How Reconceptualization of the Self Is Negotiated in Psychotherapy: An Exploratory Study of the Therapeutic Collaboration

Abstract

This case study explores the collaboration that occurs between therapist and client when reconceptualization innovative moments emerge. Reconceptualization innovative moments are exceptions to the problematic self-narrative that brought the client to therapy and are associated with successful psychotherapy. Reconceptualization innovative moments have two main components: a contrast between a past problematic facet and a current, more adjusted one (e.g., before I did/thought/felt X . . . , now, I do/think/feel Y) and an attribution for what allowed this transformation to occur (e.g., this was possible because I realized Z). The collaboration between therapist and client was analyzed using the Therapeutic Collaboration Coding System, which conceptualizes the relationship as collaborative or as noncollaborative. The majority of interactions in this case were clearly collaborative, with the therapist and client working inside the therapeutic zone of proximal development, which is typical of successful psychotherapy cases. Reconceptualization innovative moments begin with collaborative exchanges in which the therapist supported the problem and the client elaborated on the change afterward. Implications of these findings for change in psychotherapy are discussed.

Keywords

therapeutic collaboration reconceptualization innovative moment emotion-focused therapy case study

The present case study aimed to characterize the therapeutic collaboration—that is, the coordination between therapist and client—in moments when a reconceptualization innovative moment (IM) emerges. We start by characterizing reconceptualization IMs and then describe how we understand therapeutic collaboration.

Reconceptualization Innovative Moments

Research on IMs emerged from the narrative therapy conception of meaning making and change in psychotherapy (White & Epston, 1990). According to this view, people construct meaning to events and to their own identity by constructing life narratives (McAdams & McLean, 2013; McLean, 2016; Sarbin, 1986), told to others and/or to themselves. White and Epston (1990) elaborated on two implications of this view. First, sometimes life narratives are constructed in ways that lead people to view themselves, others and the world in nonpreferable ways (e.g., narratives of self-incompetence, self-criticism), that is, they construct problematic self-narratives (see Dimaggio, 2006, on several forms of narrative disruption). Problematic self-narratives may be viewed as maladaptive self-narratives that constrain clients’ lives, and in this article, we use these two terms interchangeably. Second, because life is always more than what we narrate, there are always instances that contradict such problematic self-narratives, which White and Epston termed “unique outcomes,” and these instances are empirically operationalized in psychotherapy research as “innovative moments.” Thus, from this view, as IMs emerge in psychotherapy, they constitute exceptions (i.e., alternative meanings) to the problematic self-narratives and may contribute, if properly elaborated on by clients and therapist, to change.

Studies on IMs fall under a form of research that Elliott (2010) terms the “significant event approach,” in which meaningful events are tracked in psychotherapy and are associated with final outcomes. In fact, research on person-centered therapy has been prolific under this research approach, and emotion-focused therapy (EFT) was constructed based on this model of research (see Greenberg, 1986, 2008; Watson & McMullen, 2016).

In sum, IMs are all the moments in the psychotherapeutic dialogue in which the problematic self-narrative that brought the client to therapy is interrupted and an exception emerges (Gonçalves, Matos, & Santos, 2009). Research on IMs suggests that the problematic self-narrative is progressively challenged as exceptions toward it emerge during treatment. While the problematic self-narrative may be conceptualized as implicit rules that shape the client’s life (e.g., “always considering others’ rights and neglecting my own needs”), IMs are exceptions toward these rules. The accumulation of IMs eventually leads to a revision of the problematic self-narrative, allowing for a construction of a new one (e.g., “my needs are my needs; I’m entitled to them, and I should respect them”). Previous research on therapy for major depression (EFT, Mendes, Ribeiro, Angus, Greenberg, & Gonçalves, 2010; client-centered therapy; Gonçalves et al., 2012; cognitive–behavior therapy, Gonçalves, Silva, et al., 2017; narrative therapy, Gonçalves, Ribeiro, et al., 2017), violence in couples (Matos, Santos, Gonçalves, & Martins, 2009), and complicated grief (constructive therapy, Alves et al., 2014) supports the idea that IMs are more prevalent in good than poor outcome cases. Moreover, three studies suggest that IMs may operate as process variables in predicting good outcomes. In a sample of narrative therapy (Gonçalves, Ribeiro, et al., 2017) and in another of cognitive–behavior therapy (Gonçalves, Silva, et al., 2017), IMs were found to be predictive of changes in symptoms at the following session. In a third study with the core conflictual relationship theme (Luborsky, 1998), Batista et al. (2017) found that prechanges and postchanges on depressive symptoms were partially mediated by changes in relational schemas.

Among the diversity of IMs that are identified in psychotherapy (see Table 1) is one that seems particularly relevant for change and that is the focus of this study: reconceptualization IMs. In reconceptualization IMs, two components must be present: a contrast between a previously maladaptive facet of the self and a current, more adjusted one (e.g., “before, I felt that I needed to ignore my own needs and always took as valid the needs of my husband; now, my needs and wishes have a voice”) and the transformation that allowed this contrast to occur (e.g., “I stopped seeing myself as a selfish person, and I started thinking that I should respect myself,” i.e., a transformational process). As such, reconceptualization IMs involve three different positions of the self: the self in the past (“before, I felt I needed to ignore my own needs”), the more adaptive self in the present (“now, my needs and wishes have a voice”), and a metaposition over the other two (“I made this change because I stopped seeing myself as a selfish person”), that is, the transformation process. Gonçalves and Ribeiro (2012) speculated that this type of IM has three important developmental functions. The first function is the structure it conveys that allows the organization of the events. Reconceptualization clearly has a narrative structure in which there is an emphasis on a time frame—the past self versus the present, alternative self. Second, reconceptualization assures self-continuity through contrast, as it contains a description of the self in the past, the self in the present and a connection between both. Without this connection (the metaposition), we would have a discontinuity in the person’s identity, that is, a transformation without any insight over the change process. If this discontinuity occurred, the person would have been an actor of the change, but not its author, to use a distinction proposed by Sarbin (1986). Third, reconceptualization involves a progressive identification with the emerging self (the present self-facet). This process is probably why reconceptualization IMs persistently repeat after the middle phase of treatment. There is not just one reconceptualization that triggers change. We have repetition, and reconceptualization is often the most dominant type of IM at the end of treatment. We hypothesize that the person is demonstrating (to the self and to significant others, the therapist included) how the change has developed and how the new, alternative self-narrative could be. Therefore, reconceptualization is more than a description of a change: it is a performance of change, and the process of repetition allows the unusual to become familiar. The way reconceptualization is produced in EFT has recently been the target of a task analysis, in which reconceptualization was used as a marker of self-narrative reconstruction (Cunha et al., 2017).

