IFF Research Journal

Abstract: What follows is a how-to manual designed to assist somatic awareness practitioners to document their cases in a way that allows a reader to reconstruct the flow of events – for practitioner and client -- in all or part of their sessions with clients. The method of documentation presented here assumes that the practitioner is the most informed observer of a session (a participant observer) and that practitioners can train their perceptions and writing skills to communicate the process of engagement, communication, and change over time within and across sessions with the same client. Qualitative, participant observer research methods have strong overlaps with the principles of somatic awareness treatment and educational methods. The domains of overlap are: self-awareness, attunement to the body and its experiences, non-judgment, and distinguishing the roles of self and client to enhance the client’s self-awareness. Effective, articulate case notes can serve as the basis of research on the process of change for both clients and practitioners using somatic awareness methods. Although each somatic awareness practice uses different terms for those providing and those receiving the work, the terms “practitioner” and “client” will be used in this article.

THE ROLE OF CASE DOCUMENTATION IN RESEARCH AND PRACTICE

Why document our cases? There are many reasons to document the client-practitioner relationship and how it changes. This manual is oriented toward creating written case studies of change over time with the explicit goal of communicating the actual process of the work to others both inside and outside of a disciplinary community. When the field of psychology was young and not well accepted, the published case studies of Freud and Jung transformed the dedicated work of a few individuals into one of the therapeutic mainstreams of Western culture. The consciousness-shifting work of Charles Darwin and Jean Piaget was founded upon their careful documentation of observations in which they were a direct participant. Darwin was a true naturalist, living in the field and directly experiencing the lives of the species he studied. Piaget made extensive case notes on his own three children.

As these examples show, when a field is relatively new or unknown outside of a small circle of those who practice that work, detailed case documents are one of the most powerful vehicles to spread the news of what a practice has to offer, how it works, and how it may benefit others. Documenting cases says: “this is what we do and how we do it.” It is different from a testimonial, a summary description, or an advertising blurb, all of which are highly interpretive and can be read as biased. Accurate case documents speak for themselves and have a readily transparent truth value.

What is a participant observer? A participant observer is a person who develops skills to observe and to write about his or her own and others’ experiences while engaging in a long-term and meaningful interpersonal relationship with others. Participant observation is a well-accepted scientific method in fields such as psychology, education, and anthropology. Instead of trying to be “objective,” the participant observer calls on the depth of their personal connection and their ongoing relationship with the people being observed. Participant observation seeks to communicate the compassion, authenticity, and aliveness of the process so that readers feel as if they were actually present. It does not diminish the experience by pretending to objectify it.

Somatic awareness practitioners already are direct participants in the therapeutic or educational relationships with clients and students, and the new skill that this article offers is how to write about one’s experience. Somatic awareness principles – such as being fully present with ourselves and our clients– are exactly those cultivated by participant observers. Documenting cases in writing does not necessarily change what already happens in a session but it may expand the practitioner’s awareness of what happens.

What is the purpose of case studies of change? Freud’s case studies revealed how his patients transformed over the course of repeated sessions, from states of ego fragmentation into states of integration. They also show Freud’s therapeutic stance, his comments and questions, and his process of co-discovery with the client. Darwin’s case studies revealed how species changed across millions of years and also provide a record of his own process of change as he encountered new evidence and adapted his theoretical understanding. The essence of life is change. Case studies of change are documentary records of what occurred between client and practitioner across multiple repeated sessions of a treatment that may last months or years. Case studies paint a picture in words (and possibly pictures) of what unfolds in sequence in some part of each of the repeated sessions. The writing is a report of what happens, in which judgements and interpretations are kept separate from the documentary records themselves.

Why does the community of somatic awareness practitioners need case studies of change? We all know from our personal case histories that the methods we practice change us and change our clients. At the present time, however, the number and depth of published documentary case studies on the process of change in our relationships with clients is limited. Even when client change is recorded, it is often as if the practitioner was not present, as if the “treatment” was a one-size-fits-all rather than an emergent process of interpersonal navigation and mutual understanding.

Too often, in research on health care, “treatments” are assumed to be fixed, stable, and consistent. In all of the somatic awareness disciplines with which I am familiar, this is far from what occurs. Instead, practitioners are trained to leave themselves open, to respect the process of unfolding, to allow themselves to be changed by the process as they endeavor over time to “meet” the client. By writing detailed case documents we make this process come alive at the same time that we counter the tendency in the larger culture to “reduce” our work to a linear and uni-dimensional “treatment-outcome” model. Documenting cases is a holistic, compassionate, and respectful act that serves to bring the work alive and have a self-evident face value.

As a behavioral scientist for the past 30 years, I have observed the convincing effect of careful documentation on the minds of readers, both in the scientific community and the general public. Most of the major discoveries in the fields of human development, clinical psychology, and neuroscience have originated with case studies. I have spent my scientific career establishing the importance of case studies of change and the role of interpersonal relationships to facilitate or hinder change processes (Fogel, 1993; Fogel et al., 2006).

