Bar-Ilan University

Working Through Pain to Achieve Growth:

Client Transition from Dissociation to Dialectics

and from Detached Experiencing to Subjective Experiencing

Shira Minna Haber

Submitted in partial fulfillment of the requirements for the Master’s Degree

in the Department of Psychology, Bar-Ilan University

Ramat-Gan, Israel 2016

 Bar-Ilan University

Working Through Pain to Achieve Growth:

Client Transition from Dissociation to Dialectics

and from Detached Experiencing to Subjective Experiencing

Shira Minna Haber

Submitted in partial fulfillment of the requirements for the Master’s Degree

in the Department of Psychology, Bar-Ilan University

Ramat-Gan, Israel 2016

This work was carried out under the supervision of Prof. Rivka Tuval-Mashiach

Faculty of Social Sciences, Department of Psychology, Bar-Ilan University.

 Table of Contents

Abstract…………………………………………………………………………………………...I

Theoretical Background…………………………………………………………………………1

Multiple Self-States 1

Multiple Self-States and Emotion 5

Emotional Experiencing 6

The Current Research………………………………………………………………………..….7

Research Objectives and Hypothesis 7

Method……………………………………………………………………………………….…...8

Participants and Treatments 8

Measures 9

Forming Comparison Groups 11

Session Selection 12

Procedure 12

Results………………………………………………………………………………………..….13

Preliminary Analysis 13

Main Analysis 13

Discussion…………………………………………………………………………………….....17

Summary………………………………………………………………………………………...23

References…………………………………………………………………………………….....24

Appendix……..………………………………………………………………………………….13

Hebrew Abstract……………………………………………………………………………....…‫א‬
 List of Tables

Table 1 – page 4

Two-Person APES scale (TPA) with Clinical Explication

Table 2 – page 13

Descriptive Statistics of EXP Scores and TPA Scores by Outcome Group

Table 3 – page 16

Fixed Affects Analysis – TPA Scores Predicted by EXP Scores

 Abstract

Psychotherapy research at this time, aims greatly at pinpointing the specific processes and

mechanisms which lay the base for significant and positive therapeutic change. In the same

manner, the current research objective was to examine two such change processes and their

relation to one another and to treatment outcome. One process, which is viewed as central in

psychodynamic-relational approach, is the movement of the client’s multiple self-states from

dissociation to dialectics. This process was operationalized using the Two-Person APES (TPA),

an altered and expanded version of the Assimilation of Problematic Experiences Scale (APES).

Seeing that a central understanding is that developments in one’s self-states occur through

mechanisms of emotional experiencing, the second process is the development of emotional

experiencing from detached experiencing to a subjective one. This process was operationalized

using the Experiencing Scale (EXP).

Nine good versus nine poor outcome cases of psychodynamic treatment, according to

pre-post BDI measurements, were analyzed. For each case, five sessions representing five phases

of the therapeutic process were rated by different research groups using both the TPA and EXP

scales.

Results indicated that there is no significant association between a client’s TPA score to

his or her EXP score at the session level. However, on the client level a significant association

was revealed which was moderated by treatment outcome. While in the good outcome cases a

positive correlation between a client’s TPA score to his or her EXP score was found, in the poor

outcome cases a negative correlation was found.

Findings suggest that these two psychological processes are complimentary to one

another – not necessarily required at the same time, but enable one another and enhance the

I
beneficial and healing properties of the other. Moreover, the presence and progression of only

one of these psychological processes, without the other, is a sign of poor therapeutic outcome.

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 Working Through Pain to Achieve Growth: Client Transition from Dissociation to

Dialectics and from Detached Experiencing to Subjective Experiencing

A variety of psychotherapeutic approaches offer different explanations as to the processes which

take place in psychotherapy and promote positive therapeutic change (Snyder & Ingram, 2000).

Since studies have not found differences in the effectiveness of the varying psychotherapeutic

approaches (Vandenberghe & Aquino de Sousa, 2005), researches began focusing on the

examination of the different change processes which are viewed as the basis behind treatment

improvement. For example, studies examined cognitive change in cognitive-behavioral therapy

(Tang, DeRubeis, Beberman, & Pham, 2005), insight in psychodynamic therapy (Johansson et

al., 2010) and emotional experiencing in emotionally focused therapy (Greenberg & Pascual-

Leone, 2006). The current study seeks to examine two such change processes. Both processes are

viewed as central in a variety of therapeutic approaches, psychodynamic theory in particular:

movement in self-states from dissociation to dialectics and emotional experiencing. Seeing that a

central understanding is that developments in one’s self-states occur through mechanisms of

emotional experiencing (Bromberg, 2012; Dimaggio & Stiles, 2007; Greenberg, 2002), the

current study will conduct a parallel examination throughout psychotherapy of changes in one’s

self-states from dissociation to dialectics and changes in emotional experiencing (an empirically

founded and highly acknowledged change mechanism in psychotherapy) from detached

experiencing to subjective experiencing.

Multiple Self-States

The notion that one’s identity is comprised of multiple self-states has become prevalent within

various psychological approaches (Bamberg, 2006; Dimaggio, Hermans, & Lysaker, 2010;

Gergen, 1984, 1994; Hermans & Dimaggio, 2004; Honos-Webb & Stiles, 1998). The field of

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psychotherapy has undergone a major shift over the last three decades, which psychodynamic

writers have referred to as ―the relational turn‖ (Aron & Harris, 2014; Mitchell, 1995). This shift

promotes the importance of oscillation between those multiple self-states, while striving towards

dialectics instead of integration (Bromberg, 1993). When threatening self-states are removed

from the space of identity or conflicted areas are disowned, movement becomes rigid and

defensive. This approach emphasizes the ability to acknowledge the variety of self-states, and to

bear painful conflict between them, as central to mental wellbeing (Mitchell, 1995). Thus, one of

the main goals of relational psychotherapy is to help people get to know the inner self-states that

were not previously accessible to them, so they can experience themselves and others more fully

and have a broader range of choices in their interpersonal interactions (Mitchell, 1995; Ogden,

2005).

