Table Of ContentCLIENTS` 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
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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
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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
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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
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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.
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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.
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Copyright Statement
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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
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acknowledge that it will be subjective and I will aim for transparency by acknowledging
my personal situation of researcher, manager and person-centred therapist.
1.2. PSYCHOLOGICAL THERAPIES IN THE NHS
In 2006, a report by The Centre for Economic Performance`s Mental Health Policy
Group, which has become known as The Layard Report, estimated that 16% of the UK
population have common mental health problems such as anxiety and depression
(Layard, et al, 2006, p.4). As many of these present to their General Practitioner (GP)
for treatment there is a demand for psychological therapy provided by the NHS. To
begin with much of this demand in primary care was met by counselling so that at the
end of the twentieth century it was estimated that 50% of general practices in the UK
employed a primary care counsellor (Mellor-Clark, Simms-Ellis and Burton, 2001).
Many primary care counsellors integrated CBT into their practice (eg. Hudson-Allez,
1997). Elsewhere in the NHS, CBT was delivered by clinical psychologists or by
mental health and psychiatric nurses, but there was a lack of trained CBT therapists
(Layard, et al, 2006).
The NHS is driven by government policy and the end of the 1990`s saw the start of a
series of government initiatives to improve the quality of patient care within the NHS.
The most important of these was the requirement for Evidence Based Practice to ensure
that only Empirically Supported Treatments, those which had been demonstrated to be
clinically and cost effective, were offered to patients (Department of Health, 1999). The
National Institute for Clinical Excellence (NICE) (now the National Institute for Health
and Clinical Excellence) was established to assess evidence, and produce clinical
practice guidelines to inform both clinical practice and commissioning decisions (eg.
NICE, 2010; 2011). The requirement for clinicians, service providers and
commissioners to follow NICE`s recommendations, have had a marked effect on the
delivery of mental health services in the UK. According to the evidence based practice
model which underpins NICE, randomised controlled trials and their aggregation into
systematic reviews and meta-analyses are considered to provide the best form of
evidence for identifying effective treatments (NICE, 2009, p.159). There is a
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considerable amount of this type of evidence for the effectiveness of CBT while PCT is
characterised by a lack of evidence of this type.
The NICE guidelines recommend CBT as the treatment of choice for all primary mental
health conditions (NICE, 2010, p.213, p.296; NICE, 2011, p.131, p.177). Both
guidelines attribute the development of counselling to Carl Rogers (NICE, 2010, p.261;
NICE, 2011, p.137) but describe counselling today as a generic term used to describe a
broad range of interventions into which counsellors integrate other approaches (Bower,
Rowland and Hardy, 2003). The guideline for the treatment of generalised anxiety
disorder (GAD) reviews the evidence for “non-directive therapy” and concludes that
they can make no recommendations in the treatment of GAD due to the absence of
evidence (NICE, 2011, p.174). The guideline for the treatment of depression reviews
the evidence for counselling and recommends counselling for people with persistent
subthreshold depressive symptoms or mild to moderate depression, who decline the
other recommended treatments, providing the practitioner “discuss with the person the
uncertainty of the effectiveness of counselling.....in treating depression,” (NICE, 2010,
p.297).
The Layard Report (Layard, et al, 2006) highlighted NICE`s recommendation for CBT
and calculated that an extra 10,000 CBT therapists were needed if the recommendations
were to be met. In response, the UK Government instituted The Improving Access to
Psychological Therapies (IAPT) Program with the aim of developing teams of therapists
from a range of professional groups who had been given rigorous training in CBT.
These would provide services that delivered treatments for depression and anxiety
disorders which are approved by NICE (Department of Health, 2007; 2011).
1.3. THE PRIMARY MENTAL HEALTH TEAM (PMHT)
This section provides a brief introduction to the PMHT, it`s history, development and
my own involvement with it. The counselling service, of which I was manager, began
in 2001 in response to the demand for psychological therapy in primary care and was
commissioned to provide a service to the GP practices in the locality. Initially,
counsellors were employed as part of a clinical psychology service and only counsellors
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