Theoretical and Conceptual Frameworks
mowllo
8301_week04article.docQualitative Reasoning and Analysis Walden University
Section:
RESEARCH REPORT
ABSTRACT This paper reports the methodology of a research project based on and including a review of almost 1000 texts and more than 20 years of learning and supervised practice as clinician and supervisor in the psychotherapeutic professions on the nature of the therapeutic relationship. Following a pilot study by five years, the findings were reported in a 165, 000 word document which encompasses poetry, personal experience, many textual extracts of theory or therapeutic dialogue, other research reports, theoretical considerations, clinical reflections, syllabus constructions--a post-modernist assemblage which nonetheless attempts coherence, validity and reliability. The findings have also been tested in the field for example by: (a) providing the framework for at least one four-year psychotherapy training course from which the first students have recently graduated by external assessment and (b) an independent psychotherapy accreditation process by a case study submission. It is argued that clinical practice or supervision should be inseparable from research--particularly qualitative research in psychology.
In the psychotherapeutic disciplines there is a proliferation of different schools or distinctly identifiable approaches (450 distinct schools according to Corsini, 1984). There are not 450 different ways to do coronary bypass surgery, why should there be 450 different ways to treat a 'broken heart'? Polkinghorne (1992) puts it this way: "The large number of theories claiming to have grasped the essentials of psychological functioning provide prima facie evidence that no one theory is correct" (p. 158).
In addition there is the unremitting inconclusiveness of quantitative empirical evidence attempting to prove that any one theoretical approach is more effective than another across a broad spectrum of problems (reviewed in Norcross & Goldfried, 1992). It has been said that the current state of psychotherapy outcome research is like the caucus race in Alice in Wonderland: "All have won and all must have prizes".
Furthermore as Shelef (1994) points out: "it is important to affirm Rat it is a researcher's wanting to know, wanting to understand that can be the basis of a research question" (p. 1). As well as the above questions, I wanted to explore the most frequently found common factor associated with the effectiveness of psychotherapy outcome across approaches--the therapeutic relationship.
Studies have shown that psychotherapists rarely find psychological research relevant for practice, and that they have to build up a second body of knowledge. The practitioners' expert knowledge is dynamic and context dependent; and Polkinghorne (in Kvale, 1992) goes on to argue that this largely oral knowledge of practice is in tune with postmodern ideas of knowledge as without foundation, fragmentary and constructed, as well as with the current neopragmatic shift from metaphors of correctness to those of utility. (Kvale, 1992, p. 5)
As a practitioner myself, it occurred to me that perhaps one of the reasons psychotherapy research is often so ambiguous and inconclusive is that it was trying to model itself on the quantitative investigatory paradigms of the physical sciences. Indeed it has been argued that experimental and quasi experimental methods cannot do justice to describing phenomena such as the therapeutic relationship.
A qualitative investigation into this field promised greater hope and perhaps more illumination. Denzin and Lincoln 1994's volume contains an excellent overview of the arguments in favour of and the scope and value of the field. I also wanted to explore for myself the capacities and limitations of qualitative research which was grounded in the life, liveliness and livelihood of the consulting room instead of in the laboratory rat mazes and high tech psycho-physiological quantitative measurements of my first Masters and Doctoral degrees. The research questions of phenomenological research methods would, in the words of Moustakas (1994): "reflect the interest, involvement and personal commitment of the researcher ... viewing experience and behaviour as an integrated and inseparable relationship of subject and object and of parts and whole" (p. 21).
The research questions therefore emerged quite simply: Why are there so many distinct and very different approaches to psychotherapy? Why does the relationship appear to be more important in assessing the effectiveness of psychotherapy than adherence to any of these many theoretical approaches? Could it be that these many different approaches are all talking about the therapeutic relationship, but from different universes of discourse or focusing on different aspects of it? Could I find a format for distinguishing such universes of discourses? Could it be small enough to be useful, yet large enough to encompass the whole field? Would it fit the data? Would it fit my experience as person and clinician? Would it work for others?
The core objectives of the investigation were: (a) to articulate and experiment with a qualitative research device to enhance the understanding and effectiveness of clinical practice, teaching and supervision in the psychotherapeutic professions; (b) in the words of the editor of the journal in which the phase one document (Clarkson, 1990) was piloted, to make
. . . a careful analysis of the various levels of the psychotherapeutic relationship in an attempt to find a perspective from which an overview might become possible. . . . offers a way of circumventing the inherent contradictions and incompatibilities that exist between different psychotherapies; instead of incompatibilities we have different priorities and emphasis. And this leaves a way open for the beginnings of a possible integration of psychotherapies. (Hinshelwood, 1990, p. 119)
and thirdly; (c) to explore a postmodern qualitative research methodology, context and content which was grounded in a moral universe where issues of values, ethics and the cultural/ecological situatedness of everyone accompanied the investigation instead of maintaining a pretence of objectivity, neutrality or even--authority.
