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Howard E. Book changed his mind about brief psychodynamic therapy because

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1) Traditional long-term psychodynamic psychotherapy was receiving less attention than other forms of therapy in training programs and was in danger of becoming obsolete. 2) Therapists from all theoretical orientations were feeling the impact of managed care with it's cost effective perspective. 3) Book four that brief psychodynamic psychotherapy could retain some of the psychodynamic concepts and techniques that he valued.

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Who created Core Conflictual Relationship Theme Therapy?

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Lester Luborsky (1975)

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CCRT is

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a manualized treatment of a brief psychodynamic model that has received research support.

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CCRT therapy is

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*A form of supportive-expressive psychodynamic therapy. *It emphasizes: 1) lasting effects of early childhood experiences on adult functioning 2) the power of Unconscious motivation in directing behavior. 3) the tendency towards Repetition compulsion: -- the need to repeat, re experience, and reenact traumatic memories, in an effort to master them. 4) the Transference phenomenon

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CCRT -- As a...

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*Interpersonal form of psychodynamic therapy. -- the therapist takes supportive stance (empathy, respect and support) *A Collaborative relationship is established as the therapist and client work together to identify the problem and develop treatment goals. *These supportive aspects or CCRT contribute to: -- therapeutic alliance and -- success tx outcomes

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CCRT employs two main classes of techniques

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1) Supportive 2) Expressive

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In CCRT the supportive techniques pave the way for use of more psychodynamic expressive techniques by

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*Creating an atmosphere in which clients can more freely express their thoughts and feelings.

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Expressive techniques are

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1) interpretation 2) confrontation 3) clarification *Used with the purpose of allowing repressed or unconscious material to surface

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An important part of CCRT is the identification of

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Transference issues involved with the client's current relationship problems. Ones the client understand the underlying reasons of their discomfort or unhappiness, they can begin to exert more control over their emotions.

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CCRT is *not*

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*empirically supported but research has shown the constructs of the CCRT method and their reliability. *There is empirical support for supportive-expressive psychodynamic psychotherapy. *Luborsky used scientific method and emphasized therapeutic alliance. *Luborsky also emphasized use of the therapist-client relationship enhancement through collaboration and support. (--strengthening the therapeutic alliance)

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*Theoretical bases for CCRT Method* Method: -- CCRT therapy is a brief psychodynamic method based on the hypothesis that:

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1) Current adult relationship problems are the result of repressed and unresolved negative childhood experiences. 2) Interaction with others may trigger these unconscious conflicts, which leads to maladaptive patterns. 3) Luborsky believed that identifying these patterns provides for an understanding of the specific underlying parent child conflict.

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Method: -- Once the CCRT has been identified, the problem is then interpreted as resulting from?

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a transference reaction. (transferring these childhood-based issues into current situations)

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Methods: -- Transference reaction impacts:

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current relationships, including the client-therapist relationship, and resembles patterns of behavior learned with parents of other caretakers.

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Method: -- Once the unconscious pattern is identified:

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the therapist can assist the client in becoming aware of the original childhood relationship issues that have led to problems in current relationships.

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Method: -- It is first necessary for the therapist and client to identify:

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*the core conflictual relationship theme (CCRT)* *(the unconscious pattern or schema that the client uses in certain relationships or in interpersonal situations.)*

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To ID the CCRT:

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the therapist must carefully listen to the client's description of interactions with other people, called *relationship episodes (REs)*, and from these generate possible core themes.

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CCRT can be determined by examining three aspects of the relationship episode (REs = the conflicted interpersonal communication)

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*1) Wish (W)* -What the patient wanted from the other people/interaction. -What he or she want to say or do in a specific interaction with another. *2) Response form the other person (RO)* -How the other person reacted. -Can be anticipated or imagined or an actual event. -The actual or anticipated response from the other individual. *3) Response of the self (RS)* -How the patient reacted to their reactions. -both a behavioral element and emotional element. -How the client behaves and feels at the end of the relationship episode.

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Examples of *Wish (W)* - Table 7.1

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- wanting to speak up - to be close and accepted - to be the center of attention - to be loved and understood - to achieve and help others - to be distant and avoid conflics

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Examples of *Response from other person (RO)* - Table 7.1

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- Imagined = fearing rejection - Actual event = receiving rejection from someone - helpful - likes me - understanding - strong - controlling - upset - anger - rejecting and opposing ***What is critical about ROs is the subjective evaluation of the interaction from the perspective of the client, rather than whether or not the rejection actually occurred. ***ROs are based on the client's subjective reaction and may not be based in reality.

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Examples of *Response of the Self (RS)* - Table 7.1

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- Behavioral element = what the client does in the situation - Emotional element = how they felt - helpful - respected and accepted - self-controlled and self-confident - anxious and ashamed - disappointed and depressed - unreceptive - helpless

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The goal of the CCRT method is on

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1) symptom relief with a primary focus on the one aspect of the patient's maladaptive style most clearly associated with the presenting problem.

