COMMONWEALTH OF AUSTRALIACopyright Regulations 1969WARNINGThis material has been reproduced and communicated to you by or on behalf ofThink Education Group pursuant to Part VB of…

COMMONWEALTH OF AUSTRALIACopyright Regulations 1969WARNINGThis material has been reproduced and communicated to you by or on behalf ofThink Education Group pursuant to Part VB of the Copyright Act 1968 (the Act).The material in this communication may be subject to copyright under the Act. Anyfurther reproduction or communication of this material by you may be the subject ofcopyright protection under the Act.Do not remove this notice.ORIGINAL ARTICLEPsychological change from the inside looking out: A qualitativeinvestigationTIMOTHY A. CAREY1, MARGARET CAREY2, KIRSTEN STALKER3, RICHARD J. MULLAN4,LINDSEY K. MURRAY5, & MARGARET B. SPRATT51Centre for Applied Psychology, University of Canberra, Australia, 2Canberra, Australian Capital Territory, Australia,3Applied Educational Research Centre, University of Strathclyde Scotland, 4Coleraine Northern Ireland, and5Department of Clinical Psychology, Stratheden Hospital, ScotlandAbstractRegardless of the type of psychotherapy considered, change is the predominant goal. Psychotherapies differ in theirexplanations of how change occurs and what it is that needs to change, but pursuing change of something in some way iscommon. Psychotherapeutic methods, therefore, should be enhanced as knowledge of the change process improves.Furthermore, improving our knowledge about general principles of change may be of greater benefit to psychotherapy thanincreased knowledge about any particular change technique. This study addresses the questions ‘What is psychologicalchange?’ and ‘How does it occur?’ from patients’ viewpoints. Answers to these questions were sought using qualitativemethodology. At the end of treatment, 27 people were interviewed about their experience of change. Interviews were tapedand transcripts analysed using the Framework approach. Change occurred across three domains: feelings, thoughts andactions. Participants described change as both a gradual process and an identifiable moment. In relation to how changeoccurred, six themes emerged: motivation and readiness, perceived aspects of self, tools and strategies, learning, interactionwith the therapist and the relief of talking. Change was experienced in similar ways irrespective of type of treatment. Currentstage models of change may not be suited to the explanations of change provided by the participants of this study; the processof insight through reorganization might be a more accurate explanation. Understanding change as a process involving suddenand gradual elements rather than a process occurring through sequential stages could inform the development of moreefficacious psychological treatments.Keywords: Change, psychotherapy, insight, reorganisationRegardless of the type of psychotherapy considered,change is the predominant goal. Psychotherapiesdiffer in their explanations of how change occursand what it is that needs to change, but pursuingchange of something in some way is common.Psychotherapeutic methods, therefore, should beenhanced as knowledge of the change processimproves. Furthermore, improving our knowledgeabout general principles of change may be of greaterbenefit to psychotherapy than increased knowledgeabout any particular change technique (Rosen &Davison, 2003).Research backgroundPrimarily, we were interested in two questions: Whatis psychological change? and How does it occur? Itappears common in the psychotherapy literature todiscuss change without first defining it and explanations of the change process often equate to differences in pre- and post-questionnaire scores (Careyet al., 2006). Problems have also been identified withthe way change has been researched; for example,methodological difficulties are acknowledged (Greenberg, 1991; Lampropoulos, 2000) and neglect ofrigorous research of the change phenomenon hasbeen noted (Greenberg, 1994). Some authors havesuggested that a methodology other than experimental manipulation is needed (Elliott & Anderson, 1994;Greenberg, 1999). Specifically, the patient’s role hasbeen either under-emphasised or ignored (Duncan &Miller, 2000; Gordon, 2000; Messari & Hallam, 2003).Even though the client has been recognized as the‘site of change’ (Greenberg, 1991, p. 10), questionsabout the change process often focus on examininghow psychotherapy is helpful (e.g. Murray, 2002).Some notable exceptions to this general trend are,however, available in the literature and qualitativemethods are becoming more accepted as the mosteffective way of investigating certain types of researchCorrespondence: Timothy A. Carey, Centre for Applied Psychology, University of Canberra, ACT 2601, Australia. E-mail: [email protected] and Psychotherapy Research, September 2007; 7(3): 1781871473-3145 (print)/1746-1405 (online) – 2007 British Association for Counselling and PsychotherapyDOI: 10.1080/14733140701514613questions in psychotherapy (e.g. McLeod, 2000).Clarke, Rees, and Hardy (2004), for example, used aqualitative methodology to explore the experiences offive patients undergoing cognitive therapy. Theirparticipants’ experiences mapped on to the stagesof change described in the assimilation model (Stileset al., 1990) and the authors drew tentative