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Outcomes of psychotherapy from the perspective of the users

JUKKA VALKONEN,1 VILMA HANNINEN,1 & OLAVI LINDFORS2

1

University of Eastern Finland, Department of Social Sciences, Kuopio, Finland &2

National Institute for Health andWelfare, Helsinki, Finland

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

AbstractPsychotherapy is widely held to be an effective means to decrease depression. It seems, however, that not everyone benefitsfrom every kind of therapy, and the relevant outcomes vary from person to person. In this article, the pre-therapy views andpost-therapy experiences of 14 users of either long-term psychodynamic psychotherapy or short-term solution-focusedtherapy are analyzed. The interviewees personal views about their depression and therapy are approached with the conceptof inner narrative. Three basic stories or orientations were found: life historical, situational and moral. These offeredpeople different contexts from which to evaluate the outcomes of their therapy. The findings suggest that a personsexpectations, 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 psychologi-

cal 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 pre-

and post-therapy phases, with the standard deviationdescribing 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 interpre-

tation 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

neededbecause whatis seenas anoutcomeis based on

socially constructed knowledge (McLeod, 2001).

There are several perspectives to efficiency*theusers 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-con-

structed 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: [email protected]

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

ISSN 1050-3307 print/ISSN 1468-4381 online # 2011 Society for Psychotherapy Research

DOI: 10.1080/10503307.2010.548346


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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 ad-

dressed the ways in which therapy users construe

the outcomes of the therapy they have received.

Irene Kuhnlein (1999) constructed four ideal typeson how emotional disorders and inpatient psy-

chotherapy (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 sawpsychotherapy as a means to enhance their knowl-

edge and understanding of psychosocial develop-

ment. In a more recent study by Nilsson et al.

(2007), people who had received either cognitive-

behavioral or psychodynamic therapy were inter-

viewed 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 self-

reflective 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, areespecially 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

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-out-

come cases. Instead of measuring preferences by

standardized questionnaires, qualitative methodol-

ogy can be used to give the users of therapy the

unrestricted possibility to discuss their views.

Accordingly, the persons orientation toward psy-chotherapy 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 suitabil-

ity 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 re-

search framework. In the qualitative, narrative ana-

lysis of therapy users pre-therapy orientations andpost-therapy assessments of therapy we aim at

illuminating the process in which the users under-

standing 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 psychother-

apy (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 Hanninen,

2004). The inner narrative is seen as an ongoing

mental process that weaves together a persons past

and anticipated future, taking into account thematerial 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

228 J. Valkonen et al.


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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), short-

term solution-focused therapy, short-term psychody-

namic 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

Pa-

tients were recruited for the HPS from psychiatric

services in the Helsinki region. Eligible patients

were 20 to 45 years of age and had a long-

standing disorder causing work dysfunction (Knekt& Lindfors, 2004).

The present study focused on the recorded inter-

view 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). Thefrequency 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 (102 238 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 interper-

sonal 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

LPPwas23 times a week, theaveragelength was 33.7

months (7291141 days) and the average number of

sessions in these data was 292 (194 378).

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 psy-chotherapy, 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 dis-

continuation 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 solution-

focused therapy and four women and three menreceiving 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 pre-

therapy 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 BDI59 Post-therapy BDI9 Totals

Long-term psychodynamic 2 women 2 women 4 women

psychotherapy 1 men 2 men 3 men

Short-term solution-focused 2 women 2 women 4 women

therapy 1 men 2 men 3 men

Totals 4 women 4 women 8 women

2 men 4 men 6 men

Outcomes of psychotherapy 229


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BDI score was 21 (1234) and after the therapy it

was below 10 for six persons, while eight had a post-

therapy 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 personalityassessment. In this way, the interviews were in-

formed by the psychodynamic theory. The inter-

viewers had former experience in psychiatric

assessments and they all also had experience as

psychotherapists. There were five interviewers alto-

gether 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 impor-

tant for the interviewee. Expectations about psy-

chotherapy and the therapist were also asked about.

