I’ve just come off an hour’s Skype on a qualitative research project. We’re looking at clients’ experiences of preference accommodation. Do clients want therapists to ask them about their preferences? Do they find it helpful having them accommodated? Do clients preferences change over the course of therapy? We’re engaging in a research process called Consensual Qualitative Research (CQR), and have the privilege of having one of the developers, Sarah Knox, on our research team. It was an hour, also with Gina di Malta and Hanne Oddli, going over the first part of an interview transcript and trying to put into ‘domains’ what the participant was saying about preference accommodation. Were they saying that their preferences had come from their previous therapy, or were they saying that the therapist just intuitively knew what they wanted? Back and forward: dialoguing and disagreeing and trying to make sense of things. CQR is a fascinating qualitative method where you work together on the analysis as a team. It really gets to the heart of qualitative research: working to make sense of what people are saying and experiencing in their lives.
Working on this project has really reminded me of the extraordinary things that can be achieved through qualitative research. Of course, being a pluralist, I love quantitative research too, but there’s something about the qualitative process that gets to the depth of things in a way that numbers never really can. When you’re interviewing someone, when you’re asking them about their lives and perceptions, you’re getting straight into the process by which someone comes to do the things that they do. And what things mean for them. You can look at numbers, and you can say that, for instance, ‘School counselling leads to reductions in distress’ but you don’t really know why. It’s like looking at the world through a mesh. But with qualitative research, you can really ask people about things, and then ask them again. And ask them in different ways that mean that you can build up such a rich picture of what’s going on.
Interviewer: What was it like seeing the school counsellor?
Young person: Well I- I really liked how she talked to me about things.
Interviewer: So you liked talking about things. Can you say more?
Young person: It was, I felt that the more I talked about things the more I kind of felt relieved. Less stressed.
Interviewer: So the stress came off as you talked. Is that right?
Young person: Yes, I felt a weight coming off. I talked about things and, as she listened, I felt at least someone else knew what was going on. I wasn’t alone. And I got some ideas about how to talk to my mum…
Of course, qualitative research doesn’t do everything. It’s not great if you want to compare between groups, and it’s hard to generalise too widely from it. But generalisation is based on the assumption that everyone acts according to the same laws and, actually, what qualitative research helps you to see is just how different everyone is. One participant says that they really loved going to see the school counsellor. Another says that they hated it. Taken quantitatively, you can end up averaging these two things out so that, on average, people feel fairly neutral about seeing a school counsellor; but actually that’s not the reality at all. The reality is that some loved it and some hated it. And qualitative research can really help us to hold on to, and prize, those differences.
It’s for reasons like these that so many counsellors, psychotherapists, and counselling psychologists would rather be doing qualitative research than quantitative. It’s not a million miles from being with a client: listening, understanding, deepening an empathic attunement with another’s world. A key difference though is that we’re also taking that out of the therapy room and telling others about it: so that, for instance, clinicians can use that knowledge to inform and develop their practice. That’s why one thing I am really passionate about is trying, wherever possible and ethical, to do qualitative research with clients rather than therapists. I know, I know… it’s more difficult often to find clients to do research with, and there’s additional ethical considerations. But when you’re talking to clients about what they feel about therapy, when you’re asking them what was helpful and not helpful and then bringing it all together into a coherent whole, there’s something amazing you’re learning about what we do. It’s ‘straight from the horses mouth’: deeply, profoundly affecting how we can think about the people sitting opposite us.
Just today we published a study on clients’ experiences of working with goals. Again, in many ways, it was a really simple study: we talked to clients about how they felt about working with goals in therapy. Yet I feel like I learnt so, so much to help me in my clinical work. For instance, I’m a real advocate of goal-oriented practices, but clients were also saying that, in some instances, goal setting could feel premature. They really didn’t know what they wanted. And there was some clients who felt it was mechanistic, and demotivating at times. Sure, you can say, ‘Well, I could have told you that without interviewing 22 clients,’ but then there were also some very positive things clients said about working with goals, like they could bring focus and help them progress forward step-by-step. So qualitative research, particularly with clients, can help us out of rigid positions of ‘clients want this’ or ‘clients want that’ towards an appreciation of the complex, heterogeneous, and multifacted world of clients’ experiences of therapy. A few years back, John McLeod and I published a protocol on conducting qualitative research into clients’ experiences of what is helpful in therapy, and I think it’s still a very useful framework for conducting research that can really contribute to the development of our knowledge and practice (see here).
I wish qualitative research played more of a role in informing clinical guidelines and policy. But I think it’s up to us involved in it to try and sketch out what that might be. The great thing about randomised clinical trials is that they give very clear results, and you can bring them together to produce specific and definitive guidelines for policy and practice. How do you do that with qualitative research? I am sure you can, but we need to work out how. In the meantime, though, I hope that more of us can get more time really talking to clients about what therapy is like, and learning more and more about what’s working and what’s not. It’ll never give us definitive answers, but it’ll help us build up a richer and richer picture of how, where, and why we can be most helpful in our work.