Search

Introduction: The efficacy of psychotherapy has been well established. There is growing research focusing on the negative outcomes of psychotherapy, with an estimated 10% of clients who deteriorate as a result of psychotherapy. However, there remains an overlooked population, those who show no response after psychotherapy, which has a widely variable estimated prevalence between 14-56% across the literature. This qualitative evidence synthesis (QES) aimed to synthesise the available evidence exploring client and therapist experiences of psychotherapy non-response. Method: Seven databases were systematically searched for studies using qualitative data to explore non-response. Twenty-one studies met the inclusion criteria and were analysed using the QES method Thematic Synthesis. This involved three stages of line-by-line coding, descriptive theme development, and generation of analytical themes, to develop a conceptual understanding of psychotherapy non-response from both client and therapist perspectives. Results: Six overarching client perspective themes and 18 subthemes were identified (1. Hopes and fears, 2. A difficult task, 3. Disconnected relationship, 4. Staying involved, 5. Therapy was not worth the investment, and 6. On a trajectory for improvement). Four overarching therapist perspective themes and 10 subthemes were identified (1. High expectations, 2. Experiencing a disconnect, 3. Feeling threatened, and 4. Holding onto hope). This was synthesised into a proposed model of non-response. Discussion: A large overlap with the deterioration and harm literature was found. There were varied experiences of non-response which has implications for the use of qualitative outcome measurement. The experience of non-response appears to involve both clients and therapists holding something back from the therapeutic relationship. Importantly, non-response appears not to be an absence of effects, but a range of experiences which can potentially be harmful. Clinical and research implications are discussed.

Introduction: There is a dearth of literature on third-wave Cognitive Behavioural Therapies (CBT) for Functional Neurological Disorder (FND). These approaches adopt a transdiagnostic approach to support people to change their relationship with their psychological experiences (Hayes, 2004). This thesis examines the existing literature regarding these approaches and explores the impact of a Clinical Health Psychology Service two-phase psychological intervention for FND. This consists of assessment and formulation sessions (Phase 1) and an innovative seven-week Acceptance and Commitment Therapy (ACT) group (Phase 2). Aims: A scoping review explores the extent and nature of the literature on third-wave CBT for FND and determines whether there is good quality evidence available regarding its effectiveness. Preliminary factors for intervention feasibility, acceptability and effectiveness are explored within the review. The empirical study aims to evaluate the impact and experiences of participants receiving the two-phase psychological intervention for FND. Methods: A broad scoping review of third-wave CBT for FND was carried out on the bibliographic databases PsychINFO, EMBASE and MEDLINE, which were searched from the earliest listing up to June 2020. Key information is charted and explores factors related to intervention feasibility, acceptability and effectiveness. For the two-phase psychological intervention, pre and post standardised outcome measures are explored for three participants who attended assessment and formulation and three participants who attended the ACT group and participated in a Single Case Experimental Design (SCED). Seven participants completed a semi-structured Change Interview (Elliott, 1999; Elliott et al., 2001) regarding their experiences of the intervention and perceived changes, explored through thematic analysis (Braun & Clarke, 2006). Results: The scoping review found a small number of low-quality studies have applied third-wave CBT in different formats across several FND presentations. All lacked information on feasibility and acceptability. There was promise for third-wave CBT effectiveness with improvements found for QoL, distress and psychological flexibility measures for some. The study found that changes in standardised outcome measures following each phase of the two-phase psychological intervention were complicated with a mixture of improvement, lack of change and, in some cases, worsening on standardised measures. In contrast, participants' interview accounts described the intervention positively and detailed important therapeutic changes attributable to the intervention. Conclusion: Third-wave CBT is not well established for FND. While some patients benefit from these approaches, it is unclear what factors influence effectiveness. Higher quality intervention studies are required and could be developed through feasibility studies and qualitative research on different patient's perceptions and experiences of psychological intervention. The results from the two-phase psychological intervention for FND highlight the challenges of providing psychological intervention for a complex and heterogeneous clinical population.

