Idiographic Measures in Clinical Psychology Training · measures such as the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), contain items that cover a vast range

Service Evaluation Project Idiographic Measures

1

Idiographic Measures in Clinical

Psychology Training

Emily Higgins

Commissioned by Gary Latchford and Jan Hughes, Leeds DClinPsychol programme


Prepared on the Leeds D.Clin.Psychol. Programme, 2019 2

Table of contents

1. Background ................................................................................................................................3

1.1 Outcome measures………………………................................................................................3

1.2 Limitations of standardised measures .......................................................................................3

1.3 Idiographic approach………………..........................................................................................4

1.4 Psychologists in Clinical Training (Trainees) use of outcome measures……………………...5

2. Methodology ...............................................................................................................................6

2.1 Research aims ............................................................................................................................6

2.2 Design ........................................................................................................................................6

2.3 Sample........................................................................................................................................6

2.4 Procedure ...................................................................................................................................6

2.5 Ethical considerations ................................................................................................................7

2.6 Analyses......................................................................................................................................8

3. Results .........................................................................................................................................9

3.1 Response rate .............................................................................................................................9

3.2 Usage of outcome measures and IM………………………………………………………..…..9

3.3 Confidence in using IM……....................................................................................................10

3.4 Awareness and use of different types of IM...............................................................................11

3.5 Trainee Attitudes towards IM……………………………………………………....................13

3.6 Qualitative data.........................................................................................................................15

4. Discussion.................................................................................................................................. 21

4.1 Key findings .............................................................................................................................19

4.2 Barriers to using IM .................................................................................................................19

4.3 Discussing IM in supervision....................................................................................................21

4.4 Advantages of IM.....................................................................................................................22

4.5 Limitations ...............................................................................................................................22

4.6 Conclusions and Recommendations…………………………………………………….....…23

4.7 Dissemination ……………………………………………………………………………......24

References..................................................................................................................................... 25

Appendices.................................................................................................................................... 29



1. Background

1.1 Outcome measures

Practice-based evidence (PBE) is becoming increasingly important within Clinical

Psychology. The PBE approach aims to improve psychology services by the systematic

analysis of data collected from routine clinical practice as opposed to randomised

controlled trials (Barkham, Hardy & Mellow-Clark, 2010). One component of this

approach is feedback informed therapy, which has traditionally followed a nomothetic

method, whereby clients are regularly asked to complete standardised measures to track

the process and outcomes of therapy. Clinicians are then provided with nomothetic

feedback, such as progress charts that include client scores throughout therapy, which are

compared with clinical and nonclinical populations (Barkham et al., 2010).

In recent years, the emphasis on outcome measurement has increased as a result of a

changing NHS, where there is a greater need to evidence the effectiveness and cost-

efficiency of services. As well as increased service pressures to use outcome measures an

expanding evidence base has shown that using standardised measures can improve

psychotherapeutic outcomes (Boswell, Kraus, Miller & Lambert, 2013). Several papers

have reported consistent improvements in client outcome, such as reduced psychological

symptoms and improved functioning, using this approach when compared to ‘treatment as

usual’ (Shimokawa, Lambert, & Smart, 2010; Bickman et al, 2011; Overington & Ionita,

2012).

1.2 Limitations of standardised measures

Although there are benefits to using standardised measures there are also concerns about

whether these measures are person-centred (Carr & Higginson, 2001). Standardised

measures limit clients’ opportunity to express their personal views because they contain a

set of pre-specified questions with pre-determined response choices. Standardised

measures such as the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-

OM), contain items that cover a vast range of symptoms (Barkham et al., 2001). For any



individual client, some of these items will not be pertinent to their experiences, while

relevant items may be missing (Carr & Higginson, 2001). Employing an overly broad

outcome measure can lead clinicians to conclude there has been no change in their client,

when a significant improvement or deterioration has in fact occurred. One of the perceived

benefits of standardised measures is their ability to evaluate both individual client work

and monitor performance at an organisational level. However, outcome measures that

monitor the effectiveness of psychology services are not easily adapted to tracking the

unique trajectory of a single therapeutic journey or identifying the precise mechanisms of

change (Evans, 2012).

1.3 Idiographic approach

In contrast to standardised measures, Idiographic Measures (IM) are uniquely designed for

each client. Changes in scores cannot be evaluated against population norms but only

against data previously provided by that individual (Molenaar, 2004). IM enable clients to

identify goals that are most important to them and to express these using their own language

or images (Beresford & Branfield, 2006). If the idiographic measure captures the specific

outcomes that are most important to the client and on which most therapeutic effort is

concentrated, the measures sensitivity to detect change should be enhanced. Therefore, it

makes sense both theoretically and clinically to evaluate interventions at the individual

level (Barlow & Nock, 2009).

To get a better understanding of healthcare quality, it was incorporated into Department of

Health (DH) policy that service-user perspectives should be gathered (Hermann et al, 2004)

and the service-user’s voice and participation increased (DH Research Governance

Framework, 2005). The relevance of idiographic measurement is being increasingly

recognised and there is a demand for personalised approaches that tailor assessment to the

specific needs and views of clients (e. g., Crawford et al, 2002; NICE, 2012; Sales & Alves,

2012; Taylor, 2013). Idiographic methods in psychotherapy have also been the focus of a

recent review (Piccirillo & Rodebaugh, 2019). The review suggested further development

of Idiographic methods was needed to enable their successful integration into clinical

services.



1.4 Psychologists in Clinical Training (Trainees) use of outcome measures

Competence in using outcome measures is indicated in the British Psychological Society

(BPS) accreditation criteria for the training and development of clinical psychologists

(BPS, 2019). The criteria state that trainees should be evaluating their practice through

monitoring processes and outcomes across multiple domains of functioning. It is also

recommended that trainees develop innovative evaluative measures where appropriate,

which could include the use of unique IM. A previous service evaluation project (SEP)

explored trainees’ experiences of and attitudes towards outcome measures (Allen, 2015).

