Research: Core Conflictual Relationship Theme Method (CCRT)

The Core Conflictual Relationship Theme Method (CCRT) is an instrument used in researching process of psychotherapy.  In this article, a research work is cited in which this instrument is used in psychotherapy research.

The CCRT method is a measure of central relationship schemas of a person that are revealed through his/her narratives.

The CCRT (Luborsky, 1998) is one of the most employed methods of assessing relationship patterns. Over the last decade, it has been used to study numerous forms of psychopathology and symptom impairment, as well as the process of psychotherapy.

There is also evidence that the CCRT shares many characteristics with Freud’s transference theory. The CCRT assesses interpersonal narratives in three components:

  • (1) the wishes, needs, motivations or intentions of a subject (W);
  • (2) the response of others to the subject’s wishes (RO); and
  • (3) the response of the subject to others’ response (RS).

These three components are rated using the standard categories provided by the method, which includes 35 Wishes, 30 ROs, and 31 RSs. The manual gives detailed descriptions for each Wish, RO, and RS.

The CCRT components are identified in a series of Relationship Episodes (RE) told by the subject during an interview designed to collect such narratives (Relationship Anecdotes Paradigm [RAP]). An RE is a brief story or vignette of an interaction the subject had with another person.

Table is excerpt from Bond et.al 1987

 

Table is excerpt from Bond et.al 1987

The client’s relationship pattern is studied by analyzing the recorded transcripts of the therapeutic session.

Example from Drapeau & Perry (2004) research:

Title of this research paper is: Childhood trauma and adult interpersonal functioning: A study using the Core Conflictual Relationship Theme Method (CCRT).

The interview starts with the interviewer saying: “I am going to ask you to tell me stories of interactions you have had with others that struck you as particularly important, interesting or troublesome or a combination of those. These interactions must have happened within these last 6 months.” During the interview, the interviewer inquires about the wishes or desires the subject had during the interaction, how the other person involved in the interaction felt or reacted, and how the subject felt or reacted as a result of the other person’s response. The subjects in this study freely chose which stories to report, although the direction specified three general types, specifically occupation, close relationships and any therapy or professional relationship, all within a time-frame of the past 6 months.

The narratives or relationship episodes from 119 subjects were recorded, transcribed then scored using the CCRT method, with each subject giving approximately 10 or 11 recent relationship episodes. The interviews were scored using CCRT coding procedures and the data considered quantitatively.

For any given relationship episode, the rater is required to identify :

  1. which segments represent a W, a RO, and a RS and
  2. use the definitions provided in the manual to attribute a standard category to this specific segment.

This standard category, or score, is descriptive and reflects a specific type of motive or behavior.

Considering the data quantitatively allows us to examine the proportion of each CCRT category across the entire interview in comparison with the proportions in the other categories.

Two experienced raters were used. They rated a total of 8000 relationship episodes. Consensus rating and reliability assessment were don on randomly selected cases (20% of total).

Defining Trauma: Traumatic Antecedents Interview (TAI) Scale is used to determine which of the subject have what kind of traumatic experience. These factors, together with the results of the CCRT scores were tabulated as such.



Here is an example of how the results were interpreted

Example: “Verbal abuse (see table 1). The verbally abused group reported more of the wish to be distant from others (W10; trend only). The verbally abused group experienced others as less strong (RO24) and in interpersonal interactions, they themselves more often reacted by being not open (RS8). However, none of these differences remained significant following the Bonferroni corrections.”

 

Comments

The CCRT instrument seems to give a clear quantified overview of and individual’s relationship patterns. The purpose of reading this research article was to learn about how the CCRT is applied. In addition we are also offered an insight into childhood trauma.

 

Bibliography

Bond, J. A., Hansell, J., & Shevrin, H. (1987). Locating transference paradigms in psychotherapy transcripts: Reliability of relationship episode location in the core conflictual relationship theme (CCRT) method. Psychotherapy: Theory, Research, Practice, Training24(4), 736.