Introduction: This thesis explores the use of photographs in homework tasks within a psychological intervention. The research was influenced by photo-elicitation research and methods such as Photovoice that use photographs as a tool to explore participant experiences. Visual images convey information in a manner that is processed differently to verbal or written accounts and photographs are observed to be a useful communicative tool, yet there is little empirical research investigating photograph use within therapy. This is a novel project exploring participant experiences of taking and sharing photographs within an emotional coping skills group intervention. Method: Using purposeful sampling, six participants were recruited from an emotional coping skills group in an NHS service in West Yorkshire. Photographs were used in the group to augment the homework tasks and feedback. The participants consisted of five service-users and one group-facilitator. Semi-structured interviews were conducted using the photographs taken for the group as prompts. The interviews were analysed using Interpretive Phenomenological Analysis (IPA). The photographs and information from group evaluation forms were used to support the interpretation of the data. Results: Six superordinate themes were identified from the data: (i) Expectations and assumptions, (ii) What is in an image? (iii) Emotions and images, (iv) Therapeutic impact, (v) Power and control, and (vi) Barriers. These were informed by 15 subordinate themes. Discussion: The taking and sharing of photographs had a number of therapeutic benefits, including supporting understanding and connection within the group. Participants tended to use photographs to capture positive rather than negative experiences and reported challenges to sharing such as feeling vulnerable. The study suggests that using photographs in therapy could support communication and exploration of experiences that may be difficult to express using words. The strengths and limitations of the study are discussed, and areas for future research are identified.

Introduction: Smartphones have become the primary device for accessing the online world. The potential for smartphone use to become problematic is increasingly recognised, with students at particular risk due to their high usage and reliance. There is limited research evaluating interventions for problematic smartphone use. The present research aimed to develop and evaluate a digital intervention for problematic smartphone use in the student population. Method: A mixed-methods case series design was used to evaluate the acceptability and impact of the intervention for ten participants. The intervention included: goal setting, personalised feedback, mindfulness and behavioural suggestions. Participants were asked to complete self-report measures of problematic phone use, online dependency, mindfulness, wellbeing, psychological distress, sleep and self-determination. Participants’ phone use and sleep were also measured directly. Results: The results provide evidence for the intervention package reducing problematic smartphone use, although there was no observable impact on overall screen time. There was some evidence of positive influences upon online dependency, mindfulness, wellbeing, and sleep. No particular component of the intervention seemed more effective than the others. Discussion: The findings suggest that the intervention package is both effective and acceptable to students wishing to better manage their problematic smartphone use.

Introduction: Research demonstrates that some people experience positive benefits through struggling to cope with traumatic life events, leading to the development of theories of 'posttraumatic growth'. More recently this has included an acknowledgment that common difficult experiences such as childbirth can also generate both traumatic stress and traumatic growth responses. Research on posttraumatic growth following a traumatic birth is still limited. This research project aimed to contribute to the emerging knowledge base by conducting an in-depth study with women who have experienced posttraumatic growth following a traumatic birth. Method: A qualitative approach using Interpretative Phenomenological Analysis was used to explore in-depth the experiences of women who self-identified as having found positive benefits through coping with a traumatic birth. Eight women who had given birth in the past five years were interviewed. Results: Three superordinate themes were identified with two, four and five subordinate themes respectively. The three superordinate themes were "The total opposite to what I'd expected", "I see it a bit differently now" and "A much better place". Discussion: The themes provide an insight into both the journey to growth experienced by the participants and the experience of growth 'outcomes' following a traumatic birth. Societal and cultural influences on participants' pre- conceptions of birth led to a difference between their expectation and the reality of their experience that challenged their sense of identity as women and mothers. In overcoming these challenging experiences, participants described a process of actively striving to cope and make sense of their experience. A variety of factors facilitated this, notably partner support, the opportunity to tell their story, acknowledging the impact of the birth and developing a compassionate narrative. Growth was experienced in ways that are commonly reported by survivors of challenging life events, with some aspects of growth appearing more specific to birth trauma.

