Day 7- 2015 Therapeutic Relationship Updated (1)

8/10/2019 Day 7- 2015 Therapeutic Relationship Updated (1)

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The Therapeutic Relationship in

CBT

CBT for Complex Difficulties / CAMHS

2014-2015



Therapeutic relationships; engagement and

maintenance .

By the end of the session a student will be able to:

• Describe the nature of the therapeutic relationship (TR)

• Name some of the historical and contemporary theoristsinvolved and describe current research and theories into theimportance of the TR

• Consider the value of the TR within cognitive behaviouraltherapy

• Describe relevant factors in the maintenance of a therapeuticrelationship with a client

• Recognise factors which might impact on the relationship



Classroom exercise

To start this morning, imagineyou are a fly on the wall watchingan effective CBT session. Nowdiscuss with your neighbouringflys;

• What do you notice aboutboth the therapist and clientthat demonstrates they have agood ‘therapeutic

relationship’. Think about the

context and function of thesession.



Definitions of a therapeutic

relationship:

• “Two people, both with problems in living, who agree to worktogether to study those problems, with the hope that the therapisthas fewer problems than the patient”

(Harry Stack Sullivan, 1953)

• …relationship characterised by the client’s belief in the ability of thetherapist to help him or her and the therapist’s requirement to

provide a secure environment for the client; the later developinginto a mutual relationship of working on the tasks of therapy

(Luborsky 1976)

• “The personal qualities of the patient, personal qualities of thetherapist, and the interactions between them”

(Wright & Davies, 1994)



Components of the relationship

The therapeutic alliance (Bordin 1979)

• Not to be confused with the therapeutic relationship of which the allianceis theorised to be a component.

• Bordin (1979) conceptualised the therapeutic alliance (aka workingalliance) as consisting of three parts:

a) Tasks; what the therapist and client agree need to be done to reach theclient's goals

b) Goals; what the client hopes to gain from therapy informed by his/herpresenting problems.

c) and Bond; formed from the trust and confidence that the therapy will bringthe client closer to his/her goals.



Components of the relationship

Therapeutic empathy (Burns and Auerbach 1996, InSalkovskis 1997; Greenberg 2007, In Gilbert And Leahy2007)

•Therapist’s subjective experiences in response to theperson

• Importantly, the quality of the therapeutic relationship as judged by the client predicts better outcomes than that

judged by the therapist.

• As therapists we can sometimes misjudge how good ourprofessional relationships are with people.



Definition of collaborative working in CBT

• The ‘feel’ of collaborativeworking:

“ A slow, reflective ‘ping-pong’quality…The time that

therapist and client arespeaking may be about equal,the therapist shares herthoughts about the clientsthoughts and asks forfeedback. Whilst questions

may be asked by boththerapist and client, both worktogether…To find answers…”

(Wills and Sanders, 1997).



Some developing ideas;

the therapeutic relationship!

• Relationship factors within cognitive behavioural texts,

research and practice are sometimes referred to as ‘non-

specific factors’ in therapy (also known as common factors).

• The therapeutic relationship to cognitive behavioural therapy

is as important as it is to other forms of counselling and

psychotherapy (Lambert and Barley 2002; Mahoney 2003 &

Gilbert and Leahy 2007) ?



What is it about therapy that works ?

Lambert & Barley (2002) insummarising across therapiesargue that:

1. 30% of improvement can beattributed to therapeutic

relationship factors.2. 15% to expectancy (placebo effect).

[a procedure that is objectivelywithout specificity for the difficultybeing treated]

3. 40% to extra therapeutic change

(For example family support thatwould occur without formalprofessional therapy, and mightinclude self-help).

4. 15% to specific therapeuticinterventions (see also Cooper2008 and House and Loewenthal

2008).



Some ideas about the therapeutic

relationship

• Factors such as thequality of the therapeuticrelationship, empathy,

warmth, genuineness,conditional andunconditional regard,appear crucial to the

overall effectiveness ofpsychotherapies acrossthe board.



BUT HOLD ON A

MINUTE…



12

One of the biggest items of faith…

• Therapeutic alliance will pull us through

• If a patient had a belief of this sort, we might call it

an overvalued idea, leading to a safety behaviour – do not push for behavioural change, as that will impair

the therapeutic alliance, which is the biggest factorbehind change

• Let’s think about that for a moment, consideringthe evidence base…

– three commonly held assumptions



Assumption 1

• The therapeutic relationship is relevant to theoutcome of therapy

• Yes, but only for some types of therapy

– Crits-Cristoph et al. (1991)

• Therapeutic relationship is most important when thetherapy is low in structure

• Therapeutic relationship does not have a dose-

dependent impact on CBT outcomes – necessary but not sufficient (Beck et al., 1979)



Assumption 1

• The therapeutic relationship is relevant to theoutcome of therapy

• In a big meta-analysis (Martin et al., 2000), thetherapeutic alliance had a weak association with

outcome across therapies



Assumption 2

• The therapeutic relationship drives positive outcomes

in CBT

• A radically different suggestion (Safer & Hugo, 2006)

