Validity and clinical utility of the therapist version of the referential process post-session scale (RPPS-T)

Introduction: According to Bucci’s multiple code theory (Bucci, 1997; Bucci, Maskit, Murphy, 2015) a significant change in the patient-therapist relationship should reflect a referential process that is shaped by alternating phases: (a) arousal: experiencing emotion schemas, (b) symbolization: translating into words the emotional experiences, and (c) reorganization/reflection: recognizing, understanding and expanding the emotional significance. So far, in order to monitor the development of these three phases therapists and researchers have relied on their own clinical sensitivity and automated measures of the referential process (Mariani, Maskit, Bucci, & De Coro, 2013), which require the use of transcribed session material. In order to develop a parallel and less time-consuming method, developed a self-report questionnaire measuring the phases of the referential process, the Referential Process Post-session Scale – Therapist version (RPPS-T). Six constructs we intended to measure through the questionnaire: the emotional arousal of the therapist at the end of the session, the clarity, specificity, concreteness and imagery of therapeutic conversation according to the therapist – the four linguistic dimensions of the symbolization phase – and the extent of reorganization/reflection work performed during the session according to the therapist. Methods: To test the RPPS-T factorial structure psychotherapists were asked to complete an extended version (36 items) of the questionnaire at the end of their sessions. We collected 105 evaluations form eight psychotherapists regarding 29 patients. From the extended version of the questionnaire, through an exploratory factorial analysis we developed a shortened questionnaire (12 items) completed by other nine psychotherapists on 24 patients for a total of 130 compilations. On this second administration we conducted a confirmatory factor analysis. We also tested the concurrent validity checking the correlation between the RPPS-T scores and the computerized linguistic measures of the referential process obtained onto some session transcripts (n=18) and of therapist’s notes (n=18). Results: The exploratory factorial analysis has detected a well-defined solution, consistent with the hypothesized constructs, consisting of four factors (with three items each), one regarding the therapist emotional arousal, two referring the linguistic characteristics of the in-session conversation and one concerning the in-session symbolization work. We called these four factor a) emotion memory clarity, b) concreteness/imagery, c) specificity, and d) symbolization. The four-factor solution has demonstrated a good fit ( 2(48)=105.395, p<.001; CFI=0.940; TLI=0.91; RMSA=0.97; SRMR=0.049) by the confirmatory factor analysis conducted on the second administration. Internal consistency of the scales was adequate (α >.82). Two among the four RPPS-T scales yielded significant correlations with the computerized linguistic measures of the sessions and therapist notes: the RPPS-T symbolization scale positively correlates with High Weighted Referential Activity Dictionary (HWRAD) index measured onto the in-session patients interventions – a measure of the intensity of Referential Activity – and the RPPR-T emotion memory clarity correlates with the Weighted Referential Activity Dictionary (WRAD) and HWRAD indexes measured on the therapist notes. The RPPRS concreteness/imagery and specificity scales instead did not correlate with the linguistic measures of sessions and notes. Conclusions: RPPS-T had shown a valid factor structure and internal consistency and could be considered as a valid instrument from a statistical point of view. The factorial structure found confirms that the questionnaire detects the hypothesized constructs of the referential process. Also the criterion validity is partially confirmed by the correlation with the computerized linguistic measures of the session transcriptions and therapist’s notes. The more the patient has a clear, specific, concrete and vivid language during the session the more the therapist at the end of the session will have the impression of a good work of symbolization and connection jointly carried forward. Moreover, the more the therapist have a clear memory of the emotions experienced during the session, the more her/his notes on the session itself will have a high referential activity indicating a good elaboration and emotional connection with the patient. We can conclude that RPPS-T can be used as a quick and reliable measure of the referential process along the psychotherapeutic treatment. It does not replace the computerized linguistic measures of the session transcriptions, the richer and more direct indicators of the progress of the referential process in the session and in the treatment; however it is a parallel and less timeconsuming measure available to therapists and researchers: the firsts can easily use it as a tool for clinical monitoring and supervision, the seconds can apply it to study the referential process in correlation with the outcome measure and with the other important clinical constructs.