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The Narrative Processes Coding System:

Research applications and implications for
psychotherapy practice

Article in Journal of Clinical Psychology October 1999

DOI: 10.1002/(SICI)1097-4679(199910)55:10<1255::AID-JCLP7>3.0.CO;2-F Source: PubMed

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 The Narrative Processes Coding System:

Research Applications and Implications for Psychotherapy Practice

Lynne Angus, PhD.,

Department of Psychology,

York University, North York, Ontario.

Heidi Levitt, MA.,

Department of Psychology,

York University, North York, Ontario

Karen Hardtke, MA.,

Department of Psychology,

York University, North York, Ontario

Journal of Clinical Psychology (1999)

 2

ABSTRACT

The Narrative Processes model is focused on the strategies and processes by which a

client and therapist transform the events of everyday life into a meaningful story that both

organizes and represents the clients sense of self and others in the world. Some investigators

have elected to use clients' within-session descriptions of relationship events or micro narratives

as their unit of narrative analysis. In contrast, we are centrally interested in the development of

the macro narrative framework in which the singular events described in a therapy relationship

(ie micro narratives) come to be articulated, experienced, and thematically linked together in

such a way that the client's sense of his or her life story -- in essence, the sense of self -- may be

transformed at the conclusion of the therapeutic relationship. The following paper details the

Narrative Processes theory of therapy and the coding system which has been developed to

identify and empirically evaluate key components of the model. Findings emerging from the

analyses of successful psychotherapy dyads are described and the implications for future research

and practice are discussed.

 3

Psychotherapy researchers (Goncalves 1995; Luborsky, Barber & Diguer, 1993; McLeod

& Balamoutsou, 1996; Neimeyer, 1995) have recently begun to address the role of narrative in

psychotherapy, and in so doing, have largely borrowed from the conventions of written narrative

form to guide their selection and analysis of stories told in therapy sessions. A growing chorus of

psychotherapy practitioners (Schafer, 1992), linguistic researchers (Gee, 1985) and

psychotherapy process researchers ( Angus & Hardtke, 1994; Angus, Levitt & Hardtke 1994) are

suggesting that the stories which unfold in the context of the co-constructive, spoken dialogue

of the therapy session are different in form, and at times function, from written accounts of life

events.

This perspective on the therapy dialogue is consistent with Schafer's (1992) notion of

narration in psychotherapy in which he argues that oral narratives in therapy sessions are not like

"literary fiction" in which there is a clear beginning, middle, and end to the story. For Schafer,

the acts of narrating, giving an account, presenting a version, developing a story-line, telling,

revising and reinterpreting are all core components of the narrational approach and are key to

successful outcomes in psychodynamic psychotherapy. Findings emerging from a series of

studies (Levitt 1993; Greenberg & Angus 1993; Angus & Hardtke 1994; Hardtke 1996)

analysing narrative discourse parameters in psychotherapy sessions, and drawn from a variety of

therapy approaches, are beginning to establish empirical support for a broader application of

Schafers narrational approach to conceptualizations of psychotherapy discourse as a whole.

Some investigators (Luborsky, Barber & Diguer, 1992; McMullen & Conway, 1993)

have elected to use clients within-session descriptions of relationship events or what we term

micro-narratives as their unit of narrative analysis. In contrast, we are centrally interested in the
 4

macro-narrative framework in which the individual events described in therapy sessions (ie

micro-narratives) become thematically linked together in such a way that clients views of their

life stories may be transformed at the conclusion of successful therapy relationships.

Specifically, the Narrative Processes theory of therapy (Angus & Hardtke, 1994) is predicated on

the assumption that all forms of successful psychotherapy entail the articulation, elaboration and

transformation of the client's self-told life story which is reflected in the emergence of macro-

narrative themes which predominate across therapy sessions. Both client and therapist achieve

this goal by collaboratively engaging in 3 distinct modes of inquiry : 1) External Narrative Mode,

which entails the description and elaboration of life events in which the question of what

happened is addressed; 2) Internal Narrative Mode, which entails the description and elaboration

of subjective feelings, reactions and emotions connected with the event which addresses both the

question of what was felt at the moment the event was occurring as well as what is experienced

now in the therapy session; and finally 3) Reflexive Narrative Mode, which entails the reflexive

analyses of issues attendant to what happened in the event (external) and what was felt (internal)

in which the question of what does it mean is addressed. These narrative processing modes

encompass both the cognitive and experiential strategies which both clients and therapists engage

in when co-constructing stories about self and others, irrespective of therapeutic modality, and

encompass almost all of the dialogue spoken in the context of the psychotherapy relationship. In

essence, the narrative process modes are viewed as essential components of a distinctive mode

of human meaning-making which creates, maintains and when needed, revises our sense of self

in the world.
 5

The Narrative Processing approach to psychotherapy has clear implications for both

psychotherapy researchers and practitioners. In the following paper the components of the

Narrative Processes Coding model, namely narrative process sequences and topic segments, as

well as the Narrative Processes Coding System will be addressed first followed by a discussion

of relevant research applications for the coding system and practice implications for

psychotherapy practitioners.

