The counseling and psychotherapy research literature continues to be dominated by studies that are based on quantitative measurement. However, research carried out with the use of qualitative methods, such as the analysis of interviews or therapy recordings, has a strong appeal for many clinicians and students because, in contrast to quantitative research, it remains closer to the actual phenomena and lived experience of therapy. Qualitative research articles provide a sense of being able to hear the voice of the client or therapist, and offer an understanding of the meaning that various aspects of therapy hold for them. At the same time, there are concerns about the reliability and validity of qualitative studies, for instance around difficulties in generalizing from small samples and in the possibility of researcher bias. There are also important barriers to the conduct of qualitative research. For new researchers, the domain of qualitative inquiry can appear impossibly complex and fragmented, with a confusing array of competing methodologies clamoring for attention. In addition, qualitative research is time-consuming, and requires specialist training and supervision. Although previous editions of this handbook have endorsed the value of qualitative methods, they have not included a chapter dedicated to this approach to inquiry, and authors of chapters on substantive topics have made scant reference to the contribution of qualitative investigations. In some respects, therefore, the present chapter can be viewed as evidence for the “coming of age” of qualitative research within the field of psychotherapy research.
This chapter provides an overview of the current landscape of qualitative research in counseling and psychotherapy. Methodological principles that inform the design of qualitative psychotherapy research are examined. Underlying philosophical and methodological assumptions that inform the conduct of qualitative research are outlined. The main methods of data collection and analysis are described, and critical issues are discussed. The contribution of qualitative research to the evidence base for counseling and psychotherapy is reviewed in relation to three key areas: the outcomes of therapy, therapy process, and the characteristics of effective therapists. The chapter concludes by considering some possible future directions for qualitative research on therapy.
To understand what qualitative research is trying to achieve, it is necessary to consider the contrasting philosophical assumptions that underpin mainstream quantitative research, on the one hand, and qualitative inquiry, on the other. The act of measurement is part of a long tradition in human society. People have always needed to count things, for practical purposes. From around the 17th century, a concept of science began to evolve, based on an assumption of an objective physical reality (e.g., atoms, molecules) that could be measured, and a realization that mathematical analysis of patterns within these numbers would yield theories or models that could be used to develop new technologies (e.g., machines, drugs) of immense value to human well-being. The act of making sense of the meaning of words or texts is also part of a long tradition in human society. The mythology or wisdom of a social group was initially conveyed through an oral tradition of stories and myths, then later through religious texts and other writings. But the meaning of these linguistic objects was not always clear—a different kind of “human science” needed to be developed, focusing on the interpretation of texts (Dilthey, 1977; Hiley, Bohman, & Shusterman 1991; Mueller-Vollmer, 1997; Packer & Addison, 1989; Taylor, 1971).
These alternative and competing knowledge-generating structures continue to exist in contemporary society. Although the “natural science” paradigm has enjoyed a dominant position within industrialized societies, in relation to public funding and influence over decision making, it is clear that interpretive forms of inquiry also play a significant role in cultural life. Bruner (1986) characterized these traditions as constituting discrete ways of knowing: a paradigmatic form of knowing that seeks to explain events in terms of abstract laws, and a narrative form of knowing that seeks to understand events in terms of contextualized, concrete stories. One of the barriers to the use of both of these forms of inquiry within the psychological research community has been the view that these forms of knowing are incommensurable—they provide competing perspectives that cannot be reconciled. However, it can be argued that the field of counseling and psychology represents a domain of practical knowledge that calls for clinicians and researchers to embrace both paradigmatic and narrative ways of knowing (Madill & Gough, 2008; McLeod, 2011). For example, a female client who seeks therapy to deal with her postnatal depression wishes to explore the effects of causal/paradigmatic factors such as hormonal changes and sleep deprivation, alongside interpretive/narrative themes such as the meaning of motherhood and the renegotiation of roles within her marriage.
The implication of this kind of everyday clinical scenario is that therapists (and therapy researchers) tend to find ways to integrate knowledge and understanding from apparently quite different ontological and epistemological paradigms or traditions. As a result, psychotherapy research has consistently moved in the direction of methodological pluralism (Howard, 1983) as it has matured as a field of inquiry in its own right and freed itself of the constraints of the assumptions of experimental psychology. The vision of psychotherapy research that has been most influential in recent years draws on a pragmatic image of knowledge as a basis for reasoned and responsible professional action (Fishman, 1999) that can be traced back to the ideas of William James, one of the founding figures of modern psychology. A pragmatic perspective is associated with the view that there is no single source of truth to which all knowledge claims can be reduced. All sources of knowledge are of potential value while at the same time being open to critical scrutiny.
Although it is possible to argue that quantitative and qualitative traditions each have their place in the context of the bigger picture of the psychotherapy research literature as a whole, it is undoubtedly the case that, historically, the training and professional socialization of the majority of therapy researchers has resulted in the development of deep understanding and technical skills around quantitative methodologies, and at the cost of a relative lack of knowledge and experience in relation to qualitative research. In response to this bias, several writers have sought to explicate the nature of qualitative therapy research from philosophical “first principles” (Madill & Gough, 2008; McLeod, 2011; Morrow, 2007; Polkinghorne, 1988; Ponterotto, 2005; Rennie, 2000a). There have been two main aims of these writings. First, it is argued that the positivist and critical realist philosophical positions that underpin mainstream psychological and medical research are so ingrained in researchers that researchers need to be challenged to rethink their underlying (or taken-for-granted) assumptions about ontology and epistemology if they are to engage effectively with qualitative methodologies.
The second aim has been to increase appreciation of the potential contribution of qualitative research and the necessity of understanding the distinctive values and knowledge criteria that can be used to evaluate qualitative work. Widely used qualitative methods texts, such as Hill (2012) and Smith, Flowers, and Larkin (2009), reflect these principles in providing readers with detailed accounts of the epistemological grounding of the methods that they describe.
There is a broad agreement across writers on the methodology of qualitative psychotherapy research that qualitative inquiry is informed by a specific set of interlocking philosophical traditions. The earliest of these traditions, in respect of its position within the history of human thought, is represented by the field of hermeneutics, which refers to the principles that guide valid interpretation of the meaning of a text. The hermeneutic tradition encompasses such knowledge-generating activities such as arriving at an understanding of the meaning of such diverse texts as religious writings, legal cases, plays and movies, and architectural styles (Taylor, 1971). It is but a small step to move from these examples of interpretive inquiry to contemporary research applications such as interpreting the meaning of a research interview or a therapy transcript (Gergen, 1988).
Phenomenology represents another philosophical tradition that has been incorporated into the methodology of qualitative inquiry. Phenomenology seeks to attain true knowledge by systematically bracketing-off everyday assumptions (natural attitude) concerning the meaning of an experience (Finlay, 2008; Fischer, 2009). For example, a client being interviewed about his experience in therapy stated that:
In the beginning, before therapy I blamed everything on me, everything that went wrong, I blamed it on me. But when I started speaking about it that kind of changed and my perspective changed.
Faced with this segment of interview transcript, a qualitative researcher might code it as “client perception of value of self-disclosure” and “gaining a perspective as an outcome of therapy.” Given that the researcher might need to work through many hundreds of lines of transcript, it might seem reasonable to accept these codes as providing a satisfactory rendering of that segment of the text, and move on. However, the phenomenological discipline of “bracketing-off” requires the researcher to stay with the text and ask, “What else might be there?” Within that particular passage, the researcher might then find other threads of potential meaning: the repetition and emphasis around “I blamed it on me,” the subtle qualification of therapeutic benefit implied by “kind of changed,” and the inclusion of time markers (“in the beginning,” “started”). The aim of phenomenological inquiry is to describe the phenomenon in as much detail as possible, and arrive at an appreciation of its “essence.” The process of bracketing-off slows down the researcher to a point at which a nuanced complexity can emerge and some sense of the “essential” quality of the experience being described can be at least partially grasped. The principles and practices of phenomenology have proved to be enormously useful for qualitative researchers aiming to move beyond surface or taken for granted understanding of the meaning of qualitative data and to achieve a deeper and more comprehensive appreciation of the possible layers of meaning in verbal accounts of experience.
There are two further areas of the philosophical literature that comprise essential sources of knowledge and understanding for those carrying out qualitative research: rhetoric and critical theory. The topic of rhetoric refers to the question of how an argument is constructed, to persuade an audience of its plausibility. Again, this is an area of philosophy that has substantial historical roots, and can be traced back to the origins of democracy in the open citizens debates that determined collective decision making in the ancient Greek city states (Eden, 1987; Perelman, 1982). An appreciation of rhetorical principles and structures is valuable for qualitative researchers because the basic data that are being handled (words) have been constructed by an informant in the light of his or her communicative goals in relation to their audience or interlocutor. Unlike numbers, qualitative data do not consist of bits of information that can be assembled and combined in different ways. Instead, the meaning of qualitative data, such as an interview transcript, always needs to be interpreted in relation to the context in which it was produced (Billig, 1996). A statement such as “before therapy, I blamed everything on me,” might have a different meaning if the informant was responding to an open invitation to talk about his experience of therapy, as against a situation in which the interviewer had asked a specific question about self-blame. Beyond an appreciation of rhetorical aspects of the ways in which clients give accounts of their experience, ideas about rhetoric are also relevant for qualitative researchers in respect to the way in which their research findings are communicated. Skilled qualitative researchers are sensitive to the task of explicating the personal stance of the researcher and conveying the distinctive voice or perspective of research participants. This concern with the rhetorical issues that are involved in reporting qualitative research has led to an interest within the qualitative research community in the ways in which scientific reports are written (Bazerman, 1988; Gergen, 1997; Nelson, Megill, & McCloskey, 1987; Rennie, 1995).
The notion of critical theory is of more recent origin, and is associated with the ideas of members of the Frankfurt School such as Jurgen Habermas (1972; Kincheloe & McLaren, 2005), and the writings of Michel Foucault (1972; Flyvbjerg, 2001) and Klaus Holzkamp (1992; Teo, 1998; Tolman, 2009). The primary focus of these social scientists, around methodological issues, has been to draw attention to the social role of science, and in particular to the ways in which science might appear to produce valid value-free knowledge but in reality was often conducted to support the interests of ruling elites. As result, it is essential for researchers to adopt a questioning and critical perspective in relation to the wider social meaning of their investigations. In the field of qualitative research, this position has translated into a concern for the power relationship between the researcher and the object of their research, and sensitivity to the ways in which dimensions of power and control are mediated and expressed in language and talk. This orientation toward a social justice agenda for research and practice is connected to similar developments within the field of psychotherapy as a whole (Goodman, Helms, Latta, Sparks, & Weintraub, 2004; Greenleaf & Williams, 2009).
It is possible to identify phenomenology, hermeneutics, rhetoric, and critical theory as essential methodological ingredients that constitute the practice of qualitative research. These ingredients can be combined in a range of different ways, depending on the aims and values of different researchers, and the topics that they are investigating. As a consequence, there does not exist, at the present time, a unified methodology for qualitative research. The absence of clearly defined principles and procedures for qualitative work can be confusing for those who are new to the field, and perplexing for those who have been trained in the quantitative-experimental tradition. It is therefore essential for training in qualitative methods to address underlying philosophical issues, so that researchers can make informed methodological choices.
