Client Experiences of Counseling and Treatment Interventions

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Abstract

The case is made that personal experience and social life are inherently meaningful. The presence of meaning in human affairs requires all participants to develop interpretive skills if they are to understand what is happening. Researching social life is greatly helped by methods that acknowledge the hermeneutical quality of interpersonal experience. The use of qualitative research methods to investigate all aspects of counseling is therefore highly appropriate. To illustrate the use of qualitative research designs and methods of analysis, a study of family members’ views of family therapy is briefly described.

Dilemmas of researching human experience

Although the debate over whether the social sciences can be objective and explanatory in the manner of the natural sciences is now well-rehearsed, the outcome is still far from clear (Hollis, 1994). The cause of the problem is the self-conscious and self-reflective nature of human beings. Disciplines and practices that study and deal with human behavior and experience have to grapple with some deep philosophical questions to do with the nature of being, knowledge and the methods we might use to investigate them. Is human behavior and experience determined and, if so, by what? To what extent are people able to act freely and be agents of their own destiny? Can we explain to other people, or should we aim to understand them? Whereas the objects of natural science are inherently meaningless, the content of human experience and social intercourse is inherently meaningful.

Thus it appears that those who wish to examine people’s behaviors and actions need to develop methods of inquiry that attempt to get on the inside of human experience. Simply observing and measuring what people do certainly generates useful information, but it fails to reach the vast domain of interior experience that most people believe represents the essential nature of their true selves. Those of us who wish to understand social life at the level of the personal and interpersonal feel that as well as to measure and test behavior we must also seek to explore human experience from within. Moreover, to be a human being is, in a deep sense, to be a social being. The subjective tradition aims at an ‘interpretive’ or ‘hermeneutic’ social science:

‘Its central proposition is that the social world must be understood from within, rather than explained from without. Instead of seeking the causes of behavior, we are to seek the meaning of action. Actions derive their meaning from the shared ideas and rules of social life, and are performed by actors who mean something by them’ (Hollis, 1994, pp. 16-17; emphasis added).

The insistent nature of these opening paragraphs is deliberate. In the eyes of many researchers, the only good research in the field of therapeutic practices is scientific, naturalistic and experimental. A condition is measured before treatment; sufferers of that condition are randomly allocated to an experimental procedure, to a comparison treatment, or to no treatment at all; and finally, the condition is measured again after the various procedures and treatments have been completed. This works well for physical ills, but is much more problematic for psychological and social conditions such as unhappy relationships, personal distress, unacceptable behavior and interpersonal conflict.

As a powerful complement to quantitative scientific methods of investigation, the use of designs that employ qualitative methods has allowed researchers both to appreciate and to develop understandings of what the processes and outcomes of counseling and therapy mean to those involved. What does it feel like to be distressed? What kind of help are people looking for? How do clients evaluate the help received? What do people find most helpful and least helpful? In short, what do clients have to say about their experiences of being on the receiving end of counseling and therapy? Answers to such questions help researchers to understand the subjective meaning of other people’s experiences. And as the quality of subjective experience is a fundamental aspect of personal life, it seems appropriate that counselors and researchers should seek to understand clients’ views and experiences of the counseling process and its outcome. This shift in research perspective parallels moves many counselors away from a positivistic scientific outlook towards a more humanistic orientation. Rather than seeking to change experience by modifying behavior, the preference is to alter behavior by changing experience.

Seeking the client’s view of family therapy

In the mid-1980s I was asked by a team of family therapists to evaluate their practice. It was agreed that the central strand of inquiry would be to seek ‘the consumers’ view’ of the therapeutic experience (see Howe, 1989). The family therapy team worked with around 30 to 40 families a year. The families were referred to the team by social workers and other professional groups. Most families identified the difficult behavior of a particular child as their main problem. The family therapists worked within a systemic framework using brief, focused methods of intervention. Treatment episodes would last a maximum of six one-hourly sessions.

