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

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.