clients' experiences of psychodynamic and brief psychodynamic therapy: a phenomenological study...
TRANSCRIPT
Clients' experiences of psychodynamic and brief psychodynamic therapy: A phenomenological study
Dr. Jodie Fellows
Dr. Camilla Watters
Dr. Amanda Gatherer
SPR UK Conference Ravenscar
16 March 2009
Psychodynamic (PDT) and Brief Psychodynamic (BPT) Therapy
PDT and BPT aim to increase understanding of self and relationships
Theoretically understanding = change in interpersonal behaviour
Transference and countertransference
Recurrent relationship patterns
Background
Psychotherapy is “a subjective interpersonal experience” (Macran, Ross, Hardy, Shapiro, 1997 p 327)
Yet understanding of the processes clients undergo during psychodynamic therapy is limited.
Clinical & Theoretical Perspectives
Mann (1973)
Unconscious magical expectations
Transference cure
Disappointed reality
Ending – negative affect and repression
Clinical & theoretical perspectives cont...
Leiper & Maltby (2004)
Getting it off your chest
Understanding
Relationship
Regression
Differentiation
Creativity
Qualitative Research
Swedish study – 17 clients in PDT
PDT – open, painful exploration of inner selves
Therapists distant position
Ambivalence about the therapy and therapist
Nilsson, Svensson, Sandell and Clinton, (2007)
Qualitative Research cont...
UK IPA study of psychoanalytic therapy
N=6 16-21 years old
Difficult to open up, stressful, powerful, exhausting
Ending – ambivalence, feelings of loss, deskilled, moving on
Bury, Raval and Lyon, (2007)
Aims
Qualitative approach used to: Explore working age adults experiences of PDT and BPT as it is offered in the NHS
Explore clients' experiences of receiving/working within an informed formulation of their difficulties
Explore the way clients describe their process of change.
Methodology
Interpretative Phenomenological Analysis (Smith & Osborn, 2003)
Therapists recruited adults from CMHTs in PDT/BPT
Naturalistic
Letters sent to those no longer in therapy
N=6 ongoing = 3 terminated = 3
Audiotaped interviews were transcribed verbatim
IPA (Based on Smith & Osborn, 2003)
Read the first transcript, note interesting and significant points
Add emerging theme titles to concisely represent the data
List themes, look for theoretical connections
Hierarchically organise, superordinate and subordinate themes. Name these themes
Consolidate theme list, re-analyse all transcripts in light of the new themes
Methodological rigour
Results
Three superordinate themes:
Relationship
Changes observed
Journey
Results - Relationship
Most frequently occurring theme
Wide variation in experience even when participants had the same therapist
Client factors including expectations, assertiveness and locus of control seemed to contribute to the experience
Relationship - assertiveness
Barbara
I wouldn't have the confrontational confidence to say “actually you're sitting there telling me how angry I am, but part of this now is because of you” [laughs]
Relationship – locus of control
Jenny
He’s seen what I’m up to, if I’m being abit manipulative... then I know I have togo and think about it and try to work outwhat I am doing.
Results – Changes observed
More able to cope with “reality”
Thoughts about themselves
Interpretations of other people's behaviour
Their own interpersonal behaviours
Increased self-care
Changes observed – Interpretation of others' behaviour
Deborah
I have changed, ... It's made me look
more at where he [father] is coming
from and why he does the things he
does. The whole picture has changed
because I have looked at me. So I am
able to be more understanding of him.
Changes observed – Thoughts about self
Ron
I've noticed a lot of changes within myself there's definitely been a huge improvement, there are things I've done now that I definitely wouldn't have done a year a half ago/two years ago and I feel happier in myself.
Journey
Uncertainty/leap of faith
Emotionally painful
Formulation/developing an understanding
Changing habits of a lifetime
Ending
Change after ending
Journey - Leap of faith
Ron
Can you tell me a bit about yourself?” that was actually his first question and I remember thinking “what the f*** do I say now? What does that mean?
Journey - Emotionally painful
Caroline
I went deeper into my patterns and thingsand that's when I'd get really upset. Itwasn't like an upset. It was a deepinternal sob from the centre, it was likethe very core of me.
Journey - Formulation
Phoebe
A lot of what we talked about, I knew itup here [pointing to head] but that’s thechange that I made in therapy, it wasabout the information going from here[head] to here [pointing to chest] andthat’s why it’s had such a big impact.
Journey - formulation
Jenny
...it was sort of quite like that [hand miming light bulb coming on over head] like really quite striking moments of revelation and the penny dropping and thinking “oh this is what I do, this is what I don't do and this is what I can do”.
Journey - Changing habits of a lifetime
Ron
You just think “oh for f***'s sake, whydid I do that again? It's so obvious!”... Ifeel annoyed with myself because theconversation or my reaction to them isbased in the past rather than therelationship I am having with them thereand then.
Journey - Ending
Barbara
Frightened to death, I can honestly say frightened to death, [begins to cry]
Journey - Change after ending
Caroline
I went through a bit of a grieving process andthen I went through a stage where I felt in avoid, not knowing what to do really... and then ...I started to feel passionate about things, andwhen I started to feel passionate about them, Istarted to focus more and take more action onthem so it was almost like a generator insidebeginning to whirl and move me forward.
Summary of findings
Like a roller coaster ride (Bury et al, 2007)
Relationship
Client factors
Recognition of changes throughout
Summary of findings cont...
Leap of faith
Understanding - penny dropping vs development of understanding
Differentiation - Repetition compulsion
Readiness for ending Ending negative affect - Fear and anger
Mann (1973)
Positive change after ending
Methodological considerations
Participant selection
Subjectivity
The “purity” of the therapy model employed
Multiple snapshots rather than longitudinal
Differential reinforcement within interview?
Clinical implications
Client selection
Understanding = change in how therapists prepare clients for certain elements of the therapy?
Pain of the ending
Booster session debate
Conclusion
General agreement that clients' experiences of therapy are centrally important (Rogers, 1951; Macran, et al, 1999)
Psychodynamic theory – understanding leads to change
Therapist understanding may enhance client experience.
References
• Bury, C., Raval, H. & Lyon, L. (2007). Young people's experiences of individual psychoanalytic psychotherapy. Psychology and Psychotherapy: Theory, Research and Practice, 80, 79-96.
• Leiper, R. & Maltby, M. (2004). The psychodynamic approach to therapeutic change. London: Sage.
• Macran, S., Ross, H., Hardy, G. E. & Shapiro, D. A. (1999). The importance of considering clients' perspectives in psychotherapy research. Journal of Mental Health, 8 (4), 325-337.
• Mann, J. (1973). Time-limited psychotherapy. London: Harvard University Press
•Mcleod, J. (1990). The clients experience of counselling and psychotherapy: A review of the literature. In W. Dryden & D. Mearns (Eds.), Experiences of counselling in action, (pp. 66-79). London: Sage Publications.
• Nilsson, T., Svensson, M., Sandell, R. & Clinton, D. (2007) Patients' experiences of change in cognitive-behavioural therapy and psychodynamic therapy: a qualitative comparative study. Psychotherapy Research, 17 (5), 553-566.
• Smith, J. & Osborn, M. (2003). Interpretative phenomenological analysis . In: J. A. Smith, (Ed.) , Qualitative psychology: a practical guide to research methods, (pp.51-80). London: Sage.