City Research Online City, University of London Institutional Repository Citation: Sreenan, Brian (2013). Personalised treatments in CBT and the therapeutic alliance in IAPT. (Unpublished Doctoral thesis, City University London) This is the unspecified version of the paper. This version of the publication may differ from the final published version. Permanent repository link: https://openaccess.city.ac.uk/id/eprint/3670/ Link to published version: Copyright: City Research Online aims to make research outputs of City, University of London available to a wider audience. Copyright and Moral Rights remain with the author(s) and/or copyright holders. URLs from City Research Online may be freely distributed and linked to. Reuse: Copies of full items can be used for personal research or study, educational, or not-for-profit purposes without prior permission or charge. 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City Research Online: http://openaccess.city.ac.uk/ [email protected] Personalised treatments in CBT and the therapeutic alliance in IAPT Brian Graham Sreenan Submitted in fulfilment of the requirements for the Professional Doctorate in Counselling Psychology (DPsych) City University, London Department of Psychology October 2013 1 Table of contents Table of contents ................................................................................................................ 2 List of figures .................................................................................................................... 10 List of tables ..................................................................................................................... 11 Acknowledgements ........................................................................................................... 12 Declaration of powers of discretion ................................................................................... 13 Preface ............................................................................................................................. 14 References .............................................................................................................................. 16 Chapter A – Research ........................................................................................................ 17 The importance of the therapeutic alliance in IAPT: A mixed methods investigation ........... 17 Abstract ................................................................................................................................... 18 Prolegomenon ......................................................................................................................... 19 1. Introduction ........................................................................................................................ 22 1.1 Role of the NHS in the medical model .......................................................................... 22 1.2 Manualisation of therapy .............................................................................................. 24 1.3 Manualisation and the IAPT initiative ........................................................................... 25 1.3.1 IAPT Curriculum ..................................................................................................... 30 1.3.2 Therapeutic frame ................................................................................................. 30 1.4 The evolution of the conceptualisation of the Therapeutic Relationship .................... 32 1.4.1 The operationalisation of the Therapeutic Relationship – The Therapeutic Alliance ........................................................................................................................................ 33 1.5 IAPT, CBT, and the therapeutic alliance ........................................................................ 36 2. Literature Review ................................................................................................................ 39 2.1 The TA and its relation to outcome .............................................................................. 39 2 2.2 CBT, core conditions and outcome ............................................................................... 41 2.3 Therapist experience, adherence to CBT, and their impact on the TA ......................... 44 2.3 Training and the TA ....................................................................................................... 47 2.5 Pre-therapy assessment and the TA ............................................................................. 49 2.6 Pre-therapy severity of impairment and the TA ........................................................... 52 2.7 The aim of the current study – Introducing the research question .............................. 53 2.7.1 Initial research reflections ..................................................................................... 54 3. Epistemology and Methodology ......................................................................................... 56 3.1 Overview ....................................................................................................................... 56 3.2 Research Question ........................................................................................................ 56 3.3 Mixed Methods Research - Introduction ...................................................................... 57 3.3.1 ‘Scientific’ research and the ‘scientist-practitioner’ .............................................. 57 3.3.2 Mixed methods research and Pragmatism ............................................................ 59 3.3.2.1 Positivism/Postpositivism vs Constructionism/ Interpretivism ...................... 59 3.3.2.4 Pragmatism ..................................................................................................... 60 3.3.3 Pragmatism and Counselling Psychology ............................................................... 63 3.4 Epistemological positioning: Which methodological tools can facilitate an exploration of the outlined research questions? ................................................................................... 64 3.4.1 Epistemology for Part I – Qualitative Section ........................................................ 64 3.4.1.1 Thematic Analysis and its virtues .................................................................... 66 3.4.1.2 Criticisms of Thematic Analysis ....................................................................... 66 3.4.1.3 Issues of validity and reliability in qualitative research .................................. 67 3.4.2 Epistemology for Part II – Quantitative questionnaires ......................................... 68 3.4.2.1 Criticisms of quantitative methods ................................................................. 69 3.4.2.2 Issues of validity and reliability in quantitative research ............................... 69 3.5 Linking Part I and Part II ................................................................................................ 70 4. Qualitative Method ............................................................................................................. 71 3 4.1 Part 1 – Exploring clinicians’ understanding and use of the Therapeutic Alliance in IAPT ............................................................................................................................................ 71 4.1.1 Designing Part I of the research ............................................................................. 71 4.1.2 Developing the interview schedule........................................................................ 73 4.1.3 Piloting the interview schedule.............................................................................. 