Narrative change in emotion-focused therapy: co-constructing innovative self-narratives

Programa doutoral em Psicologia (especialidade de Psicologia Clínica)
Segundo a perspetiva narrativa, a psicoterapia deve proporcionar a elaboração
de novas experiências e de narrativas inovadoras face às narrativas inflexíveis e
constritoras que os clientes usualmente apresentam no início do processo (e.g. Angus
& McLeod, 2004; White & Epston, 1990). A noção de momentos de inovação (MIs)
abrange estas novidades narrativas que aparecem como exceções às narrativas
problemáticas (e.g. novas ações, sentimentos, pensamentos ou intenções; Gonçalves,
Matos & Santos, 2009). Segundo esta premissa, Gonçalves, Matos e Santos (2009)
desenvolveram o Sistema de Codificação dos Momentos de Inovação (SCMI –
Gonçalves et al., 2011) que distingue 5 tipos de MIs (ação, reflexão, protesto,
reconceptualização e desempenho da mudança) exibidos por clientes de terapia
narrativa (TN – Matos et al., 2009). Depois deste estudo inicial, Gonçalves e
colaboradores começaram a questionar se outros modelos de terapia poderiam suscitar
a emergência de MIs, apesar de não estarem explicitamente focados na promoção da
mudança narrativa (e.g. Terapia focada nas emoções/EFT – Mendes et al., 2010;
Terapia centrada no cliente – Gonçalves, et al., 2011; Terapia construtivista – Alves et
al., no prelo). Os resultados destes estudos indicam que a elaboração de MIs também
ocorre noutras modalidades terapêuticas e evidenciam o importante papel da
reconceptualização na distinção do sucesso terapêutico face ao insucesso (Gonçalves,
Mendes et al, 2009; Matos et al., 2009; Mendes et al., 2010). Assim, tornou-se
pertinente estudar intensamente como são desenvolvidos em terapia os MIs de
reconceptualização. Dois aspetos são característicos: (a) o cliente reconhece um
contraste no self, descrevendo-se como diferente do que era e (b) explica o processo
de mudança. Como os estudos anteriores enfatizam sempre a mudança narrativa
segundo a perspetiva do cliente, surgiu também a necessidade de compreender as
contribuições do terapeuta. Deste modo, reanalisámos os dados de Mendes et al.
(2010) de uma amostra de seis clientes deprimidos seguidos em EFT (York I
Depression Project – Watson & Greenberg, 1998) e iniciou-se o conjunto de estudos
sistemáticos desta dissertação. Os nossos objetivos eram: (1) compreender a transição
para a reconceptualização e (2) os contributos dos terapeutas para a promoção da mudança narrativa em EFT. O primeiro estudo utiliza o HSS (Helping skills system –
Hill, 2009) e o SCMI para explorar as intervenções terapêuticas (focadas na
exploração, insight e ação) relacionadas com a ocorrência de MIs nestes casos de
EFT. Os resultados indicam que todas as intervenções terapêuticas aparecem mais
associadas a MIs nos casos de sucesso que nos de insucesso. As intervenções focadas
na exploração e no insight aparecem associadas à ocorrência de MIs de ação, reflexão
e protesto nas fases iniciais e intermédias da terapia e depois associadas aos MIs de
reconceptualização e desempenho da mudança na fase final. As intervenções focadas
na ação aparecem associadas aos MIs de ação, reflexão e protesto em todas as fases
de EFT. O segundo e terceiro estudos focam-se em 3 casos de sucesso terapêutico,
explorando intensamente nas sessões a transição para a reconceptualização e as
contribuições terapêuticas para este processo. Os resultados mostram que a mudança
narrativa não é linear e que esta transição pode ser bastante ambivalente. Além disso,
a recursividade da reconceptualização em terapia permite a diferenciação qualitativa
destas narrativas. Por sua vez, os terapeutas focam-se no desenvolvimento de uma
metaposição (Leiman, 2004) nos clientes, que permite a resolução da ambivalência e
a renovação de narrativas do self. O quarto estudo explora a diversidade de
reconceptualização segundo a escala de assimilação de experiências problemáticas
(EAEP – Stiles, 1999, 2001). A análise dos 108 MIs de reconceptualização presentes
nesta amostra evidenciou que a maioria foi codificada entre os níveis 4 a 6 da EAEP.
