Transforming Problems in Psychotherapy with Dr. William (Bill) Stiles

In this conversation, Dr. William Stiles discusses the significance of reflection in therapeutic practice and the challenges of measuring therapeutic techniques through process research. Dr. Stiles introduces the concept of responsiveness in therapy, highlighting the importance of understanding what the client needs at any given moment. He elaborates on the assimilation model, which focuses on transforming problematic experiences into resources, and the role of meaning bridges in facilitating this process. The conversation also touches on the integral role of emotion in therapy and the idea that while therapies may reduce distress, they do not necessarily lead to uniform outcomes among clients.

Special Guest: Dr. William Stiles

Additional Resources:

Stiles, W. B. (2021). Responsiveness in psychotherapy research: Problems and ways forward. In J. C. Watson & H. Wiseman (Eds), The responsive psychotherapist: Attuning to clients in the moment (pp. 15-35). Washington, DC: APA Books. https://doi.org/10.1037/0000240-002

Stiles, W. B. (2009). Logical operations in theory-building case studies. Pragmatic Case Studies in Psychotherapy, 5(3), 9-22. https://doi.org/10.14713/pcsp.v5i3.973. Available: http://jrul.libraries.rutgers.edu/index.php/pcsp/article/view/973

Stiles, W. B. (2017). Theory-building case studies. In D. Murphy (Ed.), Counselling psychology: A textbook for study and practice (pp. 439-452). Chichester, UK: Wiley.

Stiles, W. B. (2011). Coming to terms. Psychotherapy Research, 21, 367-384. https://doi.org/10.1080/10503307.2011.582186

Stiles, W. B. (1992). Describing talk: A taxonomy of verbal response modes. Newbury Park, CA: Sage.

Stiles, W. B., Shapiro, D. A., & Elliott, R. (1986). "Are all psychotherapies equivalent?" American Psychologist, 41, 165-180.

Stiles, W. B., Barkham, M., Mellor-Clark, J., & Connell, J. (2008). Effectiveness of cognitive-behavioural, person-centred, and psychodynamic therapies in UK primary care routine practice: Replication in a larger sample. Psychological Medicine, 38, 677–688. Published online 10 September 2007, https://doi.org/10.1017/S0033291707001511.

Stiles, W. B. (1987). "I have to talk to somebody." A fever model of disclosure. In V. J. Derlega & J. H. Berg (Eds.), Self-disclosure: Theory, research, and therapy (pp. 257-282). New York: Plenum Press.

Stiles, W. B., Honos-Webb, L., & Surko, M. (1998). Responsiveness in psychotherapy. Clinical Psychology: Science and Practice, 5, 439-458.

Stiles, W. B., (in preparation). How talking helps: The assimilation model.

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Chapters

• 0:00 Introduction and Welcome
• 1:51 How Dr. Stiles Got Into Psychotherapy Research
• 5:50 The Power of Reflection
• 10:10 Challenges in Process-Outcome Research
• 16:30 Defining Therapeutic Responsiveness
• 22:00 The Dodo Verdict: Do All Therapies Work Equally?
• 30:45 The Assimilation Model of Problematic Experiences
• 37:00 Turning Problems into Resources
• 45:30 Practical Applications of Assimilation Theory