However, trainees’ awareness of IM, attitudes towards IM, the consistency with which IM

are used, the types of IM used and trainees’ perceptions of the advantages and barriers of

using IM is currently unknown. In order to gather this information, this SEP was

commissioned.



2. Methodology

2.1 Research Aims

The aim of this SEP was to explore current awareness, usage and attitudes towards IM

among clinical psychology trainees.

2.2 Design

This project employed a mixed-methods survey design. Both quantitative and qualitative

data was collected using a range of open and closed questions. Consideration was given to

other designs including interviews. However, an online questionnaire was chosen because

it was the most efficient method to secure the largest sample of participants. An online

survey provided ease and convenience for participants, allowing responses to remain

anonymous and keeping time demands for participants to a minimum.

2.3 Sample

The sample included all trainees that were studying at the Universities of Leeds or Hull.

There were 16 trainees in each of the three cohorts at Leeds and 15 trainees in each of the

three cohorts at Hull. This provided a possible sample of 93 individuals.

2.4 Procedure

2.4.1 Questionnaire Development

The ‘Online Surveys’ website was used to develop a questionnaire in order to collect the

data. The survey questions were developed with the commissioning team and included

closed questions and Likert scales, with some free-text questions to explore in more detail

the participant’s views on advantages and barriers to using IM.

The questionnaire aimed to capture trainees’ awareness of IM, use of IM and attitudes

towards IM. Participants’ experiences of using IM both with clients and in supervision

were explored. The questionnaire was piloted on two trainees from the second year of the

Leeds training course. The feedback from these pilots informed revisions to be made to

improve the content validity of the questionnaire. A copy of the questionnaire can be found

in Appendix 1.



2.4.2 Recruitment

Participants were contacted via email and invited to complete the online survey (Appendix

2). The email was sent out by the course administrators of each course. The email included

a brief description of the project, outlining the purpose of the project, attached participant

information sheet (PIS; Appendix 3) and a link to the online survey.

2.5 Ethical Considerations

2.5.1 Ethics approval

Ethical approval for this project was sought from the School of Medicine Research Ethics

Committee and was granted on 8th March 2019. (Ethics approval number: DClinREC 18-

007; Appendix 4).

2.5.2 Informed consent

A PIS was provided via the online survey website, which participants could read before

commencing the study. The researcher’s contact details were provided on the invitation

email and potential participants were encouraged to ask any questions before taking part.

Consent was evidenced by participants continuing to complete the questionnaire after

reading the PIS.

2.5.3 Right to withdraw

Participants were informed that they could withdraw from the project by shutting down the

window of the online questionnaire. In this case their data was not retained. Once the

online questionnaire had been sent (by pressing the ‘finish’ button) participants could not

withdraw their responses as the responses were anonymous and therefore could not be

traced to individual participants.



2.5.4 Confidentiality and data storage

The anonymity of participants was maintained as no personally identifiable information

was obtained. Survey responses were exported from the Online Surveys website into

Microsoft excel and then transferred onto the M drive, a secure computer drive, which only

the researcher could access.

2.6 Analyses

Descriptive statistics were used to summarise the quantitative data collected, while

thematic analysis was used to analyse the qualitative data gathered from the free-text

responses. The steps outlined by Braun and Clarke (2006) were used to guide the thematic

analysis. This was considered the most appropriate analysis due to its relatively

straightforward and flexible approach. To ensure trustworthiness of the data the themes

were shared and discussed with an academic tutor. In the map, the themes are broken down

into advantages and barriers as these were separate questions eliciting different responses.

However, although there were separate questions about the use of IM in clinical practice

and discussing IM in supervision, these responses have been combined as they produced

similar themes.



3. Results

3.1 Response Rate

Out of the 93 individuals who were contacted, 38 completed the survey, which gave a

response rate of 40.8%. Of the 38 participants, 25 were from the Leeds training course

(65.8%) and 13 were from the Hull course (34.2%). The participants came from all three

years of the courses, with 12 from year one (31.6%), 17 from year two (44.7%) and nine

from year three (23.7%).

3.2 Usage of outcome measures and IM

Trainees were asked how often they use outcome measures and IM, how often they

discussed these with clients and how often they discuss these measures in supervision.

Figure 1. Graph depicting how often trainees use measures in practice and discuss them

with clients and supervisors

0

5

10

15

20

25

30

35

40

Outcome

Measures

Idiographic

Measures

Outcome

Measures

Idiographic

Measures

Outcome

Measures

Idiographic

Measures

Used in Clinical Practice Discussed with Clients Discussed in supervision

Never Rarely Sometimes Often Very Often



Figure 1 shows that nearly all trainees (95%) had used IM in clinical practice. However,

most trainees are not using IM frequently, with less than a third using them ‘often’ or

‘very often’. Most trainees (39%) reported using IM only sometimes. Furthermore,

Figure 1 also suggests that trainees are using IM less in clinical practice than they are

using outcome measures more generally. For example, all trainees had used outcome

measures and only 11% had used them ‘rarely’, whereas 2 trainees had never used IM

and 25% were using IM ‘rarely’.

When asked how often trainees discuss IM and outcome measures with clients and in

supervision there was a greater spread of responses for IM. However, overall IM were

discussed less frequently than outcome measures with both clients and supervisors.

Outcome measures were discussed with clients at least sometimes by 84% of trainees

compared to IM, which were discussed at least sometimes by 68% of trainees. Furthermore,

outcome measures were discussed in supervision at least sometimes by 74% of trainees

compared to IM, which were discussed at least sometimes by 58% of trainees.

3.3 Confidence in using IM

Trainees were asked how confident they felt in administering and interpreting IM. Most

commonly trainees felt ‘fairly confident’ with 27 of the sample (approx. 71%) reporting

this. Only 4 trainees (11%) rated that they were ‘not very confident’.

Figure 2. Confidence ratings for administering and interpreting IM

0

5

10

15

20

25

30

35

Not at all

confident

Not very

confident

Fairly confident Very confident Extremely

confident



3.4 Awareness and use of different types of IM

The questionnaire asked about six different types of IM and gave examples of each type

(see Table 1). These were decided upon with the commissioning team.

