Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. (2016)

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.2040

What are Peoples Experiences of a Novel Cognitive

Behavioural Therapy for Bipolar Disorders? A
Qualitative Investigation with Participants on the
TEAMS Trial
Emmeline Joyce,1,2* Sara Tai,2 Piersanti Gebbia2 and Warren Mansell2
1
Greater Manchester West Mental Health NHS Foundation Trust, Manchester, United Kingdom
2
The University of Manchester, Manchester, United Kingdom

Background: Psychological interventions for bipolar disorders typically produce mixed outcomes and
modest effects. The need for a more effective intervention prompted the development of a new
cognitive behavioural therapy, based on an integrative cognitive model (Think Effectively About
Mood Swings [TEAMS] therapy). Unlike previous interventions, TEAMS addresses current symptoms
and comorbidities, and helps clients achieve long-term goals. A pilot randomized controlled trial (the
TEAMS trial) of the therapy has recently concluded. This study explored participants experiences of
TEAMS, recommendations for improvement and experiences of useful changes post-therapy.
Methods: Fourteen TEAMS therapy participants took part in semi-structured interviews. Their accounts
were analysed using interpretative thematic analysis. Two researchers coded the dataset independently.
Member checks were conducted of the preliminary themes.
Results: Two overarching themes; useful elements of therapy and changes from therapy
encompassed 12 emerging subthemes. Participants appreciated having opportunities to talk and
described the therapy as person-centred and delivered by caring, approachable and skilled therapists.
Some recommended more sessions than the 16 provided. Helpful therapeutic techniques were reported
to be, normalization about moods, methods to increase understanding of moods, relapse-prevention,
reappraisal techniques and metaphors. However, some did not nd therapeutic techniques helpful.
Post-therapy, many reported changes in managing mood swings more effectively and in their thinking
(although some participants reported changes in neither). Many described increased acceptance of them-
selves and of having bipolar disorder, increased productivity and reduced anxiety in social situations.
Conclusions: The present study evaluates participants therapy experiences in detail, including aspects
of therapy viewed as helpful, and meaningful post-therapy outcomes. Copyright 2016 John Wiley &
Sons, Ltd.

Key Practitioner Message

This is the rst paper to qualitatively explore peoples experiences of individual psychotherapy for
bipolar disorders. It highlights elements of psychotherapy described as particularly helpful or unhelpful
and the clinical changes viewed as most impactful.
Participants reported benetting in a number of ways from TEAMS therapy. They valued learning to
reappraise and problem-solve situations and manage moods.
Participants identied TEAMS techniques as helpful, such as exploring advantages and disadvantages
of moods, and building healthy self-states.

Keywords: Bipolar Disorder, Cognitive Behavioural Therapy, TEAMS, Qualitative

BACKGROUND
Effective treatment of bipolar disorders is considered a
signicant challenge (Geddes & Miklowitz, 2013).
*Correspondence to: Emmeline Joyce, The Psychosis Research Unit,
Rico House, Greater Manchester West Mental Health NHS Founda-
Existing psychological interventions such as cognitive
tion Trust, Bury New Road, Manchester M25 3BL, United Kingdom. behavioural therapy (CBT), family-focused therapy and
E-mail: emmelinejoyce@outlook.com psychoeducation have common components including

Copyright 2016 John Wiley & Sons, Ltd.

 E. Joyce et al.

preventing relapse, stabilizing mood and increasing func- (Dodd, Mansell, Morrison, & Tai, 2011) and distinguish
tioning (Da Costa et al., 2011; Geddes & Miklowitz, people with bipolar disorders from non-clinical controls
2013). However, such interventions have produced mixed (Mansell, 2006; Mansell & Jones, 2006; Mansell et al.,
outcomes and modest effects in domains including 2011) and people with remitted unipolar depression
depressive and manic symptoms, relapses and hospital ad- (Alatiq, Crane, Williams, & Goodwin, 2010; Mansell
missions (Oud et al., 2016; Reinares, Snchez-Moreno & et al., 2011).
Fountoulakis, 2014). Reports from people experiencing bipolar disorders are
A large majority of people with bipolar disorders also consistent with the cognitive model. In studies
experience inter-episode subclinical depressive symptoms exploring recovery from bipolar disorders, participants
(Vieta et al., 2010), and comorbid diagnoses including described conicts between striving for wellness whilst
anxiety disorders (Pavlova, Perlis, Alda, & Uher, 2015), wanting to retain the positive inuences of mania
substance use disorders (Merikangas et al., 2007) and (Mansell, Powell, Pedley, Thomas, & Jones, 2010).
eating disorders (Seixas et al., 2012). Subclinical symptoms Participants also reported conicting views of mania as
and comorbid diagnoses are associated with a range of having intensely positive qualities whilst representing a
negative outcomes and are signicantly detrimental to dangerous loss of control (Veseth, Binder, Borg, &
prognosis (De Dios et al., 2012; McElroy et al., 2011; Davidson, 2012). These ndings support the idea that
Swann, 2010). However, existing interventions tend not clients have contrasting views of internal states and how
to target current subclinical symptoms and comorbid to control them (Mansell et al., 2010). In contrast, another
diagnoses, in favour of focusing on future-oriented study interviewed people with only hypomanic
outcomes such as relapse prevention and improving experiences about the factors preventing them from
long-term social and occupational functioning (Geddes & developing bipolar disorder. No participants described
Miklowitz, 2013). This may partially explain the mixed extreme negative beliefs about hypomania, or described
ndings of therapy trials. hypomania as a highly desirable state that they strived
There is also evidence that available psychotherapies for for often (Seal, Mansell, & Mannion, 2008).
bipolar disorders may be missing opportunities to provide The Mansell et al. (2007) model informed a new CBT for
optimal treatment, particularly for those with comorbid bipolar disorders and mood swings, called Think
bipolar and anxiety disorders. Some people with Effectively About Mood Swings (TEAMS). TEAMS aims
comorbid bipolar and anxiety disorders may require more to help clients increase awareness of extreme appraisals
intensive psychotherapy to recover from acute depression, of internal states and conicted attempts at controlling
compared to those without comorbid anxiety them, and develop more helpful ways of responding to
(Deckersbach et al., 2014). However, people with them (Searson, Mansell, Lowens, & Tai, 2012). TEAMS
comorbid bipolar and anxiety disorders report receiving incorporates metacognitive techniques such as worry
inadequate treatment for their needs (Hawke, Provencher, and rumination monitoring, alongside cognitive behav-
Parikh, & Zagorski, 2013). Additionally, given the ioural techniques (Searson et al., 2012). The therapy is
variation in presentation, course and sociodemographic client-led and is present-moment-focused by addressing
background in people with bipolar disorders (e.g., current symptoms rather than preventing future episodes
Greenwood et al., 2013), it is important to evaluate the (Mansell, 2010a). TEAMS also aims to treat comorbid
effectiveness of new therapies across a broad range of diagnoses and subclinical symptoms (Mansell, 2010a),
people who vary in clinical and sociodemographic acknowledging their impact on prognosis. TEAMS has
characteristics. the potential to optimally support recovery in bipolar
A cognitive model of bipolar disorders and mood disorders as the TEAMS model was informed by clients
swings was developed to address the above issues views. For example, clients have reported that living
(Mansell, Morrison, Reid, Lowens, & Tai, 2007). The purposeful lives is more important to them than avoiding
model proposes that mood swings are maintained by relapse (Mansell et al., 2010). TEAMS therefore helps
extreme, conicting, numerous, personal beliefs about clients to deal with longstanding problems and achieve
internal state changes (Mansell, 2010a). For example, important, client-specic life goals which may range from
feeling excitable may be believed to signify both an coping more effectively with low mood to improving
imminent breakdown and having unlimited creative relationships with family members or confronting
energy (Mansell et al., 2007). Consequently, individuals longstanding social fears.
attempt to control internal state changes in contrasting, A case series has demonstrated TEAMS therapy to be
extreme and counterproductive ways. They may try to preliminarily effective and acceptable (Searson et al.,
suppress or enhance internal states at different times using 2012). A pilot randomized controlled trial testing the
specic behavioural strategies (Mansell, 2010a). Extreme, feasibility and acceptability of TEAMS therapy has
conicting appraisals of internal states have been found recently concluded. It was predicted that TEAMS therapy
to predict symptoms of hypomania and depression would reduce depression compared to treatment-as-usual.

