Interpersonal Factors in CBT

Dr Rita Woo
19th May 2011

Session Outline:
Relationship
outcome

between

therapeutic

relationship

Integrating technical and relational factors in CBT

Interpersonal/relational schemas
Ruptures in the therapeutic relationship
Self and self-reflection in the therapeutic relationship

and

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)

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.

Collaborative Working in CBT

The feel of collaborative working:
A slow, reflective ping-pong qualityThe 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
togetherTo find answers
(Wills and Sanders, 1997).

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

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

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

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

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.

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, clients view of therapy

Implications: Integrating Connectedness &

Competence
Elicit the clients 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.

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 clients and
therapists pre-existing expectations, beliefs, and needs,
interacting with contextual factors.

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
self-other interactions
Schemas

schematic representations of
Interpersonal/Relational

Interpersonal (Relational) Schemas: Safran &

Muran, 2000; Safran & Segal, 1990
Relationships
shaped
by
the
complementarity (Kiesler, 1996).

principal

of

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

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
clients
interpersonal
beliefs,
expectations, and appraisal processes that contribute to
the perpetuation of unhelpful cognitive-interpersonal
cycles (Safran & Segal, 1990).
Importance of therapists reactions and interpersonal
schemas as therapy tools

Reflection Therapists Schemas: How Do You

Know When They Are Activated?
What aspects of a clients 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?

Common Therapists Schemas (Leahy, 2001):

Demanding standards
Abandonment
Need for approval
Excessive self-sacrifice
Special, superior person
Autonomy
Rejection sensitive
Control
Judgemental
Persecution
Withholding
Helplessness

Managing Ruptures - Key Ideas:

Therapists awareness of self - reactions and internal
experiences as sources of information ,Reflection-inaction (Schon, 1983), mindfulness
Therapists awareness of clients behaviours, thoughts
etc
Collaboration exploration of clients 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

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 clients construal of the
interaction
Recognition of the possible avoidance of difficult
emotions
Client expressing an underlying wish or need

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
- Clients beliefs, interpersonal schemas, expectations,
and behaviours that were activated
- How the rupture was resolved

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, therapists
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

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

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
clients 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

Interpersonal Skills & Training Strategies

Interpersonal Perceptual Skills:
Markers of Difficulties

Client not feeling heard/understood

Therapist not aware of clients emotional
state

Self-Supervision Strategies

Reflective practice reviewing session tapes

focussing on clients emotional state
Mindfulness

Supervision Strategies

Reviewing tape focussing on clients

communications verbal & non-verbal

Training Strategies

Role-play
Modelling/observation learning
Self-practice/self-reflection

Interpersonal Skills & Training Strategies

Attitudes/Beliefs/Assumptions:
Markers of Difficulties

In session feedback from clients/complaints

Therapist report

Self-Supervision Strategies

CBT techniques to identify and test therapist

beliefs/rules TR, BE, Self-Socratic questioning

Supervision Strategies

Therapist belief questionnaire

Training Strategies

Role-play
Modelling/observation learning
Self-practice/self-reflection

Interpersonal Skills & Training Strategies

Relational Skills:
Markers of Difficulties

Client- resistance to CBT approach, opts out

of therapy early

Self-Supervision Strategies

Review own tapes focusing on maintaining

therapeutic relationship

Supervision Strategies

Review of tape Interpersonal Effectiveness &

Collaboration (CTS-R)
Modelling
Supervisory relationship

Training Strategies

Role-play
Modelling/observation learning

Interpersonal Skills & Training Strategies

Interpersonal Declarative Knowledge:
Markers of Difficulties

Therapist experiences difficulty in

conceptualising interpersonal issues
Tape review therapist does not seem to
understand collaboration

Self-Supervision Strategies

Self-directed reading

Supervision Strategies

Supervisor directed reading

Didactic teaching

Training Strategies

Didactic teaching
Observational learning

Interpersonal Skills & Training Strategies

Reflection :
Markers of Difficulties

Therapist with high level of anxiety,

unwillingness to reflect on own contribution
to the relationship

Self-Supervision Strategies

Reflective writing own thoughts, feelings &

behaviours, session review
Self evaluation of tapes
Mindfulness practice

Supervision Strategies

Socratic questioning in supervision

Preparation for supervision e.g. focused question

Training Strategies

Self-practice/self-reflection

Interpersonal Skills & Training Strategies

Self-Schema :
Markers of Difficulties

Self-confidence
Activation of interpersonal schemas
Emotional exhaustion

Self-Supervision Strategies

Self-care e.g. yoga etc

Personal therapy
Self-practice/self-reflection
Reflective practice

Supervision Strategies

Normalising
Therapist self-care/sources of support
Identifying need for personal therapy

Training Strategies

Self-practice/self-reflection
Mindfulness