Behavioral Health Provider Burnout and Mental Health Care in the Veterans Health Administration.

BACKGROUND: Although many studies assess predictors of provider burnout, few analyses provide high-quality, consistent evidence on the impact of provider burnout on patient outcomes exist, particularly among behavioral health providers (BHPs). OBJECTIVE: To assess the impact of burnout among psychiatrists, psychologists, and social workers on access-related quality measures in the Veterans Health Administration (VHA). DESIGN: This study used burnout in VA All Employee Survey (AES) and Mental Health Provider Survey (MHPS) data to predict metrics assessed by the Strategic Analytics for Improvement and Learning Value, Mental Health Domain (MH-SAIL), VHA's quality monitoring system. The study used prior year (2014-2018) facility-level burnout proportion among BHPs to predict subsequent year (2015-2019) facility-level MH-SAIL domain scores. Analyses used multiple regression models, adjusting for facility characteristics, including BHP staffing and productivity. PARTICIPANTS: Psychologists, psychiatrists, and social workers who responded to the AES and MHPS at 127 VHA facilities. MAIN MEASURES: Four compositive outcomes included two objective measures (population coverage, continuity of care), one subjective measure (experience of care), and one composite measure of the former three measures (mental health domain quality). KEY RESULTS: Adjusted analyses showed prior year burnout generally had no impact on population coverage, continuity of care, and patient experiences of care but had a negative impact on provider experiences of care consistently across 5 years (p < 0.001). Pooled across years, a 5% higher facility-level burnout in AES and MHPS had a 0.05 and 0.09 standard deviation worse facility experiences of care from the prior year, respectively. CONCLUSIONS: Burnout had a significant negative impact on provider-reported experiential outcome measures. This analysis showed that burnout had a negative effect on subjective but not on objective quality measures of Veteran access to care, which could inform future policies and interventions regarding provider burnout.

How to make a job more than just a paycheck: Understanding physician disengagement.

BACKGROUND: The benefits of physician engagement are numerous, including improved physician recruitment, retention, and leadership development-outcomes associated with substantial costs or potential savings for health care organizations. However, physician disengagement is a serious detriment, associated with poorer quality of patient care and higher turnover of clinical staff. Using a workforce census survey, we examined what makes physicians engaged or disengaged in their work at a large U.S. health care system. PURPOSE: This study expands our understanding of physician engagement and disengagement, states that impact patient care service delivery and care experiences. METHODOLOGY/APPROACH: We explain group differences using qualitative survey comments from 142 engaged and disengaged physicians, which we report with illustrative quotes and frequency counts of referenced themes. RESULTS: Engaged physicians discussed positive interpersonal relationships as connected with seeing their work as meaningful. Disengaged physicians expressed concerns about out-of-touch executive leadership. Leadership played a role in psychological safety for both engaged and disengaged physicians: It was described as present and positive for the engaged group and absent for the disengaged group. CONCLUSION: There are commonalities and differences in the drivers of physician engagement and disengagement. Our results shed light on why physicians might withdraw from inherently meaningful work. These findings can inform organizational efforts toward decreasing physician disengagement and increasing and maintaining an engaged physician workforce. PRACTICE IMPLICATIONS: To reduce physician disengagement, we recommend leadership development around key skills (i.e., visibility, transparency, accessibility). We also suggest that improving supervisors' (e.g., clinical service chiefs') knowledge about workflow processes, staffing needs, patient panel sizes, and administrative tasks carried by physicians could better balance physicians' workload. Finally, human resource systems can help reduce disengagement by adjusting hiring and training processes to mitigate low staffing levels.

Relationship Between Psychological Safety and Reporting Nonadherence to a Safety Checklist.

Patient safety checklists are ubiquitous in health care. Nurses bear significant responsibility for ensuring checklist adherence. To report nonadherence to a checklist and stop an unsafe procedure, a workplace climate of psychological safety is needed. Thus, an analysis of organizational data was conducted to examine the relationship between psychological safety and reports of nonadherence to the central line bundle checklist. Results showed varied perceptions of psychological safety but no relationship with nonadherence. Considerations for this finding and assessing psychological safety are provided.

Association between psychosocial, organizational and personal factors and prevalence of musculoskeletal disorders in office workers.