The conceptual framework for this investigation is broadly drawn from the disciplinary fields of psychoanalysis/psychotherapy, psychology and counselling--all the forms of helping through talking. These can be visualized as three overlapping circles. The "heart" of the study, to use Miles and Hubermans' (1994) felicitous phrase, is the therapeutic relationship--the focus for "the case" under investigation in this instance. This case was conceptualized as primarily located in the field of psychotherapy theory, supervision and practice.
The decision to limit and concentrate on the therapeutic relationship (as opposed to other variables such as client/therapist match) is based on extensive evidence from the literature (which was reviewed in both the Clarkson 1990 and 1995 documents of this study) as well as personal, clinical and supervisory practice. The exploration or study of other variables in psychotherapy are minimised here except insofar as they impinge on the heart of this case. However, there may of course be other variables equally or better able to explain the existing reported commonalities or contrasts. However, the therapeutic relationship seemed suitable for qualitative investigation. Perhaps qualitative investigation would also suit the relationship best.
The boundary of this study maintained for the largest part a pragmatic distinctness of the central work of psychotherapists, psychologists and counsellors from the work of other helping relationships, such as those which may be involved in the practice of medicine, pastoral guidance or spiritual healing. These may be alluded to on occasion, but were not studied in depth in this case. Future studies may of course expand or test this project into other areas.
In Towards Reflexive Methodologies Gergen and Gergen, in Steier (1991), have suggested that: "By taking a reflexively dialogic approach to research, a new form of scientific work can be developed" (p. 86). Clinicians have often in the past defended their hostility, avoidance and rejection of scientific research on the grounds that the mystery of human relationship cannot be subjected to the analyses of the white coats. I had in the past myself likened it to trying to catch butterflies with tractors. Traditional scientific method has often seemed inappropriate, if not damaging, to the mystery and elusiveness of the healing human relationship.
However, the new form of scientific work may have, or develop, the capacity to honour both the mystery and its greater appreciation by understanding. Perhaps this dialogic approach to research could become acceptable--even desirable to clinicians and their co-researchers into the human psyche--their patients. "The intentional nature of human practices is well captured by qualitative methods. There is an acceptance of diverse ways of producing knowledge . . . also encompassing qualitative methods involving interactive and contextual approaches and including case studies" (Kvale, 1992, p. 51).
So, the research reported here would have to do with using the metaphor (and reality) of writing as relationship, while engaging in therapeutic relationships, as well as engaging with the writings of others about the nature and range of their understandings of the therapeutic relationship. I would intentionally include many diverse ways of producing knowledge. In this way I specifically began with "but a provisional stance towards a subject, and progressively elaborated the 'nature of the problem' as it is refracted through the intelligibilities of others" (Gergen & Gergen, in Steier, 1991, p. 79).
The study eventually comprised:
(a) The use of my own personal and professional experience as client, teacher and supervisor of psychotherapists (and allied professions) as locus of the exploration. Instead of an 'objective experimenter' on an object, I would engage from the subjective realities of my ongoing existential situation. This would correspond to Shelef's (1994) "heuristic incubation" (p. 2). The period of my personal and professional engagement with this question is catalogued in several places (including my CV) and spanned more than twenty years, several psychoanalysts and three continents. My background is considered uncommonly wide and thorough in my profession. It is during this period of immersion that I followed a strategy similar to that which is reported by Bamberger and Schon, in Steier (1991): " . . . searched for such boundaries without trying to be explicit about the criteria . . . "(p. 187).
(b) It was expected that the theory would emerge in an inductive manner from this large collection of data. The creation of a research device (Shotter, in Kvale, 1992) or qualitative research tool would follow, through which I would conduct my hermeneutical (as different from empirical) investigation into the nature of the therapeutic relationship across schools or approaches. This would consist in the "generation of categories for understanding human phenomena and the investigation of the interpretation and meaning that people give to the events they experience" (Polkinghorne, 1992, p. 112). This combination of both finding and making formed the basis for the formulation and publication of the pilot (Clarkson, 1990) document in a major journal of the psychotherapeutic profession.
(c) This publication led to the construction of a training course and further opportunities to test and verify the findings. It included as significant components extracts from authoritative texts, clinical examples, patient dreams and kinship metaphors.
The abstract and somewhat artificial separation of lived experience and sequentially unfolding research components was intentionally superseded by an alternative qualitative research paradigm (Hoshmand, 1989). What was intended was an engagement with the research problem of both passion and discipline, analysis and wholistic appreciation of the phenomena as well as use of the self as "the instrument by which the research was conducted" (p. 3). The nature of the research question however leads to it being an openended project. The publication of the major 1995 document will continue the research as readers and reviewers respond, reject, counter, expand or use the material--particularly the theoretical framework presented.
(d) In addition, my own experience of designing training courses, giving international lectures and workshops formulated around issues of the therapeutic relationship would provide me with ongoing and repeated feedback (verification or rejection) on the validity and acceptance of my interpretative framework. I used the pilot 1990 document as the basis for all these experiments with presentation, comprehensibility and acceptance to a wide range of professionals from a wide range of backgrounds and theoretical affiliations.
