The Role of the Therapeutic Relationship in CBT Final

Running Header: CRITICALLY EVALUATE THE ROLE OF THE THERAPEUTIC

RELATIONSHIP IN COGNITIVE BEHAVIOURAL THERAPY.

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Critically Evaluate the Role of the Therapeutic Relationship in

Cognitive Behavioural Therapy

Candidate Number 21415649

CRITICALLY EVALUATE THE ROLE OF THE Candidate Number 21415649

THERAPEUTIC RELATIONSHIP IN COGNITIVE

BEHAVIOURAL THERAPY.

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Contents

Introduction.................................................................................................................... 3

Therapeutic Relationship................................................................................................4

Therapeutic Alliance.......................................................................................................5

The Historical Development of the Therapeutic Relationship in Psychotherapy.............6

Rogers’ Core Conditions.................................................................................................6

Cognitive Behavioural Therapy......................................................................................8

Key Factors in Effective Therapy....................................................................................9

The Therapeutic Relationship in CBT............................................................................11

Processes in Therapy....................................................................................................11

Resolution and Repair of Ruptures...............................................................................12

Summary...................................................................................................................... 13

Conclusion.................................................................................................................... 14

References................................................................................................................... 15

What is the cognitive model? In very simplified




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Introduction

Rogers stated “In my early professional years I was asking the question: How can I treat, or

cure, or change this person? Now I would phrase the question in this way: How can I provide a

relationship which this person may use for his own personal growth?” (1961 p.32).

When Carl Rogers wrote this he had already made a critical shift in his thinking about

psychotherapy, moving forward from the first wave of psychoanalysis, towards an argument that

there were defined conditions or characteristics of the therapeutic relationship which were sufficient

to bring about therapeutic change. It seems that a similar shift may be identifiable from the early

development of Cognitive Behavioural Therapy (CBT) to a current day evidence-based therapy.

This seems to have come about through a process of comprehensive empirical research, focusing

increasingly on relationship factors and other common or non-specific factors throughout the

process of therapy and appears to have led to a broadening of the range of CBT as predicted by

Beck when he suggested that, in the future, psychotherapy will be used to treat very serious

disorders in clients whose symptoms are not completely controlled by medication, such as bipolar

disorders and schizophrenia (Beck, 1997. p.283).

This essay explores published materials, including research papers, journals, on-line texts

and information covering the subject of psychotherapy in general and also those specifically

focusing on cognitive behavioural therapy (CBT). The resulting information has been used to

critically evaluate the role of the therapeutic relationship in CBT, including a definition of what is

meant by the terms ‘therapeutic relationship’ and ‘cognitive behavioural therapy’, some background

about its development as a modality of therapy and a consideration of the possibility that there has

been a change in the importance and focus on the role of the therapeutic relationship in CBT. I will




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also offer a definition of the therapeutic/working alliance’ (which I will henceforth call the

therapeutic alliance) as this is sometimes used in place of therapeutic relationship and explain how

this could be considered a key component of the therapeutic relationship in CBT. A summary will

follow of some aspects of the historical background and development of the concept of the

therapeutic relationship and therapeutic alliance in psychotherapy generally, followed by a focus on

Rogers’ core conditions as they are a factor of the therapeutic relationship in the historical debate

around the efficacy of psychotherapy. I will explore more recent developments arising from

research which draw conclusions on what works in psychotherapy in general and in CBT in

particular, with a view to understanding what other factors may be present alongside the therapeutic

relationship in a CBT approach, the processes involved throughout therapy including managing and

working with ruptures in the therapeutic relationship and an understanding of the need to tailor the

relationship and techniques to the client. I will summarise my findings and offer my conclusions

and further thoughts about the possibilities for continued exploration.

Therapeutic Relationship

According to Clarkson (1994, p.29) “relationship or interconnectedness between two people

has been significant in all healing since the time of Hippocrates and Galen”. She goes on to point

out that “it is common knowledge that ordinary human relationships can have therapeutic value”.

