Understanding the illness representations of young people with anxiety and depression: A qualitative study

How do we know whether treatment has failed? Paradoxical outcomes in counseling with young people

Background

In both routine practice contexts and research studies, evidence from standardized self-report symptom measures, administered pre- and post-treatment, is predominantly used to determine whether psychotherapy has been successful. Understanding the nature of unsuccessful psychotherapy requires an ability to evaluate the credibility of outcome data generated by such techniques. An important body of research has identified discrepancies between outcomes assessed through symptom measures and those obtained from other sources. However, not enough is known about the extent to which such paradoxical outcomes exist.

Objective

This study analyzes the relationship between outcomes, as assessed by a standardized self-report measure, and as assessed by ratings of young people's descriptions of change at post-counseling interviews.

Methods

Participants were 50 young people (13-16 years old) who had taken part in a trial of up to 10 weeks of school-based humanistic counseling. Our primary standardized measure was the Young Person's CORE (YP-CORE). To assess young people's experiences of counseling change, three independent raters scrutinized transcripts of post-counseling interviews, and scored levels of helpfulness on a 1 (Not at all helpful) to 10 (Extremely helpful) scale. Inter-rater reliabilities were 0.94 (Cronbach's Alpha) and 0.96 (McDonald's Omega). Sensitivity analyses were conducted to explore relationships between helpfulness ratings and other outcome measures, i.e., satisfaction with counseling (ESQ) and the Goal-Based-Outcome Tool (GBO), and process measures, i.e., the Working Alliance Inventory (WAI-S) and the Barret Lennard Relationship Inventory (BLRI).

Results

Multilevel analysis indicated that helpfulness ratings were not significantly associated with changes in YP-CORE scores. Analyzed categorically, 38% of those showing reliable improvement on the standardized measure were below the median for self-described helpfulness, and 47% of those not showing reliable change were at or above the median for self-described helpfulness. Sensitivity analyses demonstrated closer correlations between helpfulness ratings and other outcome measures (ESQ and GBO), and between helpfulness ratings and process measures (WAI-S and BLRI).

Discussion

Our results raise questions about reliance on symptom change outcome measures for defining treatment success and failure, given their disparity with clients' own descriptions of the helpfulness of therapy. Implications for practice and research are discussed.

A qualitative, multi-perspective study on causal beliefs about adolescent depression

OBJECTIVES

The current study aimed to examine: (1.1) causal beliefs about adolescent depression in a sample of adolescents with a clinical depression and their mothers and fathers; (1.2) within-family overlap of causal beliefs; (2.1) mothers' and fathers' reflected causal beliefs about their child's perspective; (2.2) the accuracy of mothers' and fathers' reflected causal beliefs as related to their child's causal beliefs.

DESIGN

Qualitative study using a within-family approach.

METHODS

Adolescents with a current clinical depression (MDD/dysthymia; N = 34) and their parents (N = 34 mothers, N = 26 fathers) were independently interviewed about their causal beliefs about the adolescents' depression. Parents were additionally interviewed about their perception of their child's causal beliefs (i.e., reflected causal beliefs).

RESULTS

The causal beliefs most frequently mentioned by adolescents, mothers and fathers are: characteristics of the child, social factors, school and various stressful experiences. Parent-child overlap was relatively low, specifically for the themes of bewilderment, cumulative effect and stressful life events, whereas overlap was relatively high for themes of social factors, school and stressful experiences outside of the family. Parents were relatively accurate in their reflected causal beliefs, but tended to underestimate their child's insights into possible causes of their depression. Accuracy of parents' reflected causal beliefs was particularly low for the theme cumulative effect and high for social factors.

CONCLUSIONS

The various causal beliefs of adolescents and their parents could be used in therapeutic setting. Future research could examine whether (guided) conversations may promote alignment within families and treatment efficacy.

