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Clients` Experiences of Change in Cognitive Behavioural Therapy and Person-Centred Therapy in Primary Care: a Qualitative Analysis

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Clients` Experiences of Change in Cognitive Behavioural Therapy and Person-Centred Therapy in Primary Care: a Qualitative Analysis CLIENTS` EXPERIENCES OF CHANGE IN COGNITIVE BEHAVIOURAL THERAPY AND PERSON-CENTRED THERAPY IN PRIMARY CARE: A QUALITATIVE ANALYSIS A thesis submitted to the University of Manchester for the degree of Ph.D. in Education in the Faculty of Humanities 2013 Isabel Gibbard School of Environment, Education and Development 0 CONTENTS List of Figures 3 List of Tables 3 Abstract 4 Declaration 5 Copyright Statement 6 1. INTRODUCTION 7 1.1 INTRODUCTION TO THE CHAPTER 7 1.2 PSYCHOLOGICAL THERAPIES IN THE NHS 8 1.3 THE PRIMARY MENTAL HEALTH TEAM 9 1.4 THE POLITICAL CONTEXT AND MY PERSONAL POSITION 11 1.5 THE RATIONALE FOR THE RESEARCH 12 1.6 THE STRUCTURE OF THE THESIS 16 2. LITERATURE REVIEW 17 2.1 INTRODUCTION TO THE CHAPTER 17 2.2 THE EQUIVALENCE OF CBT AND PCT 18 2.3 THEORIES OF CHANGE 21 2.4 THE COMMON FACTORS THEORY 32 2.5 THE ACTIVE CLIENT THEORY 37 2.6 RESEARCH INTO CLIENT EXPERIENCE 47 2.7 CHAPTER REVIEW AND RESEARCH QUESTIONS 54 3. METHODOLOGY 56 3.1 INTRODUCTION TO THE CHAPTER 56 3.2 THE RESEARCH DESIGN 57 3.3 DATA COLLECTION 69 3.4 DATA ANALYSIS 82 3.5 TRUSTWORTHINESS 92 3.6 ETHICAL CONSIDERATIONS 96 3.7 CHAPTER REVIEW 100 1 4. FINDINGS 101 4.2 INTRODUCTION TO THE CHAPTER 101 4.2 OVERVIEW OF THE FINDINGS 102 4.3 HIGHER CATEGORIES 106 4.4 IT DID THE TRICK AND THE KEY 145 4.5 KEY REALISATIONS 150 4.6 CONCLUDING THE ANALYSIS 163 4.7 CHAPTER REVIEW 177 5. DISCUSSION 179 5.1 INTRODUCTION TO THE CHAPTER 179 5.2 THE ACTIVE CLIENT 180 5.3 THE THERAPEUTIC CONDITIONS 188 5.4 MECHANISMS OF CHANGE 192 5.5 THE CORE CATEGORY 199 5.6 INTERESTING PARADOXES 206 5.7 PRACTICAL IMPLICATIONS 210 5.8 CHAPTER REVIEW 214 6. FINAL SUMMARY AND CONCLUSIONS 216 6.1 A BRIEF SUMMARY OF THE PROJECT 216 6.2 CONCLUSIONS 217 6.3 METHODOLOGICAL DISCUSSION 218 6.4 POSSIBILITIES FOR FUTURE RESEARCH 222 6.5 FINAL PERSONAL REFLECTIONS 223 REFERENCES 226 2 APPENDIX 1 Participant Information Tables 262 APPENDIX 2 IAPT Minimum Dataset Outcome Measures 265 APPENDIX 3 Introductory Information and Opt-in sheets 267 APPENDIX 4 Interview Protocol 271 APPENDIX 5 Member Check 273 APPENDIX 6 Consent Form 277 APPENDIX 7 Full Categories 278 List of Figures Figure 1 Lambert`s Pie 33 Figure 2 Elements of the Research Process 58 Figure 3 Cyclical Research Design 59 Figure 4 Scatter Plot 64 Figure 5 Process Map of Higher Categories 105 List of Tables Table 1 Higher Categories 103 Table 2 Key Realisations and the Elements of Therapy that Did 149 The Trick 3 Abstract The aim of this qualitative research project was to investigate the experiences of clients who had received Cognitive Behavioural Therapy (CBT) and Person Centred Therapy (PCT) in primary care. The rationale for the investigation was to inform the assessment and referral process whereby prospective clients are assigned to the two different therapies. A total of 16 clients responded to an invitation to attend an unstructured interview (PCT = 9; CBT = 7) to talk about their experiences of therapy. The resulting transcripts were analysed using Grounded Theory methodology. Transcripts were broken down into meaning units and conceptualised as categories, using the constant comparison method. The categories were integrated, a core category conceptualised and a theory generated. A comparison of the accounts revealed similar and contrasting experiences. The main categories (eg Accessing therapy, Engaging with the therapy) could be organised in the chronological order of the client`s journey through therapy. All participants entered therapy with a particular view of reality. In successful therapy this view changed and they went on to manage their lives in a more constructive way. Participants attributed this change to different elements of the therapy (categorised as It did the trick) which brought about a new understanding (categorised as The key). Where therapy was unsuccessful this did not occur. The mechanism of change was personal to the individual and did not appear to be specific to either therapy. Some of the mechanisms appeared to be consistent with the therapy received (eg. Carrying out tasks, in the CBT group). Others appeared counterintuitive (eg. Putting me straight, in the PCT group). The differences and similarities in the participant`s experiences appeared to be due to the therapist and client`s capacity to respond to each other in order to make the therapy “work.” The Core Category, Reciprocal Responsiveness, was chosen to explain this. The findings also suggest that the ability of the therapist and client to respond to each other will affect the outcome of therapy. The theory was constructed that the outcome of therapy is determined by the occurrence of a sufficient degree of Reciprocal Responsiveness. This study has implications for the assessment process as the findings suggests that, when making a referral, it may be helpful, to take into account the potential client`s activity and responsiveness rather than relying solely on diagnosis. It also contributes to the growing body of literature emphasising the importance of therapist responsiveness to the individual needs of the client, rather than strict adherence to one therapeutic approach. The study is limited to two therapies within primary care. Future studies may consider clients experiences within other settings and with other therapeutic approaches. 