An initial evaluation, a process evaluation, and a final evaluation were carried out in the psychotherapeutic treatment of 14 drug-addicted patients at the Psychiatric Hospital of Havana to define how and from which indicators the expected changes resulting from therapy were reflected. The objective was to evaluate the therapeutic change after the application of the intervention program. A mixed exploratory-descriptive longitudinal approach was used, which took process-result research in psychotherapy as a reference. The Manual of Observation, Recording and Coding of Episodes of Change and Stagnation and psychometric evaluations of anxiety and depression were used.

Patients experienced clinically significant change in state (64.3%) and trait (85.7%) depression and state (64.3%) and trait (64.3%) anxiety. 103 moments of change were identified, 72 intra-session and 31 extra-session. The remission of state anxiety was significantly correlated for 0.689** with the establishment of new relationships between aspects of the environment and biographical elements. Most of the patients showed a clinically significant change in anxiety and depression; in turn, all manifested moments of change that vary depending on the particularities of the individual and group process. A significant relationship was found between decreased state anxiety and moments of change.

The process of change in drug addiction occurs with frequent abandonment and instability in treatment [1], lack of motivation and resistance to change [2], frequent relapses in consumption [3] and lack of awareness of the disorder. In addition, a series of factors that favor change are presented, such as social pressure, the search for better health, the negative social consequences related to consumption and the inability to abandon consumption[4,5]. Such characteristics reflect the complexity of the change in addictions, which requires a multiple perspective of its study. Studies on the change in psychotherapy in drug addictions have focused mainly on demonstrating the effectiveness of different treatment approaches or on the analysis of a certain variable of interest to the researcher. The designs are characterized by the use of a quantitative methodology and the use of psychometric instruments. Therefore, the questions associated with how and why the change occurs continue without a precise answer.

At the beginning, research in psychotherapy and interventions related to mental health was divided into outcome research, which was dedicated to studying the extent to which patients change after treatment, and process research, which was responsible for investigating what happens within of psychotherapy sessions. Greenberg [7] developed research on the process of change [6,7], articulating both study perspectives, to explain how and why it occurs; according to this author:

With the identification of change processes as a research objective, the dichotomy between process and outcome is broken down and replaced by the effort to relate the process in different episodes of change to different points along a continuum. result” (p. 8). 

Current process investigations not only analyze what happens within the therapy, but also consider the final result, thus becoming process-outcome studies [8]. This type of study consists of evaluating an aspect of the psychotherapy process and then correlating it with the results [9].

Process-outcome studies often include ratings from experienced observers; furthermore, their ratings are often made using standardized scales or specific measures [9]. These are made from the therapists' transcripts, audio or video recordings of the sessions. However, a large part of these studies have opted for quantitative methods, while the qualitative perspective has been used less, limiting the use of narrative approaches and discourse analysis [9]. Significant events are studied in change process research and the aim is to identify the most important moments that influenced the outcome of a psychotherapy. They can be studied from various perspectives: that of the patient, the therapist or an external observer [9]. They are characterized by occurring at a defined time in the session, on a specific topic and where there are emotions associated with the moment [7]. It has its benefits6 since they are: flexible, adaptable to different types of therapy and events, and integrative as they draw on the strengths of simpler models and generally share several methodological characteristics with other lines of research.

These moments of high significance during the psychotherapeutic process have been named in different ways such as: “events of change” [7], “episodes and moments of change” [8,10]. The latter is the one used in the present study. An episode of change is understood as a more extensive segment of the therapy that implies a transformation in the subjectivity of the patient and includes a moment of change as its terminal point [11]. Then, the moment of change would be the most significant interval experienced by the patient where a change of meanings occurs in relation to a topic, which can be observed in the sessions or narrated by them in reference to extra-therapeutic situations [12]. These express what changes in the patient's view of himself, his problems and symptoms, and their relationship with the context in which they occur [10].

Krause et al. [13] wrote a list of generic indicators based on the Theory of Subjective Change to empirically identify the moments and episodes of change during the sessions based on the patient's narrative. For these authors, psychotherapeutic change is a transformation in the subjective patterns of interpretation and explanation of themselves and of reality that lead to the development of a new subjective theory. Cognitions are resignified little by little through associations promoted by the therapist. The change occurs in successive stages that increase in complexity level, allowing them to be labeled and assigned to a particular indicator. The model has been validated through multiple studies [8,10,11,12,14]. 

