Figure 1 - uploaded by Isabel Caro Gabalda
Content may be subject to copyright.
Alice assimilation process. Note: Only retreats represented by solid lines were coded as setbacks. The lines with dots represent retreats that were not coded as setbacks since they involved a change of theme or they were not in adjacent passage.
Source publication
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:...
Contexts in source publication
Context 1
... (e.g., I cannot express what I feel, I need to protect myself ” ) and feelings of inadequacy ( “ I don ’ t appreciate myself ” ). Her main nondominant voices sought self-expression (e.g., “ expressing what I feel does not mean to be ridiculous, ” “ I have the right to show that I ’ m hurt, ” and “ some people love me for who I am ” ). 3. APES rating. After the voices were formulated, raters independently coded the five transcribed sessions from each case. They assigned an APES stage to each passage within each of the selected excerpts. Inter-rater reliability was ICC = .97 in the case of Alice and .81 in the case of Barbara; these ICCs are considered high (Finn, 1974). 4. Setbacks analysis . After completing the assimilation analysis, raters carried out the setbacks analysis (Caro Gabalda & Stiles, 2009, 2013; Stiles, 2005). The raters began with the case of Barbara (poor outcome case) using the nine reasons constructed conceptually and a priori by Stiles (2005). After a first review of the case, it appeared that all of the setbacks could be classified into the three categories found in the previous empirical studies by Caro Gabalda and Stiles (2009, 2013), and it was decided to use their conceptualization of setback reasons (described earlier) for the present study. Further examination, however, led to a refinement: A number of Barbara ’ s (but not Alice ’ s) setbacks fell in a subcategory of spontaneous switches that we now call exceeding the ZPD-C, as contrasted with the earlier category, exceeding the ZPD-T. Both are included in Table I. This addition makes a distinction within what had previously been called spontaneous switches, which was a residual category of setbacks not explained by therapist actions. These setbacks reflect the client reaching the limit of the current strand ’ s ZPD without being pushed by the therapist. Using the coding system shown in Table I, the raters independently classified the setbacks in the excerpts (i.e., all instances of a drop of one or more APES stages in successive passages). After coding the setbacks from each session, raters met to discuss disagreements until they reached a consensus to establish a final coding. An inter-rater agreement based on the independent coding (Cohen ’ s Kappa) was .80 for both cases, considered a good inter- rater reliability (Fleiss, 1981). Good outcome case . Alice showed both advances and setbacks in assimilation but with a clear positive trend across the five rated sessions (Figure 1). For the first half of therapy (sessions 1, 4, and 8), Alice alternated mainly between APES stages 2 and 3, reflecting the gradual emergence into awareness of the problematic experience of being assertive and expressing own needs. However a few passages were rated at APES stage 4, indicating moments of insight and the emergence of new meanings: Alice began to understand how her fear of being rejected impeded her expressing what she wanted and ...
Context 2
... in therapy, expressions of understanding and insight (APES 4) and applying the new understanding (APES 5) were much more frequent. Alice acknowl- edged throughout therapy that her need to get married was linked to her parents ’ conservative and critical views, and she also expressed the need to be autonomous from her parents. This new understanding facilitated Alice ’ s being able to confront her parents with her decision to move in with her boyfriend. Finally, toward the end of therapy, many passages were rated at APES stage 6, indicating a successful resolution of the problems and the integration of the previously nondominant voice of assert- ing her own needs into the community of voices ( “ I cannot care so much about what others may think in order to feel good ” ). That is, this previously problematic aspect of Alice had become a personal resource. Poor Outcome case. Barbara ’ s nondominant voice of self-expression remained in lower APES stages (1, 2, and 3) throughout therapy ( Figure 2). No passages from the five rated sessions of Barbara ’ s therapy reached APES stage 4 or higher. That is, the nondominant voice was clearly expressed, that is, the problem was stated explicitly (APES stage 3; e.g., “ maybe it would be helpful if I let these feelings to come out ” but “ it won ’ t solve anything if I express what I feel, so I prefer to keep quiet ” ). However, the opposed voices did not build a meaning bridge that could carry their mutual understanding (which would have been APES stage 4). We identified 26 setbacks in Alice s sessions (Table II), of which 46% were coded as balance strategy, 46% were coded as spontaneous switch, and only 8% were coded as ZPD-T. The low percentage of Alice ’ s setbacks coded as ZPD-T implies that most of the time her therapist worked within her therapeutic ZPD. The majority (73%) of Alice ’ s setbacks were small, dropping just one APES stage (e.g., from 4 to 3, or from 3 to 2). Her larger setbacks (dropping two stages or more in adjacent passages) occurred mainly later in therapy (see Figure 1). Several of these occurred when, following a moment of understanding (APES 4), the therapist introduced an empty-chair dialogue. A setback of three stages, from APES 5 to APES 2, occurred in the last session, when Alice described an episode of new assertiveness and then shifted to her ...
