The influence of significant events in conceptualising change during psychotherapy: A systematic review LY Lourens orcid.org / 0000-0002-3413-9276 Mini-dissertation accepted in fulfilment of the requirements for the degree Master of Arts in Clinical Psychology at the North-West University Supervisor: Mr. Rümando Kok Graduation: May 2020 Student number: 22106790 i ACKNOWLEDGMENTS First of all, I have to thank my Heavenly Father for His continuous blessings throughout this process. Without His grace none of this would have been possible. Thank you Lord for planting a calling and a dream in my heart and providing me with the resources to make it happen. To my parents, Jaco and Yolanda Lourens, for your on-going support, love and understanding. Thank you for instilling in me the qualities that I needed to finish this degree. Thank you for never doubting in me and believing in my dream. To my most amazing husband, Evert Jordaan, thank you for all the motivation, encouragement and unfailing love. Thank you for all the prayers and supporting me in so many ways. Thank you for having confidence in my dream and dreaming with me. To my study leader, Mr. Rümando Kok, thank you for your guidance during this process, thank you for imparting your magnitude of knowledge to me, thank you for your never-ending patience and kindness towards me, thank you for sharing your passion on this topic with me and thank you for helping me to make my dream a reality. ii SUMMARY The aims of this study were to examine current scientific literature on significant events and various other change process concepts in psychotherapy and to explore the influence thereof on conceptualising change during psychotherapy. The objectives were attained by conducting a systematic review in order to identify different themes that flowed from the included literature. An initial search strategy was conducted and yielded 124 studies from which 74 articles were excluded during the screening phase for being either duplications, book reviews or irrelevant. In the critical appraisal phase the full-text articles were evaluated for quality and relevance and a further 25 articles were excluded. Therefore, the final data set consisted of twenty-five studies that were found to be eligible for inclusion by both reviewers. Five overarching themes emerged following the thematic analysis namely: 1) definitions of change process concepts; 2) therapeutic process variables; 3) therapeutic intervention; 4) therapeutic relationship; 5) sequence of change process events. Within these themes, prominent subthemes also emerged. Subthemes that emerged from the first theme, definition of change process concepts, included helpful events, significant events, sudden gains, innovative moments, insight events and hindering events. These yielded important information regarding the definition, type and example of each one of the change process concepts. Findings indicated that the various events may have different functions in psychotherapy and that they are directly or indirectly linked to the outcome. From the second theme, therapeutic process variables, several subthemes arose integrating most components forming part of the practice of therapy including role players, pertaining to client and therapist variables, context including aspects within- and outside of iii therapy, as well as timing, impact and outcome. Within the theme of therapeutic process variables the findings showed that clients and therapists may differ in their perspectives of what is helpful and hindering in psychotherapy (Timulak, 2010). Furthermore, helpful events could be contained within sessions or happen outside of sessions, and it is possible to identify if psychotherapy will be successful from the first few sessions (McCarthy et al., 2017). The different impacts that helpful events had on the client was emotional, cognitive and an enhanced therapeutic relationship (Timulak, 2010). The third theme, therapeutic intervention, related subthemes inherent in the intervention including cognitive awareness, thought restructuring, emotion experiencing and cognitive disengagement. The fourth theme, therapeutic relationship, centered around the importance of the therapeutic relationship, whereas the fifth theme, sequence of change process events, consisted of three subthemes around the different stages of treatment namely what happens prior to events, mechanisms underlying events and process evolving after the events. The results impart an understanding of the various change process concepts and highlighted the usefulness of significant events in improvement and positive outcomes. The results also show a need for more research into significant events in relation to change in psychotherapy. Thus, further research should elucidate the influence of significant events in relation to psychotherapeutic change. The association between significant events and psychotherapeutic change is important for two reasons, firstly it shows promise by increasing the effectiveness of psychotherapy research, and secondly, it may further enhance the evidence- based nature of clinical practice to the benefit of clients. iv OPSOMMING Die doel van hierdie studie was om die huidige wetenskaplike literatuur oor belangrike gebeurtenisse en verskeie ander veranderings proses konsepte in psigoterapie te bestudeer om sodoende die invloed wat dit het op verandering in psigoterapie te verstaan. Die doelstellings is bereik deur ‘n stelselmatige oorsig van alle beskikbare literatuur te doen om verskillende temas te identifiseer wat voortvloei vanuit die betrokke studies. ’n Aanvanklike soekstrategie het 124 studies opgelewer, waaruit 74 artikels tydens die keuringsfase uitgesluit is op grond daarvan dat dit duplikate, boek resensies of irrelevante artikels was. Gedurende die kritiese beoordelingsfase is vollengte artikels geevalueer vir kwaliteit en relevansie waarna ‘n verdere 25 studies uitgesluit is. Die finale datastel bestaan daarom uit 25 studies wat deur beide navorsers goedgekeur is. Na die tematiese analise het ’n totaal van vyf temas na vore gekom, naamlik: 1) definisies van veranderings-proses-konsepte, 2) terapie-proses-veranderlikes, 3) terapeutiese intervensie, 4) terapeutiese verhouding, en, 5) volgorde van gebeure in die veranderingsproses. Vanuit hierdie temas het verdere subtemas na vore gekom. Die eerste tema, definisies van veranderings-proses-konsepte, het belangrike inligting opgelewer rakende die definisie, soort en voorbeeld van elk van die veranderingsproses konsepte insluitend: nuttige faktore; belangrike gebeure; skielike winste; innoverende oomblikke; insig gebeure; en nie-hulpvaardige gebeure. Die bevindinge het aangedui dat die verskillende konsepte verskillende funksies in psigoterapie kan hê en dat dit direk of indirek ’n invloed op die uitkoms het. Uit die tweede tema, terapie-proses-veranderlikes, het die volgende subtemas na vore gekom: rolspelers, insluitend klient- en terapeut veranderlikes, konteks wat aspekte in terapie sowel as buite terapie insluit, tydsberekening, impak en uitkoms. Binne die tema van v terapeutiese-proses-veranderlikes het die resultate getoon dat kliënte en terapeute gereeld verskil in hul perspektiewe rondom wat hulpvaardig en nie-hulpvaardig is in psigoterapie (Timulak, 2010). Verder kan belangrike gebeure binne sessies of buite sessies plaasvind, en dit is moontlik om van die eerste paar sessies af te identifiseer of psigoterapie suksesvol sal wees (McCarthy et al., 2017). Belangrike gebeurtenisse het verskillende impakte op die kliënt gehad insluitend emosioneel, kognitief en 'n beter terapeutiese verhouding (Timulak, 2010) Die derde tema, terapeutiese intervensie, bevat subtema’s wat inherent is tot die intervensie naamlik, kognitiewe bewustheid, kognitiewe herstrukturering, ervaring van emosies en kognitiewe ontkoppeling. Die vierde tema, terapeutiese verhouding, handel rondom die belangrikheid van die terapeutiese verhouding en die vyfde tema, volgorde van gebeure in die veranderingsproses, bestaan uit drie subtema’s rondom die fases van terapie naamlik, wat plaasvind voor belangrike gebeure, onderliggende meganismes van verandering en proses na afloop van gebeure. Die bevindinge verskaf ’n begrip oor verskillende veranderings-proses-konsepte en beklemtoon die bruikbaarheid daarvan vir verandering en positiewe uitkomste in psigoterapie. Die resultate beklemtoon ook ‘n behoefte aan verdere navorsing oor belangrike gebeure met betrekking tot verandering in psigoterapie. Die verband tussen belangrike gebeure en psigoterapeutiese verandering is belangrik omrede dit die effektiwiteit van psigoterapie kan verhoog. Dit kan verder ook die bewysgebaseerde aard van die kliniese praktyk, tot voordeel van die kliënt, verhoog. vi PREFACE This mini-dissertation forms part of the requirements for the completion of the Magister of Arts degree in Clinical Psychology. It is organized in article format, in adherence to rule A.5.4.2.7 of the North-West University, Potchefstroom campus. This manuscript is prepared for examination purposes according to the requirements of the APA (American Psychological Association, 6th edition). 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Signature of student: ____________________ Lelanie Lourens University number: 22106790 xiv PERMISSION TO SUBMIT ARTICLE FOR EXAMINATION PURPOSES I, the supervisor of this study, hereby declare that the dissertation entitled “The influence of significant events in conceptualising change during psychotherapy: A systematic review”, written by Lelanie Lourens, reflects the research regarding the subject matter. I hereby grant permission that she may submit the article for examination purposes and I confirm that the dissertation submitted is in fulfilment of the requirements for the degree Magister Arts in Clinical Psychology at the Potchefstroom Campus of the North-West University. The article may also be sent to The Journal of Psychology for publication purposes. Rümando Kok xv TABLE OF CONTENTS Acknowledgements i Summary ii Opsomming iv Preface vi Author Guidelines vii Solemn declaration xiii Permission to submit xiv Table of Contents xv CHAPTER 1 1 Literature Contextualisation and Orientation 1 Problem statement 9 Research Question 9 References 11 CHAPTER 2 17 Abstract 18 Introduction 19 Method 20 Scope Review 21 Inclusion and Exclusion Criteria 22 Search Strategy 22 Screening 23 Critical Appraisal 25 xvi CONTENTS CONTINUED Data Extraction 26 Data Analysis 26 Ethical Considerations 28 Findings 29 Theme 1: Definition of Change Process Concepts 31 Theme 2: Therapeutic Process Variables 52 Theme 3: Therapeutic Intervention 73 Theme 4: Therapeutic Alliance 81 Theme 5: Sequence of Change Process Events 84 Conclusion 88 Recommendations and Suggestions for Future Research and Clinical Practice 91 Limitations 92 References 94 Addendums 108 Addendum A: Critical Appraisal Tool Template 108 Addendum B: Summative Data Extraction Table 111 Addendum C: Language Editor Declaration 124 Addendum D: Ethical Clearance Certificate 125 CHAPTER 3 127 Critical Reflection 127 CHAPTER 1 1 CHAPTER 1 Literature Contextualisation and Orientation Years of thorough scientific research have recognised the efficiency of psychotherapy (Norcross & Lambert, 2011) but only more recently researchers started to concentrate on specific factors that influence the success thereof (Norcross & Wampold, 2011). Service delivery in mental health care practice has been obtaining more importance, with a specific focus on recovery as a main concept - therefore guiding the development of mental health care policies and procedures (Bledsoe, Lukens, Onken, Bellamy & Cardillo-Gellar, 2008; Resnick, Rosenheck, & Lehman, 2004). Storr (2012) defines psychotherapy as the skill of relieving personal problems through the intervention of speech together with the building of a personal, although professional, relationship. Moreover, Brent and Kolko (1998) clarify psychotherapy as a modality of treatment in which the psychotherapist and client collaborate to improve on psychopathologic disorders and functional impairment by implementing scientifically validated procedures. They explain it as an activity that includes focusing on the therapeutic relationship, the client’s viewpoints, thoughts, feelings, and behaviour whilst also considering their social background and stages of development. Essential adjustment towards more proficient psychotherapy is being influenced all the more by evidence-based practice (Brown, 2015). According to Kelly, Cyranowski and Frank (2007), there has been more interest in sudden improvements in psychotherapy and what their clinical implications are from around 1999. Since then, professional consideration in mental health practice is based upon constructing practice decisions on available research evidence CHAPTER 1 2 (Bledsoe et al., 2008) as to provide the most effective psychotherapy in the shortest amount of time. In recent years, the field of psychotherapy recognised the need to provide the best evidence-based practice especially in light of offering professional competency in the psychotherapeutic setting, ongoing development of the professional arena and the best ethical practice (Brown, 2015). The APA (APA Task Force on Evidence-Based Practice, 2006) defines evidence-based practice (EBP) as the use of the best available research in combination with the experience of the clinician while bearing in mind the individual’s background, environment and unique situation. A differentiation is made between the nomothetic research paradigm - which refers to the functioning of human beings in general (Hood & Johnson, 1997; Ponterotto, 2015) - and the idiographic research paradigm - which relates specifically to the individual (Ponterotto, 2015). Within psychotherapeutic research, the nomothetic approach is primarily involved with studying what human beings share with each other with the intention to determine general patterns of behaviour or universal statements in order to explain and understand common phenomena (Hood & Johnson, 1997; Ponterotto, 2015). Contrary to the nomothetic approach, the idiographic paradigm aims to understand the uniqueness and complexity of the individual (Ponterotto, 2015). Thorngate (1986) explains that to discover what people have in common e.g. the nomothetic paradigm, it must firstly be determined what makes each person unique, e.g. idiographic paradigm and thereafter it can only be clarified whether there are commonalities between them. Furthermore, there exists a continuous debate within psychological research and practice, about psychotherapy and the significance of the different psychotherapeutic approaches (Lindgren, Folkesson & Almqvist, 2010; Sjödin, 2009). EBP proposes that proficient CHAPTER 1 3 psychotherapy is more about what works, for whom, under which circumstances than it is about focusing on a specific psychotherapeutic approach (Miller, Zweben, & Johnson, 2005). The reason why so many different techniques are effective, is that they operate through a number of common change processes, such as change in cognitive structures; the acquisition of new cognitive and behavioural skills (Blatt, Zuroff, Hauley & Auerbach, 2010); the therapeutic relationship; and the re-evaluation of the self and the environment (Prochaska & Velicer, 1988). Psychotherapeutic techniques are not proved to be helpful in the absence of a well-established therapeutic relationship and a participative client (Hill, 2005). It seems, therefore, that the focus of psychotherapy is shifting towards therapeutic factors that might be common across different approaches. Kazantzis et al. (2015) state that there is ever growing knowledge about the helpful components of psychotherapy. For the understanding of psychotherapy to advance beyond our current knowledge, research must focus on helpful components throughout different therapeutic theories used. Research has shown that psychotherapy can be effective in producing significant changes in individuals’ lives and these changes need to be anticipated, reflected, stimulated and discussed during psychotherapeutic sessions (Gonçalves, Ribeiro, Mendes, Matos, & Santos, 2011). Many clients recognise that psychotherapy has a major impact in altering their lives in significant ways (Binder, Holgersen, & Nielsen, 2009), but there is not always a clear cut way to explain what has caused the change. Hence, there is a need for more research to understand these change processes. According to Elliot (1984), clients usually indicate different significant or helpful events in psychotherapy to those that psychotherapists normally identify as the most useful. Timulak (2010) states that there are clear discrepancies between what clients and psychotherapists find to CHAPTER 1 4 be helpful in psychotherapy, where psychotherapists usually focus on the cognitive aspects of change in psychotherapy and clients focus on the interpersonal aspects between client and psychotherapist as well as the accompanying emotional aspects during significant moments (Timulak, 2010). According to Elliot (1984), the significant events approach specifically represents the important moments in psychotherapy as identified by the client. The fundamental rationale for this form of research, is the notion that the significant events are the instances where the most fruitful psychotherapeutic work is done (Timulak, 2007). Elliot (2010) suggests four different types of change process research namely, the quantitative process-outcome, the qualitative helpful factors, the micro analytic sequential process and the significant events approach. The significant events approach successfully combines multiple elements of the former three approaches. Qualitative studies on significant events allow for detailed description of processes leading to a significant impact and thus can be particularly informative for clinical practice as it provides a more comprehensive strategy for understanding how change occurs in psychotherapy (Timulak & McElvaney, 2013). It is also important to keep in mind that there are specific elements in psychological interventions (and their associated mechanisms of change) about which we are learning a great deal, that might be more important for treating some disorders than for others (Hoffman & Barlow, 2014). Moreover, Blatt et al. (2010) states that there is a vital need to understand and empirically test the processes that underlie the efficacy and effectiveness of various treatments for various disorders. Following this line of argumentation, it becomes crucial to differentiate between efficacy and effectiveness as two main approaches to research on psychotherapeutic treatment (Lutz, 2003). These two types of approaches may produce different results, however both offer useful CHAPTER 1 5 information. Efficacy is related to the question: is a treatment capable of working under ideal circumstances - working from the rationale that if it does not work under perfect conditions, it would much less be effective in actual psychotherapeutic practice (Streiner, 2002). Therefore, efficacy-focused research tries to assess specific models and specific therapeutic protocols with the goal of achieving empirically supported psychotherapy status (Amundson, Alladin & Gill, 2003). Efficacy research has been the main focus in clinical research and studies that focus on efficacy do everything possible to increase the chances of showing an effect by basing research on randomised clinical trials (RCTs) with homogenous groups to emphasise internal validity. On the other hand, effectiveness research focuses on the idea of whether the treatment would work in the real world (Streiner, 2002). By attempting to reproduce the same circumstances that clinicians may come across in their clinical practices, effectiveness studies emphasize the suitability of the treatment. This type of research highlights the external validity of the research findings (Lutz, 2003). Consequently, it attempts to identify the factors and dynamics that influence psychotherapy, in order to increase the effectiveness of psychotherapy, irrespective of specific models or therapeutic techniques that are used (Amundson et al., 2003). Elliot (2010) describes change process research (CPR) as the investigation of the processes whereby transformation will most likely happen within psychotherapy. CPR aims to uncover the manner in which proficient psychotherapy brings forth change within individuals and how to use this data to the advantage of other individuals (Pfeiffer & Strunk, 2015). Here an important distinction must be made between process and outcome research. Within the practice of psychology, process research is seen as beneficial as it focusses on the manner in which psychotherapy operates by studying patterns of change across different models of psychotherapy (Rhodes, 2012). Process research refers to the events happening within sessions that lead to CHAPTER 1 6 change in the client whereas outcome research focus on changes that take place within the clients behaviour, experiences and/or characteristics after a therapeutic intervention (Greenberg, 1986; Hilliard, 1993). In the past, there was a prominent focus on outcome research. Predominantly, studies were done to investigate the efficacy of psychotherapeutic approaches in comparison to control conditions. Therefore, these studies did not examine the process whereby therapeutic change occurred (Greenberg, 1986). Researchers started to become concerned that even though outcome research could possibly offer valuable confirmation for the efficacy of a treatment, it was also limited because it did not continuously emphasise the realities of clinical practice (Garfield, 1996; Goldfried & Wolfe, 1996). Llewellyn, MacDonald and Aafjes-Van Doorn (2016) explain that the reason why process research was not as popular as outcome research, is because researchers had a greater need to study the effectiveness of psychotherapy rather than understanding the manner in which change occurs. It was therefore suggested that the complete psychotherapeutic outcome must be divided into sections of linked changes in order to determine which particular therapeutic approaches trigger change. The next step would be to clarify these changes by studying the psychotherapists’ interventions and the clients’ reactions to those interventions (Kiesler, 1983). Llewelyn et al. (2016) reported that in order to increase the effectiveness of psychotherapy, we need to comprehend precisely which processes guide the psychotherapist to better client outcomes. According to Elliot (2010), the diversity of features of the therapeutic process can be discovered only through a combination of process-outcome research that encompasses all the relevant aspects. CHAPTER 1 7 One of the focus areas of CPR is the influence of the significant events in psychotherapy. Elliot (1984) reports that significant psychotherapy events consist of steps of actions between client and psychotherapist that enables a particular psychological impact within the client. Furthermore, the significant events research approach may provide more inclusive strategies by combining numerous elements of the more basic therapeutic approaches for understanding how change occurs in psychotherapy (Elliot, 2010). McCarthy, Caputi and Grenyer (2017) state that there are special moments that happen in psychotherapy that can provide psychotherapists with an understanding of the therapeutic process. These useful moments in psychotherapy sessions, known as the significant change events, is shown to correlate sharply to positive results of psychotherapy outcome (McCarthy et al, 2017; Timulak, 2007). Qualitative studies on significant events allow for detailed description of processes leading to a significant impact and thus can be particularly informative for clinical practise (Timulak & McElvaney, 2013). Several studies contribute examples of such impactful processes, for instance: the gaining of insight; psychotherapists’ interpretation; empowerment of clients as well as therapeutic alliance ruptures (Elliot, 2010; Safran & Muran, 2000). Studies by Elliot (1983) and Rennie (1992) illustrate that different modalities use differing descriptions to refer to categories of significant events that contain comparable material, for example, the events involving reflexive self-understanding. Similarly, Timulak (2007) undertook a qualitative meta-analysis whereby he investigated the moments that clients found to be most impactful and he was able to sort them into seven meta-categories namely: 1) insight; 2) reassurance; 3) experiencing emotions; 4) feeling understood; 5) empowerment; 6) relief and 7) client involvement. Thereby presenting the idea CHAPTER 1 8 that the change processes operating within psychotherapy, may appear exceptionally during significant psychotherapy events. By studying and understanding these significant events, one may produce information for psychotherapists that might foster certain types of helpful events and prevent hindering events from occurring (Packer, Addison, & Elliott, 1989). Goldfried (2013) ascertains that whilst there is evidence to prove that psychotherapy is useful, it is also essential to acknowledge findings that prove certain interventions might be detrimental to clients. Two main reasons for this detrimental effect is that either the psychotherapy is producing a harmful impact on an individual or the psychotherapists’ difficulty to prove that efficient change actually transpired (Castonguy et al., 2010; Lilienfield, 2007). Studies on causes of spurious therapeutic effectiveness [CSTE] (Lilienfield, Ritschel, Lynn, Cautin & Latzman, 2014) explain that there is a large number of reasons as to why psychotherapy may be recognised to be effective by psychotherapy researchers and practitioners when it is actually not, including limitations such as naïve realism and cognitive bias. Lillienfeld (2007) report that there is an increase of studies on potentially harmful treatments (PHTs) where symptom deterioration or worsening of the clinical features takes place. Some of these treatments include critical incident stress debriefing (Adler et al., 2008) and scared straight programs which showed to have a negative impact on some individuals (Lillienfeld, 2007). Kelly et al. (2007) found that clients have better psychotherapy results when they have experienced sudden gains in psychotherapy and they show a longer state of improvement in the long term than those whose progress is slower (Tang & DuRubeis, 1999). For the abovementioned reasons, it seems to be important to explore what brings about impactful moments in psychotherapy so that these moments may possibly be reproduced within therapeutic sessions to bring about change. Two different stages of changes exist, namely: 1) the CHAPTER 1 9 in-therapy processes that bring about change; and 2) the subsequent pattern of change that happens outside of psychotherapy. This leads to the question as to which changes occur first and what leads to consequent changes. Lambert (1992) reviewed empirical studies of outcome research and compiled a four- factor model of change (Norcross & Goldfried, 1992). This model includes extra-therapeutic change factors, common factors, technique factors and expectancy factors as the four constructs (Lambert, 1992). Estimated percentages of variance in outcome creates the model that consist of these factors and how they contribute to change in the therapeutic process. Client extra- therapeutic factors are assessed to provide roughly 40% of change whilst psychotherapeutic techniques utilised by the psychotherapist account for more or less 12% of the variance across different therapeutic modalities (Lambert, 1992). Furthermore, it was found that the outcome variance for the therapeutic relationship are higher than for the use of particular therapeutic techniques (Orlinsky, Grawe, & Parks, 1994). This study focuses on specific moments within psychotherapy that produces client change, although they are termed differently by different therapeutic approaches and research studies. Examples of these different terms include: significant events (Elliot, 1983; Timulak, 2010); innovative moments (Gonçalves et al. 2011); critical incidents (Fitzpatrick & Chamodraka, 2007); sudden gains (Stiles et al., 2003); helpful events (Elliot, 1985); important moments (Martin & Stelmaczonek, 1988); and empowerment events (Timulak & Elliot, 2003). Problem statement In the light of productive service delivery as well as the ongoing research trajectory, psychotherapy is an ever evolving, transformative and developing profession and science. Numerous existing studies illustrate the valuable contribution of significant events to the CHAPTER 1 10 outcome of psychotherapy. By exploring these studies on significant events, one may produce material that might add to the understanding of helpful and hindering events, as well as how these events brings forth lasting psychotherapeutic change. A systematic review was therefore deemed as the appropriate methodology for this research study to gather and condense all the valuable and trustworthy, existing literature regarding significant events in psychotherapy. Research Question This study attempted to ascertain, from literature, the way in which significant events in psychotherapy influence how psychotherapeutic change is conceptualised. The planned objectives included reviewing relevant and scientifically sound literature on significant events (as well as similar change process concepts) in psychotherapy and exploring the different themes that arose from the collected literature. The research question to be answered by this study, is: What does scientific literature report regarding significant events in psychotherapy and the influence thereof on conceptualising change during psychotherapy? CHAPTER 1 11 References Adler, A. B., Litz, B. T., Castro, C. A., Suvak, M., Thomas, J. L. Burrel, L., et al. (2008). 