Ambivalence in emotion-focused therapy for depression: the maintenance of problematically dominant self-narratives

Objective: Ambivalence can be understood as a cyclical movement between an emerging narrative novelty—an Innovative Moment (IM)—and a return to a problematically dominant self-narrative. The return implies that the IM, with its potential for change is devalued right after its emergence. Our goal is to test the hypothesis that the probability of the client expressing such form of ambivalence decreases across treatment in good-outcome cases but not in poor-outcome cases. Method: Return-to-the-Problem Markers (RPMs) signaling moments of devaluation of IMs were coded in passages containing IMs in six clients with major depression treated with emotion-focused therapy: three good-outcome cases and three poor-outcome cases. Results: The percentage of IMs with RPMs decreased across therapy in good-outcome cases, whereas it remained unchanged and high in the poor-outcome cases. Conclusions: These results were consistent with the theoretical suggestion that therapeutic failure may be associated with this form of ambivalence.Obiettivo: L'ambivalenza può essere considerata come un movimento ciclico tra un nuovo elemento narrativo emergente - Innovative Moment (IM) - e il ritorno ad una auto-narrazione problematica dominante. Il ritorno implica che il IM perde il proprio potenziale di favorire un cambiamento nel momento in cui emerge. Il nostro obiettivo è quello di verificare l'ipotesi che la probabilità che il paziente possa esprimere tale forma di ambivalenza diminuisce nel corso di un trattamento che ha un buon esito, ma non nei casi con esito negativo. Metodo: in sei pazienti affetti da depressione maggiore trattati con terapia focalizzata sulle emozioni, sono stati codificati i passaggi contenenti IM utilizzando il Return-to-the-Problem Markers (RPMs) che segnala i passaggi in cui IM vengono svalutati: tre casi con buon esito e tre con esito negativo. Risultati: La percentuale di IM con gli RPM diminuiva nel corso delle terapie dei casi con buon esito, mentre è rimasto invariato ed elevato nei casi con scarso esito. Conclusioni: Questi risultati sono coerenti con il presupposto teorico che il fallimento terapeutico possa essere associato a questa forma di ambivalenza.Objetivo: A ambivalência pode ser entendida como um movimento cíclico entre uma novidade narrativa emergente – um Momento de Inovação (MI) – e um retorno à narrativa problemática dominante. O retorno implica que o MI, com o seu potencial para a mudança, seja desvalorizado logo após a sua emergência. O nosso objetivo é testar a hipótese de que a probabilidade do cliente expressar tal forma de ambivalência diminui ao longo do tratamento em casos de sucesso mas não em casos de insucesso terapêutico. Método: Marcadores de Retorno ao Problema (MRP) que assinalam momentos de desvalorização dos MIs foram codificados em passagens contendo MIs em seis casos de clientes com depressão major tratados com terapia focada nas emoções: três casos de sucesso e três casos de insucesso. Conclusões: Estes resultados foram consistentes com as sugestões teóricas de que o insucesso terapêutico poderá estar associado a esta forma de ambivalência.Ziel: Ambivalenz kann als zyklische Bewegung zwischen einer emergenten narrativen Neuheit – einem Innovative Moment (IM) – und einer Rückkehr zu einer problematischen dominanten Selbst-Erzählung verstanden werden. Diese Rückkehr impliziert, dass der IM mit seinem Potential für Veränderung direkt nach seinem Auftauchen abgewertet wird. Unser Ziel ist die Hypothese zu testen, dass die Wahrscheinlichkeit, dass der Klient eine solche Form der Ambivalenz zeigt, bei Fällen mit gutem Therapieergebnis über die Behandlung abnimmt, aber nicht in Fällen mit schlechtem Ergebnis. Methode: Rückkehr-zu-dem-Problem Marker (RPMs), die Momente signalisieren, in denen IMs abgewertet werden, wurden in Passagen, die IMs beinhalten, von sechs Klienten mit Major Depression, die mit emotionsfokussierter Therapie behandelt wurden, kodiert: 3 Fälle mit gutem und 3 Fälle mit schlechtem Therapieergebnis. Ergebnisse: Der Prozentsatz von IMs mit RPMs verringerte sich bei Fällen mit gutem Ergebnis über die Therapie hinweg, wohingegen er in den Fällen mit schlechtem Ergebnis unverändert und hoch blieb. Schlussfolgerung: Die Ergebnisse waren mit dem theoretischen Vorschlag konsistent, dass therapeutischer Misserfolg mit dieser Form der Ambivalenz assoziiert ist.目標：矛盾可以視為是種擺盪在新產生的新穎敘說—創意時刻(IM)—和回復到一種有問題的支配性自我敘說之間的循環動作。回復意味著潛藏改變契機的IM，其價值在出現後即被摒棄。我們的目標是檢視以下假設的可能性：「在具良好成效的案例中，案主在治療歷程中表達這種形式的矛盾會降低；而在不良成效的案例中則否」。方法：在六位具有嚴重憂鬱症患者的IM段落中，找到顯示IM價值降低時刻的故態復萌標記（RPMs）並加以編碼。這六位患者均接受情緒焦點治療，其中三位為具良好成效案例，另外三位為不良成效案例。結果：在具良好成效案例中，IM當中具有RPM的比率降低；而在不良成效的案例中，RPM的比率維持不變或更高。結論：此結果與理論假設一致，即假設治療的失敗可能與這種形式的矛盾有關