I interviewed all families who had either been offered family therapy and refused, or who had been offered family therapy and accepted, during the space of one calendar year. After a ‘case’ had been closed or the treatment completed, one of the agency’s managers wrote to the family asking if they would be willing to participate in the research. It was made clear to the families that the researcher was independent of the treatment agency and that their personal views would, if reported, remain entirely anonymous. A small fee was paid to the families in recognition of their time and co-operation.

During the 12-month period of study, 34 families had been offered family therapy. Eleven families had either declined the offeror failed to keep their first appointment. Ten of these eleven agreed to be interviewed. Twenty-three families had accepted the offer of therapy, 22 of whom agreed to be interviewed by the researcher.

The aim of the research was to explore with family members how they perceived, understood, experienced and felt about family therapy. The interest was not so much in whether the presenting problem had been ‘cured’ in some objective, measurable sense, but rather in whether or not people felt they had been helped. All family members who had attended treatment were interviewed together as a group in the family home within 4 to 8 weeks after the final treatment session. The interview was guided by a series of broad, open-ended questions and prompts. In their reflections and comments, families talked about all stages of their involvement from the time that they felt they needed help to the point of case closure. Interviews typically lasted between two and three hours. They were audio-tape-recorded and subsequently transcribed.

The research design meant that all respondents volunteered their views and experiences. Personally, in the case of willing informants, I have no qualms about asking clients to revisit old therapeutic experiences. Professional service providers, including counselors, often argue that they need to protect clients from the potentially disturbing impact of researchers opening up difficult subjects. So long as the researcher is honest and clear about the nature and purpose of his or her inquiry, I see no ethical problems in asking clients if they are willing to help. The anxieties, if they exist, usually lie with the counselor or counseling agency. It is the experience of most qualitative researchers that clients are normally only too willing to talk about and discuss being ‘on the receiving end’. They often say not only that they were pleased to be given the opportunity to express their views, but also that they found the research interview both interesting and helpful. In the case of the family therapy research, the greeting I received from the very first family I interviewed was fairly typical. Standing on the doorstep clutching my tape-recorder, I was quickly ushered in by the father and enthusiastically introduced to the rest of the family. ‘Right’, he said, ‘sit down. We’ve been wanting to talk about this family therapy business to someone for some time. We’ve got a lot we want to say, so get that machine of yours going.’ And almost before I had chance to catch my breath and rehearse the research, its purpose and the interview framework, the family were in full voice.

Analysis of qualitative data

One of the most difficult and demanding stages of qualitative research is the analysis of the data. Faced with hundreds of pages of interview transcripts, there is a tendency to under-analyze data. Under-analysis often results from a failure to understand the nature of qualitative data. Although placing a light level of descriptive order on the material can be interesting, this approach fails to generate the depth and insight that is to be discovered in such data. The researcher’s task is to enter the frame of reference of the people whose world and experience are being investigated. He or she must attempt to understand the meaning that others give to their experience. Accepting the subjectivity and inter-subjectivity of human interaction, qualitative research has no choice but to embrace the ‘double hermeneutic’ that is entailed in the study of social life. This means that not only do the subjects of the inquiry interpret the meaning of their own experience but those who study them engage in a second level of interpretation as they, in turn, attempt to make sense of what is being said, felt and one-man interpretation of an interpretation’ (Hollis, 1994, p. 146). However, the social scientist’s interpretation, unlike that of the non-social scientist, is developed using a variety of systematic and disciplined procedures which attempt to analyze the subject’s interpretation in an organized and orderly way. For example, Tesch (1990) has identified four basic approaches to qualitative research, where the interest is in:

the characteristics of language,
the discovery of regularities,
the comprehension of the meaning of text or action,
reflection (see also Robson, 1993, pp. 371-372).

There now exist a number of sophisticated procedures to help the social researcher analyze qualitative data (e.g. Strauss, 1987; Strauss & Corbin, 1990; Miles & Huberman, 1994). Essentially these depend on very careful reading and basic coding of the transcript material in which meaningful elements, significant interpretations and important understandings uttered by respondents are identified and recorded. These basic coding categories form the first layer of analysis:

‘A code is a symbol applied to a group of words to classify or categorize them. They are typically related to research questions, concepts and themes. Codes are retrieval and organizing devices that allow you to find and then collect together all instances of a particular kind’ (Robson, 1993, p. 385; emphasis original).

