The Therapeutic Relationship in Cognitive Behavioural Therapy

Stirling Moorey, Anna Lavender, Stirling Moorey, Anna Lavender

• Publisher: SAGE Publications Ltd
• Year: 2018
• ISBN:
  9781526461544
• Edition: 1
• Topic: Psicologia
• Subtopic: Psicoterapia

The therapeutic relationship in CBT is often reduced to a cursory description of establishing warmth, genuineness and empathy in order to foster a collaborative relationship. This does not reflect the different approaches needed to establish a therapeutic partnership for the wide range of disorders and settings in which CBT is applied. This book takes a client group and disorder approach with chapters split into four sections:

• General issues in the therapeutic relationship in CBT
• Therapeutic relationship issues in specific disorders
• Working with specific client groups
• Interpersonal considerations in particular delivery situations

Each chapter outlines key challenges therapists face in a specific context, how to predict and prevent ruptures in the therapeutic alliance and how to work with these ruptures when they occur. With clinical vignettes, dialogue examples and 'tips for therapists? this book is key reading for CBT therapists at all levels.

Part I The Therapeutic Relationship in CBT

1 The Foundations of the Therapeutic Relationship: Therapist Characteristics and Change

Stirling Moorey

Anna Lavender

Chapter Overview

Carl Rogers identified what he thought were the essential characteristics a therapist should embody to promote growth and change – genuineness, positive regard, empathy and unconditional acceptance. Cognitive behaviour therapists have generally accepted that these therapist characteristics form the foundations of the therapeutic relationship. But what is the evidence for an association between these factors and therapy outcome? This chapter reviews the evidence and focuses on empathy, a key requirement for building a collaborative relationship, formulating problems and employing effective change methods. Some of the pitfalls that arise from being too empathic or insufficiently empathic are considered together with ways to help therapists empathise with challenging clients.

Core Conditions of Psychological Therapy

In the seminal text on the cognitive therapy of depression, Beck cites warmth, accurate empathy and genuineness as therapist characteristics which facilitate the application of cognitive therapy (Beck et al., 1979: 45): a therapist ‘who carefully utilizes these qualities can substantially increase his effectiveness’. The core therapist conditions were identified by Carl Rogers over 60 years ago and the theory remains highly influential. Person-centred therapists believe that these elements are essential for change, while therapists from other backgrounds generally see them as necessary but not sufficient for therapeutic benefit. According to Rogers, genuineness entails the therapist expressing their true feelings, not hiding behind a false professional façade; positive regard involves valuing the client and behaving warmly towards them; empathy requires the therapist to understand what the client’s emotions feel like to them and show that they understand them; and unconditional regard means accepting the client regardless of what they say or who they are (Rogers, 1957; Rogers, 1961). Although the primary goal of CBT is to change cognitions and behaviour, these factors may facilitate the process. By acting in a genuine way, the therapist models the normalising rationale of therapy. Valuing the client encourages them to engage in CBT tasks, while the therapist needs empathy to understand and support the client in exploring alternative thoughts and strategies. Finally, all therapists would consider it a sine qua non that they do not pass moral judgement on their clients. Keijsers’ review of the evidence (Keijsers et al., 2000) found that, while cognitive behavioural therapists were more active and directive and gave higher levels of emotional support than insight-oriented therapists, they were not more superficial, cold or mechanical: they showed as much empathy and unconditional regard as therapists from other traditions. Rogers’ core conditions may be part of therapeutic conventional wisdom, but are they really necessary even if not sufficient?

How Important are the Core Conditions?