A mediana dos níveis da EAEP destes MIs é maior no grupo de sucesso terapêutico
(face ao insucesso) e vai aumentando do início ao fim da terapia. O quinto e último
estudo investigou o processo que vai da reconceptualização de um problema até à
reorganização narrativa do self em EFT, através do método de task analysis
(Greenberg, 2007). Seguindo um foco na díade terapeuta-cliente, o modelo racionalempírico
descobriu 9 passos sucessivos: 1) Reconhecimento explícito de diferenças
no presente e passos em direção à mudança; 2) Emergência de uma meta-perspetiva
que contrasta o self no passado e presente; 3) Amplificação do contraste; 4)
Apreciação positiva das mudanças; 5) Sentimentos de competência, mestria e
autonomia, acompanhadas de validação terapêutica; 6) Referência a dificuldades
ainda presentes; 7) Perda de centralidade dos problemas; 8) mudança como um
processo gradual, em desenvolvimento; e 9) Novos planos, projetos e experiências de
mudança. Por fim, os resultados dos diferentes estudos são integrados numa discussão
final segundo 3 focos: cliente, terapeuta e diádico (Elliott, 1991).
According to the narrative framework, clients seek therapeutic help due to the
constricting nature of problematic self-narratives and psychotherapy should contribute
to the elaboration of new experiences and innovative self-narratives (e.g. Angus &
McLeod, 2004; White & Epston, 1990). The notion of innovative moments (IMs)
refers to these narrative novelties, which appear as exceptions to the clients’
problematic self-narratives (like new actions, feelings, thoughts or intentions;
Gonçalves, Matos & Santos, 2009). According to this view, Gonçalves, Matos and
Santos (2009) developed the Innovative Moments Coding System (IMCS; Gonçalves
et al., 2011), which differentiates five types of IMs (action, reflection, protest,
reconceptualization and performing change) exhibited by clients in a sample of
narrative therapy (NT; Matos et al., 2009). After these initial research studies,
Gonçalves and collaborators (Matos, et al., 2009) began wondering if IMs would
appear in sessions from other therapy models that were not explicitly focused on the
promotion of narrative change (e.g. emotion-focused therapy or EFT – Mendes, et al.,
2010, 2011; client-centered therapy – Gonçalves, Mendes, et al., 2011; constructivist
therapy – Alves et al., in press). Findings from these studies indicate that the
elaboration of IMs also occurs outside NT and consistently evidence an important role
of reconceptualization as a marker of good outcome in the contrast with poor outcome
therapy (Gonçalves, Mendes et al, 2009; Matos et al., 2009; Mendes et al., 2010).
Therefore, it became important to intensively investigate how these IMs are
developed in psychotherapy. Two important features characterize reconceptualization
IMs: (a) the client recognizes a contrast in the self, describing oneself as different and
(b) explains how the transformation process happened. Furthermore, the previous
studies highlighted narrative change from the perspective of the client and there was
the need to understand therapists’ contributions. We took the findings from Mendes et
al. (2010) on a sample of six EFT clients drawn from the York I depression project
(Watson & Greenberg, 1998) and began a set of systematic studies presented in this
dissertation. Our purposes were to understand (1) the transition to reconceptualization
and (2) the therapist’ contributions in the promotion of narrative change in EFT. The According to the narrative framework, clients seek therapeutic help due to the
constricting nature of problematic self-narratives and psychotherapy should contribute
to the elaboration of new experiences and innovative self-narratives (e.g. Angus &
McLeod, 2004; White & Epston, 1990). The notion of innovative moments (IMs)
refers to these narrative novelties, which appear as exceptions to the clients’
problematic self-narratives (like new actions, feelings, thoughts or intentions;
Gonçalves, Matos & Santos, 2009). According to this view, Gonçalves, Matos and
Santos (2009) developed the Innovative Moments Coding System (IMCS; Gonçalves
et al., 2011), which differentiates five types of IMs (action, reflection, protest,
reconceptualization and performing change) exhibited by clients in a sample of
narrative therapy (NT; Matos et al., 2009). After these initial research studies,
Gonçalves and collaborators (Matos, et al., 2009) began wondering if IMs would
appear in sessions from other therapy models that were not explicitly focused on the
promotion of narrative change (e.g. emotion-focused therapy or EFT – Mendes, et al.,
2010, 2011; client-centered therapy – Gonçalves, Mendes, et al., 2011; constructivist
therapy – Alves et al., in press). Findings from these studies indicate that the
elaboration of IMs also occurs outside NT and consistently evidence an important role
of reconceptualization as a marker of good outcome in the contrast with poor outcome
therapy (Gonçalves, Mendes et al, 2009; Matos et al., 2009; Mendes et al., 2010).
