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.

Emotional processing during the therapy for complicated grief.

OBJECTIVE: Prior research, mainly conducted on depression, observed that clients' improved capability to process their emotions predicted better therapeutic outcomes. The current comparative study aimed to investigate whether emotional processing was related to therapeutic change in complicated grief. METHOD: We analyzed two contrasting cases (good or poor outcome) treated with grief constructivist therapy. In both cases we investigated the association of emotional processing (Experiencing Scale) to (1) therapeutic outcome (Inventory of Complicated Grief), and (2) change in the type of grief-related emotions (Emotions Episodes). RESULTS: The session-by-session growth of clients' emotional processing and the change of grief-related emotions were qualitatively explored throughout both cases. Compared with the poor outcome case, the good outcome case achieved more improvement in the ability to process emotions. Such improvement occurred alongside a deeper change in the type of grief-related emotions aroused, from maladaptive to more adaptive responses. CONCLUSION: Our findings suggest that a higher emotional processing capability may be associated with the transformation of grief-related maladaptive emotions and with the improvement of complicated grief condition.

Fluctuation in the assimilation of problematic experiences: A comparison of two contrasting cases of Emotion Focused Therapy.

The assimilation model suggests that therapeutic change occurs through a gradual assimilation of problematic experiences. Previous case studies have suggested that both good- and poor-outcome cases exhibit a fluctuating pattern of assimilation progress, characterized by advances and setbacks. Our study examined more closely how this fluctuating pattern is related to symptom change across therapy. We analyzed the longitudinal relations among assimilation ratings, instability (fluctuation) in assimilation ratings, and clinical symptom intensity in two contrasting cases of emotion-focused therapy for depression, one good and one poor outcome. We used the assimilation of problematic experiences scales (APES) to measure assimilation and the outcome- questionnaire (OQ-10) to measure clinical symptom intensity. To assess assimilation instability, we used a fluctuation measure that calculated the amplitude and the frequency of changes in assimilation levels. The results showed that in the good-outcome case, assimilation levels and instability tended to increase and symptom intensity tended to decrease, particularly in the final phase of treatment. In the poor-outcome case, assimilation levels and instability did not change much across sessions.

Does assimilation of problematic experiences predict a decrease in symptom intensity?

The assimilation model describes therapeutic change as an integration of experiences that had previously been problematic, distressing, avoided, or warded off. This study assessed whether assimilation was associated with treatment outcome in a sample of psychotherapeutic treatments for depression. Further, it assessed the direction of the association-whether increasing assimilation predicted decreases in symptom intensity or decreasing symptom intensity predicted increases in assimilation. METHOD: Participants were 22 clients with mild to moderate depression drawn from a clinical trial comparing cognitive behavioral therapy with emotion-focused therapy. The direction of prediction between assimilation progress and changes in self-reported symptom intensity was assessed. RESULTS: The assimilation progress was shown to be a better predictor of decreases in symptom intensity than the reverse. CONCLUSION: The results supported the assimilation model's suggestion that assimilation progress promotes decreases in symptom intensity in the treatment of clients with major depressive disorder.

Immersion and distancing during assimilation of problematic experiences in a good-outcome case of emotion-focused therapy.

OBJECTIVE: Some studies have suggested that a decrease in immersion (egocentric perspective on personal experiences) and an increase in distancing (observer perspective on personal experiences) are associated with the resolution of clinical problems and positive outcome in psychotherapy for depression. To help clarify how this change in perspectives relates to clinical change, the present study compared changes in immersion and distancing across therapy with progress in one client's assimilation of her problematic experiences. METHOD: We analyzed all passages referring to the central problematic experience in a good-outcome case of emotion-focused therapy for depression using the Measure of Immersion and Distancing Speech and the Assimilation of Problematic Experiences Scale. RESULTS: Results showed that immersion and distancing were associated with different stages of assimilation. Immersion was associated with stages of emerging awareness and clarification of the problem and in the application of new understandings to daily life. Distancing was associated with problem-solving and attaining insight. CONCLUSION: The decrease of immersion and increase of distancing associated with therapeutic improvement should not be taken as a recommendation to avoid immersion and encourage distancing. Immersion and distancing may work as coordinated aspects of the processes of psychotherapeutic change.

