USING CLIENTS’ CHILDHOOD VIDEOS WITHIN A PSYCHOTHERAPEUTIC SESSION:
QUALITATIVE EVALUATION OF A NEW THERAPEUTIC PRACTICE
Theofanis Karagiannis, Philia Issari
National and Kapodistrian University of Athens (Greece)
Abstract
Inspired by Loewenthal’ s (1) work on the therapeutic use of photographs in counselling and psychotherapy, the idea of bringing, in the therapeutic space, videos from the client’s childhood, and exploring them together as part of the client’s narrative, seemed valuable. We present here the outcome of using such videos in the therapeutic setting, through a qualitative case study evaluation based on the experience of one client. The material consisted of his personal journals, along with a semi-structured interview on his experience and effect of this therapeutic tool. The researcher’s personal journals were also included as research material. Regarding the ethics of this paper, upon its completion, the client reviewed the findings, gave feedback and commented on what he would like to be included in this presentation; he also gave written consent to use in public. Thematic Analysis was used on the transcripts from the above sources. The main themes that emerged were that use of this new therapeutic technique is a form of restarting therapy, video-therapy was experienced as a process that inspires an existential way of being, interpretations can be fruitful but also dangerous, the therapeutic relationship is enriched, and it offers new possibilities for the person in therapy. Technology and digital representation of reality is claimed to have been used as ‘a matter of inclusivity’ creating for researcher and clients ‘possibilities…for meeting up with each other in a different space and timeframe’. What this research is proposing, though it needs to be subject to further evaluation, is that by allowing technology to enter the therapeutic space it could be experienced not as a violation, but rather as ‘a playful fusion of therapy with technology’ that allows the client and the therapist to be more human, as they discover new ways of relating.
Keywords: Psychotherapy, Video, Thematic Analysis, Qualitative Evaluation
INTRODUCTION
Influenced by Loewenthal’ s (1) work in therapeutic use of photographs in psychotherapy, the idea of bringing, in the therapeutic space, videos from the client’s childhood, and exploring on them together as part of the client’s narrative, seemed valuable. Here, we present an initial effort to examine, evaluate and reframe this new therapeutic tool. Several clients from the first author’s psychotherapeutic practice agreed to bring videos from their childhood in our therapy sessions, as part of our journey in their early childhood and relationships with their significant others. One client will be presented in this paper through case study research.
Photographs videos as the client’s narrative
Loewenthal worked on the use of photographs in the therapeutic process,aiming to“enable the client to speak of what is of concern to them” (2, p.133), an activity that enrichens the client’s journey toward self-exploration and personal growth. Considering the implications of an unconscious, the process of repression and Freud’s concept of a compulsion to repeat, photographs were used as a helpful tool. In relevant research, his suggestion is that phototherapy “is carried out by a therapist who has at least some basic therapeutic interpersonal training which also involves the therapist gaining personal insight” (2, p.136).
As therapists, no matter what our approach is, we very often hear stories about our clients’ childhood and family relationships. Working phenomenologically and informed by post-modern ideas could mean that the therapist hears these stories as revealing not an absolute truth, but more as the client’s meaningful narrative. Working, thus, with a client for many years may often lead to telling and hearing the same stories in a very different way. But what would happen if we tried, for once, to bracket our clients’ perception and memory? How about dealing with raw material, even if it is nothing more than a short capture of a specific moment in the client’s early being? Would new analytic interpretations emerge, while previous could be reframed? Also, how could the therapist relate to the baby-child client through the videos, for whom he has spent so many hours imagining and trying to understand? How about the therapeutic relationship and the step towards even more love and bonding could occur in allowing such a valuable and vulnerable material to be included? And, also, how about giving clients the chance to challenge and update their narratives and memories, examine their history of relationship with their parents to whom they have always been subject?
One may wonder: How could no one until now suggest that such videos not only could, but even should be included in psychotherapeutic practice? Until recent years such process could not occur, as clients possessing homemade childhood videos should be born after 1980 and the invention of common video cameras.
