Emotional experience in psychotherapeutic interaction : Conversation analytical study on cognitive psychotherapy

The dissertation examines how emotional experiences are oriented to in the details of psychotherapeutic interaction. The data (57 audio recorded sessions) come from one therapist-patient dyad in cognitive psychotherapy. Conversation analysis is used as method. The dissertation consists of 4 original articles and a summary. The analyses explicate the therapist s practices of responding to the patient s affective expressions. Different types of affiliating responses are identified. It is shown that the affiliating responses are combined with, or build grounds for, more interpretive and challenging actions. The study also includes a case study of a session with strong misalignment between the therapist s and patient s orientations, showing how this misalignment is managed by the therapist. Moreover, through a longitudinal analysis of the transformation of a sequence type, the study suggests that therapeutic change processes can be located to sequential relations of actions. The practices found in this study are compared to earlier research on everyday talk and on medical encounters. It is suggested that in psychotherapeutic interaction, the generic norms of interaction considering affiliation and epistemic access, are modified for the purposes of therapeutic work. The study also shows that the practices of responding to emotional experience in psychotherapy can deviate from the everyday practices of affiliation. The results of the study are also discussed in terms of concepts arising from clinical theory. These include empathy, validation of emotion, therapeutic alliance, interpretation, challenging beliefs, and therapeutic change. The therapist s approach described in this study involves practical integration of different clinical theories. In general terms, the study suggests that in the details of interaction, psychotherapy recurrently performs a dual task of empathy and challenging in relation to the patient s ways of describing their experiences. Methodologically, the study discusses the problem of identifying actions in conversation analysis of psychotherapy and emotional interaction, and the possibility to apply conversation analysis in the study of therapeutic change.

Professional non-neutrality: criticising the third party in psychotherapy

Using audio-recorded data from cognitive-constructivist psychotherapy, the article shows a particular institutional context in which successful professional action does not adhere to the pattern of affective neutrality which Parsons saw as an inherent component of medicine and psychotherapy. In our data, the professional’s non-neutrality functions as a tool for achieving institutional goals. The analysis focuses on the psychotherapist’s actions that convey a critical stance towards a third party with whom the patient has experienced problems. The data analysis revealed two practices of this kind of critique: (1) the therapist can confirm the critique that the patient has expressed or (2) return to the critique from which the patient has focused away. These actions are shown to build grounds for the therapist’s further actions that challenge the patient’s dysfunctional beliefs. The article suggests that in the case of psychotherapy, actions that as such might be seen as apparent lapses from the neutral professional role can in their specific context perform the task of the institution at hand.

Psykoterapia, masennus ja sisäinen tarina

Psychotherapy has been shown to be an effective treatment for depression, but not enough is known about the subjective meanings of therapy for human life. This study focuses on experiences of the effects of psychotherapy, thoughts about changes in depression and meanings of the therapy in the inner narratives of persons who sought psychotherapy for their depression. The study was based on interviews of 14 persons, who took part in the Helsinki Psychotherapy Study (HPS). Half of them took part in short-term solution-focused therapy and half in long-term psychodynamic psychotherapy. The sample included both women and men. Part of them had recovered from their depression by the end of therapy (BDI<10), part had not. Therapy was experienced to have effects on one s immediate feelings, thoughts and social actions. Some barriers were also connected to the therapy and the HPS research frame. The relief of depression was explained by enhanced understanding and perspective changes. Also the therapeutic alliance and factors not connected to therapy were seen to have influence on the experienced changes. The resumption of depression was regarded as the consequence of ill-fitting therapy or therapist, incompleteness of the therapy or other reasons not connected to the therapy itself. With the narrative analysis three interpretations were constructed concerning how the persons had sought for therapy, what was the image they had about themselves and their problems and what were their expectations for the therapy. The interpretations were summed up to the life historical, situational and moral inner narrative. Through the psychotherapy some inner narratives came true. In these cases psychotherapy reinforced the original inner narrative. In other cases psychotherapy did not meet the inner narrative of the person, neither had the narrative changed. For some persons the inner narrative got new forms during the therapy: the analyses showed that psychotherapy had reconstructed the persons conceptions about themselves and their problems, which led to changes in the expectations concerning the therapy. Key words: psychotherapy, depression, inner narrative, qualitative research, analysis of narrative, narrative analysis

