Innovative moments and change in narrative therapy

Abstract

Narrative therapy suggests that change happens by paying close attention in therapy to “unique outcomes,” which are narrative details outside the main story (White & Epston, 1990). In this exploratory study, unique outcomes were analyzed in five good-outcome and five poor-outcome psychotherapy cases using the Innovative Moments Coding System (Gonçalves, Matos, & Santos, 2008 Gonçalves , M. M. , Matos , M. , & Santos , A. 2008 . Innovative moments coding system. Version 7.0 . Braga, , Portugal : University of Minho . ( Available from the authors ) [Google Scholar]). Across 127 sessions, innovative moments were coded in terms of salience and type. In accordance with the theory, results suggest that innovative moments are important to therapeutic change. Poor- and good-outcome groups have a global difference in the salience of the innovative moments. In addition, results suggest that two particular types of innovative moments are needed in narrative therapy for therapeutic change to take place: re-conceptualization and new experiences. Implications for future research using this model of analysis are discussed.     

Letters in cognitive analytic therapy: The patient's experience

Abstract

Patient perspectives on how therapeutic letters contributed to their experience of cognitive analytic therapy (CAT) were investigated. Eight patients took part in semistructured interviews. A grounded, thematic analysis of their accounts suggested four general processes. First, letters offered a tangible, lasting framework for the assimilation of a new perspective about themselves and their relationships and facilitated coping with a complex range of emotions and risks this awareness required. Second, they demonstrated therapists’ commitment to patients’ growth. Third, they helped to teach participants about the therapy process as an example of an interpersonal exchange. Fourth, they helped participants consider how they wished to share personal information. These data offer a more complex understanding of this standard CAT intervention. Although some findings are consistent with CAT theory, the range of emotional dilemmas associated with letters has not received specific attention. Clinical implications are discussed.     

Group person-based cognitive therapy for distressing voices: Views from the hearers

Abstract

This study investigated the experiences of people who received a contemporary form of cognitive therapy for distressing voices. Eighteen people who heard distressing voices participated in an 8-session person-based cognitive therapy (PBCT) group and were then interviewed to elicit their experiences from the group. Data were gathered during a series of five posttherapy focus groups based on a semistructured interview schedule. A grounded theory approach was used to generate, work with, and understand the data. Four categories emerged: two representing the context for reflection and change and two representing the acceptance of voices and self and the changing sense of self. The conceptual and clinical implications of the findings are discussed.     

Importance of Psychotherapy motivation in patients with somatization syndrome

Abstract

A process of change within a single case of cognitive-constructivist therapy is analyzed by means of conversation analysis (CA). The focus is on a process of change in the sequences of interaction, which consist of the therapist's conclusion and the patient's response to it. In the conclusions, the therapist investigates and challenges the patient's tendency to transform her feelings of disappointment and anger into self-blame. Over the course of the therapy, the patient's responses to these conclusions are recast: from the patient first rejecting the conclusion, to then being ambivalent, and finally to agreeing with the therapist. On the basis of this case study, we suggest that an analysis that focuses on sequences of talk that are interactionally similar offers a sensitive method to investigate the manifestation of therapeutic change. It is suggested that this line of research can complement assimilation analysis and other methods of analyzing changes in a client's talk.     

“If those tears could talk,what would they say?” Multi-method analysis of a corrective experience in brief dynamic therapy†

We analyzed master theorist/therapist Hanna Levenson’s six-session work with “Ann” in American Psychological Association’s Theories of Psychotherapy video series to determine if and how this client had a corrective experience in Brief Dynamic Therapy. First, we identified indicators of a corrective experience in the therapist’s and client’s own words. Complementing this analysis, we used observational coding to identify, moment by moment, narrative-emotion markers of shifts in Ann’s “same old story”; the frequency, type, and depth of immediacy; and the client’s and therapist’s behavioral contributions to the working alliance. Additionally, we qualitatively analyzed Levenson’s session-by-session accounts of the therapy from two sources. Convergent evidence from these multi-method analyses suggested how the intertwined relational and technical change processes seemed to bring about this client’s corrective experience. Through consistent attention to the alliance and increasingly deep immediacy, Levenson created a safe space for Ann to “bring down the wall”—by allowing herself to cry and be deeply understood and cared for in a way that she had never before experienced. Concurrently, Ann began seeing herself quite differently, signified by self-identity narrative change. Then, following Session 4, she took Levenson’s suggestion to risk behaving more authentically with a friend and with her romantic partner.     