The purpose of this study was to investigate the relationship between organizational and personal (individual) factors with the prevalence of musculoskeletal disorders (MSDs) in office workers of the Iranian Gas Transmission Company. The participants rated two questionnaires - the standardized Nordic Musculoskeletal Questionnaire to measure the prevalence of MSDs, and the Veterans Healthcare Administration All Employee Survey questionnaire (2004 version) - to measure psychosocial, organizational and individual aspects of job satisfaction and workplace climate. The highest prevalence of MSDs was found in the lower back (49.7%) and neck (49.0%) regions. Results of the logistic regression models showed that some psychosocial and organizational factors and also some individual factors were associated with prevalence of MSDs (p < 0.05).These findings illustrate the need to consider all elements of the work system as a whole in future studies and in organizational planning.

Nurse perceptions of workplace environment: differences across shifts.

AIM: To evaluate whether nurse work shift affected workplace perceptions. BACKGROUND: Although the importance of work schedule in shaping work attitudes, generally (and specifically for nurses) is well accepted, much work remains in characterising how and why nurses' perceptions might differ across shifts. METHODS: Using an exploratory study of observational data, we examined whether shift influenced non-supervisory nurses' job perceptions in the Veterans Health Administration All Employee Survey (n = 14057; years 2008, 2010, 2012). The size of differences in item means (95% C.I.) across shifts was evaluated graphically. Using ordinal logistic regression, we accounted for the ordinal outcome variables and controlled for the demographic and survey year effects. RESULTS: Nurses' perceptions of workplace climate differed across shifts. Items with the greatest differences, consistent across years and analytic methods, involved supervisors and fairness. Night and weekend shift nurse ratings were more negative than for weekday shift nurses. CONCLUSIONS: Off-shift nurses are less satisfied with work/life balance, their supervisors and especially fairness. Overall satisfaction and turnover intention are not affected to the same extent. IMPLICATIONS FOR NURSING MANAGEMENT: These results indicate several specific areas that nurse managers can address through workforce support and communication.

Employee age and tenure within organizations: relationship to workplace satisfaction and workplace climate perceptions.

This study estimated the relative influence of age/generation and tenure on job satisfaction and workplace climate perceptions. Data from the 2004, 2008, and 2012 Veterans Health Administration All Employee Survey (sample sizes >100 000) were examined in general linear models, with demographic characteristics simultaneously included as independent variables. Ten dependent variables represented a broad range of employee attitudes. Age/generation and tenure effects were compared through partial η(2) (95% confidence interval), P value of F statistic, and overall model R(2). Demographic variables taken together were only weakly related to employee attitudes, accounting for less than 10% of the variance. Consistently across survey years, for all dependent variables, age and age-squared had very weak to no effects, whereas tenure and tenure-squared had meaningfully greater partial η(2) values. Except for 1 independent variable in 1 year, none of the partial η(2) confidence intervals for age and age-squared overlapped those of tenure and tenure-squared. Much has been made in the popular and professional press of the importance of generational differences in workplace attitudes. Empirical studies have been contradictory and therefore inconclusive. The findings reported here suggest that age/generational differences might not influence employee perceptions to the extent that human resource and management practitioners have been led to believe.

Communication and psychological safety in veterans health administration work environments.

PURPOSE: The purpose of this paper is to explore employee perceptions of communication in psychologically safe and unsafe clinical care environments. DESIGN/METHODOLOGY/APPROACH: Clinical providers at the USA Veterans Health Administration were interviewed as part of planning organizational interventions. They discussed strengths, weaknesses, and desired changes in their workplaces. A subset of respondents also discussed workplace psychological safety (i.e. employee perceptions of being able to speak up or report errors without retaliation or ostracism--Edmondson, 1999). Two trained coders analysed the interview data using a grounded theory-based method. They excerpted passages that discussed job-related communication and summarized specific themes. Subsequent analyses compared frequencies of themes across workgroups defined as having psychologically safe vs unsafe climate based upon an independently administered employee survey. FINDINGS: Perceptions of work-related communication differed across clinical provider groups with high vs low psychological safety. The differences in frequencies of communication-related themes across the compared groups matched the expected pattern of problem-laden communication characterizing psychologically unsafe workplaces. ORIGINALITY/VALUE: Previous research implied the existence of a connection between communication and psychological safety whereas this study offers substantive evidence of it. The paper summarized the differences in perceptions of communication in high vs low psychological safety environments drawing from qualitative data that reflected clinical providers' direct experience on the job. The paper also illustrated the conclusions with multiple specific examples. The findings are informative to health care providers seeking to improve communication within care delivery teams.

