I sortof feelthatoneis meant to say howimportant endings always are…

160 Pages·2016·1.82 MB·English

by  Satara Lester

‘I sort of feel that one is meant to say
how important endings always are…’
Counsellors’ experiences of endings in
primary care: an interpretative
phenomenological analysis
Satara J. Lester
Thesis submitted to London
Metropolitan University in partial
requirement for the Award of
Professional Doctorate in Counselling
Psychology
2016
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Acknowledgements
Iwould liketo begin byacknowledgingthe six counsellors who so generously
gaveoftheirtime to share theirpersonal experiences ofendings with me. Thank
you. Ihopethat Ihavedonejusticeto your openness and the wealth of your
insights.
This research would not havebeenpossible without support ofthe following
individuals to whom Iwould liketo express mysincere gratitude. Iwould liketo
thank DrAngela Loulopoulou,mysupervisor, for herwisdom, encouragement and
support. Iwould also like to thank DrPhilip Haytonforhis thoughtful readingofthe
final draft. Iwould like to thank myinitial supervisor, DrElaineKasket, for her
inspirational guidance,clarityand input in theearlystages. Iwould like to thank Dr
MarkDonati,myDirectorofStudies, forbeinga constant sourceofstrength
throughout mytrainingand foran invaluable discussionabout the service
implications ofthesefindings. Thank you too to DrMelindaRees and Morris Nitzun
who generouslygave oftheir timeforthought-provokingdiscussions about the
serviceimplications,andto Elizabeth Wilson forreadingthe final draft from a
counsellor in primarycare’s perspective. And finally, Iowe great debt of gratitude to
DrAndrew Eagle, myclinical supervisorduring myfirst placement. This ideawas
bornout ofdiscussions in supervision about how therapists experience endings. Iam
indebted to his invaluable practical support and insights as myexternal advisor. This
thesis has been greatlyenrichedbyyourinput.Thank you to youall.
Lastly, Iwould like to thank myfamily,most especiallymymother; myresearch
partner,Jeanne; andmyextraordinaryfriends, Cassie,Philip andPeter.Yourinfinite
love, generosityandbelief in meoverthe years havemeant moreto me than Ican
say.
This thesis is dedicated to the memoryofmylate therapist,BenJames, who
taught meabout good endings.
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Table of Contents
ABSTRACT 7
REFLEXIVESTATEMENT 8
Personal reflexivity 8
Epistemological reflexivity 10
Overview 11
CHAPTERONE:INTRODUCTIONANDCRITICALLITERATUREREVIEW 12
OVERVIEW 12
INTRODUCTION 12
The National Health Service primary carecontext 13
Definitions of ‘counselling’ and ‘counsellor’ in primarycare 14
Thepractice of counselling in primary care 15
CRITICALREVIEWOFTHELITERATURE 16
Literature review method 16
Theoretical literature 17
Terminatingopen-ended therapy 17
Terminatingtime-limited therapy 18
Terminatingcognitive behavioural therapy (CBT) 20
Theorypertaining totherapists’ experiences 21
Empirical literature 23
Clients’ experiences 23
Therapists’ experiences 25
Terminatingpsychoanalysisand psychodynamicpsychotherapy 25
Therapistsof multipleorientationsending longer-term therapy 26
Forced terminations 27
Terminating social work 38
Terminating time-limited therapy 30
Summaryof research intotherapists’ experiences 31
Improving Accessto Psychological Therapy (IAPT) 32
EVALUATINGTHISREVIEW 34
RESEARCHQUESTION,AIMSANDRATIONALE 34
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RELEVANCETOCOUNSELLINGPSYCHOLOGY 36
CHAPTERTWO:METHODOLOGYANDPROCEDURES 38
OVERVIEW 38
RESEARCHDESIGNANDRATIONALE 38
INTERPRETATIVEPHENOMENOLOGICALANALYSIS 38
Interpretative Phenomenological Analysisand epistemological positioning 39
Rationale forInterpretative Phenomenological Analysisand compatibility with
counselling psychology 40
Alternative methods 40
PROCEDURES 42
Participants 42
Recruitment 42
Participantdemographics 42
Interview schedule 43
Pilot study 43
Interview process 43
Ethical Considerations 44
Ethical approval 44
Confidentialityand anonymity 44
Informed consent 44
Debriefing 45
RESEARCHERDECLARATION 45
ANALYTICPROCESS 45
ASSESSINGVALIDITYANDQUALITY 46
METHODOLOGICALREFLEXIVITY 47
CHAPTERTHREE:ANALYSIS 49
OVERVIEW 49
SUMMARYOFSUPERORDINATETHEMESANDSUBTHEMES 49
SUPERORDINATETHEMEONE:SELF-EXPERIENCING 50
Attachmentand loss 51
Bi-directional personal and professional development 54
Reflexivity 57
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SUPERORDINATETHEMETWO:THEQUALITYOFTHETHERAPEUTICPROCESS