Using helping skills with Korean clients: The perspectives of Korean counselors

Objective: The purpose of this study was to investigate how Korean counselors modify the helping skills they learned during training in their work with Korean clients. Method: Thirteen practicing Korean therapists who had taken two master’s level courses in the Hill helping skills model were interviewed about their experiences in applying the model in their work with clients. Data were analyzed using consensual qualitative research (CQR). Results: Several characteristics were noted of Korean clients that might influence the appropriateness of the helping skills model (e.g., clients regard counseling as authorities and wise experts). Participants had a number of reactions to the overall helping skills model (e.g., noting that Korean counselors deliver empathy and genuineness more through non-verbal rather than verbal channels). Participants also noted needed modifications to specific stages or skills in the model (e.g., using the insight stage less than the exploration stage). Discussion: Based on these findings, six guidelines are offered for modifying the Hill helping skills approach to fit the needs of Korean clients: Provide a pre-exploration stage to educate clients about approach, utilize indirect and non-verbal communication more than verbal communication, validate client’s experiences, work cautiously with emotions, be cautious about using insight skills, and respond to clients’ implicit communication when they ask for action.     

Responding to mentalization invitations in psychotherapy sessions—A conversation analysis approach

Objective: Increase in the capacity to mentalize has been proposed to be an important mechanism of change in psychotherapy. However, mentalization has primarily been studied as an individual skill that people either possess or lack, rather than as an interactional phenomenon. Method: In this study, excerpts from three different sessions in a therapy that aimed at increasing the patients mentalizing capacity were identified and studied using conversation analysis. Results: The analysis indicated that resistance to mentalizing may not only be due to lack of capacity but also may be seen as a linguistic resource in which this resistance demonstrates precisely the ability to mentalize. Conclusions: Consequences for psychotherapy practice and process research are discussed.     

Therapist perspectives on their dreams about clients: A qualitative investigation

Abstract

The authors interviewed eight experienced therapists regarding their dreams about clients and analyzed the transcribed interview data using consensual qualitative research. Results indicated that dreams typically were about difficulties with clients, intense personal concerns, and negative interpersonal interactions. Therapists used multiple methods to work with the dreams and made gains in insight focusing on countertransference or overidentification and the need to make fundamental changes in the therapeutic relationship or in the therapist's life. On the basis of the insight, therapists made changes in the treatment of the dreamed-about clients and in their personal lives. Implications for practice and research are discussed.     

The assimilation of problematic experiences in the context of a therapeutic failure

Abstract

A negative case–a therapeutic dropout–was analyzed with the Assimilation of Problematic Experiences Scale (APES). The APES has been devised from the assimilation model developed by Stiles and colleagues, and it has proven useful for describing the process of change. The APES describes assimilation as a sequence of eight stages which range from an experience being warded off, through being avoided, in vague awareness, then clarified, understood and solutions applied and finally, resolved and integrated into the self. The current study focuses on the case of Ana, who was being treated for reactive depression in five sessions of linguistic therapy of evaluation. The aims of this study were to describe the process of assimilation and to determine whether it showed the sawtooth pattern of progress found in other APES studies. Main results showed that Ana had difficulties in the process of assimilation, never reaching APES Stage 4 (insight). Ana remained at APES Stages 2 and 3. The sawtooth pattern was not as marked as the patterns found in good-outcome cases.

Zusammenfassung

Die Assimilation problematischer Erfahrungen im Kontext eines therapeutischen Misserfolges

Mit den Skalen zur Assimilation problematischer Erfahrungen (Assimilation of Problematic Experiences Scales, APES) wurde ein negativer Fall - Dropout - untersucht. APES wurde nach dem von Stiles und Kollegen entwickelten Assimilationsmodell konstruiert und hat sich als nützlich zur Erfassung des Veränderungsprozesses erwiesen. APES beschreibt Assimilation als eine Folge von acht Stadien (0-7): Abwehr des Problems; unerwünschte Gedanken; schwache Erkenntnis; Problemerkennung; Einsicht; Anwendung und Durcharbeiten; Anwendung bei der Problemlösung und schließlich Bewältigung (die Lösung wird angenommen und ins Selbst integriert). Die vorliegende Untersuchung beschäftigt sich mit Ana, die aus Anlass einer reaktiven Depression in fünf Sitzungen mit linguistischer Bewertungstherapie behandelt wurde. Als Ziel der Untersuchung wurde die Beschreibung des Assimilationsprozesses gesehen, insbesondere ob das Sägezahnmuster, das in anderen Untersuchungen mit APES gefunden wurde, auch hier aufgezeigt werden konnte. Die wichtigsten Ergebnisse zeigten, dass Ana mit dem Prozess der Assimilation Schwierigkeiten hatte und niemals die Stufe 4 (Einsicht) erreichte. Ana blieb auf den APES-Stufen 2 und 3 stecken. Das Sägezahnmuster war nicht so ausgeprägt wie in Fällen mit einem gutem Therapieergebnis.

