Mary Ablett dissertation

Institute for Clinical Social Work

Mindfulness Practice Uses in Countertransference: A Phenomenological Study

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Mary Brooks Ablett

Chicago, Illinois

June 2023

Abstract

This qualitative study sought to explore and understand the subjective experience of psychotherapists who are trained in mindfulness-based practices and how this affects countertransference (CT). The complex nature of CT and the various definitions of the concept warrant more study of the transtheoretical phenomenon. The present study is one of the few studies to examine the internal and external responses associated with CT and the ways mindfulness-based practices may be used in psychotherapy. This study provides a rich and detailed examination of CT and mindfulness-based practices through the methodology of interpretative phenomenological analysis. Six psychotherapists participated in semistructured interview revealing four themes: transformation of the self, respond versus react, holding space, and emotional regulation. Results support that mindfulness-based practices may increase greater emotional self-awareness, emotional regulation, and the other primary emotional regulatory skill of modifying emotional responses during stressful clinical situations that may include countertransference. Results also provide evidence that mindfulness improves empathy and compassion and promotes an attitude of curiosity and openness towards one’s experiences. Through this study’s exploration and analysis, relational and theories of intersubjectivity are offered as important in informing clinical work for psychotherapists who practice from a variety of theoretical orientations. Implications for theory, practice, research, training, and professional development were discussed. Study limitations were also identified.

For my husband, Matt, my son, Brian, and my cohort buddies, Julianna and Claire.

Acknowledgements

I would like to acknowledge the direction and support of my dissertation committee: Denise Duval-Tsioles, PhD, Kerstin Blumhardt, PhD, and Michelle Piotrowski, PhD, and the additional support of Karen Baker, LMSW and Patricia Seghers, PhD. I would also like to thank Stephanie Swann, Ph.D. for her support and assistance with the recruitment in this study. I want to acknowledge the guidance and support of my mentor, Jack McDowell, PhD. He has participated in and observed my personal and professional growth for more than 20 years. Thank you is extended to all the gracious participants in this study. I benefitted from each one of their stories.

mba

Specific

Theoretical and Operational Definitions of Major Concepts

Statement of Assumptions

Epistemological Foundation of the Project

Classical Conceptualization

Totalistic Conceptualization

Complementary Conceptualization

Relational Conceptualization

Integrated Conceptualization

Structural Theory of Countertransference.

Countertransference Research

Countertransference Management

Mindfulness

Empirical Research on CT and Mindfulness

Conclusions

III. Methodology...................................................................................................94

Rationale and Research Approach

Research Sample

Research

Demographic

The Researcher’s Role

Data Collection

Data Analysis

Ethical Considerations

Issues of Trustworthiness

Limitations and Delimitations

List of Abbreviations

CBCT Compassion-Based-Cognitive Therapy

CBT Cognitive Behavioral Therapy

CT Countertransference

DBT Dialectical Behavioral Therapy

MB Mindfulness-Based

MBCT Mindfulness-Based-Compassion Training

MBSR Mindfulness-Based-Stress-Reduction

PMR Progressive Muscle Relaxation

Chapter 1

Introduction

General Statement of Purpose

This phenomenological study aimed to explore the subjective experiences of psychotherapists who regularly practice mindfulness and its use in countertransference (CT) processing. This study attempted to deepen the understanding of the internal and external responses associated with CT and how mindfulness practices may be used in the therapy process. Psychotherapists can have a range of affective, emotional, cognitive, and behavioral responses to their clients (Betan et al., 2005). Mindfulness has been defined as the awareness that develops out of intentionally attending in an open and discerning way to what is happening in the present moment (Shapiro, 2009). This refers to the internal environment (e.g., a clinician’s affective, cognitive, and bodily experience) as well as the external environment (e.g., a client’s current feelings and reactions). In its most simple form, mindfulness practice involves “paying attention on purpose and in a particular way” (Kabat-Zinn, 1990, p. 23). However, mindfulness is not simply attention but “how one attends” (Shapiro et al., 1998, p. 583). It involves cultivating an attitude of nonjudgmental acceptance that encompasses all in the here and now (Gilbert & Waltz, 2010; Hayes et al., 2006).

For this study, CT was defined as “therapists’ idiosyncratic reactions (broadly defined as affective, cognitive, somatic, and behavioral) to clients that are based primarily in therapist’s own personal conflicts, biases, prejudices, or difficulties (e.g., cognitive biases, or personal narratives, or maladaptive interpersonal patterns)” (Gelso & Carter, 1994; Gelso & Hayes, 2007; Langs, 1974, as cited in Fauth, 2006, p. 17). These reactions can be conscious or unconscious and triggered by transference, client personality, diagnostic characteristics, or other aspects of the therapeutic situation (i.e., termination), but not extratherapy factors. Research has demonstrated that clinicians may have the tendency to have similar responses to certain personality disorders and client symptomatology (Betan et al., 2009). This definition retains the hallmark characteristic of CT and combines contemporary research, which distinguishes a therapist’s reactions from their reciprocal reactions to the client’s personality traits (e.g., borderline or narcissistic). In contemporary relational psychotherapy, CT is now generally understood to be a universal phenomenon that is coconstructed in the therapeutic relationship by both therapist and client (Gelso & Carter, 1994; Gelso & Hayes, 2007; Mitchell, 1993).

CT as a construct has experienced conceptual shifts and expansions.

Contemporary psychodynamic theory on CT supports it is a universal phenomenon that occurs in short- and long-term therapy (Gelso & Hayes, 2007), and it is considered part of all therapeutic relationships regardless of theoretical orientation (Gelso & Carter, 1994). Both positive and negative feelings of CT are inevitable because clinicians consciously and unconsciously experience feelings “as people are relational beings and carry their own past experiences into therapy” (Gelso & Hayes, 2007, as cited in Guest,

2019, p. 7). Research has shown that CT behaviorally manifests in a combination of avoidance and approach responses to clients (Gelso & Hayes, 2007; Hayes et al.,1998; Rosenberger & Hayes, 2002). Both psychotherapy and mindfulness practice can provide support for the individual to examine feelings, cognitions, and behaviors without reacting in habitual or automatic responses of avoidance or escape. Although a therapist may not be able to control their feelings or thoughts, they can control the way they behave.

CT can be used as a therapeutic method to interpret a client’s relationships with others. In doing so, the psychotherapist must also examine the relationship between themselves and the client because the therapist is an active participant in therapy. One of the most crucial elements of psychotherapy is the quality of the relationship, specifically the therapist’s attitude of openness and acceptance in the therapy room (Germer et al., 2013). The objective should be to maintain a high level of awareness of feelings as they change during the analytic hour and what meanings are placed on these sensorial experiences, “because our feelings are the most sensitive indicators of what is going on in the interpersonal situation” (Searles, 2017, p. 204, as cited in Loewenthal, 2018). Although the therapy relationship is of utmost importance, so is the ability for the therapist to keep the client as the primary object of awareness and become less reactive to what is happening to them in the present moment (positive, negative, or neutral; Didonna, 2009). The intersection of psychotherapy, CT, and mindfulness practice can be viewed as complementary and supportive by nature of their design.

Significance of the Study of Clinical Social Work

To integrate mindfulness into one’s clinical practice, a psychotherapist needs to experience mindfulness. Beneficial to the field of clinical social work and psychodynamic thinking is the study of mindfulness-based (MB) practices and the potential role it can have within the understanding of CT. Therapists experience CT individually and uniquely, and therefore a qualitative research approach is highly applicable. This phenomenological study can enhance therapeutic methods and expand the understanding of psychotherapy, thus directly informing the practice, education, and research in clinical social work. This qualitative research study is concerned with how subjective experience and embodiment come together to understand better oneself and the world around us. The detailed descriptive data and the analysis support the psychodynamic and mindfulness view that the “place of the body as a central element in experience must be considered” (Smith et al., 2019, p. 19). A client’s subjective, lived experience can never be completely understood but must not be glossed over or ignored (Smith et al., 2019). Instead, it must be examined closely to reveal new information that can provide data for future empirical research.

This study is important because it advances the understanding of mindfulness and possibly identifies the specific clinical mechanisms that are helpful for participants. The study may also expand understanding of mindfulness as a therapeutic tool to be used in external and internal experiences of CT. This study can add to the research on CT because it explores the CT problems therapists experience and how they address personal biases, prejudices, and conflicts during psychotherapy sessions. It has the potential to

identify diagnostic material, expand conceptualization of clinical case material, and contribute to the efficacy of the therapeutic relationship. The findings of this study could have implications for clinical training programs, professional development, and supervision. The results could also lay the groundwork for future research of the personal and professional characteristics of therapists as they interact with client personality traits and experiences (Liebman & Burnette, 2013).

Clinical Practice

Lapses in professional bounds and negative therapeutic outcomes have been reported as a result of psychotherapists’ lack of CT awareness or poorly managed CT responses (Bhola & Mehrotra, 2021). Therefore, unresolved CT issues may be at the core of unethical behavior. Malpractice claims are not based on a therapist’s feelings or thoughts. Rather, malpractice claims are based on behaviors in response to feelings and thoughts. In some situations, therapists may have their license suspended or revoked, and CT problems for therapists in training can result in choosing an alternative career path, which can be unpleasant and disappointing for all involved (Gelso & Hayes, 2007). The National Association of Social Workers’ (2017) Code of Ethics identifies a “do no harm” policy for clients as the primary ethical responsibility for social work practitioners. Therefore, the clinical social worker or psychotherapist has the ethical responsibility to examine CT reactions within psychotherapy and regulate certain affective, emotional, cognitive, and behavioral responses to maintain ethical standards of practice and to improve professional practice as well (Southern, 2007). Deepening the understanding of

individual CT responses and learning to resolve problematic internal or external reactions are each an important item in the psychotherapy process.

The contemporary understanding of CT regards it as potentially useful and as a mutually created phenomenon between the therapist and the client (Guest, 2019). The nature of the relational context allows for the understanding of countertransferential material (Stern, 2019), which is considered critical to treatment progression to be able to recognize, cope, and make application of countertransferential material (Hayes et al., 2011). The inability to cope with CT effectively can negatively affect and potentially cause harm to the therapeutic relationship, and therefore it can be damaging for the client (Hayes et al., 1997, as cited in Millwood & Halewood, 2015). Research has suggested that the majority of therapists experience CT and may feel negative emotions such as hate, envy, fear, dislike, and boredom during their interactions with clients (Gelso & Hayes, 2007; Millon & Halewood, 2015; Winnicott, 1949).

Whether affect, thought, or experience of CT is perceived as positive or negative, the inability to identify, control, or regulate affective, emotional, cognitive, and behavioral responses can influence the therapist to act out (i.e., CT enactment) to relieve the discomfort within the experience (Millon & Halewood, 2015). In a meta-analysis, Hayes et al. (2011) found that acting out on CT responses, as measured on a supervisorrated inventory of CT (Friedman & Gelso, 2000), was associated with poor therapeutic outcomes and that successfully managing a CT response was associated with improved outcomes. Exploring psychotherapists’ cultivation of mindfulness practice on CT

responses can improve ethical standards of care and potentially improve clinical practice and treatment efficacy.

Psychodynamic Concepts: Clinical Social Work Education and Research

Although CT originated in psychoanalysis, its definition has evolved over the years. Initially described negatively as “obstruction to the freedom of the analyst’s understanding of the client” (Sander et al., 1973, as cited in Sander, 1976, p. 43), CT was once viewed as a barrier to the analyst delivering effective treatment. Over the years, the concept gradually expanded to include the total reactions to a client in a therapeutic encounter (Colli & Ferri, 2015). However, there are emotional responses to client situations that are not considered CT material. The totalistic perspective is so ambiguous and general that it may dilute the clinical value and be of little use scientifically (Gelso & Hayes, 2007). Eventually, the concept was divided into objective (or homogenous) reactions or subjective (or idiosyncratic) reactions (Winnicott, 1949). Therefore, CT reactions can hold both personal and diagnostic material (Betan et al., 2005). This view emphasizes that therapists’ CT reactions can be normalized, are inevitable for some populations and clinical situations, and need to be explored (Rasic, 2010).

This study uses an “integrated” definition of CT that recognizes earlier viewpoints but is different in some significant ways (Gelso & Hayes, 2007, p. 25). Gelso and Hayes are well-known theorists who developed this integrated model and operationalized CT as “the therapist’s internal or external reactions that are shaped by the therapist’s past or present emotional conflicts or vulnerabilities” (p. 25). These conflicts may be historical,

current, or ongoing. CT involves internal reactions (e.g., feelings, thoughts, and somatic sensations) and external reactions (e.g., verbal and nonverbal behaviors). Modern views of CT consider it to be a transtheoretical construct occurring across all types of therapy (Colli & Ferri, 2015). Therefore, CT occurs beyond the field of clinical social work and outside of the psychoanalytic or psychodynamic practitioner’s office. Although a number of different theoretical approaches can be used in clinical work, clinicians and researchers generally agree that Freud’s concept of transference–CT has been “expanded and (re-)incorporated into all forms of psychotherapy” (Barsness, 2018, p. 249). In addition, CT can be characteristic to all therapeutic relationships, but the degree of importance and focus placed in therapy may differ within a clinical situation and a therapist’s theoretical frame (Fatter & Hayes, 2013). This study hopes to increase discussion of CT outside the scope of psychodynamic practices to expose a larger percentage of clinicians to the CT literature and its usefulness in the therapeutic relationship and treatment outcomes. The exploration and practical implications of mindfulness practice and CT can ultimately expand clinical social work education, training, supervision, and research beyond the 50-min session and the borders of psychodynamic practices.

Statement of the Problem

Mindfulness has become increasingly popular in the field of psychology and has been acknowledged as an effective therapeutic mechanism (Razzaque et al., 2013) and accepted as a conventional construct within psychotherapy practice (Davis & Hayes,

2011). Mindfulness practice is understood to promote attention to moment-to-moment experiences with less judgement and reactivity, as well as with increased awareness and acceptance (Kabat-Zinn, 1990). Mindfulness originated from Buddhist traditions, and the concept of mindfulness places importance on the embodied awareness and gaining insight to the “true nature of reality as dynamic and impermanent” (Gunaratana, 2002, as cited in Millon & Halewood, 2015, p. 189). Research has suggested that a psychotherapist’s ability to effectively respond to CT contributes to the therapeutic relationship’s efficacy (Gelso & Hayes, 2007). The “how” of the previous statement and the details of clinicians’ mindfulness practices relative to CT experiences has been minimally explored in the research literature (Millon & Halewood, 2015). It is the objective of the study to provide further exploration of the uses of mindfulness within CT.

The interest in and study of mindfulness practices has increased within the psychology literature and has been reported as one of the most researched topics in the last 25 years (Germer et al., 2005). Mindfulness as a transtheoretical construct is being used and integrated into different therapeutic models (i.e., humanist psychology, psychoanalysis, cognitive-behavioral therapy, constructivism, evolutionary psychology, brain science, positive psychology, and traumatology). Research on mindfulness has shown improvement of attention skills and awareness to body sensations, feelings, thoughts, and environmental surroundings (Germer et al., 2013). Research has also suggested that mindfulness meditation can facilitate therapists’ awareness of their CT (Chalif, 2001; Epstein, 1995, 2004; Fauth et al., 2007, as cited in Davis, 2011).

Neurological research has also shown that mindfulness meditation can foster an individual’s capacity to be emotionally attuned to others and develop sensitivity to physiological sensations (Siegel, 2007). It has been reported that mindfulness meditation may not only connect one to the self, but it may also cultivate a sense of connectedness with others and with a greater whole (Shapiro & Schwartz, 1998, as cited in Shapiro et al., 1998). Due to the continued growth and integration of psychotherapy and mindfulness, more research is needed to understand better which MB interventions (MBIs) work, how they work, and which strategies are more effective for both health care and client populations (Didonna, 2009).

Therapists’ CT feelings may be informative about the client’s entire treatment process. Over the years, empirical studies have contributed to the evolving definition of CT, but challenges still remain in how to approach such a methodology for measuring an elusive concept. What is the distinction between habitual CT patterns and situational affective reactions? What happens if CT is not dealt with appropriately? Research on CT has demonstrated that unresolved CT may impede therapy in several ways (Gelso & Hayes, 2007; Hayes & Gelso, 1993; Hayes et al., 1998; Hayes et al., 1997; Rosenberger & Hayes, 2002; Van Wagoner et al., 1991). For example, poorly managed (e.g., unexamined or undiagnosed) CT can lead to avoiding behaviors, becoming overinvolved in clients’ issues, having anxiety, and having distorted perceptions of clients. Furthermore, possible externalized behaviors can manifest, which include blaming, ignoring, or rejecting clients (Gelso & Hayes, 2007; Katz & Johnson, 2006). One key ingredient is whether the internal responses are managed effectively to prevent the

therapist from acting out, and when the therapist “does behave in a CT-based fashion, whether such reactions can be effectively dealt with after the fact” (Gelso & Hayes, 2007, as cited in Fatter & Hayes, 2013, p. 502). CT as a complex phenomenon is acknowledged consistently throughout the theoretical and empirical literature.

CT responses can be complex and present in conscious and unconscious subtle and obvious ways (Katz & Johnson, 2006). There are countless possibilities in terms of how the mind with its affective and cognitive components can present and affect the therapeutic responses in sessions. Empirically bridging the gap between the therapist’s cultivation of mindfulness as it relates to CT processing could potentially contribute to the empirically supported relationships between therapists and clients (Norcross, 2002).

Investigation into the role of mindfulness and deepening the understanding of the way and the extent to which therapists use mindfulness to process their CT will benefit the clinical relationship and therapy outcomes.

The terms mindfulness and countertransference have developed a wide use in psychotherapy and are associated with many different theoretical orientations. However, is it possible that overusing these terms may produce a risk that therapists will gloss over the complexity and nature of the underlying constructs? The use of the phenomenology approach in this study seeks to deeply explore and analyze the subjective experienced of a small sample of experienced psychotherapists who regularly practice mindfulness and how it may be used in CT processing. This study could help clinicians understand the nuances of how CT emerges in therapeutic encounters. The qualitative investigation of psychotherapists’ lived experience will expand the understanding of mindfulness and CT

processes that can bridge the gap between theory and practice. This qualitative method also allows for new discoveries and appreciation for the microscopic level of understanding within the therapy relationship.

Specific Objectives to Be Achieved

The specific objectives are as follow:



To describe the phenomenon of mindfulness practice and CT through interviews with psychotherapists



To explore the cultivation of mindful practice methods psychotherapists may use in relation to CT responses



To discover the possible clinical utility of mindfulness techniques in CT processing



To discover if and how mindfulness practice may change psychological tension or discomfort felt during a CT experience



To discover emerging themes, commonalities, and trends via data analysis, with the expectation that mindfulness practices may increase awareness of the presence of CT

 To explain data findings, apply knowledge, and provide information that can benefit policy, practice, and research in clinical social work

 To lay the groundwork for future research on this topic

Research Question to Be Explored

The primary question for this study is as follows: What is the subjective experience of psychotherapists who practice mindfulness and examine CT? Although this is the main research question, several subquestions will help to deepen the answer to the topic.

Research Subquestions

1. How do psychotherapists, who acknowledge using mindfulness practices, use these practices professionally?

2. How might a mindfulness practice affect the therapeutic process with a client?

3. How do therapists who use mindfulness practices conceptualize the phenomenon of CT?

4. How do psychotherapists who use mindfulness process CT?

5. How can mindfulness practice inform psychodynamic thinking?

Theoretical and Operational Definitions of Major Concepts

Psychotherapist

For this study, psychotherapists are defined as clinicians who hold at least a master’s degree in clinical social work and maintain a clinical license in social work. The terms clinician and psychotherapist are used interchangeably in this study.

Mindfulness

Mindfulness has a range of definitions because the term refers to a psychological process of being mindful, the known experience of mindful practice, and a theoretical concept (Germer et al., 2005; Kostanski & Hassed, 2008) that can be applied to clinical, educational, and scientific contexts (Siegel, 2007). The short-hand definition is “the awareness that arises through intentionally attending in an open, caring, and discerning way” (Shapiro & Carlson, 2017, p. 10). Kabat-Zinn (1990), the pioneer of mindfulness practices in the medical field, described mindfulness as “the intentional cultivation of attention and sustaining it over time in a disciplined way” (p. 283). The definition of mindfulness that is most frequently cited in the literature is “moment to moment awareness of one’s experience without judgement” (Davis & Hayes, 2011, p. 198). For this study, the definition of mindfulness is viewed as a multidimensional construct with five facets: (a) observing and noticing sensations, (b) describing an individual’s internal experience with words, (c) acting with awareness and concentration, (d) being nonreactive toward an individual’s inner experience, and (e) being nonjudgmental of experience (Baer et al., 2006).

Countertransference

For the purpose of this study, the concept of CT is defined as “therapists’ idiosyncratic reactions (broadly defined as affective, cognitive, somatic, and behavioral) to clients that are based primarily in therapists own personal conflicts, biases, or difficulties (e.g., cognitive biases, or personal narratives, or maladaptive interpersonal

patterns)” (Gelso & Carter, 1985, 1994; Gelso & Hayes, 1998, 2007; Langs, 1974 as cited in Fauth, 2006, p. 17). These reactions can be conscious or unconscious and triggered by transference, client characteristics, or other aspects of the therapeutic situation (i.e., termination), but no extratherapy factors. This moderate definition retains the hallmark characteristic of CT and combines contemporary research, which distinguishes a therapist’s reactions from their reciprocal reactions to a client’s personality (i.e., borderline, narcissistic traits).

Negative and Positive CT Reactions

The concept of CT includes both positive and negative feelings, but a gap exists in the clinical literature on clinicians who experience negative responses or negative feelings about their clients (Guest, 2019). Negative responses to CT may include negative feelings or reactions the therapist experiences toward the client, such as avoidance behaviors, withdrawal, criticism, anxiety, anger, and disgust (Friedman & Gelso, 2000). For example, a psychotherapist may have responses such as feeling overwhelmed or disorganized within the therapeutic relationship and seek to avoid or terminate early with the client to escape strong negative feelings. These may include clients who have severe personality psychopathology such as borderline or narcissistic personality traits and can induce higher levels of stress for the therapist (Fauth, 2006). Another study investigating CT and therapist responses to working with narcissistic personality disordered clients found that CT reactions can “provoke enactments of judgment, harsh comments, premature interpretation, criticism and/or accusatory statements” (Gabbard, 2009;

Ronningstam, 2016, as cited in Tanzilli et al., 2017, p. 190). Object relational theorists propose that the client may cause the clinician to experience the feelings that the client is having difficulty recognizing or may be “hooked” or pulled into enactments that mirror the client’s relational expectations or early trauma (Barsness, 2018; Gabbard, 2001). In addition, psychotherapists can respond by disengaging, which may manifest in feeling bored, withdrawn, distracted, helpless, or annoyed in session. It is clinically important for the therapist to regulate their emotions and conditioned responses and be constantly aware of them to prevent reacting outwardly (Shapiro & Carlson, 2017). If CT is not dealt with effectively, the therapists’ reactions subsequently may harm the therapeutic relationship (Guest, 2019).

Conversely, positive CT feelings and responses can also manifest in ways that may be harmful to the therapeutic relationship. For example, if a clinician is empathically attuned to the client, whom they may identify with due to an unresolved or resolving area of conflict, this identification can result in loss of objectivity or overidentification with the client, which can then lead to reacting countertransferentially (Friedman & Gelso, 2000). These reactions could result in chronic CT where the clinician may relax boundaries that manifest in responses such as extended sessions, after-hours phone calls, or reduction of professional fees (Gelso & Hayes, 2007). Although CT feelings such as empathy are perceived as positive, the consequences can potentially compromise the therapy relationship if poorly understood and unresolved. It is often necessary in therapy to understand strong emotional responses created in the therapeutic alliance and “to create a holding space for them” (Shapiro & Carlson, 2017, p. 32). The “holding space”

is the space between felt experience and acting out on feelings and thoughts. This is the space of exploration, curiosity, and containment.

The present study focuses on how mindfulness practice may be an important therapeutic tool in the CT experience. Mindfulness practice encourages acceptance, openness and nonjudgmental attention to the present moment not necessarily because we like it but because it is already happening. Mindfulness practice aims to bring clarity to the current situation where a clinician can “consciously discern what is needed and respond in an appropriate and skillful way” (Shapiro & Carlson, 2017, p. 12). This process of reperceiving information cultivates more attention to the clinical data contained in each moment, possibly even material that was previously too uncomfortable to examine (Shapiro & Carlson, 2017). Thus, mindfulness practice may encourage an investigative method for the internal CT responses, improve the clinician’s tracking of his or her CT responses, and assist therapists with improving self-awareness and responsiveness within the therapy relationship. There is potential for mindfulness practice to reduce the therapist’s automatic responses that are reactions on an unconscious level and bring these reactions into consciousness (Hayes, 2002). Ultimately, this process can facilitate therapeutic change and growth.

Statement of Assumptions

Clinical experience and scholarly research may lead to several assumptions that could have affected this study’s interviewing process and data analysis. These assumptions are as follows:

 The participants may be motivated to share their experiences freely and honestly.

 The participants may be reluctant to share experiences of negative feelings, biases, or stereotypes of clients.

 The participants and interviewer may experience CT during the interview process.

 Biases or stereotypes may be present in a CT definition.

 A mindfulness practice may have a personal meaning for each subject and can incorporate numerous affective, cognitive, and behavioral practices.

 A mindfulness practice may increase an individual’s awareness and attention to the “here and now” and facilitate acceptance of the present moment.

 The CT concept has many different definitions and may be considered challenging to operationalize for many clinicians.

 CT is a universal phenomenon and may advance the work of therapy so long as the therapist seeks to understand and use the CT therapeutically.

 Understanding how a mindfulness practice is used within the CT experience may benefit the clinical relationship, training, supervision, and education.

 Participants may be reluctant to disclose their negative CT with clients because it contradicts the “healing” or “helping” expectation of acting in the role of psychotherapist.

Epistemological Foundation of the Project

Based on the research questions, a phenomenological epistemology was selected due to its alignment with the desired product of study. This qualitative method provided

an opportunity to delve into questions of meaning and subjective experience and to examine the process of mindfulness and CT with a small population of mental health professionals. There is great latitude and freedom in this approach, and it employs disciplines of both psychology and philosophy.

Phenomenology has roots in early 20th-century European philosophy and allows for an in-depth description and close analysis of lived experience to understand how meaning is created through embodied experiences (Starks & Trinidad, 2009).

Phenomenology contributes to a “deeper understanding of lived experiences by exposing taken-for-granted assumptions about the ways of knowing” (Sokolowski, 20002, as cited by Starks & Trinidad, 2009, p. 1373). Sokolowski (2002) expanded on this:

Phenomenological statements, like philosophical statements, state the obvious and the necessary. They tell us what we already know. They are not new information but even if not new, they can still be important and illuminating, because we often are very confused about such trivialities and necessities. (p. 57, as cited in Starks & Trinidad, 2009, p. 1373)

Reality in phenomenology is understood through embodied perceptions. Through closely examining subjective experiences, a phenomenological analysis can describe the meaning and commonalities, or essences, of an event or experience. The accuracy of the event, as an abstract entity, is subjective and understandable only through embodied experience; the meaning of an event is captured through the actual experience of moving through space and time. Einstein once remarked on the phenomenological perspective in his description of the difference between embodied time and chronological time: “Put

your hand on a hot stove for a minute, and it seemed like an hour. Sit with a pretty girl for an hour and it seemed like a minute. That’s relativity” (Starks & Trinidad, 2009, p. 1374).

Phenomenologists are interested in common features of the lived experience. The ultimate goal of phenomenology research is to understand how individuals live and make sense of a particular experience. The qualitative analysis is inherently subjective because the researcher is the instrument of analysis. Although diverse samples might provide a broader view from which to capture a phenomenon’s essence, data from only a small sample who have experienced the phenomenon and who can provide a detailed account of their experience might reveal something new to be studied (Starks & Trinidad, 2009).

Working with an embodied mind in psychotherapy supports psychodynamic thinking and the combination of mindfulness approaches in relation to the CT experience. The body can inform the work done in psychotherapy and is an integral part in understanding the mind. The subjective experience of the two-person psychology creates a third space for the therapist of intrapsychic inquiry and self-examination. The phenomenological approach supports an inductive process of inquiry. This study’s outcomes can provide the groundwork for future qualitative and quantitative research.

Foregrounding

As the interest in mindfulness grows among researchers and clinicians, its conceptual meaning warrants clearer articulation to reduce confusion, especially as it relates to therapeutic application. The closely aligned relation between theory and

practice, where theory is one step ahead of practice, is critical for the development of both (Westen, 2002). The overgeneralization of this term can bleed into other literary circles and further dilute the meaning. For example, a recent book entitled Zero Proof: 90 Nonalcoholic Recipes for Mindful Drinking provides evidence of the word’s expansion to the cookbook genre (Ramirez, 2021, as cited in the Atlanta Journal Constitution, April 10, 2021). The word mindfulness has become a figure of speech, overly simplified, with no clear meaning. One of the major problems to consider is the use of a single term to describe a multiplicity of phenomena such as mindfulness.

In terms of the concept of mindfulness, what does it mean clinically? What does it mean relationally? What does it mean empirically? How can mindfulness practices inform psychodynamic thinking? What can the mindfulness approach offer clients who suffer from conditions such as anxiety, trauma, depression, and substance abuse? My interest in studying mindfulness first developed in research and training on the role of emotional response styles, most specifically experiential avoidance related to anxiety, trauma, grief, and bereavement. I understood that avoidance of pain and suffering was a natural and adaptive response to unpleasant events and sought additional clinical training to increase my understanding of response types and methods to help alleviate the suffering of clients. I participated and became trained in Mindfulness-Based Stress Reduction, a stress reduction program developed by John Kabat-Zinn (1990/2013) through the Stress Reduction Clinic at the University of Massachusetts medical Center. The program was originally developed to provide an alternative and complementary

treatment for chronically ill clients who had not benefitted from the traditional health care programs offered at the time (Kabat-Zinn, 1990/2013).

MB skills are incorporated in multiple treatment modalities that have been adapted to treat a variety of clinical conditions. Acceptance and commitment therapy (ACT) is one well-established, empirically supported MB approach that has some similarities to a psychodynamic approach. Both approaches strive to develop and expand psychological flexibility that fosters emotional exploration with openness and curiosity (Germer et al., 2013). I was trained in ACT several years ago and most recently became trained in compassion-based cognitive training, a system of contemplative exercises designed to develop and maintain compassion. These practices include mindfulness training in increased emotional awareness and examining cognitive patterns to understand better one’s relationship with self, others, and the world. The techniques aim to cultivate an inclusive and more accurate understanding of others (Negi, 2018).

Sixty years ago, it was a luxury to treat only the mind. However, scientific research advances in fields of cognitive neuroscience, neurobiology, and neuropsychology have validated what has for many years been understood as the gestalt; that is, the whole is greater than the sum of its parts (Katz & Johnson, 2006). As contemporary therapists, we evaluate and treat both the mind and body together. They cannot be separated. My ongoing research interests in the fields of cognitive neuroscience, neurobiology, psychoanalysis, and behavioral sciences complement my treatment approaches with a variety of populations. A closer analysis of the term mindfulness motivates my dissertation topic. This study does not aim to answer the

numerous questions listed above; rather, the goal is to encourage psychodynamic discourse and generate more specificity in understanding mindfulness as a therapeutic mechanism within the CT process. Although the CT construct has been established in psychoanalytic theory since its inception, its meaning and utility over the years within the therapy relationship have evolved and held multiple definitions. Regardless of conceptual understanding, research has indicated that the majority of, if not all, psychotherapists experience CT reactions (Gelso & Hayes, 2007; Hayes et al., 1998). Hayes et al. (1998) found that among eight experienced therapists who ranged in theoretical orientations and whose peers considered them experts, the therapists identified that CT occurred in 80% of the therapists’ 127 therapy sessions. Yet, several questions remain: Which CT features are universal? Can an individual objectively measure CT? How do therapists experience CT? What are the ethical responsibilities of effectively using CT in the therapeutic relationship to advance positive outcomes? These questions provide a glimpse into my curious mind and inquisitive nature, and they helped to generate my research topic and approach. However, the limitation of this dissertation project will narrow its focus on exploring the in-depth experiences related to a small sample of psychotherapists’ mindfulness practice and CT experiences. This is my scholarly contribution that aims to bring awareness to and an understanding of how mindfulness related to the CT process can inform psychotherapy and how psychotherapy can enrich mindfulness and the CT process.

Chapter 2

Literature Review

This phenomenological study aimed to explore the subjective experiences of psychotherapists who regularly practice mindfulness and its use in CT processing. This study attempts to deepen the understanding of the affective, cognitive, somatic, and behavioral responses associated with CT reactions and how mindfulness practices may be used in CT awareness, experience, and processes. The study also hopes to build upon the existing empirical research that links mindfulness and CT as complementary within the therapeutic relationship. This chapter will provide a systematic review of empirical research on CT and examine its relationship to CT management, mindfulness, and the CT experience of therapists.

The increasing attention on the relational aspects of the therapeutic process has brought more focus to CT responses that may be inevitable in clinical work (Bhola & Mehrotra, 2021). CT research is important because therapists’ and clients’ reactions and the ways in which they are understood and responded to are central to the psychotherapy process (Fauth, 2006). Therapists’ awareness of CT responses is also considered important because it has the potential to provide critical information about the client’s internal world, while helping therapists moderate their CT emotions, thoughts, and behaviors (Loffler-Satastka et al., 2017, as cited in Bhola & Mehrotra, 2021). It is a

reciprocal evaluative process, with an objective to examine the inside and the outside of the client and therapist within their social and cultural context (Berzoff et al., 2016; Namono, 2014).

The amount of empirical investigation of CT is disproportionate to the expansive body of clinical and theoretical literature (Tanzilli et al., 2015). Prior to 1980, formal scientific inquiry into CT occurred only irregularly, but nevertheless, early studies by Fielder (1951) and Cutler (1958) attempted to qualify CT (as cited in Hayes, 2004). One of the major problems with studying this concept is in using a single term (i.e., CT) to describe a multiplicity of phenomena (Westen, 1998). Historically, challenges with and measurement issues of CT have created obstacles to empirical CT research. There are also measurement issues in evaluating and accurately describing this multifaceted and complex construct that includes both conscious and unconscious processes for therapist and client.

Because there is voluminous literature on the subject, which is beyond the scope of this empirical study, I sought to examine systematically as much of the available empirical evidence as possible to reach a synthesis that compliments the complexity of the data (Westen, 1998). Based on the synthesis of literature, the chapter is divided into four sections to review relevant literature regarding CT, mindfulness, and implications for clinical practice. The first section is restricted to the four most influential and welldefined CT definitions that have evolved over the years: classical, totalistic, complementary, and moderate/relational. This section will also include an explanation of the structural theory of CT later developed by Hayes (1995) to expand on the term’s

conceptualization with the objective of improving the quality of research. Section 2 of the chapter will report on the quantitative and qualitative research that has led the way for clinically meaningful studies and expanded the conceptual understanding of CT. Section 3 explores the literature on mindfulness and discusses its potential usefulness in the CT experience. Finally, the fourth section will report on research on mindfulness and CT.

Classical Conceptualization

Historically, CT as a construct was viewed as an impediment to psychoanalytic work (Freud 1910/1959). Freud’s original conception of CT was framed in a positivist epistemology, supporting scientific rigor of study. Ideally, the analyst took a purely objective role in analyzing the client, free from subjectivity (Fosshage, 2011). Freud referred to CT in the analyst as a “blind spot, which presented an obstacle to the analysis” (Sandler, 1976, p. 43). He believed that CT responses were not objective observations of the analysand, but the result of “therapist conflict-based distortions” and recommended that therapists recognize CT and overcome it (Friedman & Gelso, 2000, p. 1221). This classical definition considered CT as the therapist’s unconscious, conflict-based response to the client’s transference material (Norcross, 2002). In this context, the CT experience was viewed as a negative influence on the therapeutic process and a hindrance to treatment (Ellis et al., 2018). Although clinical and theoretical interest remained strong over the last century, research efforts lagged behind for many years (Hayes, 2004). This may be in part because the field of psychoanalysis was disinclined toward empirical inquiry, which would formally test CT theory. Instead, time was spent debating

definitions rather than conducting empirical research (Hayes, 2004). Epistemological differences as well as major challenges for systematically investigating an extremely complex construct that includes unconscious processes and responses and defense mechanisms in therapy led to the delay and limitations in empirical research (Norcross, 2002).

Theories and clinical practice have a dialectical relationship to each other (Westen, 2002). Clinical observations lead to theory and vice versa. The Freudian concept guided practice for many years until eventually clinical observations took the lead and facilitated the construct change. In the 1950s, models of psychoanalysis progressed beyond classical drive and ego analytic theory and moved towards a more relational and interpersonal approach (Gelso & Hayes, 2007). Gradually, the conceptualization of CT was transformed. This led to new ways of understanding CT and its relationship between therapist and client. Instead of CT being considered taboo, it was considered an instrument with merit and one to be explored (Katz & Johnson, 2006). Several theorists altered the landscape of psychoanalytic thinking and formally proposed a modification of the concept. This expanded the boundaries to include all the emotions, cognitions, and behaviors that are experienced by clinicians (Heimann, 1950). Essentially, the definition swung in the opposite direction. Although the direction was positive, it may reveal gaps in understanding and emphasis placed on empirical research and testing of clinical theories within the psychoanalytic community.

Totalistic Conceptualization

The rigidity of a classical definition and growing interest in nontransferential material may have led to the deterioration of a consensus of CT. Simply stated, the classical definition was no longer adequate to task. The belief evolved away from the view of CT as the therapist’s problem and detrimental in therapy to a phenomenon with much complexity and nuance (Ellis et al., 2018). The totalistic perspective held the belief that some feelings experienced by clinicians were generated by the client’s behavior (Gabbard & Wilkinson, 2000). Heimann (1950) made the first explicit statement reporting on the positive value of CT. The usefulness of the therapist’s emotions was recognized as valuable information providing a window into the client’s internal world and relationships (Hayes, 2004). Like Heimann, other analysts felt the classical definition was too restrictive (Little 1951; Winnicott, 1949) and instead defined CT as all therapists’ feelings and attitudes towards client’s including unconscious or conscious, conflict or reality based, and in response to transference or some other material (Friedman & Gelso, 2000).

Winnicott (1949) proposed that CT had an “objective” and “subjective” meaning, which meant that there are separate and identifiable CT reactions that are based on client traits and behaviors and that were considered a natural and expected response especially when working with clients with high acuity and severe psychopathology (Norcross, 2002). In his well-known paper, “Hate in the Counter-Transference”, Winnicott (1949) postulated that a client’s diagnosis influences the intensity and/or characteristics of a therapist’s CT response. He believed that the psychoanalyst must work diligently until his

or her hate is “extremely well sorted-out and conscious” (p. 69). He believed therapists needed to recognize and actively work with intense CT responses to understand the needs of the client better (Winnicott, 1975). Winnicott believed it was important for the clinician to maintain a professional frame that would allow the therapist to remain vulnerable and open to his or her response to the client. He also cautioned that CT must be well examined before it was included in interpretations (Wishine, 2005). Although Winnicott’s (1949) classic paper on hate and CT has frequently been discussed in CT research, rarely has it translated into discussion on actual clinical techniques.

The objective view of CT may provide clinical diagnostic, training, and therapist–client relational material to be studied. However, the totalistic view made it very difficult to discern the originating source of the response and the all-inclusive definition reduced the term countertransference to be basically meaningless (Fauth, 2006). This statement does not negate the importance of therapists’ internal and external reactions to clients in therapy, but the definition of CT must be more concise for it be scientifically useful (Hayes et al., 2011). How does a therapist learn to recognize and differentiate their affect, mood, thoughts, and somatic and behavioral responses as either being brought on by the client in the room or connected to a personal aspect of their life or both? Therefore, the “mirror of CT does not always produce a crisp image of the other’s inner world. Instead, it can be opaque and distorting” (Gemignami, 2011 p. 706). This is a complicated question and one that continues to be empirically studied. As Malcolm (1980) reported, “You have to distinguish between what your reactions to the client are telling you about his psychology and what they are merely expressing about your own” (p. 115).

Clinical research over the years created a significant theoretical shift in CT, which generated professional polarization and debate that did little to advance the field (Hayes, 2004). This phenomenon of irreconcilable differences can be normalized within a field that has historically been fraught with tension based on clinician’s holding various theoretical, ontological, and epistemological viewpoints. There appears to be a general consensus that personal experience as well as social and cultural institutions probably lend support to maintaining a strong hold on one’s belief structure (McDowell, 1991).

However, regardless of differences in expectations and beliefs about CT, most clinicians would agree that CT is a phenomenon in the clinical situation and that researching the therapeutic usefulness of CT would be a desirable scholarly goal. Yet, ambiguity and confusion continued regarding the clinical utility of CT because it ultimately depended on the conceptualization of the therapist’s responses which may have originated from unresolved conflicts (classical view) or a post-Freudian perspective, including all of the therapist’s attitudes and feelings toward the client (totalistic view; Gelso & Hayes, 2007). Essentially, a totalistic view defined everything therapists experience or do, either consciously or unconsciously, as a CT response (Gelso & Hayes, 2007; Kiesler, 2001; Klein, 1946; Orr, 1988; Racker, 1968; Rosenberger & Hayes, 2002b).

Although the totalistic perspective considers CT beneficial such that it can increase understanding of the client’s internal world and provide insight into the ways other people in the client’s life may respond to them, it has been criticized for being too expansive (Gelso & Hayes, 2007). The all-encompassing definition created confusion among clinicians and students, and it caused the term countertransference to be

indiscriminately overused and generic (Hayes, 2004). A totalistic view as a therapist’s global emotional response to a particular client correlative of the client’s unconscious material adds more ambiguity to an already elusive term, making it very difficult to study empirically. If all emotional responses are considered CT, then there is no need for the term. Therapists could simply refer to CT as emotional reactions (i.e., positive and negative; Gelso & Hayes, 2007). The totalistic view may possibly be the result of a postFreudian evolutionary swing to the opposite direction being all-inclusive instead of exclusionary and negative. However, the pendulum swing did provide a new direction and encouragement for clinicians and researchers to study the concept strategically and organize the definition into those “rooted in the therapist’s unresolved conflict or ‘soft spots’, and those that are a normal, healthy, expectable reaction to the client’s material”

(Gelso & Hayes, 2007, p. 9). This is empirical study and science in action.

Complementary Conceptualization

The understanding of CT has emerged over the years and now holds common ground among psychotherapists of diverse theoretical perspectives (Kachele et al., 2015). More recent contemporary theorists have described the ways the client triggers the therapist’s reactions by “pulling” or “hooking” the therapist. These interpersonal responses may be generalizable to significant others in the client’s life (Kiesler, 1996) through projective identification (Klein, 1946; Ogden, 1982, 1994) and CT enactment (Gabbard, 1995). The concept of projective identification originated in the object

relations school of psychoanalysis and views projective identification as a defense mechanism that triggers complementary CT (Gelso & Hayes, 2007; Ogden, 1982).

Instead of acting out in similar ways as others in the client’s life do, the therapist responds differently and uses the CT information to gain insight into the client’s internal world and interpersonal patterns of relating. However, central to this understanding and in support of this study is the idea that therapists must discern client characteristics or clinical situations that create the patterned responses and not act out mindlessly and impulsively on CT feelings or thoughts. The therapist can instead hit the “pause button” to reflect, creating a gap between stimulus and response to gain insight and practice responding differently albeit empathically, compassionately, and with intentionality. It should be noted that this conception of CT is similar to the totalistic conception in the belief that CT is inevitable and can be helpful if understood. Also, CT material can contribute diagnostic and clinical material to the treatment process (Betan, et al., 2005; Gelso & Hayes, 2001, 2007).

Relational Conceptualization

The fourth and final conception of CT that Gelso and Hayes (2007) recognized throughout the literature is the relational conception (Mitchell, 1993). Several theorists over the years continued their clinical inquiry, and the concept of CT evolved to hold a more integrative definition because the therapist and client contribute to the creation of CT (Gabbard, 1995, 2001). As stated earlier, Gabbard (1995) acknowledged the understanding of CT was gaining interest among psychoanalysts of various backgrounds.

The emergence was believed to result from the development of two key concepts: projective identification and CT enactment. Projective identification’s contemporary understanding is related to an interpersonal interaction between client and therapist. That is, the therapist’s response to the client provides insight into the interpersonal patterns the client consciously or unconsciously induces from significant others (Betan et al., 2005). More recent research has shown that clinicians may have a “diagnostic response” (Casement, 1990, pp. 8165, as cited in Lowenthal, 2018, p. 366) or prototypical response, which reveals something about the client, such as is characteristic of borderline personality disorder and narcissistic personality disordered clients (Betan et al., 2005; Betan & Westen, 2009; Brody & Farber 1996; Lingiardi et al., 2015; Rossberg et al., 2010; Tanzilli et al., 2015).