There are many methodological choice-points that arise during the design and conduct of any qualitative project. It is necessary, for example, for any qualitative researcher to take a position in relation to the issue of researcher reflexivity. From a positivist epistemological standpoint, the personal experience and motivation of the researcher is only of interest as a potential source of bias, to be eliminated. In qualitative research, by contrast, it is clear that the person of the researcher may play an important role in shaping the type of data that is collected, and how it is analyzed. For instance, in a qualitative study of the emotional impact of loss of sight, research participants acknowledged that they were able to be more open in their interviews because the researcher was visually impaired, and could identify with how they felt (Thurston, 2010). Guided by phenomenological and hermeneutic principles, Thurston (2010) therefore made sure to keep a personal diary of her responses to participants, invited interviewees to comment on the experience of taking part in the study, and wrote about these matters in the method section of the resulting research article.
From a critical theory perspective, however, this kind of “first-person” account is not encouraged. The perspective of qualitative methodologies that adopt a critical theory stance, is that any personal statement on the art of the researcher needs to be regarded as a piece of discourse, or speech act, is no different in status from the words of research participants, and must be open to critical analysis and deconstruction. Researchers whose work is predominantly located within a critical theory approach deal with the issue of researcher reflexivity by ensuring that substantial amounts of basic transcript data is included in the research report, so that what the researcher does with the data is transparent to the reader. The challenge of research reflexivity is discussed in more detail in a later section of this chapter. Other methodological choices that are faced by qualitative researchers include the extent to which a study adopts an action orientation (rather than merely seeking to generate academic knowledge), the kind of rationale and procedures that are used to support validity claims, and the way that the findings of a study is reported and disseminated.
Constructivism represents a core idea that forms a shared point of contact across hermeneutics, phenomenology, rhetoric, and critical theory. Constructivism is grounded in the idea that the real nature of things is not knowable, and that human life is organized around an active process of co-construction that involves attributing meaning to experience, and continually revising these meanings through collaboration and conflict between individuals and groups. From a constructivist perspective, the concepts and theories held by individuals do not comprise a mirror to nature, but instead can be regarded as comprising an ongoing conversation about the nature of things (Rorty, 1980). Constructivism refers to a broad set of ideas, which can be traced back to the earliest philosophical writings. A version of constructivism that has been particularly influential for some qualitative researchers is social constructionism, which places particular emphasis on the role of talk and language as the primary means through which processes of construction takes place (M. Gergen & Gergen, 2003; Lock & Strong, 2010). To a large extent, the existing counseling and psychotherapy literature is grounded in an assumption of naturalism, which holds that there is an objective external reality that can be measured and known (Slife, 2004). The methodology of the randomized clinical trial is an example of the way that the psychotherapy research community has sought to converge on a single right (or objective) answer to the question of which therapy is most effective. As a result, the epistemological pluralism (Ferrara, 2010; Rescher, 1993; Woody & Viney, 2009) that is inherent in constructivist and social constructionist ways of thinking (i.e., that there can be several valid answers to one question) is hard for many researchers to accept.
Qualitative research can be viewed as a process of inquiry that aims to elucidate the construction of social reality in specific contexts. In the domain of counseling and psychotherapy, the aim of qualitative research is to describe, analyze, and understand the means through which the phenomena of therapy (for example, the therapeutic relationship, or changes in client symptoms) are constructed by various stakeholders or participants. In general terms, quantitative research seeks to establish causal links between “factors” or “variables.” So, for example, a typical quantitative study on the therapeutic relationship might aim to determine whether alliance scores at Session 3 predicted the ultimate outcome of therapy. By contrast, qualitative research into the client-therapist relationship aims to elucidate such topics as the meanings that clients attribute to different therapist activities (Bedi, Davis, & Williams, 2005), and the use of conversational strategies in arriving at a shared understanding of the goals of therapy (Davis, 1986). Quantitative and qualitative researchers are interested in the same fundamental question (what is a facilitative therapeutic relationship?). However, quantitative researchers approach the question from a perspective of trying to establish the validity of if-then statements or predictions. Qualitative researchers, by contrast, approach the question from a perspective of trying to describe the actions that people undertake in the light of the meaning structures that are available to them.
Qualitative research strives to maintain a balance between realism and relativism (Rennie, 2000b). The products of qualitative inquiry are based in a good-faith, accurate rendering of reality as it is experienced by all of those who have taken part in a study. At the same time, this product is of necessity a version, a construction of that reality, a particular reading. By including vivid examples, in the form of cases, quotes from informants or segments of therapy text, qualitative research attempts to show as well as tell, thus creating a space within which the reader has the possibility of arriving at his or her own interpretation of the material. The concept of the hermeneutic circle refers to the notion that any interpretation of reality, or story, can itself be reinterpreted or retold from a different viewpoint. There is therefore always a sense in which qualitative research recounts the history of a phenomenon or topic (Gergen, 1973). A powerful interpretive account of a phenomenon creates a temporary clearing, within which certain features of the terrain can be clearly seen (Heidegger, 1962). However, as these ideas become assimilated into the everyday, taken-for-granted understanding of participants in social life, that initial moment of clarity becomes overlaid with layers of further meaning. As a result, qualitative research is always, to some extent, a discovery-oriented activity. The qualitative researcher is like a reporter or archivist who documents and describes segments of everyday life, and at the same time an artist who is able to offer his or her audience a new way of seeing.
At the present time, there is little agreement around the types of qualitative research design that are most appropriate to use in addressing different research questions in the field of counseling and psychotherapy. Most qualitative research textbooks (for example, Creswell, 2007; Flick, 2009; Harper & Thompson, 2011) locate questions of research design in a discussion of qualitative methodologies, such as phenomenology or narrative analysis, that are derived from underlying epistemological principles. One consequence of the widespread adoption of this strategy has been a situation in which researchers become adherents of particular methodologies, and as a result fail to acknowledge the relevance of competing methodologies. This state of affairs has contributed to a somewhat fragmented, conflictual, and inward-looking research community (Denzin & Lincoln, 2011; Lincoln, Lynham, & Guba, 2011; Preissle, 2006). Within the field of qualitative therapy research, Elliott and Timulak (2005) advocate the adoption of a generic qualitative method, applicable to all or most research questions. Also from a standpoint in psychotherapy research, Moertl, Gelo, and Pokorny (in press) have categorized qualitative methodologies along two dimensions: theory-confirming versus theory-building, and content-oriented versus structure-oriented. An alternative approach, adopted in the present chapter, is to differentiate between qualitative research designs that investigate therapy outcome and process in relation to three units of scale: macro, mid-range, and micro. Macro-level studies explore the social, cultural, and historical context within which therapy takes place. Mid-range studies examine the experience of therapy for participants. Finally, micro-level investigations consider moment-by-moment processes. Each of these units of analysis present distinctive opportunities and challenges for qualitative therapy researchers, and are associated with the use of specific methods of gathering and analyzing data.
Any experienced clinicians will have their own ideas about the ways in which the historical and organizational context in which therapy takes place has an impact on the work they are able to do with clients. Qualitative research has the potential to document and describe contextual factors, and interpret their meaning and implication in relation to therapy practice. A study by Cook, Biyanova, and Coyne (2009) provides an example of the use of qualitative methods to explore the role of contextual factors in therapy. In this research, interviews were conducted with therapists in two therapy clinics within the same health care system. One of the clinics had adopted eye-movement desensitization and reprocessing (EMDR) as a favored intervention for patients with posttraumatic stress disorder, while in the other clinic this technique was not used at all. Cook et al. (2009) were able to identify the events, values, and management decision making that resulted in the dissemination (or otherwise) of EMDR in these clinics. The findings of this study were also used to generate a model of diffusion of innovation that could be applied in other settings.
The Cook et al. (2009) study was able to rely on interviews with individual informants, because in each setting it was possible to identify a set of members who had been present throughout the period of time being investigated, and were able to report on what had happened. In some studies of contexts, however, the topic of investigation calls for the collection of further sources of data, such as observation and personal or institutional documents, in order to be able to capture the complexity of the slice of social reality that is being investigated, and overcome the limitations of each source. The method of ethnographic participant observation encompasses spending time with a group of people, watching what they do, conducting informal conversations and more formal interviews, and collecting examples of the artifacts produced by the group, such as writings, objects and images (McLeod, 2011; Suzuki, Ahluwalia, Mattis, & Quizon, 2005). An example of an ethnographic study of therapy can be found in the work of Waldram (2007), who investigated the delivery of cognitive-behavior therapy (CBT) in the context of a prison-based treatment program for sex offenders. This study was able to show that the therapists in this program possessed a detailed record of the offending behavior of each client in advance of meeting him, and employed this account as a “truth” against which the openness of the client's own account of their actions could be assessed. As a result, the use of CBT within this program was fundamentally different from the collaborative way of working espoused by therapists in outpatient or private-practice settings. Unlike the Cook et al. (2009) study, where it was possible to make use of informants who were able to articulate a reflective understanding of the operation of the social context within which they were located, Waldram (2007) needed to piece together his analysis of the social context being investigated by building up relationships over time with key informants that made it possible to engage in direct observation of therapy sessions, take part in informal personal conversations, and have access to case records.
A wider perspective on the context of therapy can be developed by examining the ways in which therapy practice is shaped by shifts in external cultural, social, and economic conditions. There have been two studies that have used a historical, hermeneutic-interpretive approach to analyze these factors. Lewis, Clark, and Morgan (1992) identified two main influences on the emergence of marriage guidance counseling in Britain in the years following World War II. During that period, marital breakdown represented a significant moral and social issue that needed to be addressed through voluntary and community-based initiatives. In addition, leading figures in professional therapy promoted the adoption and application of established models of counseling and psychotherapy within the field of marital work. In a study of the historical development of psychotherapy in the United States, Cushman (1995) demonstrated the links between the growth in popularity and accessibility of therapy that took place in the 1950s, and the establishment of consumerism and individualism within American culture as a whole. The historical scope of the Lewis, Clark, and Morgan (1992) and Cushman (1995) studies meant that interviews with key informants were of limited value, because each informant could only offer a limited and partial account of the events in question. These studies therefore largely relied on analysis of documentary evidence rather than on collecting primary evidence through interviews.
A further set of qualitative studies has examined the practice of therapy in relation to the everyday lives of clients, using ethnographic methods (Dreier, 2000, 2008) and solicited diaries (Mackrill, 2008a, 2008b, 2009). This line of research has provided evidence of the extent to which clients are exposed to, and make use of, “therapeutic” ideas and techniques that are available within everyday culture and discourse, and that clients frequently interpret the methods being used by their therapists in the light of these preexisting practices. This research also found that therapeutic change in the cases that were examined did not consist of shifts in the emotional or cognitive functioning of the client, but was expressed in clients' decisions to rearrange elements of the structure of their everyday lives (Dreier, 2008). These studies draw attention to the extent to which the everyday lives of clients are not visible to their therapists.
