Researching Psychotherapy, the Importance of the Client's View: A Methodological Challenge
by
Neil Scott Gordon
+

The Qualitative Report, Volume 4, Numbers 3 & 4, March, 2000
(http://www.nova.edu/ssss/QR/QR4-3/gordon.html)


Abstract

This paper argues that research approaches which are aimed at developing our understanding of psychotherapy which fail to address the client's interpretation of events will only provide a limited picture of its true nature. The discussion explores the philosophical underpinnings of research in this area through analysing contemporary debates and controversies. The difficulties of defining the term "psychotherapy" are acknowledged while highlighting the centrality of the concept of relationship in current definitions. The question "What is psychotherapy?" is further addressed by offering a brief overview of the theoretical assumptions which influence some current approaches to clinical work. Attention is also given to previous research in psychotherapy which focuses on the client's perspective. This is followed by a discussion of the importance of researching psychotherapy from a range of ontological perspectives based on a critique of the limiting nature of current approaches. A theoretical account of the importance of the clients' perspective is also presented, concluding with an argument for the conduct of research which is more relevant to psychotherapy practice.

Introduction

When attempting to discuss the nature of psychotherapy, it has to be acknowledged that psychotherapy practice is enormously diverse. Holmes and Lindley (1989), illustrate this diversity with reference to there being well over three hundred different types of psychotherapy, ranging alphabetically from Active Analytical Psychotherapy to Zaraleya Psychoenergetic Technique. Smail (1983), discusses how this diversity has resulted in the creation of different schools with fundamentally different, and often mutually exclusive, theoretical ideas. In the past this situation has led to an emphasis on the differences, rather than the similarities, between approaches as many therapists have defended the theoretical claims of their school against the rival claims of other schools (Dryden, 1996).

Attempts have been made in more recent writings (Pilgrim, 1997; Dryden, 1996; Gelso & Hayes, 1998) to look at the whole spectrum of psychotherapy and develop a less sectarian approach. Pilgrim (1997) describes psychotherapy as a " type of personal relationship entailing a series of negotiated meetings containing conversations" (p. 97). The central feature of psychotherapy is defined by Holmes and Lindley (1989) as "..... the use of a relationship between therapist and patient - as opposed to pharmacological or social methods - to produce changes in cognition, feeling and behaviour". These more universal definitions tend to focus upon the relationship. A definition reflecting the unique social role of psychotherapy is offered by Smail (1987). He describes it as a situation where people are offered the rare opportunity to pursue the truth about themselves and their lives. This is without the threat of blame and disapproval and without the risk of offending or hurting the person to whom they are revealing themselves. Although these definitions emphasise different aspects, all indicate how central the relationship is to any understanding of the practice of psychotherapy.

A more Ďanthropological' definition is offered by Frank and Frank (1991) who see therapy as a situation comprising three main elements: Firstly, a healing agent who is either a professional with officially recognised expertise, or others such as a fellow sufferer or group of fellow sufferers; Secondly a sufferer who is seeking relief; Lastly a healing relationship that includes a structured series of contacts between healer and sufferer. This definition again acknowledges the importance of the relationship and its contribution to producing a change in the person seeking help. The language of Frank's definition emphasises the similarity between psychotherapy and other forms of "healing". In describing the main elements of therapy, Holmes and Lindley (1989) use the terms: structure, space and relationship. "Structure", they suggest, represents the regular time and place within which the therapist and client can meet. "Space", they describe as arising from the structured contact where opportunity is provided for reflection and self-exploration not normally available in everyday life. The "relationship" they describe as the most fundamental aspect of therapy will be dependent upon the quality of the relationship and the way it is used.

This does not, however, indicate that the investigation of psychotherapy is simplified by a focusing of attention on the relationship. The relationship itself is viewed differently by competing theoretical schools, who view the nature of distress differently so complicating the relationship issue. This is supported by Gelso and Haye's(1998) conclusion that the therapists' assumptions about the cause and maintenance of the client's distress contributes to the nature of the relationship established with the client.

Theoretical Approaches

Theories of psychotherapy have evolved from a variety of psychological perspectives which represent alternative theories on the nature of psychological disturbance. These provide the therapist with a theoretical framework which enables him/her to conceptualise the client's problems. This framework also guides the therapist in his/her choice of interventions which develop from the theoretical interpretation of the causes, manifestations and consequences of the client's difficulties (Pilgrim, 1997). In offering an overview of the wide range of psychotherapy approaches, several authors have attempted to group them under broad perspectives (Norcross & Prochaska, 1983; Dryden, 1996; Gelso & Hayes, 1998). For the purpose of this paper these will be described as: Psychoanalytic/Psychodynamic, Humanistic/Existential and Cognitive/Behavioural. It should be emphasised that these descriptions represent the core theoretical models of psychotherapeutic practice, and do not attempt to address the great variety of therapeutic approaches which are influenced by these ideas. These descriptions include an introduction to the underlying theoretical assumptions, the focus of intervention and the significance of the client/therapist relationship.

Psychoanalytic/Psychodynamic Approaches

Psychoanalytic/Psychodynamic Approaches have developed from the work of Freud and those described as psychoanalytical "deviationists" (Gelso & Hayes, 1998) and include Adler, Jung, Sullivan and Fromm. Practitioners who use this approach tend to view psychological distress as being related to unconscious mental processes (Jacobs, 1998). Freud's contribution has been developed by others, some of whom have followed his basic assumptions, while others have developed more independent approaches. The term "psychodynamic" offers a wider perspective which encompasses the different analytical approaches. Jacobs (1998), suggests that the term psychodynamic refers to the way in which the psyche (mind/emotions/spirit/self) is seen as active and not static. This activity is not confined to relating to people but is also suggestive of internal mental processes as dynamic forces which influence our relations to others.

Explanatory Metaphors:

In explaining these processes, different theorists have relied on a variety of explanatory terms or metaphors. Freud (1949) referred to the Id, ego and super ego. Jung (1953) described the shadow, anima and animus. Winnicott (1958) discussed the true self and false self. These descriptions were attempts to describe the nature of these interpersonal relationships. It is important to understand that these processes are not necessarily connected with feelings towards anyone else, and do not rely on an external person for their promptings (Jacobs, 1998). These internal aspects of the psyche are seen as developing and forming through childhood as counterparts to external relationships which predominate at that time (with mother and father).

