Counselling Psychology Quarterly, June 2005; 18(2): 85–93
SPECIAL ISSUE RESEARCH REPORTS
Extending the Assimilation of Problematic Experiences Scale: Commentary on the special issue
WILLIAM B. STILES Miami University, Oxford, Ohio, USA
Abstract The Assimilation of Problematic Experiences Scale (APES) describes a developmental sequence through which problematic experiences pass on their way to being assimilated in successful psychotherapy. This commentary suggests that the four studies reported in this special issue of Counselling Psychology Quarterly have extended the APES by applying it to new topics and by confronting the puzzle of irregular progression in what is hypothesized to be a fixed sequence of stages.
Keywords: assimilation model, Assimilation of Problematic Experiences Scale, stage theories, case study
The Assimilation of Problematic Experiences Scale (APES) was constructed as a way to summarize a developmental sequence that clients experience as they overcome problems in successful psychotherapy (Stiles et al., 1991, 1992b). It seeks to represent the relationship of one part of a person to other parts. For example, the APES can be used to describe the relation of traces of a traumatic experience to the person’s usual sense of self. Or, using the metaphor of voice, the APES can be used to describe the relationship of a problematic internal voice with the person’s dominant community of internal voices and the development that relationship as the problematic voice is assimilated into the community (Stiles, 2002). The APES has been elaborated and changed, mostly though case study (Stiles, 2003), though there have also been quantitative investigations (e.g., Detert, Llewelyn, Hardy, Barkham, & Stiles, in press; Field, Barkham, Shapiro, & Stiles, 1994; Stiles, Barkham, Shapiro, & Firth-Cozens, 1992a; Stiles, Shankland, Wright, & Field, 1997). Some versions of the APES have been renamed, including the APES-enlarged version, in which the vague awareness/emergence stage was divided into three stages for a study on effects of antidepressant medication (Teusch, Bo¨hme, Finke, Gastpar, & Skerra, 2003), the Assimilation of Problematic Voices Scale (APVS; Honos-Webb, Stiles, & Greenberg, 2003), the Assimilation of Problematic and Overwhelming Experiences Scale (APOES);
Correspondence: William B. Stiles, Department of Psychology, Miami University, Oxford, OH 45056, USA. E-mail:
[email protected] ISSN 0951-5070 print/ISSN 1469-3674 online ß 2005 Taylor & Francis Group Ltd DOI: 10.1080/09515070500136868
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Varvin, 2003), and the Heidelberg Structural Change Scale (HSCS; Grande, Rudolf, Oberbracht, & Jakobsen, 2001; Grande, Rudolf, Oberbracht, & Pauli-Magnus, 2003; Rudolf, Grande, & Oberbracht, 2000). Other variations have not been given separate names (e.g., Glick, Salvi, Stiles, & Greenberg, in press; Honos-Webb, Stiles, Greenberg, & Goldman, 1998; Honos-Webb, Surko, Stiles, & Greenberg, 1999; Knobloch, Endres, Stiles, & Silberschatz, 2001; Laitila & Aaltonen, 1998; Stiles & Angus, 2001; Stiles et al., 1991, 1992b, 1997; Stiles, Osatuke, Glick, & Mackay, 2004; Williams, Stiles, & Shapiro, 1999). The studies in this special issue (Caro, 2005; Henry, Stiles & Biran, 2005; Humphreys, Rubin, Knudson, & Stiles, 2005; Osatuke et al., 2005) have not renamed the APES, but they have modified our understanding of it and extended its application in ways that deserve comment. As result of this continuing evolution, there is no final or authoritative version of the APES stages, but for reference in this commentary, here is a current list of the names of stages in the developmental sequence: Stage 0: Warded off/dissociated. Stage 1: Unwanted thoughts/active avoidance. Stage 2: Vague awareness/emergence. Stage 3: Problem statement/clarification. Stage 4: Understanding/insight. Stage 5: Application/working through. Stage 6: Resourcefulness/problem solution. Stage 7: Integration/mastery.
