CHAPTER X: INTERACTIONAL PRACTICES OF ...

CHAPTER X: INTERACTIONAL PRACTICES OF PSYCHOTHERAPY Liisa Voutilainen, Finnish Centre of Excellence in the Research on Intersubjectivity in Interaction, University of Helsinki Anssi Peräkylä, Department of Social Research, University of Helsinki

In Michelle O’Reily & Jessica N. Lester (eds). The Palgrave Handbook of Adult Mental Health (2016)

Chapter contents 1. Introduction 2. Managing therapeutic collaboration 3. Combining empathy and challenge 4. Managing resistance 5. Interactional practices and therapeutic change 6. Clinical relevance

1. Introduction

Psychotherapy is done through interaction between the therapist and the client. Obviously, the ways in which psychotherapists interact with their clients are very much informed by the psychotherapeutic schools that the therapists represent. On the other hand – like interaction in any institutional context – also psychotherapy, in its various forms, is bound in general norms of conversation, for example regarding turn taking or general preference for agreement (see e.g. Sidnell & Stivers, eds, 2012). Based on conversation analytical (CA) research, this chapter discusses relations between the interactional side of psychotherapy and clinical theories concerning psychotherapeutic work. Because CA is independent from any specific clinical theories of psychotherapy, its methodic tools make it possible to investigate how psychotherapy is done through the ‘generic’ means of social interaction.

We will address four central themes of clinical theory: therapeutic collaboration; therapist’s empathy; client’s resistance; and therapeutic change. We discuss these themes through examples from one audio recorded therapy process in cognitive psychotherapy. The data from this therapy include 57 sessions from a time period of one and a half years. In this particular therapy, the client (woman in her twenties who suffered from depression) recurrently talked about difficulty in expressing or even feeling negative feelings such as anger or disappointment in her close relationships. During the process of the therapy, these issues were discussed in terms of a lack of security in her childhood and an inversion of aggression (from other people to the client herself). Within cognitive therapy, the therapist’s approach can be characterized as integrative (Norcross, J.C. & Goldried, M.R., 2005): it involved traditional cognitive work of challenging irrational cognitions but also experiential and investigative work that aimed towards expressing emotions in the therapy sessions and observing them in a reflective, interpretative way. Through focusing on this single case we will discuss different interactional practices that are used to work on the same central themes

of the therapy – client’s problematic feelings of disappointment, anger and self-blame – and how change in the client’s way to relate to these feelings emerged towards the end of the therapy. We will also briefly discuss this therapy process in terms of assimilation of problematic experiences and the zones of proximal development (Leiman and Stiles, 2001, Vygotsky 1978).

A central aspect in our discussion is the relation between empathy and challenge in the therapist’s work. We will show how empathy and challenge sometimes are combined in the therapist’s responses to the clients talk, and how, in other moments and contexts, there is a more salient tension between what was made relevant by the client’s emotional disclosure and how the therapist responds.

In CA, the basic unit of analysis is the relation between two adjacent utterances. In other words, the focus is not only on what is said by the participants but how the content, timing and form of the utterances relate to what was said just before (Schegloff, 2007). In the introduction to a collected volume on CA and psychotherapy, Peräkylä et al. (2008:16) suggest that through this core notion of sequential organization of interaction, CA can make a specific contribution to understanding psychotherapy. In the context of psychotherapy, this organization entails that anything a therapist or a client does, is done and understood in the context of the other participant’s previous turn. Because turns are tied together by nextness, “the participants inevitably have to orient to and work with the understandings that they each bring about through their actions” (Peräkylä et al., 2008a: 16). Thus, through their adjacent utterances, therapist and client inevitably create an intersubjective field—an emergent field of shared understandings regarding each other’s actions and the worlds of momentary experience that these actions embody (Heritage, 1984). As in any interaction (and in

psychotherapy, perhaps in specific and specifiable ways), this intersubjective field involves gaps, discontinuities and tensions, as well as moments where the participants’ understandings converge. Therapists’ and clients’ actions, as specified in CA research in psychotherapy, involve movement in this intersubjective field. (Peräkylä et al., 2008: 16, Peräkylä, 2012.) In this chapter, we will show how therapeutic tasks are dealt within this movement, that is, in relations between two turns at talk.

