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"Emotional EEEEs" Part 3
If you have arrived here without reading the previous pages extracted from the book "Wanterfall", the four Es in Emotional EEEEs stand for Encourage, Explore, Express and Evaluate. These are the four essential steps when dealing with any painful emotions.
Facilitated Intense Emotional Catharsis, Part 1
Appassionato e tempestoso
FACILITATED INTENSE CATHARSIS IS NOT SAFE UNLESS
The extreme form of externalisation discussed under this heading may only be of interest to a few readers. The parts which relate to the organisation of facilitated intense catharsis in a group setting may be of interest to even fewer readers. That being the case, I expect many readers will ask, why have I included it at all?
Firstly, because it represents the most comprehensive approach to externalisation, I felt that the book "Wanterfall" (from which this page is extracted) would be incomplete without it. Secondly, it provides an opportunity to consider safety aspects in relation to intense catharsis, which can then be applied to any given level of intensity, simply by reducing their stringency where appropriate. And thirdly, I am quite certain that facilitated intense catharsis can be a very valuable part of the overall approach to severe emotional distress, if all the conditions described are fulfilled.
I said towards the end of Emotional EEEEs Part 2 (under the heading Calming Catharsis) that the first step in damping down the expression of feelings, which is sometimes necessary, is withholding or withdrawing any encouragement to let them out. This page discusses the deliberate encouragement of intense catharsis – the very opposite of calming it down. Importantly, although the descriptions given will often refer to a group environment – which has certain advantages – the process can also be used as part of individual counselling work.
I will refer to those who attend an activity, and receive encouragement to express feelings as intensely as necessary, as participants; and to those who provide the encouragement as facilitators. The activity itself, as you know, is called facilitated intense catharsis. None of the ideas presented here are new, of course, but I think they are well worth revisiting.
I will have quite a lot to say about facilitated intense catharsis on this page and the next, but the first thing I want to say about it is that it is not necessary unless gentler methods fail. And the second thing I want to say about it is that it is not safe unless you make it safe. I do not say these things to disparage it, rather to put it in its place.
And that place, in my opinion, is a very important one. Because, when gentler and quieter ways of externalising emotions fail, this way usually succeeds. And when all the prerequisites discussed below are met, it is at least as safe as crossing the road – and probably safer.
However, although simple in principle, making it safe requires significant time and effort. At least as much of each, in fact, as an amateur theatrical production would require. I have written a basic script, which I have called Prerequisites (below). It isn't a particularly exciting name for a production, I admit. It could probably do with some embellishment in other ways, too. But at least the Creative Commons copyright is flexible – and free.
Even when it is found to be necessary, and made to be safe, it is still very hard work – and it doesn't suit everybody who might potentially benefit from it. But for those who choose to do this work, the benefits can be correspondingly considerable.
To make facilitated intense catharsis available in a group setting, a number of people must work together, in a determined and organised way. This may sound tedious, but a complex undertaking always involves a fair amount of unexciting, but necessary, work behind the scenes.
True, there are quite a few organisations that already provide opportunities for emotional catharsis. But they usually offer it as part of a broader type of therapy – or sometimes a religious activity. This introduces a degree of complexity, and sometimes a belief system, which may be counterproductive, or even downright dangerous, depending on many variables.
Of course, there is nothing new about intense catharsis. For example, the classical Greek tragedies were written and performed for the express purpose of encouraging emotional catharsis. And in modern times, many therapists have encouraged clients to make as much noise as they like, and also to hit something while they are screaming, swearing and putting violent ideas into words.
Elisabeth Kübler-Ross, in her residential workshops, used to provide a thick rubber hose, and a supply of telephone books, to facilitate the physical expression of angry feelings like rage or hatred. While assisting at one of those workshops, I saw a frail, gentle, elderly lady reduce a large phone book to confetti with a rubber hose, after getting in touch with some very deep-seated anger.
