Learning from the client: The challenges of psychotherapy research and the contribution of qualitative methodologies

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By Eva Fragkiadaki

The implications of nomothetic psychotherapy research

Psychotherapy research has made significant progress in providing strong evidence for process and outcome in favour of specific approaches. However, after many years of research and advanced methodologies, we are still unsure about why psychotherapy works, and how and to what degree these findings can be applied in everyday practice (Kazdin, 2009). Evidence-based approaches do not appear to be effective for everyone, and the mechanisms of change are still investigated with diverse findings. Randomised controlled trials (RCT) and meta-analyses inform policy and guidelines followed by the likes of the National Institute for Health and Care Excellence (NICE). Illustrating this, NICE Guidelines for the treatment of Depression state that “well-defined” depression can be treated with CBT based on its proven efficacy, however “it is not effective for everyone” (NICE, 2009). Clinicians need evidence-based recommendations to inform their work with clients. It is notable though that evidence-based practice is based on nomothetic, quantitative approaches of inquiry but what is actually demanded from practitioners is to apply these theories in an idiographic context and adjust to the needs of the individual who seeks help (Persons, 2008).

One cannot reduce psychotherapy to specific factors and cannot reduce the person to a specific list of symptoms. Added to that, each psychotherapeutic encounter is unique, in terms of transference and real relationship factors. Rigid diagnosis criteria are challenged and culturally sensitive, social models of diagnosis are encouraged in the literature, which question the constant pursuit of functionality, fulfilment and happiness (Kirmayer, Gomez – Carillo & Veissiere, 2017). In reality, clients with the same labels are likely to experience their diagnosis in different ways (Hayes et al, 2019). Moreover, each therapist has inherent biases and internal processes of interpreting each client before deciding which interventions to apply and how (Makhinson, 2012). The therapist’s training, expectations, overgeneralisations and pressure for positive results have a significant impact on the decisions they will make for therapeutic action plans. Lastly, each psychotherapeutic dyad is different, each process that unfolds in this context is a different experience for both parties. Even if the therapist follows the same approach guidelines, they will be different with different clients (Hill, Chui & Baumann, 2013). Each therapeutic encounter forms a new interaction and discussion; a new therapy (Baldwin & Imel, 2020).

Traditional psychotherapy efficacy research struggles to capture the level of complexity therapeutic interactions entail. The findings make inferences about the general population but do not necessarily apply to the individual (Hayes et al., 2019). Another issue is the difficulty in defining each therapeutic modality given the new approaches that appear and their variations in application. Too many approaches are now presented in the literature for too many syndromes which account for too many statistical models, and the number is growing (Hayes et al., 2019). Moreover, there are many confounding factors when trying to measure the effects of psychotherapy, such as the therapist’s subjectivity, training, supervision, the therapist and researcher’s expectations and the clients’ presenting difficulties. The researcher’s subjectivity must also be recognised in the research process even for the most rigorous RCTs. Psychotherapy research entails bias and the effectiveness of psychotherapy can be exaggerated. Moreover, many studies may remain unpublished if results support null or negative hypotheses (Dragioti, Karathanos, Gerdle & Evangelou, 2017).

Going back to case analysis: the idiographic paradigm in psychotherapy research

Psychotherapy is a multi-faceted, complex phenomenon. How can we understand and represent its variability in evidence-based findings? Research is moving away from protocol and approach specific treatments towards a more client-centred way of exploring psychotherapy efficacy; it instead becomes a “personalized treatment” (Zilcha-Mano, 2019, p. 694). The focus is on the implementation of methodologies which can do justice to the complexity and variability of the phenomenon of psychotherapy. Qualitative research allows the exploration of the multidimensional interactions in psychotherapy encounters and the emergence of unexpected results (Hill et al., 2013; McLeod, 2011). By implementing methods such as the Narrative Assessment Interview (Angus, Levitt  & Hardtke, 1999), the  Change Interview (Elliott, Slatick & Urman, 2001) or the Hermeneutic Single-Case Efficacy Design (Elliott et al., 2009), qualitative research is nowadays being used more often in exploring psychotherapeutic processes and effects.