Illness perception in functional neurological disorder: low illness coherence and personal control

Introduction

Illness perception refers to patients' subjective representations and appraisals of somatic and mental symptoms. These are relevant for self-management and outcome. In clinical practice, patients with functional neurological disorder (FND) often encounter a fragmented biomedical attitude, which leaves them without clear concepts. In this context, illness perception is relevant.

Methods

Illness perception was assessed in FND patients and compared with samples of psychosomatic patients (PSM) as well as poststroke patients (STR). The three samples (FND, n=87; PSM, n=97 and STR, n=92) were almost all in inpatient treatment or rehabilitation. Illness perception was assessed with the revised German version of the Illness Perception Questionnaire (IPQ-R). For assessments of correlations, depressive symptoms were tested with the Patient Health Questionnaire-9, dissociative and functional neurological symptoms by the German adaption of the Dissociative Experiences Scale and biopsychosocial complexity by the INTERMED Self-Assessment questionnaire.

Results

Apart from the chronicity subscale, all dimensions of the IPQ-R differed between groups. FND patients perceived lower illness coherence and personal control than both other groups and attributed their illness more to chance than to behavioural risk factors. PSM patients had the strongest emotional representations. There were only few correlations with dissociative scores and biopsychosocial complexity.

Conclusion

Illness perception is an important issue in patients with FND with particular emphasis on low illness coherence and personal control. Missing associations with biopsychosocial complexity suggest that subjective illness perception is an important complementary but separate issue, which likely influences therapeutic alliance and self-management in FND. Future studies should assess its influences on outcome.

Trial registration number

DRKS00024685; German Clinical Trials Register; www.drks.de.

Self-Compassion and Self-Forgiveness in Alcohol Risk, Treatment and Recovery: A Systematic Review

INTRODUCTION

Self-compassion and self-forgiveness are two self-focused, positive coping approaches that may reduce risk of problem drinking and/or aid in treatment/recovery from alcohol use disorder. The present systematic review aimed to evaluate support for the unique and complementary roles of self-compassion and self-forgiveness in alcohol outcomes.

METHODS

A systematic literature search yielded 18 studies examining self-compassion, 18 studies examining self-forgiveness and 1 study examining both constructs in alcohol outcomes.

RESULTS

Findings suggest greater self-compassion and self-forgiveness relate to lower likelihood of problem drinking. Self-forgiveness was considerably more researched in treatment/recovery outcomes than self-compassion; self-forgiveness-based interventions appear able to improve drinking-adjacent outcomes, and self-forgiveness may increase across various alcohol treatments. Finally, research suggests that associations of self-compassion and/or self-forgiveness with alcohol outcomes could be driven by numerous factors, including coping-motivated drinking, depression, psychache, social support perceptions, mental health status and/or psychiatric distress.

CONCLUSIONS

Self-compassion and self-forgiveness both appear protective against harmful alcohol outcomes. Nevertheless, many questions remain about the role of self-forgiveness and, particularly, self-compassion in alcohol treatment and recovery outcomes. Future research should examine whether targeted interventions and/or adjunctive therapeutic supports designed to increase self-compassion or self-forgiveness can reduce alcohol use disorder symptoms to facilitate alcohol treatment and recovery success.

The Power Threat Meaning Framework: a qualitative study of depression in adolescents and young adults

Introduction

Depression constitutes one of our largest global health concerns and current treatment strategies lack convincing evidence of effectiveness in youth. We suggest that this is partly due to inherent limitations of the present diagnostic paradigm that may group fundamentally different conditions together without sufficient consideration of etiology, developmental aspects, or context. Alternatives that complement the diagnostic system are available yet understudied. The Power Threat and Meaning Framework (PTMF) is one option, developed for explanatory and practical purposes. While based on scientific evidence, empirical research on the framework itself is still lacking. This qualitative study was performed to explore the experiences of adolescents and young adults with depression from the perspective of the PTMF.

