Assimilation Of Problematic Experiences Scale Research Articles

Shifting between Self-States and Narrative Change—Implicit and Explicit Change Processes in Psychotherapy

This study examined the relationship between implicit and explicit levels of change in psychotherapy—the ability to shift between self-states, measured by the Two Person APES (TPA), a relational extension of the Assimilation of Problematic Experiences Scale (APES), and the emergence of exceptions to the problematic self-narrative, measured by the Innovative Moments Coding System (IMCS). The contribution of each of these dimensions of change to session outcome was also examined. Eighty sessions of eight psychodynamic treatments (10 sessions each) were sampled and coded according to the TPA and the IMCS. Session outcome was measured by the Outcome Rating Scale (ORS). A repeated measures correlation approach was used, revealing a positive association between IMs and client TPA. Also, IMs showed stronger correlations with session outcome compared to TPA. These results indicate that a growing ability to shift between self-states in the implicit level is related to the client’s ability to construct new meanings in the explicit level, and that these explicit changes have stronger correlations with functioning improvement at the session level than implicit processes concerning the renewal of dialogue between self-states.

Longitudinal Changes in Suicide Bereavement Experiences: A Qualitative Study of Family Members over 18 Months after Loss

Family members bereaved by their loved ones' suicidal death normally undergo a complicated and lengthy bereavement process. In this qualitative case study, we explored longitudinal changes in the suicide bereavement process by applying assimilation analysis, based on the Assimilation Model (AM) and the Assimilation of Problematic Experiences Scale (APES), to longitudinal interview data collected from two Chinese suicide-bereaved individuals within the first 18 months after their loss. The results showed that over time the participants both progressed in adapting to their traumatic losses. Assimilation analysis both effectively elaborated the difference in the inner world of the bereaved and clearly demonstrated development in their adaptation to the loss. This study contributes new knowledge on the longitudinal changes in suicide bereavement experiences and demonstrates the applicability of assimilation analysis to suicide bereavement research. Professional help and resources need to be tailored and adapted to meet the changing needs of suicide-bereaved family members.

Is the quality of therapeutic collaboration associated with the assimilation of problematic experiences progress? A comparison of two cases

ABSTRACT Objective: How are collaborative interactions associated with clients’ progress in therapy? This study addressed this question, by assessing the quality of therapeutic collaboration and comparing it passage by passage with the clients’ assimilation of problematic experiences in two cases of major depression treated with Cognitive Behavioral Therapy, one recovered and one improved-but-not-recovered. Method: We used the Therapeutic Collaboration Coding System to code collaborative work and the Assimilation of Problematic Experiences Scale (APES) to rate clients’ progress. In both cases, for the distribution of specific collaborative therapeutic exchanges, we tested for the difference of empirical means between lower and higher APES levels. Results: Both cases progress in APES, but in contrast with Annie (Improved-but-not-recovered), Kate (Recovered) achieved higher levels of change in last sessions. In addition, we found significant differences in the types of collaborative therapeutic exchanges associated with lower and higher APES levels. Conclusion: Ambivalent therapeutic exchanges distinguished the recovered case from the not recovered case highlighting a source of difficulties in facilitating therapeutic change in CBT. In addition, observations in these cases supported the theoretical suggestion that supporting interventions would be better accepted at lower APES levels, whereas challenging interventions would be better accepted at higher APES levels.

Therapeutic collaboration in a comfort zone: a non-improved borderline patient psychotherapy case study (Colaboración terapéutica en una zona de confort: estudio de un caso de psicoterapia de un paciente borderline que no experimentó mejoría)

ABSTRACT The quality of dyad interaction seems crucial to the client’s decision to drop out of psychotherapy. To characterize the client’s lack of change and the patterns of therapeutic collaboration in a dropout of psychodynamic therapy for Borderline Personality Disorder (BPD), we used the Therapeutic Collaboration Coding System (TCCS) to assess collaborative work and the Assimilation of Problematic Experiences Scale (APES) to rate client change. The software GridWare was used to characterize patterns of therapeutic collaboration and the R software to describe the client’s change. The dyad worked in a comfort zone for the client, with the therapist supporting the client’s problematic perspective and the client responding with Safety. The APES results showed that the client did not change, remaining in control through avoidance of thinking and discussing his problematic experience. Our results challenge the potential impact of therapists’ interventions on BPD clients’ comfort zones, suggesting that too much focus on their Therapeutic Zone of Proximal Development’s actual level might not be productive.

