Observing and interpreting clinical process: Methods and findings from 'Layered analysis' of parent-infant psychotherapy.

This paper describes a method for investigating clinical process, Layered Analysis, which combines therapist countertransference reports and multi-faceted microanalytic research approaches. Findings from the application of Layered Analysis to video-recorded micro-events of rupture and repair in four psychoanalytic parent-infant psychotherapy sessions are presented. Layered analysis showed that countertransference and observation are complementary perspectives, which enable concomitant study of interactive events, conscious internal experiences, as well as nonconscious and unconscious elements of therapeutic interaction. Interactional rupture and repair were found to constitute co-constructed micro-events that occurred fleetingly and often implicitly, and differed in the structure, coherence and flow of interactions and in the relationship between verbal and nonverbal communication. Furthermore, interactional ruptures were found to sometimes 'get into' the therapist and transiently disrupt their self-organization, such that the therapist became a locus of disruption for the patient(s), actively contributing to the rupture, which thus became embedded in the therapeutic system. Interactive repair was found to be most often initiated by the therapist and to be underpinned by the therapist re-establishing self-regulation, through metabolizing embodied and verbal aspects of the rupture. Studying such processes can enhance our understanding of clinical process, inform therapist training and clinical supervision, and contribute to clinical outcomes.

Este ensayo describe un método para investigar un proceso clínico, Análisis en Capas, el cual combina los reportes de contratransferencia del terapeuta y los acercamientos investigativos micro analíticos multifacéticos. Se presentan los resultados de aplicar Análisis en Capas a micro eventos, grabados en video, de ruptura y reparación en cuatro sesiones de sicoterapia sicoanalítica de progenitor e infante. Los Análisis en capas mostraron que la contratransferencia y la observación son perspectivas complementarias que, en combinación, permiten el estudio concomitante de eventos interactivos, experiencias internas conscientes, así como elementos no conscientes de la interacción terapéutica. Adicionalmente, los resultados mostraron que la ruptura y la reparación constituyen micro eventos co-construidos que ocurren muy fugazmente y a menudo implícitamente, y que difieren en la estructura, coherencia, flujo de interacciones y en la relación entre la comunicación verbal y no verbal. Es más, rupturas interaccionales pueden 'meterse en' el terapeuta y transitoriamente interrumpir su autoorganización, de manera que el terapeuta se convierte en un punto de interrupción para el paciente y la ruptura pasa a ser parte del sistema terapéutico. La reparación interactiva está sostenida por, y depende de, la metabolización del terapeuta de los aspectos incorporados y verbales de la ruptura. Estudiar tales procesos puede mejorar nuestra comprensión del proceso clínico y ser usado en entrenamiento y supervisión de terapeutas.

Cet article décrit une méthode d'investigation du processus clinique d'Analyse Multidimensionnelle en Couches, qui combine des rapports de contre-transfert du thérapeute et des approches de recherche micro-analytique à facettes multiples. Les résultats de l'application de l'analyse multidimensionnelle en couches à des micro-événements enregistrés à la vidéo de rupture et de réparation dans quatre séances de psychothérapie psychanalytiques parent bébé sont présentés. L'analyse multidimensionnelle en couches a montré que le contre-transfert et l'observation sont des perspectives complémentaires qui, combinés l'un avec l'autre, permettent une étude concomitante d'événements interactifs, d'expériences internes conscientes et d'éléments non-conscients de l'interaction thérapeutique. De plus, les résultats ont montré que la rupture et la réparation constituent des micro-événements co-construits, qui se passent très fugacement et souvent implicitement et diffèrent en structure, cohérence et flux des interactions et dans la relation entre la communication verbale et non verbale. Enfin les ruptures interactionnelles peuvent 'entrer' dans le thérapeute et perturber de façon transitoire leur auto-organisation, de telle manière que le thérapeute devient le locus de la perturbation pour le/la/les patient(e/s) et la rupture s'encastre dans le système thérapeutique. La réparation interactive est étayée par, et elle en dépend également, la métabolisation d'aspects verbaux et incarnés de la rupture du thérapeute. L'étude de tels processus peut améliorer notre compréhension du processus clinique et être utilisée dans la formation et la supervision des thérapeutes.

