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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.

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.

Objective : This theory-building case study investigated setbacks in assimilation, seeking to replicate and elaborate previous work, in which most setbacks were one of two types, balance strategy (BS) or exceeding the therapeutic zone of proximal development (TZPD). Method : We studied the case of Alicia, a 26 year-old woman, treated successfully for depression. Her main problematic experiences were rated with the Assimilation of Problematic Experiences Scale (APES), and 267 setbacks were identified. We classified the setbacks and examined them quantitatively and qualitatively. Results : Alicia showed the usual irregular progress of assimilation, with generally increasing APES ratings, consistent with the improvements in outcome measures. Almost all setbacks could be distinguished as BS or TZPD. Replicating a previously observed pattern, BS setback passages tended to be at or above APES stage 3, whereas TZPD setback passages tended to be below APES stage 3. BS and TZPD setbacks also drew qualitatively different characterizations. Conclusion : Results represented a conceptual replication of previous work, explainable using the same theoretical tenets. As an integral part of therapeutic work, setbacks do not impede progress in therapy. BS and TZPD setbacks reflect different processes and have different implications for how therapist and client are working together.

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.

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.

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.

Objective: This study examined the therapist activities immediately preceding assimilation setbacks in the treatment of a good-outcome client treated with linguistic therapy of evaluation (LTE)., Method: Setbacks (N = 105) were defined as decreases of one or more assimilation stages from one passage to the next dealing with the same theme. The therapist activities immediately preceding those setbacks were classified using two kinds of codes: (a) therapist interventions and (b) positions the therapist took toward the client's internal voices., Results: Preceding setbacks to early assimilation stages, where the problem was unformulated, the therapist was more often actively listening, and the setbacks were more often attributable to pushing a theme beyond the client's working zone. Preceding setbacks to later assimilation stages, where the problem was at least formulated, the therapist was more likely to be directing clients to consider alternatives, following the LTE agenda, and setbacks were more often attributable to the client following these directives shifting attention to less assimilated (but nevertheless formulated) aspects of the problem., Conclusions: At least in this case, setbacks followed systematically different therapist activities depending on the problem's stage of assimilation. Possible implications for the assimilation model's account of setbacks and for practice are discussed.

This article introduces a Special Section of case studies that focus on therapeutic collaboration and setbacks in the process of assimilation with the aim of contributing to the evolution of the assimilation model of therapeutic change. The first study examined setbacks in two depression cases (a good vs. a poor outcome) treated with emotion-focused therapy. The second article traced how therapist activities and positions toward internal voices were associated with setbacks in a case treated with linguistic therapy of evaluation. The third article studied contributions of therapeutic collaboration for both advances and setbacks in assimilation in two contrasting cases treated with emotion-focused therapy. The fourth and final article analyzed the therapeutic collaboration in episodes of ambivalence in two cases of narrative therapy (one good outcome, one poor outcome) reflecting on the implications for the assimilation model's perspective on the therapeutic relationship. This Introduction concludes by offering some suggestions for theory-building within the assimilation model.

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.

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.

Objective: Our aim was to examine client mood in the initial and final sessions of cognitive-behavioral therapy (CBT) and psychodynamic-interpersonal therapy (PIT) and to determine how client mood is related to therapy outcomes., Methods: Hierarchical linear modeling was applied to data from a clinical trial comparing CBT with PIT. In this trial, client mood was assessed before and after sessions with the Session Evaluation Questionnaire-Positivity Subscale (SEQ-P)., Results: In the initial sessions, CBT clients had higher pre-session and post-session SEQ-P ratings and greater pre-to-post session mood change than did clients in PIT. In the final sessions, these pre, post, and change scores were generally equivalent across CBT and PIT. CBT outcome was predicted by pre- and post-session SEQ-P ratings from both the initial sessions and the final sessions of CBT. However, PIT outcome was predicted by pre- and post-session SEQ-P ratings from the final sessions only. Pre-to-post session mood change was unrelated to outcome in both treatments., Conclusions: These results suggest different change processes are at work in CBT and PIT.

On the occasion of the 25th anniversary of the journal, Psychotherapy research, three former editors first look back at: (i) the controversial persistence of the Dodo verdict (i.e., the observation that all bona fide therapies seem equally effective); (ii) the connection between process and outcome; (iii) the move toward methodological pluralism; and (iv) the politicization of the field around evidence-based practice and treatment guidelines. We then look forward to the next 25 years, suggesting that it would be promising to focus on three areas: (i) systematic theory-building research; (ii) renewed attention to fine-grained study of therapist techniques; and (iii) politically expedient research on the outcomes of marginalized or emerging therapies.

