Psychotherapy Research, March 2011; 21(2): 227240

Outcomes of psychotherapy from the perspective of the users

NNINEN,1 & OLAVI LINDFORS2 JUKKA VALKONEN,1 VILMA HA

1

University of Eastern Finland, Department of Social Sciences, Kuopio, Finland & 2National Institute for Health and Welfare, Helsinki, Finland

(Received 11 June 2010; revised 8 December 2010; accepted 12 December 2010)

Abstract Psychotherapy is widely held to be an effective means to decrease depression. It seems, however, that not everyone benefits from every kind of therapy, and the relevant outcomes vary from person to person. In this article, the pre-therapy views and post-therapy experiences of 14 users of either long-term psychodynamic psychotherapy or short-term solution-focused therapy are analyzed. The interviewees personal views about their depression and therapy are approached with the concept of inner narrative. Three basic stories or orientations were found: life historical, situational and moral. These offered people different contexts from which to evaluate the outcomes of their therapy. The findings suggest that a persons expectations, hopes and values are worth taking into account to ensure positive therapy outcomes.

Keywords: depression; qualitative research methods; outcome research; long term psychotherapy; brief psychotherapy; narrative approach

In recent decades, depression has become one of the main health problems in Western societies (Murray & Lopez, 1997). It causes a significant amount of work disability and ties up a lot of the resources of health services, not to mention human suffering. Psychotherapy is one of the proposed means for relieving the suffering, and indeed it seems to help many people (Wampold, 2001). However, not much is known about individual differences in what people expect and actually do get from it. In psychotherapy research, the outcome of therapy is usually seen as a change in the patients symptoms or diagnosis, or changes in the patients psychological functioning, which is assessed by standardized questionnaires or interview data rated by a trained evaluator. Most of the effectiveness studies are designed to measure these variables before and after the intervention, and sometimes during a follow-up period. Results are then obtained by comparing the group means of trial and control groups at the preand post-therapy phases, with the standard deviation describing the individual variation within the groups. The overall conclusion from several meta-analyses* focusing mainly on short-term therapies*is that psychotherapy is useful, and that there are no significant differences in the effectiveness of different forms of psychotherapy based on specific theoretical

assumptions and technical practices (e.g., Cuijpers, van Straten, Anderson, & van Oppen, 2008; Wampold, 2001). Discussion of these results has been dominated by two kinds of interpretation. The first is the idea that all kinds of psychotherapy produce beneficial effects based on common factors rather than specific effects. An alternative interpretation is that this equality paradox might be the result of methodological standards*that is, even if the objectively measured outcome is, on average, the same in both groups, there might be differences in how the outcomes are experienced and constructed (Nilsson, Svensson, Sandell, & Clinton, 2007). As Flyvberg (2006) argues, careful qualitative analysis even of a single case is of great value for understanding the range of outcomes, the contexts in which the outcomes emerge, and the mechanisms which produce them. Moreover, qualitative analysis is needed because what is seen as an outcome is based on socially constructed knowledge (McLeod, 2001). There are several perspectives to efficiency*the users perspective being highly relevant: We believe that it may be valuable in terms of developing a more comprehensive account of therapy outcomes, to talk about researcher-constructed outcomes, therapist-constructed outcomes and user-constructed outcomes, as a means of separating out the

Correspondence concerning this article should be addressed to Jukka Valkonen, University of Eastern Finland, Department of Social Sciences, FI-70211 Kuopio, Finland. Email: jukka.valkonen@uef.fi ISSN 1050-3307 print/ISSN 1468-4381 online # 2011 Society for Psychotherapy Research DOI: 10.1080/10503307.2010.548346

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J. Valkonen et al. form of treatment, while other studies (Westra, Aviram, Barnes, & Angus, 2010) have found that initial negative expectation is often expressed in good-outcome cases and vice versa in poor-outcome cases. Instead of measuring preferences by standardized questionnaires, qualitative methodology can be used to give the users of therapy the unrestricted possibility to discuss their views. Accordingly, the persons orientation toward psychotherapy would not be reduced to concrete predetermined outcome expectations or therapy preferences. The study reported in this article was conducted in connection with the Helsinki Psychotherapy Study (HPS), a primarily quantitative research project on the effectiveness, sufficiency and suitability of different forms of psychotherapy (Knekt & Lindfors, 2004: Knekt et al. 2008). The purpose of the current study is to enrich and diversify the image of the outcomes gained from the quantitative research framework. In the qualitative, narrative analysis of therapy users pre-therapy orientations and post-therapy assessments of therapy we aim at illuminating the process in which the users understanding of the nature of their problems and their expectations of therapy develop during the course of therapy. Main Concepts In this paper, we use the term user of psychotherapy (or, for brevity, user) instead of patient or client, highlighting that people are seen as active and competent participants in therapy, capable of using and interpreting the therapy in their unique ways. In addition, the term does not presuppose that the people in question are sick, as the term patient would do, or that they are free to make choices as consumers of health services, as the term client would imply (cf. Dreier, 2008). The article is based on the narrative research tradition. Its core concept is inner narrative, which refers to the individuals organization of experience, to the narrative that is told to oneself (see Ha nninen, 2004). The inner narrative is seen as an ongoing mental process that weaves together a persons past and anticipated future, taking into account the material realities present in the life situation and making use of the social stock of stories available to the person. In narrative terms, the aim of this study is to look at how the experiences of therapy are weaved into a persons inner narrative. By the term basic story of psychotherapy we refer to a shared ideal typical construction of the ideas about the nature and cause of mental problems leading to the seeking of therapy, and the ideas about

