{"id":266,"date":"2020-02-27T15:14:41","date_gmt":"2020-02-27T15:14:41","guid":{"rendered":"https:\/\/blogs.uwe.ac.uk\/psychological-sciences\/?p=266"},"modified":"2020-02-27T15:18:59","modified_gmt":"2020-02-27T15:18:59","slug":"learning-from-the-client-the-challenges-of-psychotherapy-research-and-the-contribution-of-qualitative-methodologies","status":"publish","type":"post","link":"https:\/\/blogs.uwe.ac.uk\/psychological-sciences\/learning-from-the-client-the-challenges-of-psychotherapy-research-and-the-contribution-of-qualitative-methodologies\/","title":{"rendered":"Learning from the client: The challenges of psychotherapy research and the contribution of qualitative methodologies"},"content":{"rendered":"\n

By Eva Fragkiadaki<\/a><\/h2>\n\n\n\n

The\nimplications of nomothetic psychotherapy research<\/h3>\n\n\n\n

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<\/a> for the treatment of Depression state that \u201cwell-defined\u201d depression can be treated with CBT based on its proven efficacy, however \u201cit is not effective for everyone\u201d (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). <\/p>\n\n\n\n

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 \u2013 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\u2019s 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). <\/p>\n\n\n\n

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Traditional\npsychotherapy efficacy research struggles to capture the level of complexity therapeutic\ninteractions entail. The findings make inferences about the general population but\ndo not necessarily apply to the individual (Hayes et al., 2019). Another issue\nis the difficulty in defining each therapeutic modality given the new\napproaches that appear and their variations in application. Too many approaches\nare now presented in the literature for too many syndromes which account for\ntoo many statistical models, and the number is growing (Hayes et al., 2019). Moreover,\nthere are many confounding factors when trying to measure the effects of\npsychotherapy, such as the therapist\u2019s subjectivity, training, supervision, the\ntherapist and researcher\u2019s expectations and the clients\u2019 presenting\ndifficulties. The researcher\u2019s subjectivity must also be recognised in the research\nprocess even for the most rigorous RCTs. Psychotherapy research entails bias\nand the effectiveness of psychotherapy can be exaggerated. Moreover, many\nstudies may remain unpublished if results support null or negative hypotheses\n(Dragioti, Karathanos, Gerdle & Evangelou, 2017).<\/p>\n\n\n\n

Going\nback to case analysis: the idiographic paradigm in psychotherapy research<\/h3>\n\n\n\n

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 \u201cpersonalized treatment\u201d (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<\/a> (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.<\/p>\n\n\n\n

As psychotherapy researchers, we need to pursue a route that is different to \u201cprotocol-to-syndrome.\u201d We are moving away from labels and therapy \u201cbrands\u201d (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\u2019s perspective in an open and explorative way; to enable learning and knowledge derived from the clients\u2019 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).<\/p>\n\n\n\n

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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\u2019s experiences of therapeutic processes. The philosophical, epistemological, and methodological underpinnings and guidelines of IPA allow for an in-depth exploration of the client\u2019s 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 \u201con its own terms.\u201d 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).  <\/p>\n\n\n\n

Adhering to an existential framework,\nIPA methodology does not rely on psychological theories for the collection and analysis\nof data. It is data-driven, emphasizing personal experience (Smith, 2017). It\nis deemed a useful method for psychotherapy process exploration as it frees the\nresearcher from the compounds of psychotherapy theory and gives voice to the\nclients\u2019 unique experience and intersubjective meaning-making processes\n(Larking & Thompson, 2012). Phenomenological methods have been applied to\nthe exploration of adults\u2019 experiences of psychotherapy during their childhood\nhave changed their live, clients\u2019 experience of positive change and to psychotherapy outcome studies\n(Binder et al., 2010; Midgley, Target, & Smith, 2006; Olofsson et al.,\n2019; Wilmots et al., 2019). IPA applied to psychotherapy research allows for\nthe exploration of the clients\u2019 perspective, the meaning they attribute to\nseeking and receiving help and how they conceptualise the psychotherapy process\nrendering the results useful for incorporation into everyday clinical practice\n(Binder et al., 2010; McLeod, 2011; Midgley et al., 2014). IPA guidelines help researchers keep the focus\non the participants’ experiences and meaning-making processes, and can further\nbolster and clarify the knowledge of psychotherapy effects from the clients\u2019\nperspective.<\/p>\n\n\n\n