conclusions about the way in which participants movedthrough the stages. Clarke et al. (2004) recommended conducting a study with more participantsand also looking at barriers to change by includingparticipants who did not change or who did notcomplete therapy. Perhaps incorporating other typesof therapies would also be worthwhile.Klein and Elliott (2006) combined both quantitativeand qualitative methods to explore the change process. They examined the experiences of 40 patientsundergoing process-experiential psychotherapy. Thepatients’ responses fitted pre-established categoriesbut some discordance between qualitative and quantitative approaches was noticed. This study looked atonly one type of psychotherapy and its emphasis wason the objects of change rather than the process ofchange.Rodgers (2006) also combined qualitative andquantitative measures to explore participants’ experiences of change. The 20 participants received different types of counselling and were interviewed before,during and after counselling and also at follow-up. Aswell as completing a standardised questionnaire,participants constructed life space maps (LSMs).Rodgers concluded that both the questionnaires andthe LSMs were useful in capturing information aboutparticipants’ change experience. The purpose of thiswork was to capture the individual significance ofeach participant’s change experience. However, thiswork is ongoing and Rodgers (2006) reported thatonly five people had completed therapy so far.Other researchers have used narrative methods tounderstand more clearly patients’ experiences ofpsychotherapy. Ku¨ hnlein (1999) conducted narrativebiographical interviews with 49 patients. She foundthat the processes of accommodation and assimilation could be used to explain the transformationspatients described undergoing in psychotherapy.Burnett (1999) used a different narrative approachby asking 35 patients who had completed counsellingto write a letter to a friend providing as much detail asthey could about what they learned in psychotherapy.Burnett suggested the outcomes of psychotherapycould be viewed within a learning framework throughthe Structure of Learning Outcomes taxonomy.While these studies have provided useful information about change in psychotherapy, they also indicate avenues for future research. For example, likeRodgers (2006), we were interested to interviewpeople who received different types of psychotherapies. We wanted to explore whether the same or adifferent change process could be discerned. Wewere also interested in discovering what patients’descriptions of change might be if we did notapproach the interviews with a pre-determined taxonomy or set of stages of change. The issues of howchange actually occurs does not appear to have beenaddressed in detail in other studies and we wanted topursue this area as well.To explore the questions ‘What is psychologicalchange?’ and ‘How does it occur?’ a qualitativemethodology was most appropriate. Qualitative research, derived from philosophy and anthropologyand widely used in social science, has been describedas ‘a form of social enquiry that focuses on the waypeople interpret and make sense of their experiencesand the world in which they live’ (Holloway, 1997,p.1). Qualitative research, based on subjective accounts, does not in and of itself provide unequivocalanswers but, rather, a range of experiential accounts.We considered, however, that these experientialaccounts would be essential building blocks in constructing a better understanding of change.MethodsRecruitmentWe planned to recruit between 25 and 30 participants, comprising some who reported change duringtherapy and some who did not. Because we wereinterested in exploring change generally, we did notrequire that participants had received the sameprogramme of therapy.Purposive or criterion-based sampling, common inqualitative research, was used to select participants.Here, certain criteria are identified as a basis forsample selection: generalisability is seen as lessimportant than the collection of rich data that enablesunderstanding of participants’ views and experiences(Holloway, 1997). A sampling grid (Ritchie & Lewis,2003) ensured a systematic approach to participantselection. There were no suggestions in the literaturethat change occurs differently for different groups ofpeople so we opted for general criteria.We used an age range of 1865 years and delineatedthree cohorts to maximise the likelihood of obtaining across-section of participants: 1830; 3144; and4565 (the final sample consisted almost entirely ofpeople in the older two cohorts with 13 people fillingthe third cohort and 12 filling the second cohort). Foreach cohort we set out to recruit equal numbers of menand women (although the final sample consisted of 18women and nine men). We also established the criteriaof ‘depressed’, ‘anxious’ and ‘other’ and allocatedparticipants to these categories based on informationWhat does this study explore?. The patients’ viewpoint on the questions,What is psychological change?’