Qualitative Research and Single Case Studies from a Psychodynamic Perspective

In the following, we shall briefly present the current state of research on qualitative approaches as well as single case studies in psychotherapy research from a psychodynamic perspective. This will include:

(1)  an overview of methodological standards and research approaches currently employed in qualitative psychodynamic studies as well as in single case research,

(2)  a summary of central topics and findings in qualitative research as well as single case research from a psychodynamic perspective,

(3)  a list of important areas for future research as well as controversial topics in the field.

1. Methodological Standards and Current Research Approaches

Current criteria for evaluating qualitative studies and single case studies

There exist several guidelines with criteria for qualitative research. As these are not specific for a psychodynamic perspective, we list the most recent and widespread ones here:

-       The Publications and Communications Board Task Force of the American Psychological Association (APA) has developed journal article reporting standards (JARS) for qualitative studies (JARS-Qual), qualitative meta-analyses (QMARS), and mixed methods research (MMARS) in psychology (Levitt et al., 2018).

-       The principle of methodological integrity (Levitt et al., 2017) provides a standard to evaluate the rigor of a qualitative study in general, independent of the specific methods and procedures used. Methodological integrity is comprised of two components:

(1) fidelity to the subject matter: adequacy of the data, management of the researcher’s perspective, and groundedness of findings in the data;

(2) utility of research contributions: insightfulness and meaningfulness of results, contextualization of findings, consistency of procedures, and coherent presentation.

-       Levitt and colleagues (2021) have suggested principles to support design and research review of qualitative research in academic journals based on the above standards and guidelines.

Concerning case studies, journals that are specifically psychoanalytic in nature mostly do not have guidelines for the submission of case studies with respect to format. Most of them, however, have ethical guidelines concerning confidentiality (see below). Journals focusing on clinical psychology or psychotherapy more in general sometimes give specifications, yet these are on a general level (e.g., Psychotherapy Research welcomes systematic case studies but does not specify this any further; Psychotherapy welcomes “Evidence-Based Case Studies that integrate verbatim clinical case material with standardized measures of process and outcome evaluated at different times across treatment”). Journals specifically aimed at case study research formulate stricter guidelines on the format of case studies they publish; examples are the Journal of Pragmatic Case Studies and Clinical Case Studies. In addition to journal guidelines, there is some literature discussing case study formats and suggesting case study reporting guidelines as well as evaluation criteria:

• McLeod, J. (2010). Case      study research in counseling and psychotherapy. Sage. This book      discusses different types of case study formats and how to conduct them in      a rigorous way.

• Willemsen, Della Rosa and      Kegerreis (2017) provide a review of clinical case studies on      psychoanalytic and psychodynamic treatments and formulate nine guiding      principles for conducting clinical case studies.

Qualitative research methods which have successfully been used in studies with a psychodynamic perspective

Different qualitative and case-based research approaches can be grouped according to different criteria, including aims of the study (e.g. theory or concept development, generation of hypotheses, outcome research, etc.), data collection methods (e.g., session transcripts, interviews, etc.) data-analysis methods (e.g., consensual qualitative research, thematic analysis, etc.), and perspectives considered (therapist or researcher perspective, first person perspective, etc.). As these different ways of categorizing qualitative studies are not mutually exclusive, we shall here list some typical and successfully used types of research that may cut across these different possible groupings.

The single case study is traditionally the cornerstone of psychoanalysis. There would be no psychoanalysis thinkable without it. Most case studies in the field of psychoanalysis or psychodynamic psychotherapy research are clinical case studies. These do not employ specific research methods to systematically gather or analyze data. They might be considered as a type of (unsystematic) qualitative research as they present a qualitative account of psychodynamic processes and outcomes, typically from the perspective of the therapist.

In systematic single case studies, specific research methods are used systematically to analyze data. Also, researchers other than the therapist are involved in the research process. Using qualitative research methods in the context of case studies does not exclude the use of quantitative measures. Especially in systematic case studies, mixed-method designs have commonly been used. Examples of systematic psychodynamic case studies can for example be found in: Buchholtz, Spiekermann and Kächele (2015); Cornelis and colleagues (2017a, 2017b, 2021); Kächele and colleagues (2006); Schattner, Tishby and Wiseman (2017); Van Nieuwenhove and colleagues (2020).

