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Psychotherapy as a longitudinal process is geared to facilitate change that should ideally increase the clients’ contact with their problematic emotional experiences and parts of the self, and to increase their self-reflexive abilities (Rennie 1992; Norcross and Goldfried 2005; Leiman 2012; Voutilainen and Peräkylä forthcoming). The promise of change for the better is why clients embark on the therapeutic trajectory and from the clinical viewpoint client change is the motivation for all psychotherapies (Peräkylä 2013: 573; see also Carey et al. 2007). Yet how the psychological change occurs is still poorly understood (Higginson and Mansell 2008: 310). Elliott (2012: 70) refers to the process of change in psychotherapy as “complex and nuanced” (see also Lambert 2013b) and as Murray (2002) states, questions about the change process often focus on examining how psychotherapy is helpful.

Yet client change as a result of psychotherapy, although typically conceived of as bringing positive results and thus some sort of improvement in the client, can also be of negative character. The research shows that despite receiving validated and properly performed psychological treatments, some patients “experience deterioration and adverse events” (Bystedt et al. 2014: 319; Lambert 2013b). As reported by Bystedt et al. (2014), it is estimated that the so-called deterioration effect – referring to possible negative effects of psychological treatments (see Bergin 1966) – applies to between five per cent and ten per cent of all patients. Yet not enough is known about the so-called negative effects of psychotherapy (Bystedt et al. 2014). To reiterate, even though client change can be of positive and, in some cases, negative character, the extant research however, takes the default position on client change as positive.

A substantial body of research concentrates on identifying and examining the events in the psychotherapy process marked by clients and therapists as significant (e.g., Levitt et al. 2006; Carrey et al. 2007; Nilsson et al. 2007; Higginson and Mansell 2008). It is argued that these events comprise “the effective ingredients of change” (Viklund et al. 2010: 151). For example, Carrey and colleagues (2007) conducted interviews with 27 people at the end of their treatment and found that “many described change as occurring both as a gradual process and at an identifiable – and memorable – moment” (Carrey et al. 2007: 182; see also Higginson and Mansell 2008). Additionally, Carrey et al. (2007) identified six themes in the participants’ accounts of how change occurred. These are:

1 motivation and readiness,

2 perceived aspects of self,

3 tools and strategies,

4 learning,

5 interaction with the therapist,

6 and, the relief of talking.

It is worth noting that generally the participants of Carrey et al.’s (2007) study were unable to provide a specific definition of change (see Hustvedt’s (2016) comment above) and similarly to Levitt et al.’s (2006) findings, change was not attributed to concrete therapeutic approaches. Timulak (2007) presented a meta-analysis of factors that clients described as helpful in nine meta-categories:

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).