Workshop at the 2nd EATA Transactional Analysis Research Conference, Putteridge Bury Conference Centre, Luton, UK 12-13 November 2012

The mutually beneficial process of research and practical work.

PhD Roland Johnsson

How to stimulate practitioners to be interested in research?

Workshop overview

• Lecture about George Strickers Scientist – Practitioner Model (S –R Model)

• Lecture from my research about Alliance and especially how to use the CCRT, Core Conflictual Relational Theme Method by Luborsky.

• Exercise by observing a therapy roleplay and coding from the Standard CCRT Categories (Barber, Crits-Christoph & Luborsky, 1990, pp 45-49)

The practitioner as a ”Scientist-Practitioner” or the ” Local Clinical Scientist” (Stricker, 2000; Stricker & Trierweiler, 1995) by building a bridge beteween two different attitudes connected to the scientist and the practitioner.

• Two different attitudes

Idiographic approach Nomothetic approach• Specify Generalize• Human science Natural science• Subjective Objective• Unique life history Laws, Patterns, Traits• Discover Confirm• Process Effect• ”Frog” perspective ”Eagle” perspective• Qualitative Quantitative

The Scientist-Practitioner Model

The affective dimension of alliance in transactional analysis psychotherapy

Roland Johnsson och Gunvor Stenlund

International Journal of Transactional Analysis Research Vol 1 No 1, July 2010

Article available on: www.ijtar.org

Research article about alliance

Questions posed How can the affective relational patterns of different

clients be characterized?

To what extent do these patterns manifest themselves in the relations and interactions between the client and the therapist?

How does the therapist deal with the client when the latter displays behaviour reflective of such relational patterns?

Investigated material

• Transcriptions of 24 videorecorded sessions

• Strategic selection: 10 sessions of 24 representing beginning, middle and end of the therapy.

• Randomised selection: 5 of 10 clients

Outcome factors in psychotherapy

Common fac-tors; 30%

Techniques; 15%

Expectancy; 15%

Extratherapeu-tic change;

40%

From Lambert and Berley (2002) and Norcross and Lambert (2011)

Outcome variance in psychotherapy

Unexplained variance; 40%

Patient contribu-tion; 30%

Therapy rela-tionship; 12%

Treatment method; 8%

Individual ther-apist; 7%

Other Factors; 3%

From Norcross and Lambert (2011)

The Alliance concept (common terms)

Alliance refers to the quality and strength of the collaboration between the client and the therapist in the therapy.

The concept includes: Positive affective bonds as mutual liking,

trust, respect and caring.Mutual agreements and commitments

about the goal and ways to reach it.

The Alliance concept (History) No universal definition

Freud origin (1912) who stressed the positive transference relationship.

Sterba (1934) ego-alliance, stressed the reality-testing, observing ego

Greenson (1965) ”working alliance” and ”therapeutic alliance”

Henry, Strupp, Schacht & Gaston (1994) Different views: Rational or Emotional

Stenlund (2002) Describes alliance in affect-theoretical terms (Tomkins, Luborsky)

Bordin (1976) stressed it as a pan-theoretical umbrella concept

ALLIANCE (Bordin, 1979)

· Agreement about TASK and GOAL of the therapy

· Emotional BOND

Four dimensions Working alliance - COLLABORATION Therapeutic alliance - BONDING Therapists empathy - ACCEPTANCE Therapeutic contract - GOAL

Two dimensions of alliance

· Agreement about TASK and GOAL of the therapy

Emotional BOND

Rational level

Affective level

Transactional Analysis therapy (TA)

• Stresses the Rational level

Following an egopsychological tradition the TA therapist adresses the clients reality-testing, concious part (Adult) to collaborate in dealing with the unconcious irrational (affective) parts (Script-bound Child).Rational here doesn´t mean lack of feelings.

Defining TA as rational• Berne’s original critique of a traditional psychoanalytic approach

has contributed to efforts to reduce the role of spontaneous regression in therapy and thus the time it requires as well.

• This has been accomplished by use of various techniques and approaches that encourage active, conscious choices on the part of the client.

• Choices leading to treatment goals expressed in the treatment contract. The emphasis in the TA method has thus shifted from that of long-term efforts involving what are often unarticulated, emotional and chaotic transference relationships to that of observable patterns of behaviour and manifest signs of unconscious communication processes.