Numerous studies have been conducted since Rogers suggested the importance of these therapist behaviours, and there is general consensus that clients with better outcomes rate their clinicians more highly on them (Bozarth et al., 2002; Elliott et al., 2011; Klein et al., 2001). In 2010, a task force commissioned by the American Psychological Association’s Divisions of Psychotherapy and Psychology published a review of evidence-based therapy relationships (Norcross and Lambert, 2011). Eminent researchers conducted meta-analyses of studies which had explored the link between the therapeutic relationship and outcome. These studies consistently found an association between Rogers’ core characteristics and treatment outcome. Positive regard or non-possessive warmth had a moderate association with outcome (effect size r = 0.27 from 18 studies); the only moderator identified was ethnicity: as the percentage of racial/ethnic minority groups in the study increases, the overall effect size also increases. Therapist empathy also showed a moderate association (effect size r = 0.30 from 57 studies), which was strongest for client rated empathy. Therapist genuineness/congruence refers to the combination of the therapist’s self-awareness and communication of his or her experience to the client: ‘the feelings and attitudes which are at the moment flowing within him’ (Rogers et al., 1967: 100). The effect size was 0.24 (from 16 studies). Thus, there seems to be a small, but significant, association between these factors and therapy outcome – each factor explaining between 6 and 9% of the variance – which is common across different therapies. One of the main methodological criticisms of these studies, however, is that the evaluation of the therapeutic relationship was often obtained retrospectively, so it is possible that, if your therapist gets you better, you perceive him or her to be more warm, genuine and empathic. This interpretation is reinforced by the finding that it is the client’s rating of these factors, rather than therapist or observer rating, that is most strongly correlated with outcome (see Chapters 2 and 4 for evidence that symptom change predates positive rating of alliance in CBT for depression). It has been observed that it is unlikely that ‘patient and therapist evaluations of Rogerian therapist variables are directly reflective of the actual therapist behavior [our italics] during the treatment’ (Keijsers et al., 2000: 270). Although the empirical evidence that Rogerian factors mediate change in CBT is contested, from a clinical and theoretical perspective a case can be made that they enhance the collaborative relationship and encourage the client to participate in therapy. Manipulating how warm therapists are when implementing systematic desensitisation has been shown to improve outcome with snake phobics (Morris and Magrath, 1979), though this does not seem to apply to therapist aided exposure for height phobia (Morris and Suckerman, 1974). Generally, it is felt that if the client perceives the therapist as warm, genuine and understanding, they will be more likely to engage in the tasks of therapy and consequently be more appreciative of the therapist’s positive qualities if they recover. In this sense, the core characteristics act to enhance the working alliance. The therapy alliance, and in particular CBT’s unique version of it which is termed collaborative empiricism, will be covered in depth in Chapter 2. In the rest of this chapter, we will focus on the role of empathy in CBT, because the therapist needs to have an accurate understanding of what the patient is thinking and feeling in order to help them discover alternative perspectives.

Empathy

The psychologist Hoffman defines empathy as ‘an emotional state triggered by another’s emotional state or situation, in which one feels what the other feels or would normally be expected to feel in his situation’ (Hoffman, 2008: 440). He identifies five empathy-arousing modes: mimicry, conditioning, direct association, verbally mediated association and perspective taking. The first three are automatic: passive, involuntary and triggered by stimuli. They operate preverbally and are found in infants and primates. The final two modes require language and cognitive processing. Multiple modes can be activated together:

Facial, vocal, and postural cues are picked up through mimicry; situational cues through conditioning and association; distress expressed orally, in writing, or by ...

Table of contents

• Cover
• Half Title
• Publisher Note
• Title Page
• Copyright Page
• Contents
• Illustration List
• Notes on the Editors and Contributors
• Acknowledgments
• Foreword
• Introduction
• Part I The Therapeutic Relationship in CBT
• 1 The Foundations of the Therapeutic Relationship: Therapist Characteristics and Change
• 2 The Therapeutic Alliance: Building a Collaborative Relationship and Managing Challenges
• 3 Interpersonal Schemas: Understanding Transference and Countertransference in CBT
• Part II The Therapeutic Relationship in Specific Disorders
• 4 Depression
• 5 Generalised Anxiety Disorder
• 6 Panic, Specific Phobias, Agoraphobia and Social Anxiety Disorder
• 7 Obsessive–Compulsive Disorder (OCD) and Body Dysmorphic Disorder (BDD)
• 8 Medically Unexplained Symptoms
• 9 Posttraumatic Stress Disorder
• 10 Psychosis
• 11 Eating Disorders
• 12 Physical Illness and Palliative Care
• 13 Personality Disorders
• Part III The Therapeutic Relationship in Different Client Groups
• 14 CBT with Young People
• 15 Older Adults
• 16 Transcultural Issues in the Therapeutic Relationship
• Part IV The Therapeutic Relationship and Different Modes of Delivery
• 17 CBT Delivered in Groups
• 18 Couple Therapy
• 19 Supervision and the Therapeutic Relationship
• Index