Exceeding the therapeutic zone of proximal development as a clinical error.

Abstract

The Assimilation of Problematic Experiences Scale (APES) summarizes a developmental continuum along which psychological problems progress in successful psychotherapy. The therapeutic zone of proximal development (TZPD) is the segment of the APES continuum within which the clients can proceed from their current APES level to the next with the therapist's assistance. It is the therapeutic working zone for a particular problem. As the client makes progress on a problem, its TZPD shifts up the APES. Theoretically, so long as the therapist's interventions remain within the TZPD, the client feels safe enough to work. However, when an intervention aims beyond the upper limit, the client will find it too risky and will reject or avoid the proposal. In this sense, exceeding the TZPD can be considered as a clinical error. This article presents examples of exceeding the TZPD and ways the error can be repaired. (PsycINFO Database Record

Metacognitively oriented psychotherapy for schizotypal personality disorder: A two‐case series

“…Both approaches monitor and attend to the therapeutic alliance and try to prevent and overcome any possible ruptures . Another feature of both therapies is that they work in the therapeutic zone of proximal development; that is, therapists adjust flexibly and deliver interventions only after having ensured that the patient has the capacity to make sense of that intervention in the moment. Moreover, both therapies emphasize mutual exchange and connection, continuously adjusting their action in order to ensure that the patient feels understood and validated …”

Impact of confrontations by therapists on impairment and utilization of the therapeutic alliance

“…The therapist's pushing beyond the patient's level might be a necessary process to be anticipated. Furthermore, therapists might have deliberately caused ruptures in the safe setting of a good therapeutic relationship to use them in a constructive and deliberate manner (which might include a validation of the patients' reaction to the confrontation and not a further pushing beyond their limits), as proposed by Coutinho et al (2001) or Stiles, Caro Gabalda, and Ribeiro (2016).…”

“…This anxiety, in turn, may be expressed in an alliance rupture, which might even take on the look of a strongly hostile reaction by the patient. Thus, therapists might take up on this disclosure to work through the tension together with the patient, which might provoke new insight and reinforce the alliance (Safran, Muran, & Eubanks-Carter, 2011;Stiles et al, 2016).…”

Why did she leave? Development of working alliance in a case of psychotherapy for depression

“…We assume that these repeated reactions were a sign that the intervention exhausted its potential. Invalidation of an intervention by the client may signalize that the dyad had reached the upper limit of the therapeutic zone of proximal development and may have needed a different approach (Stiles, Caro Gabalda, & Ribeiro, 2016).…”

“…The evidence-based case study, meanwhile, has been proposed as a design that enables such an integration (Dattilio, Edwards, & Fishman, 2010 ). Evidence-based case studies that combine a standardized process and outcome measures with a qualitative investigation of the process of change within psychotherapy may provide an insight into the interplay of a wide range of variables and the contextualized process of change (Carey & Stiles, 2016 ). Systematic case studies are especially valuable if we aim to explore important and unexpected events such as drop out from psychotherapy contrasting with symptomatic improvement.…”