Narrative Processes Model

According to the Narratives Processes theory of therapy, the goals of productive therapy

are threefold. First, the client and therapist focus on the remembrance of past events and the

description of current events and imagined experiences in order to "fill the gaps" of what has

been forgotten or never fully acknowledged, and hence, not understood. Second, client and

therapist undertake a detailed unfolding and exploration of associated perceptions, sensations,

emotions and thoughts, such that the lived experiences of the event can be engaged and perhaps

articulated for the first time. The third goal entails the reflexive analysis of the related

experiences and circumstances of "what happened" such that a new understanding or story is

formed which either supports or challenges the implicit beliefs about self and others that

underscore the dominant narrative.

In the context of psychoanalytic psychotherapy, Nye (1994) argues that much of the work

of exploring and reconstructing the meaning of events or memories happens in the reflective talk

about the events which have occurred in the client's life. Accordingly, in order to understand

how narrative functions in psychotherapy, it is also critical that we examine the reflexive talk

about events in which client and therapist collaborate in the generation of new ways of
 6

conceptualizing and seeing the client's life story. In the context of the Narrative Processes

model, the descriptions of subjective experiencing and relationship events are viewed as

providing both clients and therapists with a rich spawning ground for the creation of new

meanings and shared understandings.

In terms of the functions of spoken narratives, we argue that in the External sequences the

narrator or client attempts to verbally show the therapist -- by means of descriptive, specific

details -- the scene, setting and actions entailed in an event. The more detailed and specific the

description provided by the client, the more opportunity the therapist has to develop an imagistic

rendering of the event and to empathically adopt the internal frame of the client. Additionally, a

number of investigators ( Salovey & Singer, 1994; Borkovec, Roemer & Kinyon, 1995; Bucci,

1995) argue that the articulation of a detailed description of an episodic memory may provide the

client with an opportunity to more fully access emotions and thoughts experienced in the context

of a past event. Accordingly, some therapists will intentionally shift clients into an External

narrative sequence, by asking the client to give a detailed concrete example or life event to

exemplify a general concern or issue, in order to facilitate a reexperiencing as opposed to a

retelling of past memories and significant events.

A growing number of developmental (Stern, 1989) and personality researchers (Epstein,

1984; Janoff-Bulman, 1992; Salovey & Singer, 1994) are suggesting that key episodic memories

may function as schemas or templates in the context of the development of the individuals self-

theory or what we term the clients macro-narrative. Epstein (1984) points out that a persons

theory of self and the world, or macro-narrative, is a preconscious experiential and conceptual

system that automatically structures experiences and directs actions. A key therapeutic strategy to
 7

access core components of clients macro-narratives is to ask clients to describe significant

memories present in conscious awareness and to encourage the articulation of important but

forgotten past experiences and events in the context of External narrative sequences. The

generation of new experiential and conceptual meanings in the context of the External narrative

sequences emerges from the engagement in both Internal and Reflexive narrative process

sequences.

Internal sequences function to show or describe to the therapist the emotions and feelings

reexperienced by the client in the showing and telling of the event (external) or entail the

description of new emotions or feelings emerging in the moment during the therapy session. In

the context of dealing with physical and psychological trauma, Harber & Pennebaker (1992) have

provided compelling research findings which demonstrate that emotional disclosure in the

context of trauma narratives is predictive of positive immune system response in survivors.

In a similar vein, Borkovec, Roemer & Kinyon (1995) argue that obsessive worrying in

distressed clients functions to suppress the key psychological change processes of imagery recall,

affect and emotional processing in the context of the experienced traumatic events. For

Borkovec et al, the articulation and processing of distressing emotions is a key therapeutic task

when working with chronically anxious clients. While a growing consensus of psychotherapy

researchers (Greenberg, Rice & Elliot, 1993; Greenberg & Safran, 1989; Mahoney, 1991;

Pennebaker, 1995) are recognizing the importance of emotional disclosure as a basis for the

generation of new meanings of self and others and macro-narrative change, psychotherapy

approaches differ to the extent in which they priorize the description of what was experienced in

the past versus focussing on the processing of emotion schemes emerging in the session. The
 8

more evocative and descriptive the client can be regarding his or her experiencing in the session,

the greater the opportunity the therapist has to empathically resonate with and attune to the

client's feeling state (Angus, 1990). We have found the use of individual metaphor phrases

(Angus, 1996) to be particularly productive within the context of Internal narrative sequences.

Finally, in the Reflexive sequences the client attempts to make meaning of his or her

experiences by exploring personal expectations, needs, motivations, anticipations, and beliefs of

both the self and those individuals who play significant roles in the clients life. It is in the

context of reflexively processing current and past experiences that the client and therapist begin

to co-construct a meaningful framework of understanding, or macro-narrative theme

reformulation, which coherently organizes, and provides an understanding of the clients current

and past experiences in the world.

