Author: Kindsvatter, Aaron
Date published: October 1, 2010
Questions surrounding the concept of change have been considered for a long time. The pre-Socratic philosopher Heraclitus was among the first to argue that change is an omnipresent condition of life, a view that was exemplified by his famous decree regarding the impossibility of stepping into the same river twice (Mahoney, 2000). The notion that change is possible, and even inevitable, is perhaps one of the central ideas inherent in the assumptions that inform mental health disciplines. Thus, questions pertaining to the nature of therapeutic change, such as pretreatment change, are important to mental health because of their fundamental association with the counseling process.
Counseling outcome research has indicated that common factors, such as client strengths and resources, the facilitation of the therapeutic alliance, and client hope, are important contributions to the change process (Asay & Lambert, 1999; Beutler, Castonguay, & Follette, 2006; Lambert, 1992; Wampold, 2001 ). Research has also indicated that therapeutic change is more likely to be long lasting when counseling clients attribute change to their own efforts (Lambert & Bergin, 1994).
There is some evidence to suggest that clients may benefit from different therapeutic conversations at various points in counseling, as change progresses. This idea has been systematically described as a transtheoretical theory, which delineates the stages of change (Prochaska, 1999; Prochaska & DiClemente, 1982; Prochaska & Norcross, 2002). From this perspective, change consists of six stages through which clients pass as they engage in therapeutic change: precontemplation, contemplation, preparation, action, maintenance, and termination. These stages describe different client needs at different stages of change as they consider, prepare for, enact, and maintain therapeutic change. Thus, therapeutic conversations designed to facilitate, and capitalize on, the therapeutic alliance, client hope, and client strengths and resources may need to be altered to match client needs as they progress through different stages of change.
Counseling approaches that prioritize identifying and incorporating client strengths and resources and that are tailored to client needs at different points in counseling warrant further consideration. Research pertaining to client change has suggested that counselor understanding of client perceptions of pretreatment change could also help counselors meet their clients' needs.
Considering Pretreatment Change
One of the first studies to appear in the literature on the topic of change without treatment was conducted by Schorer, Lowinger, Sullivan, and Hartlaub (1968). The authors examined pretreatment change with clients assigned to counseling waiting lists. Of the 55 wait-listed clients who received no additional services, 36 (65%) experienced significant clinical improvement without treatment. Weiner-Davis, de Shazer, and Gingerich ( 1 987) interviewed 30 families seeking counseling at a community-based facility regarding pretreatment change. Specifically, the authors asked clients if desired changes related to their reasons for seeking counseling had occurred between the time of initial contact with the counselor and the first counseling appointment. The researchers found that 66% of the participants initially reported that desired pretreatment changes had occurred.
In addition to reporting the prevalence of pretreatment change, some studies have investigated the impact or uses that pretreatment changes can have during the counseling process. Beyebach, Morejon, Palenzuela, and Rodriguez- Arias (1996) found that clients reporting pretreatment changes were 4 times more likely to successfully complete counseling than were clients who did not experience pretreatment change. These results indicate that it may be especially useful to focus on pretreatment changes in the first session of counseling.
Allgood, Parham, Salts, and Smith (1995) investigated the prevalence of pretreatment change and the impact of pretreatment change on counseling outcomes. Results indicated that the presence of pretreatment change was associated with the successful completion of counseling. Specifically, client acknowledgment of pretreatment change, prompted by a pretreatment change questionnaire, may have raised clients' awareness of positive steps already taken, thus accounting for their success in the counseling process.
Johnson, Nelson, and Allgood (1998) investigated the prevalence and duration of pretreatment change, as well as the impact of counselors noticing and inquiring about pretreatment change. Results indicated that clients who reported pretreatment changes that were subsequently noticed by counselors had a lower unplanned termination rate than did those who did not report pretreatment changes. Furthermore, it was found that for clients who reported pretreatment changes, those changes persisted whether they were noticed by the counselor or not.
