Journal of Systemic Therapies, Vol. 29, No. 3, 2010, pp.

2343

FOCUSING ON THERAPISTS IN CO-RESEARCH INTERVIEWS: HOW DO THERAPISTS SEE COUPLE THERAPY?

EIJA-LIISA RAUTIAINEN Kuopio University Hospital JAAKKO SEIKKULA University of Jyvskyl

This study aimed at a collaborative evaluation of therapeutic processes, through interviews in which both therapists and clients were present. The co-research interviews (Andersen, 1997) were conducted with 28 therapists and their clients after termination of dialogically-focused couple therapy in the context of psychiatric outpatient care. The clients, who had been diagnosed as depressed, attended the interviews together with their spouses. Grounded Theory methodology was used. This paper presents (1) the questions that the therapists wished the interviewer to ask the clients, (2) the therapists ideas of what the clients might have appreciated in their way of working, (3) difficult moments for the therapists during therapy, and (4) what the therapists thought they had learned from their clients. In addition, a case example is presented. It was found that the therapists oriented themselves to couple therapy for depression in a collaborative way, and that they emphasized the importance of the initial stages of the therapy. Co-research practices can help therapists to learn from their clients and to evaluate therapeutic processes collaboratively.

During the last decade the mutual nature of the therapeutic relationship has become a central issue in psychotherapy research. The therapist effect has been discussed in relation to various forms of psychotherapy (Daniel & McLeod, 2006; Blow, Sprenkle, & Davis, 2007; Jensen, 2008). From a collaborative and dialogical

Eija-Liisa Rautiainen, Lic. A. (Psychology), clinical psychologist and family therapy trainer and supervisor, Department of Psychiatry, Kuopio University Hospital and Jaakko Seikkula, PhD, family therapy trainer and supervisor, Professor of Psychotherapy, Department of Psychology, University of Jyvskyl, Finland. Correspondence concerning this article should be addressed to Eija-Liisa Rautiainen, Department of Psychiatry, Kuopio University Hospital, P.O. Box 1777, FIN-70211, Kuopio, Finland. E-mail: eijaliisa.rautiainen@kuh.fi.

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point of view (Anderson, 1997; Seikkula et al., 1995; Seikkula, 2008) psychotherapy has been seen as a meeting of living persons at the present moment, not as a manualized, controlled activity guided by the therapist. Each meeting between therapists and clients is unique, and it is clients who know best what is useful for them. Therapists can learn from their clients. In dialogical approaches, clients are no longer seen as targets for therapeutic interventions, the focus having shifted towards seeing ourselves, the therapists, as comprehensive human beings who are participants in a mutual collaborative process (Buber, 1923/2004; Bakhtin, 1986; Seikkula & Trimble, 2005). Therapists and clients tend to have different perceptions of the therapeutic relationship. Since the clients evaluations have greater relevance to the outcome of the therapy, it is important for the therapists to monitor and listen to clients perceptions concerning the therapeutic process and the prevailing atmosphere. Therapists need to adjust their work according to the needs of the clients (Bachelor & Horvath, 1999). The task for therapists is to become attuned to clients needs and to their ways of benefiting from therapy, and to find ways of being useful to them. As Bachelor and Horvath (1999, p. 146) have observed: To develop an effective therapeutic relationship, sensitivity to clients differential phenomenological worlds as well as to relational needs and expectations seems important. Daniel and McLeod (2006) interviewed six person-centered therapists to investigate how they evaluated their everyday work, and how they made sense of the outcome. They found that therapists engaged in a process of evaluation in which they weighed up evidence from a range of sources. The therapists used four types of information: client satisfaction, evidence of change, the counseling relationship, and personal satisfaction with the work. Evaluation was a continuous activity and one that was embedded in the counseling process itself. The therapists strongly emphasized their perceptions of how the clients interacted with them; the evaluation was in this sense relational. Taking into account the collaborative nature of psychotherapy, it is important to develop new ways for therapists to learn from their clients and involve clients more in the evaluation of the therapeutic processes. In a recent paper Stath and colleagues (2009) point out that the literature concerning the training of psychotherapists has concentrated on helping skills training and supervision. Less attention has been paid to learning from clients, even though therapists are often well aware of how much clients can teach them. Stath and colleagues (2009) studied twelve students of psychotherapy and asked them what they had learned from their clients. One of the participants said: I think its sad that clients dont know how much we learn from them . . . I think some clients need to think that we know everything. But to the clients who dont have that need, I think it would mean a lot to them . . . I wonder if theres some way to talk about it that is helpful . . . I think a lot of clients would like to know they had an impact on us. (p. 388). How can therapists learn the therapeutic skills mentioned above? How can the relational nature of a persons knowledge of therapeutic processes be taken into