Relational theorists began to conceptualize CT as a critical source of understanding the client’s inner world, and this view is widely accepted today. Processes such as “self-analytic” activities are regarded as a source of information about clients (Gabbard & Wilkinson, 2000, p. 11). Gabbard and Wilkinson (2000) believed that the clinician must be attuned to “subtle or not-so-subtle forms of ‘acting in’” (p. 11) as a preventative measure for enactments in clinical situations. Although Gabbard and Wilkinson did not elaborate thoroughly on the term “self-analytic activities,” they did cite Chused’s (1991) writing as one example. Chused described a situation in which a therapist reacts to a client but “catches himself in the act” (p. 616), pauses in observation, and uses the moment to increase understanding of the cocreated experience (as cited in Gabbard & Wilkinson, 2000, p. 11). Maroda (2010) supported an attitude of acceptance,

curiosity, and openness while acknowledging negative feelings and judgements about clients. She believed an awareness and acceptance of CT can facilitate positive treatment outcomes but denial can lead to acting out. Maroda (2010) strongly recommended that therapists be very careful about disclosing negative reactions to clients without establishing safety and trust in the therapeutic relationship. The “judicious use” of selfdisclosure can be helpful in the therapeutic encounters (Myers & Hayes, 2006, as cited in Maroda, 2010, p. 109). This clinical process basically described the art of mindfulness practice and utilization of discernment, which is a primary interest in this study.

Relational theory and the concept of intersubjectivity make CT comprehensible and complex in nature (Kachele et al., 2015). CT and its social and cultural interactive process emphasize the joint nature of the experience in the intersubjective dynamic (Fauth, 2006). Relational theory through the lens of intersubjectivity emphasizes two people’s subjectivities and their experiences of unconscious defenses (i.e., distortions, projections, displacements) or unconscious selves experienced as strong emotions in the intersubjective relationship (Berzoff et al., 2011). In the clinical setting, clinicians using relational theory and the concept of intersubjectivity are taught to be reflective of their own experiences use CT. Intersubjectivity considers the self, the other, and the therapeutic environment (Berzoff et al., 2011), thereby emphasizing therapists being aware of their biases, prejudices, and societal–cultural beliefs to understand their clients better. The clinician’s and client’s subjectivities combine to produce the analytic third, or third space of meaning. This is a cocreated space in which both parties can reflect on each other (Berzoff et al., 2011).

The intersubjective space mutually influences the client and clinician through CT (Berzoff et al., 2011). One strength of relational theory and practice is the emphasis on culture having a role in client factors related to CT. This adds another complexity to the unconscious or conscious CT material that can present in the therapeutic relationship. Psychoanalytic concepts of the unconscious and CT are vital for the understanding of cultural and racial realities in treatment (Bonner, 2001). Culture influences every phase of the therapeutic encounter. Cultural attitudes and frameworks are intertwined in how clinicians feel about, think about, and respond to others. Therefore, the intersubjective space may hold our cultural attitudes, biases, and stereotypes about race and racial differences (Leary, 2000). It would be logical and likely that the therapist’s and client’s culture or race would be another variable and influence CT reactions. Tension can arise in the therapeutic relationship whether culture or racial orientation is the same or different between therapist and client. If the tension goes unnoticed and unaddressed, potential arises for overidentification or enactment, especially around cultural or racial identity issues, which can produce feelings of guilt, shame, ambivalence, despair, anger, etc. (Leary, 2000; Namono, 2014).

Vulnerability and presentations of these feelings alone do not necessarily indicate an impediment to treatment, but they inevitably influence clinical material. For example, overidentification or denial of CT reactions can sometimes result in clinicians’ avoidance of closeness and feelings of ambivalence, guilt, hostility, or shame (Bonner, 2001). These CT responses may then inhibit the clinician’s ability to confront the client’s existing psychopathology or focus on the client’s real problems in therapy (Bonner, 2001;

Namono, 2014). Feelings of guilt and shame can “hang around like all bad habits do, thriving on [their] familiarity, allowed to remain because we are either too tired or too jaded to think we can survive without [them]” (Burke & Brown, 2022, p. 81).

At times, these bad habits or parts of the self appear in interpersonal patterns in the therapy room. Ghosts or voices from the past, present, and future can influence the clinical encounter spontaneously and add to the therapeutic relationship’s complexity. These ghosts are unpredictable and may be hidden under the layers of vulnerability, fear, shame, and uncertainty. The shared and reciprocal nature of intersubjectivity in a crosscultural experience encourages collaboration and freedom to explore client and therapist similarities and differences (Bonner, 2001; Leary, 2000). The clinical encounter can become the safe space for the client to be validated and feel seen and heard. Although there is limited research on CT’s “interethnic” and “intraethnic” characteristics, there is a growing body of evidence that can improve the understanding of CT responses and overall benefit clinical practice (Bonner, 2001, p. 64).

One component of the therapist’s role is that they are attuned to the client’s emotions and their own affects “but—and the crucial point is what is called controlling CT—without transforming them into action” (Kachele et al., 2015, p. 96). The reciprocal nature recognized in the clinical situation is important, but it can be problematic if too much attention or blame is placed on the client initiating this response versus paying attention to the therapist’s personal history. For example, the concept of projective identification is an important clinical phenomenon, but it being called CT diverts attention from the impact of the therapists’ personal issues, such as defenses and

unresolved conflicts, by placing the origin of emotional reactions within the client (Gelso & Hayes, 2001; Hayes, 2004). It is generally more helpful for clinicians to investigate how client attributes and behaviors interact with their vulnerabilities and issues to understand CT triggers clearly (Gelso & Hayes, 2007). The idiosyncratic reactions that originate from therapists’ personal conflicts versus clients’ characteristics needs to be differentiated to facilitate insight, improve clinical decision making, and overall support better treatment outcomes (Kielser, 2001; Levenson 1995, as cited in Gelso & Hayes, 2007).

Integrated Conceptualization

Gelso and Hayes (2007) developed an integrated definition of CT from these four historical conceptions. CT is understood as having its origins in therapists’ unresolved conflict, but the authors contended that it is crucial for the therapist to explore these feelings to understand themselves better and learn how to use these feelings potentially to understand the client better. Gelso and Hayes believed that CT is an inevitable phenomenon regardless of theoretical orientation and recognized that no therapist is immune. Finally, they believed that CT includes transferential and nontransferential material and can be defined as the “therapist’s internal or external reactions that are shaped by the therapist’s past or present emotional conflicts and vulnerabilities” (Gelso & Hayes, 2007, p. 25). These theorists also believed that a well-defined theory of CT is not only useful in practice but also should be “scientifically generative” (Gelso & Hayes, 2007, p. 25), which means the theory should stimulate further research and theory.

Structural Theory of Countertransference.

Hayes (1995) developed a structural theory of CT to improve understanding and examination of the five main components of CT. The structural model Hayes outlined includes

(a) CT origins (e.g., unresolved conflicts within the therapist), (b) CT triggers (situational events that elicit unresolved issues),

(c) CT manifestations (affective, emotional, cognitive, and behavioral reactions that occur once the therapist is triggered),

(d) CT effects (consequences of CT manifestations in the therapy relationship and treatment outcomes), and (e) CT management (strategic methods to cope with CT phenomena; Hayes, 1995). Hayes’s structural theory of CT provides an investigative and foundational quality to be applied at various levels of the CT process.

There is general consensus that therapists and clients can experience strong emotional responses towards each other in the therapy process. In fact, research has suggested that therapists’ emotional reactions are related to client engagement in therapy but also to the therapy relationship’s strength (Westra et al., 2012). Furthermore, the therapeutic relationship’s quality has been found to be a key factor in positive treatment outcomes for clients (Fluckiger et al., 2012; Shedler, 2010). Psychoanalysts and psychodynamic and integrative therapists of all theoretical backgrounds strongly emphasize establishing a strong therapeutic relationship whether or not CT is a central tool for practice. Therapists of all modalities generally aim to establish a collaborative relationship from the beginning of therapy (Prasko et al., 2010) and a strong alliance, which is necessary for treatment to work (Cartwright & Read, 2011). Independent of the

treatment modality, qualities of the therapy relationship are most important for positive treatment outcomes (Surrey, 2005). Failure to establish rapport and maintain a stable, secure therapy relationship may cause clients to terminate early. More recently, CT has developed an increased transtheoretical appeal and is considered a transtheoretical concept. Specifically, all therapists experience CT whether or not they use the term or devote time to the exploration and utilization of the concept (Hayes, 2004). Research on CT in feminist, rational-emotive, cognitive, behavioral, constructivist, and family systems as well as experiential therapy has been conducted by Brown (2011), Ellis (2001), Hoyt, (2001), Kaslow, (2001), Mahrer (2001), and Gelso and Hayes (2007, as cited in Hayes, 2011). In fact, Norcross (2011), a well-known integrative therapist, reported that therapists from all theoretical positions acknowledge therapists’ contribution to the treatment process and the “need for self-care when experiencing the looming despair, sudden rage, or boundary confusion that is all part of countertransference” (p. 981, as cited in Germer et al., 2013). Linehan (1993), a leading CBT therapist and researcher on borderline personality disorder (BPD), described unhelpful behaviors in her presentation on CBT and BPD. She stated that “therapyinterfering behaviors” are what analysts refer to as CT (as cited in Germer et al., 2013, pp. 138–141). They include an array of feelings, cognitions, and behaviors rooted in CT, such as feelings of inadequacy, hostility, anger, and frustration directed toward the client. Therefore, attention to CT seemed very important to consider regardless of therapists’ therapeutic orientation (Hayes et al., 2011).

Regardless of therapists’ theoretical orientation, it is important for them to pay attention to their affective states, negative or positive, experienced in CT and strive to remain vigilant to identify early warning signals of emotions that may interfere with the treatment process. Affect may act as a filter through which an individual view the world and is often shaped by positive and negative experiences. The identification of early warning signs can prevent harmful enactments (Gelso & Hayes, 2007). It is generally acknowledged that feelings of CT can be positive, neutral, or negative and are expected because therapists can consciously or unconsciously experience feelings while working with clients because they carry their history and experiences with them. Exaggerated feelings, such as love, excessive idealization, and praise, or attempts to divert the attention of therapy onto the therapist are important to acknowledge, examine, and work through if necessary (Gelso & Hayes, 2007).

Yet the absence of conceptual clarity and theoretical disintegration remains a challenge in CT research regardless of how theorists from multiple orientations acknowledge CT and incorporate this construct into theory and practice (Fauth, 2006). Modern psychodynamic conceptualizations of CT consider the influence of the therapist’s and client’s personality traits and view CT as “jointly created” (Gabbard, 2001, p. 984). Contemporary research has produced a more moderate definition of CT as therapists’ idiosyncratic reactions (affective, cognitive, somatic, and behavioral) to clients, which stem primarily from the “therapist’s own personal conflicts, biases or difficulties (cognitive biases, personal narratives, or maladaptive interpersonal patterns)” (Gelso & Carter, 1985, 1994; Gelso & Hayes, 1998; Langs, 1974, as cited in Fauth, 2006,

p. 17). These responses can be considered conscious or unconscious and triggered by client psychopathology, transference, or other nontransferential material. These responses can also be “induced” among clinicians as a reaction to the client’s presenting concerns, personality characteristics, or interpersonal styles, beyond the psychotherapists’ internal conflict (Bhola & Mehotra, 2021, p. 117; McIntyre & Swartz, 1998).

The evolution of CT conceptualizations has led to a more contemporary and relational perspective, which acknowledges and incorporates the therapist’s personality, developmental history, and coping style as part of CT-response analysis (Gelso & Hayes, 2007; Maroda, 2010). It is important for therapists to understand their CT feelings and learn to use all of them to gain insight into their client and themselves. Additionally, these theorists recognized the humanness and the likelihood of experiencing CT.

Emphasis continued to be placed on personal issues for the therapist as the origin of CT and remains central to the integrative conceptualization. For example, a therapist may experience negative reactions to a client for numerous reasons, one being their own personal history. Other reasons may have completely different origins, such as clinical factors attributed to projective identification, therapist fatigue, therapist burnout, therapist inexperience, feeling sick or tired, or recovering from an illness (Betan et al., 2005).

There are countless possibilities. Ultimately, the therapist must learn the task of deciphering and the skill of discernment to determine whether it is a personal issue being stimulated and how or whether it is a client trait or situation that is being triggered in the relationship. Therapists must also gain insight into identifying idiosyncratic patterned responses that are being invoked in the CT. This emphasis on disentangling the responses

in the clinical encounter coincides with the importance of examining therapists’ subjective experiences and the countertransferential processes. The mirror of CT is focused on the therapist first, with the underlying assumption that the therapy room is a cocreative space.

Despite definitional and measurement challenges, certain assumptions remain constant in and beyond the scope of psychanalysis (Gelso & Hayes, 2007; Kielser, 2001):

(a) CT is an inevitable phenomenon in all therapeutic processes (Gelso & Hayes, 2007);

(b) there is acceptance of a coconstructed process in CT, even considering the variability of relative contributions between the therapist and client (Gabbard, 2001); (c) the idea that lack of therapist acknowledgement of CT can impede the therapy process (Ligiero & Gelso, 2002; Racker, 1968); and (d) CT can be a useful clinical tool, especially when is appropriately acknowledged and effectively managed (Gelso & Hayes, 2007; Ligiero & Gelso, 2002).

In the previous section, I explained the limitations and challenges of defining and conceptualizing CT. For the purpose of the research project, I will conceptualize CT as a psychotherapist’s internal and external reactions to a client that are influenced by the therapist’s personal vulnerabilities and unresolved conflicts (Gelso & Hayes, 2007). It is less restrictive than the integrative definition because it does not require the therapist conflict to be unresolved. Instead, it acknowledges that the conflict and subsequent emotional reaction can arise from issues or conflicts that are partially resolved or vulnerabilities arising from recent history, such as trauma or loss. This moderate definition of CT is similar to those of theorists (i.e., Gelso & Carter, 1985, 1994; Gelso &

Hayes, 1998; Langs, 1974, as cited in Fauth, 2006). Therefore, CT is defined as therapists’ idiosyncratic reactions, generally defined as emotional and cognitive, somatic, and behavioral, to clients that are primarily based in the therapist’s personal conflicts, biases, or difficulties (e.g., cognitive biases, personal narratives, and maladaptive interpersonal patterns; Fauth, 2006). These reactions can be unconscious or conscious and triggered by transference, client traits, or other aspects of the clinical situation, such as value conflicts, therapist biases, and termination, but not by extratherapy factors, such as lack of sleep or illness.

Countertransference Research

In this section, I provide a summary of clinically orientated empirical research on CT, with a brief section on CT management. I report the studies’ strengths and limitations, emphasizing research where there is empirical support of more than one study. It is undisputed in the literature that CT is considered an inevitable part of the therapeutic relationship, is generally influenced by the therapist’s personal vulnerabilities and unresolved conflicts and includes internal and external reactions from the therapist (Gelso & Hayes, 1998, 2007; Hayes et al., 2011).

Quantitative Studies

Experimental analogue studies in the 1950s and 1960s, being the first empirical studies before 1980, have helped reduce the concept’s abstract nature to study it empirically. However, failure to replicate initial analogue studies (i.e., external validity)

was a significant problem, and the research has been criticized for having such methodological problems (Kholooci, 2007). For example, three teams of reviewers using the same set of audiotaped client-participants as stimuli for therapists’ reactions found inconsistent results (Peabody & Gelso, 1982; Robbins & Jolkovski, 1987; Yulis & Kiesler, 1968, as cited in Hayes, 2004). Specifically, effects of client type (hostile, seductive, or dependent) were either missing or contradicted expectations. One possible reason for the mixture of contradictory results was that the therapists had idiosyncratic sensitivities to the threat each client-participant represented. In other words, an angry client is not equally threatening to every therapist. Therapists will vary in their comfort level with anger, and therapists who are more comfortable with anger are less likely to experience anxiety when experiencing client hostility (Bandura et al., 1993, as cited in Hayes, 2004). In addition, analogue studies in CT have been criticized for having a low probability of capturing the subtle aspects of CT manifestations (Kholooci, 2007).

As mentioned previously, the CT reactions have been operationalized in affective, emotional, somatic, cognitive, and behavioral terms (Fauth, 2006) Most empirical studies on CT have used an operational definition that involves the therapist’s unresolved conflicts as the origin and some client characteristic as the trigger for CT reactions. Also, most of the research has focused on studying therapists’ reactions to the client from the therapist’s supervisor’s and external observers’ perspectives (Colli & Ferri, 2015). The therapist’s perspective has been used to measure the intensity and quality of the clinician’s internal emotional experience. For this objective, researchers have typically used self-report instruments, such as the State Anxiety Inventory (e.g., Hayes & Gelso,

1991), the Therapist Appraisal Questionnaire (e.g., Fauth & Hayes, 2006), the Feeling World Checklists (e.g., Dahl et al., 2012; Rossberg et al., 2003), and the Therapist Response Questionnaire (e.g., Zittel Conklin, & Westen, 2003), more than qualitative methods (Hayes et al., 1998) and interviews (e.g., Bourke & Grenyer, 2010; Tahy & Wiseman, 2014). Self-report measurements have limitations, such as the possible influence on social desirability bias or implicit defensive processes (Tanzilli et al., 2015). In addition, problems have arisen with recruiting therapists who are willing to share openly about negative feelings, such as guilt, shame, and inadequacy, experienced in CT because they may be uncomfortable with acknowledging and sharing their personal conflicts and vulnerabilities (Gelso & Hayes, 2007). However, self-report measures allow researchers to obtain data regarding the clinician’s relational experience with the client from the broadest and more direct observational basis (Kachele et al., 2015; Westen & Weinberger, 2004, as cited in Tanzilli et al., 2017).

The quantitative measurement of CT and subsequent research supports the belief that CT has countless potential sources because any area of unresolved conflict may serve as the basis for it. For example, CT may originate from therapist’s issues related to “family of origin, narcissism, roles as a parent and romantic partner, unmet needs, grandiosity, and professional self-concept” (Gelso & Hayes, 2007, p. 115). Whether the unresolved conflict is unconscious or conscious, it is safe to say that virtually any area of vulnerability or unresolved conflict may serve as the basis for CT (Hayes & Gelso, 2001). However, these affects’ frequency, duration, and intensity may vary per therapist and have a temporal influence. Also, it is important to note that the roots may be traced back

to a developmental issue in early childhood, such as not “being good enough,” which may be related to a child not receiving “good enough” parenting. However, a developmental antecedent is not always the genesis of CT (Gelso & Hayes, 2007). Numerous emotional conflicts occur in the here and now that do not have early antecedents. For example, the therapist may have recently experienced a traumatic loss, job loss, loss of a loved one, or change in health status (Gelso & Hayes, 2007).

Therapists may also struggle with difficulties with termination related to intimatepartner loss or rejection (Gelso & Hayes 1998). A major consideration here is that many situations in a therapist’s life could cause great pain and suffering, being part of the human condition, that are not a result of early childhood unresolved issues. When such losses occur, it is more challenging for the therapist to work with a client who is struggling with similar affects and/or losses. A general consensus from the literature reviewed is that origins of the therapist’s CT are most likely complex, multilayered, and embedded in the therapist’s psyche (Gelso & Hayes, 2001). However, to use CT material judicially, it is important to distinguish the therapist’s reactions due to their unresolved conflicts; vulnerabilities that stem from more recent stressors or situational reactions, such as burnout due to exhausting caseload; fatigue from sleep deprivation; and distractibility due to a loud client in a colleague’s office next door.

Countertransference Manifestations

The early research on CT and therapy outcome produced a series of analogue studies that focused on defining CT as the therapist’s reactions to a client that primarily

arise from the therapist’s unresolved conflict. This focus resulted in operationalizing CT in terms of the therapist’s avoiding behaviors (i.e., disapproval, silence, ignoring, mislabeling, and changing the topic). These studies focused on negative responses to CT and were limited to what CT revealed to us about the therapists. Rosenberger and Hayes (2002) reported that experiential analogue studies’ ecological validity has improved over the years with better identification of externalized CT behavioral responses, such as avoidance or withdrawal. Positive response behaviors have also been explored in the research, and examples reported include the therapist’s overinvolvement with their clients (Gelso et al., 1995) and therapists who confused their needs with their clients’ needs, such as in the case of excessive nurturing of clients (Hayes et al., 1998; Hayes and Nelson et al., 2015). Overinvolvement may also manifest in behaviors such as talking too much in session or giving too much advice, support, affect, or reassurance (Gelso & Hayes, 2007). Keep in mind the over- or underinvolving behaviors in isolation do not necessarily indicate CT. The product of CT would depend on what in the therapist or characteristics of the client acted as the antecedent or trigger for the behavior. However, these studies had significant limitations because they did not investigate the specific internal and emotional responses or thoughts associated with CT reactions.

Cognitive and Emotional Manifestations

CT has been operationalized on a cognitive level as therapists’ perceptual distortions and inaccurate recall of the discussion content in a counseling session (Fauth & Hayes, 2006; Fielder, 1951; Hayes & Gelso, 1993; McClure & Hodge, 1987). CT can

involve error in perception of the therapeutic other. In fact, the earliest studies of CT documented that CT could distort therapists’ perception of clients (Cutler, 1958; Fielder, 1951). Although these early studies had very small sample sizes (N=2), results reported that therapists may have utilized defense mechanisms (submissive, rejecting, critical and exaggerated behaviors of the client) when the client material related to areas of therapist unresolved conflict. Therapist interventions were also deemed to be less effective by the reviewers/observers in the study. For example, the therapists both exaggerated and underestimated the amount of time that clients actually spent talking about material related to therapists’ unresolved conflicts. In a similar manner, Gelso et al., (1995) found that female therapists had more difficulty than male therapists accurately recalling a lesbian client’s sexually provocative materials, although the therapist gender differences disappeared with a heterosexual female client.

Affectively, the most common CT marker is anxiety felt in session (Hayes et al., 1988). Anxiety would be the natural consequence to a clinical situation in which the therapist identified and assessed a potential threat. Anxiety has also been shown as a fairly predictable response when a therapist experienced material related to unresolved conflicts (Hayes et al., 1998). The primary instrument used to measure anxiety is the State Anxiety Inventory (Hayes & Gelso, 1993; 2001). Research has also explored positive feelings such as empathy, happiness, hopefulness, and excitement. It should be noted that positive feelings such as love have been reported to occur in longer term treatments where the therapist and client have had the opportunity to know each other more deeply (Gelso & Hayes, 2007). On the other hand, identifying these deeper feelings

of caring as CT may undermine the support for the strong relational component of psychotherapy. Generally speaking, emotional reactions invite exploration and in particular to the origins of these feelings (Hayes & Gelso, 2001).

Negative affective manifestations of CT such as anger, sadness, fear and disappointment have been reported in multiple studies (Fauth & Hayes, 2006; Friedman & Gelso, 2000; Hayes et al., 1998; Hayes, Nelso et al., 2015). Negative affects, cognitions, and reactions or images usually center around feelings of sadness, anxiety, hate, or anger (Hayes, et al., 1998). Even though there is a substantial amount of theoretical literature on client-induced CT (McWilliams, 1994, Norcross, 2001), more empirical data to support these claims is needed (Swartz, Smith & Chopko, 2007). At times these negative feelings, thoughts and behaviors may stem from CT but other times, do not. Some negative reactions may not be related to CT at all. Instead, they represent healthy, expectable, appropriate, and understandable human reactions to the client and the clinical material at hand (Hayes et al., 1998). For example, the client who presents with narcissistic or borderline characteristics will inevitably elicit a negative reaction from the therapist. Clients with borderline personality traits are challenging with frequent displays of emotional dysregulation, the use of primitive defense mechanisms such as splitting, and difficulties maintaining appropriate boundaries in the clinical situation (Gabbard & Wilkinson, 2000). Some theorists have proposed that CT negative reactions may be the most reliable guide to diagnosing BPD (Gelso & Hayes, mcl1987). Although this viewpoint is debatable, the implication for the strong negative emotional response is noted. The determination of CT material would be supported when the therapist responds

with excessive negative affect, biased or prejudiced cognitions and acts on these feelings and thoughts to the client. Because of the recognition that some clients are more likely to activate certain responses than others, CT studies on positive and negative feelings led to the development of a CT questionnaire. This questionnaire can be used in clinical practice to examine the extent to which it can be used to create empirical prototypes of common CT patterns of responses in particular types of pathology (e.g., Betan et al., 2005).

Quantitative research has placed more focus on investigating therapist reactions to client material and developing valid self-report instruments. The development of the CT Questionnaire was completed by Drew Westen’s research group in Atlanta, Georgia who subsequently published a well-known study by Betan et al. (2005). They investigated CT responses in a random sample of 181 psychiatrists and clinical psychologists in the United States. One primary objective of the study was to examine the association between CT phenomena and clients’ personality psychopathology. The study results introduced the idea of habitual CT. Each participant completed a battery of instruments based on a randomly selected client on their caseload, including Axis II symptom measurement and the Countertransference Questionnaire, an instrument designed to assess a clinician’s affective, cognitive, and behavioral responses in interacting with a particular nonpsychotic adult client. The CT questionnaire was determined to be an empirically valid and reliable measure of CT responses that can be applied to a range of diagnostic categories and clinical populations (Kachele & Erhardt, 2015). Factor analysis of the CT Questionnaire yielded eight CT dimensions. They were clinically and

conceptually coherent factors that were independent of clinicians’ theoretical orientation: 1) overwhelmed/disorganized; 2) helpless/inadequate, 3) positive, 4) special/overinvolved, 5) sexualized, 6) disengaged, 7) parental/protective, and 8) criticized/mistreated. The eight factors were associated in predictable ways with Axis II psychopathology criteria. An aggregated picture of CT responses with narcissistic personality disorder clients provided a clinically robust, empirically based description that was very similar to theoretical and clinical descriptions. CT patterns were systematically related to clients’ personality pathology across various therapeutic approaches, suggesting that clinicians regardless of therapeutic orientation, can make diagnostic and therapeutic use of their own responses to the client. The authors believed that the results support the view that CT is also useful in distinguishing and better understanding of client’s interpersonal patterns of relating to others. There were several limitations to the Betan et al. (2005) study: 1) limits of selfreport measurements; 2) potential selection biases based on agreement to participate in the study and possible interest in the topic compared to clinicians who rejected invitation to participate in the study; and 3) sample size given the possibility of some instability of factor structure with a ratio of cases to items on the questionnaire. Despite these limitations, the CT questionnaire is an easily accessible and valid measurement that is relevant to future research, allowing clinicians to clarify the diagnostic relevance and usefulness of their reactions by comparing responses to normed psychometric data. This information can assist with understanding the interpersonal patterns that emerge in session, allowing clinicians to identify and manage CT responses to prevent enactments

or negative treatment outcomes. Finally, the questionnaire provides clinicians from theoretical orientations that do not emphasize CT in their practice to have the methods and language to capture client information and the treatment process that may hold diagnostic and therapeutic importance.

Similar to Betan’s et al (2005) study of NPD, Rossberg et al. (2007) and Liebman and Burnette (2013) conducted a study examining how BPD clients evoked or triggered negative and predicable responses within therapists. The study included 560 clinicians (mostly Caucasian, females, average age of 50). The participants read various vignette and were asked to diagnose the client and then asked questions about certain areas of CT. The study results indicated that the participants were most likely to view adolescent clients with BPD as less ill, less trustworthy, and more dangerous than adults with BPD. The researchers also found that the BPD diagnosis or categorical label was associated with negative CT reactions from the study participants such that the clinicians who accurately diagnosed the client as BPD exhibited lower empathy levels toward the client and also concluded that they were more ill. Also, the therapists with more clinical experience showed more positive CT responses to clients compared to the therapists with less clinical experience.

Although more clinical experience is noted as beneficial to improve CT reactions to BPD clients, there is a gap in the literature related to the details of professional training or attributes of clinicians studied. More research is needed to identify specific characteristics of clinicians who are more susceptible to negative CT responses but also to clinicians who have demonstrated ability to cope and effectively manage CT reactions.

Distinguishing between clinician characteristics and client characteristics that play into CT reactions is an important objective of this study.

Quantitative research has demonstrated that CT can be activated by a variety of client and therapy related causes. One of the major scholarly contributions was the “importance of the actual stimulus value of the client” (Norcross, 2002, p. 278). The literature has been consistent in finding that certain client behaviors elicited corresponding behaviors (Norcross, 2002). Also, the literature has been consistent in reporting that a therapist can experience positive feelings, negative feelings or ambivalence on a continuum of intensity to a variety of therapist-client situations. Also, therapists can experience negative thoughts about a client’s chronic enactment of problematic interpersonal patterns. However, the belief that the intense emotions are always a sign of CT is “both a misunderstanding of psychoanalysis and an accurate understanding of some psychoanalytic writings, especially classical theories that actually do imply that therapist intensity is problematic” (Gelso & Hayes, 2007, p. 77). A therapist’s inner experience will most likely vary in intensity from very low to very high, yet many clinicians and researchers believe that a very low or very high intensity of emotional reaction often is suggestive of CT (Gelso & Hayes). For example, certain topics that feel threatening to one therapist may not be to another, especially depending on the level and intensity of the unresolved conflict or vulnerability within the particular client situation. There are countless client and situational factors that can stimulate CT reactions and the subjective experience of the therapist would therefore be critical to explore to improve understanding of the CT process. This exploratory study would also

have implications for professional development, clinical training programs, supervision, and clinical practice. There are multitude possibilities about how the unconscious and conscious mind with its emotional and cognitive components can impact the therapist interactions moment to moment in therapy, nonverbal and verbal considerations as well. Studying the nuances of how CT is manifested in therapists’ experience is a primary objective in this research study. There are countless possibilities and complexities that create challenges on conducting research and measurement issues and are a second barrier to conducting empirical research beyond conceptual definitional issues (Friedman & Gelso, 2000). The most common measurement problems related to CT empirical research consist of small sample sizes, the use of CT measurement instruments that lack sound psychometric properties, which then led to weak statistical power (e.g., Pearson correlations or t-tests) (Schwartz et al., 2007) (Swartz et al., 2007) Keep in mind that the nature of the construct because it has an unconscious component to the definition, inherently makes it difficult to measure. CT researchers may need to consider following methods developed by social psychologists that include effective measures in identify implicit biases and stereotypes (Fazio et al., 1995; Greenwald & Banaji, 1995; Wittenbrink et al., 1997, as cited in Fauth, 2006). The use of a computerized implicit association task instrument with which the purpose of the study is less transparent is more likely to capture unconscious material that may reveal stereotypical or prejudiced thought patterns (Peris et al., 2009, as cited in Liebman & Burnette, 2013, p. 123),

Qualitative Research

Even the most skilled therapists will have CT reactions on occasion. No amount of clinical skill or experience creates immunity for therapists against CT. Researchers have conducted several qualitative studies to examine CT’s reported effects and have utilized a consensual-qualitative-research approach, which Hill et al. (1997) developed. In one of the primary studies, researchers examined therapist–client factors that caused impasses and subsequent early termination in therapy (Hill et al., 1996). The impasses were defined as disagreements between therapists and clients. The study involved 12 experienced therapists of varying theoretical orientations, each reporting on a single clinical case of early termination. As expected, CT was one of the conflict’s most frequent consequences. Negative CT responses were found to be linked with less therapeutic change and more treatment burnout. Most of the therapists reported on their own personal conflicts; specifically, two of the therapists reported family-of-origin issues. Both indicated that a family history of suicide led them to feel especially vulnerable when their clients threatened suicide.

Hayes et al. (1998) found that therapists whose peers judged them as excellent experienced CT reactions in 80% of their therapy sessions, debunking the classical myth that effective therapists do not experience CT. However, there is most likely an optimal therapeutic level of CT and an optimal level of skill for each therapist related to unresolved conflict and a vulnerable state of mind. In this well-known qualitative study, Hayes et al. investigated therapist perspectives on CT. This was one of the first studies to show patterns in CT: family of origin; triggers; and emotional, cognitive, and behavioral

manifestations. Consensual qualitative research was conducted to examine data from 127 interviews conducted with eight psychologists immediately following their brief therapy sessions with eight clients. This type of research is considered a rigorous qualitative methodology that focuses on examining in-depth participants’ subjective experiences (e.g., reliance on words rather than numbers to describe a phenomenon). The results revealed three areas relevant to CT: (a) origins (specific categories of family issues, values and needs, therapy issues, and cultural issues), (b) triggers (including categories of content of client material, therapist comparing client with others, change in therapy structure or procedures, therapist assessing progress of therapy, therapist perception of client, and emotions), and (c) manifestations (including categories of approach, avoidance, negative feelings, and treatment planning). The study expanded the CT empirical research significantly by adding classification categories and identifying patterns among these categories.

Gelso et al. (1999) studied a sample of 11 experienced psychodynamic therapists to examine the therapeutic process and therapist response to transference in successful long-term psychotherapy cases. The researchers completed 1-hr phone interviews and follow-up interviews that focused on a recently terminated case that met the study’s selection criteria. The results indicate that the therapists reported many CT reactions. It was also noted that positive CT seemed involved in underlying issues just as much as negative CT responses. For example, a positive CT response that was reported to be problematic was described thusly:

Therapist reported that he admired the client for doing things in his life that the therapist could not do, and at the same time enjoyed being idealized by the client.

Tied to these reactions, the therapist felt he did not give the client enough permission to express negative transference feelings. (Gilso et al., 1999, p. 264) Therefore, emotional CT responses that are possibly too positive or behaviors that indicate therapists’ need to protect or “rescue” their clients have been shown to cause problems in treatment (Bhola & Mehrotra, 2021).

Perakyla (2011a), a social scientist who is a trained psychoanalyst and studies conversation, applied conversation analysis to psychoanalytic transcribed sessions. She analyzed 58 sessions from two psychoanalysts and three clients and focused on the client’s response to the analyst’s interpretation. She found that analysts responded with a modified version of the client’s response, most frequently with an intensified emotion, or “picked up a side aspect of what the client had answered” (as cited in Kachele et al., 2015, p. 104). This study emphasized the microscopic level of implicit language in the therapeutic interaction and that the unconscious and conscious mind express CT dynamics in a myriad of ways. Perakyla closely examined the emotional and cognitive components in verbal and nonverbal language within the treatment hour. Communication messages having an emotional and cognitive component can impact spoken language. One strength of this type of qualitative investigative approach is the examination of the subtler forms of CT responses in the experience, which could be easily passed over for the more intense, salient experience in CT processes.

Arnd-Caddigan (2013) completed a qualitative study examining the experience of 12 therapists engaged in imagined conversations with clients outside of therapy sessions. The research design was based on a constructivist grounded theory approach in which Arnd-Caddigan analyzed the transcripts using a constant comparison and line by line, open, axial coding to identify themes that emerged from the data. According to the results, the use of imagined conversations was useful in identifying unconscious negative transference feelings and management of anxiety that helped improve the therapist’s ability to process difficult clinical material in session. The study participants also reported that feelings they experienced helped them increase their awareness and acted as a preventive measure against acting out CT and reducing potential harm to the client.

Negative feelings such as dislike of one’s client is generally understood within the clinical encounter. However, minimal research has been completed to investigate specific reasons and ways of coping with dislike (Linn-Walton & Pardasani, 2014). Linn-Walton and Pardasani (2014) conducted a pilot study that employed an exploratory, qualitative research design to explore the subjective experiences of five participants from three disciplines (two clinical social workers, two psychologists, and ER physician) who worked with a client they disliked. All participants had at least 5 years of postgraduate experience and worked in the New York area. The researchers interviewed the participants using a semistructured interview process and used an iterative process to analyze the interviews in order to identify themes that related to participants’ understanding of their dislike in the clinical relationship.

The study’s findings provided important information about the nature of dislike. The two primary themes that emerged from the data included (a) factors affecting dislike, which related to therapists feeling defensive and/or responding with defensiveness when “challenged by the clients to prove their professional expertise and ability to deal with the client’s issues” (Linn-Walton & Pardasani, 2014, p. 107). Another example under this theme included the therapist feeling physically or emotionally threatened and/or having an immediate dislike to a client based on certain presenting criteria (e.g., personality disorder, presence of hostility or gender and age) and (b) coping skills, including name calling (e.g., jerk, predatory), blaming clients for their negative feelings toward them, attempting to empathize with clients, difficulty utilizing empathic measures to cope with dislikeable clients, employing a strength-based perspective, and utilizing supervision or peer support. Interestingly, all five participants acknowledged the negative implications related to their lack of understanding and empathy and believed that the client had “pushed them to a space where they felt emotionally drained or angry” (Linn-Walton & Pardasani, 2014, p. 109). This small-scale study contributed to the scholarly literature on negative CT reactions, coping mechanisms implemented by clinicians to manage emotions, and how they may affect treatment, but more research is needed in this area. Also, one of the major limitations of the study is the small sample size and its lack of generalizability beyond the scope of the study (Linn-Walton & Pardasani, 2014).

As the CT research has demonstrated, negative feelings such as dislike of one’s client may not be due to unconscious material that reminded the clinician of negative personal or historical experiences with other individuals. Regardless of the trigger, it

seemed logical that dislikeable traits in clients that create negative feelings in the therapy room have the potential to be acted out in overt communication patterns. Failure to deal with these reactions may compromise progress in therapy (Liebman & Burette, 2013). These negative responses have been linked with therapy outcome in empirical psychotherapy research (Fluckiger et al., 2012; Gelso & Hayes, 2007). Several studies have reported an association between poor psychotherapy processes and outcomes and psychotherapists who communicate in hostile and controlling ways toward their clients. Conversely, cases with positive outcomes “were marked by a near absence of these communication patterns” (e.g., Constantino et al., 2006; Henry et al., 1986; Henry et al., 1990; Hillard et al., 2000; Prince & Jones, 1998, as cited in Bruce et al., 2010, p. 86).

These studies, among numerous others, have created fertile ground for researching ways to manage these negative responses to avoid CT enactments (e.g., behavioral or verbal).

Countertransference Management

Research has shifted toward understanding how CT can be beneficial in treatment. Specifically, CT reactions can augment the therapy process as long as the therapist seeks to understand, make use of, and cope with CT constructively and effectively (Hayes et al., 2007). Also, therapist approaches and characteristics have continued to be studied and can play a critical role in determining the success of treatment (Norcross, 2011).

According to some research, therapist characteristics may account for more variance in therapy outcomes than certain techniques do (Wampold, 2001, as cited in Gelso & Hayes, 2007). Such characteristics reported in the literature were found to be self-insight,

conceptualizing ability, empathy, self-integration, and anxiety management (Van Wagoner et al., 1991). Through research on CT, there is evidence to support the influence and impact of CT on the therapy relationship and treatment outcomes (Baer, 2004; Cutler, 1958; Hayes et al., 2011; Hill et al., 1996).

Over the past 2 decades, more empirical studies have focused on CT management (Norcross, 2011). The research has shown that CT feelings may be useful if they are better understood and managed by the therapist (Friedman & Gelso, 2000). Very few studies have directly studied the relationships among mindfulness, meditation, and CT awareness and management. It is also typical that the populations studied were therapists in training and unexperienced therapists (Fatter & Hayes, 2013; Sampe, 2019). Fatter and Hayes (2013) reported that years of meditation experience were the only significant predictor of CT management ability. Sampe (2019) sought to replicate the extent of these findings by examining therapist mindfulness within the context of the therapeutic relationship. Sampe similarly reported that previous meditation practice strengthened the therapist self-reported mindfulness rating and supervisor rating of CT management. In support of this study, it is important to emphasize that in order to be able to manage CT responses and use CT, the therapist needs to develop an awareness of the presence of CT and then monitor the experience in relation to the client at any given moment in therapy. Further research is needed to explore in depth the experiential awareness of CT in psychotherapists who may practice mindfulness.

As mentioned previously, an important factor in improving therapist–client relations and treatment outcomes is learning the skill of discernment and effectively

managing CT. Are these feelings and thoughts influenced by the therapist’s unresolved conflicts and vulnerabilities or are they non-CT based? However, regardless of the answer to that question, learning to identify, explore, cope, and skillfully respond to the presence of treatment interfering feelings and thoughts are important considerations requiring ongoing empirical research. CT reactions that can negatively affect psychotherapy and effectively managing these reactions have been shown to be positively associated with treatment outcomes (Hayes et al., 2011). In fact, CT management research in the last 20 years has received empirical support for playing an important role in influencing the psychotherapy process and outcome (Hayes et al., 2011).

Psychotherapists’ management of their CT responses has typically been measured with the Countertransference Factors Inventory (Van Wagoner et al., 1991) and several updated versions, all of which focusing on five therapist qualities theorized to facilitate management: self-insight, conceptualizing ability, empathy, self-integration, and anxiety management. Self-insight is the degree of the therapists’ awareness of their own feelings and cognitions, sensations and behaviors, and origins. Self-integration refers to the therapist’s capacity to differentiate themselves from others, which would include the ability to place the client’s needs over their own. Self-integration also refers to the therapist having a stable, coherent identity and overall general psychological health.

Empathy refers to the extent to which the therapist holds a cognitive understanding of another individual’s experience and the ability to understand and share the feelings of another. Anxiety management refers to the amount to which the therapist experiences feelings of anxiety as a situational occurrence (i.e., state anxiety) in therapy and

experiences general anxiety as a personal attribute (i.e., trait anxiety). Conceptualizing ability is the therapist’s degree of abstract thinking skills related to the dynamic between the therapist and client. These characteristics are generally understood to be positively associated with CT management but do not identity with specificity what therapists actually do to manage CT.

More recently, a 22-item instrument called the Countertransference Management Scale was developed to directly assess CT management during therapy sessions (PerezRojas et al., 2017). Factor analyses of 286 supervisors’ ratings of supervisees resulted in two subscales: Understanding Self and Client and Self-Integration and Regulation.

Evidence of criterion-related and convergent validity was provided through measures and correlations of theoretically applicable constructs—that is, therapist CT behavior, selfesteem, observing ego, empathic understanding, and tolerance of anxiety. This instrument appears to have promise as a direct measure of the extent to which therapists measure their CT reactions in session (Hayes et al., 2018).

In one of the first field studies to examine the relationship between CT and its management, Hayes et al. (1997) found that CT management was inversely related to counselor avoidance behavior. They further reported that an inverse relationship existed between CT and outcome in cases with poor outcome but found no relationship between CT and outcome when outcome was positive (as cited in Friedman & Gelso, 2000).

Similarly, Latts et al. (1995) reported that therapy outcomes are predicted by CT management ability. Field studies have allowed for researchers to naturally study CT (Rosenberger & Hayes, 2002). However, the limitations of self-report measures and using

therapists in training as participants are limitations in this research (Gelso & Hayes, 2007).

The growing number of studies in the last 20 years has made it possible for metaanalytic work to be completed in this area. The most recent quantitative body of literature has suggested that “therapists do not have to be perfect” (Hayes et al., 2018, p. 499). They can experience unwanted reactions, and, in many cases, therapists and clients can often cope with these reactions successfully, especially when there is a strong therapeutic alliance (Ham et al., 2013; Yeh & Hayes, 2011). Therefore, CT reactions are commonly experienced by therapists, but their reactions can be mitigated through effective management to improve treatment relationships and outcome measures (Hayes et al., 2011). Seven studies on the relation between CT management and treatment outcome (Hayes et al., 2011) reported that the overall association of CT management to treatment outcome was significant and large, r = .56, p < .05. CT management definitely appears to be positively related to outcome. Therefore, there is a potential harm to clients if therapists act out their CT, and it would be beneficial for therapists to learn preventative measures, such as increasing awareness, acknowledgment, and learning, to effectively cope with CT experiences.

An area of study in CT management is determining the key ingredients in the prevention of therapists acting out internal reactions (Gelso & Hayes, 2007). Gelso et al. (2002) examined the relationship between therapist CT management skills and therapy outcome measures. The researchers were particularly interested as to whether the five therapist characteristics associated with CT management were helpful in managing CT

(i.e., self-insight, self-integration, anxiety management, empathy, and conceptualizing skills). This study included 32 graduate student therapists in training, their clinical supervisors (21 females, 11 males), and their supervisors. The supervisors listened to audio-recorded sessions of participants’ counseling sessions with clients in which each participant had between 1–4 clients. All clients in the study were rated as having slight to moderate dysfunction. The supervisors rated the counselors’ level of CT with the Countertransference Factor Inventory-Modified (Hayes et al., 1998), and the counselors rated the counseling outcomes using the Counseling Outcome Measure (Gelso & Johnson, 1983). The results of this study indicated that CT management positively correlates with client outcome. When the therapist is better able to manage their CT, their clients exhibit more improvement at the end of brief therapy. Also, self-integration, anxiety management, and skill conceptualization were significantly associated with client outcome. This study’s limitations included the following: the small sample size, a lack of generalizability, and therapy outcome was not rated by an outside observer or client. The quantitative studies on CT management appear to be beneficial to the therapeutic process and treatment evaluation. In addition to the quantitative studies discussed, qualitative studies have also pointed to the importance of CT management in relation to how the therapists felt and thought about particular clients of the study.

Qualitative studies have consistently proposed that therapists’ subjective phenomenological understanding of therapy relational interactions is central to the CT process (Hayes et al., 1998, as cited in Fauth, 2006). These qualitative studies are critical because they sampled highly experienced therapists with two focused on long-term

therapy. Generally, a conclusion can be made that acting out of CT can be harmful and that CT management is helpful (Gelso & Hayes, 2002). However, many questions in the research remain as to these five factors and how therapists may develop and maintain these five empirically supported characteristics.

