Article: Research on Client Experiences of Therapy

Entry to 7 May 2008:

From time to time I end up writing an introduction for a special section of Psychotherapy Research. Because of my generally crazy life, these tend to get written at the last minute, under time pressure. And yet, these short pieces are among my favourite articles, because they offer an opportunity to take stock of an area of research. Meerkat-like, I get to stand up on the small hill made by the accumulation of articles on the topic at hand and look to the horizon. Like the sentinel meerkat, I’m not very big and the hill isn’t that high, so I can’t see very far, but it’s farther than the other meerkats can see, and sometimes I have been able to tell what’s coming, which the other meerkats have occasionally found useful.

A year ago, Clara Hill, long-time fellow therapy process researcher and current editor of Psychotherapy Research, asked me to do one of these introduction pieces for a special section of PR on Client Experiences of Psychotherapy. I could hardly say no, because I have spent a substantial part of my research career championing research on this topic, and also because I had published (with Elisabeth James) a qualitative meta-synthesis on client experiences in 1989. In the end, the special section turned out to have six papers, mostly qualitative studies. This provided an opportunity to characterize three current genres of therapy process research:

• Interpersonal Process Recall studies of important therapy events.
• Mental health service evaluation research using qualitative interviews to learn about what clients find helpful or hindering.
• Quantitative survey research evaluating predictors of important therapy processes.

Next, I revived my 1991 Five Dimensional Model of therapy process, the conceptual framework that underlies the Comprehensive Process Analysis method I developed in the 1980’s. This organizes therapy process along five essential dimensions:

• Perspective of observation (client, therapist, observer)
• Person being observed (client, therapist, relationship)
• Unit of process (e.g., speaking turn, session, whole therapy relationship)
• Temporal phase (context, process, consequences)
• Aspect of process (content, action, style, quality)

I used this framework to characterize the six studies, point to commonly studied and overlooked therapy process elements.

Finally, I summarized what could be learned from the six studies, concluding by underscoring the importance of the two Interpersonal Process Recall studies (from the very productive research group of Heidi Levitt at the University of Memphis). It seems to me that these studies point to the importance of studying client agency in the face of therapeutic difficulties (e.g., discovering that you and your therapist don’t see eye to eye on something). I would like to believe that these studies are pointing to an emerging research front that warrants further investigation “to identify a taxonomy of client process difficulties, along with descriptions of common client coping strategies, and lists of therapist responses that can help or hinder clients in resolving these difficulties” p. 242). Such a line of research would complement research on therapist-defined tasks, as developed by Greenberg and Rice, but would focus instead on client-defined tasks.

Reference: Elliott, R. (2008). Research on Client Experiences of Therapy: Introduction to the Special Section. Psychotherapy Research, 18, 239-242.

It turns out that PR is no longer publishing abstracts for introductions to special sections, but the following is the abstract I wrote for this paper:

Abstract: I introduce this special section of research on client experiences of therapy by looking at the six studies reported here from three different angles. First, I summarize each study and characterize it in terms of the current research genres represented. Next, I analyze the studies in terms of the Five Dimensional Model of therapy process (Elliott, 1991). Finally, I briefly summarize what we have learned about the three main questions addressed by these studies: What clients find helpful or hindering in therapy? How do clients see themselves as having changed over the course of therapy?, and, How do clients deal with difficulties in the therapeutic process?