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account? How can the evaluation of therapeutic processes be conducted in collaborative way, paying attention to local knowledge and giving consideration to both the therapists and the clients perspectives? Andersen (1997) developed the co-research interview technique, in which clients and therapists are interviewed in the presence of each other by an outsider consultant. This method was used in Sweden and Norway by teams seeking to develop their work (Wchter, 2006). The interviews were conducted after termination of therapies, enabling the participants to take an overview of the whole therapeutic process. By separating the positions of listening and talking, such an interview provides the opportunity for the participant to engage in reflective processes, and the chance to collaboratively evaluate the therapeutic process they have participated in. This kind of an interview has many levels. For the therapists, first of all, the questions in the interview invite them to reflect on their own work with the family in question. Secondly, the questions are asked while the clients are present, listening to the therapists answersa feature which gives a unique character to the talking that takes place. Thirdly, later in the interview the therapists get a chance to listen to their clients, while the clients talk with the outsider about their experiences. It is this aspect that allows therapists to learn from their clients. For the clients, there are similarly three levels. They first listen to their therapists talk with an outsider about their experiences of the therapeutic work. Later, they themselves talk, in the presence of their therapists, about their own experiences. This makes it possible for the clients to reflect on their own experience and learn from it, to provide feedback from their experiences of therapy, and to hear what their therapists have learned from them. Wchter and his colleagues (2006) conducted nine co-research interviews in a child guidance clinic. They categorized the questions that the therapists asked their clients, first of all according to the type of the question, following Bubers (1923) distinction between IThou and IIt relations (i.e., questions from the inside and questions from the outside). The second type of categorization was according to the type of possible answer (general or specific). On the basis of this categorizing method they arrived at four types of therapists questions: (1) from inside and general, (2) from inside and specific, (3) from outside and general, and (4) from outside and specific. The answers the clients gave in their co-research interviews included themes of being listened to, trust, and finding words for difficult things. The present study forms part of a research project called Dialogical and Narrative Processes in Couple Therapy for Depression (DINADEP). The study reported in this paper involved collaboration between the Department of Psychology in the University of Jyvskyl, Finland, and the Department of Psychiatry in the University of Kuopio, Finland, with the involvement also of three centers in different parts of Finland, namely the hospital districts of Northern Savo, Western Lapland, and Helsinki and Uusimaa. The aim of the broader project has been to develop couple therapy with depressed people and their spouses within mental health services. Since depression affects and is affected by the close relationships between the depressed

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person and others, couple therapy methods have been developed to help families with depression (e.g., Kung, 2000; Gupta, Coyne, & Beach, 2003). Yet despite the large number of trained family therapists working in the field of mental health in Finland, surprisingly often the spouses and families of depressed persons are not included in the treatment. A question arising from clinical practice is, therefore: How can we include the spouse of the depressed person within the therapeutic process, during mental health outpatient care? Aims of the Current Study The present study, which forms part of the larger study, sought to involve family therapists in developing their work with clients with depression and with clients spouses. It aimed to explore ways in which therapists could learn from their clients, and also ways of bringing psychotherapy research closer to practitioners. Our research questions were as follows: (1) What did the therapists wish the interviewers to ask their clients in order to learn from them? (2) What did the therapists think their clients appreciated in their way of working? (3) Were there any notably difficult moments for the therapists? (4) What did the therapists learn from their clients? It is important to note that in the interview, the therapists and the clients spoke separately to the interviewer. This feature has made it appropriate to report on the two parts of the interviews separately, with the overall intention of obtaining the kind of overview that would enable therapists to develop their work. In a previous paper (Rautiainen & Seikkula, 2009) we examined the views of the clients, while here we consider the views of the therapists. Nevertheless, the collaborative nature of the interviews should always be borne in mind: the answers of the therapists were given in the presence of the clients, and were commented upon by the clients later in the interview. A case example is presented at the beginning of the Results section in order to give the reader a picture of how this kind of collaborative interview proceeds.

METHOD Participants In the broader research project mentioned earlier (DINADEP), clients had been referred to mental health outpatient care because of depression. The diagnosis of depression was arrived at using the Structured Interview for DSM Disorders (SCID) instrument (Spitzer, Williams, Gibbon, & First, 1992). The diagnosis values on the instrument were 296.2 and 296.3 (DSM-IV). In addition, the Beck Depression Inventory (BDI) (Beck, Ward, Mendelssohn, & Erbaugh, 1961) and the Hamilton Depression Rating Scale (HDRS) (Hamilton, 1967) were used to evaluate clients depression. The inclusion criterion for the broader study was more than 13 points in the HDRS. Clients were randomly assigned to a research group and a control group. The clients in the research group participated in couple therapy, which meant

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that their spouses were invited to participate in the therapy, whereas the clients in the control group were offered treatment on an individual basis, without the involvement of the spouse. Having marital problems was not an inclusion criterion for couple therapy. The couple therapies in the overall project can be labeled as systemic couple therapy, with a special focus on dialogues and narratives (Rautiainen & Seikkula, 2009). The couple therapies lasted for as long as was considered necessary. A minimum of five sessions was set, with no maximum number determined. The average number of sessions was nine, ranging from five to 33. Antidepressant medication was used, if it was considered necessary. The clients gave their informed consent to participation in the study. The Ethics Committees for Human Research in all three hospital districts granted permission for the material to be gathered and used in the present study. For the present study, a total of 25 interviews with clients from the broader research group were conducted, using the co-research interview method, i.e., with the family therapists being interviewed along with the couple in question (Andersen, 1997). In all, 28 different family therapists took part in the interviews. They had always worked with the couples as a team of two therapists. All except one of the therapists had at least three years of training in family therapy, validated by the National Authority for Medicolegal Affairs. The average age of the therapists was 51, ranging from 35 to 63, and they had on average 10 years of experience in family therapeutic work, ranging from 3 to 30 years. The original professional training of the therapists was either as a psychologist (8 therapists), a psychiatric nurse (17 therapists), or as a social worker (two therapists). All the therapists were Caucasian. Eighteen of them were women and 10 of them men. The therapists were recruited from the three centers that were involved in the study. Within the centers, one family therapist worked as a contact person. He or she recruited the family therapists in the center. The first author of the present paper acted as a contact person in one of the centers. As part of her daily duties she also worked as a therapist in two out of the 25 cases. The second author was the leader of the overall research project, and he met the therapists in regular research meetings. The number of the interviews per therapist ranged from one to five, according to the number of couples they had worked with in the project. Most of the therapists took part in one interview. Usually, the two therapists who had conducted the original therapy were both present, but in two cases only one of them could be present. In most of the cases, both of the spouses and both of the therapists were present. In the cases where there were fewer than four participants the interview procedure followed a course similar to the other cases. Procedure The co-research interviews were conducted three months after the termination of the couple therapy. The first author conducted the interviews, except in two cases

