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Therapist verbal response and pyschotherapeutic process: analysis of a psychotherapeutic process in public mental health services.

Autor/autores: Guillermo Lahera Forteza , Karmen Bozzini Andiñach, Alberto Fernández Liria
Fecha Publicación: 27/04/2010
Área temática: .
Tipo de trabajo: 

RESUMEN

El objetivo del presente trabajo es analizar la distribución de respuestas verbales del terapeuta a lo largo de la psicoterapia. Se grabó y transcribió un proceso completo de psicoterapia, y se tipificaron las intervenciones verbales según el Sistema de Categorías de Respuesta Verbal del Consejero de Hill. Se analizó estadísticamente el coeficiente de interfiabilidad entre ambos, siendo de 0,83. Se realizó un estudio de la distribución de frecuencias entre las sesiones iniciales (1 y 2), intermedias (3 y 4) y finales (5 y 6), resultando diferencias estadísticamente significativas entre el inicio y el desarrollo (p = 0,02), y entre el desarrollo y el final (p = 0,00). Así mismo, se estudió la frecuencia de las respuestas en el primer segmento de todas las sesiones, en comparación con el segundo y tercero. Se observaron diferencias estadísticamente significativas entre el primer y tercer tercio de las sesiones (p = 0,00), aunque no en las restantes comparaciones. La respuesta verbal más utilizada por el terapeuta en la psicoterapia estudiada es ?repetición con otras palabras?, seguida de ?refuerzo verbal mínimo? y ?dar información?. El instrumento utilizado permite una tipificación de la respuesta verbal de una psicoterapia integradora aplicada al ámbito público español.

Palabras clave: Procesos psicoterapéuticos; Respuestas verbales; Pssicoterapia integrativa

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Avances en Salud Mental Relacional / Advances in relational mental health
Vol. 7, núm. 2 ­ Agosto 2008
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-Line / An International On-Line Journal

THERAPIST VERBAL RESPONSE AND
PYSCHOTHERAPEUTIC PROCESS: Analysis of a
psychotherapeutic process in public mental health services.

RESPUESTA VERBAL DEL TERAPEUTA Y PROCESO
PSICOTERAPÉUTICO: análisis de un proceso
psicoterapéutico en los servicios públicos de salud mental

Alberto Fernández Liria1, Karmen Bozzini Andiñach2, Guillermo Lahera Forteza3

1

Psiquiatra. Coordinador de área 3 de Madrid. Servicio de Psiquiatría Hospital

Príncipe de Asturias, Alcalá de Henares (Madrid, España)
2

Psicóloga .

3

Psiquiatra. Servicio de Psiquiatría Hospital Príncipe de Asturias, Alcalá de

Henares (Madrid, España)

Correspondencia: Guillermo Lahera Forteza
c) Conde de Aranda, 3, 4 B 28001 MADRID
tfno: 914314256 fax: 918816264
e-mail: glahera@inicia.es

ASMR Revista Internacional On-Line ­ Dep. Leg. BI-2824-01 ­ ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2008

2

RESUMEN

El objetivo del presente trabajo es analizar la distribución de respuestas
verbales del terapeuta a lo largo de la psicoterapia. Se grabó y transcribió un
proceso completo de psicoterapia, y se tipificaron las intervenciones verbales
según el Sistema de Categorías de Respuesta Verbal del Consejero de Hill. Se
analizó estadísticamente el coeficiente de interfiabilidad entre ambos, siendo de
0,83. Se realizó un estudio de la distribución de frecuencias entre las sesiones
iniciales (1 y 2), intermedias (3 y 4) y finales (5 y 6), resultando diferencias
estadísticamente significativas entre el inicio y el desarrollo (p = 0,02), y entre
el desarrollo y el final (p = 0,00). Así mismo, se estudió la frecuencia de las
respuestas en el primer segmento de todas las sesiones, en comparación con
el segundo y tercero. Se observaron diferencias estadísticamente significativas
entre el primer y tercer tercio de las sesiones (p = 0,00), aunque no en las
restantes comparaciones. La respuesta verbal más utilizada por el terapeuta en
la psicoterapia estudiada es "repetición con otras palabras", seguida de
"refuerzo verbal mínimo" y "dar información". El instrumento utilizado permite
una tipificación de la respuesta verbal de una psicoterapia integradora aplicada
al ámbito público español.