These factors are characterised metaphorically as dynamic forces within the psyche. The child's psychological development is, therefore, influenced not only by the nature of relationships with parents but also from the way the child perceives and fantasises about these relationships. Psychological development is seen as a process whereby the child's fantasy world is gradually modified by the experience of wider reality. An important notion in this approach is that the images formed in the mind of the child are never really lost but become internalised "objects" with a life of their own. This internal world is perceived as a dynamic force which can re-emerge into conscious awareness, particularly at times of stress (Mcleod, 1998; Jacobs, 1998).

The psychodynamic therapist sees therapy as helping the person explore their relationships with others. This is achieved through the client becoming more aware of his/her internalised aspects of personality. As much of this mental activity is unconscious (out with the person's awareness), the aim of therapy is to bring internalised conflict into conscious awareness and thus enable the person to deal more effectively with the demands of external reality. In discussing the significance of the relationship in this approach, it is important to look at further "links" related to this way of viewing the person. As already stated, the therapist acknowledges the relationship between the external and internal worlds of the client. The second set of "links" related to the relationship between the past and the present where the person is perceived as dealing with current relationships in a way that is influenced by past "experience" both real and imagined. This second set of links is then related to the therapy context where the therapist helps the client to explore how his/her experience of the therapy relationships is related to the way the client relates to persons outside therapy, both of which are intimately linked to early relationships with significant others (Casement, 1985).

The Transference Relationship

The therapist encourages the client to "transfer" these feelings into the therapy relationship where the client is helped to explore the way in which past relationships are being used inappropriately in understanding the present. This "unreal" (Gelso & Carter, 1985), or transference, relationship is central to psychodynamic approaches and is used by the therapist to help the client gain insight into current distortions in their relationships caused by internalised experience of which they are not aware (Malan, 1979). In this sense it is the exploration of and working through the transference relationship that are central in helping the client change.

Humanistic-Existential Approaches

Humanistic existential approaches have developed from the thinking of existential philosophers, such as Kierkegaard (1941), Nietzsche (1969) and Husserl (1952) and through the clinical work of Rogers (1961). The thinking and ideas and the wide range of therapeutic approaches reflected in this classification can be said to contain certain philosophical assumptions and theoretical beliefs about human nature. Existentialism is a term which represents a philosophical tradition often associated with phenomenology (Deurzen-Smith, 1996) and has its roots in twentieth century Western European thought. Proponents of this perspective are involved in a continuing reappraisal of values and assumptions in exploring the meaning of human existence. Psychotherapy evolving from this perspective involves developing a questioning philosophy to life that challenges the concept of taken for granted reality. People like Kierkegaard and Nietsche are sometimes referred to as the "philosophers of freedom" (Warnock, 1970) as they challenged individuals to explore their values in an attempt to create meaning in their lives. Husserl (1952) developed this philosophical position by offering a phenomenological perspective suggesting that all knowledge can only be subjective and the pursuit of objective understandings of the world is not possible. This emphasis on the subjective experience of the individual represented an alternative view to an increasingly scientific and objectifying world (Laing, 1970). Although these perspectives have been applied directly to practice, therapists describing themselves as Existential are small in number. These ideas however, have influenced the theorising of many contemporary practitioners (Deurzen-Smith, 1996).

Phenomenology

The phenomenological perspective greatly influenced the development of the Humanistic Movement which became known, in academic psychology, as the "Third Force" (Maslow, 1968). Burns (1983) emphasised this by stating:

Humanistic psychologists do not believe in the possibility of an ultimate science of behaviour in which explanations and specific actions can be made by reference to a common set of laws and variables applying to all people. Much of the significance in human experience will remain impossible to describe. People are not fixed entities. Because of their capacity to be aware of themselves and to initiate change they have the ability to modify and create the kind of person they can be.

This movement represented an alternative perspective to what was seen as the over-determinism and reductionism of psycho-analytical and behaviourist approaches. This approach emphasised the importance of acknowledging the uniqueness of individuals and their subjective explanations of experience. These philosophical ideas and emphases on personal experience were developed into therapeutic psychology through the work of Carl Rogers (1961). For him, the unit of concern was not the stimulus-response or past unconscious conflict, but the individual's own perceptions (Mcleod, 1998). As such, the terms "phenomenological" and "humanistic" are often used in association with his work. This "person centred" approach has had a major influence on psychotherapy practice (Thorne & Lambers, 1998). The approach emphasises the capacity of people to grow and adapt. Every person is assumed to possess an actualizing tendency, that is, a natural capacity to develop, differentiate and grow (Jones, 1982). An understanding of this theory is dependent upon understanding the distinction between the self and self-concept (Rogers, 1961).

Self Concept and Organismic Self

The self may be viewed as the real underlying "organismic self" (Rogers, 1961), with its inherent tendencies to grow and develop. The self-concept on the other hand is a person's perception of himself which does not always correspond with his organismic self. When self and self-concept are congruent, the individual will move towards self actualization. However, where self and self-concept are incongruent, the desire to actualize the self concept may work at cross purposes with the deeper need of the organismic self (Jones, 1982). In attempting to gain the approval of others, the individual begins to deny and suppress aspects of the "real" or organismic self; his/her sense of worth becomes conditional on the approval of others. This need for positive regard takes precedence, with the person becoming estranged from his or her true organismic self to such an extent that he or she becomes profoundly mistrustful of it (Mearns & Thorne, 1999). The conflict thus created is seen by Rogers (1961) as leading to psychological distress.

This incongruence is, therefore, the focus of this therapy approach, the aim of which is to re-establish trust and dependability in the organismic self, helping the client to move towards the fulfilment of his/her potential through the actualizing tendency. Rogers (1961), suggests that to enable an individual to resolve these conflicts in therapy the therapist has to provide a relationship characterized by certain facilitative conditions. These will provide an understanding atmosphere which will allow the individual the space to explore and make sense of his/her current experience. These conditions include non-possessive warmth, unconditional positive regard, empathy, a non-judgmental attitude and genuineness (Rogers, 1961).

