Research: CCRT used to study Gestalt and Emotive Behavioral Therapy

CCRT is employed in this research paper to study Gestalt and Emotive Behavioral Therapy sessions with adolescence.

With a standard treatment CCRT, 4 sessions are analyzed, 2 early

and 2 late with around 20 RE’s in all.

“In this study, only one therapy session for each of two clients was available and, therefore, only single session CCRT’s were formulated. A session CCRT is said to be “a special version of the CCRT and may differ slightly from the treatment CCRT” (Luborsky, 1990b, p. 32). “

Therefore n=2.

“Relationship episodes (RE’s) were demarcated on the written transcripts and judged as to their completeness. When the RE’s judged complete enough for the study were isolated, they were then examined for the three major components: wishes, responses from others and responses from self. A set of standard categories is available for describing the three components of the CCRT (Barber, Crits Christoph & Luborsky, 1990).”

“The standard category system is recommended for use with research while a tailor-made system seems to be more useful for clinical work. The second edition of the standard category system was used in this study. After each component was categorized, those occurring with the greatest frequency across RE’s were drawn together and the clients’ CCRT’s were formulated. A comparison was then made between the two treatment orientations.”





Agin, S., & Fodor, I. E. (1996). The use of the Core Conflictual Relationship Theme method in describing and comparing gestalt and rational emotive behavior therapy with adolescents. Journal of rational-emotive and cognitive-behavior therapy, 14(3), 173-186.

Research: CCRT-LU

  • Albani et. al (2002) introduces their revised version of Lubrovsky’s Core Conflictual Relationship Theme instrument, used in psychotherapy research. Read about the CCRT method here.

One of the main changes of the CCRT in CCRT-LU is the an introduction of “sub-dimensions of direction” subject-object and object-subject classification of wishes and responses. Whereas CCRT has got 4 main component dimensions (WO, RO, WS, RS), CCRT-LU has got 8 dimensions (WOO, WOS, WSS, WSO, ROO, ROS, RSO, RSS).

These dimensions are coded according to terms in the predicate lists.



Albani, C., Pokorny, D., Blaser, G., Gruninger, S., Konig, S., Marschke, F., … & Kachele, H. (2002). Reformulation of the core conflictual relationship theme (CCRT) categories: The CCRT-LU category system. Psychotherapy research12(3), 319-338.

Research: CCRT Method used to analyze Literature

This short note features the work of Stirn (2005) entitled, An analysis of two novels written by authors suffering from anorexia nervosa. 

The methodology was to analyze 2 novels written by 2 different authors who are known to have survived anorexia nervosa.


Objective: Two literary works of authors suffering from anorexia nervosa were analyzed with the method of the core conflictual relationship theme (CCRT) to prove that novels and/or personal accounts may reveal the same maladaptive relationship patterns typically revealed in psychotherapy sessions with this nosologic group.

Method: Two novels,  Valerie Valere’s The House of the Crazy Kids and  Andrea Graf’s Die Suppenkasperin, were selected which promised applicability of the CCRT method due to the completeness of the described relationship episodes.

Results: After several methodologic adjustments, the application of the CCRT method revealed the different courses and developments of the novels. Both the positive and negative as well as the conscious and unconscious relationship patterns were clearly expressed.

Screen Shot 2017-12-08 at 14.37.57

Discussion: The results indicate that after certain adjustments, the CCRT method may be successfully applied to data obtained from sources other than psychotherapy sessions.

More examples of tables:
Screen Shot 2017-12-08 at 14.38.48Screen Shot 2017-12-08 at 14.38.54Screen Shot 2017-12-08 at 14.39.11

Stirn, A., Overbeck, G., & Pokorny, D. (2005). The core conflictual relationship theme (CCRT) applied to literary works: An analysis of two novels written by authors suffering from anorexia nervosa. International Journal of Eating Disorders38(2), 147-156.

Research: Generic Change Indicators (CGI)

Mentioned in the article by Krause (2007), the indicators towards the evolution of change in a psychotherapy treatment are as listed:

  1. Acceptance of the existence of a problem
  2. Acceptance of his or her limits and of the need for help
  3. Acceptance of the therapist as a competent professional
  4. Expression of hope (‘‘morale boost’’ or ‘‘remoralization,’’ the expectation of being helped or being able to overcome the problems)
  5. Questioning of habitual understanding, behavior, and emotions (‘‘opening up’’; may imply the recognition of problems previously ignored, self-criticism, and the redefinition of therapeutic expectations and goals
  6. Expression of the need for change
  7. Recognition of his or her own participation in the problems
  8. Discovery of new aspects of self
  9. Manifestation of new behavior or emotions
  10. Appearance of feelings of competence
  11. Establishment of new connections among aspects of self (e.g., beliefs, behavior, emotions); aspects of self and the environment (persons or events); aspects of self and biographical elements
  12. Reconceptualization of problems or symptoms
  13. Transformation of valorizations and emotions in relation to self or others
  14. Creation of subjective constructs of self through the interconnection of personal aspects and aspects of the surroundings, including problems and symptoms
  15. Founding of the subjective constructs in own biography
  16. Autonomous comprehension and use of the context of psychological meaning
  17. Acknowledgment of help received
  18. Decreased asymmetry between patient and therapist
  19. Construction of a biographically grounded subjective theory of self and of his or her relationship with surroundings (global indicator)

Qualitative Method of Measuring Change:



Krause, M., De la Parra, G., Arístegui, R., Dagnino, P., Tomicic, A., Valdés, N., … & Ramírez, I. (2007). The evolution of therapeutic change studied through generic change indicators. Psychotherapy research17(6), 673-689.

Research: Qualitative Method of Measuring Change

Qualitative Method of Measuring Change:
Theoretical correspondence: Change agrees with the contents of a generic change indicator.

Verifiability: Change is observed in the session (or, in the case of an extrasession change, it is
mentioned during a session and an explicit reference is made to therapy).
Novelty: The specific content of change manifests for the first time.
Consistency: Change is consistent with nonverbal communication and is not denied later in the
session or the therapy. On the basis of these four criteria and on the
descriptions of the CIs contained in the hierarchy, the research group identified and then coded all the
in-session and extrasession change moments for each therapy under study, following the procedure described previously.



Krause, M., De la Parra, G., Arístegui, R., Dagnino, P., Tomicic, A., Valdés, N., … & Ramírez, I. (2007). The evolution of therapeutic change studied through generic change indicators. Psychotherapy research17(6), 673-689.

Instruments used to Collect Data in Psychotherapy Outcome Research

List of questionnaires as instruments to track psychotherapy outcome in research.

Beck Depression Inventory (BDI) Symptoms Self-report C Beck et al. (1961)

Symptom Checklist- 90-R (SCL-90-R) Symptoms Self-report C Derogatis et al. (1976)

State-Trait Anxiety Inventory (STAI) Symptoms Self-report C Spielberger et al. (1983)

Dysfunctional Attitudes Scale (DAS) Vulnerability Self-report C Weissman and Beck (1978)

Clinical Outcome Routine EvaluationOutcome Measure (CORE-OM) Symptoms, well-being Self-report C Evans et al. (2002)

Outcome Questionnaire- 45 (OQ-45) Symptoms, interpersonal problems Self-report C Lambert et al. 2004

Inventory of Interpersonal Problems (IIP) Interpersonal problems Self-report C Horowitz et al. (1988)

Rosenberg Self-Esteem Scale (RSES) Well-being Self-report C Rosenberg (1965)

Post-Therapy Questionnaire (PTQ) Treatment goals Self-report C Mintz et al. (1979)

Patient Target Complaint (PTC) Treatment goals Self-report C Battle et al. (1966)

Hamilton Rating Scale for Depression (HRSD) Symptoms Observational J Hamilton (1960)

Structured Clinical Interview for DSM personality disorders (SCID-II) Personality Observational J Spitzer et al. (1990)

Shedler-Westen Assessment Procedure (SWAP-200) Personality Observational J Shedler and Westen (2007)

Global Assessment Scale (GAS) Treatment goals Observational J Endicott et al. (1976)

Therapist Target Complaint (TTC) Treatment goals Observational J Battle et al. (1966)


Gelo, O. C. G., & Manzo, S. (2015). Quantitative approaches to treatment process, change process, and process-outcome research. In Psychotherapy Research (pp. 247-277). Springer Vienna.

Psychodynamic Interventions Rating Scale (PIRS)

The PIRS, categorizes each individual intervention. It allows for examining the therapy process at the level of moment-to-moment interactions apart from summarizing techniques used for the session overall.





Milbrath, C., Bond, M., Cooper, S., Znoj, H. J., Horowitz, M. J., & Perry, J. C. (1999). Sequential consequences of therapists’ interventions. The Journal of psychotherapy practice and research8(1), 40.

Comprehensive Psychotherapeutic Interventions Rating Scale (CPIRS)

The Comprehensive Psychotherapeutic Interventions Rating Scale (CPIRS) was designed to study different orientations of psychotherapy used in researched practices. It is a way to measure treatment adherence and/or treatment differentiation.