A general theory should have considerable scope, range and conceptual complexity, and that means also that it will be fairly abstract and have a fair degree of specificity (and so encompass much variability). It necessarily gathers up and helps to integrate what previously have been discrete theories, and elements of theories, that bear on the phenomena you are focused upon. (Strauss, 1995, p. 17)
(f) The research into relationship was furthermore itself conceptualized as relationship. The major document (Clarkson, 1995) would be indeed as and about relationship, gleaned from different methods of collecting data including: an inquiry into the field itself; texts from the field and poetics of the consulting room and surveys of research texts and samples of theoretical texts drawn from the experience of others; my own subjective experience and the resonances, reverberations, rejections and rewards it brings; and data from subjects and subjectivity and the larger community of both the discipline and the particular cultural and temporal world within which the study has taken place.
Clandinin & Connelly (1994) also view research itself as about relationship, conducted in relationship and through relationship:
Personal experience methods inevitably are relationship methods. As researchers, we cannot work with participants without sensing the fundamental human connection among us; nor can we create research texts without imagining a relationship to you, our audience. Voice and signature make it possible for there to be conversations through the texts among participants, researchers, and audiences. It is in the research relationships among participants and researchers, and among researchers and audiences, through research texts that we see the possibility for individual and social change. We see personal experience methods as a way to permit researchers to enter into and participate with the social world in ways that allow the possibility of transformations and growth. (p. 425)
Indeed one can consider the possibility that relationship is at the very heart of the recognition and growth of qualitative methodology because the qualitative research paradigm is based on the interrelatedness of subjects, not the apparently disembodied study of objects by some non-involved value-neutral analytic experimenter. It is centrally concerned with the researcher-researched unit where one can never authentically be peeled off from the other except in abstract compartments. In this sense it is consistent and congruent with the observer/field interdependence which is the particular contribution of quantum physics and the emerging sciences of chaos and complexity which I have discussed elsewhere (Clarkson, 1993). On a macroscopic scale these findings of interrelatedness corroborate the existential validity of the research hypothesis.
Any inquiry into relationship is by the same token research. And if psychotherapy is about relationship, then it must also be research in a sense. The fact that the work of the clinic is too frequently left unreflected and unreported in a rigorously reflected qualitative way, does not mean that it cannot be done. In the future, responsible clinical practice may require that it does not remain undone. Both supervisors and clinicians need to write in order not only to reflect on their experience, but also to offer it to the community of professionals for their edification, challenge and support. As the "unexamined life may not be worth living, the unexamined therapy may not be worth doing." As Richardson (in Lincoln & Denzin, 1994) has suggested, writing itself is of course a method of enquiry in its own right. And any writing done consistently over a large number of years inevitably has the mark of the researcher upon it.
All qualitative researchers are philosophers in that "universal sense in which all human beings . . . are guided by highly abstract principles" (Bateson, G. (1972), p. 320). These principles combine beliefs about ontology (What kind of being is the human being? What is the nature of reality?), epistemology (What is the relationship between the inquirer and the known?), and methodology (How do we know the world, or gain knowledge of it?) (Lincoln & Guba, 1985; Guba, 1990; Guba & Lincoln, 1994). These beliefs shape how the qualitative researcher sees the world and acts in it. And writing is a primary way of both seeing and acting in the world. (p. 517)
The documents which are some of the products of this research embody both the process and the content of the act of research in the relationship in this theoretical as well as practical way.
Specifically, poststructuralism suggests two important things to qualitative writers: First, it directs us to understand ourselves reflexively as persons writing from particular positions at specific times; and second, it frees us from trying to write a single text in which everything is said to everyone. Nurturing our own voices releases the censorious hold of "science writing" on our consciousness, as well as the arrogance it fosters in our psyche. Writing is validated as a method of knowing. (Richardson, in Lincoln & Denzin, 1994, p. 517)
Bor and Watts (1993) wrote that researchers in counselling psychology should conduct their research using a methodology which is congruent with their theoretical framework and approach to counselling and psychotherapy. It is possible to argue that the serious and dedicated writing up of subjective experience, the theories of others and the invention of one's own, the questioning of received wisdom and popular assumptions, the encounter with the other in the consulting room and their words and images, the prose as well as the poetry of healing form a congruent representation of the work of the clinician supervisor in this field. It is thus my opinion and recommendation that research should be inseparable from supervision or clinical work. This theme is developed elsewhere (Clarkson, 1995b).
Sampling strategies in this qualitative inquiry would focus on; (a) maximum variation; and (b) be theory based as well as; (c) opportunistic after Miles and Huberman (1994). So, in addition to my own experience, data would be solicited from all published and experiential sources allowing maximum variation of samples (within the field of investigation) drawn from the many different approaches to psychotherapy in order to identify important common patterns which I had studied over two decades, was teaching or which came my way, as result of unexpected discoveries, conversations or references.
The naturalist is likely to eschew random or representative sampling in favour of purposive or theoretical sampling because he or she thereby increases the scope of range of data exposed (random or representative sampling is likely to suppress more deviant cases) as well as the likelihood that the full array of multiple realities will be uncovered. (Lincoln & Guba, 1985, p. 4)
It would therefore be theory based in the sense of drawing on all the major theoretical approaches in the field, but also engaged in the initial formulation of theory--at least a theoretical framework for the exploration and utilization of the therapeutic relationship across approaches and across disciplines.