Rogers believed that awareness of these conditions on the part of the person would be sufficient to enable change to take place. In this approach the relationship between the therapist and the client is central to the change process; it is this relationship, not techniques or interventions, which effect change. As stated earlier, this approach to working with people has had a significant impact on all psychotherapy practice in that most psychotherapists acknowledge that the quality of the relationship is important. However, some therapists, depart from Rogers' view that offering this type of relationship alone is sufficient. They would argue that such a relationship provides a climate which will allow the therapist to use particular strategies that in turn will help the client to change (Ellis, 1999; Highlen & Hill, 1984).

Cognitive Behavioural Approaches

Cognitive Behavioural approaches can be seen as a synthesis of many diverse frameworks. Although they differ in their detail from one another they share many common assumptions and are sufficiently similar to be grouped together (Dryden & Rentoul, 1991). All have their origins in the work of early behaviourists such as Watson (1931) and Skinner (1953), modified by more contemporary cognitive theorists, such as Ellis (1962), Beck (1976) and Meichenbaum (1977).

The earliest roots of behavioural approaches lie in the investigative strategy of behaviourism and conditioning theories of learning. The two major types of learning stemming from this early experimental work were classical and operant conditioning. Classical conditioning (Pavlov, 1927) was developed from experimental work with animals concerned with stimulus response sequences. Operant conditioning theories describe how the consequence of behaviour can be seen to influence future behaviour. They represent a development of stimulus-response theory which looks at the part played by the environment after the response has been made. This involves the use of reinforcement contingencies. The basic premise is that the consequences following behaviour can be used to shape future behaviour.

Deterministic Beginnings

As Mackay (1984, p. 267) points out, early behaviourists were unashamedly deterministic. They assumed that, as a result of having been through a variety of classical and operant conditioning procedures, the individual would make specific responses in the presence of certain stimuli because they had been associated with certain consequences in the past. Contemporary behavioural psychotherapists would be less convinced that this perspective, derived from animal experiments, offers an adequate explanation of human functioning. Nevertheless it is an elaboration of the stimulus-response-reinforcement sequence that provides the theoretical basis for this approach. The influence of early behaviourism is evident in the rigorous behavioural analysis which is integral in the assessment of clients when using this approach (O'Sullivan, 1996). The strategies used to treat an individual are dependent upon the presenting problem. Common approaches include exposure, relaxation and social skills training. Exposure involves the client being exposed to a phobic situation often combined with response prevention strategies that encourage the client to remain in contact with the feared stimulus until anxiety reduces. Relaxation therapy is used to teach the client to relax in anxiety provoking situations. Social skills training involves the client being helped through shaping, modelling and reinforcement to develop basic interpersonal behaviour. The emphasis within these interventions is on changing the client's behaviour and, as such, therapists where possible work with the client in the actual situations that are causing him or her difficulty. It could be argued that dissatisfaction with simplistic stimulus response explanations of behaviour has had many behaviour therapists to work with more cognitive approaches as these acknowledge the causal role of thoughts and beliefs in the production and maintenance of behaviour.

Cognitive Approaches

The common features of cognitive approaches have been described by Dryden and Rentoul (1991). Cognitive therapists believe in the importance of cognitions: "cognition" referring to conceptions, ideas, meanings, beliefs, thoughts, inferences, expectations, predictions and attributions (Davis & Fallowfield, 1991). Secondly these cognitions mediate client problems and are available for scrutiny and subsequent change by the client. Finally these cognitions are the primary target for change in attempting to address the client's cognitive, affective and behavioural difficulties.

Apart from these theoretical beliefs, Spinelli (1994, 240-255) suggests that those with a cognitive perspective share the common philosophical viewpoint that humans are disturbed by the views they hold about events rather than the events themselves. Trower, Casey and Dryden (1988, p. 6), suggest that a common misconception about this approach is that it is a "talking" therapy as opposed to behavioural therapies which are more concerned with practical issues and behaviour change. They state that the difference between these approaches is one of emphasis, with the cognitive behavioural therapist using tasks but in order to change thinking. Thus, the aim in this approach is to change negative, irrational and self-defeating patterns of thinking.

A Problem Orientated Approach

The approach to treatment in this type of therapy has been described by Moorey (1996) as being problem-orientated. The aim of the therapy is to teach the client to monitor thought processes and to look for evidence which validates their thinking in real situations. The therapist views the client's perceptions about situations as "hypotheses" which require testing. There are various strategies of intervention used in this approach (Beck, Emergy, & Greenberg, 1985; Guidano & Liotti, 1983; Moorey, 1996). These include challenging automatic thoughts and Socratic questioning where the therapist aims to change the client's thinking by questioning the meanings behind the client's distress. This involves looking for evidence to support or refute the client's beliefs. Through the therapist's challenging and questioning, the client is helped to develop an awareness of the automatic and self-defeating nature of this thinking. This awareness is reinforced by the process of reality testing involving behavioural experiments. Clients become more able to monitor and control their own distorted thinking patterns. The intensity of the therapeutic session is maintained by the use of extensive homework assignments and talks which involve further behavioural experiments and thought-monitoring exercises. Change occurs as the client's thinking is modified with increasing evidence to refute his/her "distorted" view of the world (Moorey, 1996). The therapist and client are perceived as partners, collaborating to assist the client to change. This collaboration requires the development of an understanding and supportive relationship.

This relationship has been described by Gelso and Hayes (1998) as being perceived as a "means to an end". In this type of therapy, the therapist attempts to establish a good relationship with the client as this will make it more likely that the therapist will be persuasive, believable and capable of effecting changes in that person (O'Leary & Wilson, 1975). It is apparent that in cognitive-behavioural approaches the relationship is not seen as the central element of change, although it is seen as important. Relationship factors help the therapist to employ a variety of techniques more effectively and enhance client co-operation (Ellis, 1999).

From Professional Theories to Client Experience

The preceding discussion illustrates the diverse nature of psychotherapeutic approaches. As already indicated, the discussion is not exhaustive but merely representative of this diversity. In addressing the question "What is psychotherapy?", the difficulty of defining psychotherapy in a concise "non-sectarian" manner has been highlighted. The definitions that have been offered do, however, illustrate how the relationship emerges as a central component. A description of the three major theoretical viewpoints was offered which showed that the importance and focus of the relationship differs between schools of thought.