Studying Physiological Synchrony in Couple Therapy through Partial Directed Coherence: Associations with the Therapeutic Alliance and Meaning Construction.

In line with the growing recognition of the role of embodiment, affect and implicit processes in psychotherapy, several recent studies examine the role of physiological synchrony in the process and outcome of psychotherapy. This study aims to introduce Partial Directed Coherence (PDC) as a novel approach to calculating psychophysiological synchrony and examine its potential to contribute to our understanding of the therapy process. The study adopts a single-case, mixed-method design and examines physiological synchrony in one-couple therapy in relation to the therapeutic alliance and a narrative analysis of meaning construction in the sessions. Interpersonal Physiological Synchrony (IPS) was calculated, via a windowed approach, through PDC of a Heart Rate Variability-derived physiological index, which was measured in the third and penultimate sessions. Our mixed-method analysis shows that PDC quantified significant moments of IPS within and across the sessions, modeling the characteristics of interpersonal interaction as well as the effects of therapy on the interactional dynamics. The findings of this study point to the complex interplay between explicit and implicit levels of interaction and the potential contribution of including physiological synchrony in the study of interactional processes in psychotherapy.

Exploring Conversational and Physiological Aspects of Psychotherapy Talk.

This study is part of a larger exploration of 'talk and cure' that combines the examination of talk-in-interaction with nonverbal displays and measurements of the client's and therapist's autonomic arousal during therapy sessions. A key assumption of the study is that psychotherapy entails processes of intersubjective meaning-making that occur across different modalities and take place in both verbal/explicit and nonverbal/implicit domains. A single session of a psychodynamic psychotherapy is analyzed with a focus on the expression and management of affect, with an aim to describe key interactive events that promote change in both semantic and procedural domains. The clinical dialog is analyzed discursively, with a focus on the conversational processes through which new meanings are jointly constructed and affective states shared; detailed attention is paid to nonverbal displays of affiliation and affect. Furthermore, we explore whether the interactional patterns implicated in joint meaning-making, as revealed by analyzing the therapeutic conversation, have correlates in the autonomic arousal of the two protagonists, as reflected in their heart rates. Conversation analysis has still untapped potential to illuminate interactional patterns that underlie the practice of psychotherapy. In this exploratory study we suggest that discursive analyses of talk-in-interaction can be enriched through detailed focus on nonverbal displays as well as measures of physiological arousal. Drawing upon the analysis, we suggest that bringing the methodological strengths of language-based analysis into fertile dialog with embodied quantitative data can help our explorations of what's really going on in psychotherapy.

Studying the process of psychoanalytic parent-infant psychotherapy: Embodied and discursive aspects.

This paper presents findings from an intensive, mixed methods case study of one session of psychoanalytic parent-infant psychotherapy (PPIP) addressing early relational trauma, and aims to shed light on the multimodal interactive processes that take place in the moment-to-moment exchanges comprising the therapeutic encounter. Different research methods were used on video material from PPIP sessions, including microanalysis of adult-infant interactions, discourse analysis of talk, and coding systems developed to study parent-infant interaction. These different perspectives were brought together with the clinical narrative to illuminate the complex, dynamic processes of parent-infant-therapist interaction. More specifically, the detailed analysis of one interactive episode revealed brief behavioral manifestations of fearful and disoriented states of mind, reflecting dysregulated interaction between mother and infant, which also powerfully affected the therapist. The processes through which the therapist gradually resolves this rupture are also described in detail. Through this pilot study, we were able to show that it is possible to systematically study the process of PPIP. The study contributes to the growing psychotherapy research literature that takes into account both the verbal domain and implicit, interactional processes in therapeutic practice, and underscores the therapist's comprehensive engagement in the therapeutic process.