Narrative change in emotion-focused psychotherapy: a study on the evolution of reflection and protest innovative moments

Innovative moments (IMs) are exceptions to a client’s problematic self-narrative in the therapeutic dialogue. The innovative moments coding system is a tool which tracks five different types of IMs*action, reflection, protest, reconceptualization and performing change. An in-depth qualitative analysis of six therapeutic cases of emotion-focused therapy (EFT) investigated the role of two of the most common IMs*reflection and protest*in both good and poor outcome cases. Through this analysis two subtypes (I and II) of reflection and protest IMs were identified, revealing different evolution patterns. Subtype II of both reflection and protest IMs is significantly higher in the good outcome group, while subtype I of both IMs types does not present statistically significant differences between groups. The evolution from subtype I to subtype II across the therapeutic process seems to reflect a relevant developmental progression in the change process

Socially anxious mothers’ narratives to their children, and their relation to child representations and adjustment

Anxious mothers’ parenting, particularly transfer of threat information, has been considered important in their children’s risk for social anxiety disorder (SAnxD), and maternal narratives concerning potential social threat could elucidate this contribution. Maternal narratives to their pre-school 4-5 year-old children, via a picture book about starting school, were assessed in socially anxious (N=73), and non-anxious (N=63) mothers. Child representations of school were assessed via Doll Play (DP). After one school term, mothers (CBCL) and teachers (TRF) reported on child internalizing problems, and child SAnxD was assessed via maternal interview. Relations between these variables, infant behavioral inhibition, and attachment, were examined. Socially anxious mothers showed more negative (higher threat attribution), and less supportive (lower encouragement) narratives, than controls, and their children’s DP representations, SAnxD and CBCL scores were more adverse. High narrative threat predicted child SAnxD; lower encouragement predicted negative child CBCL scores and, particularly for behaviorally inhibited children, TRF scores and DP representations. In securely attached children, CBCL scores and risk for SAnxD were affected by maternal anxiety and threat attributions, respectively. Low encouragement mediated the effects of maternal anxiety on child DP representations, and CBCL scores. Maternal narratives are affected by social anxiety, and contribute to adverse child outcome

Humanistic psychotherapy research 1990-2015 : from methodological innovation to evidence-supported treatment outcomes and beyond

