Lecture 2: Building the Working Alliance as a foundation for CBT Skills

Specialist skills in CBTKevin Standish

Learning Outcomes

1. To place the working Alliance into context historically2. To place the four core elements of the working Alliance in

context3. To understand and use the role of the therapist in

establishing the Working Alliance4. To evaluate research on the therapeutic alliance5. To deal with ruptures in the therapeutic alliance

Historical context• The Western philosophical underpinnings of CBT associated

with Stoic philosophy.• "Man is disturbed not buy things, but by the views he takes of

them" Epictetus • Stoic philosophy believed that reason could overcome our

basic instincts and emotions and help us find equanimity in the face of life's vicissitudes.

• With the dominance of the principles of learning theory: classical conditioning and operant conditioning, and psychoanalysis the role of conscious mental processes was not a focus

• Bandura (1977) expanded learning theory to encompass the social realm and introduced the concept of self efficacy: "the belief in one's capabilities to organise and execute the courses of action required to manage prospective situations".

Historical context• This established one fundamental principles of CBT: a person

can exert control over their own life and can learn to become the own therapist.

• The work of Ellis and Beck now became the focus of cognitive behavioural therapy developing the classic ABC model.

• Ellis's REBT evolved with the fourth factor to rate and evaluate ourselves and others, thereby reducing the effect of self-defeating beliefs through a rational approach

Historical context: Joseph Wolpe• "All that the patient says is accepted but I question or

criticism. He is given the feeling that the therapist is unreservedly on his side. This happens not because the therapist is expressly trying to appear sympathetic, but as a natural outcome of a completely non-moralising approach to the behaviour...." (Wolpe, 1958:106)

• This is a remarkable up-to-date description of the therapeutic relationship in CBT for its time.

• He shows Rogers three core conditions in his description and approach emphasising important ingredients of the therapeutic relationship from one of the founding fathers of CBT

Historical context: Albert Ellis• Ellis critiqued Rogers core conditions as being desirable but

neither necessary nor sufficient for therapeutic change to occur• He advocated a highly active directive stance and encourage

clients identify, challenge and change irrational ideas which lie at the source of their disturbances and then to think and act in accord with their alternative rational ideas.

• Ellis deemphasised and expressed concerns regarding therapist warmth.

• He felt that while clients appear to value this condition, it serves to reinforce the need for approval and lead to them becoming more rather than less anxious, especially in regard for approval

• it is for this reason that CBT is often seen as quite "cold"

Historical context: Aaron Beck• From the beginning, Beck emphasised the role of the therapeutic

relationship in cognitive therapy• He emphasised Rogers core conditions: warmth, accurate empathy

and genuineness. He sees them as necessary but not sufficient.• there was an emphasis placed on the development and

maintenance of trust and rapport with the client• this is described as "a therapeutic alliance of collaboration" (Beck et

al, 1979 :54)• this links to the basic task of therapeutic dyad to: to investigate the

empirical status of the patients cognitions in relation to the problem• this collaborative relationship is a cornerstone of cognitive therapy• this is emphasised as part of the feedback at the end of the session

Necessary but not sufficient• In cognitive therapy the therapeutic relationship on its own

may not contribute to the potency of the treatment• but it absence means that even accurate CBT

conceptualisation and the use of specific techniques based on this conceptualisation will not bring about a meaningful change

• "The collaborative relationship permeates effective cognitive therapy and it is this that gives the techniques of assessment and treatment their power" (Dryden, 2012:87)

Historical context: Gilbert & Leahy

• This book emphasises the central importance of the therapeutic relationship in CBT

• it places emphasis on the following:• emotion in the therapeutic relationship• transference• dealing with ruptures in the therapeutic relationship• internal working models of attachment in the therapeutic relationship• using the therapeutic relationship with difficult to engage clients• schematic mismatch in the therapeutic relationship• self and self reflection in the therapeutic relationship

• Some of these themes will follow in the next few slides• to be an effective CBT therapist two conditions are required:• 1. To be technically proficient in the CBT skills• 2. To be proficient in developing and maintaining the collaborative

nature of the relationship

Working Alliance Theory ( Bordin 1979)

• Bordin’s article emphasised the importance of the working Alliance

• Broader than the concept of the therapeutic relationship, the Working Alliance is comprised of the following components:

• Bonds: the interpersonal connectedness between therapist and client

• Goals: the purpose of the therapeutic meetings• Tasks: the procedures carried out by therapist and client to

achieve the goals• a fourth one added by Dryden (2008): views: the

understandings that both participants have on the salient issues

Four components of Working Alliance

• There are four broad elements that need to be considered in the therapeutic relationship over all

1. Bonds2. The views of the therapist and client3. Goals4. Tasks

1. Bonds• Three elements: • 1. core conditions; • 2. interpersonal style; • 3. transference and counter transference

1.1.The core conditions• Unconditional positive regard• Congruence• Empathy• Small group work: • In pairs please describe your understanding of the three

concepts involved in the core conditions• highlight the difficulties you have in applying these conditions• Three minutes

1.1.The core conditions• : Necessary but not sufficient.• Recent research (Beutler, et al, 2004)

shows that core conditions are often important for most but not all clients.

