-hm] Um, like not going home [to Ontario] for Christmas was another one. [I: Mh-hm] Um. And so that change of perspect- I don't know what that is but, [I: Mhhm] - whatever that is. (chuckles) [I: Mh-hm] Um. And yeah, this one was a-again, she INTEGRATING EGO IDENTITY WITH LI THERAPY 472 kind of said it and I was like, "Oh, that's very true." Um. Even in session with my therapist there were certain, um - episodes, I guess? - I don't know. Like certain encounters with different ages [I: Mh-hm] um, but there were times where I was, like, setting boundaries even with her being like, "No. I'm not ready to go there." [I: Mh-hm] And I'm not, um, (coughs) we need to stay here or, ah. Yeah. Just sort of intriguing little bits of listening to - being attuned to my inner ME I guess, [I: Mh-hm. Mh-hm.] would be a good way of putting that. I: Is that something that you would say only happened in session or do you find yourself spontaneously more aware of your own boundaries and needs [R: Mh-hm] in other places, [R: Mh-hm] too? R: Yeah. Um. Yeah, I would say it-I'm-I'm-it has bubbled out [I: Yeah. Okay.] beyond session [I: Okay.] to be, like, ah - It's just more noticeable when you're speaking to someone versus like, [I: Yeah.] speaking to yourself, right? [I: Oh yeah. Mh-hm] But, yeah. (pause) Even actually it was - Even yesterday when I was texting friends about, like, giving myself permission to just take the evening off. [I: Mh-hm] I started off with this, I re-wrote the text like 3 times, and it first started off with, like, um, more of that like, "I know I should be doing homework, and I know I should be doing this, but I've decided [I: Mh-hm] to kind of take the evening off." More of kind of (sigh) not recognizing that this is what I needed. More of kind of like I'm slacking off from what I should. [I: Mh-hm] I: And realizing that it actually - your ‘should’ is different. R: Yeah! And so, I-I erased all of that and I said, "No. You know what, I am making a decision [I: Yeah.] to honour what I need tonight and give my consent to taking the night off. [I: Yeah] And I'm taking responsibility for whatever that does for homework or whatever. [I: Yeah] Um. Which was different than what I normally would word things or [I: Yeah. Yeah.] express things. [I: Yeah] And I was kind of like, "Hm. Coolness!" (laughs) [I: Yeah.] And felt very affirming of self, [I: Mh-hm] um, in that. So. 31:04 I: The way I heard you say it is almost like your text came out an old way first [R: Mhhm] and then you realized it didn't quite fit for you to frame it that way. [R: Yeah.] And you had to re-write it to catch up with your own [R: Yeah] position. R: Yeah. Exactly. These are the old ways I use- I [I: Yeah.] would conceptualize what I'm doing, [I: Yeah.] I actually don't need to do that anymore. I: Right. Okay. R: Yeah, yeah. Um. And on a similar kind of train. [I: Mh-hm] (chuckles) One thing that Hillary and I have really been working on the last month is a pattern we noticed in therapy of, like, I can't, um, like I couldn't dire- uh, like, even in my imagination could not address my Mom specifically and tell her how my old self or my young self would be feeling in any situation. [I: Mh-hm] It was just like, no, I can't - can't do that. [I: Mh-hm] INTEGRATING EGO IDENTITY WITH LI THERAPY 473 So we were working on this - this rule of like silencing and [I: Mh-hm] um, not being able to hold that, and [I: Mh-hm] um. In the midst of that work I was working on my ethical autobiography [I: Mh-hm. Mh-hm.] (chuckles) which was all about kind of tell us where you values came from. [I: Mh-hm] Which again is sort of a lot of my values come as a reaction to my family [I: Yeah.] not as a like living with them. [I: Yeah] Um. And so that was very m- like I can't put that down on paper. Like I can't say that. That's not allowed. That's like, [I: Mh-hm] disparaging my parents. [I: Mmm] It's not honouring them. [I: Yeah.] And so, I kind of with a friend maybe there was a way to get around it. [I: Mh-hm] But then when I sat down to write it, I was like, "You know what? No. We're going to just write it the way it is. [I: Mh-hm] Um. And tell the truth of our own experience." [I: Mh-hm] Um. Which is something that had come out in therapy, like I can tell my hurt and love my parents at the same time. [I: Yeah. Yeah.] And they are both - And they are not bad, monstrous people [I: Yeah] just because I got hurt along the way. Um. I: So, I'm listening to you [R: Mh-hm] and I'm like, okay, what's the thing I write down? [R: Yeah. (laughs)] And is it, is the essence that you're able to tell your truth with...and maintain a sense of respect for the other, or something. [R: Mh-hm] That they're not mutually exclusive, [R: Yeah.] or R: I think...like, yeah, I've-I'm thinking even like this morning I was talking with my supervisor and [I: Mh-hm] was just saying like the only person I was concerned of-about reading my thesis was my mom. [I: Mh-hm] And then as I'm talking to her, I said, "But you know what? She can read it. She can have whatever reaction she wants to, [I: Mhhm] and she can be angry or mad." And I'm like, [I: Mh-hm] "Who is this person talking?" (laughs) [I: Mh-hm] You know? So, there's this [I: Mh-hm] sense of like of releasing - releasing responsibility for other family member's emotions or reactions or responses [I: Mh-hm] And just being able to... own what's mine. Let my be [I: Mh-hm] let my truth be. [I: Mh-hm] So, yeah, like even this morning as I was - as I ss-heard that coming out of my mouth [I: Yeah] I was like, " Wow! I don't-I've definitely never said that out loud before!" Or even thought it was true. [I: Yeah] Yeah. I: There's a great psycho-babble word for that. It's differentiation. R: Is it? (laughs) I: But you just put great descriptors experientially to it. [I: Yeah, yeah.] And like it's clear that's kind of the concept you were getting at [I: Mh-hm] but so cool to hear how you were able to self and other and relationship [I: Mh-hm] and - Yeah. R: Yeah because I can differentiate on my own before that. [I: Yeah] Like I can be different. But I can't...I can't say why I'm different [I: Mh-hm] and put that negative [I: Mh-hm] spin [I: Mh-hm] on family dynamics [I: Mh-hm] and that being my response to it. [I: Yeah.] Yeah [I: Yeah] Which is cool that it's - that's kind of shifting. I: Totally! [R: Yeah] It's awesome! [R: (laughs)] INTEGRATING EGO IDENTITY WITH LI THERAPY 474 R: I like it! (chuckles) [I: Mh-hm] Um. And I think another thing - no I don't think, I know. And is part of why I - EA is so attractive to me right now. [I: Mh-hm] But, um another thing that has changed is this taking back of agency of my own life. [I: Mh-hm] And I think all of these things kind of feed into that [I: Mh-hm] but the, "I get choice in how my life goes." Um. One of the phrases that's on the front of a journal that's kind of become my hope for as-as I go forward is the - It says, "She designed th-the the life she desired." And that being kind of like, yeah, I don't have to - this-My life is not one of just waiting and fate throwing things at me. Um. But I have agency in it. [I: Mh-hm] I have ability to move. I: Yeah. It reminds me of you talking the other day about successful and fulfilling [I: Mh-hm] R: Yeah, exactly. And what is- what is a meaningful life. [I: Mh-hm] Um. And how - I actually shared on the last day, I said, like, "One thing I'm walking away with is that a meaningful life is not just for the lucky [I: Mmm] and those who happen to stumble upon it, kind of thing. [I: Mh-hm] But it's something that we can do for ourselves, [I: Hmm] and create for ourselves. [I: Yeah. Yeah.] Which was...pretty awesome. (laughs) I like that idea! [I: Yeah.] Yeah. Yeah. I: Any other changes in thinking, feeling or doing. Ideas about yourself. [R: Mh-hm] R: I think I kinda said this already, but...just, um...um...and I think maybe this is where that joy came from [I: Mh-hm] that other people noticed is in just - Like thinking back on memories now - uh, I don't know - there's like, there's a ME in it. Um. [I: Mh-hm] Yeah, I don't know how to say that. I: There's a ME in what I do? (chuckles) [R: Yeah.] More ME. [R: Yeah!] R: A continuous ME even. [I: Uh-huh] I: Or 'I' R: Oh, who knows?! (laughs) Grammatically correct, I don't know. [I: Yeah.] Yeah. I think (long pause) those are...a lot of the most significant ones. I: 'kay. [R: Yeah.] Well as you know we'll come back and look at the PQ [R: Mh-hm] ratings, too. [R: Mh-hm] Um. And you'll be able to speak to those changes. [R: Mh-hm] But we'll start with these ones [R: Yeah] that have come up. Um. It seems like these changes that you've mentioned are positive, but I want to ask if anything's changed for the worse [R: Mh-hm] since therapy started? R: Um... Not definitively. [I: Mh-hm. Mh-hm.] Um. I would say my - my healthy eating habits have kind of down a bit of a roller coaster ride. [I: Mh-hm] Um. Although my level of distress about my eating has been fairly low. Um. [I: 'kay] Yeah. INTEGRATING EGO IDENTITY WITH LI THERAPY 475 I: Both important comments, [R: Mh-hm] right? [R: Yeah.] But, your relationship to your eating habits is lower distress [I: Mh-hm] but you would say objectively your habits have improved and plummeted, both. [R: Yeah.] Yeah. [R: Yeah] I don't know if the word plummet - you said rollercoaster [R: Yeah (laughs)] I pictured R: Plummet. (both laugh) You know I: A rapid ride. R: Yeah, yeah. Ah, it could be considered a plummet. (both laugh) I: No-no reference point here [R: Yeah.] just trying to translate words. [R: Yeah] And then another change question is: Is there anything that you wanted to change that hasn't since therapy started? R: Um...and this might answer the question before more than this one. [I: Sure. Yeah.] Um. I think for me it's been - uh - it's been difficult ending therapy right here [I: Mh-hm] because like 4 or 5 weeks ago I felt more grounded and centered than I would say I do [I: Mh-hm] right this moment. [I: Mh-hm] Well, like, not just with you [I: Mh-hm] but overall. [I: Mh-hm. Mh-hm] Um. And so, there is I: Is that because you opened new stuff up, kind of? R: I think so. I think we just - we took a different turning going into family rules stuff [I: Mh-hm] and so it-it's not that I'm entirely ungrounded [I: Yeah] um, it just sort of changed-changed things around a little bit. Um. I: So, would you say that this is sort of unfinished tasks of therapy that you would like to see change in, but you have not had - been able to bring to the goal yet, around family rule? Or R: Um. I almost - hm - I'm not sure if it's something that would have...No. That's going to sound like what I don't want to say. (laughs) [I: Hmm] Um. I think we got where we needed to go in therapy. [I: Mh-hm] Um. And I was even telling Hillary this. Like I think at this point it's more a case of like it needs to roll out in real time and be given space to actually [I: Mh-hm] be lived. Um. Because like even the level of distress I had when we first kind of broached the topic was like way up high and now it's certainly [I: Mh-hm] way down lower. [I: Hm.] Um. But it's similar to what I - like we talked about like wearing- wearing this new self. [I: Mh-hm] Right? [I: Mh-hm. Yeah.] Um. And so, while there's a part of me that's afraid it won't change [I: Mh-hm] without the therapy. There's another part that's like, "No. It will keep moving forward." [I: Yeah, yeah.] Um. [I: Okay.] But I think if I was to say one area that I had hoped would move more, [I: Mhhm] um, would be the spiritual aspect [I: Mh-hm] of it [I: Mh-hm]. I'd hoped would [I: Mh-hm] would experience more change than it did. [I: 'kay]. [Long pause as Janelle writes things down] INTEGRATING EGO IDENTITY WITH LI THERAPY 476 I: 'kay. So, what we're going to do now is rate, go through each change and rate it on 3 scales. R: Oh, yeah! Right! [I: Mh-hm] I remember this! (chuckles) I: How much you expected it versus were surprised by it. How much- how likely you think it would have been if- to have happened if you hadn't been in therapy. And how important or significant to you personally is the change. And for each scale I'll just - I'll give you the anchors from very much expected to very much surprised [R: Yeah.] and let you know what each of them is. [R: Okay] Um. So, the first one is around, not experiencing triggers related to a previous abusive relationship. [R: Mh-hm] Um. This is something you described having worked on in lots of therapy [R: Mh-hm] over time. And so, the first question is: um, expected or surprised? And the ratings are 1 to 5, 1 meaning very much expected it, 2 somewhat expected it, 3 neither expected nor surprised by the change, 4 somewhat surprised, and 5 very much surprised. So, related to triggers of the previous abusive relationship what would you say? R: (pause) So funny, cause then it's like, where does like questioning and hoping come in there. (laughs) I: Yeah. R: As far as desire. I: So, it's that's a really good clarification... R: Um or expected. I:...for this. Um. We’re not really talking about hoping here. [R: Mh-hm] A hope is part of therapy. [R: Mh-hm] But we're talking about expecting it. [R: Yeah.] So, based on what you thought realistically could shift, [R: Mh-hm] were you - how much were you expecting to not experience any triggers or the kinds you described [R: Yeah.] related to the previous relationship? R: I'm going to say a 4 [I: Okay.] 'cause there were still some, "Ehh?! I'm not so sure about that." [I: Mh-hm] But, yeah. I: So, 4 means somewhat surprised. R: Yeah. I: 'kay. Um. The next scale is how likely without therapy. R: Oh, sorry go back to the other one. I: For? About expecting? INTEGRATING EGO IDENTITY WITH LI THERAPY 477 R: Somewhat surprised. I: Somewhat surprised by it is what you mean. Or do you mean... R: No. So maybe two is what I mean then. I and R (simultaneously): Somewhat expected. R: Yeah. [I: Okay.] Yeah. All of a sudden I went, No! That's the wrong word at the end of that sentence I: Yeah, so. Yeah-yeah-yeah. [R: Yeah.] So, 1 is-is [R: Yeah.] I thought this would happen [R: Yeah.] Um. 5 is I did not think this would happen at all. [R: Yeah] Yeah. Um. Without therapy. 1 - and this is the likelihood that this would have happened - 1 means very unlikely without therapy. Clearly would not have happened. 2, somewhat unlikely without therapy. Probably would not have happened. 3, neither likely nor unlikely. No way of telling. 4, Somewhat likely this would have changed without therapy. Probably would have happened. 5, very likely without therapy. Clearly would have happened anyway. R: Yeah. This is a 1 for sure. I: 'kay. And-and I won't review [I: Mh-hm] all the descriptions of the scales [R: Yeah] for every question. If you have questions, I'll answer them, [R: Yep.] but, just the first time through. So, the importance. How significant or important is this to you personally? 1 is not important at all. 2, slightly important. 3, moderately important. 4, very important. 5, extremely important. R: 5 I: 'kay. The next, um, change is about not being as activated by feedback, [R: Hmm] or the potential for negative feedback. [R: Hmm] I think maybe that [R: Yep] would be a better way to - Yeah. Um, critical. You described internship seminar, [R: Mh-hm] supervisor, yeah. How - how much was this something that you were expected? R: Not at all. Completely surprised. I: Okay. So that's a 5. R: Yeah. I: Meaning, 'very much surprised'. [R: Yeah.] Doesn't even say completely surprised?! [R: (laughs)] Where - I just want to say - so you want like a 6 not a 5... R: Ye- Yeah! (both laugh) INTEGRATING EGO IDENTITY WITH LI THERAPY 478 I: ...on the scale. 'Cause we don't have the right word. Um. Unlikely to likely without therapy. R: Um. I: Unlikely is 1. [R: Yeah.] Likely is 5 R: So, I would…my best guess is unlikely [I: Mh-hm] like I: 'Cause you were surprised? R: Yeah! I: So, 1? [R: Mh-hm] 'kay. And how important is this to you? From 1, not at all, to 5, extremely. R: Extremely. I: 'kay. Alright, the next change is feeling capable. [R: Hm.] Realizing you've lived life for 45 years, you've handled a lot of things, and your capability corresponds to that. [R: Mh-hm] I think we'll probably describe it a little more succinctly than that [R: Yeah, yeah.] but I just wanted to give you the description [R: Mh-hm] I got. [R: Yeah. Due to time constraints in preparing the rich case record, some content is missing in this last section of the transcript. This is indicated by a dashed line and includes the time stamps before and after the missing pieces, as well as a short description of the general content. The most pertinent content has been included verbatim. (laughs)] Capable. [R: Yeah] 45-years-old. 48:14 (Continuing with rating of change items – see RCR table 7 for results.) -----------------------------58:45 Attributions. In general, what do you think has caused these various changes? In other words, what do you might have brought them about? Things outside of therapy and things in therapy. [R: Okay.] So, I know you've already given me your ratings of unlikely, so, [I: Mh-hm] you've kind of in one way told me you think a lot of it happened because of therapy. [I: Mh-hm] But you can refer to things within therapy as well. [I: Mh-hm. Um.] Anything. INTEGRATING EGO IDENTITY WITH LI THERAPY 479 R: (chuckle) I think - uh - hm...Pretty much for all of them, like, I can't attribute it to anything except for therapy. [I: Mh-hm] 'Cause outside life` - outside of therapy life was either largely remained the same or got more stressful and actually would have pulled me the other way. [I: Mh-hm. Mh-hm.] Um. So, yeah. Basically, I attribute it to therapy. I: Yeah. Are there processes [I: Mh-hm] in therapy that stand out? (pause) For you as the client. [I: Mh-hm] I know you're a clinician too, and you might think about what was supposed to happen with different protocols or things. [I: Mh-hm] But, wer-we're really talking about what you lived. R: Yeah. It's - And I think this is why so many of them were very surprising because it's hard for me to, like, logically tie them in with something we did in session. [I: Mh-hm] Um. Like there isn't a natural, like, well we talked about taking agency of your life and therefore that rolled out the next day. It was sort of like...But I guess in session I was taking agency of parts of my life [I: Yeah.] through memory. I: So therefore [R: Yeah] it happened through not talking about it [R: Mh-hm] but R: But actually going - well, yeah! - Going back and meeting needs that weren't met [I: Okay] in-through imagination. Um. Empowering younger memories to have agency in moments they didn't. Um. Or to speak out in moments that in real-life they hadn't. [I: Mh-hm] Um. In - And even the experience of, like, being seen and being known by my therapist in that [I: Mh-hm] um...[I: Yeah.] Being experienced by her. [I: Mh-hm] (pause) And I-I think it was really important to have each of those selves that I connected with come back to present day [I: Mmm. Mh-hm] and...um...see where we are now and see [I: Mh-hm] what life is now. Yeah. [I: Yeah.] And be comfortable in it. Like, they weren't often comfortable the first time we arrived there. [I: Mh-hm. Yeah.] Um. But after a few repetitions it was like, "Okay. Yeah, we can be here." I: Yeah. Okay. Great. If you can I'd like you to sum up what has been helpful about your therapy: general aspects, specific events, um. It's not unrelated to the last question. That was more attributions, [I: Mh-hm] but what has been helpful?... R: What hasn't? I: Or you can transplant a little bit of this answer. [R: Yeah.] Um. R: I think one thing that was helpful was, um, - and this is kind of both questions [I: Mhhm. Sure.], but - starting with the attunement protocol. [I: Mh-hm] Um...yeah. I just being able to really establish that - a different kind of care-giving relationship than I had previously known, [I: Mh-hm] so. There was greater safety, um. [I: Mh-hm] And a lot of surprising things came up in that too. I was like, "Woah! Wow!" (chuckles) [I: Yeah.] I had no idea [I: Okay.] INTEGRATING EGO IDENTITY WITH LI THERAPY 480 I: What kinds of things about therapy have been hindering, unhelpful, negative or disappointing? General or specific. R: Mh-hm. Tsk, um. Probably the most significant sort of hindering - that didn't end up being hindering 'cause we just had to change things a little bit, but - um, was adapting to the online [I: Mh-hm] experience. [I: Mh-hm] And, me - us talking about, like, yeah, we maybe can't always note what's going on physically, [I: Mh-hm] and there isn't that emotive connection the way it is in-person. So, [I: Mh-hm] having to be a little bit more vocal [I: Yeah.] about what's going for me [I: Yeah.] And then my clinician brain sometimes got in the way a little bit. [I: Uh-huh. Uh-huh.] (laughs) Not usually. Usually it's turned right off. [I: Yeah. Yeah.] But I: Were there things that were difficult or painful but still okay or perhaps helpful? R: Oh! There were lots of things that were difficult. (both laugh) I'm like, isn't that the point of therapy? Get through the difficult things? [I: Yeah. Yeah.] Um...I think - Like if I was - The-the one thing that's coming to mind in particular is, um, the fact that we went and we actually addressed straight on the whole like, 'I need to be silent. I can't tell my mom. I can't tell my dad.' [I: Mh-hm] And that pattern that came up. [I: Mh-hm] And that was extremely difficult, [I: Mh-hm] like, paralyzingly silent .