Context and description of this new therapeutic technique
During the past years I invited more than ten clients to begin bringing childhood videos in our psychotherapeutic sessions. They were all in therapy for more than three years, and our relationship was well established, enough for them to feel comfortable to ‘have their own voice’ and feel free to be in charge of the process. I gave them time to examine the possibility of working on their videos, along with hints on the possible difficulties and emotional challenges of the process. Five clients eventually proceeded. They watched several videos and brought them in our sessions. With each one of them we discussed about how to organize it, regarding frequency, length and number of videos.
In using a new therapeutic method, one needs to be cautious at first not to harm the client and the existing therapeutic process and relationship. Through the whole process of video therapy, my basic concern had always been in my responsibility and care for my clients. Compatible with non-directive psychotherapy, it was clearly expressed that we could reform or even stop the process at any time. Furthermore, we did not have to follow a predetermined therapeutic scheme, as we would rather allow the process to show us the unique way with each client, and we were both attentive to how this technique was more helpful and appropriate. I would always make sure to have five minutes before the end of such sessions to speak about their experience.
Clients chose what videos we would view together, having watched them first alone, escaping, thus, the danger of revealing ‘too much too soon for them…as this may prevent healthy repression’ (2, p.136). During the video watching, they were invited to oversee the video-therapy process by selecting, pausing and fast-forwarding the videos. As with any story narrated by the client, childhood videos could be explored in various ways in therapy. The first author’s therapeutic responses were inspired and affected by Loewenthal’ s existential-analytic approach to psychotherapy (3). Grounded on Freud’s (3) idea of a ‘compulsion to repeat’ past patterns and relationships, the client’s being, along with the dynamics of his family, would be examined through the videos as possibly revealing something about his present ‘being in the world with others’ (4). Clients’ comments, as well as therapist’s view of the video could be informed by psychotherapeutic theories, as well as existential ideas, initiating questions and interpretations. Any remarks from the therapist were expressed tentatively, meant to open rather than restricting the client’s experience.
While their experience differed in some areas, they all relatively agreed on how insightful and emotionally intense it was, commenting on how it enriched and further strengthened the therapeutic relationship, while reframing their narrative about their past and opened new possibilities for re-meeting their significant others. Such encouraging results, along with conversations with other therapists that were impressed by and interested in such a work, generated the need to evaluate this new therapeutic technique through research.
Three of these clients gave me their personal notes and journals kept during (what I may now call) video-therapy, along with consent to use it for educational and research purposes. One individual was selected as a case study for qualitative evaluation.
METHOD
Qualitative research in the form of case study methodology was used to evaluate the use of clients’ childhood videos in psychotherapeutic sessions.
Case study in psychotherapy research
Case study methodology, “psychotherapy’s traditional approach to research” (5), is gaining space and is becoming more acknowledged as highly relevant for psychotherapy research (6,7), while being established as a significant research method in psychotherapy practice and training (6,8) and is suggested as particularly valuable for practitioners in investigating every-day psychotherapeutic practice and supervision (6,9,10). As “case study is measuring what actually happens in the therapy situation” (6, p.26), real-life therapeutic interventions can be examined and evaluated. Furthermore, in evaluating a new therapeutic technique, case study methodology is suggested as appropriate (6).
Historically, case study is linked with psychotherapy (2,6). Founding figures of psychoanalysis and psychotherapy “tended more to discover practices from which they subsequently tried to construct theories” (5). Psychotherapeutic theories have been grounded on case studies “influenced by several key case studies which triggered innovative thinking or methods in the originator(s)” (6, p.25). Case study is also relevant for existential-analytic psychotherapy, as it is linked with postmodernism and humanistic psychotherapy (6).
