Publicação
Ambivalence in psychotherapy: from measuring ambivalence to providing feedback to the therapist
| Resumo: | In the last decades, the study of factors that prevent change has been receiving increased attention from psychotherapy research. Considering the pivotal contribution of the clients to the success of treatment, much of the efforts should be centered on understanding their role in psychotherapy. Ambivalence to change is a client-related variable characterized by the dilemma “to change or not to change?”, which implies not only the client's resistance to a new perspective but also his or her willingness to change. Although expected in therapy, this inner tension results in movements towards and away from change and in a subjective feeling of inability to change. Previous studies have suggested that ambivalence is a common process in both poor- and good-outcome cases in different therapeutic models; but tends to decrease across therapy in good-outcome cases, whereas it remains high in poor-outcome cases. These results suggest that indicators of ambivalence in psychotherapy may be operationalized as red flags for the therapist to acknowledge the client’s stuckness and adapt his or her intervention efforts. Despite the deleterious effect of ambivalence in psychological treatments, few empirical studies have examined this process, and the considerable methodological differences among existing studies make it difficult to generalize results. In this PhD dissertation, a set of systematic studies was conducted and presented in order to (a) develop a self-report measure to assess client’s ambivalence levels in psychotherapy; (b) analyze the longitudinal progression of ambivalence across treatment, and; (c) use this knowledge in clinical intervention. The first study aimed to develop the Ambivalence in Psychotherapy Questionnaire (APQ). In order to develop the items a content analysis of 326 events of ambivalence from 112 sessions of psychotherapy previously analyzed using an observational coding system was performed. The factor structure, reliability and validity of the APQ were tested using 117 psychotherapy clients. The results suggested a two-factor structure, and indicated that the APQ exhibits good psychometric properties, including good convergent and divergent validity. After constructing the APQ, three empirical studies were developed with psychotherapy clients from a university-based outpatient clinic. The clients were seeking treatment for a wide diversity of psychological complaints but consistent with depression, anxiety and obsessive-compulsive disorders. The therapy was guided following The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Thus, in the second study we investigated (a) the longitudinal progression of ambivalence across treatment, (b) the predictive power of ambivalence on pre-post symptoms change, and (c) if early changes in ambivalence predict therapeutic gains. The sample consisted of 56 clients. Ambivalence in psychotherapy was assessed using the APQ and the data was analyzed using Hierarchical Linear Modeling. Results suggested that ambivalence levels tend to decrease as treatment evolves and are predictors of symptoms decrease in the next session. Moreover, the decrease of client’s ambivalence levels between sessions 4 and 8 predicted the therapeutic gains. Considering that the prolonged experience of ambivalence can contribute to the client’s disengagement, the third study intended to explore the predictive power of ambivalence regarding premature termination of therapy. A total of 50 participants were recruited and measures included the Ambivalence in Psychotherapy Questionnaire, the Outcome Questionnaire and the Working Alliance Inventory. Multilevel analysis suggested that ambivalence predicted premature discontinuation of treatment, explaining more variance than symptomatology and therapeutic alliance. This study also suggested a new approach to study therapy dropouts, the Time-Backwards Model. In the fourth study, we intended to test the impact of providing therapists with feedback about their clients’ ambivalence levels. We developed the Ambivalence in Psychotherapy Feedback (APF) system and tested its impact both on ambivalence resolution and outcomes. Forty-nine clients were randomly assigned to either Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Control group) or Unified Protocol for Transdiagnostic Treatment of Emotional plus the Ambivalence in Psychotherapy Feedback system (Experimental Group). In the latter group therapists received feedback about their client’s ambivalence to change before starting each session. Clients from the experimental group reported lower levels of ambivalence to change at session 8 when compared with control group. However, due to sample size constraints these preliminary results are inconclusive about the impact of using the Ambivalence in Psychotherapy Feedback system. Suggestions for the improvement of this undergoing project were also presented. Finally, we developed a theoretical study where a transtheoretical conceptual framework to conceptualize ambivalence in psychotherapy was developed. One psychotherapy case was used to illustrate our proposal and a set of guidelines to help therapists dealing with ambivalence in psychotherapy was suggested. Since this PhD dissertation aimed to bridge the gap between the knowledge developed by our research team and clinical practice, possible contributions both for therapists and researchers are discussed throughout the chapters. |
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| Autores principais: | Oliveira, João Tiago Terra da Cruz |
| Assunto: | Ciências Sociais::Psicologia |
| Ano: | 2018 |