Copyright 2016 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2016)
Peoples Experiences of TEAMS Therapy

The primary outcome for the trial was Beck Depression randomized to either Treatment As Usual (TAU) or
Inventory (BDI) score (Beck et al., 1961) at six months TEAMS therapy. Interviews were conducted with 14 of
post-randomization (see Mansell et al., 2014 for trial the 41 participants randomized to the TEAMS therapy
protocol). Depression was chosen as the key outcome, condition of the trial. Thirty participants were contacted
rather than mania or hypomania, as depressive symptoms in a random order using a randomization function on
are the largest contributor to impaired functioning in Microsoft Excel. Participants who did not consent to their
people with bipolar disorders (Gitlin, Swendsen, Heller, therapy sessions being recorded, who had withdrawn
& Hammen, 1995; Morriss et al., 2007). from the trial or whose therapists advised of risk factors
It is valuable to consider clients views of receiving contraindicating interviews were not contacted (N = 11).
TEAMS to understand if it works as intended and learn Six participants did not respond to two contact attempts.
about any changes that could improve its acceptability Six declined interviews, reporting reluctance to be
and helpfulness. Qualitative methods can explore areas interviewed about their therapy experiences (N = 3),
that are inaccessible to quantitative methodologies: experiencing a mood episode at time of contact (N = 2) or
insight into subjective views and beliefs; how people react no reason (N = 1). Of the 18 participants who preliminarily
to and represent experiences (Kazdin, 2008) and are ideal agreed, four subsequently disengaged from contact. This
for exploring change processes (Willig, 2009). Qualita- resulted in a sample of 14 participants.1 The average time
tively evaluating interventions is important to more fully between participants attending their TEAMS baseline
understand acceptability and effectiveness (Thompson & assessments and post-therapy interviews was 18.7 months
Harper, 2012). However, published literature on peoples (range: 835 months, median: 19 months). Participants
experiences of face-to-face psychological interventions were purposively sampled, due to the researcher actively
for bipolar disorders is limited, with only three studies recruiting only people who shared the same, unique
available (Chadwick, Kaur, Swelam, Ross, & Ellett, 2011; characteristic of having received TEAMS therapy on the
OConnor, Gordon, Graham, Kelly, & OGrady Walshe, TEAMS trial (see Table 1 for demographic details).
2008; Poole, Smith, & Simpson, 2015). The TEAMS trial sample included participants with
After reviewing the published qualitative studies, we diagnoses of Bipolar I, II and Not Otherwise Specied
concluded there is currently insufcient information to (NOS). All participants were help-seeking at baseline,
provide insight into experiences of individual, face-to-face with depressive symptoms corresponding to a score over
psychotherapy. Participants experiences were often 15 on the BDI (Beck et al., 1961) over at least two non-
strongly affected by the psychotherapy being delivered consecutive weeks. Participants with comorbid diagnoses
within a group modality (OConnor et al., 2008; Poole were not excluded, other than those with substance use
et al., 2015). Additionally, two studies reported on disorders and psychotic disorders. For further information
psychoeducation which emphasized relapse prevention about the TEAMS trial inclusion and exclusion criteria,
(OConnor et al., 2008; Poole et al., 2015), which is not please refer to the trial protocol (Mansell et al., 2014).
the emphasis of TEAMS owing to its focus on current Interested individuals were screened with the BDI (Beck
problems, quality of life and sense of purpose. et al., 1961) and an interview based on the Brief Screening
The aims of the current study were therefore to explore Interview. Eligible participants received a baseline assess-
participants experiences of TEAMS therapy and mecha- ment, comprising a battery of measures including the
nisms of effect within the therapy and clients, and elicit Structured Clinical Interview for DSM IV: Axes I and II
recommendations for improvement. The study (SCID) (First et al., 1997; First, Spitzer, Gibbon, &
highlighted views about useful and less useful aspects of Williams, 2002). The SCID assessment includes screening
TEAMS, changes participants attribute to TEAMS and for anxiety disorders, including an index of traumatic
how they perceived these changes to have occurred. These experiences reported by participants. Those meeting
ndings would inform the future delivery of TEAMS
therapy. They supplemented existing literature exploring
what people with bipolar disorders need from psycholog- 1
Statistical tests were run to determine any differences in clinical and
ical interventions, and the most impactful clinical changes. demographic characteristics of the 14 TEAMS trial therapy partici-
pants who participated in this qualitative study, compared to the 27
who did not. Comparison of means was via the independent t-test,
and the MannWhitney test was used when parametric assumptions
2
METHOD were not met. The 2 2 procedure was used to determine differ-
ences between groups when data were categorical. The level of signif-
Participants icance was set at p < 0.05. No statistically signicant differences were
found between the two groups in age, BDI scores (at baseline and six
months post-baseline) and number of mood episodes. Nor were there
The TEAMS trial was approved by the London Queens- any differences between the two groups in numbers of males and fe-
Square Research Ethics Committee (reference: 11/LO/ male participants and numbers of people with bipolar disorder sub-
1326). Eighty-two TEAMS trial participants were types I and II.

