Data mining techniques in psychotherapy: applications for studying therapeutic alliance.

Therapeutic Alliance (TA) has been consistently reported as a robust predictor of therapy outcomes and is one of the most investigated therapy relational factors. Research on therapists' and clients' contributions to the alliance development and the alliance-outcome relationship had shown mixed results. The relation of the therapist's and client's biological markers with the alliance is an important and under-investigated topic. Taking advantage of data mining techniques, this exploratory study aimed to investigate the role of different therapist and client factors, including heart rate (HR) and electrodermal activity (EDA), in relation to TA. Twenty-two dyads with 6 therapists and 22 clients participated in the study. The Working Alliance Inventory (WAI) was used to evaluate the client's and therapist's perception of the alliance at the end of each session and through the therapy processes. The Cross-Industry Standard Process for Data Mining (CRISP-DM) was used to explore patterns that may contribute to TA. Machine Learning (ML) models have been employed to provide insights into the predictors and correlates of TA. Our results showed that Linear Regression (LR) was the best technique for predicting the therapist's TA, with client "Diagnostic" and therapy "Termination" being identified as significant predictors of the therapist's TA. In addition, for clients' TA, the Random Forest (RF) was shown to have the best performance. The therapist's TA and therapy "Outcome" were observed as the most influential predictors for the client's TA. In addition, while the Heart Rate (therapist) was negatively associated with the therapist's TA, EDA in the client was a physiological indicator related to the client's TA. Overall, these findings can assist in identifying key factors that therapists should focus on to enhance the quality of therapeutic alliance. Results are discussed in terms of their consistency with empirical literature, innovative and interdisciplinary research on the therapeutic alliance field, and, in particular, the use of the Data Mining approach in a psychotherapy context.

Is the quality of therapeutic collaboration associated with the assimilation of problematic experiences progress? A comparison of two cases.

OBJECTIVE: How are collaborative interactions associated with clients' progress in therapy? This study addressed this question, by assessing the quality of therapeutic collaboration and comparing it passage by passage with the clients' assimilation of problematic experiences in two cases of major depression treated with Cognitive Behavioral Therapy, one recovered and one improved-but-not-recovered. METHOD: We used the Therapeutic Collaboration Coding System to code collaborative work and the Assimilation of Problematic Experiences Scale (APES) to rate clients' progress. In both cases, for the distribution of specific collaborative therapeutic exchanges, we tested for the difference of empirical means between lower and higher APES levels. RESULTS: Both cases progress in APES, but in contrast with Annie (Improved-but-not-recovered), Kate (Recovered) achieved higher levels of change in last sessions. In addition, we found significant differences in the types of collaborative therapeutic exchanges associated with lower and higher APES levels. CONCLUSION: Ambivalent therapeutic exchanges distinguished the recovered case from the not recovered case highlighting a source of difficulties in facilitating therapeutic change in CBT. In addition, observations in these cases supported the theoretical suggestion that supporting interventions would be better accepted at lower APES levels, whereas challenging interventions would be better accepted at higher APES levels.

Therapist's interventions immediately after exceeding the client's therapeutic zone of proximal development: A comparative case study.

OBJECTIVE: When therapists' proposals are too demanding exceeding clients' readiness to move into change, clients may resist advancing. We aimed to understand how a therapist behaved immediately after the client resisted advancing into change within Cognitive-Behavioral Therapy. METHODS: We analyzed a recovered and an unrecovered case, both with Major Depression, and followed by the same therapist. Through the Therapeutic Collaboration Coding System, we analyzed 407 exchanges of interest. RESULTS: In both cases, clients resisted more in advancing at intermediate sessions, mainly by the therapist's challenges to raise insight and debate cognitive beliefs in the recovered case, and to seek experiential meanings in the unrecovered case. Immediately after clients resisted advancing, the therapist tended to insist on challenging them in the same direction. In the recovered case, the therapist did so continually throughout the therapy, sometimes balancing between insisting or stepping back. In the unrecovered case, the therapist insisted on challenging, but mostly at the final session. Occasionally, the therapist insisted on challenging, and clients resisted over consecutive exchanges. CONCLUSION: Our results reinforce that to enact progress and change clients need to be pushed into change, however it requires therapists' skillful assessment of clients' tolerance to move in time.