In terms of with-in session patterns, Reflexive narrative sequences ideally follow upon a

depth of engagement in either External or Internal narrative sequences in the therapy session such

that both the client and therapist engage in a process of shared meaning-making in relation to the

clients understanding of self and others in the world. Greenberg & Pascual-Leone ( in press),

citing findings from Pennebakers (1995) work with trauma survivors, argue that reflexive

elaboration and meaning creation can be an important therapeutic consequence of client

emotional expression if the therapist actively facilitates the clients focussing on the creation of

new meaning (ie Reflexive narrative sequence) from the aroused emotional material (ie Internal

narrative sequence).

Reflexive narrative processing which does not emerge from the detailed description of

events and emotional expression may be a client marker of shallow, automated processing
 9

(Borkovec, Roemer & Kinyon, 1995) in which the client appears to be retelling a well rehearsed

script. By asking the client for a specific example of the problem or concern, and hence shifting

the client to describing and showing a specific instance (External narrative sequence), the

therapist may help the client to engage in a kind of depth of Internal and Reflexive narrative

processing such that deeply painful and at times disturbing feelings and beliefs about the self can

be articulated and understood in ways that engender new meanings and perspectives on self and

others.

Drawing on the work of Spence (1982), client descriptions of what happened (External

sequences) and how it felt (Internal sequences) entail processes of client-mediated memory

reconstruction. In contrast, clients' with-in session elaboration and characterization of new

feelings (Internal sequences) emerging in the showing and reexperiencing of the event as well as

the active search to make past events and past and current feelings understandable (Reflexive

sequences) entail both clients and therapists active participation in co-constructive processes of

meaning-making. With this model it is argued that all three narrative process sequence types

have an important function to fulfil in the co-construction of the client's macro or self narrative

and as such are present, although in varying degrees and patterns, in all therapeutic modalities.

Narrative Processes Coding System

In order to conduct an empirical investigation of narrative processes in psychotherapy, a

systematic method for the identification of therapy discourse parameters associated with narrative

processing modes was developed (Angus & Hardtke, 1994). The Narrative Processes Coding

System (NPCS) and revised manual (Angus, Hardtke & Levitt, 1996) has evolved from the first

author's continuing interest in the role of metaphor and figurative language in psychotherapy
 10

(Angus 1996; Angus 1990; Angus, 1992; Angus & Rennie,1989; Angus & Rennie,1988) as well

as earlier research projects which entailed the origination (Marziali & Angus 1985) and

development of a sequential coding system (Marziali & Angus, in preparation) appropriate for

application to the therapy discourse.

The NPCS provides researchers with a rational, systematic method of unitizing therapy

transcripts, regardless of therapeutic modality. The procedure entails two steps which enables

the researcher to: a) reliably subdivide and characterize therapy session transcripts into topic

segments according to content shifts in verbal dialogue; and b) further subdivide and characterize

these topic segments in terms of one of three narrative process types -- External, Internal and

Reflexive -- which are termed narrative process sequences for coding purposes:

i. External Narrative Process Sequences which include description of events (past, present

and/or future; actual or imagined);

ii. Internal Narrative Process Sequences which include a subjective/experiential description

of experience; and

iii. Reflexive Narrative Process Sequences which include analysis of current, past and/or

future events.

As a form of discourse analysis, this categorization system deals with interactional units

which can include both client and therapist turn-taking. In terms of Kiesler's (1973) descriptive

classification of psychotherapy process measures, the NPCS is a nominal method for the

categorization of psycholinguistic dimensions of the therapeutic interaction. Given that the entire

therapy session transcript (summary unit) is used for the identification of topic segments
 11

(contextual units) and narrative sequences (scoring units), the NPCS can also be characterized as

a comprehensive categorization method.

Topic Segments

Topic segments are identified when a shift or change in subject (eg., work, family,

relationship with significant other) occurs during the psychotherapy session discourse. For

research purposes, a topic segment shift can be further categorized as representing one of the

following :

i) Domain shift : which entails a description or overview of a new content area

ii) Facet shift : which entails a detailed elaboration of different facets of a general content area

Topic segments are interactional units which may contain verbal interchanges between

clients and therapists. The beginning of a new topic segment is often marked by: a) questions

posed by the therapist signalling a topic change and hence, the beginning of a new topic segment;

b) the client clearly introduces a new topic; c) a change in verb tense signalling the elaboration of

a specific content area or past experiences; and/or d) following a distinct pause by the speaker.

The ending of a topic segment is often marked by: a) an affirmation that what has been said has

been understood by the therapist and/or the client (ex. "mm-hm"), b) a pause in the conversation,

or c) a summary of the preceding issues. The length of topic segments varies from dyad to

dyad.. In a recent study (Hardtke,1996), it was found that in a sample of 5 therapy dyads ( 75

therapy sessions), the average length of a topic segment was 30 transcript lines, with a range of

10 to 133 lines.
 12

Once identified, each topic segment is labelled according to: a) Relationship Focus :

identifies whom the topic segment is addressing, whether it be an issue regarding self, other(s),

or self in relation to other(s), and b) Key issue : describes the primary issue or focus of the

discussion which comprises the topic segment.