Self-insight and self-integration allow the therapist to focus attention on how the client is affecting the therapy and why. It is important to recognize that self-insight alone or conceptualizing ability does not necessarily prevent CT acting out negative behaviors. Certainly, prevention is important because, when a therapist is better able to observe their feelings, thoughts, and behaviors, they may be better at gaining insight into themselves. Due to the belief that CT is inevitable, areas of interest for this researcher include (a) learning more about how therapists can cope with CT during and after the process and (b) empirically studying the possible impact that mindful practices have on the CT experience. Being curious and exploring the here and now are the first step in better understanding CT. The therapy process is a unique one, and therapists clearly experience both positive and negative emotions and thoughts. This researcher is very interested in using a microanalytic qualitative research approach to capture the CT processes of a small sample of experienced clinicians. This would allow for in-depth exploration of their subjective and emotional experiences with the objective to more clinically reveal relevant material as well as normalize the CT process. It is hoped that therapists will continue to identify, explore, and understand the potential use and benefits of CT for both themselves and their clients.

Mindful practice is defined as the systematic practice of being intentional about attending to the experience in an “open, caring, and discerning way, which involves both knowing and shaping the mind” (Shapiro & Carlson, 2009, p. 11). Mindfulness practices such as meditation have been found in both qualitative and quantitative research to facilitate emotional regulation (Davis & Hayes, 2011) and to benefit CT management with regard to personal awareness (Baehr, 2004; Fatter & Hayes, 2013). For example, the practice of meditation can improve mindfulness or the moment-to-moment awareness of what the individual is experiencing (Kabat-Zinn, 2003). Therefore, therapists may benefit from regularly employing mindfulness practices in order to cope with CT reactions effectively in and outside of the therapy room. The interest in this study explored the relationship between mindfulness and the impact on the CT experience of a small group of psychotherapists. It seemed that, in particular, self-insight and self-integration would be cultivated in the mindfulness practice, as a therapist must take seriously Socrates’ advice to “know thyself” or else risk having unknown aspects of the self undermine one’s work with a client. (Robiertello & Schonewolf, 1987, p. 290, as cited in Hayes et al., 2018)

The previous section examined the empirical literature conducted on CT and its management. The following section will review empirical literature on mindfulness. However, similar to CT, due to the vast amounts of research, the focus will be on qualitative and quantitative studies conducted on mindfulness practices and CT experiences within the psychotherapy profession.

Mindfulness

Mindfulness refers to a psychological process, a type of meditation practice, and a theoretical concept (Brown et al., 2007). Over the past 20 years, the construct of mindfulness has been one of the most widely researched concepts within medical and mental health fields and has grown in popularity both in psychotherapy literature and the popular press (Baer, 2003; Davis & Hayes, 2011). Drawing from primarily Western conceptualizations and psychological studies of mindfulness, the literature has consistently defined mindfulness as related to “being aware of the contents of experience” (Purser & Milillo, 2014, p. 3). Generally, mindfulness is the practice of paying attention to the present moment without judging. Mindfulness is about seeing clearly without the conditioned patterns of our “emotional reactions, evaluation, judgments and conceptual overlays” (Wallace & Bodhi, 2006, p. 16, as cited in Shapiro et a., 2009). Perception in the moment generates reality, so it is important to see with more clarity and discernment in our therapy rooms (Shapiro & Carlson, 2017). Acceptance of what is happening in the present moment with more clarity can help therapists to consciously discern the presence of CT and respond in skillful and constructive ways (Shapiro & Carlson, 2017). Therefore, the word mindfulness can be used to describe a theoretical construct (the idea of mindfulness), practices for cultivating mindfulness (such as meditation), or psychological processes (mechanisms such as action in the mind and brain).

Mindfulness refers both to a mindful awareness and a mindful practice. Mindful awareness is essentially “a way of being” to be practiced in all moments of life (Shapiro

& Carlson, 2017, p. 11). This awareness can be considered as a way of relating to experience with receptivity and openness. Mindfulness is “about seeing clearly without our conditioned patterns of perceiving clouding awareness” (Shapiro & Carlson, 2017, p. 11). Mindful practice is defined as the systematic practice of being intentional about attending to the experience in an “open, caring, and discerning way, which involves both knowing and shaping the mind” (Shapiro & Carlson, p. 11). Mindful practice can help an individual (a) bring an unconscious and conscious values to awareness; (b) discern the intension or motivation of these values (e.g., are they culturally or biologically conditioned?); and (c) place emphasis on the desired values versus acting on undesirable or harmful ones (Shapiro & Carlson, 2017). Multiple definitions of mindfulness have been cited in the literature. However, it is important to have an operational definition for scholarly research purposes. A basic definition of mindfulness is “moment-by-moment awareness” (Kabat-Zinn, 2003, p. 145). The definition of mindfulness that is most frequently cited in the literature is “moment-to-moment awareness of one’s experience without judgement” (Davis & Hayes, 2011, p. 198).

Formal mindful practices such as meditation have been a Buddhist tradition for over 2,000 years, focusing on introspective consciousness and its development (Neale, 2007, as cited in Bloom, 2012). Mindful practice has been described as the “systematic practice of intentionally attending in an open, caring, and discerning way, which involves both knowing and shaping the mind” (Shapiro & Carlson, 2009, p. 8). Thus, mindfulness meditation refers to the formal practice of “observing and shaping the mind with the mind” (Shapiro & Carlson, 2009, p. 8). The process has been defined as “the

development of skills such as greater ability to direct and sustain one’s attention, less reactivity, greater discernment and compassion, and enhanced capacity to recognize and disidentify from one’s conditioned concept of self” (Shapiro & Carlson, 2009, p. 8).

Considering the relationship to the psychotherapy process, mindfulness meditation can train the clinician to increase awareness of when the mind drifts from the present moment and return the focus to the here and now. Both psychotherapy and meditation are concerned with reversing habitual ways of responding that may be problematic and increasing awareness and acceptance of experiences in ourselves, others, and the world. Over time and with practice, the clinician’s ability to attend to the present without being distracted can be increased. In psychotherapy, this ability can translate into “being aware in the present moment, of three objects of attention: (a) the psychotherapist’s own body and mind, (b) the client, and (c) the relationship as it plays out moment by moment between the psychotherapist and the client” (Bruce et al., 2010, p. 84). Compared to having limited attention, being lost in thought, being on autopilot, or being vulnerable to defensively acting out negative emotions, mindfulness practice may assist psychotherapists with being more aware of the unconscious and conscious aspects of CT. Mindfulness is both a technique and a lifelong process to “embody awareness, compassion, and ethical behavior in one’s life” (McCown et al., 2011, p. xviii, as cited in Pollak, 2013, p. 135).

Although the concept of mindfulness originated from Buddhist doctrine, “the psychological process is universally applicable, and not exclusive to any one culture or religion” (Bruce et al., 2010, p. 84). The mind can be mindful just as it can fantasize and

daydream, as well as be sleepy, focused, unfocused, or emotional. Martin (1997) identified mindfulness as a “core psychotherapy process” (Bruce et al., 2010, p. 92) and reported that mindfulness has been implicitly included in Western psychotherapy practices since the beginning. Whether it is Freud’s “evenly hovering attention,” Bion and Ogden’s “reverie,” or Casement’s “unfocused listening” and “internal supervisor,” all concepts seem to have a strong resemblance to the tenets of mindfulness (Bruce et al., 2010; McWilliams, 2018, as cited in Barsness, 2018, p. 90). For example, Casement’s (1985) concept of “internal supervisor” identified CT as a research tool for the psychotherapist to use in their analysis. In his writing about clinical training and supervision, he wrote about the importance of therapist discernment, distinguishing between the unconscious communication from the client and the therapist’s own psychopathology (Casement, 1985).

Jon Kabat-Zinn, a long-term meditation practitioner, pioneered mindfulness work in behavioral medicine beginning in the late 1970s with the introduction of mindfulnessbased stress reduction (MBSR) interventions. Beginning with a foundation of traditional Buddhist psychology and meditation practices, he developed a nonsectarian, Western culture–oriented meditation training program to help his suffering clients. Much of the literature on mindfulness involves the MBSR program. He later developed the MBSR clinical program through the Stress Reduction Clinic at the University of Massachusetts Medical Center. The purpose of the program was to provide an alternative and complementary treatment from those chronically ill clients who were not responding to traditional medical care (Kabat-Zinn, 1990/2013). Mindfulness and mindfulness

meditation are not a performance but constitute a practice that continues to grow, and skills are strengthened with reinforcement of practice (Kabat-Zinn, 2003).

MBSR has been adapted from the Buddhist meditation practice known as Vipassana (Kabat-Zinn, 1990). It is a training program that consists of eight weekly 2.5hr mindfulness meditation classes and one all-day mindfulness retreat (Atlanta Mindfulness Institute, 2021). The multimodal curriculum includes classes on mind–body connection, the neurobiology of stress, the mindful body scan, the development of informal mindfulness in awareness of routine experiences, mindful breathing exercises, self-guided and sitting guided meditation, and yoga (Kabat-Zinn, 1990/2013). The MBSR curriculum teaches a broad range of skills that include both formal and informal techniques that can be applied daily. MBSR also provides a group experience that can be supportive and strengthen the participants’ relationships (Rozenweig et al., 2003).

Research has indicated that participating in MBSR participants has numerous benefits. For example, one study reported that clients experienced decreases in medical symptoms that accompany illnesses such as cancer and fibromyalgia (Chang et al., 2004; Reibel et al., 2001). Researchers also reported significant improvements in relief for chronic pain clients (Kabat-Zinn, 1982; Kabat-Zinn et al., 1985; Randolph et al., 1999).

In terms of psychological benefits, it is empirically well documented that participating in MBSR programs increases positive mood states (Chang et al., 2004; Galantino et al., 2005; Rosenzweig et al., 2003), mindfulness self-efficacy (Chang et al., 2004), experiences (Shapiro et al., 1998), and social functioning, quality of life, and overall well-being (Reibel et al., 2001). In addition, researchers have indicated that participating

in MBSR programs decreases individuals’ perceived stress (Chang et al., 2004; Shapiro et al., 2005), state and trait anxiety (Shapiro et al., 1998), depression and anxiety (Reibel et al., 2001; Rosenzweig et al. 2003; Shapiro et al., 1998; Weiss et al., 2005), and job burnout (Galantino et al., 2005; Shapiro et al., 2005). Research has also shown that mindfulness meditation allows the individual to have more cognitive flexibility (Davis & Hayes, 2011), which can enhance greater flexibility in the client’s problems and increase creativity in responding to their needs in the moment (Fulton, 2005). Finally, a pilot study using a randomized, controlled design found that health care professionals (i.e., physicians, nurses, social workers, physical therapists, and psychologists) participating in a MBSR course reported a statistically significant increase in self-compassion in comparison with participants in the control group (Vinca, 2009).

Mindfulness-based clinical interventions are being used to treat a variety of mental health and health issues such as insomnia, eating disorders, posttraumatic stress disorder, obsessive-compulsive disorder, anxiety, and substance use (Bowen et al., 2006; Cropley et al., 2007; Fairfax, 2008; Kristeller et al., 2006; Ong et al., 2008; Roemer & Orsillo, 2005; Walser & Westrup, 2007, as cited in Bruce et al., 2010). Mindfulnessbased practices have also been incorporated in dialectical behavioral treatment protocols. In addition, mindfulness-based cognitive therapy (MBCT) was developed as a preventative program for relapses in depression (Segal et al., 2013).

Although the 8-week course has a multimodal intervention that includes didactic instruction on stress and coping, experiential exercises in cultivating mindful listening skills and empathy, formal meditation practices, and a supportive group dynamic, it is

difficult to determine to what extent each component uniquely contributed to the positive effects. For example, the intervention provides a safe and empathic environment for participants to share their experiences, conflicts, and feelings. It is likely that some of the positive effects may be generated through participants’ disclosure of personal narratives and feeling states. Literature has supported the fact that social support and the sharing of stories can enhance physical and psychological well-being (Fawzy et al., 1993). Additional research is needed to tease out and identify the specific components of MBSR training that contributed to the positive effects (Shapiro et al., 1998).

Although the physical and psychological benefits of mindfulness are empirically supported, these findings are limited to particular populations: most notably, hospitalbased and psychotherapy clients. Empirically supported positive outcomes and future potential health benefits have fueled an interest in researching MBSR. In fact, MBSR has become the most widely researched mindfulness training program (Germer et al., 2013), and researchers have begun exploring the potential change mechanisms of mindfulness meditation (Holzel, Lazar, et al., 2011). Holzel et al. (2011) proposed that the mechanism of mindfulness meditation’s change includes the following: enhanced self-regulation that occurs through a combination of improvements in body awareness, emotional regulation, attention regulation, and perspective on the self. Studies on potential mechanisms of change within MBIs have emphasized the complexity of the individual change process that results from participation in these interventions (Schanche et al., 2020). Overall, research findings appear encouraging regarding MBSR’s positive effect on mental and physical health and stress and indicate a need for future study.

MBSR has shown to have positive effects (i.e., decreases in distraction and rumination) for a variety of populations including medical students (Rosenzweig et al., 2003; Shapiro et al., 1998). Congruent with these research findings of mindfulness, it can be inferred that these positive benefits could relate to other populations such as psychotherapists or psychotherapists in training. Grepmair et al. (2007) conducted a double-blind study in Germany and demonstrated the effectiveness of training psychotherapists to be more mindful. In this study, two groups of psychotherapists in training (N = 18) treating a total of 124 clients for 9 weeks in an in-patient hospital setting were randomized to a group participating in meditation and a group that did not meditate. The mediating group met with a Zen master 5 days a week for 1 hr of meditation and instruction. The psychotherapists in training were instructed to practice meditation before therapy sessions. After 2 months of twice-weekly individual psychotherapy sessions, clients of the mediating psychotherapists showed significantly greater symptom reduction, reported greater satisfaction, and rated their therapies more helpful. The Zen training was not tested against a placebo intervention, and the researchers recommended that additional research should include experienced therapists and larger numbers of participants to determine the generalizability of results. This study did provide data to support a positive relationship between meditation and positive treatment outcomes. However, there is a need for a variety of methodological approaches in order to capture the complexity and heterogeneity of change processes within and between individuals participating in various MBIs. Qualitative studies have the potential to systematically investigate the lived experiences of therapists in the psychotherapy

process (Elliott et al., 2018) and may be particularly suited to exploring the complex process of the CT experience and psychotherapist.

Mindfulness has some likeness to the concept of intersubjectivity (Benjamin, 1990) in psychotherapy, which has been theorized to be associated with being in the present moment in psychotherapy and Buddhist practices (Epstein, 2007; Surrey, 2005). Benjamin conceptualized the idea of intersubjectivity in “terms of a relationship of mutual recognition—a relation in which each person experiences the other as a ‘like subject,’ another mind who can be ‘felt with,’ yet has a distinct, separate center of feeling and perception” (Benjamin, 2004, p. 5). Mindfulness and intersubjectivity are similar because they both enable a feeling of being connected with others. Authentic connection has been described as the center of psychological well-being and the primary ingredient to foster and grow healing relationships. Each participant in such relationships “feels able to be and be seen empathically. Each of them feels held, enlarged, and often stretched by the presence of the other and the challenge of mutuality” (Surrey, 2005, p. 92). This cultivation of connections can provide a glimpse into our inner worlds.

As reported in the literature, mindfulness has many psychological benefits. For example, Siegel (2007) believed that one’s ability to become attuned to ourselves is tied to the same circuity that enables the attunement to others. Therefore, paying attention appears to be neurologically linked to empathic attunement to others. The idea that an individual can be attuned to themselves suggests duality of the mind as both the “knower and the known” (Bruce et al., 2010, p. 86). Within psychoanalytic thinking, the knower is what is called the observing ego. That is considered to be a part of consciousness that is

observing of one’s experience without interpretation or judgment. The known is considered to be contents of the mind, which is translated to feelings, sensations, and cognitions that are representative of the experience of being human (Bruce et al., 2010). The metaphor of a bowl has been used to explain the duality of mind concept. Mindful awareness can be seen as a bowl that contains the contents of the mind. It is through the practice of mindfulness that one’s bowl grows in size to hold more intense experiences without spilling over. It is simply knowing what is happening in the moment without trying to get more (e.g., security, pleasure) or pushing away what is not wanted (e.g., anxiety, anger, guilt, shame). Spilling over would mean losing mindful awareness, such as moving away or getting lost in the experience. One result of continued mindful practice would be improved self-attunement—that is, knowing and accepting oneself. For a psychotherapist, having an open relationship with themselves could strengthen the connection to their client. A psychotherapist whose bowl of awareness overflows may instinctually dismiss or push out of consciousness those experiences that are distressful, which may impact their capacity to hold similar experiences for clients. This is basically known as CT, and the acting out of unconsciously motivated behaviors may negatively impact the therapy process and outcome (Gelso & Hayes, 2001, 2007).

In a session of mindfulness-informed psychotherapy, the therapist is attentive to the moment-to-moment changes in their affect, cognitions, and memories. As the client is relaying their own sensations, feelings, thoughts, and perceptions, the therapist is also being attentive and metabolizes the experience of the client as the object of awareness. It is the moment-to-moment attention to the rhythm of the relationship and the shifting of

conditions of connection and disconnection. There is clinical information to be noted in the awareness of the self, the other, and the rhythmic flow of the relationship. Whether deep emotions are felt in the silence (i.e., the space between words or in verbal language), the experience of being together is a crucial element for the relational psychotherapist. During moments of suffering, confusion, tension, or stress in a session, the impulse or urge to escape may be felt by the therapist. They may be conscious of their own inner commentary, listening to their own reactions to the client: “I need a vacation,” “He’s not getting better . . . he’s hit the repeat button again,” “Maybe I should refer out,” or I am hungry and want a snack.” Similarly, unpleasant emotions, cognitions, and sensations can be felt in CT events. Practicing certain mindfulness meditation techniques during these CT events and other challenging clinical situations may help to keep therapists emotionally available (Surrey, 2005). Mindfulness presents a different way of relating and being, ideally reducing suffering by decreasing constant reactivity and resistance (Shapiro & Carlson, 2017).

Additional empirical research has suggested that mindfulness helped to increase emotional regulation in the brain (Davis & Hayes, 2011). A therapist’s emotional regulation during stressful situations is considered an important tool in developing and maintaining a good working alliance (Shapiro & Carlson, 2017). Geller and Greenberg (2012) proposed that therapists can develop an ease and the ability to feel the depth of the other’s experience, learning to metabolize the pain in the process of accepting and letting go. Therapists should also learn to regulate their emotions, stay attuned, maintain boundaries, be thoughtfully aware of internal and external experience, and refrain from

reacting outwardly similar to the discussion of acting out in the CT experience. These skills are indeed helpful in preventing a reaction to what the client is presenting.

Empirical Research on CT and Mindfulness

For the purpose of this section, research on mindfulness and CT will be reviewed. Davis and Hayes (2011) completed a quantitative study exploring the relationship between meditation, mindfulness, differentiation of self, and CT management. Seventyeight dyads of therapists in training and their supervisors completed self-report measures to assess the following: self-differentiation, mindfulness and mindfulness mediation experience, and CT management qualities. Study results found that “therapists’ nonreactivity was the only quality of CT management that was a function of mindfulness” (p. 134). The results support that MB practices may act as an emotional regulatory tool to help therapists be less reactive and more able to manage CT. Bruce et al. (2010) and Siegel (2007, 2012) proposed that mindfulness may support the ability to manage and use CT reactions in order to advance therapy outcomes. However, that hypothesis has largely been untested (Sampe, 2019). Another theorist (e.g., Surrey, 2005) reported that mindfulness practice can support the therapist’s ability to be attentive to connection and, in the process, repair its impasses. Countertransference and mindfulness theorists (Gelso & Hayes, 2007) have recognized the role of mindfulness in CT repair and management. As mentioned previously, mindfulness is a concept derived from the Buddhist meditative practice. It has been defined as attending to and being aware of one’s moment-to-moment experience (Brown & Ryan, 2004) and implies a nonjudgmental and nonreactive

relationship to those experiences (Kabat-Zinn, 1990). In mindfulness, the object of investigation is the connection to what arises in the awareness, as well as in the therapy room and within the CT experience. Using this perspective, mindfulness supports psychotherapy as it provides an expansive awareness in the therapist, which can subsequently be implicitly and explicitly extended to the client. Therefore, mindfulness practice can support the therapist’s capacity to attend to connectedness with the client and, in the process, repair its impasses (Surrey, 2005).

Psychoanalytic and psychodynamic clinicians and researchers have discussed the value of Buddhist philosophy and meditative practices in managing CT in order to benefit therapy (Christensen & Rudnick, 1999; Cooper, 1999). Fulton (2005) believed the practice of mindfulness should be incorporated into graduate curriculum programs. In the last 15 years, research is beginning to support the causal relationship between CT and mindfulness. In a qualitative study examining CT management practices, many of the psychologists interviewed reported that self-awareness was critical in managing their reactions, and they discussed practices they use to facilitate self-awareness (Baehr, 2004). Meditation was identified as one method of expanding self-awareness. Therapists who are able to observe their continuous flow of experience are better able to know when they are having CT feelings and have the opportunity to increase their understanding of their internal dynamics (Gelso & Hayes, 2007). Awareness of needs, conflicts, desires, and motivations lessens the chances of reacting to them unintentionally. Understanding of the self facilitated management of one’s conflicts and vulnerabilities (Gelso & Hayes, 2007).

Countertransferential reactions may include a variety of feelings, including hate, envy, fear, and boredom in relation to their interactions with clients (Navavits, 2000), and they have been determined as evitable for therapists of all therapy orientations (Gelso & Hayes, 2007; Hayes et al., 1998). Millon and Halewood (2015) conducted one of the first qualitative studies to explore CT experiences of psychotherapists who practice mindfulness meditation. Using a grounded theory methodological approach, the researchers interviewed five female psychotherapists who practice mindfulness exploring their CT experiences. The findings showed that participants who practiced mindfulness meditation were more receptive to CT responses using an observational stance and viewed the CT responses through an attitude of compassionate curiosity, which allowed them to be more present, in the moment. As a result, they experienced a deeper therapeutic relationship with the client. However, several limitations were noted. The small number of participants did not allow categorical findings to be fully saturated; therefore, only conceptual interpretation of the data can be concluded. The researchers also acknowledged that the behaviors identified in the data analysis could have potentially come about through other trainings of the participants and preexisting personality traits of the psychotherapists, rather than coming from mindfulness trainings. Therefore, the researchers were unable to ground their theory in the data analyzed and were unable to identify key elements of the phenomenon of study. Although the primary objective of the research was not achieved, the study can be understood as a pilot project supplying an initial frame of reference for subsequent research.

Future qualitative and qualitative research would need to be conducted to strengthen the relationship between mindfulness and having the potential mediating role in CT processes (Guest, 2019). There is great interest in being attentive to the moment-tomoment flow in psychotherapy. For example, Daniel Stern (2004) wrote on the importance of working in the here and now and points to the great potential it has in facilitating therapeutic change. He wrote, “It is remarkable how little we know of the experience that is happening right now while we know or have theorized so much more about the past” (Stern, 2003, p. 52). The research interest also includes studying how mindfulness can benefit psychotherapy training programs. Vinca (2009) employed both quantitative and qualitative measures in a single-case study to investigate the relationship between therapist trainee self-reported mindfulness, presence, and anxiety over the course of 12 to 15 sessions with a particular client and client-reported therapist empathy. The study also examined session progress and therapeutic outcomes. The results reported on the importance of the therapist’s attention turned inward in preparation for sessions and balancing the internal and external attending with a client. Vinca (2009) concluded, “However, it was not merely attention; it is the way the therapist attended that is essential. Attention that is observational in nature and accepting of whatever might pass through the individual’s awareness is key” (p. 112).

Conclusions

There is substantial research in the empirical and theoretical literature describing a connection between mindfulness and psychotherapy, as well as between mindfulness

and CT. Support for the expansion of research on mindfulness and CT processes goes hand in hand with the importance of therapists learning to cultivate attention skills, increase awareness, and nurture acceptance of whatever may be happening in the moment without acting out toward their clients. Further research is needed to understand the various mindfulness practices and how they may interface with the unfolding experience of CT. Although this research is different from Vinca’s (2009) study, this researcher is interested in systematically and intimately exploring the relationship between mindfulness, psychotherapy, and CT with seasoned psychotherapists because there is a gap in the research literature. The researcher is not necessarily interested in the effectiveness of the mindfulness techniques and CT but rather the details of the therapist’s subjective experience of their mindful practice during client CT interactions.

Chapter 3

Methodology

Qualitative research provides an in-depth and detailed account of why things happen and how they affect the individuals of concern. As a research methodology, a qualitative approach provides researchers an opportunity to use and improve their interpersonal and subjectivity skills as part of the research process (Alase, 2017). In contrast to quantitative approaches, qualitative research is primarily concerned with the meaning and quality of experience rather than causal relationships (Pietkiewicz & Smith, 2012). What is more, qualitative research is inductive and explores the “what,” “why,” and “how” questions as compared to quantitative research, which is deductive and interested in exploring questions such as “how much” or “how many” (Tuffour, 2017, p. 1).

In this study, I use a qualitative interpretive phenomenological analysis (IPA) based on a methodology outlined by Smith et al. (2009). IPA is considered as a methodology separately rather than only a means of analyzing data (Smith, 2004). IPA is part of a family of phenomenological psychology approaches and inevitably involves an interpretative process on the part of both researcher and participant. In other words, the researcher is interested in the quality of experience of their research participants (Pietkiewicz & Smith, 2012). IPA is concerned with uncovering what a lived experience

means to the individual through a process of in-depth reflective inquiry, and it is important for the researcher to “put themselves in the shoes of the participants” (Alase, 2017, p. 12; Smith et al., 2009). IPA is a useful methodology for “examining topics which are complex, ambiguous, and emotionally laden” (Smith & Osborn, 2015, p. 41).

IPA draws on phenomenological thinking and emphasizes the interpretative component of research, as humans are “sense-making organisms” (Smith et al., 2009, 2015, p. 41). The researcher uses an interpretative approach to gain insights from the participants by having an open mind that is also flexible, curious, and empathic. The researcher employs active listening as individuals tell their stories to learn how experiences and actions are shaped by the individuals’ historical, social cultural, and economic worlds (Tuffour, 2017). Therefore, a constructivist paradigm is emphasized in this research as the focus is on the understanding of the social world through subjective experience. The IPA approach will enable me to reflect on the subjective nature of reality and understand each participant’s view of mindfulness and CT while maintaining the validity and uniqueness of the individual’s lived experience.

IPA was first formulated in the United Kingdom in the 1990s and was later adopted as a research approach within the fields of psychology, health, social science, and psychology (Peat et al., 2019). Since that time, it has gained prominence, and its popularity has increased with psychology researchers throughout the world. IPA’s research approach employs a methodology that helps understand and interpret topics that are complex and emotion-laden (Smith & Osborn, 2015). IPA’s multi-stage processes are designed to provide detailed instructions for data analysis and allow for flexibility. Smith

(2011) reports that IPA has two fundamental quality measures, which are “rigour and interpretative flair” (p. 23). IPA provides a balance between creativity and intuition and a systematic process to ensure credible and reliable research (VanScoy et al., 2015). The appeal for this research project is IPA’s explicit commitment to understanding phenomena of interest from a first-person perspective and the ideological value placed on subjectivity for psychological understanding (Eatough & Smith, 2017).

This research project’s objective was to explore and analyze the subjective experiences of a small sample of experienced psychotherapists who regularly practice mindfulness and how mindfulness may be used in countertransference (CT) processing. The small sample size of the IPA studies enabled a microscopic examination of the participants’ narratives, which provided a possible entry into the understanding of mindfulness and CT experiences (Smith & Osborn, 2015). In the study, I attempted to deepen the understanding of the internal responses and thoughts associated with CT reactions and how mindfulness practices can be useful in the therapy process. The research is important because it advances the understanding of mindfulness as a therapeutic mechanism of action to be used in external and internal experiences of CT; it has the potential to identify diagnostic material, expand conceptualization of clinical case material, and contribute to the efficacy of the therapeutic relationship. To better understand this phenomenon, in this study, I addressed a central research question: What is the subjective experience of psychotherapists who practice mindfulness and examine CT?

The following sections of this chapter describe the study’s methodology, involving a detailed discussion of (a) the rationale and research approach, including the appropriateness of the selection of a qualitative design, a social constructivist paradigm, and a phenomenology methodology; (b) the research sample; (c) the overall research design; (d) data collection methods; (e) analysis and synthesis of data; (f) ethical considerations; (g) issues of trustworthiness; and (h) limitations and delimitations (Bloomberg & Volpe, 2019).

Rationale and Research Approach

In the study, I attempted to deepen the understanding of the internal responses and thoughts associated with CT reactions and how mindfulness practices may be used in the therapy process. The research is important because it explores the use of mindfulness as a therapeutic tool to increase the awareness and understanding of the external and internal experiences of CT. If psychotherapists can better understand the complexity of their CT responses towards clients, they can make clinical use of their responses to the client. This research study has the potential to expand conceptualization of clinical case material and contribute to the efficacy of the therapeutic relationship, thus contributing to the field of mental health. To better understand this phenomenon, in this study, I will address a central research question: What is the subjective experience of psychotherapists who practice mindfulness and examine CT?

The practice of psychotherapy is both complex and challenging, and the more a clinician understands the crucial importance of CT, the more appreciative and respectful

they can be of the process. This research highlights the therapist’s challenging assignment of observing both parties involved in therapy while keeping the focus on the client and monitoring and sorting out their responses during the therapy hour (Wishnie, 2005). The analytical process and IPA methodology selected for this research are complementary. The application of IPA methodology is used to gain an understanding of the lived experiences of psychotherapists who may use mindfulness practices as part of their CT experience. IPA methods draw upon phenomenology, hermeneutics, and ideography.

Phenomenological research and its early iterations by Edmund Husserl, a German philosopher, could be used to gain insights into the lived experiences of psychotherapists. For example, paying attention within the context of mindfulness involves observing the happenings of one’s moment-moment, internal and external experience. Husserl referred to this as a “return to things themselves,” which means striving to suspend the ways of interpreting experience and instead attending to the experience, as it is revealed in the here and now (Shapiro et al., 2017, p. 376). Considering this mindfulness practice, one can learn to attend, moment by moment, to the field of consciousness. The IPA approach was expanded by many theorists and minds to create a more flexible, participant-oriented, and interpretive process (Alase, 2017; Smith et al., 2009). For example, Moustakas (1994) advanced the quality of IPA research by promoting the use of “bracketing” of a researcher’s personal experience from the participants’ “lived experiences” (Alase, 2017, p. 10). In this research, I adopt a phenomenological constructivist approach in which I

seek to understand, interpret, and explore mindfulness practice and CT as a socially constructed phenomenon (Howell, 2013).

According to a constructivist perspective, knowledge is constructed and understanding is based on the development of shared meanings, a network of assumptions, and preestablished beliefs (Howell, 2013). The phenomenological philosophy in the tradition of Husserl (1913/1931), Heidegger (1927/1982), MerleauPonty, and Sartre may provide a deeper and more complete understanding of mindfulness and CT than constructivism alone can achieve. Together these philosophers and authors have proposed that people are “embedded in the world of language and social relationships and that we cannot escape the historical accuracy of all understanding”

(Finlay, 2011, as cited in Tuffour, 2017, p. 1). This study reveals the practical applications and intersection of phenomenology, constructivism, and IPA. The defined IPA approach enables researchers not just to “bear witness” to emergent themes but rather to become active participants in the discovery of those themes (Pringle et al., 2011).

The primary objective of phenomenological research is to seek reality from individuals’ narratives of their experiences and feelings, which involves in-depth descriptions and close analysis of the phenomenon (Bloomberg & Volpe, 2019).

Phenomenological research seeks to understand how meaning is created through embodied perception and contributes to a deeper understanding of lived experiences by exposing taken-for-granted assumptions about these ways of knowing (Sokolowski, 2000). Although IPA has its roots in phenomenology, IPA goes beyond simply

uncovering meaning and employs a double hermeneutic approach, or dual interpretation process, which includes both discovery and interpretation of the meaning of an experience while remaining intrinsically focused on the individual and the experience itself (Pringle et al., 2011; Smith et al., 2009). This approach enables both participants and me as the researcher to arrive at a co-constructed understanding of psychotherapists’ experiences through open dialogue that allows for the sharing and interpretation of multiple perspectives (Smith et al., 2009). The lived experiences of how and why psychotherapists who practice mindfulness with the CT experience is one such phenomenon requiring this method of analysis.

IPA acknowledges that individuals are influenced by the worlds in which they live and which they experience (Peat et al., 2019). Thus, a social constructivist paradigm acts as a guiding principle in this study, as the “basic tenet of constructivism is that reality is socially, culturally, and historically constructed” (Lincoln & Guba, 1985, 2000, as cited in Bloomberg & Volpe, 2019, p. 45). Qualitative research is essentially grounded within a constructivist paradigm, as it is focused on exploring how social and cultural complexities are understood, experienced, and interpreted within a specific context and time frame (Bloomberg & Volpe, 2019). A comprehensive approach was used to explore the understanding of the phenomenon of study.

A primary condition of the social constructivist approach is its epistemological foundation (meaning how knowledge is constructed) and the assumption that understanding is built on preestablished beliefs, suppositions, and experiences of meaning (Creswell, 2009). Social inquiry is shaped by the researcher’s epistemology and

underlying assumptions about the process of knowing (Denzin, 2002). Epistemology is concerned with the way knowledge is acquired and, as a research praxis, contributes to the development of knowledge in our field. In its purest form, constructivism asserts that reality is socially constructed, compared with quantitative research, which contends that reality is located within an objective paradigm (Denzin & Lincoln, 2000). Constructivism considers that reality is shared experiences and research results are “created through consensus and individual constructions, including the constructions of the investigator” (Howell, 2013, p. 87).

Ontology is concerned with the nature of reality. Ontological and epistemological perspectives interweave and condition each other in complex ways. They are not easily separated and are often complementary to each other. In this research study, the method of inquiry was guided by the importance of both ontology and epistemology, as they are critical in the research process. For example, I have assumed in this study that reality is co-constructed between the researcher and participants, and interpretation is at the core of the research. I continued to acknowledge that my values, history, and interests are potential influences in the production of knowledge (Guba & Lincoln, 2005). In the present study, I followed Guba and Lincoln’s (1994) subjectivist epistemology, as the purpose of the research was to gain deeper understanding of how psychotherapists’ mindfulness practices influence the CT experience.

The qualitative method of phenomenology is clearly intersubjective and dialogical in nature. The dialogic approach places emphasis on fostering dialogue between researchers with the objective of deepening understanding of a phenomenon (Eatough et

al., 2017). The term intersubjectivity was first introduced as a concept in the psychoanalytic community in the 1970s by Robert Stolorow and George Atwood. The authors contended that the field required a paradigm shift toward a “dyadic systems perspective and have been most articulate and persuasive in their radical critique of the ‘myth of the isolated mind’” (Mitchell & Aron, 1999, p. 365). Stolorow and Atwood argued convincingly of the relationship between objective epistemology and the falsehood of an isolated mind. An intersubjective field is a system of “reciprocal mutual influence” (Mitchell & Aron, 1999, p. 365). The intersubjective viewpoint emphasizes the interplay between worlds of experience, which leads inevitably to an epistemological stance that is best described as perspectivalist. This epistemological principle states that perception and knowledge of something are always bound to the interpretive perspectives of those observing. Therefore, the subjective nature of the researcher and interpretation of knowledge affects what we can understand about the phenomenon of study (Berzoff et al., 2016).

IPA is both flexible and responsive, and it encourages an organic flow of questioning, interpretation, and meaning-making as the process unfolds, for both the participant and the researcher (Smith et al., 2009). It involves not only examining what is said but also looking beyond the words themselves to begin questioning what those words might mean in the larger context of the experience. The IPA approach is different from traditional phenomenological approaches in its ability to identify and consider both convergent and divergent themes while not losing sight of the individual’s experience of the phenomenon; it highlights the importance of those differences rather than only

identifying and exploring the commonalities. The approach of seeking commonality typically is a priority in the more traditional phenomenological approaches (Pringle et al., 2011). Thus, an IPA approach will enable me to reflect on the subjective nature of reality and thereby illuminate each participant’s view of their mindfulness practices and CT while maintaining the validity and uniqueness of the individual’s experience. The detailed accounts of the experience as told by the research participants will help to create a greater understanding of what it means to practice mindfulness as a psychotherapist within the CT process and thus to explore the intersubjectivity of what it means to be a learner (Smith et al., 2009).

IPA and this research study have a complementary nature as the researcher’s relationship with data analysis is that of participant-observer. There is both a subjective and an objective quality to the process. One primary objective for the IPA researcher is to engage in an interpretative relationship with the transcripts. An IPA approach follows a systematic and rigorous engagement with the transcript to understand both content and complexity of meanings of the participants’ psychological, social, and cultural world (Smith & Osborn, 2007). The fundamentally idiographic nature of IPA, being focused on individual experience, commits to taking great care of each case and detailed analysis of the phenomenon under investigation. IPA data analysis has been described as “bottom up,” meaning the researcher generates codes from the data instead of using an existing theory to identify codes that can be applied to data collected (VanScoy, 2014, p. 345).

The data analysis is line for line, and transcripts are read several times, with margin notes used to identify important details.

Reading the text multiple times encourages and reinforces a reflective process for the researcher. Subsequently, the analysis becomes a co-creation between the participant and the analyst. This method of horizontal coding allows for connections and associations to be identified and for themes to emerge. As the data analysis continues, one must check the accuracy between themes and actual text. IPA has methods of tracking and checking the data through auditing, collaboration, and supervision that increases the consistency and credibility of the results. Over time, interpretations and meanings of the participant’s lived experience are revealed (Smith et al., 2009).

Thus, an IPA approach enabled me to reflect on the subjective nature of reality and thereby illuminate each participant’s view of their mindfulness practices and CT while maintaining the validity and uniqueness of the individual’s experience. The detailed accounts of the experience as told by the research participants helped to create a greater understanding of what it means to practice mindfulness as a psychotherapist within the CT process and thus to explore the intersubjectivity of what it means to be a participant-observer (Smith et al., 2009).

Research Sample

I used a purposive criterion-based sampling approach to recruit psychotherapists for this study (Creswell, 2013). The target population consisted of experienced psychotherapists (i.e., at least 5 years) who have completed training in mindfulness-based stress reduction or mindfulness-based practices such as meditation. The psychotherapists included indicated that they performed at least 10 hours per week of in-person or

telehealth client care. The sample population included integrated psychotherapists who practice from a variety of theoretical paradigms. The population criteria also included psychotherapists who formally (i.e., intentional commitment of time) or informally (i.e., mindfulness in everyday activities) practice mindfulness practices. The sampling method involved selecting participants on the basis that they could provide access to a particular perspective of mindfulness practices and CT (Smith et al., 2009).

As it is generally understood that therapists experience CT whether or not they use the term or devote time to the exploration and utilization of the concept (Hayes, 2004), the sample population may use other terminology to describe CT such as “therapyinterfering behaviors.” Purposeful homogeneous sampling is a good technique to deeply investigate, discover, and understand the phenomenon under study through a sample that gives detailed information (Merriam, 2002). Uniform groups with noticeable social or other theoretical factors pertinent to the study allow for close examination of the details of group psychological variability by analyzing the relationship of convergence and divergence that occurs (Smith et al., 2009). In this study, the researcher used a relatively small sample, as outlined in the IPA approach developed by Smith et al. (2009). The IPA approach uses small sample sizes to facilitate high-quality, in-depth analysis and interpretation of data. Smith et al. (2009) identified that a “reasonable sample size” is between three and six participants (p. 51).

The sample included seven participants. A sample size of seven to ten respondents has been shown to be optimal for validity in several phenomenological studies, specifically studies examining the phenomenon of psychotherapists and how

mindfulness practice impacts their professional lives. For IPA, sampling is defined in relation to a previous study on the topic (Smith et al., 2009). Dr. Stephanie Swann, owner of the Atlanta Mindfulness Institute, Atlanta, GA, agreed to assist in recruitment for this study. Dr. Swann agreed to identify candidates who met sampling criteria and send the recruitment email on my behalf.

Additional Recruitment

As a result of consultation with Dr. Swann and approval by the dissertation committee chair, Dr. Tsioles, I decided to modify the sample criteria so that participants were eligible for inclusion if their clinical practice was at least 10 hours of both in-person and/or telehealth client care per week. Over the past three years and as a direct result of the pandemic, the mental health delivery system has changed drastically to include telehealth. Our profession continues to adapt to the current pandemic, and many clinicians are using a hybrid approach to providing therapy. Dr. Swann believed that altering the inclusion requirement would net more participants for this study. Table 3 presents the basic details about each of the study participants.

Research Design

Once the Institutional Review Board approved the study and the proposal hearing had been passed, Dr. Swann sent an email that included the invitation to potential participants, informing them of study objectives and the criteria for participation; my name and contact information; the purpose of the research; a summary of criteria that included eligibility for the study, the proposed time and commitment required by participants; and the option for in-person or virtual interviews.

All participants who were interested in joining my study were instructed to contact me by phone or email and to sign and return hard copies of my informed consent form by mail. All participants were provided extra copies of my informed consent form, as well as a list of local mental health resources for their own records. All candidates were pre-interviewed to determine their appropriateness as participants. During the screening interview, I provided details about the study, the intended use of the results, participant rights, and confidentiality policies.

Participants

All six participants signed and returned the informed consent forms prior to the first interview. Participants were reminded that the study was voluntary and that they could withdraw at any time. Participants were also assigned pseudonyms to help ensure anonymity.

In total, six participants were enrolled in the study. The decision to omit the seventh participant was due to the prolonged delay in scheduling the first interview. This decision was made in consultation with the researcher’s dissertation committee chair.

Demographic Survey

I created a demographic questionnaire (see Appendices) and provided it to the psychotherapists participating in the study to collect various demographic information (i.e., gender, age, ethnicity, highest level of education, years in clinical practice, mindfulness training and practice). The demographic survey was completed prior to the beginning of the study, and the data collected was used as part of the recruitment process and in data analysis.

The Researcher’s Role

I served as a research instrument in this study and acted as a guide and interpreter of participants’ experiences during the semistructured interviews. I sought to maintain a level of open-mindedness and awareness about my own feelings and beliefs and mindfulness practices and CT. A researcher’s beliefs are not necessarily viewed as biases to be removed but rather acknowledged as a potential tool for making sense of the experiences of others (Smith et al., 2009). Several precautions were taken to “bracket” or restrict interpretations or preconceptions and practice the skill of differentiation during the interview process (Creswell, 2013). The researcher’s role of objectivity was preserved while acknowledging the subjectivity component of the exploratory process. I maintained

a research journal to monitor my own personal feelings, cognitions, and behaviors (nonverbal and verbal) both during and after the interview. I reviewed the journal entries with initial and subsequent readings of the transcripts. The journal enabled me to bracket my own internal and external experiences and to differentiate preliminary responses or impressions to interviews, which was used to inform deeper reflection and questioning during the iterative data analysis process.

Data Collection

I collected and validated data through two semistructured interview sessions with each individual respondent. In line with IPA, the objective of the interviewing process is to invite participants to “offer a rich, detailed, first-person account of their experiences”

(Smith et al., 2009, p. 56). This researcher invited participants to tell their stories; to explore their thoughts, ideas, and feelings; and to reflect on their mindfulness practice and

CT. Interview Method

The primary source of data collection was in-depth semistructured interviews, which enabled me to maintain an organized interviewing process while providing the opportunity for participants to be free and curious in their responses. The interview protocol was greatly influenced by the literature presented in Chapter 2 and was focused on obtaining information that would help inform the research question. The researcher used a “prompt sheet” that included a few main themes for discussion with the

participants as an interview guide, for example, (a) the therapeutic use of mindfulness and (b) CT viewed through the lens of mindfulness practice. The interview schedule provided the basis for conversation. The initial plan was for each participant to give two interviews, lasting approximately 60 minutes, which would be audio recorded.

Each participant decided on the interview location, and all chose the Zoom virtual setting. The goal of an interview, according to IPA, is to approach the research question “sideways” or allow for an abstract method to be used in the data collection process and obtain information to be analyzed later. Smith et al. (2009) stated that the interview should provide an opportunity for participants to “tell their stories, to speak freely and reflectively, and to develop their ideas and express their concerns at some length” (p. 56).

It was also important for the interview process to be viewed as a bidirectional, dynamic process wherein the researcher and interviewee are active participants in the research process (Smith et al., 2009).

I developed the interview question guide based on the findings in the literature presented in Chapter 2 and with the objective of understanding each participant’s experience and appraisal related to mindfulness practice and CT. All members of the dissertation committee reviewed and approved the interview guide. A pilot study was also conducted prior to the study, which allowed for testing of the interview questions as well as interviewing style and approach. Three mock interviews were completed with licensed clinicians who had five or more years of experience. There were no changes to the data-collection instrument as a result of the pilot study.

The researcher conducted virtual interviews of all six participants for the first and second interviews. The first interview lasted approximately 60 minutes, and the second interview lasted approximately 30–45 minutes. The general goal in the interview process was to understand participants’ experiences with mindfulness and CT. Open-ended questions were used to familiarize the participant with the phenomena being studied. The use of unstructured follow-up probes helped to further explore points as they occurred during the interview. Every effort was made to create a comfortable and non-threatening approach. The interviews were conducted in an empathic and conversational style (Ashworth & Lucas, 2000). The objective of the second interview was to receive the participant’s feedback on the first interview summary and any additional information or reflection on the experience of being interviewed.

