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Background: Research on interpersonal synchrony has mostly focused on a single modality, and hence little is known about the connections between different types of social attunement. In this study, the relationship between sympathetic nervous system synchrony, movement synchrony, and the amount of speech were studied in couple therapy. Methods: Data comprised 12 couple therapy cases (24 clients and 10 therapists working in pairs as co-therapists). Synchrony in electrodermal activity, head and body movement, and the amount of speech and simultaneous speech during the sessions were analyzed in 12 sessions at the start of couple therapy (all 72 dyads) and eight sessions at the end of therapy (48 dyads). Synchrony was calculated from cross-correlations using time lags and compared to segment-shuffled pseudo synchrony. The associations between the synchrony modalities and speech were analyzed using complex modeling (Mplus). Findings: Couple therapy participants’ synchrony mostly occurred in-phase (positive synchrony). Anti-phase (negative) synchrony was more common in movement than in sympathetic nervous system activity. Synchrony in sympathetic nervous system activity only correlated with movement synchrony between the client-therapist dyads (r = 0.66 body synchrony, r = 0.59 head synchrony). Movement synchrony and the amount of speech correlated negatively between spouses (r = −0.62 body synchrony, r = −0.47 head synchrony) and co-therapists (r = −0.39 body synchrony, r = −0.28 head synchrony), meaning that the more time the dyad members talked during the session, the less bodily synchrony they exhibited. Conclusion: The different roles and relationships in couple therapy were associated with the extent to which synchrony modalities were linked with each other. In the relationship between clients and therapists, synchrony in arousal levels and movement “walked hand in hand”, whereas in the other relationships (spouse or colleague) they were not linked. Generally, more talk time by the therapy participants was associated with anti-phase movement synchrony. If, as suggested, emotions prepare us for motor action, an important finding of this study is that sympathetic nervous system activity can also synchronize with that of others independently of motor action. publishedVersion

Research on nonverbal synchrony (movement coordination) in psychotherapy has recently attracted increased attention. Nonverbal synchrony has been shown to relate to the therapeutic alliance and outcome. However, research on nonverbal synchrony in couple therapy remains scarce. In this study, we examined the therapy process of one couple in detail and created a coding scheme to depict posture and movement synchrony. In this case study, we found that the relationship between nonverbal synchrony and the therapeutic alliance was complex. During the therapy process, the amount of nonverbal synchrony varied, as did the participants’ evaluations of the alliance. In couple therapy nonverbal synchrony could affect both the persons involved in it and the persons observing it. In one of the sessions, almost all the synchronies occurred between the female client and one of the therapists, and all except the female client evaluated the alliance to be weaker. In this case study, there were two therapists present, and the co-therapists’ synchrony was found to be important for the male client’s evaluations of the alliance. When there was more synchrony between the therapists, he evaluated the alliance to be stronger. Interestingly, the co-therapists’ synchrony seemed to peak in sessions that succeeded sessions with a weaker alliance, as if the therapists were implicitly making a joint effort to strengthen the alliance. A short episode from one session is given to illustrate the findings. Our coding scheme enables studying nonverbal synchrony (posture and movement synchrony) in couple therapy and combining the research results to other temporally precise data obtained from the sessions. More research is needed to validate the method.

Nonverbal synchrony between individuals has a robust relation to the positive aspects of relationships. In psychotherapy, where talking is the cure, nonverbal synchrony has been related to a positive outcome of therapy and to a stronger therapeutic alliance between therapist and client in dyadic settings. Only a few studies have focused on nonverbal synchrony in multi-actor therapy conversations. Here, we studied the synchrony of head and body movements in couple therapy, with four participants present (spouses and two therapists). We analyzed more than 2000min of couple therapy videos from 11 couple therapy cases using Motion Energy Analysis and a Surrogate Synchrony (SUSY), a procedure used earlier in dyadic psychotherapy settings. SUSY was calculated for all six dyads per session, leading to synchrony computations for 66 different dyads. Significant synchrony occurred in all 29 analyzed sessions and between the majority of dyads. Complex models were used to determine the relations between nonverbal synchrony and the clients’ well-being and all participants’ evaluations of the therapeutic alliance. The clients’ well-being was related to body synchronies in the sessions. Differences were found between the clients’ and therapists’ alliance evaluations: the clients’ alliance evaluations were related to synchrony between both dyads of opposite gender, whereas the therapists’ alliance evaluations were related to synchrony between dyads of the same gender, but opposite to themselves. With four participants present, our study introduces a new aspect of nonverbal synchrony, since as a dyad synchronizes, the other two participants are observing it. Nonverbal synchrony seems to be as important in couple therapy as in individual psychotherapy, but the presence of multiple participants makes the patterns more complex. publishedVersion