PALABRAS CLAVE
Procesos psicoterapéuticos, respuestas verbales, psicoterapia integrativa.

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SUMMARY

1. Objective. The objective is to study the distribution of the kinds of therapist
verbal response throughout the psychotherapeutic process.
2. Methods. A psychotherapeutic process was recorded on video and
transcribed and verbal contributions were categorized using the Hill
Counselor Verbal Response Category System. We studied the reliability
among observers of the instrument used and carried out an analysis on
frequency distribution of the different categories in each of the stages and
segments being studied.
3. Results. The instrument showed a high degree of reliability among
observers (0.83). Attending on the frequency distribution among the
sessions, the results showed statistically significant differences between
initial and intermediate stages (p = 0.02), and between intermediate and
termination stages (p = 0.00). Likewise, the frequency of responses in the
initial segment of all the sessions was compared to those of the
intermediate and final segment. Statistically significant differences were
observed between the first and third segments (p = 0.00), but not
elsewhere. The verbal response most used by the therapist in the
psychotherapy under study is the "restatement," followed by "minimal

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encourager" and "information.". The instrument used allows the classifying
of the contributions of an integrative therapist who works in Spain's public
sector.

KEY WORDS
psychotherapeutic process; verbal responses; integrative psychotherapy.

INTRODUCTION
In recent years, and parallel with research aimed at showing the
effectiveness of psychotherapy with regard to different mental diseases and at
developing increasingly specific techniques for approaching these diseases,
there are an increasing number of studies aimed at demonstrating the existence
of therapeutic factors common to all forms of psychotherapy (1).
To begin with, this attempt requires the development of concepts and
terms that allow us to use the same language in referring to relevant facts and
aspects of psychotherapies carried out using different theoretical foundations.
Using a common language will put into relief both the similarities and the
differences.
The objective of the present study, carried out in the Area of Psychiatry
of the University of Alcalá's Department of Medical Specialties, is to help
develop certain concepts (psychotherapeutic process and modes of therapist
verbal response) in order to facilitate research on the psychotherapeutic

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process in Spanish. Complementary studies exist that focus on patient verbal
response.
Psychotherapy, in any of its forms, can be understood as a process that
unfolds over a series of stages which are characterized by the need to achieve
certain objectives. In order to do this, in each stage a number of tasks must be
carried out by means of activities and through the application of a group of
specific techniques. The difficulties and problems that present themselves in
each of these stages are different, as are the resources available to resolve
them. In an article that has had a significant influence on the development of
schools of psychotherapy that are trying to establish a foundation in knowledge
and the better use of factors common to the different schools of psychotherapy,
Bernard Beitman (2) proposes understanding the psychotherapeutic process as
having four stages: engagement, pattern-search, change, and termination.
Beitman characterizes each stage as consisting of a search for objectives, the
predominant use of certain techniques, the pre-eminence of a type of contents
and statements peculiar to resistance, as well as to transference and countertransference.
Following the suggestion of Fernández Liria and Rodríguez Vega (3), in
this study we distinguish three stages (to which should be added the indication
stage, which precedes the decision to initiate psychotherapy and which is not
dealt with in the present study). By initial stage we mean the part of the
psychotherapeutic process that takes place between the moment
psychotherapy is indicated and the formalization of the contract according to
which patient and therapist agree about how and on what they are going to
work during the rest of the treatment. In general, this stage lasts between three

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and six sessions. The evaluation and formulation of the case are carried out in
this stage, along with the corresponding action plan, the building of the work
alliance and the above-mentioned contract agreement. The intermediate stage
is generally the one that takes the most time and that includes the nucleus of
the process. Two simultaneous and interwoven processes are carried out in it:
the construction of problem-patterns, and change. With the development of
short forms of psychotherapy, which are the forms most frequently used in the
mental health services of the public health system, the termination stage, which
comes at the end, is the focus of special attention. In this stage, among other
objectives, an attempt is made to review the therapy that has been carried out,
as well as the patient's capacity to face goals that have yet to be achieved and
to avoid relapses or future problems.
In an effort to emphasize the importance of factors common to different
forms of psychotherapy carried out from different schools of psychotherapy (and
the differences in practice that can exist among them) some researchers, using
a common vocabulary, have tried to classify the psychotherapist's contributions
(4, 5, 6, 7, 8, 9, 10, 11). What can be expected, according to the common
factor theorists (2), would be that these contributions would be relatively similar
among experienced psychotherapists from different schools of psychotherapy
and that, for each one of them, they would be different in the different stages of
the psychotherapeutic process.
The classification of verbal response is based on the classification and
codification of the elements of verbal behavior. The categories used may be
divided into: (a) categories of content, that codify the denotative and
connotative content such as references to dreams, family, or transference; (b)