Transcript

0:00

[Music] Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to episode number 36 of Psychotherapy and Applied Psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and hopefully to have some fun along the way. If you find our show helpful or interesting, it'd be much appreciated if you could share it with someone you know who might enjoy it too. It's a great way to spread the word and keep the conversation going. Today I can be more excited to welcome on the world's authorities on the process of psychotherapy. My guest is a professor emeritus from the Department of Psychology at Miami University. He's also a past president of the American Psychological Association and past president of the Society for Psychotherapy Research. He's received many prestigious awards, but a couple of these are a Distinguished Career Award from the Society for Psychotherapy Research and a Distinguished Psychologist Award for contributions to Psychology and Psychotherapy from APA's Division 29. He's also Fellow of the Association of Psychological Science and Fellow of the American Psychological Association, and he's also been noted as one of the 50 highest impact authors in Psychology. In the show description, I have links to several resources about the various topics that we discussed. In part one of our conversation, we discussed several aspects of psychotherapy process, including how therapists can be responsive to their clients, the common mechanisms of change across therapeutic approaches, the assimilation model of clients' problematic experiences, transforming problems into resources and much more. This episode starts with my guest responding to my question about how he got into doing psychotherapy research in the first place. So without further ado, it's my very special pleasure to welcome Dr. Bill Stiles. It was a supervisor in graduate school, fell by the name of Jerry Goodman, who was, you know, he was kind of a mentor to several people, I think, who influenced people like ArtBuy. like Art Bohart and Robert Elliott. We were all sort of at UCLA, in the same period, more or less, over a period of a dozen years there. He was, I think a gentleman's student, he came out of the Rogers shop in the 1960s or so, and was a client-centered therapist. And he, so I had him as a supervisor, he wasn't actually an official mentor, but in the end, he had a huge influence, which was, and he had developed this list of response modes, which I later elaborated, and we can talk about it, but the thing that it was kind of like, it seemed, as I've written, it seemed to carve nature at the joints, and the response modes were things like reflection, interpretation, disclosure, there was a kind of a directive category that he called "advisements," stuff like that. And what, and when you did these in therapy, it made a huge difference, and it was like a way of, it sliced things in a useful way. I mean, there's just technique categories. Remember I was a beginning graduate, or early graduate student anyway, not quite beginning. And the thing I think that impressed me most was the power of reflection, which you'd expect being a Rogerian shop, where he was, that just, the power that just repeating back with somebody said accurately opened up. It just, you know, it's just like all of a sudden, you just say back what they said to you, and all of a sudden it just like, things opened up. They had more to say, and it got deeper and deeper, and the more you could just kind of keep doing reflections forever, and things got more and more and bigger, and that just impressed the hell out of me. And so I, and actually was not doing that kind of research then, and didn't for some years, but a few years later I had a, you know, I had a job, and I was looking around for a research program, and this jumped out. And so, so that I, I and some good graduate students worked on this, and developed a more kind of theoretically elaborate system of response modes, it got some, with that, and tried to, trying to, I mean, I thought was, okay, we'll just do this, and we'll show that, we'll show this power of reflections, we'll divide up things into what the, all these techniques, the techniques, the therapist uses, and show that reflections are the things that really make a huge difference. Well, it didn't work, but, but it was, but it sort of got me into, into, into parsing language like that, which has been a big deal for me all along, and that's kind of where it started. So we, you know, so we spent, I spent years parsing language, not just in therapy and all kinds of, of, of, of stuff, so anyway, so that's, that's the origin story. That it was, it was, it was, it was Jerry's reflections that got me started. When you say it didn't work, could you, could you elaborate a little bit on that? Yeah, I thought, I thought, well, all you have to do is, if, if reflections are them, are the secret, the secret active, if ingredient, all you have to do is, is compare, you know, see who does more reflections than others, and the ones who get more reflections will do better than the ones who did. Well, it didn't work, and we, and we tried it, and it was not just me, everybody at that time was trying this, this kind of thing, it didn't work for anybody. And it was really puzzling because it seemed to me like, the better, the better the study, the closer to zero, the correlations, the process outcome correlations got. Between that sort of reflective sort of-- Yeah, between the, you know, the number of reflections or percentage of reflections, and outcome by whatever measure we were using then. I mean, I was not doing major clinical trials, you can't do major clinical trials with a process, thing like that, but we did it, and actually, I did, what I discovered was that, so here's this, the aggression, that there are dozens, hundreds maybe, of big data sets floating around, even back then, and you know, this was like many years ago, of people who've done psychotherapy, recorded it, done the horse race to see which therapy worked better, and generally they didn't do much better than each other either, they all worked the same. And then after they'd done that and got credit for that, they were delighted to have some process researcher come in and do process research on their data, and they'd let me use their data, and you know, they got some papers out of it, and I got to do what I was doing, so I started parasitizing, I made a career really out of parasitizing other people's data, so that for to do process research, I made friends and got to travel interesting places to boot, so that was fun. I mean, I spent, yeah.