Copyright 2016 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2016)
 E. Joyce et al.

Table 1. Participant demographic information

ID # Sex Age Employment BD type Onset Total mood Comorbid Trauma Number of
status of BD episodes diagnoses reported hospitalizations

1 M 43 Unemployed I 1990 62 (c) PD, agoraphobia, Yes 2

specic phobia
2 F 57 Employed FT II 1993 70 (c) PD with agoraphobia, No 10
specic phobia, GAD
3 F 61 Unemployed II 1965 200 (c) PD, social phobia, PTSD Yes 6
4 F 60 Retired II 1963 90 (c) None No 0
5 M 38 Employed FT II 1994 40 PD, PTSD Yes 0
6 F 46 Student I 1985 20 PD with agoraphobia, Yes 0
PTSD, GAD
7 F 52 Employed PT II 1999 200 (c) Panic disorder No 0
8 F 32 Employed PT II 1994 160 (c) PD, specic phobia, OCD, Yes 0
hypochondria
9 F 23 Student I 2011 5 OCD Yes 1
10 F 56 Unemployed II 1978 70 (c) Specic phobia Yes 4
11 F 40 Employed FT I 1989 25 PD with agoraphobia, Yes 0
PTSD
12 F 49 Retired I 2002 9 None No 5
13 F 48 Employed PT I 1990 17 PTSD Yes 2
14 M 45 Unemployed II 1990 55 (c) PD with agoraphobia, Yes 0
PTSD

Note: all information obtained from the SCID-Life interview conducted at trial baseline. BD = Bipolar Disorder. PD = Panic Disorder. GAD =
Generalised Anxiety Disorder. PTSD = Post-Traumatic Stress Disorder. OCD = Obsessive Compulsive Disorder. FT = full-time. PT = part-time.
(c) denotes an approximate number of mood episodes.

criteria for a bipolar disorder on the SCID were randomly allowing participants to raise subjects important to them
allocated to receive either TEAMS therapy plus (Byrne, 2012), thus reducing the possibility of missing
assessments at 3, 6, 12 and 18 months post-randomization, signicant topics (Langdridge & Hagger-Johnson, 2009).
or TAU (only assessments at 6, 12 and 18 months post- The rst author conducted all interviews excepting the
randomization). rst two (see Table 1), which were conducted with a
co-interviewer. Interviews utilized a topic guide (see
Table 2) developed by the TEAMS research team,
Interviews including an experienced service userresearcher.
Questions were rened during discussions and role-plays
Semi-structured interviews were digitally audio-recorded between three of the authors and the co-interviewer.
with participants verbal permission and transcribed Questions focused on participants experiences of therapy,
verbatim. Semi-structured interviews are exible in reasons for joining the TEAMS trial, recommendations for

Table 2. Interview schedule

1. Questions about the experience of TEAMS

a) Can you tell me why you were interested in taking part in the TEAMS trial?
b) Can you tell me about your experience of having the TEAMS therapy?
Open-ended and probing follow-up questions elicited information about:-

Useful/less useful aspects of the therapy

Mechanisms of change within the therapy and the participant
Changes in mood (or the way the participant thinks about their moods), thinking, behaviour, goals or values
Contexts in which participants have noticed any changes following therapy
2. Questions about modifying TEAMS
a) Is there anything that you think would have improved TEAMS therapy?
b) Are there any other points that I have missed about TEAMS therapy that were important for you?
c) Is there anything that you feel is important for designing services or improving therapies for people with bipolar disorder/
distressing mood swings?

Copyright 2016 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2016)
Peoples Experiences of TEAMS Therapy

improving TEAMS therapy and for services and interven- determine consistency between their coding, clarify
tions for bipolar disorders. Questions were open-ended to and suggest ideas about codes and themes with each
encourage participants to provide detailed, rich answers other, and aided preliminary theme development.
(Byrne, 2012). Probing follow-up questions were used to Jointly discussing and agreeing upon emerging themes
elicit further detail following interesting statements increased the reliability of the analysis (Mays & Pope,
(Millar & Tracey, 2009). Interviews ranged between 31 1995).
and 106 min long (71 min long on average). Inconsistencies in coding were resolved via discussion.
Consequently some codes were merged, removed or
renamed. For example, more able to manage bipolar
Analysis
disorder was merged with more able to manage
moods.
Interview transcripts were analysed thematically in
After the dataset had been coded and re-coded at least
accordance with Braun and Clarkes (2006) guidelines.
once, the preliminary themes and codes composing
Thematic analysis allows the identication of frequently
them were listed on a word processor. Three authors
occurring patterns across datasets. This produces themes
discussed the preliminary themes to ensure consensus
which describe the dataset in rich detail and emphasize
about the signicance of the themes.
features of the data most signicant to the research
The rst author rened the themes by drawing
question (Braun & Clarke, 2006; Joffe, 2012). Analysis
thematic maps; arranging the codes composing each
was conducted within a realist framework due to this
preliminary theme into tables and re-reading all coded
studys implicit aims, to obtain information about
data extracts at least ve times. This ensured the
participants experiences (Willig, 2009) and to ensure the
themes encapsulated coherent, distinct data patterns
ndings were relevant and accessible to clinical practice
and claried the relationships between codes and
(Braun, Clarke, & Terry, 2015). An interpretative approach
themes (Braun & Clarke, 2006). Theme renement
was used to identify assumptions and conceptual ideas
resulted in some themes being discarded or merged,
underlying the overt data (Braun et al., 2015). Analysis
and codes being added to or removed from themes.
proceeded inductively, with preliminary themes arising
Last, the rst author re-read all transcripts once to
from the data rather than according to a theoretical
ensure the nal themes accurately reected the dataset
framework (Boyatzis, 1998). Coding proceeded alongside
and that no relevant data had been omitted.
data production and transcription. The analytic procedure
Whilst in the nal stages of theme renement, the rst
is described below.
author wrote to all 14 participants inviting their
participation in member checks. Four participants
Two authors coded the dataset independently, and agreed. All participants were female, aged 32, 40, 56
without reference to coding software. Both carefully and 61; three were diagnosed with bipolar II, and one
read all transcripts at least three times before coding with bipolar I; two were unemployed and two
to ensure familiarization. employed (part-time and full-time, respectively).
All data related to, participants experiences of TEAMS The author explained the nal themes using a thematic
therapy and previous therapies; reasons for participat- map, and asked for verbal feedback. The author also
ing in the TEAMS trial; and recommendations for highlighted aspects of the analysis that individual
improving TEAMS therapy and services/ participants interviews had contributed to, and asked
interventions for bipolar disorders was coded. for feedback and clarication of these interpretations.
The authors coded iteratively by re-coding transcripts This was to acknowledge that data from different
at least once after initial coding, ensuring inclusion of participants contributed to different themes (e.g.,
all relevant data. Cutliffe & Mckenna, 1999). Participants reported that
The authors maintained an ongoing list of codes and the themes accurately reected their therapy
their data extracts. After analysing each transcript, experiences, and suggested no signicant omissions.
the authors searched for relationships between the This helped to ensure the validity of the analysis
listed codes. This allowed the identication of (Koelsch, 2013; Lincoln & Guba, 1985).
preliminary emerging themes.
Later coding and re-coding was informed by the
preliminary emerging themes that had been developed
RESULTS
through earlier coding and that had arisen purely from
the data. Twelve subthemes emerged from the data, which were
The authors held ve meetings throughout analysis to grouped into two overarching themes of useful elements
discuss codes and preliminary themes, and maintained of therapy and changes resulting from therapy (see
email contact. The discussions allowed authors to Table 3 for a summary of themes and subthemes). Many