. ‘and ‘How does it occur?’Psychological change from the inside 179contained in their referral letter. If the referral lettermentioned ‘depression’ and no other diagnostic termsthe patient was assigned to the ‘depressed’ category.Patients who were not assigned to the ‘depressed’ or‘anxious’ category were assigned to the ‘other’ category. Patients in the ‘other’ category had variousproblems such as: anger, posttraumatic stress disorder,specific phobia, chronic fatigue syndrome, obsessionsand compulsions, paranoia, panic, chronic pain andalcohol addiction. While this method of initial presenting problems might not be useful for most purposes,our intention was to obtain a range of different kinds ofproblems from the pool of people referred to ourservice. The problem categories would not then biasthe analysis of the data. The median number ofappointments patients attended for was 6 (range134; interquartile range7).Patients’ names were taken from the waiting listin the order they appeared and assigned to one ofthe cells in the grid. Because people from Blackand minority ethnic backgrounds are under-represented in our service, any such individuals wereinvited to participate whenever a referral wasreceived, even if the desired number of participantsin the cell they were allocated to had already beenrecruited.Four clinical psychologists (a male with three yearsexperience and three females each with two yearsexperience), a counseling psychologist (a female withten years experience) and two cognitive behaviourtherapists (a male with seven years experience and afemale with ten years experience) recruited participants to the study. At the initial interview, eachtherapist explained the research to the potentialparticipants and gave them an information leafletand a consent form. Patients were told that they wereunder no obligation to participate, that their psychological treatment would not be affected by theirdecision and that they could withdraw at any time. Atthe completion of treatment, MC contacted participants who had consented and arranged an interviewtime. If patients did not return a permission formwithin two weeks of receiving it, one reminder letterwas sent.A total of 203 patients were invited to participate.Of these, 47 patients agreed to participate, 27 ofwhom took part in an interview. Some patients whoinitially gave consent could not be contacted bytelephone and did not respond to letters invitingthem to an interview. Others did not attend at thearranged time. Still others withdrew the permissionthey had earlier given. No patients of ethnic originwere recruited although three were sent permissionforms.ResearchersAs the investigators of this study, we provided a blendof research and clinical expertise. Four of us (TAC,RJM, LKM, MBS) were also therapists in this study.One of us (MC) is a research psychologist withexperience in interviewing and practicing psychotherapy. For this study MC conducted all the interviewsand provided no psychotherapy to any of theparticipants. She conducted the bulk of the analysis.KS has a background in social work and extensiveexperience as a qualitative methods researcher. Sheprovided technical expertise with qualitative methodsand consulted with MC throughout the analysis of theinterviews. TAC, MC, RJM and MBS are all interestedin understanding perceptual control theory (PCT) as atheoretical model of behaviour. TAC, RJM, and MBSused the Method of Levels (MOL) in this study as theirpsychotherapeutic treatment. Method of Levels is thepsychotherapeutic method informed by the principlesof PCT. LKM bases her psychotherapy around cognitive behaviour therapy with a particular interest inschema-focused psychotherapy.InterviewA topic guide, as suggested by Arthur and Nazroo(2003), was designed around our research questions.The topic guide is different from an interviewschedule in that it does not specify particular questions to be asked in a particular order but, rather,suggests topics for exploration. The questions askedin each interview, therefore, were slightly differentbut the main questions of ‘What is change’ and ‘Howdoes it occur’ formed the foci for all questions thatwere asked. From these two general questions fivethemes were identified for the topic guide. Thesethemes were: was there change; perceptions ofchange; timing of change; questions to ask in theabsence of change; and time for participants to addany other comments. Within these themes a range ofquestions were asked in response to the materialprovided by the participant (e.g. ‘How did you knowchange had occurred?’, ‘What would other peoplesay?’, ‘How did change happen?’, ‘What did you firstnotice when change began?’). Generally then, participants were not directed to talk about any particularaspect of change but, as they were asked to describewhat they understood change to be and how ithappened, MC asked appropriate supplementaryquestions. Thus, participants provided informationabout the content of the change in terms of whatchanged for them as well as the process ofthe change in terms of how these changes cameabout.The guide was piloted in the first two interviews.Minor amendments were made as necessary to clarifywording or where questions appeared repetitive.Since few changes were needed, data from the pilotinterviews were included in the final analysis. Prior tocommencing the interview, MC checked that theparticipant still consented to be involved inthe research and agreed to have the interview taped.Typically, interviews lasted between 45 and 60minutes.180 T. A. Carey et al.AnalysisAnalysis of the interview transcripts was broadlybased on Ritchie’s and Lewis’s (2003) Frameworkapproach. Framework is ‘a matrix based method forordering and synthesising data.’ (Ritchie et al., 2003,p. 219). The analytic process of Framework can bethought of as ‘conceptual scaffolding’ (Spencer et al.,2003, p. 213) in which an analytic framework isconstructed. Analytic frameworks are common todifferent qualitative approaches but the Frameworkmethod is a ‘largely cross-sectional analysis based oninterpretations of meaning’ (Spencer et al., 2003,p. 213).Guided by the Framework approach our analysiscomprised a number of stages. First, a subset of threetranscripts was indexed (coded) by the entire teamand a number of initial themes or concepts, relatingto the research questions, were identified. Next, MCcontinued the indexing procedure for the remaining24 transcripts resulting in a total of 22 categories,such as ‘the speed of change’, ‘the change moment’and ‘characteristics of the therapist’. The categoriesincreased throughout the analysis reflecting the continuous and iterative nature of the Frameworkmethod in which new themes are added as theyemerge throughout the analysis. Next, a series ofthematic charts were developed which set out eachmain theme followed by the relevant data from eachparticipant. This stage involved some refinement ofinitial themes, for example through the creation ofsub themes. Next, the data from this chart weresummarised and synthesized, allowing us to identifyemerging patterns, ‘deviant’ cases and move towardsa broader explanatory account. This involved ‘workingthrough the data systematically to ensure that all thecontent has been considered’ (Ritchie et al., 2003,p. 233).ResultsOf the 27 participants interviewed, two experiencedchange before they attended their first interview,three did not experience change during the course oftherapy and the remaining 22 experienced changeduring the course of therapy. The final categoriesfrom which our synthesis was constructed, along withexamples for each category, are provided in theappendices. Appendix A has four categories in answerto the question ‘What is psychological change?’,Appendix B provides examples of the descriptions ofthe change moment and Appendix C has six categories in answer to the question ‘How does psychological change occur?’. The explanation wesynthesised from these categories is provided below.Domains of changeWhen answering questions relating to ‘What ischange?’ many participants experiencing changedescribed what changed for them rather than articulating a definition of change (those who did notchange answered in terms of what change theywould have liked). Participants described experiencingchange in three domains: feelings, thoughts andactions (see Appendix A). With regard to feelings,some references were to the cessation of physicalsensations such as headaches, panic attacks and ‘justuncomfortable’. More frequently, participants talkedabout changes in their emotional state. They nolonger felt, in their words, depressed, low selfesteem, guilty, angry, uptight, aggressive and absolutely miserable but, instead, now felt more tolerant,relaxed, calm, chilled out, happy, better, positive and‘a rewarding feeling’. Remarkably, pre-change descriptions were entirely negative while post-changedescriptions were wholly positive.In terms of how their thoughts and attitudes hadchanged, a theme for several participants was a senseof a new beginning or a welcome return to theirformer, ‘real’ and ‘normal’ way of life or self (‘I lovelife again as I always used to . . . I thank God for thisnew day’; ‘I am now feeling closer to how I normallyam . . . to be more realistic about how you’re feeling . . . feeling more comfortable with my life’).Acceptance was an important attitudinal changefor several participants. In some cases, this was arecognition that a resigned acceptance, be it of adifficult relationship or a perceived character trait oftheir own, had acted as a barrier to change (‘There isno blackness over my outlook now: there was a dullacceptance that this was a mediocre rotten life thatI was leading’). For others, deciding to accept something which had previously been unrecognised orresisted was a useful coping strategy and a potentialway forward (‘I had a big life change . . . I had mydaughter . . . part of the whole kind of problem wasaccepting this life change and I went from being akind of full time professional to thinking I am going tobe a full-time mum . . . I thought I can be a full-timemum, it will be fantastic. It was accepting that lifechange and then accepting that perhaps my standards were too high . . . I had needed something morefor me’).Participants also described changes in behaviour.Some of these were significant because they concerned actions or activities that had formed the nubof the participant’s difficulties such as overcomingphobic anxieties or talking honestly to family members about painful issues that had long been avoided.Amount of changeAll participants gave some indication of the amount ofchange experienced. This varied considerably buteven those who may have remained within ‘clinical’ranges expressed satisfaction with the way they werenow able to live their lives. Asked to rate the amountof change on a scale from 0‘none’ to 10‘complete’, the majority chose around seven or eight,indicating considerable change