Table 1

Types of IM with Examples

Figure 3 displays the percentage of trainees who had heard of each IM and the percentage

of trainees who had used each measure at least ‘sometimes’ in their clinical practice. The

majority of trainees were aware of most of the IM. All trainees had heard of scales. Each

other measure, apart from maps, had been heard of by at least 80% of trainees. Maps were

the least familiar IM, with just less than half of trainees reporting they had heard of this

measure.

Type of IM Examples

Client Generated Questionnaires Personal Questionnaire (Shapiro, 1961)

PSYCHLOPS (Ashworth, 2004)

Helpful Aspects of therapy form (Elliott,

1993)

Client Generated Narratives Feedback letters

Qualitative diaries

Client change interview (Elliott, Slatick, &

Urman, 2001)

Scales Subjective Units of Distress Scale (SUDS;

Wolpe & Lazarus, 1966).

Visual Analogue Scale (VAS; Scott &

Huskisson, 1976)

Goal Attainment Scale (Kiresuk &

Sherman, 1968)

Outcome Rating Scale (ORS; Miller et al.,

2003)

Counts Worry episodes

Wet/dry nights

Binge eating episodes

Maps Repertory grids

Visual tools Children’s drawings



Trainees rated how much they had used each measure on a four-point scale

(1= Never, 2= Seldom, 3= Sometimes, 4= Often). To make it easier to compare the use of

each measure ‘Never’ and ‘Seldom’ were combined and ‘Sometimes’ and ‘Often’ were

grouped together. The graph displays the percentage of trainees that reported using each

measure at least sometimes (those that reported using the measure ‘Sometimes’ or ‘Often’).

Figure 3. Trainee awareness and usage of IM

Figure 3 shows that there was a disparity between the number of trainees who had heard

of each measure compared to the number of trainees who had actually used each measure.

The average disparity across measures was 43%. The largest disparity was for visual tools.

While 95% of trainees reported that they had heard of these IM, only 33% had used them

at least sometimes, which is a difference of 62%. A similarly large disparity existed for

client generated questionnaires, with 89% of trainees having heard of these measures, but

only 29% having used them. Scales had the smallest disparity, of only 16%.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Visual Tools

Maps

Counts

Scales

Client Generated Narratives

Client Generated Questionnaires

% of trainees who have heard of each measure

% of trainees who have used each measure at least sometimes



For five out of the six measures, over 40% of trainees were using them ‘rarely or ‘never’.

The most used IM was scales, with 84% using these at least sometimes, whereas none of

the trainees had used Maps in their clinical practice.

3.5 Trainee Attitudes towards IM

Trainees were asked how much they agreed with a series of statements about IM using a

five-point Likert scale from ‘Strongly Disagree’ ‘Disagree’ ‘Undecided’ ‘Agree’ and

‘Strongly Agree’. Figure 4 illustrates trainees’ responses to each statement, which have

been colour coded to highlight positive and negative attitudes. ‘Undecided’ responses have

been centred in the middle of the graph, with ‘Agree’ responses to the right and ‘Disagree’

responses to the left to make responses easier to compare.


14

Figure 4. Trainee attitudes towards IM

38 36 34 32 30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38

IM are more sensitive to client change than nomothetic measures

IM are difficult for my clients to complete

My clients prefer IM to nomothetic measures

IM can provide evidence of effectiveness

Interpreting outcomes using IM is difficult

IM accurately reflect how well I am helping my clients

IM are co-designed with the client

IM are difficult to administer

IM are useful in my clinical practice

IM are helpful for tracking client change

IM highlight those clients that are not making progress

IM provide valid information about a client’s experience

IM contribute to good, ethical practice

IM are too simplistic to capture a client’s experience

IM can help to determine the need to alter treatment

Attitudes towards Idiographic Measures (IM)

Disagree Strongly Disagree Undecided Agree Strongly Agree


15

As can be seen in Figure 4 trainees generally held positive attitudes towards IM. Overall

trainees particularly agreed that IM can provide evidence of effectiveness, valid

information about a client’s experience, are useful for clinical practice, helpful for tracking

client change and contribute to good ethical practice. Most trainees disagreed with the

negatively worded statements that IM are too simplistic, difficult to administer and difficult

for clients to complete. Some statements had a greater spread of responses, highlighting

differing attitudes between trainees. For example, whilst 19 trainees ‘agreed’ or ‘strongly

agreed’ that IM highlight those clients that are not making progress, 12 were ‘undecided’

and 7 ‘disagreed’.

3.6 Qualitative data

The answers given to the free-text questions in the survey regarding advantages of and

barriers towards using IM and discussing these in supervision, were analysed using

thematic analysis. The thematic map is displayed in figure 5.

Advantages of IM

With regards to the advantages of using IM with clients and discussing these in supervision,

three main themes were identified; meaningful for clients, therapist tools and helpful for

supervision. Each of these themes and their subthemes are outlined.

i.) Meaningful for clients

A common reported advantage of IM was that they were felt to be meaningful for clients.

This included four sub-themes; person-centred (e.g. “Personalised, tailored to the person,

I think this is more meaningful for service-users and shows you are thinking about them as

an individual”, co-designed (e.g. “clients feel involved in their creation”), promotes

engagement (e.g. “Can also be useful to engage clients, I have found that they have been

really useful with clients who have been reluctant to begin therapy” and minimise irrelevant

data (e.g. “personal to their goals and what they want to gain from therapy. Doesn't include

any information that is irrelevant for them”).



ii.) Therapist tools

A second theme was around IM providing therapists with some useful tools for therapy.

This comprised of two sub-themes. IM were thought to track meaningful change (e.g.

“Enables you to track change in something specific to the client which nomothetic

measures may not allow you to do”) and strengthen therapeutic alliance (e.g. “Personalising

measures I think can improve the therapeutic relationship”).

iii.) Helpful for Supervision

The third theme was that IM were helpful for supervision, which included four sub-themes.

