Microanalytic Method to Investigate the Training of Psychotherapy Skills and Narrative-Emotion Processes

Abstract

The study proposes a microanalytic sequential process design to investigate humanistic-experiential psychotherapy skills in a training program. An illustrative simulated session was generated during an undergraduate clinical psychology course. External judges utilized the Narrative-Emotion Process Coding System 2.0 (NEPCS 2.0) and the Person-Centered & Experiential Psychotherapy Scale (PCEPS) for microanalytical analysis of the role-play session. The results demonstrate a higher adherence to the person-centered model of empathic reflective responses while showing lower adherence to experiential specificity and psychotherapy decisions guided by narrative-emotion markers. The findings underscore the methodological potential of this investigation in enhancing training programs and contributing to the field of Psychotherapy Change Process Research.

Keywords:
Psychotherapy Skills; Training; Humanistic-experiential Approach; Narrative-Emotion Processes

Resumo

O estudo apresenta uma proposta metodológica de análise qualitativa microanalítica de sessões psicoterápicas para investigação de habilidades psicoterapêuticas na abordagem humanista-experiencial, no âmbito da formação em psicologia. Uma sessão simulada, gerada no contexto da graduação, foi analisada de forma ilustrativa. Os instrumentos aplicados por juízes externos foram o Narrative-Emotion Process Coding System 2.0 (NEPCS 2.0) e o Person-Centred & Experiential Psychotherapy Scale (PCEPS). Os resultados demonstram uma maior adesão ao modelo humanista de intervenções do tipo resposta-reflexo em detrimento de uma tomada de decisão terapêutica orientada por marcadores narrativos de processo e especificidade experiencial. Os achados ressaltam o potencial metodológico desse tipo de investigação para o aprimoramento de programas pedagógicos de ensino na perspectiva das psicoterapias baseadas em processo.

Palavras-chave:
Habilidades Psicoterapêuticas; Formação Clínica; Psicoterapia Humanista-Experiencial; Processos Narrativo-Emocionais

Psychotherapy can be characterized as an intersubjective and interpersonal specialized context, involving the construction of meaning, emotional transformation, and, above all, an opportunity for clients to co-construct a story of repair with the therapist (Angus, 2012). Within the communicative space established by the psychotherapy relationship, emotional pain can acquire new meaning, allowing characters to be repositioned in time and space. This process provides clients with a fresh perspective and significance regarding past events or imagined experiences.

The therapist's variables and therapeutic skills can significantly impact the client's narrative process and how they will tell their story, ultimately influencing the process of therapeutic change and transformation (Angus & Greenberg, 2011). This means that the construction of meaning assigned to suffering in the psychotherapeutic context gains coherence through the dynamic interaction between the therapist and client, rather than solely relying on the client's expression. De Jaegher and Di Paolo (2007) describe this intersubjective process as "participatory sense-making," where both the therapist and client mutually influence each other, leading to the generation of new domains of sense-making that were not accessible to each individual alone.

Contemporary humanistic-experiential approaches, inspired by theorists like Carl Rogers (1902/1987), have increasingly recognized the importance of communicative interchange and the central role of narrative in investigating, assessing, and understanding psychotherapeutic processes (Aleixo, Pires, Angus, Neto, & Vaz, 2021). Carl Rogers' major goal was to understand the interactive and communicative process between the therapist and client, leading him to explore the intimate nature of what he termed the "semantic space" (Rogers, 1963, p. 82). As early as the 1950s-60s, Rogers & Kinget (1965/1977) demonstrated interest in the microscopic study of verbal interaction and highlighted the impact of different modes of narrative interaction between therapist and client in the psychotherapeutic process. As Stenzel (2021) suggests, there is a convergence between Carl Rogers' principles and the latest research on psychotherapy skills, emphasizing the novelty of humanistic studies in contemporary psychotherapy research, particularly in the investigation of microanalytic sequential processes of communicative and narrative interaction.

Building upon the Rogerian humanistic perspective, humanistic-experiential approaches emphasize that psychotherapy transformation occurs through the expansion of the client's emotional response repertoire. This enables them to express more adaptive action tendencies and find new significance and meaning in their personal story (Angus & Greenberg, 2011; Friedlander et al., 2020). Reflective processes during therapy sessions allow clients to explore the circumstances related to significant life events, potentially leading to the emergence of new narratives that challenge their implicit perceptions about self and others (Angus, Levitt, & Hardtke, 1999).

Hill (2020) developed the Helping Skills System (HSS) training model for undergraduate students, aiming to enhance their therapeutic helping skills (Anderson, Stone, Angus & Weibel, 2021). The HSS involves directive intervention techniques, particularly in the early stages of therapy, to stimulate the collaborative nature of the therapeutic relationship and empathy. By doing so, it facilitates the client's expression of narrative-emotion, creating a solid therapeutic alliance characterized by a strong bond, essential for the therapist to immerse themselves in the client's world and engage with the emotionally complex process of narrative construction (Elliott et al., 2004). Therapist-guided empathic responses further facilitate clients in engaging with productive narrative shifts, enhancing their reflective awareness and encouraging the disclosure of specific autobiographical memories (Angus et al., 2017).

In addition to the significance of common factors in the psychotherapeutic process, such as empathic understanding, Elliott et al. (2004) emphasize the importance for humanistic and experiential therapists to focus on two crucial elements: clients' experience of events and their ways of processing these experiences in the session, conveyed through both verbal and non-verbal markers. Referred to as 'process markers,' these identifiable moment-to-moment cues not only facilitate ongoing recognition of the client's immediate experience but also play a fundamental role in therapeutic decision-making (Greenberg & Goldman, 2019).

