Posttraumatic Growth During Incarceration: A Case Study From an Experiential–Existential Perspective

Method

For an in-depth understanding of a phenomenon, qualitative case studies are often preferable over large quantitative studies (Merriam, 2009). Case studies give us the opportunity to examine unique life experiences in their own context (Merriam, 2009). Although case studies provide detailed and rich information, the value of a case-study depends on the sensitivity and the meaning-making process of the researcher. The rough data of this case-study consist of the experiences of both the therapist and the client. The therapist wrote notes during and after each session. The client also reflected on each session; her feedback was written down by the therapist. Eight months after finishing therapy, the client was interviewed and audiotaped by the therapist, a social worker, and a psychiatrist. The social worker and the psychiatrist worked independently from the therapist. In a subsequent meeting the three different interviews and the entire case was discussed. This discussion brought even more clarity about the decisive elements and stages in the therapy. We integrated the results of this discussion into our case study.

Not different from any other human experience, a case study only starts to make sense by the selection and the interpretation of the rough data. The significance of an experience only appears after a process is completed (Gendlin, 1996), and the meaning we derive from an experience usually draws on a set of global meanings that already exists prior to the new information (Park, 2010). In our case, our background theory of the experiential–existential approach (Leijssen, 2013; van Deurzen, 1997) served as our global meaning system to make sense of our therapeutic encounter with this client. Based on the work of Binswanger, Boss, Buber, Jaspers and Tillich, the experiential–existential approach formulates that human existence is experienced in the conglomerate of our physical dimension (our relationship with our bodily life and our surroundings), the social dimension (the way we relate to others, our social roles, etc.), the psychological dimension (the way we relate to ourselves, our identity, etc.), and the spiritual dimension of our existence (the way we relate to the Transcendent, our meaning and purpose in life; Leijssen, 2013; van Deurzen, 1997). This holistic model influenced our observations and influenced our selection of what made sense to write about. However, the particular experiences of this client gave us also the opportunity to deepen our understanding of experiential–existential therapy with prisoners, and subsequently modified our background theory. This in-depth study also allows us to illustrate our empirical findings on posttraumatic growth with prisoners (Vanhooren et al., 2015).

As a result of this meaning-making or selection process, the first part of our case study will deal with the initial sessions (Sessions 1-3) in which the client presents herself as a woman who faces the existential challenge of being incarcerated and who experiences a loss of meaning in every dimension of human existence. We will also focus on how therapy helped her to find new ways to cope with this loss of meaning. The second part of the case study will focus on the middle stages of the therapy (Sessions 4-13). Our attention is drawn here to the experiential exploration of the client’s basic existential needs and how these needs are intertwined with the committed crime. We also see the client experimenting with new—and more adjusted—ways to meet her basic existential needs. In the closing stage (Sessions 14-16) and in the follow-up session, we find the client integrating new meanings and making different choices about the future.

Diana was offered an experiential–existential therapy which is one of the many approaches of existential therapy (Leijssen, 2014; Madison, 2010, 2014; Todres, 2012). Experiential–existential therapy draws on the common theoretical underpinnings of existential psychotherapy (Cooper, 2003; Hoffman, 2009) as well as on the experiential theories and methodologies of Eugene Gendlin (1996) and Carl Rogers (1961). Instead of using an analytical framework to understand the client, experiential–existential therapy uses an experiential–phenomenological approach to encounter the client. Moreover, the therapist facilitates the client’s awareness of her or his bodily felt inner experiences to explore and express implicit personal issues and meanings in a direct way. By emphasizing the importance of the bodily felt meaning over cognitive meaning, experiential–existential therapy differs from other forms of existential therapy (Madison, 2014). In this way it strongly resembles focusing-oriented therapy (Todres, 2012) and other process-oriented forms of person-centered therapy (Cooper, 2012). The experiential–existential therapist will try to deepen the therapeutic moment-to-moment process by tuning in to the client’s inner experience. Experiential–existential therapists frequently use focusing (Gendlin, 1996) and other experiential methods to help the client to become more aware of his or her implicit meanings, needs, and wishes (Leijssen, 2014). However, experiential–existential therapy distinguishes itself from person-centered and focusing-oriented therapy because the therapy is not solely process-oriented. The experiential–existential therapist is also interested in exploring certain themes such as the client’s world assumptions, meaning in life, relationship with the limits of life, strengths, and talents (Cooper, 2012, Leijssen, 2014). In working with offenders the experiential–existential therapist will also experientially explore the dark side of the client (Vanhooren, 2011).

