Gopfert, M. and Barnes, B., 1995. The Therapeutic Relationship and Therapy Outcome. Reformulation, ACAT News Spring, p.x.
Michael Göpfert and Bill Barnes
It is well established that the quality of the therapeutic relationship is the one variable which predicts therapy outcome to a large degree (Horvath and Greenberg. 1994; Bergin and Garfield, 1994; Safran and Wallner, 1991). The therapeutic alliance is a complex construct which can be taken apart and looked at in a variety of ways. Safran and colleagues are currently exploring the question whether patients whose therapeutic relationship has shown indications of breakdown, as indicated by post-session questionnaire results, do better with a newly developed therapeutic modality which explicitly uses attention to ruptures of the therapeutic alliance as one of the main tools of therapy within a cognitive framework (Safran and colleagues, Annual Meeting of the American Psychiatric Association, Philadelphia, 1994).
Therapists with a Rogerian bias have for a long time claimed superiority aver therapists from other schools because of the emphasis on the empathic and accepting relationship as part of the therapeutic process.
Strupp and colleagues found that when training therapists in the use of a manualized approach, adherence to the therapy protocol was increased, but they also found that this was not necessarily accompanied by an improvement of the therapists’ capacity to develop a good therapeutic affiance with their patients. in some instances, the therapeutic alliance and hence therapy outcome actually seemed to deteriorate in the course of the training. They used Benjamin’s measures (SASS and INTREX) which give both a self report measure and scores derived from coding of observed interaction (Henry, Schacht and Strupp, l990, Henry, Strupp, Butler, Schacht and Binder, 1993; Henry, Schacht, Strupp, Butler and Binder, 1993).
Attachment theory has of late been seen as of increasing relevance to therapy and thinking about therapy. Metaphorically, the therapeutic relationship is understood by some people as a secure base, at least in its supportive function (Bowlby, 1977, Holmes, 1993; Dozier 1990, 1993). This can be seen as an extension of the use of the mother-child metaphor to describe the nature and quality of the therapeutic relationship. There is increasing evidence that a parent’s attachment classification as measured by the Adult Attachment Interview is a good predictor of children’s attachment status, which could be defined as an aspect of the parent-child relationship. This also applies to mothers and their unborn children! If attachment ratings can be such powerful predictors of relationship aspects it seemed of interest to see if this would also be the case for therapeutic relationships. Also, since there is evidence that attachment status changes as a result of - therapy (Steele and Fonagy, personal communication), this could also illuminate the question of therapy for therapists as part of their training. After all, psychoanalysis has long insisted that analysis is the main ingredient of analytic training. There was no direct evidence available in the literature, though Dozier and colleagues found some evidence in a study of case managers of psychiatric patients, that attachment status of clinician and patient may interact in predictable ways (Dozier, Cue and Barnett, in preparation).
Aim of the study
To test the hypothesis that a therapists attachment status as measured by the Adult Attachment Interview (Main and Goldwyn, 1994. George, Kaplan and Main, 1985) can predict the quality of the therapeutic affiance as measured by the SASS (Grawe and Benjamin, 1989, Benjamin, 1979, Benjamin, Foster, Roberto and Estroff, 1986) which in turn can predict therapeutic outcome.
Agreement from 30 therapists practising CAT will be sought within the UK, to participate in the study. Therapists will also have to collaborate in obtaining consent from their patients to have tape recordings or video recordings of sessions made and for outcome measures to be used for research purposes.
Adult Attachment Interviews will be recorded with each therapist and independently rated by a trained rater.
A session segment of 20 minutes selected for its clinical relevance, from the third therapy session will be analyzed according to the instructions of Grawe and Benjamin.
Patients and therapists will fill in the Intrex (Benjamin, 1983), and for patients’ outcome evaluation short versions of the UP (Horowitz, Rosenberg. Baer, Ureno and Villasenor, 1988) and SCL9O (Derogatis, 1983) will be administered before the beginning of therapy, at the end of therapy, and at six and 12 months follow-up. An additional established measure of the quality of therapeutic alliance like the Wisconsin Alliance Inventory is currently considered.
Therapy will follow the format of Cognitive-Analytic Therapy as described by Ryle (1990); therapists will either have completed their basic training or be in training All therapists will be in supervision (peer or training) with another CAT therapist.
Patients’ consent will be sought in accordance with the standards of ethics as approved by the relevant ethics committees. Therapists willing to participate will sign a consent form, also approved by relevant ethics committees. Also the prescribed procedure for the Adult Attachment Interview is that interviewees should be enabled to leave the interview in a state similar to the one they were in before the start of the interview.
A full path analysis of the data will be carried out, the details of which await specification.
It is anticipated that this will be supplemented at a later stage, depending on the outcome of the study proposed so far, with an evaluation of an intervention of therapists which will aim specifically to address attachment issues within a CAT framework.
We tried to recruit enough therapists including therapists from the Borderline Project, unfortunately we were unable secure a large enough sample for an application deadline by the end of January. We want to say thank you though to the enthusiastic response to our mailing which was very encouraging. We now aim to go for a larger grant, with a proper multi-centre study. This means that we need collaborators outside Liverpool. We reckon we need at least one other senior collaborator from London for the study to be feasible, but the more the merrier within limits. Anyone interested can contact us at
Liverpool Psychotherapy and Consultation Service
Liverpool L18 8BY
Tel (0151) 250-6128; Paz (0151) 729-0457
We are very grateful for the help of Jeremy Safran and Howard Steele in putting this together.
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A Randomised Controlled Trial of the Efficacy of CAT for the Treatment of Personality Disorder
Clarke, S., 2001. A Randomised Controlled Trial of the Efficacy of CAT for the Treatment of Personality Disorder. Reformulation, ACAT News Autumn, p.x.
The Experience Of The Psychiatric Interview Following Self-Harm
Nevison, C., 2000. The Experience Of The Psychiatric Interview Following Self-Harm. Reformulation, ACAT News Spring, p.x.
Measurements of change and their relationship to each other in the course of a CAT therapy
Gallagher, G., Inge, T., McNeill, R., Pretorius, W., Oâ€™ Rourke, D. and Wrench, M., 2009. Measurements of change and their relationship to each other in the course of a CAT therapy. Reformulation, Winter, pp.27-28.
A Study of Birth Stories and Their Relevance for CAT
Wilton, A., 1995. A Study of Birth Stories and Their Relevance for CAT. Reformulation, ACAT News Spring, p.x.
The Impact of Different Views of God in Therapy: Healing or Perpetuating the Split in the Split Egg
Melton, J., 1995. The Impact of Different Views of God in Therapy: Healing or Perpetuating the Split in the Split Egg. Reformulation, ACAT News Spring, p.x.
The Use of Transference in CAT: Refinement of a Proposed Model
Bennett, D., 1995. The Use of Transference in CAT: Refinement of a Proposed Model. Reformulation, ACAT News Spring, p.x.
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