Initial-Stage Suicide Bereavement Experiences: A Case Study.

This study aimed to shed light on the initial-stage bereavement experiences of an individual bereaved by suicide, at three months from the loss of his spouse to suicide. A semi-structured in-depth interview was conducted with the individual, a man in his thirties. The data were analyzed using qualitative assimilation analysis, based on the Assimilation Model and the Assimilation of Problematic Experiences Scale (APES). The APES ratings of the interview revealed that the individual's bereavement was associated with the earlier stages of APES (all scoring under 3.5). In addition, the swift and frequent fluctuations in the APES ratings gave indications that the bereavement was unstable and complicated. It is suggested that mental health professionals could use APES to evaluate suicide bereavement and take note of the APES evaluations in clinical interventions.

Tracking Sequences of Patient-Therapist Dialogues by Coding Responses During Integrative Psychotherapy

Objective: The Assimilation of Problematic Experiences Scale (APES) to code the client’s responses and the Process Focused Conversation Analysis (PFCA) to code the therapist’s responses were applied to transcripts of a successful case of integrative psychotherapy of depression. Methods: The method used for the present research was a case study. Dialogues (150 conversations between therapist-client on the basis of meaning) between a therapist and a client in one case with a good outcome were coded and analyzed by two different systems of APES and PFCA. Results: The data revealed that combining the results of APES and PFCA is a suitable coding system for drawing a client’s change equation. In a pyramid of therapeutic change, questions, skills, and techniques applied by the therapist are located in the base, center, and high level, respectively. Meanwhile, higher APES levels are located at the top of the pyramid. The efficient intervention has to be delineated on the spot and is appropriate for a situation in which the client is at one particular moment. Case improvement has demonstrated that at high levels of APES, level 4 is the critical one. Conclusion: Setbacks and stagnations are common within psychotherapy and are generally affected by the main topic of the therapeutic conversation.

Therapeutic activities after assimilation setbacks in the case of Alicia

ABSTRACT This case study addressed what therapists do after assimilation setbacks. Previous research has shown that most setbacks reflect the client switching between strands of the problem and that most setbacks can be classified as balance strategy setbacks (BS) or setbacks due to the therapist exceeding the client’s zone of proximal development (TZPD). Alicia was a 26-year-old woman diagnosed as depressed and treated with a directive kind of therapy for 26 sessions. Sessions were transcribed and rated with the Assimilation of Problematic Experiences Scale (APES). Almost all setbacks could be classified as BS or TZPD. The therapist's succeeding interventions were coded with the List of Therapist’s Activities after a Setback and qualitatively described and summarized. Alicia showed improvement on the outcome measures, and the APES. Therapist activities following setbacks showed that exploratory activities and supportive and clarifying intentions seemed relatively more common after BS setbacks, whereas directive activities and intentions were relatively more common after TZPD setbacks. Results tended to support the conceptualization of setbacks as a switch of strands and suggested elaborations. In this directive therapy, the therapist tended to pursue the intended line of work after setbacks, using systematically different activities depending on which type of setback occurred.

Why setbacks are compatible with progress in assimilating problematic themes: Illustrations from the case of Alicia

Objective: This theory-building case study investigated setbacks in assimilation, seeking to replicate and elaborate previous work, in which most setbacks were one of two types, balance strategy (BS) or exceeding the therapeutic zone of proximal development (TZPD). Method: We studied the case of Alicia, a 26 year-old woman, treated successfully for depression. Her main problematic experiences were rated with the Assimilation of Problematic Experiences Scale (APES), and 267 setbacks were identified. We classified the setbacks and examined them quantitatively and qualitatively. Results: Alicia showed the usual irregular progress of assimilation, with generally increasing APES ratings, consistent with the improvements in outcome measures. Almost all setbacks could be distinguished as BS or TZPD. Replicating a previously observed pattern, BS setback passages tended to be at or above APES stage 3, whereas TZPD setback passages tended to be below APES stage 3. BS and TZPD setbacks also drew qualitatively different characterizations. Conclusion: Results represented a conceptual replication of previous work, explainable using the same theoretical tenets. As an integral part of therapeutic work, setbacks do not impede progress in therapy. BS and TZPD setbacks reflect different processes and have different implications for how therapist and client are working together.

Towards text mining therapeutic change: A systematic review of text-based methods for Therapeutic Change Process Research.

