Alice (a pseudonym) was a single-26 year old employed woman who was treated for depression at the Maia University Institute (ISMAI), Portugal. She participated in a randomized clinical trial called the ISMAI Depression Study, which compared the efficacy of Cognitive behavioral therapy (CBT) and Emotion Focused Therapy (EFT) for patients diagnosed with major depressive disorder.
Psychological treatment, as well as the collection and processing of data for research purposes followed principles and standards included in the ethics code (American Psychological Association's - APA - Ethical Principles of Psychologists and Code of Conduct, as well as the Code of Ethics of Portuguese Psychologists). The client of this study, like all other participants, signed an informed consent required in the Standard 3.10 of the ethics code. Previously, the client was informed about the purposes of the research, expected duration and procedures. In addition, it was clarified that participation was voluntary, preserving their right to refuse participation or to give up participating at any time. In this informed consent, Alice also authorized the use of the collected data for process and outcome studies.
Alice received 16 weekly sessions of EFT and was considered a good-outcome client, as described later. She lived with her parents, who were catholic and conservative. Her presenting problems concerned her relationships with her boyfriend and with her parents (mainly her father) and problems at work. Mendes and collaborators previously classified categories of setbacks in this case.
Alice's therapist was a Portuguese woman in her early thirties with 8 years of experience as a therapist, including 4 years of experience delivering EFT.
Emotion Focused Therapy is an empirically validated humanistic therapy that views emotions as an essential element in human functioning. According to this therapeutic model, emotions signal important needs underlying people's experiences and promote adaptive action tendencies, helping them adapt and survive. Psychological problems are viewed as consequence of maladaptive emotional processing. The main therapeutic goal is to change this maladaptive emotional processing, allowing adaptive emotions to emerge and promote more adaptive functioning.
The Portuguese version of the BDI-II (translated into Portuguese from) is a 21-item self-report questionnaire that assesses depressive symptoms. Higher total scores indicate severe depressive symptoms. For the Portuguese population, significant clinical depressive symptoms are signaled by a total score higher than 13. The results of the Portuguese validation were considered good. Internal consistency reliability measured by Cronbach's Alpha was 0.89.
The OQ-10 is a self-report questionnaire composed by 10 items that measures health functionality. Each item is scored on a scale ranging from 0 to 4 and the total score goes from 0 to 40. Obtaining a higher score in this questionnaire indicates the presence of poorer mental health functionality. The OQ-10 Cronbach's Alpha was of 0.88 (Seelert, unpublished) and the test-retest reliability of 0.62. In the sample from ISMAI Depression Study (n = 64), the internal consistency was of 0.88 (Cronbach's Alpha) and the test-retest reliability was of 0.74 over a 1-week interval.
As summarized in Table 1, the APES describes the evolution of the relation of a problematic experience (or voice) to the self (dominant community of voices) using a sequence of eight stages, numbered 0 to 7, ranging from warded off (i.e., muted or dissociated) to mastery (i.e., fully integrated and no longer a problem, serving as a resource in new situations). Theoretically, the APES is considered as a continuum, and intermediate ratings (e.g., 2.3, 4.6) are allowed. However, for this study, we used only whole numbers on the APES (e.g., 2, 3).
The BDI-II was administered at initial and post-treatment assessments and at sessions 1, 4, 8, 12. The OQ-10 was administered immediately before each session. Alice's 16 sessions were videorecorded and later transcribed verbatim following the transcription conventions described by.
Alice met criteria for the ISMAI Depression Study, which included: being diagnosed with Major Depression Disorder; Global Assessment of Functioning > 50. The exclusion criteria were: currently on medication or another form of treatment; or currently or previously diagnosed with one of the following DSM-IV Axis I disorders: panic, substance abuse, psychotic, bipolar, or eating disorder; or one of the following DSM-IV Axis II disorders: borderline, antisocial, narcissistic, or schizotypal; or at high risk of suicide. Screening for inclusion and exclusion criteria used the Structural Clinical Interview for the DSM-IV-TR. After being admitted to the study, each client was randomly attributed to a therapeutic condition (CBT or EFT) and, afterward, randomly assign to a therapist.
Alice's scores on the BDI-II the ISMAI trial's criterion measure, declined from 29 at initial assessment to 1 at her last session and 5 at 1-year follow-up. She was considered a good-outcome case because she met criteria for clinically significant and reliable improvement, as described by: (a) Her scores improved from above to below the cut-off of 13 on the Portuguese BDI-II, indicating clinically significant improvement, and (b) the amount of change was greater than the reliable change index of 7.75, that is, a difference greater than likely to have occurred by chance (at p < 0.05), indicating reliable improvement. For this case study, she was selected from among the ISMAI trial clients who met the criteria on the basis that complete transcripts were available.
