Discover How Counseling Works: Theory-Building Research

1. Discover How Counseling Works: Theory-Building Research William B. Stiles Professor Emeritus, Miami University (Ohio) Taiwan SPR August, 2014

2. Miami University Miami, Florida Glendale Springs

7. Overview of talk • What I mean by theory and by theory-building research. • Theory (paradigms) in other sciences. • Distinguish explanatory theory from treatment theories and ad hoc theories. • Distinguish the theory-building research from fact-gathering research and product-testing research. • Logical operations in theory-building research. • The assimilation model (the theory I’ve been building) • Illustrations of theory-building works using research on the assimilation model. • Qualitative and quantitative studies of single cases.

8. Theory-building and paradigms • Theory-building research seeks to test, improve, and extend an existing theory (not to invent a new theory). • Kuhn: mature sciences have a paradigm: an accepted theory with cardinal examples, methods, practices, and problems to address. • Examples of paradigms: (a) plate tectonics in geology, (b) the standard model in physics (relativity theory + quantum theory), (c) Darwinian natural selection in evolutionary biology. • Paradigms guide research, set puzzles to solve. • Scientists interpret observations within the paradigm • Results refine and elaborate the paradigm. • Particular studies solve the puzzles, test aspects of the theory against observations, modify or extend the theory.

9. Dogwood Berries vs Holly Berries

10. Evolutionary niches:dogwood berries vs holly berries • Puzzle: What selection pressures produce berries that look similar but have such different compositions? • Observation: • High-nutrition autumn fruits like dogwood berries are mainly eaten quickly by migrant birds on their way south, • Low-nutrition autumn fruits like holly berries stay are mainly eaten late in the winter by local birds, after other food sources are exhausted. • Interpretation: Dogwood and Holly trees have co-evolved with different species of birds. • Note: this research did not test Darwinian theory. Rather, it solved a puzzle • It elaborated the theory of how plants and animals co-evolve. • Psychotherapy research does not have a paradigm, but the theory-building strategy can be applied within any explanatory theory (such as psychoanalytic theory or cognitive theory. • Psychotherapy research can solve puzzles in an analogous way.

11. Theory-building vs Fact-gathering • An explanatory theory synthesizes observations. • Theory-building research aims to increase the theory's generality, precision, and realism. • Theory-building research starts with a good theory and uses observations and creativity to solve puzzles (to improve the theory’s generality, precision, and realism. • They try to improve a good explanation by reconciling the existing theory with new observations. • Building a particular theory distinguishes theory-building research from fact-gathering research. • Fact-gathering refers to describing observations or developing a new theory to account for observations. • Fact-gathering is what scientists do when they don't have a paradigm or a theory they are committed to.

12. Logical operations in theory-building research • Theory-building flows from the encounter of a theory with observations or other theories. • 1. Statements are derived from the theories by deduction. • 2. If observations support the statement, confidence in the theory is strengthened by induction • 3. Theories are modified to accommodate observations by abduction • This account of theory-building envisions continual improvement. • Through abduction, new observations become part of the theory. • A good theory conveys the accumulated observations of the scientists who have researched it.

13. Explanatory Theory vs Treatment Theory • Treatment theoriesguide clinicians in conducting therapy. • For example, interpersonal therapy, gestalt therapy, CBT. • They may based on explanatory theories, but are very different from a research perspective. • Explanatory theories are evaluated by comparisons with observations, that is, by theory-building research. • Treatment theories are evaluated by whether they are effective. I call this product-testing research. • An example of product-testing research is clinical trials, including RCTs. • These assess acceptability, efficacy, effectiveness of treatments but don’t contribute to a theoretical understanding of how therapy works.

14. The assimilation model: Voices and communities • People's experiences leave traces in their nervous system. • The traces are active and agentic, responding when they are addressed. We call them voices. • The voices of our life experiences become linked into communities. • The communities are held together by semiotic meaning bridges (e.g., self-narratives) that give smooth access • Dominant Community = collection of voices, or experiences that are normally available as resources, the usual or familiar self. • Voices that are left out of the narrative because they are discrepant or too painful may intrude when they are addressed • In therapy, clients may assimilate these intruding voices so they can become resources.

