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British Journal of Health Psychology © The British Psychological Society

Edited By: Paul Bennett and Kavita Vedhara Impact Factor: 2.697

ISI Journal Citation Reports © Ranking: 2011: 23/109 (Psychology Clinical) Online ISSN: 2044-8287

Author Guidelines

The aim of the British Journal of Health Psychology is to provide a forum for high quality research relating to health and illness. The scope of the journal includes all areas of health psychology across the life span, ranging from experimental and clinical research on aetiology and the management of acute and chronic illness, responses to ill-health, screening and medical procedures, to research on health behaviour and psychological aspects of prevention. Research carried out at the individual, group and community levels is welcome, and submissions concerning clinical applications and interventions are particularly encouraged.

The types of paper invited are:

• papers reporting original empirical investigations;

• theoretical papers which may be analyses or commentaries on established theories in health psychology, or presentations of theoretical innovations;

• review papers, which should aim to provide systematic overviews, evaluations and interpretations of research in a given field of health psychology; and

• methodological papers dealing with methodological issues of particular relevance to health psychology.

1. Circulation

The circulation of the Journal is worldwide. Papers are invited and encouraged from authors throughout the world.

2. Length

Papers should normally be no more than 5000 words (excluding the abstract, reference list, tables and figures), although the Editor retains discretion to publish papers

beyond this length in cases where the clear and concise expression of the scientific content requires greater length.

3. Editorial policy

The Journal receives a large volume of papers to review each year, and in order to make the process as efficient as possible for authors and editors alike, all papers are initially examined by the Editors to ascertain whether the article is suitable for full peer review. In order to qualify for full review, papers must meet the following criteria:

• the content of the paper falls within the scope of the Journal

• the methods and/or sample size are appropriate for the questions being addressed • research with student populations is appropriately justified

• the word count is within the stated limit for the Journal (i.e. 5000 words)

4. Submission and reviewing

All manuscripts must be submitted via http://www.editorialmanager.com/bjhp/. You may like to use the Submission Checklist to help you prepare your manuscript. The Journal operates a policy of anonymous peer review. Authors must suggest three

• Manuscripts should be preceded by a title page which includes a full list of authors and their affiliations, as well as the corresponding author's contact details. A template can be downloaded from here.

• Statement of Contribution: All authors are required to provide a clear summary of ‘what is already known on this subject?’ and ‘what does this study add?’. The 2-3 (maximum) sentences for each point should identify existing research knowledge relating to the specific research question/topic and a summary of the new knowledge added by your study. Under each of these headings, please provide 2-3 clear outcome statements (not process statements of what the paper does); the statements for 'what does this study add?' should be presented as bullet points of no more than 100 characters each. The Statement of Contribution should be a separate file.

• Tables should be typed in double spacing, each on a separate page with a self- explanatory title. Tables should be comprehensible without reference to the text. They should be placed at the end of the manuscript with their approximate locations

indicated in the text.

• Figures can be included at the end of the document or attached as separate files, carefully labelled in initial capital/lower case lettering with symbols in a form consistent with text use. Unnecessary background patterns, lines and shading should be avoided. Captions should be listed on a separate sheet. The resolution of digital images must be at least 300 dpi.

• For articles containing original scientific research, a structured abstract of up to 250 words should be included with the headings: Objectives, Design, Methods, Results, Conclusions. Review articles should use these headings: Purpose, Methods, Results, Conclusions.

• For reference citations, please use APA style. Particular care should be taken to ensure that references are accurate and complete. Give all journal titles in full. • SI units must be used for all measurements, rounded off to practical values if appropriate, with the imperial equivalent in parentheses.

• In normal circumstances, effect size should be incorporated. • Authors are requested to avoid the use o f sexist language.

• Authors are responsible for acquiring written permission to publish lengthy

quotations, illustrations, etc. for which they do not own copyright. For guidelines on editorial style, please consult the APA Publication Manual published by the American Psychological Association.

• Manuscripts describing clinical trials are encouraged to submit in accordance with the CONSORT statement on reporting randomised controlled trials (http://

APPENDIX J - BRITISH JOURNAL OF HEALTH PSYCHOLOGY STATEMENT OF CONTRIBUTION

What is already known on this subject?