Given that client strengths and resources significantly contribute to positive client change during counseling (Asay & Lambert, 1999) and that these capacities may also explain the occurrence of pretreatment change, an investigation of the nature of pretreatment change from the perspective of clients seems warranted. According to Elliott and James ( 1 989), when counselors have an understanding of client perceptions of the counseling process, they are better equipped to meet client needs. We speculate that by understanding more about client perceptions of the nature of pretreatment changes, counselors might be able to better assist clients in capitalizing on the strengths and resources that contributed to those changes. The purpose of the current study was to elicit client perceptions of change experienced after initial contact with a counselor (i.e., scheduling an appointment) and prior to the first scheduled counseling session. In learning from clients themselves about pretreatment change, including the meaning they ascribe to such change, we hope to assist counselors in their work with clients, specifically knowing how to make use of pretreatment changes in the counseling process.
To capture client perceptions of contributions to pretreatment change, we used Q methodology. Q methodology is a set of operational and psychometric principles that provide a systematic means for examining human subjectivity (McKeown & Thomas, 1988). This approach allows participants to sort statements (referred to as a Q-set) that are representative of a range of opinions around a given topic, or a communication concourse (Brown, 1993; Cross, 2005). Statements are sorted by participants on a continuum generally ranging from, for example, +4 (most like the opinion of the participant) to -4 (most unlike the opinion of the participant), with middle values (i.e., -1, 0, +1) reflecting neutral opinions (see Figure 1 ). The individual sorts are then factor analyzed, and the resulting factors represent the viewpoints of participants on the topic in question.
Q methodology differs from other applications of factor analysis in that the points of view of the participants (i.e., Qsorts), as opposed to a cluster of items on a given measure, are analyzed. In addition, despite its mathematical substructure, Q methodology is oriented toward uncovering different perceptions rather than averages across a sample. That is, factor analysis in Q methodology is used simply and exclusively as a tool for organizing the data into coherent themes (i.e., factors) that represent the subjective points of view of like-minded participants. Unlike research methods that generalize data across certain demographics, Q methodology is designed to systematically describe the subjective experiences of a given population of interest. Q methodology has been used in studies pertaining to counseling and psychology (for examples of Q methodology, see Bryant, Green, & Hewison, 2006; West, Bubenzer, Osborn, Paez, & Desmond, 2006).
Defining the Communication Concourse
The communication concourse (i.e., the range of perceptions surrounding a given topic) is used to generate the statements to be sorted (i.e., the Q-set). A concourse can be constructed in several ways. In the current study, the concourse was derived from interviews with clients who had experienced pretreatment change as well as from a review of the scholarly literature.
Nine adult clients who were voluntarily seeking individual counseling were recruited to assist in constructing the communication concourse. At least two participants were recruited from each of the three data collection sites: a community mental health center, a counseling private practice, and a university counseling center. The concourse client participants were three men and six women ranging in age from 1 9 to 49 years. Six of the concourse client participants were Caucasian, one was Asian, and two were African American.
The concourse interviews lasted approximately 30 minutes. The Pretreatment Change Questionnaire (PTQ), developed by Weiner-Davis et al. (1987), was used to guide the interviews. The questionnaire consists of three questions pertaining to the occurrence of pretreatment change. Specifically, the PTQ addresses (a) client perceptions of the presence of pretreatment change, (b) whether such changes were related to the client's reason for seeking counseling, and (c) if pretreatment changes were desired changes. During the interviews, clients were asked if they had experienced positive changes prior to counseling that were relevant to the problem for which they had sought help. The interviews with participants were audio taped and transcribed. We met on two occasions to review the transcripts. During these meetings, an attempt was made to categorize the statements according to the themes contained within them. Using this process allowed us to reach the consensus that there were six domains of statements, each with different meanings. These domains were (a) influential others (i.e., helpful people in clients' lives), (b) hope (i.e., expectation for change), (c) change focus (i.e., expressed willingness to change), (d) cognitive changes (e.g., reframing), (e) self-focus (i.e., attending to one's own needs), and (f) negative contributions to change (i.e., change due to fear of loss).
In addition to items generated from client interviews, the communication concourse for this study also contained items informed by the scholarly literature pertaining to pretreatment change. Research on client perceptions of change suggested specific areas of client experiences that should be included in the concourse. There was some overlap in themes derived from the concourse interviews and the themes derived from the literature. These areas included (a) extratherapeutic contributions (i.e., helpful others, personal strengths), (b) task impact contributions (i.e., engaging in therapeutic endeavors), (c) affective impact contributions (i.e., facing/expressing emotions), and (d) negative contributions to pretreatment change.