Résumé

L'assimilation des expériences problématiques dans le contexte d'un échec thérapeutique.

Un cas négatif de rupture thérapeutique a été analysé à l'aide de l'Echelle d'Assimilation d'Expériences Problématiques (APES). L'APES est issue du modèle de l'assimilation développé par Stiles et collègues et elle été trouvée utile pour décrire le processus de changement. L'APES décrit l'assimilation comme une séquence de 8 phases?: écarter le problème, pensées non désirées, perception vague, clarification du problème, compréhension, application et perlaboration, solutions de problèmes appliquées, et finalement maîtrise (l'expérience est résolue et intégrée dans le Soi). Cette étude est centrée sur le cas d'Ana qui était traitée pour une dépression réactive par 5 séances de thérapie linguistique d’évaluation. Les buts de cette étude étaient de décrire le processus d'assimilation et de déterminer s'il montrait le pattern de progrès en dents de scie trouvé dans d'autres études APES. Les résultats principaux montrent qu'Ana avait des difficultés dans le processus d'assimilation, n'atteignant jamais la phase APES 4 (insight). Ana restait aux phases APES 2 et 3. Le pattern en dents de scie n’était pas aussi marqué que dans des cas à résultat favorable.

Resumen

Asimilación de experiencias problemáticas en el contexto de un fracaso terapéutico

Se analizó un caso negativo – una deserción terapéutica - con la Escala de Asimilación de Experiencias Problemáticas (APES). La APES se diseñó a partir del modelo de asimilación desarrollado por Stiles y colegas, y se ha mostrado útil para describir el proceso de cambio. La APES describe la asimilación como una secuencia de ocho etapas: prevención del problema, pensamientos indeseados, vaga consciencia, clarificación del problema, comprensión, aplicación y elaboración, soluciones aplicadas al problema y, finalmente, dominación (la experiencia se resuelve e integra en el self). Este estudio se centra en el caso de Ana, quien fue tratada por depresión reactiva en cinco sesiones de terapia lingüística de evaluación. Los objetivos de este estudio fueron describir el proceso de asimilación y determinar si mostraba la pauta de dientes serrados (sawtooth) de progreso encontrado en otros estudios APES. Los principales resultados mostraron que Ana tenía dificultades en el proceso de asimilación sin alcanzar nunca la etapa 4 (insight). Ana permaneció en las etapas 2 y 3 de APES. La pauta de diente serrado no fue tan marcada como las pautas encontradas en casos de buenos resultados.

Resumo

A assimilação de experiências problemáticas no contexto do falhanço terapêutico

Um caso negativo/um abandono terapêutico foi analisado com a Escala de Assimiliação de Experiências Problemáticas (EAEP). A EAEP foi criada a partir do modelo de assimilação desenvolvido por Stiles e colaboradores e tem-se revelado útil na descrição do processo de mudança. A EAEP descreve a assimilação como uma sequência de oito estádios: supressão/negação do problema, pensamentos indesejados, consciência vaga, clarificação do problema, compreensão, aplicação e prática, aplicação de soluções para o problema e finalmente, mestria (a experiência é resolvida e integrada no eu). O presente estudo foca-se no caso da Ana, que foi tratada para uma depressão reactiva com terapia linguística de avaliação. Os objectivos deste estudo consistiram em descrever o processo de assimilação e determinar se demonstrava o padrão oscilante do progresso encontrado noutros estudos com a EAEP. Os principais resultados demonstram que a Ana teve dificuldades no processo de assimilação, nunca alcançando o estádio 4 (insight). A Ana permaneceu nos estádios 2 e 3 da EAEP. O padrão oscilante não foi tão marcado como os encontrados em casos com resultados terapêuticos positivos.

