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Introduction
In psychotherapy, the variables related to therapeutic
communication have earned a strong emphasis and empir-
ical support (Bickman, 2008). According to Salvatore and
Tschacher (2012), we can see the temporal dependency of
the therapeutic process through a semantic communication
level, since the meaning of any event in the dyadic com-
munication does not end in the event itself. Inversely, as
psychotherapy is a dynamic process, what happens now is
a consequence of what happened before, and a starting
point to what will happen next (Salvatore & Tschacher,
2012). In this sense, the therapeutic process can be seen as
a resource to help people change problematic patterns of
thought or interaction that occur in an interdynamic sys-
tem. More specifically, therapist and client contribute to-
Client’s immersed and distanced speech and therapist’s interventions
in emotion-focused therapy for depression: an intensive analysis
of a case study
Ana Bela Couto,1,2 Eunice Barbosa,3Sara Silva,1,2 Tiago Bento,1,2 Ana Sofia Teixeira,4João Salgado,1,2 Carla Cunha1,2
1Center of Psychology, University of Porto, Porto; 2Department of Psychology and Communication, University Institute of Maia-ISMAI,
Maia; 3Cognitive-Behavioural Research Centre, Department of Psychology, University of Coimbra, Coimbra; 4Research Center on
Psychology, Department of Psychology, University of Minho, Braga, Portugal
ABSTRACT
Previous laboratory studies have explored the importance of
participants adopting an immersed or distanced perspective in
the analysis of their experiences. These studies concluded that
distancing allows analyzing emotions in a healthier way and im-
mersion leads to higher vulnerability. However, in psychothe-
rapy, the relationship between these perspectives and clinical
change has been less investigated. The present study aims to
contribute to understanding how these variables evolve during
psychotherapy and also to explore the therapist’s contributions
to this process. This study analyzes a good-outcome case of
emotion-focused therapy for depression through two observa-
tional measures of psychotherapy process: the measure of im-
mersed and distanced speech – which identifies client’s adoption
of an immersed or distanced stance when talking about their pro-
blems – and the helping skills system – which identifies thera-
pist’s interventions focused on exploration, insight or action.
Results showed a decrease of immersed speech and an increase
of distanced speech along the process, with a higher frequency
of exploration skills preceding both types of client’s speech. Fi-
nally, the evolution of therapist’s and client’s speech showed a
reasonable flexibility of therapeutic dialogue throughout the ses-
sions, in particular due to the evolution of client variables (evi-
dencing a higher diversity of behaviors).
Key words: Immersion; Distancing; Therapist’s interventions;
Emotion-focused therapy; Depression.
Correspondence: Carla Alexandra Castro Cunha, University Insti-
tute of Maia-ISMAI, Avenida Carlos Oliveira Campos, Castêlo da
Maia, 4475-690 Avioso S. Pedro, Portugal.
Tel: +351.229.866000 - Fax: +351.808202214.
E-mail: ccunha@ismai.pt
Citation: Couto, A.B., Barbosa, E., Silva, S., Bento, T., Teixeira,
A.S., Salgado, J., & Cunha, C. (2016). Client’s immersed and dis-
tanced speech and therapist’s interventions in emotion-focused
therapy for depression: an intensive analysis of a case study. Re-
search in Psychotherapy: Psychopathology, Process and Outcome,
19(2), 136-149. doi: 10.4081/ripppo.2016.205
Contributions: the sample was provided by the head research JS,
which is the therapist of the clinical case analysed. Coding process
was performed by ABC, EB and AST. The data analysis was per-
formed by ABC, EB, CC and TB (State Space Grids’ analysis). The
writing of the manuscript was performed by ABC and SS, with all
the reviews performed by CC and EB (client’s immersed and dis-
tanced speech revisions).
Conflict of interest: the authors declare no potential conflict of in-
terest.
Funding: this article was supported by the Foundation for Science
and Technology (FCT; Lisboa, Portugal) by the funded project
PTDC/PSI-PCL/103432/2008 and by doctoral individual grant
(SFRH/BD/77183/2011).
Conference presentation: this research was presented at national
and international conferences. Communications: i) IX Congresso
Iberoamericano de Psicologia/2º Congresso da OPP, Lisboa, Por-
tugal (2014); ii) VIII Simpósio Nacional de Investigação em Psi-
cologia, Aveiro, Portugal (2013). Poster: i) 45th Annual Meeting of
Society for Psychotherapy Research, Copenhagen, Denmark
(2014); ii) VI Congreso Internacional y XI Nacional de Psicología
Clínica, Santiago de Compostela, Spain (2013).
Received for publication: 2 November 2015.
Revision received: 10 April 2016.
Accepted for publication: 4 August 2016.
This work is licensed under a Creative Commons Attribution Non-
Commercial 4.0 License (CC BY-NC 4.0).
©Copyright A.B. Couto et al., 2016
Licensee PAGEPress, Italy
Research in Psychotherapy:
Psychopathology, Process and Outcome 2016; 19:136-149
doi:10.4081/ripppo.2016.205
[page 136] [Research in Psychotherapy: Psychopathology, Process and Outcome 2016; 19:205]
Research in Psychotherapy: Psychopathology, Process and Outcome 2016; volume 19:136-149
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gether to the moment-by-moment dynamics of their inter-
action and develop strategies to unsettle this system (Trop,
Burke, & Trop, 2013). In this way, the dyadic therapeutic
relationship can be seen as a non-constant process across
psychotherapy since both elements of the dyad work as a
dynamic system that may have different impacts in differ-
ent moments (Salvatore & Tschacher, 2012). Therefore, it
is supposed that across this process there will be a diver-
sification of therapist’s interactions (e.g. therapist’s inter-
ventions) and client changes (e.g. client’s immersed and
distancing perspectives adopted in discourse) (Town,
Hardy, Mccullough, & Stride, 2012). To investigate how
therapist’s interventions and client’s discourse perspectives
evolve throughout a single case of emotion-focused ther-
apy (EFT) for depression, the present study will explore
the interaction between these variables through a state
space grids (SSG) analysis (Lewis, Zimmerman, Hollen-
stein & Lamey, 2004).
Immersion and distancing: a definition of concepts
and a brief review of clinical implications
When a person is disclosing a difficult or problematic
experience that is lived in the present, two perspectives
can be adopted in the analysis of one’s own personal ex-
perience: an immersed or a distanced perspective. In an
immersed perspective, the experience is analyzed in the
first person; that is, original thoughts, feelings, behaviors
and events experienced repeat themselves (Nigro &
Neisser, 1983). In contrast, in a distanced perspective, per-
sonal experience is analyzed adopting a third person
stance; that is, as an observer who is able to recognize pat-
terns or new aspects. Some authors use the following ex-
pressions: seeing the experience through his/her own eyes
(Ayduk & Kross, 2010b, p. 810), to refer to an immersed
stance and, in turn, seeing the experience as a fly on the
wall to refer to a distanced, observer stance (Ayduk &
Kross, 2010b, p. 809).
According to previous laboratory and experimental
studies under this approach, when immersed, people tend
to reflect on problematic experiences on a more concrete
way, recounting specificities and characteristics of the ex-
perience in a more passive way. This can lead or intensify
negative affect (I was robbed this week and I felt very
scared. They took me my house key and I need to switch
the lock immediately). In contrast, when distanced, people
tend to reflect on problematic experiences in a more ab-
stract way, creating new meanings and more positive
emotional states (I concluded that I cannot punish myself
for things that I cannot change) (Ayduk & Kross, 2010a,
2010b; Kross, Ayduk, & Mischel, 2005).
Previous laboratory and clinical studies by authors
such as Ayduk and Kross (e.g. Ayduk & Kross, 2010a,
2010b; Kross, 2009; Kross & Ayduk, 2008, 2011; Kross
et al., 2005) have shown that adopting a distancing stance
has been associated with more positive outcomes, such
as: i) better reconstruction of clinical problems; ii) lower
ruminative processes; iii) decrease of depressive symp-
toms; and iv) the promotion of individual well-being.
