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a modality of treatment in which the therapist and patient(s) work together toameliorate psychopathologic conditions and functional impairment throughfocus on the therapeutic relationship; the patient's attitudes, thoughts, affect,and behaviour; and social context and developmentengagement between twoindividuals, namely the therapist and the client, who are focused on bringingabout change within the client via the therapeutic relationship.However, the degree of emphasis placed on the value of the therapeutic relationship,as a tool for predicting outcomes, differs from orientation to orientation. Withinpsychoanalysis the relationship is regarded as “the primary vehicle of change” (Beach& Power, 1996, p. 1). Other perspectives, such as cognitive and behavioural therapies,have explored the client/therapist relationship, but to a lesser degree, focusing insteadon the techniques that are employed (Beach & Power, 1996). A polarized debate hasensued – is the relationship curative in its own right, or is it merely facilitative ofother therapeutic processes? While it is yet to be resolved whether the relationship isboth a necessary and sufficient condition for realising positive outcomes, it isgenerally agreed that the relationship is at least necessary, and functions as the contextwithin which all the various other psychotherapeutic processes can occur.AsKemplar (cited in Teyber, 2006, p. 302) explains, the principle of engaging, of moving toward or in relation to another, is theessential principle in common [across therapeutic orientations] – essentialbecause it is only in the context of one another that the possibility for changecan live.Kemplar’s statement indicates that it is only through the interaction between therapistand client that therapy can be undertaken.Safran, Crocker, McMain and Murray (1990) argue that therapeutic techniques are notdisembodied processes that exist separately from this interaction, but are essentiallyembedded within it. Within the relationship between client and therapist,psychotherapeutic processes take on meaning (Safran et al., 1990; Safran & Muran,2000), which contributes to their complexity and efficacy (Butler & Strupp, 1986). In2

sum, the therapeutic relationship is a central component of all psychotherapies, andneeds to be understood in detail for it to maximize positive client outcomes.In an effort to better understand its nature and processes, theoretical examinations ofthe therapeutic relationship have been undertaken by numerous scholars. Scholarssuch as Bordin (1979), Freud (1958), Greenson (1976) Zetzel (1956), and playedparticularly seminal roles in establishing the theoretical framework of this debate.Based on initial theories postulated by Freud, these examinations have uncoveredthree interrelated components of the therapeutic relationship, namely: the ‘real’relationship; a transference component; and the working or therapeutic alliance(Bordin, 1979; Gelso & Hayes, 1998; Teyber, 2006; Zack, Castonguay & Boswell,2007). The therapeutic alliance is defined in this study as the collaborative,interpersonal relationship that is formed between therapist and client; a relationshipwhich is based on a secure and empathic affective bond, and which is the meanswhereby an agreement is reached on the specific tasks and goals that will realisesuccessful therapeutic outcomes.The therapeutic alliance has been cited as the most significant variable of any processto-outcome relationship across all theoretical orientations of psychotherapy (Norcross,2002; Wampold, 2001). This means that much of the efficacy of the therapeuticrelationship as a change mechanism can be attributed to the role played by thealliance. In theory, an effective alliance is one that meets the conditions that willultimately foster a positive therapeutic outcome for the client.The second chapter of this study is a theoretical examination of the construct of thetherapeutic alliance. The chapter briefly traces the history of the alliance and itsemergence in the field of psychotherapy as a meta-construct, arriving at anoperational definition. The primary features of the alliance are explored, namely (i)collaboration, and (ii) the secure and empathic affective bond that is formed betweentherapist and client.Chapter Two goes on to propose that the alliance is itself a differential variable ofoutcome, meaning that its quality is neither a given, nor is it constant. This entailsthat the alliance can hold various causal positions in relation to therapy outcome,3

depending on the extent to which the conditions of the alliance are satisfied(Johannson & Høglend, 2007). Both therapist and client construct the relationship,each with their own skills, characteristics, personality and history (Gelso & Carter,1994), and so in effect, no two therapy dyads are the same (Kieffer, 2007), and no twoalliances are the same. This research is primarily interested in the role of the therapistin establishing the alliance. Chapter Two attempts to explicate the therapist’s role, byexamining the demands placed on therapists if they are to meet the conditions of aneffective alliance.This inquiry was first motivated by the identification of compatibility between, on theone hand, the demands placed on therapists for effective alliance formation, and, onthe other, the outcomes of mindfulness-based practices. For example, two of thedemands on therapists that are identified in Chapter Two are therapist presence andnon-judgment. Simply defined, mindfulness-based practice is awareness of andattention to present-moment experience, coupled with an accepting and nonjudgmental attitude (Epstein, 2007; Kabat-Zinn, 1994). Thus, it is immediatelyapparent that non-judgment and presence are common features to both mindfulnessbased practice and therapist demands for effective alliance formation.Further reading into the topic of mindfulness-based practices revealed that traditionalBuddhist mindfulness practice – that is, insight (vipassana), or mindfuness meditation– is used to cultivate an experience of anatta, or ‘no self’ (Gilpin, 2008), andshunyata, meaning ‘emptiness’ (Novick, 1999). Both of these experiences areperceived within Buddhism as cultivating a more compassionate way of beingtowards others (Sri Dhammananda, 2002) – they are thought to foster a favourableattitude of kindness, tenderness and understanding, grounded in the ability to perceiveand experience equality with all sentient beings (Hopkins, 2001). A compassionatedisposition is clearly advantageous for therapists in the context of establishing secureand empathic affective bonds with their clients.In addition to these observations, there exists a small but encouraging body ofresearch concerning mindfulness-based practices, including mindfulness meditation,amongst therapists. These studies have revealed numerous positive outcomes,including reduced stress and subsequent increases in attention (Shapiro, Brown &4