At other times, her physical activity was really quite limited. After the session, she felt very much relieved. She had sore muscles later, of course. I don't know where her strength came from, and neither did she. That and countless other examples of powerful externalisation have convinced me that considerable energy is associated with strong emotions.
But is it safe to meddle with such powerful feelings? My answer is, it is safe if you make it safe – but not otherwise. This answer is based primarily on my own experience with the process, both as participant and facilitator. During the year I spent training under Kübler-Ross and her associates, I externalised unfinished business of my own, or facilitated externalisation by others, for roughly five hundred hours.
During that year, hundreds of other participants also took part in facilitated intense catharsis. In all that time, only one significant physical injury came to my attention – and it was due to a fall during psychodrama, not during intense externalisation. Also, no case of new precipitation or significant exacerbation of mental or physical illness as a result of the process came to my attention during that year. And this was a close community, with a very efficient grape vine.
We were taught to make it safe, and we did. Much safer than playing football, certainly. Safety is not the only important aspect of facilitated intense catharsis, of course – but it is the most important. It must be integrated with every aspect of the process. For this reason, I am going to describe the process entirely in terms of the prerequisites that make it safe.
FACILITATED INTENSE CATHARSIS IS NOT SAFE UNLESS
To make sure that vigorous catharsis is both safe and effective for all concerned, various prerequisites must be met. They also apply, though to a lesser extent, to the less vigorous forms of externalisation which I have described on other pages in this series. Towards the end of Emotional EEEEs Part 1, under the heading Playing Safely, I mentioned the essential principles, saying that externalisation must be done
in a safe way, in a safe place, at an agreed time and with the permission and co-operation of everyone who is directly or indirectly affected.
That statement is designed with brevity in mind, and does not attempt to include details of practical procedures. To expand on it, and to discuss those procedures, I have chosen five headings which are derived from it, but which use different words. The principles themselves, however, are not changed at all. Here are the five headings:
· Methods & Equipment
· Time and Place
I will say very little about administration here. It pops in and out of the picture under all the other headings, doing what is necessary, always available, but never in the way – which is, by the way, exactly my idea of good administration. Incidentally, in the text, I often refer to the administration as "the organisers", and to what they organise as "the activity".
Among its many responsibilities, the administration has to find the venue, arrange public liability insurance, negotiate agreements with participants, employees and volunteers, and deal with all the financial aspects. I will not go into the details of these matters, but they are all essential. So the administration, which gets passing mentions in the text, has a very large and important task in reality.
The minimum number of participants is one, but there is an advantage in having a larger number. The feelings expressed by one person often trigger unfinished business in others. Kübler-Ross often used to work with around a hundred participants, and four to six facilitators. Those workshops were very noisy – in the Mozartian sense mentioned earlier in this series (she used to say of the screams, "They sound like Mozart to me").
A formal registration procedure for prospective participants is essential, to avoid missing one or more of the necessary steps. The main issues which must be addressed before any person participates in facilitated intense catharsis are information, assessment and agreement. Each of these applies to both participants and organisers, but not necessarily symmetrically.
Prospective participants need to be given information about the activity, so that they will know what to expect and (equally important) what will be expected of them. This allows them to make informed choices. The necessary information could be provided by word of mouth, holding a meeting, or providing a brochure – but preferably all three.
It is particularly important that each participant understands that the process is both physically and emotionally tiring, and that emotions will come to the surface which may well cause increased distress until they have been worked through. The participant must be willing to accept these aspects of the work. Otherwise, it should not be attempted.
Next, the participants need to provide certain information about themselves to the organisers, so that they can be assessed for suitability. This is necessary for the safety of the individual participant, and sometimes also for the safety of others who will be present. It could be collected by questionnaire, interview, medical report or a combination of these.
The design of questionnaires and medical report forms would be a matter for the organisers, but examples might be sourced from health care providers. Ideally, the screening process should be managed by a mental health care professional. Where this is not possible, a medical report on all participants would be advisable.