In order to guarantee the clients’ anonymity, we gave her the pseudonym “Diana” and we changed a few details to guarantee her anonymity. Diana signed an informed-consent form and agreed to have the process and outcome of her therapy published.

Initial Information About the Client

Diana is a 35-year-old single woman and a teacher. She was convicted for committing arson in the house of her ex-boyfriend. From a diagnostic point of view there were no signs of a personality disorder or psychopathy, but it was clear that Diana was suffering in many ways. Diana was a first-time prisoner in the prison of Bruges in Belgium. She asked for individual psychotherapy, which was delivered by CGG Prisma, a mental health clinic that provides psychotherapy in prison, with maximum confidentiality for the client.

In the past, Diana had experienced depressive episodes, which she had been hiding from the outside world. Ten years ago, Diana attempted to commit suicide after a relationship break-up. After a short stay in an emergency hospital Diana returned back home. There was no communication in her family about what had happened. Diana went to therapy for a couple of sessions but she declared that she felt alright and that therapy was no longer necessary. Instead, she just continued living as if nothing had happened. Diana explained to us that she had “erased” this dark period. Incarceration pushed her to remember this earlier dark period in her life. In contrast to her earlier life experiences, the experience of being incarcerated and having committed a crime were too strong for Diana to deny. Relying on her formal ways of coping, she got stuck in judgmental ruminations and did not know how to share her pain with other people. Diana hoped to find a way out of this emotional nightmare through psychotherapy. She wanted to figure out what caused her to commit the crime in the first place, in order to prevent impulsive actions in the future. With this information we started our weekly therapy which would end up as 16 sessions in total. The therapy stopped because of Diana’s release from prison. Diana gave us permission to contact her for a follow-up session 8 months later.

The Loss of Meaning

Stressful life situations that challenge a person’s fundamental beliefs or global meanings about oneself, the other, and the world, often result in a deep existential crisis (Park, 2010). Imprisonment has been described as this kind of highly stressful situation (Liebling & Maruna, 2011). The entry period of confinement has been identified as a period of heightened vulnerability with higher rates of self-harm and suicide (Haney, 2003; Harvey, 2011). Prison tends to be a place where peoples’ global meanings about themselves and about the world are challenged by the experience of incarceration itself (van Ginneken, 2014; Vanhooren et al., 2015). As a consequence, confinement often means the onset of a deep personal crisis (Harvey, 2011; Maruna, Wilson, & Curran, 2006). This was also the case for Diana as we will demonstrate below.

Psychotherapy as a Different Answer Toward the Existential Challenge

From an experiential–existential point of view, the vehicle of therapeutic change is an offering of a radically different human experience in all four dimensions of existence. Especially in prison, psychotherapy is profoundly different from what prisoners experience in their daily life. Even on a basic physical level, simply being in the therapy office can make a small change. As Diana noticed when she entered the therapy room for the first time, there was no desk between her and the therapist. For her, it was the first time in months that she talked with a professional without there being a physical barrier between both parties. Also, the armchairs—nonexistent in the majority of the prison but common in therapy offices in the outside world as well as in prison—felt to her like a sign of basic care and human respect.

Psychotherapy also offers a different reality in the social realm. In general, the importance of the therapeutic relationship for change has been described by many studies (for an overview, see Norcross, 2002). Research has also shown that attention for the therapeutic relationship and empathic understanding produce a better therapeutic outcome with offenders than confrontational styles and a limited focus on the negative (Beech & Hamilton-Giachritsis, 2005; Marshall & Serran, 2004; McNeill, Batchelor, Burnett, & Knox, 2005; Ross, Polashek, & Ward, 2008). The therapeutic relationship itself is a very important means to recover from the loss of global meanings (Janoff-Bulman, 1992). For offenders, the therapists’ acceptance is quite essential (Elisha et al., 2013). However, acceptance or unconditional positive regard should not be confused with the approval of criminal behavior. In the context of therapy acceptance means that the therapist can hold a space for all kinds of emotions and thoughts of the client. In holding this space, the therapist gives the inner self of the client the right to exist. He or she communicates that the client is not a lost cause, and that there is still hope for change and a better life in the future. As we will see, the therapeutic relationship was of tremendous importance for Diana.

