Therapeutic Change In Counseling

Change is the predominant goal of psychotherapy for all the theoretical orientations. Psychotherapies differ in their explanations of what needs to be changed and how change occurs, but reviews of psychotherapy outcome research showed little or no differential effectiveness of different types of psychotherapies. How to explain this phenomenon? Exploring the therapeutic mechanism of equivalence has become a new research field.William B. Stiles and colleagues put forward the Assimilation Model, which integrated theories of development, cognition, and psychotherapy, establishing an integrative framework to explain the general change process of successful psychotherapy. The model suggested that, in successful psychotherapy, clients followed a regular developmental sequence of recognizing, reformulating, understanding, and eventually resolving the problematic experiences that brought them into treatment. The developmental sequence was summarized in the eight stages or levels of the Assimilation of Problematic Experiences Scale (APES). The Assimilation Model provided a pan-theoretical framework for understanding the essential process underlying all or most modes successful psychotherapy, and thus crossed the type of psychotherapy and enriched the understanding of change process.However, whether the model was an internally consistent, precise, general, and realistic theory still needed further examination. In order to better understand and recognize client’s change, the process and internal mechanism of change, this paper presented four studies to test, revise, improve and deepen the model.1. A study of a successful case’s change process. To verify the model and the Assimilation of Problematic Experiences Scale, a successful case was selected and the session transcripts were studied with qualitative research method of Assimilation Analysis. Three investigators identified and tracked two major themes. Results showed that after eight sessions, she gained a successful change, and assimilated the two problematic voices, the process of which was consistent with the assimilation model’s conception of successful psychotherapy and followed the sequence of development proposed by this model. However, the whole process of assimilation was a spiraling trend.2. A comparison of assimilation in good- and poor-outcome cases of counseling. The aim of this study was to verify, revise, and improve the theoretical construct of Assimilation Model regarding the change process of successful psychotherapy, and to find the key point which might distinguish the cases of good and poor outcomes, by increasing the sample size to four with good outcome and four with poor outcome and comparing the assimilation levels of these cases. Three research teams used Assimilation Analysis to analysis the clients’ transcripts. Consistent with the former study, the findings supported the theoretical expectation that relief of symptoms was associated with higher levels of assimilation. However, it was found that all cases’ assimilation process were accompanied with both advances and setbacks, based on which we proposed that some improvements on the model’s developmental sequence might be necessary:the former linear developmental sequence should be revised as a cycling up sequence. Furthermore, the findings showed that all of the good outcome cases reached Assimilation Level 4, whereas none of the poor outcome cases did so. Thus, the Assimilation Level 4 was likely the key point that could distinguish the good and the poor outcome cases.3. An in-depth analysis of key point of change. The aim of this study was to explore why the level of APES4 could be the key point of change. Further qualitative analysis of the APES4 data, which came from 14 foreign cases and 5 domestic cases with good outcomes. Nine categories were generated:(1) understanding the causes of problems; (2) the accompanying feelings; (3) the emergence of a new awareness; (4) removing the problematic voice’s threat; (5) discovering behavior pattern; (6) allowing the coexistence of both original conflicts; (7) directly expressing the problematic voice desired to be expressed; (8) viewing things with different perspectives; (9) finding out the direction of future action. At the same time, according to frequencies of the occurrence, time, and the inherent logic relation of the categories, we extracted 7 categories from the nine, tried to establish the path relationship of the 7 categories, and extracted the core categories. The core categories were "removing the problematic voice’s threat" and "allowing the coexistence of both original conflicts", which were merged these into one category of "self acceptance of the problematic experience." Its preconditions were "finding the direction of future action" and "understanding the causes of the problem", as well as the facilitating roles of "the emergence of a new awareness" and "the accompanying feelings", while the post reaction was usually "finding the direction of future action".4. Micro analysis of interactive collaboration on the good- and poor-outcome cases. This study was aimed at exploring the characteristics of interactions in counseling of the good- and poor-outcome cases, with the hope to guide the clinical practice. Based on the conception of "Therapeutic Zone of Proximal Development", a Content Analysis was conducted to analyze the interactions in counseling of 5 good-outcome cases and 3 poor-outcome cases, employing the "Therapeutic Collaboration Coding System". Following findings was revealed:(1) there were significant differences in the therapist interventions between the good- and poor-outcome cases. Good-outcome cases used more supporting interventions and less challenging interventions than the poor-outcome cases did. Furthermore, there were also significant differences in the supporting interventions between the good- and poor-outcome cases. Good-outcome cases supported the dominant voice less than the poor ones, and supported the problematic voice more than the poor ones. (2) On the client response, there was no significant difference between the good- and poor-outcome cases. The majority were validation responses, among which many cover-up invalidation may be coded as the validation and thus the ratio of validation responses was increased. This situation was more likely to occur in the cases of poor-outcome. (3) On the types of therapeutic exchanges, there were significant differences in the zone of "validation-safety" and "validation-tolerable risk" between the good- and poor-outcome cases, while there were no significant differences in the other zones. In the zone of "validation-safety", good-outcome cases were less than the poor ones, while in the zone of "validation-tolerable risk" good-outcome cases were more than the poor ones. (4) Clinical implications:counselors should consider to use more supporting interventions with appropriate combination of challenging interventions, increase support on the problematic voice. It could be helpful for counselors to carefully distinguish the cover components of validation response and adjust the interventions accordingly. In addition, it was suggested that counselors should "gently push the client forward along the ’Therapeutic Zone of Proximal Development’", and help clients eventually assimilate the problematic experiences.