had occurred. However there were exceptions (‘To be honest with you,Psychological change from the inside 181no, probably 0, the same, it didn’t help at all’; ‘Ithelped 100%. I am fine now. I feel better about 810now’). Several indicated that while a good deal ofchange had occurred, they hoped there was more tocome, suggesting the process was not complete(‘Two-thirds of the way. I feel as if I had read abook, I had read the first part, the middle part and thelast part of the book is missing’).How does change occur?When describing how change occurred*or how theyknew it had occurred, since this tended to be thefocus of participants’ comments*it was striking thatmany described change occurring both as a gradualprocess and at an identifiable*and memorable*moment (see Appendix B). Indeed, it seems changewas often experienced as both (‘I know that’s aparadox; it was sudden but it was gradual . . . One dayI felt so much better . . . one day I felt really good butwhen I thought about it, I had been feeling betterbefore that . . . it was gradual but the realization wassudden’).Many participants clearly expressed the vividness ofthe change moment. One participant reported hecould ‘visualise the point’ and another, ‘I couldactually hear it’. Some reported where they were atthe time they became aware of change ‘in the poolwith my husband’ or ‘in the second meeting with thetherapist’. The experience was described by several interms of a light going on, putting a shilling in themeter, a load being lifted. Others used more dramaticmetaphors*‘somebody has given me a shot ofsomething’, ‘like letting steam out of a kettle’.Although many of these participants also talked aboutchange as a process, there were fewer descriptions ofwhat this felt like, although one referred to ‘a buildingprocess, like a pyramid’.Participants’ accounts of how change occurred canbe grouped into six themes: motivation and readiness;perceived aspects of self; tools and strategies; learning; interaction with therapist; and the relief of talking(see Appendix C).Motivation and readinessFeeling ready and motivated to change was important. A common theme among several participantswas that they had reached ‘rock bottom’, did not likeit, and realised they could either stay there or start tocome back up. This was illustrated in use of phraseslike ‘enough is enough’, ‘not the road I want to goon’, ‘the end of my tether’ and ‘being down there’.Additionally, a couple of participants identified asense of shame about the state they were in, or fearof how others would view them, as a driver forseeking change. Other factors contributing to readiness were a realisation that avoiding the problem wasnot going to solve it and a determination to tackle theissues.Perceived aspects of selfThe second theme encompassed factors that participants believed both hindered and facilitated change.These included personality type, character attributes,past experiences including childhood trauma, culturalinfluences, anxiety about what others thought ofthem, and the perceived impact of their ‘illness’ (‘I ama bit of a perfectionist’, ‘My past’s with me everyday . . . I need to prove that I’m not my mum’). Someparticipants recognised that they were resistant tofacing up to certain issues and, thus, to change.Tools and strategiesSome participants referred to various tools andstrategies that helped bring about change. Theseincluded relaxation techniques, diaries, activity charts,information, homework set by the therapist andmedication. With the possible exception of the last,a common element was that these tools were ameans whereby participants felt able to gain controlover their situation.LearningA number of participants identified learning as anecessary part of the change process. Some hadgained new insights about themselves, some hadlearnt a different way of looking at their situation andsome had become aware of the root of their problem.For several, there was a sense of arriving at a ‘realself’. A few had been aware of learning as an iterativeprocess (‘I have not really been a learning fromtextbook person. I learn probably more hands-ontype person so probably talking in the therapy mademore impact for me than doing homework; it justisn’t my way of learning’). In contrast, a couple ofparticipants suggested that learning had taken placewithout their having been aware of the process(‘I don’t realise at the time what has gone in; it’sthere and you think, ‘Oh, I’ve learnt!’ I don’t knowwhat I have got until it’s displayed to me’).Interaction with therapistThe majority of participants had a good deal to sayabout the nature of their interactions with thetherapist and again a number of common themesemerged. The feeling that they were not being judgedwas crucial and often contrasted with perceivedreactions of family and friends. Similarly, the factthat the therapist had no personal connections withthe participant, no previous knowledge or preconceptions about them, was reassuring. Although in thatsense removed, the therapist was also seen as asource of help and support (‘It was nice to talk tosomebody outside the family . . . somebody thatdidn’t have any background on me, didn’t knowwhether I was good, bad or anything but prepared tosit and listen to me, listen to my problems and try andhelp you get over them’).182 T. A. Carey et al.These