"If those tears could talk, what would they say?" Multi-method analysis of a corrective experience in brief dynamic therapy

Beyond treatment modalities: Clinical decisions and relational dynamics that facilitate change in group treatments

This commentary on six articles comprising this Journal of Clinical Psychology: In Session issue on the therapeutic process in group psychotherapy brings together relevant clinical challenges and opportunities concerning the unique processes of change in group treatments. As illustrated by these six inspiring group therapy cases, therapy groups may vary widely in content and context. To balance the rich clinical illustrations of successful group treatments and the different theoretical formulations offered in these case studies, we highlight the processes that these treatments appear to have in common. Specifically, we describe the clinical considerations about the group format and the group members. We also reflect on the relational dynamics as they play out within the complex interplay between group leaders and group members; the facilitation of the corrective emotional experience as a change mechanism in group therapy, as well as the relational challenges and opportunities inherent in group treatments more generally. It is hoped that in this issue, clinicians will not only be inspired by the clinical description of successful change processes in group treatments but will also be reminded of the therapeutic nuances and opportunities of this multilayered treatment format.

Measuring Perceptions of the Therapeutic Alliance in Individual, Family, and Group Therapy from a Systemic Perspective: Structural Validity of the SOFTA-s

This study examined the multidimensional structure of the client and therapist versions of the self-report measure, System for Observing Family Therapy Alliances (SOFTA-s; Friedlander, Escudero, & Heatherington, Therapeutic alliances in couple and family therapy: An empirically informed guide to practice. Washington, DC: American Psychological Association, 2006) across three distinct therapeutic modalities (individual, family, group). Specifically, we investigated whether the originally theorized model of four first-order factors (Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System, and Shared Sense of Purpose within the Family) would be reflected in a second-order factor (Therapeutic Alliance). The sample included 105 therapists who worked with 858 clients (165 individuals, 233 families, and 43 groups) in several Spanish community agencies. To control for dependent data, we used multilevel modeling. Results of the multilevel confirmatory factor analyses showed adequate reliabilities, fit indices, and factor loadings across the three therapy contexts for both versions of the measure (client and therapist). Adequate measurement invariance was also found across respondents and therapy modalities. Taken together, these results support the structural validity of the SOFTA-s, a brief and flexible self-report alliance measure that can be used reliably in clinical practice as well as in studies of individual, family, and group therapy.

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.

A close look at therapist contributions to narrative-emotion shifting in a case illustration of brief dynamic therapy

Objective: In a secondary analysis of Friedlander et al.'s [(2018). "If those tears could talk, what would they say?" multi-method analysis of a corrective experience in brief dynamic therapy. Psychotherapy Research, 28, 217-234. doi:10.1080/10503307.2016.1184350] case study of Hanna Levenson's Brief Dynamic Therapy over Time (from APA's Psychotherapy in Six Sessions DVD series), we re-visited the Narrative-Emotion Process Coding (Angus, L. E., Boritz, T., Bryntwick, E., Carpenter, N., Macaulay, C., & Khattra, J. (2017). The Narrative-Emotion Process Coding System 2.0: A multi-methodological approach to identifying and assessing narrative-emotion process markers in psychotherapy. Psychotherapy Research, 27, 253-269. doi:10.1080/10503307.2016.1238525) to identify specific therapist behaviors that may have facilitated the client's movement from expressing mostly Problem markers in early sessions to expressing considerably more Transition and Change markers in later sessions. Method: Using open coding and constant comparison qualitative methods, we identified Levenson's behaviors immediately preceding the client's "change shifts" (Problem → Transition/Change and Transition → Change) and "problem shifts" (Transition/Change → Problem). Results: Compared to problem shifts, change shifts were preceded by more therapist behavior reflecting Attaching New Meaning (e.g., linking the client's self-deprecation to her avoidant behavior) and Exploring/Expanding emotions (e.g., inviting the client to give voice to her tears), cognitions (e.g., pointing out the client's self-talk) and motivation (e.g., reflecting on the client's dissatisfaction with her defenses). Conclusions: In this successful case, facilitative therapist behavior reflected common therapeutic responses (e.g., validating the client's perspective) as well as responses characteristic of brief dynamic therapy (e.g., interpreting the client's defenses) and the therapist's personal style (e.g., repeating the client's words for emphasis).

The Narrative-Emotion Process Coding System 2.0: A multi-methodological approach to identifying and assessing narrative-emotion process markers in psychotherapy

OBJECTIVE

Recent studies suggest that it is not simply the expression of emotion or emotional arousal in session that is important, but rather it is the reflective processing of emergent, adaptive emotions, arising in the context of personal storytelling and/or Emotion-Focused Therapy (EFT) interventions, that is associated with change.

METHOD

To enhance narrative-emotion integration specifically in EFT, Angus and Greenberg originally identified a set of eight clinically derived narrative-emotion integration markers were originally identified for the implementation of process-guiding therapeutic responses. Further evaluation and testing by the Angus Narrative-Emotion Marker Lab resulted in the identification of 10 empirically validated Narrative-Emotion Process (N-EP) markers that are included in the Narrative-Emotion Process Coding System Version 2.0 (NEPCS 2.0).

RESULTS

Based on empirical research findings, individual markers are clustered into Problem (e.g., stuckness in repetitive story patterns, over-controlled or dysregulated emotion, lack of reflectivity), Transition (e.g., reflective, access to adaptive emotions and new emotional plotlines, heightened narrative and emotion integration), and Change (e.g., new story outcomes and self-narrative discovery, and co-construction and re-conceptualization) subgroups. To date, research using the NEPCS 2.0 has investigated the proportion and pattern of narrative-emotion markers in Emotion-Focused, Client-Centered, and Cognitive Therapy for Major Depression, Motivational Interviewing plus Cognitive Behavioral Therapy for Generalized Anxiety Disorder, and EFT for Complex Trauma. Results have consistently identified significantly higher proportions of N-EP Transition and Change markers, and productive shifts, in mid- and late phase sessions, for clients who achieved recovery by treatment termination.

CONCLUSIONS

Recovery is consistently associated with client storytelling that is emotionally engaged, reflective, and evidencing new story outcomes and self-narrative change. Implications for future research, practice and training are discussed.