Linguistic Measures of the Therapeutic Process in Carl Rogers's Case of Miss Vib

In the "parallel studies" project led by Carl Rogers at the Counseling Center of the University of Chicago over 70 years ago, measures of personality organization and other clinical ratings were applied to 10 recorded and transcribed cases. This paper applied computerized measures of the referential process to the treatment by Rogers of the client known as Miss Vib. The treatment was considered successful and used by Rogers to illustrate his theory of personality, and his view of the therapeutic process. Using the DAAP system, the measures were applied to therapist and client speech at embedded levels of magnification, including measures for the treatment as a whole to be compared to other treatments in the referential process data base; measures for individual sessions to show progression across the trajectory of a treatment for comparison with the clinical ratings; and measures representing word by word variation within a session to enable close examination of the process. The initial prediction concerning the relation of the referential process measures to the clinical measures was not confirmed. Close examination of pivotal sessions provided an account of the results beyond that emphasized in the client-centered approach.

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 and validation of measures of referential activity

Early research on the referential process (RP) focused on the function of connecting words and the entities to which they refer, as a trait, a dimension on which people differed in a relatively stable manner. The first study found a correspondence between retrieval time for a small set of color names, hand movements accompanying speech, and features of language content and style, such as use of particular pronouns and direct quotes. The second study supported these results using an early version of the Referential Activity (RA) scales, as well as a task of generating labels for subtly differing stimuli where labels had not been provided. Another study provided a close examination of the relation of hand and body movements to the functions of the RP. The current forms of the RA scales, Concreteness, Specificity, Clarity, and Imagery, which serve as the basis for the computerized measures of the Symbolizing function, were developed based on those early studies. Recent research on the RP, some of which will be presented in this issue, has focused primarily on the Symbolizing function as a state rather than trait dimension, and has examined factors affecting variation in this function. The early research also serves as a basis for empirical study of the other functions of the RP. Through interactive development of measures and theory, in experimental and clinical settings, the constructs of the multiple code theory and the RP continue to be refined and redefined.

Narrativity and Referential Activity Predict Episodic Memory Strength in Autobiographical Memories

Narrativity has been proposed as an indicator of episodic memory strength when people discuss their past (Nelson and Horowitz in Discourse Processes 31:307-324, 2001. https://doi.org/10.1207/S15326950dp31-3_5 ). Referential Activity, the extent to which words convey a speaker's experience of being present in the event being described, has been independently hypothesized to indicate episodic memory strength (Maskit in J Psycholinguist Res, 2021. https://doi.org/10.1007/s10936-021-09761-8 ). These hypotheses are tested using a linguistic measure of narrativity and a computerized measure of referential activity to predict previous independent ratings of episodic memory strength that used the Levine et al. (Psychol Aging 17(4):677-689, 2002. https://doi.org/10.1037//0882-7974.17.4.677 ) measure of internal details in retold personal memories provided by Schacter (Addis et al. in Psychol Sci 19(1):33-41, 2008. https://doi.org/10.1111/j.1467-9280.2008.02043.x ). Raters scored narrativity on four brief near and far past memories elicited from 32 subjects, using Nelson's narrative temporal sequence method based on Labov's (J Narrat Life Hist 7(1-4):395-415, 1997. https://doi.org/10.1075/jnlh.7.49som ) analysis of spoken narratives of personal experience; computerized weighted scores of referential activity (WRAD) were obtained on these same 128 memories. Data analysis showed that narrative temporal sequences predict internal details and WRAD predict internal details. Adding WRAD to narrative temporal sequences improved the prediction of internal details.

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.