This work defends the use of the process-result approach given its benefits for research, greater access to the process of change through various qualitative and quantitative instruments. For this, the general objective was proposed: to evaluate the therapeutic change during the application of an intervention program in a group of addicts in the Psychiatric Hospital of Havana.

The study is based on a mixed research approach (QUANTITATIVE-qualitative) with a nested or embedded intervention design [15], with an exploratory-descriptive cut, which presents a longitudinal panel nature. 
Sample 
There were 14 male patients between 21 and 54 years old with Drug Use Disorder, who were selected in the specialized service. The selection was intentional, according to the established inclusion/exclusion criteria. The inclusion criteria were: being between 20 and 60 years old, willing to participate in the study, being recently admitted to the hospital for a Substance Use Disorder. The exclusion criteria were: to present a dual pathology of a psychotic and/or defective level. Table 1 below shows the sociodemographic data of the sample.

Instruments used 

1. State-Trait Anxiety Inventory (IDARE) by Ch. Spielberger, R. Díaz Guerrero et al. (1966) Cuban versión [16]. 
2. State Trait Depression Inventory (IDERE) by Martín, Grau, Ramírez and Grau, (Cuban version) [16]. 
3. Manual of Observation, Recording and Coding of Episodes of Change and Stagnation [17,18]. The procedure of observation, recording and coding of the episodes of change comprises two stages, the first consists of the observation of the psychotherapeutic process by the observers and the second, is comprised of a process of conciliation between the observers, where the episodes of change are delimited. change and the change indicator (CI). 

Procedure 

Permission was requested from the management of the Psychiatric Hospital of Havana to develop the study, as well as the informed consent of the patients. The study was organized in three stages. The pre-test was carried out, then the sessions were observed to identify and codify the moments of change and at the end the post-test was carried out.

Data processing The Reliable Rate of Change (RCI) [19] was calculated to identify significant clinical changes in patients due to the treatment received. An observation record was made where the moments of change and their origin (intra-session or extra-session) were identified. For this, the observers took a quote from the speech and placed it in the therapeutic process. The observations and the content of the transcripts were analyzed. The episode of change in the transcript of the sessions was then categorized and delimited. The presence of clinically significant changes obtained from the ICC of the anxiety and depression scores was correlated (Spearman's Rho), with the manifestation of the CI in the patients and their frequency according to their character (intra-session or extra-session) and corresponding phases. This procedure is used to achieve an adequate integration of the results achieved. Finally, the methodological triangulation was carried out to ensure the consistency of the data collected.

Identification of moments of change 

From the 15 sessions analyzed, a total of 103 moments of change were distinguished, which corresponded to (14) of the (19) indicators evaluated. The presence of both extra-session and intra-session CI were confirmed, although the manifestation of the latter is much greater, being more than double the frequency of the former. From the total moments of change, 72 correspond to those of intra-session, while 31 were detected outside the integrative group therapy associated with other therapeutic modalities that are carried out in the medical service where the study was carried out. It was possible to identify a higher prevalence of low-level CI with 62; while the average level was 40, a lower figure but relevant in the evolution of the cases. Regarding the indicators with the highest level of hierarchy, only one appearance of the CI was reported. 17; result consistent with the levels of complexity reached in relation to the number of sessions administered to the group that received integrative group therapy.

The CI that stood out with greater frequency were (2), (5), (7), (9) and (11). While, the indicator of low level or initial phase of the therapy that stood out the most was (5), which alludes to the initial questioning of the usual forms of understanding and behavior. Of those belonging to the middle phase, indicator (11) was observed more repeatedly, which refers to the establishment of new relationships between personal, environmental and biographical aspects. Among the moments of changes identified (N=103), the indicator with the highest prevalence was (11), with 15.5%, and the second most frequent was (5), with 13.6%. In this sense, it was observed that the patients alluded to the establishment of new relationships between their own aspects, the environment, and biographical elements (11), as well as the questioning of habitual ways of understanding, behaviors and emotions (5), based on of identification with the narrated testimonies and the experiences of the other members of the group. It was observed that the distribution of these indicators in the 14 members of the group is not given equally; that is, there are members who manifest a greater number of moments of change, while others present a poor presence of indicators during the development of the program. These results can be seen in the following Figure 1.