The Importance of Autonomy and Performance Goals in Perceived Workload Among Behavioral Health Providers.

OBJECTIVE: The authors sought to assess workplace characteristics associated with perceived reasonable workload among behavioral health care providers in the Veterans Health Administration. METHODS: The authors evaluated perceived reasonable workload and workplace characteristics from the 2019 All Employee Survey (AES; N=14,824) and 2019 Mental Health Provider Survey (MHPS; N=10,490) and facility-level staffing ratios from Mental Health Onboard Clinical Dashboard data. Nine AES and 15 MHPS workplace predictors of perceived reasonable workload, 11 AES and six MHPS demographic predictors, and facility-level staffing ratios were included in mixed-effects logistic regression models. RESULTS: In total, 8,874 (59.9%) AES respondents and 5,915 (56.4%) MHPS respondents reported having a reasonable workload. The characteristics most strongly associated with perceived reasonable workload were having attainable performance goals (average marginal effect [AME]=0.10) in the AES and ability to schedule patients as frequently as indicated (AME=0.09) in the MHPS. Other AES characteristics significantly associated with reasonable workload included having appropriate resources, support for personal life, skill building, performance recognition, concerns being addressed, and no supervisor favoritism. MHPS characteristics included not having collateral duties that reduce care time, staffing levels not affecting care, support staff taking over some responsibilities, having spirit of teamwork, primary care-mental health integration, participation in performance discussions, well-coordinated mental health care, effective veteran programs, working at the top of licensure, and feeling involved in improving access. Facility-level staffing ratios were not significantly associated with perceived reasonable workload. CONCLUSIONS: Leadership may consider focusing resources on initiatives that support behavioral health providers' autonomy to schedule patients as clinically indicated and develop attainable performance goals.

Studying the relationships between authentic leadership, structural empowerment, and civility in the palliative care sector in Portugal.

PURPOSE: This paper aims to propose a model studying the relationship of authentic leadership (AL), structural empowerment (SE) and civility in the palliative care sector. This model proposes SE as a mediator between AL and civility. DESIGN/METHODOLOGY/APPROACH: Data was collected from 213 employees working in five major public palliative care hospitals in central Portugal. The study sample was predominantly female (80.3%) and the response rate was 42.6%. Variables were measured using the Authentic Leadership Inventory, Workplace Civility Scale and Conditions of Work Effectiveness Questionnaire II scales. Hayes' PROCESS macro for mediation analysis in SPSS was used to test the hypothesized model. FINDINGS: Results suggest that AL has a significant positive direct relationship with both SE and civility. Furthermore, SE demonstrated to play a partial mediation effect between AL and civility. PRACTICAL IMPLICATIONS: This study may be of use for healthcare administration encouraging the development of AL, suggesting that the more leaders are seen as authentic, the more employees will perceive they have access to workplace empowerment structures and a civil environment. ORIGINALITY/VALUE: Considering the mainstream literature in healthcare management, to the best of the authors' knowledge, this is the first study to date to integrate the relation of AL, SE and civility in the palliative care sector. Further, the research model has not previously been introduced when considering the mediating role structural empowerment can play between AL and civility.

Assessing workplace civility: Validity and 1-year test-retest reliability of a Japanese version of the CREW Civility Scale.

OBJECTIVES: This study aimed to examine the reliability and validity of the Japanese version of the eight-item CREW Civility Scale which measures workplace civility norms and compare the civility scores among various occupations. METHODS: A longitudinal study included all employees in a social care organization (N = 658) and a cross-sectional study included all civil servants in one city (N = 3242) in Japan. Structural validity was tested through confirmatory factor analyses (CFA). Construct validity was assessed through Pearson's correlations of civility with other variables. Internal consistency was assessed by Cronbach's alpha and 1-year test-retest reliability was assessed by the Intraclass Correlation Coefficient (ICC). RESULTS: The results of CFA showed an acceptable level of model fit (TLI =0.929; CFI =0.949; and SRMR =0.034). CREW Civility Scale scores were significantly positively correlated with supervisor support, co-worker support, and work engagement, while significantly negatively correlated with incivility, workplace bullying, intention to leave, and psychological distress, which were consistent with our hypotheses. Cronbach's alpha coefficient was 0.93 and ICC was 0.52. Younger, high-educated, and managerial employees and, childminder/nursery staff reported higher civility. High school graduates and respondents who did not graduate from high school, part-time employees, nurses, paramedical staff, and care workers reported lower civility. CONCLUSIONS: The Japanese version of the CREW Civility scale is a reliable, valid measure of civility, appropriate for Japanese workplaces as well as for use in multi-national studies alongside other existing versions of this scale in English, Portuguese and Farsi.

