Significant events in psychotherapy: An update of research findings. Ladislav Timulak Trinity College Dublin Significant events research ►Significant events research (Elliott, 1985) represents a specific approach to studying client-identified important moments in therapy process. ►The underlying rationale is the idea that the events are the moments of the most fruitful therapeutic work (Timulak, 2007) in the case of helpful events, or the most problematic points in the case of nonhelpful (hindering) events. > Significant events research (cont.) ►Significant events research is part of a broader ‘event paradigm’ research (Rice & Greenberg, 1984; Greenberg, 2007) ►Significant events research is similar to the research on helpful and hindering processes > History and methodological approaches of significant events research ►started by Robert Elliott in the mid eighties (e.g. Elliott, 1983) ►though it has its precursors in Bloch’s and Berzon’s studies on important events (Berzon, Pious, & Farson, 1963; Bloch Reibstein, Crouch, Holroyd, & Themen, 1979) ►that built up on therapeutic factors studies in group psychotherapy (see e.g. Yalom, 1975) in the late seventies. > History and methodological approaches (cont.) ►different ways of identifying significant events and ►different strategies for obtaining reflections and other important information on studied events ►it is the client who identifies the event, which is then studied sometimes using the transcript of the session, quantitative process measures and in-depth qualitative interviews. > History and methodological approaches (cont.) ►the studies which aim at establishing types and prevalence of different types of events use §(a) a qualitative or semi-qualitative analysis (e.g. cluster analysis) leading to the establishment of types of events or §(b) a pre-established taxonomy of events derived from a previous significant events research study or §(c) a pre-established taxonomy derived specifically for the study, being at least partially informed by previous research. ►Intensive studies analyse processes within the events > The aim of the presentation ►to provide an update on the research into significant events and assess its usefulness. ►For that purpose, PsychInfo database was searched with key words such as significant events, important events, significant moments, important moments and counselling or psychotherapy. ►40 studies were identified that used the client-identified significant event(s) as a main or side focus of the study. > Types of events and their prevalence - findings ►more studies focus on helpful rather than nonhelpful events ►Helpful events: §important contributions to the therapeutic relationship (e.g. reassurance, feeling understood, and personal contact) and §to in-session outcomes (e.g. insight, relief, behavioural change, new feelings, and empowerment) > Types of events and their prevalence – findings (cont.) ►Timulak (2007) identified six original studies that came with their original conceptualisation of helpful events. ►He applied a method of qualitative meta-analysis to establish what impact categories are usually found ►The meta-categories that the study produced were named: §Awareness/Insight/Self-understanding, §Behavioural change/Problem solution, §Empowerment, §Relief, §Exploring feelings/Emotional experiencing, §Feeling understood, §Client involvement, §Reassurance/support/safety, and §Personal contact. > Types of events and their prevalence – findings (cont.) ►Significant events in group therapy (e.g. Berzon, Pious, & Farson, 1963;) §found also events specific for the group format such as Learning from interpersonal actions, Vicarious learning (see Bloch et al., 1979), Identification, and Universality (Moreno, Fuhriman, and Hileman, 1995). ►Holmes and Kivlighan (2000) compared helpful impacts in individual vs. group therapy. §emotional awareness-insight and problem definition-change type of impacts were more typical for individual than group treatment §in the case of relationship-climate and other- vs. self-focus type of impacts, it was the opposite. > Types of events and their prevalence – findings (cont.) ►The prevalence of reported events in group modality may also be a function of participants’ interpersonal styles (Kivlighan & Goldfine, 1991; Kivlighan & Mullison, 1988): §more affiliative participants reported event types such as universality and vicarious learning §less-affiliative participants more often reported events such as learning from interpersonal actions. §Friendly-submissive and hostile-dominant participants reported more acceptance events. The finding was partially consistent with an earlier study > Types of events and their