[I: Mh-hm. Mh-hm.] Um. But in the end w-like I'm excited that we went there. And [I: Mh-hm] excited to see kind of where it rolls out. I: Yeah. But helpful. R: Mh-hm!! [I: Yeah.] Yeah. I: Um. Has anything been missing from your treatment, from your therapy? Or, another way to phrase it is: What would make or would have made your therapy more effective or helpful? [R: Hmm.] Besides maybe the - it would have been nice to have everything in person. [R: Mh-hm. Yeah.] 1:05:36 R: Um. Hmm. Adopt Hillary? No. (laughs) I: Usually their goal is defined, so. R: Yeah. Can't. No. I: I don't think that would have ch- needed therapy, but. Yeah. 'kay. (chuckles) Any other ideas? [R: Ahh, dear!!] We take that tongue-and-cheek. R: Yes. Totally tongue-and-cheek. Um. Yeah. Other than it-uh- and maybe not even, like, it needed to all be in person but if we had been able to find, like a time when we could have done one more session in person [I: Mh-hm] um, that would have been ideal. [I: Mh-hm] Um. But that's the only thing [I: 'kay] that coming to mind. Yeah. INTEGRATING EGO IDENTITY WITH LI THERAPY 481 I: Sure. 'kay. Um. Do you have suggestions for us regarding research or therapy? Anything else you want me to know. R: Hm. (both laugh) Wide open! I: I know. Wide open. Yeah. R: Um. I don't...Other than like I've-th-the, the actual - as far as, like, research my brain goes to, like, I'd love to understand, like, what was going on [I: Mh-hm] maybe in my brain as like these surprising things happened. [I: Mh-hm. Mh-hm.] Right? Um, and understand the connection from, like, what are we doing in session that's producing this random thing outside that you don't kind of expect I: So, you want to make those connections or you - that's R: That would be a great thing to research, kind of. [I: Yeah.] Yeah. [I: Yeah.] Yeah. Do I wanna know? Yes, I'd love to know. [I: Yeah.] (laughs) I: Um. I thought there was...Oh! Yeah. I just wanted to point out something, that I know that you have been at, um, completing the personal questionnaire daily instead of weekly. [R: Mh-hm. Yeah.] Do you suggest that as a way to measure this? R: Other than the fact, like - I wou -I, there were times where it was quite onerous but Yeah. I would actually. 'Cause I think you bet a better - better sense of even your own change [I: Mh-hm] as it goes along and a better sense of like... [I: Yeah.] what -what is a significant change? [I: Mh-hm] Um, when you're doing that. Um. Yeah, I mean just, I just remember, like, there is no way I can remember 7 days! (chuckle) [I: Mh-hm] Like, (laughs) I could give you some number, but they don't probably don't actually reflect I: So that was your suggestion from early on [R: Yeah.] and you just did it. [R: Yeah. Yeah.] Instead of telling me now and - [R: Yeah.] But that's something to consider. [R: Mh-hm. Definitely.] Okay, now. That's kind of it for that part. [R: Mh-hm] Now we can review your personal questionnaire pre-therapy and post-therapy current ratings, and note, um, changes. So, we want to understand how you use the PQ and what your ratings mean. So, I don't have with me your current ratings. [R: Mh-hm] Um. R: I have, um, my session from yesterday. [I: 'kay] So, I have the current ratings with me. I: Um. And I probably have your initial one here. What we're wanting to do is look for each one that's changed 2 points or more, um, identify it and then you get to decide if you want to add it to your change list. [R: Okay.] Um. On change ratings. What you think it means. Um. 'kay, but first a general question about the PQ. Do you think that your ratings mean the same now as they did before therapy? R: Um, some do, some don't. INTEGRATING EGO IDENTITY WITH LI THERAPY 482 I: Okay. [R: Okay.] How has there been a change for those that are different. R: Um. Even that's different for different ones. Um. like I-I just even in the last couples weeks was like, oh, you know, I'm not sure that like a four of distress that I record as a 4 now is the same as a 4 [I: Okay] in distress that was [I: Okay] there late-before. So, like different tolerance for distress. I: So, would you say your 4 now is more distress or less distressed? R: Less distress. I: 'Cause it's relative to a different range. [R: Mh-hm. Yeah.] Okay. Um. Almost like the rating is relative to what was most normal. R: Yeah, yeah. I: So, what you're saying is, if anything there may be greater changes than is captured because your 4 now, might have been a 3 months ago, something. R: Yeah. Yeah. I: 'kay. So now we get to compare them. [I: Woo-hoo!]. Um. And we're looking for problem changes that are two or more points different.... 1:11:26 (Find PQ items that have changed significantly - 2 points or more – see RCR Table 8 for results) ------------------------1:15:55 R: Um. Just as we were going through it there was, um, one other way that somehow the ratings on the-on these ones [I: Mh-hm] {pre-session summary reports} may have changed that haven't changes on my in my daily ones. [I: Oh, okay.] But sometimes like it - I-I had one point had said, like, if it's a 1.8 , 1.9 I round up. [I: Mh-hm] And then I changed that part of it. I: So, on your daily ones you'll do 1.8 but- yeah. Fair enough. That's fine. R: So, the daily's will fix that part. [I: Yeah.] --------------------- INTEGRATING EGO IDENTITY WITH LI THERAPY 483 1:16:43 (adding PQ's to the change list and completing the 3 rating scales – see RCR Table 8 for results) --------------------1:18:10 {Self-sabotage PQ item - debating whether to add it as a change.} I: For reference it went from a 5 to a 1. R: Yeah. But some of that is - yeah, no. Maybe it's good to leave that one in. Some of it's just a change in perception. [I: Mh-hm] Like, this is self-sabotaging, this is actually just intentionally choosing. I: But then it's different. R: Yeah. Exactly. [I: Yeah.] -----------------------1:18:32 I: I use food to cope with stress. R: Um...Yeah. That one's more like I don't feel as much distress [I: Mh-hm] about the way I use food. I: Yeah. R: But I mean, it's still change I: So, it's going from 5 to 1. [I: Mh-hm] Yeah. --------------------1:32:49 {Adding another change item} R: I'm struggling because what was more surprising was this change in relationship [I: Mh-hm. Mh-hm.] to my se-to my own sexuality, I guess. [I: Mh-hm. Mh-hm]. Um which just I: You want to add that as a change item? R: I do! INTEGRATING EGO IDENTITY WITH LI THERAPY 484 --------------------1:33:16 I: Let's just add right now [I: Yeah.] this next one which is, 'I have a more positive relationship to my sexuality'? R: Yeah, yeah. ---------------------1:35:37 I: And, 'I don't feel confident in my own opinions or viewpoints,' was the previous statement. R: {emphatically and dramatically spoken} I HAVE A VOICE! (laughs) I: Okay! "I have a voice." Parentheses: confidence [R: Yes.] in opinions and viewpoints? R: Yeah. Yeah. I: And also, like, freedom to express them, [R: Mh-hm] it sounds like. R: Hm. Even that stand like that, that's [I: Yeah. I liked those body] - those body movement [I: Yeah.] we did in therapy actually. [I: Totally.] Yeah. ------------------1:36:29 I: 23 change items later!!!! [R: Phew!! (laughs)] This is NOT for the faint of heart. (both laugh) R: So nothing really changed over therapy. I: Nothing really changed. [R: No.] Yeah. Wow! R: It's pretty much the same. Actually, Hillary had the same reaction yesterday. She's like - 'cause she didn't realize we hadn't done a change interview since August. [I: Right. Yeah.] But she was like, even if it had been last month, like you've done so much [I: I know!!] in the last month. So, she was - after she did the whole recap [I: Yeah.] she was like, "So?!" (laughs) [I: Yeah. ] And I was like, "Okay, yeah. Maybe a little has changed." 1:37:04 INTEGRATING EGO IDENTITY WITH LI THERAPY End of interview. 485 INTEGRATING EGO IDENTITY WITH LI THERAPY 486 RCR Appendix E Follow-up Change Interview - Full Transcript Client: Rose (R) Interviewer: Janelle (I) TRANSCRIPT: I: So, we are finally at this place of the [R: Oh, my gosh!] so called follow up interview. [R: That's crazy!] It's a whole month ago that you completed the interview. R: That's right. I: And we did the post therapy and this will feel very familiar [R: Yep] but, but I hope is that as we talk today you'll be able to spontaneously feel from today what your answers are [R: mm-hm] and be they . . . . happier, different, um, more complicated whatever it is [R: Yeah]. So um, I need to read this as we've talked about at other times, I want to remind you that during this interview you have the right to choose not answer any questions you prefer not to answer, to ask questions of the researcher and of course to withdraw your participation at any time [R: mm-hm]. R: Okay. I: So, let's jump in . . . Um . . . As you know the major topics of this interview are any changes you've noticed since therapy began, what you believe may have brought about these changes, and helpful and unhelpful aspects of therapy. The main purpose of the interview is to allow you to tell us about the therapy and the research in your own words. This information helps us to better understand how the therapy works. It will also help us to improve Lifespan Integration therapy. This interview is recorded for later auditing and transcription. And so, as we talk, please provide as much detail as possible [R: Okay] in your answers. So just general questions that you've heard before. I just want to review what medications you're currently on [R: mm-hm] and any, any dosage changes [R: mmhm]. R: So, there haven't been any dosage changes [I: Okay] so you don't have to worry about that [I: Okay]. Um, I'm still on Pristiq. I: Okay . . . mm-hm, [R: Um]. And that is for anxiety? R: Yep. INTEGRATING EGO IDENTITY WITH LI THERAPY 487 I: And I can just say same as last . . ? [R: Mm-hm. Yep.] And, we probably wrote down for how long last time. R: I believe so, yeah. I: Kay. I'll just say no recent adjustments. Okay. R: Yeah. Um, and I'm on Nexium, which is for acid reflux. I: Kay. . . [R: Um] No changes? R: No changes. No. . . [I: Kay.] Um, I don't know if I - I know if this count, but I am, like I do take Claritin. For allergies. [I: Okay] And that hasn't changed since last time. I don't remember if I mentioned it last time though. [I: Okay] A pill a day keeps the allergies away. (laughs). Oh. Um, and then my asthma inhalers. Um. I: Kay. . . [R: um] I think that [R: Yeah] it's like, um. . . what we're looking for is anything that is psychoactive [R: mm-hm. Yeah.] probably. But that's . . . R: The only thing that does is make me shaky. But... (laughs) I: Yeah. But it's helpful to capture. Yeah. [R: Yeah.] To have a full data set. And-and now even though it's a month later after you’ve finished, this general question is, what has therapy been like for you? Um, or what was therapy like for you? [R: Um hm.] Would be the more accurate wording. R: Wow. It does feel like a long time ago. (laughs) [I: Does it?] . Yeah. I: Yeah. Different then. [R: Yeah] Which is cool to get today's perspective. R: Yeah . . . Um . . . Hm. I'm just noticing that there's like sadness coming up because I miss it. I: Uh huh. [R: um] So, sadness today. [R: Mm-hm] What does that have to do with what therapy was like? R: Um. I think it's two-fold. I think one part of it... is the relationship I had with Hillary as a therapist. [I: Yeah] Um and coming to recognize that as . . . potentially one of my first positive attachment relationships with another human. (chuckles) [I: mmm.] Um, yeah. I mean, I've had a really positive attachment relationship with a cat that I had. Um, but yeah, this was . . . significant for with another human being. Um . . . and then the other side of that, more difficult to put words to. Um . . . (tsk) . . . Kind of the, like, missing the . . . mmm, um . . . the set aside time to focus on improving, to focus on moving forward. Um. INTEGRATING EGO IDENTITY WITH LI THERAPY 488 I: So, you're saying now you're missing having that dedicated time? R: Yeah (sigh). And so, there's been a little bit more fear of like, "Am I going backwards? Am I [I: Yeah] slipping back into, [I: mm-hm] like, did we accomplish anything? Am I just back where we started? [I: Um-hm] Um, primarily in those first like two or three weeks [I: mm-hm] right after therapy there was a lot of like, "Oh no, the anxiety's right back where it started. I'm not, [I: Mm] really nothing had changed. Nothing happened." Um. [I: Hmm] But then there's been a few more concrete experiences of like, "Oh wait a second. No. Like I wouldn't have done that before and that's different [I: mm-hm]. So, um [I: yeah] Just having that like, like almost weekly reminder or weekly kind of [I: um-hm] check-in, um, and . . . [I: Kay] Yeah. I: Um. Let me just, I'm going to give you the high level, [R: um-hm] there's two questions here that are related. One is what was therapy, or what has therapy been like for you and how has it felt to be in therapy. And then the other one is how are you doing now in general. [R: um-hm] and I think you're probably answering the how are you doing now. [R: right] a little bit in contrast. So, I'm just going to open it up for both [R: Umhm] As you reflect back on what was therapy like. I want to make sure I capture your view of that today. [R: yeah] but also, how are you today [R: um-hm] so you said for two or three weeks you had some questions [R: yeah] of . . R: Just a fear that, you know, what I had experienced in therapy was just this blip and that I was like totally going back [I: mm-hm] to where I started [I: mm-hm]. Um, . . . yeah and it was, probably the most . . obvious experience I've had of grieving or mourning [I: mm-hm] those, those couple of weeks afterwards [I: mm-hm]. I: And, you're now four and half or so weeks? R: Five weeks actually. [I: Five weeks.] Yeah. I: What's the difference between those two to three weeks and now the two to three weeks. R: mm-hm. Um . . . well I think there's still some emotional there of like missing it and like still [I: mm-hm] um, maybe grieving the loss of that relationship. It's not as intense Um. [I: mm-hm] there's been some space to allow it to be and then to kind of settle a bit. [I: mm-hm] Um . . . and . . . yeah, there's been bit of like, return to a baseline I guess might be a good way to put it [I: mm-hm], like it kind of was a . . . weee. (Hand motion. laughs). [I: mm-hm] Or I guess down more than that. [I: mm-hm] But… So, you... INTEGRATING EGO IDENTITY WITH LI THERAPY 489 I: Like there's a bouncing back [R: Mm-hm] you feel towards something that you were experiencing at the end [R: yeah.] Okay. [R: Yeah. And more...] So, kind of your postbaseline, not your pre-baseline. R: Yeah. Exactly. [I: Okay] So feeling more . . . even feeling like more grounded in myself, more centered in myself [I: uh-huh, uh-huh] Being able to . . . like I kind of came out of it not sure whether I could handle life again [I: Yeah] and whether it's, like you know that kind of thing [I: yeah] And now it's kind of, "You know what? And I made it even through that and through life. so, we're okay. We can, we can do this." [I: mm-hm] So. Yeah, and then again like I said there was a few instances of just kind of realizing like, "Oh. I actually haven't gone back to square one. I'm actually still am further ahead." [I: mm-hm] Um, which was encouraging [I: yeah] and was kind of like, "Okay. [I: yeah] I can breathe again." (laughs) I: Totally. Um, anything else you want to say about what therapy was like? That's the piece [R: Yeah] I don't think you've really [R: No.] spoke to today yet. R: Um . . . It's so funny, my answer is like, "It just was." Like, how do you explain what it was? [I: mm-hm] Um . . . tsk . . . ah . . . it wa-, yeah, I don't even know if this is explaining it or describing it, but it was intimate, [I: mm-hm] but intimate with myself. [I: mm-hm] Um, and I mean and with Hillary as well, but [I: mm-hm] there was… a lot of rediscovering or meeting again [I: mm-hm] pieces of myself I hadn't been with in a long time [I: mm-hm]. Um, it was surprising, um, oftentimes things would happen during LI protocols that I was like, "Oh. I didn't expect that to happen!" (laughs) [I: Okay] Um . . . and, and it was even at my surprising at my ability to... like go with the flow and allow those, like, if something strange with like, "I don't know why that's happening" to like let it be. [I: mm-hm, mm-hm] Um. And then I: You were able to let it be though? R: Yeah! [I: Yeah] Yeah. Which was surprising [I: mm-hm] that I was able to let it be, but good that I was able to let it be. Um . . . Yeah and even some of the like, like the twists, I'm going to call them twists and turns of like [I: mm-hm] of how where we went [I: mm-hm] and where things took us. Um . . . were exciting and terrifying [I: mm-hm] and surprising all kind of at the same time. I: Mm-hm. [R: yeah. (laughs)] Anything else you want to say about either those areas what therapy was like and how you're doing now? R: No. I don't think so. Yeah. I: How would you describe yourself? This is the about you part. INTEGRATING EGO IDENTITY WITH LI THERAPY 490 R: What did I say the other day? (laughs). I totally surprised myself. I: Oh! Like not related, like not our interview [R: No] but you said it in another . . . oooh. R: Just yesterday, I think. I: What did you say? R: Somebody said, oh . . . I think somebody said, "Yeah, you're really smart Rose." And I said, "Yeah, I know I am." It was like, "Wow! Who said that?!" (laughs) Um, because that's been an area that I haven't always recognized. Um, I've always thought like, "Oh, the teachers are just too lenient, and they give out too many bonus points and I don't really deserve my marks I'm not that smart." [I: mm-hm] And so for me to say, "Yeah. I know I am." Surprised even me. (laughs). I remember saying even after it came out of my mouth, I was like, "You said that." (laughs). So that was cool [I: yeah] Um . . . who am I? I am [full name in Spanish]. (laughs) Um, and why is that important? Because I think that honours the Mexican part of me that's still there [I: mm-hm, mm-hm]. Margherita. Not Margaret. Blah. [I: mm-hm] (laughs) [I: mm-hm] Um, I am . . . I'm strong . . . wow that comes with a lot of emotion. (chuckles) [I: mm-hm] Um, um . . . hm. My, part of my brain wants to say something and the other part's like, "No! Don't say it out loud." But. (chuckles) Um, I'm beautiful. . . hm. . . um. . . It's funny, I'm avoiding like the obvious ones. Funny. (chuckles) Because sometimes that's coping mechanisms, [I: mm-hm] and I think that's kind of why I'm avoiding it. Um, I'm kind. Um . . . I think I'm learning; I don't know if I'm solid on this one yet, but I'm learning I'm not as selfish as I think I am. Um . . . hm . . . and I think this is going to sound really cheesy, but I'm me. Which doesn't really describe me, but it does. (laughs). [I: mm-hm] yeah. I'm hardworking. . . I'm not as lazy as I think myself to be [I: mm-hm] . . . yeah. I: Is there any examples of these descriptions that you, that come to you? [R: Hm] Especially, I'm interested in the ones that you hesitated [R: Mm] and you had emotion about [R: mm-hm . . . Um . . ] Smart. Strong. [R: mm-hm] Beautiful. R: Smart. . . Um . . . I have examples of that. I mean, the logical example is to look at grades, but it, it's more than that. [I: mm-hm] Um . . . I think even . . . Okay, yeah, this is a good example. Um, even realizing that I have an ability to um . . . ah I better be more concrete because this isn't going to work any other way. (laughs). Um, . . . ah, for example the, um . . . oh what was it? Creating like, creating electronic versions of forms [I: mm-hm] and then just automatically thinking, "Well I guess I should share that with other people." So, there's like an intelligence of I can do the technical part, but there's also this intelligence of like this is something other people would, ah, take advant-, not take advantage of, but be helpful for them. And so, sharing that with all the cohorts and, INTEGRATING EGO IDENTITY WITH LI THERAPY 491 and giving that. And I’ve realize that that, that is a type of intelligence [I: mm-hm] Um, because a lot of people create things, but rarely do they actually share it...around. I: Yeah. It's generous and applied. R: Um hm [I: mm-hm] Yeah. Um, and even just the . . . things I've, like in conversations with friends and being um, the things I have learnt through life [I: mm-hm] and been like, yeah, kind of understand emotional boundaries [I: yeah] and I didn't realize I understood it better than other people did [I: mm-hm] but I kind of understand what that is and how that works [I: Yeah]. Um, so there's sort of, there's ack-, and part of it is the academic because I haven't always seen myself as smart academically. Um, but then there's also this broadening of it to be like, but there's also like just life intelligence [I: mm-hm] and like ability to understand, even understanding cultures and understanding [I: mm-hm], um, like one of the big things that's been part of the program here is my understanding of like things that Vanessa might need being in a wheelchair that she's like, "Oh, nobody's ever like thought about that for me. [I: mm-hm] or told me that or understood that part of me." [I: mm-hm] And I was like, "Oh. I had no idea that wasn't just something [I: mmhm] everybody got kind of thing." [I: mm-hm] Um, so that's, that's a part of that intelligence is broadening up the definition of what it is. I: Yeah. Yeah. Totally. R: Um, strong? I've known I'm brave for a while. Um . . . so I think . . . huh . . . Yeah. That one was really surprising to me.