What to do when Therapy isn t Working:

Transcription

1 What to do when Therapy isn t Working: Dealing with Ruptures in Therapy Friday 20 th November 2015 Prof Gillian Hardy, Prof Mike Lucock, Dr James Macdonald

2 Small Groups Describe to each other a recent experience when you think you may have had a rupture with a client. (Recall that ruptures are defined as problems in the bond dimension of the alliance or as disagreements about the tasks or goals of therapy). What do you think the client may have contributed to the rupture? How did you feel during (and perhaps after) the rupture? What, if anything, do you think you yourself may have (unwittingly) contributed to the rupture?

3 Role Play in pairs where possible Take turns to role play the client you had a rupture with. Briefly explain to your partner what task you were aiming to achieve with the client. Then during the role play try to feel your way into the Client s experience of the session, talking as them to your partner who will role play you (the Therapist). As the role playing Therapist, attempt to carry out the task with the Client or resolve the rupture as best you can. Discussion: How did you feel and what was important to you as a Client? What was evoked by different Therapist approaches? Do you understand anything about your Client that you may not have been clear about before? As Therapist, how did you feel, and what was evoked in you by the Client at different moments in the role play?

4 Coffee (15 mins)

5 Negative Complementarity

6 Hans Strupp Pioneering research on interpersonal process Studied both qualitatively and quantitatively Illustration of rupture from Macdonald et al (2007)

7 Macdonald et al (2007) Macdonald, J., Cartwright, A. & Brown, G. (2007). A quantitative and qualitative exploration of client-therapist interaction and engagement in treatment in an alcohol service. Psychology and Psychotherapy: Theory, Research and Practice, 80,

8 Interpersonal Process and Negative Process - Theory The difficulty of responding in an affiliative manner to hostile client communication Complementarity (Benjamin, 1996; Kiesler, 1996) E.g. hostile & submissive client may pull hostile dominant therapist response Influence of social norms (Tracey, 1993)

9 Alan Assessment interview in alcohol service 30 year old client, unemployed & living at home. Drinking heavily. In debt. (Macdonald, J., Cartwright, A. & Brown, G., 2007)

10 Illustration of process [after describing how empty and meaningless his life is, the client says bitterly] CLIENT: I just get so frustrated that there is nothing else to do except go out and sit on a beach or something, and have a drink. THERAPIST: (Sighs) Some people use different words to describe themselves in terms of drinking like some people say they re light drinkers or alcoholic or got a drink problem or they re OK, all sorts of different words.

11 The Vanderbilt Studies Henry, Schacht and Strupp (1986) (Vanderbilt 1) Pioneering quantitative analysis of data from 8 clients and 4 therapists - Coded moment-by-moment interpersonal behaviour assumed to underpin the alliance (15-20 mins 3 rd session) - therapists in low change cases more belittling and blaming (and less affirming, less supportive) - evidence of hostile complementarity - complex communications in low change cases

12 In our study we failed to encounter a single instance in which a difficult patient s hostility and negativism were successfully confronted or resolved Therapists negative responses to difficult patients are far more common and far more intractable than has been generally accepted....the plain fact is that any therapist - indeed any human being - cannot remain immune from negative reactions to the suppressed and repressed rage regularly encountered in patients with moderate to severe disturbances. (Strupp, 1980)

13 Interpersonal process and premature termination of therapy Swift & Greenberg (2012) meta-analysis of 669 studies 19.7% drop out overall 26% drop out in effectiveness studies (i.e. routine practice settings) E.g. Samstag et al (1998); Piper et al (1999) The patient and therapist argued with each other. They engaged in a power struggle. At times the therapist was drawn into being sharp, blunt, sarcastic, insistent, impatient, or condescending

14 RCTs Rule NICE GUIDELINES PSYCHOTHERAPY RESEARCH AS A WHOLE Specific treatment techniques for Specific problems Bona fide treatments equivalent even when very different treatment rationales Lack of evidence for essential techniques Technical adherence can clash with relational attunement, with poor results Many relational variables linked to outcome

15 The meaning of any technical factor can only be understood in the relational context in which it is applied. Any intervention may have a positive or a negative impact on the quality of the bond between the patient and the therapist depending on its idiosyncratic meaning to the patient, and conversely any intervention may be experienced as more or less facilitative depending on the preexisting bond (Safran & Muran, 2000, p14)

