Importance of Therapeutic Relationship in Cognitive Therapy

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17th Apr 2018 Psychology Reference this

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Within cognitive therapy, the therapeutic relationship, along with the emotional aspects of therapy in general, has historically been of less importance than for other therapeutic modalities. In the last decade this has changed and in the so-called ‘third wave’ in cognitive therapy there is a much greater interest in the therapeutic relationship (Hayes, Strosahl & Wilson, 2004). This essay evaluates the relevance of the therapeutic relationship in cognitive therapy with reference to the outcome research.

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The term ‘therapeutic relationship’ covers a wide range of factors within therapy, each of which have been examined separately in the research. Hardy, Cahill and Barkham (2007) have suggested that it is useful to break down this research into three areas: establishing the relationship, developing the relationship and, finally, maintaining the relationship. Starting with establishing a relationship, Sexton, Littauer, Sexton and Tømmerås (2005) examined the first two sessions with 34 different clients using anonymous ratings at 20 second intervals. They found that better therapeutic alliances were associated with earlier meaningful connection and emotional involvement.

Empathy is also thought to be a major component in establishing a relationship. The research on the contribution of empathy towards the therapeutic outcome has been subject to meta-analysis by Bohart, Elliott, Greenberg and Watson (2002). This found that between 7% and 10% of psychotherapy outcomes were explained by empathy – indeed this relationship was particularly strong in cognitive therapies. Two further components central to establishing a relationship which have also garnered positive relationship with outcomes in the literature are engagement (e.g. Tryon, 2002) and mutual involvement (e.g. Tryon & Winograd, 2002).

The second research area is developing a relationship; in order to progress clients must have a sense of commitment, trust and openness towards their therapist (Hardy, Cahill & Barkham, 2007). This means the therapist must effectively manage the relationship, including negotiating factors like transference and counter-transference (Ligiero & Gelso, 2002). This area, however, has not been extensively examined within cognitive therapy.

The third research area is maintaining the relationship. Research has examined how therapists deal with the inevitable problems that arise in therapeutic relationships. Better outcomes are generally predicted by successfully dealing with challenges to the therapeutic relationship. Challenges studied have included negative feelings towards clients (Gelso & Carter, 1985), disagreements (Safran, Muran, Samstag & Stevens, 2001) and resistance (Binder & Strupp, 1997). Stiles et al. (2004) looked at the overall pattern of alliance development over the course of both cognitive and psychodynamic therapies. They found that those who had ruptures in the therapeutic alliance, which were subsequently repaired, had the best treatment outcomes. This, along with similar previous research by Kivlighan and Shaughnessy (2000) strongly underlines the importance of relationship maintenance in treatment outcome.

Much of the research on the therapeutic alliance across treatment modalities has been reviewed in two meta-analyses (Horvath & Symonds, 1991; Martin, Garske & Davis, 2000). Both found positive support for its effect on outcome. In addition Norcross (2002) has estimated that 30% of psychotherapeutic outcomes are related to ‘common factors’ – mostly therapeutic alliance. This is compared to only a 15% influence of techniques – a component of cognitive therapy that has traditionally been emphasised. This point, though, has proved controversial and DeRubeis, Brotman and Gibbons (2005) have criticised studies such as those cited above for merely providing correlational evidence. For example, almost without exception the studies analysed by Martin et al. (2000) were correlational. DeRubeis et al. (2005) argue that a good outcome could well be producing a good alliance, rather than the reverse. Further Safran and Muran (2006) criticise the meta-analyses for only explaining 6% of the outcome variance. Despite these criticisms Craighead, Sheets and Bjornsson (2005) point out that a strong therapeutic alliance is still a vital component of positive change and research continues to underline its importance in cognitive therapy (e.g. Krupnick et al., 2006).

