Therapists' experiences of the therapeutic alliance with clients with drug problems

177 Pages·2014·1.79 MB·English

Therapists’ experiences of the therapeutic alliance
with clients with drug problems: An interpretative
phenomenological analysis

By
Henrike Andersson

Thesis submitted in partial fulfilment of the requirements of the University of East London
for the degree of Professional Doctorate in Counselling Psychology

February 2014
Acknowledgements
The submission of this thesis has been made possible with the assistance of a number of
people to whom I am greatly indebted.

I would like to thank the therapists who gave so generously of their time to my study, thus
allowing me to explore how they make sense of the alliance with clients with drug
problems. I am also grateful to the organisation within which I carried out the research for
providing me with the opportunity to interview their therapists.

My supervisor, Dr Jane Lawrence, deserves much praise for her guidance and availability.
Your supervision provided the holding space that enabled me to make sense of the struggles
on my research journey, and your clinical experience and capacity for overview have been
invaluable to me.

I am particularly grateful for the relentless support given to me by my parents over the
years. You are far away, but words cannot express how much I value your continued
presence, encouragement and belief in me. This thesis is for you, and for those we lost
along the way.

I
Abstract
The therapeutic alliance is fundamental for therapists who work with clients with drug
problems. The alliance is central to engaging and retaining clients with drug problems in
treatment and in facilitating a positive treatment outcome. Moreover, clients with drug
problems may have significant difficulties in relating to others, which manifests itself in the
client-therapist relationship. There is a paucity of research investigating therapists’
perceptions of the alliance with clients who use drugs. Consequently, this study aimed to
explore how therapists experience and understand the alliance with clients who use drugs.
Six therapists were interviewed and their narratives analysed using Interpretative
Phenomenological Analysis.

The data analysis generated four superordinate themes; Trapped in the system; Struggling
to connect; The contradictory therapist and Resources transcending the alliance. The
themes illustrate the participants’ experiences of how they have little choice but to work
within a treatment system they perceive as impacting upon the alliance. Moreover, most
participants experience their clients as unreachable, and the results suggest that therapists
may take responsibility for developing and maintaining the alliance to accommodate their
clients’ ambivalence. The participants further seem contradictory in their understanding of
the alliance, which indicates their struggle to acknowledge the difficulties and differences in
forming the alliance with their clients as opposed to with generic clients. The participants
describe how clinical supervision, peer support and the use of self enable them to connect
with their clients. Finally, the study demonstrates that the participants experience the
alliance as heavily intertwined with unconscious processes.

The study results suggest that therapists require specific and structured support to
acknowledge and manage the challenges inherent in relating to clients with drug problems,
focussing particularly upon the use of self and the management of countertransference.
Moreover, the study highlights the necessity of acknowledging the therapeutic alliance as
inseparable from unconscious processes. Additional recommendations are made in relation
to clinical practice, training and research.
II
Contents
Acknowledgements I
Abstract II
Content page 1
Abbreviations 6
List of tables and accompanying materials 7
Introduction 8

Chapter 1: Literature Review 11
1.1 A note to the reader 11
1.2 Introduction 11
1.3 The therapeutic alliance 12
1.3.1 Therapeutic alliance history and definitions 12
1.3.2 Therapeutic alliance measures 14
1.3.3 Common factors, the alliance and outcome 15
1.3.4 Alliance ruptures 16
1.3.5 Theory of the alliance underpinning the current study 16
1.3.6 ‘Therapeutic alliance’ or ‘therapeutic relationship’? 16
1.3.7 Summary of The therapeutic alliance 17
1.4 The significance of the alliance for therapists who work with clients with drug
problems 17
1.4.1 Attachment theory, substance use and the alliance 17
1.4.2 Stigma and substance use 20
1.4.3 The alliance and outcome and retention in drug treatment 21
1.4.4 Client and counsellor ratings of the alliance 22
1.4.5 Therapist factors 22
1.4.6 Summary of The significance of the alliance for therapists who work with
clients with drug problems 23
1.5 Is quantitative research adequate in exploring the alliance? 23
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1.6 Subjective experiences of the alliance in substance use 24
1.6.1 Clients’ subjective perceptions of treatment 24
1.6.2 Psychologists’ experiences of working with clients who use substances 25
1.6.3 Professionals’ experiences of working with clients who use substance 27
1.6.4 Critique of research exploring professionals’ experiences of working with
clients who use substances 28
1.6.5 Qualitative concerns 28
1.6.6 Summary of Subjective experiences of the alliance in substance use 29
1.7 Therapists’ resources 30
1.7.1 Clinical supervision 31
1.7.2 Use of self 31
1.7.3 Summary of Therapists’ resources 32
1.8 Summary of literature review 32
1.9 Research questions 33
1.10 Relevance to counselling psychology 34