different ways in which therapy can be evaluated from different stakeholder positions (McLeod, McLeod, Shoemark, & Cooper, 2009). Qualitative research addressing the users views of effectiveness of therapy is still rare. There are, however, some qualitative studies that have addressed the ways in which therapy users construe the outcomes of the therapy they have received. Irene Ku hnlein (1999) constructed four ideal types on how emotional disorders and inpatient psychotherapy (CBT) were connected to a persons autobiography. The study demonstrated how people can evaluate the outcomes of the same therapy from different perspectives. People who saw themselves as overburdened evaluated their therapy on the basis of how it helped them to cope with life tasks. Patients who saw themselves as deviants expected that therapy would lead to their living a normal life. In the deficit type, patients saw psychotherapy as necessary to compensate for their deficiencies and, finally, patients who construed their problems as stemming from a development disturbance saw psychotherapy as a means to enhance their knowledge and understanding of psychosocial development. In a more recent study by Nilsson et al. (2007), people who had received either cognitivebehavioral or psychodynamic therapy were interviewed retrospectively about their experiences. Nilsson et al. also discovered that those who were satisfied with their therapy described the outcomes in different ways depending on which form of therapy they had received: The CBT patient was directly satisfied with her ability to apply specific techniques to cope with specific problems, whereas the PDT patient described herself as more selfreflective and with wider range of personality-related changes (p. 563). As both of the studies mentioned above were retrospective, the question of how the different views have taken shape is left open. The users views have also been taken into account in the research tradition concerning the effects of persons pre-therapy expectations on therapy outcomes (see Greenberg, Constantino, & Bruce, 2006 for review). Within this tradition preferences are distinguished from expectations (Arnkoff, Glass, & Shapiro, 2002). Preferences, which are far less studied than expectations, are especially relevant for the study at hand. A recent meta-analysis by Swift and Callahan (2009) shows a positive effect of match between preferences and treatment on the outcome, represented by greater symptomatic improvement and lesser drop-out. In some studies, using questionnaires (Levy Berg, Sandahl, & Clinton, 2008) the match of treatment preferences with treatment experiences has been found more significant for the outcomes than the

Outcomes of psychotherapy 229 the ways psychotherapy would help in solving these problems. In our conceptual framework, the basic story is the rather stereotypical conception of mental problems which people bring along, as a part of their inner narrative, when they enter the therapeutic process and against which they assess the outcomes of therapy. Method Patients, Therapies and Therapists In the Helsinki Psychotherapy Study (HPS), shortterm solution-focused therapy, short-term psychodynamic psychotherapy and long-term psychodynamic psychotherapy were compared in a randomized trial with regard to their comprehensive effectiveness for patients with depressive or anxiety disorders.1 Patients were recruited for the HPS from psychiatric services in the Helsinki region. Eligible patients were 20 to 45 years of age and had a longstanding disorder causing work dysfunction (Knekt & Lindfors, 2004). The present study focused on the recorded interview data from patients with depressive disorder who were allocated to short-term solution-focused therapy (SFT) or to long-term psychodynamic psychotherapy (LPP). We considered these forms of therapy to be theoretically and structurally at the extreme ends of the forms of therapy covered by the study. SFT is a brief, resource-oriented, goal-focused therapeutic approach which helps clients change by constructing solutions (Johnson and Miller, 1994). It is based on an approach developed by de Shazer et al. (1986). The frequency of sessions in SFT was flexible, usually one session every 2 or 3 weeks. The average length of SFT in these data was 6.8 months (102238 days) and it consisted of 9 to 12 sessions. LPP is an open-ended, intensive, transference-based therapeutic approach which helps patients by exploring and working through a broad range of intra-psychic and interpersonal conflicts. The therapy includes both expressive and supportive elements, depending on the patients needs. The orientation followed the clinical principles of LPP (Gabbard, 2004). The frequency of sessions in LPP was 23 times a week, the average length was 33.7 months (7291141 days) and the average number of sessions in these data was 292 (194378). Eligible therapists were required to have at least 2 years of experience in the relevant therapy form after completion of their training. All the therapists who provided SFT had received their qualification in solution-focused therapy by a local institute and all the therapists providing LPP had received standard training in psychodynamically orientated psychotherapy, approved by some of the psychoanalytic or psychodynamic training institutes in Finland. The mean number of years of experience in the respective therapies was 9 (range 315) for therapists providing SFT and 18 (range 630) for therapists providing LPP. None of the psychodynamic therapists had any experience of SFT or vice versa. The data for the present study consisted of a sample (n 0 14) from the research patients of HPS, randomized to either SFT or LPP (n 0 225). Only those patients were included who had a mood disorder with the BDI score over 9 at the baseline, who attended their therapy without premature discontinuation or extended duration, and for whom there were complete interview data. The members of the original sample fulfilling these criteria (n 0 51) were then categorized according to the following variables: Gender, form of therapy, and whether the symptoms had remitted or not by the end of therapy. From all these subgroups, two people, altogether 16 persons, were randomly selected for the sample. After two men, one from each therapy form, refused to allow their data for the study, the sample included four women and three men receiving solutionfocused therapy and four women and three men receiving psychodynamic psychotherapy (Table I). The average age of the participants was 34 (21 44) years. Nine of them were single, four were married or cohabited and one was widowed or divorced. Three of them had university degrees, five had college-level training, five had matriculation and one had an elementary school education. All but one were employed or studied at the time of pretherapy interviews. The symptoms of depression were assessed using the 21-item Beck Depression Inventory (BDI) (Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961). Before the therapy, the average

Table I. The distribution of the participants by therapy form, post-therapy BDI, and gender Post-therapy BDI 59 Long-term psychodynamic psychotherapy Short-term solution-focused therapy Totals 2 1 2 1 4 2 women men women men women men Post-therapy BDI 9 2 2 2 2 4 4 women men women men women men 4 3 4 3 8 6 Totals women men women men women men

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J. Valkonen et al. additional inquiry about therapy experiences and the possible changes in ones condition and life situation or any other relevant life area for the person. All the interviews were videotaped. In this study, we used only the sound tracks of the recordings. A typist transcribed them verbatim. The text corpus of the transcribed interviews included 460 pages (singlespaced Arial 11 font). The files of the transcriptions were anonymized and saved into the Atlas ti software. Procedures of Data Analysis The process of analysis in the present study followed a kind of hermeneutic circle (e.g., McLeod, 2001, p. 27). Two distinct forms of analytical processes were combined: First, the formation of ideal types of stories on the basis of thematic coding of the whole data; then looking again at the individual interviews prior to and after the therapy in the light of these ideal types. The reliability of the analysis is based on the explicit description of the process (McLeod, 2001, pp. 181189) which is outlined in the following. The study proceeded in five main phases. (1) The first step was to analyze the views of the interviewees about their forthcoming therapy during the pre-therapy interviews. First, the transcribed data were coded and classified into three thematic categories: (i) the interviewees reasons for seeking psychotherapy, (ii) their ways of talking about themselves and their problems, and (iii) their expectations regarding psychotherapy. Then the contents of these categories were analysed further to reveal the temporal and situational logic by which the interviewees thought about these issues. By combining these forms of logic across the categories, we formed three basic stories (or ideal types of orientations), which represent different orientations towards therapy. We considered these stories to reflect the social stock of stories that the participants of our sample were able to use to configure their images and expectations concerning psychotherapy. (2) As the second step of analysis, the meaning of psychotherapy in the individual inner narratives of the users of particular forms of therapy was figured out. For this purpose, the basic stories were mapped onto the individual interviewees. First, it was assessed which ideal type basic stories were present in the pre-therapy interview of a particular person. Then the inner narrative of each participant was reconstructed on the basis of their use of these basic stories in their interpretations and categorized the interviewees according to them.