Conclusions<\/h3>\n\n\n\n

Nomothetic\napproaches to research claim that there is one absolute truth outside of us to\nbe discovered (Ponterotto, 2005). As psychotherapy researchers, the\nphenomenological perception of truth helps us view psychotherapy as real\nhowever it is the individual\u2019 consciousness that determines its reality. IPA\nexploration of psychotherapy brings research back to the clients, to their\nexperience of change, from which we can acquire significant insight on how and\nwhy psychotherapy works. We go back to the individual case and understand the\npsychotherapy processes from their perspective. Thus, the findings are closely\nlinked to practice. Inventories and questionnaires may capture a small proportion\nof this variability in psychotherapy change procedures, but they are restricted\nto overt behaviours and symptoms whilst the questions might not be applicable\nto the person\u2019s issues. The use of qualitative research methods in\npsychotherapy effectiveness and outcome research adds to our efforts to\ncomprehend when and how psychotherapy works in an explorative and descriptive\nmanner.<\/p>\n\n\n\n

Qualitative\npsychotherapy research allows for the client\u2019s voice to be heard. Their\nperceptions and interpretations of psychotherapy process and change may guide\nresearch conclusions, theory advancements and policies. Hence, psychotherapy is\nadjusted to the clients and the service users, and not the other way around. In\nrecent literature, a more pluralistic method of inquiry is now considered in an\neffort to address the diversity of psychotherapy processes, encouraging\nresearchers\u2019 reflexivity on the aspect of psychotherapy they choose to explore (Rieken\n& Gelo, 2015). Various methodologies and epistemologies are now employed in\nthe search for an answer to why psychotherapy works. Qualitative methodologies,\nand especially IPA, places the client in\u2013context considering psychological,\nphysical and social aspects of their experience of psychotherapy. Like\nclinicians who tailor their use of techniques to the specific client in the\nspecific therapeutic relationship, researchers should consider individual needs,\nculture and social context, tailoring research methods to specific aspects of\npsychotherapy process and change.<\/p>\n\n\n\n

References<\/h3>\n\n\n\n

Angus, L., Levitt, H. & Hardtke, K. (1999). The narrative processes coding system: Research applications and implications for psychotherapy practice. Journal of Clinical Psychology, 55(10), <\/em>1255 \u2013 1270. <\/p>\n\n\n\n

Baldwin, S. A., & Imel,\nZ. E. (2020). Studying specificity in psychotherapy with meta-analysis is hard.\nPsychotherapy Research<\/em>, 30<\/em>(3), 294\u2013296. https:\/\/doi.org\/10.1080\/10503307.2019.1679403<\/a><\/p>\n\n\n\n

Binder, P.-E.,\nHolgersen, H., & Gier H\u00f8stmark, N. (2010). What is a \u201cgood outcome\u201d in\npsychotherapy? A qualitative exploration of former patients\u2019 point of view. Psychotherapy\nResearch, 20(3), <\/em>285 \u2013 294. doi: 10.1080\/10503300903376338 <\/p>\n\n\n\n

Dragioti, E., Karathanos, V.,\nGerdle, B., & Evangelou, E. (2017). Does psychotherapy work? An umbrella\nreview of meta-analyses of randomized controlled trials. Acta Psychiatrica\nScandinavica<\/em>, 136<\/em>(3), 236\u2013246. https:\/\/doi.org\/10.1111\/acps.12713<\/a><\/p>\n\n\n\n

Elliott, R., Partyka, R., Alperin, R.,\nDobrenski, R., Wagner, J., Messer, S. B., . . . Castonguay, L. G. (2009). An\nadjudicated hermeneutic single-case efficacy design study of experiential\ntherapy for panic\/ phobia. Psychotherapy Research, 19, <\/em>543\u2013557.\ndoi:10.1080\/
\n10503300902905947<\/p>\n\n\n\n