Research on human intersubjectivity has found that humans participate in a dialogue throughout their life, and that this is manifested not only via language, but also nonverbally, with the entire body. Such an understanding of human life has brought into focus some basic systemic ideas concerning the human relational mind. For Gregory Bateson, the mind works as a system, formed from components that are in continuous interaction with each other. In our Relational Mind research project, we followed twelve couple therapy processes involving two therapists per session, looking at the ways in which the four participants attuned to each other with their bodies, including their autonomic nervous system activity. Using observations from the project, we here describe the ways through which the relational and embodied mind can be realized in a couple therapy setting.

This article reports on the added value of embodied responses identified through sympathetic nervous system (SNS) activity in couple therapy research. It focuses on moments of change and the timing of therapeutic interventions or therapeutic moves in a couple therapy session. The data for this single‐case study comprise couple therapy process videotapes recorded in a multi‐camera setting, and measurements of participants’ SNS activity. The voluntary participants were a marital couple in their late thirties and two middle‐aged male psychotherapists. The division into topic segments showed how the key issue of seeking help, which was found to comprise three separate components, was repeatedly dealt with in the session. SNS activity showed different degrees of synchronization between the couple, between the therapists, and between the couple and therapists during the dialogue pertaining to these three components. The issue of timing emerged as a complex, even ambivalent, phenomenon. Arousal in the therapists was in line with their therapeutic activity, whereas in the clients it was more anticipatory. The approach used here rendered visible some of the intensity that therapeutic dialogue can generate when dealing with issues of relationship change in the couple context and showed how this intensity can be dialogically regulated in the therapeutic system. peerReviewed

The aim of this study was to examine the extent to which intimate partner violence (IPV) is discussed in couple therapy, what the participants say about it and how, and how the participants’ electrodermal activity (EDA) is activated during these discussions. We studied four couples for whom IPV was an issue in dialog with their therapists. We used thematic analysis and examined the differences in EDA (measured as skin conductance responses, SCRs) between the participants. We found that although IPV was discussed relatively little in therapy, when the topic arose the victims took an active part in the discussion. We also found that the main themes were descriptions of IPV, explanations for IPV and the consequences of IPV, and that most of the SCR peaks occurred during talk on these themes. Moreover, differences were observed between participants in the frequency of peaks, therapists manifesting more peaks than clients. However, the overall proportions of the peaks were rather small, and no difference in mean SCR was found between victims, perpetrators or therapists. These results indicate that victims are not afraid to speak about IPV and that therapists are able to deal with it; however, dealing with IPV in therapy merits more attention. Moreover, our results showed that the participants experienced talking about IPV differently, an observation that should be taken into account in the therapy process. peerReviewed

The subjective experiences of participants in couple therapy have been explored through Stimulated Recall Interviews (SRIs), in which both clients and therapists come individually to watch video clips of their therapy sessions. We believe SRIs offer a good resource for Practice Oriented Research (POR) by promoting meaningful, flexible interplay between scientific research and clinical practice. Team members have different roles, either as “insiders” or “outsiders” of the therapeutic setting. The potential benefits of these interviews are illustrated by a case study conducted within the Relational Mind research project, in which SRIs helped to promote the emergence of reflections. SRIs, hitherto regarded as a research tool, showed great intervention potential: clients used it as means to gain insight about themselves while therapists used it to reflect on how best to proceed. This study could serve as a starting point for applying SRIs in POR. peerReviewed

