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Resolution of assimilation setbacks in the case of Alicia: the dance of strands
Counselling Psychology Quarterly
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Objective: To evaluate the efficacy of different approaches to personalization in psychological therapy.
Method: This was a systematic review and meta-analysis of randomized controlled trials that compared the mental health outcomes of personalized treatment with standardized treatment and other control groups. Eligible studies were identified through three databases (Scopus, PsychINFO and Web of Science). We conducted a narrative synthesis and random effects meta-analysis of available outcomes data, including subgroup analyses to examine sources of effect size heterogeneity. The review protocol was pre-registered in the Open Science Framework.
Results: Seventeen studies (N = 7617) met inclusion criteria for the review, nine of which (N = 5134) provided sufficient data for inclusion in meta-analysis. Eight studies were classed as having high risk of bias, eight had moderate risk, and one had low risk. There was no significant evidence of publication bias. A statistically significant effect size was found in favor of personalized treatments relative to standardized treatments (d = 0.22 [95% CI = 0.05, 0.39], p = 0.011). When studies with a high risk of bias were removed, this effect size was smaller but remained statistically significant (d = 0.14 [95% CI = 0.08, 0.20], p <0.001).
Conclusions: Current evidence indicates that personalization is an effective strategy to improve outcomes from psychological therapy, and the seemingly small effect size advantage of personalization could have an important impact at a clinical population level.
Objective: We tested qualitative metasynthesis of a series of Hermeneutic Single Case Efficacy Design (HSCED) studies as a method for comparing within-session processes that may explain good and poor therapeutic outcome. Method: We selected eight HSCED studies according to change in clients’ scores on the Strathclyde Inventory (SI), a brief self-report instrument used to measure outcome in person-centered psychotherapy. Four of the case studies investigated the experience of clients whose pre–post change in SI scores showed improvement by the end of therapy, and the other four focused on clients whose change in SI scores indicated deterioration. We conducted a qualitative metasynthesis, adopting a generic descriptive-interpretive approach to analyze and compare the data generated by the HSCED studies. Results: In contrast to improvers, deteriorators appeared to be less ready to engage in therapeutic work at the beginning of therapy, and found the process more difficult; their therapists were less able to respond to these difficulties in a responsive, empathic manner; deteriorators were less able to cope successfully with changes of therapist and, eventually, gave up on therapy. Conclusion: We found that our qualitative metasynthesis of a series of HSCED studies produced a plausible explanation for the contrasting outcomes that occurred.
This study aimed to investigate (a) what clients’ within-treatment activity preferences were; (b) whether match between preferences and psychotherapy approach predicted outcomes and alliance; (c) whether scores on preference dimensions, per se, predicted outcomes and alliance. Participants were 470 clients engaging in one of five approaches with trainee psychotherapists. We used the Cooper–Norcross Inventory of Preferences to identify clients’ within-treatment activity preferences; and multilevel modelling to examine the relationship between these preferences—and match on these preferences—to outcomes and alliance. Clients had an overall preference for therapist directiveness and emotional intensity. We found no evidence of a preference matching effect. Clients who expressed a desire for focused challenge over warm support showed greater progress. Client preferences for focused challenge may be indicative of their readiness to change and indicate a positive prognosis. Further research should directly observe therapeutic practices and assess a range of client variables.
This study aimed to investigate (a) what clients’ within-treatment activity preferences were; (b) whether match between preferences and psychotherapy approach predicted outcomes and alliance; (c) whether scores on preference dimensions, per se, predicted outcomes and alliance. Participants were 470 clients engaging in one of five approaches with trainee psychotherapists. We used the Cooper–Norcross Inventory of Preferences to identify clients’ within-treatment activity preferences; and multilevel modelling to examine the relationship between these preferences—and match on these preferences—to outcomes and alliance. Clients had an overall preference for therapist directiveness and emotional intensity. We found no evidence of a preference matching effect. Clients who expressed a desire for focused challenge over warm support showed greater progress. Client preferences for focused challenge may be indicative of their readiness to change and indicate a positive prognosis. Further research should directly observe therapeutic practices and assess a range of client variables.