Objective: Ambivalence can be understood as a cyclical movement between an emerging narrative novelty-an Innovative Moment (IM)-and a return to a problematically dominant self-narrative. The return implies that the IM, with its potential for change is devalued right after its emergence. Our goal is to test the hypothesis that the probability of the client expressing such form of ambivalence decreases across treatment in good-outcome cases but not in poor-outcome cases., Method: Return-to-the-Problem Markers (RPMs) signaling moments of devaluation of IMs were coded in passages containing IMs in six clients with major depression treated with emotion-focused therapy: three good-outcome cases and three poor-outcome cases., Results: The percentage of IMs with RPMs decreased across therapy in good-outcome cases, whereas it remained unchanged and high in the poor-outcome cases., Conclusions: These results were consistent with the theoretical suggestion that therapeutic failure may be associated with this form of ambivalence.

The Assimilation of Problematic Experiences Scale (APES) and the Innovative Moments Coding System were applied to transcripts of a successful case of linguistic therapy of evaluation independently by different research groups. Assimilation theory and research suggest that higher APES scores reflect therapeutic gains, with a level of approximately 4.0 separating good from poor outcome cases. The innovative moments (IMs) model suggests that IMs classified as reconceptualization and performing change occur mainly in good outcome cases, whereas action, reflection and protest occur in both good and poor outcome cases. Passages coded as reconceptualization and performing change were rare in this case, but 100% of them were rated at or above APES 4. By contrast, 63% passages coded as action, reflection or protest were rated below APES 4 (Chi-square = 28.62, p < .001). Implications for research are discussed.

Objectives: We understand ambivalence as a cyclical movement between two opposing parts of the self. The emergence of a novel part produces an innovative moment, challenging the current maladaptive self-narrative. However, the novel part is subsequently attenuated by a return to the maladaptive self-narrative. This study focused on the analysis of the therapeutic collaboration in episodes in which a relatively poor-outcome client in narrative therapy expressed ambivalence., Method: For our analysis we used the Therapeutic Collaboration Coding System, developed to assess whether and how the therapeutic dyad is working within the therapeutic zone of proximal development (TZPD)., Results: Results showed that when the therapist challenged the client after the emergence of ambivalence, the client tended to invalidate (reject or ignore) the therapist's intervention., Conclusions: This suggests that in such ambivalence episodes the therapist did not match the client's developmental level, and by working outside the TZPD unintentionally contributed to the maintaining the client's ambivalence.

Abstract This study examined a client's therapeutic progress within one session of an 18-session child neurological assessment. The analysis focused on a parent-psychologist dialogue in one session of the assessment process. Dialogical sequence analysis (DSA; Leiman, 2004, 2012) was used as a micro-analytic method to examine the developing discourse. The analysis traced the mother's developing of a reflective stance toward herself and her problematic ways of interacting with her daughter, who was the client. During the dialogue, the mother began to recognize her own contribution in maintaining the problematic pattern. Her gradual acknowledgment of the child's perspective and her growing sense of the child's otherness were mediated by an observer position (third-person view) toward the problematic pattern, which allowed a flexible exchange between the perspectives of self and the other. The results demonstrate the parallel development of intrapersonal and interpersonal empathy shown previously to characterize the transition from stage 3 (problem statement/clarification) to stage 4 (understanding/insight) in the assimilation of problematic experiences sequence (Brinegar, Salvi, Stiles, & Greenberg, 2006).

The assimilation model suggests progress in psychotherapy follows an eight-stage sequence described by the Assimilation of Problematic Experiences Scale (APES). This study sought to reconcile this developmental stage model with the common but superficially contradictory clinical observation that therapeutic advances alternate with setbacks. Setbacks (n=466) were identified in therapy transcripts of two clients and classified using a preliminary nine-category list of possible alternative reasons for setbacks. Most of the setbacks involved switches among the multiple strands of a problem due to (a) therapists exceeding clients' therapeutic zone of proximal development, (b) therapists guiding clients to shift toward relatively problematic material (balance metaphor), or (c) spontaneous switches. Rather than contradicting the theory, this close examination of setbacks yielded elaborations of it.

This study compared participants' speech acts in low-hostile versus moderate-hostile interpersonal episodes in time-limited psychodynamic psychotherapy. Sixty-two cases from the Vanderbilt II psychotherapy project were categorized as low or moderate in interpersonal hostility based on ratings of interpersonal process using Structural Analysis of Social Behavior (Benjamin, 1996). Representative episodes were coded using a taxonomy of speech acts (Stiles, 1992), and speech acts were compared across low- and moderate-hostile episodes. Therapists in moderate-hostility episodes used more interpretations and edifications, and fewer questions and reflections. Patients in moderate-hostility episodes used more disclosures and fewer edifications. Content coding showed that therapist interpretations with a self/intrapsychic self focus were more characteristic of moderate-hostility than low-hostility episodes, whereas the two types of episodes contained similar levels of interpretations focused on the patient's interpersonal relationships and the therapeutic relationship.