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SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 17 CHAPTER 2 The influence of significant events in conceptualising change during psychotherapy: A systematic review Lelanie Jordaan, Rümando Kok North-West University Rümando Kok * 26 Segootsane Street, Tuscany Ridge Estate, Potchefstroom 2520 rumandokok@gmail.com * To whom the correspondence should be addressed SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 18 Abstract The aim of this study was to explore scientific literature on significant events in psychotherapy and the influence thereof on conceptualising change during psychotherapy. In order to achieve this objectives, a systematic review was done to identify different themes that arose from the gathered literature. From the data analysis, five main themes emerged, namely: 1) definitions of change process concepts; 2) therapeutic process variables; 3) therapeutic intervention; 4) therapeutic relationship; 5) sequence of change process events. Within these themes, prominent subthemes also emerged. The findings provide understanding of different change process concepts and highlighted the usefulness of these events in improvement and positive outcomes. Findings highlighted the valuable contribution of the therapeutic alliance in producing significant events and also in utilizing significant events to produce lasting change. The processes that underlie high level innovative moments (IMs) are seen as the mechanisms of change, leading clients from a problematic narrative to a more effective storyline. Additionally, cognitive restructuring, emotion processing and client readiness for change are indicated as important factors for change. The results also show a need for more research into significant events in relation to change in psychotherapy. Keywords: critical incident, helpful event, important moment, innovative moment, psychotherapy, significant event, sudden gain SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 19 Introduction Greenberg (1986) indicated the necessity of research on change processes in order to understand what brings about change in the course of psychotherapy. Although there has been extensive research done on psychotherapy there is still not a clear, evidence-based understanding of all the mechanisms that produce change in treatment (Kazdin, 2006). Evidence shows that psychotherapy may be effective in helping clients however it may also do harm to them (Goldfried, 2013). With this in mind it seems all the more appropriate and even necessary to conduct research that extends beyond outcome research and randomized controlled trials (RCTs) to change process research with a focus on common factors and therapeutic relationship that may play a role in change across different interventions (Goldfried, 2013). One form of process research is significant events research that makes use of word-by- word transcripts of psychotherapeutic sessions as well as interviews or questionnaires about the thoughts of clients and psychotherapists after these sessions. Important moments in psychotherapy sessions as recognized by clients themselves form the foundation of significant events research (Elliott, 1985; Timulak, 2010). The reasoning behind research that focusses on key moments or significant events in psychotherapy is that it appears to be occasions when either the most productive- or most hindering work are respectively done (Timulak, 2010). Consequently the findings may provide psychotherapists with both the most effective elements to use and the most problematic elements to avoid. Moreover it can guide the psychotherapist to recognize these significant moments so that they may utilize them to their full potential. The focus of this study are on specific moments within psychotherapy that brings forth change and because there are various different terms for these type of moments, within different theories and modalities, they are all included and reviewed. The research question that this systematic SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 20 review intends to respond to is: What does current scientific literature report about significant events in psychotherapy and the influence thereof on conceptualising change during psychotherapy? Method A systematic review is chosen as the method for the anticipated study as this research methodology is becoming progressively more essential in health care research to assist clinicians to keep up to date in a specific field (Moher, Liberati, Tetzlaff, Altman, 2009). When individual articles are examined in isolation (or as stand-alone entities), little insight might be gained into significant events across different psychological approaches and, therefore, it is hypothesised that a systematic review may give a clearer and more stable picture of existing research about change events within psychotherapy. According to Dickson, Cherry and Boland (2014), a systematic review is intended to locate, appraise and synthesise the optimum available evidence connecting to the research question, with the aim of providing an evidence-based answer. Thus, doing a critical appraisal of literature according to a fixed plan (Gough, Oliver, & Thomas, 2012). Moreover, Dickson et al. (2014) explain that a systematic review needs to follow clear, well-defined stages that include a definition of the research question, searching for and critically assessment of the existing evidence and combining the findings to establish applicable conclusions. A synthesis is meant to be an integration of findings from trustworthy and relevant studies to help answer the review question (Gough et al., 2012). The structure of this article is in line with present guidelines recommended for reporting systematic reviews in the field of psychology (Liberati et al., 2009). Figure 2.1 illustrates the research process that was followed in this study in order to conduct the systematic review. SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 21 1. Performing the scoping searches 2. Screening titles and abstracts Use keywords to search for records in Critical appraisal of compliance to databases keywords, inclusion and exclusion criteria [Inclusion and exclusion criteria filtered through Boolean operators] [Two independent reviewers appraise titles and abstracts – if disagreement, involve 3rd reviewer] 3. Quality assessment Use a quality assessment tool to critical appraise the quality of selected studies [Combination of NICE (2012), QCC Exclusion of inappropriate studies (ADA, 2008), and Petticrew and Roberts (2006)] Exclusion of studies due to poor quality or irrelevance 5. Data analysis 4. Data extraction (Qualitative analysis: Represented as a (Identify, extract and organize relevant narrative synthesis and organised into aspects of final selected studies to word- themes and subthemes) document) Figure 2.1 Flow diagram of the selection of relevant studies in the systematic review process Scope Review A scoping search was carried out by using initial keywords, derived from the research question, to search for records in databases as an initial evaluation of the nature and possible size of available research articles (Grant & Booth, 2009). The scope review specifically investigated the feasibility of a systematic review on the influence of significant events in psychotherapy. SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 22 The initial scope review was done by an experienced librarian and yielded 578 records that could be appropriate for use in this study. According to Petticrew and Roberts (2006), this is an adequate number of articles in order to conduct a systematic review on the proposed topic. After the scope review the keywords were refined and the focus of the search were narrowed. Other keywords from the change process research paradigm were considered for inclusion, however it seemed to take the focus from significant events within psychotherapy by broadening the scope of the search greatly. Inclusion and Exclusion Criteria The inclusion criteria that were used for the purpose of the systematic review, are: full- text journal articles; peer-reviewed articles; quantitative studies, qualitative studies and mixed- method studies; review studies; PhD theses and; studies that have been published between 1 January 1960 and 20 February 2019 (the date of the electronic search). As numerous articles on process research in psychotherapy were already published during the 1960s (e.g. Rogers, Gendlin, Kiesler & Truax, 1967; Truax, 1963), the time span of more than 50 years is considered to be acceptable. The exclusion criteria that were used for the purpose of this systematic review, are: non- peer reviewed studies; unpublished masters’ dissertations; conference proceedings; duplicate reports of the same study; non-research reports, letters and commentaries and studies published in other languages than English. According to Cochrane Handbook for Systematic Reviews of Interventions (Sterne, Egger & Moher, 2011) research showed that there is still no convincing evidence to indicate that the exclusive focus on English as a language of publications leads to prejudiced outcomes. Furthermore, the exclusion of non-English languages does not appear to have a significant SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 23 impact on the results of systematic reviews, therefore the expense and time to translate non- English studies does not necessarily justify the inclusion of such studies and needs to be considered on a case-to-case basis (Sterne, Egger & Moher, 2011). Search Strategy In the next stage, a rigorous literature search was conducted of all relevant electronic databases in consultation with an experienced librarian at the Potchefstroom Campus of the North-West University (NWU). The search was conducted through the OneSearch portal of the NWU that searches through multiple databases including those related to the discipline of psychology, namely: Academic Search Premier; CINAHL; Cochrane Library; EBSCOHost; PsychARTICLES; PsychINFO; SocINDEX; and ScienceDirect. The keywords and Boolean configurations linked the operators and the keywords as follows: psychotherap* AND “significant event*” OR “innovative moment*” OR “critical incident*” OR “sudden gain*” OR “helpful event*” OR “important moment*” on the level of abstracts. The search generated a total of 124 journal articles that was found to be sufficient to answer the research question. Screening During the screening phase, both the first and second reviewer determined the relevance of the 124 articles by screening the records for relevance based on their titles and abstracts alone. The research question was applied as the main guideline in order to determine the relevance of each record. That is to say, for every record’s abstract and title, the question was raised whether the information presented would assist the reviewers in answering the research question. With regards to the initial 124 articles, 10 were excluded because they were duplicates and 17 because they were either book reviews, commentaries, introduction to special editions, SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 24 editorials or lectures and a further 47 articles were excluded due to irrelevance. As a result, 50 articles were considered as relevant to advance to the critical appraisal phase of this systematic review process. Figure 2.2 illustrates the screening process that was followed in this study. Initial search strategy (n = 124) Electronic databases searched: Academic Search Premier (n = 67) PsychINFO (n = 34) ScienceDirect (n = 6) MEDLINE (n = 4) SocINDEX (n = 4) JSTOR Journals (n = 2) MasterFILE (n = 2) CINAHL (n = 2) SportDiscus (n = 1) Art & Architecture (n = 1) Directory of Open Access Journals (n= 1) Excluded Titles and abstracts screened for Duplicates (n = 10) relevance. (n = 124) Book reviews, etc. (n = 17) Irrelevant (n = 47) Full text screened for quality. Excluded Progress to critical appraisal phase. Poor quality and/or irrelevant (n = 25) (n = 50) Final number of studies included (n = 25) Figure 2.2 Flow diagram of the screening for relevant studies in the systematic review process SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 25 Critical Appraisal The goal of the critical appraisal is to establish the scientific quality and further relevance of the full text articles. To this extent, the two reviewers independently reviewed all full text articles that were deemed as relevant during the screening phase. As the specific nature of this study called for the inclusion of both qualitative and quantitative studies as potential sources to be reviewed, an appraisal tool was needed that would be flexible enough to evaluate all the collected studies. Therefore, the quality appraisal tool is suitable to evaluate any appropriate study irrespective of the research design. It was done by integrating the principles and guidelines of three well established, standardized critical appraisal tools into one concise document. These tools include: the national institute for health and care excellence [NICE] (2012); the quality criteria checklists [QCC] (ADA, 2008) and the guidelines proposed by Petticrew and Roberts (2006). This form served two purposes, firstly it presented distinct direction for assessment of scientific quality, reliability and trustworthiness, by assessing the methodology of each article through 13 questions. Secondly, it presented clear direction for assessment of the relevance of each article by asking whether the study will aid the reviewer in answering the research question. A copy of the Critical Appraisal Tool is presented in Addendum A. At first the two reviewers independently assessed the overall quality and relevance of the included articles, by completing a critical appraisal form for each article. Thereafter the two reviewers met to co-review their independent quality appraisal in order to determine their level of agreement. Articles were only directly included when it scored either two positive scores or one positive score and one moderate score. Articles with either two moderate scores or one positive and one low score where discussed between the two reviewers and re-evaluated, whilst SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 26 articles with one or two low scores were excluded. Provision was made for instances where the two reviewers could not agree that a third reviewer, prof. K. Botha, might be consulted. Of the 50 articles, the two reviewers reached immediate agreement on 48 articles, while two articles required additional discussions before consensus was reached, without a need to consult a third reviewer. Of the 50 articles, only 25 articles met the quality and relevance criteria to be included for the full review. Thus, 25 articles were excluded based on lack of relevance and/or poor scientific quality. Data Extraction The first reviewer read through the full text of the 25 included articles several times with the research question in mind. Subsequently, the reviewer highlighted, in yellow, the text phrases considered to be capable of answering the review question and these sections were copied into a single Word document. The second reviewer, whom has previous experience in conducting systematic reviews, checked the data extraction document for consistency in method, for accuracy and for relevance as related to the research question. After an agreement was reached, the data was recorded into a concise table (Brown & Sutton, 2010; Dickson, Cherry, & Boland, 2014). This newly compiled document was then considered to be the final data set from where the next stage of data analyses was performed. A concise version of the data extraction table is presented in Addendum B. Data Analysis In the last stage of the review, a qualitative synthesis of all the extracted data was performed. For this stage an inductive content analysis was implemented, as it is a systematic and objective method of describing data (Elo & Kyngäs, 2007; Sandelowski, 1995). Instead of using pre-identified categories, the inductive approach allowed the themes to flow from the data. SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 27 The intention of the content analysis was to condense the data of all the studies to a summative description of the research question (Elo & Kyngäs, 2007). The five stages of inductive content analyses were followed as set out by Thomas (2003) and executed by the first reviewer. The second reviewer monitored the process for accuracy and relevance and assisted in deciding on the final themes. These stages included: 1) preparing the extracted data; 2) reading and familiarising the self with the data; 3) organising the data into specific categories; 4) integrating the specific categories into broader categories; and 5) compiling the results (Thomas, 2003). At first the raw data files were prepared by means of organising them into a common format and making a back-up of the data. Thereafter, the texts were read in-depth so that the reviewer became acquainted with the content and gained a sense of the broader themes. As relevant aspects from the text emerged, notes were taken in the margins in order to express all suitable aspects of the content. Thereafter, headings were gathered from the margins into another Word document (Cole, 1988). As part of this step, the reviewer started to divide the individual phrases into categories where they seemed to have the best fit and even more themes started to flow freely out of this process. Thereafter, a rough draft list of themes (or categories) was put together. This part of the process was done by the first reviewer only. In the second last stage, the reviewer reduced the amount of initial categories by integrating them into broader categories. Dey (1993) explains that by collapsing categories that are similar or different into larger higher order categories the number of smaller categories are reduced. The categories were labelled using words that are descriptive of the content- characteristic. Both reviewers independently sorted through the labelled categories and during a meeting an organised layout of themes was compiled by both researchers collectively. The results SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 28 were then compiled in a concise format and each theme was defined by systematically going through the entire dataset and organising the data into the themes. In an effort to ensure trustworthiness throughout this process a methodical approach was taken to clearly and transparently record every step during the course of the review. Finally the available data was presented according to the identified themes, including examples and citations from the literature. The following section offers a qualitative narrative synthesis of the available themes and subthemes as relating to the influence of significant events in psychotherapy. Ethical Considerations In an attempt to follow strict ethical protocol during the entire course of this systematic review the following guidelines for trustworthiness and transparency as set out by Petticrew and Roberts (2001) and Wager and Wiffen (2011) was followed. Scientific rigour was ensured by representing all data fairly and accurately through reporting all the steps of the study clearly. Ethical approval was obtained from the North-West University Health Research Ethics Committee (NWU-HREC), before the study commenced. According to Bown and Sutton (2010) the results from a systematic review is merely as valuable as the source data upon which it is based. For this reason all the studies went through a rigorous critical appraisal by both reviewers in order to ensure that only reliable, trustworthy and appropriate studies were included in this review. Accuracy of findings was ascertained by strictly following the systematic review protocol (Wager & Wiffen, 2011). Transparency was ensured throughout the process, by providing clear steps as to how the data was generated (Petticrew & Roberts, 2006), so that the study may be replicated by other researchers. Care was taken to avoid SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 29 plagiarism (Wager & Wiffen, 2011) and the final document was submitted to the anti-plagiarism software program, Turnitin to confirm that plagiarism has been prevented throughout the study. Findings The final data set consisted of a collection of selected studies that were all published between 1999 and 2019. Following the search strategy- and critical appraisal phases it transpired that all included articles originated from 1999 and onwards and not earlier as was previously anticipated. Perhaps because the earlier studies did not meet the criteria involved in those phases. All of the included literature were articles. The highest number of articles were published between 2010 and 2019 (n=17; 68%), while only one article was published between 1990 and 1999 (n=1; 4%) and the remaining seven were published between 2000 and 2009 (n=7; 28%). The greater part of the studies were empirical in nature (n=24; 96%), while only one study (4%) was theoretical by nature. Out of the 25 selected articles, 14 were conducted within a qualitative research design (n=14; 56%), with seven studies (28%) conducted from a quantitative research design and four studies (16%) conducted from a mixed-method research design. The 25 articles were published in 15 different journals, the majority in Psychotherapy Research (n=8; 32%), followed by Pragmatic Case Studies in Psychotherapy (n=2; 8%) and Psychology and Psychotherapy: Theory, Research and Practice (n=2; 8%). The remainder of articles in the final collection of studies were each from a different journal. Out of the 25 identified articles, the researchers distinguished a total of five encompassing themes. Several subthemes emerged from the themes and each theme with their subthemes are discussed individually in the following paragraphs. See table 2.1 for a summative overview of the themes and subthemes. SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 30 Table 2: Themes and Subthemes Themes Subthemes 1. Definition of change process concepts 1.1. Helpful factors 1.1.1. Definition; 1.1.2. Type; 1.1.3. Examples; 1.2. Significant events 1.2.1. Definition; 1.2.2. Type; 1.2.3. Examples; 1.3. Sudden gains 1.3.1. Definition; 1.3.2. Type; 1.3.3. Examples; 1.4. Innovative moments 1.4.1. Definition; 1.4.2. Type; 1.4.3. Examples; 1.5. Insight events 1.5.1. Definition; 1.5.2. Type; 1.5.3. Examples; 1.6. Significant hindering events 1.6.1. Definition; 1.6.2. Type;1.6.3. Examples; 2. Therapeutic process variables 2.1. Role players 2.1.1. Client variables 2.1.2. Therapist variables 2.2. Context 2.2.1. Within-session 2.2.2. Outside-session 2.3. Timing 2.4. Impact 2.5. Outcome 3. Therapeutic intervention 3.1. Cognitive awareness 3.2. Thought restructuring 3.3. Emotion experiencing 3.4. Cognitive disengagement 3.5. Interpersonal 4. Therapeutic Relationship 5. Sequence of change process events 5.1. Prior to events 5.2. Mechanisms underlying events 5.3. Process unfolding after events SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 31 Theme 1: Definitions of Change Process Concepts In attempting to understand the various change process concepts, it is important to distinguish between the differing meanings thereof. This line of research is focused on key moments as recognised by clients. These moments are categorised as either significantly helpful or hindering events, which impacts the therapeutic process and is therefore important for the ongoing improvement of psychotherapeutic outcomes (Elliot, 1985; McCarthy et al., 2017; Quick et al., 2018). Various type of events such as insight events, problem clarifying events and empowerment events are currently being studied through qualitative research methodologies by exploring factors such as the in-session impact of the event, the long term outcomes and the processes inspiring the helpful events (Timulak, 2007). Along similar lines, studies also demonstrate that these various events may have different functions in psychotherapy, that these events has the potential to be directly or indirectly linked to the outcome of psychotherapy and that they occur within or out of the context of psychotherapy sessions (Timulak, 2010). Subtheme 1: Helpful factors. Definition of helpful factors. Helpful factors focus on moments that transpire within the therapeutic process, are identified by the clients as significant and have an influence on the therapeutic process. This involves the presenting problem of the client, the therapeutic intervention to the problem and the direct in-session impact it produces (Greenberg, 1986; Quick, Dowd, & Spong, 2018). Helpful events are seen as instances where the most productive work is done within the psychotherapeutic context. These helpful events are particularly useful in predicting outcome and specifically to study therapeutic change processes (Timulak, 2007; Quick et al., 2018). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 32 Several studies highlighted that most of the helpful events may contain many smaller hindering or painful events set with-in them, for example sessions where the focus is on working through painful emotions and events (Swift, Tompkins, & Parkin, 2017; Timulak, 2010). Furthermore, clients reported the impact of helpful events in several categories, for instance, that it is contributing to the therapeutic relationship or contributing to in-session accomplishments (Timulak, 2010). Grafanaki and McLeod (1999) emphasised the clients’ discovery or negotiation of a new storyline or the realisation of incongruity between a present story and a newly developing story as helpful events - where the new storyline seems to be empowering and liberating. In addition, they mention that helpful events might be linked to the client’s experience of a sense of agency, of being on the right track and moving on the path to personal meaning (Grafanaki & McLeod, 1999; Rennie, 1994). Although, the client may covertly be processing the story, helpful events often depict the first appearance of a new reconstruction of the life story (Grafanaki & McLeod, 1999). Different change processes from different modalities of psychotherapy were encapsulated by the finding of helpful impacts in several different areas, including new perspective, new behaviour and motivation - which indirectly supports the significance of integration of different psychotherapeutic approaches (Timulak, 2007). Types of helpful factors. Helpful events can be grouped together into different categories. Timulak (2007) distinguished three such categories: firstly, he mentions new perspective which includes awareness, insight and self-understanding; secondly new behaviour that encompasses behavioural change and problem solution; and lastly new experiencing containing aspects like exploring feelings, emotional experiencing, empowerment and relief. SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 33 Swift et al. (2017) grouped factors together that clients used to describe whether an event is perceived as being helpful or hindering, namely: 1) the change process of psychotherapy that needs to take place by organising curiosity and intense engagement in the identification of patterns and narrative reconstruction; 2) psychotherapist features including care, understanding and acceptance to permit internalisation of affirmative messages and to acquire self-awareness; 3) specialised and skilled arrangement of sessions generates clarity although it may shed doubt on the therapeutic relationship; 4) psychotherapy needs to be a collaborative activity that includes communication of differences between psychotherapist and client; and 5) appreciation for the client's independence and frame of reference lets the psychotherapist use interventions that suites the needs of the client (Swift et al., 2017). Quick et al. (2018) mentions three main types of helpful events as identified by clients, namely: 1) the nature of the therapeutic intervention (psychotherapists’ response); 2) in-session impact (immediate effect); and 3) the event as a whole (interaction and impact). In addition, Quick et al. (2018) also highlighted the nine core categories as set out by Timulak (2007; 2010) that were continually described as key helpful events, namely: 1) awareness/insight/ understanding; 2) behavioural change/problem solution; 3) empowerment; 4) exploring feelings/emotional experiencing; 5) relief; 6) feeling understood; 7) client involvement; 8) reassurance/support/safety; and 9) personal contact. Elliot (1983) further divided the abovementioned nine categories into two clusters namely the task supercluster and the interpersonal supercluster. The task supercluster involves new perspective, problem solution, problem clarification and focusing awareness, while the interpersonal supercluster including understanding, client involvement, reassurance and personal contact (Timulak, 2010). Insight and awareness as well as problem solution were the most SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 34 common helpful events identified with some studies also demonstrating an elevated incidence of interpersonal impacts - for example: clients that felt understood, reassured and relieved (Timulak, 2010). Swift et al. (2017) proposed that during the most helpful sections of psychotherapy the psychotherapist took specific action and used specific therapeutic skills in order to do so. Under the theme of psychotherapists’ actions, the psychotherapists mainly made use of psychoeducation, taught the client new skills and/or made connections for the client. Furthermore, the therapeutic skills that were employed during the most helpful parts of psychotherapy were active listening, expression of empathy, support and praise and discussion of the process that was transpiring. Specifically, moments were described as helpful when emphasis was placed on the client feeling heard and understood, the client learning a new skill, the client gaining insight and the client being able to process difficult emotions (Swift et al., 2017). Examples of helpful factors. According to the types of helpful factors, as set out by Quick et al. (2018), this subtheme will provide some examples of how clients described such helpful events: As examples of awareness, insight and self-understanding events, clients referred to new realisations, for instance, as recognising a certain issue had an impact on their entire life, and also if something was due to their own actions or behaviour. As an example of behavioural change and problem solving events, clients found it helpful to find solutions to their problems and seemed encouraged by having a plan of action. As an example of reassurance and support events, clients commented that they felt completely safe within sessions, safe to experience emotions that they were not able to do between or outside of psychotherapy sessions. SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 35 As an example of client involvement events, clients explained what they did to help themselves, for instance, writing in a diary or making lists (Quick et al., 2018). As an example of exploring of feelings and emotional experiencing events, clients referred to crying, mourning and accepting the feelings they had inside. According to the helpful event themes, as described by Swift et al. (2017), the following is given as examples: An example of clients that felt heard and understood was clients commenting that a moment was helpful because they were able to put their feelings into words to someone that did not make them feel bad or ashamed as the psychotherapist really demonstrated that they were listening (Swift et al., 2017). Often times in psychotherapy a client would worry about recounting a story of something in their life that they perceived as shameful or embarrassing. The ability of the psychotherapist to encourage the client to complete their story by listening to the client in such a manner that they did not feel ashamed, was experienced as helpful. Clients would often be concerned to tell a story that they feel embarrassed about, but by successfully completing such a story, the client can experience a sense of relief and accomplishment (Grafanaki & McLeod, 1999; Swift et al, 2017). Examples of clients that developed a new skill, are clients that commented that they found a new way to view things, that psychotherapy helped them understand what they could do from their side and that the psychotherapist gave good information (Swift et al., 2017). Examples of clients that gained insight, are clients that commented that they realised they forgot about the good things that were also happening and the psychotherapist reminded them that there was a positive side and another commented that she was able to examine her assumptions (Swift et al., 2017). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 36 Examples of clients who were able to process emotions, as part of a helpful event, were clients commenting that it was ‘like getting a load of my chest’ because they were able to open up the feelings and another stating that they ‘had to keep it inside for ages’ (Swift et al., 2017). Examples of important factors contributing to the therapeutic relationship and consequently to the helpful events, are: reassurance; feeling understood; as well as personal contact. Factors that contributed to in-session outcomes are: gaining insight; experiencing relief; change in behaviour; experiencing new emotions; and empowerment (Timulak, 2010). Subtheme 2: Sudden gains. Definition of sudden gains. Sudden gains are described as large, stable improvements from one psychotherapy session to the next which are favourable in terms of prognosis and highlight sudden symptom improvements (Koffman, 2018; Lorenz et al., 2013; Wucherpfennig et al., 2017). It refers to a sudden, large symptom reduction that usually occurs in a single between-session interval and does not take place gradually (Lorenz et al., 2013; Wucherpfennig et al., 2017). Sudden gains might be predictive of improvement as they indicate a phase shift and cause changes in the levels of distress caused by symptoms (Koffman, 2018). In other words, a sudden gain or sudden setback can be defined as change in a client’s symptoms between consecutive psychotherapy sessions that demonstrates a statistically significant reduction or escalation in symptoms (Hansen, Lambert, & Vlass, 2015; Wucherpfennig et al., 2017). Tang and DeRubeis (1999) proposed that sudden gains should be significant relative to the symptoms before the gain, as well as relative to symptom fluctuations both prior to and after the gain (Lorenz et al., 2013). Even though Koffman (2018) found that average sudden gains signified 62% of all improvement in treatment (Koffman, 2018), Hansen et al. (2015) reported SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 37 that the amount of change during sudden gain periods typically amounted to between 50% and 65% of overall change. Furthermore, several other studies have indicated that dramatic treatment reactions were maintained by clients who experienced sudden gains (Hansen, Lambert, & Vlass, 2015; Jensen et al., 2013). However, some clients may be more prone to consolidate a sudden gain in order to recover (Wucherpfennig et al., 2017). Currently, there is mixed evidence for the treatment factors that produce sudden gains (Lorenz et al., 2013), although evidence suggest that sudden gains represent a shared phenomenon among clients of different diagnoses and treatment modalities (Wucherpfennig et al., 2017). Processes, other than purely cognitive ones, may be involved in sudden gains as they have been seen to occur in different types of psychotherapies (Goodridge, & Hardy, 2009). Sudden gains are mostly associated with psychotherapist-directed treatments, although it might be possible that they also transpire from self-directed treatments, like expressive writing (Lorenz et al., 2013). Similarly, a better therapeutic alliance may be effective in producing sudden gains although it is not a necessary component (Lorenz et al., 2013). Furthermore, sudden gains may elicit hope and other positive emotions that are key for the re-moralisation process and commitment to treatment, engagement in complicated cognitive work, strengthening of the therapeutic bond and consequently the refinement of coping skills (Wucherpfennig et al., 2017). Types of sudden gains. It seems that sudden gains can be arranged into different types depending on whether they occur within session or outside of the session, whether they happen early-on or later in psychotherapy and whether it is a sudden gain or a sudden set back. Furthermore, sudden gains can also be distinguished by therapeutic modality. Researchers distinguish within-session sudden gains, for example repairing alliance ruptures between client and psychotherapist (Koffman, 2018) from outside-session sudden gains, SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 38 for example sudden gains that may be seen in individuals that does not participate in psychotherapy (Koffman, 2018). Sudden gains were initially confirmed in cognitive behavioural therapy for depression, suggesting that their influence is distinctively occurring in treatments targeting cognitive changes. However, sudden gains have subsequently been observed in treatments for other disorders and with other modalities of psychotherapy including, but not limited to: supportive- expressive therapy; systemic behavioural family therapy; and nondirective supportive psychotherapy (Goodridge, & Hardy, 2009; Lorenz et al., 2013; Wucherpfennig et al., 2017). Examples of sudden gains. Jensen et al., (2013) specified three conditions in order to identify a sudden gain, namely: 1) that the improvement of symptoms between sessions needs to be large in complete terms; 2) it needs to signify a symptom decrease of 25% or more; and 3) it needs to be fairly stable. Subtheme 3: Significant events. Definition of significant events. Significant events are key helpful moments or productive sections in a psychotherapy session that has an impact on the psychotherapy process, identified by either clients or psychotherapist, proven to relate strongly to outcome in evidence- based research studies (McCarthy et al., 2017; Swift et al., 2017; Timulak, 2010; Quick et al. 2018). Qualitative studies of significant events provide an in-depth description of processes leading to changes and therefore it may be helpful and/or valuable in clinical practice (Sousa et al., 2018; Timulak & McElvaney, 2013). The event may be anything that the client or psychotherapist has communicated or demonstrated and also something that may be experienced as either helpful or harmful that impacts the progress of psychotherapy (Sousa et al., 2018). Findings have demonstrated a co- SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 39 occurrence of empowering and painful events within significant events (Timulak & McElvaney, 2013). Seeing that significant events has a valuable effect on the clients’ level of optimism and trust in the effectiveness of psychotherapy, clients tend to becoming more involved in the psychotherapeutic process when a significant event occurs. It is also regarded as important that psychotherapists should be able to facilitate changes following a significant event (Timulak & McElvaney, 2013). Souse et al. (2018) exerts that significant events studies assumes the position that events in psychotherapy sessions encourage small changes that may add to bigger changes over time. Two qualitative studies indicated that when clients can identify a particular significant event, they are more likely to successfully achieve their therapeutic goals and to complete their psychotherapeutic processes (Sousa et al., 2018). Types of significant events. Examples of categories of significant events that were found to be specifically helpful included: statements reflecting emotional and cognitive awareness and insight; moments of alliance strengthening; problem clarification and solving; insight moments; behaviour change; meta-perception; and self-awareness (McCarthy et al., 2017). Furthermore, the same authors discovered that significant event sections included a large number of words representing affective processes including positive and negative emotions, mainly anger or sadness. Another study stated that client identified significant events included feeling reassured, feeling understood, having personal contact, gaining insight, experiencing relief, behavioural change, exploring and experiencing new feelings, and empowerment (Timulak, 2010). O’Halloran et al. (2016) divided significant events into therapeutic domains and described each SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 40 domain through a definition. These domains included: the process of psychotherapy; making changes and progress in psychotherapy; content and structure of psychotherapy; therapist contributions; negative contributions to psychotherapy; as well as other factors (O’Halloran et al., 2016). The process of psychotherapy domain entails all the factors of a session that convey the emotional and psychological aspects of psychotherapy (O’Halloran et al., 2016). The making progress in psychotherapy domain entails specific events where clients made certain changes in their situation as a consequence of undergoing psychotherapy or made progress by working on their presenting problem (O’Halloran et al., 2016). The content and structure of psychotherapy domain involves all events pertaining to the structure of therapeutic session, for example, the timeframe, timetable, interventions used and how all of these factors shapes the clients psychotherapeutic process (O’Halloran et al., 2016). The therapist contributions domain involves the factors that the psychotherapist includes in the psychotherapy session and how the client perceives the psychotherapist (O’Halloran et al., 2016). The negative contributions to psychotherapy domain entails all events that had a negative impact on a client or group and refers to factors seen as unhelpful (O’Halloran et al., 2016). The authors also included a domain for other factors domain to encompass all the other events that might not match another domain (O’Halloran et al., 2016). It also seems that there are various ways in which significant change events could be produced from processes of narrative reconstruction (Grafanaki & McLeod, 1999). Examples of significant events. Examples of significant events includes: 1) statements reflecting emotional and cognitive awareness; 2) moments of alliance strengthening; 3) problem solving; 4) insight moments; and 5) behaviour change (McCarthy et al., 2017). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 41 The ability to disclose personal stories and getting things of their chest is a significant feature of sharing experiences (O’Halloran et al., 2016). As an example, a client commented that he felt relief as he shared things within the psychotherapeutic context (O’Halloran et al., 2016). In the study by O’Halloran et al. (2016), the most commonly identified themes were from the domains: 1) process of psychotherapy; and 2) making changes and progress in psychotherapy. This finding highlights that by sharing, receiving support and providing a positive atmosphere, clients are enabled to acquire new skills and experience a positive therapeutic alliance with their psychotherapist. Within a cognitive therapeutic case, it appeared that events such as personal insight and reassurance were at the forefront, whereas in a dynamic experiential case it seemed that personal insight, awareness and client involvement were more typically regarded as important (Timulak, 2010). Thus, it appears that the significance of events is strongly influenced by the therapeutic approach of the psychotherapist. Significant events often involve interpretations made by the psychotherapist at a time that clients were ready and able to accept such interpretations (Elliott, 1984) as they were in the process of trying to deepen their self-understanding and indirectly, they were asking for help from the psychotherapist regarding the specific task (Timulak, 2010). Even though successful interpretations can never be absolutely perfect, they succeed in pointing to the main intra- and interpersonal problems that clients experience. In addition, successful interpretations should be conveyed in a collaborative manner which results in the client experiencing relief and clarity and, consequently, a positive relationship with the psychotherapist (Timulak, 2010). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 42 In order for a psychotherapist to gain insight into a client’s intra- and interpersonal experiences, it is important to empathically process possible misunderstanding that may occur between client and psychotherapist as this might also lead to significant events (Timulak, 2010). Subtheme 4: Innovative moments (IMs). Definition of IMs. IMs are exceptions to the maladaptive structure or problematic pattern of meaning that encouraged the client to attend psychotherapy (Batista et al., 2017; Gonçalves et al., 2017; Nasim et al., 2018). In other words, IMs are narrative markers of meaning transformation that challenge the problematic pattern and ultimately guides to transformation through the psychotherapeutic process (Batista et al., 2019). Innovative moments can also be understood as instances in the client’s dialogue that signify exceptions to the different aspects of the list of problems where the client elaborates on these meanings (Nasim et al., 2018). Each moment in which the clients’ patterns (be it behaviour/cognition/emotion) are interrupted, even if only temporarily, it is assumed that recurrence of these interruptions would lead to more enduring change (Nasim et al., 2018). Therefore, IMs facilitate change by promoting new understanding of the problem and by prompting the client to express new feelings and intentions and to develop different (or new) actions. Researchers hypothesise that IMs are mechanisms that can bring forth change in more stable structures, such as relational schemas, that contribute to symptom recovery in a substantial manner, since recovered clients show the presence of more IMs throughout their psychotherapeutic process than unchanged clients. IMs also have a favourable outcome for different psychotherapeutic models, like constructivist grief therapy, client-centred therapy, SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 43 narrative therapy, cognitive behaviour therapy and emotion-focused therapy (Batista et al., 2019; Gonçalves et al., 2012). The innovative moments coding system (IMCS) is a method that was developed to qualitatively assess the progression of novel moments during the psychotherapeutic process (Gonçalves, Ribeiro, Matos, Santos, & Mendes, 2010; Gonçalves, Ribeiro, Mendes, Matos, & Santos, 2011). An IM may develop either without the influence of the psychotherapist or it can arise as a consequence of the interaction between psychotherapist and client (Piazza-Bonin, Neimeyer, Alves, Smigelsky, & Crunk, 2016). IMs can occur in-sessions for instance making new discoveries and insight or they may occur outside sessions and, consequently, discussed in the sessions (Nasim et al., 2018). Types of IMs. It has been suggested that IMs could be arranged on three levels according to the impact they have on change. The first level IMs are moments that let clients create distance or separate themselves from the problematic pattern. Level one IMs are usually seen in unchanged cases, or at the start of psychotherapy in recovered cases (Gonçalves, Ribeiro, et al., 2017; Nasim et al., 2018). Level two IMs usually have two factors that differentiate them from the first level in that they hold a contrast between the past problematic aspect and the new, emerging story line. Level two IMs allows clients to generate a separation from the problematic pattern and a clear representation of what the new pattern might be (Nasim et al., 2018). Level three IMs is about consolidating the change that is brought forth by level two. It contains a contrast and an explanation of how the contrast appeared (Nasim et al., 2018). Contrast IMs occurs with the recognition of the disparity between problematic past positions and newly adjusted ones. SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 44 Further studies grouped them into low level and high level IMs where low level IMs were not predictors of symptom change (Batista et al., 2019). High level IMs are focused on change and the associated aspects there of including adaptive contrasts, processes of change and strategies related to improvement. The high level IM’s therefore enables clients discover from their own point of view what changed and the reasons for the change (Batista et al., 2019). Therefore, it is recognised as a list of alternative meanings that leads to a more open, flexible manner in which to connect to others and the psychotherapy process (Batista et al., 2019). Batista et al. (2019), Cunha et al. (2012), Nasim et al. (2018) and Piazza-Bonin et al. (2016) distinguish between five different types of IMs, namely: 1) action IMs; 2) reflection IMs; 3) protest IMs; 4) re-conceptualisation IMs; and 5) performing change IMs. Action IMs encapsulate behaviours that the client displays which are different to the problematic self- narrative that may include aspects like, for example, looking for solutions or information about the problem and using new coping behaviours (Cunha et al., 2012; Piazza-Bonin et al., 2016). Reflection IMs refers to when a problematic narrative is challenged and the client develops new perceptions, thus creating space between the new understanding and the problem. They can also be the clients’ reflection on the change process in psychotherapy or reflection on methods to deal with the presenting problem, reconsidering what caused the problem and a new perspective on how it impacted the client’s life (Cunha et al., 2012; Piazza-Bonin et al., 2016). Protest IMs, like action and reflection IMs, include new actions or thoughts that are different to the problematic pattern, however it takes an extra step by which the client disapproves the problem and those involved in the problem. The client then re-orientate themselves with regard to the problem to gain a new perspective (Piazza-Bonin et al., 2016). Re-conceptualisation IMs represent a high level of IMs in which the client experiences and realises the shift from the past attitude to the SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 45 problem to the present position. Therefore, re-conceptualisation IMs are a type of meta-reflection where the client is able to describe the change process (Piazza-Bonin et al., 2016). The last type of IMs are performing change IMs and refers to events where the client engages in new experiences, pursuits or relationships. At times, the client may refer to aspects of the self that were disregarded due to being absorbed by the problematic pattern (Piazza-Bonin et al., 2016). Examples of IMs. An example of an action IM where the act done by the client is different than their usual problematic pattern would be when a client socialises with their peers after they have not gone out for weeks (Piazza-Bonin et al., 2016). An example of a reflection IM where the client describes a new level of awareness of their behaviour and the negative impact it has on their functioning, would be when a client realises that they are avoiding their friends because they are scared to embarrass themselves, but that this behaviour is making them feel even worse. Another example of a reflection IM would be when a client expresses awareness of the changes produced by psychotherapy by, for example, reflecting on what specifically happens in psychotherapy and how it is helpful in particular (Piazza-Bonin et al., 2016). An example of a protest IM would be an event where the client shifts themselves in relation to the problematic pattern and eliminate this pattern with strong conviction like, for example, deciding to change their behaviour in certain events as they realise that it no longer serves them. This might be when a client no longer hides away because she is scared of a negative reaction from peers (Piazza-Bonin et al., 2016). This occurs when clients announce a need that they have not recognised before and rejects the problematic pattern with strong associated emotion. SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 46 An example of a re-conceptualisation IM would be when a client demonstrates a shift from the previous problematic pattern and move another step further by displaying an understanding of the process underlying the shift. For example a client that goes out to an event and engages with people despite the fact that she is afraid of sharing her feelings and usually keeps to herself and afterwards she is able to describe this process in detail. These IMs would occur when clients acknowledge that experiencing emotions, such as sadness, is an inevitable part of being human (Piazza-Bonin et al., 2016). An example of a protest IM would be when the client verbalises a new version of themselves that is clearly different to their previous problematic narrative and plans new actions, behaviours in relation to this new self. For instance, a client that goes on to be part of an event or initiative that would previously have been too painful and explaining that they can feel this new self while describing their desire to act, think and behave differently (Piazza-Bonin et al., 2016). Within the dialogue between the psychotherapist and client, new situations surface as they talk about events within or outside of the therapeutic session that moves away from the main problematic story line. The IM follows after the client experiences, ponder or conduct themselves in a different manner than what they are used to in the problematic narrative (Piazza- Bonin et al., 2016). Nasim et al. (2018) states that examples from psychotherapeutic studies demonstrates that IMs play an important part in the process of change (Nasim et al., 2018). In the therapeutic process, the client may proceed to deal with their problematic narrative and leave their typical way of coping with their problematic situation. Enduring change may follow by repeating this novel way of being (Nasim et al., 2018). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 47 Subtheme 5: Insight events. Definition of insight events. The client’s experience of an insight is considered an important in-session outcome of psychotherapy as well as a major change in self-understanding as a result thereof (Hill & Knox, 2008). Psychodynamic approaches view insight as both a mechanism and an outcome of psychotherapy and one of the most helpful processes to occur within psychotherapy, whilst the cognitive behavioural perspective views insight as the acquiring of new understanding and a transformation of knowledge constructions regarding the self and others (Grafanaki & McLeod, 1999; Timulak & McElvaney, 2013) Researchers found differences in insight events for psychodynamic therapy and cognitive behavioural therapy for example in psychodynamic therapy events there were elements of new painful awareness that were not found in cognitive behavioural therapy insight events. Also, psychodynamic therapy events linked interpersonal conflict across different sessions whereas cognitive behavioural therapy had a different focus (Timulak, 2010). Insight is understood as an acquisition of understanding the role of cognitions in the client’s problematic pattern and is seen as ‘a conscious meaning shift involving new connections’ (Timulak & McElvaney, 2013). Moreover, insight events could be one of two types: firstly, where therapeutic processes (for example, empathy) leads to an understanding of the essence of the presenting problem; and secondly, where the emphasis is placed on positive experiences, for example reframing by the psychotherapist that highlights to the client what they would want to change (Timulak & McElvaney, 2013; Timulak, 2007). Thus, vital processes lead to insight events in psychotherapy (Timulak & McElvaney, 2013). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 48 A reasonably good therapeutic alliance creates the context for insight events to occur (Timulak & McElvaney, 2013). Although errors or misinterpretations on the side of psychotherapists have been an element that brought about insight in some change events and has led researchers to note that the approach to an interpretation is important since most effective psychotherapists were sensitive in interpretations and collaborating with clients (Timulak & McElvaney, 2013). Types of insight events. Various processes in insight events could be grouped into two types according to a formulation of the main impacts they have, namely: 1) painful or poignant insight and, 2) self-asserting or empowering insight (Timulak & McElvaney, 2013). Painful insight events are described according to the main impact they have on clients, where clients become aware of something about themselves or somebody close to them that evokes feelings of hurt and sadness (Timulak & McElvaney, 2013). Empowering insight events are described according to the sense of self-assertion and empowerment that a client my experience (Timulak & McElvaney, 2013). These two types of events actually have a lot in common considering that self-asserting/ empowering events include difficult emotional elements whereas painful/poignant insight events also contain empowering features (Timulak & McElvaney, 2013). Timulak (2010) mentions a process where researchers created a model of processes that lead to positive insight events by concentrating on events that had an insight event as a helpful impact, specifically in psychodynamic and cognitive behavioural therapies (Timulak, 2010). The model contained five stages for insight events, namely: (1) contextual priming; (2) novel information; (3) initial distantiating process; (4) insight; and (5) elaboration (in which the insight stimulates the client's further exploration) (Timulak, 2010). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 49 Examples of insight events. Elliott (1984) described that the clients who reported insight events were ready for the interpretation from the psychotherapist, as they were in the process of trying to deepen their self-understanding and indirectly they were asking for help from the psychotherapist in this task. The target intervention consequently contained an interpretation targeting a core interpersonal issue. The interpretation was delivered in an affiliative manner, was interactive and multipart. Even though it was not entirely correct, the client still experienced relief, newness and accuracy of the interpretation. The relationship with the psychotherapist was also positively affected (Timulak, 2010). Aspects such as a relatively good alliance between psychotherapist and client and openness on the client’s part act as the framework for insight events and pursuit of self- understanding to occur (Timulak & McElvaney, 2013). Empathic reflection and collaborative interpretation form part of the key interventions leading to painful insights (Timulak & McElvaney, 2013). Within empowerment insight events the supportive, affirmative reframing from the psychotherapist serves to encourage the client and they have to work together to consolidate the new insight (Timulak & McElvaney, 2013). Subtheme 6: Significant hindering events. Definition of hindering events. It is known that psychotherapy does not work for everyone. Numerous clients leave psychotherapy too early, a substantial amount of clients do not show any improvement, whilst some clients experience a decline in functioning or increase in symptoms during psychotherapeutic treatment (Lambert, 2013; Swift et al., 2017). Clients referred to hindering events as periods in psychotherapy where the treatment or psychotherapist left them feeling disappointed (Swift et al., 2017). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 50 Another form of hindering event is a sudden loss which is defined as a statistical escalation in a client's symptoms in two consecutive treatment sessions (Hansen, Lambert, & Vlass, 2015). Thus, a sudden loss is the reversed phenomenon of a sudden gain (Wucherpfennig et al., 2017). Whenever a client with a sudden gain experienced a sudden loss in the following sessions, it is defined as a stable reversal (Lutz et al., 2013). Among sudden gainers that did not recover, there were considerably more stable reversals than among recovered sudden gainers (Wucherpfennig et al., 2017). 74% of clients presented with a reversal of the sudden gain and 38% experienced a sudden gain before a sudden loss (stable reversal) (Wucherpfennig et al., 2017). Type of hindering events. Two categories of hindering factors that may prevent change includes the psychotherapist’s use of customary psychotherapeutic techniques and when the psychotherapist assumes a directive position. Firstly, with regard to the use of psychotherapeutic skills, it was found hindering that the psychotherapist listened while the psychotherapy went of topic or psychotherapist moving away from the subject and the expression of empathy in an unhelpful manner. Secondly, the category pertaining to the psychotherapist assuming a directive role it, consists of factors like bringing too much structure into the session, attempting to lead the session in a certain direction, offering advice camouflaged as questions, unwanted sharing of psychotherapists’ perspective and unwanted sharing of psychoeducation (Swift et al. 2017). These events were experienced as being hindering by the clients as they felt that time was wasted on unimportant information as well as feeling judged by their psychotherapists or found the topics too hard to talk about (Swift et al., 2017). The quality of empathy provided by the psychotherapist is important as a demonstration of empathy was regarded as either helpful or hindering in various events reported by clients. SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 51 When the extension of empathy was perceived as unhelpful it was either because it was inaccurate or not genuine so that the client felt judged by the psychotherapist or that the psychotherapist was not ‘on track’ with the process (Swift et al., 2017). In a study conducted by Elliot (1985), six categories of unhelpful events were described as non-helpful, where the clients appeared to be disappointment with the psychotherapist in all of the categories, including misperception, negative counsellor reaction, unwanted responsibility, repetition, misdirection and unwanted thoughts (Timulak, 2010). The clients identified negative events that they considered to be hindrances in the therapeutic process. Clients regarded appointment times, the amount of sessions and the duration of psychotherapy to be inadequate. At times, the clients’ experienced the psychotherapists as failing to understand them correctly, unable to connect or that they experienced an inability to communicate their true thoughts or feelings to the psychotherapist and therefore experienced a lack of relief from suffering. One example is a client that stated that the psychotherapist interpreted to fast and the true painful issue was overlooked (Sousa et al., 2018). Another hindering event was described by one study as ‘moments of interrupted flow’ that become noticeable when a client finds that the storyline seems to be confusing or stuck or experience that the psychotherapist as audience might be critical, detached, or not understanding of the storyline (Grafanaki & McLeod, 1999). Examples of hindering events. Hindering events could also be detected within the negotiation of a new storyline as described by clients (Grafanaki & McLeod, 1999). At times the new storyline could be considered to be intimidating, painful, or occurring prematurely. Sometimes the hindering aspect of the event occurred when the psychotherapist was unable to understand or find value in the new storyline (Grafanaki & McLeod, 1999). As previously SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 52 mentioned, when an interruption of flow occurs, it may symbolise a disruption in the relationship between client and psychotherapist where clients might carry on to process the narrative covertly (Grafanaki & McLeod, 1999). From the psychotherapists’ perspective, they frequently portrayed themselves as being preoccupied and not fully connected with the client during events that turned out to be unhelpful. It may be that the psychotherapist was tired or in pursuit of the wrong storyline (Grafanaki & McLeod, 1999). Theme 2: Therapeutic Process Variables Subtheme 1: Role players. It seems that psychotherapists may have a preference for therapeutic work like insight and cognitive impacts, whereas clients may value the relational and emotional aspects of psychotherapy like reassurance (Timulak, 2010). Different client-therapist alliances may vary in their capacity to develop a sudden gain into lasting change (Wucherpfennig et al., 2017). Inter-individual differences might impact on how various clients perceive a sudden gain (Wucherpfennig et al., 2017). Particularly interesting was that to a great extent the new storyline was collaboratively negotiated by both the client and the psychotherapist (Grafanaki & McLeod, 1999). Client variables. During the first few sessions the clients’ quality of insight seemed limited and improved over the course of psychotherapy (Goodridge & Hardy, 2009). Client variables during insight events includes readiness for intervention, being emotionally vulnerable and having a quest for self-understanding (Timulak & McElvaney, 2013). During the insight events the clients were usually allowing themselves to be vulnerable and to experience difficult emotions such as intense sadness, trauma or embarrassment (Timulak, 2010; Timulak & McElvaney, 2013). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 53 Clients placed a lot of emphasis on how they are perceived by the psychotherapist or how they perceive the psychotherapist is treating them with regard to a specific issue that they are confronting in psychotherapy (Timulak, 2010). They also showed tolerance of psychotherapists’ mistakes during the course of helpful significant events (Timulak, 2010). Clients that consider particular factors to lead to a better therapeutic alliance might engage more in those specific factors, for example to open up more or respond positively to a certain intervention in order to improve the quality of the therapeutic alliance (Bedi et al., 2005). Clients implicitly referred to feelings of shame when they were trying to tell difficult stories (Grafanaki & McLeod, 1999) and the support and safety provided by the therapeutic alliance allowed them to participate more fully in the process. Positivity seemed to be a very important characteristic for clients who experienced significant change events. If a client has a positive attitude it may facilitate the process of acquiring new ideas and performing actions as well as the strengthening of social bonds (Wucherpfennig et al., 2017). Moreover, clients with positive outcomes were vastly more positive in their description of their self-images compared to cases that did now show positive outcomes (Hansen, et al., 2015). Sousa et al. (2018) add to this view by stating that clients who were most successful in psychotherapy were focused on their own improvement, they had a positive view of people as well as the treatment plan and they were less critical of themselves. Client involvement has a visible impact on helpful significant events (Timulak, 2007) and clients who realised that they had to invest themselves in psychotherapy if they wanted to see improvement usually showed the most change (Hansen, et al., 2018). It appears as if clients experience events as significant as a result of their motivational level, relational style as well as their reaction towards the therapeutic situation (Timulak, 2010). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 54 Treatment readiness and a desire for change is important factors of change in significant therapeutic events (Cunha et al., 2012; O’Halloran et al., 2016). When clients are not ready for change the psychotherapists might want to push for change and the direct consequences may be poorer (Cunha et al., 2012). The study by Hansen et al. (2015) reports on five positive outcome cases where each client started treatment with high levels of disturbance, displaying dramatic positive change after the first session of treatment and by the end of treatment also displaying levels of disturbance far below the mean of normal functioning. The good outcome cases improved faster in psychotherapy despite the fact that they were considerably more distressed at the start of psychotherapy than the bad outcome cases, which may be because they were in more of a crisis event that could be resolved much quicker (Hansen, et al., 2015). Both groups remarked that changes took place inside and outside of themselves (Hansen, et al., 2015). With regard to sudden gains, it is possible that sudden gain clients were more likely to buy into particular therapeutic values, for instance acceptance and vulnerability because psychotherapy might be more effective for clients that share principles and objectives that are similar to those of the psychotherapist. Thus the psychotherapist should realise that the outcome might be more successful if the interventions align with the preferences of the client (Hansen, et al., 2015). It may be that the sudden gain clients were a better fit for psychotherapy as they displayed the ability to beneficially engage with psychotherapy, make use of therapeutic interventions and start to speak the language of psychotherapy. (Hansen, et al., 2015). In contrast, poor outcome clients tended to endorse negative aspects of psychotherapy, particularly SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 55 in areas that seemed to be helpful to other clients like empathy and positive affirmation but seemed to elicit the opposite reactions in poor outcome cases (Hansen, et al., 2015) It is important to keep in mind that the experiences of clients in the research studies might not speak for the experiences of all other clients participating in psychotherapy (Swift et al., 2017). Even the individual clients within couples’ therapy may have different perspectives on which events were significantly helpful (Helmeke & Sprenkle, 2000; Timulak, 2010) and this indicates that different therapeutic aspects may appeal to different individuals. Moreover, there are various ways in which subgroups of clients may change including those who change positively and rapidly, those who change positively and steadily, those who stay the same and those who show a deteriorating course of change (Erekson et al., 2018). Therapist variables. Often when clients described personal characteristics of psychotherapists as critical change agents, it was mostly of how the characteristics manifested within their professional role (Binder et al., 2009). In studies of good outcome cases, the psychotherapist was able to use complex interpretations, which is a way to make connections between distinct parts of the client’s experience (Timulak & McElvaney, 2013). The psychotherapist should be gentle and collaborative whilst they make an interpretation (Elliott, 1983). It may also be that a psychotherapist can make an incorrect interpretation or an erroneous judgment of a client, however, these improper interpretations may at times prove to be helpful (Timulak & McElvaney, 2013). In most studies, the important qualities of psychotherapists’ were that they were comforting, validating, provided reframing to the client and worked in collaboration with the SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 56 client where the goal was to create opportunities where the client could have positive experiences (Timulak & McElvaney, 2013). The following psychotherapist factors were reliably related to positive changes: Empathy, warmth and genuineness. During significantly helpful events, the psychotherapist is able to maintain an environment where the client feels safe and cared for so that the client is able to productively engage in psychotherapy (Timulak, 2010). Furthermore, it was found that empathy and empathic understanding, as well as reflection, are crucial in facilitating a restorative experience (Timulak, 2010; Timulak & McElvaney, 2013). Various studies highlighted the importance of a psychotherapist’s warmth, empathy, genuineness, and presence, including empathic understanding and affirmation of the client (Binder et al., 2009; Hansen, et al., 2015; O’Halloran et al., 2016; Timulak, 2010). Qualities that were highly valued in one study of a ‘supershrink’ were her ability to validate, her ability to relate to a client’s pain, her kindness, her personal nature, her acceptance of clients as people and a degree of spirituality (Hansen, et al., 2015). In this study, all the clients were equally appreciative of the psychotherapist’s way of being with them and her distinctive presence, they commented on her spiritual nature: ‘she has this aura about her’ and the importance of feeling comfortable before discussing difficult issues. One client noted her skill to empathise based on her own past experiences and the compassion she exuded (Hansen, et al., 2015). Yet in another study, clients mentioned that the most important mechanism during certain times in psychotherapy was that the psychotherapist was ‘there’ and not necessarily her interventions as such (Binder et al., 2009). Through an affirmative presence and a growth promoting attitude, psychotherapists are capable of facilitating the process by which problematic issues can be explored (Timulak, 2003). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 57 Therapist affirmation, at the correct time, may be an important component in certain forms of client empowerment (Timulak, 2003). Furthermore, psychotherapists may take a humanistic, supportive stance by following the pace as set out by the clients and prioritising the clients’ background to allow therapeutic movement and set the foundation for narrative change (Cunha et al., 2012). Other researchers proposed that psychotherapists are able to resolve shame by exhibiting an open attitude and noncritical stance (Timulak, 2010; Sousa et al., 2018). Finally help and support provided by psychotherapists and their style of conducting psychotherapy are also helpful contributions to the therapeutic process (O’Halloran et al., 2016). Reformulation of the story. The capacity of the psychotherapist to listen to a story that the client considered to be very difficult or shameful and allowing the client to complete this story in a way that resolved the embarrassment and discomfort, is seen as helpful (Grafanaki & McLeod, 1999). The therapeutic process provides a way to reformulate their story by co-construction between psychotherapist and client where the psychotherapist needs to exhibit an awareness of the client and be fully engaged in the experiential reformulation of the narrative (Sousa et al., 2018; Timulak, 2010) A central category which emerged from analysis of this material was that of psychotherapist as audience (Grafanaki & McLeod, 1999). Clients gave high helpfulness ratings to events where they felt that the psychotherapist understood their story and low ratings to occasions where they experienced the psychotherapist as failing to appreciate the meaning of their narrative (Grafanaki & McLeod, 1999). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 58 Being fully aware and in-tune with the client. Important psychotherapist factors of being fully aware in sessions includes being in-tune with the clients’ experience, regularly checking in with clients, continually monitoring their distress levels, being watchful for signs of disappointment, or feeling misunderstood (Safran & Muran, 2000; Timulak, 2010). Hansen et al. (2015) demonstrated that active engagement with the client's concerns, typically resulted in better outcomes and highlighted aspects such as well-timed identification and affirmation of the clients ideas, as significant in this regard (Timulak, 2003). Timulak (2003) further stated that the psychotherapist needs to be alert to identify and acknowledge the client’s achievements and Cunha et al. (2012) similarly contends that observing how the client react to learning new skills, may guide the prediction of therapeutic outcome. Likewise, the psychotherapist needs to be fully aware of the vulnerability that the client experiences during an event (Elliot, 1983; Timulak, 2010). In the study by Hansen et al. (2015) it was shown that the psychotherapist was always open to new possibilities to improve client outcome whilst also gathering data on the client's response to treatment. This dynamic and frequent feedback loop between the client's responses and the therapists’ interventions within the session, aids her to rapidly adjust therapeutic techniques so that she is able to meet the current needs of the client (Hansen et al., 2015). Indicating the benefit of being constantly aware and in-tune with the client. Allow autonomy of client. The psychotherapists with very high success rate hold at the forefront of their mind the principle that clients are largely in control of their own change processes and they values this autonomy and independence (Hansen et al., 2015). Timulak (2010) suggest that the psychotherapist should allow the client to play an active role. Similarly, the psychotherapist can help the client explore specific possible actions (Timulak, 2003). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 59 Empowering clients to find their own solutions is a practical approach that may lead to change and does not require lengthy treatment (Hansen et al., 2015). During certain empowering events the psychotherapist’s helps to give a voice to a suppressed part of the client’s self so that emergent empowerment may result as a consequence (Timulak, 2003). Competence and skills of psychotherapist. The psychotherapist should make meaningful contributions to the session by actively selecting and applying skilful interventions in a caring manner (Timulak, 2010; Timulak & McElvaney, 2013). Various studies related psychotherapist features like being perceived as wise, competent, knowledgeable and credible to positive changes (Binder et al., 2009; Hansen et al., 2015; Sousa et al., 2018). Clients highlighted the importance of psychotherapists displaying a professional stance and using specific skilled methods and techniques (Binder et al., 2009; Sousa et al., 2018). Especially in displaying a balance between professional conduct and being personal and flexible (Binder et al., 2009). One psychotherapist with a very high success rate was described as an active problem solver with a highly efficient therapeutic approach (Hansen et al., 2015). The psychotherapist’s personality and competence in communication and interpersonal level had a big influence on the outcome of psychotherapy (Wampold, 2001). Moreover, clients did not seem to place as much importance on the specific theoretical orientation or the modality of psychotherapy (Binder et al., 2009). The psychotherapist seems to make a valuable contribution to the clients’ psychotherapy process by their capability to manage the process and give guidance (O’Halloran et al., 2016) as well as using reflection in a skilful manner (O’Halloran et al., 2016). Yet another psychotherapist SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 60 skill that features prominently in research, is the contribution that psychotherapists could make to the process of psychotherapy through increased self-care (O’Halloran et al., 2016). Able to establish a therapeutic relationship. It is shown that a certain modality’s power for change is always limited in comparison to the personal influences of the psychotherapist and better outcomes were associated with a strong therapeutic relationship, creative approaches to a client's problems, as well as giving a credible rationale and ritual that matched her or his symptom presentation (Hansen et al., 2015). Sousa et al. (2018) also emphasised the ability of the psychotherapist to establish an authentic, human relationship and actively collaborating in the therapeutic process as valuable factors for change to occur. Factors related to the psychotherapist's personality and approach in psychotherapy that they found helpful in making changes was her ease of connecting, being able to discuss things that needed to be worked on, forming easy rapport and establishing trust (Hansen et al., 2015). Further, client descriptions of their therapeutic relationship depicted a psychotherapist with charisma, with the ability to make a strong, immediate connection, with a clear and persuasive plan for change - based on both medical and psychological principles -and with an expectation of quick change (Hansen et al., 2015). Psychotherapists that engaged in self- disclosure also showed elevated connection with clients (Sousa et al., 2018). Instillation of hope. In one example, the client experienced that the psychotherapist carried hope on her behalf and felt that her existence depended on the idea that the psychotherapist will carry the hope throughout the therapeutic process (Binder et al., 2009). Similarly, other studies stated that the psychotherapist needs to maintain the hope for change (O’Halloran et al., 2016), whilst clients commented that merely talking to the psychotherapist made them feel more hopeful (Piazza-Bonin et al., 2016). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 61 Some interventions might raise hopefulness, which can be a powerful facilitator of change, for instance providing a holistic, top-down view of the client’s psychopathology in the first session, so that they have a working rubric to organise their symptoms and seek to find solutions in a timely period (Hansen et al., 2015). It is assumed that sudden gains may cause an upsurge in clients’ hope and satisfaction in the therapeutic process (Wucherphennig et al. 2017). Able to help client explore emotions. Effective psychotherapists are able to validate the client’s emotional experiences. The manner in which the psychotherapist handles painful emotions, is also very valuable in understanding what clients perceived as helpful (Sousa et al., 2018). A very successful psychotherapist displayed a particularly effective way to communicate her understanding of pain and was able to demonstrate to clients that facing and learning to handle pain may be an important aspect of therapeutic change (Hansen et al., 2015). The ability of the psychotherapist to understand and explore their own emotions may help them to help their clients to explore their own emotions (O’Halloran et al., 2016). Moreover, during significant events in psychotherapy, psychotherapists assisted their clients in exploring their emotions, needs and concerns and led the clients to follow their own path as experienced during the tasks in psychotherapy (Timulak, 2003). In particular, they noticed that psychotherapists who direct the client's attention to the client's own personal internal experiences are more likely to have successful outcomes (Hansen et al., 2015). Although many different therapist operations may be helpful in psychotherapy (Timulak, 2003) certain therapist variables might be ethically questioned within various helpful cases, such as, meeting with the client after hours; walking with the client to get food after a session; hugging the client; giving out their personal phone number; etc. (Bedi et al., 2005). However, these examples were taken out of context and it is challenging to determine what the therapeutic SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 62 rationale for such actions might have been (Bedi et al., 2005). Also, there is an indication that psychotherapists may overvalue their impact in psychotherapy and clients might not value the impact that the psychotherapist has within-therapy enough - based on the prominence clients placed on the role of extra-therapeutic factors (O’Halloran et al., 2016). Subtheme 2: Context. Helpful events could either occur within or outside of sessions, for example, during a psychotherapy session new discoveries and insights can be made, whereas events may take place outside of psychotherapy that has a big impact on the client and may be discussed or reflected on in the next psychotherapy session (Nasim et al., 2018). Research found that a reduction in depression in both a client-directed expressive writing treatment as well as therapist-guided psychotherapy (Lorenz et al., 2013), concluding that change may take place within or outside of psychotherapy sessions. Within-session. In order to anticipate the kind of change that may lead to a client’s recovery it may be valuable to detect dramatic change within psychotherapy to steer treatment planning in a beneficial direction (Erekson et al., 2018). Evidence widely supports the effectiveness of psychotherapy, for example, Hardy et al. (2005) suggested that sudden gains may be part of the course of recovery from depression and part of the psychotherapeutic process and, therefore, might not be caused by external life events. Timulak (2003), however warned that psychotherapists needs to be cautious to place too much emphasis on helpful events as instances of within-therapy change (Timulak, 2003). Quick et al. (2018) described various aspects including, the clients presenting problem; the psychotherapist’s intervention to the presenting problem; and the direct in-session influence as the event. Within one session a substantial amount of variation may occur where clients experienced numerous ups and downs (Swift et al., 2017). However, it is proposed that SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 63 symptomatic distress seems to change steadily throughout psychotherapy, although phases of vigorous variability may take place and a new steady level of functioning may be a consequence thereof. This type of dynamic instability might happen within a single session or occur over a number of sessions (Koffman, 2018). Helpful fragments within sessions were related to clients gaining valuable new insight and knowledge as well as the experiencing thereof that the psychotherapist is listening attentively with comprehension or understanding (Swift et al., 2017). Client also reported feelings of connection with the psychotherapist as helpful within psychotherapeutic sessions, as supported by numerous studies (Koffman, 2018; Timulak, & McElvaney, 2013; Swift et al., 2017; Wucherpfennig et al., 2017). In a typical helpful insight event, the client worked through insight by expanding on it, making links, or reflecting on consequences thereof in session. Various other impacts were also experienced, like relief, avoidance of painful emotions and conflict with the psychotherapist, whereby the client started to feel hopeful about the psychotherapy in its entirety (Timulak & McElvaney, 2013). Clients also recognised the significance of in-session interventions that are strength-based with skill building and expansion of knowledge building (O’Halloran et al., 2016) In one study, themes related to the content and structure of therapeutic sessions were identified by clients and psychotherapists alike and made up one of the domains as identified by O’Halloran et al. (2016). Helpful material in sessions, activities and in-session efforts that assisted clients to gain new skills, are examples of what clients reported in this domain. Furthermore it involves aspect such as how the psychotherapy session is organised, how sessions are scheduled, what happens during the session and how these factors may contribute to a client’s psychotherapy and are grouped together as follows: 1) content and structure; 2) acquiring SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 64 skills; 3) thinking back; 4) challenging client’s behaviour; 5) implication or outcome; 6) difficult work; 7) identifying goals in life; 8) leaving sessions stronger; 9) power and control; and 10) focused attention (O’Halloran et al., 2016). Outside-session. Helpful events that occur outside of therapy may facilitate change in the client (Bedi et al., 2005; Binder et al., 2009) and clients are able to describe how events external to psychotherapy had an effect on their change process (O’Halloran et al., 2016). Moreover, outside events may also be associated with helpful events that occur within psychotherapy. For example, work external of the psychotherapeutic session such as, implementing and completing homework assignments in order to apply psychotherapeutic principles to the daily life of the client (Timulak & McElvaney, 2013) may lead to discussion within sessions and resulting in lasting change. In addition, Jensen et al. (2013) indicated that reviewing homework at the start of sessions may assist the therapist in tracking the clients’ development and that the daily exposure outside of therapy may bring about change. As therapy progresses it also seems that the connection between psychotherapeutic events and extra-therapeutic events changes, so that skills learned within treatment is linked to positive changes in day to day functioning (Hansen et al., 2015). Another aspect of significant events that happened outside of psychotherapy was discussed by Bedi et al. (2005) as contact between psychotherapist and client in a non- professional manner, such as walking to a coffee shop together after a session where after they go their separate ways. Clients appears to view these extra actions as beneficial to the psychotherapeutic relationship, although psychotherapists might be engaging in these behaviours for their own benefit (Bedi et al., 2005). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 65 Subtheme 3: Timing. Research proposes that it is possible to identify whether or not psychotherapy will be successful from as early as the first few sessions (McCarthy et al., 2017). Moreover, change between the first and last session was anticipated by early overall progress (Koffman, 2018) and it was found that the majority of dramatic change took place before the tenth session and usually within the first three sessions (Erekson et al., 2018). With regard to the duration of treatment, Piazza-Bonin et al. (2106) found that six sessions of psychotherapy might be insufficient to integrate the new versions of self, as well as the performing of new goals and activities related to this change. Research in cognitive based therapy has also shown that significant events are specifically important as they show that clients with no improvement up to the fourth session will also have the least improvement 12 months after psychotherapy is terminated (McCarthy et al., 2017). Along the same lines, findings about significant events indicated that key moments may already take place in the early sessions of psychotherapy and that changes in emotions and cognitions can be observed during these initial sessions (McCarthy et al., 2017). In all dramatic change, the bulk of clients experienced dramatic change in the first three sessions, except for sudden gains, which were more likely to take place somewhat evenly throughout psychotherapy (Erekson et al., 2018). However, the majority of clients experienced a sudden gain within the first half of treatment (Wucherpfennig et al., 2017). Yet another study, including 147 clients, determined that the clients that made the most progress experienced the change to occur within the first three sessions and they remained the most improved six to 24 months later (Koffman, 2018). Researchers implied that sudden gains in later therapeutic sessions produce poorer results than those experienced early on (Wucherpfennig et al., 2017). Clients who experience sudden SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 66 gains presented with longer treatment periods and, although variation in time points of sudden gains occur, it does not diminish the link between sudden gains and treatment outcomes (Wucherpfennig et al., 2017). It seems that clients have a tendency to achieve their most important gains before the majority of the therapeutic work has been done. In one study, all of the clients with successful outcomes experienced sudden gains very quickly (most of them already in the second session), with all of them making a sudden gain by the fourth session. In comparison with other studies where sudden gains were reported by session five or six (Hardy et al., 2005; Stiles et al., 2003). Furthermore, two other studies found the eighth session to be the average session for the occurrence of such sudden gains (Tang et al., 2005; Vittengl et al., 2005; Hansen et al., 2015). However, another article mentioned that 32% of clients already made a sudden gain after the second session or subsequent sessions (Koffman, 2018). One study with a sample of five clients with positive dramatic change, the changes seemed to transpire very rapidly in advance of any explicit cognitive or behavioural work. On the contrary, the clients with less dramatic change, mostly experienced sudden losses much later in psychotherapy (Hansen et al., 2015). With regard to IMs, low level IMs seemed to be more prominent during the first stages of treatment, while high level IMs, where the most change occurred, appeared more often from the later stages of treatment (Nasim et al., 2018). One study grouped action-, reflection and protest IMs together (as ARP IMs) and this group seemed to be more present in the initial and middle phases of psychotherapy where exploration and insight interventions usually preceded these IMs. Moreover, this study also grouped re-conceptualisation and performing change IMs together (as RCPC IMs) and this group was more present during the middle and final phases of SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 67 psychotherapy where insight and exploration skills also precede them – which often occurs in good outcome cases (Cunha et al., 2012). Subtheme 4: Impact. Impact may be described as the instant personal impression of the session on the client, by taking their appraisal of the session, their evaluation of the nature of the session and their affective state at the conclusion of the session into consideration (Nasim et al., 2018). In significant events, different therapeutic processes lead to diverse types of helpful impacts with the specific need of the client and how the psychotherapist responds to it, as the main indicators (Timulak, 2010). Psychotherapy clients recalled interventions similar to those identified by Timulak (2007), which contained helpful impacts during psychotherapy sessions (Quick et al., 2018). Certain responses made by clients indicates that the helpful impact may be located in the processing, although it does not define the manner of processing. In addition, other responses by clients suggested ‘voicing’ to be the impact that include examples such as: ‘because I was able to get it off my chest…’ and ‘because I said it out loud’. These reactions seem to point toward the process of ‘voicing’ as an important impact (Quick et al., 2018). Post session, there are two factors that may be used in order to assess the impact of the session, namely: 1) evaluation - consisting of depth and dimension; and 2) the client’s mood - consisting of level of positivity and arousal (Nasim et al., 2018). At times, empowering impacts and painful impacts might both occur at the same time during significant events (Timulak & McElvaney, 2013). In order to view an event as helpful, the client’s reflection on that event should consider that the impact of the event lead to an intentional meaning shift as the client was able to make new connections (Timulak & McElvaney, 2013). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 68 The main impact of these events were self-assertion at the level of the client manifesting in an increased awareness into their needs and desires. Whist clients might feel understood and supported, they may also be cognisant of unfulfilling and painful factors that still needs to be dealt with. Different impacts emerged from the perspectives of psychotherapists and clients, for instance, in one reflection the client emphasised problem clarification and the psychotherapist emphasised problem solution (Timulak & McElvaney, 2013). Similarly, another author concluded that impact could be related in terms of a number of categories, which includes, but are not limited to: therapeutic relationship and cognitive-; emotive-; behavioural-; and motivational in-session outcomes (Sousa et al., 2018; Timulak, 2010). Furthermore, it is important to highlight that although an events main impact might seem to be cognitive or emotive, the interpersonal context still had the most significant influence on the impact (Timulak, 2010). Furthermore, it is also essential to note that one event may have several different impacts on the client (Timulak, 2007). Subtheme 5: Outcome. Within the significant research paradigm, an event is described as containing the presenting problem of the client, the intervention from the psychotherapist to the presenting problem and the direct outcome of the session on the client (Quick et al., 2018). It seems as if dramatic change is a significant element in change throughout psychotherapy and where dramatic change is experienced it is more likely that clinically relevant improvement will be experienced by the end of psychotherapy (Erekson et al., 2018). Improvement early in the therapeutic process predicts a lower intensity of distress about 42 sessions later and is a valuable predictor of improvement later in psychotherapy (Koffman, 2018). Outcomes of early dramatic responders have been significantly better than those who have not experienced early dramatic change (Erekson et al., 2018; Koffman, 2018). The long- SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 69 term outcomes of rapid-responders found that they tend to maintain their gains (Hansen et al., 2015). All shifts predict outcome regardless of the improvement early in psychotherapy, the type of psychotherapy and the duration of treatment. Thus, Koffman (2018) found that outcome was not predicted by these three factors. A swift symptom improvement produces hope and increases commitment to psychotherapy, even more so if the improvement can be ascribed to the intervention or the client’s ability. Consecutively, hope and commitment may increase satisfaction with psychotherapy and therefore strengthen the therapeutic alliance and bond between the client and psychotherapist (Wucherpfennig et al., 2017). Taking personal responsibility seems to be another positive outcome of psychotherapy and an actual mechanism of change (Hansen et al., 2015). An upward spiral of recovery may be the result when certain psychotherapists use a sudden gain moment to reinforce the self-efficacy of the client (Wucherpfennig et al., 2017). Similarly, certain events may promote an improved therapeutic connection and impacts of events may be accumulative as they build upon one another and contribute to outcome (Sousa et al., 2018). Clients seem to place a lot of importance on how they are perceived by the psychotherapist and how the psychotherapist is treating them in relation to the presenting problem being addressed in psychotherapy. Emotional experiencing is also important during psychotherapy as clients may terminate psychotherapy if they experience it as too difficult to cope with, even if it seems to be helpful (Sousa et al., 2018). Research indicates that better outcomes are strongly related to the quality of the therapeutic relationship, to innovative approaches used during psychotherapy and to being able to formulate a sound and reliable explanation for the clients presenting problem (Hansen et al., 2015). As an example, one client SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 70 reflected on her psychotherapeutic process as a relationship that transformed her entire world- view (Binder et al., 2009). The outcome of psychotherapy is described according to the different change process concepts in numerous studies, such as percentage improvement- 50% (PI-50), IMs, sudden gains and insight events, to be discussed further independently. According to Erekson et al. (2018), PI-50 is one of the first criterion for change used in psychotherapy research and is used to describe a symptom decrease that is larger than or equal to 50% of the baseline level. In their study, rapid response, sudden gains and PI-50 each displayed a statistically significant effect on the outcome of psychotherapy (Erekson et al., 2018). Erekson et al. (2018) found that PI-50 was the best predictor of final outcomes in psychotherapy. Very noteworthy is a finding that indicates that if a client meets the criteria for PI-50, they tend to end psychotherapy 30 times more likely to recover than clients who did not experience PI-50 and they are almost 12 times more likely to maintain a general higher level of improvement (Erekson et al., 2018). In previous research, it was shown that IMs were related to outcomes and the occurrence of high-level IMs was the main predictor of the outcome (Batista et al., 2019). Furthermore, it was emphasised that IMs occurred more often in good outcomes than poor outcome cases (Cunha et al., 2012). It was indicated that action-, reflection- and protest IMs are required for the process of change but further, more complex IMs are needed in order to consolidate this new narrative (Cunha et al., 2012). Even though IMs typically occur throughout the course of psychotherapy in good outcome and poor outcome cases, the good outcome cases contain much more IMs than the poor outcome cases and the patterns of these IMs are different (Cunha et al., 2012). In good SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 71 outcome cases the action-, reflection- and protest IMs occur in the early and middle phases and progress into the more complex re-conceptualisation and performing change IMs. Poor outcome cases, on the other hand, remain within the primary IMs throughout the course of treatment (Cunha et al., 2012; Piazza-Bonin et al., 2016). Looking at IMs occurring in narrative therapy and emotion-focused therapy, it is suggested that re-conceptualisation and performing change IMs occurs more often in good outcome cases. In client centred therapy, however, performing change IMs occur in both types of outcomes (Cunha et al., 2012). In good outcome cases, it appears that productivity of learnt skills during the middle phases of psychotherapy is maintained into the final phases, whereas it occurs in the middle phases of poor outcome cases but are not carried over to the latter stages of treatment (Cunha et al., 2012). A poor outcome may occur when clients do not engage in active interventions in the earlier phase of treatment and do not respond to the active interventions with IMs (Cunha et al., 2012). According to Lorenz et al. (2013), clients with sudden gains displayed far greater improvements than the clients without such gains. It is postulated that a long lasting upward spiral is triggered by sudden gains experienced in sessions (Wucherpfennig et al., 2017). Clients who have had a sudden gain in psychotherapy are significantly more likely to show an overall recovery from their depressive symptoms towards the end of psychotherapy (Goodridge & Hardy, 2009). In addition, sudden improvements predicted better treatment outcome at termination and clients that sustain sudden gains accomplish better outcomes than clients without sudden gains (Koffman, 2018; Wucherpfennig et al., 2017). Clients with sudden gains were expected to have SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 72 about 2.69 times higher level of improvement and significant changes at the end of psychotherapy than clients without sudden gains (Erekson et al., 2018). In addition, Hansen et al. (2015) revealed that of all clients that experienced sudden gains, 79% of clients presented with sub-clinical symptomology at the end of psychotherapy whilst only 41% of clients in the contrast group showed sub-clinical symptomology afterwards. The positive correlation between sudden gains and outcome might be due to clients making significant progress and therefore being more prone to be recognised (Koffman, 2018). In some cases, more than half of all symptom improvement has been shown to be a consequence of sudden gains and it appears to have many benefits. For example: faster improvement; better long-term outcomes; a diminished likelihood of relapse; or longer duration of time for relapse to occur (Lorenz et al., 2013). It is also highlighted that long term treatment outcome is predicted by processes taking place before a sudden gain, such as the clients verbalising more hope and emotional processing, in response, sudden gains trigger hope and satisfaction with treatment (Wucherpfennig et al., 2017). It is expected that clients that experienced sudden gains, will undergo significant increases in their therapeutic alliance and coping skills in sessions following the sudden gain. In addition, they experience an increase belief in their ability to accomplish their therapeutic goals (Wucherpfennig et al., 2017). Sudden gains in one session are correlated with elevated levels of therapeutic relationship and coping skills in subsequent sessions (Wucherpfennig et al., 2017). Insight events. The client’s experience of an insight is considered an important in-session outcome of psychotherapy as well as a major change in self-understanding as a result of psychotherapy (Timulak & McElvaney, 2013). An in-depth investigation of insight events could capture how change can be activated and stimulated. With skilful intervention, important SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 73 outcomes may possibly be created (Timulak & McElvaney, 2013). Particularly in psychodynamic psychotherapy, increased insight within psychotherapy is associated with long- term outcomes (Timulak & McElvaney, 2013). Negative outcomes. One study found that the ‘disappointment with therapists' interventions’ events related harmfully with psychotherapy outcome (Timulak, 2010). It was also observed that the more serious the symptomatology at the start of psychotherapy, the poorer the outcomes and the longer the treatment (Hansen et al., 2015). Contrary to the abovementioned aspects of outcome, some researchers suggested that there might not be a strong link between significant events and treatment outcome. Furthermore, they indicated that clients without shifts did not improve slower than those with shifts and that the average client displays a gradual improvement during treatment (Koffman, 2018; Sousa et al., 2018, Timulak, 2010). Theme 3: Therapeutic Intervention Hansen et al. (2015) emphasise that the outcome of psychotherapy is likely to be more successful if the interventions accurately match and relate to the preferences of the client. In a variety of psychotherapeutic modalities, for instance: constructivist grief therapy; client-centred therapy; narrative therapy; cognitive behaviour therapy; and emotion-focused therapy, recovered clients experienced more IMs than their unchanged counterparts (Batista et al., 2019). O’Halloran et al. (2016) classified data into six domains based on themes and each domain signifies an individual feature of the significant events within psychotherapy. The themes are: (a) the process of psychotherapy; (b) making changes and progress in psychotherapy; (c) content and structure of psychotherapy; (d) psychotherapist contributions; (e) negative contributions to psychotherapy; and (f) other factors (O’Halloran et al., 2016). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 74 Subtheme 1: Cognitive awareness. The treatment process offers opportunities for the clients to achieve clearer perspectives by gaining insights and self-awareness about their presenting problem, which may produce cognitive-, emotional- and behavioural effects (McCarthy et al., 2017; Sousa et al., 2018). Factors that may stimulate the improvement of awareness and lead to forming new meanings about past experiences, includes: 1) being able to express their feelings in words; 2) a safe environment; 3) experiencing alleviation from distress; 4) to form a trusting alliance with the psychotherapist; 5) to be actively involved in the therapeutic process; and 6) to recount their experiences (Sousa et al., 2018; Timulak & Keogh, 2017). According to Sousa et al. (2018), clients identify increased awareness by identifying underlying meaning patterns as forming part of significant change events. This is supported by Timulak (2010), also highlighting increased awareness as a significant event in the context of experiential- and psychodynamic psychotherapy. Some forms of insight and awareness, as well as problem solution, were seen in most helpful events. In addition, a high occurrence of interpersonal impacts may also be present, such as feeling understood (Elliott, 1985; Llewelyn, 1988; Timulak, 2010). Quick et al. (2018) found that helpful factors often highlighted by cognitive behavioural therapy clients, include insight and awareness; behavioural change, problem solution and empowerment. It is important that psychotherapists prepare clients for insight to occur and, in order to facilitate such preparation, elements such as a good therapeutic relationship, a higher level of emotional arousal and clients seeking better self-understanding, may serve as an indicator for work on insight to ensue (Timulak & McElvaney, 2013). Psychotherapist aspects such as reflection and empathy may encouraged clients’ self-insight (Timulak & McElvaney, 2013). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 75 Thus, interventions reported in the reviewed studies to improve insight and awareness, seem to be vast and diverse. Therapeutic techniques found to be beneficial by some clients seem to be whether material in sessions are useful and how this material and in-session work assisted clients to think back and to gain new skills (O’Halloran et al., 2016). Clients seem to gain significant realisations and insightful links following certain work-enhancing interventions (Lepper & Mergenthaler, 2007). Clients may experience that the psychotherapist is giving a voice to their feelings when the psychotherapists’ make use of metaphors that resonate exactly with the clients’ circumstances (Grafanaki & McLeod, 1999). Grafanaki and McLeod (1999) suggested that it is essential within psychotherapy to concentrate on clients’ stories because critical moments in psychotherapy may be linked to the appearance of a new storyline (Grafanaki & McLeod, 1999). The manner in which an interpretation (specifically transference interpretations) is conveyed seems to be important because clients reported interpretations as one of the main helpful events (Timulak & McElvaney, 2013). Cognitive restructuring correlate with low-level IMs as they activate change in clients by helping them to gain a new comprehension of the problem, which allows them to use improved actions or to express new feelings (Batista et al., 2019). In other words, these IMs enable the client’s separation from the problem however it does not stimulate a new framework by themselves (Batista et al., 2019). Subtheme 2: Thought restructuring. Thought restructuring still forms part of the low level IMs. The first form of IM, namely contrast, allows the client to realise the difference between past dysfunctional positions and more adjusted positions and see the positive SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 76 consequences of the adjusted position (Batista et al., 2019). The second form of IMs, namely process, helps the client to describe the different ways of being, such as, partaking in new actions and experiencing new feelings, as well as different ways to handle relationships (Batista et al., 2019). Action skills in all phases of psychotherapy, were related to action, reflection, and protest IMs in all good outcome cases. These skills may provide valuable assessment of whether the psychotherapy is developing correctly, although they may become less important as psychotherapy progresses (Cunha et al., 2012). Events may occur where the client advances to a new way of dealing with their issue and repetition of this newly found pattern may lead to more lasting change (Nasim et al., 2018). One of the themes emphasised by Binder et al. (2009) was having beliefs about oneself and one’s relational world corrected and having beliefs about a significant person in one’s life corrected. This theme is frequently seen as a core component of psychotherapy, particularly by psychotherapists’ with a cognitive stance (Binder et al., 2009). Jensen et al. (2013) illustrated, through a specific case study, how a client found video footage of herself (as an exposure exercise) very helpful, as it guided her toward a corrected image of herself in a field perspective which led to significant impact. The corrected image may have helped the client to understand and accept her blushing to a better degree as she saw for herself that she did not look the way she had once imagined (Jensen et al., 2013). Facilitating client narrative changes may also be valuable as a way of arranging and securing other changes such as the representation of new emotions as well as assisting in the narrative reconstruction of the self (Cunha et al., 2012). Binder et al. (2009) reflects on one client, undergoing psychodynamic psychotherapy, explained that the most important contributor to her successful treatment, was that she felt SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 77 changes in how she saw other people by exploring her childhood events with the psychotherapist. Another client described her most significant insight when she was confronted with the facts of how she allowed herself to be dominated by how others viewed her (Binder et al., 2009). Yet another client commented that exploration of important meaning patterns that was linked to her experiences as a child allowed her to also share the content of her psychotic events (Binder et al., 2009). Subtheme 3: Emotion experiencing. Literature indicates a course of change that starts with the initial experience of negative or unpleasant emotions that leads to problem exploration, after which there is an increase in positive emotions which in turn enables the phase of problem is solving (McCarthy et al., 2017). A key intervention includes guiding clients’ towards the expression of underlying pain (Timulak & McElvaney, 2013). It seems that by connecting thoughts with feelings assist clients in understanding the reasons behind their emotions and through this newfound understanding, clients’ experience an increased sense of relief (Hansen et al., 2015). In the study of McCarthy et al. (2017), it was discovered that there were more negative emotions observed during change moments. They reiterated that all positive and negative feelings need to be completely worked through in psychotherapy (McCarthy et al., 2017). Significant change events, in this study, portrayed positive as well as negative feelings and mainly included: anger and sadness. In addition, language that suggested more unpleasant emotions were reported more frequently during change events (McCarthy et al., 2017). Grafanaki and McLeod (1999) found, from several event descriptions collected during their study, that clients‘ feelings shifted as their stories were being told. Particularly when clients experienced intense feelings, confusion and inner incoherence, the steadiness provided by the SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 78 therapeutic relationship (with an emotionally stable person) seems to be a very important source of hope and security (Binder et al., 2009). Clients described the function of undergoing a corrective emotional experience as significant to their treatment process (O’Halloran et al., 2016). For some clients gaining ‘new meaning’ as part of the therapeutic work appears to be very important, as formerly, there has been chaos and confusion in parts of their self-experience and their emotional life (Binder et al., 2009). Clients who used positive emotion words and vocabulary, displayed insight to a greater degree and, consequently, reported better health outcomes (McCarthy et al., 2017). According to the broaden-and-build theory, positive emotions broaden an individual’s momentary thought- action repertoire by promoting the discovery of new ideas and consolidation of interpersonal connections, which then again strengthens the clients’ ability to deal with distress (Fredrickson, 2004; Wucherpfennig et al., 2017). Theory propose that negative emotional language enables the appearance of problematic material, while positive emotions starts the problem solving process of significant event (McCarthy et al., 2017). Different interventions seem to lead to emotional experiencing and the ability to work through difficult emotions. Significant moments in therapeutic sessions seems to be collaborative sequences in which clients communicate their emotions or make insightful connections and psychotherapists’ consequently utilises interpretive interventions (Lepper & Mergenthaler, 2007). More clients in cognitive behavioural therapy related with categories of empowerment and exploring feelings or emotional experiencing as helpful, than clients receiving integrative psychotherapy (Quick et al., 2018) SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 79 One case study focused on a client with strong negative emotional problems and anxiety about her blushing. Previously the client used suppression and over-control as an emotion regulation strategy when faced with anxiety provoking situations. After exposure exercises, she started to gradually endure her blushing as well as the corresponding negative emotional responses (Jensen et al., 2013). Subtheme 4: Cognitive disengagement. By recognising the strategies and processes that a client links with their changes, the client is encouraged to take a self-observing, metacognitive perspective, which relates to better self-understanding and general improvement in psychotherapy (Batista et al., 2019). Cognitive perspective into positive and negative emotional functioning is important in the therapeutic process (McCarthy et al., 2017). As soon as clients start describing events where they have used a different way of coping, high level IMs start to occur, likewise if they are able to describe how events/actions /thoughts are different from before (Batista et al., 2019). Re-conceptualisation IMs consists of two parts, first, it entails a shift in the clients’ position toward the problem from past to present and the client needs to be aware of this shift. Secondly, the client has the ability to explain the process leading to the change. Therefore, equating re-conceptualisation IMs with ‘meta-reflection’ (Gonçalves et al., 2011; Piazza-Bonin et al., 2016). When the psychotherapists detect that clients are prepared to receive an interpretation, they start by connecting the material of the present session with that of the previous sessions, usually by reflecting on the emotions already aroused (Timulak & McElvaney, 2013). It is described as linking past reactions and emotions with current emotions and actions in order to bring forth change in the future (O’Halloran et al., 2016). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 80 A common answer from recovered clients, was that the experience of gaining skills to cope with problems and an understanding of their problems, assisted them to approach life in a new and more flexible way (Binder et al., 2009). Clients that develop a flexible and integrated view of themselves, through psychotherapy, may experience subsequent changes in their relational schemas (Batista et al., 2019). Subtheme 5: Interpersonal. Timulak (2010) mentions that interpersonal impacts, such as feeling understood or reassured, played a big part in clients’ therapeutic process (Timulak, 2010). In effective psychotherapies, the clients and psychotherapist collaborate and decide together on relevant themes to discuss (Lepper & Mergenthaler, 2007). Moreover, there exists a co-construction between psychotherapists and client of an underlying and integrative narrative of what occurred in psychotherapy (Grafanaki & McLeod, 1999). It seems that the co-construction of the story of psychotherapy is significant to clients (Grafanaki & McLeod, 1999). By focusing on the core problem in psychotherapy, usually intra- or interpersonal by nature, creates the right setting for helpful events to occur (Timulak & McElvaney, 2013). The quality of the communication between psychotherapist and client has clinical value. There are significant links between the interactional process of psychotherapy, in-session impacts and outcomes (Lepper & Mergenthaler, 2007). The interpersonal aspects of participating in a psychotherapy seem to have a significant impact on clients’ change process. Yet another interpersonal aspect of psychotherapy, is the psychotherapist modelling suitable behaviours during the psychotherapeutic process (O’Halloran et al., 2016). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 81 Theme 4: Therapeutic Relationship The therapeutic relationship, or alliance, seems to play an important role in the understanding of change in psychotherapy, since most of the articles included in this review, included and discussed it at some point (although at times with much brevity). All of the articles, mentioning therapeutic relationship at some point, related a positive therapeutic bond to a positive impact and outcome (Hansen et al., 2015). Significant moments in the psychotherapeutic process presented with greater therapeutic alliance (McCarthy et al., 2017). Moreover, clients who have been assisted through the therapeutic relationship to talk about difficult and painful topics found that in itself this had a helpful impact (Quick et al., 2018). There appears to be a strong link between the quality of the therapeutic alliance and symptom reduction (Wucherpfennig et al., 2017). Clients identified two main helpful dimensions, namely: 1) an increase in awareness amidst discovery of patterns of meaning; and 2) a therapeutic relationship experienced to be protective and compassionate (Sousa et al., 2018). Sousa et al. (2018) listed numerous dimensions that clients deemed as very valuable concerning the therapeutic relationship and it included aspects such as: 1) gaining a real and human connection with the psychotherapist; 2) having feelings of security and support; 3) being in a collaborative and reciprocal relationship; 4) becoming aware of the psychotherapists competence; and 5) identifying the strain and moments of disconnect in the therapeutic relationship (Sousa et al., 2018). It seems that the therapeutic relationship and therapeutic process influence each other, each one impacting the other in a distinct manner. The impact that the therapeutic relationship SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 82 has on the therapeutic process, is described by how the collaboration between psychotherapist and client assists the client to engage in therapeutic work. For example, the working through of both negative and positive emotions may be as a result of a strong therapeutic alliance and has the potential to lead towards greater cognitive insight (McCarthy et al., 2017). Certain studies clearly described good collaboration between the psychotherapist and client as helpful (Timulak & McElvaney, 2013). In line with this finding, clients often recognise the psychotherapist’s input during a helpful event (Timulak & McElvaney, 2013). McCarthy et al. (2017) emphasise that a heightened therapeutic alliance creates the platform within which fruitful therapeutic work can be done. Within the context of helpful events, the thoughtful empathic understanding of the psychotherapists can assist clients in opening up about vulnerable feelings and can increase their use of emotional language during psychotherapy sessions (Timulak & McElvaney, 2013). On the other hand, there is a direct relationship between the therapeutic alliance and the therapeutic process. For example, when clients experience sudden gains, there is a significant improvement in the quality of the therapeutic alliance as well is in the effectiveness of coping skills utilised by clients (Wucherpfennig et al., 2017). Higher levels of therapeutic alliance and increase in cognitive changes are rather associated with post-gain sessions than with pre-gain sessions (Goodridge & Hardy, 2009; Wucherpfennig et al., 2017). The course that sudden gains seems to take starts with cognitive changes in the pre-gain session, producing improvement in depressive symptoms which, in turn, may lead to a positive escalation in mood, as indicated by a better therapeutic alliance (Goodridge & Hardy, 2009). It may also be that a client may assume that psychotherapy is helping when they experience a sudden improvement of symptoms and, as SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 83 a consequence, they form a stronger therapeutic alliance with the psychotherapist (Koffman, 2018). Furthermore, therapeutic alliance seemed to improve with suitable psychodynamic interpretations and deteriorate with less suitable interpretations (Bedi et al., 2005). Roughly 14% of all critical incidents were grouped together under technical activities and noteworthy that 72.5% of the clients stated one or more technical activities as crucial in the growth of therapeutic alliance (Bedi et al., 2005). Interestingly, in one study, psychotherapists emphasised cognitive or problem solution focused factors in helpful events, whereas clients tended to emphasise the emotional impact of the helpful events (Timulak & McElvaney, 2013). The qualities of a positive therapeutic relationship centres on the psychotherapists’ characteristics as well as experiences of the client within the relationship. One study indicated that clients felt supported by psychotherapists that recognised their efforts to make changes, and by psychotherapists validating clients in vulnerable times (O’Halloran et al., 2016). Another study indicated two themes that clients reported as valuable with regard to the therapeutic relationship: 1) obtaining a relationship to a wise, warm and competent person; and 2) being in a relationship where there is continuity, safety and hope when they are experiencing inner turmoil (Binder et al., 2009). It seems therefore that clients gather hope and security from a stable relationship when they feel emotionally unstable. Numerous clients pointed to the stability and length of psychotherapy as the most important factors (Binder et al., 2009). The relationship between clients and psychotherapists plays an important role in different empowerment event types, most clearly seen in empathy and affirmation from the psychotherapist, in addition to the technical SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 84 aspects of work between client and psychotherapist. This highlights the new found emphasis on the part of the therapeutic relationship in psychotherapy (Norcross, 2002). Because the relationship between sudden gains and outcome of treatment may be explained by the improved therapeutic alliance in sessions after sudden gains, it is advised that psychotherapists should try to take advantage of possible ways to improve the therapeutic alliance through sudden symptom improvements in post-gain sessions (Wucherpfennig et al., 2017). Ruptures or strains in the therapeutic alliance may also take place, and depending on how the psychotherapist handles these incidents, it may have positive or negative consequences on the therapeutic process. At times psychotherapists are not aware of the intensity of an event where clients experience particularly painful emotions and high emotional arousal and this may cause momentary ruptures in the therapeutic alliance (Timulak & McElvaney, 2013). However, tensions in the working alliance may be seen as possibilities for the psychotherapist to facilitate insight (Timulak & McElvaney, 2013). The psychotherapists should, therefore, be watchful of any signs of disappointment or experiences of being misunderstood, in their clients, so they could open them up and work through them in psychotherapy (Timulak, 2010). Theme 5: Sequence of Change Process Events Erekson et al. (2018) debates that since improvement becomes the criteria against which dramatic change is measured, clients that improve suddenly are therefore more likely to remain improved. He explains that even though clients may have related problems and undergo similar treatments, they still have many different courses of improvement (Erekson et al., 2018). And along the same lines, Lorenz et al (2012) states that progress happens at an irregular tempo that consists of small surges of great improvement. Factors such as a high degree of awareness into SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 85 thoughts and feelings, making connections between problems and thoughts and feelings, as well as occasions of alliance strengthening can become significant events in the context of psychotherapy (McCarthy et al., 2017). Subtheme 1: Prior to events. Interventions that led to helpful events included psychotherapists being supportive, validating and collaborative, while offering reframing and trying to create moments for positive experiences. The clients responded by being involved in the process and collaborating with directions that the psychotherapists provided (Timulak & McElvaney, 2013). Events and interventions that promoted the relationship between psychotherapist and client seems to be typical for the beginning phases of psychotherapy. Elements such as the relationship-climate, therapist’s guidance and experience of hope events, seemed to be more important in the start of psychotherapy and decreased as psychotherapy progressed (Timulak, 2010). Several possible influences are mentioned that appears to act as preparation for sudden gains to take place. Firstly, there appears to be improved meaning making processes happening in the sessions before a sudden gain (Wucherpfennig et al., 2017), while an emotional experience in one session also predicts a change in functioning as a consequence (Nasim et al., 2018). Another factor is that high levels of cognitive change occurs in the session before a gain and operates as the active precursor for sudden gains to take place (Goodridge & Hardy, 2009; Lorenz et al., 2013; Wucherpfennig et al., 2017). Partial insight in one session appears to develop into a full understanding in the next session (Goodridge & Hardy, 2009). In one or two sessions before sudden gains, clients appeared to reach levels of insight and understanding that displayed a great degree of assimilation (Goodridge & Hardy, 2009). Lastly, there is evidence for and SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 86 against the notion that there is an increase of therapeutic change factors in the sessions before the gain (Wucherpfennig et al., 2017). Regarding factors that happen before IMs occur, it is said that helping skills, elaboration and insight preceded IMs across treatments in recovered clients (Nasim et al., 2018). There appears to be a relationship between high level IMs, which may have a contributing role in creating change, the personal experience of the session and symptom improvement (Nasim et al., 2018). Nasim et al. (2018) found that the use of action skills and interventions in one session, positively correlated with the appearance of high level IMs in the following session (Nasim et al., 2018). According to Nasim et al. (2018), change occurs when a client progress from a problematic narrative to a more functional one (Nasim et al., 2018). Subtheme 2: Mechanisms underlying events. It is hypothesized that IMs are mechanisms that promote change in more pronounced and stable structures contributing to symptom recovery in a significant manner (Batista et al., 2019). The mechanisms of change found by IM-studies are similar to the mechanisms of change found in other studies (Batista et al., 2019). Batista et al. (2019) stated that their results support the idea that the processes that lead up to high-level IMs, are facilitators or mechanisms of change in psychotherapy. Improvement in the flexibility and adaptability of relational schemas has been associated with decrease in symptoms in psychotherapy (Batista et al., 2019). High level IMs bring together both adaptability and a sense of self-continuity by following the contrast between different frameworks of meaning, including the maladaptive and alternative ones to highlight the manner in which change has occurred and thereby allowing the adaptive forms of functioning to be integrated into the new storylines (Batista et al., 2019). SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 87 Although clients may prefer common factors (e.g. empathy) to specific treatment techniques (e.g. skills training), Swift et al. (2017) has shown the importance of both these factors as important in psychotherapy. Hansen et al. (2015) advised not to view common factors and specific ingredients only as distinct entities as this may cause a restricted depiction of the full range of change mechanisms in psychotherapy. Several studies suggested that non-specific aspects of psychotherapy, for example therapeutic alliance or accuracy of therapist interpretation accuracy, may be the mechanisms producing sudden gains (Lorenz et al., 2013). Because clients’ need to experience a safe environment before starting the main therapeutic work, events pertaining to relational aspects may be more common at the start and end of psychotherapy, whereas the middle phase may contain more task-oriented events (Timulak, 2010). Presently there are mixed findings around the mechanisms that cause sudden gains, there is support for both cognitive factors and support for psychotherapist traits such as the therapeutic alliance (Lorenz et al., 2013). Central change mechanisms do not only originate on a strategic cognitive level but may also be found on a primitive and automatic level as stated by the theory of emotional processing (Jensen et al., 2013). However numerous clients underlined change mechanisms connected to cognitive restructuring and clients with successful outcomes made comments linked to specific ingredients in psychotherapy (Hansen et al., 2015). A positive outcome and mechanism of change in psychotherapy seems to be a client that is able to accept personal responsibility (Hansen et al., 2015). Finally, Jensen et al. (2013) identified enhanced self-efficacy as another potential mechanism of change from a case study publication. SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 88 Subtheme 3: Process unfolding after the events. It is indicated that clients have the opportunity to consolidate symptom improvements and to gain value from psychotherapy in the long term (Wucherpfennig et al., 2017). Strict criteria for exploring sudden gains ensure that they reveal substantial change over time instead of simply indicating symptom fluctuations or natural improvement (Lorenz et al., 2012). Clients with high level IMs have a real chance of deepening and consolidating changes (Nasim et al., 2018). Work needs to be carried on after the event in order to consolidate insight (Timulak & McElvaney, 2013). A definite consequence of significant change events is an improvement in the therapeutic relationship (Goodridge & Hardy, 2009; Wucherpfennig et al., 2017). Measures of therapeutic alliance seems to improve in psychotherapy sessions after sudden gains occurred implying that this alteration is a result of the sudden gain (Lorenz et al., 2013). Relationship events seems to naturally occur more in the start and end of psychotherapy whereas insight and client growth events seem more characteristic of the middle phases (Timulak, 2010). Different stages of psychotherapy prove to have a focus on different important themes or factors. With the passing of time, aspects such as therapist guidance was more often reported and aspects such as universality decreased towards the end of psychotherapy, similarly events centred on hope showed a decrease later in psychotherapy with catharsis events showing an increase over time (Timulak, 2010). Conclusion With this review, the intention was to systematically analyse scientific literature on significant events in psychotherapy in order to ascertain the influence thereof on conceptualising psychotherapeutic change. Following a systematic review and inductive content analysis of the data set, a vast amount of categories were generated and condensed into five overarching themes, SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 89 namely: 1) definitions of change process concepts; 2) creating a context of significant events; 3) therapeutic interventions 4) therapeutic relationship; and 5) the sequence of change process events. Together, these five themes offer a full depiction of significant events in understanding psychotherapeutic change. Although significant events research has already started in the 1960s, it seems that the last decade has started to yield more empirical studies regarding the effects of significant events and their influence on conceptualising change in psychotherapy. This line of research is focused on important moments within the process of psychotherapy, indicated by clients and psychotherapists independently and grouped together as either helpful or hindering events. As they have a major impact on the change process of psychotherapy, these helpful moments are invaluable for the ongoing improvement of psychotherapeutic outcomes (Elliot, 1985; McCarthy et al., 2017; Quick et al., 2018). Examination of helpful events could describe how change can be initiated within psychotherapy and through informed intervention, the result may be positive outcomes (Timulak & McElvaney, 2013). It appears that helpful events plays an important role in change throughout psychotherapy and where sudden symptom improvements are experienced it is more probable for the client to experience clinically relevant recovery by the termination of psychotherapy (Erekson et al., 2018; Koffman, 2018; Wucherpfennig et al., 2017). Additionally, in several instances clients sustaining sudden improvements accomplished better outcomes than clients without such gains (Koffman, 2018; Wucherpfennig et al., 2017). Sudden symptom improvement seems to improve the therapeutic relationship, produces hope and increases commitment to psychotherapy (Hansen et al., 2015; McCarty et al., 2017; SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 90 Wucherphennig et al., 2017) that appears to further induce and consolidate change. The role players, including all the client- and therapist variables, in the psychotherapeutic process provide important factors that constantly interacts with each other and shapes the process. Swift et al. (2017) has indicated the importance of both common factors and specific treatment techniques in psychotherapy, although clients may prefer common factors, such as the therapeutic alliance and empathy, over specific treatment techniques such as exposure procedures or skills training. It was recommended that common factors and specific ingredients should not only be viewed as distinct entities as this may cause a restricted representation of the full range of change mechanisms in psychotherapy (Hansen et al., 2015). Furthermore ruptures in the therapeutic relationship may occur and these strains in alliance may have a positive or negative impact on the change process depending on how the psychotherapist handles these incidents. Psychotherapists needs to cultivate awareness of the intensity of an event as well as the experience of painful emotions and high emotional arousal in order to avoid ruptures in the alliance (Timulak & McElvaney, 2013 Scientific literature reports that significant events can be utilised in order to understand change in psychotherapy. Some key aspects were highlighted during the course of the thematic analysis to be of specific value in determining how significant events manifested in psychotherapeutic change. Firstly one of the main findings emerging from the study is that a therapeutic alliance seems to be a central element in achieving significant events as well as long- lasting change after termination of therapy. Furthermore, the processes that leads to high level IMs may be the same process that ultimately leads to change otherwise also seen as the mechanisms of change (Batista et al., 2019) since change occurs when the client moves from the problematic story line to a more functional narrative (Nasim et al., 2018). Other important SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 91 change factors that are noted by this study is cognitive restructuring and taking personal responsibility for the work that needs to be done within psychotherapy. According to the examination of the literature, the five themes with their subthemes may be considered to be a combination of the current literature on significant events and the change process. Therefore, both objectives were achieved by reviewing the relevant literature and exploring the themes that flowed from it. Thus the reader is presented with a prevalent description of the different change process concepts in relation to significant events and all the variables that have an impact in understanding significant events to conceptualise change. Consequently the gap identified by the literature review was addressed and the resultant information may serve as a portrayal of the important aspects of change process concepts, their context and how they feature within therapeutic intervention in relation to impact and outcome for practitioners. Recommendations and Suggestions for Future Research and Clinical Practice The themes flowing from this review provided rich information on the impact that various change process concepts and variables appear to have on the outcome of psychotherapy. This synthesized material may be applied to researchers and practitioners to enhance psychotherapeutic practice and increase improvement following therapy. In significant events, different therapeutic processes lead to diverse types of helpful impacts (Timulak, 2010). It was evident from the literature that numerous change process concepts exist that have a lot of similarities as well as unique qualities. It seems necessary to conduct further in-depth systematic reviews of each of the change process concepts in order to provide more clarity and SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 92 synthesis of these concepts in understanding how each influence the change process independently. Furthermore, an integration of the change process concepts may be valuable in order to simplify and structure them more clearly and maybe even to use these concepts across different modalities. The lack of significant event studies or articles in the South African context became evident through this study and it needs to be noted that the included articles may not reflect the experiences of the South African population. Therefore, it is recommended that significant event studies be performed in the South African context. Likewise, Swift et al. (2017) noted the importance of keeping in mind that the experiences, ideas and feelings of clients in the various research studies might not be the same for all other clients participating in psychotherapy. Future research should shed more light on the importance of significant events in relation to psychotherapeutic change as this association shows promise by not only increasing the effectiveness of psychotherapy research, but can also further enhance the evidence-based nature of clinical practice to the benefit of clients. Limitations One limitation is that no African studies and therefore also no South African literature was found on the topic of significant events in conceptualising change in psychotherapy and therefore, the South African perspective could not be included in this study. This needs to be considered when relating the study to the South African context. The size of the review group may also be a limitation. Only two reviewers that also served as coders in the data analysis phase, conducted the entire process. As there were only two reviewers to ensure the quality of the process, it may be that the level of trustworthiness could SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 93 have been impacted. A third reviewer was available to settle disagreements between the first two reviewers, however the reviewers were able to settle all disagreements with discussions, without the assistance of the third reviewer. Lastly, in the search strategy phase of this study, only the Onesearch engine was implemented as a means to find appropriate literature for this review. Onesearch is the search engine that has access to all the databases that the NWU is subscribed to, that might not be all the databases that could have rendered valuable literature. 