The correlation between the client's narrative-emotion process and psychotherapy skills and competencies has been the focus of various international studies (Aleixo, Pires, Angus, Neto & Vaz, 2021; Anderson et al., 2021; Friedlander et al., 2020). Contemporary empirical research, utilizing naturally occurring data such as recorded psychotherapy sessions, aims to analyze microanalytic sequential processes of interaction by examining communicational, narrative, and linguistic aspects (Elliott, 2010; Friedlander et al., 2020). Recent studies have shown that through the analysis of psychotherapy sessions using microanalytic methods, it is possible to identify significant narrative changes and their correlation with the role of interventions and psychotherapy skills.

Despite a wealth of scientific evidence pointing to the significance of interpersonal therapeutic attitudes and skills for achieving successful psychotherapeutic outcomes (Hill, 2020; Norcross & Lambert, 2018; Wampold, 2015), Angus, Watson, Elliott, Schneider, and Timulak (2015) emphasize that the majority of professional training programs mainly focus on enhancing diagnostic assessment techniques based on traditional diagnostic systems. The authors highlight that training still primarily revolves around nosological aspects of mental disorders, lacking sufficient emphasis on the interpersonal and microanalytic elements that play a vital role in the psychotherapeutic process. Consistent with this, Greenberg and Goldman (2019) argue that the most effective way of learning should involve self-experience, aligning with the Rogerian humanistic tradition that prioritizes "attitudes" over techniques in psychotherapy training (Rogers & Kinget, 1965/1977). However, providing such experiences and managing different roles presents challenges for students and young therapists. Consequently, studies on psychotherapy skills during clinical training should place greater focus on interactive and intersubjective elements, applicable to both undergraduate (Hill, Roffman, Stahl, Friedman, Hummel & Wallace, 2008) and postgraduate levels (Hill, Stahl, & Roffman, 2007).

Lundh (2019) proposes that training programs should encompass therapist skills in action, with a focus on the interaction established between therapist and client. Students and young therapists need to learn helping skills in a practical context that allows for some form of clinical experimentation, whether real or simulated (Hill, 2020). According to Pilnick, Trusson, Beeke, O’Brien, Goldberg, and Harwood (2018), interpersonal skills, such as communication, cannot be solely developed during the clinical internship period when students are already interacting with real clients. The authors argue that future professionals need to engage in activities early in their training that challenge them in experiential situations, requiring real-time decision-making and responses, similar to clinical practice. Therefore, they suggest that simulation in role-play could be one of the techniques used for the training of these future professionals.

While several training models aimed at cultivating psychotherapy skills do exist, they continue to necessitate further research scrutiny (Greenberg & Goldman, 2019; Hill, 2020; Hill et al., 2008). This study aligns with this research interest, aiming to enhance clinical teaching and training in undergraduate psychology education through empirical investigation by employing role-play as a pedagogical practice to develop psychotherapy skills. As a result, a methodological design was devised for conducting a microanalytic analysis of recorded simulated sessions. This design aimed to assess the proficiency of students' psychotherapy skills and their diverse intervention approaches within the context of clinical decision-making during a training program.

Method

This study introduces a methodological proposal for the qualitative and microanalytic examination of psychotherapy sessions to investigate psychotherapy skills within the humanistic-experiential approach in a training context. The research is based on the Microanalytic Sequential Process Design, as proposed by Elliot (2010), and falls under the umbrella of Process-Based Research, which involves empirical investigations of turn-to-turn interactions between clients and therapists to identify correlations between process variables and psychotherapeutic outcomes.

This methodological analysis is part of a larger project titled "Interpersonal Therapeutic Skills Simulated in Roleplay: An Action Research with Undergraduate Psychology Students.". The project received approval from the Ethics Committee (CEP/UFCSPA) under Approval Number: 4.275.991. The original project generated a database of 82 simulated sessions conducted between 2020-2023, which is currently undergoing a comprehensive analysis. It is important to emphasize that these simulated sessions are an intrinsic component of the required psychology course curriculum, specifically designed to cultivate clinical competency from humanistic and experiential approaches, irrespective of the ongoing research endeavors.

The comprehensive analysis of the entire roleplay sessions database is currently underway; nevertheless, this article will provide an illustrative example of the methodological approach. The investigation of narrative-emotion markers combined with psychotherapy skills within the context of a student training program can be regarded as an innovative methodology in the Brazilian context. For illustrative purposes, this article employs the analysis of a single session out of a total of nine simulated sessions from the 2020 database (the first phase of data generation in the original project).

The pedagogical program that led to the generation of the database was previously documented in a publication by Stenzel (2020). In brief, the program is centered around developing psychotherapy skills through immersive role-play sessions, with a primary focus on enhancing interpersonal competencies and fostering therapeutic decision-making through the identification and understanding of narrative-emotion process markers. This research, aligned with the pedagogical approach, aims to provide valuable scientific insights for improving undergraduate psychology education. Students are encouraged to actively cultivate their ability to attentively listen and comprehend clients' experiences, while also identifying process markers in simulated sessions. As a result, it becomes essential to scientifically examine students' adherence and competence in conducting psychotherapy sessions using narrative-emotion markers. The findings of this study can further enrich the understanding of the efficacy of the pedagogical approach in training future psychotherapists.