Therefore, it became important to intensively investigate how these IMs are
developed in psychotherapy. Two important features characterize reconceptualization
IMs: (a) the client recognizes a contrast in the self, describing oneself as different and
(b) explains how the transformation process happened. Furthermore, the previous
studies highlighted narrative change from the perspective of the client and there was
the need to understand therapists’ contributions. We took the findings from Mendes et
al. (2010) on a sample of six EFT clients drawn from the York I depression project
(Watson & Greenberg, 1998) and began a set of systematic studies presented in this
dissertation. Our purposes were to understand (1) the transition to reconceptualization
and (2) the therapist’ contributions in the promotion of narrative change in EFT. The According to the narrative framework, clients seek therapeutic help due to the
constricting nature of problematic self-narratives and psychotherapy should contribute
to the elaboration of new experiences and innovative self-narratives (e.g. Angus &
McLeod, 2004; White & Epston, 1990). The notion of innovative moments (IMs)
refers to these narrative novelties, which appear as exceptions to the clients’
problematic self-narratives (like new actions, feelings, thoughts or intentions;
Gonçalves, Matos & Santos, 2009). According to this view, Gonçalves, Matos and
Santos (2009) developed the Innovative Moments Coding System (IMCS; Gonçalves
et al., 2011), which differentiates five types of IMs (action, reflection, protest,
reconceptualization and performing change) exhibited by clients in a sample of
narrative therapy (NT; Matos et al., 2009). After these initial research studies,
Gonçalves and collaborators (Matos, et al., 2009) began wondering if IMs would
appear in sessions from other therapy models that were not explicitly focused on the
promotion of narrative change (e.g. emotion-focused therapy or EFT – Mendes, et al.,
2010, 2011; client-centered therapy – Gonçalves, Mendes, et al., 2011; constructivist
therapy – Alves et al., in press). Findings from these studies indicate that the
elaboration of IMs also occurs outside NT and consistently evidence an important role
of reconceptualization as a marker of good outcome in the contrast with poor outcome
therapy (Gonçalves, Mendes et al, 2009; Matos et al., 2009; Mendes et al., 2010).
Therefore, it became important to intensively investigate how these IMs are
developed in psychotherapy. Two important features characterize reconceptualization
IMs: (a) the client recognizes a contrast in the self, describing oneself as different and
(b) explains how the transformation process happened. Furthermore, the previous
studies highlighted narrative change from the perspective of the client and there was
the need to understand therapists’ contributions. We took the findings from Mendes et
al. (2010) on a sample of six EFT clients drawn from the York I depression project
(Watson & Greenberg, 1998) and began a set of systematic studies presented in this
dissertation. Our purposes were to understand (1) the transition to reconceptualization
and (2) the therapist’ contributions in the promotion of narrative change in EFT. The first study uses the helping skills system (Hill, 2009) and the IMCS to explore the
therapist skills (exploration, insight or action) related to the occurrence of IMs in the
six EFT cases. Results show that all skills appear more associated to IMs in good than
in poor outcome cases. Exploration and insight skills appear more associated to the
occurrence of action, reflection and protest IMs in the initial and middle phases of
therapy and then appear more associated to reconceptualization and performing
change in the final phase of therapy. Action IMs appear more associated to action,
reflection and protest IMs throughout all EFT phases. The second and third studies
focus on three good outcome cases, exploring intensively within sessions the
transition to reconceptualization and the therapists’ contributions for this process. The
findings show that narrative change is not linear and that this transition can be quite
ambivalent. Thus, the recursivity of reconceptualization IMs throughout therapy leads
to a qualitative differentiation of these narratives. The therapists are focused on the
development of a metaposition (or observer position – Leiman, 2004) in the client,
which allows the resolution of ambivalences and the renewal of new self-narratives.
The fourth study explores the diversity of reconceptualization IMs according to the
assimilation of problematic experiences scale (APES – Stiles, 1999, 2001). The
analysis of the 108 reconceptualization IMs appearing in this EFT sample evidenced
that the majority were coded with APES levels 4 to 6. The median APES levels of
reconceptualization IMs were higher in the good outcome group (in relation to poor
outcome), and kept increasing until the end of EFT. The fifth and last study explored
the process that unfolds from the reconceptualization of a problem to the narrative
reorganization of the self in EFT, through the method of task analysis (Greenberg,
2007). Following a focus on the client-therapist dyad, the rational-empirical model
discovered nine necessary steps: 1) Explicit recognition of differences in the present
and steps in the path of change; 2) Emergence of a meta-perspective contrast between
present self and past self; 3) Amplification of contrast in the self; 4) Positive
appreciation of changes; 5) Feelings of empowerment, competence and mastery,
accompanied by therapist validation; 6) Reference to difficulties still present; 7) Loss
of centrality of the problem; 8) Change as a gradual, developing process; and 9) New
plans, projects or experiences of change. Central aspects of therapist activity in
facilitating the client’s progression in this process are also elaborated. Finally, the
several findings from the five studies are integrated in a discussion according to three
foci: client, therapist and dyadic focus (Elliott, 1991).