This view of the self as multiple is also prevalent in additional approaches. The

Assimilation Model (Stiles et al., 1990), which stemmed from the Humanistic approach,

understands the self as multifaceted and as inhabited by several—sometimes contradictory—

internal voices (Honos-Webb & Stiles, 1998). In order to examine the connection between

different internal voices to each other within the person, Stiles (2002) developed the Assimilation

of Problematic Experiences Scale (APES; Stiles et al., 1991). This empirically grounded measure

enables the description of self-states as voices, thus paving the way for an examination of the

extent to which one self-state is recognized by another. The level of assimilation pertains to the

relationship between the voices, ranging along a developmental continuum from denial through

acceptance to integration (Osatuke & Stiles, 2011; see appendix 1). Numerous studies of this

model have demonstrated that growth in therapy (most frequently examined in Cognitive-

Behavioral Therapy) is associated with a progression towards higher assimilation levels, with the

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formerly dissociated voice(s) becoming increasingly integrated (for reviews see Stiles, 2002,

2011).

While the lower levels of the APES — dissociation, active avoidance, and vague

awareness — appear to commensurate with the relational approach, the higher levels –

clarification, insight, working through, problem solution, and integration – significantly diverge

from it. While the assimilation model regards integration as the prime goal, relational theory

views live conflict, dialectics, and the reciprocal creation of self-states as the goal of the

therapeutic process (Bromberg, 1993, 1996). For this purpose, a relational adaptation of the

APES was developed, entitled Two-Person APES (TPA; HaCohen, Atzil-Slonim, Tuval-

Mashiach, & Haber, manuscript in preparation), in order to facilitate identification of the

relationship between self-states in such a way as to evince their patterns of movement as the

treatment progresses.

The TPA measures the transition of one’s multiple self-states along a continuum:

dissociation (0), active avoidance (1), vague awareness (2), conflict (3), dialectic (4), and mutual

co-creation of self-states (5) (see table 1). In determining the appropriate TPA phase, three

element are taken into account: the relationship between the multiple self-states that are

observed, the affective experience of the current self-states’ interaction that is being expressed,

and the patient-therapist relationship as evidenced by the nature of the interaction between them.

Studies conducted with the TPA have yielded promising results. Results indicate that clients

experience more conflict and dialectic as treatment progresses, i.e., higher TPA levels (HaCohen,

Atzil-Slonim, Tuval-Mashiach, Bar-Kalifa, & Haber, under review), and that this pattern of

progression is associated to good outcome (HaCohen, Atzil-Slonim, Tuval-Mashiach, & Bar-

Kalifa, under review).

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 Table 1

Two-Person APES scale (TPA) with Clinical Explication

TPA Level e.g.

Dissociation:

Complete disconnect between self-states. Parts of the self must be cut Uncontrollable laughter, losing one's
off. The fear is twofold: of the content and of potential movement/ train of thought, somatization, fatigue,
creation. The experience cannot be held or contained by the individual forgetfulness.
without a flooding of unintegratible emotion and might appear as
somatization. The self is frozen and is unaware of this fact.

Active avoidance:

Dissociated self-states are approaching the self-scope but denied and Asking concrete questions in response
repressed. Anxiety appears, and force and resistance are then applied to emotional content or mechanical and
in order to ―push‖ away ―not-me‖ self-states. At this point, the mind defensive integrative descriptions.
insists on remaining frozen.

Vague awareness:

Dissociated areas approach revelation but still are unable to be S/he may not know the reason for why
conceptualized. An ability to tolerate the feeling of helplessness that is things are being said out of confusion
part and parcel of the therapeutic process. The mind begins to or free exploration. It can be followed
unfreeze: things being to "crack." by an emotional flooding.

Conflict:

The existence of the dissociated self-states can be acknowledged as
part of the tapestry of one’s self, even if these states disavowed one
another. There is a renewal of the ability to move between them and to
reflect upon them. The affect is less anxious although it may also be
more tortured. Clumsy inner movement begins to occur.
The therapist holds/represent the
patient’s self-state for him/her and the
patient interacts with this self-state via
the therapeutic dyad, thus enacting his
internal conflict. (If s/he is not in
contact with this part, s/he will return to
phase 1).

Dialectic:

The multiple self-states acknowledge the value of one another. Even if Using arguments structured as: "I know
they are hateful, there is a fundamental understanding that the bad self- for a fact that I ... But more and more I
states brings meaning to the good self-state and vice versa, and neither realize that I have other parts that are
requires idealization. Affect is one of acceptance, empathy. The mind not less meaningful. It's complicated,
move between states gracefully. but it makes me who I am."

Mutual co-creation:

A transition to multiplying selves which creates new forms within the The patterns of movement have a wide
multiplicity. The ability to develop and be born anew from the range: in parallel, counter to one
movement and from the contact of the self-states with one another, and another, or both at the same time, etc.
others. The affect is one of curiosity.

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Multiple Self-States and Emotion

The Assimilation Model that was described above, and on which the TPA is based upon, enables

the examination of the extent to which one self-state, or voice, is recognized by another (Stiles et

el., 1990). Each APES stage is associated with a characteristic range of feeling (Stiles, Osatuke,

Glick, & Mackay, 2004). A schematic plot of clients’ feelings across APES stages yields an S-

shaped ―feelings curve‖ which represents the mathematical product of valence and salience (see

appendix 2). The theoretical hypothesis is that across very early stages clients’ are emotionally

detached as they defend themselves from the threatening self-state, or voice. In later stages

clients experience negative emotional arousal as they begin to cope with what was once

dissociated – feeling worse before feeling better. Then, feelings improve steadily as the client

continues to progress in the stages and process his or her feelings. At the highest stages of the

Assimilation Model, the feeling level is assumed to return to neutral as the experiences become

integrated. This theoretical hypothesis was reinforced in a recent case-study examining the

relation of assimilation and changes in emotional valence in the treatment of depression via

cognitive-behavioral therapy (Basto, Pinheiro, Stiles, Rijo, & Salgado, 2016). Results of the case

study showed the theoretically expected relation which corresponded closely to the assimilation

model’s theoretical feelings curve, and how emotions work as markers for the client’s current

assimilation level.

