MARIE-JOSE DHAESE AND HOLISTIC EXPRESSIVE THERAPY: A NATURALISTIC INQUIRY by Dawn Marlene Sather B.S.W., University of Northern British Columbia, 2000 PROPOSAL SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK THE UNIVERSITY OF NORTHERN BRITISH COLUMBIA April 2011 © Dawn Marlene Sather, 2011 1*1 Library and Archives Canada Bibliotheque et Archives Canada Published Heritage Branch Direction du Patrimoine de I'edition 395 Wellington Street Ottawa ON K1A 0N4 Canada 395, rue Wellington OttawaONK1A0N4 Canada Your file Votre r6f6rence ISBN: 978-0-494-75189-3 Our file Notre r6f6rence ISBN: 978-0-494-75189-3 NOTICE: AVIS: The author has granted a nonexclusive license allowing Library and Archives Canada to reproduce, publish, archive, preserve, conserve, communicate to the public by telecommunication or on the Internet, loan, distribute and sell theses worldwide, for commercial or noncommercial purposes, in microform, paper, electronic and/or any other formats. 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Conformement a la loi canadienne sur la protection de la vie privee, quelques formulaires secondaires ont ete enleves de cette these. While these forms may be included in the document page count, their removal does not represent any loss of content from the thesis. Bien que ces formulaires aient inclus dans la pagination, il n'y aura aucun contenu manquant. 1*1 Canada Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Abstract This is a naturalistic inquiry to describe a therapeutic approach called Holistic Expressive Therapy, developed by Marie-Jose Dhaese. Dhaese is renowned in the play therapy community and has been recognized by the Canadian Association of Child and Play Therapy (CACPT) as one of five leading play therapists in Canada. Dhaese's focus has been on clinical practice, supervision, and teaching at her Centre of Expressive Therapy in Parksville, British Columbia (BC), and at the Justice Institute in Burnaby, BC, Canada. The inquiry begins with a literature review of play, therapeutic play, history of play therapy, and expressive therapy to situate Holistic Expressive Therapy. Marie-Jose Dhaese was interviewed, and a thematic analysis was used to develop a case study on the principles and components of Holistic Expressive Therapy. Then four participants volunteered to be interviewed to describe the influences of Dhaese's approach on their therapeutic practice. A grounded theory method was used to analyze the data — seven categories and 14 subcategories emerged. There is a marked congruence between Dhaese's description of Holistic Expressive Therapy and the influences described by the four participants. The congruence discovered in the findings can be linked with the current literature. This naturalistic inquiry positions Holistic Expressive Therapy as a distinctive, original therapeutic approach that is grounded in theory and empirical research of insights from Dhaese's personal and professional self-healing journey. ii Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Acknowledgements I have gratitude for the many family, friends, colleagues, and thesis committee members who have supported this journey. I desire to thank my best friend Bruce Carmichael, for your support, my children Thomas, Sarah and John Mills for your love and for instilling my love of being with children, and thank you to my parents, Marlene Jean and Hans Ole Sather for your wisdom and guidance. I desire to thank my friends and colleagues who have listened, shared, and encouraged me along the way. I desire to thank my Thesis Supervisor, Dr. Glen Schmidt for his guidance and support. Dr. Schmidt is an Associate Professor, School of Social Work at the University of Northern British Columbia, Prince George; and Registered Clinical Social Worker. Dr. Schmidt serves on other provincial Boards including the BC School of Social Workers, Parent Support Services, the Canadian Mental Health Association and the National Board of the Canadian Mental Health Association. I desire to thank my thesis committee members Mrs. Joanna Pierce, Field Education Director, Assistant Professor, School of Social Work at the University of Northern British Columbia, Prince George; and Registered Social Worker. I desire to thank my thesis committee member Dr. Nancy Riedel Bowers, recognized as one of the top five play therapists in Canada by the Canadian Association of Child and Play Therapy. Dr. Riedel Bowers is an Assistant Professor of the Social Work Program at Wilfred Laurier University, Waterloo, Ontario, Registered Play Therapist and supervisor with the Canadian Association of Child and Play Therapy (CACPT) and the American Play Therapy (APT). I have gratitude to Marie-Jose Dhaese for her trust, consent and participation in the naturalistic inquiry of Holistic Expressive Therapy. I admire your integrity - the foundation of Holistic Expressive Therapy. I desire to thank the participants involved in this study. I recognize the gifts you each bring in your practice of Holistic Expressive Therapy. I have special thanks to the children for inspiring Marie-Jose Dhaese on her journey. iii Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry iv Table of Contents Abstract ii Acknowledgements iii Table of Contents iv List of Figures vii Chapter One: The Beginning 1 Statement of the Problem 2 Research Questions 3 Rationale for Studying this Topic 3 Overview 5 Chapter Two: Review of the Literature 7 Defining Play 7 History of Play 8 Neurobiology of Play 10 Defining Therapeutic Play 11 History of Play Therapy 13 Expressive Therapy 18 Holistic Therapy 19 Summary 20 Chapter Three: Research Procedures 21 Methodology 21 Naturalistic Inquiry 21 Researcher's Standpoint 23 Methods 25 Case Study 25 Ethical Considerations 26 Trustworthiness 28 Procedure Preparation of Marie-Jose Dhaese Interview 29 29 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Preparation of Participants' Interviews Data Collection Method v 29 30 Informal Conversational Interview 30 Interview with Marie-Jose Dhaese 31 Data Analysis of Marie-Jose Dhaese Interview 33 Data Analysis of Participant Interviews 34 Limitations of the Study 40 Summary 40 Chapter Four: Dhaese's Holistic Expressive Therapy — A Case Study 41 Theory: Insights to the Self-Healing Process 42 Historical Development 43 Major Components 48 Client/Therapist Relationship 49 Milieu 50 Expressive Therapies 51 Family Therapy 52 Insights: Healing from the Inside Out and the Outside In 53 Limitations of Holistic Expressive Therapy 55 Summary 55 Chapter Five: Voices of the Participants: A Grounded Theory Background 57 57 Category 1: Supervisory Relationship 58 Category 2: Holistic 60 Category 3: Way of Being 61 Category 4: Client/Therapist Relationship 62 Category 5: Milieu 64 Category 6: Expressive Therapies 66 Category 7: Cognitive Behavioural Therapy is Limiting 68 Summary Chapter Six: Linking the Findings with the Literature 68 70 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry vi Implications for Children and Youth Mental Health 77 Implications for Structural Social Work 80 Summary 81 Chapter Seven: The Ending 83 Suggestions for Further Research 83 Final Thoughts 84 References 87 Appendix A: Information Sheet and Consent Form for Marie-Jose Dhaese 95 Appendix B: Letter of Invitation to Participate in the Study 100 Appendix C: Therapist Participant Pre-Screen Interview 101 Appendix D: Information Sheet and Consent Form for Participants 102 Appendix E: Initial Tables of Analysis (Analysis 1) 107 Appendix E: Initial Tables of Analysis (Analysis 2) 108 Appendix E: Initial Tables of Analysis (Analysis 3) 109 Appendix E: Initial Tables of Analysis (Analysis 4) 110 Appendix F: Focussed Coding Ill Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry vii List of Figures Figure 1. Outline of Themes 34 Figure 2. Focused Coding (Sample Only) 36 Figure 3. Linkages Between Coded Text, Subcategories, and Categories 38 Figure 4. Categories and Subcategories 39 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Chapter One: The Beginning My introduction to Marie-Jose Dhaese and Holistic Expressive Therapy began in January 2005, when I heard that Marie-Jose was facilitating a workshop in Prince George, British Columbia (BC). It was too late to register for the workshop but I really wanted to meet Marie-Jose. Through the connection of a friend, I invited Marie-Jose to my home for dinner. I had been informed of her food allergies and sensitivities so I made some special preparations. The fireplace was roaring, and candles were glowing, all creating an inviting ambiance for my special guest. It was a dark, cold, windy, and snowy night with temperatures in the minus 40 degree range. Marie-Jose arrived and was welcomed inside, away from the bitter cold. No sooner had she stepped inside the front entrance than she covered her nose with her scarf. She peeked in the living room and commented on how lovely everything looked with the fire and candles. Apologetically, Marie-Jose shared that she could not stay because she was having a major allergic reaction to the scents in my house and her face was beginning to puff up. I felt so badly for my guest that I quickly opened the door, trying to air out the home, but it was to no avail. Marie-Jose stated that she really needed to step outside or her eyes and throat would swell to the point of closure. She was quickly ushered outside into the cold -40° temperature and we ran to my car to escape the bitter cold and wind. I started the engine and turned the heat on high to keep us warm. In my car, the air was cool and fresh, so it was not long before Marie-Jose was feeling some relief. Rather than having the foods I had prepared, my friend brought out some organic tomato soup and boiled eggs, which seemed the easiest under the circumstances. We ate, talked and laughed with the hum of the car engine in the background — thankfully, we were 1 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry warm. It was there, in my car, that I had the most memorable conversation with Marie-Jose Dhaese. She shared that she could teach me to be a holistic expressive therapist, but that it would be a good idea to get my Master's degree. My experience of meeting Marie-Jose Dhaese was significant and resonated so deeply within; however I was unable to put words to the experience. All I knew was, since that wintery evening, I was inspired to learn all that I could about Holistic Expressive Therapy. Over the years, I have participated in many of Marie-Jose Dhaese workshops and obtained play therapy supervision to further support my learning. On that cold winter evening, a seed was planted that would later grow to be the subject of my Master's thesis. I was curious to explore with other therapists how their practice has been influenced by MarieJose Dhaese's Holistic Expressive Therapy. I believe it is human nature to want to share knowledge and experiences that have had an influence on our lives. So begins this naturalistic inquiry into Marie-Jose Dhaese's Holistic Expressive Therapy. Statement of the Problem Since the 1980s, Marie-Jose Dhaese has been developing an approach to play therapy that she named Holistic Expressive Therapy. Over the last thirty years, Dhaese has been teaching experiential workshops on her approach in her private studio — the Centre for Expressive Therapy, which was first established in Vancouver, then moved to Hornby Island, and most recently to Parksville, BC, Canada. Dhaese recently celebrated thirty years of teaching at the Justice Institute in Burnaby, BC. Dhaese has been presenting workshops at the Canadian and American annual play therapy conferences. The publication of the Canadian Association of Child and Play Therapy (CACPT) Playground Magazine identified her as one of five leading specialists in the field of play therapy in Canada. Dhaese is a 2 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry certified play therapist and supervisor with the CACPT and the Association of Play Therapy (APT). She is also a certified art therapist and registered clinical counsellor. Many therapists have taken training workshops provided by Dhaese and are using a Holistic Expressive Therapy approach in their work with clients. Dhaese has focused her work on practice, supervision, and teaching. This naturalistic inquiry is intended to honor play therapy through the work of Marie-Jose Dhaese, a well-respected Canadian play therapist, and to contribute to the research literature pertaining to therapy. Research Questions I have conducted a qualitative naturalistic inquiry to describe Holistic Expressive Therapy. The research questions were designed to guide the research procedures, objectives, data collection, and analysis. The inquiry is intended to be an introduction to Holistic Expressive Therapy, and the research questions have been formulated for this purpose. The two research questions are: How does Marie-Jose Dhaese describe and define Holistic Expressive Therapy? How has Holistic Expressive Therapy influenced therapists in their practice? Rationale for Studying this Topic There are three rationales for studying this topic. The first is to contribute to the literature, an account of an approach to therapy developed by Marie-Jose Dhaese: Holistic Expressive Therapy. Marie-Jose Dhaese is recognized as a well-respected play therapist in Canada in the play therapeutic profession. The intent of this inquiry is for Holistic Expressive Therapy to become more widely known in the therapeutic community. The second rationale is that the statistics on the long term consequences of untreated children's issues are startling and any therapeutic approach that aims to reduce these statistics 3 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry is worthy of study. Authors of The Adverse Childhood Experiences (ACE) study reported that people with a history of severe child maltreatment and untreated trauma are at higher risk for engaging in detrimental health-related behaviors and consequences (Felitti, Anda, Nordernberg, Williamson, Spitz, Edwards, Koss, & Marks, 1998). Furthermore, ACE revealed that persons with a history of child maltreatment are at 4 to 12 times greater risk of developing alcoholism, depression, drug abuse, and attempting suicide; 2 to 4 times at greater risk of smoking, having at least 50 sex partners, and acquiring sexually transmitted diseases. Another important study is the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS) (Trocme, Fallon, MacLaurin, Felstiner, Black, & Tonmyr, et al, 2005). The CIS study reported that the rate of substantiated maltreatment cases in Canada increased 125 percent from 2003. The ACE study and the CIS national child health survey provide evidence of the long term consequences of untreated trauma and maltreatment (Felitti, et al., 1998), which further the need for an inquiry into therapeutic approaches to help children experiencing difficulties. The third rationale for this study is that psychotherapy and science have always remained at opposite ends of the spectrum; however, in recent years, neuroscience research has been instrumental in the merging of disciplines such as psychiatry, psychology, social work, and science (Schore, 1994, 2003a, & 2003b). The neuroscience research has given insight to how interpersonal experiences change physical, structural, and functioning patterns of the brain. Researchers have been able to use magnetic resonance imaging (MRI) and positron emission tomography (PET) to study brain structure and brain activity, and to understand how the brain is affected by environmental and social factors. This research is contributing to the movement towards a social construction of human experience. Our 4 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry understanding of human development began with an individualistic perspective and was then extended to a social perspective. Neurobiology has further shifted attention to an interpersonal perspective of human development and the importance of affective communication in relationships. "The term affect is used rather than emotion because affect is a more inclusive concept and emotion is really known as a subset of affect" (Russ, 1993, p. 7). Affective communication includes a broad range of cognitive, emotional, and behavioural expression, both verbal and nonverbal. The use of the term affect encompasses the full range (or wholeness) of human expression. More attention is being given to the non-verbal and non-interpretive stance and affective communication that is a large component of play therapy. Specifically, there has been a movement for increased recognition of the right-brain to right-brain attunement, which has formally been dismissed in psychotherapy. The research in neurobiology has given therapists new understandings of the neurobiology of play, and play therapy. In conclusion, the statistics on the long term consequences of untreated maltreatment and the cutting edge research in neurobiology contribute to the rationale for a naturalistic inquiry into Holistic Expressive Therapy. Overview This naturalistic inquiry into Holistic Expressive Therapy is comprised of seven chapters. Chapter one provided an introduction to the statement of the problem, the research questions and a rationale for studying this topic. Chapter two will provide a review of the literature, beginning with a definition of play, history of play, neurobiology of play, then a definition of therapeutic play, history of play therapy, expressive therapy followed by a summary of the chapter. Chapter three will provide information on the research procedures, 5 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry methodology and methods, followed by a description of the research procedures, data collection method, and limitations of the study. Chapter four will provide a case study of Holistic Expressive Therapy, as described by Marie-Jose Dhaese. Chapter five will provide a grounded theory on the influences of Holistic Expressive Therapy on the practice of four participants. Chapter six will link the research findings with the literature, and will explore the implications for child and youth mental health and the implications for structural social work. Chapter seven will provide a conclusion of the inquiry, along with suggestions for further research and final thoughts. Next, chapter two will provide an exploration of the literature on the definition and history of play, therapeutic play and expressive therapy. The review will assist to situate Holistic Expressive Therapy. 6 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Chapter Two: Review of the Literature Children are born with a natural propensity to grow and learn. It has long been established that play is a normal part of a child's life and development (Lieberman, 1979). Through play, children learn, discover, and form an understanding of their world. Play is a natural medium for children to express their thoughts, feelings, and emotions without the explicit use of words. The focus of this review will be on defining play, the history of play, the neurobiology of play, and defining therapeutic play, the history of play therapy, and expressive therapy. The sources of literature include journals, major books, and theses. The review will provide an overall framework that will situate Holistic Expressive Therapy. Defining Play Play is children's language; however there is no single definition of play. The definitions of play are extensive and each contributes to a broad concept of play. O'Connor (2000) claims that psychologist Erik Erikson wrote the most frequently cited definition of play. In Erikson's Childhood and Society, he states: "play, then, is a function of the ego, an attempt to synchronize the bodily and the social processes with the s e l f (1993, p. 211). Stuart Brown, psychiatrist and founder of the National Institute for Play, describes play as having the following properties: "[play] is apparently purposeless (done for its own sake), voluntary, inherent attraction, freedom from time, diminished consciousness of self, improvisational potential and continuation desire" (2010, p. 17). Furthermore, Brown states that "the critical fact that the opposite of play is not work — the opposite of play is depression" (2010, p. 126). He describes play and work as being mutually supportive. 7 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry The following section will explore the history of play, which will include various ideas of the purpose and function of play. History of Play The earliest mention of play in the literature is from the mid-18 th century. French Enlightenment thinker and philosopher, Jean-Jacques Rousseau, described the importance of play in understanding children in his book Emile, first published in 1782: subsequently burned because his ideas were so radical. "Hold childhood in reverence, and do not be in any hurry to judge it for good or ill" (Rousseau, 1974, p. 71). He proposed that childhood was separate from adulthood and that childhood had distinct life stages, a revolutionary concept for the time. Groos (1901), in the Play of Man, theorizes that play was a means by which children developed consciousness and was a preparation for adulthood. Johann Huizinga, one of the great scholars of the 20' century, renowned for his book Homo Ludens (1955), which translates as Man the Player, investigates the role of play in human civilization. Huizinga's vision of play is described in Homo Ludens: It [play] is a significant function — that is to say; there is some sense to it. In play there is something 'at play' which transcends the immediate need of life and imparts meaning to the action. All play means something. (1955, p. 446) These ideas of play tended to have origins of a philosophical and/or a sociological nature. At the turn of the last century, a new field of inquiry known as child guidance emerged to explore the guidance and psychology of the child. The ideas of play were broadened to the psychoanalytic and educational tradition (Cohen, 1996). Prominent figures in the psychoanalytic tradition included Sigmund Freud, Carl Jung, Erik Erikson, Alfred Adler, and Donald Winnicott. Each had his own ideas about the value of play with children. 8 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry The educational tradition includes Rudolf Steiner, Lev Vygotsky, Jean Piaget, and Maria Montessori, all of whom were instrumental in the acknowledgement of play in education. For example, Rudolf Steiner founded Anthroposophy and the Waldorf Education system, a humanistic approach to learning that focuses on imagination and creativity. The essentials described in Waldorf Education are qualitative in nature. First, they are concerned with the inner qualities and attributes of the teacher, to foster growth and development for children. Secondly, they are concerned with providing an environment that nourishes the senses. The physical environment must be understood in the widest sense imaginable. It includes not just what happens around the child in the material sense, but everything that occurs in their environment, everything that can be perceived by their senses that can work in the inner powers of the child from the surrounding physical space (Steiner, 2006.) Vygotsky (1978) believed play was a leading factor in cognitive development: "a child's greatest achievements are possible in play, achievements that tomorrow will become her basic level of real action and morality" (p. 97). Piaget (1962) was the first to shift the focus of play away from social and emotional development towards cognitive development. Piaget formulated a series of developmental stages of play that corresponded to the stages in his influential theory on cognitive development in children. Maria Montessori is renowned for the Montessori Method of education, which is focused on taking a humanistic approach to learning and is based on the principle of spontaneous self-development, where children develop their own skills at the pace they set. Burrhus Skinner (1938) conceptualized play as a learned response to a set of stimuli and, as such, viewed play as a problem-solving behaviour. Overall, there is agreement in the historical literature that play has an important role in healthy development. 