The foregoing discussion has centred on the "professional" attempts to define psychotherapy which have evolved from a variety of psychological theories and assumptions about the nature of personal distress. This serves to highlight the central argument of this paper which emphasises the importance of definitions and meanings that the "help-seeking" partner ascribes to the experience of psychotherapy. The "professionals" appear to view the relationship as central to psychotherapy and the "professional" in this relationship, as already suggested, may approach the relationship in a particular way, this approach being based on the therapist's theoretical assumptions. Relationship, however, suggests that the interaction cannot be one-sided and the client is a partner within the therapeutic encounter and must have a personal definition or answer to the question "What is psychotherapy?".

The Importance of Qualitative Methodology

This focus on the personal subjective experience of the client challenges uncritical quantitative research approaches which reduce human beings to measurables. These reductionist methods fail to engage with the complexity of personal experience and do not take account of context and human agency in their attempt to provide simplistic cause and effect explanations. Many practising psychotherapists, the author included, relate poorly to numerical representations of the world which claim to help them understand it. This resistance to the hegemony of scientistic research (Polkinghorne, 1984) has led to the development of non-exploitative relational methodologies that accept the socially constructed nature of reality (Gergen, 1994) and reflexively acknowledge the role of values and power in the research enterprise (Rennie, 1996).

Part of the rationale for this paper is the contention that our understanding of psychotherapy and its effects would be developed by a more detailed exploration of the client's perspective using more "user friendly" qualitative methodology. As stated earlier, psychotherapy involves two people, one usually a professional or identified "expert" and the other a help-seeker. These two people meet on a regular basis and become involved in a dialogue which aims to establish the nature of the help-seeker's problem and the ways in which it can be addressed. It is reasonable to assume that what goes on in this relationship will be affected by the interpretations and understandings that each of the participants brings (Howe, 1993).

Because those in the field of psychotherapy research have been eager to establish the "scientific credibility" of therapeutic practice (Saunders, 1999), attempts to understand the nature of therapy have been heavily influenced by the theoretical perspectives of the researcher. The result is that the client's view has never really found a place on the agenda. As Smail (1983, p. 12) argues, those who have been involved in psychotherapy know most about it but are unable to elaborate on it "...... because the structure of official scientific psychology is uninterested in their experience and unwilling to alter its methods and assumptions in order to take account of it". However, the literature does reveal some attention to the client's perspective of psychotherapy from more quantitatively orientated researchers.

Research in Psychotherapy: the Client's Perspective

The following offers an overview of psychotherapy research that appears to acknowledge the importance of the client's perspective. This review will comprise of three main sections: psychotherapy research examining client variables, clients' expectations and finally the "events paradigm". Research in psychotherapy can make evaluative statements regarding the effectiveness, or not, of particular procedures. This tends to be described as outcome research. Research which attempts to explain why improvement or deterioration occurs is usually referred to as process research (Barkham, 1990; Mcleod, 1998). Process research tends to focus on everything that can be observed to occur between and within the client and the therapist during their work together and usually encompasses client characteristics (Orlinsky & Howard, 1986). The assumptions underlying psychotherapy process-outcome research have recently been questioned (Stiles & Shapiro, 1988) and there has been a movement towards the adoption of new styles of research aimed at investigating the change process (Greenberg, 1986).

Client Variables

Barkham (1990) suggests that there exists a considerable gap between psychotherapy practice and research. Greenberg (1986) sees this gap as arising from researchers choosing to study phenomena they know how to study or can study relatives easily, rather than what is important to the conduct of psychotherapy. It may be argued that the earlier research which focused on the client, , reflects Greenberg's point. Studies such as Rosenthal and Frank (1958) explored demographic characteristics of clients with respect to referral and acceptance of psychotherapy. This type of research design has formed the basis for a variety of studies which attempt to relate different client attributes to selected variables. Among the attributes which have been selected are social class, diagnosis, gender, personality traits and intelligence. These have been compared with, and related to, factors such as therapeutic outcome, continuation in therapy, in-therapy behaviour and process issues. For a comprehensive review see Garfield and Bergin (1986). The criticisms of this type of research have been summarised by Garfield and Bergin (1986, p. 246) as relating to the great diversity of variables and the variation in methods of appraisal. In listing the problems he describes the constructs used, measuring devices, type of therapy, sampling procedures and outcome criteria. Garfield and Bergin go on to state, "Although the personal qualities and expectations of the client appear to be of importance to most therapists, the more exact description of these qualities in the relationship to outcome in psychotherapy still await more definite research".

Client Expectations

This type of research stems from theories in social science that view learning as a function of the reinforcement of an individual's expectations regarding the outcome of their behaviour in a given situation (Rotter, 1954). Researchers involved in this area tend to view psychotherapy as a one-to-one social learning relationship, suggesting that clients approach therapy with expectations regarding the nature of the interview and the role they and their therapists will assume (Strong, 1968; Tinsley & Harris, 1976). It is argued that the clients' expectations may either have a positive or negative effect on the relationship and outcome of psychotherapy (Frank, 1968; Goldstein, 1962; Clairborn & Strong, 1982). The areas that have been investigated include the relationship between expectations and help-seeking behaviour (Yanico & Hardin, 1985), expectations and early termination (Sandler as cited in Tinsley, Bowman, & Ray, 1988), and expectations and involvement in the psychotherapy relationship (Frank, 1968). The more committed adherents to this perspective such as Frank (1968) suggest that therapeutic gain is contingent upon clients' expectations that they will benefit from therapy. It seems well accepted that the clients' expectations exert influence on their decisions to enter and remain in therapy and that these expectations moderate the effectiveness of therapy. The recent developments in this area have focused on attempts to influence client expectations through manipulation of variables such as therapist credibility and therapist/client matching.

