Role of the Therapeutic Relationship in Cognitive Behavioural Therapy

The therapeutic relationship is seen as one of the main therapeutic tools for achieving client change (Luborsky, 1994).

Critically evaluate the above comment, describing the role of the therapeutic relationship and of theory and technique in CBT.

The importance of the relationship between practitioner and client has long been documented in psychodynamic therapy to be a fundamental tool in achieving client change (Rosenzweig 1936; Rogers, Laurance, & Shaffer, 1957; Orlinsky, Grawe & Parks, 1994). Conflictingly, CBT has been historically criticised for its textbook, structured approach and ignoring the importance of the practitioner-client interaction with a focus instead on theory and technique (Easterbrook & Meehan, 2017). In 2001, Wampold in his controversial article, “The Great Psychotherapy Debate”, criticised the use of empirically supported treatment for specific psychological presentations and explored the concept of common factors across all therapies with an emphasis on the therapeutic relationship when considering change outcomes (Wampold, 2001; Wampold, 2015). This therefore suggests that the therapeutic relationship is as important in CBT as other therapies. In agreement with this, there are some researchers which even suggest a stronger association between therapeutic relationship and outcome in CBT more than any other therapy (Bohart et al., 2002; Stiles et al., 1998). Conversely, researchers such as Raykos et al., (2014) concluded that in their study on the use of the therapeutic relationship in CBT with clients living with bulimia, there showed no evidence that the relationship can predict treatment retention or outcome. In my previous work as a Psychological Wellbeing Practitioner (PWP) and in my current role as a Trainee Counselling Psychologist, I find the therapeutic relationship of crucial importance particularly when working with clients from a range of backgrounds in a short term therapeutic setting. Thus, due to the conflicting evidence on this topic; this essay will aim to critically explore and evaluate the scope of the therapeutic relationship within CBT and of theory and technique, focusing also on the role of the practitioner versus the client in this relationship and the consequences, if any, in achieving client change when the therapeutic relationship is challenged or ruptured.

How important is the therapeutic relationship in CBT?

Throughout research the therapeutic relationship within CBT has been defined in many ways. Leahy & Gilbert, (2017, p.10) offer the most updated definition stating that the therapeutic relationship is, “the affective bond and partnership; the cognitive consensus on goals and tasks and relationship history of the participants”. Today the majority of CBT research acknowledges some form of therapeutic relationship and the impact of this on change outcomes (Wampold, 2015; Easterbrook & Meehan, 2017; Leahy & Gilbert, 2017, p.10). Moreover, at present, the British Association for Behavioural & Cognitive Psychotherapies (BABCP) as one of its accreditation criteria, stipulate that practitioners should be reflecting a genuine, warm, concerned interest in the client’s perspective and presentation (BABCP, 2017). In psychodynamic theory, the therapeutic relationship is often considered to be in three parts; the working alliance, transference/countertransference and the real relationship (Bordin & Kovacs, 1979). Critically, Kazantzsis (2018) also state within CBT there are also 3 specific elements present within therapeutic relationship; collaboration, empiricism and Socratic questioning. Despite this, both practice based research and technique in CBT are also seen to have key influence and there is ongoing debate about which of these factors has the most significance in achieving lasting client change.

To work collaboratively with their clients; CBT textbooks suggest practitioners should operate as the guide rather than the instructor and acknowledge the client as the expert in their experience (Bennett-Levy, 2010 p90). Arguably, this is similar to the working alliance of psychodynamic theory which suggests, “A therapeutic alliance based on the patient experiencing the therapist as supportive and helpful” and “a sense of working together in a joint struggle against what is impeding the patient” (Horvath, 1993). Despite this similarity in this first key aspect of the therapeutic relationship, Kennerley, Kirk & Westbrook (2017 p. 44) suggest it is instead the nature of the client’s participation that is the strongest predictor of client change and outcome and not the relationship when it comes to CBT. An idea mirrored by Kazantzsis, Whittington & Dattilio, (2010) who suggest that a CBT client who engages in tasks, offers suggestions about treatment and consistently completes homework will have better outcomes than a client who does not regardless of therapeutic relationship.

