Therapeutic Zone Of Proximal Development Research Articles

Therapist’s interventions immediately after exceeding the client’s therapeutic zone of proximal development: A comparative case study

Objective When therapists’ proposals are too demanding exceeding clients’ readiness to move into change, clients may resist advancing. We aimed to understand how a therapist behaved immediately after the client resisted advancing into change within Cognitive–Behavioral Therapy. Methods We analyzed a recovered and an unrecovered case, both with Major Depression, and followed by the same therapist. Through the Therapeutic Collaboration Coding System, we analyzed 407 exchanges of interest. Results In both cases, clients resisted more in advancing at intermediate sessions, mainly by the therapist’s challenges to raise insight and debate cognitive beliefs in the recovered case, and to seek experiential meanings in the unrecovered case. Immediately after clients resisted advancing, the therapist tended to insist on challenging them in the same direction. In the recovered case, the therapist did so continually throughout the therapy, sometimes balancing between insisting or stepping back. In the unrecovered case, the therapist insisted on challenging, but mostly at the final session. Occasionally, the therapist insisted on challenging, and clients resisted over consecutive exchanges. Conclusion: Our results reinforce that to enact progress and change clients need to be pushed into change, however it requires therapists’ skillful assessment of clients’ tolerance to move in time.

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.

Facilitating the client change: A perspective from the therapeutic zone of proximal development

<p id=C6>Therapeutic zone of proximal development (TZPD) is an extension of Vygotskys concept of the zone of proximal development in the field of psychotherapy. Based on the assimilation model, TZPD represents the space between the actual development level and the potential development level of clients within a developmental sequence. As a new concept to understand the change process of psychotherapy, it can enhance the understanding of setbacks in psychotherapy, provide an easy-to-operate theoretical framework for promoting the change of the client, and provide precise guidance for the therapist to choose supportive or challenging intervention strategies. In terms of research, TZPD theory is based on an unconventional methodology of Theory-Building Qualitative Research. TZPD theory is built upon accumulating observations in qualitative case studies in which TZPD helped the therapist understand and interpret the psychotherapy process. Under this methodology, researchers mainly use a therapeutic collaboration coding system (TCCS) as a research tool to analyze different case studies, understand the causes and characteristics of different counseling cases, and compare the effects of good and bad results based on TZPD, to describe the characteristics of the psychotherapy process. This kind of practice will provide a richer perspective for future research on the theoretical construction of psychological counseling and therapy and the understanding of psychological treatment mechanisms. In clinical practice, as the working area of psychotherapy, TZPD provides a new perspective for understanding the setback phenomenon in the psychotherapy process. Early researchers regarded setbacks as a hindrance in the psychotherapy process, but the TZPD suggests that setbacks may be therapists exploration of the clients TZPD boundaries and preparation for subsequent progress. The key point of therapists work is not to avoid setbacks, but to discover and differentiate the phenomenon of setbacks under the enlightenment of TZPD theory, and choose the appropriate intervention technique at the appropriate stage. The future of TZPD hinges on further exploration of the clinical wisdom of experienced therapists. Its also worthy of carrying out theoretical exploration from different approaches and perspectives, which might ultimately explain setbacks in the process of assimilation and lead to a better understanding of the dynamics of the psychotherapy process.

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.

Breaking the Dominance of Dominant Voices: How the Therapist Promotes Assimilation by Facilitating Dialogue with the Client’s Problematic Voices

Assimilation requires a dialogue between the client’s dominant and non-dominant internal voices, that is between the client’s usual self and his or her problematic experiences. This dialogue is established through conjoint work between therapist and client. This article seeks to consolidate some developments in the assimilation model by reviewing how therapist activities, particularly in directive therapies, can facilitate assimilation of the non-dominant voices into the dominant community. Therapeutic gain requires that the dominant voices (usual self) must give up control and the non-dominant (problematic) voices must be able to express themselves. In service of this goal, two main therapist’s positions toward voices have been distinguished, empathizing with the client's non-dominant voices and defying the dominant voices to break their dominance. These positions lead to an assimilation process that is irregular, as advances alternate with setbacks. This conceptualization is illustrated with examples from a good-outcome case and a poor-outcome case and related to the two main types of setbacks, which explain the irregular progress: exceeding the therapeutic zone of proximal development and the balance strategy.