Finally, experimental case studies are less common yet not absent in the field of psychoanalysis or psychodynamic research. Controlled single case designs (e.g. A-B-A designs), as for example described by Chambles and Hollon (1998), are conceived as a way to demonstrate treatment efficacy in the context of evidence-based medicine. These types of predominantly quantitative research designs are thus to be understood as outcome research. It has to be noted that borders between the above types of case studies are not always clear-cut (Iwakabe, 2009). Case studies can also involve other units of analysis than the individual patient. Barron, Honig and Lebovitz (2023) for example investigate an institution as a case, exploring how a psychoanalytic institute responds to existential threats.

An elaboration of different ways of thinking about psychoanalytic case studies can be found in Kaluzeviciute and Willemsen (2020). Willemsen (2023) gives an overview of the unique contributions case study research can make to evidence-based practice and provides suggestions as to what could be done to increase its impact in the contemporary discourse.

Finding published clinical, systematic, and experimental case studies from different theoretical backgrounds is possible through the online database The Single Case Archive: www.singlecasearchive.com. This freely accessible database inventories case studies published in peer-reviewed journals that can be searched based on different entries (keywords, diagnosis, treatment duration, frequency, outcome, etc.). From about 3,500 cases in the database, >1,500 are from a psychodynamic or psychoanalytic perspective (see Meganck et. al., 2022).

Aside from case studies, another common research approach in the field of psychodynamic psychotherapy is interview-based research. Here data is gathered through interviews with research participants, such as patients (De Smet et al., 2019, 2020a, 2020b), therapists (Goddard, Murray, & Simpson, 2008; Khoshfetrat, Moore, & Kiernan, 2022; Tanner, 2023), clinical supervisors (Sant & Milton, 2023), and others.

Other data sources in qualitative psychotherapy research include session transcripts (Achelson, et. al., 2020; Avdi & Evans, 2020; Chourdaki, et. al., 2023), practitioners’ case notes (Perez, Crick, & Lawrence, 2015), or often also a combination of different types of data.

In the following we list some commonly used data analysis methods, together with exemplar studies with a psychodynamic focus for each method:

• Thematic analysis (TA; Braun & Clarke, 2021;      Terry & Hayfield, 2021); psychodynamic studies using TA: Perez, Crick,      and Lawrence (2015); Cooke, and colleagues (2021); Tanner (2023); De Ganck      and Vanheule (2015).

• Conversation analysis (CA; Hepburn & Potter,      2021; Peräkylä, 2019; Buchholtz, Spiekermann, & Kächele, 2015 for      methodological reflections on how to use CA specifically as part of      psychoanalytic research); psychodynamic studies using CA: Knol and      colleagues (2020); Peräkylä and Bergmann (2020); Madill, Widdicombe, and      Barkham (2001); Franzen and colleagues (2023).

• Consensual qualitative research      (CQR;      Hill & Knox, 2021); psychodynamic studies using CQR:      Knox, Hill, Goldberg and Woodhouse (1999); Coutinho, Ribeiro, Hill and      Safran (2011); Hill and colleagues (2022).

• Interpretative phenomenological      analysis (IPA;      Smith, Flower & Larkin, 2009; Smith & Nizza, 2021); psychodynamic      studies using IPA: Pietkiewicz and Wlodarczyk (2015); Banerjee and Bsu      (2016); Gardner and colleagues (2020); Taels and colleagues (2023).

• Grounded theory methodology (GTM; Charmaz, 2014; Levitt,      2021); psychodynamic studies using GTM: Lilliengren and Werbart (2005);      Stokes and Ross (2020); De Smet and colleagues (2019).

Increasingly, there are also Mixed-Method Studies that combine quantitative and qualitative methodology in fruitful ways: Arias-Pujol and Anguera, 2017; Avdi and Evans, 2020; Ilkmen and Halfon, 2019. Also, different qualitative methods are sometimes combined within the same study (e.g., Gumz & Spranz-Fogasy, 2022).

Discussions of ethical standards in qualitative and single case research

There is a set of moral issues which are either specific to single case research, or particularly pronounced in it (s. McLeod, 2010 for an introductory overview).

Authors discussing the issue of confidentiality and informed consent in the context of case study research are for example Aaron (2008), Goldberg (1997), Mosher and Berman (2015), and Thomas-Antilla (2015). In their qualitative study, Goddard, Murray, and Simpson (2008) also explicitly investigate this topic through a qualitative interview study with psychodynamic therapists.

Psychoanalytic journals and journals for psychotherapy research mostly have specific guidelines with respect to handling confidentiality in case study research or refer to general ethical regulations. Such guidelines can usually be found in the author instructions on the journal website.

