Qualitative Research in Counselling and Psychotherapy

John McLeod

• Editorial: SAGE Publications Ltd
• Año: 2011
• ISBN:
  9781446244593
• Edición: 2
• Categoría: Psychologie
• Categoría: Forschung & Methodik in der Psychologie

The need to show how and why counselling works has led to an explosion of research activity, and a growing focus on research in counselling and psychotherapy teaching and practice. Yet this book, even now in its second edition, stands alone in addressing qualitative research in therapy.

Leading expert John McLeod helps readers through each stage of the research process, explaining techniques for gathering data, writing up the study and evaluating the findings. Each qualitative method is clearly described and critically assessed in terms of its own strengths and weaknesses. Examples from actual research studies are given to show how the methods work in practice. This new edition incorporates developments in qualititative research over the last ten years and includes eight new chapters, covering:

-interpretative phenomenological analysis (IPA)

-autoethnographic methods

-action research

-case study methods

For all those involved in research - whether as part of academic study or in practice -this book will be essential reading. As an introduction to qualitative methods, it is the perfect course text for all training programmes in counselling, counselling psychology and psychotherapy, and will also be of interest to those who work in areas such as psychiatry, clinical psychology and mental health nursing, or who provide counselling in other professional areas such as teaching, nursing and social work.

McLeod is Professor of Counselling, University of Abertay Dundee.

1

Qualitative research in counselling and psychotherapy: achievement and potential

In recent years, qualitative research has become increasingly influential within social science, education and healthcare research. For many people wishing to do research into real-life topics and problems in these fields, qualitative inquiry offers a set of flexible and sensitive methods for opening up the meanings of areas of social life that were previously not well understood. Qualitative inquiry holds the promise of discovery, of generating new insights into old problems, and producing nuanced accounts that do justice to the experience of all those participating in the research.

If qualitative research in counselling and psychotherapy is to make a significant contribution to the quality of services that are offered to users, it is essential for both researchers and consumers of research to possess a clear idea of the nature and achievements of qualitative research within the field of counselling/psychotherapy. The aim of this chapter is to examine the role of qualitative research in counselling and psychotherapy. A definition of qualitative research is offered. This is followed by a look at some of the achievements of qualitative research in therapy, and a discussion of the historical context in which these studies were carried out.

Defining qualitative research

What is the point or purpose of conducting research into an activity such as counselling or psychotherapy? The answer to this question is perhaps obvious. The purpose of research is to enhance knowledge, to enable us to know more about the way counselling and psychotherapy operate and how or why they are effective (or perhaps not effective). But there are deeper questions that lie behind this type of common-sense perspective on the role of research. What do we mean by ‘knowing’ and ‘knowledge’? It is possible to identify two broad styles of knowing that exist within Western culture and society. The psychologist Jerome Bruner (1986, 1990, 2002) has described these distinct ways of knowing as ‘paradigmatic’ and ‘narrative’. Paradigmatic knowing is associated with positivist physical sciences and involves the establishment of abstract ‘if–then’ statements about the world, which seek to explain how observable phenomena are the result of specific causal factors and processes. By contrast, narrative knowing is associated with everyday accounts of human action, usually in the form of stories. We make sense of the events of our lives by telling stories to ourselves, and others, about what happened, when it happened, what each person said and did, and so on. Paradigmatic knowledge reflects an ‘objective’ deterministic world; narrative knowing reflects a ‘constructed’ world in which human agency can make things happen.

Exercise 1.1 Reflecting on forms of knowing

Take a few minutes to think about your work as a counsellor or psychotherapist. How do you know what to do in response to your clients? What are the sources of your knowledge? How adequate is the narrative–paradigmatic distinction as a means of classifying the types of knowledge that you use? What other categories come to mind, in relation to knowledge sources that are meaningful for you?

