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>