Table 1.

Innovative Moments (IMs).

Types of IM	Subtypes	Definition	Contents
Level 1 IMs: Creating distance from the problematic pattern
Moments of critique, thoughts, intentions, interrogations, doubts, desires, strategies, and/or behaviors focus on dealing with the problems brought to therapy	Action 1	Performed and intended actions to overcome the problem	• New behavioral strategies to overcome the problem(s) • Active exploration of solutions • Searching for information about the problem(s)
	Reflection 1	New understandings of the problem	• Reconsidering problem(s)’ causes • Awareness of the problem(s)’ effects • New problem(s) formulations • Adaptive self-instructions and thoughts • Intention to fight problem(s)’ demands • General references of self-worth and/or feelings of well-being
	Protest 1	Objecting the problem and its assumptions	• Rejecting or objecting the problem(s) • Position of critique toward others who support it • Position of critique toward problematic facets of oneself
Level 2 IMs: Centered on change
New aims, experiences, activities, or projects, anticipated or in action, as consequence of change (not directly related with the problematic experience)	Action 2 (performing change)	Generalization of good outcomes (performed or projected actions) into the future and other life dimensions	• Investment in new projects as a result of the process of change • Investment in new relationships as a result of the process of change • New skills unrelated to the problem • Problematic experience as a resource for new situations
Level 3 IMs: Consolidating and expanding change
	Reconceptualization	Metacognitive process description. Requires a shift between two self-positions and some access to the process underlying this transformation	• Contrasting self (what changed?) and self-transformation process (how/why change occurred?)

Source. Gonçalves, M. M., Matos, M., Santos, A., Ribeiro, A. P., Mendes, I., Silva, J., Batista, J., Rosa, C., & Fernández-Navarro, P. (2018). From innovative moments coding system manual, Version 9. University of Minho, January 2016. Available from the authors.

Some of these ingredients have similarities (as well as differences) with concepts proposed by other researchers, such as metaposition (Hermans & Hermans-Konopka, 2010), observer position (Leiman, 2012), metacognitive functioning (Lysaker & Dimaggio, 2014), reflective functioning (Fonagy et al., 2016), or insight (Castonguay & Hill, 2007). The present case study is not the place to review all of these concepts and compare the similarities and differences among them (see Fernandez-Navarro et al., 2018). In this research, our main aim was to explore how collaboration between therapist and client is associated with the emergence of reconceptualization IMs. In EFT, reconceptualization is likely central to integrate the experiencing self into better adjusted self-narratives. For instance, in chair work, protest IMs (see Table 1) are very common, whereas when the therapist focuses on reflection over what changed, reconceptualization IMs tend to emerge (Cunha et al., 2017; Mendes et al., 2010). Reconceptualization IMs may likely be viewed in EFT as markers of the quality of the dialectical integration between experience and reflection.

Therapeutic Collaboration

In the context of the therapeutic conversation, the therapist and the client influence each other, and both contribute to the quality of the therapeutic collaboration. It is the interaction that promotes change in therapy. The therapeutic collaboration is commonly considered a shared-responsibility process characterized by a therapist and client mutually participating in what occurs in therapy (Boardman, Catley, Grobe, Little, & Ahluwalia, 2006; Colli & Lingiardi, 2009; L. Hatcher & Barends, 2006; R. Hatcher, 1999; Horvath, 2013; Tryon & Winograd, 2011). With the purpose of understanding the development of this collaborative process and to analyze how it contributes to change, E. Ribeiro, Ribeiro, Gonçalves, Horvath, and Stiles (2013) developed the Therapeutic Collaboration Coding System (TCCS) that allows tracking the interactions that occur in therapy. This system maps these interactions and assists in making sense of how the interactive process is connected with the client’s changes on a moment-to-moment basis.

Theoretically, the TCCS is based on developmental conceptualizations of both therapeutic collaboration and change. This proposal integrates the concept of the zone of proximal development, proposed by Vygotsky (1978) and adapted for psychotherapy by Leiman and Stiles (2001) in the context of the assimilation model (Stiles, 2001), into the conceptualization of narrative change articulated by the IMs model (Gonçalves et al., 2009). Within this conceptual framework, the therapeutic collaboration is considered a joint effort of the dyad to maintain the focus of their interaction within the limits of the client’s therapeutic zone of proximal development (TZPD; E. Ribeiro et al., 2013). Similar to the application of the concept of proximal development to child development, the client’s TZPD defines a segment of the developmental continuum of change that the client can reach with the help of the therapist. Based on the conceptual models of change that inspired the TCCS, the TZPD can be understood as “the space between the client’s current capacity to accommodate IMs and a potential capacity that can be reached in collaboration with the therapist” (E. Ribeiro et al., 2013, p. 297). Thus, therapeutic interactions can be classified as being inside the client’s TZPD or outside the client’s TZPD. We assume that when therapist and client are operating inside the TZPD, their interaction is marked by collaboration, whereas if they are outside the TZPD, they are proceeding in a noncollaborative way (e.g., the therapist is exerting excessive pressure to change).

Previous case studies with narrative therapy (Ferreira, Ribeiro, Pinto, Pereira, & Pinheiro, 2015), cognitive–constructivist therapy (A. P. Ribeiro et al., 2014), person-centered therapy (E. Ribeiro et al., 2014), and EFT (E. Ribeiro et al., 2016) have supported the theoretical assumption that in effective therapy, the dyad works more within the TZPD. In all these studies, successful cases had a higher proportion of therapeutic exchanges within the client’s TZPD and a lower proportion of therapeutic exchanges outside the client’s TZPD. Thus, these studies have suggested that, in contrast with unrecovered cases, in recovered cases clients tend to progressively accept and elaborate more on the therapist’s invitations to reformulate the maladaptive self-narrative.

E. Ribeiro et al. (2013) proposed that therapists facilitate change within the client’s TZPD using and balancing two types of actions: supporting or challenging interventions. While using supporting interventions, the therapist works closer to the actual level of the client’s TZPD by focusing on trying to understand the usual maladaptive self-narrative or by focusing on and accepting the innovations (i.e., IMs) produced by the client, which in both situations would likely provide a sense of safety in the client. While using challenging interventions, the therapist works closer to the potential level of the client’s TZPD, inviting the client to consider alternative perspectives for the maladaptive self-narrative, thereby facilitating the emergence of innovation, even though doing so could produce a sense of vulnerability in the client.