Methods

We conducted semi-structured interviews with 11 Swedish individuals aged 15- 22 years, mainly female, currently enrolled in a clinical trial for major depressive disorder. Interviews were transcribed verbatim and analyzed with framework analysis informed by the PTMF.

Results

A complex multitude of adversities preceding the onset of depression was described, with a rich variety of effects, interpretations, and reactions. In total, 17 themes were identified in the four dimensions of the PTMF, highlighting the explanatory power of the framework in this context. Not all participants were able to formulate coherent narratives.

Discussion

The PTMF provides a framework for understanding the complexities, common themes, and lived experiences of young individuals with depression. This may be essential for the development of new interventions with increased precision and effectiveness in the young.

Parents' illness representations of their child with anorexia nervosa: A systematic review of qualitative studies using the common-sense model

OBJECTIVE

Research indicates that parents experience distress while caring for a child with anorexia nervosa. Applying the Common Sense Model of Self-Regulation (CSM), a framework to describe responses to illness may help to understand the antecedents of parental distress, which could inform how to support parents in treatment. The aim of this systematic review was to synthesize outcomes from qualitative research in relation to parents' experiences of caring for a child with anorexia nervosa using the CSM.

METHOD

Systematic search of four electronic databases (psychINFO, MEDLINE, EMBASE, ProQuest Dissertation, and Theses Database) alongside a two-way screening process was used to identify eligible studies. Qualitative themes were synthesized using a "best fit" framework analysis and reported according to CSM dimensions of cognitive and emotional illness representations.

RESULTS

A total of 32 studies published between 1970 and 2023 were eligible for inclusion for review. Parents perceived their child's anorexia nervosa as a major health threat observable by illness representations that anorexia nervosa was uncontrollable, incomprehensible, chronic, and associated with negative consequences. The themes also suggested parents take responsibility for causing anorexia nervosa. These illness representations were linked with emotional representations of fear, anxiety, shame, guilt, loneliness, and depression.

CONCLUSIONS

The findings provide evidence of the utility of using the CSM to understand the antecedents of parents' distress and negative impacts of caring for a child with anorexia nervosa. Recommendations for future research and clinical practice are discussed emphasizing the need to understand parents' perceptions of their child's illness to putatively maximize treatment benefits for families.

PUBLIC SIGNIFICANCE

This review emphasizes the salience of understanding parents distress while caring for a child with anorexia nervosa. The findings present opportunities to best support parents in treatment, with a focus on addressing their cognitive and emotional representations of their child's illness. A multicomponent treatment regimen may be required to support parents if they present with illness representations that negatively affect their well-being and ability to cope with distress.

Systematic Review and Meta-Synthesis: How Is Depression Experienced by Adolescents? A Synthesis of the Qualitative Literature

OBJECTIVE

To systematically investigate how youth with lived experience report their experience of depression in terms of features of depression and in relation to themselves and their environment.

METHOD

We conducted a systematic review of qualitative research around the world that explored the subjective experience of depression among youth (age range, 10-24 years) who had self-reported, screened positive for, or received a formal diagnosis of the disorder. We used multiple databases to search for relevant studies published in any language up until March 2023. Studies were coded regarding features of depression reported by adolescents. We also used thematic synthesis to extract and synthesize descriptions of the lived experience of depression, and to develop analytic themes. The study was registered with PROSPERO, CRD42021218300.

RESULTS

We identified a total of 23,424 unique records, and included 39 studies in the final review, representing the views of 884 adolescents with lived experience of depression. Most of the studies were conducted in high-income countries (72.8%), and the majority of participants were female (65%). The most frequently reported features of depression were sadness (present in 92.3% of the studies), social withdrawal (76.9%), and loneliness (69.2%). In addition, we constructed 3 themes that aimed to synthesize youths' accounts of their perceptions and experiences of depression: (1) making sense; (2) factoring in culture and contextual influences; and (3) accessing support and care.

