Psykoterapia, masennus ja sisäinen tarina

Psychotherapy has been shown to be an effective treatment for depression, but not enough is known about the subjective meanings of therapy for human life. This study focuses on experiences of the effects of psychotherapy, thoughts about changes in depression and meanings of the therapy in the inner narratives of persons who sought psychotherapy for their depression. The study was based on interviews of 14 persons, who took part in the Helsinki Psychotherapy Study (HPS). Half of them took part in short-term solution-focused therapy and half in long-term psychodynamic psychotherapy. The sample included both women and men. Part of them had recovered from their depression by the end of therapy (BDI<10), part had not. Therapy was experienced to have effects on one s immediate feelings, thoughts and social actions. Some barriers were also connected to the therapy and the HPS research frame. The relief of depression was explained by enhanced understanding and perspective changes. Also the therapeutic alliance and factors not connected to therapy were seen to have influence on the experienced changes. The resumption of depression was regarded as the consequence of ill-fitting therapy or therapist, incompleteness of the therapy or other reasons not connected to the therapy itself. With the narrative analysis three interpretations were constructed concerning how the persons had sought for therapy, what was the image they had about themselves and their problems and what were their expectations for the therapy. The interpretations were summed up to the life historical, situational and moral inner narrative. Through the psychotherapy some inner narratives came true. In these cases psychotherapy reinforced the original inner narrative. In other cases psychotherapy did not meet the inner narrative of the person, neither had the narrative changed. For some persons the inner narrative got new forms during the therapy: the analyses showed that psychotherapy had reconstructed the persons conceptions about themselves and their problems, which led to changes in the expectations concerning the therapy. Key words: psychotherapy, depression, inner narrative, qualitative research, analysis of narrative, narrative analysis

Psykoterapian vaikutusten arvioiminen : Keskustelunanalyttinen tutkimus arviointihaastattelun käytänteistä

In the field of psychiatry semi-structured interview is one of the central tools in assessing the psychiatric state of a patient. In semi-structured interview the interviewer participates in the interaction both by the prepared interview questions and by his or her own, unstructured turns. It has been stated that in the context of psychiatric assessment interviewers' unstructured turns help to get focused information but simultaneously may weaken the reliability of the data. This study examines the practices by which semi-structured psychiatric interviews are conducted. The method for the study is conversation analysis, which is both a theory of interaction and a methodology for its empirical, detailed analysis. Using data from 80 video-recorded psychiatric interviews with 16 patients and five interviewers it describes in detail both the structured and unstructured interviewing practices. In the analysis also psychotherapeutic concepts are used to describe phenomena that are characteristic for therapeutic discourse. The data was received from the Helsinki Psychotherapy Study (HPS). HPS is a randomized clinical trial comparing the effectiveness of four forms of psychotherapy in the treatment of depressive and anxiety disorders. A total of 326 patients were randomly assigned to one of three treatment groups: solution-focused therapy, short-term psychodynamic psychotherapy, and long-term psychodynamic psychotherapy. The patients assigned to the long-term psychodynamic psychotherapy group and 41 patients self-selected for psychoanalysis were included in a quasi-experimental design. The primary outcome measures were depressive and anxiety symptoms, while secondary measures included work ability, need for treatment, personality functions, social functioning, and life style. Cost-effectiveness was determined. The data were collected from interviews, questionnaires, psychological tests, and public health registers. The follow-up interviews were conducted five times during a 5-year follow-up. The study shows that interviewers pose elaborated questions that are formulated in a friendly and sensitive way and that make relevant patients' long and story-like responses. When receiving patients' answers interviewers use a wide variety of different interviewing practices by which they direct patients' talk or offer an understanding of the meaning of patients' response. The results of the study are two-fold. Firstly, the study shows that understanding the meaning of mental experiences requires interaction between interviewer and patient. It is stated that therefore semi-structured interview is both relevant and necessary method for collecting data in psychotherapy outcome study. Secondly, the study suggests that conversation analysis, enriched with psychotherapeutic concepts, offers methodological possibilities for psychotherapy process research, especially for process-outcome paradigm.