Interview Question Guide

Interview Questions:

Overview of Mindfulness Practice and Clinical Practice

 Tell me about your training and experience with mindfulness and how you use it in your personal and professional life.

o How do you conceptualize mindfulness? Tell me about your current mindfulness practice.

o Describe any feelings that may come up as you explain your practice to me.

 How many months or years have you had a mindfulness practice?

o Describe the frequency and details of your mindfulness practice.

 Do you practice mindfulness in-between clients? While in session? Immediately before a session?

 How would you describe your clinical orientation?

The relationship between mindfulness and countertransference

There have been many modifications of the definition of CT over the years. For the purpose of this research study, countertransference is defined as follows: Therapists’ idiosyncratic reactions (broadly defined as affective, cognitive, somatic, and behavioral) to clients are based primarily on the therapists’ own personal conflicts, biases, or difficulties (e.g., cognitive biases, personal narratives, or maladaptive interpersonal patterns). These reactions can be conscious or unconscious (e.g., implicit or explicit). These reactions can be triggered by transference, client characteristics (e.g., narcissistic

or borderline personality characteristics), or other aspects of the therapeutic situation (e.g., termination) but not by extratherapy factors.

 Would you agree with this definition?

o If not, please explain your understanding of countertransference.

 Describe how mindfulness practice may influence your ability to make sense of clinical material and countertransference experience.

 Please reflect on your use of mindfulness practice in relationship to CT and to the therapeutic relationship.

 Are there any adverse effects you experience with mindfulness practice and your experience within countertransference?

Data Analysis

I forwarded a general questionnaire outline to all participants prior to the interview to provide some time to prepare for the interview cognitively and emotionally. The interview questions are in-depth and may require additional self-reflection and independent thought prior to the formal interview. For example, participants may have long-standing philosophical and ideological positions on mindfulness practice and its potential to coexist in their personal and professional lives. In addition, the concept of CT may involve a more complex deliberation of the intersection between the two experiences. The initial interview was transcribed, and a summary was promptly forwarded to the respondent requesting careful review, feedback, and clarification, and then the second interview was scheduled.

The primary interviews with each participant were followed by secondary interviews completed in a 2–4-week time frame. This timeline was useful for reflection and review of the interview data. It gave me space for recording additional notes, thoughts, observations, and reflections that occurred to me while reading the transcripts or other text. At this stage, I gained knowledge from recurring phrases, questions, emotional responses, reveries, or the language used. I also reflected on the experiences of engaging with the text and the interviewee’s subjectivity. The second conversations served as an opportunity to validate the data obtained in the primary interview and begin to conceptualize the location of the “gem” of emergent interpretations (Eatough et al., 2017).

After each interview, the audio recording was transcribed with meticulous attention to detail and accuracy, including pause indications, mis-hearings, speech, and mistakes noted (Biggerstaff & Thompson, 2008). A transcription service was used. The interview data was transcribed for the process of reflecting, interpreting, and analyzing using an IPA methodology. The transcripts were analyzed in conjunction with the original recordings, and interview themes were identified that may or may not correspond with my interview prompt sheet. While reading the text, I attempted to acknowledge and reduce judgment and suspend presuppositions to focus on what was presented in the transcript data (Creswell, 2013). This involved the practice of bracketing and is a necessary component in the field of phenomenological research (Creswell, 1998; Crotty, 1998; Vagle, 2014, as cited in Weatherford & Maitra, 2019). Practically, bracketing is a way for researchers to separate their own experiences from what is being studied (Creswell, 2003). Bracketing is considered a “multilayered process that is meant to access various levels of consciousness” (Tufford & Newman, 2010, p. 84.). Although IPA emphasizes the role of interpretation in the research process, it does not require researchers to completely “bracket” themselves out of the research. It welcomes the prior knowledge that is brought to the research and acknowledges the role it can play in making meaning. Bracketing in this study included careful examination of experience and attentive focus which supports IPA’s systematic and detailed analysis of consciousness as part of the interpretative process and data analysis (Tuffour, 2017).

IPA is idiographic and recommends that each transcript be individually analyzed (Smith et al., 2009). In this research study, data analysis began with close examination of

the first case, leading to the development of case themes and then consideration of themes across the data set. IPA recommends using several levels of coding: descriptive, linguistic, and conceptual. The method adopted in IPA is a cyclical process where the researcher proceeds through several iterative stages:

1. Reading and rereading: I read and reread the transcript data of a single case.

2. Initial coding: I conducted a free textual analysis, that is, I read the case, making and recording observations in the left and right margins of the transcript. There also was an additional level of exploring the text through a free association method, writing down whatever came to my mind when reading certain words or phrases of the text. The text was used as an object whose meanings and significance were being interpreted (Smith et al., 2009, p. 83).

3. Developing emerging themes: I identified “chunks of data” that related to observations noted in each single case. A document was constructed after the first three interviews listing the clustered themes. Some of the themes were extracts from the words or phrases of the participants. These themes involved an interpretive essence that related directly to the research participant and to me as the researcher.

4. Exploring for themes that emerge from the data: I identified “clusters of data” and “notes” together and determined how they could be related. Repetitive uses of words or phrases were considered, as well as how this information may be tied to the literature presented in Chapter 2. This involved “breaking

up of the narrative flow of the interview” and a reorganization of the data. This is the hermeneutic process of IPA research (Smith et al., 2009, p. 91). The analysis shifted to examination of initial notes rather than the transcript.

5. Moving to the next case: Emerging themes revealed from the previous case were “bracketed” as the new case was analyzed with “open and fresh” eyes; I again deeply explored the transcript data. The list of themes was put aside for each subsequent transcript to respect the convergences or divergences in themes. Once I had completed the interpretative analysis of all six transcripts, I constructed a list of thematic statements and sub-ordinate themes. This list is included in Chapter 4.

6. During the transcript analysis process, I provided a summary of the first interview to each participant and invited them to provide feedback on the interpretation of the data. A second interview as scheduled and completed within a 2–4-week time frame.

7. The second interviews were transcribed and IPA processes were completed for each transcript, including rereading, initial coding, thematic analysis, and identifying additional interpretative qualities of the transcripts.

8. Searching for patterns across cases: I questioned whether any other themes were identified across the cases. If so, these were highlighted while making additional notes of “idiosyncratic differences.”

9. Deeper interpretation level: I reviewed the themes across the data set using metaphors and “temporal referents”; I searched for additional meanings of the

experience (Peat et al., 2019, p. 8). I translated the themes into a narrative account, and the findings are discussed in Chapter 4. An explanation of the understanding of the listed themes is included, combined with verbatim extracts from the transcripts, which organizes interpretations of meaning to provide qualitative support for the basis of Chapter 5, which expands the discussion of the study’s results.

10. The textual analysis, interpretation of data, and emerging and subordinate themes are linked to the literature review in Chapter 5. A double hermeneutic process overlapped every step of this research endeavor. I tried to make sense of the participants’ attempts to make sense of their own experiences. States of reflection, meaning, and curiosity to experience were maintained while conducting this research. Therefore, there is a state of mindfulness when considering my own beliefs, perceptions, and experiences to enrich the interpretations rather than impose or become an impediment to discovery. I offered detailed reflection and included documentation to support the decisions identified at each stage of the IPA research (Peat et al., 2019).

11. The method described produced five subordinate themes mentioned in Chapter 4. In the process of presenting the results in Chapter 5, I systematically returned to the full interview transcripts in order to extract quotations interpreted in a hermeneutic process. This process supported an awareness of moving between individual examples of themes (i.e., parts) and maintaining the awareness of the study as a whole. This is understood as the

gestalt, that is, the whole is greater than the sum of its parts (Katz & Johnson, 2006).

Levels of Coding

Initial Coding. A preliminary reading of the transcript was made, immediately following the interview, during which no comments were made in the margins. This initial reading acted as an informal introduction to the text, a familiarization, and had a priming effect for the free textual associative process to follow. The second reading was accompanied by the audio recording, and I noted first impressions in my dissertation journal. This preliminary level of analysis was considered an experiential process, to get “close” to the data, and enabled a full immersion in the process (Noon, 2018, p. 75). The level of coding gave me an opportunity to note phrases; periods of silence; and changes in tone, pace, or texture in language or word in the wide margins of the transcript. As the text was annotated, I made notes regarding my subjective experience such as cognitions, observations, and/or reflections related to the narrative of each participant. The initial coding became an exploratory process to identify content and link connections to the research questions and literature review in Chapter 2.

Descriptive Coding. The next step was to reread and complete a line-by-line analysis, bringing the focus and attention to particular words or phrases that appeared to have significance in the text. The words or phrases were highlighted in this level of “descriptive comments,” as outlined by Smith et al. (2009). Descriptive statements began to highlight the importance of meaning of the participant’s unique experience. Using an

open annotated coding process assisted me in identifying the “distinctive voices” that emerged from the participant’s narratives. This can also help to bracket the interpretative data analysis from pre-existing ideas presented in the literature review. Descriptive coding extends beyond meaning for the participant by associating frequency, connotation, or perceived importance to both the participant and researcher. The highlighted text added a dimension of inquiry developed in the initial coding and classified further areas of research to be explored in subsequent readings and interpretations of the text (Noon et al., 2018., p. 77).

Linguistic Coding. The coding of linguistic comments brings depth to the process of inquiry into the text. This next level of coding includes a higher level of examination of previously highlighted sections as well as making note of frequently repeated words or phrases in the text. There are many aspects of this coding which identify the use of metaphors or other linguistic elements that are used to describe the meaning of the experience. The “meaning-making” process in IPA supports many levels of linguistic coding analysis both within and outside the context of the sentence. In other words, it is important to go beyond description and consider what was said and how, as well as what it tells the researcher about each participant’s experience (Noon et al., 2018).

Conceptual Coding. Linguistic coding helped to create the landscape for “conceptual comments,” establishing the third level of coding. This level of annotation has a more interpretative quality, exploring underneath the “explicit claims of the participant” (Smith et al., 2009, p. 88). The conceptual coding process required me to

think in an abstract way, using a wider lens to reflect and refine my ideas about the data. The conceptual comments extracted deeper levels of meaning within the context of experience. This level of interpretation helped to shape the identification of emergent themes that captured the psychological essence of the participants’ experiences. I completed a thematic analysis table of coding types for participants (See Appendix H).

Ethical Considerations

The protection of human subjects in a qualitative research study has always been a “sacred obligation of the research, but more so for an IPA researcher” (Alase, 2017, p. 18). The participant-oriented approach of IPA research studies must prioritize the protection of participants’ rights, dignity, and privacy. Ethical research standards are an organizing principle throughout data collection and analysis and require monitoring throughout the research endeavor. Psychotherapists are morally and legally bound to conduct research that minimizes potential harm to all those involved in the study (Bloomberg & Volpe, 2019). A risk analysis completed in the planning of this research study determined that there would be minimal risks to participants. All study participants were volunteers, and there was no physical risk related to the study. Attention to emotional distress or vulnerabilities was included in the risk analysis, a multistep process continuing throughout the research to support and maintain the ethical considerations. Qualitative researchers must be aware of safety and professional conduct, and it remains paramount to include a system of checks and balances within the research method. These steps to minimize risk extend beyond the

regulations of the institutional review boards of higher education and professional organizations. For this study, I took several steps to minimize the risk to participants:

1. I defined and communicated the ethical standards of privacy, anonymity, and confidentiality. The details of the informed consent were communicated at length, read, and signed prior to starting the study. All data was password protected, and only I maintained access. The participant names were excluded from the data, and a pseudonym was provided for each participant.

2. I created an environment that is confidential, safe, and comfortable during the interview process and encouraged participants to communicate any discomfort with questions or ask for more time to respond.

3. The researcher respected participants’ voluntary status in this research process and attempted to provide an atmosphere of flexibility, giving participants the freedom to explore their thoughts and feelings related to the study and the right to terminate at any time.

4. I was prepared to offer community mental health or other resources if information surfaced in the interview that warranted this type of referral consideration.

Issues of Trustworthiness

Trustworthiness or the truth value of qualitative research pertains to the researcher’s ability to establish credibility (i.e., reliability and validity) in research.

Trustworthiness or confidence in qualitative research is demonstrated by findings that accurately reflect the experiences of participants in relation to the phenomena under

exploration (Peat et al., 2019). The concepts of reliability and validity cannot be addressed in the same way in naturalistic research compared with a positivist paradigm. Nevertheless, qualitative researchers can institute certain measures to respond directly to credibility. Guba (1981) proposed four criteria that should be considered in qualitative studies to produce a trustworthy research study: credibility, dependability, confirmability, and transferability. The four criteria as related to this research study are described in detail below.

Credibility

Smith et al. (2009) recommended using criteria developed by Yardley (2000) to ensure quality and credibility of research. Yardley’s criteria are “sensitivity to context,”

“commitment and rigour,” “transparency and coherence,” and “importance and impact”

(p. 219). In addition to Yardley’s criteria, Smith (2011) developed detailed measures of quality for IPA studies. These criteria are described as “clear focus, strong data (resulting from good interviewing), support for themes extracted from each participants data, sufficient elaboration of each theme, interpretative, rather than merely descriptive, analysis includes patterns of similarity as well as uniqueness, and paper carefully written”

(p. 24).

In qualitative research, credibility or internal validity ensures that the study measures or tests what is intended. In other words, the findings are congruent with reality

(Merriam, 2002). Lincoln and Guba (1985, as cited in Bloomberg & Volpe, 2019) argued that ensuring credibility is one of the most important factors in establishing

trustworthiness. To ensure credibility in this study, the research methods will include the following techniques:

1. Bracketing (described earlier in the Data Analysis section): Using this method, I attempted to reveal any presuppositions to reduce bias that could influence data collection and analysis.

2. Peer critique: This involved peer debriefings with committee members to critique each stage of the research process and provide feedback on the descriptive validity and transparency of the interpretation of the data and findings.

3. Participant verification: The participants were invited to comment on my interpretation of the data.

4. Triangulation: I used different data collection methods, such memoing, a reflexive research diary, and additional notetaking.

5. There was continuous observation and prolonged engagement with the participants during the research process.

Dependability

Bloomberg and Volpe (2019) stated that researchers achieve dependability (in preference to reliability) in their research studies by taking the necessary steps in conducting a study that is succinctly “documented, logical and traceable” (p. 204). Thus, achieving dependability points to a stable and consistent data set over time, which maintains congruency with answering the research questions. Dependability in this study

was demonstrated by (a) describing what was planned and executed on a strategic level;

(b) the operational details of data gathering, addressing the minutiae of what was done in the field; and

(c) reflective appraisal of the project, evaluating the effectiveness of the process of inquiry completed.

Confirmability

The concept of confirmability is the qualitative investigator’s concern comparable to objectivity (Bloomberg & Volpe, 2019). The concept of objectivity is associated with a positivist paradigm, and it is generally accepted by scholarly researchers that there is difficulty in ensuring real objectivity when tests and questionnaires are designed by humans and researcher biases are inevitable. However, steps must be taken to ensure as much as possible that the work’s findings are the result of participants, rather than the characteristics or biases of the researcher. In this study, I used triangulation to increase the validity. The different data collection methods included individual interviews, memo writing, a reflexive research diary, an audit trail, and observational data to promote confirmability and reduce the effect of researcher bias (Sheldon, 2004).

Transferability

The concept of transferability is the qualitative researcher’s concern comparable to external validity or “the extent to which the findings of one study can be applied to other situations” (Shenton, 2004, p. 70). In qualitative research, the goal is to “develop descriptive context-relevant findings that can be applicable to broader contexts while still

maintaining their content-specific richness” (Bloomberg & Volpe, 2019, p. 205). The data analysis in IPA is organized into a step-by-step approach. I provided detailed interpretative commentary, thick descriptions of the phenomenon under investigation, and contextual information for the reader to make such a transfer.

Limitations and Delimitations

A limitation associated with this study is the sampling process, related to validity and reliability. This delimitation may call into question the generalizability of this study; however, it is important to remember that this research was not designed for generalization to a large population but instead focused on understanding individual experiences and developing a body of research that is “useful” and “meaningful” in the eyes of the participants so that the results help to deepen their understanding of their reality (Lincoln et al., 2011).

The small number of participants, which is a specific delimitation of the study, may result in most of the participants being limited to the area of Atlanta, Georgia. The small number of participants was recommended by Smith et al. (2009) and is specifically related to the qualitative method of IPA.

The aim of this phenomenological study was to explore the subjective experiences of psychotherapists who regularly practice mindfulness and its use in CT processing. My own subjectivity is acknowledged as part of the chosen research design, data collection, data analysis, and interpretative process. My objective was to increase the trustworthiness of my analysis using IPA through memoing, keeping a reflective research diary, field

notes, ongoing self-analysis and self-evaluation, and regular member committee consultation and peer review. Memo writing was a method of bracketing that records observations, conceptual and theoretical ideas, and cognitive, affectual experiences while participating in the research. Similarly, reflexive journaling provided an opportunity to acknowledge my feelings, biases, and experiences throughout the research endeavor (Ortlipp, 2008). The bracketing attempts allowed me to formulate ideas and theories, analyzing, reviewing, and sorting throughout each stage of the research project.

The Role and Background of the Researcher

I played a dual role of researcher and psychotherapist, and there was close engagement and interpretation involving both the participant and me as the researcher in this study. This is the double hermeneutic approach to IPA analysis. My role and responsibility as a qualitative IPA researcher were to explore and interpret the impact of the research subject matter on the lived experiences of the research participants. My own prior conceptions interacted with new experiences, which is significant to IPA research. It was important for me to be mindful of my own beliefs, biases, perceptions, and experiences so that they could enrich the interpretations rather than impose upon the participants’ experience (Fade, 2004). This was achieved through the process of reflexivity and “being aware” of how I could influence the research process (Peat et al., 2019). Researcher reflexivity included self-examination, self-analysis, and selfevaluation to describe how my preconceptions shaped knowledge produced in this study (Tuffour, 2017). My goal in conducting this IPA study was congruent with what

Polkinghore (1989) wrote in his book, “I understand better (now) what it is like for someone to experience that” (p. 46).

Chapter 4

Results

The purpose of this phenomenological study was to understand the subjective experiences of psychotherapists who regularly practice mindfulness and its use in CT processing. Participants’ identifying information was confidential, and to maintain this objective, everyone selected a pseudonym: Marie, Brooks, Madeline, Al, Emily, and Lynn. Interpretative analysis of the data was completed while remaining grounded in the participants’ testimonies. A table was produced to organize each level of coding, emerging themes, and subordinate themes for each participant. Converging of the data and searching for patterns across each transcript. A final table of superordinate themes and their respective subthemes were produced (Table 1).

During this iterative process, I went back to the table of themes for each participant, reviewed them, and if necessary, modified them and returned to the original transcripts. I identified four main subordinate themes that emerged from the data: (a) transformation of the self, (b) respond versus react, (c) holding space, and (d) emotional regulation. To understand the research process for this study, the chapter will include a detailed description of how these themes emerged and the different phases of research IPA also emphasizes the identification of divergent and convergent material that is revealed in the interpretation of participants’ lived experiences (Smith et al., 2009). This

chapter will conclude with a section on field notes and the important steps taken to ensure quality of research.

Phases of Research

In the first phase of this study, a questionnaire was sent via email and completed by all participants. The demographic questionnaire collected general demographic information and the results are presented in Table 3 (See Appendix G).

During the second phase of this study, psychotherapists were asked to share their lived experiences of mindfulness practice and CT. Each participant completed two interviews using a video conferencing format. Twelve interviews were conducted, with the first interview lasting approximately 60 min. To deepen the level of subjective experience, several research subquestions were used:

 How do psychotherapists, who acknowledge using mindfulness practices, use these practices professionally?

 How might a mindfulness practice affect the therapeutic process with a client?

 How do therapists who use mindfulness practices conceptualize the phenomenon of CT?

 How do psychotherapists who use mindfulness process CT?

 How can mindfulness practice inform psychodynamic thinking?

The second interview lasted approximately 30 min and was an opportunity for participants to verify summary transcript data, provide feedback to me, and to comment on their experience as a participant in this study. Overall, the second interview did not reveal any new data for this study. In addition, participants agreed with the transcript

summary, and each expressed positive experiences related to their involvement in the research.

Analysis of the raw data yielded four overall subordinate themes and subthemes.

Table 1 represents the themes and subthemes that emerged from the research interviews.

Table 1: Themes and SubThemes

Superordinate Themes Subthemes

Transformation of the self “The practice”—MB state of mind

Key concepts: awareness and acceptance

Knowing the self

 Therapist vulnerabilities

Learning to cope with not knowing Broadening the Subjective Experience

 Shift in beliefs, emotions and attitudes

Respond versus react

The space between

 “The pause button”—a time for reflection

 Noticing defensive processes

Discernment

Participant–observer

Holding space

Empathic and compassionate holding Building tolerance for discomfort and emotional pulls

Therapist presence

Emotional regulation

Self-regulation

 The fullness of experience

Mutual regulation

The body feels first

 Somatic experiences

Introduction to Participants

Table 2 provides background of participants in psychotherapy.

Superordinate Themes, Subthemes, and Participants’ Experiences

Theme 1: Transformation of the Self

The superordinate theme of transformation of the self highlights the participants’ sharing of professional MB training, descriptions of their current MB practices, and an

Table 2: Participant Background

explanation of how it shaped their lives. Each of their stories has a unique quality, weaving together rich details of the ways they understand mindfulness and the ways it has contributed to transforming ideas of the self. Four subthemes emerged under this superordinate theme: (a) mindfulness state of mind: awareness and acceptance; (b) knowing the self: vulnerabilities; (c) learning to cope with not knowing; and (d) broadening the subjective experience. The subthemes will be discussed in the next section.

Mindfulness State of Mind: Awareness and Acceptance.

The first subtheme that emerged from the superordinate theme of transformation of the self was mindfulness state of mind: awareness and acceptance. All participants described ways their practice encouraged acceptance and awareness. Their stories reveal individuality and yet, they used similar language to describe the intentionality of their mindfulness. For example, participants used the words, “acceptance,” “awareness,” and “transformative” to explain their perception and state of mind.

Participants were asked to share how MB practices were first introduced into their life and their intentions or motivations for MB training. This first section will briefly introduce the participants in this study and their lived experience with mindfulness.

Marie

Marie is a 59-year-old White female who is in private practice and has been a psychotherapist for 7 years. This is her second career because she practiced law for 20 years prior. Marie practices mindfulness meditation at least five-to-six times a week. She

explained that feelings of uncertainty and anxiety motivated her to participate in MBSR training. She made it clear that the expectation and outcome of training were not the same, contrary to her belief. Her narrative described a salient experience of accepting this fact, an experience that she often shares with others.

And I came in to MBSR because I was all jacked up about what was happening politically in our country, and I will never forget on the last day of the session of the course, I started crying because I didn’t feel better [laughs]. And, you know, I’ve told that story to quite a few clients because mindfulness isn’t about eliminating these difficult feelings. It’s about how to be with them with more equanimity and so, of course, I didn’t know that; and it just kind of makes me laugh, but that was my expectation.

Marie was asked what she noticed in her professional life with regards to MB practice and learning. She emphasized the object of awareness was particularly important in her practice

I just felt like, my practice was, you know, helter-skelter and I wasn’t doing it correctly like I said. And so, my motivation to approach the problem from a structured way with MBSR. I learned that the core of mindfulness is awareness. And I say to people, if it’s not about awareness, I honestly don’t know what to talk about.

Brooks

Brooks is a 42-year-old White female who has been in private practice for 3 years and has worked in the clinical social work field for 12 years. She has 10 years of

experience in grief counseling. She explained that her mindfulness practice has evolved over the years and includes formal and informal MB practice. She has completed MBSR training four times, with her husband accompanying her for one of the training sessions.

Brooks wanted him to understand MB practices from an experiential perspective versus knowing MBSR only through her practice lens. She practices meditation daily with a friend who brings more focus to yoga and bodywork in MB practice. It’s evolving and it comes in waves and there are periods where I will go, for a week or two without doing formal practice, but that’s kind of rare at this point, and it’s usually, I have a friend who I do the practice with daily, and we have found that meditating together on weekdays has been really helpful for allowing us to stay committed to doing the formal part. I think we both feel pretty comfortable with our informal practices around going for walks and really paying attention to what’s going on around and being able to try to engage in a nonnarrative way about what we’re experiencing around us and noticing our internal experiences in conversation, in our private and personal lives.

Brooks was asked to expand on her MB practice within her personal and professional life. She explained that participating in MBSR training with other professionals introduced another layer of distraction. She discussed the insight gained from this experience.

So, I had multiple motivations and I wanted to bring a more mindful presence and an understanding of what I was doing professionally and personally. Well, once we actually got into the practices together, some of the identity stuff began to fall

away, and because the practices require such constant coming back to focusing on just what’s happening right now and to have the dialogue about, “Oh, I wonder what so-and-so’s experience of this is, I wonder if my husband is getting bored or is falling asleep.” All those things come up; that’s just phenomena, right? Those are just thoughts, you know, and part of the purpose for me that I’ve. . . What I do is, I try to observe that is just another bit of data, like the, the rattling of the fan or the itch on my leg, all these things are just things that I’m observing, not working to assign meaning or attach meaning to them but to notice it when they come up, because that becomes my cue to come back to the thing that I’m attempting to bring my focus to.

Madeline

Madeline is a 60-year-old White female in private practice. She has more than 30 years of experience in the field of clinical social work and has worked in a variety of inclient and out-client work settings. She originally trained in psychoanalysis and has since shifted to an integrative clinical orientation. She explained that she was introduced to MB practices while completing the dialectical behavioral training (DBT) certificate program.

Madeline’s formal practice consists primarily within professional DBT consultation groups where they each take turns leading MB practices at the beginning of the group meeting. “One of the components/modules of DBT is the mindfulness piece, and it’s my understanding that that’s how they see themselves as different than CBT. It’s because of the addition of mindfulness.”

Madeline continued to describe MB informal practices within her psychotherapy practice and placed value on “noticing.”

As a teacher of DBT skills, I’m actually leading mindfulness multiple times per week for kids and adolescents. And then, outside of that, the more that you are practicing and teaching mindfulness, the more it gets incorporated into your daily life. I think the art of noticing and being in the present of what’s going on in the room in the moment is incorporated into my daily life. Sometimes I am deliberate about practicing mindfulness myself by myself, without part of a team or part of teaching, et cetera. But I would say that more often than not, the mindful moments come up, in an informal way, when I’m doing something else.

Al is a 52-year-old African American female who has been in the field of social work for 17 years. She is employed in an out-client brain health center and works primarily with a geriatric population and their families. She has an informal MB practice both inside and outside of the therapy room. She completed training in MBSR, MBCT and psychotherapy, and CBCT.

I completed the MBSR 8-week training. This was go give an understanding of mindfulness and what it was about. And then, after that, they offered a mindfulness in psychotherapy [course]. And so, I took that 8-week course because I wanted to be able to make sure that I’ve got it and how I can use mindfulness with my clients. I do not have a routine practice of mindfulness. I think, for me, it kind of comes down to that awareness of I think I’m more aware of my breath and

what’s going on also on my body. I can feel it and then, I’m like, okay, I need to kind of let me make sure I’m relaxing. I can feel myself and let me come back to the present. I’m starting to drift and that’s what I’m saying, it’s more about understanding what’s going on with me in the moment. It is not routine for me or formal. It is not that I do a body scan. It’s just more so that day the day, what’s going on with me? And, with my clients, I would say, and I say clients because I’m in the medical setting.

Al described the MB techniques she uses with clients and her focus on and attentiveness to their physical responses within the therapy room. She is especially attentive to the flow of the therapeutic relationship in the here and now.

With my clients, when I’m talking with them and I’m not seeing them breathe and things like that. So, it’s all come and, and point that out to say, okay, I can see you’re not breathing right now, let’s go ahead and take a breath. So that’s how it’s more so when it comes into play with me.

Al is tasked with complex clinical situations that include clients and their families as they attempt to cope with cognitive and physical decline of their loved one. She explained that clinical situations can easily escalate. She described the importance of awareness of her clients’ responses to judge whether their psychological responses affect their ability to cope in the moment.

For me, it’s because I recognized the state of, I guess, the state of mind of not being present. And so, I, if somebody’s is highly activated, you know, they’re, they’re not breathing, they’re in this state where it’s like, I know I’m not going to

be able to reach you. I know you are sitting there going off and not coming down.

I need for you to be able to come down so that you can hear what’s going on, instead of just being reactive. So that’s, that’s why it’s important for me because people are usually in the reactive mode, and I need for them to come back down.

Emily

Emily is a 42-year-old White female who works in private practice. She has been employed in the social work field for 15 years. She has completed training in Vipassana meditation, MBSR, CBCT, and mindfulness meditation teacher training, and she had a daily meditation practice for 10 years until the pandemic hit. Emily explained her motivation for MB training began during graduate school while she was working in child welfare. This demanding work created a rethinking process regarding her self-care needs. She asked herself why she was so tired and what was missing.

I was in graduate school and that is really when I first got exposure to mindfulness and meditation. And it was really probably especially in my second year, that I started going on day-long retreats. And really, in my second-year internship and had a child welfare focus in graduate school, you know. I was just working with these like super intense, highly traumatized, high acuity and highly emotional clients, child welfare cases.

Emily paused, in what appeared to be a moment of reflection, and then turned her attention to the continuation of her narrative. That was when I really realized in that second-year internship, like I remember I always tell the story, but I came home one day and collapsed in a chair in the

corner. And I remember thinking, “Okay, I’m exercising, I’m eating right, getting enough sleep. You know, what, how am I this tired?” And just realized, like, this is being a young clinician, young helping professional and I’m just carrying a lot of heavy stuff. And that was when I knew that I needed to start doing something. And that was really when I started meditating. Emily demonstrated the art of listening to herself and did not ask “why me?” but instead sought what she needed to reduce stress and anxiety and expand the capacity to hold. Mindfulness may have acted to buffer the stressful conditions of working with this challenging population.

And really leaned on my practice a lot then. I did my first two retreats in 2009 and then, yeah, I mean, the work was really hard, and I really leaned on my practice in that time like I was quite committed to getting up every morning and meditating before going to do this really hard work. And it helped a lot, which is why, you know [chuckles], I kept doing it [chuckles]. I actually had a really hard supervisor, which was harder. The work I was doing and how difficult it was made me realize the importance of self-care. It helped me maintain some bandwidth to be able to show up day after day in the work. Does that make sense?

Emily continued to explain that her MB practice and her process of growth had evolved. She sought additional training that focused on self-compassion and compassion for others.

So, fast forward, I did that for a while, then I went into private practice and, along the way, that’s when I took MBSR and I took cognitively based compassion

training And ultimately, I did the mindfulness meditation teacher certification program with Jack Kornfield and Tara Brach.

I started teaching mindfulness meditation myself. And then the pandemic hit. This is a very recent thing for me that I can say is that the pandemic hit, and it was awful. I had young kids at home, trying to just survive. And at a time when I probably needed my practice the most, it felt totally impossible and inaccessible to me. Just like I didn’t have the time and the day.

As Emily told her story, she reflected on a recent conversation with her husband and the realization of the effect her MB “reset” had on her daily life: I will tell you that it had- it has made such a difference again in this past month. And I was saying to my husband just this morning on a walk like, “It’s amazing how you can forget.” Right? And all during the pandemic, I was saying, well, actually, in the beginning, I was just in crisis mode. But as time went on, I was able to reflect a real awareness of my lack of bandwidth like that if I had this much bandwidth normally. In the pandemic, so much was being taken up by work, that I had little left over. I was really struggling at the end of the day, feeling like I didn’t have anything left to give with my kids. I was irritable, feeling like I didn’t have that pause. Emily had recently realized that the years of formal practice had generalized into a daily informal practice that sustained her during the pandemic. Formal MB practice was not necessarily who she was but what she did to cope with life complexities. She was confident that she would return to her daily sitting.

And I never doubted that all along the way. “I’ll get back to you and I’ll get back to it.” And, like I said, I had these conversations of, I’m really far from our formal practice, but, you know, I’m lucky that I have natural ways built in. So just sit for a minute or just sit briefly. And I had moments where I was out of it. But this is the first time since the pandemic started that I’ve been back to my daily practice.

I’m committed to my daily practice. It’s really helping.

Emily continued reflecting on how difficult the pandemic was for her and exemplified empathy, compassion, and humility in her narrative. She repeatedly used the word hard to describe her experience.

Yeah, it just feels like such a support for kind of showing up how I want to show up in the world and doesn’t mean that I don’t still obviously make mistakes and have regrets. But, especially around parenting, you know? And then, parenting in the pandemic, I really had a hard time. I had to work really hard to give myself compassion. But it’s really hard for me when I, and for all mothers probably, when I was at the end of day, the kids are finally asleep and I’d be like, “Oh, so irritable with them.” Or like, I wasn’t really being able to be present with them. And I still get irritable with them, still have a hard time being present with them sometimes, of course. But since I’ve been back practicing regularly, I feel so much more accessible, so much more available.

Lynne

Lynne is a 42-year-old White female who is in private practice. She has been employed in the field of clinical social work for 17 years. Lynne completed MBSR

training, mindfulness meditation teacher training, and mindfulness training education certification. Lynne incorporates both formal and informal practices into her daily life and practices every day. She explained her interest in MB training and how her practice has evolved.

So, I was first introduced to mindfulness meditation when I was in college, which now is like, you know, early in college. So, 25 years ago, and started, you know, and kind of dabbled with that a little bit over the years. And then in 2012, I took MBSR. And that began my, you know, daily meditation practice, which I’ve maintained since then. So, it's been 10 years and there's been times where there's been longer formal daily meditation than others. But I still practice mindfulness meditation at- you know, at least five or six times a week. And the length can vary depending on, you know, sometimes I might 5 or 10 minutes several times a day and then sometimes I might do 30 minutes or an hour, but kind of depending on what’s called for. And then because I found that experience to be so transformative and powerful for me personally, I then added in, over the years, some professional training around practicing and teaching and sharing the curriculum.

Lynne continued to expand on her MB training that extended to children and families within the educational system.

So, I did the teacher training with Mindfulness in Schools Project, which is a program out of the U.K., and I did their training for teaching to middle and high school students. And then I also completed the Mindful School’s Curriculum

Training, which is for kids, just all school-age kids, so, like elementary through high school. And so, I’ve completed both of those and then I’ve continued to do, you know, some silent meditation retreats and I’ve taught mindfulness strategies.

So, I don’t teach, I’m not like a meditation teacher, but I have taught a lot of mindfulness strategies in high schools and middle schools and to parents, and then to my own kids when they were preschoolers. I’ve taught a family mindfulness retreat and day-long retreats for families with kids 16 and under where they would participate together.

Lynne detailed her daily practice and the varying levels of MB practices she incorporates into her day.

So, it could be different, you know. I always practice silent meditation. When I practice it as, like, every day, there’s my silent meditation practice, and I use a timer typically. Although sometimes I might also when I’m in the car for pickup, waiting to pick up my kids, I might practice then, like, in addition to my standard practice each morning. I practice each morning for at least 10 minutes. And then before our day gets started with my kids and everything and then some at work, at a minimum. And then I also will add in body scans in the evening often and might do a guided meditation and my kids will listen to a guided meditation every night before they go to sleep. I will participate in that. And then I have my cushion in my office. Also, if there’s a cancellation or a break that would be a time that I might do some walking or moving meditation and then some sitting meditation as well.

Lynne summed up the mind–body connection and the way mindfulness acts as a conduit for this process: “And I think, practicing mindfulness meditation over years really is like it just, it’s in every cell of your body. It’s in everything that you do.”

Mindfulness practices cultivate an awareness that holds all experience with openness and acceptance. Kabat-Zinn (2005) stated it simply: “Your awareness is a very big space within which to reside. It is never not an ally, a friend, a sanctuary, a refuge. It is never not there, only sometimes veiled” (p. 298). In therapy, mindfulness practice means remaining attentive to the moment-to-moment changes in a therapist’s feelings, sensations, cognitions, and memories. It is a state of being, a continuous moment-tomoment process of “turning toward, turning away, and returning” (Germer et al., 2005, p. 94).

Knowing the Self.

Knowing the self is a subtheme under the superordinate theme transformation of the self. A psychotherapist’s internal and external reactions to a client are influenced by his or her personal vulnerabilities as well as unresolved and/or resolved conflicts. MB practice does not end with the therapist; it extends to the client. CT experiences are in some instances where vulnerable states connect.

Therapist Vulnerabilities.

As participants continued to explore their conceptualization of MB practices, their narratives acknowledged individual vulnerabilities and/or blind spots, and they believed it was a crucial component in responding in a discerning way in therapy. It is important for the therapist to focus on the client’s experience, while understanding that both client and therapist are involved in a collaborative process and relational connection (Germer et al., 2005). Participants’ stories demonstrated self-awareness of areas of emotional and personal vulnerability.

Marie explained that she is conditioned towards a cognitive mental process that may cloud her awareness of embodiment. Mindfulness practices have helped her become aware of this patterned response.

The one I struggle with the most now is the embodiment piece. Like, most people I’m up here [she points to her head]. I was a lawyer for twenty years. Most of my clients are lawyers, so we’re all super comfortable up here. I believe in embodiment in my heart and soul. And like, someone will ask me a question and be like, “Yup, nope. Didn’t check in with my body. Nope,” and I’ve got chronic

pain, which may be part of the reason why I don’t check in with my body because it’s almost an aversion.

Marie was asked specifically about her interpretation of blind spots and recognized the unconscious material that can be revealed in this material. “I'm like, ‘Whoa, yes, I need, I need people that will help me see my blind spots because if it’s unconscious, I don’t see it.’ That’s the whole point, you know,” she said.

Marie reflected on the intersection of grief and the beginnings of graduate school and her career change. She contemplated whether a complicated mother–daughter relationship could be a blind spot in CT.

My mother died in June and I started this program in August. So, it was just really interesting, you know, integration of grief and living and moving forward, you know, with a different chapter and everything. And, you know, like so few other people, I had a very complicated relationship with my mother. And where I see the countertransference, I think I’m using this right, is that it’s interesting.

Brooks discussed an area of vulnerability related to identification of CT. She demonstrated that MB practices can enhance intrapersonal and interpersonal selfawareness and said that she became more attentive to the presence of stress or sources of stress, all of which can lead to feeling vulnerable.

So when it comes to the mother–daughter relationship and when I can see the ways in which mothers of my young clients, teens and [people in their] early twenties, are having some difficulty with individuation or having some difficulty not moving into, a sort of enmeshment or a sort of involuntary perpetuation of

patriarchal values that I define as patriarchal, that I think specifically, I would say demean the worth of the child or the young person, particularly if it’s a girl. I can be very careful to not get in my feelings about my own experiences of being a teenager [or] early twenty-something, bright but with a learning disability, very aware of the ways in which I was having to follow the rules of people who I didn’t think saw my humanity because I was a girl, because I was young, and I have to really watch to make sure that I remember that this is a unique individual, living her own life within a time frame that is twenty years later than mine, that I’m thinking of twenty-five years later than mine and that if I’m not careful, I can treat this like it’s easy, like it’s simple, like it’s not infinitely complex.

Madeline focused on describing interactions with her supervisees as situations that can contain blind spots. She related areas of vulnerability and the ways she makes sense of this experience. She placed great value on mindful communication and was strategic with her responses.

So, so one thing that I have become aware like, this supervisee is talk, talk, talk, talk talking and I’m following along, but I’m starting to notice how they are kind of jumbled or disorganized. . . it’s not even disorganized, but it’s, it is all over the place. And she’ll say, I know I’m all over the place, and I really noticed that I am starting to get either anxious or like, oh my gosh, where’s this going? Not bored, irritable and so, I will take a deep breath. And also, this is where mindfulness really helps me because I want to be really deliberate in terms of choosing my words to be both encouraging.

Madeline then shifted to a very difficult clinical situation and her feelings of doubt and uncertainty in her decision to terminate with the client. She recognized her vulnerability and sought the support of colleagues to cope with her misgiving and challenges in this case. No amount of clinical experience or expertise can create immunity to CT. It is inevitable because we are human. Anyway, I suspect that both parents were high-functioning personality disorders. But the father was, you know, psychoanalytically, I think this father was what we would call a closet narcissist. So, it wasn’t in that, that it wasn’t the narcissism, this is how I understand it. That it is like, in your face, like, you know, but there were a lot of more subtle ways that he operated and so, you know, I had to get consultation on this case repeatedly in my consultation teams, and inside my teams, outside my teams. And so, finally this week, I just fired them. And, you know, the mom was devastated and felt rejected. Al described the complexity of vulnerability and stated professional expertise did not provide immunity in challenging situations with an impaired aunt. There are limits to power and influence when making decisions about ways to intervene with a family member. This was a very upsetting situation for her, and she described how selfcompassion played a role in understanding her vulnerability to her inner critic.

I think it’s the being able to for me, mindfulness kind of calms me back to being okay with the present right now. It is, I would say, later on when I’m reflecting or I’m thinking about it, I think also it’s like, “Oh, my gosh, I can’t believe,” you know, thinking this at the same time or whatever. “Okay, Al, you know what? It

is okay. You know, you had thoughts,” it’s offering myself that kindness, that compassion, self-compassion. I think that for me is what’s important because I have a very critical inner critic.

Emily addressed the compassionate component in MB practice and quieting her inner critic. She found that her inner critic seemed to be especially loud during periods of vulnerability and with feelings of shame. But I will say to you that over time and evolution for me and this was partly during my training with Jack and Tara is like such an emphasis on the compassion piece. You know, Tara talks about the two wings of-of mindfulness and compassion, and then both are required in order to be able, you know, for the bird to fly has to have two wings. And it’s really a lot of focus on the compassion piece. I do a lot of work with self-compassion and softening toward yourself, noticing inner critic voices or shame parts or whatever, and then being able to-to notice and be with. It’s a lot of noticing and being in the moment.

Emily continued the discussion on the vulnerable space and relayed her thoughts about a clinical situation where she decided to terminate the counseling relationship, telling the client, “I’m really not the best fit for you anymore. I’ve held enough space and enough compassion for you for long enough.”

Emily was asked to comment on MB practices as preparation for challenging client situations where she felt a sense of vulnerability and empathic strain that left her feeling disconnected.

And I’m, I was really aware of my own kind of compassion fatigue. And it was all that-that stuff that we did, that the countertransference stuff that we were talking about of and the energy it takes to sit with her. There definitely times where I’m stacked back-to-back all the time and didn’t have time to meditate before our session. In those time, I would kind of have to take a deep breath. There’s various things that I do either before or after difficult clients if I have the space to do it, you know? Just like standing in a kind of mountain pose in yoga and feeling my feet on the ground or doing a little sun breath. And as I exhale and fold, like letting things go or, if my energy is low, I’ll move my body back and forth, like a washing machine, allowing the energy to flow.

Emily was asked about CT and the emotional hook of the experience with a challenging client situation. A client had emotionally drained her over the years, and she sought consultation from colleagues for support and guidance. And so that was what I was going to say, in terms of getting pulled, I fortunately I don’t have any clients like that right now. Thank goodness. But I think I haven’t, I had a very, very difficult client for years who I actually terminated with. I don’t remember when. Earlier this year or late last year, best decision ever. Oh man, it was hard. I got a lot of consultation and support around that one. Ultimately, I was like, “I’m not doing her any good and I’m not definitely, not doing me any good by continuing to be in this relationship.”

Lynne explored the transformation of the critical voice and learning to expand her awareness of its meaning. There may be messiness in the pain, but freedom increased when she sought to understand the internal workings of the mind.

I mean truly, MBSR felt life-changing for me and I remember very vividly. Yeah, that was, I don’t know, ten-and-a-half years ago when I did it. But that, you know, this kind of the awareness of thought that some of the judgment that I had had this like, you know, the critical voice in my head I realized that that was not actually my voice but a parent’s voice. And the realization of that. Because I was able to interact with that, you know, negative self-talk or, you know, self-critical voice differently because of the course and mindfulness meditation. It really allowed me to notice that for the first time even though, you know, I’ve been a therapist, I’ve been in therapy, and it was really, it was really, really transformative, and freeing. In many ways, the participants showed a deeper knowledge of themselves that appears to be a byproduct of their MB practices and awareness. This process may be similar to self-analysis and engagement with their inner worlds. According to Yalom (2002), “The therapist’s most important tool . . . is his or her own person, through which the therapist engages with the client” (p. 482). CT can interfere with this process, and growing conscious awareness of vulnerability can help to manage CT.

Learning to Cope with Not Knowing.

The in-depth interview process allowed participants to provide more details of their MB practices and experience. Their reflections produced a secondary theme,

learning to cope with not knowing, which emerged under the subordinate theme 1: transformation of the self.

The term “not knowing” holds clinical meaning within the psychodynamic literature and has been described within the context of CT in the lived experience of these participants. Feelings of anxiety are commonly manifested in “not knowing” experiences and are the most common affective experience in CT (Gelso & Hayes, 2007).

Marie acknowledged her feelings of anxiety as she coped with uncertainty in her personal and professional life. Marie expanded on her acceptance of uncertainty and learning to live at least part of her life not knowing the future.