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out of 25 cases in which the second author was the interviewer. In these two cases she herself had worked as one of the two therapists. In this way the first author gained experience, in addition to her earlier clinical experience, of the therapeutic work done with the couples in this project. In addition, this allowed both authors to gain an insider view on the interviews. Nevertheless, in the majority of cases the first author took on the role of interviewer. The research methodology and the memos written during the entire research project helped the first author to analyze all the interviews in a similar way. The interviews, which were semi-structured, lasted from 1 to 1.5 hours. All the participants sat together in the same room. The interviews had four parts. In the first part the interviewer introduced the interview to the participants. She told them that the goal of the interview was to gather information on couple therapy for depression, with a view to developing family therapeutic work on depression, and she made it clear that all kinds of experiences were welcome. She also explained the structure of the interview: in the second part of the interview she would converse with the therapists while the clients listened; then in the third part of the interview she would converse with the clients while the therapists listened. Finally, in the last part of the interview she would converse with all the participants. If, during the interview, the participants began to talk to each other (clients to therapists or vice-versa) the interviewer would remind them of the structure of the interview. The therapists were first asked about the questions that they would like to be asked in relation to their collaboration with the couple in question. What would they wish the interviewer to ask the clients during the present interview? Then there were questions about the things that (in the therapists view) the couple might have appreciated in the work the therapists had carried out, about difficult moments during the therapy (i.e., difficult for the therapists), and about how the therapists had overcome those difficulties. There were also questions about matters that were possibly left unspoken during the therapy, about the collaboration between the therapists (bearing in mind that there had been a team of two co-therapists), and about changes that had taken place in the couples situation. This part of the interview usually lasted somewhat less than a half an hour; during this time the clients sat silently and listened to the talk between the interviewer and the therapists. After the interview with the therapists, the clients were first asked to comment freely on what they had thought while listening to the answers given by the therapists. They were then asked about topics that the therapists had mentioned. After going through these themes, the clients were also asked to raise topics that they themselves found important. The themes of what was useful and how it was useful, and also what was not useful, were always talked about. The same applied to the question of change: clients were always asked what had changed, and how it had changed. In the last part of the interview all the participants talked together, with the possibility of commenting on the whole interview. The interviews were videotaped and transcribed. After the interview the therapists were invited to reflect on the

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interview by writing down answers to two questions: What did you learn from the experience of being interviewed? What did you think about the interview method? This was done in order to strengthen the learning process. Answers to the question concerning learning were used in the analysis (see below) and were combined with the answers the therapists gave in relation to this theme during the interviews. The interview guide can be found in our previous paper (Rautiainen & Seikkula, 2009). Analysis Grounded Theory methodology (Strauss & Corbin, 1998) was used in the analysis of the co-research interviews. We chose a method that was strongly grounded in the data because of the novelty of the interview method. In fact, pre-existing information on this kind of interview was not available. The analysis that we conducted can be regarded as a modified GT analysis. The structure of the interview directed the analysis more than would be typical in classical GT. The research questions were formulated according to the interview guide, and the answers given to each research question formed the categories. It should be noted that since the interviews were semi-structured, the answers given to the research questions could emerge in different parts of the interview. The interview data guided the analysis as much as possible; no pre-existing theoretical model was used in the analysis. The categorization was conducted using constant comparison and open coding. During the analysis, memos were written in order to record ideas as they developed, and to keep track of the decisions that were made. An Atlas-ti program was used. Credibility Checks At the end of each interview the participants were always questioned concerning their experiences and their thoughts about being interviewed. This was intended to give them the opportunity to reflect, and to talk about things that the interviewer might not have asked. In general, the participants had experienced the interviews as interesting and positive. They did not report that there had been problems in expressing their ideas during the interview. The analysis was conducted by the first author. The second author independently categorized eight randomly selected cases. The latter categories were mostly found to fit well with the categories of the first author. Out of 102 meaning units the authors disagreed in the naming of 12 units. In these cases a consensus was arrived at concerning the analysis. The results of the analysis were later introduced to the therapists who had taken part in the research project, in the course of seminars held on a regular basis during the research project. The therapists found the results credible and interesting, and in accordance with their experiences. In two phases of the analyzing process the categories were presented to an outsider group of fellow Ph.D. students, in the course of research workshops connected with a doctoral program for psychotherapy research.

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The Researchers Both authors of the present paper are clinical psychologists, and family therapists at the advanced specialist level. The primary researcher has worked for fifteen years in a mental health outpatient setting, mostly with depressed patients. She is interested in dialogical and collaborative ways of working with couples. The co-author has had about thirty years of experience of family therapy (for severe psychiatric problems such as psychosis and depression), and of developing dialogical therapies.

RESULTS A Case Example In order to give the reader a picture of the collaborative interview, a case example of one interview is presented here, followed by presentation of the results of the Grounded Theory analysis. Saija and Matti, a young couple of 22 and 23 years of age, and their therapists Tiina and Mikko, came to the co-research interview three months after the therapy had ended. They had gone through seven therapy sessions. In the interview the therapists were interested in hearing how the couple therapy process had been for Saija and Matti; the focus was on what had proved to be important, and what might not have been so necessary or important. Tiina commented that without the research project they might not have invited Matti to join Saijas therapy. She also mentioned that the couple had said, at the end of the couple therapy, that they thought they would have divorced without the therapyin other words, coming to therapy together had been very important for them. Tiina thought that helping Saija and Matti to listen to each other could have been something that the couple might have appreciated in their way of working. Giving Matti information about depression might also have been appreciated by the couple. Mikko thought that giving the couple space to talk in many different ways, and having reflective talks between the therapists, might have been aspects that Saija and Matti valued. Tiina wondered if Saija had enough time and space to talk about her own symptoms or difficulties in the couple therapy setting. After all, Saijas depression was the reason for the therapy to take place. Mikko wondered if the spouses had enough possibilities to talk about their emotions. As a difficult moment for them as therapists, Tiina and Mikko mentioned situations when Saija and Matti had seemed to be stuck in their relationship, and when the therapists were unsure about how their relationship would continue in the future. Tiina and Mikko also talked about their feelings of not knowing how to proceed in the therapy. Answering the question of what they had learned from Saija and Matti, Mikko spoke about the aspect of hope. Because it had been possible to move forward in