Measures

For the microanalytic analysis of the illustrative session, external judges applied the Narrative-Emotion Process Coding System 2.0 (NEPCS 2.0) and the Person-Centered & Experiential Psychotherapy Scale (PCEPS). The NEPCS 2.0 is a widely recognized coding system used for analyzing narratives in psychotherapy sessions. It was developed by Lynne Angus and colleagues (Angus et al., 2017) and is based on the premise that rigid and problematic narratives coincide with distressing emotions. In contrast, significant change is observed when clients begin to articulate something new, which is more psychologically adaptive and accompanied by more coherent narrative constructions of personal identity (Angus et al., 2017; Friedlander et al., 2020).

The final version of the NEPCS 2.0 coding system consists of ten narrative markers, which are further categorized into three analysis categories and their respective subtypes: 1) Problem markers (PM): Same Old Story; Empty Story; Unstoried Emotion; Superficial Story; 2) Transition Markers (TM): Competing Plotlines; Inchoate Story; Experiential Story; Reflective Story; and 3) Change Markers (CM): Unexpected Outcome and Discovery Story. A comprehensive description of the coding system can be found in the article authored by Lynne Angus and colleagues (Angus et al., 2017).

According to Angus et al. (2017), these markers aim to identify how the client accesses the following narrative-emotion elements: specific autobiographical memories, symbolization of felt bodily experience, expression of emotions, reflection on one's actions and personal stories, coherent integration between actions, emotions, and personal meanings, and articulation between experiences of emotional, behavioral, and interpersonal change. These elements integrate and indicate degrees or levels of the three main narrative-emotion dimensions: client emotional engagement (i.e., emotion awareness, emotion expression, and emotional arousal), narrative organization (narrative content, narrative structure, and narrative coherence), and the degree of client meaning-making and experiential engagement (Angus et al., 2017).

The NEPCS 2.0 coding is performed by external observers (hetero-evaluation), aiming to reach agreement among raters in identifying clients' narrative markers within each segment¹ of video-recorded psychotherapy sessions. Typically, the video-recorded session is divided into one-minute units, which can be done manually or using specific software, such as the Observer XT (Noldus Information Technology, 2015). During the coding process, "no client marker" is assigned when the therapist speaks for more than 30 seconds within a one-minute segment or when the conversation is not related to the client's narrative, such as segments dominated by therapy-related comments. One of the coding objectives is to identify productive narrative-emotion markers (PM → TM/CM) and unproductive ones (TM/CM → PM) within each minute of the session (or within each segment). A productive shift occurs when the client changes from a problem marker (PM) to a transition marker (TM) or a change marker (CM). Conversely, an unproductive shift occurs when the client moves from a transition marker (TM) or change marker (CM) to a problem marker (PM).

Despite emerging within the context of humanistic-experiential approaches (Angus et al., 2015), NEPCS 2.0 has been reliably applied and validated across a variety of clinical samples (e.g., depression, generalized anxiety, complex trauma) and therapy approaches, including Person-Centered Approach (PCA), Emotion-Focused Therapy (EFT), Motivational Interviewing, Cognitive Behavioral Therapy (CBT), Psychodynamic Therapy, and Experiential Psychotherapy (Angus et al., 2017). The NEPCS 2.0 has proven to be a reliable tool for researching transdiagnostic psychotherapeutic processes, suitable for implementation in various psychotherapeutic treatment modalities (Aleixo et al., 2021).

To contextualize NEPCS 2.0 for the Brazilian context, a translation and adaptation process was undertaken through a collaborative effort involving Prof. Lynne Angus, the original creator of NEPCS (Project approved by ComPesq/UFCSPA; Approval Number: 18/2022). However, it is important to note that the translated version remains unpublished due to the ongoing peer-review process in another journal.

The Person-Centered and Experiential Psychotherapy Scale (PCEPS) was developed to assess therapists' adherence to and competence in experiential and person-centered psychotherapeutic models. According to Freire, Elliott, and Westwell (2014), adherence refers to the extent to which a therapist utilized interventions prescribed by the approach, and competence refers to the level of skill demonstrated by the therapist in conducting the session within the humanistic-experiential framework.

The PCEPS instrument comprises two subscales: 1) the Person-Centered Process Subscale (PCS), which consists of ten items, such as the client frame of reference/track, assessing the extent to which the therapist's responses convey an understanding of the client's experiences (how the client understands or perceives them); and 2) the Experiential Process Subscale (EPS), which consists of five items, including experiential specificity, which is related to the extent to which the therapist appropriately and skillfully helps the client to focus, elaborate, or differentiate specific, idiosyncratic, or personal experiences and memories, as opposed to abstractions or generalities.

Each item consists of a descriptive summary followed by a six-point qualitative and descriptive scale (scale points 4 to 6 represent varying degrees of competent performance, while points 1 to 3 indicate performance below adequate levels of competence.). The instrument developers attempted to separate adherence from competence but ultimately adopted a hybrid approach, with lower scores representing a lack of adherence, while higher scores indicate increasing levels of competence. Freire et al. (2014) found the PCEPS to be a reliable measure of adherence/competence for experiential and person-centered psychotherapies, reporting an overall inter-rater reliability (Cronbach's α) of 0.87 and internal consistency (α) of 0.98 for the PCEPS.