BDI score was 21 (1234) and after the therapy it was below 10 for six persons, while eight had a posttherapy BDI score of 10 or more. All the persons in this sample signed a written informed consent for the use of their interviews and other material concerning them in this study. Procedures of Data Collection All the participants in the HPS were interviewed several times before, during and after the therapy (Knekt & Lindfors, 2004). The data for the present study included pre- and post-therapy interviews. The third author was one of the interviewers, but he was not aware of the present study at the time of the interviews. The interviewer was always the same in the pre- and post-therapy interviews of a person. The interviewers were experienced psychologists or psychiatrists who had received specific training (during a period of several months, about 60100 hours) in using a modification of Kernbergs (1984) semi-structured interview technique for personality assessment. In this way, the interviews were informed by the psychodynamic theory. The interviewers had former experience in psychiatric assessments and they all also had experience as psychotherapists. There were five interviewers altogether in this sample. One of them was a man, who had interviewed four participants, of which one was a man. A pre-therapy interview was conducted before the random assignment to a specific therapy. It consisted of three sessions, conducted at about a weeks interval. Altogether, they took approximately two and a half hours. In these semi-structured interview sessions, the interviewer carried out a thorough evaluation of the presenting problems and reasons for seeking therapy as well as a description of the person and her or his life history. The themes of the pre-therapy interview covered family and other interpersonal relations, sexuality, work, leisure time, self-concept and other possible issues important for the interviewee. Expectations about psychotherapy and the therapist were also asked about. The last part of the pre-therapy interview was diagnostic and structured. The post-therapy interviews were conducted either 7 or 12 months after the beginning of the therapy for the users of solution-focused therapy, and 3 years after the baseline for the users of longterm psychodynamic psychotherapy. The post-therapy interviews were conducted in one session lasting approximately one and a half hour. The structure of the post-therapy interview was identical to the pretherapy one, with the exclusion of life historical and referral-related themes and the inclusion of an

Outcomes of psychotherapy 231 (3, 4) Steps 1 and 2 were repeated for the posttherapy interviews using the coding system developed for the pre-therapy interviews. The assessment was made independently of the pre-therapy assessments. (5) The individual pre- and post therapy inner narratives were compared and the interviewees were categorized according to the type of the course of the inner narrative as progressing, stagnant, and changed. In narrative analysis all information available was utilized, including interviews, results of therapy allocation and self-reported symptoms (BDI scores), to see how the inner narratives continued between the two interviews. As the study was the first of its kind, no manual or established protocol for analysis was available, although the thematic analysis and the narrative analysis as such are established methods in social and behavioral sciences and also in psychotherapy research (McLeod, 2001; Timulak, 2009). The empirical analysis of the data was carried out mainly by the first author, whose academic discipline is social psychology. He had no training in or affiliations to any psychotherapy forms. Instead he had experience in qualitative research on rehabilitation, especially in narrative analysis. Even though the empirical analysis was carried out mainly by one researcher, the research team participated actively to evaluate the validity and credibility of the findings. Reliability was checked by reporting the empirical basis of the interpretations to the team. If an interview displayed elements of several basic stories, the case was categorized according to which basic story was thought to be most prominent in the interview. In ambiguous cases (three interviewees) consensus was sought by discussions between the first and second author, who also read the original transcripts. Results The Basic Stories of Therapy Using a thematic analysis of the pre-therapy interviews, three ideal types of basic stories were constructed to illustrate the ways in which people orientate themselves towards their depression and their psychotherapy. These basic stories were constructed by combining the views presented by the interviewees about their reasons for seeking psychotherapy, their views about themselves and their problems, and their expectations about psychotherapy. Thus the basic stories can be considered as plots that linked these themes together. We referred to these three orientations as life historical, situational and moral basic stories. Often those individuals felt that they could not tell what specifically had happened or where the origin of their problems was. Still, they had a sense that something traumatic had to have happened in their life, and finding out what it was would give an explanation for their problems. . . . Ive acquainted myself a bit with these things, so obviously as a child [I have] been left without all of them, the basic security and that satisfaction inside there. (Woman, 1) Psychotherapy is then expected to help a person construct a coherent life story and to fill in the gaps The first of these was based on the idea of life history as the essential source of problems as well as the idea that the sorting out of these problems is essential to recovery. The second orientation pointed to the components of the persons current life situation as the most essential element: Depression was seen as a part of life itself and present resources needed to be enhanced to cope with it. In the third story, the moral order of the social context was the main element: The person felt their life did not fulfill the cultural standards of a good life. In the following pages we describe the basic stories in more detail. The formation of these ideal typical orientations toward psychotherapy is described above. In summary, thematic analysis was conducted on the pretherapy data as a whole; that is, the focus was on the logics of the orientations (or argumentations), not on the participants. From the themes mentioned above similarities and differences were sought. Three logics were found, and these were written out as basic stories. The plot of each basic story shows how the temporal and contextual elements are linked together in each logic. In several pre-therapy interviews, elements of more than one basic story could be seen. So it should be kept in mind that the basic stories below are ideal types, not the same as a persons individual inner narrative. The life historical story. Some of the participants saw their depression as connected to events that had taken place earlier in their life. Certain experiences or conditions in childhood had disturbed their development or had otherwise continued bothering them. . . . the burnout has brought back the memories of incest in my childhood ( . . .) it has shaped me as a woman, I feel that I have been mistreated, I havent been allowed to live the kind of womans life as I would have wanted. (Woman, 13)2

