Excerpted from:
Stiles, W. B. (2002). Assimilation of problematic experiences. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 357-365). New York: Oxford University Press.
[download assimilation model reference list]
Assimilation
of Problematic Experiences
Miami
University
The
assimilation model (Stiles et al., 1990) offers an approach to
customizing the
therapeutic relationship through responsiveness (Stiles,
Honos-Webb, & Surko,
1998) to the degree of assimilation of clients' problems.
Briefly, the therapist
discerns a problem, assesses its assimilation level, and works
with the client,
using the chosen therapeutic approach, to move the problem
from one level to the
next.
Definitions
The assimilation model conceptualizes psychotherapy outcome as change in relation to particular problematic experiences--memories, wishes, feelings, attitudes, or behaviors that are threatening or painful, destructive relationships, or traumatic incidents--rather than as change in the person as a whole. It suggests that, in successful psychotherapy, clients follow a regular developmental sequence of recognizing, reformulating, understanding, and eventually resolving the problematic experiences that brought them into treatment. The sequence is summarized in the eight stages or levels of the Assimilation of Problematic Experiences Scale (APES, Table 1), numbered 0 to 7: (0) Warded off/dissociated; (1) Unwanted thoughts/active avoidance; (2) Vague awareness/emergence; (3) Problem statement/clarification; (4) Understanding/insight; (5) Application/working through; (6) Resourcefulness/problem solution; and (7) Integration/mastery. The APES uses both cognitive and affective features to characterize each level, which represent anchor points along a continuum, rather than discrete states. Clients may enter treatment at any point along the APES continuum, and any movement along the continuum might be considered as therapeutic progress.
Table
1
Assimilation
of Problematic Experiences Scale (APES)
_______________________________________________________________________
0.
Warded off/dissociated. Client is unaware
of the problem; the
[problematic voice is silent or dissociated. Affect may be
minimal, reflecting
successful avoidance.
1.
Unwanted thoughts/active avoidance. Client
prefers not to
think about the experience. Problematic voices emerge in response
to therapist
interventions or external circumstances and are suppressed or
avoided. Affect is
intensely negative but episodic and unfocused; the connection with
the content
may be unclear.
2.
Vague awareness/emergence. Client is
aware of a problematic
experience but cannot formulate the problem clearly. Problematic
voice emerges
into sustained awareness. Affect includes acute psychological pain
or panic
associated with the problematic material.
3.
Problem statement/clarification. Content
includes a clear
statement of a problem--something that can be worked on. Opposing
voices are
differentiated and can talk about each other. Affect is negative
but manageable,
not panicky.
4.
Understanding/insight. The problematic
experience is
formulated and understood in some way. Voices reach an
understanding with each
other (a meaning bridge). Affect may be mixed, with some
unpleasant recognition
but also some pleasant surprise.
5.
Application/working through. The
understanding is used to work
on a problem. Voices work together to address problems of living.
Affective tone
is positive, optimistic.
6.
Resourcefulness/problem solution. The
formerly problematic
experience has become a resource, used for solving problems.
Voices can be used
flexibly. Affect is positive, satisfied.
7.
Integration/mastery. Client automatically
generalizes
solutions; voices are fully integrated, serving as resources in
new situations.
Affect is positive or neutral (i.e., this is no longer something
to get excited
about).
_______________________________________________________________________
Note.
Assimilation is considered as a continuum, and intermediate
levels are allowed,
for example, 2.5 represents a level of assimilation half way
between vague
awareness/emergence (2.0) and problem statement/clarification
(3.0).
In
assimilation research, we identify problematic experiences,
extract multiple
passages dealing with them from tapes or transcripts of
completed therapies, and
study how the expressions of each problem change across
sessions. We observe
that the problematic experiences change from being feared or
unwanted in early
sessions to being understood and integrated by the end of
successful treatments.
As one way to formulate this, following Piaget (1970), we can
say the
problematic experience is assimilated into a schema--a
way
of thinking and acting that is developed or modified within
the therapeutic
relationship (accommodation) in order to assimilate the
problematic experience
(Stiles et al., 1990).
The
process of assimilation can also be described using the
metaphor of voice
(Honos-Webb & Stiles, 1998; Stiles, 1997, 1999a, 1999b,
1999c). This
metaphor expresses the theoretical tenet that the traces of
past experiences are
active agents within people and are capable of communication.