Within the academic and professional community, there has been considerable tension between these alternative ways of knowing. Paradigmatic knowledge has accrued status and influence through its use within medicine, the physical sciences and technology. Narrative knowing, by contrast, represents the domain of ‘softer’ (and economically less powerful) disciplines such as literature, art, anthropology and history. There have been many individuals and groups who have argued for the incommensurability of these approaches to knowledge. However, it is also possible to adopt a more pluralistic or pragmatic position (the perspective adopted in this book), which views both paradigmatic and narrative forms of knowing as essential human accomplishments that can be combined in many ways in order to serve different purposes. Within everyday life, and therapy practice, we routinely tack back and forward between narrative and paradigmatic ways of making sense of problems. For instance, if someone comes into therapy because they are struggling to come to terms with the effects of a serious car accident, then both therapist and client are comfortable with talking about the causal, determinist aspects of what has happened (the ice on the road, the speed at which the other person was driving, the effect of the drugs taken to alleviate pain) as well as the personally and collectively constructed meaning of the event (e.g., the significance of losing one’s job). Similarly, the research literature as a whole necessarily encompasses examples of both narrative and paradigmatic ways of making sense of specific issues and phenomena. And within any individual research article, there is usually a story or stories that are being told, alongside some kind of more generalized or abstract model that is being proposed.

Where does qualitative research fit into these types of knowing? The starting point for qualitative research is conversations and stories, and interpretation of objects, images and rituals that tell stories or are meaningful in some way. Qualitative research is therefore firmly rooted in the ‘narrative’ side of Bruner’s narrative–paradigmatic distinction. However, qualitative methods can readily be used, as reflected by many examples in the chapters that follow, to generate or test abstract ‘paradigmatic’ cause–effect models. Qualitative research starts with language and meaning and can reach out into the domain of numbers and ‘variables’. Quantitative research starts with numbers and causal linkages between variables and can reach out into the domain of stories. Mixed methods research seeks to harness both forms of knowing at the same time. The key point here, and the underlying philosophy of this book, is that for practical purposes, qualitative/narrative and quantitative/paradigmatic forms of knowing complement each other. They are both necessary. This is particularly important within the field of research into counselling and psychotherapy. A knowledge or evidence base for therapy that consisted only of qualitative findings, or only quantitative findings, would be like thinking with one hemisphere of the brain anesthetised–it can be done, sort of, but it is not very effective.

There are many definitions of qualitative research that can be found in textbooks and in the writings of leading figures in this field. I would like to offer my own definition, that I believe is particularly attuned to the needs and interests of therapy researchers and practitioners. In my view, qualitative methods contribute a particular kind of knowledge about the world, which can be summed up in these terms: the primary aim of qualitative research is to develop an understanding of how the social world is constructed. The notion of the world being ‘constructed’ implies that we inhabit a social, personal and relational world that is complex, layered and can be viewed from different perspectives. All of this is the result of human activity. We construct our world through many forms of individual and collective action: talk and language (stories, conversations), systems of meaning, memory, rituals and institutions, and all the myriad ways in which the world is physically and materially shaped by human purposes. The various qualitative methodologies that have been devised, and that are introduced in later chapters, all seek to contribute to an understanding of how the world is constructed, but each of them takes on a different facet of this task. For example, some qualitative research focuses on the meanings through which people construct their realities. Other researchers concentrate on the way that shared cultural worlds are constructed through ritual, myth and social practices such as kinship rules. Still other researchers seek to make sense of how reality is constructed through talk and language use. Finally, there are qualitative researchers who are interested in challenging existing structures of understanding (de-constructing) or in building new ways of doing things (re-constructing).

This is why qualitative research is so useful for therapy. It is certainly important to have access to paradigmatic cause-and-effect knowledge, such as the finding that cognitive-behavioural therapy (CBT) is more effective than other forms of therapy with clients experiencing panic disorder. But that CBT intervention consists of therapists and clients who each act as purposeful, intentional agents on the basis of their different meaning systems, who engage in conversation around what the problem is and what can be done, and whose meetings are located within and shaped by complex cultural and organisational systems. Qualitative research holds the promise of opening up these multiple levels of construction for deeper scrutiny. The following section offers some examples of how this promise has begun to be fulfilled.