The previous laboratory studies, led these authors
(Ayduk & Kross, 2010a, 2010b; Kross & Ayduk, 2009,
2011; Kross et al., 2005) to conclude that an increased dis-
tancing stance allows analyzing personal experiences more
adaptively, generating more positive emotions and thus
contributing to a reconstruction of their meanings and to a
more adaptive reflection. On the other hand, in the case of
higher immersed stance, the person will be more vulnerable
to rumination as a result of a greater focus on retelling the
experience and confronting negative, painful experiences
(Kross & Ayduk, 2009; Kross et al., 2005). Rumination, as
defined by Nolen-Hoeksema (1991), refers to behaviors
and thoughts that focus one’s attention on one’s depressive
symptoms and on the implications of these symptoms (p.
569). Going further in the attempt to explore the link be-
tween these perspectives and clinical symptoms, Kross and
Ayduk (2008) also analyzed feelings associated with an ex-
perience of depression. In this study, they found that a more
distanced perspective upon problematic experiences al-
lows less emotional reactivity, comparing to the analysis
from an immersed perspective.
Despite the relevance of the studies carried out by
Kross and Ayduk (2011) denoting that distancing may be
a beneficial process for the reconstruction of meaning re-
lated to the negative experiences of more vulnerable pop-
ulations (e.g. depressed participants), up until now, few
studies have explored the evolution of immersed and dis-
tanced perspectives along psychotherapy. The present
study attempts to address this issue, aiming to contribute
to the understanding of how immersed and distanced per-
spectives evolve in other clinical contexts, such as psy-
chotherapy, beyond laboratory, experimental studies.
Immersion and distancing in psychotherapy
Along this line of reasoning, previous studies within
our research team have applied the study of immersion
and distancing in psychotherapy (Barbosa, Bento, Amen-
doeira, Mendes, Gouveia, Salgado, 2012; Barbosa et al.,
2013; Barbosa, Salgado et al., 2012). For that, a measure
of immersed and distanced speech (MIDS) was devel-
oped, based on the research by Kross and collaborators
(2005), to code how immersed or distanced the client is
in his/her perspective along each statement during the
therapeutic conversation (more on this measure below, on
the method section).
A previous study using the MIDS conducted with a
good-outcome case of cognitive behavioral therapy
(CBT) with a depressed participant, analyzed the evolution
of the immersion and distancing processes and explored its
relation with the evolution of clinical symptoms, during the
therapeutic process (Barbosa, Bento et al., 2012). Prelimi-
nary results revealed a decrease in the immersed speech
and an increase in the distancing speech during the thera-
peutic process (Barbosa, Bento et al., 2012). At a first
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Dyad dialogue in psychotherapy
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glance, the findings seem to match the results of laboratory
studies. However, other results were not as consistent with
the argument by Ayduk and Kross (2010a, 2010b), Kross
and Ayduk (2008, 2009, 2011), Kross et al. (2005): namely,
psychotherapy process was mainly characterized by an im-
mersed perspective, even though clinical symptoms were
diminishing. This case pretended another interesting find-
ing related with emotional arousal of negative emotions:
from the middle phase there was a transformation of emo-
tional arousal, passing from negative to positive emotions.
Yet, the client was still mainly adopting an immersed stance
(changes in the predominance of a distanced over an im-
mersed stance only occurred at a final phase of therapy). In
this sense, Barbosa, Bento and collaborators (2012) con-
cluded that it seems important to reduce immersion and in-
crease distancing along the therapeutic process, as
expected. Furthermore, their findings suggest that this
movement is important for client well being and improving
therapeutic outcome. However, a predominance of an im-
mersed stance was not impeditive of a decrease of symp-
tomatology. Therefore, these authors argue against
immersion being considered as harmful to the therapeutic
process (contrary to the claims by Ayduk & Kross, 2010a,
2010b; Kross & Ayduk, 2008, 2009, 2011; Kross et al.,
2005). However, given the exploratory nature of the previ-
ous studies, further efforts need to be conducted to improve
understanding of the role of immersion and distancing in
psychotherapy.
The present study: therapist’s interventions
and client’s immersed and distanced speech
in emotion-focused therapy
The present study attempts to contribute to address
two specific gaps on the current literature on immersion
and distancing. The first contribution builds on the previ-
ous work on immersion and distancing in psychotherapy,
by Barbosa, Bento and collaborators (2012). While Bar-
bosa, Bento and collaborators (2012) studied a case of
CBT, in the present study, we will focus on another ther-
apeutic modality: EFT. As proposed by Greenberg, Elliott
and colleagues (cf. Elliott, Watson, Goldman, & Green-
berg, 2004; Greenberg, 2006; Greenberg, Rice, & Elliott,
1993; Greenberg & Watson, 2006), EFT assumes that en-
during change happens by having clients focus on their
core, maladaptive painful experiences and unmet needs.
According to this view, when the therapeutic context fa-
cilitates an increased access, regulation and reflection
upon core, maladaptive emotions, emotion transformation
is promoted by having clients experience new, more adap-
tive alternatives (Elliott et al., 2004; Greenberg & Watson,
2006). Thus, we consider especially compelling to address
the role of client immersion and distancing in a good out-
come case of this experiential model, since EFT assumes
that change derives from having clients focus on painful
issues and explore problematic experiences throughout
therapy (Greenberg, 2006). Therefore, client immersion
might have a more prominent role in this therapy modality
than in others, such as CBT (Barbosa, Bento et al., 2012).
Furthermore, studying EFT may contribute further to the
discussion around the potential or harmful effects of an
immersed stance on personal problems (cf. Ayduk &
Kross, 2010a, 2010b; Kross & Ayduk, 2008, 2009, 2011;
Kross et al., 2005).
The second contribution of the present study addresses
therapist’s contributions to client change in immersion
and distancing. Previous studies looking at changes on
client immersion and distancing in psychotherapy have
not yet addressed therapist’s contributions. Nevertheless,
therapist variables have gained an increasingly strong em-
phasis in the last decades. A special focus has been given
to the therapist’s role and the relationship between thera-
peutic process and clinical outcome (Nuovo, 2011), as
well as conversation patterns between therapists and
clients (Bucci, 2013; Dagnino, Krause, Pérez, Valdés, &
Tomicic, 2012). We consider that this line of research has
important implications, namely to the training of under-
graduate students (Nuovo, 2011) in the use of these tech-
niques (Chui et al., 2014; Hill et al., 2015; Hill, Spangler,
Chui, & Jackson, 2014; Hill, Spangler, Jackson, & Chui,
2014; Jackson et al., 2014; Meystre et al., 2014; Spangler
et al., 2014) due to the effectiveness of these on therapeu-
tic outcome across different modalities of psychotherapy
(Cunha et al., 2012; Goates-Jones, 2004; Goates-Jones,
Hill, Stahl, & Doscheck, 2009; Hill et al., 2015).
A specific system chosen in this study to evaluate ther-
apist’s interventions is the helping skills system (HSS;
Hill, 2002, 2014), which remains one of the most well-
known and widely used until now (cf. Chui et al., 2014;
Goates-Jones, 2004; Goates-Jones et al., 2009; Hill, 2005;
Hill et al., 2015; Hill, Spangler, Chui, & Jackson, 2014;
Hill, Spangler, Jackson et al., 2014; Jackson et al., 2014;
Meystre et al., 2014; Spangler et al., 2014). The HSS
codes several types of therapist interventions, organized
around three major categories: i) exploration skills (re-
lated to an exploration phase of psychotherapy, aim to
deepen the exploration of client problems, through the use
of approval and reassurance, closed questions, open
questions, restatements and reflections of feelings); ii) in-
sight skills (related to an insight phase of psychotherapy,
aim to facilitate increased client insight regarding diffi-
culties, through the use of challenges, interpretations, dis-
closures and immediacy); and iii) action skills (related to
an action phase of psychotherapy, aim to help clients
transform their lives through new actions or behaviors,
through information and direct guidance – Hill, 2014).
A recent study looking at therapist’s interventions
(through the HSS) in EFT in depression conducted by
Cunha and collaborators (2012) focused on how different
skills were related to client narrative change in good and
poor outcome cases (more specifically, innovative mo-
ments appearing in client speech). Results indicated that
exploration skills were more frequent than other skills
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across all different therapy phases of good and poor-out-
come cases. Action and insight skills, although they were
less frequent, occurred more often in poor-outcome cases
than in good-outcome cases (Cunha et al., 2012). Yet,
whereas Cunha and collaborators (2012), focused on
client narrative change (through the presence of innova-
tive moments in client speech), the present study looks
specifically to the perspectives adopted in client speech –
i.e. an immersed or a distancing stance – and to how these
evolve in an EFT dyad.