In the same manner that the APES corresponds with emotion, the TPA holds close ties

with emotional processes as well. Based on the theoretical understanding that dissociation takes

place when an experience causes unintegratable affect (Bromberg, 2003), and that treatment

should therefore connect components of emotion schemas that have been dissociated (Bucci,

2002) – the theoretical hypothesis of the TPA is that affect ranges along a continuum from

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detached emotion, through painful emotional arousal, to emotional regulation. Unlike the APES

which defines its final aim as integration, a process which softens the emotional load and leads to

emotional neutrality, the TPA seeks to leave formally dissociated self-states distinct and present

while giving them new meaning and value in the client’s self-scope.

Emotional Experiencing

One such construct which follows the movement from emotional detachment, through arousal, to

processing is Emotional Experiencing. Emotional experience during psychotherapy has been

defined as the client’s ability to approach, activate, and be in contact with the experience of

emotion (Greenberg & Safran, 1984; Rachman, 1980). One of the most robust and consistent

findings in psychotherapy process research, is that emotional experiencing is positively related to

treatment outcome, across theoretical orientations and across disorders (Greenberg, 2012;

Orlinsky & Howard, 1978; Pascual-Leone, Paivio, & Harrington, 2016; Thoma & McKay, 2015;

Watson & Bedard, 2006; Whelton, 2004).

The concept of emotional experiencing is most commonly measured using the well-

established Experiencing Scale (EXP). The observer rated scale goes from a low score at level 1,

an emotionally detached account of the client’s experience from an impersonal point of view, to

level 3, in which initial emotional arousal appears and emotional involvement begins, to the high

levels of 5 through 7, where different degrees of emotional processing take place (Klein,

Mathieu-Coughlan, & Kiesler, 1986; see appendix 3).

In a study which examined both client emotional experiencing using the EXP and client

assimilation using the APES in psychodynamic-interpersonal therapy, it was showed that clients

who had higher levels of emotional experiencing also exhibited higher levels of assimilation and

better outcome (Rudkin, Llewelyn, Hardy, Stiles, & Barkham, 2007). These results solidify the

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premise of the current research to examine the relationship between client emotional

experiencing and client self-states movement from dissociation to dialectics, as is conceptualized

by the relational approach, and how these two combined relate to treatment outcome.

The Current Research

To sum, the TPA is a measurement tool able to assess self-states movement from dissociation to

dialectic using affect as one of the markers used to distinguish between the different stages.

Therefore, given the importance of emotional experiencing in psychotherapy and given the

substantial role that emotion holds in self-states processes and the TPA, the current research

seeks to examine the association between TPA levels and those of emotional experiencing.

Research Objectives and Hypothesis

The objectives of the current research are to examine:

(a) Whether there is an association between a client’s TPA score to his or her EXP score.

It is hypothesized that there is a positive association between TPA levels and EXP levels,

such that an increase in one coincides with an increase in the other.

(b) The association between a client’s TPA score and his or her EXP score when

treatment outcome is taken into account. It is hypothesized that clients who exhibit good

therapeutic outcome will display a different association between their TPA score to their

EXP score, compared to clients who exhibit poor therapeutic outcome.

7
 Method

Participants and Treatment

Patients. The participants were 18 adults recruited from an existing pool at a large

university outpatient clinic. The clients were over 18 years old (Mage= 42.66 years, SD = 13.71,

age range 25 – 70 years), and the majority were female (12 women and 6 men). Eight of them

were single or divorced and 01 were married or in a permanent relationship. Half of them had at

least a bachelor's degree and 15 clients were fully or partially employed. In addition, only three

clients had been in psychological treatment before.

Diagnoses were based on the Axis I Diagnostic and Statistical Manual of Mental

Disorders-IV (4th ed., text rev.; DSM–IV–TR; American Psychiatric Association [APA], 2000).

The clinician conducting the intake was not the same as the one who actually provided the

treatment. Ten clients were diagnosed as suffering from affective disorder and three from anxiety

disorder, as the primary diagnosis. The rest of the clients reported experiencing relationship

problems, academic/occupational stress, or other problems but did not meet the clinical criteria

for axis I diagnosis. According to pretreatment assessments, the mean Global Assessment of

Functioning score for the sample was 69.61 (SD = 11.34, range = 55-90). Patients completed the

Beck Depression Inventory-II (BDI-II) before treatment. The mean score for the sample was

25.16 (SD = 6.55) on the BDI-II. This mean score indicates moderate to mild depressive

symptoms.

Therapists. 16 therapists, 13 women and 3 men. Two therapists treated two patients each.

The patients were assigned to therapists in an ecologically valid manner based on real-world

issues such as therapist availability and caseload. The therapists were MA or doctoral student

trainees in the university's psychology department training program. Each therapist received one

8
hour of individual supervision and four hours of group supervision on a weekly basis. All

therapy sessions were audiotaped for use in supervision. Supervisors were senior clinicians in

psychodynamic psychotherapy. Individual and group supervisions focused heavily on the review

of audiotaped case material and technical interventions designed to facilitate the appropriate use

of psychodynamic psychotherapy interventions. Examination of treatment vignettes was

structured to provide specific and direct feedback to supervisees. The supervisors often invited

the trainees to explore the patient dynamics as well as their own experience and interventions. At

the time of treatment, the therapists were unfamiliar with neither the TPA nor the EXP and the

research hypotheses.