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categories of paralinguistic / non-verbal communication, with information from
non-verbal means of communication, such as laughter, gestures or
expressions; and (c) intersubjective speech acts or categories. The system
designed by Hill and O'Grady (13)--which we will study here--focussed on the
study of modes of verbal response that have to do with the grammatical
structure of the therapist's verbal response, regardless of the topic or the
content of the words used by the therapist, and therefore belongs to the third
type of category.

OBJECTIVE
Starting from the theoretical framework described above, our study had
four objectives:
1. Use an actual therapy to test a Spanish version of the instrument
designed by Hill and O'Grady (13).
2. Analyze the use of different modes of verbal response by therapist
during a single entire therapeutic process in order to characterize the
therapist's activity during the psychotherapeutic process and during
each individual session.
3. Establish the degree of reliability of two independent judges involved
in classifying therapist verbal responses using the proposed
instrument.
4. Finally, our study allows us to carry out an analysis, independent from
the influence of the variables being studied, of the most frequent
verbal responses in the psychotherapy under study.

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HYPOTHESIS
1. The instrument allows the classification of therapist contributions in
therapy conducted in public sector mental health services in Spain.
2. The classification carried out by two observers coincides.
3. The distribution of verbal response modes depends on the stage in
the psychotherapeutic process in which they occur (initial,
intermediate, or termination stage) and the point within each session
at which they take place (initial, intermediate, or final segment).

MATERIAL AND METHOD
An integrative psychotherapy conducted at the Department of Psychiatry
of the Príncipe de Asturias University Hospital in Alcalá was video-taped with
the aim of measuring the effects of the variables psychotherapy stage and
segment of the session on the distribution of the therapist's verbal responses.
The therapy was made up of 12 sessions of from 30 to 60 minutes and was
conducted by a therapist who was not involved in evaluation. The sessions
were video-taped with the consent of the patient, a 58-year old woman with
symptoms of depression following the loss of her schizophrenic son through
suicide two years prior to her seeking medical assistance. With respect to its
content, the therapy had the characteristics of a grief process from an
integrative perspective. During the taping both therapist and patient knew they
were being video-taped, although they didn't know the purpose of the taping,
namely the classifying and counting up of their contributions (the design of the
study was drawn up later). After the taping was completed full transcriptions
were made of 6 sessions, which were divided into three parts corresponding to
the initial stage (sessions 1 and 2), the intermediate stage (sessions 5 and 6),
and the termination stage (sessions 11 and 12). Afterwards the therapist's
responses were classified using the Hill Counselor Verbal Response Category
System (HCVRCS), an instrument used by Bernard Beitman in his
psychotherapy training manual (9). The 14 therapist response categories are
listed in Table 1.

TABLE 1: Frequencies of the categories of the Hill Counselor Verbal Response
Category System (Hill, 1978) in the 1099 contributions that were studied in the
entire psychotherapeutic process.

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VERBAL RESPONSE %

VERBAL

%

RESPONSE
Minimal encourager

20.31

Restatement

30.16

Silence

0.12

Reflection

3.31

Approval-reassurance 4.21

Interpretation

7.49

Information

11.40

Confrontation

2.07

Direct guidance

1.85

Nonverbal referent

0

Closed question

7.34

Self-disclosure

0.06

Open question

11.19

Other

0.19

Classification was carried out independently by two researchers in order
to calculate the degree of reliability among different observers. The evaluations
were carried out by a psychologist and a psychiatrist trained in psychotherapy
who based their evaluations on videotapes of the sessions. A statistical
analysis was done (Cohen's kappa coefficient, Pearson's chi-square test for
frequency distribution, and percentage analysis) in order to test the stated
hypotheses. The verbal response frequency distribution in the initial stage
(sessions 1 and 2, which include 502 contributions) was compared with the
distribution in the intermediate stage (sessions 5 and 6, with 258 contributions),
and in the termination stage (sessions 11 and 12, with 344 contributions).
Each session was divided into three equal segments--initial,
intermediate, and final, each segment including 362 contributions.. The initial
segments of all the sessions were grouped together for analysis as Group 1.
Similarly, intermediate segments were grouped together and analyzed as Group
2, and final segments as Group 3.

