Psychology (Functional Area: Clinical Psychology)

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Open Access
An Examination of the Interrelation of Narrative and Emotion Processes in Emotion-Focused Therapy for Trauma
(2017-07-27) Bryntwick, Emily Gail; Angus, Lynne
According to narrative-informed approaches to psychotherapy, self-narratives that no longer align with lived experience, and thereby impede coherent meaning-making, often bring individuals into treatment. Exposure to trauma can result in fragmented or disorganized self-narratives, and Emotion-focused Therapy for Trauma (EFTT) (Paivio & Pascual-Leone, 2010) is one treatment approach that helps trauma clients access, explore, and integrate traumatic memories into coherent personal narratives. The Narrative-Emotion Process Coding System (NEPCS 2.0; Angus Narrative-Emotion Marker Lab, 2015) is a video-based coding system that consists of 10 narrative-emotion markers (i.e., client storytelling processes) that have been divided into three NEPCS marker subgroups, based on their degree of narrative-emotion integration: Problem, Transition, and Change markers. The aim of the current study was to examine the relationship between NEPCS markers and outcome (i.e., recovered vs. unchanged) across stage of therapy in a complex trauma sample receiving EFTT (N = 12 clients). The key hypotheses included: recovered clients would have significantly higher proportions of Transition markers in the early and middle stages of therapy, and significantly higher proportions of Change markers in the late stage of therapy, while unchanged clients would have significantly higher proportions of Problem markers across all stages of therapy. Additionally, recovered clients would have significantly higher proportions of shifting (i.e., movement between one NEPCS marker and a different NEPCS marker), and significantly higher proportions of productive shifting (i.e., movement away from Problem markers), whereas unchanged clients would have higher proportions of unproductive shifting (i.e., movement to Problem markers). Results suggested that, in line with theoretical expectations and previous NEPCS research applications, recovered clients showed significantly higher proportions of Transition and Change markers, whereas unchanged clients demonstrated higher proportions of Problem markers. Increased levels of NEPCS shifting, or flexibly moving between NEPCS markers, was also associated with recovery. Furthermore, recovered clients demonstrated significantly higher proportions of productive shifting, while their unchanged counterparts demonstrated more unproductive shifting, suggesting that the type of narrative flexibility may be an important prognostic indicator. A direction for future NEPCS research is to elucidate therapeutic interventions that facilitate client movement from unproductive to more productive modes of narrative-emotion processing.
Open Access
Bringing Into Presence: Client Experiences of SpeakArt, a Group Therapy for Complex Trauma
(2021-03-08) Macaulay, Christianne Braid; Angus, Lynne
This qualitative study explored the experiences of women who completed an art therapy group for the treatment of difficulties related to complex trauma. Increasingly, treatments that address problems with self-organization (emotion regulation, self-concept, and relationship difficulties), in addition to classic symptoms of post-traumatic stress disorder, are recommended for individuals with complex trauma histories (e.g., Courtois & Ford, 2016). To date, evidence for the effectiveness of art therapy for complex trauma is limited but promising (e.g., Gantt & Tinnin, 2007; Pifalo, 2006), and process studies are non-existent. No study to date has examined client experiences of art therapy, with the goal of understanding how it is helpful (or not) from the client perspective. The present study aimed to address this gap, through a qualitative investigation of SpeakArt, a 12-week group offered through a hospital-based trauma therapy program. Ten participants completed interviews, conducted after their initial group session, about their goals, expectations, and concerns about the group. A second post-therapy interview invited participants to review a written summary of their initial interview, reflect on their experience of the group overall, and identify personal changes that they attributed to SpeakArt. The post-therapy interviews were analyzed using grounded theory techniques, applied from an interpretive-constructivist stance (Charmaz, 2006; Rennie, 2000). The analysis yielded four conceptual domains, comprising participants experience of art therapy and associated shifts: (1) Negotiating (Un)safeness in the Present; (2) Bringing It Up; (3) Witnessing the Invisible and the Invalidated; and (4) Transferring Transformation. A core category and heuristic model was also developed, describing two participant pathways in the group and a dynamic relationship among the four domains. The core category, Bringing into Presence, refers to processes of integrating old/trauma-related memories and emotions, and creating new meanings and adaptive responses. It is concluded that these integration and creation processes are contingent on experiencing intrapersonal and interpersonal safeness in group, and are mediated by the material, visual, and interactive nature of art-making in a group setting. Bringing into Presence as a concept is discussed and expanded on with reference to literature on integration in trauma recovery, relevant concepts from the psychotherapy process literature, and complex trauma conceptualization.