- Before we get, can you describe what process, or explain what process research is?- Oh, it's, for me, it's sort of anything that's not outcome research, it's studying what happens on a smaller level, so I mean, in this case, it was looking at verbal responses. I mean, we were, at that point, I mean, that's really classic process research, we would classify, so one of the big things I did as I went to Sheffield, parasitized their data set, and in England, David Shapiro, and later Michael Barkham, and Juliet Hardy, and some others, and we coded, we got some coders, and we coded, I figured about half a million utterances, a lot, maybe a record, and half of their data in this study that we're working on at the time, and just finished at the time. And then correlated with outcome measures, which they had at the time, which was, was the then version of the Becht Depression inventory in the symptom checklist 90 and a couple of others. And so we would see, we can see how many reflections, the therapist used, and how many, you know, what Cali did on these self-report measures, whether they improved, and the answer was, correlations were pretty close to zero. They were, you know, you could code all these things, and get mostly non-significant correlations, were at best trivial ones that didn't make any sense. So what do you conclude from that? I mean, what people were doing at the time was saying, well, we don't have it, the techniques don't make too much difference. What really matters is the relationship, which, yeah, is right. Oh, that mean, that's an interesting line of thought, because what do we mean by relationship? But if not, what people are saying to each other. But, you know, these are like the things that, they were big differences between the different kinds of therapy that were, as they were, you know, different as they were supposed to be, and they were in the directions they were supposed to be. They had a sort of psychodynamic therapy that used more reflections and interpretations, and a cognitive therapy that was using more advisements and so on. And so on. So, and the people got better, the treatments were effective. So, you know, everything was falling into place, and they were using these techniques, the way they were supposed to be doing, as according to the theories, apparently it was working. And the correlations were zip. So, do we conclude that they're useless? The reflections, using reflections as a useless thing? People were saying, that's what people were saying. Well, it's not techniques, and they would try all kinds of other measures. So, people invented a lot of systems of coding and so forth. And so, I mean, eventually, to make a long story short, and we got to the basically a response, you were asking about responsiveness.- Yeah, and that's what, so that's, it's interesting listening to you talk about the sort of this work that you did, you know, several decades ago, because as you're talking, and as you're talking about your past self, who had a hypothesis that was not supported, and you're going, and I can imagine you going, what the hell? Like, how does this not, like, I've experienced this in therapy? When I do these things, it facilitates these processes, blah blah blah, right? But it's a total dud. Why is that? And in my head, as you're talking, sort of, being your younger self, I'm thinking about, that I'm thinking about you in your present day and work that you've done and say, like, oh, this is why, like this, what, but obviously, you got there. So, I'm wondering if it would make sense. I think we're sort of naturally getting there because it does at least as far as I'm concerned, as far as I understand or would think about it, you know, answer your younger self's question or problem, is to get into responsiveness and what therapeutic responsiveness is. Yeah, sure. Well, okay, I'll give you a quick definition of responsiveness is behavior being influenced by emerging contacts. It means people are what people do, depends on what's happening in around them or in particular, what other people do. So, I'm talking to you and I respond to, you know, those things you say, I'm aware that you're not in your head and that kind of encourages me to go on. And that, you know, so it's at all sorts of levels. And I think that's just what I would say now. I mean, it took me years to get to that point. But I think now that's the problem. The problem was not that the measures were bad. The measures I think still are excellent. But we developed on to go, I'm very proud of the verbal response mode system. But it doesn't work. And the first manifestation of that, an early manifestation of that, well, an early one was the fever model, which we could, we maybe we'll get back there at some point. But the, but is the process outcome correlations. I mean, the idea, and the problem is the model is wrong. And I've said this many times, but I'll say it again now, which is that the idea is that what you're testing is whether using more of some technique is better. And when you think about it, that can't possibly be true because it's clear that it would not help. That it wouldn't be the case that the more reflections you manage to fit into a therapy hour, the better the person would get. The therapy hours would not look human. If all therapists were maximizing as many reflections as they could get it is they could squeeze in, or any other technique. The more is better thing which is being tested there is nuts. Even though, I mean, I say that having done it for years, and people, and other people doing it two for years. So, you, I mean, when you think about it, what happens is, are you doing the right thing? Are you using the responses that are appropriate for this person at this moment with this approach to therapy and so forth? So that, I mean, I still believe that if you're doing good person centered therapy, that there's a big place for reflections. And I still think they're extremely powerful. I no longer believe that it's the only way to go, but it's a way to go. And it can be very