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Frequency distributions were compared using Pearson's chi-square test
to determine whether the variable segment of psychotherapy session changed
the distribution of therapist verbal response modes. In light of the results, a
descriptive analysis of the most frequent kinds of verbal responses in each
segment was then carried out.

RESULTS
A) Applicability of instrument
The instrument allowed evaluators to classify the therapist's contributions in
the sessions that were studied.
B) Reliability among observers
Cohen's kappa coefficient, which measures the instrument's degree of
reliability among observers, was 0.83; the main divergences were found in the
categories approval-reassurance, interpretation, and information.
C) Structure of contribution
C1: Response frequency in entire process
Table 1 shows the frequency of the different types of response in the
1099 contributions studied over the entire process. As can be observed,
restatement and minimal encourager are the most frequent.

C2: Differences between sessions of different stages (initial, intermediate and
termination) of the psychotherapy process
Using Pearson's chi-square test, the distribution of Group A (initial stage,
sessions 1 and 2) and the distribution of Group B (intermediate stage, sessions
5 and 6) were different (p = 0.021). The differences between Group B

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(intermediate stage, sessions 5 and 6) and Group C (termination stage,
sessions 11 and 12) were also significant (p = 0.000). On the contrary, no
significant differences were obtained between A (initial stage, sessions 1 and 2)
and C (termination stage, sessions 11 and 12) (p = 0.248). This would indicate
that there are differences between response frequencies in the initial and
intermediate stages, and between response frequencies in the intermediate and
termination stages, but not between response frequencies in the initial and
termination stages, which would be more similar in this respect.
Table 2 shows the frequencies by percentage of each type of verbal
response in each of the different stages (initial, intermediate, and termination) of
the psychotherapeutic process.
TABLE 2: DISTRIBUTION OF RESPONSES BY STAGE OF THE
PSYCHOTHERAPEUTIC PROCESS

INITIAL STAGE

INTERMEDIATE STAGE TERMINATION STAGE

Restatement (31.80 %)

Restatement (32.71 %)

Minimal encourager
(30.65 %)

Minimal encourager

Minimal encourager

Restatement (25.89 %)

(16.76%)

(13.75 %)

Open question (13.8 %)

Open question (12.64 %)

Information (11.90 %)

Information (12.26 %)

Information (10.04 %)

Interpretation (10.41%)

Closed question (9.47 %)

Interpretation (8.92 %)

Open question (7.14 %)

Approval-reassurance

Closed question (7.81%)

Closed question (4.76 %)

Reflection (5.20 %)

Approval-reassurance

(6.11%)
Interpretation (3.15 %)

(3.57 %)
Reflection (2.96 %)

Direct guidance (4.09 %)

Reflection (1.78 %)

Confrontation (2.96 %)

Approval-reassurance

Confrontation (1.78 %)

(2.97 %)

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Self-disclosure (0.19 %)

Confrontation (1.49 %)

Direct guidance (1.48 %)

Nonverbal referent (0 %)

Silence (0.37 %)

Silence (0 %)

Silence (0 %)

Nonverbal referent (0 %)

Nonverbal referent (0 %)

Direct guidance (0 %)

Self-disclosure (0 %)

Self-disclosure (0 %)

Other (0 %)

Other (0 %)

Other (0 %)

The following differences are noteworthy:
·

The most frequent response in the initial and intermediate stages is
restatement (31.9% and 32.7%, respectively). In the termination
stage it is minimal encourager (30.65%).

·

The frequency of the category open question decreases as
psychotherapy proceeds. In the initial stage it amounts to 13.8% of
contributions, in the intermediate stage 12.64%, and in the
termination stage 7.14%.

·

Likewise, the frequency of closed question decreases: 9.47% in the
initial stage, 7.81% in the intermediate stage, and 4.76% in the
termination stage.

·

Reflection is more frequent in the initial and intermediate stages
(2.96% and 5.20%) than in the termination stage (1.78%).

