The use of psychometric tools to measure client change in manualised programmes is common and this study similarly administered psychometric tools. However, the clinicians also used their clinical judgment, insight and clinical assessment when evaluating how the participants were responding to the therapy to determine whether clinically significant change had occurred. Clinical significance is defined as the degree the intervention effects change in comparison to the everyday functioning of the client (Kendall & Grove, 1988). Therefore, it was important to explore how the therapists evaluated their sessions. Usually, this was in a collaborative manner, such as Diane’s account.
Clinician Findings 125 We would spend the whole trip coming back talking about it so a good at
least half hour debriefing… and evaluate how that session really went, what worked really well, what didn’t work so well, what we might do differently next time. Whether there were members of the group who seemed more particularly engaged. What we could do to bring the less engaged members back in for the next session. So yes we did quite a lot of time evaluating how the group went… And it was good because we were on the same page but then sometimes one of us would have picked up on something perhaps the other one didn’t so that was nice as well. To be able to have two people be able to notice… Diane
When Diane recalled her experience, it was the dynamic nature of their conversations as they talked after the sessions. Diane reflected on how involved the conversations were and how widespread their evaluation of the session was. Having the time to discuss a therapeutic session in this manner does not normally occur in one-on- one sessions where a clinician may have limited time to discuss a number of cases in supervision. In this situation, Diane was able to process events in therapy directly after the session with another clinician. As she reflected on this, Diane was aware of how good it was to have weekly input from another clinician and gain a wider perspective. Consequently, she became aware of elements that she had not noticed occurring in the group. Further, she was able to do this with someone else who shared the same
therapeutic session. When she reflected on this, Diane realised she was accurate in her clinical judgment, but also gained the benefit of someone else’s insight too.
Rose also gained valuable insight through having another clinician present to evaluate the session.
The other clinician and I would debrief, after each session and we would think about what we would of thought were important aspects to bring up at the next session. And whether there was any need to follow up on anything we needed to do in terms of the content of that session. But really that was our debrief with each other and it wasn’t a formal evaluation as such…. We would talk about what had gone on and processed stuff that had happened. Then we would, with a view to what
…we might run in the next one, or we would have particular things we would have needed to address at next session. So, we went through each person and debriefed on their input and what we thought was going on and what was useful and what wasn’t useful…. We would think about whether the people had enjoyed a particular activity or whether people looked like they were interested in it, or what people’s comments were about things as we went along. But again we didn’t document this kind of stuff either. It was our perspective of it. So and so seemed to really enjoy that piece, and maybe someone else didn’t pick up on that, or looked like they didn’t quite understand that. Maybe we want to revisit that again. Rose
Rose and the other clinician also debriefed directly after the session. They used their time together not only to evaluate the participants’ responses but also to forward plan for the next session. Rose considered multiple aspects of how she evaluated the programme. She thought about how participants responded to content, how the session may have benefited the client, and what needed to occur next. Rose was aware that her evaluation was not a formal process, but it was nevertheless valuable as it impacted directly on participants care. Rose considered while psychometric tools are helpful, they do not provide answers to all the facets which occur in a therapeutic setting. As she evaluated what had occurred, Rose continued to formulate treatment and consider participants’ individual needs. Claire thought about evaluation from two perspectives. Firstly, as with Diane and Rose, she considered aspects of the manual and how the participants were responding to material. In her second account Claire reflected on what the participants articulated about the programme.
And absolutely looking at their buy-in, investment or I guess engagement with the topics we were covering and the kind of work we were doing. Also how it was fitting for people who were attending who were there for a variety of different reasons as well and whether they were helped. And how relevant it was to those participants in each session as well.… So there were aspects (of the manual) that worked well. One was the group exercises and to be honest I was a little bit dubious about how they were going to go and actually they went well. People did really well, they were
Clinician Findings 127 quite involved with them and the exercises and it was a good ice breaker for the sessions and created some humour as well at times you know writing with the other hand and so they were good. And it is good to have guides, the way it guides the clinician in terms of what to say and the order in which to do things that is a strength of the manual I think. And it is also a strength that you can, somebody new can have that there to use but you don’t have to use it. You can use your own words or descriptions for things as well. That’s a nice component of it… Claire
Claire also reflected on how her thinking changed. When she had initially considered elements in the manual, she anticipated the possibility that components might not work. When they did work well, Claire reflected on how involved the participants were and whether the exercises drew participants into engaging with each other. As she reflected Claire realised other parts of the manual structure and layout were also beneficial in aiding the clinicians in helping the participants engage in therapy. As she thought about the manual, Claire realised the manual was suitable for clinicians with a wide range of experience from novice to skilled clinicians. Claire’s insight into how she evaluated the sessions was she had doubts about components of the manual but changed her thinking to realising it was a tool most clinicians could use.
In her second account, Claire considered the participants’ actual responses to being asked about the therapeutic group sessions.