The client’s immediate response to the therapist’s interventions indicates if the therapist’s intervention was responsive to the client’s TZPD (E. Ribeiro et al., 2013). The client may validate the therapist’s intervention (e.g., by giving information or extending the therapist’s proposal), which, according to this model, is a confirmation that the dyadic interaction is occurring within the TZPD. In contrast, the client may not validate the therapist’s supporting or challenging interventions, by refusing it in one of several ways. For example, the client could reject the therapist’s perspective by showing disagreement, by remaining focused on her own perspective, or by becoming confused. If the client invalidates the therapist’s intervention, this model suggests that the therapist is pushing the client away from the TZPD. The client may also respond with ambivalence toward the therapist’s intervention by validating and invalidating it in the same speaking turn. This type of response indicates that the client started by accepting the therapist’s intervention but immediately refused it, suggesting that the client does not feel safe enough to accept the therapist proposal and that the dyadic interaction is occurring at the limits of the client’s TZPD.

Thus, based on the type of the immediate response—that is, validation, invalidation or ambivalence toward the therapist’s intervention—we may infer whether the dyad is working collaboratively or noncollaboratively (i.e., within, outside or at the limits of the client’s TZPD, respectively). Figure 1 illustrates different types of therapeutic exchanges involving supporting or challenging interventions from the therapist and validation, invalidation or ambivalence as responses from the client.

Figure 1.

Therapeutic exchanges involving supporting and challenging therapist’s interventions and validation, invalidation, and ambivalence client’s responses.

It is important to emphasize that both the IMs model and the TCCS are metatheoretical models that transcend a particular theoretical approach. Using the common factors model proposed by Wampold and Imel (2015), we suggest that IMs may occur in all paths seen as therapeutic in this model. IMs may emerge as clients are remoralized and develop positive expectations over the change process, IMs may be the outcome of negotiating the therapeutic relationship (e.g., repairing ruptures), or IMs may emerge (likely, necessarily emerge) as clients involve themselves in therapeutic rituals that facilitate healthy actions. The TCCS suggests that these positive therapeutic events tend to occur in collaborative interchanges, whereas noncollaborative interchanges hinder the opportunity for IMs to occur.

The main aim of this study is to explore the characteristics of the therapeutic collaboration occurring in reconceptualization IMs by using a case study design (Stiles, 2009). For this purpose, we choose to analyze a clinical case whose process of change has been widely studied: the case of Lisa. Indeed, in a special issue addressing Lisa’s change process, there were convergent conclusions from theoretically distinct models, despite its specifics at a more concrete level. From the assimilation model and states of mind model’s points of view, Lisa’s change involves a process of reorganization and progressive integration of parts or states of self (Brinegar, Salvi, & Stiles, 2008; Greenberg, 2008; Nicolò et al., 2008), which is coherent with an increasing ability to understand others and her own mental states and to manage her problematic states of mind through the therapy (Carcione et al., 2008).

Consistent with these studies, Gonçalves, Mendes, Ribeiro, Angus, and Greenberg, (2010) analyzed the case of Lisa with the IMCS and found that reconceptualization IMs increased over time starting from the middle of therapy (Session 5), meaning that Lisa becomes progressively able to contrast and integrate her self-positions into a new self-narrative. Because reconceptualization IMs are important markers of therapeutic change that are highly associated with successful therapy, the relevance of this study is to start shedding light on the patterns of collaboration between therapist and client when these markers of change emerge.

Method

Client

Lisa was 27 years old when she participated in the York I Depression Study (Greenberg & Watson, 1998). At that time, she was married and had two school-age children. She met the criteria for major depressive disorder according to the Structured Clinical Interview for DSM-IV Axis I Disorders ( Spitzer, Williams, Gibbon, & First, 1989). The client was randomly assigned to EFT and completed 15 sessions. Lisa complained about feelings of sadness, guilt, and resentment toward her family. She was unable to understand her depressed feelings prior to entering therapy.

As therapy unfolded, it became apparent that Lisa’s motivation for asking for help was her difficulty in dealing with the negative consequences of her husband’s gambling addiction. In addition to the feelings of sadness and resentment that her husband’s addiction spawned, the client also referred to the same type of negative feelings toward her parents. Lisa felt that her parents did not allow her to be a child, because she had to take care of her three brothers. As an adult, the client complained about the fact that she was never allowed to be herself. Her own mother thought that she had to put up with her husband, because she did the same with her father, who was also addicted to gambling.

The case of Lisa was selected for the current study on the basis of significant symptomatic change evidenced on prestandardized and poststandardized outcome measures. Her pretherapy BDI (Beck Depression Inventory, Beck, Steer & Carbin, 1988) score of 23 dropped to 3 at therapy termination and to 0 at a 3-month follow-up. A reliable change index analysis of her BDI pretest to posttest change score classified Lisa as having met criteria for recovery (i.e., surpassing both a BDI cut-off score of 11.08 and reliable change index criteria) at treatment termination (see Jacobson & Truax, 1991; McGlinchey, Atkins, & Jacobson, 2002). The 15 therapy sessions in this case were transcribed as part of a larger process-outcome study of client-centered and EFT treatments (Greenberg & Watson, 1998).

Therapy and Therapist

Emotion-focused therapists use client-centered relational conditions and experiential and gestalt interventions to facilitate the resolution of maladaptive affective–cognitive processing. These interventions included focusing (Gendlin, 1981) on a marker of an unclear felt sense, systematic evocative unfolding for problematic reactions, two-chair dialogue for self-evaluative and self-interruptive conflict splits, and empty-chair dialogue for unfinished business with a significant other (Elliott, Watson, Goldman, & Greenberg, 2004; Greenberg, Rice, & Elliott, 1993; Greenberg & Watson, 2006).

The therapist who treated Lisa was a 28-year-old PhD student in clinical psychology who had 2 years of clinical experience and had attended a 30-hour training in EFT prior to participating in this study.

Measures

Beck Depression Inventory

The outcome measure was BDI (Beck et al., 1988), which was used for the pretest, posttest, and follow-up. This inventory consists of 21 items that evaluate depressive symptoms. The items are rated on a 4-point Likert-type scale (0-3), and the total score ranges from 0 to 63 points. Higher values on the BDI correspond to greater depressive symptomatology. The psychometric properties of the BDI show that it is a reliable and valid instrument that can discriminate between psychiatric and nonpsychiatric populations. The BDI has been shown to have a mean alpha coefficient of .86 for psychiatric patients and .81 for nonpsychiatric subjects (Beck et al., 1988).