·

Interpretation is more frequent in the intermediate and termination
stages (8.92% and 10.41%) than in the initial stage (3.15%).

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·

Direct guidance does not occur in the initial stage (0%), but does in
the intermediate stage (4.09%) and termination stage (1.48%).

·

Approval-reassurance occurs more in the initial stage (6.11%) than
in the intermediate state (2.97%) and termination stage (3.57%).

.

C3: Differences among different segments (initial, intermediate and final) in
each session.
Using Pearson's chi-square test, we compared the verbal response
frequency distribution of Group 1 (first third of each session of the 6 sessions
studied) with that of Group 2 (second third of each session of the 6 sessions)
and with that of Group 3 (final third of each session of the 6 sessions). The
results were as follows:
·

The differences between Group 1 (first third) and Group 2 (second
third) were not significant (p = 0.628).

·

The differences between Group 2 and Group 3 were not
significant (p = 0.359).

·

The differences between Group 1 and Group 3 were significant (p
= 0.000).

Table 3 shows the distribution of therapist verbal responses in each of
the three segments of the sessions.
TABLE 3: THERAPIST VERBAL RESPONSE DISTRIBUTION IN EACH OF
THE THREE SEGMENTS OF THE SESSIONS

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INITIAL SEGMENT

INTERMEDIATE

FINAL SEGMENT

SEGMENT
Restatement (37.13 %)

Restatement (29.16 %)

Restatement (27.90 %)

Minimal encourager (23.60

Minimal encourager (24.10 Information (16.02 %)

%)

%)

Open question (14.85 %)

Information (15.00 %)

Minimal encourager
(15.16 %)

Closed question (8.48 %)

Open question (11.66 %)

Interpretation (12.15 %)

Reflection (3.97 %)

Closed question (7.22%)

Open question (7.73 %)

Information (3.71 %)

Interpretation (4.72 %)

Closed question (6.32 %)

Confrontation (3.18 %)

Approval-reassurance

Approval-reassurance

(4.16 %)

(6.62 %)

Approval-reassurance (2.38 Reflection (2.50 %)

Reflection (3.31 %)

%)
Interpretation (2.12 %)

Confrontation (0.83 %)

Confrontation (2.76 %)

Self-disclosure (0.26 %)

Silence (0.27 %)

Direct guidance (1.10 %)

Direct guidance (0.26 %)

Direct guidance (0 %)

Silence (0 %)

Nonverbal referent (0 %)

Nonverbal referent (0 %)

Nonverbal referent (0 %)

Silence (0 %)

Self-disclosure (0 %)

Self-disclosure (0 %)

Other (0 %)

Other (0 %)

Other (0.82 %)

From these data the following is of particular note:
·

The frequency of minimal encourager is greater in the first segment
(23.6%) and in the second (24.10%) than in the third (15.19%).

·

The frequency of approval-reassurance is greater in the third
segment (6.62%) than in the rest (2.38% and 4.16%).

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·

Restatement occurs more frequently in the first segment of the
session (37.13% as opposed to 29.16% and 27.90%).

·

Interpretation occurs more frequently in the third segment (12.15%
as opposed to 2.12% and 4.72%).

·

Information occurs more frequently in the second and third segment
than in the first (15% and 16.02% as opposed to 3.71%).

·

Open question occurs more in the first segment (14.85% as opposed
to 11.66% and 7.73%).

In other words, in the first segment of each session there are many
narrative-facilitating contributions, especially restatement and open
question, and in the third stage there is a greater frequency of
information, interpretation, and approval-reassurance in relative
terms, given that the most frequent contribution continues to be the
restatement.

DISCUSSION
To begin with, it should be noted that Hill's system consists of 14
mutually exclusive categories, such that each verbal response should be
classified using one single category out of the 14 options. Hill's system also is
intended to be exhaustive, so that no verbal response is left without a category.
As we shall see, as an instrument this system poses certain epistemological
problems, because it includes strictly syntactic categories (open question,
closed question...), other categories that involve semantic content
(interpretation, confrontation...), and others that even involve intentionality
(minimal encourager, for example).