The traces can act and speak. Dissociated
(unassimilated) voices tend to
be problems, whereas assimilated voices can be
resources--available to be called
upon when circumstances call for their capacities and talents.
The interlinked
traces of experiences that have been assimilated previously
can be considered as
a community of voices within the person. In
successful therapy, a problematic, unwanted voice establishes
contact with the
community, negotiates an understanding, and is assimilated
into the community.
For example, in one successful treatment (Stiles, 1999b),
Debbie's sudden,
uncontrolled angry outbursts (a problem) were gradually
assimilated and
transformed into a capacity for appropriate assertiveness (a
resource). The
process of contact between the problematic voice and the
community can be
described as building a meaning bridge. A meaning bridge is
any sign (word,
image, gesture, etc.) or system of signs that means the same
thing to both the
author and addressee of a communication (e.g., the problematic
voice and the
community). In Debbie's case, an element of the meaning bridge
was the concept
of a "rejecting" aspect of herself--a complement or shadow to
Debbie's
predominant experience of being "rejected." This concept was
introduced by the therapist as a way of naming the angry
outbursts (i.e., the
problematic voice). Debbie used the name "rejecting" for
talking about
and to this problematic aspect of herself as she assimilated
it.
Research
Review
The
assimilation model's description of change has been derived
mainly from a series
of intensive case studies, in which problematic experiences
have been tracked
across sessions in tapes or transcripts of completed
psychotherapies. The
therapies have been conducted using a variety of approaches,
including
psychodynamic, interpersonal, cognitive, process-experiential,
and
client-centered. These studies have used assimilation
analysis, a systematic,
theoretically-based, qualitative approach to case study
(Stiles & Angus,
2001; Stiles et al., 1992) illustrated briefly in the
foregoing review of the
case of John Jones. The studies have yielded a provisional
description of the
assimilation sequence, summarized in the APES (Table 1).
Interpretive
Studies
Assimilation
analyses of cases have yielded a variety of examples of
problematic experiences
that have been assimilated, to a greater or lesser degree,
following the pattern
described in the model and the APES. Each case was different
and has, in varied
proportions, drawn upon, confirmed, modified, and elaborated
aspects of the
model. There has also been much overlap, and the aggregate
offers a substantial
basis for confidence in the model. The cases (pseudonyms) and
problematic
experiences have included the following: (a) John made partial
progress in
assimilating an angry resentment of people that led to a sense
of anxiety or
panic in social situations (Stiles et al., 1991). (b) Joan
assimilated a feeling
of emptiness that seemed to stem from a deep-seated feeling of
personal
inadequacy (Stiles, et al., 1991). (c) John Jones assimilated
his homosexual
feelings by accommodating his acceptance-of-others schema to
include himself
(Stiles et al, 1992). (d) Mrs. M. assimilated a wish to
develop her own personal
space, which at times meant putting her own needs before those
of her children
(Shapiro, Barkham, Reynolds, Hardy, & Stiles, 1992). (e)
June assimilated a
sense of personal vulnerability, which was expressed in
anxiety over talking
about her feelings (Stiles, Shapiro, & Harper, 1994). (f)
Marie assimilated
a guilt-producing wish to let go of her mother (Field,
Barkham, Shapiro, &
Stiles, 1994). (g) Jane Davis assimilated the problematic
expression of risky
feelings, the avoidance of which had led to use of
third-person constructions
and other objectifying language in describing her own feelings
(Stiles, Shapiro,
Harper, & Morrison, 1995). (h) Lisa assimilated her
resentment at her
husband's gambling (Honos-Webb, Stiles, Greenberg, &
Goldman, 1998) and a
sense of personal responsibility for other's hurtful behaviors
(Honos-Webb,
Stiles, Greenberg, & Goldman, in press). (i) George made
steps toward
assimilating an urge to avoid his wife and run away, though
progress stalled,
and assimilation was not far advanced by the time treatment
ended ( Honos-Webb
et al., 1998). (j) Jan assimilated problematic voices of
neediness and weakness
and of rebellion (Honos-Webb, Surko, Stiles, & Greenberg,
1999). (k) Fatima
made progress in assimilating the trauma of her infant
daughter's death (Varvin
& Stiles, 1999). (l) Debbie assimilated her verbal
outbursts, which became a
resource of appropriate assertiveness (Stiles, 1999b). (m)
Vicky assimilated
expressions of her sexuality in ways that were related to but
somewhat augmented
problems in her relationship with her mother (Knobloch,
Endres, Stiles, &
Silberschatz, 2001). The cited studies include examples of
dialogue illustrating
each of the APES levels.