15. Assimilation of Problematic Experiences Sequence (APES) 0. Warded off / dissociated 1. Unwanted thoughts / active avoidance 2. Vague awareness / emergence 3. Problem statement / clarification 4. Understanding / insight 5. Application / working through 6. Resourcefulness / problem solution 7. Integration / mastery

16. Assimilation of Problematic Experiences Sequence (APES) 0. Warded off / dissociated 1. Unwanted thoughts / active avoidance 2. Vague awareness / emergence 3. Problem statement / clarification 4. Understanding / insight 5. Application / working through 6. Resourcefulness / problem solution 7. Integration / mastery

17. Case of Fatima • Political refugee from a middle eastern country. • Seen in psychoanalytic therapy. • Case helped to elaborate the warded-off stage. • The episode I will present involved Fatima's traumatic memories surrounding the birth and death of a daughter while she was a political prisoner. • As we understood it, a warded-off voice had been addressed, and Fatima was reliving her traumatic experience.

18. Fatima: Yes, I have been thinking: if I had my daughter, she would have been 13 years old and .. (crying). (40-sec. pause) Therapist: You feel sorrow for her. (90-sec. pause) Therapist: Maybe you saw her before your inner eyes, your daughter? Fatima: eh? Therapist: Did you see her, your daughter, before you? Did you think about her? (Fatima crying; 55-sec. pause) Therapist: You have; ...You have not told me how she was, how you remember her. (25-sec. pause; Fatima crying) Therapist: It is difficult to remember her? (Fatima breathes heavily, sniffs). (110-sec. pause) Therapist: It is painful to cry? eh? (Fatima sniffs) (130-sec. pause) Therapist: I don't know if you want to say something of what you think of now? (20-sec. pause) Fatima: It is like a film which goes (incomprehensible).I have thought about it ... (55-sec. pause) Therapist: when it starts, ... It is OK to just take your time and cry. (Fatima cries and laughs at the same time. Therapist laughs). (60-sec. pause) Therapist: Yes, you have many feelings inside yourself now. Fatima: Yes. Fatima’s Film-Like Memory

19. Assimilation of Problematic Experiences Sequence (APES) 0. Warded off / dissociated 1. Unwanted thoughts / active avoidance 2. Vague awareness / emergence 3. Problem statement / clarification 4. Understanding / insight 5. Application / working through 6. Resourcefulness / problem solution 7. Integration / mastery

20. Substages between APES 3 and 4 3. Problem statement / clarification Clear statement of a problem--something that can be worked on. Opposing voices are differentiated and can talk about each other. Affect is negative but manageable, not panicky. 3.2: Rapid Cross-Fire 3.4: Entitlement 3.6: Mutual Respect and Attention 3.8: Active Search for Understanding 4. Understanding / insight The problematic experience is formulated and understood. Voices reach an understanding with each other (a meaning bridge). Affect may be mixed.

21. Margaret’s Voices at APES 3.2 Caretaker: hyper-responsible; seemed to represent Margaret's dominant community. Care for me: unhappy, self-focused, and demanding; a problematic voice. APES 3.2: Rapid Cross-Fire. Opposing voices fought for the floor. Care for me voice triggered contradictions from the Caretaker voice and vice-versa.

22. Caretaker voice in Bold; Care for me voice in italics Margaret: When you've been from my generation, [Therapist: Mm-hm.]you know that you've always got your husband's supper. Its very difficult to change, like to say, like, 'get your own' (slight laugh), you know. And, but, I know that he doesn't expect it, because he has said “if I [come home late?] that's my problem,and if you're in the middle of something...”, because For a long time, if I was in the middle of something, I did resent it. I felt, well, I had my dinner. He's-he's the one who's ruined the routine, not me. Why should I stop what I'm doing? Therapist: Right. Margaret: But I still felt I should do it. (laughs) because this is my generation, you know.And, um, But I resented doing it. So I kind of I'm sort of resolving that as I go along.(Session 3)

23. Comment on examples from Fatima and Margaret cases • Each case reveals something different. • By abduction, the model can incorporate distinctive features. • Fatima's film-like memories • Margaret's step-by-step transition between stages • Central point of each case study was decided opportunistically. • Expanded account was constrained by previous observations as embodied in theory. • The theory is stronger because both sets of observations have permeated it.