Data Analysis

The microanalytic qualitative analysis of the illustrative session presented in this article involved three stages. In the first stage, three working groups comprising a total of 12 external judges were engaged in coding the session. Each coding group was composed of four members: a psychologist/psychotherapist, a graduate psychology student (with involvement in the study's research topic), and two undergraduate psychology students. The three different groups were provided with the English version of the NEPCS 2.0 manual (Angus Narrative-Emotion Marker Lab., 2015), the pilot session recording, and the minute-by-minute segmented transcription. For reliability purposes, each group independently analyzed the pilot session.

In the second stage of analysis, a cross-check of the NEPCS 2.0 and PCEPS codes was carried out by comparing the results independently derived by the different groups in the first stage. To accomplish this, a new group of judges was formed, including one representative from each of the three groups from the first stage. This new group consisted of the research coordinator, one graduate student, and two undergraduate students. The purpose of this stage was to address any discrepancies that arose during the first stage of analysis. To achieve a synthesized coding, each dialogue segment of the session was carefully reviewed while accompanied by the recorded session, and decisions were made collaboratively.

In the third stage, all the materials used for coding were translated into English to enable the creator of the NEPCS 2.0 instrument to assist in making final coding decisions for the session in terms of narrative-emotion markers. The illustrative session was fully translated, including both the transcribed version and the video with subtitles. Utilizing this translated material, the third and final phase of the study concluded with a comprehensive coding of the session, which will be presented next.

Results and Discussion

Figure 1 presents an illustrative representation of the microanalytic qualitative analysis of the session, which integrates coding through the NEPCS 2.0 and PCEPS instruments. Additionally, it describes some therapeutic interventions preceding the client's narrative-emotion shifts, illustrating examples of the student/therapist's speech. The illustration model used in Friedlander et al.'s study (2020) was adopted, which also showcases therapeutic interventions preceding and contributing to narrative-emotion changes in a brief dynamic therapy session.

Figure 1.
Coding of the Simulated Session (NEPCS 2.0 e PCEPS)

The narrative-emotion changes consisted of a total of eighteen shifts, classified as nine productive shifts (PM→TM) and nine unproductive shifts (TM→PM). Specifically, there were nineteen transition markers (TM) and ten problem markers (PM) observed in the session, while no change markers (CM) were identified. In one segment, it was not possible to identify client markers (No Client Marker, NCM), as the therapist's speech predominated. Among the transition markers (TM), there were eleven segments of Competing Plotlines, six segments of Reflective Story, and two segments of Inchoate Story. On the other hand, among the ten problem markers (PM), eight segments were classified as Same Old Story, while two segments were identified as Superficial Story.

The analysis revealed a predominant use of interventions from the Person-Centered Process Subscale (PCS) during the session, while interventions from the Experiential Process Subscale (EPS) were less frequently employed. Additionally, only three interventions did not align with the PCEPS subscales, indicating a high level of adherence by the student/therapist to the humanistic-experiential approach.

The results indicate that, in this session, productive shifts were more associated with the SPE subscale, while unproductive shifts were associated with the SCP subscale, as illustrated in Figure 1. Among the problem markers (PM), the most predominant was the Same Old Story marker, characterized by strong feelings of experiential entrapment/stagnation and repetitive patterns resistant to change (Angus & Greenberg, 2011).

The client's enacted narrative in this role-play session is marked by problematic patterns, displaying characteristics of global undifferentiated distress, as described by Pascual-Leone (2018). This type of distress, typically observed in early treatment stages, refers to undifferentiated negative feelings, such as helplessness and symptomatic anxiety. As evident in the client's enacted narrative, individuals experiencing global distress often find it challenging to access the source of their suffering, feeling trapped in distress. As the simulated session unfolds, the client/student's maladaptive emotions gradually take on the form of distinct autobiographical contexts, eliciting feelings of shame, anger, and guilt for the character/client.

The problem markers linked to the Same Old Story consistently emerge across multiple segments of this session, highlighting indicators of vulnerability and hopelessness (seg.4: Sometimes I feel like giving up on everything, you know? And I think that's what I'm doing now, actually), along with pronounced self-criticism (seg.26: I'm feeling like trash (...) a mix of things and none of them are good). Nevertheless, throughout various instances in the session, an alternative narrative surface, delving into diverse facets of the experience, thereby questioning or unsettling the prevailing maladaptive perspective (seg. 12: I wanted to think of an alternative to fill this void, to learn to live without them because I can't stay in this situation anymore). The phrase "I can't stay in this situation anymore" subtly signifies the emergence of an implicit alternative protest or frustration against the problematic narrative pattern, indicative of a distinctive transitional shift within Competing Plotlines.

Therapeutic interventions were consistently frequent in all segments. In each minute of the session, one or more interventions were observed, which characterizes a highly active role of the student/therapist in terms of interference in the simulated client's narrative. This characteristic is quite common in beginner students who struggle with active listening and providing more space for the client to speak (Hill et al., 2008). In training contexts, young therapists tend to interrupt the client's narrative more frequently, offering advice, suggesting topics, and revealing elements of their own story (Hill, Stahl, & Roffman, 2007).

Among the interruptions made by the student/therapist, there were few instances of Content directiveness (PC6) (five interventions) and no instances of Dominant or overpowering Presence (PC10) interventions, as classified by the PCEPS (Freire, Elliott, & Westwell, 2014). The student/therapist refrained from adopting the role of an advisor or expert, thereby avoiding guiding the session's content beyond the client's frame of reference, nor did they attempt to exert control over the process. Instead, the interruptions were primarily geared towards validating the perceptions and simulated emotions articulated by the client/student, which will undergo in-depth analysis in the subsequent examples related to productive and unproductive shifts.

