Eugénia Ribeiro

How collaboration in therapy becomes therapeutic: The therapeutic collaboration coding system

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 systems psychometric properties. The TCCS evaluates each speaking turn and assesses whether and how therapists are working within the clients therapeutic zone of proximal development, defined as the space between the clients 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.

Versão portuguesa da escala de dificuldades de regulação emocional e sua relação com sintomas psicopatológicos

CONTEXTO: As dificuldades de regulacao emocional estao presentes em varios quadros psicopatologicos, sendo necessario o recurso a um instrumento que as possa medir adequadamente. OBJECTIVOS: Fazer a adaptacao para o portugues da Escala de Dificuldades de Regulacao Emocional e analisar as suas qualidades psicometricas. Um segundo objectivo do estudo era o de explorar a associacao entre as dimensoes da DERS e sintomas psicopatologicos especificos. METODO: A escala original foi traduzida para o portugues e preenchida por uma amostra de 324 sujeitos que tambem preencheram o Inventario Breve de Sintomas. RESULTADOS: Os resultados revelam uma estrutura factorial muito semelhante a da versao original, bons valores de estabilidade temporal, de consistencia interna (Cronbachs α = ,93) e bons niveis de validade externa com o BSI. A analise realizada com o subgrupo de 115 sujeitos que compuseram a amostra clinica revelou que os individuos com psicopatologia apresentam mais dificuldades de regulacao emocional do que os individuos normais. Por meio da analise de correlacao entre as diferentes subescalas da DERS e do BSI, verificamos que as subescalas Estrategias e Objectivos apresentam o valor mais elevado de associacao com todos os sintomas psicopatologicos. DISCUSSAO: Esses resultados sugerem que essas duas dimensoes sao transversais as varias perturbacoes psicopatologicas e poderiam, por isso, ser incluidas em intervencoes psicologicas focadas na capacidade de regulacao emocional.CONTEXTO: As dificuldades de regulacao emocional estao presentes em varios quadros psicopatologicos, sendo necessario o recurso a um instrumento que as possa medir adequadamente. OBJECTIVOS: Fazer a adaptacao para o portugues da Escala de Dificuldades de Regulacao Emocional e analisar as suas qualidades psicometricas. Um segundo objectivo do estudo era o de explorar a associacao entre as dimensoes da DERS e sintomas psicopatologicos especificos. METODO: A escala original foi traduzida para o portugues e preenchida por uma amostra de 324 sujeitos que tambem preencheram o Inventario Breve de Sintomas. RESULTADOS: Os resultados revelam uma estrutura factorial muito semelhante a da versao original, bons valores de estabilidade temporal, de consistencia interna (Cronbachs α = ,93) e bons niveis de validade externa com o BSI. A analise realizada com o subgrupo de 115 sujeitos que compuseram a amostra clinica revelou que os individuos com psicopatologia apresentam mais dificuldades de regulacao emocional do que os individuos normais. Por meio da analise de correlacao entre as diferentes subescalas da DERS e do BSI, verificamos que as subescalas Estrategias e Objectivos apresentam o valor mais elevado de associacao com todos os sintomas psicopatologicos. DISCUSSAO: Esses resultados sugerem que essas duas dimensoes sao transversais as varias perturbacoes psicopatologicas e poderiam, por isso, ser incluidas em intervencoes psicologicas focadas na capacidade de regulacao emocional.

Therapeutic collaboration and resistance: Describing the nature and quality of the therapeutic relationship within ambivalence events using the Therapeutic Collaboration Coding System

Abstract Objectives: We understand ambivalence as a cyclical movement between two opposing parts of the self. The emergence of a novel part produces an innovative moment, challenging the current maladaptive self-narrative. However, the novel part is subsequently attenuated by a return to the maladaptive self-narrative. This study focused on the analysis of the therapeutic collaboration in episodes in which a relatively poor-outcome client in narrative therapy expressed ambivalence. Method: For our analysis we used the Therapeutic Collaboration Coding System, developed to assess whether and how the therapeutic dyad is working within the therapeutic zone of proximal development (TZPD). Results: Results showed that when the therapist challenged the client after the emergence of ambivalence, the client tended to invalidate (reject or ignore) the therapists intervention. Conclusions: This suggests that in such ambivalence episodes the therapist did not match the clients developmental level, and by working outside the TZPD unintentionally contributed to the maintaining the clients ambivalence.