2. Managing therapeutic collaboration

Psychotherapy researchers and clinicians agree about the utmost importance of the relationship between the therapist and the client. This relationship is understood to be a key aspect of the ‘common factors’ (features of therapy that do not pertain to any particular therapeutic approach such as psychoanalysis or CBT) that arguably explain a great deal of the outcome of psychotherapy (cf. Wampold, 2001). A basic aspect in a successful therapy is the collaborative working relationship between the therapist and the client, often referred to as therapeutic alliance (e.g. Horvath and Symonds, 1991).

One key issue in maintaining the therapeutic collaboration is the therapist’s empathetic attitude towards the client. In clinical work, however, sometimes the displays of empathy can be dilemmatic in terms of how the therapist relates her/himself to the experience that the client has described and expressed. For example if the client expresses transferential emotions towards the therapist, or if his/her narratives reveal rigid interpersonal patterns, it may be unclear whether or not the therapist should respond affectively to the client’s affective expressions, and how this responding should be done in order to retain and ‘refresh’ their therapeutic alliance (e.g. Safran and Muran, 2006). Furthermore, for maintaining the

collaboration, it is important that the therapist is able to recognize and work with situations where the collaboration is somehow threatened, i.e. in instances of alliance ruptures. A rupture in the therapeutic alliance can be defined as a tension or breakdown in the collaborative relationship between the client and therapist. (Safran and Muran, 2006.) Safran and Muran and Eubanks-Carter (2011: 80) state that “ruptures vary in intensity from relatively minor tensions, which one or both of the participants may be only vaguely aware of, to major breakdowns in collaboration, understanding, or communication”.

We will discuss interactional practices that deal with these issues in the case that we have chosen from our data (Voutilainen, Peräkylä and Ruusuvuori, 2010; see also Muntigl and Horvath 2014, Muntigl et al., 2013 on CA and therapeutic alliance). Our focus is on two frames of talk (cf. Goffman 1974) that usually were both present in the therapy: a frame of affective talk and empathetic response on one hand, and a frame of cognitive investigation of the client’s experience and circumstances, involving therapist’s challenging responses, on the other. In one session in the therapy, however, a situation that appeared us as a rupture of therapeutic alliance emerged through exchanges during which the client recurrently returned to affective expression of anxiety, and refused to engage in more investigative elaboration of her experience and circumstances, where the therapist was inviting her to. In other words, there was a continuing disalignment between these two frames.

Extract 1 below shows one segment of disaligning talk. Prior to the extract, the therapist topicalized the client’s feelings of anxiety and invited the client to talk about what she thinks might be behind the anxiety. However, in her response, beginning from line 1, the client does not take this kind of investigative position but describes how her experience is like.

Extract 1

1 P: ↑Nii (0.8) #joteki on niinku viime aikoina aina# ↑Yeah (0.8) #somehow I have these days felt#

2

.hhh #mh# hhh ollu kauheen (0.3) ahdistunu olo (.) .hhh #mh# hhh felt terribly (0.3) anxious (.)

3

#jatkuvasti ja semmonen huono olo# (1.4) #constantly and had like a bad feeling# (1.4)

4

niiku fyysisesti ja psyykkisesti he.hhh (2.0) like physically and mentally he.hhh (2.0)

5

hirveen väsyny ja, awfully tired and,

6

(4.0)

7 T: Mut onk- #tarkottaaks s-# (0.7) #mth# ahdistus siis But is-#does it mean # (0.7) #mth# anxiety then

8

et enemmän ahdistunu ku masentunu vai et sekä että that more anxious than depressed or both and

9

sekä masentunu että ahdistunu [.hhh both depressed and anxious [.hhh

In lines 1–5 the client describes what her experience is like, using several intensifiers (kauheen, “terribly,”jatkuvasti, “constantly,” hirveen, “awfully”). In these ways, the client offers her utterance as an expression of a problematic emotional experience that invites an empathic response from the therapist (Jefferson, 1988). The therapist (lines 7–9), however, does not respond empathetically but poses a question concerning the quality and quantity of the client’s anxiety. The therapist formulates her question as one about the meaning of the client’s words, indicating that she is not able to recognize fully the experience the client has. The question is marked as a departure from the preceding topical line of talk with mut, “but,” and with that question the therapist directs the client away from expressing the affect as such toward investigation of the affect (cf. orientation to professional action versus troubles telling in Jefferson & Lee, 1992; Ruusuvuori, 2007).