effective, but it has to be used appropriately. And it doesn't mean you have to reflect when it's appropriate and do other things when other things are appropriate and appropriate. It's a big problem. OK. So just to put a bit of a fight, make sure it's particularly clear that what was missing was, it's not that reflections in these sorts of responses, therapist responses are not helpful, or don't matter. What was sort of missing in your model was, what does the client let's need? That's perhaps not the most scientific word. But what does the client need in this moment? Because not all of the time, forever and always, are reflections the things that they need. Yeah. I mean, duh. I mean, like, I mean, I mean, now it seems so obvious. But it didn't at the time. And I don't know why. I think probably something to do with. It's sort of grinds into this-- you can measure it. You could get lots of numbers. We had enormous numbers of numbers that we ground into these statistics. And it seemed very scientific. And it was. But the statistical model was wrong. Well, and I think to be a little more generous to your younger self, that sort of reflection and those sorts of behaviors that facilitate depth-- therapist response-- they are extremely powerful. And that-- and that-- and particularly when you're doing therapy, whether it's particularly perhaps a person centered sort of approach. But regardless, you can distort all sorts of work with all sorts of cognitive distortions by using-- you know, so if I was coming from a cognitive model, using these behaviors, they are also very powerful. So it's powerful, in my opinion, trans theoretically or cross theoretically, that it is really powerful. So I totally understand. And it's so much-- I mean, also as the therapist, we're focused on us. So what I'm I doing-- so there is that part of it. And figuring out verbal response modes is you've done a lot of work on. It's obviously a challenge and very sophisticated to develop a really well thought through system and to make it so it's one can code it validally and reliably is challenging. But it's also like, oh, yeah, that makes sense. Where what the client needs in this moment-- I mean, conceptually, that's a really tough nut to crack. Well, yeah. I mean, so right, I agree. That's sort of anticipating. Yeah, but anyway, yes. I completely agree. One interesting piece that sort of fits in here, I think, was this really early study that we did with response methods. One of the things is we generalized it. So the response modes are not just for measuring therapists, their responses. The verbal response mode, you can code any verbal behavior. And we coded a whole bunch of stuff that wasn't psychotherapy. But one thing that we did learn was that we actually used to study-- these were, I believe, were teaching tapes. You know, they were like good examples of different kinds of therapy, which we had used to show that different kinds of different approaches to therapy-- therapists taking different approaches used vastly different profiles of response modes, as you would expect. But what was interesting was if you code what the clients were doing, they were all doing the same thing in terms of verbal response modes. The verbal response modes that the clients used were the same in all of these different therapies. And it's not surprising. Disclosures were the headline. And then they used a thing that we called edifications, informational objective information things as opposed to subjective stuff, which is subjective utterances about what the person's own experience we call disclosures, objective information that they knew. We called edifications. They used those and a few other things, but those were the main things. So it was simple. It was not surprising again. But when you put it in that context, to me, at least, it was like it was startling. Because here, all these things-- OK, back-- can I say one backdrop? It was a piece here that was prominent then. And it's a continuing thing, which is the Dodo verdict. It's probably all your listeners know about Dodo already. But everybody is one and almost have prizes. All the legitimate type of psychotherapy seem to work. Now, people will quibble about that. They will claim that their one does better in some specialized circumstances, maybe so. I don't know. But it's startling that, to me, that, if one of these therapies was much better than all the others, you'd think they would be better. So anyway, so that's the backdrop that everything works. More or less, you can quibble. But everything seems to work pretty well. And then here, we found, although the process was different, the therapies were really different. One of the employees people were using that saying, well, actually, even though they say they were different, they've got these different theoretical constructions. They were all actually doing the same thing when you look at them. That's not wasn't true. They actually were doing different things in terms of real-world response modes, at least. Maybe at some other level, they were doing the same thing. But the clients were doing the same thing. And so what's going on here were the clients that's the same. And that was-- that's kind of a-- it was an early study. But it's actually where I'm going, where I would-- nowadays, where I would put most of my interest, which is what's going on with the clients in psychotherapy. That's the same, all the-- so we could get to that later, maybe. Yeah, well, so when you were doing that work, where you were realizing, OK, therapists are doing different things, depending on their school or their approach. But the clients are pretty much doing the same thing, regardless. Where was that in terms of where the field was at that time, in terms of this general finding that-- what does Wampold call it? He calls the treatments. It's not that you can just do anything. He sort of says that they have to be like, what's the word he uses to say that the treatment is like a valid treatment? Oh, he bonafide, he calls. Thank you. He does bonafide. Right. Yeah, it has to be a bonafide to me. People have to be serious. I mean, you can certainly talk to people and do damage. So waterboarding is not a great psychotherapy. It will not help people very much. Rebrothing therapy, maybe not. So in time, where was it? Where was the field