CONCLUSION

Some of the more commonly reported features of depression among youth are not explicitly included in the DSM/ICD diagnostic criteria but are highly relevant and closely connected to the experiences of adolescents. Moreover, contextual interpretations of depression may be more sensitive to capture representations and narratives of depression among youth. Thus, incorporating features of depression reported by adolescents could potentially increase accuracy of detection, promote collaborative work, and enhance therapeutic and care outcomes.

STUDY PREREGISTRATION INFORMATION

The lived experience of depression in adolescence: a systematic review of the qualitative literature; https://www.crd.york.ac.uk/prospero/; CRD42021218300.

Adolescents' qualitative expressions of functional seizure illness representation

INTRODUCTION

Adolescents with functional (nonepileptic) seizures experience challenges self-managing this mental health condition, especially at school where adolescents experience stress, bullying, accusations of faking seizures, and stigma. According to the Common Sense Model of Self-Regulation, adolescents' self-management decisions and outcomes may be shaped by their functional seizure illness representation (perceptions or mental depictions formed in response to a health threat). However, current research has only explored adults' functional seizure illness representation; little is known about adolescents. The aim of this study was to explore adolescents' expressions of illness representation characteristics (identity, cause, consequence, controllability/curability, and timeline) when describing their experience attending school with functional seizures.

METHODS

We analyzed qualitative data from 10 adolescents (age 12-19 years, 100% female) from the United States with functional seizures. Data collection occurred in 2019 via semistructured interviews about adolescents' school experiences. The theme of illness representation emerged without prompting adolescents to discuss illness representation or its characteristics. This study involved inductive analyses and magnitude coding of adolescents' unsolicited expressions of illness representation.

RESULTS

All five characteristics of illness representation were mentioned by adolescents; however, not all characteristics were mentioned by all adolescents. Adolescents' expressions of illness representation characteristics resulted in the following descriptive themes: clashing labels and mind-body façade for identity, stress for cause, gains and losses for consequence, control/lack of control for controllability/curability, and no end of seizures in sight for timeline.

CONCLUSIONS

Adolescents' expressions of illness representation reveal perceptions considered "threatening" within the Common Sense Model, especially those expressing lack of controllability/curability and condition timelines with no end in sight. The Common Sense Model offers a framework for understanding how these threatening perceptions may impact health and academic outcomes or change with intervention.

Nature-based biopsychosocial resilience: An integrative theoretical framework for research on nature and health

Nature-based solutions including urban forests and wetlands can help communities cope better with climate change and other environmental stressors by enhancing social-ecological resilience. Natural ecosystems, settings, elements and affordances can also help individuals become more personally resilient to a variety of stressors, although the mechanisms underpinning individual-level nature-based resilience, and their relations to social-ecological resilience, are not well articulated. We propose 'nature-based biopsychosocial resilience theory' (NBRT) to address these gaps. Our framework begins by suggesting that individual-level resilience can refer to both: a) a person's set of adaptive resources; and b) the processes by which these resources are deployed. Drawing on existing nature-health perspectives, we argue that nature contact can support individuals build and maintain biological, psychological, and social (i.e. biopsychosocial) resilience-related resources. Together with nature-based social-ecological resilience, these biopsychosocial resilience resources can: i) reduce the risk of various stressors (preventive resilience); ii) enhance adaptive reactions to stressful circumstances (response resilience), and/or iii) facilitate more rapid and/or complete recovery from stress (recovery resilience). Reference to these three resilience processes supports integration across more familiar pathways involving harm reduction, capacity building, and restoration. Evidence in support of the theory, potential interventions to promote nature-based biopsychosocial resilience, and issues that require further consideration are discussed.

