Change Process Research, Grenberg 1986

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JournalofConsultinguidClinicalPsychology1986, Vol.54, No.1.4-9 Copyright 1986by theAmericanPsychological Association, Inc.0022-006X/S6/M0.75

Change ProcessResearchLeslieS.GreenbergDepartment of Counseling PsychologyUniversity ofBritish Columbia

Research onchangeprocessesis needed to helpexplain howpsychotherapy produces change.Toexplainprocessesof changeit willbeimportanttomeasure threetypes ofoutcomesimmediate,intermediate,and finaland threelevelsof processspeechact,episode,andrelationship.Emphasiswillneedto beplacedonspecifying differenttypes ofin-sessionchangeepisodesandthe intermediateoutcomestheyproduce. The assumption that allprocesseshavethesamemeaning(regardlessofcontext)needs to be dropped, and acontext-sensitiveprocessresearchneeds to bedeveloped.Speechactsneedto beviewedin the context of the types ofepisodesinwhich theyoccur,andepisodesneedto beviewedin thecontextof thetypeofrelationshipinwhichthey occur.This approach wouldresultin the use of a battery ofprocessinstruments tomeasureprocesspatternsin context and torelatethesetooutcome.

Researchon theprocessofpsychotherapyhasyielded someinterestingfindings(Orlinsky&Howard, 1978)but has not ledto the type of understanding and explanations of psychotherapythatthe field hasneeded. Abasic problem with mostof theprocess research is its lack of attention to context (Elliott,1983a;Rice Greenberg, 1974,1984).Rather than assuming thatanygivenprocess has equalsignificanceor a similar meaning at anypointintherapy,it isimportanttosegment therapy intodifferenttherapeuticepisodesor events in order to understand process inthecontextofclinically meaningfulunits.One of themostim-portant criteriaforselecting episodesforstudyiswhetheror nottheyrepresenttheprocessofchange.

A focus onprocesses ofchange servesto transcend the di-chotomybetweenprocessand outcomethathas previously hin-dered the field(Kiesler,1983).In studying the process of change,both beginning points andendpointsare taken into account, aswellastheformof thefunctionbetween thesepoints.With pro-cessesofchangeas the focusof investigation,theemphasisisnot onstudying whatisgoingon intherapy (process research)noronlyon thecomparison of twomeasurement points beforeandafter therapy(efficacy research)but ratheron identifying,describing,explaining, andpredictingtheeffectsof theprocessesthat bring about therapeutic changeover theentire courseoftherapy(Greenberg,1982,inpress).

OutcomeInstudyingtheprocess ofchangeit ispossible tomeasure

three typesofpatient outcomesorchanges overthecourseoftherapy,namely,immediate outcomes, intermediate outcomes,andultimate(or final)outcomes (Greenberg,1982,inpress; Pin-sof, 1981).Animmediate outcomeorimpactis thatchange that

Theauthorwishes to acknowledge thesupportofSocial SciencesandHumanitiesResearchCouncil ofCanadaGrants 410-80-0210and 410-84-0135.Recognition is due D.Kieslerfor thetermchange process research.

Correspondence concerningthisarticleshould be addressed to LeslieS.Greenberg,DepartmentofCounselingPsychology UniversityofBritishColumbia, 5780TorontoRoad, Vancouver BritishColumbiaV6T 1L2.

isevidentin thesession.It isimportantto beabletospecifyandmeasure important in-session changes that result from specificintervention or from theoverall interaction. These in-sessionchanges then needto berelated toextrasessional, intermediatechanges such as those measured by session outcome measuresdesignedto evaluate changes in target attitudes and behaviors.Changes inthese targets then needto betracked over timetoestablish the robustness of the intermediate changes and to shedlighton the process of outcome, that is, to see how these inter-mediate changes vary over time and how they relate to finaloutcomes. Final outcomes are taken at the end of treatment andatfollow-upand represent ultimate change. To provide a completepicture of the changeprocess,outcomes at all three points needto be simultaneously related to each other.