( laughs). Um . . . possibly . . . yeah I think it has to do with like my determination [I: mm-hm], my . . . even the fact that I've juggled all these things for the last 10 years and then even in this program, um, juggling emotional stuff with academic stuff with um [I: mm-hm, mm-hm]. Even coming through thesis and being like, determined that, "No. This is something I want to do." [I: yeah] And you know despite the struggles I think was a big part of where that word comes from [I: mm-hm] Um, [I: yeah] . . . and I don't, yeah, beautiful? . . . The only thing that comes to mind . . . is after my abusive relationship that word was so dangerous because he used that word with me all the time. [I: hm] Um, and so . . . my ability to even use that to describe myself is kind of . . . yeah . . . what's the ending to that sentence? Um, . . . recovering that word? There's another word for it, but like, re---possessing that word as me. Um, but I also, one of the things that I've noticed even the last five weeks in my relationship to my body is changing. [I: mm] So, perhaps that's reflective of that as well. [I: mm-hm] We'll see. (laughs) I: Thank you. R: You're welcome. INTEGRATING EGO IDENTITY WITH LI THERAPY 492 I: For taking the time to deepen those [R: mm-hm] with examples. How would others who know you well describe you? R: Hm . . . tsk. Um, . . . sigh. I have a concept in my head and the word gentle is coming to mind but that's not exactly what I mean. Um . . . the, well maybe it is what I mean, the over, the opposite of like aggressive or [I: mm-hm] pushy? [I: mm-hm, mm-hm]. Um, . . . um . . . wise. . . . generous . . . at least in some areas. (laughs). Um . . . well I'm funny is yeah, (laughs). That's a given for everybody but (laughs). But I think beyond that, I guess, fun to be with [I: uh-huh, uh-huh] would be more what the people who know me well [I: Yeah, yeah.] I: If you could change something about yourself, what would it be? R: . . . hm, (chuckles) my first things are like all concrete things, I'd have more money, I'd be like (laughs). But that's not something about me. I: But not really about you. [R: Exactly.] Yeah. [R: Exactly.] I'd be rich! (laughs) Student loans are gone. R: Exactly! That's more circumstantial than about me (laughs) I: Oh, but that's good. Yeah. Um, so if there were some things about you, does anything come to mind? R: Um, . . . yeah, the one thing that comes to mind that I feel like it actually is in process is that whole relationship between me and my body [I: mm-hm, mm-hm]. Yeah. And what that, what it means for me to exist in this body [I: hm] and to, not always like my body, but to understand that it's part of me [I: mm-hm]. It is me. So, I: Yeah! both (laughs) Yeah! R: So, like obvious and yet [I: so mysterious] such a wild concept. I: Yeah. Totally. Hm. Anything else you want to say on that? R: . . . hm, I mean I'd love for like anxiety to never exist again. I: Kay, kay. . . You ready to talk about changes? [R: Yes.] Kay. So, the question, as you know, what changes if any have you noticed in yourself since therapy started? For example, are you doing, feeling or thinking differently from the way you did before? Or what specific ideas, if any, have you gotten from therapy? Including ideas about yourself or other people. Or have any changes been brought to your attention by other people? INTEGRATING EGO IDENTITY WITH LI THERAPY 493 And, I am going to return to the record form [R: (laughs)] and start writing down changes. R: Um . . . Yes, there have been changes [I: Phew.] So. Yeah, exactly. I: If you were saying nah (Both laugh) R: Yes, there have been. [I: yeah] Yeah, and obviously I don't think I'm going to get to all the ones, just because I: Well, and remember we're going to go back to the cue and compare your [R: yeah] preratings and today's ratings [R: yeah]. But - but the things that come to mind for you right now [R: mm-hm] I want to capture. R: Yeah. Um . . . oh I just had one in my head. Anyways, so one of them is my relationship to my body [I: mm-hm] is changing and . . . even the discovery that . . so, one of the things that has happened in even the last five weeks that I still attribute to therapy [I: mm-hm, mm-hm] um, is the realization that I am in full control of my body. Um, I had no idea I had actually thought other people had control of my body [I: mm]. I was like, "Hm. Interesting." Um, to the point where I was like, and it was interesting to me who, who I, who it was. Like it was more my mom that I thought [I: mm-hm] somehow. 'Cause I remember, like I read it in an article, which I know is something I've read before but this time it smacked me in the face. And I was like, "That's not true! My body is not my own." And I was like, "Whoa!" (laughs) "Where did that come from?" [I: hm] And then I thought of like, "No, you know, like my mom also has authority over my body." And then when I was in conversation with her and she was like, "Well just make sure you keep exercising." And I was like, "Okay." That's part of that script that's gotten in there [I: mm-hm] is that somehow, she also has this control over it somehow. [I: Yeah] Um . . . and there was another one . . . I hate it when that happens and all of sudden you had like five and now, you're down to zero. (laughs). Um, things that have changed since therapy. Ah! There we go. I've got it back again. Um, so . . . ability to follow through with a-a-a desire. So, specifically I mean like there has been a desire throughout my life to, like offer help to people when they're going through difficult times [I: mmhm], but I've rarely every followed through with it. I've always been like, "Well there's other people in their life [I: mm-hm] who've probably offered and they're just a burden" And all that kind of stuff [I: hm]. Um, now once in therapy and now once after therapy, I've actually done it. And I've like, put that out there and said, "Hey, is there anything practical I can do for you?" And like made suggestions, which was kind of like, "Hm. Never really done that before." So that was . . . I guess following through on . . . it was being me. [I: mm-hm] Allowing me to be me. [I: mm-hm] That's a good way to put it. Um, and not silencing a part of me that [I: yeah] . . . and I guess on the flip side of that is also like not feeling guilty that I don't want to do that for everybody. [I: yeah] You INTEGRATING EGO IDENTITY WITH LI THERAPY 494 know, to only do it when I feel I want to do it. [I: yeah, yeah. hm] Um . . . (clears throat). So that was one of those situations where I was like, "Oh. Change is still there. This is good." (laughs) Because I was like, "Oh. I did that." Um . . . wow, this is, it's like eleven months of stuff. (laughs) I: I know. It's hard to probably to actually capture what things you would say as changes. But - [R: yeah] but feel free to take . . . some time [R: mm hm] in yourself, just to think about . . . what you feel might be different [R: mm hm] about you, your experience of yourself, your experience of the world now. The prompts here are good. Is there . . . it just kind of makes it, simplifies it. Are you doing things different? Feeling different? Thinking different? [R: um hm] New ideas. Have other people noticed changes? R: Right. I: Let that prompt your reflection. R: So, one other one that came to mind, um . . . was . . . this is kind of like, I, I, I no-, I noticed a change in how I dealt with it, but I'm not sure how, like what it means yet. [I: mm-hm] Um, but . . . in . . . when you sent me your feedback from my thesis [I: mm-hm] um, my first reaction was like panic. [I: Oh no! (laughs)] Like, I know it's dangerous, right? I: Right. Is that before you read it or after you read it? R: It was . . . when I read the email. So, I was split, like part of my brain was like, "That's a very positive email. This is really good eg-, good feedback." And then another part of my brain went automatically into panic mode [I: mm-hm] and it's like, "Oh no. They're going to find out I'm a fraud. They're going to find out I have no abilities here." kind of idea [I: mm-hm, mm-hm]. Yeah, um, but I was able to like really quickly recognize that, um, and sent that to a couple friends and just said like, "Here is what my brain is doing, and I know it's crazy so." (laughs). Just to get that feedback from them. [I: mm-hm] Um, so that I could just say, "Okay. It's not just me. They agree with that side of my brain that's like, 'this is positive, and this is good feedback.'" [I: mm-hm] Um, which . . . very, like much f-, it was a much quicker process to actually getting to like reading [I: mm-hm] the actual thesis and like feeling confident in it than it had been before. Um, so that transition from full-panic mode to like, "Oh. This is manageable. I can do this." Was like, before where it might have been a couple weeks, it was like, maybe a day and a half [I: mm-hm] kind of thing [I: mm-hm]. So, um, and, and the severity, or the, not the severity, the . . .well yeah, the severity is the only word. (laughs). The severity of the panic was not as high [I: mm-hm] as it had been. Um . . . so INTEGRATING EGO IDENTITY WITH LI THERAPY 495 I: So, receiving feedback in a way that, what you're describing is that maybe threw you less catastrophically, [R: yeah] Like, it still threw you [R: mm-hm] but you had that dialogue [R: mm-hm] so, I'm, I'm just going to write, "Receiving feedback, not being thrown slash panic as much as previously?" [R: mm-hm] Does that capture? [R: Yeah, yeah] Okay. Um, tsk, and also just being able to recover. [R: mm-hm] And constructively stay with yourself R: Well I guess part of that it was like, holding onto my voice because I think that this is particular, like I don't feel this way every time I get feedback on an assignment. [I: mmhm, mm-hm] Right, like this particular project has been very different [I: mm-hm] because it's me speaking. [I: Totally] It's me being in the world, right? [I: yeah] And so, that ability to kind of navigate that and say, "No, I have a voice and it's a good voice and it's a strong voice and we can be there." [I: mm-hm] And like allow myself to have space in the world [I: yeah, yeah] Um, has that transitioned from like full panic to like, "No, it's okay if I have a voice in the world" [I: mm-hm] has been much shorter [I: mm-hm] and almost stronger on the, on the other, on the flip side, right? [I: Yeah, yeah] Um, which is cool. (laughs) [I: Totally] Very cool. Um, there was also something about like to tie with, do I think about myself or about others differently, right? [I: mm-hm, mm-hm]. That tweaked something. [I: yeah] Now if I can only remember what it tweaked. . . . . . . No, the only thing that's coming up is the body stuff that we already talked about, so. [I: mm] I: It's okay I think if you come back to it later [R: mm-hm] Um, I had that sense too that you were like, there was something that was right there [R: mm-hm] and then R: It floated away. (laughs) I: It floated as thoughts do. Um, what about, has anything changed for the worse for you since therapy started? R: Um . . . I would say the, the only negative has been that just, the, the post-therapy grieving and mourning. Like that was, that was actually really hard. [I: mm-hm] Um . . . and then there's the fear that I wasn't [I: yeah] that I was going back to square one. But during therapy, so I don't, I don't feel like anything that I kind of walked into therapy got worse. [I: mm-hm] Um . . . more obvious maybe (laughs) I: I'm trying to figure out where it goes like grieving, suffering at the end. Is that a change or is that a process that you went through? R: It's just more a process. yeah. INTEGRATING EGO IDENTITY WITH LI THERAPY 496 I: Because it doesn't have to do with pre-therapy baseline [R: no] and, like I want to capture it adequately here [R: mm-hm]. Maybe I hear you saying this is pain that was brought on by the therapy that you went through? R: The only thing I guess that could be constituted as a change [I: mm-hm] is I now know what attachment feels like. Whereas before therapy I wouldn't say I knew I understood. I: Okay. But is that a worse thing in you? R: No. No. But it does cause suffering because then you know what was missing all those years and [I: mm-hm] so . . . no, there's change there but it's not for the worse. Even though, it causes sorrow. (laughs) [I: mm-hm] Yeah. I: But is that, is that something that we should capture as a change? Not necessarily as a negative one, but like having experienced positive attachment. And when you say attachment, do you mean that in a specific way? Like, [R: Umm] You have, you have stable relationships [R: mm-hm] and friendships in your life, but I feel like you're getting at something [R: yeah] kind of unique. R: So, I kind of noticed it in two ways. One I noticed like even before therapy ended, like, in the last like month and a half, I guess or so. There was this, um, . . . I want to call it a craving um, which thankfully my therapeutic brain was able to say (laughs) temper that with logic, [I: mm-hm] but this craving for more [I: mm-hm]. And so, it was, and I puzzled with it a while. Like wh-, what is it that I'm craving? [I: mm-hm] But this craving of more of being held, [I: mm-hm] more of being cared for [I: mm-hm], more of, um being seen and completely accepted, um, and, . . . huh. I'm hesitant to say the word, but I want to. Um, and loved [I: mm-hm] in that, um. [I: mm-hm] And even in using that language of love, right, like it's not something that we do a lot in Canadian society [I: mm-hm] and so hearing someone say that, um . . . yeah. It just really impactful. (laughs) [I: mm-hm] Um, so yeah, having that, and having someone who had seen and knew parts of me, younger parts of me and, and different parts of me, that still expressed care and compassion [I: mm-hm] and protection even, um, defense of that. [I: yeah, yeah] Um, is sort of what I mean by [I: okay], by attachment. I: Yeah. Almost like, yeah, a younger more primal [R: mm-hm]. Yeah. R: And definitely not a two-way [I: mm-hm]. Right? It wasn't a, like, "I care for you and you care for me [I: Yeah] and we're like friends." And it was very much not a friendship. [I: Yeah] It was very much like, "I come to you very vulnerable and you just care [I: yeah] and hold [I: yeah]. Very much like that. I: More in line with a re-parenting philosophy. [R: Yeah]. yeah. Okay. INTEGRATING EGO IDENTITY WITH LI THERAPY 497 R: I'm almost in tears even just talking about it. Wow. I: It's very touching and it is, I can feel too you're, the way you're exposing yourself [R: mm-hm] in that vulnerability that you entered the relationship with [R: mm-hm, yeah] And how precious it is [R; yeah] As you talk about it. Um, anything you wanted to change that hasn't since therapy started that you want to comment about. R: . . .. tsk. Um. . . I guess it has changed, I wish I had kind of changed more [I: mm] um, would be my sleep patterns. [I: okay] Um, although I guess that's one thing that has changed even in the last five weeks. [I: Hmmm] It's gotten better. Which is kind of weird. I: Is that something that you actually would want to note on this? R: Yeah, you know what? I would. Yeah. And that reminds me of another one too (laughs) I: okay. Okay. Um, so it's like in process [R: Yeah, yeah] is what you're saying. So improved sleep patterns would be the change? [R: mm-hm] Okay. And you said there was another thing coming to you? R: Yeah, and then the other thing, um, was, um morning and evening TV watching. [I: mm] has just organically changed. Which has been pretty wild. (laughs). . . . In that, like, that used to be kind of what motivated me to get out of bed was that I got to watch a TV show [I: mmm] and so I'd like have the TV on as soon as I was like, up in the morning and it's my iPad so I can take it with me. (laughs). So, I'd have it when I was showering, 'cause I have glass doors and I'd have like, [I: mmm] I'd just do everything while I was watching a TV program. [I: mm-hm] Um, and actually there was one specific TV program that I watched five, all six seasons five times in a row. [I: hmm] And like I was, at one point, I think after the fourth time watching it, I considered not watching it again. I was almost in tears at the thought of it. [I: hm] I was just Like I can't. I have to watch this again. Um, and so I did, I actually journaled about that [I: mm] and kind of figured out why-what was going on there, but [I: yeah] so now it's more, it's not something I decided, "Okay I'm not going to watch morning TV anymore." It was just sort of like one morning I woke up and I was like, "Yeah, well I don't need to today. I'm good. I can just go about getting ready without the TV being on." [I: Hm] Um, and that's probably been generally the pattern for the last, like two, two and a half weeks. [I: Hm] which is kind of like, weird. (laughs) [I: yeah] Um, and then . . . yeah and then the same at bedtime, like, there's less of a fear of going to bed. More of a kind of organic like [I: mm-hm], "oh, it's time to go to bed." [I: yeah] Alright. We'll get ready for bed, but we won't do it with the TV on. We'll put that away first and, and then we'll spend some time getting ready and [I: mm-hm]. So that's been cool. Yeah [I: yeah] Especially because it INTEGRATING EGO IDENTITY WITH LI THERAPY 498 wasn't something that I've decided because I've done that a few times, but this was more like I: Yeah, you were feeling from the inside. R: mm-hm. [I: like how you wanted...] I felt inner consent. (laughs) I: Yeah. Yeah! R: To use that EA language I’m learning about. (laughs) I: Totally. Um-hm. Um, this was a tangent [R: mm-hm] or like, your memory was kind of triggered by the question actually if there was anything that you wanted to change that hasn't, [R: mm-hm, right] so I just want to come back to that to check if there's anything else that you wanted to say. This leap kind of landed on both because you'd wanted more, but then surprisingly [R: mm-hm] you experienced shifts recently. [R: right, yeah] So, anything else [R: I don’t] that comes to mind? R: I don't think so. I: Okay. R: Yeah. [I: So, what-] It's funny actually because I think the two things that I mentioned in the last interview we did are the two things have demonstrated change [I: since] since. I: Interesting, hey? [R: yeah] Yeah. Wow. Um, well, we're going to go to each of these, we came up with six changes and you know the scale [R: (laughs)] I'm going to ask you about how much you expected them [R: yeah] or how unexpected they were. How likely or unlikely they were. And how important they were. And I'll, I'll anchor for the first one and then if you, if you, as much as you need. [R: yeah] so the first one is the relationship to your body and the realization that it's yours, that you are in control [R: mm-hm], agency in it, and about this change, I want you to, to say where you land on whether this change was very much expected, that would be a one, somewhat expected is a two, three would be neither expected nor surprised, four somewhat surprised, or five very much surprised. R: Five. (laughs) I: You didn't hesitate, [R: Nope.] Rose. Are you sure? R: I am sure. [I: okay] (laughs) I: And then the likeliness to unlikeliness scale, um, is just you rating how likely you think it would have been if you hadn't been in therapy. 1 is very unlikely without therapy that INTEGRATING EGO IDENTITY WITH LI THERAPY 499 it would not have happened [R: mm-hm]. 2 somewhat unlikely - probably would not have happened. 3 neither likely nor unlikely - we can't tell. 4, somewhat likely without therapy. And 5, very likely without therapy. R: I'm going to say 5. I: Very likely without therapy? R: Oh wait. I: 'Cause you also had said. R: No wait [I: Um] I totally misread that when I was in on Monday. What's 1 then? I: Yeah, it's actually kind of opposite, the, the expected is, 1 is expected, 5 is surprised. The likely or unlikely, 1 is unlikely [R: right] and 5 is likely. R: I heard unlikely at 5 and likely at 1. (laughs) I: That's what I thought the way you were talking. That's why I wanted to double check. R: Yes. So, 1. I: Unlikely? [R: Yes] Okay. And then the importance. How important um, is this to you personally? Not important at all is 1. Slightly important 2. Moderately important 3. Very important 4. Or extremely important 5. R: I haven't decided yet. (laughs). [I: okay] Isn't that weird? I'm like, "I don't know!" (laughs). Um . . . 'cause there's a bit of fear in that, so it's kind of like, "well, I don't know what, what it's going to come to, so I don't know how important it is." Um . . . I'm going to s- …yeah, I'm going to say a 4. I: Okay. . . I love how this is a process [R: I know.] Right, as we say rate, you're like, "Ahhhh." R: I don't know! (laughs) I: Maybe later you'll have a different answer, but this is today's [R: exactly] answer (laugh). [R: Exactly.] So, the next thing you mention is the ability to follow through with a desire, but more specifically when you want to do something that you are in control of doing it. [R: mm-hm] You get to choose, and you gave the example of, of wanting to do something kind for someone else who had a need and not holding back [R: mm-hm] Just being you. But um, I'll just say ability to follow through with a desire [R: Yep, (laughs)] And how expected or surprising was this? 1 is expected, 5 is surprised. INTEGRATING EGO IDENTITY WITH LI THERAPY 500 R: Um, 5. Surprised. I: And how likely or unlikely um, without therapy. 1 would be it's unlikely it would not have, would not have happened without therapy. 