Biegel, 2007); increased self-compassion (Shapiro et al., 2007); increased clarity ofthought and capacity for reflection (Schure, Christopher & Christopher, 2008); andexperiences of a greater capacity for empathy and compassion (Schure et al., 2008).The authors of these studies have linked several of the abovementioned outcomes toan increase in ability on the part of therapists to form effective relationships with theirclients, and have recommended that future researchers pursue this topic further.However, despite such links being explicated, and despite the recommendations forfurther research, studies looking directly at the impact of mindfulness-based practiceon therapists’ ability to form effective relationships with their clients have not yetbeen conducted, as far as the researcher is aware. This research aims to fill this gap inthe literature and to respond to those recommendations for further study, by lookingspecifically at the alliance dimension of the therapeutic relationship.Chapter Three will explore the links between the demands placed on therapists forestablishing effective alliances and some of the known outcomes of mindfulnessbased practices in greater detail. This exploration will be located within the discourseof mindfulness, thus Chapter Three begins with an examination of mindfulness as aconstruct and also as a practice. Beginning with a review of Buddhist mindfulnessmeditation and moving to the application of mindfulness in the context of Westernclinical psychology, this chapter attempts to present a rubric for understandingmindfulness-based practices, particularly mindfulness meditation, in terms of theirconceptualizations, processes and their effects. The different paradigms within whichmindfulness is situated will be shown to have implications for how the aims andoutcomes of mindfulness-based practices are interpreted.The extant literature on mindfulness, the alliance, and on some of the effects ofmindfulness-based practices on therapists’ relationships with their clients, clarifies theresearch problem and, simultaneously, provides a theoretical framework forunderstanding participants’ experiences. However, because the subject has not beendirectly researched before, and because the construct of mindfulness remainsconceptually unresolved (Gilpin, 2008; Kotanski & Hassed, 2009), this framework is(at least at present) unsophisticated.5

The limitations of the theoretical framework point to the need for theory building,rather than theory falsification. In order to meet this need, a qualitative approachtowards designing the research was selected. The adoption of a qualitative approachalso fills a gap within the field of mindfulness-based practices, as the majority of itsresearch thus far has come from an empirical, positivist perspective, thus there is littledepth to these descriptions of mindfulness-based practices.Chapter Four explores the key features of the qualitative design employed in thisstudy. The chapter begins by presenting the study’s primary objectives – (i) tounderstand the experiences and meanings of therapists regarding the impact of theirmindfulness meditation practice on their role in the therapeutic alliance, and (ii) tobuild theory on this topic. Chapter Four goes on to present the design of this research.It shows that an interpretive phenomenological analysis (IPA) strategy was deemedthe most appropriate to meet the research objectives, because the IPA design aims toexplore how participants make sense of their personal and social worlds (Smith &Osborn, 2003). The IPA strategy is grounded in the philosophies of phenomenology,hermeneutics, and interpretation. The ontological assumptions underpinning thesephilosophies, and their epistemological implications for research design, are describedand discussed.Chapter Five of this study details the results of the research and presents the findingsof the data analysis procedure. Summaries of participant accounts are presented forthe purpose of contextualising the results and analysis to follow. Three superordinatethemes emerged from analysing the collected data, and they are presented along withtheir respective sub-themes in a tabulated format. The themes are as follows:Table 1:Presentation of data themes1.Self-care1.1. Physical well-being1.2. Occupational impairment prevention1.3. Personal growth: ‘Doing the work yourself’2.Insight into the structures of selfhood2.1. The self as interconnected2.2. The self as multidimensional6

2.3. The self as limited3.Immediate mindfulness meditation during therapy3.1. Embodied empathy3.2. Therapist presence3.3. Responding mindfullyChapter Five includes a description of each theme, an explanation of the researcher’sprocess of interpretation, and a presentation of detailed excerpts from the participants’accounts.The research results are further discussed in Chapter Six, where the participants’accounts are theoretically contextualised. This is achieved by relating them to thediscourses of mindfulness and the therapeutic alliance.Chapter Seven concludes the study, providing an overview of the project, a summaryof the main findings and a reflection on their implications for future research into thetopic. The limitations of the study are also discussed.7