I attempted to "abandon the problem of the origin of ideas within the head, and shift concern to the emergence of language within communities" (Gergen & Gergen, in Steier, 1991, p. 80)--in this case therapeutic 'schools' or communities--all of whom articulate and speak about the therapeutic relationship in the grammar, idiom and vocabulary of their specific linguistic capacities--thereby creating as all languages do voids--which cannot be spoken, or perhaps even thought.
After this invention phase of research design, Kirk and Miller's (1986) discovery phase followed. However in this study it was inextricably intertwined in a feedback loop fashion with the interpretation or analysis phase in the sense that the information sought and the data collected were constantly subject to analysis and evaluation in terms of possibility of "fit" within the framework being tested. (The so-called explanation phase of communication was contained in the Clarkson 1995 document.)
This pilot study drew from a basis of 58 specific referenced sources. (Later, for the major document, I would use twenty times more sources, a much wider palette of discourses and a more imaginative sampling sieve subjecting some further 1,000 texts--specified in my books and i unpublished manuscript (Clarkson, 1995).--to thematic analysis. As here in the pilot, these would be drawn from an intentionally wide variety of therapeutic communities to reflective practice and theoretical analysis focused on the importance of "identifying contrasts between ways of speaking; and identifying points where these ways of speaking overlap" (Banister et al., 1994). I would do this by means of constructing what Marcus (1994) might call a messy text--substantial enough to have face validity, with the requisite variety to at least explore reliability.
See Figure 1 for a summary of the entire process to date.
The researched Clarkson 1995 document can also be presented as a product of discourse analysis or more specifically thematic analysis (Aronson, 1994). I conceive of this in the sense that it is the task of the textual and practical analysis "to tease apart the discourses that are at work" (Banister et al., 1994, p. 94). There are of course many possible fruits of such analyses--my intention was to find the smallest number of categories with the largest explanatory potential and the greatest inclusivity of universes of discourse about the therapeutic relationship.
This process has been engaged in a number of different phases--each of which is but a punctuation mark in an ongoing investigation conceived of as a longitudinal study lasting a professional lifetime. So any report can never be the final report, but is only a report on the most recent findings and the methods and means of acquiring them. It is intended as the beginning of collegial conversation, not an end.
First there was the thorough exploration of the "diversity of meaning, the different contradictory ways of speaking that govern what we [as psychotherapists] do (and who we can be)" (Banister et al., 1994, p. 92). I sought to explore all the major relationship discourses in psychoanalysis, psychotherapy and psychological counselling. This phase is documented primarily by certificates of study, academic and professional recognitions, lecture and workshop notes and the list of publications which preceded it.
Next was the construction of categories--the five relationships--which provided a way of structuring the textual research into a hypothetical sorting matrix. This device actually emerged one evening in my consciousness as a completed Gestalt, suddenly clarifying boundaries between the different kinds of therapeutic relationship about which is spoken and which indeed I had experienced, both as practitioner/supervisor and as client. The experience constituted the kind of shift of knowing which Shotter (in Kvale, 1992) described from knowing by "looking at" to knowing by being "in contact, or in touch with" (p. 56).
The efficacy of this thematic analysis matrix would be assessed by its: (1) usefulness in clinical, teaching, and supervisory practice as well as actual programme construction and validation; (2) the ease of understanding by novice and experienced practitioners in the field under investigation (the recognition factor); and (3) the adequacy of fit. This is here conceived of as the extent to which it made manageable or comprehensible the multiplicity of perspectives--often contradictory-which co-exist in the psychotherapeutic literature regarding the "relationship".
The 1990 pilot study was launched with the publication of an original paper in a major journal for psychoanalysis and psychotherapy. A first test in this regard was peer review and acceptance by a premier journal in a "first world" country. "One of the functions of the text, as of any text, is to bring to life (again for us now as researchers) a network of relationships. . . . " (Banister et al., 1994, p. 117). Verbal and written reports supported the initial formulation and hopefully helped to bring it more to life.
In this case as well, the place of overlap between all forms of psychotherapeutic endeavour seemed to be the central importance of the therapeutic relationship. I hypothesized that the contrasts between the different schools depended on the ways of speaking about this relationship and therefore the different universes of discourse associated with each. This formulation became an early categorization subjected to constant and rigorous analysis and evaluation.
In this process I identified five primary universes of discourse in the major texts dealing with psychoanalysis, counselling psychology and psychotherapy. The analysis was thematic rather than statistical partly because of the interpreter fluency/rater expertise required. They emerged as themes in the way the solution to a puzzle sometimes emerges clearly but essentially inexplicably from long-term intense engagement with it.
It appeared to me that there are five kinds of such relationship which can repeatedly be identified in the extant research and theoretical literature by such a thematic engaged analysis. These are: the working alliance, the transference/countertransference relationship; the developmentally needed or reparative relationship; the person-to-person or real relationship; and the transpersonal relationship. I hypothesized that all five of these kinds of therapeutic relationship are at least theoretically. potent/ally available in most approaches to therapy and that aspects of each actually appear in most of the major approaches studied. (See the 1995 document for details, this paper is focused on the methodological issues involved.)