What happens to case studies once they are written? One possibility is that they can be published for others to read and study. Another possibility is that these documentary records can be analyzed to extract regularities of the change process. What works and what does not work, in general and for particular clients? What are the processes of change and are they the same as what the clinical theory predicts? These analyses can also be written in the form of articles that can be submitted for publication in order to establish the efficacy of a practice for particular types of treatment or more specifically, how to adapt a practice to differences between clients.

What can you learn from this manual? This manual will provide interested practitioners with all the conceptual and practical tools they will need to document one or more of their cases. The analysis of documented cases is another topic and will not be included here. This manual has the following sections. A section on participant observation includes how to stay connected while maintaining boundaries, the role of presence, and suspending judgement (not knowing). The next section covers how to write case notes by being disciplined, by documenting sequences of events, and by separating observations from interpretations. The third section is on how to develop an orientation to your case study by finding a particular question or questions that motivate your work.

Each section is accompanied by experiential exercises. These exercises can be done alone or in a group. The author conducts workshops teaching this method using these and other exercises.

In addition to these three sections, there are three supplements to aid your work. The first is a set of examples of case documentaries taken from published accounts of different somatic awareness practices. These examples are intended to be read along with the experiential exercises. Second, there is a sample “consent form,” which may be given to the clients whose cases you plan to document. In a university setting such as where I do my research, client consent is required by our Institutional Review Board for the protection of human subjects. I have included a consent form based on what would be required by my university. Whether you use this form or adapt it to your own needs, I highly recommend that you seek client permission in advance of beginning the documentation. I know of several practitioners who could not publish their careful documentations because the clients, when shown the document after it was completed, refused to allow it to be used. Advanced consent lets the clients feel as if they are collaborators in the work. Finally, there is a bibliography should you desire to read further.

PARTICIPANT OBSERVATION

Keeping track of your own and the client’s experience. The goal is to record your own bodily sensations and feelings that correspond with what you are observing in the client.
“You will want to maintain a dual purpose: You will want to seek to participate and to watch yourself and others at the same time” (Spradley, 1980).

Maintaining boundaries while staying connected. Compassionate analysis means that the practitioners’ emotions are connected to the clients’ and yet they are kept separate. “A researcher must become deeply involved with his material and allow it to absorb him while remaining emotionally vital enough to step back and perceive the contours of the data. It is a rigorous, affective exercise demanding emotional reserves and critical perceptiveness” (Glazer, 1980, p. 29).

Prolonged engagement with the data. Over the course of many repeated sessions with the same client, there is a growing awareness of recurring patterns, places where openings occur and where they do not. This allows the practitioner to sharpen the focus of description and to further separate self from other. “The more the investigator is immersed in the data, the more s/he relates to the data, the more qualified his/her interpretations become” (Jansen & Peshkin, 1992). “The investigator’s prolonged engagement with the data is a crucial criterion for evaluating the validity of qualitative research studies” (Lavelli, Pantoja, Hsu, Messinger, & Fogel, 2003).

Suspending judgment, not knowing. While being present without judgment is theoretically central to being a practitioner, each practitioner can be captured by their own biases and preconceptions. Research methods that aim to describe direct felt experience as it appears are called phenomenological research methods. These methods require what is called the “epoche,” an invitation to presence and aliveness of noticing. “In the Epoche, the everyday understandings, judgements, and knowing are set aside, and phenomena are revisited, freshly, naively, in a wide open sense…” (Moustakas, 1994, p. 33). “Epoche includes entering a pure internal place, as an open self, ready to embrace life in what it truly offers” (p. 86). “Interpretation … removes the aliveness and vitality from the nature, roots, meanings, and essences of experience” (p. 19)

Presence. The intent of the practitioner is to assist clients in becoming more fully alive. The practitioner as participant observer has an additional task; that of bringing the session alive for those who were not physically present but who, upon reading the case documentation, can feel as if they were present. “Phenomenology is committed to descriptions of experiences, not explanations or analyses. Descriptions retain, as close as possible, the original texture of things…Descriptions keep a phenomenon alive, illuminate its presence, accentuate its underlying meanings, enable the phenomenon to linger, retain its spirit, as near to its actual nature as possible” (Moustakas, p. 58-59) . “This work presupposes that the perceiving self is an authentic self, that the self is actually present” (p. 61).

One approaches the client with a participatory consciousness, “an attitude of profound openness and receptivity . . . One is turned toward the other ‘without being in need of [the other]’ or wanting to appropriate [the other] to achieve something.” Participatory consciousness “requires a ‘total turning to’ the other which leads not to a loss of self but to a heightened feeling of aliveness and awareness” (Heshusius, p. 16).

PARTICIPANT OBSERVATION: EXERCISES

For the following questions and inquiries, study in detail one or more of the case examples in the supplement at the end of this article.