Cortical auditory evoked potentials in 1-month-old infants predict language outcomes at 12 months.

The neurophysiological assessment of infants in their first developmental year can provide important information about the functional changes of the brain and supports the study of behavioral and developmental characteristics. Infants' cortical auditory evoked potentials (CAEPs) reflect cortical maturation and appear to predict subsequent language abilities. This study aimed to identify CAEP components to two auditory stimulus intensities in 1-month-old infants and to understand how these are associated with social interactive and self-regulatory behaviors. In addition, it examined whether CAEPs predicted developmental outcomes when infants were assessed at 12 months of age. At 1 month, P2 and N2 components were present for both auditory stimulus intensities, with an increased P2 amplitude being observed for the higher-intensity stimuli. We also observed that an increased P2 amplitude in the lower intensity predicted receptive and expressive language competencies at 12 months. These results are consistent with previous findings indicating an association between auditory processing and developmental outcomes in infants. This study suggests that specific auditory neurophysiological markers are associated with developmental outcomes in the first developmental year.

Going virtual and going wide: comparing Team-Based Learning in-class versus online and across disciplines.

Team-based learning (TBL) is an active learning pedagogy developed for in-class sessions and based on the collaborative work of small groups of students. The increasing push to online and blended learning has enhanced the need to expand this pedagogy to a virtual environment, but little evidence has been produced on how students accept online synchronous sessions of TBL. The purpose of this study, that relies on 427 responses, is to present a comparative perspective of traditional in-class versus adapted fully synchronous online TBL and across different disciplinary fields. Students of two different academic years and different programs were surveyed for their acceptance of TBL. They were invited to answer closed-ended questions focused on their engagement in all TBL learning process and the final outcomes provided. Results obtained from this unique comparative study revealed a wide approval of TBL, regardless of the environment (online or in-class TBL sessions), scientific area of courses and student gender. The acceptance of fully online TBL sessions, in a similar way as traditional in-class sessions, could be a rationale for giving more use to the 'virtual' context. Other results corroborated previous researches on TBL, such the need of student awareness of TBL benefits to get more engaged in the process or the impact of student activities overload on the TBL process. Implications are informative for pedagogical practice.

Experiences of parent-adolescent dyads regarding a Facebook-based intervention to improve overweight/obesity treatment in adolescents: A qualitative study.

APOLO-Teens is a Facebook-based psychological intervention aiming to optimize hospital treatment for adolescents with overweight/obesity. The present qualitative study aims to explore (1) how adolescents experienced participation in APOLO-Teens and (2) how parents perceived adolescents' participation. Sixteen adolescent-parent dyads were interviewed by telephone using semistructured guides. An inductive approach of thematic analysis was used to analyze data by two independent codifiers. The consensus was used to resolve differences in coding/themes, and two independent auditors reviewed the codes and the themes proposed. We identified four themes from adolescents' interviews, namely, expectations, perception of outcomes, participation in the intervention, and sharing of acquired knowledge. From parents' interviews, we identified five themes: expectations for son/daughter participation, perception of adolescents' outcomes, son/daughter participation, parental role, and use of social networks in intervention programs for adolescents. Both elements of the dyad indicated that adolescents' participation in APOLO-Teens contributed to favorable outcomes, further highlighting the use of online interventions to complement the hospital treatment of adolescents with overweight/obesity. Future studies should address the viewpoints of adolescents and parents in the design of Facebook-based interventions, namely, to implement tailored, shorter, less time-demanding interventions that favor engagement between participants and parental involvement.

Face-to-Face Clinical Practice Under COVID-19 Pandemic: How Psychotherapists Describe Their Experiences.