9 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Neurobiology of Play Cutting edge research in neuroscience is providing insight into the neurobiology of play. With the aid of technology, in the development of magnetic resonance imaging (MRI) and positron emission tomography (PET), neuroscientists have been able to study brain structure and brain activity, which has furthered the understanding of how the brain is affected by environmental and social factors. Neurobiology is providing scientific evidence of the important function of play for healthy human development. Psychologists Singer and Singer (1990) have extensively studied play in children. Over the many years of observing children in free play, we have found that those who engage in make believe, what Piaget calls symbolic play, are more joyful, and smile and laugh more often than those who seem to be at odds with themselves — the children who wander aimlessly around the nursing school or daycare centre looking for something to do, who play in a preservative way with a few blocks, or who annoy their peers by teasing them or interrupting their games, (p. 64). Psychiatrist, therapist, and author Dan Siegel (1999), in The Developing Mind, describes how our interpersonal experiences shape whom we are. In his recent groundbreaking books, The Mindful Brain (2007) and Mindsight (2010), Siegel combines science and practice to develop an awareness of our experience in the present moment. This focus of attention or attunement harnesses specific social and emotional circuits in the brain. Mindful practices are a way of enhancing our physical, emotional, mental, and social wellbeing. Allan Schore (1994, 2003a, 2003b), neuroscientist, psychiatrist, and therapist has an impressive synthesis of biology, neurology, developmental studies, and attachment theory that has shed a new light on right-brain emotional and cognitive processes of therapy. Schore is known for his research on affect regulation, attachment, and psychotherapy. Schore 10 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry describes the early play episodes of mother and infant as providing a mirroring of affect, also known as attunement, which is necessary for healthy attachment. This attunement activates the right-brain-to-right-brain communication which is essential for the organization of emotional development. "Attachment is not just the establishment of security after a dysregulating experience and a stressful negative state; it is also the interactive amplification of positive affects, as in play states" (Schore, 2003a, p. 78). The dyadic relationship between mother and infant is critical to the child's future capacity to self-regulate emotions, appraise and recognize others' emotions, and to the development of the self. Schore (2003a) cites play researcher Jaak Panksepp: ...play may have direct trophic effects on neuronal and synaptic growth in many brain systems, and suggests that play serves as the adaptive role for organizing affective information in emotional circuits. A function also performed by rapid eye movement (REM) dream sleep (p. 148). Bruce Perry and Maia Szalavitz (2008) co-authored The Boy Who Was Raised by a Dog — a collection of stories from their own clinical notes of working with traumatized children. Perry, psychiatrist describes what happens to the brain when children are exposed to extreme stress and what can be done to help these children. Perry highlights that it is only when we understand how the mind works, that we can heal the spirit of the most wounded child. Defining Therapeutic Play The therapeutic use of play is termed play therapy. The Canadian Association for Child and Play Therapy (CACPT) subscribes to renowned play therapy pioneer Virginia Axline's (1950) definition of play therapy: 11 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry ...as a play experience that is therapeutic because it provides a secure relationship between the child and the adult, so that the child has the freedom and room to state himself in his own terms, exactly as he is at that moment in his own way and in his/her own time. (p. 68) There is a body of literature that explores the efficacy, processes, and therapeutic aspects of play therapy (Bratton, Ray, Rhine, & Jones, 2005; Kot, 1995; Mills, 1995; Moustakas, 1959; Ray et al., 2001; Riedel Bowers, 2001; Riedel Bowers, 2009; Schaefer, 1993). For nearly 70 years, play therapy has been used to treat children who have psychological disorders or have experienced trauma (Benedict, 2003). Successful play therapy cases have been discussed in the play therapy literature (Carroll, 2001), and most of this research has been qualitative, not quantitative. Bratton, Ray, Rhine, and Jones (2005) conducted a meta-analysis of play therapy outcomes research from 1947 to 2001. This metaanalysis combined the results of 94 individual play therapy studies to determine behavioural change in children in the treatment group versus those in the control group or comparison group. The meta-analysis concluded: "play therapy is an effective intervention for a broad range of children's problems — across both behavioural and humanistic schools of thought, in various settings, across modalities, across age and gender" (Bratton et al., 2005, p. 85). Play therapy can be used for a wide range of verbal and non verbal creative expression. Although the use of talk is considered essential for making sense of difficult experiences or traumas, for young clients talk therapy may not be possible. These clients require an approach that will help them to bring understand to their difficult experiences. Young clients' difficult experiences and disorganized sensations cannot be integrated by words alone. MRI and PET scans have shown that when people remember a traumatic event, the left frontal cortex shuts down — in particular Broca's area, the centre of speech and 12 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry language. This is often why clients cannot find the words to express their experiences. During difficult experiences or traumas, emotional states and autonomic arousal are high, involving the right hemisphere, especially the amygdale, which is the centre for detecting threat. When clients engage in creative expression or play therapy, the right hemisphere is activated, which can assist in the expression of difficult experiences. History of Play Therapy The emergence of the child guidance movement highlighted that children were not little adults and that therapeutic practices needed to be different for children than for adults. Austrian psychiatrist Freud, well known as the forefather of psychoanalytic theory, was the first to apply his theories to children in clinical practice. In 1909, the earliest published documentation of a case history of play therapy is found in The Complete Psychological Works of Sigmund Freud, Volume 10 (2001), which describes the story of Little Hans, a fiveyear-old-boy with a phobia. Donald Winnicott (2005) was also a later part of the psychoanalytic movement. In Playing and Reality (2005), Winnicott states: Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. The corollary of this is that where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play. (p. 51) Freud's daughter, Anna Freud, was a trained psychoanalyst, and she continued to develop the theory and practice of child psychoanalysis. Freud began to use play as a means of encouraging children to engage in a therapeutic alliance. Melanie Klein (1984) was an Austrian-born British psychoanalyst who was involved with the British Psychoanalytic Society along with Anna Freud. According to Kevin O'Connor in Play Therapy Primer. "One of the most important developments relative to work with children was an increasing 13 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry emphasis on the role of the environment in the development of the child's personality and, related to this, the importance of attachment" (2000, p. 12). The psychoanalytic movement is credited with providing new methods for studying child development and with the emergence of play therapy. British paediatrician Margaret Lowenfeld was a pioneer in child psychology and psychotherapy. Lowenfeld was inspired by H. G. Wells' Floor Games (1975), originally published in 1911, which described the fascination of children in creating a miniature world with small toys. In 1929 Lowenfeld introduced the wonder box — using sand in a wooden box — later to be named The Lowenfeld World Technique (1979). Lowenfeld used trays filled with sand and miniature toys for the children to build a mosaic to represent their inner world. My own endeavour in my work with children is to devise an instrument with which a child can demonstrate his own emotional and mental state without the necessary intervention of an adult, either by transference or interpretation, and which will allow a record to be made of such a demonstration. My objective is to help children produce something which will stand by itself and be independent of any theory as to its nature. (1979, p. 3) In the 1920s, Lowenfeld established a guidance clinic in London, England, which later became the Institute for Child Psychology. The Institute is currently funded by the National Health Service and continues to provide education in sand play therapy and child guidance training. Dora Kalff (1980) is known for her contribution to the therapeutic use of miniatures in the sand in her book: Sandplay: A Therapeutic Approach to the Psyche. Kalff was a neighbour of Carl Jung and studied to become a Jungian analyst. Kalff studied world 14 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry technique with Margaret Lowenfeld in London. Later, Kalff developed Jungian sand play therapy, which was distinctly different from Lowenfeld's world technique, as she explained: When I went to London in 1956 to study with Dr. Margaret Lowenfeld her World Technique, my main interest was in this technique as an ideal medium to approach the child's unconscious. However, I soon discovered that when the patient, be it a child or an adult, constructs 'worlds' in regular intervals, one can observe a process of development beginning to move, guided by the hidden unconscious totality.... [T] he analytical process progresses toward a union of opposites through the act of playing. I therefore gave this method the name "Sandplay. " (Bradway, Signell, Spare, Stewart, Stewart, Jr., & Thompson, 1981, p. viii) Play therapy theories and practices continued to develop and spread to North America. In 1942 American psychologist Carl Rogers published Counseling and Psychotherapy: New Concepts in Practice. Rogers describes the client-centered approach, which aims directly towards the greater independence and integration of the individual rather than hoping that such results will accrue if the counsellor assists in solving the problem. The individual and not the problem is the focus. The aim is not to solve one particular problem, but to assist the individual to grow, so that he can cope with the present problem, and later problems in a better — integrated fashion. (Rogers, 2008, p. 28) In 1951 Rogers published Client-centered therapy, a humanistic approach to therapy later called person-centered therapy, which stood opposite to other therapies of its time. Rogers believed that a therapist needs to fully understand the strengths of the client and accept that the client knows more about his inner psychological self than the therapist can possibly know. Rogers described three main attitudes of the therapist that are integral to 15 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry client-centered therapy: congruence, unconditional positive regard, and empathy. Clientcentered theory is the most actively used theory applied to play therapy today (2003). Virginia Axline (1947), pioneer of play therapy, was a student of Rogers. Axline received her doctorate and taught at a university level, but most of her personal history is largely unknown. Axline's non-directive approach to play therapy followed Roger's clientcentered theoretical orientation of non-judgmental listening and acceptance of clients, based on genuineness, authenticity, unconditional positive regard, and empathic understanding. Axline stated that "non-directive counselling is really more than a technique...it is a basic philosophy of human capacities, which stresses the ability within the individual to be selfdirective" (Axline, 1947, p. 26). In Play Therapy (1947), Axline identified eight basic principles to guide client-centered therapists who work with children: (1) The therapist must develop a warm, friendly relationship with the child, in which good rapport is established as soon as possible; (2) the therapist must accept the child exactly as he is; (3) the therapist establishes a feeling of permissiveness in the relationship so that the child feels free to express his feelings completely; (4) the therapist is alert to recognize the feelings the child is expressing and reflects those feelings back to him in such a manner that he gains insight into his behaviour; (5) the therapist maintains a deep respect for the child's ability to solve his own problems if given an opportunity to do so. The responsibility to make choices and to institute change is the child's; (6) the therapist does not attempt to direct the child's actions or conversation in any manner. The child leads the way; the therapist follows; (7) the therapist does not attempt to hurry the therapy along. It is a gradual process and is recognized as such by the therapist; (8) the therapist establishes only those limitations that are necessary to anchor the therapy to the world of reality and to make to the child aware of his responsibility in the relationship, (p. 73-74) 16 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry These principles continue to be the primary foundation of client-centered, nondirective play therapy, and serve to guide the therapist in therapeutic contacts with the child. Virginia Axline also published Dibs in Search for Self{\96A), which is a case study of a young boy named Dibs who was helped by her approach. Gary Landreth, an enthusiast of Axline's, is a play therapist, author, and teacher who practices within the client-centered framework. Landreth described the non-directive approach to play therapy in his book entitled Play Therapy: The Art of the Relationship (2002): Non-directive play therapy makes no effort to control or change the child and is based on the theory that the child's behaviour is at all times caused by the drive for self-realization. The objectives of nondirective play therapy are self-awareness and self-direction by the child, (p. 35) Gary Landreth has worked on promoting the development of play therapy. Landreth is Regents Professor at the University of North Texas, United States and founder of the Center for Play Therapy, the largest play therapy training program in the world. Play therapy continued to go through a period of evolution, as play therapists would learn from the work of previous theorists and therapists and would then add their own ideas to further develop theoretical models. For example, some of these approaches include: Levy (1938) release therapy, Solomon (1938) active play therapy, and Brody (1978) developmental play therapy. As well, Axline's work influenced Violet Oaklander, an American clinical psychologist who combined Gestalt Theory with play therapy, and extended the tool-kit concept as described in her book, Windows to Our Children (1988). Moustakas (1959) was a prominent play therapy researcher who furthered the profession. In 1960, British psychologists Bernard and Louise Guerney further developed a new approach 17 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry called Filial Play Therapy, a traditional client-centered play therapy approach that involves the parent and child in therapy. In 1962, psychologist Boris Levinson presented a paper on the use of his dog, Jingles, as a co-therapist with children. Levinson has published three books and numerous articles on the subject of pet-facilitatedtherapy with children. Since then, many clinicians have implemented pet-assisted therapy into the therapeutic environment. Eliana Gil (1991, 2010), a student of Landreth, integrated a non-directive and directive play therapy approach in the treatment of trauma in children. Expressive Therapy Expressive therapy is the term given to a broad range of mediums used for selfexpression in therapy. In the 1930s and 1940s, creative therapies became more widely known in psychotherapy with clients who had severe mental health problems. For many of these patients, talking was not possible and therefore other forms of expression were used in treatment. Professional associations were established and university training programs emerged at the graduate level. Expressive therapists may be found in the field of psychology, psychiatry, social work, and counselling. Under the umbrella of expressive therapies, there are three main categories: art therapy, play therapy, and sand therapy. The use of music, dance, movement, drama, poetry, creative writing, and pet-assisted therapy all fit within the realm of expressive therapies. In The Arts and Psychotherapy, McNiff (1981) stated that "action within therapy and life is rarely limited to a specific mode of expression" (p. viii). Although talking is known as the most traditional form of communication, for some people, talking may be more challenging. Expressive therapies can be both non-verbal and verbal. Children who may have limited language or who have experienced trauma may be unable to express their experience 18 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry verbally and therefore expression through art, play, and sand may be the primary form of communication. Expressive therapies have the capacity to engage all of the senses of human experience. Some people find it easier to express themselves using a medium that engages their visual, sensory, and/or tactile senses. Malchiodi writes: "expressive therapists generally do not seek to interpret individuals' drawings, movements, poems, or play, but instead try to facilitate their clients' discovery of personal meaning and understanding" (2005, p. 9). Knill, Levine, and Levine (2005) shared that all expressive therapies involve action and each has its gifts and limitations. The therapeutic use of art, play, and sand play can assist individuals to work through difficult experiences that have interfered with their ability to live a fully functioning life. Holistic Therapy "The term holistic was coined by Jan C. Smuts (1926) from the Greek holos, which means whole in the sense that a living entity is more than the sum of its parts" (Gross, 1980, p. 96). Holistic is a conceptual framework that has a historical tradition in ancient and aboriginal cultures around the world. Holistic healing and wellbeing focuses on the importance of the cognitive, emotional, physical and spiritual aspects of the person being treated. The focus is on an integrative treatment strategies aimed at treating the whole person rather than the problem or symptom. The holistic framework guides practice when applied to any number of health sciences including medicine, psychology, and psychotherapy (Serlin, 2007). 19 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Summary This literature review has defined play, provided a history of play and a brief review of the neurobiology of play. Play is essential for the cognitive, emotional, physical, and neurological development of healthy children. The therapeutic application of play, known as play therapy and expressive therapy, illustrate that play is the first language of children. The development of play therapy began as a European tradition and had elements of child psychotherapy and Humanistic psychology. The profession evolved and expanded as new theories were applied. Play therapy spread to North America and professional associations sprang up around the world. Along with the development of play therapy, expressive therapy was developed to include a wide range of creative approaches, including play, art, and sand. This review has provided a definition of play, the history of play, the neurobiology of play, and has provided a definition of therapeutic play, the history of play therapy, and expressive therapy to situate Holistic Expressive Therapy within the literature. 20 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Chapter Three: Research Procedures Methodology Naturalistic Inquiry I have chosen a naturalistic inquiry for a few reasons. First, the naturalistic approach is complementary to the development, theory, practices, and techniques of Holistic Expressive Therapy. Second, the principles, components, and techniques of Holistic Expressive Therapy are founded in part on natural and organic elements and qualities that bring healing. Third, I have a natural curiosity to explore the influences of Holistic Expressive Therapy in the practice of four therapists. Creswell states (1998): Qualitative research is an inquiry process of understanding based on distinct methodological traditions of inquiry that explore a social or human problem. The researcher builds a complex, holistic picture, analyzes words, reports detailed views of informants, and conducts the study in a natural setting, (p. 15) Lincoln and Guba (1985) argue the importance of choosing a paradigm that is congruent with our own epistemology and ontology. A naturalistic paradigm provides an open-ended framework for all of the ideas to be shared by the research participants: Paradigms represent a distillation of what we think about the world (but cannot prove). Our actions in the world, including actions that we take as inquirers, cannot occur without a reference to those paradigms: 'As we think, so do we act.' (p. 15) A paradigm is a general perspective, a way of breaking down the complexity of the world in which we live. As such, paradigms are deeply embedded in the socialization of adherents and practitioners: Paradigms tell them what is important, legitimate, and reasonable. Paradigms are also normative, telling the practitioner what to do without the necessity of long existential or epistemological considerations. 