Chronic illnesses can profoundly impact on essential life domains and cause significant psychosocial distress. Being diagnosed with a chronic condition is usually a life-changing experience and the challenges faced by someone with a chronic illness are complex and ongoing, requiring the individual to constantly adapt to developing symptoms and circumstances. Individuals who are diagnosed at a young age must negotiate more life stages and have more time ahead of them to adapt to living with the illness and to managing symptoms than someone older with a shorter life- expectancy.

What does this study add?

Provides a theoretical framework with which to understand the experiences of people who were diagnosed with a chronic illness when they were young.

Supports and adds to previous research and provides new insights into the experiences of people who were diagnosed with a chronic illness when they were young.

Research Report 2:

‘Closing the gap’: Personal meanings among psychotherapists working with clients with long-term health conditions.

Abstract

Background: While there is a substantial body of research on clients’ experiences of chronic illness, there is a dearth of qualitative research examining chronic illness from practitioners’ perspectives.

Aims and Objectives: The aim of this study was to explore how practitioners make sense of clients’ long-term conditions. The objective was to develop a better understanding of long-term conditions from the perspective of psychotherapists. For this purpose the research asked: How do psychotherapists make sense of their clients’ long-term conditions?

Method: Five female therapists who had worked with people with long-term conditions for a range of 3-27 years were interviewed. Data was analysed using an Interpretative Phenomenological Analysis approach.

Results: Two superordinate themes emerged from the data analysis: No ‘them ’ and ‘u s ’ and Redrawing boundaries. Participants in this study anchored their understanding of their clients’ experiences and of their therapeutic work by drawing similarities between themselves and their clients and non-health-related distinctions with other client groups.

Conclusions: Dealing with chronic conditions in a psychotherapeutic context is a process that requires psychotherapists’ understanding of their clients’ experiences and of their therapeutic work together. This study elucidated some psychological and therapeutic processes relevant to practitioners working with people with long-term health conditions.

Introduction

Chronic or long-term conditions^ are health problems which, at present, cannot be cured and which, according to the World Health Organisation (WHO) (2002), are the leading cause o f mortality, morbidity and disability worldwide. In England, more than 15 million people are living with long-term conditions, a figure which is expected to increase over the next decade (Department of Health (DOH), 2013). Indeed, the incidence of chronic illnesses is increasing globally and is expected to be the main cause of disability by 2020 (WHO, 2002).

Chronic illnesses vary greatly in terms of symptoms, severity and progression and can profoundly impact on essential life domains including education, employment, financial opportunities and relationships (Lubkin & Larsen, 2006). In addition, chronic conditions are often associated with increased difficulties in psychosocial functioning including anxiety, depression, cognitive strain, social isolation, self­ esteem, self-concept and interpersonal relationships (Lubkin & Larsen, 2006). Diagnoses are usually life-changing and require individuals to learn to recognise and manage symptoms, deal with flare-ups or illness exacerbations, use medication, treatments and services effectively and develop strategies to manage the psychosocial consequences of the illness (DOH, 2001). Whilst long-term conditions cannot be cured, they can often be managed through medication and other therapies (DOH, 2013).

Surawy, Zahl, & Salt, 2010). Rather, they are typically clients who are experiencing distress owing to the onset of a life-changing and medically ‘framed’ condition.

There is ample evidence that psychological therapy can improve the quality of life and alleviate the distress of people suffering from chronic illnesses (e.g. British Association for Counselling and Psychotherapy, 2005; Petrie & Revenson, 2005). Rumble (2012) emphasises that whilst it would be irresponsible not to take medical diagnoses into account in therapy, “welcoming diagnosis to therapy should be tempered by an ethical commitment to go beyond diagnosis to the client” (p. 116). Counselling psychology’s emphasis on depathologising psychological difficulties seems especially pertinent when working therapeutically with clients with chronic illnesses. This means viewing problems as a part of human experience and as ways of coping with life’s difficulties and focusing instead on understanding the dynamics and processes that shape individual experience and the meanings that psychological difficulties have for individuals at particular junctures in their lives (Strawbridge & Woolfe, 2003). Furthermore, it seems paramount to understand whether and in what ways therapists working within a context dominated by a medical model can uphold counselling psychology values such as focusing on wellbeing rather than pathology or maintaining a collaborative rather than expert-client therapeutic relationship.