The research reports in this special issue offer descriptions and elaborations of these stages. The APES, in effect, describes formal commonalities in the process of change, across clients, problems, and therapeutic approaches. For example, in the Osatuke et al. (2005) study, it offered a common metric for comparing the rate and pace of progress in client-centered therapy with that in cognitive-behavioural therapy. The APES goes beyond measures of symptom intensity to disentangle the ‘‘what’’ (specific changes, evolution of problematic voices) from the ‘‘how much’’ (the amount of progress).
Continuity and transformation of the APES The APES serves as a repository for a growing theoretical understanding of the developmental sequence (Stiles, 2002, 2003, in press). Each new study has elaborated or added something to the theory, and, as appropriate, these additions and modifications have been incorporated into the various versions of the APES. Thus, there is a continual process of differentiation and synthesis–trying out the APES in new areas, modifying and expanding the scale’s descriptions, and then reconciling the new findings with previous versions and with each other. Both differentiation and synthesis go on in every study, but the richness of the four research reports in this special issue is on the side of elaboration and differentiation. That is, these studies notably extend the APES to new topics and uncover phenomena not previously addressed by the assimilation model.
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How case studies change theories All four reports are case studies. In my view, the goal of case studies, like the goal of all scientific research, is to build a theoretical understanding. I think that rather than simply adding facts, new observations permeate the theory. The appropriate metaphor for growth of a theory is not building a brick wall but chemical diffusion: Particles of observation spread through theoretical interstices. The ideas change to fit the observations, and in this way aspects of the observations become part of the theory. The theory may be explained differently, for example, using different words that accommodate the new observations along with the previous ones or using the new observations as illustrations (Stiles, in press). In contrast to statistical hypothesis-testing research, where only one or a very few derivations from the theory are examined across multiple cases, case studies address many theoretical issues at the same time. No one question is answered definitively—there are no firm conclusions—but the fit of the observations to many aspects of the theory lends confidence to the theory or, alternatively, suggests how the theory must be changed in order to account for the observations (Campbell, 1979; Stiles, 2003, in press). Using the APES in qualitative research Like most qualitative research on human experience, assimilation research makes use of empathy to understand the participants’ feelings in the moment. In the following example, taken from Caro’s paper, a reader needs some empathy to understand how the passage (translated from the original Spanish) relates to the problem that Silvia brought for discussion in the session: ‘‘When I have to go home, I start feeling bad, I don’t want to go home and I can’t understand why this is happening to me’’. The therapist pointed out a contrast: Therapist: Let’s see. Hmmm. So, let’s relate what you are feeling to a specific situation. Uh-hum? The situation is that you get out of the house where you do the cleaning up happy and singing. Silvia: Right, I feel very well there. Therapist: Very well. Silvia: It is true, I . . . , I am there listening to music, singing, but I do not do that at my home.
Understanding how this could puzzle Sylvia draws on a grasp of human feeling that is not spelled out in a theory. We must empathically understand at least a little of the contrast in her feeling between home and work (as well as much else) to follow Caro’s argument and to assess the APES level of Silvia’s problems. The APES is numeric and can be used as an independently applied rating scale, as illustrated in the report by Caro (2005). However, in some studies, there are no independent ratings, and the APES is used as a way to be precise about the investigators’ understanding. For example, in the Henry et al. (2005) paper, there were no independent raters. Instead, readers were invited to consider the investigators’ evaluation of interviewees’ APES levels together with qualitative evidence, including verbatim excerpts of transcribed interviews. APES extensions The assimilation model has gained an increment of confidence from its consistency with the observations made in this special issue’s four studies. It has also gained an increment of
