The Client's Perspective on the Nature

385 Pages·2015·3.11 MB·English

School of Psychology and Speech Pathology
Faculty of Health Sciences

Theory of Change:
The Client’s Perspective on the Nature of Change in Psychotherapy

Magdalena Goryczko

This thesis is presented for the Degree of
Doctor of Philosophy
of
Curtin University

September 2015
Thesis Declaration

To the best of my knowledge and belief this thesis contains no material previously
published by any other person except when due acknowledgement have been made.

This thesis contains no material that has been accepted for the award of any other
degree or diploma in any university.

Signature……………………………………………..

Date……………………

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Acknowledgements
____________________________________________________________________

I would like to acknowledge and thank all of those people have helped contribute to
the development and completion of this dissertation. First, and foremost, I would
like to thank my supervisors, Dr. Jan Grant and Dr. Jenny Thornton for their time,
expertise, and effort in supervising this project. I especially want to say thank you to
Dr. Jan Grant for her invaluable help in coding, discussing, and developing
categories and themes during analysis. She devoted much time, energy, and insight
to this project. My thinking and ideas have been greatly enriched by her guidance,
observations, and suggestions.

I am sincerely grateful to all of the participants for graciously granting me access to
their deeply personal stories and innermost experiences. Without their candidness
and generosity this project would not have been possible. I also wish to
acknowledge and thank all of these therapists who have helped recruiting
participants for this study.

I would like to thank my family and friends for their continued support, humour, and
believe in my abilities. I am also grateful for the help and encouragement of my
fellow PhD colleagues.