Yet, when considering the importance of the relationship versus theory and technique in CBT, it is also important to account for the many varieties in which CBT can be offered. For example, Turner, Carpenter & Brown (2018) explored the effects on the therapeutic relationship when looking at CBT completed over the phone. They found that telephone work can accommodate collaboration but not other aspects of the therapeutic relationship which often practitioners and service users hope for. Furthermore, with online therapy there can often be a complete absence of a relationship particularly when clients use guided self-help computer programmes but dropout rates for these programmes are high and improved when a practitioner is assigned to interact with the client (Papworth & Marrinan, 2013). This would therefore suggest that clients require more than just evidenced based practice and technique from sessions. Moreover, Chaddock (2013) has proposed that attending to interpersonal factors is even more important in short term therapies where a relationship must be built quickly to increase client participation and facilitate change. In my own experience as a PWP in primary care, the therapeutic relationship is one of the biggest factors for change and in increasing homework adherence and client attendance. Often clients whom I struggled to build this relationship as quickly would complete less homework and often not attend sessions as regularly. It could then be argued that the relationship allows the client to engage with theories and technique more easily; an idea echoed by Teyber (2011) who states that the therapeutic relationship is the foundation of trust a key factor in leading to change for the client.

The second criteria for the therapeutic relationship within CBT according to Kazantzsis (2018) explores empiricism. As part of applying theory to practice and in successfully using CBT techniques, the CBT practitioner has the responsibility for individualising each intervention to the client’s experience (e.g. mood ratings, thought diaries) and using these as a gauge for evaluating client’s hypothesis about what will happen in treatment and the changes they would like to make going forward in their lives (Glenn et al., 2013). It can therefore be argued that in addition to the skilful use of common factors and counselling skills, CBT has specific structured components which require the practitioner to be even more flexible with the relationship (Glenn et al, 2013). This then suggests some support for studies which show that the therapeutic relationship is even more important in CBT than in other forms of therapy (Bohart et al., 2002; Stiles et al., 1998). Additionally, the second aspect of the therapeutic relationship in psychodynamic theory highlights the importance of countertransference and transference. These two are also closely monitored in CBT and not absent. Practitioners are required to be self-reflecting and research highlights the importance of the CBT therapist becoming aware of their own dysfunctional thoughts, behaviours and emotions as to not negatively impact their relationships with their clients. As a result, much of these concepts are built into reflective and supervision processes within CBT (Leahy & Gilbert, 2017). In my personal experience, using empiricism and careful application of technique individualised to clients, can create substantial motivation for change particularly with clients who may have tried to apply CBT approaches in the past and found them unsuccessful. For example, I have experience of using mindful chocolate eating or mindful tea making in sessions to allow creativity for clients who feel they have been unsuccessful with learning more traditional mindfulness approaches in the past and found by individualising the technique this increased mindfulness uptake. Additionally, supervision and reflection in my opinion, allows me to further explore the relationship and aids positive outcomes.

The third criteria by Kazantzsis (2018) for the effective therapeutic relationship in CBT is the use of Socratic questioning (Padesky, 1995). Used in CBT to aid guided discovery, Socratic questioning it is a key part of CBT’s value that clients should become their own therapists at the end of their treatment (Kennerley, Kirk & Westbrook, 2017). In my work, I feel this is the ultimate goal for client change and for preventing relapse. Teaching clients to become their own practitioners has also been shown to be effective in preventing relapse by Degnan et al., (2016). Unfortunately, limited research exists on the third aspect of the psychodynamic therapeutic relationship the ‘real relationship’ and the meaning of this within psychodynamic therapy.

