Premature termination of the unified protocol for the transdiagnostic treatment of emotional disorders: The role of ambivalence towards change.

Ambivalence towards change is an expected, recurrent process in psychological change. However, the prolonged experience of ambivalence in psychotherapy contributes to client disengagement, which could result in treatment dropout. Considering the negative effects of premature termination of therapy and the convenience of the identification of clients who are at risk of dropping out before achieving good-outcome, the current study explored the predictive power of ambivalence for premature therapy termination using a multilevel time-backwards model (i.e., considering the session of the dropout as session zero and then modelling what occurred from the dropout until session 1). Participants included a total of 96 psychotherapy clients (38 dropouts) treated in a university-based clinic following the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Multilevel modelling using a time-backwards model to analyse dropout data provided evidence of the predictive power of ambivalence evolution throughout treatment on the decision to prematurely discontinue treatment (p < .0001; R2 adj = .29). Specifically, good-outcome dropouts presented a decreasing ambivalence trend throughout treatment, whereas poor-outcome dropouts tended to experience the same levels of ambivalence before deciding to drop out (time × dropout; ß11 = .64, p = .014). Additionally, poor-outcome dropouts presented higher levels of ambivalence (ß01 = 9.92, p < .0001) in the last session. The results suggest that the pattern of client ambivalence towards change is a predictor of premature termination of therapy. Implications for clinical and research contexts are discussed.

Ambivalence in Psychotherapy Questionnaire: Development and validation studies.

Research emphasizes that individuals' engagement with change process is a significant predictor of therapeutic outcomes. Ambivalence is a natural phenomenon in change processes, but when individuals cannot overcome it, their problems may intensify. Ambivalence towards change, a client variable characterized by an intrapersonal conflict between two positions of the self, one in favour of change and another one in favour of the status quo, is shown to play a determinant role in psychotherapy. Despite its importance, few empirical studies have examined this process, and the considerable methodological differences among existing studies make it difficult to generalize results. Therefore, instruments measuring ambivalence in an effective way can help broaden the understanding of the process. First, we performed a content analysis of ambivalence events identified in psychotherapy sessions from previous studies using an observational coding system. The factor structure, reliability and validity of the measure were tested using 91 and confirmed with 223 psychotherapy clients at any time during the therapeutic process. A two-factor structure was found, suggesting two components of Ambivalence-Demoralization and Wavering. The results indicated that the Ambivalence in Psychotherapy Questionnaire exhibits good psychometric properties, including good convergent and divergent validity. The implications are discussed.

Reconceptualization innovative moments as a predictor of symptomatology improvement in treatment for depression.

OBJECTIVES: In previous studies, reconceptualization innovative moments were associated with successful psychotherapy. Reconceptualization has two components-(a) a positive temporal contrast between the past self and the present self (contrasting self [CS]) and (b) a description of how and/or why this change has occurred (change process [CP])-from the perspective of the client. The aim of this study is to analyse if CS and CP have the same association with outcomes as reconceptualization. METHOD: Sixteen cases of clients with major depression (305 sessions) were analysed. Longitudinal regression models were used to explore if proportions of CS, CP, and reconceptualization predicted outcome measures and if outcome measures predicted CS, CP, and reconceptualization. RESULTS: Reconceptualization is less frequent than CS and CP taken separately, but reconceptualization was a better predictor of treatment outcomes than were its separate components. Moreover, symptom improvement did not predict reconceptualization. CONCLUSION: The construction of new meanings is important in improving depressive symptomatology. Psychotherapists can elicit these new meanings in their regular practice by posing questions that may help clients to conceptualize what is changing in themselves (CS) and questions of how this change is occurring (CP). The construction of an integrative account of these new meanings is associated with psychotherapeutic gains, and thus, reconceptualizing change could improve symptoms of depression.

Ambivalence resolution in brief psychotherapy for depression.