Psykoterapian vaikutusten arvioiminen : Keskustelunanalyttinen tutkimus arviointihaastattelun käytänteistä

In the field of psychiatry semi-structured interview is one of the central tools in assessing the psychiatric state of a patient. In semi-structured interview the interviewer participates in the interaction both by the prepared interview questions and by his or her own, unstructured turns. It has been stated that in the context of psychiatric assessment interviewers' unstructured turns help to get focused information but simultaneously may weaken the reliability of the data. This study examines the practices by which semi-structured psychiatric interviews are conducted. The method for the study is conversation analysis, which is both a theory of interaction and a methodology for its empirical, detailed analysis. Using data from 80 video-recorded psychiatric interviews with 16 patients and five interviewers it describes in detail both the structured and unstructured interviewing practices. In the analysis also psychotherapeutic concepts are used to describe phenomena that are characteristic for therapeutic discourse. The data was received from the Helsinki Psychotherapy Study (HPS). HPS is a randomized clinical trial comparing the effectiveness of four forms of psychotherapy in the treatment of depressive and anxiety disorders. A total of 326 patients were randomly assigned to one of three treatment groups: solution-focused therapy, short-term psychodynamic psychotherapy, and long-term psychodynamic psychotherapy. The patients assigned to the long-term psychodynamic psychotherapy group and 41 patients self-selected for psychoanalysis were included in a quasi-experimental design. The primary outcome measures were depressive and anxiety symptoms, while secondary measures included work ability, need for treatment, personality functions, social functioning, and life style. Cost-effectiveness was determined. The data were collected from interviews, questionnaires, psychological tests, and public health registers. The follow-up interviews were conducted five times during a 5-year follow-up. The study shows that interviewers pose elaborated questions that are formulated in a friendly and sensitive way and that make relevant patients' long and story-like responses. When receiving patients' answers interviewers use a wide variety of different interviewing practices by which they direct patients' talk or offer an understanding of the meaning of patients' response. The results of the study are two-fold. Firstly, the study shows that understanding the meaning of mental experiences requires interaction between interviewer and patient. It is stated that therefore semi-structured interview is both relevant and necessary method for collecting data in psychotherapy outcome study. Secondly, the study suggests that conversation analysis, enriched with psychotherapeutic concepts, offers methodological possibilities for psychotherapy process research, especially for process-outcome paradigm.

Depression in / by / for women : agency, feminism and self-help in groups

Depression in / by / for Women: Agency, Feminism and Self-Help in Groups on ensimmäinen väitöstasoinen tutkimus feministisestä terapiasta Suomessa sijoittuen psykologian, sosiaalitieteellisen mielenterveystutkimuksen sekä feministisen tutkimuksen alueille. Perinteisen näkemyksen mukaan feministisen tutkimuksen tulee olla ”naisista, naisten tekemää ja naisille kohdistettua”. Naiset ja masennus -projektitutkimus keskittyy naisten kokemaan masennukseen sisältäen mahdollisen miesten sekä patriarkaalisen hyvinvointivaltion osuuden masennukseen. Masennusta kokevat naiset ovat tutkimuksessa sekä tutkimuksen kohteena että aktiivisia osanottajia, mikä tuo heidän äänensä kuuluville. Tutkimus perustuu vuosien 1994-2000 välisenä aikana kerättyyn 11 ryhmän osallistujia koskevaan kvalitatiivisiin ja kvantitatiivisiin aineistoon. Irmeli Laitinen on ollut suunnittelemassa, keräämässä ja analysoimassa sitä yhdessä projektin muiden jäsenten kanssa. Tutkimuksessa mitattiin kuinka ryhmiin osallistuvien seka masennuksen tunteet että toiminnat muuttuivat yhden vuoden aikana. Tutkimuksen tavoitteena oli sekä masennuksesta kärsivien naisten osallistuminen feministiseen toimintatutkimukseen että ammatillisesti ohjatun oma-apuryhmämenetelmän kehittäminen suomalaiseen mielenterveyspalveluun. Projektin tutkimustulosten mukaan siihen osallistuneet naiset voimaantuivat ymmärtämään itseään sekä saivat luottamusta sosiaaliisiin taitoihinsa. Pidemmällä aikavälillä naisten tunteet muuttuivat myönteisiksi, heidän suhteensa itseensä positiivisemmaksi ja he aktivoituivat fyysisesti. Lisäksi tutkimustulokset viittaavat siihen, että masennus voi johtua näkymättömästä, sukupuolisesti virittyneestä jännitteestä naisystävällisessä hyvinvointivaltiossa paljastaen ”hyvinvointimasennusoireilun”. Suomalaisen sosiologi Erik Allardtin hyvinvointitypologian - having, loving, being – mukaisesti nämä ryhmään osallistuvat naiset eivät koe puutteita niinkään materiaalisessa hyvinvoinnissa (having) vaan pikeminkin suhteiden, sosiaalisen ja emotionaalisen hyvinvoinnin ulottuvuuksilla (loving ja being). Se, että masentuneet naiset pystyvät tuomaan esille pitkään vaiennettuja kokemuksiaan, voi merkitä paljon heidän paranemisessaan ja voimaantumisessaan. Ammatillisesti ohjatut oma-apuryhmät ja naisystävälliset hoitokäytännöt mahdollistivat tämänkaltaisen paranemisprosessin alkamisen tutkimukseen osallistuneissa ryhmissä.