As psychotherapy researchers, we need to pursue a route that is different to “protocol-to-syndrome.” We are moving away from labels and therapy “brands” (Hofman, 2020, pp. 297 – 298) towards elaborate descriptions of people and therapies, focusing on what works, why and how, for both specific individuals or groups that share common characteristics. The suggestion is to distance ourselves from theory-driven process and outcome studies, from measurable and quantifiable behavioural changes (Hill et al., 2013) and instead to approach the client’s perspective in an open and explorative way; to enable learning and knowledge derived from the clients’ experience of psychotherapy efficacy. In particular, idiographic qualitative phenomenological research offers the means to explore intrapsychic change. A well-designed case study provides detailed, in-depth knowledge which is readily applicable to everyday clinical practice (Persons & Boswell, 2019).

Interpretative Phenomenological Analysis (IPA) is a qualitative methodology that focuses on the individual’s unique experiences of the situation studied. IPA can make a significant contribution by enabling researchers and practitioners to gain insights into client’s experiences of therapeutic processes. The philosophical, epistemological, and methodological underpinnings and guidelines of IPA allow for an in-depth exploration of the client’s experience, leading to significant conceptualisations on how therapeutic approaches work (Larkin & Thompson, 2012). It is based on the phenomenological paradigm as outlined by Husserl, Heidegger, and Merlau-Ponty (Smith, 1996; Smith, Flowers, & Larkin, 2009). It provides the framework to place the therapeutic encounter in context and analyse it; to go back to the phenomenon of psychotherapy “on its own terms.” The focus is on individuals, their subjective accounts and perceptions, bracketing the understanding of preconceived ideas, beliefs, and expectations.  IPA methodology views persons in-context as they expound on embodied, dynamic, and interactive experiences. Interpretation in IPA implies moving away from the obvious, focusing on the meaning participants attribute to their experience, engaging in a dialogue with the data, and illuminating sense-making (Smith, 1996; Smith et al., 2009). 

Adhering to an existential framework, IPA methodology does not rely on psychological theories for the collection and analysis of data. It is data-driven, emphasizing personal experience (Smith, 2017). It is deemed a useful method for psychotherapy process exploration as it frees the researcher from the compounds of psychotherapy theory and gives voice to the clients’ unique experience and intersubjective meaning-making processes (Larking & Thompson, 2012). Phenomenological methods have been applied to the exploration of adults’ experiences of psychotherapy during their childhood have changed their live, clients’ experience of positive change and to psychotherapy outcome studies (Binder et al., 2010; Midgley, Target, & Smith, 2006; Olofsson et al., 2019; Wilmots et al., 2019). IPA applied to psychotherapy research allows for the exploration of the clients’ perspective, the meaning they attribute to seeking and receiving help and how they conceptualise the psychotherapy process rendering the results useful for incorporation into everyday clinical practice (Binder et al., 2010; McLeod, 2011; Midgley et al., 2014). IPA guidelines help researchers keep the focus on the participants’ experiences and meaning-making processes, and can further bolster and clarify the knowledge of psychotherapy effects from the clients’ perspective.

Conclusions

Nomothetic approaches to research claim that there is one absolute truth outside of us to be discovered (Ponterotto, 2005). As psychotherapy researchers, the phenomenological perception of truth helps us view psychotherapy as real however it is the individual’ consciousness that determines its reality. IPA exploration of psychotherapy brings research back to the clients, to their experience of change, from which we can acquire significant insight on how and why psychotherapy works. We go back to the individual case and understand the psychotherapy processes from their perspective. Thus, the findings are closely linked to practice. Inventories and questionnaires may capture a small proportion of this variability in psychotherapy change procedures, but they are restricted to overt behaviours and symptoms whilst the questions might not be applicable to the person’s issues. The use of qualitative research methods in psychotherapy effectiveness and outcome research adds to our efforts to comprehend when and how psychotherapy works in an explorative and descriptive manner.

Qualitative psychotherapy research allows for the client’s voice to be heard. Their perceptions and interpretations of psychotherapy process and change may guide research conclusions, theory advancements and policies. Hence, psychotherapy is adjusted to the clients and the service users, and not the other way around. In recent literature, a more pluralistic method of inquiry is now considered in an effort to address the diversity of psychotherapy processes, encouraging researchers’ reflexivity on the aspect of psychotherapy they choose to explore (Rieken & Gelo, 2015). Various methodologies and epistemologies are now employed in the search for an answer to why psychotherapy works. Qualitative methodologies, and especially IPA, places the client in–context considering psychological, physical and social aspects of their experience of psychotherapy. Like clinicians who tailor their use of techniques to the specific client in the specific therapeutic relationship, researchers should consider individual needs, culture and social context, tailoring research methods to specific aspects of psychotherapy process and change.

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