Elliott, R., Slatick, E., & Urman, M.\n(2001). Qualitative change process research on psychotherapy: Alternative\nstrategies. In J. Frommer & D. L. Rennie (Eds.), Qualitative psychotherapy research: Methods and methodology<\/em> (pp.\n69\u2013111). Lengerich, Germany: Pabst Science Publishers<\/p>\n\n\n\n

Hayes, S. C., Hofmann, S. G.,\nStanton, C. E., Carpenter, J. K., Sanford, B. T., Curtiss, J. E., &\nCiarrochi, J. (2019). The role of the individual in the coming era of\nprocess-based therapy. Behaviour Research and Therapy<\/em>, 117<\/em>(October\n2018), 40\u201353. https:\/\/doi.org\/10.1016\/j.brat.2018.10.005<\/a><\/p>\n\n\n\n

Hill, C. E., Chui, H., & Baumann, E.\n(2013). Revisiting and reenvisioning the outcome problem in psychotherapy: an\nargument to include individualized and qualitative measurement. Psychotherapy, 50(1), <\/em>68 \u2013 76. doi: 10.1037\/a0030571<\/p>\n\n\n\n

Hofmann, S. G. (2020).\nImagine there are no therapy brands, it isn\u2019t hard to do. Psychotherapy\nResearch<\/em>, 30<\/em>(3), 297\u2013299. https:\/\/doi.org\/10.1080\/10503307.2019.1630781<\/p>\n\n\n\n

Kazdin, A. E. (2009).\nUnderstanding how and why psychotherapy leads to change. Psychotherapy\nResearch<\/em>, 19<\/em>(4\u20135), 418\u2013428. https:\/\/doi.org\/10.1080\/10503300802448899<\/a><\/p>\n\n\n\n

Kirmayer, L. J.,\nGomez-Carrillo, A., & Veissi\u00e8re, S. (2017). Culture and depression in\nglobal mental health: An ecosocial approach to the phenomenology of psychiatric\ndisorders. Social Science and Medicine<\/em>, 183<\/em>, 163\u2013168. https:\/\/doi.org\/10.1016\/j.socscimed.2017.04.034<\/a><\/p>\n\n\n\n

Larkin, M. & Thompson, A. (2012).\nInterpretative phenomenological analysis. In Thompson, A. & Harper, D.\n(eds), Qualitative research methods in mental health and psychotherapy: a\nguide for students and practitioners<\/em>. John Wiley & Sons: Oxford, pp.\n99-116. <\/p>\n\n\n\n

Makhinson, M. (2012). Biases\nin the evaluation of psychiatric clinical evidence. Journal of Nervous and\nMental Disease<\/em>, 200<\/em>(1), 76\u201382. https:\/\/doi.org\/10.1097\/NMD.0b013e31823e62cd<\/a><\/p>\n\n\n\n

McLeod, J. (2011). Qualitative research in counselling and\npsychotherapy. <\/em>London: Sage.<\/p>\n\n\n\n

Midgley, N., Ansaldo, F., & Target, M.\n(2014). The meaningful assessment of therapy outcomes: Incorporating a\nqualitative study into a randomized controlled trial evaluating the treatment\nof adolescent depression. Psychotherapy, 51(1), <\/em>128 \u2013 137. doi: 10.1037\/a0034179 <\/p>\n\n\n\n

National Institute for Health\nand Care Excellence. (2009). Depression\nin adults: Recognition and management <\/em>(NICE Clinical Guideline CG 90).\nRetrieved from https:\/\/www.nice.org.uk\/guidance\/cg90<\/a><\/p>\n\n\n\n

Olofsson, M. E., Oddli, H. W., Hoffart, A.,\nEielsen, H. P., & Vrabel, K. R. (2019). Change processes related to\nlong-term outcomes in eating disorders with childhood trauma: An explorative\nqualitative study. Journal of Counseling Psychology, advanced online publication.\n<\/em>doi: 10.1037\/cou0000375<\/a><\/p>\n\n\n\n