Driven by the theory-building around the role of the non-verbal components to communication, we aimed to understand how therapists experience the therapeutic process using a facial mask. The empirical evidence of the power of non-verbal communication to engage therapists and clients in therapeutic work, develop a positive and collaborative relationship between them, and display empathy is quite large. A mixed-methods approach was adopted, drawing from the therapists' participation in an online survey. A sample of 137 psychotherapists with different therapy orientations and years of clinical practice participated in the study. Therapists conducted face-to-face therapy wearing face masks with existing and/or new clients. We performed an exploratory analysis, using descriptive statistics, to explore the psychotherapists' evaluations regarding perceived impact of face masks on different therapy quality dimensions. In a complementary rationale, we analyzed the therapists' perspectives on their experience wearing face masks using the thematic analysis methodology. Results show that among 137 psychotherapists, 114 were attending both existing and new clients, whereas only 13 were seeing exclusively existing clients and 10 were working exclusively with new clients. Despite no major differences were found between conditions regarding the perceived impact of face masks on different therapy quality dimensions and strategies adopted, the qualitative analysis allowed us to expand the quantitative results and deepen understanding of psychotherapists' experience. Based on general and typical patterns, we propose two distinct models to describe the therapist's experiences narrative when working with existing or new clients wearing face masks. Based on the results, we propose some recommendations to clinical practice in similar conditions.

Therapeutic Collaboration in Career Construction Counseling: Case Studies of an Integrative Model.

The mapping of therapeutic collaboration throughout counseling deepens our understanding of how the helping relationship fosters client change. To better understand the process of career construction counseling (CCC), we analyzed the therapeutic collaboration on six successful face-to-face cases. The participants were six Portuguese adults, five women and one man, real clients of a career counseling service, and four psychologists, three female and one male trained in the career intervention model. The participants completed demographic questions and measures of career certainty, vocational identity, career indecision, and psychological functioning. The Therapeutic Collaboration Coding System was used to track collaboration throughout all interactive episodes. The clinical significance of the intervention was calculated by analyzing pre-post-test statistical differences for each case, with the Reliable Change Index and Z score. The findings evidenced a pattern of therapeutic collaboration evolution for good outcome cases. Based on this pattern, we propose a model of process-outcome evolution for the three phases of CCC.

Therapist's actions after therapeutic collaboration breaks: a single case study.

Aim: This study analyzes how a therapist contributed to therapeutic collaboration reestablishment by describing his actions after therapeutic collaboration breaks in a recovered completer clinical case. Method: Data was collected from a narrative therapy case with the diagnosis of depression spanning 19 sessions. We identified sequences in which therapeutic collaboration breaks were re-established (or not) through the Therapeutic Collaboration Coding System. We analyzed the therapist's actions after the therapeutic collaboration breaks through Conversation Analysis. Results: Typically, the therapist maintained the action that preceded the therapeutic collaboration break. When he did so by proposing a new meaning to the client's experience or by highlighting the client's agency, the therapeutic collaboration was usually re-established; however, when he did so by guiding or making exploratory questions to deepen the client's experience, the therapeutic collaboration was usually not re-established. When the therapist retreated from his previous action, the therapeutic collaboration tended to be re-established, mainly when he reflected the client's previous turn. Conclusion: This study suggests that more important than maintaining or retreating from the previous action is how the therapist does so. The therapist's actions of acknowledging the client's experience and agency contributed to therapeutic collaboration reestablishment.

Impact of confrontations by therapists on impairment and utilization of the therapeutic alliance.

OBJECTIVE: Striking the balance between creating challenge through confrontation (drawing attention to discrepancies) to encourage change and offering support through the therapeutic relationship to ensure safety for patients represents a central issue for psychotherapists. The aim of the present study was to assess immediate effects of confrontations by therapists on the therapeutic alliance. METHOD: We rated video recordings of 77 therapies to measure incidences of alliance ruptures/resolution attempts as well as confrontations by therapists. Change in the therapeutic alliance and therapy outcome were measured through questionnaires filled out by patients. RESULTS: Confrontations were significantly associated with ruptures/resolution attempts on the micro level. Changes in the therapeutic alliance moderated the association between confrontations and alliance ruptures on the macro level: The bigger the fraction of a session containing confrontations, the larger the fraction containing ruptures, given a prior positive change in the therapeutic alliance. Therapists' use of confrontation during a resolution attempt was associated with significantly better therapy outcomes than no use of confrontation during or no resolution attempt. CONCLUSIONS: Confrontations by therapists may temporarily impair the therapeutic alliance, but might also lead to better therapy outcomes when used to make an alliance rupture explicit as part of a resolution attempt. Clinical or methodological significance: This study provides quantitative explorations of therapists' fears and hopes regarding the use of confrontations (defined as focus on a discrepancy by the therapist). Results point to associations between confrontations and alliance ruptures, especially in the context of a secure alliance. Furthermore, resolution attempts might profit from initial confrontations regarding the relevant alliance rupture.