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Cochrane Handbook for Systematic Reviews of Interventions. The Cochrane Collaboration. http://www.cochrane-handbook.org Stiles, W. B., Leach, C., Barkham, M., Lucock, M., Iveson, S., Shapiro, D. A., Iveson, M., & Hardy, G. E. (2003). Early sudden gains in psychotherapy under routine clinic conditions: Practice based evidence. Journal of Consulting and Clinical Psychology, 71, 14-21. Storr, A. (2012). The art of psychotherapy. London: Routledge. Streiner, D. L. (2002). The 2 “Es” of Research: Efficacy and effectiveness. Research Methods in Psychiatry. Canadian Journal of Psychiatry, 47(6), 552-556. Swift, J. K., Tompkins, K. A., & Parkin, S. R. (2017). Understanding the client’s perspective of helpful and hindering events in psychotherapy sessions: A micro-process approach. Journal of Clinical Psychology, 73, 1543-1555. DOI:10.1002/jclp.22531 SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 106 Tang, T. Z., DeRubeis, R. J., Beberman, R., & Pham, T. (2005). Cognitive changes, critical sessions, and sudden gains in cognitive-behavioral therapy for depression. Journal of Consulting and Clinical Psychology, 73, 168–172. http://dx.doi.org/10.1037/0022-06X.73.1.168 Thomas, D. R. (2003). A general inductive approach for qualitative data analysis: School of population health. University of Auckland: New Zealand. Timulak, L. (2003). Empowerment events in process-experiential psychotherapy of depression: an exploratory qualitative analysis. Psychotherapy Research, 13(4), 443-460. https://doi.org/10.1093/ptr/kpg043 Timulak, L. (2007). Identifying core categories of client-identified impact of helpful events in psychotherapy: A qualitative meta-analysis. Psychotherapy Research, 17, 305-314. Timulak, L. (2010). Significant events in Psychotherapy: An update of research findings. Psychology and Psychotherapy: Theory, Research and Practice 83(4), 421-447. Timulak, L., Belicova, A., & Miler, M. (2010). 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New York: Platinum Press. Truax, C. B. (1963). Effective ingredients in psychotherapy: An approach to unravelling the patient-therapist interaction. Journal of counselling psychology, 10, 256-263. Sjödin, C. (2009). The exclusion of psychoanalysis and psychodynamic psychotherapy from the publicly financed medical health sector in Sweden. Taylor & Francis Group, 18(3), 131-134. Vittengl, J. R., Clark, L. A., & Jarrett, R. B. (2005). Validity of sudden gains in acute phase treatment of depression. Journal of Consulting and Clinical Psychology, 73, 173–182. http://dx.doi.org/10.1037/0022-006X.73.1.173 Wager, E., & Wiffen, P. J. (2011). Ethical issues in preparing and publishing systematic reviews. Journal of Evidence-Based Medicine, 4(2), 130-134. doi: 10.1111/j.1756 5391.2011.01122.x Wucherpfennig, F., Rubel, J. A., Hofmann, S. G., & Lutz, W. (2017). Processes of change after a sudden gain and relation to treatment outcome evidence for an upward spiral. Journal of Counselling and Clinical Psychology, 85(12), 1199-1210. doi:10.1037/ccp0000263 SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 108 Addendums Addendum A: Critical Appraisal Tool Template CRITICAL APPRAISSAL TOOL Article number: Study Identification (Author and title): Critical appraisal completed by: 1. Was the research questions clearly stated? Comments: YES NO UNCLEAR N/A Page number: 2. Is the approach to the research question Comments: appropriate? YES NO UNCLEAR N/A Page number: 3. Is the study design/ methodology rigorous and Comments: justified? YES NO UNCLEAR N/A Page number: 4. Was the data collection carried out appropriately? Comments: YES NO UNCLEAR N/A Page number: 5. Was the appropriate data Comments: collected to address the research question? YES NO UNCLEAR N/A Page number: SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 109 6. Is the data analysis sufficiently rigorous? Comments: YES NO UNCLEAR N/A Page number: 7. Is the analysis reliable? Comments: YES NO UNCLEAR N/A Page number: 8. Are the findings relevant? Comments: YES NO UNCLEAR N/A Page number: 9. Are the findings/ interpretations valid and Comments: trustworthy? YES NO UNCLEAR N/A Page number: 10. Are the ethical considerations clearly stated Comments: and adequately discussed? YES NO UNCLEAR N/A Page number: 11. Are the implications of the study clearly reported? Comments: YES NO UNCLEAR N/A Page number: Inclusive assessment of the study Scientific Quality Positive ( ++) Neutral (+) Negative ( - ) All or most of the criteria Some of the criteria have Little or no criteria fulfilled. have been fulfilled. been fulfilled. Conclusions of the study are likely to alter. Relevance to the research question Will this article aid in answering the research question? SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 110 “What does scientific literature report regarding significant events in psychotherapy and the influence thereof on conceptualising change during psychotherapy?” YES NO Terminology used in this article as synonym for “significant events”: o innovative moment o critical incidents o sudden gains o helpful events o important moments FINAL OUTCOME- Inclusion of study: YES NO POSSIBLY SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 111 Addendum B: Summative Data Extraction Table # Reference Methodology & Aim Core Findings 1 Quick, E. L., Dowd, Methodology Findings reflect all nine impacts identified by Timulak C. & Spong, S. Mixed methods study (2007). (2018). Revisiting a meta-synthesis Suggest that voicing may be a potential new category. meta-analysis of A higher percentage of CBT clients reporting helpful aspects of Aim ‘behavioural change/problem solution’, ‘reassurance’ therapy in a To examine helpful events and ‘client involvement’ as helpful than clients community in a community counselling receiving integrative therapy. counselling service. setting in order to categorise British Journal of the impacts of events Helpful factors: Guidance & according to the meta- Focusing on self; Problem solving; Counselling, 46(2), synthesis of significant Behaviour change; Problem solution; Reassurance; 148-159. events of Timulak (2007) Client involvement; Expressing and exploring feelings. Significant Events: Client-identified key moments; Significant helpful and hindering events. Three categories of client-identified helpful events: The nature of the therapeutic interaction; In-session impact; The whole event. Nine categories of client-identified helpful events: Awareness/ Insight/ understanding; Behaviour change / Problem solution; Empowerment; Exploring feelings / Emotional experiencing; Relief; Feeling understood; Client involvement; Reassurance / Support / Safety; Personal contact. 2 Koffman, A. (2018). Methodology Sudden gains possibly predict outcome because of Intersession Quantitative improvement inherent in the gains themselves. improvement and Sample: 149 adults Early improvement predicts outcome almost as outcome in Complete distress measure effectively as sudden gains. psychotherapy. at each session. Redefining sudden gains as large intersession Clinical Psychology For each criterion of sudden improvement, regardless of local score stability may be Psychotherapy, 26, gains, prediction of an advantage for research. 146-155. outcome, possible Definition of sudden gains: large, stable moderating variables, local improvements from one psychotherapy session to the score instability, and next which are favourable in terms of prognosis / a multisession change before phase shift / changes in levels of symptomatic distress; and after score shifts was Within-session sudden gains and evaluated. Outside-session sudden gains; Overall improvement: relationship between shifts and Aim outcomes (change) To investigate sudden gains and outcome in either cognitive behaviour therapy (CBT), interpersonal therapy (IPT), or in combination. Assessed over a limited number of sessions, therefore shifts in session 3 to 7. SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 112 3 Batista, J., Silva, J., Methodology The flexibility of the Responses of the Self (RS) seems Freitas, S., Alves, Quantitative. to be a mediator between IMs and outcomes, but D., Machado, A., Using the Core Conflictual Wishes and Responses of Others (RO) were not Sousa, I., Relationship Theme involved. Fernández-Navarro, (CCRT) to assess relational Results support previous research showing that RS is P., Magalhães, C. & schemas and evaluating IMs most open to change, and the other components seem Gonçalves, M. M. using the Innovative less sensitive to change during brief therapy. (2019). Relational Moments Coding System. Definition of Innovative Moments: exceptions to the schemas as Sample: 22 clients maladaptive framework of meaning that brought the mediators of diagnosed with major client to therapy / narrative markers of meaning innovative moments depressive disorder. The transformation in symptom flexibility of the three that challenge the maladaptive framework and improvement in components of the CCRT eventually leads to its transformation via major depression. (Wishes, responses of the psychotherapy; Psychotherapy self (RS), and responses of IM’s facilitate change – promoting new understanding Research, 29(1), 58- others (RO)) were tested as of the problem & prompting the client to express new 69. mediators between IMs and feelings and intentions + develop new actions; outcomes. Contrast IM’s – recognising the difference between maladaptive past positions and adjusted ones (in favour Aim of the adjusted ones); To test the hypothesis that Mediating factors: symptom severity + ambivalence IMs contribute to outcomes towards change + readiness for change by improving the flexibility Changes in client’s relational schemas: development of relational schemas. of a more flexible and integrated view of self and others. 4 McCarthy, K. L., Methodology Significant events include statements displaying Caputi, P., & Quantitative. emotional and cognitive awareness and insight, and Grenyer, B. F. S. Studying significant change moments of alliance strengthening. Events were packed (2017). Significant events versus non-event with positive and negative emotion words, (anger and change events in passages in 1195 word sadness), plus cognitive insight words. There was proof psychodynamic blocks of transcribed of the integration of positive and negative emotional psychotherapy: Is psychotherapy. content with cognitive insight. cognition or 20 participants, comorbid Key moments of psychotherapeutic development emotion more depression and personality contained high therapeutic alliance. important? disorders. Definition of Significant change events: Psychology and Independent raters manually helpful moments within a psychotherapy session that Psychotherapy: determined significant have been proven to relate strongly to outcome in Theory, Research events. Identified significant evidence based research studies; and Practice, 90, events via linguistic markers Examples of significant events: 377–388. with Mergenthaler’s Statements reflecting emotional and cognitive Therapeutic Cycles Model awareness and insight; (TCM)-computerized text Moments of alliance strengthening; analysis. Problem solving; Insight moments; Behaviour change; Then emotional and The integration of emotional and cognitive processing cognitive aspects in therapy is related to differentiated by Linguistic symptomatic outcome; Inquiry and Word Count Association between anger, sadness and significant (LIWC). change events (relevant emotions related to significant change events). Aim To investigate clinical and linguistic features of helpful moments by using and comparing human ratings as SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 113 well as computerized text analysis strategies. 5 Swift, J. K., Methodology Findings suggest that clients perceive a substantial Tompkins, K. A., & Mixed method. amount of variability within a single session. Parkin, S. R. (2017). Using a micro-process Moreover, results indicated that clients perceive both Understanding the approach. specific treatment and common factors techniques as client’s perspective 16 clients asked to review a being helpful. Some therapist actions were rated as of helpful and psychotherapy session and both helpful and hindering, however they differed in hindering events in complete a moment-by the timing. Whether client's experience being heard and psychotherapy moment rating of understood versus feeling judged or given advice had sessions: A micro- helpful/hindrance events an impact on helpfulness. process approach. using a dial rating system Helpful psychotherapy Journal of Clinical while watching the session. When the therapist provides a safe environment and Psychology, 73, Also had to describe the uses decisive, skillful and caring interventions; 1543-1555. most helpful and hindering Hindering psychotherapy sections. when clients feel some type of disappointment in the therapist or treatment; Aim Helpful events To link the methodologies has smaller painful events embedded in them, such as of significant events and processing difficult emotions and experiences; micro-process research in Determine if an event is helpful or hindering: order to understand clients' Process of change - deep engagement in pattern personal perceptions of identification and narrative reconstruction; Develops helpful and hindering events self-awareness; in psychotherapy. Professional structure creates clarity; Collaborative effort with discussion on differences; Clients’ agency – responsive interventions – fitting the clients’ needs; Factors that facilitates change: Therapists’ actions / Techniques: Therapists’ skills: Therapist discussions on session process Factors that prevents change: Therapist taking on a more directive role Therapist being off topic; Client feels judged by therapist; Topics are too difficult for the client to talk about. 6 Erekson, D. M., Methodology: All three definitions were related to higher rates of Horner, J., & Quantitative. clinically significant change by the end of treatment. Lambert, M. J. Examine client Dramatic changers displayed higher initial severity of (2018). Different characteristics and treatment symptoms as well as a more overall change compared lens or different outcomes using a database to those who recovered gradually. RR presented with picture Comparing from a University fewer sessions and PI-50 and SG showed more methods of defining counseling center with the sessions than those who recovered gradually. Because dramatic change in Outcome Questionnaire-45. of the differences between the definitions, agreement psychotherapy. needs to be reached in the literature concerning the Psychotherapy Aim: definition of dramatic change. research, 28(5), 750- To compare three Different change patterns: 760. methods— namely the No change; Rapid change; Dramatic change; Early percentage improvement- change; Gradual improvement; Sudden gains; 50% (PI-50), rapid response Early dramatic responses vs. later dramatic responses; (RR), and sudden gains (SG)—to find similarities SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 114 and differences between Link between timing and dramatic change patterns these approaches. (first 3 sessions most important, first 10 sessions are important); Sudden gains can occur during all stages. 7 Piazza-Bonin, E., Methodology: Findings reinforce the salience of reflection, Neimeyer, R. A., Qualitative analysis. reconceptualisation, and performing change IMs in Alves, D., Sessions transcribed and successful grief therapy cases, and also suggest the Smigelsky, M., & coded, followed by importance of meaning-making interventions in grief Crunk, E. (2016). identification of IMs. therapy. Innovative Moments in Humanistic Aim: Innovative Moments Coding System (IMCS): provides Therapy I: Process To inform theory regarding a trans-theoretical approach to analysing the process of and Outcome of the patterns of IMs across psychotherapeutic change; Eminent three humanistic approaches Common goal of therapy: to disrupt unhelpful patterns Psychotherapists (constructivist, person- in order to create alternatives of feeling, thinking, Working with centered, and existential) acting and relating bereaved Clients. when working with Different types of IM’s: Journal of bereaved clients Action IMs Constructivist Also linking these patterns Reflection IMs Psychology, 29(3), to observable change in Protest IMs 269-297. each client's functioning. Reconceptualization IMs 8 Wucherpfennig, F., Methodology Results propose that sudden gains trigger change Rubel, J. A., Quantitative. factors that facilitate the association between gains and Hofmann, S. G., & Analyze 211 depressed treatment outcome. It suggests that client and therapist Lutz, W. (2017). patients who underwent should work with sudden gains to consolidate symptom Processes of Change cognitive– behavioral relief. After a Sudden Gain therapy. and Relation to Identify sudden gains by Definition of sudden gains: refers to sudden symptom Treatment Outcome- using a session-by-session improvements (or meaningful change) / usually occurs Evidence for an self-report symptom between two consecutive sessions and not gradually; Upward Spiral. measure. Sudden gains effects Journal of Increase in therapeutic alliance in subsequent sessions; Counselling and Aim Increase in engagement in challenging cognitive work Clinical Psychology, To investigate the processes Increase in coping skills in subsequent sessions; 85(12), 1199-1210. that may facilitate treatment Increase in hope & positive emotions; outcome after a sudden gain Sudden loss: the reversed phenomenon of a sudden occurred. gain; Sudden gains spike an upward spiral in the sessions following a sudden gain. 9 Nasim, R., Shimshi, Methodology Results indicate that IMs are linked to symptomatic S., Ziv-Beiman, S., Mixed method. change. Exploration and insight interventions are Peri, T., Fernández- Case study of 12 sessions of linked to the emergence of more primary IMs, while Navarro, P., a 27-year-old female client action interventions are found to be related to more Oliveira, J. T., & coded according to the developed IMs. IMs are also strongly related with 3 Gonçalves, M. M. Innovative Moments Coding dimensions of client’s subjective experience of the (2018). Exploring System. session namely depth, smoothness, and positivity. Innovative Moments Outcome improvement in a Brief Integrative measured by the Outcome IMs can occur in sessions or can occur outside sessions Psychotherapy Case Questionnaire (OQ-45.2). (consequently discussed in the sessions); Study. Journal of Therapist’s interventions IMs: each moment in which the interpersonal pattern Psychotherapy coded according to the (behaviour/cognition/emotion) is interrupted, even if Integration. Helping Skills Scale (HSS). only temporarily; SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 115 Advance online The subjective experience Enduring change occur by the repetition of these publication. for each session measured exceptions by the Session Evaluation 2 Levels of IMs Questionnaire (SEQ) Level 1: Allows clients to create distance between themselves and the problematic patterns; Aim Level 2: Allows clients to create a differentiation from To examine the emergence the problematic pattern and a clear representation of of innovative moments in a what the new pattern might be; successful case of Brief IM skills: Integrative Psychotherapy Exploration skills: lays the foundation for clients to (BIP) based on Hill’s 3- understand their motivations for change and to take stage model. responsibility for change; Moreover the study aim to Insight skills: fosters self-awareness & facilitates self- examine the associations perception; between IMs, on the one Action skills. hand, and (a) symptomatic improvement, (b) therapist’s interventions, and (c) client’s subjective experience, on the other hand. 10 Lorenz, T. A., Methodology Provided evidence of sudden gains in trauma Pulverman, C. S., & Quantitative. symptoms in a randomized clinical trial of a patient- Meston, C. M. Secondary analysis of directed expressive writing intervention. The clients in (2013). Sudden previously collected data. the active treatment condition, writing about their Gains During Examine sudden gains beliefs about sexual trauma, and consequently Patient-Directed within a 5-session experiencing sudden gains in trauma symptoms also Expressive Writing expressive writing treatment had larger improvements in depression. Whereas Treatment Predicts for female survivors of clients in the control condition, writing about their Depression childhood sexual abuse daily needs did not have the same impact. The Reduction in (CSA) experiencing extension of sudden gains from psychotherapy to a Women with symptoms of depression. client-directed treatment improves the understanding of History of Cognitive change measured the mechanisms underlying these gains. Childhood Sexual with a validated measure of Abuse: Results from sexual self-schema. Sudden gains links: a Randomized Clients improve faster after a sudden gain; Clinical Trial. Aim Clients improve to a greater degree after a sudden gain; Cognitive Therapy To investigate whether Clients are less likely to relapse after a sudden gain or Research, 37, 690- sudden gains feature in a exhibit a longer duration before relapsing (if they 696. client-directed intervention relapse); in order to explain if the therapist is a key factor in producing sudden gains. 