Objective: This theory-building case study investigated setbacks in assimilation, seeking to replicate and elaborate previous work, in which most setbacks were one of two types, balance strategy (BS) or exceeding the therapeutic zone of proximal development (TZPD).
Method: We studied the case of Alicia, a 26 year-old woman, treated successfully for depression. Her main problematic experiences were rated with the Assimilation of Problematic Experiences Scale (APES), and 267 setbacks were identified. We classified the setbacks and examined them quantitatively and qualitatively.
Results: Alicia showed the usual irregular progress of assimilation, with generally increasing APES ratings, consistent with the improvements in outcome measures. Almost all setbacks could be distinguished as BS or TZPD. Replicating a previously observed pattern, BS setback passages tended to be at or above APES stage 3, whereas TZPD setback passages tended to be below APES stage 3. BS and TZPD setbacks also drew qualitatively different characterizations.
Conclusion: Results represented a conceptual replication of previous work, explainable using the same theoretical tenets. As an integral part of therapeutic work, setbacks do not impede progress in therapy. BS and TZPD setbacks reflect different processes and have different implications for how therapist and client are working together.
This paper offers a theoretical and methodological formulation of setbacks in the process of assimilation of problematic experiences in psychotherapy. It is based on a series of theory-building case studies, in which case observations were used to modify and confirm an evolving understanding. Assimilation typically follows a sawtoothed progression in which advances alternate with setbacks. Research has identified two main types of setbacks, called exceeding the therapeutic zone of proximal development, and the balance strategy, which occur under systematically different conditions. Both types of setbacks can be understood as switching strands within a problematic theme. This formulation defines and elaborates the methodological concepts of topic, theme, and strand, as well as the underlying theoretical concepts of internal voices and sub-voices. These are illustrated with examples from a clinical case. This elaboration of the assimilation model is related to other perspectives that emphasize people’s multiplicity of internal voices and used to suggest further studies.
Objective:
Research on the assimilation model has suggested that psychological change takes place in a sequence of stages punctuated by setbacks, that is, by transient reversals in the developmental course. This study analyzed such setbacks in one good outcome case and one poor outcome case of Emotion-focused therapy (EFT) for depression.
Method:
Intensive analyses of five transcribed sessions from each case identified 26 setbacks in the good outcome case and 27 in the poor outcome case. The reason for each setback was classified into one of four categories: balance strategy, exceeding the therapeutic zone of proximal development either induced by the therapist (ZPD-T) or induced by the client (ZPD-C), or spontaneous switches.
Results:
In the good outcome case the most frequent reasons for setbacks were balance strategy and spontaneous switches, whereas in the poor outcome case the most frequent reason for setbacks was ZPD-T.
Conclusions:
As in previously studied therapies, setbacks in EFT, usually represent productive work on relatively less advanced strands of the client's major problems. Results point to the importance of the therapist attending to the limits of the client's therapeutic ZPD.
In this chapter, I draw distinctions among three classes of research purposes: theory building, enriching, and fact gathering. Theory-building research seeks to test, improve, and extend a particular theory. Enriching research seeks to deepen and enrich people’s appreciation or understanding of a phenomenon. Factgathering research seeks to discover facts without explicitly focusing on a unified theory or systematically unpacking the meanings in a phenomenon. Insofar as the distinction concerns the purposes of research, not the methods, any method may be used to advance any of the purposes.
The assimilation model offers an approach to customizing the therapeutic relationship. Assimilation research has tracked problematic experiences (e.g., destructive relationships or traumatic memories) across therapy sessions and has described a sequence of 8 stages of levels of assimilation of the problematic experience, from being dissociated or unwanted to being understood and integrated. This article reviews some assimilation model research and discusses its limitations. Therapists can use the model in assessing a problem's current level of assimilation and facilitating its movement to the next level. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Psychotherapy is a 'talking cure'- clients voice their troubles to therapists, who listen, prompt, question, interpret and generally try to engage in a positive and rehabilitating conversation with their clients. Using the sophisticated theoretical and methodological apparatus of Conversation Analysis - a radical approach to how language in interaction works - this book sheds light on the subtle and minutely organised sequences of speech in psychotherapeutic sessions. It examines how therapists deliver questions, cope with resistance, reinterpret experiences and how they can use conversation to achieve success. Conversation is a key component of people's everyday and professional lives and this book provides an unusually detailed insight into the complexity and power of talk in institutional settings. Featuring contributions from a collection of internationally renowned authors, Conversation Analysis and Psychotherapy will appeal to researchers and graduate students studying conversation analysis across the disciplines of psychology, sociology and linguistics.
