Mapping the dialogue of change: A systematic review of sequential and moment-to-moment dynamics in psychotherapy

This systematic review (PROSPERO CRD42023399665) synthesized evidence from process-based microanalytic studies investigating therapist-client verbal exchanges in psychotherapy, focusing on sequential and time-series patterns.

From an initial pool of 1890 articles, 33 studies were included. Studies were conducted in 10 countries, retrieved from seven databases in three languages, and focused exclusively on outpatient psychotherapy. All studies employed observational coding systems and microanalytic methods to examine moment-to-moment interactions.

Despite variation in coding systems and contexts, a consistent pattern emerged: when clients engaged in improvement-related verbalizations or followed therapeutic directions, therapists typically responded with approval, forming a triadic sequence (therapist prompt → client change-oriented verbalization → therapist approval). In contrast, therapists' responses to client verbalizations misaligned with therapeutic goals were inconsistent, showing no reproducible pattern across studies.

Although outcomes were not directly assessed, findings suggest that therapist-client verbal interaction systematicity relates to in-session change. To enhance microanalytic research, we argue for a bottom-up approach emphasizing detailed, AI-assisted descriptions of therapist-client interactions before applying theory-driven sequential analyses.