The Therapeutic Relationship in the Cognitive Behavioral Psychotherapies

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• Publisher: Routledge
• Year: 2007
• ISBN:
  9781134222841
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Although the therapeutic relationship is a major contributor to therapeutic outcomes, the cognitive behavioral psychotherapies have not explored this aspect in any detail. This book addresses this shortfall and explores the therapeutic relationship from a range of different perspectives within cognitive behavioral and emotion focused therapy traditions.

The Therapeutic Relationship in the Cognitive Behavioral Psychotherapies covers new research on basic models of the process of the therapeutic relationship, and explores key issues related to developing emotional sensitivity, empathic understanding, mindfulness, compassion and validation within the therapeutic relationship. The contributors draw on their extensive experience in different schools of cognitive behavioral therapy to address their understanding and use of the therapeutic relationship. Subjects covered include:

· the process and changing nature of the therapeutic relationship over time

· recognizing and resolving ruptures in the therapeutic alliance

· the role of evolved social needs and compassion in the therapeutic relationship

· the therapeutic relationship with difficult to engage clients

· self and self-reflection in the therapeutic relationship.

This book will be of great interest to all psychotherapists who want to deepen their understanding of the therapeutic relationship, especially those who wish to follow cognitive behavioral approaches.

Part I
Key issues

Chapter 1

Introduction and overview

Basic issues in the therapeutic relationship

Paul Gilbert and Robert L. Leahy

Background

Efforts to heal people of a variety of aliments, via the nature of the relationship created between a “healer” and “sufferer”, have been part of human culture for hundreds of years (Ellenberger, 1970). Over two thousand years ago the early Greek physician Hippocrates suggested that the relationship between a physician and patient was key to the process of healing. In other societies Csordas (1996, 2002) suggests that healing often involves “ritual events” including public behaviours, a focus for healing (e.g. mind, body and/or spirit), performative acts (e.g. laying on of hands, speaking in tongues) and rhetoric that creates a world of meaning in which healing takes place. He argues that “the rhetoric of transformation achieves its therapeutic purpose by creating a disposition to be healed, invoking experience of the sacred, elaborating previously unrecognised alternatives, and actualising change in incremental steps” (Csordas, 1996, p. 94). In these contexts the socially constructed powers invested in the healer, the emotional and relational experiences shared by sufferer and healer, and the agreed steps for change, are seen as key to success.

Although Franz Anton Mesmer (1734–1815) thought he had found a new form of energy that he could manipulate to heal his patients, others thought his results were more to do with his charisma, the type of patients attracted to him and his ability to alter patients’ beliefs (Ellenberger, 1970). From Mesmer grew the new ideas of hypnosis by which a hypnotist could alter the states of mind of another. Even in its earliest days it was recognised that some patients are easier to hypnotise and some hypnotists are better at inducing certain states.

By the nineteenth century Western societies were under the influence of science, positivism and evolutionary ideas that our minds had evolved from earlier life forms (Ellenberger, 1970). Psychological disorders were seen no longer as sourced by supernatural forces but by processes operating from within the sufferer’s own mind, especially the inner conflicts between (evolved) desires and impulses, and social acceptance. A new profession of psychotherapist was born where the role of the therapist was to create a relationship that could help a patient become conscious of unconscious conflicts and repressed memories and in so doing restore balance and health (Ellenberger, 1970). Whereas shamanic healers could act as a bridge to a supernatural world, the psychoanalyst could act a bridge to the unconscious world. During the 1940s and 1950s Carl Rogers (1965) suggested a major alternative to psychoanalytic views. He argued that the therapist’s role was not to interpret or explore transferences but to create the conditions (via empathy, positive regard and warmth) such that the patients could find their own ways to heal themselves – that is, the therapy relationship stimulates the patient’s movement to health and growth.

We offer this brief background to highlight the fact that the notion that relationships have healing properties is an old one, and shared in many cultures. How a healing relationship is contextualised and given meaning, how it unfolds, and the activities, tasks and goals embedded in that relationship, are socially constructed. Thus, how a therapeutic relationship is constructed is dependent on the shared meanings and beliefs of the sources of the difficulty and what is necessary to bring relief. Our Western concepts of the therapeutic relationship, how it should be construed, the skills and knowledge a therapist brings to that relationship, and how it should be used, are therefore deeply embedded in what we believe about the nature of the world we inhabit, our human psychologies, and the causes of suffering.