Through the beginning part of this session, this disalignment between the frames of action of the participants continues: the client recurrently returns to expression of anxiety, inviting empathy, whereas the therapist challenges this frame as she pursues investigation of the reasons for the anxiety. Eventually, this leads to a culmination in the disalignment that is shown in the next extract. After yet another affective expression by the client, the therapist calls into question the client’s way to describe her experience. Prior to the extract, the client has stated that she would prefer to stay indoors, just to close the curtains and sleep. The therapist has asked whether this would really alleviate the client’s problem. The client first partly agrees with the therapist by stating that it probably would not solve anything. In the beginning of the extract, after a gap in the interaction, the client returns to talk about her preference to stay at home.

Extract 2

1. P: #Emmä tiiä ku: kotona on jotenki niin#.hh #I don’t know ’co:z at home it is somehow so#.hh

2

£turvallinen #ja# (0.5) #hyvä olla#£#semmonen että ei# £safe #and# (0.5)£#good to be#£#like that not#

3

(2.0) #mmm (0.7) #ei tota# (1.5) #jos ei tarvii (2.0) #mmm (0.7) #not like# (1.5) #if you don’t have to

4

mihinkään mennä ei jännitä mitään go anywhere you are not nervous about anything you

5

ni ei oo pahoinvointia# don’t feel sick#

6

(.) #ainakaan niin usein tai#.hff (0.3) #mmh#, (.) #at least not so often#.hff (0.3) #mmh#,

7

(.)

8 T: #Eli sul on oikeesti on sit kotona jos sä panisit #So you really feel then at home if you drew

9

verhot kiinni ni sulla oikeesti olis siellä#.hhh the curtains you would really #.hhh feel#.hhh

10

>#hyvä olo#< [hhh

>good there# [hhh

The client’s account in lines 1–6 has an affective tone: she utters the expression turvallinen ja hyvä olla, “safe and good to be,” in a smiley, soft voice, and leaves the experiencer unmentioned in the utterance, which all can be heard as inviting a recognition of the experience. In her response (lines 8–10), the therapist, however, reformulates the client’s words in a way that, instead of expressing empathic recognition, calls into question the client’s description of her experience (conveying skepticism through the adverb oikeesti, “really,” in lines 8 and 9). The therapist thus strongly directs the client to rethink her experience. In contrast to what is typical elsewhere in this therapy, the therapist’s turn is overtly challenging and does not involve empathetic elements. After the extract, the disalignment is maintained in the client’s subsequent talk where she continues to describe a situation where she indeed feels good at home.

The two extracts above illustrated a disalignment between the participant’s frames. Later in this session this disalignment became topicalized – not as a mismatch between frames, as we have described it, or in terms of alliance rupture – but in terms of the client’s unwillingness to talk about another topic: her failure to take up an opportunity in her professional life and her belief that the therapist is disappointed at her because of that. When this became topicalized, the tension that was present in the earlier interaction seemed to be released (e.g. through mutual laughter) and the participants reached a shared frame: reflective talk about their interaction and about emotion in their therapeutic relationship.