Cognitive conflicts in major depression: Between desired change and personal coherence

Objectives The notion of intrapsychic conflict has been present in psychopathology for more than a century within different theoretical orientations. However, internal conflicts have not received enough empirical attention, nor has their importance in depression been fully elaborated. This study is based on the notion of cognitive conflict, understood as implicative dilemma (ID), and on a new way of identifying these conflicts by means of the Repertory Grid Technique. Our aim was to explore the relevance of cognitive conflicts among depressive patients. Design Comparison between persons with a diagnosis of major depressive disorder and community controls. Methods A total of 161 patients with major depression and 110 non-depressed participants were assessed for presence of IDs and level of symptom severity. The content of these cognitive conflicts was also analysed. Results Repertory grid analysis indicated conflict (presence of ID/s) in a greater proportion of depressive patients than in controls. Taking only those grids with conflict, the average number of IDs per person was higher in the depression group. In addition, participants with cognitive conflicts displayed higher symptom severity. Within the clinical sample, patients with IDs presented lower levels of global functioning and a more frequent history of suicide attempts. Conclusions Cognitive conflicts were more prevalent in depressive patients and were associated with clinical severity. Conflict assessment at pre-therapy could aid in treatment planning to fit patient characteristics. Practitioner points Internal conflicts have been postulated in clinical psychology for a long time but there is little evidence about its relevance due to the lack of methods to measure them. We developed a method for identifying conflicts using the Repertory Grid Technique. Depressive patients have higher presence and number of conflicts than controls. Conflicts (implicative dilemmas) can be a new target for intervention in depression. Cautions/Limitations A cross-sectional design precluded causal conclusions. The role of implicative dilemmas in the causation or maintenance of depression cannot be ascertained from this study.

Comparing Two Methods of Identifying Alliance Rupture Events

This study compared two methods of detecting ruptures in therapy sessions, a procedure based on a self-report measure, the Working Alliance Inventory (WAI), and an observational Rupture Resolution Rating System (3RS). We anticipated that the 3RS would detect more ruptures than the WAI. We examined the longitudinal data of 38 patient-therapist dyads in a cognitive-behavioral therapy condition. The sample included cases that did not complete treatment (dropped cases) as well as good-outcome and poor-outcome cases. At the end of each session, patients completed the WAI self-report questionnaire. Six judges were trained to observe and detect the occurrence of ruptures, and then rated 201 videotaped sessions. Longitudinal statistical models were applied to the data retrieved from the WAI questionnaires completed by patients. We found discrepancies in the ability of the two methods to detect rupture events with the observational 3RS detecting more ruptures than the WAI. Thus, the use of observational systems for the detection of alliance ruptures is crucial for effectively assessing the quality of the therapeutic alliance over the course of treatment. Furthermore, observational systems proven to detect ruptures can be used to improve clinical practice and training of new clinicians.

Processos narrativos de mudança em psicoterapia: Estudo de um caso de sucesso de terapia construtivista

According to White’s narrative therapy, the identification and amplification of unique outcomes, known as exceptional moments outside the problematic narrative, are crucial processes for change to occur. The Innovative Moments’ Coding System (IMCS) was developed in order to classify these novelty moments – which we call innovative moments (i-moments) – in psychotherapy sessions. This system allows tracking the occurrence of 5 types of i-moments: action, reflection, protest, re-conceptualization and performing change. Our central aim is to highlight the way the different types of i-moments emerge along the therapeutic process. Therefore we present an analysis of the change process of a good outcome case of constructivist therapy, using the IMCS. Congruently with previous studies, re-conceptualization develops from the middle of the therapy with clear upward tendency. Reflection remains stable and consistently salient across initial and intermediate phases, decreasing in the final phase. Action, protest and performing change i-moments are rather absent.

Efficacy of a dilemma-focused intervention for unipolar depression: study protocol for a multicenter randomized controlled trial