Innovative Moments Coding System (IMCS)

The IMCS (Gonçalves et al., 2011) is a coding system that categorizes IMs into seven categories (see Table 1 for definitions and clinical examples). Reconceptualization IM is the type more associated with client’s change in previous studies and is a more complex form of IM. As stated previously, the dual components of contrast and transformation process only appear in reconceptualization IMs. Studies that have used the IMCS (Gonçalves et al., 2012; Matos et al., 2009; Mendes et al., 2010) have reported interjudge agreements ranging from .86 to .97.

Therapeutic Collaboration Coding System

The TCCS is an observational and transcription-based method developed to analyze the therapeutic collaboration moment-by-moment in the therapeutic conversation (E. Ribeiro et al., 2013). This coding system takes the therapist’s and client’s consecutive speaking turns as the unit of analysis and considers the client’s immediately preceding turn and, more broadly, the previous interaction during the session as the context of the analysis. The TCCS allows coding of the therapist’s interventions as supporting or challenging interventions (Table 2) and coding of the client’s responses as validation, invalidation or ambivalent responses (Table 3).

Table 2.

Therapist’s Intervention: Supporting and Challenging Subcategories.

Supporting subcategories	Definitions
Reflecting	The therapist reflects the content; meaning or feeling present in the client’s words. He or she uses his or her or client’s words but does not add any new content in the reflection, asking for an implicit or explicit feedback.
Confirming	The therapist makes sure he or she understood the content of the client’s speech, asking the client in an explicit and direct mode.
Summarizing	The therapist synthesizes the client’s discourse, using his or her own and client’s words, asking for feedback (implicit or explicit).
Demonstrating interest/attention	The therapist shows/affirms interest on client’s discourse.
Open questioning	The therapist explores clients experience using open questioning. The question opens to a variety of answers, not anticipated and/or linked to contents that the client does not reported or only reported briefly. This includes the therapist asking for feedback of the session or of the therapeutic task.
Minimal encouragement	The therapist makes minimal encouragement of client’s speech, repeating client’s words, in an affirmative or interrogative mode (ambiguous expressions with different possible meanings are not codified, like a simple “Hum . . . hum” or “ok”).
Specifying information	The therapist asks for concretization or clarification of the (imprecise) information given by the client, using closed questions, specific focused questions, asking for examples.
Challenging subcategories	Definitions
Interpreting	The therapist proposes to the client a new perspective over his or her perspective, by using his or her own words (instead of client words). There is, although, a sense of continuity in relation to the client’s previous speaking turn.
Confronting	The therapist proposes to the client a new perspective over his or her perspective or questions the client about a new perspective over his or her perspective. There is a clear discontinuity (i.e., opposition) with in relation to the client’s speaking turn.
Inviting to adopt a new perspective	The therapist invites (implicitly or explicitly) the client to understand a given experience in an alternative.
Inviting to put into practice a new action	The therapist invites the client to act in a different way, in the session or out of the session.
Inviting to explore hypothetical scenarios	The therapist invites the client to imagine hypothetical scenarios, that is, cognitive, emotional and/or behavioral possibilities that are different from client’s usual way of understanding and experiencing.
Changing level of analysis	The therapist changes the level of the analysis of the client’s experience from the descriptive and concrete level to a more abstract one or vice versa.
Emphasizing novelty	The therapist invites the client to elaborate on the emergence of novelty.
Debating client’s beliefs	The therapist debates the evidence or logic of the client’s believes and thoughts.
Tracking change evidence	The therapist searches for markers of change and tries to highlight them.

Source. Adapted from E. Ribeiro et al. (2013) with permission.

Table 3.

Client’s Experiences and Responses: Validation and Invalidation Subcategories.

Client’s experiences	Validation subcategories	Definitions
Safety	Confirming	The client agrees with the therapist’s intervention, but does not extend it.
Safety	Giving information	The client provides information according to therapist’s specific request.
Tolerable risk	Extending	The client not only agrees with the therapist intervention but also expands it (i.e., going further).
	Reformulating own perspective	The client answers the therapist’s question or reflects on the therapist’s prior affirmation and, in doing so, reformulates his or her perspective over the experience being explored.
	Clarifying	The client attempts to clarify the sense of his or her response to the therapist prior intervention or clarify the sense of the therapist’s intervention itself.
Client’s experiences	Invalidation subcategories	Definitions
Disinterest	Denying progress	Client states the absence of change (novelty) or progress.
	Lack of involvement in response	Client gives minimal responses to therapist’s efforts to explore and understand client’s experience.
	Sarcastic answer	The client questions therapist’s intervention or is ironic toward therapist’s intervention.
Intolerable risk	Expressing confusion	Client feels confused and/or states his or her inability to answer the therapist’s question.
	Focusing/persisting on the dominant maladaptive self-narrative	Client persists on looking at a specific experience or topic from his or her standpoint.
	Defending own perspective and/or disagreeing with therapist’s intervention	Client defends his or her thoughts, feelings, or behavior by using self-enhancing strategies or self-justifying statements.
	Self-criticism and/or hopelessness	Client is self-critical or self-blaming and becomes absorbed in a process of hopelessness (e.g., client doubts about the progress that can be made).
	Shifting topic	Client changes topic or tangentially answers the therapist.
	Topic/focus disconnection	The client persists in elaborating on a given topic despite the therapist’s efforts to engage in the discussion of a new one.
	Nonmeaningful storytelling and/or focusing on others’ reactions	Client talks in a wordy manner or overly elaborates nonsignificant stories to explain an experience and/or spends inordinate amount of time talking about other people.

Source. Adapted from E. Ribeiro et al. (2013) with permission.

The “supporting” category is specified as supporting the problem if the therapist’s intervention is focused on the client’s maladaptive self-narrative or as supporting innovation if the intervention is focused on the IMs produced by the client. Either way, the therapist is trying to understand or affirm the client’s perspective and experience.