Workplace bullying among mental health providers with lived experience of a mental health challenge.

Mental health care providers who have a personal lived experience of mental health challenges are valuable employees who may be vulnerable to workplace bullying, which causes harm both to these individuals and to their organizations. We used snowball sampling to survey 40 mental health professionals with lived experience about their history of workplace bullying and whether or not their lived experience was known ("out") or concealed ("closeted"). We found that our sample experienced workplace bullying at much higher rates than published samples from the general population. More than three-quarters of our sample reported having ever experienced bullying and almost half had been bullied in the past year. Furthermore, most of those who had ever experienced bullying reported having been closeted at the time. Further exploratory analyses identified some specific aspects of bullying that might be fruitful areas for future research. We conclude with implications for employee recruitment and retention, vocational rehabilitation, and organizational development. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Relationships between work-environment characteristics and behavioral health provider burnout in the Veterans Health Administration.

OBJECTIVE: To identify work-environment characteristics associated with Veterans Health Administration (VHA) behavioral health provider (BHP) burnout among psychiatrists, psychologists, and social workers. DATA SOURCES: The 2015-2018 data from Annual All Employee Survey (AES); Mental Health Provider Survey (MHPS); N = 57,397 respondents; facility-level Mental Health Onboard Clinical (MHOC) staffing and productivity data, N = 140 facilities. STUDY DESIGN: For AES and MHPS separately, we used mixed-effects logistic regression to predict BHP burnout using surveys from year pairs (2015-2016, 2016-2017, 2017-2018; six models). Within each year-pair, we used the earlier year of data to train models and tested the model in the later year, with burnout (emotional exhaustion and/or depersonalization) as the outcome for each survey. We used potentially modifiable work-environment characteristics as predictors, controlling for employee demographic characteristics as covariates, and employment facility as random intercepts. DATA COLLECTION/EXTRACTION METHODS: We included work-environment predictors that appeared in all 4 years (11 in AES; 17 in MHPS). PRINCIPAL FINDINGS: In 2015-2018, 31.0%-38.0% of BHPs reported burnout in AES or MHPS. Work characteristics consistently associated with significantly lower burnout were included for AES: reasonable workload; having appropriate resources to perform a job well; supervisors address concerns; given an opportunity to improve skills. For MHPS, characteristics included: reasonable workload; work improves veterans' lives; mental health care provided is well-coordinated; and three reverse-coded items: staffing vacancies; daily work that clerical/support staff could complete; and collateral duties reduce availability for patient care. Facility-level staffing ratios and productivity did not significantly predict individual-level burnout. Workload represented the strongest predictor of burnout in both surveys. CONCLUSIONS: This study demonstrated substantial, ongoing impacts that having appropriate resources including staff, workload, and supervisor support had on VHA BHP burnout. VHA may consider investing in approaches to mitigate the impact of BHP burnout on employees and their patients through providing staff supports, managing workload, and goal setting.

Relationship between mental states in depression: the assimilation model perspective.

Metacognitive theories describe relationships between mental-affective self-states, including the capacity of one self-state to reflect upon another self-state. The assimilation model is a metacognitive approach that understands self-states as made of traces of experiences at different levels of integration. Psychological problems are understood as impaired accessibility of certain self-states to the person's normal awareness. These states are distressing or otherwise subjectively problematic when they emerge. This exploratory study used the assimilation framework to describe mental states in 17 clients who participated in a clinical trial of cognitive-behavioral therapy for depression. Three clinically sophisticated raters examined transcripts of 1h-long psychotherapy session per client to construct qualitative descriptions of self-states and their relationship patterns in these depressed individuals. We then systematically compared and integrated these raters' descriptions of the clients' self-states. In each case, we found a conflict between two internally incompatible states: an interpersonally submissive state and an interpersonally dominant one, a pattern consistent with the model's theoretical description of depression.

Narrative evolution and assimilation of problematic experiences in a case of pharmacotherapy for schizophrenia.

