Therapist activities preceding therapy setbacks in a poor-outcome case

Progress in psychotherapy is typically irregular, as advances alternate with setbacks. This study investigated the therapist’s activities prior to two main types of setbacks, one involving the client following therapist proposals and one involving the client failing to follow from therapist proposals, in the case of a poor-outcome client treated with a linguistically-oriented kind of cognitive therapy. Setbacks were defined as decreases of at least one level on an index of therapeutic progress, the 8-level Assimilation of Problematic Experiences Scale (APES), in adjacent client passages. Therapist activities were coded in 361 setback episodes that each included a client pre-setback passage, a therapist passage, and a client setback passage; both client passages had been previously rated on the APES. The main categories of therapist activities showed distinctive patterns in relation to the two main types of setbacks, the therapeutic zone of proximal development and the balance strategy. The two main patterns were described as an exploratory and a challenging configuration. These patterns of therapist activities and setbacks showed how the therapist seemed to persevere with approach-guided interventions while this poor-outcome client continued to have setbacks to low APES levels.