Exploring real-world psychotherapy processes and endings : a meta-ethnography and reflexive thematic analysis

Johnson, Liv and Kelly, James and Griffiths, Robert (2025) Exploring real-world psychotherapy processes and endings : a meta-ethnography and reflexive thematic analysis. PhD thesis, Lancaster University.

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Abstract

Much literature explores psychotherapy processes from a theoretical lens or within heavily controlled environments. This thesis deepens understanding by examining the perspectives of those directly involved in psychotherapy - service users and therapists - to provide evidence grounded in real-world experiences. Section One presents a meta-ethnography of first-hand accounts from service users who experienced an ending from individual psychotherapy. Four databases were searched (PsycINFO, MEDLINE, EMBASE, Web of Science), resulting in 16 included papers. Two over-arching themes resulted from the synthesis, each with various sub-themes: Cohesion within the Ending Process, and Personal Agency within the Ending. Service users placed high importance on their perceptions of interactions with their therapists, and the amount of control they felt they had over the ending. Section Two reports a Reflexive Thematic Analysis, exploring what therapists who deliver CBT for depression believe creates change. It aimed to understand how CBT is applied in real-world practice. Twelve participants took part in semi-structured interviews. Three themes were identified: “There’s some real power in that relationship that you’ve got with them”, “They’re buying what you’re selling”, and “Giving them that bit of insight […] ‘What do I need now to help me navigate it a little bit better”. The analysis yielded that therapists actively attempt to facilitate perceptions of themselves for clients as empathetic, honest, and hopeful. It explores how therapists balance CBT fidelity with their own beliefs about how their therapeutic approach creates change and clients’ needs. Section Three provides a critical appraisal which focuses on the process of conducting both the review and research paper. It discusses reflexivity, limitations of the papers, areas for future research, and the impact of my learning on my clinical practice.