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reflexive validity from its ability to accommodate to the new features these studies encountered. Reflexive validity refers to whether a theory is changed by the observations it encounters (Lather, 1986; Stiles, 1993). A valid theory must expand to incorporate new ideas as it is applied to new data. I will comment on two directions in which these studies have extended the model and particularly the APES. Extensions to new topics First, these studies have applied the APES to new topics. Most obviously, Henry et al. (2005) have extended the APES beyond psychotherapy to the study of acculturation. Most of the previous APES investigators have studied psychological problems– conceptualized as problematic internal voices—being assimilated into a larger dominant community of voices. Henry et al. have instead studied two disparate constellations of internal voices: the voices of the native culture and the voices of the host culture. The voice metaphor describes traces of experience, which are presumed to be active agents in the assimilation model. By definition immigrants have had experiences in two cultures. Thus, the existence of internal voices of the native and host cultures may be presumed. Such hugely different constellations of experience may be regarded as mutually unassimilated, at least initially. Each cultural constellation may tend to be problematic to the other and encounters between them may be psychologically painful (e.g., loneliness, fear, alienation, or self-disgust, depending on the nature of the encounter). Showing that the APES can be used to describe the different relations these constellations of voices have achieved within individual immigrants is thus an important generalization for the theory. Caro’s (2005) application of the APES to Linguistic Therapy of Evaluation (LTE) represents extension to a new form of therapy. The central finding that problems considered as resolved from an LTE perspective were rated higher on the APES than problems considered as unresolved represents an important convergence between LTE and the assimilation model. The convergence adds construct validity to the suggestion that movement along the APES corresponds to psychotherapeutic progress by confirming this from the perspective of another formal treatment theory. (Note that the assimilation model is not a treatment model, but rather a description of changes thought to occur in all successful treatments.) Humphreys et al.’s. (2005) application of the APES to Kristen, a client with dissociative identity disorder (DID), represents an extension to a new psychological disorder. In addition to broadening the scope of the model by showing these extensions are possible, each of these studies also raised new puzzles and pointed to new theoretical elaborations that are addressed in the next section. The puzzle of irregular progression Three of the reports highlighted the observation that clients’ movement along the APES often fails to follow the steady course implied by a stage theory. Rather than progressing from stage to stage in an orderly way, clients studied by Osatuke et al. (2005) and Caro (2005) seemed to advance and then fall back. The general trend was toward higher APES stages, but there were many instances where later passages were rated at lower APES stages than earlier passages. An even more discrepant pattern appeared in the Humphreys et al. (2005) case. Particularly across the early sessions, some passages were rated far higher than other
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passages dealing with the same anger-related content. Considered as a single developmental progression, these ratings differed greatly from the expected sequence. Humphreys et al. explained the discrepancy by concluding that the low-rated passages could be attributed to Kristen, the compliant and helpless host personality, whereas the high-rated passages could be attributed to Zac, the angry and aggressive primary alter. The study reported by Henry et al. (2005), could not have detected irregular progression because it was cross-sectional in design, considering each person at one point in time and illustrating the APES progression by comparisons across cases. A longitudinal study of acculturation, however, might also show irregular progression in the mutual assimilation of the two cultures’ voices. Irregular progression through the APES, which has been observed in many of the studies cited earlier as well as in the reports in this special issue, seems directly contrary to the suggestion that the APES sequence is developmental. As suggested by Osatuke et al. (2005), in a strict stage model, ‘‘each next level builds upon the previous one, stages cannot be skipped, and their order cannot be reversed’’. Theoretically, the APES stage progression is underlain by the building of meaning bridges (Glick et al., submitted; Stiles, 2002; Stiles et al., 2004) and abandoning the concept of systematic progression would require major theoretical revisions. Consequently, the observed irregular progression deserves special attention. Several accounts that could reconcile the observations with the assimilation model and the APES progression were proposed in the special issue papers. The following list summarizes these along with a few other possibilities. These possibilities are not mutually exclusive, and combinations of factors may be responsible for irregular progression in some cases. (1) Imprecision of measurement. Some of the irregular progression could simply reflect measurement error. Assessing the APES stage of a particular problem at a point in time requires knowledge of context and clinical inference, and these leave much room for imprecision. The material on which ratings are based may be misleading due to all the influences that interfere with people fully understanding each other. External raters may lack knowledge of crucial contextual features, perhaps including some that were known to client and therapist but not made explicit in the material on which ratings were based. Client speech may be misunderstood in many ways, and raters may have different or inadequate