Deriving the Q-Set From the Concourse
Over the course of three meetings, we generated statements representative of the different themes that emerged from the concourse interviews and the review of the literature. A total of 89 concourse items were developed: 58 from individual interviews with the nine concourse client participants and 31 selected from the scholarly literature. The number of items in the Q-set needed to remain manageable so that participants were not overwhelmed or confused (McKeown & Thomas, 1988). Therefore, we met on four occasions to review and reduce the number of items. This process involved clarifying the wording of some statements and reducing items that contained similar meanings. For example, it was decided that the following items all expressed a common meaning: "Knowing that others have changed let me know that I could change," "I saw how helpful counseling has been to other people," and "I have heard from others how helpful counseling can be." We decided, therefore, that all three statements would be represented by the statement, "Knowing that others have changed let me know that I could change." This process allowed us to reduce the number of Q-set items to 45 statements.
The participant sample in Q methodology is referred to as a Person-sample or P-set. According to McKeown and Thomas (1988), the recruitment of participants is often affected by the pragmatic consideration of who is available. This was the case in the current study because we could not predict which clients would experience pretreatment change. Participants were 36 individual counseling clients from three counseling venues: a university counseling clinic, a community mental health center, and a private practice setting. In order to have as wide a range of opinions as possible, at least 10 clients were recruited from each of the three settings. University counseling center clients were 14 women and two men, ranging in age from 18 to 39 years. Fourteen of these participants were Caucasian and two were African American. Participants from the private practice setting were eight women and two men, ranging in age from 20 to 57 years, all of whom were Caucasian. Participants from the community mental health center were five men and five women, ranging in age from 19 to 57 years; they were all Caucasian. The 36 client participants were seeking counseling services for issues such as depression, anxiety, grief, and relationship problems.
Written instructions were given to and reviewed with each participant. Participants were provided with 45 cards, each card containing one of the 45 statements derived from the communication concourse. The clients were asked to read all of the cards. The first author was available during the sorting to answer questions. A grid approximately conforming to an inverted bell curve ranging from +4 to -4 (see Figure 1 ) was provided to ensure proper distribution of statements from the Q-set. This forced-distribution grid allowed participants to place two statements under the +4 and -4 positions, with an increasing number of statements allowed in each position inward toward zero (the middle or neutral position), which allowed for nine statements. To assist with the interpretation of factors, postsort interviews, designed to last approximately 20 minutes, were conducted with all 36 participants immediately after they completed the sorting. Postsort interview questions addressed (a) how participants understood the different statements in the Q-set and (b) how they decided to place those statements on the continuum as they did. Participant responses were audiotaped and were used to elaborate upon the meaning of the factors.
Factor analysis is used in Q methodology to determine how individual Q-sorts cluster together to form factors. These factors conform to mathematical criteria as being distinct from other clusters that may emerge from the analysis (Stainton-Rogers, 1991). Brown (1993) described factors as groups of Q-sorts that bear a "family resemblance" to one another: sorts belonging to one family are highly correlated with each other and not highly correlated with other families or factors sorted by other participants in a different way. Factors are analyzed to determine which Q-set statements comprise factor arrays (composite Q-sorts that mathematically best represent the underlying "community voice" of a factor). The computer software program used for data analysis was PQ Method 2.11 (Schmolck & Atkinson, 2002).
Factor loadings describe the degree to which an individual Q-sort (i.e., point of view) is associated with a given factor. Factors were considered significant for this study if they contained at least four statistically significant loadings. Factor loadings were considered to be statistically significant (p < .0 1 ) if they were in excess of ±2.58 times the standard error (SE), with SE calculated as SE = 1/^/N where N is the number of statements in the Q-set (McKeown & Thomas, 1988). In the current study, SE = 1/^45 = .149; therefore, factor loadings in excess of ±.385 were considered statistically significant. When a sort loaded significantly on more than one factor, the higher loading was used, and the lower loading was dropped from the analysis.
Findings and Discussion
Four factors emerged from the study. The four- factor solution was identified as the most satisfactory solution, taking into account the variance explained (49%) and the number of loadings on each factor. Additionally, the four-factor solution (on which 34 participants loaded significantly) reflected factors that were deemed to be of theoretical importance.