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this therapy, it gave hope to him as a therapist dealing with other clients in similar situations. Tiina emphasized the importance of inviting the spouse to join the treatment for depression. This was not new to her, but working with this particular couple had reminded her of how important it was. Saija and Matti, having listened to their therapists interview first, commented that everything sounded very familiar to them. They also said that couple therapy had been very useful for them. Matti commented that it had previously been difficult for them to begin to talk to each other, since they usually got into a fight. When they were in neutral territory (i.e., the therapy) they started to be able to talk to each other in a calmer way. The topic of beginning the therapy and coming together as a couple was discussed. Saija had been worried about whether Matti would be willing to come or not. Their relationship had been difficult for both of them, and they had both thought that they had nothing to lose, that they might as well begin the couple therapy. Both of them also commented that they were happy that they came. For them the couple therapy had been a good choice. They thought that for others it might be useful to combine individual sessions with couple sessions. Saija was planning to begin her own individual therapy in the future. The couple had found that the way the therapists had helped them to start talking was useful. The therapists did this by first listening to the spouses talking and then starting to ask questions that helped the spouses to talk to each other. For Saija it was easier to talk in the session than at home; she felt that she was in some respects different in the sessions. According to Saija the therapists had been able, through the questions, to guide them into areas they themselves had not thought of approaching. Furthermore (Saija commented), when the therapists talked to each other, the couple had to sit back and think. Saija felt that in those moments she felt obliged to listen to Mattis point of view in a different way. The fact that they sat facing the therapists had also helped them to listen to one another better. One further important thing for Saija was that their relationship was taken seriously by the therapists. They were both young, and this was the first time they had sought help together. Coming to couple therapy had given them fighting spirit, the will to try to continue the relationship, even in difficult times. Tiina had raised the question of whether Saija had had enough time and space to talk about her problems and symptoms. Saija felt that there was a good balance in the talking. There were times in the couple therapy when she did most of the talking, while Matti listened and commented. In addition, now after couple therapy, she was planning to go to individual therapy, since there were still some themes that she felt needed to be talked about in greater depth. From Saijas point of view it was good that they had first dealt with the problems in the relationship. Another way could have been to have the individual therapy going on at the same time as the couple therapy. Matti pointed out that when the couple relationship works better it gives hope for depression too. Saija agreed, and spoke about the feelings of guilt she had had because of her depression, knowing that Matti had had to suffer for that too.

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How did couple therapy change the couple? Matti said that the atmosphere at home was now freer, with both spouses having more space. Saija commented that they now tried to speak about difficult issues; they also met more friends, and Matti was more relaxed and less affected by her depression than he had been earlier. She added that they had learned in the sessions that they (herself and Matti) actually thought and felt quite differentlyand that it was still possible for them to find common ground. Saija said she talked a lot, but seldom about her own stuff. After going to couple therapy she had begun to talk more about these personal matters at home too, and not only in therapy. Another change that happened in the therapy was that previously Matti had gotten worried when Saija was silent at home, and had tried to make her say what the problem was. As a result, Saija had become more anxious and even less able to talk. Now, after therapy, Matti had begun to give Saija space, no longer asking right away what the problem was. In this way Saija herself had been able to start talking. How could this couple therapeutic work be developed? Both Matti and Saija felt that including the spouse in the treatment of depression is important, and that in addition, the children in families need to be taken into account. Matti thought that the therapists could help by talking with the depressed person and explaining why it is important that the spouse of the depressed person should join the treatment. In this way it would be easier for the couple to come together. The interview ended with a short talk together. Tiina and Mikko commented that it was interesting to hear that the couple actually used many of the tools they had received from the therapy and that they seemed to be doing quite well. The spouses gave some details about their life, about their hobbies, and their plans for the future. Results of the Grounded Theory Analysis The categories will be presented with extracts from the participants answers. The categories are also presented in Table 1. The analysis was conducted in Finnish and only the extracts presented in this paper were translated into English. The therapists were numbered according to the case they had worked in; for example Th14 can mean either of the two therapists working with case number 14. This was done in order to protect the privacy of the therapists, since in this way the therapists are not directly identifiable from the text. In the extracts below, upper-case H means the husband with the depression diagnosis, upper-case W the wife with the depression diagnosis, and lower-case h and w the non-diagnosed spouses. What did the therapists wish their clients to be asked, in order to learn from them? The therapists were first asked about the questions they would want the interviewer to ask the clients. The goal for these questions was defined by the interviewer as learning from the clients. The therapists raised 143 questions; these were taken as forming meaning units. The first category (29 questions) included questions about

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the therapists actions. The therapists wanted to know if they could have done something other than they did in order to help the clients better, or if they should have done some things in a different way; also how the clients had experienced their way of working.
I would like to hear . . . because somehow it felt like we . . . were barely able to begin . . . or I dont know if we were even able to begin at all . . . I myself have some ideas about the things that affected that . . . why it went in such a way that really we were not able to actually begin to work together . . . but I would very much like to hear what they thought about this . . . whether we could have done something differently. (T24) I dont know if we could have encouraged them to talk more with each other in the sessions . . . [the talking] took place quite a lot in relation to us . . . I dont know if that could have had an effect. (T15) In other ways too . . . our way of working . . . like how . . . I mean our questions and listening and being there . . . (T18)

In the second category (25 questions) the therapists asked about clients experiences of the therapy. The therapists wanted to know whether the clients had felt free to talk and whether they had felt listened to. Other questions in this category dealt with the clients experience of the therapy as a whole.
And umm . . . whether they were able to talk . . . in these sessions . . . about things that they wanted to talk about. (T15) And then of course it would be kind of interesting to hear in general about the overall experience . . . it was like, almost a year that we were together . . . how it was in general. (T10)

