Focusing manner and posttraumatic growth

ABSTRACT Recent scholarship in the person-centered experiential (PCE) approach has theorized how organismic valuing might be an important process factor in the development of posttraumatic growth. In a test of this prediction we investigated the association between Gendlin’s focusing and posttraumatic growth in 87 participants. All completed measures of focusing attitudes, posttraumatic stress and posttraumatic growth. The results showed that higher scores on focusing attitudes were significantly associated with lower scores on posttraumatic stress (r = −.39, p < .001), and higher scores on posttraumatic growth (lowest r = .32, p < .001), and that the associations with posttraumatic growth remained even with scores on posttraumatic stress partialled out (lowest r = .33, p < .001). Implications of these findings are discussed for therapeutic work with trauma survivors. Specifically, the results provide support that the use of Gendlin’s focusing and/or focusing evocative language may be effective in supporting those who suffer from severe and chronic trauma-related problems. These results provide sufficient support to warrant further clinical research using more sophisticated experimental approaches to test whether therapeutic work using focusing is able to promote posttraumatic growth.


Introduction
More than 80% of individuals in the general population have experienced at least one incidence of trauma during their lifetime (American Psychiatric Association, 2013). It is estimated that posttraumatic stress disorder (PTSD) along with the co-morbid conditions such as depression, panic disorder, generalized anxiety disorder, obsessive compulsive disorderall rooted in traumatic experiences, affect at least 6.06% of the UK's adult population (Murphy, Archard, Regel, & Joseph, 2013). Person-centered experiential (PCE) theory and case study evidence is able to account for the wide range of human reactions to adverse events and the idiosyncrasy of the clients' needs in various post-trauma environments (e.g. Brice, 2011;Carrick & Joseph, 2013;Murphy, 2009;Rutherford, 2007;Tickle & Murphy, 2014). However, there remains a need for empirical research to test specific predictions for how the person-centered experiential approach might be helpful to survivors of trauma.
To date the most sophisticated theoretical conceptualization of person-centered experiential therapies for trauma is described in the Organismic Valuing Theory of Growth Following Adversity (OVP) (Joseph, 2015;Joseph & Linley, 2005). This account is based on Rogers' (1959) theory of how experiences incongruent to the self-structure lead to a process of breakdown and disorganization. According to the OVP theory of posttraumatic growth, after a person's pre-trauma assumptions become shattered, the process of 'working through' the adverse experience is signified by alternating phases of intrusion and avoidance, typical of the diagnostic category of PTSD. However, the eventual accommodation of the new traumarelated experience as self and experience become aligned involves not only a reduction in these experiences of intrusion and avoidance, but also a shift in the person's assumptive world and is a manifestation of an intrinsic drive for moving toward posttraumatic growth (Joseph & Linley, 2005).
This internal directional force, a guide which informs us that something is wrong or that an action is needed in order to amend a situation, is what person-centered experiential theory recognizes as the organismic valuing process. For Rogers (1961Rogers ( , 1964), to be able to follow one's organismic valuing was to find balance between all important internal and external sources of information and to assess how these interactions are going.
The available empirical evidence from the field of positive psychology validates the thesis that the OVP is a real and tangible force which aspects can be discriminated and observed. Research into human ability to attain goals (Sheldon & Elliot, 1999), intrinsic goal orientation (Schmuck, Kasser, & Ryan, 2000) and people's preference for choosing directions that enhance well-being (Sheldon, Arndt, & Houser-Marko, 2003) continuously supported the evaluative and progressive character of human nature. Striving toward the fulfillment of psychological needs, self-actualization and psychological well-being, as well as research into its correlates e.g. intrinsic motivation and the concept of flow, are all viewed as supportive of the concept of the organismic valuing process (Joseph & Linley, 2005).
Restoring contact with the organismic valuing process means opening access to one's living experience. Rogers' (1961) view of experiencing as a living, fluctuating and directional process is consistent with Gendlin's perspective.
Experiencing is a constant, ever present, underlying phenomenon of inwardly sentient living, and therefore there is an experiential side of anything, no matter how specifically detailed and finely specified, no matter whether it is a concept, an observed act, an inwardly felt behaviour, or a sense of a situation. (Gendlin, 1962, p.15) Gendlin (2004) states that experiencing is inherently a valuing process. As such, it always involves confronting, differentiating and discovering the specific good or bad, resolved or conflicted 'feel' of a direct referent. The process of experiential valuing can simultaneously hold aspects of being completed and being open for interaction with further differentiated, newer felt senses that appear next, 'queuing' to be approached (Gendlin, 1967). The organismic inherency of values, their directional nature and purposefulness are also discussed in Gendlin's 'A Process Model' (1997). Gendlin notes that the acts of 'experiencing', 'expression' and 'understanding' never occur as separate but are involved in a simultaneous and self-enhancing process that signifies progress which, in the context of this study, can be thought of as growth.
Whereas both Rogers and Gendlin emphasized the importance of the bodily dimension to experiencing (Gendlin, 1991(Gendlin, , 1992Rogers, 1980), Gendlin furthered this line of thought. He stated that the very essence of experience, the bodily based felt sense can be grasped by extracting it, saying it out loud and giving it the accurate conceptualization (Gendlin, 1978). Based on the arguments introduced above, we conclude that the concept of the organismic valuing process is equal to Gendlin's felt sense and as such, it can be intentionally sought for and made explicit through the practice of focusing.
Focusing is a well-researched practice for restoring contact with the flow of experiencing (see for review Hendricks, 2001;Krycka & Ikemi, 2016). It has been effectively used to facilitate the process of working through trauma-related experience (Morse, 2003;Parker, 2009;Phillips & Phillips, 2012) also by approaching its embodied forms (McGavin, 1997). Focusing involves six steps which are: clearing a space, felt sense, a handle, resonating, asking and receiving. The steps can be adjusted to the specifics of working with posttraumatic stress (Coffeng, 2004;Santen, 2014;Scharwachter, 2005) and destructive patterns of behavior underlaid by trauma (Gunst & Vanhooren, 2018). Rappaport (2010) supports her trauma therapy work with focusing practice combined with tools provided by expressive arts. Focusing can be used in accordance with the naturally evolving process of trauma recovery which often involves stages of establishing safety, remembrance and mourning, and finally, reconnection with ordinary life (Herman, 1992).
The aim of the current quantitative study was to contribute to building a theoretically informed evidence base for person-centered experiential trauma work by investigating the associations between focusing attitudes, posttraumatic stress, and posttraumatic growth. It was predicted that stronger focusing attitudes would be associated with lower posttraumatic stress and higher posttraumatic growth.

