20 Qualitative methods at the intersection of psychodynamic therapy and functional neurological disorder: a crisis of interpretation

Background Psychodynamic therapy (PDT), has an empirical evidence base, and a rich literature of therapist perspectives, but a dearth of patient perspectives. People with functional neurological disorder (FND), are often or poorly treated by psychiatry and neurology, because they have physical problems, without the usual neurological causes, and treatment is often prolonged and complicated. The intersection of PDT and FND introduces a dilemma about interpreting unconscious processes, and centres the importance of researcher reflexivity. Aims This paper will explore the intersection of FND and PDT, which represents a crisis of interpretation in qualitative research. Methods This exploration uses the wider literature on FND and PDT, and the analysis of 22 exit interviews from adults with FND after completing a four-session pilot study including PDT. Reflexive thematic analysis was used with critical a realist epistemology. Results Some participants rejected the suggestion by the therapist that their problems were connected to emotions or past experiences, while others found the experience helpful. Psychodynamic theory argues that we may be unconscious of, or actively avoid important aspects of our lives, yet participants should have more privileged access to their own inner world than a therapist. These disagreements may arise from avoidance of unconscious and disturbing material, inaccurate interpretations by the therapist, or shortcomings of the psychodynamic model. Interpreting this data, requires acknowledging the theory-ladenness of PDT, and its limitations, yet we should not dismiss PDT because of this. Above all, it is not acceptable to dismiss participants' consciously reported experience and assume that distress caused by eliciting painful emotions is evidence for the psychodynamic interpretation, as this would be a circular argument and an act of violence. Conclusion Researchers (and therapists) must not assume superior knowledge about their clients' internal world and should instead maintain theory reflexively, as a tentative hypothesis.