On the psychological level the experiential and existential therapist offers the client a specific approach toward his or her inner world that is often completely new for the client. Frequently, prisoners try to deny their inner world (Haney, 2003) as Diana initially did. Similarly, some prisoners judge themselves harshly for the crime and for being imprisoned. Instead of denying or judging, the therapist encourages the client to engage in a phenomenological and experiential exploration (Leijssen, 2014; van Deurzen & Adams, 2011). Research has shown that judgmental ruminating or evaluative emotional processing doesn’t actually lead to a better adjustment to the new situation. Experiential exploration at the other hand fuels the creation of new constructive meanings, resulting in better adjustment (Greenberg & Pascual-Leone, 2001; Park, 2010; Pascual-Leone, Gillespie, Orr, & Harrington, 2015; Rude, Maestas, & Neff, 2007; Watkins, 2004).

Last but not least, experiential–existential psychotherapy also addresses the search for meaning in an explicit way. In general, therapists underestimate the prisoner’s need to talk about existential issues (Morgan & Winterowd, 2002). The experience of the loss of meaning and purpose in life during incarceration is very common (Maruna et al., 2006). With Diana, we saw how life didn’t make sense to her anymore. Experiential–existential therapy offered her the opportunity to talk about her experience of having lost all meaning in life. Instead of persuading her to adopt one or another set of meanings, therapy helped her to explore the loss of meaning itself. Going back to the source of this loss—the crime itself and its antecedents in her life story—will paradoxically lead her to a better understanding of herself and will help her to find new meaning in life (cf. infra).

In the first three sessions, the offering of these psychotherapeutic essentials helped Diana to find a different way to connect with herself over the four different dimensions. In the following excerpt, the therapist tries to initiate an experiential exploration and encourages Diana to reflect on what was happening.

Diana condemned herself very strongly for committing the crime. She couldn’t find answers and this drove her—in her own words—“crazy.” She didn’t want to stop thinking about what had happened, and punished herself by refusing to sleep and by neglecting her physical appearance. She lost herself in obsessive judgmental thinking which led to punitive thoughts: She defined herself now as a “bad non-trustworthy person” and had to pay for it.

In this excerpt, the therapist didn’t judge Diana’s punitive voice or her inner critic (Stinckens, Lietaer, & Leijssen, 2013) when it felt the need to speak (T1). At the same time, he encouraged Diana to explore why a part of herself felt the need to punish (T2). The therapist also accepted and acknowledged the pain that was related to her need for self-punishment (T3). For Diana, it became clear that the loss of her assumption to be a “good and trustworthy person” and her need to get control over herself were closely related to this punitive voice. Remarkably, by engaging in this more experiential and reflective search, stimulated by the therapist (T3, T4, T5), the need to punish herself disappeared rather quickly during the first couple of sessions. Instead of maltreating herself, therapy helped her to experience her pain about her loss in a more direct and adjusted way (T3: I sense a kind of pain here . . . C7: It’s so hard . . . I feel awful). Diana reported that by focusing on her pain in a direct way, sadness took the place of her punitive voice. As a result she could allow herself to sleep again.

Experiential Exploration of the Basic Existential Needs (Sessions 4-7)

Diana reported that her punitive voice was less present after the first three sessions. There was more space now for the actual exploration of what was most puzzling to her: the question why she committed the crime in the first place. Very different from cognitive-behavioral approaches, experiential and existential offender therapies focus on the exploration of the underlying dynamics of criminal behavior in terms of their basic existential needs (Braswell & Wells, 2014; Gunst, 2012; Ronel & Segev, 2014; Vanhooren et al., 2015; Ward & Fortune, 2014). Just like all human beings, offenders try to reach fulfillment of their existential needs, such as the need for efficacy, connectedness, love, and meaning (Braswell & Wells, 2014; Ward & Fortune, 2014). The way they try to fulfill their needs or the way they cope with the inability to reach their goals is often through unadjusted or antisocial behavior (Ward & Fortune, 2014). When the basic existential needs are not met, offenders gradually become stuck in a criminal spin: a downward process marked by existential loneliness and alienation (Ronel & Segev, 2014).