1. Find those places in the example in which the observer has described his or her own experience.

2. Find those places in which the observer documents the client’s experience.

3. Find those places in which the observer makes interpretations, hunches or judgements.

4. Where in the writing did you have a sense of change over time in the relationship.

5. What skills do you already possess that would support your becoming a participant observer of your own cases?

6. What are the obstacles you foresee that might impede your becoming a participant observer of your own cases?

WRITING WITH PRESENCE AND DISCIPLINE

Background-foreground: At the beginning of your document, describe the client in detail. Give your first impressions and whatever “history” you can learn from your first contacts. What do you notice about how the client looks, how she holds her body, the quality of her voice, your sense of connection to her, and other details you would typically notice with a new client. Note details of all conversations, including phone contacts. Background information should also be included for each subsequent session. This is not the main data but rather the background. The foreground is the specific sequences of events that you record following every session, the session log.

Doing documentary work. Your goal is to create a documentary work, one that allows the reader to replicate what actually happened in your session with the client. “Detail is everything; only that which is recorded in the log is available for research” (Ely, 1991, p. 70). Your job is to be a recorder of what occurs. Here is what one participant observer wrote about her work: “My quick generalizations were not acceptable. Here’s what I mean: During our first field observation, my tendency would have been to log, ‘E told me about her day as a substitute teacher.’ Instead, I had to learn to log: E said, ‘You’ll never guess what I did yesterday. I subbed for a first-grade class, and boy, was I wiped out at the end of the day.’ She explained to me that their regular teacher was on maternity leave. She said she had lots planned, but didn’t get to do much of it because the children were restless. I asked her what they did do and she said she read them stories. I remarked I bet they liked that. She said she was physically and emotional exhausted from it and couldn’t see herself doing that every day” (Ely, 1991, p. 70). Note how this log records what actually occurred, so far as it could be remembered, and that both the observer’s and the teacher’s actions are recorded.

Writing sequence narratives. Logs are of the most scientific and clinical value if they provide a chronological or sequential record of what took place. “A chronological narrative is the description of the observed phenomena in terms of sequences of events. The primary goals are thus (1) to transform the observational data into text – a text composed of successive events that are relatively “open and theoretically indefinite” (Ricoeur, 1991, p. 22), and (2) to create a “careful record of the changes in the dyad’s communication development across time” (Lavelli, Pantoja, Hsu, Messinger, & Fogel, 2003).

Beauty, depth and discipline. Write as soon as possible following the sessions. Forgetting begins immediately after the session is over. This takes discipline similar to the kind of discipline required to be present for the client during the session. Don’t hold back. Write from the heart but without judgement or interpretation. “Write as lushly as you can, as loosely as you can, as long as you put yourself into it, where you say, ‘I felt that’ . . . To be scientific in this area, you’ve got to start trusting yourself and writing as fully and as lushly as you can. That’s part of the discipline itself, too” (Goffman, 1989, p. 131).

Distinguishing what goes on in the session from your reflections and interpretations about the session. In addition to the background and the log, one can make optional personal notes that come out of introspection, doubts, thoughts, questions, judgements, hunches. These personal comments must be set off from the log itself. This can be done with statements, with highlighting, with brackets, or by making comments in the margins (leaving room for wide margins). “This is the place where the researcher faces the self as instrument through a personal dialogue about moments of victory and disheartenment, hunches, feelings, insights, assumptions, biases, and ongoing ideas about method” (Ely, 1991, p. 69). In these personal notes, follow what appear to be distractions, let yourself be open to developing insights, maintain your stream of consciousness without imposing too much judgement on what your words mean. Do not expect conclusions or answers. Instead, expect confusion and let the “not knowing” be reflected in the writing.

Focus writing on key moments: There is usually no need to record the entire session. Few people can remember the details of an entire session. Focus on key moments that seem to highlight the session for you, in which there is a salient change process or discovery. On the other hand, don’t ignore the “boring” parts of the session in which not much is changing. Choose one or two examples in each session to characterize moments of being stuck or lost.

DOCUMENTARY WRITING: EXERCISES

For the following questions and inquiries, study in detail one or more of the case examples in the supplement at the end of this article.

1. Find places in the example in which the writer gives background, as opposed to foreground, information.

2. Find places where the writer gives sequential vs. general information about the session itself.

3. Note the depth and quality of the writing.

4. Check whether there is an overall sense of completeness.

RESEARCH QUESTIONS THAT FOCUS OBSERVATION AND EXPAND CREATIVITY

Making choices. Without some recording device (tape recorder, videotape) it is impossible to describe an entire session. If you would like to record the whole session, think about digital recording so that you can easily enter the record into your computer. Such recordings, however, do not replace written case documentaries as described here. It may not be clear from the recordings when and how the practitioners experienced the connection, when the moments of meeting and moments of change occurred. Having a research question provides focus and depth to the session log. The following are some examples of research questions. Many others are possible and it depends upon the practitioner’s personal interest/curiosity with the work.

• When does the client talk about emotions compared to express/feel them in the present? What facilitates or hampers feeling? What specific emotions and sensations does the client have? Are the emotions linked to particular events or memories? What happens following periods of actual felt experiencing by the client compared to periods when the client merely talks about emotions? What is your experience in each of these situations? Does your client steadily grow in the ability to feel himself across sessions or are there ups and downs? What accounts for these changes over time?

