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.