Search

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., (© 2023 John Wiley & Sons Ltd.)

Recently, Goldfried suggested that one main reason for the underdevelopment of psychotherapy as a scientific enterprise was the lack of acknowledgment of past contributions. In this article, this issue is illustrated by analysing the particular case of acceptance and commitment therapy (ACT). ACT has clear overlaps with therapies from the systemic tradition, such as strategic therapy in the line of the Mental Research Institute in Palo Alto and with the more recent models of solution-focused therapy and narrative therapy. This article analyses theoretical overlaps with these models (e.g. the paradoxical nature of human problems and the nature of language) as well as examples of similarities in therapeutic strategies (externalization and the miracle question). It concludes by suggesting that this practice of inadvertently obliterating the past does not favour the development of the field or the creation of consensus but rather contributes to the ongoing proliferation of 'new' psychotherapy models. Trends that may contribute to circumventing this problem are discussed., (© 2022 John Wiley & Sons Ltd.)

Ambivalence towards change is an expected, recurrent process in psychological change. However, the prolonged experience of ambivalence in psychotherapy contributes to client disengagement, which could result in treatment dropout. Considering the negative effects of premature termination of therapy and the convenience of the identification of clients who are at risk of dropping out before achieving good-outcome, the current study explored the predictive power of ambivalence for premature therapy termination using a multilevel time-backwards model (i.e., considering the session of the dropout as session zero and then modelling what occurred from the dropout until session 1). Participants included a total of 96 psychotherapy clients (38 dropouts) treated in a university-based clinic following the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Multilevel modelling using a time-backwards model to analyse dropout data provided evidence of the predictive power of ambivalence evolution throughout treatment on the decision to prematurely discontinue treatment (p < .0001; R 2 adj  = .29). Specifically, good-outcome dropouts presented a decreasing ambivalence trend throughout treatment, whereas poor-outcome dropouts tended to experience the same levels of ambivalence before deciding to drop out (time × dropout; β 11  = .64, p = .014). Additionally, poor-outcome dropouts presented higher levels of ambivalence (β 01  = 9.92, p < .0001) in the last session. The results suggest that the pattern of client ambivalence towards change is a predictor of premature termination of therapy. Implications for clinical and research contexts are discussed., (© 2021 John Wiley & Sons, Ltd.)

Research emphasizes that individuals' engagement with change process is a significant predictor of therapeutic outcomes. Ambivalence is a natural phenomenon in change processes, but when individuals cannot overcome it, their problems may intensify. Ambivalence towards change, a client variable characterized by an intrapersonal conflict between two positions of the self, one in favour of change and another one in favour of the status quo, is shown to play a determinant role in psychotherapy. Despite its importance, few empirical studies have examined this process, and the considerable methodological differences among existing studies make it difficult to generalize results. Therefore, instruments measuring ambivalence in an effective way can help broaden the understanding of the process. First, we performed a content analysis of ambivalence events identified in psychotherapy sessions from previous studies using an observational coding system. The factor structure, reliability and validity of the measure were tested using 91 and confirmed with 223 psychotherapy clients at any time during the therapeutic process. A two-factor structure was found, suggesting two components of Ambivalence-Demoralization and Wavering. The results indicated that the Ambivalence in Psychotherapy Questionnaire exhibits good psychometric properties, including good convergent and divergent validity. The implications are discussed., (© 2020 John Wiley & Sons, Ltd.)

Previous studies have found an association between therapeutic alliance and treatment outcome, but only recently have researchers begun to analyse time-lagged relationships between session-to-session measures of alliance and outcomes with hierarchical linear modelling (HLM). HLM assumes simple correlation structures between any two measurements from the same client. In this paper, we suggest that this assumption might be problematic. Session-to-session measurements of outcomes (Outcome Questionnaire-10.2) and alliance (Working Alliance Inventory) in a sample (N = 63) were used to perform HLM analyses to test time-lagged (lag +1) relations between outcomes and alliance in both directions. A first set of analyses replicated the models consistently used in the literature, whereas a second set of models considered a correlation structure as a function of time. A correlation independent of time distance resulted in a bidirectional influence between alliance and outcomes (the model commonly used in the literature), but when considering a correlation structure as a function of time, only the outcomes were predictive of alliance. Considering a more complex correlation structure as a function of time seems to be an important analytical strategy for addressing the issue of variability in within-client measurements over time. This study highlights how the misspecification of a statistical model, namely, not considering a time-dependent correlation structure of the response variable, may lead to misleading findings in HLM studies. This is particularly relevant in process-outcome research, such as studies analysing the impact of therapeutic alliance on clinical outcomes., (© 2019 John Wiley & Sons, Ltd.)

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., (© 2018 John Wiley & Sons, Ltd.)

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., (Copyright © 2018 John Wiley & Sons, Ltd.)

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., (Copyright © 2016 John Wiley & Sons, Ltd.)

Unlabelled: Research on the identification of poor outcome predictors is crucial for the prevention of therapeutic failure. Previous research suggests that clients' persistent ambivalence is one possible path to unsuccessful psychotherapy. The present study analyses ambivalence--here operationalized as return-to-the-problem markers (RPMs)--in five recovered and five unchanged cases of narrative psychotherapy for major depression. The results suggest that both recovered and unchanged cases presented a similar proportion of RPMs at baseline and a decreasing pattern of these ambivalence markers throughout therapy. However, the decreasing was more accentuated in recovered than in unchanged cases, and at the end of the treatment, the proportion of RPMs of the unchanged cases was significantly higher. The results are discussed in light of previous research on ambivalence in psychotherapy, focusing on the meaning of ambivalence and its clinical implications., Key Practitioner Message: Ambivalence towards change, here operationalized as RPMs, seems to be a common process in both recovered and unchanged cases, perhaps signalling the uncertainty and anxiety that change may elicit. Although the number of RPMs decreased in both the recovered and unchanged cases, this reduction was significantly higher in the recovered group. Moreover, at the end of therapy, the recovered group revealed a significantly lower proportion of RPMs than the unchanged group, suggesting that ambivalence resolution (or lack thereof) may play a determining role in the therapy's evolution and outcome. RPMs in later stages of therapy may be operationalized as 'red flags' for the therapist to acknowledge the client's stuckness and adapt his or her intervention efforts, turning these instances into developmental opportunities., (Copyright © 2015 John Wiley & Sons, Ltd.)

Results from an earlier clinical trial comparing narrative therapy with cognitive-behavioural therapy (Lopes et al., 2013) suggested that narrative therapy is efficacious for depression. However, there were significant differences in symptom reduction on the Beck Depression Inventory-II, favouring cognitive-behavioural therapy, if dropouts were included in the analysis, suggesting that time to recovery or improvement would differ in both treatments. Contrarily, results showed that treatment assignment was not a predictor for differential effect. Using a survival analytic approach, it was found that four sessions were necessary for 50% improvement and 16 sessions for 50% recovery. Additionally, depressive symptoms changes occurred significantly faster than interpersonal changes, again regardless of treatment assignment. These results support previous findings of the dose-response literature and of the phase model of change, with the advantage of being specific to psychotherapy with depressive clients., (Copyright © 2013 John Wiley & Sons, Ltd.)