Pragmatik der Veränderung

1 awareness/insight/self-understanding,

2 reassurance/support/safety,

3 behavioral change/problem solution,

4 empowerment,

5 relief,

6 exploring feelings/emotional experiencing,

7 feeling understood,

8 client involvement

9 and, personal contact.

One important factor that has emerged from clients’ accounts and that is conducive to change has to do with the therapeutic relationship. The participants of Levitt et al.’s (2006) study used the term “relationship” itself while e.g., “interaction with the therapist” was documented in Carrey et al.’s (2007) research and “feeling understood” and “personal contact” were identified in Timulak’s (2007) meta-analysis. This line of research follows the assumption that “clients’ perceptions of the therapy process are valuable indicators of outcome” (Viklund et al. 2010: 162). Yet, as Viklund et al. (2010: 152) explain, this type of research in which clients are asked to identify the significant moments in their therapies suffers a number of limitations:

… identifying psychotherapy events that clients find important may help us capture the effective ingredients of change, but in order to better understand what goes on in those moments there is also a need for detailed examinations of the microprocesses of interaction within the events.

The remark concerning the necessity of a detailed examination of those interactional moments deemed as significant by clients (and therapists) will be discussed further in the paper.

The current perspective on studying client change, i.e., change process research (CPR) has been proposed by Greenberg (1986) and combines the earlier outcome research paradigm with the process research approach. CPR “concerns itself with explaining both how and why change occurs” (Elliott 2012: 69) and is “a necessary complement to randomized clinical trials and other forms of efficacy research” (Elliott 2010: 123). As discussed by Elliott (2010: 123), CPR comprises four types of research designs such as: quantitative process-outcome, qualitative helpful factors, microanalytic sequential process and the significant events approach, referring to “methods such as task analysis and comprehensive process analysis that integrate the first three.”

The complexity of studying client change has been aptly captured by Kazdin (2009: 421) in the quotation: “’How does one get from: ‘My therapist and I are bonding’ to ‘My marriage, anxiety, and tics are better’”. This quotation gives a sense of just one of the salient issues in studying client change, i.e., how we go about finding out the implications and/or consequences of what happens in the therapy room for the client’s actual non-therapy life. The intricacy of this issue, in fact, has been pointed out by Levitt et al. (2006: 318), who discussed how the clients in their study “vividly describ[ed] the process of moving between these two separate worlds of therapy and ‘real life’” that entailed “transforming from person to client and back to person again”.

Another likely obstacle to identifying how the client change occurs has to do with the many therapy schools and approaches. Can we really offer an explanation of client change that will be applicable to often seemingly distant therapy schools but sharing the pursuit of change? This issue has been addressed, for example, in the line of research employing the Dialogical Self Theory (Hermans and Dimaggio 2004; see also Norcross and Goldfried 2005). Leiman (2012: 125) proposes “the fundamental twin process of all psychotherapies” that combines promoting client’s disclosure and helping him/her “to adopt a self-observing stance concerning the presenting problems and the underlying problematic patterns of action and experience”. The self-observation, as Leiman (2012: 125) expounds, “permits an altered relationship to the original problem whatever it may be” by increased awareness of the original issue(s). Leiman (2012: 126) sees the concept of observer position taken by the client as “the common mediator of client change in psychotherapy”. Similarly Avdi (2012: 64) claims that the process of client change “can be evidenced in the development of richer dialogues between voices in the client’s narrative, in a decrease in disorganization or dissociation, and in the development of a reflexive meta-position” (see also Angus et al. 2006; Lambert 2013b; Rennie 1992).

Another complexity that needs to be considered in studying client change revolves around the question whose perspective should be adopted in identifying and evaluating potential change. This concurrently relates to the sets of data to be collected and analyzed (see Elliott 2012). Is it the client who is the ultimate/decisive figure in identifying and/or assessing whether the therapy brought positive changes in his/her life and what events they found most helpful (see e.g., Levitt et al. 2006; Carey et al. 2007) or is it his/her therapist? Interestingly the research shows that the clients’ and therapists’ insights as to what gets identified as ‘helpful’ or ‘hindering’ in psychotherapy do not always overlap (Elliott 2012; see also Caskey et al. 1984). The concept of the analyst’s paradox (Sarangi 2002, 2007, 2010) refers to the necessity to consult discourse analytic findings with the people whose communicative and interactional practices are studied. This is to say that psychotherapists’ and clients’ perspectives are vital for the analytic practice and ultimately for the findings if they are to be applied to the work of therapists (see Sarangi 2010). The question of whose perspective is to be taken on board is not an easy one and cannot be resolved in the same manner for every case, yet it should sensitize researchers’ reflexivity and analytical gaze (cf. Sarangi 2019).

Kazdin (2009: 419) states that despite “rather vast literature, there is little empirical research to provide an evidence-based explanation of precisely why treatment works and how the changes come about.” Elliott (2012: 76) underlines that truly evidence-based practice “should be based on multiple lines of CPR evidence” thus, for example, combining various sources of data to arrive at a better understanding of how client change occurs. This seems to be of pivotal importance as the majority of studies still rely on one set of data and consequently neglect other crucial insights in explaining the process of change.

To sum up, studying client change in psychotherapy poses a methodological and analytical challenge and “certainly not an easy path on which to embark” (Kazdin 2009: 428). The complexity however, needs to be properly addressed by the researcher on every stage of research process (see Sarangi 2019).

Elliott (2012: 70) encourages more qualitative work in CPR by emphasizing that discourse analytic approaches have been so far “under-utilized”. Since the CPR’s focus is also on how change occurs, the broad DA perspective should be of particular relevance. After all:

While clients process internally their experiences and content of mind in and between the sessions, what prompts and maintains this processing is the interaction between the client and the therapist, the therapeutic relationship ( Voutilainen and Peräkylä forthcoming ).

CA, as one of the approaches within DA and a method of engaging with data, identifies the sequential organization and interactional functions of certain practices that in the local interactional context enable the client to approach a certain issue in a transformed manner. In the context of psychotherapy, CA helps to examine “what sort of features in the therapist’s turns would guide the patient to respond in a particular way, and vice versa” (Voutilainen et al. 2010a: 300).