Treatment. Individual psychotherapy consisted of once or twice weekly sessions of

psychodynamic psychotherapy organized, aided, and informed (but not prescribed) by a short-

term psychodynamic psychotherapy treatment model (Blagys & Hilsenroth, 2000; Shedler,

2010). The key features of this model include (1) a focus on affect and the experience and

expression of emotions; (2) exploration of attempts to avoid distressing thoughts and feelings;

(3) identification of recurring themes and patterns; (4) emphasis on past experiences; (5) focus

on interpersonal experiences; (6) emphasis on the therapeutic relationship; and (7) exploration of

wishes, dreams or fantasies (Shedler, 2010). Treatment was open-ended in length, however given

that psychotherapy was provided by clinical trainees at a university-based outpatient community

clinic, these treatments were often limited from 9 months to 1 year. The mean treatment length

was 26.61 sessions (SD = 6.47, range = 15-43).

Measures

Beck Depression Inventory-II (BDI-II). The BDI-II is a 21-item self-report measure of

depression that asks respondents to rate the severity of their depressive symptoms during the

9
previous 2 weeks using a variable Likert scale. Individual item scores are summed to create a

total severity score with a range of 0 to 63. Total scores can be used to categorize respondents by

depressive severity using the following ranges: 0 to 13 (minimal); 14 to 19 (mild); 20 to 28

(moderate); ˃28 (severe; Beck, Steer, & Brown, 1996). Analyses has revealed high internal

consistency (α = .93) and significant (p ˂ .01) inter-correlations between the BDI-II total scale

and Behavior and Symptom Identification Scale–24’s Depression/Functioning (r = .79) and

Overall (r = .82) subscales (Subica et al., 2014).

Experiencing Scale (EXP). The EXP scale assesses client’s emotional involvement and

level of emotional processing throughout the duration of the therapeutic session by analyzing its

recording. Statements made by the client are rated by clinical judges on a 7 level scale. The

ratings are made based on awareness, reflection and internal investigation of the client's inner

experiences in order to achieve self-understanding and promote problem solving (Klein,

Mathieu, Gendlin, & Kiesler, 1969). The EXP scale moves from a low level of experiencing (i.e.,

Stage 1: ―impersonal‖), in which clients objectify their feelings, towards a higher level of

experiencing (i.e., Stage 7: ―increased awareness‖), in which feelings are readily available for

productive communication, self-understanding and action.

Inter-rater reliability is high, ranging from 0.76 to 0.93 as has been seen in more than

fifteen studies, despite the variety of treatment methods and various problems presented by

clients. Highest reliability is achieved after a training period, yet the raters’ level of expertise had

no effect on the degree of reliability. In this study an analysis method known as ―running rating‖

was used. In this method raters are asked to monitor the client's speech and when they notice a

change taking place with the EXP level, they assign a new score. At the end of the rating

process, raters create two overall scores for each segment being analyzed. The one, is the most

10
common score presented throughout the segment (Modal), and the second, is the highest score

reached during that segment (Peak).

Two-Person Apes Scale (TPA). The TPA is an observer-rated coding system which

evaluates self-states movement from dissociation to dialectic (HaCohen et al., manuscript in

preparation). Seeing that the scale stems from the relational approach which accentuates the fact

that the therapeutic relationship is a dyad in which both sets of self-states are affected, the TPA

examines both the patient and the therapist. For the purposes of the current study, the TPA

measure was used in order to evaluate solely the client. The TPA is an extension of the

Assimilation of Problematic Experiencing Sequence (APES; Osatuke & Stiles, 2011). The TPA

consists of six levels, representing six possible relationships between self-states, identified by

three elements: 1) the transition between the multiple self-states; 2) the patient-therapist

relationship; and 3) Affect. The TPA levels are: dissociation (0), active avoidance (1), vague

awareness (2), conflict (3), dialectic (4), and mutual co-creation of self-states (5) (for a detailed

description and an illustration of each level of the TPA, see table 1). Each selected session for

analysis was divided into 5 equal sections of 10 minutes each. Each section was coded via the

TPA, and then an overall mean was calculated for each session. Thus, producing a TPA score

representing the session in it’s entirely. Inter-rater reliability yielding satisfactory results of ICC:

single measures= .91 for patient TPA and .94 for therapist TPA.

Forming Comparison Groups

Once treatment was completed, specific treatments were chosen for participation in the study.

Participation requirements included an initial BDI-II score between the range of 17-40 indicating

mild to severe depression, psychodynamic treatment orientation and a minimum of 10 therapy

sessions throughout the treatment. In order to create comparison groups between good outcome

11
cases and poor outcome cases, the reliable change index (RCI) of pre–post change on the BDI-II

was computed for each eligible case, categorizing all clients into two subgroups: those who

scored above versus those who scored below the RCI cutoff of 8.46. This method has been used

in previous studies (e.g., Seggar, Lambert & Hansen, 2002) and was used in the current research

to divide the sample posteriori into two subgroups with regard to outcome: n=9 good-outcome

cases and n=9 poor-outcome cases.

Session Selection

From each therapeutic process, five sessions were chosen in even intervals. However, session 1

was excluded because it often might have had the quality of an initial interview. The final

therapy session was also excluded because the focus of this session was presumed to be the

treatment termination (Crits-Christoph, Gibbons, Temes, Elkin & Gallop, 2010).

Procedure

The study was conducted in a university-based outpatient clinic between November 2013 and

August 2015. Clients and therapists were asked to sign consent forms if they agreed to

participate in the voluntary study, and they were told that they could choose to terminate their

participation in the study at any time without jeopardizing the treatment. Clients and therapists

were also told that their anonymity would be preserved and that data from the clients would not

be transferred to the therapist.

Clients completed the BDI-II at pre- and post-treatment. For each client, five therapy

sessions were sampled, representing five phases from the therapeutic process. All sessions were

audiotaped and transcribed and then rated by separate clinical judges via the TPA and the EXP.

The raters were blind to the treatment stage and the research hypotheses.