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The Spanish version of this instrument, however, proved to be very
reliable among different judges (Cohen's kappa coefficient was 0.83) and the
main divergences were in categories found to be problematic by Beitman and
Yue when they used the system to train American resident physicians in
psychiatry (9).
When we applied this system to the differences between sessions
belonging to different stages of the psychotherapeutic process, we found--as we
have said--significant differences between initial and intermediate sessions, and
between intermediate and termination sessions. If we group the categories
under the headings: therapist contributions favoring patient expression (open
question, closed question, minimal encourager, restatement, reflection)
and contributions that prompt information on the part of the therapist
(information, interpretation, direct guidance, confrontation), we observe
the distribution shown in Graph 1:
GRAPH 1: FACILITATING CONTRIBUTIONS AND PROMPTING
CONTRIBUTIONS IN EACH OF THE STAGES OF THE
PSYCHOTHERAPEUTIC PROCESS

90
80
70
60
50
40
30
20
10
0

81,44

18,56

initial stage

75,46

74,43

24,54

25,57

intermediate
stage

termination
stage

facilitating
contributions
prompting
contributions

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The percentage of prompting responses (especially interpretation and direct
guidance) in the initial stage is lower and increases as psychotherapy
proceeds. The facilitating responses (restatement, reflection...) occur mainly
in the initial stage and then decrease in frequency. It is noteworthy that this
pattern is not followed in the case of the category minimal encourager, whose
frequency in the final stage increases spectacularly from 13.75% to 30.65%,
which suggests that the facilitating of patient expression by the therapist is
greater in the initial stage than in the termination stage. In the termination stage
the therapist's responses are often limited to agreeing, stimulating with brief
contributions, etc., that is, to minimal stimulation or reinforcement of patient's
narrative activity. We would say that the patient has already created a coherent
alternative narrative and that simple promptings by the therapist are sufficient to
permit its verbalization by the patient. When this narrative takes shape
(intermediate stage), minimal encourager is not sufficient, and reflection is
needed, along with restatement, reinforcing the original outline of the narrative.
When we interpreted the results among the segments of each session,
we found that verbal responses at the beginning of the session have a different
frequency distribution from the one they have at the end of the session, and this
difference is sufficiently large for it not to be attributable to chance. However,
this conclusion cannot be reached when we compare initial segments with
intermediate segments or intermediate segments with final segments. We take
this to mean that our conventional limit (exactly 33% of contributions of each
session) is, since it is arbitrary, not very significant. In establishing a limit for all
sessions, we found transition periods in which it is difficult to find significant
differences. On the other hand, we did find differences between initial

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segments and final segments, except for these transitional periods. For future
studies it would be necessary to formulate a procedure--other than one based
on number of contributions--for determining when the initial, intermediate, and
final segments may be considered to have concluded.
In spite of this limitation, our study allows us to say that the first segment
of each session includes many facilitating contributions favoring the
verbalization of the narrative, especially restatement and open question, and
that the third segment includes a relatively greater frequency of information,
interpretation, and approval-reassurance, given that the most frequent
contribution continues to be restatement (Graph 2 shows the division between
facilitating contributions and prompting contributions in each segment).
We observe that prompting contributions increase as the session
progresses (9.61%, 20.55% and 32.03%) and facilitating contributions
decrease. At the beginning of the session, independently of the stage we are
in, it is difficult to find interpretation, information or direct guidance, probably
because these contributions require a "warming up" period that only later on in
the session can have had time occur.
It is noteworthy that the phenomenon we detected in differences between
sessions, that is, that the category minimal encourager increases in frequency
in the final stage of the psychotherapy in comparison with other facilitating
contributions, but in the course of a session its frequency decreases as the
session progresses.

Limitations of this Study

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The following limitations, which prevent us from generalizing from our
results to general conclusions, must be taken into account in the present study
of the psychotherapeutic process:
·

Only one psychotherapy process was analyzed, with only one patient
and only one therapist. Besides the variables segment of session and
stage of therapy, there may be other variables that help determine the
frequency of verbal responses: therapist personality and communication
style, pathology and personality of patient--whose responses alter the
distribution of therapist responses--therapy's theoretical model, etc. This
study did not attempt to establish the effect of these other variables. This
means that the results are only applicable to the psychotherapy under
study and not to psychotherapy in general, for which studies of more
cases and more patients would be needed.

·

We did not analyze the life events that the patient may have experienced
during the psychotherapy and that may have altered his responses (i.e. if
the patient had had an accident before the seventh session, the therapist
would probably ask questions relating to it).