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17 Facilitative Interpersonal Skills Ratings of verbal fluency Emotional expression Persuasiveness Hopefulness Warmth Empathy Alliance Bond Capacity Problem Focus Anderson, T., Ogles, B., Patterson, C., Lambert, M., & Vermeersch, D. (2009). Therapist Effects: Facilitative interpersonal skills as a predictor of therapist success. Journal of Clinical Psychology, 65(7),

18 Facilitative Interpersonal Skills 23 Therapists - High FIS/Low FIS 11 Clinical Psychology Doctoral Students (at least 2 years clinical training) 12 Non-Clinical Doctoral Students (no clinical training e.g. post grads training in biology, chemistry, comparative arts, etc) 82 volunteer undergrad clients scored above clinical cut-off on SCL 90, 7 Sessions. Anderson, T., Crowley, M., Himawan, L., Holmberg, J, & Uhlin, B. (2015). Therapist Facilitative Interpersonal Skills and Training Status: A Randomised Clinical Trial on Alliance and Outcome. Psychotherapy Research

19 Facilitative Interpersonal Skills Video Vignettes Taken from tricky moments in actual therapies Played word for word by professional actors Whilst watching, reflect honestly on: What feelings does this person evoke in me? What actions I might feel drawn to taking with this person? Anderson, T., Ogles, B., Patterson, C., Lambert, M., & Vermeersch, D. (2009). Therapist Effects: Facilitative interpersonal skills as a predictor of therapist success. Journal of Clinical Psychology, 65(7),

20 Henry, Schacht & Strupp (1990) (Vanderbilt 2) comparison of good outcome and poor outcome cases in 14 therapeutic dyads. Concluded: while the absence of a negative interpersonal process may not be sufficient for therapeutic change, the presence of even relatively low levels of negative therapist behaviour may be sufficient to prevent change therapists introjects impact of 1 year manualised psychotherapy training program (Henry et al, 1993)

21 Henry et al. 1993(Vanderbilt 2) impact of 1 year manualised psychotherapy training program (Henry et al, 1993) Manualised training: training changed therapists technical interventions in line with the manual but also led to a sig increase in complex communications (typically with embedded criticism) and hostile communications (though latter not statistically sig). Therapists with self-reported disaffiliative introjects achieved greater technical adherence but also had greatest increase in complexity and hostility

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23 Safran et al (2014) AFT study CBT patient expresses difficulty doing homework and apprehension about therapy tasks. Therapist: friendly and dominant (explains rationale and why homework will help). [Nurturing & Protecting, 1-4]. Patient: resentfully compliant (sighs loudly, expresses doubts, anxieties about task). [ Sulking and Scurrying, 2-6].

24 Safran et al (2014) AFT study AFT similar situation. T: (not hostile or dominant) I m getting the sense that this feels really difficult. Almost like I m asking you to face what you find most difficult. (2-2, Disclosing & Expressing) P: (no self-focused hostility) Yeah I don t know It is like, I can hold on to the fact that I know that it ll be helpful, but it is really tough for me. (2-2. Disclosing & Expressing)

25 Safran et al (2014) AFT study Therapist Relationship Interview (TRI) Pre AFT: Q Is there anything that puzzles you or that you find challenging in your work with your patient? Therapist: it s been hard to pin down what she [the patient] wants to get out of the entire endeavor. It s clear that she was in a great deal of pain when she came in, and she would like for that pain to be eased, but she has had real difficulty conceptualizing what she wants to be happening. (p 14) [EXP level 2]

26 Safran et al (2014) AFT study Post AFT: Q Is there anything that puzzles you or that you find challenging in your work with your patient? Therapist: I guess initially I felt that it was hard to create a comfortable place for S to share and disclose with me and I guess I felt a little hesitant to force disclosure I guess I felt like it was hard to be flexible and I felt that S needed a lot of flexibility on my part. I also felt like there were times in our work together when I had no idea what was going to happen when S came in. (p 15) [EXP level 4]

27 Lunch

28 Resolving Ruptures

29 Typology of rupture repair strategies DIRECT Providing a rationale or clarifying a misunderstanding SURFACE INDIRECT Changing or reframing the meaning of tasks or goals DIRECT Exploring the Core Relational Theme DEPTH INDIRECT Providing new relational experience Muran, Safran & Eubanks-Carter (2010)

30 Alliance-Focused Training Adherence Measure Jeremy D. Safran, Chris Muran & Catherine Eubanks-Carter Spend 10 minutes reading this measure. The next task will be to use it to see which strategies are being used in some video material

