So Many Possibilies: Psychotherapy Research and Narrative Therapy

So many possibilities: Psychotherapy research and narrative therapy AUTHOR JOHn McleOd An interview with John McLeod John McLeod is Emeritus Professor of Counselling at the University of Abertay Dundee. He is committed to promoting the relevance of research as a means of informing therapy practice and improving the quality of services that are available to clients. His enthusiastic search for finding ways to make research interesting and accessible for practitioners has resulted in a teaching award from the students at his own university and an award for exceptional contribution to research from the British Association for Counselling and Psychotherapy. His writing has influenced a generation of trainees in the field of counselling and psychotherapy, and his books are widely adopted on training programs across the world. John McLeod can be contacted c/o J.McLeod@abertay.ac.uk The interviewer was David Denborough. In this inter view, John McLeod invites and encouarges narrative therapists to engage more rigorously with counselling and psychotherapy research; acknowledge a distinctive narrative therapy research identity, and provides an over view of a range of research methodologies par ticularly relevant to narrative therapists. Keywords: outcome research, narrative analysis, conversational analysis, practice innovations, action research. THE INTERNATIONAL JOURNAL OF NARRATIVE THERAPY AND COMMUNITY WORK 2014 No.2 www.dulwichcentre.com.au Page 31 David: As you well know, for all sorts of reasons, narrative therapists have been reticent to engage with formalised, academic research. We’re basically now in the process of exploring ways to engage and excite the field of narrative therapy in research that is directly relevant for practice. As you have significant knowledge of narrative practice and narrative psychology and a particular passion and thoughtfulness about research, are there any particular messages, encouragements or challenges that you would like to offer to narrative practitioners? John: That’s a difficult question. I suppose my initial reaction is that within the mainstream counselling and psychotherapy research field, I believe there is a huge amount of literature that has the potential to be informative and interesting for narrative therapy practitioners, and yet as far as I can see, narrative therapy practitioners don’t seem to be reading it. I would say that narrative therapists have really tried to develop a distinctive research identity that’s informed by the philosophy and values of narrative therapy. I would characterise this identity as trying to develop a kind of reflexive politically aware collaborative approach to research. There’s a great deal that I applaud in this approach. At the same time, however, there are other people within the psychotherapy research field who are trying to develop a similar approach and I believe there are connections to be made there. And I also think even within the work of psychotherapy and researchers who are doing quite different types of research, for instance even various randomised control trials, can be of interest to narrative practitioners. So I guess my first encouragement to narrative therapy practitioners would be to be a bit more open to wider fields of psychotherapy research. I’d like to make mention here of the work of Lyn Vromans and Ron Schweitzer which does bridge the gap between narrative therapy mainstream psychotherapy research. I think your encouragement comes at just the right time. I know there are many diverse forms of psychotherapy research, but perhaps we can start with outcome research. If you were to encourage narrative practitioners to get interested in outcome research, what within these realms is most interesting to you at present? Outcome research is basically asking the big questions: • Does it work? • Does it help people? • To what extent do different kinds of therapy help people? Over the last 30 to 40 years there has been a massive investment in various kinds of medical model outcome research. These involve measuring people’s ‘symptoms’ and then they get therapy and then measuring the symptoms again. Sometimes these involve randomised clinical or control trials in which people are randomly allocated people to different kinds of therapy or no therapy and the differences between the outcomes for these groups are measured. To my mind, this type of research probably needed to be done and it has driven forward the field in some ways around developing ways of measuring and defining types of therapy. However, at this point in time, I believe it has largely reached a dead end. This is because when studies are conducted to compare one form of therapy to another form of therapy, if you do these studies in a fair minded way, what you tend to come up with is ‘Therapy A is equivalent to therapy B is equivalent to therapy C’. It seems there is little point in carrying on with this form of research because this is what has been found over and over again. People within the cognitive behavioural therapy, CBT, tradition, might argue that the research results favour CBT but I don’t think that’s actually true. I