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 Results

Preliminary Analyses

Table 2 presents the descriptive statistics, along the zero order correlations of the study's

variables. As the table shows, both the EXP and TPA levels were higher in the good-cases group

than in the poor-cases group. However, whereas the group-differences in the EXP levels reached

statistical significance (t(44)=1.85, p=.044), the group-differences in the TPA levels did not

(t(44)=1.33, p=.350). In addition, whereas the association between these variables was positive

and significant for the good-cases group, it was negative (though not significant) for the poor

cases group.

Table 2

Descriptive Statistics of EXP Scores and TPA Scores by Outcome Group

Good Cases Poor Cases

Mean(SD) R Mean(SD) R

EXP 2.70(0.96) 2.47(0.70) -.164

.507 (p<.001)
TPA 2.14(0.58) 1.82(0.67) (p=0.283)

Note. EXP = Experiencing Scale; TPA = Two-Person APES.

Main Analyses

The dataset had a hierarchical structure (sessions nested within clients); as a result, individual

observations were not independent of one another. For this reason, to test the study's hypotheses,

we used multilevel modeling (MLM; Hox, 2010). Specifically, to analyze the present data set, a

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two-level MLM was used, partitioning the total variability in TPA ratings for session s of client c

into two components: within-client variability at Level-1, and between-clients variability at

Level-2. The variability of the predictor (i.e., EXP) is also partitioned into within-client and

between-client predictors. The former tests the association at the within-client level (i.e., whether

in sessions in which EXP was higher, relative to the client's own average level, TPA was also

higher), while the latter tests the association at the between-clients level (i.e., whether clients

with higher average levels of EXP, relative to the entire sample, had also higher TPA average

levels). At level-1 the predictor was created by centering the EXP score from each session for

each client on the client's own mean (person-mean centering); At level-2 the predictor was

created by averaging the EXP scores from all sessions for each client, and then centering these

person-mean scores on the sample's mean (grand-mean centering). To test whether group

moderated the associations between EXP and TPA, we tested the interaction with Group (effect

coded; Group=0.5 for good-cases group, Group= -0.5 for poor-cases group) at both the within-

client and between-clients levels. Finally, to control for the linear effect of time, we entered Time

(centered around the 3rd session) as a covariate in the model (Curran & Bauer, 2011; Wang &

Maxwell, 2015).

Thus, the mixed multi-level equation, in which both the intercept and the level-1

predictor were considered to be random, was:

TPAtc=

(γ00 + γ01*Groupc + γ02*Avg. Expereincec + γ03*Avg. Expereincec* Groupc + u0c)

+ (γ10+γ11*Groupc+u1c)*Expereincect + (γ20+ u2c)*Timetc + etc;

Where the TPA level in time t of client c is predicted by the sample's intercept (i.e., fixed

effect; γ00), the clients' group deviation from the intercept (i.e., γ01), this client's average level of

14
EXP (i.e., γ02), the interaction between this client's group and this client's average level of EXP

(i.e., γ03), and this client's deviation from the predicted intercept by all these four fixed effects

(i.e., random effect; u0c); and by the client's EXP level in this session multiplied by the sample's

effects of within-client EXP (i.e., γ10), the clients' group deviation from this effects (i.e., γ11), and

this client's deviations from his/her group's effect (i.e., u1c); and by the time of this session

multiplied by the sample's effect of time (i.e., γ20) and this client's deviation from the sample's

effect of time (i.e., u2c); and finally, by a level-1 residual (ect), quantifying this session's deviation

from all the previous effects. This level-1 residual was allowed to differ from session to session,

and its first-order autoregressive structure was estimated.

The results of the fixed effects part of this model are presented in Table 3 (found on the

following page). As the table shows, at the within-client level, no association was found between

EXP levels and TPA levels, as well as no interaction between EXP and group. In contrast, at the

between-clients level, the analysis yielded a significant interaction between EXP and group.

Simple effects analyses indicated that whereas for clients in the good-cases group the association

between average levels of EXP and TPA was positive and significant (Estimate=0.44, SE=0.16,

p=.018), for clients in the poor-cases group this association was negative and significant

(Estimate=-0.98, SE=0.42, p=.036).

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Table 3

Fixed Affects Analysis – TPA Scores Predicted by EXP Scores

Estimate (SE) T DF P

Intercept 1.91(0.09) 20.57 14 <.001

Group -0.40(0.19) 2.14 14 .051

Avg. EXP -0.25(0.22) -1.12 14 >.250

Group * Avg. EXP 1.40(0.45) 3.12 14 .008

EXP -0.04(0.10) -0.39 69 >.250

Group * EXP 0.01(0.20) 0.04 69 >.250

Time 0.01(0.04) 0.32 69 >.250

Note. EXP = Experiencing Scale; TPA = Two-Person APES.

16
 Discussion

Psychotherapy research at this time, aims greatly at pinpointing the specific processes and

mechanisms which lay the base for significant and positive therapeutic change (Barber, 2009). In

the same manner, the current research objective was to examine two such change processes and

their relation to one another and to treatment outcome. Specifically, we conducted a parallel

examination throughout psychotherapy of changes in one’s self-states movement from

dissociation to dialectic to changes in emotional experiencing. Whilst depth of emotional

experiencing as a construct and specifically the EXP as a measurement tool, have been

rigorously studied and repeatedly correlated with psychotherapy success (e.g., Pos, Greenberg, &

Warwar, 2009; Pascual-Leone, Paivio, & Harrington, 2016), the TPA is a new research tool

which reflects the relational approach and the understanding of the self’s multiplicity.

Initially, our preliminary analysis examined the differences between the two measures in

good therapeutic outcome cases as compared to poor therapeutic outcome cases. Results revealed

that despite the fact that both emotional experiencing and self-states movement from dissociation

to dialectic were higher in the good outcome cases rather than in the poor outcome cases, the

difference between the groups reached statistical significance for only emotional experiencing.

