Understanding the factors that contribute to the outcome of cognitive behavioural therapy as adjunct to medical treatment in a sample of individuals with psoriasis : a constructivist grounded theory study
Psoriasis is a chronic autoimmune skin condition that can impair psychological, social, and physical functioning. The psychological implications of psoriasis can be highly disturbing and a significant number of patients with psoriasis live with considerable and enduring psychological distress. An accumulating body of evidence suggests that Cognitive Behavioural Therapy (CBT) may be the most effective in ameliorating the psychological distress resulting from living with psoriasis. CBT has been effective in reducing the emotional distress, the quality of life impairment associated with psoriasis and as a result the clinical severity of it. The mechanisms behind these changes are not known, however. Outcome studies in CBT have shown that common factors (i.e., therapeutic relationship) and/or technical ones (i.e., CBT techniques) account for therapeutic change. The aim of this study is to identify the factors that influence the treatment process and the outcome of CBT for individuals with psoriasis and develop a model of it. This study adopted a constructivist Grounded Theory approach. In-depth semi-structured interviews were conducted with nine patients who had completed a course of CBT within the Psychodermatology Clinic of a hospital in England. From the analysis emerged the model of “Guided Therapeutic Growth” which was the core conceptual framework that subsumed the factors that influence the patients’ experiences of their therapeutic processes in CBT. These factors were: (a) “feeling engaged with the therapeutic process”; (b) “establishing a trusting therapeutic relationship”; (c) “legitimising the expression of distress associated with psoriasis”; and (d) “guided cognitive restructuring of the meanings attached to psoriasis”. The integration of these four interrelated factors forms a tentative model that was found to impact the therapeutic growth by reducing distress, alleviating emotional pain and helping individuals with psoriasis to become more self-compassionate, all of which were found to motivate and empower them to move forward and achieve positive changes in their adjustment to their psoriasis. Conversely, the absence of these factors or the presence of certain hindering conditions could compromise the therapeutic experience of CBT and jeopardise progress. In this context, the following hindering conditions were reported: (a) negative preconceived notions about homework; (b) too much or too little directiveness by the therapist; and (c) externalisation process of emotional release experienced by the patient as too revealing.
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