Introduction: Building on from the small body of research that has investigated client and therapist experiences of non-improvement in psychological therapy, this study aimed to investigate how client-therapist dyads experience therapy in which the outcome measures suggest no significant change has taken place, and explore the themes that emerge from these accounts regarding the interpersonal process of these therapies. Method: Three client-therapist dyads from NHS secondary care psychological therapies services who ended therapy with standardised outcome measures in the 'no reliable change' range took part in semi-structured interviews about their experiences. Their accounts were transcribed and analysed using Interpretative Phenomenological Analysis (IPA). Results: The themes of each dyad were presented in detail in the style of a case study series. The overarching theme of dyad 1 was 'a risk worth taking', which was comprised of the subthemes 'feeling safe enough to explore', 'beginning to heal the wound' and 'being left with conflicting feelings'. The overarching theme of dyad 2 was 'dipping a toe in the water', which had the subthemes 'fragile alliance', 'struggling towards collaboration' and 'ambivalence at the end'. The overarching theme of dyad 3 was 'reacting to threat', which had the subthemes 'starting with irreconcilable demands' and 'pulling away and leaning in'. From the group analysis of the three pairs, the master theme 'a mixed bag' was developed, which had the following four subthemes: 'opening up', 'closing off', 'growing' and 'struggling'. Discussion: For the participants in this study, experiences fell on a continuum of change and non-improvement, with subjective experiences being more complex and contradictory than the outcome measures suggested. The quality of the therapeutic relationship and engagement in therapy varied across the dyads. The findings are discussed in relation to the existing research on non-improvement and theoretical literature relevant to this subject. The strengths, limitations and clinical implications of the study are considered, along with recommendations for future research.

Background. This study investigated the use of Interoceptive Exposure (IE) in treatment of disabling fear of pain using a single-case series design. IE is used in treatment of a variety of problems where body sensations are experienced as threatening. IE was used here as an extension of the Fear Avoidance Model. The main hypotheses were that the intervention will reduce fear of pain and increase activity. Additionally, we expected to see a decrease in pain distress and interference, and increase in acceptance of pain. Method. An ABC multiple baseline single-case series design was used. Eight adults referred to clinical psychology through a Pain Clinic were recruited; seven completed treatment. The intervention comprised: one pain education session, two sessions of training in IE plus selfmonitored home practice twice daily for two weeks. Depending on the length of the baseline the study lasted between six and seven weeks. A nine-item instrument was designed to measure fear of pain, pain distress and interference on a daily basis. Physical activity was measured using wearable activity monitors. Standard outcome measures included: pain anxiety, catastrophising, disability and general anxiety and depression. Results. The intervention resulted in reduced fear of pain in some participants, but not all. Six participants improved on at least one of three measures of fear of pain, with two participants improving on all three measures. For one participant there were no changes in fear of pain. Our strongest finding was that the treatment reduced catastrophising, with five participants making significant reliable improvement. All study participants increased their activity levels following the intervention, but for only four participants was this change meaningful. Additionally, contrary to our hypothesis, reduction in fear of pain did not lead to increase in activity. The intervention had no effect on pain acceptance, disability, nor depression and anxiety.

Students are at greater risk of compromised wellbeing and elevated levels of psychological distress when compared with their non-student peers. They are also less likely to seek help. Web-based interventions may be able to support students to improve their wellbeing. This thesis was undertaken in order to investigate the impact of one such web-based intervention, thedesk, on students' levels of wellbeing and psychological distress. The project used a mixed-methods, systematic case series design. Nine participants completed the study. They were asked to use thedesk for six weeks whilst completing measures of their wellbeing, psychological distress, coping style and general self-efficacy, and were later interviewed about their experiences of using thedesk. The results indicated that thedesk had a positive impact on two of the participants' levels of wellbeing and psychological distress. None of the participants displayed improvements in their coping style or levels of self-efficacy. Usage data showed that many of the participants' engagement with thedesk during the study was low. During the interviews, participants gave both positive and constructive feedback about thedesk. They reported thinking that a web-based intervention designed for students was a good idea, that the content was helpful and appropriate for a student population, but that more content should be added to thedesk and it would benefit from being updated in several ways. The results indicate that students are receptive to web-based interventions, but that further research should be conducted to determine how to make these interventions as engaging and helpful as possible.