The influences of faith on illness representations and coping procedures of mental and cognitive health among aging Arab refugees: a qualitative study

Introduction

Refugees experience higher rates of mental illness such as depression and post-traumatic stress disorder (PTSD) which are documented risk factors for dementia. Faith and spiritual practices have been shown to play a significant role in patients' understanding and coping with illness, however, this field of study among refugee populations remains lacking. This study aims to address this literature gap by examining the role of faith on mental health and cognitive health among Arab refugees resettled in Arab and Western countries.

Materials and methods

A total of 61 Arab refugees were recruited through ethnic community-based organizations in San Diego, California, United States (N = 29) and Amman, Jordan (N = 32). Participants were interviewed through in-depth, semi-structured interviews or focus groups. Interviews and focus groups were transcribed, translated, and coded using inductive thematic analysis and organized based on Leventhal's Self-Regulation Model.

Results

Faith and spiritual practices significantly impact participants' illness perceptions and coping procedures regardless of resettlement country or gender. Several themes emerged: (1) participants believe in the interdependent relationship between mental and cognitive health. (2) There is a self-awareness of the impact of the refugee experience and trauma on participants' mental health problems, leading to a belief of increased personal risk for developing dementia. (3) Spiritual fatalism (belief that events are predetermined by God, fate, or destiny) greatly informs these perceptions of mental and cognitive health. (4) Participants acknowledge that practicing faith improves their mental and cognitive health, and many read scripture to prevent dementia. (5) Finally, spiritual gratitude and trust are important coping procedures that build resilience among participants.

Conclusions

Faith and spirituality play an important role in shaping Arab refugees' illness representations and coping procedures of mental and cognitive health. Holistic public health and clinical interventions tailored to the spiritual needs of aging refugees and incorporating religion in prevention strategies are increasingly needed to improve the brain health and wellbeing of refugees.

Understanding treatment non-responders: A qualitative study of depressed adolescents' experiences of 'unsuccessful' psychotherapy

OBJECTIVES

This paper aimed to explore the experiences of depressed adolescents who completed but did not 'respond' to standard psychotherapy, based on a lack of improvement in pre-post symptoms scores.

DESIGN

This was a qualitative study employing interpretative phenomenological analysis (IPA).

METHOD

Seventy-seven adolescents with moderate to severe depression were interviewed as part of a qualitative arm of a randomised controlled trial. Five adolescents' post-treatment interviews were purposively sampled, based on lack of improvement on pre-post symptom scores, and adolescents still scoring above the clinical threshold for depression. The interviews were analysed using IPA.

RESULTS

Adolescents made sense of their depression as part of their identity and held negative expectations of therapy. Some aspects of therapy brought up intolerable feelings that contributed to disengagement in the therapeutic process and culminated in disappointing and hopeless endings. On the other hand, where a stronger therapeutic relationship was developed, some participants experienced certain improvements.

CONCLUSIONS

Findings highlight how actively exploring the adolescent's therapy expectations, developing a strong early therapeutic relationship and being mindful of the potential impact of endings are important in therapeutic work with adolescents with depression, especially where they may have a strong sense of hopelessness and self-criticism. Moreover, the finding that adolescents experienced improvements in other domains despite a lack of symptom reduction highlights the need to review how treatment outcomes are currently defined. Integrating individual perspectives of therapy with quantitative outcome measures can provide a more nuanced insight of treatment effects.

What treatment outcomes matter most? A Q-study of outcome priority profiles among youth with lived experience of depression