ProcessTorigorously studytheprocess ofchangein thesession,re-

searchers need to focuson (a)specifying immediate outcomesinthesessionand (b)measuring those in-sessionprocessesthatleadto this change. To enable a rigorous study of change, thereliablemeasurement ofin-session changeprocesseshas to be-come a priority issue in psychotherapy research. Measuring in-sessionprocess raises a number of measurement issues withwhichprocess researchers have struggled overtheyears;amajorissueisthetypeandsizeofunitforprocess ratings.Inaddressingtheproblem ofchoiceofunitsinprocess research, Kiesler(1973,p. 37) concluded that in process research there are as manydifferentunitsastherearedistinct constructs requiring separatemeasurement. Inthisviewtheunit chosen,be it aword, phrase,utterance, problem area,initialperiodoftherapy,and soforth,willdependon theconstructs ofinterestand on thequestionsbeingaskedby aparticular study. Thisis howprocess researchhasproceeded until now,andthishasmadeitdifficulttocomparefindingsfromonestudytoanotheror todraw general conclusionsfromthese studies.

Asolutiontothis problemisneededin theformof aconcep-tualizationofstandardlevelsofunitsofstudy. Some agreeduponframework ofunits wouldhelptocoordinatedifferent processmeasurements and would greatly enhance process research.


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PearceandCronen(1980),workingin theareaofcommunicationand social interaction,haveproposedahierarchical modelofmeaning, whichsuggests that acomplexnetwork ofrelationsexists among various hierarchicallevelsof meaning and that sev-eral levelsofthis hierarchy need to bedescribed in order tounderstand the meaning of any communicative act. Psychother-apyprocessresearch couldbenefitbyusingthree (possiblyfour)oftheir hierarchically arranged standardized levelstodescribein-sessionprocess.Thelevels that appearto bemost relevantarethe levelsofcontent, speech act,episode,andrelationship,whichare arranged hierarchically in the order given.Content isforthe purpose of the study of changeprocessesthe mostdis-pensableof thelevels.Itrefersto theactual content being talkedabout withoutreferenceto the kind of message being used.

Thelevelofspeechactsrepresentswhatonepersonisdoingto another by saying or doing something. This levelrefersto thepragmaticsofdiscourse,howpeoplegetwhat they wantbyusinglanguage(Austin, 1962; Searles, 1969).Speech acts, accordingto these linguists, involve such things asinform,advise, promise,threaten, insult,direct,and soforth.Anumberofcoding systemsofthislevelare reported in the literature. Coding of such featuresastherapist and client response modes most clearly representthislevel(Hill,inpress;Snyder, 1963;Stiles,inpress).Inadditiontodescriptionsof thefunctionoreffect ofpatientandtherapistspeech acts,featuresof theacts that helpinunderstanding themeaningof the speech act such as depth of experience (Klein,Mathieu,Gendlin,&Kiesler,1969), voice quality (Rice,Koke,Greenberg,&Wagstaff, 1980),speech durationandsilence (Ma-tarazzo,Wiens, Matarazzo & Saslow,1968),and otherparalin-guisticvariables would alsofallinto this level.Inpsychotherapyresearch coding ofthislevel would be done on thesmallestunitofanalystsin anyparticular study.

Thenextlargerunitto becoded shouldbe theepisode.Epi-sodesare"communicative routineswhich[the participants]viewasdistinctwholes,separatefromother types of discourse, char-acterizedbyspecial rulesofspeechandnon-verbal behaviorandoften distinguished byclearly recognizable openingorclosingsequences"(Gumperz,1972,p. 17).Theepisodeunit has beenused in descriptive studies in anthropology, sociology, andsocialpsychology. Inconversational analysis, the concept ofepisodehas been used to describe how conversants fill in missing mean-ingsbydrawingontheir knowledgeof thestructureofepisodes(Schank &Abelson, 1977). In psychotherapy research, thera-peuticepisodesaremeaningful unitsoftherapeutic interactionwhich,accordingto the therapeutic approach being used,aredesignedtoachieveanintermediate therapeutic goal. Most ther-apies and therapistshaveexplicit and sometimes implicit sets ofsubtasksinwhichthepatientisengagedinordertoachieve spe-cificsubgoals. The strategicinteractionsbetween the therapistand patientinthesesubtasks constitutethemeaningfulepisodesofthat approach. For example, in cognitive therapy anepisodiclevelsubtaskinwhichthepatientisaskedtoengagemay be thecreationof anagendafor thesession (Beck, Rush,Shaw,&Emery,1979),whereas important change episodesmay be thechallengingof aspecific irrational belief(Ellis, 1962)or the collection ofschema-inconsistent evidence(Becketal., 1979).