Conditions relevant to the assessment process include both physical and mental illnesses. Activities like those described in Emotional EEEEs Part 4 under Methods and Equipment are physically very demanding. The powerful emotions driving the activity ensure that it will usually be both vigorous and prolonged. The degree of effort involved may not be noticed in the heat of the moment – but its results will probably be felt later.
In the case of healthy participants, muscular discomfort is all that is likely to occur as a result of such activities. In some cases, other soft tissues might also become inflamed. However, people affected by any significant illness should always consult their doctor in advance, and provide a medical report to the organisers. There are some conditions which make vigorous exercise potentially life threatening.
The commonest condition requiring caution is probably ischaemic heart disease (often loosely called angina) in which the blood supply to the heart muscle is restricted. In combination with extreme exertion, this can precipitate a dangerous arrhythmia (fast or irregular heartbeat). A person with known ischaemic heart disease should already have a cardiologist, who can advise about the activities which may safely be undertaken. Any other person who is not accustomed to regular vigorous exercise should be advised to have a medical checkup and report before participating.
It is not only physical illness that can be worsened by facilitated intense catharsis. Anyone prone to manic or hypomanic mood states runs some risk of precipitating an episode by engaging in extreme forms of catharsis. This risk is very much lower if the illness is well controlled at the time.
Even then, careful observation is necessary. That is simply because the release of distressing emotions sometimes causes a natural mood elevation in the aftermath of the session, which may be enough, in some cases, to trigger an acute manic or hypomanic episode. This might be delayed in some cases.
Any severe depressive disorder would likewise preclude this work until the condition is stabilised, as a natural lowering of mood may occur when painful feelings have been brought into consciousness but have not yet been resolved. This might trigger a severe depressive episode in some cases.
There are also potential risks associated with psychoses and personality disorders, which are difficult to predict. The advice of the person's doctor and/or psychiatrist would be essential in all such cases. In many cases, increased risk of adverse effects and decreased likelihood of benefit would indicate exclusion.
There may be occasions when significant medical or psychiatric history is known but not disclosed – or perhaps has been forgotten. A participant's unsuitability might then not be discovered until after the activity had commenced. This could necessitate urgent medical or psychiatric review. Depending on the severity of the condition, the participant might then need to withdraw from the activity.
There is only a very little to say about assessment, but it is very important. On the basis of the information available to them, as mentioned above, participants assess the activity and decide whether to proceed with an application. And on the basis of the information provided by them, the participants are assessed by the organisers, who decide whether to accept their applications. Both sides of this assessment process are absolutely essential.
Prospective participants who are assessed as suitable then have a very important choice to consider. If they are to proceed, they must make a commitment to co-operate with the facilitators, and especially to accept safety directions from them. This cannot be negotiated – it is an absolute requirement. There are other matters requiring agreement between participants and organisers, which I will discuss fairly soon, but none is as important as this one.
The agreement of each prospective participant to comply with safety directions is usually adhered to. If it were not, the participant would have to be asked to leave. But co-operative participants are overwhelmingly the norm – and they themselves create an atmosphere in which troublesome tendencies simply do not flourish. Indeed, the participants are usually just as determined to prevent problems as the facilitators themselves are.
Although that is the most important agreement, it is not the only one that is necessary. Here is a list of suggested agreements for prospective participants to enter into, including the one already mentioned:
· to accept safety directions from facilitators (this is the most important agreement)
· to attend in a satisfactory state of health, and free of the influence of any non-prescribed drugs or alcohol
· to report any changes in the previously disclosed medical or psychiatric conditions to a facilitator
· to maintain complete confidentiality about anything which is overheard (it should not even be discussed with the owner of the information, unless raised by them)
· to behave non-judgmentally as regards disclosures made by other participants, even if unable to refrain from judgmental thoughts about them
· to use the same (allocated and identified) rubber hose at all times, so that it cannot pose a cross infection risk
· to report any contamination of the environment by blood or other potential hazards to a facilitator immediately
In addition to a list of agreements such as the one given above, a formal consent procedure must be followed. It is true that the participants imply their willingness to be involved, by attending the activity. However, informed, explicit, written consent is also necessary, and must form part of the registration process. The exact procedure varies with time and place, so it will need to be researched during the preparations. It is essential that the consent procedure complies with local regulations, otherwise it will be ineffectual.
