Coming to an end: A case study of an ambigous process of ending

Aim: When the duration of therapy is not preset and the outcome is a matter for negotiation, the decision to end psychotherapy will be an experiential concern for the two participants. This case study draws attention to how ambiguities may be settled in a process where ending is initiated by the therapist and resisted by the client. Method and analysis: The actual case was strategically selected as exceptional owing to a combination of circumstances. The client and the therapist had developed a ‘good enough’ alliance (WAI) and reached a ‘good enough’ outcome (OQ-45), and still the client felt she was far from finished. A close inspection of interactional data in sessions together with both clients' and therapists' reflections in post-therapy interviews elicited information about both substantial content and structural aspects of this complicated process of ending. Findings and discussion: The discrepancy between therapist and client was not addressed, but rather postponed and revisited again later. Structural elements like preparations for a break for vacations and reducing the frequency of sessions were used to test experiential qualities, such as how the client managed life without therapy. Carefully preserving a ‘good enough’ emotional bond through the negotiations seemed important to both parties. Significantly, the client's autonomy was interpreted as the final proof of improvement and the client came to a point where she could affirm that she had got better only by accepting that treatment was coming to an end. This is an Author's Accepted Manuscript of an article published in Counselling and Psychotherapy Research: Linking research with practice, Copyright 2012 British Association for Counselling and Psychotherapy, available onlin

Creating art from research:a theatre play based on research interviews with senior therapists

The growing scope and influence of qualitative research methodologies has generated an interest in the use of art-informed approaches to disseminating research findings. In the present article, our aim is to present a methodological case study of the development of a theatre play based on a qualitative study of senior therapists' life and work. Lessons learned from this project are presented in relation to ethical issues, the process through which qualitative data are transformed into a theatre performance, and the distinctive perspective afforded by a dramaturgical approach. Implications for research practice are discussed

Relational development in psychotherapy from beginning to end : Connecting structural and interpersonal aspects

With the concept of the working alliance as a starting point, the aim is to explore relational development in psychotherapy in an experience-near and clinically relevant way. The approach is qualitative and hermeneutic phenomenological. Reflexive data from participants in psychotherapy is combined with observational data from the therapeutic interaction. Case studies are used to explore relational processes of development from different perspectives. The findings are presented in three separate articles. The first article is a single case study which explores the relational struggles early in a therapy process and the development of a therapeutic alliance in a case which started with relational strains but developed a good alliance and ended with good outcomes. The second article is a single case study which explores an ambiguous process of ending in an exceptional case. The third article explores the process of ending across twelve cases. A main finding is that patients and therapists seemed to share an ideal of reaching a concerted decision to end. The agreement seemed to be based on sensed affect, rather than for instance metacommunication

Early relationship struggles: A case study of alliance formation and reparation

Aim: A good alliance established during the early sessions of psychotherapy will most likely lead to a good outcome. As a result, there is much to learn from a case in which both the patient and therapist regarded the alliance as being poor for an extended period (the first 15 sessions), yet still managed to develop a solid and stable alliance and reach a successful completion of therapy. The aim is to give a close inspection of this reparation process. Methods and analysis: Ratings on the Working Alliance Inventory (WAI) were used to guide the strategic selection of a case in which a depressed woman in her thirties sought help from an experienced senior male psychotherapist. A detailed analysis of the therapeutic dialogue brought forth what the parties expected from each other and how they responded to explicit and implicit expressions about how to proceed. Post-termination interviews revealed their subjective configurations of events in therapy and their corresponding reflections. Findings and discussion: Important steps and hallmarks of the alliance formation and reparation were identified: (i) Early in the process, incompatible expectations about what the relationship could achieve led to repetitious struggles. (ii) Their conflicting notions came forward in a more open dialogue about two specific issues (her medication and sick leave). (iii) Through the recognition of different viewpoints they were able to expand on their interactional pattern and develop playful ways to explore her decision making in everyday life. (iv) Temporary breaks seemed to consolidate her autonomy. (v) Late in the course of therapy, the therapist introduced a literary metaphor that seemed to further consolidate the alliance. This is an Author's Accepted Manuscript of an article published in British Association for Counselling and Psychotherapy, available onlin

We have travelled a long distance and sorted out the mess in the drawers: Metaphors for moving toward the end in psychotherapy

Aim: To explore the process of ending in psychotherapy, in particular how clients and therapists draw on their notions of client improvements and prepare for the upcoming end. Data: The data comes from an intensive process-outcome study at the University of Oslo, Norway. The study includes audio-recording from all sessions and separate post-therapy interviews with clients and therapists. Twelve psychotherapy dyads were selected because they had reached a ‘good enough’ ending. Therapy duration ranged from 7–43 months. The number of sessions ranged from 10–67. Method and analysis: A hermeneutical-phenomenological approach analysed and combined the observational and reflexive data. The analysis was carried out using a method for systematic text condensation and through reflexive dialogues with the material and between the researchers. Findings and discussion: The language of improvement towards the end of treatment seemed packed with metaphors conveying growth in both affective and relational management. Metaphors based on travel (how they have moved); cleaning (how they have cleaned up and sorted out things); sensing (how the clients have grown stronger, got their heads above water and see things differently); and the clients’ feeling of having received something (gifts or tools) are widely used. Such metaphors are created in the interaction with a mutual sensitivity to their capacity to confirm and regulate affect towards the end. In this sense, the metaphors celebrate accomplishments in a way that exceeds therapy, and the client can keep them to use afterwards. This is an Author's Accepted Manuscript of an article published in Counselling and Psychotherapy Research: Linking research with practice, Volume 13, Issue 1, 2013, Published online: 01 Aug 2012. Copyright 2013 British Association for Counselling and Psychotherapy, available onlin