Aggregating data and findings from qualitative research and case studies

Different secondary analysis methods have been proposed to integrate findings from multiple qualitative studies or case studies in the field of psychodynamic psychotherapy or psychotherapy in general. Qualitative meta-analysis (Timulak, 2009; Levitt, 2018) – also called ‘metasynthesis’ (Lachal, Revah-Levy, Orri & Moro, 2017) – is an umbrella term for approaches using qualitative data analysis methods to aggregate findings and identify patterns across published qualitative studies in relation to a specific research question (Timulak, 2014). Procedurally, the selection of primary studies commonly has similar criteria as in quantitative meta-analyses or systematic reviews. Following several preparatory steps (including, for example, assessing the original studies’ methodological quality and epistemological attitudes, identifying whether several articles present data from the same empirical study, and breaking up the data into manageable portions), the meta-analytic researchers then develop a new conceptual framework in which to jointly organize and categorize all of the original studies’ findings. Such meta-analytic studies thereby often integrate data from non-psychodynamic and psychodynamic studies alike. The aims of qualitative meta-analysis are 1) to arrive at a global picture of qualitative findings on certain phenomena relevant for a specific overarching research question, and 2) to assess whether different methodological approaches have led researchers to different conclusions about the phenomena in question.

Recent examples of qualitative meta-analyses can be found in:

• Levitt and colleagues (2017) on      clients’ experience in psychotherapy. In this study, the authors argue for the      importance of practitioners being able to draw on the substantial body of      qualitative evidence that exists on clients’ experiences of therapy. They      conduct a multi-method meta-analysis of a total of 109 primary qualitative      studies on different therapeutic orientations published in peer-reviewed      journals. Their results provide a comprehensive account of critical client      experiences across different treatment modalities that allows to formulate      process-focused principles to inform clinical decision making. The core      category that resulted from these analyses was that “Being known and cared      for supports clients’ ability to agentically recognize obstructive      experiential patterns and address unmet vulnerable needs”. A more refined      set of clusters and categories subsumed under this core category provides      detailed insights into crucial therapy processes from clients’      perspectives.

• Ladmanová and colleagues (2022)      on client-identified helpful and hindering events in psychotherapy. For this meta-analysis, the      authors included 17 qualitative studies on significant therapy events as      reported by psychotherapy patients. The resulting conceptual framework      entails 12 meta-categories of helpful events (e.g. feeling heard,      understood, and accepted) and 8 meta-categories of hindering events (e.g.      feeling emotionally overwhelmed).

• Levitt and Morrill (2023) on      forms of silence in psychotherapy. This review is an example of qualitative and      quantitative findings being integrated in meta-analytic research.

A methodological approach to aggregate findings from case studiesis outlined by Krivzov, Hanon and Meganck (2021). Examples of meta-synthesis of psychodynamic or psychoanalytic single case studies can be found in: Willemsen and colleagues (2015) as well as Krivzov and colleagues (2021).

1. Central topics and findings      from qualitative and single case research

Qualitative and single case research in the field of psychoanalysis and psychodynamic psychotherapy focuses on different topics. While these are again not mutually exclusive and it is not possible to be exhaustive, we list some central topics with a number of examples and illustrations.

There are studies that qualitatively investigate outcome. Often these studies do not exclusively focus on psychoanalysis or psychodynamic psychotherapy. Examples of relevant findings from qualitative research on therapy outcome include:

• Binder, Holgersen, and Nielsen      (2010) investigated through interviews what former patients consider a      “good outcome” of psychotherapy. Patients reported seeing symptom      reduction and change in behavioral patterns as well as gaining a better      self-understanding all as necessary parts of “good” outcome. Patients      described that through a deeper insight, they were also able to value      themselves more which in turn led to changes in their behavior and the way      they related to others. The authors concluded from these results that      insight and behavioral change cannot be regarded independently from each      other.

• De Smet and colleagues (2020)      studied patients with good treatment outcome after treatment for major      depression. They identified factors associated with good outcome such as      feeling empowered or finding personal balance. However, patients also reported      on some more pessimistic nuances of outcome such as encountering an      ongoing struggle. The authors emphasize the interconnection of those      factors and the complexity in the patients’ reports.

• Midgley, Target, and Smith      (2006) focused on adult patients who had been in psychoanalysis as      children to investigate how such an early experience of therapy can lead      to changes later in life. The results suggest that in child analysis, the      aspect of being heard and understood by the therapist as well as developing      the capacity to understand and reflect on oneself play important roles in      how the experience of therapy is perceived in the long run. From the      retrospective perspective of the patients, the more important changes were      perceived to be something internal rather than purely behavioral.