• When is there an interpersonal resonance between the client’s “unformed feelings” and the practitioner’s words or touch? What specific feelings or sensations let you know that there is resonance? What facilitates or hampers it? What happens following periods of resonance? Do the client’s feelings or actions become more clear or less compulsive? Is there a deepening of experience? Is there a change in breathing? Is there a shift in your feelings of connection with the client? Does resonance steadily increase over sessions or are there ups and downs? Why?

• When do you notice feelings of “aliveness” in the client compared to feelings of distance or being closed? How do you notice aliveness in yourself and in the client? What happens in the client and you following such moments of aliveness? Do these moments of aliveness increase or decrease over sessions?

• Where is the body holding tension? Where is there more softness and responsiveness? What facilitates or hinders contacting the tension for the client? What happens in you and in the client before and after the client begins to feel the tension? Does this process change over sessions?

Disconfirming evidence. Note that the foregoing are questions. Taking a scientific stance means that the practitioner does not know the answer to the questions but may suspect, because of clinical experience or theory, that there these phenomena are important for the client’s change process. The goal of documenting using these research methods is to discover what actually does happen. If the theory or one’s long-held beliefs need to change as a result of this process, then it is time to let them go. Careful documentation is the basis for enriching and expanding theory and practice, and one’s own ideas about the work.

The best clinicians keep an open, questioning stance regarding the process of change. What “works” or does not work can be directly confirmed by a change or sameness in the client. As participant observers, it is essential to record things that do not work, the disconfirming evidence, as well as things that do work so that the log reflects what actually does happen. Inherent biases in the log come from feeling that one “knows” what is right for the client or what is wrong with the client, or feeling that one knows what works or does not work for the client.

Staying open, being creative. Let the work speak to you so that the documentary process is a living thing. The research question that kept your focus at the beginning may seem less valuable or appropriate as you continue to observe and write. Participant observation requires that the research questions may change in light of ongoing participation and observation. The research question is not what the study is “about,” but rather the research question guides the work temporarily. Allow your sentiments about what seems important to change. Approach the writing creatively. Documentary work is something that unfolds and is itself part of the discovery process; not something that is done as a mindless chore. The best documentary films are works of creative spontaneity that grow and change in the process of their making, in which the filmmaker learns to follow rather than lead and to let the assembly of images speak for themselves.

RESEARCH QUESTIONS: EXERCISES

1. Think about what makes you curious about your somatic practice in general or a client in particular.

2. Try to formulate one or more research questions based on your curiosity.

SUPPLEMENTARY INFORMATION

Included in this supplement are case examples written by practitioners of Rosen Method Bodywork and Somatic Psychotherapy. A case example of a Feldenkrais Functional Integration Lesson can be found in the article by Goldfarb in this issue of the IFF.

Case Documentation Examples:

Rosen Method, from Sandra Wooten, Rosen Method Bodywork senior teacher and practitioner (used with permission of Sandra Wooten and the client)

This is taken from the cases notes for an adult female who come to the Rosen practitioner with chronic back pain. She had received 11 weekly Rosen sessions prior to the one described here.

Now that the exam she had to take is over I expected more ease in her breath than I found. She was quiet at the beginning, then said that her low back on the right side was bothering her some, she has had headaches for the past three days and a couple of other things. She says she is anxious waiting for the test results. There was a response in her breath with this, but little and I became very curious about what else was there.

As she speaks my right hand is feeling the deep tension in her low back on the right side, my right hand resting on her arm. This low back area remains tense as she talks.

The roommate: Apparently uncommunicative and noisy during the night when he gets up to use the bathroom. She is still locking her door when she is at home. This week her female roommate is gone. What is he doing at all hours of the night, she wonders. He does not participate in any way in the household. She plans to talk with him, but never sees him. This is not news, but an on-going litany of how she has felt about him from the beginning. I feel my shoulders drop and I think to myself there is some kind of resignation within her. I wonder, again to myself, why doesn’t she begin by writing him a letter?? I feel my frustration with this and then, wonder about her frustration. And yet, is it frustration, or something else? These thoughts and feelings move through me, but I just listen to myself and to her.

The ‘giving up” has got my attention. She is quiet again, little movement, but then, gurgling in her belly. Something has shifted, but the breath doesn’t follow. The deep relaxation in her belly is not in her consciousness yet. I’m curious that the breath is not more full. My hands on her are soft and resting, but with an aliveness that is in deep contact.

I don’t know exactly when the word loneliness came to my mind. I noticed the sense of it within myself. I asked her if she was lonely. She became quiet and the breath did move from her sacrum up to her chest. I wanted to allow plenty of room to see how she responded to this. I could see some color come into her face, but there was no expression of emotion. At one point she said her parents were never home. She and her siblings were ‘latchkey’ kids, always going home with no parents there. She and her siblings would fight.

More breath and she says “I really like being with the people I love”. Then, “I wish I had spent more time with my mom before she died.” And “Everyone is too busy now.”