People Engaging Each Other: A dual-perspective Study of Interpersonal Processes in Useful Therapy

To explore how clients and therapists experience and engage in a therapeutic relationship which the client can make use of. We explored 11 psychotherapy dyads using in-depth qualitative methods. Selected dyads were ones in which the client experienced the therapy as useful. The data collection method was serial interviews with both therapists and clients. Therapists and clients were interviewed separately, four and two times, respectively, about their personal development, their views on and experiences with therapy, and their collaboration in the concrete therapeutic dyad. Transcripts of interviews were analyzed using a hermeneutic phenomenological qualitative analysis. The analysis yielded an overarching theme identified as “engaging each other.” This theme consisted of three constituent processes, developed from complementary descriptions from clients and therapists: 1) opening up to an encounter between humans, 2) trusting professionality, and 3) creating space for an unbearable story. We discuss how technical skill and personal warmth underlie the development of a helping relationship within which humans can open up to a personal encounter with suffering. We discuss how the personal aspect of the therapist position relates to psychotherapy as a moral practice, and suggest that this perspective is meaningful in understanding the therapist factor and the real relationship

Wisdom in professional knowledge: Why it can be valuable to listen to the voices of senior psychotherapists

Objective: To explore the nature of professional wisdom, through learning from the experiences of a group of highly experienced senior therapists. Method: Twelve senior psychotherapists took part in qualitative in-depth interviews about their professional role and their views around a range of aspects of therapy theory and practice. Interview transcripts were subjected to thematic analysis. Results: The analysis yielded nine wisdom themes, clustered within three domains. Each domain represented efforts to resolve dilemmas arising from the experience of being a therapist, around the use of theory in psychotherapy practice, the type of therapeutic relationship that is most helpful for clients, and the experience of therapeutic failure. Conclusions: Therapist wisdom can be viewed as a form of contextualized knowledge, which functions as a source of emergent insights that arise as responses to the limitations of prevailing ways of thinking. Research into the nature of therapist wisdom draws attention to sources of knowledge within philosophy and the humanities that have the potential to enhance therapy practice and contribute to our understanding of therapist expertise. The final version of this research has been published in Psychotherapy Research. © 2017 Taylor & Franci

Negotiating ending: A qualitative study of the process of ending psychotherapy

Objectives: When psychotherapy is open-ended, the question of termination is a matter for negotiation. A model based on both content and the process of ending may explain how ‘good enough’ psychotherapies can be brought to ‘good enough’ endings. Design: Twelve processes of ending were explored through a combination of audio recordings made during therapy sessions and post-therapy interviews with clients and therapists. Therapies had been tailored to the needs of the clients and were based on a broad spectrum of theoretical affiliations. Methods: A procedure for systematic text condensation was used on a case-by-case basis. Issues surrounding the initiation and negotiation of ending were pointed out in each case and were then compared across cases. Results: The initiation of ending and exchanges concerned with when and how to end therapy unfolded as a concerted process because both parties seemed to be aware that the theme of ending contained a potential challenge to the alliance. Dual affect regulation, implicit communication and a future-oriented perspective were important features. Structural elements such as schedule changes and temporary breaks served several psychological functions. Therapies seemed to reach ‘good enough’ endings when the client and therapist joined in their efforts to resolve basic ambivalences embedded in the decision to terminate contact with the affirmation of a continuing emotional bond

People Engaging Each Other: A dual-perspective Study of Interpersonal Processes in Useful Therapy

To explore how clients and therapists experience and engage in a therapeutic relationship which the client can make use of. We explored 11 psychotherapy dyads using in-depth qualitative methods. Selected dyads were ones in which the client experienced the therapy as useful. The data collection method was serial interviews with both therapists and clients. Therapists and clients were interviewed separately, four and two times, respectively, about their personal development, their views on and experiences with therapy, and their collaboration in the concrete therapeutic dyad. Transcripts of interviews were analyzed using a hermeneutic phenomenological qualitative analysis. The analysis yielded an overarching theme identified as “engaging each other.” This theme consisted of three constituent processes, developed from complementary descriptions from clients and therapists: 1) opening up to an encounter between humans, 2) trusting professionality, and 3) creating space for an unbearable story. We discuss how technical skill and personal warmth underlie the development of a helping relationship within which humans can open up to a personal encounter with suffering. We discuss how the personal aspect of the therapist position relates to psychotherapy as a moral practice, and suggest that this perspective is meaningful in understanding the therapist factor and the real relationship

Coming to terms: Client subjective experience of ending psychotherapy

How do clients consider their own contribution and that of their therapist in the last phase of therapy when they are moving toward the end? Thirty-seven clients who had received therapy from highly experienced clinicians were interviewed. Since the time for ending had not been decided at the onset, clients in both short- and long-term therapies were included. Thematic case-by-case analyses were carried out. Clients actively engaged in looking back and looking ahead, as means of reflecting on their capability to handle issues on their own. The majority of clients were satisfied with what they perceived as a reciprocal engagement that enabled them to come to terms with emotionally charged issues in life and in therapy. For some clients unresolved issues remained: wondering whether a therapist with another approach could have helped more; feeling pushed away by the therapist; having to take the lead in ending therapy; the fear of being an “unworthy” client; or wanting to end without the therapist’s approval. Coming to terms with the ending of therapy was highly personally meaningful and loaded with affective tensions, in ways that were not always shared with their therapist. The final version of this research has been published in Counselling Psychology Quarterly. © 2017 Taylor & Franci