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J. Valkonen et al. resources in their lives. They considered problems in life as such to be a natural part of life. . . . somehow I have always thought it as natural that man is this kind of manic-depressive creature, that we go on slightly whirling or like in a cyclic motion. Because of that I havent paid any ( . . . ) Ive taken it as natural that a man has his bad moments and good moments, but at that situation . . . (Man, 4) These persons did not expect to get rid of depression altogether; instead, they saw the changes in mood as something that was an integral part of life. During that particular situation, the problems just exceeded ones resources. Users of therapy hoped that psychotherapy would help to solve some of the problems in their present situation or reinforce their resources in order to restore the balance and feelings of empowerment in their life. I have just thought mostly that that [the therapy] would be of help so that I will get my life back on track. And fine if it does; if it doesnt, so be it. I have nothing, Ive given up long ago the idea that someone else could really be capable of solving my problems. If it just would help somehow to get my life in shape. (Woman, 6) The second, situational orientation to psychotherapy is summarized in the following basic story: Im seeking psychotherapy because of the problems in my present life situation. They are connected to my relationships with other people, my job, my studies and/ or my economical situation. The difficult situation determines my sense of myself and my problems. I feel exhausted and powerless to act to change the situation. My own resources are not enough and I need support from outside. Whatever the causes of my difficulties are, debating them wont help to enhance the situation. Instead, I expect that therapy will help me to find solutions to my problems and to control my life. By consolidating my social status, by reinforcing my own resources or by finding a new perspective for my life situation, I may cope better with the challenges of my present life. So, we could say that the second type of basic story is concerned with present problems which have to be solved in order to go on in life. The moral story. Some of the participants justified their seeking psychotherapy by mentioning dissatisfaction either with themselves or with their

in the persons life story. From this perspective, psychotherapy helps the person to find an explanation for his or her problems that is felt to be authentic. Of course [I hoped], that it would become clear whats the basic cause of these problems ( . . .). In earlier times I had the idea that it was somehow innate and impossible to change . . . I mean these bouts of anxiety . . . That it would be nice if I would get a clear diagnosis to the causes ( . . .) and by that my identity would begin to become clearer and perhaps I would find a real future then, and would find out what I could start doing. And of course my relationships would become better too and my self-esteem. Then I wouldnt need anything else. (Man, 2) The ideas presented above can be summarized as the following basic story: Im seeking psychotherapy because I want to clear up the reasons for my depression. My sense of myself is based on my life history and I feel that my past determines my thoughts, feelings and actions. I have faced threatening events and harmful circumstances in my life. I have had to protect myself from painful memories by rejecting some of these memories from my consciousness. Becoming aware of the causes for my problems and connecting them to part of who I am as a person would relieve my depression. Thus, I am expecting that my life history will be treated in psychotherapy and by that I will get an explanation for my problems. That, then, would help me to accept myself and act more autonomously in the future. All in all, the life historical story sees the source of the problems as residing in the past. Working out the past problems is seen as a means to heal the present ailments. The situational story. Some of the participants explained their depression by factors connected to their present life situation. Perhaps the core thing that I hoped and still hope to be treated for in therapy is that kind of a difficulty that is connected to a particular person who played a significant role in my life a couple of years ago. (Man, 11) Present relationships, problems at work or school or housing or economical circumstances made a persons life situation hard and caused or maintained depression. Seeking psychotherapy was justified by suggesting a disturbed balance of the challenges and

Outcomes of psychotherapy 233 life. They felt their life was not going as expected and their sense of self was negative. . . . life does not proceed as it should any more. Thats the reason for seeking [psychotherapy] ( ... ) how would I say it, that at that point when for the last 10 years you wake up every morning thinking that you are a loser and capable of nothing, then the life does not go forward anyway. (Man, 12) These persons felt themselves to be incapable of meeting the demands which they had placed upon themselves or which they felt that the prevailing culture had imposed upon their life. For some, even these expectations were lost: They saw their depression as a consequence of not knowing what they want or where to aim in their life. Their sense of active agency, the experience of being able to conduct ones life in a hoped-for direction, thus remained deficient. Normally people at this age begin to be, begin to be something already. Someone has become some kind of engineer, someone else will be a musician and I dont have the slightest idea of what I will be. Of course that is not, I dont mean that a profession is the identity of a person. (Man, 2) On the other hand, depression could be connected to the idea that a person had made wrong choices in life. In the end, users of therapy accepted moral responsibility for the situation as well as for resolving to their problems. They needed psychotherapy to clarify their goals in life and to find inspiring narratives from the culture around them to become attached to and for finding reference points by which they would be able to evaluate their life. Naturally, it would be desirable that ones life would then be honored and significant and that such a narrative interpretation would offer the meaning of life for the person. I imagine that if I just could get my fuzzy thoughts in my mind into some kind of order . . . maybe then I will know what is valuable in that and what is not. Im afraid of becoming embittered, that after 20 years I will think that I should have acted somehow, now, in a different way than I have acted . . . that it will be too late then. (Woman, 5) The ideas presented above could be summarized in the following basic story: Im seeking psychotherapy because Im dissatisfied with myself and with my life. I havent achieved things in my life which are valued in our culture, or I dont even know what I want in my life. My Self is constructed through my actions toward the goals which are meaningful to me and when these goals are missing also my Self is lost. Although events and circumstances in my life may have affected my development, Im responsible for my actions and my life. Feelings of shame, which are connected with the wrong choices, hurt, but the core of my problems is still that I dont find myself as an active agent in life and Im not competent to achieve what I want (if only I may even know what it would be). That is why I expect that psychotherapy would help me to clarify my goals and to help me experience my life as valued and meaningful. In the third basic story, the persons see their main problems as residing in their future prospects and therapy is expected to help them to find a purpose and meaning in their life. Thus, psychotherapy was needed to restore the moral value of the person and to fill the perceived existential vacuum with culturally dignified and socially unifying narratives. Comparison of the basic stories. The three different basic stories formed distinct contexts for a person to evaluate their acts and experiences. One of them was directed to the past, one to the present and one to the future. One of them interpreted the problem as residing within the person, one in the relationship between the person and the situation and one within individuals relation with the cultural and social milieu. Agency, the sense of an ability to have an influence on ones life, is a crucial feature in all those basic stories. However, the basic stories seemed to be different in terms of the aspect of agency entailed. In the life historical context, agency was connected to autonomy, that is, ones experience of an authentic self in charge of ones actions; in the situational context, agency meant the persons ability to achieve their aims, and in the moral context, agency was linked to being able to form meaningful aims. We could also say that the life historical story sought coherence, the situational story sought control and competence, and the moral story sought connectedness to the social context. The Course of Inner Narrative and the Meaning of Psychotherapy The results presented above give a perspective on the ways in which the interviewees were orientated towards psychotherapy before they were told which form of therapy and which therapist they would be allocated to. Construction of the basic stories was the first step in understanding the outcomes of psychotherapy from the users perspective. As we have seen, these formed distinct contexts of

