Importance of the therapeutic alliance in TF-CBTp
People with psychosis experience increased rates of interpersonal victimisation and post-traumatic-stress disorder, which can lead to difficulties building trusting relationships.
Working to maintain a safe therapeutic alliance, navigating ruptures, boundaries and endings, is vital in TF-CBTp
Quote from STAR research participant
Experience of interpersonal traumatic events has been linked to longstanding difficulties with relationships and identity including:
Problems manging emotions
Feeling diminished, defeated and worthless
Problems sustaining relationships or feeling close to others.
These difficulties can be barriers to therapy, and can require:
Extra time to develop trust
Consideration of how interpersonal difficulties may impact engagement
Attention to overcoming barriers (such as interpersonal difficulties, emotional regulation, substance misuse, dissociation etc)
Consideration of safety and stability of personal circumstances
Planning for ongoing support after treatment for residual or other symptoms.
Tips for managing ruptures, boundaries & endings in TF-CBTp
When working with complexity, particularly with survivors who has experienced inconsistent, untrustworthy, and/or abusive relationships, you need to carefully consider how interpersonal factors may create barriers to TF-CBTp.
1 Monitoring therapeutic alliance & managing ruptures
Building a strong therapeutic alliance can be a significant positive outcome of trauma-focused therapy yet it is rarely formally monitored or measured.
Your therapeutic relationship is a key tool to build trust and empowered engagement.
Aim for a goal-orientated approach grounded in empathy – act as a guide and collaborator, rather than an authoritative figure.
Acknowledge difficulties can and do occur within relationships. Together you can learn to navigate these to build an even stronger, sustained relationship.
Acknowledge you may get things wrong, even inadvertently upset them.
Show a commitment to being open to and valuing feedback.
Be responsive to any feedback given.
Demonstrate willingness to work to repair ruptures.
2 Managing boundaries and self-disclosure
When working with complex trauma, you need to be particularly thoughtful about how ‘self-disclosure’ may support the therapeutic relationship. Your motives to disclose personal information must be guided by how this may benefit the client, the clinical setting, and your own levels of comfort around this.
Therapists on the STAR trial found that some therapeutic relationships benefited from sharing some of our own experiences. For some this helped normalise and validate universal experiences. For others, it was important to recognise we are all fallible, relatable humans with our own multi-faceted histories, drivers and cultural/life contexts.
3 Building a relational blueprint - Extending engagement achievements beyond therapy
The therapeutic alliance can serve as a ‘relationship blueprint’ - a testing ground for what safe and trusting relationships look like. It can offer opportunities to test out having choice and control, as a counter to the dynamics of interpersonal victimisation.
Developing a therapeutic relationship is a significant accomplishment, especially for individuals who have good reason not to trust others. There is value in acknowledging this.
Acknowledge their skills and bravery in trusting enough to approach therapy.
Reflect on their achievement of developing your alliance. Highlight this as evidence that safe relationships are possible, and they are capable of forming trusting relationships with others.
Discuss ways to generalise their relational skills from the therapy room, out into relationships in their wider world.
Create reminders of the safeness and significance of this relationship e.g. audio recordings of key ideas or coping tools.
Quote from STAR research participant
4 Navigating Endings
When considering therapeutic alliance to acknowledge the value of well-planned endings. (See Endings blog for more details)
Endings are part of life. Having a well-planned, expected ending can support people to learn relational endings are manageable.
Routinely discuss endings throughout your therapy journey.
Set time for ‘Ending Phase’ sessions focusing on consolidation and ending.
Reflect on the significance of your therapy alliance and attend to the emotional impact of ending.
Consider a ‘celebration’ session out of the therapy room, such as sharing a coffee and cake or going for a walk.
Celebrate all glimmers of achievements and create reminders of these
Consider steps for onward progress and who may support them.