Figure 2 shows the frequency of indicators per session, in the first five sessions the highest peaks of moments of change are observed, while in the final sessions a slight growth is seen

Analysis of intra-session and extra-session moments of change 

The moments of change were manifested more frequently within the sessions (69.9%) than outside them (30.1%). Therefore, the questioning of usual forms of understanding, behaviors and emotions were identified more frequently in the intra-session CI group. 5, and the establishment of new connections between different aspects of the self, current and biographical experiences, and aspects of the CI environment. eleven; as shown in figure 3. The indicator (5) responds to the initial phase, while the indicator (11) responds to the phase or middle level of the process. The nature of these moments of change corresponds to what is usually known as "insight", which is consistent with the proposal of the program that seeks the recognition and understanding of one's own aspects and the relationship that these have with respect to his addiction and his environment.

From the analysis carried out on each of the participants based on the 

presence of Indicators of Change (CI), it was observed that the indicators do not follow the expected theoretical sequence regarding their evolution. Analysis of intra-session and extra-session moments of change The moments of change were manifested more frequently within the sessions (69.9%) than outside them (30.1%). Therefore, the questioning of usual forms of understanding, behaviors and emotions were identified more frequently in the intra-session CI group. 5, and the establishment of new connections between different aspects of the self, current and biographical experiences, and aspects of the CI environment. eleven; as shown in figure 3. The indicator (5) responds to the initial phase, while the indicator (11) responds to the phase or middle level of the process. The nature of these moments of change corresponds to what is usually known as "insight", which is consistent with the proposal of the program that seeks the recognition and understanding of one's own aspects and the relationship that these have with respect to his addiction and his environment.

Other CIs that stand out, but with less presence, are indicators 2, 3, 6 and 7, all belonging to the low level or initial phase. These indicators are associated with the acceptance of limits and recognition of the need to be helped (2), the acceptance of the therapist as a professional capable of offering timely help (3), the manifestation of the need for change (6), and the recognition of their own participation in the problems (7). Regarding the presence of extra-session CI, the expression of a new CI behavior or emotion was identified more frequently. 9; as shown in figure 4. This is consistent with its behavioral nature and was determined through the locution of an experience, reaction or handling of a situation in his current life in a different and new way, explicitly referred to as a change related to the therapeutic experience. This CI responds to a medium level of the process

In the second degree of predominance, the acceptance of the existence of a CI problem appears. 1, and acknowledgment of one's own participation in CI problems. 7. In drug addictions, the inability to recognize and accept the existence of a problem and their participation in it is very characteristic. The conjunction of events that occurred during their stays at home and the psychological effects of the treatment received, provoked this movement towards awareness of the problem and its consequences. 

Correlation between indicators of change and the results of the ICC 

A positive and significant correlation was found between the IDARE (state) and the Indicators of Change (CI) both intra-session and extra-session; that is, a greater presence of intra-session CI and extra-session CI are associated with changes of clinical significance in anxiety as a state. 

Spearman's correlation coefficients were determined according to the frequency of the Indicator of Change (CI) number and the presence of clinically significant changes in psychometric assessments. A positive and significant correlation was found between the IDARE (state) and the Indicators of Change (CI) 5 and 11, in addition, the CI 11 was also correlated with the IDERE (trait) as observed in Table 3. The establishment of new connections with the patient's own, environment, and biographical aspects are associated with clinically significant change in state anxiety and trait depression; while questioning habitual forms of understanding, behavior and/or emotion are associated with a reduction in state anxiety. 

A positive and significant correlation is observed between the IDARE (state) and the moments of change found in the second phase of the psychotherapeutic process, that is, the increase in permeability towards new understandings is associated with clinically significant changes in state anxiety

The results of the pre-test confirm those found in other studies on the presence of these symptoms associated to this pathology [20]. It is observed that the change measured through the results does not keep a close relationship with the evolutionary process of the change during the sessions. In other words, the final result sometimes did not agree with the process of therapeutic change during the sessions. In relation to this, Echávarri et al. [14] affirm that: “the evolution of meanings may have a counterpart in the evolution of subjective well-being at the symptomatic level, but the fact that it does not have it, or has it only partially, does not invalidate the results of neither of the two dimensions of change” (p. 19). The therapeutic change caused by the treatment was verified from the CIs proposed by Krause et al. [10,13]; in addition, this instrument demonstrated its validity to evaluate the change in addicts under treatment [21].

In contrast to previous studies [13,21], an evolution of the moments of change is shown in a helical manner, manifesting large fluctuations in the hierarchy of the indicators. In other words, the CIs didn’t behave according to the evolution sequence for psychotherapeutic interventions proposed by the aforementioned authors. This behavior could also be observed in other works[1,23]. This result may be associated with two main reasons: the non-consideration of the novelty criterion for the analysis and/or instability in the various spheres of life of addicted patients. Only 14 of the 19 indicators described were detected. The explanation could be the short time that the treatment lasted, which could have influenced it. In addition, associated with the complexity and characteristics of substance addictions, it was not possible to reach higher levels in the hierarchy of indicators.