| País: | Portugal |
| Tipo de documento: | tese de doutoramento |
| Tipo de acesso: | acesso restrito |
| Instituição associada: | Universidade do Minho |
| Idioma: | inglês |
| Origem: | RepositóriUM - Universidade do Minho |
| Resumo: | In the last decades, the study of factors that prevent change has been receiving increased attention from psychotherapy research. Considering the pivotal contribution of the clients to the success of treatment, much of the efforts should be centered on understanding their role in psychotherapy. Ambivalence to change is a client-related variable characterized by the dilemma “to change or not to change?”, which implies not only the client's resistance to a new perspective but also his or her willingness to change. Although expected in therapy, this inner tension results in movements towards and away from change and in a subjective feeling of inability to change. Previous studies have suggested that ambivalence is a common process in both poor- and good-outcome cases in different therapeutic models; but tends to decrease across therapy in good-outcome cases, whereas it remains high in poor-outcome cases. These results suggest that indicators of ambivalence in psychotherapy may be operationalized as red flags for the therapist to acknowledge the client’s stuckness and adapt his or her intervention efforts. Despite the deleterious effect of ambivalence in psychological treatments, few empirical studies have examined this process, and the considerable methodological differences among existing studies make it difficult to generalize results. In this PhD dissertation, a set of systematic studies was conducted and presented in order to (a) develop a self-report measure to assess client’s ambivalence levels in psychotherapy; (b) analyze the longitudinal progression of ambivalence across treatment, and; (c) use this knowledge in clinical intervention. The first study aimed to develop the Ambivalence in Psychotherapy Questionnaire (APQ). In order to develop the items a content analysis of 326 events of ambivalence from 112 sessions of psychotherapy previously analyzed using an observational coding system was performed. The factor structure, reliability and validity of the APQ were tested using 117 psychotherapy clients. The results suggested a two-factor structure, and indicated that the APQ exhibits good psychometric properties, including good convergent and divergent validity. After constructing the APQ, three empirical studies were developed with psychotherapy clients from a university-based outpatient clinic. The clients were seeking treatment for a wide diversity of psychological complaints but consistent with depression, anxiety and obsessive-compulsive disorders. The therapy was guided following The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Thus, in the second study we investigated (a) the longitudinal progression of ambivalence across treatment, (b) the predictive power of ambivalence on pre-post symptoms change, and (c) if early changes in ambivalence predict therapeutic gains. The sample consisted of 56 clients. Ambivalence in psychotherapy was assessed using the APQ and the data was analyzed using Hierarchical Linear Modeling. Results suggested that ambivalence levels tend to decrease as treatment evolves and are predictors of symptoms decrease in the next session. Moreover, the decrease of client’s ambivalence levels between sessions 4 and 8 predicted the therapeutic gains. Considering that the prolonged experience of ambivalence can contribute to the client’s disengagement, the third study intended to explore the predictive power of ambivalence regarding premature termination of therapy. A total of 50 participants were recruited and measures included the Ambivalence in Psychotherapy Questionnaire, the Outcome Questionnaire and the Working Alliance Inventory. Multilevel analysis suggested that ambivalence predicted premature discontinuation of treatment, explaining more variance than symptomatology and therapeutic alliance. This study also suggested a new approach to study therapy dropouts, the Time-Backwards Model. In the fourth study, we intended to test the impact of providing therapists with feedback about their clients’ ambivalence levels. We developed the Ambivalence in Psychotherapy Feedback (APF) system and tested its impact both on ambivalence resolution and outcomes. Forty-nine clients were randomly assigned to either Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Control group) or Unified Protocol for Transdiagnostic Treatment of Emotional plus the Ambivalence in Psychotherapy Feedback system (Experimental Group). In the latter group therapists received feedback about their client’s ambivalence to change before starting each session. Clients from the experimental group reported lower levels of ambivalence to change at session 8 when compared with control group. However, due to sample size constraints these preliminary results are inconclusive about the impact of using the Ambivalence in Psychotherapy Feedback system. Suggestions for the improvement of this undergoing project were also presented. Finally, we developed a theoretical study where a transtheoretical conceptual framework to conceptualize ambivalence in psychotherapy was developed. One psychotherapy case was used to illustrate our proposal and a set of guidelines to help therapists dealing with ambivalence in psychotherapy was suggested. Since this PhD dissertation aimed to bridge the gap between the knowledge developed by our research team and clinical practice, possible contributions both for therapists and researchers are discussed throughout the chapters. |
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