Some of the questions dealt with collaboration between themselves and the clients (23 questions). The therapists wanted to know how the couples had felt about the termination of therapy, whether they would have wanted the therapists to invite other members of the families to participate in the sessions, and whether the timing of the sessions had been suitable for the couple.
Well maybe one thing . . . we . . . I dont know why but . . . I have thought about it afterwards . . . our collaboration ended . . . so what it was that affected that aspect . . . that they thought that it was a good time to end . . . for example I mentioned that my co-therapist changed to a different job and I had a new co-therapist and there must have been many . . . whether there were many kinds of things [that played a part]. (T28) At some stage . . . I was thinking . . . because the children . . . their adult children had an important role in their lives . . . whether umm . . . we should also have invited the children to a session. (T23)

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In the fourth category (17 questions) there were questions about factors that were found helpful. The therapists wanted to hear whether the couple therapy had been helpful, andif it had been helpfulin what ways it had been helpful.
How did they feel about coming to couple therapy . . . was it helpful for them . . . and if it was helpful, how was it helpful? (T8) But that is the question that Im very interested in . . . to hear from them whether these sessions were at all helpful for them or whether they were more difficult. (T11)

The fifth category (16 questions) included questions about the suitability of the approach for the clients. The therapists wanted to know if couple therapy had been a good choice for the treatment and if the spouses would have liked to have individual treatment.
Is this a good way to work with depression, to have the spouse there too . . . how is it? Its of course terribly difficult to compare, since they dont have previous experience of individual treatment, but like somehow, an overview of how it felt to share everything. (T6) Well I guess the question is, if H had come alone to the treatment, would things be different now? (T4)

In the sixth category (15 questions) there were questions concerning themes that had been talked about in the sessions.
Umm whether we . . . spoke clearly enough about things and . . . whether we talked enough about the things . . . that they brought up . . . whether we didnt ignore those themes. (T7). I have begun to think about this . . . when the reason for beginning the therapy was Ws depression and then they were assigned to a couple therapy group . . . and kind of . . . their relationship and difficulties in talking within the relationship and these things . . . they were strongly present in our discussions . . . so like, I have began to wonder . . . how much we actually talked about depression in these sessions and about the kind of effect the depression had on their relationship. (T10)

Finally there were five questions concerning the change that had happened in couple therapy, five questions concerning the couples current life situation, and seven questions concerning various topics (e.g., divorce). What did the therapists think their clients appreciated in their way of working? The therapists were asked what the clients might have appreciated in the way they had worked with the couple. There were 85 meaning units. Most of them (62) had to do with the therapists actions. The therapists named the following as things that their clients might have appreciated: they listened, spoke about the clients

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everyday life, were active, spoke in a reflective way, were flexible, worked well as a team, didnt teach or say how the clients should live their lives, tried to look at things from many viewpoints, listened to both spouses in an even-handed way, and were able to continue conversations in difficult situations. Some examples of these meaning units are as follows:
I also think that we . . . gave them space to talk . . . we were not too eager to ask questions . . . I think that maybe they appreciated the fact . . . that we listened. (T15) Well . . . I think it might have had something to do with . . . or I could imagine that . . . that we were not so airy-fairy . . . we were to quite a large extent . . . keeping our feet on the ground and speaking about everyday life and . . . (T13) And then there was also this aspect that we also said . . . or thats how I remember it at least . . . that we also gave our own opinions about things, like, we didnt just sit there listening and then saying hmm-hmm . . . (laughing) (T9) For some reason I began to think about some kind of clich . . . some kind of openness . . . I mean we didnt have any particular rule or format . . . instead we listened to what the situation was like and [considered] what we should speak about . . . how we should proceed. (T14)

The second category (23 meaning units) dealt with the therapists way of relating to the clients. The therapists described the atmosphere in the sessions as relaxed, informal, trusting, and safe. They also spoke about being present, respecting, and wanting to help the clients.
We have worked quite a lot together as a team and I suppose weve gotten used to working together, and then on the other hand, with W and h it was somehow easy to create such an atmosphere . . . somehow a kind of honest and relaxed atmosphere. (T6) Well . . . I hope we have been able to . . . somehow relate to them in a respectful way . . . and [to show] somehow a kind of respect to them as young people who have come into this process so honestly and openly. (T22)

The third category (16 meaning units) had to do with arranging the space and the time for speaking. The therapists indicated that giving space for both spouses to talk, so that there was no need to hurry, and enhancing the talking could have been aspects that their clients appreciated.
Well at least we gave them the opportunity to speak about their relationship . . . a particular time . . . one and a half hours . . . (T5) I have this feeling that maybe also the fact that . . . it could be thought that . . . we showed appreciation by sitting down together with them to face these matters. (T30)

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Where there difficult moments for the therapists? The therapists were asked if they had had difficult moments during the therapy. Moments or themes experienced as difficult were mentioned by 18 out of the 28 therapists. Difficult moments during therapy were mentioned in 15 meaning units, difficult themes (in terms of discussion) were mentioned in 9 meaning units, and feeling uncertain about how to proceed was described in 9 meaning units. The therapists described difficult moments like this:
I think it was the situation initially . . . it was quite hopeless and confused . . . I think H had already been given the diagnosis of depression and it had made the situation a little bit easier, but then the question of how to accept it [the diagnosis] . . . thats what we must have spoken about to begin with. (T4) Difficult moments . . . well I guess it was a difficult moment for us as therapists when . . . if I remember correctly now . . . when w and H together said that they had decided . . . or maybe it was w who said that she had gotten a new apartment and that she was moving . . . taking a distance [from the situation] and wanting to think about things, and then H said that if she left, then it was over . . . he would move on as well, and . . . and something else and . . . I think that was a difficult moment for us, and we thought . . . or at least I thought . . . well what have we done now . . . it was like, is this something to do with what we have spoken about or . . . has it come from somewhere else? (T19)