This case study applied the assimilation model to examine the changing narrative of an outpatient with schizophrenia and symptoms of depression across a successful pharmacotherapy. The assimilation model describes how clients assimilate painful, problematic experiences. Therapeutic progress is understood to reflect increasing assimilation, measured by the Assimilation of Problematic Experiences Scale (APES). The authors used a 15-min semistructured interview (Problematic Experiences Questionnaire) to elicit narrative descriptions of the patient's problems and coping across five interviews throughout his 12-week treatment. They describe how the patient's narrative and APES ratings of his main problems by two clinicians changed in concert through treatment, explain these developments using assimilation concepts, and interpret the results in relation to assimilation and insight in schizophrenia.

Accounting for variation in technical quality and patient satisfaction: the contribution of patient, provider, team, and medical center.

BACKGROUND: The delivery of healthcare depends on individual providers, coordination within teams, and the structure of the work setting. We analyzed the amount of variation in technical quality and patient satisfaction accounted for at the patient, provider, team, and medical center level. METHODS: Data abstracted from Veterans Health Administration patient medical records for 2007 were used to calculate measures of technical quality based on adherence to best practice guidelines in 5 domains. Outpatient satisfaction was obtained from a 2007 standardized national mail survey. Hierarchical linear models that accounted for the clustering of patients within providers, providers within teams, and teams within medical centers were used to partition the variation in technical quality and satisfaction across patients and components of the system (ie, providers, teams, and medical centers). RESULTS: Providers accounted for the largest percent of system-level variance for all technical quality domains, ranging from 46.5% to 71.9%. For the single-item measure of patient satisfaction, medical centers, teams, and providers accounted for about the same percent of system-level variance (31%-34%). For the doctor/patient interaction scale providers explained 59.9% of system-level variance, more than double that of teams and medical centers. For all the measures, the residual variance (composed of patient-level and random error) explained the largest proportion of the total variance. CONCLUSIONS: Providers explained the greatest amount of system-level variation in technical quality and patient satisfaction. However, in both of these domains, differences between patients were the predominant source of nonrandom variance.

Creative consensus on interpretations of qualitative data: the Ward method.

The Ward method (1987) offers an iterative approach to consensus building that encourages the development and consideration of each contributor's unique perspectives. Collaborators begin by orienting to the method and project-specific goals and then engage in an iterative process, cycling between individual creative work and group meetings. Meetings serve as opportunities to share ideas within a noncritical atmosphere. Paradoxically, much of the work of reaching consensus occurs while collaborators are working independently; across iterations, versions tend to converge as collaborators adapt and adopt what they like of one another's ideas. This article, which was itself written using the Ward method, describes the method, its strengths, and challenges associated with its use.

Examining burnout profiles in relation to health and well-being in the Veterans Health Administration employee population.

The goals of this paper were twofold: (a) To provide a population overview of burnout profiles by occupation in a large, health care sector employee population and (b) to investigate how burnout profiles relate to self-reported health behaviours, chronic conditions, and absenteeism. Burnout profiles were considered by 5 main occupational groups (physicians, nurses, other clinical, administrative, and wage grade [trade, craft, and labor workers]) in survey respondents (n = 86,257 employees). Logistic regression analyses were conducted to examine how burnout profiles were associated with health controlling for gender, age, race, ethnicity, and occupational group. Employees in the "Frustrated/Burning Up" and "Withdrawing/Burned Out" profiles, respectively, had significantly increased odds of anxiety (OR = 2.17; 99% CI [2.04, 2.31]; OR = 2.21; 99% CI [2.05, 2.38]), depression (OR = 2.06; 99% CI [1.93, 2.20]; OR = 2.20; 99% CI [2.04, 2.38]), sleep disorders (OR = 1.98; 99% CI [1.85, 2.12]; OR = 1.97; 99% CI [1.81, 2.13]), low back disease (OR = 1.60; 99% CI [1.50, 1.71]; OR = 1.58; 99% CI [1.47, 1.70]), physical inactivity (OR = 1.49; 99% CI [1.38, 1.60]; OR = 1.68; 99% CI [1.54, 1.83]), and 5 or more days away from work (OR = 1.74; 99% CI [1.65, 1.85]; OR = 2.15; 99% CI [2.01, 2.30]). Burnout is related to the health of employees. Burnout profiles offer a way to assess patterns of burnout by occupational group and may help customize future interventions.

Does nurse job satisfaction influence adherence to the central line insertion checklist and central line-associated bloodstream infections in the Veterans Health Administration?