–CONNECTING 58
Was it good work? 58
Relational depth 60
Reflexivity 63
SUPERORDINATETHEMETHREE:CONFLICTINGFRAMEWORKS 64
–ITWOULD’VEBEENCRUEL
Psychoanalytic termination theory versustime-limited counselling 64
Ethical frameworksversusendings 66
Autonomy versusomnipresent system 68
Reflexivity 70
SUPERORDINATETHEMEFOUR:TOWARDSCONGRUENCE
–WALKINGALONGSIDEFORABIT 71
Adjusting the frame 71
Detaching andaccepting 74
Metaphorsofending –journeying 77
Reflexivity 79
CHAPTERFOUR:DISCUSSION 81
OVERVIEW 81
SUMMARYOFFINDINGSANDRELATIONTOEXTANTRESEARCH 81
SELF-EXPERIENCING 82
THEQUALITYOFTHETHERAPEUTICPROCESS 84
CONFLICTINGFRAMEWORKS 86
TOWARDSCONGRUENCE 89
Adjusting the frame 89
Detaching andaccepting 92
Metaphorsofending –journeying 93
IMPLICATIONS 96
Implications forpractice 96
Implications fortraining 97
Implications forservices 98
Implications forcounselling psychology 99
LIMITATIONSOFTHECURRENTSTUDY 100
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EPISTEMOLOGICALREFLEXIVITY 101
FUTURERESEARCH 102
FINALREFLECTIONS 103
CONCLUSIONS 104
REFERENCES 106
APPENDICES 136
Appendix 1 –Research Proposal sent to service manager priorto recruitment
presentation at counselling team meeting 137
Appendix 2 –ParticipantInformation Sheet 144
Appendix 3 –ParticipantConsentForm 147
Appendix 4 –DistressProtocol 148
Appendix 5 –Semi-Structured Interview Schedule 149
Appendix 6 –DebriefingInformation Form 151
Appendix 7 –Sample ofannotated participant transcript –Jan 152
Appendix 8 –Table ofmaster themes 154
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Abstract
Ending therapy well iswidely acknowledgedascrucial fortherapeutic gainstobe
maintained over time,yetnumerousauthorscomment on the paucity oftermination
research. There appearsto be no extant research intocounsellors’ experiencesofending
time-limited counselling in primary care (CPC), despite thisbeing a rapidly-expanding
area ofpractice, and theoretical literature suggesting elevated stresslevels, ideological
battlesand burnoutas counsellors adjustto time-limited working within Improving
AccesstoPsychological Therapies(IAPT)services. When the ‘hallmark’ of a good
ending ismutual agreement concerning clientreadiness, towhat extent do traditional
modelsoftermination still hold?The aim ofthisresearch isprovide some preliminary
understanding ofcounsellors’ experiences ofendingswithin thiscontext. A qualitative
design wasemployed. Data were collectedin semi-structured interviewswith six
counsellors, andanalysed using interpretative phenomenological analysis(IPA). Four
overarching themesemerged: ‘self-experiencing’, ‘the quality ofthe therapeutic process’,
‘conflicting frameworks’,and ‘towardscongruence’.These are related towider literature
and implicationsforcounselling psychology (CoP)are discussed. Limitationsand
suggestionsforfuture research are explored.
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Reflexive Statement
Thiscounselling psychology thesisbeginswith a reflexive statement to describe
the researcher’spersonal, ontological andepistemological positioning. Subjectivity isan
inevitable partofresearch (Gough, 2003); however,in reflexive research, the researcher
seeksto maintain awareness ofpersonal biasesand, asfaraspossible, to ‘bracket’ these
tosupport greater rigour (Kasket, 2012). Thisisparticularly important in qualitative
research where the researcher’s personhoodand epistemology are implicated atthe level
ofinterpretative engagementwith the data (Willig, 2008). Reflexivity improvesvalidity,
creating transparency toenable othersto better evaluate trustworthiness(Finlay &
Gough, 2003). It isalsoethical in seeking toaddress power imbalancesbetween
researchersand researched(Etherington, 2004), in keeping with counsellingpsychology
(CoP) values. CoP isdistinguished from other branches ofpsychology by the
philosophical position fromwhich it ispracticed(BritishPsychological Society, 2014;
Duffy, 1990). Itwas inspired by nineteenth-centuryEuropean phenomenological and
existential-phenomenological traditionsand North AmericanHumanism, andit isrooted
in valuing subjective worlds(Strawbridge & Woolfe, 2010). ItsHumanistic originsare
additionally present in itsorientation towardswellbeing and empowerment (Cooper &
Macleod, 2010, p.ix). These influences translate intoresearch that isrespecting of
multiple subjective truths, engageswith inter-subjectivity, valuesdifference, recognises
social contexts, andaspires to empower rather than control (Strawbridge & Woolfe,
2010).