Sommario

L'assimilazione delle esperienze problematiche nel contesto di un fallimento terapeutico

Un caso negativo, il drop-out di una terapia, è stato analizzato con l'Assimilation of Problematic Experiences Scale (APES). L'APES è stata progettata a partire dal modello di assimilazione sviluppato da Stiles e colleghi e si è rivelata utile per descrivere il processo di cambiamento. L'APES descrive l'assimilazione come una sequenza di 8 stati: evitare il problema, pensieri indesiderati, vaga consapevolezza, chiarificazione del problema, comprensione, applicazione e lavoro, applicazione delle soluzioni del problema ed infine padroneggiamento (l'esperienza è risolta ed integrata nel Sé). Il presente studio si focalizza sul caso di Ana, che è stata trattata per depressione reattiva in 5 sedute di terapia linguistica di valutazione. Lo scopo di questo studio è stato descrivere il processo di assimilazione e determinare se ha mostrato il modello dei progressi trovati negli altri studi APES. I risultati principali hanno mostrato che Ana aveva difficoltà nel processo dell'assimilazione, che non ha mai raggiunto lo stadio APES 4 (insight). Ana è rimasta agli stadi APES 2 e 3. Il modello non è stato indicato come modello trovato nei casi di buon esito.

     

Clients' Perceptions of Marriage and Family Therapists Addressing the Religious and Spiritual Aspects of Clients' Lives

Abstract

As marriage and family therapists are emphasizing the actual contexts of clients' lives, religion and spirituality are being addressed as important aspects of culture. This pilot study investigated whether clients felt their therapist adequately addressed the religious and spiritual aspects of their lives according to their desires for such. Thirty-eight clients who attended therapy at university clinics were surveyed using a questionnaire about their own religiosity and spirituality, about their preferences to have religion and spirituality addressed, and whether they perceived their therapist addressed religion and spirituality in the therapy process according to their desires. Results show these family therapists did rather well at addressing the religious and spiritual aspects of their clients' lives. Demographic correlations showed that the gender of the client and whether the university clinic they attended was affiliated with a religious denomination were each positively correlated to whether the clients wanted religion and spirituality addressed and whether their therapist adequately addressed these issues. Detailed limitations are noted.     

Clients’ experiences of difference with therapists: Sustaining faith in psychotherapy

Abstract

Informed by the research literatures on values and multiculturalism, this study was designed to investigate clients’ experiences of difference with therapists. Using a qualitative method—grounded theory—a model was developed to capture the essence of these experiences of difference. Five clusters highlight the client processes of being vigilant for differences, feeling threatened by differences, minimizing differences and focusing on positive relational factors, discussing differences, and beneficial personal growth resulting from differences. The core category describes the importance of clients maintaining faith in themselves, the therapist, and the therapeutic technique as differences are negotiated. Contributions and implications for practice and research on issues of managing values, multicultural differences, and transference are discussed.     

Client reflections on confirmation and disconfirmation of expectations in cognitive behavioral therapy for generalized anxiety disorder with and without motivational interviewing

Objective: Addressing methodological shortcomings of prior work on process expectations, this study examined client process expectations both prospectively and retrospectively following treatment. Differences between clients receiving cognitive behavioral therapy (CBT) versus motivational interviewing integrated with CBT (MI-CBT) were also examined. Method: Grounded theory analysis was used to study narratives of 10 participants (N?=?5 CBT, 5 MI-CBT) who completed treatment for severe generalized anxiety disorder as part of a larger randomized controlled trial. Results: Clients in both groups reported and elaborated expectancy disconfirmations more than expectancy confirmations. Compared to CBT clients, MI-CBT clients reported experiencing greater agency in the treatment process than expected (e.g., that they did most of the work) and that therapy provided a corrective experience. Despite nearly all clients achieving recovery status, CBT clients described therapy as not working in some ways (i.e., tasks did not fit, lack of improvement) and that they overcame initial skepticism regarding treatment. Conclusions: Largely converging with MI theory, findings highlight the role of key therapist behaviors (e.g., encouraging client autonomy, validating) in facilitating client experiences of the self as an agentic individual who is actively engaged in the therapy process and capable of effecting change.     

Alliance and termination status in couple therapy: A comparison of methods for assessing discrepancies

Abstract

Much of the empirical data available about therapeutic alliance and its relationship to termination status come from individual psychotherapies. We know less about therapeutic alliance in couple therapy. A unique characteristic of alliance in couple or family therapy is the possibility of discrepancies in alliance between system members. In this study we sought to demonstrate three statistical techniques: standard deviations, the intraclass correlation to assess discrepancies in alliance over time during the initial stage of couple therapy, and the use of these various measures to predict termination status using a sample of 72 couples from a university-based training clinic. Differences in partners' alliances operationalized either as categorical or continuous variables but when analyzed separately at each time point were not predictive of termination status. When multilevel modeling was used, a difference in the way the discrepancies changed over a period of time was related to termination status.     

