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Innovative moments in psychotherapy: From narrative outputs to dialogical processes 7 th Conference on Dialogical Self, Athens, USA, 2012 Miguel M. Gonalves (University of Minho, Portugal)

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Psychotherapy and meaning Change in psychotherapy Symptoms Meanings Aim of psychotherapy Change in the assumptions that lead the client to demoralization (Frank, 1961)

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Effective psychotherapies combat demoralization by persuading patients to transform these pathogenic meanings to ones that rekindle hope, enhance mastery, heighten self-esteem, and reintegrate patients with their groups. Frank (1961, p. 52)

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Pathogenic meanings Central beliefs, maladaptive schemas, emotional schemas, object representations, incongruent self- schemas, unassimilated experiences, and so on Meaning and narrative organization Problematic self-narratives Meaning and narratives

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Implicit rules of meaning that are maladaptive e.g. always privileging others opinions and neglect my own These rules constraint the meaning-making processes, with a wide impact Actions, emotions, relationships, and so on Problematic self-narratives

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Implicit rules create a pattern of meaning From a DS perspective few I-positions dominate the self Other positions are silenced or invisible The multivocality of the self (Hermans) is highly reduced Problematic self-narratives

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Alternative meanings are more flexible, restoring the multivocality of the self Transformation of problematic self-narratives Emergence of exceptions towards the rules That is, innovative moments (IMs) Transformation of problematic self- narratives

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One rule of the problematic self-narrative Resentment and difficulty expressing own feelings That is why I dont tell my husband what I feel inside and even if I said he would probably laugh One exception, that is, an innovative moment (IM) could be But my feelings are my feelings and Im entitled to them One example

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Transformation of problematic self-narratives Emergence of innovative moments (IMs) New or dominated I-positions come to the foreground The emergence of different I-positions create the possibility for the transformation of the previous problematic self- narratives

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The emergence of innovative moments along therapy (e.g. their diversity) as well their pattern of emergence, facilitate the transformation of the previous rules of meaning- making Transformation of problematic self-narratives

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Occur in several forms as actions, thoughts, feelings, projects They are defined as exceptions to the rule Each narrative (problematic of innovative) has its own narrator (I-position) Innovative moments (IMs)

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Study the therapeutic change processes All the therapeutic sessions are coded with the Innovative Moments Coding System Several samples of brief therapy and several intensive cases studies. Usually we contrast good with poor outcome cases Innovative Moments Research

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Dimensions of analysis Salience Length of each innovative moment in the conversation, related to the total amount of the session Type Action, reflection, protest, reconceptualization, and performing change Innovative Moments Coding System

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Actions or specific behaviors that challenge the problematic self-narrative Clinical vignette (problematic self-narrative: depression) Client: Yesterday, I went to the cinema for the first time in months! Action IMs

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Thoughts, feelings, intentions, projects or other cognitive products that are not akin to the problematic self-narrative C: Im starting to wonder about what my life will be like if I keep feeding my depression. T: Its becoming clear that depression has a hidden agenda for your life? C: Yes, sure. T: What is it that depression wants from you? C: It wants to rule my whole life, and in the end it wants to steal my life from me. Reflection IMs

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Entail new behaviours (like action IMs) and/or thoughts (like reflection IMs) that challenge the problematic self-narrative, representing a refusal of its assumptions. Client: I am an adult and I am responsible for my life, and, and, I want to acknowledge these feelings and Im going to let them out! I want to experience life, I want to grow and it feels good to be in charge of my own life. Protest IMs

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Involves a process description, at a meta-cognitive level The client not only manifests thoughts and behaviours outside the domain of the problematic self-narrative, but also understands the processes that are involved in it Reconceptualization IMs

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There are two ingredients in these IMs Contrast between problematic self-narrative and an alternative one Some access to the process that allowed this transformation Reconceptualization IMs

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Client: You know when I was there at the museum, I thought to myself: you really are different A year ago you wouldnt be able to go to the supermarket! Ever since I started going out, I started feeling less depressed it is also related to our conversations and changing jobs Therapist: How did you have this idea of going to the museum? Client: I called my dad and told him: were going out today! Therapist: This is new, isnt it? Client: Yes, its like I tell you I sense that Im different Reconceptualization IMs