74 4.1.4 Inclusion criteria ..................................................................................................... 74 4.1.5 Recruitment strategy ............................................................................................. 74 4.1.6 Sample size ............................................................................................................. 76 4.1.7 Participant characteristics ...................................................................................... 77 4.1.7.1 Trainee focus group ........................................................................................ 77 4.1.7.2 Qualified focus group ...................................................................................... 77 4.1.8 Process of analysis ................................................................................................. 77 4.1.9 Ethical considerations ............................................................................................ 78 5. Qualitative Results .............................................................................................................. 80 5.1.1 The impact of the IAPT trainee experience on the TA ........................................... 81 5.1.1.1 Extent of therapists’ experience and the TA ................................................... 81 5.1.1.2 The TA within IAPT training ............................................................................. 82 5.1.1.3 The trainee “agenda” in therapy .................................................................... 84 5.1.2 Equality in the relationship versus early IAPT protocol ......................................... 85 5.1.2.1 Perceived impact of protocol on TA ............................................................... 85 5.1.2.2 The perceived importance of humanistic principles in the TA ....................... 89 5.1.3 Severity of client symptoms and impact on TA ..................................................... 91 5.1.4 Summary ................................................................................................................ 92 6. Quantitative Method .......................................................................................................... 93 6.1 Part 2 – The impact of the Therapeutic Alliance in IAPT .............................................. 93 6.1.1 Designing Part I of the research ............................................................................. 93 6.1.2 Selecting appropriate questionnaires .................................................................... 94 4 6.1.2.1 Helping Alliance Questionnaire II (HAq-II) ...................................................... 94 6.1.2.2 Patient Health Questionnaire-9 (PHQ-9) ........................................................ 94 6.1.2.3 Generalised Anxiety Disorder-7 (GAD-7) ........................................................ 95 6.1.2.4 Data screening ................................................................................................ 95 6.1.3 Inclusion criteria ..................................................................................................... 95 6.1.3.1 Therapists ........................................................................................................ 95 6.1.3.2 Clients .............................................................................................................. 95 6.1.4 Recruitment strategy ............................................................................................. 96 6.1.5 Sample characteristics ........................................................................................... 96 6.1.5.1 Sample size ...................................................................................................... 96 6.1.5.2 Participants ..................................................................................................... 96 6.1.5.2.1 Therapists ................................................................................................. 96 6.1.5.2.2 Clients ....................................................................................................... 97 6.1.5.4 The IAPT context ............................................................................................. 99 6.1.6 Ethical considerations and Methodological reflexivity .......................................... 99 6.1.6.1 The exclusion of non-English speakers ......................................................... 100 6.1.6.2 Disruption of the therapeutic process due to the HAq-II ............................. 101 6.1.6.3 Methodological reflexivity ............................................................................ 101 7. Quantitative Results .......................................................................................................... 103 7.1.1 Quantitative Questions ........................................................................................ 103 7.1.2 Layout of quantitative results .............................................................................. 104 7.1.3 Those included in the study - Comparing the two groups – Trainees vs. Qualified IAPT therapists .............................................................................................................. 105 7.1.3.1 Therapists (n=18) .......................................................................................... 105 7.1.3.2 Clients ............................................................................................................ 106 7.1.4 Question 1 – Is there a difference in TA scores between the Trainee and Qualified groups at session two and end of treatment? .............................................................. 106 5 7.1.5 Question 2– Was a strong early TA present in both groups? Was there a significant difference between early and late TA between the two groups? ............... 108 7.1.6 Question 3 – Does symptom severity relate to therapist and client TA scores? . 109 7.1.7 Question 4 – Does the TA (therapist versus client perception) predict outcome in depression and anxiety? ............................................................................................... 110 7.1.7.1 Tests of normality and homogeneity of variance for multiple linear regression .................................................................................................................................. 111 7.1.7.2 Bivariate correlations between Dependent variables, Independent variable, and between Dependent and Independent variables .............................................. 112 7.1.7.2.1 Correlations between the IVs ................................................................ 112 7.1.7.2.2 Correlations between DVs ..................................................................... 113 7.1.7.2.3 Correlations between DVs and their respective time 1 measures ........ 113 7.1.7.2.4 Correlations between DVs and IVs ......................................................... 114 7.1.7.3 Backward Multiple Linear Regression ........................................................... 114 7.1.7.3.1 Regression using Depression as DV ....................................................... 115 Statistical Assumptions for Backward Regression – Change in Depression as DV 117 5.2.7.3.2 Regression using Anxiety as DV ............................................................. 117 Statistical Assumptions for Backward Regression – Change in Anxiety as DV ..... 119 7.1.7.3.3 Summary of regression results .............................................................. 119 8. Discussion .......................................................................................................................... 121 8.1 Summary of findings and their relation to current research ...................................... 