No matter what I do, things are still the way they are. So, when I get super focused on “doing” and am feeling overwhelmed or distracted and a lot of times, anxious.” And it’s like, it doesn’t change the fact that the Supreme Court overruled Roe, you know, like, it doesn’t change that. It doesn’t mean I should be passive, but also being activated isn’t going to make that difference.

Brooks acknowledged the “not knowing” space within CT and sought a rhythm of openness in the situation.

So, there are times when I might use a mindful stance to observe my potential for countertransference. “That’s it, that’s what we’re going to do” and then “that” becomes a little rigid. So really trying to stay in the flow and allow for the not knowing?

Brooks described an MB technique she learned early in her medical social work career. This technique encourages social workers to embrace each clinical situation with awareness, openness, and curiosity.

The first time that I ever encountered this idea was before I even really had heard a whole lot about mindfulness. There was a man who was doing a presentation when I was in grad school and he talked about PIC, P-I-C and it was a training, it was a CEU event and he talked about, before you meet with a client and at that point, I was meeting with clients in the hospital and he said, “Before you meet with clients, take a moment, even if it’s just 60 seconds, to present.” That’s the P, “Come into the present, an experiential way, being with someone else in the present moment” Inspiration is the I, “How can you bring an inspiring presence into the intervention that you’re about to engage” and C is curiosity. Can you go in with a spirit of not knowing, he didn’t say that but I realize that’s basically what he was saying, with the sense of curiosity about what you are experiencing with the recognition that, this is not someone you’ve ever met before, even if it was, this is somebody who you’re meeting for the first time in this moment. So really kind of bringing that presence, inspiration, and curiosity online, and for years I used that, before I had the grounding practices which I tend to prefer, but it was a lovely introduction.

Madeline discussed imposter syndrome and how self-doubt is normal and expected in new clinicians. She viewed feelings of self-doubt as an opportunity for growth and explained her internal struggle.

It’s so interesting, 33 years out as a clinician, you know, I mean, I supervise other clinicians and it’s common that we talk about the imposter syndrome. And how building yourself as a clinician that those are normal feelings, and, sometimes I actually self-disclose that, there are times where I still feel that way. I don’t necessarily feel like an impostor but at the same time struggling internally with the mastery of the material like. I don’t feel the need to pretend that I know or look competent.

Madeline continued to describe the feelings related to the challenging clinical situation where she experienced self-doubt. Ethical decision making is a component in her evaluation.

You would think, relief would be the feeling. Relieved. But yeah, I know, it’s more like, doubt. Or hurt feelings? It’s a relationship, right? But, I guess, did I do something wrong? I didn’t do anything unethical, but did I handle the termination in the most effective way possible?

Al spoke about feelings of uncertainty within the illness of dementia. Families and clients are tasked with learning to cope with uncertainty daily. The most painful time for the client is when they have a moment of lucidity. It sometimes appears and disappears quickly. In that moment, it is not the “unknown” but the “knowing” of reality that is painful to feel and observe.

And especially, you know, a lot of times, I shouldn’t say a lot of times, many times, you know, it’s there’s different challenges at different stages of the dementia. You know, some people are like, well, they’re aware, they may be

aware that something is going on, that something’s happening, but that creates actually sometimes more distress for them because it’s the fact that they realize something’s not right. And so, that increases the anxiety, that increases the depression that they’re dealing with. But then, especially if the family is trying to do and trying to take over, and so you have this independence that’s kind of being taken away. And so that creates a lot of challenges. Whereas also you have, you know, where someone doesn’t recognize you in that, in the later stages of dementia.

Al expanded on the level of anxiety felt and the ways she used MB practices to focus on grounding in the present moment. This technique helped her to cope with both the knowing and not knowing.

When I describe it, I talked with them about, it’s a space to come to, to where you can be present, to where you can just really pay attention to what’s going on in yourself, in your surroundings, and it can help you get grounded because we can so much live so much in the future in this anxiety producing thing because we don’t know what’s going to happen or we can live in the past.

Emily continued to discuss how she learned to adapt to the uncertainty and parenting challenges of the pandemic. She also found that her many years of MB practice provided the emotional scaffolding for coping.

And then the pandemic hit [laughter]. This is like a very recent thing for me that I can say is that the pandemic hit was like You know, I mean, it was awful. I had young kids at home, trying to just s-survive. And at a time when I probably

needed my practice the most, it felt totally impossible inaccessible to me, and inaccessible to me. Just like I didn't have the time and the day. Yeah, just sit down. I didn’t have the energy to get up early and meditate before the kids were up. It felt just like I was in straight survival mode, and it just went out the window. And I really, I mean, I had conversations with other practitioners of the time about it. And I remember saying like I’m really far from my formal practice these days. By then, I think my practice had been well enough established for long enough that I still benefited from like informal, you know, informal mindfulness practice and just you know, being in private practice and as a therapist, I do a lot of mindfulness exercises or breathing exercises with clients.

Lynne discussed the way uncertainty and anxiety occur together and the way she extends compassion to herself by placing her hand on her heart. This is a component of loving kindness meditation.

And, like, being in this interview, you know. It’s always a little anxiety producing I’m not really sure what’s going to come up, there’s some uncertainty in that. So, even just being able- it feels like both being in touch with this warming in my chest and my heart area. And, I think of this as like, you know, my own mothering protection where I’m able feel the warmth and also the care together?

Madeline and Emily said ethical situations can be fraught with uncertainty and feelings of anxiety. In fact, research supports that anxiety is the most common emotion for therapists when conflicts arise in treatment and CT. The therapist’s response to anxiety within CT may be withdrawal, avoidance, or under involvement with the client

and/or clinical material. It is noted that the other end of the continuum is overinvolvement, which may manifest in behavioral terms as talking too much, giving advice, or excessive reassurance. Each of these clinicians learned to trust mindfulness as they coped with difficult situations such as uncertainty.

Broadening the Subjective Experience - Shift in Beliefs, Emotions, and Attitudes.

As participants continued to explore their conceptualization of MB practice and CT, it appeared to me that they had gained a deeper capacity for meaning-making and mental flexibility. Participants frequently used the word transformative, marking the broadening of subjective experience in emotions, cognitions, consciousness, and as a core element in CT. The shift affected the therapist’s perceptual and interpersonal skills. This evolutional process was revealed in their narratives.

Marie spoke about her inner critic and how MB practices had created more psychological flexibility for her in CT. The language of inclusiveness is noted in this section.

I really see the inner critic has backed away. That’s how I feel with mindfulness. I feel like we’re all fellow travelers and we do the best we can and sometimes, sometimes we don’t do the best we can. Sometimes, I mean, I know it’s not the best I can be if I don’t sit and ground myself before a challenge. But, you know, I always joke and say the universe is going to give me an opportunity to do it again, you know.

Marie explained that MB practices can create a reconditioning process, altering habitual ways of feeling, thinking, and responding during internal or external conflict. She gained insight into her automatic ways of responding and commented that mindfulness has significantly contributed to her life. And believe me, that is not how I was conditioned, as you probably know. I mean, and I, and I have shared with a lot of people that I think the biggest gift of mindfulness to me has been quieting the inner critic, you know, because it’s like, you know, it’s just some of the things that I’ll say to myself, “I would literally not say to another living being. Would not.” And so that creates more freedom for me.

Brooks provided details on what she noticed first in her subjective experiences with MB practice and CT.

My immediate response was, was somatic. It was the sense of, a kind of, muscles being tense, almost like I’m moving into a fight or flight state but it’s going to be more of a fight, kind of like more of like get in there and grapple kind of thing. I think when that comes online and I and I don’t find that there’s a fluidity of, “Yeah.” I even have moments of feeling some muscular tension around, like, trying to renegotiate the space. But if I don’t feel that beginning to lessen, then I have this incident pushing too hard, that I’m hanging onto rigidly, to something and then it’s important to just come back into a place of what is needed right now for you, client, how can I be with you right now in a way that honors what’s going on and rather than white-knuckle it with my ideas?

It helped me recognize just how much we can change, the way that we, enter our encounters with others by bringing attention to our own nervous system.

Brooks expanded on how the internal and external experience interact with each other and how she seeks to calm her internal state to be more present and focused on the client in session. She demonstrated awareness of two-personal dynamic.

Yes, I do and if I notice that I am feeling too much of the world, too flustered or if I feel a lot of emotional residue from something that has happened prior or if I’ve been rushing around the whole day, it’s really important to me to bring my energy in, because I’m very aware that if I come in with a kind of frenetic energy, there’s real potential for that to be assigned-meaning by the person I’m working with?

Madeline noted the priority of noticing with MB practice and the influence on the supervisory relationship and conceptualization of what her client needs to grow clinically. She may identify with her client but seeks to make sense of this information as clinical material rather than an imposing CT moment.

So, you know again, as I said before, I think for me, mindfulness is so much about just noticing. There’s a lot that can happen when one is really noticing, as much as I try to. So, with my supervisees, I would say things like, there are some that I’ve noticed, wow, they curse a lot. And I, you know, I noticed it, I try not to have judgment. And then, I go back like, I wonder if they do that with their clients. And so then, of course, I have this discussion more openly, or there’s, you know, sometimes, I’m like, noticing that I have a new supervisee, who is verbose. And I think I’m so mindful of it because it reminds me of myself. and sometimes I’ll

stay to parents like, hey, I want to try to explain something. I’m going to go branch, branch, branch, but I promise, I’m going to circle up my tree. And so, they’ll say, okay, we’re hanging on.

Madeline spoke about her abilities to differentiate between herself and the client’s presentation. She tries to model mindfulness with her supervisees. Where I’m at with this supervisee is, you know, really trying to help her understand not just to be all over the place, but to do so with noticing. To do so with-with a strategy, with being mindful of where she's going, how she's conceptualizing things, and how to ask topics and questions from there.

Al reflected on the mechanism of MB practice that is most helpful to her. She provided an example using a first-person narrative to quiet the inner critic chatter.

I think it’s the being able to, mindfulness kind of calms back to being okay with the present right now. It is, I would say, later on when I’m reflecting or I’m thinking about it, I think also it’s like, “Oh, my gosh, I can’t believe,” you know, thinking this at the same time or whatever. It’s, “Okay, Al, you know what? It is okay. You know, you had thoughts.” It’s offering myself that kindness, that compassion.

Emily continued this discussion of MB practice and CT experience and used the word “invitation” to describe a space of encouragement that MB practice may bring to the clinical situation.

And, of course, I’m out always attuned enough or awake up or whatever to be able to do that. But when I am, it really helps and so sometimes it can be an

embodied thing. Sometimes I’ll feel like, you know, as you’re saying this like I’m just, I’m aware that I’m feeling sad and that can be a real invitation, especially for a client who’s withdrawn or kind of detached or has an avoidant, you know, attachment history or something. To be able to name my own emotional experience can sometimes invite them into theirs. And sometimes just be a demonstration of compassion or care, you know. Like, maybe they even feel that for themselves but it’s something meaningful, I think to know that I do. Does that make sense?

Emily spoke about Jack Kornfield and the loving kindness component of meditation. She believed it is an essential ingredient in not only being connected to others but also to herself.

And you know, Jack talks about mindfulness is loving awareness, and I love thatthat definition that like yet include the loving part. You can be aware, but you can be aware and a very cold or unfeeling, or unkind way, and that’s not mindfulness. Mindfulness is awareness with, with acceptance awareness with, you know, that there’s that tender quality that I think often gets missed and that kind of colloquial teaching of mindfulness. And then I think I missed for a long time, even in MBSR. So, you know, there can be like a real focus on attention and concentration, and of course, that’s important. And I think for many of us especially in the Western world these days, the part that’s missing is yes, and how can you embrace and well, hold it.

Lynne shared that MB practice has changed her perspective of CT. She seeks to explore and learn rather than push away the discomfort or embrace the desire to withdraw from the client.

Yeah. I mean, I do think it’s been, it has really altered how I consider countertransference. And that it no longer feels like, you know, an indictment against me as a clinician. and as like, you know, of course, that’s here. This is here for all of us. And how then how can I notice it without getting further hooked into it or pushing away from it in some way.

MB practices can widen the subjective lens because of their ethical position towards experience. The shift away from the contents of the mind to the observation of content marked a change of the self to include therapists’ attitudes towards life, relationships, vulnerabilities, and coping with feelings of uncertainty. Many participants communicated they had experienced a significant self-transformation because of their MB training and practice. Mindfulness was seen as an experience that indicates a constant shift in their beliefs, emotions, and the way in which the psyche is perceived. Expansion of the subjectivity is part of the transformation described in their lived experience.

Theme 2: Respond Versus React

As the interview questions shifted to exploring MB practice within the concept of CT, a fundamental concept within the teachings of mindfulness was discovered in the data. This concept is the recognition that reacting in habitual ways causes suffering. A difference exists between reacting automatically to stimuli as opposed to responding consciously and discerningly. Mindfulness teaches one to bring awareness to the difficult emotions that arise during an experience and to the felt sense in one’s body. MB practices may help to produce a gap or “pause” between reflective and automatic reactions. By “hitting the pause button,” one can stop, attend to the present moment, and centering in the body instead of automatically reacting (Shapiro, 2009). The integration of this concept into each participant’s life was the foundation of theme 2: respond versus react. Three subthemes will be discussed under this section: the space between, discernment, and participant–observer.

The Space Between

“The Pause Button”: Reflection. The space between words may be a special moment for therapists who are learning to be together with a client in the here and now (Germer et al., 2013). The “pause button” metaphor is a theme that represented the MB moment of reflection where participants consciously chose to respond versus react. Participants described a special way of attending in the moment as a way of being with the “other” in therapy. To invite the “pause” in reflection enables a therapist to be responsive versus habitually reacting to automatic thoughts and feelings. Each participant reflected on their ability to embrace the space between with compassion and flexibility.

Marie described how understanding her body’s biological response to stress aids in creating the space between reaction and response.

Between stimulus and response there is a space, and in that space is our power to choose our response. And I talked about people, we all know what it’s like to be reactive. And to me, being reactive, by definition, means I’m not being mindful. And to me, being reactive, by definition, means I’m not being mindful. I’m just getting hijacked, and I talked all about the amygdala. I’m sure neuroscientist would take many, quibbles with what I talked about, but I talked about when the fear part of the brain is activated, we lose, we lose contact with the prefrontal cortex, which is a pretty important part of the brain.

Brooks described silence as a reflective stimulus to bring attention to the pace in the clinical encounter. This allows Brooks to remain emotional available to her clients. Almost moving more into something that looks a little like assessment but is really more, I kind of think of it as recognizing when I need to really decenter myself and just get more information and really allow there to be sometimes, therapeutic use of silence, sometimes just allowing for there to be a slower pacing for a few minutes so that we can observe what's going on and not try to introduce more information but to simply allow things to arise as they will.

Brooks described how MB practice has created more space for emotional flexibility and being able to separate the circuitous nature of thought processes without becoming attached to the content. She maintains an observational stance versus a reactive one. She described how she was able to separate sensory information from her narrative.

There’s like, layers, there’s like the context of the situation, the narrative, all the stories that I could make up about it but as we get into the practices, it’s really more about bringing attention to the non-narrative element of it, the experiential and there’s real transformation, we could start those classes after having an argument or I could have like, communicated with my colleague that’s in the group about something totally different, you know, earlier in the day and those things as I come into the beginning of the class, they’re all sort of like floating around in my mind but as we do the practices, we come to a space that feels simpler or less fraught. It feels very structured and it’s very safe, very grounded, and allows for a certain recognition of all of that, as being kind of the stuff of life, but not necessarily tapping into lived experience itself. Madeline relies on breathing technique as one MB mechanism that fosters awareness and a space for reflection. She also described observation skills as a space to choose the response to a client in the waiting room.

I’m trying to think in terms of other, I think the times where I’m doing it in the moment. I’m about to see so and so I’ve got a really get my wits about me and breathe, and those sorts of things. I don’t really do it. I don’t find myself doing that strategically before certain clients. What I do though is, when I go to the lobby and I see a kid, who’s obviously, off in some way, whether they’re quiet and they’re normally talkative or whether they look like, they don’t feel well, I really stop and, you know, consider, how, you know, I don’t want to continue to be if they’re sitting there. I don’t want to be continuing to be peppy. I really want

to honor the space that they’re in. And generally, we’ll start with, are you okay?

You know, how are you feeling?

Al described the MB space in terms of attention, grounding in the present, and learning to cope with anxiety. She provided an example of the way she might speak with a client who is stuck in anticipatory anxiety.

When I describe it, I talked with them about, it’s, it’s a space to come to, to where you can be present, to where you can, just really pay attention to what’s going on in yourself, in your surroundings, and it can help you get grounded because we can so much live so much sometimes in the future in this anxiety producing thing because we don’t know what’s going to happen or we can live in the past of, okay, you know, this has happened before and I can’t, I can’t deal with it. There’s something going on. I said so, to be able to be in a space where you can reflect and, and learn to be okay with what you’re, with what you’re experiencing, what you’re feeling that it’s not a negative. That the feelings that come in are not negative, they are thoughts and we can. . . well, feelings and thoughts, two different things but that you can look at it kind of with sometimes as I guess curiosity. And it doesn’t have to be this, ooh, you know, you’re bad, you know, or, ooh, you know, you always have to live in this heightened state. That you have control of this space for you to be in. So that’s usually what I would say.

Al explained that she introduces MB practice to her clients and their families. She focuses on awareness and nonreactivity. “I mean, I haven’t explained in-depth like that to people. Usually, it’s more so it just helps you to be aware of what’s going on so that you can be more responsive instead of reactive.”

Emily continued her difficulty in holding space for compassion with a challenging client and how she experienced CT. So, and she, I thought pulled by her for sure. And it was that interpersonal piece of like, I end up with some of my own anger rising, like I’ll feel mad at her, you know? I feel really irritated and frustrated with her just like want to shake her like, “What are you doing?” You know, and also like, “Do you not see this pattern?” Then yeah and then relatedly being able to recognize like I’m experiencing her the way like when she tells these stories week after week about the way that she’s being victimized and misunderstood and, you know, that like I was having that parallel experience of her and with her.

Emily described her CT experience with the client and the judicious decision to self-disclose.

So, there was a lot of stuff going on there that I had to watch in myself like. . . And I, that was hard, it was hard to be skillful with that one because most of the time, it felt like it was too sort of fragile or unhelpful to name how I was experiencing her. Like, she didn’t have a tolerance to kind of have that be useful. But then there would be times where it would get so big and I want to know where else to go that I’ll be like, “I got to be honest with you,” you know. “I am

really feeling a lot of big energy in my body right now. Like I’m feeling almost angry.” I’m trying to be like, got to do something different. Let’s try bringing this into the room and just being really transparent with her about what it’s like. And that usually didn’t go very well with her.

Lynne recognized that her MB practice diminished the tendency to act out her thoughts and feelings of CT. Lynn used the word invitation to describe an aspect of understanding CT and MB practice within the therapeutic relationship. I didn’t have to dive into it. I don’t have to get hooked into it. I could watch it. I could really do it differently. Yeah, I might also, you know, ground myself with my feet a little bit more or in my chair. It’s often a time where then I will like, really notice what my exhale of my breath is like and you know, and often when I become most aware of some countertransference, it also is a sign that-that my client is ramping up or becoming more activated or disengaged. And so, it’s also that an invitation for me. Not only to like, notice what’s happening in my own body and care for it, but to become more attuned to what’s happening in their body and to say something like, you know, yeah I can say like, okay you’re really, you’re moving in, you know, you’re feeling this surge in your body of this emotion, the shame, this excitement, this fear, whatever and I, you know, and when that happens, our brain can kind of kick in. So, I wonder what it, you know, wonder what you’re feeling in it. Where are you feeling this in your body right now?

The space or “pause” can be viewed as the “black box” between affect, behavior, and environment that is to be appreciated and explored in therapy. Participants used the space of reflection to recognize the contents of their mind and did not avoid or push them away. Instead, they used observation skills to gain insight and attempt to bring focus back to the present moment.

Noticing Defensive Processes. Noticing defensive processes is a subtheme that emerged under the theme of the space between. Exploration of defensive processes is a core active ingredient in psychodynamic psychotherapy (Berzoff, et al., 2016). It is important that therapists learn to gain awareness of their defensive processes. MB practices can help to explore whether feelings, thoughts, ideas, and memories are being held tighter than is necessary. Loosening the grip on automatic ways of reacting can bring space into embracing CT as a clinical instrument to explore underlying meanings within the relational context. Such recognition will aid therapists in learning to respond differently in challenging clinical encounters.

Marie explained that certain client characteristics can act as a CT trigger in therapy: “I have so many clients that are young women, couple of young men too. But young women, anywhere between their late twenties and late thirties and there is a really strong maternal instinct that comes out for me.”

Brooks described her common defensive response and becomes aware how her values may become an area of tension or trigger for CT.

I think the thing is, I might overanalyze, my tendency is intellectualization. There is a recognition, a kind of sense of how my personal presence, my value systems,

my triggers, my past experiences show up in the room any given day, how it maybe shows up in more consistent or persistent ways around things that I have strong feelings about. But then like, how it might show up, maybe how I might monitor what could be experienced by the other person as an intrusion of my value system.

Brooks explained her self-evaluative process for reflection in the moment. She used the metaphor of an “alarm” as a potential trigger signal. But recognize the ways in which I sometimes need to check myself before I say something because I am asking myself, “Is this about this person? Is this is going to be useful for this person is or is this me inserting something because it feels right to me or because I want to or because it would be satisfying in some way or because did this little activist urge just come up or something in me that really would love to be (what’s the word I’m looking for?) gratified for something?”

And usually, well its always well received, that I can think of, I’m sure I’m forgetting something but it feels like there are times when I just have a little tiny alarm bell go off, it’s like okay, we are reaching the top end of the tolerance level, let’s move into something that would, kind of bring it down just a little bit so that we can continue to do the work.

Al clearly knew that her inner critic is her defense against uncomfortable situations: “I have a very strong inner critic, and, and so it’s being able to say, okay, you know, it’s okay, offer yourself back compassion, you know, just continue to strive and just to be present.”

Emily described how her somatic response becomes the signal of exploration. She uses the awareness as a clinical tool to understand herself better within the context of the relationship. Is this clinical information? Is this tightness about me?

So, and the more that I have practiced over time, I think the more I have been able to see that stuff come up and just be like, okay, so there’s a thing, you know, be able to then work with it. I think that it’s probably related to my mindfulness practice over time but also to minus evolution as a therapist over time. It’s how much more often I bring that into the room, explicitly with clients. Like, I just had a consultation group this morning. We were just talking about this. How much more likely I am to be like, you know, I’m really aware of like a tightness in my chest as you’re talking about that. And I want to check it out with you, like. . . Like, what’s happening in your body right now? Or maybe the reverse, maybe I’ll ask them and then say, “Yeah, I wanted to ask you because as you were talking, I really felt this constriction in my chest, and I wondered what was coming up for you?” You know, to sort of like, let it be a tool. Sometimes it’s an invitation and sometimes it’s a genuine checking it out like, is this mine, or is this yours? You know?

Lynne described the inner critic and how she can make sense of this inner voice, this internal response, in a way that brings her freedom. It allowed me then to recognize that that was a, that was a voice, but it wasn’t my voice. And then I could then better work with my own critical voice, which was for sure, still there. But it was different. And so, it, it allowed me to work with my

own mind in a way that didn’t feel overwhelming, and also felt like something I could do something about.

Therapists need to stay awake to the pulls of their defensive processes. For example, responses such as experiential avoidance is considered natural and adaptive at times. Mindfulness practices can be one solution in learning to become more aware of our conditioned reactions and embrace “being” with them instead of pushing them out of our mind. Choosing to engage with compassion and kindness rather than judgment and criticism builds a protective and safe holding space for individuals.

Discernment. The skill of discernment was another theme under the superordinate theme of respond versus react. This study supports the idea that therapists learn to discern personal or client characteristics as well as clinical situations that create defensive or automatic responses rather than act out mindlessly and impulsively. Essentially, a “pause” is the time interval between stimulus and response. Participants demonstrated using the skill of discernment as they were faced with ethical dilemmas such as termination of a long-term client or difficult clinical situations where CT was present. They were asked to explore specific clinical situations where CT was present.

Marie described her experience watching the Still Face Experiment (Tronick, 1970) and described a client situation that involved transference. She provided this example of the way mindfulness skills and discernment can be used to evaluate the presence of CT, stay focus on the client, and respond to the transference material versus acting out of her personal needs and desires. Marie communicated the use of reflection and being responsive to the client’s needs in session.

So, if you have ever seen that video where the little boy is with his mother and they’re engaged with each other and then she goes completely dark, and I mean, it makes me want to throw up every time. I sat there and I thought, I don’t know how they even got permission for that. I started crying when I saw this. I get the chills now. But I was describing that to one of my clients, I guess talking about attachment and how palpable it is when someone goes away. And so, that’s why we know neglect can actually be as problematic, if not more problematic than trauma, but we don’t see it that way. So anyway, I was explaining this and I got pretty passionate in the way that I discussed it and he’s looking at me and goes, “I’ve just gone blank,” and I go, “oh,” I said, “well, what happened?” And he goes, he started hemming and hawing and he got really embarrassed. He goes, “I found you attractive right now. I got distracted by how attractive you look.” And I said, “oh,” I said, “well, do you know, tell me what it was?” He really couldn’t understand. And I say, “well, I have a theory,” I said, “but that’s all it is,” and he said, “yeah, I’d like to hear.” I said, “I think because you were feeling so much maternal energy for me and so much passion that,” I said, I don’t know if that’s true. He said it tracked for him, but it was just an interesting moment. I don’t feel any countertransference with him. He’s way too old for me to have a maternal feeling but in that moment, it was just a way that we connected.

Brooks shared the internal conflicts of resolving and the process of using reflective listening to keep her focus on the client rather than retreating inward. She also discussed the importance of social work ethics in discernment.

So, it’s very important to me to recognize when my own righteous indignation, my own feelings of hurt and belittlement, and invalidation that I experienced. When I see something come up and someone is experiencing that, it’s really important to me to remember to allow this young person to say it in her words and to do a lot of reflection, a lot of reflective listening because part of what my experience was was not having someone validate my unique reality and also my sense that something was amiss, this is showing up in these people too and I really don’t want to be someone who comes in and is another external authority figure saying, “Oh I know, I know what you’re experiencing. I know what’s happening.”

It’s the man, it’s they try, but it’s what it is for her and I take my social work ethics very seriously and I do believe very much in the value of the individual and I am a humanist but I also take a very experiential approach to therapy and believe that the best work that I do, is work that facilitates a person, understanding herself, or themselves or himself better. And usually if can reflect back and maybe ask some very carefully, crafted questions, the person is going to get there on their own.

Madeline seemed to use the word deliberate to describe the process of discernment. She also uses her breath as a tool to construct a response carefully. “I will take a deep breath. And also, this is where mindfulness really helps me because I want to be really deliberate in terms of choosing my words.”

Madeline was strategic with her explanation of MB techniques and was careful in how she explained her clinical techniques to parents.

Well, I qualify that to I am aware that when I am talking the parents about mindfulness that’s some of them come to the table with a lot of free determined thoughts. You know, like I’m trying to teach their kids Buddhist or Buddhist philosophies. And so, you know, I don’t really, When I’m trying to do, I have noticed, I’m doing psychoeducation not necessarily a session at that time, and I’ve always been grateful that I could say, yes there is that eastern philosophy and, FYI, Marsha Linehan was a devout Catholic. She was. So, I, can kind of, I like being able to [laugh] sort of dissuade that rigid stance, right off the bat. I sometimes think I might need to tread lightly here. So, I am observing that they’re in-in the concept that teaching mindfulness that I might hold back a little bit.

Al frequently reminded herself of the difference between her subjectivity and her clients and their families. This approach clearly demonstrates the importance of differentiation between subjective and objective experiences. Her inner world is important, yet it can act as an interference and impose or overlap her experience onto the client.

Well, because I think it’s a matter of my situation is also not their situation. I need to hear where they are and what’s going on and what resources may be available to them or may not be available to them to see what steps, you know, future planning that they need to take, you know. It’s. . . because all our situations are different and so, for me, it’s like, I need to know this is. . . it’s not about me, it’s not about me, it’s about them. And so, I need to pay attention to them and not me.

Emily described discernment in one sentence and explained that practicing discernment can be a way to manage CT effectively.

I have to figure this out for me first. I’m aware of feeling tired right now. Like, I don’t think that would be clinically helpful. Like I would only say it-- if it feels like it has a purpose, clinically. With that, that can easily send her into a shame spiral. Like, “I know I’m hard to be around,”

And sometimes it’s just like boredom, like the other client I’m thinking of I think sometimes I’m just like, “Okay, here we are.” And that’s not countertransference necessarily although it probably is relevant to how other people experience are experiencing her. And so that was what I was going to say, in terms of getting pulled, I fortunately I don’t have any clients like that right now. Thank goodness. But I think I haven’t, I had a very, very difficult client for years who I terminated with. I don’t remember when. Earlier this year or late last year, best decision ever [laughter].

Lynne used the word intention as a discerning factor in her clinical decision making:

We can notice again what’s happening in this room here with us and decide so that you can then decide. Do you want to keep going with this story or this experience, or does it feel important to intentionally choose something different? So, it feels like, you know, it starts with my own awareness and grounding and attunement and then modeling or allowing them to do the same experience. And,

you know, it is like, this is part of it. It’s, you know, it’s in, it’s in me, it’s in them, it’s in the room. How do we all work with it in a similar way?

Lynne described the MB mechanism she uses in the process she described above: I might also, you know, ground myself with my feet a little bit more or in my chair. It’s often a time where then I will like, really notice what my exhale of my breath is like and you know, and often when I become most aware of some countertransference, it also is a sign that, that my client is ramping up or becoming more activated or disengaged. And so, it’s also that an invitation for me. Not only to like, notice what’s happening in my own body and care for it, but to become more attuned to what’s happening in their body and to say something like, you know, yeah I can say like, okay you’re really, you’re moving in, you know, you’re feeling this surge in your body of this emotion, the shame, this excitement, this fear, whatever and I, you know, and when that happens, our brain can kind of kick in. So, I wonder what it, you know, wonder what you’re feeling in it. Where are you feeling this in your body right now?

Participants provided a broader perspective of the term mindfulness by including discernment as an interrelated process especially present in ethical decision making. Several therapeutic practices were discussed such as boundaries, seeking consultation, practicing self-care, and bringing awareness and attentiveness to internal and external processes. Using MD practices to improve discernment skills may be beneficial in understanding of CT as well as determining how to use this clinical material.

Participant–Observer. A subtheme under the superordinate theme of respond versus react is participant–observer. This construct builds upon discernment skills in the previous section. Sullivan (1955) was the first psychiatrist to introduce this concept within relational psychoanalysis. He believed the process of therapy included recognizing the humanness of the therapist and the importance of full engagement in the “detailed inquiry” with the client (as cited in Berzoff et al., 2016, p. 252). The therapist operates from two roles in the clinical situation: a participant in the client’s inner and interpersonal world and observer of what happens in the two-person dynamic. The participants were asked to explore MB practice, CT, and the therapeutic relationship.

Marie explained that she was grateful for her client’s responsiveness to her interpretation. These moments in therapy are unique and possibly representative of unconscious material to be used later in the therapy process. Marie was able to shift in her response quickly and smoothly to the client and something new was created between them. She reflected on an improvisational moment in therapy. And I think to myself there, but for the grace of God, because it could have so easily been where I would have gotten stuck, you know, because it’s, it’s, I mean this never happened to me before where someone has said that, and I happen to know he adores his wife and that probably helped me. Like, I knew this was just like a wrench in the gear, you know. I didn’t think he was falling in love with me or anything but, but it was interesting. I was really grateful that I, that I offered that interpretation. I wanted to hear what his was first but he didn’t really have

one and I kind of feel like I wanted also let him off the hook because he was really, and I think it was true. I think it was accurate. So, we’ll see.

Brooks discussed the observations she makes in the room and the way her face and body language communicate attentiveness and active participation. She focuses on learning about the client’s experience.

I tend to match emotion, in those moments I tend to, if someone’s feeling something, I lean in and I get the little wrinkle between my eyes and I like really, like I’m trying to really show them that I’m with them in it and that I’m not just leaning back and taking notes and evaluating, that I’m really trying to get their experience.

Madeline seemed to use keen observation skills to manage the anticipation of a young child’s impulsivity. She views the energy in the room as informative, guiding her intervention. In this situation, her participation was active and telling in her description below.

But, with him in particular, I have to be, again, very mindful and strategic in terms of, well, I am strategic about the games that we play, because I make sure that I’m trying to sort of activate him, and then calm him, and so, in the process, you know, I do have to be very mindful about just that energy in the room, both within myself and within him, because he, he can like take a corner or that I didn’t anticipate really quick because he is very impulsive.

Al described being her participant–observer role as knowing the potential for reactivity and escalation in her client population. She described the spontaneity in her participation to deescalate the client’s reaction in session.

Right. Again, I think it’s. . . besides, like you said, that kind of CT piece just being aware of how you’re doing it, but I think it’s the relationship, in general, with again sometimes what will happen even in a therapy session, if I’m seeing somebody getting escalated and, and I will sit there and take that pause and I’m like, okay, you know what, let’s, let’s take a moment right here. Let’s talk and let’s breathe. Because I can also feel myself amping up and I can feel them, I mean, I had. . . I had a woman jump up and start cussing at herself and I’m like and she was about to walk out and I’m like, okay, let’s all. . . let’s just take. . .

let’s just take this moment, you know, so we can all just kind of be here and let’s be calm and, and understand and recognize, you know, what’s going on.

Al placed importance on the therapist being the person to create a safe, secure, and trusting space to face difficult emotions and situations together.

I think for the relationship having that as one of the tools in terms of the whole, you know, let’s all accept where we are, that this is uncomfortable. Let’s all accept this fact, but that it’s okay, that again, we’re able to be here in this space.

Emily identified awareness as paramount in being both a participant and an observer in the therapy room.

So first, it’s like everything, right, that my own ability to be aware of what’s happening in my body and heart and mind is the only way that I can even know

that it’s countertransference, right? If I wasn’t aware then it would just be a thing I was merged with and maybe thought was true and thought I was right or, you know, did, couldn’t even see it as a thing to work with.

Emily used her observation skills to evaluate the somatic sensations in therapy and was curious about this information. Or really staying afterwards like after particularly having session, it would be like, and sort of those, right? Realizing whatever came before it so that I can be prepared for whoever is coming in. I definitely not always do that, certainly not between every session but if I feel like, “Whoa! That was hard.” Like feel a lot of energy in it that I need to shift.” You know, I’m feeling sluggish. I need to up the energy or I’m feeling like [sighs] there’s kind of a buzz frenzied intensity.

Lynne believed that she had grown to accept the discomfort in her thoughts in a CT experience. Regardless of the noise in her head, she remains engaged in the client’s inner world and does not lose her focus on the client’s needs.

Where I’m like oh, those are really bad and so to be able to instead like, you know, work with my own kind of critical mind or judgmental mind and concern for her and him in this way that allows me to stay grounded and, and be able to like let that pass and, you know.

The participants’ lived stories described how MB practice helped to bring unconscious material into conscious awareness to respond with awareness as opposed to habitually responding within CT experiences. The superordinate theme of respond versus react included subthemes of the pause button: reflection and noticing defensive

processes; discernment; and participant–observer. The subthemes complemented each other, similar to the concept of building blocks. Relational therapists recognize the space of subjectivity without denying the role of objectivity as maintaining primary focus on the client’s experience. With regards to CT experiences, the therapist can step back and observe the presence of CT, stay in touch with it, and accept it as it arises, rather than act out on their impulses.

Theme 3: Holding Space

Each participant was asked to comment on the MB practice and conceptualization of CT. The holding space emerged as the third subordinate theme within data analysis.

Mindfulness emphasizes an accepting and attentive holding environment to create a safe, secure, and supportive space for clients to explore their internal and external worlds.

Mindfulness practices have consistently been reported to promote empathy and compassion, two qualities that can support the therapeutic holding environment. The subordinate theme of empathic and compassionate holding has two subthemes (building tolerance for discomfort and emotional pulls and therapist presence), which will be discussed in this section.

Empathic and Compassion Holding.

Empathic and compassion holding was the first subtheme to emerge under the superordinate theme of holding space. By bringing in mindfulness to the highs and lows of the relationship, the therapist and client can focus their shared attention on the client’s experience as it happens moment-to-moment. Participants were asked to deeply explore

their experience of MB practice and CT. They consistently used the words empathy and compassion to describe qualities in the holding environment.

Marie explained that it is important to validate the client’s experiences. She uses psychoeducation in neuroscience to help her clients understand their reactions and conditioned responses to stress.

And I try to do it to really validate people’s experiences. This isn’t you, it isn’t you just losing your shit for no reason, this is how the brain works. So, I really, I pair it with compassion that once we realized, and I’m getting, I’m in an amygdala hijack, and now, I’ve lost all power and control. Like I can’t, I can’t do anything bad. Okay, now we can touch in with our breath. So, I, I usually present the neuroscience of mindfulness, and then I talked about how the research tells us about the feedback between the mind and the body. It’s like eighty percent is going from the body to the mind.

Brooks reported that her MB practice has created a reduction in pathologizing client’s behaviors, instead bringing attention to the ineffectiveness of these responses within an interpersonal context.

And if I’m working with families or couples or even if I’m working with someone whose primary concerns are around relationship issues, I use a lot of emotionally focused therapy, about the cycle and recognition that the cycle is the problem, the person is not the problem and that much of what we do is adaptive and is rooted in Schemas from long ago and core beliefs about the self and it’s really trying to

depathologize which people have adapted while gently kind of checking in to see if they believe those adaptations are still working for them.

Marie described the MB mechanism she used, “the breath,” as a placeholder in the moment. Instead of responding critically, she seeks to respond with compassion: “I will, take a deep breath. And also, this is where mindfulness really helps me because I want to be really deliberate in terms of choosing my words to be both encouraging and critical is not the right word, but. . ..”

Al identified her role as a coach because she seeks to help families better understand their loved one’s illness. She hopes that her compassionate behavior acts as a model for families as they learn to cope with stressful stages of dementia.

They see the same. . . they hear the same voice, they see the same face, and they’re not recognizing this person is compromised. And so, they want to respond or they’re in this different space to talk back or to do this, and not recognizing that this person has an illness. That this is the disease talking. And so, I’m having to coach them and helping them to learn how to breathe, to step away to things like that.

Conversely, Emily recognized that the holding space of compassion and empathy has limits. She acknowledged her humanness and recognized the challenges of sitting with a certain client.

She just wanted to talk. I mean, that was part of my difficulty with her is she just wanted, and, you know? And my best moments and for actually years, I was able to like hold compassion and space, and like, she just needs to be heard, and she

needs to be held. But at a certain point, it was like, okay. There’s a limit to how much holding and hearing I can do when it’s this same exact story week after week after week.

Lynne also commented on the reduction of pathologizing client behaviors and instead seeking compassion and empathy in her response. Which I think, is really, has been a very powerful tool therapeutically. I think it also allows me to recognize how my perception has changed in my work with clients. And now, when I think of how I practice now versus the past, even when I started my mindfulness meditation journey. I say things are significantly less pathologizing.

In summary, a lack of compassion can lead to judgement. All participants used the words empathy and compassion repeatedly to describe MB practices and the ways they expand the ability to create a holding space for discomfort. These narratives depict each therapist’s continuous effort to enter the client’s internal world empathically and compassionately. It seemed likely that their efforts would help to at least reduce the chances of acting out on CT experiences.

Building Tolerance for Discomfort and Emotional Pulls. One interview question focused on therapists’ describing how MB practice may influence their ability to understand CT experiences. In the participants’ responses, the last subtheme emerged: building tolerance for discomfort and emotional pulls. This subtheme fell under the superordinate theme of holding space. As therapists, remaining present and engaged is

difficult at times. The participants demonstrated an attitude of openness, acceptance, and an interest in learning about the emotional pulls with certain clients.

Marie explained that meditation is not about becoming more skilled at sitting but about growing the capacity of togetherness: “I mean, you know, like everybody says, we don’t sit to become, most of us aren’t sitting to become better meditators. We’re sitting to expand our capacity. You know, bring mindfulness into our daily lives.”

Brooks explained that her big feelings do not overwhelm her and the way she brings her focus repeatedly to the client’s emotional experience. She is diligent in locating the focal point of the person in front of her, while acknowledging the backdrop of cognitive activity.

I think I’m aware most of the time that I’m having some pretty big feelings and it feels like, it doesn’t feel like it gets stuck in me all those feelings. If I can stay with that person in their emotion and continue to keep, that’s how it’s like meditation, to keep coming back, to what they’re saying, to what they’re feeling and it usually requires so much intellectual and cognitive bandwidth that I can have my feelings notice that it’s happening and of course, make missteps regularly, I’m sure but really try to keep coming back, to bring my focus to that person and when I do that then I’m not getting all wound up in my own narratives, then I’m able to actually stay with that person and their experience and I have had the experience of many people telling me that it is like what Dan Siegel talks about, that feeling felt, kind of feeling like someone’s with you in it,

not as an evaluator, not as an advice giver but simply someone who’s there with you, yeah, joining.

Madeline used humor to describe a rather challenging experience in the moment with a 4-year-old and explained how she uses MB practice as an intervention for her young client. The humor in her story depicts a level of tolerance of its own. She felt difficult emotions but she did not become disturbed in the moment. One time he was like [laughs], my penis is itchy. I mean, like the dude was trying to flash me. I was so grateful that his mother was right there. So, I have been trying to teach him how to belly breathe and, you know, teach him some mindfulness, so he’s less impulsive. Again, he’s 4, I’m not calling it mindfulness.

But he does understand that if he lays on his back and I put a stuffed animal on his belly, he can make the animal rise and fall with his deep breathing. So, that’s how I’m using it in terms of play therapy and games.

Madeline described the client situation as an opportunity to activate the client, increase his level of energy, and then help him grow tolerance for emotions. They work together.

But with him, I have to be very mindful and strategic in terms of, well, I am strategic about the games that we play because I make sure that I’m trying to activate him, and then calm him. So, in the process, I do have to be very mindful about just that energy in the room. Both within myself and within him, because he can like take a corner or that I didn’t anticipate quick because he is very impulsive.

Al sought to understand the emotional pulls in CT because she experiences anxiety when she identifies with certain clients and the aging process. So, all of that, even my own, you know, even like you talked about, us understanding aging and that fear of, okay, being. . . okay, seeing people who don’t have any support, who don’t have people around them, you know, looking at things like that, and it’s like, you know, we don’t have spouses anymore or we don’t. . . all of that and kids who may not step up.

Emily tried to make sense of the somatic response she experiences during sessions and reflected on the possibilities of unconscious communications of the client.

I haven’t thought about this way until right now. But like, I also wonder if I’m not feeling a sense of collapse of, like [sighs], how am I going to help this person? I don’t know. You know, like if I’m having an embodied response of my own, like kind of helplessness. Mostly just like, okay, it’s I’m tired. I’m struggling to be here with her right now.

Lynne noticed the presence of the “pull” in her body to respond by withdrawing or in a disconnected way.

And so, kind of knowing it, feeling comfortable, noticing it and also being able to not attach to either, you know, my pull to. . . to reparent this particular client, or rescue them from their destructiveness or to pull away from and some kind of repulsion or fear with their anger or pathology and how I can notice it both between us in the room and my body and let it settle a bit rather than becoming more reactive to it.

I can notice it both between us in the room and my body and let it settle a bit rather than becoming more reactive to it. And so, it’s allowed me to really engage differently with this, with the client than I would have had before, or they’ve experienced before.

Perhaps Lynne was holding space for both herself and her client as she learns to perceive CT differently and respond in kind within therapy.

Therapist Presence. Therapist presence was a subtheme that emerged under the superordinate theme of holding space. Consciousness of the present moment relates to attuning to the present moment and establishing a holding space for psychological closeness. CT experiences can result in a therapist pulling away or withdrawing from a client during moments of distress. Participants were asked specifically to describe their quality of mindfulness in the therapy room and whether or the way in which this process was instrumental in understanding CT.

Marie explained that she harnesses power through grounding her body in the moment and the overall influence on decision making.

And so, I talked about, you know, how empowering it is. If I must make you change your behavior for me to be okay, I have no power. But if I recognize that even sitting and breathing and feeling my feet on the floor, feeling my butt in the chair, that’s a way for me to access my own power. So, I also use it from an empowerment standpoint as well. We have a choice. I can either look at all the things that I can’t control and feel out of control or I can say, let me touch in with my breath.

Brooks described the loosening of her grip on theory or judgments and used the word lightness to symbolize openness and presence of mind. She tries not to become entangled in her cognitive processes.

I worry sometimes that I lack awareness so much and I think that I’m getting better at observing my thoughts and observing what’s going on in my body and my reactions to what’s going. I worry that occasionally what I call awareness or observation may actually be thought, maybe an opinion or a judgment and so I wanted to try to even hold the things that I come to through mindful observation with a certain lightness because I don’t have the sense that I’m tapping into some magical ability to observe purely and clearly and see reality entirely, objectively. I know it’s still a subjective observation, so if there are ever moments when I feel too confident in my intuition or too much trying to go by the book, I guess with the practices that I’m implementing, I think the thing is, I might overanalyze, my tendency is intellectualization.

