Journal of Consulting and Clinical Psychology Copyright 1998 by the American Psychological Association, Inc.

1998, Vol. 66, No. 6. 939-947 0022-006X/98/$3.00

Dynamic Systems Theory as a Paradigm for the Study of Change in

Psychotherapy: An Application to Cognitive Therapy for Depression

Adele M. Hayes and Jennifer L. Strauss

University of Miami

Dynamic systems theory provides a conceptual framework for the study of change in psychotherapy
that is consistent with that used in other sciences. A dynamic systems model of change was proposed
and evaluated in the context of cognitive therapy for depression. Consistent with this model, less
client protection and more destabilization of depressive patterns predicted more improvement at the
end of treatment. Less protection was associated with more therapist support/stabilization. More
destabilization was associated with more affective intensity in the session and with more of a therapist
focus on the historical antecedents of current problems, exposure to multiple sources of corrective
information, and repeated practice of new skills. Although preliminary, this pattern of findings is
consistent with the model proposed and with principles of dynamic systems from other sciences.

Stiles and Shapiro (1994) urged researchers to find new ways
to study the change process in psychotherapy because, in their
view, progress with existing paradigms has been slow and disap-
pointing. Nonlinear dynamic systems' theory has gained mo-
mentum as a unifying paradigm for the study of pattern forma-
tion and change across a number of sciences, such as physics,
biology, neuroscience, political science, and economics. This
new science is revealing common principles across systems as
diverse as cells, neurons, and entire ecosystems (Thelen, 1995).
There have been a number of excellent reviews of recent
applications of dynamic systems theory to developmental psy-
chology (Thelen & Smith, 1994), social and personality psy-
chology (Carver & Scheier, in press; Heatherton & Weinberger,
1994; Vallacher & Nowak, 1994), psychotherapy (Mahoney,
1991; Tschacher, Schiepek, & Brunner, 1992), and psychology
in general (Abraham & Gilgen, 1995; Barton, 1994; Roberson &
Combs, 1995). The research in developmental psychology is
particularly sophisticated, and we believe that it can be applied
readily to the study of change in psychotherapy. As background,
we present only the most basic principles of dynamic systems
theory from developmental psychology. We present a model of
change that integrates these principles with those from dynamic
systems theories of psychotherapy and then evaluate this model
in the context of cognitive therapy (CT) for depression.
Adele M. Hayes and Jennifer L. Strauss, Department of Psychology,
University of Miami.
We thank Steve Hollon and Robert DeRubeis for providing the ar-
chived sessions and the data from the Cognitive-Pharmacotherapy Treat-
ment project. We are grateful to our raters for their many hours of hard
work. We also thank Charles Carver, Marvin Goldfried, Melanie Harris,
and Michael Mahoney for their very helpful comments on earlier versions
of this article.
Correspondence concerning this article should be addressed to Adele
M. Hayes, Department of Psychology, University of Miami, P. O. Box
249229, Coral Gables, Florida 33124-0721. Electronic mail may be sent
to ahayes@umiami.ir.miami.edu.
Dynamic Systems Theory in Developmental Psychology
Basic Principles
A dynamic system consists of interacting components that
change and evolve over time. An adaptive system maintains a
dynamic balance between the opposing processes of stability
and variability. Stabilizing forces maintain the coherence or in-
tegrity of a system, whereas variability provides the flexibility
necessary for growth and change. Change is viewed as move-
ment through a series of states of stability, variability, and shifts
in attractor states (Thelen & Smith, 1994).
The history of a system can reveal its current dynamics and
likelihood for change (Siegler & Ellis, 1996; Thelen, 1995).
When a dynamic system self-organizes, the components settle
into preferred patterns called attractor states. Attractors that
have been approached repeatedly over time are particularly sta-
ble, are activated over a variety of conditions, and require a
significant amount of energy to move from their preferred state.
Attractors with less of a history or less stability are most sensi-
tive to perturbation and thus have the greatest potential for
change.
Dynamically stable systems undergo constant perturbations
that arise from internal dynamics and exchanges with the envi-
ronment. Stabilizing forces maintain system coherence and in-
tegrity by assimilating perturbations, thereby keeping the system
organized around the same attractor state. When the flow of
energy and new information increases variability to the point
that it can no longer be assimilated, the existing system becomes
destabilized, and new dynamic patterns can emerge or be discov-
ered (Kelso, Ding, & Schoner, 1993; cf. Piaget, 1975/1985;
Thelen & Smith, 1994). A shift to a new organization is called
a phase transition or bifurcation. After transition, old patterns
compete with the new, and there is an ongoing process of trial
1
Both the terms dynamic and dynamical systems are used in the
psychology literature, but it should be noted that the term dynamical
systems is preferred in most other sciences.

