Introduction: The efficacy of psychotherapy has been well established. There is growing research focusing on the negative outcomes of psychotherapy, with an estimated 10% of clients who deteriorate as a result of psychotherapy. However, there remains an overlooked population, those who show no response after psychotherapy, which has a widely variable estimated prevalence between 14-56% across the literature. This qualitative evidence synthesis (QES) aimed to synthesise the available evidence exploring client and therapist experiences of psychotherapy non-response.
Method: Seven databases were systematically searched for studies using qualitative data to explore non-response. Twenty-one studies met the inclusion criteria and were analysed using the QES method Thematic Synthesis. This involved three stages of line-by-line coding, descriptive theme development, and generation of analytical themes, to develop a conceptual understanding of psychotherapy non-response from both client and therapist perspectives.
Results: Six overarching client perspective themes and 18 subthemes were identified (1. Hopes and fears, 2. A difficult task, 3. Disconnected relationship, 4. Staying involved, 5. Therapy was not worth the investment, and 6. On a trajectory for improvement). Four overarching therapist perspective themes and 10 subthemes were identified (1. High expectations, 2. Experiencing a disconnect, 3. Feeling threatened, and 4. Holding onto hope). This was synthesised into a proposed model of non-response.
Discussion: A large overlap with the deterioration and harm literature was found. There were varied experiences of non-response which has implications for the use of qualitative outcome measurement. The experience of non-response appears to involve both clients and therapists holding something back from the therapeutic relationship. Importantly, non-response appears not to be an absence of effects, but a range of experiences which can potentially be harmful. Clinical and research implications are discussed.