21 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry But it is this aspect of paradigms that constitutes both their strength and their weakness — their strength in that it makes action possible; their weakness is that the very reason for action is hidden in the unquestioned assumptions of the paradigm. (Patton, 1978, p. 203) Lincoln and Guba (1985) explain that beliefs or paradigms guide an inquiry. They define axioms as "the set of undemonstrated (and demonstratable) 'basic beliefs' accepted by convention or established by practice as the building blocks of some conceptual or theoretical structure or system" (1985, p. 33). I will provide a description of Lincoln and Guba's five axioms, followed by the specific application to this study. Axiom 1: The nature of reality (ontology) (p. 37): Marie-Jose Dhaese has multiple constructed realities that describe and define Holistic Expressive Therapy, deepening an understanding of what it means to be a Holistic Expressive Therapist. There are many factors that have contributed to the knowledge that has arisen out of the Dhaese and participant audio interview process, most of which are unknown and uncontrollable. Axiom 2: The relationship of knower to known (epistemology) (p. 37): During the five separate interview processes, the participants and I (the interviewer), influenced one another and this coming together has been a process in and of itself. There were separate processes happening all the time, some of which were implicit and others that were explicit. As a researcher with practice and knowledge of a play therapist, I entered into the world of the participants and Marie-Jose Dhaese. During the informal conversational interview, 1 used the skill of attunement to the interviewee. Axiom 3: The possibility of generalization (p. 38): The goal is to document the interviews of Marie-Jose Dhaese and the participants to describe Holistic Expressive Therapy and document how the approach has influenced other therapists in practice. When I analyzed 22 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry the data, the categories and subcategories that emerged were used to develop a case study and a grounded theory. Axiom 4: The possibility of causal linkages (p. 38): This study has captured the definition and description of Holistic Expressive Therapy, at a particular time and space. The approach will continue to evolve over time, just as the therapists will evolve over time, as they integrate their experiences into practice. The processes are not linear or fixed and it may be difficult to distinguish cause from effect. Axiom 5: The role of values in inquiry (axiology) (p. 38): I have chosen the object of inquiry and the method to carry out the inquiry because it has value resonance in my professional life. Axiology involves an inquiry into a description of Holistic Expressive Therapy by Dhaese and an exploration of how the participants determine the value and influence of Holistic Expressive Therapy. To value is to think and to assign meaning and importance to something. The five axioms from Lincoln and Guba (1985) serve as an initial guide into the inquiry. Overall, I have determined that a naturalistic inquiry is the most suitable paradigm because it complements the theory and practice of Holistic Expressive Therapy. Researcher's Standpoint I am currently influenced by several theoretical and practical contexts, hi 2000,1 graduated from the School of Social Work at the University of Northern British Columbia in Prince George, BC. I consider myself a structural social worker. The concepts that are derived from structural social work are progressive and opposed to social convention. The fundamental values are founded on humanitarianism and on egalitarian ideals. Humanitarianism means the practice of the doctrine humanism, which is a system of views 23 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry based on the respect, dignity, and rights of all people. Egalitarianism focuses on the notion of social equality from a social work perspective. "The central value of social equality is that every person is of equal intrinsic worth and therefore is entitled to equal civil, political, social, and economic rights responsibilities and treatment" (Mullaly, 1997, p. 28). In April 2000,1 obtained fulltime employment at a mental health agency called Intersect Youth and Family Services Society. In my position as a child and youth mental health counselor, I practice play therapy with the skills I have learned from taking training from Marie-Jose Dhaese in Holistic Expressive Therapy. I believe that a structural social work model of practice provides a framework that is congruent with my position as a play therapist in a mental health setting. Mullaly (1997) describes: the goal of structural social work is twofold: (1) to alleviate the negative effects on people of an exploitative and alienating social order; and (2) to transform the conditions and social structures that cause these negative effects (p. 133). Similarly, in my position as a Holistic Expressive Therapist, my approach involves: (1) helping clients express, transform and heal from their difficult experiences - so working at a micro level; and (2) helping the client's family or other systems to support change and development. It is important to acknowledge my biases in this study. My position of having participated in workshops and play therapy supervision with Marie-Jose Dhaese may be viewed as a bias that would interfere with the ability to be objective. It is important to acknowledge that biases do exist and to understand how my biases may impact the research. I believe the relationship with Dhaese has been beneficial in conducting this study because I have prior knowledge about Holistic Expressive Therapy. I believe there is a shared common language and that I have a tacit knowing and understanding as a play therapist. However, I 24 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry have taken some measures to further minimize bias. I chose not to have any supervision or take any workshops from Marie-Jose Dhaese since the proposal was approved. Marie-Jose Dhaese has been involved in the formulation of the case (member checking) but she has not been involved in any other facet, such as, participant data collection, analysis, or findings of the study. I have used a reflective process, including journaling and field notes, to be mindful of my thoughts and feelings throughout the research study. In addition, I have sought guidance from my thesis supervisor and committee members, as needed. Methods Case Study I have chosen an intrinsic case study as the best method for the inquiry with Dhaese and Holistic Expressive Therapy. An intrinsic case study is taken when there is a special interest in a particular case and when "one wants better understanding of a particular case" (Stake, 1994, p. 237). My participation in play therapy training with Dhaese and the CACPT Program (level one) in Ontario provided various training experiences with different play therapists. During this training period, I have identified Dhaese's Holistic Expressive Therapy as a special interest. Guba and Lincoln (1985) define a case as "snapshot of reality, a slice of life, or an episode" (p. 370-371). Rubin and Babbie (2005) define a case study as involving "an ideographic examination of a single individual using a full variety of evidence regarding that case" (p. 744). Case studies are generally seen as a qualitative approach and the most suitable format for the presentation of a naturalistic inquiry. Qualitative research also tends to work with a relatively small number of cases, with a very detailed focus on a specific area of interest. This research is not adequate to test a theory, but the accumulation of many case studies integrating the same theory can contribute supporting evidence to the 25 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry literature. Guba and Lincoln (1985) describe three major reasons the naturalist uses a case study approach: 1. It provides a "thick description" and is a "portrayal of a situation", 2. It is the form most responsive to the axioms of the naturalistic paradigm, 3. It provides an ideal method to convey a grounded, holistic and lifelike experience for the reader, (p. 214) The focus of the case study is not to generalize to other cases of play therapy approaches but to provide an intrinsic case study of Holistic Expressive Therapy, as described by Marie-Jose Dhaese. Grounded Theory I have chosen a grounded theory approach as the best method to describe the influences of Holistic Expressive Therapy in the practice of four participants. A grounded theory approach aims to discover the theory implicit in the data. The theory is emergent, and therefore does not test a hypothesis: "researchers must have the patience, trust and security for its emergence" (Glaser & Strauss, 1967, p. 26). Its approach fosters a continuing search for evidence that disconfirms the emerging theory. Glaser and Strauss, who developed the grounded theory approach, state: "[it] is a general methodology of analysis linked with data collection that uses a systematically applied set of methods to generate an inductive theory about a substantive theory" (p. 16). Ethical Considerations There were four ethical issues related to this study, as follows: 1. Reducing the risk of unanticipated harm. 2. Protecting interview information effectively. 26 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry 3. Informing participants about the purpose of the study. 4. Reducing the risk of exploitation. Reducing the risk of unanticipated harm involved providing the participants with information and consents on the nature of the study and a clear written description of the expectations of their participation in the study. Protecting interview information effectively involved informing all participants that the interview recordings and transcriptions were used for the sole purpose of the study. The interview recordings and transcriptions were stored in a locked file cabinet at the researcher's residence. I informed the participants that the purpose of the study involved providing them with a form describing the nature of the study and what they are being asked to do, as well as requesting written consent. Reducing the risk of exploitation involved following the parameters of the study, as outlined in the proposal, and as verified by the Ethics Approval Board of the University of Northern British Columbia. I have been a member of the professional association of social work for eleven years and I abide by the code of ethics. I am a member of three professional associations that have established standards of practice within the profession. The standards include guidelines and codes of ethics to promote professional excellence. I am a member of the Canadian Association of Child and Play Therapy (CACPT). In Canada, CACPT is the regulatory governing body of play therapists that provides certification. The CACPT currently has a registered membership of 450 members, including 80 certified play therapists (www.cacpt.com). CACPT has specific play therapy practice guidelines to ensure that children in need receive the best possible mental health services. The aim of certification is to acquire a high level of proficiency and competency that will maintain the status of play therapy as a profession. 27 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Secondly, I am a member of the British Columbia College of Social Workers (BCCSW), membership number 08349. The BCCSW is the regulatory body for the profession in BC and entitles members to use the designation of Registered Social Worker. Thirdly, I am a member of the British Columbia Association of Social Workers (BCASW), membership number 1004717. The BCASW is a voluntary, not-for-profit membership association that supports and promotes the profession of social work and advocates for social justice. I believe my membership in all three professional associations has numerous benefits that support and enhance my practice as a social worker and a graduate student. Trustworthiness The aim of trustworthiness is to persuade the audience that the findings of an inquiry are "worth paying attention to" (Lincoln & Guba, 1985, p. 290). Lincoln and Guba (1985) describe the appropriate criteria to ensure the trustworthiness of a naturalistic inquiry, as: credibility, transferability, dependability, and confirmability. The technique I used to ensure credibility of the interviews and the analysis, include: my prolonged engagement with the phenomenon (Holistic Expressive Therapy) and interviewees was crucial in building trust; and my persistent observation of the data collected to identify categories most relevant; and I used member checking with the participants to ensure the categories that emerged were accurate. The technique I used to ensure transferability, included: I provided a thick description of the findings to invite others interested in making a transfer of their own possible. The techniques I used to ensure dependability and confirmability, included: I kept the raw data (interview recordings, field notes, and reflexive journal), the data reduction and analysis products (field notes), and records of the data reconstruction process (raw data, and 28 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry data tables) in a locked filing cabinet. These measures, as recommended by Lincoln and Guba (1985) ensure the trustworthiness of the naturalistic inquiry of Holistic Expressive Therapy. Procedure Preparation of Marie-Jose Dhaese Interview I have identified and selected Marie-Jose Dhaese's approach to play therapy as a subject of interest and a special case worthy of study for two main reasons. First, Dhaese is well respected by the Canadian play therapy community; however, her approach is not as well known to the larger therapeutic community. Secondly, I have experiential knowledge and this is my own chosen approach in my work with children. Marie-Jose Dhaese was provided a copy of the information and consent form (see Appendix A), which she signed and returned via post. She was paid her hourly rate ($100) in appreciation of her time to conduct the interview. An interview time was scheduled at her convenience at her Centre in Parksville, British Columbia. Preparation of Participants' Interviews The identification and selection of participants was a different process than that of selecting Dhaese. I wrote a letter to invite therapists to participate in the study, which was distributed with permission by Dhaese's Centre for Expressive Therapy's electronic contact list (see Appendix B). Six people volunteered for the study by responding to the letter of invitation and made contact with me directly by email. I responded by telephone to confirm their interest. I then electronically sent all six people the pre-screen interview (see Appendix C) to complete and return electronically to screen for eligibility. Four pre-screen interviews were completed and returned. All four persons met the pre-screen interview 29 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry requirement, so they were sent, by mail, the information sheet and consent form (see Appendix D) to complete and return. Four information sheets and consent forms were signed and returned via post. I contacted each person by telephone to thank them for volunteering to participate in my study and to confirm the process. (I was responsible for the telephone costs of the interviews). Although I had a sample pool of six potential participants who completed the prescreen interview, initially only two participants were selected, interviewed then the data was analyzed using the constant comparison method before a third participant was selected. I interviewed the third participant then I analyzed the data using the constant comparison method before it was determined that a fourth participant was selected. As mentioned, there were six therapists who met the pre-screen criteria to participate in the study; however, after the four participant interviews were analyzed, no new categories emerged, and therefore no further data was collected. Data Collection Method Informal Conversational Interview I have used an informal conversational interview approach to gather data from MarieJose Dhaese and the four participants. Patton (1980), in Qualitative Interviewing, describes the informal conversational interview approach: "It relies entirely on the spontaneous generation of questions in the natural flow of an interaction, typically an interview that occurs as a part of an ongoing participant observation fieldwork" (p. 110). The natural flow of an interaction is congruent with a naturalistic inquiry. The purpose of the inquiry is twofold: 1) to have Dhaese describe and define Holistic Expressive Therapy, and 2) to have the participants describe the influences of Holistic Expressive Therapy on their practice. 30 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Patton (1980) further states: "The purpose of interviewing then is to allow us to enter the other person's perspective" (p. 109). Selection of the interview approach is determined by the methodology in which the information is being sought. The informal conversational interview approach offers maximum flexibility for a naturalistic inquiry. It can be responsive to individual differences and situational changes and questions can be individualized. Wengraf (2001) describes research interviews as tools designed for the purpose of improving knowledge as a special kind of conversational interaction. He has written a rule book for those who want to be thorough, while also maintaining spontaneity. Wengraf further states: [WJhat is planned is a deliberate half scripted or quarter scripted interview; its questions are only partially prepared in advance (semi structured) and will therefore be largely improvised by you as interviewer. But only largely: the interview as a whole is a joint process, a co-production, by you and your interviewee, (p. 3) Some of the key issues in collecting and analyzing interview information are to know the strengths and weaknesses of the various approaches. The challenges are that the informal conversational interview approach can be time consuming, and the interviewer must be skillful. The strengths are that the informal conversational interview approach is flexible and allows for the free flow of information and is therefore best suited for a naturalistic inquiry. Interview with Marie-Jose Dhaese On October 30, 2009 I conducted a two-hour, in-person video/audio recorded interview with Marie-Jose Dhaese in her therapy room at the Centre for Expressive Therapy in Parksville, BC. The Centre is situated a few minutes' walk from the natural beauty of the Pacific Ocean. I chose to interview her in-person because the depth of the research question demanded a setting that would honor her 30 years' development of Holistic Expressive Therapy. This interview with Dhaese provided the frame of reference for the second research 31 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry question. The interview was comprehensive and longer in length to ensure enough time for Dhaese to describe and define Holistic Expressive Therapy. The interview began with a grand tour question, as follows: How would you describe and define Holistic Expressive Therapy? Dhaese responds, as follows: The first part is holistic, and therefore that means that I take into consideration the physical, emotional, cognitive, and spiritual needs of the people that come my way, in order to help them. (M. J. Dhaese, personal communication, October 30, 2009) At the end of the interview, I removed myself from the natural interview setting to document field notes of my own empirical observations, interpretations, and reflections of the interview process, to utilize my own tacit knowledge. Interviews with Participants I conducted four separate one-hour telephone interviews with the participants. It was decided a telephone interview would be an efficient method to pose the grand tour question: How has Holistic Expressive Therapy influenced you in your practice? The four participants lived in different communities and therefore a telephone interview method was chosen for its efficacy given the logistics and economics. It would not be economically feasible to provide travel costs required for an in-person interview. The participants were given an honorarium ($50) in appreciation of their time after the interview was completed. Participant names have been kept in strictest confidence. At the end of each interview, I removed myself from the interview setting to document field notes of my own empirical observations, interpretations, and reflections of the interview process. 32 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Recordings. The Dhaese in-person interview was audio-digital recorded and video recorded for observation to ensure information was recorded accurately, and for backup in case the digital recording system failed. The four telephone interviews were audio-digitally recorded to ensure accuracy for transcription and analysis. Transcriptions. All five interviews were downloaded from the digital recorder onto my computer. To ensure preservation of the data, a backup copy was kept in a locked fireproof filing cabinet in my home. I transcribed the video/audio and audio recordings into text for analysis. The time I spent transcribing the interviews was an important part of my immersion phase of the naturalistic inquiry. I noted my feelings and responses that enhanced the depth and quality of my research process. Data Analysis of Marie-Jose Dhaese Interview A thematic analysis was chosen as the best method to formulate a case study. I transcribed Dhaese's interview into text, highlighted themes, and developed an organizational outline for the writing of the case study (see Figure 1). A case study was chosen as the best method to define and describe the themes that emerged from the analysis. The complete case study on the description and definition of Holistic Expressive Therapy can be found in chapter four. 33 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Figure 1. Outline of Themes Holistic Principles- Concept of human being Healing from the inside out Art of following & guiding ; Major Components- Relationship—> Self-knowledge & awareness Safety Milieu—> Design Materials Nature Expressive Therapi*3S—> Art, sand, play Animal companions Modes of Expression- Data Analysis of Participant Interviews Grounded theory coding provides a systematic method for the data analysis and the emergent theory from the participant interviews. The data analysis was conducted after interview A and B, using a constant comparison technique, searching for categories (similarities), and property of categories (differences). After the third interview (C), there were no new properties of categories. However, to ensure no new themes emerged, a fourth interview (D) was completed. After the fourth interview it was determined that saturation was achieved. The term saturation is used to describe a stage in the data analysis when no new themes emerge from the data. To ensure trustworthiness, a member check was completed by giving the participants the list of the themes that emerged from their individual interviews (A, B, C, and D). Lincoln and Guba (1985) recommend "the best way to determine [trustworthiness] is to take the reconstruction back to the respondents for their examination and reaction" (p. 351). All four participants sent a return email confirming the analysis of their individual interviews. The four participants were not apprised of the themes that emerged from the other participant interviews. 