prevalence – findings (cont.) ►As to the frequency of different types of events §some versions of insight/awareness and/or problem solution dominated the helpful events (e.g. Berzon, Pious, & Farson, 1963; Llewelyn, 1988; Llewelyn et al., 1988; Martin & Stelmaczonek, 1988) §some studies also showed a high prevalence of interpersonal impacts such as feeling understood or reassured (e.g. Elliott, 1985; Booth et al., 1997) or relief (e.g. concern attenuated in Wilcox-Mathew et al., 1997). > Types of events and their prevalence – findings (cont.) ►Six main types of events were nonhelpful in Elliott’s (1985) study §Misperception, §Negative Counsellor Reaction, §Unwanted Responsibility, §Repetition, §Misdirection, §Unwanted Thoughts). ►One study (Doxsee & Kivlighan, 1994) looked at hindering events in a group context. The dominating events were: §absence of a group member, §experience of being discounted by a member of the group or the leader, §withholding self-disclosure of an important issue, §other member disconnection from the group, and §member attack. > Types of events and their prevalence – findings (cont.) ►As to the prevalence of the type of reported significant events across the process of individual therapy (Cummings, Slemon, and Hallberg, 1993), §Relationship events were typical for the beginning and ending of therapy, §Insight and Client Growth events were more typical for the middle stages of therapy. ► ►Holmes and Kivlighan (2000) observed that §the problem definition-change impacts present in significant events were increasing linearly throughout while the relationship-climate component was higher at the beginning and at the end of treatment in both individual and group therapy. ► ►As to the prevalence of a different type of events in different phases of group therapy (Kivlighan & Goldfine, 1991): §over time, guidance was more often and universality less often reported §Hope events decreased and catharsis events increased over time. ► ►In an earlier study, Kivlighan and Mullison (1988) observed that §cognitive impacts decreased over time, §behavioural impacts increased in group therapy. > Types of events and their prevalence – conclusions ►a quite definite list of what distinct events/impacts clients see as helpful in psychotherapy ►As to the prevalence of different types of events §task-oriented events with awareness/insight often dominating (sometimes also problem solution or relief) and §relationship-oriented events with reassurance, feeling understood and personal contact being the most common. §relational events may be more frequent at the beginning and end of therapy, while task oriented events may be more frequent in the middle stages, but this may vary in group therapy. §the unique interpersonal style of the client may also affect the type of events found > Types of events and their prevalence – conclusions ►As to the methodology of examined studies §Major methodological caveat may be the fact that there may be several helpful impacts in one event > Match in the clients’ and therapists’ perceptions of significant events - findings ►Seven studies inspected this ►The perspectives on what is significant in therapy differed significantly. Roughly said, the therapists and the clients match in around 30-40% of events (Martin & Stelmaczonek, 1988; Cummings, Hallberg, Slemon, & Martin, 1992). ►The therapists may prefer events of therapeutic work such as insight, while clients may put more emphasis on the relational aspects such as reassurance (cf. Llewelyn, 1988; Elliott, 1983). ►Cummings, Martin, Hallberg, and Slemon (1992): §counsellors more specific in their recalls §the likelihood of the match between the counsellors’ and clients’ perspective grew if the counsellors rated the working alliance higher. ►Kivlighan & Arthur (2000) found that the convergence of client and counsellor recall increased over time and was related to counselling outcomes. (cf. Cumming, Hallberg et al., 1992). > Match in the clients’ and therapists’ perceptions of significant events – findings (cont.) ►Cummings, Slemon, & Hallberg, 1993 novice vs. experienced therapists: §no difference was found between what events were identified as important by the clients, §the therapists differed with the experienced therapists pointing to Attaining Insight events and novice therapists pointing to Exploring Feelings and the therapist’s Self-Critique (negative evaluation of own work). ►a study from couple therapy showed that (Helmeke and Sprenkle, 2000) clients within the couple may differ in their perspective on what event was significantly helpful in the session too. ►clients in group therapy (Shaughnessy and Kivlighan, 1995) differ in what they perceive as