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Therapeutic Processes in Clinical Interventions : A View of Qualitative Methodological Approaches

This article examines several qualitative methods to capture and analyze processes in therapeutic and clinical interventions. The study of therapeutic processes provides an understanding of what leads to changes in clinical interventions. This is a goal of any therapeutic intervention. This interest should allow us to try to identify what the therapists do and think they are doing, how they do it, how they think about their interventions, and what happens during the session that might explain changes. These types of studies require that researchers provide clarifications about their epistemological and methodological choices. To meet that requirement, we propose to review a range of issues, methodologies, and tools – which come from qualitative research that guide us in conducting research in the psychotherapeutic and clinical field. The aim of our article is to put forward a methodological framework for researchers to better explore the patient’s or the therapist’s lived-experience and better reveal, moment-to-moment, the clinical practice.


Introduction
For decades, the evaluation of therapeutic processes has widely belonged to the field of empirical research in psychotherapy. Early studies on therapeutic processes were often associated with outcome studies (Kordy & Kachele, 1999). Researchers tried to discover which therapeutic processes led to such and such results. We know that therapies are effective and efficient, but it is hard to figure out what makes them effective (e.g., American Psychological Association [APA], 2013;De Roten et al., 2005;Duncan et al., 2010). Indeed, the literature demonstrates that combining a type of psychotherapy with a specific mental disorder is insufficient and does not result necessarily in more effective changes (Norcross & Lambert, 2011;Roth & Fonagy, 2005).
For example, in clinical crisis intervention, we also know that interventions are effective in reducing depressive symptoms, anxiety or suicidal ideation (e.g., Roberts & Everly, 2006). However, it is not known what are the variables that affect the observed changes and how they participate in the positive or negative recovery of people in crisis (Séguin et al., 2006).
Following all these findings, the efficacy studies progressively focused on the "therapeutic alliance." Many years of research have widely demonstrated that the establishment of a good therapeutic alliance generates positive results in all types of psychotherapies (Ardito & Rabellino, 2011;Duncan et al., 2010;Horvath et al., 2011), even if the therapeutic alliance is not always defined in the same way by various therapeutic approaches. These studies reveal the importance of regulating interpersonal factors in interventions (Bogwald et al., 2007).
These studies also show the needs for evaluating the individual characteristics in therapeutic processes (Kendall et al., 2007;Kraemer et al., 2001Kraemer et al., , 2002. Hoch and Zubin (1958) were the first to highlight "therapeutic processes evaluation." They focused on the necessary consideration about theoretical approaches, which qualify the therapeutic interventions "throughout" and "within" clinical processes. Indeed, the influences of personal and interpersonal variables lead the clinician to adhere to specific therapeutic techniques by showing an allegiance to some theoretical models rather than others during the therapeutic intervention (Barker et al., 2002;Sexton et al., 2004). The literature review of Lambert and Ogles (2004) and the research of Hauser and Hays (2011) also attest to the centrality of empirical evidence of the efficacy of psychotherapy based on specific techniques in the evaluation of therapeutic processes.
Later, studies on therapeutic processes became interested in interactions "within" and "between" therapeutic interventions, that is the interventions of the therapist and the patient's response (e.g., Denis & Hendrick, 2019;Hill & Lambert, 2004;Kramer et al., 2006). The objectives of this sort of evaluation are to understand "what therapists actually do, what they think they are doing, who are the effective therapists and what are the variables that lead to change." Indeed, theories consider that to qualitatively understand the factors of change, it is useful to highlight what therapists set up during their interventions (Greenberg & Pinsof, 1986;Thurin & Thurin, 2007). Therefore, within the process, the variable "therapist," as well as the variables "patient" and "therapeutic alliance," hold a prominent place. For some authors, these three variables would have more impact than specific treatments (Wampold & Brown, 2005). Throughout their interventions, the therapists support their patients in his subjective experience, filled with emotional and cognitive states. The therapist resonates reflexively and constantly fits to their patients. The therapists' proposals and their therapeutic techniques (input) are regulated and depend on the interaction (e.g., transference and countertransference), on non-verbal behavior, and on the emotional and cognitive status of the patient. During therapeutic interventions we also focused on the dynamics of the relationships like "coconstruction working" with peers (internal and/or external colleagues to the institution) and collaborative exchanges with families and/or conjugal systems of patients. These complex interactions and regulations between various protagonists and their mutual influences are not clearly defined by literature.
It is our intent to demonstrate the benefits of evaluating therapeutic processes with a qualitative approach in terms of generating new understanding of these complexities. We will demonstrate several clinical and methodological methods to explore the phenomenon inside a clinical intervention. What actually "do" (-or "plan to do") therapists? But also, how do they explore their subjective experiences regarding their professional practice?
The data collection and analysis presented in this article consider all these multiple interactions and regulations involved during a therapeutic intervention. This investigation of therapeutic processes will inevitably bring a better understanding of the results of clinical interventions (Denis, 2016;Pinsof, 1994;Strupp, 1986).