34 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry There were 80 categories that emerged from the four participant interviews. I wrote these categories on their own individual recipe card, coded to represent each participant. I sorted the recipe cards into themes and then entered them in a table, until there was a consistent finding of themes, which took four rounds. After each round, the themes were entered on a table for easy viewing (see Appendix E, Analysis Table 1, 2, 3, and 4). No knew themes emerged within the data. At this stage of the analysis, the task was to organize the themes into categories. I chose to use a second analysis method by Charmaz (2006) to ensure there was a thorough exploration of the categorization of the themes. Charmaz (2006) outlines three main phases in a grounded theory data analysis, such as: (1) initial coding, (2) focused coding, and (3) axial coding. The purpose of coding is to describe, but more importantly, to acquire, a new understanding of the phenomenon of interest. The initial coding phase involves the use of in vivo codes: "In vivo codes help us to preserve participant's meanings of their views and actions in the coding itself. Pay attention to language while you are coding" (Charmaz, 2006, p. 55). The initial coding also involved a constant comparative method (Glaser & Strauss, 1967) to establish distinction between data, searching for similarities and differences. During the in vivo stage, the data was indexed using the initials of the participant name and the order of where text was found in the transcription. This allowed for the quick recovery of text and helped me to further understand context, which added a new dimension to the analysis. Although the constant comparison method was completed in the first round of analysis, it did not involve the indexing of text. The second phase is called focused coding by Glaser and described in Charmaz (2006): "Focused coding means using the most significant and/or frequent earlier codes to sift through large amounts of data" (p. 57). During the focused coding stage, each coded text 35 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry was transferred onto a coloured sticky note. The colours: blue represented participant A; yellow represented B; pink represented C; and purple represented D. The coloured sticky notes were grouped into categories on a large white board. Being able to physically arrange the colour-coded texts into categories added another dimension to the process. All the data could be viewed in one visual scan of the poster board, allowing for rapid organization of the data. It appeared that the data came alive and the identification of categories became more apparent (see Appendix F). Once the focused coding was completed, the information was entered into a table for further viewing (see Figure 2). In total, I identified 24 categories during the focused coding stage, and subcategories began to emerge as I prepared for the next stage of analysis. Figure 2. Focused Coding (Sample Only) Categories Codes Text Supervisory Relationship D60 'Breath of fresh air' and helps me to renew my energy as a therapist Essential to have supervision Attracted to her. her presence is lovely Like her style, client-centred D44 C7 B12 Otgamc C37 M-J is organic way and of couise she points out, it really depends on who you are as a peison, because you are working at that level Wisdom and Knowledge Based on Experience B37 She has a lot of experience C36 M-J developed HET after 20 years of working with children solid place to come from Dhaese's wisdom and knowledge is based on experience D54 The final phase is called the axial coding, where the 24 categories were further developed into subcategories. I reviewed the coded texts in each category to determine which ones could be developed into subcategories This involved observing the number of coded 36 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry texts in each category, and noticing the range of pervasiveness in each category. For example, the category supervisory relationship has 34 coded texts and the majority of participants made comments. From the main category, supervisory relationship, three subcategories were developed: role, appreciation, and process of learning. Finally, I organized the data in a table to emphasize the linkages between the categories, subcateg and coded text (see Figure 3). Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Figure 3. Linkages Between Coded Text, Subcategories, and Categories Categories Subcategories Codes Text Supervisory Relationship Role C3, B8, D48 Teacher B30, C50, D41 A9 A18 A8 Supervisor Appreciation D60 D44 A42 B39 C7 C7 B12 C37 B37 C36 D54 C31 B23 D62 Process of Learning B22 B25 C13 C52 C43 D33 A18 D57 C7 A10 Group supervisor Apprenticeship Mentor's mentor 'Breath of fresh air' and helps me to renew my energy as a therapist Essential to have supervision Personal qualities humbleness, teacher, healer, childlike nature She is a lovely person Attracted to her her presence is lovely Love her Like her style, client centred M-J is organic way and of course she points out, it really depends on who you are as a person, because you are working at that level She has a lot of experience M-J developed Holistic Expressive Therapy after 20 years of working with children solid place to come from Dhaese's wisdom and knowledge is based on experience But I think you are changing the trajectoiy of where they are going to go M-J quote "when you come to therapy, it is like your soul has found a fnend" Knowledge is expenenced based what she has woiked thiough with others and with herself It is like a piocess, you know like when the ram comes down on the heart and softens it up after a while Always learning Cause I needed to know more Dedicated to the woik It has been a long journey Want to incorporate more but I will use what I have Learning new languages lequues piactice Pnnciples resonate with my beliefs about therapy Play appeals to me HET is my foundation 38 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Seven categories and 14 subcategories emerged from the four participant interviews (see Figure 4). From the categories and subcategories, I began to generate theoretical properties and to develop a grounded theory, which will be discussed in chapter five. Figure 4. Categories and Subcategories Categories Subcategories Supervisory Relationship Holistic Way of Being Client/Therapist Relationships Milieu Expressive Therapies Cognitive Behaviour Therapy is limiting Role, Appreciation, Process of Learning Principles Art of Following/Guiding, View of Self-Healing Self-Knowledge/Self Awareness, Safety, Presence Therapy Room, Nature Symbolic Language, Multisensory Neuroscience The issue of bias and preconceptions in the analysis of the data is a question that arises in research. There were three main approaches taken to deal with bias. The first step was in the coding, which involved constant comparison of the data to discover underlying patterns. During this step, I listened to my inner dialogue and I used a reflexive journal to record my inner dialogue. The second step was to cultivate an attitude of neutrality for the themes to emerge from the data. During this step, I sorted the data on four rounds to explore all possible combinations or creations of categories. The third step was to recognize my own assumptions, experience, and knowledge (theoretical sensitivity), and try to put those aside during the analysis stage. During this step, although I had my own tacit knowledge of Holistic Expressive Therapy, I positioned myself as the researcher with a curiosity to understand the experiences of the participants. 39 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Limitations of the Study It is important to acknowledge the limitations of this study. The first limitation is that the study has a primary focus on an intensive description of a single approach via case study of Holistic Expressive Therapy, as developed by Dhaese. The study identified the influences of Holistic Expressive Therapy in counselling practice of a small sample of participants. However because the sample size is small this will not allow for generalizability. The second limitation is that it is not within the scope of this study to focus on the application of Holistic Expressive Therapy to a specific mental health problem or mental disorder. The limitations narrow the study to provide an introduction to Holistic Expressive Therapy. Summary This is a qualitative study using a naturalistic inquiry to explore Holistic Expressive Therapy with the developer Marie-Jose Dhaese and four therapists. A naturalistic inquiry has been identified as being the most suitable methodology. Marie-Jose Dhaese and four therapists were interviewed using an informal conversational interview. The data collected was transcribed to text for analysis. For the interview with Marie-Jose Dhaese, an intrinsic case study was used to describe Holistic Expressive Therapy. For the interview with the four participants a grounded theory approach was used to analyze the data collected. The researcher's standpoint is a structural social worker and a mental health counsellor with training and supervision in Holistic Expressive Therapy. Ethical considerations and limitations of the study were also explored in this chapter. 40 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Chapter Four: Dhaese's Holistic Expressive Therapy — A Case Study On October 30, 2009,1 conducted a two-hour, informal conversational interview with Marie-Jose Dhaese in her therapy room at the Centre for Expressive Therapy in Parksville, BC. The information collected from the interview with Marie-Jose Dhaese is the basis for this case study on Holistic Expressive Therapy. The focus of the interview was to address the research question: How does Marie-Jose Dhaese describe and define Holistic Expressive Therapy? Dhaese describes the theory, historical development, major components, insights to the self-healing process, and limitations of Holistic Expressive Therapy. Dhaese combined her personal and professional experience with knowledge and wisdom to create an approach for self-healing called Holistic Expressive Therapy. The first part is holistic, which means taking into consideration the physical, emotional, cognitive, and spiritual needs of the people that come my way. When I first started presenting over 25 years ago, my focus was to bring back into psychotherapy another layer of who we are, that is, the spiritual layer - the place of innate wisdom. Carl Jung called this the self-healing mechanism. This self-healing mechanism is called upon to cope with whatever difficulties the person is dealing with at the present time. Basically, my focus was to remember the spiritual layer of my clients and to know that who they are is not limited to the physical, emotional, and cognitive. (M. J. Dhaese, personal communication, October 30, 2009) Over the course of her journey, Dhaese deepened her empathic understanding of the struggle and the journey involved in the self-healing process. The understanding was not thinking only with the intellect, but thinking that also involved the heart. Holistic Expressive Therapy unifies a clear thought process with compassion of the heart, to bring together the 41 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry right brain and left brain modes of thinking. The symbolic expression is being accompanied by verbal expression. It must be understood that thinking is involved and the clarity of thinking is important, but it must include the warmth of the heart. Marie-Jose Dhaese's own insights she acquired on her journey are the basis of her approach. Transference and counter transference issues invariably come up in the life of the therapist. As I worked with these ongoing issues, I was able to deepen and clarify the use of my therapeutic methods. This allowed me to avoid projecting my own issues on to my clients. First, I observed and experienced the therapeutic methods on myself and then when there was a quality of neutrality and compassion, I was able to use the methods with my clients. This approach made the methods very effective. My personal journey provided the empirical research. (M. J. Dhaese, personal communication, October 30, 2009) Theory: Insights to the Self-Healing Process Marie-Jose Dhaese grew up in a Catholic farming community in Normandy, France. Dhaese was raised by parents who were traumatized by two world wars. Dhaese shares that the early experiences with her mother were invaluable in providing insights to the selfhealing process. Dhaese tells a story of when she was a young child with her mother on the family farm: In the summer it would be time to cut the wheat. We still had horse drawn carts. The men would cut and gather the wheat by hand...there was no machinery. They would put it into sheathes to be stored. Now the women would gather the little pieces of wheat that were left and then we would gather them to give to the animals for feed. As a child, I would he following my mother around the field as she gathered wheat. Now, in school and catechism, they talked about God and that God had no beginning, no middle, and no end. I could not understand what that meant. I really wanted to know what everybody called God, because God seemed to be something different to everyone. So we were gathering the wheat and at some point I sat down with my 42 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry mother in the shade, and I asked her where God was? She took a sheath of wheat and she took out one of the grains. She pointed out the little white dot on the grain of wheat, and she said, 'this is where God is.' That moment has always stayed with me. When I talk about Spirit and innate wisdom, it is that part of us as human beings that is the life force. Inside the little white dot is the potential of what that seed is meant to become and inside it also has the capacity for self-healing. Each seed has a DNA that includes its own unique immune system. In my own experience and I have come across thousands of people over the years — each and every one of us has a little white dot which I call the true nature. Each true nature is unique and has the potential to uniquely express the life force. The true nature has in it everything we know and need to know to become what we are meant to be. I think the purpose in life is for each of us to become that potential in the physical world as much as possible. (M. J. Dhaese, personal communication, October 30, 2009) Historical Development Dhaese describes herself as a thinking child who was always searching for meaning in life. Nature has always been a great personal comfort in her own search for healing. Dhaese shares that the early childhood stories told by her mother as being at the core of her view of human beings and the self-healing process. Dhaese's search for meaning was answered in the story told by her mother of God being represented as the white dot on the seed that holds the true nature of the potential the person is meant to be. Dhaese studied prominent thinker Rudolf Steiner's Anthroposophy (first published in 1923), which is a holistic approach that includes the reality of a spiritual world that manifests itself to the inner eye in the form of images. Steiner's Anthroposophy helped Dhaese to solidify the concept that a human being not only has a physical body but also an emotional, intellectual, and spiritual body. Steiner's ideas have always been close to Dhaese's heart. Dhaese acknowledges that Steiner's work gave her the courage to continue to search for meaning. It 43 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry was at this time in Dhaese's life that she decided she wanted to become a therapist. Dhaese's search took her away from her village in France to a life of teaching English in universities in England, the United States, and finally in Canada. In the early 1970s, Dhaese was working full time with adolescents at a residential mental health treatment facility in Vancouver, where she had the opportunity to be trained in a wide range of therapeutic approaches. Dhaese observed that many of the verbal therapies were not effective with adolescents' severe emotional and behavioural difficulties, so she began to search for new ways of helping. In her five years at the treatment facility, she observed that it was the quality of the therapeutic relationship that was most effective in allowing improvement. Qualities of the therapeutic relationship that were not effective were disrespect, harshness, and insensitivity. The most effective therapist qualities were firm friendliness, with a grounded personal sense of power and no fear. As well, therapists who had an attitude of genuine respect and honour for the adolescents were very effective. It became clear to Dhaese that a therapist's ability to emotionally regulate and have selfawareness, where the adolescent was not regulated, was most important. Dhaese came to know that the qualities of the relationship provided an essential layer of safety that would hold the self-healing process. Dhaese continued to search other ways in addition to the therapeutic relationship that would provide safety for the adolescents who came to her for help. In 1980, after ten years of practice, Dhaese began sharing with her colleagues her insights and experiences from her professional journey of self-healing. The responses she received from her colleagues were profoundly encouraging so she continued to develop her methods to help her most difficult clients. During this time, Dhaese completed both Art 44 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Therapy and Expressive Therapy training certification. Dhaese was subsequently hired by the British Columbia Ministry of Social Services to run a therapeutic day program for disenfranchised youth in Vancouver, BC. This program ran for several years and then, due to funding cuts, the program was abruptly shut down. Dhaese was given two weeks to close all of her cases. This experience taught her the importance of incorporating closing rituals at the end of each session, particularly when working with disenfranchised youth or any clients who have experienced multiple losses. The purpose of the closing ritual is to provide an image or an experience that will be internalized and that will remain with the client when they leave the therapy room. The closing ritual provides a gentle wrapping and bringing together of the whole experience of the session. In this way, the healing imagery of the session is preserved once the client leaves the therapy room, and until they return. An example of a closing ritual used by Dhaese is for the client to have a snack, while Dhaese reads a story and then lights a candle. The client makes a wish and then blows the candle out. The ritual of closing a session became an essential feature of Holistic Expressive Therapy, as there were times when her program was closed unexpectedly or clients would move away and would not return to have a closure session. Dhaese discovered other means of creating safety in 1980 when her first co-therapist, Monseigneur, a black standard poodle, began to join her in the sessions with the clients Dhaese observed that Monseigneur's accepting presence provided a great source of safety, soothing, and calming to resistant clients who were disenfranchised youth. Over the years, Dhaese has had six co-therapists (Monseigneur, Dauphine, Bijou, Yannick, Fleur, and Dauphin) who taught her about witnessing, comforting, reassuring, and being present. Each co-therapist has had a particular nature and style to assist clients in the expression of painful 45 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry experiences while staying present in their body. For example, Yannick sat on clients' feet that helped them to settle. Over the years, Dhaese, her co-therapists, and her clients have spent many sessions outdoors, walking on the beach, storytelling, playing in the outdoor sandbox, and collecting shells, feathers, stones, and pieces of driftwood. Dhaese discovered from her own experiences that walking and playing in the sand is a very grounding and healing experience. One rainy day, one of her clients asked if he could bring some sand inside. (For ease of reading, the pronoun he will be used in reference to clients and she will be used in reference to therapist). After many rainy days of being indoors, they brought sand from outside, inside and an indoor sand box was created. They brought the natural objects they had collected from the beach for the indoor sandbox: images were created and stories evolved. Dhaese's development of sand and play in therapy was discovered long before she had heard or read of sand play by Dora Kalff (1980) or play therapy by Virginia Axline (1947). It was during this time that Dhaese discovered the strength of herself as a therapist and further developed her insights into the self-healing journey. Dhaese shares, "the inspiration came from the children, [clients] this is where it all came from and without them; none of Holistic Expressive Therapy would exist." In 1980 Dhaese started sharing her therapeutic discoveries at conferences in Canada and the United States and then in 1985 at the Justice Institute in Vancouver, BC where she continues to teach today. In order to teach, Dhaese needed to find a common language to translate her personal and professional experiences into words so that her students would understand. Dhaese's experiences resonate with Jung's concept of the Self, the totality and the organizing principle, and with Carl Rogers's self-actualizing tendency. Dhaese calls the 46 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Self the true nature or germ of the seed that holds the DNA, the innate wisdom that holds the potential of what is meant to become. When there is an opportunity for the Self to experience innate wisdom, health and wellness will flourish. Dhaese's understanding is that Jung viewed the human psyche as a self-regulatory system that naturally seeks wholeness and, that under adequate circumstances, has the ability to heal itself. Jung saw this system as being comprised of the conscious and the unconscious (both personal and collective). In Jung's Man and His Symbols (1964), he describes the totality as the Selfand as the organizing principle: The organizing centre from which the regulatory effect stems seems to be a sort of 'nuclear atom' in our psychic system. One could also call it the inventor, organizer, and source of dream images. Jung called this centre the 'Self and described it as the totality of the whole psyche, in order to distinguish it from the 'ego,' which constitutes only a small part of the total psyche" (p. 161-162). In Jung's Man and His Symbols (1964), he defines Self "as an inner guiding factor that is different from the conscious personality and that can be grasped only through the investigation of one's own dreams" (p. 163). Dhaese views the self as being the seat of our deepest feelings, holding the reservoir of knowledge and wisdom passed down through the ages. Carl Rogers's fundamental theory on self-actualization resonates with Dhaese's views of human beings and the self-healing journey. The belief that each human being has an innate wisdom that holds their potential for growth has always been at the core of Dhaese's understanding of the self-healing process. In Roger's Client-centered Therapy (2003), he describes the organism's drive to self-actualize: "The organism has one basic tendency and striving — to actualize, maintain, and enhance the experiencing organism" (p. 487). These 47 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry concepts from Jung and Rogers would provide a language to contribute to her theory of the self-healing journey. Dhaese continued to develop the language to teach Holistic Expressive Therapy, while continuing her clinical practice. By this time, Dhaese developed the foundation of her ideas of Holistic Expressive Therapy, and decided to pursue further formal education to establish credibility. In 1986, Dhaese obtained her Master's Degree from the University of British Columbia, and in 1995, she obtained her Doctoral Degree in Expressive Therapy from the National Institute of Expressive Therapy, from New York, New York. Throughout her schooling, Dhaese's Holistic Expressive Therapy approach continued to evolve and solidify, as she taught, supervised, and developed new ways of helping children. Major Components There are four main components of Holistic Expressive Therapy: 1) relationship; 2) milieu; 3) expressive therapy; and 4) family therapy. The relationship that develops between the client and the therapist is crucial: without the relationship, the therapy will not proceed. The milieu is the term used to describe the therapy environment or space where the therapist and client are together. The milieu includes the layout, design, contents, placement, colour, smells, quality, and quantity of all that is in the therapy environment. The expressive therapy refers to the various techniques available for the client, including art therapy, sand play therapy, play therapy, mask making, face painting, playing music, storytelling, sewing, eating food, and gardening. The client or the therapist may choose a particular mode of expression and trans formation. The family therapy refers to the client's family member's involvement in nurturing and supporting change and development. All of these therapies may also be assisted by co-therapists, such as companion animals. 