Physiological synchronization and innovative moments in psychotherapy: A single-case study of micro-process.

OBJECTIVE: Interpersonal synchronization is increasingly studied as a biomarker of empathy, therapeutic alliance, and treatment outcome. However, most studies average data over sessions, leaving associations between synchrony and actual interactions largely unexplored. We aim to showcase a novel approach examining synchronization during specific micro-processes: Innovative Moments (IM) as markers of exceptions to clients' problematic patterns of meaning. METHODS: Electrodermal activity was recorded over 15 sessions of a psychodynamic psychotherapy single case. Moment-to-moment patient-therapist synchrony was calculated using the Adaptive Matching Interpolated Correlations (AMICo) algorithm. The Innovative Moments Coding System was utilized to identify IMs within session transcripts with precise timing. Monte-Carlo permutation tests were conducted to examine the association between physiological synchrony and IM Levels of increasing complexity (Levels 1-3). RESULTS: Higher-than-random synchronization emerged during Level 3 IMs (p = 0.046; d = 0.21) but not in lower Levels. Post-hoc qualitative analyses linked high synchrony to sub-processes of Level 3 IMs, such as positive contrasts and attributions for change. CONCLUSION: Our findings show it is possible to link moment-by-moment physiological co-regulation to theoretically identified meaning-making processes. While generalization of these observations is undue, this work demonstrates a robust and promising application of a multimodal approach to investigating psychotherapy, providing insights into both the clinical case and the theoretical model adopted.

Client resources and the prediction of therapeutic change using an interview: An exploratory study.

OBJECTIVES: Although psychotherapy research suggests that clients' resources are related to positive outcomes, there is a lack of clinical tools available to consider their integration into psychotherapy. In this exploratory research, we studied the feasibility of a semi-structured interview to identify resources reported by clients at the onset of therapy and the relationship between resources and therapy outcomes. METHODS: Data consisted of interviews with 30 clients from a clinical trial, in which elicitation of resources and their relationship with the outcomes were the main study objectives. RESULTS: This interview was content analyzed and both adaptative resources and maladaptive resources (dysfunctional coping strategies) were identified. The association between the adaptive resources and the evolution of outcomes throughout treatment was analyzed. Time (i.e. sessions) and resources were negatively correlated with psychological distress. Moreover, resources positively influenced the impact of time on distress. CONCLUSIONS: Clinicians should not take at face value resources that are self-reported, as they may reflect the maladaptive functioning of the client. The finding that clients with higher resources at onset have better outcomes points to the need to study how resources may be elicited effectively during therapy, and if this improves psychotherapy outcomes.

Innovative moments with young patients treated for depression: An analysis of post-therapy interviews.

INTRODUCTION: Innovative moments (IMs) pinpoint new and more adaptative meanings that emerge in clients' discourse during psychotherapy. Studies with adult clients have found a greater proportion of IMs in recovered compared to unchanged cases, but similar studies have yet to be conducted with adolescents. AIMS: The paper aims (1) to study retrospectively the emergence of IMs in therapy, using a post-therapy interview, in adolescents that underwent psychotherapy for depression, and (2) to characterize the themes present in IMs identified retrospectively in the interviews. METHOD: Semi-structured post-treatment interviews conducted with 24 adolescents on the experience of taking part in a clinical trial of youth depression, were coded using the Innovative Moments Coding System. After identifying IMs, a thematic analysis identified the prominent themes within them. RESULTS: Higher presence of IMs were found in recovered compared to unchanged cases. Two main themes emerged in the IMs, changes that occurred with therapy and attributions of changes. Recovered cases presented more IMs centred on the self, whereas unchanged cases identified more non-specific changes. CONCLUSION: This study suggests that it is possible to code IMs, identified retrospectively, based on post-therapy interviews with adolescents. Meaningful differences were found between recovered compared to unchanged cases. Therapeutic recovery was associated with a higher focus on the self and more specificity in clients' representations of the change process.

Ambivalence Resolution in Meaning Reconstruction Grief Therapy: An Exploratory Study.

In psychotherapy, ambivalence may be conceptualized as a conflict between two distinct motivations: one that is favorable to change (pro-change) and another that favors the maintenance of a problematic pattern (pro status quo). Previous studies identified two processes by which clients resolve this conflict: imposing the innovative part and silencing the problematic one (dominance), and establishing negotiations between the innovative and the pro status quo parts (negotiation). The present exploratory study examined ambivalence resolution in a sample of clients diagnosed with complicated grief. Results revealed that, in recovered cases, negotiation increases and dominance decreases from the beginning until the middle sessions of therapy and the opposite tendency is observed from the middle to the final sessions. Unchanged cases reveal an overall high proportion of dominance and an overall low proportion of negotiation. These results are partially divergent from those reported in previous studies with samples of clients diagnosed with major depression.