Therapeutic Processes, Qualitative Methods and Clinical Interventions
Depending on the interest of the researcher and on context of data collection, various methods exist to evaluate the therapeutic processes. Some researchers use qualitative methodologies to capture thorough and detailed substantial segments of an intervention and understand the change that occurs during that clinical intervention (Helmeke & Sprenkle, 2000;Levitt et al., 2006;Llewelyn et al., 1988). Other researchers use quantitative methodologies to highlight the significant moments and their frequency of appearance happening during the process perceived by the patient (Cummings et al., 1993), the therapist or the researcher.
Nonetheless, we highlight that the best way to approach therapeutic processes in clinical interventions is qualitative research. Theories consider that to qualitatively understand the factors of change, it is useful to know what the clinician sets up during his therapy session (Greenberg & Pinsof, 1986;Thurin & Thurin, 2007) by approaching closer clinical actions and interventions.
Qualitative literature concerning the evaluation of clinical interventions was framed within a variety of methodological approaches. The predominant methods used in qualitative research are the "narrative approaches" (Lapsley et al., 2002), the "grounded theory methodology" (Ball et al., 2005;Cutcliffe et al., 2006) as well as the "lived experience studies" using phenomenology, the "content mapping" and a variety of "semi-structured interviewing techniques with content or thematic analysis" (Edward, 2005;Lakeman, 2008;O'Hagan, 2006). These methods can also be used to evaluate the therapists' interventions.
Qualitative research is required to better understand clinical and therapeutic interventions, to better capture verbal and nonverbal communication, and to recognize right issues for rapid decision-making concerning structures and supports to treat people in distress. The thorough analysis of these critical thinking skills allows the enhancement of the therapeutic processes (Fortinash & Holoday-Worret, 1996;Jones, 1985;Ogrodniczuk & Piper, 1999).
To illustrate the choice of the methodological approaches that evaluate the therapeutic processes, we draw inspiration from the clinical framework. By focusing on the therapeutic processes in a qualitative approach, researchersas clinicians and psychotherapistsare interested in modeling the complex interaction of "relational processes," "emotional" and "cognitive," which appear between the protagonists of the intervention. Greenberg and Pinsof (1986) add that the researcher or clinician should also take into consideration qualitative aspects related to the "temporality of the clinical activity" (e.g., duration of the intervention), to the "directional changes during intervention" and to the "movement toward completion" (e.g., treatment goals) to highlight what is happening "within" and "between" processes. Currently, we will set forth some pertinent qualitative methods that could explore the phenomenon of therapeutic processes. All these methods take into consideration the context of data collection, in order words, the clinical setting.

Methodological Issues
Just as therapists must continually reinvent themselves to stay relevant and essential to present and future patients (Winslade, 2009), researchers also must continually seek out the most effective ways to gather and to analyze data to focus on noticing and systematically describing complex processes and experiences, rather than on causal or correlational links between variables.