In this hierarchical approach to the selection of units, thelargest unitofanalysiswouldyield ratingsof the relationship.Therelationshipleveldescribestheparticular qualities that people

attributeto theongoing relationship thatgobeyondanyparticularcontent, act,orepisode. Theseareunderstandings, usuallyim-plicit, that makeup acollective senseof theattributes of therelationship, the sense ofwe.Relationship has beendiscussedindetailin thetherapeutic literature,andvarious measuresof therelationship have been devised (Lambert, 1983) using eithertherapistandpatientreportsorthird-party ratings.

This hierarchical modelissuggested hereas aheuristic devicefor identifyingunitsofanalysisand levelsofmeaningfor un-derstanding communicationinpsychotherapy.Thedifferentlevelsprovide a context for each other, and this helps to define themeaning of any communication. The same act in a differentcontextwillhaveadifferentmeaning.Forexample,thestatementin psychotherapy"Ifeel likeasmallchild"countsas aspeechactofdisclosurein theepisodic contextofresolvingaconflictintherelationship contextof agood working alliance(Bordin,1979). However,in theepisodiccontext ofdiscussingproblemsinthe therapeutic relationship or a relationship context ofpooralliance (inwhichgoals andtaskswere not agreed upon andthere was no sense ofworking together [Bordin, 1979]), thisstatement could countas anaccusationor acomplaint.

Socialmeanings,therefore, are context dependent. A messageisgivenmeaningbyreferenceto thecontextinwhichitoccurs.Withthe perspective that systems of meaning are organized hi-erarchically, researcherswillhave to contend with the complex-itiesof doing research on phenomena that are viewed ashier-archical systems.

The suggested approach to the problem of choice of unit istotreatpsychotherapeuticprocessas a three- orfour-levelphe-nomenon (depending on the relevance of content) where contentand/or speechactsaregivenmeaningbytheir episodicand re-lationship contexts. Rather than implyingthatcontentorspeechactsare thefundamental dataofprocess researchto theexclusionofother variablessuchas stylistic,kinesic,orparalinguisticvari-ables, the intent here is to suggestthatcontext is of great im-portance in changeprocessresearch and should be incorporatedinourresearch strategy.Theframeworkofratingprocess,in thecontext ofepisodesand in the context of relationship,definesatypeof processresearchin which one uses a battery ofprocessinstruments ofdifferent types to ensure that one captures thethree levels previouslydiscussed.This type of research wouldenable investigatorstodescribeboth clientandtherapistprocessfromboth observerandparticipantperspectives insucha wayas toallowthe meaning of the act to be more clearly described.

What isbeing suggested, therefore,is theestablishmentof anagreed uponset ofhierarchically organized categoriesformea-suringprocess. Modern category formation theory provides someguidelines for formulatingcategories.CantorandMischel(1979)andRosch(1978) havemadeusefuldistinctions regardingthelevelofabstraction usedincategory formation. Recognizing thatobjects can becategorizedatvaryinglevelsofinclusiveness, Rosch(1978)identified a basic, or middle, categorylevelas the optimalone for most categorization tasks. Categories at a middle levelofabstractionare rich indetailsyet arewelldifferentiated fromone another.

Followingthisline of thinking it would behelpfultoattempttocategorize psychotherapy interactionsas a set ofmidlevelep-isodiccategories,describingparticularstrategic interactionsinwhichboth patient and therapist are engaged in resolving a par-


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ticular typeofproblematic patient condition.Todate, psycho-therapyprocess researchers havetended to focuson (a) lowerlevelcategorization schemes, devising rating systemsofactsthaton theirown are too richindetail tocapturetherapeuticallymeaningful unitsofchangeand (b)higherlevelsuperordinatecategorizationofrelationshipsinwhichtoomuch detailissac-rificedfor thesakeofcommonality.Theeffortstodevelopa setoflow-andhigh-level inferencecategorieswouldbegreatlyen-hanced by the developmentofamidlevelsetofepisodic categoriesofin-session strategic interactions between the participants aimedat achieving an intermediate therapeutic goal.

Recentworkinstudying change episodesintherapy (Rice&Greenberg, 1984),suchasresolution ofconflicts(Greenberg,1984a),resolution ofproblematic reactions (Rice&Saperia,1984),changesinstates ofmindintherapy (Horowitz,1979),changes insymptomsintherapy(Luborsky,Singer,Hartke,Crits-Christoph, &Cohen, 1984),andresolution ofcore conflictualthemes(Levine&Luborsky,1981;Luborsky, 1984),showssomepromise ofhelpingto isolate processes ofchangein differenttypes oftherapeutic interactions.