In clinical terms, the interactional difficulties, and the ensuing reflective talk about them, could be seen as rupture in therapeutic alliance and its repair. There was an implicit tension in

the interaction that was jointly taken under consideration. Through the joint consideration, the tension got released (cf. Safran & Muran 2006). The rupture occurred when there was a disalignment in the frames of action: the client resisted the therapist’s investigative line of action, whereas the therapist, in turn, resisted the client’s movements towards an affective frame. This mismatch was consequential: the participants ended up explicating the reasons for it. They treated the mismatch between “affective frame” and “investigative frame” and empathetic vs. challenging response as observable and accountable (Garfinkel, 1967). Nevertheless, in the latter part of the session, the disalignment became a resource of therapeutic work as the participants reflected upon it and, on the basis of it, went on to discuss therapeutically relevant issues and the therapeutic relationship (for a more detailed discussion on this session see Voutilainen, Peräkylä, & Ruusuvuori, 2010).

It should be pointed out that in this particular therapy, mere challenging was not how the therapist normally responded to the client’s descriptions of her emotional experiences. It is possible that it was this unusual way of responding, by the therapist, that the client treated as problematic. On the other hand, in these particular moments of interaction (some of which were shown in extracts 1 and 2 above), it might have been problematic for the therapist to empathize with the client, because there may have been implicit attributions of negative emotion to the therapist in the client’s displays of anxiety (that became explicated later). Through keeping her and the client’s perspectives separate – by not empathically reflecting the client’s frame of reference but speaking from her own perspective (see Stiles, 1992), the therapist perhaps avoided responding to the implicit attributions of negative emotion before they were brought to the surface of interaction (see Voutilainen, Peräkylä & Ruusuvuori, 2010).

In the next section, we will discuss the “normal” way of responding in this therapy: the therapist’s responses that combine both understanding from the client’s perspective and suggesting a further consideration of the experience in question, thus in this sense challenging the client to reflect her experience.

3. Combining empathy and challenge

Arguably, in very general terms, there are two basic orientations or facets in psychotherapist’s ways to relate to the client: to empathize and to challenge. To empathize means that the therapist attunes him- or herself to the client’s experience conveyed by the client’s talk; to challenge means that the therapist questions the client’s beliefs about self and the world and his/her ways of being with others. Empathy and challenge bring about the change in the patient. These two facets of therapeutic work have been described in clinical literature, using different terms (see e.g., Greenson, 1967; Beck, 1976; Stern, 2004; Warner, 1997; Greenberg, 2004). Empirical studies suggest that empathy and challenge are “embodied” in psychotherapy: there are “empathetic moments” when the therapist reciprocates client’s facial expressions and mirrors the prosodic patterns of the client’s talk, and “challenging moments” when the therapist’s face and prosody are disjunctive in relation to the client’s expressions (see Bänninger-Huber, 2014; Weiste and Peräkylä, 2014).

One line of CA work has explored the ways in which empathy and challenge are linked to each other in the therapists’ ways of responding to the clients’ talk. A central observation from cognitive therapy is that challenging responses (responses that suggest that the clients’ experience involves something more than what the client said) are preceded by a response that displays empathy (Voutilainen et al, 2010b; Weiste and Peräkylä, 2014). Turns that

combine empathy and slight perspective shifts have been described also from psychoanalysis (Peräkylä, 2011).

The therapist’s empathy or challenge is often delivered interventions that in CA are called formulations. Formulations have indeed been perhaps the most extensively researched facet of psychotherapeutic interaction in CA (see e.g. Antaki, 2008; Buttny, 1996; Hutchby, 2005; Madill et al., 2001; Peräkylä, 2004; Vehviläinen, 2003). According to Heritage and Watson (1979) formulations are utterances in which the current speaker suggests a meaning of what another participant has said in the prior turn or turns. A formulation is inevitably selective: it foregrounds something in the prior talk, and leaves something else in the background.

Besides formulations that are framed to display understanding of the client’s words, the therapist’s responses to the client’s emotion can be delivered as extensions that as it were continue the client’s turn at talk, and so convey understanding through, as it were speaking “from within” the client’s experience (Vehviläinen, 2003; Vehviläinen et al., 2008; Peräkylä, 2008; Voutilainen et al., 2010; Pawelczyk 2011: 189-195; Weiste, Voutilainen and Peräkylä, submitted).