Proposition 1: Choosing a Qualitative Method
Some studies postulate that using single or only several measurements is insufficient to capture the essence of treatment process in intervention (Taschacher & Jacobshagen, 2002). For this reason, mostly qualitative methods are combined to quantitative methods. While qualitative methods are interested in lived experience, quantitative methods are rather focused on matters such as treatment outcomes, survival rates and clinical governance.
The term "qualitative research" refers to a variety of approaches aimed at enquiring in the health and social sciences that address the meaning of verbal text in verbal rather than numerical terms (Rennie et al., 2002). Qualitative approaches are generally used to build "scientific contexts analysis" or describe processes of interpretation to better understand a social phenomenon (Mucchielli, 2004). Good qualitative research results from hard work and systematic approaches. That means gathering enough data, synthesizing them, and making analytic sense with them (Charmaz, 2006). Qualitative approaches are not opposed to quantitative approaches. They are sensibly complementary. Indeed, quantitative approaches involve varied measures. The extent mixed methods used in psychology research have widely evidenced that fact.
The choice of a qualitative approach depends on aroused research questions and the state of initial knowledge about the studied phenomenon. This implies, as we shall see, to engage in rigorous and complex methodological approaches. In social sciences, these methodologies are carriers of theoretical innovations. They also allow researchers and practitioners to renew their interests in the clinic. These necessary qualitative methods include the development of "relationship structures" (building trust and respect with participants), "opportunities for reflexivity" (memos and iterative process), and a "systemic approach" (the research process encapsulating many entities included context and individualities).
Also, in qualitative methods, researchers must consider their subjectivity as an instrument of knowledge and not a single undesirable "artefact" that researcher attempt to avoid (Brunet, 2008). However, if subjectivity can be an instrument of knowledge, it is necessary that the researcher, as well as the clinician, develops validation requirements of this subjectivity. Otherwise, the subjective is nothing other than the unverified intuition, arbitrariness, and the projection of the researcher. In recent years, qualitative research has been applied to describe various ways to approach validation of subjectivity and induction. There is a set of measures that can contribute to this validation. Among them are the usual notions of "saturation, consistency, convergence, analysis by consensus or bottom-up/bottom-down analysis" (Brunet, 2008).

Identify a Studied Phenomenon
When the researcher opts for an epistemological position based on qualitative methodologies, he must consider the influence of theories and methods already used for the construction of pre-existing scientific knowledge. The goal of these research is to build a new knowledge by bringing meaning to the analysis of studied phenomena by creating an interest for the subjective reality of some witnesses interviewed for the study. This principle is known through the aphorism that "Nothing is given, everything is built" (Bachelard, 1971).
Thereby, the phenomena studied in clinical interventions can be oriented by several research questions: How do expert therapists make sense of their clinical interventions? How can they explain their decision-making? How do they explain the continuity of the intervention? What are the characteristics of good therapists?

Focus on a Methodological Approach
Qualitative analysis aims at generating a meaning where it appears absent, vague, or confusing. At each step of his analysis, the researcher must explore subjective meanings of participants. His role is to clarify the discourse. Qualitative research is also grounded in samples of concrete everyday-life experience, such as conversation between a therapist and client. It is inactive, purposeful, and relational being to better understand therapeutic processes.

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The Qualitative Report 2022 Proposition 2: Exploring how to deal with data collection

Thematic Analysis (Braun & Clarke, 2006)
Description -Thematic analysis is a method of analyzing written, verbal, or visual communication messages. This method identifies, analyses, and report's themes within all kind of data. Thematic analysis should be seen as a foundational method for qualitative analysis. It is the first qualitative method of analysis that researchers should learn, as it provides core skills that will be useful for conducting many other forms of qualitative analysis (Braun & Clarke, 2006). When researchers use thematic analysis, the aim is to build a model to describe the phenomenon in a conceptual form. Boyatzis (1998) characterizes it not as a specific method but as a tool to use across different methods. Indeed, both inductive and deductive analysis processes are represented in this analysis. Through thematic analysis, it is possible to distill words into fewer content-related categories. It is assumed that when classified into the same categories, words, phrases and the like share the same meaning (Cavanagh, 1997).
Thematic analysis is a research method for making replicable and valid inferences from data to their context, with the purpose of providing knowledge, new insights, a representation of facts and a practical guide to action (Krippendorff, 1980). One of the benefits of thematic analysis is its flexibility. There is a relatively limited variability in how the method is applied (Braun & Clarke, 2006). It is extremely well-suited to analyzing data on the multifaceted, sensitive phenomena characteristic of psychology or clinical practice as clinical intervention.
Limitation -Firstly, there are different manifestations of the method, from within the broad theoretical framework. Secondly, there are methods that are essentially independent of theory and epistemology and can be applied across a range of theoretical and epistemological approaches (Braun & Clarke, 2006). Qualitative psychologists need to be clear about what they are doing and why and include the often-omitted how they did their analysis in their reports (Attride-Stirling, 2001). It is the main limitation in this method.