These examples of qualitative studies of the social context of therapy illustrate several key methodological principles. Qualitative contextual studies require the identification of a specific case to be examined. The case can be relatively limited in scope, for example one therapy program (Waldram, 2007), one family (Dreier, 2008), a case comparison of two programs (Cook et al., 2009), the relationship between the therapy profession and managed care organizations (Greer & Rennie, 2006), or the influence on clients of being participants in a randomized controlled trial (Anderson & Strupp, 1986). Alternatively, contextual studies can be much wider in scope, such as the “case” of therapy in the United States (Cushman, 1995) or psychotherapeutic responses to depression in Greek women (Peglidou, 2010). Sufficiently rich data need to be collected to enable cross-checking of interpretations and conclusions (triangulation) across different sources of evidence. Analysis of data usually consists of identifying a coherent narrative of the stages in the development of the ideas and practices that are being investigated. Within these general methodological principles, a range of specific data collection and analysis strategies may be employed, depending on the aims of each particular study. Although few qualitative contextual studies of psychotherapy have been carried out, it seems clear that this type of research has the potential to make a significant contribution to the counseling and psychotherapy literature as a whole. Essentially, these studies show that the type of therapy that is delivered, and the effectiveness of that therapy, may depend less on the level of empirical support for the approach being used, or the skillfulness of the therapists who are delivering it, than on the ways in which these ideas and skills are adapted and reconstructed in the light of local conditions.
The largest body of work within the field of qualitative research in counseling and psychotherapy consists of studies of the experiences of therapy participants. Although most of these studies have focused on client experiences, there have also been studies of therapist experiences of aspects of therapy (Arthern & Madill, 1999; Beck et al., 2005; Daniel & McLeod, 2006; Frontman & Kunkel, 1994; Goddard, Murray, & Simpson, 2008; O'Neill, 1998), and the experiences of third parties such as family members (Jensen et al., 2010; Roberts, 1996). The rationale for research into the experience of therapy is compelling: There is an endless curiosity about what it is “really” like to be a client or a therapist. This curiosity is reinforced by an appreciation that the process of training and professional socialization undertaken by therapists may make it difficult or impossible for clinicians to appreciate what it feels like to be a client who is in therapy for the first time, or who is on the receiving end of a routine intervention. The appeal of qualitative research into the experience of therapy is that it offers participants a voice, and helps to de-familiarize taken-for-granted practices in ways that allow clinicians to remain receptive and responsive to clients and trainees. The basic methodological strategy that is employed within this genre of qualitative research is to collect self-reports of experience from a group of informants who have been selected on the basis of their exposure to a particular type of therapy event (e.g., they have all completed therapy, or they have all undergone a particular type of intervention). These qualitative accounts are then systematically analyzed to identify constituent themes or categories. Ultimately, the researcher is trying to answer the question: How is this aspect of therapy constructed by participants, in terms of a set of meanings that they are able to articulate? The aim is to achieve a “thick description” of the phenomenon being investigated (Geertz, 1973). What the researcher is looking for is not to arrive at a simple rendering of an experience (for example, that it was helpful), but instead to generate a multifaceted, nuanced, or layered account that will enable the reader to arrive at a deeper understanding or insight of the topic. It is also important to make a distinction between qualitative research and content analysis.
The aim of content analysis is to count the number of times a word or topic occurs within a research text such as an interview transcript. For example, for some research purposes it may be of interest to count the frequency with which a client engages in storytelling or refers to particular emotional states. Qualitative research always seeks to go beyond an itemization of content categories, in order to make some kind of sense of the meaning that the category has for research participants. For example, it is valuable to know about the average number of times a client engages in storytelling in a typical therapy session (Luborsky & Crits-Christoph, 1990), because this information can sensitize a therapist to the potential clinical significance of an absence, or overabundance, of storytelling within the therapy discourse of a particular client. But what a qualitative study, such as Rennie (1994a), adds to this knowledge is an appreciation of what the client is doing when he or she uses time within a therapy session to recount a story of an everyday event. Using careful analysis of stimulated recall interviews with clients, Rennie (1994a) was able to demonstrate that storytelling could function as a means of delaying entry into difficult feelings, and that the act of telling the story involved a process of internal reflection and sense-making.
There are several alternative methodological procedures that have been developed to carry out qualitative research on the experience of therapy. It is possible to identify four specific qualitative methodologies that are widely used. The most straightforward and flexible approach is thematic analysis (Boyatzis, 1998; Braun & Clarke, 2006), which consists of conducting a careful line-by-line reading of interview transcripts to identify themes within informants accounts of the topic being explored. A second group of qualitative methodologies are similar in intention to thematic analysis, but have developed more elaborate protocols for data analysis. The most widely used of these approaches are grounded theory (Charmaz, 2006; Rennie, Phillips, & Quartaro, 11988), interpretive phenomenological analysis (IPA; Smith, Flowers, & Larkin, 2009) and consensual qualitative research (CQR; Hill, 2012; Hill, Thompson, & Nutt-Williams, 1997). Each of these qualitative methodologies provides researchers with substantial guidance around how to organize the analysis of data, and what the finished product should look like. There are relatively minor differences between these approaches, which may be helpful or hindering in relation to the goals of a particular project. For example, grounded theory analysis requires the researcher to be able to identify a single overarching category that encapsulates the core meaning of the phenomenon being studied. IPA encourages analysis on a case-by-case basis, and invites the researcher to attend to structural and linguistic aspects of informant accounts (for instance, the potential meaning of long silences during an interview). CQR allows for the use of a start list of categories derived from previous research, theory, or clinical experience, and requires the analysis to be conducted by a team of researchers. These differences in technique can be viewed as alternative routes to arrive at the same general destination. Essentially, grounded theory, IPA, and CQR represent epistemologically eclectic strategies for assembling a pragmatic account of the categories through which individuals construct the meaning of their experience of specific segments of social life.
A third tradition of qualitative research into individual experience has adopted a more epistemologically purist approach, informed by phenomenological philosophy. Qualitative methodologies such as grounded theory, IPA, and CQR seek to use the description of the meaning of experience as the basis for deriving some kind of interpretive structure or framework for understanding that experience. By contrast, the aim of phenomenological research is to elucidate the meaning of an experience through comprehensive description alone. This is a remarkably hard thing to accomplish, because it requires being able to encourage research informants to generate detailed accounts of their experiences, and a capacity on the part of the researcher to bracket-off his or her assumptions about what the informant is saying, to remain open to subtle or implicit meanings that are present. Several groups of phenomenological researchers have developed protocols for undertaking phenomenological analysis (Giorgi & Giorgi, 2003; Halling, Leifer, & Rowe, 2006; Wertz, 2005). Some versions of this style of qualitative inquiry use the phrase phenomenological-hermeneutic to describe their approach (Dahlberg, Drew, & Nystrom, 2001).
In recent years, a further group of qualitative researchers has sought to develop methodologies for using systematic analysis of the subjective, personal experience of the researcher as a basis for exploration of the meaning of aspects of social life. This genre of research has taken the form of heuristic inquiry, a phenomenologically inspired approach constructed by Moustakas (1990), and autoethnography, an integration of practices from autobiographical writing and ethnography (Chang, 2008). The rationale for these methodologies should be clear to anyone with firsthand experience of psychotherapy: The full meaning of an area of experience can never be adequately captured in a single interview with a stranger, but only emerges through weeks or months of disciplined self-attention. In practice, however, successful completion (to the point of publication) of heuristic or autoethnographic inquiry calls for a high level of emotional maturity and writing skill. As a result, at the present time few studies of this kind have been published within the field of counseling and psychotherapy.
The area of personal experience of therapy comprises a particularly fertile territory for qualitative researchers. There are a wide range of questions that can be asked and topics that can be explored, and virtually any competently managed study will produce findings that are interesting and surprising. Most of the studies in this area have used structured step-by-step inquiry protocols, such as IPA and CQR, because these frameworks force the researcher to engage closely with the material, and are associated with tried and trusted formats for the reporting of findings. These protocols are also valuable sources of guidance for students undertaking their first qualitative study, who remain the main source of published work in this area.
Research into client or therapist experience of therapy can be regarded as similar to taking or making a picture of what the participant can see with their naked eye. Research into the context of therapy is like using a telescope or satellite camera to represent an image of a wider vista. Continuing this visual metaphor, studies of therapy micro-processes are concerned with the patterns that become visible through the use of devices such as microscopes. Micro-process research focuses on phenomena that are unseen and/or unseeable because they happen too quickly and are out of awareness.
There are two qualitative research designs that have been extensively used in the investigation of therapy micro-processes: interpersonal process recall (IPR) and conversation analysis (CA). IPR is derived from a training method developed by Kagan (1984) in which therapy trainees made audio or video recordings of their work with clients, then played back the recording, regularly pausing the tape at points of particular interest and talking about what they recalled of their experience at that moment in the original therapy session. Kagan (1984) hypothesized that if the recall interview took place soon after the therapy session (usually within 24 hours), the act of watching or hearing the recording would restimulate the person's memory of what they had been experiencing at that time. This technique was soon adopted by therapy researchers, who realized its potential to capture information about client and therapist experiences of hitherto transient aspects of the process of therapy. An example of therapy process research carried out with this approach can be found in studies by Angus and Rennie (1988, 1989) on the significance for the client of periods in therapy when metaphors arise during their conversations with their therapist. In these studies, audio recordings were made of therapy sessions. The researchers then identified episodes during the session when metaphoric language was being used. These segments of the recording were played back to the client, who was invited to report on what they had been experiencing during these parts of the therapy session.
The other qualitative methodology that has been used to explore therapy micro-processes is conversation analysis (CA; Madill, Widdicombe, & Barkham, 2001; Perakyla, Antaki, Vehvilainen, & Leudar, 2008). This approach originated in ethnomethodology, a branch of micro-sociology that examines the accomplishment of joint action (such as turn-taking, formulation of a problem, or arriving at an agreement) within conversation. Conversation analysis provides one of the earliest examples of rigorous qualitative research in psychotherapy, in the form of the analysis of a single session of therapy (Labov & Fanshel, 1977). Most CA studies are based on the analysis of a transcript of an example of “naturally occurring” talk (such as a therapy session), which has been prepared to a high level of precision using notation rules to indicate the length of pauses, intonation patterns, overlapping speech, and other aspects of conversational performance. The aim of the analysis is to identify the ways in which language is used in order to accomplish the institutional objectives of actors within a particular social context.
An example of how this methodology can be applied in the study of psychotherapy can be found in a study by Davis (1986), which examined the way in which a therapist used various conversational strategies to reformulate a problem presented by a client in her first session of therapy. Further examples can be found in an extensive body of work by Peräkylä and colleagues, involving analysis of conversational strategies used by therapists in facilitating decision making in clients contemplating HIV testing (Peräkylä, 1995; Peräkylä & Silverman, 1991), making interpretations (Peräkylä, 2004), and encouraging client movement into immediacy (Kondratyuk & Peräkylä, 2011). Strong and Pyle (2009) have applied conversation analysis in the exploration of how therapists use particular forms of language to engage clients in solution-focused interventions. Some qualitative researchers have used CA analytic strategies with the somewhat broader interpretive framework afforded by discourse analysis (DA; Avdi & Georgaca, 2007; Madill, 2006). A key feature of discourse analytic research has been its use of the concept of “subject positioning” (Harre & Van Langenhove, 1999) to enable micro-analysis of subtle ways in which therapists offer their clients alternative ways of talking about their problems. This perspective has been applied within psychotherapy research to examine the discursive construction of moments of change in individual therapy (Madill & Barkham, 1997; Madill & Docherty, 1994), and attribution of responsibility in couples therapy (Kurri & Wahlström 2005, 2007), family therapy (Suoninen & Wahlström, 2009) and group therapy for perpetrators of domestic violence (Holma, Partanen, Wahlström, Laitila, & Seikkula, 2006; Partanen, Wahlström, & Holma, 2006).