The extract below shows a case where the therapist responds to the client’s talk, first with an extension that shows empathy, and then continues with a more challenging intervention, delivered as a formulation. Here the empathetic extension is only one word, but it functions in similar vein as more elaborated empathetic responses: it receives the content of the client’s experience as it was offered by the client and displays understanding of it. Prior to the extract, the therapist and the client have talked about the client’s depressed mood. The therapist has asked what the client would change in her life if she could. The client has pondered that she

might change her childhood. In the beginning of the extract, the client responds to the therapist’s question about what she would change in there.

Extract 3: 1 P: .hhhhh ts mhhhhhhhhhhhhhhhhhhhhhhh No #mmmmm# .hhhhh ts mhhhhhhhhhhhhhhhhhhhhhhh well #mmmmm#

2

.hhhhhh (1.2) ssss (0.4) ö-ähhhhhhhhhh ehkä .hhhhhh (1.2) sss (0.4) ermhhhhhhhhhhhh mmaybe

3

just (.) sen et ois (.) that very thing (.) that one would feel more

4

↓turvallisempi olo ja et ois (1.7) ois tota niin ↓safe and that one would have (1.7.) have erm

5

like that ca- care and love and ni sitä välittämi- välittämistä ja rakkautta ja

6

semmosta (0.5) ↓hellyyttä (2.3) enempi. such (0.5) ↓tenderness (2.3) more.

7

(0.4)

8 T: Received. Saanu.

9

(.)

10 P: Ts nii. Yes.

11

(0.7)

12 T: Eli sit sää (.) muuttasit (.) ↓äitiä. So then you (.) would alter (.)↓mother.

13

(.)

14 P: .hhhhhhhh Ehh nii.= .hhhhhhhh Ehh yeah.=

15 T: = Toisenlaiseks. To be different.

16

(0.5)

17 P: Nii (0.5) £kaih£. Yeah (0.5) £perhaps£.

The client ponders that in her hypothetical childhood, she would feel more secure and she would receive more care, love and tenderness. In the original Finnish utterance the auxiliary verb “olis” can have the meaning of both “would be” and “I would have”. In Finnish, the utterance can be heard as syntactically complete in the sense “there would have been more care, love and tenderness” but incomplete in the sense “I would have received”; the client does not say the verb “received”. Importantly, the turn is prosodically produced as complete and there is a short pause in line 7, indicating that the client’s turn is not in progress. In line 8 the therapist does an extension that completes the syntactical construction (cf. Lerner, 1991) with the main verb “received”. In this way, as it were talking from within the client’s turn, the therapist displays empathetic understanding of the content of the client’s talk. In a discreet way, the extension also intensifies the emotional content of the turn by making a shift from somewhat passive or abstract voice of “there would have been” to the form that addresses more directly the client’s wish and disappointment “I would have received”.

In line 12, the therapist does a formulation So that you would alter mother. This formulation brings out the critical stance towards the mother that was implicit in the client’s turn (the client’s childhood memories that have been talked about in the therapy have mainly focused on her relationship with her mother). In this way the formulation is challenging: it invites the client to talk more directly about her disappointment with her mother. It is important to note that this formulation would have been a possible response already in the place of the extension in line 8. However, the extension and the client’s confirmation (line 10) build a more solid ground of mutual understanding on what has been described. That can be seen as therapeutically relevant as such, and as a ground on which the challenge can be more safely built (see Voutilainen et al, 2010b).

The combinations of empathy and challenge generally invite reflective talk about the experience from the client (Voutilainen et al, 2010b; Peräkylä 2011). In her response starting from line 14, the client confirms the formulation, albeit somewhat hesitantly (there is a long inbreath and some kind of sneer before the confirming yeah). After the therapist’s expansion of the conclusion in line 15, the client starts to waiver by qualifying her stance with perhaps (line 17). After what is shown in the extract, the client backs further off from the conclusion by adding that she would change her father too, and eventually calling into question the assumption that the hypothetical change would make her feel better. In her response to the therapist’s formulation, thus, the client does not go further to reflect her experience in ways that were made relevant by the therapist. Importantly, however, the client still orients to what was suggested by the therapist through expressing ambivalence.