understanding of the client’s expressions. Raters may also have different or inadequate understandings of the APES itself. That said, imprecision of measurement seems insufficient to account for the observed irregularities of progression in the special issue papers. The setbacks and sawtooth patterns that Caro and Osatuke et al. describe seem too salient and plausible to be attributed entirely to errors in rating. Readers will have to decide this for themselves, however, based on the grounding provided in the quoted passages, narratives, and background material. (2) Multiple strands of a problem. Theoretically, a problematic voice (traces of a problematic constellation of experiences) is never sharply delimited, and it may be considered as a set of subvoices that cohere imperfectly. Different strands of a problem may be assimilated at different rates. In effect, the identified problem may be psychologically dissected into multiple interrelated subproblems, each of which may have a somewhat different rate of progression. Both Caro (2005) studying cases of LTE and Osatuke et al. (2005) studying a case of cognitive-behavioural therapy (Karen) observed that progress on the APES plotted across passages within sessions had a sawtooth shape. That is, the APES level would increase for a while and then drop back to a lower level. One account of this is that each tooth of the saw represented a slightly different strand of the problem. That is, the developmental
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sequence was preserved within each narrow strand, while the irregularity reflected attention to different strands. As emphasized by Osatuke et al. (2005), a directive therapist (the cognitivebehavioural therapist in the Osatuke et al. study) may exploit this multiple-strand structure by picking up one strand at a time and concentrating on it. The client would make as much progress as possible on one strand (i.e., one aspect of the problem), and then the therapist would drop back to pick up another related strand. Thus, the sawtooth pattern observed in the case of Karen was not haphazard but represented systematic backtracking. By contrast Margaret, who received a non-directive (client-centred) therapy, seemed to progress relatively smoothly though the APES stages. Margaret did not seem to advance strands differentially on her own, at least not to the same degree. The problematic voice somehow tended to preserve its own coherence; strands of the problem tended to remain together. Scores on standard assessment instruments indicated that Margaret and Karen experienced similar decreases in the intensity of their depressive symptoms across therapy, but apparently by different paths. (3) Work in the zone of proximal development (ZPD). The activity of the therapist suggests another possible contribution to the irregularity. The out-of-sequence examples could be understood by assuming that the clients worked at slightly more advanced APES levels when they were being actively facilitated by their therapists than they would have done otherwise. This phenomenon has been described as a manifestation of the therapeutic zone of proximal development (ZPD; Leiman & Stiles, 2001). The ZPD is a concept drawn from developmental psychology, where it has been used to describe the distance between a child’s current developmental level as assessed by independent problem solving and the level of potential development as assessed through problem solving with the guidance of an adult (Vygotsky, 1978). As applied to psychotherapy, the ZPD can be understood as a region between the client’s present APES level and the level that the client can achieve in collaboration with the therapist (Leiman & Stiles, 2001). The implication is that the APES levels reached during active intervention by therapists may be somewhat higher than that produced by clients left to their own devices. Combining the concepts of the ZPD and multiple strands yields an explanation that advances assimilation theory and simultaneously helps us understand why the observed irregularities were particularly salient in the directive therapies. It suggests that directive therapists, including cognitive-behavioural and LTE therapists, select promising strands and then press clients to the far edge of their ZPD for that strand. Thus one strand is advanced along the APES continuum beyond other strands and also beyond what the client would have achieved without this active intervention. Presumably, clinical signs show therapists when the limit has been reached, so that rather than try to push clients beyond their ZPD, therapists drop back to pick up another strand. Non-directive (e.g., client-centred) therapists aim to stay with the client rather than leading the client. Probably because they do not actively maintain a focus on a selected strand, the clients in such therapies do not advance narrowly on one strand at a time, but on a broader front, albeit more slowly (Glick et al., submitted). Clients in non-directive therapies may nevertheless advance more rapidly with the assistance of a therapist than alone (as in the Osatuke et al. report) but they make a different use of the ZPD. This account is hypothetical and requires more research, but it is consistent with assimilation theory, with the therapeutic approaches we have studied (LTE, cognitivebehavioural, client-centred), and with the observations of Osatuke et al. (2005), Caro (2005), and others (e.g., Glick et al., submitted).