at that place where they were starting to realize, hey, it seems like all these bonafide treatments seemed to work about the same. Oh, yeah. Was that happening? Oh, yeah. I mean, the dodo verdict was first cited back in the 1930s. And when I came up, when I was doing this sort of work, it was 70s, mostly. And just a bit before that, Laborski had written an important paper that basically was talking about that. And we did a review paper too that are all psychotherapies equivalent. And the data were pretty much. Well, so people were interested in that. That's not quite your question. So where were they with respect to what? Well, OK, let me be more direct. So I think I guess what I'm wondering is when you saw this at all the clients were doing about the same thing, did you go, oh, that's consistent with this other-- No, I mean, I remember it because that was an early study I had trouble getting things published early on. And that was 1979. It was just a brief report made face all time who was under graduate at the time later. She became an academic herself. And I think she still practiced it. Years since I've heard from her. But we just did this tiny little project. It was a small and it was a brief report on. And I just kind of noted it. And I used it in my talks. But there's no uptake that I ever noticed. OK, well, I was just thinking. It aligns so well with-- because I think that there is this thing that is nonintuitive, which is that these specific treatments, which, as you noted, they are different. If I do some sort of a specific psychodynamic approach for somebody with a major depressive episode, versus a cognitive approach, versus a behavioral approach, versus a person-centered approach, the fact that they all show pretty much the same outcome-- like to me, even though I'm on the same page, it is not intuitive. And your explanation is like you're finding-- that's a really interesting puzzle piece-- to help people get their heads wrapped around what might be happening here. I thought so. But I don't think there was a-- I mean, I'm sure you've had the experience to-- you write all these brilliant things. And it takes years of hammering away at it before anybody takes any notice. At least that's been my experience. Maybe you get better uptake than I do. No, I've definitely written those-- there was one paper in particular. I remember what I was, I don't know, just not too far into my career. And I was like, oh, man, this is going to be great. This could be really impactful. Five years later, there's seven people that have cited it. And then you go and look at those citations. And it's just like they weren't even really getting at what-- anyway. Right. When it comes to responsiveness, how have you come to think about or conceptualize this idea of need, what the client needs in this moment, making sense of that problem, if you will? That's a good question. I'm not sure I really come to grips with that. Well, I mean, I think-- well, another way of saying it is that it's-- to me, at least, it seems hugely complicated. But we are trained and evolved to be socially sensitive creatures. And to have a-- I mean, we're trained to have an armamentarium. I've got a repertoire of things that we can deploy in these situations. And we recognize different things. And we have-- for my theories, we have an idea. So we-- all that stuff somehow comes together. And we try to do the right thing. And we're not as anywhere close to perfect. But we don't do too badly. Most of us can be reasonably socially appropriate. We've got good intentions. We're trying to help people. We have some idea of what we're working towards. Although I think that actually is a cutting-edge issue, is sort of-- is the kind of what happens-- what should be work on next? This is-- I'm thinking a simulation model stuff, which is on your list of topics that I've worked on. It's a more recent. Well, thanks. But it's a way of talking about what happens next. And so what you might expect to work on. But so it's kind of like-- where are you driving to? What's the next-- what is the next bit of the road look like? So I wonder-- maybe this would be a good entry point into the assimilation model. Because you're right. I mean, it does provide a useful framework for thinking about what does the client need in this moment. So could you give us just a 30,000-foot view of the assimilation model? I've tried to do that. I'll see if I can reproduce it. So unfortunately, I can't do it without introducing certain amount of jargon. But people have problematic experiences. And the problematic experiences sometimes, they get pushed out and they take a sort of a life of their own. And what therapy does is it builds meaning bridges to make contact and give access to people's problematic experiences so that they become-- and with smooth access, it kind of overcomes the distress that these experiences cause and terms them into resources like other experiences. OK, so I mean, there's a lot of explaining. In order to get there. So I'm wondering if we could start with helping us understand what a problematic experience is. Oh, trauma is a good or dysfunctional primary relationship. I'm talking about all the kinds of things that we teach as there are sources of psychopathology. I mean, I don't know them all. I mean, but people have a lot of quite horrible experiences and experience things as quite horribly. And the idea is that those experiences leave traces and they're still there. And when you encounter those traces, that is when the traces get reactivated and you remember those things or your face to brought face to face in some ways that that is distressing. That's a sort of a test for whether or not it was a problematic experience. Is it distressing when you come in contact with it? And that's where I think about the assimilation model. I think mostly about it. In terms of explaining psychological distress or psychological pain that people experience. Yeah. And particularly how do you-- the process of overcoming it? So what's the mechanism and what's the sequence that you go through in the process of those kinds of questions? So if I'm a client who comes in and I'm experienced some sort of substantial psychological distress, which is what brought me in, how do you think about the assimilation model in terms of working with that client and with