Putting it into Words: A Clinical and Linguistic Analysis of Trauma Narratives in Two Short-Term Exposure Therapies for Co-Morbid PTSD and SUD

Nearly half of the individuals who experience Posttraumatic Stress Disorder (PTSD) will also have a Substance Use Disorder (SUD) in their lifetimes. Prolonged Exposure Therapy (PE), considered the "gold standard" in treating PTSD, has been increasingly used and studied as an intervention for PTSD, yet little is known about the mechanisms of change in this type of treatment. In PE for PTSD, participants tell and re-tell the story of their primary trauma many times over. This re-telling is called an "Imaginal Exposure." When efficacious, this type of treatment allows for habituation, and PTSD symptom severity begins to dissipate. This paper seeks to better understand the psychological and linguistic processes that occur in such a treatment in order to contemplate for whom such a treatment might be beneficial, and why, (This article is a distillation of the doctoral dissertation by Zachary Kahn, "Words of Change: How Linguistic Shifts Over the Course of a Short-Term Exposure Therapy Represent Movement Towards Psychological Health" (2017).) by exploring the clinical and linguistic differences in the narratives of a treatment responder (decreased PTSD and SUD severity) and a treatment non-responder. A qualitative analysis of portions of the narratives (which were recorded and transcribed) demonstrated that there were clear clinical differences between the responder and non-responder. A linguistic analysis of the narratives using measures of the referential process showed that the treatment responder increasingly engaged in the referential process during exposures over the course of treatment, whereas the non-responder engaged in the referential process less frequently over the course of the treatment and less consistently throughout.

Overview of Computer Measures of the Referential Process

The Referential Process (RP) has three functions or processes, called Arousal, Symbolizing, and Reflecting/Reorganizing. Taken together, these provide a framework within which to address the question: how do people connect nonverbal experience and verbal forms. The purpose of this paper is to describe the Discourse Attributes Analysis Program (DAAP), which uses certain dictionaries or word lists to produce measures that model the referential process functions. These dictionaries are also described. The referential process may occur in any type of discourse context and the DAAP computer system may be applied to any type of verbal data. The focus in this paper is on transcripts of psychotherapy sessions. DAAP provides numeric and graphic data at several levels of discourse including word-by-word data concerning dictionary matches; average data for each turn of speech; average data for each speaker for each session; numeric data and graphic images for each session; and overall session data for each treatment. Graphic images of the ebb and flow of these computer generated functions of the referential process over the course of a therapy session are presented and interpreted. There are also discussions of new relational measures, as well as the referential process data base, which currently contains numerical data for 22 treatments, and presentations of several applications.

The Effects of Story-Telling on Emotional Experience: An Experimental Paradigm

Telling about emotionally significant events is a basic activity in human relationships and plays an integral role in the process of psychotherapy, in film and literature, and in other contexts where emotional experiences are shared using language. Bringing events and images to mind activates feelings anew; talking about them may further activate and perhaps alter the experiences as registered in the speaker's memory. We review the results of five studies where participants were asked to bring an emotionally significant event to mind and report how they felt at the time (time 1); report how they feel now in the moment of thinking about it (time 2); tell about the event, and report how they felt after telling (time 3). Overall, we see a pattern whereby participants' ratings of emotional intensity are high at time 1, lower at time 2 and high again at time 3. Most participants reported some change in the characterization of their emotions after describing the event, e.g. angry to neutral, and a smaller proportion reported more marked changes e.g. happy to sad. Language style indicating the presence of a referential process was shown to be moderately related to change in characterization of emotion in two of the three studies in which language measures were applied. In combination the studies suggest that change in emotional characterization comes about in the context of the referential process associated with an increase in reflection. Revisions of the paradigm in future research are discussed.

Locating Nodal Moments Within Psychotherapy Sessions: A Mixed-Methods Study Using a Computerized Measure and Therapist Comments

A computerized linguistic measure, the Weighted Referential Activity Dictionary (WRAD), was applied to locate nodal turns of speech in psychotherapy, defined here as significant moments of patient emotional communication that are likely to reveal important themes. Two published demonstration sessions conducted by a senior clinician, who made extensive comments on this material, were utilized to illustrate the method. The WRAD, defined in the context of referential process theory, was developed and has been validated as assessing the vividness and immediacy of language. Segments of patient speech (turns of speech) were classified based on WRAD level and sufficient length. The themes of the therapist's clinical comments concerning high WRAD segments were coded using a category system developed for this study, and were compared to themes of comments for the remaining segments. Results showed a significant difference in the therapist's comments between the two groups of segments using Fisher's exact test. In particular, the therapist's comments on the nodal turns showed more focus on the emotional effects of the patient's utterances on him, as well as identification of unexpected disclosures in these utterances. The implications and limitations of this method are discussed.