In the subsequent sessions, Diana engaged in an experiential search process about the meaning of the crime in terms of her basic existential needs. It became clear that certain patterns, which had previously ruled her life most of the time, led to the impulsive act of the crime.

In this excerpt the therapist initiated an experiential exploration of her dark side (T1). Intrigued by how Diana seemed to split her reality between “good” and “bad” in previous sessions he decided to explore this theme. Knowing that the dark side often refers to important needs, he literally used the word “need” in the first intervention (T1). Paradoxically, instead of exploring the crime he started to explore her need to be “good” and her tendency to avoid conflicts. Knowing that her crime was very conflict-laden, he assumed that there was a connection between the underlying dynamics of the crime and the origins of her need to “always be good” to others. Rather than rely on an intellectual search for the origins of her need to be good, the exploration evoked lively memories (C1). She was in direct contact with her felt senses that accompanied her memories. The therapist followed this track and invited her to reflect on how it was to be that “happy child” (T2). Interestingly, this simple intervention helped Diana to unfold the felt sense of her childhood. For the outside world she was that happy child but inside she felt lonely and disconnected (C2). Her experience became even more vivid when she realized that she was hiding from her parents (C3). Attuned to the client’s experiential process, the therapist validated Diana’s words (T4). At the same time he encouraged her to explore her felt meaning of “hiding that angry part for yourself” (T4). The core of this felt meaning became explicit in C5. As a child Diana was scared that she would be rejected if she showed her anger.

Diana discovered gradually that her life had being marked by a profound experience of existential loneliness. Since childhood, she had developed an incongruence between her outer self—the happy popular child—and her inner world: a place where sad and angry feelings were hidden from the outside world. She was scared of being rejected by significant others if she would show them her true self. As a result, she had the feeling that people didn’t know who she was, and became more lonely.

As time went by, Diana identified more and more with that outer person who was “always happy.” She distorted her self-experience, and also resisted experiencing the darker sides of life in general. In this way, Diana’s loneliness caused a form of existential alienation from reality. In partner relationships for instance, Diana shut herself down from the negative feelings or her own relational needs. In only paying attention to positive feelings, Diana created a kind of a fairy-tale reality wherein everything had to be good and beautiful.

In distorting reality and losing connection with herself, Diana had a hard time knowing what was meaningful or important to her in life. Being gifted in many ways, she was successful nonetheless, whether she engaged fully in her activities or studies or not. Diana couldn’t tell if she was living the life she wanted to live.

In discovering all these patterns, Diana realized that her past suicide attempt and the crime she committed made sense in the context of her existential loneliness, the distortion of her reality, and her meaningless life. Both destructive episodes were linked with the downfall of this “fairy-tale reality.” Both times this led to an outburst of self-destructive or destructive behavior. It also became clear what she had to do to prevent another explosion in the future. Instead of hiding negative feelings toward herself and toward others she started to acknowledge the complexity of her inner experience. She learned to communicate about her feelings in a constructive way. At this point in the therapy, the crime felt less “absurd” to her and the symptoms disappeared at the same time.

Finding New Ways to Meet Basic Existential Needs (Sessions 8-13)

Gradually it became clear that Diana previously had fulfilled her basic existential needs for acceptance and love by distorting her self-experience and her perception of the reality. As a consequence, she became estranged from significant others and from herself. In a more concrete way, she avoided conflicts in her relationships and didn’t even know if she really loved her partner or not. She also didn’t know what she liked or wanted in general. This resulted in wrong choices about studies and work, and the experience of life being quite meaningless. As a result, her existential need to live a meaningful life (Frankl, 1946/2006) was also unfulfilled.

The potential for growth for Diana lay in becoming more connected to her inner experience and allowing herself a full range of feelings. Step by step she learned to tolerate reality rather than to escape from it. Going into therapy was Diana’s first step toward acknowledging her inner reality. Talking about her inner punitive voice and the crime were other important steps. The presence of the therapist helped her refrain from avoiding certain parts of herself. Diana explained how speaking out loud during the sessions helped her to be more aware of her inner self. The ongoing sequence of experiential explorations and her attempts to give words to her inner experience helped her to be more in touch with reality.