factors in turn enabled the participants toplace trust in the therapist and thus, to be open andhonest about their situation. In many cases this contrasted with the difficulties they had experienced insharing information and feelings with those ‘close’ tothem. For some, it was important that the journey wasbeing shared, others felt they were on their own butwith the therapist playing a supportive role, whileothers wanted to be told what to do. Most, however,attributed the change to their own hard work (‘It wasme that was doing all the talking . . . [the therapist]wasn’t just telling me what to do all the time and thatmade a difference . . . he was like asking you what youwere wanting to do, instead of telling you what to do’).The relief of talkingSome participants identified talking as an importantfactor in change. In particular, they contrasted therelief of finally being able to speak openly about theirproblems with the tension arising from endlesslythinking about them and the associated unpleasantemotions. There was a sense that it was both hard totalk and good to talk (‘Just being able to speak aboutit instead of just keeping it into myself, thinking in myhead and going round and round, bottling itup . . . that is something I have never ever reallydone’). These participants felt an enormous releaseas they shared feelings and experiences that they hadnever previously told anyone (‘I was letting everythingout, I felt like I was cleaning out the rubbish bin’).In summary, participants clearly identified whatchanged in terms of their feelings, thoughts andactions. They also quantified the change from negative to positive experiences. Those who reported thatchange had not occurred were nevertheless able todescribe what had prevented change occurring*usually in terms of perceived aspects of self. Manyparticipants described change as both a gradualprocess and a sudden moment when things ‘clicked’into place. There was no systematic description of aseries of stages that participants felt they had movedthrough. Rather, our findings suggest that, for changeto occur, the individual needs to be ready andmotivated, play an active role, use appropriate toolsand strategies which work for them, learn, talk to animpartial but supportive person and move beyondthinking about the problem. Additionally, the dataindicate that certain aspects of self or of personalexperience can facilitate change, including determination and open mindedness, while others may get inthe way. Participants’ accounts point to an interplaybetween internal and external factors but the activerole they ascribe to themselves gives support to thenotion of the patient as an active self-healer (Gordon,2000).DiscussionIn setting out to learn about the process of psychological change from people who were seeking toundergo this change we posed two research questions and recruited 27 people to be interviewed aboutthe process of change. Despite the fact that participants were both men and women, of different ages,who experienced different problems and underwentdifferent types of psychotherapy from different psychotherapists, a number of common elementsemerged in their accounts of change.Generally, participants were unable to provide adefinition of change. Given how convinced participants were of the change they had experienced wewere surprised that they were unable to define thisprocess and we were unable to arrive at a compellingexplanation for why this might be so. Participantscould, however, quantify the change they experienced. Participants were certain about whether or notthey had experienced a change moment but thenature of this moment was less tangible. Someaspects of participants’ accounts, such as the needto be motivated or ready to change or the importanceof the relationship with the psychotherapist, are notnew. What this study offers that is new, however, isthat these descriptions have come from the peopleexperiencing the change rather than other sourcesand the descriptions were not guided by assumptionsabout any particular stages of change model.The notion of change emerging from these accounts may raise questions about models that describe change as a series of stages (e.g. Prochaska &Norcross, 2001). Participants did not describe proceeding through a series of stages as they changed.Rather, they described a period of negativity, then asudden change moment and then a protracted periodof positivity. Possibly, participants progressed througha series of stages and were unaware that this waswhat they were doing. Also, perhaps a different kindof interview with more structured questions mighthave produced responses that endorsed stages ofchange. It might also be possible, however, thatchange is not accurately or fully conceptualized by astages model. For example, the findings of thepresent study are in contrast to those of Clarkeet al. (2004). The small number of participants theyinterviewed (five), along with the homogeneity of thecognitive therapy received, may explain their findingsin support of a stages-of-change model. Perhapsparticipants’ reports reflected the structured andWhat does this study tell us?. Change occurred across three domains:feelings, thoughts and actions. It was described as both a gradual process andan identifiable moment. Six themes described how change occurred:motivation