Grounded Theory Methodology (Glaser & Strauss, 1967)
For a more detailed analysis of therapeutic processes, Levitt, Butler, and Hill (2006) propose to adopt an inductive approach. The method of Grounded Theory Methodology (GTM) developed by Glaser and Strauss in 1967 allows the exploration of subjective experiences by conducting an analysis called "grounded" in the research field. The immersion in an empirical starting point is the development of a theory about a phenomenon.
Description -The Grounded Theory Methodology (GTM) is a method to better evaluate processes by looking at the perspective of the research field. The researcher who uses the GTM knows that he must develop a progressive and simultaneous construction (operation spiral, circular) of categories the goal thereof is to develop a substantive theory (Strauss & Corbin, 1998). Through a theoretical sampling or phenomena, the analysis continues with a validation process that keeps coming to the data collection. Validation involves more than a simple verification. Indeed, for Glaser and Strauss (1967), the production of the theory must also be done using comparative analysis between the data. The logic of the analysis leads to theoretical saturation. This is a rich qualitative method for researchers. It generates a lot of data that are articulated in reports (open and axial). Urquhart (2013) tells us that research creates its theory based on codes from data and not literature, although the literature elements gradually come to feed the emerging theory.
This technique of qualitative analysis corresponds exactly to the clinical approach and adapts perfectly to the study of the therapeutic process. For a better understanding of the innovative nature of this method, we refer to the article by Guillemette (2006) entitled: "The Approach of Grounded Theory: Innovation?" Limitation -The GTM is a time-consuming method. The verbatim transcript of interviews; conducting multiple rendering accounts, the difficulty of finding subjects to compose theoretical sampling, the implementation of various technical checks, the triangulation of data or researchers, and obtaining consents for audio recording. The researcher is working with a smaller theoretical sampling in this qualitative approach. The use in the clinical and therapeutic field is certainly very interesting even if it takes a long time. This method is to be considered as having a positive and a negative side. In its positive aspect, it depends on the data and the establishment of validation and verification process made by the researcher's inferences. As for the negative aspects, it requires to expose the emerging theory to the participated subject at the end of the research process. This research process extends generally over one to two years for meeting a couple of subjects. Therefore, it is sometimes difficult to re-address the phenomenon explored several months after the initial collection.

Interpretative Phenomenological Approach (IPA; Smith & Osborn, 2003)
Description -The IPA was initially applied in psychology but became more and more popular in other fields. It can be a suitable approach in clinical psychology and psychotherapy to examine study cases (Smith et al., 2009). The IPA puts the lived experiences of a subject at the center of the interview. Indeed, the aim of this method is to investigate how individuals make meaning of their life experiences. Three fundamental principles are used in this method: phenomenology, hermeneutics, and idiographic (Smith et al., 2009). The usual approach adopted by the researcher is to collect data from semi-structured interviews after having develop a few main themes for discussion with participants. After each interview, the recording is transcribed with meticulous accuracy, often including indications of pauses or mis-hearings. The researcher makes notes of any thought and observation that occur while reading the transcript. This method can be used with practitioners and patients. It could be relevant to analyze therapeutic processes.
Limitation -As every qualitative method, the IPA framework is an inspiring activity, although complex and time-consuming. It is recommended that researchers totally immerse themselves into the data by trying to step into the participant's shoes as much as possible. The researcher should be careful, however, when applying theories developed in one setting to explain phenomena belonging to a different one. He must be flexible and creative. The best manner to really take in charge the method is to do a training and share his results with other researchers (crossing data). Another limitation is the interpretation phase that comes very quickly in the analysis process.