24. Zone of Proximal Development (ZPD) • In developmental psychology, the zone of proximal development (ZPD), describes the region on the continuum of intellectual development from a child's current ability to his or her potential ability to perform with the help of an adult (Vygotsky). • Analogously, the therapeutic ZPD is the region on the APES between a problem's current degree of assimilation to the degree that can be attained with the help of a therapist. • The location and width of the ZPD may vary from client to client and problem to problem. • As a problem is assimilated, its ZPD shifts up the APES. • Theoretically, interventions should be within the problem’s ZPD. • Interventions below the ZPD will be rejected as uninteresting or unhelpful. • Interventions above the ZPD will be rejected as too threatening.

25. Setbacks in APES stages Puzzle: Clinical observation shows that progress through APES stages is not smooth, but has many setbacks. 0. Warded off/dissociated. 1. Unwanted thoughts/active avoidance. 2. Vague awareness/emergence. 3. Problem statement/clarification. 4. Understanding/insight. 5. Application/working through. 6. Resourcefulness/problem solution. 7. Integration/mastery.

26. Gabriel: good outcome case • 24-year-old, male, 2 brothers • University student (Agriculture) • Performance anxiety • Symptoms: feeling tense, nervousness, intrusive thoughts about performance, avoidance, muscle pain, palpitations, etc. • Linguistic therapy of evaluation (LTE): 13 sessions • A cognitive therapy based on Korzybski’s General Semantics • Transcripts divided into thought units. Thought units sorted into themes representing problematic experiences. • Analysis: Gabriel's 578 thought units were sorted into 4 problematic themes and rated using the APES.

27. Gabriel: APES ratings of “performance” problematic experience

28. Alternative explanations for setbacks (hypothetical) • Shift to less assimilated strand of a problem • Exceeded ZPD • Directed to a more problematic strand (for balance) • Spontaneous switches • Interference from a life event • Failure of memory • Interference from progress on other problems • Imprecision of measurement • Limitations of the theory

29. Explanations of setbacks in the treatment of Gabriel Note. ZPD = Zone of Proximal Development

30. Ambivalence and Ambivalence Markers • Ambivalence describes a cyclical movement between opposing internal voices, • An Ambivalence Marker assesses ambivalence as an expression by an intruding voice (Innovative Moment) immediately followed by a return to the dominant community’s perspective (dominant self-narrative). Client:I’ve been facing my issues, bringing them into the open... and that is fine (Innovative Moment) but then I feel that going beyond that point, confronting people is dangerous...(Ambivalence Marker) • Theoretically, such ambivalence reflects working at the upper limit of the therapeutic ZPD.

31. Maria: Poor-outcome case • Maria was a 47-year-old retired industrial worker, married 20 years. • Maria’s was a relatively poor-outcome case selected from a sample of women who were victims of intimate violence gathered in a previous study (Matos et al., 2009). • She received 15 sessions of individual narrative therapy. All sessions were transcribed and coded (see next slide). • Her female therapist had 5 years of experience with battered women. • Alliance (Working Alliance Inventory) remained high throughout.