How Reconceptualization of the Self Is Negotiated in Psychotherapy: An Exploratory Study of the Therapeutic Collaboration

This case study explores the collaboration that occurs between therapist and client when reconceptualization innovative moments emerge. Reconceptualization innovative moments are exceptions to the problematic self-narrative that brought the client to therapy and are associated with successful psychotherapy. Reconceptualization innovative moments have two main components: a contrast between a past problematic facet and a current, more adjusted one (e.g., before I did/thought/felt X . . . , now, I do/think/feel Y) and an attribution for what allowed this transformation to occur (e.g., this was possible because I realized Z). The collaboration between therapist and client was analyzed using the Therapeutic Collaboration Coding System, which conceptualizes the relationship as collaborative or as noncollaborative. The majority of interactions in this case were clearly collaborative, with the therapist and client working inside the therapeutic zone of proximal development, which is typical of successful psychotherapy cases. Reconceptualization innovative moments begin with collaborative exchanges in which the therapist supported the problem and the client elaborated on the change afterward. Implications of these findings for change in psychotherapy are discussed.

Assimilation Setbacks as Switching Strands: A Theoretical and Methodological Conceptualization

This paper offers a theoretical and methodological formulation of setbacks in the process of assimilation of problematic experiences in psychotherapy. It is based on a series of theory-building case studies, in which case observations were used to modify and confirm an evolving understanding. Assimilation typically follows a sawtoothed progression in which advances alternate with setbacks. Research has identified two main types of setbacks, called exceeding the therapeutic zone of proximal development, and the balance strategy, which occur under systematically different conditions. Both types of setbacks can be understood as switching strands within a problematic theme. This formulation defines and elaborates the methodological concepts of topic, theme, and strand, as well as the underlying theoretical concepts of internal voices and sub-voices. These are illustrated with examples from a clinical case. This elaboration of the assimilation model is related to other perspectives that emphasize people’s multiplicity of internal voices and used to suggest further studies.

The therapeutic collaboration in life design counselling: The case of Ryan

This study examined the therapeutic collaboration in a case of Life Design Counseling (LDC) with narrative change and positive career outcomes. The therapeutic collaboration-change model and correspondent coding system were used to in-tensively study the helping relationship throughout three sessions of LDC. The collaboration coding system enables the assessment of each therapeutic exchange within and outside of the client’s therapeutic zone of proximal development, defined as the space between the client’s actual therapeutic developmental level and his/her potential developmental level fomented by a collaborative relationship. Results show that in all sessions, counsellor and client worked mainly within the therapeutic proximal development zone, that is, they were able to interact collaboratively. The coding of the counsellor’s interventions throughout the counselling process was in accordance with the life-design framework. The collaboration-change model and coding system contributed to understand the process of change in LDC. Keywords : career construction; career counselling; career intervention; case study; coding system; Life Design Counselling; process of change; therapeutic collaboration; zone of proximal development

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.

Therapist interventions and client ambivalence in two cases of narrative therapy for depression

Aim: We understand ambivalence as a cycle of opposing expressions by two internal voices. The emergence of a suppressed voice produces an innovative moment (IM), challenging the dominant voice, which represents the client’s problematic self-narrative. The emergence of the IM is opposed by the dominant voice, leading to a return to the problematic self-narrative. This study analyzed therapist and client responses to each other in episodes of ambivalence. Method: The therapeutic collaboration coding system (TCCS) assesses whether and how the therapeutic dyad is working within the therapeutic zone of proximal development (TZPD) by examining client responses to therapist interventions. We applied the TCCS to episodes in which a good- and a poor-outcome client in narrative therapy expressed ambivalence. Results: In both the good- and poor-outcome cases, the therapist responded to the emergence of ambivalence similarly, balancing challenging and supporting. The good-outcome case responded at the developmental level proposed by the therapist when challenged, while the poor-outcome case lagged behind the level proposed. Discussion: This supports the theoretical explanation that the therapist did not match client’s developmental level in the poor-outcome case, working beyond the client’s current TZPD and contributing to the maintenance of ambivalence.

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.