Psychotherapy's equivalence paradox refers to clients achieving similar degrees of overall improvement in different treatment approaches, despite the non-equivalent processes. The current intensive qualitative study described and compared how different processes brought about their respective outcomes in one case of client-centred therapy (CCT) and one of cognitive-behaviour therapy (CBT). The assimilation model of psychotherapeutic change was used to compare processes of change and patterns of improvement in these two demographically and diagnostically similar clients, who had equally favourable outcomes on post-treatment measures. We applied the method of assimilation analysis to both therapies, and compared the assimilation account of client change with the theoretical models used in the two treatments.
In addition to their potential for healing, psychotherapy and counselling offer extraordinary opportunities to observe human experience and behaviour. I suggest practitioners have expertise in and daily access to the phenomena that theories of counselling and psychotherapy seek to explain. Practitioners’ clinical experience can be accumulated and shared through theory-building case study research. This article summarizes the logic of theory-building case studies and offers practical suggestions for conducting case study research.
The Assimilation of Problematic Experiences Scale (APES) describes a developmental sequence through which problematic experiences pass on their way to being assimilated in successful psychotherapy. This commentary suggests that the four studies reported in this special issue of Counselling Psychology Quarterly have extended the APES by applying it to new topics and by confronting the puzzle of irregular progression in what is hypothesized to be a fixed sequence of stages.
Dialog implies an interchange between mutually influencing voices. Two metaphors playing a major role in contemporary research are analyzed from such a perspective: the computer metaphor, in which the self is studied as an information-processing device, and the narrative metaphor, in which story and storytelling are guiding principles for the self. It is argued that, on the metaphorical level, the computer and the narrative analogy allow voice and intersubjective exchange to play important roles in self-organization. In actual research, however, these elements are neglected. Theoretical and empirical arguments emphasize the relevance of the dialogical view for the study of the self. Finally, the role of dominance in inter- and intrapersonal processes and the relevance of collective voices for contemporary psychology are sketched. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The assimilation model offers an approach to customizing the therapeutic relationship. Assimilation research has tracked problematic experiences (e.g., destructive relationships or traumatic memories) across therapy sessions and has described a sequence of 8 stages of levels of assimilation of the problematic experience, from being dissociated or unwanted to being understood and integrated. This article reviews some assimilation model research and discusses its limitations. Therapists can use the model in assessing a problem's current level of assimilation and facilitating its movement to the next level. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Presents an integrative model for a central aspect of change in psychotherapy. According to the assimilation model, clients in successful psychotherapy follow a regular sequence in processing their problematic experiences as these are assimilated into schemata developed in the therapeutic interaction. The model's principal concepts include schema, problematic experience, and assimilation and accommodation. Stages of assimilation are discussed, and case illustrations of a 37-yr-old man and a 37-yr-old woman illustrate this process. Advantages of the assimilation model for research, for clinicians, and for the therapeutic relationship are addressed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
There is growing awareness among psychologists that the individualistic and rationalistic character of contemporary psychological theories of the self reflect an ethnocentric Western view of personhood. In opposition to this view, it is argued from a constructionist perspective that the self can be conceived of as dialogical, a view that transcends individualism and rationalism. A comparison of 3 contructionist forerunners (G. Vico [1966], H. Vaihinger [1935], and G. A. Kelly [1955]) suggests that to transcend individualism and rationalism, the embodied nature of the self must be taken into consideration. Moving through space and time, the self can imaginatively occupy a number of positions that permit mutual dialogical relations. The classic Jamesian distinction between the I and the Me is translated in a narrative framework. The implications for 3 areas of psychological research (attribution theory, moral development, and the individual differences paradigm) are briefly discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Changes in 4 clients' ideas across a series of exploratory psychotherapy sessions were traced to explore the theory (W. B. Stiles et al; see record