939
940 HAYES AND STRAUSS
and error, until these attractor states stabilize with repeated prac-
tice (Thelen, 1995).
The Study of Change
Kelso et al. (1993) advocated the study of phase transitions
to develop a theoretical understanding of learning and change.
To accelerate or induce phase transitions, developmental re-
searchers have children engage in repeated practice of novel
behavior. Repeated practice is thought to both induce change
and maintain it (Kuhn, 1995; Siegler, 1994; Thelen, 1995).
Researchers then examine individual growth or learning patterns
across the trials, identify transition points, and study intensively
the trials immediately before and after transition.
In an elegant series of experiments on biological coordination,
Kelso et al. (1993) used this method to demonstrate that phase
transitions are preceded by periods of heightened system vari-
ability and are followed by periods of increased stability. In-
creased variability also has been demonstrated to precede chil-
dren's learning of new motor and language skills (Thelen &
Smith, 1994), arithmetic problem-solving skills (Goldin-
Meadow & Alibali, 1995; Siegler, 1994), and inductive causal
inference strategies (Kuhn, 1995). After identifying this critical
variability before transition, researchers study the organization
of the system, the factors that induce variability, and the mecha-
nisms that underlie the variability. With this information, more
precise qualitative and quantitative models can be developed (for
guidelines, see Abarbanel, 1996; Kelso et al., 1993; Levine &
Fitzgerald, 1992; Vallacher & Nowak, 1994). This research
strategy has led to significant theoretical and applied advances
in developmental psychology (Thelen, 1995) and thus may be
a fruitful way to study similar processes of learning and growth
in psychotherapy.
Dynamic Systems Theory in Individual Psychotherapy
Basic Principles: A. Theoretical Synthesis
Several authors have reconceptualized the process of change
in individual psychotherapy from the perspective of dynamic
systems theory (Caspar, Rothenfluh, & Segal, 1992; Greenberg,
Rice, & Elliott, 1993; Mahoney, 1991; Schiepek, Fricke, &
Kaimer, 1992).2 The components of these theories are not new;
they have been presented in different literatures with a variety of
labels and associated theories of change. The dynamic systems
perspective provides a conceptual framework that integrates this
rather fragmented literature and is compatible with models of
change in other sciences. Mahoney's (1991) theory is the most
comprehensive, but these authors converge on a number of im-
portant points. The integrated model that we present is based
on these points of convergence and on principles of dynamic
systems from developmental psychology.
According to dynamic systems theorists in individual psycho-
therapy (Caspar et al., 1992; Greenberg et al., 1993; Mahoney,
1991; Schiepek et al., 1992), psychological growth is a lifelong
process that is characterized by periods of stability and instabil-
ity. Psychopathology is a state of dynamic equilibrium, where
the attractor state consists of well-organized patterns of cogni-
tive, affective, behavioral, and somatic functioning that interfere
with the individual's well-being and everyday functioning (Ma-
honey, 1991). These patterns can become so well established
that they are considered lifestyles (Schiepek et al., 1992). Be-
cause they provide structure to the individual's life, stabilizing
forces maintain these patterns, even if the existing system does
not function optimally.
Self-protective mechanisms must be overcome before change
can occur, and thus they influence the pacing and direction of
change (Mahoney, 1991). It is perhaps for this reason that client
protection (often called resistance3) is a well-documented pre-
dictor of worse outcomes in psychotherapy (for reviews, see
Beutler, Sandowicz, Fisher, & Albanese, 1996; Hanna, 1996;
Orlinsky, Grawe, & Parks, 1994). To decrease protection, the
therapist can provide a secure, safe environment; augment the
client's strengths, self-esteem, coping resources, and social sup-
port; and provide a sense of hope (cf. Hanna, 1996). These
strategies also can help maintain new changes.
As in other dynamic systems, destabilization is viewed as a
necessary and natural process that allows for growth and change.
Unless challenged, the system will gravitate to the preferred
attractor state. Minor change can occur by making adjustments
within the existing attractor state or by increasing the system's
ability to shift between existing attractor states (Schiepek et al.,
1992). For a major reorganization of the system to take place,
old patterns must be shaken loose or destabilized to allow for
new configurations to emerge or be discovered.
Mahoney (1991) described destabilization as a period of sys-
temwide disorder marked by variability in such domains as
thought patterns, affect, behavior, intimacy, sleep, appetite, and
somatic functioning (cf. Hager, 1992; Stiles et al., 1991). Clients
often report feeling a sense of disorganization (as if they are
falling apart or coming unglued), fear, dread, and intense vulner-
ability, as the structure that once gave them support is shaken.
Paradoxically, "aha" experiences and perspective shifts often
accompany this turbulence. If destabilization occurs when the
client is ready, it can herald movement toward an attractor state
that is more flexible and adaptive than the one that maintained
current problems. However, a person may return to the old at-
tractor state or even to a less adaptive one if he or she does not
have the capacities or resources to sustain the transformation
(Mahoney, 1991). Although destabilization before change is
theoretically important in the psychotherapy literature, it has not
been examined empirically.
Consistent with dynamic systems theories in developmental
psychology (Siegler & Ellis, 1996; Thelen, 1995), destabiliza-
tion can be facilitated in therapy by understanding the history
of the existing system and by increasing the flow of energy and
new information in the system. An exploration of a system's
history can be a potent way to identify and activate long-standing
patterns related to current problems and can reveal information
on the stability of these patterns. A focus on such central patterns
2
In this review, we focus on theories of change in individual psycho-
therapy, the most simple of cases, rather than on the dynamic systems
theories that address more complex systems, such as the marital dyad
(e.g., Gottman, 1993), family system (e.g., Bateson, 1979; Haley, 1971),
and group (e.g., Burlingame, Fuhriman, & Barnum, 1995),
3
See Mahoney (1991) for an excellent discussion of the different
connotations of the terms resistance and self-protection.
 DYNAMIC SYSTEMS IN PSYCHOTHERAPY
is also likely to increase the affective intensity or energy in the
system (Caspar et al., 1992; Greenberg et al., 1993; Mahoney
1991; Schiepek et al., 1992). Although not studied from a dy-
namic systems perspective, preliminary evidence suggests that
a historical focus is associated with more improvement in CT
for depression (Hayes, Castonguay, & Goldfried, 1996; Jones &
Pulos, 1993).
With an understanding of the system's history, the therapist