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Clients appropriate for CCRT

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1) must have good ego strength 2) adequate reality testing 3) impulse control 4) frustration tolerance 5) adaptive defenses 6) Insightful and motivated 7) have the ability to engage in therapy 8) see connections between present and past events

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*Supportive element necessary for a strong therapist client bond* The task to be of primary importance in CCRT:

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*Establishing a strong therapist-client bond.* -- This enables the client to more easily deal with anx-provoking or threatening material, and opens a path for the use of expressing techniques

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A good working relationship involves the therapist:

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1) Establishing a collaborative relationship with the client 2) Working with the client so they both have a similar understanding of the problem. 3) Encouraging the client to believe that the intervention will be helpful 4) Ensuring that the client feels understood by the therapist. 5) Helping the client maintain optimism that the therapy will work 6) Acknowledging the positive changes occurring during therapy. **This is a critical first step.

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How can the therapist display the specific supportive elements encouraged in CCRT Tx?

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- therapist verbally and non verbally convey respect - support the client's desire to accomplish identified goals - understanding and accepting the client - therapist to communicate a belief that tx goals are achievable - affirmation as client gains skills

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Expressive techniques: listening and identifying the relationship episodes

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*The therapist is looking for episodes that represent a conflict between what the client hopes or wishes for in a relationship and what the client is experiencing. *After collecting a number of RE's, the therapist reviews each with the help of the client with an emphasis on identifying: 1) The clients wish (W) 2) Response from others (RO) 3) Response to the self (RS)

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The therapist can write down the

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REs and its components as they are discussed in session with client. *After review of multiple REs, a common or overarching theme often emerges. *This the is identified at the "core" since it lies in the heart of the client's sx and interpersonal difficulties, and represents the repetitive, interpersonal concern that brings the client in for tx.

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Regressive wishes

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Unhealthy or destructive wishes * Therapist would interpret this wish as a response from the self (RS) and the therapist would search for a progressive wish (a wish that involve appropriate adult behaviors). ** it is always necessary to ID and reinterpret regressive wishes before therapy proceeds. Examples= - wanting to isolate oneself - be overly independent - to retaliate against or injure someone

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Progressive wish

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A wish that involve appropriate adult behaviors.

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How to identify the core conflictual relationship theme/steps in identifying:

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1) Listen and write down each relationship episodes mentioned 2) Therapist analyzes each episode for and understanding of the W, RO, RS/Generate possible core themes. (in unclear, utilize f/u questions) 3) Therapist Evaluates the set of narratives to determine possible CCRT and then present to client for consideration and feedback. **MUST have at least 5-10 REs and their corresponding W, RO, RS before CCRT is identified. 4) Therapist and client work together to determine if the theme is important to to be emphasized during tx. - If CCRT is confirmed by client, this focus usually becomes a treatment goal. - Therapist works w/client to find other possible themes.

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*Therapeutic goals with CCRT*

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1) Help the client obtain sx relief by actualizing the wish (W), that is behaving in a manner that results in the need being met. 2) Helping clients become more aware of the source of their conflict. Recognizing the pain of past memories/working through defenses.

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How to actualize the wish

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*Behaving in a manner that results in the need being met. *The actualization of a wish can occur when a client begins to understand the RO as either a transference phenomenon or a repetition disorder

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*Transference* interpretations focus on:

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allowing clients to see that the anticipated response from others is due to expectations developed during childhood

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Transference issues involving the client and therapist are referred to as:

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Enactments - Can be most therapeutic because they involve the here and now interaction.

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*Repetition disorder/compulsion*:

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a maladaptive behavior pattern in which a client behaves in a manner that actually elicits negative responses from others.

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Before client can master early childhood experiences, clients must understand

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how the CCRT relates to their unhappiness or psychic pain.

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The process involves learning more about how the CCRT is present in problematic interactions with:

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1) Current family members, friends, coworkers, or others 2) Past relationships with early caregivers 3) The relationship between the therapist and the client. (GREATEST THERAPEUTIC POTENTIAL b/c in involves a here and now experience.)

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Problematic patterns that appear in the client-therapist relationship provide an opportunity for exploration of the CCRT...

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Maladaptive behaviors are interpreted as coping attempts; once clients understanding this, they can begin generating alternate and more productive responses.

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After ID and agreeing on the CCRT's:

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The real work of CCRT begins: Now we concretely demonstrate how the current attitudes and behaviors towards others are produced by unresolved childhood experiences.

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Successful understanding of the CCRT in current relationship problems is demonstrated when the client shows increased:

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1) Ability to see current relationship problems as aspects of the CCRT 2) Understanding of how he or she contributes to relationship problems rather than blaming communication problems on others. 3) Recognition of the power of the core relationship theme and its association with other relationship issues. 4) Insight into how the CCRT originated from early childhood experience.s 5) Understanding of how the behavior produced by the CCRT can also result in reinforcement as a secondary gain, such as receiving sympathy or attention from other people. 6) Skill in generatING alternative bx when confronted with situations that reflexively bring up the CCRT.

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How many phases are there in CCRT therapy

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* 3 phases *16 sessions (50 min each)

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Phase 1 - Sessions 1-4

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Involves: - assessment, - identifying the CCRT with the client, - determines the goals of therapy, - and providing the treatment rationale.

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Phase 2 - Sessions 5-12

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*The primary focus is: working through the RO by examining the childhood roots of this pattern. *The Response from others is interpreted as the transference of unconscious attitudes and behaviors derived form past relationships with parents or caregivers. *The transference perspective is offered every time the clients bring up a problematic relationship issue. *Therapist weaves current problems with similar issues from the past *Enactments (the transference displayed to the therapist) are especially valuable for learning during this phase.

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Phase 3 - Sessions 13-16

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*Deals with termination issues.

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