In sum, in the present study we will: i) describe the
evolution of client’s immersed and distanced speech in a
good outcome case of EFT; ii) identify which therapist in-
terventions precede each types of speech; and, iii) char-
acterize the evolution of the dyadic interaction
(therapist-client) in function of these processes. Based on
these goals and on the literature reviewed above, we raise
the following hypotheses: i) a decrease of immersion and
an increase of distancing along the therapeutic process,
with a higher prevalence of immersion in the initial stage;
ii) a higher prevalence of exploration skills throughout the
process, with a slight evolution of insight and action skills
along the therapeutic process; iii) a flexible dyadic pattern
throughout the process, with a stable evolution of some
attractors, namely exploration with immersion in the ini-
tially and middle phase, and exploration with distancing
in final stage.
Materials and Methods
Sample and selection of participants
Client
Julia (fictional name) was a 30-year-old, single and
unemployed, white woman when she participated in the
research project. This project was a randomized clinical
study that contrasted CBT with EFT conditions for the
treatment of mild to moderate depression (without phar-
macotherapy).
Julia had a diagnosis of major depressive disorder,
mild (American Psychiatric Association, 2006) assessed
at intake through the structured clinical interview for
DSM-IV disorders – Axis I (SCID-I; First, Spitzer, Gib-
bon, & Williams, 1997) and Axis II (SCID-II; First, Gib-
bon, Williams, & Benjamin, 1997). She met the inclusion
criteria for the study, specifically: she was diagnosed with
major depressive disorder (mild or moderate), was not
taking psychotropic medication, and exhibited a global
functional evaluation superior than 50. The clinical prob-
lems identified for this participant were her feelings of in-
security and inadequacy, and the rejection and negligence
of her dysfunctional family. The evolution of global clin-
ical symptoms and depressive symptoms, measured by
the Outcome Questionnaire-45.2 (OQ-45) [Lambert
(2012); Portuguese version by Machado and Fassnacht
(2014)] and Beck Depression Inventory-II (BDI-II) [Steer,
Ball, Ranieri, and Beck (1999); Portuguese version by
Coelho, Martins, and Barros (2002)] respectively,
throughout five sessions of the therapeutic process
(namely, session 1, 4, 8, 12 and 16) can be observed in
Table 1. In order to check if Julia presented a reliable and
clinically significant change, a reliable change index
(RCI) criteria was calculated for BDI-II and OQ-45, ac-
cording to the guidelines by Jacobson and colleagues (Ja-
cobson & Truax, 1991; McGlinchey, Atkins, & Jacobson,
2002). Julia decreased from a score of 19 to 2 in the BDI-
II (below the cutoff point of 14.29 and a change higher
than 8.46 from pre to post-test – RCI=2.95; Seggar, Lam-
bert, & Hansen, 2002) in depressive symptoms and from
a score of 82 to 59 in the OQ-45 (below the cutoff point
of 62 and a with a higher decreased than 15 from pre to
post-test – RCI=2.49; Machado & Fassnacht, 2014) in
clinical symptoms. As both RCIs are higher than 1.96 (Ja-
cobson, & Truax, 1991), Julia was considered a recovered
and good-outcome case.
Therapist
The therapist was a 43-year-old European, white male.
He had 20 years of experience as a psychotherapist and 5
years of training and supervision in EFT. He received
weekly peer-supervision throughout the study, based on
the analysis of video-recorded sessions.
Research team
A total of three judges, all females in her twenties, par-
ticipated in this study as judges: two were PhD students
in clinical psychology and one a graduate student in clin-
ical psychology. One of the judges was aware of the out-
come status of this case; the other two were blind to it.
Treatment
Sessions of the Julia case were based on the EFT man-
uals for depression (Elliott et al., 2004; Greenberg & Wat-
son, 2006), which aim to access and restructure
maladaptive emotional responses, as well as enable and
validate the emergence of new emotions that facilitate
emotional change and self-reorganization (Greenberg &
Pascoal-Leone, 2006; Greenberg & Watson, 2006). EFT
combines the empathic, client-centered relationship from
humanistic therapies, and the more directive, experiential
techniques from gestalt therapy and focusing-oriented
[Research in Psychotherapy: Psychopathology, Process and Outcome 2016; 19:205] [page 139]
Dyad dialogue in psychotherapy
Table 1. Evolution of clinical symptoms.
Measures Pre-test Session
1 4 8 12 16
BDI-II 19 11 15 18 8 2
OQ-45.2 82 77 75 72 72 59
BDI-II, Beck Depression Inventory-II; OQ-45.2, Outcome Questionnaire 45.2.
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psychotherapy (Gendlin, 1996; Greenberg, 2002). EFT is
marker-guided psychotherapy, since it evolves through
specific tasks that match and are implemented when
clients present specific problem markers (Elliott et al.,
2004; Greenberg, 2002, 2010; Greenberg & Watson,
2006; Pos & Greenberg, 2007). Some examples are: i)
two-chair work for conflict splits; ii) empty-chair work
for unfinished business; iii) evocative enfolding for prob-
lematic reactions; iv) focusing for unclear felt sense.
Measures
Outcome measures
In order to monitor clinical symptoms, the present
study used the following measures applied in sessions 1,
4, 8, 12 and 16:
Beck Depression Inventory - II (BDI-II) [Steer et al.
(1999); Portuguese version by Coelho et al. (2002)]. The
BDI-II is a 21-item self-report measure used to character-
ize the intensity and diversity of depressive symptoms in
the two weeks prior to its completion. The instrument has
a high internal consistency (α=.91; reported by Steer,
Brown, Beck, & Sanderson, 2001), and a cut-off point of
14.29 points with a RCI of 8.46 (Seggar et al., 2002).
Outcome Questionnaire-45.2 (OQ-45.2) [Lambert
(2012); Portuguese version by Machado & Fassnacht
(2014)]. The OQ-45.2 is a 45-item self-report measure,
designed to assess global clinical symptoms in the client
reported in the previous week to its completion (Lambert,
2012). In the study of psychometric properties of the Por-
tuguese version, the cut-off was defined as 62, and the
RCI as 15 points. This instrument has evidenced high in-
ternal consistency (α=.93, reported by Machado & Fass-
nacht, 2014).
Measure of immersed and distanced speech
To code client speech we used is the measure of im-
mersed and distanced speech (MIDS) (a measure adapted
from Ayduk & Kross, 2010a; Barbosa, Bento et al., 2012).
This measure focuses on the analysis of client’s speech,
coding how immersed or distanced clients are in their per-
spective along each statement during the therapeutic con-
versation. This measure classifies immersed speech in two
nominal and mutually exclusive categories: what state-
ments and attributive statements. These two categories
correspond to concrete description of the experience ac-
cording to an egocentric point of view. However, while
what statements are assigned to speech in which clients
describe a sequence of events, thoughts or behaviors about
him/herself or others (What happened), attributive state-
ments are assigned to speech in which client describes
characteristics that show his/her emotional involvement,
feelings or internal states about him/herself or others
(How I/others feel/felt). Distancing speech is classified
also according to two nominal and mutually exclusive cat-
egories: insight statements and closure statements. These
categories correspond to an abstract description of the ex-
perience as if it was seen by a third person. More specif-
ically, while insight statements are assigned to speech in
which clients establish connections between events, be-
haviors, feelings and cognitions, showing a clearer under-
standing about the experience; closure statements are
assigned to speech in which client expresses the experi-
ence in a broader context based on past and current expe-
riences, providing a sense of closure, as, for example
reevaluation of the situations. The speech that it is not re-
lated to clinical problems or to therapy issues is consid-
ered as uncodable. These categories were adapted from
previous investigations of Kross and collaborators (2005).
The article of the validation of MIDS is under preparation,
however, preliminary results show a good internal consis-
tency for both immersion and distancing categories (α=.95
and .91 respectively), as well as an interrater agreement
that ranged from .75 to .96 (good to strong agreement;
Hill & Lambert, 2004), with a strong agreement between
pairs of judges for the entire sample (K=.82).