The following example of a topic segment entails the description a specific content area

- a client's relationship with her mother-in-law. The relationship focus identified by NPCS raters

for this segment is self in relation to mother-in-law and the key issue is characterized as mother-

in-laws visit.

Relationship Focus: Self / Mother-in-law

Issue : Mother-in-law's current visit

T: Good morning, how are you?

C: OK. It has been a pretty hectic week. My Mother-in-law arrived in town. She'll be staying
with us for two weeks. She's just taken over the house. She's cleaning everything. I mean, she
even went out and bought Ajax (cleaning powder) and spent almost an hour scrubbing the
kitchen sink. I mean it's not like the place was dirty. I made sure it was spotless before she
arrived. The night before I even got up to check everything over so I could clean whatever was
missed. She always does this.

T: Okay, your Mother-in-law arrived for a visit and what, the next day you walked into the
kitchen and she was cleaning your sink?

C: Yeah, she arrived Thursday afternoon. R.(husband) picked her up from the airport. The next
morning I dropped the kids off at school and when I got back there she was in the kitchen
scrubbing the sink, you know with Ajax. So I just stood there with a dazed look on my face and
said, you know, that she was on vacation and if the sink was dirty I would clean it. Well she said
something like she knew I was busy and she was only trying to help.

T: Mm-hm.

C: Yeah and like she always does this.

T: Mm-hm. So how does it make you feel when she acts like this?
 13

C: I feel like she's intruding. I mean she's the guest. I don't know I just want to scream I get so
frustrated. She makes me feel hopeless, like a little kid. There is no point telling R.(husband).
He just sides with her. I just get really upset. I just feel like one of the kids when she's around.

T: Mm-hm. So when she visits you feel like she is the parent and you're the little kid?

C: Yeah, like when she cleans or says that I'm not dressing my kids right I feel like I've failed
again. It is so aggravating. No matter how hard I try I can't please her. I think I'm starting to
experience panic attacks when I know she's coming for a visit.

T: Panic attacks?

C: Like before she arrived I had a headache for a week. My stomach was in a knot and I could
hardly eat. I just felt really tense and nervous. I just know that she will find something to
criticize me about.

T: Mm-hm.

C: And I don't know why I feel so obsessed with pleasing her anyway. She usually only comes to
visit twice a year. I mean it's not like we're really close. I've talked to R.(husband) who says I
should just put up with her for two weeks, then forget about her. But I can't seem to do that.
Maybe it's because I felt she never thought much of me. She was against R.(husband) and I
marrying. We were both still in school when we married. She's always given me the impression
that she thought R.(husband) would marry someone who would be more than a housewife. Why
don't I have the guts to stand up to her? Why do I let her invade my home? I always let her take
charge. I should stand up for myself and tell her what I think about all her cleaning and stuff.
Maybe if I stood up to her she'd respect me more? Or at least she might shut up!

T: hm.

C: I don't know. I do know that I don't want to waste my time with you talking about her for the
whole hour (laughs). (shift / end of Topic Segment #1 / beginning of Topic Segment #2)

To date, topic segment analyses have been completed on 09 good outcome dyads

(Greenberg & Angus, 1993) and 09 poor outcome Brief Experiential psychotherapy dyads - a

total of a 270 fully analysed psychotherapy sessions. In terms of interrater agreement levels for

the identification of topic segment units in the transcript, it was found that after 20-25 hours of
 14

training, raters were are able to establish a 90% hit rate (Cohen Kappa +.78) for both the

identification of Topic Segment units and the labelling of central issue and relational focus.

Narrative Process Sequences

Once the therapy session transcript has been unitized according to topic shifts , each topic

segment is then further subdivided and coded in terms of shifts -- external, internal or reflexive --

in narrative process type. The resulting smaller units of text are coined narrative sequences. The

number of narrative sequences in each topic segment naturally varies. The client, and/or

client/therapist interaction, may remain in a certain narrative process mode throughout the entire

segment or shift between the three types. For rating purposes, a narrative process sequence

should be no less than 4 transcript lines.

It has been found that with 25-30 hours of training time, raters are able to reliably

identify and categorize narrative sequence units in therapy session transcripts. Using a sample of

5 therapy transcripts, ratersinterrater agreement levels - 83% - 88% (Cohens Kappa .75) were

found to fall within an acceptable range for reliability.

Identifying External Narrative Sequences

When an individual provides a descriptive elaboration of a life event (actual or imagined

/ past, present or future), the narrative sequence is coded as External. Two distinctions can be

made within this narrative sequence type. The client may a) provide a general overview of the

event or b) highlight a specific incident or event (past, present or future; actual or imagined).
 15

The following are markers to help the researcher identify external narrative sequences: a)

the description of personal memories, and therefore a shift in verb tense may indicate the start of

an External narrative sequence; b) concrete examples used to demonstrate issues raised in all of

the narrative sequence types; and c) an External narrative sequence may be describing either a

specific event, or an event which is a general description or composite of many specific events.

The following dialogue is an example of an External narrative sequence which was identified

within the context of the mother-in-law topic segment :

T: Good morning, how are you?