Box 1.1

Tracing the growth in qualitative research

Historically, counselling and psychotherapy research has been dominated by the methods of inquiry used within the disciplines of psychology and psychiatry, such as standardised measurement instruments (tests), diagnostic categories and experimental designs. Compared to the amount of quantitative research that has been produced, relatively little qualitative research in counselling and psychotherapy is being published. Analyses by Rennie, Watson and Monteiro (2002) and Marchel and Owens (2007) of all articles in journals published by the American Psychological Association (APA) reported that between 0.45% and 1.3% (depending on the search strategy employed) of all articles were qualitative studies. The majority of these qualitative studies were published in psychotherapy and counselling psychology journals (Munley et al. 2002). In these therapy journals, less than one quarter of published studies used qualitative methods, although the proportion of qualitative studies had increased in recent years. In the UK, the reporting of qualitative research has been promoted by two journals–Psychology and Psychotherapy: Theory, Research and Practice and Counselling and Psychotherapy Research. Of the research studies published in these journals during 2009, the proportion of research studies using qualitative or mixed methods was 81% (22/27) for Counselling and Psychotherapy Research and 27% (8/30) for Psychology and Psychotherapy: Theory, Research and Practice. In Psychotherapy Research, a journal with an explicitly international readership, the proportion of qualitative studies in 2009 was 17% (5/29), and in the Journal of Counseling Psychology (American Psychological Association) the proportion was also 17% (8/48).

The achievements of qualitative research in counselling and psychotherapy

The studies that are highlighted below are offered as exemplars of the kind of enhanced knowledge and understanding that can be achieved through the use of qualitative inquiry. It is necessary to proceed with caution to interpret the significance of these studies. As outlined in Box 1.1, there is still only a relatively small amount of qualitative therapy research that is being published. At this point, there are few areas of therapeutic endeavour in which there exist enough published qualitative studies to carry out meaningful meta-analysis or meta-synthesis that integrates the findings of multiple studies on the same topic. The studies that are discussed here are therefore examples of what can be accomplished with the use of qualitative methods, rather than indicating definitive conclusions.

• Clients report different outcomes from different types of therapy. Research into the outcomes of therapy is hugely important within the field, because clients, taxpayers, health service managers and other groups of people are vitally interested in knowing ‘what works’. Many hundreds of quantitative outcome studies have been published (for an overview of this literature, see Cooper 2008). For the most part, the results of this vast investment in scientific activity has yielded a puzzling finding–the equivalence paradox. Research seems to show that very different types of therapeutic intervention, when compared to each other in a fair test, appear to have the same level of success. A qualitative study carried out in Sweden by Thomas Nilsson, Martin Svensson, Rolf Sandell and David Clinton (2007) produced findings that begin to explain why the equivalence paradox exists, and what it means. Nilsson et al. (2007) interviewed clients who had received either CBT or psychodynamic therapy. Their analysis of the interview transcripts uncovered a great deal of interesting information about how these clients had experienced the therapy they had received, but in relation to the equivalence paradox two particular findings were particularly relevant. First, among the clients who reported that they had benefitted from therapy, quite different types of learning were described by those who had received CBT, compared to those who had received psychodynamic interventions. The CBT clients stated that what had changed was that they were now better able to deal with difficult situations and had taken control of their lives. By contrast, the psychodynamic clients said that what had changed was that they could understand themselves better, and could set limits and boundaries in their relationships with others. Both groups of clients had improved to the same extent in terms of symptoms of anxiety and depression, but had changed in different ways. Second, among the clients who had not been helped by therapy, those who had received CBT complained that they had been disappointed that their therapist had not allowed them to talk more extensively about their emotions and relationships (i.e., had been more like a psychodynamic therapist), while those who were disappointed with their psychodynamic therapy stated that what they had really wanted was someone who would provide structured problem-solving (i.e., a CBT therapist). When contrasted with the evidence accrued from quantitative outcome studies, the Nilsson et al. (2007) study opens up a more nuanced, and potentially more practically useful, account of therapy outcome, one that begins to uncover the ways in which the benefits of therapy are shaped by the interplay between the meaning systems of client and therapist around what is helpful.
• How therapists control the therapeutic agenda. Part of the legacy of Carl Rogers is the idea that counselling and psychotherapy are, or should be, fundamentally client-centred, in the sense of respecting and working with the way that the client defines his or her problem, rather than imposing an external, expert-drive perspective. There have been several qualitative studies that have challenged this idea by looking at what actually happens in conversations between clients and their therapists. One of the clearest and most convincing studies of this type was carried out in Holland by Kathy Davis (1986). In this study, an analysis was conducted of the conversation during the first meeting between a client (a young woman) and an experienced and highly regarded male therapist. The transcript of this session reveals that the client begins by describing the difficulties in her life (two young children, lack of contact outside the family, some tension with her husband). During the opening phase of the conversation, the therapist reflected back what the client was saying, and encouraged her to keep talking. As the session proceeded, however, the therapist introduced a gradual reformulation of the problem, redefining it as an issue around maintaining a façade and not being able to be open about feelings. Careful analysis of the conversational interaction was able to identify ways in which the therapist led the client into an agreement with his way of defining her problem. Davis (1986) comments that it took her a long time to be able to ‘see’ what had been happening in this session–on the face of it, what was in the transcript seemed to be an example of a typical good first meeting. It was only through detailed line-by-line analysis of the ways in which meaning was constructed and reconstructed through various conversational strategies that it became apparent that what was happening reflected a high level of therapist professional control of the interaction, in the direction of a therapeutically-tractable problem definition. Another study that arrives at a similar conclusion is Antaki, Barnes and Leudar (2007).

