Are we saying the same thing? Articulating therapeutic relationship and alliance across different models.

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.