Exceeding the therapeutic zone of proximal development as a clinical error.

The Assimilation of Problematic Experiences Scale (APES) summarizes a developmental continuum along which psychological problems progress in successful psychotherapy. The therapeutic zone of proximal development (TZPD) is the segment of the APES continuum within which the clients can proceed from their current APES level to the next with the therapist's assistance. It is the therapeutic working zone for a particular problem. As the client makes progress on a problem, its TZPD shifts up the APES. Theoretically, so long as the therapist's interventions remain within the TZPD, the client feels safe enough to work. However, when an intervention aims beyond the upper limit, the client will find it too risky and will reject or avoid the proposal. In this sense, exceeding the TZPD can be considered as a clinical error. This article presents examples of exceeding the TZPD and ways the error can be repaired. (PsycINFO Database Record

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.

Therapeutic collaboration and the assimilation of problematic experiences in emotion-focused therapy for depression: Comparison of two cases.

OBJECTIVE: The Assimilation model argues that therapists should work responsively within the client's therapeutic zone of proximal development (TZPD). This study analyzed the association between the collaborative processes assessed by the Therapeutic Collaboration Coding System (TCCS) and advances in assimilation, as assessed by the Assimilation of Problematic Experiences Scale (APES). METHOD: Sessions 1, 4, 8, 12, and 16 of two contrasting cases, Julia and Afonso (pseudonyms), drawn from a clinical trial of 16-sessions emotion-focused therapy (EFT) for depression, were coded according to the APES and the TCCS. Julia met criteria for reliable and clinically significant improvement, whereas Afonso did not. RESULTS: As expected, Julia advanced farther along the APES than did Afonso. Both therapists worked mainly within their client's TZPD. However, Julia's therapist used a balance of supporting and challenging interventions, whereas Afonso's therapist used mainly supporting interventions. Setbacks were common in both cases. CONCLUSIONS: This study supports the theoretical expectation that EFT therapists work mainly within their client's TZPD. Therapeutic exchanges involving challenging interventions may foster client change if they occur in an overall climate of safety.

Therapeutic collaboration and significant event to the client´s change: a systematic review

This study presents a systematic review of literature on research focused in significant events in psychotherapy and their relation with collaborative nature process between therapist and client. Researchers argue that attention to significant events can be effectively an important strategy to improve the understanding of how change process occurs in psychotherapy. Moreover, the therapeutic collaboration as a central dimension of alliance has been consistently associated with therapeutic change. This study aimed to understand how these two research topics have been addressed in conjunction by psychotherapy researchers. Medline and PubMed Resources Guide, Scielo, Web of Science, Scopus, PsycINFO, EBSCO and OVID electronic databases was searched between the years 2000 and 2015, with keywords such as therapeutic alliance or collaboration, and significant events, helpful aspects, important moments, or episodes, and process or outcomes, with all possible combinations of derivatives. Regarding the results of this review, we found only four qualitative studies that meet the inclusion criteria. These studies had different aims and used different methodologies to collect and to analyze the significant events. The analysis of these studies suggest a need for further investigations aiming to do microanalysis the interactive and relational processes occurring within the significant events in psychotherapy (AU)

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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.