– positive change in therapy makes for a better therapeutic

relationship

• And the picture is still not a neat one – evidence is that initial changes in behaviour explain

improvements in the alliance

– then the alliance starts to improve outcomes

• The process starts with behavioural change• e.g., Tang & DeRubeis (1999); Webb et al. (2011)



Assumption 3

•

The therapeutic relationship is worse in CBT

• The evidence is that this is not the case

– structured therapies tend to have a more positive level of

therapeutic relationship

• DBT has a more positive therapeutic alliance thantreatment as usual (Linehan)

• Different but not poorer

– “a judicious blend of firmness and empathy” (Wilson et al.,

1997)





What factors influence the therapeutic

relationship?

– Expertise and Credibility of the therapist (Goldstein and Myers,1988;Schaap et al 1993; Gilbert and Leahy 2007)

–

Motivation, transparency of the therapist and expertise shown in psychoeducation (Grant et al 2009)

– Demonstration of warmth, empathy by the therapist (Rogers 1957; Schaapet al 1993; Gilbert and Leahy 2007; Thwaites and Bennett-Levy 2007)

–

Collaboration (Beck et al 1979; Schaap et al 1993)

– Therapist beliefs about the client, Client beliefs about the therapist andassociated feelings and behaviours (Linehan 1993; Rudd and Joiner 1997;Padesky 1999; Leahy 2001; 2007; Gilbert and Leahy 2007; Regina andAndersen 2007;)



Four components which enhance

credibility (Townend and Grant 2008)

1. The level of expertisedemonstrated by the therapist.

2. The reliability of the therapist asa source of information, includingqualities such as beingdependable, behaving in apredictable way and remainingconsistent throughout the

therapeutic relationship.

3. The therapist’s motivation andintentions, which must bedemonstrated as always havingthe persons interests at the

forefront of the relationship andhaving no other inappropriatemotivations.

4. The charisma of the therapist,which can be defined as attentionto detail, working to instilconfidence and being proactivewhen dealing with the personsissues.





Maintenance of the relationship

• Establish expectations, both yours and the

clients ?

• Establish previous experience of therapy; what

worked well, what worked less well ?

• Consider a therapy ‘contract’ . . . ?

Role modelling; engagement & contracting



Classroom exercise

• In your small groupsremember an incidentwhen something hasn't‘gone right’ in atherapeutic relationship.

• How did you know thatthings weren’t going right(thoughts, feelings andbehaviour)?

•

What do you think werethe contributing factors?

• What happened to movethings on ?



What is an alliance rupture

• Deteriorations in the

relationship between therapist

and patient (Safran and Muran

1996 p447)

•

Breach in relatedness(therapeutic alliance) whenunhelpful interpersonalschemas are triggered. (Safran1998)

•

Interference with tasks/goalsof therapy.

Th i t / li t l t d f t



Therapist / client related factors;

transference•

Transference andcountertransference Regina and

Andersen in Gilbert and Leahy

(2007)

• Transference proposes mental

representations of significantothers exists in memories.

• These memories can be triggered

by cues in any context which lead

people to view new others through

schema relating to pre-existing

significant others

• When therapists experience a

similar occurrence this is

commonly referred to as counter

transference



Therapist / client related factors;

cognitive matching

• Cognitive mismatch’

Rudd and Joiner (1997)

in Grant et al (2004)



Therapist related factors; ‘unhelpful’

therapist schemas (Leahy 2001)

– Demanding standards

– Abandonment

– Need for approval

– Excessive self-sacrifice

– Special, superior person – Autonomy

– Rejection sensitive

– Control

–

Judgemental – Persecution

– Withholding

– Helplessness



Classroom exercise

• Fill in therapist Schema

Questionnaire

• On completion, in pairs,have a discussion about

what it felt like to

complete and what

thoughts did it elicit.



Client related factors; dimensions of

‘resistance’ (Gilbert & Leahy 2007)

• Vulnerability assumption: Person is vulnerable and hasbeliefs and strategies to protect them from exposure

• Validation resistance: The person gets stuck with theidea that the focus of therapy is exclusively onvalidating their pain.

• Victim resistance: The client believes that his or heridentity is defined only by being victim. External locusof control re change.

• Moral resistance: Change runs the risk of violating onesown moral or ethical standards. Egodystonia.



Client related factors; dimensions of

‘resistance’ (Gilbert & Leahy 2007)

• Schematic resistance: The clients cognitive bias istowards confirming the validly of schema.

•

Self consistency: aka ‘sunk costs’ the client believes heor she has invested too much in failure.

• Risk aversion: All change involves an increase inuncertainty and therefore client may try to avoid taking

perceived risk.

• Self handicapping: Sabotaging therapy to guard againstfailure and thus protect self-esteem.