The construction of the 1995 document both as research question and research result
The 165,000 word Clarkson 1995a document marks a recent temporary but defined stagepost in this research study. It includes case material, poetry, chunks of texts from other writers, ponderings, arguments, conflicts, confusions, juxtapositions and particularly a constant acknowledgement of flux in the field in which it is situated and the contradictions, paradoxes and growth potential of the author.
Almost 10% (a tithe) of the text is explicitly engaged in moral/ethical discourse. A section on the inescapability of values in counselling and psychotherapy carries the implicit and explicit acknowledgement that all actions and non-actions (including writing) are valuing acts. Throughout this the author and reader are being questioned as well as informed and challenged. It was meant as a messy text.
Marcus (1994) writes that: "The postmodern premise that there is no possibility of fixed, final, or monologically authoritative meaning has radicalized the critique within anthropology of its own forms of representation by challenging the authority on which they have been based" (p. 566). I attempted to experiment with this kind of approach as a contribution to the literature of psychotherapy by repeated exercises in the construction of the bulk of a chapter in the final 1995 document, often followed by a deconstructive piece disengaging from, challenging or blatantly questioning the foundations upon which the chapter had been constructed. In this way I hoped to invite the reader into serious consideration of opposing viewpoints; the discomfort of theoretical uncertainty; and the excitement of the deconstructive process of individual discovery. An example of this is the chapter in which I write an extensive overview of the literature on the developmentally needed relationship, but the so-called "counterpoint" piece is concerned with undermining the very notion of the usefulness, credibility or moral defensibility of developmental perspectives in psychoanalysis and psychotherapy.
Marcus (1994) explains at least three justifiable and valid reasons for constructing messy texts:
First, they arise simply from confronting the remarkable space/time compression that defines the conditions of peoples and culture globally . . . Second, they wrestle with the loss of a credible holism. . . . In messy texts there is a sense of a whole, without evoking totality, that emerges from the research process itself. . . . Third, messy texts are messy because they insist on an open-endedness, an incompleteness, and an uncertainty about how to draw a text/analysis to a close. Such open-endedness often marks a concern with an ethics of dialogue and partial knowledge that a work is incomplete without critical, and differently positioned, responses to it by its (one hopes) varied readers. (p. 567)
The construction of the five relationship framework provided an analytic tool which is itself a commentary about multiplicity of co-existing universes of discourse in the field. It certainly is a research device. I am not sure if the five relationship framework constitutes a theory. It may be more of a hypothesis or a framework for complex data analysis.
Collegial feedback have however insisted quite strongly that it is indeed a meta-narrative in its own right (Christoph-Lemke, personal communication, 1994). In this sense the formulation of the five relationship framework could be a theory (Strauss, 1995) based on the continuous interplay of data and conceptualisation over many years. The theory I was developing became more complex and delineated as I constantly (theoretically and practically). compared the sampled data sources from the body of literature researched one with each other and also in terms of my proposed analytic framework. Exploration of the data yielded sufficient confirmation to use the framework as an ongoing categorization of relevant universes of discourse relevant to what is generally understood as "the therapeutic relationship".
If it is a theory, the five-relationship framework is a fairly abstract theory of therapeutic relationships. It gathers up and helps to integrate hundreds of different approaches to psychotherapy, at the same time as being able to encompass much variability. The extent and limitations of this theoretical or pragmatic model as a theory can be further pursued in the future by myself and other researchers.
The design and construction of a training course for psychotherapists based on this model would test the theoretical framework as a formula for learning the practice of psychotherapy by externally assessed standards. Although obviously not tightly controlled in the more traditional quantitative mode, the students were indeed engaged as co-researchers testing and using the framework to support their learning and their practice. This is research tested by application.
This is partly for Kvale's (1992) suggestion: "by discarding a modern legitimation mania, justification of knowledge is replaced by application, with a pragmatic concept of validity" (p. 19). This criterion of validity is particularly applicable in this case where usefulness of the framework is its raison d'etre--not its "truth" per se.
In addition this work has supported my own personal and professional application of the device or framework in psychotherapy, supervision-and organizational consultancy at least over the period of duration of the study. All people in psychotherapy, supervision and training with me interacted dialogically with me living the material day by day in relationship. From them I learnt what made sense, what worked, what didn't. They were my first co-researchers and my best teachers. In another sense all the writers of books and papers in psychology, psychoanalysis and psychotherapy were also my co-researchers as they were reporting on the vagaries and vicissitudes of their researchers and experiences of the therapeutic relationship in their settings and within and relevant to their idiosyncratic theoretical approaches-each in their own individual universe of discourse. (Gergen & Gergen, in Steier, 1991) also showed "the advantages of allowing a multiplicity of voices to speak to the research issues of concern" (p. 79).
