Relational and Interviewing Skills for Assessment and Formulation in Cognitive Behavioral Practice

Contents

Introduction

The Client

Establishing a collaborative relationship

Unconditional Positive Regard

Empathic Listening

Open-Ended Questioning

Close-Ended Questioning

Clarification Questioning

Paraphrasing and Reflecting Meaning

Self-Disclosure

Information Giving Response

Summarizing statements

Paraphrasing and Reflection of Feelings

Transference and Counter-Transference

Attending Skills

Summary of Therapist’s Performance

Recommendations

References

Introduction

Research suggested that therapist interpersonal skills facilitate therapy processes and good client-therapist collaboration (Norcross, 2002,p.7-9). Therapeutic relationship is a helpful and positive relationship, whereby a client is reliant on the therapist’s help (Coyle & Doherty, 2013, p.1). The helper relational skills include empathy; genuine, receptive, good communicator and can reflect client’s feelings and thoughts accurately without prejudice (Prasko et al., 2012, p.72). In a person-centered approach, the therapist creates therapeutic conditions based on cognitive behavioural therapy (CBT) framework and evidence based treatment models (Beck, 1976 as cited in Gonzales-Prendes, 2012, p.3). Unlike other talking therapies, the person-centered CBT instills client’s collaboration and determination in making choices about the therapeutic process. The declarative, procedural and reflective (DPR) model provides theoretical guidelines for CBT therapists important in acquiring and maintaining the technical and relational skills throughout their profession (James Bennett-Levy’s, 2006, p.58). The DPR framework is an information-processing model, within which interpersonal flexibility, conceptual knowledge and technical skills are core components vital in establishing developing and maintaining a therapeutic relationship with the client (Bennett-Levy, 2006, p. 63). Client-therapist inter-personal variables, perspectives about CBT and cultural differences risk causing ruptures in the collaborative efforts (Harmon et al., 2007, p.380). Hence, a good interviewing skill that conveys empathy, congruence and unconditional positive regard can be used to clarify underlying problems, build confidence, trust, commitment to therapy and motivation to carry out CBT tasks and treatment (Vyskocilova, Prasko & Slepecky, 2011, p. 74). Reflective practices and Socratic supervision help therapists to identify their strength, limitations and respond effectively (Bennett-Levy, 2007, p.68).

Accordingly, this essay evaluates the therapist’s relational and interviewing skills in conducting CBT assessment critical in establishing, developing and maintaining a therapeutic relationship with the client.

The Client

The client presented to CBT assessment with anxiety related problems. From one point of view, the client has put in enormous efforts to perform in an office presentation. On the other, she is feeling a loss of confidence following a poor presentation session in front of a four member-interviewing panel and nine other colleagues. The client felt performance anxiety is stopping her from job promotions.

Establishing a collaborative relationship

The therapist’s observation, reflection, understanding, and performance were by the CBT framework. The session began with the therapist greeting the client to establish rapport (Clip 1 at 11 seconds0. Establishing rapport is crucial specifically when clients are new to the CBT process. He introduced the assessment process as constructed by CBT framework (Clip 1 at 4 minutes and 39 seconds). Collaboration in CBT involves a structured procedure in which the client and the therapist had to work together to establish collective treatment goals (Dattilio & Hanna, 2012, p.1). By orienting the client to the structured nature of CBT, the therapist was able to guide the client towards a collaborative empiricism. Positive collaboration mediates beneficial change and treatment outcome. Unstable client-therapist relationship discourages clients from pursuing future or subsequent sessions (Dattilio & Hanna, 2012, p. 2).

Unconditional Positive Regard

By conveying unconditional positive regard, the therapist is seen to gather detailed information pertaining to client’s concern (Clip 1 at 7 minutes and 43 seconds), expectancies (Clip 2 at 2 minutes and 7 seconds), intentions (Clip 1 at 5 minutes and 50 seconds), motivation (Clip 1 at 1 minutes and 57 seconds) and hope for change (Clip 2 at 3 minutes and 45 seconds). According to Rogers (1962, as cited in Wilkins, 2000, p.26) respect is an attitude that conveys unconditional positive regard and acceptance of others regardless of their behavioral disposition. Rogers (1962, as cited in Wilkins, 2000, p.27) proposed that communication that conveys non-judgmental and appreciation facilitates conditions for goal negotiation, educating clients about therapy and instills hope.