Case Selection
The selected case in a study should be helpful towards answering the research and evaluative questions (16). In this research, the specific client was chosen due to his capacity to be self-reflective and his interest in examining his childhood and early relationships. As a therapist himself, he is keen on analytic description, emotional expression and knowledgeable on psychotherapy. In handling the intrusion of research upon the therapy process (6), this client was also chosen because he has been in therapy eight years, having shown signs of feeling comfortable to be critical of the process and express his own voice.
Research procedure
With the individual presented in this case study, video-therapy lasted for two months, for a total of seven videos. In this case study, both the client’s and the therapist’s sense of the process and its effect on the client and the therapeutic relationship were researched and included. Therapist and client kept separate personal journals during the video-therapy sessions. Four months after the end of the video-therapy process, the client was given an interview where he expressed how he experienced the whole process and what effect it had on him. The therapist-researcher’s sense on the effect of video therapy to the client and the therapeutic relationship were written right after the end of the process and, after the interview, new notes were added.
The semi-structured interview (6,8,9) was handled in a person-centered way, aiming to open up the client’s experience and allow him to speak about it in detail, while visiting unpredicted places. Interview questions were oriented towards capturing how he lived video-therapy process from the beginning until the end. The questions were broad trying to investigate “what is happening here and what are the important features and relationships that explain the impact of this intervention” (9, p.445). The focus was on how he experienced the therapeutic relationship, what was the effect that video-therapy had on him, including his feedback on what could be changed.
In qualitative evaluation and case study research, thematic analysis is usually chosen for identifying patterns (16). Here, thematic analysis from Braun & Clarke (17) was used, capturing qualitative data as they emerged from the therapist’s and the client’s journals, and the final interview.
Reflexivity in the practitioner-researcher
While writing and presenting a case study, the therapist-researcher needs to be self-reflective (8). Therapist’s reflexivity is enrichened in a relational process involving his supervisor; similarly, researcher’s reflexivity can be enhanced in his collaboration with his research supervisor (12) and his expert advice (9). In this research, creative dialogues with D. Loewenthal and P. Issari, with expertise in phototherapy, psychotherapy and narrative analysis, guided the way.
Within the culture of qualitative research, it is preferable for the researcher to “externalize personal biases so that they can be tackled in the open rather than operating at an unconscious level” (13, p.29). Reflexivity requires systematic efforts to include researcher’s being in the whole research process, while examining his interference during the design and the analysis of the data. Finlay (14, p.224) views reflexivity as a “confessional account of methodology or as examining one’s own personal, possibly unconscious, reactions“, which can allow the researcher to explore on what emerges between himself and the researched, as “research is co-constituted and socially situated” (14, p.224).
Here it is attempted to grasp research participant’s experience that is embodied and involves feelings. It is this “ineffability of embodied experience” (15, p.9) that stresses the need for researcher’s reflexivity as a way to “engage with the ontological as well as the epistemological” (15, p.6), let alone the ethical. The question of how therapist-researcher’s being was influencing the therapeutic and the research process was always kept in mind and is included in the analysis.
Ethics
Regarding the ethics of this research, the client reviewed the findings, gave feedback and commented on what he would like to be included in this presentation. His personal and intimate details were transformed in order to ensure confidentiality and the client’s on-going consent for his case to be presented and published was given throughout the whole research process (6).
RESULTS
In this thematic analysis five main themes emerged, presented below along with relevant excerpts.
