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Therapist Discourse in Manualised Therapy for Alcohol Addictions

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Therapist Discourse in Manualised Therapy for Alcohol Addictions View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by White Rose E-theses Online THERAPIST DISCOURSE IN MANUALISED THERAPY FOR ALCOHOL ADDICTIONS Hannah Rachel Capon Submitted in accordance with the requirements for the degree of Doctor of Clinical Psychology (D. Clin. Psychol.) The University of Leeds Academic Unit of Psychiatry and Behavioural Sciences School of Medicine February 2014 1 The candidate confirms that the work submitted is his/her own and that appropriate credit has been given where reference has been made to the work of others This copy has been supplied on the understanding that it is copyright material and that no quotation from the thesis may be published without proper acknowledgement. © 2014 The University of Leeds and Hannah Rachel Capon The right of Hannah Rachel Capon to be identified as Author of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act 1988. 2 Acknowledgements Firstly, I would like to thank my supervisors Dr Carol Martin and Dr Shona Hunter for their wise words, support and encouragement throughout my research. I don’t know what I would have done without them. I would like to thank Gillian and Duncan for giving me access to the data, and all the research team at the Addiction Unit for their good humoured help with getting to grips with the pragmatics of the data. I am also extremely grateful to all the therapists and clients who took part in the UKATT trial, which enabled this research to be possible. Finally, I would like to thank my family and friends especially Paul, Matt, Judy, Phil, and Ellen, for their kind words and even kinder actions which have kept me going when I otherwise would not have been able to. 3 Abstract In the context of the rising agenda of evidence based practice, the use of treatment manuals is now common in psychotherapeutic treatments for addiction and other mental health issues. There is debate amongst clinicians and researchers regarding the trade-off between the costs and benefits of manuals; and differing opinions regarding the importance of treatment fidelity. One concern that clinicians often raise is the effect that manuals have on clinical judgement and responsivity, and one benefit that researchers raise is the standardisation of treatment. The purpose of this study was to consider how therapists enact the delivery of manualised through analysing the discourses used. Particular attention was given to how therapists attempted to facilitate behaviour change using both adherent and non-adherent techniques, and how therapists addressed the expression of client emotions. Two types of manualised alcohol addiction therapy sessions were investigated in this study; Motivational Enhancement Therapy, and Social Behaviour and Network Therapy, both taken from the large scale UK Alcohol Treatment Trial (UKATT research team, 2005). A discursive psychology informed analysis was conducted, spanning nineteen therapy sessions with six therapist-client dyads. The interpretative repertoires that therapists used to promote behaviour change were: therapist actions are responsible for enabling change, clients are responsible for changing their own behaviour, and therapeutic alliance is required for change. These were enacted through the following discursive practices: being paternalistic, being critical, persuading, lecturing, using humour, being collaborative, acting as benevolent expert and constructing oneself as a powerful expert. Therapists managed adherence to the manuals and responsivity to the clients in differing ways; at times prioritising one over the other, at other times attending to both, and at other times attending to neither. Therapists responded to clients’ expression of emotions in a variety of ways categorised under two themes of acknowledging and avoiding. The analysis highlighted the variability of therapist responses within both manualised therapies, which is discussed in further detail. The clinical implications, opportunities for further research, and limitations of the study are discussed. 4 Table of Contents Acknowledgements ....................................................................................................................................... 3 Abstract .............................................................................................................................................................. 4 Table of Contents ............................................................................................................................................ 5 List of Tables .................................................................................................................................................... 8 List of Figures .................................................................................................................................................. 8 Abbreviations................................................................................................................................................... 9 Chapter 1. Introduction ............................................................................................................................ 10 1.1 Personal experiences and expectations................................................................................. 10 1.2 Focus of this research study ....................................................................................................... 11 1.3 Understanding of Psychotherapy and discourses used in this context .................... 12 1.3.1 Construction of therapy ....................................................................................................... 12 1.3.2 Discourses used in Therapy ............................................................................................... 14 1.4 The use of treatment manuals in therapeutic interventions ........................................ 19 1.4.1 Common factors in the context of the movement towards evidence based practice (EBP) ..................................................................................................................................... 19 1.4.2 The debate over use of manualised therapy ............................................................... 22 1.4.3 Fidelity when using manuals ............................................................................................. 24 1.5 Therapist factors affecting therapeutic outcomes ............................................................ 28 1.5.1 Research context of therapist factors ............................................................................ 28 1.5.2 Impact of therapist factors ................................................................................................. 29 1.5.3 Therapist factors and manualised therapy .................................................................. 31 1.6 Treatment considerations for alcohol addiction ............................................................... 33 1.6.1 Current treatment guidelines ............................................................................................ 34 1.6.2 Specific alcohol treatments ................................................................................................ 34 1.6.3 Motivational Interviewing and Motivational Enhancement Therapy .............. 35 1.6.4 Manualised Motivational Interviewing (MI) ............................................................... 36 1.6.5 Social Behaviour and Network Therapy (SBNT) ....................................................... 36 1.6.6 The dodo bird in alcohol treatments .............................................................................. 37 1.7 Summary of literature and links to research question .................................................... 38 1.8 Research question and aims ....................................................................................................... 39 1.8.1 Research Question ................................................................................................................. 39 5 1.8.2 Research aims .......................................................................................................................... 39 Chapter 2. Method ....................................................................................................................................... 40 2.1 Theoretical rationale for methodology .................................................................................. 40 2.1.1 Discourse Analysis of psychotherapy interactions................................................... 40 2.1.2 Discursive Psychology (DP) ............................................................................................... 42 2.1.3 Using naturalistic data .......................................................................................................... 42 2.2 Use of secondary data ................................................................................................................... 43 2.3 Ethical Issues .................................................................................................................................... 43 2.3.1 Informed Consent ................................................................................................................... 43 2.3.2 Confidentiality ......................................................................................................................... 44 2.4 Sample ................................................................................................................................................
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