that client's distress? Does that make sense? Yeah. I mean, the assimilation model is not a treatment model. It doesn't prescribe a particular treatment. In fact, the point of it was to try to-- like really most of the stuff I've done is to try to confront this dodoverting problem. And I'm not going to try to propose another approach to therapy. We've got a lot and good ones, I think. So it's more-- I mean, I think it's potentially-- can be used for sort of assessments, sort of like where is this problem at this point? I mean, what's the problem? Where is it? There's one of the things the assimilation model does is that we've sort of worked it up to do. In some ways, it was an early part that was the sequence, the assimilation we call it, the assimilation of problematic experiences sequence, which is talking about how a problem changes. So at the most extreme, the problem is completely worded off. So there's like repressed stuff, experiences that the person has no contact with, but are in there somehow. And then the sequence then is worded off, and then it's avoided, which means it's there. They can trigger it, but they immediately avoid it. But it's kind of an intentional avoidance, and I'm not going to talk about that. And then sort of the emergence or awareness of the problem, which is when confronting at very painful stage usually, and then sort of a problem formulation or problem statement stage, and then kind of an understanding stage where you actually insight, and then a stage of working through applying the thing, and then a sort of problem solution that is finally solving it, which was a happy stage. And then after that, we call it an integration or mastery stage. And the point is turning the problems into resources. That's the little mantra. Turning problems into resources. So it's turning problematic experiences into experiences that are just normal experiences, and we can use as resources the same as we use all the rest of our experiences. So I mean, our normal experiences are resources. That's the ideas. You learn where the coffee shop is, or you learn something to teach your students, or what have you. Then that experience is a resource. You can make use of it in daily life. But if you have a-- if you've been abused, then it's much more difficult to do that. And the question is, fully assimilating it, it's not to say you can do it. But if you can do it, then that could conceivably become a resource. So even though it's not-- doesn't become good, but it becomes at least something that you can access smoothly without distress, and make use of people make use of-- I mean, there's plenty of stories of people who've made use of their abuse experiences to help other people, or to-- and knowing how to raise or protect their own kids, or whatever. So it's turning problems into resources. That's kind of a description of what the simulation is about. Right. What I'm thinking as you're talking the whole area of post-traumatic growth to an extent. That may be an extreme example. But-- Yeah. People can do that. And that one of the things that therapy can help with. And so it's turning that experience into a resource. And it's also in going through that assimilation process that is taking something that is very psychologically painful and reducing that pain. Yeah. Coming to terms with that piece of yourself, with that part of your experience, with that part of your life, yeah, so that you can-- it's there. You can talk about it. You can use it. You don't get all upset when the topic comes up. I mean, it's not to say you like it. It's not about positive judgment. It's about being able to deal with it with equanimity. Right. And so when you were developing this, how much of cognitive dissonance theory and all that sort of stuff was influencing your thinking? Well, I knew about cognitive dissonance theory. I don't remember it being specifically that. I mean, I think-- I don't know. There's a lot of things that influence you. Well, maybe a more general question is, because this part of your work is something I've spent a lot of time reading about. I would be curious about how that-- the genesis and sort of the development of this, like how you sort of-- what your muse was for it. Well, I mean, one-- I guess there's different kinds of answers. So that-- I mean, the history was that the background was-- what I've been saying. It's just dodo verdict. And this kind of feeling that-- so the question is, what's the same? What about the process is the same? I mean, it's not the number of reflections. And what emerged was this was a process of change that could be described in some ways. The key event in kicking this off was a seminar that Robert Elliott was leading in-- in Sheffield. We were both in Sheffield on sabbatical in 1984, '85-- one time ago. And we had this seminar where a lot of us got together. And I mean, I don't know. Six or eight of us at least. David Shapiro and I think Jillian Hardee was there. Anyway, Frank Barguss and people were there. And tried to do a sort of what Robert calls a comprehensive process analysis of inside events. So the idea is you find these inside events. And look at all the precedents and antecedents, all the influences on this thing and all and the influences that the insight had. And use that as a description. There's a paper about that. We wrote a paper about that that didn't show up until much later. But for me, it seemed like what was striking to me about it was that insight is something that looks the same across a bunch of different people that-- that insight is like-- so here's a hit's like a marker. It's like there's something that's all clearly the same. And it turns out there are a bunch of things like that. Robert had actually found a bunch of them. And he could call them helpful events in therapy. And so he kind of started with that list and organized them. I mean chronologically, that was sort of thinking about beginning to think about it developmentally. I think from there-- I mean, clearly a simulation is a P. O. Jettian word that a key term for me, which actually has been a key term even long before that, was experience, which is really a kind of rogera in concept. I mean, I think about it the way Rodgers wrote about it. That's a key term. So that's not-- and the influence-- Freud is always on the influence and everybody, including