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Caroline McDougall, Academic Reflections

Process Experiential Therapy in Action

Case Studies


The client is a 30 year old male. He achieved well academically and enjoyed a fulfilling professional life until he became mentally unwell in his early 20’s. Since then he has been unemployed and socially isolated. He has not had a relationship since the onset of his illness.

Due to his illness, the client has suffered a loss of meaning, with an intense shattering of assumptions about himself and his life, as he knew it prior to his illness. His cherished beliefs are therefore related largely to grief and loss, and indicate the need for meaning creation work.

Common statements made in an aroused emotional state are:

However, sometimes he is not aroused at all, but the same statements emerge. He starts to speak, but stops himself, and usually says he can’t continue because he ‘can’t think straight’ or feels unwell. This is a marker for self-interruption, and that a two-chair enactment for self-interruption splits would be appropriate.

Furthermore, the above statements may be preempted or followed by other statements which represent negative evaluative aspects of self. Therefore there is also a critic-experiencer configuration, which indicates two-chair dialogue for self-evaluation conflict splits. For example: I can’t believe I have given in to all this. I should’ve been able to cope, but I can’t. I must be weak.

There is unresolved hurt and anger around his entire circle of significant others who have abandoned him since his illness. His parents are a particular source of pain and loss. The above cherished belief statements may emerge, but then be followed by statements regarding his parents where there is a tone of complaint and blame. This indicates the need for empty chair work for unfinished business. Common statements are: My mother told me the other day that she’s the only one of all her friends without grandchildren. She made me feel as if it’s my fault. She says there’s nothing wrong with me, that I’m just fat and lazy. My parents are to blame for my being unwell.

Most confusing of all is that the client’s mood, emotion scheme, mode of expression and therefore the markers for interventions can change from moment to moment. I am aware that this is component of his mental illness. However, just as I decide to utilize for example, meaning creation work, he may become stuck, and say the same thing in a blocked way with physical symptoms. Just as I am about to move into self-interruption work, in an aroused way he quotes a critical statement made by his mother, and I perceive unfinished business. This very quickly can move into a self-critical comment around the same theme. The cycle may continue throughout the session, and I feel as if I am not implementing interventions with any consistency.

However, I feel sure that the self-critic and unfinished business are very closely aligned. He has integrated his parents’ criticisms into a self-critic which often emerges as his mother. The self-interruptive behaviour is learnt from not being allowed to express himself and is once again associated with his primary caregivers. The cherished beliefs are often based on his parent’s unreasonable and generalized expectations, which were intensely instilled in him throughout his childhood. I therefore try to focus on empty-chair work and two-chair dialogue to address the inner critic, in which self and parents are integrated. I am hoping to assist the client to recognize this integration, and its major impact on his emotional processes. The potential outcome is improved insight, negotiation between aspects of self and emerging self-affirmation.


The client is a 27 year old male with a childhood history of mental and physical abuse. He was severely bullied at school and systematically victimized by an older sibling. He presents as a highly articulate, motivated man. He has had a lot of therapy over the past ten years, and has also done a great deal of meditation with an emphasis on visualization.

He is dedicated to reaching his best potential and is therefore a most enthusiastic client who takes therapy seriously. During the past eight sessions, he has embraced therapy wholeheartedly. Each session includes focusing at some stage, as he generally presents with an unclear feeling, the marker being a nagging concern which has been troubling him during the week. He is able to offer the most florid descriptions of felt quality words and images.

After a few sessions I realized that he moved from forming a visual image of his feeling to carrying forward in a matter of minutes. There was no need for ‘resonating’, as he was ‘so sure his felt-sense was right’, and in the ‘asking’ part, he ‘knew straight away what it was about’, and rushed straight into ‘carrying forward’, so it could all be easily ‘resolved’. It became clear that as much as he seemed enthused about focusing, it was in reality very threatening to him.