Tinsley, Bowman, and Ray (1988) provide a comprehensive critical review of this work. They conclude that future research in this area should be organised around three main issues: Firstly the identification of the full range of client expectancies and the development of valid and reliable measures of those expectancies; Secondly an exploration of expectations, perceptions and preferences and their relationship to therapeutic process and outcom; . Finally they advocate research on expectation manipulation and ways of changing client expectation. It could be suggested that manipulation of client expectation is both morally and ethically questionable, but there does seem to be a need to develop a greater understanding of what the client expects and perceives as being offered in psychotherapy.

The "Events Paradigm"

The dissatisfaction with this type of research has led to a greater emphasis on the change process in therapy which has been described by Barkham (1990) as the "events paradigm". This perspective suggests that in order to be able to study the change process, the intense study of significant moments during therapy provide researchers with a rich source of data. This approach to therapy research views the therapy process as a chain of client states and sub-outcomes that are linked together on a pathway to ultimate outcomes (Saffran, Greenberg, & Rice, 1988). Specific episodes within therapy sessions are seen as being a more profitable way of establishing process-outcome links than those which correlate a single process measure with outcome. The study of significant moments occurring during therapy is relevant to this review because of its acknowledgement of the importance of the experiences and perceptions of both the client and therapist. Access to this data is achieved through post-session evaluation using tools such as the Interpersonal Process Recall (Elliot, 1986) or a variant of this (Elliot & Shapiro, 1988). These schedules are completed by therapists and clients post-session where they identify significant events in the session which are then illuminated with reference to the client's and therapist's perceptions of this episode.

Llewellyn, Elliott, Shapiro, Hardy, and Firth-Cozens (1988) describe a project where they measured the views and experience of therapy for both clients and therapists. This article criticises approaches to psychotherapy research which tend to be suspicious of the subjective data of clients, which is often viewed as being "too global, too vague, too limited and too dependent on memory". Llewellyn argues for the use of methodologies that focus on specific clinical events (critical incidents) such as Elliot's (1986) Interpersonal Process Recall (IPR) or his Therapeutic Impact Analysis Stem (TICAS) which explores the view of both participants in the therapy relationship. The important finding from her own research (Llewellyn et al., 1988) was that aspects of the therapeutic encounter had a different degree of salience for therapist and client. This type of research demonstrates that researchers may need to become more aware of the ways in which events occurring in therapy are perceived differently by therapist and client. This discussion supports the argument that exposing the social encounter described as psychotherapy to a more qualitative analysis will develop our understanding both of the client's perspective and of the implications this may have for the psychotherapy relationship.

Those researching psychotherapy have examined the client's perspective with reference to a broad array of stimuli, interventions, settings and persons. The research tends to focus on the relationship between personality traits, mood states, motivations, expectations and how these factors influence the client's behaviour. These studies are designed and understood from the perspective of the researcher conducting the investigation. It is apparent that a focus on the client which attempts to identify some kind of client typology which can in turn be related to client behaviour assumes the conceptual validity of the approach used and as Smail (1984, p. 127) observes, "... looks for entities of the type it expects to find".

The Critique of Current Approaches to Psychotherapy Research

From this review it is apparent that psychotherapy researchers do perceive the client as an important area of focus in developing our understanding of the psychotherapeutic process and its effects. However, to date most of those involved in researching psychotherapy have developed their understandings from testing theory, often from a scientific psychological perspective, using more quantitative methods. When discussing research in psychotherapy Smail (1983, p. 10) states "..... the reason these approaches have been so dominant seems to be a tacit faith that by following a prescribed methodological path, scientific authority can be rendered absolute and impersonal; can in guiding human activity and intervention, exclude the frailty of human judgement by appealing to such principles as objectivity, lawfulness, quantifiability, generality, stability and determinism (prediction and control) and so on".

Most research of this kind has been limited in what it has found because it has been conducted within a particular paradigm, which has been described as the "received view" of science (Polkinghorne, 1984). This perspective stems from the philosophical concept of positivism. This framework, which developed from the natural sciences, assumes that there are laws that govern the social world and that by using appropriate methods of analysis these will be uncovered. As a result of the use of this framework research which attempts to examine the client's perspective tends, in fact, to examine client variables or the client as a variable rather than actually pay attention to the client's view.

Factors Which Have Limited the Research Approach

The reasons why psychotherapy researchers have paid limited attention the client's perspective has recently been discussed by Mcleod (1998). Mcleod makes the point that very few people have attempted to conduct research which asks clients what they think about the therapy they are receiving. He suggests the reasons for this can be understood as the convergence of forces within the professional culture surrounding psychotherapy research activity. Mcleod argues that strong institutional pressures exist which encourage researchers to follow the assumptions and practices of natural science. These pressures promote approaches to research that are characterised by certain features. Such features would include the use of reliable objective measures of variables derived from theories and models, these are used to create controlled experimental conditions within which to test hypotheses. From this perspective the subjective feelings, states of mind or beliefs of clients are not legitimate topics of interest. This issue is addressed by Smail (1987) who suggests that most of these studies simply ignore how the person in the role of client perceives their treatment. He suggests that they are more concerned with statistically significant differences in some kind of objective measure.

A further challenge stems from the work of Frank and Frank (1991), who question the relevance of current scientific methods when researching psychotherapy. This challenge is based on the perception that these methods deal poorly with the meanings of the therapeutic situation. It could be argued that therapeutic outcomes can be understood as changes in systems of meaning and reality construction and to investigate such phenomena a more interpretive research approach is necessary. Deductive logic which underlies the positivist approach is limited in its capacity to identify individual meanings (Richardson, 1996). If researchers impose a theoretical structure on the events they are studying in order to exclude phenomena that can be neither measured or controlled, they set limits on what can be investigated and artificially narrow the field of inquiry. In this type of research people in the role of client are often viewed as passive respondents to external influences and/or possessors of certain traits and states that are held to be responsible for their actions. Rarely have psychotherapy researchers considered client behaviours as meaningful purposeful actions carried out by active agents involved in performances. As Howard (1984), states "... much of this research is tied to inappropriate models from the physical sciences, is trivial, atomistic and is obsessed with statistics, technical matters and research design". Researchers committed to these mechanistic approaches have been described by Smail (1984, p. 138) as having a religious stake in the "mythology of objectivity".