Note:
The exam took over her life for a while, as it would for anyone, I’m sure. She has never liked it that she now has a male roommate, but she was able to put that away during these last couple of weeks before the exam. Now, here is the situation again that she cannot ignore. It seems to me there are many unexpressed words and feelings that tie back into her early life.

Rosen Method, from Gail Bourque, Rosen Method Bodywork practitioner, Physical Therapist, and Somatic Psychotherapist (used with permission of Gail Bourque and the client)

“Melissa” is a middle aged single woman who is very involved in her profession as a teacher. At the beginning of our work together, she said a goal for her was to stop being so busy. She often described herself as quite "rushed", and "tense". She was in fact very tense in her body. She has a particularly difficult chronic pain in her left shoulder that was often the focus of our work. This was her 15th weekly Rosen session.

RANDOM The word came up as M described what some young students said about her. She was, they said, “Random”. We laughed.

M I mean what does that mean. Then the whole class had to go around and say what they thought the word random meant.

M It was a compliment. I think. At first I wasn’t sure. Then I think they meant that I gave all kinds of examples in my teaching, that I was all over the place. But I think that they meant it in a good way.

She takes a big breath.

It’s funny, but that’s the word for the session. Random. We were all over the map. We started by focusing on her upper left back and shoulder girdle. Her “place.” She talked about how she has thought and thought about it, and she can’t figure out what it is all about.

Her shoulder is tight though the rhomboids and the levator scapula and trapezius. All hunched up. She is slowly relaxing, the muscles are twitching and softening. Her breathing is slowing.

G I remember that you had said a goal was to stop rushing. How is that going?

M I am glad you reminded me. I’m not rushing as much. I remind myself that I don’t have to do everything all at once.

G Does rushing have anything to do with your shoulder getting tight?

M Well, maybe. Hmm. I mean when I am rushing I am stressed. And any stress goes to that shoulder first.

She takes a small breath. Like “yep” that’s the truth. But it doesn’t settle in and generate more space.

G Does it remind you of anything? This tightness? Sometimes people get a memory like “oh yeah that was that telephone call, or I remember when I got stressed.”

M Well, I know this sounds funny, but I think it’s because of the cold weather. Sometimes my house is too cold and I hunch up trying to stay warm.

She then pulls her shoulders in and up, just in the way the holding is. This is new information and definitely a thread to follow (in the midst of this randomness).

G Yes. That is exactly how your shoulders are held. All hunched up.

She relaxes down some more. Being met and having a verbal mirror of what her body is doing and/or what she is doing in her body, gives her some security.

But she then goes into a long description of how she is intolerant of her students’ whining about the heat or cold. And that really, she is not a person who complains about the weather or the heat or cold.

She laughs. I work quietly for a while. She is quiet and more relaxed, but present.

G I remember last week, you had a memory about being called Gig because you were so giggly as a child.

M She laughs. Yes, and now my parents have died, no one calls me that anymore. It’s sad, or weird or something. It’s like something is missing. But I did tell my best friend, whom I’ve known for 28 years. She didn’t know that was my nickname.

She talks about nicknames for awhile. She remembers a nickname for her twin brother. “Prunes” and tells the story about how he used to ruin everything. PR ruins everything.

M That’s what is wrong with my shoulder. My brother is what is wrong with my shoulder.

She breaths. She looks softer in her face.

There are a couple of things worth noting here. One is that M said she hadn’t thought about being called Gig in years. But she had told me about the nickname and the meaning many weeks ago, maybe two months ago. It is an interesting thing about memory on the bodywork table. As with trauma memory, although this is a different mechanism, a memory will come up get talked about, and then go back to long term storage as though it had not been remembered. She said it again today, that she hadn’t thought about being called Gig in years.

Another interesting phenomenon is that a person will only be ready to know or hear something when they are ready. We had a session, again months ago, about her shoulder where, following her story, and the threads of her body language, I wondered if the holding had anything to do with her twin brother. She was adamant that it did not. And there was no response in the body at the time, so I let it go. Yet today, she has a new thought, a new experience and a “yes”, a connection with him and her feeling that it is not safe for her to expand into her own full space around him.

Somatic Psychotherapy, from Holifield (1998)(used with permission of Don Hanlon Johnson and Ian Grand).

The client, Dolores, is speaking. “My sister Rebecca and I shared a bedroom. I would lie in my bed and with my fingers I would scratch and peel the paint on the wall. The patch of peeled paint on the wall was big; my sister would be so upset. I didn’t want to feel so upset.”

I see Dolores across from me. To me she looks wide-eyed and frozen in terror. I feel a panicky trembling in my belly which I did not have before. “I wonder if you were really scared,” I say gently and concerned.

“ Yes. My sister would bang her head on the wall to get to sleep.” She added, “I don’t know how she could. I could never do that so I would peel the paint.”

The trembling in my belly and the panic lessen somewhat. “What was that like for you peeling and peeling?” I ask.

“ I don’t know, I guess when I was peeling with my hands like that I wouldn’t think or feel, and it would help me to go to sleep.”

“ What’s you inner experience as you talk to me?”