48 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Client/Therapist Relationship The relationship that develops between the client and the therapist is crucial to bring all the elements together to facilitate the self-healing process. As Carl Rogers (2003) described it, the main qualities the therapist needs to bring to the session are: being real, unconditionally accepting, understanding, and being able to communicate all this in her ability to be totally there for the client. The main tool of therapy is the therapist herself. Dhaese describes the layers of safety the therapist must create: The therapist creates an emotional egg that provides physical, emotional, cognitive, and spiritual safety. This is created primarily in the therapists" attitude, and nonverbal messages. On the physical, the message is: 'no one gets hurt here'; on the emotional:' all feelings expressed here are accepted, no matter what you do, say or play out, you will not be invaded or rejected'; on the cognitive: 'as best I can, I will help you make sense of, understand, find and speak truth to your situation'; and on the spiritual: T remember and see who you are, the power and sacredness of your true nature and I am here to help you reconnect with it.' (M. J. Dhaese, personal communication, October 17, 2010) The client also recognizes that he has the resources and the freedom to create any world he chooses to share, in any way he chooses to do so. The relationship gives the client the supports necessary to develop the strength to eventually face his painful feelings and to work through them. Through this process, the client discovers new strengths he never suspected he had. The therapist/client relationship is the main facilitator and container of the self-healing process. When Dhaese first sees a client, her focus is to search for the client's gifts and strengths, pleasures and natural means of expression. Then secondly, she begins to amplify and reflect back to the client, so their true natural gifts grow and support the healing process. 49 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry The art of following and guiding. Dhaese shares that the therapist always begins with an awareness of the client's primary need. Dhaese provides an example: if the client's primary need is hunger, then the client must eat before they are able to play or draw. The therapist must always attune to the client's primary need. Dhaese describes the attunement as the art of following and guiding. First, the therapist grounds, then attunes herself to the client's need, meets the client's primary need and then follows the client's lead in the play. The therapist reflects verbally and guides the client when he feels stuck in the play. Throughout this process of following and guiding the therapist is aware of the amount of containment and freedom the client needs and adjusts accordingly. The art of following and guiding is client centered on the client's needs in the here and now. Milieu Dhaese refers to milieu as the environment where the therapy sessions take place. Wherever the therapy sessions are, indoors or outdoors, there is always the presence of nature as part of the nurturing environment, including flowers, stones, shells, driftwood, feathers, a garden, and a nature corner, which can be used in a variety of ways in the play sessions. The beauty of nature helps the client reconnect with his sense of wonder and sense of belonging in the world, which are both unpredictable and ever changing. The goal in establishing the milieu is to create a safe and protected space, to facilitate and reflect on the sacredness of the self-healing process. Dhaese uses a metaphor of a greenhouse to describe the milieu: The playroom is like a greenhouse. The plant is in need of help because it has been infested by some bug or fungus that is in their roots. Something is interfering with their growth and is stopping them from being the plant they are meant to be. So the plant is brought into the greenhouse, to seek help to discover what they need and in 50 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry some cases, remember what kind of plant they are. When the plant's infestation is so great, they may have lost track of who they are. (M. J. Dhaese, personal communication, October 30, 2009) Dhaese creates a milieu where a client who has been bombarded with chaotic, harsh, and painful impressions can now be exposed to a soothing, harmonious environment. All elements that go into creating the space are important and serve a purpose. The layout of the room should allow the freedom of movement, imagination, and creativity. All the expressive materials used, whether art materials or therapy toys, should have the following qualities: they offer harmonious, enriching sensory experiences; they are easy to manipulate, ensuring successful results with minimal frustration; and they are neutral enough that their form allows for the greatest possible freedom of imagination. It takes a certain dedication and willingness to be conscious of creating the milieu. There must be thought, care, and attention to detail. The milieu is the reflection of what is important to the therapist. The milieu can convey a sense of consistency and reliability for the client when things are in order and the space is arranged in the same way each week. This predictability helps the client to feel safe, which is an essential part of the healing process. Expressive Therapies Dhaese explains that there are a variety of modes of expression that come under the term expressive therapy. These include: art therapy, sand play therapy, play therapy, masks, face painting, music, storytelling, sewing, food, and gardening. The age, need, and inclination of the client determine the choice of a particular mode. The therapist must be attuned to the needs of the client, so whatever method is being used is chosen based on the attunement of the primary need. The expressive therapies include anything that brings the 51 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry client closer to being connected with his true nature. Dhaese shares that the process begins at the physical level — the client needs to be in their body; otherwise, any expressive therapy can be hurtful and even destructive. Dhaese describes speaking in metaphors as the language of the heart, because it brings thinking and feeling together. It is the images and the metaphors that hold the feeling and it is a way of thinking in pictures rather than thinking in words. This is based on the Jungian approach to the psyche, which says that the unconscious manifests itself to consciousness through images, dreams, or fantasies (Jung, 1964). When the therapist reflects the actions of the client, giving the words helps the client develop a narrative of his experience. The weaving of the play experience with the verbal narrative provides the client the opportunity to develop self-awareness and self-regulation, allowing difficult experiences to be worked through. Each expressive therapy has gifts and limitations. The therapist needs to have an understanding of what and how the expressive therapy, such as art therapy, sand play therapy, play therapy, masks, face painting, music, storytelling, sewing, food, and gardening can help the client with expression. Dhaese always suggests that therapists have their own working experience to build their own connection and understanding of the approach before the therapist brings the expressive therapies into the milieu. Family Therapy Another major component of Holistic Expressive Therapy is family therapy. The family therapy refers to treatment that involves the client's family members or the system that will be able to nurture change and development. The family system may consist of mother, father, and social worker, or any other care giver. The therapist needs to be aware of how much support and change the system is capable of providing to the client. When the 52 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry therapist is dealing with a client with attachment issues, a 50-minute session once a week does not provide enough repetition to repair past traumas. There need to be opportunities for repetitious healing experiences in all domains of the client's social and relational life. The repetition of new therapeutic experiences weaves the integration of the right and left brain, creating new neurobiological pathways. The therapist needs the family system to help change the repetition and it is very difficult for change to happen if the family cannot be involved. If the family is not capable of giving the client new experiences, the therapist still works with the client and hopes that the quality of the therapeutic experience and the memory of safety remains, sustains, and soothes the client to provide healing at a later time. The four components — relationship, milieu, expressive therapy, and family therapy — are integral to the application of Holistic Expressive Therapy. Each component has a particular role and purpose in the therapeutic process. The therapy process assists the client to remove the emotional blocks that interfere with the connection to the client's true nature. Dhaese reminds us that the self-healing mechanism is the client's true nature that is called upon to cope with whatever difficulty the client is dealing with at the present moment. In the safety of the milieu and the therapist/client relationship, the client plays out their false selves one by one until they are no longer needed. The family therapy can assist to provide the support the client requires to maintain the changes and foster their reconnection to their true nature. Insights: Healing from the Inside Out and the Outside In Dhaese calls the self-healing process: healing from the inside out and the outside in. Dhaese describes emotional healing in metaphorical terms: 53 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Emotional healing can be likened to the healing of a physical wound. The wound needs to be cleaned, and if it is infected, the pus needs to be cleaned. Then the wound needs to be disinfected (using expressive therapies), covered with ointment and bandaged, (milieu) and left alone to heal (ritual of closing of the session). Each week, the dressing is removed, (opening), the wound is checked and perhaps more cleansing is needed (more expressive therapies from the outside in. Then more ointment applied, (soothing from the inside out) and afresh dressing added (containing the imagery), then the wound is left alone for another week (ritual of closing the session). The natural healing process continues to take place, and with that, sometimes pain is involved (feelings are felt, expressed and transformed). (M. J. Dhaese, personal communication, October 30, 2009) The healing from the inside out is provided by the expressive therapies, such as art, sand play, and music. These modes of expression help to release the inner tensions and repressed feelings related to difficult experiences, and these releases bring about transformation and integration. The expressive therapies have the element ofhealing from the inside out, so they help with expression; and also have the element of healing from the outside in, so it soothes the sense impression from the milieu. The milieu component of the therapy room offers soothing and delights through all the senses (colour, light), smell (flowers, lemon, lavender), hearing (wind chimes, water fountains, rain, and birds), and touch (silk, sheep's wool, handmade toys, and the coats of the animal co-therapists). Other forms of healing from the outside in are stories, celebrations, and rituals that provide closure to the session. The link between the two processes, inside out and outside in, is the therapeutic relationship component. Emotional healing is facilitated by the capacity of the therapist to attune herself, follow, intervene, and guide the self-healing process. The relationship is the 54 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry crucial factor in therapy. A fancy playroom with many expressive therapies is not as important as the therapist's capacity to be present for the client. It is the being of the therapist and the capacity of self-awareness that helps to facilitate the client's self-healing process. However, if the client experiences constant re-wounding after the therapy session, the wound cannot heal, even with the most skilled therapist and excellent therapies. This is where family therapy is critical to the outcome. Family therapy can help to ensure that the client's life is emotionally safe so there is not constant re-wounding taking place. The emotional immune system of the client will take over and do the healing, but that takes time and cannot be forced. Limitations of Holistic Expressive Therapy Marie-Jose Dhaese explains that Holistic Expressive Therapy can be adjusted to address most difficulties but it does have limitations. Similar to any approach, it is only as effective as the therapist who is skilled to use the approach. The therapist really needs to have self-awareness and a certain degree of self-knowledge in order to know what problems can be helped. Dhaese believes the 50-minute session per week is insufficient to treat clients with complex traumas or chaotic histories. These clients require a comprehensive plan that includes the involvement of the client's family, teacher, counsellor, social worker, and physician. Summary Holistic Expressive Therapy is an approach developed by Marie-Jose Dhaese. Her insights came from her own personal and professional knowledge and experiences that were combined with wisdom to develop an approach that combines the clarity of thinking and the warmth of the heart. 55 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Dhaese grew up in a small farming village in Normandy France. Dhaese describes her greatest influence as being her mother and the childhood stories told by her mother. It is from these early stories that her insights to the self-healing journey and the concept of true nature began. Dhaese ideas have been further shaped by the theoretical influences of Rudolf Steiner, Carl Jung, and Carl Rogers. Dhaese acknowledges the children she has worked with over the past 30 years, for without them, none of Holistic Expressive Therapy would exist. Dhaese's focus has been to bring spirituality back into psychotherapy. Holistic Expressive Therapy takes into consideration the physical, emotional, cognitive, and spiritual needs of the people who come to therapy. Holistic Expressive Therapy is a client centered approach in the 'here and now' based on the client's primary need at the moment. Dhaese has developed her own metaphors of the self-healing journey which she describes as: healing from the inside out and the outside in. The four major components are the client/therapist relationship, the milieu, the expressive therapies and family therapy. The therapist creates layers of safety on all levels: physical, emotional, cognitive, and spiritual in their way of being and presence. During the therapy session, the therapist uses a method with the client described as: the art of following and guiding. Each session has a beginning, middle, and closing ritual. The focus of the sessions is to help the client to draw upon their own innate wisdom, so they can grow and heal in their own unique way. 56 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Chapter Five: Voices of the Participants: A Grounded Theory A naturalistic paradigm provides guidelines for the grounded theory to emerge from the data rather than proceeding from the data (Lincoln & Guba, 1985). This chapter will begin by providing some background information about the participants, as well as how they came to know about Holistic Expressive Therapy. The chapter will provide a description of how the participants have been influenced by Holistic Expressive Therapy. From the data collection emerged seven categories: supervisory relationship, holistic, way of being, client/therapist relationship, milieu, expressive therapies and cognitive behavioural therapy is limiting and 14 subcategories (see Figure 4). The categories and subcategories will be described using coded text excerpts taken directly from the participant interviews. In this way, a grounded theory begins to develop that describes the collective influences of Holistic Expressive Therapy on their practice. Background The background information collected from the participant's pre-screen interview is useful in contextualizing the findings. However, the information shared will be nonidentifying to maintain the confidentiality of the participants. All four participants are female and have an age range of 33 to 59 years. All of the participants have their Master's degree in social work or counselling psychology. One has two Master's degrees and another has a PhD. Two of the participants are registered art therapists, one participant is a registered play therapist, and another has certification as a cognitive behavioural therapist and a structural family therapist. The participants shared that they have past or current experience with First Nation organizations. Two participants are in private practice and one participant is in a 57 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry school setting. All of the participants have shared they have knowledge, practice, and have been influenced by Holistic Expressive Therapy. All the participants have a high level of specialized education and practical experience that adds a richness, validity, and credibility to their involvement in this study. Category 1: Supervisory Relationship The category that first emerged for all participants was supervisory relationship, with subcategories of role, appreciation, and process of learning. Dhaese plays the role of supervisor and teacher for all participants, and the role of group supervisor, mentor's mentor, and apprentice for one participant: The way I learned all the different languages and I guess it is really the way you use any language is that you have to practice. You have your teacher and you have to practice and you learn and then you go out and feel what you do and then you come back to your teacher, and so it is like an apprenticeship. (A 18) All of the participants describe their feelings of appreciation of the supervisory relationship with Marie-Jose Dhaese. Participants described Dhaese as being well liked, lovely, and a breath of fresh air. I guess with Marie-Jose you kind of got the feeling where all of that stuff was paid attention to...your being, being paid attention to. And I think that part of her, um, I know some people have theories and I think it is a very wordy thing and is very interesting but, um, that is not really what you got from her. It was more of a whole, acceptance or warmth or acknowledgement of that other stuff. (CIO) / describe her as a breath of fresh air and she helps me to renew my energy as a therapist. (D60) / like Marie-Jose. She is a lovely person, I really like her and I think clients do too and that is important! She is a lovely person. (B39) 58 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry / do remember feeling very attracted to just not the play therapy but just her. Her presence is very lovely! (C7) ... she [Marie-Jose] has innocence and a humbleness...a childlike nature and she has qualities of a teacher and healer. (A42) Furthermore, there is a deep appreciation and acknowledgment that Holistic Expressive Therapy was developed by Marie-Jose Dhaese's from her own personal and professional experiences. This is recognized by the participants as being significant and valid: Marie-Jose came up with this [Holistic Expressive Therapy] after 20 years of working with children and knows exactly how this [Holistic Expressive Therapy] works with children, which is a very solid place to come from because research with children below 8 years of age does not exist (C36) The first thing she said was that if you come for 1, 2, 3, how to do this or if you want a bibliography to refer to and up to date research then you are in the wrong place...so right of the bat that told me that her wisdom and knowledge was built on experience. (D54) ...she [Marie-Jose Dhaese] is really one of the pioneers in the area, not only of art therapy but of expressive therapy and play therapy and sand tray work...(AS) All of the participants describe the approach as a process of learning that continues throughout their lifetime. One participant describes being deeply influenced but has some difficulty putting her ideas into words and therefore uses a metaphor of "rain softening the heart": So as far as what Marie-Jose has offered me — would be using dijferent modalities...you know how you are with someone when you like their style —you can take that in. It is a process, like when the 'rain comes down on the heart and it softens it up after a while'. So it is a process, but I cannot say specifically but definitely I 59 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry know she was a great influence for me and I do use a lot of her stuff and sometimes I am probably not even aware of it. It is like a process, you know like when the rain comes down on the heart and softens it up after a while. (B22) / remember taking time to go over to Hornby Island to take more workshops from Marie-Jose...because I needed to know more! (CI 3) / am a lifetime learner, so I am always reading and learning. I read academic-wise but really I would say that the academic work is only part of the learning. If you look at the learning theory... when you read something you only retain so much, if you hear it you retain a little bit more... if you read it and do it and then if you read it and doing it with a witness, in this case with Marie-Jose then ah...this is true learning. (A 19) Category 2: Holistic Holistic is a category that consistently emerges as an important influence in the participants' practice, and out of this a subcategory, principles emerges. Holistic means being able to provide an overall theory that encompasses the variety of mediums used in the milieu: ...so whether I am working with just words, um, or through sand or through the art, or through sand, through art, through clay, it does not matter which medium that I am working with in my studio, even with the dogs, everything is symbolic, including words, so I look at everything as symbols, as metaphors, as patterns, yeah, so it does not matter which way anything comes to me, it is always thinking, I guess that is just the definition of holistic? (Al 1) Several participants describe how well the holistic approach fits with their Native clientele: Ifind that this is a culture [Native] that does a lot of work with their hands...carving, beading, quilting and very much into the outdoors...not necessarily verbal, so I think that Holistic Expressive Therapy would be quite beneficial with this population. (D39) 60 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Holistic is viewed as having respect for all parts of self and recognizes the strengths of each child in therapy: Respect for the Holistic, the other stuff that make up the world, physical, emotional, cognitive, and spiritual — when you are working with children, cognitive is not necessarily their strength. (C60) Category 3: Way of Being The participants describe Holistic Expressive Therapy as enhancing their way of being in the world, personally and professionally: It is a way of being — // is apart of my life, as well as in my work life. (A 12) Holistic Expressive Therapy is a way of being and once you start doing that it does affect your whole life. (B30) Within the way of being category emerges the subcategory, view of self-healing. The view of self-healing provides the theory and guides practice. The theory helps to define the participants' role, actions, and techniques of each session: You know with cognitive behavioural therapy you feel like you are...the focus is more on teaching skills as opposed to allowing the person to harness their existing skills, and to bring those to light. (D8) It is again honouring their innate abilities and skills and gifts. As opposed to telling them what their gifts are, telling them what their deficiencies are. It is more...I am walking with you through this journey as opposed to pulling you along. You come here for help. (D12) She [Marie-Jose] talks a lot about healing the children from