can facilitate destabilization by exposing the client to new infor-
mation that powerfully challenges the existing patterns and by
having the client try and repeatedly practice novel behavior
(Caspar et al., 1992; Greenberg et al., 1993; Mahoney, 1991;
Schiepek et al., 1992). Corrective information from multiple
data streams (cognitive, affective, behavioral, and somatic) is
thought to most fully activate and challenge existing patterns
and to increase the affective intensity in the system (Caspar et
al., 1992; R>a & Kozak, 1986; Teasdale & Barnard, 1993). As in
developmental psychology (Kuhn, 1995; Siegler, 1994; Thelen,
1995), a number of studies have demonstrated that between-
sessions practice (homework) is an important component of CT
for depression (Robins & Hayes, 1993).
The Study of Change
As a first step, we used a new measure to operationalize the
proposed model of change and then applied a rough approxima-
tion of the research strategy from developmental psychology to
study the process of change in CT for depression. CT is a good
place to begin because its tasks are similar to those studied in
developmental psychology in that both involve introducing new
information, teaching new skills and strategies, and encouraging
repeated practice.
Sessions were sampled from the phase of therapy that pre-
ceded the transition point, which we defined as the session by
which most of the change in depression had occurred for all
clients. On the basis of the proposed model, lower ratings of
client protection and higher ratings of destabilization were ex-
pected to predict more improvement in depression and global
adjustment at outcome. More therapist support/stabilization was
predicted to be associated with lower ratings of protection. More
exploration of the historical antecedents of current problems,
exposure to multiple sources of corrective information, encour-
agement of repeated practice, and affective intensity in the ses-
sion were predicted to be associated with higher ratings of
destabilization.
Method
The present study was based on archival data collected as part of
the Cognitive-Pharmacotherapy Treatment Project (CPT; Hollon et al.,
1992), an outcome study that compared the efficacy of CT (Beck,
Rush, Shaw, & Emery, 1979), with and without pharmacotherapy, and
pharmacotherapy, with and without maintenance medication, over the
follow-up period. The CT groups were combined for statistical analyses,
as has been done in other published studies with the CPT data set (e.g.,
DeRubeis et al., 1990; Hayes et al., 1996; Jones & Pulos, 1993). The
CPT study design and methods are described in detail by Hollon et al.
(1992).
941
CPT Client Sample
The CPT sample consisted of 107 depressed outpatients who met
research diagnostic criteria (RDC; Spitzer, Endicott, & Robins, 1979)
for major depressive disorder, scored 20 or above on the Beck Depression
Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), and
scored 14 or above on the Hamilton Rating Scale for Depression (HRSD;
Hamilton, 1960). Exclusion criteria included past or current RDC diag-
nosis of schizophrenia, bipolar I affective disorder, organic brain syn-
drome, antisocial personality disorder, panic disorder or generalized anx-
iety disorder, substance abuse, an IQ less than SO, or a suicide risk
necessitating immediate hospitalization. A total of 64 clients (16 in each
group) completed the 12-week treatment protocol.
The pooled CT sample used in the present study included 32 (25
female and 7 male) clients. Of these, 88% were Caucasian and 12%
were African American. The mean age was 33.8 years (SD = 10.6;
range = 18-62). The median number of previous episodes of depression
was 3.5. As many as 75% of the clients reported suicidal ideation at
intake, and 31 % reported having made at least one prior suicide attempt.
In general, this sample was lower middle class and moderately to severely
depressed. Of the 32 CT clients, 30 had both complete data at posttreat-
ment and audible session tapes available from the phase of treatment
sampled in the present study.
Therapists and Treatments
The four therapists were a PhD-level psychologist (male) and three
clinical social workers (two male and one female), who had a range of
8 to 20 years of therapy experience and no previous training in CT.
Therapists received training for 6 to 14 months and weekly supervision
throughout the course of the study. Each therapist treated 4 clients in
each of the two CT conditions.
Clients assigned to the two CT groups were seen over a 12-week
period for a maximum of twenty 50-min sessions. In the combined
group, clients were administered imipramine hydrochloride (up to 200-
300 ing of imipramine per day by the 3rd week of treatment) and met
weekly with their pharmacotherapist for medication monitoring. At the
end of the 12 weeks, the participants were tapered off the medication
for a 2-week period and did not receive maintenance doses of medication.
Both CT groups were at least as effective as the pharmacotherapy groups
(Hollon et al., 1992). Evans et al. (1992) estimated that, compared with
pharmacotherapy without maintenance, there was a 64% reduction in
the risk of relapse when clients in the CPT study had previous CT.
Transcripts
Using a rough approximation of the research strategy used in develop-
mental psychology, we identified the point by which 90% of the total
change in depression had occurred for the client sample, which was by
the 6th week of therapy (Hollon et al., 1992). During this period, ses-
sions were held one to two times per week. Sessions were selected from
the phase of therapy that preceded the transition point but followed the
orientation to CT (Sessions 4-7). A better strategy would have been
to identify the transition point for each individual and then to rate the
sessions that immediately preceded that point, but we did not have access
to session-by-session symptom ratings. However, three other studies that
have examined the process of change in the CPT data set selected
sessions from this same phase of therapy and identified some important
variables related to change (Castonguay, Goldfried, Wiser, Raue, &
Hayes, 1996; Hayes et al., 1996; Jones & Pulos, 1993). All sessions
included a focus on a problem related to the individual's depression.
Measures
Depression measure. Depressive symptomatology at pretreatment
and posltreatment was measured by a composite score. This score was
942 HAYES AND STRAUSS
calculated by standardizing scores on the BDI and HRSD and then
averaging them. Hollon et al. (1992) reported excellent interrater agree-
ment between clinicians on the HRSD (r = .96).
Global adjustment Clients' general psychological, social, and occu-
pational functioning at pretreatment and postlreatment was assessed by
the Global Adjustment Scale (GAS; Endicott, Spitzer, Fleiss, & Cohen,
1976). The GAS is a clinician-rated instrument that ranges from 1 to
100, with higher scores representing better functioning. Hollon et al.
(1992) reported excellent interrater agreement between clinicians on the
GAS (r = .84).
Therapy process ratings. The Rating Scale of Therapy Change Pro-
cesses (TCP; Hayes & Goldfried, 1996) is an observational measure
thai was designed to assess the variables in the integrated dynamic