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(4) Multiple internal perspectives. Discontinuities in APES ratings may reflect assessing assimilation from different internal perspectives. This was dramatically illustrated by Humphreys et al. (2005), where the same sort of material (anger and assertiveness) was highly problematic from Kristen’s perspective and well assimilated from Zac’s perspective. To my knowledge, this is the first research report that has presented systematically different APES ratings of the same sorts of experience from different internal perspectives within the same individual. The alternative perspectives are stark in DID and in borderline disorders, but, in principle, multiple internal perspectives may be present in all of us. DID is distinctive not so much for internal multiplicity as for the extreme dissociation among the parts. Just as problems may be composed of multiple strands, the community of voices that comprise the self may be composed of multiple subcommunities. To the extent that subcommunities are dissociated, they are likely to react differently to new experiences, find them differentially problematic, and assimilate them to different degrees (Osatuke & Stiles, submitted). The Humphreys et al. study also showed nicely how a dissociated problematic part can gradually become a useful resource. The problematic anger material can be regarded as an assimilated part of Zac, and Kristen’s difficulties with anger were thus emblematic of the dissociation between these two subcommunities of voices. Kristen’s progress in dealing with anger amounted to a gradual assimilation of parts of Zac into a common community, though this reconciliation was far from finished by the time the Humphreys et al. narrative ended. The assimilation was marked by the expression of anger gradually becoming more moderated and controlled—and less frightening to Kristen—as meaning bridges were built between Kristen and Zac. Importantly, although Zac became less violent (imaginally), she was not ‘‘killed off’’ as she feared early in therapy. On the contrary, the Zac part was actually more accessible to Kristen and was experienced as a friendly collaborator rather than an occupying force, a resource rather than a problem. Assimilation, at least in this model, does not imply homogenization. Experiences do not disappear or lose their identify because they are used and useful. This transformation of dissociated parts into mutual resources is parallel to the argument advanced by Henry et al. (2005) that assimilation between the voices of the host culture and native culture is the antithesis of suppression of one by the other. Instead, through their continuing bond, the voices of immigrants’ native culture can become resources that help them adjust to their new countries, solve problems they may face, and provide them with solace. Caro’s (2005) balance metaphor may also sometimes involve differing internal perspectives. The metaphor refers to the process of comparing rationally (balancing) the merits of the old dysfunctional ways of thinking against the new, more flexible and viable ones introduced in the therapy. The balancing may lead the client to alternate between the old, dysfunctional way of thinking and a newer perspective constructed from experiences in therapy (e.g., understanding the therapist’s logic, identifying with the therapist). A problematic experience may receive different APES ratings depending on which perspective the client was taking at the point where the rating is made. (5) Interference from progress on other problems. Though not emphasized by the authors in this special issue, another source of irregular APES progression for one problematic experience may be interference from the successful assimilation of other problematic experiences. As pointed out by Knobloch et al. (2001), clients’ problems cannot be resolved in isolation; instead, they may influence each other towards resolution or stagnation in complex and unpredictable ways. In the case they studied, ‘‘Vicky’s resolution of one problem interfered with resolution in another: expanding her freedom in her personal life, including her