Luborsky, L. (1998). The Core Conflictual Relationship Theme: A basic case formulation method. In T. D. Eells (Ed.), Handbook of psychotherapy case formulation (pp. 53–83). New York: The Guilford Press.

Luborsky, L., & Crits-Christoph, P. (1998). Understanding transference: The Core Conflictual Relationship Theme method (2nd ed.). Washington, DC: American Psychological Association.

Drapeau, M., & Perry, J. C. (2004). Childhood trauma and adult interpersonal functioning: A study using the Core Conflictual Relationship Theme Method (CCRT). Child abuse & neglect28(10), 1049-1066.

Research: Conversation Analysis in Psychotherapy

Conversation analysis is a research method used to study the phenomena that arises within the psychotherapeutic session. Analysis of the conversation is fundamental to change processes psychotherapeutic sessions, since most psychotherapy work is centered around patient-therapist dialogue, as founded on the words, “talking cure” coined by Anna O. the first patient whose therapy sessions were written in-depth by Freud.

“Conversation analysis has a unique place in the cluster of methods generally considered qualitative (Madill and Gough 2008 ). It is avowedly empirical and has a claim to being relatively atheoretical…

The argument is that conversation analysis

  • avoids use of pre-conceived theories,
  • non-interpretive
  • is primarily inductive and data driven.
  • foundational (assumes that objective principles can be established)
  • progressive (builds a corpus of knowledge)
  • no attempt is made to categorize the content of the data with a view to theorizing how social processes or individual experiences are to be understood.
  • is not concerned with how sociocultural meanings
  • uses rigorous empirical observations
  • applies method that will reveal the (normative) rules of conversational exchange

Conversational analysis of psychotherapeutic dialogue begins with transcription of actual recordings of the therapeutic session.  Jeffersonian transcription conventions have been designed for this (see http://www.sscnet.ucla.edu/soc/faculty/schegloff/ ) and are under constant development.

Since the work is intensively micro-analytically focused, small areas (phenomena) of interest are identified and studied.

Typically, the sequence of analysis would entail:

  1. identification of a conversation phenomenon of interest,
  2. the collection of a series of instances of that phenomenon from available conversational data,
  3. cross-comparison of these instances in order to determine the common practices through which the phenomenon is regulated (informed by current knowledge regarding interactional exchange),
  4. the presentation of a carefully evidenced and argued case for the pattern discovered using detailed analysis of examples of real conversational data.

Aspects of conversation that are of Interest

There are five main features of talk-in-interaction of interest in conversation analysis:

  1. turn-taking,
  2. sequence organization,
  3. repair,
  4. word selection, and
  5. action formation.

 

Bibliography

Madill, A. (2015). Conversation analysis and psychotherapy process research. In Psychotherapy Research (pp. 501-515). Springer Vienna.

Psychotherapy expertise in Singapore: A qualitative investigation

These are summarized findings obtained from this 2008 study by Jennings et. al. entitled Psychotherapy expertise in Singapore: A qualitative investigation. The researcher cited Singapore as a good place for studying psychotherapy due to it cultural diversity relative to its geographical size.

In this study, a group of 9 therapists and/or counselors were selected from a pool based on being seconded by colleagues as “master therapists”. The interviews were conducted with structured questions, and video-taped. These were later analyzed using grounded theory.

Results of the Study

Here are the viewpoints of the master therapists.

Needed personal characteristics that therapists should have:

  • Empathic : Master therapists spoke of possessing a great empathy for their clients. As one master therapist explained, once the client felt genuinely understood and accepted in whatever circumstances, true change and healing began.
  • Non-judgmental:  This trait can produce a sense of safety for clients.
  • Respectful: The master therapists were mindful of their impact on clients and the importance of working with clients in a respectful manner. Respect for clients, whoever they are and whatever their issues may be, was a pervasive theme among these master therapists.

