Change Process Research: Realizing the Promise

Entry for 23 June 2007:

Reference: Elliott, R. (June 2007). Change Process Research: Realizing the Promise. Paper Presented at meeting of the Society for Psychotherapy Research, Madison, Wisconsin, June 2007

[Conversion of Powerpoint slides follows; see next entry for personal commentary on this presentation:]

Change Process Research (CPR): Definition
-Term introduced by Greenberg (JCCP, 1986)
-The study of the processes by which change occurs in psychotherapy
-How change occurs
-In particular: The in-therapy processes that bring about client change
-Update: 20 years later

Role of Change Process Research
-Necessary complement to:
-Randomized clinical trials (RCT) and
-Experimental or interpretive single case causal designs
-These focus narrowly on establishing existence of a causal relationship between therapy and client change
-But do not specify the nature of that relationship
-Also, causal relationships will not be accepted unless there is a plausible explanation or narrative linking cause to effect
-CPR can provide and support these explanations

Review of Main Genres of Change Process Research
A. Basic Genres:
1. Process-Outcome
2. Helpful Factors
3. Micro-analytic Sequential Process
B. More Complex Genres:
4. Task Analysis
5. Comprehensive Process Analysis
C. Outline:
-Description
-Appeal
-Challenges
-Recommendations/ Innovations

1. Process-Outcome Genre (Quantitative)
a. Description:
-Includes correlational & experimental designs
-E.g., transference interpretations -> Outcome
b. Appeal:
-The most popular genre; intuitively obvious, easy to design
-Works well with measures of good process (e.g., depth of client exploration, alliance)
c. Challenges:
-Therapist responsiveness affects key theory relevant therapist processes (e.g., interpretation, chairwork, homework)
-Limited by area of dose-response curve sampled
-Correlational design challenged as subject to third variable causation, not currently accepted by several major review schemes
-Process-outcome gap limits clinical application
d. Recommendations/ Innovations:
-Should be accepted but only as one line of evidence for Evidence-Based Practice (EBP)
-Use new psychometric techniques (Rasch/IRT) to improve predictor & criterion validity
-Within-case analyses?
-Combine with other methods (e.g., Task analysis)

2. Helpful Factors Genre (Qualitative)
a. Description:
-Includes Consensual, Grounded Theory, Narrative etc.
-Post-therapy (Change Interview) or post-session (Helpful Aspects of Therapy Form)
b. Appeal:
-Intuitively obvious
-Fits with mental health consumer movement (“Ask the client”)
-Draws on current popularity of qualitative research in professional training programs
-Rapidly maturing
c. Challenges:
-Attributional errors; clients may follow cultural scripts
-May not be aware of or able to describe important processes
-Poor interviewing (e.g., leading questions) and superficial data analysis appear to be common => “flat” or misleading results
d. Recommendations/Innovations:
-Should be accepted but only as one line of evidence for EBP
-Develop methods for qualitative research integration (qualitative meta-analysis, e.g., Timulak, 2007)
-Encourage deeper, more interpretive or critical analysis, better training for qualitative interviewers
-Combine with other methods (e.g., interpretive single case designs)

3. Micro-analytic Sequential Process Genre
a. Description:
-Generally quantitative; usually theory-testing
-E.g., therapist empathy -> client experiencing
b. Appeal:
-Useful for testing practice theories
-Very close to practice: if X, then Y
-Study causal influence processes directly
c. Challenges:
-Distance from therapy outcome
-Third variable causation may operate
-Difficult/time-consuming: selection, transcription, measurement, analysis issues
-Not particularly good for discovery-oriented research
-Has never really caught on; field has moved away from
d. Recommendations/Innovations:
-Should be accepted but only as one line of evidence for EBP
-Qualitative micro-analytic sequence analysis is underdeveloped and should be used more widely: e.g., Conversation Analysis of important processes or events
-Combine with other methods (e.g., Task Analysis, Comprehensive Process Analysis)

4. Task Analysis of Key Therapeutic Processes/Events
a. Description:
-Focused, rational-empirical mixed method research strategy (Rice & Greenberg, 1984; Greenberg, 2007)
-Combines: qualitative/quantitative micro-process sequence analysis; process-outcome; helpful factors
-E.g., Narrative Retelling Task
b. Appeal:
-Useful for explicating therapist implicit knowledge
-Close to practice; useful for building clinical micro-theories
-Defines program of research across studies
-Can relate process to outcome
-Uses pluralistic, converging operations
c. Challenges:
-Complexity; not suited to one-shot investigations
-Based on a specific model of therapy as task-focused/client as active change agent
-Micro-analytic element is difficult/time-consuming
-Under-utilized; has not really caught on
d. Recommendations/Innovations:
-Should be more widely used to construct rational models of good practice
-Initial therapist qualitative interview phase under-utilized & should appeal to qualitative researchers as an initial step

5. Comprehensive Process Analysis of Significant Therapy Events
a. Description:
-Focused, inductive mixed method approach (e.g., Insight events in psychodynamic & CBT; Elliott et al., 1994)
-Significant events typically identified by clients and on the basis of successful outcome, but can use rational criteria also
-Use with or without client tape-assisted recall data
-Combines: helpful factors, interpretive qualitative analysis, qualitative micro-process, quantitative outcome assessment,
b. Appeal:
-Uses pluralistic, converging operations within single study
-Yields rich understandings of significant events
-Close to practice; useful for building clinical micro-theories
-Useful source of analytic tools for other approaches (e.g., Stiles’ Assimilation Model)
-Flexibility: can be used to study a wide variety of therapies and types of events
c. Challenges:
-Time-consuming/complexity/technical difficulty (requires mastery of range of methods)
-Under-utilized; has not really caught on
d. Recommendations:
-Advocate small-n use for student research projects in professional training programs, as alternative to qualitative interview research
-Should be more widely used to construct rational models of good practice

Conclusions
-Many of Change Process Research genres have proven useful over the past 50 years of therapy research
-Some have been over-used at the expense of others
-However, all have serious limitations and face various challenges:
-Fallible, partial approaches to understanding how change occurs in therapy
-Or: Are time-consuming and technically difficult
-Thus, Change Process Research methods have not fully realized their potential to contribute to our understanding of how clients change.
-Future progress is likely to benefit most strongly from a more balanced approach that builds on several recent developments, among them:
-More careful, deeper qualitative methods
-Advances in psychometric methods (Rasch analysis)
-Interpretive case study methods (events or cases)
-Overall, what is needed is systematic methodological pluralism requiring multiple lines of evidence to provide a more sound foundation for the evidence-based practice of psychotherapy.