These were aid reflective discussions (e.g. “Demonstrate a narrative that can enhance and

enable supervision discussions; Can help discuss/reflect on therapeutic processes rather

than content”), gain support and advice (e.g. “Could discuss how to set up IM with

supervisors; If the supervisor has a better understanding of the client’s goals (through using

these types of measures) then they can assist you with intervention choices”), highlight

barriers (e.g. “shows how the work is progressing and any barriers” and increase

supervisor understanding (e.g. “May give the supervisor a better understanding of the

client and your work together, may help to recognise change that other measures don’t

capture which can be helpful for the supervisor and supervisee”).

Barriers to using IM

Three themes regarding barriers to using IM and discussing these in supervision were

identified; negative attitudes, inaccessible and practical barriers.

i.) Negative attitudes

A barrier to using IM and discussing them with supervisors related to several negative

attitudes from trainees themselves and their perception of negative attitudes held by their

supervisors. Two sub-themes were trainees’ perceived lack of creativity/fear of judgement

(e.g. “Can be difficult to identify exactly what to use, particularly if you aren't very creative

(e.g. when working with children); If the measures are a little strange/ unique it might be

embarrassing” and trainees’ perception that supervisors do not value IM (e.g. “Supervisor



not wanting to discuss or seeing the point of the measure; If your supervisor doesn't like

using idiographic measures”).

ii.) Inaccessible

IM were considered inaccessible due to client and trainee limited understanding (e.g. “A

lack of understanding about the usefulness of them/how to administer; Lack of

understanding from both the client and practitioner”), IM being difficult to interpret (e.g.

“they are harder to interpret without norms”) and client ambivalence/difficulty identifying

goals (e.g. “Client ambivalence. Sometimes people struggle to identify treatment goals;

Sometimes clients find it difficult to identify what changes they would like to capture and

how, it can be difficult to identify and prioritise specific areas they would like to measure

over others”).

iii.) Practical barriers

The final theme was practical barriers which comprised of three sub-themes. These were

time consuming (e.g. “Depending on which/how you use idiographic measures can be more

time consuming”), difficulty recording on electronic systems (e.g. “Difficult recording

them on things like Paris/Lorenzo. They have tabs for some outcome measures e.g. PHQ-

9 etc but not all” and service pressures to use standardised measures (e.g. “Service

pressures to evidence effectiveness seem to seek more feedback from standardised

measures than any idiographic feedback; they can feel less 'professional' and persuasive

when set against available validated measures; Services may insist on standardised

measures and then I wouldn't want to inundate client with additional ones”).



Figure 5. Trainees’ reports on the advantages of and barriers to using IM with clients and

discussing these in supervision

Advantages

Meaningful for clients

Person-centred

Co-designed

Promotes Engagement

Minimise irrelevant data

Therapist tools

Track meaningful change

Strengthen therapeutic alliance

Helpful for supervision

Aid reflective discussions

Gain support and advice

Highilight barriers

Increase supervisor understanding

Barriers

Negative attitudes

Trainees' perceived lack of creativity/fear of

judgement

Trainees' perception that supervisors do not value

IM

Inaccesible

Client and trainee limited understanding

Difficult to interpret

Client ambivalence/difficulty

identifying goals

Practical Barriers

Time consuming

Difficulty recording on electronic systems

Service pressures to use standardised measures



4. Discussion

4.1 Key findings

Results suggest that most trainees have used IM at some point during their clinical practice.

However, a considerable proportion of trainees (approx. 30%) reported that they had

‘rarely’ or ‘never’ used IM. Furthermore, 39% of trainees were using IM only sometimes.

As well as exploring general usage it was interesting to explore the use of specific types of

IM. Results showed that trainees have heard of most of the IM, however most of the

measures do not appear to be frequently used. This is despite trainees holding positive

attitudes about IM and feeling ‘fairly confident’ about administering and interpreting them.

This reflects the wider picture in clinical psychology, where despite the benefits of IM the

idiographic approach has not been fully embedded in routine clinical practice (Green,

2016).

4.2 Barriers to using IM

There appears to be several reasons why IM are not consistently used by trainees. Some of

the reasons will be explored in more depth. Trainees identified practical barriers of using

IM and discussing them in supervision, such as time. Existing literature identifies time

constraints to be a disadvantage of using IM (Hatfield & Ogles, 2004). It is more time-

consuming to design an IM for a specific client than it is to use a ready-made standardised

measure, and this may be felt to place an unreasonable demand on under-resourced

services. However, IM such as the PSYCHLOPS, which is a self-report questionnaire that

allows clients to choose their own items and to rate them for intensity and duration, have

been designed for quick administration (Ashworth, Evans, & Clement, 2009).

Another benefit of the PSYCHLOPS measure is that the data can be recorded on CORE-

Net. CORE-Net is an electronic system, used by several UK psychological services,

designed to record and track client therapy outcomes (Barkham et al., 2010). Leeds and

Hull trainees have access to CORE-NET and are encouraged to record and monitor their

outcome data using this system. The fact that the PSYCHLOPS is one of the few IM that



can be recorded on CORE-NET means it overcomes another barrier identified by trainees

which was that IM are difficult to record on electronic systems. The PSYCHLOPS

therefore may overcome some of the practical barriers identified by trainees. However, the

results showed a large disparity between the number of trainees who had heard of client

generated questionnaires, such as the PSYCHLOPS (89%), compared to those trainees who

used these IM at least sometimes (29%). The reasons for this require further exploration,

but it could be due to limited teaching on IM, including specifically client-generated

questionnaires. For example, in the additional comments section one trainee wrote ‘I think

it would be helpful to have more teaching on them. Also perhaps spread over the 3 years

rather than just first year. I have never seen them used by anyone other than fellow

trainees.’ This suggests that as well as limited teaching, there are perhaps limited

opportunities on placement to observe supervisors and colleagues using IM.

Another barrier was that IM were felt to be inaccessible. It cannot be expected that

everyone who has therapy can readily articulate what they want to achieve (Green, 2016).