Codings represent the earliest phase of the researcher’s ‘interpretation of interpretations’. The researcher’s interpretation attempts to respond and remain close to the meanings, interpretations and understandings of the subjects under study. These basic codings are then available to be re-worked and re-ordered into increasingly high levels of abstraction (Carney, 1990; Miles & Huberman, 1994, p. 92). Thus beneath any one level of abstraction exists a ‘tree’ of lower-order themes, regularities, codes and categories, culminating in the actual words and understandings of individual respondents whose specific utterances exemplify a particular interpretation and concept which has been generated by the researcher. This way of handling the data depends heavily, though not exclusively, on inductive methods of analysis: categories, themes and concepts are drawn out of the data, ‘grounded’ in the raw material of the interview. In practice, my own method of analysis tolerates the presence of a small amount of preconceived conceptual material that is already part of my theoretical repertoire, particularly if such concepts seem to provide particularly powerful frameworks of organization and interpretation.

The analytical concepts and themes generated by the researcher are much more than simple descriptions of what respondents have said. They offer a way of ‘making sense’ that was not previously available or apparent to the research subjects. It is the global analysis of what all respondents have said individually that generates new understandings and ways of seeing personal experience and social life. The findings and interpretations are then represented back to social life. They add to the ‘way of seeing and understanding’ that are part and parcel of the dense fabric of language, meaning and interpersonal experience. If the researcher has generated new understandings out of the experiences of subjects that do make sense both to the subjects and others, then he or she has added to that culture’s repertoire of ideas that help people understand, interpret and cope with experiences of that kind. For example, women who had relinquished a baby for adoption (often a difficult and painful experience), whom we interviewed as part of a research project, upon reading the book based on our findings would typically exclaim: ‘The way you described and reflected on things was really helpful; it has helped me make sense of what happened to me’–even though the findings were fundamentally based on what the women said to us in the first place (Howe et al., 1992).

In the case of the families who had been offered and experienced family therapy, detailed coding, categorizing and theme construction produced a broad framework within which the finer interpretations could be contained. The major categories of the framework were defined by two parallel dimensions: one chronological, the other psychological. This produced three higher-order categories:

To be engaged.
To understand.
To be understood.

These themes will be familiar to both counseling researchers and practitioners alike, but it remains interesting that so much of what family members had to say about their experiences of therapy concerned whether or not they felt engaged by the therapists, understood what was happening during treatment, and felt understood by the therapist and the treatment team. One standard split that nearly always runs through ‘user views’ research is between clients who were satisfied and those who were dissatisfied. This offers a neat, simple further sub-divide of the major analytical categories. The family therapy research also developed further, lower-order levels of analysis that supported the three major conceptual themes. I shall trace one analytical line in a little more detail here to illustrate the links between abstract concepts and clients’ actual words; the interested reader might wish to turn to the full report to gain a fuller picture of the research and its findings (Howe, 1989).

From verbatim quotes through basic codings to conceptual abstraction, and back again

We have already heard that before families felt able to proceed with therapy, they first had to become ‘engaged’ in the treatment process. It is worth noting that although some families remained in therapy, in practice they never felt engaged by or committed to family therapy. To be engaged, therefore, emerged as an important first stage in the therapeutic process. ‘Engagement’, write Masson & O’Byrne (1984,p. 28), ‘involves careful, thorough self-introduction and a full and repeated explanation of the roles of the worker and the family, of the purpose of the involvement and the manner of proceedings’. Families with problems feel vulnerable and wary. They feel anxious about both the problem and the treatment. The normal response of people who feel anxious is to withdraw or escape from the cause of the anxiety. Families who remained very anxious about the treatment process either withdrew from treatment or stayed in therapy but failed to become engaged. It was possible to place the families into one of four ‘engagement’ categories:

the non-takers who were offered therapy but did not accept;
the early leavers who began therapy but withdrew after one, two or three sessions;
the ambivalent who remained in therapy but were not fully engaged (although they still held out the prospect of being helped);
the relaxed and satisfied who became fully engaged and remained in treatment.