Ambivalence in the process of psychotherapeutic change should be addressed and resolved if we are to avoid psychotherapeutic failure and promote sustained change. In this context, ambivalence can be defined as the cyclical conflictual relation between two opposed positions of the self: one expressed as an innovation, and a subsequent one expressed in a trivialization or rejection of the innovation (problematic position). This conflict may be resolved in two different ways: (a) the dominance of the innovative position and the consequent inhibition of the problematic one and (b) the negotiation between the innovative and the problematic positions. In this study, we sought to study the evolution of the dominance and the negotiation processes in recovered and unchanged cases; to analyse if different therapeutic models produce different results on the evolution of the dominance and negotiation processes, and finally, to study if these processes are predictive of ambivalence resolution. The complete sessions of 22 clinical cases of depression (6 cognitive-behavioural therapy, 10 narrative therapy, and 6 emotion-focused therapy cases) were independently coded for innovative moments, ambivalence, and ambivalence resolution. Results revealed that recovered cases had a progressively higher proportion of negotiation along treatment, whereas in unchanged cases, negotiation was virtually absent throughout treatment. Both dominance and negotiation were significant predictors of ambivalence reduction, however, negotiation had a higher impact than dominance. Overall, these results did not significantly differ for the 3 therapeutic models. The theoretical implications of these findings are discussed, and theoretical derived suggestions for clinicians are presented.

Ambivalence resolution in emotion-focused therapy: The successful case of Sarah.

Ambivalence can be understood as a cyclical movement between two opposing positions of the self: one expressed in a novelty-an innovative moment (IM)-and another one conveyed by a return to the maladaptive pattern. If not properly addressed and resolved during therapy, ambivalence can prevent change and lead to psychotherapeutic failure. Two processes of ambivalence resolution have been suggested: (1) the dominance of the innovative position and consequent inhibition of the problematic position and (2) the negotiation between both positions. OBJECTIVES: To empirically study both processes of ambivalence resolution in a successful case of emotion-focused therapy. METHOD: Sessions were independently coded with three coding systems-the IMs, the return to the problem and the ambivalence resolution. RESULTS: Ambivalence tended to be resolved from the initial to the final sessions. Although resolutions through dominance tended to decrease and resolutions through negotiation seemingly increased along treatment, dominance was, nonetheless, the most prominent process of resolution along the whole treatment. CONCLUSIONS: Although it has been suggested that integrating opposing parts of the self is a necessary process for psychotherapeutic success, a less integrative process of ambivalence resolution may also be an important resource along the process.

Narrative Changes Predict a Decrease in Symptoms in CBT for Depression: An Exploratory Study.

OBJECTIVE: Innovative moments (IMs) are new and more adjusted ways of thinking, acting, feeling and relating that emerge during psychotherapy. Previous research on IMs has provided sustainable evidence that IMs differentiate recovered from unchanged psychotherapy cases. However, studies with cognitive behavioural therapy (CBT) are so far absent. The present study tests whether IMs can be reliably identified in CBT and examines if IMs and symptoms' improvement are associated. METHODS: The following variables were assessed in each session from a sample of six cases of CBT for depression (a total of 111 sessions): (a) symptomatology outcomes (Outcome Questionnaire-OQ-10) and (b) IMs. Two hierarchical linear models were used: one to test whether IMs predicted a symptom decrease in the next session and a second one to test whether symptoms in one session predicted the emergence of IMs in the next session. RESULTS: Innovative moments were better predictors of symptom decrease than the reverse. A higher proportion of a specific type of IMs-reflection 2-in one session predicted a decrease in symptoms in the next session. Thus, when clients further elaborated this type of IM (in which clients describe positive contrasts or elaborate on changes processes), a reduction in symptoms was observed in the next session. DISCUSSION: A higher expression and elaboration of reflection 2 IMs appear to have a facilitative function in the reduction of depressive symptoms in this sample of CBT. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Elaborating innovative moments (IMs) that are new ways of thinking, feeling, behaving and relating, in the therapeutic dialogue, may facilitate change. IMs that are more predictive of amelioration of symptoms in CBT are the ones focused on contrasts between former problematic patterns and new adjusted ones; and the ones in which the clients elaborate on processes of change. Therapists may integrate these kinds of questions (centred on contrasts and centred on what allowed change from the client's perspective), in the usual CBT techniques. When elaborating these IMs successfully, therapists may expect an improvement in symptoms in the next session of psychotherapy.

Self-narrative reconstruction in emotion-focused therapy: A preliminary task analysis.

