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When psychotherapy does not help: ...and when it does: Lessons from young adults' experiences of psychoanalytic psychotherapy
Stockholm University, Faculty of Social Sciences, Department of Psychology.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The process and outcome of psychoanalytic psychotherapy have been studied for a long time. However, the experiences of patients, particularly in therapies where goals were not met, have not yet been the target of extensive research. Psychoanalytic psychotherapy with young adults might face particular challenges. The overall aim of this thesis was to explore the experiences of young adults in psychoanalytic psychotherapy, with a particular focus on differences between suboptimal therapies and therapies with generally good outcome. The setting was naturalistic, and perspectives of the patient, therapist and observer were combined. Qualitative and quantitative methods were used. Study I explored experiences of psychotherapy process and outcome among seven patients in psychoanalytic psychotherapy, who expressed dissatisfaction. Interviews at termination and 18 months later were analysed using grounded theory and compared to therapist experiences. Patients experienced abandonment with their problems in and after therapy, since therapy according to the patients lacked connections to daily life, as well as flexibility, activity and understanding from the therapist. Therapists presented a different picture of the same therapies, mainly focused on the difficulties of the patients. Study II analysed the experiences of 20 non-improved or deteriorated young adult psychotherapy patients at termination of therapy and 36 months later. Non-improvement and deterioration were calculated based on the reliable change index on self-rating scores. The grounded theory analysis of interviews established spinning one’s wheels as a core category. The relationship to the therapist was described as artificial, although at times helpful. Participants experienced their own activity in life and active components of therapy as helpful, but thought focus in therapy was too much on past experiences. Study III explored the experiences of 17 young adult patients, in psychoanalytic individual or group therapy, overcoming depression. The analysis of interviews from therapy termination and 18 months later indicated that finding an identity and a place in life were perceived as intertwined with symptom relief. Negative experiences included difficulties to change oneself, fear of change, and problems in therapy, such as too little activity on the therapist’s part.

The results were discussed in relation to young adulthood, therapeutic alliance, mentalization, and attachment. The conclusion was expressed in a comprehensive process model of suboptimal therapy with young adults, with suggested ways to prevent such a development. The therapist’s meta-communication and correct assessment of the patient’s mentalization capacity from moment to moment are proposed as crucial. Regarding clinical implications, therapists of young adult patients need to establish meta-communication on therapy progress, as even experienced therapists might be unaware of dissatisfaction or deterioration. Meta-communication could be considered part of the treatment itself, as it may foster mentalization and good outcome. Further, the period of young adulthood entails decisions and developing an adult life, and therapists need to make room for this by active interventions.

Place, publisher, year, edition, pages
Stockholm: Department of Psychology, Stockholm University , 2017.
Keywords [en]
young adults, emerging adulthood, psychoanalytic, psychodynamic, psychotherapy, patient perspective, deterioration, dissatisfaction, mixed method, grounded theory, therapeutic alliance
National Category
Applied Psychology
Research subject
Psychology
Identifiers
URN: urn:nbn:se:su:diva-144399ISBN: 978-91-7649-913-9 (print)ISBN: 978-91-7649-914-6 (electronic)OAI: oai:DiVA.org:su-144399DiVA, id: diva2:1112340
Public defence
2017-10-20, David Magnussonsalen (U31), Frescati Hagväg 8, Stockholm, 10:00 (English)
Opponent
Supervisors
Available from: 2017-09-27 Created: 2017-06-20 Last updated: 2017-09-05Bibliographically approved
List of papers
1. Dissatisfied psychotherapy patients: A tentative conceptual model grounded in the participants' view
Open this publication in new window or tab >>Dissatisfied psychotherapy patients: A tentative conceptual model grounded in the participants' view
2012 (English)In: Psychoanalytic Psychotherapy, ISSN 0266-8734, E-ISSN 1474-9734, Vol. 26, no 3, p. 211-229Article in journal (Refereed) Published
Abstract [en]