Innovative moments in recovered cases treated with the unified protocol for transdiagnostic treatment of emotional disorders.

OBJECTIVE: Innovative moments (IMs) are moments in which the previous problematic pattern of meaning is challenged. Studies have shown that IMs are associated with good psychotherapy outcomes. A three-level hierarchy of IMs was observed in recent studies, with level 1 IMs being more elementary and levels 2 and 3 being more complex and associated with treatment success. However, studies with manualized protocol treatments are thus far lacking. This study analyzed the longitudinal progression of IMs in the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and explored its associations with changes in psychological distress. METHODS: Data were collected from a Portuguese university-based outpatient clinic and included 18 cases with positive outcomes. Nine sessions of each case were coded with the IM coding system (N=162). RESULTS: Multilevel analyses showed a significant increase in all IM levels across treatments. The decrease in psychological distress predicted an increase in level 2 IMs in the same session. CONCLUSION: The evolution of IMs is similar to what was found previously in other studies. Contrary to what was found in previous studies, IMs did not predict outcomes in the following session, whereas the reduction in psychological distress predicted the emergence of level 2 IMs.

Relational schemas as mediators of innovative moments in symptom improvement in major depression.

OBJECTIVES: Innovative moments (IMs) are exceptions to the maladaptive framework of meaning that typically motivates clients to seek psychotherapy, and previous studies have shown that IMs are associated with psychotherapy outcomes. While IMs are exceptions that occur at the level of the therapeutic conversation, relational schemas are more stable patterns, and their increased flexibility may facilitate change during psychotherapy. With this in mind, we tested the hypothesis that IMs contribute to outcomes by improving the flexibility of relational schemas. METHOD: The Core Conflictual Relationship Theme (CCRT) was used to assess relational schemas. IMs were evaluated using the Innovative Moments Coding System. The sample included 22 clients diagnosed with major depressive disorder. The flexibility of the three components of the CCRT (Wishes, responses of the self (RS), and responses of others (RO)) were tested as mediators between IMs and outcomes. RESULTS: The flexibility of the RS was a mediator between IMs and outcomes, but Wishes and RO were not. CONCLUSION: These findings align with previous research showing that RS is the component most open to change, whereas the other components seem less sensitive to change during brief therapy. Clinical or methodological significance of this article: This study shows the mediation role of relational schemas in the association between in-session events (innovative moments (IMs)) and the symptoms improvement. It contributes to the literature that emphasizes the importance of relational schemas in psychotherapy by using a mediation model, which has rarely been tested.

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.

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 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.

Narrative change in Gloria Films: Comparing various processes of therapeutic innovation.

AIMS: The present study focuses on the analysis of novelty emergence in classic Gloria Films with Rogers, Perls, and Ellis to understand how the same client formulated her own problem and if and how change occurred in those three sessions. METHOD: The Innovative Moments Coding System was applied to track innovative moments (IMs) and their themes. RESULTS: The session with Rogers showed more diversity in disclosed problems and themes of IMs, as well as a higher proportion of reflection IMs. The session with Perls demonstrated a high proportion of protest IMs. The session with Ellis showed less innovation than other sessions. The changes found were based mostly on reflection and protest IMs in three sessions. CONCLUSION: Narrative innovations occurred in the three single sessions. The type of dominant innovation is consistent with the therapeutic model and the IMs model. The exploration of the IMs' themes allowed a more precise identification of Gloria's new narrative positions and their development throughout those sessions.

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.

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.

Self-narrative reconstruction after dilemma-focused therapy for depression: A comparison of good and poor outcome cases.

OBJECTIVE: The aim of this study is to improve the understanding of self-changes after an intervention for depression focused on implicative dilemmas, a type of cognitive conflict related to identity. As recent research has highlighted the relevance of identity-related dilemmas in clients with depression, we sought to assess the way in which clients resolve such inner conflicts after a tailored dilemma-focused intervention and how this is reflected in the clients' self-narratives. METHOD: We used three instruments to observe differences between good (n = 5) and poor (n = 5) outcome cases: (i) the Repertory Grid Technique to track the resolution of dilemmas, (ii) the Change Interview to compile clients' accounts of changes at posttreatment, and (iii) the Innovative Moments Coding System to examine the emergence of clients' novelties at the Change Interview. RESULTS: Groups did not differ in terms of the number and relevance of client-identified significantly helpful events. However, between-group differences were found for the resolution of dilemmas and for the proportion of high-level innovative moment (IM) types. Furthermore, a greater self-narrative reconstruction was associated with higher levels of symptom improvement. CONCLUSIONS: Good outcome cases seem to be associated with the resolution of conflicts and high-level IMs.