Regarding adherence and competence, the student/therapist demonstrates an initial ability to remain within the client's frame of reference. This non-directive approach, along with appropriate acceptance, emotional connection, and empathy towards the simulated client's distress, indicates a predominant use of skills related to the client's perspective, suggesting a high level of adherence to a Rogerian approach. The interventions, mainly centered on reflection, underscore the student/therapist's commitment to exploring a person-centered approach through the client/student's frame of reference, exemplifying an appropriate adherence to the humanistic model of intervention, particularly concerning the use of reflective responses (Rogers & Kinget, 1965/1977). Other interventions in addition to rephrasing the client's thoughts were also related to the Rogerian therapy and can be exemplified by segment four, where the student/therapist uses a reflection of feelings: "You seem really down today" (seg.4).

Overall, the student/therapist empathetically accompanied the client's simulated distress through a non-directive and person-centered approach, displaying good adherence to the PCS subscale. However, the student faced challenges in adhering to the intervention items characteristic of the EPS subscale, which involve assisting the client in focusing, elaborating, or differentiating specific experiences and memories, rather than dealing with abstractions or generalities (Freire, Elliott, & Westwell, 2014). The unproductive changes indicate that the student/therapist tends to rely predominantly on reflective/empathic responses (Rogers & Kinget, 1965/1977) rather than therapeutic actions and decision-making guided by process markers and experiential specificity. As mentioned by Elliot et al. (2004), students in training may develop a simplified understanding of humanistic theory and, at times, feel paralyzed by excessive directions from teachers and supervisors regarding the importance of maintaining "non-directiveness" of content. In the case of the humanistic approach, instructions related to "not giving advice or making interpretations" may lead to a more passive and hesitant stance in adopting therapeutic interventions that could guide the process towards greater experiential specificity, which appears to have occurred in this simulated session.

Previous studies suggest that a client-centered and empathic understanding model is essential for building a therapeutic foundation of trust and establishing a therapeutic bond (Hill, 2020; Pascual-Leone, 2018). However, in some cases, an undifferentiated, repetitive, and maladaptive narrative prevails (Angus & Greenberg, 2011; Lundh, 2019), making this approach insufficient, as observed in the illustrative session. In such cases, where problem markers are predominant, an ideal therapeutic approach involves both "following" and preferably "guiding" the client's process (Elliott, Watson, Goldman, & Greenberg, 2004). According to the authors, the experiential process approach is characterized by active collaboration between the client and the therapist, co-exploration, and a balance between active stimulation and responsive attunement. Merely following without guidance can lead the client to "go in circles," especially in cases with markers characteristic of the Same Old Story. On the other hand, guiding without adhering to the client's frame of reference is also considered counterproductive, as it can undermine the client's attempts to develop more autonomously.

In cases of narratives heavily marked by the Same Old Story, as in this illustrative session, the therapist needs to try to identify the central meaning of the conflict, which often involves deeply rooted emotions such as sadness and fear of abandonment or shame associated with feelings of inadequacy (Angus & Greenberg, 2011). To reach the core meaning, interventions like reiteration or reflection of feelings may not seem sufficient, as it requires challenging the narrative by assisting the client in accessing and expressing more specific autobiographical memories and meaningful emotions (Angus & Greenberg, 2004). Instead of using interventions that encourage repeating the Same Old Story - as often happens with the use of interventions of repeating or reflecting the client's thoughts or feelings (Rogers & Kinget, 1965/1977) - the therapist needs to evoke specific experiences related to this recurrent story, provoking and eliciting a narrative change.

From now on, we will explore some examples of the most significant segments of the session, preceded by interventions that either facilitated or hindered the process of narrative-emotion transformation in the client/student, resulting in productive and unproductive shifts in the illustrated session.

Unproductive Narrative-Emotion Shifts (TM→ PM)

As illustrated in Figure 1, in segments five and six, we observe an unproductive shift (TM → PM) from a Transition Marker (TM) to a Problem Marker (PM) that deserves special attention due to the intervention made by the student/therapist, which fails to encourage experiential specificity when it seemed necessary and appropriate.

C: I'm feeling like... I feel exhausted, worthless, stressed, and everything I've already told you, totally lost mainly... Anyway, I think you're the only person I can talk to, you know? Without feeling strange. T: I'm really glad to hear that from you, Mariana. And... aside from the relationship we have, how do you feel about your current relationships? C: I don't know, I feel like... like a disposable thing, you know? Like an extra piece that's just there, anyway. It wouldn't make a difference if I were there or not, I could easily be replaced. I think people even befriend me out of pity, I don't know... T: I see. I understand. And what about the relationship you mentioned trying to establish with your college classmates, maybe? C: Yeah, but they talk about things I don't understand, and I just stand there, listening and... I speak very little, sometimes not even getting noticed, you know... [silence]. I've never been good at that. T: I see. And do you think you're still feeling like that today? C: Yes, I think I still feel that way. I... I don't know, I think... I really don't know.

In this excerpt, although the student/therapist initially employed a proximity-focused intervention, there was a predominance of more closed exploratory interventions that directed the client's narrative towards less precise and vague elements (“I... I don't know, I think... I really don't know") and elicited less specific internal reflection ("I've never been good at that"). According to Paivio and Angus (2017), in the face of Inchoate Story, the therapeutic goal is to encourage the client towards a more reflective, experiential, and coherent narrative. In these cases, the authors suggest that the therapist may foster an attitude of curiosity, exploration, and acceptance of what appears to be emerging in a still rudimentary and incipient form for the client.