31 Video Exercise What kind of rupture? What strategies does the therapist use to deal with the rupture (Use the Alliance-Focused Adherence Measure)? Where would you put these in the typology of rupture repair strategies? (ie. Direct/indirect; Surface/depth) Aafjes-van Doorn, K., Macdonald, J., Stein, M., Cooper, A., & Tucker, S. (2014). Experiential Dynamic Therapy: A Preliminary Investigation into the Effectiveness and Process of the Initial Extended Session. Journal of Clinical Psychology DOI: /jclp.22094

32 Alliance-Focused Training Adherence Measure Jeremy D. Safran, Chris Muran & Catherine Eubanks-Carter Remind yourself of the skills of metacommunication in the AFT adherence measure. We will be looking for these skills in the next video we watch

33 Video Exercise Illustration of the first stages of working with a rupture, from Safran s APA video. What feelings and impulses does the client evoke in you? See if you can identify what Jeremy Safran does to try to disembed himself and the client from the rupture Video (Session 2, mins)

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35 Tea (15 mins)

36 Alliance-Focused Training Aims: to develop three interdependent skills 1. Self-awareness 2. Affect regulation 3. Interpersonal sensitivity

37 Alliance Focused Training Alliance-Focused Training 3 Main Supervisory Tasks 1. Videotape analysis of rupture moments 2. Awareness-oriented role-plays 3. Mindfulness training Eubanks-Carter, C., Muran, J. & Safran, J. (2015) Alliance-Focused Training. Psychotherapy, 52, (2)

38 AFT Mindfulness Training Gradually, over time, this type of mindfulness work helps trainees to become more aware of subtle feelings, thoughts, and fantasies emerging on the edge of awareness when working with their patients, which can subsequently provide an important source of information about what is occurring in the relationship.

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40 AFT Mindfulness Exercise Get comfortable in your chair, and you can close your eyes or just lower your gaze. Focus your attention on your breath. Pay attention to each inhale and exhale. Now start to count each breath. Whenever you notice your mind wandering, just note this, no judgement, no criticism, just note that your attention has wandered, and then refocus your attention on your breath, and start counting again, beginning again at one. (p172)

41 Metacommunicate This!

42 Pairs or groups of 3 (Client, Therapist, Observer). 15 minutes per role play. Client: role play a client who in some way you are finding difficult (could be the client you thought of this morning). Try to get into the role and feel what it is like for you to be in the client s situation. Therapist: be as mindful as you can of how you are feeling with the client (e.g. pay attention to your body, how you are breathing, whether your mind wanders, goes blank, etc). Take a stance of welcoming the client s experience into the conversation. See if you can meta-communicate and explore the client s construal of the situation. Observer: listen carefully to what is said. See if you can spot any of the inevitable enactments (where the therapist may engage in some form of negative complementarity). See if you can spot direct and indirect, surface and deep, rupture repair strategies. See if you can identify elements of deep & direct rupture repair strategies (i.e. meta-communication; exploring the relational theme underlying the rupture).

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44 Meta-analysis (Safran et al, 2011) 1. Rupture repair episodes and outcome 3 studies Medium effect size 2. Impact of rupture repair training or supervision on outcome 7 studies with control groups Small but statistically significant improvement relative to those not trained

45 Mick

46 Resolving Ruptures in the Therapeutic Alliance Using Session-by-Session Feedback A Task Analytic Study Christopher Laraway (Oxford DClinPsych Course) Objective: This study aimed to develop an explanatory model of how session-by-session feedback may be used to facilitate the identification of ruptures and aid the process of rupture resolution. Method: A task-analytic design was employed. Participants were five experts in the field of the therapeutic alliance and/or session-by-session feedback. They were interviewed to develop a theoretical model of how this therapeutic task might be achieved. Five patients receiving integrative therapy from one of two therapists also took part in the study. An analysis of selected sessions led to the development of an empirical model of in-session performance of this therapeutic task. The two models were then combined to produce a rational-empirical model. Results: A rational-empirical model of rupture resolution using session-by-session feedback was developed. Conclusions: Results suggest that session-by-session feedback can be used to identify ruptures and aid in the process of rupture resolution. The patient contribution to this process is crucial in its success. Limitations of the study, clinical implications, and suggestions for further research are discussed. Keywords: Task analysis; session-by-session feedback; therapeutic alliance, ruptures.

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49 Take Home Messages? Cultivate mindfulness-in-action Be aware of any subtle blaming of patient (beware negative side-effects of training!) Foster collaborative, tentative exploration of what is happening in the here-and-now Elicit and value patient construal of difficult situations