Emotional experience in psychotherapeutic interaction : Conversation analytical study on cognitive psychotherapy

The dissertation examines how emotional experiences are oriented to in the details of psychotherapeutic interaction. The data (57 audio recorded sessions) come from one therapist-patient dyad in cognitive psychotherapy. Conversation analysis is used as method. The dissertation consists of 4 original articles and a summary. The analyses explicate the therapist s practices of responding to the patient s affective expressions. Different types of affiliating responses are identified. It is shown that the affiliating responses are combined with, or build grounds for, more interpretive and challenging actions. The study also includes a case study of a session with strong misalignment between the therapist s and patient s orientations, showing how this misalignment is managed by the therapist. Moreover, through a longitudinal analysis of the transformation of a sequence type, the study suggests that therapeutic change processes can be located to sequential relations of actions. The practices found in this study are compared to earlier research on everyday talk and on medical encounters. It is suggested that in psychotherapeutic interaction, the generic norms of interaction considering affiliation and epistemic access, are modified for the purposes of therapeutic work. The study also shows that the practices of responding to emotional experience in psychotherapy can deviate from the everyday practices of affiliation. The results of the study are also discussed in terms of concepts arising from clinical theory. These include empathy, validation of emotion, therapeutic alliance, interpretation, challenging beliefs, and therapeutic change. The therapist s approach described in this study involves practical integration of different clinical theories. In general terms, the study suggests that in the details of interaction, psychotherapy recurrently performs a dual task of empathy and challenging in relation to the patient s ways of describing their experiences. Methodologically, the study discusses the problem of identifying actions in conversation analysis of psychotherapy and emotional interaction, and the possibility to apply conversation analysis in the study of therapeutic change.

Psykoterapeutit Suomessa. Psykoterapiapalvelut ja niiden järjestäminen

67 s.

”Täytyy miettii koko elämä ihan uudestaan” – Nuorten mielenterveyskuntoutujien kokemukset mielenterveyskuntoutuksen onnistumiseen vaikuttavista tekijöistä

Pro gradu- tutkielmassa on tarkasteltu nuorten 20–45-vuotiaiden mielenterveyskuntoutujien henkilökohtaisia kokemuksia mielenterveyskuntoutuksen onnistumiseen positiivisesti ja negatiivisesti vaikuttaneista tekijöistä. Tutkielma tuo esiin mielenterveyskuntoutuksen onnistumiseen vaikuttavien tekijöiden monipuolisuuden, ja erityisesti muiden kuin lääkinnällisten kuntoutustoimien roolin kuntoutumisen edistymisessä. Tutkielmassa on tarkasteltu suomalaisen yhteiskunnan tarjoaman kuntoutusjärjestelmän toimivuutta sekä sen ongelmia. Tutkielman teoreettiset lähtökohdat pohjaavat hulluuden, mielenterveyden ja – sairauden sekä mielenterveyskuntoutuksen historian ja nykypäivän sosiologiseen tarkasteluun. Tutkielmassa mielenterveysongelmat mielletään sosiaalisiksi konstruktioiksi, joiden määrittely ja ylläpitäminen tapahtuvat yhteiskunnallisissa käytännöissä ja suhteissa kielen, tiedon ja vallan avulla. Mielenterveyden ongelmien tarkastelu perustuu tutkielmassa sosiologian antipsykiatristen tutkijoiden näkemyksiin hulluudesta ja mielisairaudesta sosiaalisesti rakentuneina kontrollin keinoina ja sosiaalisen leimaamisen ja moraalisen tuomitsemisen välineinä. Pro gradu- tutkielma on toteutettu laadullisin tutkimusmenetelmin. Tutkielman aineistona on yhdeksän nuoren mielenterveyskuntoutujan teemahaastattelua, ja aineiston analyysi on toteutettu temaattisella verkostoanalyysilla. Mielenterveyskuntoutuksen onnistumiseen vaikuttivat tutkielmaan osallistuneiden mielenterveyskuntoutujien kokemusten perusteella positiiviset ja negatiiviset kokemukset perusterveydenhuollon ja psykiatrisen sairaanhoidon palveluista sekä lääkehoidosta. Psykoterapia, vertaistuki, läheisten tuki, opiskelu ja työnteko edistivät kuntoutumista terveydenhuollon ulkopuolella. Yksilön oma aktiivisuus kuntoutuksessa, omien voimavarojen ja niiden rajojen tunnistaminen sekä sairauteen suhtautuminen vaikuttivat mielenterveyskuntoutuksen edistymiseen. Tutkielma tuo esiin yhteiskunnan palvelujärjestelmien toimimattomuuden tarkasteltaessa perusterveydenhuollon palveluita, hoitoon pääsyä, rahallisten tukien saantia sekä kouluttautumiselle ja työn teolle asetettuja säännöksiä mielenterveyskuntoutujien näkökulmasta. Rakenteellisen joustamattomuuden purkaminen, mielenterveysongelmien leimaavuuden poistaminen, sosiaalisten kuntoutusmuotojen lisääminen ja psykiatriseen avohoitoon panostaminen auttaisivat tutkielman löydösten perusteella toimivamman mielenterveyspalvelujärjestelmän rakentamista.