Citations
... All three cases showed many APES advances and setbacks during the process (see Figures 1-3). These results are consistent with previous research (Caro -Gabalda, 2006a-Gabalda, , 2006bCaro-Gabalda & Stiles, 2009Mendes et al., 2016;Osatuke et al., 2005), suggesting that setbacks are a normal feature of psychotherapy, regardless of eventual outcome (Basto et al., , 2021Caro-Gabalda & Stiles, 2009). Setbacks seem to indicate that the client is in an active change phase, and the community of voices is reorganizing itself to accommodate this new experience (Basto et al., , 2021, switching among strands of the problem that are at different APES levels (Caro Gabalda & Stiles, 2013. ...
The Assimilation Model describes therapeutic change as a gradual integration of problematic experiences into the self. Previous studies associated higher assimilation levels with a reduction of depressive symptoms throughout therapy and better therapeutic outcomes at the end. We explored the relation between the assimilation of problematic experiences during therapy and the maintenance of therapeutic gains after the therapeutic process. Three depressed clients were studied: one remained asymptomatic throughout the follow-up; one relapsed after the end of therapy; and one become asymptomatic during the follow-up. The assimilation process was assessed through the Assimilation of Problematic Experiences Scale (APES) and depressive symptoms through the Beck Depression Inventory-II (BDI-II). Higher APES levels were associated with lower intensity of symptoms across sessions. The client who maintained gains and the client who recovered during follow-up achieved higher APES levels during treatment than did the client who relapsed. APES levels of at least 4 were associated with good outcomes during therapy and further improvement after therapy and levels of at least 6 were associated with maintenance of therapeutic gains. These results suggest that a more thorough assimilation of problematic experiences may help clients maintain therapeutic gains and/or recover after therapy, thereby reducing the likelihood of relapse.
... From a variety of theoretically possible reasons for setbacks (Stiles, 2005), two main ones seemed to account for most setbacks in the studies conducted so far. These were exceeding the therapeutic zone of proximal development (TZPD) and the balance strategy (BS) (Caro Gabalda & Stiles, 2013;Mendes et al., 2016). Both can be understood as the client switching from one strand of a problem to another, where the second strand is at a lower APES level than the first. ...
... While there is some variation between conceptualizations, when clients process their distress, they progress from (a) avoiding distressing thoughts to (b) acknowledging, (c) understanding, and (d) integrating their distress (Basto et al., 2017;Detert et al., 2006;Ribeiro et al., 2016). Across different therapeutic approaches, processing has been associated with reduced distress (e.g., Harmon-Jones & Mills, 2019) and client outcomes (e.g., Detert et al., 2006;Mendes et al., 2016). Furthermore, in postsuicidal crisis helping contexts, chain analysis has been used to facilitate a timeline of clients' suicidal crisis. ...
... To better understand how clients in crisis make sense of their distress, we developed and then validated a five-stage distress-processing model for clients in suicidal crisis. Consistent with other distress-processing frameworks (e.g., Mendes et al., 2016), our findings indicate that clients in suicidal crisis sequentially move through the distress-processing stages. Each stage can be conceptualized as a building block upon which the next stage is built. ...
Background: While crisis intervention frameworks have indicated the importance of clients in suicidal crisis better understanding their distress to decrease suicidality, it is unclear how clients in suicidal crisis process their distress. Aims: To develop (Study 1) and validate (Study 2) a sequential distress-processing model for clients in suicidal crisis. Methods: Applying task analysis, Study 1 consisted of three phases, which resulted in a theoretically and empirically informed model. In Study 2, we examined the distress-processing model’s validity using a longitudinal design. In both studies, data were online crisis chats with adults in suicidal crisis. Results: In Study 1, we developed a sequential five-stage distress-processing model: (Stage 1) unengaged with distress, (Stage 2) distress awareness, (Stage 3) distress clarity, (Stage 4) distress insight, and (Stage 5) applying distress insight. In Study 2, the model’s validity was supported via evidence that (H1) progression through the processing stages was sequential and (H2) clients with good outcomes had greater progression in their processing than clients with poor outcomes. Limitation: Clients who were suicidal but did not disclose their suicidality were not included. Conclusion: Our findings provide a framework for conceptualizing and operationalizing how clients move through suicidal crises, which can facilitate intervention and research developments.
... Our finding that Kate achieved APES levels higher than level 4 later in therapy (Figure 2(a)) was consistent with assimilation theory and with previous results for good outcome cases (e.g., Basto et al., 2018;Detert et al., 2006;Ribeiro, et al., 2016b). Annie's achieving APES 4 early in therapy but not later (Figure 2(b)) is more unusual, though taken by themselves, the lower APES levels in the final phase was consistent with other poor outcome cases (e.g., Basto et al., 2018;Mendes et al., 2016). ...
