Narrative theorists suggest that the major change clients make in therapy involves how they talk about or tell their stories. They measure this change by identifying innovative moments (IMs) in client speech. Five types of IMs have been identified: action (the client acting in ways that are discrepant with the problematic self-narrative), reflection (new understandings that undermine the dominance of the problematic self-narrative), protest (challenging the problematic self-narrative), reconceptualization (a shift between two positions and a transformation process), and performing change (new activities or experiences that become possible because of changes). Previous studies have found more IMs in successful than unsuccessful therapy, in particular, with more occurrences of reconceptualization and action IMs. Cunha et al. wondered whether specific therapist skills facilitated IMs. Therapist skills were conceptualized as exploration (includes approval- reassurance, closed questions, open questions and probes, restatements, reflections of feelings), insight (includes challenges, interpretations, self-disclosures, and immediacy), and action (includes information and direct guidance).
Method: Three good-outcome and three poor-outcome cases of emotion-focused therapy for depression were selected based on examination of a number of outcome measures. The first two sessions, two sequential middle sessions, and the two final sessions of these six cases were coded for therapist skills and client IMs.
Interesting Findings: Exploration skills were used more often, whereas insight skills were used less often, in good- compared with poor-outcome cases across all three phases of therapy. Action skills were used more often in initial phases of good- than poor-outcome cases but more often in the final sessions of poor- than good-outcome cases. IMs more often followed skills in the good- than poor-outcome cases. In good-outcome cases, the connection between skills and IMs increased from the initial to middle phase of therapy and was maintained in the final phases. In poor-outcome cases, the connection between skills and IMs increased from the beginning to middle but then decreased in the final phase. In terms of types of IMs, the authors divided these into easier IMs (action, reflection, protest) and more advanced IMs (reconceptualization, performing change). In the initial and middle phases of the good-outcome cases, all three types of skills were associated more with easier IMs but not with more advanced IMs; in the final phase, exploration and insight skills were more often associated with easy IMs than with the more advanced IMs. In the final phase of poor-outcome cases, all skills were more associated with the easy than advanced IMs.
Conclusions: Therapists used the skills more effectively in good- than poor-outcome cases (i.e., all three types of skills led to more IMs in good- than poor-outcome cases). Experiential therapists used mostly exploration skills, which fits with this theoretical perspective as being client centered. However, exploration skills did not lead to more IMs than did insight skills.
Insight skills were used more often in poor- than good-outcome cases. The authors speculated that therapists were trying to engage clients when the more theoretically preferred exploration skills were not working. Exploration and insight skills led mostly to the easier IMs in the initial and middle phases of therapy, whereas they led mostly to the more advanced skills later in therapy. It appears that the foundation must be set early in therapy with the easier IMs before the complex IMs can occur. Action skills were used more in the beginning and middle phases of good-outcome cases, which the authors speculate was because therapists were engaging in in-session experiential activities such as chair work. They speculated that action skills were used less in the final phase because therapists were helping clients consolidate gains. In contrast, in poor-outcome cases, action skills increased steadily across phases, perhaps because therapists continued to try to engage clients in therapeutic tasks even when they were not working. Action skills led more often to the easier than the more complex IMs.
Implications for Therapy: Therapists should pay attention to the immediate effects of their interventions. Therapists can use both exploration and insight skills to promote easy IMs in the early and middle phases of therapy and the more complex IMs in the final sessions of therapy. Therapists can use action skills (remember that these were usually the in-session directives) to promote the easy IMs throughout therapy.