In Q methodology, data are interpreted by examining statements that compose the factor arrays of each factor, with particular attention given to the statements that are at the +4 or "most like" positions (see Table 1 for the factor arrays). Postsort interview data (obtained immediately after participants completed the sorting) were also used to explain the underlying meaning of the factors.
The four factors that emerged were distinct, yet there was some shared subjectivity among them. Specifically, each factor indicated the importance of the realization of unmet needs or the realization of the existence of a significant problem as an important contribution to pretreatment change. This pattern was strongly represented in Factor 1 , but was present in all of the factors. The following section provides a description of the meaning and clinical implications of the factors.
Client Perceptions of Pretreatment Change: Interpretation and Clinical Applications
Factor 1: Problem Legitimacy
Participants whose responses loaded on Factor 1 indicated that recognizing problems and unmet needs contributed to the pretreatment change they experienced. Factor 1 is distinguished by the items "I realized that I do have a problem and that I have to do something about it" (Statement 7) and "1 realized that I have emotional needs to take care of" (Statement 2). It appears that participants whose responses loaded on Factor 1 had some external reasons for change. Additionally, a certain amount of trepidation concerning a perceived future without change appeared to have been important. The underlying meaning of Factor 1 is further illustrated by the comments of Participant C9:
I had pretty much given up on school and classes . . . [Then] I realized that I had a real problem ... it is affecting my life in a real way which means its a real problem . . . that's what led me to realize that I had something to change. That's when I discovered that I have emotional needs. My situation demanded that 1 change because if I don't stay in classes and do well, I will lose my scholarship and I won't be able to stay in college. ( Participant C9)
Participants' responses that loaded on Factor 1 indicated that they recognized the need for a change. In fact, these participants appeared to resemble persons in the preparation stage of change; that is, they intended to take action to ameliorate situations they only recently realized constituted significant problems (see Prochaska & DiClemente, 1982; Prochaska & Norcross, 2002). According to Prochaska (1999), helpful counseling interventions for clients in the preparation stage of change include self-reevaluation (i.e., helping clients to envision a hypothetical future that is problem free) and self-liberation, that is, strengthen clients' belief in their ability to change and encouraging them to act on this belief (Prochaska, 1999). Furthermore, helpful counseling interventions for clients such as those whose responses loaded on Factor 1 might include assisting clients to identify several choices for advancing change (Prochaska, 1999). For example, a counselor working with a client who is attempting to reduce social isolation may suggest multiple activities, such as monitoring social anxiety for 1 week without attempting to engage socially, calling an acquaintance, or joining a committee in the community.
Factor 2: Spiritual Resources
Factor 2 is distinguished by the endorsement of items pertaining to faith: "I put my trust in God" (Statement 2 1 ) and "I experienced contact with God or a spiritual presence, and I felt accepted and knew that all would be well" (Statement 26). It appears that participants whose responses loaded on Factor 2 were assisted by their trust in and contact with God in at least two ways. First, trust in and contact with God appeared to be viewed as a catalyst for further change; that is, participants felt that their trust in God allowed them to begin and continue the process of change. Second, it appears that participants whose responses loaded on Factor 2 received comfort from the stability or reliability of God in a time that they perceived that they were fraught with uncertainty. These perceptions are illustrated by the following statements obtained from two interviews:
[TABLE 2 OMITTED]
I had to let go of myself. 1 don't know where I am going or who I will become. Trust in God allows me to let go. It's an anchor, and it's a way. It provides me with the catalyst to change myself. God's a very big deal. 1 don't subscribe to any organized religion, but God is a very big deal. (Participant B5)
The last 5 days this is the start of something new. Yeah, I have a part in this, but God has ultimate control. He sees all, knows all, and is in control of all. I put my trust in him and know he's going to see me through it. Knowing that I wouldn't be doing this on my own, that God would be with me really helped .... 1 put my trust in God, and that got me going. (Participant C6)
Participants represented on Factor 2 indicated the importance of faith and spirituality as personal resources. Research supports the integration of spiritual and religious practices in counseling with clients for whom these are important domains of life (Walker, Gorsuch, & Tan, 2005). Thus, useful counseling interventions for clients resembling those represented on Factor 2 might include exploration of how these spiritual resources could be identified, amplified, used, or mobilized (Gutterman & Leite, 2006). For example, counselors could explore how clients might use inspirational readings or religious rituals to comfort themselves or to inspire or engender further change. Additionally, counselors and clients might discuss the possibility of a religious or spiritual ideal toward which clients could aspire. Counselors and clients may also find it useful to discuss how consultation with fellow religious or spiritual community members or leaders might enhance change.