Changes in symptom intensity and emotion valence during the process of assimilation of a problematic experience: A quantitative study of a good outcome case of cognitive-behavioral therapy.

The assimilation model describes the change process in psychotherapy. In this study we analyzed the relation of assimilation with changes in symptom intensity, measured session by session, and changes in emotional valence, measured for each emotional episode, in the case of a 33-year-old woman treated for depression with cognitive-behavioral therapy. Results showed the theoretically expected negative relation between assimilation of the client's main concerns and symptom intensity, and the relation between assimilation levels and emotional valence corresponded closely to the assimilation model's theoretical feelings curve. The results show how emotions work as markers of the client's current assimilation level, which could help the therapist adjust the intervention, moment by moment, to the client's needs.

Setbacks in the process of assimilation of problematic experiences in two cases of emotion-focused therapy for depression.

OBJECTIVE: Research on the assimilation model has suggested that psychological change takes place in a sequence of stages punctuated by setbacks, that is, by transient reversals in the developmental course. This study analyzed such setbacks in one good outcome case and one poor outcome case of Emotion-focused therapy (EFT) for depression. METHOD: Intensive analyses of five transcribed sessions from each case identified 26 setbacks in the good outcome case and 27 in the poor outcome case. The reason for each setback was classified into one of four categories: balance strategy, exceeding the therapeutic zone of proximal development either induced by the therapist (ZPD-T) or induced by the client (ZPD-C), or spontaneous switches. RESULTS: In the good outcome case the most frequent reasons for setbacks were balance strategy and spontaneous switches, whereas in the poor outcome case the most frequent reason for setbacks was ZPD-T. CONCLUSIONS: As in previously studied therapies, setbacks in EFT, usually represent productive work on relatively less advanced strands of the client's major problems. Results point to the importance of the therapist attending to the limits of the client's therapeutic ZPD.

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.

Validation of the client satisfaction questionnaire: a pilot psychometric analysis in Portuguese routine practice.

Treatment satisfaction has been found to have good therapeu- tic results in psychotherapy, and the 18-item version of the client satisfaction questionnaire (CSQ-18) is one of the most widely used measures to evaluate it. This study sought to carry out a pilot analysis of the psychometric's properties and factorial structure, as well as validate the CSQ-18's applicability to the Portuguese population within the context of routine clinical practice. It also sought to explore the association that treatment satisfaction has with general symptoms, therapeutic alliance, and expectations at an early stage of psychotherapy. The sample comprised 98 clients who were undergoing psychotherapy in a routine practice context. All these clients completed self-reported measures for symptom assessment and therapeutic relationship, namely the clinical out- come routine evaluation-outcome measure, working alliance in- ventory, and credibility/expectancy questionnaire, in addition to the CSQ-18. The semi-confirmatory factorial analysis demon- strated that the CSQ-18 has good psychometric properties and re- vealed an association between treatment satisfaction and therapeutic alliance. The results corroborate the findings of other versions of the measure and present a good adjustment model for the semi-confirmatory factorial analysis.

Fluctuation in the Assimilation of Problematic Experiences: A Case Study of Dynamic Systems Analysis.

Dynamic systems theory suggests that instability can be a key element in the promotion of human change processes. Several studies have confirmed an association between unstable patterns and successful psychotherapeutic outcome. Somewhat similarly, the assimilation model of psychotherapeutic change argues that clinical change occurs through the integration of problematic experiences that initially threaten the stability of the self. This study examined how instability in assimilation levels was related to assimilation progress and change in symptom intensity, within and across sessions, in a good-outcome case of Emotion Focused Therapy. We used the assimilation of problematic experiences scales (APES) to measure assimilation and the outcome-questionnaire (OQ-10) to measure clinical symptom intensity. To assess assimilation instability, we used a fluctuation measure that calculated the amplitude and the frequency of changes in assimilation levels. To analyze the structural relationships between variables we used a dynamic factor model. The results showed that APES level and APES fluctuation tended to increase across treatment, while OQ-10 scores tended to decrease. However, contrary to expectations, the dynamic factor model showed no significant associations between APES fluctuation and OQ-10 scores either within sessions or between adjacent sessions.