Therapeutic Change Process Research (TCPR) connects within-therapeutic change processes to outcomes. The labour intensity of qualitative methods limit their use to small scale studies. Automated text-analyses (e.g. text mining) provide means for analysing large scale text patterns. We aimed to provide an overview of the frequently used qualitative text-based TCPR methods and assess the extent to which these methods are reliable and valid, and have potential for automation. We systematically reviewed PsycINFO, Scopus, and Web of Science to identify articles concerning change processes and text or language. We evaluated the reliability and validity based on replicability, the availability of code books, training data and inter-rater reliability, and evaluated the potential for automation based on the example- and rule-based approach. From 318 articles we identified four often used methods: Innovative Moments Coding Scheme, the Narrative Process Coding Scheme, Assimilation of Problematic Experiences Scale, and Conversation Analysis. The reliability and validity of the first three is sufficient to hold promise for automation. While some text features (content, grammar) lend themselves for automation through a rule-based approach, it should be possible to automate higher order constructs (e.g. schemas) when sufficient annotated data for an example-based approach are available.

Ability to move between self-states and emotional experiencing and processing as predictors of symptomatic change.

Contemporary relational theories consider clients' ability to move between multiple self-states and clients' ability to experience and process emotions to be two therapeutic processes inherently connected and fundamental to growth and change in psychotherapy. The current research aimed to empirically explore these theoretical assumptions by (1) examining the between- and within-client temporal association between clients' levels of ability to move between multiple self-states and clients' emotional experiencing and processing over the course of therapy, and by (2) testing whether this association would be more prominent for clients presenting good treatment outcomes. Based on treatment outcome measures, two contrasting groups were selected, nine successful and nine unsuccessful. Ninety session transcripts (five per client) were analysed using the Two-Person APES (TPA), an extension of the Assimilation of Problematic Experiences Scale (APES), for the measurement of the ability to move between self-states. Sessions were also analysed using the Experiencing Scale (EXP), for the measurement of emotional experiencing. For all predictors, we disaggregated within- and between-client effects. No association was found between EXP and TPA levels. However, at the between-client level, an interaction effect was found indicating a positive correlation between TPA and EXP only for the good-outcome cases, whereas a negative correlation between these variables was found for the poor-outcome cases. The ability to move between multiple self-states and accessibility to emotional experiencing may be seen as complementary processes enhancing the effectiveness of therapy. However, a high level of one process combined with a low level of the other may be a sign of poor therapeutic outcome. Clients' capacity to negotiate between conflicted self-states and their ability to experience and process emotions are two determinants working in a synergistic way to predict improvement in clients' symptoms. The presence of only one of these psychological processes without the other might be an indication of poor therapeutic outcome. Therapists should aim to increase their clients' progress in both the movement between self-states and emotional experiencing.

Multiplicity and mutuality in the transition of patient and therapist’s self-states: Comparison of good vs. poor outcome groups

Objective: According to the Assimilation Model, the self is consisted of multiple internal voices which are sometimes conflicted, or even dissociated, from one another. Thus, a key therapeutic goal is to create awareness and dialogue between a patient’s various internal voices, in order to facilitate positive change. A recent development of this theoretical line suggests that clinically addressing both the patients’ and therapists’ internal voices, and their mutual influences, contributes significantly to the treatment outcome. Current study aims to examine: (a) Patients’ progression throughout treatment in their quality of movement of self-states, from lower levels of dissociation to higher ones of dialectics, and whether this pattern is associated with positive outcomes; (b) temporal congruence in patient–therapist quality of movement of self-states and its association with session outcome. Method: Nine good and nine poor-outcome cases of psychodynamic treatment were analyzed (N = 18) for both the patient and the therapist using the TPA, an expansion of the assimilation of problematic experiences scale (APES). Patients completed the Outcome Rating Scale (i.e., ORS), a session-by-session measure that assesses overall functioning, and symptomatic pre-and-post treatment measures (BDI). Results: A quadratic pattern of change was observed on the TPA of patients from the good-outcome cases: Patients showed more conflict in the beginning, avoidance between self-states in the middle phase, and dialectics towards the end. Additionally, the patient–therapist TPA temporal congruence was significantly related to session outcome of the good-outcome group. Conclusion: These findings emphasize the importance of combining an intra-psychic and inter-psychic set of lenses when inquiring therapeutic processes.