Chapter 2: Methodology 36
2.1 Epistemological position 36
2.1.1 Qualitative inquiry 36
2.1.2 Phenomenology 37
2.1.3 Hermeneutics 38
2.1.4 Limitations of hermeneutic-phenomenology 38
2.2 Methodology 39
2.2.1 Interpretative phenomenological analysis 39
2.2.2 Limitations of IPA 40
2.3 Reflexivity 40
2.3.1 The researcher’s subjectivity 41
2.4 Sampling and recruitment 42
2.4.1 Sampling 42
2.4.2 Issues of homogeneity 42
2.4.3 Recruitment 43
2
2.5 Data collection 44
2.5.1 Semi-structured interview 44
2.5.2 Procedure and participant profile 44
2.6 Data analysis 46
2.7 Ethical considerations 47
2.8 Quality and credibility 47
2.9 Summary of methodology 48

Chapter 3: Results 49
3.1 Overview 49
3.2 Introduction to the themes 49
3.3 Theme 1: Trapped in the system 50
3.3.1 The trapped therapist 50
3.3.2 The trapped client 52
3.3.3 Hopelessness 53
3.3.4 Navigating the system 54
3.3.5 Summary of Trapped in the system 56
3.4 Theme 2: Struggling to connect 56
3.4.1 The unreachable client 57
3.4.2 Summary of The unreachable client 62
3.4.3 Taking responsibility to avoid disconnection 63
3.4.4 Summary of Struggling to connect 70
3.5 Theme 3: The contradictory therapist 71
3.5.1 I understand...or do? 72
3.5.2 Summary of I understand...or do I? 79
3.5.3 It’s not that difficult or different...or is it? 79
3.5.4 Summary of The contradictory therapist 86
3.6 Theme 4: Resources transcending the alliance 86
3.6.1 Clinical supervision 87
3.6.2 Peer support 91
3.6.3 Use of self 93
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3.6.4 Summary of Resources transcending the alliance 96
3.7 Reflexivity 97
3.7.1 Researcher - participant - organisation relationship 97
3.7.2 Researcher – participant relationship 98
3.7.3 Impact of my personal experience on the data analysis 99

Chapter 4: Discussion 101
4.1 Introduction 101
4.2 Overview of the study findings 101
4.3 Trapped in the system 103
4.3.1 Trapped therapist and client 103
4.3.2 Contextualising ‘the system’ 104
4.3.3 Hopelessness 105
4.3.4 Navigating the system 105
4.4 Struggling to connect 106
4.4.1 The unreachable client 106
4.4.2 Ambivalence 106
4.4.3 Mistrust 107
4.4.4 Contextualising ambivalence and mistrust in attachment theory 107
4.4.5 Taking responsibility to avoid disconnection 108
4.4.6 Self doubt 109
4.4.7 Stretching therapeutic boundaries 109
4.4.8 Walking on egg shells 110
4.4.9 Changing self 110
4.4.10 Contextualising ‘taking responsibility to connect’ 111
4.5 The contradictory therapist 111
4.5.1 Contextualising the contradictions 112
4.6 Resources transcending the alliance 113
4.6.1 Clinical supervision 113
4.6.2 Peer support 114
4.6.3 Use of self 115
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4.7 Unconscious processes and alliance theory 116
4.8 Critique of the research 117
4.8.1 Participants 118
4.8.2 Data analysis 118
4.8.3 Credibility 119
4.9 Implications for clinical practice, training and research 120
4.9.1 Clinical practice and training implications 120
4.9.2 Research implications 121

Conclusions 123
References 124
Appendices
Appendix 1: Email to Consultant Psychologist 140
Appendix 2: Written invitation and information about the study 141
Appendix 3: Interview schedule 144
Appendix 4: Ethics approval from University of East London Research Ethics
Committee 145
Appendix 5: Written information about the study 146
Appendix 6: Leaflet summarising the study 149
Appendix 7: Consent form 150
Appendix 8: Email informing participants that their identity is known to the
Consultant Psychologist 151
Appendix 9: Information on support services 152
Appendix 10: Example of reflective diary 153
Appendix 11: Participant interview transcripts (CD)
Appendix 12: Example of interview transcript with comments (Melissa) 154
Appendix 13: Example of individual themes table with quotes (Melissa) 161
Appendix 14: Master table of superordinate themes and subthemes without quotes 165
Appendix 15: Master table of superordinate themes and subthemes with quotes 166

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Abbreviations

BPS British Psychology Society
CBT Cognitive behavioural therapy
DCoP Division of Counselling Psychology
DoH Department of Health
GP General Practitioner
IPA Interpretative phenomenological analysis
NHS National Health Service
NICE National Institute for Clinical Excellence
PHE Public Health England

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List of tables and accompanying material
Table 1. Participant profile p. 45
Accompanying Material: 1 CD – Appendix 11

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