Open Access
Clients' Perspectives of the Working Alliance Inventory
(2018-03-01) Watson-Gaze, James Eliot; Angus, Lynne
The working alliance is one of the most widely studied constructs in the psychotherapy research literature, and ratings of the working alliance are widely used in clinical research and practice to measure the relationships between clients and their therapists and courses of treatments. Nonetheless, relatively little is known about how clients understand and engage with the scales from which such ratings are derived. To address this gap in the literature, clients in ongoing psychotherapy were interviewed after completing a version of the most widely used alliance rating scale, the Working Alliance Inventory (WAI). This study was comprised of two primary phases. In the first phase, 12 clients took part in semi-structured interviews focused on understanding what they were aware of when completing a version of the WAI, the WAI Short Revised (WAI-SR). Then, transcripts from this phase were analyzed using Grounded Theory methods. Analyses yielded a core category of Rolling on the Right Track, which encapsulated participant reflections of the scale as a means to communicate the degree to which clients and therapists are moving together towards shared therapeutic goals. In the second phase, 10 clients took part in cognitive interviews that targeted specific information about whether clients identified any difficulties with understanding elements of the WAI-SR. Transcripts were analyzed using the Classification Coding Scheme and findings indicated that participants noted difficulties with several parts of the scale. Item comprehension challenges were the most frequently raised areas of concern. Results were triangulated across both primary phases and key findings discussed in the context of ongoing debates in the research literature. This study exemplifies and underscores the dynamic nature of clients rating processes when completing a version of the WAI, as well as the ways they use the measure as a means to assess and communicate the degree to which they are working effectively in treatment. This study also raises concerns about the intelligibility of the WAI-SR for clients who complete it and calls into question the confidence with which researchers and clinicians can maintain their faith in the accuracy of clients ratings.
Open Access
Comparing Narrative and Emotion Processing in Two Versions of Emotion-Focused Therapy for Trauma: Imaginal Confrontation vs. Empathic Exploration
(2018-05-28) Carpenter, Naomi Reidun; Angus, Lynne
A goal of Emotion-Focused Therapy for Trauma (EFTT) is narrative and emotion integration for trauma recovery (Paivio & Pascual-Leone, 2010). EFTT employs two re-experiencing interventions. Clients in Imaginal Confrontation (IC) imagine the perpetrator of abuse in an empty chair across from him/her and express thoughts and feelings. Clients in Empathic Exploration (EE) imagine the perpetrator in their minds eye and expresses thoughts and feelings to the therapist. EE is considered a less emotionally evocative alternative to IC. EFTT-IC and EFTT-EE are equally effective (Paivio et al., 2010), and may evidence unique pathways to recovery. The Narrative-Emotion Process Coding System (NEPCS; Angus et al., 2017) is a behavioural coding system that identifies 10 markers that are clustered into Problem, Transition, and Change Markers. The NEPCS markers and subgroups represent narrative-emotion process indicators occurring within one-minute time segments from videotaped therapy sessions. The current study investigated differences in the proportion of NEPCS markers and subgroups between the EFTT-IC and EFTT-EE conditions, and the relation to treatment outcome. The NEPCS was applied to two early, two middle and two late videotaped therapy sessions from four recovered and four unchanged EFTT-IC and EFTT-EE clients (N=16). In regard to Problem Markers, Negative Binomial Regression analysis revealed a main effect for Problem Markers, and a main effect and stage by condition interaction for Superficial Storytelling for EFTT-EE versus EFTT-IC. There was a stage by outcome interaction for Unstoried Emotion for unchanged versus recovered EFTT-IC clients. In regard to Transition Markers, there was a stage by condition interaction for the Transition Markers in EFTT-IC than EFTT-EE, and a stage by outcome interaction for Inchoate Storytelling for recovered versus unchanged EFTT-EE clients. In regard to Change Markers, a stage by outcome interaction was present for Unexpected Outcome Storytelling and Discovery Storytelling for recovered versus unchanged EFTT-IC and EFTT-EE clients. Finally, there was a main effect and a stage by condition interaction for No Client Marker for EFTT-IC versus EFTT-EE clients, and a stage by outcome interaction for recovered versus unchanged EFTT-EE clients. Implications for EFTT therapists, limitations of the current study and directions for future research are discussed.