El Modelo de Asimilación como un Modelo Integrador sobre el Cambio Terapéutico


 
 
 Este trabajo se centra en el modelo de asimilación de experiencias problemáticas. Dicho modelo es un modelo de corte integrador que nos permite estudiar el proceso de cambio en cualquier enfoque terapéutico y con diversos tipos de pacientes y sujetos. Por ello, expondremos, en primer lugar, los principales conceptos y características del modelo, como por ejemplo, qué significa asimilar, el concepto de voz y de voz no dominante y voz dominante, junto con la descripción de la Escala de Asimilación de Experiencias Problemáticas. A continuación, se describirán los resultados más destacados alcanzados en tres áreas principales: el estudio del proceso de cambio en pacientes; el proceso irregular y dentado de asimilación y el papel que tiene el terapeuta en dicho proceso. Esta última cuestión se relaciona con el concepto de responsividad y con el concepto de integración asimilativa.
 
 

Therapist activities preceding therapy setbacks in a poor-outcome case

Progress in psychotherapy is typically irregular, as advances alternate with setbacks. This study investigated the therapist’s activities prior to two main types of setbacks, one involving the client following therapist proposals and one involving the client failing to follow from therapist proposals, in the case of a poor-outcome client treated with a linguistically-oriented kind of cognitive therapy. Setbacks were defined as decreases of at least one level on an index of therapeutic progress, the 8-level Assimilation of Problematic Experiences Scale (APES), in adjacent client passages. Therapist activities were coded in 361 setback episodes that each included a client pre-setback passage, a therapist passage, and a client setback passage; both client passages had been previously rated on the APES. The main categories of therapist activities showed distinctive patterns in relation to the two main types of setbacks, the therapeutic zone of proximal development and the balance strategy. The two main patterns were described as an exploratory and a challenging configuration. These patterns of therapist activities and setbacks showed how the therapist seemed to persevere with approach-guided interventions while this poor-outcome client continued to have setbacks to low APES levels.

Assimilation of problematic experiences in Brief Strategic Therapy: Olivia and her fear of dying / La asimilación de experiencias problemáticas en la Terapia Breve Estratégica: Olivia y su miedo a morir

In this research process, Stiles’ assimilation of problematic experiences scale is used to study Olivia’s process of change. The objectives of this study are: first, to describe Olivia’s therapeutically successful assimilation of the problematic experience of fear of dying, treated with brief strategic therapy; and second, to study how that pattern of assimilation unfolded. We can conclude that Olivia assimilated her problematic experience of fear of dying by following a fluctuating and irregular pattern.

Therapeutic collaboration and the assimilation of problematic experiences in emotion-focused therapy for depression: Comparison of two cases

Objective: The Assimilation model argues that therapists should work responsively within the client’s therapeutic zone of proximal development (TZPD). This study analyzed the association between the collaborative processes assessed by the Therapeutic Collaboration Coding System (TCCS) and advances in assimilation, as assessed by the Assimilation of Problematic Experiences Scale (APES). Method: Sessions 1, 4, 8, 12, and 16 of two contrasting cases, Julia and Afonso (pseudonyms), drawn from a clinical trial of 16-sessions emotion-focused therapy (EFT) for depression, were coded according to the APES and the TCCS. Julia met criteria for reliable and clinically significant improvement, whereas Afonso did not. Results: As expected, Julia advanced farther along the APES than did Afonso. Both therapists worked mainly within their client’s TZPD. However, Julia’s therapist used a balance of supporting and challenging interventions, whereas Afonso’s therapist used mainly supporting interventions. Setbacks were common in both cases. Conclusions: This study supports the theoretical expectation that EFT therapists work mainly within their client’s TZPD. Therapeutic exchanges involving challenging interventions may foster client change if they occur in an overall climate of safety.

Immersion and distancing during assimilation of problematic experiences in a good-outcome case of emotion-focused therapy

Objective: Some studies have suggested that a decrease in immersion (egocentric perspective on personal experiences) and an increase in distancing (observer perspective on personal experiences) are associated with the resolution of clinical problems and positive outcome in psychotherapy for depression. To help clarify how this change in perspectives relates to clinical change, the present study compared changes in immersion and distancing across therapy with progress in one client’s assimilation of her problematic experiences. Method: We analyzed all passages referring to the central problematic experience in a good-outcome case of emotion-focused therapy for depression using the Measure of Immersion and Distancing Speech and the Assimilation of Problematic Experiences Scale. Results: Results showed that immersion and distancing were associated with different stages of assimilation. Immersion was associated with stages of emerging awareness and clarification of the problem and in the application of new understandings to daily life. Distancing was associated with problem-solving and attaining insight. Conclusion: The decrease of immersion and increase of distancing associated with therapeutic improvement should not be taken as a recommendation to avoid immersion and encourage distancing. Immersion and distancing may work as coordinated aspects of the processes of psychotherapeutic change.