Participants
Participants were recruited online from several trauma and PTSD informed groups which were moderated and all inquired about the ethical approval of the research before the link was placed online. Participants of above 18 years old who within the last 6 months experienced a significant stressful event were invited to the study. A total of 87 participants completed the survey with 75 (86%) of them describing their gender as female, 8 (9%) as male and 4 (4%) who defined their gender as non-binary.

Procedure
The ethical approval for the study was granted by the University of Nottingham, School of Education Research Ethics Committee. Potential participants were required to read an information sheet containing the details of the study and to provide consent to taking part, prior to being able to proceed. Participants were offered advice on forms of accessing psychological support in case such was needed as a result of exploring their experience. The measures described below were made accessible via Bristol Online Surveys.

Traumatic experience
The Distressing Events Checklist (DEC: Vrana & Lauterbach, 1994) was adapted for the purpose of this study. This checklist asked participants to discriminate between recent adverse events and to focus the attention on the most upsetting one. This event was placed on a 6 to 1 month time frame and its intensity was indicated on a 0-6 Likert scale.

Posttraumatic stress
The Impact of Event Scale (IES, Horowitz, Wilner, & Alvarez, 1979) is a 15-item self-report measure of subjective distress which is based on a Horowitz's (1976) model of processing following a trauma. It assesses the frequency of intrusive and avoidant phenomena. Possible participant scores could range from the total of 0-75, with Intrusion (0-35) and Avoidance (0-40) subscales.

Posttraumatic growth
Posttraumatic Growth Inventory (PTGI, Tedeschi & Calhoun, 1996) is a 21-item (e.g. 'I have a greater appreciation for the value of my own life') measure of reported PTG. Each participant rates their responses on a six-point Likert scale. Possible participant scores could range from 0 to 105.
The Changes in Outlook Questionnaire -Short Form (CiOQ-S, Joseph, Linley, Shevlin, Goodfellow, & Butler, 2006) is a method of assessing positive and negative changes following a traumatic experience. This two-factor tool consists of a total of 10 items, with 5 items per scale where changes of a positive character are seen as indicative of growth (Joseph & Linley, 2005). Participants were asked to place their answers on a 6-point scale and the possible scores could range from 10 to 60 for the total score and 5-30 equally for both subscales. In the current study we were only concerned with positive changes.
Focusing/experiential attitudes Focusing Manner Scale (FMS-A.E., Aoki & Ikemi, 2014) is a 25-item tool based on the original FMS (Fukumori & Morikawa, 2003) which measures the degree to which one has focusing attitudes. These are understood as paying inward bodily attention to one's felt senses, acknowledging them and having a friendly attitude toward them. The review of correlational studies has consistently shown positive associations between FMS scores and positive psychological or somatic health (Aoki & Ikemi, 2014). Participant scores could range from 25 to 100.