Helping skills system
To code therapist’s interventions we used the HSS
(Hill, 2002), which remains one of the most well-known
and widely used until now (Chui et al., 2014; Cunha et al.,
2012; Goates-Jones, 2004; Goates-Jones et al., 2009; Hill,
2005; Hill et al., 2015; Hill, Spangler, Chui, & Jackson,
2014; Hill, Spangler, Jackson, et al., 2014; Jackson et al.,
2014; Meystre et al., 2014; Spangler et al., 2014). The HSS
is a revision of the hill counselor verbal response category
system (Hill, 1978) and consists in 12 nominal and mutu-
ally exclusive categories of therapist’s interventions, or-
ganized around three major categories, namely
exploration, insight and action skills. Exploration skills
(related to an exploration phase of psychotherapy, aim to
deepen emotional exploration in the client) group approval
and reassurance, closed questions, open questions, restate-
ments and reflection of feelings. Insight skills (related to
an insight phase of psychotherapy, aim to facilitate in-
creased client insight) group challenges, interpretations,
self-disclosures and therapist immediacy. Action skills (re-
lated to an action phase of psychotherapy, aim to help
clients transform their lives through new actions or behav-
iors) group information and direct guidance (Hill, 2014).
When therapist’s statements do not fit in any of these skills,
they are coded as Other. In terms of the reliability of this
system, Hess, Knox and Hill (2006) reported a strong in-
terrater agreement (Hill & Lambert, 2004) between pairs
of judges (K=.91).
Procedures
In this study we analyzed 5 psychotherapy sessions
with Julia: sessions 1 and 4 (representing the initial phase
of psychotherapy), 8 and 12 (representing the middle
phase), and 16 (representing the final phase). These ses-
sions were selected to match the sessions where clinical
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symptoms were monitored (i.e. BDI-II and OQ-45; cf.
above). These sessions were initially transcribed accord-
ing to the rules of Mergenthaler and Stinson (1992) and
the qualitative analysis of these sessions took place along
the steps described below.
Step 1: unitizing
For unitizing therapist and client speech, each talking
turn was divided into units of grammatical sentences (i.e.
every minimal unit with a subject and a verb), based on
the procedures described by Hill (2004). This unit con-
sists of an independent or a main clause, which occurs
by itself or with more than one dependent or subordinate
clauses. Initially, training sessions were performed by
the three judges, reaching a satisfactory level of agree-
ment (at least 90% agreement in unitizing between pairs
of judges). Afterwards, judges advanced to the division
in units of the five sessions to analyze, reaching a satis-
factory agreement for the client (92.62%) and therapist
(93.7%) units of analysis. As each talking turn can have
more than one unit, the judges subsequently chose,
through consensual agreement, which unit of analysis
was predominant and would be coded according to the
HSS and the MIDS. The criterion used to choose was
based on the unit in which the content was responded or
used by the other dyadic element in the next talking turn.
For example, if therapist says I wonder if we could ex-
plore a little more what you have just said. How did you
felt in that situation? and client respond I felt stressed,
then the predominant unit of therapist talking turn is
How did you felt in that situation?
Step 2: coding with the helping skills system
In the next phase all judges initiated the training in
HSS, reaching a satisfactory agreement (.789, calculated
by Cohen’s Kappa). According to Hill and Lambert
(2004), an agreement is satisfactory when the Cohen’s
Kappa is greater than .75. After this, all judges were reli-
able to proceed to the coding of all therapist units of
analysis, classified according to the categories of therapist
interventions according to the HSS. The three judges ob-
tained high reliability (Cohen’s Kappa=.854; according
to Hill & Lambert, 2004). Then, disagreements were re-
solved by consensus between the three judges.
Step 3: coding with the measure of immersed and distanced
speech
The third phase was initiated through training of
judges in the MIDS. According to the application of this
measure, all client units of analysis were classified ac-
cording to the subcategories of immersed or distancing
speech, described above. Inter-judge reliability in the
MIDS was high (Cohen’s Kappa=.831; according to Hill
& Lambert, 2004). Disagreements were resolved through
consensus between the two judges.
Step 4: qualitative and quantitative analysis of results
MS Excel was used for the descriptive analysis of the
evolution of immersed and distanced speech and of the
therapeutic interventions.
To study the evolution of the dynamic system through-
out the process and according to the variables under study
(types of client speech and therapist interventions), we
used the SSG analysis through the Gridware software
(Lamey, Hollenstein, Lewis, & Granic, 2004). The state
space grids are a graphical and statistical approach bor-
rowed from the dynamic systems theory and applied to
developmental psychology (Lewis, Lamey & Douglas,
1999). SSG allows the development of hypotheses about
dyadic behavioral processes, on a moment-to-moment
basis, and also to describe dyadic behavioral patterns that
emerge from the interaction within dyad (Provenzi, Bor-
gatti, Menozzi, & Montirosso, 2015); in this case – be-
tween therapist and client. These patterns are depicted
graphically in the present study by a 4x3 grid with two
mutually exclusive and synchronized categorical time se-
ries (Hollenstein, 2015). Here, the 4 types of client speech
(what and attributive statements as categories for client
immersed speech, plus insight and closure statements as
categories for client distancing speech) are represented in
the y-axis, and the 3 types of therapist interventions in the
x-axis (exploration, insight and action interventions ac-
cording to the HSS). We constructed 5 different grids to
represent sessions 1, 4, 8, 12 and 16, each one with 12
cells (4x3 categories).
These grids show all possible states or behaviors oc-
curring in the dyad in a given time frame (Hollenstein,
2007, 2015). In our study, each grid represents the dyadic
exchanges occurring in a given session, by showing the
shift between therapist interventions and client speech cat-
egories (immersed or distanced). Each cell represents a si-
multaneous interception of dyadic behaviors, and each
circle (placed inside the cell) represents an interaction be-
tween therapist and client categories, i.e., a circle repre-
sents a given, therapist interventions followed by a specific
client speech category. Additionally, as a SSG allows rep-
resenting the temporal evolution of the dyadic exchange,
each line and arrow between circles (and cells) depicts the
trajectory and the succession of exchanges, given the di-
rection from one interaction to another. Finally, the hollow
circle represents the first behavior occurrence in the ses-
sion (Granic & Hollenstein, 2003; Hollenstein, 2007,
2015; Ribeiro et al., 2011). To specify with an example, a
dyad may start a session with an exploratory intervention
from the therapist how are you today?, followed by a client
attributive statement I’m sad (depicted by a hollow circle
in a cell that intersects therapist exploratory intervention
and client attributive statement) and then, in the next turn-
taking, the therapist can use an action intervention let’s talk
about it. Responded by the client with an insight statement
this feeling is so repetitive in my life (depicted by a full cir-
cle in a cell that intersects therapist action intervention and
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Dyad dialogue in psychotherapy
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client insight statement, connected to the previous turn-
taking by a line).
The system can only be in a given state (cell) at a par-
ticular moment in time, even if other possibilities in the
dyad were available (represented by other cells; Hollen-
stein, 2015). However, when a change occurs in dyadic
behavior, a new circle appears in the cell, and a new line
and arrow are drawn. This depicts a graphic movement, a
pattern of dyadic interaction along the grid, providing in-
formation on the structural dynamics and temporal trajec-
tory of the dyad, i.e. flexibility between cells (referring to
movements across the cells, creating a trajectory that is
more or less spread along the grid – evidencing more or
less flexibility in the dyadic interaction) or attractors (a
name for the cells that concentrate most of the interactions
occurring in the dyad (Hollenstein, Granic, Stoolmiller,
& Snyder, 2004; Ribeiro et al., 2011).
Theoretically, all dynamic systems that are self-orga-
nized tend to stabilize in certain states, known as attrac-
tors. The attractors are a recurrent, redundant and stable
intersection of dyadic behaviors that absorb and attract
the system from other potential states (Hollenstein et al.,
2004, p. 597). Attractors correspond to the cells with a
higher frequency of occurrences (Tomicic et al., 2015).
To make this concept clearer, Hollenstein and collabora-
tors (2004) provide some examples that illustrated this
pattern in a family dynamic: a state of mutual hostility can
be understood as an attractor for a particular family that
means that they easily get drawn toward a hostile pattern
of interaction and once the conflict has begun, it is diffi-
cult to pull out of this (p. 597). The process of change is
evidenced when there is movement between and variabil-
ity in different attractors over time (Hayes, Yasinski,
Barnes, & Bockting, 2015; Hollenstein, 2007; Howertwe,
Hollenstein, Boon, Niemeyer, & Brulee, 2012; Lewis et
al., 1999, 2004; Ribeiro et al., 2011, for other studies
using this type of analysis).