Concluding Notes and Future Directions

The articles in this issue include experimental research and clinical studies on the bidirectional process of connecting experience and words, which we term the Referential Process (RP). These concluding notes focus on new questions and new directions for research. Studies now under way include characterization and measurement of the Arousal function of the referential process, which involves how people talk when the connection to specific ideas is not yet fully developed, and new research on paralinguistic features of interpersonal communication. Further work in these areas will involve automatic transcription technology to incorporate pitch, rate of speech and loudness, as well as development of a Time-DAAP program to enable such assessment. Research is also needed to investigate the relationship between language and underlying physiological and neurological mechanisms. These relationships can be examined using physiological measures such as galvanic skin response (GSR) and changes in heart rate and respiration. While fMRI scans are not compatible with tasks requiring speech production, fMRI compatible tablet systems are available for writing tasks. Participants may also be scanned while reading literary passages that show differences in RP functions. A major goal of our research program is the application of RP measures in large scale treatment efficacy and effectiveness studies evaluating particular treatment forms. The computerized referential process procedures have the potential to study whole trajectories of large numbers of treatments; and also to identify important turning points within treatments and within sessions. The interpretation of these measures in the context of a systematic theory of treatment process has the value of enabling results that are not only statistically powerful but clinically significant as well. Other potential areas of study include application of the language measures in large scale studies of political, religious and literary discourse.

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.

First Validation of the Referential Process Post-Session Scale - Therapist Version (RPPS-T)

OBJECTIVE

Bucci's multiple code theory maintains that for a significant change the patient-therapist relationship should foster a referential process shaping in three alternating phases: arousal of emotion schemas, symbolizing/narrating emotional experiences, and reflecting/reorganizing the emotional meanings. Until now to monitor these phases clinicians and researchers have used several referential process computerized linguistic measures, which however need the sessions verbatim transcription. In order to have a less time-consuming method we developed and tested a therapist self-report questionnaire measuring the referential process phases.

METHOD

We asked eight psychotherapists in a first study and nine psychotherapists in a second study to complete the Referential Process Post-session Scale - Therapist version (RPPS-T) just after the end of their sessions. In a third study we transcribed 29 sessions conducted by three psychotherapists to calculate the correlations between the RPPS-T scores and the computerized linguistic measures of the referential process calculated on the session transcripts.

RESULTS

In the first study we collected 105 evaluations regarding 29 patients and an exploratory factor analysis revealed a four-factor pattern consistent with the hypothesized constructs. The analysis reduced the initial pool of 42 items to 12. In the second study 130 sessions with 25 different patients have been evaluated on the shortened version of the RPPS-T and a confirmatory factor analysis found that the four-factor model satisfactorily fitted the new data as well. In the third study we found that the factors of RPPS-T regarding the symbolizing phase correlated with the corresponding computerized linguistic measures calculated on the session transcripts.

CONCLUSIONS

The RPPS-T received a first validation as a concurrent measure of the referential process, especially for the symbolizing phase, and could be considered a useful instrument for research and supervision.

Treatment notes: objective measures of language style point to clinical insights

Application of a computerized text analysis procedure is proposed that has the potential for use by psychoanalytic and psychodynamic clinicians: the systematic examination of linguistic style as reflected by clinicians in their ongoing process and case notes, which are ubiquitous in the mental health field. The studies reported here are, as far as is known, the first attempts to study treatment notes systematically using such procedures. Linguistic measures are used to track the trajectory of the clinical process throughout the treatment in two contrasting cases, one rated successful, the other not. The computerized linguistic analysis used here focuses on two analytically relevant linguistic variables: Mean High Referential Activity (MHW), a measure of the degree to which language is connected to emotional processing, and Reflection (REF), the use of words referring to logical functions. Changes in the relative position of these measures indicate nodal points in the treatment that might be analytically or therapeutically problematic, and that might be overlooked in a solely clinical reading. The analyst's activity as reported in notes during such nodal periods is clinically examined to see how it may have affected the course of the analysis. This method has the potential for use in ongoing treatments, and may help clinicians refine their interventions.