C: OK. It's been a pretty hectic week. My mother-in-law arrived in town. She'll be staying with
us for two weeks. She's just taken over the house. She's cleaning everything. I mean, she even
went out and bought Ajax and spent almost an hour scrubbing the kitchen sink. I mean it's not
like the place was dirty. I made sure it was spotless before she arrived. The night before I even
got up to check everything over so I could clean whatever was missed. She always does this.

T: Okay, your mother-in-law arrived for a visit and what, the next day you walked into the
kitchen and she was cleaning your sink?

C: Yeah, she arrived Thursday afternoon. R.(husband) picked her up from the airport. The next
morning I dropped the kids off at school and when I got back there she was in the kitchen
scrubbing the sink, you know with Ajax. So I just stood there with a dazed look on my face and
said, you know, that she was on vacation and if the sink was dirty I would clean it. Well she said
something like she knew I was busy and she was only trying to help.

T: Mm-hm.

C: Yeah and like she always does this. (shift/end of External narrative sequence).

Identifying Internal Narrative Sequences

When an individual provides a descriptive elaboration of subjective experiences or

points of view, the narrative sequence is coded as Internal. It is an experiential description and

entails a description of how one feels in relation to one's self and/or to others. The following are
 16

cues to help the researcher identify Internal narrative sequences: a) the therapist asks directly how

the client feels; b) frequent use of words describing emotions (eg. sad, angry, frustrated); c)

emotional expressions such as sighing, crying or shouting; d) metaphoric descriptions of

experiential states (ex. I feel as if I am going to explode!); and e) long pauses in which the

individual appears to be searching for words to articulate an experiential state. The following

dialogue is an example of an Internal narrative sequence identified in the mother-in-law topic

segment :

T: Mm-hm. So how does it make you feel when she acts like this?

C: I feel like she's intruding. I mean, she's the guest. I don't know I just want to scream I get so
frustrated. She makes me feel hopeless, like a little kid. There is no point telling R.(husband).
He just sides with her. I just get really upset. Just feel like one of the kids when she's around.

T: Mm-hm. So when she visits you feel like she is the parent and you're the little kid?

C: Yeah. Like when she cleans or says that I'm not dressing my kids right I feel like I've failed
again. It is so aggravating. No matter how hard I try I can't please her. I think I'm starting to
experience panic attacks when I know she's coming for a visit.

T: Panic attacks?

C: Like before she arrived I had a headache for a week. My stomach was in a knot and I could
hardly eat. I just felt really tense and nervous. I just know that she will find something to
criticize me about.

T: Mm-hm. (end of Internal Narrative Sequence).

Identifying Reflexive Narrative Sequences

Reflexive narrative sequences are identified when an individual focuses on the reflexive

or interpretive analysis of event descriptions and/or descriptions of subjective experiences. In

these instances, the individual attempts to understand his or her own feelings regarding self,

others or events. The following cues help the researcher identify Reflexive narrative sequences.
 17

The client may be actively : a) examining his or her own actions in situations/relationships; b)

planning future actions alternatives; c) examining his or her own thinking in situations; d)

exploring his/her own emotions in situations; e) discussing patterns in his/her behaviour and/or

that of others; or f) self-questioning using words such as "why," "maybe", "I guess," "I wonder,"

"I realize," "I think," "It could be," "I don't know" may all be markers depending on their context.

The following dialogue is an example of a Reflexive narrative sequence identified in the mother-

in-law topic segment:

T: Mm-hm.

C: And I don't know why I feel so obsessed with pleasing her anyway. She usually only comes to
visit twice a year. I mean it's not like we're really close. I've talked to R.(husband) who says I
should just put up with her for 2 weeks, then forget about her. But I can't seem to do that.
Maybe it's because I felt she never thought much of me. She was against R.(husband) and I
marrying. We were still in school. She's always given me the impression that she thought
R.(husband) would marry someone who would be more than a housewife. Why don't I have the
guts to stand up to her? Why do I let her invade my home? I always let her take charge. I
should stand up for myself and tell her what I think about all her cleaning. Maybe it I stood up
to her she'd respect me more. Or at least she might shut up!

Research Findings and Implications for Therapeutic Practice

Narrative Process Sequences

In terms of assessing narrative process modes in psychotherapy transcripts, both the

frequency and pattern of narrative sequences occurring within an individual therapy session or

across a completed therapy relationship, can be identified and evaluated. Furthermore, with this

strategy the predominance of particular narrative modes in different therapeutic modalities and/or

outcome groups can be evaluated. While our research investigations are at a preliminary stage of

development, some noteworthy trends have already emerged from our ongoing research

endeavours.
 18

More specifically, within the context of the Narrative Processes model, it is argued that it

is the pattern of narrative process sequences and topic segment shifts that is of interest for

psychotherapy practitioners and researchers, rather than the overall dominance of one narrative

sequence type or topic focus in the therapy. Specifically, the NPCS was designed to identify and

track the patterns of narrative sequences which occur most frequently in a particular therapeutic

modality as well as empirically ascertain the frequency with which therapists or clients initiate

shifts into the different narrative sequence categories. Given that therapists and clients are

viewed as co-constructing meaning during the therapy hour, it is expected that both clients and

therapists will initiate narrative sequence shifts during the therapy hour. The NPCS offers the

possibility of establishing an empirical index of therapist and client agency by generating a

precise accounting of the number of narrative mode shifts initiated by client and therapist.