This article reports the development and psychometric properties of two short forms of the 28-item Agnew Relationship Measure, the ARM-12 and ARM-5. For the ARM-12, results of previous research were used together with conceptual considerations to select three items to represent each of four ARM subscales: Bond, Partnership, Confidence, and Openness. For the ARM-5, item-analytic principles were used to select five items to represent overall alliance. In all three ARMs, client and therapist versions were constructed to contain parallel items. We drew data to assess reliability and validity from three UK trials of brief therapy for depression. Results indicated that the two short ARMs have acceptable psychometric properties and that they converged with each other and with the full ARM.

Child neurological diagnostic procedures involve extensive encounters with a multi-professional team and may have therapeutic effects. This study explored the therapeutic potential of the diagnostic process using the assimilation model as the conceptual frame of reference. The process of assimilation was tracked across nine consecutive encounters during the assessment of a 4-year-old girl who was referred to the child neurological team due to contact and communication problems. All parent-professional dialogues were transcribed and analyzed using dialogical sequence analysis, which yielded a core problematic reciprocal pattern that was named "controlling in relation to defiant and uncontrolled." Parent development in finding alternative patterns to excessive control was traced using the assimilation model. We could identify assimilation stages in parent development, from disowning the impact of their own actions and mainly seeing the problem as belonging to the child into a more flexible and self-related understanding of the problem. The parents also described more accommodating ways of managing the child at the follow-up. Benefits and limitations in applying the assimilation model in a non-therapy context are discussed.

The assimilation model is a theory of psychological change that depicts the self as a community of internal voices, composed of traces of the person's experiences. The model suggests that disconnection of certain voices from the community underlies many forms of psychopathology and psychological distress. Such problematic voices may be assimilated through psychotherapeutic dialogue by building meaning bridges. Meaning bridges are signs (e.g., words, images, gestures, narratives) that have similar meaning to author and addressee, that is, to the signs' producer and recipient, which may be different people or interacting internal voices. Building meaning bridges is thus a process of coming to terms with problematic voices, which reduces distress and gives access to experiential resources within the self. This article describes and illustrates meaning bridges, voices, signs, and associated concepts as elaborated in a program of research on the assimilation model.

According to the author's narrative model of change, clients may maintain a problematic self-stability across therapy, leading to therapeutic failure, by a mutual in-feeding process, which involves a cyclical movement between two opposing parts of the self. During innovative moments (IMs) in the therapy dialogue, clients' dominant self-narrative is interrupted by exceptions to that self-narrative, but subsequently the dominant self-narrative returns. The authors identified return-to-the-problem markers (RPMs), which are empirical indicators of the mutual in-feeding process, in passages containing IMs in 10 cases of narrative therapy (five good-outcome cases and five poor-outcome cases) with females who were victims of intimate violence. The poor-outcome group had a significantly higher percentage of IMs with RPMs than the good-outcome group. The results suggest that therapeutic failures may reflect a systematic return to a dominant self-narrative after the emergence of novelties (IMs).

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.

This study aims to further the understanding of how innovative moments (IMs), which are exceptions to a client's problematic self-narrative in the therapy dialogue, progress to the construction of a new self-narrative, leading to successful psychotherapy. The authors' research strategy involved tracking IMs, and the themes expressed therein (or protonarratives), and analysing the dynamic relation between IMs and protonarratives within and across sessions using state space grids in a good-outcome case of constructivist psychotherapy. The concept of protonarrative helped explain how IMs transform a problematic self-narrative into a new, more flexible, self-narrative. The increased flexibility of the new self-narrative was manifested as an increase in the diversity of IM types and of protonarratives. Results suggest that new self-narratives may develop through the elaboration of protonarratives present in IMs, yielding an organizing framework that is more flexible than the problematic self-narrative.

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.

This study examines Lisa, a successful case of emotion-focused therapy, using the assimilation model as a lens to view and understand her changes. The assimilation model construes problems as voices, or parts of the self, that are unwanted and kept separate from other voices in the community that constitute the self. Progress in therapy, then, is construed as increasing the assimilation or integration of problematic voices into the community. Lisa made significant progress assimilating two distinct but related voices, described as movement through the Assimilation of Problematic Experiences Sequence. In the course of the analysis, the case of Lisa also informed the assimilation model by raising issues concerning the interrelatedness of problems and the dynamic nature of assimilation in the context of a multivoiced self.