All the requirements mentioned above, along with any others added by the organisers (or their legal advisers) need to be explained to each participant, and must be properly understood before they are accepted. The participant's agreement should then be given in writing as well as verbally. This may all seem rather officious, but quite apart from its legal necessity, it is really the only way of being sure that the essentials are understood by all concerned.
There is still one aspect of agreement that I have not discussed under the present heading, and that is permission. Unless the participants are convinced that they have the permission of the facilitators to express their feelings, and also give themselves permission to do so, little progress will be made. This will have been explained in the information given to participants as part of the registration process. The reminder "give yourself permission" is also popular with facilitators during the activity.
FACILITATED INTENSE CATHARSIS IS NOT SAFE UNLESS
As with participants, the minimum number of facilitators is one. However, the number of participants actively encouraged to externalise at one time should not exceed the number of facilitators present. Of course, the number externalising intensely without active encouragement may sometimes exceed the number of facilitators. That cannot be helped.
When more than one facilitator is present, it is necessary that one of them acts as the director of the session. Occasionally, a procedural decision will be necessary during the activity, and it is not practicable to hold a meeting and take a vote at such a time. The director should be an experienced facilitator who is trusted by the other facilitators present.
The director and the other facilitators must obviously be chosen by the organisers, who will presumably be influenced by qualities such as those suggested below. All facilitators must agree to accept the leadership of the director, and specifically to cease acting as a facilitator if the director considers this to be necessary.
They must also be in satisfactory mental and physical health, agree to disclose relevant medical or psychiatric conditions, maintain complete confidentiality and attend the activity free of the influence of non-prescribed drugs or alcohol. If any participants are minors, a police check will be required in many jurisdictions. In some jurisdictions, this may be required regardless of the age of the participants.
The facilitator's role should be formalised by a written agreement. This may be more complex if they are paid employees, as local employment regulations will have to be complied with. However, volunteers also need to negotiate a clear agreement with those organising the activity, and local regulations may be relevant to this agreement also.
I mentioned earlier that the facilitators provide more than just encouragement. They bring considerable personal resources to a dedicated helping role, which includes encouraging, guiding and educating the participants, and especially, keeping them safe while they do their work. The facilitators are thus critical to both the safety and efficacy of the venture.
Not everyone is suitable for this role. Tertiary qualifications in some aspect of health care are certainly no guarantee of suitability. Some facilitators might come from a mental health background, but many will not. It is an essentially practical task, and the best preparation for it is experience – experience of life, experience as a participant, and supervised experience as a facilitator.
However, together with such preparation, certain qualities are very important in a facilitator. I will describe the main qualities that I see as necessary for the role under six headings – personality, attitudes, knowledge, skills, experience and focus. Of course, some qualities might have an entry under more than one heading – and others might not fit very neatly under any.
In general terms, personality refers to a person's individual way of being, acting, reacting and relating. It excludes the universal characteristics of Homo sapiens, and it also excludes most innate and acquired qualities of a physical or intellectual nature (though it may be influenced by them). Consequently, it is primarily the result of emotional and social attributes.
Because personality is such a broad quality, it can often influence, or be influenced by, other qualities – especially attitudes. In fact, a good case could be made for including attitudes within personality. Also because personality is such a broad quality, the few comments I am going to make about it will be dwarfed by the magnitude of their subject. However, I hope this will not render them completely invisible.