Whilst there is abundant literature on the difficulties that people with chronic illness may grapple with and some literature on the experiences of practitioners who themselves are diagnosed with long-term illnesses (e.g. DeMarce, 2007; Kaschak, 2001; Maggio, 2007; Sollod, 2002), there is a dearth of literature pertaining to therapists’ subjective experiences of working with clients with long-term conditions. Understanding how therapists make sense of their clients’ experiences and conditions and how they reflect on their work with this client group may help to elucidate some psychological and therapeutic processes relevant to practitioners’ personal and professional development. This is important, as it may shed light on how practitioners approach their work and it may inform new therapists who wish to work with this client group.

Qualitative methods are said to enable unique personal accounts to be explored in detail, yielding new and profound insights into participants’ experiences (Yardley, 2000). Therefore, this research focuses on broadening the existing literature on this topic by adopting a qualitative perspective to explore in depth what positions therapists adopt when working with people with chronic illnesses and how they make sense of their therapeutic relationships and endeavours. Upon considering different qualitative methods, an Interpretative Phenomenological Analysis (IPA henceforth) approach to data collection and analysis was considered the most appropriate for the purposes of this study. Firstly, IPA has been described as “especially useful when one is concerned with complexity, process or novelty’ (Smith and Osborn, 2003, p. 53), all o f which are relevant in the exploration of practitioners’ understanding o f long-term conditions. Additionally, Brocki and Wearden (2006) explain how our understanding of illness has shifted away from the biomedical model of illness, where bodily processes where assumed to “map onto a predictable illness experience in a fairly simple way” (Brocki & Wearden, 2006, p.88), towards an understanding of illness as a more complex and constructed experience. Consequently, IPA is considered particularly relevant because it allows the exploration of individuals’ subjective perceptions, interpretations and meanings regarding illness and bodily experiences and of the dynamics and processes that shape their experiences and hence, of how their experience is understood and constructed (Brocki & Wearden, 2006). Furthermore, IPA aims to capture and explore contextualised and detailed accounts of the individual participants’ personal experiences and the meanings they assign to them (Eatough & Smith, 2008; Reid, Flowers, & Larkin, 2005). IPA is informed by

experiences and how they make sense of them, in order that the researcher may develop an interpretation of the participant’s experience (Smith et a l, 2009).

The aim of this study was to explore how psychotherapists make sense of their clients’ long-term conditions. The objective was to develop a better understanding of chronic illness from the perspective of psychotherapists, which could provide new and richer understandings of the perspectives that inform psychotherapists working with clients with chronic illnesses. Additionally, this could help to develop new ways of understanding and dealing with chronic illnesses psychotherapeutically. For this purpose, the research asked: How do psychotherapists make sense of their clients’ long-term conditions?

Method

Participants

A purposive sampling strategy was employed in order to explore therapists’ particular perspective on clients’ long-term conditions (Smith et al., 2009). This involved selecting participants who shared a particular lived experience, for whom the phenomenon being studied was meaningful and who therefore could “grant access to a particular perspective on the phenomena under study” (Smith et al., 2009, p. 49). The sample was homogenous. That is, participants were similar enough to represent a specific perspective in order that psychological variability and convergence within the sample could be examined (Smith et al., 2009). Additionally, a small sample was chosen to allow engagement with the idiographic and the particular in order to gain indepth insight into the phenomenon under study.

The participants were five female therapists whose ages ranged from 28-58. They had approximately 6-36 years of clinical experience, out of which they had worked specifically with people with long-term illnesses for a range of 3-27 years. The participants worked within a secondary care context and followed a primarily 3’’^^ wave

CET approach to therapeutic work. The participants predominantly worked with clients whose psychological difficulties/presenting problems were secondary to their health condition. Participants were recruited through snowballing.