The client’s response subcategories are interpreted as specifying different client’s experiences. Thus, regarding the validation responses, the accepting and giving of information subcategories are interpreted as indicating a client’s safe experience, and the “extending the therapist proposal” or “reformulating the self” subcategories are interpreted as indicating a tolerable risk experience. In turn, regarding the invalidation responses, the “lack of involvement” and “denying progress” subcategories are interpreted as indicating an experience of disinterest, and the other subcategories, such as “rejecting” or “persisting in own perspective” subcategories, are interpreted as indicating an intolerable risk experience (Table 3). The client’s response might also oscillate between validation and invalidation of the therapist’s intervention, which is interpreted as an experience of ambivalence toward the therapist’s proposal. Connections between therapist’s intervention and the client’s experience allow us to describe 18 alternative types of therapeutic exchanges (Table 4), which are interpreted as reflecting the position of the dyad relative to the TZPD. Before starting the coding using the TCCS’s categories and subcategories, based on the reading of the first sessions, the coders should consensually agree on the client’s maladaptive self-narrative and set what will be coded as the client’s problem or the client’s innovation. Previous studies using the TCCS (Ferreira et al., 2015; A. P. Ribeiro et al., 2014; E. Ribeiro et al., 2013; E. Ribeiro, et al., 2014; E. Ribeiro et al., 2016) have shown good reliability, with a mean agreement of 94.8% for the therapist’s interventions and 92.7% for the client’s responses.

Table 4.

Types of Therapist–Client Exchanges.

				Therapist’s interventions
				Supporting problematic narrative	Supporting innovation	Challenging
Client’s response and experience	Outside TZPD	Invalidation: Disinterest	Client states that is experiencing the therapist as being redundant.	Supporting problematic narrative – Disinterest	Supporting innovation – Disinterest	Challenging – Disinterest
	Lower limit of TZPD	Ambivalence: Moving toward risk	Client validates therapist’s intervention but immediately invalidates it. or invalidates but immediately validates.	Supporting problematic narrative – Ambivalence toward risk	Supporting innovation – Ambivalence toward risk	Challenging – Ambivalence toward risk
	Within TZPD	Validation: Safety	Client confirms or gives information.	Supporting problematic narrative – Safety	Supporting innovation – Safety	Challenging – Safety
	Within TZPD	Validation: Tolerable risk	Client extends or reformulates oneself perspective.	Supporting problematic narrative – Tolerable risk	Supporting innovation – Tolerable risk	Challenging – Tolerable risk
	Upper limit of TZPD	Ambivalence: Returning to safety	Client validates therapist’s intervention but immediately invalidates it or invalidates but immediately validates).	Supporting problematic narrative – Ambivalence returning to safety	Supporting innovation – Ambivalence returning to safety	Challenging – Ambivalence returning to safety
	Outside TZPD	Invalidation: Intolerable risk	Client is not able to follow the therapist, without stating that is experiencing the therapist as being redundant.	Supporting problematic narrative – Intolerable risk	Supporting innovation – Intolerable risk	Challenging – Intolerable risk

Note. E. Ribeiro et al. (2013) with permission.

Procedure

This research used archival data. Lisa’s case was part of the York I Depression Study (Greenberg & Watson, 1998) and was one of the cases with transcripts for process research purposes. A special section of this case was organized by Angus, Goldman, and Mergenthaler (2008), illustrating a diversity of process research methods. This case was also previously studied by Gonçalves et al. (2010) with the IMCS. Gonçalves et al. reported an 84% interjudge agreement with regard to the proportion of IMs. This agreement means that there was overlap of the thought units cited as IMs between both judges in 84% of the transcripts of the 15 sessions. Cohen’s kappa was used as a measure of agreement regarding the specific type of IM, and in this case, it was .76, which shows strong agreement between judges (Fleiss, 1981, quoted by Hill & Lambert, 2004). In the current research study, the therapeutic collaboration was analyzed with the purpose of characterizing the therapeutic relationship when reconceptualization IMs emerged.

Therapeutic Collaboration Coding

TCCS Training

Training with the TCCS involved three phases. First, both judges read the article that described the TCCS (E. Ribeiro et al., 2013) and the previous studies that used the TCCS as well. In a second phase, the judges read previously coded sessions of different therapy approaches and discussed their doubts at the team meetings. In a third phase, the judges independently coded new sessions of psychotherapy. Uncertainties or disagreements were discussed twice a week with the research team. This training lasted for approximately 5 months and ended when the judges achieved a percentage of agreement ⩾ 80%.

TCCS Coding

Two trained female master’s students in clinical psychology independently coded one third of the sessions (n = 5 sessions; n = 912 interactions), and one of the judges coded the remaining two thirds of the sessions (n = 10 sessions; n = 1,820 interactions). The coding procedure involved two main steps: the first step consisted of the identification of the maladaptive self-narrative and the innovation, which is a procedure necessary to allow coding of therapeutic interventions and the client’s responses according to the TCCS in the next step. The judges carefully read and discussed the first two sessions to reach a consensual definition of the client’s problems. They listed the problems that characterized the client’s maladaptive self-narrative and identified potential changes (innovations). The judges agreed that Lisa’s problematic self-narrative was characterized by resentment toward both her husband and her family, who behaved in a way that let her feel confused about who she was or feel as those she was being controlled. For example, in Session 1, referring to her husband, she said,

. . . And now, when I maybe, you know, want something different, he’ll um, comment like “oh no, you shouldn’t be thinking that way or you shouldn’t be doing that”; it’s almost as if he doesn’t allow me, or that’s where the protectiveness comes in.

Additionally, she was feeling helpless and ambivalent regarding others’ behaviors, and she felt unable to show her own feelings of anger, guilt, and sadness. For example, in Session 1 as an expression of these difficulties, Lisa said,

. . . Maybe that’s why I don’t tell him (husband) how I really feel inside (sniff). Yeah, there’s, or um, even though I express it, it’s just kind of laughed at. ( . . . ) That’s right, I’m um, I’m helpless about it; I can’t do anything.

As we referenced previously, the TCCS adopted the IMs concept of Gonçalves et al. (2011). Therefore, the exceptions to Lisa’s problematic self-narrative were coded whenever she expressed her feelings of anger, sadness, or guilt, considered her own needs, accepted her internal experience or saw herself in a new and empowered perspective in the context of the relationship with her husband and family. For example, innovation was coded when she elaborated on feelings, as in Session 1: “Then my feelings are my feelings and (sigh) and I, you know, I’m entitled to them”; or as in Session 2, when she expressed a new perspective about herself:

Yeah, just accept me the way I am; . . . well, I kind of put it in my mind and say, you know, I have the right to live the way I want, and these are my kids, or it’s my place, you know, I pay for it, and I can live the way I want.