A further variant of a broadly conversational analytic approach to psychotherapy research can be found in methodologies that have focused on the significance of client narratives within the overall flow of therapy talk. Boothe and von Wyl (2004), McLeod and Balamoutsou (2000, 2001) and Rober, Van Eesbeek, and Elliott (2006) have developed structured qualitative methods for exploring the role of specific storytelling events in the co-construction of meaning in therapy.
The genre of qualitative research represented by the conversation analysis, discourse analysis, and narrative analysis tradition is characterized by intensive analysis of single instances of therapy talk, selected as typical or theoretically significant. There has been some debate around the relevance of CA/DA research to counseling and psychotherapy practice, on the grounds that these approaches appear to deny the possibility of human agency and choice (Madill & Docherty, 1994) and are therefore grounded in a concept of the person that is hard to reconcile with most theories of therapy. Strong, Zeman, and Foskett (2006) have attempted to overcome this difficulty by combining techniques from IPR and CA, in inviting clients and therapists to comment on their experience of conversational patterns that have been identified through microanalysis of their discourse in a therapy session. Viklund, Holmqvist, and Nelson (2010) addressed this issue by asking clients to identify helpful events in therapy, and then conducting a conversation analysis of the interaction patterns that occurred within these episodes.
One of the potential strengths of qualitative research designs is that they make available a wide range of sources of data. The interview remains the most widely used method of data collection in qualitative research in counseling and psychotherapy (Knox & Burkard, 2009). However, many different forms of interview are possible. The structure of the interview schedule can vary, from highly structured to open-ended. Interviews can be carried out with individual informants, couples, families and groups. A range of strategies can be used to supplement the use of questions within an interview—for example, informants can be invited to listen to a recording of a therapy session in which they have participated, or to depict their experience as an image or drawing and then reflect on what they produced, or to comment on case vignettes.
The interpersonal style of the interviewer can be relatively formal, or more personal and self-disclosing. Interview questions may be provided to informants ahead of the interview, or used in a way that seeks to elicit an immediate spontaneous response. In many studies, only one interview is carried out with each participant, while in other studies a series of interviews are conducted. The interview method therefore represents a highly flexible tool for qualitative researchers. In addition to interviews, there are many other sources of qualitative data that have been used by therapy researchers: diaries, open-ended questionnaires, written reports, personal and official documents, transcripts of therapy sessions, observation, projective techniques, and photographs.
The diversity of data collection techniques that can be used within qualitative designs represents a valuable asset but also a significant challenge for researchers. The advantage lies in the capacity of qualitative research to gain access to vivid and intrinsically interesting examples of what can happen within a therapy session. The existence of a range of data collection tools has allowed hidden or subtle aspects of therapy process to be uncovered, and silenced aspects of self to be heard. At the same time, a disadvantage of this diversity lies in the fact that there has been relatively little research into the attributes of qualitative research tools, and the types of information that are likely to be highlighted or occluded by the use of different methods. For example, in a study of client experiences of therapy, will different themes emerge if information is collected through weekly open-ended diaries, or by means of a single follow-up interview? At the present time, it is hard to answer this kind of question with any confidence, because of the absence of research into method factors in qualitative inquiry. This situation can be contrasted with the extensive literature that has accumulated around issues of reliability, validity and sensitivity to change in quantitative outcome and process measures.
A further methodological challenge for the qualitative research community arises in relation to the uncritical use of self-report methods, such as interviews and open-ended questionnaires. Although there is no doubt that valuable insights can flow from “just asking people,” it is also the case that what a person reports in an interview, or writes in an open-ended questionnaire, needs to be understood as an act of communication within a particular context. Older traditions of qualitative research, such as ethnography (Fetterman, 2009) or introspection (Danziger, 1990), were characterized by high levels of sensitivity to these factors. Ethnographic researchers, for instance, are careful to balance interview material with observational data, and to interpret the former in the light of the quality of the relationship between informant and interlocutor. In the early years of laboratory-based psychology, research subjects were trained in systematic techniques of introspection, so that they could differentiate between their actual experience, and their assumptions around what the experimenter might expect them to experience.
In the main, qualitative and quantitative methodologies have tended to have been used in isolation from each other. The nature of research training has made an important contribution to this kind of methodological apartheid. For the most part, new researchers have concentrated on developing skills in one or the other of these paradigms, and as a result have lacked confidence in designing mixed method studies. However, in recent years, there has been a lot of interest in mixed methods designs within the broader social science research community, leading to the identification of methodological principles and guidelines (Hanson, Creswell, Plano-Clark, Petska, & Creswell, 2005). Until now, mixed methods research has been featured to only a limited extent within the counseling and psychotherapy literature.
A range of strategies has been developed for combining qualitative and quantitative methods in a single study, or within a broader program of research. One approach has been to treat both qualitative and quantitative data as material that is open to interpretation. The operation of this strategy, which is informed by hermeneutic principles (Maracek, 2011), can be seen in the work of Robert Elliott over many years, through the development of comprehensive process analysis (CPA; Elliott, 1984) and hermeneutic single case outcome studies (Elliott et al., 2009), and in the program of case-based research into the assimilation model of therapeutic change (Osatuke & Stiles, 2011).
An alternative mixed methods strategy involves building an understanding of a phenomenon through qualitative inquiry, then using quantitative methods to determine the prevalence of that phenomenon, or to investigate its co-occurrence with other factors. Examples of this approach include research into therapist presence (Geller & Greenberg, 2002; Geller, Greenberg, & Watson, 2010), self-esteem (Mruk, 2010), the process of coming to terms with loss (Lichtenthal, Currier, Neimeyer, & Keesee, 2010), and interaction sequences in therapist-client discourse (Westerman, 2011). A further strategy consists of using quantitative research as a starting point, and then conducting a qualitative study to resolve ambiguities that have been identified in the quantitative analysis. An example of this kind of research is a study by Råbu, Halvorsen, Seeger, and Haavind (2011), which used qualitative methods to examine the process of a successful therapy in a case in which the therapist and client reported a poor alliance—a finding at odds with the results of quantitative studies of the working alliance. Another type of mixed methods design that seeks to use qualitative methods to “fill the gaps” in quantitative research can be found in Miller and Crabtree (2005), who have argued for the adoption of a “double helix” randomized trial design, in which a qualitative strand of inquiry is wrapped around a standard randomized clinical trial, thereby enabling the meaning of quantitative results to be understood in the light of the experiences of clients and clinicians who were involved in the study. Although it is too early for this type of research to have been widely applied, its potential value is illustrated in the Allen, Bromley, Kuyken, and Sonnenberg (2009) study of client experiences of mindfulness-based cognitive therapy, which was embedded within a wider randomized trial of that form of therapy (Kuyken et al., 2008).
There have in fact been many qualitative studies of client experiences of cognitive, cognitive-behavioral and mindfulness-oriented therapies in recent years (Berg, Raminani, Greer, Harwood, & Safren, 2008; Borrill & Foreman, 1996; Clarke, Rees, & Hardy, 2004; Cunningham, Wolbert, & Lillie, 2004; Glasman, Finlay, & Bock, 2004; Mason & Hargreaves, 2001; McGowan, Lavender, & Garety, 2005; Messari & Hallam, 2003; Morone, Lynch, Greco, Tindle, & Weiner, 2008; Nilsson, Svensson, Sandell, & Clinton, 2007; Perseius, Öjehagen, Ekdahl, Åsberg, & Samuelsson, 2003; Smith, Graham, & Senthinathan, 2007; York, 2007). Although this body of research has not been explicitly interpreted within the cognitive-behavioral literature in the light of the double-helix model proposed by Miller and Crabtree (2005), there seems little doubt it shares similar goals and intentions. It can be argued that the methodologically pluralist research strategy adopted within the CBT professional community has made a major contribution to the construction of a comprehensive evidence base in support of that particular therapy orientation.
A final approach to combining qualitative and quantitative methods within a single study is to use a qualitative approach to collect rich descriptions of experience, then make use of a coding system that transforms that material into quantitative data. An example of how this approach has been used to good effect in psychotherapy research can be found in work on the process of narrative change in therapy (Adler, 2012; Adler & McAdams, 2007; Adler, Skalina, & McAdams, 2008; Angus, Levitt, & Hardtke, 1999).
The strength of mixed method designs are that they combine the capacity of quantitative measures to integrate data across large samples, and make comparisons across groups, with the ability of qualitative methodologies to capture the lived experience and complexity of the phenomena being investigated.
At the present time, there exists a number of critical methodological issues within the area of qualitative research design. Some of these issues reflect debates within the wider domain of qualitative inquiry in the social sciences as a whole, while other concerns are more specific to the application of qualitative methods within the field of psychotherapy research. It is possible to identify two broad categories of critical issues: challenges and dilemmas arising from the conduct of qualitative research, and barriers to the further development and practical utilization of qualitative methods.
As discussed earlier, there are some well-established research designs that have been widely deployed within the field of qualitative research in psychotherapy, such as grounded theory, conversation analysis, interpretive phenomenological analysis, and consensual qualitative research. However, even within these tried and trusted methodologies, there are key critical choice points at which qualitative researchers need to make decisions that call on knowledge and understanding of underlying methodological, ethical, and epistemological issues. The most important of these decision-points centers on the adoption of validity procedures. Quantitative research designs are supported by criteria for reliability and validity of measures, statistical power estimates that inform sample size calculations, randomization strategies, and many other ways of determining the validity of a study. By contrast, the validity criteria that are appropriate to the conduct of qualitative research are less well-defined. Important contributions to the literature on the validity of qualitative research in psychotherapy have been made by Elliott, Fischer, and Rennie (1999), Morrow (2005), Stiles (1993), Williams and Hill (2012), and Williams and Morrow (2009), among others. There is now a general acceptance on the part of thesis supervisors and journal reviewers that some kind of external auditing or dialogue between co-researchers is desirable within qualitative data analysis and that processes of data selection, condensation, and interpretation should be transparent to readers of qualitative reports. There is less agreement within the field around the value or feasibility of inviting research participants or informants about their views of the credibility and accuracy of findings.
In general the recent literature around the validity, plausibility, or trustworthiness of qualitative therapy research has tended to emphasize the principle that research findings are most credible when they emerge from a process of dialogue between participants in the research process. The field has tended to move away from the idea, expressed by Rennie (1994d) and other early adopters of grounded theory methodology, that adequacy of data analysis depends on immersion in the data by a single analyst. While acknowledging the necessity for immersion in the data, the current view is that sensitivity to implicit meaning within a qualitative text, is best facilitated by opening up the analysis to a plurality of perspectives. Influential examples of how teams of researchers can work together in the analysis of rich qualitative data can be found in Elliott et al. (2009), Halling, Leifer, and Rowe (2006), Hill (2012), Morrow (2007), and Schielke, Fishman, Osatuke, and Stiles (2009).