Factor 3: Ambivalence
For participants whose responses loaded on Factor 3, an important contribution to pretreatment change pertained to the decision to seek counseling. For these participants, the decision to seek counseling appeared to have involved a great deal of ambivalence. This was indicated by the high endorsement of the item "I overcame my reservations about being in counseling so that I can get the help that I need" (Statement 42). Perhaps they were reluctant to pursue counseling or perceived that counseling would not be helpful, yet found themselves with few other viable options for the resolution of problems. External circumstances (e.g., a desire to save or maintain a relationship, a desire to maintain mental health) may have played an important role in these participants' decision to seek counseling. The comments of Participant B5 exemplify the underlying meaning of Factor 3:
I didn't tell anybody that 1 was coming; 1 didn't even tell my husband. Nobody knows that I am coming here ... I guess I made the right decision to come ... I didn't want to risk my marriage for me being a sissy and not coming here to find out what was wrong. I'm really like, "Ooh, I'm going to talk to somebody . . . What are they going to do?" you know? ... "What could they possibly do? . . . How are they going to make it better?" Well, they must do something ... I started to call a couple of times, but then I said, "No, no, you're overreacting, you're just being silly, it's not that bad." But I finally got to the point where, yeah, it was that bad. (Participant B5)
In working with clients such as those whose responses loaded on Factor 3, it would likely be a therapeutic mistake for a counselor to prematurely focus on solutions without addressing the client's concerns about the process itself. Indeed, such clients may perceive the pursuit of counseling itself to constitute a major change and may experience some hesitancy about making additional changes early in the counseling process.
Research has indicated that counseling should constitute a collaborative alliance between the counselor and the client (Creed & Kendall, 2005). Important components of the therapeutic alliance include the facilitation of an agreement between the counselor and the client on counseling goals and tasks (Bordin, 1979) and the client's perceived freedom to express concerns or criticism regarding the process itself (Bachelor, 1995; Hatcher & Barends, 1996). It may be useful for counselors working with clients who resemble those represented on Factor 3 to assist them in articulating concerns and doubts about counseling and change before discussing an actual change in behavior, thinking, or relating. Prochaska (1999) noted that clients in the early stages of change may benefit from consciousness raising, dramatic relief, and environmental révaluation. Specific counseling practices intended to realize these benefits include raising the client's awareness about potential causes, contributions, and interventions pertaining to their problem; encouraging the client to express significant emotions pertaining to their situation; and assisting clients to assess the impact of their current behavior on their situation and how change would further affect their situation.
Factor 4: Hope
Factor 4 was distinguished by the endorsement of a group of items that seemed to indicate the importance of seeking help from a professional as well as maintaining a positive outlook. For example, participants whose responses loaded on Factor 4 positively endorsed the items "I felt better knowing I was going to talk to a trustworthy expert" (Statement 40) and "Knowing that I would no longer have to handle everything on my own really helped" (Statement 43). Factor 4 was further illustrated through the following comments of one participant:
I felt like, "Okay, I am taking a step forward; I am finding out how to handle this." Finding out that I could come to counseling really helped. . . . After I made the call, 1 felt more like there was something I could do that was going to help. (Participant C11)
According to Snyder, Michael, and Cheavens (1999), hope can be understood as having two forms: pathways hope and agency hope. Pathways hope pertains to a client having a "route" to change or a "new direction" that will assist them to live in a less problematic way. Agency hope pertains to clients' belief that their personal strengths and resources will lead to change. Counselors might be helpful to clients who resemble participants represented on Factor 4 by attending closely to different themes of hope and assisting clients to intentionally capitalize upon them. For example, the newfound personal agency of Participant Cl 1 may signal a sense of empowerment, and it may be useful for a counselor to explore with her further how she might begin to have a greater impact on her situation. Counselors might be of further assistance to clients who are similar to participants represented on Factor 4 by assisting them in exploring ideas about new behaviors, resources, or attitudes that may lead them to try something new, or to make use of new, or perhaps forgotten, strengths and resources.
