Marit Råbu

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

Abstract Aim: To explore the process of ending in psychotherapy, in particular how clients and therapists draw on their notions of client improvements and prepare for the upcoming end. Data: The data comes from an intensive process-outcome study at the University of Oslo, Norway. The study includes audio-recording from all sessions and separate post-therapy interviews with clients and therapists. Twelve psychotherapy dyads were selected because they had reached a ‘good enough’ ending. Therapy duration ranged from 7–43 months. The number of sessions ranged from 10–67. Method and analysis: A hermeneutical-phenomenological approach analysed and combined the observational and reflexive data. The analysis was carried out using a method for systematic text condensation and through reflexive dialogues with the material and between the researchers. Findings and discussion: The language of improvement towards the end of treatment seemed packed with metaphors conveying growth in both affective and relational manage...

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

Abstract Aim: A good alliance established during the early sessions of psychotherapy will most likely lead to a good outcome. As a result, there is much to learn from a case in which both the patient and therapist regarded the alliance as being poor for an extended period (the first 15 sessions), yet still managed to develop a solid and stable alliance and reach a successful completion of therapy. The aim is to give a close inspection of this reparation process. Methods and analysis: Ratings on the Working Alliance Inventory (WAI) were used to guide the strategic selection of a case in which a depressed woman in her thirties sought help from an experienced senior male psychotherapist. A detailed analysis of the therapeutic dialogue brought forth what the parties expected from each other and how they responded to explicit and implicit expressions about how to proceed. Post-termination interviews revealed their subjective configurations of events in therapy and their corresponding reflections. Findings and ...

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

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

Norwegian translation and validation of a routine outcomes monitoring measure: The treatment outcome package

To evaluate the factor structure and clinical validity of a Norwegian translation of the treatment outcome package (TOP). Exploratory factor analysis was used to confirm the factor structure of the TOP (n = 334). Samples collected from university students (n = 137) were used to evaluate 1-week test–retest reliability. Concurrent validity was examined using data collected from a hospital sample (n = 197), who completed several referent measures. Logistic regression (n = 293) was applied to determine the translated TOPs ability to differentiate between clinical and non-clinical samples. A 12-factor solution was the best-fit for the data, largely supporting the US TOP structure. One-week test–retest reliability ranged from ICC = 0.56 to ICC = 1.00. Internal validity ranged from α = 0.49 to α = 0.93. The TOP subscales correlated most highly with referent measures or appropriate subscales. Logistic regressions correctly identified 77% of subjects as clinical or non-clinical. Conclusions: While larger and more representative samples may be necessary to fully explore the factor structure, the validity and reliability data indicate that the Norwegian version appears to be assessing similar areas of distress and functioning as the original. The translated TOP appears appropriate for clinical use.

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

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

“It’s both a strength and a drawback.” How therapists’ personal qualities are experienced in their professional work

ABSTRACT Objective: The aim of this study was to gain knowledge about how the integration of personal and professional experiences affects therapeutic work. Method: Therapists (N = 14) who had been recommended by their leaders at their individual workplaces were interviewed twice with semi-structured qualitative interviews, which were then subjected to thematic and Interpretative Phenomenological Analysis. Results: All the therapists in the sample described their personal qualities as an experienced tension between their personal strengths and vulnerabilities in the therapeutic setting. This tension came to expression through four subordinate themes: (a) The tension between perceiving oneself as a helper while dealing with one’s own needs for attention and care; (b) The tension between the ability for embodied listening to the patient while tuning into oneself; (c) The tension between staying present while handling aggression and rejection from clients; and (d) The tension in striving for a constructive balance between closeness and distance. Conclusion: The results point to ways in which the personal selves of the therapists may affect their professional role performance. Drawing upon previous research and literature on the topic, the paper discusses how therapists’ personal qualities are experienced as affecting their work and suggests several implications for psychotherapy training and practice.

Coming to terms: Client subjective experience of ending psychotherapy

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

Development through interruptions and reparations – A case study of a dual challenging psychotherapy

The aim of this study was to understand how relational difficulties in psychotherapy may be handled to represent possibilities for change. Temporary interruptions and subsequent reestablishment of contact were chosen as the strategic focus in one severely challenging case of long term psychodynamic psychotherapy where outcome was known to be good. Interruptions and reestablishments were conceptualised by how the informants gave meaning to them. The choice of focus represented a strategic selection of events in the course of therapy where the regulation of the alliance by the therapist as well as by the patient was at stake. A detailed case record was studied and interviews with patient and therapist were conducted. A hermeneutical-phenomenological approach was used to analyse the material. The narrative dimension was important in structuring and interpreting the data. It was shown how important relational difficulties, such as mutual incompatible expectations and demands was handled both on a structural and interpersonal level, and some important steps and hallmarks of the healing process was identified. Close inspection of the course of events in psychotherapies is seen as a promising method for bringing a better understanding of how change processes unfold.