Over the past twenty five years, humanistic psychotherapy (HP) researchers have actively contributed to the development and implementation of innovative practice-informed research measures and coding systems. Qualitative and quantitative research findings, including meta-analyses, support the identification of HP approaches as evidence-based treatments for a variety of psychological conditions. Implications for future psychotherapy research, training and practice are discussed in terms of addressing the persistent disjunction between significant HP research productivity and relatively low support for HP approaches in university-based clinical training programs, funding agencies and government-supported clinical guidelines. Finally, specific recommendations are provided to further enhance and expand the impact of humanistic psychotherapy research for clinical training programs and the development of treatment guidelines

Self-narrative reconstruction in emotion-focused therapy: A preliminary task analysis

Objective: This research explored the consolidation phase of emotion-focused therapy (EFT) for depression and studies—through a task-analysis method—how client–therapist dyads evolved from the exploration of the problem to self-narrative reconstruction. Method: Innovative moments (IMs) were used to situate the process of self-narrative reconstruction within sessions, particularly through reconceptualization and performing change IMs. We contrasted the observation of these occurrences with a rational model of self-narrative reconstruction, previously built. Results: This study presents the rational model and the revised rational-empirical model of the self-narrative reconstruction task in three EFT dyads, suggesting nine steps necessary for task resolution: (1) Explicit recognition of differences in the present and steps in the path of change; (2) Development of a meta-perspective contrast between present self and past self; (3) Amplification of contrast in the self; (4) A positive appreciation of changes is conveyed; (5) Occurrence of feelings of empowerment, competence, and mastery; (6) Reference to difficulties still present; (7) Emphasis on the loss of centrality of the problem; (8) Perception of change as a gradual, developing process; and (9) Reference to projects, experiences of change, or elaboration of new plans. Conclusions: Central aspects of therapist activity in facilitating the client's progression along these nine steps are also elaboratedtuguese Foun- dation for Science and Technology [grant PTDC/PSI-PCL/121525/2010] (Ambivalence and unsuccessful psychotherapy, 2007–2010) and by the Ph.D. grant [SFRH/BD/30880/2006

Ten-year mortality, disease progression, and treatment-related side effects in men with localised prostate cancer from the ProtecT randomised controlled trial according to treatment received

Background The ProtecT trial reported intention-to-treat analysis of men with localised prostate cancer randomly allocated to active monitoring (AM), radical prostatectomy, and external beam radiotherapy. Objective To report outcomes according to treatment received in men in randomised and treatment choice cohorts. Design, setting, and participants This study focuses on secondary care. Men with clinically localised prostate cancer at one of nine UK centres were invited to participate in the treatment trial comparing AM, radical prostatectomy, and radiotherapy. Intervention Two cohorts included 1643 men who agreed to be randomised and 997 who declined randomisation and chose treatment. Outcome measurements and statistical analysis Analysis was carried out to assess mortality, metastasis and progression and health-related quality of life impacts on urinary, bowel, and sexual function using patient-reported outcome measures. Analysis was based on comparisons between groups defined by treatment received for both randomised and treatment choice cohorts in turn, with pooled estimates of intervention effect obtained using meta-analysis. Differences were estimated with adjustment for known prognostic factors using propensity scores. Results and limitations According to treatment received, more men receiving AM died of PCa (AM 1.85%, surgery 0.67%, radiotherapy 0.73%), whilst this difference remained consistent with chance in the randomised cohort (p = 0.08); stronger evidence was found in the exploratory analyses (randomised plus choice cohort) when AM was compared with the combined radical treatment group (p = 0.003). There was also strong evidence that metastasis (AM 5.6%, surgery 2.4%, radiotherapy 2.7%) and disease progression (AM 20.35%, surgery 5.87%, radiotherapy 6.62%) were more common in the AM group. Compared with AM, there were higher risks of sexual dysfunction (95% at 6 mo) and urinary incontinence (55% at 6 mo) after surgery, and of sexual dysfunction (88% at 6 mo) and bowel dysfunction (5% at 6 mo) after radiotherapy. The key limitations are the potential for bias when comparing groups defined by treatment received and changes in the protocol for AM during the lengthy follow-up required in trials of screen-detected PCa. Conclusions Analyses according to treatment received showed increased rates of disease-related events and lower rates of patient-reported harms in men managed by AM compared with men managed by radical treatment, and stronger evidence of greater PCa mortality in the AM group. Patient summary More than 95 out of every 100 men with low or intermediate risk localised prostate cancer do not die of prostate cancer within 10 yr, irrespective of whether treatment is by means of monitoring, surgery, or radiotherapy. Side effects on sexual and bladder function are better after active monitoring, but the risks of spreading of prostate cancer are more common