We were asking them for their feedback and certainly encouraged them at the end as well, that they had the opportunity to give feedback if they wanted to. And have implications and direct effect on how the manual was developed further down the track. So they could use their experience to guide how we did this planning for how other people might find it in the future as well… Claire
Claire reflected on how important it was for her that the participants could affect the structure and programme of the groups. This is not unexpected as her core value as a clinician was to ensure participants’ needs were met. She wanted to directly know the
participants’ experience. She had spent time thinking about their responses, their engagement with the material, and had spoken and debriefed with the other clinician. But Claire wanted to gain a deeper understanding and insight into what the group was actually like for the participants. Claire realised the unique and valuable perspective the participants had, was not able to be gleaned during the manual development. By gaining their views, Claire realised the manual could be further shaped to meet the needs of future participants.
In summary, the gap between practice-based research and published results is evident in this theme. How clinicians make therapeutic decisions in a session, evaluate participants’ responses, and assess treatment usually relies on evidence-based practice and psychometric tools. The therapists in this study used intensive and extensive feedback with each other regarding the sessions and the participants. Further, they
actively sought participants’ feedback as well on the session’s content and effectiveness. This poses the question of whether there are levels of processing of a therapeutic
relationship for the therapists and whether a collaborative approach has an impact on outcomes.
The therapeutic value and the effectiveness of using a collaborative approach in therapy which the clinicians experienced parallels with family therapy research. Family therapy research findings include concepts such as how a therapist can turn over power to a group, generate new ideas, encourage insight to bring about change, and promote an active learning environment, through the use of reflection and feedback from other members of the group or co-facilitators (Harrawood, Parmanand, & Wilde, 2011).
Clinician Findings 129 9.8 Summary
In this chapter the experience of three clinical psychologists working in the HCPS were explored. The themes of meeting the individual participants’ needs, becoming a group facilitator, managing a group, preparing for the session, and evaluating the session emerged along with accompanying sub-themes. The therapeutic environment consisted of a multitude of relationships with the clinicians attending to the individual needs of each participant. It is possible they were able to accomplish this more easily given the small participant numbers in each group. With regards to the group process, the clinicians talked about the satisfaction they found in working with groups despite none having previously run a therapeutic group. In general, through their experiences as facilitators, the clinicians became more aware of group processes and social support available in groups. However, they talked about group processes as they occurred with individuals rather than global group processes.
Also, the clinicians’ perspectives provided insight into their experience of facilitating a therapeutic group. The clinicians described their core value for the therapeutic group was providing individualised care and prioritised the individuals’ needs within the group and adapted to meet client needs. They understood the need for care and considered multiple aspects in order for the therapeutic care to be effective. Hudon et al. (2012) state the need for patient centred care especially in long term CHC care. The findings tentatively suggested that the clinicians found the therapeutic group setting differed from other settings, when compared to one-on-one therapy, and couples and family therapy. In addition, they worked proactively and anticipated issues and problems which may have arisen within a therapeutic group setting, such as, conflict
between participants and engaging reticent members. There were two facilitators in each group. An awareness of the different competencies of each clinician and how the
clinicians worked collaboratively and with mutual acceptance as a team were not identified within the questions and framework of the study. Lau, Ogrodniczuk, Joyce, Sochting (2010) and Sochting and Third (2011) criticised current group therapy
research as having limited practical clinical utility. Specifically, practice-based research needed to consider further, among other priorities, group processes and group leader issues. This was evident in this research whereby clinicians’ experiential perspectives of therapeutic groups were difficult to locate.
However, in using the manual, the clinicians also faced challenges in bringing about therapeutic change for individuals in a therapeutic group setting. They were able to use the manual to aid discussions and group exchanges. But in some instances, they found that it was difficult to adhere strictly to the manual, while simultaneously meeting the participants’ needs. This suggested that the clinicians valued the ability to work flexibly even when using a manual. Garmy, Berg, and Clausson (2014) similarly found in their implementation of a CBT group therapy by school health professionals that facilitators tried to balance manual adherence with meeting participants’ needs. What is unclear from this study is how the clinicians considered fidelity when dilemmas arose in following the manual. Manualised therapy, while providing a medium for evidence based therapy, can have the drawback when followed slavishly. It may prevent the facilitator from using the group process to engage in relevant issues presented in the group. At the same time, departing from the prescribed therapy may interfere with effectiveness. Doel and Kelly, (2014) suggest the manual can be followed in essence,
Clinician Findings 131 with the manual being flexible enough to amalgamate the material and group process into a useful experience for the participants. However, they also recommend facilitators need to have specialist group knowledge, training and skills; otherwise the material is likely to be administered in an academic rather than therapeutic manner, which would reduce participant’s effective outcomes.
The issue of attending to the group process is complex and highlighted by this study. The question arises for therapeutic group practice; how do clinician’s identify and develop group process skills as they experience and implement therapy in a group setting? In this study, clinicians’ core values played a role, as they considered the individual client needs were paramount. Yalom and Leszcz (2005) discuss a two tier approach for facilitators to bring effective change in groups when working in “the here- and-now.” Firstly, they need to attend to the immediate events in a session, especially the dynamic interrelationships occurring in a group. The next tier is a self-reflective examination process of the “here-and-now” experience which has occurred. They discuss that in most groups, the facilitators attend to the first aspect, but few facilitators consider the group process. Further, they infer it is only through the facilitators gaining experience with groups that this can occur (Yalom & Leszcz, 2005). The facilitators’ experience is an area in group research which is seldom discussed.