According to Luborsky (as cited in Gilbert & Leahy, 2009, p.25) there are two phases of the

therapeutic relationship, initially it is a “…..relationship being characterised by the client’s belief in

the ability of the therapist to help him or her and the therapist’s requirement to provide a secure

environment for the client” this then develops into “…..a mutual relationship of working on the

tasks of therapy.”. This latter definition points to the importance of the client’s perceptions of the

therapist’s skills and an offering of hope which feels important in starting therapy of any kind. It




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also begins to describe the fluctuations that may occur over time in the contribution that different

aspects of therapy make to the outcomes of therapy, particularly in CBT.

The accumulated evidence importantly states that the quality and nature of the therapeutic

relationship or alliance is predictive of outcome. Fiedler in his research into the nature of the

therapeutic relationship in different modalities of therapy concluded that “These factors are related

to the therapist's ability to communicate with and understand the patient, and to his security and his

emotional distance to the patient. No factors were found which clearly separate therapists of

one school from those of another”. This supported the hypothesis of his research, that the nature of

the therapeutic relationship is a function of expertness rather than school. Norcross concludes that

(2011, p.101) “psychotherapy is at root a human relationship”.

Therapeutic Alliance

Constantino, Ladany, & Borkovec (2010) writing about the influence of Bordin as an

innovative thinker and teacher, recorded Bordin’s definition of the therapeutic or working alliance

as “the perpetual negotiation of therapeutic goals and tasks between client and therapist as a

function of client and therapist characteristics and the related strain of the work”. This refers to his

theory that the components of the therapeutic alliance include goals and tasks as well as a bond

which supports collaboration and that this alliance is a component of the therapeutic relationship. In

speaking about “the related strain of the work” Bordin (as cited in Constantino, Ladany, &

Borkovec, 2010, p.8) seems to suggest that working with ruptures and making these explicit in the

relationship is a key aspect of the therapeutic alliance. I discuss this aspect further, when exploring

the work of resolution and repair of ruptures to the therapeutic relationship in CBT. As Castonguay,

Constantino and Holtforth (2006) discovered, it is possible to view the working alliance as a

component of the therapeutic relationship alongside and in interaction with other important




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interpersonal skills such as empathy, positive regard and congruence. There are other skills and

micro-skills which evidence suggests form a part of CBT that I will discuss in greater depth later.

The Historical Development of the Therapeutic Relationship in Psychotherapy

The concept of the therapeutic relationship developed from Freud’s early

psychoanalytic theories involving attachment, transference and counter-

transference and included “the possibility of a beneficial client-therapist

attachment grounded in reality” (as cited in Horvath & Luborsky, 1993, p.561)

this was later elaborated on by Greenson (as cited in Horvath & Luborsky,

1993, p.561) who suggested “a concept of a reality-based collaboration

between therapist and client and coined the term working alliance”. Empathy

and therapist warmth is strongly indicated as a factor in behavioural therapy

and Gilbert and Leahy (2009, pp.6-7) cite the conclusions of a review of studies

of interactions between therapists and clients which “indicate that behaviour

therapists are rated higher on relationship variables such as empathy,

unconditional positive regard (UPR) and congruence” than other modalities.

Rogers’ Core Conditions

Rogers put forward his theory of the “Necessary and Sufficient Conditions of Therapeutic

Personality Change” in the Journal of Consulting Psychiatry in 1957. Rogers described six

conditions proposed as being the necessary and sufficient conditions for therapeutic personality

change, being that:

I. Two persons are in psychological contact

II. The first (the client) is in a state of incongruence, being vulnerable or anxious




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III. The second (the therapist) is congruent or integrated in the relationship

IV. The therapist experiences unconditional positive regard for the client

V. The therapist experiences an empathic understanding of the client’s internal frame of reference,

and endeavours to communicate this experience to the client

VI. The communication to the client of the therapist’s empathic understanding and unconditional

positive regard is to a minimal degree achieved

The first two conditions allow a therapeutic relationship to develop that holds the core

conditions of empathy, unconditional positive regard and congruence within itself and encourages

and enables the client to come to her own conclusions and reach her full potential, with the therapist

taking a non-directive role. Clients are able to provide their own solutions to their problems when

the therapist assumes that the client and not the therapist is really the expert on the client’s problem.

His argument seemed to differ widely from other psychotherapies at the time in that the

therapist was the expert, and had the skills or tools to excise or cure the part of the person that was

“sick” or in need of change.