Personal reflexivity
Thissection describes my personal position in relation to the research topic. Loss
wasa theme ofmy childhood. By the age offive, Ihad lived in three different countries
andsaid many goodbyes.A traumatic separation inearly adolescence heraldeda few
difficult yearsin a remoteNamibian town without accessto therapeutic support. I
believe that itwasaroundthistime that my interest in psychology began. Aged18, Iwas
again living in a new country, embarking on my first psychology degree. However,
presentedwith the opportunity to pursue clinical psychology training, Ifelt
uncomfortable with the medical model, turning instead to meditation andthe artsuntil
serendipity led me toCoPwith itsdifferent philosophical underpinnings. Over the years,
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the theme oflosscontinuedin a seriesofbereavements, including the murderofmy
former long-term partner and continued friend. Thisfinal bereavement ledtomy
beginning therapy,andsoon after embarking on mynew training. Towardsthe end of
my training, Ibelieve thatIhave adopted the position ofa reflective scientist
practitioner: to the extentthat empirical research servesourclientsand therapeutic
practice, Iwholeheartedly embrace it, while neverthelessattempting to maintain a
reflective stance on itsusein practice.
My interest in researching therapy endings beganwhile practicing time-limited
therapy within secondarycare during my first year oftraining. Iexperiencedmany ‘good
endings’, sadnesssaying goodbye tempered by joy in clients’ growth and progress;
however, where clients remained vulnerable, managing endingswasoften more difficult.
Irealised that initially thisreflected my inexperienceworking with severe andenduring
psychological difficulties; however, in time, Irealisedthat it additionally relatedto the
intensity ofmy ownpain without psychological supporthaving beenavailable when I
had needed it. Therapy was invaluable in increasing my awareness of these processes, and
through therapy, supervision and experience my endings practice has matured. However,
in my initial searching forliterature on how other therapists managed ending time-limited
therapies, Ifound little tosupport my development andso itseemed to me that this
could offer a valuable contribution to CoP research.
Beginning thisresearch, my assumptions included that caring practitionerswould
experience clientendingswith the same intensity asIhave done. My previous experience
ofresearching the relationship betweenadult attachment style and personality variables
meant that Iwasreceptiveto the considerable empirical evidence forattachment theory.
On the basisofpersonal experience and extensive reading, Ialsoassumed that therapists’
losshistoriesandattachmentstyleswould be implicated in their experiencesofendings. I
wasaware that these assumptionsmight blind me toalternatives. In order to maintain
rigour, Ireadaswidely aspossible, attempting to remain open to multiple perspectives,
and kept a reflexive journal throughout. Isought advice on the design of my interview
schedule. Ire-readanearly reflexive statement priorto the interviews. Iattempted to
remainwithin participants’ frames ofreference both by bracketing, and by asking open
questionsto be guidedby participants’ meanings. Throughout the analysis processitself,
Iattempted to remainas open aspossible to multiple experiences ofendings, and finally,
Isought to ‘triangulate’ my final themeswith research colleagues in a ‘verification step’
(Kasket, 2012). Ihave been transparentabout the potential influence ofpersonal
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experiences; nevertheless, Ihope that my commitment to managing thisinfluence has
resulted in findingsgrounded in participants’ experiences. Maintaining such balance
between reflexivity andawarenessofan intransitive reality functioning independently of
constructionsofit, is compatible with the reflectivescientist practitionerstance that I
have sought to adopt throughout my counselling psychology training.
Epistemological reflexivity
It isincumbent upon researcherstostate their epistemological stance and
conduct research consistentwith it (Madill, Jordan & Shirley 2009). Life experiences that
have led me tovalue subjective ‘realities’ over nomothetic ideals, mean thatIvalue
qualitative research’s capacity to give ideographic voice. Iaccept the existence ofan
external reality functioning independently ofsocialconstructions ofit, while at the same
time understanding ‘knowledge’ ofthisreality asfiltered through interpretative lenses,
and embedded within social contexts. Iunderstand language asanattempt toexpress
‘real’ experience. In thisway, Iespouse a realist ontology with a relativist epistemology,
compatible with Bhaskar’s (1976) critical realism. Iadditionally value critical realism’saim
ofpositively developing knowledge, over constructionism’sscepticism, whichpotentially
rendersethical views obsolete (Cruikshank, 2011; Elder-Vass, 2011). Inkeeping with this,
Iam committed to representing a faithful phenomenological account ofthe ‘reality’ of
participants’ experiences through triangulating findingswith independentresearchers,
while using reflexivity to maintain awarenessof how interpretation may have influenced
the research.
IPA isa qualitative approach committed to exploring lived experience in depth,
complexity, and detail through both phenomenological and interpretative means. It does
notadopt a fixed epistemology; however, it iscompatible with critical realismboth in
seeking knowledge ofanenduring reality, and in recognising such knowledgeas
constructed by interpretation. I concurwith Rizq (2010) that IPA’sconstructivistaspects
are compatible with relational processes, andbelieved thatIPA’ssensitivity toa range of
nuance, expression andsubtleties, including emotion, would support research into
ending therapeutic relationships. In itsvaluing ofsubjective experiencing andits
epistemological openness, IPA isadditionally fundamentally aligned with CoPand
chimeswith my ownpersonal epistemology, ontology, andvalues.
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