The therapeutic relationship in cognitive-behavioral therapy and pharmacotherapy for anxious youth.
PDF | Cognitive behavioral therapy has often been criticized for ignoring the role of the therapeutic relationship. In this article, I outline several dimensions for. Studies examining the role of the therapeutic relationship and alliance in CBT for youth anxiety have yielded mixed results, perhaps due to methodological. By Mary Sykes Wylie and Judith Beck - Today, cognitive behavioral therapy is among the most widely practiced and promulgated approach in.
According to Mooreythe model for depression was developed based on a CBT understanding of maintenance factors in depression. The model is considered useful in conceptualising cases and when used in treatment planning, when working with depression. Automatic negative thinking is the negative thoughts one experiences in any given event or situation that are biased from a negative perspective. Cognitive distortions and their misinterpretations also fall within this cycle.
The cycle of rumination involves thinking about a negative event, in which thoughts are about what one could have done differently, how it happened and what went wrong. Ruminations may form part of the past or present, as part of this cycle.
Self-attacking describes how one persistently attacks and provides criticism to the self. Mood and emotion as a cycle involves feeling in a low mood, feelings of sadness and emptiness, anxiety and irritability.
This leads to further self-attacking. The withdrawal and avoidance cycle is a significant maintenance factor in depression.
When a person is in a depressed mode, they may feel worthless and may have thoughts of failure, which results in less engagement in activities than what they used to take part in and enjoy.
The disengagement of activities prevents the negative thoughts from being tested and reduces the possibility of finding pleasure in activities that one enjoys.
The unhelpful behaviour cycle describes behaviours that try to compensate for unpleasant feelings and negative beliefs. The cycle of motivation and physical symptoms describes the biological symptoms of depression and may lock the person into the depressive mode.
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Feelings of inadequacy may result in the person with depression, leaving them with feeling worthless and with nothing to offer. The environment also forms part of the six cycles and may trigger and maintain depression. The six cycles do not naturally occur in a step-by-step fashion and clients will not necessarily fall into all six cycles Moorey, Her ruminations include thoughts of feeling as though she is to blame and feelings of guilt, as she feels that perhaps she could do something different to change the circumstances within her family.
She then places much pressure and responsibility on herself for aspects of her life that are beyond her control.THERAPEUTIC ALLIANCE
Her mood and emotions include feelings of being depressed, guilt, irritability, inadequacy, and suppression from having any feeling.
The unhelpful behaviours that she engages in are her inactivity, the suicide attempt she made earlier in the year, not eating, and avoiding her feelings. The Treatment Plan [ TOP ] In working with Noluthando, I experienced difficulty in following a treatment model strictly, and this will further be elaborated on through the discussion on what happened in therapy, below.
The reasons that I found implementing the therapy model difficult at times, was that often Noluthando was in an uncommunicative state and I feared developing a further barrier between us, and at times, it felt inappropriate and damaging to the relationship.
However, the treatment plan was followed and was often naturally integrated into therapy. I battled at times this was part of my process of integration of using CBT and focusing on the therapeutic relationship, and seeing them as separate constructs to find the balance of the implementation of the therapeutic relationship and using technique.
When applying this treatment model to Noluthando, I tried to work with the automatic negative thinking cycle, by testing negative thoughts and beliefs.
This involved confronting her negative beliefs, the way she thinks about things, and testing them against reality and other viewpoints. When working with her ruminations and the self-attacking cycle, I used problem-solving and the development of compassion.
Developing compassion would be important for Noluthando, as she frequently believed that she was a failure and needed to learn to be gentler with herself. In approaching the withdrawal and avoidance cycle, I suggested that Noluthando start to slowly engage herself in activities again and to start opening up, rather than isolating herself. Noluthando could deal with her unhelpful behaviour cycle by not avoiding her feelings, eating when it is difficult, and to rather engage in problem-solving and reaching out to someone for help when things do become too difficult.
Psycho-education aided in this. In terms of the motivation and the physical symptoms cycle, it benefited her to become aware of her symptoms, to keep healthy through exercise, and sleeping and eating in a healthier way. It is of value to create awareness of this for Noluthando and for her to come to an understanding of how to live in her environment and possible alternatives to this. Therapy Narratives [ TOP ] The description of the sessions below provides the details and reflections of 11 therapy sessions, to outline what happened in therapy and to provide a narrative of the therapeutic relationship that developed between Noluthando and myself.
The sessions are divided into four themes regarding the development and changes in therapy and the therapeutic relationship. After a description of what happened in therapy sessions, under each theme, the therapeutic relationship, its value in therapy, and my experience of the therapeutic relationship are discussed. In the first session, Noluthando was extremely quiet, her voice was strained and she spoke very little, and she seemed to find the experience difficult. She had a depressed mood and displayed low energy throughout the session.
She spoke of the problems that she experiences when she lives at home with her family and how she has been experiencing this for a number of years. I spoke about the suicide attempt with her and she provided little detail other than the method that she used drinking a poisonous substanceand that she left no suicide note.