think that there’s more research on CBT so that when you do a systematic review, there’s definitely a bigger pile of evidence about the effectiveness of CBT. But when you look at the studies that compare the results of CBT to the effectiveness of other forms of therapy, the results don’t really favour CBT. So in my opinion, the generalised comparative outcome research between models is a dead end. Having said this, I think there’s a kind of subsection of randomised trial research that is producing very useful findings. These are randomised trials of outcome which compare a standard form of therapy to a version of the same therapy but with some innovative practice added to it. The best examples have been inspired by Michael Lambert and his group in America where they’ve taken a standard therapy and then added a rigorous form of regular client feedback to the therapists (using brief feedback scales like Scott Miller’s outcome rating scale). This research has shown over and over again that therapists are actually pretty useless at actually knowing how much their client is benefitting from therapy, and show that even a kind of simple ritualised procedure like the client filling in a brief questionnaire and giving it to the therapist and then having a conversation about this, actually produces better outcomes. This process of adding client feedback to various models of therapy has been studied through randomised trials. These sorts of trials in which you test whether your new idea is helpful to add to existing therapeutic practice is producing interesting results. I know you are also interested in qualitative outcome research. Can you say something about this? Qualitative outcome research is really promising. This involves clients being interviewed about the extent to which, and the ways that therapy, has helped them. What you immediately start to see when you consider qualitative outcome research is that clients’ criterion for deciding whether the therapy’s been helpful or not are quite different from what’s studied in mainstream research! Clients on the whole do not talk about ‘symptom change’, they talk about their lives moving on and so forth. If clients’ criteria for change are quite different from their own therapists’ criteria for change, then we often see clients describing things about particular therapies as being helpful or unhelpful in ways that don’t actually match the kind of model of therapy that they’re receiving! I think that there’s a lot to be learned from this. Ultimately, qualitative outcome research is about giving clients a voice. It’s about actually listening to what clients have to say in a way that goes far beyond the client filling in a questionnaire. If a client fills in a questionnaire, the answers that they give are pre-structured in terms of the questions, whereas if you interview somebody, particularly if you are willing to do more than one interview so clarifications and some kind of dialogue and collaborative discussion with the client can take place, it opens up whole realms to explore. I think it’s amazing actually that so few studies of this kind have been done. The therapy profession as a whole has not really been willing to listen to what clients have to say about therapy. So that’s the kind of outcome research that I am particularly interested in. THE INTERNATIONAL JOURNAL OF NARRATIVE THERAPY AND COMMUNITY WORK 2014 No.2 www.dulwichcentre.com.au Page 32 I know you are also interested in what’s called ‘case study research’ … Yes, in my view, one of the main types of psychotherapy research that seems to offer a lot of promise at the moment are systematic case studies. These involve looking at a case in terms of rich case data. For instance on a regular basis throughout the therapy, the client is interviewed, the therapist is interviewed, the client and therapist might fill in questionnaires/ measures and sessions might be recorded. This generates rich case data which can then be examined. It becomes possible to ask: • what has worked? • how did the therapy work? • what were the outcomes and how were these outcomes linked to what happened in the therapy? I think these forms of case study research are beginning to produce findings that are quite different from randomised control trials. Within the narrative therapy field there are many case descriptions that have been written by the therapist. I think these are interesting, but I think there’s a different kind of perspective that occurs when someone other than the therapist conducts follow up interviews with clients. The client is perhaps somewhat freed up to say things that they may not say to the therapist. And then when all the material is analysed by a team of researchers that may or may not include the therapist there are all sorts of ways to introduce other perspectives on the material. In principle, clients could also be involved in the interpretation of the material. I think this would probably fit most congruently for narrative practitioners. In the research teams I’ve been involved in, we haven’t managed to have that longer term involvement with the client in terms of looking at material, but in narrative therapy, you’ve got a much stronger community