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The Effective Practitioner: the Role and Contribution of Therapist Effects in the Delivery of Psychological Therapies

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The Effective Practitioner: the Role and Contribution of Therapist Effects in the Delivery of Psychological Therapies "THE EFFECTIVE PRACTITIONER: THE ROLE AND CONTRIBUTION OF THERAPIST EFFECTS IN THE DELIVERY OF PSYCHOLOGICAL THERAPIES” A thesis submitted in fulfilment of the requirement for the Degree of Doctor of Philosophy Jo-Ann Pereira Department of Psychology University of Sheffield 2015 i Declaration I hereby declare that this thesis is my work and effort carried out under the supervision of Professor Michael Barkham and Dr Stephen Kellett. It has not been submitted anywhere for any award. Where other sources of information have been used, they have been acknowledged. Signature: …………………………………… Date: ……15 March 2016……………… i Abstract Background: Variability in human performance is a naturally occurring phenomenon and applies to practitioners. Mainstream psychotherapy research has focused on treatments rather than practitioners and has viewed variability as error within the dominant paradigm of the randomised controlled trial. Aims: To investigate variability via the role of practitioner personal qualities and their association with differential patient outcomes, their contribution to effective practice, and the extent these qualities vary with patient severity. Method: A practice-based paradigm was adopted and sampled practitioners and data within a single Improving Access to Psychological Therapies (IAPT) service. The full sample comprised 42 practitioners – psychological wellbeing practitioners, counsellors, and cognitive-behaviour therapists – who completed measures of resilience, empathy, and mindfulness as well as provided qualitative accounts of their practice. A series of seven sequential studies utilised subsamples of the responses from these 42 practitioners, which were analysed prior to yoking with their patient outcome data to determine associations with more and less effective practice. Studies comprised mixed and integrated quantitative and qualitative analyses comparing benchmarking and multilevel modelling research methods (N=37) and thematic analysis (N=6). Results: Significant variability in practitioner effectiveness was found. Practitioners’ personal aspects were associated with patient outcomes and were influenced by their professional roles, level of treatment intensity provided, and their theoretical orientation. Practitioners’ mindfulness and combined resilience and mindfulness were associated with better patient outcomes and this role increased as patient severity increased. In contrast, empathy did not differ between more and less effective practitioners, with more effective practitioners showing marginally lower levels of empathy. Conclusion: Findings suggest that more effective practitioners do differ from less effective practitioners in the personal aspects they bring to their professional practice. Findings have implications for practitioner training and routine practice. The findings are limited in their generalisability and may only apply to IAPT services. ii Acknowledgements This thesis is beyond what I could ever dream of and I am grateful to all those who have helped, supported and/or challenged me on this road. I am grateful to Michael Barkham, as my primary supervisor, for believing in me, especially at times when I found it hard to believe that I could keep going. Thank you for your commitment to enrich my learning, and giving your time and effort while maintaining high academic standards. Also, for giving me the opportunity to experience first-hand (through attending conferences and delivering presentations), that research thrives within a research community. And that ideas can flourish out of connections and relationships with other researchers/practitioners. Thank you. Many thanks to Stephen Kellett, as my secondary supervisor, for helping me appreciate more of what is involved while working in a team and how to draw on different perspectives. I am grateful for your support, encouragement, and providing me with a more practical appreciation of research and its application to practitioners. Thank you for giving me the opportunity to approach practitioners in the Trust and the opportunity to present our research findings to a more diverse group of researchers. I am grateful to Dave Saxon as my statistics mentor. Thank you for being available and giving time to help me find my feet with multilevel modelling. Being someone who initially did not realise what I was getting into, you helped make my experience of learning the analyses so much lighter and easier. Your passion for multilevel modelling is contagious. It has been a joy to work with you. To university staff, especially staff at the Centre for Psychological Services Research (CPSR), the Psychology Department, and the University Library. Thank you for assisting me with my many needs – particularly administrative and academic (know how on technical tasks). Your support helped me feel at home especially in my first year while I adjusted geographically (having travelled from Australia to Sheffield), and career-wise (from being a practitioner to researcher). iii To the NHS Trust staff and practitioners. I remain grateful to you. Thank you to the Sheffield NHS Trust for giving me the opportunity to conduct this research. To the practitioners, for your time and willingness to be part of yet another research project, given your primary work at hand. You have been an inspiration to me and shown me first-hand how research and routine practice can certainly go together. To my family who know me the most, thank you for your love, faith and encouragement. Especially to my mother who has been there for me every step of the way. Thank you for walking this road with me. To God who has been my foundation, especially through times when I have been called to adjust or adapt to more changes and challenges. Thank you for everything and graces that have seen me through this endeavour. In thanking all who have helped me arrive, I further thank you. iv Scientific dissemination and related publication Published paper: Pereira J-A., & Barkham M. (2015). An exceptional, efficient, and resilient therapist: A case study in practice-based evidence. Commentary on Hansen B. P., Lambert, M. J., & Vlass, E. N. Sudden gains and sudden losses in clients of a “Supershrink”: 10 case studies. Conference, special interest group and masterclass presentations: Pereira J-A., Barkham M., Kellett S., & Saxon, D. (2015, July). Examining practitioners’ personal aspects that contribute to effective practice. Research presentation at the 43rd British Association for Behavioural & Cognitive Psychotherapies (BABCP) Conference and Workshops, Warwick, UK. Pereira J-A., Barkham M., Kellett S., & Saxon, D. (2014, Oct). IAPT Masterclass: Using data to enhance practice – Effective practice. Research presentation at Sheffield IAPT Masterclass, Sheffield UK. Pereira J-A., Barkham M., Kellett S., & Saxon, D. (2014, June). The Art of Practice: Examining common factors that contribute to effective practice. Research presentation at Society for Psychotherapy Research (SPR), 45th International Annual Meeting, Copenhagen, Denmark. Pereira J-A., Barkham M., Kellett S., & Saxon, D. (2014, May). The Art of Practice: Examining common factors which contribute to effective practice of psychological therapies. Research presentation at British Association for Counselling & Psychotherapy (BACP) Annual research conference, London. Pereira J-A., Barkham M., Kellett S., & Saxon, D. (2013, Oct). The Art of Practice: Assessing mindfulness in practitioners. Research presentation at practitioner Special Interest Group for mindfulness. Sheffield, UK. v Pereira J-A., Barkham M., Kellett S., & Saxon, D. (2013, May). Examining characteristics of effective practitioners. Research presentation at psychology postgraduate conference. The University of Sheffield, UK. (Awarded best 2nd year post-graduate level presentation) Pereira J-A., Barkham M., Kellett S., & Saxon, D. (2012, May). Therapist effects in Routine Practice. Research presentation at psychology postgraduate conference. The University of Sheffield, UK. vi Table of contents Declaration ....................................................................................................................................... i Abstract ........................................................................................................................................... ii Acknowledgements ........................................................................................................................ iii Scientific dissemination and related publication ............................................................................. v Table of contents ........................................................................................................................... vii Table of appendices...................................................................................................................... xiv List of figures ................................................................................................................................ xv List of tables ................................................................................................................................ xvii Abbreviations ................................................................................................................................ xx 1 Chapter 1 Variability as a phenomenon in the psychological therapies .......................................................... 1 1.1 Variability ...............................................................................................................................
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