Hypothesis-Testing
Studies
There
have also been a few hypothesis-testing studies bearing on the
assimilation
model. Two of these have been based on the consideration that
clients' aptitude
for responding to one treatment or another may depend on the
APES level of their
presenting problems more than their diagnosis or stable
aspects of their
personality. Theoretically, problems at low APES levels are
poorly formulated or
dissociated, so that psychodynamic, experiential, or
interpersonal approaches,
which emphasize exploration, might be most appropriate. On the
other hand,
problems at intermediate APES levels are relatively
well-formulated and might be
more efficiently addressed by cognitive or behavioral
approaches, which
emphasize more prescriptive techniques. The studies supported
this suggestion
(Stiles, Barkham, Shapiro, & Firth-Cozens, 1992;
Stiles, Shankland,
Wright, & Field, 1997).
Therapeutic
Practices
The
assimilation model suggests not only a generic treatment
goal--to facilitate the
client's progress along the assimilation continuum--but also a
series of
specific subgoals, corresponding to the APES levels (Table 1).
This guidance is
not a mechanical prescription, however, but involves
appropriate responsiveness
to client requirements as they emerge during treatment. As the
client changes,
the therapeutic relationship changes (or should change)
responsively, reflecting
the evolving goals, feelings, and behaviors that represent
therapeutic progress.
Markers
of assimilation levels are recognizable types of events in
psychotherapy
discourse that are empirically and theoretically linked to those
levels.
Research on finding and describing reliably-recognizable markers
has yielded
over two dozen candidates (Honos-Webb, Lani, & Stiles, 1999;
Honos-Webb,
Surko, et al., 1999). Markers of a problem's current level
of
assimilation, expressed in terms of the APES (Table 1), could
guide therapists
in facilitating the problem's movement to the next level (Stiles
et al., 1995).
When an interacting client and therapist are considered
jointly, they may
reach higher levels on the APES than when the client is
considered alone (Leiman
& Stiles, 2001). For example, the dyad jointly may be able
to formulate a
problem (APES level 3) while the client alone would be avoiding
the topic (APES
level 1). This difference may be understood using a concept
drawn from
developmental psychology, the zone of proximal development (ZPD;
Stetsenko,
1999), defined as "the distance between the actual developmental
level as
determined by independent problem solving and the level of
potential development
as determined through problem solving under adult guidance or in
collaboration
with more capable peers" (Vygotsky, 1978, p. 86). Applied to the
psychotherapeutic relationship, the ZPD can be understood as the
segment of the
APES continuum (Table 1) within which a problematic voice can
proceed from one
level to the next
with the therapist's assistance. Therapists using
different
theoretical approaches appear to use the ZPD differently to
facilitate movement
through the APES levels. In one pair of assimilation analyses, a
client-centered
therapist's interventions followed the APES level of client's
own descriptions,
while the client took the initiative to advance to higher levels
(Glick et al.,
2000). In contrast, a cognitive-behavioral therapist tended to
lead the client
in APES terms, in effect challenging her and pulling her along
(Osatuke et al.,
2000). Graphically, the client-centered case made smooth but
gradual progress
along the APES continuum, whereas the cognitive-behavioral case
followed a
saw-tooth pattern--movement
towards
greater assimilation through repeated sequences of a rapid
advance
followed by a falling back to an earlier level. Each "tooth"
seemed to
represent a different narrow topic or domain, reflecting the
therapist’s
strategy of focusing on issues one by one, actively leading
the client to the
cutting edge of each issue.
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Acknowledgments
I
thank Meredith J. Glick, Michael Gray, Carol L. Humphreys,
James A. Lani,
Katerine Osatuke, and D'Arcy Reynolds for helpful comments on
drafts of this
chapter.
Download description of assimilation analysis:
Address
for correspondence:
William
B. Stiles
Department of Psychology
Miami University
Oxford, OH 45056, USA
Email <stileswb@muohio.edu>
