Taking a turn for the better: Conversation redirection throughout the course of mental-health therapy (2024)

Abstract: Mental-health therapy involves a complex conversation flow in which patients and therapists continuously negotiate what should be talked about next. For example, therapists might try to shift the conversation’s direction to keep the therapeutic process on track and avoid stagnation, or patients might push the discussion towards issues they want to focus on.How do such patient and therapist redirections relate to the development and quality of their relationship? To answer this question, we introduce a probabilistic measure of the extent to which a certain utterance immediately redirects the flow of the conversation, accounting for both the intention and the actual realization of such a change. We apply this new measure to characterize the development of patient- therapist relationships over multiple sessions in a very large, widely-used online therapy platform. Our analysis reveals that (1) patient control of the conversation’s direction generally increases relative to that of the therapist as their relationship progresses; and (2) patients who have less control in the first few sessions are significantly more likely to eventually express dissatisfaction with their therapist and terminate the relationship.

## introduction mental-health therapy conversations are remarkably and consequentially complex. they involve an ongoing negotiation between a patient and a therapist regarding what should be talked about, how it should be talked about, and by whom. conversational bids to shift the direction of the discussion (henceforth redirections) are a common and essential aspect of any therapeutic relationship. however, we lack an understanding of how these dynamics play out throughout the course of the therapeutic relationship and how they might relate to its quality. figure 1 : top: examples of attempted redirection, both realized (left) and unrealized (right). bottom: example where redirection is not attempted. t k and c k refer to the therapist's and patient's k th utterance, respectively. note that in general, both parties can redirect. one key aspect of redirections that may explain why they have yet to be studied in a systematic and rigorous way is their joint, rather single-utterance, manifestation. in contrast to other commonly studied strategies and conversational acts @xcite ) that tend to be executed by either the therapist (e.g., empathy @xcite ) or the patient (e.g., change talk @xcite ), redirection is a truly shared patient-therapist act: to be realized, a bid to redirect the conversation must be accepted by the other participant. our first contribution is to introduce a measure to quantify an utterance's redirection effect in a way that explicitly takes into account this twopart nature: it jointly captures both the intention to change the course of the conversation and the actual realization of this change through a reply that complies with this intention. figure 1 (top, left branch) illustrates an example of an utterance with high redirection effect: the therapist intends to switch the focus towards specific sources of stress, and the patient conforms by mentioning frustration at work. in contrast, if the patient resists the switch (figure 1 , top, right branch), the redirection is not realized. there is a third alternative: figure 1 (bottom) shows an utterance with low redirection effect due to the lack of intention to redirect. key to our work is capturing this type of interplay between two participants at a specific utterance juncture, rather than a discourse-level notion of shift, where a single person can change the focus even on their own (e.g., topic control @xcite ). our redirection measure's inherent joint nature is particularly well-suited for examining the therapeutic relationship, and thus adds to the toolkit of computational methods available for studying therapeutic practice @xcite @xcite . we illustrate this in collaboration with talkspace-a large online text-based therapy platform-by applying it to characterize the development and perceived quality of the patient-therapist relationship. our analysis reveals that as their relationship develops, both patients and therapists redirect to a lesser extent, suggesting an overall smoother and more focused conversation flow. however, in relative terms, patients gain increasing control of the direction of the conversation in comparison to the therapists; this discovery is our second contribution. furthermore, as our third contribution, we find that patients are more likely to eventually express dissatisfaction with the therapeutic relationship and terminate it when they are not able to redirect the conversation in the first few sessions. cumulatively, these results underline the importance of considering patient agency in psychotherapy @xcite , or, concomitantly, therapist willingness to follow the patient's lead. while here we focus on the mental-health domain, one final contribution is to highlight the possibilities in examining any sort of longer-term relationships developed through multiple conversations over time. future work could apply our measure and analysis framework to study the conversational process in other conversation-rich settings where complex long-term relationships are developed, such as education (e.g., advisor-advisee relationships). to encourage such work, we make our code publicly available as part of convokit @xcite , together with a demo on a publicly-available dataset in a different domain, us supreme court oral arguments (appendix c). foot_0 2 therapy setting long-term text-based therapy. we develop our methodology in the context of talkspace, a telehealth therapy platform. patients can choose between different plans, which may include video therapy alongside messaging therapy. after a consultation in which they answer a few questions about their symptoms and describe their preferences, patients are matched by the platform to a suitable therapist who is licensed in their state. in this work, we use the (english-language) textbased conversations (after redaction of personally identifiable information by talkspace) from a fiveyear span. foot_1 during this time, talkspace hosted over 18,000 licensed therapists providing services to over 300,000 patients. in total, over 65 million messages were exchanged. therapies can be sustained over long periods of time, with more than 26,000 therapies lasting over a year and 17,000 therapies comprising over 500 messages. this setting thus provides an opportunity to study the long-term conversational dynamics as the therapeutic relationship develops. at any point, patients can either cancel their therapy or switch to a different therapist. when doing so, they are asked to provide a reason, either by selecting from a drop-down menu (e.g., "the treatment provided by