Violence and alcohol were examples of aspects mentioned as difficult themes to talk about.
Yes . . . there have been difficult . . . or awkward moments . . . maybe kind of especially talking about violence . . . like how to talk about it in such a way that we wouldnt increase feelings of guilt and force anyone in a corner, but rather talk about in a way that would make it easier to understand . . . in a way that could help . . . those were awkward moments . . . how to speak in a way that would help and not make things worse. (T22) Well . . . if I think from my own point of view about the beginning of the therapy, I think it was Ws use of alcohol . . . h did not have any problems with alcohol . . . so I guess I was kind of thinking . . . whether it was going to be a stumbling-block for us. (T9)

Some therapists talked about moments when they had felt uncertain about how to proceed in the therapy.
I guess there were these moments when one thought about how to proceed . . . somehow one felt stuck . . . at least I as the therapist felt that occasionally we ended up in exactly the same spot where we had already been. (T10)

Focusing on Therapists in Co-Research Interviews Or maybe it was that I wasnt able to ask . . . like, the kind of questions that would have opened up my own feelings about the present moment . . . I didnt find that . . . maybe my idea was not right for that moment . . . or maybe it was not ready yet . . . I mean how to go on and . . . (T14)

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What did the therapists learn? The therapists were asked to talk about what they had learned from working with the couple. The answers fell into the following three categories: (1) arranging family therapeutic help for clients with depression, (2) a new understanding of the therapeutic processes, and (3) a new understanding of the clients situation. In the category arranging family therapeutic help for clients with depression, the therapists spoke about the importance of including the spouse within the depressed clients treatment, about the benefits of using couple therapy for depression, and about their ideas concerning when to choose couple therapy and when to choose individual therapy.
And certainly, when we talk together in the session during that one and a half hours . . . then it will continue . . . and then, when we have the next session, lets say after three weeks . . . even after one month . . . the process will continue . . . but if a person comes to the session alone, that person wont have anyone to continue the talk with [ . . . ] and [the next session] will only be after another three weeks, and the person might have so many inner dialogues . . . so I thought that it might be worse then . . . or, I mean, we would need to have more frequent sessions . . . [ . . . ] so, I really think [couple therapy] is more effective and better. (Th23) I dont know if this is anything new . . . anything I could call learning, but still I think that this reminds me about paying attention to the spouse of the depressed person . . . how important it is to remember him or her, and how hard this situation can be on both spouses . . . I mean this feels very important. (Th2)

A new understanding of the couple therapeutic process included understanding how to work with couples with depression. The therapists made particular reference to the importance of the beginning of the therapy: the significance of the first meetings with the clients, the importance of defining together with the couple what they were about to do together, and how important it is to listen extremely carefully to clients goals and to their hopes for the therapy.
Th1: For me the first thing that comes to mind is that we should remember to ask right at the beginning about what people want . . . to prevent what W just mentioned from happening . . . that it was somehow unclear what we were doing . . . like, somehow we should remember to ask . . . umm . . . Where . . . what kind of a journey

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Rautiainen and Seikkula would you be willing to take with us . . . or, are you willing or . . . Th2: Yes and maybe we should also listen to the starting points in a peaceful manner . . . think and give space to think about how they felt when they came to meet us and the kinds of obstacles or wishes that existed. Th1: Yes . . . beginning more slowly . . . (Th1 and Th2 in case 17)

In addition, ideas about how to take better care of the whole therapeutic process were raised, particularly in regard to more active attention to the continuity of the process, and better evaluation of the collaboration with the clients throughout the process.
I was thinking . . . since there were quite long breaks in between the sessions . . . maybe we should have been more active in remembering or bringing into the discussion . . . what we had talked about last time . . . what the previous topic was . . . and whether we should go back to it this time or whether we should think about it . . . and whether we had space to talk about it . . . maybe we should have done more to bring out these kinds of ideas . . . (Th2)

The therapists also spoke about new understandings that they had gained concerning the clients during the therapeutic processes and in the co-research interviews. They evaluated the collaboration between themselves and the clients.
What I feel I have learned is also . . . what came out of the fact that always, when H evaluated our session, in the end . . . I think he always gave the best points . . . as if he felt they were very good . . . he felt listened to and everything . . . but then, in the next session, he still said that, well . . . for one or two days he had felt better, but then the bad feeling came back again . . . so coming to sessions and talking did not in itself . . . at least quickly . . . help that much . . . so that something else needs to happen in life, or the talking should somehow move further forward, or we should somehow talk in a different way . . . maybe the thing I learned was that we need to listen even more closely and even more carefully, and we need to be as patient as possible. (Th19) I was left with the feeling that they were doing better, but maybe there were still some issues that we could have continued to talk about; H was still hurt because w had been unfaithful. What will the future of their relationship be, I wonder? (Th4, post-interview writing)

DISCUSSION In this paper we have presented therapists questions and answers in co-research interviews, together with a case example illustrating how this kind of interview proceeds. The novelty of this study was the use of the collaborative interview method, which is well suited to the collaborative nature of psychotherapy.