Inaddition to multilevel measurement it appears that aprofileofdifferentattributesat the same level isneeded in order tocapturedifferentdimensionsof theperformanceat any onelevel.How manyattributesorprofilevariablesareneededateachlevelwouldbe determined by the research question being asked. Itmay,however,bestandard proceduretoutilizeatleastone re-lationship variable, suchas, forexample, alliance;oneepisodelevel,suchasresolvingconflict; and a numberoflower levelinferencevariablesat thelevelof thespeech act, suchasvoicequality (Rice&Kerr,inpress), depthofexperience (Kleinet al.,1969),andtypeofconceptual/perceptual processing(Toukman-ian,inpress). Thiswouldresultin thestandarduseofamultilevel,multidimensional,and multiperspective (observer and partici-pant) approach to process research inwhicha battery of processinstruments is used to measure changeprocesses.

ChangeEventsRice andGreenberg(1974, 1984)havesuggestedan events-

based approachto thestudyofchange processes. Aneventis atherapeuticepisodeconsisting offourcomponents: the patientproblemmarker, the therapist operation, the client performance,andtheimmediate in-session outcome.Thepatientmarkeris astatement or set of statements by the patient that indicates tothetherapist that the patient is in a particular problem state atthemoment(suchasconflict)and isamenableto intervention.These markerscan bereliablyidentified byjudges (Greenberg,1984a;Rice&Saperia,1984).Thetherapist operationis the setofinterventions madeby thetherapisttopromote problemres-olution and isdescribed in anoperation manual.Theongoingclientresponsesto thetherapist intervention constitutetheclientperformance, whichinresolution events ends withaparticulartypeofin-sessionoutcomesuchasintegrationofconflictingten-denciesorcognitive reorganization.Eventscanvaryinsizefroma three-statementclient-therapist-clientinterchangeto anepi-sode occupyingamajorpartof asessionorevenpossiblya fewsessions.Eventsarebest selectedforstudy because theyare re-garded aspotentchange eventsorbecausetheyhave relevancetounderstandinghowchange occursintherapy (Elliott, 1983b).

Usingthisevents framework, theinvestigator attemptsto an-swer thefollowingquestions about potent eventsintherapy:

1. What clientin-therapyperformances,ormarkers, suggestthemselvesasproblemstatesrequiringandreadyforinterven-tion?

2. What therapist operations are appropriate at these markers?Whattherapist operations will best facilitate aprocessof changeatthis marker?

3. What client performancesfollowing themarkers lead tochange? Whatare theaspectsof theclient performancethatseemto carry the changeprocess,and whatdoesthe final in-therapyperformanceorimmediate outcome looklike?

Thisset ofquestions bringsthe investigator much closer tostudyingwhat patient andtherapistactually do in therapy. In-creased understandingoftherapy will emergebydiscovering whatinterventionsmake what typeofimpactatwhat particular clientmoments intherapy. Researchonthis questionin themultilevel,multidimensionalprocessframeworkpreviously suggested wouldallowadescription ofspecifictherapist activities (suchasreflec-tion, interpretation, anddirectguidance) in specific strategic ep-isodecontexts (suchaschallenging irrationalbeliefsandrepro-cessing acritical incidentfromthepast)and inspecificrelation-shipcontexts(agood working allianceortherapist perceivedasempathic). Similarly, client process couldbecodedon anumberofdescriptorsin thecontextofhigher leveldescriptors.