the inside out and the outside in and how that can happen and I really like that, it just made a lot of sense to me. (B12) 61 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Within the way of being category emerges a second subcategory: the art of following and guiding that guides the session. The participant follows, reflects, mirrors, and guides the child with clarity of thinking and warmth of the heart: ...this is a child who has experienced abuse and then as a clinician, that then becomes the focus and you want to go straight for it. So you can intentionally bring it up but that is not moving at the child's pace and it is not honouring how they communicate because they do not have the cognitive capacity to do that, they communicate through the symbolic language. It is really having to let go, having to let go and relinquish control that we can sometimes have as a clinician and allowing the natural healing process to present itself (D9) ...not interpreting but reflecting...um, meaning that when we interpret, it is almost like we take what they are giving and manipulate it based on our own personal perception. Whereas reflecting is taking it and mirroring it right back, maybe in a different way but just mirroring that back. (D13) ...reflecting, giving words to the images or to what they are doing is very powerful...there is something very valuable in that. (C28) ...the following, the guiding and the containing, the following, the guiding and the containing — that is the kind of thing that really helps young children. (C29) Category 4: Client/Therapist Relationship The participants identify Dhaese's views on the importance of the client/therapist relationship as influencing their practice. Dhaese describes the client/therapist relationship as being a vehicle for transformation and healing. One participant describes the holistic approach as being a transformative process in her own development as a therapist: It is holistic work. It is all about the transformation of the therapist at the same time there is a deep recognition that we are all one. (A20) And another who practices in a school setting: 62 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry / do know that if you have a relationship with that child it makes it a whole lot easier for things to happen... I think you can change the trajectory of where they are going to go. (C31) There are four subcategories that emerge from the category of client-therapist relationship. They are self-knowledge, self-awareness, safety, and presence. Three participants describe the importance of consciousness and self-development of the therapist. The therapists must have awareness of their strengths and their weaknesses and they must know how much safety and containment they can provide: / think who you are really probably dictates who comes to you. (C39) Other participants describe the importance of having self-knowledge and selfawareness in the development of the therapy room and in the selection of expressive therapies. This really connects with being able to bring your self into the therapy room, and to do that, there must be an understanding of the self of the therapist. Holistic Expressive Therapy is not a manualized approach to therapy. Each therapist brings a unique self to the therapy room. The subcategory safety is identified as being integral to Holistic Expressive Therapy. The child must have a sense of safety during the therapy process and there are many layers o safety the therapist must create. This is achieved by creating safety within the physical pace of the therapy room, within the client-therapist relationship, and within the expressive therapies that are being used in the therapy room: The other thing is, it must be stressed that the therapy room is a safe place. I am much more conscientious and much more aware of it being a safe place. (D15) Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Safety must also be created by the presence of the therapist. The therapist's ability to attune to the needs of the child and for the child to have the experience of being seen and heard by the therapist: In [university] we are taught a very systemic, we are taught from the medical model, we are taught that there is cause and effect. Whereas, this [approach] is really understanding that there is something taking place, 'your presence' but you are not necessarily the cause. (D49) It is your physical, spiritual, and emotional presence, and children and teenagers pick up on that. (D50) Category 5: Milieu All of the participants make positive reference to the milieu in therapy as influencing their practice. The milieu is a concept that was not taught in their university education. Several participants describe Dhaese as being very skilled in conveying the importance and design of space: The milieu is important because when you are in school [university] they talk about the internal part but now how the environment effects children...the effect of a nurturing office on the children is really lovely and the space becomes a nice place for the children to be and I may not have thought about that as much if it were not for Marie-Jose teachings. (B17) Marie-Jose is brilliant in terms of how you set up a space! (A30) Milieu refers to the physical space in which the therapy takes place, which may occur indoors and outdoors in nature. Some children who have been abused cannot tolerate the confinement and restrictiveness of an indoor office. Therefore, the therapists must create a sense of safety in some other way: 64 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry When I first started I had a very tiny office and the agency I worked for was very encouraging — told me to do whatever I needed to connect with these hard to reach kids, then I met Marie-Jose who taught me Ijust needed to reach these kids in whatever way I can and meeting in my little office was just not going to do it. (B19) So I had to learn to use what I have, so then I used to spend a lot of time outdoors with clients. There was an elementary school across the street so we would go and play basketball. It was really lovely. In that setting it worked...we could go outside and use the world. (B18) The way in which the milieu is designed can communicate a sense of trust and safety to the client much more than any words can ever convey. The milieu has the ability to express who you are to the child. The way in which the milieu is designed, organized, arranged, as well as the selection of expressive mediums, all have symbolic meaning for the therapist. In this way, everything in the milieu has significance: So for really hurt children, their immediate crucial problem is trust. Do they trust you or not? So consistency and reliability are crucial. The space needs to be set up the same way each week which communicates to the child without any words, you can rely on me, and you can trust me. This place is tight, it is a container, it is sealed, and it is safe. (A26) The milieu represents who you are because there is a process in designing, developing, and acquiring all that goes into the creation of the space. It is a thoughtful process to choose and place all that exists in the therapeutic space: Marie-Jose has taught me that 90 percent of the work could be done with the creation of space — because everything is symbolic —your space is a metaphor of who you are as a practitioner. (A25) 65 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Category 6: Expressive Therapies All the participants shared how important it was to learn the various techniques of the expressive therapies. Dhaese workshops involve an experiential learning model whereby knowledge and theory are taught, and then there is an opportunity to practice the techniques in order to experience the felt sense of knowing. Dhaese believes therapists must have an experiential understanding of the expressive therapies' capacities to transform and heal. The participants share that their university training was inadequate and did not prepare them to work with children in therapeutic practice. / needed to learn a different language so that I could work with children because specifically children have not developed rational linear thought yet, and in order to work with words you have to develop rational linear thoughts...although I was an art therapist, this was not enough for severely emotionally disturbed children — so sand tray and play therapy was the answer because you are already working with images that are formed. (A 16) Several of the participants describe the importance of developing their own working relationship with the expressive therapies they choose to have in their milieu. They need to be well versed in the language of expressive therapies to know what it can and can't do: You have a relationship with the medium. (D17) Another participant shares that the expressive arts allows the freedom to reach people who may want to express themselves holistically: ...expressive arts...is a way of reaching people holistically. (B35) Many participants shared the strong influence of learning the languages of symbols, metaphors, and imagery. The expressive mediums are like having a repertoire of languages, each one serving its own puipose: 66 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Mediums are like different languages, each one has its place. (A 17) Actually giving kids some voice to their world or what is going on with them. Giving them some positives and pointing out or just giving them some vocabulary about their feelings...this all comes through with the sand tray. Connecting them with some words about what is going on. (C24) One participant describes the important role of dogs, as having a co-therapist' role: ...the healing power of dogs...oh, my god, these dogs do so much work! (A3 9) / think what I liked about her workshops was there was something to the non-verbal; something very powerful in images — there is something in bringing those images to consciousness and in giving words to the images. (C28) The symbolic language is a subcategory of expressive therapies. Several participants describe how much Holistic Expressive Therapy influences their understanding of the symbolic language of the expressive therapies, particularly when working with sand tray: / would say the fact that I work with sand now is totally influenced by her [MarieJose]...the whole idea of symbols, symbols as a way of communicating, as best you can. Symbols are not as accurate as words, they are much muddier but that is the place or space the kids are coming from. (C55) Communicate through the symbolic language. It is really having to let go, having to let go and relinquish control that we can sometimes have as a clinician and allowing the natural healing process to present itself. (D9) One participant shares the application of expressive therapies for children who have tactile, visual, auditory, and/or olfactory sensitiveness: A lot of the kids I see have been so damaged you cannot always use just one mode — so the multisensory works, Marie-Jose is a master at using multisensory...it is another way of reaching people holistically. (B35) 67 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Category 7: Cognitive Behavioural Therapy is Limiting All of the participants described Holistic Expressive Therapy as influencing their practice because it has given them more tools or languages to work with children. Many of the participants were trained in Cognitive Behavioural Therapy (CBT); however they shared CBT was inadequate and insufficient to help children: Cognitive was limiting, Ineeded something more... I needed sand and play therapy training. (B13) Cognitive behavioural therapy does not fit with very young kids, kids who are learning disabled, or if language or cognitive is not their strength. (C34) Cognitive behavioural...the focus is more on teaching skills as opposed to allowing the person to harness their existing skills, um, you know, and kind of bring those to light. (D8) Summary The seven main categories: supervisory relationship, holistic, way of being, client/therapist relationship, milieu, expressive therapies and cognitive behavioural therapy is limiting, serve to describe the influences of Holistic Expressive Therapy on the participant's therapeutic practice. The category: supervisory relationship is identified as being a very important part of the participant's professional development. Each participant speaks highly of Dhaese's own process of developing her approach from a place of knowledge, trust and wisdom. The holistic principles appear to shape their way of being in the world, both professionally and personally. Holistic is almost described as a philosophy that enhances their life and creates more self-awareness and self-knowledge. There is general agreement amongst the participants that the self of the therapist is an instrument that needs to be fully known and understood. The participants recognize the need for the therapist to have 68 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry self-knowledge and self-awareness in order to learn the symbolic languages of expressive therapies. Awareness of self is identified as being a necessary for the development of the client/therapist relationship and for the development of the milieu. All of the participants expressed their commitment to continue learning and practicing this approach to assist the children they work with. The majority of the participants have identified Holistic Expressive Therapy as influencing their decision to pursue further university education. The participants all shared that they have been positively influenced by their relationship with Marie-Jose Dhaese and Holistic Expressive Therapy. 69 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Chapter Six: Linking the Findings with the Literature The case study and grounded theory findings reveal a congruence of ideas. The seven categories in the grounded theory are as follows: supervisory relationship, holistic, way of being, client/therapist relationship, milieu, expressive therapies, and cognitive behaviour is limiting. The case study provides a frame of reference and context for the grounded theory. The study findings illustrate that Holistic Expressive Therapy is an original approach developed by Dhaese from her 30 years of personal and professional insights into the selfhealing journey. The study findings also illustrate the profound influence her approach had on four participants. There are two findings that emerged in the case study and the grounded theory that will be linked with the literature, and they are: client/therapist relationship and cognitive behavioural therapy is limiting. The first finding client/therapist relationship has been identified as an important feature of Holistic Expressive Therapy. There is a body of literature that explores the importance of the client/therapist relationship in play therapy (Kimary, 1994; Riedel Bowers, 2001; Riedel Bowers, 2009). The second finding cognitive behavioural therapy is limiting has been identified in the grounded theory. There is some debate in the literature on the research and practice of cognitive behavioural therapy and the challenges of applying evidenced-based practice with children (Kazdin, 2003; Waddell & Godderis, 2005; Westen, Novotny, & Thompson-Brenner, 2004). First, the client/therapist relationship is one of the oldest themes discussed in the literature (Freud, 1958). Carl Rogers (1995), founder of client-centered therapy, whose theory has been influential in the development of non-directed play therapy, describes the 70 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry importance of the client/therapist relationship: "The self-awareness and human presence of the therapist is more important than the therapist's technical training" (Rogers, 1995, p. vii). Therapists bring themselves to the therapy room — they use themselves as an instrument of change. This remains true for clients of all ages. There is a lot of literature on child psychotherapy that discusses the importance of the client/therapist relationship. Shirk and Saiz (1992) have written extensively on the working alliance and the change process in child psychotherapy. They refer to the relationship or treatment alliance as: The positive feelings the child had for the therapist that enabled the child to accept the therapist as an aid in overcoming emotional or interpersonal problems. In essence, the alliance was a means to an end. It referred to the affective quality of the relationship between the child and therapist that enabled the child to work purposefully on resolving problems, (p. 715) Kimary (1994) has researched the development of the therapeutic relationship in a non-directed play therapy setting. His study reveals that the therapists' ability to be alert, responsive, aware and empathetic have a profound effect on the development of the relationship, which is critical to assist the client through the process of counselling. Within the category of client/therapist relationship there emerged three subcategories: self-knowledge/ self-awareness, safety, and presence. Self-knowledge and self-awareness of the therapist is essential. There is not one particular way the therapist develops self-knowledge and self-awareness; however, experiential learning and reflection are two ideas described in the literature. Dhaese emphasizes the importance of experiential learning when she teaches Holistic Expressive Therapy. Experiential learning can be defined as: "the process of making meaning from direct experience" (Itin, 1999, p. 91). This particular approach to learning is 71 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry not new. Aristotle said, "For the things we have to learn before we can do them, we learn by doing them" (Bynum & Porter, Eds., 2005, p. 21). Rogers (2003) stresses the importance of experiential learning as being fundamental to counsellor training. Dhaese uses an experiential learning approach to her teaching because it provides a greater depth of self-understanding and awareness of the theories, insights, and components of Holistic Expressive Therapy. Gendlin (1979), known for his classic work in psychotherapy and counselling research and his book titled Focusing supports the process of experiential therapy. It is through a process of experiential understanding that the therapist develops a greater sense of self awareness. Experiential learning involves reflection. Schon (1986) explores the importance of reflection, reflection-in-action, and the relevance of using reflection to turn experience into learning. It is well known that the therapist needs to integrate personal and professional experiences into a practice framework in order to develop an authentic framework of practice. Eisler (2006) describes the importance of having a strong and enthusiastic allegiance to a therapeutic model: "doing something we are wholeheartedly committed to must surely be more effective than something we only half believe in" (p. 330). Rizq and Target (2008) explore the role of personal therapy in developing practitioner competence: "One of the most significant themes identified includes the ability for the practitioner to be reflective is connected to the nature, quality and status of the therapist's early attachment experiences" (p. 146). Dhaese emphasizes the importance of the therapist to be aware of their own attachment style, because the development of attachment between the therapist and the client is an integral part of the therapeutic alliance. The discussion on the importance of self-awareness in the therapeutic process includes the understanding of one's worldview. Simon (2006) argues that when the therapist 72 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry becomes aware of their worldview, and adopts a model that is congruent with this view, the therapist is able to reach their potential. Therapists are then able to develop an authentic framework of practice. Sprenkle and Blow (2007) agree with Simon's argument, stating that further attention in research needs to be paid to the expertise of the therapist, independent of the model that is practiced — models work through therapists. Donati and Watts (2005) acknowledged that personal development remains a poorly defined area of training. The professional development of a therapist is not static. There is a common belief in the literature that a therapist needs to attain a degree of personal development and self-awareness as "the counsellor can only take their clients as far as they have been themselves" (Sinason, 1999, cited in Donati & Watts, 2005 p. 475). Experiences shape the journey that spans the length of the therapist's career. Skoveholt and Ronnestad (1992) provided a qualitative study on therapist-counsellor development by interviewing 100 participants to develop a stage model: The themes presented here suggest that development involves a movement from reliance on external authority to reliance on internal authority and that this process occurs through the individual's interaction with multiple sources of influence over a long period of time. (p. 514) A subcategory under client/therapist relationship is safety. The therapist's awareness of their worldview is related to the subcategory safety. Dhaese describes safety as being established by the therapist in their own self development and awareness — the being of the therapist, but also in the establishment of the milieu. Over the past two decades there has been a body of new literature on trauma treatment for children (Cattanach, 1992; Gaensbauer, 2000; Levine, 1997; Nader, 2008; Osofsky, 2007; Pearce & Pezzot-Pearce, 1997; Ryan & Needham, 2001; Terr, 1989 & 2003; van der Kolk, 1989). Safety is one of the 73 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry essential features that must be present within the client/therapist relationship and within the therapy room. Sills speaks to the elements necessary in healing of the wounded self, which include trust and safety. "In order for basic trust to be established, the therapist must generate a holding environment that is experienced as both safe and non-collusive. (Sills, 2009, p. 262) Another subcategory under client/therapist relationship is presence. Presence is a state of existence: being in the here and now, and being aware of and awake to the internal and external experiences of the present moment. The concept of presence has been discussed in the psychotherapeutic literature at great lengths and is being described in terms of neurobiology (Cozolino, 2010). The concept of presence can be linked to Daniel Stern's (2004) ideas of what he refers to as moments of meeting between the therapist and client, Donald Winnicott (2005) makes reference to transitional space, Allan Schore (2003a & 2003b) describes the existence of presence in right brain to right brain communication, and Daniel Siegel (1999, 2007, & 2010) makes several references to presence in the here and now as mindsight. Daniel Siegel (1999) describes interpersonal neurobiology as a scientifically grounded paradigm that intersects neuroscience and psychotherapy. In Siegel's groundbreaking book, The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are (1999), he explores the processes of interpersonal relationships and how they can shape the mind. The research on interpersonal neurobiology is providing the scientific language to describe Marie-Jose Dhaese's Holistic Expressive Therapy — which was developed from the insights from her own personal and professional self-healing journey. 