Meetings and mismeetings – A qualitative meta-synthesis of clients’ experiences of the therapeutic relationship

Background: The importance of the therapeutic relationship for change in psychotherapy is well established. Understanding the client’s subjective experiences of the interplay with the therapist may sensitize researchers and clinicians to important phenomena, which in turn may enhance clinical effectiveness and improve our understanding of the working mechanisms of psychotherapy. Aim: The aim was to review and synthesize qualitative studies on clients’ subjective experiences of the therapeutic relationship, to highlight their meaning-making in the dyadic context. The focus was how they see themselves as a participant in the relationship and their perception of struggles and resolutions. Method: We conducted a meta-synthesis of literature studying adult clients’ experiences of psychotherapy, using the meta-ethnographic method of Noblit and Hare (1988). Following a literature search in two databases, 2631 studies were systematically screened, resulting in 23 studies that met our inclusion criteria. We extracted findings from the primary studies, which were then systematically compared and synthesized in order to develop higher-level sub-themes, themes and meta-themes. Results: Three meta-themes (as well as seven themes and 20 sub-themes) were developed: (1) If clients sense support, they overcome initial fears and commit to the process, describing needs clients may have that are not disclosed and how they assess their therapist before potentially engaging in therapeutic work. (2) The inner drama and vulnerability of being involved in an asymmetrical relationship reflects how clients may understand and deal with difficulties arising in the dyad. These include distress accompanying perceived rejection and how client-therapist roles could lead to feelings of inferiority. (3) Doing the hard work together concerns how relational tensions may be worked through with a humble therapist; the hard work of exposing oneself which may not be disclosed, and how clients with the help of the therapist may discover new ways of being. Conclusions: The findings show how clients are meaning-making participants in the therapeutic relationship who engage in activities that are not always apparent to their therapists, and shed light on the dynamics of ruptures and power differences. Clinical implications include the importance of seeking feedback from clients and knowledge of how ruptures may be experienced, as this may sensitize therapists and thus enhance their responsiveness. In the future, we recommend investigation of clients’ possible experiences of contribution to resolution, studying client and therapist experiences simultaneously and using methods suited to explore micro-processes in-depth. Involving participants in all phases of the research project seems to have the potential to explore new and important phenomena. The importance of critically considering findings in light of their context is underlined