The five-relationship model was then subjected to further practical test in the consulting and lecturing room, through teaching and in supervision as well as the construction of a training programme based on it. It has been used consistently by myself for at least 5 years after its published formulation and has stood the tests of time, diversity of approaches of and accessibility and interest to novice as well as very experienced clinician/supervisors. This is the interweaving of researcher and researched, folding in on the self and out into the practice. "It is through this spiral movement, through experiencing lived space with others, that the researcher would learn, illuminate, and generate data" (Shelef, 1994, p. 3). Also, of course, test the data.
The first psychotherapy training programme which used this framework as its primary integrative shape has recently been completed. Several of the students have been awarded merits or distinctions by an external examining board based on their casework presentations and dissertations. (The award of an academic MSc may follow.)
It should be noted that the other staff on the programme which I had originally conceptualized and most of the adjunct supervisors were familiar with the model through my teaching and supervision--although each one hopefully brought their own particular uniqueness to its interpretation and implementation. Students would, in the best cases, amplify and diversify according to their proclivities and theoretical and clinical pre-occupations. Indeed this is the very form and function of the model as originally intended--to create a theoretical framework within which many different .approaches can be articulated, shared and understood without necessarily privileging any one or more as the authorised discourse on this theme.
The five-relationship framework has been used as a basis for a number of other courses in psychology, counselling or psychotherapy. Investigation of these would be a possible future avenue for further research as to whether it can meet multiple interests and needs. I did subject it to evaluation by formulation, programme construction and participant evaluation or publication in peer-reviewed journals in three specific other areas--organizational consultancy, couples therapy and group therapy.
A further external accreditation test
As a further test of the theory I constructed a case study in prose-poetry with a discussion paper and submitted it as an example of competent clinical psychotherapy to a major national psychotherapy accreditation body. (Authorities such as Eisner (1991) have argued before that qualitative research is art, based on connoisseurship and criticism and which accepts the personal, literary, and even poetic as valid sources of knowledge.)
The five-relationship theoretical framework applied to a real client who had been in psychotherapy with me and described in this way was accepted by this organization's accreditation board as valid and sufficient (with my CV) to become a member of their organization. I submit this as further evidence of recognizability of the model as well as one possibility among many to test validity and reliability. It is another aspect of qualitative enquiry which I have not yet seen documented elsewhere.
The final (Clarkson, 1995) document itself exists as the summary transcript of the research process itself including the fact that it is a text of texts as well as containing reflections on its own textuality and situatedness in contemporary post-modernity--particularly as it affects issues of ethics and epistemology.
It is currently being presented to the psychotherapeutic community as a book for review and sale. The responses received to it will again shape the findings, birth new hypotheses and further the general dialogic relationship with professionals and theoreticians in these fields. This will lead to further refinements and more differentiated small-scale studies which can again continue the research process.
Every day new material emerges which can be incorporated, alternative frameworks are posited, questions, amplifications and reservations are articulated which problematize or valorize certain aspects more than others. Its justification lies in its engagement and the showing of the relationship between text and author, and in making this struggle accessible in this form--an ongoing invitation to reflection, exploration and relationship.
Finally I would submit that this study has not only been post-modern in the diversity and particularities of its components and its construction drawing from a multiplicity of Styles, instances and cultures from different periods and cultures in and around psychotherapy--it has also itself been a product of the postmodern turn in psychology as described and discussed particularly in Kvale's (1992) Psychology and Postmodernism. Table II attempts to summarize some other main features.
Every day new directions for future research emerge and become clearer. I will only mention some here:
(a) An investigation of inter-rater reliability of the assessment of transcripts of therapeutic transactions in terms of which relationship vector is intended or acted upon by extensive and thorough discourse analysis of therapeutic sessions. This will test or give some indication of the recognizability of the five different kinds of therapeutic relationship. It may facilitate the development of criteria for differentiating them for ease of use in practice, supervision and further research.
(b) A comparison of the discourse analyses done in such a way within and between different schools or approaches to psychotherapy to explore whether the differences reported in the literature between schools are indeed an artefact of language or social constructions rather than fundamental incompatibilities (as is sometimes believed).
(c) A phenomenological exploration into the five relationships--subjective differences, experienced value at different stages or critical incidents of psychotherapy and/or perceived failures or misunderstandings--conducted with psychological therapy clients as active co-researchers.
(d) A further exploration and exposition of the perceived affinity of qualitative research paradigms with the models and procedures of chaos and complexity theory as well as the quantum physics. A small example concerns the fractal iterative nature across scale of say the five-relationship device (from therapy transcript segment to case study to the whole of the field?).
(e) A further and much more detailed investigation into the usefulness of this paradigm of research specifically in clinical supervision building on the initial formulation already published in the 1995 document.
(f) According to Rudestam and Newton (1992): "Because the researcher is regarded as a person who comes to the scene with his or her own operative reality, rather than as a totally detached scientific observer, it becomes vital to understand, acknowledge and share one's own underlying values, assumptions and expectations" (p. 38). A further exploration of the ethical and moral situatedness of the researcher/clinician/ supervisor in psychotherapy is thus indicated. This may involve taking the postmodern works concerning ethics, politics and moral action of for example Anderson (1990), Bauman (1993), and Hutcheon (1989) as well as an qualitative investigation into the professional, cultural, social and psychological aspects of bystanding behaviour into the discursive domain of avowed and enacted values (Clarkson, 1996).