The second step consisted of coding each therapist’s intervention and the client’s subsequent response. First, one third of the sessions (n = 5) were fully coded, which means that the judges independently coded 912 therapist–client adjacent pairs (interventions and responses). The interjudge agreement was calculated session-by-session, and the judges in subsequent discussions consensually resolved their disagreements on coding. A third trained judge audited the consensual version of the independently coded sessions. The two judges had 78% agreement on the therapist’s interventions (based on n = 912) and 86% agreement on the client’s responses (based on n = 912), which indicates acceptable agreement (Fleiss, 1981 as cited by Martins & Machado, 2006). Then, the first judge continued to code the remaining two thirds of the sessions (n = 10 sessions; n = 1,820 adjacency pairs) using an auditing process.

Results

Evolution of Therapeutic Collaboration During Treatment

The evolution of therapeutic collaboration is described by the percentage of therapeutic exchanges (i.e., sequences of therapist’s intervention and the client’s immediate response) throughout the therapy process. Note that in each session, there was different number of therapeutic interactions (therapist’s interventions and client’s responses; see Table 5).

Table 5.

Percentage of Therapeutic Exchanges Across Sessions.

Therapeutic exchanges		S1	S2	S3	S4	S5	S6	S7	S8	S9	S10	S11	S12	S13	S14	S15	M
SP-ATR	n	0	1	0	0	2	1	0	0	0	0	0	3	0	2	0	0.60
SP-ATR	%	0.00	0.83	0.00	0.00	0.87	0.63	0.00	0.00	0.00	0.00	0.00	1.39	0.00	1.02	0.00	0.32
SP-S	n	107	60	28	88	81	86	105	61	63	54	65	102	67	97	70	75.60
SP-S	%	58.79	50.00	18.30	38.77	35.22	54.09	36.71	33.89	38.89	39.13	34.39	47.22	50.00	49.49	43.75	41.91
SP-TR	n	7	6	3	12	10	7	6	14	2	6	4	8	6	11	12	7.60
SP-TR	%	3.85	5.00	1.96	5.29	4.35	4.40	2.10	7.78	1.23	4.35	2.12	3.70	4.48	5.61	7.50	4.25
SP-ARS	n	3	1	0	0	3	3	2	5	2	0	0	1	1	0	2	1.40
SP-ARS	%	1.65	0.83	0.00	0.00	1.30	1.89	0.70	2.78	1.23	0.00	0.00	0.46	0.75	0.00	1.25	0.86
SP-IR	n	0	1	0	0	0	0	0	0	0	0	0	1	0	0	0	0.13
SP-IR	%	0.00	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.46	0.00	0.00	0.00	0.09
SI-S	n	17	16	13	22	36	24	30	12	8	21	9	12	8	14	20	17.47
SI-S	%	9.34	13.33	8.50	9.69	15.65	15.09	10.49	6.67	4.94	15.22	4.76	5.56	5.97	7.14	12.50	9.66
SI-TR	n	12	19	11	10	19	11	27	37	24	29	34	22	15	19	39	21.87
SI-TR	%	6.59	15.83	7.19	4.41	8.26	6.92	9.44	20.56	14.81	21.01	17.99	10.19	11.19	9.69	24.38	12.56
SI-ARS	n	4	0	0	0	2	1	0	1	0	0	1	1	1	0	0	0.73
SI-ARS	%	2.20	0.00	0.00	0.00	0.87	0.63	0.00	0.56	0.00	0.00	0.53	0.46	0.75	0.00	0.00	0.40
SI-IR	n	1	0	0	0	1	0	0	0	0	0	0	0	0	0	0	0.13
SI-IR	%	0.55	0.00	0.00	0.00	0.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.07
C-ATR	n	0	1	1	0	1	0	0	0	0	0	0	0	0	0	0	0.2
C-ATR	%	0.00	0.83	0.65	0.00	0.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.13
C-S	n	12	9	52	71	56	16	74	20	40	16	49	35	24	35	8	34.47
C-S	%	6.59	7.50	33.99	31.28	24.35	10.06	25.87	11.11	24.69	11.59	25.93	16.20	17.91	17.86	5.00	18.00
C-TR	n	16	3	42	23	16	9	41	30	23	12	27	29	12	18	9	20.67
C-TR	%	8.79	2.50	27.45	10.13	6.96	5.66	14.34	16.67	14.20	8.70	14.29	13.43	8.96	9.18	5.63	11.13
C-ARS	n	1	0	0	0	0	0	1	0	0	0	0	2	0	0	0	0.27
C-ARS	%	0.55	0.00	0.00	0.00	0.00	0.00	0.35	0.00	0.00	0.00	0.00	0.93	0.00	0.00	0.00	0.12
C-IR	n	2	3	3	1	3	1	0	0	0	0	0	0	0	0	0	0.87
C-IR	%	1.10	2.50	1.96	0.44	1.30	0.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.53
Total	n	182	120	153	227	230	159	286	180	162	138	189	216	134	196	160	182.13
Total	%	100	100	100	100	100	100	100	100	100	100	100	100	100	100	100	100
Outside TZPD	n	3	4	3	1	4	1	0	0	0	0	0	1	0	0	0	1.13
Outside TZPD	%	1.64	3.33	1.98	0.44	1.75	0.63	0.00	0.00	.00	0.00	0.00	0.46	0.00	0.00	0.00	0.68
Limit TZPD	n	8	3	1	0	8	5	3	6	2	0	1	7	2	2	2	3.33
Limit TZPD	%	4.40	2.46	0.66	0.00	3.42	3.20	1.05	3.32	1.14	0.00	0.53	3.24	1.49	1.02	1.25	1.86
Within TZPD	n	171	113	149	226	218	153	283	174	160	138	188	208	132	194	158	177.67
Within TZPD	%	93.96	94.16	97.39	99.57	94.79	96.20	98.98	96.67	98.85	100.00	99.48	96.38	98.51	98.98	98.75	97.51

Note. SP-ATR = Supporting Problem–Ambivalence Toward Risk; SP-S = Supporting Problem–Safety; SP-TR = Supporting Problem–Tolerable Risk; SP-ARS = Supporting Problem–Ambivalence Returning to Safety; SP-IR = Supporting Problem–Intolerable Risk; SI-S = Supporting Innovation–Safety; SI-TR = Supporting Innovation–Tolerable Risk; SI-ARS = Supporting Innovation–Ambivalence Returning to Safety; SI-IR = Supporting innovation–Intolerable Risk; C-ATR = Challenging–Ambivalence Toward Risk; C-S = Challenging–Safety; C-TR = Challenging–Tolerable risk; C-ARS = Challenging–Ambivalence Returning to Safety; C-IR = Challenging–Intolerable Risk.