and readiness, perceived aspects ofself, tools and strategies, learning, interactionwith the therapist and the relief of talkingPsychological change from the inside 183sequential nature of cognitive therapy rather thanrevealing an underlying process of alteration.Research in the insight literature appears to matchthe descriptions from participants in our study. Insight, which can be thought of as ‘the clear andsudden understanding of how to solve a problem’(Bowden et al., 2005, p. 322), seems to have thefollowing properties: an impasse is reached whereprogress towards a solution is halted, the ‘Aha!’ isexperienced; the solution is experienced as arisingsuddenly; the correctness of the solution is immediately recognised; the processing that leads fromimpasse to solution is not able to be reported (JungBeeman et al., 2004). Additionally, some authorsdescribe a period of time after the ‘Aha!’ experiencewhere the details of the solution are fleshed out orthe implications for their realisation are applied(Davidson, 1995; Schooler et al., 1995). The descriptions provided by the participants of our study seemto embody these principles.An account of how insight might occur is providedby the process of reorganisation as described inperceptual control theory (PCT) (Powers, 2005). Inreorganisation, aspects of the neural network arealtered by a random, trial-and-error process until errorin the network is reduced and the ability to functionas desired is restored (Powers, 2005). People experiencing psychological distress are unable to controlexperiences that are important to them. Reorganisation is posited to be the process that re-establishescontrol when it is compromised (Carey, 2006).Perceptual control theory, therefore, could serve asan integrative theory that explains how changeoccurs, in the form of insight, during psychologicaldistress.In some ways, the assimilation model (Stiles et al.,1990) is very similar to the process of reorganisationdescribed in PCT. The principal components of theassimilation model include ‘(a) schema, (b) problematic experience, and (c) the complementary processes of assimiliation and accommodation’ (Stileset al., 1990, pp. 411412). Whereas the assimilationmodel is a conceptual model of change, however,PCT is a functional model that uses simulations to testbasic principles. From a PCT perspective the process ofhow change occurs is common while the content ofwhat changes is idiosyncratic. In psychological treatments then, rather than teaching skills or providinginformation, it may be more important to facilitateprogress towards an impasse and then to support theperson while they experience this impasse anddevelop insights to resolve it rather than trying toavoid it. The procedure suggested here seems consistent with some well-established procedures such asexposure. Perhaps psychotherapy treatments wouldbenefit from investigating ways of applying the sameunderlying principles to other treatments.This study is not without its limitations. Althoughthe qualitative methodology is appropriate for thequestions we have asked, the conclusions we candraw are limited. The participants we recruited weremostly adults in our upper age category and, perhaps,a higher proportion of younger people may have ledto different findings. We did not pay attention towhether or not participants had received psychological therapy prior to their current treatment butperhaps a consideration of the experience of relapsewould shed further light on the phenomenon ofinsight. Furthermore, we only interviewed patients atthe end of their treatment programme.Our learning from this research suggests newavenues of investigation. It might be useful to comparea stages-of-change model, such as the assimilationmodel, with a change-by-reorganisation model. Perhaps functional models of these could be constructedand the data used to judge which model mostaccurately simulates the phenomenon of changedescribed by patients receiving psychotherapytreatment. Also, a psychotherapy based on a stagesof-change model could be compared with a psychotherapy based on a change-by-reorganisationmodel. Are there any differences? Do different typesof problems suit one model better than the other?Other pragmatic considerations might provide information regarding the robustness of the explanation of change constructed from this study. Futurestudies could perhaps target a younger populationmore specifically to explore how compatible youngpeople’s experiences of change are with the accountwe have constructed here. Following Rodgers (2006)lead, it might also be illuminating to collect data fromparticipants at different times during their psychotherapy experience.If the aim of psychological treatment is topromote change, these findings may have importantimplications. Perhaps the most fundamental implication is that it is essential to listen to those who areundergoing change in order to understand thisprocess more accurately. By listening more carefullyto clients we may discover that some treatmentsneed to be revised dramatically while others needto change hardly at all. If all treatments, however,become more consistent with facilitating the changeprocess as it is experienced by those who undergoit, then the effectiveness of these treatments shouldimprove. This seems like an important outcome topursue.AcknowledgementsThis research was supported by a grant from East ofScotland Primary Care Research Network (EastRen),Grant number 92-03.ReferencesArthur, S., & Nazroo, J. (2003). Designing fieldwork strategies andmaterials. In J. Ritchie & J. Lewis (Eds.), Qualitative ResearchPractice: A Guide for Social Science Students and Researchers(pp. 109137). London: Sage.Bowden, E. M., Jung-Beeman, M., Fleck, J., & Kounios, J. (2005).New approaches to demystifying insight. TRENDS in CognitiveScience, 9, 323328.184 T. A. Carey et al.Burnett, P. C. (1999). 