THERAPISTS' EXPERIENCES OF THERAPEUTIC MISTAKES David William Aaron Submitted in ...

148 Pages·2012·3.49 MB·English

by  Dave Aaron

THERAPISTS’ EXPERIENCES OF THERAPEUTIC MISTAKES

David William Aaron

Submitted in accordance with the requirements for the degree of
Doctor of Clinical Psychology (D. Clin. Psychol.)
The University of Leeds
Academic Unit of Psychiatry and Behavioural Sciences
School of Medicine

August 2012
The candidate confirms that the work submitted is his own and that appropriate
credit has been given where reference has been made to the work of others.

This copy has been supplied on the understanding that it is copyright material and
that no quotation from the thesis may be published without proper
acknowledgement.

© 2012
The University of Leeds
David William Aaron
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Acknowledgements

I would firstly like to thank Carol and Sheila who supervised me throughout the
study. To Carol, I would like to thank you for challenging me yet also containing
my anxiety as I embarked upon the greatest learning experience in my short career
so far. I have gained so much from working with you and feel I have developed
both personally and professionally as a result. I will carry this learning with me as
I begin my life as a qualified Clinical Psychologist. To Sheila, I would like to
thank you for sparing me some valuable hours in your ever busy schedule. I have
learnt much from our conversations. I would like to thank my wonderful wife
Louise and beautiful new born son Charlie for providing me with the inspiration
to complete the study in spite of some challenging times both on and off the
course. I would like to acknowledge the invaluable support from my family,
course mates and friends outside the course; you have helped me to cope, each in
your own way. Finally, I would like to thank the participants who gave up their
time to take part in the study and provide such rich data for what was a fascinating
study to conduct.
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Abstract

Introduction: In contrast to the extensive literature on related areas such as
therapeutic boundaries, alliance and ruptures, little empirical research has been
conducted on therapeutic mistakes. Existing research based predominantly on case
studies and observations have focused on systems for categorising mistakes.
Empirical research on therapeutic mistakes has focused on supervisors’ and
clients’ perspectives. This study is the first to explore therapists’ experiences of
therapeutic mistakes.
Method: Seven psychological therapists were interviewed using semi-structured
interviews on their experience of therapeutic mistakes in therapy sessions.
Interviews were transcribed and analysed using Interpretative Phenomenological
Analysis (IPA). Initially, individual transcripts were analysed separately, resulting
in a number of themes for each participant. A group analysis was then conducted
across participants, yielding super-ordinate themes and sub-themes, based on their
psychological relatedness.
Results: A seven-stage process was identified across participants’ accounts
(including participants’ experience of before the session, in the session, the
emergence of a problem, in the midst of the problem, ‘The aftermath’, making
sense and ‘How I’m left’), detailing the experiential themes for participants at each
stage. Some of the main themes that emerged were a sense of ‘something
brewing’, feeling criticised by their client or self-criticism, relief and recovery,
reflecting on roles and responsibility and pre-occupation with the mistake. Four
key findings were presented including participants’ complex constitution of
mistakes, the role of emotion in participants’ experiences of mistakes,
participants’ on-going meaning making process and participants’ experience of
mistakes as an interpersonal negotiation. The findings also suggested a difference
between how participants constituted mistakes in principle (more aligned with the
literature on boundary transgressions and categorisations of mistakes) and the
mistakes they shared in their accounts (which reflected more ordinary and minor
mistakes, e.g. administrative errors or sharing an interpretation that was not well
received).
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Discussion: The findings were examined in relation to existing literature. An
evaluation of the methodology was presented, resulting in suggestions for future
research. Finally the clinical implications of the study for therapists, supervisors,
clients and services were discussed, including recommendations for clinical
practice.
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Table of contents