Nurses satisfied with their jobs report less job stress, more effective nurse-physician collaboration, and higher patient satisfaction scores. It is unknown if job satisfaction influences adherence to best practices or patient outcomes. This secondary data analysis investigated the relationship between job satisfaction, adherence to the central line insertion checklist, and central line-associated bloodstream infections (CLABSIs). Results showed a decreased risk of CLABSI with higher job satisfaction, on average. No relationship was observed with checklist adherence.

Escitalopram for comorbid depression and anxiety in elderly patients: A 12-week, open-label, flexible-dose, pilot trial.

BACKGROUND: Comorbid depression and anxiety may result in greater symptom severity and poorer treatment response than either condition alone. Selective serotonin reuptake inhibitors have been found to be effective in treating both depression and anxiety; however, pharmacodynamic and pharmacokinetic changes associated with aging warrant special attention in medication trials in older patients. OBJECTIVE: The objective of this study was to assess the efficacy and tolerability of short-term (12-week) administration of escitalopram oxalate 10 to 20 mg/d for moderate to marked comorbid depression and anxiety in elderly patients. METHODS: This open-label, flexible-dose (10-20 mg/d), pilot trial was conducted at the Psychiatry Service, Veterans Affairs Medical Center, Cincinnati, Ohio. Outpatients aged > or =65 years were included if they met the criteria for comorbid major depressive disorder (MDD) and generalized anxiety disorder (GAD), as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, for > or =4 weeks and had a baseline Montgomery-Asberg Depression Rating Scale (MADRS) score of >22 and a Hamilton Rating Scale for Anxiety (HAM-A) score of > or =18. All patients received escitalopram 10 to 20 mg/d. The primary efficacy variables were the mean changes from baseline in total MADRS and HAM-A scores at 12 weeks (last observation carried forward). The secondary efficacy end point was the change from baseline in Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) 8 subscale scores. Adverse events were assessed at each visit (treatment weeks 1, 2, 3, 4, 6, 8, 10, and 12) with the use of open-ended questioning. RESULTS: Twenty patients were enrolled (mean [SD] age, 73.0 [4.8] years; 6 [30%] women; race: 17 [85%] white, 2 [10%] black, and 1 [5%] "other"). Seventeen (85%) of 20 patients completed the study; 3 (15%) withdrew: 1 (5%) due to lack of efficacy and 2 (10%) due to adverse events (dizziness and somnolence [1 (5%) patient each]). Statistically significant improvements from baseline to end point were found with escitalopram treatment (MADRS: t19 = 7.38, P < 0.001, effect size = 2.93; HAM-A: t19 = 4.19, P < 0.001, effect size = 1.83). Significant changes from baseline in scores on 4 (Social Functioning, Role Functioning-Emotional, Mental Health, and Energy/Fatigue) of the 8 subscales of the SF-36 were also found (all, P < 0.01). CONCLUSION: In this small study in elderly patients with comorbid MDD and GAD, treatment with escitalopram 10 to 20 mg/d for 12 weeks was associated with significant improvements in symptoms of depression and anxiety.

Acknowledging problematic voices: processes occurring at early stages of conflict assimilation in patients with functional somatic disorder.

OBJECTIVES: This study elaborates the assimilation model's account of client processes at an early stage (Level I). This model describes therapeutic change as a gradual assimilation of problematic experiences, or voices, into the client's personality. The Assimilation of Problematic Experiences Scale (APES; Stiles et al., 1991) measures client's increasing ability to recognize, accept and utilize these previously avoided voices. DESIGN AND METHODOLOGY: Two researchers rated session excerpts from two psychotherapy cases, where the 'problematic voice' (PV) was initially unassimilated. Passages rated at APES Level I, along with their verbal assimilation descriptions, were later scrutinized for change processes. Voice dynamics within each passage were detailed and reviewed, to hypothesize substage processes representing movement. Both procedures involved a convergence process: raters first independently analysed, then shared their findings over successive rounds. CONCLUSIONS: Across cases, shifts in the quality of negative affect were evident. Anxiety increased throughout this stage, as clients began to sustain exposure to intrusive problematic experiences. Later, Level I substages also showed an increase in conscious apperception of dominant voice characteristics including its resistance to experiencing PVs. Together, these relatively subtle changes indicated clients' increasing ability to familiarize themselves with PV qualities and recognize their historic defences against them, prior to identifying and accepting them as part of their personalities.