Usually, between 5% and 20% of psychotherapy patients are dissatisfied with their treatments. This naturalistic study explores seven clearly dissatisfied patients' view of the therapeutic process and outcome. Interviews at termination of psychoanalytic psychotherapy and at a 1.5-year follow-up were analysed to create a tentative conceptual model of patient dissatisfaction using grounded theory approach. At the core of the model is an experience of abandonment by a therapist felt to be insufficiently flexible, a therapy lacking intensity, and links missing between therapy and everyday life. Dissatisfied patients lacked confidence in their relationship with the therapist, described their therapists in negative terms and concluded that their therapies lacked direction. They wanted more response from the therapist. Paying greater attention to the patient's emerging dissatisfaction may prevent lasting disappointment, unnecessary continuation of fruitless treatment, and probably increase efficiency.

Keywords
psychoanalytic psychotherapy, process research, grounded theory, dissatisfied patients, young adults
National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:su:diva-83477 (URN)10.1080/02668734.2012.709536 (DOI)
Available from: 2012-12-11 Created: 2012-12-11 Last updated: 2017-08-03Bibliographically approved
2. "Spinning one's wheels": Nonimproved patients view their psychotherapy
Open this publication in new window or tab >>"Spinning one's wheels": Nonimproved patients view their psychotherapy
2015 (English)In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 25, no 5, p. 546-564Article in journal (Refereed) Published
Abstract [en]

Objective: To explore psychotherapy experiences among nonimproved young adults in psychoanalytic psychotherapy. Method: A two-stage, mixed-method design was used. Twenty patients in the clinical range at pretreatment were identified as either with reliable deterioration or with no reliable change at termination. Interviews at termination and 3-year follow-up were analyzed with grounded theory methodology. Results: Spinning One's Wheels emerged as a core category. The patients described the therapeutic relationship as distanced and artificial. While they saw active components in therapy and their own activities in life as beneficial, therapy itself was experienced as overly focused on problem insight and past history. Conclusions: When the therapist does not contribute to the achievement of the patient's treatment goals-even when the patient gains some benefit-the patient does not fully profit from the therapy.

Keywords
qualitative research methods, outcome research, psychoanalytic/psychodynamic therapy, process research, patient perspective, nonimprovement
National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:su:diva-119109 (URN)10.1080/10503307.2014.989291 (DOI)000356424200004 ()
Available from: 2015-07-31 Created: 2015-07-29 Last updated: 2017-08-03Bibliographically approved
3. Experiences of overcoming depression in young adults in psychoanalytic psychotherapy
Open this publication in new window or tab >>Experiences of overcoming depression in young adults in psychoanalytic psychotherapy
2010 (English)In: European Journal of Psychotherapy, ISSN 1364-2537, E-ISSN 1469-5901, Vol. 12, no 2, p. 129-147Article in journal (Refereed) Published
Abstract [en]

The study aims to explore the process of overcoming depression as experienced by young adult psychotherapy patients. Seventeen patients in individual or group psychotherapy with diagnoses within the depression spectrum were interviewed at termination of psychotherapy and at 1.5 years' follow-up. Grounded theory analysis of transcripts resulted in 15 distinct categories, organized into five general domains: experiences of positive change, in-therapy contributions to positive change, extra-therapeutic contributions to positive change, obstacles in therapy and negative experienced outcomes. Exploration of interplay between these domains resulted in a process model for the way out of depression. The positive changes experienced extended beyond symptom relief. The patients emphasised finding out how they wanted to live and how they started forming their lives in that direction. Obstacles in therapy interplayed with the experience of being stuck in depression. These findings are related to age-specific challenges on the threshold of adulthood.

Keywords
depression, young adults, psychoanalytic psychotherapy, patients' perspective, grounded theory
National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:su:diva-47364 (URN)10.1080/13642537.2010.482745 (DOI)
Available from: 2010-12-01 Created: 2010-12-01 Last updated: 2017-08-03Bibliographically approved

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