Video-therapy process as restarting therapy
The client that is presented in this case study has been working with me for more than eight years. However, we both felt like starting all over again when we initiated our video-therapy sessions. The new setting within the room, as I sat to an armchair next to him to watch the videos, changed the physical distance between us:
“Next to each other. A bit awkward when I am moving to the armchair, but very warm as soon as we start” (Therapist)
The proximity of our bodies, and the image from the videos seemed to revive for both of us a new, even more intense shared sense of mystery and bodily felt warm tension:
“When the videos begun, they were so magic, so capturing, so intense emotionally on me and, I think, for him” (Therapist)
“You were sitting next to me, closer. Weird, inconvenient and beautiful. I could feel your body next to mine, I could sense you more. After a few videos it was not weird, but fulfilling” (Client)
For my client, it seemed like video-therapy was making him very vulnerable and needed to feel safe again in our relationship:
“Difficult process from the beginning” (Client)
“Very vulnerable to show my family to you” (Client)
“In the beginning I was not completely sure that you were feeling such warmth for me” (Client)
As the sessions continued though, it seems like insecurity and awkwardness gave place to a sense of creativity, excitement and a sense that new possibilities are emerging for the client’s self-exploration, the therapeutic relationship and our work together:
“I am looking forward to the sessions!” (Therapist)
“A great chance to be creative, to ‘revisit’ his narrative, to feel astonished again by his story” (Therapist)
“Different sessions, not just conversation. Very refreshing” (Client)
“More creative. I envied you as a therapist. I would like new creative ideas in my practice too” (Client)
Richness, vulnerability and danger of interpretations
“Instead of interpreting we could just see, instead of thinking we could feel and experience” – these were my words from a journal of early cases of video-therapy. As new, ‘pure and raw’ material came into our therapy space, I was tempted on many occasions to comment on what we were watching; glances, moments of interaction among family members, ineffable feelings that my client did not seem to see. And temptation did not come from a ‘kink’ on analytic interpretations, but rather from very intense internal emotional reactions to what I was watching:
“I see him restricted in the baby’s chair, frustrated as he is not heard in his desire to be freed. The baby is not crying, only some weak noises. I want to take him from there. I tell my client that. I tell him that I am angry with his mother. When his mother finally sets him free I tell him that I am now relieved. He says that she seems happy in some moments. I see her not happy, but more distressed and ‘hyper’. I bring that tentatively. I am not sure I did right to tell him that” (Therapist)
My emotionally affected remarks that did not follow his experience of the video seemed to be stepping on a thin, dangerous line. I provided him with new insight through a very warm, and empathetic moment from myside? Did I intruded through his defenses? Or even worse, was my baby-self brought in the room (need for supervision alert!):
Our/your interpretations were very close to what we saw in the videos. But it was more difficult to hear them there. It was easier for me to react and not accept them, I was becoming defensive. (Client)
“The video gave you the chance to see it differently from my narrative, it was very interesting but also very difficult.” (Client)
“Initially I was disengaged with the baby self, I did not emotionally empathize with myself” (Client)
“As you were feeling me, observing and interpreting me, feeling compassion for me, it triggered my capability to do the same to myself” (Client)
It was also the interpretations that both him and me had done in all these years of therapy that were under the microscope now:
“Happy that we were able to test some of my/our hypothetic interpretations (Therapist)
“Confirmation of his memories and my interpretations, along with new contradictory senses and narratives” (Therapist)
Video-therapy and existential dimensions
(time, death, ageing, change)
Watching a home video from the early 1990s, nostalgia and a sense of ‘paradise lost’ seemed to be triggered. Old tv, weird furniture, funny clothes, oddly decorated houses and ridiculous haircuts seemed very familiar to both of us. But it was also a chance to be reminded on how time passes; our parents were young as we are at the moment and now they are old; and we will grow old as well; life is short:
“I miss the 90s. I will play old video games today!” (Therapist)
“My daughters will watch the videos I am now filming with them in a few decades. I will be old. If not dead already!” (Therapist)
“It was like time travelling, which enabled within me a sense of something metaphysical. Even the old video images gave me nostalgia”(Client)
“I felt nostalgic. Seeing my parents revealed how they have changed, which in my mind was not obvious, very intense, time passes”(Client)