Synchrony, or the moment-by-moment coordination between people in social situations, has been connected with increased liking and rapport. However, this type of synchrony is an underexplored area with regard to autonomic nervous system activity. The purpose of this research was to study physiological synchrony between participants in couple therapy by focusing on the sympathetic nervous system (SNS), which reflects arousal and emotional reactions. The data comprised 12 couple therapy cases (24 clients, 10 therapists) participating in the Relational Mind in Events of Change in Multiactor Therapeutic Dialogues (2013-2016) research project. Electrodermal activity (EDA) and heart rate were recorded from the clients and therapists at the start and at the end of the therapy. The aim of the research was threefold: to study the physiological reactions and synchrony that can be observed between participants in couple therapy, to analyze whether the levels of EDA synchrony change throughout the therapy processes, and to assess whether the possible changes in EDA synchrony are related to the therapeutic alliance or the therapy outcome. The results showed that between the participants of couple therapy, significant SNS synchrony occurred, which was not due merely to chance or to the presence of similar features within the therapy sessions. At the start of the therapy, the couples had the lowest level of SNS synchrony, whereas the co-therapists had the highest synchrony. The only significant SNS changes observed were in the couples, whose mutual synchrony increased towards the end of the therapy. The changes in SNS synchrony between the couples, and between the clients and the therapists, mostly showed a positive relationship with the increasing alliance and with the clients’ better wellbeing – although one specific pattern of decreasing synchrony seemed to be beneficial. The results highlight the role of embodiment in human interaction, and assist in understanding the healing mechanisms of therapy

Tutkimuksemme tarkoituksena oli tarkastella, kuinka paljon parisuhdeväkivallasta puhutaan pariterapiassa, mitä ja kuinka osallistujat puhuvat siitä sekä kuinka osallistujien ihon sähkönjohtavuus liittyy väkivaltakeskusteluihin. Tutkimukseemme kuului neljä paria ja heidän terapeuttinsa, ja parit olivat hakeutuneet terapiaan parisuhdeväkivallan vuoksi. Tarkastellessamme teemoja ja keskustelukäytäntöjä käytimme temaattista analyysia ja diskurssianalyysia. Ihon sähkönjohtavuuden osalta puolestaan tarkastelimme, onko osallistujien välillä eroja keskiarvoissa, piikkien määrässä ja osuuksissa sekä synkroniassa. Tuloksemme osoittivat, että vaikka väkivallasta puhuttiin melko vähän terapiassa, uhrit ja terapeutit osallistuivat aktiivisesti keskusteluun. Havaitsimme myös, että yleisen väkivaltakeskustelun ja ihon sähkönjohtavuuspiikkien aikana useimmiten ilmenneet teemat olivat samanlaisia, käsittäen väkivallan kuvailun, selitykset ja seuraukset. Osallistujien ihon sähkönjohtavuudessa oli eroja, jotka ilmenivät yksilöllisinä eroina piikkien määrässä. Lisäksi terapeuteilla oli enemmän piikkejä kuin asiakkailla. Kuitenkin piikkien suhteelliset osuudet olivat melko pieniä, emmekä havainneet eroa väkivallan uhrien, tekijöiden ja terapeuttien keskiarvojen välillä. Osa terapeutti-asiakaspareista vaikutti olevan synkroniassa keskenään, kun puolestaan asiakas- ja terapeuttipareilla oli matala synkronia. Tämän tutkimuksen perusteella vaikuttaa siltä, että uhrit eivät pelkää väkivallasta puhumista ja terapeutit kykenevät käsittelemään parisuhdeväkivaltaa, mutta väkivallan käsittelyyn terapiassa pitäisi kuitenkin kiinnittää enemmän huomiota. Lisäksi tuloksemme näyttävät ilmentävän, että osallistujat kokivat väkivallan käsittelyn eri tavoin, mikä olisi hyvä huomioida terapiaprosessissa. The aim of our study was to examine how much intimate partner violence (IPV) is discussed in couple therapy, what and how the participants talk about it, and how electrodermal activity (EDA) of the participants is related to IPV discussions. We studied four couples with their therapists dealing with IPV. For analyzing themes and discussion practices we used thematic and discourse analysis, whereas in EDA analysis we examined whether there are differences in EDA between the participants, manifested in means, the frequencies and proportions of the peaks and synchrony. Our results showed that although IPV was discussed quite little in therapy, the victims took actively part in discussion. We also found that the themes during general IPV discussions and mostly occurred themes during EDA peaks were similar, including description of IPV, explanations on IPV and consequences of IPV. Moreover, there were differences between EDA of the participants, manifested as individual differences in frequency of the peaks, and therapists having more peaks than clients. However, the overall proportions of the peaks were quite small, and no difference in EDA means between the victims, perpetrators and therapists was found. In addition there were therapist-client dyads that seemed to have EDA synchrony between each other, whereas the clients and therapists dyads had low synchrony. Based on this study, it seems that the victims are not afraid to speak about IPV and the therapists are able to deal with it, but however dealing with IPV needs more attention in therapy. Moreover, our results seem to reflect that the participants experienced dealing with IPV differently, which would be good to take into account in therapy process.