Capacidades familiares para cuidar de enfermos oncológicos paliativos: un estudio cualitativo / The ability of family members to care palliative cancer patients: A qualitative study

El objetivo de este estudio fue evaluar los factores que pueden influir en la capacidad de que dispone una familia para cuidar de un paciente oncológico que requiere cuidados paliativos. Se trata de un estudio amplio, cualitativo y de observación, respaldado por la Teoría Fundamentada (Grounded Theory) y el uso de la técnica de grupos focales. En el periodo de enero a agosto de 2009 reunimos a 13 familiares de pacientes con enfermedad oncológica incurable y progresiva que estaban siendo atendidos por un servicio de cuidados paliativos de un hospital oncológico situado en el norte de Portugal, separados por 2 grupos focales distintos. Mediante el análisis de lo transcrito del grupo focal se identificaron 4 ejes que aportan factores (categorías), que pueden condicionar la capacidad de cuidar: el eje práctico (ingreso, asistencia técnica, recursos sociales/salud, cuidados paliativos, apoyo psicológico, traslado, gastos de la casa); el eje relacional (los vínculos, la pérdida, la privacidad, la intimidad, el apoyo al cuidador, compartir), el eje de experiencia interna (sentimientos, estrategias de afrontamiento, afecto, sufrimiento, muerte, apoyo psicológico), y la condición del eje de la salud (la recuperación, los síntomas, la información sobre la enfermedad, la vulnerabilidad del cuidador). La construcción de los indicadores identificados en la investigación pueden resultar muy útiles para detectar en una evaluación integral a la familia factores que pueden poner en riesgo la capacidad del grupo familiar para atender al paciente y asegurar la continuidad del manejo por Cuidados Paliativos

The aim of this study is to assess the factors that can influence the capability of a family to take care of an oncology patient in Palliative Care. It is a broad, qualitative and observational study, backed by the Grounded Theory and using the Focus Group technique. Meetings, separated into 2 focal groups, were held in the period from January to August 2009, with 13 relatives of patients with incurable cancer and progressive disease, who were being cared for in a Palliative Care Unit of an oncology hospital in northern Portugal. By analyzing the focal groups transcripts, 4 axes that carry factors (categories) that may condition the ability to be a caregiver could be identified: The practical axis (admission, technical assistance, social/health resources, palliative care, psychological support, relocation, home expenses), the relational axis (bonds, loss, privacy, intimacy, support to the caregiver, sharing), the internal experience axis (feelings, coping strategies, affection, suffering, death, psychological support), and the health condition axis (recovering, symptoms, information about the illness, vulnerability of the caregiver). A list of the identified indicators is of help in the holistic evaluation of the family, by enabling an early detection of traits that may be of risk to their caring capacity, determining the continuity of the palliative care and/or a possible discharge

A VEP study in sleeping and awake one-month-old infants and its relation with social behavior.

With the present study we aimed to analyze the relationship between infants' behavior and their visual evoked-potential (VEPs) response. Specifically, we want to verify differences regarding the VEP response in sleeping and awake infants and if an association between VEP components, in both groups, with neurobehavioral outcome could be identified. To do so, thirty-two full-term and healthy infants, approximately 1-month of age, were assessed through a VEP unpatterned flashlight stimuli paradigm, offered in two different intensities, and were assessed using a neurobehavioral scale. However, only 18 infants have both assessments, and therefore, these is the total included in both analysis. Infants displayed a mature neurobehavioral outcome, expected for their age. We observed that P2 and N3 components were present in both sleeping and awake infants. Differences between intensities were found regarding the P2 amplitude, but only in awake infants. Regression analysis showed that N3 amplitude predicted an adequate social interactive and internal regulatory behavior in infants who were awake during the stimuli presentation. Taking into account that social orientation and regulatory behaviors are fundamental keys for social-like behavior in 1-month-old infants, this study provides an important approach for assessing physiological biomarkers (VEPs) and its relation with social behavior, very early in postnatal development. Moreover, we evidence the importance of the infant's state when studying differences regarding visual threshold processing and its association with behavioral outcome.