based tradition. The idea of clients being consultants has a long history in narrative therapy so perhaps you would have a better basis for involving clients in an ongoing case study. There is, of course, a really long history of psychotherapy case studies, starting with Freud. But I think what’s really clear from history is that the therapist’s understanding of the case is really important because they are a key participant in it, but it’s never going to be the whole story. Yes, finding ways for clients to be co-researchers of therapeutic practices is certainly something that would be very congruent with the narrative practice ethos … These days of course different sort of case studies are possible. In Freud’s day there were no videos of his sessions! Within the Michael White archive, I understand you have videos of Michael’s sessions. Even when we can see the actual therapy session on video, it would be very interesting to learn what was going on behind the scenes in the client’s mind, or what did the client think about this when they went home or a month later, and so on. All these considerations can be taken up in a more complete analysis and I think this what the more cutting edge of case study research is trying to achieve, There is a really interesting group at the University of Copenhagen, including Uli Dreier and Thomas Mackrill who have tried to research the interface between the everyday lives of clients and therapy. In narrative therapy there’s a considerable emphasis on de-centring, in that it’s not just the relationship between the therapist and the client that is deemed as significant but also what’s happening in the everyday lives of clients. This research group started to investigate much more what was happening in the everyday lives of clients over the course of the therapy. So it’s no longer just what is happening in the therapy room which is of interest. In doing so, they found that this gave a completely different understanding to what was actually happening in the therapy. To me, this sort of research is very consistent with what happens in narrative therapy. Narrative therapists are often working with the person for them to reshape their social life, to generate and re-author a new story of identity and to tell this new story to other people and develop other relationships and so on. So, I think that a kind of case study that brought in the story and descriptions of the everyday life of the client could be very fruitful! It could certainly make the research more interesting too … considering what factors in everyday life are sustaining developments in therapy conversations … and the interplay of all of this … Of course, the closer you get to the client’s actual of experience of the therapy, the more you unearth a nuanced account from the client in which they may well flag their disappointments with the therapy. I’m not reading everything within the field of narrative therapy, but in terms of what I have read, there doesn’t seem to be much in the narrative therapy literature on the failures of narrative therapy. I think this is an area that’s beginning to be taken a lot more seriously within the mainstream therapy research field. What can be learnt by researching the experiences of those who have had negative experiences of narrative therapy, or negative experiences of a particular session? I think there’s increasing attention to research that enquires about negative outcomes, harmful therapy, disappointed clients and so forth, and I wonder what helpful research in these realms could take place in relation to narrative therapy... So many options! I’d like ask you a little bit about some specific research methodologies, most particularly narrative analysis, both quantitative and qualitative, and also conversational analysis. I think narrative practitioners would be drawn to these forms of research. Sure. Quantitative approaches to narrative analysis generally involve examining transcripts of therapy sessions and then coding what’s happening in the conversation using a number of pre-existing coding schemes. One example is Lynne Angus’ narrative process coding scheme which identifies different modes of narrative processing, for instance external storytelling versus reflecting on the story versus the inner meaning of story. Another example is the work of Portuguese researchers, Gonçalves et al. (2011) who examine therapy transcripts looking for ‘innovative moments’ or what could be called unique outcome moments. Having coded the conversations, various analyses can take place about how these innovative moments were produced, whether they’re associated with good outcomes and so on. The challenge in these detailed examinations of a particular conversation, however, is that in therapy, narratives or storylines develop over time. It’s an unfolding process in that what the client says in the second session builds on your shared understanding of what was said in the first session. It can therefore be challenging to analyse the contextualised nature of discussions using pre- THE INTERNATIONAL JOURNAL OF NARRATIVE THERAPY AND COMMUNITY WORK 2014 No.2 www.dulwichcentre.com.au Page 33 existing coding schemes. This then leads to