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= 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 a bit manipulative... then I know I have to go and think about it and try to work out what 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 things and that's when I'd get really upset. It wasn't like an upset. It was a deep internal sob from the centre, it was like the very core of me.

Journey - Formulation Phoebe A lot of what we talked about, I knew it up here [pointing to head] but that’s the change that I made in therapy, it was about the information going from here [head] to here [pointing to chest] and that’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, why did I do that again? It's so obvious!”... I feel annoyed with myself because the conversation or my reaction to them is based in the past rather than the relationship I am having with them there and 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 and then I went through a stage where I felt in a void, not knowing what to do really... and then... I started to feel passionate about things, and when I started to feel passionate about them, I started to focus more and take more action on them so it was almost like a generator inside beginning 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, 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), 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 ). 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), 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.