Transcript Slide 1

Are we saying the same thing? Articulating
therapeutic relationship and alliance across
different models.
Sarah Patrick (Senior Lecturer) &
Bill Penson (Teacher Fellow)
Aims of the workshop
• Introduce the Evidence Based therapeutic
Interventions module
• Introduce the CB and PI model
• Consider the similarity and variation in the
understanding of the therapeutic
relationship
• Relate this to experiences of workshop
participants
• Consider implications of the above.
Intro to EBTI
• Skills based module.
• Delivered via a supervisory as well as
taught element.
• Rationale; to appraise evidence based
approaches and develop knowledge, skills
and competencies in application.
Exercise 1
Working on your own take 5 minutes to make
notes/a list on the following:
• Imagine you are observing a pair (therapist and
client) what would you hope to see that would
indicate a good therapeutic relationship?
• Place these items/qualities in a hierarchy
The therapeutic relationship
‘You will get further with a patient with a
good relationship and lousy techniques,
than you will with good techniques and a
lousy relationship’
Meyer, 1984 (cited in
Aubuchon & Malatesta, 1998)
Therapeutic relationship
A ‘professional’ therapeutic relationship may have a number
of characteristics:
• Unilateral, with focus being on solving the problems of the
client
• Time limited, duration is defined by the achievement of
stated goals/objectives
• Explicit/implicit contracts to guide behaviours within the
boundaries of the relationship
• Approaches defined by specific models of professional
practice
• A narrow definition of relationship, ‘uncluttered’ by
additional roles of friend, partner, parent.
Morgan, 1996
Therapeutic Alliance
BOND-positive
TASKS- agreement on
GOALS- agreement on
(From Safran & Muran, 2000)
What is the Conversational
Approach?
• The Conversational Model is an Integrative model
– Draws on psychodynamic, humanistic and
Interpersonal Concepts
• Centres on the relationship between service user
and practitioner
– Aims to develop a ‘Conversation’ in which problems are
expressed and resolved, not simply ‘talked about’
• Is also known as ‘Psychodynamic Interpersonal
Therapy’ (PI)
• Has a good evidence base
– Is recognised as having a robust evidence base, based
on outcomes in clinical control trials in the
Psychodynamic Competency Framework (Lemma,
Roth & Pilling 2008)
So what is the Evidence?
• Depression;
– as effective as CBT (Shapiro et al 1994)
• Somatisation and physical conditions
– Guthrie et al (1991)
• Deliberate Self Harm
– Guthrie et al (2001 & 2003)
• Complex non-psychotic
– Guthrie et al (1998; 1999)
• Emerging literature for schizophrenia
– Davenport et al (2000)
• People with BPD
– (Stevenson & Meares (1992); Meares et al (1999)
• Binge Eating Disorder
– As effective as CBT (Tasca et al 2004)
So …. The conversational
approach is…
• A way of being when
holding a `conversation` with
a service user.
• A therapeutic style or stance
that underpins any
conversation with a service
user.
• A Conversation that can take
place in any ‘treatment’
setting.
PSYCHODYNAMIC – INTERPERSONAL THERAPY
HELP A CLIENT FEEL UNDERSTOOD
Understanding hypotheses
Statements not questions
Linking hypotheses
Focus on feelings
Explanatory hypotheses
Focus on ‘Here and now’
Sequencing of
interventions etc.
Metaphor
HELP A CLIENT MANAGE THEIR EMOTIONS
 GRAHAM PALEY (PI TRAINING MARCH 2005)
Shared understanding
Encourages openness and understanding through
the PI Skills;
• Use of statements rather than
questions
• Language of mutuality (‘I’ and ‘we’)
• Negotiating and tentative style
• Understanding hypotheses - attempt to
take exploration of feelings further
Staying with Feelings
• Focus is on the ‘here and now’ and what is ‘in
the room’
• Picking up on cues – verbal, vocal, non-verbal,
the feelings of the therapist
• Being explicit and bringing into the room,
difficult feelings such as anger, avoidance,
denial etc
• Purpose is to make meaning and create
understanding together through a focus on
feelings….looking to add a further dimension to
the client’s understandings.
“Putting it all together”
Sequencing of interventions in the Conversational Model
Non Verbal
Verbal
Explanatory hypothesis
Vocal
Make a
guess about
why this
might be
Pick up
on Cues
Statements not questions
Understanding hypothesis
Make a guess
about what the
feelings might be
Linking hypothesis
Make a guess
about them and
you; here & now
Focus on the relationship
Focus on
feelings; stay
with them “now”
Sarah Patrick 2005
‘I’ and
‘We’
Here and
now
Core Sequencing
Less Frequent
Least Frequent (but crucial)
CBT
• Assumes that disturbances in mood result from an interaction of
certain ways of thinking and behaving which maintain problems.
• The problematic ways of thinking (the C) reflect rules for living
formed out of experience. In this way they also include unhelpful
distortions, predictions and biases.
• We behave (B) in ways that are consistent with our beliefs which
reduces the opportunity for discomfirmatory experiences eg
avoidance, isolation.
• Getting people to weigh up and reflect on their personal meaning
and beliefs in a given circumstance can lead to a shift or change in
understanding eg weighing the evidence for a conclusion.
• Testing out predictions (experimentation), raising activity levels,
doing things differently (such as exposure) can in itself result in
change as well as offer opportunities for further data collection.
CBT & the relationship.
• Viewed as having been neglected.
• Wills (2008) points out that as far back as Beck (1979)
there has been attention to relationship including:
genuineness, respect and ‘within reason warmth’.
Although the experience of qualities like empathy are
filtered through the cognitive apparatus and interpreted.
• Davidson (2000)describe the relationship as a
‘laboratory’ testing out the ways of being in other
relationships, although isn’t the vehicle for change in
itself.
• Blackburn & Twaddle (1996) talk about being in tune with
self and client in the ‘now’, the importance of personal
meaning and the relationship as an important context.
Cognitive Therapy Scale:
General area (CTS
original)
Specific area (CTS
original)
CTS (adapted for
psychosis)
Agenda
√
Feedback
√
Understanding
√
Interpersonal effectiveness
√
Collaboration
√
Pacing and efficient use of time
Guided discovery
√
Focusing on key cognitions &
behaviour
√
Strategy for change
Choice of intervention
Application of CBT techniques
Quality of intervention
Homework
Additional considerations
√
sources
Aubuchon, P.G. & Maltesta, V.J. (1998) Managing the relationship in
behaviour therapy: the need for case formulation’. In Bruch, M. &
Bond, F.W. (eds) Beyond Diagnosis- Case Formulation Approaches
in CBT. Chichester. Wiley.
Blackburn, I., & Twaddle, V. (1996) Cognitive Therapy in Action.
Souvenir Press. London.
Davidson, K. (2000) Cognitive Therapy for Personality Disorders.
Oxford. Butterworth Hienemann.
Morgan, S. (1996) Helping Relationships in Mental Health. London.
Chapman & hall.
Safran, J.D. & Muran, J.C. (2000) Negotiating the Therapeutic Alliance.
London. The Guilford Press.
Wills, F. (2008) Skills in Cognitive Behaviour Counselling and
Psychotherapy. London. Sage.