A TWICE-TOLD TALE: A PHENOMENOLOGICAL INQUIRY INTO CLIENTS' PERCEPTIONS OF THERAPY

Journal of Marital and Family Therapy, Jul 2005 by Singer, Muriel

Typically, what we understand about therapy and the families we work with comes from the therapist's observations. This inquiry evolved out of the empirical data that indicate the dramatic importance of the client's perceptions to achieving a successful outcome. The research was guided by the understanding that it is vitally important for therapists and therapy researchers to listen to clients and to examine our practices and theoretical approaches in the light of the client's experience of them. This study is a phenomenological inquiry into the client's experience of therapy.

For years, I worked as a psychiatric nurse and every day at the end of my shift, I would have to write a note in each patient's chart describing his or her mood that day and perceived level of contact with reality. Just the very notion that I could accurately decipher another's state of mind seems preposterous to me now. In any case, the hospital charts contained various psychological assessments and evaluations, and whenever professionals came on to the unit to see patients, they would invariably consult the chart first, rather that asking the patients themselves how they were doing and if they thought that they were getting any better.

Years later, when I went on to earn my PhD in family therapy, I was often reminded about the absence of the patient's voice when I wrote up case studies or watched clinical presentations. Eventually, my hospital experience became an impetus for a study that looked into the clients' perceptions of the process of therapy and offered a different slice of the client's reality. The merit of such an approach can be illustrated through the systemic concept of double description, the ability to hear different ideas from separate sources within a system and consider each to be valid and useful, despite discrepancies and oppositions. As one remains receptive to several views, a more complete picture comes into focus than would have emerged from just one understanding (Keeney, 1983). As a researcher and a therapist, I am interested in this double description of therapy and the way different descriptions come together in a meaningful way.

In this article, I will provide an overview of the study, sharing with readers how I came to the research, what I learned, and the implications for practice and research. The main question that guided this study was, "How do clients make sense of the experience of therapy?" I wanted to respect the lived validity of the client's account and to narrow the gap between the theory and practice of therapy. It is grounded in the assumption that clients should be acknowledged as reliable on matters that relate to their own needs and preferences, and that it is important for us to listen to clients and examine our practices in light of the client's experience of them.

THE SHIFT TO COLLABORATIVE THERAPY AND RESEARCH

As postmodern ideas of social constructionism have influenced the fields of family therapy, clinicians have become more collaborative by including clients' experiences and views throughout the process of therapy (Bertolino & O'Hanlon, 2002). Although there are various constructionist models, they all hold in common the epistemological belief that a totally, objective reality, one that stands apart from the knowing subject, can never be fully apprehended. Rather, all human knowledge is socially constructed (Watzlawick, 1984). All individuals engage in a process of sense making in understanding the world and their differences in perspective and experience shape that understanding. As a result, there is not a single, unitary reality; rather there are multiple realities articulated through the lived experiences of individuals (Andersen, 1991; Anderson & Goolishian, 1988). A constructivist approach in therapy and research aims to help clarify the way that individuals construct meaning in their world as well as to create practices for using those understandings in beneficial or useful ways.

Over the years, the need to research the process of family therapy has been increasingly emphasized (Friedlander, Wildman, Heatherington, & Skowron, 1994; Pinsof, 1989) as outcome studies have left researchers and clinicians with questions about how change reported in therapy might have occurred. Several major reviews and proposed models have addressed issues of context (Greenberg, 1984), the relationship of process to outcome research (Greenberg & Pinsof, 1986; Gurman, Kniskern, & Pinsof, 1986), the roles of qualitative and quantitative approaches to research (Moon, Dillon, & Sprenkle, 1990), stages of change (Prochaska, 1999), and the role of common factors across models and theoretical orientations (Lambert & Bergin, 1994; Miller, Duncan, & Hubble, 1997). Other research has transgressed the process-outcome distinction to focus on the circular interaction of the therapist and family system that accounts for change (Miller, Duncan, & Hubble, 2004; Pinsof, 1989). In a comprehensive review of outcome studies, Orlinsky and Howard (1986) found that "the most decisive aspect of therapeutic process seems to be the patient's experience of it" (p. 348). These authors recommend that we accept the client's meaning system as the guiding theory from which to operate and conclude that "The quality of clients' participation, their perception of the therapist and what the therapist is doing, determine whether any treatment will work" (Miller et al., 1997, p. 25).