“Painful for me to see in the videos that once we existed as a proper family. That my grandfather was alive. Every time I watch these videos I realise that this family no longer exists” (Client)
“My parents were way happier back then. I am crying when I see them, because I see their youth, their lost joy” (Client)
Video-therapy and new possibilities for the person in therapy
The first new possibility that perhaps only such videos may create are the very intense emotions that raw images of such a significant period may cause to the person in therapy, as well as to the emotionally engaged therapist. Apart from the intense emotions that were raised by the process itself and the new way of being in a therapeutic relationship, the videos in themselves gave us plenty of chances to be moved on:
“It was very painful for me watching these videos” (Client)
“I felt so much emotion from seeing my mother hugging me and playing with me (cries) (Client)”
“In this session we finally watched a happier situation. He seems very emotional. I am happy to see him this way. He did not have much sense of happy playful memories and we had the chance to witness one” (Therapist)
As a new therapy, within therapy, the process of watching together videos from his childhood opened new perspectives on his narration of his past and our work in the present:
“Watching my sister in the videos I could now see how my relationship with her exists in my romantic life through my choices on partners and my ever-existing sense of compassion and guilt” (Client)
“Tender loving scene with my mother was something unique as I could never remember it, very significant for me. I print screened this moment and put it desktop in my pc” (Client)
“I was able through the video to experience and express care for his sister as her neglection and exclusion was present” (Therapist)
“Opened up new questions for my therapy and self-knowledge” (Client)
There existed afterwards a sense of reparative work on his baby self:
“I could not engage with myself. After the process I achieved with you to connect with myself. It stayed with me. Engaged with my sense, my needs, my desires, in and out of therapy” (Client)
“Satisfy myself as a kid, with the help of someone else” (Client)
Therapeutic relationship
Before the videos, my client seemed to be working through the issue of moving away from others’ desire, his projections of my ‘desires for him’ and his desire for me desiring something from him. As he was reflecting on how he looks up to others, especially other men and downgrades himself, he agreed to participate in this research, which, in this case, indeed brought my desire in the therapeutic space. After many discussions within sessions after the video-therapy process, he seemed to acknowledge how through such a process he found value in putting himself first, especially as his view of himself seemed to always be diminished by his idolized view of other men and mentors:
“We have had the chance to even look back in our psychotherapeutic journey and doubt it, and it is like he decided to trust more his sense and not put me on a position of an alpha male-model” (Therapist)
“I feel proud to stay more with my experience and not listen others even including you” (Client)
“Four months have passed after video-therapy was ended and our relationship seems more equal” (Therapist)
“He has expressed often that he does not blindly look up to me as a mentor and sees himself as more powerful” (Therapist)
“Helpful towards trusting myself more” (Client)
“He was able to say that maybe I’m not like you” (Therapist)
This empowerment and distancing from looking up to me, though, did not seem to harm our relationship; it rather enhanced it, as I felt more connected to him, and he seemed freer:
“It never felt as an atomic experience but rather a shared one” (Therapist)
“Warmer bond with him, as I was experiencing him as a baby through the video” (Therapist)
“I felt like after it I was more able to feel sense of love for my client” (Therapist)
“Very beautiful to work together with you on something” (Client)
“I feel more equal (with you); and mostly freer to be myself with you, not be like you, be close to you while being myself” (Client)
DISCUSSION
This paper was written to be included in the European Congress of Qualitative Inquiry 2022: “Qualitative Inquiry in the online technological realm”. In this research case, technology and digital representation of reality through childhood videos was used as ‘a matter of inclusivity’, creating for therapist-researcher and client ‘possibilities…for meeting up with each other in a different space and timeframe’, opening the possibility for the client to preserve what has once been, while giving him the opportunity to see it again through different eyes of the present. Subject to further research, it is suggested here that by allowing technology to enter the therapeutic space it could be experienced not as a violation, but rather as a playful fusion that allows the client and the therapist to be more human. As digital self, nowadays, seems to be a part of the person’s identity, inclusion of videos, photos and social media profiles could become more necessary for future’s therapeutic practice.