These conditions were clearly emphasising a focus on the qualities and attributes offered to the

client by the therapist in a non-directive way and emphasised the approach believed to be effective

in person-centred therapy. However, according to Beck (as cited in Kinsella & Garland, 2008,

p.55)”…..the core conditions of warmth, accurate empathy and genuineness are necessary (but not

sufficient) to conduct CBT”. So whilst Beck’s cognitive therapy also placed importance on the

therapeutic relationship, according to Gilbert & Leahy (2009, p.5) “the parallel development of

Rogers’ helping relationship and the assumption that these were core skills for trainees, meant that

the focus of cognitive therapy was on using these skills to develop collaboration and facilitate

guided discovery, a cognitive formulation and an invitation to explore alternative thoughts and




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ideas”. Evidence suggests that the therapeutic relationship is a common factor in most therapies but

research is still not conclusive as to whether therapeutic change is purely driven by the efficacy of

the client/therapist relationship or whether this is a factor amongst many. Ellis (2003, p.204)

pointed out “that although basic constructive personality change—as opposed to symptom

removal — seems to require fundamental modifications in the ideologies and value systems of the

disturbed individual, there is probably no single condition which is absolutely necessary for the

inducement of such changed attitudes and behavior patterns”.

Horvath and Luborsky (1993) stated that “the majority of findings indicate that it is the client's

perception of the therapist as an empathic individual, rather than the actual therapist behavior, that

yielded the most robust correlation with outcome”. This would seem to point to an overt

demonstration of the core conditions but could also be based on the client’s subjective judgement of

their therapist resulting from the outcome being a positive one.

Cognitive Behavioural Therapy

As its name suggests CBT developed from the merging of two distinct therapeutic

approaches; behaviour therapy (Westbrook, Kennerley & Kirk, 2011, pp.1-2) as developed by

Wolpe and others in the 1950s and 1960s, and cognitive therapy developed by Beck at the

beginning of the 1960’s. Westbrook (Westbrook, Kennerley & Kirk, 2011, pp1-2) describes CBT as

a broad movement, rather than a single therapy, that continues to develop after its early beginnings

and is based on several principles that; It is interpretations of events, not events themselves, which

are crucial; What we do has a powerful influence on our thoughts and emotions; Mental-health

problems are best conceptualised as exaggerations of normal processes; It is usually more fruitful to

focus on current processes rather than the past; It is helpful to look at problems as interactions

between thoughts, emotions, behaviour and physiology and the environment in which the person




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operates (physical as well as social, family, cultural and economic); It is important to evaluate both

our theories and our therapy empirically.

CBT is a therapy which has been extensively researched and as a result, has a strong

evidence-base for its efficacy. It is used to treat many psychological disorders such as Depression

and Anxiety and has been extended and adapted to treat a wider range of disorders. Moorey (1996)

points out that CBT involves the therapist and client working collaboratively to identify current

problems and find solutions, with the client actively engaged in assignments and work in between

sessions (1996, p.17). This supports the idea that a cognitive change or shift is the most important

component in treating a psychological disorder (Beck, 2001). When considering brief CBT for

substance misuse clients (Center for Substance Abuse Treatment, 1999) these principles are

particularly effective in addressing coping mechanisms which support recovery rather than focusing

on “…..global themes or long-standing issues”. They also support the idea that it is important to

“understand the connection between the origins of a set of cognitions and the client's current

behaviour in order to promote the development of goals to “reverse dysfunctional thought

processes, emotions, and behaviour” and through this to understand the mechanism by which these

can be changed in the present day. “Clients are enlisted as co-investigators or scientists who study

their own thought patterns and associated consequences.”

Key Factors in Effective Therapy

Much research has been completed over many decades into what brings about effective

therapeutic change and particularly the idea stated by many that all psychotherapies are equally

effective and Rosenzweig’s (2002) ‘Dodo Bird verdict’ (as cited in Siev, Huppert & Chambless,

2009, pp.69-76) “.….that common factors, therapist, and relationship variables account for the

majority of the variance in therapy outcome studies”. Raymond DiGiuseppe (as cited in Siev,




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Huppert & Chambless, 2009, pp.69-76) “observed that efforts to disseminate empirically supported

treatments (ESTs), and especially cognitive-behavioral treatments, have been limited by these

statements” and goes on to suggest that this outcome rests on flawed evidence and has not been

updated since the original meta-analyses were completed some 20 years ago. This seemed to be a

‘call to arms’ to take account of the scientific evidence that supports the importance of other ‘active

ingredients’ such as techniques and specific interventions and the other skills, expertise and

knowledge that a CBT therapist may draw upon.