Trainees suggested that IM were inaccessible to some due to clients’ difficulty identifying

goals or client ambivalence. Developing IM may become harder when the intervention

involves several clients. Research suggests that agreement among multiple people seeking

a psychology intervention should not be assumed (Hawley & Weisz, 2003; Yeh & Weisz,

2001). For example, couples accessing therapy may have incongruent opinions as to what

they hope to gain from therapy. Also, clinicians and their clients can have different views

of the preferred outcome of their work together. However, agreeing on goals at the start of

therapy should be a required part of negotiating a therapy contract as opposed to something

additional required by the decision to use IM (Tryon & Winograd, 2002).

Another barrier to using IM was service pressures to use standardised measures.

Standardised measures can be analysed at both a micro and macro level. For example,

services can analyse data to compare the relative effectiveness of different therapists, or

audit the outcomes recorded from a whole service against national criteria. As IM are

personalised to the priorities and characteristics of each client, cumulative analysis at a

service level is intrinsically problematic (Maggin & Chafouleas, 2013). Therefore,



although trainees hold positive attitudes about IM, they may find it challenging utilising

them on placement when services may not encourage their use. On the attitude statements

most trainees agreed that their clients preferred IM to standardised measures and that IM

are more sensitive to client change than standardised measures. Trainees may therefore feel

a mismatch between their placements/teams’ approach, which may discourage the use of

IM and that of their own attitude and their training course, which may encourage the use

of IM. To avoid either/or positions as regards to choosing standardised or IM to track client

progress, one approach is to try and combine both types of measures. A standardised

measure such as the CORE-OM could be employed at the beginning and end of therapy,

but an IM, such as a personal questionnaire, could be used to monitor the process of therapy

(Sales & Alves, 2012). This allows group data about the overall effectiveness of a service

to be gathered while using personalised measures to review sessional changes throughout

therapy.

4.3 Discussing IM in supervision

It is interesting that as well as using IM less than outcome measures generally, most trainees

also discussed IM less in supervision. This can be linked with one of the qualitative sub-

themes identified as a barrier to using IM, which was trainees’ perception that supervisors

do not see the value of IM. It is likely that the supervisor’s beliefs about IM will have

influenced how much trainees were able to utilise IM on their placements. However, those

that had discussed IM with supervisors had highlighted how IM can be helpful for

supervision. Sub-themes emphasised how IM can aid reflective discussions in supervision,

increase supervisor understanding and highlight barriers in client work. Another sub-theme

was around supervision being helpful in the development and creation of IM for clients. A

barrier to using IM was some trainees’ perception that they lacked creativity. It therefore

might be useful for IM to be discussed in supervision to increase trainee’s confidence in

designing unique measures and so they can gain advice from supervisors. However, it

would also be beneficial to have a better understanding about supervisors’ current attitudes

and knowledge about IM.



4.4 Advantages of IM

Despite not all IM being in frequent use it was encouraging to find that trainees held

positive attitudes about IM and several advantages of IM were highlighted. Trainees

identified that IM were meaningful for clients. Existing literature highlights that IM are

person centred as they empower clients to identify their own areas of difficulty and clinical

improvement is evaluated according to areas which are relevant (Ashworth et al., 2007;

Ashworth et al., 2009). Trainees in this project identified similar strengths of IM, for

example one trainee wrote ‘IM are more person centred and can often capture the

experiences relevant to the client rather than nomothetic measures that may largely be

irrelevant or fail to appreciate significant change for the client’.

Although time was identified as a barrier to using IM, trainees noted how using IM can

minimise irrelevant data. Literature has also identified a strength of IM being that time is

not wasted assessing irrelevant problems (Wagner & Elliott, 2001). Another strength

highlighted in the literature is that IM are flexible and take client variables such as

personality, cultural background and socioeconomic status into account. Trainees

identified similar advantages e.g. ‘Can be personalised; removes cultural biases inherent

within other measures.’ Furthermore, IM help to clarify client goals. Research has shown

that clients are more willing to engage with interventions if the treatment goals are

meaningful and address their individual needs (Turner-Stokes, 2011). Promoting

engagement was a theme to emerge in this dataset and several trainees felt IM helped to

promote client engagement.

4.5 Limitations

There are several limitations with this project. Firstly, there was less than a 50% response

rate, making it difficult to assume that the responses obtained were representative of the

total sample. It could be possible that non-responders had different views.

Secondly, after analysing participant responses it became clear that some of the questions

could have been worded better. For example. One question asked clients to identify how



confident they felt in administering and interpreting IM. This question is touching upon

two separate issues and it may be that trainees’ confidence differs for each aspect of the

question. This is probable as on the attitude statements, which ask about administration and

interpretation separately, there is a difference of responses. For example, no trainees agreed

with the statement that administering IM is difficult. However, 21% of trainees agreed that

interpreting IM is difficult. Furthermore, interpreting IM emerged as a barrier to their use.

Therefore, although most trainees selected ‘fairly confident’ for administering and

interpreting IM, it may be that this is not a true reflection of their confidence. Moreover,

the attitude statements could have been more evenly balanced with positive and negative

worded statements as the fact that there were more positive statements could have

influenced trainees to express positive attitudes.

Finally, on reflection it would have been preferable to directly compare the usage of IM

with standardised measures. Instead trainees were asked about IM and outcome measures,

but outcome measures include both standardised measures and IM. This makes it difficult

to be confident that IM are used infrequently as the usage could be in line with other

measures. However, there is a strong hypothesis that IM are used less than standardised

measures because IM were used ‘rarely’ or ‘never’ by 29% of trainees, whereas outcome

measures generally were only used ‘rarely’ by 11% of trainees. Nevertheless, the results

should be interpreted with some caution. It would also be useful to know whether trainees

use both measures alongside each other.

4.6 Conclusions and recommendations

Trainees were generally positive about IM, but the different types of IM did not appear to

be frequently used. Barriers were identified that may help to explain this. To enable and

support trainees to use IM more in clinical practice and discuss these types of measures in

supervision the following recommendations are suggested:

A future SEP could explore supervisors’ attitudes towards IM, to confirm

whether or not trainees’ perceptions of supervisors having negative

attitudes towards IM is accurate.