attempts to generate more finely-grained qualitative narrative methodologies. be of real interest to narrative practitioners is grounded theory qualitative research. But can I ask you a question now? This is something that you have been very involved in … Of course! Yes I did quite a lot of work on this maybe 10 years ago. The research that I was doing involved taking transcripts of therapy sessions and cases and trying to understand how the therapist and the client engaged in different kinds of narrative processes. For instance, examining how the client begins to tell their story and the therapist then offering them back a kind of retelling of that story through the lens of the kind of meta-narrative of the therapist’s particular therapy theory and then analysing the turning points in the therapy through which a kind of new story begins to emerge. In the Master of Narrative Therapy and Community Work, as far as I can see, the research places an emphasis on enquiring into or describing or evaluating or researching practice innovations, is that right? I basically developed a methodology for beginning to make sense of this therapeutic process. As a research team we would slowly conduct a first reading of a transcript to make sense of it and to try to record our own reactions or empathic engagement or what had interested us in the case. Then we’d conduct a second reading to identify turning points. And then we’d conduct a third reading to look at what was happening in the therapy conversation and storytelling leading up to each turning point or after each turning point. This was a rigorous qualitative narrative analysis of therapeutic conversations. Sounds very interesting … can you also say a little about conversational analysis … I think conversational analysis is a really difficult thing to do, because it relies on considerable technical knowledge. It depends on a very detailed transcription of therapy sessions with particular measuring of pauses, voice intonation and other non-verbals and this can pose challenges for new researchers unless they have a supervisor who really knows what they’re doing. Even then, it requires some considerable time to actually learn the technicalities. Until quite recently, most conversation analysis in relation to psychotherapy has been more interested in researching the conversation rather than using conversational analysis to research what is happening in the psychotherapy. Most research in relation to psychotherapy using conversational analysis has therefore been more relevant to conversational analysts than to therapists. In recent years, however, the work of Tom Strong in Canada offers a really good example of how you can take conversation analysis and then use it in a way that brings new meaning and understanding to what is happening in psychotherapy conversations in order to assist people to become better psychotherapists. I think this has some meaningful application. There are also opportunities to extend conversation analysis. For instance, conversational analysis provides a microanalysis of conversational strategies but does not generally address the question of where do these conversational strategies come from within the cultural world that the therapist and client live in? Nor does it ask whether or how the client uses these conversational strategies in their everyday life. These are questions that could be pursued through an extension of conversation analysis and I think these could be interesting areas of research that have not yet been considered. By the way, the other research methodology that I think may Yes, that’s right. I think this is really, really important. To me, it fits into a tradition of action research and there’s been lamentably very little action research within psychotherapy. If the narrative therapy community could take a lead in showing people how to do action research, well obviously there would be benefits to the narrative therapy community, but I think there’d be considerable wider interest as well. If could summarise for a minute, I think one of the problems at the moment is that over the last 30 to 40 years of psychotherapy research, there’s been a huge expansion in ways of doing research and a great diversity of ideas and tools and strategies and methodologies. But on the whole, this is all used to produce journal articles that describe the research and then at very end of a standard research paper, there’s usually perhaps a paragraph that says ‘the implications for practice of this study are x, y and z’. So it’s only one paragraph of the paper that suggests what a practitioner could do. And then, very rarely, does anybody ever actually try out x, y and z. Or if they do, it’s years later and not really connected up with the original paper. So what is being created in the field of psychotherapy research is a knowledge base of published papers that is potentially very useful but kind of divorced or detached from practice. You actually have to work quite hard to make the connections with practice. Whereas action research papers tell a really different kind of story. They tell a story a story that goes like this … ‘Well, we looked at what we were doing and we could see that there