Este ensayo presenta resultados de un intensivo estudio de caso, con métodos mixtos, de una sesión de sicoterapia sicoanalítica de progenitor e infante (PPIP) dirigida al temprano trauma en la relación, y se propone arrojar luz sobre los procesos interactivos multimodales que se llevan a cabo en los intercambios de momento a momento que componen el encuentro terapéutico. Se usaron diferentes métodos de investigación en el material de video de las sesiones de PPIP, incluyendo el micro-análisis de las interacciones adulto-infante, análisis discursivos del habla y sistemas de codificación desarrollados para estudiar la interacción progenitor-infante. Estas diferentes perspectivas se pusieron juntas con la narrativa clínica para dar luz a los complejos, dinámicos procesos de interacción progenitor-infante-terapeuta. Más específicamente, los análisis detallados de un episodio interactivo revelaron breves manifestaciones de conducta de estados mentales de miedo y desorientación, lo cual refleja la interacción desregulada entre la madre y el bebé, lo que también afecta poderosamente al terapeuta. También se describen en detalle los procesos a través de los cuales el terapeuta gradualmente resuelve esta ruptura. Por medio de este estudio piloto, pudimos mostrar que es posible estudiar sistemáticamente el proceso de sicoterapia sicoanalítica de progenitor e infante. El estudio contribuye al creciente cuerpo investigativo sobre sicoterapia que toma en cuenta tanto el dominio verbal como los implícitos procesos interactivos en la práctica terapéutica y subraya la participación comprensiva del terapeuta en el proceso terapéutico. Palabras claves: sicoterapia progenitor-infante, comunicación multimodal, dominio implícito, investigación de procesos, trauma en la relación.

Studying the process of psychoanalytic parent-infant psychotherapy: Embodied and discursive aspects Cet article présente les résultats d'une étude de cas intensive par méthodes mixtes d'une session de psychothérapie psychanalytique parent-bébé adressant un trauma relationnel précoce. Il se donne pour but de mettre en lumière les processus interactifs multimodaux qui prennent place dans les échanges de moment-à-moment que comprend la rencontre thérapeutique. Différentes méthodes de recherches ont utilisé du matériel vidéo de séances PPIP, y compris des micro-analyses des interactions adulte-bébé, une analyse textuelle du dialogue et des systèmes de codage développés afin d'étudier l'interaction parent-bébé. Ces différentes perspectives ont été rassemblées avec la narration clinique afin d'illuminer les processus complexes et dynamiques de l'interaction parent-bébé-thérapeute. Plus particulièrement l'analyse détaillée d'un épisode interactif a révélé de brèves manifestations comportementales d'états d'esprit craintifs et désorientés, reflétant une interaction dys-régulée entre la mère et le bébé, qui ont aussi profondément affecté le thérapeute. Les processus au travers desquels le thérapeute a graduellement résolu cette rupture sont également décrits en détail. A travers cette étude pilote nous avons pu montrer qu'il est possible d'étudier systématiquement le processus de psychothérapie psychanalytique parent-bébé. L'étude contribue aux recherches en psychothérapie qui tiennent en compte à la fois le domaine verbal et implicite et les processus interactionnels dans la pratique thérapeutique, et souligne l'engagement total du thérapeute dans le processus thérapeutique. Mots clés: Psychothérapie parent-bébé, communication multimodale, domaine implicite, recherches processus, trauma relationn.

Shifts in subjectivity during the therapy for psychosis.