Interest in youth perspectives on what constitutes an important outcome in the treatment of depression has been growing, but limited attention has been given to heterogeneity in outcome priorities, and minority viewpoints. These are important to consider for person-centred outcome tracking in clinical practice, or when conducting clinical trials targeting specific populations. This study used Q-methodology to identify outcome priority profiles among youth with lived experience of service use for depression. A purposive sample of 28 youth (aged 16-21 years) rank-ordered 35 outcome statements by importance and completed brief semi-structured interviews eliciting their sorting rationales. By-person principal component analysis was used to identify outcome priority profiles based on all Q-sort configurations. Priority profiles were described and interpreted with reference to the qualitative interview data. Four distinct outcome priority profiles were identified: "Relieving distress and experiencing a happier emotional state"; "Learning to cope with cyclical distressing emotional states"; "Understanding and processing distressing emotional states"; and "Reduced interference of ongoing distressing emotional states with daily life". All four profiles prioritised improvements in mood and the ability to feel pleasure but differed in the level of importance assigned to learning coping skills, processing experiences, and the reduced interference of depression with life and identity. As part of a person-centered approach to care delivery, care providers should routinely engage young people in conversation and shared decision-making about the types of change they would like to prioritise and track during treatment, beyond a common core of consensus outcomes.

Using Arts-Based Methodologies to Understand Adolescent and Youth Manifestations, Representations, and Potential Causes of Depression and Anxiety in Low-Income Urban Settings in Peru

BACKGROUND

Arts-based methodologies can be beneficial to identify different representations of stigmatized topics such as mental health conditions. This study used a theater-based workshop to describe manifestations, representations, and potential causes of depression and anxiety as perceived by adolescents and young adults.

METHODS

The theater company Teatro La Plaza conducted three online sessions with a group of adolescents and another with a group of young adults from Lima, Peru. The artistic outputs, which included images, similes, monologues, and narrations, were used to describe the experiences of depression and anxiety symptoms following a content analysis using posteriori categories.

RESULTS

Seventeen participants joined the sessions. The artistic outputs showed: physical, behavioral, cognitive, and emotional manifestations of depression and anxiety; a perception that both disorders have a cyclical nature; and an awareness that it is often difficult to notice symptom triggers. The mandatory social isolation due to the COVID-19 pandemic was highlighted as an important symptom trigger, mostly linked to anxiety.

CONCLUSIONS

The findings are consistent with the literature, especially with regard to the manifestations, representations, and potential causes that trigger depression and anxiety. Using arts-based methods allowed adolescents and young adults to expand the articulation of their representations of mental disorders.

Review: Young people's recovery processes from mental health problems - a scoping review

BACKGROUND

Recovery from mental illness and mental health problems is relatively well-researched among adults, but evidence that focuses on the recovery experiences of young people and what characterizes it is scarce. With this in mind, this article aims to map out the existing research in order to identify prevailing knowledge about the recovery of young people between the ages of 12 and 25.

METHOD

Drawing on scoping review methodology, this article is based on an analysis of 33 articles conducted in the USA, Australia, and Europe.

RESULTS

Our findings reveal that young people express both similar and divergent lines of reasoning about recovery compared with adults. Our findings also indicate that young people often fluctuate in the way they view recovery, and that they thus tend to be ambivalent about what recovery means. Parents usually highlight the importance of professionals facilitating recovery, while care staff problematize the organizational frameworks available as aggravating circumstances for implementing personal recovery. Young people, parents, and care staff consistently describe recovery as a way to, despite lingering problems, enable a satisfying life.

CONCLUSIONS

Through this review, we outline the need for a more distinct focus on agency and participation in young people's recovery processes, at the same time as family involvement needs to be further investigated and operationalized.

The Common-Sense Model and Mental Illness Outcomes: A Meta-Analysis

Psychotherapists can improve their patients' outcomes during and after therapy by improving patients' self-management. Patients who do not effectively manage their mental illness generally have worse outcomes. Leventhal's Common-Sense Model of Self-Regulation theorizes that patients' perceptions of their illness (illness representations) guide their self-management, influencing health outcomes. The present study quantified the relations between illness representations, self-management, and outcomes for mental illnesses. We conducted a meta-analysis and included articles if they reported: 1) on adults with mental illnesses; and 2) the correlation between mental illness representations and mental illness outcomes. 25 articles were included which represented 28 independent samples. The pattern of correlations among illness representations (identity, consequences, timeline, control, coherence, and emotional representations), self-management strategies (attendance, engagement, and adherence to treatment) and mental illness outcomes (symptom severity and quality of life) was consistent with analyses from previous studies of mental and physical illnesses. The results found threat-related illness representations mostly had a large relationship with worse mental illness outcomes and self-management. Protective illness representations had a small-to-large relationship with better mental illness outcomes and self-management. The results suggest patients' perceptions of their mental illness may be a critical indicator of their mental illness outcomes, including symptom severity and quality of life. This theory-driven meta-analysis supports calls for the inclusion of illness representations in psychotherapy for mental illness.