Our finding that emotional experiencing is higher in good outcome psychotherapy versus poor

outcome psychotherapy, is in line with former research (e.g., Greenberg, 2012; Missirlian,

Toukmanian, Warwar, & Greenberg, 2005; Pos, Greenberg, & Warwar, 2009).

The lack of statistical significance for the group difference in self-states movement from

dissociation to dialectic may be explained by the sample size. It might be that these psychic

structural changes that the TPA addresses are subtle, and therefore a greater amount of

therapeutic sessions must be investigated in order for these delicate changes to get displayed

17
statistically. In addition, it’s possible that the lack of statistical significance stems from

incompatible patterns of change. It seems that change processes of multiple self-states

throughout psychotherapy are not linear, but rather curvilinear – a quadratic pattern to be exact

(HaCohen et al., under review). In the process of comparing means, differences in curvilinear

patterns may be indistinct. In contrast, emotional changes in psychotherapy tend to display a

more linear progression when examined across treatment sessions (Pascual-Leone, 2009), as was

examined in the current research. Therefore aiding to reveal group mean differences.

Our first hypothesis was that there is a positive association between self-states movement

from dissociation to dialectic to emotional experiencing, regardless of outcome. This hypothesis

was not supported in the current research, so as at the within-client level no association was

found between self-states movement and levels of emotional experiencing. This finding could

also be related to the relative small sample size and incompatible patterns of change, as

explained previously.

Our second hypothesis was that the association between a client’s self-states movement

from dissociation to dialectics to his or her emotional experiencing will differ depending on

outcome. This hypothesis was partially supported by the results of the current research. On the

session level, no association and no interaction was found amongst the research variables.

However, on the treatment level a significant interaction was revealed. Clients in the good

outcome group who on average exhibited higher levels in their self-states movement also

exhibited on average higher levels of emotional experiencing. In contrast, clients in the poor

outcome group who on average exhibited higher levels in their self-states movement, exhibited

on average lower levels of emotional experiencing, and vice versa. These findings suggest, that

18
these two psychological processes do not necessarily need to transpire within the same

therapeutic session but they both do need to take place within the course of treatment.

One way in which these findings can be understood, is that both process are beneficial

and possess potential for therapeutic healing. Therefore, the more these processes are present

during the psychotherapeutic process, the better the chance for positive outcome. An additional

way to understand the findings is that these two psychological processes are complimentary to

one another – not necessarily required at the same time, but enable one another and enhance the

beneficial and healing properties of the other. Moreover, the presence and progression of only

one of these psychological processes, without the other, is a sign of poor therapeutic outcome. It

should be noted that these two views for understanding the findings of the current research do

not exclude each other, and are both interesting inquiries in the field psychotherapeutic research

worthy of future research.

Taking these findings together, it seems that healthy and beneficiary emotional

experiencing, at least within the realm of psychotherapeutic work, requires flexibility and the

capability for psychic movement and internal shifts (Pascual-Leone, 2009). In other words, it is

important for one’s emotional experiencing to encompass a wide range of multiple self-states,

and not remain fixed upon a single one. In the same way that when increasing one’s capacity to

acknowledge and accept their multiple self-states while striving towards dialectics, there must be

an emotional component and connection as well (Bucci, 2002).

The negative correlation exhibited in the current research between self-states movement

from dissociation to dialectic and emotional experiencing within the poor outcome groups,

outlines two client profiles. The first profile corresponds with clients who tend to remain highly

emotionally involved but this emotional work and experience is lacking psychic movement

19
between multiple self-states. When a patient is in contact with limited aspects in himself, even if

within this limited experience the patient is able to conduct extensive emotional work and

insight, threating dissociated self-states remain cut off and the experience of the self becomes

reduced and limited (Bromberg, 1996). An extreme clinical example for this first profile is

Borderline Personality Disorder (BPD). Client’s suffering from BPD, are considered to possess

emotional hyper-reactivity (Sansone & Sansone, 2010). Their interactions with the world and the

others surrounding them are emotionally intense and experienced through the prism of emotion,

but they stay trapped in a narrow understanding of themselves and others – rather than lingering

with the uncomfortable reality of multiplicity. The second profile corresponds with clients who

―talk well‖, are able to speak unbearable conflict, but are not willing to suffer it. Meaning, they

conceptualize the complex inner workings of their soul nicely, but have no emotional connection

to the implications of what is being expressed. A possible clinical example for this second profile

is through the defense mechanism of intellectualization. In this case, reasoning is used to block

the confrontation with emotional stress – ―thinking is used to avoid feeling‖ (Gabbard, 2010, p.

35). These two profiles presented clarify how self-states dialectics and meaningful emotional

experiencing are psychological change processes in psychotherapy that complement one another

and are mutually required for positive outcome to occur. When combined, one can also

experience emotion in a meaningful authentic way and alongside that contain the complexity of

multiplicity and experience movement.

This understanding leads to important clinical implication. Therapists in their work

should aim to increase their clients progression in both processes presented and examined in the

current study (not necessarily simultaneously). The implications for the client can be considered

as well. It can be understood that tolerating parts of one’s inner-self that were so threatening they

20
were once guarded off for the purpose of defense, is an unpleasant process. Therefore

maintaining a detached emotional position can be understood, yet not beneficial for successful

outcome in therapy. Consequently, the mutual incorporation of both processes into

psychotherapeutic work would most likely cause some degree of mental pain – pain which

becomes necessary in the psychotherapeutic process. It would be interesting to empirically

explore the incorporation of mental pain in the correlations presented in the current research.

Several limitations of the current study should be noted. First, the therapy sessions

analyzed for the purpose of the current study, were conducted by clinical psychology graduates

students and interns. Meaning, these are clinicians with relatively limited field experience in

psychodynamic therapy and perhaps different results would have been obtained with more

experienced therapists. Additionally, adherence tests were not conducted, so that the results

cannot fully exclude alternative explanations concerning therapeutic orientation and clinical

technique. However, although this type of design is inherently limited in its internal validity, it

benefits from substantial external validity, as it more accurately reflects the reality of clinical

work with clients in public clinics (Levy & Ablon, 2009). An additional limitation concerns the

small sample size available in the current research. Future research might consider further

exploring the field of the current research with a large sample size, adequate adherence testing

and while controlling for therapists’ experience level.

