The Process of Change in Couples Therapy: A Qualitative Investigation

By Christensen, Lisa L.; Russell, Candyce S. et al. | Journal of Marital and Family Therapy, April 1998 | Go to article overview

The Process of Change in Couples Therapy: A Qualitative Investigation


Christensen, Lisa L., Russell, Candyce S., Miller, Richard B., Peterson, Colleen M., Journal of Marital and Family Therapy


Open-ended interviews with 24 couples therapy clients regarding their experience of the process of change revealed shifts in clusters of affect, communication, and cognition. Six additional contextual preconditions for change were also identified. The change process within couples was uniformly reported to be gradual.

Recent reviews of marriage and family therapy outcome research have compiled an impressive list of studies that demonstrate the overall efficacy of marriage and family therapy (MFI) (Alexander, Holtzworth-Monroe, & Jameson, 1994; Lebow & Gurman, 1995; Pinsof & Wynne, 1995; Shadish, Ragsdale, Glaser, & Montgomery, 1995). While there is a continuing need for MFT outcome research, especially in view of the political landscape of health care reform, there is also a need for studies that explore why MFT is effective (Wynne, 1988). There has been a call for research examining the therapeutic change process and how it comes about within the therapy context (Sprenkle & Bischoff, 1995).

The past decade has seen a significant increase in the number of studies exploring the process of change. Most of these studies (Adams, Piercy, &Jurich, 1991; Heatherington & Friedlander, 1990; Holtzworth-Monroe, Jacobson, DeKlyen, & Whisman, 1989; Johnson & Greenberg, 1988; Patterson & Chamberlain, 1988) quantified the process and outcome using objective measures. For example, Shields, Sprenkle, and Constantine (1991) used the Therapeutic Interaction Coding System to measure therapists' behaviors during the first session and found that their use of executive skills was related to positive outcome.

An alternative approach is to examine change qualitatively, using the clients' perceptions of therapy and the change process. Researchers ask clients what they believe has been helpful during the therapy process, why they think therapy was helpful or not helpful, and what they think the therapist did that helped to bring about change in their lives. A qualitative, open-ended approach analyzing the change process from the clients' perspective can reveal aspects of the change process that may have been overlooked by hypothesis-testing quantitative methods (Moon, Dillon, & Sprenkle, 1990).

Although there are studies that used qualitative methods to explore clients' experiences in family therapy (Kuehl, Newfield, & Joanning, 1990; Newfield, Kuehl, Joanning, & Quinn, 1990; Sells, Smith, & Moon, 1996; Stith, Rosen, McCollum, Coleman, & Herman, 1996), only two studies have specifically examined the change process. Greenberg, James, and Conry (1988) conducted a study that identified what clients perceive as most important in the therapy process. Four months after the completion of eight emotionally focused therapy sessions, 21 couples described the specific "incidents in therapy that stood out . . . as helpful or hindering" (p. 8). Similarly, Wark (1994) examined client couples' perceptions of change in marital therapy using the critical incident technique. Wark's work differed from the earlier study in that data were collected immediately after a session at three separate times during the course of therapy, and questions focused on critical incidents in that particular session rather than on the overall therapy experience. Moreover, the therapists in Wark's study did not subscribe to the same theoretical model.

These two studies show two separate sets of critical incidents categories that clients in couples therapy believe have an impact on the change process. One set of categories refers to clients' perception of the overall therapy experience, and the other focuses on critical incidents in specific sessions. These studies assume that therapeutic change occurs during a noteworthy, significant incident. They do not address whether change could also occur as a subtle, gradual process that is without significant markers. How are these elements of the therapeutic process connected in a way that brings about positive or negative change in couples? …

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