Regarding the therapeutic exchanges during treatment (Table 5), Supporting Problem–Safety, M_{all sessions} = 75.6 (41.94%) was the most frequent type of interaction on average. Apart from the therapeutic exchanges of Challenging–Safety, M_{all sessions} = 34.47 (18.00%), Supporting Innovation–Tolerable Risk, M_{all sessions} = 21.87 (12.56%), Challenging–Tolerable Risk, M_{all sessions} = 20.67 (11.13%), and Supporting Innovation–Safety, M_{all sessions} = 17.47 (9.66%), the other types of therapeutic exchanges were rare or absent. These findings indicate that the dyad worked over the sessions in a mostly collaborative manner—that is, within the client’s TZPD (ranging from 93.96%, n = 171, to 100%, n = 138; see Table 5). The dyad interaction was characterized by a low number of therapeutic exchanges at the limit of Lisa’s TZPD (ranging from 0.0%, n = 0, to 4.4%, n = 8) and a low number of therapeutic exchanges outside the client’s TZPD (ranging from 0.44%, n = 1, to 3.33%, n = 4, through Session 6; to 0.46%, n = 1, through Session 12; and to 0.0%, n = 0, in the other sessions), which indicates that rarely did the dyad proceed in a noncollaborative way at the limits of or outside the client’s TZPD. The evolution of the most frequent therapeutic exchanges during treatment is shown in Figure 2.

Figure 2.

Evolution of the most frequent therapeutic exchanges along treatment.

Therapeutic Exchanges Initiating the Reconceptualization Innovative Moment

Among the 15 types of therapeutic exchanges identified by the TCCS that occurred thorough this case, only 6 characterized the therapeutic collaboration when the reconceptualization IMs (n = 27) emerged. As Figure 3 shows, these six included the Supporting Problem–Tolerable Risk exchange (n = 11, 40.74%), which was rare across all the sessions, M_{all sessions} = 7.6 (4.25%; see Table 5); in contrast, Supporting Innovation–Tolerable Risk (n = 8, 29.63%) and Challenging–Tolerable risk (n = 5, 18.52%) were the most prevalent therapeutic exchanges initiating this type of IM. The results also show that the majority of the reconceptualization IMs (n = 19; 70.37%) emerged with the client moving beyond the level proposed by the therapist—that is, the client responded with tolerable risk whether the therapist supported the problem or the innovation.

Figure 3.

Therapeutic exchanges initiating the reconceptualization innovative moments.

The supporting innovation was the most frequent therapist intervention following the client’s responses of tolerable risk while initiating the reconceptualization IMs. As Figure 4 shows, in 21 (77.78%) of the 27 reconceptualization IMs, the therapist chose to remain close to the client’s innovative experiences and to support them. The therapist insisted on challenging the client’s emergent innovative perspective only four times, and when the client initiated the reconceptualization IMs with an ambivalent response twice, the therapist was more cautious and supported the client’s problematic perspective.

Figure 4.

Therapist’s Intervention following the client’s response included in the therapeutic exchanges initiating reconceptualization innovative moments.

Discussion

The findings of this case study highlight that the dyadic interaction throughout the therapy process was collaborative and congruent with what occurs in successful psychotherapy. However, there was a difference between the therapeutic exchanges that characterized the dyad’s therapeutic interaction across treatment and the specific therapeutic interactions that initiated the reconceptualization IMs. Regarding the collaborative therapeutic exchanges that characterized the overall treatment, findings showed that the dyad worked most of time within Lisa’s TZPD, which means that she validated most of the therapist’s interventions. Although the therapeutic interaction was performed on the low (actual) and upper (potential) zones of Lisa’s TZPD, there was a higher percentage of therapeutic exchange involving the client’s safe response following the therapist’s supporting problem interventions. This type of therapeutic exchange suggests that the therapist usually chose to respect the client’s actual developmental level by understanding her problematic experience and maintaining this focus across treatment. However, the other, less frequent therapeutic exchanges show that, sometimes, the therapist challenged Lisa’s perspective by inviting her to focus on and be aware of her emotions or by inviting her to interpret her experience in alternative ways. In general, whether the therapist’s intervention supported or challenged the client’s perspective, the most frequent client response was safety. In terms of TCCS, the higher prevalence of safety responses means that Lisa was receptive to giving information from her own perspective in line with the therapist’s interventions and gave indications of being understood with regard to her internal experiences, needs and capacities. Although the tolerable risk responses, indicated by extending the therapist’s proposal, were less common across treatment, it seems that Lisa frequently accepted and felt comfortable when the therapist risked pushing the therapeutic work toward her potential developmental level. In line with the concept of responsiveness (Honos-Webb & Stiles, 1998; Stiles, 2009; Stiles, Honos-Webb, & Surko, 1998), these findings suggest that in general, the therapeutic interaction occurred in a climate of responsiveness and comfort as the therapist seemed to appropriately adapt her interventions to the client’s specific responses.

Moreover, the overall low percentage of therapeutic exchanges at the limit of or outside Lisa’s TZPD reinforces the indication of responsive and empathic therapist interventions and a comfortable client experience across treatment. These results are consistent with other case studies on therapeutic collaboration using the TCCS in person-centered therapy (E. Ribeiro et al., 2014) and EFT (E. Ribeiro et al., 2016). As in the previous studies, in the present study, the therapeutic dyad worked most of the time within the client’s TZPD. However, with Lisa, the therapist seemed to appropriately balance her supporting and challenging interventions, being responsive not only to the client’s need to be understood in her problematic experience but also to the need to move forward in her TZPD, as indicated by the validating and safe challenging interventions from the client. Not only do these results emphasize the therapist’s ability to empathically understand the client’s experience and follow her moment-to-moment readiness for change but they also underscore the active attitude from the therapist to facilitate the client’s change. This process might be expected in EFT, taking into account that this treatment integrates client-centered therapy relationship conditions with process-directive experiential interventions (Elliott et al., 2004; Greenberg & Watson, 1998). In addition, it is likely that the general therapy climate of responsiveness and safety was a facilitator of the client’s receptivity to accept and to give information on unfamiliar and new therapist proposals, which thereby promoted movement toward the upper levels of her TZPD. This idea conforms to a basic relational assumption in therapy, wherein movement toward change demands that clients feel safe and confident at being able to take risks and open themselves to the unknown (e.g., Angus & Kagan, 2007; Constantino & Westra, 2012; E. Ribeiro et al., 2013). It is consistent with the humanistic proposals for empathically considering the client’s frame of reference and their resources as vital for successful therapy (e.g., Bozarth, Zimring, & Tausch, 2002, Rogers, 1975).