·

The number of variables analyzed (the 14 categories of verbal response
and the 2 variables of session segment and therapy stage) is sufficiently
large to require a larger sample if significant conclusions are desired.
For this reason, we were only able to carry out an overall frequency
distribution analysis, rather than an analysis by category (we can
conclude that the verbal responses used are different, but not that a
particular category is specific to a certain stage).

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·

In order to establish when one segment ended and the next began an
arithmetic criterion was used (1/3 of the therapist's contributions),
whereas what is needed would be to have defined an functional criterion
that allowed us to establish the change of segment on the basis of
criteria related to the content of the narrative and the interaction between
patient and therapist, such as those used to distinguish among stages of
the therapeutic process (9, 11).

CONCLUSIONS
1. The Hill Counselor Verbal Response Category System is a useful
instrument for classifying therapist contributions.
2. The verbal responses used most by the therapist in the psychotherapy
under study are restatement, followed by minimal encourager and
information.
3. Verbal response frequency distribution in the psychotherapy under study
varies according to stage of the therapeutic process: initial and
intermediate or intermediate and termination.
4. Verbal response frequency distribution in the psychotherapy under study
varies according to the segment of the session in which it occurs, if we
compare the initial segment (first third of contributions) and the final
segment (final third).
5. Although our sample doesn't allow us to reach general conclusions, we
observe that in the initial stage of the psychotherapeutic process there is
an elevated level of narrative-facilitating contributions (restatement,
reflection, open and closed question) and in the

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intermediate/termination stages an elevated level of prompting
contributions (information, interpretation, direct guidance) or simple
facilitating contributions (minimal encourager). These findings are in
agreement with the integrative theoretical model based on the creation of
an alternative narrative by the patient with the help of the therapist.
6. Differences are also observed among the different segments of each
session. In the first third of the session narrative-facilitating contributions
are more frequent (both complex as well as simple: restatement,
reflection, open and closed question, minimal encourager) but
decrease as the session proceeds, while prompting contributions
increase.
7. Future research designed to study the psychotherapeutic process may
replicate these results with other patients and therapists, adding
empirical support for the hypothesis that psychotherapy comprises three
distinct stages, each with its characteristic therapist contributions, and
that this constitutes one of the chief common factors contributing to the
results of the therapy.

REFERENCES
(1) Norcross, J.C. & Goldfried, M.R. (2003). Handbook of Psychotherapy
Integration (2nd Ed.). New York: Oxford University Press.
(2) Beitman, B.D. (1987) The Structure of Individual Psychotherapy. New York:
Guilford Press.

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(3) Fernández Liria, A., Rodríguez Vega, B. (2001) La práctica de la
psicoterapia. (The Practice of Psychotherapy.) Desclée de Brouwer, Bilbao.
(4) Frank, J.D. (1961) Persuasion and Healing. Baltimore: Johns Hopkins
University Press.
(5) Frank, J.D. (1971) Therapeutic Factors in Psychotherapy. Am. J.
Psychiatry; 25: 350-361.
(6) Frank, J.D. (1973) Persuasion and Healing (2nd Ed.). Baltimore: Johns
Hopkins University Press.
(7) Garfield, S.L. (1989) The Practice of Brief Psychotherapy. New York.
Pergamon Press.
(8) Kleinke, C.L. (1994) Common Principles of Psychotherapy. Belmont:
Wasworth (Span. trans.: Principios comunes en psicoterapia. Bilbao: Desclée
de Brouwer, 1995).
(9) Beitman, B.D., Yue, D. (1999) Learning Psychotherapy: A Time-efficient,
Research-based and Outcome-measured Psychotherapy Training Program.
New York: Norton.
(10) Stiles W.B. (1979) Verbal Response Modes and Psychoterapeutic
Technique. Psychiatry, 42, 42-62.
(11) Stiles W.B. (1992) Describing talk : a taxonomy of verbal response modes.
Newbury Park, CA: Sage.
(12) Hill, C.E. (1978) Development of a Counselor Verbal Response Category
System. Journal of Counseling Psychology, 25, 461 ­ 468.
(13) Hill, C.E., & O'Grady, K.E. (1985). List of Therapist Intentions: Illustrated in
a Single Case and with Therapists of Varying Theoretical Orientations. Journal
of Counseling Psychology, 32, 3-22.