In this particular situation, the student/therapist's interventions should have aligned with the client's exploration of finding words or images to symbolize the "feeling strange," an experience that remained unclear and confusing for her. By neglecting to address the experiential specificity and guiding her questions toward the client's present relationships, the student/therapist steers the client/student into discussing her interpersonal relationships broadly, deviating from an experiential focus and moving towards a general abstraction. The student/therapist fails to encourage the client's deeper self-reflection and, instead, redirects her focus toward external factors and others. In this instance, the client's dialogue becomes vague as she discusses her feelings about relationships, reverting to a Problem Marker (Superficial Story) and indicating an unproductive narrative shift during the transition from segment five to six.

An example of an alternative intervention for this session segment could be: "Can you share a specific situation where you felt this way you define as 'feeling strange'?" This type of intervention would facilitate the connection between the experience ("feeling strange") and a more specific autobiographical memory (sharing a situation), encouraging the client to connect with specific moments in the past when this feeling arose. This would stimulate a richer and more experiential narrative.

Another unproductive shift that can be correlated with a low degree of therapeutic skill, according to the PECPS, occurs in segments 11 and 12, where transition markers are followed by a return to a diffuse and empty discourse of loneliness, characteristic of problem markers.

C: (...), which wasn't so common, is really weighing me down. And... I wake up thinking about... taking care of them, taking care sometimes, anyway, I see that my siblings aren't there... I don't know what to do, now I don't have... I don't know, a purpose, like I said. T: Do you think one of the purposes of your life was to take care of your siblings? C: I think so. It made me feel fulfilled, it made me feel complete, you know. Sometimes I wonder if I... I don't know... shouldn't... if I'm not guilty, maybe, if they... I don't know if they grew up well if they need my care, if they don't, if I should be taking care of someone else now... I don't know... Sometimes even myself, but I don't know, I feel selfish thinking about taking care of myself, you know. T: So you feel selfish and guilty for having lost that role? C: Yes, a lot. I wanted to think of some alternative to fill this void, to learn to live without them, because I can't stay in this condition anymore. But I can't think of anything (...) I don't think I'm capable. I'm already too old... and I also can't have the company of a proper friend, so... there's not much hope for me, you know. I don't think I... was born to... be happy. T: You're expressing a lot of hopelessness, a lot of distress. Do you feel incomplete today? You said you weren't feeling complete, right? C: I think so, I feel very lonely, and there's a huge void that I can't really describe, if it's a mix of everything (...).

According to Paivio and Angus (2017), when the client is immersed in a Transition Marker (TM), the therapist should seek more adaptive emotional responses, encouraging the client to connect with the needs associated with such responses and directly challenging maladaptive assumptions and expectations. As can be observed in the illustration, although the student/therapist adequately reflects the feeling of guilt present in the enactment, she fails to explore the client/student's movement of questioning her values and concerns, which are characteristic of Competing Plotlines. By reinforcing the Problem Marker (PM) and the recurring maladaptive feeling ("Do you feel incomplete today?") the student/therapist somehow keeps the client stuck in retelling her story, as evidenced in the final statement in segment 13: "I think so, I feel very lonely, and there's a huge void that I can't really describe, if it's a mix of everything (...)."

An alternative intervention for these segments would be to facilitate the ownership, elaboration, and differentiation of competing plotlines: "whether they [siblings] need my care or not." According to Paivio & Angus (2017), the narrative expression of two or more emotional plots can result in a deep sense of experiential incoherence, leaving the client unable to act to resolve the situation and make sense of what happened. The therapeutic action should, therefore, involve stimulating the recognition of the different poles of conflict.

To address this sense of emotional incoherence, the student/therapist could have first helped the client/student symbolize and differentiate each emotional plotline, and then elaborate and highlight the present doubt: "Do my siblings still need my care?" In the case of this enacted client, it was this belief in the need for a constant presence in her siblings' lives in terms of care that kept her trapped in a feeling of guilt for taking care of herself. The dominant pole of the client's narrative is related to a strong self-critical feeling: thinking about herself makes her a selfish person. However, in the next statement, "I wanted to think of some alternative to fill this void, to learn to live without them," the client produces a question probably more associated with her healthier needs and resources. In this last sentence, the narrative focus that was centered on others, on the external (taking care of her siblings), transforms into a level of reflection that not only offers "a window" into her inner world but also allows for exploration of possible emotional resources for coping (“think of some alternative”). This seems to be an emerging and incipient movement of discovering a new perspective and experience that leads to a narrative of self-identity that is more compassionate and agentic (Paivio & Angus, 2017).

Although in this segment, the student/therapist did not have the opportunity to skillfully address the competing plotlines, in other moments of the session, the student successfully brings back this line of reflection with the client/student, as we will see in the examples of productive narrative-emotion shifts.