OBJECTIVE: This research explored the consolidation phase of emotion-focused therapy (EFT) for depression and studies-through a task-analysis method-how client-therapist dyads evolved from the exploration of the problem to self-narrative reconstruction. METHOD: Innovative moments (IMs) were used to situate the process of self-narrative reconstruction within sessions, particularly through reconceptualization and performing change IMs. We contrasted the observation of these occurrences with a rational model of self-narrative reconstruction, previously built. RESULTS: This study presents the rational model and the revised rational-empirical model of the self-narrative reconstruction task in three EFT dyads, suggesting nine steps necessary for task resolution: (1) Explicit recognition of differences in the present and steps in the path of change; (2) Development of a meta-perspective contrast between present self and past self; (3) Amplification of contrast in the self; (4) A positive appreciation of changes is conveyed; (5) Occurrence of feelings of empowerment, competence, and mastery; (6) Reference to difficulties still present; (7) Emphasis on the loss of centrality of the problem; (8) Perception of change as a gradual, developing process; and (9) Reference to projects, experiences of change, or elaboration of new plans. CONCLUSIONS: Central aspects of therapist activity in facilitating the client's progression along these nine steps are also elaborated.

Three narrative-based coding systems: Innovative moments, ambivalence and ambivalence resolution.

Narrative and dialogical perspectives suggest that personal meaning systems' flexibility is an important resource for change in psychotherapy. Drawn from these theoretical backgrounds, a research program focused on the identification of Innovative Moments (IMs)-exceptions to the inflexible meaning systems present in psychopathological suffering-has been carried out. For this purpose, three process-oriented coding systems were developed: The IMs Coding System, the Ambivalence Coding System, and the Ambivalence Resolution Coding System. They allow, respectively, for the study of change, ambivalence, and ambivalence resolution in therapy. This paper presents these coding systems, the main findings that resulted from their application to different samples and therapeutic models, the main current and future lines of research, as well as the clinical applications of this research program.

Ambivalence in grief therapy: The interplay between change and self-stability.

This article explores the role of ambivalence in grief therapy within a narrative framework. From this perspective, change starts with the occurrence of innovative moments, which can be nullified by reaffirmation of the problematic self-narrative as a sign of ambivalence. This study analyzed ambivalence in six complicated grief cases using the "Return to the Problem Coding System." Markers of ambivalence emerged in all cases, with a decreasing profile in cases with greater symptomatic improvement, suggesting an association between clinical change and ambivalence evolution in therapy. Addressing ambivalence may bring to light important aspects of client's self-reconstruction after a major loss.

Ambivalence in Narrative Therapy: A Comparison Between Recovered and Unchanged Cases.

UNLABELLED: Research on the identification of poor outcome predictors is crucial for the prevention of therapeutic failure. Previous research suggests that clients' persistent ambivalence is one possible path to unsuccessful psychotherapy. The present study analyses ambivalence--here operationalized as return-to-the-problem markers (RPMs)--in five recovered and five unchanged cases of narrative psychotherapy for major depression. The results suggest that both recovered and unchanged cases presented a similar proportion of RPMs at baseline and a decreasing pattern of these ambivalence markers throughout therapy. However, the decreasing was more accentuated in recovered than in unchanged cases, and at the end of the treatment, the proportion of RPMs of the unchanged cases was significantly higher. The results are discussed in light of previous research on ambivalence in psychotherapy, focusing on the meaning of ambivalence and its clinical implications. KEY PRACTITIONER MESSAGE: Ambivalence towards change, here operationalized as RPMs, seems to be a common process in both recovered and unchanged cases, perhaps signalling the uncertainty and anxiety that change may elicit. Although the number of RPMs decreased in both the recovered and unchanged cases, this reduction was significantly higher in the recovered group. Moreover, at the end of therapy, the recovered group revealed a significantly lower proportion of RPMs than the unchanged group, suggesting that ambivalence resolution (or lack thereof) may play a determining role in the therapy's evolution and outcome. RPMs in later stages of therapy may be operationalized as 'red flags' for the therapist to acknowledge the client's stuckness and adapt his or her intervention efforts, turning these instances into developmental opportunities.

Narrative innovations predict symptom improvement: Studying innovative moments in narrative therapy of depression.