5 is it would have happened anyways for sure. R: Definitely a 1. I: Okay. And then how important? 1 to 5 with not at all 1, extremely 5. R: 5. I: Okay. The next one is receiving feedback. Um, kind of the emotional [R: mm] implications of receiving feedback. Um, being, and you said not being thrown or panicked as much as you would have been previously [R: mm-hm], recovering more quickly. So easier to receive feedback [R: mm-hm]. I don't know, we can probably reword it, but R: Um . . . so . . . yeah, this one is a hard one because like even the response was surprising. I: Like the panic? R: The panic was surprising [I; yeah, yeah] and so then I guess it was surprising that that changed or I: That it was there and that it went away? R: yeah. [I: mm] So then it's kind of like I: you're able to dialogue with it. R: (laughs) I: But the change you're, kay what you're noting though is not that you experienced panic, but that it didn't throw you as much [R: mm-hm] or for as long [R: right, right]. So that's what you're answering to here. [R: right] Because you've always experienced, the way you described it [R: mm-hm] that was, that was common baseline. R: mm-hm. Um, so I would say . . . probably a 3. [I: kay]. Yeah. I: Neither expected nor surprised. [R: yeah] And then without therapy, how, how likely or unlikely is that shift? INTEGRATING EGO IDENTITY WITH LI THERAPY 501 R: Oh. Very unlikely. Like 1. (laughs) For sure. I: How important is that to you? R: 5. I: Okay. Um, the next one is the one that came out [R: mm] of our conversation about attachment. So the way it's worded now is, ability or having the ability to experience, almost like an ability or achievement, of, of [R: mm] you did it, it's positive and real attachment [R: mm] and craving for more of being held, and cared for, and accepted, and loved. R: Mm-hm. Very surprised. . . is there a 6? (laughs) I: And how likely ... No, we're stuck [R: Darn! (laughs)] with this measurement limits. (laughs) [R: um] On likely to unlikely, 1 to, unlikely is 1 [R: yeah], likely is 5. R: 1. I: Okay and then how important is that? R: 5. That's interesting. Can I add a little thing in there? [I: sure] It's interesting to me, that that has even, kind of, given me hope for like, like if I do get into a relationship one day, [I: mm-hm] that there is that possibility of having an intimate relationship with someone [I: mm-hm]. It's like, "oh. okay. This is good." [I: mm-hm] (chuckles) So that was, surprising. I: um, sleep patterns. You said improved sleep patterns [R: mm-hm] that have just, just been a newer thing [R: mm-hm] that have shifted [R: mm-hm]. How expected or surprising is this? R: I would say it's a 5. It was very surprising. After 10 years. (laughs) I: And how, how likely or unlikely without therapy. Unlikely 1. R: Yeah. Ah, 1. I: How important? R: 5. Yeah. If I don't sleep, I don't do anything. (laughs) I: And then you lastly mentioned that your TV watching habits have just shifted from inside of you [R: mm-hm] basically, you said organically [R: mm-hm], um, I think was the word. And that it wasn't really a cognitive decision but you just [R: mm] felt less INTEGRATING EGO IDENTITY WITH LI THERAPY 502 need to have your day be bookended with TV [R: mm-hm]. How expected versus surprising is this change? R: tsk. Um . . . Yeah, I would say it's a 5. Yeah. There's hope, but didn't really think it would happen (chuckles) [I: yeah] so I: How likely without therapy? R: um . . . tsk. So, like I'd done it before with more of like a decision so this organic piece is probably what's most surprising about it [I: mm] and I think that part of it, I don't think was [I: mm] was very unlikely to happen [I: I see. Yeah.] without therapy. Yeah. I: That's a fair clarification. And then how important is that to you? R: (laughs). There's really a little, but I like my TV. (laughs) I: You can still watch it. R: Exactly. (Both laugh) Um, there's that little voice in me like, "Don't say 5... I: I wonder what good shows you'd recommend. [R: (laughs)] Like you've, you've logged a lot of hours previewing. You're going to have a list. R: They're all sci-fi shows and fantasy [I: okay (laughs)] The geek squad in me are good?? on that one. (laughs) Um, I'd say 5 actually. It was really important to me. I: Cool . . . We’re plugging along. Um, in general, what do you think has caused these various changes. In other words, what do you think might have brought them about and you're welcome to include things both outside of therapy and in therapy? [R: okay]. Although, given that you mentioned the um, unlikeliness of every single one of them without therapy, I'm assuming you'll want to refer to things [R: mm-hm, yeah] within therapy. R: Um . . . yeah. So, I would s-, say that a lot of it had to do with like . . . what we worked on in therapy. Getting me connected with myself [I: kay] (coughs). Excuse me. Um . . . and . . . that piece that's, I think a bit unique to LI in that, um, really bolsters the like, "I have the capability of protecting and caring for myself in the midst of that, um, in the midst of life or whatever life brings." [I: mm-hm] Um . . . and allowing there fr-, be space for me to be and be cared for kind of... There was something at the end there, but then I lost it. (laughs) [I: mm-hm] I: Anything else [R: um] you want to say? INTEGRATING EGO IDENTITY WITH LI THERAPY 503 R: I would say a factor in that has also been having a couple of really close friends who have walked with me [I: mm-hm] through therapy and who I've been able to reach out with, reach out to as I was in therapy, before therapy, and then now after as well [I: mmhm]. So, yeah. I: Yeah. Sounds good. And then . . . this is gonna just be natural segue to the attribution’s questions. This is a helpful aspects question [R: mm] and, it's, we're asking you to sum up what has been helpful about your therapy so far with examples, general aspects, specific events [R: mm-hm], specific protocols. [R: yeah] Wh-, Whatever comes to mind. How would you, yeah, 10 months of this. (Both laugh). 35R: 32 I: 32 [R: yeah] 32 sessions later [R: (laughs)] I know it's a daunting thing to reflect on, but you're, you're possibly today at the very best vantage point [R: mm-hm] to have the distance and the specificity. In 5 years, you'll have better distance [R: mm-hm], but you may remember less of the specifics [R: right, yeah, yeah.] So, for whatever it's worth, let's capitalize on today's value [R: mm-hm] in getting you to, to sum up what has been helpful. R: Mm-hm. So, I think one of the things that was helpful was starting with the attachment protocol [I: mm-hm]. Um . . . (coughs). Excusez- moi. And just really establishing that relationship between the two of us. [I: mm-hm] Um, . . . tsk . . . I just had like 5 ideas. Why does this keep happening? (laughs) I: Well just listen to the question again. [R: yeah] Can you sum up what has been helpful? [R: mm-hm] And maybe you're working too hard. [R: (laughs)] When people ask you, [R: yeah] what has been helpful about therapy so far in those months what are the examples? R: I think that another part of it, um . . . has been like going back to specific memories [I: mm-hm] that have a lot of um . . . emotional content attached to them [I: mm-hm]. Um, it's kind of like two-sided actually, like going back to memories that have a lot of attachor emotion that I knew was there, but then also touching on a memories that I didn't know [I: mm-hm] had, but that had a lot of emotion I didn't know was there. [I: mm-hm] Um and interacting with those younger parts of self [I: mm-hm]. Oh, it was so precious [I: mm-hm]. It just . . .like I said, I was often very surprised at like . . . like we would, I'd take her back to my place and one of the things Hillary would say was like, "Well just notice how she behaves in there." [I: mm-hm] And I would, like, it was always different [I: mm-hm]. Like it was never the same. [I: mm-hm] And it was organic. Like it wasn't like I sat down and thought, "Okay, how would I behave as a 9-year-old in this apartment?" It just was there. [I: mm-hm] It was just happening. Um, which was very INTEGRATING EGO IDENTITY WITH LI THERAPY 504 cool. (laughs). Um, yeah and I think another part of that was like, bringing them to my place. Bringing them to where I am present-day. [I: mm]. Um. Seeing them, like seeing my 4-year-old playing with my rose doll and um . . . yeah. Seeing my 7-year-old doing stuff in my apartment, like. [I: hm]. Just that connection, that that, like where I live now, they're also there [I: mm-hm, mm-hm] kind of peace was really, important [I: yeah]. Um. And then I think like, on the flip side of things, there was also parts about like how I came to therapy that also were really helpful [I: yeah]. Um, and just being very open, um, [I: mm-hm] and . . . kind of in one sense attuned to what was going inside of me, but also willing to, kinda like, push through that [I: mm-hm] to get it out there kind of thing and not just dismiss myself [I: mm-hm]. I: So being willing to, make it, a-, available for therapy [R: mm-hm, yeah], or to speak it. Okay R: Yeah. Exactly. Yep. Like not try to control what the 7-year-old does in my apartment, but just let it be [I: mm-hm]. And then. I: Yeah. Awesome. If there's anything else [R: mm-hm] that comes up about that feel free to circle. I want to also ask you about problematic aspects. If there’s, what things, or what kinds of things about the therapy have been hindering, unhelpful, negative, or disappointing? General or specific aspects. R: Hm. My first response is - ending. (laughs) [I: mm-hm] Ah, um, yeah. That was harder than I expected [I: mm-hm]. Um . . . not necessarily a negative thing, but it was definitely more difficult than I expected [I: mm-hm]. Um . . . there was um, maybe like a couple session in there where maybe like the emotional connection between Hillary and I was missing a bit. [I: mm-hm] I think it was sort of the beginning of going into the online [I: mm] um and so . . . recognizing that and then bringing it to the table with Hillary and then us talking about it and just recognizing some of what we might need to do differently because it's online. [I: mm-hm] Um, and so me being, me being more aware that she can't always get body cues [I: mm-hm] over a camera. Um and that I might have to speak up a bit more [I: yeah, yeah.] So, I think those are the two that I can think of. [I: mm-hm] I: Um, were there things that were difficult or painful, but still okay or perhaps helpful. R: (chuckles). Every single session. (laughs). Oh definitely! Um . . . yeah, like some of the memories were difficult to [I: mm-hm] sit in. Some of the emotions were big and probably the one that was most difficult is when they were about parts of myself that didn't have a lot of language [I: mm-hm], so trying to . . . put words to an experience of self that is so young, um, it was really hard. [I: mm-hm] Yeah. . . but helpful. INTEGRATING EGO IDENTITY WITH LI THERAPY 505 I: Yeah [R: yeah]. Has anything been, has anything been missing from your treatment? Or what would have made it, therapy, be more effective or more helpful? R: Um, the only thing I would say that, and we tried to have this happen a couple times, it just never worked [I: mm-hm], um, it would have been great to have had like one more in-person session with her before we ended. I: yeah. [R: um, it just] You just couldn't get on the ferry. R: (laughs). Timing just did not work out [I: Yeah] That was unfortunate, but I: For sure. . . . Do you have suggestions for us regarding the research or the therapy? Anything else you want to tell me about it? R: Hm. . . .I recommend it to everybody. (laughs). Yeah. I: The research too? R: Yes. I: Just wanted to check [R: yeah] if it was just the therapy or (laughs) R: No. No. The research too. It's been a fascinating journey, not always an easy one. [I: mm-hm] But just fascinating to watch. It's almost like every once in a while, my researcher brain comes out and watches me and goes like, "Whoa, what the heck's going on?" [I: mm-hm] This is so fascinating. So yeah. I: That's pretty cool. [R: mm hm] (chuckles) Do you have your most recent, um, PQ? [R: I-] Or your, is it the week composite or the daily? R: Yeah. Huh, what did I do - I actually did – I: What did we use last time because when we, we're going to compare your pre-therapy and current [R: mm-hm]. Um, noting number of points changed for each item and what the ratings mean. But which, is it, did we use the daily or did we use the weekly when we -? R: We used the weekly. I: Okay. [R: yeah] So that's what we'll do the same then. R: So actually, what I did was I, because there's been 5 weeks, I was like I just did a review for each week that we'll just have as part of the data. [I: okay, okay] but we'll only look at the last one for today obviously. INTEGRATING EGO IDENTITY WITH LI THERAPY 506 I: Sure. Yep. Perfect. I: Um . . . the first of all I want to understand how you used the PQ and what the ratings mean. You and I have talked a little bit about how you began to answer certain questions possibly in a [R: mm-hm] little bit of a different way. Um, tsk, so just generally do you think your ratings mean now that they did before therapy. And if not, how has their meanings changed? So, as you look at your PQs is there anything that you want to highlight for me about how ratings may have [R: mm-hm] changed over the last 9 months? R: Well I even just noticed doing the I: 10 or 11 months. (Both chuckle) Yeah, [R: yeah, exactly.] it was May. Yeah. Wow. R. Crazy. (laughs). Um, that I think, like even as I was like completing the daily and the summary, um, I think even maybe even my understanding of what my PQ items mean has changed a little bit [I: mm-hm, mm-hm]. Um . . . and so in that sense . . . I don't think they've drastically changed but I think um . . . like they still mean the same in essence, but there's more nuance [I: mm-hm] maybe to what, to what I'm looking for. Um, so yeah if anything, I would say I have less of a tolerance level for things, so it's more, so on a lot of the items they get higher scores for less distress. [I: mm-hm] If that makes sense. [I: mm-hm] I: Ah. Okay. Yeah. It's like your range has decreased R: Has shrunk. Yeah. Yeah. I: Okay. Um . . . so, you're now 5, like this is theoretically might have been you're then 3 [R: right] because now 3 is your highest possible [R: yeah]. Okay. So, if anything R: I'm scoring higher. I: It's exaggerated towards negative [R: mm-hm]. . . kay. R. Um, just as I was looking through this, there was a question we had of like [I: mm-hm] was there something I wished had changed. [I: mm-hm! Yep.] Yeah. So, this would be, just as I'm looking through these items, I'm like, "Oh yeah. that's one of them. [I: yeah. yeah] And that was just my relationship with God. It has changed a bit [I: mm-hm], but I wish I had experienced more there. I: So that, I'm just going to circle back to three C so when that gets transcribed (laughs), saying 3C out loud that that question gets captured. [R: Right. Exactly. Yeah.] Okay. Um, so what we're going to do next is compare each PQ problem to the changes listed INTEGRATING EGO IDENTITY WITH LI THERAPY 507 um, earlier in the interview and then if it's not, we're going to, or the ones that have changed two points or more [R: mm-hm], um the ones that have, we're going to add to the, the list if you'd like [R: mm-hm]. So, let's just go through the list first and look at the numbers. Um, so #1 - I feel shame about who I am, and I who have been. What number do you? It's a 6 here. R: I have a 1. I: Okay. So, I'm just going to star, um. What's with #2 - I am not enough. Is that how we changed? R: Yeah. That's um, I feel I'm not enough. ‘Shoulding.’ Yep. I: Okay. Okay. R: It was written twice. I: That is how it was revised. [R: Yeah. (chuckles)] Yeah. But it's still different than I feel shame about who I am. R: Yeah, but this one and this one were the same thing. I: So, we don't have 2 anymore? R: We do. I: We do. R: It's just that these, you wrote down the [I: Ooohhhh] number one twice and so I [I: Yes, yes] just changed that to the one it should be. I: That's right. The ‘shoulding.’ So, #2 - 5. R: I have one. I: Okay. #3 - I feel like I don't belong - 5. R: 1. I: Kay. R: So, no changes really. (Both laugh.) I: No, I know, this is not dramatic. I have a fear of failing at life. 5. INTEGRATING EGO IDENTITY WITH LI THERAPY 508 R: 1. I: I have trouble feeling present in the moment - chest tightness, brain feeling fuzzy, not feeling connected to others was a 4. R: I have a 1. I: Okay. My sleep is interrupted was a 6. R: I have a 3. Woo-hoo. Wow. I: Okay. Um, I self-sabotage my own goals was a 5. R: 1. I: okay. I cannot make decisions was a 3. R: 1. I have a lot of 1's basically. I: Okay. I'm feeling that. R: Pretty much the rest is 1. (chuckles) [I: really?] yeah, really. I: Okay, so . . . I'll star them all then [R: (laughs)] but then what we need to do is decide um, which ones you want to add. R: Except for maybe the last one. What did I have? Oh, you don't have 15 on there. I: No, that was added. [R: right] So, 15 R: So that one I don't think has changed. I: um, Okay. . . . um . . . What do you have for 15? Because I can pull up your R: I have 1. [I: 15?] mm-hm. Because 15 is reversed scored. [I: okay] I want to see an increase. I: So, you want it to be higher. Okay. [R: mm-hm] So then we won't. Is that the only one that was reverse? [R: mm-hm] Kay. So, of these, you're looking at the same list as me, um, is there any that . . . you wouldn't want to include in your change list? Because they all count in terms of numbers. [R: No] They're all two or more. R: No, I think I'd want to include all of them. Yep. INTEGRATING EGO IDENTITY WITH LI THERAPY 509 I: okay, so then what we're going to do is just see if any of these line-up to what you have already commented on. So, sleep I would say [R: mm-hm, that one’s.] we've um, we've addressed already [R: mm-hm]. I'm just gonna check it. Um, relationship to body, is that addressed in a specific item on here or not? [R: not really, no.] Not really so we'll keep that separate, or we won't eliminate anything here. Um, tsk . . . you have I cannot make decisions and then today said an ability to follow through with a desire. They're similar, but different. R: Yeah, they're quite different actually. Yeah. [I: okay, okay] Because sometimes that was like, "I can't decide what to have for lunch." And it was like traumatic. (chuckles). [I: Right, yeah] or distressing. I: Um . . . Is TV watching captured in any of these? [R: Um] I'm looking through and I'm not seeing them be the same on any of them. Except for sleep. R: Yeah. I mean it's connected with I'm stuck in an avoidant pattern, but different as well because it could involve more than just watching TV. [I: Okay] Yeah. I: Okay. Well then what we're going to do is we're just going to add these to the list for today [R: alright] and we'll go through the same expected, surprised, likely, unlikely all of that [R: okay]. So. [R: What fun. (chuckles)] I'm just going to for reference, [R: yeah, just number them] punch in the number that was on the PQ. [R: yep] Um and [R: That’s okay, number the numbers] I'm also going to abbreviate what I write here [R: yeah] but I'm going to read them from the original wording [R: okay]. I'm just doing that purely for logistically efficiency [R: Yeah.] 8 and 9. . . . . . . . . . . . . . [very long pause while stuff is being written down in preparation] Almost there. R: No. No problem. I'm rehearsing my 3MT speech. (laughs) I: Love it. [long pause - talking to self softly occasionally while writing that wasn't transcribed]. Okay. So, we're going to do the same thing and look at each of these items in relations to those ratings. So, jumping right in at number 7, which is your #1 from the PQ is I feel shame about who I am and who I've been and that's gone from a 6 to a 1. How expected or surprising is this change? R: Very surprising - 5. [I: okay] I: And how likely or unlikely. R: Um, very unlikely. 1. I: 1. How important to you? INTEGRATING EGO IDENTITY WITH LI THERAPY 510 R: 5. I: The next one I'll abbreviate as ‘shoulding’ [R: mm-hm (chuckles)] I feel I am not enough. [R: Should-ing (Both laugh)] And how expected or surprising. R: Um, very surprising. So, 5. I: Likely or unlikely? R: Ah, I'm going to say 2. I: Kay. And then how important to you? R: Mm, 5. I: Kay. Next one is ‘I feel I don't belong’ and you’ve reduced this from a 5. How expected is this change or surprising is this change? R: Um . . . 5. Yeah. I: And likely or unlikely? R: 1. I: Unlikely? [R: yeah] How important um, [R: mm-hm] to you? R: 5. I: Kay. This fear of failing, um, where did, I have a fear of failing at life. [R: mm-hm] How expected or surprising? R: Very surprising - 5. I: And how unlikely or likely? R: Um, I'm going to say a 2 so mostly unlikely. I: Okay. And how important to you? R: mm. 5. Yeah. I: Okay. The next one is about being present that's worded I have trouble feeling present in the moment - chest tightness, brain feeling fuzzy, not feeling connected to others. R: Mm-hm. Yes. INTEGRATING EGO IDENTITY WITH LI THERAPY 511 I: This is reduced. [R: (laughs)] Um. How surprising or expected is this one? R: Um, this is where I'm like, "Well I really I really hoped, but" [I: yeah] Um, so I guess yeah, I'd s-, it's surprising. It's 5. I: It's a 5 still even though you'd hoped. R: Because I hoped it had for many other reasons [I: yeah] but it had never changed. I: So that's maybe a comment, just, I'll punctuate it for the reviewing later. Is that in your PQ ratings when you identified problem areas, you hoped for changes that you didn't always [R: right] expect and that's the difference you're making now [R: mm-hm, yeah] Kay. And how unlikely or likely is this change? R: Unlikely - 1. I: Kay. And how important or not important. R: Seven and half. (laughs). 