Another important factor which has limited research focusing on the client's experience is related to the way research approaches are influenced by the theoretical beliefs to which the researcher is committed. For example, practitioners with a psychoanalytical orientation often interpret what the client says as evidence of defensiveness and fantasy associated with transference phenomena. This position leads researchers sharing this perspective to assume that what the client says about their experience cannot be taken at face value. Similarly, those who work behaviourally have traditionally focused on changes in client behaviour showing limited concern with "vague internal events such as experiences" (Mcleod, 1990, p. 67). It can, therefore, be seen that focusing on the client's perspective may be difficult for those who have a commitment to certain theoretical assumptions concerning the nature and aims of psychotherapy.

Other difficulties when researching the client's perspective are associated with ethical and practical issues. The researcher requires to be sensitive to how the research may have an effect on the ongoing process of psychotherapy. Also, there may be problems with confidentiality as it may be difficult to contact a representative cohort of clients without going through the psychotherapists who are working with them.

The Importance of the Client's View

The argument in this paper is based on the contention that a more complete understanding of psychotherapy can only be achieved by considering a range of ontological perspectives based on a variety of different views on the nature of persons. In exploring the nature of psychotherapy the focus of interest is human interaction. Therefore, it is the special characteristics of the human realm that should inform research choices. Included is human consciousness which permeates human experience with meaning, creating what Polkinghorne (1984) terms a "second order non physical realm of ideas" that influences behaviour. Human interaction can, therefore, be seen in terms of multi-layered meanings and interpretations that give experience both depth and context.

As discussed above, the use of positivist research methods shape the way the researcher sees the world. Deductive logic and experimental methods provide a "picture" of reality that can be characterised as a tightly related system of parts. The approach enables the researcher to collect portions of the "spectrum of reality" (Polkinghorne, 1984) from which the researcher draws a network of connections linking these parts to describe the phenomena under investigation. Psychotherapy research which relies on the isolation and observation of variables and describing their relationship using numerical abstractions can be challenged on the grounds that as psychotherapy operates in the realm of meanings, these methods are ill equipped to deal with it (Frank & Frank, 1991). This puts into context the argument being presented here, where it is suggested that any attempt to explore psychotherapy should acknowledge the client's causal powers, based on the belief that human action is purposeful with the recognition that individuals are active agents. Harre (1996) suggests the adoption of the active agent model in social science undercuts much of the traditional research in psychology and psychotherapy, as he states, "to adopt such a conception of science requires a radical departure from simple minded positivist methodology of dependent and independent variables, of statistics and correlation coefficients". This critique suggests that researchers in psychotherapy require to acknowledge that the clients they observe are responsible agents capable of constructing and managing their social world.

Following from this position it is important for researchers to grasp the centrality of the subjective world of the psychotherapy client characterised by personal meanings, understandings and interpretation of events. The social behaviour of the people involved is then viewed as representing meaningful action in the service of aims, goals, plans and intentions. This approach is supported by the ideas of Manicas and Secord (1983) in their description of the "Agents Model", a concept which suggests that individuals represent the world to themselves by means of models. Further support for this perspective comes from the work of Kelly (1955) who in describing the "Person as Scientist" considers that each individual has their own view (or theory) of the world which influences their expectations of what will happen in given situations.

The "theoretical world" of the psychotherapy client needs to be explored in an attempt to develop an understanding of how people in this role interpret and make sense of their experience. The appropriate methods needed to investigate the systems people use to construct and interpret their experience as meaningful are reflective of the processes of psychotherapy itself and ideally should involve in depth interviews. This approach can be seen as a reflection of the psychotherapist mode of thought, with the researcher, in order to understand the actions and communications of others, attending to the framework that a client uses to interpret and order the meaning of his/her experience.

This offers an alternative to viewing the client as a passive recipient of the therapist's interventions; a perspective which, it could be argued, limits the study of the therapeutic encounter. This limited perspective, emanating from the "received view", does not seem to acknowledge the reflexive nature of the psychotherapy relationship. Bannister (as cited in Smail, 1987) illustrates this well with his description of the dilemma of the Master Chemist, "The master chemist has finally produced a bubbling green slime is his test tube, the potential of which is great but the properties of which are mysterious. He sits alone in his laboratory, his test tube in hand, brooding about what to do with the bubbling green slime. Then it slowly dawns on his the bubbling green slime is sitting alone in its test tube wondering what to do about him".

As stated earlier in this paper part of the argument for this re-emphasis on research approaches was the way current understandings of what psychotherapy is tend to be based on the "professional" viewpoint, and that some recognition of the client's viewpoint, because the client is also involved in a relationship, would further understandings of psychotherapy. This rationale was developed by an acknowledgement that most research which seems to pay attention to the client's perspective is limited because it is conducted from within the positivist paradigm. From this argument emerges a rationale for the development of research approaches in which the client is viewed as an active agent whose subjective understandings are best explored from an interpretive paradigm.

The Relevance of Research to Practice

Rowan (1992, p. 160), suggests that those who are involved in research in psychotherapy have become remote from those who practise it, he goes on to state "It is difficult for the ordinary person to realize just how irrelevant most of the research actually is". This point is supported by Greenberg (1981) who argues that much of the research in psychotherapy offers little to practising therapists with knowledge about what effects therapeutic outcomes being "disappointingly meagre". In the standard work on outcome research Garfield and Bergin (1986) offer a comprehensive review of current psychotherapy research. Rowan (1992), when discussing this work, suggests that the interesting thing about many of the studies described is that no clear results emerge at all. He concludes that the best controlled studies tell us virtually nothing about psychotherapy as ordinarily practised and suggests that we have to move to a new paradigm of research which does not even attempt to talk about variables, ".... but which talks instead about people, and to people and with people".

The paper is representative of the developing professional awareness that psychotherapy research focusing on the perspectives of the consumer will provide relevant data which will increase our understanding of psychotherapy and its effects (Mcleod, 1998; Howe, 1994; Barker & Baldwin, 1991). It supports the view of Rowan (1992) and Mahrer (1985) that our understanding is limited by our attempts to isolate and manipulate experimental variables, rather than be concerned with talking with people and exploring how they make sense of their experience. Such inquiry is seen as relevant to psychotherapy practitioners in that the clients' understanding of psychotherapy will influence how they interact and become involved in the therapeutic task. Psychotherapy aims to help clients. The participants in this activity, therapist and client, are responsible for sustaining and creating meanings with respect to this encounter. In order to conduct meaningful enquiry concerning these meanings it is necessary to explore these issues with those involved.