The development of the therapeutic alliance and the emergence of alliance ruptures / El desarrollo de la alianza terapéutica y la aparición de rupturas en la Alianza

Objectives: This study evaluated the development of the therapeutic alliance and the emergence of alliance ruptures, in a sample of patients with different diagnosis and different therapeutic outcome. Design: We examined the longitudinal data of 38 therapeutic dyads receiving cognitive-behavioural therapy, including dropouts as well as successful and unsuccessful cases. The sample included cases with Axis I and Axis II disorders. Method: At the end of each session, patients evaluated the alliance using the Working Alliance Inventory (WAI). Six judges trained in the observation of alliance rupture markers with an observational system of ruptures, rated 201 videotaped sessions. Longitudinal statistical models were applied to the data. Results: We found that the pattern of alliance development of successful cases was different from the unsuccessful and dropouts cases. In addition on average, patients with personality disorders began therapy with a lower WAI score that decreased over time, whereas patients with Axis-I disorders began therapy with a higher WAI score that increased over time

Objetivos: Este estudio evaluó el desarrollo de la alianza terapéutica y la aparición de rupturas de alianzas, en una muestra de pacientes con diferentes diagnósticos y resultados terapéuticos. Diseño: Se analizaron los datos longitudinales de 38 díadas terapéuticas que recibieran terapia cognitivo-conductual. La muestra incluyó a casos de abandonos, así como casos exitosos y no exitosos. La muestra incluyó a casos con trastornos del Eje I y Eje II. Método: Al final de cada sesión, los pacientes evaluaron la alianza mediante el Inventario de Alianza de Terapéutica (WAI). Seis jueces entrenados en la observación de los marcadores de ruptura de alianza con un sistema de observación de rupturas, codificaran 201 sesiones terapéuticas grabadas en vídeo. Se aplicaran modelos estadísticos longitudinales a los datos. Resultados: Se encontró que el patrón de desarrollo de la alianza de los casos de éxito era diferente de la de los casos sin éxito y abandonos. En media, los pacientes con trastornos de la personalidad iniciaran la terapia con una menor puntuación en el WAI que disminuyó con el tiempo, mientras que los pacientes con trastornos del Eje I iniciaran la terapia con una mayor puntuación en el WAI que aumentó con el tiempo

Cognitive conflicts in major depression: between desired change and personal coherence.

OBJECTIVES: The notion of intrapsychic conflict has been present in psychopathology for more than a century within different theoretical orientations. However, internal conflicts have not received enough empirical attention, nor has their importance in depression been fully elaborated. This study is based on the notion of cognitive conflict, understood as implicative dilemma (ID), and on a new way of identifying these conflicts by means of the Repertory Grid Technique. Our aim was to explore the relevance of cognitive conflicts among depressive patients. DESIGN: Comparison between persons with a diagnosis of major depressive disorder and community controls. METHODS: A total of 161 patients with major depression and 110 non-depressed participants were assessed for presence of IDs and level of symptom severity. The content of these cognitive conflicts was also analysed. RESULTS: Repertory grid analysis indicated conflict (presence of ID/s) in a greater proportion of depressive patients than in controls. Taking only those grids with conflict, the average number of IDs per person was higher in the depression group. In addition, participants with cognitive conflicts displayed higher symptom severity. Within the clinical sample, patients with IDs presented lower levels of global functioning and a more frequent history of suicide attempts. CONCLUSIONS: Cognitive conflicts were more prevalent in depressive patients and were associated with clinical severity. Conflict assessment at pre-therapy could aid in treatment planning to fit patient characteristics.

Ambivalence and innovative moments in grief psychotherapy: the cases of Emily and Rose.

Several studies have suggested that the process of narrative change in psychotherapy occurs through the emergence and expansion of moments of novelty, known as innovative moments (IMs), that allow changes in the problematic self-narrative responsible for the client's suffering. However, as these IMs challenge typical (and problematic) ways of acting, feeling, and thinking, they may also generate discrepancy or uncertainty. Clients may reduce uncertainty by returning to the problematic self-narrative immediately after the emergence of an IM, thus ensuring the homeostasis of the previous meaning system. This cyclical movement is a form of ambivalence, which can maintain problematic stability across therapy and lead to therapeutic failure. In this study, we identified return to the problem markers (RPMs), which are empirical indicators of the ambivalence process, for all IMs in two cases of constructivist grief psychotherapy. Both cases evidenced a high percentage of IMs with RPMs, and the evolution of IMs and RPMs along treatment was significantly correlated. We suggest that stability of the ambivalence process in grief psychotherapy may represent a form of self-protection from the anxiety or guilt of releasing pain as a disconnection from the deceased.