Attemptsat this type ofepisode-based,explanation-orientedchangeevents research would leadto anumberofdifferenttypesofstudiesofpsychotherapy.First,differentialintervention studiesat theepisodelevel, inwhichthe focus is on immediateandintermediate outcomes forparticular problem states,provideevidence ofwhichinterventionsaremosteffective atparticularpointsintherapy. GreenbergandDompierre(1981),forexample,showedthataGestalttwo-chairinterventionwasmoreeffectivethanempathic reflectioninhelpingtoresolveanin-session state-mentofintrapsychicconflict.Second, studies thatidentifywhatproblems clients actuallydiscussintherapy that suggestareadi-nessforinterventionwould beginthedelineationof asystemofprocessdiagnosisofdifferenttypesofclient problemstatespre-sentedintherapyforresolution. Asystemofprocessdiagnosisofthis typewouldhelptoorganizethedomainofclient processandwould becomethebasisfor afunctional diagnostic systemthatwouldsuggest particular interventionsforparticularin-ses-sion patient conditions. Third, studies of client resolution per-formancewould leadto aspecificationofimmediate outcomesand improved understandingof howclients actually changeintherapy.Inthese studiesofresolution performance, both inves-tigativesingle-case studiesandgroupverificationstudies couldbeperformed (Rice Greenberg, 1984).This would lead toimproved understanding and explanation of changebothby in-tensivediscovery-oriented investigationand by testing of hy-potheses.

Questions regardingdifferent typesofoutcomes would leadto amuch clearer understandingofwhat kindofin-therapy per-formances and outcomes lead to what type ofextratherapychanges.This would sharpen outcome research immenselyandwouldhelptobeginastudyof theprocessofextratherapy change.Rather thanviewingoutcome as a single unitary event, theprocessofdailyandweeklyimpactoftherapy would come into focus,and studies of outcome as a process would result. For example,GreenbergandWebster(1982)showed that particular conflictresolution performance patterns intherapy led to changeinpossessionreportsofconflict resolution, improved mood and


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goalattainmentovertheweekfollowingthesession,and reductioninindecision and improvement intargetcomplaint at terminationandfollow-up.

Changeepisode researchwouldtherefore posea setofquestionsmuchcloser to the practice of psychotherapy and would lead toresearch that could more directlyaffectpractice.Onceweknewwhatinterventionsweremostappropriateforwhich client statesandwhat resulting client performancesled toproblem resolution,wewouldbemuchclosertodescribinghowchange actually takesplaceintherapy.Wewould thenbeableto identify theactiveingredients of change and explain the mechanisms that lead tothis change.

Patternsof ChangeInitial attemptsatexplanation inpsychotherapy process re-

search generally soughtfor simpleassociationsbetween singlevariables in isolationfrom their context. This approach reliesona viewofexplanation in whichnotionsofprediction andentaihnent predominate, that is,ifx,theny,rather than inter-pretationofpattern.Amore promising strategy,whichwillaidimprovedexplanation, is the identification and discovery of pat-ternsofin-session clientandtherapist behaviors(Gottraan&Markman, 1978; Greenberg,inpress;Rice&Greenberg,1984).Identificationof patterns in client and therapist in-session per-formance is the keystrategyin studies aimed at explanation(Gottman,Markman,&Notarius,1977; Greenberg, 1980, 1983,1984a, 1984b;Horowitz, 1979).

The basic problem with most earlier process studies has beentheir neglectofpatterns.Often,only singlevariableswerestudied,andtherewasalwaysthebuilt-inassumption thattheprocessunderstudydid notvarysignificantlyovertimeand wasbasicallyhomogeneouswithinasession. Studiesofprocessovertimehaveshown that this homogeneity assumption isuntrue (Rice&Greenberg, 1984;Gurman, 1973). Clearly process variesovertime,anddifferentprocesses havedifferentmeaningsindifferentin-sessioncontexts. Aggregating process,asthoughallprocessduringsessionsoracrosstherapyis thesame, perpetuatesauni-formitymythfromwhich psychotherapy research must escape.Particularprocessesoccuratdifferenttimesintherapyandhavedifferentmeaningsindifferentcontexts.It ismoretheoccurrenceofa particular pattern of variables than their simple presence orfrequency ofoccurrence that indicates thetherapeutic signifi-canceofwhatisoccurringintherapy. Typically,however, fre-quencydata havebeen usedas thebasisofprocess research.Percentageofoccurrenceof thenumberofstatementshasbeenthe summaryfigure(e.g., percentageofinterpretations, headnods, etc.).Theassumptionisthatallbehaviorsareequivalentregardlessofcontext,timing,appropriateness,andquality. Clearlythe timing,context,andsequenceofinterpretationsorconfron-tationsare ofmuch greatersignificancethanistheir frequency.