Psychotherapeutic methods described in this scale

Client Centered, psychodynamic, behavioral, cognitive, group psychodynamic, and systemic orientations are included in the CPIRS.

Apart from these orientations, interventions and attitudes derived from common factors are included. The scale is also useful in determining how far the treatment is eclectic/integrative or pure form.

Items of the Interventions Rating Scale


Validity Studies

3 Studies were carried out, that are also presented in this article to validate this scale.

The first 2 studies indicated unconvincing differentiation between psychodynamic therapies and experiential therapies studied.  The differentiation was clearer in the third study.

General Conclusion


Trijsburg, R. W., Frederiks, G. C., Gorlee, M., Klouwer, E., den Hollander, A. M., & Duivenvoorden, H. J. (2002). Development of the comprehensive psychotherapeutic interventions rating scale (CPIRS). Psychotherapy Research12(3), 287-317.

Research: Orlinsky Generic Model of Psychotherapy

What is psychotherapy as a profession deconstructed? This paper by Orlinsky (2009)  provides some definable guides, providing graphical structure of psychotherapy. The profession of psychotherapy is more complex than meets the eye, because most of what is important in the work is difficult to measure by empirical methods. This is a meta-theory for the use of psychotherapy research.

The “Generic Model of Psychotherapy” was initially presented 25 years ago and was conceived as a trans-theoretical frame for integrating the varied empirical findings of hundreds of studies relating therapeutic process to outcome that had appeared during the previous 3 decades into a coherent body of knowledge


This conceptual model offers a comprehensive framework in which various clinical theories of psychotherapy can be systematically combined and compared. 

It was considered almost impossible to compare these different branches of therapies because of their different focus and “operating language”. This is of course not a very good description of what psychotherapy is about.

Aspects of the Psychotherapeutic Process

If we were to detangle the layers of the psychotherapy profession, we can imagine these parts that make up the whole

1. The Therapeutic Contract: 

This is the getting together of the client and therapist; it is an agreement on the set, setting and conditions of the therapy.

2. Therapeutic Operations : Technical Aspects

After the formalities are set, the client comes into the therapy session and begins his/her dialogue with the therapist. The patient presents his/her situation, the therapist provides interventions. From the figure below one can see the co-createdness of this step.

3. The Therapeutic Bond

When people meet, the interpersonal relationship that builds in-between is unique. How this bond is formed is multi-factorial.  These factors have been used a variables in psychotherapy research, e.g. age, gender, socio-cultural-economic status, and personality. The therapeutic bond is dynamic and changes over time.

4. Self Relatedness
This is the intra-personal aspects of both therapists and client: how open each are to the conditions and situations that arises within and outside of the therapy sessions.

5. In-Session Impacts
These are happenings that occur during the therapy session that impacts the client-therapist relationship.

6. Temporal Patterns
As the name suggests, this is about taking into account how change evolves with time. Small changes and ah-ha moments, together with outside influences through time creates changes to the therapeutic relationship.

Considering the Context of Therapy

The client and therapists are also affected by what goes on in life outside the therapy hours. This brings into consideration the larger context related to the therapist and client as individuals.

The big picture is a schema of how fluid and ever-changing the influences of the psychotherapeutic alliance is. This makes psychotherapy research very challenging and also interesting.

Read also my essay on the psychotherapeutic alliance and change.


Orlinsky, D. E. (2009). The “Generic Model of Psychotherapy” after 25 years: Evolution of a research-based metatheory. Journal of Psychotherapy Integration19(4), 319.

Research: The Psychotherapeutic Alliance in Research

Interdependent factors that make an alliance:

  • *the agreement between patient and therapist on the tasks and goals of treatment and
  • *the affective bond between patient and therapist.


Refer also to the 3RS manual on ruptures here.

Ruptures are understood as: misunderstanding events, impasses, alliance threats and markers of enactments.

A rupture is a deterioration in the alliance, manifested by

  1. a lack of collaboration between patient and therapist on tasks or goals, or
  2. by a strain in the emotional bond.

Although the word “rupture” connotes a major breakdown in the relationship, the term is also used to describe minor tensions of which one or both of the participants may be only vaguely aware. Ruptures can be obstacles to treatment and can contribute to patient dropout.

Resolution of Rupture as Opportunity for Therapeutic Change

Successful resolution of a rupture can serve as a corrective emotional experience (Alexander & French, 1946), providing a powerful opportunity for therapeutic change

Recognizing the negative impact that unresolved ruptures can have on
treatment outcome, and realizing that these ruptures can go unnoticed by the therapists research is done that is centered around the investigation of whether integrating rupture resolution techniques can improve the efficacy of a particular treatment.