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.
... Diese Return-to-the-Problem-Marker (RPMs) nahmen in den Fällen mit gutem Ergebnis über die Therapie hinweg ab, während sie bei Klient*innen mit schlechtem Ergebnis unverändert und hoch blieben. Cunha et al. (2012) Mendes et al. (2016) analysierte solche Depressionsrückschläge anhand eines Falls mit gutem und eines Falls mit schlechtem Outcome bei Einsatz von EFT. Das Datenmaterial wurde aus fünf transkribierten Sitzungen generiert. ...
File, Hutterer, Keil, Korunka und Macke-Bruck beschäftigten sich in einem 2008 veröffentlichten Artikel vorrangig mit publizierten Wirksamkeitsstudien über Klienten-/Personzentrierte und Experienzielle Psychotherapien aus den Jahren 1991 bis 2008. Aktuell wurde systematisch der Frage nachgegangen, welche Entwicklungen es in den elf Folgejahren gegeben hat. 343 in facheinschlägigen Zeitschriften publizierte Forschungsarbeiten wurden ausgewertet. Der erste narrative Review setzte sich mit der Forschung von am personzentrierten Ansatz orientierten Psychotherapien breiter auseinander. Dieser zweite Teil befasst sich mit der Ausbildungsforschung, den Störungsbildern in der personzentrierten Forschung und mit dem Bereich der Kinder-, Spiel- und Jugendlichenpsychotherapie.
... Gelo & Salvatore, 2016;Hayes, Laurenceau, Feldman, Strauss, & Cardaciotto, 2007;Pascual-Leone, 2009). As the assimilation model is a developmental, stage theory, the common observation of irregular and unstable progress through the stages (for instance, Basto, Stiles, Rijo, & Salgado, 2018;Mendes et al., 2016;Ribeiro et al., 2016) is potentially problematic for the theory. Conceptualizing setbacks as a switch of strands instead of a reversal in the overall progress in assimilation explained how the observation that setbacks are common in therapy can be reconciled with an assimilation account of productive therapeutic work (Caro Gabalda & Stiles, 2018). ...
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.
... A recent line of research has focused on the relation between narrative processes and Stiles' (2001) assimilation of problematic experiences (APES) model, a stage model of client change. Mendes et al. (2016) examined change in one good and one poor outcome case drawn from an EFT treatment study for depression using the assimilation model (APES; Stiles, 2001). They found that both clients experienced setbacks, that is moments in the session when their ratings on the APES reverted to a lower level. ...
We review recent research on humanistic-experiential psychotherapies (HEPs), which include person-centered therapy (PCT), emotion-focused therapy (EFT), gestalt, and psychodrama approaches, along with generic relationship control conditions characterized as supportive or nondirective. A key part of this review is a meta-analysis of 91 studies of the effectiveness/efficacy of HEPs, published between 2009 and 2018, which produced the following results: (1) HEPs were associated with large pre-post client change (d = .86). (2) In controlled studies, clients in HEPs generally showed large gains relative to clients who received no therapy (.88). (3) In comparative outcome studies, HEPs in general were statistically and clinically equivalent in effectiveness to other therapies (-.08). (4) Overall, CBT appeared to have an equivocal advantage over HEPs (-.26). However, these studies were overwhelmingly delivered by CBT researchers in largely non-bona fide versions of HEPs as comparison conditions. Overall, the strongest results were found for EFT, followed by PCT; generic supportive-nondirective approaches were least effective, especially when compared to CBT. HEPs appeared to be most effective with relationship/interpersonal difficulties, self-damaging activities, coping with chronic medical conditions, and psychosis. Findings were more mixed for depression and anxiety. In addition, we offer an updated meta-synthesis of the qualitative outcomes of these therapies, which fell into three main categories: appreciating experiences of self; appreciating experience of self in relationship to others; and changed view of self/others. We also provide narrative reviews of recent qualitative research on helpful and unhelpful factors in HEPs, along with quantitative process-outcome research on HEPs including process-outcome research and work on mediating processes. In an integrative summary we identify a core set of interwoven client change processes involving emotional expression, deepening and transformation, the emergence of new client narratives, and the assimilation of problematic experiences. We conclude with a set of recommendations for research, practice and mental health guideline development. Humanistic-Experiential Psychotherapies Update, p. 2 Content Outline
... We aimed to compare our case observations with the assimilation model to assess the fit and to identify needs and opportunities for elaborating the theory. Thus, we do not aim at testing the effectiveness of the treatment, although the use of the APES as an outcome measure has been supported in nomothetic studies (e.g., Basto et al., 2018;Detert et al., 2006) and in case studies (e.g., Mendes et al., 2016). ...