A particularly contentious area of debate within the qualitative research community centers on the role and significance of researcher reflexivity (Etherington, 2004; Finlay & Gough, 2003). It is clear that the personal involvement of the researcher has the potential to shape the type of data that are collected, as well as the subsequent analysis of these data. Typically, a participant in a qualitative research study will engage in a fairly intense exploration of personal experience, in the presence of an interviewer who has a powerful interest in the topic that is being discussed. This is a situation in which there may be subtle pressures on an informant to emphasize certain aspects of his or her story, in reaction to the responsiveness of the interviewer. Similarly, interview transcripts tend to incorporate ambiguous information that may be read by the researcher in ways that are consistent with his or her preexisting biases. It seems clear, in the light of these issues, that it is important for qualitative researchers to reflect on possible ways in which they might exert an influence on data collection and analysis.
What is less clear, at the present time, is how researcher reflexivity should be organized and reported. Researchers within the traditions of discourse analysis and conversation analysis argue that the data with which they work (segments of text) and the analysis that they carry out, are open to the scrutiny of readers, who are therefore in a position to make up their own minds around any possible researcher bias (see, for example, Parker, 1994, 2004). Within these traditions, it is also sometimes argued that reflexive statements on the part of the researcher are themselves example of text, requiring the same sort of deconstructive analysis that is applied to other sources of evidence. Researchers who use methods such as grounded theory, CQR, and IPA to explore the experience of therapy, usually include a brief paragraph within the method section of their papers, describing the professional identity and background of the members of the research team, their expectations for what they would find, and the mechanisms for addressing power imbalances within the team. By contrast, studies that make use of heuristic research and autoethnographic techniques typically report in detail on all aspects of the researcher's experience of conducting the study (see, for example, Meekums, 2008). Behind these differences in style of reporting lie further divergences in the attention that is paid during the research process to the systematic collection of information around the reflexive self-awareness of the researcher, such as the use of a research diary.
Some critics of qualitative research regard the issue of researcher reflexivity as a sign of an ineradicable degree of subjectivity within this form of inquiry, which makes its findings worthless in scientific terms. It is perhaps worth pointing out, in this context, that the problem of experimenter bias has been widely studied within experimental psychology (Rosnow & Rosenthal, 1997), and researcher allegiance effects have been demonstrated within randomized trials of the outcomes of psychotherapy (Berman & Reich, 2010; Luborsky, Diguer, & Seligman, 1999). It can be argued that well-conducted qualitative studies are well placed to address issues of researcher bias, because they force the researcher to engage with the experiences of research participants at a level of intensity that is likely to challenge his or her preexisting assumptions (Flyvbjerg, 2006).
A further critical issue that is associated with qualitative research concerns the challenge of how to convey the findings of such studies in an effective manner (McLeod, 2011; Ponterotto & Grieger, 2007). In quantitative research, large amounts of data can be summarized in a single numerical table. In qualitative research, by contrast, the researcher needs to find ways to condense the words of several informants into a limited set of quotations or exemplars, and to find appropriate phrases that will capture the meaning of themes or categories. There is an expectation in qualitative work that research reports will reflect the “lived experience” of participants. Not all researchers are equally skillful in writing.
In addition, the style formats adopted by APA (and other) journals have been largely developed to facilitate the reporting of quantitative studies, and are experienced by some qualitative researchers as restricting their capacity to do justice to their findings. It would seem useful for the qualitative therapy research community to consider the advantages and disadvantages of alternative communication formats. For example, O'Neill (1998) used a monograph-length report as a means of presenting detailed client accounts of their experiences of negotiating consent over the type of therapeutic intervention they were to receive. By contrast, some medical journals, such as the British Journal of General Practice, have created effective formats for 2,000-word qualitative articles that are intended to be highly accessible for practitioners. Elliott et al. (2009) have demonstrated how online supplementary documents can be used to allow readers to gain access to interview transcripts. Speedy (2008) has argued that some qualitative findings demand representation through various types of performance, as well as in written form.
There are distinctive ethical challenges that can arise in qualitative research (Brinkmann & Kvale, 2005; Guillemin & Gillam, 2004; Van den Hoonard, 2002). The experience of being interviewed may re-evoke personal issues for clients, and the inclusion of lengthy quotations in qualitative research reports may threaten the degree to which informant confidentiality can be maintained. The use of unstructured or semi-structured interviews means that it can be hard for a researcher to predict what an informant will discuss, which raises difficulties for ethics committees and institutional review boards in terms of evaluating the type of risk management strategies that may be necessary. There are also ethical issues that center on the well-being of the researcher. For example, it can be emotionally demanding for qualitative researchers to listen to stories of abuse recounted by informants, and then to spend hours transcribing and analyzing these accounts.
The critical issues highlighted in this section reflect a need for ongoing conceptual and empirical investigations into the methodology of qualitative research. Some qualitative research communities have contributed to this task through critical review of methodologies such as IPA (Brocki & Wearden, 2006), CQR (Hill, 2012), IPR (Larsen, Flesaker, & Stege, 2008), heuristic inquiry (Sela-Smith, 2002), and solicited diaries (Mackrill, 2008b). In addition, Madill, Jordan, and Shirley (2000) have examined the validity implications of comparison of qualitative analysis carried out by different researchers on the same data. There have been projects that have explored the use of different qualitative methodologies in relation to analysis of a single set of data (Frost et al., 2011; Frost & Nolas, 2011). The latter initiative is part of a broader movement within qualitative research to question the application of predetermined research procedures and methodologies (such as grounded theory or CQR) and replace it with an image of the qualitative researcher as a “bricoleur” who “employ(s) methodological processes as they are needed in the unfolding context of the research situation” (Kincheloe, McLaren, & Steinberg, 2011, p. 168). These methodological initiatives, which intriguingly mirror some of the debates within the field of psychotherapy itself, around the relative merits of treatment manuals versus integrative or pluralistic ways of working with clients, have made valuable contributions to enhancing the rigor of qualitative studies. However, there remain a number of areas in which additional meta-methodological work on these issues would be useful.
The relevance of qualitative research for counseling and psychotherapy practice is contingent on two factors. First, there needs to be a sufficient number of high-quality published studies on key topics to allow an accumulation of qualitative evidence. Second, there need to be rational and transparent procedures for reviewing the cumulative findings of these studies, in a manner that will enable credible implications for policy and practice to be derived.
Although the proportion of qualitative studies being published in counseling and psychotherapy journals has increased over the past decade, it is still the case that fewer than 20% of therapy research studies make use of these approaches (McLeod, 2011; Munley et al., 2002; Rennie, Watson, & Monteiro, 2002). The impact of the qualitative papers that are published is further constrained by the fragmented nature of this literature—there have been no coordinated, large-scale programs of research that have used qualitative methods. Informal scrutiny of bibliographic databases, as well as personal experience, suggests that many more qualitative studies are completed as dissertation work, than are ever published. This phenomenon possibly reflects the challenges involved in reducing dissertation-length qualitative studies to comply with the word count requirements of research journals. It may also reflect differential career trajectories, in which students who undertake qualitative research for their dissertation tend to become clinicians, while those who conduct quantitative studies are relatively more likely to end up in academic positions. Behind these publication patterns are a series of critical issues around the nature of research training.
Relatively few counseling and psychotherapy training programs include sufficient training in qualitative methodologies to enable students to develop the competence and confidence required to produce publishable qualitative work. Effective training in qualitative research is time-consuming, incorporating experiential learning within an expert-apprentice relationship, the development of practical skills around interviewing and data analysis, and the acquisition of an understanding of critical conceptual and methodological issues (Eisenhart & Jarrow, 2011; Hansen & Rapley, 2008; Josselson, Lieblich, & McAdams, 2003). If the field of counseling and psychotherapy research is to embrace methodological pluralism in a manner that creates a more equitable balance among quantitative, qualitative, and mixed methods approaches, it may be necessary to initiate a process of review of the extent to which current models of research training produce graduates who are comfortable reading and conducting studies across the quantitative-qualitative continuum. Of course such a recommendation has implications for the expertise of faculty mentors and the need to include individuals with such expertise among the faculty.
The question of how best to bring together the findings of qualitative studies continues to stimulate debate within the social sciences (Dixon-Woods, Booth, & Sutton, 2007; Paterson et al., 2009). Within the field of quantitative research, highly sophisticated methods of meta-analysis have been evolved that enable findings from multiple studies to be combined (Borenstein, Hedges, Higgins, & Rothstein, 2009; Higgins & Green, 2008). Essentially, the logic of quantitative meta-analysis relies on an ability to differentiate between good- and poor-quality studies, and to aggregate treatment outcomes in terms of effect sizes. In addition, the establishment of agreed criteria for inclusion in systematic reviews has meant that quantitative researchers conduct and write up their studies in ways that are conducive to subsequent meta-analyses. At the present time, none of these factors can be readily mapped onto the task of carrying out a systematic review of qualitative studies of psychotherapy process or outcome. It may therefore be misleading to use the term meta-analysis in relation to reviews of the findings of qualitative studies. As a result, some qualitative research groups use the term metasynthesis to describe the process of conducting a systematic review of the cumulative findings of a set of qualitative studies. Narrative reviews of qualitative research have been carried out in relation to negative experiences in therapy (Hill, 2010), and grounded theory research into the client's experience of therapy (Rennie, 2000a). These reviews offered summaries of key studies, discussion of areas of agreement and disagreement between studies, and implications for practice. Timulak (2009) developed a systematic approach to metasynthesis of qualitative psychotherapy research that compared themes or categories reported in the results sections of published studies, leading to identification of shared categories and deviant categories. The fruits of this method can be found in two metasyntheses of qualitative research into client and therapist experiences of significant events in psychotherapy (Timulak, 2007, 2010), and one review of qualitative outcomes in person-centered and experiential psychotherapy (Timulak & Creaner, 2010). A further example of this type of qualitative metasynthesis has been carried out by Khan, Bower, and Rogers (2007) in a review of qualitative studies of patient experiences of guided self-help in primary care mental health, and by Hill, Knox, and Hess (2012), in the context of an appraisal of participants reasons for taking part in CQR studies. The Khan et al. (2007) review is notable in the level of detailed implications for practice that were generated.
Timulak (2009) and Hill et al. (2012) have called for the psychotherapy community to carry out further qualitative metasynthesis projects, to enable further refinement and extension of qualitative meta-analytic methodology. There is an inevitable tension within qualitative metasynthesis, between seeking to identify recurring categories, and the wish to retain the rich narrative data that give meaning to these categories. A strategy that might enable metasynthesis to incorporate more descriptive data might be to map the multiple meanings of a single theme or category, across a number of studies. For example, Timulak (2010) reported that clients in several studies described insight events as being highly meaningful. It would be useful to go back to the accounts of such events, in the original publications, to develop a more nuanced appreciation of the process and impact on insight, than would be possible in a review that aimed to consider all categories of significant events. Another approach to qualitative meta-analysis that may be valuable would be to strengthen the link between research and practice by analyzing qualitative findings not in terms of categories but in terms of therapeutic principles (Levitt, Neimeyer, & Williams, 2005; Williams & Levitt, 2007a, 2007b).
