Exercise 3 cbt-l5 The cbt relationship The Therapeutic Relationship – Case Presentation (2)

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Exercise 3 - CBT-L5 The CBT relationship

The Therapeutic Relationship – Case Presentation (2)

In this presentation I want to show how I have worked with the CBT relationship for the benefit of my client. Cognitive therapy has often been criticised for ignoring the role of the therapeutic relationship. In this presentation I aim to evidence the importance I attach to the relationship in CBT.

My first aim is to establish a sound collaborative relationship, this is crucial as it is my belief that my client’s perception of our strong therapeutic relationship will enhance their outcomes for them (Martin, Gorske and Davis 2000; Orlinsky, Ronnestad and Willutzki, 2004) with an early alliance being predictive of our later outcome (Gaston, Marmar, Gallagher and Thompson, 1991).

One of the significant features of the CBT relationship is that I work empathically and collaboratively to encourage the client in our therapy (this emphasised by D Westbrook et al 2011; p42), that we have clear formulation and identified goals to work with. I am mindful of the need to socialise my client into the CBT way of working, and to familiarise them with some of the concepts and language. Prior to my first meeting with A I was mindful of my need to listen out for his choice of expression and whether this focussed on thinking, feeling, behaving or his bodily awareness. This would then be something I could utilise to inform my choice of interventions within our therapy.

The minute A walked through the door I sensed that trust and safety was an issue. His body language was closed and he seemed defensive. He sat forward in his chair as if he was expecting me to challenge him in some way; my immediate thought was to remain open and relaxed, hoping that he would eventually begin to relax. I decided to take things slowly and be empathic to try to build a collaborative working alliance.

I was aware of feeing anxious in the room. I questioned whether this was my anxiety alone and realised that it was probably A’s anxiety, and I decided to share this with him.’A first meeting can be anxiety provoking …’ he nodded. I think this and my first impressions above, picked up on the implicit aspects within our relationship. Whilst I didn’t use full self disclosure I’m aware that if I chose to in our ongoing relationship that this could be beneficial to our working relationship and could provide an important vehicle for A’s learning (Beda, 2011).

I asked A what his goals for therapy were, recognising that this is a core component in the therapeutic alliance. His goal was to be able to control the aggression he felt when he argued with his partner. I encouraged him to say more and listened out for negative automatic thoughts and dysfunctional assumptions. ‘This sounds like an excellent goal. We will identify a plan or formulation and this will guide our therapy relationship – rather like a map for the territory, and this will direct us and keep us on track towards your goal.’ A seemed relieved and sighed slowly. I recognised the important of his bodily responses in our first meeting. ‘You will be an active participant in our relationship, I will ask you to complete some paperwork and maybe to try out some new tasks that we have discussed, and also to do some work outside of our sessions – how does that sound?’. ‘It sounds good but I’m still not really sure how it will work exactly’. I reassured him and said that as we were running out of time, we would start with this in our next session.

In the second week we jointly set our agenda and I introduced the hot cross bun ‘in order that he could start to feel part of the therapy and to engage in our relationship as an active participant’. There was an immediate shift in his body language; he became more engaged in the process. Because of this developing engagement I handed him a pen and together we completed the hot cross bun focussing on his Thinking, feeling, behaviour and physiology at the time that he became angry. I explained that it isn’t always what happens to us that causes the problem, in this case his anger but rather what we make of what happens to us and that often this is a point where we can easily find ourselves stuck. When we finished this task A said’ this really made sense to me to see it on paper’ because he had noted the details of his inner mechanisms he was fully able to own he was fully able to own and understand the process. This felt like the beginning of a productive collaborative and therapeutic relationship. I responded to A’s feedback and we worked more with pen and pad with A in charge of the pen with the result that he became more engaged in the process and a real sense of progress developed. We worked together to identify his triggers for his angry outbursts.

I was aware that there was a chance that A may feel that our relationship might become ‘technolatry’ (Mahoney, 1991) or overshadowed by techniques and I focussed particularly on my active listening, regulating his emotion to the optimum level and attending skills to ensure that he felt our collaboration and my intention for us to continue to work together.

As our collaborative relationship deepened A started to open up and we worked with his negative automatic thoughts and then started to identify dysfunctional assumptions. Whilst this is not a complete illustration of our relationship I was confident that my early intervention with the hot cross bun exercise could according to DeRubeis and Feeley, 1990 also lead A to have a more robust perception of a better working alliance for us.

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