“ Yeah, I guess I’m holding my breath. I don’t feel so good.”

“ Holding your breath and feeling a little scared. No wonder, given what you’ve experienced in the past. I wonder if you feel uncertain as to how I may respond to you.”

“ No, you’re always very gentle.”

“ Mm. What’s it like inside holding your breath?”

“ I feel tight in my chest, trapped.”

“ Mm…it must have been so frightening for you to feel so alone with your fear and hurt, confused and uncertain what was happening.”

“ My sister and I were there for each other but sometimes she was so upset. I didn’t want to upset her more.”

“ Of course you wouldn’t want to upset her more and see her in pain. It sounds like you were very upset and scared also.”

“ Yeah, I was scared. It was scary.”

“I wonder who was there for you?” I ask.

“ No one,” she says quietly.

“ I can really understand how important it was for you to try not to be upset when your sister was, and it seems sad to me that at times you were so alone and overwhelmed with scary feelings.”

“ Yeah,” she says, a welling in her eye, breathing a little deeper.

I breathe deeper both in a mirroring response and in response to my own inner ease as she is able to integrate some of the powerful affect laden in the account.
We sit quietly with her sadness. In time she says, “I fell better, my chest isn’t so tight.”

“ You’re feeling a little easier, your chest not so tight…and your breath?”

“ Yes, breathing a little more, just experiencing that feeling of breathing a little easier.”

In some small but significant way I feel I have been let into her room, the room she describes as having been so isolated in and trapped. She recounts to me that she and Rebecca together would push the heavy chest of drawers against the door to keep out the terror, the unpredictable. Then Dolores would lie in her bed listening for and not wanting to hear the creaking wood stairs, footfalls, often her father’s, which could only mean the pain of being yelled at or being the target of some heavy object heaved in anger or the hinted-at but hard-to-hold possibility of sexual assault.
And so we worked slowly like this. By attending to my own felt sensation, inquiring into it, I feel on a visceral level some sense of what perhaps Dolores experienced. Through this embodied attunement I can more fully hold an empathic container for her terror. Initially, I thought of my somatic experiences with Dolores as part of a projective identification sequence. As I learned more about our intersubjective field, I came to think of my feelings, like these, as a kind of somatic attunement or resonance. I was experiencing with her what she could not name, experiences about which she was mute.

It is clear to me that there is much more for Dolores to integrate here. At this time, I follow her lead and go on. I’m aware of not wanting to impose anything that could give rise to her again feeling her world overridden by another and trapped again, so I simply work to contain and track her responses and felt sensations. I want to aid her in building an underlying sense of support through her organism, to help her learn that she can feel sensations and find resolve through doing so.

Somatic psychotherapy, from Burstein (1998) (used with permission of Don Hanlon Johnson and Ian Grand).
.
Anne, a forty-five-year-old woman, comes into her session looking agitated. “I’m a wreck,” she moans with an exasperated sigh. “I just came from the doctor. I was sure I was pregnant this time. I had all the signs! Maybe the universe is telling me to give up-but I can’t. My boyfriend desperately wants a child and I know he’ll leave me for a younger woman if I don’t produce…Anyway, I want to be a mother so badly I can’t think of anything else anymore. I dream babies day and night, and my thirty-two-year-old sister-in-law just announced she’s pregnant with her third child. I’m fighting a losing battle against time and it’s killing me.”

Beyond the content of her words, what impressed me most was the movement of urgency in her voice, her face, and her gesticulations. My body reacted with increasing intensity as I listened. Instead of looking for ways to become less urgent, we spent our hour together inquiring into the phenomenon of urgency. “Urgency…well, I can’t actually remember not feeling it.” From a precipitous birth in a taxi-cab en route to the hospital, to standing up and walking at ten months of age because she wanted a toy that no one would bring to her, so much of Anne’s behavior seemed to occur within the context of urgency. “What does urgency feel like in your body?” I asked. Quick with an answer, she replied, “It’s like I can’t get enough breath so I don’t let them out, I just keep taking them in [She demonstrates]. They are shallow. Gee, when I do it my shoulders get all tense. O.K. I see that being urgent all the time is majorly affecting everything but I can’t just turn it off like a light switch, you know. It’s like the air I breathe has urgency in it…I can’t help it, that’s just how it is with me. [She is now sobbing.] What a mess I am. I just want to die.”
“ Whoa,” I cautioned, “let’s slow down here. It sounds as if urgency has moved in on us and is now creating an urgency about not being urgent! All we are doing now is becoming more acquainted with what urgency means to you. We’re on a fact-finding mission. That is all!”

CONSENT TO PARTICIPATE IN RESEARCH

Why is informed consent useful? After discovering abuses done in the name of “science” perpetrated on unwitting prisoners by the Nazis and on minority groups and soldiers by the US government during the early part of the 20th century, the US government adopted guidelines for the protection of human subjects. Although not required by law, the federal government can withhold funding to institutions that fail to comply. A central premise of protecting human subjects is “informed consent.” This means that the research participant must first fully understand the research procedures, their risks and benefits, and the purpose of the study. Only then can the participant make an informed choice.

