A grounded theory analysis of the experience of therapy in the context of negative change

Negative change occurring during psychotherapy is relatively underresearched and current theories take little account of social context. Eight clients and four therapists were interviewed about their therapy experience when reliable score deterioration on an outcome measure was observed, with the aim of generating a Grounded Theory model of negative change. The emerging model identified three major themes: a context of adversity, the therapeutic experience, and help withdrawn (within the context of positive outcomes). Difficulties included wanting therapy to provide more advice, talking about distressing issues, relationship difficulties, ambivalence, and a wish for support instead of change. Client context merits increased attention. Changes in outcome measures used, more diverse supervision models, training to use outcome measures constructively, and sensitive, routine analysis of negative change are indicated. Increased availability of therapies able to address clients’ interpersonal and social context and a wider choice of therapy type would allow interventions to better fit the individual in context

Predictors of IAPT psychological well-being practitioners’ intention to use CBT self-help materials routinely in their clinical practice

Despite efficacy and effectiveness evidence, and recommendations from the National Institute for Health and Care Excellence (NICE), use of CBT self-help materials remains inconsistent in UK mental health services. Since 2006, the Improving Access to Psychological Therapies (IAPT) programme has provided standardized training and mandates routine use of CBT self-help materials by their trainee psychological well-being practitioners (PWPs). This study tested whether the main constructs of the theory of planned behaviour (TPB; attitudes, subjective norms, and perceived behavioural control), past use, prior training and demographic characteristics, would predict PWPs’ intention to use self-help materials routinely in their clinical practice. Stage 1 utilized a standardized procedure to create measures for the constructs of TPB, before the design and testing of a web-based, cross-sectional questionnaire. In stage 2, the questionnaire was administered to a convenience sample of trainee PWPs (n = 94). Data was analysed using multiple linear regression, mediation analyses, and content analysis. TPB constructs predicted intention to use self-help materials, with only direct attitude contributing significantly to 70% of the variance in intention. Past use of materials predicted intention, via direct and indirect mediation. Qualitative data from 43 trainees highlighted clients’ experience of self-help materials as positive, albeit with some practical constraints. The results suggest that the main constructs of TPB have some utility in predicting trainee PWPs’ intention to use self-help materials routinely. Future prospective, longitudinal research could investigate actual use of self-help materials to elucidate cognitive factors involved in trainees’ clinical decision-making post-qualification

"My heart on this bit of paper": A grounded theory of the mechanisms of change in art therapy for military veterans.

A proportion of veterans experience post-traumatic stress disorder (PTSD). Research has shown reduced effectiveness of commonly offered psychotherapies in military personnel. Some research suggested the usefulness of art therapy for veterans with PTSD, but its mechanism of operation has been unclear. The current project aimed to establish participants' perceptions of any impact of group art therapy and some of the perceived mechanisms of change. In a grounded theory design, single semi-structured interviews were conducted with nine veterans who had received group art therapy, two art therapists, and a veteran's wife. Interviews were transcribed and analysed. Theorised categories included (a) art therapy group as "the family", (b) "the gentle conductor", (c) trust, (d) doing the work, (e) art therapy as "a communication tool", (f) "points of recognition", (g) "making things concrete", and (h) "not a cure". Shortcomings included a homogenous sample who all attended art therapy alongside other interventions, reliance on subjective and unmeasured symptom change, and researcher effects related to qualitative methodology. The developed grounded theory is consistent with existing evidence and neuropsychological theory. Group art therapy may enable some veterans to prepare for verbal-only therapy, by offering a safe space in which to approach non-verbal traumatic and trauma-related contextual material in a controlled way. Artworks may provide a bridge to facilitate communication of experiences within subsequent verbal therapy and with loved-ones. It is suggested to replicate the project at different sites. Elements of the developed theory may be investigated further to establish its transferability. [Abstract copyright: Copyright © 2021 Elsevier B.V. All rights reserved.

