Introduction: Building on from the small body of research that has investigated client and therapist experiences of non-improvement in psychological therapy, this study aimed to investigate how client-therapist dyads experience therapy in which the outcome measures suggest no significant change has taken place, and explore the themes that emerge from these accounts regarding the interpersonal process of these therapies.
Method: Three client-therapist dyads from NHS secondary care psychological therapies services who ended therapy with standardised outcome measures in the ‘no reliable change’ range took part in semi-structured interviews about their experiences. Their accounts were transcribed and analysed using Interpretative Phenomenological Analysis (IPA).
Results: The themes of each dyad were presented in detail in the style of a case study series. The overarching theme of dyad 1 was ‘a risk worth taking’, which was comprised of the subthemes ‘feeling safe enough to explore’, ‘beginning to heal the wound’ and ‘being left with conflicting feelings’. The overarching theme of dyad 2 was ‘dipping a toe in the water’, which had the subthemes ‘fragile alliance’, ‘struggling towards collaboration’ and ‘ambivalence at the end’. The overarching theme of dyad 3 was ‘reacting to threat’, which had the subthemes ‘starting with irreconcilable demands’ and ‘pulling away and leaning in’. From the group analysis of the three pairs, the master theme ‘a mixed bag’ was developed, which had the following four subthemes: ‘opening up’, ‘closing off’, ‘growing’ and ‘struggling’.
Discussion: For the participants in this study, experiences fell on a continuum of change and non-improvement, with subjective experiences being more complex and contradictory than the outcome measures suggested. The quality of the therapeutic relationship and engagement in therapy varied across the dyads. The findings are discussed in relation to the existing research on non-improvement and theoretical literature relevant to this subject. The strengths, limitations and clinical implications of the study are considered, along with recommendations for future research.