Another reason is that the informed consent document protects the researcher/practitioner who may wish to publish the case documentation. The client understands this from the beginning. Although research participants are given the option to withdraw at any time, once they sign the document this rarely occurs.

How to use this sample consent form. This sample consent form serves only as a general guideline. You are encouraged to adapt it for your particular needs and for the type of relationship you want to have with your client-participant. It is written is a fairly rigorous way as would be required by policy at a research university. Hence, there are a number of legal protections, such as the disclaimer about abuse, that you may want to eliminate.

Also, in italics, is an optional set of guidelines in case you would like your client to keep notes about the sessions. If you see some value in client documentation, or you have a client who loves to journal about their experiences, you can use this.

RESEARCH PARTICIPANT INFORMATION AND INFORMED PARTICIPANT CONSENT

Title: Change processes in practitioner-client interactions

BACKGROUND
The purpose of this study is to learn more about how change happens during interactions and how change develops within therapeutic relationships. To investigate change processes, we are asking you to participate in a study of the developmental changes that may occur while you are doing sessions with your practitioner. We are interested in how the relationship between you and your practitioner contributes to your development and self-awareness. During the course of the study, your practitioner will be making notes after each session about his or her observations of the changes that occur in your therapeutic relationship. These case notes simply document what your practitioner is already trained to observe. The case notes will be used along with case notes from other practitioners in order to better understand how this therapeutic method can be used to help people like yourself. Your name and any other identifying information will be removed from the case notes, so that you can be assured of complete anonymity and confidentiality.

All you need to do is to attend your regular sessions with your practitioner. During these sessions, please interact with your practitioner as you normally would. We would like this study to represent the normal course of progress over time. Because many developments may take place outside of your sessions, we would also like you to keep a journal of your experiences (see “Procedure” below). You will be asked to write about your reactions to the sessions and to discuss if your understanding of yourself and development has changed.

We wish to emphasize that you have the freedom to withdraw from the study at any time, and that we are not asking you to do anything that makes you feel uncomfortable. Please take the time to read the following information carefully and to discuss it with others if you wish. If you agree to participate, please sign this form at the bottom. If you should have any other questions, you can contact _________________ at ( ) _____- ________ or ________________at ( ) _____-_________.

PROCEDURE
Your practitioner will provide treatment to you in the same manner as she/he would for any client. The only difference is that she/he will be documenting the events of your sessions in writing. During your visits, he/she will go over any questions you may have about the study. You are welcome to ask questions at any time during the study. One of the goals of this research is to use your own words to document reactions to your sessions including changes in your self-understanding and your perspective on the usefulness of the work that you are undergoing. We will ask you to keep a written journal about your experiences. You will be asked to write about your reactions to the sessions and to discuss if your understanding of yourself and development has changed. We will make copies of your journals for analysis. These copies will be only be viewed by people directly involved in the research study. In written reports the case notes will be presented in a way that protects your confidentiality (see “Confidentiality” below).

RISKS OR DISCOMFORTS
Minimal risks are expected in this study. Although we do take steps to ensure that the practitioner’s case notes and your journal entries are not recognized or identified by anyone else, that cannot be guaranteed. You are the person who is most likely to recognize any descriptions in publications from this study. Please be aware that such recognition may cause some discomfort or embarrassment.

BENEFITS OF THE STUDY
Apart from the benefits that you would normally receive from the sessions that you engage in, we anticipate few, if any, direct benefits from participating in this study. We hope that your journals will provide you with special opportunities learn more about your developmental process and self-awareness. You may enjoy knowing that you could be helping practitioners and students who will do this type of work in the future. We will share any knowledge from this study that may be valuable to you and we are always open to answer your questions.

ALTERNATIVE PROCEDURES
The only alternative procedure to participating in this study is to not participate.

CONFIDENTIALITY
The practitioner case notes and the diaries that you have completed will not be made available to any unauthorized persons or to persons not directly associated with this study. These documents will remain in the possession of your practitioner, except when they are being analyzed by research assistants. In that case, all identifying information about you will be removed from the documents.

If you choose to check the box for consent (last page) you agree that portions of your practitioner’s case notes or of your written journal entries may be shown to students in practitioner training or to other practitioners/researchers in the field, or printed in scientific or therapeutic articles or books, as exemplary of the general results. In addition, with increasing technology, the possibilities for sharing scientific research on the internet is expanding. We will specifically ask you whether you would agree to us posting portions of the practitioner case notes or your journals on the worldwide web.

In any case, we will only use fictitious names for you, unless you decide otherwise. If you wish, none of the data and results of the study which are associated with you will bear your name, to ensure confidentiality. Alternatively, you may decide that we can use your real first name for research presentations. This last choice does not ensure complete confidentiality and may expose you to being recognized or contacted by researchers, students, or others who may have learned about this study and who may be interested in learning more. You can check the box at the bottom of this form if you do agree that we use your real names. If you prefer that we use a fictitious name, you can leave this box unchecked.
The only time when we are required to break confidentiality is when we have any evidence that you or someone you report is abusing children or other family members. We are legally required by State law to report this.