5 I: Unlimited. [R: (laughs)] Um, I still sabotage my own goals. This has moved down from a 5. [R: okay. Right] And how surprising or expected is this? R: Um, very surprising, yeah, 5. I: You didn't think therapy was going to do anything for you. R: Well, I'd hoped. I: Yeah, no you did. Yeah. R: But it was sort of like goals I'd had for a really long time [I: right, yeah] and I'd been in therapy for so long, it was kind of like, "Maybe this will make a difference, but [I: sure, sure that's fair] everything else I had done hadn't made a difference. I: You'd done a lot of personal work though. [R: mm-hm] Yeah. And how likely or unlikely is this change? R: Ah, I'm going to say 1. I: How important to you? R: 4. I: Kay. The next one is I cannot make decisions and that moved down from a 3 to a 1. INTEGRATING EGO IDENTITY WITH LI THERAPY 512 R: Um . . . that one probably wasn't as surprising, so I'm going to say a 4 on that one. I: mm-hm. How likely or unlikely? R: I still think it was an unlikely - 1. I: And how important? R: Oh, that's a five. It's so nice. (laughs) I: You want to know what you're having for lunch. R: Yes, exactly! It's so nice not to be distressed about that. I: Um, I'm stuck in an avoidant pattern is the next item. And we, it was at a 4. So, when you think about where you're at now, [R: mm-hm] how expected or surprising is your change? R: . . . tsk, um . . . I don't know. It's stuck with me for quite a, I'm just going to go with a 4. I: Okay. Which, I'm just gonna remind you exactly what 4 means [R: mm-hm]. Um . . . 4 is somewhat surprised. [R: mm-hm, yeah] Perfect. And how likely or unlikely? This is change without therapy. R: mm-hm. Unlikely. I: Okay. and how important to you? R: mmm. I'm like stuck in the middle (laughs). I liked being avoidant though. (laughs). No, it's 5. [I: really?] Yeah, yeah, yeah. 'Cause yeah. I: 'Cause there's a difference between doing the same thing with, with like as avoidance or as a choice [R: Exactly, yeah]. Yeah. So, um, I use food to cope with stress. Called it food-coping on this list. I was like, how was it worded? (Both laugh). this was at a 5 and so it has gone down significantly. [R: mm-hm] Um, how expected or surprising is this one? R: Ah, quite surprising actually. 5. [I: 5?] Yeah. [I: and] I, I'm just going to qualify to say that like part of what's surprising is that, is that it hasn't, some of the [I: mm-hm] behaviours changed but how I view it has also changed [I: yeah]. Like that's part of what makes that one so surprising. INTEGRATING EGO IDENTITY WITH LI THERAPY 513 I: Less about coping. [R: mm-hm] Yeah. Kay. Um, and how likely to unlikely was this without therapy. R: tsk. Um, I'm going to say 2, so still somewhat unlikely. I: Mm-hm. How important to you? R: Mm. A five. [I: yeah] I think part of what's changed with that one is I experience less distress about using food [I: mm-hm] to cope too. There's kind of [I: mm-hm] that part of it. I: Yeah. The next one is I self-medicate my own pain with poor strategies. And this was from a 4 to a 1. [R: mm-hm] and how expected or surprising has that been? R: Um, this one . . . yeah, it's a 4. [I: kay] I had more hope for this one. (chuckles) [I: yeah] Or more expectation. I: More expectation [R: yeah] Um, let's just wish, right? [R: mm-hm] And how likely or unlikely do you see it without therapy. R: Oh, definitely a 1. I: Okay, what, and how important to you? R: . . . Um . . . Yeah, I'm gonna say a 5. Yeah. I: Kay. The next question is, is about, it's worded I don't accept my limitations slash weaknesses. And the change was from a 5 [R: mm-hm] to a 1. And, how expected or surprising is this one? R: Oh, the was definitely a 5. [I: okay] Very surprised. I: And how unlikely or likely without therapy? R: 1. I: How important to you? R: . . . Mmmm, I'm gonna say 4. I: Kay. Just to mix it up. No [R: exactly, (laughs)] I'm just teasing you. I know you're actually being really thoughtful about each one. Just looks too R: It's so funny too, because it's like, "Yeah everything is important, but yeah there are some that are slightly more important. INTEGRATING EGO IDENTITY WITH LI THERAPY 514 I: Right. Yeah, and that's where you can emphasize the slightly more because a 4 means very important [R: mm-hm, yeah] right? Moderately important. Like. They all obviously matter. [R: mm-hm] So 5 is extremely important. Um, the next one is worded, I have a tendency to think in all or nothing. And it was initially rated as a 5. R: mm-hm. Um, I would say it's quite surprising. So, 5. I: 5. And how likely or unlikely? R: It's so funny. I’m like, today I'm like reading that going, "I don't even remember what that means." I know I remembered what it means all week, like three days ago [I: mmhm], but today I'm like, that's really quite a difference [I: yeah]. Um, how unlikely or likely? um . . . Yeah, I'm gonna say one. I: Okay [R: yeah] And how important to you? It's this all or nothing business. R: Um . . . I, yeah, I'm like at a 3. [I: Kay] I don't know if I would have had the same answer a week ago, but… (laughs) [I: sure, yeah] …but today it's a 3. I: Yeah. And then the very last one, so, have hope, we're going to get done. I don't feel confident in my own opinions slash viewpoints was ranked at a 5 initially and a 1 now. How expected was that or surprised by that are you? R: Very surprised. 5. I: Kay. And how unlikely or likely without therapy? R: Very unlikely 1. I: And how important? R: 5. I: Kay. . . that brings us to the end of those questions. And . . . [R: excuse me] . . . Oh, gosh I'm supposed to ask you about the change in ratings. Um, tsk, so for each of these if you think the change in PQ ratings is accurate, you told me generally that this, that there was a shift [R: mm-hm] in kind of your range, but you're also bottomed out on these, most of these ratings this time [R: mm-hm]. Um, R: I don't know if I can answer that without actually going back [I: Yeah] because it's such a long time ago. I: I think . . . INTEGRATING EGO IDENTITY WITH LI THERAPY 515 R: Like specifically for each item it would be hard to answer. I: Yeah, I think if you're ratings had changed in the other direction it would be a bigger deal [R: mm-hm] to ask this. But, if you, like just eye-balling your list there and realizing that those are represent [R: mm-hm] fairly dramatic changes from, and we just went through them. When you look at that, are there, do you feel that it's accurate? That it went from the ratings, you know you varied from there was one that was little, 3 that were moderate, most of them bothered you considerably [R: mm-hm] and two very considerably. Is that, as you recollect, do you feel like a fair reflection of where you were and where you are. R: yeah. I do actually, [I: okay] Yeah. Yeah, I think what probably has changed . . . not so much my ratings, but, and I mentioned this about the food one [I: mm-hm] um, is that my experience of distress [I: mm-hm] at the same behaviour [I: Yeah] has gone down. Like the behaviour may not have changed [I: yeah], but I view it differently [I: mm-hm] and I don't see it as being as, for some of them [I: Yeah] like some of them, like number 5 - I have trouble feeling present in the moment. That is a very [I: It's more objective] It's more objective [I: yeah] And that has gone from like I know even on there I was like a 5 [I: you were a 4 on here] A four. But there's was days where it was a 6 or a 7 [I: mm] And I haven't gotten to a 6 or a 7 for quite a while [I: mm-hm] So, that one definitely was like, yeah, that's gone. phew. [I: mm-hm] I have way more 1 days than I've ever had [I: hm] Um, so, which is true of a number of them, right? [I: yeah] Where it's . . . very clear. I: Um, the other thing I was supposed to ask you when we're including them on the PQ, on your change list is just, what do you think the changes mean. [R: mm-hm] I think you have actually as we went through it, you've elaborated [R: mm-hm] for example this one, [R: right] like, behaviour was this, maybe I eat good, like food I would have used to eat to escape, but it, it's a different [R: mm-hm] relationship now. Are there any others that you feel would benefit from just naming [R: Right] how you understand the change as you look through there? R: Um . . . I think I was, the number 9 I'm stuck in an avoidant pattern [I: mm-hm] which will be different on the change list, but, um, I think that again, and maybe I did mention it already, like sometimes [I: mm-hm] I'm taking a break, I don't automatically see that as avoiding [I: yeah] kind of thing. I: So same activities can be intentional now. R: Mm-hm [I: yeah] Yeah. And yet, yet there still is also, there's this objective piece too where I would like . . . like get stuck . . . I would for example be doing a puzzle and I'd think, "Okay, I'm going to do this for an hour and then I'm gonna go back to work." And then I'd be like, panicked, because I can't, like I can't stop it, I can't go back to work. So INTEGRATING EGO IDENTITY WITH LI THERAPY 516 there's both and [I: mm-hm] So that behaviour has totally gone, well not totally gone away, it comes back every once in a while, but [I: mm-hm] that sense of panic at not doing the activity [I: right, yeah] has decreased quite a lot. But then I also don't see every break as avoidance as well [I: yeah] And I'm more compassionate [R: mm-hm] with myself if I'm like, "No I don't want to stop quite yet. [I: mm-hm] Okay, we'll do it for a little while longer. [I: Sure] Um, I think it's same for number 7 - I self-sabotage my own goals [I: mm-hm]. Um, I'm, I was kind of at the beginning very like, strict that these are my goals for today [I: Ahh] And I have to get them done and so any kind of break from them or change in my goals or anything like that. I: yeah, you're allowing yourself more freedom [R: Yeah] in the moment now, maybe. R: Exactly. Yeah so, I don't see it as this like, stringent [I: mm-hm] group of goals and then I, anything that diverges from that [I: mm-hm] is self-sabotage. [I: yeah] Um, I think those are the main ones that had a lot of [I: kay] a little bit of nuance in how I view them. Yeah. I: Then, I think officially our follow-up change interview is done. R: Whoa. (laughs) INTEGRATING EGO IDENTITY WITH LI THERAPY 517 APPENDIX T25 Affirmative Case Brief POSITION: Affirmation of evidence of client experiencing change in ego identity fragmentation and of these changes occurring due to LI therapy work. EGO IDENTITY:      Self-organizing mechanism Personal: A sense of internal coherence across a lifetime. Social: A contextually appropriate and understandable social presence within the social sphere which enables group belonging and effective interactions with others. “feeling of being at home in one’s body, a sense of ‘knowing where one is going’, and an inner assuredness of anticipated recognition from those who count,” (Erikson, 1968) “the sense of one’s self as a continuous entity or agent, in a variety of contexts, and over the passage of time” (Côté and Levine, 2002) EGO IDENTITY:      25 Self-organizing mechanism Personal: A sense of internal coherence across a lifetime. Social: A contextually appropriate and understandable social presence within the social sphere which enables group belonging and effective interactions with others. “feeling of being at home in one’s body, a sense of ‘knowing where one is going’, and an inner assuredness of anticipated recognition from those who count,” (Erikson, 1968) “the sense of one’s self as a continuous entity or agent, in a variety of contexts, and over the passage of time” (Côté and Levine, 2002) As existing documents compiled during data analysis, the affirmative and skeptic briefs and rebuttals included here do not follow APA formatting but are presented exactly as was provided to adjudicators. INTEGRATING EGO IDENTITY WITH LI THERAPY 518 EVIDENCE AND ARGUMENTS: CLIENT EXPERIENCED CHANGE: Improvement in long-standing problem areas: PQ Item Ratings:  Out of 15 PQ items, 13 demonstrated significant change (decrease of 2+ points) over the course of therapy - #1-7, 9-14 (RCR p. 347-348).  Of these 13 items, 10 of them have been areas of distress for Rose for over 10 years (#1-4, 7, 10-14; see RCR p. 271).  The remaining 3 have been areas of difficulty for Rose for between 6-10 years (#5, 6, 8, 9; see RCR p. 271). Journals:  November 9 (RCR p. 251): Rose reports the absence of emotional arousal and dissociation in the presence of a familiar trigger (someone speaking about trauma). Session Notes:  In session 25 (RCR p. 315), Client described the experiential processing of grief – more than simple cognitive acknowledgment. Evidence of ego identity change PQ Items:  Significant change in mean ratings over therapy in items #1(‘I feel shame about who I am and who I've been.’ – mean decrease of 4.8), #3 (‘I feel I don't belong.’ – mean decrease of 3.6) and #5 (‘I have trouble feeling present in the moment.’ – mean decrease of 2.2) indicate a shift in ego identity. Journal:  the ability to stay present in a previously experienced overwhelming scenario or dissociation, and her ability to coach herself through remaining present through the event.  January 23 (RCR p. 353): Rose depicts a sense of core identity being formed. A “ME” starting to emerge. The image on this page depicts a significant change in Rose’s relationship to self as evidenced by centering herself in relation to anxiety - from being hounded by anxiety to a self that is in control of anxiety.  February 21 (RCR p. 355): A different iteration of the same theme as the January 23 journal – the emergence of “ME”; a new groundedness and centering of self; a new relationship with inner turbulent emotional experience of the world. INTEGRATING EGO IDENTITY WITH LI THERAPY   519 Sense of core identity is clearly displayed in the journal entries provided in the rich case record. February 10th (RCR p. 354): Rose describes a new relationship to self as evidenced by her first experience of embodiment – “I am my body.” Session Notes:  In session 9 (RCR p. 290), Rose clearly refers to ego identity change when describing an emerging “me” – “It was a first conscious realization that a defined ME was emerging/had emerged.”  In session 25 (RCR p. 314), therapist and client both describe an integration process – T: “…. you are her, she is you,” / R: “since she is me, she is not really lost – she is recoverable. I can bring her back again. Everything that she was is still within me and therefore can be a part of who I am once again.” Additionally, this session demonstrates the experiential processing of grief – more than simple cognitive acknowledgment.  In session 28 (RCR p. 319), Mirrored content in client and therapist notes on session. Rose finds her voice; she can speak up which is the opposite of the voicelessness evident in other therapy sessions (e.g. session 26, p. 53).  In session 31 (RCR p. 323), a pivotal session in which Rose, for the first time, can speak directly to her mom in her imaginal interaction, again demonstrating the use of voice in relation to family.  In session 31 (RCR p. 323), Rose describes going through the timeline as a cohesive unit with her younger self; made use of ‘we’ language indicating that older and younger self experienced the timeline event together.   Videos/session notes: October 11 video clip/Session 19 notes (RCR p. 305): Both 11year-old Rose and adult Rose share a desire to go home to Mexico. Adult Rose describes, “I want to go home…. never before have I admitted that I wanted to go home”. This is another example of the opposite of voicelessness indicating the presence of a distinct self. [Researcher notes: Additionally, this indicates integration of personal qualities of younger self and older self in recognizing or reclaiming a cultural past (Mexico) as ‘home’.] INTEGRATING EGO IDENTITY WITH LI THERAPY 520 CHANGE DUE TO THERAPY: Client attribution. Client specifically attributes change to the therapy process. (Change X is explained by therapy process Y. Change X would clearly not have happened without therapy.) Change Interview:  Quantitative ratings (RCR pp. 338-349). Rose rated most of the changes she experienced as surprising and as unlikely without therapy. By the follow-up interview, changes reported were all rated as either very unlikely without therapy (1) or somewhat unlikely without therapy (2) with the majority receiving a rating of 1. Session Notes:  Session 18 (RCR p. 303): Therapist reports that Rose shared that “others have indicated to her noticing her joyfulness”. It is implied in reporting this that Rose is then attributing this new level of joyfulness to the work being done in therapy.  [Researcher note: Rose further elaborates on the attribution of newfound joy in the post-therapy change interview (RCR p. 448) – “R: … I think maybe this is where that joy came from that other people noticed ….there's a ME in it. / I: There's a ME in what I do? [R: Yeah.] More ME. [R: Yeah!] / R: A continuous ME even.”] Session Notes/Client HAT/Therapist TSNQ form:  Session 2 (RCR p. 280): Rose reports her first real connection with baby self – being able to envision herself as a two-week old baby and to realize that she truly was once that young.  Session 6 (RCR p. 286): Rose reports a very important event in session was her own realization that her 7-year-old self is her and exclaiming in session “She is me!” .... “Not just the declaration that my 7-year-old self is me, but the process of discovering this, coming to this realization – through my interaction with her in the timeline. Seeing how much my 7-year-old self and I had in common …. it was like discovering a ‘kindred spirit’ and realizing that person is YOU. Not odd, weird, bizarre but beautiful, full of life, joy, wonder.”  [Researcher note: Session 6 therapist TSNQ also records, “The client reported (after 4 repetitions) that she felt she was the same person as her 7-year-old self…feeling as if she has ‘merged’ her younger and present-day self.”] INTEGRATING EGO IDENTITY WITH LI THERAPY 521 Process-outcome mapping Client describes helpful aspect in therapy clearly linked to the post-therapy changes. (High client helpful event rating and linked post-therapy change.) Session Notes:  Sessions 2 & 3 (RCR pp. 280-283): In session 2, Rose was able to envision and experience herself as the two-week old which she rated as greatly and extremely helpful/important. This was followed by a client report of experiencing a moment in between session 2 and 3 where “[Rose] knew and felt the worth of her baby self as precious.” The processes in session 2 seem to have led to this new realization for Rose.  Session 4 (RCR p. 283)/see also video clip from this session: Rose held her baby self in session and said, “She’s so beautiful!” She rated this event as extremely helpful/important (9). Evidence of acceptance of past self.  Session 26 (RCR p. 316): the younger self feeling reassured that she was not alone and that someone was coming for her – “I’m okay. [Adult] Rose is coming.” Journals:  January 23 (RCR p. 353): picture, different relationship to fear, opposite of voicelessness, drawing depicts an overcoming of voicelessness  [Researcher note: Related post-therapy changes are evident in reported general changes and significant PQ rating changes as listed on pp. 346 and forward. In particular change items #: 3, 4, 8, 11, 13, 14, 15, 21, 23.] Researcher additions:  Session 6 (RCR p. 286): integration of 7-year-old self with present-day self rated between greatly and extremely helpful/important (8.5).  Session 20 (RCR p. 306): TSNQ – Rose apologizes for silencing younger self. Therapist reports this as greatly to extremely helpful/important (8.5) as “the client continued to connect with a part of herself that she felt she had silenced or not allowed to express itself following the return to Canada.”  Session 22 (RCR p. 309): Rose describe “an intimate and precious time” between herself, little Rose and therapist; “for me to hear the therapist’s words to little ME – welcoming, kind, tender, loving – and her description of adult ME to little ME was ‘heart-expanding’. The therapist was seeing and responding to a part of me that hasn’t been seen in a very long time,”.  Session 27 (RCR p. 317): Rose rating as extremely helpful (9) the interaction between her terrified 11-year-old self and her adult self because, “it distinguished INTEGRATING EGO IDENTITY WITH LI THERAPY   522 what belonged to the 11-year-old and what belongs to the adult me….I can now see how the terror, panic, anxiety isn’t’ my adult-self responding to the world around her, but is the response of a terrified, abandoned, lonely, isolated young girl.” TSNQ – Therapist reports integration as occurring between adult and child self – “Reassured her child self ‘we are 45 now’ and ‘we have choices now’.” Related to post-therapy change items (RCR p. 346): 3, 4, 5, 8, 11, 13, 14, 16, 17, 18, 21, 23. Session 4 (RCR p. 283): Therapist and Rose rate as extremely helpful/important (9) Rose holding baby self and “bursting out with ‘She’s so beautiful!’