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J. Valkonen et al. the user expressed the same inner narrative in both interviews. Third, a persons inner narrative could twist in an unanticipated direction. That is, a person provided in the post-therapy interview a new interpretation of themselves and their problems as well as a new reference point from which to assess psychotherapy. Table II tells how the participants course of inner narrative was related to the pre-therapy inner narrative and the form of therapy. It can be seen that in this sample there was an association between the pre-therapy orientation and the outcome of the therapy assessed on the basis of the post-therapy inner narrative. The progressing inner narratives can be found in the cells in which a life-historical orientation is combined with long-term psychodynamic therapy, or when a situational orientation meets short-term solution-focused therapy. On the other hand, stagnant inner narratives are found in the cells in which the pre-therapy orientation differs from the ideas inherent in the form of therapy. It is interesting to note that none of those at the pretherapy interview with a moral inner narrative thought that the therapy had met their original expectations. In three cases, the inner narrative had changed during therapy to comply with the ideas of the received therapy; that is to say, a person with a situational or a moral inner narrative had found a life-historical way to interpret their problems during the long-term psychodynamic psychotherapy, or a person with a life historical inner narrative learned to use situational explanations in short-term solutionfocused therapy. There was only one case in which the inner narrative changed in spite of the congruence between the pre-therapy orientation and therapy form. In this case, the symptoms of depression had not diminished and the person thought that, after all, his problems may stem from his current situation instead of his past. In the following, well give examples of progressive, stagnant and changing inner narratives using three vignettes based on individual cases from the sample. Let us call the protagonists of the vignettes

orientation with regard to therapy. The next step of analysis focused on the consequences of being assigned to a certain form of therapy from the perspective of inner narratives. In the following, we will present the findings obtained by looking at how the basic stories figured in the hypothetical inner narratives of the individual interviewees. We assessed first case by case how the basic stories seemed to be present in the inner narratives of the interviewees at the pre-therapy phase. Of the 14 interviewees, five were assessed to represent mainly the life historical type of narrative, five of them represented the situational type and four the moral basic stories. The next phase of analysis focused on the continuation of inner narratives, in other words, what kinds of endings could be found in the post-therapy interviews. So, after the assessment of the pretherapy interviews, we analyzed case by case what kinds of differences, if any, appeared between the pre- and post-therapy interviews in terms of how the basic stories were present in the interviewees expressions. That is, we read the post-therapy interviews by looking at how the interviewees talked about themselves and their problems at that time and how the therapy had met their expectations. We found three ways of how the inner narratives continued after the pre-therapy period. First, it could progress just as expected, that is, the same basic story was prominent both in the pre- and posttherapy interviews and the narrative had an ending which was consistent with the ideas held in the beginning; for example, things were better now thanks to the successful therapy. In this kind of narrative, psychotherapy turned out to be just what the user had imagined and hoped for and it relieved the symptoms of depression as expected. Second, a narrative could be stagnant, that is, the expected ending was still missing as told in the post-therapy interview. For example, a person felt that the problems were basically the same before and after the therapy and that the therapy had not met the interviewees prior expectations. In these narratives,

Table II. The course of the inner narrative of the participants by pre-therapy inner narrative and therapy form (number of cases) Life historical Long-term psychodynamic psychotherapy Progressing Changing Stagnant Short-term solution-focused therapy Progressing Changing Stagnant Totals

Situational

Moral

Totals

2 1 1 1 5

1 2 2 5

1 3 4

2 3 2 2 1 4 14

Outcomes of psychotherapy 235 by the pseudonyms Ella, Mira and Sari. Three women were selected because they were the clearest examples of each basic story. pre-therapy interview, she did not want to surrender to depression. Now she felt that she did not want to leave her agency to the therapy. Now she wanted to and could cope by herself. On the other hand, I thought sometimes that its good that it [psychotherapy] ended. You couldnt continue it forever ( . . .) you want to cope by yourself in the end. (Post-therapy interview) Ellas vignette is an example of a story with a happy ending, in which the inner narrative had come true. The form of therapy to which Ella had been allocated had matched well with her understandings of herself and hers problems and the therapy worked in accordance with Ellas expectations. In Ellas case, psychotherapy helped her to organize her somehow fragmented inner narrative with an increased understanding of her life history, which in her case led also to increased autonomy and agency. We found analogous experiences among those for whom the situational inner narrative corresponded to the short-term solution-focused therapy they had received (see Table I).

Progressing Inner Narrative Example: Ella (7, LH, LPP ). Ella is a single, employed woman in her thirties. She had sought psychotherapy because of depression. At the pretherapy interview Ella connected her problems to her childhood and felt uncomfortable and disturbed because she had no clear recollection of it. She told the interviewer that she does not want to surrender to depression. Ella expects that, with the help of psychotherapy, she will be able to clear up her childhood and to construct a more coherent or truthful sense of herself. Its unclear also for myself that how . . . what has caused this. So, in a way, Im thinking by myself then that childhood and all possible, but it is just something which I cant . . . it feels that I cant get hold of something, but I dont know what it is. (Pre-therapy interview) Ella was assigned to long-term psychodynamic psychotherapy. At the post-therapy interview, she said that she felt that psychotherapy had met her expectations and had helped her to understand herself and her problems. Then in a way . . . I wanted to go to my childhood . . . I feel that therapy has helped. (Posttherapy interview) As Ella had hoped, psychotherapy had offered her opportunities to sort out her childhood memories. That, in one way or another, had increased her autonomy. During the therapy, she managed to make significant changes in her life. One of them was to begin to study for an occupation she was interested in. Ella felt that her bad feelings and depression had been relieved through her increased sense of self. So the feelings of inferiority had disappeared and then being myself . . . I think such a thing has come more forward. (Post-therapy interview) [Psychotherapy] has brought such a new perspective to almost everything, one is seeing things more realistically than before. (Post-therapy interview) Ella was satisfied with her psychotherapy and with her therapist and that is why she felt a bit ambivalent about ending her treatment. As she had said at the
3

Stagnated Inner Narrative Example: Mira (1, M, SFT). Mira is a single woman below the age of 40. She had sought psychotherapy because she was dissatisfied with herself and her life. At the pre-therapy interview, Mira thought that she was at some kind of crossroads in her life. Mira thought that her childhood experiences had restricted her from developing in different areas of life, but mainly she was worried about her future. Mira did not believe in short and resourceoriented therapies. Instead, she wanted therapy to help her find a direction for the rest of her life. Mira also hoped that therapy might help her, for example, to develop her relationships with other people. . . . or one is at this age and realizes herself to be at such a junction that what would I do now for the rest of my life . . . I feel that so far I have failed, so Im terrified about what I will choose for the rest of my life, what I would like to do. (Pre-therapy interview) Mira was allocated to short-term solution-focused therapy. Not much had changed during the therapy. At the post-therapy interview, Mira talked about herself and her problems mainly in same manner as before. Her symptoms of depression remained unchanged as well as her sense of her problems.