Results
All participants reported having experienced a significant traumatic event within the past 6 months at the point of taking part in the study. The most common event as assessed using the DEC was 'relationship breakdown' (35%) followed by 'bereavement' (18%), 'someone else's serious illness or an accident' (12%), 'participant serious illness' (10%) and other (20%).
The means for all measures suggested that participants in the present study were generally experiencing high level of posttraumatic stress (IES cut off score for PTSD-35), low to moderate level of growth and moderate level of focusing attitudes (Table 1.) Pearson correlation analysis was used to test the association between scores on measurements of posttraumatic stress (IES), perceived posttraumatic growth (CiOQ and PTGI) and focusing attitudes (FMS-A.E.). Table 2 shows all correlations between posttraumatic stress, posttraumatic growth and focusing attitudes.
Statistically significant positive correlations were found between scores on the FMS-A. E. and the total score in PTGI (r = .43, p < .000) and the positive changes subscale of the CiOQ (r = .32, p < .001).
Partial correlation was used to further explore the relationship between the focusing attitudes and posttraumatic growth controlling for the severity of posttraumatic stress. The association between scores on the FMS-A.E. and the PTGI (r = .43, p < .000) and the positive changes subscale of the CiOQ (r = .33, p < .001) remained statistically significant.

Discussion
The current quantitative study is the first attempt to explore the relationship between focusing attitudes and the potential for growth from adverse experiences. The findings provide support for the prediction that focusing/experiential attitudes are significantly positively correlated with posttraumatic growth. The results suggest that people who are aware of their felt senses, accept and act on them, but also are capable of finding a comfortable distance from them, find it easier to overcome and grow from traumatic situations. Several limitations to this study should however be noted.
First, the convenience sampling methodology did not permit to clarify how typical the final participant group was of the general population. In particular, those who use online trauma-related groups and forums might not be representative of trauma exposed people. The current participant sample were characterized by a significant predominance of women which made it difficult to explore the potential influence of gender.
Second, previous research has shown that higher self-reports of posttraumatic growth may sometimes reflect defense styles (Boerner, Joseph, & Murphy, 2017). As such, we cannot be certain that our measures of posttraumatic growth are not influenced by defensive processes. Therefore, future studies would potentially benefit from including a relevant measure to control for defense styles. Research in this area would also benefit from a longitudinal design which enables capturing the actual PTG as a difference in scores of participant well-being at different points in time after an adverse event (Flanagan, Patterson, Hume, & Joseph, 2015;Joseph & Linley, 2008).
Third, the results of the current study suggest that stronger focusing attitudes are accompanied by higher capability to grow from traumatic experiences. However, our cross-sectional study does not provide direct evidence for this. Following individuals through the ongoing processes as they emerge would potentially elucidate how focusing attitudes influence perceived and actual posttraumatic growth. It is important that further studies in this area investigate as to what degree focusing attitudes change naturally as an outcome of person-centered experiential therapy. Available research indicates that focusing attitudes measured with FMS-A.E. remain rather stable without interventions but can be enhanced by certain activities specifically designed to have experiential effects (Aoki & Ikemi, 2014). Consequently, therapeutic proceedings that have a definite experiential influence should present high potential for developing capabilities that are crucial in resolving and growing from trauma. Practice-based research with its potential for pre-/post-therapy and other longitudinal study designs seems to hold promise for bringing new insights and involving us more deeply in an understanding of the phenomena of human change in the face of trauma.

Disclosure statement
No potential conflict of interest was reported by the authors.

Notes on contributors
Alicja Zwiercan, BA (Hons), MA, works in a third sector organization as a person-centred experiential therapist. The focus of her work is on adult members of the community who are at risk of self-harm and suicide. She completed her Masters Degree at the University of Nottingham, UK.
Stephen Joseph is a senior practitioner member of the British Psychological Society's register of psychologists specialising in psychotherapy. He is a professor at the University of Nottingham in the School of Education where he is part of the human flourishing research group and convener of the counselling and psychotherapy teaching group. He is editor of 'The Handbook of Person-Centred Therapy and Mental Health: Theory, Research and Practice' (PCCS, 2017).