The Change Process: Clients' Perspectives and Understanding of Change During Psychological Therapy

Background: Talking therapies, predominantly Cognitive Behaviour Therapy (CBT), represent a key approach to supporting mental health distress in the UK. CBT is beneficial for many individuals, yet it is common to ‘relapse’ and there are a significant number of individuals for whom it is unhelpful. Although research can evidence its effectiveness, decades of studies have yet to find clarity on the change mechanisms, the central tenet of therapy. Researchers propose that understanding how therapy works is a complex multifactorial process that has perhaps been skewed by a dominant quantitative approach. As the site of change and largest contributing variable of change, clients’ viewpoint is considered critical to the success of therapy. However, clients' perspective of how therapy works is limited and conflicting within the literature.
Aims: To gain clients’ perspectives by exploring their understanding of how change occurs in therapy, as well as exploring how clients define change in therapy.
Method: Drawing on a critical realist approach, this study utilised qualitative methods. Ten self-selecting participants who experienced positive change through CBT in NHS secondary care services partook in semi-structured interviews. Interview transcripts were analysed using Thematic Analysis.
Results: Three main themes were identified from participants accounts: ‘Change as changeable’, ‘External help’ and ‘It’s not magic’.
Conclusions: Findings highlighted the nonlinear, dynamic, complex and individualised process of change in therapy. A working definition of participants’ understanding of change has been offered, which can be utilised in research, policy and practice. Participants emphasised common factors of change. A Perceptual Control Theory framework was considered as one possible explanation of participants’ experiences as it was able to account for descriptions of change more than other theories. Implications of the study and further research ideas have been presented.