Aim: Research to date has shown small effects of Cognitive Behavioural Therapy for Psychosis (CBTp) on reducing psychotic symptoms. Some have subsequently questioned whether CBTp should continue to be a recommended treatment for psychosis. There have been parallel advances in the understanding of psychosis and in the evolution of CBT that is specific to psychosis. The aim of this study is to examine whether these parallel advances have led to an improved effectiveness of CBTp across time. Method: The design of this study is a systematic review and meta-analysis. MEDLINE, EMBASE, PsycINFO, and CENTRAL were searched for randomised controlled trials examining CBTp interventions targeting positive and/or negative symptoms versus treatment as usual. Four meta-analyses were carried out to examine the effectiveness of CBTp for positive symptoms, delusions, hallucinations, and negative symptoms, with four meta-regressions to examine whether the effectiveness of CBTp for these symptoms improved across time. Result: A total of 28 studies (n = 2698) were included in the meta-analysis of positive symptoms which yielded a pooled g of -0.24 (95% CI -0.32, -0.16, P < .001) favouring CBTp, with non-significant heterogeneity (Q = 26.87, P = 0.47; I2 = 0%). A total of 13 studies (n=890) were included in the meta-analysis of delusions which yielded a pooled g of -0.36 (-0.59, -0.13, P = 0.002), with substantial heterogeneity (Q = 31.99, P = 0.001; I2 = 62%). A total of 16 studies (n = 849) were included in the meta-analysis of hallucinations which yielded a pooled g of -0.26 (95% CI -0.42, -0.11, P < 0.001), with non-significant heterogeneity (Q = 18.10, P = 0.26; I2 = 17%). A total of 19 studies (n = 1761) were included in the meta-analysis of negative symptoms which yielded a pooled g of -0.22 (95% CI -0.33, -0.12, P < 0.001), with non-significant heterogeneity (Q = 20.32, P = 0.32, I2 = 11%). Meta-regressions indicated a significant effect of year on the effectiveness of CBTp only for delusions (F(1, 11) = 5.99, p = 0.032; R2 = 0.594). Conclusion: The findings indicate small-to-medium effects of CBTp for positive symptoms, delusions, hallucinations, and negative symptoms, and that over time, there has been an improvement in the effectiveness of CBTp for delusional symptoms.

Objectives. This study aims to assess: clients’ responsiveness to the delivery of CAT-specific tools in order to gain a better understanding about which tools lead to therapeutic change; the impact of CAT upon insight; and clients’ perspectives on receiving CAT and how much they ascribe the process of change to CAT-specific tools. Design. A hermeneutic single-case efficacy design, repeated with a small number of participants, was used to assess whether CAT-specific tools stimulate therapeutic change. Mixed methods were used to generate data on change processes. Methods. The case-series comprised of six therapist/client dyads. Therapists were asked to keep a weekly record of their delivery of CAT- specific tools. Participating clients were asked to complete the recognition and revision rating scale, two corrective experience questions, the insight sub-scale of the Self-Reflection and Insight Scale and the Clinical Outcome in Routine Evaluation-10. Outcomes were supplemented with qualitative data taken from client change interviews. Template analysis was used to analyse the qualitative data. Results. For all but two participants there were no statistically significant changes on the CORE-10 in the session immediately or shortly after the introduction of a CAT-specific tool. Five themes emerged from the qualitative data: making links, breaking the links in patterns, experiences that disconfirm beliefs, working in partnership, and real world influences. CAT-specific mechanisms were identified by participants as helpful for bringing about recognition and revision of faulty patterns. Both CAT-specific and non-specific mechanisms of change were identified as being helpful. Conclusions. CAT-specific tools were seen to facilitate cognitive and emotional insight which was a necessary element of the process of CAT in bringing about behavioural change through revision. It was also found that a genuine therapeutic relationship is an important mechanism operating through, and strengthened by CAT-specific tools.