Each of these four categories was further analyzed. For example, the analysis of the early leavers revealed that family members experienced considerable anxiety over three particular aspects of treatment. Their failure to overcome these anxieties contributed to the family’s early withdrawal from therapy. As treatment progressed, levels of anxiety tended to increase rather than decrease. Three features of the treatment technique appeared to raise anxiety: the machines, the method, and the manner. The therapists operated as a team. One therapist remained with the family in the treatment room. Both the family and the therapist were observed, via a video (and audio) link, by the remainder of the treatment group who acted as treatment supervisors. In counseling terms, the treatment technique was relative ‘high-tech’. These families (the early leavers) felt bothered by the camera (machines), the unseen group of observers who communicated only with the front-line therapist (method), and the brief and systemic method of treatment employed by the therapists (manner).

Taking the families’ anxieties about the method of treatment as an example of the next level of analysis, it is at this point we can begin to make liberal use of the clients’ own words. However, even at this level it was possible to recognize three further sub-divisions. As far as the families were concerned, the place of treatment mattered (home rather than clinic). The style of practice was of concern. And the participation of children and non-problem siblings unsettled some parents. We now follow the analytic branch down the practice line.

The style of questioning, the use of supervisors who remained unseen and unheard in an adjacent room, and the formulation of hypotheses about possible relationships between the symptom and the operating characteristics of the family’s system, all served to raise the family’s feelings of anxiety. Families fantasized about the supervisors, projecting all kinds of fears and worries onto their unseen presence. The camera only added to the threatening atmosphere of the occasion. For example, Mr and Mrs Spree were having difficulties with their 14-year-old daughter, Rachel. This is how they recalled their first session (Howe, 1989, pp. 53-54):

Mr S: ‘Well first, what I felt like was that it was them against us. There was no relationship at all. The panel in the next room could feedback to the person in the room with us, but we had nothing directly to do with them. They were like “Big Brother” out there. I found it very disconcerting.’
Mrs S: ‘We didn’t even know who was in there.’
Mr S: ‘It could have been anyone.’
Mrs S: ‘I mean, if they’d given us a cup of tea, that would have been helpful.’
Mr S: ‘The panel kept interrupting. It was very off-putting, very confusing. We never seemed to get anywhere.’
Mrs S: ‘He’d say something like… er… after he got a message from the panel, “Oh, I’ve got to bring in Rachel now” and you were cut short. I felt like a guinea pig.’
Mr S: ‘I did actually, too. We were like puppets and it was like they were experimenting with us, because they’d found this new thing, this camera and things, and could try out certain techniques of interviewing.’

Many parents felt that they were being accused of failing to be good parents and that they were to blame for the family’s troubles. But the Kafkaesque quality of the occasion became even more pronounced in the case of Mrs Kay (Howe, 1989, p. 54) who felt that she did not even know of what she was being accused of:

Mrs K: ‘They looked at you funny. They seemed more interested in my past than Darren’s. I felt that I was the one in the wrong, like it was me on trial, you know, like they were saying “you’re the guilty party”.’
DH: ‘Guilty of what?’
Mrs K: ‘Ah, that’s it you see! I don’t know. You never know!’

This journey from broad levels of abstraction down through increasingly more concrete themes to the actual words of particular respondents in fact reverses the analytical process, which begins with basic coding of the raw data and slowly examines ways of bringing higher levels of conceptual order to the data. Out of this process, which can be one of the most demanding stages of the research enterprise, emerges the logic and order of the analytic framework.