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Main Findings: 1. The therapists in this study raised a variety of questions concerning their own actions, the clients experiences of therapy, the collaboration between clients and therapists, factors found to be helpful, the suitability of the approach, and the themes discussed during therapy. 2. The therapists thought that the clients appreciated empathy, genuineness, unconditional positive regard, healing, and the potential for growth. 3. Relatively few answers were given to the question concerning difficult moments for the therapists during the therapy. 4. The therapists talked about the importance of the beginning of therapy: about discussing goals, and about clarifying the overall idea of therapy. 5. For many therapists, participating in the research project had reminded them of the importance of including within the psychiatric outpatient treatment the spouse of the person diagnosed as depressed. Discussion of the Main Findings In the interviews the therapists were first asked to raise questions they wanted the interviewer to put to their clients. In this way, according to our experience, the therapists were also being asked to give their clients permission to talk about their collaboration with an outsider, i.e., the interviewer. The therapists seemed to orient themselves in a collaborative way: they were curious to hear how their clients had perceived them and whether they had been useful for them. When we compare our results to those of the study by Wchter and his colleagues (2006), we can see that the therapists in our study asked both insider and outsider questions, some focusing on general and some on more specific questions. The therapists were also asked what they thought their clients appreciated most in their conduct of the therapy. The answers were similar to many found in previous studies with clients. According to Bachelor and Horvath (2004), empathy, genuineness, unconditional positive regard, healing, and growth potential are Rogerian elements that clients usually appreciate. Moreover, the answers that the therapists gave to Bachelor and Horvath are similar to the answers that the clients gave during interviews in the previous study we conducted (Rautiainen & Seikkula, 2009). In that study, the clients spoke about the therapists actions, the therapists way of relating to them, and the therapists general qualities. They also spoke about the usefulness of talking during therapy, and about the fact that their spouses had participated in the therapy. One aspect that could be seen as specific to this way of working was that the therapists did not mention the technical aspects of therapeutic methods; instead they spoke in fairly general terms about being active participants within a living dialogue. Relatively few answers were given to the question concerning whether there were difficult moments for the therapists during the therapy. Either many of the therapeutic processes went wellfrom the therapists point of viewor else the interview context, i.e., with clients present, inhibited the therapists from saying

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much about this topic. It is also possible that the therapists might have forgotten difficult moments, if the process as a whole had ended well. Nevertheless, some therapists did choose to talk about difficult moments, mentioning for example the beginning of the therapy, themes such as violence and alcohol, and their own feelings of uncertainty during the process. It is not very common for the therapists to reflect on these kinds of difficulties openly in the presence of clients. Talking about difficult moments made some of the therapists inner conversations visible: the therapists had paid attention to clients needs; they were aware that it can be difficult for clients to approach difficult themes; they had had feelings of being unsure and lost. Some clients commented on this general aspect at the end of the interview, indicating that it had been very interesting and important to listen to therapists putting forward their thoughts in this way. What did the therapists learn? In the interviews, local knowledge concerning each particular therapeutic process was co-created, with the most important stakeholders in this understanding being the clients and the therapists involved. Nevertheless, it is possible to make some general remarks. The therapists talked about the importance of the start of the therapy: about talking about goals, about clarifying the overall idea of therapy. This underlines the view of Bachelor and Horvath (1999) to the effect that the start of therapy is a window of opportunity for an alliance. In couple therapy, the question of an alliance is more complex than in individual therapy. Therapists need to create an alliance with both spouses individually, and also with the spouses as a couple (Odell, Butler, & Dielman, 2005). The clients expectations are important, but are frequently left unexpressed by the clients themselves (Odell et al., 2005). All this underlines the importance of focusing more on the beginning of therapy and of listening very carefully to clients needs. The therapists commented on the use of couple therapy for depression. Many of them felt that participating in the research project had reminded them of the importance of including within the psychiatric outpatient treatment the spouse of the person diagnosed as depressed. This result could be seen as surprising. After all, all the therapists were trained family therapists. How could they not remember this? Is mental health outpatient care so individually oriented that even trained family therapists tend to work with depressed patients individually, neglecting family members? This point has been noted also by Denton and Burwell (2006). Or does this orientation have something to do with depression as a phenomenon? It is not unusual for a depressed person to think that she/he does not want to burden family members by inviting them to participate in the therapy, even if she/he has been asked to do so (Gupta, Coyne, & Beach, 2003). Is this by its very nature a depressed thought, reflecting the negative view that the depressed person might have of him/ herself? Do therapists too easily desist from inviting the family members? Evaluation of the Interview Method Co-research interviews are special kinds of dialogues; both therapists and clients talk with an outsider about the therapeutic process they have had with each other. The

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question of power can thus be raised: How do power relations operate in this kind of collaborative practice? Guilfoyle (2006) suggests that the therapists and the client are institutionalized, primary positions that orient therapeutic participants (and observers) to the actions and speech of each party. He further suggests that to some degree, these positions predetermine and fix the shape of the therapeutic relationship (p. 90). He argues that even in collaborative therapies the therapist is expected to be the expert knower, and the clients accounts are understood as evolving, their meanings as yet-to-be-decided. He emphasizes that participants in a therapeutic dialogue inherit a power relation that cannot be undone by local intentions or practices; institutional factors of necessity place the participants in a power relation (Guilfoyle, 2003). Co-research interviews might change this view by placing both therapists and clients in a similar position in relation to an outsider interviewer, and by encouraging both participants to reflect on their ideas and thoughts concerning the therapeutic process. At the same time, the distinct positions of therapists and clients will remain clear; the therapists will reflect on their thoughts as professionals whereas the clients will speak from the position of people who have come to seek help. Hence, co-research practices could be an alternative for creating collaboration between clients and therapists in a new way. The voices of both therapists and clients will be heard, forming and informing each other; hence a new understanding of the therapeutic process may be co-created. In evaluating the interview method from the point of view of the researcher, we noted that the co-research interviews were intense and demanding, but also of great interest. As clinicians we experienced them as being useful, informative and inspiring. We would recommend the use of this type of interview, both in family therapy training courses and in everyday clinical work, when therapists are seeking to evaluate their work collaboratively with their clients, and to learn together with them. We would also encourage other practitioner-researchers to use this method in studying different forms of psychotherapy. The interview method can be seen as both a strength and a limitation of the study. It is a new, collaborative method in psychotherapy research, and one that enables researchers interested in social constructionist ideas to use a method that suits their theoretical thinking. This way of interviewing also brings psychotherapy research closer to the everyday work of therapists. On the other hand, the interview context can inhibit both clients and therapists from talking freely about their experience, since the other party in the therapeutic relationship is present and listening. Measures were taken in order to help the clients and the therapists talk as freely as possible. According to our experience, the structure of the interview, and the fact that the therapists talked with the interviewer, not to their clients, seemed to give participants the freedom to talk. The participants spoke about their experiences of couple therapy three months after the termination of therapy. In this way an overall picture of their experience was gained, not a detailed description of the sessions. Our approach to psychotherapy research focuses on the idea of psychotherapy in everyday life (Dreier, 2008); psychotherapy is part of peoples everyday life and it cannot be useful unless