I had a ‘hunch’ that he was having trouble approaching focusing on an emotional rather that an intellectual level. Although he was able to symbolize the felt-sense, he launched into verbal descriptions without appearing to take time to experience the sensation. I guessed that sensing the whole thing and the murky discomfort was just too frightening. On a theoretical level, as soon as he ‘got in touch’ with a felt-sense, the powerful primary emotions associated with his abuse such as anger, shame, sadness, fear, became extremely overwhelming. He would inevitably become physically agitated and his facial expression contorted. However, he would be formulating quite a pleasant, superficial label as he did this.

Once I recognized this, we had a discussion about it. He finally acknowledged that, due to the confronting nature of the focusing, and the frightening images, sensations and memories it evoked, he would automatically slip into a meditation/soothing visualization to prevent exploring his felt-sense on a deeper level.

In order to overcome this, we agreed that he would try to stay with the felt-sense, without going inside it, to let the feeling exist in its own way for a time. I was persistent with this, and became more speculative in finding a label and resonating. As much as he found this very difficult, it seemed to become easier after a few weeks. His physical agitation eased and he was able to talk about his discomfort and his shame as he delved into his felt-sense.

This has been a really major challenge so far, and I am happy that we have been able to collaborate about this and work through it together. The client feels that he is making really positive progress in terms of dealing with his abuse and unlocking the suppression around it. He is actively reflecting on this between sessions and is now keeping a journal to track his own progress through practicing focusing each time he becomes anxious.


Sally is a 32 year old male with a history of abuse. The major challenge is to evoke a sense of trust, as he has inherently perceived anyone in a caregiving role as potentially dangerous. Process Experiential therapy challenges the pervasive defense mechanisms clients have developed in order to survive challenging histories and even mental illness.

Sam, who has been responding very well to therapy, arrived to his appointment in an extremely avoidant and angry state. I ventured into focusing with him, with a great deal of reluctance due to his presentation. He finally agreed to this task after a great deal of empathic work, which did not reveal what was troubling him. Upon mutual reflection it came to light he had been feeling uneasy after a particularly intense previous session where he had got ‘in touch’ with his primary emotions for the first time. This had been a very difficult and painful for him, and evoked memories and feelings that he had blocked for about 10 years. As we continued to discuss the issue, the client acknowledged that he had felt extremely threatened at the end of the previous session and for several days to follow. We discussed the possibility that fear may have caused him to unconsciously want to ‘back away’ from the therapy and discontinue our sessions altogether. The rupture has since been resolved.

In order to combat such challenges I frequently return to empathic work. In doing so I am generally able to maintain the alliance when I sense that the more confronting interventions such as focusing and chair work are not workable according to the client or the specific situation. Recurring ruptures are also opportunities to teach the clients about their distortions, whilst treading carefully due to their vulnerability. I also see these ruptures as a chance to revisit our goals, and discuss which tasks the client feels comfortable with, and how the client feels about the counselling process in general. As this process continues, the genuine interaction between me and my clients will generally continue to evolve with a developing sense of trust and collaboration.

It is also useful to use empathic attunement and conjecture to offer a meaning bridge. We may also utilize ‘clearing a space’ to re-establish a sense of calm. Some gentle focusing at this point can enable both the client and I to explore the primary emotions around the alliance rupture. In an indirect way we tend to find a new understanding and explore implications for change. It is apparent that the challenge lies in maintaining one specific intervention task when a clear marker is present.


Though it is sometimes challenging to employ these complex approaches in therapeutic intervention, and change is difficult for some, the process for me is one of deep privilege, and one for which I always derive great satisfaction and gratitude. I have learnt a great deal through utilizing this most effective and astounding therapeutic approach. I simply love working with each individual, unraveling their potential outcome, evolving a person who is ‘comfortable in his/her own skin’, and assisting clients to recognize, embrace and fulfill their valuable emotional wants, needs and goals. That is an exciting challenge.

If you are worried about yourself or someone you care about, Caroline is happy to speak with you and guide you in the right direction.