Assimilation, reflexivity, and therapist responsiveness in group psychotherapy for social phobia: A case study

Objective: This case study examined reflexivity and the assimilation of problematic experiences, especially its progress within and between the Assimilation of Problematic Experiences Scale (APES) Stages 2–3, in group psychotherapy for social phobia. Method: The data consisted of all of one client's turns expressing the two voices of her main problematic experience in 12 sessions, and all replies by the therapist in direct connection to them. The client's utterances were rated on the APES. Results: A detailed analysis of 13 conversational passages revealed that progress in assimilation happened only when the client took a reflexive stance towards her inner experience or outer actions. There were a few instances when she took a reflexive stance, but no progress in assimilation could be noted. A qualitative analysis of three conversational episodes showed how therapist responsiveness facilitated the client's increased reflexivity and progress in assimilation. Conclusions: Reflexivity appears to be a necessary condition for progress in assimilation both at APES Stages 2 and 3, but the model should recognize that reflexivity can appear in diverse forms and at different levels. Therapist responsiveness and sensitivity to the client's assimilation process is crucial for a successful transition from Stage 2 to Stage 3.

Insight level in the assimilation process: A comparison of good- and poor-outcome cases in short-term dynamic psychotherapy of depressive inpatients

The present study aimed to investigate the association between treatment outcome and the assimilation of problematic experiences during psychotherapy. The assimilation process is described in an eight-level sequence, the Assimilation of Problematic Experiences Scale (APES); insight is conceived as one level in this developmental sequence. This level is considered central as related to decreases in distress and symptomatic improvements. Based on treatment outcome measures, two contrasting groups were selected from a randomized controlled trial. The cases, three successful and three unsuccessful, included clients hospitalized for moderate or severe depression who received a short-term dynamic psychotherapy. Thirty-six session transcripts (six per client) were rated for assimilation level using the APES. In an exploratory purpose, linear mixed effects models were performed to compare successful and unsuccessful cases on their assimilation evolution. Results were partially consistent with the observations of previous studies linking a successful treatment outcome with insight events. Two successful cases reached the insight level, while none of the unsuccessful cases did. The quantitative analyses revealed that both groups presented a significant and similar increase in assimilation during psychotherapy. This study raised different issues concerning the association between assimilation, insight events, and treatment outcome.

What interventions facilitate client progress through the assimilation model? A task analysis of interventions in the psychodynamic treatment of depression

A variation of task analysis was used to build an empirical model of how therapists may facilitate client assimilation process, described in the Assimilation of Problematic Experiences Scale. A rational model was specified and considered in light of an analysis of therapist in-session performances (N = 117) drawn from six inpatient therapies for depression. The therapist interventions were measured by the Comprehensive Psychotherapeutic Interventions Rating Scale. Consistent with the rational model, confronting interventions were particularly useful in helping clients elaborate insight. However, rather than there being a small number of progress-related interventions at lower levels of assimilation, therapists' use of interventions was broader than hypothesized and drew from a wide range of therapeutic approaches. Concerning the higher levels of assimilation, there was insufficient data to allow an analysis of the therapist's progress-related interventions.

How psychotherapeutic exchanges become responsive: A theory‐building case study in the framework of the Assimilation Model

Objectives: The Assimilation of Problematic Experiences Scale (APES) describes eight levels that a problematic experience passes through en route to becoming part of the person's self. Theoretically, progress along this continuum may be facilitated by therapist interventions that are appropriately responsive to the problem's current APES level, in the sense that they help the patient move from the current level to the next. This study aimed to investigate links between therapist intervention choice and progress across APES levels. Design: A theory‐building case study was undertaken to assess and revise hypotheses concerning which therapeutic interventions are optimally responsive at each APES level. Method: Therapeutic interventions, measured by the Comprehensive Psychotherapeutic Interventions Rating Scale and assimilation level, measured by the APES, were assessed in 34 session transcripts of a 30‐year old woman treated with brief psychodynamic therapy for bouts of weeping and diffuse anxiety. Results and conclusion: Results were promising and enabled us to adjust our hypotheses, expanding and elaborating the Assimilation Model. Implications for practice: Our case study showed how specific therapist interventions may facilitate assimilation and underlined the dialogical dimension of the therapy process.