Something happens: elements of therapeutic change

Reconceptualising Exposure and Some Implications for Cognitive-Behavioural and Psychodynamic Practice

The concept of exposure is ubiquitous in the research and practice of clinical psychology, most notably in cognitive-behavioural models. Yet there remains confusion and ambiguity around how exposure in ‘exposure therapy’ is characterised. Current definitions are found to be inadequate, as each identifies certain features of the exposure process but omits others. As such, an elaborated model of exposure is presented, referred to here as the re-exposure-extinction learning process. This process involves a complex causal situation consisting of clinical features (the cause/causes, C), acting upon a person (the field, F), to bring about re-exposure to anxiety-provoking stimuli and then extinction learning, leading, over time, to therapeutic change (the effect/effects, E). Importantly, re-exposure and extinction learning are two processes distinct from the therapeutic procedures (i.e., techniques and methods) used to bring them about. Furthermore, these processes are not inherently tied to a particular model of therapy or clinical intervention. They are, therefore, logically independent of the procedures used to facilitate them. Considering this reconceptualisation, we propose that working in the transference, a cornerstone of psychodynamic psychotherapy, can be understood as a complementary and effective method of facilitating the re-exposure-extinction learning process. We argue that this is achieved through enabling a person to repeatedly re-evaluate their fearful expectations as they manifest in the unfolding dynamics of the therapeutic relationship. Finally, some clinical implications indicated by this elaborated model are explored.

Training Methods in Cognitive Behavioral Therapy: Tradition and Invention

Cognitive behavioral supervisors influence new generations of clients and clinicians. Accordingly, the task is meaningful, rewarding, challenging, and critically important. This article describes traditional and unconventional approaches to supervising clinicians in cognitive behavioral therapy (CBT). Traditional methods such as the use of the Cognitive Therapy Rating Scale, videotape/audiotape review, live supervision, and cotherapy are reviewed. Further, inventive procedures for teaching supervisees cognitive flexibility, empathy, tolerance for ambiguity, and remaining steadfast when faced with negative emotional arousal are explained. Popular media, improvisation and acting exercises, and working with professional actors as teaching methods are explained.

Therapeutic relationship: developing a new understanding for nurses and care workers within an eating disorder unit

The establishment of a positive therapeutic relationship has been widely acknowledged internationally as an intrinsic part of therapy and caring services, even healing and restorative in its own right. In this paper, current understandings of the therapeutic relationship are presented and reconsidered within the context of caring for patients with anorexia in hospital in the UK. The relevance of interpersonal processes and the expectations of care and recovery are re-evaluated and the question posed as to whether these principles can be wholly employed in this setting. The service in which the therapeutic relationship exists (eating disorder services), current understandings of 'therapeutic relationship', responsibility, and tensions that exist in attaining a relationship are examined.