The supervisor training course could increase supervisors’ awareness of

IM. The training could inform supervisors how they can best support

trainees to use IM, by highlighting what trainees have found helpful.

Training courses could provide more teaching on IM, making sure this is

spread across the three years. The teaching should aim to increase

trainees’ awareness of the range of different IM and provide tips on how

to administer and interpret them.

Further development of software that will allow trainees to record

idiographic data. For example, there needs to be more options and

flexibility for CORE-NET to incorporate IM.

Trainees/clinicians should be encouraged to publish single-case studies

illustrating how IM have been employed to track client progress.

A future SEP could also explore clients’ perspectives on IM. Some

trainees felt that clients may find it difficult to identify relevant items, but

it would be interesting to hear client’s experiences of co-designing and

using IM.

4.7 Dissemination

The findings of this SEP were shared with the commissioners and presented to staff

and students, via a poster and presentation, at the annual SEP conference held at the

University of Leeds.



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Appendices

Appendix 1 – Survey

Appendix 2 – Invitation email

Appendix 3 – Participant information sheet

Appendix 4 – Ethics approval

Appendix 1 – Survey



1 / 15

Idiographic Measures in Clinical Psychology Training

Page 1: Welcome

Welcome to this online survey. Please read the information sheet below.

Participant Information Sheet

Project Title: Idiographic Measures in Clinical Psychology Training

You are being invited to take part in a Service Evaluation Project (SEP) with the above title.

Before you decide whether to take part it is important for you to understand why the project is

being done and what it will involve. Please take time to read the following information

carefully and discuss it with others if you wish. Ask us if there is anything that is not clear or if

you would like more information. You can contact the lead researcher, Emily Higgins, using

the contact information at the bottom of this document. Take time to decide whether or not

you wish to take part in this SEP.

What is the purpose of the project?

Idiographic measures are designed to capture aspects of psychotherapy process and

outcome that are unique to each client. These come in many forms, from creative

adaptations of visual scales for use with children, to simple ratings of distress or goal

attainment, and more structured tools such as Personal Questionnaires. The aim of the

project is to explore current awareness and attitudes towards idiographic measures among

Psychologists in Clinical Training.

***Note that once you have clicked on the CONTINUE button at the bottom of each page you

can not return to review or amend that page***



Why have I been chosen?

This questionnaire is targeting awareness and attitudes of Psychologists in Clinical

Training at either Leeds or Hull universities, hence why you have been chosen.

What do I have to do?

You will be asked to complete an online questionnaire. You will be given a unique

username and password to log into the questionnaire so that your answers remain

anonymous. The questionnaire will contain both closed and open-ended questions. It will

contain questions designed to elicit your awareness of and attitudes towards idiographic

measures. The questionnaire will take approximately 15 minutes to complete.

What are the possible advantages and disadvantages of taking part?

Whilst there are no immediate benefits to you participating in this project, we hope that

the work will help support the use of idiographic measures in clinical practice. The only

disadvantage may be the time required to complete the questionnaire.

Do I have to take part?

Your participation in this project is entirely voluntary. If you do decide to take part after

reading the information sheet you will be asked to proceed to the survey questions. You

can withdraw at any time during the questionnaire, by shutting down the questionnaire

screen, without it affecting your links to the Clinical Psychology training programme. You

do not have to give a reason. Once the survey has been sent (by pressing the ‘finish’

button) you will not be able to withdraw your responses as the responses are anonymous

and cannot be traced back to you.

Will my taking part in this project be kept confidential?

All the information that we collect about you during the course of this project will be kept

strictly confidential. As mentioned above, you will receive a unique identifier that keeps

your data anonymous. You will not be able to be identified in any reports or publications.

Cookies, personal data stored by your web browser, are not used in this questionnaire.

Once all the questionnaires have been completed, the data will be downloaded and

stored on a secure password protected University of Leeds server. Your responses to the

questionnaire will be identified only by a number randomly assigned to you.

What will happen to the results of the research project?

The data from this survey is being used for a SEP. The results will be written as a report

and presented at a Leeds University SEP conference.



Page 2: Demographics

What training course are you on?

What year are you in?

Who is organising/ funding the research?

This project has been commissioned by the Programme Directors of the Leeds training

course, as a SEP. Ethical approval has been sought from the School of Medicine Research

Ethics Committee (Ethics approval number: DClinREC 18-007).

Contact for further information

If you would like any further information on how this data will be used or are interested to hear

the outcomes of the project, please contact:

Researcher: Emily Higgins, Psychologist in Clinical Training, [email protected]

Supervisors: Dr Gary Latchford, Joint Programme Director, [email protected] or Dr

Jan Hughes, Joint Programme Director, [email protected]

Thank you for reading this information sheet.

By pressing the next button below you agree to participate in this study.

1.

2.



Page 3: Experience of outcome measures

Outcome measures are a way of monitoring a client's progress over time and identifying

change.

How often have you used outcome measures in clinical practice?

How often have you discussed outcome measures with your clients?

How often have you discussed outcome measures in supervision?

3.

3.a.

3.b.

Never

Rarely

Sometimes

Often

Very Often

Never

Rarely

Sometimes

Often

Very Often

Never

Rarely

Sometimes

Often

Very Often



Page 4: Experience of Idiographic Measures

Idiographic measures are designed to capture aspects of psychological therapy process and

outcome that are unique to each individual client. They are personal to each individual and

measures are derived from individual performance criteria rather than global constructs.

Idiographic measures come in many forms, from creative adaptations of visual scales for use

with children, to simple ratings of distress or goal attainment, and more structured tools such as

Personal Questionnaires.

Have you ever used idiographic measures in clinical practice?

How often have you used idiographic measures in clinical practice?

Have you ever discussed idiographic measures with clients?

How often have you discussed idiographic measures with clients?

4.

4.a.

4.b.

4.b.i.

Yes

No

Very Often

Often

Sometimes

Rarely

Yes

No

Very Often

Often

Sometimes



Have you ever discussed idiographic measures in supervision?

How often have you discussed idiographic measures in supervision?