Needed developmental influences that therapists should have are:

  • Experience: The interviewees described a journey, explaining the many elements that created and influenced their path to expertise. When exploring elements of expertise, experience was mentioned frequently as an important factor. One master therapist made the point that there were no quick developmental influences and no guarantee that experience alone leads to expertise.
  • Self-awareness: The master therapists spoke of how their self-awareness has served them well when conducting therapy. One master described it as recognizing your internal processes when working with clients and being able to be a participant/ observer of interactions with clients.
  • Humility. The master therapists recognized humility as another important component in the development of expertise. Recognizing one’s limits may serve as a source of motivation and growth. One master therapist described the importance of the humbling process of recognizing and learning from one’s mistakes.
  • Self-doubt: Despite their experience and reputation, some of the master therapists addressed another issue related to the development of expertise* periodic self-doubt*and how this feeling motivated them to keep growing their clinical skills.

Therapists’ approach to practice:

  • Balance between support and challenge: Many of the master therapists spoke of the importance of maintaining a balance between support and challenge when working with clients.
  • Flexible therapeutic stance. The master therapists described a flexible approach in their work with Psychotherapy clients. If client variables required them to adapt their style, they did. One theory does not fit all.
  • Empowerment/strength-based approach: A number of master therapists spoke about their clients’ internal resources and how the therapist’s task was to reinforce these strengths and bring them to bear in dealing with the problem at hand.
  • Primacy of the therapeutic alliance: Many of the master therapists acknowledged the importance of the therapeutic relationship. The impact of the relationship varied from a necessary condition in the therapeutic process to the relationship being the actual source of healing.
  • Comfortable addressing spirituality: Beyond observance of any particular religion, many master therapists spoke of a broad personal spiritual mind-set, which primarily functioned as a backdrop when working with clients but also included some therapists privately praying for clients.
  • Embraces working within a multicultural context: A number of master therapists spoke of the importance of cultural awareness in their work and the challenges of adapting Western therapeutic approaches to Eastern values and systems.

On on-going professional growth:

  • Professional development practices: Professional development, a key factor in developing and maintaining expertise, was not limited to conferences, literature, or textbooks. One master therapist believed that therapists should extend beyond their areas of practice to broaden development.
  • Benefits of teaching/training others: Now highly regarded and seasoned, the master therapists have much to offer other therapists. Many of the master therapists viewed teaching and training as an opportunity to hone their own skills and to reflect upon their practice.
  • Challenges to professional development in Singapore. During the interviews, master therapists identified several ‘‘professional growth edges’’ in the Singapore psychotherapy profession. For instance, a training need recognized by several therapists was that of basic counseling skills. One master therapist explained that basic counseling skills are not natural for many Singaporean trainees.

 

Comments on the Study and it’s Results

As a Singaporean therapist with training in Austria, it appears that what the master therapists highlight regarding personal characteristics, development and education of therapists are not so different in Singapore than in Europe.

There is one difference that stands out for me, and that is of the need of the Singapore-based therapist to address spirituality. Although it is also important in Europe, the emphasis in this article gives me the impression that is more important and challenging in Singapore.

What is somewhat disappointing about the results is that (and it was articulate also in the article) is that the Master therapists shared very little of their own emotional experiences. The researchers attributed it to the cultural background of the therapist. As someone doing qualitative research myself, I am of the opinion the it is the job of the researchers to lead the subjects to provide this information.

It could be that the shortfall in this study is the interviewers own discomfort in checking with the interviewees on more personal levels.

As a whole, I do agree that Singapore is good ground for psychotherapy research.

Bibliography

Jennings, L., D’Rozario, V., Goh, M., Sovereign, A., Brogger, M., & Skovholt, T. (2008). Psychotherapy expertise in Singapore: A qualitative investigation. Psychotherapy research18(5), 508-522.

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.”

 

 


Bibliography

 

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 Method used to analyze Literature

This short note features the work of Stirn et.al. (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.

ABSTRACT

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.

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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:
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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.

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


Bibliography

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.

Bibliography

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.

Ruptures

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.

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Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80-87.
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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.

Reference

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