OBJECTIVES: This paper examines the process of therapy with families in which a member has a diagnosis of psychosis. On a methodological level, the study aims to demonstrate the usefulness of discourse analysis as a method for analysing texts produced in therapy in the context of process research. On a clinical and theoretical level, it aims to contribute to the literature that approaches psychosis and its treatment from the viewpoint of narrative and discourse. DESIGN: Several contemporary conceptualizations emphasize the role of discursive processes, such as a collapse of meaning and narrative and an alienation from shared communicative practices, in psychosis. Drawing from this perspective, discourse analysis was used on family therapy session transcripts to empirically examine these processes. Moreover, given that in different conceptualizations psychosis is seen to entail a profound disturbance to the person's sense of self, the analysis focuses more specifically on the identified patients' subjectivity. METHODS: Seven sessions were analysed, drawn from the beginning, middle, and end phases of two therapies with families with a member with a diagnosis of psychosis. Discourse analysis was used and the analysis focused on the transformation of meaning and more specifically on shifts in the subject positions occupied by the identified patient in the clinical dialogue. RESULTS: With regards to the identified patients' subjectivity, the analysis suggests that (a) psychosis was associated with the 'patient' being rigidly positioned exclusively through the psychiatric discourse in the first case and the lack of a voice in the second, and (b) that therapeutic change was associated with increased flexibility in the subject positions that the identified patient occupied in the first case and with the emergence of a personal and reflective voice in the second. CONCLUSIONS: The findings in this study suggest that an important aspect in clinical work with families with a member with a diagnosis of psychosis relates to de-centring the dominant, pathology maintaining accounts and to the emergence of a wider range of less problematic explanatory frames.

Narrative research in psychotherapy: a critical review.

PURPOSE: This paper is a review of studies which utilise the notion of narrative to analyse psychotherapy. Its purpose is to systematically present this diverse field of research, to highlight common themes and divergences between different strands and to further the development and integration of narrative research in psychotherapy. METHODS: The paper reviews studies which employ an applied textual analysis of narratives produced in the context of psychotherapy. Criteria for inclusion of studies are, firstly, the analysis of therapeutic and therapy-related texts and, secondly, the adoption of a narrative psychological perspective. The studies were examined on the basis of the notion of narrative they employ and the aspects of client narratives they focus on, and were grouped accordingly in the review. RESULTS: The majority of the studies reviewed assume a constructivist approach to narrative, adopt a representational view of language, focus primarily on client micro-narratives and relate to cognitive-constructivist and process-experiential psychotherapeutic approaches. A smaller group of studies assume a social constructionist approach to narrative and a functional view of language, focus on micro-narratives, highlight the interactional and wider social aspects of narrative and relate to postmodern trends in psychotherapy. CONCLUSIONS: The range of conceptualisations of narrative in the studies reviewed, from a representational psychological view to a constructionist social view, reflects tensions within narrative psychology itself. Moreover, two trends can be discerned in the field reviewed, narrative analysis of therapy, which draws from narrative theory and utilises the analytic approaches of narrative research to study psychotherapy, and analyses of narrative in therapy, which study client narratives using non-narrative qualitative methods. Finally, the paper highlights the need for integration of this diverse field of research and urges for the development of narrative studies of psychotherapy which employ a broader social understanding of narrative production and transformation.

Negotiating a pathological identity in the clinical dialogue: discourse analysis of a family therapy.

Within the framework of social constructionism, psychotherapy has been re-conceptualized as a semiotic process, which consists of the creative generation of new meanings in the context of collaborative discourse. In recent years, research approaches that draw from social constructionism, such as discourse analysis, have been fruitfully employed in the study of psychotherapy processes, whilst being in line with the contemporary emphasis on language, narrative, and meaning making. This paper aims to further the exploration of the usefulness of discourse analysis in the study of psychotherapy processes, and in particular, in situations where the medical discourse is powerfully implicated in the construction of a person's identity. It is based on the analysis of a family therapy with a family whose child has a diagnosis of autism. The analysis focuses on two features of the family's talk, namely shifts in the flexibility of employment of a diverse range of discourses and subject positions, and shifts in the ways agency is constructed and discursively negotiated in the clinical conversations. It is suggested that these shifts can be used as indications of change in the family's network of meanings. The analysis suggests that an important aspect in clinical work with families with a member with a psychiatric diagnosis lies in decentring, or deconstructing, the dominant, pathology-maintaining accounts, and allowing for a wider range of less problematic narratives and subject positions to emerge.