In conclusion, the research on the therapeutic alliance in cognitive therapy has generally demonstrated its association with a positive outcome for clients. The importance of establishing and maintaining relationships have both been demonstrated in cognitive therapy. Some have even suggested the supremacy of ‘common factors’ such as the therapeutic alliance over specific techniques of the cognitive modality. These claims are tempered, however, by methodological concerns with correlational data, which mean that the therapeutic alliance could be a result of a good outcome. Despite this, given that current research continues to point to the benefits associated with the therapeutic alliance, it seems likely this factor will continue to emerge as a vital component of cognitive therapy.

References

Binder, J. L., & Strupp, H. H. (1997). Negative process: a recurrently discovered and underestimated facet of therapeutic process and outcome in the individual psychotherapy of adults. Clinical Psychology: Science and Practice, 4(2), 121-139.

Bohart, A. C. , Elliott, R., Greenberg, L., & Watson, J. C. (2002). Empathy. In J. R. Norcross et al. (Eds.), Psychotherapy Relationships That Work (pp. 89-108). New York: Oxford University Press.

Craighead, W. E., Sheets, E. S., & Bjornsson, A. S. (2005). Specificity and nonspecificity in psychotherapy. Clinical Psychology: Science and Practice, 12(2), 189-193.

DeRubeis, R. J., Brotman, M. A., & Gibbons, C. J. (2005). A conceptual and methodological analysis of the nonspecifics argument. Clinical Psychology: Science and Practice, 12(2), 174-183.

Gelso, C. J., & Carter, J. A. (1985). The relationship in counseling and psychotherapy: components, consequences, and theoretical antecedents. The Counseling Psychologist, 13(2), 155.

Hardy, G., Cahill, J., & Barkham, M. (2007). Active ingredients of the therapeutic relationship that promote client change: a research perspective. In: P. Gilbert & R. L. Leahy (Eds.). The Therapeutic Relationship in the Cognitive Behavioral Psychotherapies (pp. 24-42). Oxford: Routledge.

Hayes, S. C., Strosahl, K. D., & Wilson, K. D. (2004). Acceptance and commitment therapy: an experiential approach to behaviour change. New York: Guildford Press.

Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139–149.

Kivlighan, D., & Shaughnessy, P. (2000). Patterns of working alliance development: A typology of client’s working alliance ratings. Journal of Counseling Psychology, 47(3), 362-371.

Krupnick, J. L., Sotsky, S. M., Elkin, I., Simmens, S., Moyer, J., Watkins, J., et al. (2006). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the national institute of mental health treatment of depression collaborative research program. Focus, 4(2), 269-277.

Ligiero, D. P., & Gelso, C. J. (2002). Countertransference, attachment, and the working alliance: The therapist’s contributions. Psychotherapy: Theory, Research, Practice, and Training, 39(1), 3-11.

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450.

Norcross, J. C. (2002). Psychotherapy relationships that work: therapist contributions and responsiveness to patients. Oxford: Oxford University Press.

Safran, J. D., & Muran, J. C. (2006). Has the concept of the therapeutic alliance outlived its usefulness. Psychotherapy: Theory, Research, Practice, Training, 43(3), 286-291.

Safran, J. D., Muran, J. C., Samstag, L. W., & Stevens, C. (2001). Repairing alliance ruptures. Psychotherapy, 38(4), 406-412.

Sexton, H., Littauer, H., Sexton, A., & Tømmerås, E. (2005). Building an alliance: Early therapy process and the client–therapist connection. Psychotherapy Research, 15(1), 103-116.

Stiles, W. B., Glick, M. J., Osatuke, K., Hardy, G. E., Shapiro, D. A., Agnew-Davies, R., et al. (2004). Patterns of alliance development and the rupture-repair hypothesis: are productive relationships U-shaped or V-shaped? Journal of Counseling Psychology, 51(1), 81-92.

Tryon, G. S. (2002). Engagement in counselling. In: G. S. Tryon (Ed.). Counseling based on process research: Applying what we know (pp. 1-26). Boston: Allyn & Bacon.

Tryon, G. S., & Winograd, G. (2002). Goal consensus and collaboration. In: J. R. Norcross (Ed.). Psychotherapy Relationships That Work (pp. 109-125). New York: Oxford University Press.