All clinical psychology trainees engage in supervision with their placement supervisors throughout training. We know much about the function of supervision, the supervisory relationship and that a great deal of learning and development takes place within the four walls of supervision. But what is less clear is how this process of learning and development takes place. This study focuses on key moments of learning in supervision for the trainee (from both the trainee and supervisor perspective). A qualitative design using Grounded Theory (GT) was adopted to develop a theory as to how such a shift occurs. Participants recorded a supervision session and Interpersonal Process Recall (IPR) was then used as the method of data collection, to capture the participants’ experiences. Six core themes emerged from the analysis – anxiety context: drivers behind trainee perspective, developmental context: drivers behind supervisor perspective, competency capability, developmental enactments, supervisory enactments and shift in perspective. The findings suggest that the overtly evaluative nature of the supervisory relationship, the trainees’ anxiety and their reassurance/guidance seeking influences the learning and development that takes place. Supervisory enactments based on collaboration lead to a more profound shift in perspective. Enactments based on rupture still lead to a shift in perspective, but it takes longer to get there. The findings are discussed in relation to relevant theory and research. The implications for future research, theory and training are highlighted.

This study aimed to explore the therapist subjective experience of client non-response, how they made sense of their experience and how they managed the experience. A total of seven therapists were recruited and interviewed using a semi-structured interview format, designed for the purposes of the study. The resulting transcribed interviews were analysed using interpretative-phenomenological analysis. Fifteen super-ordinate themes were found and organised across four discrete, but interacting stages; ‘starting out’, ‘when therapy fails to progress’, trying to end’ and ‘it’s over’. The over-arching theme of ‘the destruction of hope’ encompasses the experiential and time-ordered themes. The therapist experience was marked by challenging feelings of anxiety, helplessness, inadequacy, anger and guilt. Feelings of loss were also apparent, specifically regarding the omnipotence of therapy and the therapist’s identity as a healer. The novel findings are discussed in the context of the extant evidence concerned with the therapist experience of non-response, the distinct contribution made by the current findings and the identified methodological limitations of the research approach.

Introduction: There has been an expansion of research into psychotherapy outcomes for both clients who improve and clients who deteriorate as a result of therapy. However, those who fail to respond to therapy have been overlooked. Estimates of non-response to therapy vary from 14% to 60%, yet research with this client group is lacking. Additionally, research suggests therapists are limited in their ability to predict negative outcomes in therapy. If this is equivalent for non-response to therapy, our ability to respond appropriately to these clients may be an issue that needs addressing further. This study aims to begin to understand what sense clients make of therapy which, they feel, has brought about no change. Method: Eight clients who had completed a course of therapy within psychological therapy services (6+ sessions) and subjectively felt that they had not benefitted from this were interviewed about their experience. An interpretative phenomenological analysis was employed to allow an in depth, inductive study of a new area, in order to develop a model of participants’ experiences. Results: Five themes emerged regarding the therapy experience; ‘what I expected’, ‘how I found my therapist’, ‘what was therapy like’, ‘external influences’ and ‘what I am left with’. These were brought together into a model which allowed further meaning to be drawn from the accounts and the experience understood as a process. Discussion: The analysis and model were explored in relation to the available literature. This included consideration of attachment theory in relation to managing therapy expectations, facilitating emotional expression and length of therapy required, in addition to seeking further clarity with regard to what is meant by the term ‘non-response’ in psychological therapy. Novel findings of this research were examined in the context of the strengths and limitations of this particular study. From this, areas of future research and potential clinical impactions were considered.