systems model of change described in this article. To define and clarify
the categories in the rating scale, Adele M. Hayes studied and rated
cognitive and interpersonal therapy transcripts from the first Sheffield
Psychotherapy Project (Shapiro & Firth, 1987) and from another study
on turning-point sessions submitted by expert cognitive and interpersonal
therapists (described in Wiser & Goldfried, 1993). The TCP is divided
into two separate sections, the therapist interventions used and the client
reactions to these interventions. Ratings are made for the entire session,
rather than utterance by utterance.
Raters assess the extent to which a therapist intervention is a focus
of the session, using a scale ranging from 0 (not a significant focus of
the session) to 3 (a very significant focus of the session). An intervention
that is a very significant focus of the session is one that is a major theme
of the therapist's work in the session, apart from the impact that it has on
the client. Therapist support or stabilization is defined as interventions
designed to enhance the client's readiness for change or to stabilize new
patterns after change occurs. This can include providing a sense of
safety, trust, respect, and security; augmenting the client's strengths,
self-esteem, coping resources, and social support; and providing a sense
of hope. Exploration of historical antecedents is a focus on the client's
early experiences with parents or primary caregivers to identify, explore,
or examine issues related to the current problems. Exposure to multiple
sources of corrective information is using interventions that encourage
the client to gather information that challenges the existing problematic
patterns in some way. This can include exposure to avoided material
and to new information and experiences that are designed to challenge
old patterns. The extent to which the therapist focuses on exposing the
client to corrective information is rated in each of four domains: cogni-
tive, affective, behavioral, and somatic. Interventions can target more
than one domain of functioning. A summary score is derived from these
ratings to reflect the extent of focus and breadth of the interventions,
This summary score is based on the number of domains in which the
interventions are a moderately to very significant focus of the session.
Summary ratings range from 0 (not a significant focus—i.e., no ratings
of moderately to very significant focus in any of the domains) to 3 (very
significant focus—i.e., ratings of at least a moderately significant focus
in three or more domains, with a rating of a very significant focus in
at least one of these domains). Repeated practice is encouraging the
client to apply and practice new ways of thinking, feeling, or behaving
outside of the therapy session. This can include suggestions, assignments,
and exercises.
Client reactions are rated as 1 (low), 2 (medium), or 3 (high).
Protection is coded when there is evidence that the client is engaging
in defensive maneuvers that influence whether he or she engages in
therapy, confronts previously avoided material, processes new informa-
tion, or engages in new experiences. Affective intensity is the degree
of discomfort expressed by the client in the session when addressing
therapeutic issues. This can be expressed verbally, nonverbally, or
through silences. Destabilizjation is defined as the extent of variability
or turbulence in cognitive, affective, behavioral, and somatic functioning.
Variability can include signs of distress (e.g., cognitive disorganization
and confusion, anxiety, dread, panic, changes in intimacy, changes in
sleep and appetite, and various somatic complaints), as well as increased
flexibility or softening of old patterns (perspective shifts, sudden insight
and aha experiences, emergence of new beliefs, emotions, and behav-
iors). This variability can be accompanied by a sense of enlightenment,
clarity, or peacefulness. A low level of destabilization reflects little
variability or minor fluctuations across the four domains of functioning.
A medium level reflects moderate variability in no more than two do-
mains, and this variability is not strong or dramatic in more than one
domain. A high level reflects moderate variability across three or more
domains, with strong variability in al least one of these domains.
Because the destabilization variable is central to the integrated model
of change examined in this study, we provide a brief example of a
session that would receive a high rating for destabilization.
Soon after the therapist and client explored the client's feelings of
being shut down and unloved by his father, the client visited his
family. During that visit, his father was distant, critical, and did not
express affection. The client wanted to say something but did not.
Over the following week, he reported feeling lost, confused, and
afraid. In addition, he had headaches, stomach aches, and problems
sleeping. As the therapist explored the connection between these
feelings of distress, the visit, and the past, the client became increas-
ingly hostile and avoidant. He realized suddenly that during the
visit, he had again felt unloved and that he had shut down his
feelings, just as he had always done. He then was ready to explore
these feelings further and develop a plan for talking with his father,
tasks that he previously had avoided.
In this example, there is evidence of variability in the cognitive, affective,
behavioral, and somatic domains.
Raters and Interrater Agreement
Three clinical psychology graduate students served as raters in this
study. Raters were trained to a criterion level of interrater agreement of
.80 before they were assigned to rate the transcripts from the CPT study
(Hollon et al., 1992). Each transcript was rated by two raters, who were
rotated so as to be paired with each other rater an equal number of
times. All raters were unaware of the clients' symptom status at all
assessment points. Intraclass correlation coefficients (Case 1, 1;
Shrout & Fleiss, 1979) were used to estimate agreement on independent
codings of pairs of raters for all 30 transcripts. The estimates of agree-
ment on the coding categories ranged from .78 to .90, and the modal
agreement for categories was approximately .82. For each transcript, the
ratings for each pair were averaged, and these averaged scores were
used in all of the analvses.
Results
Table 1 shows the means and Intel-correlations of the therapist
interventions and the client reactions. Table 2 shows the partial
correlations between each of the therapist interventions and cli-
ent change processes with outcome measures, after controlling
for prelreatment severity. This hierarchical multiple regression
strategy was used to facilitate comparisons with other studies
that have used the same strategy with the CPT data set (e.g.,
Castonguay et ah, 1996; Hayes et ah, 1996; Jones & Pulos,
1993). However, we acknowledge the controversy among con-
temporary methodologists regarding the best measure of change
(e.g., Speer & Greenbaum, 1995) and recommend the use of
growth curve analyses for studies that include more assessment
points. Because we predicted the direction of the relations be-
 DYNAMIC SYSTEMS IN PSYCHOTHERAPY 943