The Cocreation of Pretreatment Change
All 36 participants in the current study reported pretreatment change. We attribute this to the presumption inherent in our design that some pretreatment change had occurred for all participants. Indeed, we have wondered if a useful question pertaining to pretreatment change may not be whether pretreatment change has occurred, but rather what pretreatment changes have occurred, and furthermore, how can useful meaning be made out of these changes. It could be argued that a client who seeks counseling has indeed made a change; exploration of the meaning behind this may provide avenues for enhancing and capitalizing on this change.
We believe that understanding pretreatment change as a phenomenon cocreated in conversation by a client and counselor engenders further possibilities for client change by allowing for the expression and utilization of unique client strengths and experiences. Thus, an alternative (and potentially more useful) way of considering pretreatment change is as a socially created phenomenon rather than, or in addition to, a phenomenon specific to the psychology of individual clients that either is or is not present.
Pretreatment Change and Implications for Counseling Practices
Previous studies have found that pretreatment changes (especially those intentionally noticed by counselors) are associated with positive counseling outcomes (Allgood et al., 1995; Beyebach et al., 1996; Johnson et al., 1998). Indeed, because pretreatment change was found to be related to successful counseling outcomes (R = .26 1 ,p < .05) more so than structured therapeutic goals, Beyebach et al. ( 1 996) speculated that it might ultimately be more beneficial to clients if counseling focused more on pretreatment changes in the initial session than on goal formulation. Furthermore, Allgood et al. ( 1 995) noted that unacknowledged pretreatment change may indicate that clients are at risk for treatment failure and suggested that such clients should be asked about pretreatment change in such a way that assumes that pretreatment changes have occurred.
The language of diagnosis and pathology is an accepted and established vernacular in mental health disciplines. Yet counseling continues to distinguish itself from other professions by focusing on the domains of wellness and development as a means toward problem resolution (Myers & Sweeney, 2008). Given the close association between the use of pretreatment change in counseling and positive counseling outcomes, it seems that the adoption of practices pertaining to pretreatment change in facilitating wellness and development is warranted. For example, clinicians might consider adopting pretreatment change questions as part of the intake process and inquire about the relevance of such changes throughout the counseling process. In addition, counselor educators might teach students to incorporate pretreatment change strategies into their practicum experiences. The results of this study present a few of the "faces" of pretreatment change. There are undoubtedly many more. However, if counselors can be cognizant of taking advantage of variations of the pretreatment changes presented here, or of novel presentations of pretreatment change, they will be in a better position to aid clients in the construction of solutions.
Limitations and Future Directions
There were more views present in this study than we are able to describe. For example, the negative loadings on Factors 1 and 4 indicated the presence of views that were the opposite of the views associated with a positive loading on those factors. However, because there were few negative loadings on either factor, we determined that we could not adequately portray these views. Additionally, because only four participants' responses loaded on Factor 3, it may be that Factor 3 was not portrayed as clearly as it might have been if there had been more loadings on that factor. Future research that further investigates the impact of counselors' exploration of negative pretreatment experiences with clients would be likely to contribute useful data. In addition, more research exploring how clients use and build on pretreatment changes during the counseling process would be helpful.
When clients present for counseling services, it is an indication that they have done something different to cope with a problem; thus, one could reason that they have made a change. However, as illustrated by Allgood et al. ( 1 995 ) and as asserted by Miller (1992), when counselors do not intentionally and actively assist clients in making meaning of change experiences that have occurred before counseling begins, the benefit of those changes may be lost or go unrealized. Therefore, although one could assert that all clients who decide to pursue counseling have engaged in pretreatment change, it does not follow that the change was meaningful or even noticed. The results of this study suggest that meaningful pretreatment changes can almost always be identified or brought forth in conversation for consideration, utilization, and amplification.
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Aaron Kindsvatter and Jill D. Duba, Department of Counseling and Student Affairs, Western Kentucky University; Cynthia J. Osborn and Donald Bubenzer, Department of Counseling and Human Development Services, Kent State University. Aaron Kindsvatter is now at Counseling Program, The University of Vermont. Correspondence concerning this article should be addressed to Aaron Kindsvatter, The University of Vermont, Counseling Program, 208 Colchester Avenue, Burlington, VT 05405 (e-mail: firstname.lastname@example.org).