Since the use of language is a core aspect of psychotherapy, its study requires instruments that allow for further research. The aim of this study is to present an observational instrument capable of analyzing the language used in psychotherapeutic settings, both by therapists and clients. The SICOLENTE instrument was applied to two different samples: The Three Approaches to Psychotherapy film and a naturalistic sample. 7710 utterances from 31 sessions (three from the demonstration film and 28 from a naturalistic setting) were coded. Two studies were conducted: in the first study, inter and intra coder reliability (dimension and category levels) and Generalizability theory analyzes were assessed, whilst in the second study, construct validity was tested with several hypotheses. The final instrument resulted in 20 categories with three dimensions: Conversational Act (7 categories), Therapeutic topic (6 categories) and Content (7 categories). The three dimensions showed excellent inter and intra coder reliability and the generalizability coefficients were excellent. Out of the 24 validity hypothesis proposed,19 were accepted. The finding suggests that the SICOLENTE is a reliable and valid instrument that can be applied to investigate the performance of various theoretical models. Its three dimensional structure gives it the flexibility to be able to carry out macroscopic or microscopic language research.

Introduction

Psychotherapy is a spoken profession and the conversation between the professional and the client is the central aspect of this work [1,2]. The different psychotherapeutic models have emphasized this dialogue in a range of ways. Since Freud [3] declared that "Words were originally magic, and to this day words have retained much of their ancient magical power" (p.17), many attempts have been made to develop that magic to make psychological treatments successful. Among the humanists, Rogers raised the importance of the therapist's expressions in building the therapeutic relationship [4]; whilst a Gestalt perspective teaches users that the responsibility they have for their lives begins in language [5]. Beck and Ellis’s influential cognitive therapies [6,7] focus their therapeutic potential on discussing client beliefs in sessions. Third-generation therapies focus on the direct or metaphorical use of language to make it easier for people to become detached from their thoughts [8]. However, it is the constructivist therapies that have assigned more importance to linguistic interaction as a tool for constructing changes in-session [9–12].

If language is the basic tool to produce changes in the session, analyzing its use is undoubtedly a relevant issue for research into the process of psychotherapy. The study of this process will help to optimize therapeutic communication with the consequent benefits of improving the therapeutic outcomes and the training programs for new therapists.

The analysis of language in psychotherapy generally requires the use of an observational system or methodology. Gumz, Treese, Marx, Strauss and Wendt [13] have conducted a systematic review that sheds light on the instruments created to date. In this review, the authors found 34 language analysis instruments that met the review eligibility criteria. Among the inclusion criteria, the most basic was to present data regarding the psychometric properties, and this review highlighted the limitations of the selected instruments. The main flaw is that only two of the instruments had been developed to measure the therapist-client interaction [14,15], while the rest of the instruments focused on measuring aspects such as adherence to treatment and competence [16–19], the difference between models [20–23] or the relationship between specific techniques and therapeutic outcomes [24–27]. In addition, the review found that all the instruments evaluated had a specific theoretical orientation—or several in the case of pantheoretical instruments, and there were no instruments that could be regarded as truly atheoretical.

The objective of this work is to present a new observational system of analysis, the System of Codification of Therapeutic Language–Sistema de Codificación del Lenguaje Terapéutico in Spanish or SICOLENTE, designed with the objective of overcoming both limitations. This system is concerned with studying the psychotherapist-client interaction. In addition, since the ability to use language for different purposes (create a therapeutic relationship, change meanings, help regulate emotions, or encourage new behaviors) is a cross-cutting and basic therapeutic element common to most therapeutics models, the instrument is developed without any bias towards specific therapeutic theories.

Previous research reveals that the language used by the therapist is influenced by the theoretical models with which they work [28–30]. In particular, evidence has been found to suggest that the therapeutic models condition the discussion topic of the clients during the session, allowing them to focus more on describing the problem or the improvements [31,32]. In this regard, the study by Cuhna et al., [33] showed how a certain therapist's language skills made it easier for the client to express moments of improvement during the session. Therapists also use those language skills to respond to issues expressed by the clients. In this way, there is a stronger likelihood that therapists will show responses of approval when clients verbalize aspects that favor the achievement of treatment goals (e.g., show greater well-being or verbalization of achievements) or responses of disapproval when the clients verbalize aspects that distance them from the therapeutic objectives (e.g., when the clients verbalize that they did not perform the task or anticipate problems regarding the treatment) [34,35].