The TA Redecision Approach in short

• Contracts (mutual agreement)• Double-chair (contractual regression)• Experential techniques (tasks, exercises)• Responsibility model (Autonomy,

Change)• Short-term psychotherapy

Methodological Design

• Individual reading and coding• Common discussion and

assessments to consensus• Reliabilitytest: Two separate sessions

Operative Approach• Identify Relational Episodes (RE)• Code all components into tailor-made

categories. • Transfer this to Standard categories.• Formulate every clients CCRT• Identify enactments (= test)• Code therapists response on the

”tests”

To measure the affective interaction

CCRT Core Conflictual

Relational Theme

Luborsky, L. (1990)

Plan-diagnosis method

Weiss, J. & Sampson, H. (1986)

METHODS

How the methods are used

CCRT Identify affective relational patterns

Plan-diagnosis method

Investigate how therapist is respondonding to clients ”pathological” beliefs (plan).

CCRT – Core Conflictual Relationship Theme

Class A Class B

W = Wishes, needs, intentions

RA and RS = Controlfunction that stops the client from satisfying his wish.

Repetetive patterns in the clients narratives that often are in conflict with each other.

Two classes of components

RA = Response from OthersRS = Response from Self

The Plan-diagnosis method Hypothesis

Client is testing

TherapistRefutes

(successful)

Anxiety decreases

CHANGE

Result

• Identified 176 RE (Relational Episods)• Coded 539 CCRT components (W,RA,RS)• Identified 44 Enactments• Enactments that matched the clients CCRT(”test“) 35• Therapist refuted “successful” 24½ tests• Therapist confirmed“failed” 10,5 tests

Numbers of CCRT components (W, RA & RS)

  Numbers of CCRT components 

Client Wish (W)

Response from Others

(RA)

Response from Self

(RS) Total

Agneta 18 19 43 80

Barbro 30 29 61 120

Daniel 26 28 55 109

Erik 45 31 72 148

Harriet 17 24 41 82

Totalt 136 131 272 539

Total numbers of RE and Enactments and the numbers that match the clients individual CCRT

(”test”).

Note. The clients individual CCRT is decided from at least one of the CCRT W, RA and RS

Client RE Enactments

Individual CCRT

(”test”) Agneta 35 13 8Barbro 46 12 10Daniel 31 12 11Erik 38 2 2

Harriet 26 5 5Total 176 44 35

Therapists response to the clients”test”

Client ”test” failed successfulAgneta 8 3 5Barbro 10 4 6Daniel 11 2 9Erik 2 0 2

Harriet 4 1,5 2,5Total 35 10,5 24,5

Qualitative data

•To give a deeper understanding of the affective interaction our interpretation procedure is shown

from two examples

•Client Agneta when therapist fails in the ”test”

•Client Daniel when therapist succeed in the ”test”.

Exampel when therapist fails in the ”test”.

• Quotation, page 52 (session 4, RE 1). • Agneta: “I feel awfully afraid. I’m having heart

palpitations. They came from your forcing me to decide what I wanted to take up today....begin... (Therapist: Mm) It feels almost as though I’d decided to make a speech, that I was forced to do something, as though others were dependent on me in some way (.) Earlier in the week, though, I thought a lot about what I could bring up and that sort of thing. I’d still like to, although I feel afraid...”

• Therapist: “Will you only try, or do you plan to do it?”

Clients (Agnetas) individual CCRT

• W: To assert myself, To be helped• RA: Are controlling, Are rejecting• RS: Am not open, Somatic symptoms

Our interpretation(of the”test” between the therapist and client

Agneta)

• The therapist is maintaining control and is trying to steer. His response is at a rational level. He should instead have acknowledged her anxiety and fear, as well as her heart palpitations – and thus have responded at an emotional level so as to give her the possibility of steering on her own, and in that way have provided her the possibility too of asserting herself.

• Events following the test. Agneta responds in an abrupt way, saying she wants to talk about that later on in the therapy. Acting as though she’s clenching her teeth, she says,...”I was forced to be strong just now.”

Exampel when the therapist is successful with the ”test”

• Quotation, page 54 (session 19, RE 11) • Daniel: “Yes, but I’m wondering why you’re smiling the way you

are.”• Therapist: “How do you feel?”• Daniel: “I was set back a little by the way you smiled. I don’t know

what it was, but I felt a little bit irritated at it.”• Therapist: “Yes, I smiled feeling that it was somewhat exaggerated,

and realizing that you were experiencing it that way.”• Daniel: “That’s what I felt, that it wasn’t completely as it should

be.”• Therapist: “I was being ironic. What do you think of that.”• Daniel: “About being ironic in general?” • Therapist: “No, about what I did.” (laughter)• Daniel: “No, it was okay...” (laughter generally and small talk)

• continuing next picture

Continuing: Daniel

• Daniel: “It was dirt-cheap too. It didn’t cost much of anything. In that connection, I like it a lot, if it gets me to stand up for what I want. I realize very much that I need to do that, and take advantage of the little bit I’ve gotten here, things aren’t neutral any more, but I feel something for it all. That’s really important, as I see it. Feeling for things...”