A further challenge in this area consists of finding ways to carry out systematic reviews that incorporate findings from both qualitative and quantitative studies (Dixon-Woods et al. 2006). A review of research into the impact on clinicians of participating in their own personal therapy, by Orlinsky, Norcross, Rønnestad, and Wiseman (2005) provides an example of how qualitative findings are merely used to support the conclusions of a review of quantitative evidence, rather than as findings that may have something more to offer. At least these reviewers acknowledged the existence of qualitative studies; most systematic reviews of psychotherapy research tend to disregard this source of evidence. An important task, for reviewers seeking to integrate evidence from quantitative, qualitative, and mixed methods studies, will be to find ways to give equal weighting to findings derived from different types of study.
Qualitative research has made a made a contribution to many aspects of contemporary theory and practice in counseling and psychotherapy. This section explores the nature of that contribution in relation to four areas: therapy outcome, the process of therapy, the client-therapist relationship, and therapist development.
Historically, research into the outcomes of therapy represents the domain of therapy research that has had the most impact on practice. The adoption by governments and health care provider organizations of service-delivery policies based on principles of evidence-based or empirically validated treatment, has created a direct link between the findings of outcome research, and the types of therapy that are offered to clients. Almost all of the evidence base for the effectiveness of psychotherapy is derived from research in which symptoms are measured before therapy and on completion of treatment. Few qualitative outcome studies have been carried out. However, the findings of qualitative studies offer a significant challenge to assumptions about outcome that derive from mainstream quantitative research on this topic, in relation to two key questions: how outcome is conceptualized, and the overall effectiveness of therapy.
In principle, there are a number of qualitative methods that might be employed to explore client experiences of outcome, such as diaries, analysis of therapy transcripts, and ethnographic observation. In practice, almost all qualitative outcome studies have relied on interviews in which clients have been invited to describe, in their own terms, the effect that therapy has had on their lives. Some studies have used only posttherapy interviews, while other studies have interviewed clients at the start of therapy and at follow-up. McKenna and Todd (1997) interviewed clients who had received several episodes of therapy over the course of their lives, and found that the outcome of each episode was evaluated in relation to its position within a wider therapy trajectory. Participants reported that they mainly evaluated the success of their first encounter with therapy not in terms of symptom reduction or the amelioration of distress, but in terms of the extent to which they gained a sense of whether that kind of treatment might in principle be useful in resolving their problems at some point in the future. By contrast, subsequent involvement in therapy was evaluated in relation to the degree to which problems were resolved. Finally, further therapy episodes were evaluated on the basis of whether the client was able to use treatment to maintain earlier gains. This study suggests that, from the point of view of the client, the effectiveness of therapy may be evaluated in quite different ways at different stages in a treatment career. If replicated by other studies, the results obtained by McKenna and Todd (1997) could have important implications for the way in which therapy effectiveness is understood. Up to now, the therapy outcome literature is organized around research of the impact of a single therapy episode, whose effectiveness is defined in terms of symptom and behavioral change. From the client's perspective, by contrast, it seems likely that “good” therapy may sometimes involve measurable symptom or behavioral change, but in other instances may involve learning about the possible value of therapy, or engaging in relapse prevention that maintains previous gains. In addition, the usefulness of therapy may depend to some extent on the promise or availability of on-going care across the life course (Cummings, 2007).
More detailed elaboration of the categories that clients use to assess the effectiveness of therapy can be found in the findings of qualitative outcome studies by Kuhnlein (1999) and Valkonen, Hanninen, and Lindfors (2011). What these studies have shown is that clients enter therapy with preexisting ideas about the reasons for their distress, and the type of treatment experience that is necessary to help them. These studies have yielded complex results, which at the present time are not easily assimilated into a single model. However, a common theme across this set of studies is the finding that there are at least three broad types of client understanding. One group of clients views current difficulties as arising from early childhood difficulties, and evaluates therapy in terms of the extent to which it enables them to come to terms with these early events. A second group of clients view themselves as generally enjoying positive psychological and emotional functioning, other than a temporary inability to cope with certain stressful events. These clients evaluate therapy in terms of the degree to which they have acquired coping skills.
A third group of clients understand their distress as arising from a lack of meaning in their lives, and evaluate outcome in relation to what they have learned around cultivating sources of meaning. In these studies, several examples are offered of clients who received what they regarded as the “wrong” type of treatment. These clients described their therapists as caring and competent, but not able to provide them with what they needed. Broadly similar findings have been reported by further qualitative studies of client “ideas of cure,” carried out by Lilliengren and Werbart (2005), Philips, Wennberg, and Werbart (2007) and Philips, Werbart, Wennberg, and Schubert (2007). An important implication of this line of research is that estimates of treatment effectiveness should take clients' criteria for success into account.
When clients in qualitative studies have been invited to describe the changes that they have experienced as a result of therapy, they frequently report various forms of enhanced personal agency, such as a capacity to apply insights or skills that they learned from their therapist (Burnett, 1999; Carey et al., 2007; Clarke et al., 2004; Glasman, Finlay, & Brock, 2004; Perren, Godfrey, & Rowland, 2009). Other qualitative studies have found that clients' account for the success of their therapy in terms of their acquisition of a benign or wise internal representation of their therapist (Knox, Goldberg, Woodhouse, & Hill, 1999; Mosher & Stiles, 2009; Myers & White, 2010). These clients report that, in moments of stress, they are able to recall the words of their therapists, or even to engage in internal dialogue with an imagined therapist. Phillips and Daniluk (2004) found that survivors of child sexual abuse reported that changes in their fundamental sense of identity were more salient, as therapy outcomes, than amelioration of symptoms.
One study, by Nilsson et al. (2007), compared accounts of outcome offered by clients in two different forms of therapy—psychodynamic and cognitive-behavioral. The satisfied recipients of psychodynamic therapy described what they had learned in terms of an enhanced capacity to manage relationships. The satisfied cognitive-behavioral clients described what they had learned in terms of an enhanced capacity to manage anxiety. Within the context of the field of psychotherapy outcome research as a whole, the Nilsson et al. (2007) study is of particular significance because it suggests a possible resolution to the “equivalence” paradox—the consistent finding that very different forms of therapy report similar levels of outcome. The groups of psychodynamic of CBT clients studied by Nilsson et al. (2007) were equally satisfied with their therapy, but gained in different ways.
There have been few qualitative studies that have examined client perceptions of the extent to which they have gained from therapy. In many of these studies, information about how the client evaluates the outcome of their therapy is embedded within a wider exploration of their experience of therapy as a whole. As a result, the experience of outcome is discussed in a limited way, with a lack of detail. There is a need for further qualitative research that focuses directly on outcome. Nevertheless, despite these limitations, it is possible to identify some emerging themes. All the studies carried out in this area have found that clients are able to provide a considered, nuanced appraisal of the helpfulness of the therapy they have received. In general, when clients are given time and space to talk at length about the outcomes of their therapy, they tend to offer a somewhat more critical account, when contrasted with the findings of quantitative outcome studies (Dale, Allen, & Measor, 1998; Howe, 1996; Morris, 2005) that merely report changes in level of functioning.
In most of these studies, a phenomenon that emerges is that of clients who are mainly positive about the benefits of therapy, yet express a theme of disappointment: They are aware of what they wished to gain from therapy, and did not receive. Other clients may be generally satisfied and comment that that the problem that motivated them to enter therapy remains a factor in their lives: They have learned to live with the problem, and manage it, rather than having been able to arrive at a complete resolution of their difficulties (Osborn & Smith, 2008). These qualitative outcome studies are based on relatively small samples of clients, which raises questions about the extent to which the findings that are reported are typical of all clients. Morris (2005) observed that participants in her qualitative study of the outcomes of psychodynamic psychotherapy who were less positive about their therapy experience required a considerable amount of encouragement and support to get to a point of being able to engage in the study. The implication here is that there may be a tendency for qualitative outcome studies to be more likely to recruit those clients who were satisfied with treatment, unless vigorous efforts are made (as in Morris, 2005) to reach out to the less-satisfied group. In the light of these issues, it is all the more striking that, compared to the high effect sizes reported in most quantitative outcome studies, the picture that emerges from qualitative outcome research is characterized by a significant degree of client disappointment and ambivalence with respect to the benefits that they have gained from therapy.
Mixed methods outcome studies, in which both qualitative and quantitative outcome data have been collected, make it possible to directly compare the outcome information from each source. Svanborg, Bäärnhielm, and Wistedt (2008) reported a high degree of overlap between qualitative and quantitative estimates of outcome. By contrast, Elliott et al. (2009) and Klein and Elliott (2006) reported a lack of correspondence between estimates of success from qualitative and quantitative data sources. At the present time, too few studies of this type have been carried out to allow firm conclusions to be reached regarding the factors that might contribute to convergence or divergence between qualitative and quantitative analyses of therapeutic success. Given the powerful investment in quantitative methods within the psychotherapy research community, it may be tempting to argue that the qualitative findings must be wrong. However, there does exist a coherent, if somewhat neglected, body of work that has identified important conceptual limitations in current strategies for quantitative assessment of therapy outcomes (Kazdin, 2006; McLeod, 2001; Meier, 2008; Michell, 1999, 2011). Mixed methods outcome research represents an important area for further research, because it has the potential of generating ways of evaluating outcome that is sensitive to the interests and perspectives of different stakeholders, particularly clients.
Taken together, the findings of qualitative studies into the outcomes of counseling and psychotherapy raise a number of important questions for further investigation. It is clear that more qualitative outcome studies need to be carried out, both to establish the generalizability of current findings, and to develop better solutions to methodological issues around recruitment participation, data collection strategies, and data reporting. However, what seems clear even at this stage is that mainstream symptom-oriented outcome measures may be missing dimensions of outcome that are also important to clients (Binder, Holgersen, & Nielsen, 2010). In addition, qualitative outcome research appears to yield an understanding of outcome that is somewhat less optimistic than the version that is conveyed through quantitative studies. When clients are provided with opportunities to evaluate outcome in their own terms, many of them describe their therapy as having been a valuable experience, but one that was only partially successful is resolving the problems in living for which they originally sought help.
Qualitative methodologies have proved to be particularly suitable for the task of exploring the process of therapy. The range of qualitative process studies that has been carried out is too extensive to provide comprehensive coverage within this section. Instead, three specific areas of process research are discussed: the client's experience of the moment-by-moment process of therapy; assimilation of problematic experiences over the course of therapy; and the characteristics of significant events within therapy. These topics represent areas in which qualitative research has made a distinctive contribution to theory and practice.
