Some functions of narrative in the assimilation of problematic experiences.

We present three current, complementary formulations of the assimilation model: (a) the schema formulation, based on cognitive developmental concepts: (b) the voices formulation, in which assimilation is understood as the construction of a meaning bridge between active internal voices; and (c) the cognitive science formulation, which uses cognitive concepts of memory types to understand the failure of memory in cases of warded-off and avoided experiences. These views of assimilation are used to understand the varied functions that narratives (stories about real or imagined events outside of therapy) may play in psychotherapy, including narratives that avoid encounters with threatening material, narratives that approach such material indirectly or symbolically, narratives by which clients reexperience trauma, and narratives that help construct a mature understanding.

Discovering markers of assimilation stages: the fear-of-losing-control marker.

One way research can discover how to do successful psychotherapy is by intensive examination of the process of psychological change as it occurs within single clients. The assimilation model describes a series of stages through which clients' problematic experiences are hypothesized to progress during successful psychotherapy. Markers of assimilation stages are recognizable types of events in psychotherapy discourse that are linked empirically and theoretically to those stages. Validated markers may be clinically useful signs of clients' progress and current therapeutic requirements, as well as useful tools for research on the assimilation model. We describe how we discovered the "fear-of-losing-control" marker, which signals the emergence of unwanted thoughts, an early stage in the hypothesized sequence. Analysis of examples of the fear-of-losing-of-control marker suggests mechanisms by which client progression may be suspended between warding off and exploration of problematic experiences.

Relations of the alliance with psychotherapy outcome: findings in the Second Sheffield Psychotherapy Project.

Clients (n = 79) and therapists (n = 5) rated their alliance using parallel forms of the Agnew Relationship Measure (ARM) after every session of their time-limited psychodynamic-interpersonal or cognitive-behavioral treatments for depression. The ARM assesses 5 dimensions of the alliance: Bond, Partnership, Confidence, Openness, and Client Initiative. Treatment outcome was assessed as residual gain from pretreatment assessment to end of treatment, 3-month follow-up, and 1-year follow-up on 6 standard measures. Some aspects of the alliance as measured by the ARM were correlated with clients' gains in treatment. The strength of the association varied across assessment measures, occasions of outcome assessment, ARM scales, and the session number when the alliance was measured.

Alliance structure assessed by the Agnew Relationship Measure (ARM).

OBJECTIVES: We used a new instrument, the Agnew Relationship Measure (ARM), to examine the alliance's dimensionality and to construct scales for use in future studies. DESIGN: We studied the alliance as reported on the ARM by both clients and therapists in the Second Sheffield Psychotherapy Project, a randomized comparison of two contrasting time-limited psychotherapies for depression. METHODS: Clients (N = 95) and therapists (N = 5) completed parallel forms of the (ARM) after every session (N = 1120). RESULTS: Five scales were constructed, based on results of simultaneous components analyses and considerations of conceptual coherence and comparability across client and therapist perspectives. CONCLUSIONS: Bond, partnership, and confidence overlapped statistically (consistent with previous studies), but there are conceptual and empirical reasons for retaining the distinctions. Openness represented a relatively independent dimension. The client initiative scale had low internal consistency but the items may have value for future investigations.

Therapist responsiveness to client interpersonal styles during time-limited treatments for depression.

Effective treatment involves therapists responding appropriately to their clients' varying requirements, including clients' predominant interpersonal styles. In 2 manualized time-limited treatments for depression, psychodynamic-interpersonal (PI) and cognitive-behavioral (CB) clients were assigned to 1 of 3 interpersonal style groups. Therapists, who were not told their clients' interpersonal style, nevertheless responded with systematically different interventions depending on clients' interpersonal style. Consistent with predictions, therapists tended to use more affective and relationship-oriented interventions with overinvolved clients, particularly in PI therapy. Therapists tended to use more cognitive treatment methods with underinvolved clients, particularly in CB therapy. Outcomes of the interpersonal style groups were approximately equivalent, consistent with a view that the differences in treatment implementation reflected appropriate responsiveness to clients' interpersonal styles.

Verbal exchange structure of general practice consultations with patients presenting psychological problems.

The consultations of 88 patients presenting with psychological problems to primary care medical practitioners were tape- recorded, coded, and factor- analyzed to identify their constituent verbal exchanges. A verbal exchange is a set of speech act categories that tend to occur together and are used for some subtask within an encounter. The verbal exchange structure of these consultations replicated that of previously studied medical consultations except that they had some distinctive features in common with previously studied psychotherapy sessions. Patient- centered exchanges called Social Exposition and Emotional Exposition, which may serve psychotherapeutic purposes, were relatively prominent in those consultations rated relatively positively by patients and by external raters.