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J. Valkonen et al. Also, some participants with a situational inner narrative who were allocated to long-term psychodynamic psychotherapy had similar experiences of disappointment. However, they were not as explicitly critical towards the form of therapy as Mira. These interviewees saw their problems as being related to their situational conditions, for instance marriage problems, conflicts in a job, interrupted studies or economical difficulties. Even though they felt that psychotherapy and the therapist were giving valuable support in a difficult situation, they felt that solutions were not found for the acute problems. And that was what mattered for them. At the end of the therapy process, the same problems and the same understanding of depression were present as before. These users of therapy felt that something needed to be done to solve the concrete problems and that psychodynamic psychotherapy was not helpful in this regard. . . . I appreciate it as a whole quite a lot ( . . . ) then there were some moments when you, in a way, had nothing to say, then it gave such an uneasy feeling ( . . . ) it felt that you go on the same thing and that we are not proceeding at all or even go quite backward . . . (Man, 4, after long-term psychodynamic psychotherapy)

. . . these characteristics [of personality] of mine, all these certain problems are still there, I know that for sure. (Post-therapy interview) It is no wonder that Mira was not satisfied with her therapy. She blamed the form of therapy for her continuing depression and the fact that it did not match her expectations. Mira told the interviewer that already before the therapy she had had an attitude that the short-term solution-focused form of therapy would not be the right one. I knew it already before the beginning of the therapy that this kind of therapy of 12 meetings wont help these kind of things. (Post-therapy interview) Mira also had some positive experiences with the therapy, but these were mainly connected with the therapist. However, solution-focused ideas were not totally absent at the end of the therapy, but they were not enough for Mira, who had also had some experience with other kinds of therapy. I have learned [new solutions], but maybe I havent had the opportunity to realize them yet. ( . . . ) Well, theres something in fact Ive tried to carry out. Maybe it was something that was related to work, that I wouldnt demand so much of myself or something, but . . . (Posttherapy interview) I wouldnt . . . its just conversation. As I said its nice that I have had a support person there. But really, it [solution-focused therapy] wont touch a persons deepest problems in there. Because I have gone to psychodrama and those, so I know that they are in a way much more touching. (Post-therapy interview) In our interpretation, Miras vignette is an example of a situation in which a moral inner narrative remained stagnant during the therapy process. In her pre-therapy interview, the life historical basic story was also strongly present. From the point of view of the expectations formed on the basis of the moral or life historical story, the solution-focused therapy was not optimal. Mira felt that short-term solutionfocused therapy had not met her expectations. Because short-term therapy did not demand significant economical, social or emotional sacrifices, it was easy to attribute the lack of positive outcomes to therapy. Mira was not alone in the sample in this respect. There were also other interviewees with a life historical or moral inner narrative who expressed the same kind of experiences after short-term solution-focused therapy.

Changing Inner Narrative Example: Sari (6, S, LPP). The third vignette is an example of the situation in which unanticipated changes took place in a persons inner narrative during the therapy process. Sari is a woman below 30. When she came to the HPS she was single and studied at the university. Sari was disappointed with herself, as her studies had not progressed as expected, and that was her reason to seek psychotherapy. She hoped to receive short-term therapy to help her to solve the problems related to her studies and to get her life back on track. I dont actually know of anything else*if I just could pull myself together and take those exams . . . so if I only could fix that study part, I feel that it might repair then many other things at the same time. (Pre-therapy interview) It doesnt have to be terribly long, my future is just so strangely hidden in mist that I dont know, even in three years, so much can happen. In that respect, I am of course a bad patient . . . even if I wanted to commit myself to that kind [of therapy]. (Pre-therapy interview)

Outcomes of psychotherapy 237 Contrary to her wish, Sari was allocated to longterm psychodynamic psychotherapy. Her experiences with the therapy were not too encouraging at first. At the beginning, I didnt like it at all. It was somehow terribly . . . somehow it felt quite stupid in my opinion. I had to even ask from him [therapist] what was the meaning of it, what should I do there. I felt that I just sat down like a fool and didnt find anything to talk. ( . . . ) Id have liked to get some kind of hint about whats the idea that I sit and talk, and of course it annoyed me that he didnt comment at all. ( . . . ) in normal interaction between persons it is not the way just to sit down and sulk quietly. (Post-therapy interview) The therapists behavior was quite confusing to Sari and she was not aware of the aims of psychotherapy. Other problems arose when Sari asked if she could change the meetings from three times a week to twice a week. Sari felt that she had to surrender her own desires for those of the therapist and continue the therapy as planned. Nevertheless, she did not stop the therapy and at some point during the process something changed. Saris idea of her problems and her life history turned in a direction she had not expected. . . . just like at the beginning I whinged that I would certainly not begin to talk about any childhood things and family relations, as they havent any effect on me, so that is so surprising that how they have however . . . been part of this. (Posttherapy interview) Not just the inner narrative turned in a new direction, but also Saris behavior and situation changed. Her studies began to progress, she met a new boyfriend and she also noticed she was now capable of making her own decisions. That was not the situation earlier. Maybe even more important was the fact that she began to be more satisfied with herself. One day I was yelling out of delight when I had bought curtains just by myself (laughing). Like such a little thing. That I could decide just by myself, that these I will take [without asking the mothers opinion]. (Post-therapy interview) . . . suddenly I began to be quite satisfied with that what I am. Not so awfully much blamed myself for everything. (Post-therapy interview) In our interpretation, Sari started with a situational interpretation of the problem. She did not manage to take the exams that were part of her studies and she thought that if she could solve that specific problem her life would get back on the track. Psychotherapy turned out to be something quite different with regard to her inner narrative. For some reason, Sari continued going to psychotherapy in spite of some difficulties with her therapist. In psychodynamic psychotherapy, Saris situational inner narrative gave way to a new one based on the life historical basic story. Sari learned to interpret her problems with psychodynamic concepts and explanations. Obviously, these stories matched well enough with Saris experiences and ideas, so the new inner narrative could take shape for her. The life historical inner narrative helped her to increase her autonomy. She found herself capable of making decisions on her own, she could solve the problems connected to her studies and she began to be satisfied with herself and her life. Also, the symptoms of depression had decreased by the end of therapy. In the case of a participant with a morally oriented inner narrative, the same kind of reorientation was found at the post-therapy interview. She had learned in psychodynamic psychotherapy to use psychodynamic concepts to help her to understand herself. Even though her level of symptoms remained high, the meaning of the symptoms changed. They did not threaten her sense of self anymore, because she could understand them better. . . . when you have a lot of that kind of automatic thought patterns and then of course for a person like me . . . they are quite pessimistic, so these ( . . . ) I have learned to recognize them and then when its discussed why I have them and what kind of associations they bring, what kind of memories of earlier situations I have . . . (Woman, 14, after long-term psychodynamic psychotherapy) There was one case in the sample in which a life historical inner narrative seemed to have changed in the solution-focused therapy. This was a man who had explained his problems by events in his history and who had learned in therapy to construct them as related to his situation rather than as related to his mind. Even the symptoms of depression got new meanings with the changed inner narrative. I was suspicious of the therapy and thought whether it would be reasonable to talk about my childhood . . . . The therapist said its most important to work with the uppermost thing in ones mind, that it would help me to go on, that it just would make me more depressed, if I begin to bring more problems into my head to turn over. Talk about the most topical issues in such a way that a