There have been a number of studies that have interviewed clients about their experience of being involved in the moment-by-moment work of therapy. In some of these studies, clients have been invited to reflect on their experience in a recent session, while other studies have employed a stimulated recall technique in which a recording of a session is played back to the participant, who is asked to pause the tape at any point where they were able to recall what they had been experiencing at that moment in the session. The findings reported in a stimulated recall by Fessler (1983) illustrate the way that this approach yields insight into the co-constructed nature of the therapy process:
Therapist and…patient do not take turns speaking and listening. Rather they participate in a speech that is taking place between and through them—a speech that is both spoken and listened to simultaneously. (Fessler, 1983, p. 44)
A series of studies by Rennie and his colleagues (Rennie, 1994a, 1994b, 1994c, 2000a; Watson & Rennie, 1994) exemplifies the theoretical and practical implications of qualitative research into clients' experiences of therapy process. Using a grounded theory method of analysis, these studies generated a conceptual model of client involvement in therapy that highlighted the interplay between client agency and reflexivity in a relational context. In other words, during therapy the client is actively pursuing his or her track or implicit sense of where the conversation needs to go. At the same time, the client is engaged in reflexively monitoring his or her experience, and deciding on what to say, and how to say it, in the light of his or her perception of the responsiveness of the therapist. The implications for practice of this model have been explored by Bohart and Tallmann (1999) and Rennie (1998).
The assimilation model, developed by Stiles (2002; Stiles & Angus, 2000) represents an important example of the use of qualitative research to develop a theory of therapy process. The assimilation model proposes that a central goal of therapy is to enable clients to come to terms with problematic experiences in their lives that remain outside of their primary sense of self, and are experienced in the form of disruptive or puzzling thoughts, behaviors, and feelings. The evolution of the assimilation model has been based on a series of qualitative case studies, in which assimilation stages, and the client and therapist actions that facilitate movement between stages, are analyzed through systematic interpretation of therapy session transcript material by a research team. Some of these studies have used ideas and techniques from dialogical sequence analysis, a form of discourse analysis, to enable microprocesses of therapist-client interaction to be scrutinized (Stiles et al., 2006). The assimilation process literature is distinctive in its use of case-level data to investigate processes that can take several sessions to unfold, and also in its adoption of an explicit theory-building orientation.
The largest single body of research into the process of therapy consists of studies that have elicited clients' views of significant events, or helpful/hindering events, within the therapy that they have received. Some of these studies have involved postsession interviews with clients, while other studies have been based on client written accounts. In a few studies, similar data are collected from therapists, enabling comparison between client and therapist views of what was helpful. A systematic metasynthesis of this research has been carried out by Timulak (2007), which concluded that there are several different types of experience that clients report as valuable within their therapy: awareness/insight/ self-understanding; behavioral change/problem solution; exploring feelings/emotional experiencing; empowerment; relief; feeling understood; client involvement; reassurance/support/safety; personal contact. The lessons for practice that can be derived from these studies offer support to integrative and pluralistic approaches to therapy, which seek to facilitate client engagement in a range of change processes, in contrast to approaches that focus on a more limited set of change mechanisms.
Other qualitative research into the helpfulness of therapy events has examined client experiences of specific interventions that are considered by clinicians to have particular relevance to the effectiveness of the kind of therapy that they offer. O'Connor, Meakes, Pickering, and Schuman (1997) and Young and Cooper (2008) have explored client experiences of narrative therapy techniques such as externalizing their problem. Client experiences of specific interventions have also been explored in relation to a structured, task-oriented methods of working on problematic reactions (Watson & Rennie, 1994), receiving letters from their therapist (Hamill, Reid, & Reynolds, 2008), motivational interviewing procedures (Angus & Kagan, 2009), receiving intensive psychotherapy in a day center (Mörtl & Von Wietersheim, 2008), person-centered therapy for alcohol misuse (Moerman & McLeod, 2006), psychodynamic therapy (Poulsen, 2004; Poulsen, Lunn, & Sandros, 2010), minimal intervention therapy (Macdonald, Mead, Bower, Richards, & Lovell, 2007), couples therapy (Rautiainen & Seikkula, 2009), cognitive analytic therapy (Rayner, Thompson, & Walsh, 2011), and participation in mindfulness training (Allen, Bromley, Kuyken, & Sonnenberg, 2009; Chadwick, Kaur, Swelam, Ross, & Ellett, 2011; Fitzpatrick, Simpson, & Smith, 2010; Moss, Waugh, & Barnes, 2008; Proulx, 2008; Stelter, 2009). Qualitative studies have also been used to explore client experiences of generic processes that occur in all forms of therapy. Dalenberg (2004) analyzed the views of clients on the issue of how their therapists responded to their anger. Hanson (2005), Burkard, Knox, Groen, Perez, & Hess (2006), and Knox, Hess, Petersen, and Hill (1997) investigated client experiences of therapist self-disclosure. Roe, Dekel, Harel, Fennig, and Fennig (2006), Knox, Adrians, Everson, Hess, Hill, and Crook-Lyon (2011), and others, have interviewed clients on their experience of termination of therapy.
In relation to qualitative research into client experiences of specific interventions, a series of studies on the role of metaphor in collaborative meaning-making in psychotherapy is of particular interest. Angus and Rennie (1988, 1989) used recall interviews to invite clients and therapists to describe their experiences during segments of therapy that were identified as involving the use of metaphor. Two patterns of therapist-client interaction were observed. In some cases, the therapist and client used the shared metaphor to access networks of associative meaning, which were highly productive in relation to overall progress of therapy. In other cases, there were misunderstandings around the meaning that the metaphor held for each participant, with the consequence that attention to the metaphor was not therapeutically productive.
Rasmussen and Angus (1996) and Rasmussen (2000) extended this work into a study in which metaphor-oriented experience of clients with borderline personality disorder characteristics and those without such characteristics were compared. For those without such characteristics, the emergence of a shared metaphor contributed to the development of a stable theme for the session. However, shared exploration of the meanings of metaphors that arose in-session did not appear to occur in the cases with borderline characteristics. Angus (1996), Levitt, Korman, and Angus (2000) and Long and Lepper (2008) tracked the occurrence of metaphor themes across multiple sessions of therapy, using qualitative analysis of therapy transcripts. In both studies, it was found that consistent metaphor themes (clusters of metaphors that drew on the same underlying meaning, such as “My marriage is like a battleground” and “I have to defend myself against him”) represented central topic threads within the therapy, and that client change was marked by metaphor shift.
Long and Lepper (2008) identified specific types of client reflective processing that were linked to shifts in metaphor use. Other studies have identified ways in which cultural metaphors enter therapy discourse, for example in clients with issues around depression (Levitt, Korman, & Angus, 2000; McMullen, 1999) and addiction (Shinebourne & Smith, 2010). These qualitative studies of metaphor use as a therapeutic process indicate the potential of qualitative process research, in being able to extend an initial inquiry (Angus & Rennie, 1988, 1989) into new areas, and gradually construct a comprehensive model. At the same time, this set of studies also illustrates the limitations of contemporary qualitative process research in terms of the small number of studies that are published. Making the step beyond exploring metaphor process, to using these ideas to inform practice, requires further replication studies to be carried out.
This brief account of some representative areas of qualitative research into client experience of the process of counseling and psychotherapy cannot do justice to the richness and clinical relevance of the studies that have been outlined. The distinctive contribution of qualitative methodologies, in this area of research in counseling and psychotherapy, is that it facilitates understanding of the complexity of the process of therapy as it unfolds over time, in a manner that represents both client and therapist as co-creators of meaning.
The conceptualization by Bordin (1979) of the therapeutic relationship as a “working alliance” characterized by a secure emotional bond between therapist and client, and agreement around the goals and tasks of therapy, has functioned for more than 20 years as a cornerstone of counseling and psychotherapy research. A generation of researchers has used this framework to develop measures that have been used to examine the links between alliance and outcome, the nature of failed alliances, and the effectiveness of methods for training therapists to form better alliances with their clients (Muran & Barber, 2010). In recent years, however, it has become apparent that although the alliance perspective can be seen as a metaphor that has served the field well in respect of highlighting important dimensions of the therapeutic relationship, it has also had the effect of diverting attention from other aspects of the relationship that are of clinical significance (Safran & Muran, 2006; Stiles & Goldsmith, 2010). In this context, the role of qualitative research into relationship factors has been to go “beyond the alliance,” to identify relationship phenomena that challenge and extend the prevailing alliance perspective.
One area in which qualitative research has uncovered aspects of the therapeutic relationship that are not explicitly addressed within alliance theory and research concerns the extent to which the client-therapist relationship involves negotiating issues of power, control, and status. Interview research by Rennie (1994a, 1994c) has identified the extent to which clients defer to their therapists—when they believe that the therapist has misunderstood them, or made an unhelpful interpretation or suggestion, they are likely to say nothing. Conversation analysis studies of therapist use of language demonstrates that clinicians take control of the course of therapy by redefining client problem statements so that they correspond with the theoretical model of the therapist (Antaki, Barnes, & Leudar, 2007; Davis, 1986) or steer client discourse in the direction of certain solutions (Peräkylä, 1995; Peräkylä & Silverman, 1991). Clients who view themselves as lower in social status than their therapists report that they typically held back on engagement in the therapeutic process, and did not expect that therapy would be helpful (Balmforth, 2006). Similar results have been found in qualitative research into the experiences of black and ethnic minority clients (Chang & Berk, 2009; Chang & Yoon, 2011; Thompson, Bazile, & Akbar, 2004; Ward, 2005).
A further set of findings from qualitative research into the therapeutic relationship suggests that on some occasions the client-therapist relationship is more than an alliance between two people working together to tackle a problem, and represents a potent curative experience in its own right. Some studies into client and therapist experience of the therapeutic relationship have collected accounts of moments in therapy when each participant is open to the other and experiences a sense of profound interpersonal contact (Grafanaki & McLeod, 1999; McMillan & McLeod, 2006). This sense of mutual connectedness or “relational depth” (Cooper, 2005; Knox, 2008; Knox & Cooper, 2010, 2011; McMillan & McLeod, 2006) can in some cases come to form a continuing strand within the ongoing relationship. Clients who have experienced this phenomenon describe it as representing as highly memorable, and as a turning point in their capacity to enter into meaningful relationships with other people in their life as a whole (Knox, 2008). Along similar lines, Schnellbacher and Leijssen (2009) found some clients who believed that the level of authenticity of their therapist as having been a central curative factor. When it occurs, this new type of relationship schema may be retained by the client as an internal dialogue with a supportive “other” that can be drawn upon at times of stress (Knox et al., 1999; Mosher & Stiles, 2009; Myers & White, 2010).
Other qualitative research into the process of therapy has highlighted the value for clients of working with a therapist who cares about them (Bachelor, 1995). Clients interviewed by Bedi, Davis, and Williams (2005), Levitt, Butler, and Hill (2006), and MacCormack et al. (2001) described how much they appreciated the fact that their therapists actively cared about them, and were “willing to go the extra mile” (e.g., by allowing session to go over time, or visiting them at home) to help them. Similarly, Binder, Moltu, Hummelsund, Sagen, and Holgersen (2011) reported that adolescent clients formed stronger relationships with clinicians who they perceived as being comfortable and confident in the role of therapist. These findings can be interpreted as being consistent with an image of the therapist-client relationship as similar to a relationship with a caregiver or good parent.