In studyingpatternsofclient behavior,themajor strategyisratherone oflookingforcovaryingrelations over time betweenvariablesof thesamelevelofdescription.Inaddition, this patternmayneedto beviewedasbeingofparticularsignificance in aparticular higher level context.Forexample,insuccessfulepi-sodes ofseeking insight, Elliott (1984) found that a seriesofcovaryingindexesat thelevelofspeech actsandobservable sty-listic indicators could identifya pattern ascomplexas a clientstatement of attempting to achieveself-understanding,accom-

panied by an experience ofdistressat not being able to attainit, leading to a statement of a problem and a request for help.Whenthis markerofseeking self-understandingwas followed byaprocessingof newinternally generated informationand adif-ferentiation ofmeaningand newlyexpressed feelings,insightoccurred.

Twomain approachesto theanalysisofpattern have emergedinprocess research; one is arational-empiricalmethod calledtaskanalysis inwhichahuman observer identifiesthepattern(Rice&Greenberg, 1984),and theotheris apurely empiricalapproachinwhichcomputational methodsareusedto identifysequences (Sackett, 1978).

Usingatask-analyticapproach (Greenberg, 1984b),the in-vestigator selectsaparticularkindofrecurring change eventforintensiveanalysis. Then a hypothetical idealized client perfor-mance,which represents theclinician's best understandingofhowresolution takes place,iscomparedwithdescriptionsof ac-tual client resolution performancesfrom aseries ofintensivesingle-caseanalyses.Thisisdonein aniterative manner, movingbackandforthbetween idealizedandactual performancesuntilarefinedproposed modelof aresolution performance isbuilt.Thispostdictive,discovery-oriented aspectof theapproachin-volvesaprocessofmovingfromclinicalandtheoreticalexpec-tationsto observation and back againuntilthe investigator issatisfiedthatthephenomenaathandhavebeen described. Themodelconstructed bythismethod isthen subjectedtoappro-priateverification procedures, such as relating these perfor-mances to outcome. This iterative procedure of comparing actualandpossible performances representsa rigorousformofinductiveclinicaltheorizing that results in the construction of a model interms thatcan betestedbyprocess measurement.

Usingthis typeoftask-analytic approachto thestudyofther-apeutic events,thecomponentsofcompetenceofsuccessfulin-trapsychicconflict resolutionhavebeen described (Greenberg,1984a)aswellas thecomponentsofcompetenceof thesuccessfulresolutionofproblematic reactions (Rice&Saperia, 1984).Inaninitial studyofGestalttwo-chair dialogue, Greenberg (1980)showedthatforeach sideof theconflict,characteristicpatternsofvoicequalityanddepthofexperiencingwereassociated withresolution. It appeared that acriticalaspect of resolution wasthechangein apreviously externally focused, harshcriticto amoreinternally focused stance,asmeasuredbyhigher levelsofexperiencingand a use offocused voice.In anextensionofthisstudy(Greenberg,1983,1984a),asampleof 14resolvers(selectedon thebasisofclientandtherapistreport)were shown to beclearlydistinguishablefrom 14 nonresolvers on thebasisof in-session performance patternsofaffiliationanddominance (Ben-jamin, 1974)aswellasvoice andexperiencing.In theinitialphase,thedialogue betweenthepartsof the selfinconflict inthe twogroupswasfoundto beindistinguishableon thethreemeasures; but,as thedialogue progressed,theharsh criticin theresolutiongroup became more affiliative, andthis processofbecomingmore acceptingof theselfclearly distinguishedresol-versfromnonresolvers.Thechangeofvoice qualityin thecriticwasalsoanimportant indicator that distinguished betweenthegroups,andthis indicatorplustheincreaseindepthofexperi-encingof thecritic suggested thatthesofteningof theattitudeinthe critic occurs by a process in which attention is deployedinternallytogeneratenewmeanings (Greenberg, 1984a).

Amorepurelyempirical approachtopattern identification


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utilizespattern analysisorsequential analysis methods suchasMarkovchain analysis, lag sequentialanalysis,and uncertaintyanalysis(Attneave,1959; Sackett, 1978).In this approach, sta-tistical methodsareusedto findsequences, usually probabilisticsequences, collapsingtheoccurrenceofsequences over timetoprovideanoverallpicture ofwhatoccursin a session.Becauseofitsaggregationofdata, this approach doesnot provideanopportunityforisolatingtheunique pattern;however,it is ausefulone formoving beyondfrequencycountsofvariablesinisolationtoward identification ofsequential dependencies among a numberofvariables.