1991-10592-001) that the assimilation of problematic experiences follows a predictable path. Passages dealing with a common topic were extracted from recordings and examined for movement along the predicted path. The Assimilation of Problematic Experience Scale was developed to assess the degree of assimilation. Two case studies illustrate the themes of pain and anger in social relationships and of emptiness. By measuring change in specific ideas, this new approach circumvents many conceptual and methodological problems in relating psychotherapy process to outcome. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Abstract The assimilation model suggests progress in psychotherapy follows an eight-stage sequence described by the Assimilation of Problematic Experiences Scale (APES). This study sought to reconcile this developmental stage model with the common but superficially contradictory clinical observation that therapeutic advances alternate with setbacks. Setbacks (n=466) were identified in therapy transcripts of two clients and classified using a preliminary nine-category list of possible alternative reasons for setbacks. Most of the setbacks involved switches among the multiple strands of a problem due to (a) therapists exceeding clients' therapeutic zone of proximal development, (b) therapists guiding clients to shift toward relatively problematic material (balance metaphor), or (c) spontaneous switches. Rather than contradicting the theory, this close examination of setbacks yielded elaborations of it.
Cognitive therapy, linguistic therapy of evaluation, and constructivist psychotherapy display prominent points of both convergence and divergence at conceptual and practical levels. This article considers these comparisons and contrasts, focusing on their respective positions regarding their meta-theoretical models of human beings, science, and epistemology, as well as key aspects of their therapeutic stance, style, and strategic preferences. The resulting analysis suggests that these three contemporary approaches to cognitive therapy make distinctive contributions to clinical practice, adding to the richness of the field in different ways.
This article describes the treatment of Gabriel, 24, an undergraduate student suffering from performance anxiety. His main symptoms were heart palpitations, aching muscles, inability to relax, nervousness, worry, and negative anticipation about performance in various classes. The treatment applied was 13 sessions of linguistic therapy of evaluation (LTE), a variety of cognitive therapy based on the theory of general semantics. The main therapeutic techniques involved emphasizing the difference between words and "facts" (the "map" and the "territory"), general semantics debate, and the focusing on orders of abstraction. Across treatment Gabriel showed a clear shift from an intensional orientation to an extensional orientation, which for Gabriel meant stopping anticipating and instead focusing on the here and now and dealing with uncertainty. At the end of therapy and at two-year follow-up, Gabriel showed a complete recovery.
The assimilation model has proposed a set of developmental stages through which a client's problematic experiences pass in successful psychotherapy. We present 2 conceptual additions to the model. First, we examine the client's problematic experiences using dialogical sequence analysis, an intensive method for studying the moment-to-moment process. Second, we extend the developmental stages to describe the intersubjective exchange between client and therapist by introducing Vygotsky's concept of the zone of proximal development. We illustrate the application of the new conceptual tools by presenting 3 excerpts from the 1st session with Jan, a 42-year-old woman whose therapy has been studied previously. Our analysis suggested that, during the 1st session, Jan's problems reached higher developmental stages in the joint exchange with her therapist (i.e., in the zone of proximal development) than in her internal assimilation.
The assimilation model is a theory of psychological change that depicts the self as a community of internal voices, composed of traces of the person's experiences. The model suggests that disconnection of certain voices from the community underlies many forms of psychopathology and psychological distress. Such problematic voices may be assimilated through psychotherapeutic dialogue by building meaning bridges. Meaning bridges are signs (e.g., words, images, gestures, narratives) that have similar meaning to author and addressee, that is, to the signs' producer and recipient, which may be different people or interacting internal voices. Building meaning bridges is thus a process of coming to terms with problematic voices, which reduces distress and gives access to experiential resources within the self. This article describes and illustrates meaning bridges, voices, signs, and associated concepts as elaborated in a program of research on the assimilation model.