Table 1
Intercorrelations, Means, and Standard Deviations of Therapy Change Process Variables

Variable SD

Therapist interventions {range - 0-3)

1. Support and stabilization — .11 .17 .29 -.59*** .08 .19 1.10 0.80
2. Repeated practice — .21 .17 .00 .23 .36* 1.00 1.23
3. Multiple sources of
corrective information — .13 —.17 .33* .48** 2.43 0.38
4. Historical antecedents — —.02 .34* .43** 0.50 0.97

Client reactions (range - 1-3)

5. Protection — -.15 -.20 1.83 0.83

6. Affective intensity — .66*** 1.87 0.73
7. Destabilization — 1.78 0.86

Note, n = 30.
*ps.05. **ps.Ql. ***ps.001.

tween variables, one-tailed tests of significance were used for duction, after controlling for the symptom reduction that had
all analyses. occurred from pretreatment to the transition point (the 6th week
As predicted, Table 2 shows that less client protection pre- of therapy). Partial correlations of the relations between destabi-
dicted more improvement at the end of treatment (but only in lization and posttreatment symptom reduction remained statisti-
global adjustment), and more destabilization predicted improve- cally significant (for depression, r = — .48, p = .008; for global
ment in both depression and global adjustment. A therapist focus adjustment, r = .40, p = .03). These findings make it difficult
on the historical antecedents of current problems also predicted to argue that destabilization predicted change at the end of treat-
improvement in depression. Using an alpha level of .05, we ment because it simply reflected change that had already oc-
found that no other therapist interventions or client processes curred. It is also important to note that destabilization, as we
predicted change on either of the measures of outcome. defined it, actually looks like a worsening of symptoms rather
Because we rated sessions that preceded the point by which than an improvement.
most of the change had occurred for the client sample, rather Table 1 shows the correlates of client protection and destabili-
than for a given individual, it is possible that some clients had zation. Using Pearson product-moment correlations, we found
already experienced significant symptom reduction before the that, as predicted, less client protection was associated with
session that we selected for them. Therefore, we examined the more therapist support/stabilization. Also consistent with pre-
relation between destabilization and posttreatment symptom re- dictions, destabilization was associated with a focus on the his-
torical antecedents of the client's problems, exposure to multiple
sources of corrective information, the encouragement of re-
Table 2 peated practice, and with more affective intensity in the session.
Partial Correlations of Therapy Change Process Variables When the three therapist interventions were entered simultane-
and Posttreatment Outcome, Controlling ously into a multiple regression equation as predictors of desta-
for Initial Symptom Seventy bilization, a focus on historical antecedents (B = .35, p = .02)
and exposure to multiple sources of corrective information (B
Depression Global
Variable composite adjustment
= .39, p = .01) contributed uniquely to the variance, with a
total adjusted R2 for the equation of .34. These two interventions
Therapist interventions also were associated with more affective intensity.
Support and stabilization -.24 .29 Because a therapist focus on the historical antecedents of
Repeated practice -.27 .12 current problems and client destabilization were correlated sig-
Multiple sources of corrective information -.13 .09 nificantly with one another and both were significant predictors
Historical antecedents -.44** .19
of improvement in depression, we used path analysis (e.g.,
Client reactions Baron & Kenny, 1986) to examine destabilization as a mediator
of change (see Figure 1). Historical antecedents and destabiliza-
Protection .27 -.34*
tion were entered simultaneously as predictors of posttreatment
Affective intensity -.15 .11
Destabilization -.46** .41** depression. Because pretreatment level of depression was not a
significant predictor of posttreatment depression in any of the
Note, n - 30. A negative partial correlation on the composite measure partial correlations conducted earlier, it was not entered into
of depression is associated with less depression. A positive partial corre-
these regression analyses. As seen in Figure 1, destabilization
lation on the Global Assessment Scale is associated with better function-
ing. remained a significant predictor of improvement in depression,
*p a .05. **p s .01. whereas the correlation between historical antecedents and out-
944 HAYES AND STRAUSS
-.23 us (-.40')
Historical Antecedents » Depression
(.43*)
Destabilization
Figure 7. Path diagram for testing direct and indirect effects of explo-
ration of historical antecedents on treatment outcome, with destabiliza-
tion as a mediator. (The historical antecedents variable was assessed
concurrently with destabilization. Model predicted depression at post-
treatment.) The values inside the parentheses are simple correlations,
and the values outside the parentheses are standardized regression coef-
ficients. *p s .05. **p a .01.
come was reduced and did not remain significant. These findings
suggest that destabilization partially mediates the relation be-
tween a focus on historical antecedents and improvement in
depression. However, a stronger case for mediation could be
made if the correlation were reduced to near zero and if the focus
on historical antecedents were measured before destabilization
occurred, rather than during the same session.
Discussion
In this preliminary study of change in CT for depression,
we used a new measure, the Rating Scale of Therapy Change
Processes (Hayes & Goldfried, 1996), to evaluate the proposed
model of change. We examined protection and destabilization
as predictors of treatment outcome and also examined their
relations with therapist interventions. Because this study is the
first in a program of research, the results should be considered
preliminary.
Protection
The study of psychotherapy introduces a new level of com-
plexity to the modeling of change because it can involve chang-
ing long-standing and pervasive patterns, or lifestyles, rather
than a single cell, neuron, or developmental task. In Mahoney's
(1991) dynamic systems perspective, it is natural and healthy
for an individual to resist moving too far and too quickly beyond
familiar patterns, even if those patterns interfere with function-
ing and cause distress. Self-protective mechanisms can be
viewed as rate-limiting factors in that change can only occur to
the extent that these mechanisms do not block challenges to the
existing system. In line with this, we found that more protection
predicted less change in global adjustment, and there was a
similar tendency with depression. This is consistent with the
well-documented demonstrations of the relation between client
resistance and poor treatment outcomes across theoretical orien-
tations (Beutler et al., 1996; Hanna, 1996; Orlinsky et al., 1994).
From a dynamic systems perspective, though, self-protection is