Regarding the therapeutic collaboration in moments when reconceptualization IMs emerged, the findings show that the supporting problem intervention–tolerable risk response was the most frequent therapeutic exchange. Apart from the rare response of safety and of ambivalence, the tolerable risk response was the only client’s response initiating the reconceptualization IMs. In terms of the TCCS, the tolerable risk response means that the client extends the therapist proposal and indicates that the dyad is working at the client’s upper TZPD (potential developmental level). Taking into account the definition of the reconceptualization, a match between this IM and the tolerable risk response would be expected, because they both mean that the client is elaborating her experience of change.

The therapist’s supporting intervention, whether focused on the problem or on the innovation, was her most frequent when compared with the challenging interventions preceding the tolerable risk response that initiated the reconceptualization. This finding means that, even when the therapist intervened closer to the client’s actual developmental level (maladaptive or innovative perspective), Lisa extended the therapist’s proposal, going beyond her actual developmental level and placing the dyadic interaction in her upper TZPD. These results suggest that, regardless of the therapist’s intervention, reconceptualization emerged in moments when the client was able to elaborate on her process of change and assumed a proactive role in the therapeutic interaction. Taking into account that reconceptualization is considered an advanced IM, indicating a higher order of change, it seems reasonable that the client leads the therapeutic interaction associated with it. Apart from being consistent with the client’s crucial role in their successful change process, as reported in previous good-outcome case studies of different therapy approaches using TCCS (A. P. Ribeiro, Teixeira, Ribeiro, Gonçalves, & Stiles, 2016; E. Ribeiro at al., 2014; E. Ribeiro et al., 2016), this idea is congruent with the humanistic hypothesis that clients are active agents in their own healing and tend to actualize their own potential if they are in a safe relationship (e.g., Angus & Hardtke, 2006; Bohart & Tallman, 2010; Hoener, Stiles, Luka, & Gordon, 2012; Moon & Rice, 2012; E. Ribeiro et al., 2014; Stiles, Caro-Gabalda, & Ribeiro, 2016; Tallman & Bohart, 1999). On the other hand, as some authors noted, the therapist’s empathic validation of the client’s agency and accounts of positive change, as occurred in this study regarding Lisa’s initiative for producing reconceptualization, may have facilitated the elaboration and consolidation of the change (Angus & Kagan, 2007).

This study is a theory-building case study based on detailed observations of the therapeutic collaboration associated with reconceptualization IMs. Consistent with this methodology (Stiles, 2009), we do not intend to generalize the findings of this specific case study but rather to show how it contributes to tentatively elaborating on the theory of therapeutic collaboration and change in psychotherapy and specifically the emergence of reconceptualization IMs.

The results of this study are consistent with the previous results of case studies on person-centered therapy (E. Ribeiro et al., 2014) and EFT (E. Ribeiro et al., 2016) using the TCCS. In addition, this case study suggests that the client’s agency in a safe relationship might be a facilitator of the reconceptualization IMs emergence.

Although the results contribute to support and elaborate on the theory of therapeutic collaboration and change in humanistic therapies, some limitations require moderation in their interpretation. One limitation of this case study is the restriction of the analysis to reconceptualization IMs. It would be important to analyze if the therapeutic collaboration associated with reconceptualization is or is not similar to that associated with other types of IMs. Additionally, to confirm and elaborate on the client’s agency and on the therapist’s choice to engage at the client’s level, instead of analyzing only the therapeutic exchanges initiating the reconceptualization IMs, it would be important to analyze the therapeutic collaboration sequence across all reconceptualization IMs. Another limitation is that we cannot be completely sure about the specific role of the client’s proactive attitude on the therapeutic collaboration initiating reconceptualization IMs without analyzing other and more directive therapy approaches and cases with different outcomes. To analyze an unsuccessful or a dropout case would help us to confirm the effectiveness of the higher prevalence of supporting-safety therapeutic exchanges and the more active client role in particular moments of change, such as the reconceptualization IMs. Therefore, to consolidate the results of the present study, it would be important to develop multiple case studies replicating the same analytical procedure with similar and contrasting cases, which will allow comparison across cases. Finally, because Lisa is a clinical case already reported in the literature, the coders were familiar with the status of the case prior to their coding. This issue can be considered a limitation because this knowledge may inadvertently have influenced their coding. However, we believe that in addition to the large sample of therapeutic exchanges, the good reliability and the auditing process might have reduced the possible impact of this limitation.

Footnotes

Acknowledgements

The authors would like to thank Dr. Leslie. Greenberg and Dr. Lynne Angus (York University) for the kind permission to analyze the case of Lisa in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was conducted at Psychology Research Centre (UID/PSI/01662/2013), University of Minho, and supported by the Portuguese Foundation for Science and Technology and the Portuguese Ministry of Science, Technology, and Higher Education through national funds and cofinanced by FEDER through COMPETE2020 under the PT2020 Partnership Agreement (POCI-01-0145-FEDER-007653).

ORCID iD

Eugénia Ribeiro

Author Biographies

Eugénia Ribeiro is assistant professor at School of Psychology and member of the Directive Commission of the Centre of Research in Psychology—CIPsi—of University of Minho, Portugal. Her main research interests focuses in relational and dyadic processes in psychotherapy. She has been studying the concept of therapeutic collaboration in a developmental and biopsychosocial perspective. She developed the Therapeutic Collaboration Coding System—TCCS, as a research tool to microanalyze the therapeutic collaboration.

Miguel M. Gonçalves is a professor at School of Psychology, University of Minho, Portugal. He is vice president of the International Society of Dialogical Self and former associate editor of Psychotherapy Research. His main research interests centers in the narrative and dialogical processes in psychotherapy. He has developed the concept of innovative moment, as events in psychotherapy in which novelties to a previous problematic pattern emerge. This concept has been inspiring his research projects from the past few years.

Beatriz Santos has a master’s degree in clinical psychology from University of Minho, Portugal. Her research interest include therapeutic alliance and the process of change within psychotherapy, in particular, the way that specific innovative moment emerge in the Therapeutic Collaboration Coding System. Her current practice is focused on the intervention and rehabilitation of patients in the scope of a psychiatric unit in a Central Hospital.

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