How confident do you feel in administering and interpreting idiographic measures?

Not at all confident

Not very confident

Fairly confident

Very confident

Extremely confident

4.c.

4.c.i.

5.

Yes

No

Very Often

Often

Sometimes

Rarely



Page 5: Knowledge and Use of Idiographic Measures

Idiographic Measures

Have you

heard of

this type of

measure?

How often have you used this

type of measure?

Yes No Never Seldom Sometimes Often

Client Generated Questionnaires

e.g. Personal Questionnaire,

PSYCHLOPS, Helpful Aspects of

Therapy Form

Patient Generated Narratives

e.g. feedback letter, qualitative

diaries, client change interview

Scales e.g. Subjective units of

distress scale (SUDS), Visual

Analogue Scale (VAS), Goal

Attainment Scaling (GAS),

Outcome Rating Scale (ORS)

Counts (frequency a behaviour

occurred) e.g. worry episodes,

wet/dry nights, binge episodes

Maps e.g. repertory grids

Visual Tools (graphic

representations of client

experience or goal) e.g.

children’s drawings

Are you aware of any other idiographic outcome measures?

6.

7.



Have you used any other idiographic measure in your clinical practice?

7.a.

Page 6: Attitudes to Idiographic Measures

Outcome measures may be either nomothetic (standardised) or idiographic.

Nomothetic measures are derived from global constructs. The same measure is

administered to a large sample in a standard manner. The distribution of resulting scores

from the whole sample forms the basis for any inference about a particular individual.

Nomothetic measures use a standardised self-report questionnaire with a broad generic

content. They can be used by all clients attending a service. The measure must have

demonstrated validity and reliability. An example of a nomothetic outcome measure is the

CORE-34.

Idiographic measures are uniquely designed for each individual client. Changes in

scores cannot be evaluated against population norms but only against similar data

previously provided by that individual. The idiographic approach enables clients to

express their goals in terms that accurately reflect their priorities using their own preferred

vocabulary. The intention is to capture their own aims using their own words and/or

images.

We recognise that it can be hard to generalise your experiences of working with different clients.

However, when answering the questions below, please try and think generally, and mark your

answers in response to how you feel about your work with the majority of your clients.

If you feel the multiple choice questions do not capture your full experience, please say more in

the open-ended questions which follow



How much do you agree with the following statement?

Strongly

disagree Disagree Undecided Agree

Strongly

agree

Idiographic measures are more

sensitive to client change than

nomothetic measures

Idiographic measures are

difficult for my clients to

complete

8.



My clients prefer idiographic

measures to nomothetic

measures

Idiographic measures can

provide evidence of

effectiveness

Interpreting outcomes using

idiographic measures is difficult

Idiographic measures

accurately reflect how well I am

helping my clients

Idiographic measures are co-

designed with the client


difficult to administer


useful in my clinical practice


helpful for tracking client

change

Idiographic measures highlight

those clients that are not making

progress

Idiographic measures provide

valid information about a

client’s experience

Idiographic measures

contribute to good, ethical

practice

Idiographic measures are too

simplistic to capture a client’s

experience



9.

10.

11.

Idiographic measures can help

to determine the need to alter

treatment

The next 4 questions are open-ended. Please fill them out if you can. If you have any

relevant experiences to reflect on, please do.

Can you think of any advantages of using idiographic measures? If so please give

details.

Can you think of any barriers to using idiographic measures? If so please give

details.

Can you think of any advantages of discussing idiographic measures in

supervision? If so please give details.



12. Can you think of any barriers of discussing idiographic measures in supervision? If

so please give details.

13.

Page 7: Final Thoughts

Are there any additional other comments you would like to make on the use of

idiographic measures?

Page 8: Thank You!

Many thanks for taking the time to complete this questionnaire.

Your support with this service evaluation project is much

appreciated.



Appendix 2 – Invitation Email

Hi everyone,

I’m Emily Higgins from 2nd year of the DClin course at Leeds.

I'd really appreciate it if you could take part in an online questionnaire for a Service

Evaluation Project (SEP) that I am doing.

The SEP is exploring IM in clinical psychology training. IM are designed to capture

aspects of psychotherapy process and outcome that are unique to each client. These come

in many forms, from creative adaptations of visual scales for use with children, to simple

ratings of distress or goal attainment, and more structured tools such as Personal

Questionnaires. The aim of the project is to explore current awareness and attitudes

towards IM among Psychologists in Clinical Training.

The SEP is targeting awareness and attitudes of Psychologists in Clinical Training at

Leeds and Hull universities, hence why you have received this email.

The online questionnaire should take approximately 10-15 minutes to complete. The

questions are mostly multiple choice, with opportunities to provide fuller answers if you

wish. Your responses are all anonymous. The programme hopes to use the findings to

help support the use of IM in clinical practice.

Participation is voluntary. If you decide that you would like to take part, please click the

link below which will take you to the online survey. Your consent will be inferred

through your action to proceed to the study’s questionnaire after reading the information

sheet, which will be presented on the first page of the survey.

https://leeds.onlinesurveys.ac.uk/idiographic-measures-in-clinical-psychology-training

If you would like any further information or have any questions, please contact me using

my email [email protected]. This study was given ethical approval by the School of

Medicine Research Ethics Committee (Ethics approval number: DClinREC 18-007).

Thanks!

Emily

https://leeds.onlinesurveys.ac.uk/idiographic-measures-in-clinical-psychology-training

mailto:[email protected]



Appendix 3 – Participant Information Sheet

Participant Information Sheet

Project Title: IM in Clinical Psychology Training You are being invited to take part in a service evaluation project with the above title.

Before you decide whether to take part it is important for you to understand why the

project is being done and what it will involve. Please take time to read the following

information carefully and discuss it with others if you wish. Ask us if there is anything

that is not clear or if you would like more information. You can contact the lead researcher,

Emily Higgins, using the contact information at the bottom of this document. Take time to

decide whether or not you wish to take part in this service evaluation project.

What is the purpose of the project?