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J. Valkonen et al. some people, this may be even more rewarding than the expected outcomes would have been. The utility or use value of psychotherapy is connected with the way a person interprets themselves and their problems. Persons are not a tabula rasa when they enter therapy (e.g., Miller, 2004). Nor are the outcomes of therapy drawn on a blank sheet of paper. Instead, they are always, in one way or another, related to the persons previous life and thoughts (see Nilsson et al., 2007). There has to be some kind of biographical continuity with the preexistent self-narratives and the narratives people tell as an outcome of psychotherapy (Ku hnlein, 1999). Levy Berg et al. (2008) have reached the same kind of conclusion. In their study, they showed how the preferences of the users of psychotherapy are related to the outcomes and satisfaction with a certain kind of therapy. Moreover, as Westra et al. (2010) have noted, a concordance between client expectations and experiences of therapy is not always needed for a good outcome. In a similar way a change in a persons inner narratives was found to be a satisfying outcome for someone in this study. The present study had a research interest similar to those of Ku hnlein (1999), Nilsson et al. (2007), Westra et al. (2010) and Levy Berg et al. (2008). They all approach the outcomes of psychotherapy from the perspective of the users. The results of these studies confirm the value of this type of approach; people enter psychotherapy with many kinds of expectations and preferences and the outcomes of psychotherapy should be considered in light of these. What is added here in comparison with the studies by Ku hnlein and Nilsson et al. and that of Westra et al. is the use of pre-therapy data. Whereas previous studies approached the participants preferences retrospectively, in our study we considered these preferences before the participants even knew what form of therapy they would receive. Moreover, the present study differs from the study by Levy Berg et al. in that we conducted an intensive case analysis. We did not use any pre-determined measures to assess the outcomes, so it was also possible to find unanticipated outcomes. Also, expectations and preferences were just part of the inner narratives of the person. Thus, in this study, a broader concept has been used to assess the pretherapy orientation. From the perspective of inner narrative, the utility of psychotherapy can be seen to be based on the ability of the therapy (or therapist) to help the person to progress in line with their inner narrative or change it in a way that signifies progress, so that these narratives may help them to live autonomous,

light is seen or they could be passed or something, theres always a way to go on. (Man, 3, after shortterm solution-focused therapy) I have forgiven myself a lot, when it has been found out that kind of reasons [sleeping disorder], because I have blamed myself for many things when I didnt know what it was with me. So that has been . . . kind of answers has been a relief . . . in that therapy (Man, 3, after short-term solution-focused therapy) As in the progressing and stagnated inner narratives above, the interpretation of the changing inner narratives could only be tentative. Many things could have happened in therapy and outside it which may have caused the change. However, it seems to be that sometimes in therapy people learn new concepts and language, which they can use to tell new stories about themselves. For some persons this change is accompanied by a decrease in symptoms, for others the meaning of the symptoms may have changed. Discussion The aim of this study was to examine and interpret the experiences of users of psychotherapy as regards the outcomes of their therapy. From the perspective of the users, the outcomes are perceived as the utility of a particular therapy. Using the concept of inner narrative, we have tried to interpret how these outcomes are linked to the personal contexts of a particular person. The concept of inner narrative has been an analytical tool for understanding the therapy users ways of thinking. This kind of approach to the outcomes of therapy differs from the mainstream research tradition by not fixing beforehand what should be counted as the outcome. This kind of unique outcome cannot be measured. Instead, we have looked carefully on a case-by-case basis with which orientation each participant entered the therapy, and how the narratives they told about themselves unfolded in time. In the sample used in the present study, it seemed that long-term psychodynamic psychotherapy helped people with life historical inner narrative to progress in line with their inner narrative. In the same way, short-term solution-focused therapy supported the progress of situational inner narrative. However, there were also cases in the sample which proved to be exceptions to this generalization. Sometimes a discrepancy between ones orientation and form of therapy made it possible to formulate a new story about ones problems and oneself. For

Outcomes of psychotherapy 239 empowered and meaningful lives. Greenberg et al. (2006) proposed in their review article that reshaping of patients (or clients) expectations (or assumptions) may be seen as a goal of treatment (p. 670). Our findings both support and challenge this proposition. Even though the inner narrative is a broader concept than a pure expectation, it shows that both a reinforcement of persons inner narrative and a reshaping of it may lead to a relief of the problems. In line with the ideas of, for example, Parker (1999) and McLeod (1997), we propose that peoples aims in therapy are diverse. People with a life historical orientation expect that therapy should help them to repair a fragmented or a broken selfnarrative*which is in line with psychodynamic views of therapy. On the other hand, people with a situational story expect that therapy should help them to overcome their present problems, which is the idea behind solution-focused therapy. Finally, people with the moral inner narrative expected therapy to help them to clarify their future perspectives and to join in dignified and desirable cultural narratives. Here we come to Victor Frankls (1978) idea of psychotherapy as an attempt to find meaning for ones life. Neither of the forms of therapy studied here seemed to meet this kind of existential need. Discussion of the Limitations of the Study The study at hand unavoidably has some limitations demanding discussion. The sample size was of course too small for statistically based assertions concerning the associations between inner narrative, form of therapy, and outcome. However, that was not the aim of the study, and on the other hand, the small number of participants has made it possible to analyze the individual cases intensively. One challenge of this study was that because of its pilot study nature it was not possible to use a set of prescribed analytic standards but the solutions had to be made during the course of analysis. This kind of flexibility and creativity can be seen as an integral feature of qualitative research (Kvale, 1996). However, the analysis could have been strengthened by engaging the whole team in the coding process, but that was not possible for practical reasons. For analytical purposes we have bracketed out a big part of the richness of the content of the interviews. The interviewees inner narratives were much more complex than we have been able to describe in this paper. In real life people use their social stock of stories creatively and flexibly. Even though we have assessed what basic story was most evident in the interviews, almost every individual interview included elements of one or both other basic stories. Thus the results above should be read as abstracted interpretations, not as exhaustive descriptions of the individual interviewees. Ideas for Further Research The model of narrative circulation used as the theoretical background of this study allows several further points to be studied. One of them could be to investigate the social stock of narratives on mental health that people use as their resource when making sense of their mental problems. Moreover, intensive case studies could be conducted about the ways in which people enact their mental health-related inner narratives in real life (see Dreier, 2008). It might also be interesting to look at the concrete therapy sessions from the point of view of the inner narratives of the users. Also the therapists narrative understanding of mental health problems and therapy would be an interesting topic, since therapy can be seen as negotiation between the therapist and the therapy user about the nature of the problems and the ways of seeking solutions to them.