Productive Narrative-Emotion Shifts (PM → MT)

The productive narrative-emotion shifts were predominantly marked by changes between the Same Old Story marker (repetitive maladaptive patterns) and the Competing Plotlines (conflicting feelings challenging maladaptive patterns), which is considered a constructive narrative-emotion shift ( Paivio &Angus, 2017). According to Angus and Greenberg (2011), the Same Old Story is frequently present at the beginning of treatment and involves central themes of conflicting relationships, such as consistently feeling rejected or experiencing oneself as a failure or powerless (seg. 28: "That's probably why people pity me"). The therapeutic goal, then, should be focused on accessing more adaptive emotions and, most importantly, addressing the client's unmet needs (Paivio & Angus, 2017). Core emotional experiences, such as pain or sadness, must be integrated and represented within the client's personal story, enabling their needs to surface and allowing the personal significance of these experiences to be expressed and comprehended (Angus & Greenberg, 2011).

As previously mentioned, it is the Competing Plotlines that generally provide an opening for these sometimes unclear needs of the client. Therefore, the therapist must capture this transitional movement. Alternative views to repetitive patterns often arise spontaneously in the form of protest, frustration, or through the disclosure of underlying needs in conflict. When they do not emerge spontaneously, the therapist can encourage them.

In the following sections, we will explore the events unfolding between segments 13 and 14 of the session to gain a deeper understanding of the dynamics at play.

C: Yeah, I guess so. I feel really lonely, and there's this huge void inside me that I can't quite put my finger on. It's like a mix of everything or maybe something simple, I just can't figure out what it is. T: Uh-huh. [pause] What do you think would make you feel complete? C: Huh? T: What do you think would make you feel complete today? C: That's a good question... My family, for sure, but I haven't really thought about other things. You know, other things I could have. Like having someone else, a close friend, those would be an option, but I don't see myself having those choices.

When questioning the client “What do you think would make you feel complete?” the student/therapist attempts to address unmet needs with the aim of stimulating tendencies of action that go beyond the frustration, confusion, and emptiness expressed in the previous segments. This intervention seems to generate a feeling in the client/student of being entitled to meet these needs, leading to the emergence of a fresh emotional storyline/narrative. By saying "That's a good question," the client/student surprises herself in being able to consider her needs and directs her focus of reflection towards them, even naming them, as can be observed in the passage: "Having someone else, a close friend."

Shortly after, the client/student enacts a feeling of incapacity again (but I don't see myself having those choices), but by having previously identified some of her needs, she opens the opportunity for the student/therapist to develop other therapeutic skills towards exploring the desires she had mentioned earlier. As Paivio and Angus (2017) emphasize, the therapeutic approach aims to transform the expression of these needs into more assertive narratives, such as "I want," "I deserve," "I insist," or even "I refuse." In the context of an actual client, it would be possible to explore existential and relational implicit needs, which in this simulated case are associated with a need for connection and relationships.

Another example of a productive narrative change (PM →TM) occurs between segments 24-25:

C: I can't get very far. When I started thinking about myself, I messed up and brought myself down. And I'm definitely to blame for that too. T: What did you mess up? C: Overthinking. About what's happening. Thinking about myself. Anyway, I ended up running out of energy to do everything. And I got stuck in this cycle between waking up, lying in bed thinking, and... feeling bad. I don't know anymore. T: So, you consider overthinking about yourself as a mistake C: I guess so. I waste so much time doing that, I... I could be focusing on other things, I don't know. Maybe... I don't know, I think I'm contradicting myself now. I have that feeling, but I'm not sure.

In this segment, we see that the student/therapist shows an understanding of the client/student's perspective while also observing how she engages in her narrative. The student/therapist empathetically follows the client's train of thought, but she doesn't fall into the "trap" of the problem narrative ("I can't get very far"). Instead, she chooses to explore the risky connection that the client begins to make, that "thinking about herself is a mistake."

In these segments, it is noticeable that the student/therapist was able to pinpoint unclear aspects of the narrative for the client ("What did you mess up?"), facilitating perceptual and emotional specificity. As mentioned by Elliott, Watson, Goldman, and Greenberg (2004), the therapist's ability to direct clients' attention to specific types of experiences may include perceptions, feelings, or underlying needs - as exemplified earlier in segments 13-14.

In segments 24-25, the student/therapist rephrases and clarifies the client's perception ("So, you consider overthinking about yourself as a mistake?"), offering a possibility for her to recognize her contradiction (“I don't know, I think I'm contradicting myself now”) and the effects of this perception on her experience. Elliott et al. (2004) argue that this type of intervention is not a directive strategy used by the therapist to steer the client toward a specific goal or content predetermined by the therapist. On the contrary, in the authors' view, it is a strategy to guide the "process" in its unique path. As a metaphor, Elliott et al. (2004) compare "guiding the psychotherapeutic process" to "guiding a sailboat". According to the authors, the task of a guide requires careful attunement to the direction and speed of the wind, involving riskier maneuvers that may sometimes go against the wind but ultimately aim to lead the sailboat on its course.

Another Problem Marker (PM) that appeared several times in the session was the Superficial Story, characterized by a generalized, vague, or incoherent narrative. In this type of storytelling, the client may discuss their feelings, situations, or relevant ideas, but struggles with self-reflective exploration. Often, the client includes biographical information about others, descriptions, or explanations, but these tend to revolve around hypothetical scenarios or show a lack of focus on oneself (Angus Narrative-Emotion Marker Lab., 2015). The therapist's role is to heighten the client's focus and introspection regarding their inner experiences, facilitating connections between events and fostering the emergence of new meanings (Paivio & Angus, 2017).