OBJECTIVE: Innovative moments (IMs) are moments in the therapeutic dialog that constitute exceptions toward the client's problems. These narrative markers of meaning transformation are associated with change in different models of therapy and diverse diagnoses. Our goal is to test if IMs precede symptoms change, or, on the contrary, are a mere consequence of symptomatic 15 change. METHOD: For this purpose, IMs and symptomatology (Outcome Questionnaire-10.2) were assessed at every session in a sample of 10 cases of narrative therapy for depression. Hierarchical linear modeling was conducted to explore whether (i) IMs in a given session predict patients' symptoms in the following session and/or (ii) symptoms in a given session predict IMs in the next session. RESULTS: Results suggested that IMs are better predictors of symptoms than the reverse. CONCLUSIONS: These results are discussed considering the contribution of meanings and narrative processes' changes to symptomatic improvement.

Therapist interventions and client ambivalence in two cases of narrative therapy for depression.

AIM: We understand ambivalence as a cycle of opposing expressions by two internal voices. The emergence of a suppressed voice produces an innovative moment (IM), challenging the dominant voice, which represents the client's problematic self-narrative. The emergence of the IM is opposed by the dominant voice, leading to a return to the problematic self-narrative. This study analyzed therapist and client responses to each other in episodes of ambivalence. METHOD: The therapeutic collaboration coding system (TCCS) assesses whether and how the therapeutic dyad is working within the therapeutic zone of proximal development (TZPD) by examining client responses to therapist interventions. We applied the TCCS to episodes in which a good- and a poor-outcome client in narrative therapy expressed ambivalence. RESULTS: In both the good- and poor-outcome cases, the therapist responded to the emergence of ambivalence similarly, balancing challenging and supporting. The good-outcome case responded at the developmental level proposed by the therapist when challenged, while the poor-outcome case lagged behind the level proposed. DISCUSSION: This supports the theoretical explanation that the therapist did not match client's developmental level in the poor-outcome case, working beyond the client's current TZPD and contributing to the maintenance of ambivalence.

Ambivalence in emotion-focused therapy for depression: the maintenance of problematically dominant self-narratives.

OBJECTIVE: Ambivalence can be understood as a cyclical movement between an emerging narrative novelty-an Innovative Moment (IM)-and a return to a problematically dominant self-narrative. The return implies that the IM, with its potential for change is devalued right after its emergence. Our goal is to test the hypothesis that the probability of the client expressing such form of ambivalence decreases across treatment in good-outcome cases but not in poor-outcome cases. METHOD: Return-to-the-Problem Markers (RPMs) signaling moments of devaluation of IMs were coded in passages containing IMs in six clients with major depression treated with emotion-focused therapy: three good-outcome cases and three poor-outcome cases. RESULTS: The percentage of IMs with RPMs decreased across therapy in good-outcome cases, whereas it remained unchanged and high in the poor-outcome cases. CONCLUSIONS: These results were consistent with the theoretical suggestion that therapeutic failure may be associated with this form of ambivalence.

The innovative moments coding system and the assimilation of problematic experiences scale: a case study comparing two methods to track change in psychotherapy.

The Assimilation of Problematic Experiences Scale (APES) and the Innovative Moments Coding System were applied to transcripts of a successful case of linguistic therapy of evaluation independently by different research groups. Assimilation theory and research suggest that higher APES scores reflect therapeutic gains, with a level of approximately 4.0 separating good from poor outcome cases. The innovative moments (IMs) model suggests that IMs classified as reconceptualization and performing change occur mainly in good outcome cases, whereas action, reflection and protest occur in both good and poor outcome cases. Passages coded as reconceptualization and performing change were rare in this case, but 100% of them were rated at or above APES 4. By contrast, 63% passages coded as action, reflection or protest were rated below APES 4 (Chi-square = 28.62, p < .001). Implications for research are discussed.

Therapeutic collaboration and resistance: describing the nature and quality of the therapeutic relationship within ambivalence events using the Therapeutic Collaboration Coding System.