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References to new aims, experiences, activities or projects, as consequence of change Therapist: You seem to have so many projects for the future now! Client: Yes, youre right. I want to do all the things that were impossible for me to do while I was dominated by sadness. I want to work again and to have the time to enjoy my life with my children. I want to have friends again, to have people to talk to, to share experiences and to feel the complicity in my life again. Performing Change IMs

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Poor outcome cases Good outcome cases An example of our typical results

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Reconceptualization in good outcome (GO) cases and poor outcome (PO) cases

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Performing change in GO cases

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There is a progressive tendency in the salience of Ims Action, reflection and protest have a higher salience at the beginning of psychotherapy Reconceptualization tends to emerge at the middle of therapy and increases until the end Reconceptualization seems to be central in good outcome cases Performing change tends to emerge after reconceptualization Global picture of GO cases

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Action IMs Reflection IMs Protest IMs Therapy evolution Reconceptualization IMs Performing change IMs New Action IMs New Reflection IMs New Protest IMs Former problematic narrative New Emergent Self Narrative An heuristic model of GO cases

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The average salience of IMs is lower than in GO cases Action, reflection and protest IMs occur without a clear progressive tendency throughout therapy Reconceptualization and performing changes are absent or have a very low salience Global picture of PO cases

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Action IMs Reflection IMs Protest IMs Time Problematic self- narrative Emergent Self Narrative Absence of reconceptualization Problematic self- narrative An heuristic model of PO cases

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1.Which processes block the development of innovative moments from the middle of the therapy, particularly the emergence of reconceptualization? 1.Why is reconceptualization so central to the change process? Two main questions relevant to DS theory

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Good and poor outcome therapies have very similar trajectories in the emergence of IMs at the beginning They start to become different in the middle phase of therapy In GO cases There is an increase in the salience of IMs Reconceptualization and performing change emerge and become dominant by the end of therapy 1. Innovative moments and PO therapy

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Which processes are responsible for the differences between good and poor outcome cases in the middle phase of therapy? Interesting question

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As IMs are associated with new or dominated voices, their emergence challenges the dominant perspective of the client The emergence of novelties threats clients sense of (problematic) stability To re-establish the sense of stability the innovation potential may be attenuated, and the usual sense of self reaffirmed IMs and unsuccessful therapy

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When IMs are attenuated in their change potential the problematic self-narrative re-emerges The sense of stability, even if problematic, is reasserted Two positions in a process of mutual-in feeding (Valsiner, 2002) Innovative problematic innovative problematic - IMs and unsuccessful therapy

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Problematic Self-narrative I-position A e.g. I cant free myself from my fears. My life always will be like that. e.g. One day I will enjoy real freedom. Alternative Self-narrative (IMs) Alternative Self-narrative (IMs) BUT, My fears are too strong! I-position B Mutual in-feeding

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The production of an IM frees the client from the oppression of the problematic self-narrative dominance, BUT it produces anxiety, threating clients sense of stability Thus, the client returns to the problematic self-narrative, reducing anxiety JUST to feel oppressed once more by the problematic self-narrative The person oscillates ambivalently

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Mutual in-feeding Return to the problem markers (RPM) PhenomenonEmpirical observation We code RPMs when they emerge just after the elaboration of the IM The empirical study of mutual in- feeding

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The client produces an IM, but just after its emergence also produces a return to problem (RPM) Ive been feeling less depressed this week (Reflection IM), BUT I feel depressed anyway (RPM) Return to the problem markers

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RPM involves several forms of attenuation of the change potential of IMs (e.g. Ive feeling less depressed), by Contradicting it but Im still a depressed person after all Reaffirming the dominance of the problematic self- narrative but Im to weak to continue that way Return to the problem markers

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Reattributing the change away from the self but perhaps it is just the medication Trivializing the change but this is such a small change after all

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GO cases in therapy have less RPM And/Or In GO cases the presence of RPM decrease along treatment RPM do not decrease in poor outcome-cases Empirical findings on RPMs

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Average mean of RPMs in good and poor outcome cases T-test (t(8)=-5.25, p