Linguistic measures of the referential process in psychodynamic treatment: the English and Italian versions

The referential process is defined in the context of Bucci's multiple code theory as the process by which nonverbal experience is connected to language. The English computerized measures of the referential process, which have been applied in psychotherapy research, include the Weighted Referential Activity Dictionary (WRAD), and measures of Reflection, Affect and Disfluency. This paper presents the development of the Italian version of the IWRAD by modeling Italian texts scored by judges, and shows the application of the IWRAD and other Italian measures in three psychodynamic treatments evaluated for personality change using the Shedler-Westen Assessment Procedure (SWAP-200). Clinical predictions based on applications of the English measures were supported.

Objective measures of subjective experience: the use of therapist notes in process-outcome research

Computerized linguistic measures of emotional engagement, and reflective and affective language, previously applied to session transcripts, were applied to notes of 14 treatments by candidates under supervision at the New York Psychoanalytic Society and Institute, covering the five decades from the 1950s to the 1990s. The findings indicate a strong relationship between candidates' subjective experience as represented unintentionally in the linguistic style of their case notes and the effectiveness of their clinical work. The treatments were evaluated for effectiveness by experienced clinicians using the Global Assessment of Functioning (GAF) and the Psychodynamic Functioning Scales of Høglend and colleagues; a Composite Clinical Effectiveness (CCE) measure was constructed based on level and change in these measures. The Mean High Weighted Referential Activity Dictionary (MHW), a computerized measure of emotional engagement developed in the framework of Bucci's theory of multiple coding and the referential process, showed a positive correlation of .73 with CCE. The Hostility subcategory of the Negative Affect Dictionary (ANH) showed a negative correlation, -.48, with CCE. In a multiple regression analysis, these two variables accounted for over three-quarters of the variance in the CCE. Implications of the findings for process/outcome research and supervision and evaluation of trainees are discussed.

Beneath the surface of the therapeutic interaction: the psychoanalytic method in modern dress

This study represents a new generation of psychotherapy process research, using multiple perspectives on the data of the analytic situation, including impressions of the treating analyst, ratings of complete sessions by clinical judges, and objective linguistic measures. Computerized measures of language style developed in the framework of multiple code theory were applied to verbatim session recordings from a psychoanalytic case; the measures are illustrated in microanalyses of the process in two sessions. The results show agreement between the linguistic measures and clinical ratings based on a psychoanalytic perspective. The linguistic measures look beneath the surface of the therapeutic interaction by relying largely on lexical items of which clinicians are not likely to be explicitly aware, and enable a new perspective on the therapeutic discourse as seen in the graphic images of the microprocess. While the results of this study were limited to a single case, the automatized measures can be readily applied to large samples and in repeated single case designs. Two goals of process research, using measures such as those developed in this study, are discussed: to develop measures of mediating variables that can be used to identify specific treatment effects in comparative outcome studies; and, beyond this pragmatic aim, to assess development of capacities for self-exploration and self-regulation as psychoanalytic treatment goals.

Factors Affecting Change in Private Psychotherapy Patients of Senior Psychoanalysts: An Effectiveness Study

Each of 51 experienced psychiatrist/psychoanalysts was queried about the clinical characteristics of every private psychotherapy patient presently in treatment: 551 patients were included in the study; 88% of patients had an Axis I disorder, 59% had Axis I and Axis II disorders concurrently, and 11% Axis II only. Of these patients, 44% had been prescribed psychotropic medication on a daily basis for at least 2 weeks during the present treatment. Patients treated for the longest time (5 years or more) were the most seriously psychiatrically disturbed. Patients improved with psychotherapy, and the improvement was related to the duration of treatment. The combined impact of diagnosis status, treatment duration, and treatment modalities provided a consistent pattern of treatment effectiveness.

The Penn Psychoanalytic Treatment Collection: a set of complete and recorded psychoanalyses as a research resource

From a set of seventeen complete and tape-recorded psychoanalyses, a sample of findings is presented: (a) the level of agreement of two clinical judges on the psychological health of these patients is adequate for the late sessions, but not for the early sessions; (b) the amount of change during psychoanalysis appears to be similar to that in the Menninger Foundation Psychotherapy Research Project; (c) psychiatric severity measures from the early sessions can yield a significant level of prediction of the later benefits from psychoanalysis. Finally, further research uses of this collection of psychoanalyses are suggested.