Thus, within CBT it seems difficult if not impossible to separate theory and technique from the therapeutic relationship. For example, Persons, Davidson & Thompkins, (2001), suggest between session interventions or ‘home practice’ work as the main vehicle for change, more so than any other element in CBT. Yet CBT therapists take a collaborative, empirical and Socratic approach to reviewing home practice. For this reason, further research is needed to explore the breakdown of specific aspects of the therapeutic relationship and the application of these to each evidence-based technique used in CBT. Some research has already begun in this area with Kazantzis et al. (2018) suggesting a, “Russian doll”, process which concludes that techniques (including homework, agenda adherence and other key factors) are inseparable from the therapeutic relationship but also highlights that some aspects of the therapeutic relationship are more significant than others but this paper also acknowledges the need for further research. Moreover, it would be helpful for future research to compare further the therapeutic relationship in CBT and the similarities and differences to the therapeutic relationship in psychodynamic and other therapies.

Roles within the relationship: Client versus Practitioner

Like all relationships roles are adopted in CBT and as a result both therapist and client have roles to play when it comes to the therapeutic relationship. Recent research has highlighted the importance of thinking outside of the immediate dynamic between client and practitioner and beyond collaboration, empiricism and Socratic questioning to look at within characteristics of both client and practitioner and the impact this may have on outcomes. For example, research by Zuroff et al., (2016) states that the within characteristics of the therapist are one of the biggest factors in determining client outcomes when it comes to depression. Further, more recent research by Kazantzsis (2018) also suggests that the amount of flexibility the therapist has with a client and the more open minded the therapist can be, the better implications client change. Moreover, Bennett-Levy (2010) suggest the therapist’s level of training is also a key factor and that insecure therapists are often over involved in their client’s goals and have poorer client outcomes. Research by Fonagy, Allison & Hilsenroth, (2014) has also highlighted the therapist characteristics which are associated with negative aspects of the therapeutic relationship including being ridged, uncertain, distant, and tense or distracted as a therapist. This research would therefore suggest the therapist has a great deal of power in the therapeutic relationship to produce change perhaps sometimes even more so than the client.

However, some researchers argue there are several within characteristics influencing the client in the relationship which have the biggest impact on outcomes. For example, Degnan et al., (2016) suggest that service users with more preoccupied attachment styles may find it difficult to form positive attachments. In my personal experience in assessing clients with attachment disorders as an assistant psychologist the therapeutic relationship is more difficult to establish and maintain but is helped with appropriate supervision from more experienced colleagues. However, in a study conducted by Hollon, Stewart & Strunk et al., (2006), clients show no increased vulnerability following the end of therapy suggesting perhaps the have the role of the therapist becomes less important over time. Moreover, an alternative hypothesis is also suggested by Derubis, Brotman & Gibbons, (2005), who state that in depressed client’s cognitive symptom reduction causes improvements in the therapeutic relationship and not vice versa.

In my own experience, it is a combination of both the client and the therapist unique characteristics which can create the biggest change in the client. As described by Leahy & Gilbert (2017) both client and therapist bring their own experiences of past relationships to the therapeutic setting. Therefore, it is a dysfunctional belief that all therapists have the flexibility, interpersonal and technical skills to work with all clients and this is an important factor to consider. For both parties the therapeutic relationship will be a process of an ongoing negotiation between the needs of self versus the needs of other (Leahy & Gilbert, 2017). In this way the therapeutic relationship is an important tool for change within CBT, but the role of the therapist and client can vary drastically from one therapist-client relationship to the next. Although further research is needed in this area, the potential uniqueness of each client-practitioner relationship could have important ramifications particularly in terms of the reproducibility and external validity of studies.

Moreover, there are a number of factors outside the role of the client and the therapist which affect the therapeutic relationship. For example, Leahy & Gilbert (2017) suggest for clients to benefit from therapy the treatment often needs to be of more than six months in length in order for there to be enough time for a sufficient therapeutic relationship to form. Additionally, culture, social status and other demographic variables also have a role to play (Hays, 2013). For example, Chu et al., (2016) also found that in a number of studies matching therapist and client in terms of cultural background can improve outcomes, enhance the therapeutic relationship and decrease premature termination of therapy. Therefore, as well as the therapeutic relationship itself and the within characteristics of both client and therapist external factors are an important consideration.