were limitations in what we were doing in the therapy, so we had some consultations with our clients, and then we collaboratively further developed a different way of offering the therapy, and then we evaluated this, we looked at whether that was better than the previous way and here’s what we found, and then we made these further alterations …’ and so on. That’s a whole action research cycle. And this produces much more useful research. I think encouraging and sponsoring this sort of action research would be just great. The other thing that is such a neat idea about the concept of innovation is that it cuts through what I regard as quite sterile debates around trying to prove that one form of therapy is better than another form of therapy, because in a way you are regarding whatever form of therapy you’re using as an open system. It’s got lots of good ideas and good practices and it’s useful and so on but it’s never the final version, there’s always changes and innovations that are going to happen … That is very much the aim. This seems particularly important to us because people are engaging with narrative practice, and the Master program, from so many different cultural locations. The last thing we want is to encourage the use of narrative practices developed in one place to be replicated in exactly the same way in a different context. Instead we hope for practitioners to be innovating and contributing to making different forms of narrative practice. It’s really heartening to THE INTERNATIONAL JOURNAL OF NARRATIVE THERAPY AND COMMUNITY WORK 2014 No.2 www.dulwichcentre.com.au Page 34 hear you embracing this idea from your perspective as a researcher. It also, I believe fits with the history of narrative therapy. Michael White’s practice used to change overtime due to what could be called ‘action research’. For instance, the categories of questioning that shape Outsider Witnessing changed over time, due to specific enquiries that Michael made with people who came to therapy who experienced outsider witness groups. It was feedback from them about what sort of outsider witness responses were most significant to them that led him to change the questions he asked outsider witnesses. This was a continuing process. While Michael didn’t formalise this ‘action research’ and nor did he even call it ‘research’, this whole approach to co-developing practice with those who are consulting therapists could easily be taken into more formal practice research realms. This has been an energising conversation, John! I really believe that your work is going to make an inordinate difference in creating a pathway for narrative practitioners to get excited about research. Thank you. RefeRences And sUggesTiOns fOR fURTHeR ReAding McLeod, J. (2010). Case study research in counselling and psychotherapy. London: Sage McLeod, J. (2011). Qualitative research in counselling and psychotherapy. 2nd edn. London: Sage McLeod, J. (2013). An introduction to research in counselling and psychotherapy. London: Sage McLeod, J. (2014). Doing research in counselling and psychotherapy. 3rd edn. London: Sage. McLeod, J. and Balamoutsou, S. (2001). A method for qualitative narrative analysis of psychotherapy transcripts. In J. Frommer and D. Rennie (eds) Qualitative psychotherapy research: methods and methodology. Lengerich: Pabst. Lambert, M.J. (2010). “Yes, it is time for clinicians to routinely monitor treatment outcome”. In B.L. Duncan, S.D. Miller, B.E.Wampold and M.A. Hubble (eds) The heart and soul of change. Delivering what works in therapy. 2nd edn. Washington, DC: American Psychological Association. Morris, B. (2005). Discovering bits and pieces of me: research exploring women’s experiences of psychoanalytical psychotherapy. London: Women’s Therapy Centre. (available on-line) Dreier, O. (2000). Psychotherapy in clients’ trajectories across contexts. In Mattingly, C. and Garro, L. (eds.) Narratives and the cultural construction of illness and healing. University of California Press O’Connor, T.S., Meakes, E., Pickering, R. and Schuman, M. (1997). On the right track: client experience of narrative therapy. Contemporary Family Therapy, 19, 479-96. Gonçalves, M., Ribeiro, A.P., Mendes, I., Matos, M. and Santos, A. (2011). Tracking novelties in psychotherapy process research: The innovative moments coding system. Psychotherapy Research, 21, 497-509. Perren, S., Godfrey, M. and Rowland, N. (2009). The long-term effects of counselling: The process and mechanisms that contribute to ongoing change from a user perspective. Counselling and Psychotherapy Research, 9, 241-9. Lambert, M.J. (2010). “Yes, it is time for clinicians to routinely monitor treatment outcome”. In B.L. Duncan, S.D. Miller, B.E.Wampold and M.A. Hubble (eds) The heart and soul of change. Delivering what works in therapy. 2nd edn. Washington, DC: American Psychological Association. Vromans, L.P. and Schweitzer. R. (2011). Narrative therapy for adults with major depressive disorder: Improved symptom and interpersonal outcomes. Psychotherapy Research, 21, 4-15. Mackrill, T. (2008). Exploring psychotherapy clients’ independent strategies for change while in therapy. 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