BackgroundDepression is one of the more severe and serious health problems because of its morbidity, disabling effects and for its societal and economic burden. Despite the variety of existing pharmacological and psychological treatments, most of the cases evolve with only partial remission, relapse and recurrence.Cognitive models have contributed significantly to the understanding of unipolar depression and its psychological treatment. However, success is only partial and many authors affirm the need to improve those models and also the treatment programs derived from them. One of the issues that requires further elaboration is the difficulty these patients experience in responding to treatment and in maintaining therapeutic gains across time without relapse or recurrence. Our research group has been working on the notion of cognitive conflict viewed as personal dilemmas according to personal construct theory. We use a novel method for identifying those conflicts using the repertory grid technique (RGT). Preliminary results with depressive patients show that about 90% of them have one or more of those conflicts. This fact might explain the blockage and the difficult progress of these patients, especially the more severe and/or chronic. These results justify the need for specific interventions focused on the resolution of these internal conflicts. This study aims to empirically test the hypothesis that an intervention focused on the dilemma(s) specifically detected for each patient will enhance the efficacy of cognitive behavioral therapy (CBT) for depression.DesignA therapy manual for a dilemma-focused intervention will be tested using a randomized clinical trial by comparing the outcome of two treatment conditions: combined group CBT (eight, 2-hour weekly sessions) plus individual dilemma-focused therapy (eight, 1-hour weekly sessions) and CBT alone (eight, 2-hour group weekly sessions plus eight, 1-hour individual weekly sessions).MethodParticipants are patients aged over 18 years meeting diagnostic criteria for major depressive disorder or dysthymic disorder, with a score of 19 or above on the Beck depression inventory, second edition (BDI-II) and presenting at least one cognitive conflict (implicative dilemma or dilemmatic construct) as assessed using the RGT. The BDI-II is the primary outcome measure, collected at baseline, at the end of therapy, and at 3- and 12-month follow-up; other secondary measures are also used.DiscussionWe expect that adding a dilemma-focused intervention to CBT will increase the efficacy of one of the more prestigious therapies for depression, thus resulting in a significant contribution to the psychological treatment of depression.Trial registrationISRCTN92443999; ClinicalTrials.gov Identifier: NCT01542957.

War exposure and post-traumatic stress as predictors of Portuguese colonial war veterans' physical health

Abstract The relationship between war exposure and post-traumatic stress disorder (PTSD) has been largely investigated but the impact of the combat experience on physical health has only recently merited attention. The authors investigated the relationship between war exposure and psychological and physical health among 350 Portuguese colonial war veterans. The role of current PTSD symptoms as a mediator of these relationships was also investigated. The results showed that 39% of the veterans met criteria for current PTSD diagnosis and psychological distress was present in half of the sample. Pain, fatigue, and sleep problems were the most reported physical symptoms and mental health and gastro-intestinal problems, the most reported illnesses. Combat exposure variables were significant predictors of current health. The results indicated that veterans with higher exposure to war trauma maintained higher current levels of psychological distress and presented more physical health problems and physical symptoms than those less exposed. Mediation analyses showed that current PTSD was a full mediator of the relationship between war exposure and physical health outcomes.

The psychological impact of motor vehicle accidents on emergency service workers.

Emergency service workers continuously face situations where they are in charge of the lives of others, and this can be a risk factor for their mental health. This study aims to determine the psychological impact of exposure to current death and physical injury events in the context of motor vehicle accidents among emergency personnel and which variables better predict posttraumatic stress disorder. Participants were National Institute of Medical Emergency workers (nurses and medical doctors; n=59) in the north of Portugal. They filled out a trauma exposure and posttraumatic stress disorder scale (PTSD), a scale that assesses distress (General Health Questionnaire 12), a peritraumatic dissociation scale (Peritraumatic Dissociative Experiences Questionnaire) and a coping scale (Ways of Coping Questionnaire). Participants reported high exposure to events evaluated as traumatic, but low prevalence of PTSD. When the relation between exposure, time in emergency, sex, distress symptoms, peritraumatic dissociation, and PTSD symptoms was examined, peritraumatic dissociation and distress were the only predictors of PTSD symptoms, but beyond their contribution direct coping explains PTSD variance. In conclusion, taking into account the contribution of distress and peritraumatic dissociation to predict psychopathological symptoms, and the contribution of coping to lower PTSD scores, education and training should help the professionals deal with these reactions and improve coping, and organizations should support professionals in the most disturbing situations.

Exceeding the therapeutic zone of proximal development as a clinical error.

The Assimilation of Problematic Experiences Scale (APES) summarizes a developmental continuum along which psychological problems progress in successful psychotherapy. The therapeutic zone of proximal development (TZPD) is the segment of the APES continuum within which the clients can proceed from their current APES level to the next with the therapists assistance. It is the therapeutic working zone for a particular problem. As the client makes progress on a problem, its TZPD shifts up the APES. Theoretically, so long as the therapists interventions remain within the TZPD, the client feels safe enough to work. However, when an intervention aims beyond the upper limit, the client will find it too risky and will reject or avoid the proposal. In this sense, exceeding the TZPD can be considered as a clinical error. This article presents examples of exceeding the TZPD and ways the error can be repaired. (PsycINFO Database Record