This paper has examined the definitions and theoretical assumption that reflect current professional perspectives on the nature of psychotherapy. It has shown how viewing psychotherapy as applied behavioural science leads to research approaches that narrow the field of enquiry (Rennie, 1996). The limitations of these approaches have been discussed and a rationale provided for the need to develop alternative perspectives which acknowledge the importance of individual interpretations and meanings. By adopting this type of approach to research, it is argued that our understanding of the nature of psychotherapy will be advanced.

References

      Barker, P. J., & Baldwin, S. (Eds.). (1991). Ethical issues in mental health. London: Chapman and Hall.

      Barkham, M. (1990). Research and individual therapy. In W. Dryden (Ed.), Individual therapy: A handbook. Milton Keynes: Open University.

      Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press.

      Beck, A, T., Emergy, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.

      Burns, R. B. (1983). Counselling and therapy: An introductory survey. Lancaster: MTP Press.

      Casement, P. (1985). On learning from the patient. London: Routledge.

      Clairborn, C. D., & Strong, S. R. (1982). Change through interaction. New York: Wiley Interscience.

      Davis, H., & Fallowfield, L. (1991). Counselling and communication in health care. Chichester: John Wiley and Sons.

      Deurzen-Smith, E. (1996). Everyday mysteries: Existential dimensions of psychotherapy. London: Routledge.

      Dryden, W. (Ed). (1996). Handbook of individual therapy in Britain. London: Sage.

      Dryden W., & Rentoul, R. (Eds.). (1991). Adult clinical problems: A cognitive-behavioural approach. London: Routledge.

      Elliot, R. (1986). Interpersonal process recall (IPR) as a psychotherapy process research method. In L. Greenberg & W. Pinsoff (Eds.), The psychotherapeutic process: A research handbook (pp. 503-528). New York: Guildford Press.

      Elliot, R., & Shapiro, D. A. (1988). Brief structured recall: A more effective method for studying significant therapy events. British Journal of Medical Psychology, 61,141-153.

      Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart.

      Ellis, A. (1999). The main change agent in effective psychotherapy is specific technique and skill. In C. Feltham (Ed.), Controversies in psychotherapy and counselling (pp. 86-94). London: Sage.

      Frank, J. D. (1968). The influence of patient and therapist on the outcome of psychotherapy. British Journal of Medical Psychology, 41, 349-356.

      Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy (3rd ed.). Baltimore: Johns Hopkins University Press.

      Freud, S. (1949). An outline of psychoanalysis. London: Hogarth Press.

      Garfield, S. L., & Bergin, A. E. (Eds.). (1986). Handbook of psychotherapy and behaviour change. New York: Wiley.

      Gelso, C. J., & Carter, J. A. (1985). The relationship in counselling and psychotherapy: Components, consequences and theoretical antecedents. Counselling Psychologist, 13, 155-243.

      Gelso, C. J., & Hayes, J. A. (1998). The psychotherapy relationship: Theory research and practice. New York: John Wiley and Sons.

      Gergen, K. (1994). Realities and relationships. Cambridge, MA: Harvard University Press.

      Goldstein, A. P. (1962). Therapist-patient expectancies in psychotherapy. New York: Macmillan.

      Greenberg, L. G. (1981). Advances in clinical intervention research: A decade review. Canadian Psychology, 22(1), 25-34.

      Greenberg, L. S. (1986). Change process research. Journal of Consulting and Clinical Psychology, 54, 4-9.

      Guidano, V. F., & Liotti, G. (1983). Cognitive processes and emotional disorders: A structural approach to psychotherapy. New York: Guildford.

      Harre, R. (1974). Blueprint for a new science. In A. Nigel (Ed.), Reconstructing social psychology (pp. 240-259). Baltimore: Penguin Books.

      Highlen, P. S., & Hill, C. E. (1984). Factors affecting client change in individual counselling current status and theoretical speculations. In S. D. Brown & R. W. Lent (Eds.), The handbook of counselling psychology (pp. 134-148). New York: John Wiley.

      Holmes, J., & Lindley, R. (1989). The values of psychotherapy. London: Oxford University Press.

      Howard, G. S. (1984). A Modest proposal for a revision of strategies for counselling research. Journal of Counselling Psychology, 31, 430-442.

      Howe, D. (1993). On being a client: Understanding the processes of counselling and psychotherapy. London: Sage.

      Husserl, E. (1952). Idea. New York: Collier.

      Jacobs, M. (1989). Psychodynamic counselling in action. London: Sage Publications.

      Jacobs, M. (1998). The Presenting Past: The core of psychodynamic counselling and therapy. Buckingham, Open University Press.

      Jones, R. N. (1982). The theory and practice of counselling psychology. London: Cassell.

      Jung, C. G. (1953). Two essays on analytical psychology. London: Routledge and Kegan.

      Kelly, G. (1955). The psychology of personal constructs. New York: W. W. Norton.

      Kierkegaard, S. (1941). Concluding unscientific postscripts. Princeton, NJ: Princeton University Press.

      Laing, R. D. (1970). The politics of experience. Harmondsworth: Penguin.

      Llewellyn, S. D., Elliott, R., Shapiro, D. A., Hardy, G., & Firth-Cozens, J. (1988). Clients perceptions of significant events in prescriptive and exploratory phases of individual therapy. British Journal of Clinical Psychology, 27,105-114.

      Mackay, D. (1984). Behavioural psychotherapy. In W. Dryden (Ed.), Individual therapy in Britain (pp. ). London, Harper Row.

      Mahrer, A. R. (1985). Psychotherapeutic change New York: W. W. Norton.

      Malan, D. H. (1979). Individual psychotherapy and the science of psychodynamics. London: Butterworths.

      Manicas, P. T., & Secord, P. F. (1983). Implications for psychology of the new philosophy of science. American Psychologist, 38, 399-413.