Exercise 1.2 Reading qualitative research

How much do you draw on qualitative research to inform your practice as a counsellor or psychotherapist? Identify a topic that is relevant to your practice. This could be a therapy process concept (e.g., self-disclosure, empathy, contracting) or a type of presenting problem (e.g., depression, work stress). Using an online search tool to which you have access (e.g., Google Scholar, PsyInfo, Web of Science) enter the key word or phrase that best captures your interest, along with ‘qualitative research’. How useful and interesting for you are the articles that you find?

• Entering the lived experience of clients with different types of problem. One of the challenges of being a counsellor or psychotherapist involves entering the worlds of people who are struggling to cope with issues that the practitioner has not come across before in their personal or professional life. Good therapists are empathic and curious, and work collaboratively with clients in order to at least begin to understand the reality of their worlds. But it is also useful to draw on external sources of information. Qualitative research can be an invaluable source of insight into the experiences of people who are living with specific problems. For example, in the area of acquired brain and spinal cord injury, Andrew Sparkes and Brett Smith (2006) and Masahiro Nochi (1998, 2000) have explored the ways in which the person’s self-narrative can be changed for ever by a chance event, such as a sporting or industrial accident, and how people in this situation are eventually able to construct a new narrative and different relationships. For any therapist working with a client who is suffering from acquired brain injury, reading these qualitative studies will sensitise them to the possible ways in which their client may be thinking and responding, and the ways that other people may be relating to them. This kind of research does not look at the process or outcome of counselling or psychotherapy, but provides therapists with essential background information. Within the qualitative research literature, there are studies that have looked at the lived experience of people undergoing a wide range of health conditions and social problems. The findings of these studies represent an invaluable resource for the therapist, as a means of tuning in to the unique experience of individual clients and as a basis for designing interventions for groups of clients.
• What are the characteristics of good therapists? There have been a number of large-scale quantitative studies into the outcomes of therapy that have found that there are quite wide variations in the effectiveness of individual therapists who are randomly allocated clients of equivalent levels of problem severity. In particular, there appear to be a small number of therapists who are markedly more effective than their colleagues. What is it about these star performers that makes them able to achieve such high success rates? Thomas Skovholt and Len Jennings (2004; Jennings and Skovholt 1999) asked therapists in the region in which they worked to nominate those colleagues whom they regarded as ‘the best of the best’–the therapists to whom they would refer close friends and family members. Skovholt and Jennings (2004) then identified a set of ‘master therapists’, each of whom had been nominated by several colleagues, and invited them to take part in an in-depth interview that explored all aspects of their careers and their approach to their therapeutic work. What they found was that these master therapists were voracious learners. Even if they defined themselves as working within a sp...