Moreover, it is argued that different psychotherapy models tend to priorize different

combinations of the three narrative process sequences in their theories of therapy, and therapists

adherence to these models can be empirically evaluated by means of the NPCS methodology.

For example, in Process-Experiential psychotherapy (Greenberg, Rice & Elliot 1993) it is

emphasized therapists should be process-directive (ie, therapist initiates marker-driven narrative

sequence shifts) with an explicit goal of accessing emotional schemes (Internal narrative

sequences). Furthermore, with this approach, new meanings and understandings (Reflexive

narrative sequences) are viewed as emerging out of the processing and elaboration of emotional

schemes in the session.

Accordingly, within the context of the Narrative Processes model, the Process-

Experiential therapist would be expected to initiate client shifts into the description and
 19

elaboration of felt emotions and feelings (Internal narrative process mode) followed by shifts to

the articulation and differentiation of new meanings (Reflexive narrative process mode)

emerging from the disclosure and processing of emotions. In essence, with this therapeutic

approach, new meanings are thought to emerge from the client's elaborated processing of core

emotional schemes in which a dynamic pattern of Internal and Reflexive narrative sequence

modes are viewed as essential for the facilitation of second-order or deep structural change

(Lyddon 1995). In contrast, the External mode is viewed primarily as a necessary starting point

for the real work of accessing and articulating felt emotions (Internal sequences) and elaborating

new meanings (Reflexive sequences). The analyses of narrative sequence patterns in good

outcome, brief Process Experiential therapies (Hardtke, 1996; Levitt, 1993) have confirmed that

effective Process-Experiential therapists do indeed consistently priorize shifts into Reflexive and

Internal narrative sequences.

Using log linear statistical procedures, Levitt (1993) established that the predominance

and patterns of narrative sequence types identified in 3 early, 3 middle and 3 late sessions from 3

brief, good outcome psychotherapy dyads were significantly different from one another. For this

study, therapists representing three distinctly different modes of brief therapy intervention --

Process-Experiential, Perceptual-Processing and Psychodynamic -- were asked to select one

successful psychotherapy dyad for intensive narrative sequence analyses. Using standardized

outcome measures (Beck Depression Inventory; Beck et al.,1988; the Tennessee Self-Concept

Scale; Fitts, 1965 and the Social Adjustment Scale; Weissman & Bothwell,1976), all three

clients were identified as having achieved clinically significant outcomes at the termination of

therapy and consented to participate in the research study.

 20

All three clients were self-referred female adults who reported no previous psychiatric

history or use of psychotropic medication. All three therapists -- 2 male and 1 female -- had

over 20 years of therapeutic experience and 2 were founders of their respective therapeutic

orientations. The Perceptual-Processing therapy model (Toukmanian,1992) maintains that clients

are in need of broadened perceptual bases for processing and gathering information. The

Perceptual-Processing therapist attempts to focus clients attention on processing patterns so that

increasingly functional and flexible perceptual processes can be developed. The Process-

Experiential orientation is emotionally focused and directed towards the evocation and

restructuring of emotional schemes (Greenberg, Rice & Elliott, 1993). Different Client-Centred

and Gestalt therapy interventions are used to facilitate clients emotional experiences and assist

them in reorganizing or restructuring these schemes. The Psychodynamic approach is predicated

on the assumption that psychological difficulties are rooted in unconscious inner conflicts and

represented in interpersonal relationship patterns (Arlow,1989). A focus on current and past

relationship patterns and the use of interpretation distinguish this brief, psychodynamic therapy

approach. Adherence rating analyses of the selected therapy session tapes established that all

three dyads represented the core characteristics of their respective therapeutic models and

approaches.

All of the therapy sessions selected for analysis in this study were transcribed and then

randomly sorted for rating using the NPCS. Two clinical psychology graduate students

underwent 30 hours of NPCS training and then rated 5 randomly selected session transcripts

(20% of the total sample). The two raters established an inter-rater agreement level of 88% for

topic segment and narrative sequence identification (Cohens Kappa .75). A further sample of
 21

three sessions were rated by both judges toward the conclusion of the analyses and confirmed

that inter-rater agreement levels had been maintained throughout the therapy session analyses.

In terms of the log-linear narrative sequence analyses, it was confirmed that the 3

therapeutic approaches were significantly different from one another in terms of both the number

of identified narrative sequences (p=0.0007) and the type of narrative sequences (External,

Internal, Reflexive) identified in the therapy sessions across the three therapy dyads (p=0.0001).