Open Access
Development and Application of the Narration-Emotion Process Coding System (NEPCS-CBT): Exploratory Analyses of Therapist and Client Narrative-Emotion Markers in Cognitive Behavioural Therapy for Generalized Anxiety Disorder Psychotherapy Sessions
(2023-12-08) Khattra, Jasmine; Angus, Lynne
The narrative-informed, dialectical-constructivist model (Angus & Greenberg, 2011) suggests that narrative contextualization of emotional experiences in which affect, actions, and thoughts are organized as a told story, enables new self-reflection, emotional awareness, and meaning-making for sustained change in psychotherapy sessions. The Narrative-Emotion Process Coding System Version 2.0 (NEPCS; Angus et al., 2017) is a standardized tool that consists of 10 client markers that capture clients’ mode of storytelling, emotional processing, and reflective meaning making, in therapy sessions in addition to a ‘No Client marker’ dominated by therapist-talk. These 10 client markers are classified into three subgroups: Problem (Same Old, Empty, Unstoried Emotion, and Superficial Storytelling), Transition (Reflective, Inchoate, Experiential, and Competing Plotlines Storytelling), and Change Markers (Unexpected Outcome, and Discovery Storytelling). The NEPCS 2.0 (Angus et al., 2017) was applied to a small Cognitive Behavioural Therapy (CBT) for Generalized Anxiety Disorder (GAD) sample (N = 6; 36 therapy sessions; drawn from Westra et al., 2016) in a pilot study (Khattra et al., 2018). Pilot study (Khattra et al., 2018) findings indicated that therapists contributed up to 45% (‘No Client marker’) of all coded minutes in CBT sessions. The exploration of therapist interventions in ‘No Client markers’ was highlighted as a future direction given therapists’ extensive role in guiding session process in CBT treatment for GAD. Additionally, it was noted that nuances of client narrative-emotion processes during CBT session tasks may have been missed and coded homogenously as the ‘Superficial Storytelling’ marker (22.4% of coded session time; second most frequently occurring marker). The present study aimed to address these limitations and future directions, and had two primary goals: 1) The development of the NEPCS-CBT manual, based on NEPCS 2.0 (Angus et al., 2017), including the differentiation of ‘No Client marker’ category into discrete therapist marker interventions, and refinement of client markers with CBT-task criteria; and 2) Application of the NEPCS-CBT manual to a larger CBT for GAD sample (N = 10; 60 therapy sessions; drawn from Westra et al., 2016). Multilevel mixed-effects models demonstrated significantly higher proportions of Client (C)-Problem markers subgroup (specifically, C-Same Old Storytelling marker), and lower proportions of the C-Transition markers subgroup (specifically, C-Reflective Storytelling marker) for unchanged clients (vs. recovered clients) overall, and at the early, middle, and late stages of therapy. Recovered clients narrated significantly higher proportions of the C-Competing Plotlines Storytelling marker overall, and at the late therapy stages, and the C-Unexpected Outcome Storytelling marker at the middle and late therapy stages. Therapists of unchanged clients engaged in significantly higher proportions of the Therapist (T)-Transition marker subgroup at the late therapy stage, and specifically, higher proportions of the T-Competing Plotlines marker (‘Therapist challenges client’s maladaptive patterns’) overall, and at the middle and late therapy stages. Findings are discussed in the context of previous NEPCS research findings, and current CBT and GAD research literature focusing on client ambivalence for change and interpersonal resistance. Clinical implications and the value of the development of the NEPCS-CBT manual are also discussed.
Open Access
Examining Autobiographical Memory Specificity, Expressed Emotional Arousal and Client Experiencing in Emotion - Focused and Client - Centered Treatments of Depression: A Process - Outcome Analysis
(2015-08-28) Hilborn, Jennifer Victoria; Angus, Lynne
Research has consistently demonstrated that clinical depression is associated with a propensity toward generic, nonspecific autobiographical memory (ABM) recall (for a review see Williams, Barnhofer, Crane, Hermans, Raes, Watkins, et al., 2007). A recent study demonstrated that although increasing degree of ABM specificity was not independently related to treatment outcome in experiential therapy for depression, a relationship between higher levels of expressed emotional arousal and more specific memory narratives existed in clients who demonstrated positive therapeutic outcome (Boritz, Angus, Monette, Hollis-Walker & Warwar, 2011). The purpose of the present study was to extend the research of Boritz et al. (2011) by examining the relation between expressed emotional arousal, ABM specificity, and client experiencing in a significantly larger depressed sample than was utilized in the original study. To this end, data from the York I & II Depression Studies of 72 depressed clients undergoing manualized psychotherapy treatment for depression was analyzed. Therapy transcripts from early, middle and late sessions were analyzed to evaluate ABM specificity, client experiencing (i.e. level of client self-reflection) and client expressed emotional arousal. Treatment outcome groups (Recovered, Unchanged) were classified based on the Beck Depression Inventory (BDI) using clinically significant change criteria identified by Jacobson and Truax (1991). Four primary findings were as follows: (1) increasing degree of ABM specificity with the progress of therapy did independently predict membership in the Recovered group at treatment end; (2) no relationship was evidenced between ABM specificity and expressed emotional arousal that distinguished clients who were Recovered vs. Unchanged; (3) there was no evidence found supporting a relationship between ABM specificity and client experiencing in predicting outcome; and (4) level of expressed emotional arousal and level of client experiencing were positively related in the Recovered group at all three phases of therapy. The findings hold clinical implications for the treatment of depression and theoretical implications for understanding the relationship between depression, memory, emotion and experiencing.