In a meta-analysis of clinical research completed by Norcross and Lambert (2011) they

conclude that “The relationship acts in concert with treatment methods, patient characteristics,

and practitioner qualities in determining effectiveness. A comprehensive understanding of effective

(and ineffective) psychotherapy will consider all these determinants and their optimal

combinations.”

Historically, research into evidence based therapies such as CBT had not focused on

relationship factors. However, in 1995 the American Psychological Association (APA) conducted

“the largest ever review of empirical evidence” (Cooper 2008, p.101) in the area of the therapeutic

relationship in an attempt to identify the relationship components of effective therapy. According to

Cooper (2008) this review “identified four ‘demonstrably effective’ elements and seven ‘promising

and probably effective elements’”. These, listed in order of strength of affect, were “goal consensus

and collaboration; cohesion in group therapy; therapeutic alliance; empathy which were

demonstrably effective and management of countertransference; feedback; positive

regard; congruence; self-disclosure; relational interpretations; repair of alliance ruptures, which

were found to be promising and probably effective elements”. In considering the therapeutic

alliance it is important to attend to the subjective measurement of the relationship between client




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and therapist. As Cooper states (2008) “It may be that clients who feel they are doing well in

therapy then start to feel more positive about their therapists.” Feedback is also important when

considering the impact of the client’s perception of their relationship with the therapist and how this

affects the outcomes of therapy.




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The Therapeutic Relationship in CBT

It seems clear that a therapeutic relationship between client and therapist is an essential

component for most psychotherapy with differing levels of emphasis at different points in the

therapeutic process. However, there are also many additional components for skilled CBT therapists

to be aware of alongside the therapeutic relationship in order to deliver effective therapy and

support relapse prevention/management. These are described in the Cognitive Therapy Scale -

Revised (CTS-r) as developed by Blackburn et al. (2000). This is a CBT therapist rating scale which

attempts to describe an optimal approach to offering therapy, utilising structured procedural

competencies such as agenda setting and adherence and goal setting alongside relational skills to

support the eliciting of thoughts and feelings which could be seen to ‘approach and recede’ in focus

according to many different factors including; the client; their presenting difficulty (and particularly

whether this centres around difficulties in forming and maintaining relationships); the type of

intervention according to the formulation and tasks agreed with the client; therapist self-awareness

and understanding of their own schemas and the manner in which these may hinder therapy, guided

discovery, persuasiveness, interpersonal effectiveness, flexibility, and the ability to put the client at

the centre of recovery. This ebb and flow; has led me to consider the processes in therapy which I

explore further below.

Processes in Therapy

Much recent research has also considered whether the therapeutic relationship is more or less

important at different points throughout therapy, with differing outcomes, but drawing some

important conclusions regarding key factors in offering evidence based therapy. In considering this,

Leahy states that “It is important to think of the therapeutic relationship or alliance as an on-going

process, rather than an achievement that is fixed at one point in time, since the relationship is




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interactive and iterative, reflecting the patient’s response to the therapist’s response to the patient”

(2008). The process of therapy can be viewed as having key stages as described by Gilbert & Leahy

(2009, p.10) in that the therapeutic relationship is particularly important at the beginning of therapy

in order for the client to feel safe and able to disclose painful experiences. This begins the interplay

between communication and relationship building skills alongside other key skills required in CBT

and seems important in socialising the client to the concepts of CBT and to support the client in

working collaboratively. The therapeutic relationship could be seen as ‘bookends’ to therapy with

ruptures and breaks in the relationship arising between them and drawing both therapist and client

back to attend to the deepening of the relational alliance and other tasks and goals of therapy. I

discuss working with difficulties and ruptures in more detail below. A factor acknowledged by

Norcross (2002, p.4) as being important when considering customisation of the therapeutic

relationship to the client considers the stages of change and that it is helpful to match the

therapeutic relationship and the treatment method to the stage of change (Prochaska and

DiClemente, 1986) that the client is at e.g. pre-contemplation, contemplation etc. This is a further

area of study that has implications for development in future research.