The client’s response can be seen as a partial resistance towards the issue in question; the client resists further examination of her experience but however produces a relevant next

action that takes a position towards what the therapist suggested (see Peräkylä, 2005; 2011), and the discussion on the topic continues. In what follows, we will turn to discuss cases where the client’s resistance towards the therapist’s agenda is more salient, and the ways in which the therapist manages the resistance.

4. Managing resistance

As Vehviläinen (2008: 120) points out, some mismatch between the professionals’ and the clients’ actions is common in perhaps all institutional settings: “professionals encounter moments where clients resist their actions and institutional agendas.” In psychotherapy, resistance is particularly important and possibly significant. Client resistance is not only an obstacle (i.e. something that needs to be sorted out in order for the therapy to take place), but rather, part and parcel of the very activity of doing therapy (see Vehviläinen, 2008). CA research on psychotherapy has located resistance for example in clients’ claims of not knowing (Hutchby, 2002; Falk, 2013) or not remembering (Muntigl and Kwok, 2010), and in client’s resistance towards presuppositions in therapist’s questions (MacMartin, 2008). Resistance may occur in instances of overt disagreement (Weiste, 2015) or it can be more discreet, embedded in what appears to be agreement (Peräkylä, 2005).

One way in which the clients often resist the therapist’s agenda is by changing the topic of the talk. In such instances, the therapists often manage the resistance by responses that do not overtly resist the client’s topical shift but do not further the topic either (Koivisto & Voutilainen, submitted). An example is shown in the extract below. Prior to the extract the therapist has asked about a discussion in the previous session about the client’s mother,

which the client obviously had experienced as emotionally stressful. The client responded only briefly to the question that apparently invited a more extensive elaboration, and then moved on to talk about a positive enounter with her mother: how it was nice to talk to her mother in phone in the previous day. The client told that her mother spoke about her stress at work. The extract begins after some talk on that topic.

Extract 4

1 P:

=Ja nyt se oli

sit lääkäri pakottanu sen jäämää (0.3)

= And now she has then the doctor has told her to a leave

2

(0.3)

3

stressilomalle että. from work because of stress so.

(.)

4 T:

↓Mm-hm.=

5 P:

=Että tota niin ni. = I mean like.

6

(0.5)

7 P:

Ts mut että oisko sekin sitte just periytyvää toi että

But I mean would it be inherited too that thing that

8

.hhh £ähhäh [hä että£].

9 T:

[Et se on] se: (.) vatsa joka [reagoi]. (You mean) it is the (.) stomach that reacts.

The client’s talk about her mother’s stress in this context can be seen as a way to resist the therapist’s suggestion to talk about the previous session -- a topic that would involve problematic emotions both in the client’s relation to her mother and in her relation to the therapist. During the client’s earlier talk, the therapist has responded only minimally. In lines 7-8 the client ends up pondering whether “it” is inherited, referring to what she has just told about her mother’s somatic stress reactions. In her response in line 9 the therapist responds locally to this aspect in the client’s talk with an extension that explicates the reference of the “it” in the client’s turn: that it is the stomach that reacts (to stress). In this response, the therapist does not respond to the earlier content of the client’s turn: neither to the part in which the client rapidly responded to the therapist’s topicalization of the previous session, nor to the part in which the client talked about her positive feelings about the phone call with the mother. In other words, the therapist’s response is given very locally to what the client said in lines 7-8. It explicates the obvious, concrete content that was left unsaid in the client’s turn (but was clear from the context) without taking up anything more about the topic that the client has now brought to the discussion. In other words, the therapist takes a turn in a relevant place but does not initiate any further aspect on the topic (see Koivisto & Voutilainen, submitted).