To verify which dyadic behaviors are considered as
attractors of the system we used Marc Lewis’ winnowing
technique (Lewis et al., 1999), which consists of a series
of runs in order to calculate the heterogeneity of each grid.
At the beginning, we started with all cells visited (with
circles) in the grid and shift, at each round, to a smaller
set of cells (Tomicic et al., 2015). The mathematical
process continues until we have a percentage of the het-
erogeneity of the grid lower than 50%. For that, in each
round we have to remove cell-by-cell, starting from the
lowest frequencies and divide the heterogeneity score for
each round by the heterogeneity grid score (Ribeiro et al.,
2011). The following formula is used to measure the het-
erogeneity of each cell (Ribeiro et al., 2011, p. 63):
Hc=[(D/n) - d)]2/(D/n)
where Dcorresponds to the total number of circles on the
grid; nis the number of cells with circles; dcorresponds
to the number of circles in a specific cell. After that, it is
necessary to calculate heterogeneity of the grid by the fol-
lowing formula:
Hg=[nƩ(c)/n]
where nis the number of cells with circles and cis the
heterogeneity of each cell (obtained by the formula above)
(Ribeiro et al., 2011).
On the other hand, measures such as flexibility also
provide important information about the dyadic exchange.
Flexibility is the system ability to adapt to changes that
occur throughout the different dyadic behaviors (Hollen-
stein, 2007), in other words, the dispersion and transition
of circles through the cells of the grid. According to Hol-
lenstein and Lewis (2006), flexibility is the sum of the
squared proportional durations across all cells, adjusted
for the total number of cells in the grid matrix, and in-
verted so that values range from 0 (no dispersion: all be-
havior in one cell) to 1 (maximum dispersion: behavior
equally distributed across the grid) (p. 659). There are no
benchmarks in literature for assessing a good flexibility
because this measure depends of the phenomenon under
study. However, Hollenstein (2007) draws attention to
some aspects that should be considered in the exploration
of dyadic flexibility: i) the range or number of different
behavioral states (p. 11), namely the number of cells with
circles; ii) the number of transitions between those states
(p. 11), namely the number of lines and arrows; and iii)
the tendency to perseverate or get “stuck” in a small num-
ber of states (p. 11), namely very few variance in attrac-
tors. In this sense, a higher flexibility is associated with a
higher dispersion and transitions within cells, and a lower
flexibility is associated with a higher rigidity of dyadic
behaviors (fewer cells). We choose here the dispersion
measure since it has been considered a good indicator of
flexibility (Oliveira, 2015). In Gridware, the following
formula is used for its calculation:
D(dispersion) = 1 - [(n Σ (di/D) 2) - 1)/n- 1]
where ncorresponds to the number of cells with circles;
dicorresponds to the number of circles on a specific cell
(i); Dcorresponds to the total number of circles on the
grid (Hollenstein, 2007).
Results
Evolution of immersion and distancing speech
throughout the sessions
In relation to the evolution of immersed and distanced
speech, it is possible to observe, in Figure 1, that the im-
mersed speech remains higher than the distanced speech
until session 12, whereas in session 16 the distanced
speech becomes predominant.
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Evolution of therapist’s interventions
and client’s speech
As for the therapist’s interventions (Figure 2), these
have a stable evolution over time, with a predominance
of exploration skills regarding other skills. However, in-
sight and action skills slowly increase in session 1, 4 and
8. In terms of session 12, insight skills continue to in-
crease and action skills start to decrease. Finally, in ses-
sion 16, both skills decrease again.
Figure 3 shows the frequency of therapist’s interven-
tions that precede immersed and distanced speech. The
analysis of this figure allows us to see that exploration
[Research in Psychotherapy: Psychopathology, Process and Outcome 2016; 19:205] [page 143]
Dyad dialogue in psychotherapy
Figure 1. Absolute percentage of immersed and distanced
speech. Figure 2. Absolute percentage of therapist’s interventions.
Figure 3. Percentage of immersed and distanced speech in therapist’s interventions.
Non-commercial use only
skills are the intervention that more frequently precedes
both speeches, in all five sessions analyzed. By contrast,
insight and action skills precede both speeches at a lower
frequency, with small differences between them. More
specifically, exploration skills, for most of the sessions
(except for session 1), precede immersed speech more fre-
quently than distancing speech.
In terms of insight skills, session 1 is the only session
that precedes immersed speech but not distancing speech.
From session 4 to 8 there is an increase of insight skills
preceding immersed speech, decreasing to session 12 and
16. By contrast, an increase of insight skills preceding dis-
tancing speech appears from session 1 to 12, decreasing
in session 16.
Finally, the frequency of action skills preceding im-
mersed speech increases from session 1 to session 4, de-
creasing to session 8, increasing again to session 12, and
decreasing once again to session 16. However, the fre-
quency of action skills preceding distancing speech in-
creases from session 1 to 8, and decrease to session 16.
Overall, the exploration skills were the most frequent
interventions that precede both client speeches (given that
it was the most used by the therapist). However, it is not
clear what happens in different phases of therapy. For this,
we conducted a more intensive analysis of the different
skills composing exploration interventions (Figure 4).
The results appearing in Figure 4 showed that open
questions appear in session 1 as the most frequent thera-
pist’s skill preceding client’s distancing speech (some-
thing that does occur in immersed speech). Approval was
frequent in both speeches even though it occurred more
in immersed than in distancing speech. It is important to
point out that approval is a higher frequency intervention
in immersed speech from session 8 to 16, finalizing as the
most frequent in both speeches. Finally, we found restate-
ment and reflection of feelings in both immersed and dis-
tancing speech, but in different sessions. More
specifically, we found restatement in session 1 for im-
mersed speech and session 4 for distancing speech, and
reflection of feelings in session 4 for immersed speech
and session 12 for distancing speech.
Dyadic patterns (client-therapist)
The dyadic patterns according to the variables under
study were analyzed using the Gridware and analysis
of State Space Grids (Lamey et al., 2004), which illus-
trates which therapist interventions precede client im-
mersed or distanced speech.
Figure 5 illustrates these patterns in sessions 1, 4, 8, 12
and 16, and its dispersion (equivalent to the dispersion of
the circles in the cells) along the therapeutic process. The
visual aspect of State Space Grids (Figure 5), which de-
scribes the evolution of the dyad, as well as shows the at-
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Figure 4. Percentage of immersed and distanced speech in exploration skills.
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tractors, is complemented by the values shown in Table 2,
where it is possible to check the measure of flexibility of
the dyadic behaviors in each session. The global flexibility
increased from session 1 to 8, stabilizing in session 12,
which shows a gradual expansion of therapist interventions
and client speech. Then, in session 16 the global values of
flexibility decrease. In terms of attractors (cells limited by
black lines), it can be seen that behaviors were less dis-
persed in session 1 and 16 than in other sessions.
Observing each session individually, the attractors are
distributed as follows: in session 1, the attractors were de-
scriptive statements and attributive statements (client im-
mersed speech) and exploration skills; in session 4, the
attractors were descriptive statements (immersed speech)
with exploration and action skills, and also attributive
statements (immersed speech) and insight statements (dis-
tanced speech) with exploration skills; in session 8, the
attractors were exploration with both immersed and dis-
tanced speech and action skills with insight statements
(distanced speech); in session 12, the attractors were ex-
ploration with both immersed and distanced speech and
insight skills with insight statements (distanced speech),
as well as action skills with attributive (immersed speech)
and insight statements (distanced speech); finally, session
16 exhibited a retreat for exploration skills with all client
speeches (immersed and distanced speech).
Limitations and future directions
One of the major limitations of this study is that it was
focused on a single case, with only five sessions analyzed,
which limited the quantitative analysis as well as the
scope of the conclusions drawn from (i.e. these cannot be
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Dyad dialogue in psychotherapy
Figure 5. Dyadic patterns.
Table 2. Measures of flexibility of the dyad.
