Interpersonal Factors in CBT

1. Interpersonal Factors in CBT Dr Rita Woo 19th May 2011

2. Session Outline: • Relationship between therapeutic relationship and outcome • Integrating ‘technical’ and ‘relational’ factors in CBT • Interpersonal/relational schemas • Ruptures in the therapeutic relationship • Self and self-reflection in the therapeutic relationship

3. Definitions: • “Two people, both with problems in living, who agree to work together to study those problems, with the hope that the therapist has fewer problems than the patient” (Harry, Stack Sullivan, 1953) • “An agreement on goals, an assignment of task or series of tasks, and the development of bonds” (Bordin, 1979) • “The personal qualities of the patient, personal qualities of the therapist, and the interactions between them” (Wright & Davies, 1994)

4. Historical Understanding of the Therapeutic Relationship in CBT: • Traditionally, CBT focussed on the technical aspects of therapy rather than the relationship. “the therapeutic relationship is an important source of reinforcements for clients that do not get immediate relief from technical interventions” (Beck et al., 1990) • A good therapeutic relationship was seen as necessary but not sufficient for therapeutic change. • Recent work in CBT that has focused on applying the model to a wider range of clinical presentations, has seen some reconsideration of the role of the relationship as an active ingredient of change.

5. Collaborative Working in CBT • The ‘feel’ of collaborative working: “ A slow, reflective ‘ping-pong’ quality…The time that therapist and client are speaking may be about equal, the therapist shares her thoughts about the clients thoughts and asks for feedback. Whilst questions may be asked by both therapist and client, both work together…To find answers…” (Wills and Sanders, 1997).

6. Implications: • Relationship develops on a reciprocal basis • Shared & explicit goals – no hidden agendas • Facilitates guided discovery • Collaborative empiricism – client as expert on their experience, therapist with expertise with specific strategies and theories • Avoid: interpretations, long silences, lecturing

7. Therapeutic Relationship & Outcome:Empirical Evidence • Persons & Burns (1985) - Both the therapeutic relationship & changes in conviction of NATs had independent and additive impacts on end of session mood. (single session) • Tang & De Rubeis (1999) – Explored rapid improvement in mood between sessions. Association between cognitive change in relation to therapeutic alliance & outcome. • Causality difficult to determine • Associations from a single session cannot be generalised over a course of therapy

8. Empirical Evidence: Course of Therapy • Stiles et al., 1998 – Sheffield Psychotherapy Project. 79 clients offered either CBT, interpersonal, psychodynamic therapy. Association found between mean alliance ratings across all sessions and outcomes. The association was stronger for CBT • Gaston et al., 1998 - 120 depressed elderly clients. Pre therapy levels of depression and alliance assessed at sessions 5, 10& 15 predicted outcome. • Klein et al (2003). 367 depressed clients. Early alliance predicted improvement after controlling for other factors. - Causality unclear

9. Empirical Evidence: Role of Technical Factors • De Rubeis & Freely (1990). 25 clients offered highly structured cognitive therapy for depression (12 sessions). Use of specific interventions predicted outcome but the quality of the relationship did not. • Freeley, DeRubeis & Gelfand (1999) temporal sequencing 25 client in treatment for depression. A positive alliance as measured in session 2 did not predict outcome. A positive relationship emerges as a non significant by-product of symptom change - Numerous methodological issues

10. Empirical Evidence: Interaction Between the Relationship & Technical Factors • Burns & Nolen-Hoeksema (1992) - 185 clients offered CT for affective disorders (some with personality difficulties). Therapist warmth & empathy associated with outcome when technical factors controlled for. Relational & technical factors independent and additive effect on outcome. • Muran et al., 1995 – 20 session CT for depression and anxiety. 53 clients. Both the relationship and cognitive change were predictive of outcome. • Rector, Zuroff, & Segal (1999). 20 session CT for 47 depressed & anxious clients. High ratings of bond & change in cognitions associated with best improvement.

11. Empirical Evidence: Summary • “an association between the therapy relationship and outcome has been observed more often than not, with the role of technical intervention as a possible mediator of this association greatly debated”- a need to move beyond ‘black and white’ thinking. (Waddington, 2002) • Other factors to consider:- complex presentations, severity, client’s view of therapy

12. Implications: Integrating Connectedness & Competence • Elicit the client’s view of the relationship. • Aim to generate hope through the relationship. • Use CBT skills to establish relationship- collaboration, guided discovery, feedback, thought records. • Attend to therapeutic ruptures. • Aim for positive therapist characteristics- personal adjustment, schemas, stress levels. • Consider client issues in the therapeutic relationship • Use supervision and self-reflection to work on relational factors.

13. Interaction of Therapist & Client Factors: • More recently, CBT conceptualises the relationship as an integral part of the treatment - can be used to produce change (Leahy, 1993; Safran & Segal, 1990; Young et al., 2003). • Bordin (79) – “an agreement on goals, an assignment of task or series of tasks, and the development of bonds”. • Negotiation between therapist and client being central to the change process (Safran & Muran, 2000). • This process is inevitably influenced by client’s and therapist’s pre-existing expectations, beliefs, and needs, interacting with contextual factors.