Copyright 2016 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2016)
 E. Joyce et al.

Table 3. Themes Useful Elements of Therapy

Overarching themes Emerging subthemes
This theme encompasses seven subthemes describing
1. Useful elements 1.1. A chance to talk aspects of TEAMS therapy that participants highlighted
of therapy as particularly helpful (see Table 5 for quotes related to
1.2. A kind, calming and skilled therapist this theme).
1.3. Normalizing
1.4. A person-centred therapy
1.5. Methods to broaden understanding A Chance to Talk
of mood states Participants consistently reported that therapy provided
1.6. Therapeutic techniques an outlet to talk freely about topics important to them, and
1.7. Metaphors
2. Changes from 2.1. Managing mood swings
disclose difcult life events. This was important, as
therapy participants described talking as a necessary process that
2.2. Thinking differently improved their wellbeing, and often lacking the opportu-
2.3. Acceptance of bipolar disorder, nity within day-to-day life. Talking freely in therapy was
moods and the self seen as a cathartic, therapeutic process.
2.4. Productive and positive
2.5. Empowered and less anxious in
Its good to get it out cos it no-one ever really talks about
social situations
anything Theres never been anyone to talk to (ID #1)

participants found it difcult to recall specic helpful A Kind, Calming and Skilled Therapist
techniques, or identify mechanisms of effect within ther- All participants expressed liking for their therapists.
apy. However, all participants described helpful and un- They appreciated therapists kind and caring attitudes,
helpful aspects of therapy, and changes, where they had which facilitated engagement and therapeutic alliances.
experienced any. Most participants found it difcult to Participants reported that therapists made them feel
suggest recommendations, or specify unhelpful aspects comfortable through exuding calming (ID #12) natures,
of therapy. Consequently there was not enough data on and visually appearing approachable through casual
these topics to adequately support themes. Recommenda- dress and attentive body language. Participants valued
tions and unhelpful aspects that participants did describe therapists expert understanding of bipolar disorders,
are incorporated within the 12 themes. Table 4 provides which therapists demonstrated through explaining
information about participants BDI scores across sessions participants moods and behaviour. Finally, participants
and summations of their individual TEAMS therapy perceived therapists to be skilled and intuitive, which
experiences. facilitated trust in therapists.

Table 4. Participant BDI scores and therapy information

ID # Baseline Total therapy 3 m post- 6 m post- 12 m post- 18 m post- Baseline-last Summation of

sessions baseline baseline baseline baseline session interval therapy experience

1 15 16 8 8 3 5 Mainly benecial
4 9 16 22 0 15 13 Mainly benecial
6 21 16 15 12 12 33 6 Mainly benecial
8 22 16 32 23 15 19 10 Mainly benecial
9 30 17 6 16 20 34 15 Mainly benecial
10 5 16 16 21 16 27 7 Mainly benecial
11 8 18 26 55 0 0 12 Mainly benecial
12 20 16 21 18 3 24 8 Mainly benecial
13 19 16 13 4 8 6 5 Mainly benecial
14 37 16 33 23 46 34 7 Mainly benecial
2 26 16 12 12 1 1 8 Mixed
3 30 16 35 24 23 29 7 Mixed
5 26 16 2 0 22 4 13 Not benecial
7 4 8 24 11 48 11 7 Not benecial
Note
denotes missing scores. Baseline-Last Session Interval and Baseline-Interview Interval data given in months.

Copyright 2016 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2016)
Peoples Experiences of TEAMS Therapy