In addition, seeing that the TPA is a new research measure entails its own limitations as

well. More research is needed to further investigate its validity and reliability. However, it

should be noted that the TPA development team carried-out extensive analysis and research in

order to establish the tool’s initial merits and empirical work conducted thus far (the current

research included) have set the scene for the potential of the tool. For additional information

21
regarding the development, reliability and validity of the TPA, see HaCohen et al., manuscript in

preparation.

An additional limitation concerns the use of a single measure (BDI to assess level of

depression) for the purpose of creating the two research group regarding outcome. Additional

properties could be considered for future research. For example, emotional regulation.

Difficulties in emotional regulation have been found as a common denominator among a broad

range of mental disorders (Kret & Ploeger, 2015). This finding lead researches to the claim that

emotional regulation should be implemented as an outcome measure for psychotherapy and that

treatment should aim to bring to its improvement (Berking et al., 2008). Emotional regulation

may also be more specifically connected to the two processes examined and discussed in the

current research. It can be presumed that emotional regulation abilities would assist the client in

maintaining therapeutic work by reducing the over-whelming effect of intense emotions and

increasing his or her ability to cope with them. Thus, facilitating the progression of multiple self-

states dynamics from dissociation to dialectics.

22
 Summary

Compatible to current trend in psychotherapy research of identifying the determinants of

therapeutic change, the current research conducted a parallel examination of two psychological

change processes. One process, which is viewed as central in psychodynamic-relational

approach, is the movement of multiple self-states from dissociation to dialectics. Seeing that a

central understanding is that developments in one’s self-states occur through mechanisms of

emotional experiencing (Bromberg, 2012; Dimaggio & Stiles, 2007; Greenberg, 2002), the

second process is the development of emotional experiencing – an empirically founded and

highly acknowledged change mechanism in psychotherapy. We conducted a parallel exploration

of these two processes as they occurred in 18 clients receiving psychodynamic therapy. Our

findings suggest that these two psychological processes are complimentary to one another – not

necessarily required at the same time, but enable one another and enhance the beneficial and

healing properties of the other. Moreover, the presence and progression of only one of these

psychological processes, without the other, is a sign of poor therapeutic outcome. Therefore,

therapists should aim to increase their clients’ progression in both processes, yet not necessarily

simultaneously. The mutual incorporation of both processes into psychotherapeutic work will

allow the client to transition from dissociation to dialectics as well as from detached emotional

experiencing to a subjective one, and thus achieve meaningful therapeutic change.

23
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 Appendix 1

Assimilation of Problematic Experiences Scale (APES) with clinical explication

0. Client seems unaware of the problem. The problematic voice is silent or

Warded off/ dissociated. Affect may be minimal, reflecting successful avoidance.
Dissociated Alternatively, the problem appears as somatic symptoms, acting out, or
state-switches.
1. Client prefers not to think about the experience. Problematic voices
Unwanted thoughts/ emerge in response to therapist interventions or external circumstances
active avoidance and are suppressed or actively avoided. Affect involves unfocused
negative feelings whose connection with the content may be unclear.
2. Client is aware of the problem but cannot formulate it clearly—can
Vague awareness/ express it but cannot reflect on it. Problematic voice emerges into
Emergence sustained awareness. Affect includes intense psychological pain—fear,
sadness, anger, disgust—associated with the problematic experience.
3. Content includes a clear statement of a problem—something that can be
Problem statement/ worked on. Opposing voices are differentiated and can talk about one
Clarification another. Affect is negative but manageable, not panic.
4. The problematic experience is formulated and understood in some way.
Understanding/ Voices reach an understanding with each other (a meaning bridge). Affect
Insight may be mixed, with some unpleasant recognition but also some pleasant
surprise.
5. The understanding is used to work on a problem. Voices work together to
Application/ address problems of living. Affective tone is positive and optimistic.
Working through
6. The formerly problematic experience has become a resource for solving
Resourcefulness/ problems. Voices can be used flexibly. Affect is positive and satisfied.
Problem solution
7. Client automatically generalizes solutions. Voices are fully integrated,
Integration/ serving as resources in new situations. Affect is positive or neutral (i.e.,
Mastery this is no longer something to get excited about).

31
 Appendix 2

Changes in attention (salience) and feelings (valence) associated with levels of assimilation

of problematic experiences

Assimilation levels: 0 = warded off / dissociated, 1 = unwanted thoughts / avoidance,

2 = vague awareness / emergence, 3 = problem statement / clarification, 4 = understanding /
insight, 5 = working through / application, 6 = problem solution / resourcefulness, and
7 = mastery / integration.

32
 Appendix 3

The Client Experiencing Scale

Stage Content Treatment

1 External events; refusal to participate. Impersonal, detached.

The content is not about the speaker. The speaker tells a

story, describes other people or events in which he or she is
not involved or presents a generalized or detached account
of ideas.

