Conceptualisation and Measurement of Reflective Process in Psychotherapy: A Systematic Scoping Review

Psychological therapies use talk as a means to produce change for individuals who are experiencing distress. Despite a significant body of research comparing approaches, there is little evidence for the superiority of one model over another. The process of reflection has been suggested as a common factor across modalities, and research aiming to measure this phenomenon is emerging. This scoping review is focussed on the conceptualisations, measurement and process outcomes of reflective talk as it occurs during therapy. Twenty-two studies were selected from a total of 3712 papers identified following a systematic search of SCOPUS, MEDLINE, PsychINFO and Web of Science databases. A variety of descriptors emerged: intrapersonal constructs such as mentalization and metacognition tended to view reflectivity as an individually acquired skill or trait, where other descriptors adopted an interpersonal understanding of reflection as co-constructed through dialogue. Our findings suggest a shift from individual to intersubjective understandings of reflecting processes in therapy may be a valuable area for future research.

"You helped me out of that darkness" Children as dialogical partners in the collaborative post-family therapy research interview

Applying Dialogical Methods for Investigations of Happening of Change (DIHC), this study investigated how children who had been diagnosed with an oppositional defiant or conduct disorder participated in a collaborative post-therapy research interview and talked about their experiences of family therapy. The results showed that the children participated as dialogical partners talking in genuine, emotional, and reflective ways. Encountered as full-membership partners, the children also co-constructed meanings for their sensitive experiences. However, their verbal initiatives and responses appeared in very brief moments and could easily have been missed. The collaborative post-therapy interview offered a safe forum for co-reflection by participants on what they had found useful or difficult in the family therapy process. In this interview setting, the family first listens to reflection by the therapists on the therapy process and their thoughts on some of the family's related sensitive issues. The results indicate that when therapists present themselves as not-knowing, receptive and accountable, therapists may facilitate reflection for all family members, including children.

A Review of Empirical Studies Investigating Narrative, Emotion and Meaning-Making Modes and Client Process Markers in Psychotherapy

Despite the importance of narrative, emotional and meaning-making processes in psychotherapy, there has been no review of studies using the main instruments developed to address these processes. The objective is to review the studies about client narrative and narrative-emotional processes in psychotherapy that used the Narrative Process Coding System or the Narrative-Emotion Process Coding System (1.0 and 2.0). To identify the studies, we searched The Book Collection, PsycINFO, PsycARTICLES, PsycBOOKS, PEP Archive, Psychology and Behavioral Sciences Collection, Academic Search Complete and the Web of Knowledge databases. We found 27 empirical studies using one of the three coding systems. The studies applied the Narrative Process Coding System and the Narrative-Emotion Process Coding System to different therapeutic modalities and patients with various clinical disorders. In some studies, early, middle and late phases of therapy were compared, while other studies conducted intensive case analyses of Narrative Process Coding System and Narrative-Emotion Process Coding System patterns comparing recovered vs unchanged clients. The review supports the importance to look for the contribution of narrative, emotion, meaning-making patterns or narrative-emotion markers, to treatment outcomes and encourages the application of these instruments in process-outcome research in psychotherapy.

Therapeutic conversations: Therapists' use of observational language contributes to optimal therapeutic outcomes

OBJECTIVE

Reflexivity is the process of critically examining one's own experience. Emerging literature suggests that reflexivity is a positive predictor of outcomes in psychotherapy. However, limited research has been conducted regarding therapists' use of reflexivity as a therapeutic technique. In particular, we have a limited understanding of how therapists use language to initiate reflexive conversations. This study investigates the characteristics of therapist language that elicit reflexivity focused on internal and external processes.

DESIGN AND METHODS

Therapeutic outcomes of 42 trainee-therapists who provided psychotherapy to 173 clients were tracked with the OQ-45.2 with the view of identifying client-trainee-therapist dyads (CTTDs) with the best and poorest outcomes. Six best outcome and six poorest outcome CTTDs were identified. Thirty-six therapy transcripts were initially coded with the Narrative Process Coding System to identify each Narrative Process Mode (NPM). Sixty external, internal, and reflexive NPMs (N = 180 NPMs) were randomly selected across all therapy transcripts for the best outcome group and the same number for the poorest outcome group. The Narrative Initiating Language Element Coding Manual, developed for this study, was used to code therapists' use of language to initiate each NPM.

RESULTS

Therapists belonging to the best outcome group utilized more observational language to initiate internal and reflexive NPMs. Therapists belonging to the poorest outcome group evidenced high proportions of questioning language to elicit each NPM.

CONCLUSIONS

Examining how therapists use language to elicit NPMs provides further insight as to how therapeutic language may contribute to successful therapeutic outcomes.

PRACTITIONER POINTS

Reflexive therapeutic conversations characterized by a greater use of observational language were associated with positive therapeutic outcomes. Therapeutic conversations characterized by a high proportion of questioning language were associated with poorer therapeutic outcomes. Supervisors of trainee-therapists have a key role in coaching supervisees to use language that contributes to client treatment outcomes.

Positioning microanalysis: studying the self through the exploration of dialogical processes

Self-multiplicity is a widely recognized phenomenon within psychology. The study of how self-continuity emerges amidst self-multiplicity remains a crucial issue, however. Dialogical approaches are widely viewed as suitable for developing this field of study but they demand coherent methods compatible with their theoretical bases. After reviewing the available methods for the study of the dialogical self, as well as other dialogical methods for the study of psychotherapy, we conclude that we still lack a method which can be used by external observers and is devoted to the systematic tracing of the dialogical dynamics of self-positions as they unfold over time. A new method, positioning microanalysis, is described in detail as a possible way to overcome current limitations in methods focused on the dialogicality inherent in selfhood processes. Positioning microanalysis takes a genetic-developmental perspective on dialogical processes in the self and allows for the depiction of microgenetic movements of self-positions over time and the establishment of more or less stable sequences or patterns of positions. This is illustrated by its application to an emotion-focused therapy session.

Making sense of multi-actor dialogues in family therapy and network meetings

In recent years, a number of family therapists have conceptualized psychotherapy as a dialogical activity. This view presents family therapy researchers with specific challenges, the most important of which is to find ways of dealing with the dialogical qualities of the multi-actor dialogues that occur, for example, in family therapeutic conversations. In this article, we propose some preliminary ideas concerning qualitative investigations of multi-actor dialogues. Our aim is to work toward an integration of Bakhtin's theoretical concepts with good practices in qualitative research (e.g., dialogical tools and concepts of a narrative processes coding system) in order to make sense of family therapy dialogues. A specific method that we have called Dialogical Methods for Investigations of Happening of Change is described. This method allows for a general categorization of the qualities of responsive dialogues in a single session, and also for a detailed focus on particular sequences through a microanalysis of specific topical episodes. The particular focus is on the voices present in the utterances, the positioning of each speaker, and the addressees of the utterances. The method is illustrated via an analysis of a couple therapy session with a depressed woman and her husband.