After what is shown in the extract, the client continues the talk about her mother and the somatic stress reactions. In her response after that, then, the therapist returns to the question about the client’s inconvenience in the previous session. The therapist thus does not take up the topic that was initiated by the client (the positive experience with mother) in any way, but returns to the agenda that she initiated earlier. However, through the local response in lines 78, the therapist avoided overtly dismissing the topic that the client introduced (Koivisto & Voutilainen, submitted). It is interesting to compare the therapist’s extension in this extract to the one in the previous extract: unlike in the previous one, here the extension is not in the service of a further intervention by the therapist but rather in the service of not furthering the talk on topic introduced by the client. In a way, also this practice can be seen as a version of combining empathy and challenge: through this kind of “minimalistic” response the therapist communicates on the one hand that she listens to the client, understands her point, and gives her possibility to continue her talk, but on the other hand also implicitly resists the client’s project of moving away from the topic that the therapist was suggesting. In the two extracts above, the therapist therapist’s agenda, broadly speaking, was to invite the client to express and reflect her negative emotions towards her mother, and in the latter case, also towards the therapist. The client, however, resisted this agenda – in the former extract in a more subtle way, and in the latter extract by changing topic. As was noted above, this kind of resistance is normal and essential part of the therapeutic process, and we believe that the therapist’s subtle ways of dealing with it – combining empathy and challenge – helped the client to move towards the problematic experiences. In this therapy, the client’s way of talking about her experiences eventually changed; in latter part of the therapy the client moved towards expressing negative emotions more openly and expressing less self-blame. Next, we will discuss how this kind of change process can be seen from the CA perspective, i.e. in relations between turns at talk.

5. Interactional practices and therapeutic change

Psychotherapies generally aim at a change in the client, at improved mental health. A fundamental aim in many types of psychotherapy is to increase the clients’ contact with their problematic emotional experiences and parts of the self, and increase their self-reflective abilities (e.g. Lilja, 2012). In clinical research, one way to conceptualize this process is the assimilation model of a problematic experience (Stiles al, 1990). In this model, therapeutic change is seen as a process in which a painful or threatening experience becomes integrated to the client’s self. According to the assimilation model, this process can be divided to certain phases, starting from vague awareness of the problematic content and proceeding through seven stages to finally integrating the experience (Stiles et al, 1990). Despite the longitudinal nature of psychotherapy and the clinical interest in the therapeutic change, most of the conversation analysis of psychotherapy has focused on phenomena that occur in more microscopic time: in the temporality of the turn and sequence, rather than the temporality of a continuum of sessions. Recently, however, the time span of the phenomena of interest in CA studies of psychotherapy has got wider. Researchers have started to investigate longitudinal, “across sessions” interactional processes. This has made it possible to address more directly also the question of therapeutic change (Voutilainen et al., 2011; Peräkylä, 2011; 2012, Bercelli et al., 2013; Muntigl, 2013). Inspiration for this new line of research has been drawn from studies on learning in interaction (e.g. Mondada and Pekarek Doehler, 2004; Melander & Sahlström, 2009). In their study on cognitive therapy Voutilainen, Peräkylä and Ruusuvuori (2011) suggest that therapeutic change can be documented from a change in a particular type of sequence (pair of particular types of turns) that recurs across sessions. The data of this study were the same

therapy that we have discussed in this chapter. The focus was on change over time in the client’s responses to particular types of turns. The therapist’s focus turns were conclusions (or so called upshot formulations, see Heritage and Watson, 1979) in which the therapist challenged the client’s tendency to transform her anger to self-blame. The study showed that the client’s responses to these interventions were recast over time: from rejection through ambivalence to agreement. (The extract 3above was one instance from the phase of ambivalent responses.)

The perspective of CA – looking at relations between adjacent turns – offers a way to investigate how the therapeutic process, for example the assimilation of problematic experiences, is bound to particular kinds of social actions. The assimilation of a particular problematic experience is “embodied” in interactional sequences. It is possible that an individual patient is not the right unit of observation for assimilation, because the assimilation of a particular experience may be at different stages in different interactional contexts. For example, in our focus therapy, the client talked in different ways about her negative emotions in her turn prior to the therapist’s focus conclusions than after the conclusion (Voutilainen et al, 2011). This is shown also in the extract 4 above: in the beginning of the extract the client expressed her wish to have different childhood and so talked about her problematic emotions in relation to her mother. However, after the therapist’s formulation that explicated the content of the client’s turn, the client backed off from this position and started to ponder if the different childhood would have made any difference in her life. In other words, if we look at the clients’ talk in terms of assimilation it seems different in different interactional contexts (e.g. before and after a particular intervention).