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clients can make it work outside the therapy room. Asking about the experiences after the entire therapeutic process offers us a view of therapy as part of a lived life. Future Research At this stage of our research we wished to use the co-research interviews to gain an overview of the answers given by clients (Rautiainen & Seikkula, 2009) and therapists, our broader aim being to develop our work with couples with depression. As the case example illustrates, the collaborative nature of the interview has an effect on everything that is said; the understanding of the therapeutic process in question is co-created. By choosing to look for an overview we lost part of the local knowledge that was specific to each therapeutic process. The next step of the analysis could be to use the interviews individually, and to combine this information with data concerning the therapeutic process in question (data gathered in the DINADEP project) using outcome measures such as the following: BDI (Beck, Ward, Mendelssohn, & Erbaugh, 1961); HDRS (Hamilton, 1967); Dyadic Adjustment Scale DAS (Spanier, 1976); Outcome Rating Scale and Session Rating Scale (Miller & Duncan, 2004). In adopting this approach, we would use data collected from every couple-therapeutic process within the overall research project. Such a case study approach would take better account of the nature of the interview, making it possible to combine the answers of the clients and the therapists in each case. Another direction for future research would be to analyze the focus group interview that was conducted after all the co-research interviews. In the focus group, a group of therapists who had taken part in this research process talked with each other about their experience of being interviewed in front of their clients. Research of this kind would give us further understanding of the therapists point of view within collaborative practices. REFERENCES
Andersen, T. (1997). Researching client-therapist relationships: A collaborative study for informing therapy. Journal of Systemic Therapies, 16, 125133. Anderson, H. (1997). Conversation, language and possibilities: A postmodern approach to therapy. New York: Basic Books. Bachelor, A., & Horvath, A. (1999). The Therapeutic Relationship. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The Heart and Soul of Change. What Works in Therapy (pp. 133178). Washington DC: American Psychological Association. Bakhtin, M. (1986). Speech genres & other late essays. Austin, TX: University of Texas Press. Beck, A. T., Ward, C. H., Mendelssohn, M. J., & Erbaugh J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561571. Blow, A. J., Sprenkle, D. H., & Davis, S. D. (2007). Is who delivers the treatment more important than the treatment itself? The role of the therapist in common factors. Journal of Marital and Family Therapy, 33, 298317. Buber, M. (2004) I and Thou (R. G. Smith, Trans.). London : Continuum. (Original work published 1923.)

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Daniel, T., & McLeod, J. (2006). Weighing up the evidence: A qualitative analysis of how person-centred counselors evaluate the effectiveness of their practice. Counselling and Psychotherapy Research, 6, 244249. Denton, W. H., & Burwell, S. R. (2006). Systemic couple intervention for depression in women. Journal of Systemic Therapies, 25, 4357. Dreier, O. (2008). Psychotherapy in everyday life. New York: Cambridge University Press. Guilfoyle, M. (2003). Dialogue and power: A critical analysis of power in dialogical therapy. Family Process, 42, 331334. Guilfoyle, M. (2006). Using power to question dialogical self and its therapeutic application. Counselling Psychology Quarterly, 19, 89104. Gupta, M., Coyne, J. C., & Beach, S. R. H. (2003). Couples treatment for major depression: Critique of the literature and suggestions for some different directions. Journal of Family Therapy, 25, 317346. Hamilton, M. (1967). Development of a rating scale for primary depressive illness. British Journal of Social and Clinical Psychology, 6, 27896. Jensen, P. (2007). On learning from experience: Personal and private experiences as the context for psychotherapeutic practice. Clinical Child Psychology and Psychiatry, 12, 375384. Kung, W. (2000). The intertwined relationship between depression and marital distress: Elements of marital therapy conductive to effective treatment outcome. Journal of Marital and Family Therapy, 26, 5163. Miller, S. D., & Duncan, B. L. (2004). The outcome and session rating scales. Administration and scoring manual. Chicago, IL: Institute for the study of therapeutic change. Odell, M., Butler, T. J., & Dielman, M. B. (2005). An exploratory study of clients experiences of therapeutic alliance and outcome in solution-focused marital therapy. Journal of Couple & Relationship Therapy, 4, 121. Rautiainen, E-L., & Seikkula, J. (2009). Clients as co-researchers: How do couples evaluate couple therapy for depression? Journal of Systemic Therapies, 28, 4160. Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., Keranen, J., & Sutela, M. (1995). Treating psychosis by means of open dialogue. In S. Friedman (Ed), The reflecting team in action: Collaborative practice in family therapy (pp. 6280). New York: Guilford Press. Seikkula, J., & Trimble, D. (2005). Healing elements of therapeutic conversation: Dialogue as an embodiment of love. Family Process, 44, 461475. Seikkula, J. (2008). Inner and outer voices in the present moment of family and network therapy. Journal of Family Therapy, 30, 478491. Spanier, G. (1976). Measuring dyadic adjustment: New scales of assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38, 1528. Spitzer, R. L, Williams, J. B., Gibbon, M., & First, M. B. (1992). The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Archives of General Psychiatry, 49, 624629. Stahl, J. V., Hill, C. E., Jacobs, T., Kleinman, S., Isenberg, D., & Stern, A. (2009). When the shoe is on the other foot: A qualitative study of intern-level trainees perceived learning from clients. Psychotherapy Theory, Research, Practice, Training, 46, 378389. Strauss, A., & Corbin, J. (1998). Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage. Wchter, A. (Ed.) (2006). Samforskningatt lra av klienten [Co-researchlearning from the clients]. Falun: Mareld.

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