• "As CBT therapists you need to emphasise certain conditions with some clients and deemphasised other conditions with other clients in order to establish the most productive and idiosyncratic therapeutic bond with each individual client" (Dryden, 2012:89) Case study 5.1

1.2. Interpersonal style• This refers to the "fit" between the interpersonal styles of

counsellor and client• when the fit is good the therapeutic alliance is enhanced• when the fit is poor the therapeutic alliance is threatened

• In CBT the preferred style is active collaboration, working with the cognitive behavioural elements of the client’s problems

• not all clients can collaborate with the therapist e.g. the more passive client wants be told what to do. Case study 5.2

• Socratic questioning is preferred style in CBT, but this also has some limits with particular clients

• what kind of clients would struggle with Socratic questioning?

1.2. Interpersonal style• 4 alternatives to Socratic questioning:• 1. A didactically style: points are made directly matter of factly to the

client and the therapist checks the client's understanding of and response to the point made

• 2. a metaphorical style: a metaphor, story or parable is used often linking to the client's own life to bring across the point. Understanding of the meta-fur needs to be checked out with the client

• 3. A humorous style: human can facilitate the Working Alliance and encourages clients to put their life situation into healthier perspective. You may may also increase the tendency to defend themselves by minimisation or leave them with a sense that they are being ridiculed. Getting client feedback on the use of humour is critical

• 4. A self disclosing style: self disclosure may be a powerful way of encouraging clients to re-evaluate dysfunctional beliefs. Using an example of a coping model of the therapist self disclosure helps clients and re-evaluate their own dysfunctional beliefs.

1.2. Interpersonal style• It is important that the therapist demonstrate interpersonal

flexibility in CBT.

• This needs to be done genuinely, with sensitivity to the client's responses, whilst at the same time remaining authentic in the here and now of the therapeutic relationship

1.3. Transference and counter-transference• What is your understanding of these concepts of transfer in's

and countertransference?• Small-group work:• define the two concepts and give an example• two minutes

1.3. Transference and counter-transference• Derived from psychoanalytic approaches to psychotherapy• the phenomena that the terms point are more crucial than the terms themselves.• the terms point to the fact that both clients and therapist bring to the counselling

relationship tendencies to perceive, feel and act towards another person influenced by the prior interaction with significant others.

• These tendencies have a profound influence on the development and maintenance of the therapeutic alliance

• Miranda & Andersen ( 2007) suggest the following social cognitive model of transference:

• 1. Ask the client to name and describe significant others with special reference to facets of interpersonal relating

• 2. Once identified the therapist can see when these are activated in the therapeutic relationship

• 3. Help identify the link between present response to the therapist and the representations of significant others

• 4. Self acceptance, compassion and humility are important if the therapist is to acknowledge anti-therapeutic reactions to clients and their own dysfunctional schemas

2. The views of the therapist and client

• Views refers to the understanding that both participants have on salient issues

• 2.1 Views of the therapist

• 2.2. Views of the client• 2.3. Similar views:

effective therapy

2.1 Views of the therapist• What are you most effected by when it comes to

understanding the nature of the client's problems?• Answer: CBT theory• CBT therapists differ concerning their views on how to help

clients with their problems depending upon the theoretical formulation of a problem

• the conceptualisation of the problems becomes salient when it comes to helping the client with the dysfunctional cognitions.

2.2. Views of the client

• Clients will come with views of their problems and how they can best be helped.

• Clients may have read self-help books or gone online and will come with accurate ideas.

• Whilst others will have misconceptions about what CBT is and may have been referred by their GP for therapy without any clear understanding of the process.

• Misconceptions and myths client's carry about CBT need to be clarified

2.3. Similar views: effective therapy• Working Alliance theory holds that when clients' views are

similar to their therapist' on issues, then therapy is likely to be effective than when such views are different.