me. But so there was the kind of people that are some of them that I think-- but then really what happened after that was we started doing case studies and trying to figure out what the problem was and then sort of track it across sessions. I mean, it actually wasn't quite as clear as that. It was sort of like the topics that would come up. And if you listen to a particular client and listen to a bunch of tapes, which all of us were doing, was you say, oh, here they're talking about it. And over here they're talking about it again later in some other session. And they would use the same words, even. They would refer to things using the same phrases, that sort of thing. And what you could do then is to sort of pull those things out. And line them up and kind of track how things changed across therapy, looking at those moments that were kind of similar. So that was sort of an initial strategy. And we've done a lot of case studies. And I think that the refinement of these sort of initial-- I mean, so it keeps getting refined and elaborated. And it's been mostly by sort of case studies-- I mean, theoretically guided case studies. I don't know if I have answered your question. So then this assimilation process, and you're thinking, this is sort of a trans theoretical process that's happening for clients. And this helps us also to understand what it is that why we're getting similar outcomes across approaches, because regardless clients are moving through this process, regardless of the approach that's being used. Yeah, right. I mean, people-- they get moved through it because of the thing. I can't resist. This was just an idea I had wrote a paper about it many, many years ago, like which was-- yeah, they're all the same. I mean, they all get better. But the measures of saying that they're all the same are mostly sort of distress measures. They're symptom-- we use symptom intensity inventory so that they're not hurting as much. That's what we mean by better. It doesn't mean that they're turning into identical products. That is, it doesn't mean that everybody gets-- through therapy, everybody comes out of therapy the same. If anything, just the opposite, they come out more different. And we, person-centered people, like to say, they become more like themselves. But another possibility is that different kinds of therapy turn out different kinds of people. That if you go to a cognitive therapist or you go to a person-centered therapist, you'll be a different person. I mean, either one will make you feel better. But that doesn't mean that you'll come out the same. It's a kind of a joke. But I wrote a paper about a long time ago. And I saw-- it's sort of a way of opening up the possibilities. That is, that there's not just one way. I mean, that we get trapped by the medical model. And medical, you know, if you want to say, you know, your blood pressure and your temperature and a zillion physiological measures have got standard norms. And the way you want to be is normal. You want all those physical things to be normal. But what's normal for people is not clear. People are all different personalities, the kinds of things that we psychotherapists are working whether or not all the same. And what happens in psychotherapy and people change? So just sort of riff on that. So that's a really interesting point, which is that sort of this sort of this dot overt this idea that all the therapies are equivalent. What that saying is that all therapies reduce-- Distressed. Yeah. The pain that we're measuring about the same. But that-- at least what I'm hearing you say is that that doesn't mean that there aren't other things that aren't changing differently. Yeah, exactly. Yeah. Well, and put-- and that's where-- I mean, in assimilation terms, it's where-- I mean, one way of talking about that is with meaning bridges. So the idea of a meaning bridge is that it's-- this is the verbal part of therapy, which is-- so a meaning bridge is a sign or a set of signs. OK, sign means things like words, but it can also be gestures and all sorts of things, or a system of signs, which like a narrative or an interpretation or something like that. That-- OK, a sign or a set of signs that has the same meaning to the author and the address C. That is-- so that if-- to the extent that you understand what I'm saying now, those words, my sentences, my stories, are a meaning bridge between us. So to the extent that you understand-- so it's not perfect. You don't understand me perfectly. I don't understand. Nobody understands other people perfectly. But to some extent, we do OK. We do manage to make things clear to each other. And the mediators for those things, the signs that we use, that we exchange, those are meaning bridges. The signs are the meaning-- the signs-- to the extent that we are understanding each other, they're meaning bridges. And so-- Right, so like me, me, dotting my head right now and like whatever is communicating to you that I get what you're saying. That you're-- Or at least that you're listening to it. You've at least partly got it. So yeah, no, exactly. But that's right. And the idea is that these different parts of the person, the parts that are-- so I don't really-- we didn't get that part of the meaning of the assimilation model. I mean, the assimilation model uses the metaphor of voice. The idea is that the experiences are active and agentic in people. So when you have a-- when you tell me what you had for breakfast, it's your experience of breakfast that's speaking. OK, it's just a way of thinking about this. There's a like-- it's not-- it's a contrast with the idea of a sort of a CPU or a library or something who is sort of a central-- a central, noative consciousness that goes out and gets all these different bits of information and uses. It is saying that the acts like the books were taught-- the books in the library are actually talking. That's the notion. And so if you have a traumatic experience that's worded off, then that experience has got a life of its own. And you can get to it with a flashback sometimes. If you-- if you-- if somebody's got a traumatic battle experience and you make a loud noise, all of a sudden they're back there. And it's pretty horrible. They're having-- so it's that experience that we call voices as a metaphor. It's a voice that's speaking. So the