CHAPTER TWOA LITERATURE REVIEW: THE THERAPEUTIC ALLIANCE2.1. IntroductionThe primary aim of this study is to explore therapists’ experiences and meanings ofhow their mindfulness meditation practice impacts upon their role in effective allianceformation. The following chapter serves to conceptualise the therapeutic alliance, andthe role of the therapist in establishing it. A theoretical context for this construct isprovided, which traces the development of the alliance from its emergence in earlypsychoanalytic theory to its becoming, due to its consistent correlation to therapyoutcomes, a meta-theoretical construct relevant to all orientations of psychotherapy.From this context, the primary features of a theoretically ideal alliance – that is, analliance that yields positive therapeutic outcomes – are identified. These features are(i) collaboration and (ii) the forming of a secure and empathic affective bond betweentherapist and client. Based on these features, an operational definition of the allianceis developed. The chapter goes on to explicate the importance of the role of thetherapist in establishing the alliance. The therapist’s role is explored by looking at thedemands placed on therapists by the need to work collaboratively and to create secureand empathic affective bonds with their clients.2.2. Conceptualising the alliance: A context and definition2.2.1. Pioneering notions of the allianceSince the advent of psychoanalytic psychology, the therapeutic relationship has beenprioritized as a factor explaining client change (Johnson & Wright, 2002). Freud’s(1958) focus on the concept of transference – where the unconscious impulses anddesires of a client are projected onto the therapist during therapy – resulted in effortsto more thoroughly understand the therapeutic relationship within which thistransference occurs (Johnson & Wright, 2002). Freud believed that transference wasan unrealistic component of the relationship, fuelled by the client’s neurosis(Saketopoulou, 1999), and often manifested as resistance towards therapy, or a refusalto change (De Mijolla, 2010). In dealing with this resistance, Freud recognized thenecessity to form an “analytic pact” with the client (De Mijolla, 2010, p. 1), where thetherapist appealed to the client’s desire to heal, and encouraged them to allythemselves with the therapist to work against their neurotic aspects (Saketopoulou,8

1999). The pact formed with a client was differentiated from the negative transferencecomponent of the relationship, and viewed as constituting the positive, reality-basedcomponent of the relationship (Saketopoulou, 1999). This reality-based componentformed the basis for developing the concept of the therapeutic alliance, although theterm itself was not introduced until 1956 by Elizabeth Zetzel (Saketopoulou, 1999).Prominent psychoanalytic theorists, namely Richard Sterba (1934), Edward Birbring(1937) and Zetzel (1956), went on to expand Freud’s initial ideas about forming apact with the client. Zetzel’s theory, in particular, has greatly influencedcontemporary views of the alliance. Zetzel proposed that in order to work with thehealthy and functional aspects of the client’s ego, the client needed to perceive theanalyst as being helpful (Saketopoulou, 1999). She theorized that analysts, byacknowledging the difficulties of the client’s situation and offering supportivecomments, could encourage this perception, and form a therapeutic alliance with theirclients (Saketopoulou, 1999). She likened the attitude that the analyst adopts towardtheir client to that of a mother towards her child (De Mijolla, 2010). This parallel,between the relationship of mother and child and the relationship of therapist andclient, has since undergone extensive development within the field of attachmenttheory (Angus & Kagan, 2007).Attachment theory is primarily concerned with the affective bond that forms betweena child and their primary caregiver (Sonkin, 2005). John Bowlby (1969) theorised thatin its infancy, the child is entirely dependent on their primary caregiver, and that thedevelopment of a behavioural system of attachment between these two figures is anecessary evolutionary function that ensures the infant’s survival (Sonkin, 2005). Theattachment figure – the primary caregiver in this instance – is responsible for meetingboth the infant’s physical and psychological needs. The infant’s development islargely dependent on the caregiving style, within which specific affects of thecaregiver play an important role (Senior, 2002). Attachment theorist Harry Harlow(1958) conducted controversial experiments on neonatal and infant macaquemonkeys, with the aim of identifying attachment variables. Harlow presented dataidentifying a correlation between adaptive behaviour and the quality of attachmentbetween the infant and the primary caregiver. The infant monkeys achieved security9

(evident through exploratory behaviour and lowered fear responses to stimuli) throughpresence, consistent contact, warmth and nurturing behavior from the caregiver.Similarly in human populations, attachment theory proposes that an infant is able tobecome progressively more independent, and to explore their surroundings, if there isa secure attachment with the attachment figure (Ainsworth, Blehar, Waters & Wall,1978). Bowlby (1969) proposed that through sensitive and emotionally availablecaregiving, a secure base is formed that provides the infant with a sense of protection,enabling them to engage in ex

THE MINDFUL THERAPIST: AN INTERPRETIVE PHENOMENOLOGICAL ANALYSIS OF MINDFULNESS MEDITATION AND THE THERAPEUTIC ALLIANCE A thesis submitted in fulfilment of the requirements for the degree of MASTER OF ARTS IN PSYCHOLOGY of RHODES UNIVERSITY by TARRYN