In 1984, Jacobson, Follette, and Revenstorf defined clinically significant change as the extent to which therapy moves someone outside the range of the dysfunctional population or within the range of the functional population. In the present article, ways of operationalizing this definition are described, and examples are used to show how clients can be categorized on the basis of this definition. A reliable change index (RC) is also proposed to determine whether the magnitude of change for a given client is statistically reliable. The inclusion of the RC leads to a twofold criterion for clinically significant change.
The view that the self has multiple parts and that these appear in people seeking psychotherapy--and people conducting psychotherapy--is shared by clinicians of various orientations and supported by psychological research. It is useful for clinicians to think of patients as multifaceted and pay attention to the changes between facets that occur during therapy. They can thus help hidden parts to surface, facilitate dialogue between parts not in contact with each other, and convince excessively dominant or oppressive parts to make room for other adaptive facets. The authors contributing to this issue of Journal of Clinical Psychology: In Session describe, from their different theoretical perspectives, how they deal with patients' and therapists' inner multiplicity in clinical practice.
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.
Objective
: A growing body of empirical evidence suggests that psychotherapy is more effective when therapists tailor interventions to fit their specific clients’ needs, a concept referred to as therapist responsiveness in the psychotherapy literature. However, the question of how therapists learn to become responsive rarely has been examined.
Method
: The central question of this study, put to eleven graduate student therapist trainees, was, “How did you learn to be responsive to clients as a novice therapist, and in what ways have you become responsive?” A critical-constructivist grounded theory method was employed to generate themes from trainees’ replies.
Results
: The analysis showed that trainees learned to improve their responsiveness to clients by: (1) becoming more aware of cues that signaled the need to adapt interventions (as related to psychotherapy change processes, client-therapist relational dynamics, clients’ identities and cultural contexts, and the maximizing of clients’ agency); (2) developing attunement to their own emotions and engaging in self-care; and (3) adopting mindsets that facilitated their trying new relational or therapy approaches while also maintaining professionalism.
Conclusion
Based upon these findings, preliminary suggestions for responsiveness training are presented to guide programs that wish to train responsive psychotherapists .
Objective
Understanding the client perspective is important for the provision of psychotherapy. The significant events paradigm, within which clients report on the most significant events of a therapy session immediately after the session, represents a useful means to explore clients’ in-session experience.
Method
The aim of this study was to investigate what types of client-identified impacts are reported in qualitative studies on helpful and hindering events in psychotherapy. Seventeen primary studies focusing on client-identified helpful and hindering events were identified through database searches and subsequent manual searches. The data were subjected to qualitative meta-analysis.
Results
The descriptions of event impacts were classified into 12 helpful (e.g., gaining a new perspective on the self; feeling heard, understood, and accepted; and feeling engaged in the therapeutic process) and eight hindering (e.g., lacking guidance from the therapist and feeling emotionally overwhelmed) impact meta-categories.
Conclusion
The findings provide an update to a previous meta-analysis by identifying several new categories of helpful event impacts and by categorizing hindering event impacts.
This theory-building case study examined an application of the Assimilation of Grief Experiences Scale (AGES), a conceptual account of a bereaved person’s process of change in grief recovery, in a case study of a 40-year old woman in bereavement counselling. An assessment session and 44 counselling sessions were analysed intensively, comparing the description provided by the AGES with the details of the case. Results showed how the AGES tracked and described details of Sophie’s recovery.
Background: It is estimated that between 3% and 15% of patients have a negative experience of psychotherapy, but little is understood about this. Aims: The aim of this study was to investigate the factors associated with patients’ negative therapy experiences. Method: The data comprised 185 patient and 304 therapist questionnaires, 20 patient and 20 therapist interviews. Patients reported on an unhelpful or harmful experience of therapy, and therapists on a therapy where they thought the patient they were working with had a poor or harmful experience. These were transcribed and analysed using thematic analysis. Results: There was a Lack of fit between Patient needs, Therapist skills, and Service structures. This could result in Fault Lines, a tension between Safety and containment and Power and control. This tension led to Strain and Poor Engagement, which led to Consequences following the negative therapy experience. Conclusions: Patients require clear information, choice, involvement in decision-making, explicit contracting and clarity about sessions and progress. Opportunities for patient feedback should be the norm, where the therapist and service are vigilant for signs of deterioration and solutions considered.