my therapist was not helpful," "i met my goal / i feel better") or by entering free text. we have some assurance that these reasons are authentic because patients are informed that therapists cannot access them. these reasons serve as imperfect indicators of the perceived quality of the therapeutic relation (for a broader discussion of difficulties in operationalizing the quality of the therapeutic relationship, see section 8). session identification. one challenge in studying the development of therapeutic relationships in this text-based setting is accounting for the wide variety of durations, tempos, and volubility exhibited in different therapies. a longitudinal analysis requires a methodology that captures the progression of the therapeutic process while allowing for meaningful aggregation across therapies with these vastly different interaction patterns. to address this challenge, we need to account for several factors. first, each therapist-patient pair develops a unique interaction style and tempo, including frequency of interaction, response time, and how often turns are split into multiple messages. second, exchanges between a therapist and a patient include not only therapeutic conversation, but also short check-ins that deal with brief updates, scheduling, or survey completions. last, an important component of many therapies is the occurrence of spans of approximately synchronous conversations, or sessions, over the therapy's duration. these three factors render conventional units of progression in conversational analysis-such as time or number of utterances-unsuited for this complex interactional setting. explicit session boundaries are lacking in textbased conversations and so must be inferred. we start by distinguishing high-activity periods interwoven with periods of little or no activity, using the method from @xcite to capture these bursts. for each therapy, we define session-split points as moments when an utterance's reply time exceeds n × (median reply time of that entire therapy). 3 we further ensure that each session represents an actual conversation between the patient and the therapist (as opposed to, for example, a short notification and acknowledgement regarding scheduling) by filtering out short exchanges-any burst of activity with fewer than four turns (so that what remains includes at least two nonconsecutive utterances from each speaker)-or includes a video session. we further remove any automated messages related to video sessions, survey completion, or scheduling. to validate the quality of the session splits, we sampled therapies with at least 10 sessions and ran a bayesian distinguishing-word analysis @xcite on the first and last utterance of each session. the distinguishing words are intuitive: sessions start with greetings ("hi", "morning", "hey", "how") and end with a farewell or expression of gratitude ("enjoy", "welcome", "thank", "thanks"). 3 we settle on @xmath0; see appendix a.1 for details. ## redirection in online therapy we employ our formalism to study redirection in online text-based therapies. we first validate that our redirection measure corresponds to human intuition in the therapy setting. we then explore how redirection relates to the development of the therapeutic relationship. we move on to study the relation between redirection and the patient's perception of the quality of the therapy. finally, we apply the related measures discussed in section 3 to gain additional insight into which interactional dynamics might account for the observed trends. ## qualitative analysis we conduct a qualitative analysis of high-and lowredirection examples to explore therapy strategies that are tied to this phenomenon and to further for patients, highly redirecting utterances tend to introduce personal experiences or feelings that shape the immediate course of the conversation. they may initiate subjects they wish to explore or verbalize the specific obstacles they are facing (example 6: challenges at work). low-redirecting patient utterances, on the other hand, extend the current subject of discussion. these observations are consistent with the decreasing trend in redirection for both speakers. initially, patients and therapists both focus on introducing the context of the therapy and setting therapeutic goals. therapists tend to actively discuss the objectives of the therapy and suggest behavioral strategies and cognitive techniques. patients, likewise, will share their background or expectations as they start out their therapeutic relationship. later sessions, conversely, usually consist of more concentrated discussions on the identified issues. comparison with other metrics. we also examined cases where the redirection measure is at odds with the related measures. as expected, orientation can be high even when redirection is resisted. for instance, in example 3, the therapist attempts to steer the conversation towards discussing who to talk to, but the patient disregards their suggestions and continues explaining their plans, thus causing redirection to be low. importantly, unlike similarity difference, our metric captures utterances with redirection effects even when the reply is not semantically similar. in example 2, the therapist redirects the focus of the conversation by suggesting a potential solution to the patient's problem, which the patient acknowledges in their reply. while similarity difference is low since acknowledging the suggestion is not semantically similar, the patient does reflect on the therapist's suggestion, which deviates from their prior discussion focused on the problem. our measure also differs from uptake in that it uses a reference point: the previous conversational context. example 7 illustrates a segment where the patient reflects on having someone to vent to. the therapist addresses the patient's utterance by continuing to encourage the patient to vent, exhibiting high uptake. however, the focus of the conversation does not change, indicating low redirection. ## further related work our work relates to prior research on conversational dynamics, analyzing the development and quality of therapeutic relationships, and exploring language on mental-health platforms. development and quality of therapeutic relationships. the development of the patient-therapist relationship and its impact on therapy outcomes have been extensively studied @xcite carter, # example r o sd u 1 t: it seems like this anxiety doesn't arise when you're in a relationship with someone. p: now that i remember no. i feel more secure. t: where does the strong reaction to being alone originate from? p: honestly, i think it has to do with my relationship with my family. high low low mid 2 t: it seems like the issue is your lack of control over being alone. p: yes, that's interesting; i think that's a part of it. t: try sitting with your feelings and exploring them without