Measures Sessions
1 4 8 12 16
Flexibility 0.742 0.82 0.865 0.865 0.854
Non-commercial use only
generalized to other cases). However, we chose these ses-
sions in order to converge our analysis with the sessions
in which the depressive and general symptoms (BDI-II;
OQ-45.2) were accessed throughout the process. In the
future, other studies should be extended to more cases,
with different outcomes, and also focus on other types of
therapies, and other types of disorders (beyond depres-
sion), trying to analyze the evolution of the variables pre-
sented here in a broader sample
In our data analysis, the present study only looked to
the relation between adjacent pairs’ of interactions in the
dyad (client and therapist) and respective categories,
which is considered as the lag 1 association (Greenberg,
1986). Yet, this could not be sufficient to capture the an-
tecedent processes (lag>1), which extend beyond the im-
mediate outcomes and provide a longer impact of the
therapist interventions in client speech (Elliott, 2010).
However, Elliott, James, Reimschuessel, Cislo and Sack
(1985) suggest that the study of immediate therapeutic im-
pacts can still be useful to access the association between
therapist and client processes (namely therapist interven-
tions and client speech, in this case).
One of the main difficulties encountered during the
development of this study was the fact that clinical studies
on immersion and distancing are still very limited. The
main findings are derived from laboratory experiments,
with scarce applications to the field of clinical and psy-
chotherapy research up until now (e.g. Barbosa, Bento, et
al., 2012). This made the theoretical framing of the vari-
ables difficult yet, at the same time, this adds relevant and
innovation to the present study.
Another difficulty was related to the use of the HSS,
which is a transtheoretical model of therapist interven-
tions. Like any other transtheoretical model, despite the
advantage of providing a common lens for the compar-
ison of different therapeutic modalities, it usually leads
to some added difficulties when it is applied to a specific
modality such as EFT. This difficulty here may have
been aggravated as some of the judges did not have a
significant, direct, clinical experience with the psy-
chotherapy model in focus, at least when they were per-
forming that stage of the analysis, even though they had
previous theoretical training and observed the video-
taped EFT sessions. Similarly to the distancing and im-
mersed measure (MIDS), HSS only very recently it is
being applied in clinical studies, namely, in experiential
therapies (i.e. EFT).
Discussion
In this EFT case, the client progresses in the direction
of a gradual decrease of immersed speech and an in-
crease of distanced speech during the psychotherapy
process. The turning point for the predominance of dis-
tanced speech is the last session (16), which is in line
with previous investigations (Barbosa, Bento et al.,
2012; Barbosa et al., 2013; Barbosa, Salgado et al.,
2012). These results suggest that, for the development
of a good-outcome process, in the initial phase of EFT,
it may be important for the client to be immersed. At
least for this case, we argue that a higher immersed
speech, at an initial stage, may facilitate a greater access
of this client to her own experience, allowing new un-
derstandings, and even the resolution of relevant prob-
lems. The higher frequency of distanced speech in the
last session is a finding also consistent with previous lab-
oratory investigations (Ayduk & Kross, 2010a, 2010b;
Kross, 2009; Kross & Ayduk, 2009, 2011; Kross et al.,
2005), raising the hypothesis that the predominance of
distanced speech in a final phase of therapy may also be
an important step of a good-outcome process in an ex-
periential therapy such as EFT.
In terms of specific therapist’s interventions, in this
case the client’s immersed and distancing speeches were
preceded by therapist’s exploration skills such as restate-
ments and reflection of feelings in an initial phase, and
approval and reassurance in a final phase. These differ-
ences seem to occur in the middle phase (session 12), cor-
responding to a working-through phase of EFT, where
therapist empathy leads to an increased awareness and
arousal of client painful emotions (throughout approval).
Also in this phase of EFT, through the use of therapist ex-
ploration skills like reflection of feelings, the therapist
may have facilitated client’s distanced speech during the
process of reflecting and transforming emotional re-
sponses: for example, when the therapist followed client
reflections about the way she felt before and the differ-
ences regarding the way she feels now (closure statement
of distancing speech). The predominance of exploration
skills in this case is consistent with previous studies on
EFT that show a high prevalence of this type of therapist
interventions, congruently to the development of good-
outcome process of EFT (Cunha et al., 2012; Goates-
Jones, 2004; Goates-Jones et al., 2009).
In terms of flexibility measures, the findings in this
case point to a flexible style of interaction from both in-
terlocutors of dyad (therapist and client), characterized
with a higher frequency of therapist exploration interven-
tions (although with some action skills in sessions 4, 8
and 12 and insight skills, in session 8). As for Julia, the
client, she showed some flexibility, moving through the
various speeches across sessions. This flexibility of the
dyad added some dispersion, particularly from session 1
to 12. We consider that these results are consistent with
the EFT model, where a high flexibility in the therapeutic
process needs to exist, as therapists try to work on the here
and now, focusing on what is more poignant and more
salient in what the client brings for that specific session
(Elliott et al., 2004; Greenberg, 2010; Greenberg & Wat-
son, 2006; Pos & Greenberg, 2007). In other words, in a
working-through phase of EFT, therapists work with the
experiences that clients provide to focus in the sessions
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(Greenberg & Watson, 2006), which could lead to an in-
crease of dispersion or diversity of behavior between ther-
apist and client.
In addition, this case evidenced that attractors remain
stable in terms of exploration skills between session 8 and
12, even though in session 1 exploration skills were asso-
ciated only with descriptive and attributive statements
(immersed speech) and, in session 16, exploration skills
were associated with all client speeches (immersed and
distanced speech). These results are consistent with the
specificities of EFT, due to a greater focus on client emo-
tional experience which may led to a more detailed ex-
ploration in order to understand core, maladaptive
emotional patterns (Greenberg & Watson, 2006; Pos &
Greenberg, 2007). On the other hand, action skills ap-
peared as attractors from session 4 to 12, which is ex-
pected of EFT, once the therapist tries to facilitate specific
tasks from the EFT model during this working-through,
middle phase of the process (Pos & Greenberg, 2007;
Greenberg & Watson, 2006).
Conclusions
To conclude, the results found in the present study,
both at the level of speech evolution and the dyadic pat-
terns can be related to the specificity of the therapy (EFT),
namely: i) the focus on client’s emotional experience, and
ii) the detailed exploration of client’s experience. This is
a therapy that, at an initial stage, could lead therapists to
drive clients to a more immersed speech in such a way as
to be able to access, in a more detailed, profound manner,
their own experience (Greenberg & Watson, 2006;
Pos & Greenberg, 2007).
References
American Psychiatric Association (2006). DSM-IV-TR: manual
de diagnóstico das perturbações mentais [DSM-IV-TR: di-
agnostic and statistical manual of mental disorders]. 4th ed.
Washington, DC: American Psychiatric Association Publ.
Ayduk, Ö., & Kross, E. (2010a). Analyzing negative experiences
without ruminating: the role of self-distancing in enabling
adaptive self-reflection. Social and Personality Psychology
Compass, 4, 841-854. doi: 10.1111/j.1751-9004.2010.00301.x
Ayduk, Ö., & Kross, E. (2010b). From a distance: implications
of spontaneous self-distancing for adaptative self-reflection.
Journal of Personality and Social Psychology, 98, 809-829.
doi: 10.1037/a0019205
Barbosa, E., Bento, T., Amendoeira, M., Mendes, S., Gouveia,
J., & Salgado, J. (2012). Immersion, distancing and emo-
tional arousal: an intensive case study of a good outcome
case of CBT. Paper presented at the 3th Conference of So-
ciety for Psychotherapy Re-search European and UK Chap-
ters, Porto, Portugal.
Barbosa, E., Lourenço, P., Amendoeira, M., Gouveia, J., & Sal-
gado, J. (2013). Inmersión, distanciamiento y activación
emocional en casos de éxito de terapia focalizada en la eción
y terapia cognitivo-conductual. [Immersion, distancing and
emotional arousal in cases of cognitive-beahvioral therapy].
Paper presented at the 6th International Congress of Clinic
Psychology, Santiago de Compostela, Spain.
Barbosa, E., Salgado, J., Ferreira, T., Lourenço, P., Pinto, P.
(2012). Immersion, distancing and emotional arousal: an in-
tensive case study of a good outcome case of EFT. Paper
presented at the 43th International Conference of Society for
Psychotherapy Research, Virginia Beach, VA, USA.