(g) Finally--to do an equally broad and wide sweep of research writings in psychology/psychoanalysis/psychotherapeutic counselling engaging with the five-relationship device in a thematic analysis of the field of research. It would be looking for patterns or clusters of pre-occupations in the languages and discourse of researchers in this field which may sort into the relationship categories of: (1) the working alliance; (2) the transference/countertransferential; (3) the developmentally needed or reparative; (4) the person-to-person; and (5) the transpersonal (or a category for the currently inexplicable).
I can imagine sifting the literature in the nature of a thematic analysis to explore the clarity or ambiguity with which researchers in theory and practice deal with: (1) quantitative methods; (2) data distortion and expectancy effects; (3) as learning or educational acts for the researcher and researched; (4) as engagement and dialogue of the kind which qualitative research valorizes; or (5) allow place for the ultimately mysterious--even itself again as a kind of research exploring the human quest for knowledge or the end of it where individuality or a separate voice no longer exist. Or as the phenomenologist Merleau-Ponty (1962) phrases it:
In the experience of dialogue, there is constituted between the other person and myself a common ground; my thought and his are interwoven into a single fabric, my words and those of my interlocutor are called forth by the stage of the discussion, and they are inserted into a shared operation of which neither of us is the creator. We have here a dual being, where the other is for me no longer a mere bit of behaviour in my transcendental field, nor I in his; we are collaborators for each other in consummate reciprocity. (p. 354)
On the other hand, the heuristic device which has proved so useful in this instance may give way to a completely different way of relating to the meta-theoretical analysis of the multitude of varieties of practice of research in this field.
This paper discussed and summarized the qualitative methodology which formed the basis for the construction of a researched text documenting the ethnography of textual and applied understandings of "the relationship" within a theoretical framework drawn from the psychotherapeutic profession.
The research yielded repeatedly and under a variety of conditions five major categories of discourse about the therapeutic relationship. This original theoretical framework has been found to function at least in some cases as a unifying and inclusive framework which allows for the co-existence of multiple perspectives on the therapeutic relationship as well as developments within any one approach. In this sense it reflects a contemporary post-modernist attempt to give validity to all the "different stories about stories" (Anderson, 1990, p. 267) which currently constitute the body of knowledge and practice we call psychotherapy and psychotherapeutic counselling psychology. It also allows for future development.
The enquiry is here presented to my scientific community of peers for constructive feedback, suggestions for improvement and perhaps recognition of this kind of approach (as a valid if tentative beginning) of building a more dialogic relationship between the clinic and the academy.
"In particular I am suggesting that the practice of the clinic should not be separated from rigorous and constant research. In this way the therapeutic relationship can be returned to itself. For example a qualitative research project such as a disciplined and methodologically informed case study is not something to be done once for a dissertation or paper--I believe it needs to be conducted with every client, every session, for a long as a clinician/supervisor works professionally." (Clarkson, 1995b, pp. 203-204)
Inter-rater reliability in assessing between clinician, client and supervisor whether an intervention was effective or not, is but one example of such reflexive practice. The analysis of transcripts or disciplined inquiry by means of writing can augment this. The supervisor is then not someone to whom one is in a hierarchical relationship, but becomes someone who acts as a co-worker researching the clinical as well as the supervisory work at every step. The engagement of the client in this process is also to be explored.
In order to accomplish this, it would be necessarily for all clinicians to become familiar and at ease with research, particularly the paradigms and disciplines of qualitative inquiry. It is possible that qualitative research is the method of choice for clinicians because it overcomes the sterility and alienation of much quantitative research in its close relationship with the ambiguities, imponderables and unmeasurables of the healing encounter. It would therefore also be necessary for all supervisors to be skilled in acting as co-researchers in every case or situation brought to disciplined reflection also subjecting their own clinical and supervisory work to investigation--all the time. Although there will probably always be important differences in experience, interests and expertise, conjoining the work of doing and reflection in this way might even signal the end of the difference between research and clinical supervision in training and supervision. This could potentially be to the benefit of all concerned--not least the clients. Learning with the client in such a way introduces a praxis of the recovery of knowledge which is surely at the very heart of the therapeutic endeavour itself.
Life is achieved by resolving the tension in responsive feeling and creative activity, in which having is not eliminated but is assimilated to being, in which one and another become I and thou; in which science is integrated with metaphysics; in which autonomy (managing my own affairs) is transcended in liberty, which is participation; in which my body and the world with which it is consubstantial and which enlarges and multiplies its powers is the place in which I bear witness to Being; in which I work out my fidelity and my hope and keep myself open, fluid and ready to spend. (Marcel, 1952, p. 66)
FIG. 1. Diagrammatic summary of entire research process to date.
Immersion in literature-reading and writing
Clinical practice
Supervision and teaching
Problem formulation-why the heterogeneity of and frequent hostility between different approaches to effective therapy?