The last part of the pre-therapy interview was

diagnostic and structured.

The post-therapy interviews were conductedeither 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 long-

term psychodynamic psychotherapy. The post-ther-

apy interviews were conducted in one session lasting

approximately one and a half hour. The structure of

the post-therapy interview was identical to the pre-

therapy one, with the exclusion of life historical and

referral-related themes and the inclusion of an

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 (single-

spaced Arial 11 font). The files of the transcriptionswere 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 ex-

pectations regarding psychotherapy. Then the con-

tents of these categories were analysed further toreveal 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 partici-

pants of our sample were able to use to configure

their images and expectations concerning psy-

chotherapy.

(2) As the second step of analysis, the meaning of

psychotherapy in the individual inner narratives ofthe 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 partici-

pant was reconstructed on the basis of their use of

these basic stories in their interpretations and

categorized the interviewees according to them.



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(3, 4) Steps 1 and 2 were repeated for the post-

therapy interviews using the coding system devel-

oped for the pre-therapy interviews. The assessment

was made independently of the pre-therapy assess-

ments.

(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, andchanged. In narrative analysis all information avail-

able 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 affilia-

tions 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 partici-

pated 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 theinterview. 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 inter-

views, three ideal types of basic stories were

constructed to illustrate the ways in which people

orientate themselves towards their depression andtheir psychotherapy. These basic stories were con-

structed by combining the views presented by the

interviewees about their reasons for seeking psy-

chotherapy, their views about themselves and their

problems, and their expectations about psychother-

apy. Thus the basic stories can be considered as plots

that linked these themes together. We referred to

these three orientations as life historical, situa-

tional and moral basic stories.

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: Depres-

sion 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 contextwas 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 sum-

mary, thematic analysis was conducted on the pre-

therapy 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 thetemporal and contextual elements are linked to-

gether in each logic. In several pre-therapy inter-

views, 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 partici-

pants saw their depression as connected to events

that had taken place earlier in their life. Certain

experiences or conditions in childhood had dis-

turbed their development or had otherwise contin-ued 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

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 anexplanation 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



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in the persons life story. From this perspective,

psychotherapy helps the person to find an explana-

tion 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 thesebouts 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 any-

thing else. (Man, 2)

The ideas presented above can be summarized as

the following basic story:

Im seeking psychotherapy because I want to clear upthe 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 adifficulty 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

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 thatsituation . . . (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 psychother-

apy is summarized in the following basic story:

Im seeking psychotherapy because of the problems in

my present life situation. They are connected to myrelationships 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



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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 depres-

sion 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 tobe 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 actedsomehow, 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 don t

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 don t

find myself as an active agent in life and Im notcompetent 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 cultu-

rally 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 con-

trol 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



8/15

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 indivi-

dual interviewees. We assessed first case by case how

the basic stories seemed to be present in the innernarratives 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 con-

tinuation of inner narratives, in other words, what

kinds of endings could be found in the post-therapy

interviews. So, after the assessment of the pre-

therapy 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 intervieweesexpressions. That is, we read the post-therapy inter-

views 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 post-

therapy 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,

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 inter-

pretation of themselves and their problems as well as

a new reference point from which to assess psy-

chotherapy.

Table II tells how the participants course of inner

narrative was related to the pre-therapy inner narra-tive 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 psychody-

namic 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 pre-therapy 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 solution-

focused therapy. There was only one case in which

the inner narrative changed in spite of the congru-ence between the pre-therapy orientation and ther-

apy 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 progres-

sive, stagnant and changing inner narratives using

three vignettes based on individual cases from the

sample. Let us call the protagonists of the vignettes

Table II. The course of the inner narrative of the participants by pre-therapy inner narrative and therapy form (number of cases)

Life

historical Situational Moral Totals

Long-term psychodynamic psychotherapy

Progressing 2 2

Changing 1 1 1 3

Stagnant 2 2

Short-term solution-focused therapy

Progressing 2 2

Changing 1 1

Stagnant 1 3 4

Totals 5 5 4 14



9/15

by the pseudonyms Ella, Mira and Sari. Three

women were selected because they were the clearest

examples of each basic story.