I asked Noluthando to make a commitment to therapy and we signed a contract that detailed our working together in therapy.
Both Noluthando and I kept a copy of this contract. During the session, I asked her about what she would like to gain from therapy and what her goals were.
Noluthando reported having difficulty trusting people as they have broken her trust in the past. We worked through the questions together, which aided me in understanding some of her symptoms. She obtained a score of 16 points. This score is indicative that the client is on the borderline between a mild mood disturbance to clinical depression. Therefore, I made plans to be more practical in Session 2 and introduced the idea of a timeline.
Noluthando seemed willing to give the exercise a try, which involved placing a horizontal line across a page and placing dates as we worked collaboratively in collecting her history. She wanted me to write, and looked at the page whilst dates and events were added.
When she spoke of her mother and father, she recalled how she has never experienced her mother not drinking alcohol. However, through the timeline, she was able to speak about hopes for her future and a possible career in drama. I noted how her posture and voice changed to being upright and more assertive, revealing an uplifted mood when speaking about drama.
In fact, I felt that I did most of the talking in the session, as Noluthando would not answer questions in more than a few words. How would you describe yourself? Is there anyone that you like to talk to? It may be quite difficult for you to be here, because in therapy you will do a lot of the talking.
This is the reason I want to come here. I want to overcome that. Maybe that can be a goal in therapy, something we can work and challenge together?
Yes quiet short laugh. I felt that it would possibly take time for her to develop trust with me as she has difficulty with trust in her other relationships. In the second session, I noted that by me being more practical in the session by working on a timeline together, allowed more information to be shared between Noluthando and myself.
This could be because the focus appeared to not be on her but rather on the task. I reflected on how difficult it was for Noluthando to openly communicate and how I could try to create a space in therapy where she could begin to open up more.
This would entail moving at a pace, which would be comfortable for her. I felt that she might have difficulty speaking in the session because of the emotional content, as shown in the transcript below.
It sounds like quite a few people in your family do not get along. What is that like for you? It is hard, silence because now you have to choose between family members. What do you think of your family not getting along?
He is not open to talking about it. How often is your mother drunk? I felt that the collaborative relationship in CBT may help her to feel responsible for therapy and may assist in her working together with me.
Belsher and Wilkes believe collaboration in CBT to be one of the key therapeutic principles when working with adolescents. I was concerned that the techniques of CBT may break down communication in therapy and that the therapeutic relationship may not develop. Strunk and DeRubeis describe how the techniques of CBT may be experienced as boring and not age appropriate, by younger people, and I did not want her to have this experience.
The Development of the Therapeutic Relationship: It was hoped that by doing this it may relieve some of the anxiety she may have been experiencing in sessions so that she may open up similar to the previous session with the timeline. Whilst drawing, she spoke about her father and how she learnt of his HIV positive status by reading about it in some notes he had made, which she had come across by accident.
She related how difficult it was for her as she did not know who to speak to about the information that she had learnt about her father.
She described her father as not wanting to talk about his feelings. She described a family that does not communicate with one another. Although I experienced Noluthando finding the session difficult, I found her to open up more than the initial two sessions. Noluthando completed the BDI in this session and her score increased from 16 points to 19 points.
I was concerned about this and reflected about it after the session and discussed it with my supervisor. I thought that perhaps she under reports her experiences and feelings as, in this particular session, she shared how she often smiles even though she is not okay on the inside. Before the session ended, I provided her with an automatic thought record to start recording her thoughts.
The Therapeutic Relationship in Cognitive-Behavioral Therapy and Pharmacotherapy for Anxious Youth
Thought records provide the client with the task of responding and challenging negative automatic thoughts in writing and the therapist can then help the client to find a more balanced or alternative thought. I felt that perhaps she would not be accepting of completing the thought record on her own, and was interested to see if she would bring it with her to the following session.
Session 4 [ TOP ] Noluthando started the session by saying she was very stressed about the examinations that she was presently busy with at school. That day, she had written her theoretical drama exam and was anxious about her performance, as she felt she had not done well. This allowed us to explore what she often reported, on her BDI, as feeling like a failure.
Noluthando reported how she feels like a failure not only in her studies, but also when her father beats her mother and she does not stand up for her. She said that being a failure is what she really believes about herself and may represent her core belief.
A core belief is described by Westbrook et al. We challenged this belief about being a failure by referring to how she has performed at school despite difficult circumstances. I also provided a space for her to reflect on what may happen if she did stand up for her mother when her father became violent. This was not easy for her and she became somewhat disassociated in the session when talking about the feeling and thoughts of being a failure.
In the session, I provided psycho-education about CBT and the hot cross bun that looks at five aspects of life that are interconnected, namely: Noluthando and I applied this to her belief of failure at school, and she then later said that she would like to try this in future sessions. The session closed with her speaking about a play that she was involved with as part of a school project, in which she was acting the part of a man who is a husband who fights with his wife.