Table 5. Quotations for Theme 1: useful elements of therapy

A chance to talk Sometimes you need to just talk its a good thing to just like get it out cos maybe youve never
been able to talk about it before or youve not known people that can be accepting (ID #8)
Everything really thats happened in my life Ive never really talked about before I dont think to
anybody all these problems and issues have come out of my head and its healed (ID #11)
A kind, calming and He was really nice and patient and calm he had a like a nice nature so I felt comfortable talking
skilled therapist about things (ID #8)
He was quite relaxed and open just sat here talking, legs crossed, chilled out it was easy to
relate to someone (ID #6)
He would pick up on maybe a word I said or I dunno maybe a facial expression I also remember
thinking at the time that hes very skilled to pick up those innuendos (ID #2)
A person-centred It was more meaningful for me because I wasnt being forced into some programme or box that
therapy you know someone else had decided the ball was in my court to use the session for what
I wanted to (ID #2)
I nd it very difcult to score on numbers, Im not a numbers person, Im artistic it was quite
quite straightforward for me you know, when he asked me what colour mood I was in, I could say
I was a blue or a grey (ID #6)
He spaced it out and thats where a lot more of the benet, I I found a lot more of the benet
because I, no no Im not seeing [therapist] this week, well Ill just try that again (ID #14)
Normalizing I was thinking that there was something wrong with me more because of the way I reacted to
things when I was talking about it with the therapist its making me realise that Im not it is
normal to feel like paranoid or irritable (ID #11)
He said, well everybody gets like that and er its not as serious or as bad as you think (ID #4)
Methods to broaden The pros of being a little happy is that I need to enjoy the things that I like to do, but the cons of
understanding of being too happy for example would be, impulse buying the pros and cons in general it would
mood states help me realise what is too little and what it does to you and what is too much and what that
does to you (ID #9)
We looked at where the happy medium would be like 1100 where would I be looking at the
chart like that made me realise really this is the best way to be I need to stay in this happy area
here and where Im stable (ID #11)
Therapeutic techniques I can be aware as well if Ive had some really good stimulus or you know whatever, that that might
take me on into somewhere else and perhaps I need to tone it down (ID #13)
Wed talk through why what I say upset her so then we talked through that and then I realised
well it wouldnt so I talked through how, how she would react to me, and how I can talk to
her properly without being worried (ID #11)
Normal counselling would have probably been just as good for me (ID #3)
We were always looking at connections, between behaviour and then mood there just didnt seem
to be the connections what was going on in my life was not relevant to whether I got ill (ID #5)
Metaphors We broke it down into tennis balls and I said look my head now is a game of tennis in my case
what was happening was there were several ball boys and they were all coming on the pitch trying
to play tennis at the same time (ID #13)
The abuse thing about sending it writing it on a leaf and sending it down the stream I remember
that really clearly and it felt like it had gone in an instant (ID #12)

She makes it very easy for you to talk to, err and you He would give examples of things, so like and say like so
know she just makes the conversation ow very well as if you did this and you felt like this, do you think thats
well you feel very relaxed with her so you do talk quite bad or do you think thats normal, do you think you
a lot (ID #5) should be allowed to show your feelings, and Id be like
yeah (ID #8)

Normalizing
Participants described previously believing that A Person-Centred Therapy
experiencing different moods or thoughts meant that they Participants liked that therapy addressed their current
were different or weird (ID #8). Therapists enabled individual needs rather than adhering to a rigid structure.
participants to understand that experiencing different This gave participants a sense of control and ensured that
moods is normal through helping participants to consider therapy proceeded in the most helpful way for them. One
other explanations for experiencing different moods, or participant contrasted the exibility of TEAMS to his past
simply reassuring them that everyone experiences experience of CBT, where the explicit structure was seen
different moods. as restrictive.

Copyright 2016 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2016)
 E. Joyce et al.

There was loads of goal-oriented, and this wasnt really, and looking at how all these people had an effect and it
this wasnt like that at all there were no goals set that wasnt just me looking at that made me feel better
I had to achieve. (ID #1) about it (ID #11)

Six participants reported that therapists adapted the

Metaphors
delivery of therapy according to participants needs. Three
Five participants described metaphors as useful. For
participants provided recommendations for making the
two participants, metaphors challenged negative views
therapy more person-centred. These included adequately
they held of themselves and facilitated more positive
spacing sessions apart to allow clients to achieve goals
perspectives, leading to more stable self-esteem. Three
set in sessions, and providing more sessions if required.
participants said that metaphors helped them to under-
One suggested that the number of sessions should be
stand and/or take detached perspectives on internal
determined by clients ongoing difculties, whilst another
states.
recommended another ve or six (ID #8) sessions.
He said look at other options and other possibilities as in
I could sort of do whatever I thought would be helpful, so
the dimmer switch you know if I think, I dont know,
we could talk about low moods or high moods we could
lets say, Id never y to Australia, well, theres a lot in
drag up bits from the past, if that helped. We didnt have
between doing nothing and ying to Australia so
to bother with it. (ID #1)
much of my thinking was all-or-nothing, now Im aware
of it (ID #10)
Methods to Broaden Understanding of Mood States
Participants found specic TEAMS methods helpful.
Examining the advantages and disadvantages of moods
Changes Resulting from Therapy
was considered useful, as this provided a greater
This theme encompasses ve subthemes describing
understanding of extreme moods and their consequences.
changes in behaviour, thinking and attitudes that
Five participants said that nding a middle ground (ID
participants attributed to TEAMS therapy (see Table 6
#13) of mood between depression and mania was helpful.
for quotes related to this theme).
This enabled participants to conceptualize ideal self-
states, which acted as guidelines of desirable mood and
behaviour. Managing Mood Swings
Participants frequently reported an increased ability to
Its important just to keep me balanced When Im very avoid mood relapses post-therapy. Four participants
very happy, I would be willing to do things er, like er reported attending to early warning signs and acting to
impulse buying or when Im very very sad I would be avoid mood escalation. Five participants described
stuck in a circle, erm but when Im in the middle, it, it increased awareness of how thoughts and behaviour can
would help me to to come back to that range (ID #9) maintain and escalate moods. They sometimes used
distraction techniques to prevent mood escalation. Two
reported increased awareness of mood triggers, and
Therapeutic Techniques
consciously avoiding these post-therapy. Four reported
Some participants reported other specic techniques
no impact of therapy on mood swing management or
commonly used in psychotherapies. These included
reducing episodes. However two of these participants
relapse-prevention techniques, including identifying
described being primarily interested in research
mood triggers, and creating safety plans (ID #6), which
participation, with receiving psychotherapy seen as an
increased understanding of mood episode causation and
added bonus (ID #2).
progression. Six participants who experienced anxiety or
had experienced trauma highlighted that reappraisal
Activating and deactivating, those are my choices, either
techniques helped them to consider alternative
I can just stay where I am and do nothing or I can actu-
perspectives on anxiety-provoking situations and
ally do something, so instead of spiralling downwards,
problem-solve them. However, two participants reported
getting in bed, eating loads of chocolate I can choose
not requiring therapeutic techniques, and described
to do something (ID #10)
therapy as useful only for providing emotional support.
One expressed frustration with the techniques, which he
perceived not to address the cause of his problems. Thinking Differently
Participants who experienced anxiety and/or had
I was blaming myself really, and making myself ill about experienced traumatic events described a new ability to
it [a past traumatic event], so looking at that pie chart reappraise anxiety-provoking situations by considering