Tämän tutkimuksen tarkoituksena oli syventää hiljaisten hetkien merkitystä pariterapiassa keskusteltaessa parisuhdekonfliktista. Lisäksi tarkastelimme, löytyykö hiljaisten hetkien aikana synkroniaa osallistujien väliltä keskustelun ja kehon tasolla. Monimenetelmäinen tutkimuksemme keskittyi kolmeen tasoon: terapeuttiseen keskusteluun, psykofysiologisista mittareista (autonominen hermosto) saatuun informaatioon sekä osallistujien ajatuksiin ja tunteisiin SR- haastattelussa. Nämä mittarit analysoitiin ensin erikseen, jonka jälkeen niiden antama informaatio yhdistettiin. Tarkoituksena oli saada mahdollisimman luotettavaa tietoa hiljaisten hetkien merkityksestä parisuhdekonfliktin käsittelyssä. Kaksi kohtaa, joiden sisältä löytyi yhteensä yhdeksän hiljaista hetkeä, valittiin lähempään tarkasteluun. Tutkimustuloksiemme mukaan puhe oli ainoastaan yksi keino ottaa osaa keskusteluun ja osallistujat jatkoivat keskustelua kehollisesti hiljaisten hetkien aikana. Esimerkiksi eräs osallistuja näytti ulkoisesti passiiviselta, vaikka samanaikaisesti hän oli hyvin aktiivinen kehollisesti. Huomasimme myös hiljaisten hetkien ilmaantuvan keskusteluun sen jälkeen kun jotain merkityksellistä oli tapahtunut joko keskustelun- tai kehon tasolla. Tuloksiin perustuen hiljaiset hetket rytmittivät ja kantoivat keskustelua eteenpäin sekä antoivat mahdollisuuden keskustella vaikeista ja vakavista aiheista. Näemme, että hiljaiset hetket olivat avainasemassa parisuhdekonfliktista keskusteltaessa. This study aims to deepen the understanding of the role of silent moments in couple therapy dialogue when relational conflict is discussed. We also studied whether synchrony occurs in the silent moments. Our multi-method analysis focused on three aspects: therapeutic conversation, psychophysiological data (Autonomic Nervous System, ANS) and the participants’ thoughts and feelings from Stimulated Recall interviews. These measurements were analyzed separately at first, and then integrated into the description of the silent moments’ meaning during the relational conflict discussion. Two episodes within nine silent moments were selected for further analysis. Our results showed that speech is only one way of participating in conversation, and that the couple continued the conversation through their bodies during the silent moments. For example one participant, who seemed passive, had strong bodily reactions. We also noticed that silences occurred after a meaningful moment in either the embodied or conversational dialogue. Based on these results, the silent moments created rhythm and carried the conversation, giving the couple an opportunity to continue the conversation in a situation when their relationship was at stake. We see that the silent moments played a key role in relational conflict discussions.