Therapy processes (whether or not in combination with outcome) are also a common subject matter of qualitative studies with a psychodynamic perspective. There is a great variety of such approaches. We list some examples on different therapeutic dimensions:

• Studies on the therapeutic      alliance or the transference-countertransference relationship can for      example be found in Van Nieuwenhove, and colleagues (2022) or Cauwe and      Vanheule (2018).

• Experiences of change as well      as helpful and hindering factors are studied for example by De Smet and      colleagues (2020), Liliengren and Werbart, (2005) or Nilssen and      colleagues (2007).

• Qualitative studies on other      specific topics include investigations of therapeutic immediacy (Kuprian      et al., 2022; Mayotte-Blum et al., 2012), or experiences of silence during      treatment sessions (Knol et al., 2020).

There are also qualitative studies investigating the issue of supervision for psychodynamic practitioners. Examples of such studies include:

• Dulsster and colleagues (2021)      investigate supervision from a lacanian perspective. The results highlight      the neutral position adopted by lacanian supervisors, who focus on the      level of language in the therapeutic work rather than on the person of the      supervisee. The participants also report aiming centrally to encourage      their supervisees to develop their own style and technique.

• Koshfetrat, Moore, and Kiernan      (2022) focus on negative experiences in supervision. Here the supervisees      report feelings of frustration and deprivation. In discussing the results,      the authors emphasize the importance of supervisors taking into account      difficult life experiences and other individual vulnerabilities of their      supervisees.

• Sant and Milton (2023) examine      supervisors’ experiences of working with their supervisees’      countertransference. Some of the reports suggest that countertransference      can be experienced as disturbing and that it may have an enduring effect      on therapists. Other participants felt that boundaries had been crossed      when their supervisor tried to address their countertransference. They      reported feeling disempowered by the supervision process.

Examples of studies investigating first-person experiences of different mental health issues are Moernaut and colleagues (2022) on the experience of negative psychotic symptoms, or Taels and colleagues (2023) on experiences of hypersensitivity in autistic individuals.

1. Areas for future research and      controversies in the field

Some areas for future research

• The role of (psychoanalytic)      theory in qualitative research. Methodological elaborations on how to conduct      qualitative research from a theoretical starting point are mostly missing      in the field of psychodynamic and psychoanalytic psychotherapy research.      While there is a lot of theoretical assumptions underlying psychodynamic      practice as well as research, it remains an open question how this can be      accommodated vis-a-vis the predominantly inductive and explorative spirit      prevalent among many qualitative researchers. Articles like the one by      Moernaut (2021) that address the issue of using theory in guiding      qualitative analysis and the work on theory building case studies (e.g.      Stiles, 2010) are good starting points. However, this remains a      controversial and difficult topic that requires work at a methodological      level.

Controversial issues in the field

• The state of clinical      psychoanalytic research (“Junktim research”). In the postscript to The      Question of Lay Analysis, Freud (1927) famously advances a      far-reaching epistemological thesis: he claims that psychoanalytic      research is tied to the clinical practice of psychoanalysis. Freud here      speaks about "an inseparable bond [German: ‘Junktim’] between cure      and research" (p. 256). He goes on to elaborate: "Knowledge      brought therapeutic success. It was impossible to treat a patient without      learning something new; it is impossible to gain fresh insight without      perceiving its beneficent results“ (ibid.). In the wake of Freud, the      tradition of clinical psychoanalytic research (‘Junktim research’) has      evolved in the psychodynamic community. It is still the basis for many      psychoanalytic publications. Within this approach, psychoanalytic      practitioners develop, revise, and compare clinical psychoanalytic      concepts on the basis of their own work with patients. While this paradigm      has been heavily criticized by some, it has also been passionately      defended by others for offering a unique and privileged perspective on      unconscious processes. Altmann de Litvan (ed., 2021) provides a      contemporary collection of writings (with associated commentaries)      representing the full spectrum of contributions to this still-ongoing      discussion.

• Whether qualitative research      can be used to establish causal relationships. Many standard texts on      qualitative research reject the idea that qualitative inquiry is concerned      with causal relations (Maxwell, 2019 for a summary of the discussion).      Maxwell and Levitt (2023) argue, however, that certain ways of doing      qualitative research offer unique advantages for studying causation in      psychotherapeutic processes. Also, Elliott (2002) claims that the Hermeneutic      Single Case Efficacy Design (HSCED) is particularly suited to study      causal mechanisms of change through systematic case studies.