Collaborative Presentation of the Treatment Model and Ongoing Attention to the Therapeutic Relationship

Attention to patient reactions to the cognitive model may be particularly important when therapists work with severely depressed patients. Among the patients who received CT in our recent trial, those who did poorly were more likely to be severely depressed and to have significant problems with their primary support group when they began treatment (in addition to having greater functional impairment; Coffman et al., 2007). The specific support group problems that were common to these patients included death of a family member, health problems in the family, and family disruption such as separation, divorce, and estrangement. For patients with such problems the sensitivity of the presentation of the cognitive model may be particularly critical. By emphasizing the meaning that patients attach to situations, the cognitive model highlights that problems reside not only in the environment but also in the beliefs and biases that affect individuals' information processing. To the extent that severity of depression is associated with significant interpersonal stress, therapists must take particular care to ensure that patients do not experience the cognitive conceptualization as either blaming or dismissive of the realities of the life problems they experience. Therapists are advised to ask patients for direct feedback about their understanding of the cognitive model and to elicit any patient concerns or negative reactions.

Moreover, breaches in the alliance may be particularly likely when therapist and patient explore cognitions about interpersonal problems (Hayes, Castonguay, & Goldfried, 1996). These findings suggest that particular skill may be needed to address interpersonal problems such that the therapist empathizes with the patient's experience, yet does not validate irrational beliefs and faulty attributions. The importance of the therapeutic relationship has been stressed in CT generally and in the treatment of complex patients with personality disorders specifically (Beck et al., 1979; Beck, Freeman, & Associates, 1990; Kohlenberg & Tsai, 1994; Safran & Segal, 1990). Given the high degree of overlap between severity and interpersonal difficulty, it is often helpful to include greater attention to the therapist-patient relationship than may be the case in standard CT for less severely depressed patients. For example, early in therapy, it may be prudent for the therapist to discuss the possibility that the patient may feel criticized, judged, or dismissed by the therapist at some point during their work together. The therapist can invite the patient to work collaboratively with him/her to watch for and discuss any possible instances. Identifying in session the patient's automatic thoughts about the therapist or therapy also provides an important opportunity to explore and evaluate such thoughts.

In summary, attention to the patient's reaction to the cognitive model, and to the development and maintenance of the therapeutic relationship over time, is central in working with more severely depressed patients. The frequent association between severity of depression and significant social support problems creates a context in which patients may experience the therapist's focus on cognitive change as problematic. It is important for the therapist to inquire about this possibility and to address it directly, openly, and nondefensively when it does occur.

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