14. Interpersonal (Relational) Schemas: Safran & Muran, 2000; Safran & Segal, 1990 • Roots in attachment theory (Bowlby, 1969, 1980; Sullivan, 1953) • From interactions with attachment figures – learn the behaviours and emotions than contribute to maintenance of relatedness as well as those that might jeopardise it. • Learning experiences schematic representations of self-other interactions Interpersonal/Relational Schemas

15. Interpersonal (Relational) Schemas: Safran & Muran, 2000; Safran & Segal, 1990 • Relationships shaped by the principal of ‘complementarity’ (Kiesler, 1996). • Framework for understanding how unhelpful interpersonal schemas can be self-reinforced. • Unhelpful interpersonal schemas influences behaviour, thereby little opportunity to disconfirm beliefs and expectations (cognitive-interpersonal cycle) - Avoid situations that evoke unhelpful interpersonal schemas - Seek out others who are comfortable with interpersonal style - Control/conceal emotions that can threaten relationship

16. Ruptures: • Breach in relatedness (therapeutic alliance) when unhelpful interpersonal schemas are triggered. • Interference with tasks/goals of therapy. • Historically, standard CBT techniques e.g. challenging cognitive distortions used to address difficulties in the therapeutic relationship. • Empathic confrontation (Young, 2003) • 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

17. Reflection – Therapist’s Schemas: How Do You Know When They Are Activated? • What aspects of a client’s presentation or what type of client arouses strong feelings in you? • Are there some clients or aspects of their presentation that you are more/less interested in? • Are their some clients that feel like friends? • For the examples elicited from the previous questions, what schemas do you think have been activated? • What might some of the potential difficulties be when therapist and client schemas conflict or when they are similar?

18. Common Therapist’s Schemas (Leahy, 2001): • Demanding standards • Abandonment • Need for approval • Excessive self-sacrifice • Special, superior person • Autonomy • Rejection sensitive • Control • Judgemental • Persecution • Withholding • Helplessness

19. Managing Ruptures - Key Ideas: • Therapist’s awareness of self - reactions and internal experiences as sources of information ,‘Reflection-in-action’ (Schon, 1983), mindfulness • Therapist’s awareness of client’s behaviours, thoughts etc… • Collaboration – exploration of client’s experience and understanding of events and therapist accepting responsibility for own contribution to enactment of unhelpful cognitive-interpersonal cycle • Focus on ‘here and now’ – tracking emotional shifts during the session • Emphasis on understanding rather than change

20. A Model for Working With Ruptures: • Recognising when a rupture in the therapeutic relationship has occurred. • Realisation that both therapist and client are embedded and contributing to unhelpful cognitive-interpersonal style - therapist communicates observation of cycle in the “here and now” • Collaborative exploration of the client’s construal of the interaction • Recognition of the possible avoidance of difficult emotions • Client expressing an underlying wish or need

21. Exercise: • In pairs, discuss your experience of a rupture in the therapeutic relationship with a client, thinking about: • How you noticed a rupture had occurred • Therapist beliefs, interpersonal schemas, expectations, and behaviours that were activated • Client’s beliefs, interpersonal schemas, expectations, and behaviours that were activated • How the rupture was resolved

22. Self Practice & Self-Reflection – Bennett-Levy (2006): • Based on Declarative-Procedural-Reflective (DRP) model - Declarative: knowledge base for therapy – interpersonal, conceptual & technical knowledge - Procedural: Implicit storehouse of skills, declarative knowledge in practice, theory-practice links – interpersonal perceptual & relational skills, therapist’s attitudes, beliefs and assumptions and self-schema - Reflective: not a permanent memory store of knowledge/skill but created and dissolved in situations requiring reflection – self reflection & general reflection

23. Self Schema & Self-as-Therapist Schema: • Self schema – ‘non-therapist’ self. Beliefs about ourselves, others, the world, skills & attributes, values & attitudes, experience • Self-as-therapist schema – your identity as a therapist. Therapist attitudes, technical and conceptual skills, interpersonal relationship skills - Self-as-therapist never entirely separate from the non-therapist self schema - Self-as-therapist schema more dominant during training - Interpersonal skills separate from conceptual and technical CT skills different training strategies

24. DRP Model - Interpersonal Skills: • Interpersonal perceptual skills – empathy, mindfulness & reflection-in-action. Determines what information we pick up and miss during therapy. Receptive skills focussed on client’s communications • Therapist attitudes, beliefs & assumptions – values, beliefs & assumptions about the self & clients, and therapy process • Interpersonal relational skills – therapist communication skills. Expression of warmth, empathy, compassion • Interpersonal declarative knowledge – understanding of the key elements of interpersonal processes, their role in therapy, ways to conceptualise difficulties • Importance of reflection – general and self

25. Interpersonal Skills & Training Strategies – Interpersonal Perceptual Skills:

26. Interpersonal Skills & Training Strategies – Attitudes/Beliefs/Assumptions:

27. Interpersonal Skills & Training Strategies – Relational Skills:

28. Interpersonal Skills & Training Strategies – Interpersonal Declarative Knowledge:

29. Interpersonal Skills & Training Strategies – Reflection :

30. Interpersonal Skills & Training Strategies – Self-Schema :