How I see is how I feel. Identification of illness perception schema and its association with adaptation outcomes in multiple sclerosis - a 5-year prospective study

The aim of the study was to assess the role of illness perception in adaptation to chronic disease among patients with relapsing-remitting multiple sclerosis (RRMS). The differences between the obtained configurations of the illness perception components during four measurements and the model of predictions of the values of adaptation indicators, i.e. depression, anxiety and quality of life during subsequent measurements, were analyzed. Illness representation was assessed at baseline via the Illness Representation Questionnaire–Revised. The adaptation indicators–anxiety, depression (measured by HADS) and quality of life (measured by MSIS-29) were measured at baseline and three more times over a five-year period. The k-means cluster analysis (with two-way and repeated measures ANOVA) was conducted in a group of 90 patients (48.89% women and 51.11% men). Subsequently, the mean values of depression, anxiety, physical and psychological quality of life were compared between the clusters using the Kruskall-Wallis test. Finally, a cross-lagged panel modeled for HADS and MSIS-29 subscales in each measurement occasion (T1-T4). Three different illness perception clusters (Anxious, Realistic and Fatalistic Illness Perception named AIP, RIP and FIP) were composed which differentiated the depression, anxiety, quality of life level and age. FIP showed the lowest adaptation outcomes with small differences between AIP and RIP. It was also significantly characterized by the highest age. The positive adaptation indicators were related to the RIP cluster. The model presented rather satisfactory fit (χ²(48) = 81.05; CFI = .968; TLI = .925; SRMR = .050) with slightly inflated RMSEA = .087 (90%CI .053-.120). Based on initial measurements of individual characteristics, it was possible to predict the functioning of patients after several years. For patients with AIP, the covariance of anxiety and depression was significant, for patients with RIP–depression and anxiety, and for patients with FIP–depression. In addition, each of the variables was a predictor of subsequent measurements in particular time intervals, illustrating the dynamics of changes. Results highlight that illness perceptions formed at the beginning of RRMS are important for the process of adaptation to the disease. Moreover, they showed the differences between the adaptation outcomes supporting the idea that a cognitive representation might be important for the level of psychological functioning.

A Pluralistic Perspective on Research in Psychotherapy: Harnessing Passion, Difference and Dialogue to Promote Justice and Relevance

The adoption of a pluralistic perspective on research design, processes of data collection and analysis and dissemination of findings, has the potential to enable psychotherapy research to make a more effective contribution to building a just society. A review of the key features of the concept of pluralism is followed by a historical analysis of the ways in which research in counselling, psychotherapy and related disciplines has moved in the direction of a pluralistic position around knowledge creation. Core principles of a pluralistic approach to research are identified and explored in the context of a critical case study of contemporary research into psychotherapy for depression, examples of pluralistically oriented research practices, and analysis of a pluralistic conceptualisation of the nature of evidence. Implications of a pluralistic perspective for research training and practice are discussed. Pluralistic inquiry that emphasises dialogue, collaboration, epistemic justice and the co-existence of multiple truths, creates opportunities for individuals, families and communities from a wide range of backgrounds to co-produce knowledge in ways that support their capacities for active citizenship and involvement in open democratic decision-making. To fulfil these possibilities, it is necessary for psychotherapy research to be oriented towards social goals that are sufficiently relevant to both researchers and co-participants to harness their passion and work together for a common good.