Hypothesis and work plan The objective of this study is to present the SICOLENTE and describe its psychometric characteristics. For this, two studies were carried out. Given that this is an observational instrument aimed at analyzing the psychotherapist-client dialogue, the fundamental psychometric characteristics to be investigated are the instrument’s reliability (Study 1) and its construct validity (Study 2) [36]. For the first study, the aim was to evaluate the inter-coder and intra-coder reliability using Cohen's Kappa [37] and to carry out a study based on the Theory of Generalizability (G-theory) [38]. To assess construct validity, two experts hypothesized about the language of the therapists based on five different models (see Results section of Study 2).

SICOLENTE: Creation of the instrument The coding manual can be obtained on the web page https://osf.io/dyuz2/. The observational instrument SICOLENTE was developed to fulfill the following four requirements: (a) to analyze all the verbal language present in a psychotherapy session, not only measuring the impact of a specific technique or a specific variable; (b) to investigate the language of the therapist, the client and the interaction between them; (c) to be able to study therapists of any model, i.e. to not respond only to the theoretical assumptions of a particular model, but instead work towards a way of understanding communication in therapy that will be discussed later; and (d) enable external observers to apply this model to study the participants of the therapist-client interaction. For the design of the instrument, we worked on combining up-down and bottom-up strategies. The up-down strategy is based on a simple model that understands psychotherapy as an interactional process between a therapist and a client [39]. The therapist is formed in a model that adopts a series of theoretical assumptions: a way of understanding the human being, a theory that explains why people have problems, and a vision about what should be done so that problems can be solved. These theoretical assumptions are translated into practice in a series of procedures: two basic types of skills (creating a therapeutic relationship and promoting changes in meanings) and a varied repertoire of techniques. The theoretical assumptions vary substantially between models and each approach has its own set of techniques. Moreover, the basic linguistic abilities needed to create a relationship or work with meanings can be very similar between approaches, and this is the starting point of the SICOLENTE. From this perspective, therapy is a conversation for change in which the clients are the protagonists: they are the expert in their problem and have their own theories about why it exists and how it can be resolved [40]. Therefore, the ability of the therapist to adjust the treatments to people is understood as being key to the process and one of the aspects that should be measured by the SICOLENTE through language analysis. To implement the bottom-up strategy, we worked from an inductive approach in two phases. Firstly, a group of four expert clinicians made non-systematic observations of sessions of five different psychotherapy models to have an overview of the therapeutic process. The second phase began by recording a session in which two experienced therapists (a cognitive-behavioral and a systemic therapist) created an initial treatment session with a simulated client. The sessions were analyzed by twenty people with three distinct training levels: eight psychology students without knowledge of psychotherapy, seven doctoral students in psychology, and five clinical psychologists of different therapeutic orientations. Everyone is asked two questions: what therapeutic elements can be identified in the session? And what does the therapist do to try to bring about changes in the client? From their answers, the first ideas emerged for building the system. From there, a team of six professionals (ARM, AMG, GI, DNC, PMP, and an external codifier) began to propose dimensions and categories, and through an iterative process of evaluating psychotherapy sessions, they obtained the final structure. In addition, a coding manual was developed with category examples and counterexamples, as well as the coding process.

SICOLENTE: Instrument categories The "language" construct that measures the final instrument consists of three dimensions (a) Conversational Act, (b) Therapeutic Topic and (c) Content, which correspond to the three classic dimensions of semiotics: pragmatics, semantics, and syntax respectively. Each dimension has several categories, which are mutually exclusive and exhaustive (See Table 1). The first dimension, Conversational Act, asks "what are the psychotherapist and the client doing?" This dimension encompasses the aspect of language pragmatics and is the only dimension with different codes for psychotherapist and client. The codes for the therapist distinguish between current meaning, what they already share (e.g., the client's demographic information, their background, what they have talked about so far) and new meaning (e.g., asking for exceptions, reframing, interpreting, cognitive restructuring, and empty chairs). In addition, they distinguish themselves in terms of whether the therapist asks a question or if it is a statement. For the client, the codes are whether he or she follows or rejects the new or current meaning or changes the subject. PPT PowerPoint slide

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larger image TIFF original image Download: Table 1. Categories of the therapeutic language coding system (SICOLENTE). https://doi.org/10.1371/journal.pone.0209751.t001 The second dimension, Therapeutic Topic, asks "What are they talking about?" This evaluates the topic and locates it in time (e.g., a good topic in the future is a goal, whilst a problem can be in the past, present, or future). This dimension is included within semantics i.e. the meaning (to the participants) of what is expressed in the dialogue. Finally, the Content dimension asks "What action or user status is being referred to in the language?" It includes whether it is observable or not, intentional or not, and whether it was with or about another person. Given the fact that answering this dimension required the coding process to be centered on the verb used, this dimension is included in the syntax.