helpful. §They could be divided into 4 types according to the type of impacts reported: ►broad-spectrum responders, ►self-reflective responders, ►other-directed responders, and ►affective responders. ►the clients seeking expression in the treatment reported more reassurance events than problem solution events (Booth et al., 1997); ►the clients of novice therapists reported more relationship-focused significant events than the clients of experienced therapists (Cummings, Slemon, and Hallberg, 1993) and ►higher rated Problem Solving – Behaviour Change impacts were reported by participants seeing the climate in the group therapy as engaging and leader’s behaviour as technically oriented (Kivlighan, Multon, and Brossart, 1996). ► > Match in the clients’ and therapists’ perceptions of significant events – conclusions ►there are clear discrepancies between what the clients and the therapist find helpful in therapy. ►clients seem to value more the relational aspects of events, while therapists prefer the more cognitive impacts. ►evidence also suggests that the match may be greater in successful sessions and therapies. ►Interestingly, the clients differ in their perceptions too and ►it may be a function of the clients’ motivation and cognitive, affective, and relational styles as well as their reaction to the therapeutic situation. > Significant events in different therapies - findings. ►Llewelyn et al. (1988) – a typical significant event for exploratory (psychodynamic) therapy was Awareness and for prescriptive (CBT) therapy Problem Solution. ►Elliott et al. (1985) – Personal Insight and Reassurance dominated in a cognitive therapy case, and Personal Insight, Awareness and Client Involvement were typical in a dynamic-experiential case. ►Mushet, Whalan, & Power (1989) compared in-patient and out-patient group therapy with self-understanding being dominant in the outpatient group and universality in the inpatient group. ►Booth et al., 1996 differences in the frequencies of the reported type of events in therapies of different therapists (5 ecclectic/humanistic and 1 psychodynamic), it is not clear whether the differences could be attributed to the theoretical orientation or to the personal style of the therapist. > Significant events in different therapies - conclusions. ►There are preliminary findings which would suggest that different therapies could be leading to different impacts ►it is not clear what role a different methodology can play (e.g. different taxonomy of events or different raters) in that finding, especially as there are potentially multiple impacts in one event. ►only one of the studies took good precautions to enhance the validity of the study (Llewelyn et al., 1988) by checking for adherence to specific treatment protocol ►It could be meaningful to see whether different in-session positive moments correspond with different models of therapeutic change in different approaches. > Significant events and treatment outcome - findings ►Llewelyn, 1988 found positive correlation between the presence of Problem Solution and therapeutic outcome. ►Booth et al., 1997 found Disappointment with therapist’s interventions correlating negatively with the outcome. ►diaries of significant events showed that the more successful patients were more focused on individual progress during the treatment, less self-critical over time, more positive in the view of others outside the treatment, and had a more positive view of the treatment programme (Stephenson, Laszlo, Ehmann, Lefever, and Lefever, 1997). > Significant events and treatment outcome - conclusions ►there is only a moderate evidence speaking in favour of the link between in-session positive (or nonpresence of negative) events and therapy outcome. ►Methodologically, its main problem is the non-linearity of therapy process – the counting of simple frequencies does not do justice to the qualitative weight of different events. ►Refined methodology, introducing the weighing of the importance of the helpful impact, would have to be used. ►Another alternative would be the use of an intensive single case design (cf. Elliott, 2002; Parry, Shapiro, & Firth, 1986). > Significant events and therapeutic processes - findings ►clients showed a higher level of information processing in significant events than in control events (Martin & Stelmaczonek, 1988) and remembered 70% of events after 6 months ►insight events (Elliott, 1983; 1984; Elliott, Shapiro, Firth-Cozens et al., 1994): §1. contextual priming, §2. novel information, §3. initial distantiating process §4. insight §5. elaboration > Significant events and therapeutic processes – findings (cont.) ►Elliott, Shapiro, Firth-Cozens et al. (1994): §insight