No Change? A grounded theory analysis of depressed patients' perspectives on non-improvement in psychotherapy

Melissa Miléna De Smet, Reitske Meganck, Kimberly Van Nieuwenhove, Femke Truijens, Mattias Desmet

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Aim: Understanding the effects of psychotherapy is a crucial concern for both research and clinical practice, especially when outcome tends to be negative. Yet, while outcome is predominantly evaluated by means of quantitative pre-post outcome questionnaires, it remains unclear what this actually means for patients in their daily lives. To explore this meaning, it is imperative to combine treatment evaluation with quantitative and qualitative outcome measures. This study investigates the phenomenon of non-improvement in psychotherapy, by complementing quantitative pre-post outcome scores that indicate no reliable change in depression symptoms with a qualitative inquiry of patients' perspectives.

Methods: The study took place in the context of a Randomised Controlled Trial evaluating time-limited psychodynamic and cognitive behavioral therapy for major depression. A mixed methods study was conducted including patients' pre-post outcome scores on the BDI-II-NL and post treatment Client Change Interviews. Nineteen patients whose data showed no reliable change in depression symptoms were selected. A grounded theory analysis was conducted on the transcripts of patients' interviews.

Findings: From the patients' perspective, non-improvement can be understood as being stuck between knowing versus doing, resulting in a stalemate. Positive changes (mental stability, personal strength, and insight) were stimulated by therapy offering moments of self-reflection and guidance, the benevolent therapist approach and the context as important motivations. Remaining issues (ambition to change but inability to do so) were attributed to the therapy hitting its limits, patients' resistance and impossibility and the context as a source of distress. “No change” in outcome scores therefore seems to involve a “partial change” when considering the patients' perspectives.

Conclusion: The study shows the value of integrating qualitative first-person analyses into standard quantitative outcome evaluation and particularly for understanding the phenomenon of non-improvement. It argues for more multi-method and multi-perspective research to gain a better understanding of (negative) outcome and treatment effects. Implications for both research and practice are discussed.
Original languageEnglish
Article number588
JournalFrontiers in Psychology
Publication statusPublished - 26 Mar 2019
Externally publishedYes

Bibliographical note

We want to thank all patients and therapists for participating
in the study. Acknowledgements to Ufuoma Norman for the
careful reading of the final draft of this manuscript. Gratitude for
contributing to the data collection for the Ghent Psychotherapy
Study goes to Ruth Inslegers, Rosa De Geest, Goedele Hermans,
Vicky Hennissen, and Ufuoma Norman. MDS is funded by the
Flanders Research Foundation (FWO, Belgium).

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