• When there are different these differences need to be acknowledged and openly discussed

• Helping clients to see that they have used principles of CBT in their lives encourages them to see the relevance of CBT and encourages the engagement with the process

• If clients do not fit with the CBT approach and cannot take on board a common view then they need to be referred to a more appropriate therapeutic approach

3.Goals • This pertains to objectives both client and councillor have for

coming together.• CBT therapists are more goal focused and deal explicitly with

clients goalsetting than other therapy.• Goals in CBT are reformulated into specific elements which fall

within the client's power to address• Good therapeutic outcome is facilitated when the therapist

client agree what the client goals are, and agreed to work towards the fulfilment of these goals

• the Working Alliance is threatened when therapist and client have different outcome goals in mind, these are often implicit and not expressed clearly.

4. Tasks• Tasks are activities carried out by therapist and client in a goal

directed manner.• While CBT is rich in its use of techniques it is important from

the Working Alliance perspective to consider the following for effective CBT to occur:

• does the client understand the nature of the therapeutic task he needs to undertake?

• Does he see the value of carrying out these tasks?• Does the client have the ability to carry out the therapeutic

tasks required?• Does the client have confidence to carry out the task?• Will the task help achieve the goal?

What if your client does not "buy in" to the model• There are times when clients will not agree with specific goals will

even be interested in the CBT model of change.• It is important to consider reasons behind this lack of buy in.

Possible reasons include:• 1. Lack of understanding of the model• 2. Lack of credibility of the model• 3. Disagreement about case formulation• 4. Lack of suitability of the model• 5. Persistence in asking "why?" questions

• Dobson, D. and Dobson, K.S 9 (2009) Evidence-based Practice of Cognitive Behavioural Therapy, London. Guildford press. Chapter 4 Beginning Treatment: Planning for Therapy and Building Alliance

The role of the therapistClients looking to their therapists to be experts in the provision of treatment , which include having good professional boundaries and interpersonal skills.You must balance the number of interpersonal demands while remaining sensitive to the needs of clientsthe following demands need awarenessexpertise versus equalitycoping versus masteryuse of self disclosureuse of affectencouraging courage

Expertise vs equality• This element involves a powerplay between being an expert in

your skills and knowledge but allowing the client the space to make decisions that suit them best.

• You need to not know in your role as expert.• It is important to see the client as the expert on their own

history, functioning and current concerns• it is important to acknowledge the expertise the client may

have in other areas that could contribute towards the therapeutic work.

• The relationship can never be one of complete equality as clients will view you as powerful and as the expert

• as the "expert" you are also an educator but you need to do this with humility and respect

Coping versus mastery• You're not expected to be an expert in all areas.• You will appear as unauthentic if you show mastery in all areas

to your client• Clients learn more from a coping model than a mastery model• It is reassuring for clients to see the therapist makes mistakes,

acknowledge them and work to improve their own behaviour. Being real and authentic.

Use of self disclosure• Self disclosure can be broken into the disclosure of content versus process.• Content disclosure includes your response to questions asked by the client.• Do not answer questions with which you do not shall comfortable by simply

stating that.• Consider the intention of the client when they ask those sorts of questions.• It is your responsibility to answer questions regarding your training

background and experience• Process disclosure involves occasionally disclosing problems you have

encountered in your life and how you have dealt with them. The purpose is to facilitate the client to disclose more. It is in the interests of the client that the self disclosure is made. They should be kept a minimum and allow the client to build upon your self disclosure. It is the process of disclosure that keeps the therapeutic process going

• A second type of process disclosure include sharing your automatic thoughts or emotional responses with clients who have particular interpersonal problems. This allows them to receive honest feedback that they do not normally receive from people in their life.

• It also allows the modelling of a skill of reflection

Use of an affect• Whilst CBT is focused on thoughts and behaviours, the affect

of clients needs to be acknowledged and dealt with.• Affect is triggered by many interventions and is required for

them to be effective• Being genuine in affect when touch by client's experiences is

important. You do not need to be stoical in the face of distressing stories. It is important for clients to see that you have been touched by their distress but not overwhelmed

Encouraging courage• When we ask clients to undertake difficult tasks it is important

to understand that they have often avoided the very things we are asking them to do.

• We asked them not only to become more aware of their problems but also to face them head on.

• It is crucial to encourage clients to be courageous in their quest for change.

• You support change through encouragement, support and reinforcement of small changes that you see.

