Sarah Patrick (Senior Lecturer) & Bill Penson (Teacher Fellow)

1. Are we saying the same thing? Articulating therapeutic relationship and alliance across different models. Sarah Patrick (Senior Lecturer) & Bill Penson (Teacher Fellow)

2. 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.

3. 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.

4. 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

5. 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)

6. 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

7. Therapeutic Alliance BOND-positive TASKS- agreement on GOALS- agreement on (From Safran & Muran, 2000)

8. 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)

9. 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)

10. 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.

11. HELP A CLIENT FEEL UNDERSTOOD COLLABORATION/MUTUALITY TENTATIVE/OPEN TO CORRECTION Understanding hypotheses Statements not questions Linking hypotheses Focus on feelings Explanatory hypotheses Focus on ‘Here and now’ Sequencing of Metaphor interventions etc. VALIDATION AND SUPPORT TRANSPARENCY/HONEST COMMUNICATION HELP A CLIENT MANAGE THEIR EMOTIONS GRAHAM PALEY (PI TRAINING MARCH 2005) PSYCHODYNAMIC – INTERPERSONAL THERAPY USE A THERAPEUTIC RELATIONSHIP FORM A THERAPEUTIC RELATIONSHIP

12. 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

13. 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.

14. “Putting it all together”Sequencing of interventions in the Conversational Model Non Verbal Explanatory hypothesis Verbal 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 ‘I’ and ‘We’ Focus on the relationship Here and now Focus on feelings; stay with them “now” Core Sequencing Less Frequent Least Frequent (but crucial) Sarah Patrick 2005

15. 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.

16. 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.

17. Cognitive Therapy Scale:

18. 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.