Qualitative analysis, meta-analysis and theory

Implied in this analysis of client views of a therapeutic intervention is that we are unable to make sense of experience without employing theoretical constructs to organize, order and relate perception–an epistemological position known as ‘idealism’. This idealist position has it that meaningful perception of experience is a consequence of our ability to conceive and theorize experience. The structures that pre-exist in language and culture furnish us with the ability to participate in and make sense of social life in a competent manner. But as all social experience is driven by the ‘double hermeneutic’, mentioned earlier, interpretation of both one’s own and other people’s experience is a constant feature of the world of the interpersonal and the inter-subjective. We have no choice but to make sense of experience, but that sense can change, evolve and re-form as we constantly interact and engage with other people. The deliberate and formal attempt by social researchers to make sense of particular aspects of social life (in our case, client experiences of counseling and therapy) requires them to be self-conscious and systematic interpreters. The theories that they produce to make sense of other people’s experiences have to be rigorously and explicitly crafted. And if at the end of this process people have been helped to make more interesting, practical or effective ways of making sense, then the exercise may count itself successful. In this sense, not only has the research added to our understanding of an aspect of social life: it has also helped, in its small way, to roll the hermeneutic cycle along through the ceaseless history of thought, language and social action.

What clients say appears as verbal outcrops, hinting at deeper orders of meaning and understanding. The research interview offers an incomplete map that has to be carefully analyzed and interpreted before the theoretical substructure can be hypothesized. It is in the coding of the raw data and the search for greater abstraction that the researcher must remain creatively alert to the possible connections and relationships which could help to make theoretical sense of what is being said. This is why the analysis of data remains–and must remain–the most demanding and arduous stage of the qualitative researcher’s enterprise.

The research into the user’s view of family therapy, and the pointers it gave to possible deeper mechanisms operating within the therapeutic relationship, prompted me to examine the findings of other researchers who had looked at client experiences of counseling and psychotherapy. This produced a ‘meta-analysis’ that explored what clients in general found helpful. It then went on to ask why similar consumer messages were reported in study after study (Howe, 1993). Analysis of some 80 client perspective studies abstracted the following idealized psychotherapeutic sequence: formation of a therapeutic alliance right arrow talk and dialogue right arrow making sense right arrow controlling the meaning of experience right arrow coping better with life. Heavily distilled, this meta-analysis of client views says: clients seek to control the meaning of their own experience and the meanings that others give to that experience (Howe, 1993, p. 195).

The point of this brief excursion into the wider waters of consumer research is to indicate the potential of qualitative research designs to contribute to theory-building in counseling and psychotherapy. Practices such as counseling and counseling research, that are immersed in the business of language and relationships, profit hugely if they are linked to ontologies, epistemologies and methodologies which acknowledge the hermeneutical nature of social life. Seeking to understand subjective and interpersonal experience using qualitative methods of inquiry is likely to produce thoughts that will speak loud and clear both to counselors and to their clients.

References

CARNEY, T.F. (1990) Collaborative Inquiry Methodology (Windsor, Ontario, University of Windsor).

HOLLIS, M. (1994) The Philosophy of Social Science (Cambridge, Cambridge University Press).

HOWE, D. (1989) The Consumers’ View of Family Therapy (Aldershot, Gower).

HOWE, D. (1993) On Being a Client: Understanding the Process of Counselling and Psychotherapy (London, Sage).

HOWE, D., SAWBRIDGE, P. & HININGS, D. (1992) Half a Million Women: Mothers Who Lose their Children by Adoption (Harmondsworth, Penguin).

MASSON, H. & O’BYRNE, P. Applying Family Therapy (Oxford, Pergamon).

MILES, M.B. & HUBERMAN, A.M. (1994) Qualitative Data Analysis (2nd edn) (Thousand Oaks, CA, Sage).

ROBSON, C. (1993) Real World Research (Oxford, Blackwell).

STRAUSS, A.L. (1987) Qualitative Analysis for Social Scientists (Cambridge, Cambridge University Press).

STRAUSS, A.L. & CORBIN, J. (1990) Basics of Qualitative Research: Grounded Theory Procedures and Techniques (Newbury Park, CA, Sage).

TESCH, R. (1990) Qualitative Research: Analysis Types and Software Tools (London, Falmer).

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