Tämä pro gradu – tutkielma on osa Dialogiset ja narratiiviset prosessit masennuksen pariterapiassa – projektia (DINADEP), jonka tarkoituksena oli tutkia masennuksen pariterapiaa ja mahdollisia tekijöitä, jotka voisivat vaikuttaa sen lopputulokseen. Tämän tutkimuksen tarkoituksena oli selvittää, miten pariterapiaprosessia kuvaavaa Q-set-menetelmää (PTQS) voidaan käyttää masennuksen pariterapiaprosessien kuvailuun tutkimalla kolmea tapausta, joista kaksi oli hyvin onnistuneita hoitoja ja yksi oli huonosti onnistunut hoito. PTQS arvioi yhtä terapiaistuntoa kerrallaan ja analysoitaessa useita istuntoja, saadaan tarkka kuva koko prosessista. Toinen tutkimuksen tavoite oli tutkia, kuinka terapeutit vastaavat prosessin aikana pariskunnan tunneilmaisuihin, ja niiden mahdollista vaikutusta terapian lopputulokseen. Tutkimusaineisto koostui sekä nauhoitetuista pariterapiaistunnoista, että itsearviointimittareista. Kokonaisuudessaan tutkimusaineisto koostui yhdestätoista pariterapiaistunnosta ja ne valittiin jokaisen tapauksen alusta, keskeltä ja lopusta, jotta saataisiin mahdollisimman tarkka kuvaus koko prosessista. Tulosten mukaan PTQS kuvailee tarkasti pariterapiaprosessin aikana tapahtuvia muutoksia. Lisäksi huomattiin että onnistuneissa tapauksissa terapeutit käyttävät erilaisia terapeuttisia työkaluja lähestyessään pariskunnan tunneilmaisuja ja ylipäätään koko terapiatilannetta. Tämä tulos tukee aiemmin tehtyä tutkimusta. Huonosti onnistuneessa tapauksessa terapeutit pitäytyivät pääsääntöisesti yhdessä strategiassa. PTQS tarvitsee vielä lisätutkimusta, jotta sen kaikki ulottuvuudet voidaan löytää ja hyödyntää pariterapiatutkimuksessa. This Master’s Thesis is part of the Dialogical and Narrative Processes of Couple Therapy for Depression project (DINADEP), which aimed to investigate treatment and factors predicting the treatment outcome of couple therapy where another of the spouses suffered from either moderate or severe depression. In this study, one aim was to investigate three couple therapy for depression- treatment processes with a developing method Couple Therapy Process Q-set (CTQS). Another aim was to investigate the response of the therapists when the couple expressed emotions, and their possible causality towards the therapeutic outcome. CTQS is a scaling technique capturing different aspects of therapy process by analyzing a single couple therapy session. The material was analyzed from videotapes and by detecting self –evaluation questionnaires. The material for this thesis consisted of 11 sessions which were chosen from the beginning, middle and at the end of every treatment, to capture the variation of the process. It was found that the Couple Therapy Process Q-set is a suitable method in description of couple therapy processes, and with the CTQS, the description can also be precise. In addition, it was found that in succeeded treatments, therapists used a wider variation of strategies when facing the emotional expressions of the clients. This finding is analogous with previous studies. In the poor outcome case the therapists maintained using the same therapeutic tool, even though the clients did not seem to response on that. The CTQS requires further research, to make sure that all of its dimensions can be found and benefit from in the research of couple therapy.

This Master’s Thesis is part of the Dialogical and Narrative Processes in Couple Therapy for Depression project (DINADEP). In this case study the aim was to investigate how the assimilation model, a theory of psychological change, can be applied in couple therapy for depression. To further study the process of assimilation, individual changes were traced across 21 sessions in a couple therapy process of Ralph and Rose, a couple who came to therapy due to Ralph’s moderate depression and crisis in the relationship. The material of the research consisted of both qualitative and quantitative data: videotaped and transcribed couple therapy sessions and self-evaluation questionnaires. The Assimilation of Problematic Experiences Scale (APES) was utilized simultaneously with quantitative methods. It was found that assimilation model is a suitable method for a couple therapy setting. In addition, assimilation was tracked in four themes: one in Ralph’s case (disgust at sex) and three in Rose’s (feeling of responsibility, guilt, and fear of failure). Qualitative analysis of these themes suggested that Ralph reached assimilation level 5 (application and working-through) but ended up in lower levels at the end of therapy, thus his case was considered as an unsuccessful one. Rose progressed to the higher levels of assimilation and her case was considered as a successful one. The findings were analogous with previous studies in two ways: first, depressive symptoms improved in the successful case but not in the unsuccessful one, and second, assimilation analysis was amenable to be combined with qualitative and quantitative methods.