PERSONS TO CONTACT
Your participation in this study is strictly voluntary and will in no way be used for anything other than research purposes. If you have any questions, or if you want to learn more about this research, please do not hesitate to contact your practitioner.

OUTSIDE CONTACT PERSONS
If you have questions regarding your rights as a research participant, or if problems arise which you do not feel you can discuss with your practitioner, please contact

_________________________

_________________________
VOLUNTARY PARTICIPATION
We wish to emphasize that your participation in this research study is completely voluntary. After you have signed the consent form, you will maintain the right to withdraw from the study at any time for any reason or without providing a reason. This will not affect the relationship you have with your practitioner.

UNFORESEEABLE RISKS
Although we foresee minimal risks in this study, it is possible that there may be risks that we currently do not anticipate. We will make every effort to minimize risks.

NEW INFORMATION
If new information becomes available that may affect your willingness to participate in the study, your practitioner will discuss this with you and you may decide regarding your continued participation.

CONSENT
By signing this consent form, I confirm that I have read and understood the information and have had the opportunity to ask questions. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving a reason and without cost. I understand that I will be given a copy of this consent form. I voluntarily agree to take part in this study.

Please check all that apply:

I give my permission for the release of practitioner case notes and my journal entries, for the purpose of presentation in instruction or research conferences, or publication in scientific or therapeutic articles or books.

I give my permission for the release of practitioner case notes and my journal entries for scientific or instructional purposes on the World Wide Web.

I give my permission to use my real first name for the purpose of research presentations as indicated above.

I only give my permission to use my research information if all identifying information is removed from the practitioner case notes and my journal entries and fictitious names are used.

I would like to receive articles or other papers about this study

Burstein, C. (1998). Living inquiry. In D. H. Johnson & I.J. Grand (Eds.) The body in psychotherapy: Inquiries in somatic psychology. (119-120).
Elman, D. (1997). F. M. Alexander. In D. H. Johnson (Ed.) Groundworks: Narratives of embodiment. (40-42).
Ely, M. (1991). Doing qualitative research: Circles within circles. New York; Falmer Press.
Fogel, A. (1993). Developing through relationships. University of Chicago Press.
Fogel, A., Garvey, A., Hsu, H., & West-Stroming, D. (2006). Change processes in relationships: A relational – historical research approach. Cambridge, UK: Cambridge University Press.
Glazer, M. (1980). The threat of the stranger. Briarcliff, NY: The Hasting Center Report.
Goffman, E. (1989). On fieldwork. Journal of Contemporary Ethnography, 18, 123-132.
Heshusius, L (1994). Freeing ourselves from objectivity. Educational Researcher, 23, 15-22.
Holifield, B. (1998). Against the wall / her beating heart: Working with the somatic aspects of transference, countertransference, and dissociation. In D.H. Johnson & I.J. Grand (Eds.) The body in psychotherapy: Inquiries in somatic psychology. (66-68).
Jansen, G., & Peshkin, A. (1992). Subjectivity in qualitative research. In M. D. LeCompte, L. W. Millroy, and J. Preissle (Eds.), The handbook of qualitative research in education. San Diego, CA: Academic Press.
Lavelli, M., Pantoja, A. P. F., Hsu, H.C., Messinger, D., & Fogel, A. (2003). Using microgenetic designs to study change processes. In D. G. Teti, (Ed.), Handbook of research methods in developmental psychology. Cambridge: Blackwell Publishers:
Moustakas, C. (1994). Phenomenological research methods. Sage.
Ricoeur, P. (1991). Life in quest of narrative. In D. Wood (Ed.), On Paul Ricoeur: Narrative and interpretation. London: Routledge.
Spradley, J. (1980). Participant observation. New York: Holt, Rinehart, & Winston.

Alan Fogel, PhD
Professor of Psychology, University of Utah, alan.fogel@psych.utah.edu

About the author: Alan Fogel does research on individual differences in social and emotional development during parent-infant communication, and in somatic awareness practices with adults, including the effects of Feldenkrais Functional Integration lessons on autistic adults’ ability to communicate and express emotions, and the role of emotional self-awareness using Rosen Method Bodywork with sufferers of chronic back pain. Professor Fogel is a Rosen Method Bodywork practitioner. He also collaborated with Marc Reese, Feldenkrais practitioner and teacher, to develop a series of Feldenkrais Awareness Through Movement lessons, published in A. Fogel (2001) Infancy: Infant, family, and Society, that replicate the movements and postures of infants. Fogel has lectured world-wide to audiences of psychologists, developmental scientists, infant and family mental health practitioners, and practitioners in multiple forms of somatic awareness and somatic psychotherapeutic methods. He has authored multiple books and over 100 research articles. His research approach is qualitative and holistic. The author conducts experiential workshops for parent-infant mental health practitioners, in Rosen Method Bodywork, and in research methods for documenting cases for somatic awareness practitioners. For more information, see http://www.psych.utah.edu/lab/somatics/.