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Table of Contents
Abstract ....................................................................................................................... 9
PART ONE: LITERATURE REVIWE AND METHOD .................................... 11
Chapter One: Literature Review ............................................................................ 12
The Client’s Perspective: Why is it significant? ................................................ 14
The Importance of Incorporating Client’s Perspective .................................. 15
Conceptual and Political Contributions about Client’s Perspective .............. 18
Client’s Overall Levels of Satisfaction .......................................................... 22
The Client’s Experience of Therapy: Research Overview ............................... 24
Client’s Experience of Change in Therapy .................................................... 25
Therapist’s Experience of Personal Therapy ............................................. 30
Client-identified Helpful and Hindering Factors ........................................... 33
Helpful Factors .......................................................................................... 33
Hindering Factors ...................................................................................... 38
Client-identified Significant Moments ........................................................... 41
Client Agency and Expectancy ...................................................................... 46
Change in Psychotherapy: Review of Selected Models .................................... 50
Models of Change ......................................................................................... 51
The Transtheoretical Model of Change...................................................... 51
The Assimilation of Problematic Experience Model ................................ 54
Summary and Conclusions .................................................................................. 55
Chapter Two: Method ............................................................................................. 60
Research Aim and Objectives ............................................................................. 60
Methodology: The Interpretative Paradigm ..................................................... 60
Sampling ............................................................................................................... 64
Recruitment Process ............................................................................................ 65
Ethical Considerations ......................................................................................... 66
Participants ........................................................................................................... 67
Demographic Data ......................................................................................... 68
Data Collection .............................................................................................. 70
Interviews ....................................................................................................... 71
Data Analysis ........................................................................................................ 71
The Researcher ..................................................................................................... 77
Rigor of the Study ................................................................................................ 78
Methodological Limitations ................................................................................ 80
Summary and Conclusions .................................................................................. 81
PART TWO: RESULTS AND DISCUSSION…………..……………………….82
Chapter Three: Experience of Change .................................................................. 84
Dimensions of Change ......................................................................................... 85
Change as a continuum .................................................................................. 86
Change as a relational shift ............................................................................ 89
Change as timing ............................................................................................ 90
Intense, Growth Facilitating Experience ........................................................... 92
Intense, difficult, valuable experience ........................................................... 92
Challenging process that leads to insight ....................................................... 93
Deep, nurturing experience ............................................................................ 94
Intra-psychic and Interpersonal Space .............................................................. 95
Being given space for intense focus on self ................................................... 96
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Silence and time as space ............................................................................... 98
Being witnessed ........................................................................................... 100
Cohesion and Continuity of Self ...................................................................... 101
Increased self-integration ............................................................................. 102
Becoming more of oneself ........................................................................... 109
Chapter Four: Stages of Change .......................................................................... 115
Beginning Phase-Disorganization and Detachment ....................................... 116
Chaos and entrapment .................................................................................. 116
Depression and distress ................................................................................ 118
Uploading feelings ....................................................................................... 120
Middle Phase-From Symptomatic to Structural Change ............................. 121
Progression from surface to deeper levels ................................................... 121
Testing newly acquired insights ................................................................... 124
Experiencing gradual improvement ............................................................. 126
End Phase-Consolidation ................................................................................ 126
Greater authenticity and integration ............................................................. 127
Self-sufficiency and independence .............................................................. 129
No emergence of new material .................................................................... 130
Emergence of more real relationship ........................................................... 131
Chapter Five: Problem Formation and Resolution ............................................ 135
Problem Formation and Resolution .............................................................. 136
General sense of problem formation and resolution .................................... 137
Explicit theory .............................................................................................. 139
No explicit theory ......................................................................................... 141
Allegiance and Expectancy ............................................................................. 142
Client’s allegiance to treatment model ......................................................... 143
Preference for type of therapist .................................................................... 144
Client Agency ................................................................................................... 147
Openness with therapist ............................................................................... 148
Applications in life ....................................................................................... 154
Chapter Six: Helpful and Hindering Factors ...................................................... 161
Helpful Factors ..................................................................................................... 161
Strong therapeutic frame ............................................................................... 162
Secure therapeutic space .............................................................................. 164
Good boundaries .......................................................................................... 166
Predictability and availability ...................................................................... 167
Therapist as Developmental Object .............................................................. 169
Containment ................................................................................................ 169
Secure attachment and attunement ............................................................... 172
Experience of re-parenting ........................................................................... 175
Internalization of therapist ........................................................................... 177
Very Strong Alliance ...................................................................................... 179
Acceptance, support, and non-judgmentalness ............................................ 180
Real and deep relationship ........................................................................... 182
Therapist qualities ........................................................................................ 185
Rapture reparation ........................................................................................ 188
Change Facilitating Strategies ....................................................................... 191
Greater therapeutic interventions ................................................................. 191
Model specific interventions ........................................................................ 197
Hindering Factors ................................................................................................ 202
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Routinized Approach ...................................................................................... 204
Rigid preconceptions .................................................................................... 205
Premature goal setting .................................................................................. 206
Mechanized process ..................................................................................... 207
Hindering Technique ....................................................................................... 209
Inaccurate interpretations ............................................................................. 210
Excessive or Limited structure ..................................................................... 211
Impaired Therapeutic Relationship ............................................................... 213
Fear of being judged..................................................................................... 214
Limited attunement ...................................................................................... 215
Lack of safe space ........................................................................................ 218
Difficult terminations ................................................................................... 220
Chapter Seven: Significant Moments ................................................................... 228
Transforming Experiences .............................................................................. 229
Moments of insight ...................................................................................... 230
Deeply felt emotions .................................................................................... 237
Honesty and realness .................................................................................... 241
Small realizations ......................................................................................... 244
Therapist disclosure ..................................................................................... 245
Empowering Experiences ............................................................................... 250
Owning and validating feelings ................................................................... 250
Self-assurance and inner strength................................................................. 252
Changes in the relational self ....................................................................... 255
Regaining future orientation ........................................................................ 257
Chapter Eight: General Discussion ...................................................................... 260
Summary of Key Findings ................................................................................ 261
Experience of Change .................................................................................. 261
Stages of Change .......................................................................................... 262
Problem Formation and Resolution ............................................................. 264
Helpful Factors ............................................................................................. 265
Hindering Factors ......................................................................................... 266
Significant Moments .................................................................................... 267
Stage Models of Change .................................................................................... 269
The Client’s Model of Change .......................................................................... 271
The Client’s Model of Change within Contemporary Psychoanalytic
Frameworks .................................................................................................. 274
Discussion and Implications for the Field ....................................................... 279
Limitations of the Current Study .................................................................... 294
Future Directions .............................................................................................. 297
Conclusions ........................................................................................................ 298
References ............................................................................................................... 300
Appendices .............................................................................................................. 355

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List of Tables
Table 1: Demographic Characteristic of the Overall Sample .................................... 68
Table 2: Duration of Therapy for the Overall Sample and Each Study Group .......... 69
Table 3: Number of Sessions Per Week ..................................................................... 69
Table 4: Previous Therapy for the Overall Sample and Each Study Group .............. 69
Table 5: Theoretical Orientation for Treatment Modality as Described by the
Participants ..................................................................................................... 70
Table 6: Frequency of Occurrence of the Theme....................................................... 77
Table 7: Summary Table of Superordinate and Emergent Themes .......................... 83
Table 8: Experience of Change: Frequency of Occurrence of the Theme ................. 85
Table 9: Stages of Change: Frequency of Occurrence of the Theme ...................... 115
Table 10: Problem Formation & Resolution: Frequency of Occurrence of the
Theme ....................................................................................................... 135
Table 11: Helpful factors: Frequency of Occurrence of the Theme ....................... 160
Table 12: Unhelpful Factors: Frequency of Occurrence of the Theme .................. 203
Table 13: Significant Moments: Frequency of Occurrence of the Theme .............. 227