More specifically, in the Psychodynamic therapy sessions, a pattern of Reflexive (40%)

and External (54%) narrative sequences predominated in which therapist and client engaged in a

process of meaning construction (Reflexive) linked to the clients descriptions of past and current

episodic memories (External). An intensive analysis of the patterns of occurrence in sessions

revealed that External sequences in the Psychodynamic therapy sessions were either bounded by

consecutive strings of External sequences or alternated with Reflexive narrative sequences.

Bucci (1995) argues that retrieving memories and describing life events in therapy may help

clients revive and experience specific emotional and cognitive states connected with the

incidents. By means of the exploration of implicit connections between episodic memories

(External sequences), and the elaboration of new understandings connected to these themes

(Reflexive sequences), the Psychodynamic therapist attempts to engender new perspectives and

insights in relation to interpersonal conflicts and relationship issues.

In contrast to the Psychodynamic therapy sessions, the Process-Experiential therapy

sessions evidenced a pattern of Internal (29%) and Reflexive (46%) narrative sequences in which

the client and therapist engaged in a process of identifying and differentiating emotional

experience (Internal) and then generating new understandings of those experiences (Reflexive)
 22

during the therapy hour. As compared to the other two dyads, the proportion of Internal

narrative sequences were three times higher in the Process-Experiential therapy sessions than in

the Perceptual-Processing sessions and five times higher than in the Psychodynamic sessions.

The primary goal of Process Experiential psychotherapy is to assist clients in developing more

differentiated and functional emotion schemes and the evidence from the NPCS analyses indicate

that this goal is achieved by an alternating focus on client exploration of experiential states

(Internal narrative sequences) followed by meaning making inquiries (Reflexive narrative

sequences) in which new feelings, beliefs and attitudes are contextualized and understood.

Finally, the Perceptual-Processing therapy dyad revealed a pattern of consecutive

Reflexive narrative sequences (54%) occurring across topic segments in which client and

therapist engaged in extended reflexive analyses of both life events (External, 36%) and to a

lesser extent emotional experiences (Internal, 10%). The chaining of the Reflective narrative

sequences appeared to facilitate an extended client inquiry into core self-related issues in which

automatic processing patterns were identified and challenged.

While the restricted sample size for this study necessarily limits the generalizability of

the findings, certain trends are worthy of note. The three Narrative sequence types do appear to

capture differential therapeutic processing strategies representing differing therapeutic

approaches. Moreover, the patterns and predominance of the Narrative sequence modes are

consistent with the stated goals and aims of the different therapy approaches. The next step in

the development of this research programme will be the investigation of narrative sequence and

topic segment patterns in larger samples of both good and poor outcome brief therapy dyads in

order to validate the findings emerging from this case study analysis.
 23

Relational Themes and Topic Segment Shifts

While there has been an increasing interest in the identification of content topics (Brown

& Yule, 1983; Planalp & Tracy, 1980; Reichman, 1978; Sigman, 1983) and key content themes

(Luborksy & Crits-Christoph, 1990) in selected therapy sessions, very few psychotherapy

researchers (Milbrath, Bauknight, Horowitz, Amaro & Sugahar, 1995) have developed methods

or strategies to represent the emergence and predominance of content themes across therapy

sessions. The NPCS is in part designed to identify the frequency and pattern of content topics or

topic segments as represented in sequential psychotherapy sessions. In terms of the Narrative

Processes Coding method, a topic segment shift is characterized by either the introduction of a

new topic or the elaboration of a specific facet of a broader topic domain. Furthermore, each

topic segment can be characterized in terms of the key issue under discussion and the relational

focus of the discussion. The collation and sorting of individual topic segments into recurring

relational and/or issue-based themes provides a method for naming and tracing the emergence of

core themes across therapy sessions. It is the analysis of core therapeutic themes which provides

an understanding of the content of the clients macro-narrative or life story as represented in the

cut and thrust of the therapeutic discourse.

As stated previously, topic shifts may initiate a clear change in content focus or they may

represent a focused elaboration of a subpart or facet of a larger issue or domain. Constant

within-session topic shifting, with rapid shifting from one content domain to another, may

indicate that both client and therapist are having difficulty finding a sustained focus of inquiry in

the session (Rasmussen & Angus, 1996). In contrast, sessions in which clients and therapists

collaboratively initiate shifts into thematically related topics, or pursue facets of one content
 24

domain, convey a sense of having established a shared focus of inquiry in the session

(Rasmussen & Angus, 1997). Therapists can strategically initiate topic facet shifts by asking

clients for specific information in relation to core issues, by asking clients to provide specific

examples of general concerns, and by identifying thematic connections between past concerns

and present issues. These strategies help to facilitate a shared, extended inquiry into key

concerns and also help to establish a sense of coherence and focus in the therapy hour.

Findings from a qualitative, comparative analysis of metaphoric expression in

psychodynamic therapy with Borderline and non-Borderline clients (Rasmussen, 1995 ;

Rasmussen & Angus, 1996; 1997) indicate the non-Borderline clients and their therapists identify

experiencing a sense of narrative coherence in their therapy sessions in which topic facet shifts

occur predominantly in the context of core client issues. Conversely, Borderline clients and their

therapists reported searching for and having difficulty finding shared understandings and

coherence in sessions in which topic segments frequently shifted from one seemingly

disconnected issue or relationship focus to another.

