Understanding Therapist Responsive Processes Gillian Hardy and Sari Saatsi University of Sheffield

26/04/2015© The University of Sheffield Therapist Responsiveness Therapist responsiveness: responding appropriately to differing client requirements, needs, circumstances Doing this appropriately to ensure the achievement of a specified goal or standard Focus at the micro level Therapist within-session behaviour Identify responsive patterns and events Within the context of client interpersonal styles and needs

26/04/2015© The University of Sheffield The Context Indicators of Responsiveness: Alliance Therapy completion Good outcome Appropriate responsiveness Client interpersonal style Therapist actions

26/04/2015© The University of Sheffield Leeds Depression Research Clinic Joint NHS and University research clinic Clients currently depressed sessions of Cognitive therapy Therapists UK trained clinical psychologists with additional CT training and weekly supervision Routine data collection including: BDI pre therapy and at each session Attachment measure pre-therapy Agnew Relationship Measure at each session

26/04/2015© The University of Sheffield Therapy Completion vs Non- completion Outcome differences 24/94 clients did not complete therapy. This group had poorer outcomes (BDI M= 14 vs. M 27) Alliance differences …and weaker alliances Interpersonal style.. And an overinvolved interpersonal style Clients with a underinvolved interpersonal style had poorer outcomes compared with other clients

26/04/2015© The University of Sheffield Study 1 : Understanding therapist actions with clients completing or not completing cognitive therapy for depression Aims How is adequate/lacking responsiveness reflected in client and therapist actions? How do therapists vary their responses based on clients’ interpersonal needs? Design Comparative qualitative, grounded theory analysis

26/04/2015© The University of Sheffield Study 1 Method Comparative 5 cell design 10 clients: 4 overinvolved; 4 underinvolved; 2 secure Matched (therapist and BDI scores) pairs: 4 who completed and 4 who did not complete therapy 7 women; age range Penultimate session of non-completer group (sessions 3, 3, 5 and 12) and matched session of completer group used for analysis

26/04/2015© The University of Sheffield Study 1: Findings SHARED HOPE Flexibility (Therapeutic boundaries, relationship strains) Continuity (Between sessions, beyond therapy, future gains) Connection (Understanding, participation) Ownership (Ownership, progress, avoidance and reliance)

26/04/2015© The University of Sheffield Study 1 Implications Tentative model of appropriate responsiveness: T Connection C Ownership T Flexibility Which together encourage a sense of Continuity, leading to Shared Hope.

26/04/2015© The University of Sheffield Study 2. CPA of Responsive Significant Event Aims To build a model of therapist responsive dialogue Looking at therapist actions, therapeutic processes and relevant contextual factors Design In-depth analysis of a significant event that provided an example of themes developed in the previous study

26/04/2015© The University of Sheffield Study 2 Background The alliance Strains in the relationship Responding to ruptures Pushing for change Working within the client’s Zone of Proximal Development (ZPD)

26/04/2015© The University of Sheffield Comprehensive Process Analysis (CPA) Detailed interpretive procedure for describing significant events systematically CPA framework: Implicit meanings of the event are expanded Context described (background, pre-session, session and episode Event process Impact of the event

26/04/2015© The University of Sheffield Case Selection and Event Client Exemplified categories from Study 1 Intake BDI = 32, End of therapy = 12; Secure interpersonal style Event Helpful Aspects of Therapy Form (HAT) Rated as ‘Greatly Helpful’ (3 on a 4-point scale) Therapist skill rated 6 (1=poor to 7=excellent) “Working on my need to say ‘yes’ or why I can’t say ‘no’ in my work environment.”

26/04/2015© The University of Sheffield Significant event T: So there is this very helpful part of you that enjoys helping people and… C: Oh I love it. I mean its…. T:..and has always tended to do that, but maybe the key of it is that combined with unreasonable work demands, has been part of what has led to C: I should have just shut up and listen to you, shouldn’t I, (laughs) because it’s exactly it, isn’t it T Well, no, but it sounds like maybe that’s the key, because, it’s combined with that that has led you to--find it hard to look after yourself… C: Which I have to impose myself, because I’m being driven there, but the only way to drive there is for me to drive it T: -and being in the situation where you can’t actually meet that personal rule

26/04/2015© The University of Sheffield Study 2: Proposed Model. T Reflection on C’s central wish C interrupts T and agrees C feels supported Involved T interrupts C and introduces new element to problem C experiences loss of control C interrupts T and threatens to disengage C feels pressure and control by T Distancing from T

26/04/2015© The University of Sheffield continued. T acknowledges C’s anxiety. Suggests remain with issue C reassured and contained by T C relieved and re-engages C elaborates T’s explanation Insight T supports C’s insight C feels understood and supported Increased self awareness

26/04/2015© The University of Sheffield Effects of the Event Session effects Exploration of factors maintaining Cs need to say yes C states need to understand this issue more as is anxious about implementing new understanding outside of therapy Delayed effects In subsequent sessions issue returned to, including: “If I say no I’ll be punished’ (underlying assumptions) and “My needs aren’t important’ (core beliefs) Later C reports being able to ask for help and negotiate Post treatment C stated helping him say no as very important

26/04/2015© The University of Sheffield Summary Differences in tone of sessions between clients who completed and those who didn’t. Grounded theory analysis leading to model of appropriate responsiveness This then explored in CPA of significant event, providing support at the moment to moment level for the model.