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Psychotherapy, 27, 411420.Psychological change from the inside 185Appendix AExamples of participants’ responses to the question ‘‘What is psychological change’’.Categories Concrete examplesFeelings ‘I feel better, I feel much better . . . because I said things that I have wanted to say for years.’‘I am happier, I am happier with life, I am not so depressed . . . more tolerant.’‘I was just overcome by it all . . . went home and cried and cried . . . and felt better . . . it was like anemptiness . . . but it wasn’t a feeling of sadness.’Thoughts ‘I am not a bad, bad person, those were the thoughts that I had, am I a bad person that I am getting allthis, why me . . . I would burst into tears for nothing . . . I don’t think like that now.’‘Everything was confused inside me . . . your life is such a mess . . . now I have the inner strength*astrength to deal with what I have to deal with . . . I wanted my life back.’‘I used to think . . . if I say this, make a suggestion and everybody thinks it’s stupid . . . why should Ithink that . . . it’s just believing that you are just equal to everybody else.’Actions/behaviour ‘I started hill walking, doing a bit of running, I went swimming, it definitely made a difference.’‘When I am really down, I fight it . . . by telling myself to get up and do something.’‘I don’t really want to be different, I just want to be better . . . I am just working on it.’Amount of change ‘It’s like night and day.’‘About an 8 . . . now, about a 7 to 8 . . . not quite there yet but it’s getting there.’‘A big change . . . from 0 . . . to about 7 . . . I am still about the 7 mark . . . I would like to think that Icould get to 9.’Examples of participants’ descriptions of the change moment.Concrete examples‘As if somebody has pressed a button . . . switched the bad parts off and the good parts on.’‘I kind of felt better within myself at that point . . . it suddenly clicked . . . everything that had gone on in my life previous . . . not beingaccepted, it clicked and that was it, it felt right . . . it clicked into place.’‘It was like a wee volcano . . . it clicked.’‘It was like one of those big things on the wall at an electricity plant and that’s exactly it, it went, it was it was like ‘ping’ and then itwas like I could see things clearly.’Appendix BAppendix CExamples of participants’ responses to the question ‘How does psychological change occur’.Categories Concrete examplesLearning ‘I also learned that there were also . . . many, many different ways of reacting to anything.’‘I would take a lot of stuff home to read about assertiveness . . . as I was reading it . . . I would just think, ohyeah well let’s try that and let’s think that.’‘I realised the root of the problem and tried to put them into perspective.’Motivation and readiness ‘I was desperate to get back, it took a wee while before I wanted to get back, I kind of self-wallowed . . . Iwas desperate to get back to my old self because where I was, wasn’t me, it was alien and I didn’t want tobe there.’‘I was ashamed of being down there, I was ashamed of that . . . I was ashamed of it . . . why are you lettingyourself go down there?’‘I felt the situation just couldn’t go on the way it was going on.’Perceived aspects of self ‘Quite strong . . . if I put my mind to do something . . . I force myself because I know if I don’t I will just getinto a rut and I don’t want to . . . I think it my inner strength that allows me to fight it.’‘I really, really wanted to get back to work . . . I am a very strong person mentally.’‘I am really deep and my own worst enemy.’The relief of talking ‘Let me get everything out, let me relieve myself of everything.’‘Never opened up as much . . . I’ve spoke and spoke and spoke.’‘It’s amazing . . . hearing your own thoughts coming out, because I had never really spoken them before.’186 T. A. Carey et al.Appendix C (continued)Categories Concrete examplesInteraction with therapist ‘A totally independent person . . . not biased to anything they know about you, they don’t judge yourcharacter or they think they know you . . . on neutral ground.’‘It was braw [great] . . . to get things off my chest . . . a stranger, they didn’t know me . . . they widn’t butt inor have an answer for me.’‘Being able to talk freely to somebody who isn’t going to judge you, who doesn’t have anything to do withyou.’Tools and strategies ‘It’s the changes in behaviour that I learned . . . I basically just applied those techniques to everything andeverything seemed easier.’‘I’ll try to do it before I come to see you next, so that gave me a goal . . . I knew I would have to do it becauseI said I was going to do it.’Psychological change from the inside 187
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