As Angus & Greenberg (2011) point out, therapists face a significant risk of "getting lost" in superficial-type narratives, which hinders comprehension and may lead them to make a series of inferences in search of clarifications. However, between segments 15 and 16, where a productive change occurs, it is evident that the student/therapist does not fall into this trap and addresses the feelings related to the core experience with great accuracy, as illustrated below:

C: And it's even more frustrating that right after I left, well, my father brought up that situation again, which I thought was all settled, and it makes me feel even more powerless, you know? Anyway, it hasn't crossed my mind much in the past few weeks… T: Uh-huh. C: I don't know if my siblings tell me everything. T: How do you feel about the idea of your siblings hiding things from you? C: Well, I... like I said before, a bit betrayed, you know... And... I don't know, I feel angry, but I blame myself for feeling that anger. I think this... all of this started more when I began asking myself these questions, you know, like I mentioned before when I started thinking about the meaning of things for me, how I feel about certain things... and I began paying a bit more attention, although I still consider it very selfish.

Angus, Levitt, and Hardtke (1999) assert that therapeutic moments of change involve dialectical transitions among narrative disclosure of autobiographical memory (external narrative processes), emotional differentiation (internal narrative processes), and sense-making (reflective narrative processes). This type of change becomes evident when observing segments 15 and 16: from an external narrative (siblings not telling her everything), the client/student moves towards exploring and symbolizing the meaning prompted by the intervention ("How do you feel about the idea of your siblings hiding things from you?"), and finally delves into a reflective internal narrative, exploring the meaning of her suffering (feeling betrayed).

The therapeutic intervention between segments 15 and 16 appears to have facilitated the narrative-emotion change, leading to a redefinition of the experience. Instead of focusing on "what happened" (siblings not telling her everything), the client/student shifts to describing and elaborating on painful emotions and experiences linked to her memories, addressing the issue from the perspective of "what was felt" during an event. In the dialogue, a noteworthy transition is observed, moving from an externalized and complaining account concerning her siblings (self about others) to an internal emotional differentiation and an emerging sense of meaning. This shift enables the client/student to initiate a discussion about the feeling of betrayal (self about oneself).

Conclusion

In conclusion, while acknowledging the need for cautious generalizations, this microanalytic examination of the role-play session constitutes a vital initial stride toward the development of a methodological framework for investigating integrated psychotherapy skills with narrative-emotion coding systems. The findings underscore the potential for discerning clinical decision-making and the immediate impact of psychotherapy interventions that precede narrative shifts within the illustrative session. Moreover, the application of NEPCS for narrative-emotion coding, coupled with the analysis of psychotherapy interventions using PCEPS, revealed a commendable adherence of the student/therapist to the humanistic-experiential approach, particularly concerning person-centered interventions.

However, productive shifts were more associated with interventions focused on experiential specificity, while unproductive shifts were more associated with a predominant use of reflexive response-type interventions. As discussed, the client's narrative characteristics were centered on repetitive maladaptive patterns, requiring the student/therapist to actively pursue greater experiential specificity. The student's difficulty in meeting this demand aligns with the literature concerning young therapists, who often demonstrate a stereotyped and simplified understanding of humanistic theory. Training orientations emphasizing nondirectiveness, a core aspect of the person-centered perspective that involves avoiding giving advice or making interpretations, may have led to therapeutic interventions that lacked experiential specificity. This aspect may partially account for the unproductive narrative changes observed in the session concerning person-centered interventions; nevertheless, additional studies are required to validate this hypothesis.

A limitation of this study is the fact that the session was not conducted with a real client, and as such, the identified narrative-emotion process markers were representative of a simulated (non-real) therapy session. As a result, further research is necessary to conduct a comparative analysis of training programs aimed at developing psychotherapy skills, involving both real and simulated psychotherapy sessions. This will help identify significant differences in clinical competency training.

Lastly, it is important to highlight that this study's specific focus was centered on psychotherapy skills, with narrative-emotion markers playing a central role as guiding elements for clinical decision-making. The student who assumed the role of the client in the illustrated session played a critical function in fostering the development of psychotherapy skills. By providing a unique narrative and a diverse range of opportunities for clinical management and decision-making within the simulation, she contributed significantly to the study's outcomes.

Hence, it is suggested that the narrative simulation in the client role offers a conducive environment for the spontaneous and experiential development of "psychotherapy skills in action," as underscored in the relevant literature for the training of young therapists. Further research is warranted to explore and refine the use of simulated psychotherapy sessions in developing therapeutic competencies, ultimately enhancing the training of future psychologists and mental health practitioners.

Acknowledgments

I would like to express my sincere gratitude to Professor Lynne Angus (York University/Toronto, Canada) for her invaluable support and guidance throughout the coding of the session and her unwavering encouragement in the completion of this study. Additionally, I extend my heartfelt appreciation to the students and research assistants: Jéssica de Matos Nunes (CAPES/UFCSPA), João Pedro Borges Ferrari (PIBIC/CNPq) and Marina Helena Dias da Costa (PIC/UFCSPA). Their dedication, hard work, and commitment to this research project have been instrumental in its successful execution

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• Data availability statement

  The author does not authorize the disclosure of research data.

• 1
  Within this context, a 'segment' is defined as the duration of one complete minute within the session. Throughout the presentation of findings, the abbreviation 'seg.' will be employed in certain sections to represent the term 'segment,' accompanied by illustrative speech examples.

Edited by

Responsible editor

Alexander Hochdorn

Data availability

The author does not authorize the disclosure of research data.

Publication Dates

• Publication in this collection
  09 Aug 2024
• Date of issue
  2024

History

• Received
  18 Nov 2022
• Accepted
  13 Mar 2023