Comparing helpful and hindering processes in good and poor outcome cases: a qualitative metasynthesis of eight Hermeneutic Single Case Efficacy Design studies

Susan Stephen, Laura Bell, Maha Khan, Ruth Love, Hannah MacIntosh, Melanie Martin, Rebecca Moran, Emily Price, Brigid Whitehead, Robert Elliott

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Objective: We tested qualitative metasynthesis of a series of Hermeneutic Single Case Efficacy Design (HSCED) studies as a method for comparing within-session processes that may explain good and poor therapeutic outcome. Method: We selected eight HSCED studies according to change in clients' scores on the Strathclyde Inventory (SI), a brief self-report instrument used to measure outcome in person-centered psychotherapy. Four of the case studies investigated the experience of clients whose pre-post change in SI scores showed improvement by the end of therapy, and the other four focused on clients whose change in SI scores indicated deterioration. We conducted a qualitative metasynthesis, adopting a generic descriptive-interpretive approach to analyze and compare the data generated by the HSCED studies. Results: In contrast to improvers, deteriorators appeared to be less ready to engage in therapeutic work at the beginning of therapy, and found the process more difficult; their therapists were less able to respond to these difficulties in a responsive, empathic manner; deteriorators were less able to cope successfully with changes of therapist and, eventually, gave up on therapy. Conclusion: We found that our qualitative metasynthesis of a series of HSCED studies produced a plausible explanation for the contrasting outcomes that occurred.
Original languageEnglish
Number of pages15
JournalPsychotherapy Research
Early online date4 Jun 2021
Publication statusE-pub ahead of print - 4 Jun 2021


  • hermeneutic single case efficacy design method
  • qualitative metasynthesis
  • known groups
  • process-outcome research
  • person-centred therapy

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