Original research article, published on 02 october 2014 in „frontiers in psychchology„
In recent years, models have been developed that conceive psychotherapy as a self-organizing process of bio-psycho-social systems. These models originate from the theory of self-organization (Synergetics), from the theory of deterministic chaos, or from the approach of self-organized criticality. This process-outcome study examines several hypotheses mainly derived from Synergetics, including the assumption of discontinuous changes in psychotherapy (instead of linear incremental gains), the occurrence of critical instabilities in temporal proximity of pattern transitions, the hypothesis of necessary stable boundary conditions during destabilization processes, and of motivation to change playing the role of a control parameter for psychotherapeutic self-organization. Our study was realized at a day treatment center; 23 patients with obsessive compulsive disorder (OCD) were included. Client self-assessment was performed by an Internet-based process monitoring (referred to as the Synergetic Navigation System), whereby daily ratings were recorded through administering the Therapy Process Questionnaire (TPQ). The process measures of the study were extracted from the subscale dynamics (including the dynamic complexity of their time series) of the TPQ. The outcome criterion was measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) which was completed pre-post and on a bi-weekly schedule by all patients. A second outcome criterion was based on the symptom severity subscale of the TPQ. Results supported the hypothesis of discontinuous changes (pattern transitions), the occurrence of critical instabilities preparing pattern transitions, and of stable boundary conditions as prerequisites for such transitions, but not the assumption of motivation to change as a control parameter.
A large number of findings within psychotherapy research during recent years have revealed phenomena that, in classical medical models, would be considered anomalies. An example of such a phenomenon is the occurence of sudden gains in the course of symptoms, which go along with substantial changes in outcome criteria before the employment of any psychotherapeutic interventions (Ilardy and Craighead, 1999; Stiles et al., 2003; Tang et al., 2005, 2007; Vittengl et al., 2005; Busch et al., 2006; Kelly et al., 2007; Stulz et al., 2007). These findings suggest the psychotherapeutic process to be discontinuous and non-stationary instead of continuous and linear (Schiepek et al., 1992; Hayes and Strauss, 1998; Hayes et al., 2007; Schiepek and Perlitz, 2009; Haken and Schiepek, 2010). Together with findings that ascribe a comparatively small part of outcome variance to interventions and therapeutic techniques (Shapiro et al., 1994; Ahn and Wampold, 2001; Lambert and Ogles, 2004; Wampold, 2010), they give raise to substantial doubts on the classical view of linear proportionality between input (dosage) and output (outcome) in psychotherapy. Whereas input-output-mechanisms or mainstream dose-outcome models suppose some kind of linear or damped proportionalities between interventions and outcome, non-linear dynamic systems do not assume such proportionalities. Here small interventions can result in large effects on further system trajectories, or big interventions can be counterbalanced by the system dynamics—depending on the stability state of the system under consideration. By this, the mentioned results from the common factors research in psychotherapy point toward the non-linearity of therapeutic processes as a complex system, but further straightforward and positive indications of non-linear characteristics of change processes are necessary. Indeed, some studies produced findings of deterministic chaos, pattern formation and pattern transitions, non-linear precursors of critical events, and dynamic synchronization in high-resolution process markers of psychotherapy (e.g., Kowalik et al., 1997; Schiepek et al., 1997, 2009, in press; Tschacher et al., 1998, 2000; Granic et al., 2007; Ramseyer and Tschacher, 2008; Lichtwarck-Aschoff et al., 2012; Heinzel et al., 2014).