Millett, Lottie; (2022) Exploring the influence of pre-therapy epistemic trust levels on the effectiveness of therapy delivered in IAPT settings. Doctoral thesis (D.Clin.Psy), UCL (University College London).

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Abstract

Background: There is emerging evidence that a key factor in therapeutic effectiveness is epistemic trust: put simply, the capacity of an individual to trust that others may have benevolent/supportive intentions and therefore take on any information from others that may be helpful for them. The evidence base in this area is limited. Furthering knowledge regarding what factors improve the effectiveness of therapy can be highly impactful in terms of financial efficiency as well as improving the lives of those who experience mental health difficulties. As such, we aimed to explore the relationship between patient levels of epistemic trust pre-therapy with therapeutic effectiveness. This included examining whether a lower epistemic trust score pre-therapy is associated with a higher symptom score pre-therapy, whether the demographic factors of place of birth and ethnicity predict pre-therapy epistemic trust score, whether epistemic trust levels change post-therapy, and whether pre-therapy epistemic trust score was related to symptom score change between pre and post therapy. We also examined whether mentalising capacity changed after therapy, and whether this change was related to changes seen in epistemic trust. Methods: Adults diagnosed with a depressive and/or anxious mental health difficulty within two Improving Access to Psychological Therapy (IAPT) services participated in the study. Participants completed a demographic questionnaire, The Epistemic Trust Scale (ETS), The Mentalization Questionnaire (MZQ), and the Beck Depression Inventory (BD III) pre-therapy. Participants completed the Patient Health Questionnaire - 9 (PHQ-9), and the General Anxiety Disorder - 7 (GAD-7) pre-therapy and at every therapy session. Some participants completed the pre-therapy outcome measures post-therapy. Linear regression was used to investigate the relationship between pre therapy and post therapy levels of the concepts discussed, as well as whether pre-therapy levels affected the effectiveness of therapy. Results: Pre-therapy it was found that, on average, lower ETS total scores, and lower ETS for therapists scores, were moderately correlated with more severe symptoms on the PHQ-9 and BDI II. Similarly lower ETS for others scores, on average were moderately correlated with PHQ-9 and BDI II, and weakly with GAD-7 scores. Neither of the demographic factors, of being born outside of England and/or of being of a black, asian, middle eastern, or mixed race, were significantly associated with ETS scores. Epistemic trust total scores, and both subscale scores, significantly improved after therapy within IAPT services. These were medium sized effects. Scores on the MZQ did not significantly improve after therapy and score change on the MZQ after therapy was not significantly associated with changes in ETS score. Those with a lower level of total ETS and ETS for therapists were found to have significantly less depression and anxiety symptom improvement on the BDI II and GAD-7. Only having a lower level of ETS for others was associated with less symptom change on the PHQ-9, this effect was not seen on the BDI II or GAD-7. When controlling for symptom severity, the association between pre-therapy ETS for others and symptom change on the PHQ-9 did not remain. Comparatively, it was found that for the BDI II, pre-therApy ETS total score increased the explanatory power of the model by 18.5%. Compared to pre-therapy symptom severity alone. Discussion: As hypothesised, it does seem that there is a relationship between epistemic trust and mental health symptom severity, where a lower level of epistemic trust is associated with more severe mental health difficulties. Therapy within IAPT services seems to improve epistemic trust levels yet this does not seem to be mediated by changes in mentalisation ability. Further, those with higher levels of epistemic trust had greater improvement in their mental health symptoms, as measured on the BDI II and GAD-7. The same improvement was not seen on the PHQ-9.

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