blocking them, and see what insights come up for you. p: okay, i'll meditate on that. thanks. high mid low mid 3 t: i believe using conflict resolution methods might help you better communicate with your husband about this issue, rather than withdrawing and shutting down. p: he keeps saying he doesn't want to get involved with her problems. t: then, are you planning to talk to your daughter first, or are you waiting to speak with her counselor? p: i'll just ground her and take things away. low high low mid 4 t: when you are ready to process the trauma, we can go through it. p: now, i'm feeling better mentally, but physically my heart is thumping, and i began having panic attacks at work. t: that sounds awful. is it a thumping sensation in your chest or feeling in your ears? p: i wore a heart monitor in my chest. i feel a thump each time before my heart skips beats. low low high high 5 p: i dislike how i get easily attached to a man i like. i had thoughts of being in a relationship just because we were spending time with each other. t: some people are attachers in relationships, while some people it takes a while for the heart to thaw out. p: i feel like it may be because of not having my dad present. t: i think that is a good insight on your part. your upbringing and personality formation definitely affects attachment styles. high low low low 6 p: how was your day? t: i'm also waiting for warm weather; i think today's supposed to be pretty nice! how are things going at home for you? p: it's going okay. i'm nervous about having to hit numbers at work every day though. that is going to be a challenge. t: i understand productivity requirements. it sounds like you have an amazing work ethic and your trainer is already impressed with you though. high high mid low 7 p: i'm going to take a walk tonight if weather permits. t: the walk sounds like a great idea. it is good to let it all out, so don't be afraid to vent as much as you need to. p: thanks. not used to having someone to vent to. t: hope the rest of the day went better and the weather allows you to take a walk. feel free to vent as things come up. low low low high 8 p: when i have trouble concentrating, i tend to eat. t: does that help you concentrate better? p: i don't know. t: so what's behind eating when you are having trouble concentrating? low low low mid conversational dynamics. prior computational work examined different aspects of conversation flow @xcite , including work on topic segmentation @xcite @xcite @xcite and topic shift @xcite . while these conversationlevel concepts are related, our probabilistic measure seeks to quantify the immediate effect of a single utterance, an effect different from semantic similarity and topic coherence. furthermore, we develop a framework for a longitudinal analysis of conversational dynamics in the distinctive domain of online mental-health therapy. online mental-health platforms. prior literature extensively explores linguistic behaviors and conversational choices users make in online mentalhealth-related platforms, whether in crisis counseling platforms @xcite , peer-support platforms @xcite @xcite , or therapy platforms @xcite . accompanying growing attention to online mental-health resources and use of technology in psychotherapy @xcite , many studies highlighted the benefits of online social support @xcite . we specifically focus on long-term sustained relationships in text-based therapy platforms, offering a novel perspective on development of the patienttherapy relation through longitudinal analyses. ## discussion and conclusion redirection is a joint act often performed by therapists and patients. its realization requires both speakers to understand the initial direction of the conversation, one's attempt to redirect it, and the other's compliance with this attempt. as such, its study has the potential to characterize the patienttherapist dyad, in particular with respect to their ability to negotiate the focus of the conversation. in this work, we introduce a computational method for quantifying the redirection effect of an utterance and apply it to a mental-health-therapy domain. we find that both the patient and the therapist redirect less as therapy progresses. our qualitative analysis suggests that after initial exploration and contextualization prompted by both speakers, the relationship matures to a more stable stage with less redirection. moreover, we reveal that the less patients redirect early on, the more likely they are to eventually express dissatisfaction with the therapist and abandon the relationship. connection with psychotherapy literature. several decades of research in psychotherapy suggest that the "treatment model" approach in which an expert clinician provides curative treatment that the patient passively receives is not well supported by outcomes or engagement data @xcite . instead, shifting focus from which aspects of treatment are delivered to how dyads collaboratively negotiate therapeutic conversations has provided evidence of improved access, efficiency, and effectiveness of mental-health services for "patient-led" approaches @xcite @xcite . our results offer a computational perspective into one dimension of patient agency in therapeutic relationships. future work. a computational approach to redirection enables us to observe the evolution of therapeutic relationships and could assist therapists in fostering them. a complementary line of work can include a more in-depth exploration of how to foster healthy levels of redirection in therapy and the causal relationship between redirection and the quality of therapeutic relationships. for instance, labeling messages with therapeutic strategies and techniques can provide insight into the effectiveness of each strategy and determine which ones are more applicable for specific contexts (e.g., when patients resist therapists' redirection attempts). in their current observational form, these results suggest that early conversational patterns can signal the eventual dissatisfaction of the patient. future work could examine the predictive power of these ties and test the extent to which they might be explained by other (unalterable) factors, such as the characteristics of the patient or of their condition. our methodology can extend beyond the mentalhealth domain and be applied to other conversationrich domains, such as education, online discussions, or interviews, where discussions are carried out in relatively unstructured ways with only a few general agendas set. exploration of redirection in these contexts may present a unique perspective into how speakers are able to redirect and control the flow of the discussions. finally, understanding how humans redirect the flow of conversations is important for supporting more naturalistic human-ai conversations, where the ai could pick up on humans' redirection attempts and initiate their own.