seen as a natural and healthy response to threats to a system's
integrity. As such, it is to be respected and used as a guide in
the pacing of change (Mahoney, 1991).
According to Mahoney (1991), the therapist needs to assess
and then enhance the client's readiness for change. Providing a
secure, supportive therapeutic environment and strengthening
internal and external resources can prepare the client to undergo
destabilization (Caspar et al., 1992; Greenberg et al., 1993;
Schiepek et al., 1992). In line with this, we found that more
therapist support and stabilization strategies were associated
with less client protection. Part of this stabilization process may
involve fostering a strong therapeutic alliance, which has been
demonstrated to be an important predictor of change hi therapy
(Mahoney, 1991; Orlinsky et al., 1994; Tschacher, Scheier, &
Grawe, 1997). When taken alone, our findings on client protec-
tion are not particularly new. However, in the context of the
larger model proposed, further understanding of the self-protec-
tion process may shed light on when destabilization will be
blocked, and when it will result in decompensation, minor
changes, or movement toward more adaptive patterns.
Destabilization
Because destabilization reflects turbulence in the system, it
can appear to be a worsening of symptoms, but this increased
turbulence should be followed by improvement and the emer-
gence of more adaptive patterns (Caspar et al., 1992; Greenberg
et al., 1993; Mahoney, 1991; Schiepek et al., 1992). Indeed, we
found that destabilization was associated with more affective
intensity and that it predicted improvement in both depression
and global adjustment. These findings are consistent with the
assertion that change in therapy may involve "getting worse
before getting better" (Hager, 1992; Mahoney, 1991; Reynolds
et al., 1996; Thompson, Thompson, & Gallagher-Thompson,
1995).
There appears to be significant convergence across areas of
psychology on the importance of destabilization in the change
process. Variability plays a central role in theories of change in
developmental psychology (Kelso et al., 1993; Siegler & Ellis,
1996; Thelen, 1995; Thelen & Smith, 1994), marital relation-
ships (Gottman, 1993), social cognition and behavior (Val-
lacher & Nowak, 1994), and in theories of change proposed
nearly 20 years ago in family therapy (e.g., Bateson, 1979;
Haley, 1971). Similarly, Carver and Scheier (in press) suggested
that there are naturally occurring instances of destabilization
that may be similar to what happens in therapy. For instance,
there is evidence that traumatic events that are associated with
significant emotional distress can shake up a person's worldview
and facilitate major reorganization (Foa, 1997; McMillen,
Smith, & Fisher, 1997; Tedeschi & Calhoun, 1995).
If this finding on the importance of destabili?.arion holds up
in future empirical studies on the process of change in psycho-
therapy, both therapists and clients need to recognize that desta-
bilization may be fundamental to a healthy growth process.
From this point of view, variability and chaos are not viewed
as noise in the system or as disturbances to quell, but rather as
opportunities for change. A related principle, though, is that
the client must have the capacities or resources to sustain the
transformation; that is, the client must be stable enough to desta-
bilize (Mahoney, 1991). For instance, Thompson et al. (1995)
 DYNAMIC SYSTEMS IN PSYCHOTHERAPY
reported that more variability (as measured by worsening and
improvement shifts in depression) was associated with more
improvement at the end of CT but that too much variability
seemed to predict an early relapse. Thus, an important task is
to identify who can tolerate destabilization, and to what degree,
and when destabilization results in progress rather than decom-
pensation or relapse.
Another issue to consider is that destabilization may be only
one route to change. Change also can occur by slight adjust-
ments within the current attractor state or by increasing the
system's ability to shift between existing attractors (cf. Bateson,
1972; Schiepek et al., 1992). Some therapies for depression
may involve less direct challenges than CT and therefore facili-
tate change that is more gradual and linear, with no distinct
periods of destabilization. The study of different therapies (e.g.,
interpersonal therapy) may reveal that they differ in the extent
of destabilization and perhaps in the types of change that they
produce.
By sampling from sessions that preceded change, we were
able to identify sessions with destabilization and to demonstrate
that this process was a significant predictor of improvement on
both measures of outcome. This provided a unique opportunity
to identify therapist interventions that may facilitate destabiliza-
tion. Dynamic systems theorists in the developmental psychol-
ogy (Kelso et al., 1993; Siegler & Ellis, 1996; Thelen, 1995;
Thelen & Smith, 1994) and psychotherapy (Caspar et al., 1992;
Greenberg et al., 1993; Mahoney, 1991; Schiepek et al., 1992)
have proposed that destabilization is facilitated by understanding
the history of the existing system and by increasing the flow of
energy and new information.
In the treatment of depression, a focus on the client's develop-
mental history is thought to activate the cognitive-affective net-
works and the patterns of interaction related to the depression
(Gotlib & Hammen, 1992; Robins & Hayes, 1993). Addressing
these core cognitive and interpersonal vulnerabilities is typically
affectively charged, which, from a dynamic systems perspective,
may provide the energy needed to activate and shake up the
current attractor. Two studies (Hayes et al., 1996; Jones & Pulos,
1993) used different rating systems to analyze sessions from
the same CPT data set (Hollon et al., 1992) and found, as we
did, that a historical focus was associated with more change in
depression. The present study elaborated on these findings in
that a historical focus also was associated with more affective
intensity and with destabilization. Destabilization partially me-
diated the relation between a historical focus and improvement
in depression. This focus on early experiences highlights a com-
mon emphasis in psychodynamic, interpersonal, cognitive, and
dynamic systems theories of change.
Interventions that challenge the patterns central to clients'
depression should be particularly potent and should facilitate
destabilization. One way to challenge these patterns is to expose
clients to corrective information, especially information that in-
volves the cognitive, affective, behavioral, and physiological
aspects of the patterns (Caspar et al., 1992; Foa & Kozak,
1986; Teasdale & Barnard, 1993). Indeed, exposure to multiple
sources of corrective information was associated with more af-
fective intensity and with more destabilization. These findings
are consistent with those on the process of change in exposure-
based treatments for anxiety disorders (e.g., Foa, Riggs, Mas-
945
sie, & Yarczower, 1995; Kozak, Foa, & Steketee, 1988), in
which affective arousal and repeated exposure to multiple