IM are designed to capture aspects of psychotherapy process and outcome that are unique to

each client. These come in many forms, from creative adaptations of visual scales for use

with children, to simple ratings of distress or goal attainment, and more structured tools such

as Personal Questionnaires. The aim of the project is to explore current awareness and

attitudes towards IM among Psychologists in Clinical Training.

Why have I been chosen?

This questionnaire is targeting awareness and attitudes of Psychologists in Clinical Training

at either Leeds or Hull universities, hence why you have been chosen.

What do I have to do?

You will be asked to complete an online questionnaire. You will be given a unique

username and password to log into the questionnaire so that your answers remain

anonymous. The questionnaire will contain both closed and open-ended questions. It will

contain questions designed to elicit your awareness of and attitudes towards IM. The

questionnaire will take approximately 15 minutes to complete.

What are the possible advantages and disadvantages of taking part?

Whilst there are no immediate benefits to you participating in this project, we hope that

the work will help support the use of IM in clinical practice. The only disadvantage may be

the time required to complete the questionnaire.

Do I have to take part?

Your participation in this project is entirely voluntary. If you do decide to take part after

reading the information sheet you will be asked to proceed to the survey questions. You can

withdraw at any time during the questionnaire, by shutting down the questionnaire screen,

without it affecting your links to the Clinical Psychology training programme. You do not

have to give a reason. Once the survey has been sent (by pressing the ‘finish’ button) you will



not be able to withdraw your responses as the responses are anonymous and cannot be traced

back to you.

Will my taking part in this project be kept confidential?

All the information that we collect about you during the course of this project will be kept

strictly confidential. As mentioned above, you will receive a unique identifier that keeps your

data anonymous. You will not be able to be identified in any reports or publications. Cookies,

personal data stored by your web browser, are not used in this questionnaire. Once all the

questionnaires have been completed, the data will be downloaded and stored on a secure

password protected University of Leeds server. Your responses to the questionnaire will be

identified only by a number randomly assigned to you.

What will happen to the results of the research project?

The data from this survey is being used for a service evaluation project (SEP). The results

will be written as a report and presented at a Leeds University SEP conference.

Who is organising/ funding the research?

This project has been commissioned by the Programme Directors of the Leeds training

course, as a Service Evaluation Project (SEP). Ethical approval has been sought from the

School of Medicine Research Ethics Committee (Ethics approval number: DClinREC 18-

007).

Contact for further information

If you would like any further information on how this data will be used or are interested

to hear the outcomes of the project, please contact:

Researcher: Emily Higgins, Psychologist in Clinical Training, [email protected]

Supervisors: Dr Gary Latchford, Joint Programme Director, [email protected] or

Dr Jan Hughes, Joint Programme Director, [email protected]

Thank you for reading this information sheet.






Appendix 4 – Ethics Approval

HI Emily The reviewers have met today and approved your application. If you can just make the following minor amendments and let me have the final, final version for our records that will be fine. She still needs to add the ethics approval number to the PIS DClinREC 18-007 The start and end dates for the ‘fieldwork’ C5 are the same 01/03/19 Also in c21 Emily should tick the box to say she is using - University approved cloud computing services (Microsoft Office 365 for email (Exchange online) and Microsoft OneDrive for Business) Many thanks Debby

Faculty of Medicine & Health - Ethics Reviewer Decision

Application reference DClinREC 18-007 Date 12/12/2018

Project title IM in Clinical Psychology Training

Name of applicant Emily Higgins

Name of reviewer

Reviewers Recommendation

Does not require ethical review (state why in comments)

Not approved: major flaws – refer to co-chairs

Amendments required prior to approval Y

Approved

Conditional approval

Is the application subject to approval from other bodies, i.e. Trust R&D, NOMS (please state)?

Please send us managerial approval– In this case an email from someone senior from the Hull staff

indicating that they are aware of this project and happy for it to proceed with their trainees. You

already have approval for Leeds as Gary’s signature is on the application form.

Also please send us gatekeeper approval for use of the email lists – an administrator who looks after

the list for Leeds, and the same from Hull (or alternatively gatekeeper approval can be incorporated

into the managerial approval email for Hull).



General comments to the applicant

A very straightforward low risk anonymous online survey, and a good application. Just a couple of points

of consistency to iron out in the participant information (below) and some approval emails (above).

Reviewer Comments

(Applicant to address the following comments)

Is a revised

document

required? Yes/No

Application Form No

Section A A10 Anonymity. -See additional comments section below.

Section B

Section C C5 The fieldwork start date will have passed by the time we see

your response to our review. Please confirm that no work will

be carried out until approval has been granted and provide a

suitable alternative date.

Section D

Supporting Documentation

(if applicable)

Consent Form No

You can dispense with the consent form for this low risk online

survey. At the end of the participant information sheet text you

can have a button to proceed to the questions if people are

happy to take part.

Participant Information Sheet Yes

There is some confusion in the paragraphs ‘do I have to take

part?’ and ‘will my taking part in this project be kept

confidential?’ Please unpick the following so you are

consistent:

-you talk about randomly assigned identifiers and also say

responses are anonymous and cannot be traced back.

-you say ‘we will use any data collected so far unless you ask us

not to’, this is not consistent with what you’ve previously

stated, that either they can shut down during the questionnaire

and the responses won’t be kept, or they press submit and the

responses will be used.

Please include a statement highlighting that ethical approval has

been sought from the School of Medicine Research Ethics

Committee (SoMREC/SHREC project number……)

Otherwise good.

Additional Comments (re: supporting documentation that is not covered in the above list)



Signature of the Applicant -----------------------------------------------------------------

Name of the Applicant ----------------------------------------------------------------- Date ------------

----

Signature of the Supervisor -----------------------------------------------------------------

Name of the Supervisor ----------------------------------------------------------------- Date ------------

-----

Thank you for including the draft survey – please look at the

first few questions – they talk about relative ratings (more

difficult… or preferred….) without being explicit regarding

what they are being compared to - it would be best to amend

these

Documents

Idiographic Measures in Clinical Psychology Training · measures such as the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), contain items that cover a vast range