Within cognitive therapy, the therapeutic relationship, along with the emotional aspects of therapy in general, has historically been of less importance than for other therapeutic modalities. In the last decade this has changed and in the so-called ‘third wave’ in cognitive therapy there is a much greater interest in the therapeutic relationship (Hayes, Strosahl & Wilson, 2004). This essay evaluates the relevance of the therapeutic relationship in cognitive therapy with reference to the outcome research.

The term ‘therapeutic relationship’ covers a wide range of factors within therapy, each of which have been examined separately in the research. Hardy, Cahill and Barkham (2007) have suggested that it is useful to break down this research into three areas: establishing the relationship, developing the relationship and, finally, maintaining the relationship. Starting with establishing a relationship, Sexton, Littauer, Sexton and Tømmerås (2005) examined the first two sessions with 34 different clients using anonymous ratings at 20 second intervals. They found that better therapeutic alliances were associated with earlier meaningful connection and emotional involvement.

Empathy is also thought to be a major component in establishing a relationship. The research on the contribution of empathy towards the therapeutic outcome has been subject to meta-analysis by Bohart, Elliott, Greenberg and Watson (2002). This found that between 7% and 10% of psychotherapy outcomes were explained by empathy – indeed this relationship was particularly strong in cognitive therapies. Two further components central to establishing a relationship which have also garnered positive relationship with outcomes in the literature are engagement (e.g. Tryon, 2002) and mutual involvement (e.g. Tryon & Winograd, 2002).

The second research area is developing a relationship; in order to progress clients must have a sense of commitment, trust and openness towards their therapist (Hardy, Cahill & Barkham, 2007). This means the therapist must effectively manage the relationship, including negotiating factors like transference and counter-transference (Ligiero & Gelso, 2002). This area, however, has not been extensively examined within cognitive therapy.

The third research area is maintaining the relationship. Research has examined how therapists deal with the inevitable problems that arise in therapeutic relationships. Better outcomes are generally predicted by successfully dealing with challenges to the therapeutic relationship. Challenges studied have included negative feelings towards clients (Gelso & Carter, 1985), disagreements (Safran, Muran, Samstag & Stevens, 2001) and resistance (Binder & Strupp, 1997). Stiles et al. (2004) looked at the overall pattern of alliance development over the course of both cognitive and psychodynamic therapies. They found that those who had ruptures in the therapeutic alliance, which were subsequently repaired, had the best treatment outcomes. This, along with similar previous research by Kivlighan and Shaughnessy (2000) strongly underlines the importance of relationship maintenance in treatment outcome.

Much of the research on the therapeutic alliance across treatment modalities has been reviewed in two meta-analyses (Horvath & Symonds, 1991; Martin, Garske & Davis, 2000). Both found positive support for its effect on outcome. In addition Norcross (2002) has estimated that 30% of psychotherapeutic outcomes are related to ‘common factors’ – mostly therapeutic alliance. This is compared to only a 15% influence of techniques – a component of cognitive therapy that has traditionally been emphasised. This point, though, has proved controversial and DeRubeis, Brotman and Gibbons (2005) have criticised studies such as those cited above for merely providing correlational evidence. For example, almost without exception the studies analysed by Martin et al. (2000) were correlational. DeRubeis et al. (2005) argue that a good outcome could well be producing a good alliance, rather than the reverse. Further Safran and Muran (2006) criticise the meta-analyses for only explaining 6% of the outcome variance. Despite these criticisms Craighead, Sheets and Bjornsson (2005) point out that a strong therapeutic alliance is still a vital component of positive change and research continues to underline its importance in cognitive therapy (e.g. Krupnick et al., 2006).