Brooks discussed that CT material may include a “veil” of deception that can bring confusion into her perception of the happenings in the moment. It appeared that she brought conscious awareness and introspection into her mindful observation.

I see those as being, almost like things that could potentially make me less likely to notice the countertransference as it was coming up. Almost like they are, I don’t want to say frailties but like if there’s a veil, you know if there’s a veil between me and the world, if not getting enough sleep is going to make that veil a little thinner and it makes my ability to use introspection and you monitor what’s

going on in terms of coregulation and maybe makes me less able to survey what’s going on because there are things that do get triggered in me when someone is talking about.

Madeline connected to the skill of “noticing” and the way it can increase awareness in the present moment. Noticing what arises in the moment provides an opportunity to relate to her internal world and to make choices and how to act.

Mindfulness is so much about just noticing. And like, there’s a lot that can happen when one is really noticing, as much as I try to. So, with my supervisees, I would say things like, there are some that I’ve noticed, wow, they curse a lot. I’ve noticed it, I try not to have judgment. And then, I go back, like, I wonder if they do that with their clients. And so then, of course, I will have this discussion more openly or choose sometimes to just observe and practice the art of noticing.

Al was asked to expand on her CT experience and identifying with aging clients and their families.

All of that can activate countertransference. It’s like, okay, let me, okay, let me not, let me recognize this, and this is not about me right now, but let me recognize this. I feel it. Okay. I’ll think about that. Right now, let me get back to being present to what this person, and where they are.

Lynne demonstrated the art of empathy and compassion within her presence of mind. She places her hand on her heart, a symbol of loving-kindness and warmth towards herself and her client.

I’m, you know, I find myself like my brain is going off and being like, ooh, you know, I wonder about this about her and you know my brain is getting kind of activated and so one of the things that I have found to be helpful as I’m putting my hand on my heart apart from, you know, touch, it feels good. But is also this reminder of, like, I’m not just up here in my head and, and I’m feeling both in my body this real warmth towards her. You know, someone who I think can often be very difficult and has gone through several therapists. And so, this warmth and care for her and, and also like my body feels some warmth, too, for the experience of, like, coming and having to share all your stuff and how your stuff interacts with your parenting in a way that like, you know, nobody wants somebody to think that they’re not a good parent and, you know, and a little care for myself, too.

Participants’ MB practices and qualities of empathy and compassion seem to inform their therapeutic presence, which included a psychological presence of mind and body. Therapists are not passive participants. Mindfulness can improve clinical technique as well as a therapist’s ability to be present in a session. The intention is to embrace a receptive attitude towards emotional availability and be involved but removed enough to think about, observe, and be aware of events happening in the moment. The holding space or container can embody feelings ranging from hate to love and every emotion in between. For example, while in session, feelings of irritation may arise. The irritation is noted with acceptance and compassion. One should keep in mind that MB practices are not meant to make the irritation disappear but rather to hold it

gently in a container, allowing the process to unfold. MB practices can help to enlarge the container, and each of the four subthemes contribute to the holding space.

Theme 4: Emotional Regulation

It is essential for therapists to be aware of their emotions and learn methods to regulate the full range of them. It is also crucial for therapists to be discerning of whether to express their emotions or when it is necessary to withhold sharing with their clients. Often, strong emotions are present in therapy and regulation becomes part of the holding space. In addition, a great deal of empirical research on MB training has supported improving emotional regulation for health care professionals as discussed in Chapter 2. The themes of self-regulation, mutual regulation, and the body feels first will be discussed in this section.

Participants were asked to describe the influence MB practice may have on their ability to understand responses to CT experience. The superordinate theme of emotional regulation emerged as an essential element in managing CT.

Self-Regulation.

Marie described one client who had difficulty regulating their emotions. She wondered out loud whether the client had borderline characteristics.

I’m not going to say that was the first time I wondered whether there were some borderline aspects, and I certainly don’t think she’s, she meets the criteria. But just like there was just a tension and I just, you know, I felt like either she thought I was amazing or, you know, I was doing something wrong and, you know, and I, that was tricky. And I know one of the questions was “do you sometimes, like,

use mindfulness to prepare for a client?” And I’ll tell you, there are several times where I was, like, literally letting her in on the Zoom and thinking, “Why didn’t I, like, ground myself before I got on the call with her?” So [chuckles], so, I thought about it but it was too late. And, you know, it is, it’s interesting because sometimes I will be in process of connecting. Let me, let me give myself some breaths, but I need to be more proactive about it, you know. I’m just not good with that.

Madeline remembered a time when she would become anxious in session and the way she used breathing to regulate her feelings: “I noticed the tension in my body and wondering if I was anxious, where's this going? I will take a deep breath.”

Al spoke about grounding exercises to regulate strong emotions in session: “I do think when you can sit here and get grounded and be okay with your thoughts or recognize that, okay, you know what? Here’s where I’m flowing, but I I can regulate, you know, I can actually do this.”

Emily discussed using self-compassion when she notices self-critical thoughts: “I practice lot of work with awareness of my body in session and noticing my mental activity and the parts of myself that are not being judgmental or harsh. I really try hard just to be with the feelings, whatever is present.

Lynne described dysregulation as becoming activated, and she practices loving kindness meditation, bringing compassion to herself.

I find myself becoming overwhelmed in session. I try to bring breath into the space of discomfort and be willing to feel what I don’t want to feel even if I don’t understand what is happening.

Lynne then described the benefits of loving-kindness meditation as a compassionate practice to the self, others, and the world. And so, like that was my first taste of it and then this allowed me to like really move into a more integrated experience in my body, which felt incredibly powerful and has followed me as I now do more somatic experiencing work professionally. And then the other part that felt so transformative and so powerful was doing the love and kindness meditation, the concentration practice of that. And just how much more powerfully I could offer care and love for myself and others and, you know, I did it for, I added it into my daily practice for a full year.

All emotions are felt physiologically. Strong feelings can be welcomed with the same mindset of acceptance and curiosity as any emotional experience. Placing body sensations in the experience of emotions (i.e., feelings) and steering more focus towards the development of a new relationship with one’s bodily sensations is important. Mindfulness practices teach the impermanence of emotional states and learning to tolerate the discomfort of overwhelming emotions. Learning to practice self-regulatory MB skills such as grounding exercises, breathing, and awareness meditation and lovingkindness meditation can grow a new relationship with one’s mind and body.

Mutual Regulation.

As I asked participants to reflect on their MB practice, mindfulness, and CT, the second theme emerged under the superordinate theme of emotional regulation: mutual regulation. Each participant described clinical situations in which they practiced attunement and joining their clients in coregulatory practices.

Marie described a situation in which she was gratified because she finally found an MB technique that worked for her client. These are tools that are practiced together in session.

I teach clients the rain meditation. That is probably the one that I do the most, and I’ve done it in live audiences, too, which is a little scary, but it’s, I think it is such, it is so available. And I say to people, “You can spend two minutes with it or twenty minutes. You can be going into a meeting and just check it, recognize, allow, sweep the body, nurture.” So, I really love that practice. I think it’s super available.

Brooks was attentive to the presence and levels of energy in her body and sought to self-regulate to support mutual regulation.

I don’t know what that meaning is going to be, so I try to get into a place where I am self-regulated enough to be able to coregulate with the person I’m working with in a way that allows their story and their experience and their energy to really be the theme rather than my own.

Madeline is especially attentive and observant with her young clients. She is fully engaged in the practice of mutual regulation.

There are times where I have to change my plan. If I wasn’t mindful when in the beginning about the energy that I see in front of me or, you know, observing about what’s going on, there may be times that he could be on the ceiling, so I’d rather take him down from midway the room than on the ceiling. Not taking down like restraining but helping him to calm down.

Al recognized the therapist as the object and that being present and attentive has a regulatory effect in therapy.

Again, we are, you know, as therapists, we are the tool. You know, sometimes, again, it’s not a matter of all the . . . all the stuff that we do. We’re the tool, just being that present person who may not have had anybody to sit and listen and pay attention to them and what they’re going through.

Al continued to describe therapists as an instrument for mutual regulation. We have the technicians who have the instruments. We have the mechanics who have the tools, but in therapy, we’re the tool, we’re the ones who . . . it’s through our experiences, it’s through our training of what we learn and how to be there with this person and to recognize where this person is in their experience and we’re helping to guide, we’re helping to pull out, we’re helping to reinforce. It is us who is doing it. There is no special instrument or medication, necessarily, in terms of the therapy room.

Al remembered a session in which the client was distraught and became flooded with emotions. She placed importance on remaining calm and steady to help the client achieve a more balanced emotional state to help the client feel safe and supported.

For me, it’s because I recognized the state of, I guess, the state of mind of not being present. And so, I, if, if somebody’s on high, you know, they’re, they’re not breathing, they’re in this state where it’s like, I know I’m not going to be able to reach you. I know you are sitting there going off and not coming down. I need for you to be able to come down so that you can hear what’s going on instead of just being reactive. So that’s, that’s why it’s important for me, because people are usually in that reactive mode, and I need for them to come back down.

Al remembered another session in which family members became dysregulated. It can happen very quickly, and she worked hard to stay alert to the happenings in the room. It’s okay because you know what? It’s . . . what I told, I love the example, and I tell, not my clients, not my clients, but usually, their caregivers when they’re, when I’m seeing the high anxiety for sometimes when they’re overdoing some things, I’m like, you know, there’s not a tiger in the bush. You’re not in danger. And that’s, and that’s what you have to think about, it’s, you’re uncomfortable. Emily viewed compassion as a tool for mutual regulation with her clients. She strongly believes in adding love to the field of compassion. I do a lot of MB practice with my clients. Being with and then softening towards, like, you need to take that thing that feels hard and big, huge and soft and towards a little [inaudible] tenderness. Can you bring some compassion to it? You know, not to push it away or is this it or get into a fight with it or be at war with it? But can you allow it and the space of a tender and compassionate heart? I didn’t answer your question directly.

Lynne believed that mutual regulation is a way to attune with her clients. She paid attention to herself and responded empathically to the client. And in this way that allows us to connect, and I might say like, yeah, you know, if they’re talking about like this fear, the shame, and I was like, yeah, I was feeling some of that, too. You know, my body was feeling activated, too. What you were saying is so big and important. I wonder if, for a moment, we can just ground. So you can know that your body is safe, I will do this with you.

Lynne discussed how she softens towards a client who probably needs it the most. You know, someone who I think can often be very difficult and has gone through several therapists. And so, this warmth and care for her and also like my body feels some warmth, too, for the experience of like coming and having to share all your stuff and how your stuff interacts with your parenting in a way that like, you know, nobody wants somebody to think that they’re not a good parent, and, you know, and a little care for myself, too.

Mutual regulation can be seen as a comediating experience. There is a momentto-moment flow in the relationship that has ups and downs. Each participant presented a unique perspective or method of mutual regulation. Some of the narratives described using meditation practices; matching the client’s energy, attentiveness, and observational skills; and considering the therapist as the regulatory instrument. Emily and Lynne described “softening” toward the client and the importance of extending compassion to help them self-regulate.

The Body Feels First.

Somatic Experiences. This last theme, the body feels first, emerged under the superordinate theme of emotional regulation and reflected participants’ focus on somatic sensations and how the body relates to mindfulness practice. This theme emerged from the interview question related to MB practice, CT, and the therapeutic relationship. The body, including posture and breathing, is one of the foundations of mindfulness. All participants described attending to the body as they described their practice as well as CT experiences.

Marie explained that it was important for her to choose a psychotherapist who also had awareness of mindfulness of the body.

I wanted somebody to say to me, “Where are you feeling that on your body?” I’ll tell you one thing I’ll never forget because I’ve had this chronic pain issue, and “S” one day, this when we were in person, she said, “What does your body need right now?” And without skipping a beat, I said, “I can’t do this every time I feel bad.” Like, I didn’t even answer the question. What I needed was I needed to put my feet up and, like, lay down for a few minutes. But I immediately went to but I can’t do that every time I feel bad, and it was just such a moment where I saw it. It was like, “Holy shit.”

Brooks recognized that she can naturally default to the thinking part of her brain and discussed the importance of balance between mind and body.

I try to get into a place where I am can match their emotions and be focused on the person in front of me. Repeatedly, I refocus on what is being said and what other ways the client is communicating to me. Someone asked Brooks if there was a technique in session that she uses to “coregulate.” She described an MB grounding exercise. It really does seem to be, when I feel that it’s needed, I’m more likely, when I have this sense of my own sort of maybe mild dysregulation, I’m always more likely to do an exercise that, I’m not sure it has a name, but it’s something that a MBSR instructor taught in a presentation, and it’s three things that you observe through sight, three things you observe through hearing, three things you observe through tactile sensation, and you do that again, with two things and then one thing.

Madeline does not use the word “mindfulness” with children because it does not work. Rather, she uses feelings in the body to help children learn emotional regulation. I’m not calling it mindfulness, but he does understand that if he lays on his back and I put a stuffed animal on his belly, he can make the animal rise and fall with his deep breathing. So, that’s how I’m using it in terms of play therapy and kind of games.

But, with him, I have to be, again, very mindful and strategic in terms of, well, I am strategic about the games that we play because I make sure that I’m trying to sort of activate him and then calm him. So, in the process, you know, I do have to be very mindful about just that energy in the room both within myself and within

him because he, he can, like, take a corner or that I didn’t anticipate really quick because he is very impulsive.

Al recognized when she has lost focus and then shifts in her body and uses her breath to bring her attention to the here and now. Clients with cognitive impairment present with special challenges.

I have probably shifted my body to kind of shift the . . . . I want to say, snap me out, you know. It’s kind of like, okay, let me, right? Kind of like, let me . . . let me shift, not be on this automatic, and I will try to think when I’m doing it because sometimes it’s just so, you know, it just, it’s just happening at the moment. I’m trying to think when that’s happened. I will probably shift, and then I may take. . .

. I don’t know if I take a breath. I don’t know if I’m consciously taking a breath or taking a deep breath or not. I know I start looking intently, you know, in terms of the person’s face, trying. . . and I think I probably may lean forward a little bit more.

Al stated the scariest moments for her clients are the moments of lucidity. when they realize something is wrong.

You know, some people are like, well, they’re aware, they may be aware that something is going on, that something’s happening, but that creates sometimes more distress for them because it’s the fact that I realize something’s not right. And so, that increases the anxiety; that increases the depression that they’re dealing with. But then, you have those, you know, and especially if the family is

trying to do and trying to take over, and so you have this independence that’s kind of being taken away.

Lynne spoke about the difficulty of being present in therapy with her client, as she feels the emotional pulls in CT.

One client that I have is a single mother, as I am, too . . . and she’s a little younger, and so often, when she speaks about, like, an interaction that she might have . . . with her son and she is processing, like, really what she’s trying to say is how overwhelmed she feels and exasperated and uncertain about the right way to go or how, you know, how to explain something to him and, and how she could be present with him and that she is feeling overwhelmed when she is feeling so emotionally flooded.

Somatic experiences as part of the body feels first demonstrated inclusion of the body and physically-felt emotions as an important element in MB practice and CT. Psychodynamic therapy also focuses on the body and involves listening to and observing the body as an experience and an appreciation of the connection between psyche and soma. The awareness and attention to the body and CT helped these therapists discern the patterns of connection and when disconnection had happened. Focusing on somatic phenomena in CT may deepen the analysis of the experience to make sense of the information for clinical use.

The theme of transformation of the self involved examination of how MB practices created a state of mind for therapists. The person learns to observe the mind with the mind. It is a way of being with clients in therapy that fosters an attitude of

awareness and acceptance. Analysis of the data revealed an altered therapist’s view of the self, identifying vulnerabilities, coping with uncertainty in the moment, and broadening subjectivity. Respond versus react involves the importance of reflection, discernment, and responding to CT with thoughtfulness instead of acting out and risking harming the client. Holding space shows that empathy, compassion, and therapist presence can build tolerance and a supportive holding environment for all experiences. Last, the theme of emotional regulation was discussed as well as how self-regulation, mutual regulation, and somatic experiences can enhance empathic attunement in the therapeutic relationship.

Field Notes

I completed field notes, journal writing, free associative writing analysis, and a dissertation process diary during the research process from the onset. I wondered how her MB training and practice would influence the research process. Understanding the benefits and limitations of my subjectivity and bias reinforced my commitment to being thoughtful and organized in this study. I used MB practices to maintain a connected yet professional stance with the participants and the data collected and analyzed. I used this awareness to bracket my values, beliefs, and feelings about MB practice and CT.

I completed field notes and journal writing before and after conducting interviews and prior to coding each transcript. Notes I made in the margins of transcripts included feelings, somatic sensations, and free-association material. As the data analysis evolved, I identified descriptive, linguistic, and conceptual coding to capture the essence of the participants’ lived experience. I continuously reviewed all member checking sources and

coding material. The organization and scrutiny of each data source acted as a process of checks and balances to ensure the participants’ safety and the study’s quality. Most important, I was aware of the objectives identified in my study and worked diligently to remain conscious of my bias and the pull toward predetermined expectations versus allowing for the natural rhythm of exploring something new or different. This is the process of intersubjective reflexivity.

Chapter 5

Findings and Implications

The purpose of this chapter is to analyze and discuss the results I presented in Chapter 4. Based on the results of this IPA study, I will discuss implications while focusing on and addressing the primary and supporting research questions. Finally, I will include a section on study limitations and recommendations for future research.

The primary question for this study is, “What is the subjective experience of psychotherapists who practice mindfulness and examine CT?”

Beyond expanding the phenomenological experience of mindful therapists and CT, the question of “how” was central to this investigation. The following are subquestions.

1. How do psychotherapists who acknowledge mindfulness practices use these practices professionally?

2. How might a mindfulness practice affect the therapeutic process with a client?

3. How do therapists who use mindfulness practices conceptualize the phenomenon of CT?

4. How do psychotherapists who use mindfulness process CT?

5. How can mindfulness practice inform psychodynamic thinking?

IPA is an idiographic and hermeneutic phenomenological approach with the objective of explaining the ways an individual makes sense of their lived experience. The

in-depth method of engaging with qualitative inquiry can help the researcher create a rich and insightful interpretative account of experience that can broaden the understanding of clinical research (Peat et al., 2018). Such an approach generated themes and subthemes that emerged in the data, which I list below.

Theme

1: Transformation of the Self.

A transitory nature of the self with openness and elasticity is the foundation of this theme. This theme concerned the way participants altered their perceptions of the self. The subthemes are as follows:

 “the practice”—MB state of mind

o awareness and acceptance

 knowing the self

o therapist vulnerabilities

 learning to cope with not knowing

 broadening the subjective experience

o shift in beliefs, emotions, and attitudes

Theme 2: Respond Versus React

This theme encompasses how participants made sense of the connection between MB practices and their relationship with thoughts, feelings, and responses with clients. Respond versus react contained several subthemes.

 the space between

o “the pause button”—reflection

o noticing defensive processes

 discernment

 participant–observer

Theme 3: Holding Space

This theme delved into how participants made sense of their MB practices, the influence on CT, and the relationship between the self and clients. The holding space described was a space for others but also a compassionate space for themselves.

 empathic and compassionate holding

 building tolerance for discomfort and emotional pulls

 therapist presence

Theme 4: Emotional Regulation

Building on the subordinate theme of holding space, this theme demonstrated the attentiveness to conscious and unconscious processes in therapy and CT experiences. I explored somatic presentations as potential clinical material.

 self-regulation

 mutual regulation

 the body feels first

o somatic experiences

Findings

IPA is a multistage process that centers on phenomenology and hermeneutics; it is an inductive approach that ensures that themes are derived and closely bound to the data (Smith et al., 2009). Based on the data interpretation and analysis in this study, four findings emerged from the participants’ lived experience.

1. Psychotherapists who use MB practices supported self-transformation by cultivating a state of mind that fostered an attitude of awareness and acceptance. This included the ability to observe and experience the expansive range of mental and physical reality. Instead of turning away from experience, therapists were more likely to surrender to what was happening in the moment. This finding directly relates to the first research question: How do psychotherapists who practice mindfulness use these practices professionally?

2. Psychotherapists who use MB practices reported increased relational capacity, facilitating the role of participant–observer and supporting the differentiation process. It is then plausible to conclude that MB therapists may be less likely to be pulled into limited states of defensive processes and mental conditioning that can be present in CT. This finding directly relates to the main research question and all subquestions of this study.

3. Mindfulness practices may be a method for developing and enhancing important therapist characteristics such as compassion, empathy, and attunement. The development of important therapist characteristics may suggest a link between

mindfulness, relational qualities, and identification of CT, which could aid in CT management and minimizing enactments. This finding relates to the main research question and subquestion of how a mindfulness practice might affect the therapeutic process with a client. This finding also relates to how mindfulness can inform psychodynamic thinking.

4. Psychotherapists who practice mindfulness reported improved emotional regulatory capacity during their clinical work. This finding relates to the main research question and all research subquestions.

5. Psychotherapists who practice mindfulness cultivated a mind–body approach. This finding relates to the main research question and all research subquestions.

The objective of the primary research question was to capture the lived experience of therapists who practice mindfulness and their understanding of CT. Using an interview guide, I developed the first interview question to set the foundation for the study. Participants shared a part of themselves, a part to be held with kindness and compassion, that was situated in an MB framework. The subordinate theme of transformation of the self answered the question of how therapists conceptualized mindfulness and MB practice specifics. Each story was unique but contained some similarities in language and meaning. Collectively, emphasis was placed on cultivating an attitude of awareness and acceptance, recognizing vulnerable states, learning to cope with not knowing, and broadening the subjective space.

Self Transformation

Mindfulness is a way of living. MB practice in essence emphasizes attention to the nature of the self and encourages in-depth examination (Kornfield, 2008). All participants endorsed a connection between MB practice and understanding of the self. However, the six participants exhibited various levels of self-analysis, which may be related to the number of years of MB training and experience. For example, Emily and Lynne have more MB training than the others, and their narratives in this section were more detailed and longer. On the other hand, Emily was the only participant who shared her experiences and hardship with the pandemic and having two young children at home.

All participants shared experiences of self-transformation. These same two participants

(i.e., Emily and Lynne) used the words “transformative” and “freeing” to describe how MB practice impacted their lives. Other participants used words and phrases associated with positive self-attitudes, such as “quieting the inner critic, “evolving,” “nonjudgement,” “acceptance,” and “awareness.” These descriptive phrases show the research literature on mindfulness practice is linked with experiencing the self as an interdependent, transitory, and evolving process rather than a static or unchanging being (Schmidt, 2011).

The terms “acceptance” and “awareness” are repeatedly discussed in MB research and similarly were represented in the language participants used to describe their subjective experiences in CT. MB awareness relates to the subjectivity of internal and external experience. This is the hallmark of mindfulness practice (Shapiro and Carlson, 2017). MB attention is focused awareness of certain aspects of reality. In gestalt terms,

“awareness is the field upon which perceived phenomena are expressed, and attention continually pulls figures out of the ground to hold them up for closer examination” (Brown & Ryan, 2004, p. 243).

An interpretative perspective of participants’ lived stories revealed a shift in perceiving and experiencing the self with awareness and more acceptance. The process of reperceiving can be described as a “rotation in consciousness in which what was previously subject becomes object” (Shapiro & Carlson, 2017, p. 101). Instead of becoming fused in one’s own narrative or life story, one can take a step back, observe and become a witness (Shapiro & Carlson, 2017). Participants recognized multiple voices and parts of their self. These voices and parts were described as “the inner critic”, “single mother”, “the little activist”, “the supervisor”, “the lawyer”, and “the pandemic survivor”.

Participants provided many examples of stepping outside their subjective experience to differentiate between subject and object. Lynne described being able to perceive a clinical situation differently and respond in a nonjudgmental manner with a client who is a single mother like herself. Brooks and Marie described their experience with young female clients and learning to stand back and witness their emotional responses without automatically responding to the triggers. Al worked hard to quiet her inner critic and to widen her perception of its meaning. Madeline noticed fleeting thoughts that held presumptions about a supervisee. She used her MB skills for reflection and to “be with” these thoughts instead of projecting onto her client. Most participants spoke being more compassionate to the self and focusing nonjudgmental

attention on the contents of their conscious material. Participants also reported on the emotional and physical experience in clinical work. These examples all support that MB may help to strengthen mindful observing of inner experience, thus reducing the risk of acting out impulsively on thoughts and feelings in the therapy relationship.

This data would support the theory that MB practice increases the capacity to be more objective in the therapeutic relationship (Shapiro & Carlson, 2017). Furthermore, they viewed an attitude of openness as an invitation to practice awareness and acceptance of vulnerable states. There was not necessarily an open-arms approach with vulnerability but acknowledgement of its inevitability and subsequently normalizing this state of being. More important, as it relates to CT and this study, participants’ openness may decrease experiential avoidance and the natural tendency to escape or avoid discomfort.

For psychodynamic therapists, recognizing multiple self-states, paradoxes, and ambiguity are key to understanding the complexities of human relationships (Barsness, 2018). An attitude of openness to the therapist’s inner experience is a fundamental component of psychodynamic practice. From the beginnings of psychoanalysis, Freud wrote that the analyst’s internal world contains “thoughts and fantasies aimed at understanding the client, and a kind of openness that allowed the therapist to perceive and subceive material that was not conscious in the client” (Gelso & Hayes, 2007, p. 85).

Post-Freudian therapists focus more on relationships and emphasize the fullness of experience, making meaning of emotions to understand the client (Gelso & Hayes, 2007).

Relational psychoanalysts Mitchell and Aaron (1999) practice a 2-person psychology in

which the therapist and client together cause the happenings in the therapy room. This practice would include a consideration of therapist subjectivity and external responses that can encourage deeper understanding of psychological events (Barsness, 2018).

An attitude of acceptance and awareness supports an openness to learning in times of not knowing. Marie was one participant who shared her learning experience of accepting the anxiety she felt in a highly charged political world. The growing tolerance of ambiguity, uncertainty, and anxiety may allow for understanding of the complexities in our minds and social relationships. Alice’s geriatric population and impaired cognitive abilities seemed to present the most challenging of uncertainties for client and families, which can arise in the therapy room. She consistently used her MB training and practices to support a loosening of the desire for certainty and instead moved forward into areas that are unknown or hold tension or confusion.

Many years of higher education, clinical training, and experience provide therapists a sense of “knowing,” which creates a level of certainty but may also produce an intolerance to uncertainty (Berzoff et al., 2016). Regardless of years of experience, if a therapist imposes a therapeutic ideal on herself that they should always know what to do, anxiety feelings are more likely to be felt (Casement, 1985). Madeline understood that no amount of education or training created an immunity against feelings of uncertainty, especially when one terminates a client. Emily spoke of the same hardships in client termination, and both participants discussed feelings of ambivalence when reviewing case details. Overall, the findings indicate that mindful psychotherapists whose intention is to practice awareness and acceptance may be more likely to embrace the idea that there

is more than one explanation for behaviors, more than one interpretation, and more than one way to conceptualize clinical situations and treat psychological disorders (Burke & Brown, 2022; Southern, 2007).

There are multiple interacting influences to explain psychological symptoms and behaviors (Barsness, 2018). This statement is not meant to diminish empirical research that has shown effectiveness specific to disorders, such as cognitive behavioral therapy for panic disorder, exposure and response treatment for obsessive compulsive disorder, and exposure therapy for social phobia (DeRubeis et al., 2005). However, many theorists, scholars, and clinicians subscribe to an integrative approach in psychotherapy practice and continuously examine treatment methods to help reduce client suffering. Even Karl Popper, who greatly influences the field of empirical science, proposed the idea of falsification in the scientific method, meaning scientific theories can never be proven; rather, empirical data can support or refute it. Popper (1959) rejected the idea of absolute truth.

To acknowledge knowing, one must paradoxically recognize not knowing and strive to hold both possibilities of experience (Berzoff et al., 2016). That is easier said than done. Freud (1909) wrote about the challenge of embracing the fullness of knowledge and experience while remaining empty. He advised psychoanalysts on how to listen and attend within the analytic hour. Freud referred to this attention and listening as evenly hovering attention. This is the manner in which the analyst can attune their unconscious to the client’s, gaining access to the client’s internal world (Berzoff et al., 2016). Yet, he did not necessarily provide positive recommendations for how to cultivate

these skills, and even if he had, those techniques would not necessarily be generalizable to our clinical world today. There does appear to be a contradiction between focused attention and an observing capacity of consciousness to reveal unconscious material. Certain forms of meditative practices involve a conscious decision to discard one’s agenda and engage in an active process of experiencing current thoughts, feelings, and sensations (Hayes et al., 2011). Many researchers believe that two forms of meditation are important, one that fosters concentration and one that involves active observation of the changing present experience that may provide access to material outside of conscious awareness (Brown & Ryan, 2004). MB practices are not a panacea for the challenges and complexities of how and what to pay attention to in psychotherapy. They do provide therapeutic tools to help psychotherapists who are tasked with holding and organizing large amounts of clinical and client information while being receptive to vulnerable states, such as uncertainty, that present in the here and now.

Bion (1967) wrote about the importance of not knowing and being open to learning in the present moment and proposed that clinicians need to “be without a memory or desire” (Berzoff et al., 2016). Bion believed that clinicians should be in a “state of ‘unconditioned preparedness’, as if seeing it for the first time” (White, 2011, p. 233). Bion advocated for being without memory or desire in the “form of premature understanding. It is not memory per se that is the problem, but the attachment to memory” (p. 233). This reference to attachment can be viewed within a MB lens as “clinging” to presumptions or to the illusion of “all knowing”. Instead, one seeks to be a more modest thinker and recognize the flaws inherent in their assumptions. Bion’s (1967)

concept is also comparable to the mindfulness idea of “beginner’s mind”; a way of looking at the world free from prejudice as if it were seen for the very first time. This attitude provides more freedom and an advantage in how one responds towards situations or events (Shapiro & Carlson, 2017).

Another like term is “wiping the slate clean” in the sense that attention is refocused and open to receiving impressions of “reality” undistorted by our biases and prejudices. Bion (1970) also wrote that “through the practice of detachment and release, there is an ever-greater receptivity, openness, and elimination of barriers” (White, 2011, p. 235). Mindfulness research explains that detachment is not about distancing oneself from the experience to the point of dissociating, withdrawing, or feeling numb. Instead, detachment is the process of being deeply aware of thoughts and feelings by observation, decentering from them, and gaining a better understanding of one’s own cognitive and emotional functioning in the moment (Shapiro & Carlson, 2017; Didonna & Gonzalez, 2019).

MB practices cultivate a perception of the unknown as a mysterious space to discover more about ourselves, others and the world. Psychotherapists who strive or grasp for certitude may unknowingly miss out on clinical material in the moment. Even the most seasoned therapist who has the best-laid plan for the session must be ready to enter the jungle with branches flying around and wild animals lurking in the bushes (J. J. McDowell, personal communication, November 21, 2011). The therapist, as the guide in the jungle, may not know the future, but they have the knowledge to make the experience safe (Barsness, 2018).

The therapeutic relationship often reflects a state of not knowing, and therapist and client may feel the tension in times of uncertainty (Grupe & Nitschke, 2013). This study showed that MB practices can aid in self-transformation and allow space to examine assumptions that may be held in the not knowing space. Growing to know the self with its vulnerable states creates the psychological space with which clinicians can acknowledge biases, stereotypes, and the patterns of the mind that can be clouded and tied to the quest for certainty. Instead of perceiving vulnerability as something to avoid, participants demonstrated a perception that feeling vulnerable had a growing edge toward feeling what needed to be felt. For example, Lynne described learning to feel more connected to her mental and physical sensations.

I began to notice, both a mental and my physical sensation and how my body was being activated. That piece was one that felt truly life changing. The other piece was really connecting to my physical being. It was the first time I had ever really had a practice for it, and how to connect with my body and the sensations that were happening in it.

In MB practices, participants did not buy into the narrative that therapists should always be certain despite the reality of being human. Emily and Madeline reported feeling ambivalent with terminating long-term clients, recognizing multiple feeling states when establishing ethical and professional boundaries in treatment. Al reported feelings of anxiety and how she and her client’s thoughts are naturally pulled to worrying about the future and how they will cope with dementia or the illness of their loved one. Al reconnected with her breathing as a calming technique and as a way of staying connected

in the moment. Instead of disengaging or moving away, she engaged her clients and sought to help calm them as well. MB practice introduces methods for the therapist to gain more comfort to sit with not knowing and to hold feelings of uncertainty long enough to allow for resolution of tension and resistance or possible defenses that prevent the experiencing of reality (Germer et al., 2013; Grupe & Nitschke, 2013).

Because participants’ MB practices are linked to the study of CT, this qualitative data indicates mindfulness provides a way to enhance self-knowledge. This is achieved through learning to observe and be open to whatever is being offered in the field of experience (Vinca, 2009). The therapist is then able to attune to the client in a sensitive manner with greater receptivity as they learn to draw their attention inward and then extend outward toward the object of focus (i.e., the client). It is most likely that as the attention expands to include internal and external processes, a therapist’s subjectivity is broadened, as well. Being emotionally full instead of leaning into one’s subjectivity may improve the therapist’s capacity to experience the client’s internal world from the “vantage point of the client’s lived experience” (Vinca, 2009, p. 99).

In essence, there is a connection between therapist and client’s internal and external worlds, a field that holds CT experience. By bringing focus and attention continuously to the here and now, the therapist situates herself as observant to feelings and thoughts that may signal unconscious and conscious material that could indicate CT. For psychodynamic clinicians, there is also an understanding and vigilance to how associational learning patterns, conditioning, and emotional memories represent defensive and interpersonal patterns of relating. Psychodynamic theorists and clinicians

recognize that emotional memories from the past can greatly influence how an individual processes and responds to life situations and events (Gilbert & Tirch, 2019).

Robertiello and Schoenewolf (1987) recommended that “we should be constant objects of our own observation, looking for any intense feelings about clients, and being vigilant about what the next instant will be in which our unconscious many betray us” (p. 290, as cited in Gelso & Hayes, 2007, p. 96).

Brooks and Al both reported how they bring their focus again and again into the present moment. Brooks compared the process in therapy to meditation. Al reported on the challenges working with the geriatric population and their family members who struggle with cognitive impairment. She understood the risks of emotional lability due to their illness and the confusion it causes in the individual and the family system.

Interestingly, Al was the only participant who did not report a formal practice of meditation, yet she used informal MB practices every day in session to ground herself, increase awareness of her internal processes, and to provide coping methods for her families.

Increase in Relational Capacity and the Participant–Observer

This finding directly relates to the research question about how a mindfulness practice might affect the therapeutic process with a client. Central to the tenets of mindfulness is that suffering is the result of our automatic ways of reacting and the mental habits that are deeply ingrained in the unconscious. This is opposed to responding discerningly and consciously. All respondents’ narratives contained similar language,

using the words “react,” “respond,” and “pause” to describe how MB practices had changed how they responded in therapy. Instead of reacting, the therapists seemed to hit the “pause button” to reflect and consciously discern what is needed in the moment and to respond in a skillful manner (Shapiro et al., 2017). The pause can be a reflective space between thought, feeling, and action. MB reflection may provide support for an increasing relational capacity among psychotherapists during the CT experience.

The process is similar to Sullivan’s (1953) idea of the psychotherapist playing the role of participant–observer of self, other, and process (as cited in Bruce et al., 2010). In Sullivan’s (1927) publication, “The Common Field of Research and Clinical Psychiatry,” he wrote of the choice that lies before the clinical psychiatrist between scientific rigor of observation, which is the “touchstone of psychiatric research,” and the “blissful meandering through the day’s alleged work, with results of no therapeutic importance to the client or scientific importance to anyone” (as cited in Spiegel, 1977, p. 372). Sullivan repeatedly acknowledged that the clinician’s emotional content can influence perception and that the observer’s self can “play tricks on his reliability” (p. 372). The interpersonal nature of the therapy relationship adds another dimension to the clinical content’s complexity. The interpersonal relationship can add distortions, which may arise from the clinician’s bias and preconceptions, influences of values and belief systems, and distortions from their personal history and subjectivity (Spiegel, 1977).

Because therapists are considered a tool in the treatment process, Sullivan (1949) advised that there is an obligation to “perfect this tool” (as cited in Spiegel, 1977, p. 374).

It is important for the therapist as the participant to gain the necessary skills in self-

observation to improve observational skills. He related participant observation as a “double process” and stated, “that which one cannot experience cannot be observed” (as cited in Spiegel, 1977, p. 375). One participant, Al, did not mention Sullivan’s theory per se, but she used the word “tool” to describe the clinician’s role. She stated, Mechanics have tools and instruments to perform diagnostic tests; doctors have medication and stethoscopes and all different diagnostic tools to help them figure things out. But we’re the tool, we’re the ones, through our experiences, training, and what we learn to how to be with this person. We are the guide and to know what to pull out of the experience to reinforce and what to throw away as unusable.

In this study, the participants described their observational skills and paid close attention to internal responses, noticing, and labeling any arousal of intense feelings, such as agitation and anxiety, or activation of their defensive system. All participants communicated their ongoing efforts to be attentive to thoughts and emotions as they were triggered and had potential links to emotional memories or conditioning. When we consider the complexity of communication in therapy, the “observing-describing mode” of attention is especially important during a CT experience to stay focused, grounded, and attuned to the possibility of enactments (Gilbert & Tirch, 2019, p. 99).

The mindful psychotherapist may intend to relate to whatever presents in the psychotherapy moment and to allow for reflection and response reflexivity. It was also in this space that participants were likely to notice their own defensive processes and demonstrated insight into CT triggers. As participants’ stories unfolded to include their

understandings of the intersection between MB practice and CT, it became clear that they had gained a vantage point in learning when to hit the “pause button” and knowing their defensive processes. This advantage is the skill of discernment or being able to differentiate between self and other, which is a critical skill in the management of CT responses.

For therapists, it is about learning their own reactive states and the potential for the conscious and unconscious material to surface in the therapeutic relationship. Mindfulness-based practices do not stand alone in the facilitation of discernment skills, yet this study data revealed that MB practice can offer methods to aid in the development of these skills.

In their CT research, Hayes et al. (1998) reported that therapists’ family of origin issues were sources of unresolved conflicts that can act as triggers for CT. It may be inferred that therapists who practice mindfulness and have learned discernment skills are more capable of managing CT responses. This capability is important because acting out defensively reduces the capacity and/or tolerance to understand what is developing in the complexities of the relationship (Barsness, 2018). Discernment skills align with MB practices in that the therapists were learning how to differentiate themselves from their thoughts and feelings. Participants Al, Brooks, and Emily specifically made comments about differentiating the client’s experience from theirs. For example, Al stated, “I think it’s a matter of my situation it’s also not their situation. I need to hear where they are.”

Being mindful would enhance the ability to be emotionally nonreactive, still noting feelings but not necessarily projecting them onto the client (Davis, 2011).

Mindfulness can be conceptualized as holding a conscious state in which one can “passively observe the present moment, pleasant or unpleasant, just as it is, neither clinging to it nor rejecting it.” There is a focus on internal experience or on specific characteristics of the environment (Weiss, 2009, p. 3). Practicing participant–observer skills allows the therapist to start becoming an observer of themselves and can create a differentiation between the observer and what is being observed (Weiss, 2009). This is the skill of discernment. This is a challenging process because it is normal for the mind to wander and be distracted by stimuli. Acquiring participant–observer skills require ongoing efforts towards intention, effort, and practice. MB practice is one tool that can assist with this endeavor, and specifically growing the “internal observer” would be accompanied by MB practices, such as meditation. MB practices may help therapists learn to distinguish their experience from their clients’ experience, thus improving clarity in their work with clients (Davis & Hayes, 2011). It is important to be aware of the inner workings of the mind, holding them loosely, understanding that questions about repeated wandering attention, defenses, and conflicts can be explored later and worked through if necessary. (White, 2011). This is learning to consciously discern what is clinical material and what is superfluous distractions and noise.

The findings support research showing that mindfulness meditation practice helps the learning be less reactive or nonreactive, which involves response flexibility and internal-affect regulation (Siegel, 2007). Participants reflected on their reactive states, especially when speaking about CT. They noted defensive processes and commented on

being in touch with their inner experience. Lynne described how she used loving kindness meditation to practice self-regulation and compassion towards her client. I find myself; my brain is going off and being activated and I wonder about this and my response to my client. Am I responding to her in an activated way and why? What I have found to be helpful for me is place my hand on my heart. Apart from the touch, it feels good. But is it also this reminder that I'm not just up here in my head and-and I'm feeling both in my body this real warmth towards her. I think it can often be very difficult for a client who has gone through several therapists. And so this warmth and care for her and also how my body feels some warmth too for the experience of coming together and having to share all your stuff and how your stuff interacts with your parenting. Nobody wants somebody to think that they're not a good parent and I am taking the time in session care a little for myself, too.

Empirical evidence indicates that mindfulness meditators can develop selfobservation skills that neurologically separate automatic pathways established from previous learning and allow for present moment information to be integrated in new ways (Siegel, 2007). Through practice, the observer and material observed can be differentiated, allowing for the recognition of separate but connected entities in the intersubjective space. This is not a disconnected space but one that ultimately creates integration instead of being pulled or merged into the CT experience (Siegel, 2007). The role of participant–observer may allow CT to emerge as a feeling state that fluctuates and a place where the therapist can stop, reflect, and find compassion and curiosity for the

experience. The participants used the observed elements as a source to help make meaning of the CT process.

As I listened to participants’ stories and how they made sense of MB practice and CT together, I felt a deep appreciation of what the participant and their clients had cultivated together. Each described their version of how they use MB methods to create the “pause” for reflection. This cocreated space is created repeatedly in the therapy room, unconsciously and consciously. It is a bidirectional and evolving process that includes the inside and outside workings of mind and body. Relational theory and its practice foundations provide the special ingredients of the subjective and objective experience and the “space between them” (Mitchell, 1988, p. 33). Concepts such as the “space between,”

“intersubjectivity,” and “analytic third” have flourished during the last two decades in psychodynamic literature (Barsness, 2018). Contemporary psychodynamic psychotherapists have come to believe that there is no such thing as an isolated mind and that our field is relational by design “because we are built that way” (Mitchell, 1988, p. 21). Relational theorists have focused on the needs of the relationship and the interpersonal field of experience. The subjectivities of clinician and client combine to create the analytic third, or third space of meaning. This is a cocreated space where both people can reflect on the other (Berzoff et al., 2011). The intersubjective space mutually influences the client and clinician through CT (Berzoff et al., 2011). Although the concept of intersubjectivity has multiple understandings (Barsness, 2018), the theory generally assumes that no two individuals can be seen as separate or detached subjects of objects. The phenomena of intersubjectivity or the study of experience brings focus to the

reciprocal process of the unconscious and conscious experience and the fact that individuals “grow in and through the relationship with other subjects” (Benjamin, 1988, p. 20).

Psychodynamic thinking in the last 20 years has progressively converged with the fields of cognitive, developmental, and social-psychology research. Therefore, change requires engagement in the space between, which is where freedom or uncertainty produces levels of energy required to take risks in development. These are risks in the individual intrapsychic and intersubjective fields. Regular MB training and practice can enhance a state of reflection, response flexibility, and development of discernment and participant–observer skills. The space between intrapsychic and intersubjective fields could unlock the door to unconscious material that holds habitual patterns of behavior, intense emotions, biases, stereotypes, and prejudices. Each participant demonstrated the unique way they embraced the space between with an understanding of compassion and flexibility to recognize the very personal and possible vulnerable space of the other, allowing for individual strengths and limitations to enhance their connection to themselves and clients.

Psychotherapist Relational Qualities and Interpersonal Attunement

This finding speaks directly to how mindfulness practice can affect the therapeutic process and CT experiences by cultivating two important clinical relational qualities: compassion and empathy. Psychotherapy and CT can be viewed as an interpersonal phenomenon. Therapists seek to establish an environment with certain relational dimensions to promote healthy development. In the therapy room, this would translate into creating a space in which the client feels safe, accepted, seen, and heard (Winnicott, 1965). Mindfulness practice helps enhance an important therapeutic quality of compassion, which is foundational in establishing and maintaining a safe and accepted therapeutic relationship.

All participants described a variety of unique formal and informal MB practices and sought to internalize a compassionate attitude toward the self and toward the other. For example, Lynne practiced loving kindness meditation in therapy by placing a hand on her heart. Emily, Al, and Marie all used grounding exercises in session to bring awareness to the body and how it is physically situation in the moment. All participants described an increased awareness and learning to interact differently with the inner critic voice.

Compassion has been conceptualized as a combination of two qualities: “the ability to feel empathy for the suffering of the self or other, along with the wish to act upon these feelings to alleviate the suffering (Shapiro & Carlson, 2017, p. 28). In MB practice, one learns to feel compassion and kindness toward oneself, attending to selfjudgement. Participants in the study referred to this process as learning to suspend

judgment and quiet the inner critic. Collectively, all participants shared their experiences of learning to recognize self-judgment and practice self-compassion to prevent internalizing negative self-evaluation.

This continual learning to be self-compassionate and less judgmental seemed to allow for self-attunement, which is the first step in fostering an attunement to others.

“Attunement” is a term used in the neurobiological literature in which an individual focuses on the internal world of the other, and in turn, the other feels understood, felt, and connected. Stern (1985) wrote, “It is a two-way street where one person senses the mind of the other, and the other senses his own mind in the mind of the first. As one person ‘feels’ the other, the recipient feels ‘felt’” (as cited in Bruce et al., 2010, p. 85). Siegel (2007) believed that attunement is important for individuals to feel understood, alive, and at peace in a relationship (Bruce et al., 2010).