One aspect of personality which is very important to the role of facilitator is a deep seated and sincere urge to help. This is related to the qualities of sympathy, empathy and compassion, which were excluded from membership of the propathy club, earlier in the book "Wanterfall" – but are not expected to receive quite such short shrift in the gradually evolving Philosophical Musings series.
Another very important quality is the ability to remain calm (and not just superficially) while all hell breaks loose. It is necessary for a facilitator to maintain a congruent equanimity in the face of rage, terror, despair etc. Not to do so would tend to contradict the first premise of the activity – that the sharing of any feeling is not only acceptable in every way, but is in fact strongly encouraged as an essential part of the process.
In other words, just as the participants must give themselves permission to share feelings, the facilitators must give the participants permission to share feelings. And this permission will be interpreted as specious, if any communication from a facilitator, whether verbal or non-verbal, suggests that anything about the sharing of feelings is not OK.
Congruent equanimity is not really feasible if the emotions being expressed cause great distress to the facilitator. Consequently, most people need to have done a lot of work on their own pool of pain before they are capable of acting in this role. Perhaps there are exceptions, but for practical purposes I think this quality should at least be tested by working as a participant – which will also help to develop it further.
I would like to include a non-judgmental attitude here, as an essential aspect of the personality of a facilitator – but I accept that, logically, it belongs under the next heading. However, the ability to actually be non-judgmental – and therefore to show it congruently – probably does have a foot in the personality camp. So I am going to put it under both headings. If that is an honour, it deserves it. It is probably the most important of all the essential qualities that a facilitator needs.
As promised, here is the repetition. The only essential attitude for a facilitator to possess is the non-judgmental attitude mentioned above. Importantly, as I hinted there, it must be more than skin deep. And it will be very clear, from a facilitator's non-verbal output during a session, just how deep, or shallow, this attitude is.
If you do not have a non-judgmental attitude, the best way to grow one is to externalise as much as possible of your own pool of pain, and evaluate that process as you go along. It is mainly guilt, shame and beliefs, largely laid down during childhood, which keep judgmental attitudes alive. You will like being free of them – and so will everyone you know.
There are other attitudes which are helpful, though not essential. Like all attitudes, they will shine like a beacon, via non-verbal signals, to anyone who is working with their feelings. These other attitudes include:
· the attitude that the activity itself is worth doing
· the attitude that the participant really can discover – and release – the contents of their pool of pain
· the attitude that there is no such thing as a feeling which is too bad to share – or too painful to let go of
· the attitude that life keeps getting better and better as the painful emotions are left behind
· the attitude that goodness exists within all people – and can find its way to the surface if given the chance
I am sure you can think of plenty of others. But the only absolutely essential attitude is the non-judgmental one.
Knowledge is, in many ways, the least important heading. This is not rocket science, after all. It is far more important – to survival as well as happiness – than rocket science, but it is not a knowledge-intensive discipline. A basic understanding of emotions is the main knowledge that is needed. This might have been gained during childhood, or later in life. Some of it may come from study, but its application is mainly practical.
Obviously, it is also essential to be well versed in the methods of externalisation to be used, and especially how to keep participants safe while using them. This will be discussed under Methods and Equipment on the next page. At least one of the facilitators should also be trained in first aid (which of course includes skills as well as knowledge) even though accident or illness during the activity is uncommon, and almost always minor. A first aid kit, and a telephone, should also be available.
When assessing participants for suitability, someone with knowledge of clinical psychology or psychiatry should ideally be involved. This person need not be a facilitator, though. If such a person is not available, a medical report on each participant provides a partial solution.
I mentioned the methods of externalisation under Knowledge, but those methods also include a small but important element of skill. However, the main skills that a facilitator needs are communication skills. These, as previously mentioned, are outside the scope of this book, but I will mention two aspects of communication here. The first is an ability to provide necessary input with minimal interruption. For example, a single word or a slight gesture can easily encourage continued expression, or point out that something is missing. On the other hand, a whole sentence tends to wake up the participant's intellect – which will be very useful for the next E (Evaluate) but is more often a liability during this one.