2 External events; behavioral or intellectual self-description. Interested, personal,

self-participation.
Either the speaker is the central character in the narrative or
his or her interest is clear. Comments and reactions serve to
get the story across but do not refer to the speaker's feelings.
3 Personal reactions to external events; limited self- Reactive, emotionally
descriptions; behavioral descriptions of feelings. involved.
The content is a narrative about the speaker in external or
behavioral terms with added comments on feelings or
private experiences. These remarks are limited to the
situations described, giving the narrative a personal touch
without describing the speaker more generally.
4 Descriptions of feelings and personal experiences. Self-descriptive;
associative.
Feelings or the experience of events, rather than the events
themselves, are the subject of the discourse. The client tries
to attend to and hold onto the direct inner reference of
experiencing and make it the basic datum of
communications.
5 Problems or propositions about feelings and personal Exploratory,
experiences. elaborative,
hypothetical.
The content is a purposeful exploration of the speaker's
feelings and experiencing. The speaker must pose or define
a problem or proposition about self explicitly in terms of
feelings. And must explore or work with the problem in a
personal way. The client now can focus on the vague,
implicitly meaningful aspects of experiencing and struggle

33
 to elaborate it.
6 Synthesis of readily accessible feelings and experiences to Feelings vividly
resolve personally significant issues. expressed, integrative,
conclusive or
The subject matter concerns the speaker's present, emergent
affirmative.
experience. A sense of active, immediate involvement in an
experientially anchored issue is conveyed with evidence of
its resolution or acceptance. The feelings themselves change
or shift.
7 Full, easy presentation of experiencing; all elements Expansive,
confidently integrated. illuminating, confident,
buoyant.
Experiencing at stage seven is expansive, unfolding. The
speaker readily uses a fresh way of knowing the self to
expand experiencing further. The experiential perspective is
now a trusted and reliable source of self-awareness and is
steadily carried forward and employed as the primary
referent for thought and action.

34
 ‫תקציר‬
‫מחקרי פסיכותרפיה בשלב זה‪ ,‬מכוונים במידה רבה לזיהוי התהליכים והמנגנוניים הספציפיים אשר עומדים‬
‫בבסיס שינוי טיפולי חיובי ומשמעותי‪ .‬בהתאמה לכך‪ ,‬מטרת המחקר הנוכחי היתה לחקור שני תהליכי שינוי‬
‫טיפוליים ואת הקשר בינם לבין עצמם ובינם ובין תוצאות טיפול‪ .‬התהליך האחד‪ ,‬אשר נתפס כמרכזי בגישה‬
‫הפסיכודינמית‪-‬התייחסותית‪ ,‬נוגע לתנועה של מצבי‪-‬העצמי המרובים של המטופל מדיסוציאציה‬
‫לדיאלקטיקה‪ .‬תהליך זה נאמד באמצעות ה‪ ,)TPA( Two-Person APES-‬מדד המהווה אדפציה והרחבה‬
‫של ה‪ .)APES( Assimilation of Problematic Experiences Scale-‬היות ותהליכי שינוי והרחבה במצבי‪-‬‬
‫העצמי מתרחשים דרך מנגנונים של חוויה רגשית‪ ,‬התהליך השני הינו ההתפתחות של החוויה הרגשית מחוויוה‬
‫מנותקת לחוויה סובייקטיבית‪ .‬תהליך זה נאמד באמצעות ה‪.)EXP( Experiencing Scale-‬‬
‫‪ 81‬טיפולים פסיכודינמיים חולקו לשתי קבוצות השוואה שוות בגודלן ביחס לתוצאות הטיפול על‪-‬‬
‫סמך מדדי דיכאון לפני ואחרי טיפול‪ .‬עבור כל טיפול‪ ,‬חמש פגישות (המייצגות חמישה שלבים שונים בתהליך‬
‫הטיפולי) קודדו על‪-‬ידי קבוצות מחקר שונות עבור הן מדד ה‪ TPA-‬והן מדד ה‪.EXP-‬‬
‫לפי תוצאות המחקר‪ ,‬לא התגלה קשר מובהק ברמת הפגישה בין רמות ה‪ TPA-‬לרמות ה‪ EXP-‬של‬
‫המטופל‪ .‬עם זאת‪ ,‬ברמת המטופל התגלה קשר מובהק בין משתני המחקר אשר מותן דרך תוצאות הטיפול‪.‬‬
‫בעוד ובקבוצת הטיפולים הטובים נמצא קשר חיובי בין רמות ה‪ TPA-‬לרמות ה‪ EXP-‬של המטופל‪ ,‬בקבוצת‬
‫הטיפולים הלא טובים נמצא קשר שלילי‪.‬‬
‫ממצאי המחקר מצביעים על כך ששני תהליכי השינוי הטיפוליים שנחקרו הינם משלימים – לא‬
‫בהכרח חייבים להתקיים יחדיו באותה פגישה‪ ,‬אך מאפשרים אחד את השני ומגבירים את המאפיינים‬
‫המיטיבים והמרפאים של השני‪ .‬מעבר לכך‪ ,‬נראה כי ההימצאות של תהליך שינוי טיפולי אחד ללא השני‬
‫מהווה אינדיקציה לטיפול לא טוב‪.‬‬

‫‏א‬
 ‫עבודה זו נעשתה בהדרכתה של פרופ' רבקה תובל‪-‬משיח‬
‫מן הפקולטה למדעי החברה‪ ,‬המחלקה לפסיכולוגיה של אוניברסיטת בר‪-‬אילן‬
 ‫אוניברסיטת בר‪-‬אילן‬

‫התמודדות עם כאב לשם השגת צמיחה‪:‬‬

‫מעבר המטופל מדיסוציאציה לדיאלקטיקה‬
‫ומחוויה מנותקת לחוויה סובייקטיבית‬

‫שירה מינה הבר‬

‫עבודה זו מוגשת כחלק מהדרישות לשם קבלת תואר מוסמך‬

‫במחלקה לפסיכולוגיה של אוניברסיטת בר‪-‬אילן‬

‫תשע"ו‬ ‫רמת גן‬

 ‫אוניברסיטת בר‪-‬אילן‬

‫התמודדות עם כאב לשם השגת צמיחה‪:‬‬

‫מעבר המטופל מדיסוציאציה לדיאלקטיקה‬
‫ומחוויה מנותקת לחוויה סובייקטיבית‬

‫שירה מינה הבר‬

‫עבודה זו מוגשת כחלק מהדרישות לשם קבלת תואר מוסמך‬

‫במחלקה לפסיכולוגיה של אוניברסיטת בר‪-‬אילן‬

‫תשע"ו‬ ‫רמת גן‬