4 Declaration No portion of the work referred to in the thesis has been submitted in support of an application for another degree or qualification of this or any other university or other institute of learning. 5 Copyright Statement The author of this thesis (including any appendices and/or schedules to this thesis) owns certain copyright or related rights in it (the “Copyright”) and she has given The University of Manchester certain rights to use such Copyright, including for administrative purposes. Copies of this thesis, either in full or in extracts and whether in hard or electronic copy, may be made only in accordance with the Copyright, Designs and Patents Act 1988 (as amended) and regulations issued under it or, where appropriate, in accordance with licensing agreements which the University has from time to time. This page must form part of any such copies made. The ownership of certain Copyright, patents, designs, trademarks and other intellectual property (the “Intellectual Property”) and any reproductions of copyright works in the thesis, for example graphs and tables (“Reproductions”), which may be described in this thesis, may not be owned by the author and may be owned by third parties. Such Intellectual Property and Reproductions cannot and must not be made available for use without the prior written permission of the owner(s) of the relevant Intellectual Property and/or Reproductions. Further information on the conditions under which disclosure, publication and commercialisation of this thesis, the Copyright and any Intellectual Property and/or Reproductions described in it may take place is available in the University IP Policy (see www.campus.manchester.ac.uk/medialibrary/policies/intellectual-property.pdf ), in any relevant Thesis restriction declarations deposited in the University Library, The University Library’s regulations (see www.manchester.ac.uk/library/aboutus/regulations) and in The University’s policy on Presentation of Theses. 6 1. INTRODUCTION 1.1 INTRODUCTION TO THE CHAPTER Short term Person-Centred Therapy (PCT) and Cognitive Behavioural Therapy (CBT) are both interventions in primary mental health care. The philosophy, theory and interventions of the two approaches are very different, while in routine practice they have been demonstrated to be similarly effective and beneficial (eg. Stiles, et al, 2008). In this thesis I present an account of a qualitative research study into the experiences of clients who have received the two different kinds of therapy, CBT and PCT. I conducted this research over a period of four years in the naturalistic setting of a primary mental health team (PMHT) in the National Health Service (NHS) in England. The PMHT offers both CBT and PCT to potential clients and decisions are made about people`s suitability for either therapy during the assessment procedure. I undertook this research with the aim of informing the assessment and referral procedure, and of contributing to the development of a theoretical basis for the integration of different therapies in a single service. In this introductory chapter, I hope to give the reader an understanding of the operational, political and personal context in which the research took place. The operational context is relatively straightforward. However, the situation in the NHS and the wider world of psychotherapy is extremely complex and this account will reflect the multilayered and often confusing situation which, for me, is an everyday reality. I begin by outlining the background to the project. This consists of a brief account of the development of psychological therapies within the NHS and a description of the PMHT where the research took place. I follow this with a short discussion of the political situation in the NHS and the wider psychotherapy world, and of my own position in relation to the project. I then go on to give a brief explanation of the rationale for the research. I will make some reference to the supporting literature in this chapter, but the greater part is presented within the Literature Review of this thesis. I hope the reader will appreciate that the complexity of the circumstances and the limits of space means that this account will inevitably be far from complete. I end the chapter with a brief overview of the structure of the whole thesis. In presenting this account I also 7 acknowledge that it will be subjective and I will aim for transparency by acknowledging my personal situation of researcher, manager and person-centred therapist.
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