Empathic Listening

The therapist ability to engage in empathic listening is observable through his questioning and responding skill. Active listening is a process, which involves empathy and understanding to elicit information about client’s distressful experiences (Thwaites & Bennett-Levy, 2007, p.595). According to Thwaites and Bennett-Levy (2007, p.595), active listening permits both the client and the therapist time to reflect and respond in a meaningful way and at the same time, enhances client-therapist alliance. For therapists, it helps to prevent forming a premature evaluation and judgment biases about client’s distress. For the client, it shows the therapist is genuinely interested in helping (Bennett-Levy, 2007, p.604). Empathy involves cognitive perspective taking to tune into client’s inner experiences and problems (Thwaites & Bennett-Levy, 2007, p.593). By tuning into client’s experiences, the therapist helps lessen the client’s psychological burden by transforming problematic thoughts to an objective perspective needed for healthy change (Rogers, 1967 as cited in Thwaites & Bennett-Levy, 2007, p. 594). Empathy also stimulates an authentic atmosphere for interaction to transpire which is essential to the maintenance of trust in a collaborative relationship (Thwaites & Bennett-Levy, p.594). Empathic listening involves accurate reflection of emotions and the underlying meanings (Thwaites & Bennett-Levy, p. 594). Socratic questioning such as paraphrasing, open, closed-ended and summarizing are some of the interviewing skills that facilitate in the delivery of therapeutic empathy (Thwaites & Bennett-Levy, p.597).

Open-Ended Questioning

Open-ended questioning involves collaborative discussion, whereby the client is lead through a guided discovery process (Paul & Elder, 2006, p.24). The guided discussion allows the client to reach own conclusions whether to reconsider previously held assumptions or reconstruct a new one (Paul & Elder, 2006, p.24).

Some example where the therapist conveyed genuine interest to tune into client’s emotional content by using open-ended questioning:

Engaging client to identify primary concerns, “so give me an overview of the kind of difficulties that you have been having (Clip 1 at 6 minutes and 34 seconds)”?

Allowing the client to analyze underlying assumptions, “How does that feel for you today, being here, meeting me for the first time and having to speak out (Clip 1 at 7 minutes and 23 seconds)”?

Leading the client to analyze perspectives in real-world functioning, “How’s this problem stopping you living your life (Clip 2 at 10 seconds)?”

According to Padesky (1993, p.5), open questions foster client-therapist collaboration and encourage client’s to elaborate in detail and facilities exploration of multiple perspectives. Also, open-ended questions are non-coercive and, therefore, useful with clients who are resistant or inhibited (Padesky, 1993, p.5). The limitation is that clients tend to postulate the embedded evidence based on the therapist’s propositions rather than self-discovering the dysfunctional beliefs (Padesky, 1993, p. 5).

Close-Ended Questioning

The therapist utilized closed questioning effectively to elicit ‘yes’ or ‘no’ answers where it necessitates for precise information. According to Goss and colleagues 9101, p.38), close-ended questions aids in scrutinizing particular area of analysis whereby proving quick and focused information on important aspects of the discussion. However, over-use of closed-ended questions impedes client participation, which in turn limits information sharing by the client (Goss et al., 2011, p.39).

Some examples where proper use of close questioning was employed:

“This process is confidential …Is that okay (Clip 1 at 5 minutes and 9 seconds)”?

“Just talking about experiences of psychotherapy the client, have you had any previous experiences of psychotherapy in the past (Clip 1 at 5 minutes and 41 seconds)”?

Clarification Questioning

The therapist employed sufficient clarification questioning followed by an appropriate phase of silence to encourage the client to continue elaborating her story. Clarification responses help the therapist to identify and validate underlying beliefs and assumptions from the client’s perspectives. By helping clients to focus in detail, unnecessary divergences are reduced (Cully & Teten, 2008, p.15). The period of silence allows the client to consolidate their thoughts and take accountability for their viewpoints and assumptions (Cully & Teten, 2008, p.15).

“So it’s stopping you from getting a promotion because of that fear of presentations (Clip 2 at 58 seconds)”.

“So it’s very, very specific to you, to being in meetings, being in front of your colleagues, and then just feeling like, well what do you think is going to happen (Clip 2 at 2 minutes and 7 seconds)”?

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