74 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Secondly, there is a body of literature that explores the challenges of using cognitive behavioural therapy (CBT) with children and the problems associated with conducting evidence-based research with children. Dhaese acknowledges that the cognitive is one part of a holistic approach to therapy. To focus only on the cognitive, would not be considered holistic. Whatever expressive therapy is used is based on the awareness of all parts of the client, such as the cognitive, emotional, physical, and spiritual needs of the client. The art of following and guiding is used by the therapist to attune to the needs of the child in the here and now. Sometimes the needs of the client may be physical, such as the need to walk, dance, eat, or drink and sometimes the needs of the client may be cognitive, such as the need to talk or sing and other times the needs of the client maybe a combination of all parts of the self. Dhaese acknowledges that with all therapeutic approaches there are limitations and it is important for the therapist to be aware of limitations of the approaches they choose to use. In February 2003, the Child and Youth Mental Health Plan (CYMHP) emphasized the need for evidence-based practice (EBP), recommending two interventions as an approach for children, youth, and families: Cognitive Behavioural Therapy and Interpersonal Psychotherapy. Social workers recognize that EBP does have an important role in the establishment of good practice; however, the limitations must be understood by the therapists in developing treatment plans for children. There has been a lot of research on cognitive behavioural therapy (Cohen, 1998); the interventions are inappropriate for infants and very young children, given their limited cognitive abilities. Kazdin (2003) has written extensively on the tasks and challenges of psychotherapy with children. According to Kazdin, CBT randomized controlled trials and single-case experimental studies have been completed for children 9 - 1 3 years of age but not for children younger than 9 years of age (p. 5). 75 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry There are a number of problems when conducting evidence-based treatment with children. One problem is that children are changing and developing, so it is difficult to obtain cohort groups of children to study. Secondly, the ethics around studying children are problematic. Many research studies require a control group where treatments are not applied. Research of this nature would be considered unethical and would never obtain ethic board approvals. Thirdly, some argue research is defined too narrowly and is focused on modernist scientific paradigms, rationalism, and objectivity (Waddell & Godderis, 2005). Tanenbaum (2005) argues current evidence-based research is based on studies often conducted in controlled research settings, which lack the realism of a clinical practice setting, the natural setting. She also recognized that therapeutic relationships are central to mental health practice but efficacy research typically focuses on techniques that can be investigated quantitatively, which does not allow the opportunity to measure the therapeutic benefit of the relationship (Tanenbaum, 2005). There is another set of arguments with regard to the application of evidence-based treatment. Shirk and Russell (1996) argue that developmental intervention on the exclusive basis of a formal diagnosis is inadequate. They criticize the Diagnostic Statistical Manual — IV- TR (2000) (DSM-1V-TR) as omitting references to underlying, inferred pathogenic processes, but instead focusing on observable patterns of symptoms. A second argument is that evidence-based practices are designed for single DSM-IV-TR mental health disorder diagnoses, and treatments are manualized, and often limited to an 8- or 10-week period (Messer, 2004; Pearce & Pezzot-Pearce, 2007; Westen et al., 2004). Most children seen in clinical practice have more than one condition — comorbid or concurrent conditions. When there is more than one condition, treatment plans are more 76 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry complex and require a separate and individualized treatment plan for each disorder. A third argument is that a treatment manual is structured and directive and may have an adverse effect on the client/therapist relationship (Goldfried & Eubanks-Carter, 2004; Wampold, 2001). Therapists must have a clear understanding of the strengths and limitations of all the approaches they choose to use in the therapy room. In qualitative research, there are a variety of methodologies, ranging from narrative approaches to single case study experimental design and full-scale randomized control trials. These studies provide a realistic clinical perspective that offers a richness and intensity in learning. The lack of evidence-based research for approaches other than Cognitive Behavioural Therapy and Interpersonal Psychotherapy does not mean that other approaches are less effective. There is encouragement for outcome research despite the methodological challenges. The case study of Holistic Expressive Therapy emphasizes a holistic approach to therapy. In the eyes of the therapists who participated in the study, Cognitive Behavioral Therapy was limiting. Implications for Children and Youth Mental Health This inquiry has implications for children and youth mental health, relating to the misunderstanding that a generalist or manualized approach to therapy is appropriate for all clients. Each client presents with a unique history, strengths, and challenges, and therefore requires a treatment approach that honors personal uniqueness. The increasing demands for services in mental health are putting pressure on a system in search for quick fixes, whereas it needs to be understood that none exists! There is no magic wand that will erase children's difficult experiences and any approach that proposes to do so is a false pretense. Children and youth accessing mental health services often require more than a manualized approach to therapy. 77 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry In British Columbia, Children and Youth Mental Health (CYMH) falls under the Ministry of Children and Family Development (MCFD). In February 2003, the release of the Child and Youth Mental Health Plan (CYMHP) outlined a 5-year implementation plan to improve services to children, youth, and families. The key strategies of the CYMHP were for risk reduction, capacity building, treatment and support, and performance improvement. There are many children in the foster care system that are referred for mental health services, who do not have the stability, sense of safety, or a family willing to participate in therapy. Foster children have a common experience of being in limbo because of frequent foster placement changes, changes of their social workers, or because of lengthy court proceedings which limit future planning. This unpredictability compounds children's behavioural and emotional issues. It is common for children who have experienced trauma, abuse, or neglect to reenact their traumatic experiences. This reenactment frequently leads to foster placement breakdown, reinforcing core beliefs of being rejected and unwanted. This inquiry has identified safety and family therapy as being essential components in the practice of Holistic Expressive Therapy. Dhaese emphasizes the need that safety and family therapy be present in order to proceed with therapy. On June 1, 2008 the MCFD published a document, Strong, Safe and Supported: A Commitment to BC's Children and Youth, which introduced a new initiative called the Child and Family Support, Assessment, Planning and Practice (CAPP), that will make dramatic changes to service delivery. The CAPP proposes a strength-based, developmental approach to assessment, planning, and practice. In September 2010, the BC Association of Social Workers (BCASW) released a response letter to the MCFD CAPP Description and Discussion Paper. The BCASW expresses concern with the proposal to "dissolve practice 78 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry boundaries between child welfare services, mental health, youth justice and contracted agencies" (p. 1). Furthermore, "the proposal for combined roles of 'key workers (case managers) assessing child safety, providing mental health services, and even for arranging voluntary care agreements gives us great concern" (p. 2). This plan is already being introduced at five initial implementations sites across the province. The CAPP plan has significant implications for clinical social workers in mental health because it proposes an expansion of a generic or generalist approach to children and youth mental health. Waitlists continue to increase and cases are becoming more complex, making demands on clinical social workers. The CYMHP (2003) needs to change to reflect the current neurobiology research that sheds a new light on the plasticity of the brain and its ability to restore and repair traumatic experiences. The neuroscience research is providing new hope for children who have experienced trauma. I believe the CAPP proposal is taking children and youth mental health a step backward in time because the neuroscience literature is not being cited. The naturalistic inquiry on Holistic Expressive Therapy describes an approach consistent with the neuroscience research on affective communication and right brain emotional and cognitive processes of therapy. In rural, remote, and northern mental health settings, a generalist approach in children and family mental health is most common. Schmidt (2000) suggests a northern social development approach which links economic factors to personal presenting problems, and the application of a multidisciplinary system. The participants in this study described how they were limited or unable to work with children, prior to taking workshops in Holistic Expressive Therapy with Dhaese. The desire to develop specific skills and knowledge was driven by the needs of the client population they served. The knowledge and practice skills 79 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry they learned have provided them with more methods of reaching children experiencing difficulties. In this respect, the participants situated in remote, northern mental health settings used a social development approach to their social work practice. Implications for Structural Social Work What implications does this naturalistic inquiry have for structural social work? First, I will review what it means to be a structural social worker and the empowerment of vulnerable populations. A structural social worker is any person with a degree in social work who has been educated in structural social work ideology, theory, and practice and uses this framework as a theory of practice. Structural social workers may be employed in a variety of settings, for example: child welfare, mental health, or youth forensics. Bob Mullaly's Structural Social Work (1997) argues the primary focus of structural social work practice is on behalf of oppressed groups. Oppression is viewed as a social construction rather than blame the victim. The naturalistic inquiry within Holistic Expressive Therapy explores an approach that can be used with all ages and therefore, when linked with our most vulnerable populations such as children, youth, and seniors, it has specific implications for structural social work. Children, youth and seniors are groups who may experience various forms of oppression such as exploitation, marginalization, powerlessness, cultural imperialism, and violence. For example, Anne Bishop writes about the oppression of children in Becoming an Ally (1994): What most North American children carry with them into adult life, however, are the fears and low self-esteem that come from experiences of powerlessness, and the strategies they learn for self-protection, (p. 49-50) 80 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Structural social workers' goal is social transformation of the oppressed and empowerment. This demands working creatively within and against a system to create change for the oppressed and vulnerable groups. Summary This inquiry has provided an awareness of a therapeutic approach called Holistic Expressive Therapy, developed by Marie-Jose Dhaese whose focus is to help those who have been hurt by difficult experiences, express, and transform their experiences into wisdom. Structural social workers practicing this therapeutic approach deal with various levels of the client system. These include the individual client, family, community, and larger societal context. In this way, both a micro and a macro approach are at the heart of structural social work practice. Assessment and treatment is not solely focused on the client (micro), but involves the family, school, physician, and any other system with which the client connects (macro). They all have the potential of becoming part of the treatment plan to assist and support the transformation of the client's difficult experiences. For structural social work the political end is to change the status quo and leave oppression behind. This does not preclude intervention at the individual or family level, but instead of dealing with each of these levels by itself the connection between private troubles and the structural source of these troubles is made in every case. Each structural social worker must see her or his individual work as an integral element of the larger movement of social transformation. (Mullaly, 1997, p. 165) Mullaly (1997) describes exactly how structural social work practice achieves this goal of social transformation. Empowerment and consciousness-raising are the two primary means of practice. These ideas are congruent with a Holistic Expressive Therapy approach to practice. Dhaese describes theories, insights, and techniques to help those who have been 81 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry hurt connect with their true nature — this is a self-empowerment process. On the healing journey, clients go through a process of transformation, self-understanding, and consciousness-raising which leads to empowerment. This empowerment process initially begins at an individual level and then has the potential to spread, bringing change and transformation to the systems the individual is connected with, such as family and society. Individuals make up the whole of society. Therefore, social transformation must begin with one person at a time. In this way, Holistic Expressive Therapy has a cohesive and congruent link to structural social work. 82 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Chapter Seven: The Ending This naturalistic inquiry into Holistic Expressive Therapy is an introduction conducted with the purpose of contributing to the literature an approach developed by MarieJose Dhaese. There is a lifetime of theory, insights, methods, and practices in Dhaese's Holistic Expressive Therapy. The participants described how Holistic Expressive Therapy influenced their practice and how the influences shaped their way of being in the world professionally and personally. Suggestions for Further Research My suggestions for further qualitative research would begin with a deepening of the knowledge and practice of Holistic Expressive Therapy. In the advance workshops, Dhaese applies her approach to specific challenges such as grief and loss, neglect, abuse, and trauma. Dhaese also conducts specific workshops on the various expressive therapies, such as sand tray and play therapy, at her Centre for Expressive Therapy in Parksville, BC and at the Justice Institute in Bumaby, BC. Research in these areas would be a natural progression for learning about more advanced knowledge and practice of Holistic Expressive Therapy. Case studies of Dhaese's clinical experience of Holistic Expressive Therapy with traumatized children would provide further insight to the therapeutic process. Equally interesting would be a naturalistic research study investigating development in becoming a Holistic Expressive Therapist. Further qualitative research into Dhaese's Holistic Expressive Therapy is unlimited and would be an exciting endeavor. 83 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Final Thoughts This inquiry has come to an end. I reflect back to my first visit with Marie-Jose Dhaese in January 2005, in -40° temperature, sipping on a cup of organic tomato soup. I recall how daunting it was to focus my thesis on Dhaese's life work; but my desire to have her work known was greater than my fears. Finally, I realize how Holistic Expressive Therapy has influenced me. First, I believe it is very important for play therapists to understand how their particular practice of play therapy comes to be known. It is through this process of understanding that a greater sense of self-awareness is developed, which is essential for therapists. The cultivation of self-awareness is also fostered by supervision. Play therapy supervision is very important, as transference and counter transference issues are guaranteed to arise. The development and growth of the therapist is inherently a lifelong journey. Dhaese's Holistic Expressive Therapy approach complements my style of play therapy practice, as it contains multi layers of knowing and importance. The experiential learning and application of the approach has touched me personally and professionally. Dhaese's approach needs to be understood and integrated from a head and heart center, meaning that a holistic approach includes the cognitive, emotional, physical, and spiritual parts of self. Holistic Expressive Therapy has influenced me in developing and understanding my own personal sense of ontology and epistemology. My epistemology perspective refers to my way of knowing and way of understanding the social world. My position as a structural social worker complements the humanistic approach to play therapy. According to O'Connor, "the humanistic model posits environmental toxicity as the cause of child's psychopathology (2000, p. 29). In this way, 84 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Dhaese's insights to the self-healing journey are congruent with a structural social work perspective. The therapeutic posture of unconditional acceptance of the client fosters the healthy growth and development of self and connection to their true nature. My onto logical perspective refers to a way of being and a way of behaving in the social world. I have learned that an ontological perspective is a position that needs to be firmly understood and established because it provides the foundation for my practice. My ontological perspective includes values such as integrity, honesty, generosity, and spirituality. I strive to have and maintain these values in my personal life. Holistic Expressive Therapy has shaped my way of being in the world. Specifically, the holistic principles, insights to the self-healing process, healing from the outside in and the inside out and concept of human beings all resonate with my beliefs and values. Holistic Expressive Therapy can be viewed from a much larger perspective than the therapeutic or helping profession. Dhaese's insight on human beings as having a true nature and innate wisdom to manifest to their full potential in life can be viewed as a basic human need — in the sense that there is a drive or a life force to become all that one is meant to be, and to strive and thrive despite life's challenges. I believe this insight applies to the therapeutic domain, but may also be universally applied and has the potential to shape one's way of being in the world. My experience of being with Marie-Jose Dhaese as she shared her own insights of the self-healing process has been a valuable experience. Dhaese transformed her own personal and professional experiences into wisdom. I find it very inspirational when teachers walk their talk. Dhaese has developed a grass roots approach to helping others. When I reflect on my times with Marie-Jose, I have a visceral memory of being seen and heard, similar to the 85 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry experiences of the four therapists, as described in this study. My epistemology and ontology resonate with Marie-Jose Dhaese's focus to bring spirituality back into psychotherapy. Overall, Holistic Expressive Therapy is consistent with my worldview and has helped me to develop an authentic framework of practice. It was through Dhaese's self-healing journey that she developed an approach to therapy to help others whom she met on her path. Dhaese's approach is based on the thinking with the intellect and the wisdom of the heart coming together. The journey began with a little farm girl from Normandy, France, whose search for meaning took her away from her home, across the ocean to a new land where she uncovered personal insights and made surprising discoveries. In Dhaese's words, "sometimes you have to go very far, to discover what is very near. " In closing, my wish is for the knowledge and practice of Holistic Expressive Therapy to continue to help clients draw upon their own innate wisdom in ways that will lead them to growth and healing. 86 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4* ed., text revision). Washington, DC: American Psychiatric Association; 2000. Axline, V. (1947). Play therapy. Boston: Houghton Mifflin. Axline, V. (1950). Entering the child's world via play experiences. Progressive Education, 27, 68-75. Axline, V. (1964). 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New York: Arnos Press. (Original work published 1911.Final) Wengraf, T. (2001). Qualitative research interviewing: Biographic narrative and semistructured method. London: Sage. Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical status of empirically supported psycho therapies: Assumptions, findings, and reporting in controlled clinical trials. Psychology Bulletin, 130, 631-663. Winnicott, D. W. (2005). Playing and reality. New York: Routledge. 94 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Appendix A: Information Sheet and Consent Form for Marie-Jose Dhaese Information Sheet and Consent Form for Marie-Jose Dhaese This information sheet and consent form has been developed for two reasons. First, to provide you with an understanding of the thesis I am working on for completion of my Master of Social Work Degree at the University of Northern British Columbia and. second, to explain your potential role in the research study should you choose to participate. I will be filling the role of researcher for the purposes of this thesis. Researcher: Dawn Sather, Master of Social Work Student C/o intersect 1294 3 rd Avenue Prince George, BC V2L 31-7 (250) 562-6639 Supervisor: Glen Schmidt, Chair of Master of Social Work Program University of Northern British Columbia 3333 University Way Prince George, BC V2N 4Z9 (250) 960- 6629 Thesis Title: A Journey with Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry 95 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Part 1: Information About The Thesis You are invited to participate in a research study entitled A Journey with Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry, the research is being conducted by myself, Dawn Sathcr in partial fulfillment of (lie requirements for the degree of Master of Social Work from the University of Northern British Columbia. Purpose: The researcher, Dawn Sather's purpose in this research is 10 contribute to the literature by providing an opportunity for Marie-Jose Dhaese to describe and define Holistic Expressive Therapy and for three therapist participants to share the influences Holistic Expressive Therapy have had on their practice. There is no current published literature on the work of Marie- 'ose Dhaese. The sharing of experiences by Marie-Jose Dhaese and the three therapist participants can provide new information on a therapeutic approach that may be beneficial for children experiencing difficulties. I will conduct a qualitative study using a naturalistic inquiry to describe and define Holistic Expressive Therapy. 