idea is it's not just a stable thing that was and is consistent. But that you're constantly making meaning of that experience. I don't know if that's the right language to use. Well, the experience-- yes, there's a trace of the experience. But then-- OK, you're right. I've maybe lost the thread here. The meaning bridge notion is, oh, what the point I was trying to get to was that meaning bridges can be interpersonal, but they can also be interpersonal. So that there are these problematic experiences that are-- that's why I needed to say they can be separate in people. Problematic experiences are-- to some degree separated from there that because encountering them is painful, that's a kind of a separation. And the idea of the meaning bridge is to make contact between the two voices, between the two experiences, to find-- I mean, you can say a form of words that pulls the things together. So like an insight will pull together and give access to the terrible childhood experiences and your usual self. And you can-- and so-- and it's mediated by an insight or by-- can be mediated by a interpretation and gradually they become-- they gain access to each other. But words can make things similar. So on a basic-- on a basic-- maybe this is-- I'll say it-- but maybe this is-- maybe this is too much of a digression. But you know, you have a word like dog. And it pulls together a whole bunch of experiences of furry things that come around and so forth. And-- or an example I sometimes use is like, we can make different things similar. Like they can say beetles paraphernalia. So there's all this-- everything that's associated with the beetle, which you would never put together in a category if it were if you didn't have this concept of beetles paraphernalia. And so I mean, that's just the magic of words is that they can make different things similar. And-- or a life story. If you can-- if you have a life story, if you have a life narrative that doesn't include, your parents' divorce or something like, I don't know, whatever was painful, then that means that there's a whole piece of your experience that you don't have access to. You can't use regularly. And the idea of a meaning bridge is that using words, you can change the story. You can make a new story. We're changed the story so that it somehow includes that. And so-- and that's what I mean by smooth access to that bit of the experience. So you can have problematic experiences that were actually-- you were not using because you couldn't think about or couldn't think about without pain. And by building a meaning bridge in therapy or anywhere, you can gain that kind of smooth access to it. So where does emotion fit into that process? Emotion theory-- emotion is what happens when two experiences come in contact with each other. So any two experiences, if they come-- but usually it's fairly neutral emotion. But if they're incompatible, then it's painful. I mean, if you have a trace of an experience that was-- some action you took that was just totally inconsistent with your principles, then thinking about it is very painful. And you have to work pretty hard to find a way to come to terms with that, come to terms, build a meaning bridge with that. OK, so did I make the point? So the-- so I guess-- yeah, I mean, that does make sense. I mean, that's sort of this idea of-- so you can use changed my language here, but that's kind of the idea of dissonance. So like, that there's this thing that happened, which is inconsistent with my perception of myself or the world or whatever. So I perceive myself as a loving father, but this morning I yelled at my son more than blah, blah, right? And so that-- and then when I'm-- so when I'm driving to work, I still feel-- I still feel bad about that. Yeah, I still feel distressed, right? And so because those things are incompatible. But in terms of then assimilating that experience of-- and sort of making sense of that, you've talked about sort of the language or words that helped to create that meaning bridge. Where-- what's the role-- or what's your thinking about the role of emotion in also in terms of making that meaning bridge? Does that make sense? Well, the process of making the meaning bridge is a process of confronting these experiences. And that's going to involve some negative emotion if it's a problematic experience. And conversely, that's what emotion is. So that's why emotion is, I think, so crucial in psychotherapy, because it's-- I mean, emotion is essentially always-- I mean, when you're sitting in a room and there aren't actually emotional things going-- new emotional events come along around you where basically the emotion is from encountering your own experiences. That's a clue that there's a problem there. You wouldn't have distress if there wasn't a problem. And so we gravitate towards it. And another side of it is that it's kind of no pain, no gain. If you don't confront those things, I mean, there's different ways to do it. You can do it gradually or suddenly. There's different-- all the different therapies have got all sorts of different ways. You can do it in the session or you can get coached to do homework so you experience it out of the session. There's all kinds of strategies for how you might encounter it. But if you don't encounter it, you're not going to be able-- that's part of building the meaning bridge is encountering and making a bridge. And so it's integral. If I'm talking about-- I mean, if that's your question, emotion is just kind of like an inevitable part of the process. And also, it's a signal. It's why-- and it can be positive. You can think about jokes and joy as being compatible things that you would expect and think if things fit, then that's happy. So not all emotion is negative. But we therapist mostly are paying attention to negative emotions. So I think that this might be a good time to touch on the fever model which you developed, which I think is all kind of related to this in terms of where psychological distress comes from and the function of psychological distress. Oh, maybe so. The fever model. That's a wrap on the first part of our conversation about the process of psychotherapy. As I noted at the top, it'd be much appreciated if you could spread the word to anyone else who you think might enjoy the show. Until next time.[MUSIC PLAYING][Music]