Open Access
Narrative - Emotion processing in Motivational Interviewing and Cognitive Behavioural Therapy for Generalized Anxiety Disorder
(2015-01-26) Macaulay, Christianne Braid; Angus, Lynne
Constructing adaptive narratives in therapy involves processing and symbolizing (i.e., storying) emotional experience. The Narrative-Emotion Process Coding System (NEPCS) is a tool for coding in-session client behaviors that indicate 10 underlying narrative-emotion processes: Same Old Story, Empty Story, Unstoried Emotion, Superficial Story, Reflexive Story, Inchoate Story, Experiential Story, Competing Plotlines, Unexpected Outcome, and Discovery Story. The NEPCS was applied to videotaped therapy sessions of three recovered and three unchanged clients who underwent cognitive behavioral therapy (CBT) and motivational interviewing (MI) for Generalized Anxiety Disorder (GAD). Multilevel modeling analyses demonstrated a significant effect of outcome for Reflexive Story, Competing Plotlines, and Unexpected Outcome, and a significant outcome x stage effect for Discovery Story. Findings are discussed in the context of ambivalence about worry and emotion avoidance as key features of GAD. Limitations and future research directions, including avenues for further elucidation of mechanisms of MI for GAD, are also discussed.
Open Access
Narrative-Emotion Process Markers in Cognitive Behavioural Therapy For Generalized Anxiety Disorder: A Process-Outcome Study
(2016-11-25) Khattra, Jasmine; Angus, Lynne
According to a narrative-emotion informed approach to psychotherapy, individuals enter psychotherapy when their narratives lack flexibility, emotional coherence and fail to integrate important lived experiences. Effective psychotherapy provides clients with an opportunity to integrate emotionally salient life experiences, as a told story or self narrative that enables new meaning-making and a more adaptive view of self. The Narrative-Emotion Process Coding System Version 2.0 (NEPCS; Angus Narrative-emotion Marker Lab, 2015) is a standardized measure that consists of a set of 10 clinically-derived markers that capture a client's capacity to disclose, emotionally re-experience, and reflect on salient personal stories in videotaped psychotherapy sessions. These 10 markers are classified into three subgroups: Problem (Same Old, Empty, Unstoried Emotion, and Superficial Storytelling), Transition (Reflective, Inchoate, Experiential, and Competing Plotlines Storytelling), and Change Markers (Unexpected Outcome, and Discovery Storytelling). The present study applied the NEPCS Version 2.0 to a sample of clients (N = 6; 36 therapy sessions) engaging in cognitive behavioural therapy (CBT) for generalized anxiety disorder (GAD). The NEPCS Version 2.0 was applied to two early, two middle, and two late-stage videotaped therapy sessions for each of the six clients (three recovered, and three unchanged outcome status), who were drawn from a randomized controlled trial comparing the efficacy of CBT and motivational interviewing integrated with CBT for GAD (Westra, Constantino, & Antony, 2016). Multilevel modeling analyses demonstrated significantly higher proportions of Reflective Storytelling (p < .001), Unexpected Outcome Storytelling (p = .023), as well as the Transition (p = .003), and Change (p = .021) markers subgroups, for recovered versus unchanged CBT clients. Additionally, there was a significant stage effect for individual markers, Competing Plotlines Storytelling (p = .006), Unexpected Outcome Storytelling (p < .001; p = .031; p = .036), No Client Marker (p = .014), and for overall Transition (p = .001; p = .034) and Change (p = .001) markers subgroups. Findings will be discussed in the context of current CBT research literature on GAD as well as research examining NEPCS marker patterns in other diagnostic populations, and treatment modalities.
Open Access
Untying The Knot: A Qualitative Inquiry into the Enduring Marriage
(2015-01-26) Kagan, Fern Hyla; Angus, Lynne
A qualitative analysis using a modified grounded theory approach was performed on 11 interviews from one representative of 11 marriages, including examples of both happy and unhappy marriages, in order to generate a participant-informed account of the enduring marriage. The heuristic model created through the qualitative analysis was contrasted and compared to the existing body of literature on lasting marriage in order to identify areas of convergence and divergence. The qualitative analysis identified a core category termed Emotional Anchoring and seven defining categories that thematically united all examples of lasting marriage in the present study. Results suggest that there are different ways of remaining married but that each example of a lasting marriage is a testament to participants’ ability to balance the competing demands of autonomy and connection in their union.

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