. Later in session 6 (RCR p. 286), Rose rates as greatly to extremely helpful/important (8.5) finding a ‘kindred’ spirit in her 7-year-old which she describes as beautiful. At follow-up change interview (RCR p. 328 & p. 464), Rose struggles to say it out loud but describes her present-day self as ‘beautiful’. Data-event relationship Evidence of a relationship between in-session therapy processes and weekly client changes as demonstrated in daily PQ data and in-therapy processes. (Helpful therapeutic exploration of a difficulty followed by change in that difficulty the following week.) Session Notes and related PQ Ratings:  Session 6 (RCR p. 286): There is an emergence of voice in response to her dad – I needed my dad hear say something – therapist helped. This session is followed by a decrease in many PQ item ratings (see also Appendix A - provided electronically separate from RCR).  Session 25 (RCR p. 314: working with 11-year-old self. Therapist records, “this was the first time when client ‘felt’ integrated, as if parts had come together at the end instead of apart,” – experience of ‘I am her, she is me’. Many PQ ratings showed a marked spike at session 25 and then a decrease in PQ item ratings between session 25 and 26 (see also Appendix A - provided electronically separate from RCR). Researcher Addition (possibly evident in expert argumentation which mention session 22 which was followed by an increase in PQ ratings, but uncertain due to mix-up on session dates of recorded HAT responses – see further explanation on RCR p. 306):  Session 20 (RCR p. 306): Adult Rose offers comfort, reassurance and care to 11year-old self that feels “crushed” by the responsibilities of Canadian life. Therapist reports that integration and repair happened during session. Many PQ ratings showed a marked spike at session 25 and then a decrease in PQ item ratings INTEGRATING EGO IDENTITY WITH LI THERAPY 523 between session 20 and 21 (see also Appendix A - provided electronically separate from RCR). Event-shift sequences Change occurs in close temporal proximity to a helpful therapy event demonstrating a clear connection between shifts in problematic areas and therapy processes. (Important therapy events are followed by a shift in thoughts, feelings, behaviours.) Client HAT form:  Session 6 (RCR p. 286): Discovering her 7-year-old self as a “kindred spirit”.  Session 9 (RCR p. 290): Rose was sharing some shifts she had noticed occurring between session 8 and 9 and described this as, “I showed up!” Rose also described this in session moment as the “first conscious realization that a defined ME was emerging,” which she rated as extremely important/helpful (9).  Session 29 (RCR p. 321): Both therapist and Rose rated as extremely helpful/important (9) that Rose can both tell the truth about her pain and hurt and love her mom and dad at the same time. Session Notes:  Session 30 (RCR p. 322): Both therapist and Rose rated as greatly to extremely helpful/important (8.5-9) that Rose is not being responsible for mom’s feelings. IMPACT: All of these reflect a change in Rose’s thought patterns towards self, as well as her perceptions and feelings towards her emotions. EVENTS/PROCESSES: Attunement Protocol:  [Researcher Note - I think there was some confusion between attunement protocol and standard protocol within the affirmative team, so this point is unclear in case development notes but is implied and appears clearly in rich case record data: Established a strong attachment relationship between client and therapist right from the start of therapy which Rose reported as being particularly helpful/important in HAT (RCR session 27, p. 317) her mid-therapy change interview.]  Also established a baseline for dialogue between adult and younger self in creating safety and security within the therapeutic context. Standard Protocol:  Helped develop a dialogue between the adult self and younger parts of self. INTEGRATING EGO IDENTITY WITH LI THERAPY    524 Imaginally addressing needs of younger selves brought about change as evidenced in the change interview. The therapist coaching internal dialogue between adult and younger self (ego state dialogue); giving different parts the words to say to address needs in the source memory or in the present-day encounter. Change occurred because of the process of going back to heal younger selves in timeline. LI Time Line:  The LI Time Line was the tool used to help get around a block, deal with unresolved material, to help the client to see it differently. Over numerous repetitions positive change always resulted from Time Line work.  Time Line is distinctive from conversation about or talk therapy.  Rose also mentions the importance of bringing past selves into the present using the LI Time Line (p. 328). It ‘unstuck’ younger parts of self and allowed them to move on and integrate with present day self.] Posturing of the Therapist:  The therapist was an attuned attachment figure for the client throughout therapy.  The therapist was not frazzled by interruptions but instead leaned into ‘glitches’ in the LI process and into unresolved content/’stuff’. Client therefore felt free to share when these things came up and did not feel a need to hide them. Therapist also felt free to address difficult content; challenge the client when appropriate.  Speaking in colloquial terms, not buzz words or key terms, reflects a personal connection between Rose and the therapist. See change attribution and other qualitative data from change interviews. INTEGRATING EGO IDENTITY WITH LI THERAPY 525 APPENDIX U Skeptic Case Brief POSITION: Against evidence of client experiencing change and/or change in ego identity fragmentation, or for these changes being due to contextual matters apart from LI therapy work. EGO IDENTITY:      Self-organizing mechanism Personal: A sense of internal coherence across a lifetime. Social: A contextually appropriate and understandable social presence within the social sphere which enables group belonging and effective interactions with others. “feeling of being at home in one’s body, a sense of ‘knowing where one is going’, and an inner assuredness of anticipated recognition from those who count,” (Erikson, 1968) “the sense of one’s self as a continuous entity or agent, in a variety of contexts, and over the passage of time” (Côté and Levine, 2002) EGO IDENTITY:      Self-organizing mechanism Personal: A sense of internal coherence across a lifetime. Social: A contextually appropriate and understandable social presence within the social sphere which enables group belonging and effective interactions with others. “feeling of being at home in one’s body, a sense of ‘knowing where one is going’, and an inner assuredness of anticipated recognition from those who count,” (Erikson, 1968) “the sense of one’s self as a continuous entity or agent, in a variety of contexts, and over the passage of time” (Côté and Levine, 2002) INTEGRATING EGO IDENTITY WITH LI THERAPY 526 EVIDENCE AND ARGUMENTS: CLIENT EXPERIENCED CHANGE:  Agreement that data supports the client having clearly experienced important and significant change over the course of therapy. Evidence against experiencing ego identity change: Nonimprovement: Negative change: decline in functioning; increase in symptoms. Trivial or irrelevant: client ambivalence; dubious nature of change; change is unimportant/insignificant.     Change is irrelevant to research question regarding ego identity change in a TCK as evidence is more accurately reflective of an acceptance of self, acceptance of life change and post traumatic growth. Rose reports several PQ items (RCR Table 6) that changed in meaning of ratings to reflect more acceptance of the behaviours which decreased levels of distress rather than change in sense of self. Even if data demonstrates some degree of integration of ego identity, it does not specifically address the cultural elements of integration that are necessary and unique for TCK identity consolidation. Integration of cultural self would have been more thoroughly achieved had the therapist been more conversant in TCK issues and therapy been more focused on integration with Mexican self. 2 PQ items did not change significantly, and one changed negatively. Statistical artefact: Errors in measurement. Regression to the mean. Experiment-wise error.    Insufficient data specifically targeting repatriation experience and integration with 11-year-old self or Mexican self to qualify whether TCK elements of ego identity have been resolved. The cultural piece of integration is missing and as such the TCK integration piece appears to be incomplete. All data collected is based on self-report measures, including experiential data. Lacking the presence of outsider perspectives and/or objective assessment measures to verify the validity of client self-reports regarding change and ego identity change. Sessions 18-24 (pp. 303-314): evidence of relational disruption during sessions focused on therapy content surrounding repatriation and 11-year-old self that coincides with a decrease in HAT ratings. Reflective of Rose’s need to stop the therapy process to explain the TCK experience to the therapist which reflects a disruption in attunement within the therapeutic relationship. INTEGRATING EGO IDENTITY WITH LI THERAPY 527 Relational artefact: Client’s desire to meet therapist expectations (people-please). Interpersonal dynamics between therapist and client. (“Hello-goodbye effect: emphasize distress at the beginning, positive functioning at the end.)  Sessions 18-24 (RCR pp. 303-314): evidence of relational disruption that coincides with therapy content surrounding repatriation and 11-year-old self that coincides with a decrease in HAT ratings. Reflective of Rose’s need to stop the therapy process to explain the TCK experience to the therapist which reflects a disruption in attunement within the therapeutic relationship.26 Researcher additions:  Session 6 (RCR p. 286): Rose reports struggling with perfectionism and expresses a desire to be a ‘good client’, ‘get it right’, ‘follow the rule’. She rated this as slightly to moderately hindering in her interactions in with the therapist in session.  Session 12 (RCR p. 294): Rose reports a belief that she is “failing at LI therapy – that [she] was doing something wrong.” This indicates a desire to please the therapist and ‘do therapy right’. Expectancy artefacts: Client’s wishful thinking and expectations of change. (Client tries to convince self and others that change has occurred when it has not.)   26 Rose has a dual role in being both the client for this project and acting as primary researcher. As such she is fully aware throughout therapy that this data was collected for use in her thesis project. This reflects a certain level of expectation that therapy will produce change in ego identity fragmentation otherwise her thesis would not be a viable project – if she didn’t believe it had the potential to effect change she would have chosen a different therapy technique or a different project all together. Rose is also being trained as an LI clinician which demonstrates her belief that this therapy intervention is capable of effecting change in clients. If she didn’t believe the therapy to be effective, she would not be investing time and finances in being trained to use it. This argument was unclear and appeared under both statistical and relational artefacts in the skeptic team notes. Clarity was sought from note-taker as this relational disruption would appear to better support the affirmative team argument against relational artefacts. As much details as possible was provided here. Despite lack of clarity on this point, it still seemed important to include it in the skeptic case brief. INTEGRATING EGO IDENTITY WITH LI THERAPY     528 Rose’s rated level of surprise at changes experienced is suspect – she rated almost all changes recorded in all three change interviews (mid-therapy, post-therapy, and follow-up) as either somewhat or very much surprising. This is suspect as she should have known that changes would have occurred, especially in relation to PQ items, otherwise why was she undergoing therapy and why did she select these items to include on her PQ? Rose mentions in a personal journal (February 27, RCR p. 356) that, “I think I got used to this pattern of surprising changes that I expect it now as evidence of growth through LI.” Indicative of a pattern where starting off by being surprised at change draws you into looking for more surprises. Rose consistently reports at least one (if not two) greatly to extremely helpful events (rated between 8-9) in each therapy session. This level of optimism can build momentum in therapy that leads to further expectation of positive change. Rose makes reference to comments made by others regarding changes they have noted within her, however, especially in relation to her friend Kristin and Vanessa, it is unclear whether these friends would have noticed any change had they not been primed by Rose in having her pointing them out beforehand. CHANGE DUE TO THERAPY: Self-corrections - self-generated return to baseline: Change reflects the client’s ability to help themselves and self-correct. (Temporary initial state of distress or dysfunction. Reversion to normal baseline through client’s own natural corrective or self-help processes. Change would have occurred with or without therapy.)    Rose began training as an LI clinician prior to entering therapy and therefore, due to experiential nature or LI training, began her LI therapy journey before data collection for this project began. As such, entering official LI therapy is consistent with a narrative of self-help in which the client was motivated to create own change. This type of personal narrative or inner script of continuing change could account for between session shifts which represent most of the client change. Mid-therapy Change Interview – change item #15 explanatory evidence (RCR p. 338): Further evidence for this self-help narrative is found here as Rose expresses uncertainty and fear regarding reaching her therapy goals. This demonstrates a high degree of investment in achieving her goals and an assessment that they are yet unmet. This fear would lead to an increase in motivation to see change occur and even to make change happen which would be considered self-correction or self-generated change. Rose took the tools that were being built in therapy session and used them on her own between sessions. This is reflective of a typical TCK pattern in which they INTEGRATING EGO IDENTITY WITH LI THERAPY  529 learn to do things on their own as they are never completely understood by others. Issues may have been stirred up in therapy but then Rose was pulled into the TCK pattern of pulling away from the attuned relationship to not burden anyone else and assume full responsibility for self. There is evidence of Rose exemplifying this pattern in “finding it extremely uncomfortable [taking] in the therapist’s delight in her,” (session 21 therapist notes, RCR p. 308). Therapist also noted in the next session, “possibility that last session (therapist sharing her delight) might have felt too much for the client and activated some defences,” (session 22 therapist notes, RCR p. 309; session 32 client HAT, RCR p. 325). The emergence of evidence of cultural reclaiming for Rose – seeing Mexico as home and acknowledging a longing for home - only appears over 2 weeks after therapy had ended (March 19 journal, RCR p. 357). This would seem to indicate this process was self-generated and not related to therapy session work. Extra therapy events (positive life events): Change is due to extra-therapy (or outside therapy) life events.      While formerly being quite isolated from the TCK community, for the past 3 years Rose has been employed part-time with a non-profit organization that works specifically within the TCK community. Within this position she has had opportunity to build relationships with other TCKs including her boss and other coworkers. The introduction of this new community focus could account for the resolution of elements of Rose’s TCK experience. Rose is currently completing her studies in her master’s in counselling psychology which has her immersed within a highly intuitive and psychological conversant community of peers. This context and her interactions with members within this community during therapy could account for the significant shifts experienced outside of therapy sessions and therefore these cannot be reliably attributed to therapy processes. Distance from family of origin (live several provinces away from each other) would account for decreases in levels of distress; distancing from triggers produces decrease in distress. Thesis process: In compiling her literature review on TCK issues and patterns Rose was primed for change during therapy. Rose did not include a PQ item that demonstrated substantial change (decrease of 2+ points) in her list of change items at mid-therapy change interview as she was unsure whether the decrease in ratings was reflective of true personal change or reflective of different circumstances over the summer months (not being in classes and interacting with peers as much). If this was true of one item that Rose was INTEGRATING EGO IDENTITY WITH LI THERAPY   530 aware of, this same dynamic could be at work in relation to other change items that demonstrated significant change but of which she was not consciously aware. Ethics project on individualist vs collectivist communities and discovering familial collectivist relational patterns that could have impacted change.27 Crisis course28: first few lectures in January focused on ‘acceptance of suffering’ – not fighting or wrestling with it but changing one’s perspective - which would account for pattern of acceptance of self and current situation as evidenced in explanatory comments of change items from post-therapy and follow-up change interviews (RCR pp. 343-348). Researcher additions – I know these were mentioned in discussion by the skeptic team but didn’t appear in the notes provided so they are being added here:  TV shows: Rose reported the obsessive watching of two different TV shows that seemed to ‘meet a need’: a) therapist notes Session 24 (RCR p. 313); b) March 9 journal entry (RCR p. 357). These shows were watched repeatedly for several weeks at a time during therapy and could explain many between session shifts in serving a therapeutic purpose in and of themselves. Psychobiological causes: Change is due to adjustments in medication or physical health changes.  Increase in anxiety medication dosage (Pristiq – 50mg to 100mg) which occurred just prior to mid-therapy change interview would account for pattern of decrease in PQ ratings between mid-therapy and end of therapy (see RCR figures 2 and 3, and RCR Appendix A results provided in electronic form separate from rich case record.) 29 Reactive effects of research: Change is due to the client’s desire to produce positive results for use in this research project. (Effects of research activities - e.g., assessments, interviews, etc. Relations with research staff. Sense of altruism.)  27 Client is also acting as primary researcher and this data is being used towards the completion of her thesis as part of her MA in Counselling Psychology program. Researcher note: While this point is true and Rose did complete this project and make these discoveries, I was unable to find reference to it in the rich case record and therefore no page number is provided. 28 Researcher note: While there is no evidence of this within the rich case record data, the Crisis course instructor was a member of the skeptic team and therefore had insider knowledge of class content. 29 Dosage adjustments in SNRI medications such as Pristiq generally take about 6 weeks to manifest in noticeable changes in behaviours, feelings, and thought processes. INTEGRATING EGO IDENTITY WITH LI THERAPY  531 Additionally, client/reflexive researcher is currently undergoing training as an LI clinician which demonstrates her investment in this therapy intervention. This creates a conflict of interest which could lead to a propensity to overestimate the positive outcomes of therapy within the data being collected. Recruitment of self as project client can be construed as manipulating the project parameter in order to produce positive research results. EVENTS/PROCESSES:  Uncertainty as to whether the two ‘I ams’ – the Canadian and Mexican selves – integrated due to the therapy process. There is evidence in journal entries and change interview that these connections were made but it did not show up in session notes, HAT reports or TSNQ reports. Therefore, this change cannot be reliably attributed to LI therapy processes.  The therapist did not appear to fully understand the unique nature of the TCK experience and Rose felt the need to educate the therapist on repatriation being a process and not a single event. If the therapist had been more conversant in TCK issues and experiences, then the TCK theme could have been more drawn out and a fuller change in TCK issues achieved. INTEGRATING EGO IDENTITY WITH LI THERAPY 532 APPENDIX V Affirmative Rebuttal SKEPTIC ARGUMENT AFFIRMATIVE REBUTTAL EVIDENCE AGAINST EGO IDENTITY CHANGE: NONIMPROVEMENT  Having PQ items that didn’t change significantly and one that changed negatively speaks to credibility of the data set and data collection process. Because the PQ was quite broad with many items this small set that did not change positively does not reflect nonimprovement.  