According to the phases of psychotherapy, there was a predominance of low level indicators (62) followed by medium level (40). The first could be due to not considering the novelty criterion in the analysis. It is interpreted that the patients returned to the initial phase CIs as ways to reinforce previous changes, perhaps associated with characteristics of addictions. The moments of change were not distributed equally in the participants, that is, if a person participates less, it is difficult to detect their moments of change with respect to more active patients. The fact that CI could not be detected does not mean that it is not possible to observe it in this way [23]. For this reason, the outcome study with psychometric evaluation as a complement was decided. Seven patients showed a frequency of less than five moments of change; however, four of them showed significant psychometric changes.

The highest frequency of moments of change was found in the first five sessions of the program. Patients usually experience significant changes in the initial phases of treatment [24]. In the five intermediate sessions a reduction was observed and in the last sessions an increase. This could be due to the fact that the relational phenomena and the evolutionary stages of the group can favor or inhibit change in its members [25], and be reflected in the appearance of moments of change during the process; this does not diminish the importance of the gains made in later phases of therapy [24].

A greater presence of intra-session moments of change was found with a predominance of 69.9% in relation to extra-session moments of change with the remaining 30.1%. Patients received psychotherapy for 45 days, while in other studies the therapies lasted longer and still reported a similar number of intra-session and extra-session moments of change [1,13,21]. At the beginning of treatment, more moments of change were recorded intra-session than extra-session. This result coincides with Farkas et al.[21] and Krause et al. [13]. Although in the final sessions, these works reflect an increase in the moments of extra-session change with respect to those of intra-session, obtaining an opposite result with the present study. There were more moments of extra-session change in initial sessions than in the final ones. This could be due to the fact that the patients did not reach higher levels of CI as a result of the number of sessions applied, where high-ranking indicators are linked to extra-session changes and where the patients are more autonomous and independent [13].

The indicators of Change (CI) most frequently observed were: CI 11: establishment of new relationships between personal aspects, the environment and biographical elements: CI. 5: unfreezing of habitual ways of understanding, behaviors and emotions CI. 2: acceptance of one's own limits and recognition of the need for help CI. 7: acknowledgment of own participation in the “problems” CI. 9: manifestation of a new behavior or emotion

When compared with the study by Valdés et al.21, it coincides with the CI. 2, 9 and 11, while in relation to Farkas et al.23 the similarity is in the CIs. 9 and 11. Regarding the study by Echávarri et al. [14], the concordance of the results was sustained by the CIs. 5, 9 and 11. The high presence of these indicators can be understood in relation to the objectives of the program, where the catharsis of experiences of high personal significance associated or not with addiction was stimulated. Patients who reflect a change of opinion regarding themselves and others are, in general, those who obtain more significant results in treatment [26]. This agrees with what was found in the investigation where the patients who changed their self-assessment and the assessments with respect to others, showed a greater reduction in anxiety and depression. These results could be associated with the time of consumption, type of dependency and treatments previously received.

A relationship was found between intra-session and extra-session CIs with changes expressed in state anxiety. A similar result was found in Echávarri et al. [14] where CI intra-session and extra-session in two therapies studied correlated significantly with the subjective discomfort subscale of the OQ-45.2, a subscale that includes anxiety and depression as most common intra-psychic symptoms [27]. The opening and development of new understandings (indicators 5 and 11), is associated with changes in state anxiety and trait depression, that is, a greater understanding of personal history and negative emotions associated with addictions would explain it. A significant relationship was found between the frequency of moments of change present during the phase of permeability towards new understandings (Phase 2) and the significant decrease in state anxiety.

A clinically significant change in both state and trait anxiety and depression were identified in most patients. It was also found that all the patients manifested moments of change identifiable from the Generic Indicators of Change (GIC), although the appearance of these did not correspond to the hierarchy established by the theory. In addition, the frequency of the moments of change varied with respect to the CI, the patient, the session and the phase of the therapeutic process, that is, they responded to the particularities of the individual and group process. A statistically significant relationship was determined between the moments of change found from the CI and the changes of clinical significance, where the decrease in state anxiety was associated with the presence of the moments of change. Measurement of psychotherapeutic change through CIs in conjunction with outcome assessments is highly relevant.