Vamos a Traducir los MRV (let's translate the VRM): linguistic and cultural inferences drawn from translating a verbal coding system from English into Spanish.

Translating a verbal coding system from one language to another can yield unexpected insights into the process of communication in different cultures. This paper describes the problems and understandings we encountered as we translated a verbal response modes (VRM) taxonomy from English into Spanish. Standard translations of text (e.g., psychotherapeutic dialogue) systematically change the form of certain expressions, so supposedly equivalent expressions had different VRM codings in the two languages. Prominent examples of English forms whose translation had different codes in Spanish included tags, question forms, and "let's" expressions. Insofar as participants use such forms to convey nuances of their relationship, standard translations of counseling or psychotherapy sessions or other conversations may systematically misrepresent the relationship between the participants. The differences revealed in translating the VRM system point to subtle but important differences in the degrees of verbal directiveness and inclusion in English versus Spanish, which converge with other observations of differences in individualism and collectivism between Anglo and Hispanic cultures.

Aptitude-treatment interactions based on clients' assimilation of their presenting problems.

Assigning clients to treatments on the basis of their differential aptitudes for those treatments may reduce variability and improve the mean outcomes of psychotherapy. The assimilation model suggests that in time-limited treatments, clients with well-assimilated problems would do better in cognitive or behavioral therapies than in psychodynamic, experiential, or interpersonal therapies, whereas the reverse should be the case for clients with poorly assimilated problems. Results for high-, moderate-, and low-assimilation subgroups (based on rating the level of assimilation of problems presented in the first 20 min of first sessions) of clients (N = 112) randomly assigned to time-limited cognitive-behavioral or psychodynamic-interpersonal treatment supported the first suggestion but not the second (clients with poorly assimilated problems did equally well in both treatments).

Signs and voices: joining a conversation in progress.

This commentary joins a conversation between Ryle and Leiman, which represents a larger conversation among theories of psychotherapy, semiotics and linguistics. The emerging collaborative understanding involves viewing people not as separate, unitary individuals but as mosaics or communities of different voices. The voices share their experiences by sign-mediated communication and engage in joint action. Projective identification may be considered as joint action mediated by non-verbal signs exchanged without awareness, in which the dyad becomes an effector for voices within both participants. The concepts of active voices and meaning-accumulating signs overcome the cognitive fallacy-the misleading notion that information in people is passive.

When more of a good thing is better: reply to Hayes et al. (1996)

More of a good process component is better when clients are not already getting enough. Process components may be in short supply because of limited resources or ignorance, because they are evaluations themselves, or because they are difficult-to-attain subgoals on the way to valued outcomes. Levels of crucially important process components that are not in short supply (including most commonly used therapeutic interventions) are unlikely to be statistical predictors of outcome. Conversely, then, null correlations with outcome do not impugn a component's therapeutic importance. Many of A.M. Hayes, L.G. Castonguay, and M.R. Goldfried's (1996b) examples of positive correlations usefully illustrated clients' cognitive and emotional processes that were treatment subgoals or evaluative indexes. However, by focusing on the (relatively rare) positive correlations, they overlooked the more common null or inconsistent correlations of theoretically important process components with outcome, which are the central topic of the responsiveness critique.

Dose-effect relations in time-limited psychotherapy for depression.

Criteria for reliable and clinically significant improvement were applied to standard and individually tailored outcome measures data from 212 depressed clients who had been randomly assigned to receive either 8 or 16 sessions of time-limiting psychotherapy. The data were used to address 2 questions: (a) Is the dose-effect curve for psychological symptoms negatively accelerated? and (b) is there a differential rate of response for acute, chronic, and characterological/interpersonal components of depression? The results supported the differential rate of response of different components of depression and suggested qualifications to the acute, chronic, and characterological/interpersonal components and evidence that both supported and qualified previous suggestions that the dose-effect curve is negatively accelerated.

Outcomes of time-limited psychotherapy in applied settings: replicating the Second Sheffield Psychotherapy Project.

In a replication and extension of the Second Sheffield Psychotherapy Project (SPP2), a collaborative psychotherapy project (CPP) was carried out at 3 sites within the National Health Service of the United Kingdom. Clients (N = 36) stratified at 3 levels of severity of depression were randomly assigned to one of 2 treatment approaches (psychodynamic-interpersonal or cognitive-behavioral) of 2 time-limited durations (8 or 16 sessions). Gains in both treatment approaches were approximately equivalent and were similar for CPP and SPP2 clients when measured at the end of treatment. However, CPP patients did not maintain their gains to the extent that the SPP2 clients did at 3-month and 1-year follow-up assessments. In the CPP, clients given 16 sessions showed a statistically significant advantage over clients given 8 sessions on some measures at some assessments; in the SPP2, similar effects were noted only among some subgroups of clients.