sources of corrective information have been identified as key
ingredients of change. Furthermore, both exposure and correc-
tive experiences have been proposed as common factors of ther-
apy by several authors (e.g., Arkowitz & Hannah, 1989; Gold-
fried, 1991;Grencavage & Norcross, 1990; Weinberger, 1993).
Studies on attitude change in social psychology also have em-
phasized the importance of increasing the flow of new informa-
tion into the system to create dissonance, increase energy, and
facilitate destabilization (Vallacher & Nowak, 1994). Taken to-
gether, these findings suggest that a historical focus and exposure
to multiple sources of corrective information may activate and
destabilize the depressive network.
In developmental research, repeated practice is used both to
bring about destabilization and to stabilize new changes (Kuhn,
1995; Siegler, 1994; Thelen, 1995). In therapy, the role of re-
peated practice is similar in that the client is encouraged to
break out of old patterns and to explore and practice new ways
of thinking, feeling, and acting. This experimentation introduces
novelty into the existing system, an important first step in the
change process (Mahoney, 1991; Schiepek et al., 1992). Consis-
tent with a growing number of studies that have demonstrated
that between-sessions practice, or homework, is an important
component of the CT treatment package (Robins & Hayes,
1993), we found that repeated practice was associated with
more destabilization.
Because the therapist interventions were rated in the same
session as was destabilization, it is not clear whether these inter-
ventions facilitated destabilization or whether they were used in
response to destabilization. For this reason, an important task
will be to study the interventions used in the sessions that imme-
diately precede destabilization.
Future Research
The next step in this program of research is to study an entire
course of cognitive therapy for depression and to apply a closer
approximation of the research strategy used in developmental
psychology. In such a design, the transition point for each client
can be identified rather than transition point for the entire client
sample. The sessions immediately before and after that transition
point can be sampled and the temporal sequencing of therapist
interventions and client change processes can be examined. Such
a design permits researchers to study another principle of dy-
namic systems theory—that system variability decreases after
destabilization—and to examine the roles of therapist support/
stabilization and repeated practice after change. In addition, it
will be important to move from simple pre—post designs and
toward more sophisticated growth curve analyses that generate
trajectories of change by individual and by group (Newman &
Howard, 1991).
As a body of information accumulates, researchers can con-
duct intensive qualitative analyses that track the nonlinear and
chaotic time course of the variables under investigation and,
eventually, move toward more sophisticated quantitative model-
ing of the change process (Abarbanel, 1996; Kelso et al., 1993;
Levine & Fitzgerald, 1992; Vallacher & Nowak, 1994). Dy-
namic systems theory provides a promising paradigm from
946 HAYES AND STRAUSS
which to develop and test more comprehensive models of change
in psychotherapy, but much exciting work remains to be done.
References
Abarbanel, H.D.I. (1996). Analysis of observed chaotic data. New
York: Springer-Verlag.
Abraham, F. D., & Gilgen, A. R. (1995). Chaos theory in psychology.
Westport, CT. Praeger.
Arkowitz, H., & Hannah, M. T. (1989). Cognitive, behavioral, and psy-
chodynamic therapies: Converging or diverging pathways to change.
In A. Freeman, K. M. Simon, L. E. Beutler, & H. Arkowitz (Eds.),
Comprehensive handbook of cognitive therapy (pp. 143-167). New
York: Plenum.
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable
distinction in social psychology research: Conceptual, strategic, and
statistical considerations. Journal of Personality and Social Psychol-
ogy. 51, 1173-1182.
Barton, S. (1994). Chaos, self-organization, and psychology. American
Psychologist, 49, 5-14.
Bateson, G. (1972). Steps to an ecology of mind. New York: Ballantine.
Bateson, G. (1979). Mind and nature: A necessary unity. New York:
Bantam.
Beck, A. T, Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive
therapy of depression. New York: Guilford Press.
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. E., & Erbaugh, I. K.
( 1 9 6 1 ) . An inventory for measuring depression. Archives of General
Psychiatry, 4, 561-571.
Beutier, L. E., Sandowicz, M., Fisher, D., & Albanese, A. L. (1996).
Resistance in psychotherapy: Conclusions that are supported by re-
search. In Session: Psychotherapy in Practice, 2, 77-86.
Burlingame, G. M., Fuhriman. A., & Barnum, K. R. (1995). Group
therapy as a nonlinear dynamical system: Analysis of therapeutic com-
munication for chaotic patterns. In F. D. Abraham & A. R. Gilgen
(Eds.), Chaos theory in psychology (pp. 87-105). Westport, CT:
Praeger.
Carver, C. S., & Scheier, M. F. (in press). On the self-regulation of
behavior. New York: Cambridge University Press.
Caspar, F, Rothenfluh, T., & Segal, Z. V. (1992). The appeal of connec-
tionism for clinical psychology. Clinical Psychology Review, 12, 719-
762.
Castonguay, L. G., Goldfried, M. R., Wiser, S., Raue, P. J., & Hayes,
A. M. (1996). Predicting the effect of cognitive therapy for depres-
sion: A study of unique and common factors. Journal of Consulting
and Clinical Psychology, 64, 497-504.
DeRubeis, R. J., Evans, M. D., Hollon, S. D., Garvey, M. J., Grove,
W. M., & Tuason, V. B. (1990). How does cognitive therapy work?
Cognitive change and symptom change in cognitive therapy and phar-
macotherapy for depression. Journal of Consulting and Clinical Psy-
chology, 58, 862-869.
Endicott, J., Spitzer, R. L., Fleiss, J. L., & Cohen, J. (1976). The Global
Assessment Scale: A procedure for measuring overall severity of psy-
chiatric disturbance. Archives of General Psychiatry, 33, 766-771.
Evans, M. D., Hollon, S. D., DeRubeis, R. J., Piasecki, J. M.. Grove,
W. M., Garvey, M. J., & Tuason, V. M. (1992). Differential relapse
following cognitive therapy and pharmacotherapy for depression. Ar-
chives of General Psychiatry, 49, 802-808.
Foa, E. B. (1997). Psychological processes related to recovery from a
trauma and an effective treatment for PTSD. In R. Yehuda & A. C.
McFarlane (Eds.), Psychobiology of posttraumalic stress disorder:
Annuals of the New York Academy of Sciences (pp. 410-424). New
York: New York Academy of Sciences.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Expo-
sure to corrective information. Psychological Bulletin, 99, 20-35.
Foa, E. B., Riggs, D. S., Massie, E. D., & Yarczower, M. (1995). The
impact of fear activation and anger on the efficacy of exposure treat-
ment for posttraumatic stress disorder. Behavior Therapy, 26, 487-
499.
Goldfried, M. R. (1991). Transtheoretical ingredients in therapeutic
change. In R. C. Curtis & G. Striker (Eds.), How people change:
Inside and outside of therapy (pp. 29-37). New York: Plenum.
Goldin-Meadow, S., & Alibali, M. W. (1995). Mechanisms of transition:
Learning with a helping hand. Psychology of Learning and Motiva-
tion, 33, 115-157.
Gotlib, I. H., & Hammen, C. L. (1992). Psychological aspects of de-
pression: Toward a cognitive-interpersonal integration. West Susses,
England: Wiley.
Gottman, J. M. (1993). A theory of marital dissolution and stability.
Journal of Family Psychology, 7, 57-75.
Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating emo-
tional change: The moment-by-moment process. New York: Guilford
Press.
Grencavage, L. M., &Norcross, J. C. (1990). What are the commonali-
ties among the therapeutic common factors? Professional Psychology:
Research and Practice, 21, 372-378.
Hager, D. (1992). Chaos and growth. Psychotherapy, 29, 378-384.
Haley, J. (Ed.). (1971). Changing families: A family therapy reader.
New York: Grune & Stratton.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurol-
ogy, Neurosurgery, and Psychiatry, 23, 56—62.
Hanna, F. J. (1996). Precursors of change: Pivotal points of involvement
and resistance in psychotherapy. Journal of Psychotherapy Integra-
tion, 6, 227-264.
Hayes, A. M., Castonguay, L. G., & Goldfried, M. R. (1996). The effec-
tiveness of targeting the vulnerability factors of depression in cognitive
Therapy. Journal of Consulting and Clinical Psychology, 64, 623-
627.
Hayes, A. M., & Goldfried, M. R. (1996). Rating Scale of Therapy
Change Processes. Unpublished manuscript, University of Miami.
Heatherton, T. F., &. Weinberger, J. L. (1994). Dynamical, nonlinear,
conditional, and functional models of behavior change. Washington,
DC; American Psychological Association.
Hollon, S. D., DeRubeis, R. I., Evans, M. D., Wiemer, M. J., Garvey,
M. J., Grove, W. M., & Tuason, V. B. (1992). Cognitive therapy and
pharmacotherapy for depression: Singly and in combination. Archives
of General Psychiatry, 49, 774-781.
Jones, E. E., & Pulos, S. M. (1993). Comparing the process of psycho-
dynamic and cognitive-behavioral therapies. Journal of Consulting
and Clinical Psychology, 61, 306-316.
Kelso, ]. A. S., Ding, M., & Schoner; G. (1993). Dynamic pattern forma-
tion: A primer. In L. B. Smith & E. Thelen (Eds.), A dynamic systems
approach to development: Applications (pp. 13—50). Cambridge,
MA: MIT Press.
Kozak, M. J., Foa, E. B., & Steketee, G. (1988). Process and outcome of
exposure treatment with obsessive-compulsives: Psychophysiological
indicators of emotional processing. Behavior Therapy, 19, 157-169.
Kulm, D. (1995). Microgenetic study of change: What has it told us?
Psychological Science, 6, 133-139.
Levine, R. L., & Fitzgerald, H. E. (1992). Analysis of dynamic psycho-
logical systems: Vol. L Basic approaches to general systems. New
"fork: Plenum Press.
Mahoney, M. J. (1991). Human change processes: The scientific foun-
dations of psychotherapy. New %rk: Basic Books.
McMillen, I. C., Smith, E. M., & Fisher, R. H. (1997). Perceived benefit
and mental health after three types of disaster. Journal of Consulting
and Clinical Psychology, 65, 733-739.
Newman, F. L., & Howard, K. I. (1991). Introduction to the special
 DYNAMIC SYSTEMS IN PSYCHOTHERAPY
section on seeking new clinical research methods. Journal of Con-
sulting and Clinical Psychology, 59, 8-11.
Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Process and outcome
in psychotherapy—Noch einmal. In A. E. Bergin & S. L. Garfield
(Eds.), Handbook of psychotherapy and behavior change (4th ed.,
pp. 270-376). New York: Wiley.
Piaget, J. (1985). The equilibrium of cognitive structures. Chicago:
University of Chicago Press. (Original work published 1975)
Reynolds, S., Stiles, W. B.. Barkham, M., Shapiro, D. A., Hardy,
G. E., & Rees, A. (1996). Acceleration of changes in session impact
during contrasting time-limited psychotherapies. Journal of Con-
sulting and Clinical Psychology, 64, 577-586.
Roberson, R., & Combs, A. (1995). Chaos theory in psychology and
the life sciences. Mahwah, NJ: Erlbaum.
Robins, C. J., & Hayes, A. M. (1993). An appraisal of cognitive therapy.
Journal of Consulting and Clinical Psychology, 61, 205-214.
Schiepek, G., Fricke, B., & Kaimer, P. (1992). Synergetics of psycho-
therapy. In W. Tschacher, G. Schiepek, & E. J. Brunner (Eds.), Self-
organization and clinical psychology (pp. 239-267). Berlin, Ger-
many: Springer-Verlag.
Shapiro, D. A., & Firth, J. A. (1987). Prescriptive vs. exploratory psy-
chotherapy: Outcomes of the Sheffield Psychotherapy Project. British
Journal of Psychiatry, 151, 790-799.
Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations: Uses in
assessing rater reliability. Psychological Bulletin, 86, 420-428.
Siegler, R. S. (1994). Cognitive variability: A key to understanding cog-
nitive development. Current Directions in Psychological Science, 3,
1-5.
Siegler, R. S., & Ellis, S. (1996). Piaget on childhood. Psychological
Science, 7, 211-215.
Speer, D. C., & Greenbaum, P. E. (1995). Five methods for computing
significant individual client change and improvement rates: Support
for an individual growth curve approach. Journal of Consulting and
Clinical Psychology, 63, 1044-1048.
Spitzer, R. L., Endicott, J., & Robins, E. (1979). Research diagnostic
criteria. New York: New 'tork State Psychiatric Institute, Biometrics
Research, Evaluation Section.
947
Stiles, W. B., Morrison, L. A., Haw, S. K., Harper, H., Shapiro, D. A., &
Firth-Cozens, J. (1991). Longitudinal study of assimilation in explor-
atory psychotherapy. Psychotherapy, 28, 195-206.
Stiles, W. B., & Shapiro, D. A. (1994). Disabuse of the drug metaphor:
Psychotherapy process-outcome correlations. Journal of Consulting
and Clinical Psychology, 62, 942-948.
Teasdale, J. D., & Barnard, P. J. (1993). Psychological treatment for
depression—The ICS [Interacting Cognitive Subsystems] perspec-
tive. In J. D. Teasdale & P. J. Barnard (Eds.), Affect, cognition, and
change (pp. 225-245). Hove, England: Erlbaum.
Tedeschi, R. G., & Calhoun, L. G. (1995). Trauma and transformation.
Thousand Oaks, CA: Sage.
Thelen, E. (1995). Motor development: A new synthesis. American
Psychologist, 50, 79-95.
Thelen, E., & Smith, L. B. (1994). A dynamic systems approach to
the development of cognition and action. Cambridge, MA: MIT
Press.
Thompson, M. G., Thompson, L., & Gallagher-Thompson, D. (1995).
Linear and nonlinear changes in mood between psychotherapy ses-
sions: Implications for treatment outcome and relapse risk. Psycho-
therapy Research, 5, 327-336.
Tschacher, W., Scheier, C., & Grawe, K. (1997). Order and pattern
formation in psychotherapy. Manuscript submitted for publication.
Tschacher, W., Schiepek, G., & Brunner, E. J. (1992). Self-organization
and clinical psychology. Berlin, Germany: Springer-Verlag.
Vallacher, R. R., & Nowak, A. (1994). Dynamical systems in social
psychology. San Diego, CA: Academic Press.
Weinberger, J. (1993). Common factors in psychotherapy. In J. Gold &
G. Strieker (Eds.), Handbook of psychotherapy integration (pp. 43-
56). New York: Plenum Press.
Wiser, S. L., & Goldfried, M. R. (1993). Comparative study of emo-
tional experiencing in psychodynamic-interpersonal and cognitive-
behavioral therapies. Journal of Consulting and Clinical Psychology,
61, 892-895.
Received September 25, 1996
Accepted June 8, 1998 •