Innovative moments in psychotherapy: From narrative outputs to dialogical processes

1. Innovative moments in psychotherapy: From narrative outputs to dialogical processes 7th Conference on Dialogical Self, Athens, USA, 2012 Miguel M. Gonçalves (University of Minho, Portugal)

2. Psychotherapy and meaning Change in psychotherapy Symptoms Meanings Aim of psychotherapy Change in the assumptions that lead the client to demoralization (Frank, 1961)

3. “Effective psychotherapies combat demoralization by persuading patients to transform these pathogenic meanings to ones that rekindle hope, enhance mastery, heighten self-esteem, and reintegrate patients with their groups.” Frank (1961, p. 52)

4. Meaning and narratives Pathogenic meanings Central beliefs, maladaptive schemas, emotional schemas, object representations, incongruent self-schemas, unassimilated experiences, and so on Meaning and narrative organization Problematic self-narratives

5. Problematic self-narratives Implicit rules of meaning that are maladaptive e.g. always privileging others’ opinions and neglect my own These rules constraint the meaning-making processes, with a wide impact Actions, emotions, relationships, and so on

6. Problematic self-narratives Implicit rules create a pattern of meaning From a DS perspective few I-positions dominate the self Other positions are silenced or invisible The multivocalityof the self (Hermans) is highly reduced

7. Transformation of problematic 
self-narratives Alternative meanings are more flexible, restoring the multivocality of the self Transformation of problematic self-narratives Emergence of exceptions towards the rules That is, innovative moments (IMs)

8. One example One rule of the problematic self-narrative Resentment and difficulty expressing own feelings “That is why I don’t tell my husband what I feel inside… and even if I said he would probably laugh” One exception, that is, an innovative moment (IM) could be “But my feelings are my feelings and I’m entitled to them”

9. Transformation of problematic self-narratives Emergence of innovative moments (IMs) New or dominated I-positions come to the foreground The emergence of different I-positions create the possibility for the transformation of the previous problematic self-narratives

10. Transformation of problematic self-narratives The emergence of innovative moments along therapy (e.g. their diversity) as well their pattern of emergence, facilitate the transformation of the previous rules of meaning-making

11. Innovative moments (IMs) Occur in several forms as actions, thoughts, feelings, projects… They are defined as exceptions to the rule Each narrative (problematic of innovative) has its own narrator (I-position)

12. Innovative Moments Research Study the therapeutic change processes All the therapeutic sessions are coded with the InnovativeMomentsCodingSystem Several samples of brief therapy and several intensive cases studies. Usually we contrast good with poor outcome cases

13. Innovative Moments Coding System Dimensions of analysis Salience Length of each innovative moment in the conversation, related to the total amount of the session Type Action, reflection, protest, reconceptualization, and performing change

14. Action IMs • Actions or specific behaviors that challenge the problematic self-narrative • Clinical vignette (problematic self-narrative: depression) • Client: Yesterday, I went to the cinema for the first time in months!

15. Reflection IMs • Thoughts, feelings, intentions, projects or other cognitive products that are not akin to the problematic self-narrative • C: I’m starting to wonder about what my life will be like if I keep feeding my depression. • T: It’s becoming clear that depression has a hidden agenda for your life? • C: Yes, sure. • T: What is it that depression wants from you? • C: It wants to rule my whole life, and in the end it wants to steal my life from me.

16. Protest IMs Entail new behaviours (like action IMs) and/or thoughts (like reflection IMs) that challenge the problematic self-narrative, representing a refusal of its assumptions. Client: I am an adult and I am responsible for my life, and, and, I want to acknowledge these feelings and I’m going to let them out! I want to experience life, I want to grow and it feels good to be in charge of my own life.