Acceleration of changes in session impact during contrasting time-limited psychotherapies.

Following the suggestion that therapeutic change is accelerated in time-limited psychotherapy, this study investigated the across-session patterns of session impact in the treatments of 117 depressed clients who were randomly allocated to 8 or 16 sessions of cognitive-behavioral (CB) or psychodynamic-interpersonal (PI) therapy. After each session, all clients completed the Session Evaluation Questionnaire and 75 of the clients completed the Session Impacts Scale. Session ratings indicated that sessions were perceived increasingly positively on most impact dimensions (e.g., session depth and smoothness, relationship with the therapist, feelings of understanding and problem solving, postsession positive mood) as treatment progressed. Early in treatment, PI therapy sessions were less smooth (i.e., more tense and uncomfortable) and less focused on problem solving, but PI sessions changed more rapidly than CB sessions on these dimensions, so that later in treatment, sessions of both treatments were equivalently positive. In both treatments, the trend toward more positive sessions was more rapid (i.e., the across-session slope was steeper) in 8-session treatments than in 16-session treatments. Such accelerated changes in session impact may reflect the suggested acceleration of therapeutic change associated with shorter time limits.

Impact of Cluster C personality disorders on outcomes of contrasting brief psychotherapies for depression.

Twenty-seven of 114 depressed clients, stratified for severity of depression, obtained a Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; American Psychiatric Association, 1980) diagnosis of Cluster C personality disorder--that is, avoidant, obsessive-compulsive or dependent personality disorder (PD clients)--whereas the remaining 87 did not (non-personality-disorder [NPD] clients). All clients completed either 8 or 16 sessions of cognitive-behavioral (CB) or psychodynamic-interpersonal (PI) psychotherapy. On most measures, PD clients began with more severe symptomatology than NPD clients. Among those who received PI therapy, PD clients maintained this difference posttreatment and at 1-year follow-up. Among those who received CB therapy, posttreatment differences between PD and NPD groups were not significant. Treatment length did not influence outcome for PD clients. PD clients whose depression was also relatively severe showed significantly less improvement after treatment than either PD clients with less severe depression or NPD clients.

Credibility and outcome of cognitive-behavioural and psychodynamic-interpersonal psychotherapy.

Depressed psychotherapy clients (N = 117) rated the treatment principle credibility of cognitive-behavioural (CB) and psychodynamic-interpersonal (PI) before they were randomly assigned to receive either eight or 16 sessions of one of these treatments, and they rated their expectations of the treatment to which they were assigned immediately before (initial credibility) and immediately after their first session (emergent credibility). Results indicated that before they were assigned to a treatment, clients rated CB treatment principle credibility higher than PI treatment principle credibility. After assignment, however, clients rated initial credibility similar regardless of whether they were assigned to CB or PI therapy, and their ratings of emergent credibility increased to a similar degree from immediately before to immediately after the first session in both treatments. Clients' endorsement of CB and PI treatment principle credibility predicted improvement in PI therapy but not improvement in CB therapy. Initial and emergent credibility of clients' assigned treatment predicted improvement for clients who received eight sessions of therapy, but not for clients who received 16 sessions of therapy. The implications of these findings are discussed.

Therapist contributions to psychotherapeutic assimilation: an alternative to the drug metaphor.

A psychotherapist's verbal interventions may be understood as promoting a client's eventual improvement by facilitating developmental change processes within the client. This approach is an alternative to the traditional search for statistical links between aggregates of therapist interventions and global outcome measures. Our approach employs models of clients' assimilation of problematic experiences within problem domains and therapists' implementation of theoretically specified aims. In an empirical illustration, one client's change within a particular problem domain and its links with therapist interventions were assessed qualitatively across the course of brief psychodynamic-interpersonal treatment.

Verbal exchange structure of brief psychodynamic-interpersonal and cognitive-behavioral psychotherapy.

A verbal exchange is a set of 2 people's co-occurring speech-act categories that accomplish some subtask within an interpersonal encounter. Factor analysis of verbal response mode (speech act) frequencies in 1,630 segments (each approximately 10 to 12 min) drawn from the brief psychodynamic-interpersonal or cognitive-behavioral treatment of 39 mainly depressed clients identified 6 exchanges in each treatment--4 that were the same in both treatments (Revealing, Storytelling, Explaining, and Inquiring) and 2 that distinguished each treatment (Exploring and Interpreting in psychodynamic-interpersonal treatment; Prescribing and Reframing in cognitive-behavioral treatment). The exchanges showed distinctive temporal patterns across segments of sessions and across sessions of each time-limited treatment. The verbal exchange is a midsize concept that links atomistic verbal codes with clinical or theoretical concepts.