Our assimilation analysis followed procedures used in previous studies (e.g.,).
The two APES raters were a PhD clinical psychologist, and a Ph.D. student in clinical Psychology, both with previous experience in research on the assimilation model. Training took approximately 4 months and included weekly meetings in which journal articles about the assimilation model were read and discussed and, sample sessions were coded according to the APES until all raters were considered reliable, achieving an intraclass correlation coefficient reliability of ICC [2,1] >= 0.60.
Next, both members of the team read transcripts of the entire case and identified the main recurring issues. By consensual agreement, they chose and characterized two main themes based on clinical relevance and time spent in therapy. The first theme was "fear of being rejected and abandoned," which concerned Alice's difficulty in imposing her needs to others, motived by an intense fear of not being accepted for what she was. The other theme selected was "hurt toward her father," which concerned unfinished business with her father concerning an episode in which, at the age of 15, she discovered an affair her father was having. She had never confronted him about this, but she resented his infidelity. Alice's dominant voice was labeled as "fear of being rejected," as she presented a similar interpersonal pattern across contexts: work, relationships with family and boyfriend. The problematic voice for both themes was labeled as "I have the right to express myself and be accepted," characterizing similar experiences of wanting to assert her needs and rights. These two voices seemed closely similar for both of these themes.
After selecting the themes, raters excerpted all passages where the themes appeared (N = 554) and rated them, independently according to the APES. The passage was the rating unit and was defined as a stretch of discourse delineated by a change in the topic of the conversation or by markers of changes in APES level (see). Reliability of these independent APES ratings was assessed using the Intraclass Correlation Coefficient designated ICC (2,2) by, which is the reliability of the average of two raters. The ICC (2,2) was of 0.966, which is considered good. Subsequently, raters discussed and reached consensus on APES ratings of passages where they disagreed (see). The consensus ratings were used in our analyses.
Figures 1, 2 show the assimilation progress in each theme, across passages. Passages dealing with particular themes were not evenly spaced across sessions, and the divisions shown in the figures are meant to indicate the approximate parts of the treatment in which each theme was addressed. The "fear of being rejected and abandoned" theme was much more frequent than the "hurt toward her father" theme. However, because both themes involved the same problematic and dominant voices, suggesting they were different expressions of a common core problem, we decided to combine these themes for our analysis. We also noted that the evolution of the two themes, considered separately, appeared very similar in terms of both APES levels and instability. Thus, to obtain mean APES levels for each session, we averaged APES ratings across passages of both themes within each session.
Assimilation of problematic experiences scales fluctuation in each session was indexed using a measure fully described by, which assessed the amplitude and the frequency of changes in APES levels across one session. In effect, the APES fluctuations index is a way to index the incidence of APES setbacks. Fluctuation values can vary from 0 (low fluctuation) to 1 (high fluctuation). That is, the formula yields a normalized fluctuation intensity, 0 <=F <= 1:
where
yi = |xnk + 1 - xnkj
xn = nth session score
k = points of return (changes in slope in the data sequence)
i = periods between points of return
I = total number of such periods within the window
m = number of measurement points within a moving window
m - 1 = number of intervals between all measurement points of a window
s = xmax - xmin with xmin smallest value of the scale, xmax largest value of the scale.
In the present study we employed a dynamic factor model that is a vector-autoregressive (VAR) method to measure contemporaneous correlations and time-lagged regressions in multivariate time series, using a structural equation model framework. The first step for this analysis was to smooth the time-series data and remove its trend. A moving average was calculated for the APES level, APES fluctuation, and symptom intensity measured by the OQ-10. The moving average was calculated by taking the arithmetic mean of a moving-window of four sessions. Total observations within each variable was equal to 16, the total number of sessions of Alice's treatment. For the dynamic factor analysis, we treated each variable as a separated dependent variable.
A VAR model with a lag of 1 session was tested by creating a block-Toeplitz matrix. The VAR model allowed to analyze intra- and intersession relationships between each variable. All VAR analyses were carried out in LISREL (Version 8.80). Since we had a single indicator for each latent variable, the lambda (lambda) was set to identify and the beta (theta) matrix was fixed at zero. The beta matrix was then analyzed to search for meaningful modification indices (MIs). To improve our model, whenever there was a significant MI, we rerun the analysis with the significant path. The final model was accepted when no more significant MIs were observed within the matrix.