The Significant Event Method
Description - Llewellyn et al. (1988) created methodological tool for data collection to gather the subjective views of patients and therapists regarding the conduct of therapy. The "significant events method" aims at focusing on relevant moments during the therapeutic process. It is often used with patients to identify events they highlight as positive or as hindering during the therapy (Elliott et al., 2001;Timulak, 2010). Therapists to progressively improve their practice can also use this method. This method of data collection shares two points of view. On one hand, some researchers use structured interviews -type Brief Structured Recall or BSR - (Elliott, 1984). On the other hand, written questionnaires as "Helpful Aspect of Therapy Questionnaire" or HAT - (Llewelyn et al., 1988) are favored. In their article, Gelin, Denis, Livemont, and Hendrick (2013) present research in clinical psychology that demonstrate the relevance of using this method for the evaluation of process changes in therapy.
Limitation -The significant events method does not highlight all the processes at work in therapy. This method should be accompanied by other analytical techniques to explore up the vast field of investigation that covers the study of therapeutic processes. Also, the time of harvest of the data may have an impact on the subsequent results of the therapy. Potential biases can appear (e.g., distance in therapeutic alliance, researcher's influences, destruction of hopes for therapeutic improvement). The use of an outside observer (judge), trained in clinical psychology and in methodology, is time-consuming but necessary for the proper conduct of a research using the method of significant events. However, it appears that the current assessment of the observers (or judges) may also be biased by their previous experience of participation in other research or by personal variables (mood, attitude, etc.; Hill et al., 1994;Mahrer & Nadler, 1986).

Think Aloud Method
Description and indication -This qualitative method (McLeod, 1999) provides rich data on verbal reasoning by referring to a task resolution. The use of the think aloud method analysis leads researchers to identify information on how participants solve a problem. Then, it is possible to make inferences about the reasoning process used for example throughout the resolution of a clinical intervention.
Limitation -The "Think Aloud Method" slows the process of mindfulness of the participants. Therefore, it is sometimes difficult to identify certain specificities that would have been produced in the context of studied phenomenon. With this method, some information is lost by the effect of the memory of the participants. This method may seem against nature and be distracting for participants. All participants have not necessarily this learning style of thinking aloud. There is also an exhausting verbalization process that can continuously last from two to three hours. The best results require a researcher trained in this technique. (Vermersch, 1994) Description and indication -The explicitation interview is focused on a qualitative technique to describe the singular lived experiences of an action (Vermersch, 2004). It could helpresearchers or cliniciansto bring out details of representations concerning multiple procedures used to obtain specific results in specific contexts. Indeed, this qualitative method allows to analyze how to conduct tasks. It can be applied to describe moment-to-moment therapeutic interventions. Therefore, it is a relevant method to analyze therapeutic processes. The aim is to analyze how the clinician, or the researcher do their interventions and how do difficulties emerge causing errors or neglect. The objective is to better understand the stakes of success or failure of the therapeutic actions. According to Vermersch (1994), one of the essential terms of the explicitation interview is to say, "How it has been realized" and especially "at the time where the action was performed." Usually, we all tend to describe a temporal structure of "routine" "I do this, and then I do this ". But even in these situations called "routine moment," micro events are still happening, and micro decisions must be made. The "Explicitation Interview" leads a person towards this ability to describe and focus on a situation by giving a singular lived experience in this structure. It is not a simple description. With this method it is possible to give access to "knowledge inscribed in action." Firstly, the interview brings to the interviewee a pre-thought of his action. Secondly, by a reflexive process, the researcher progressively guides the interviewee by the self-informing of how the action was realized now of the action/intervention. When the researcher wishes to turn to what has not reach the patient's awareness yet and that still cannot be seen, this technique of verbalization remains relevant. It will assess the singular moments of the action through focalizations to lived experiences.