Participants placed importance on striving to achieve compassion and empathy for themselves and their clients. With a growing awareness of their internal experience, therapists may be more likely to remain empathically attuned to their clients, which is likely an asset in CT management and repair. This finding also relates to the way mindfulness practice can inform psychodynamic thinking. According to Siegel (2007), attunement is the antecedent to compassion because it involves becoming familiar with and even befriending one’s inner experience, thereby cultivating the ability to know and befriend the other (as cited in Shapiro & Carlson, 2017). Self-attunement involves the observing ego, allowing for conscious awareness and observation of the content of one’s experience from an objective stance, accepting whatever is happening in the here and

now as a component of the human experience. Siegel (2007) believed that mindfulness entails being in the present moment, acknowledging experience with respect and kindness. He proposed that this kind of interpersonal attunement promotes love. He stated, “The intrapersonal attunement that helps us see how mindfulness awareness can promote love for oneself” (pp. 16–17).

Empathy for the other is much more likely to occur when a therapist has achieved a level of compassion and attunement toward themselves (Shapiro & Carlson, 2017). A state of intrapersonal attunement in which an individual attends to themselves with empathy and compassion can then manifest in being better able to attune to others. Participants emphasized self-compassion and recognizing the universality of being human; everyone suffers, and no one is immune. Lynne spoke about the different parts of bring human when working with a challenging client.

When I’m working with a client who is engaging in some-some real verbal cruelty either to themselves or somebody else, I'm able say, “we all-we all have that part of us. We've all wanted to do”. Instead of being critical in my mind about her, offering some compassion. Especially in that borderline experience of, the demonizing and pushing away. That’s one part of what's happening in a way that allows there to be space for it all and then the same client that might have previously experienced like some demonizing of that part of them, or even shutting down the other parts. It then allows us to be okay, that's one part of you but let’s watch it settle. Let's see another part or you.

Madeline similarly described recognizing humanness in her statement about stimulus control.

And I try to do it to really validate people's experiences. This isn't you, it isn't you just losing your shit for no reason, this is how the brain works. I really pair it with compassion that once we realized that you are getting activated, I’m in an amygdala hijack moment, and now, I've lost all power and control. Okay, now we can touch in with our breath. I usually present the neuroscience as an explanation. I talk about how the research tells us that the feedback between the mind and the body. It's like eighty percent is going from the body to the mind.

Mindful practices may enhance a psychotherapist’s ability to create an attuned relationship, and attunement is an important element of the therapeutic relationship. Relational qualities and cultivating a space that holds empathy and compassion may help clients perceive their experiences in a new manner (Germer et al., 2013).

As discussed earlier in the findings, the holding space can be viewed as the shared space, an intersubjective interaction between therapist and client. Participants spoke about holding space for self-compassion, and empathy and compassion for the client. From a theoretical perspective, the mindfulness-holding space sounds similar to Winnicott’s (1962) concept of the container, which relates to the development of the relationship between the interactions of mother and child. During interactions that may hold anxiety and other affectual experiences, the mother is able to metabolize the child’s feelings and respond in ways that support growth and development. On the other hand, Bion’s theory of containment was different because he recognized the two-person

interaction that acts as type of communication, and the existence of a separate internal world of mother and child while emphasizing the child’s abilities (White, 2011; Berzoff et al., 2016). This speaks to the process of differentiating or being able to recognize and the other’s separate subjectivity. The research findings seemed to be a better fit to Bion’s theory of containment, in which therapist and client as two separate subjectivities are focused on developing a capacity for reverie to explore and expand inner worlds.

Mindfulness therapy practice strives to be collaborative while demonstrating qualities of empathy and compassion for self and others. Especially in CT experiences, the process of containment is important to hold subjective experiences of anxiety, which is the most common affective experience reported in the literature. Bion suggested clinicians move away from techniques and concerns for causality towards a phenomenological perspective of “what is” (White, 2011, p. 218). His concept of containment seems to support the mindfulness attitudes of openness and curiosity of the clinical experience (Symington & Symington, 1996).

Emily provided insight into her struggle and difficulty containing the intense emotions of a deeply wounded long-term client. She acknowledged her limitations, sought ongoing consultation, modified her approaches, and eventually decided to terminate the relationship. The recognition of limitations both intellectually and experientially has importance in optimal mental and physical health inside and outside of the therapy room. The task of containment of all emotions of client and therapist is an unrealistic and problematic expectation for therapists who have limitations like any other human being. If therapists are encouraged to be aware of their own growing edges and

limitations, they may be more likely to make use of consultation, peer support or counseling.

Benjamin (2009) encouraged the psychoanalytic community to “give up the ideal of being the ‘complete container’, to surrender to the fact that we survive causing pain” (p. 442). Containment is an important concept and practice within CT and the therapy relationship but so is recognizing limitations, feelings of impotence, and humanness. However, being unable to contain emotions during CT may result in therapist enactments and “becoming either over or under available in the therapeutic relationship” (Gait & Halewood, 2019, p. 256). In clinical situations where the emotions are less contained or not contained, the relational psychotherapist accepts responsibility for her part of the enactment and seeks to repair the disconnection. The active surrender and recognition of our impotence becomes the growing edge of clinical practice (Germer et al., 2013).

New ways of conceptualizing CT through an MB lens may enhance the therapist’s ability to offer a repair following an enactment, a new relational experience and modeling realistic expectations in a healthy working alliance (Weiss, 2009). Mindfulness skills practiced within the clinical setting can act as an adjunct to the containment process. Collectively, participants working in an MB frame acknowledged their intention of fostering growth for the client in the present moment and sharing the present space with the client. They recognized the complexity of human relationships and were more accepting of their full range of their internal and external experiences.

Emotional Regulatory Capacity

There is a phenomenological quality of mindfulness that centers on an experiential nature of emotions and cognitive processing. It trains an individual to focus internally and teaches acceptance of emotion as part of being human (Wolever & Best, 2009). This is not an easy task considering we live in a culture that is highly focused on and pulled into external material. Because MB practice involves deconditioning of habitual emotional and cognitive responding, it may lead to a more balanced state or core affect (Brown & Cordon, 2009). Because mindfulness is thought to provide a clearer objective perception, stressful events and experiences are less likely to be distorted by misinterpretations or cognitive biases (Brown & Cordon, 2009). CT research discussed earlier in this study showed that the most emotionally charged situations that a psychotherapist may find themselves in are those involving interpersonal conflict, which could signal CT. The study’s results supported the theory that MB practices can offer opportunities to improve emotional regulation for health care professionals during CT and non-CT challenging situations.

The social interactions in our daily life produce emotions affecting our internal and interpersonal experiences. Regarding psychodynamic practices, the analytic process entails expressing and regulating emotions. Learning to regulate emotions and emotiondriven actions is important for successfully creating and maintaining healthy and safe relationships. Psychotherapists have a foundational task of establishing a safe and secure therapeutic relationship, which would include learning to practice their regulatory skills to prevent being flooded by clinical material. There is a vast amount of empirical

research and several neurobiological theories of emotional regulation as well as a great deal of research on mindfulness practices that can help clients regulate their emotions (Hill, 2015; Linehan, 1993). For example, regulation theory has been clinically discussed in the last 25 years (Schore, 2012). This theory proposes “early-forming automatic, fast, nonconscious, psychoneurobiological processes” (Hill, 2015, p. 11).

Regulation theory and interpersonal neurobiology are focused on the socioemotional brain, which is shaped by experiences in early childhood relationships (Schore, 2012, 2012; Siegel, 1999). The socioemotional brain remains malleable throughout life and grows in the context of experiences (Hill, 2015). The psychotherapy relationship can be understood in a sociocultural-relational context that provides the landscape for psychic and neuro growth (Hill, 2015). I recognize the peripheral relevance of regulation theory and interpersonal neurobiology. However, due to the breadth of research on regulatory theory, the primary objective of this study was to explore how psychotherapists may use MB practices in therapy as it relates to CT as well as what MB mechanisms, they find effective during CT.

Psychotherapists must be attentive to their own affect, thoughts, behaviors, and somatic sensations and the potential this information brings to the meanings and affective state of the client (Pally, 2001). Elizabeth Zetzel (1970) first explained affect tolerance, also known as emotional regulation, in psychoanalytic terms, and it is currently believed to be a therapeutic mechanism in mindfulness meditation (as cited in Garland et al., 2011).

An emotion can be understood in its content (i.e., felt experience) and its underlying neurobiological causes and processes (Barrett et al., 2007). Emotional content at its core is concerned with subjective feelings of like or dislike. As Barrett et al. (2007) explained, an emotional experience is usually about something, an intentional state that is dependent on arousal levels and has relational and situational meaning. These variables create the psychologically distinct experiences of many emotions, such as happiness, calm, anger, and sadness. Also, emotions are usually accompanied by specific physiological changes. It is the cognitive appraisal or meaning that is assigned to a particular situation through which the study of emotional-content regulation has been most conducted.

Affect can be understood as the conscious experience of such emotions. Ekman and Friesen (2003) and Westen (2007) believed that emotions strongly influence actions, in what is spoken and determining what is right for a particular situation. The reflective self can be absent when therapists are unable to regulate their emotions effectively (Cozolino, 2017). MB practices, such as meditation, may provide the training ground for affect regulation because strong emotions can accompany the experience. The felt experience in MB content is viewed in a welcoming and accepting manner, knowing emotions are impermanent and believing that one can hold more emotion than believed.

Participants’ lived stories demonstrated a willingness to explore strong emotions and explained the complimentary nature of MB practice and CT. Terms such as “softening” and “embracing” the experience are used repeatedly in the literature to describe tolerance and emotional regulation in a mindfulness experience. Participants

also used such terms when they described an emotional experience with clients and CT. In this study, narratives portrayed an openness and receptivity to feel what the participants did not necessarily want to feel but were willing to feel anyway. These were feelings of anxiety, vulnerability, guilt, shame, confusion, and anger. Paradoxically, they were also willing to feel love and compassion for themselves and others. This is the process of interactive regulation that begins with the therapist practicing emotional regulation and then branching outward as she strives to connect and build a working alliance with clients.

As therapists, we are tasked with synthesizing a vast amount of information, recognizing our brains store much of the information due to economic reasons. Therefore, individuals are automated much of the time to function and adapt to daily life (Cozolino, 2017). Research has shown that MB practices can be a therapeutic method to change the response following a reaction generated by emotion (Germer et al., 2013). All participants described methods used in the therapy room, such as breath work, grounding exercises, loving kindness, meditative practices, and harnessing focus and attention skills. This included CT and non-CT material in therapy. Instead of automatically suppressing, resisting, or pulling away from an uncomfortable experience, participants sought to work with the experience to understand meaning on a deeper level.

Empirical research has extensively documented that CT may result from interpersonal patterns in therapy and that it often stems from unresolved or resolving childhood memories and conflicts (Gelso & Hayes, 2007). Memories, pain, and trauma find hiding spaces in the mind and body. These memories can also contain hidden

narratives that may include biases, stereotypes, and prejudices. They remain hidden in deep crevices of mind and body and can present instantaneously, often producing a dysregulated affect. When affect is dysregulated, so is the mind–body, along with the loss of attention control and attentional flexibility (Hill, 2015). It is certainly understandable that as humans, we can easily avoid such experiences and instead pursue the path of least resistance as an adaptive method of seeking short-term rewards that require little effort. Many studies have shown continuous efforts to avoid sensations, feelings, or memories are counterproductive and strengthen the pull, intrusiveness and frequency of painful feelings, thoughts, and memories (Hayes, et al., 1996). Avoidance as a common coping mechanism serves to entrap the individual more deeply in the experiences they are attempting to avoid (Germer et al., 2013).

As discussed earlier, MB practices can be one antidote for these experiential avoidance tendencies in CT, which can arise with minimal effort from the therapist. MB practices such as cultivating an attitude of awareness may provide insight into identifying CT triggers and automatic responses. For example, Brooks spoke of the “little activist urge” that shows up in therapy when she identifies with a young female client. She described an important self-analysis process of exploration: “What is going on with me?”

“What’s going on with them” “Is it me or them?” Brooks recognized the CT material and believed it had the potential to interfere with her connection to the client’s experience. Because vulnerability can present spontaneously in therapy, being consciously aware and mindful of trigger points supports the use of MB methods to manage CT effectively (Gelso & Hayes, 2007). Brooks sought to be aware of her internal states, being conscious

of her felt experience and empathic connection to the client in the moment, and an ongoing awareness of any relational changes between her and her client. This is in essence practicing relational mindfulness (Surrey & Kramer, 2013, as cited in Germer et al., 2013).

Viewing CT from an interpersonal lens, studies have shown that psychotherapists’ self-insight is an asset in CT management (Davis, 2011; Gelso & Hayes, 2007). As discussed earlier, awareness of or insight into internal states will not necessarily prevent acting out on CT triggers or impulses. However, it is an important step in being consciously aware of the “hook” or “pull” of these triggers that may disrupt emotional regulation. Using MB practices to understand CT may counteract the automatic tendency to push away or suppress in favor of exploring the internal responses by clinicians. The mindful therapist may notice that they are talking too much, feeling empty, or taking on too much responsibility in session. They may notice that their patterns of communication are more advice giving rather than trying to understand and connect to the client’s internal and external experiences. The noticing of such feelings and behaviors can be seen as diagnostic material pointing to CT. For example, in this study, Madeline used the phrase “the art of noticing” in her conceptualization of mindfulness and understanding of clinical material in therapy.

MB practices may help the therapist notice subtle and obvious signs of negative reactions in therapy. Because they become more familiar with their minds and bodies due to mindful or meditation practices, these participants seemed attuned to regulating their emotions in response to a client’s behaviors. Maintaining an emotional equilibrium can

prevent therapists becoming flooded by upsetting therapy content or situations. However, when flooding does occur, MB practices, such as breath awareness and grounding exercises, can act as soothing mechanisms for the body. By learning to attend to and regulate emotions, therapists can become more attentive and present and accepting of clients’ challenging personality characteristics and emotionally charged clinical situations. Ultimately, being present to the mind–body experience in the moment is likely to maintain a supportive and strong therapeutic relationship (Shapiro & Carlson, 2017.

The Body Feels First

Body changes are essential to emotion and function as a communication device to the self (Damasio, 1994, as cited in Pally, 2011). To emphasize the workings of the mind in psychodynamic therapy, clinicians must also explore somatic experiences in the therapeutic relationship. Relational theorist Karen Maroda (1999) explained, “We experience feeling viscerally. Our minds do not cue us that we are feeling something strongly; our bodies do. Without the bodily sensation, there is no inquiry” (p. 126).

Maroda contends that psychotherapy has unfortunately ignored or misunderstood the role of the body in interpersonal communication by emphasizing the study of the mind without recognizing the interconnectedness of mind and body.

Learning to regulate emotions promotes care and healing of the mind-body connection. Experiencing negative, positive, or visceral somatic responses in therapy could signal CT, and the body’s response may be the first to feel the effects (FedericiNebboisi & Nebboisi, 2012). Ultimately, mindfulness can change the relationship between mind and body. As participant stories revealed, mindfulness is a living practice,

a way of being with their affect, emotions, thoughts, and somatic sensations differently. This curiosity, flexibility in thought, and willingness to explore the body’s responses were evident in participants’ lived experiences. Similar to a therapist’s responses, a client’s nonverbal cues may signal distress and activate responses in therapists. These responses can exist both consciously and unconsciously, and MB skills appeared to help participants identify emotions that may play a role in the interpersonal interactions of CT. As participants appraised their nonverbal experiences in CT, they appeared to focus on a kind, compassionate response and listening nonjudgmentally. For example, all participants used descriptive phrases to identify how their bodily sensations and perceptions became a network for information regarding thoughts and feelings (Didonna, 2009). Emily spoke about “showing up” in therapy and “wanting to be present.” Al described “using the breath” and “connecting with the body” as her practice skill and one she encourages clients and families to do during an emotional flooding experience. Even before therapy begins, Madeline observes her young client’s affective state in the waiting room and “checks in on how he is feeling” and “I want to honor the space he is in.”

Although Marie reported struggling with embodiment, her acknowledgment reveals an understanding of her limitations and the confounding nature of her history with chronic pain. Brooks spoke about staying focused on the client’s face and matching emotions to connect and “co-regulate.” She tries hard not to get lost in distracting cognitive material, as it tends to clog the arteries of emotion. Lastly, Lynne placed her hand on her heart, a symbolic gesture that communicates compassion, comfort, and empathy. Therefore, it is not always necessary to know more but to feel more in a therapy setting. Overall,

participants seemed to pay close attention to implicit and explicit communication in therapy, and their lived stories represented a more holistic way of understanding human experience.

As discussed earlier, CT responses in the therapist likely involve automatic or encoded bodily responses to the verbal and nonverbal responses of the client. Depending on past, present, and future associative memory links, a therapist can respond positively, negatively, or neutrally to CT material. CT responses may include self-protective actions or simply be a typical expression of how humans react by being together. Regardless of CT responses, it is beneficial that any material that may be “disruptive of the third conversation- the third” be judiciously examined and differentiated as either clinical material for the client and interpersonal interaction or simply internal material that is superfluous and to be discarded (Benjamin, 2009, p. 442). This study showed support for using MB training and skills as methods of listening nonjudgmentally, activating regulatory behaviors in response to stress, and promoting feelings of self-care, compassion, empathic presence, and discernment skills.

Considering the IPA methodology choice for this study, it is essential to recall the work of Merleau-Ponty (1945), where there was a focus on subjectivity, embodiment, and an individual’s relationship to the world. Thus, he linked phenomenological description to “being in the world. . . is a preobjective view, and for this reason, it can affect the union of the psychic and the physiological” (p. 128, as cited in FedericiNebbiosi & Nebbiosi, 2012, p. 431). Merleau-Ponty believed that unique individuals engage in the world holistically and that the body plays a vital role in knowing about the

world. The connectedness of mind and body engage actively and continuously, representing the concept of a “whole living being that continuously interacts with its internal world” (Didonna, 2009, p. 5).

While phenomenologists place different emphases on the role of sensation and physiology in an intellectual and rational domain, the role of the body as an essential element in experience cannot be overlooked. As one speaks about the somatic experiences today, there must be a clear epistemological understanding of the mind-body connection versus perpetuating outdated beliefs of a “mind-body dichotomy” (FedericiNebbiosi and Nebbiosi, 2012, p. 430). The mind-body unification is of central importance in MB approaches as it encourages the exploration of physical and emotional states.

Participants’ stories demonstrated an invitational space for inquiry beyond the first glance of somatic representations. Ongoing analysis, discovery, and discernment skills were used because it is often difficult to understand all being communicated in the therapy relationship. Responses rooted in compassion and kindness towards mind-body experiences encouraged participants to use an MB perspective to focus less on “doing” and more on “being with” the other (Federici-Nebbiosi & Nebbiosi, 2012, p. 433).

Regardless of therapeutic orientation, most psychotherapists strive to learn how to “know” their clients better (Blum, 2015, p. 115). A therapist “will use every tool possible to understand the world of the other” (J. Savlov, 2013, as cited in Blum, 2015, p. 115). There is a unique quality within the psychotherapeutic relationship, emphasizing how bodies may relate to one another (Federici-Nebbiosi & Nebbioso, 2012). Contemporary relational psychotherapists attempt to bring greater awareness of somatic experience; to

be explored on both implicit and explicit levels while considering the continuous flow of information in verbal and nonverbal communication. The body is not an abstract entity, but “rather it is considered ‘embodied experience’” (Federici-Nebbiosi & Nebbiosi, 2012, p. 430).

As this last theme suggests, the body feels first and is the host of implicit and explicit material to be examined in the therapy relationship and within CT. Participants were oriented toward body posture, gaze, and the “back and forth” interactions between therapist and client (Pally, 2001, p. 77). The art and science of psychotherapy facilitate a mutual exploration of somatic meanings relating to the experience of the client and therapist. The relationship between implicit and explicit information is similar to Jessica Benjamin’s (1988) concept of thirdness or intersubjectivity. As more contemporary research focuses on body experiences and implicit and explicit meanings in therapy, MB practices can be one change mechanism to support the therapy relationship. MB practices can also manage the complexity of the physiological and psychic experiences of CT. This study supports the positive influence of MB on the awareness of CT and its mind-body interpretative quality. However, awareness of CT’s feelings, triggers, and behaviors is only the first step in considering CT as a potential source of clinical material. There is limited research on somatic experiences of CT, and additional empirical study is needed to understand the connection between the body’s responses and CT.

There is some parallel between the phenomenological nature of participants’ MB experiences and CT and my subjective experiences within the interpretative space. I immersed myself in the participants’ world through a lens of cultural-socio-historical

lens. At first glance, the transcripts revealed only cursory details of subjective experiences, including my own. Using an IPA inductive research method (i.e., reading, rereading, coding, note taking, and journaling) revealed thematic information, and research “gems” were discovered. This study required that I play the role of a detective and investigate how CT and mindfulness are experienced by each participant, using her preconceptions, assumptions, and prior experience to make sense of the experience once it is revealed. Implicit and explicit communication messages were considered, and the felt experience of “being with” the data provided an interpretative quality unique to this methodology.

As stated earlier, there is a complementary nature between this study and the chosen methodology. As the interest in MB grows in clinical and research settings, it is vital to explain mindfulness “as a living practice, as a way of being,” with self, others, and the world (Didonna, 2009, p. xxx). To teach, one must practice. As clinicians and researchers seek to find resources to better cope with stress and prepare future clinicians for the demands of clinical practice, this study supports the use of mindfulness skills as tools to use in CT both inside and outside the therapy room.

Limitations

To judiciously understand and interpret the findings of this research, it is crucial to identify the limitations of this study. First, IPA research does not have the objective of generalizability, so the results are limited to the lives of the participants interviewed. Based on a different epistemological view compared to quantitative research, IPA is more

concerned with the quality of lived experience versus establishing causal relationships in research (Pietkiewicz & Smith, 2012). This type of research can have both its strengths and limitations. It is also essential to recognize that the interpretative analysis of participants’ experiences is understood through the subjective lens of the researcher. While IPA seeks to understand the lived experience of individuals, it does not explain why these experiences occur. Quantitative research inquiries seek to understand the experiences of its participants and explore the conditions that triggered the experiences, which are in past events, histories, or sociocultural influences. However, Smith et al. (2009) believed that IPA uses hermeneutic, idiographic, and contextual analysis to understand the cultural position of the lived experiences of individuals (Tuffour, 2017, p.

4). Due to the nature of the IPA methodology, there are limitations as to the accuracy of its ability to capture participants’ lived experiences considering the influence of the researcher’s subjectivity. Although I employed bracketing methods using epistemological reflexivity techniques to improve the quality of findings, acknowledgment of my interpretative role has its limitations.

Second, collecting data using a virtual format also has limitations with IPA methodology. Qualitative research is usually collected in natural settings such as schools, hospitals, or homes. COVID-19 may have resulted in increased use of telehealth and virtual qualitative interviewing for research. Convenient for both researcher and participant, virtual interviewing and data collection in this format could have influenced my ability to form an interpersonal connection with the participants and observe certain non-verbal behaviors (McGlinchey et al., 2021). Both my and the study participants’

interpretations of phenomena were considered during the analysis process. In addition, the sociocultural and emotional context is limited when restricted to a computer screen. Combined with the dynamic intersubjective nature of the research encounter, virtual interviewing may limit interpretative activity and make sense of the subject’s personal world (Pietkiewicz & Smith, 2012). There are also limitations on verifying confidentiality in participants’ natural settings. However, all protocol measures were taken to construct a confidential, safe, and trusting environment where participants could openly and honestly share their stories.

Third, the study could be criticized regarding the sample population. Five of the six participants were White, and one participant was African American. This lack of racial diversity is viewed as a significant limitation. The study is also limited to female clinicians who lived in Atlanta, Georgia. Therefore, the results may not reflect those of other clinicians in other parts of the country or the world. Although IPA recommends using purposive sampling procedures to capture a small and homogeneous sample, subsequent studies to be conducted with other groups are suggested as general claims can be made, which was beyond the scope of this study.

Fourth, I did not conduct a behavioral assessment of CT, and identification of CT was based on participants’ ability to recall, reflect, and discuss their CT experiences within the frame of mindfulness. In addition, I did not conduct a behavioral assessment of mindfulness or meditation practices. The conceptualization of mindfulness also relied on participants’ ability to recall, reflect, and discuss their mindfulness practices and experiences within a clinical setting. However, identifying the “type” of meditation also

has limitations because there is no way to determine how committed or closely the meditators followed instructions during their practice. The details of practice can determine the outcome, so more quantitative research using an intervention and control group would be helpful.

Finally, two identities of psychotherapists and mindfulness practitioners played a role in the data collection and interpretive process. As mentioned previously, this was the expectation regarding my role as the researcher. Participants were unaware of my mindfulness skills training, and ethical boundaries were maintained throughout the research. However, my background could have increased the potential for unconscious biases or presumptions influencing the data analysis. IPA methodology prioritizes that researchers stay focused on the “new object” of study rather than on the researcher’s presumptions (Shinebourne, 2011). I used mindfulness skills to practice awareness of preconceived ideas and beliefs. I sought to understand that “rather than putting one’s preconceptions up front before doing interpretation, one may only get to know what the preconceptions. . . are once the interpretation is underway” (Smith, 2007, as cited in Shinebourne, 2011, p. 20). It is not a question of “if” but “when” the preconceived ideas present during the research.

As the process of interpretation is iterative and dynamic, preconceived ideas frequently changed during this study. Several transparency methods were used to extend the contextual scope of analysis: (a) peer debriefing sessions following interviews, (b) ongoing reflection and feedback, and (c) discussion with the dissertation chair and committee members. All these methods supported and added rigor and richness of

interpretation (Larkin et al., 2018). This provided an opportunity for self-reflection, selfexamination, and analysis during the entire data collection and interpretation, where preconceptions and assumptions were acknowledged and judiciously considered (i.e., discernment) as an ongoing practice.

The in-depth process of shared reflection continued throughout each research phase to interpret data collectively. A reflective journal to record such issues and potential biases were maintained and reviewed weekly. Furthermore, emerging codes and themes were cross-examined throughout the analysis to ensure that these remained bound to the data. This helped ensure that the data interpretation was rooted in the participants' stories and was less likely influenced by other confounding data. However, there are still limitations because the IPA methods compromise causality by focusing on meaningmaking and in-depth analysis of a smaller sample. Although limited in its reach, this study offers important insights, innovation, and opportunities to develop quantitative research and mixed methods designs that support future research of two very complex phenomena: CT and mindfulness populations (Larkin, Shaw, & Flowers, 2018).

Implications for Social Work and Future Research

Future research holds excellent value for revealing more about CT experiences and how mindfulness practices interact with this universal phenomenon. Qualitative methodologies such as IPA can be fundamental when examining ambiguous, complex, and emotional topics such as CT and mindfulness. However, future research on the interrelatedness of CT and mindfulness could embrace quantitative or mixed methods

designs incorporating quantitative and qualitative measures. Ideally, this would consist of objective, reliable testing instruments adapted to measuring CT and mindfulness (i.e., meditation) and their impact on the therapeutic relationship. Given the difficulty of measuring both CT and MB, a research design involving both MB and non-MB practitioners may be the best methodological approach to capture the effects of MB practice on CT (Davis, 2011). In addition, using various means of measuring mindfulness beyond self-reports, such as neuroimaging data, behavioral observations, and proxy reports may provide an additional objective assessment of mindfulness (Shapiro & Carlson, 2017). Future studies could also explore CT responses before and after mindfulness training to better understand the developmental process of relating to CT experiences with a different lens (Millon & Halewood, 2015).

The sociocultural intersubjective nature of the therapeutic relationship adds multiple dimensions to the complexity of CT and warrants additional empirical investigation (Southern, 2007). Future research is needed to examine the intersubjectivity of CT in clinical dyads, which would also include supervisory relationships. A better understanding of CT, MB, and intersubjectivity constructs can facilitate learning and deepen clinical and supervisory relationships (Southern, 2007). The dynamics of CT and mindfulness are interwoven in ways that need to be understood within the social-cultural contexts of the client, therapist, and supervisor.

This study also showed that CT and MB practices work well together to help people become aware of and accept that this phenomenon is interactive, complex, dynamic, and sometimes has conflicting narratives. However, awareness and acceptance

are only the first steps in recognizing the sociocultural forces in CT. Exploring cultural CT was beyond the scope of this study and is another topic that warrants scholarly research. It is crucial to examine relational dynamics such as culture, overidentification, vulnerability, trauma, discrimination, and violence may be triggers for CT that affect the therapy relationship. Minimizing the powerful influence of cultural dynamics and other CT risks may limit the potential of psychotherapy effectiveness which may lead to the replication of oppressive situations (LaRoche, 1999, p. 396).

Unconscious biases in CT are still a relatively new and underdeveloped area of scholarly inquiry. The current study highlighted the need for ongoing discussion of blind spots and biases in CT that may interfere with treatment and helps guide future research examining these topics. This study found that mindfulness skills can help people be more aware of and compassionately process CT, which may reduce CT enactments. How mindfulness may enhance empathy and self-compassion as it may relate to CT are empirical questions that require additional research to determine the pathways by which skill enhancement and a shift of perspective develop (Shapiro et al., 2006).

The study of somatic phenomena in CT has received minimal research attention despite evidence of therapists relating to their bodies and acknowledgment of the “embodied” experience in CT. Understanding the “bodily-felt experience” of CT within the context of intersubjectivity may be central to understanding the therapist’s selftransformative process (Dosamantes-Beaudry, 2007, p. 76). For example, this study’s results indicated that somatic presentation during CT may signal defensive behaviors or an adverse response to negative thoughts or emotions during therapy. Instead of

emotionally distancing themselves, therapists can learn more about somatic signs of CT to understand themselves and the client better. Understanding somatic CT may also help therapists normalize some of these symptoms or, at the minimum, stimulate conversation to learn what bodily reactions might mean within the therapy dyad.

Future research must continue to explore the change mechanisms inherent in MB practices. One final suggestion for additional research is to uncover which mechanisms of the multi-modal MBSR intervention work the best within the examination and understanding of CT. MBSR, an 8-week course, includes psychoeducation, experiential exercises to practice mindfulness listening skills and empathy, didactic learning on coping with stress, formal meditation practices, body scans, and gentle yoga stretching and is facilitated within a supportive group format. Each of these components forms the basis of mindfulness. However, it is difficult to determine to what extent each contributed to the mindfulness practices of the participants studied in this research. Future research should explore the explanatory mechanisms of mindfulness intervention and CT in more in-depth. For example, more sophisticated quantitative experimental designs using random sampling techniques and comparison or control groups could be used to compare MBSR (8-week course) and progressive muscle relaxation (PMR) and the impact on CT experiences.

Findings from this study may contribute to the education and professional training of clinical social workers and related mental health fields. Taking into account the empirical evidence presented in this dissertation on the benefits of mindfulness-based skills and their use in CT processing, research is warranted not only on the effectiveness

of training but also on practical ways to teach clinical social workers, social workers in training, and other mindfulness practices for mental health professionals. Costs of MBSR may prohibit some clinical social workers and trainees from attending, so incorporating mindfulness training into undergraduate and graduate curriculum programs may be an option to facilitate more diversity and opportunity for training.

MB skills and practices benefit clinical social workers and trainees regardless of their theoretical and practice orientations. Specifically, for psychodynamic practices, which place focus and importance on exploring CT, mindfulness can facilitate therapy by cultivating curiosity and openness to experience within the clinical setting. MB practices can encourage a willingness to work through difficult emotions through an observational and less defended position (Gelso & Hayes, 2007). Regarding CT management, mindfulness may foster nonreactivity and psychological flexibility that may help clinical social workers respond with openness and less defensiveness (Gelso & Hayes, 2007). As demonstrated in this study, mindfulness can positively affect CT experiences as it allows the therapist to use the “pause button” to reflect, creating space for receptivity, emotional availability, and metabolizing nonverbal and verbal messages in the present moment.

Conclusions

Conducting this IPA study was a challenging and rewarding endeavor. This research attempted to answer the broad-based question, “What is the subjective experience of psychotherapists who practice mindfulness and examine CT? Participants described their training and mindfulness practice as a way of living and having a process

of transformation in their daily lives. Self-transformation included the act of paying attention with an attitude of awareness, acceptance, openness, and curiosity. This finding can be understood psychodynamically through the concepts of Freud’s (1909) “evenly hovering attention” and Bion’s (1967) “without memory or desire”. The second finding of relational capacity identifies the objective and subjective qualities of a therapeutic relationship, being reflective in the pause, practicing discernment skills and growing integrity in being with our clients. Specifically, it is during the space of reflection and nonjudgmental awareness that one can recognize moments of disconnection, misattunement, and defensiveness and CT. MB practice may provide a method for the therapist to stay alive during those times, engaged in the dyad instead of withdrawing and distancing herself. The psychodynamic theory of “participant-observer as coined by Harry Stack Sullivan’s (1953) encouraged clinicians to hone their observational skills, learning to step back, notice defensive processes, and find curiosity for the experience. The third finding of enhancement of therapist qualities illustrated the role of empathy, compassion, and attunement as important therapist characteristics in the holding environment. This finding can be related to Bion’s (1963) psychoanalytic theory of “container/contained” and the importance placed on the co-created space of the therapeutic relationship and minimizing enactments. Participants shared how MB skills grew their capacity to regulate emotions in clinical situations, learning to engage in thinking, feeling, acting or responding versus reacting.

Central to psychodynamic therapy is encouraging clients to share freely about their feelings, wishes, and fears within a safe and secure holding environment. MB skills

may provide therapists with methods to tolerate and express intense emotions effectively and to avoid acting out. The last finding, a mind-body approach finding brings focus into the connection between the psyche and somatic experiences. The fourth and fifth finding could be explained psychodynamically through the concepts of intersubjectivity and third space. The shared understanding within thirdness can be explained as physiologically and psychically complex and unique to the individuals involved. These findings have significant clinical implications regarding the use of MB in strengthening our understanding of its value in conceptualization and processing of CT. Participant stories spoke to the journey of someone who has been transformed by MB and the evolution that continues inside and outside of the therapy room. Most likely this is not the first self-transformation experience in their lives and probably will not be the last. For this study, their MB training and practices reshaped their narratives about self, others, and the world and this was reflected in their shared experienced of CT. Narratives revealed the powerful interaction of mindfulness practices and CT had on their lives, shaping the narrative self as the many parts of the individual made their selves known in the therapeutic relationship.

Appendix A

Participant Recruitment Email 1

Hi everyone!

My name is Mary Brooks Ablett, LCSW and I am a doctoral candidate at the Institute for Clinical Social Work in Chicago, Illinois. I am inviting you to participate in my dissertation project entitled: Mindfulness Practice Uses in Countertransference: A Phenomenological Study of Psychotherapists. This research study is my final requirement for completing my doctoral degree at the Institute for Clinical Social Work in Chicago, Illinois. I am interested in researching clinical social workers, licensed professional counselors, and psychologists who may practice mindfulness and how their experience relates to countertransference. I am recruiting clinical practitioners who have been in practice for at least five years and have a caseload of at least 10 hours per week of inperson direct patient care and/or telehealth.

The interest and study of mindfulness practices has increased within the psychotherapy literature and are now one of the most researched topics. Also, countertransference (CT) is generally understood as a universal phenomenon co-constructed in the therapeutic relationship by both therapist and client. However, the challenge remains to approach such a methodology for studying the subjective experience of mindfulness and its usefulness in understanding CT experiences. I hope to learn more about mindfulness and CT as a utility for clinical practice and technique.

I would like you to take part in two 60-minute interviews. We can do the interview in person at my private practice office in Atlanta, Ga, or we can interview by phone, Zoom, or whatever is most convenient for you.

You will receive a $50 Visa gift card for each interview as a thank you. The gift card will be sent to you after each interview. Participation is free. Your interest in the study, your participation in the study, and all information shared will remain confidential.

I may publish the results of this study; however, I will keep your name and other identifying information private. All participant identifiers will be placed with pseudonyms, and all audio files and transcripts will be stored on a locked, passwordprotected computer. Only the primary investigator (me) and my dissertation chairperson, Dr. Denise Duval Tsioles, will have access to these files. The audio files will be destroyed once transcribed. Data will be used for a dissertation study and reviewed only by faculty members of my dissertation committee at the Institute of Clinical Social Work.

If you are interested in participating or gathering more information, please privately message me, email me at mablett@icsw.edu or call me at 404-387-9310. Or, if you prefer, provide your contact information, and I would be happy to reach out to you. Please do not respond publicly. I hope to hear from you.

Sincerely,

Mary Brooks Ablett, LCSW, BCD Institute for Clinical Social Work

License # CSW003020

Appendix B

Participant Recruitment Email 2

Dr. Stephanie Swann

Atlanta Mindfulness Institute

675 Seminole Ave., Suite 103, NE

Atlanta, GA 30307

April 18, 2022

The Institute for Clinical Social Work

1345 W. Argyle Street

Chicago, IL 60640

To Whom it May Concern:

I am writing this letter at the request of your doctoral student, Mary Ablett, LCSW, who is preparing to conduct her dissertation research study on mindfulness practice uses in countertransference. As part of the recruitment process, I have agreed to share her study with my contact list of clinicians who have participated in a Mindful Based Stress Reduction training program I have facilitated for many years.

Please contact me if you have questions or need more information.

Sincerely,

Stephanie Swann, Ph.D., LCSW

stephanie@atlantamindfulness.com

404-358-3205

Appendix C

Telephone Interview Guide

“Hello, my name is Mary Ablett, and I am a doctoral student at the Institute for Clinical Social Work in Chicago, Illinois. I am working on my dissertation as part of the completion of a doctoral degree in Clinical Social Work. My research will explore the subjective experiences of psychotherapists who regularly practice mindfulness and its use in countertransference (CT) processing. This study attempts to deepen the understanding of the internal and external responses associated with CT reactions and how mindfulness practices may be used in therapy. Overall, I am interested in the lived experiences of psychotherapists who may use mindfulness as a therapeutic tool in countertransference.

Based on what you have heard so far, does this study sound like something you would be interested in?

[If answered no]

I understand and appreciate your time. Thank you and goodbye.

[If answered yes]

Great, and thank you!

Before we move forward, there are a few things I need to confirm about your eligibility for this study. This information is confidential, and your answers will not be shared with anyone else. There are a few inclusion criteria for this study.

1. What is your professional license? LCSW, LPC, PsyD, Ph.D.?

2. How long have you been in practice?

3. What is your practice setting? Do you have an active caseload?

4. Would you be willing to complete a demographic survey? You can always decline to answer any question on the survey.

5. Do you agree to be interviewed multiple times and audio-taped each time?

This study would include two 60-90-minute interviews with you so I can thoroughly understand your feelings, thoughts, and experiences. You will receive a $50.00 gift card for each interview. The gift card will be issued after each interview. As a participant, you can interview a person at my private practice office, by phone, or by Zoom video conference.

A possible risk to participating in this study is the inconvenience of being interviewed two times and any discomfort you may experience when discussing clinical cases involving countertransference. If you experience discomfort during the interview process, you may choose not to answer the question, stop the interview or withdraw your participation in the study. I will ask you questions pertaining to the details of your

mindfulness practice and how you may or may not use these techniques or processes within countertransference. I would also want you to describe in detail your feelings, thoughts, and experiences of mindfulness during either a positive or negative countertransference experience, including sharing information about your therapeutic encounter. I assure you that confidentiality and privacy will be maintained throughout the process. Do you have any questions about confidentiality or privacy thus far?

Based on what you have heard so far, is there anything about this study you feel would make you uncomfortable, unsafe, or emotionally vulnerable?

Do you feel you would be able to reflect on your experiences with mindfulness and countertransference?

Great, you seem to meet the criteria for participation. The next step is to schedule a meeting to review the informed consent process in detail and begin the interviews. I will email you the informed consent and the demographic survey today, so we can begin scheduling the interview.

Do you have any additional questions? “

[if the answer is yes, the interview will continue to answer any questions]

[if the answer is no, the interview will conclude].

Thank you for your time today, and I appreciate your willingness to participate in my study.”

Appendix D

Consent for Participation

MARY B. ABLETT, LCSW INFORMED CONSENT

Institute for Clinical Social Work

Research Information and Consent for Participation in Social Behavioral Research

Title of Study: MINDFULNESS PRACTICE USES IN THE COUNTERTRANSFERENCE PROCESS: A PHENOMENOLOGICAL STUDY OF PSYCHOTHERAPISTS.

I, _____________________________________, acting for myself, agree to take part in the research entitled MINDFULNESS PRACTICE USES IN THE COUNTERTRANSFERENCE PROCESS: A PHENOMENOLOGICAL STUDY OF PSYCHOTHERAPISTS.

This work will be conducted by Mary Brooks Ablett, LCSW, under the supervision of Dr. Denise Duval Tsioles.

This work is being conducted under the auspices of the Institute for Clinical Social Work; At St. Augustine College, 1345 W. Argyle St., Chicago, IL 60640; (773)935-6500.

Purpose

The purpose of the phenomenological study is to explore the subjective experiences of psychotherapists who regularly practice mindfulness and its use in countertransference (CT) processing. This study attempts to deepen the understanding of the internal and external responses associated with CT reactions and how mindfulness practices may be used in therapy. The study results will be used to expand clinical work practice, clinical training programs, professional development, and supervision. This dissertation document will be available online once completed and may be published or presented at professional conferences.

Procedures used in the study and duration

Once the first interview is scheduled, you will receive a demographic survey to complete via email and return to the researcher. Two semi-structured interviews will be required, lasting no more than 60 minutes per interview. Each interview will be audio recorded and transcribed, and all audio recordings will be destroyed after the transcription. Data from these interviews will be secured via password-protected files and stored in locked file cabinets. You will receive a $50.00 gift card for each interview and will be mailed the gift card after completing each interview.

Benefits

There are several potential benefits for participation in this study: 1) an increase in awareness and/or into your mindfulness practice and countertransference, 2) an increase in your mindfulness practice, 3) an increased awareness of countertransference processes, 4) an increased curiosity about mindfulness and countertransference, and 5) your participation will add to the body of knowledge about the practice of mindfulness and countertransference, which can benefit other clinicians looking for help understanding and experiencing countertransference.

There are several benefits to the field of clinical social work and mental health, which include: 1) the research will add to the body of knowledge and practice of mindfulness and countertransference, 2) the research may increase the understanding of mindfulness and countertransference as a therapeutic tool, and 3) this research can contribute to the literature and social work profession by increasing the knowledge about the therapeutic relationship and clinical process that will be beneficial to clients and clinicians.

Costs

The costs for the study participants include travel to an interview site determined collaboratively by the researcher and the participant. Costs also include time devoted to two interviews and a review of transcription summary data for clarification and feedback.

Possible Risks and/or Side Effects

Your safety and comfort are important. There is minimal risk associated with participation in this study. However, there is a possibility that you may experience some psychological discomfort or negative emotional responses when reflecting on or discussing experiences with mindfulness practice and countertransference. If you decide you are no longer comfortable participating in this study, please remember you have the right to withdraw (see the section below “Right to Refuse or Withdraw”).

Privacy and Confidentiality

Your participation in this study will be kept private and confidential, and all identifying information will be protected. In addition, the records of this study will be strictly confidential. The e-mail address and computer from which you received your participant information is password protected and accessible only by this researcher. Your contact information will not be connected with any other information you provide during the course of this study. Additionally, your contact information will be immediately deleted upon termination of the data collection phase of this study.

All research materials, including recordings, transcriptions, analyses, and consent/assent documents, will be stored in a secure location for five years, according to federal regulations. In the event that materials are needed beyond this period, they will be kept secure until no longer needed and then destroyed. All electronically stored data will be password protected during the storage period. We will not include any information in any

report we may publish that would allow us to identify you.

Subject Assurances

By signing this consent form, you agree to participate in this study. You have not given up any of your rights or released this institution from responsibility for carelessness.

You may cancel your consent and refuse to continue in this study at any time without any loss of benefits (including access to services) to which you are otherwise entitled. Furthermore, other than the initial research recruitment email/information, any interaction regarding this study will occur strictly between you and the researcher and will not be shared with anyone.

You have the right not to answer any single question and withdraw from further participation. If you choose to withdraw, you may simply stop your participation and will not receive any more information regarding this study. You understand that you must notify the researcher of the decision to withdraw by email or phone as soon as the decision is made to withdraw to ensure that you no longer receive any additional information from the researcher.

Right to Ask Questions and Report Concerns

You have the right to ask questions about this research study and to have those questions answered by me before, during, or after the research. If you have any further questions about the study, at any time, feel free to contact me, Mary Brooks Ablett, at 404-3879310; mablett@icsw.edu or Dr. Denise Duval Tsioles at 773-880-1485; dduval@icsw.edu.

If you would like a summary of the study results, one will be sent to you once the study is completed.

If you have any questions about your rights as a research subject, you may contact Dr. John Ridings, Chair of the Institutional Review Board; the Institute for Clinical Social Work; At St. Augustine College, 1345 W. Argyle St., Chicago, IL 60640; (773)9356500.; irbchair@icsw.edu.