17. Reconceptualization IMs • Involves a process description, at a meta-cognitive level • The client not only manifests thoughts and behaviours outside the domain of the problematic self-narrative, but also understands the processes that are involved in it

18. Reconceptualization IMs • There are two ingredients in these IMs • Contrast between problematic self-narrative and an alternative one • Some access to the process that allowed this transformation

19. Reconceptualization IMs Client: You know… when I was there at the museum, I thought to myself: you really are different… A year ago you wouldn’t be able to go to the supermarket! Ever since I started going out, I started feeling less depressed… it is also related to our conversations and changing jobs… Therapist: How did you have this idea of going to the museum? Client: I called my dad and told him: we’re going out today! Therapist: This is new, isn’t it? Client: Yes, it’s like I tell you… I sense that I’m different…

20. Performing Change IMs • References to new aims, experiences, activities or projects, as consequence of change Therapist: You seem to have so many projects for the future now! Client: Yes, you’re right. I want to do all the things that were impossible for me to do while I was dominated by sadness. I want to work again and to have the time to enjoy my life with my children. I want to have friends again, to have people to talk to, to share experiences and to feel the complicity in my life again.

21. An example of our typical results Good outcome cases Poor outcome cases

22. Reconceptualization in good outcome (GO) cases and poor outcome (PO) cases

23. Performing change in GO cases

24. Global picture of GO cases There is a progressive tendency in the salience of Ims Action, reflection and protest have a higher salience at the beginning of psychotherapy Reconceptualization tends to emerge at the middle of therapy and increases until the end Reconceptualization seems to be central in good outcome cases Performing changetends to emerge after reconceptualization

25. An heuristic model of GO cases Action IMs Reflection IMs Protest IMs Reconceptualization IMs Performing change IMs New Emergent Self Narrative Former problematic narrative New Action IMs New Reflection IMs New Protest IMs Therapy evolution

26. Global picture of PO cases The average salience of IMs is lower than in GO cases Action, reflection and protest IMs occur without a clear progressive tendency throughout therapy Reconceptualization and performing changes are absent or have a very low salience

27. An heuristic model of PO cases Action IMs Reflection IMs Protest IMs Emergent Self Narrative Problematic self-narrative Problematic self-narrative Absence of reconceptualization Time

28. Two main questions relevant to DS theory Which processes block the development of innovative moments from the middle of the therapy, particularly the emergence of reconceptualization? Why is reconceptualization so central to the change process?

29. 1. Innovative moments and PO therapy Good and poor outcome therapies have very similar trajectories in the emergence of IMs at the beginning They start to become different in the middle phase of therapy In GO cases There is an increase in the salience of IMs Reconceptualization and performing change emerge and become dominant by the end of therapy

30. Interesting question Which processes are responsible for the differences between good and poor outcome cases in the middle phase of therapy?

31. IMs and unsuccessful therapy As IMs are associated with new or dominated voices, their emergence challenges the dominant perspective of the client The emergence of novelties threats clients’ sense of (problematic) stability To re-establish the sense of stability the innovation potential may be attenuated, and the usual sense of self reaffirmed

32. IMs and unsuccessful therapy When IMs are attenuated in their change potential the problematic self-narrative re-emerges The sense of stability, even if problematic, is reasserted Two positions in a process of mutual-in feeding (Valsiner, 2002) Innovative – problematic – innovative – problematic - …

33. Mutual in-feeding Problematic Self-narrative Alternative Self-narrative (IMs) I-position A I-position B e.g. One day I will enjoy real freedom. e.g. I can’tfreemyselffrommyfears. Mylifealwayswillbelikethat. BUT, My fears are too strong!

34. The person oscillates ambivalently The production of an IM frees the client from the oppression of the problematic self-narrative dominance, BUT it produces anxiety, threating client’s sense of stability Thus, the client returns to the problematic self-narrative, reducing anxiety JUST to feel oppressed once more by the problematic self-narrative

35. Phenomenon Empirical observation The empirical study of mutual in-feeding Mutual in-feeding We code RPMs when they emerge just after the elaboration of the IM Return to the problem markers (RPM)

36. Return to the problem markers The client produces an IM, but just after its emergence also produces a return to problem (RPM) I’ve been feeling less depressed this week (Reflection IM), BUT I feel depressed anyway (RPM)

37. Return to the problem markers RPM involves several forms of attenuation of the change potential of IMs (e.g. I’ve feeling less depressed), by Contradicting it but I’m still a depressed person after all Reaffirming the dominance of the problematic self-narrative but I’m to weak to continue that way