Meta-analyses of quantitative research show that it is the therapeutic relationship which is a more significant factor in effectiveness of psychotherapy judged by a variety of measures than theoretical orientation-Farrell's (1979) WOT, or "way of talking",
Hypothesis-Post-modern proliferation of discourses
If this were so, what would the smallest number of universes of discourse be with the greatest utility for coding the literature and clinical and supervisory applicability
Discovery and formulation of qualitative research device which provides a frame for the analysis of the sampled discourses
Testing the 5-set coding instrument for discourse analysis
The 1990 pilot document published
Major external clinical verification 1994-accreditation based on CV and poetic prose case study with discussion using the 5-relationship framework
Feedback and corrections via colleagues, programme construction and readers
External verification (training & supervision)-Graduates from first psychotherapy training programme based on the 5-relationship model pass exams.
Construction of the 1995 document
Publication
TABLE 1. Summary of method with reference to Lincoln & Guba (1985)
Focus for enquiry The therapeutic relationship.
Fit of paradigm to focus Amenability. to qualitative
inquiry.
"Fit" of inquiry paradigm Combination of phenomenological
to the theory selected to (therapy sessions/interviews);
guide the inquiry heuristic (literature analysis);
& ethnographic (study of the
texts of different "tribes" of
psychotherapy).
Where and from whom data Clients, colleagues, self as
will be collected client, therapist, supervisor
and teacher, major texts, psych.
lit., trainees, journal and
book reviewers, poets and formal
accreditation panels.
Successive phases of Theoretical and experiential
the inquiry immersion, formulation/discovery
of 'categories' based on an
impressionistic discourse
analysis--the making of the
qualitative research device,
field application, pilot study
(1990), incorporation of
feedback, training programme
construction and implementation,
further discourse analysis and
much enlarged (diversity and
volume) field sampling
procedures.
Instrumentation The application of the
five-relationship framework to
the field with the researcher as
instrument.
Data collection and Library retrieval, collegial
recording modes discussion, extensive reading,
ongoing clinical, teaching and
supervisory practice, course
design, consultancy workshop and
conference presentations the
writing, rewriting and eventual
construction of the major
document (1995).
Data analysis procedures Multiple.
Logistics Best left to the
imagination--management of a
personal and professional
clinical/supervisory and teaching
life including conferences and
workshops in several different
countries while consuming large
quantities of professional
literature as well as writing
and rewriting a 165,000 word
book.
Trustworthiness The coding frame (5
relationships) was repeatedly
presented to clients,
supervisees and colleagues in
order to test whether they
could understand the themes and
arrive at similar
conclusions--for example to the
journal reviewers of the 1990
document and to the 12 senior
manuscript reviewers of the
1995 document.
No causal relationship was
postulated about the five kinds
of therapeutic relationships.
The possibility that at least
some of the conflicts and
misunderstandings in theory and
practice between different
schools of psychotherapy
were attributable to
differential prioritisings of
different aspects of the
therapeutic relationship is by
no means proved.
However, prolonged engagement
(20 + years in the field)
persistent reported reflections
on observation
(80 + professional publications)
and the checking of multiple
sources of data such as my own
practice, the descriptions of
the practices of my colleagues,
1000 + texts and other research
studies provide at least some
evidence for internal
validity--to be further
explored.
External validity was
specifically tested by the
external assessment of the first
graduates from the programme
designed on the basis of this
framework and by the submission
of a case study in poetic prose
as part of an application for
membership accreditation by the
procedures of a national
recognized psychotherapy
accrediting organization.
TABLE II. Summary of other post-modern features of this inquiry
Legend for Chart:
A - From
B - To
C - Source
A B
C
Theory Practice
Shorter, in Kvale (1992) p. 59
Theorizing Instructive account
Shotter, in Kvale (1992) p. 59
An interest in things Interest in activities/uses
Shotter, in Kvale (1992) p. 59
Preformed psychological Devised tools
instruments
Shorter, in Kvale (1992) p. 59
What goes on in the Sociality/relationship
heads of individuals
Shorter, in Kvale (1992) p. 59
Reflection as origin Embeddedness in activity
Shorter, in Kvale (1992) p. 59
Reality in language Social relations in language
Shotter, in Kvale (1992) p. 59
Reliance on experience A questioning of the social
as the basis for
understanding the world processes of their construction
Shorter, in Kvale (1992) p. 59
Investigations based Modes which allow for error
on authoritative correction on the spot
foundations
Shorter, in Kvale (1992) p. 59
A unitary perspective Plurality of perspectives
Shorter, in Kvale (1992) p. 36
A split of culture into A rehabilitation of the ethical
science, morality and and aesthetic domains
art
Shorter, in Kvale (1992) p. 36
Quest for extrinsic Intrinsic legitimization,
legitimization, uniqueness, intuition and
universality, quality
rationality
and commensurability
After Gergen, in Kvale (1992) p. 41
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~~~~~~~~
By PETRUSKA CLARKSON
Honorary Reader in the Psychology of Supervision, University of Surrey, Department of Psychology, Guildford, Surrey, U
Correspondence to: Dr P. Clarkson, Consultant Chartered Counselling and Clinical Psychologist and Psychotherapeutic Supervisor, PHYSIS, 12 North Common Road, London W5 2QB, UK.
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