Multiple novel prostate cancer susceptibility signals identified by fine-mapping of known risk loci among Europeans

Genome-wide association studies (GWAS) have identified numerous common prostate cancer (PrCa) susceptibility loci. We have fine-mapped 64 GWAS regions known at the conclusion of the iCOGS study using large-scale genotyping and imputation in 25 723 PrCa cases and 26 274 controls of European ancestry. We detected evidence for multiple independent signals at 16 regions, 12 of which contained additional newly identified significant associations. A single signal comprising a spectrum of correlated variation was observed at 39 regions; 35 of which are now described by a novel more significantly associated lead SNP, while the originally reported variant remained as the lead SNP only in 4 regions. We also confirmed two association signals in Europeans that had been previously reported only in East-Asian GWAS. Based on statistical evidence and linkage disequilibrium (LD) structure, we have curated and narrowed down the list of the most likely candidate causal variants for each region. Functional annotation using data from ENCODE filtered for PrCa cell lines and eQTL analysis demonstrated significant enrichment for overlap with bio-features within this set. By incorporating the novel risk variants identified here alongside the refined data for existing association signals, we estimate that these loci now explain ∼38.9% of the familial relative risk of PrCa, an 8.9% improvement over the previously reported GWAS tag SNPs. This suggests that a significant fraction of the heritability of PrCa may have been hidden during the discovery phase of GWAS, in particular due to the presence of multiple independent signals within the same regio

Functional and quality of life outcomes of localised prostate cancer treatments (prostate testing for cancer and treatment [ProtecT] study)

Objective To investigate the functional and quality of life (QoL) outcomes of treatments for localised prostate cancer and inform treatment decision-making. Patients and Methods Men aged 50–69 years diagnosed with localised prostate cancer by prostate-specific antigen testing and biopsies at nine UK centres in the Prostate Testing for Cancer and Treatment (ProtecT) trial were randomised to, or chose one of, three treatments. Of 2565 participants, 1135 men received active monitoring (AM), 750 a radical prostatectomy (RP), 603 external-beam radiotherapy (EBRT) with concurrent androgen-deprivation therapy (ADT) and 77 low-dose-rate brachytherapy (BT, not a randomised treatment). Patient-reported outcome measures (PROMs) completed annually for 6 years were analysed by initial treatment and censored for subsequent treatments. Mixed effects models were adjusted for baseline characteristics using propensity scores. Results Treatment-received analyses revealed different impacts of treatments over 6 years. Men remaining on AM experienced gradual declines in sexual and urinary function with age (e.g., increases in erectile dysfunction from 35% of men at baseline to 53% at 6 years and nocturia similarly from 20% to 38%). Radical treatment impacts were immediate and continued over 6 years. After RP, 95% of men reported erectile dysfunction persisting for 85% at 6 years, and after EBRT this was reported by 69% and 74%, respectively (P < 0.001 compared with AM). After RP, 36% of men reported urinary leakage requiring at least 1 pad/day, persisting for 20% at 6 years, compared with no change in men receiving EBRT or AM (P < 0.001). Worse bowel function and bother (e.g., bloody stools 6% at 6 years and faecal incontinence 10%) was experienced by men after EBRT than after RP or AM (P < 0.001) with lesser effects after BT. No treatment affected mental or physical QoL. Conclusion Treatment decision-making for localised prostate cancer can be informed by these 6-year functional and QoL outcomes