Copyright 2016 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2016)
Peoples Experiences of TEAMS Therapy

Table 6. Quotations for Theme 2: changes from therapy

Managing mood swings When its like woah hang on if this is physical force and certain noises Im getting in my ears thats
the time when you go do you know what, you do need to take some f-cking medication (ID #13)
Dont go shopping if youre feeling really agitated itll only take somebody to say the wrong
thing, and Ill boom (ID #6)
Thinking differently Ive got an awareness now I just stop and think, yeah but is that real? Is that me being paranoid?
Does she really, is she really ignoring me, maybe shes busy with her family? (ID #10)
It didnt help the moods although its made me say maybe, look at things or understand things
better about myself, it didnt change the outcome (ID #5)
Acceptance of bipolar The therapy it learns you to get on with life rather than this illness has taken over my mind,
disorder, moods and I have got control over it and just accept Ive got it and deal with it (ID #12)
the self I dont worry as much about bobbing up or down. Its just nothing to worry about, so dont
worry (ID #1)
It really helped me conrm that I had gone past a point of no return, and that erm I was just the
same as anybody else the situations and problems I was encountering I was dealing with in
as good a way as anybody (ID #2)
Productive and positive Thats the biggest change, er, keeping keeping on track, and doing the things that Ive set
myself to do since 2013 Ive had no interruptions I know Im getting better because Im
not needing those interruptions anymore (ID #9)
I was always cancelling things cos I was stressed or upset or get anxious or whatever so Ive
been more organised and been able to like stick to things (ID #8)
Empowered and less With my mum I found her hard work when I joined the therapy and I feel like I can deal with
anxious in social situations her better and be able to speak up to her and sort of tell her how I feel better than what I did
before, erm I dont feel scared to say things (ID #11)
My daughter got married in September and I hadnt been in a situation with more than say
20 people for eight, nine years I had the condence to get there, get up and put one foot in
front of the other And that was purely because of the TEAMS (ID #14)

them more objectively. This reduced anxiety levels, which However, therapy apparently conrmed to one
was described as an important gain. Reappraisal was also participant that she did not have bipolar disorder.
signicant in social situations. Three participants reported
increased metacognitive awareness in accepting that their Ive got more understanding of why I do things the way I
appraisals of situations are not always truthful, allowing do and why I, you know, at least I dont think negative
them to consider alternative reasons for others behaviour. about the way I think and feel or the way I react to
However, three reported no changes in thinking. One things I feel alright now within myself (ID #11)
participant acknowledged an increased ability to
reappraise situations, but saw this as insignicant.
Productive and Positive
Participants frequently described increased functioning
I can actually step out of situations, look at the whole
and quality of life post-therapy. Increased functioning
picture How important is it? Well the little tiny thing
was characterized through being better able to manage
Im stressing over now, how important will it be next
responsibilities such as childcare and work. Three
year So many things I get uptight about that really
participants related their increased functioning directly
dont matter (ID #10)
to reduced anxiety. Seven participants described increased
engagement with life, such as pursuing personal goals
and enjoyable activities. This improved participants life
Acceptance of Bipolar Disorder, Moods and the Self
satisfaction and self-esteem.
Eight participants reported a change of attitude towards
themselves and having bipolar disorder. They described
Id still be taking my pill for my bipolar condition but I
increased acceptance of having bipolar disorder. This
wouldnt have the quality of life that Ive got now
reduced feelings of self-stigma and isolation, and
Living, rather than existing. Having a productive life,
increased participants determination to manage their
doing things things I enjoyed before I got bipolar
moods. Three participants described increased tolerance
(ID #12)
of mood swings, which reduced anxiety about them. Six
participants said that normalizing (see theme 1.3) helped
them recognize that it is normal to experience different Empowered and Less Anxious in Social Situations
moods. This increased self-acceptance, self-esteem and Participants reported feeling empowered and thus able
self-understanding, and reduced feelings of isolation. to be more assertive and express their needs in social

Copyright 2016 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2016)
 E. Joyce et al.

situations, which had provoked anxiety or irritability pre- contributed towards participants viewing therapists as
therapy. Participants also described increased condence kind and caring. Additionally, rather than imposing
and decreased anxiety in social situations, which enabled prolonged socializing into the TEAMS model, therapists
a sense of independence. are required to take a curious approach and listen
carefully to clients to discover their goals for therapy.
I used to just hide away and not want to see people The therapists active listening may have further
now I feel that I can just go and cope with anyone whos contributed to participants positive views of therapists
at the door, or anywhere for that matter! (ID #4) and to the reported benet of talking to the therapists.
Alternatively, the participants views of therapists may
have arisen from other, non-specic factors. Other
potential factors include therapists unique characteristics
DISCUSSION and personalities, clients mood states during therapy and
Study Aims and Outcome at time of interview, or the non-specic positivity of re-
ceiving new, increased contact with clinical professionals
The current study is the rst qualitative exploration of (many participants reported not having previously re-
peoples experiences of individual psychotherapy for ceived psychotherapy). Interviewing participants in the
bipolar disorders. It aimed to provide an understanding TAU arm of the TEAMS trial may have provided more
of peoples views of receiving TEAMS therapy for bipolar insight on whether specic or non-specic factors may
disorders through semi-structured interviews. It sought to have contributed to participants positive views of
identify helpful and less helpful components, changes therapists. Nonetheless, the therapeutic relationship is
attributable to therapy, recommendations for improving highly important and is a strong predictor of psychother-
the therapy and mechanisms of effect within the client apy outcome (Holtforth & Castonguay, 2005). The current
and therapy. The helpful aspects included therapeutic results provide insight into the therapist characteristics
techniques, impressions of the therapists and the exible valued by people with bipolar disorders, and exactly
therapy. Participants also attributed changes in thinking, why they nd talking helpful.
behaviour and attitudes to TEAMS therapy. The two Participants described TEAMS therapy as person-
overarching themes are discussed in turn, followed by centred. It addressed current issues rather than adhering
recommendations and negative cases. to a linear structure and its delivery was adapted to
participants needs. TEAMS is formulation-based and
individualized, and emphasizes exibility in working
Useful Elements of Therapy with clients current problems and facilitating clients
control over the therapys direction (Mansell, 2010a).
All participants described positive relationships with TEAMS differs to previous future-oriented psychological
therapists. They perceived therapists as compassionate, interventions that emphasized relapse prevention and
approachable and skilled, which seemed to contribute were designed for groups rather than being individually
towards the therapys usefulness by facilitating positive tailored (Chadwick et al., 2011; OConnor et al., 2008;
therapeutic alliances, communication and engagement. Poole et al., 2015). The range of problems that participants
Even for those who did not nd the therapy benecial, reported addressing in therapy implicates the importance
therapists were still regarded as sufciently caring and of a person-centred approach that allows clients to choose
trustworthy to talk and disclose problems with. This is goals for psychotherapy and individual sessions.
important given that being able to talk freely in therapy Some participants reported that a particularly useful
was regarded as highly positive for many participants. facet of TEAMS therapy was being able to decide session
These ndings are consistent with reports from partici- agendas based on the current problems they were
pants in psychoeducation (Poole et al., 2015) and CBT experiencing. One participant contrasted this aspect
for depression (Wiles et al., 2014). Therapists expertise favourably to his previous experience of CBT, which he
and skill are developed during training in the TEAMS reported was more linearly structured. It may be that
model, such as picking up on present moment affect addressing current, client-dened problems is a unique
(Mansell, 2010a, 2010b). feature of TEAMS psychotherapy. TEAMS is not the only
TEAMS therapy is delivered according to a hierarchical psychotherapy to have the capacity to address current
Pyramid of Principles (Searson et al., 2012). To full the comorbid symptoms, such as anxiety disorders (Stratford
initial safety and engagement stages, therapists must et al., 2015). However, TEAMS may be more exible in
develop clients sense of safety within therapy, and engage allowing clients to dene session agendas based on their
clients sufciently enough that they are comfortable dis- unique, current problems, rather than addressing the
closing and discussing experiences (Searson et al., 2012). same comorbid difculties for all clients, such as through
This manner of delivering psychotherapy may have including specic anxiety modules (e.g., Gonzles-Isasi