In conclusion, the research on the therapeutic alliance in cognitive therapy has generally demonstrated its association with a positive outcome for clients. The importance of establishing and maintaining relationships have both been demonstrated in cognitive therapy. Some have even suggested the supremacy of ‘common factors’ such as the therapeutic alliance over specific techniques of the cognitive modality. These claims are tempered, however, by methodological concerns with correlational data, which mean that the therapeutic alliance could be a result of a good outcome. Despite this, given that current research continues to point to the benefits associated with the therapeutic alliance, it seems likely this factor will continue to emerge as a vital component of cognitive therapy.

References

Binder, J. L., & Strupp, H. H. (1997). Negative process: a recurrently discovered and underestimated facet of therapeutic process and outcome in the individual psychotherapy of adults. Clinical Psychology: Science and Practice, 4(2), 121-139.

Bohart, A. C. , Elliott, R., Greenberg, L., & Watson, J. C. (2002). Empathy. In J. R. Norcross et al. (Eds.), Psychotherapy Relationships That Work (pp. 89-108). New York: Oxford University Press.

Craighead, W. E., Sheets, E. S., & Bjornsson, A. S. (2005). Specificity and nonspecificity in psychotherapy. Clinical Psychology: Science and Practice, 12(2), 189-193.

DeRubeis, R. J., Brotman, M. A., & Gibbons, C. J. (2005). A conceptual and methodological analysis of the nonspecifics argument. Clinical Psychology: Science and Practice, 12(2), 174-183.

Gelso, C. J., & Carter, J. A. (1985). The relationship in counseling and psychotherapy: components, consequences, and theoretical antecedents. The Counseling Psychologist, 13(2), 155.

Hardy, G., Cahill, J., & Barkham, M. (2007). Active ingredients of the therapeutic relationship that promote client change: a research perspective. In: P. Gilbert & R. L. Leahy (Eds.). The Therapeutic Relationship in the Cognitive Behavioral Psychotherapies (pp. 24-42). Oxford: Routledge.

Hayes, S. C., Strosahl, K. D., & Wilson, K. D. (2004). Acceptance and commitment therapy: an experiential approach to behaviour change. New York: Guildford Press.

Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139–149.

Kivlighan, D., & Shaughnessy, P. (2000). Patterns of working alliance development: A typology of client’s working alliance ratings. Journal of Counseling Psychology, 47(3), 362-371.

Krupnick, J. L., Sotsky, S. M., Elkin, I., Simmens, S., Moyer, J., Watkins, J., et al. (2006). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the national institute of mental health treatment of depression collaborative research program. Focus, 4(2), 269-277.

Ligiero, D. P., & Gelso, C. J. (2002). Countertransference, attachment, and the working alliance: The therapist’s contributions. Psychotherapy: Theory, Research, Practice, and Training, 39(1), 3-11.

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450.

Norcross, J. C. (2002). Psychotherapy relationships that work: therapist contributions and responsiveness to patients. Oxford: Oxford University Press.

Safran, J. D., & Muran, J. C. (2006). Has the concept of the therapeutic alliance outlived its usefulness. Psychotherapy: Theory, Research, Practice, Training, 43(3), 286-291.

Safran, J. D., Muran, J. C., Samstag, L. W., & Stevens, C. (2001). Repairing alliance ruptures. Psychotherapy, 38(4), 406-412.

Sexton, H., Littauer, H., Sexton, A., & Tømmerås, E. (2005). Building an alliance: Early therapy process and the client–therapist connection. Psychotherapy Research, 15(1), 103-116.

Stiles, W. B., Glick, M. J., Osatuke, K., Hardy, G. E., Shapiro, D. A., Agnew-Davies, R., et al. (2004). Patterns of alliance development and the rupture-repair hypothesis: are productive relationships U-shaped or V-shaped? Journal of Counseling Psychology, 51(1), 81-92.

Tryon, G. S. (2002). Engagement in counselling. In: G. S. Tryon (Ed.). Counseling based on process research: Applying what we know (pp. 1-26). Boston: Allyn & Bacon.

Tryon, G. S., & Winograd, G. (2002). Goal consensus and collaboration. In: J. R. Norcross (Ed.). Psychotherapy Relationships That Work (pp. 109-125). New York: Oxford University Press.

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