OBJECTIVES: We understand ambivalence as a cyclical movement between two opposing parts of the self. The emergence of a novel part produces an innovative moment, challenging the current maladaptive self-narrative. However, the novel part is subsequently attenuated by a return to the maladaptive self-narrative. This study focused on the analysis of the therapeutic collaboration in episodes in which a relatively poor-outcome client in narrative therapy expressed ambivalence. METHOD: For our analysis we used the Therapeutic Collaboration Coding System, developed to assess whether and how the therapeutic dyad is working within the therapeutic zone of proximal development (TZPD). RESULTS: Results showed that when the therapist challenged the client after the emergence of ambivalence, the client tended to invalidate (reject or ignore) the therapist's intervention. CONCLUSIONS: This suggests that in such ambivalence episodes the therapist did not match the client's developmental level, and by working outside the TZPD unintentionally contributed to the maintaining the client's ambivalence.

Innovative moments and change in client-centered therapy.

Previous studies have used the Innovative Moments Coding System (IMCS) to describe the process of change in Narrative Therapy (NT) and in Emotion-Focused Therapy (EFT). This study aims to extend this research program to a sample of Client-Centered Therapy (CCT). The IMCS was applied to six cases of CCT for depression to track the Innovative Moments (IMs) which are exceptions to the problematic self-narrative in therapeutic conversation. Results suggest that IMCS can be applied to CCT, allowing the tracking of IMs' emergence. The analysis based on a generalized linear model revealed that the overall amount of IMs is significantly associated with symptom improvement, which is congruent with former studies done with the IMCS.

Narrative change in emotion-focused psychotherapy: a study on the evolution of reflection and protest innovative moments.

Innovative moments (IMs) are exceptions to a client's problematic self-narrative in the therapeutic dialogue. The innovative moments coding system is a tool which tracks five different types of IMs-action, reflection, protest, reconceptualization and performing change. An in-depth qualitative analysis of six therapeutic cases of emotion-focused therapy (EFT) investigated the role of two of the most common IMs-reflection and protest-in both good and poor outcome cases. Through this analysis two subtypes (I and II) of reflection and protest IMs were identified, revealing different evolution patterns. Subtype II of both reflection and protest IMs is significantly higher in the good outcome group, while subtype I of both IMs types does not present statistically significant differences between groups. The evolution from subtype I to subtype II across the therapeutic process seems to reflect a relevant developmental progression in the change process.

Tracking novelties in psychotherapy process research: the innovative moments coding system.

This article presents a method for the assessment of innovative moments, which are novelties that emerge in contrast to a client's problematic self-narrative as expressed in therapy, the innovative moments coding system (IMCS). The authors discuss the theoretical background of the IMCS as well as its coding procedures. Results from several studies suggest that the IMCS is a reliable and valid coding system that can be applied to several modalities of psychotherapy. Finally, future research implications are discussed.

A dynamic look at narrative change in psychotherapy: a case study tracking innovative moments and protonarratives using state space grids.

This study aims to further the understanding of how innovative moments (IMs), which are exceptions to a client's problematic self-narrative in the therapy dialogue, progress to the construction of a new self-narrative, leading to successful psychotherapy. The authors' research strategy involved tracking IMs, and the themes expressed therein (or protonarratives), and analysing the dynamic relation between IMs and protonarratives within and across sessions using state space grids in a good-outcome case of constructivist psychotherapy. The concept of protonarrative helped explain how IMs transform a problematic self-narrative into a new, more flexible, self-narrative. The increased flexibility of the new self-narrative was manifested as an increase in the diversity of IM types and of protonarratives. Results suggest that new self-narratives may develop through the elaboration of protonarratives present in IMs, yielding an organizing framework that is more flexible than the problematic self-narrative.

The role of mutual in-feeding in maintaining problematic self-narratives: exploring one path to therapeutic failure.

According to the author's narrative model of change, clients may maintain a problematic self-stability across therapy, leading to therapeutic failure, by a mutual in-feeding process, which involves a cyclical movement between two opposing parts of the self. During innovative moments (IMs) in the therapy dialogue, clients' dominant self-narrative is interrupted by exceptions to that self-narrative, but subsequently the dominant self-narrative returns. The authors identified return-to-the-problem markers (RPMs), which are empirical indicators of the mutual in-feeding process, in passages containing IMs in 10 cases of narrative therapy (five good-outcome cases and five poor-outcome cases) with females who were victims of intimate violence. The poor-outcome group had a significantly higher percentage of IMs with RPMs than the good-outcome group. The results suggest that therapeutic failures may reflect a systematic return to a dominant self-narrative after the emergence of novelties (IMs).