in psychodynamic therapy - a new painful awareness involving cross-session linking of interpersonal conflict §in CBT it usually was reattribution of depressing causes. ►several studies pointed to the fact that §despite the event being considered as positive, it still could contain painful emotions §the empathy and skillfulness played role in different types of therapies ► > Significant events and therapeutic processes – findings (cont.) ►Hardy, Aldridge, Davidson et al. (1999) §Reflection - a more typical response to the preoccupied attachment, §interpretation - a more typical response to the dismissive attachment ►Timulak & Elliott, 2003: 5 different types of empowerment: §Poignant §Emerging §Decisional §Determined §Accomplishment > Significant events and therapeutic processes – findings (cont.) ►Grafanaki and McLeod, 1999: narrative processes §the important role of the therapist was to defuse shame experienced by the client. §empowering aspect of the reformulation of an ‘old story’ into a new one. §the therapist’s and client’s co-constructing of the story of therapy, so it could be presented in the world outside of therapy. ►a rhythm – characterised as either ‘interrupted flow’ (the process was hindering) or ‘achieved flow’ when (the process was productive) > Significant events and therapeutic processes – findings (cont.) ►Grafanaki & McLeod, 2002: ‘congruence-incongruence’. §of congruence and incongruence did not simply match helpful or hindering type of events ►The clients’ experiences of congruence: §disclosure (sharing) or new awareness or behaviour including more personal contact with the therapist. ►The client experiences of incongruence §unpleasant experiences or insight or nondisclosure (deference). ►The therapists’ experiences of congruence §empathic attunement, skilful work, personal knowledge and disclosure. ►The therapists’ experiences of incongruence §negative feelings or self-doubt. > Significant events and therapeutic processes – conclusions ►moments of productive therapeutic work that stand out from the rest of the session (e.g. Martin & Stelmazconek, 1988). ►the clients in them formulate a task that needs to be addressed and this is successfully done by the therapist (e.g. Timulak & Lietaer, 2001). ►the processes involved in significant events are complex and ambiguous ►specific events are deeply contextually embedded in preceding events of therapy ►the active role of the client in using the therapy ►potentially decisive therapists’ intervention that often comes from a deep sense of caring for the client, combined with professional skilfulness, ►many ways where the therapist may miss important aspects of the therapeutic process ► > Significant events and therapeutic processes – conclusions (cont.) ►a good process §(1) the therapist ►(a) provides a safe caring environment that allows the client to be pro-active and use therapy productively, ►(b) actively participates in the client change by decisive, skilful, and at the same time caring interventions; and §(2) the client is capable of tolerating potential mistakes in the therapist way of being and working > Conclusions ► > What do we know? ►there is quite elaborate evidence of the kinds of helpful impacts ►These centre on the relationship impacts (e.g. personal contact) and on in-session outcomes (e.g. insight) ►nonhelpful events are less studied ►discrepancy between clients and therapists ►the match is better in effective therapy sessions or therapies > What do we know? (cont.) ►helpful significant events are therapeutically productive events ►how they are linked with the treatment outcome may need yet to be established ►specific intensive studies show the potential richness of significant events in informing therapeutic practice > Limitations ►generalisations across the studies, e.g. different raters, different taxonomies, multiple impacts ►the intensive studies, may be so contextually embedded that it may be hard to make generalisations from them. ►whether or not there are some other therapeutically productive moments that would not be perceived by the client as significant; their significance would not reach the client’s awareness yet ►many significant events are reported - we cannot expect that they would be equally important for the progression of therapy ► > Future directions ►to study significant events in the context of therapy cases that would be monitored for their outcome (cf. Elliott, 2002) §the mechanisms responsible for change in a particular case ►‘sudden gain’ cases (Tang & DeRubeis, 1999; Tang et al., Shelton, 2007) §the sessions prior to the gain could be inspected for significant events which could be subsequently studied thoroughly >