The use of a session bridging worksheet within cognitive behaviour therapy: Year 1 of Blended PhD Study – Epistemology & epistemological assumptions of Improving Access to Psychological Therapy Services.

This paper begins with a scientist practitioner reflexive outlining the experience of starting a PhD course and discovering new knowledge and how this has influenced the development of the PhD question. Cognitive behaviour therapy (CBT) is commonly delivered in the NHS within new and emerging Improving Access to Psychological Therapy (IAPT) teams and the paper will be explored within the context of this NHS service framework.

 

CBT is recommended as a primary treatment choice in the England, for anxiety and depression, by the National Institute for Health & Care Excellence (NICE). It has been argued that CBT has enjoyed political and cultural dominance and this has arguably led to maintained government investment in England for the cognitive and behavioural treatment of mental health problems. The government programme ‘Improving Access to Psychological Therapies’ (IAPT) aims to improve the availability of CBT. Therapist non adherence to evidence based interventions, also called ‘therapy drift’, can be problematic in the implementation of CBT in routine practice settings. The IAPT programme is governed by practice based competence to improve adherence to the evidence based ingredients of CBT, however this provides no assurance that therapies will be delivered in line with evidence based manuals. The criticism of the NICE evidence based guidelines supporting the IAPT programme and the implementation of CBT as part of the service model has been the dominance of the gold standard randomised controlled trial methodology. The definition of ‘recovery’ used by IAPT is based on a positivist position, with a focus on numerical outcome data garnered through psychometric measures. An interpretative perspective of recovery, which would include a subjective individual patient / service user narrative and would include a collaborative qualitative dialogue is arguably absent from the IAPT programme. The challenge inherent in the IAPT programme is the high demand / high turnover culture and therefore psychometric measures are quick to administer, however this culture is driven from one research paradigm. An interpretative paradigm may assist in shaping service based cultures, alter how services are evaluated and improve the richness of CBT research. The paper argues that an interpretive epistemology can assist the inclusion of a patient / service user narrative, can assist the evaluation of CBT from the user perspective, can understand the context in which people live and how they access services. The paper also explores how such a strategy could reach out to under represented groups, such as people from sexual, gender and ethnic minorities.

 

Recommendations

  1. In order to understand the experience of therapist drift and the service user experience of CBT, an constructivist / interpretative epistemology should inform the construction of the research question regarding therapy drift;
  2. Methodological methods should be informed by the epistemological assumptions underpinning the question of experience and application of clinical methods
  3. The notion of recovery should ideally be explored through a mixed methods approach due to the dominance of positivist assumptions and quantitative methods in the IAPT model and service framework.
  4. A narrative synthesis of recovery and therapist drift should ideally inform the development of a session bridging worksheet and the quantitative evaluation of within session drift.
  5. The findings from the first year of the PhD will be disseminated in a peer review publication in 2015.

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