This social aspect to assimilation can be considered also in relation to what Leiman and Sitles (2001) suggested about the zones of proximal development: in joint exchange with the therapist, clients reach higher levels of assimilation than they reach in their internal assimilation. In this view, new ways to relate to an experience are mutually achieved in interaction. In the example case (extract 4), the client and the therapist jointly, for a moment, achieved a an expression of disappointment towards the client’s mother: the client offered to the therapist material that the therapist as it were finished in her conclusion, which the client then confirmed – and then again, being again more ‘on her own’ after the conclusion, the client backed off from what was just mutually achieved. What the therapist did in the conclusion might be seen as a position that was in the zone of proximal development of the client (Voutilainen et al, 2011).

In the longitudinal analysis of the “conclusion and response” sequences of our focus therapy (Voutilainen et al, 2011), it was shown that towards the end of the therapy, the client’s responses to the conclusions changed to acceptance and agreement. This was shown in the client’s elaborated response that accommodated what the therapist had suggested in her conclusion: that the way the client’s mother reacts to the client are due to the mother’s personality and not something that the client should blame herself for. This could be seen as internal assimilation of the problematic experience that was collaboratively worked with in the earlier phases of the process. Even though it may not be possible to connect the change in a social action directly to internal change, it was at that point of the therapy at least possible for the client to agree with the therapist in the surface of social interaction. This change is very salient when the client’s response is compared to the beginning phase of the therapy where she responded to the therapist’s conclusions with silence and a refusal to say or even think anything negative about her mother.

6. Clinical relevance

In this chapter we have described CA research on psychotherapy, pertaining to four themes that are clinically important: therapeutic collaboration, empathy, resistance, and therapeutic change. Compared to clinical literature, CA research is detailed and cumulative. CA studies have their focus on distinctive practices. The price of the focus on detail has been, perhaps, CA’s weakness in global and comprehensive theorizing on psychotherapy. Furthermore, CA research is usually descriptive rather than normative in relation to the therapeutic work it describes. This is our stance in this chapter too. The practices that we have described can be seen rather as tools for reflection for clinical practioners than as instructions or suggestions to be applied in clinical work as such. On the other hand, the strength of CA is in the naturalistic, data-driven approach that can be seen to complement the often more abstract and idealized way to describe psychotherapy in clinical literature (see Peräkylä and Vehviläinen, 2003).

In this chapter we hope to have demonstrated two things 1) the interconnectedness and possible mismatch of empathy and challenge in the therapist’s ways to respond to the client’s talk on problematic experiences, and 2) the ways in which clinical work is done through particular types of social actions that involve a particular relation to the previous turn, such as formulations and extensions. We hope that CA perspective can give clinical practitioners inspiration to observe the interactional side of the therapeutic process, and the ways in which the clinical work connects with the norms and expectations of conversation in general.

Clinical practice highlights 1. Psychotherapy is done in relations between turns at talk. 2. Some interactional difficulties can be seen as mismatch of frames of talk. 3. Empathy can build grounds for challenging actions. 4. Resistance can be managed through local responses to client’s narration. 5. Therapeutic change can be observed from social contexts.

Recommended reading

Peräkylä, A., Antaki, C., Veheviläinen, S., and Leudar, I, (eds.) (2008). Conversation analysis and Psychotherapy. Cambridge: Cambridge University Press.

Fitzgerald, P. (2013) Therapy Talk: Conversation Analysis in Practice. Palgrave Macmillan.

Muntigl, P. & Horvath, A. O. (2013). The therapeutic relationship in action: How therapists and clients co-manage relational disaffiliation. Psychotherapy Research 24(3), 327-345.

Vehviläinen, S. (2003). Preparing and delivering interpretations in psychoanalytic interaction. Text 23, 573-606.

Terms to the glossary: Transferential emotions: Emotions associated with one person (e.g. parent) redirected to another person (e.g. therapist) Interpersonal patterns: Person’s recurrent ways to relate to others

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