Patients’ thoughts on psychotherapy Ola Lindgren, Licensed psychotherapist and PhD student at the University of Karlstad and the County Council of Värmland, Sweden. ola.lindgren@liv.se   Kjerstin Almqvist, Licensed psychotherapist and Professor of Medical Psychology at the University of Karlstad and the County Council of Värmland, Sweden. Per Folkesson, Licensed psychotherapist and PhD at the University of Karlstad, Sweden.

Starting points of the study Earlier studies of patients' experiences in psychotherapy identify relationship factors as being significant for patients (Norcross & Lambert, 2006). Patients take an active part in psychotherapy (Bohart, 2006). The psychotherapy methods will not be effective without patient-therapist interaction (Spek, et al., 2006). Patient feed-back therefore might enhance the psychotherapy process and outcome (Duncan, Miller, Wampold, & Hubble, 2010).

Aim of the study Our aim in this study was to explore patients’ thoughts on what is effective in psychotherapy and thereby increase the knowledge about patients’ perceptions of the psychotherapy process.

Method The data collection, sampling procedures and analysis in this interview study were conducted according to grounded theory.

Grounded theory has some distinctive features: The sampling procedure is iterative and cumulative; most interviews were transcribed and analyzed before the next interview was made. A starting point is chosen where rich data relevant to the phenomenon are expected to be found; eventually, theoretical sampling begins and data collection is guided by emerging concepts and the theoretical framework.

Saturation; theoretical sampling ends when new data do not develope the theoretical concepts further. This determines the sample size in grounded theory.

Sample Persons who had been in individual psychotherapy with a licenced psychotherapist were recruited by advertising in local newspapers. Exclusion criteria: a) a non-licenced therapist, b) an informant who had been a patient of the interviewer and c) informants currently in psychotherapy or planning to begin therapy in the near future.

Data from 16 therapies were sufficient to saturate the core concept. The sample included 8 informants, both male and female.

Background data collected at first contact, for example: informant age, gender, length of therapy, frequency of sessions, time elapsed since end of therapy, private practice therapist or public health care therapist and whether or not the patient was satisfied with therapy.

All four combinations of male/female patient and therapist are represented. The informants were between 42 and 67 years old and they had been in open-ended or time-limited therapies with different theoretical orientations. The informants labeled 9 therapies as satisfying, 4 as unsatisfying and 3 were labeled as neither.

Interviews The interviews lasted between 27 and 52 minutes and were conducted as an open dialogue. We had one initial question: “What do you think was effective in the psychotherapy or psychotherapies that you have been in? If you were not satisfied with the therapy, why was that?” When the informant had experienced more than one psychotherapy, data were collected about one therapy at a time.

Analysis Statements made by the informants were coded statement by statement. The codes were gradually grouped into categories and sub-categories, and eventually, a core concept was formulated. When the core concept was saturated, a theory grounded in the data was developed, guided by the standards set by Glaser (1998).

Results

Patient–therapist interaction

Specific interventions Questions and comments Advice and guidance The therapist’s actions Challenge to behaviour and conclusions Patient–therapist interaction

Specific interventions Questions and comments Advice and guidance The therapist’s actions Challenge to behaviour and conclusions Patient–therapist interaction The therapist’s robust being there Upholding a structure The therapist as a person

Specific interventions Questions and comments Advice and guidance The therapist’s actions The patient learns new skills Challenge to behaviour and conclusions Patient–therapist interaction The therapist’s robust being there Upholding a structure The therapist as a person

Specific interventions Questions and comments Advice and guidance The therapist’s actions The patient learns new skills Challenge to behaviour and conclusions Patient–therapist interaction The patient makes new experiences with the therapist The therapist’s robust being there Upholding a structure The therapist as a person

Specific interventions Questions and comments Advice and guidance The therapist’s actions The patient learns new skills Challenge to behaviour and conclusions Patient–therapist interaction The therapist’s responsive acceptance The patient makes new experiences with the therapist The therapist’s robust being there Upholding a structure The therapist as a person A graphic model of the Grounded theory of what patients think is effective in psychotherapy.

Conclusions The therapists’ emotional robustness and ability to perceive and respond adequately to the patients’ needs, are described as fundamental aspects of effective psychotherapy in our material. During the process patients accumulate both trust and apprehensions. Trust leads to forgiveness when the therapist makes mistakes. Apprehension and lack of trust might cause the termination of psychotherapy.

Patients have clear perceptions and opinions of the therapy process, of what they benefit from and not. Our study also emphasizes the interactive quality of psychotherapy. It is not simply a “treatment”.

Some quotes from the interviews

“(…) I often talk more on an analytical level, disconnected from the feeling (…) but if I explore feelings in the body [my body sensations] I think thoughts that are connected to my feelings so I’m more able to express what I’m experiencing.” (Specific interventions)

” In the tone of voice, in the nuances of that person [the psychotherapist], if that person becomes a bit like this, if he or she just pulls back or if he or she becomes a little more rigid, or if a person can sit there and just listen to what I’m saying and just feel that it doesn’t hurt inside that person (…), it’s very subtle.” (The therapist’s robust being there)

”She sort of sat there for me once a week in fifty weeks.” (Upholding a structure)

”I took notice of it [the therapist passing unfair judgement] and I forgave her.” (The therapist as a person)

”and then I got to learn to interpret my signals and see what needs do you have and which are the needs that you neglect.” (The patient learns new skills)

Thank you for listening! ola.lindgren@liv.se