List of tables ...................................................................................................................... vii
List of figures ................................................................................................................... viii
Abbreviations ..................................................................................................................... ix
CHAPTER ONE ............................................................................................................... 10
Introduction to the study ............................................................................................... 10
Literature review ........................................................................................................... 10
Process of conducting the initial literature review ................................................... 10
Ethical guidelines and codes of conduct ................................................................... 11
Clinical competence .................................................................................................. 13
Decision making ........................................................................................................ 14
Boundaries ................................................................................................................ 15
The therapeutic relationship: therapeutic alliance and ruptures ............................. 21
Therapeutic Mistakes ................................................................................................ 23
A gap in the literature ............................................................................................... 29
Summary of current literature ................................................................................... 30
Research questions .................................................................................................... 31
CHAPTER TWO .............................................................................................................. 32
Methodological approach .............................................................................................. 32
Interpretative Phenomenological Analysis ............................................................... 32
Alternative methodological approaches ................................................................... 34
Sampling ................................................................................................................... 34
Data collection .......................................................................................................... 35
Interpretative Phenomenological Analysis: The process .......................................... 36
Method .......................................................................................................................... 36
Research Design ....................................................................................................... 36
Sampling and recruitment ......................................................................................... 37
Information & Consent ............................................................................................. 37
Ethical issues ............................................................................................................ 38
Procedure .................................................................................................................. 39
Interviews .............................................................................................................. 39
Interview schedule ................................................................................................ 39
Data Analysis ............................................................................................................ 42
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Organising different types of data ......................................................................... 42
IPA Procedure ....................................................................................................... 43
Quality checks: reliability and credibility................................................................. 45
Reflexivity .................................................................................................................. 46
CHAPER THREE ............................................................................................................. 48
Results ........................................................................................................................... 48
Participants ............................................................................................................... 48
Pen Portraits ............................................................................................................. 49
Alex ....................................................................................................................... 49
Linda ..................................................................................................................... 51
Elaine .................................................................................................................... 54
Simon .................................................................................................................... 55
Michael ................................................................................................................. 58
Ruth ....................................................................................................................... 60
Margaret ................................................................................................................ 61
Mistake Characteristics ............................................................................................ 63
Group analysis .......................................................................................................... 65
1. Before the session ......................................................................................... 67
2. In the session ................................................................................................. 69
3. The emergence of a problem ......................................................................... 72
4. The experience of being in the midst of a problem ....................................... 75
5. ‘The aftermath’ ............................................................................................. 79
6. Making sense ................................................................................................ 83
7. ‘How I’m left’ ............................................................................................... 86
Summary of results .................................................................................................... 88
Reflections on analysing the transcripts ................................................................... 88
CHAPTER FOUR ............................................................................................................. 91
Discussion ..................................................................................................................... 91
Key finding 1: Participants’ constitution of mistakes was complex.......................... 91
Key Finding 2: Emotion was a key characteristic in participants’ experiences ....... 95
Key Finding 3: Participants engaged in an on-going and iterative process of
meaning making ........................................................................................................ 98
The role of supervision ....................................................................................... 103
Key Finding 4: Participants’ therapeutic mistakes were experienced as an
interpersonal negotiation ........................................................................................ 105
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Evaluation of methodology: Strengths and limitations ........................................... 109
General research design and methodology ......................................................... 109
Sampling and recruitment ................................................................................... 109
Interviews ............................................................................................................ 110
Quality checks ..................................................................................................... 112
Future research ....................................................................................................... 113
Clinical Implications and recommendations .......................................................... 114
Conclusion .............................................................................................................. 118
Closing reflections .................................................................................................. 119
References ....................................................................................................................... 120
Appendices ...................................................................................................................... 129
Appendix I. Participant e-mail invitation. .................................................................. 129
Appendix II. Participant information sheet. ................................................................ 130
Appendix III. Participant consent form. ...................................................................... 134
Appendix IV. Interview schedule. ................................................................................ 135
Appendix V. ‘Who said what’ table. ............................................................................ 138
Appendix VI. Section of transcript analysis. ............................................................... 142
Appendix VII. Ethics Approval Letter. ........................................................................ 143
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List of tables

Table 1. Summary of ethical principles applicable to psychological therapy....... 12
Table 2. Common errors in psychotherapy training (Buckley, 1979)................... 25
Table 3. Participant information ........................................................................... 49
Table 4. Characteristics of participants’ mistakes................................................. 64
Table 5. Participants’ themes relating to their experience before the session ...... 67
Table 6. Participant themes relating to their in-session experience. ..................... 69
Table 7. Participant themes relating to the emergence of a problem .................... 72
Table 8. Participant themes relating to the experience of being in the midst of the
problem ................................................................................................................. 76
Table 9. Participant themes relating to their experience of ‘The aftermath’ ........ 80
Table 10. Participant themes relating to making sense of their mistake ............... 83
Table 11. Participants’ themes relating to ‘How I’m left’. ................................... 86
viii

List of figures

Figure 1. A model of boundary transgressions within clinical practice ................ 17
Figure 2. Participants' stages of experiencing a therapeutic mistake ................... 66
Figure 3. The split between participants’ before session experiences .................. 67
Figure 4. Participants’ in session experience ........................................................ 71
Figure 5. Participants’ experience of the emergence of a problem ....................... 74
Figure 6. Participants’ experience of being in the midst of the problem. ............. 77
Figure 7. Participants’ experience of ‘The aftermath’. ......................................... 81
Figure 8. Participants’ experience of reflecting upon their mistakes .................... 84
Figure 9. Participants’ experience of ‘How I’m left’ ............................................ 87
Figure 10. Flowchart illustrating the full process of participants’ experience ...... 90