Based on a Grounded Theory analyses of post-session Interpersonal Process Recall

interviews conducted with the Borderline clients, Rasmussen & Angus (1996; 1997) argue that

disjunctive topic shifts were typically initiated by Borderline clients in response to feeling

emotionally overwhelmed in therapy sessions. In these instances, therapists focal inquiries were

experienced as feeling too close to home for Borderline clients comfort levels. Borderline

clients appeared to initiate topic shifts at these critical moments in therapy sessions in order to

shift awareness and attention away from internal feelings and emotions and instead focus on new

and often unrelated topics.

 25

In turn, therapists report feeling confused, puzzled and frustrated by their Borderline

clients propensities to change topics at those critical moments in sessions. Therapists report

feeling less satisfied with therapy sessions in which there have been frequent topic shifts in the

therapy discourse. In particular, therapists seem to experience a lack of closure and describe

feeling as if little depth of understanding has been achieved in the therapy sessions.

Although these findings should be treated cautiously given the limited sample size, a few

interesting trends should be highlighted for psychotherapy practitioners. First, it may be helpful

for therapists to regard radical client-initiated shifts in topic focus as possible markers of client

emotional distress; especially when topic shifts occur in the context of moments of heightened

emotion in therapy sessions. Further exploration and articulation of what emotions the client

actually experienced in the session, prior to the initiation of the radical topic shift, may be a

productive route to accessing core conflicts and emotional schemes (Angus & Gillies, 1994).

Second, therapists may facilitate the development of a shared sense of narrative

coherence and focus in the therapy relationship by initiating topic facet shifts in the context of

salient client issues and concerns. Therapist facilitation of topic facet shifts helps both clients

and therapists to develop a more differentiated, contextual understanding of clients key concerns

and aids in the germination of core themes which integrate disparate client experiences across

sessions. And third, therapeutic interventions -- such as Gestalt two chair and empty chair

dialogues -- initiated within the context of core client themes, also function as topic facet shifts

in which more differentiated, new understandings of key client concerns emerge within sessions.

Discussion
 26

The Narrative Processes system provides psychotherapists with a conceptual framework

within which to embed an understanding of the roles and functions of three narrative process

modes -- External, Internal and Reflexive -- as they relate to the construction of macro-narrative

themes in the therapy hour. It is argued that differing therapy approaches, in their theories of

therapy practice, priorize unique patterns of narrative sequence types in the quest to facilitate

significant client change. The NPCS is based on the primary assumptions articulated in the

Narrative Processes model and offers psychotherapy researchers a systematic, empirical method

for the identification of both content domains and narrative sequence types in therapy session

transcripts.

A definite strength of the NPCS is that it provides psychotherapy process researchers with

a standard unit of analysis for the segmentation of psychotherapy session transcripts representing

differing therapeutic approaches. Additionally, the NPCS tracks the processes of narrative

construction in therapy in at least three different ways. First, the recurrence of content identified

topic segments in the therapy discourse can be charted both within and across sessions and the

degree to which a focus emerges in the therapy discourse can be empirically evaluated.

Furthermore, using the topic segment labelling system, topics representing a particular

relationship issue can be easily identified in the coded therapy transcripts and then assessed for

changes in cognitive and experiential processing style by standardized psychotherapy measures

(such as the Experiencing Scale; Klein, Mathieu-Coughlan & Kiesler, 1986). Second, the

narrative sequence patterns characteristic of good and poor outcome psychotherapies can be

identified as well as narrative patterns which characterize differing therapeutic approaches.

Selected narrative sequence patterns can be further assessed using standardized process rating
 27

measures. And third, the degree to which the client or therapist initiate topic segment and

narrative sequences shifts within sessions can be empirically assessed.

The NPCS offers the promise of providing psychotherapy researchers with a rationally-

based, empirical method for the unitization of the therapy session discourse in terms of shifts in

narrative process sequence types. By providing psychotherapy researchers with a common unit of

analysis for the application of a variety of different process measures, research findings from

different research projects could be combined to increase the power of statistical analyses for the

assessment of therapeutic trends and outcomes. In essence, the NPCS may provide researchers

and clinicians with a shared framework for the implementation of collaborative projects in the

domain of psychotherapy research.

Ongoing research using the NPCS includes the sequential analyses of topic segment and

narrative sequence patterns in both good and poor outcome Client-Centred and Process-

Experiential psychotherapies. In these studies, we are strategically targeting characteristic

narrative sequence patterns for further assessment of client vocal quality and depth of

experiencing in order to better understand the differential roles of the three narrative sequence

modes in the facilitation of client change. And finally, it will be important in future studies to

more fully explore the full range of roles and functions which narrative mode and topic changes

play in the therapy hour.

 28

Authors Note

The authors gratefully acknowledge that this study was supported in part by a Standard Grant

from the Social Sciences and Humanities Research Council of Canada. We would also like to

thank Jacqueline Brunshaw for her invaluable editorial assistance.

 29

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