1 will collect data via %'ideo/audio interviews from Marie-Jose Dhaese using a case study approach. Then I will collect data via audio interviews from three therapists who have been influenced by Holistic Expressive Therapy. I will then transcribe all the interviews for analysis using a grounded theory method. Finally, 1 will conclude with a discussion of the findings. Funding Source: n/a Anonymity and Confidentiality: Marie-Jose Dhaese will be identified by name throughout the content of the thesis study. If during the interview process of Marie-Jose Dhaese or the participants discloses information they request be made confidential and not entered into the thesis study, these requests will be honoured During the interview process, if third party information is disclosed, the researcher may give third party information a pseudo uainc to Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry protect their confidentiality. The video/audio interview recordings and transcriptions of MarieJose Dhaese will be kept in a locked filing cabinet in the researcher's residence and will not be destroyed. If after the thesis study is completed, further release of the video/audio interview recordings and transcriptions is requested, the researcher will obtain consent. The names and contact information of the three therapist participants will be given pseuao names to protect confidentiality. The audio interview recordings and transcriptions of the three therapist participants will be kept in a locked tiling cabinet in the researcher's residence for a two year period and then the recordings will be destroyed by the researcher. Voluntary Participation: Participation in this study is voluntary. There is no obligation on your part to participate. If Marie-Jose Dhaese chooses to withdraw from the study, prior to thesis completion, her interview recordings and any information will be destroyed immediately. If any of the three therapist participants choose to withdraw from the study, their recordings and any information the participant has provided will be destroyed immediately. Risks and Benefits: Only, the researcher will have access to the interview recordings and transcriptions. The three therapist participants, their names and contact information will be kept in strict confidence, in a locked filing cabinet at the researcher's residence. Marie-Jose Dhaese and the three therapist participants may request the electronic recording device to be turned oil'at any time during Ihe interview process and this request will be respected. Marie-Jose Dhaese and the three therapist participants will have the personal freedom to choose what they would like to share during the inlet view process It the pai ueipants require emotional support as a result of their sharing, the researcher has recommended participants contact their support person for debriefing. 97 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry The researcher, Dawn Sather is a registered member of the Board of Registration for Sot.al Workcis in British Columbia (BRSW) (registration number 8349). The researcher i.s bound by the Code of Ethics of the Association. \4arie-Jose Dhaese and the three therapist participants may obtain a summary of the researcii results by contacting the researcher, Dawn Sather at sajfiejdgthmbj^ca. At their request, the researcher will mail a summary of the results to them, provided the request is made within two years completion of the study. What will be done if you take part in the research? Marie-Jose Dhaese will be asked to participate in a video/audio recorded informal conversational interview by the researcher, to describe and define Holistic Impressive Therapy. The interview will consist of three- one hour interviews, with rest breaks in between each session. The researcher will transeiibe the recordings. The researcher will analyze the uanseriptions, identifying themes and categories, using a grounded theory method of analysis. During the analysis process, Marie-.Tose Dhaese will be asked, to review identifying themes and categories for reliability. Part 2: Informed Consent Instructions: please circle your response I understand that this study involves an analysis and a written report of information shared in the interview process (Yes) Mo 1 understand that this study will include a video/audio lecorded interview (Yrf No yi'cs) No I nndcistand that F will he invited to review identifying themes and categories from the analysis for lcliability [ understand that I will be paid my hourly rate of $100 for the video/audio recorded interview sessions for an approximate total of S300 (Yes) No Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry 99 I have read and received a copy of the information sheet fres/ No 1 understand the benefits and risks involved in participation of this study fYes) No Q™) No V^/ ^° ] have been given an opportunity to ask questions about the study 1 understand that I am free to refuse to participate in this research study, at any time Any complaints about the study should be directed to the Office of Research (tcb^unbc.ca or 250.960.5650) This thesis study was explained to me by Dawn Safher. I. Marie-Jose Dhaese agree to participate in this project as explained above. Signature of Maiie-Jose Dhaese Witness Date i Date For the Researcher: L . Daun..Sathcr. certif) that I have reviewed the contents of this foim with the person signiti" above, who in my opinion imdcrstood the explanation I have explained the Known benefits and risks of paiticipating in this research study. Researcher's Signature Thank you for your contribution to this study. Date ' Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Appendix B: Letter of Invitation to Participate in the Study Voluntary Therapists Participants are needed for Thesis Study As a voluntary therapist participant in this study you will be interviewed for one hour (audio recorded). The research question is: How has Holistic Expressive Therapy influenced you in your practice? In appreciation for your time, you will receive an honorarium of $50. If you are interested in participating in this study or you would like more information, please contact: Dawn Sather, BSW, RSW University of Northern British Columbia, Prince George, BC 250-562-9474 satherd@unbc.ca Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry 101 Appendix C: Therapist Participant Pre-Screen Interview Date: Demographic: Age: Gender Ethnic Origin Name: Address: Phone number: (day) (evening) (email) Contact comments: I have a university master's degree Yes No Yes No Yes No I have knowledge and practice experience in Holistic Expressive Therapy Yes No I have over ten years experience as an expressive therapist No My master's degree is in I have participated in workshops from Marie-Jose Dhaese These are the workshops I have participated in I am influenced by Holistic Expressive Therapy Yes I work at My client population is ages I have a support person that would be available for debriefing after the interview, if required Yes No Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Appendix D: Information Sheet and Consent Form for Participants This information sheet and consent form has been developed for two reasons. First, to provide you with an understanding of the thesis I am working on for completion of my Master of Social Work Degree at the University of Northern British Columbia and, second, to explain your potential role in the research study should you choose to participate. I will be filling the role of researcher for the purposes of this thesis. Researcher: Dawn Sather, Master of Social Work Student C/o Intersect 1294 3 rd Avenue Prince George, BC V2L 3E7 (250) 562-6639 Supervisor: Dr. Glen Schmidt University of Northern British Columbia 3333 University Way Prince George, BC V2N 4Z9 (250) 960- 6629 Thesis Title: A Journey with Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Part I: Information About The Thesis You are invited to participate in a research study entitled A Journey with Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry. The research is being conducted by myself, Dawn Sather in partial fulfillment of the requirements for the degree of Master of Social Work from the University of Northern British Columbia. Purpose: The researcher, Dawn Sather's purpose in this research is to contribute to the literature by providing an opportunity for Marie-Jose Dhaese to describe and define Holistic Expressive Therapy and for three therapist participants to share the influences of Holistic Expressive Therapy have had on their practice. There is no current published literature on the work of Marie-Jose Dhaese. The sharing of experiences by Marie-Jose Dhaese and the three therapist participants can provide new information on a therapeutic approach that may be beneficial for children experiencing difficulties. I will conduct a qualitative study using a naturalistic inquiry to describe and define Holistic Expressive Therapy. I will collect data via video/audio interviews from Marie-Jose Dhaese using a case study approach. Then I will collect data via audio interviews from three therapists who have been influenced by Holistic Expressive Therapy. I will then transcribe all the interviews for analysis using a grounded theory method. Finally, I will conclude with a discussion of the findings. Funding Source: n/a Anonymity and Confidentiality: The names and contact information of the three therapist participants will be given pseudo names to protect confidentiality. The audio interview recordings and transcriptions of the three therapist participants will be kept in a locked filing cabinet in the researcher's residence for a two year period and then the recordings will be destroyed by the researcher. Marie-Jose Dhaese will be identified by name throughout the Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry content of the thesis study. If during the interview process of Marie-Jose Dhaese or the participants discloses information they request be made confidential and not entered into the thesis study, these requests will be honoured. During the interview process, if third party information is disclosed, the researcher may give third party information a pseudo name to protect their confidentiality. Voluntary Participation: Participation in this study is voluntary. There is no obligation on your part to participate. If any of the three therapist participants choose to withdraw from the study, their recordings and any information the participant has provided will be destroyed immediately. Risks and Benefits: Only, the researcher will have access to the interview recordings and transcriptions. The three therapist participants' names and contact information will be kept in strict confidence, in a locked filing cabinet at the researcher's residence. Marie-Jose Dhaese and the three therapist participants may request the electronic recording device to be turned off at any time during the interview process and this request will be respected. Marie-Jose Dhaese and the three therapist participants will have the personal freedom to choose what they would like to share during the interview process. If the participants require emotional support as a result of their sharing, the researcher has recommended participants contact their support person for debriefing. The Researcher, Dawn Sather is a registered member of the Board of Registration for Social Workers in British Columbia (BRSW) (registration number 8349). The researcher is bound by the Code of Ethics of the Association. Marie-Jose Dhaese and the three therapist participants may obtain a summary of the research results by contacting the researcher, Dawn 104 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Sather at sathcrd@unbc.ca. At their request, the researcher will mail a summary of the results to them, provided the request is made within two years completion of the study. What will be done if you take part in the research? The three therapist participants will be asked to participate in an audio recorded informal conversational interview by the researcher, to describe the influences of Holistic Expressive Therapy on their practice. The interview will be conducted individually via telephone or in person and will consist of one - one hour interview session. The researcher will transcribe the recordings. The researcher will analyze the transcriptions, identifying themes and categories, using a grounded theory method of analysis. During the analysis process, the therapist participants will be asked to review identifying themes and categories for reliability. Part 2: Informed Consent Instructions: please circle your response I understand that this study involves an analysis and a written report of information shared in the interview process Yes No I understand that this study will include an audio recorded interview Yes No I understand that I will be invited to review identifying themes and categories from the analysis for reliability Yes No I understand that I will be given an honorarium of $50 to participate in the one hour audio recorded interview session.... Yes No I have read and received a copy of the information sheet... Yes I understand the benefits and risks involved in participation of this study.. Yes No I have been given an opportunity to ask questions about the study Yes No No I understand that I am free to refuse to participate in this research study, at any time. Yes No Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Any complaints about the study should be directed to the Office of Research ("rcb@unbc.ca or 250.960.5650). This thesis study was explained to me by Dawn Sather. L, agree to participate in this project, as explained above. Signature of Participant Date Witness Date For the Researcher: I, Dawn Sather certify that I have reviewed the contents of this form with the person signing above, who in my opinion understood the explanation. I have explained the known benefits and risks of participating in this research study. Researcher's Signature Thank you for your contribution to this study. Date 106 Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry 107 Appendix E: Initial Tables of Analysis (Analysis 1) Theme Theme 2 Theme 3 Theme 4 Theme 5 Theme 6 Theme 7 Thernc 8 Theme 9 Theme 10 Theme 11 Theme 12 Theme 13 HET Principle s HET Tcchniqu c HET Medium Self Healing Process Therapy Relationship Unique Milieu M-J Role M-J Personal Quality Holistic Crcdibili Develop nicnt Epistemo ty Principles arc important A,B,C,D Works well in schools (C) Working with d o g s (A,B) Nature part of self healing process (A,B) Importance (A,B,C,D Of practice (A3) Importan ec of space (A,B,C) Lovely person (B,C) Way of being (A,B) Scientific language ofHET process (A,C) Process of becoming HET (A,B) Resonate with belief system A,B,C,D Know led geof principles (B,C) Foi young children (C) Condition , quality of tools (A) Metaphor of egg (D) Therapist self knowledge, awarencs s(C) Of design, space, milieu (A) Placemen t of play stuff, containm cnt (D) Humbleness, innocence , healer, child like natuic (A) Do not teach holistic in university A,B,C,D Motivatio n for further schooling (C) Lifelong process (A) Fit iny style (B) Presence A,B,CD Can change trajectory (C) Fosters symbolic language (A,C,D) Healing from inside out, outside in (B,D) Of toys and tools in milieu, different than M-J (A) Nature, colours, Smells (A) Group supervision (A) Brilliint, knowledge of spjee (A) Limits of cognitive only (A,C,D) Motivatio n for PhD (A) Learning Theory (A) Continues to learn A,B,C,D Your being iii paid attention to (C) Follow, lead (D) Therapist has a conncctio n with medium (A,D C,D Theories ofthe self healing piocess (B.D) Personal qualities, organic (C) Natural sp ICC, environment, outdoo rs (B) Apprcntic e-ship (A) Organic (Q Way of woi king with complex issues (AB) Past viewed as flaky (A) Qualities of the therapist (C) Child s pace (D) Minor, reflect (D) Holistic concepts values by Natives (A,B,D) Play therapy needs more research (C) M-J after 30yisof piactiee — solid place (C) Helps childicn cxpicss (A,B,C,D Comcys trust, consistency, reliability familiarit y(A) Supeiviso r A,B,C,D) Teacher A, B, C, (0) Mentor's mentor (A) She lives what she teaches (D) i«sy Ontology Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry 108 Appendix E: Initial Tables of Analysis (Analysis 2) Theme Theme 2 Theme 3 Theme 4 Theme 5 Theme 6 Theme 7 Theme 8 Theme 9 M-J Role M-J Qualities Self Healing Process Holistic Milieu Relationship Principles Exprcssi\c Therapies Lifelong Process Personal qualities Organic (C) Theories of the Self Healing Process (B,D) Holistic as a Spiritual Concept (A,D) Placement of p lay stuff, containment (D) Importance of therapeutic relationship A,B,C,D Principles are important (A,B,C,D) Therapist has a connection with medium (A,B,C,D) Continues to learn (A,B,C,D) Wisdom and knowledge based on expciience Nature is part of the Self Healing Process (A,B) Do not teach Holistic Appi oach in university (A,B,C,D) Condition & quality of tools (A) Therapist self knowledge and awareness (C) Knowledge of Principles (B,C) Sand tray is sensory experience (Q Influences others in therapeutic community (B) Healing from the inside out and the outside in (B,D) Holistic Principles in Therapy Context (B) Uniqueness of design, space/ milieu (A) Process of becoming a HET (A) Qualities of the therapist (C) Working with dogs Motivation for further schooling (C) Natural space, environment, outdoors (B) Teacher (A,B,C,D) Group supervision (A) IP) Mentor's Mentor (A) Calm, open, client-centred Learning Theory (A) Respect (C) Nature, colours, and smells (A) Connected Native ways doing/being (A) My foundation (A) Lovely person (B,D) Metaphor/ Egg Oneness (A) Defines my role ID) (B) Humbleness, innocence, healer, and child-like niUiic (D) Scientific language of I1ET (A,C) Conveys tiust, consistency, reliability and familiarity (A) Mirror, Reflect (D) (A.B) Uniqueness of toys, tools in milieu, different than M-J (A) Motivation for PhD (A) Reflection (D) Limits of cognitive, only (A,B,C) Past viewed as flaky (A) Connected to Lvuythmg (13) Importance of space (A 13,C) fit my style (13) Non-verbal is powerful (A B,C D) Play therapy needs inoic research (Q Holistic concepts valued by Natives (A,C,D) Brilliant, knowledge of space (A) Resonate \\ ith belief system (A,B,C,D) Non- linear, nonverbal Thought (A) Lifelong process (A) She lives what she teaches (D) Can change tiajectory (C) (A) Apprentice-ship (A) Supervisor (A,C,D) Pioneer (A) Influenced others in therapeutic community (B) Organic (B) Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry 109 Appendix E: Initial Tables of Analysis (Analysis 3) Theme 1 Theme 2 Theme 3 Theme 4 Theme 5 Theme 6 Theme 7 Theme 8 Importance of the Holistic Approach Therapist must have Self knowledge and Self awareness Presence of the Therapist Importance of Expressive Therapies The Uniqueness of the Milieu Theories of the Self Healing Process More Research is Needed for Credibility All Participants Appreciate M-J as a person with whom all have different roles My foundation (A) Qualities of the therapist (C) H E T Principles arc important (A,B,C,D) Working with dogs(A,B) Importance of space (A,B,C) Nature is part of self healing process (A,B) Needs more research (C) She lives what she teaches (D) Holistic concepts valued by Natives (A,B,D) Resonate with belief system (A,B,C,D) W a y of being Condition & quality of tools (A) M-J brilliant knowledge of space (A) Healing from the inside out & the outside in (B,D) Past viewed as flaky(A) Personal qualities, organic (C) Wisdom and knowledge based on experience (D) Process of becoming a HET (A,B) (D) For young children (C) Nature, colours, and smells (A) Metaphor of egg (D) Motivation for PhD (A) Humbleness, innocence, healer, & childlike nature (A) Developed after 30 years of practice comes from a solid place (C) Uniqueness of design, space, and milieu (A) Being with the client (C,D) Helps children express (A,B,C,D) Placement of play stuff, containment (D) Theories of self healing process (B,D) HET can change trajectory (C) Lovely person (B,C) Holistic principles in therapy context (B) Therapist's self knowledge and awareness (Q Knowledge of principles (B.O Way of working with complex issues (A,B) Natural space, enviionmcnt, outdoors (B) Connected to everything (B) Uniqueness of practice (A,B) Calm open clientcentred (B) Non-verbal is powerful (A.B.C.D) Fit my style (B) Lifelong process (A) Your being is paid attention to (Q Non linear, non-verbal thought (A) Huhstic as a spiritual concept (A,D) Continues to learn (A,B,C,D) Mirror, reflect (D) Limits of cognitive only (A,B,C) Mentor's mentor (A) Do not teach Holistic in university (A,B,C,D) Uniqueness of pi act ice (A,B) follow, lead (D) Fosters symbolic language (A,C D) Supervisor (A,C,D) Chi Id 'b p.itc Jung/symbols (A) Apprenticeship Oneness (A) (A,B) Reflection (D) Motivation for further learning Master's (C) Scientific h n g u i g c to explain HET process (A,C) Conveys tuist, consistency, funiliaiity, reliability (A) Respect (C) Group supervision (A) Le.irning theoiy (A) (A) Marie-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry 110 Appendix E: Initial Tables of Analysis (Analysis 4) Theme 1 Theme 2 Theme 3 Theme 4 Theme 5 Theme 6 Theme 7 HET has introduced the concept of holistic and my unique connection to all that is. The H E T must have self knowledge and self awareness - HET must resonate with the therapist's belief system. The therapist/child relationship and the presence of the therapist arc very important in HET. HEX helps children to express t h e m s e h e s with or without words and fosters the symbolic language. An understanding of the importance of the milieu. Motivated for further learning, study and lifelong learning - as well as research to build credibility. H E T becomes my way of being in the world. My foundation Qualities of the therapist (Q HET Principles are important (A,B,C,D) Working with dogs (A,B) Importance of space (A.B.C) Needs more research (C) She lives what she teaches (D) Holistic concepts valued by Natives (A,B,D) Wisdom and knowledge based on experience (D) Resonate with belief system (A,B,C,D) Process of becoming a Way of being (A,B) (D) M-J's brilliant knowledge of space (A) Nature, colours, and smells (A) Past viewed as flaky (A) HET(A,B) Condition and quality of tools (A) For young children (Q Personal qualities, organic (C) Humbleness, innocence, healer, and childlike nature (A) Developed after 30 years of practice tonics from a. solid place (C) Uniqueness of design, space, and milieu (A) Being with the client (C,D) Helps children express (A,B,C,D) Placement of play stuff, containment (D) Holistic principles in therapy context (B) Therapist self knowledge and awareness (C) Knowledge of pnneiplcs (B,C) Connected to everything (B) Uniqueness of practice (A,B) Calm, open clientcentred (B) Way of working with complex issues (A,B) Non-verbal is powerful (A,B,C,D) Natural space, environment, outdoors (B) Conveys trust, consistency, familiarity, reliability (A) Fit my style (B) Lifelong process (A) Your being is paid attention to (C) Non-linear, nonverbal thought (A) Holistic as a spiritu.il concept (A,D) Do not teach Holistic in University (A,B,C,D) Oneness (A) Continues to learn (A,U,C,D) Uniqueness of practice Mnror, reflect (D) (A,B) Follow, lcad(D) Limits of cognitive only(A,B,C) Fosters symbolic language (A,C,D) Mentor's mentor (A) Supervisor (A,D) Child's pace (D) Jung/Symbols (A) Apprenticeship (A) Importance of therapeutic relationship (A,B,C D) Images (A) (A) Connected to Native ways orbcing/doing (A) Defines my role (D) Influenced othcis in the community (B) Woiks well in schools (Q Educ itc & translate to schools (C) Oiganic (C) Nature of a part of self healing process (A,B) Healing from the inside out and the outside in (B,D) Metaphor of ej!g (D) Theories of self healing pioccss(B,D) Reflection Pi escnee (A,B,C,D) Motivation for PhD (A) HET can change trajectory (C) Motivation for further learning Master's degree (C) Scientific language to explain HET process (A,B) Lovely person (B,C) Respect (C) Group supervision (A) Learning thcoiy (A) Teacher (A,B,C,D) Theiapist has connection with medium (A,B,C,D) Uniqueness of toys, tools in milieu (A) Master of multiscnsoiy techniques (B) Sand tray is sensory (C) Personal qualities organic (C) Pioneer (A) Mane-Jose Dhaese and Holistic Expressive Therapy: A Naturalistic Inquiry Appendix F: Focussed Coding 111