JAKOB narrative analysis: The psychodynamic conflict as a narrative model

Abstract

When a patient tells a story during psychotherapy sessions, it is both a mutual interaction between patient and therapist and a presentation of personal experience. The patient calls up and re-creates a biographical occurrence and puts it before a listener for viewing, enacting it verbally in the perspective of wish fulfillment and anxiety coping. JAKOB narrative analysis, situated in the field of psychoanalytical and narrative analytical research, is an encoding-supported qualitative instrument for the systematic reconstruction of verbal everyday narratives in the context of psychotherapeutic processes. In this study, the JAKOB narrative analysis is described in detail with the aid of an example narrative, put in relation to the therapeutic process, and discussed critically from a methodological viewpoint.     

Juggling thoughts and feelings: How do female patients with borderline symptomology and substance use disorder experience change in mentalization-based treatment?

Objective: The aim of this study was to explore the experience of central psychological change processes for female patients with borderline symptomology and substance use disorder in mentalization-based treatment. Method: Semi-structured qualitative interviews on experiences from mentalization-based treatment with 13 participants were conducted. The interview material was analysed within a hermeneutical–phenomenological epistemology, with emphasis on researcher reflexivity. Results: The following themes regarding central psychological change processes were found: “by feeling the feeling,” “by thinking things through,” “by walking in your shoes to see myself” and “by stepping outside of own bad feelings in seeing you.” Two of these themes dealt with intra-psychic modes of how to relate to own mind-states. First, they had a shift from avoiding emotions into tolerating emotions. Second, they discovered the ability to think mental states through. Two themes dealt with mental stances for dealing with interpersonal situations, where one mode included a self-reflective stance in difficult encounters, and the other mode entailed an empathic reflective stance by exploring others’ intentionality. Conclusions: The findings are in line with theoretical assumptions that increasing mentalizing capacity is a central change process for these patients. Furthermore, the findings demonstrate the complex interaction between different modes of mentalizing.

Clinical or methodological significance of this article: The article explores change processes in manualized psychotherapy for patients with comorbid borderline personality disorder and substance use disorder, a focus which is not researched in the clinical literature. We claim that putting attention to this patient group and investigating their potential in psychotherapy is of clinical significance. Methodologically, this article utilizes thematic analyses within an epistemology following a specific procedure that is step based and transparent, thus it is of interest for qualitative researchers who also utilize thematic analyses.     

Art therapy and dementia: An update on work in progress

Abstract

In my last paper for Inscape, ‘Ways in Which Photographic and Other Images are Used in Research: An Introductory Overview’ (July, 2012), I summarised the ways in which the arts are being used by social scientists. In this paper I look at less mainstream developments which are nevertheless of interest. In particular, I outline Iain Edgar's idea of ‘imagework’, which is the use of creative visualisation within research processes (although much of what he does is rather akin to some forms of art therapy). Probably less well documented and explored is the interesting borderline between social science research and personal therapy represented by both social art therapy and phototherapy, both of which will be explored in further detail. This paper is then contextualised with reference to other recent papers discussing the potential contribution of art therapy to social science, psychological and ethnographic research projects.     

Therapists' and clients' experiences of alliance ruptures: A qualitative study

Abstract

Aim: We explored therapists' and clients' experiences of alliance rupture events for the first 15 sessions of each of eight cases; therapists were each paired with one client who had a personality disorder. Method: All sessions were videotaped and rated with the Rupture Resolution Rating System. Approximately 1 week after a rupture, clients and therapists were individually interviewed about the causes of the rupture, how the rupture evolved, the impact of the rupture on the therapeutic process, and experiences during the event. The interviews were analyzed by five judges using consensual qualitative research (CQR; Hill, 2011). Results: Typically, rupture events involved a repetition of a previous rupture event, the rupture emerged when the client was not prepared to respond to the therapist's intervention, both therapists and clients felt confused and ambivalent, and confrontation events activated intense and negative feelings. We discuss the implications for practice, training, and research.     

The perspectives of psychosexual therapists towards using play therapy techniques in sex and relationship therapy: A qualitative study

Play therapy is an intervention traditionally used with children that is beginning to be used with adults. One area of use is within the psychosexual context; however, there is an absence of empirical research in this area. This qualitative study explored therapists’ perspectives on using play therapy techniques in psychosexual therapy. The 16 participants were either qualified or trainee psychosexual therapists. Data were collected through focus group interviews and analysed thematically. Four interlinking themes were identified: (1) playfulness already used but not recognised as play therapy; (2) delivery and receiving of play techniques; (3) attachment; and (4) well-being and social skills. Overall, participants believed there were benefits to using play therapy in the psychosexual context but that the therapeutic environment should be conducive to its use. Recommendations for practice include views about whether or not play therapy can be further developed and refined for use within the psychosexual context.