38. Reattributingthe change away from the self but perhaps it is just the medication Trivializing the change but this is such a small change after all

39. Empirical findings on RPMs GO cases in therapy have less RPM And/Or In GO cases the presence of RPM decrease along treatment RPM do not decrease in poor outcome-cases

40. An example from narrative therapy AveragemeanofRPMsingoodandpooroutcome cases T-test (t(8)=-5.25, p<.0001)

41. Emergence of RPMs in different types of IMs Two-wayMixedANOVA MaineffectofType (F(2.19, 17.54)=19.22, p<.0001) Main effect of Group (F(1,8)=.00, p=1) Type x Group interaction (F(2.19, 17.54)=.75, p=.50)

42. How is mutual in-feeding surpassed? Two processes were so far identified Escalation of the non-dominant voice and inhibition of the dominant one Negotiating and engaging in joint action

43. Negotiating and engaging in joint action The problematic voice and the innovative voice engage in dialogue, transforming each other Assimilationof problematic experiences (Stiles, 2002) Development of a meaning bridge Integrative internal negotiation (Nir, 2012) Good dialogue (Hermans & Hermans-Konopka, 2010)

44. An example Joan (a pseudonym) was a 42-year-old female participant in a EFT, sufferingfrom major depression. Joan oscillated between two opposing voices: the dominant voice which was described as seeking others’ approval (e.g., “I guess I'm scared, I'll be end up alone”) ­ – a good-girl voice – ­ and the non-dominant voice which was described as thoughts and feelings that challenge the good-girl voice (e.g., “I think deep down I know I'm strong enough that I could survive on my own”) ­ – a rebellious voice.

45. [Following a two–chair dialogue between thegood-girl voiceand to the rebellious voice] Joan: It's always like I see myself as two split personalities [referring to her two voices] as two altogether different people and... Therapist: So, who's sitting there right now? Which one is sitting there? Joan: I feel like the stronger part of me [referring to the rebellious voice] now is thinking go over and coming together and it's overpowering and overpowering the weaker person [referring to the good-girl voice]. (...) Joan: I wonder it's a way to, to be supportive and to lend strength

46. Therapist: So kind of like ... it just all of a sudden happened? Joan: Yes. Therapist: So somehow it's almost like you didn't have to ask her - for what you wanted - and she didn't have to sort of tell you it's sort of like, she, just kind of came over and you feel stronger. Joan: It's, it's just like when I was there [sitting in the good-girl voice’s chair] and I was feeling so vulnerable and weak and then it seemed like these [two voices] coming together as two things ... two people coming together is like, and one and all of a sudden I felt like a lot stronger (...) Joan: I guess we can confront the issues and talk to T. [husband] about it, it doesn't have to be so scary [Re-conceptualization IM]

47. Escalation of non-dominant voice The innovative voice escalates and dominates the previously dominant one Dominance reversal (Hermans, 1996) Coercive internal negotiation (Nir, 2012) What is the therapeutic potential of this form of resolution?

48. An example Susan (a pseudonym) was a 38-year-old female client in a study of IMs in women who were survivors of intimate violence Two voices were present A forgiving voice (of husband’s abuse) – the problematic voice A resisting voice, refusing responsibility for husband’s abuse – an innovative voice

49. Susan: I see things from another perspective…I no longer excuse or minimize his violent behaviors…It’s gone [referring to the forgiving voice]… Therapist: It’s curious…because there are a lot of people trying to convince you (otherwise)… Susan: The more people try to convince me that I must forgive him, the more I convince myself that things cannot be fixed. Therapist: What helps you resisting others’ pressures for excusing him? Susan: I realized that things were worse than I ever imagined! (…) I used to repress my feelings because I used to believe that if I thought too much about it I would become very depressed and wouldn’t be able to take care of my son (…) Now, I let things come…[Reconceptualization IM]

50. One central feature of both resolutions Reconceptualization is present and allows surpassing the oscillation between opposing voices, by a meta-position that articulates past (problematic self-narrative) with new innovative voices Even if we have two very different types of articulations, like escalation and negotiation.