Innovative moments in low-intensity, telephone-based cognitive-behavioral therapy for depression.

Background: Innovative moments (IMs), defined as moments in psychotherapy when patients' problematic patterns change toward more elaborated and adaptive patterns, have been shown to be associated with a clinical change in patients with depression. Thus, far IMs have been studied in face-to-face settings but not in telephone-based cognitive-behavioral therapy (t-CBT). This study investigates whether IMs occur in t-CBT and examines the association between IMs and symptom improvement, and reconceptualization and symptom improvement. Methods: The therapy transcripts of n = 10 patients with mild to moderate depression (range: 7-11 sessions, in total 94 sessions) undergoing t-CBT were qualitatively and quantitatively analyzed. Symptom severity (Patient Health Questionnaire-9) and IMs (levels and proportions) were assessed for each therapy session. Hierarchical linear models were used to test the prediction models. Results: The rating of IMs was shown to be feasible and reliable using the Innovative Moments Coding System (IMCS) (84.04% agreement in words coded), which is indicative of the applicability of the concept of IMs in t-CBT. Only reconceptualization IMs were shown to have a predictive value for treatment success (R2 = 0.05, p = 0.01). Discussion: The results should be interpreted with caution due to the exploratory nature of this study. Due to the telephone setting, it was necessary to adapt the IMCS. Nonetheless, the extent of IMs identified in the low-intensity t-CBT investigated was comparable to IMs in face-to-face therapy. Further studies are needed to clarify the association between IMs and treatment success as a change process, especially for low-intensity treatments.

Intervention and evaluation of the life design counseling: A case study.

This article aims to explore the effectiveness of Life Design Counseling (LDC) for a high school student before choosing the subject. To evaluate LDC outcomes, the Career Adapt-Abilities Scale-China Form was used before and after the intervention. Two measures were used to evaluate the process of LDC: the Innovative Moments Coding System (IMCS) and Future Career Autobiography (FCA). The results show that the LDC approach produced a significant change in career adaptability. In addition, the findings demonstrate a significant narrative movement or change with the evaluation of the process. Implications for future research and practice are discussed.

Differences Between Subclinical Ruminators and Reflectors in Narrating Autobiographical Memories: Innovative Moments and Autobiographical Reasoning.

Reasoning may help solving problems and understanding personal experiences. Ruminative reasoning, however, is inconclusive, repetitive, and usually regards negative thoughts. We asked how reasoning as manifested in oral autobiographical narratives might differ when it is ruminative versus when it is adaptive by comparing two constructs from the fields of psychotherapy research and narrative research that are potentially beneficial: innovative moments (IMs) and autobiographical reasoning (AR). IMs captures statements in that elaborate on changes regarding an earlier personal previous problem of the narrator, and AR capture the connecting of past events with other parts of the narrator's life or enduring aspects of the narrator. A total of N = 94 university students had been selected from 492 students to differ maximally on trait rumination and trait adaptive reflection, and were grouped as ruminators (N = 38), reflectors (N = 37), and a group with little ruminative and reflective tendencies ("unconcerned," N = 19). Participants narrated three negative personal experiences (disappointing oneself, harming someone, and being rejected) and two self-related experiences of more mixed valence (turning point and lesson learnt). Reflectors used more IMs and more negative than positive autobiographical arguments (AAs), but not more overall AAs than ruminators. Group differences were not moderated by the valence of memories, and groups did not differ in the positive effect of narrating on mood. Trait depression/anxiety was predicted negatively by IMs and positively by AAs. Thus, IMs are typical for reflectors but not ruminators, whereas the construct of AR appears to capture reasoning processes irrespective of their ruminative versus adaptive uses.

Ambivalence Predicts Symptomatology in Cognitive-Behavioral and Narrative Therapies: An Exploratory Study.

Background: The identification of poor outcome predictors is essential if we are to prevent therapeutic failure. Ambivalence - defined as a conflictual relationship between two positions of the self: one favoring change and another one favoring problematic stability - has been consistently associated with poor outcomes. However, the precise relationship between ambivalence and clients' symptomatology remains unclear. Objective: This study aims at assessing ambivalence's power to predict symptomatology, using a longitudinal design. Methods: The complete 305 sessions of 16 narrative and cognitive-behavioral cases have been analyzed with the Ambivalence Coding System and outcome measures have been used for each session. Results: Ambivalence emerged as a significant predictor of subsequent symptomatology suggesting that ambivalence is not only related to treatment outcomes, but that it represents a strong predictor of subsequent symptomatology. Discussion: The implications of ambivalence's power to predict outcomes for research and clinical practice are discussed.