121 8.1.1 Question 1 – Is there a difference in TA scores between the Trainee and Qualified groups at session two and end of treatment? .............................................................. 121 Summary of previous research ................................................................................. 122 Contrasts or additions to previous research ............................................................. 123 Future research ......................................................................................................... 124 8.1.2 Question 2 - Was a strong early TA present in both groups? Was there a significant difference between early and late TA between the two groups? ............... 125 Summary of previous research ................................................................................. 127 6 Contrasts or additions to previous research ............................................................. 127 Future research ......................................................................................................... 128 8.1.3 Question 3 – Does symptom severity relate to therapist and client TA scores ... 128 Summary of previous research ................................................................................. 129 Contrasts or additions to previous research ............................................................. 129 Future research ......................................................................................................... 129 8.1.4 Question 4 - Therapist versus client perception of the TA as a predictor of outcome ........................................................................................................................ 130 Contrasts or additions to previous research ............................................................. 130 Future research ......................................................................................................... 132 8.2 Delimitations of the current study .............................................................................. 133 Recording outcomes in IAPT ......................................................................................... 133 Lack of a control group ................................................................................................. 136 Potential confounding variables ................................................................................... 137 Number of participants ................................................................................................. 137 8.3 Implications for general practice and Counselling Psychology ................................... 138 8.4 Conclusions and reflections ........................................................................................ 141 Research reflections ...................................................................................................... 142 Reflection on the design of the project ........................................................................ 143 References ............................................................................................................................ 145 List of Appendices ................................................................................................................. 166 Appendix 1 - Genealogy of alliance concepts and scales - adapted from Elvins & Green, 2008 – Scale acronyms and references ............................................................................ 166 Appendix 2 – Phases of thematic analysis ........................................................................ 171 Appendix 3 – Interview schedule ...................................................................................... 172 Appendix 4 – Invitation – Therapist version ..................................................................... 174 Appendix 5 – Participant information sheet – Therapist version ..................................... 175 Appendix 6 – Consent form – Therapist version ............................................................... 179 7 Appendix 7 – Invitation – Client version ........................................................................... 180 Appendix 8 – Participant information sheet – Client version ........................................... 181 Appendix 9 – Consent form – Client version .................................................................... 185 Appendix 10 – The Helping Alliance Questionnaire – Revised (HAq-II) – Therapist version .......................................................................................................................................... 186 Appendix 11 – The Helping Alliance Questionnaire – Revised (HAq-II) – Client version .. 188 Appendix 12 – Patient Health Questionnaire (PHQ-9) ..................................................... 190 Appendix 13 – Generalised Anxiety Disorder (GAD-7) Questionnaire ............................. 191 Appendix 14 – Full regression table; Change in Depression as Outcome......................... 192 Appendix 15 - Full regression table; Change in Anxiety as Outcome ............................... 193 Chapter B – Critical Literature Review .............................................................................. 194 Compulsive hoarding: A subtype of OCD or separate disorder? Exploring the success of CBT- style treatments and neuropsychological approaches ......................................................... 194 Prolegomenon ....................................................................................................................... 194 1. Introduction ...................................................................................................................... 195 1.1 OCD ............................................................................................................................. 195 1.2 Epidemiology ............................................................................................................... 195 1.3 OCD as a Heterogeneous disorder .............................................................................. 196 1.4 Delineating Hoarding from OCD ................................................................................. 197 3. OCD Symptom type as predictors of outcome for treatment .......................................... 201 3.1 Checking v Cleaning .................................................................................................... 201 3.2 Sexual/Religious Obsessions ....................................................................................... 202 3.3 Hoarding ...................................................................................................................... 202 4. Models of Hoarding and Treatment trials ........................................................................ 203 4.1 Exposure with Response prevention (ERP/CBT) ......................................................... 203 4.1.1. Trials using ERP/CBT ............................................................................................ 203 4.2 Specialised CBT Model for Compulsive Hoarding ....................................................... 206 4.2.1 Trials using Specialised CBT for Compulsive Hoarding ........................................ 207 8 4.3 Multimodal (psycho- and pharmaco-therapy) Treatment for OCD and Compulsive- Hoarding ............................................................................................................................ 209 5. Conclusion ......................................................................................................................... 210 References ............................................................................................................................ 213 9