Diana gradually opened up to the different layers of her situation, after she was encouraged to explore her thoughts, feelings, and bodily felt senses. Instead of thinking or talking about her experiences, focusing (Gendlin, 1996) helped her to be aware of her bodily felt senses about the situation in the here-and-now and to open up to new aspects of her internal and interpersonal reality. By learning to be open to her experience and realizing that her “negative” feelings were accepted by the therapist, Diana felt less of a need to deny or distort her inner and outer world. She could see how her next challenge was mobilizing the courage to be her real self in the presence of others.

Aware of this shift, the therapist encouraged her to show her vulnerable, depressive, angry, and other “unhappy” sides to her friends and family as well. In the next session, Diana reported that she had indeed made herself vulnerable with her visitors and took steps to let others take care of her. For the first time in her life she had a very honest and confrontational talk with her father. Previously scared that others would reject her if she wasn’t the “happy Diana,” she was surprised to learn that her family still loved her. Diana experienced a lot of sorrow, noticing that it took a crime for her to realize that her family wouldn’t reject her in the end.

As therapy went on, she stopped calling herself a “lost cause” or an entirely bad person. Former aspects of her global meanings about herself—being an entirely good person, the idea of knowing herself completely and not being in need of help from others—shifted to more balanced and nuanced meanings. Diana could see that if she didn’t accept all the different parts of herself, she would never be able to build a stable relationship with a new partner, nor live a life that would be meaningful to her.

Concluding Sessions (Sessions 14-16)

The ending stages of experiential and existential therapies are often marked by a higher openness to experience, integrative tendencies toward different aspects of one’s self, a different stance toward others, higher levels of meaningfulness, and the making of better choices toward the future (Cooper, 2003; Rogers, 1961). Or to put it in terms of posttraumatic growth: a changed experience of one’s self, a different appreciation of relationships, and a changed philosophy of life (Calhoun & Tedeschi, 2013). With Diana, the last sessions of therapy were marked by deeper explorations, higher levels of experiencing, and more openness to all angles of difficult subjects. Now that she had been growing in openness to her inner experience, she could explore her darker side in a more profound way. As a result, Diana developed a stronger ownership over the consequences of her crime and also stronger agency over her life in general.

Diana heard that the victims of her crime portrayed her as a misleading and manipulative person. Even though Diana genuinely felt guilty about her crime, she had a hard time hearing that negative portrayal and became confused. In the following session, she wondered if she was indeed manipulative. Could it be that people felt manipulated because she didn’t show what she really felt? She could understand that her ex-partner must have felt really deceived by her. Interestingly, in the same session she argued with the therapist about something she didn’t agree on with him. Apparently, she was brave enough now not to run away from conflicts and allowed herself to stand firm by her own experience.

Another topic that became a more direct subject of exploration was that she had avoided taking risks in life. Concerned about failure, Diana never fully engaged in sports, arts, studies, or work. In fact, by avoiding taking risks, Diana realized now that she had never fully lived before. In retrospect, she felt—in her own words—“stupid” for not having used her full capacities in the past. She realized she had been handicapping herself in many ways. The therapist confronted her with the fact that in the end she fulfilled her worst case scenario of failure: She spent time in prison and would have a criminal record which would make it harder in the future to accomplish what she wanted. The therapist challenged her to live more fully instead of avoiding risks, precisely because she had already hit rock bottom. Initially this intervention confused her but eventually she felt a burden fall from her shoulders. Indeed, if the worst case scenario had already happened there was little risk in living life more fully. In the last session, Diana asserted that she was now fully aware that she really had to live her life and that she would have to make her own choices. Diana realized that her life was finite and that there was no time to waste. It also was very clear that she would have to listen to herself, learn to trust herself, and stay in touch with reality. Life was real and worth living.

Follow-Up Interview

After 16 sessions, the therapy was finished because of Diana’s release from prison. There was a follow-up interview 8 months later. In that time, Diana began to make some important decisions in her life. She started studying again so she could change jobs in the future. She decided to become a social worker: “This was always what I wanted.” She was also more open toward her friends when things weren’t going well. Being more aware of the reality now Diana could experience how she had doubts about the future. She was still struggling on many levels with the fact that she had been a prisoner. Since Diana couldn’t live in a fairy-tale world anymore, she was trying to live now with many uncertainties. Taking everything into consideration, Diana concluded that the experience of incarceration turned her into a better and “happier” (her own words) person.