Copyright 2016 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2016)
Peoples Experiences of TEAMS Therapy

et al., 2010, 2012). However, the researcher did not that therapists can adapt to clients individual require-
specically ask participants to compare their experience ments, if necessary, focusing more on building a strong
of TEAMS therapy to other psychotherapies they had relationship or on applying techniques.
received. An interesting future research avenue might
involve asking TEAMS therapy participants to compare
their experience of TEAMS therapy with other Changes Resulting from Therapy
psychotherapies.
Many participants discussed specic TEAMS therapy Participants reported an increased ability to recognize
techniques that they found helpful. They reported that mood triggers and prodromal symptoms to avoid relapse.
normalizing experiences of different moods countered People with bipolar disorders have previously described
their previous beliefs that experiencing different moods these relapse prevention techniques as useful post-
meant something very negative about them. This is intervention changes (Chadwick et al., 2011; OConnor
consistent with Mansell et al.s (2007) model. Participants et al., 2008; Todd, Jones, & Lobban, 2012) and ways of
also found metaphors useful. Metaphors facilitated remaining well (Murray et al., 2010; Russell & Browne,
awareness of internal states and enabled detachment from 2005). However, others reported that fear of relapse can
them. Additionally, metaphors facilitated reappraisal of lead to hyper-attentiveness around warning signs and
views about themselves, and distancing themselves from counterproductive safety behaviours (Mansell et al.,
traumatic experiences. These are consistent with some of 2010). The current participants also described increased
the aims of using metaphors in TEAMS (Mansell, 2010b). tolerance of experiencing moods and mood swings.
Many participants reported the usefulness of addressing Participants accounts of recognizing prodromal
comorbid anxiety and trauma symptoms through symptoms resonate more with the mindful awareness of
reappraisal and problem-solving techniques. This internal states described as useful (Chadwick et al., 2011;
implicates a need to address comorbid diagnoses in Russell & Browne, 2005). Although TEAMS does not
bipolar disorders, which is signicant given their emphasize relapse prevention, its exibility around
commonality. TEAMS elicits clients goals and appraisals clients needs means that relapse prevention can be
around anxiety, and its focus on conict can highlight addressed if identied as a goal. Two out of the 14 current
fears prohibiting clients from achieving important goals, participants identied relapse prevention as being one of
which can be addressed in therapy (Mansell, 2010a). their goals for TEAMS therapy, prior to beginning therapy.
Participants found reecting on advantages and TEAMS can complement relapse prevention techniques
disadvantages of moods useful, as it increased their with focusing on building healthy self-states and fostering
understanding of moods and their consequences. This tolerance of moods, to allow clients to achieve important
technique aims to elicit conicting beliefs about moods personal goals.
(Mansell et al., 2007). It allows therapists to remain Participants reported increased acceptance of bipolar
unbiased about potential advantages and disadvantages disorder and mood swings, and of themselves. Some
of internal states, and facilitates clients developing reported no longer endorsing negative beliefs about their
awareness of conicted beliefs about internal states so that moods, which some attributed to normalizing in therapy.
they might reach balanced solutions (Mansell, 2010a). They were more tolerant of experiencing moods and
Participants also valued nding a happy medium area mood swings, and reported more stable self-esteem.
of mood. This helped participants identify ideal self-states Normalizing may challenge negative beliefs around
which promoted better functioning and ability to pursue moods, leading to less extreme appraisals of mood
goals. This technique challenges traditional approaches changes and associated positive effects on participants
of identifying warning signs and avoiding certain internal self-views. Metacognitive techniques may also be useful
states. Building healthy self-states and exploring advan- in promoting acceptance. Mindfulness-based CBT partici-
tages and disadvantages of moods allow the therapy to pants also described increased tolerance of mood changes,
be further individualized to and directed by clients. acceptance of bipolar disorder and self-acceptance
Possibly, this may result in a stronger therapeutic alliance (Chadwick et al., 2011). Importantly, accepting bipolar
and a more person-centred stance than in other psycho- disorder has been described as important in remaining
therapies typically used in bipolar disorder. well (Russell & Browne, 2005).
Whether technique application or the therapeutic Addressing anxiety and trauma in therapy may have
relationship is more responsible for CBT effectiveness has helped the current participants to live more fullling lives.
been debated (e.g., Holtforth & Castonguay, 2005). Many Participants described increased assertiveness and
participants described both the relationship and tech- condence, and increased social activity, whereas social
niques as helpful, challenging the need for this debate. situations had previously provoked overwhelming
However, some emphasized either the relationship or irritability or anxiety. Participants also reported increased
techniques as more helpful. An advantage of TEAMS is functioning, and feeling more positive and optimistic.