11 Timulak, L., & Methodology Two distinctive types of events are identified according McElvaney, R. Qualitative meta-analysis. to their main impacts as reported by the clients. The (2013). Qualitative 7 Studies selected that first is painful/poignant insight where clients realize meta-analysis of examined significant events something that was painful, evoking feelings of insight events in in psychotherapy leading to sadness or upset/ hurt; and the second is self- psychotherapy. insight. Asserting/empowering insight that lead to an impact Counselling Session recordings and characterized by a sense of self-assertion and Psychology Interpersonal Process Recall empowerment for the client. Quarterly, 26(2), interviews with clients and 131-150. therapists used. SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 116 A matrix grid used to Results indicate that a good alliance and vulnerability conceptually organize the and a quest for self-understanding on the client’s part data. represent the context for insight events. The key interventions leading to poignant/painful Aim insight contain either empathic reflection or To report on the collaborative interpretation. In empowerment/self- phenomenon of insight in assertive insight events the therapists seem to offer psychotherapy through a supportive, validating reframing that promotes positive qualitative meta-analysis. experience. In both types of events the therapist and the client need to together to consolidate insight. Therapists seem to emphasize cognitive or problem solution focused impacts, while clients emphasize emotional impacts. Context for Insight Events: Reasonably good therapeutic alliance; Vulnerability on the clients’ part; Clients’ quest for self-understanding. Insight: Supportive, validating reframing promoting positive experience. Aspects increasing insightfulness: Delivery of interpretations; Transference interpretations; Clients’ state of readiness to accept the therapist interpretation; Trust in therapists’ capacity to deal with the clients’ pain; Therapist accurate evaluation of clients’ avoiding behaviour; Therapists’ employing sensitive empathic understanding; Therapist use of emotionally evocative language; The importance of the language used by the therapist makes a felt difference. Impact of insight events: Increased feelings of connection with the therapist; Relief; Hope; Self-assertion; Empowerment; Cognitive reframing, 12 Daniel Sousa, D., Methodology The results emphasized the following categories: the Pestana, A., & Qualitative. promotion of self-awareness, the possibility of Tavares, A. (2018). Sample: 10 clients, verbalizing experiences, and the deepening of Self-Awareness, existential psychotherapy meanings. In addition to emphasizing human Verbalization and consisted of 48 sessions. relationships, the patients also emphasized a preference New Meanings as Data analyzed using for interventions by existential therapists that were the Heart and Soul grounded theory more directive, such as providing feedback, of Significant challenging personal beliefs, and asking questions. The Events in Existential Aim results further highlighted the integrated use of the two Psychotherapy. To qualitatively analyze phenomenological methods, specifically, the static and Journal of significant events occurring the genetic methods. Contemporary in existential psychotherapy Emphasized that the most mentioned dimension in Psychotherapy sessions from the clients Significant events is awareness/perception/ self- perspective. knowledge. The study aims to answer 3 Second most mentioned dimension was verbalizing questions in order to their experiences. contribute to knowledge Third most mentioned dimension is the identification about existential and deepening of new meanings. psychotherapy: 1. What are the events Self-awareness leads to cognitive, emotional and considered most significant behavioral impacts by patients? SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 117 2. What types of impacts do Activities that leads to increase in awareness: significant events have on Being able to speak; to experience in a safe space; to the therapeutic process? have relief from suffering; establish a relationship with 3. What do patients consider the therapist; to explore emotions; being actively to be the most important involved; to symbolize/ narrate their experiences therapist’s interventions? Clients value: 1. Real and human, trusting relationship with therapist 2. Therapist that challenge them to question their beliefs etc. 13 Timulak, L. (2010). Methodology Findings showed that clients report impacts of helpful Significant events in Theoretical. events that are focused on the therapeutic relationship psychotherapy: An Review of 41 primary and in-session outcomes. Hindering events appears to update of research studies that used client- focus on client disappointment with the therapist or findings. identified significant events therapy. The intensive qualitative studies reviewed Psychology and as a main or secondary confirm that the processes involved in significant Psychotherapy: focus of the study. events are complex and ambiguous. It was indicated Theory, Research that helpful events may contain many hindering and Practice, 83, Aim elements and that specific events are deeply 421-447. To provide an overview of contextually embedded in the preceding events of the significant events therapy. research conducted, as well Perspectives on what is significant in therapy vary as the methodology used between clients and therapists. Therapist often together with findings and emphasize cognitive aspects of therapy whereas the implications relational and emotional aspects of significant moments may be more important for the clients. Significant Events are helpful or hindering events that stands out from the rest of the session, either positively or negatively; Significant Events identified by clients: Reassurance; Feeling understood; Personal contact; Insight; Relief; Behaviour change; New feeling; Empowerment. Two clusters of helpful events: Cluster A: Task: New Perspective; Problem Solution; Problem Clarification; Focusing Awareness; Cluster B: Interpersonal: Understanding; Client Involvement; Reassurance; Personal Contact Meta-categories of helpful events: Awareness / Insight / Self-Understanding; Behaviour Change / Problem Solution; Empowerment; Relief; Emotional Experiencing / Exploring Feelings; Feeling Understood; Client Involvement; Reassurance / Support / Safety; Personal Contact Six categories of unhelpful events Misperceptions; Negative Counsellor Reaction; Unwanted Responsibility; Repetition; Misdirection; Unwanted Thoughts; 14 O’Halloran, D. M., Methodology: Thematic analysis resulted in a model of significant O’Reilly, G., Qualitative design. events in therapy. In this model, significant events Travers, O., Quinn, Using two qualitative were categorized into six domains. The six domains P., Stack, J., Cartin, measures: were as follows: (a) the process of therapy, (b) making M., Finnegan, E., & changes and progress in therapy, (c) content and SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 118 Ewart-Boyle, S. The Significant Aspects of structure of therapy, (d) therapist contributions, (e) (2016). Exploring Therapy Form administered negative contributions to therapy, and (f) other factors client and therapist every second session for Each domain further contained between 6 and 18 experiences of each intervention program. themes, which are also reported. sexual offender The Significant Aspects There is overlap between therapists and clients in the intervention: Follow-Up Interview aspects of therapy they identify as significant. developing a model administered on a sub- Significant Therapeutic Events Categorised into Six of “significant sample of participants at the Domains: events”. Sexual conclusion of each Domain 1: The process of therapy: Abuse: A Journal of treatment module. Sharing experiences; Advice, support and feedback; Research and Thematic analysis used to Role model; Hope; Universality of experiences; Treatment, 28(4), identify significant themes Listening; Positive Regard; Acceptance and 314-339. noted by clients and Nonjudgment; therapists. Use of humour Domain 2: Making changes and progress: Aim: Evidence of change; Applying learning and making To explore the therapeutic connections; Desire for change; Showing empathy; events in psychotherapy that Taking control of cognitions; Expressing emotions; both clients and therapists Taking responsibility; Making changes in life; from community-based Recognising risks and triggers; External support treatment interventions for network; Acceptance of consequences; perpetrators of sexual abuse Domain 3: Content and structure of therapy: identify as significant. Acquiring skills; Thinking back / reflecting; Challenging clients’ behaviour; Implication or outcome; Identifying goals; Power and control; Focused attention; Domain 4: Therapist contributions: Therapists’ guidance; Therapists’ style; Support from therapist; Therapists reflections; Therapists emotion; Maintaining hope for change; Therapists’ self-care; Domain 5: Negative contributions to therapy: Negative client contributions; Client not taking responsibility; Poor attendance issues; Negative thoughts; Not maintaining changes; Clients’ reluctance to being challenged; Domain 6: Other factors: Family dynamics / external factors; Comments about research; Levels of honesty and depth of sharing in sessions; Level of trust and safety; Significant Events: Universality and Corrective Emotional Experience; Treatment Readiness and Desire for Change. 15 Hansen, B. P., Methodology: The results suggested that clients with sudden gains Lambert, M. J., & Mixed method design. made dramatic improvements in reducing distress and Vlass, E. N. (2015). A randomized sample of increasing functioning, whereas the sudden-loss clients Sudden gains and five sudden-gain clients and showed almost no improvement. A statistically sudden losses in the five sudden-loss clients, significant higher working alliance was found in the clients of a from one therapist, were sudden-gain group as compared to those with sudden “supershrink”: 10 selected and their results losses. case studies. compared with quantitative Pragmatic Case and qualitative data Distinctive aspects of the results, including the role of Studies in collected at two-year-plus the therapist as an outcome variable; the uneven rate of Psychotherapy, follow-up. change reflected in the sudden gain/sudden loss 11(3), 154-201. phenomena; and the ability of a supershrink therapist Aim like Vlass to achieve dramatically positive results--as measured over two years after the end of therapy. SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 119 To obtain further in-depth knowledge of the nature and process of sudden gains, this article presents qualitative and quantitative case studies of the clients of a clinical psychologist who is a private practitioner, namely Erigoni Vlass. 16 Binder, P., Methodology Definition of sudden gains / losses: a statistically Holgersen, H., & Qualitative. exceptional decrease or increase, respectively, in a Nielsen, H. (2009). Semi-structured, in-depth clients’ symptoms between two treatment sessions; Why did I change interviews done with ten Between 50 and 65% of total change during therapy when I went to former psychotherapy takes place as sudden gains; therapy? A clients. Sudden gains also link with sustained change during qualitative analysis A descriptive and follow-ups; of former patients’ hermeneutically modified Sudden change challenges the belief that change in conceptions of phenomenological approach psychotherapy is linear, gradual and similar among successful used to analyse the themselves; psychotherapy. interview transcripts. -There is a link between rapid and early changes in Counselling and therapy and common factors in therapy; Psychotherapy Aim -A Review of 2000 process-outcome studies regarding Research, 9(4), 250- To identify and elucidate positive change revealed: 256. specific experiences and Therapist Credibility; Skill; Emphatic Understanding; reflections of former Affirmation of the client; Active engagement with the psychotherapy clients that client; defined their previous -Dynamic frequent feedback loop between client and therapy as successful. therapist (therapist responsiveness); -Clients’ responses and therapists’ interventions Significant Events in therapy: 1. Unique therapist qualities: Spirituality; personality; approach; skills; 2. Potent and specific ingredients: Change Mechanisms; Cognitive Restructuring; Linking Thoughts and Emotions; 3. Client changes: Changes outside of themselves; Changes within themselves. 17 Jensen, V. L., Methodology: Change: Hougaard, E., & Qualitative 1. The experience of having acquired tools to handle Fishman, D. B. (…). Case study life; Sara, A Social 2. An understanding of illness that facilitated a new Phobia Client with Aim: way of approaching a particular problem; Sudden Change To investigate the 3. Enhanced flexibility of thinking; After Exposure mechanisms of change for Therapist experienced as wise, warm and competent; Exercises in one particular client, and Therapists’ use of skills and specific methods and Intensive Cognitive- thereby demonstrate the techniques and professional stance; Behavior Group prospects of pragmatic case Therapeutic relationship that is stable, predictable, safe Therapy: A Case- studies in meticulous and that provides hope; Based Analysis of process research. A focus I Having beliefs about oneself and one’s relational world Mechanisms of put on the question of how corrected; Change. Pragmatic therapy works. Creating new meaning and seeing new connections in Case Studies in life patterns; SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 120 Psychotherapy, 9(3), Having old and dysfunctional beliefs corrected. 275-336. Sudden change: Behavioural experiments; Exposure exercises; Emotional regulation; Enhanced self-efficacy. 18 Goodridge, D. & Methodology Findings indicated that insight and understanding of the Hardy, G. E. (2009). Qualitative problematic experience was reached in the session Patterns of change Sample: 5 clients with before the sudden gain. The case analyses recognized in psychotherapy: sudden gains receiving the abovementioned findings however suggested that An investigation of cognitive therapy for insight was partial and did not develop into full insight sudden gains in depression until the after gain session. cognitive therapy Passages from sessions using the before and after the sudden Assimilation Model: predicts that progress in therapy assimilation model. gain were rated for occurs in a sequential fashion; Psychotherapy assimilation level. Successful outcome in therapy clients: reach levels of Research, 19(1), A descriptive account was insight and understanding (leading into sudden gains); 114-123, completed for each client Sudden gains: through the procedure of Affect becomes more positive; multiple single-case Cognitive involvement is high; qualitative methods. Insight: 1. Depth of insight; Aim 2. Quality of insight; To provide a detailed 3. Shift in insight; descriptive account of the 4. Transitory insight; large improvement seen 5. Partial insight; over a single-session 6. Full insight / Stable insight; interval in psychotherapy, known as “sudden gain,”. 19 Lepper, G., & Methodology The authors determined that significant events may be Mergenthaler, E. A mixed method design. compared within and across cases to understand how (2008). Observing 15 session transcripts of the therapist interventions contribute to within-session therapeutic ‘‘Lisa’’ case from the York micro-outcomes and, ultimately, to outcomes across interaction in the 1 Depression Study was populations of cases. “Lisa” case, studied. Psychotherapy “The identification and Analysis of A significant Research, 18:6, 634- Aim clinical Interaction suggests that it is possible to 644. To try to validate a method observe in detail how the therapist and client develop a for the identification and core theme and deepen the therapeutic process through analysis of clinically their collaborative interaction.” significant interactions in the psychotherapy process. 20 Lepper, G., & Methodology Findings support the correlation of topic coherence to Mergenthaler, E. Mixed method design. periods of high therapeutic productivity. (2007). Therapeutic Analyze transcripts from collaboration: How eight sessions of successful “The context in which therapists most consistently does it work? brief psychodynamic made interpretive interventions was when patients Psychotherapy psychotherapy. Identify conveyed emotions or made insightful connections. Research, 17(5), topics from the transcripts, These interactive sequences may represent particularly 576-587. compute topic density, topic important moments in the therapy hour, when both sequence, and participation patient and therapist are actively engaged in significant structure as markers for therapeutic topic coherence. work’’ SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 121 Aim: Link between specific therapeutic interventions by the To use conversation therapist and significant realisations and insightful analysis to observe the turn- connections by the client; by-turn analysis of the “the client, in concert with the therapist, agree on dialogue, in combination relevant themes”; with a computerized text When clients’ conveyed emotions which were followed analysis following the by interpretive interventions by therapists lead to therapeutic cycles model. In insightful connections by clients (known as interactive order to identify clinically sequence); significant events and Thus: Interactive sequences: important moments in indicate how collaboration therapy. in psychotherapy works. 21 Timulak, L. (2007). Methodology After the qualitative meta-analysis of the impact of Identifying core Qualitative meta-analysis. helpful events, categories were reduced to nine core categories of client- Secondary analysis of categories: identified impact of primary qualitative studies (a) awareness/insight/self-understanding; (b) helpful events in to focus on client-identified behavioral change/problem solution; (c) empowerment; psychotherapy: A impacts of helpful (d) relief; (e) exploring feelings/ emotional qualitative meta- significant events. experiencing; (f) feeling understood; (g) client analysis. involvement; (h) reassurance/ support/safety; (i) Psychotherapy Aim personal contact. Research, 17(3), Exploring, through an “one event can have several impacts” 305-314. application of meta- analytical procedures that Helpful impacts of events diverse impacts: result in a rigorous Insight Events; secondary analysis of Problem Clarification Events; primary qualitative findings, Vague Awareness Events; the kinds of impacts that Empowerment Events; clients identify as helpful. Empathic Exploration Events; One event can have several impacts: Impacts relating to therapeutic relationship: Feeling Understood; Client Involvement; Reassurance / Support / Safety; Personal Contact; Impacts relating to within-session therapy outcomes: Awareness / Insight / Self-Understanding; Behavioural Change / Problem Solution; Exploring Feelings / Emotional Experiencing; Empowerment; Relief; Impacts describing cognitive and behavioural change: Awareness / Insight / Self-Understanding; Behaviour Change / Problem Solution; Impacts describing motivational and experiential change: Exploring feelings / Emotional Experiencing; Empowerment; Relief; Three broad areas of impacts: New Perspective; New Behaviour; New Experiencing and Motivation. 22 Timulak, L. (2003). Methodology Findings suggested 5 types of empowerment events Empowerment Qualitative design. namely: poignant, emergent, decisional, empowerment, SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 122 Events in Process- Transcripts of client- and accomplishment, where each type has different Experiential identified significant events processes. Therefore, each event type is describe across Psychotherapy of as well as sections of client the following domains: client processes, therapist Depression: An and therapist Brief processes and interaction, and therapeutic impact. Exploratory Structured Recall interviews Different therapeutic processes present in an Qualitative used as data. Firstly events assortment of empowerment types. Some therapist Analysis. sorted into broad domains interventions contributed to several different types of Psychotherapy and then into types. empowerment. Research, 13(4), 443-460. Aim Empowerment: therapists’ facilitation of giving a voice To analyze different types to a submerged / important part of the clients’ self; of empowering therapy helps the clients to express this part and validate its events. existence and meaning through empathic understanding; 23 Cunha, C., Methodology Results showed that IMs occurred more often in Good Gonçalves, M. M., Qualitative data analysis. outcome (GO) than Poor outcome (PO) cases. In GO Hill, C. E., Mendes, Analyze two initial, two exploration and insight skills more often preceded I., Ribeiro, A. P., middle, and two final action, reflection, and protest IMs in the initial and Sousa, I., Angus, L., sessions of three good middle phases of therapy than in PO cases, but more & Greenberg, L. S. outcome (GO) and three often occur ahead of reconceptualization and (2012). Therapist poor outcome (PO) cases of performing change IMs in the final phase. Action skills Interventions and emotion-focused therapy were more often associated with action, reflection, and client innovative (EFT) for depression. protest IMs across all phases, especially in the final moments in phase, of GO EFT. emotion-focused Aim therapy for To understand which Action IM’s, Reflection IM’s and Protest IM’s emerge depression. therapist skills are related to first and challenge the problematic self-narrative; Psychotherapy, client IMs, by analyzing the Reconceptualisation IM’s appear in the middle phase 49(4), 536-548. association between of therapy and continue until the end; exploration, insight, and Performing IM’s emerge and expand after therapy into action skills and IMs. the changing self-narrative; Exploration, Insight and Action skills are important in the middle phase of therapy and ought to be maintained until the end; Middle phase of therapy: known as the working phase of therapy; Clients more open and ready to change: respond better to insight and exploration skills (and have an increased probability to be good outcomes cases); Clients less ready to change: push for change through the use of insight skills (and have an increased probability to be poor outcome cases). 24 Bedi, R. P., Davis, Methodology The results indicate differences in client – and therapist M. D., & Williams, Qualitative design. perspectives about alliance. M. (2005). Critical Interviews conducted “if clients believe that a particular factor results in a incidents in the through critical incident better alliance, it might lead them to engage in formation of the technique, with questions behaviors such as opening up more or responding Therapeutic alliance about observable behaviors positively.” from the client’s and verbalizations that Through discussion and consensus, a final 25 Perspective. clients thought had categories were created, namely: Technical activity; Psychotherapy: significantly helped Nonverbal communication; Active listening; Choices; Theory, Research, establish the alliance. Sorted Psychotherapy Environment; Client agency; Personal into categories. Characteristics; Service beyond normative expectation; SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 123 Practice, Training, Sample: 40 participants Self-disclosure; Positive commentary; Greetings and 42(3), 311-323. Farewells; Positive initial Contact; Normalization and Aim Validation; Respecting Agreements; Positive To identify and categorize sentiment; Recommendations; Confidentiality, Candor; the variables that clients Crying in the presence of the psychotherapist; Role consider important for induction; Humor; Emphasizing client expertness; forming and strengthening a Previous knowledge of psychotherapist; Openness to positive therapeutic alliance. personal criticism; External contact. Critical Incidents: - 14% - related to technical activities; - 72.5% - related to therapeutic alliance; 25 Grafanaki, S., & Methodology The findings indicated three categories that clients McLeod, J. (1999). Qualitative design. perceived as helpful: 1) therapist as audience; 2) Narrative Processes Qualitative data collected negotiation of a new story line; and 3) co-constructing in the Construction through Helpful Aspects of the story of therapy. Helpful events were categorized of Helpful and Therapy questionnaire and by the experience of a sense of 'flow' between client Hindering Events in Brief Structured Recall and therapist. The study suggest that current narrative Experiential interviews. approaches to therapy have not given enough thought Psychotherapy. Structured narrative analysis to the role of the client–therapist relationship in Psychotherapy of psychotherapy transcripts allowing the client to construct a life narrative. Research, (9)3, 289- to analyze data. 303. Helpful Events Aim Generated by the discovery of a new storyline; To identify narrative The realisation of contrast or incongruity between an processes occurring in existing “problem” story and a newly emergent therapeutic events that are “solution” story; seen by the client as either A clients’ perception of being “on a track” moving in helpful or hindering, in the direction of pursuit of new personal meanings; order to develop a Therapist needs to understand the clients’ story for framework for change to occur; understanding how clients Helpful Moment: when clients can begin to use a in psychotherapy construct mutative metaphor in psychotherapy as the genesis of a these moments through new storyline; different kinds of meaning New story: making. Empowering and Emancipating; Provides unique outcomes (moments when something different happens); Co-constructing the story: Negotiated by client & therapist; Creating an integrative narrative of what happened in therapy; “Flow”: Achieved flow: opened up new story in from of an affirming audience; leads to increased therapeutic alliance; Interrupted flow: confused or stuck story in from of a critical audience; leads to possible alliance ruptures; Significant events: Promoting Awareness and Processing of Emotional Meanings (Greenberg); SIGNIFICANT EVENTS IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW 124 Addendum C: Language Editor Declaration DECLARATION I, C Vorster (ID: 710924 0034 084), Language editor and Translator and member of the South African Translators’ Institute (SATI member number 1003172), herewith declare that I did the language editing of a mini- dissertation, written by Ms LY Lourens (student no 22106790), from the North-West University. Title of the mini-dissertation: The influence of significant events in conceptualising change during psychotherapy: A systematic review 24 November 2019 _______________________ _______________________ C Vorster Date cvlanguage.editing@gmail.com CHAPTER 3 125 Addendum D: Ethical Clearance Certificate CHAPTER 3 126 CHAPTER 3 127 CHAPTER 3 Critical Reflection While critically considering the process and findings of this systematic review, certain aspects became prominent and seems worthy to be reflected on. Through years of scientific research it was indicated that psychotherapy is effective in treating clients, however lately there seems to be a new focus on specific aspects that have an impact on the successful outcome. Importance is placed on service delivery in mental health care practice with the main focus being improvement and recovery. Based on the findings from this study, that significant change events have a strong association to positive outcome and that key moments in psychotherapy provide valuable data for understanding the therapeutic- and change process, it is all the more necessary to explore which type of events have the biggest impact on change in psychotherapy. In line with this reasoning, the significant event approach to research is proving that large, stable improvements between psychotherapeutic sessions produces a positive prognosis. Furthermore, practitioners feel a need to establish which clients will be likely to recover and which clients are likely not to improve in treatment. It is also important to take note that certain events may be hindering to a client’s change process or even detrimental to their functioning in order to ensure ethical practice. Moreover it appears through the findings that a reliable appreciation of psychotherapeutic change is offered. A large portion of the data in this study seemed to focus on the importance of interpersonal factors in psychotherapy. Each article referring to the therapeutic relationship associated a positive therapeutic alliance with a positive impact and outcome. On the other hand CHAPTER 3 128 significant moments in psychotherapy almost always seems to result in a better therapeutic alliance. Current research should be utilised to increase understanding of significant events underlying changes and in-session impacts. Moreover, there is still a need for convergence of theoretical orientations and differing modalities in order to provide a broader and more sophisticated understanding of change so that clinical practice may duly evolve. From the included studies it seems that psychotherapists and researchers are currently partnering together effectively to learn from real experiences within practice, making it more viable to bring research into practice. Personally, through systematically reviewing the relevant articles and becoming deeply acquainted with the current literature on significant events and the change process I have gained an understanding of the change process concepts that did not previously form part of my knowledge base. This process had an impact on how I view key moments within the therapeutic process and the findings are now integrated into my knowledge of the change processes involved in treatment and the clients journey to improvement. I have had a lot of previous misconceptions around the structure and effectiveness of psychotherapy to which I gained more clarity from different perspectives including those of the psychotherapist, the researcher and the client. Also it has drawn my attention to some other aspects of therapy for example the harmful and damaging effects that psychotherapy may have on a client. I have found the review process to be a time consuming and laborious activity. I specifically experienced the data extraction- and analysis phase to be the most lengthy and tedious phase. It was difficult to work through the included articles to extract all the usable data and it produced a large dataset for me to break down into categories and then to condense those CHAPTER 3 129 categories into overarching themes. It took several weeks to try and make sense of the dataset. However it has changed my perspective on psychotherapy in a tremendous way as discussed previously. One of the highlights of this study was in working with my study leader, whom in my opinion has a very large knowledge base in change process research and experience in systematic reviews, and how he imparted this knowledge to me and assisted me in understanding this subject better. Lastly, it feels that I have gained a better grasp on this type of research, and what an entire research study process entails. As a last remark, I consider the five themes and their ensuing subthemes to offer a current and accurate view on all the relevant aspects involved in the change process specifically relating to significant events. For this reason it may guide practitioners in gaining awareness of significant helpful or hindering moments within therapy and being able to understand the impact that these may have. Psychotherapists might be able to adapt the way they look at therapy and certain interventions that they apply, in order to optimise the effects thereof. Recognising these moments and acting on them promptly and correctly or replicating them again at certain stages may optimise the effectiveness and thus also the overall outcome. These findings may also be valuable to consider at the start of a new process in order to gage whether specific techniques or components of therapy might or might not work. Thus the findings as structured by the five themes may serve as an operational framework to inform good practice in diverse theoretical modalities.