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sexuality, came at the expense of harming her relationship with her mother, which she described as ‘collapsed’ in her last therapy session’’ (p. 37). As a result, although the APES ratings of Vicky’s problem expressing sexuality and personal freedom increased, the APES ratings of her problems with her mother regressed. (6) Failure of memory. For completeness, I also note that assimilation is a form of learning and requires retention. If a meaning bridge lost from memory, the APES advance won’t be sustained. Thus, patients with advanced Alzheimer’s disease or hippocampal ablations, or people who are intoxicated or under the influence of some drugs may not show assimilation progress. Advances made in one psychotherapy session might well disappear by the next session, along with memory for the session itself. This account doesn’t seem particularly cogent for the cases described in this special issue, but in other circumstances it might be relevant. (7) Limitations of the theory. Finally, it must be emphasized that the APES is an evolving description and is undoubtedly wrong in some respects. Irregularities in APES scores could be consistent with an underlying regular developmental sequence that happens to be inaccurately described in the current APES version. Investigators must remain alert to this possibility and be willing to alter the scale when evidence mounts that it is misleading in some way. References Campbell, D. T. (1979). Degrees of freedom and the case study. In T. D. Cook & C. S. Reichardt (Eds.), Qualitative and quantitative methods in evaluation research (pp. 49–67). Beverley Hills, CA: Sage. Caro Gabalda, I. (2005). A micro-analysis of the assimilation process in the Linguistic Therapy of Evaluation. Counselling Psychology Quarterly, 18, 113–148. Detert, N., Llewelyn, S. P., Hardy, G. E., Barkham, M., & Stiles, W. B. (in press). Assimilation in good- and pooroutcome cases of very brief psychotherapy for mild depression. Psychotherapy Research. Field, S. D., Barkham, M., Shapiro, D. A., & Stiles, W. B. (1994). Assessment of assimilation in psychotherapy: A quantitative case study of problematic experiences with a significant other. Journal of Counseling Psychology, 41, 397–406. Glick, M. J., Salvi, L. M., Stiles, W. B., & Greenberg, L. S. (submitted 2005). Building a meaning bridge: Therapeutic progress from problem formulation to understanding (manuscript submitted for publication). Grande, T., Rudolf, G., Oberbracht, C., & Jakobsen, T. (2001). Therapeutic changes beyond the symptoms: Effects of inpatient treatment in the view of the Heidelberg Structural Change Scale. Zeitschrift fur Psychosomatische Medizin und Psychotherapie, 47, 213–233. Grande, T., Rudolf, G., Oberbracht, C., & Pauli-Magnus, C. (2003). Progressive changes in patients’ lives after psychotherapy: Which treatment effects support them? Psychotherapy Research, 13, 43–58. Henry, H. M., Stiles, W. B., & Biran, M. W. (2005). Loss and mourning in immigration: Using the assimilation model to assess continuing bonds with native culture. Counselling Psychology Quarterly, 18, 109–119. Honos-Webb, L., Stiles, W. B., & Greenberg, L. S. (2003). A method of rating assimilation in psychotherapy based on markers of change. Journal of Counseling Psychology, 50, 189–198. Honos-Webb, L., Stiles, W. B., Greenberg, L. S., & Goldman, R. (1998). Assimilation analysis of processexperiential psychotherapy: A comparison of two cases. Psychotherapy Research, 8, 264–286. Honos-Webb, L., Surko, M., Stiles, W. B., & Greenberg, L. S. (1999). Assimilation of voices in psychotherapy: The case of Jan. Journal of Counseling Psychology, 46, 448–460. Humphreys, C. L., Rubin, J. S., Knudson, R. M., & Stiles. W. B. (2005). The assimilation of anger in a case of dissociative identity disorder. Counselling Psychology Quarterly, 18, 121–132. Knobloch, L. M., Endres, L. M., Stiles, W. B., & Silberschatz, G. (2001). Convergence and divergence of themes in successful psychotherapy: An assimilation analysis. Psychotherapy, 38, 31–39. Lather, P. (1986). Research as praxis. Harvard Educational Review, 56, 257–277. Laitila, A., & Aaltonen, J. (1998). Application of the assimilation model in the context of family therapy: A case study. Contemporary Family Therapy, 20, 277–290. Leiman, M., & Stiles, W. B. (2001). Dialogical sequence analysis and the zone of proximal development as conceptual enhancements to the assimilation model: The case of Jan revisited. Psychotherapy Research, 11, 311–330. Osatuke, K. Glick, M. J. Stiles, W. B., Greenberg, L. S., Shapiro, D. A., & Barkham, M. (2005). Temporal patterns of improvement in client-centred therapy and cognitive-behaviour therapy. Counselling Psychology Quarterly, 18, 95–108.
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