Clinical and methodological significance of this article: Estimates of “unwanted effects,” including long-lasting effects, of psychotherapy have ranged from 3% to 15%. Few empirical studies have been conducted in this area. This study aimed to address this gap and provide clinicians with a model of risk factors for negative therapy effects. The findings of this study indicate the importance of providing patients with a supportive service structure that offers clear information, choice and involvement in decision-making. Explicit contracting at the beginning of therapy and clarity about sessions and progress are also important in managing patient expectations throughout. Opportunities for patient feedback should be provided.
Progress in psychotherapy is typically irregular, as advances alternate with setbacks. This study investigated the therapist’s activities prior to two main types of setbacks, one involving the client following therapist proposals and one involving the client failing to follow from therapist proposals, in the case of a poor-outcome client treated with a linguistically-oriented kind of cognitive therapy. Setbacks were defined as decreases of at least one level on an index of therapeutic progress, the 8-level Assimilation of Problematic Experiences Scale (APES), in adjacent client passages. Therapist activities were coded in 361 setback episodes that each included a client pre-setback passage, a therapist passage, and a client setback passage; both client passages had been previously rated on the APES. The main categories of therapist activities showed distinctive patterns in relation to the two main types of setbacks, the therapeutic zone of proximal development and the balance strategy. The two main patterns were described as an exploratory and a challenging configuration. These patterns of therapist activities and setbacks showed how the therapist seemed to persevere with approach-guided interventions while this poor-outcome client continued to have setbacks to low APES levels.
Background. The quality and strength of the therapeutic collaboration, the core of the alliance, is reliably associated with positive therapy outcomes. The urgent challenge for clinicians and researchers is constructing a conceptual framework to integrate the dialectical work that fosters collaboration, with a model of how clients make progress in therapy. Aim. We propose a conceptual account of how collaboration in therapy becomes therapeutic. In addition, we report on the construction of a coding system - the therapeutic collaboration coding system (TCCS) - designed to analyse and track on a moment-by-moment basis the interaction between therapist and client. Preliminary evidence is presented regarding the coding system's psychometric properties. The TCCS evaluates each speaking turn and assesses whether and how therapists are working within the client's therapeutic zone of proximal development, defined as the space between the client's actual therapeutic developmental level and their potential developmental level that can be reached in collaboration with the therapist. Method. We applied the TCCS to five cases: a good and a poor outcome case of narrative therapy, a good and a poor outcome case of cognitive-behavioural therapy, and a dropout case of narrative therapy. Conclusion. The TCCS offers markers that may help researchers better understand the therapeutic collaboration on a moment-to-moment basis and may help therapists better regulate the relationship.
• To promote therapeutic collaboration. • To facilitate regulation of therapeutic relationship • To facilitate therapeutic change.
The aim of this study was to provide a detailed descriptive account of the large improvement seen over a single-session interval in psychotherapy, known as "sudden gain," by applying a process model of psychotherapeutic change. Passages from sessions before and after the sudden gain of five clients receiving cognitive therapy for depression were rated for assimilation level. Results indicated that insight and understanding of the problematic experience was reached in the session before the sudden gain. Case analyses confirmed this but suggested that this insight was only partial and did not develop into full insight until the therapy session after the gain.
The linguistic therapy of evaluation: A perspective on language in psychotherapy
- Caro Gabalda
Caro Gabalda, I. (1996). The linguistic therapy of evaluation: A perspective on language in
psychotherapy. Journal of Cognitive Psychotherapy, 10(2), 83-104. doi:10.1080/10720530903400962
Therapist activities preceding setbacks in the assimilation process
- Caro Gabalda
- I Stiles
- W B Ruiz
Caro Gabalda, I., Stiles, W. B., & Pérez Ruiz, S. (2016). Therapist activities preceding setbacks in the
assimilation process. Psychotherapy Research, 26(6), 653-664. doi:10.1080/10503307.2016.
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