Development of WRRL: A New Computerized Measure of the Reflecting/Reorganizing Function

Reflecting/Reorganizing (R/R) is one of the three functions described by Bucci (Overview of the referential process: the operation of language within and between people, 2021a) as part of the referential process. The Weighted Referential Activity Dictionary (WRAD) was previously developed to model the Symbolizing function of the referential process. This paper presents the development of the Weighted Reflecting Reorganizing List (WRRL) as a model of the R/R function. The basic premise of this approach is that by rating segments of text rather than individual words, and using a word by word weighting procedure designed for this purpose, it is possible to identify the nature of the language style that is connected with particular degrees of involvement in the psychological process being modeled. Starting with a brief description of the R/R function, an iterative process was applied that resulted in a clear scoring manual for the R/R function. The method of developing the dictionary is described, a study providing validation for the measure is presented, and the nature of the language style used to express the R/R function is discussed. As was described for the WRAD, the language style of the WRRL was found to involve use of particular function words, applicable across a wide range of contents.

Assessing Key Linguistic Dimensions of Ruptures in the Therapeutic Alliance

Over the past two decades, therapeutic alliance research has increasingly focused on understanding the process by which the alliance is ruptured and repaired. This paper is the first to explore how alliance rupture segments from psychotherapy sessions differ from non-rupture segments on key dimensions of the referential process. A sample of 27 psychotherapy sessions were scored using a measure designed to identify rupture from non-rupture segments. These segments were then scored for key linguistic dimensions of the referential process. During ruptures patients manifested a referential process marked by a decrease in emotional engagement, an increase in a measure of distancing, and an increase in negation as compared to non-rupture segments. Therapists show similar patterns but, in addition, manifest a language pattern that suggests that during ruptures, therapists are attempting to make sense of, and self-disclose, aspects of their inner experience. Implications for research and clinical work are explored.

Referntial Activity as a Measure of Episodic Memory

A computerized measure of Referential Activity (RA), the High WRAD Proportion (HWP), which assesses the proportion of high RA language in a text, was compared to a widely used measure of episodic memory, the proportion of internal details (IP), those pertaining directly to the main event being described. Both measures, along with several additional computerized measures, were applied to narratives of past and future events, produced by two groups of speakers varying in age. The HWP and IP showed correlations with high effect sizes for all age groups and narrative time periods, providing strong validation for the RA concept and for HWP as a computerized measure of episodic memory. Differences were also found between the results for both narrative time and participant age based on the two measures. HWP scores for narratives of past experience were higher than for future narratives; these differences were supported by other computerized measures applied to the narratives. The differences were in the same direction but were not significant for IP. Older participants showed significantly lower levels of episodic memory, according to IP; the differences were in the same direction but were not significant for HWP. The implications of these results for the RA concept and for the multiple code theory of episodic memory are discussed.

Overview of the Referential Process: The Operation of Language Within and Between People

Human mentation involves multiple formats of thought, which are connected substantially but partially, and may operate within or outside of awareness. The modes of thought include symbolic processes which are discrete representations with properties of reference and generativity, and which may be images or words, and subsymbolic components which are continuous in format and based on analogic relationships. The organization of experience is based on memory schemas, including emotion schemas organized through episodes that involve related sensory and bodily experiences with particular people in particular contexts. The referential process is a set of bidirectional functions that enable connection between the subsymbolic components operating in multiple sensory channels and the discrete single channel verbal code. The process involves three major functions: Arousal, the activation of an emotion schema not yet in symbolic form; Symbolizing, describing an event in which the schema has been activated; and Reflection/Reorganizing, exploring and elaborating the emotional meaning of such an event. The concepts of the theory concern psychological aspects of thought, but are potentially mappable onto the underlying neural structure.

Linguistic features of the therapeutic alliance in the first session: a psychotherapy process study

Critical aspects of the therapeutic alliance appear to be established as early as the first session. Specifically, the affective bond between the therapeutic dyad appears to develop early in treatment and tends to remain stable over time, while agreements on goals and tasks tend to fluctuate over the course of treatment. Are there distinguishable early signs of a strong therapeutic alliance? In this study, we examined how some linguistic measures indicative of joint emotional elaboration correlated with a measure of the therapeutic alliance assessed within a single session. Initial intake sessions with 40 patients with varying diagnoses were videotaped, transcribed, and analyzed using linguistic measures of referential process and then scored with the Segmented Working Alliance Inventory-Observer form. Results showed that patients who were rated as more emotionally engaged in relating their experiences and then reflecting on them by mid-session also had higher scores in the therapeutic alliance by the final part of that same session. An implication of this study is that the interpersonal factors facilitating elaboration of inner experience, including elements of warmth, safety, and analytic trust, are related to the development of early therapeutic alliance. These findings did not appear to be dependent on the patient's psychopathology. This study is one in a growing line of research exploring how patients speak rather than just the content of what they say.