A theme that has emerged within some qualitative studies of client experience of therapy has been the finding that clients do not readily differentiate between “interventions” and “relationships” (for example, in studies by Bedi et al., 2005, and Borrill & Foreman, 1996). Clients may view the use of specific therapy techniques as indicative of their therapist's commitment to them, or may be willing to persevere with emotionally challenging activities because of their trust in their therapist. These findings imply that the search for causal links between alliance and outcome may be in danger of oversimplifying what, in the eyes of clients, is a process of reciprocal causality in which interventions and the quality of the relationship mutually interact in complex ways. Qualitative research into the therapeutic relationship provides an example of how the discovery-oriented nature of qualitative inquiry can be used within a professional community to sustain creative dialogue around important issues of theory and practice. The concept of the working alliance has made a massive contribution to the field of psychotherapy over more than three decades. However, the generativity of the alliance paradigm, as a source of ideas for research and practice, has perhaps run its course (Safran & Muran, 2006). It may be that an overreliance on quantitative methods has limited the capacity of the psychotherapy research community to do justice to the complexity of the client-therapist relationship. Stiles and Goldsmith (2010) have argued that there is a tendency for forms of psychological measurement to reduce to a single dimension of “evaluation” (i.e., a general sense of how good something is). What seems to have been happening within the domain of qualitative research into the client-therapist relationship is a gradual opening up of other dimensions of the relationship. This process of discovery can be regarded as beginning to provide confirmation, within the field of psychotherapy, of the relevance of multidimensional models of interpersonal relationships (Josselson, 1996, 2003; Stiles & Goldsmith, 2010). There have been relatively few qualitative studies into relationship factors in therapy, and the theoretical and clinical implications of the findings of these studies have yet to be incorporated into practice. Nevertheless, what has emerged from these investigations points toward a concept of the client-therapist relationship as involving multiple points of negotiation (Safran & Muran, 2006) between client and therapist around a fairly broad set of possible ways of constructive engagement.
Qualitative methods have been used to examine the meaning of being a therapist, the experience of training, and the shifts in perspective that occur over the course of a career. A key starting point for this area of work has been the classic Rønnestad and Skovholt (2003, 2012; Skovholt & Ronnestad, 1995) study of counselor professional development. This study is of special significance in identifying a set of stages of counselor development that have served as a basis for further focused inquiry, and establishing high standards of methodological rigor that have remained influential within this domain of research. The Skovholt and Rønnestad (1995, 2003) model of counselor development suggests that therapists pass through six phases during their professional lifetime: lay helper; beginning student; advanced student; novice professional; experienced professional; and senior professional. Each of these phases is associated with its own set of developmental challenges. Subsequent qualitative research has explored the experiences of therapists at each of these stages, adding further detail to the understanding of therapist development that is available. One of the most striking features of recent research on therapist development has been an increasing use of autoethnographic methods, in which clinicians systematically reflect on their own experience of training and practice (Grant, 2006, 2010a, 2010b; Moxnes, 2006). Possibly the most methodologically satisfying example of this type of work can be found in a study by McIlveen (2007), in which the author analyses the factors that influenced his own development as a theorist and researcher. McIlveen (2007) uses biographical material to question the validity of a conventional scientist-practitioner account of the links between research and practice, and to offer an alternative model that places the meaning of research within a life history perspective.
Qualitative studies have examined the experiences of therapists in relation to formative learning experiences, such as different types of training (Armstrong, 2003; Carlsson, Norberg, Sandell, & Schubert, 2011; Nerdrum & Rønnestad, 2002; Smith, 2011), and engagement in personal therapy (Grimmer & Tribe, 2001; Mackey & Mackey, 1993; Macran, Stiles, & Smith, 1999; Moller, Timms, & Alilovic 2009; Murphy, 2005; Rake & Paley, 2009; Rizq & Target, 2008a, 2008b; Wiseman & Shefler, 2001). The bibliography of CQR studies assembled by Chui, Jackson, Liu, and Hill (2012) lists a total of 23 qualitative studies on topics related to different aspects of counselor development. Taken together, these studies contribute a nuanced account of what it means to become and be a therapist. Unfortunately little is known about the relationships between these developmental and training factors and client outcomes.
One of the most influential domains of current research in counseling and psychotherapy comprises the accumulating body of work that confirms striking differences in effectiveness across therapists (Kraus, Castonguay, Boswell, Nordberg, & Hayes, 2011). Qualitative research has made a significant contribution to this area in exploring the personal characteristics of senior and “master” therapists, clinicians nominated by their peers as the “best of the best”—the therapists that they would recommend a family member to consult. The value of these studies lies in their capacity to use the broader perspective available to highly successful practitioners, who have survived the hazards of practice and thrived, as a means of highlighting the attitudes and strategies that are associated with excellence in the field of counseling and psychotherapy (Jennings & Skovholt, 1999; Levitt & Williams, 2010; Miller, 2007; Skovholt & Jennings, 2004; Skovholt, Rønnestad, & Jennings, 1997). In the first of this series of studies, Jennings and Skovholt (1999) interviewed 10 master therapists, representing a wide range of theoretical orientations. All of these therapists worked full time in private practice. The conclusions that emerged from this study were that master therapists are:
These conclusions have been largely supported by the findings of subsequent studies. The findings, along with the results of other qualitative research on therapist training, suggest that the therapist role incorporates a high level of integration of personal experience and professional knowledge. Implications for practice based on qualitative research on master therapists are discussed in Skovholt and Jennings (2004) and O'Donohue, Cummings, and Cummings (2006). Unfortunately two major problems have emerged from this research. The first is that the identification of “master therapists” did not include the actual effects of their treatments on clients. That is, no evidence was presented that they were unusually effective, other than peer nominations. The second problem was that the research design did not call for qualitative study of typical or poorly regarded therapists, who may turn out to share many of the values, attitudes, and behaviors that are demonstrated by their more highly regarded colleagues. Further research into these issues is required to determine the validity and general applicability of the “master therapist” literature.
Qualitative methods have been used to investigate a wide range of questions that have been of interest to counseling and psychotherapy practitioners and researchers. Qualitative research can be seen to complement mainstream measurement-oriented research in a variety of ways—by opening up new topics of inquiry, representing complex phenomena, and introducing a perspective that is grounded in the phenomenological world of the participant. The practice-focused nature of psychotherapy research requires the pursuit of methodologically pluralist research strategies that build on clinical experience. The practitioner status of qualitative therapy researchers, and their willingness to acknowledge the value of measurement-based approaches, has resulted in qualitative psychotherapy research inhabiting a methodological space somewhat apart from current debates within the wider field of qualitative inquiry. For example, the most recent edition of the authoritative Handbook of Qualitative Research (Denzin & Lincoln, 2011) makes no mention of qualitative research in psychotherapy. The relative isolation of the qualitative therapy research community is both a strength and a weakness. It is a weakness because it inhibits exploitation of new ideas and methods around the process of qualitative inquiry that have been developed within cognate disciplines such as education, health studies and management studies. It is a strength because qualitative researchers in the field of counseling and psychotherapy have, for the most part, avoided being drawn into “paradigm wars” and have therefore been able to retain their focus on the task of producing knowledge for practice.
The contribution of qualitative research to the counseling and psychotherapy evidence base is limited by a number of factors. Qualitative research relies on the “power of example” (Flyvbjerg, 2001), in the form of descriptions or accounts of key moments of action and interaction. Being able to communicate such segments of lived experience effectively remains a challenge both for researchers and journal editors—all too often the meaning and significance of a qualitative investigation is hidden behind dead writing. The descriptive basis of qualitative research also presents difficulties at the level of meta-analysis, or metasynthesis of findings. In a good qualitative study, the meaning of a theme or category is carried not merely in the title of the category, but in “thick descriptions” that are provided within the text: Qualitative papers are intended to be read all the way through.
For qualitative work to have its full impact on policy and practice, methods are needed for synthesizing results across studies. Since quantitative research syntheses like meta-analysis are having a powerful impact on public policy and practice decisions it is tempting to try to mimic these procedures for qualitative research integration. The work of Timulak (2007) and Hill et al. (2012) have moved in this direction. Hill et al. (2012) suggest that around 12 studies on a specific topic are necessary in order to generate a plausible qualitative meta-analysis. At the present time, there are few areas of qualitative therapy research that have accumulated anything approaching this number of studies. Alongside an uplift in the number of published qualitative studies, it is also important for researchers to provide sufficient information around sampling, validity procedures, exemplification of categories, and other basic reporting requirements, to enable those carrying out meta-analyses to arrive at well-founded conclusions.
It would also be valuable for the field of counseling and psychotherapy research to take greater advantage of the possibilities afforded by mixed methods research designs. One way of moving forward on this goal would be for qualitative and quantitative researchers to work together to plan and participate in multisite programs around key research priority areas.
It is possible to identify three tentative priority areas for qualitative therapy research over the next decade. The first priority is devote effort and resources, using the whole range of qualitative methodologies, to the issue of understanding how therapy outcomes are co-constructed, by clients, clinicians and other stakeholders, on the basis of cultural discourses around the meaning of suffering, well-being, and cure. This area of inquiry is of particular importance because an appreciation of “what works for whom” is of immense practical and economic significance, and because early returns from the small number of qualitative outcome studies that have been carried out suggest that there is a risk that outcome estimates based on standardized measures may not be telling the whole story. Within the broader field of mental health research, there has been increasing willingness to involve service users in the design and conduct of studies, as a means of maximizing the relevance of research findings in relation to the needs and wishes of recipients of care (Faulkner, 2000; Wallcraft, Schrank & Amering, 2009). Although qualitative research in psychotherapy has done a great deal to explore and document the experiences of therapy clients, few researchers have taken the next step of engaging in a collaborative process of inquiry with clients. This kind of development could do a great deal to enhance the impact of qualitative outcome research in psychotherapy.
A second priority area for qualitative therapy research is to examine the ways in which therapists actually make decisions about how to respond to clients. Gabbay and Le May (2011) used ethnographic methods to analyze the role of theory and research in shaping the clinical decisions of doctors. What they found was that the physicians in their study were certainly scientifically informed, but that they had little time for clinical guidelines, and in practice took a complex range of contextual factors into account in arriving at a view on how to treat each patient. This kind of investigation has major implications for the delivery of evidence-based treatment, for the type of treatment research that is carried out, and for the training, supervision, support and working conditions of clinicians.
A third priority area for qualitative research is to follow through on the potential and promise of certain areas of qualitative therapy research, to the point where learning from that research can directly influence practice in ways that can be evaluated. Being able to point to some examples of practical questions where qualitative research findings have yielded tangible improvements in efficacy, will transform the way that qualitative methodologies are perceived within the clinical, academic, and policy communities.
In conclusion, it can be suggested that it is essential for the knowledge base of counseling and psychotherapy to maintain a balanced commitment to the pursuit of practical knowledge through both quantitative and qualitative methodologies. Qualitative research yields nuanced, contextualized knowledge (Seikkula & Arnkil, 2006) that seeks to describe and make sense of the complexity of what is happening at ground level, and which provides a counterpoint to the more simplified, broad-brush general statements that are typically derived from quantitative studies.
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