      Maslow, A. (1968). Towards a psychology of being. New York: Van Nostran Reinhold.

      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.

      Mcleod, J. (1998). An introduction to counselling (2nd ed.). Bukingham: Open University Press.

      Mearns, D., & Thorne, B. (1988). Person centred counselling in action. London: Sage Publications.

      Meichenbaum, D. (1977). Cognitive behaviour modification. New York: Plenum Press.

      Moorey, S. (1996). Cognitive therapy. In W. Dryden (Ed.), Handbook of individual therapy (2nd ed.). (pp. 254-282). London: Sage.

      Nietzsche, F. (1969). The genealogy of morals (W. Kauffman, Trans.). New York: Vintage.

      Norcross, J. C., & Prochaska, J. O. (1983). Contemporary psychotherapists: A national survey of characteristics, practices, orientations and attitudes. Psychotherapy: Theory, Research and Practice, 20(2), 161-173.

      O'Leary, K. D., & Wilson, G. T. (1975). Behaviour-therapy: Application and outcome. New York: Prentice Hall.

      Orlinsky, D. E., & Howard, K. I. (1986). Process and outcome in psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behaviour change (pp. 311-385). New York: John Wiley and Sons.

      O'Sullivan, G. (1996). Behaviour therapy. In W. Dryden (Ed.), Handbook of individual therapy (2nd ed.). (pp. 282-304). London: Sage

      Pavlov, I. P. (1927). Conditional reflexes. New York: Oxford University Press.

      Pilgrim, D. (1997). Psychotherapy and society. London, Sage.

      Polkinghorne, D. E. (1984). Further extensions of methodological diversity for counselling psychology. Journal of Counselling Psychology, 31, 416-429.

      Rennie, D. L. (1996). Fifteen years of doing qualitative psychotherapy research. British Journal Of Guidance and Counselling, 24, 317-327.

      Richardson, J. T. E. (Eds.). (1996). Handbook of qualitative research methods for psychology and social sciences. Leicester: The British Psychological Society.

      Rogers, C. R. (1961). On becoming a person: A therapist's view of psychotherapy. London: Constable.

      Rosenthal, D., & Frank, J. D. (1958). The fate of psychiatric out-patients referred to psychotherapy. Psychological Bulletin, 53, 294-302.

      Rotter, J. B. (1954). Social learning and clinical psychology. Englewood Cliffs, NY: Prentice Hall.

      Rowan, J. (1992). In a response to, Mair, K . The myth of therapist expertise. In W. Dryden & C. Feltham (Eds.), Psychotherapy and its discontents (pp. 160-166). Buckingham: Open University Press.

      Saffran, J. D., Greenberg, L. S., & Rice, L. N. (1988). Integrating psychotherapy research and practice: Modelling the change process. Psychotherapy, 25, 1-17.

      Saunders, . (1999). It has been amply demonstrated that psychotherapy is effective. In C. Feltham (Ed.), Controversies in psychotherapy and counselling (pp. 294-302). London: Sage.

      Skinner, F. B. (1953). Science and human behaviour. New York: Macmillan.

      Smail, D. J. (1983). Psychotherapy and psychology. In D. Pilgrim (Ed.), Psychology and psychotherapy (pp. 7-20). London: Routledge and Kegan.

      Smail, D. J. (1984). Illusion and reality: The meaning of anxiety. London: J. M. Dent and Sons.

      Smail, D. (1987). Taking care: An alternative to therapy. London: J. M. Dent and Sons.

      Spinelli, E. (1994). Demystifying therapy. London: Constable.

      Strong, S. R. (1968). Counselling an interpersonal influence process. Journal of Counselling Psychology, 15, 215-224.

      Stiles, W. B., & Shapiro, D. A. (1988). The abuse of the drug metaphor in psychotherapy process outcome research. Clinical Psychology Review, 58, 352-359.

      Tinsley, H. E. A. (1988). Manipulation of Expectancies about counselling and psychotherapy. Journal of Counselling Psychology, 35(1), 99-108.

      Thorne, B., & Lambers, E. (1998). Person centred therapy: A European perspective. London: Sage.

      Tinsley, H. E. A., Bowman, S. L., & Ray, S. B. (1988). Manipulation of expectancies about counselling and psychotherapy: Review and analysis of expectancy manipulation strategies and results. Journal of Counselling Psychology, 35(1), 99-108.

      Tinsley, H. E. A., & Harris, D. J. (1976). Clients expectations for counselling. Journal of Counselling Psychology, 23, 173-177.

      Trower, P., Casey, A., & Dryden, W. (1988). Cognitive-behavioural counselling in action. London: Sage Publications.

      Warnock, M. (1970). Existentialism. London: Oxford University Press.

      Watson, J. B. (1931). Behaviourism. London: Kegan Paul Trench and Traubner.

      Winnicott, D. W. (1958). Through paediatrics to psychoanalysis. London: Tavistock Publications.

      Yanico, B. J., & Hardin, S. I. (1985). Relation of type of problem and expectations of counsellor knowledge and understanding to students gender preferences for counselling. Journal for Counselling Psychology, 32, 197-200.

Author Note

+Neil Scott Gordon MSc, Dip Psych Coun, Dip, MN, Cert Ed, RMN. is a Senior Lecturer in Mental Health at the University of North London where he is the Course leader for the MA Mental Health. He is also a visiting Senior Lecturer at the Tavistock Institute. His current research and academic interests include user involvement in mental health practice, radical approaches to mental health service delivery and narrative approaches to psychotherapy. Neil can be contacted at the University of North London, School of Community Health Psychology and Social Work Ladbroke House 62-66 Highbury Grove, London, N5 2AD, tel 0171 6072789 ex5015. His e-mail address is: n.gordon@unl.ac.uk.

The author would also like to thank Jo Skinner and Michele O'Brien for helpful editorial and analytical comments on an earlier draft of this paper.

Article Citation

      Gordon, N. S. (2000, March). Researching psychotherapy, the importance of the client's view: A methodological challenge. [50 paragraphs]. The Qualitative Report [On-line serial], 4(3/4). Available: http://www.nova.edu/ssss/QR/QR4-1/gordon.html

Neil Scott Gordon
2000 copyright


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