32. Coding and reliabilty 1.Identification of Ambivalence Markers. • The case was independently coded for Ambivalence Markers (N = 114) by two trained judges in a previous study; • Cohen’s K=.93 2. Therapeutic Collaboration Coding System (TCCS) coding of the therapeutic interaction immediately after the emergence of Ambivalence Markers • Two trained judges independently coded all sessions; • Therapist’s interventions: Cohen’s K=.95 • Client’s responses: Cohen’s K=.95

33. Four-turn sequences around Maria's Ambivalence Markers:TCCS coding (N = 114) • 1. Therapist intervention preceding Ambivalence Marker: • (a) Supporting dominant self-narrative; (b) Supporting innovative voice; (c) Challenging • 2. The Ambivalence Marker itself: • An innovative moment followed immediately by a return to the dominant self-narrative. • 3. Therapist intervention following Ambivalence Marker: • (a) Supporting dominant self-narrative; (b) Supporting innovative voice; (c) Challenging • 4. Client response indicates a feeling of: • (a) Safety; (b) Tolerable Risk; (c) Ambivalence; (d) Intolerable Risk • Interpreted as indicating this intervention (#3) was (a) below, (b) near, (c) at, or (d) above the upper limit of that problem’s ZPD.

34. Therapist interventions preceding and following Maria’s expressions of ambivalence

35. Client response following therapist intervention following expressions of ambivalence

36. Comments on Maria’s ambivalence • Recall: theoretically, ambivalence indicates work at the upper limit of the ZPD. • Ambivalence tended to emerge following challenging interventions (problem pushed to its limit); • But the therapist tended to respond to Maria’s ambivalence by further challenging her. • Maria responded by invalidating 62% of the challenges. (indicating Intolerable Risk) • Perhaps the response would have been more positive if the therapist had supported one of the client’s perspectives (dominant or innovative).

37. Contributions of examples (abductions) to assimilation model • Fatima: characterization of warded-off experiences. Some experiences may remain unprocessed. • Margaret: elaboration of assimilation sequence. Four substages between stating a problem and coming to a new understanding. • Gabriel: setbacks in APES stages may represent appropriate switching attention to a strand of the problem that needs more work. • Maria: challenging interventions may not be accepted if the client is ambivalent, already working the upper limit of the ZPD. • Of course, these abductions are very tentative. But they strengthen the theory by encompassing new sorts of observations. • Will the elaborated theory help account for new observations?.

38. Concluding comments: What it takes to build a theory • Commitment to that theory. (But you don't have to think it is perfect). • You should be surprised when your theory is wrong. • Skepticism about the theory: a belief that it can be improved. • Knowledge of the theory, to know when it works and when it fails. • Careful thought and creativity. • Psychotherapy researchers do not agree which theory is worth building. Particular theory-building studies will not interest everybody. • Don’t worry if outsiders think your research addresses a small point. • Research that improves a theory will yield a more general, precise, realistic theory. And the improved theory will draw larger audiences. • If you stick with a theory, it will get better, and more people will listen.

39. Thank you.

40. References Theory-Building • Stiles, W. B. (2009). Logical operations in theory-building case studies. Pragmatic Case Studies in Psychotherapy, 5(3), 9-22. Available: http://jrul.libraries.rutgers.edu/index.php/pcsp/article/view/973/2384 Fatima: • Varvin, S., & Stiles, W. B. (1999). Emergence of severe traumatic experiences: An assimilation analysis of psychoanalytic therapy with a political refugee. Psychotherapy Research, 9, 381-404. Margaret: • Brinegar, M. G., Salvi, L. M., Stiles, W. B., & Greenberg, L. S. (2006). Building a meaning bridge: Therapeutic progress from problem formulation to understanding. Journal of Counseling Psychology, 53, 165-180. Gabriel: • Caro Gabalda, I., & Stiles, W. B. (2013). Irregular assimilation progress: Reasons for setbacks in the context of linguistic therapy of evaluation. Psychotherapy Research, 23, 35-53. Maria: • Ribeiro, A. P., Ribeiro. E., Loura, J., Gonçalves, M. M., Stiles, W. B., Horvath, A. O., & Sousa, I. (2014). Therapeutic collaboration and resistance: Describing the nature and quality of the therapeutic relationship within ambivalence events using the Therapeutic Collaboration Coding System. Psychotherapy Research. 24, 346-359.