Factors affecting change: Ruptures and Boundaries

Finally, when considering the therapeutic relationship as one of the main therapeutic tools for achieving client change in CBT it is important to consider what happens when the relationship goes wrong. Notably, within therapy a positive therapeutic relationship is seen as necessary but not sufficient for change to occur (Leahy & Gilbert, 2017). Heins, Knoop & Bleijenberg (2013) suggest that when using CBT for chronic fatigue syndrome a large part of treatment variance (25%) relies on a positive working relationship developed early on in therapy and being developed and maintained throughout treatment. In contrast, Kennerley, Kirk & Westbrook (2017, p 49) encourage practitioners to not be afraid of ruptures in the relationship. They advise practitioners to, “not be surprised that ruptures in the working alliance occur’ stating that ‘your client’s problems have often become so entrenched that he is unable to deal with them independently”. They suggest emotional distress, not carrying out homework and various other client signals as signs that there is a rupture in the relationship. Similarly, Watson, Thomas & Daffern (2017) suggest using ruptures as a chance to provide the client with a corrective emotional experience; however they emphasise doing this carefully as clients in their study who end therapy with poorer therapeutic alliance and major ruptures were associated with poorer outcomes.

Furthermore, when using ruptures in the relationship to create change, it is also imperative to consider the power within the relationship and the client’s view of this. In my experience, the nature of the therapeutic relationship means the practitioner often knows the client’s deepest feelings and the client knowing only superficial facts about the therapist. This can easily lead to a power imbalances throughout therapy (Bhui, 2018). Within CBT power is typically balanced using collaboration and other aspects of the relationship (Bhui, 2018), but the idea of using ruptures may force a client to engage in material (s)he is not ready for causing a significant power imbalance. Muran et al., (2009) suggest power can be rebalanced if the therapist develops self-awareness to their own subjective feelings and understands the rupture as an ongoing negotiation process constantly in flux and uses the rupture as a window into the patient’s interpersonal belief system. However, therapists can easily underestimate the seriousness of a client’s problem (Snow et al., 1990). It then seems plausible that they could easily led a client to address something for which they are not yet ready which could have an impact on client outcomes. Moreover, clients are often likely to feel inferior to their therapist and made hide this for fear of losing the therapeutic relationship (Leahy & Gilbert, 2017).

With this in mind, there is also conflicting research on the best ways to use ruptures in CBT. Aspland et al., (2008) suggest a rupture repair model for CBT therapists which does not involve discussing the rupture with the client. Conversely, Muran et al., (2009) recommend a five stage approach to ruptures including exploring the rupture with the client in sessions. Upon reflection on my own practice, I find ruptures in relationships with clients a difficult process. As a trainee, keen to please the client and improve service outcomes, I struggle to use ruptures as a way of emphasising the change process. Research in this area is limited and I would therefore welcome further research into more specific methods of using ruptures with clients in CBT and would be keen to learn more about the impact of the concept of wanting to please in practitioners, particularly trainees who may be keen to prove themselves.

In conclusion, the myth that the therapeutic relationship is not important in CBT is in more recent times largely unsupported. At the most fundamental level, if a client is willing to reveal personally significant material, carry out behavioural experiments and trust the therapist, a positive relationship must be formed for effective therapy to occur (Kennerley, Kirk & Westbrook 2017, p35). As highlighted by Kazantzis et al., (2018) when CBT was designed by Beck the need for the therapeutic relationship or ‘collective empiricism’ seems to have been not clearly understood. The therapeutic relationship in CBT is embedded within its evidence base and techniques and shares common factors with other therapeutic relationships in other forms of therapy. As described by Leahy & Gilbert (2017), there is much to suggest the therapeutic relationship and technical aspects of skill building in CBT are likely to act in reinforcing ways. In this respect the therapeutic relationship can be seen as one of the main therapeutic tools for achieving client change. However, more research is needed to explore the exact definition of the therapeutic relationship in CBT, the links between each aspect of the relationship and the evidence based techniques used and careful consideration is needed for other factors of the relationship including the within characteristics of the practitioner and of the client, external factors including session length, social and cultural factors and the impact of client-therapist matching. Careful consideration must also be given to the best use of ruptures in the relationship. In my experience, only in this way can the therapeutic relationship within CBT be fully utilised as a tool to achieving lasting client change.

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