Copyright 2016 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2016)
 E. Joyce et al.

These ndings are consistent with accounts of recovery psychotherapy in research trials. For example, meeting
from bipolar disorders, suggesting that the TEAMS research assistants for assessments can provide opportuni-
approach may help promote recovery. Participants have ties for social contact (Byrne & Morrison, 2014). Increasing
emphasized the importance of a purposeful, fullling life social contact has been reported as a contributor to
over remaining relapse-free (Todd et al., 2012) including recovering from bipolar disorders (Mansell et al., 2010).
facing social fears through increasing social activity and
learning to express ones own needs (Mansell et al.,
Recommendations
2010). No participants reporting benets of TEAMS
therapy for their social anxiety met criteria for social
One participant said that TEAMS therapy was most useful
phobia at baseline. In the future, it would be interesting
when sessions were fortnightly instead of weekly, as this
to explore whether TEAMS therapy participants who
provided more time to practice techniques and achieve
meet criteria for social phobia report benets of TEAMS
goals. This implicates the importance of therapists seeking
therapy on their anxiety similar to the current
regular feedback about clients satisfaction with therapy
participants.
delivery, and adapting it if necessary. Two participants
recommended there be more sessions to maximize the
therapys effectiveness. Ideally, TEAMS clients should
Negative Cases
receive as many sessions as the client perceives are needed
(Mansell, 2010a). However, the current research context
Some participants reported not nding TEAMS therapy
constrained this exibility.
helpful or experiencing any changes. One perceived the
therapy to focus on identifying mood triggers and links
between mood and behaviour, and saw this as irrelevant Study Limitations
to his own moods. Although he recognized an increased
ability to reappraise situations, he did not consider this a Most participants were interviewed between seven and
signicant benet in comparison to his aim of reducing 30 months post-therapy, which may have contributed to
mood episodes. The participant did not report upon other participants frequently struggling to remember specic
TEAMS techniques, such as development of healthy self- useful elements. This limited the identication of
states. There may be a need for increased emphasis of therapeutic mechanisms of effect. However, in support
these techniques for participants who are dissatised with of TEAMS long-term efcacy, even participants
other techniques. However, the participants perception interviewed over two years post-therapy described
that the therapy was not useful may have fostered helpful aspects and positive changes. Additionally, these
resistance to fully engaging in therapy. ndings may over-represent positive views about TEAMS
Two participants reported having no need for therapeu- therapy as no participants in this study had withdrawn
tic techniques as they had already overcome major from the trial. However, some consenting participants
problems pre-therapy. This assumption may have fostered readily described aspects of therapy that were not helpful.
resistance to engaging with therapeutic techniques. The relatively small sample of 14 participants limits the
TEAMS techniques may not necessarily be suitable for ability to apply these encouraging ndings to a wider
such clients. The exibility of TEAMS seemed to have sample of people who received TEAMS therapy in the
nonetheless allowed therapists to build strong therapeutic trial, or will do in the future. Additionally, the absence of
alliances with these clients to provide helpful opportuni- a parallel qualitative study for participants in the TAU
ties for emotional support. The four participants who arm of the trial limits the ability to determine the
reported mixed experiences of the therapy or that it was specicity of TEAMS therapy content in promoting
non-benecial (see Table 4) reported that it was useful to improved outcomes for clients. Many participants
see therapists regularly to talk about problems as they described specic helpful therapeutic tools, perhaps
arose, and that therapists were consistently caring, calm indicative of the benets of TEAMS therapy, but this
and willing to listen. Perhaps, having a regular opportu- cannot be inferred due to the lack of parallel qualitative
nity to talk to a sympathetic clinician encouraged these study.
participants to attend sessions (three out of the four It was only possible to recruit participants for this study
participants attended all 16 sessions offered). However, from a pre-existing sample of participants who had been
this is only a speculative conclusion as the interviewer randomly allocated into the treatment arm of the TEAMS
did not specically ask these participants why they trial. Eleven participants were not contacted due to
continued to attend. withdrawing from the trial, presenting with pertinent risk
Some participants reported being less concerned about issues, or declining to have their therapy sessions
receiving therapeutic benets than research participation. recorded. This left a small pool of 30 participants, all of
Research participation may contribute to the benet of whom were contacted, and 16 of whom did not want to

Copyright 2016 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2016)
Peoples Experiences of TEAMS Therapy

participate in interviews. Therefore, the effort to obtain a TEAMS trial and therapy, including the co-principal
representative sample was hindered to an extent. It is investigators: Tony Morrison, Richard Morriss, Neil
likely that those who agreed to interviews were more Tinning and Linda Davies, and all of the research
motivated to take part in research, more well, and possi- assistants who were employed on the trial.
bly had better experiences of TEAMS therapy (although
some participating interviewees readily described
unhelpful aspects of therapy). This sample may not be
representative of all those who received TEAMS therapy. ROLE OF THE FUNDING SOURCE
However, statistical analyses revealed no signicant
differences in some important characteristics of TEAMS The research described here was funded by the National
participants who did, and did not, participate in this Institute for Health Research (NIHR) under the Research
qualitative study; including BDI scores at baseline and for Patient Benet (RfPB) Programme (Grant Reference
six months-post baseline, and number of mood episodes. Number PB-PG-0110-21087). Greater Manchester West
It is also possible that the relatively small sample size Mental Health NHS Foundation Trust provided addi-
may have resulted in a lack of power to detect any tional support costs and infrastructure. The trial sponsor
statistically signicant differences. is the University of Manchester. The contact is Lynn
The authors experience and knowledge of mental MacRae, Faculty Research Practice Coordinator, FMHS
health problems and psychotherapy may have inuenced Research Ofce, 3.53 Simon Building, University of
the interviews and analysis, such as through recognizing Manchester, Manchester, M15 6FH, United Kingdom,
meaningful issues for therapy participants (Mansell email: lynne.macrae@manchester.ac.uk; telephone: 0161
et al., 2010). Independent coding by two authors and the 275 5436. Neither the study sponsor nor funders had any
agreement of three authors on the preliminary themes will involvement in the study design; in data collection,
hopefully have mitigated this bias, due to the authors analysis or interpretation; in writing this report; or in
differing experiences and viewpoints. deciding to submit this report for publication.

Conclusion
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