The therapeutic relationship that promotes client change

• There are three broad phases in the therapeutic relationship that require different aspects and attention in their development

• 1. Establishing a relationship• 2. Developing a relationship• 3. Maintaining a relationship• Awareness of Contextual factors

Hardy et al ( 2007) Chap 2: Active ingredients if the therapeutic relationship that promote client change: a research perspective. Found in Gilbert & Leahy The Therapeutic relationship in the cognitive behavioural psychotherapies.this is also a Dawson Book

1. Establishing a relationshipEngagement processes Engagement objectives

Empathy, warmth and genuineness Expectancies

Negotiation of goals Intentions

Collaborative framework Motivation

Support Hope

Guidance

Affirmation

2. Developing a relationshipProcesses Objectives

Exploration Openness

Reflection Trust

Feedback Commitment

Relational interpretations

Non-verbal communications

3.Maintaining a relationshipThreats Processes Objectives

Therapist behaviour Self reflection

Intrusive Meta-communication

Defensive

Negative feelings

Self disclosure

Client behaviour Flexibility Satisfaction

Resistance Responsiveness Alliance

Hostility Emotional expression

Negative feelings Changing view of self

Relationship challenges Repair

Ruptures/confrontations/withdrawalMisunderstandings

4. Contextual factors• The broader client, therapist and contextual factors that impact on the quality of

the therapeutic relationship.• Two main client characteristics that moderate treatment outcome are functional

impairment and coping style.• Functional impairment includes problems in work, social and intimate

relationships. The more difficulties clients have in these areas are less likely there are to benefit from therapy. For such clients treatment often need to be more than six months in length to give time for the therapeutic relationship to develop.

• Paying attention to therapeutic ruptures is important than sticking rigidly to therapeutic techniques.

• Clients who have insecure attachment styles less able to form satisfactory alliances.

• Some cultural and demographic variables may impact on the therapy relationship. In cultures with therapy is not encouraged the chances of success are decreased.

• What other contextual factors do you think play a role in effecting positively or negatively the therapeutic relationship?

Ruptures in the therapeutic allianceSigns of a ruptureDealing with rupturesBoundary issues

Ruptures in the therapeutic alliance

• CBT anticipate ruptures in the alliance as problems are well entrenched and change is likely to be difficult

• Signs of a rupture in the therapeutic alliance: non-verbal cues such as the discomfort, anger or mistrust. Behavioural science such is not carrying out homework, expressing scepticism, or high levels of expressed emotion.

• When ruptures identified it is important to intervene early in the difficulties arise

Dealing with ruptures in the alliance

• Ruptures can be related to: 1. the goals and tasks of therapy: deal with directly by clarifying

the rationale for treatment or changing the approach. 2. The client - therapist bond: first deal with this within the

current therapeutic relationship without assuming it is a reflection of your client’s characteristic interpersonal relationship style. If this is unsuccessful then consider the rupture as a characteristic pattern of the client interpersonal style and use the therapeutic relationship to provide the client with a corrective emotional experience.

• Consider what contribution you as the therapist are making to any therapeutic impasse rather than assume all problems reside within the client.

Boundary issues• Therapeutic boundaries are set in such a way that the client

can:• Feel safe• Trust the therapist to act in his interest• Feel free to disclose material of a deep personal significance• Be confident that they understand the therapist and understood

by the therapist

Boundary issues• The therapeutic relationship is non-reciprocal:• Extensive self disclosure by client was total nondisclosure by the

therapist• Emotional neediness of the client is expressed compared with the

exclusion of the therapist emotional needs• To be aware of the power imbalance attributed to people in

“healing positions”

conclusion• An effective alliance between therapist and client is an

essential condition for implementation of specific methods of CBT

• As therapist engage clients in the process of CBT they need to show understanding, empathy and warmth, and flexibility in their responses.

• A good therapeutic relationship in CBT is characterised by high degree of collaboration, empirical style of questioning, and a range of client learning through jointly defining problems and searching for solutions

Readings for this lecture• 1. Gilbert, P. & Leahy, R. (2009) The Therapeutic Relationship

in the Cognitive Behavioral Psychotherapies, London, Routledge. Chapters 1-4 are all very useful.

• 2. Wright, J.H; Basco, M.R; & Thase, M.E (2006) Learning Cognitive Behaviour therapy: An illustrated guide, Chapter 2

• Westbrook D, Kennerley H & Kirk J (2008) An Introduction to Cognitive Behavioural Therapy: Skills and Applications. chap 3

• Dryden & Branch (2012) chapter 5 the therapeutic relationship in CBT

• Dryden & Branch (2012) chapter 13 challenges in the CBT client – therapist relationship

• Castonguay et al (2010) The therapeutic alliance in cognitive behavioural therapy on NL

Journal article for this lecture• Hayes et al (2007) Working Alliance for Clients the Social

Anxiety Disorder: Relationship with Session Helpfulness and with in the Session Habituation. Cognitive Behaviour Therapy volume 36, no 1, pp 34 – 42

Readings for next week• Westbrook et al (2007) chapter 4: assessment and formulation• Dryden & Branch (2012) chapter 6: assessment and

formulation in CBT

http://www.psychotherapy.net/article/therapeutic-alliance#section-the-therapeutic-alliance