We applied the assimilation of problematic experiences sequence (APES) to a six-year-old girl’s processing of traumatic experiences involving violence and death in play therapy. We analyzed the post-session notes from the first 34 sessions of a much longer treatment, during which the girl repeatedly enacted a drama we called the cottage play, involving characters assumed by the child and characters assigned to the therapist. We distinguished four phases based on changes in play themes. In phase 1, the girl expressed her need for safety in response to an overwhelming internal threat (APES stage 0, warded off/dissociated). In phase 2, she worked to escape and avoid the threat, referenced in the play as monsters and bad memories (APES 1, unwanted thoughts/avoidance). Phase 3 was a brief period of consolidation. In phase 4, she actively faced the trauma, referenced as murderers, soldiers, and death (APES 2, awareness/emergence). Our observations underlined the child–therapist collaboration and dyadic processing. The expressions of the problematic experiences suggested increasing but limited assimilation (stages 0 to 2 out of eight stages). The assimilation model usefully described symbolic processing in play therapy, and the results pointed to tentative elaborations in APES stage descriptions.
... Die Studie von Mendes et al. (2016) steht exemplarisch für jene Arbeiten, die in unserem Sample diesen Anspruch erfüllten. Es wurde der Therapiefortschritt von Klient*innen u. a. mit Hilfe der Assimilation of Problematic Experiences Scale (APES) gemessen. ...
... Der Therapiefortschritt wird schulenübergreifend daran gemessen, inwiefern sich die Beziehung zu den abgelehnten Selbst-Teilen verbesserte. Besonders interessant ist dabei die offensichtliche Nähe dieser Modells und der daraus entwickelten Skala mit Rogers' siebenstufigem und mehrdimensionalem Prozesskontinuum.In der Studie vonMendes et al. (2016) wurde festgestellt, dass sich der Therapiefortschritt aber nicht kontinuierlich verbesserte. Auch Rogers wies bereits auf schwankende Verläufe im Prozesskontinuum hin. ...
File, Hutterer, Keil, Korunka und Macke-Bruck beschäftigten sich in einem 2008 veröffentlichten Artikel vorrangig mit publizierten Wirksamkeitsstudien über Klienten-/Personzentrierte und Experienzielle Psychotherapien aus den Jahren 1991 bis 2008. Aktuell wurde systematisch der Frage nachgegangen, welche Entwicklungen es in den elf Folgejahren gegeben hat. Der entstandene narrative Review setzt sich mit der Forschung von am personzentrierten Ansatz orientierten Psychotherapien breiter auseinander. Im Zentrum stehen 343 in facheinschlägigen Zeitschriften publizierte Forschungsarbeiten der Jahre 2008 bis 2019. Im 1. Teil werden die zugeordneten Ergebnisse aus Metaanalysen, Fallstudien und empirisch beforschten Aspekten des Psychotherapieprozesses präsentiert.
... Although the theory proposes a regular sequence of stages of change, in practice, this process often appears discontinuous and irregular. This instability has been studied through the analysis of moment-to-moment setbacks and advances in assimilation progress (Caro Gabalda, 2006;Mendes et al., 2016). Previous studies have consistently suggested that instability is a normal and important part of therapeutic change (Basto, Stiles, Bento et al., 2018;Detert et al., 2006;Knobloch et al., 2001;Osatuke et al., 2005). ...
... Although in good-outcome cases APES levels tended to increase during therapy, researchers who have analyzed assimilation progress more carefully have observed a fluctuating, sawtoothed pattern of progress, with frequent setbacks alternating with the advances within the broader pattern APES progress (Caro Gabalda, 2006Gabalda, , 2008Caro Gabalda & Stiles, 2013;Detert et al., 2006;Knobloch et al., 2001;Mendes et al., 2016;Osatuke et al., 2005). In these studies, a setback was defined as a decrease of at least one APES level from one passage to the next (Caro Gabalda & Stiles, 2013). ...
... Thus, rather than being an undesirable phenomenon, setbacks seem to be an important feature of assimilation progress. Previous case studies have shown that both good-and poor-outcome cases exhibit numerous, marked setbacks (Caro Gabalda, 2006, Mendes et al., 2016. ...
The assimilation model suggests that therapeutic change occurs through a gradual assimilation of problematic experiences. Previous case studies have suggested that both good-and poor-outcome cases exhibit a fluctuating pattern of assimilation progress, characterized by advances and setbacks. Our study examined more closely how this fluctuating pattern is related to symptom change across therapy. We analyzed the longitudinal relations among assimilation ratings, instability (fluctuation) in assimilation ratings, and clinical symptom intensity in two contrasting cases of emotion-focused therapy for depression, one good and one poor outcome. The results showed that in the good-outcome case, assimilation levels and instability tended to increase and symptom intensity tended to decrease, particularly in the final phase of treatment. In the poor-outcome case, assimilation levels and instability did not change much across sessions.