The MATISSE Trial–A Critique

U.K. national guidelines for the treatment of schizophrenia recommend art therapy among other approaches. However, a recent major trial called MATISSE (Multicenter evaluation of Art Therapy in Schizophrenia: Systematic Evaluation) suggests that art therapy may not be helpful. The purpose of the present study was to explore reasons for the MATISSE trial findings. A critical review of the MATISSE trial drawing on six papers reporting on the trial and its processes was performed. The MATISSE trial appeared to have weak conceptualization of the mechanisms for change, lack of piloting, incomplete process and subgroup analyses, and inappropriate assumptions about the generalizability of findings. The MATISSE trial’s conclusion that art therapy is of no value to people with a diagnosis of schizophrenia is unwarranted. More account should be taken of extant quality guidelines for complex interventions, including proposed change mechanisms, piloting, process analyses, variations in practice and contexts, and the effect of randomization on generalizability

Identifying the mechanisms of poetry therapy and associated effects on participants: A synthesised review of empirical literature

Poetry therapy is a promising but heterogeneous and under-evidenced form of creative arts therapy. Theories of change have been proffered but are model-specific and poorly evidenced in the empirical literature. The aim of this paper, then, was to provide a united understanding of how poetry therapy operates to guide future research and practice. To do this, empirical literature exploring mechanisms of poetry therapy across theoretical traditions was systematically retrieved, reviewed, and synthesised. A systematic search of six databases yielded 554 papers, of which 14 met the inclusion criteria, spanning individual and group approaches. Mechanisms and effects were extracted and synthesised into a governing framework and logic model, and stakeholder consultation was used to validate results. In total, 25 primary mechanisms and 54 associated effects were identified. These were synthesised into a logic model characterised by five primary tasks: Engaging, Feeling, Exploring, Connecting, and Transferring (“EFECT”). These tasks were associated with multifarious benefits, apparently impacting cognitive, emotional and behavioural domains. Future research could now seek to test this model empirically. It might then be used to guide a united, rigorous research programme, helping to bring poetry therapy into evidence-based policy and practice

Seeing through the façade of Anorexia: A grounded theory of emotional change processes associated with recovery from Anorexia Nervosa

Objectives: Difficulties in managing emotions have been implicated in the development and maintenance of anorexia nervosa (AN), and psychological treatment models seek to address this in putative targets of change. Yet the field of psychotherapy remains unclear and insufficiently evidenced about the process of change and how this is actually achieved, including in what steps and in what order within clinical treatment. This qualitative study sought to develop theory about the process of emotional change during recovery from anorexia. Methods: Semi-structured interviews were carried out with nine women currently engaged in psychological treatment for anorexia. Interviews included questions pertaining to participants’ experience of anorexia, emotions, and emotion management. A constructivist version of grounded theory was employed. Results: The analysis produced 10 major categories, comprising over 60 focused codes. Categories were clustered together into three super categories, reflecting 3 distinct but interrelated phases of participants’ journeys toward recovery. The phases were: (1) Coping in a world of uncertainty, (2) Seeing through the façade of anorexia, and (3) Recovery and growth. Whilst movement toward later positions often appeared to be contingent on earlier ones, the analysis suggests that this was not an entirely linear process and that participants moved between positions as they grappled with the process of change. Participants came to view behaviors associated with anorexia as emotion-management strategies that were not working and as a façade. As they moved toward recovery and growth, they became less confined by their need for safety, and to see emotions as meaningful and valuable. Becoming more connected to emotional experience and expression, coincided with positive shifts in their intra and interpersonal relationships. Conclusion: These findings support the recent shift toward emotion-focused models of anorexia. They also highlight an important focus in supporting individuals with AN to connect with, and be guided by, emotional experiences in their relationships with themselves and the world around them. This new grounded theory offers a putative process of change that could be utilized to guide intervention development

Identifying the mechanisms of poetry therapy and perceived effects on participants: A synthesised replication case study