These PQ items also reflect unanticipated effects and items that were not quantifiable in a way that could be easily worked with. Researcher additions:  Do not contest the presence of greater acceptance of behaviours impacting levels of distress. Disagree that this is concrete evidence that ego identity change is not occurring as acceptance evidence is minimal given the larger scope of project data. Additionally, it does not impact ratings of PQ items directly related to ego identity #1(‘I feel shame about who I am and who I've been.’ – mean decrease of 4.8), #3 (‘I feel I don't belong.’ – mean decrease of 3.6) and #5 (‘I have trouble feeling present in the moment.’ – mean decrease of 2.2). STATISTICAL ARTEFACT    Agree that different experiential measure (e.g., sand tray) would have enhanced the available data set and been helpful in evidencing ego identity change in particular. However, HSCED methodology privileges client’s authority in determining progress and providing evidence of change. It is not unusual for other voices of knowledge to not be present in HSCED studies, but this does not undermine the evidence that is available. Blips in PQ data over the course of therapy evidence of client honesty and reflective of normal client questioning as to whether this is sustainable, or real. INTEGRATING EGO IDENTITY WITH LI THERAPY 533 Given that data was being collected on a human subject, a perfectly clean data set would be cause for skepticism.  The explanatory evidence for changes in PQ ratings were reasonable and believable during 10 months of data collection.  This is additional evidence of Rose not attempting to be the ideal or perfect client but being genuine and authentic within her therapy journey. Researcher additions:  There is no claim within this project that TCK ego identity integration has been completed nor that all TCK issues have been resolved. As such, the skeptic team’s observation that TCK integration piece appears to be incomplete is valid. Therapy was not terminated because goals were fully achieved but instead because there was a need to end data collection for this project. The desire within this project is only to provide probabilistic evidence that change in ego identity fragmentation experienced by an ATCK can be achieved through LI therapy. This does not require that the process be complete.  Cultural elements of TCK experience may not have been overtly addressed in session, however, in working with 11year-old self at time of repatriation, and younger selves who lived in Mexico, LI therapy is allowing for neural integration of life experiences in Mexico with who the client is now, including cultural pieces. One particular piece of evidence in this regard is Rose’s use of a special pen with her heart journal she is keeping with her friend Vanessa and Kristin (book is briefly mentioned in therapist notes for Session 26, RCR p. 316). Rose chose to write in this journal the way the Mexican kids used to write. They would tape two pens together (a blue and a red pen) and would write all capitals and punctuation in red and everything else in blue. This always fascinated Rose as a child in Mexico and she always wanted to try it. So, she was reclaiming that cultural memory and putting it to use in a present-day experience.  INTEGRATING EGO IDENTITY WITH LI THERAPY RELATIONAL ARTEFACT 534  Neural integration of cultural elements of TCK experience is also evidenced in March 19 journal entry (RCR p. 385).  Session 12 (RCR p. 294): Rose’s concern with failure is more an indication of the prevalence of her ‘fear of failing at life’ (PQ item # 4). It would be shady if this were not to show up. This is also a common and normal experience for clients – fear that they are not ‘doing it right’ – in particular not being able to follow the therapist instructions and do what is being asked of them (session 12, RCR p. 294). Researcher additions:  Session 21-22 (RCR pp. 308-311): Disruptions experienced in the therapeutic relationship are evidence that the client was not attempting to people-please but was willing to disagree with or question the clinician and address difficult content.  Not all comments by peers were prompted or primed by Rose. For example, comments about her joy coming through and Rose coming into her own (RCR p. 303) were completely spontaneous comments by other peers (not Vanessa or Kristin). At least some changes, therefore, were readily visible to others. EXPECTANCY ARTEFACT   Positive expectancy is encouraged in therapeutic practice and is definitely a factor in all therapeutic change. Agree that having the dual roles of both researcher, LI clinician in training, and client has the potential to impact how therapy is received. However, instead of making it easier it would actually make it harder for Rose as the therapy has lost some of its magic as an insider. INTEGRATING EGO IDENTITY WITH LI THERAPY 535 As a trained LI clinician, Rose is likely to be more skeptical especially when LI protocols are not followed precisely.  As a trained LI clinician, Rose know what is happening during her LI sessions, the theory that lies behind the therapy and how it effects change. The fact that Rose rates her changes as highly surprising is all the more meaningful and significant given this background.  Rose had been in therapy for 10+ years with the hope that these same issues would be addresses and experience change. Rose would arguably be more skeptical of change happening having been disappointed so many times in the past. LI therapy is the first time she was not disappointed.  LI therapy is designed to work implicitly, and integration is expected to continue in between sessions and often show up in ways that clients do not expect or anticipate. The neural integration occurring often shows up in unexpected and sudden changes in behaviours, thoughts and feelings. As Rose describes it in her January 23 (RCR p. 353) journal entry, “And the shock – the unbelievability that this change or at least my conscious awareness and experience of it – has happened THIS WEEK!! It just sort of all of a sudden – WAS – and was surprising, unexpected, even unsettling in its appearance.” Researcher addition:   Mid-therapy change interview item #15: Rose expresses uncertainty and fear about reaching goals. Further evidence that change is not produce merely through wishful thinking. CHANGE DUE TO THERAPY: SELF-CORRECTION  LI therapy is an implicit process involving neural integration processes whereby change works itself over time as the brain reorganizes. As such, it is not reasonable to declare that anything that happens outside of the 1-hour therapy session is not due to therapy processes but is due to client self-help efforts.  Rose’s expression of uncertainty and fear regarding reaching therapy goals implies that she is not in control over whether change occurs which would indicate that it is not due to self-help efforts. INTEGRATING EGO IDENTITY WITH LI THERAPY 536 As clinician we expect and desire our clients to take the tools presented in session and make use of them in the outside world (good therapy homework practices). The fact that Rose had these tools to use is attributable to therapy.  TCK pattern of pulling away from others and shouldering responsibility for self all on their own is not generalizable to all TCKs. (see further evidence below in researcher additions). Researcher additions:  Evidence would seem to point to Rose not pulling away from researcher attunement and in fact reaching out for an accepting help from the therapist and other members of her support community so as NOT to carry her burdens on her own: March 9 journal (RCR p. 357) Rose is grieving loss of the therapeutic relationship (a new pattern) and describes an intimate and personal relationship with the therapist; August 11 and February 10 are just two examples of texting conversations in which Rose reaches out to share, be seen and known, by her friends Kristin and Vanessa.  By the end of therapy Rose is better able to tolerate the therapist’s delight in her. Staying with the therapist’s positive affect towards her Rose described as a “difficult but a good type of challenge” (RCR p. 326).  EXTRA THERAPY EVENTS    At the time of therapy start, Rose had been existing within the TCK and counselling intensive school community for 2 years with no discernible change. She had also consistently been involved in personal therapy with other clinicians within these contexts What had changed was the type of therapy she was receiving in now receiving LI therapy. In confronting difficult family dynamics and family rules in therapy, Rose expresses experiencing greater levels of family tension despite the geographic distance (midtherapy change interview). Rose had not completed her thesis and was merely at the starting stages of collecting data and putting together her proposal during therapy. She hadn’t even hit was is typically the most stressful part of the thesis journey. INTEGRATING EGO IDENTITY WITH LI THERAPY   537 Crisis course: A couple of classes on acceptance of suffering would not have such a significant impact on a client who has been in therapy for 10+ years and had heard these concepts before. Changes in personal circumstances are inevitable and impact how we live and experience our lives, but uncertainty of accuracy of ratings for 2 PQ items at midtherapy is insufficient evidence of a skewed data set. Researcher additions:  Rose reported acceptance of behaviours during the midtherapy change interview which took place in August 2018. The crisis course began in January 2019. PSYCHOBIOLOGICAL Researcher additions: CAUSES  Do not contest the possible impact of medication adjustment to PQ ratings between mid-therapy and posttherapy change interviews. However, given that this is a span of 29 weeks, PQ ratings would be expected to plateau at a certain point if medication was the only variable effecting change. The fact that distress ratings continue to decrease throughout the entire course of therapy signifies that medication is not the sole cause of client change. REACTIVE EFFECTS OF RESEARCH  Recruitment of self: All clients voluntarily admit themselves to therapy and all research participants do so on a voluntary basis. Reflexive research designs are well established academically. In both the client and researcher role, Rose was very diligent with all research protocols. INTEGRATING EGO IDENTITY WITH LI THERAPY 538 APPENDIX W Skeptic Rebuttal AFFIRMATIVE ARGUMENT SKEPTIC REBUTTAL CLIENT EXPERIENCED CHANGE: IMPROVEMENT IN  Skeptic team does not contest this claim as data clearly LONG-STANDING evidences client change in long-standing problem areas. PROBLEM AREAS. EVIDENCE OF EGO  Skeptic team agreed that there were elements of ego IDENTITY CHANGE. identity integration but, as is evident in their case brief, also found evidence for acceptance producing significant shifts.  Skeptic team also presented in their brief that it was unclear in the data whether the ego identity integration experienced truly addressed integrating cultural elements of self present among TCKs. CHANGE DUE TO THERAPY: CLIENT  This is purely based on client self-report with no external ATTRIBUTION evidence or data to support these client attributions.  Change interviews did not include asking Rose about other things that may have contributed to change. They focused solely on Rose’s rating of the likelihood of this change happening without therapy.  Is the change being experienced truly reflective of therapy related change or are shifts due to situational and contextual differences from pre to post. Researcher addition:  Change interviews also did not specifically ask Rose to rate the likelihood of change happening without LI therapy. Her ratings may reflect a general attribution to any therapy and not specifically to LI therapy. PROCESSOUTCOME MAPPING.  Session 4 – Holding baby self: Researcher elaborated during case development that Rose also wonders if her response to holding her baby self is more reflective of accessing a INTEGRATING EGO IDENTITY WITH LI THERAPY 539 current yearning for children of her own (45, never married, no children) or a true recognition of self as a baby.  Largely tracks process and outcomes links between events at the beginning (sessions 2 & 3) and end of therapy (session 27) but do not address the bulk of the therapy relationship (sessions 5-25). [Researcher note: The skeptic team did not have access to the researcher additions to this section of argumentation that were added after the case development meeting.] DATA-EVENT RELATIONSHIP.  Largely tracks data and event links that occurred near the beginning (sessions 6) and end of therapy (session 25) but do not address the bulk of the therapy relationship (sessions 7-24). [Researcher note: The skeptic team did not have access to the researcher addition to this section of argumentation that was added after the case development meeting.] Researcher additions:  Uncertainty as to whether the emergence of personal voice is evidence of ego identity integration EVENT-SHIFT SEQUENCES.  Difficult to attribute change to LI processes alone due to the numerous external events that primed the client for change and likely contributed to the significance of the shifts that were happening.  Therapy processes used in session were not ‘pure’ in that the therapist integrated other therapeutic techniques – AEDP triangle, embodiment, bilateral stimulation. It is difficult to separate out the influence of these additional therapeutic processes and the extent of their impact on client change. Other attunement therapies use similar approaches to those in LI and have similar outcomes. It is unclear whether change can be attributable to any unique aspects of LI therapy compared to other similar techniques. EVENTS/PROCESSES:  INTEGRATING EGO IDENTITY WITH LI THERAPY     540 Additionally, research clarified during case development meeting, that this was the first time where therapy had specifically zeroed-in on identity fragmentation as the target for therapy. It is therefore conceivable that, had previous therapy experiences focused on this content (as opposed to being secondary targets) they may have produced the same change. [Researcher note: The one exception to this is the focus on flashbacks, dissociation and anxiety related to abusive relationship and sexual assault. This has been the focus in a previous relationship without finding complete resolution of symptoms.] There was a lack of investigation into extra-therapy events that likely also significantly contributed to client change. Blips in PQ ratings would appear to coincide with external events that likely affected reported levels, e.g. shifts in ratings over the summer months without the pressure and intensity of classes, or due to absence of family stress in staying in BC over Christmas, or being triggered by obsessive watching of TV shows both before and after Christmas. Is emergence of voice a specific by-product of LI therapy or an additional therapeutic tool that the clinician is integrating into the therapy process? INTEGRATING EGO IDENTITY WITH LI THERAPY 541 APPENDIX X Adjudicator A Response Form A. EGO IDENTITY CHANGE: 1a.To what extent did the client experience ego identity change over the course of therapy? CONSIDERABLY - 60% 1b. How certain are you? CONSIDERABLY - 60% 1c. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? AND How did you make use of this evidence? *       Affirmative case: The change in the PQ scores shows positive change and the PQ questions #1,2,3,5 seem to reflect areas related to ego identity. Journal entries and session notes with data that specifically mentioned development of core identity, the emergence of "ME", and her ability to see younger Rose as the same person as current adult Rose. Also journal entry Feb 10th indicates the integration of self with her body, a key component in the definition of ego identity. Skeptic team did not find reason to doubt ego identity change happened - they only disputed the cause of the change. Skeptic argument that the ego change did not address cultural elements necessary and unique for TCK identity. Even if this is true, that is not the element being measured. I thought we are measuring, is there ego identity change in this client (who happens to be a TCK) ? We are not asking the question about change for a TCK vs non-TCK. It may be true that the ego identity change for a TCK will look different than the ego identity change for a non-TCK. I do not think that was the focus of this study. "Considerable change 60%" was chosen due to the fact that only 4 of the PQ questions seem to be related to ego identity change. As to whether these 4 questions actually can accurately measure ego identity change is unclear to me. They do measure change in those 4 areas but I am not convinced that those 4 questions are absolutely measuring identity change. Perhaps they are measuring something else. 2a.To what extent is this ego identity change due to therapy? * INTEGRATING EGO IDENTITY WITH LI THERAPY 542 CONSIDERABLY DUE TO THERAPY - 60% 2b. How certain are you? CONSIDERABLY - 60% 2c. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? AND How did you make use of this evidence? *          DUE TO LI THERAPY PROCESSES = 40% - MODERATELY Rose rated the changes as surprising without therapy. I agree with the affirmative team that this rating is reliable as there is no good reason to doubt the client's opinion. The client had tried therapy before and not seen this kind of change. Skeptic : her surprise is suspect as she should have expected change. I disagree as she had previous experience of no or little change in therapy and I would suggest that expectancy of change does not guarantee actual change. Skeptic argument is that data collected was based on self -report. This is in accordance with this type of research and is not hidden from the reader. Skeptic: that Rose had a dual role as client and researcher and LI trainee. Yes this is true and could contribute to bias. However that should not affect the PQ scores unless we assume that the client lied about her answers to the PQ. The PQ scores show a range of scores over considerable time. harder to fake. Thus my answer rated 60% Skeptic : the client created her own change and was motivated to change, therefore change occurred. Yes this is possible but what change ? It may not result in ego identity change. The PQ scores measure several types of change and the ego identity change is one such change. The skeptic arguments about Extra therapy events were not convincing to me to explain the change The skeptic argument that medication could have accounted for decrease in PQ ratings. yes I agree this is possible. Thus my answer rating of 60% and not higher. Agree with conclusion pg 14 under Events/Processes that the change cannot reliably be attributed to LI therapy. It can be attributed to therapy but not necessarily to LI as a method of therapy. B. OTHER CHANGE: 3a. To what extent did the client experience general change over the course of therapy? SUBSTANTIALLY - 80% INTEGRATING EGO IDENTITY WITH LI THERAPY 543 3b. How certain are you? SUBSTANTIALLY - 80% 4a. To what extent is this general change due to therapy? * CONSIDERABLY DUE TO THERAPY - 60% 4b. How certain are you? SUBSTANTIALLY - 80% C. MEDIATOR/MODERATOR FACTORS: 5. Which therapy processes (mediator factors) do you feel were helpful to the client? *          Therapeutic alliance was in my opinion the most helpful factor in helping the client to change. The client repeatedly referred to how the trust relationship with the therapist affected her ability to feel safe, face issues, go places in therapy, that she had never gone before. I would even suggest that this research gives further evidence for previous research by Scott Miller and others that has shown that therapist -client relationship is a primary factor in change in the client. This is written throughout the HAT record. Therapist non-judgmental stance was helpful for client. Therapist attunement and attention and flexibility to adapt were helpful. Although I agree that there was indication of ego integration, I would say that there is no clear indication of what caused the ego integration. Was it due to LI ? or due to the therapeutic alliance ? or due to something else ? or a combination of things ? The use of the PQ may have helped the client to be more motivated to change.Thus the PQ tool was helpful in itself. Journal entries and reflections may have contributed to change. Doing the research and reflecting deeply on the therapy and the results of the therapy may have been mediator factors. Watching videos of yourself could contribute to self awareness and enhance change. Connection with baby self and younger self and having a methodology like LI to help the client connect with those feelings of the younger self were helpful. Also dialogue between older and younger self with guidance from therapsit helped. However there are other methods of therapy that use this approach and possibly could have been just as helpful. INTEGRATING EGO IDENTITY WITH LI THERAPY 544  6. Which characteristics and/or personal resources of the client (moderator factors) do you feel enabled the client to make the best use of therapy? *         Client motivation seemed high - combination of desperation, desire to heal/change, dual role of doing research, curiosity about LI- all seemed to contribute to motivation. Willingness to go into the hard stuff and face painful memories. Co-operation with the therapist's choice of modality Commitment to remain in therapy - not giving up Resiliency of client Client's sense of support from Master's program staff and fellow students/friends Timing in the client's life - stage,age, and circumstances Extra-therapy events such as community connection, work situation, change in distance from family INTEGRATING EGO IDENTITY WITH LI THERAPY 545 APPENDIX Y Adjudicator B Response Form A. EGO IDENTITY CHANGE: 1a.To what extent did the client experience ego identity change over the course of therapy? SUBSTANTIALLY - 80% 1b. How certain are you? SUBSTANTIALLY - 80% 1c. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? AND How did you make use of this evidence? *     Client reporting being less triggered in the presence of usal triggers which seems to signify feeling more grounded in who she is and confidence in her sense of belonging to self and the world Client's language and reports of emerging "ME" throughout journsla Therapist's coinciding reports of observing integration, finding of client's voice, etc A separation between self and symptoms (i.e. seeing herself as separate from the anxiety 2a.To what extent is this ego identity change due to therapy? * SUBSTANTIALLY DUE TO THERAPY - 80% 2b. How certain are you? SUBSTANTIALLY - 80% 2c. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? AND How did you make use of this evidence? *      Client & therapist's coinciding reports in many areas the fact that there is change in long standing problem areas, across PQ score Clear increase in tolerance for triggers and reduction in symptoms in spite of these triggers (i.e. client is a grad student so very clearly under stress, therefore it is remarkable that these all reduced in spite of the stress An increase in joy reported Client's own reports INTEGRATING EGO IDENTITY WITH LI THERAPY   546 Experiential component of facing caregivers which required support of the therapist (i.e session 29) I agreed with the skeptic argument the change did not seem to specifically address repatriation and/or TCK identity consolidation B. OTHER CHANGE: 3a. To what extent did the client change over the course of therapy? SUBSTANTIALLY - 80% 3b. How certain are you? SUBSTANTIALLY - 80% 4a. To what extent is this change due to therapy? * SUBSTANTIALLY DUE TO THERAPY - 80% 4b. How certain are you? SUBSTANTIALLY - 80% C. MEDIATOR/MODERATOR FACTORS: 5. Which therapy processes (mediator factors) do you feel were helpful to the client? *       Therapeutic rapport between client and therapist Experiential processing of child/baby/old self and more integrated self Client hoping and believing that things would change (expectancy) Trust in the therapist - perhaps due to relationship, but also possibly due to how the client found the therapist (i.e. referral source - must have known she was a good therapist to select her for the research). Medication other extratherapeutic factors 6. Which characteristics and/or personal resources of the client (moderator factors) do you feel enabled the client to make the best use of therapy? * INTEGRATING EGO IDENTITY WITH LI THERAPY     Client as the researcher Education - currently in a MA counselling program Being an LI Trained therapist Personality (i.e. Perfectionism, acheivement-focused). 547 INTEGRATING EGO IDENTITY WITH LI THERAPY 548 APPENDIX Z Adjudicator C Response Form A. EGO IDENTITY CHANGE: 1a. To what extent did the client experience ego identity change over the course of therapy? CONSIDERABLY - 60% 1b. How certain are you? CONSIDERABLY - 60% 1c. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? AND How did you make use of this evidence? *          The significant number of PQ items that demonstrated significant change especially as 10 of the items have been areas of significant stress for Rose for over 10 years The absence of emotional arousal and dissociation in the presence of a familiar trigger Client describing the experiential processing of grief which is a significant shift from previously only being able to process the grief cognitively Rose's journal reflects the emergence of a "ME" that wasn't previously present as wella s a sense of self that is more able to control previously "hounding" anxiety Evidence of Integration of self as reflected in journal recordings that "I am my body" Integration of younger self with older self regarding Mexican cultural past as reflected in the Video clip re:identity Data reflected in the skeptic argument that seems to be relevant is the dual relationship for Rose as both client and researcher and her investment in reflecting ego change in her data. It is difficult to ascertain what changes were generally attributable to the process of therapy and what was unconscious shifts due to needing and wanting a particular outcome. I used the evidence presented in the affirmative case to validate my rationale that ego change did take place. The skeptics evidece assisted me in validating pieces of the change that I am unclear about with regards to the mechanism of change and whether there were elements of conflict between the therapy itself and the underlying inherent conflict in the client also being the researcher Skeptic discussion regarding TCK dynamics and patterns does seem to indicate that some elements of TCK self determination and self help patterns would lend itself to querying how much integration of the cultural ego related dynamics were actually changed, however there is also evidence that overall Rose experienced INTEGRATING EGO IDENTITY WITH LI THERAPY 549 ego identity change and recognised the need for more work in the future to continue the process. 2a.To what extent is this ego identity change due to therapy? * SUBSTANTIALLY DUE TO THERAPY - 80% 2b. How certain are you? CONSIDERABLY - 60% 2c. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? AND How did you make use of this evidence? *        DUE TO LI THERAPY PROCESSES = 60% - SUBSTANTIALLY The biggest distinction for me in this section is the degree to which change occurred due to LIfespan Integration Therapy and how much occurred due to the therapeutic alliance and attunement with the therapist in general. While not mentioned in the affirmative and skeptic cases one significant observation I made in reviewing the rich case record was the low number of timeline repetitions for the majority of the LI sessions. As part of the LI protocols there are an expected number of reps that need to take place during a sessions in order to make the neccesary neural connections. Out of the 32 sessions that were conducted 26 involved LI therapy. Of these 26 sessions only 4 sessions involved what would be considered minimum number of reps in the sessions to constitute an expected neurological and integrative outcome. In a number of places within the data summaries there was mention of the relationship and attunement with the therapist being significant. Due to the lack of significant reps of the protocol in the majority of sessions it is difficult to ascertain if the changes that took place were due to LI therapy or more due to the therapeutic relationship which seemed to be significant.. I am considerably confident that change happened but I am less confident that the change occurred due to LI. Rose's report of changes occurring that she feels would not have changed without therapy is compelling but also hard to separate from the dual relationship of the client also being the researcher in this case and therefore having a vested interest in change occurring. Rose's reports of connection to her baby self and 7 yr old self support change occurring as a result of the therapy (session 2 and session 6) Others reporting that they are noticing Rose's joyfulness Decrease of PQ item ratings following sessioin 6 reflected a significant change due to the therapeutic process. Rose reporting that she felt a significant connection to her baby self indicated change due to the LI therapy as the connection would not have been made in INTEGRATING EGO IDENTITY WITH LI THERAPY  550 other forms of therapy or by talking about previous distressing issues and lack of connection. Session 27 offered an LI specific interaction that held significant meaning and awareness for Rose. The sense of integration and bringing her 11 yr old self into the present supports change occurring due to LI B. OTHER CHANGE: 3a. To what extent did the client change over the course of therapy? SELECT ONE 3b. How certain are you? SELECT ONE 4a. To what extent is this change due to therapy? * SELECT ONE 4b. How certain are you? SELECT ONE C. MEDIATOR/MODERATOR FACTORS: 1. Which therapy processes (mediator factors) do you feel were helpful to the client? *     Attunement with therapist Embodiement session (session 14) seemed to be a significant session for Rose finding her voice PTSD protocol General neural integration of younger ego states into adult self through some LI processes as well as client working on integration between sessions. 2. Which characteristics and/or personal resources of the client (moderator factors) do you feel enabled the client to make the best use of therapy? * INTEGRATING EGO IDENTITY WITH LI THERAPY     551 Invested in positive outcome due to rinvestment in research outcomes Insightful and aware of LI processes and methodologies Motivated to change resourceful and able to integrate therapeutic experiences with self awareness and her own therapeutic tools INTEGRATING EGO IDENTITY WITH LI THERAPY 552 APPENDIX AA Reflexive Researcher Adjudicator Response A. EGO IDENTITY CHANGE: 1a. To what extent did the client experience ego identity change over the course of therapy? SUBSTANTIALLY - 80% 1b. How certain are you? COMPLETELY - 100% 1c. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? AND How did you make use of this evidence? *     The PQ items that the affirmative team named as centrally demonstrating ego identity change (#1, 3 and 5) demonstrated significant shifts over the course of therapy. I interpret these results as indicating a greater knowledge of self, acceptance of self, and anchoring in a self that has inherent worth and value. While this could be interpreted as merely the appearance of self-worth or selflove, the many examples in both session notes, HAT and TSNQ forms and journals of where I describe a ME emerging - a sense of voice, and ability to be centered and grounded, a change in relationship to fear and anxiety - directly in relation to meeting younger parts of self demonstrates that ego identity integration played a pivotal role in bringing about this shift in relationship to self. Furthermore, within the rich case record reference is made to my sense and the therapist's sense of being more my age, feeling more capable as I come to understand that I am no longer a little child but an adult and recognize the resources that I have accumulated throughout my life experience (p. 39, 55, 63, 80). My experience was one of a process of unfreezing my core self that was becae stuck at repatriation in a child state of vulnerability, dependency, fear, and helplessness. In returning to these younger states of self, acknowledging hurt and harm, meeting needs, and bringing them into the present there was 'permission' to mature, move on, become more. A valid point is made by the skeptic team who argue that insufficient time was spent specifically working with my 11-year-old self at time of repatriation to make claims about ego identity integration as part of TCK healing. I must admit this was also a concern of mine at first glance. However, I was then reminded of the adjudicator orientation where attachment and family dynamics were mentioned as being able to significantly impact a TCKs ability to manage the challenges of the TCK lifestyle resulting in emotional, mental and psychological INTEGRATING EGO IDENTITY WITH LI THERAPY   553 difficulties including, as I propose in this study, the development of ego identity fragmentation (i.e., ego identity fragmentation can result from an inbalance between cultural adjustment challenges and available resiliency resources). Therefore, to the affirmative argument I would add that building an attuned attachment relationship with the therapist, addressing family dynamics of silencing and voicelenssness, and enabling younger Mexican selves (4-5 year old, 7-year-old) to be seen and heard, were also a part of addressing and repairing TCK ego identity fragmentation. They provided corrective emotional experiences and activated self-attunement and self-care leading to the development of internal resiliency resources and enabling all parts of me to become unstuck in child states and to mature and move on (integrate). While the skeptic team argues that TCK cultural integration is not adequately demonstrated, I would disagree. While it may not have been explicitly addressed or verbally expressed within sessions there are indications that cultural integration of my Mexican and Canadian selves was happening. The most poignant contained within the rich case record are the video clip and journal entries of me naming Mexico as home and recognizing myself as the one who experienced my memories of Mexico. In this manner I am reclaiming these memories as my own, belonging to me, reflecting parts of who I am. While some of these occur post-therapy I have no doubt they are directly related to the work done in therapy reconnecting with who I was as a child living in Mexico. I was unable to judge the change as 100% or completely as, like the skeptic team, I agree that the work is incomplete - that this ego identity integration had begun to take place but was not complete at time of therapy termination. I disagree with the skeptic team's interpretation that this indicates a lack of ability for LI therapy or for the clinician to effect complete change in me. Therapy did not end because the work was over but because data collection needed to end and a minimum 1-month break was necessary to get an accurate post-therapy measurement of change. Additionally, I needed space to transition into my role of researcher as opposed to client/participant. 2a. To what extent is this ego identity change due to therapy? * COMPLETELY DUE TO THERAPY - 100% 2b. How certain are you? COMPLETELY - 100% 2c. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? AND How did you make use of this evidence? *  DUE TO LI THERAPY PROCESSES = 80% - SUBSTANTIALLY INTEGRATING EGO IDENTITY WITH LI THERAPY     554 100% due to therapy but 80% due to LI therapy because of the inclusion of other therapy techniques as indicated in the skeptic rebuttal. These additional techniques, especially embodiment, when they occurred, featured significantly in my HAT reports making them a significant part of my experience of therapy and undoubtedly contributed to some degree to the changes that occurred. The affirmative team argues well for change due to therapy pointing out the long-standing nature of reported issues and the fact that, in over 10 years of therapy with hopes for changes in this sense of core self, this is the first time any significant change has actually occurred. The surprising nature of the shifts and changes that were occurring as is evidenced in my change interview ratings also point to processes occurring that are beyond my ability to manipulate or control. This is the beauty of an implicit therapeutic process such as LI that works below the level of conscious awarenes and involves neural integration processes wherein things continue to shift and move around whether I, as a client, am aware of it or not. It is expected within the LI framework that processing continues 'behind the scenes' between therapy sessions enabling change "to work itself out over time as the brain reorganizes" (Affirmative rebuttal - p. 18). Skeptic team suggestions regarding multiple role of client/clinician-intraining/researcher and impact of therapy results on academic progress were compelling but there appeared to be insufficient evidence within the data to suggest this was the case. The affirmative team points to various indications that I am interacting genuinely and authentically with the therapy process (imperfections in PQ ratings, natural fears and concerns regarding therapy process and change, disruption in therapist-client relationship) and being diligent in following appropriate research protocols and practices within each of these roles. While not contained within the rich case record some examples of this include: being careful how I participated in LI training experiential pieces so as to minimize impact on therapy results; trusting the therapist's clinical experience and decisions, and her knowledge of the research process and project, enabling me to remain in my client role when other techniques were brought into sessions; not continuing with regular therapy after the follow-up interview so as to allow space to extricate myself from the role of client and take on the role of researcher. None of the evidence on extra-therapy influences on therapy were convincing or persuasive. This was further solidified in how the affirmative team addressed these events in their rebuttal. B. OTHER CHANGE: 3a. To what extent did the client change over the course of therapy? SUBSTANTIALLY - 80% INTEGRATING EGO IDENTITY WITH LI THERAPY 555 3b. How certain are you? COMPLETELY - 100% 4a. To what extent is this change due to therapy? * COMPLETELY DUE TO THERAPY - 100% 4b. How certain are you? COMPLETELY - 100% C. MEDIATOR/MODERATOR FACTORS: 5. Which therapy processes (mediator factors) do you feel were helpful to the client? *       Attunement protocol and bringing in the baby self. Forming of a secure attachment relationship with the therapist in which client felt safe and secure, known, seen, cared for. This appeared to meet a very core need within the client. Standard Protocol: The dialogue that occurred between older and younger versions. Really differentiated younger selves from older selves as it highlighted the age, experience and knowledge differential between the two selves. The therapist coaching of this internal dialogue was also pivotal in helping the client become aware of what they already knew or of what they thought they knew or didn't. Also countered client voicelessness in providing words for what they wanted/needed to say. Source memory and adult self: brining the adult or older self into the source memory to address needs of younger selves was empowering and liberating. Not only did this provide a corrective experience for younger selves but it also permitted self to heal self - healing from within. This is important because then the resources for healing are always present as they come from within ourselves. Time Line: demonstrating to younger selves that what happened was in the past by showing them the timeline; bringing them year by year from the source memory into present day. This not only 'unstuck' younger selves - hard to stay stuck somewhere when you're constantly moving on through the timeline - but was also pivotal in integration. Interacting with younger parts of self within the present day environment was often quite significant and meaningful in understanding that we are the same person. Having a highly attuned therapist who was able to hold the space and remain grounded throughout therapy, and who assisted me in regulating my own INTEGRATING EGO IDENTITY WITH LI THERAPY   556 emotions was key to staying in my window of tolerance and permitting positive neural integration to occur. This is both specific to LI therapy - therapist's ability to remain attuned to client and grounded is mentioned frequently in training materials as pivotal to LI success - and a common factor in successful therapy practices overall. It was also important that the therapist was not thrown by client presentation during session. She was able to go with the flow and allow the client to dictate direction of imaginal work, even when it might deviate from typical responses. The therapist also serves as a partner with the client in co-creating a cohesive autobiographical narrative of their life. This was achieved through the therapist witnessing the client at various ages and stages of life and experiencing both older and younger parts of the client over the course of therapy while remaining constant in her attunement, affection, and care for the client. 6. Which characteristics and/or personal resources of the client (moderator factors) do you feel enabled the client to make the best use of therapy? *    Rose appeared to be someone who is highly invested in personal growth and healing as evidenced by investing the time and energy and finances into 10 months of intensive therapy in the midst of intensive (and expensive) academic work in her master's program. She was additionally motivated by 35 years of carrying this pain and a 10-year pursuit of healing in this area of core identity. So far therapy had led to change in other areas but had only led to disappointment in the pursuit to integrate with her 11-year-old self; to heal her great identity divide. The fact that she was willing to try again is evidence of a combination of courage and desperation ("I'll try anything") to see change occur. Her knowledge of LI therapy - seeing it in action in a previous thesis study and then taking the clinician training - often made sessions more difficult as she was aware when in-session practice when 'off-script' and had to put her clinician self aside, step into her client role and rely on the trust that had been built with the therapist. On the flip side, her knowledge and experience of LI's potential is likely what made her more persistent in sticking with the therapy and not giving up.