Sequential analysis utilizes conditional probabilitiestheprobabilityofxoccurring,giventhatyhas occurredto describetheeffects of antecedents on consequents. In psychotherapyre-search,however,analysisof tworesponsesin asequence rarelyrepresentsameaningfulinteraction sequence.Two-stepcontin-gencies,say a client statementfollowedby a therapist statementorvice versa,may not be anideal unitforinvestigationof alltherapeutic change. Longer sequences needto beconsidered.Thedifficultyinanalyzing longer sequencesbysimple conditionalprobabilitiesis theincreasing paucityofdatapointsthat occursbycombining events. Increasingthechaintoinclude three events(the probabilityofzfollowingx,given thatyhas occurred) leadsto a sizable reduction in datapointsand an increase in samplingerrorbecausetheAateach data point decreaseswiththeadditionofeachnewstepin thesequence.

One proposed solution to this problem is the use of laggedsequentialanalysis, where responsesareconsidered inrelationto antecedents more than one step back in time, irrespective ofwhathappensinbetween.AsRevenstorf,Hahlweg, Schindler,andVogel (1984)pointed out,theproblem with this approachisthat this analysisis notreally considering chainsofbehaviorbutrather behaviors that are simply more distantfromthe initialantecedents. Some authors have,however, inferred characteristicsofbehaviorsequencesfromthese lagged probabilities (Gottmanetal., 1977; Patterson&Moore, 1979).

A furtherlimitingfeatureofempirical identificationofpatternsbysequential analysisisthattheresultsof theanalysisaretotallydependent on the coding systems selected to obtain thedata.Ifonedoes nothavesystems that reflect dependencies in the data,they willnot befound.Intask analysishowever,human observerswhointensively inspect the data maynoticea dependence insomefeaturesandthenmayconstructnewmeasurement systems.Purelyempirical methods are thereforeonlyas good as the mea-surement systems theyuse andprematurelyrestrictobservation.Inaddition, human performanceintherapy doesnottendto becharacteristically regularorclear-cut.Sequential dependenciesdo not occur in neat predictable fashions. Clients might reactsometimestosomethingthetherapist just said,but atothertimes,clients might react to something said afewstatements back orevensaid at thelastsession. Similarly, the sequential dependenceofoneclient statementon aprevious client statementpossessesasimilarvariability.

ConclusionChangeprocess researchof thetype discussed,whichidentifies

thepatternedcharacteristicsofsuccessfulin-therapychange per-formancesand relates these toextratherapychange, holds promiseforincreasingourunderstandingofmechanismsofclientchange

inpsychotherapy. Withtheidentificationofchange processesasaresearch target, the dichotomy between process and outcomebreaks down. It is replaced by the endeavor of relatingprocessindifferentchangeepisodestodifferentpoints alonganoutcomecontinuum.

Littleliteraturecurrentlyexistsrelating in-therapyprocess tothedifferenttypesofchangediscussed.Ifempiricallyidentifiablepatternsofchangecan bereliablyidentified fordifferent typesofchange events and if thesepatternscan be related to outcome,then this relationwillbe demonstratedonlywith the use of im-provedmeasuresofbothprocessandoutcome. These measureswillneed to be sensitive to subtle changes in both domains. Inadditionto theneedforimproved measurement(Greenberg&Pinsof,in press), the role of the individualdifferencevariable inunderstanding howpeople change would needto bemore clearlyspecified(Rice&Greenberg,1984).

Finally,itmightbeargued thattheprocessesandinterventionsthathavebeen studied by this approach and thatwouldyield toitare too global, complex, and unspecified and that what is re-quiredis amore atomisticdefinitionofvariablesand thedem-onstration of causal links between them. There has, however,beenalargegapbetweentheresearchandpracticeofpsycho-therapy(Luborsky,1972),andresearchershavetendedtostudywhattheyknowhow tostudyor canstudyrelativelyeasily ratherthan whatis ofimportance to theconduct ofpsychotherapy.Possiblyfor thisreason,research has had little impact on thepractice of psychotherapy. It is suggested here thatpractitionerswillbegintotake greater guidancefromresearchfindings ifstud-iesofthe type suggested here can illuminate the practice of ther-apybydiscovering patternsofperformancethatexplainthepro-cess of change.

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ReceivedNovember2, 1984Revisionreceived June6,1985

Change Process Research, Grenberg 1986

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