I reflected on how this role may be difficult for her to act and how it is similar to her own life story with her father who abuses her mother. Both Noluthando and I felt it was sad. Noluthando forgot her thought record form as she was busy with studying and said that she would bring it with her the following week.
In lieu of her being busy with examinations, I did not challenge her on not completing the thought record as I felt it to be inappropriate at the time and may close communication down between us.
On reflection of her not completing her thought record, a possible explanation could be that due to the thought record only being introduced at the end of the session, it may have provided too little time to demonstrate its use effectively.
However, she seemed to understand the thought record homework without any further explanation in the session, and therefore, her not completing her homework may have been a preoccupation with her examinations, which seemed appropriate due to her grade level and number of subjects she was writing at the time. Further Discovery and Process [ TOP ] The significance of Sessions 3 and 4 was the beginning of the development of the therapeutic relationship. In Session 3, I found that our relationship was developing and Noluthando was beginning to open up.
I felt that perhaps as she was beginning to develop a relationship with me, she may have felt more able and willing to disclose how she was feeling and, therefore, was able to report how she often smiles even when she is not feeling okay. This was aided by the drawing that she completed, as it provided a space for her to communicate in an indirect way, as revealed in the below transcript.
Like when I went home on the weekend, long pausewas it Monday, no Tuesday pause, silence and mumbled voice I got home and my mother and father were arguing about the chicken.
They were both so angry strained voice and he just slapped her. I had to help carry her by her feet to the room. I thought she had taken the chicken. When my mother does something wrong she will cry and then stop. Otherwise she cries and will talk about it. This time silentshe cried and went to the neighbours afterwards. In Session 4, I felt that the therapeutic relationship was growing and that Noluthando was becoming more communicative in the therapy setting.
This was revealed by her being able to talk about her feelings and thoughts of failure. She opened up about feeling like a failure when she experiences her father abusing her mother and she takes no action, as revealed in the below transcript. One of the things I have noticed is how you mark past failures on the questionnaire BDI in every session.
Can you tell me a bit about this? You feel as though you could have done something? I could cover her and then my father would stop very quiet and mumbled voice. Although I experienced Noluthando as being more communicative, I was aware that she was battling with this but was trying.
I felt this because I could hear in her voice how emotional she was and yet how she did not avoid talking about the issue. In regard to her not completing the thought record, I felt uncertain of being more assertive with her not completing the homework exercise and battled with this.
Intuitively, I decided not to follow up on the homework in a confrontational manner, as I felt that doing so may break down any relationship that had developed. I felt a pull between following CBT techniques strictly and focusing on the relationship. I wondered whether CBT was necessarily the best choice for my client, as, although Noluthando understood CBT and how it was applicable to how her thoughts were impacting on her depression, I was unsure of the fit between myself, the techniques and the client.
Leahy describes how through the experience of the training of CBT, often emphasis is placed on technique and little attention is given to the therapeutic relationship, resulting in a misconception of the therapeutic relationship not needing much attention in CBT. I felt the need for emphasis to be on the therapeutic relationship so that communication could be opened between us.
A Change and Progress: Sessions 5 to 9 [ TOP ] Session 5 [ TOP ] Noluthando arrived 20 minutes late for her session as she reported that she was trying to help someone find a museum in the area. She was quite out of breath when she arrived for the session and was very apologetic. Noluthando was starting holidays and this was to be the last session for a number of weeks because of the long break due to the Soccer World Cup.
She wanted to during the time away from therapy work on her own and to do her own therapy. She wanted to work on her thought records she had completed the thought record homework from the previous session and reflecting. She reported that she was trying to pick up weight, was sleeping a bit better, and was feeling excited about the Soccer World Cup. Her BDI score reduced markedly to a score of 10 points. The score could be attributed to positive changes she was trying to make in her own life by trying to eat more and being more active in her daily life helping a stranger, etc.
Session 6 [ TOP ] Six weeks later extended school holidays due to Soccer World CupNoluthando displayed herself in a very introverted manner, she appeared down and her speech was soft, and almost inaudible.
Her mother moved out of the house and moved to a different town during the holiday and Noluthando reported not knowing why this had happened. I experienced her as being very closed off. I wondered if not hearing the bad referred to the fighting that she witnesses between her mother and her father. However, I battled to question this as Noluthando was very uncommunicative. When asking her how she felt about being at school, she said that she felt neither good nor bad about it.
This further revealed to me how she was attempting to prevent herself from feeling anything and provided understanding regarding why she was quiet, as she was blocking herself from feeling anything. She did reveal feeling positive about a play she would be auditioning for in the following week. I felt that although there was a closing down in communication, there was new insight gained into how she was trying to cope with difficult life issues and her use of suppression as a defence against hurtful feelings.
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- The Therapeutic Relationship in Cognitive-Behavioral Therapy and Pharmacotherapy for Anxious Youth
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The Therapeutic Relationship in Cognitive-Behavioral Therapy
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