Conclusions The main conclusion of this study as regards psychotherapy research is that in assessing the outcomes, the therapy users pre-therapy orientations, preferences and values as well as their own conceptions about the desired outcome should be taken into account. This is often neglected in randomized trials. The concept of inner narrative (Ha nninen, 2004) proved to be useful for the study of the outcomes of psychotherapy. It gave us an individual-focused means to examine these outcomes from the perspective of the users. Interviews from the pre- and posttherapy phase offered an opportunity to study the development of these inner narratives. As regards the development of therapeutic treatment of depression, our conclusion is that sufferers of depression should be seen as active agents in their social and cultural context, who use psychotherapy to help them to form the best possible life narrative for themselves (McLeod, 1997). The criteria for a good narrative are diverse for different persons and contexts (Holma, 1999). Sometimes a user may benefit from a therapy form which does not match their orientation. In the best possible world, however, people would be given a choice of therapy forms together with enough information to choose the form which the individual finds as most suitable for their needs.

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J. Valkonen et al. Acknowledgements

viewpoint (Jyva skyla studies in education, psychology and social research 150). Jyva skyla : University of Jyva skyla . Ha nninen, V. (2004). A model of narrative circulation. Narrative Inquiry, 14(1), 6985. Johnson, L.D., & Miller, S.D. (1994). Modication of depression risk factors: A solution-focused approach. Psychotherapy: Theory, Research, Practice Training, 31, 244253. Kernberg, O. (1984). Severe personal disorders: Psychotherapeutic strategies. New Haven: Yale University Press. Knekt, P., & Lindfors, O. (Eds.). (2004). A randomized trial of the effects of four forms of psychotherapy on depressive and anxiety disorders. Design, methods, and results on the effectiveness of shortterm psychodynamic psychotherapy and solution-focused therapy during a one-year follow-up (Studies in social security and health 77). Helsinki: The Social Insurance Institution, Finland. Knekt, P., Lindfors, O., Ha rka nen, T., Va likoski, M., Virtala, E., Laaksonen, M.A., Marttunen, M., et al. (2008). Randomized trial on the effectiveness of long- and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during a 3-year follow-up. Psychological Medicine, 38, 689703. Ku hnlein, I. (1999). Psychotherapy as a process of transformation: Analysis of post-therapeutic autobiographic narrations. Psychotherapy Research, 9, 274288. Kvale, S. (1996). InterViews. An introduction to qualitative research interviewing. Thousand Oaks: Sage. Levy Berg, A., Sandahl, C., & Clinton, D. (2008). The relationship of treatment preferences and experiences to outcome in general anxiety disorder (GAD). Psychology and Psychotherapy: Theory. Research and Practice, 81, 247259. McLeod, J. (1997). Narrative and psychotherapy. London: Sage. McLeod, J. (2001). Qualitative research in counseling and psychotherapy. London: Sage. McLeod, J., McLeod, J., Shoemark, A., & Cooper, M. (2009, February). User constructed outcomes: Therapy and everyday life. Paper presented at the Psychotherapy Research Conference, University of Jyva skyla , Finland. Miller, R.B. (2004). Facing human suffering: Psychology and psychotherapy as moral engagement. Washington DC: American Psychological Association. Murray, J.L., & Lopez, A.D. (1997). Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet, 349, 14361442. Nilsson, T., Svensson, M., Sandell, R., & Clinton, D. (2007). Patients experiences of change in cognitive-behavioral therapy and psycho-dynamic therapy: A qualitative comparative study. Psychotherapy Research, 17(5), 553566. Parker, I. (1999). Deconstruction and psychotherapy. In I. Parker (Ed.), Deconstructing psychotherapy. London: Sage. Swift, J.K., & Callahan, J.L. (2009). The impact of client treatment preferences on outcome: A meta-analysis. Journal of Clinical Psychology, 65, 368381. Timulak, L. (2009). Meta-analysis of qualitative studies: A tool for reviewing qualitative research ndings in psychotherapy. Psychotherapy Research, 19(45), 591600. Valkonen, J. (2007) Psykoterapia, masennus ja sisa inen tarina (Tutkimuksia 77) [Psychotherapy, depression and inner narrative (Research Reports 77)] (Doctoral dissertation). Helsinki: Rehabilitation Foundation. (Abstract in English.) Wampold, B.E. (2001). The great psychotherapy debate. Models, methods, and ndings. Mahwah: Lawrence Ehrlbaum. Westra, H.A., Aviram, A., Barnes, M., & Angus, L. (2010) Therapy was not what I expected: A preliminary qualitative analysis of concordance between client expectations and experience of cognitive-behavioral therapy. Psychotherapy Research, 2010, 111, iFirst article.

This article is based on the doctoral dissertation of the rst author (Valkonen, 2007). We gratefully acknowledge the nancial support for the study from the Social Insurance Institution, Finland. The article was written as a part of the research project Coping with depression in social context, funded by the Academy of Finland. We thank the participants of the Helsinki Psychotherapy Study, the Study Group and especially the head of the study, Professor Paul Knekt. Warm thanks to Professor John McLeod for his valuable advice. Notes
1

In this section, we use the term patient consistently with the HPS terminology even though the term user of psychotherapy was used elsewhere in this article. Quotations are translated from spoken Finnish by the authors. An effort has been made to capture the rhythm and tone of the original expressions, even though dialect words and unique word order was not always possible to restore. If the quotation is shortened in between, it is marked with three dots in brackets. Added and replaced words are written in square brackets with italics to improve the readability and anonymity of the text. After a quotation the gender and the code number of interviewee is mentioned. All quotations in this section are from pretherapy interviews. The code number of the participant (114), the assessed basic story at pre-therapy phase (LH for life-historical, S for situational and M for moral), the allocated form of therapy (LPP or SFT).

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