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(14) Fernández Liria, A., Rodríguez Vega, B. (2002) Habilidades de entrevista
para psicoterapeutas. (Interviewing Techniques for Psychotherapists.) Bilbao:
Desclée de Brouwer.

TABLE 1: Frequencies of the categories of the Hill Counselor Verbal Response
Category System (Hill, 1978) in the 1099 contributions that were studied in the entire
psychotherapeutic process.

VERBAL RESPONSE

%

VERBAL RESPONSE %

Minimal encourager

20.31

Restatement

30.16

Silence

0.12

Reflection

3.31

Approval-reassurance

4.21

Interpretation

7.49

Information

11.40

Confrontation

2.07

Direct guidance

1.85

Nonverbal referent

0

Closed question

7.34

Self-disclosure

0.06

Open question

11.19

Other

0.19

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TABLE 2: DISTRIBUTION OF RESPONSES BY STAGE OF THE
PSYCHOTHERAPEUTIC PROCESS

INITIAL STAGE

INTERMEDIATE

TERMINATION STAGE

STAGE
Restatement (31.80 %)

Restatement (32.71 %)

Minimal encourager (30.65
%)

Minimal encourager (16.76%) Minimal encourager (13.75

Restatement (25.89 %)

%)
Open question (13.8 %)

Open question (12.64 %)

Information (11.90 %)

Information (12.26 %)

Information (10.04 %)

Interpretation (10.41%)

Closed question (9.47 %)

Interpretation (8.92 %)

Open question (7.14 %)

Approval-reassurance (6.11%) Closed question (7.81%)

Closed question (4.76 %)

Interpretation (3.15 %)

Approval-reassurance (3.57

Reflection (5.20 %)

%)
Reflection (2.96 %)

Direct guidance (4.09 %)

Reflection (1.78 %)

Confrontation (2.96 %)

Approval-reassurance (2.97

Confrontation (1.78 %)

%)
Self-disclosure (0.19 %)

Confrontation (1.49 %)

Direct guidance (1.48 %)

Nonverbal referent (0 %)

Silence (0.37 %)

Silence (0 %)

Silence (0 %)

Nonverbal referent (0 %)

Nonverbal referent (0 %)

Direct guidance (0 %)

Self-disclosure (0 %)

Self-disclosure (0 %)

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25
Other (0 %)

Other (0 %)

Other (0 %)

TABLE 3: THERAPIST VERBAL RESPONSE DISTRIBUTION IN EACH OF THE
THREE SEGMENTS OF THE SESSIONS

INITIAL SEGMENT

INTERMEDIATE

FINAL SEGMENT

SEGMENT
Restatement (37.13 %)

Restatement (29.16 %)

Restatement (27.90 %)

Minimal encourager (23.60

Minimal encourager (24.10

Information (16.02 %)

%)

%)

Open question (14.85 %)

Information (15.00 %)

Minimal encourager (15.16
%)

Closed question (8.48 %)

Open question (11.66 %)

Interpretation (12.15 %)

Reflection (3.97 %)

Closed question (7.22%)

Open question (7.73 %)

Information (3.71 %)

Interpretation (4.72 %)

Closed question (6.32 %)

Confrontation (3.18 %)

Approval-reassurance (4.16

Approval-reassurance (6.62

%)

%)

Reflection (2.50 %)

Reflection (3.31 %)

Interpretation (2.12 %)

Confrontation (0.83 %)

Confrontation (2.76 %)

Self-disclosure (0.26 %)

Silence (0.27 %)

Direct guidance (1.10 %)

Direct guidance (0.26 %)

Direct guidance (0 %)

Silence (0 %)

Nonverbal referent (0 %)

Nonverbal referent (0 %)

Nonverbal referent (0 %)

Silence (0 %)

Self-disclosure (0 %)

Self-disclosure (0 %)

Other (0 %)

Other (0 %)

Other (0.82 %)

Approval-reassurance (2.38
%)

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GRAPH 1: FACILITATING CONTRIBUTIONS AND PROMPTING
CONTRIBUTIONS IN EACH OF THE STAGES OF THE PSYCHOTHERAPEUTIC
PROCESS

90
80
70
60
50
40
30
20
10
0

81,44

18,56

initial stage

75,46

74,43

24,54

25,57

intermediate
stage

termination
stage

facilitating
contributions
prompting
contributions

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