Bickman, L. (2008). A measurement feedback system (MFS) is
necessary to improve mental health outcomes. Journal of
American Academy of Child and Adolescent Psychiatry, 47,
1114-1119. doi: 10.1097/CHI.0b013e3181825af8
Bucci, W. (2013). The referential process as a common factor
across treatment modalities. Research in Psychotherapy: Psy-
chopathology, Process and Outcome, 16, 16-23. doi: 10.7411/
RP.2013.003
Chui, H., Hill, C., Ain, S., Ericson, S., Del Pino, H., Hummel,
A., Spangler, P. (2014). Training undergraduate students to
use challenges. The Counseling Psychologist, 42, 758-777.
doi 10.1177/0011000014542599
Coelho, R., Martins, A., Barros, H. (2002). Clinical profiles relating
gender and depressive symptoms among adolescents ascer-
tained by the Beck Depression Inventory II. European Psychi-
atry, 17, 222-226. doi: 10.1016/S0924-9338(02)00663-6
Cunha, C., Gonçalves, M., Hill, C., Mendes, I., Ribeiro, A.,
Sousa, A., …, Greenberg, L. (2012). Therapist interventions
and client innovative moments in emotion-focused therapy
for depression. Psychotherapy: Theory, Research, Practice,
Training, 49, 536-548. doi: 10.1037/a0028259
Dagnino, P., Krause, M., Pérez, C., Valdés, N., & Tomicic, A.
(2012). The evolution of communicative intentions during
change episodes and throughout the therapeutic process. Re-
search in Psychotherapy: Psychopathology, Process and
Outcome, 15, 75-86. doi: 10.7411/RP.2012.008
Elliott, R. (2010). Psychotherapy change process research: re-
alizing the promise. Psychotherapy Research, 20, 123-135.
doi: 10.1080/10503300903470743
Elliott, R., James, E., Reimschuessel, C., Cislo, D., & Sack, N.
(1985). Significant events and the analysis of immediate
therapeutic impacts. Psychotherapy, 2, 620-630. doi: 10.
1037/h0085548
Elliott, R., Watson, J., Goldman, R., & Greenberg, L. (2004).
Learning emotion focused therapy. Washington, DC: Amer-
ican Psychiatric Association Publ.
First, M., Gibbon, M., Williams, J., & Benjamin, L. (1997).
Structured clinical interview for DSM-IV Axis II personality
disorders (SCID-II). Washington, DC: American Psychiatric
Association Publ.
First, M., Spitzer, R., Gibbon, M., & Williams, J. (1997). Struc-
tured clinical interview for DSM-IV Axis I personality dis-
orders (SCID-I). Washington, DC: American Psychiatric
Association Publ.
Gendlin, E. (1996). Focusing oriented psychotherapy. New
York, NY: Guildford.
Goates-Jones, M. (2004). Psychotherapy process in the explo-
ration stage. Washington, DC: Faculty of the Graduate
School of the University of Maryland.
Goates-Jones, M., Hill, C., Stahl, J., & Doscheck, E. (2009).
Therapist response modes in the exploration stage: timing
and effectiveness. Counselling Psychology Quarterly, 22,
221-231. doi: 10.1080/09515070903185256
Granic, I. & Hollenstein, T.P. (2003). Dynamic systems methods
[Research in Psychotherapy: Psychopathology, Process and Outcome 2016; 19:205] [page 147]
Dyad dialogue in psychotherapy
Non-commercial use only
for models of developmental psychopathology. Develop-
ment and Psychopathology, 15, 641-669. doi: 10.1017/S095
4579403000324
Greenberg, L.S. (1986). Change process research. Journal of
Consulting and Clinical Psychology, 54, 4-9. doi: 10.1037/
0022-006X.54.1.4
Greenberg, L.S. (2002). Emotion-focused therapy: coaching
clients to work through their feelings. Washington, DC:
American Psychiatric Association.
Greenberg, L.S. (2006). Emotion focused therapy: a synopsis.
Journal of Contemporary Psychotherapy, 36, 86-93. doi:
10.1007/s10879-006-9011-3
Greenberg, L.S. (2010). Emotion-focused therapy: an overview.
Turkish Psychological Counseling and Guidance Journal,
4, 1-12. doi: 1058000242/1058000244
Greenberg, L., & Pacoal-Leone, A. (2006). Emotion in psy-
chotherapy: a practice-friendly research review. Journal
Clinical Psychology, 62, 611-630. doi:10.1002/jclp.20252
Greenberg, L., Rice, L. & Elliott, R. (1993). The moment by mo-
ment process: facilitating emotional change. New York, NY:
Guilford Press.
Greenberg, L., & Watson, J. (2006). Emotion-focused therapy
for depression. Washington, DC: American Psychiatric As-
sociation.
Hayes, A., Yasinski, C., Barnes J.B., & Bockting, C. (2015). Net-
work destabilization and transition in depression: new meth-
ods for studying the dynamics of therapeutic change.
Clinical Psychology Review, 41, 27-39. doi: 10.1016/j.cpr.
2015.06.007
Hess, S., Knox, S., & Hill, C.E. (2006). Teaching graduate stu-
dent trainees how to manage client anger: a comparison of
three types of training. Psychotherapy Research, 16, 282-
292. doi: 10.1080/10503300500264838
Hill, C.E. (1978). Development of a counselor verbal category
system. Journal of Counseling Psychology, 25, 461-468.
doi: 10.1037/0022-0167.25.5.461
Hill, C. (2002). Development and use of the helping skills meas-
ure to assess client perceptions of the effects of training and
of helping skills in sessions. Journal of Counseling Psychol-
ogy, 49, 164-172. doi: 10.1037//0022-0167.49.2.264
Hill, C. (2004). Helping skills: facilitating exploration, insight,
and action. 3rd ed. Washington, DC: American Psychiatric
Association.
Hill, C. (2005). Therapist techniques, client involvement, and the
therapeutic relationship: inextricably intertwined in the ther-
apy process. Psychotherapy: Theory, Research, Practice,
Training, 42, 431-442. doi: 10.1037/0033-3204.42.4.431
Hill, C. (2014). Helping skills: facilitating exploration, insight,
and action. 4th ed. Washington, DC: American Psychiatric
Association.
Hill, C., Baumann, E., Shafran, N., Gupta, S., Morrison, A.,
Rojas, A., Gelso, C. (2015). Is training effective? A study of
counseling psychology doctoral trainees in a psychody-
namic/interpersonal training clinic. Journal of Counseling
Psychology, 62, 184-201. doi.org/10.1037/cou0000053
Hill, C., & Lambert, M. (2004). Methodological issues in study-
ing psychotherapy processes and outcomes. In: M.J. Lam-
bert (Ed.), Bergin and Garfield’s handbook of psychotherapy
and behavior change (5th ed., pp. 84-135). New York, NY:
John Wiley & Sons.
Hill, C., Spangler, P., Chui, H., & Jackson, J. (2014). Training
undergraduate students to use insight skills: overview of the
rationale, methods, and analyses for three studies. The Coun-
seling Psychologist, 42, 702-728. doi: 10.1177/00110000
14542598
Hill, C., Spangler, P., Jackson, J., & Chui, H. (2014). Training
undergraduate students to use insight skills: integrating the
results of three studies. The Counseling Psychologist,
42:800-820. doi: 10.1177/0011000014542602
Hollenstein, T. (2007). State space grids: analyzing dynamics
across development. International Journal of Behavioral De-
velopment, 31, 384-396. doi: 10.1177/0165025407077765
Hollenstein, T. (2015). The dynamic systems perspective: what
is the system? In: L.C. Mayes & M. Lewis (Eds.), The Cam-
bridge handbook of environment in human development (pp.
138-151). New York, NY: Cambridge University Press.
Hollenstein, T., Granic, I., Stoolmiller, M., & Snyder, J. (2004).
Rigidity in parent-child interactions and the development of
externalizing and internalizing behavior in early childhood.