The second particularly important communication skill is the ability to make routine use of all input and output channels simultaneously – with the outputs all being congruent. This is a tall order. Indeed, it is impossible to achieve by artifice alone; and it is especially likely to fail when something less than the whole truth is being communicated.
In that situation – which is not uncommon when working with vulnerable clients – a number of factors influence the result. Careful attention to the nuts and bolts of the communication process, as a routine and effortless habit, is just the beginning. Some familiarity with one's own pool of pain is also essential.
Adding the regular practice of non-judgmental self-awareness, as previously discussed, should gradually result in a modicum of self knowledge. That in turn makes it possible for something less than the whole, mercilessly unvarnished truth to be communicated without causing conflict in the mind of the communicator. And that in turn makes it reasonably likely that the communication will be made congruently via all channels.
Some may question the need to communicate less than the whole truth. After all, brutally unfiltered honesty will usually result in congruent communication, without requiring any special skills. But it is better for the participant to choose the rate at which the truth is explored, rather than suddenly being interred beneath an uninvited mountain of it. And to avoid that, it is sometimes necessary to save part of the truth for later.
The most important specific experience needed is previous and recurrent experience as a participant in facilitated intense catharsis. This has also been mentioned under other headings. It is simply essential to have experience of the method, if you intend to facilitate the process yourself. In this context, one practice is worth a thousand words. After that, experience working as a facilitator, initially under supervision, will provide further learning opportunities for as long as it is done.
There is not very much that can be said about the general aspects of experience, except that they are very important here – as they are in any field of endeavour. Life comes with experience as a non-optional extra, but I think some sorts are particularly applicable to work as a facilitator.
Working in fields such as (but not limited to) mental health care, dementia care, hospice care, or education is likely to be very useful. So is living in a refugee camp or a prison, going through a divorce, suffering a bereavement or losing a job or business. In other words, any experience involving the emotions can be useful background training for a facilitator.
A facilitator must give undivided attention to the participant working on feelings. Also, the majority of facilitators must remain in role until the last participant has left. Assuming a willingness to do the job, the only threat to this focus is the facilitator's own unfinished business.
Triggering of a facilitator's own unfinished business is not an infrequent occurrence, because the work being done by the participants subjects everyone in the room to a wide range of powerful stimuli. However, whatever is triggered cannot always be dealt with immediately.
Depending on its nature, an emerging issue might be dealt with by deferring it to a later occasion, working on it briefly with another facilitator, continuing the activity as a participant or withdrawing from part or all of the remaining duration of the activity. This would be determined by the director. Externalisation by a facilitator during the activity must always be managed, because working as a facilitator requires a clear and steady focus on the participant. Like a medical or surgical procedure, it cannot simply be interrupted at random.
The above possibilities should cause little or no disruption as long as all the facilitators have previously done considerable personal growth work – and continue to do this work as and when necessary. Without that essential preparation, most people would find the role of facilitator too painful, fulfil it very badly, or (most likely) both.
This topic is continued on the next page
FACILITATED INTENSE CATHARSIS IS
NOT SAFE UNLESS
(Click the number of a footnote to return to its reference in the text)
 See page 2 of "Wanterfall", or go to the relevant Creative Commons web page.
 For more information about the work of the late Dr Elisabeth Kübler-Ross, see http://www.ekrfoundation.org/
 With a view to a simple explanation of these states, an eBook entitled "An Introduction to Mental Illness" may be published at a future date by Wanterfall eBooks at www.wanterfall.com
 Philosophical Musings, a slowly evolving series of articles at www.wanterfall.com
 Congruence is discussed in Notes on Communication, a free e-booklet available from www.wanterfall.com
 An introduction to these skills is provided in Notes on Communication, a free e-booklet from www.wanterfall.com
(Click the number of a footnote to return to its reference in the text)
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