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Innovative moments in psychotherapy: From narrative outputs to dialogical processes 7 th Conference on Dialogical Self, Athens, USA, 2012 Miguel M. Gonçalves.

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Presentation on theme: "Innovative moments in psychotherapy: From narrative outputs to dialogical processes 7 th Conference on Dialogical Self, Athens, USA, 2012 Miguel M. Gonçalves."— Presentation transcript:

1 Innovative moments in psychotherapy: From narrative outputs to dialogical processes 7 th 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 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 Meaning and narratives

5 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 Problematic self-narratives

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

7 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) Transformation of problematic self- narratives

8 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” One example

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 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 Transformation of problematic self-narratives

11 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) Innovative moments (IMs)

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

13 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 Innovative Moments Coding System

14 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! Action IMs

15 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. Reflection IMs

16 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. Protest IMs

17 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 Reconceptualization IMs

18 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 Reconceptualization IMs

19 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… Reconceptualization IMs

20 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. Performing Change IMs

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

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

23 Performing change in GO cases

24 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 change tends to emerge after reconceptualization Global picture of GO cases

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

26 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 Global picture of PO cases

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

28 1.Which processes block the development of innovative moments from the middle of the therapy, particularly the emergence of reconceptualization? 1.Why is reconceptualization so central to the change process? Two main questions relevant to DS theory

29 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 1. Innovative moments and PO therapy

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

31 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 IMs and unsuccessful therapy

32 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 - … IMs and unsuccessful therapy

33 Problematic Self-narrative I-position A e.g. I can’t free myself from my fears. My life always will be like that. e.g. One day I will enjoy real freedom. Alternative Self-narrative (IMs) Alternative Self-narrative (IMs) BUT, My fears are too strong! I-position B Mutual in-feeding

34 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 The person oscillates ambivalently

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

36 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) Return to the problem markers

37 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 Return to the problem markers

38 Reattributing the 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 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 Empirical findings on RPMs

40 Average mean of RPMs in good and poor outcome cases T-test (t(8)=-5.25, p<.0001) An example from narrative therapy

41 Two-way Mixed ANOVA Main effect of Type (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) Emergence of RPMs in different types of IMs

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

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

44 Joan (a pseudonym) was a 42-year-old female participant in a EFT, suffering from 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. An example

45 [Following a two–chair dialogue between the good-girl voice and 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 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? Escalation of non-dominant voice

48 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 An example

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 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. One central feature of both resolutions

51 Is the escalation of the innovative voice a less optimal change? Is it an intermediate stage towards a negotiating phase? Perhaps in very disturbing situations (as abuse) the escalating process is necessary, before negotiating can take place Interesting questions

52 Two components Contrast between a problematic past self-narrative and an innovative new facet Some description of the process by which the change occurred Three positions Self in the past Self in the present Meta-position 2. Why is reconceptualization so central in the change process?

53 Lisa: Yeah, yeah get back into my feelings, yeah and that's, I guess, because the awareness I know is there now, and before I never knew it existed (laugh). So I'm an individual, I realize I'm an individual, and I have the right to vent my feelings and what I think is right or good for me and that's been the improvement of the therapy. Therapist: Yeah, really finding your feet. Lisa: Mm hm, as an individual yeah, which before I-I thought I was glued to him [the husband]. Yeah, I didn't have an existence and now I do, and that's a good feeling. [Process of change] [Contrast between the self in the past and the self in the present] An example

54 Hermans and Hermans-Konopka (2010) proposed 3 main functions of metapositions - Unifying - Executive - Liberating And a developmental one? reconceptualization facilitates the connection between well developed positions (previous problematic self-narrative) and emergent ones (alternative self-narrative), prompting change Reconceptualization and meta- positions

55 Narrative structure By the emphasis on a time frame: the past self-narrative versus the present self-narrative Self-continuity Through the contrast Without reconceptualization we would have a “jump” in identity, a transformation without a continuity How does reconceptualization facilitate development?

56 Progressive identification with the newer self-narrative Why keeps reconceptualization repeating itself after mid- treatment? By narrating reconceptualizations the person is always demonstrating to him or herself (and to others) that he or she is changing and what its possible direction is The process of repetition allows the person to experiment the change before it becomes familiar How does reconceptualization facilitate development?

57 Resolution of ambivalence over the change process In a sense reconceptualization is the contrary of the mutual in- feeding process While in the process of mutual in-feeding voices keep reacting to one another, without any resonance and any transformation When reconceptualization occurs some integration of the old (problematic) with the new (innovative) takes place How does reconceptualization facilitate development?

58 Perhaps reconceptualization is the final aim of successful psychotherapy, given that as suggested by Dimaggio (2012): “Psychotherapy is about forming meta-positions able to reflect upon the more crystalized aspects of the self and provide new solutions to problems” (p. 358) Reconceptualization centrality in psychotherapy

59 Mutual in-feeding and failure to change in psychotherapy Study forms of surpassing this impasse Are there other processes, besides negotiating and escalating of previous dominated voice, involved in surpassing mutual in- feeding? Are situations in which one form of resolution is preferable over the other? Summary and future work

60 Reconceptualization as central to meaningful change Is it possible to change in psychotherapy without the development of reconceptualization? Is it possible to track empirically the four ingredients proposed? If so, how can they be sustained and developed by therapists? Summary and future work


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