The chapter in this reference gives a detailed account of the kind of research that has been done, that works on the alliance rupture and repair, with the goal of improving probability of training therapists to focus on the alliance.

Screen Shot 2017-12-17 at 19.35.51
Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80-87.
Screen Shot 2017-12-17 at 19.49.12
Barber, J. P., Khalsa, S. R., Sharpless, B. A., Muran, J. C., & Barber, J. P. (2010). The validity of the alliance as a predictor of psychotherapy outcome. The therapeutic alliance: An evidence-based guide to practice, 29-43.

Empirical studies that have shown that alliance is correlated to good outcome:

Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 37–70). New York: Oxford University Press.

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450.

Samstag, L. W., Batchelder, S. T., Muran, J. C., Safran, J. D., & Winston, A. (1998). Early identification of treatment failures in short-term psychotherapy: An assessment of therapeutic alliance and interpersonal behavior. Journal of Psychotherapy Practice and Research, 7, 126–143.

Samstag, L. W., Muran, J. C., Wachtel, P. L., Slade, A., Safran, J. D., & Winston, A. (2008). Evaluating negative process: A comparison of working alliance, interpersonal behavior, and narrative coherency among three psychotherapy outcome conditions. American Journal of Psychotherapy, 62, 165–194.

Tryon, G. S., & Kane, A. S. (1990). The helping alliance and premature termination. Counselling Psychology Quarterly, 3, 233–238.

Tryon, G. S., & Kane, A. S. (1993). Relationship of working alliance to mutual and unilateral termination. Journal of Counseling Psychology, 40, 33–36.

Tryon, G. S., & Kane, A. S. (1995). Client involvement, working alliance, and type of therapy termination. Psychotherapy Research, 5, 189–198.


Eubanks-Carter, C., Muran, J. C., & Safran, J. D. (2010). Alliance ruptures and resolution. The therapeutic alliance: An evidence-based guide to practice, 74-94.

Index of this book:

I. Critical Studies of the Therapeutic Alliance

  1. Alliance Theory and Measurement 7 Robert L. Hatcher

  2. The Validity of the Alliance as a Predictor 29 of Psychotherapy Outcome Jacques P. Barber, Shabad-Ratan Khalsa, and Brian A. Sharpless

  3. The Alliance over Time 44 William B. Stiles and Jacob Z. Goldsmith

  4. Qualitative Studies of Negative Experiences 63 in Psychotherapy Clara E. Hill

  5. Alliance Ruptures and Resolution 74 Catherine Eubanks-Carter, J. Christopher Muran, and Jeremy D. Safran xiv

Contents II. Practice and the Therapeutic Alliance

  1. A Psychodynamic Perspective 97 on the Therapeutic Alliance: Theory, Research, and Practice Stanley B. Messer and David L. Wolitzky 7. An Interpersonal Perspective on Therapy 123 Alliances and Techniques Lorna Smith Benjamin and Kenneth L. Critchfield 8. The Therapeutic Alliance 150 in Cognitive-Behavioral Therapy Louis G. Castonguay, Michael J. Constantino, Andrew A. McAleavey, and Marvin R. Goldfried 9. A Functional Analytic Psychotherapy (FAP) 172 Approach to the Therapeutic Alliance Mavis Tsai, Robert J. Kohlenberg, and Jonathan W. Kanter 10. The Therapeutic Alliance 191 in Humanistic Psychotherapy Jeanne C. Watson and Freda Kalogerakos 11. Therapeutic Alliances in Couple Therapy: 210 The Web of Relationships Adam O. Horvath, Dianne Symonds, and Luis Tapia 12. Therapeutic Alliances and Alliance Building 240 in Family Therapy Valentín Escudero, Laurie Heatherington, and Myrna L. Friedlander 13. The Therapeutic Alliance in Group Therapy 263 William E. Piper and John S. Ogrodniczuk III. Training Programs on the Therapeutic Alliance 14. Developing Skills in Managing 285 Negative Process Jeffrey L. Binder and William P. Henry Contents xv 15. Training in Alliance-Fostering Techniques 304 Paul Crits-Christoph, Katherine Crits-Christoph, and Mary Beth Connolly Gibbons 16. Developing Therapist Abilities to Negotiate 320 Alliance Ruptures J. Christopher Muran, Jeremy D. Safran, and Catherine Eubanks-Carter 17. Coda: Recommendations for Practice 341 and Training Brian A. Sharpless, J. Christopher Muran, and Jacques P. Barber