Journal of Abnormal Child Psychology, 32, 595-607. doi:
10.1023%2FB%3AJACP.0000047209.37650.41
Hollenstein, T., & Lewis, M.D. (2006). A state space analysis of
emotion and flexibility in parent-child interactions. Emotion,
6, 663-669. doi: 10.1037/1528-3542.6.4.656
Howertwe, A., Hollenstein, T., Boon, H., Niemeyer, K., & Brule,
D. (2012). State-space grid analysis: applications for clinical
whole systems complementary and alternative medicine re-
search. Forsch Komplementmed, 19, 30-35. doi: 10.1159/
000335187
Jackson, J., Hill, H., Spangler, P., Ericson, S., Merson E., Liu,
J., …, Reen, G. (2014). Training undergraduate students to
use interpretation. The Counseling Psychologist, 42, 778-
799. doi: 10.1177/0011000014542600
Jacobson, N., & Truax, P. (1991). Clinical significance: a statis-
tical approach to defining meaningful change in psychother-
apy research. Journal of Consulting and Clinical
Psychology, 59, 12-19. doi: 10.1037/0022-006X.59.1.12
Kross, E. (2009). When the self becomes other: toward an inte-
grative understanding of the processes distinguishing adap-
tive self-reflection from rumination. Values, Empathy, and
Fairness across Social Barriers: Annals of the New York
Academy of Sciences, 1167, 35-40. doi: 10.1111/j.1749-
6632.2009.04545.x
Kross, E., & Ayduk, Ö. (2008). Facilitating adaptive emotional
analysis: distinguishing distanced-analysis of depressive ex-
periences from immersed-analysis and distraction. Person-
ality and Social Psychology Bulletin, 34, 924-938. doi:
10.1177/0146167208315938
Kross, E., & Ayduk, Ö. (2009). Boundary conditions and buffer-
ing effects: does depressive symptomology moderate the ef-
fectiveness of self-distancing for facilitating adaptive
emotional analysis? Journal of Research in Personality, 43,
923-927. doi: 10.1016/j.jrp.2009.04.004
Kross, E., & Ayduk, Ö. (2011). Making meaning out of negative
experiences by self-distancing. Current Directions in Psy-
chological Science, 20, 187-191. doi: 10.1177/0963721411
408883
Kross, E., Ayduk, Ö., & Mischel, W. (2005). When asking
“why” does not hurt: distinguishing rumination from reflec-
tive processing of negative emotions. Psychological Sci-
ence, 16, 709-715. doi: 10.1111/j.1467-9280.2005.01600.x
Lambert, M. (2012). The outcome questionnaire-45. Integrating
Science and Practice, 2, 24-27.
Lamey, A., Hollenstein, T., Lewis, M., & Granic, I. (2004). Grid-
Ware (version 1.1). [Computer software]. Retrieved from:
http://statespacegrids.org
[page 148] [Research in Psychotherapy: Psychopathology, Process and Outcome 2016; 19:205]
Article
Non-commercial use only
Lewis, M., Lamey, A., & Douglas, L. (1999). A new dynamic sys-
tems method for the analysis of early socioemotional devel-
opment. Developmental Science, 2, 458-476. doi: 10.1111/
1467-7687.00090
Lewis, M., Zimmerman, S., Hollenstein, T., & Lamey, A. (2004).
Reorganization in coping behavior at 1½ years: dynamic
systems and normative change. Developmental Science, 7,
56-73. doi: 10.1111/j.1467-7687.2004.00323.x
Machado, P., & Fassnacht, D. (2014). The Portuguese version
of the outcome questionnaire (OQ-45): normative data, re-
liability, and clinical significance cut-offs scores. Psychol-
ogy and Psychotherapy: Theory, Research and Practice, 88,
427-437.doi:10.1111/papt.12048
McGlinchey, J.B., Atkins, D.C., & Jacobson, N.S. (2002). Clin-
ical significance methods: which one to use and how useful
are they? Behavior Therapy, 33, 529-550. doi: 10.1016/
S0005-7894(02)80015-6
Mergenthaler, E., & Stinson, C. (1992). Psychotherapy tran-
scription standards. Psychotherapy Research, 2, 125-142.
doi: 10.1080/10503309212331332904
Meystre, C., Pascual-Leone, A., Roten, Y., Despland, J.N., &
Kramer, U. (2014). What interventions facilitate client
progress through the assimilation model? A task analysis of
interventions in the psychodynamic treatment of depression.
Psychotherapy Research, 25, 484-502. doi: 10.1080/1050
3307.2014.921352
Nigro, G., & Neisser, U. (1983). Point of view in personal mem-
ories. Cognitive Psychology, 15, 467-482. doi:10.1016/0010
-0285(83)90016-6
Nolen-Hoeksema, S. (1991). Responses to depression and their
effects on the duration of depressive episodes. Journal of
Abnormal Psychology, 100, 569-82. doi: 10.1037/0021-
843X.100.4.569
Nuovo, S. (2011). Speaking about therapists… Old questions
and some answers derived from empirical evidence. Re-
search in Psychotherapy: Psychopathology, Process and
Outcome, 14, 52-75. doi: 10.4081/ripppo.2011.22
Oliveira, D. (2015). Momentos de inovação: emergência e
evolução das protonarrativas em terapia narrativa [Inno-
vation moments: emergency and evolution of protonarrative
in narrative therapy]. Braga: Universidade de Minho Publ.
Pos, A.E., & Greenberg, L.S. (2007). Emotion-focused therapy:
the transforming power of affect. Journal of Contemporary
Psychotherapy, 37, 25-31. doi: 10.1007/s10879-006-9031-z
Provenzi, L., Borgatti, R., Menozzi, G., & Montirosso, R.
(2015). A dynamic system analysis of dyadic flexibility and
stability across the face-to-face still-face procedure: appli-
cation of the State Space Grid. Infant Behavior and Devel-
opment, 38, 1-10. doi: 10.1016/j.infbeh.2014.10.001
Ribeiro, A., Bento, T., Salgado, J., Stiles, W., & Gonçalves, M.
(2011). A dynamic look at narrative change in psychother-
apy: a case study tracking innovative moments and pro-
tonarratives using state space grids. Psychotherapy
Research, 21, 54-69. doi: 10.1080/10503307.2010.504241
Salvatore, S., & Tschacher, W. (2012). Time dependency of psy-
chotherapeutic exchanges: the contribution of the theory of
dynamic systems in analyzing process. Frontiers in Psychol-
ogy, 3, 1-14. doi: 10.3389/fpsyg.2012.00253
Seggar, L.B., Lambert, M.J., & Hansen, N.B. (2002). Assessing
clinical significance: application to the Beck Depression In-
ventory. Behavior Therapy, 33, 253-269. doi:10.1016/
S0005-7894(02)80028-4
Spangler, P., Hill, C., Dunn, M., Hummel, A., Walden, T., Liu,
J., …, Salahuddin, N. (2014). Training undergraduate stu-
dents to use immediacy. The Counseling Psychologist, 42,
729-757. doi: 10.1177/0011000014542835
Steer, R., Ball, R., Ranieri, W., & Beck, A., (1999). Dimension of
Beck Depression-II in clinical depressed outpatients. Journal
of clinical Psychology, 55, 117-128. doi: 10.1002/(SICI)1097-
4679(199901)55:1<117::AID-JCLP12>3.0.CO;2-A
Steer, R.A., Brown, G.K., Beck, A.T., & Sanderson, W.C.
(2001). Mean Beck Depression Inventory-II scores by sever-
ity of major depressive episode. Psychological Reports, 88,
1075-1076. doi: 10.2466/pr0.2001.88.3c.1075
Tomicic, A., Martínez, C., Pérez, J., Hollenstein, T., Angulo, S.,
Gerstmann, A., ..., Krause, M. (2015). Discourse-voice reg-
ulatory strategies in the psychotherapeutic interaction: a
state-space dynamics analysis. Frontiers in Psychology, 6,
1-17. doi:10.3389/fpsyg.2015.00378
Town, J., Hardy, G., Mccullough, L., & Stride, C. (2012). Patient
affect experiencing following therapist interventions in
short-term dynamic psychotherapy. Psychotherapy Re-
search, 22, 208-219. doi: 10.1080/10503307.2011.637243
Trop, J., Burke, M., & Trop, G. (2013). Psychoanalytic theory
and psychotherapy: a dynamic systems view of change.
Clinical Social work Journal, 41, 34-42. doi: 10.1007%
2Fs10615-012-0403-4
[Research in Psychotherapy: Psychopathology, Process and Outcome 2016; 19:205] [page 149]
Dyad dialogue in psychotherapy
Non-commercial use only