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List of Figures
Figure 1: Process of Data Analysis ............................................................................ 75
Figure 2: Overview of the Data Analysis ................................................................... 76
Figure 3: Dimensions of Change ............................................................................... 86
Figure 4: Intense, Growth-facilitating Experience ..................................................... 92
Figure 5: Intrapsychic and Interpersonal Space ......................................................... 95
Figure 6: Cohesion and Continuity of the Self ........................................................ 102
Figure 7: Beginning Phase: Disorganization and Detachment ................................ 116
Figure 8: Middle Phase: From Symptomatic to Structural Change ......................... 121
Figure 9: End Phase: Consolidation ......................................................................... 127
Figure 10: Problem Formation & Resolution........................................................... 136
Figure 11: Allegiance and Expectancy .................................................................... 141
Figure 12: Client Agency ......................................................................................... 146
Figure 13: Strong Therapeutic Frame ...................................................................... 162
Figure 14: Therapist as Developmental Object ........................................................ 168
Figure 15: Very Solid Alliance ................................................................................ 179
Figure 16: Change Facilitating Strategies ................................................................ 190
Figure 17: Routinized Approach .............................................................................. 203
Figure 18: Hindering Techniques............................................................................. 209
Figure 19: Impaired Therapeutic Relationship ........................................................ 212
Figure 20: Transforming Experiences ...................................................................... 228
Figure 21: Model of Change: Inducing Insight ........................................................ 232
Figure 22: Empowering Experiences ....................................................................... 248
Figure 23: The Client’s Model of Change – first dimension ................................... 271
Figure 24: The Client’s Model of Change – first and second dimension ................ 272
Figure 25: Core Differences in Comparative Samples ............................................ 279

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Abstract
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In recent years, research into the client's experience of therapy has been an
important and growing area of inquiry. Although a significant amount of research
has attempted to ascertain the client’s perceptions of therapy, these studies typically
use self-reports of satisfaction or change that only allow the client to respond in
accordance with sets of predetermined categories expressed in rating scales or
questionnaires. Attempts to understand the nature of change in therapy have been
predominantly influenced by researchers’ theoretical perspectives, in which the
client’s perspective on therapeutic change has been largely omitted. Therefore, the
cardinal consideration of this study is investigation of the factors precipitating and
facilitating the occurrence of therapeutic change as perceived by the client. This
notion has been supported by a significant body of research, indicating that the client
is the single most potent factor responsible for successful therapy outcomes (Bohart,
2000; Duncan, Miller, Wampold, & Hubble, 2011; Lambert & Barley, 2002). The
core research question in this study is: How does therapeutic change occur from the
client’s perspective and what factors account for that change? The data were
collected via semi-structured interviews and analysed using the Interpretative
Phenomenological Analysis (IPA) as the primary methodological approach. The
issues central to promoting therapeutic change were studied from the perspective of
two client groups, therapist and non-therapist, and from the myriad types of
therapies. Results of this analysis showed that there were only minor differences
between groups with therapist-participants staying longer in therapy and often
seeking therapy for personal development rather than clinical reasons. The results
revealed strong elements of shared experience among the therapist and non-therapist
clients irrespective of the treatment modality and even the length of treatment.
Change was experienced as a gradual development of new structures rather than
distinct stage-like phases of transition. One of the most consistent themes to emerge
from this study is the pivotal role of relational mechanisms in psychological change.
In particular, findings suggest that change was a deeply relational process, in which
the therapists’ full emotional presence in the context of a safe and stable therapeutic
relationship offered not only symptom reduction but also developmentally corrective
experiences. Furthermore, research findings suggest that clients experienced
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change-promoting, significant moments as a multi-dimensional process of alignment
in the cognitive, affective, and bodily domains. The current data indicates that these
change-inducing moments of insight emerged spontaneously out of deep and
authentic interaction between the client and the therapist. The study also identified a
number of factors hindering to the therapeutic process including routinized approach
to treatment, premature establishment of goals, provision of quick solutions,
imposition of excessive or limited structure, and insufficient attention to termination
phase. The research has various implications for the education and training of
psychotherapists with regard to the use of theory and technique. The general
recommendation of this study is that therapists need to be mindful that clients find
mechanised adherence to technique as depersonalising and instrumental. The
findings also suggest a need for more careful and effective management of the
termination stage of therapy. A comprehensive range of additional suggestions for
future research, education, and clinical practice is provided.

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