The Explicitation Interview
Limitation -The use of "explicitation interview" is not intended to directly analyze actions. These are unobservable. What researchers -or clinicians -analyze is what happens while the knowledge is in action. This method of questioning is based on three main principles: The analysis must relate to a specific task; the analysis is always done after the fact and the analysis focuses on experiences of the action. Thus, researchers who decide to evaluate therapeutic processes should target salient times (selected by participants and by researchers) because it is impossible to evaluate the entire process. It will take a considerable time for researchers. In fact, this method is costly because it requires time to entirely transcribe all verbatim audio recorded and subsequently analyze them. Furthermore, numerous researchers who are interested in the description of the lived experience must be themselves practitioners.

Discussion
Currently, models of clinical intervention are based on unwritten rules hence the importance of describing therapeutic processes to understand how interventions work. Many skills and techniques used in qualitative research are like those used in clinical intervention: eliciting people's story, sensitive listening, building up an understanding and checking it out. The focus of the research question must be correctly defined to choose the right method. The evaluation of clinical practices remains so difficult and must take into consideration specific methodologies. Despite divergent looks on assessment of what practitioners really "dobelieve" to do, we must recognize the need to update knowledge and skills in clinical intervention. To fulfill this objective of research, clinicians should join researchers. While, on one hand, practitioners are faced with "ideographic approaches"; with constant decision processes that are specific to each clinical situation at each moment, in each context, etc. (How to deal now with this individual?). On the other hand, researchers are faced with nomothetic approaches by searching regularity, general laws. (How to do with this category of individual in general?). If researchers and clinicians want to move towards a better understanding of what happens inside therapeutic interventions, there is a need to reduce this gap between them.
Clearly, the researcher should ideally be a psychotherapist (or the practitioner must be himself a researcher). Otherwise, researchers formulate generalities and remain on the superficial area of the phenomena they purport to identify. As for as researchers in clinical psychology, they are concerned by concrete, natural, relational situations so they must definitely consider the context of the intervention. To better understand this type of clinical research, it is important to master it. For that reason, we are convinced that an acknowledged place for the incorporation of qualitative research methods in the standard psychology degree structure must be considered.
Besides, another requirement is difficult to satisfy namely, that the researcherpractitioner is sufficiently detached from the rituals of belonging and loyalty required by the membership of a "psychotherapeutic school" (Hendrick, 2009;Wampold, 2010). The objective is to keep a clinical openness to the studied phenomenon without being linked to a particular school of psychology. Indeed, it is a question of starting from the subjective reality of the interveners and not from the theoretical knowledge of the researcher-practitioner. Furthermore, each research question is anchored into real-life topics and problems and qualitative research offers a set of flexible and sensitive methods for opening the meanings of areas of social and professional life that were previously not well understood.
One thing for sure is that to approach the phenomenon of clinical interventions, it is necessary to better understand the pros and cons of therapeutic processes. The qualitative methodologies are a royal way. The advantage of these methodologies is that they leave a place as co-researchers -to the participants. Thus, they are encouraged to reveal aspects of their clinical experiences that were not expected by the researcher and may propose improvements to the search procedure. All these methods also use data triangulation strategies. The interest is then to collect the data through various research methods (e.g., observation method and semistructured interview), cross-results them and make the phenomenon studied more robust and balanced.
Due to the difficulty to precisely measure the impact of the complexity of therapeutic processes (Ahn et al., 2001), it is important to continue to cross-qualitative methodological techniques in research. It is crucial to recognize that a variety of methodological strategies exist and coexist to explore all the components of therapeutic processes. However, the goal, according to this author is to use a research paradigm that respects the ecological validity of the studied phenomena (e.g., site constraints). The challenge is to integrate various methodological strategies with sufficiently robust crosscutting approaches to inform practitioners of clinical intervention.
Thus, we support the same idea, as Greenberg et al. (1995) mentioned at the time, to promulgate a type of methodological approach oriented to the subjective experience of action. The noninvasive nature of the "explicitation interview" remains a good complement to favor methodological approach alongside grounded methods such as, for example, the "Grounded Theory Methodology." These two methods complement each other perfectly and have demonstrated that multiple regulations during a clinical intervention are not always well known. On the one hand, the GTM allows updating what stakeholders do and say, and on the other side, the "explicitation interview" goes by analyzing what practitioners do and how they do it. Research to go further can also be consulted (Denis & Hendrick, 2019).