• Therapist: “I don’t want to seem rejecting of you to make you feel that way.”

• Daniel: “That I understand perfectly well. It doesn’t seem that way at all. I sensed that I understood the meaning of feeling for things generally.”

• Therapist: “Good. How do you feel now?”

Clients (Daniels) individual CCRT

W: To be open, To be understoodRA: Are controlling, Are rejectingRS: Feel anxious, Feel angry

Our interpretation(of the”test” between the therapist and client

Daniel)Daniel dares to question the approach the therapist takes

and to test him still further, possibly because the therapist, in connection with Daniel’s earlier testing of him, repaired and thus strengthened the alliance between them. In the case considered here, Daniel becomes upset at the therapist’s smiling at him, making him feel that he was being mocked. The therapist again repairs the alliance through admitting he had done it in ironic intent. The therapist is able to show that even this seeming triviality is meaningful – that Daniel dared to open himself up in connection with it. The repair the therapist performs then makes the contact between them still closer than before.

Conclusion In TA therapy rational aspects of alliance are

emphasized. The results of our study showed that affective

dimensions of alliance played a considerably stronger role than would be expected if alliance were based on a predominance of rational considerations.

It appears that emotional aspects of the alliance between the client and the therapist represent an important factor in TA therapy.

Results of the study thus appear to be of clear clinical relevance to transactional analysis psychotherapy.

The number of ”tests” is the same as in individual

psychodynamic short-term therapy (Stenlund, 2002) which means there are no difference if you emphasis a rational or an affective approach.

The affective dimension of alliance is an important part of TA therapy, even if its not emphasised.

It´s not possible to reduce the affective elements. Maybe the rational perspective only can be reached from an affective interaction = Are the affects the primary motivational force (Tomkins)

Clinical implications

ExerciseObserving a roleplayed therapy session for 10 minutes from a scientifical ”Eagle-perspective”

Using the CCRT components Wish (W), Response from Others (RO) and Response from Self (RS) from the lecture to code and analyze the client.

Using the Standardized Categories and Classification to code the CCRT of the client.

A Guide to the CCRT Standard Categories and Their Classification

Standard CCRT Categories (Edition 2) (Barber, Crits-Christoph & Luborsky, 1990. In Understanding Transference: The Core

Conflictual Relationship Theme Method, (pp. 45-49). New York: Basic Books.

. 1 To be understood. To be comprehended; to be empathized with; to be seen accurately. • 2 To be accepted. To be approved of; to not be judged; to be affirmed. • 3 To be respected. To be valued; to be treated fairly; to be important to others. • 4 To accept others. To be receptive to others. • 5 To respect others. To value others. • 6 To have trust. Others to be honest; others to be genuine; • 7 To be liked. Others to be interested in me. • 8 To be opened up to. To be responded to; to be talked to. • 9 To be open. To express myself; to communicate. • 10 To be distant from others. To not express myself/my feelings; to be left alone. • 11 To be closed to others. To be included; to not be alone; to be friends. • 12 To help others. To nurture others; to give to others. • 13 To be helped. To be nurtured; to be given support; to be given something valuable; to be protected. • 14 To not be hurt. To avoid pain and aggravation; to avoid rejection; to protect/defend myself. • 15 To be hurt. To be punished; to be treated badly; to be injured. • 16 To hurt others. To get revenge; to reject others; to express anger at others. • 17 To avoid conflict. To compromise; to not anger others; to get along; to be flexible. • 18 To oppose others. To resist domination; to compete against others. • 19 To have control over others. To dominate; to have power; to have things my own way. • 20 To be controlled by others. To be submissive; to be dependent; to be passive; to be given direction. • 21 To have self-control. To be consistent; to be rational. • 22 To achieve. To be competent; to do well; to win. • 23 To be independent. To be self-sufficient; to be self- reliant; to be autonomous. • 24 To feel good about myself. To be self-confident; to accept myself; to have sense of well-being. • 25 To better myself. To improve; to get well. • 26 To be good. To do the right thing; to be perfect; to be correct. • 27 To be like other. To identify with other; to be similar to other; to model after other. • 28 To be my own person. To not conform; to be unique. • 29 To not be responsible or obligated. To be free; to not be constrained. • 30 To be stable. To be secure; to have structure. • 31 To feel comfortable. To relax; to not feel bad. • 32 To feel happy. To have fun; to enjoy; to feel good. • 33 To be loved. To be romantically involved. • 34 To assert myself. To compel recognition of one’s rights. • 35 To compete with someone for another persons affection.