Therapeutic work with the present moment: A conversation analytical study of guidance into immediacy

Therapeutic work with the client’s present moment experience in existential therapy was studied by means of conversation analysis. Using publicly available video recordings of therapy sessions as data, an existential therapist’s practice of guiding a client into immediacy, or refocusing the talk on a client’s immediate experience, was described and compared with a therapist’s corresponding action in cognitive therapy. The study contributes to the description of interactional practice of existential therapy, and involves the first application of conversation analysis to a comparative study of psychotherapy process. The potential utility of this approach and the clinical and empirical implications of the present findings are discussed.

Therapeutic change in interaction

A process of change within a single case of cognitive-constructivist therapy is analyzed by means of conversation analysis (CA). The focus is on a process of change in the sequences of interaction, which consist of the therapist’s conclusion and the patient’s response to it. In the conclusions, the therapist investigates and challenges the patient’s tendency to transform her feelings of disappointment and anger into self-blame. Over the course of the therapy, the patient’s responses to these conclusions are recast: from the patient first rejecting the conclusion, to then being ambivalent, and finally to agreeing with the therapist. On the basis of this case study, we suggest that an analysis that focuses on sequences of talk that are interactionally similar offers a sensitive method to investigate the manifestation of therapeutic change. It is suggested that this line of research can complement assimilation analysis and other methods of analyzing changes in a client’s talk.

After interpretation.

Using 58 audio recorded sessions of psychoanalysis (coming from two analysts and three patients) as data and conversation analysis as method, this paper shows how psychoanalysts deal with patients’ responses to interpretations. After the analyst offers an interpretation, the patient responds: at that point (in the “third position”), the analysts recurrently modify the tenor of the description from what it was in the patients’ responses. They intensify the emotional valence of the description, or they reveal layers of the patients’ experience other than those that the patient reported. Both are usually accomplished in an implicit, non-marked way, and they discreetly index possible opportunities for the patients to modify their understandings of the initial interpretation. Although the patients usually do not fully endorse these modifications, the data available suggests that during the sessions that follow, the participants do work with the aspects of patients’ experience that the analyst highlighted. In discussion, it is suggested that actions that the psychoanalysts produce in therapy, such as choices of turn design in third position, may be informed by working understanding of the minds and mental conflicts of individual patients, alongside the more general therapeutic model of mind they hold to.

Misalignment as a Therapeutic Resource

The article reports conversation analysis of a single cognitive psychotherapy session in which an interactional misalignment between the therapist and the patient emerges, culminates, and is mitigated. Through this case study, the interactional practices lead- ing to a rupture in therapeutic alliance and the practices leading to its mending are explored. In the session the therapist pursues investigative orientation in relation to the patient’s experience under discussion, whereas the patient maintains orientation to “troubles-telling.” The diverging projects of the participants amount to overt misalign- ment. Eventually, the therapist brings the relationship of the patient and herself as a topic of conversation in ways which turn the misalignment into a resource of therapeu- tic work. The microanalysis of actual interactional patterns in this single case is linked to discussions of therapeutic alliance in psychotherapeutic literature.