Resolution and Repair of Ruptures

In their research, Castonguay et al. (as cited in Castonguay (Ed), 1996, p.197) “found clear

evidence of strains in the alliance (e.g., clients were negative, unresponsive, avoidant) in several

cases of cognitive therapy; they noted that therapists addressed the strain by increasing their

adherence to the cognitive therapy protocol and emphasizing the impact of the clients’ distorted

thoughts, which unfortunately then led to therapist-client power struggles”. This again highlights

the need for the therapist to be aware of their own schemas - core beliefs or cognitive patterns -

particularly those that impact their relationships with others and may be in conflict with a client’s




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beliefs - to ensure that these are not working against the client as this can lead to ruptures or

disengagement. Counter-transference, defined by Norcross as referring to “reactions in which the

unresolved conflicts of the psychotherapist, usually but not always unconscious, are implicated.”

also needs to be managed as research suggests that a therapist acting out counter-transference

hinders effective therapy.

Leahy (2008) states that “During the last decade there has been increased interest in the

nature of the therapeutic relationship in cognitive behavioral therapy” and goes on to emphasise the

opportunities presented for using this relationship to resolve ruptures in the therapeutic relationship.

Safran, Muran, Samstag, & Stevens, (2002) (as cited in Chambers (Ed), 2011, p.197), have

identified how therapeutic alliance ruptures provide a clinical opportunity to explore and restructure

a patient’s maladaptive relational schemas and thereby function as an important mechanism of

psychological transformation. Safran et al. (1990) concluded that “the positive outcome of therapy

was more closely associated with the successful resolution of ruptures in the alliance than with a

linear growth pattern as the therapy proceeds.”

Safran & Muran state that “Ruptures in the therapeutic alliance are episodes of tension or

breakdown in the collaborative relationship between patient and therapist. Exploring and repairing

alliance ruptures when they occur can be an important element contributing to positive treatment

outcome.” (as cited in Norcross & Lambert, 2011).

Summary

I have explored a broad range of texts and information regarding the therapeutic relationship

across a range of therapies, throughout the history and development of psychotherapy and

specifically in CBT and have learnt a great deal about the debate which still continues around which

school or modality is most effective and why, as well as the role that the therapeutic relationship




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plays in psychotherapy and CBT in particular. I have defined the key terms and explored the

historical background and themes including various acknowledgements of the key factors, processes

and phases involved in building the therapeutic relationship including Rogers’ core conditions and

Beck’s opinion that these may be necessary but not sufficient in CBT. I have also considered the

importance of the resolution and repair of ruptures in the therapeutic relationship and the

relationship factors which may lead to ruptures such as client/therapist schema and counter-

transference.

Conclusion

From my reading there seem to be many opinions and developments concerning the role of the

therapeutic relationship in CBT. The accumulated evidence seems to suggest that the therapeutic

relationship plays an important role in CBT but that this alone is not sufficient for therapeutic

change to take place. It seems that the therapeutic relationship is most effective when used in

concert with and alongside specific CBT skills that are a strong functional component of the

efficacy of CBT and this is emphasized when considering the CTS-r and the competencies

described therein. The importance and role of the therapeutic relationship also seems to fluctuate

across the process of therapy. The Dodo bird may have suggested that - "Everybody has won and

all must have prizes" (Carroll, L., Alice’s Adventures in Wonderland) but this seems to be a flawed

argument when considering the evidence of research that continues for specific evidence based

treatments and interventions which are designed to address particular issues and that show a clear

reduction in symptoms of mental illness and reduce the likelihood of these returning. The skills

required to be an effective CBT therapist are many and varied and clearly place the therapeutic

relationship in a central role but that is certainly not the whole story. Further developments into

areas of treatment and research, for instance around Schizophrenia and Psychosis and specificity of




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technique and treatment, while keeping the client at the centre of recovery and adapting the

relationship to the individual client”, i.e. adapting the therapy relationship to specific client needs

and characteristics (in addition to diagnosis) will hopefully add to the evidence for what is required

to deliver effective CBT.




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