Ethical considerations and confidentiality

This study did not require ethical approval from the University of Surrey’s Faculty of Arts and Human Sciences (FAHS) Ethics Committee. The researcher and her supervisor consulted the ethical flowchart published by the Committee and confirmed that: deception would not be used in the study; the participants were not considered vulnerable and were not current members or staff of the university; the questions in the interview schedule could not be deemed to be sensitive or offensive; and issues of confidentiality and anonymity would be guaranteed.

Procedure

Participants were informed of the purpose of the study, that their participation was voluntary and that they could withdraw from the study at any time up to the stage of data analysis (see Appendix A). Written, informed consent was obtained from all of the participants (see Appendix B) and following the interview, participants were provided with a debrief form explaining the purpose of the research (see Appendix C).

lasting approximately 40 minutes and participants were asked to complete a demographic information questionnaire (see Appendix D). The interview schedule was based on existing literature and the researchers’ personal interests. The questions aimed to explore therapists’ perspectives on clients with long-term conditions and their experiences of working with them and asked participants: what was their understanding of chronic conditions; what they thought it was like to have a chronic condition; what it was like to work with clients who had chronic conditions; whether they could compare clients who did have chronic conditions with those who did not; and what they thought the future was like for people with chronic conditions (see Appendix E).

Smith et al. (2009) view independent audits as “a really powerful way of thinking about validity in qualitative research” (p. 183). Mini independent audits were conducted with the researcher’s supervisor and a peer using an extract from a transcript, in order to ascertain whether the researcher’s annotations had some validity/credibility in relation to the transcript (Smith et al. 2009). In addition, the researcher has attempted to contextualise the sample, provide a clear and coherent account of the research process and to provide extracts from each participant to illustrate each theme in line with Yardley’s (2008) criteria for validity and quality in qualitative research.

Analysis

Interviews were audio-recorded, transcribed verbatim and analysed using the steps of IPA described by Smith et al. (2009) and Smith, Jarman and Osborn (1999) outlined below (see Appendix F for an example of an interview transcript). Firstly, each transcript was read several times in order to focus on the participant’s experiences. At this stage, the researcher aimed to note and bracket off initial observations, assumptions, connections and ideas in order to focus on actively engaging with the data.

The second step involved generating exploratory descriptive, linguistic and conceptual comments, which were annotated along the right margin of the transcript. The researcher aimed to generate comprehensive and detailed comments which examined semantic content and language use and to identify specific ways in which participants understood different issues. Some of the notes had a phenomenological focus describing participants’ personally salient experiences and the meanings they ascribed to them, while interpretative notes focused on how participants made sense o f these phenomena. The context in which the participants’ experience was embedded was also considered.

Next, the exploratory comments generated in stage two were analysed to identify and develop emergent themes/concepts. The researcher aimed to create themes which captured and reflected both the participant’s account and the researcher’s understanding of the participant’s account. These were annotated along the left-hand column of the transcript.

Step four involved looking for patterns and connections which drew together the emergent themes and developing a structure which incorporated the most salient/ interesting aspects of the participant’s account. Related themes were grouped together to create ‘super-ordinate’ themes and were consolidated in a table.

The steps outlined above were repeated with each transcript, while aiming to treat each case individually and to bracket the ideas which emerged from previous

Results

Although all participants varied in their demographic backgrounds, the data yielded some commonalities. Two superordinate themes were identified in the analysis. The first superordinate theme. No “them ” and “u s ”, presents an account of participants’ perspectives and understanding of the similarities between themselves and their clients. The second superordinate theme. Redrawing boundaries, describes participants’ perception of their clients (and by implication themselves) as different to ‘traditional’ mental health clients in non-health-related ways and the implications of this distinction for the therapeutic process, relationship and outcome. These superordinate themes are developed below.

1. No ‘them and ‘us’

Participants described understanding their clients’ conditions and difficulties as either experiences that they could one day possibly experience themselves, given that they could one day be faced with a similar diagnosis, or as experiences that are inherently human and thus inescapable, and which they were therefore certain that they would share with their clients at some stage. Participants also described how a large element of their work and their understanding of their clients was based on a focus on embodied experience and on focusing on the person in therapy rather than on the condition. These subordinate themes are described in more detail below.

1.1 Focus on a shared vulnerability to illness. Participants emphasised practitioners’ vulnerability to illness and the sense that therapists are not exempt from