Progressing Inner Narrative

Example: Ella (7, LH, LPP3). Ella is a single,

employed woman in her thirties. She had sought

psychotherapy because of depression. At the pre-

therapy 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 child-

hood . . . I feel that therapy has helped. (Post-

therapy 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 hascome more forward. (Post-therapy interview)

[Psychotherapy] has brought such a new perspec-

tive to almost everything, one is seeing things

more realistically than before. (Post-therapy inter-

view)

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

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 under-

standing 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 re-

ceived (see Table I).

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 experi-ences 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 resource-

oriented 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 un-

changed as well as her sense of her problems.



10/15

. . . 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 anattitude 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 someexperience 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 . . . (Post-

therapy 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 Ihave gone to psychodrama and those, so I know

that they are in a way much more touching.

(Post-therapy inter view)

In our interpretation, Miras vignette is an exam-

ple 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 solution-

focused therapy had not met her expectations.Because short-term therapy did not demand signifi-

cant 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 solu-

tion-focused therapy.

Also, some participants with a situational inner

narrative who were allocated to long-term psycho-

dynamic 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 thatpsychotherapy and the therapist were giving valuable

support in a difficult situation, they felt that solu-

tions 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 (. . .

) thenthere 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 psycho-

dynamic psychotherapy)

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 narrativeduring 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 ex-

pected, and that was her reason to seek psychother-

apy. 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 thatit 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)



11/15

Contrary to her wish, Sari was allocated to long-

term psychodynamic psychotherapy. Her experi-

ences 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 shouldI 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 psy-

chotherapy. 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 tosurrender 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 child-

hood 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. (Post-

therapy 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 bymyself, 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 psychody-

namic 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 symptomsof

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 psychody-

namic 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 kindof 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 im-

portant to work with the uppermost thing in one s

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



12/15

light is seen or they could be passed or something,

theres always a way to go on. (Man, 3, after short-

term 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 solu-tion-focused therapy)

As in the progressing and stagnated inner narra-

tives 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 therapyusers 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 sup-

ported 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

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 them-

selves 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 andthoughts (see Nilsson et al., 2007). There has to be

some kind of biographical continuity with the pre-

existent self-narratives and the narratives people tell

as an outcome of psychotherapy (Kuhnlein, 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 wasfound to be a satisfying outcome for someone in

this study.

The present study had a research interest similar

to those of Kuhnlein (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 out-

comes of psychotherapy should be considered in

light of these. What is added here in comparison

with the studies by Kuhnlein and Nilsson et al. and

that of Westra et al. is the use of pre-therapy data.

Whereas previous studies approached the partici-

pants 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 pre-

therapy 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,



13/15

empowered and meaningful lives. Greenberg et al.

(2006) proposed in their review article that reshap-

ing of patients (or clients) expectations (or assump-

tions) may be seen as a goal of treatment (p. 670).

Our findings both support and challenge this pro-

position. 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 theproblems.

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 self-

narrative*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 perspec-tives 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). How-

ever, 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 severalfurther 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 ther-

apy would be an interesting topic, since therapy can

be seen as negotiation between the therapist and thetherapy 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 orienta-

tions, 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 (Hanninen, 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 perspec-

tive of the users. Interviews from the pre- and post-

therapy phase offered an opportunity to study the

development of these inner narratives.

As regards the development of therapeutic treat-

ment 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 agood 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, how-

ever, 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.



14/15

Acknowledgements

This article is based on the doctoral dissertation of

the first author (Valkonen, 2007). We gratefully

acknowledge the financial 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 partici-

pants of the Helsinki Psychotherapy Study, theStudy 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.2 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 inter-

viewee is mentioned. All quotations in this section are from pre-

therapy interviews.3 The code number of the participant (114), the assessed basic

story at pre-therapy phase (LH for life-historical, S for situa-

tional and M for moral), the allocated form of therapy (LPP or

SFT).

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