Persons, J. B. (2008). The case formulation approach to cognitive \u2013\nbehaviour therapy. <\/em>Guildford Press.<\/p>\n\n\n\n

Persons, J. B., &\nBoswell, J. F. (2019). Single case and idiographic research: Introduction to\nthe special issue. Behaviour Research and Therapy<\/em>, 117<\/em>(March),\n1\u20132. https:\/\/doi.org\/10.1016\/j.brat.2019.03.007<\/a><\/p>\n\n\n\n

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Rieken, B. & Gelo, O. C.\nG. (2015). The philosophy of psychotherapy science: Mainstream and alternative\nviews.\n In: Gelo O., Pritz A., Rieken B. (eds) Psychotherapy Research<\/em>. Springer, Vienna<\/p>\n\n\n\n

Smith,\nJ. A. (1996). Beyond the divide between cognition and discourse: Using interpretative\nphenomenological analysis in health psychology. Psychology and Health, 11(2), <\/em>261 \u2013 271. doi: 10.1080\/08870449608400256<\/p>\n\n\n\n

Smith, J. A. (2017). Interpretative\nphenomenological analysis: Getting at lived experience. The Journal of Positive Psychology, 12(3), <\/em>303 \u2013 304. doi: 10.1080\/17439760.2016.1262622 <\/p>\n\n\n\n

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Wilmots, E., Midgley, N., Thackeray, L.,\nReynolds, S. & Loades, M., (2019). The therapeutic relationship in\nCognitive Behaviour Therapy with depressed adolescents: A qualitative study of\ngood-outcome cases. Psychology and Psychotherapy: Theory, Research and\nPractice. <\/em>doi: 10.1111\/papt.12232<\/p>\n\n\n\n

Zilcha-Mano, S. (2019). Major\ndevelopments in methods addressing for whom psychotherapy may work and why. Psychotherapy\nResearch<\/em>, 29<\/em>(6), 693\u2013708.\nhttps:\/\/doi.org\/10.1080\/10503307.2018.1429691<\/p>\n","protected":false},"excerpt":{"rendered":"

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 … Continue reading “Learning from the client: The challenges of psychotherapy research and the contribution of qualitative methodologies”<\/span><\/a><\/p>\n","protected":false},"author":34,"featured_media":267,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"wds_primary_category":0,"footnotes":""},"categories":[10,3],"tags":[60,9,50,8],"class_list":["post-266","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-promoting-psychological-health","category-research","tag-ipa","tag-psychology","tag-psychotherapy","tag-research"],"_links":{"self":[{"href":"https:\/\/blogs.uwe.ac.uk\/psychological-sciences\/wp-json\/wp\/v2\/posts\/266","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.uwe.ac.uk\/psychological-sciences\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.uwe.ac.uk\/psychological-sciences\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.uwe.ac.uk\/psychological-sciences\/wp-json\/wp\/v2\/users\/34"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.uwe.ac.uk\/psychological-sciences\/wp-json\/wp\/v2\/comments?post=266"}],"version-history":[{"count":2,"href":"https:\/\/blogs.uwe.ac.uk\/psychological-sciences\/wp-json\/wp\/v2\/posts\/266\/revisions"}],"predecessor-version":[{"id":271,"href":"https:\/\/blogs.uwe.ac.uk\/psychological-sciences\/wp-json\/wp\/v2\/posts\/266\/revisions\/271"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/blogs.uwe.ac.uk\/psychological-sciences\/wp-json\/wp\/v2\/media\/267"}],"wp:attachment":[{"href":"https:\/\/blogs.uwe.ac.uk\/psychological-sciences\/wp-json\/wp\/v2\/media?parent=266"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.uwe.ac.uk\/psychological-sciences\/wp-json\/wp\/v2\/categories?post=266"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.uwe.ac.uk\/psychological-sciences\/wp-json\/wp\/v2\/tags?post=266"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}