Early suggestions and alterations on this new therapeutic practice
Results from this case study, along with early experience of video-therapy and clients’ feedback, led to some suggestions about this newborn therapeutic practice. Firstly, clients should be given introduced in the idea of video-therapy, along with some hints on the process, and they should be given time to work it through before beginning, while being informed that it can be emotionally very intense. Protecting the client in such a vulnerable place, therapist must be less interpretative in the process. Apart from long-term and well established, relationship with the clients-candidates for video-therapy must be also boundaried, without at least visible major issues of any form of ‘transference’ at that time. Personally, getting my clients’ feedback on video-therapy generated once again the desire to include my clients in my reflections about our therapy’s vividness and effect on them in general, while also being more open to their and my creative initiatives to enrichen their narrative and our work.
Initial conclusions from this case study that will be examined in further research
Regarding this new proposed therapeutic practice, in its early form, it is suggested that video-therapy can be emotionally very intense both for the client and the therapist. It engages the client with a sense that time passes, and as the client travels back to his past, therapy can also be restarting, generating a sense of anxiety, astonishment, nostalgia, grief and excitement. As a therapeutic tool, it seems to be able to give the client space to be empowered, evolve, work through and come to terms with his early years and relationships with his significant others.
Finally, finding ground on existing therapeutic approaches, but also finding their own way of being, even some that may be seen as escaping the boundaries of traditional talking only therapy, could facilitate therapists to evolve, reinvent their own practice, responding to “the call for existential therapies to be astonishing and ever changing“(18).
REFERENCES
- Loewenthal, D. (Ed.) (2013). Phototherapy and Therapeutic Photography in a Digital Age. Routledge: Taylor & Francis Group.
- Loewenthal, D. (2017). Existential psychotherapy and counselling after postmodernism: The selected works of Del Loewenthal. World Library of Mental Health. London: Routledge.
- Snell, R. and Loewenthal, D. (2011). In Post-Existentialism and the Psychological Therapies: Towards a Therapy without Foundations. London: Karnac (pp.137-156).
- Loewenthal, D. (2011). On the very idea of post-existentialism. In D. Loewenthal Post-Existentialism and the Psychological Therapies: Towards a Therapy without Foundations. London: Karnac (pp.1-12)
- Loewenthal, D. (2020b). Critical Existential-Analytic, Rather Than ‘Evidence-Based’ Psychotherapies: Some Implications for Practices, Theories and Research. Special Issue, European Journal of Psychotherapy and Counselling, 22: 1-2
- Widdowson, M. (2011). Case Study Research Methodology. International Journal of Transactional Analysis Research & Practice, 2(1).
- McLeod, J. (2010) Case Study Research in Counselling and Psychotherapy. London, Sage.
- McLeod, J. (2011). Qualitative research in counselling and psychotherapy, 2nd ed. London, United Kingdom: Sage.
- Keen J, Packwood T: Qualitative research; case study evaluation. BMJ. 1995, 311: 444-446.
- Willemsen J., Della Rosa E. and Kegerreis S. (2017). Clinical case studies in psychoanalytic and psychodynamic treatment, Frontiers in Psychology 8:108. doi: 10.3389/fpsyg.2017.00108
- Fishman, D.B. (1999) The Case for a Pragmatic Psychology. New York, New York University Press.
- Maione, P. V., & Chenail, R. J. (1999). Qualitative inquiry in psychotherapy: Research on the common factors. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 57–88). American Psychological Association. https://doi.org/10.1037/11132-002
- McLeod, J. (1994). Doing counselling research. Sage Publications, Inc.
- Finlay, L. (2002) ‘“Outing” the Researcher: The Provenance, Principles and Practice of Reflexivity’, Qualitative Health Research 12(4): 531-545.
- Cromby, J. (2012). Feeling the way: Qualitative clinical research and the affective turn. Qualitative Research in Psychology, 9(1), 88–98. https://doi.org/10.1080/14780887.2012.630831
- Daykin, N., & Stickley, T. (2015). The role of qualitative research in arts and health. In S. Clift & P. Camic (Eds.), Oxford Textbook of arts, health and wellbeing (pp. 73-82). Oxford: Oxford University Press.
- Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101.
- Loewenthal, D. (2010). Post-existentialism instead of CBT. Journal of Existential Analysis, 21(2)