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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 (University of Minho, Portugal)
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)
Psychotherapy and meaning
Change in psychotherapy
Symptoms
Meanings
Aim of psychotherapy
Change in the assumptions that lead the client to
demoralization (Frank, 1961)
“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)
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
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
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
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
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
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
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
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)
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
Dimensions of analysis
SalienceLength 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
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
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
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
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
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
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
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
Case 1 Case 2 Case 3 Case 4 Case 5 Case 60
5
10
15
20
25
30
35
40
NERCPRA
Mea
n Sa
lienc
e (%
)
Poor outcome casesGood outcome cases
An example of our typical results
Reconceptualization in good outcome (GO) cases and poor outcome (PO) cases
Performing change in 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 change tends to emerge after reconceptualization
Global picture of GO cases
Action IMs
Reflection IMs
Protest IMs
Therapy evolution
Reconceptualization IMs
Performing change
IMs
New Action IMs
New Reflection IMs
New Protest IMs
Form
er p
robl
emat
ic
narra
tive
New Emergent Self
NarrativeAn heuristic model of GO 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
Global picture of PO cases
Action IMs
Reflection IMs
Protest IMs
Time
Prob
lem
atic
sel
f-na
rrativ
e Em
ergent Self Narrative
Absence of
reconceptualization
Prob
lem
atic
sel
f-na
rrativ
e
An heuristic model of PO cases
1. Which processes block the development of
innovative moments from the middle of the therapy,
particularly the emergence of reconceptualization?
2. Why is reconceptualization so central to the change
process?
Two main questions relevant to DS theory
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
Which processes are responsible for the differences
between good and poor outcome cases in the middle
phase of therapy?
Interesting question
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
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
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)
BUT, My fears are too strong!
I-position B
Mutual in-feeding
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 anxietyJUST to feel oppressed once more by the problematic self-narrative
The person oscillates ambivalently
Mutual in-feeding Return to the problem
markers (RPM)
Phenomenon Empirical observation
We code RPMs when they emerge just after the elaboration of the IM
The empirical study of mutual in-feeding
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
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
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
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
Average mean of RPMs in good and poor outcome cases
Good outcome group Poor outome group0.005.00
10.0015.0020.0025.0030.0035.0040.0045.00
IMS with RPMs
Mea
n Pe
rcen
tage
(%) o
f RPM
s
T-test
(t(8)=-5.25, p<.0001)
An example from narrative therapy
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
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?
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
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
[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
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]
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
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 presentA forgiving voice (of husband’s abuse) – the problematic voice
A resisting voice, refusing responsibility for husband’s abuse – an
innovative voice
An example
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]
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
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
Two componentsContrast between a problematic past self-narrative and an
innovative new facet
Some description of the process by which the change occurred
Three positionsSelf in the past
Self in the present
Meta-position
2. Why is reconceptualization so central in the change process?
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
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
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?
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?
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?
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
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
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
THANK YOU FOR YOUR ATTENTION!