Poetry therapy lacks a unifying, evidence-based operational model. This study was designed to test the utility and construct validity of extant models of poetry therapy using observational and experience-close data. Replication case study methodology was used, wherein two cases each comprised a video-recorded poetry therapy session and 4-5 interviews with session participants. The second case study was treated as a replication of the first. Mechanisms and perceived effects of poetry therapy were extracted from case material and synthesised to create an overall operational framework comprising 37 superordinate mechanisms and 58 associated effects. These findings were replicated in the second case study, with no new categories or conflicting evidence identified. Investigator triangulation and member checking were used to strengthen validity and reliability. Results were assessed for goodness-of-fit with two models of poetry therapy. The framework was well described by one of the models and concordant with both. Member checking indicated that the synthesised framework adequately described participants’ experiences. We conclude that there is empirical evidence to support the utility and validity of existing models of poetry therapy, and hope that our more detailed explication will enable greater specificity of questions in further research on practice. Implications for clinical practice are discussed

Evaluation of Arts based Courses within a UK Recovery College for People with Mental Health Challenges

No previous studies have evaluated arts based recovery college courses. Yet arts may assist in personal recovery, as often defined by service users, through social connection and personal meaning. This interdisciplinary study evaluated (i) whether self-reported wellbeing and arts activities increased following arts based recovery college courses, and (ii) how students, peer trainers and artist-trainers understood courses’ impact. The design was mixed-methods. Of 42 service user students enrolling, 39 completed a course and 37 consented to provide data. Of these, 14 completed pre and post course questionnaires on mental wellbeing and 28 on arts participation. Post course focus groups were held with six of eight peer trainers and five of seven artist-trainers, and 28 students gave written feedback. Twenty-four students were interviewed up to three times in the subsequent nine months. There were statistically significant increases in self-reported mental wellbeing and range of arts activities following course attendance. At follow-up 17 of 24 students reported improved mental wellbeing, while seven reported little or no change. Some spoke of increased social inclusion and continuing to use skills learned in the course to maintain wellbeing. Initial in-course experience of ‘artistic growth’ predicted follow-up reports of improvement. Future controlled studies should employ standardized measures of social inclusion and arts participation

Primary-school-based art therapy: exploratory study of changes in children’s social, emotional and mental health

AIM: This exploratory mixed methods study aimed to inform future research by investigating if teachers and children from one primary school perceived any changes in children’s social, emotional and mental health difficulties following art therapy and if so, what the children perceived as helpful about the sessions. METHODS: The study included 45 children and 10 class teachers within one UK primary school. The researchers analysed routine questionnaires from teachers and a children's evaluation interviews, triangulating these with data from a teacher focus group. RESULTS: The findings show significant and medium effect sizes for positive teacher-rated changes in children’s overall stress, conduct, hyperactivity, and procsocial behaviour and a large effect on perceived impact of children’s difficulties on their lives. Teacher-rated emotional distress and peer problems showed small changes that did not reach statistical significance. The positive changes were corroborated by the teachers' and children's qualitative reports. Aspects of art therapy which children found particularly helpful were; making and thinking about art; expressing, thinking and learning about thoughts and feelings; and sessions being fun. CONCLUSION: The study highlighted perceived positive changes and no negative changes in children’s SEMH difficulties. However, future research is necessary to examine clinical effectiveness. Plain-language summary In this article we describe a research study which aimed to explore if teachers and children perceived any changes to children’s social, emotional or mental health difficulties after the children attended art therapy within their primary school. We were also interested in learning from the children if they thought anything in particular had been helpful about their art therapy sessions in order to inform future research and the development of this particular approach to art therapy. The art therapists asked the class teachers to fill out a Strengths and Difficulties Questionnaires at the beginning and end of art therapy. The class teachers also attended a focus group so we could learn more about their general observations of the children before and after attending art therapy. The art therapists also interviewed the children to learn if they perceived any changes since coming to art therapy and if so, what in particular they thought had helped bring about these changes. We found that statistical analysis of the questionnaire scores mostly agreed with what the teachers and children said and that there was generally some positive change to the social, emotional and mental health difficulties the children had been experiencing. The teachers also let us know that some of the children still had residual problems. The children emphasised that making and thinking about art along with expressing, thinking and learning about thoughts and feelings had been particularly helpful. It was also important to the children that the sessions were fun. In conclusion, the teachers and children in this primary school perceived art therapy as helpful to the children and that it merits further research in order to develop the approach used by the art therapists and to see if it is effective in larger research studies including more children, schools and art therapists