Table 1, Wishes, Needs, Intentions

Table 2. Responses from Others.

• 1 Are understanding. Are empathic; are sympathetic; see me accurately. • 2 Are not understanding. Are not empathic; are unsympathetic; are inconsiderate. • 3 Are accepting. Are not rejecting; approve of me; include me. • 4 Are rejecting. Are disapproving; are critical. • 5 Respect me. Treat me fairly; value me; admire me. • 6 Don’t respect me. Don’t treat me fairly; don’t value me; don’t admire me. • 7 Don’t trust me. Don’t believe me; are suspicious of me. • 8 Are not trustworthy. Betray me; are deceitful; are dishonest. • 9 Like me. Are interested in me. • 10 Dislike me. Are not interested in me. • 11 Are open. Are expressive; are disclosing; are available. • 12 Are distant. Are unresponsive; are unavailable. • 13 Are helpful. Are supportive; give to me; explain. • 14 Are unhelpful. Are not comforting; are not reassuring; are not supportive. • 15 Hurt me. Are violent; treat me badly; are punishing. • 16 Are hurt. Are pained; are injured; are wounded. • 17 Appose me. Are competitive; deny/block my wishes; go against me. • 18 Are cooperative. Are agreeable. • 19 Are out of control. Are unreliable; are not dependable; are irresponsible. • 20 Are controlling. Are dominating; are intimidating; are aggressive; take charge. • 21 Give me independence. Give me autonomy; encourage self-direction. • 22 Are dependent. Are influenced by me; are submissive. • 23 Are independent. Are self-directive; are not conforming; are autonomous. • 24 Are strong. Are superior; are responsible, are important. • 25 Are bad. Are wrong; are guilty; are at fault. • 26 Are strict. Are rigid; are stern; are severe. • 27 Are angry. Are irritable; are resentful; are frustrated. • 28 Are anxious. Are scarred; are worried; are nervous. • 29 Are happy. Are fun; are glad; enjoy. • 30 Loves me. Is romantically interested in me.

Table 3. Responses of Self. • 1 Understand. Comprehend; realise; see accurately. • 2 Don’t understand. Am confused; am surprised; have poor self-understanding. • 3 Feel accepted. Feel approved of. • 4 Feel respected. Feel valued; feel admired. • 5 Like others. Am friendly. • 6 Dislike others. Hate others. • 7 Am open. Express myself. • 8 Am not open. Am inhibited; am not expressive; am distant. • 9 Am helpful. Am supportive; try to please others; am giving. • 10 Hurt others. Am violent; act hostile. • 11 Oppose others. Am competitive; refuse/deny other; conflict with others. • 12 Am controlling. Am dominating; am influential; manipulate others; am assertive; am aggressive. • 13 Am out of control. Am irresponsible; am impulsive; am unreliable. • 14 Am self-controlled. Am responsible. • 15 Am independent. Make my own decisions; am self-directive; am autonomous. • 16 Am dependent. Am submissive; am passive. • 17 Am helpless. Am incompetent; am inadequate. • 18 Feel self-confident. Am or feel successful; feel proud; feel self-assured. • 19 Am uncertain. Feel torn; am ambivalent; feel conflicted. • 20 Feel disappointed. Am not satisfied; feel displeased; feel unfulfilled. • 21 Feel angry. Feel resentful; feel irritated; feel frustrated. • 22 Feel depressed. Feel hopeless; feel sad; feel bad. • 23 Feel unloved. Feel alone; feel rejected. • 24 Feel jealous. Feel envious. • 25 Feel guilty. Blame myself; feel wrong; feel at fault. • 26 Feel ashamed. Am embarrassed; feel abashed. • 27 Feel anxious. Feel scarred; feel worried; feel nervous. • 28 Feel comfortable. Feel safe; am or feel satisfied; feel secure. • 29 Feel happy. Feel excited; feel good; feel joy; feel elated. • 30 Feel loved. • 31 Somatic symptoms. Headache; rash; pain.