Object relations and referential activity in physically abused adolescents

This study compared the object relations and language functions of 15 physically abused and 15 nonabused adolescents. The adolescents provided a 5-minute narrative about their mothers, which was scored for referential activity and object relations. As predicted, the abused adolescents tended to have lower levels of affect tone, indicating more malevolent relationship paradigms. Contrary to what was predicted, however, there were no significant differences between groups on overall measures of referential activity and object relations. Further, the abused adolescents tended to have higher levels of two elements of referential activity (concreteness, imagery), indicating increased verbal ability to express emotional experience. While predicted correlations were found between object relations and referential activity for the nonabused group, the abused group showed higher symbolizing and verbalizing capacity, associated with more malevolent representations of relationships. The findings do not support the view that physically abused adolescents experience developmental lags, instead suggesting that they organize and use emotional and symbolizing processes differently from nonabused adolescents. The implications for treatment are discussed.

Linking verbal and non-verbal representations: computer analysis of referential activity

The objective of this study was to develop a computer assisted procedure to model the Referencial Activity scales as scored by raters. Referential Activity is defined as the function of connecting non-verbal experience with language. Using a large text corpus that had been rated by experienced and reliable judges, extreme samples from both ends of the Referential Activity Scales were selected. The Characteristic Vocabularies for each of these corpora, words that were significantly more frequent in each corpus as compared to the other, were then identified. A small set of 181 frequent words was derived that accounted for half of all words in the text corpora. These words were used as dictionaries for a Computerized Referential Activity measure based on computer assisted content analysis techniques. The new measure showed a correlation with judge-scored Referential Activity of around .50 across both the development and test corpora.

Private psychotherapy patients of psychiatrist psychoanalysts

OBJECTIVE

The characteristics of private psychotherapy patients of medical psychoanalysts are described.

METHOD

A structured interview was administered to 51 medical psychoanalysts. Patients' demographic characteristics, historical features, and other clinically relevant aspects of behavior were assessed.

RESULTS

Of 575 patients, 88% had at least one axis I disorder and 46% had at least one axis I and one axis II disorder. Treatment duration varied from less than 6 months to more than 6 years. Forty-three percent of the patients were also treated with psychotropic drugs.

CONCLUSIONS

The patients in this cohort met the criteria for DSM-IV psychiatric disorders, had lifetime histories of major psychiatric disturbances, and were not the "worried well."

Discourse patterns in "good" and troubled hours: a multiple code interpretation

Multiple code theory is a theory of psychological organization, which is rooted in current research in the areas of cognitive psychology, emotion, and development; it accounts for adaptive functions as well as pathology. The theory incorporates Freud's seminal discovery of modes of thought outside the conscious, rational mode, but recognizes three rather than two forms: subsymbolic nonverbal, symbolic nonverbal, and symbolic verbal. Computer-assisted procedures assessing these three forms are applied to verbatim transcripts of a long-term, fully recorded psychoanalysis. The measures point to the patient's central themes, allow evaluation of the analyst's interventions as facilitating or impeding the patient's explorations, and facilitate more rigorous comparison of differing clinical views. The discourse pattern in an early session was found to anticipate that in the treatment as a whole; the pattern in a later session indicates how this treatment may have become disrupted. The measures point to affiliative themes in the patient material that were not emphasized by previous researchers studying this case.

Topics and signs: defensive control of emotional expression

This single-case study examined frank disclosure of important topics in a brief exploratory psychotherapy, including topics closely related to a recent, unintegrated stressor life event. Quantitative measures of emotion and control variables showed heightened levels of both emotionally and defensive control during discourse on the topic of the stressor event. In future studies, such measures of verbal and nonverbal signs of emotional expression and defensive control might be used to identify topics in an unresolved state.