Setbacks in the process of assimilation of problematic experiences in two cases of emotion-focused therapy for depression

Objective: Research on the assimilation model has suggested that psychological change takes place in a sequence of stages punctuated by setbacks, that is, by transient reversals in the developmental course. This study analyzed such setbacks in one good outcome case and one poor outcome case of Emotion-focused therapy (EFT) for depression. Method: Intensive analyses of five transcribed sessions from each case identified 26 setbacks in the good outcome case and 27 in the poor outcome case. The reason for each setback was classified into one of four categories: balance strategy, exceeding the therapeutic zone of proximal development either induced by the therapist (ZPD-T) or induced by the client (ZPD-C), or spontaneous switches. Results: In the good outcome case the most frequent reasons for setbacks were balance strategy and spontaneous switches, whereas in the poor outcome case the most frequent reason for setbacks was ZPD-T. Conclusions: As in previously studied therapies, setbacks in EFT, usually represent productive work on relatively less advanced strands of the client's major problems. Results point to the importance of the therapist attending to the limits of the client's therapeutic ZPD.

The development of therapeutic collaboration in a good outcome case of person-centered therapy

This paper explores the development of therapeutic collaboration in Person-Centered Therapy (PCT). It presents a good outcome case – “Mary” – selected from York I Depression Study, treated with PCT. The study examined how therapist and client worked together throughout the therapy, using the Therapeutic Collaboration Coding System (TCCS). The TCCS assumes that effective therapeutic collaboration occurs within the client’s therapeutic zone of proximal development (TZPD), defined as the distance between the actual and the potential client’s developmental level. It consists of a transcript-based method by which therapist’s interventions and client’s responses are analyzed on a moment-to moment basis. Two independent trained judges coded 15 sessions of this case, using the TCCS. Results showed that the therapeutic dyad worked most of the time within the client’s TZPD, thus suggesting a collaborative pattern throughout the therapy process. In addition, the results showed that the client proactively interacted with the therapist, moving forward in her TZPD.

Therapeutic collaboration and resistance: Describing the nature and quality of the therapeutic relationship within ambivalence events using the Therapeutic Collaboration Coding System

Objectives: We understand ambivalence as a cyclical movement between two opposing parts of the self. The emergence of a novel part produces an innovative moment, challenging the current maladaptive self-narrative. However, the novel part is subsequently attenuated by a return to the maladaptive self-narrative. This study focused on the analysis of the therapeutic collaboration in episodes in which a relatively poor-outcome client in narrative therapy expressed ambivalence. Method: For our analysis we used the Therapeutic Collaboration Coding System, developed to assess whether and how the therapeutic dyad is working within the therapeutic zone of proximal development (TZPD). Results: Results showed that when the therapist challenged the client after the emergence of ambivalence, the client tended to invalidate (reject or ignore) the therapist's intervention. Conclusions: This suggests that in such ambivalence episodes the therapist did not match the client's developmental level, and by working outside the TZPD unintentionally contributed to the maintaining the client's ambivalence.

Irregular assimilation progress: Reasons for setbacks in the context of linguistic therapy of evaluation

The assimilation model suggests progress in psychotherapy follows an eight-stage sequence described by the Assimilation of Problematic Experiences Scale (APES). This study sought to reconcile this developmental stage model with the common but superficially contradictory clinical observation that therapeutic advances alternate with setbacks. Setbacks (n=466) were identified in therapy transcripts of two clients and classified using a preliminary nine-category list of possible alternative reasons for setbacks. Most of the setbacks involved switches among the multiple strands of a problem due to (a) therapists exceeding clients' therapeutic zone of proximal development, (b) therapists guiding clients to shift toward relatively problematic material (balance metaphor), or (c) spontaneous switches. Rather than contradicting the theory, this close examination of setbacks yielded elaborations of it.

How collaboration in therapy becomes therapeutic: The therapeutic collaboration coding system

The quality and strength of the therapeutic collaboration, the core of the alliance, is reliably associated with positive therapy outcomes. The urgent challenge for clinicians and researchers is constructing a conceptual framework to integrate the dialectical work that fosters collaboration, with a model of how clients make progress in therapy. We propose a conceptual account of how collaboration in therapy becomes therapeutic. In addition, we report on the construction of a coding system - the therapeutic collaboration coding system (TCCS) - designed to analyse and track on a moment-by-moment basis the interaction between therapist and client. Preliminary evidence is presented regarding the coding system's psychometric properties. The TCCS evaluates each speaking turn and assesses whether and how therapists are working within the client's therapeutic zone of proximal development, defined as the space between the client's actual therapeutic developmental level and their potential developmental level that can be reached in collaboration with the therapist. We applied the TCCS to five cases: a good and a poor outcome case of narrative therapy, a good and a poor outcome case of cognitive-behavioural therapy, and a dropout case of narrative therapy. The TCCS offers markers that may help researchers better understand the therapeutic collaboration on a moment-to-moment basis and may help therapists better regulate the relationship.