Signatures For the Participant

I have read this consent form, and I agree to take part in this study as it is explained in this consent form:

Participant Name (please print): ___________________________________

Participant Signature: Date:

1. Would you like a summary of the results of this study?

Yes: ____

No: ____ For the Primary Researcher

I certify that I have explained the research to _________________________ and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward.

Researcher Name (please print): ___________________________________

Researcher Signature: __________________________________________

Date:

Appendix E

Demographic Questionnaire

Demographic Questionnaire

Please answer the following questions about yourself.

1. How old are you? ______

2. What is your gender?

o Female

o Male

o I describe myself in a different way

3. With what ethnic/racial identity do you identify?

o African American or Black

o Asian American or Asian

o European American or White

o Hispanic/Latino

o Multiethnic or Multiracial

o Native American

o Pacific Islands American or Pacific Islander

o I describe myself in a different way

4. What is the highest level of education you have achieved?

o Middle school

o High school

o High school equivalent (GED)

o Some college o College degree

o Graduate degree

5. What best describes your average mindfulness meditation practice over the last month?

o No mindfulness meditation experience/no current mindfulness meditation experience

o Less than once per week

o Once per week

o 2 to 6 days/week

o Daily

6. What is your current theoretical orientation?

o Psychodynamic

o Cognitive/Behavioral

o Humanistic

o Integrative

7. How many clinical hours of direct service (i.e., in-person or telehealth) do you work per week?

Appendix F

Interview Guide

Interview Questions:

Overview of Mindfulness Practice and Clinical Practice

 Tell me about your training and experience with mindfulness and how you use it in your personal and professional life.

o How do you conceptualize mindfulness?

o Tell me about your current mindfulness practice.

o Describe any feelings that may come up as you explain your practice to me.

 How many months or years have you had a mindfulness practice?

o Describe the frequency and details of your mindfulness practice.

 Do you practice mindfulness in-between clients? While in session? Immediately before a session?

 How would you describe your clinical orientation?

The relationship between mindfulness and countertransference

There have been many modifications to the definition of CT over the years. For the purpose of this research study, countertransference is defined as therapists’ idiosyncratic reactions (broadly defined as sensory, affective, somatic, cognitive, and behavioral) to clients that are based primarily on the therapists’ emotional conflicts, vulnerabilities, biases, or difficulties (e.g., cognitive-biases, personal narratives, or interpersonal relational patterns). These responses can be conscious or unconscious (e.g., implicit or explicit). Therapy events can trigger these responses, patient characteristics, or other aspects of the therapeutic situation (e.g., termination), but not by extratherapy factors.

 Would you agree with this definition?

o If no, please explain your understanding of countertransference.

 Describe how mindfulness practice may influence your understanding of responses to client countertransference experiences.

 Please reflect on your practice of mindfulness in relationship to CT

 Please reflect on your practice of mindfulness in the therapeutic relationship.

 Are there any adverse effects you experience with mindfulness practice within countertransference?

 Do you experience any positive effects with mindfulness practice and your CT experience?

 If you were trained in MBSR, is there any one aspect of this curriculum that you find most helpful or practice most frequently in your CT responses in therapy?

Research Subquestions:

6. How do psychotherapists, who acknowledge using mindfulness practices, use these practices professionally?

7. How do psychotherapists who use mindfulness relate to countertransference responses?

8. How might a mindfulness practice affect the therapeutic process with a client?

9. How do therapists who use mindfulness practices conceptualize the phenomenon of countertransference?

10. How can mindfulness practice inform psychodynamic thinking?

Appendix G

Demographic Information

Table 3: Demographic Information

Appendix H

Thematic Coding of Analysis (Participant 1)

Descriptive Frequency / Importance

Linguistic / Key Words

Thematic Coding of Analysis (Participant 1)

Conceptual Comments

Emergent Themes

Subordinate Themes

anxiety "jacked up" "bring mindfulness to anxiety" seeking alleviation of suffering - fantasies about the world should be different

Mindfulness

Training and Practice

Mindfulness

Training and Practice

correctly "I never thought I was doing it correctly" nonjudgment

crying "I never forget the last day of the course, I started crying because I didn't feel better"

[laughs]

difficult feelings expectations It's not about eliminating difficult feelings". It's about equanimity"

acceptance of the different parts of her- feelings states

embodiment struggle, chronic pain, aversion

pulling away from discomfort

nonjudgmental exploration of self

gentle and accepting relationship towards "parts" of a person that were negatively perceived before.

avoidance of pain and suffering defensive response

motivation for

MBSR "helter skelter"lacking something wishing political situation in our country was different and very upset about the "political situation"

alleviation of suffering seeking comfort

internal observer

Descriptive Frequency / Importance

Linguistic / Key Words

anxiety' high anxiety lawyer

Conceptual Comments

Emergent Themes

Subordinate Themes

She mentions being a lawyer for twenty years before pursuing a graduate degree in counseling.

lawyer "non woo-woo" prescriptive element to MB and population served "lawyers don't like woo-woo".

power

"empowering and power to choose"

transitional space

attention to selfknowing the self

goodness of fit attention to the therapeutic relationship

we have choices in how we respond regulatory effect

experiential component to therapy

reactive versus responsive choice feeling in control -mastery space between intersubjectivity

mind/body "amygdala hijack" She mentions how the brain is hijacked by emotions and using neuroscience to help her clients understand their emotional responses to stress and anxiety.

energy

"aliveness" Positive energy is felt makes the shift easily to the emotions felt in her body.

identification with population- MB is a practice and a way of life.

Belief structure

grief and loss

complicated relationship with mother

She experiences strong maternal feelings towards certain clients (young females).

manifestation of MB in her psychological beingthoughts and feelings

attention to the relationship to self

short-lived identification knowing the self and vulnerabilities

countertransference "strong maternal instinct"

She understands her maternal "pulls" towards certain clients

soft spots knowing the self

Descriptive Frequency / Importance

Linguistic / Key Words Conceptual Comments

CT "quit biting your nails"

Showing of compassion and understanding of vulnerability

maternal feeling "grateful" She explains response to CT and the importance of the relationship in providing an interpretation to client.

empathy trauma and neglect

She notes the impact of childhood neglect and trauma and how it impacts an individual

Emergent Themes Subordinate Themes

manifestation of MB in her psychological beingthoughts and feelings

"good enough mother"

strong working alliance mutuality - attention to the therapy relationship

tension and challenge

"grounding"

activated breath and awareness

She wants to be more proactive with grounding herself before certain clients

"Me being reactive means me not being mindful".

She brings the importance of awareness in MB approach.

diagnostic material in clinical setting

acceptance of vulnerabilities; insight oriented

learning to respond differently to anxiety and stress; acceptance of the present moment.

journey "fellow travelers" inclusionary statement reducing authoritative stance in clinical practice joining the clientmutuality

awareness "cognizant" being in touch with her feelings and thoughts internal observer skills transformation element "quieting the inner critic" "biggest gift of mindfulness to me"

She wholeheartedly recognizes the benefits of MB and wants to share with others.

a way of life and practice in every day transformative

Descriptive Frequency / Importance

Linguistic / Key Words Conceptual Comments

Emergent Themes Subordinate Themes

love and kindness empathy, curiosity, compassion

elements of MB practice -living the practice in her life both personally and professionally

fostering of MB attitude compassion towards self and others anxiety

"sometimes I don't feel like meditating" It's stupid. Why would I not want to meditate?" I remember Stephanie Swann telling me one time and I wrote it down: "No matter what I do, things are still the way they are".

MB practice space

"It doesn't change the fact that the Supreme Court overruled Row you know, like, it doesn't change that. Like it doesn't mean I should be passive, but it also me being activated isn't going to make a difference".

learning to cope with uncertainty grief and loss

Repeatedly speaks to the space MB brings to her level of awareness and responses to situations in clinical practice.

space between intersubjectivitythirdness

References

Alase, A. (2017). The interpretative phenomenological analysis: A guide to a good qualitative research approach. International Journal of Education and Literacy Studies, 5(2), 9–19.

Arnd-Caddigan, M. (2013). Imagined conversations and negative countertransference. Journal of Psychotherapy Integration, 23(2), 146–157.

Ashworth, P., & Lucas, U. (2000). Achieving empathy and engagement: A practical approach to the design, conduct, and reporting of phenomenographic research. Studies in higher education, 25(3), 295–308.

Baer, R. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125–143.

Baer, A. (2004). Wounded healers and relational experts: A grounded theory of experienced therapists’ management use of countertransference [Unpublished doctoral dissertation]. Penn State University.

Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13(1), 27–45.

Barrett, L. F., Mesquite, B., Ochsner, K. N. & Gross, J. J. (2007). The experience of emotion. Annual Review of Psychology, 58, 373.

Barsness, R. E. (2018). Core competencies of relational psychoanalysis: A guide to practice, study, and research. Routledge.

Benjamin, J. (1988). The bonds of love: Psychoanalysis, feminism, and the problem with domination. Pantheon.

Benjamin, J. (1990). An outline of intersubjectivity: The development of recognition. Psychoanalytic Psychology: The Official Journal of the Division of Psychoanalysis, American Psychological Association, Division 39, 7(Suppl), 33–46.

Benjamin, J. (2004). Beyond doer and done to: An intersubjective view of thirdness. Psychoanalytic Quarterly, 73(1), 5-46.

Berzoff, J. (Ed.). (2011). Falling through the cracks: Psychodynamic practice with vulnerable populations. Columbia University Press.

Berzoff, J., Flanagan, L. M., & Hertz, P. (2016). Inside out and outside in: Psychodynamic clinical theory and psychopathology in contemporary multicultural contexts (4th ed.).

Rowan & Littlefield.

Betan, E., Heim, A. K., Conklin, C. Z., & Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: An empirical investigation. American Journal of Psychiatry, 162(5), 890–898.

Betan, E., & Westen, D. (2009). Countertransference and personality pathology. Development of clinical application of the Countertransference Questionnaire. In R.A. Levy & J. S. Ablon (Eds). Handbook of evidence-based psychodynamic psychology. Bridging the gap between science and practice (pp. 179–198). Humana Press.

Bhola, P., & Mehrotra, K. (2021). Associations between countertransference reactions towards clients with borderline personality disorder and therapist experience levels and mentalization ability. Trends Psychiatric Psychotherapy, 43(2), 116–125.

Biggerstaff, D., & Thompson, A. R. (2008). Interpretative phenomenological analysis (IPA): A qualitative methodology of choice in healthcare research.

Bion, W. R. (1963). Elements of psychoanalysis. Karnac.

Bion, W. R. (1967). Notes on memory and desire. Classics in psychoanalytic technique, 259260.

Bloom, E. P. (2012). Mindfulness meditation, and acceptance: The lived experience of psychotherapist practitioners [Doctoral dissertation]. The Chicago School of Professional Psychology.

Bloomberg, L. D., & Volpe, M. (2019). Completing your qualitative dissertation: A road map from beginning to end. Sage.

Blum, M. C. (2015). Embodied mirroring: A relational, body-body technique promoting movement in therapy. Journal of Psychotherapy Integration, 25(2), 115.

Bonner, K. M. (2001). Reflexivity and interpretive sociology: The case of analysis and problem of nihilism. Human Studies, 24(4), 267–292.

Bourke, M. E., & Grenyer, B. F. (2010). Psychotherapists’ response to borderline personality disorder: A core conflictual relationship theme analysis. Psychotherapy Research 20(6), 680–691.

Brody, F., & Farber, B. (1996). The effects of therapist experience and client diagnosis on countertransference. Psychotherapy, 33(3), 372–380.

Brown, K. W., & Cordon, S. (2009). Toward a phenomenology of mindfulness: Subjective experience and emotional correlates. In Clinical handbook of mindfulness (pp. 59–81). Springer.

Brown, K. W., & Ryan, R. M. (2004). The benefits of being present and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), 822–848.

Brown, K. W., Ryan, R. M., & Creswell, J. D. (2007). Addressing fundamental questions about mindfulness. Psychological Inquiry, 18(4), 272–281.

Bruce, N. G., Mahber, R., Shapiro, S. L., & Constantino, M. K. (2010). Psychotherapist mindfulness and the psychotherapy process. Psychotherapy, Theory, Research, Training, 47(1), 83–97

Burke, T., & Brown, B. (2022). You are your best thing: Vulnerability, shame resilience, and the black experience. Random House.

Cartwright, C., & Read, J. (2011). An exploratory investigation of psychologists’ responses for considering “objective countertransference.” New Zealand Journal of Psychology, 40(1), 46–54.

Casement, P. J. (1985). On Learning from the client. Tavistock.

Chang, V. Y., Palesh, O., Caldwell, R., Glasgow, H., Abramson, M. Luskin, F. & Koopman, C. (2004). The effects of a mindfulness-based stress reduction program on stress, mindfulness, self-efficacy, and positive states of mind. Stress and Health: Journal of the International Society for the Investigation of Stress, 20(3), 141–147.

Childs, D. (2007). Mindfulness and the psychology of presence. Psychology and Psychotherapy: Theory, Research and Practice, 80(3), 367-376.

Christensen, A., & Rudnick, S. (1999). A glimpse of Zen practice within the realm of countertransference. American Journal of Psychoanalysis, 59(1), 59–69.

Chused, J. (1991). The evocative power of enactments. Journal of American Psychoanalytic Association, 39, 615–640.

Chused, J. (1997). Discussion of “Observing-participation, mutual enactment, and the new classical models” by Irwin Hirsch, Ph.D. Contemporary Psychoanalysis, 33, 263–277.

Colli, A., & Ferri, M. (2015). Client personality and therapist countertransference. Current Opinion Psychiatry, 28, 46–56.

Cooper, P. C. (1999). Buddhist meditation and countertransference: A case study. American Journal of Psychoanalysis, 59(1), 71–85.

Cozolino, L. (2017). The neuroscience of psychotherapy: Healing the social brain. Norton & Company.

Creswell, J. W. (2003). Research design: Qualitative, quantitative, and mixed methods approaches. Sage.

Creswell, J. W. (2013). Qualitative inquiry and research design choosing among five approaches (3rd ed.). Sage.

Cushman, P. (1995). Constructing the self, constructing America: A cultural history of psychotherapy. Da Capo Press.

Cutler, R. L. (1958). Countertransference effects in psychotherapy. Journal of Consulting Psychology, 22, 349–356.

Dahl, H.S. J., Rossberg, J. I., Bogwald, K. P., Gabbard, G. O., & Hoglend, P. A. (2012). Countertransference feelings in one year of individual therapy: An evaluation of the factor structure in the Feeling Word Checklist-58. Psychotherapy Research 22(1), 12–25.

Davis, D. (2011). Relations among medication experience, mindfulness, differentiation of self, and countertransference management [Unpublished doctoral dissertation]. Pennsylvania State University.

Davis, D. M., & Hayes, J. A. (2011). What are the benefits of mindfulness? A practice review of psychotherapy-related research. Psychotherapy, 48, 198–208.

Denzin, H. (2002). Social work in the seventh moment. Qualitative Social Work, 1, 25–38.

Denzin, K. N., & Lincoln, S. Y. (2003). Introduction: The discipline and practice of qualitative research. In H. K. Denizen & Y. S. Lincoln (Eds.), Qualitative research (3rd ed., pp. 1–32). Sage.

DeRubeis, R. J., Hollon, S. D., & Amsterdam, J. D., Shelton, R., C., Young, R. R., Salomon, R. M. & Gallop, R. (2005). Cognitive therapy vs. medications in the treatment of moderate to severe depression. Archives of general psychiatry, 62(4), 409–416.

Didonna, F. (2009). In F. Didonna (Ed.), Clinical handbook of mindfulness (Vol. 18). Springer.

Didonna, F. & Gonzalez, Y. R. (2009). Mindfulness and feelings of emptiness. In Clinical handbook of mindfulness (125-151). Springer.

Dosamantes-Beaudry, I. (2007). Somatic transference and countertransference in psychoanalytic intersubjective dance/movement therapy. American Journal of Dance Therapy, 29(2), 73–89.

Eatough, V., & Smith, J. A. (2017). Interpretive phenomenological analysis. The Sage handbook of qualitative research in psychology, 193-209.

Ekman, P., & Friesen, W. V. (2003). Unmasking the face: A guide to recognizing emotions from facial cues,

Elliott, T. E., Schwartz, J. A. J., & Rufino, K. A. (2018). Negative reactions of therapists working with suicidal clients: A CBT/mindfulness perspective on “countertransference.”

Journal of Cognitive Therapy, 11, 80–99.

Epstein, R., Quill, T. Krasner, M., & McDonald, S. (2007). A curriculum of mindful practice for student and residents faculty manual. University of Rochester, School of Medicine and Dentistry.

Fade, S. (2004). Using interpretative phenomenological analysis for public health nutrition and dietetic research: A practice guide. Proceedings of the Nutrition Society, 63(4), 647–653.

Fatter, D. M., & Hayes, J. A. (2013). What facilitates countertransference management? The roles of therapist meditation, mindfulness, and self-differentiation. Psychotherapy Research, 23(5), 502–513.

Fauth, J. (2006). Toward more (and better) countertransference research. Psychotherapy, Theory, Research, Practice, Training, 1, 16–31.

Fawzy, F. L., Fawzy, N. W., & Hyun, C. S. (1993). Malignant melanoma: Effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival

6 years later. Archives of General Psychiatry, 50(9), 681–689.

Federici-Nebbiosi, S., & Nebbiosi, G. (2012). The experience of another body on our body in psychoanalysis: Commentary on paper by Jon Sletvold. Psychoanalytic Dialogues, 22, 430-436.

Fielder, F. E. (1951). A method of objective quantification of certain countertransference attitudes. Journal of Clinical Psychology, 7, 101–107.

Fluckiger, C., Del Re, A. C., Wampold, B. E., Znoj, H., Caspar, F., & Jorg, U. (2012). Valuing clients’ perspective and the effects on the therapeutic alliance: A randomized controlled study of adjunctive instruction. Journal of Counseling Psychology, 59(1), 18–26.

Foshage, J. (1995). Countertransference as the analyst’s experience of the analysand: Influence of listening perspectives. Psychoanalytic Psychology, 12(3), 375–391.

Foshage, J. L. (2011). The use and impact of the analyst’s subjectivity with empathic and other listening/experiencing perspectives. The Psychoanalytic Quarterly, 80(1), 139–160.

Freud, S. (1909). Analysis of a phobia in a five-year-old boy. Standard edition, 10(3).

Freud, S. (1959). Future prospects of psychoanalytic psychology. In J. Strachey (Ed., Trans.). The standard edition of the complete works of Sigmund Freud. Vol. 11, 139-151. Hogarth Press. (Original work published 1910)

Friedman, S. M., & Gelso, C. J. (2000). The development of the inventory of countertransference behavior. Journal of Clinical Psychology, 26(9), 1221–1235.

Fulton, P. R. (2005). Mindfulness as clinical training. In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 55–72).

Gabbard, G. O. (1993). An overview of countertransference with borderline clients. Journal of Psychotherapy Practice and Research, 2, 7–18.

Gabbard, G. O. (1995). Countertransference: The emerging common ground. International Journal of Psychoanalysis, 76, 475–485.

Gabbard, G. O. (2001). A contemporary psychoanalytic model of countertransference. Journal of Clinical Psychology, 57, 983–991.

Gabbard, G. O., & Wilkinson, S. M. (2000). Management of countertransference with borderline clients. Rowan & Littlefield.

Galintino, M. L., Baime, M., Maguire, M., Szapary, P. O., & Farrar, J. T. (2005). Association of psychological and physiological measures of stress in healthcare professionals during an 8-week mindfulness meditation program. Mindfulness in practice. Journal of the International Society for the Investigation of Stress, 21(4), 255–261.

Garland, E. L. (2011). Trait mindfulness predicts attentional and autonomic regulation of alcohol cue-reactivity. Journal of Psychophysiology, 25(4), 180–189.

Geller, S. M. & Greenberg, L.S. (2012). Therapeutic presence: A mindful approach to effective therapy. American Psychological Association.

Gelso, C. J. (2014). A tripartite model of therapeutic relationship: Theory, research, and practice. Psychotherapy Research, 24, 117–131.

Gelso, C. J., & Carter, J. A. (1994). Components of the psychotherapy relationship: Their interaction and unfolding during treatment. Journal of Counseling Psychology, 41(3), 296–306.

Gelso, C. J., Fassinger, R. E., Gomes, M. J., & Latts, M. G. (1995). Countertransference reactions to lesbian clients: The role of homophobia, counselor gender, and countertransference management. Journal of Counseling Psychology, 42(3), 356.

Gelso, C. J., & Hayes, J. A. (1998). The psychotherapy relationship: Theory, research, and practice. Wiley.

Gelso, C. J., & Hayes, J. A. (2001). Clinical implications of research on countertransference: Science informing practice. Journal of Clinical Psychology. 57(8), 1041–1051.

Gelso, C. J., & Hayes, J. A. (2002). The management of countertransference. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to clients (pp. 267–283). Oxford University Press.

Gelso, C. J., & Hayes, J.A. (2007). Countertransference and the inner world of the psychotherapist: Perils and possibilities. Erlbaum.

Gelso, C. J., Hill, C. E., Mohr, J. J., Rochen, A. B., & Zack, J. (1999). Describing the face of transference: Psychodynamic therapists‘ recollections about transference in cases of successful long-term therapy. Journal of Counseling Psychology, 46(2), 257–267.

Gelso, C. J., & Johnson, D. H. (1983). In C. J. Gelso & D. H. Johnson (Eds.), Explorations in time-limited counseling and psychology. Teacher’s College.

Gelso, C. J., Latts, M., Gomez, M., & Fassinger, R. E. (2002). Countertransference management and therapy outcome. Journal of Clinical Psychology, 58, 861–867.

Gemignani, M. (2011). Between researcher and researched: An introduction to countertransference in qualitative inquiry. Qualitative Inquiry, 17(8), 701–708.

Germer, C. K., Siegel, R. D., & Fulton, P. R. (2013). Mindfulness and psychotherapy (2nd ed.) Guilford Press.

Gilbert, D., & Waltz, J. (2010). Mindfulness and health behaviors. Mindfulness, 1, 227–234.

Grepmair, L., Mitterlehner, F., Loew, T., Bachler, E., Rother, W., & Nickel, M. (2007). Promoting mindfulness in psychotherapists in training influences the treatment results of their clients: A randomized, double-blind, controlled study. Psychotherapy and psychosomatics, 76(6), 332–338.

Grupe, D. W. & Nitschke, J. B. (2013). Uncertainty and anticipation in anxiety: an integrated neurobiological and psychological perspective. Nature Reviews Neuroscience, 17(7), 488–501.

Guba, E. G. (1981). Criteria for assessing the trustworthiness of naturalistic inquiries. Educational Technology Research and Development, 29, 75–91.

Guba, E. G., & Lincoln, Y. S. (1994). Competing paradigms in qualitative research. In N. K. D. Y. S. Lincoln (Ed.), Handbook of qualitative research (pp. 105–117). Sage.

Guba, E. G., & Lincoln, Y. S. (2005). Paradigmatic controversies and emerging confluences. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (3rd ed., pp. 191–216). Sage.

Guest, J. D. (2019). Managing negative transference utilizing an integrated counselor mindfulness training for counselors working with children exhibiting externalized

behaviors. [Doctoral dissertation, University of South Carolina]. Scholar Commons.

http://scholarcommons.sc.edu/etd.5322.

Ham, C. C., LeMasson, K. D. S., & Hayes, J. A. (2013). The use of self-disclosure: Lived experiences of recovering substance abuse counselors. Alcoholism Treatment Quarterly, 31(3), 348–374.

Hayes, J. A. (1995). Countertransference in group psychotherapy: Waking a sleeping dog. International Journal of Group Therapy, 45(4), 521–535.

Hayes, J. A. (2002). Acceptance, mindfulness, and science. Clinical Psychology: Science and Practice, 9, 101–106.

Hayes, J. A. (2004). The inner world of the psychotherapist: A program of research on countertransference. Psychotherapy Research, 14(1), 21–36.

Hayes, S. C., & Gelso, C. J. (1993). Male counselors’ discomfort with gay and HIV-infected clients. Journal of Counseling Psychology, 40, 86–93.

Hayes, S. C., & Gelso, C. J. (2001). Clinical implications of research on countertransference: Science informing practice. Journal of Clinical Psychology, 57(8), 1041–1051.

Hayes, J. A., Gelso, C.J., Goldberg, S., & Kivilighan, D. M. (2018). Countertransference management and effective psychotherapy: Meta-analytic findings. Psychotherapy, 55(4), 496–507.

Hayes, J. A., Gelso, C. J., & Hummel, A. M. (2011). Managing countertransference. Psychotherapy, 48, 88–97.

Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes, and outcomes. Behavioral Research and Therapy, 44(1), 1–25.

Hayes, J. A., McCracken, J. E., McClanahan, M. K., & Hill, C. E. (1998). Therapist perspectives on countertransference: Qualitative data in search for a theory. Journal of Counseling Psychology, 45(4), 468–482.

Hayes, J. A., Nelson, D. L. B. & Fauth, J. (2015). Countertransference in successful and unsuccessful cases of psychotherapy. Psychotherapy, 52(1), 127–133.

Hayes, J. A., Riker, J. R., & Ingram, K. M. (1997). Countertransference behavior and management in brief counseling: A field study. Psychotherapy Research, 7(2), 145–153.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change. Guilford press

Hayes, J. A., Yeh, Y., & Eisenberg, A. (2007). Good grief and not-so-good-grief: Countertransference in bereavement therapy. Journal of Clinical Psychology, 63, 345–355.

Heimann, P. (1950). On countertransference. International Journal of Psychoanalysis, 31, 81–84.

Hill, D. (2015). Affect regulation theory: A clinical model. W. W. Norton.

Hill, C. E., Nutt-Williams, E., Heaton, K. J., Thompson, B. J., & Rhodes, R. H. (1996). Journal of Counseling Psychology, 43(2), 207–217

Hill, C. E., Thompson, B. J., & Williams, E. N. (1997). A guide to conducting consensual qualitative research. The Counseling Psychologist, 25, 517–572.

Holzel, B., Lazar, S., Gard, T., Schuman-Oliver, Z., Vago, D., & Ott, U. (2011). How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspectives on Psychological Stress, 6(6), 537–559.

http://www.doi.org/10.1177/1745691611419671.

Howell, K. K. (2013). An introduction to the philosophy of methodology. Sage.

Kabat-Zinn, J. (1982). An outclient program in behavioral medicine for chronic pain clients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, 4, 33–47.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your mind and body to face stress, pain, and illness. Revised and updated edition. Bantam.

Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10, 144–156.

Kabat-Zinn, J. (2005). Coming to our senses: Healing ourselves and the world through mindfulness. Hyperion.

Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. Bantam

Kabat-Zinn, J., Lipworth, L., & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8(2), 163–90.

Kachele, H., Erhardt, I., Seybert, C., & Buchholz, M. B. (2015). Countertransference as object of empirical research? International Forum of Psychoanalysis, 24(2), 96–108.

Katz R. S., & Johnson, T. A. (2006). When professionals week. Routledge.

Kholooci, H. (2007). An examination of the relationship between countertransference and mindfulness and its potential role in limiting therapist abuse [Doctoral dissertation, California School of Professional Psychology].

Kiesler, D. J. (1996). Contemporary interpersonal theory and research: Personality psychopathology and psychotherapy. Wiley.

Kiesler, D. J. (2001). Therapist countertransference: In search of common themes and empirical referents. Journal of Clinical Psychology, 57(8), 1053–1063.

Klein, M. (1946). Notes on some schizoid mechanisms. Internal Journal of Psychoanalysis, 27, 99–110.

Kornfield, J. (2008). The wise heart: A guide to the universal teachings of Buddhist psychology. Bantam.

Kostanski, M., & Hassed, C. (2008). Mindfulness as a concept and a process. Australian Psychologist, 43, 15–21. http://www.doi.org/10.1080/ 00050060701593942

Larkin, M., Shaw, R., & Flowers, P. (2019). Multiperspectival designs and processes in interpretative phenomenological analysis research. Qualitative Research in Psychology, 16(2), 182–198.

LaRoche, M. J. (1999). Culture, transference, and countertransference among Latinos. Psychotherapy, 36(4), 398–397.

Latts, M. G., & Gelso, C. J. (1995). Countertransference behavior and management with survivors of sexual assault. Psychotherapy, 32, 405–415.

Leary, K. (2000). Racial enactments in dynamic treatment. Psychoanalytic Dialogues, 10(4), 639–653.

Levenson, H. (1995). Time-limited dynamic psychotherapy. Basic.

Ligiero, D. P. & Gelso, C. J. (2002). Countertransference, attachment, and the working alliance: The therapist’s contribution. Psychotherapy: Theory, Research, Training, 39(1), 3–11.

Liebman, R. E., & Burnette, M. (2013). It’s not you, it’s me. An examination of clinician-and client-level influences on countertransference toward borderline personality disorder. American Journal of Orthopsychiatry, 83(1), 115–125.

Lincoln, Y., Lynam, S., & Guba, E. (2011). Paradigmatic controversies, contradictions, and emerging confluences, revisited. In N. Denzin & Lincoln (Eds.), The Sage handbook of qualitative research (4th ed., 97–128). Sage.

Linehan, M. M. (1993). Skills training manual for treatment borderline personality disorder. Guilford Press.

Lingiardi, V., Tanzilli, A., & Colli, A. (2015). Does the severity of psychopathological symptoms mediate the relationship between client personality and response?

Psychotherapy, Theory, Research, & Practice, 52, 228–237.

Linn-Walton, R., & Pardasani, J. (2014). Dislikeable clients or countertransference: A clinician’s perspective. The Clinical Supervisor, 33, 100–121.

Little, M. (1951). Countertransference and the clients’ response to it. International Journal of Psychoanalysis, 32, 32–40.

Loffler-Staska, H., Datz, F., Preusche, I., Bukowski, X., & Siedman, C. (2017). Empathy in psychoanalysis and medical education – What can we learn from each other? BMC Medical Education, 17, 74.

Lowenthal, D. (2018). Countertransference, phenomenology, and research: Was Freud right?

European Journal of Psychotherapy & Counseling, 20(4), 365–372.

Malcolm, J. (1980). Psychoanalysis: The impossible profession. Vintage.

Maroda, K. J. (1999). Seduction, surrender, and transformation: Emotional engagement in the analytic process. Analytic Press.

Maroda, K. J. (2010). Psychodynamic techniques: Working with emotion in the therapeutic relationship. Guilford Press.

McClure, B. A., & Hodge, R. W. (1987). Measuring countertransference and attitude in therapeutic relationships. Psychotherapy: Theory, Research, Practice, Training, 24(3), 325.

McDowell, J. J. (1991). Irreconcilable differences and political reality in these dark ages. Behavioral Analysis, 14(1), 29–33.

McGlinchey, E., Hitch, C., Butler, S., McCaughey, L., Berry, E., & Armour, C. (2021). Understanding the lived experiences of healthcare professionals during the COVID-19 pandemic: An interpretative phenomenological analysis. European Journal of Psychotraumatology, 12(1), 1904700.

McWilliams, N. (1994). Psychoanalytic diagnosis. Guilford Press.

Merriam, S. B. (2002). Introduction to qualitative research. Qualitative research in practice. Examples for discussion and analysis, 1(1). 1-17.

Millon, G., & Halewood, A. (2015). Mindfulness meditation and countertransference in the therapeutic relationship: A small scale exploration of therapists’ experiences using grounded theory methods. Counseling and Psychotherapy Research, 15(3), 188–196.

Mitchell, S. (1988). Relational concepts in psychoanalysis. Harvard University Press.

Mitchell, S. A. (1993). Hope and dread in psychoanalysis. Basic.

Mitchell, S. A., & Aron, L. (1999). Relational psychoanalysis: The emergence of a tradition. Analytic Press.

Moustakas, C. (1994). Phenomenological research methods. Sage.

Namono, J. (2014). The cultural influences which motivate countertransference for the collectivist-oriented clinician working with clients in the United States [Master’s thesis. Smith College, Northampton, MA]. http://scholarworks.smith.edu//theses/766

National Association of Social Workers. (2017). NASW standards for the practice of clinical social work (revised edition). National Association of Social Workers.

Navavits, L. M. (2000). Researching therapist emotions and countertransference. Cognitive and Behavioral Practice, 7(3), 322–328.

Negi, L. T. (2018). Curricular summary for CBCT. Emory University.

Noon, E. J. (2018). Interpretive phenomenological analysis: An appropriate methodology for educational research. Journal of Perspectives in Applied Academic Practice, 6(1), 75–83.

Norcross, J. C. (2001). Introduction. In search of the meaning and utility of countertransference. Journal of Clinical Psychology, 57, 981–982.

Norcross, J. C. (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to clients. Oxford University Press.

Ogden, T. H. (1982). Projective identification and psychotherapeutic technique. Jason Aaron.

Ogden, T. H. (1984). Subjects of analysis. Jason Aaron.

Ortlipp, M. (2008). Keeping and using reflective journals in qualitative research process. The Qualitative Report, 13(4), 695–705.

Orr, D. W. (1988). Transference and countertransference: A historical survey. In B. Wolstein (Ed.), Essential papers on countertransference (pp. 91–110). New York University Press.

Pally, R. (2001). A primary role for nonverbal communication in psychoanalysis. Psychoanalytic inquiry, 21(1), 71–93.

Peat, G., Rodriques, A., & Smith, J. (2019). Interpretive phenomenological analysis applied to healthcare research. Evidence Based Nursing, 22, 7–9.

Perez-Rojas, A. E., Palma, B., Bhatia, A., Jackson, J., Norwood, E., Hayes, J. A., & Gelso, C. J. (2017). The development and initial validation of the Countertransference Management Scale. Psychotherapy, 54(3), 307–319. http://www.doi.org/10.1037/pst0000126

Pietkiewicz, I., & Smith, J. A. (2012). A practical guide to using interpretative phenomenological analysis in qualitative research psychology. Counseling Psychology, 18(2), 361–369.

Polkinghorne, D. E. (1989). Phenomenological research methods. In R. S. Valle & S. Halling (Eds.), Existential phenomenological perspectives in psychology (pp. 41–60). Plenum.

Pollak, S. M. (2013). Teaching mindfulness in therapy. In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 55–72).

Popper, K. (1959). The logic of scientific discovery. Routledge.

Praska, J., Divkey, T., Grambal, A., Kamaradova, D., Mozy, P., Sigmundova, Z, Slepecky, M., & Vyskocilova, J. (2010). Transference and countertransference in cognitive behavioral therapy. Biomed Pap Med Fac University Palacky Olomouc Czech Repub, 154(3), 189–198.

Pringle, J., Drummond, J., McLafferty, E., & Hendry C. (2011). Interpretative phenomenological analysis: A discussion and critique. Nurse Researcher, 18(3), 20–24.

Purser, R. E., & Milillo, J. (2014). Mindfulness revisited. A Buddhist-based conceptualization. Journal of Management Inquiry, 24(1), 3–24.

Racker, E. (1957). The meaning and use of countertransference. The Psychoanalytic Quarterly, 26(3), 303–357.

Racker, E. (1968). Transference and countertransference. International University Press.

Ramirez, E. (2021). Zero proof: 90 nonalcoholic recipes for mindful drinking. Mariner.

Randolph, P. D., Caldera, Y. M., Tacone, A. M., & Greak, B. L. (1999). The long-term combined effects of medical treatment and a mindfulness-based behavioral program for the multidisciplinary management of chronic pain in West Texas. Pain Digest, 9, 103–112.

Rasic, D. (2010). Countertransference in child and adolescent psychiatry: A forgotten concept? Journal of Canadian Academy of Child and Adolescent Psychiatry, 19(4), 249–254.

Razzaque, R., Okoro, E., & Wood, L. (2013). Mindfulness in clinician therapeutic relationships. Mindfulness, 10, 1–5.

Reibel, D. K., Greeson, J. M., Brainard, G. C., & Rosenzweig, S. (2001). Mindfulness-based stress reduction and health related quality of life in a heterogeneous client population. General Hospital Psychiatry, 23(4), 183–192.

Rosenberg, E. W., & Hayes, J. A. (2002). Origins, consequences, and management of countertransference: A case study. Journal of Counseling Psychology, 49(2), 221–232.

Rossberg, J. I., Hoffard, A., & Friis, S. (2003). Psychiatric staff members’ emotional reactions toward clients. A psychometric evaluation for an extended version of the Feeling Word Checklist (FWC-58). Nordic Journal of Psychiatry, 57(1), 45–53.

Rossberg, J. I., Karterud, S. Pedersen, G. & Friis, S. (2010). Psychiatric symptoms and countertransference feelings: An empirical investigation. Psychiatry Research, 178(1), 191–195.

Rosenzweig, S. Reibel, D. K., Greeson, J. M., Brainard, G. C., & Hojat, M. (2003). Mindfulnessbased stress reduction lowers psychological distress in medical students. Teaching and learning in medicine, 15(2), 88–92.

Rossberg, J. I., Karterudm, S., Pedersen, G., & Friis, S. (2007). An empirical study of countertransference toward clients with personality disorders. Comprehensive Psychiatry, 48(3), 225–230.

Sampe, M. C. (2019). Therapist mindfulness and effective therapeutic relating: Exploring the mediating role of countertransference management. [Unpublished doctoral dissertation]. University of Wisconsin-Madison.

Sandler, J. (1976). Countertransference and role-responsiveness. International Review of Psychoanalysis, 3, 43–47.

Schanche, E., Vollestad, J., Visted, E., Svendsen, J. L., Osnes, B., Binder, P. E., Franer, P., & Sorensen, L. (2020). The effects of mindfulness-based cognitive therapy on risk and protective factors of depressive relapse – a randomized wait-list controlled trial. BMC Psychology, 8(1), 1–16.

Schmidt, S. (2011) Mindfulness in east and west-is it the same? In Neuroscience, consciousness, and spirituality (pp. 23–38). Springer.

Schore, A. (2012). The science of the art of psychotherapy. Norton.

Schwartz, R. C., Smith, S. D., & Chopko, B. (2007). American Journal of Psychotherapy, 61(4), 375–393.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression (2nd ed.). Guilford Press.

Shapiro, S. L. (2009). The integration of mindfulness and psychology. Journal of Clinical Psychology, 65(6), 555–560.

Shapiro, S. L., Astin, J. A., Bishop, S. R., & Cordova, M. (2005). Mindfulness-based stress reduction for health professionals: Results from a randomized trial. International journal of Stress Management, 12(2), 164–176.

Shapiro, S. L., Carlson, L. E., Astin, J.A. & Freeman, B. (2006). Mechanisms of mindfulness. Journal of Clinical Psychology, 62(3), 373–386.

Shapiro, S. L., & Carlson, L. E. (2009). The art and science of mindfulness: Integrating mindfulness into psychology and the helping professions. American Psychological Association.

Shapiro, S. L., & Carlson, L. E. (2017). The art and science of mindfulness: Integrating mindfulness into psychology and the helping professions (2nd edition). American Psychological Association.

Shapiro, S. L., Swartz, G. E., & Bonner, G. (1998). Effect of mindfulness-based stress reduction on medical and premedical students. Journal of behavioral medicine, 21(6), 581–559.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65, 98–109.

Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Educational Information, 22, 62–75.

Shinebourne, P. (2011). The theoretical underpinnings of interpretative phenomenological analysis (IPA). Existential Analysis, 22(1), 16–32.

Siegel, D. J. (2007). The mindful brain: Reflection and attunement in the cultivation of wellbeing. Norton.

Siegel, D. J. (2009). The developing mind: Toward a neurobiology of interpersonal experience. Guilford Press.

Siegel, D. J. (2010). The mindful therapist: A clinician’s guide to mindsight and neuro integration. Norton.

Siegel, D. J. (2012). The developing mind): How relationships and the brain interact to shape who we are (2nd ed.) Guilford Press.

Shedler, J. (2010). The efficacy of psychodynamic therapy. American Psychologist, 65, 98–109.

Smith, J. (2004). Reflecting on the development of interpretative phenomenological analysis and its contribution to qualitative research in psychology. Qualitative Research in Psychology, 1(1), 39–54.

Smith, J. A. (2011). Evaluating the contribution of interpretative phenomenological analysis. Health Psychology Review, 5(1), 9–27.

Smith, J., Flowers, P., & Larkin, M. (2009). Interpretive phenomenological analysis: Theory, method, and research. Sage.

Smith, J. A., & Osborn, X. (2015). Interpretative phenomenological analysis as a useful methodology for research on the lived experience of pain. British Journal of Pain, 9(1), 41–42.

Sokolowski, R. (2000). Introduction to phenomenology. Cambridge.

Southern, S. (2007). Countertransference and intersubjectivity: Golden opportunities in clinical supervision. Sexual Addiction & Compulsivity, 14(4), 279–302.

Spiegel, R. (1977). Development of Sullivan’s theory of participant observation. Contemporary Psychoanalysis, 13, 372–376.

Starks, H., & Trinidad, S. B. (2009). Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory. Qualitative Health Research, 17(10), 1372–1380.

Stern, D. B. (2003). The present moment. Psychotherapy Networker, 27(6), 52–57.

Stern, D. B. (2004). The present moment in psychotherapy and everyday life. Norton.

Stern, D. B. (2019). The infinity of the unsaid: Unformulated experience, language, and the nonverbal. Routledge.

Sullivan, H. S. (1953). The Interpersonal Theory of Psychiatry. Norton.

Surrey, J. L. (2005). Relational psychotherapy, relational mindfulness. Mindfulness and Psychotherapy, 91–110.

Symington, J. & Symington, N. (1996). The clinical thinking of Wilfred Bion. Routledge.

Tanzilli, A., Muzi, L., Ronningstam, E., & Lingiardi, V. (2017). Countertransference when working with narcissistic personality disorder: An empirical investigation. Psychotherapy, 54(2), 184–194.

Tanzilli, A., Colli, A., Del Corno, F., & Lingiardi, V. (2015). Factor structure, reliability, and validity of Therapist Response Questionnaire. Personality Disorders: Theory, Research, and Treatment. http://doi.org.1037/per0000146

Tishby, O., & Wiseman, H. (2014). Types of countertransference dynamics: An exploration of their impact on the client-therapist relationship. Psychotherapy Research, 24(3), 360–375.

Tufford, L., & Newman, P. (2010). Bracketing in qualitative research. Quantitative Social Work, 11(1), 80–96.

Tuffour, I. (2017). A critical overview of interpretative phenomenological analysis: A contemporary research approach. Journal of Healthcare Communications, 2(4), 52.

VanScoy, A., & Evenstad, S. B. (2015). Interpretative phenomenological analysis for LIS research. Journal of Documentation, 71(2), 338–357.

Van Wagoner, S. L., Gelso, C. J., Hayes, J. A., & Diemer, R. (1991). Countertransference and the reputedly excellent psychotherapist. Psychotherapy, Theory, Research, Practice, Training, 28(3), 411–421.

Vinca, M. A. (2009). Mindfulness and psychotherapy: A mixed methods investigation [Unpublished doctoral dissertation]. Pennsylvania State University, University Park, PA.

Weatherford, J., & Maitra, D., (2019). How online students approach bracketing: A survey research study. Educational Research: Theory and Practice, 30(2), 91–102.

Weiss, H. (2009). The use of mindfulness in psychodynamic and body oriented psychotherapy. Body, Movement, and Dance in Psychotherapy, 4(1), 5–16.

Westen, D. (1998). The scientific legacy of Sigmund Freud: Toward a psychodynamically informed psychological science. Psychological Bulletin, 124(3), 333–371.

Westen, D. (2002). The language of psychoanalytic discourse. Psychoanalytic Dialogues, 12(6), 857–898.

Westen, D. (2002). The political brain: The role of emotion in deciding the fate of the nation. Public Affairs.

Westra, H. A., Aviram, A., Connors, L., Kertes, A., & Ahmed, M. (2012). Therapist emotional reactions and client resistance in cognitive behavioral therapy. Psychotherapy, 49(2), 173–172.

White, R. S. (2011). Bion and mysticism: The Western tradition. American Imago, 68(2), 213240.

Winnicott, D. W. (1949). Hate in the countertransference. Journal of Psychoanalysis, 30, 69–75.

Winnicott, D. W. (1962). The theory of the parent-infant relationship-further remarks.

International Journal of Psycho-Analysis, 43, 238–239.

Winnicott, D. W. (1965). A clinical study of the effect of failure of the average expectable environment on a child’s mental functioning. International Journal of Psycho-Analysis, 46, 81–87.

Winnicott, D. W. (1975). Chapter XV. Hate in the countertransference (1947). The International Psycho-Analytic Library, 100, 194–203.

Wishnie, H.A. (2005). Working in the countertransference: Necessary entanglements. Jason Aronson.

Wolever, R. Q., & Best, J. L. (2009). Mindfulness-based approaches to eating disorders. In Clinical handbook of mindfulness (pp. 259–287) Springer.

Yalom, I. D. (2002). The gift of therapy: An open letter to a new generation of therapists and their clients. Harper Collins.

Yeh, Y., & Hayes, J. A. (2011). How does disclosing countertransference affect perceptions of the therapist and the session? Psychotherapy, 48(4), 322–329.

Zittel Conklin, C., & Westen, D. (2003). The therapist response questionnaire. Atlanta: Emory University, Departments of Psychology and Psychiatry and Behavioral Sciences.