Therapy depends on three core elements

• Leg 1 – the

technology has to

be good

• Leg 3 – the therapist has to

deliver the therapy

• Leg 2 – the

client has to

participate



What is therapist drift? (Waller, 2009)

•

When clinicians actively decide not to deliver keycomponents of a therapy or passively avoid them

– whatever the apparent justification

• e.g., complex cases, patient not ready, treatment resistant, etc.

•When clinicians ignore a therapy’s limitations andstrengths, or fail to learn about them

– over-valued ideas, and all that…

• When clinicians do a therapy because it is their favourite

• Is ‘drift’ the right term?





Patterns of therapist drift

• When there is a crisis in therapy, we tend to drift off

target without a clear plan (Schulte & Eifert, 2002)

• We go off track when faced with complex cases,even when the evidence says our original track wasthe right one (Thompson-Brenner & Westen, 2005)

• Failure to stick to protocol has a particular impact onthe outcome of treatment for low-motivated cases(Huppert et al., 2006)

• Among IAPT therapists with different outcomes,those with poorer outcomes avoid structure,manuals, etc. (Green, 2013)



Impasse flow chartClint describes a difficulty

Therapist tries to helpclient with difficulty

Client ‘yes buts’

Therapist becomes frustrated

(Pushes on withcontent/therapy to no avail)

Therapist and client reach an

impasse

Client may be blamed,

therapist may feel defensive

Therapist thinks with the client about

the process underpinning the impasse

(Stop. Therapist formulates impasse

with client)

Therapist explores/assesses

the impasse

Impasse is addressed

Therapy progresses



Some more ideas...

• Historically, standard CBT techniques e.g. Finding alternatives

to unhelpful thoughts are used to address difficulties in the

therapeutic relationship.

• Understanding client’s interpersonal beliefs, expectations, and

appraisal processes that contribute to the perpetuation of

unhelpful cognitive-interpersonal cycles (Safran & Segal,

1990).

• Importance of therapist’s reactions and interpersonal

schemas as therapy tools



Golden rules to working through an

impasse (Mueller et al 2010)

• Use the formulation; either the main formulationor a ‘mini-formulation ‘ that helps explain theimpasse.

• Remain collaborative; talk to your client and use

both of your heads to resolve the problem.• Use the structure; remember to regularly review,

take stock of the agenda, keep the goals in mindand your treatment protocols.

• Remain empirical; gather and consider theevidence and work accordingly rather thanobstinately adhering to a prescribed model.



Classroom exercise.

• In three’s;

Your client has returned for his/her second

session. You place homework on your agenda

(as usual) and discover your client has not

completed any mood/activity diaries. ..



Some references:

Bordin E S (1979) The generalizability of the psychoanalytic concept of the workingalliance.Psychotherapy: Theory, Research & Practice, 16: 252-60.

Brosan, L., Reynolds, S., & Moore, R. G. (2007). Factors associated with competence incognitive therapists. Behavioural and Cognitive Psychotherapy, 35, 179 –190.

Brosan, L., Reynolds, S., & Moore, R. G. (2008). Self-evaluation of cognitive therapyperformance: Do therapists know how competent they are? Behavioural andCognitive Psychotherapy, 36, 581 –587.

Cooper M (2008) Essential Research Findings in Counselling and Psychotherapy.London: SAGE Publications Ltd.

Gilbert P, Leahy R L (Eds) ( 2007) The Therapeutic Relationship in the CognitiveBehavioural Psychotherapies. Hove: Routledge.

House R, Loewenthal D (2008) (Eds). Against and For CBT: Towards a constructivedialogue. Ross-on-Wye: PCCS Books.

Lambert M J, Barley D E (2002) Research summary on the therapeutic relationship andpsychotherapeutic outcome. In: Norcross J. (Ed). 2002. PsychotherapyRelationships that Work: Therapist Contribution and Responsibility to Patients. Vol

III. Oxford: Oxford University Press.



Some references:

Leahy RL. (2001). Overcoming Resistance in Cognitive Therapy. New York andLondon: The Guilford Press.

Mahoney M J (2003) Constructive Psychotherapy: A Practical Guide. New York andLondon: The Guilford Press.

Salkovskis P (1997) Frontiers of Cognitive Therapy: The State of the Art and Beyond.London: Guilford Press.

Schaap C. Bennun A, Schindler L, Hoogduin K. (1993) The Therapeutic Relationship inBehavioural Psychotherapy. Chichester: John Wiley and Sons.

Townend M, Grant A (2008) Process and related issues in cognitive behaviouralassessment. In: Grant A, Townend M, Mills J, Cockx A. 2008. Assessment and CaseFormulation in Cognitive Behavioural Therapy. London: SAGE Publications Ltd.

Waller, G. (2009). Evidence-based treatment and therapist drift. Behaviour Researchand Therapy, 47, 119-127

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Day 7- 2015 Therapeutic Relationship Updated (1)