Introduction When a person becomes depressed, partnership can either be a source of strength, advancing recovery, or a source of further suffering, harming the health of both partners (Cordova & Gee, 2001). Also, depression in one spouse can create feelings of helplessness and hopelessness in both spouses (Cordova & Gee). These are some of the reasons why couple therapy has been used with persons diagnosed with depression and their spouses. Yet, according to Denton and Burwell's (2006) experience, which is similar to our own, the spouses of depressed patients often are not part of the treatment in psychiatric outpatient care, and hence feel unsupported, uninformed, isolated, confused, and frustrated. When one of the spouses is depressed, a goal in using couple therapy as treatment for depression can be considered to be the development of a stronger sense of agency in both spouses (Holma & Aaltonen, 1998). According to White and Epston (1990), the objective of therapeutic work is to recruit an audience for a new and preferred self-narrative in the medium of the social world. In the couple therapy situation, one could regard both the therapist and the spouse as an audience for the depressed person's narrative. The spouse also can be regarded as a person who shares and who can co-construct the depressed partner's narrative. If the depressed person's spouse is present, the description of life can become more comprehensive and more complex, and in this way it can help the couple acquire a stronger sense of agency, find new ways of seeing their situation as well as new ways of behaving in it (White & Epston). In recent decades, increasing attention has been paid to couple therapy in working with depressed persons (e.g., Beach, 2001; Beach, Finchman, & Katz, 1998; Denton & Burwell, 2006; Gillian & Cottone, 2005; Gupta, Coyne, & Beach, 2003; Keitner & Miller, 1990; Mead, 2002). For example, Gupta et al. recommended that couple therapy should be used when the couple reports significant relationship discord. Researchers such as Cordova and Gee (2001) and Coyne and Benazon (2001) have recommended working with couples whose relationship is satisfactory. Involvement of the spouse in the treatment of a depressed person has been considered to be important (Denton & Burwell). Obstacles and difficulties in involving the spouses in the treatment have been reported (Gupta et al.). Couples may find it difficult or disagreeable if they sense that their relationship is to blame for depression. On the other hand, couples who seek therapy because they have problems in their relationship and who do not collaborate well, may find it senseless if collaboration is the means for addressing their problems. In addition, committing to conjoint sessions can be difficult for couples due to pressures of work and childcare responsibilities (Gupta et al.). Studies dealing with couple therapy for depression have mostly dealt with treatment effectiveness. Beach and O'Leary (1992) studied cognitive-behavioral couple therapy; Emanuels-Zuurveen and Emmelkamp (1996) studied communication-focused couple therapy; Foley, Rounsaville, Weissman, Sholomskas, and Chevron (1989) studied interpersonal couple therapy; Teichman, Bar-el, Shor, Sirota, and Elizur (1995) studied cognitive-systemic couple therapy and Leff, Vearnals, Brewin, Wolff, Alexander, Asen, et al. (2000) studied systemic couple therapy. The authors of these reports have indicated that couple therapy approaches are as effective as individual therapy in helping depressed people, and that couple therapy also increases marital satisfaction. In addition to studying the effectiveness of couple therapy for depression, there is also a need to do more psychotherapy research that would utilize qualitative methods, with a view toward obtaining a more detailed picture of what actually happens in therapy sessions (Moon, Dillon, & Sprenkle, 1990). …

Katja Kurri tutki väitöskirjassaan terapiatapahtumaa eli asiakkaan ja terapeutin vuorovaikutustilannetta. Kurri tuo tutkimuksessaan esiin uuden näkökulman asiakkaan elämänvastuun uudelleen rakentumiseen ja pohtii myös terapiatilanteeseen liittyvää moraalista ulottuvuutta.Kurrin mukaan terapiaa pitäisi tarkastella nykyistä enemmän tilanteisena toimintana. Terapiatapahtumaa on hyödyllistä tutkia sellaisenaan, eikä ainoastaan jälkikäteen tehtyjen kyselytutkimusten tai erilaisten mittarien avulla. Kun terapiaa tutkitaan keskusteluna, voidaan nähdä, kuinka tähän asti piilossa olleet terapian moraaliset dilemmat rakentuvat ja kuinka niitä voidaan ratkaista. This study examines psychotherapy conversations. The methodology employed in this study, discursive psychology, is used to examine the ways in which the participants in therapy conversations manage their moral positions. The study consists of three articles in which single conversations are analysed and one article in which three conversations from a therapeutic process are examined. Analysis of the therapeutic action in situ demonstrates that therapeutic interaction has a logic of its own that reflects the inherent and inevitable moral nature of the conversation.The results of the analysis draw attention to the discursive practices employed in managing moral order in a conversation. The implicit placements of responsibility through agentic discourse, justifications, excuses, blaming, counter-blaming, the use of categorizations, sighs and sights, all play their part in the constant renegotiation of the ‘invisible’ moral order. What makes the moral order invisible, is the fact that it is embedded in the conventions of oral interaction.On the basis of a detailed analysis of the moral practices of the therapy conversation it was possible to discuss the ethical foundations on which the therapy practices were based. I claim that awareness of the different practices of managing moral order benefits the development, and ethical evaluation of, therapeutic practices.This dissertation consists of four original articles and an introduction in which I examine the idea of therapy as a conversation, the concepts of moral order, agency, accountability and responsibility, and the methodology used. The end of the introduction is made up of summaries of the original articles, in which I present the main questions and results of the analysis. In the discussion I approach the overall themes of the dissertation.