Cognitive therapy

The origins of the cognitive therapies can be traced back over 50 years. They emerged from a hybrid of historical influences that came together in the 1950 and 1960s. First were the ego analytic theorists, who 20 years earlier had broken away from Freud’s drive theory and focused on attitudes, beliefs and the tyranny of the “shoulds” (e.g., Bibring, 1953). The 1950s saw new developments in the cognitive and social psychology of attitudes and beliefs (Festinger, 1954). With the rise of computer metaphors and science began the age of “information processing systems” and evidence testing. Kelly (1955) suggested humans construct “theories” about the world and then seek evidence to confirm them. These personal theories, and the constructs from which they are derived, give rise to vulnerabilities to psychopathology. Helping people examine and change these constructs could produce therapeutic change. In a similar vein, Ellis (1962) developed his ideas that psychological problems and emotions could be regulated with the use of reason – as the ancient Greeks had argued two thousand years earlier. Although trained as an analyst, Beck (1967, 1976) suggested that patients’ emotions and moods were less influenced by nonconscious conflicts than by current ongoing, automatic thoughts and interpretations of events. Directing therapeutic attention specifically to these cognitive processes produced significant change. Although these ideas were based primarily on observation, it was not long before hypothesised constructs such as “core beliefs”, “assumptions” and “schemata” were seen as sources for biases in automatic thoughts (see Padesky (2004) for a historical overview). So the ego analysts, Kelly (1955), Ellis (1962) and Beck (1967) shifted the therapeutic process from one of interpretation of unconscious material to one of education with the use of Socratic questions and evidence testing. This was obviously going to affect the therapeutic relationship, not least because unconscious material and how it played out in the mind of the therapist (central to psychodynamic formations) was considered less relevant.

The therapeutic relationship was always considered important in Beck’s therapy but by this time the impact of Rogers (1965) on the key ingredients of a helping relationship (careful listening, positive regard and empathy) had permeated a range of therapeutic approaches (Kirschenbaum & Jourdan, 2005). So people training in cognitive therapy were assumed to have basic micro-skills and counselling skills from their core professional training. 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 ideas. Although transference and countertransference were recognised in early cognitive therapy, they were not a focus for therapeutic engagement apart from being examples of the activation of core beliefs and assumptions – and subject to reality testing. Specific problems in forming, maintaining, understanding and dealing with ruptures in the therapeutic relationship were rarely addressed (Safran & Muran, 2000), at least until the advent of cognitive therapies’ exploration of personality disorders.

Behaviour therapy

The origins of behavioural therapy stretched back further, to the work of the Russian physiologist Pavlov, famous for his salivating dogs, Thorndike’s operant laws of learning, and Watson’s application of behavioural principles of the “laws of effect to humans” (Reisman, 1991). The key focus of behaviourism was on inputs and outputs of systems, be these physiological systems (e.g., salivation), motor systems (e.g., avoidance, running away) or emotions. In a way, therefore, behaviourism refers to the “science of the behaviour and learning of living systems” and should not be overly identified with any particular system (Timberlake, 1994). From the days of Pavlov it was clear that many basic physiological systems could be conditioned simply via association of stimuli, and this became known as classical conditioning (Gray, 1980). Conditioning is possible without any cognitive awareness (Hassin, Uleman & Bargh, 2005). Moreover, if two stimuli, one associated with reward and one associated with punishment, are presented together, this produces approach–avoidance conflicts, and at times severe disorganisation (“experimental neurosis”), with bizarre and stereotypic behaviours (Gray, 1980). We suspect that approach–avoidance conflicts are more common in the therapeutic relationship than is sometimes recognised and may produce confusion in the patient and therapist.

In a different paradigm Thorndike had shown that animals learn to behave in ways that influence consequences and outcomes (for example, increase certain behaviours for rewards and reduce them to avoid punishment). This became known as operant or instrumental learning. Subsequent research has shown that learning is somewhat more complex but these “laws” still hold good as a basic science for how animals and humans adapt to their environments (Timberlake, 1994; Rescorla, 1988).

The therapeutic implications of behaviourism were radically different from those of the psychoanalysts. For behaviourists the focus is on retraining the mind via direct experiences – that is, “exposure”, utilising concepts such as desensitisation and reciprocal inhibition – or emphasis on increasing rewards through behavioural activation and assertion. Interestingly, the value of guided exposure to replace avoidance and encouragement has been recognised in many cultures for hundreds of years. For example, in Buddhist practice, if you have a fear of death you might be encouraged to meditate on a corpse and to focus on the thought that all things decay! Even Freud understood the value of exposure for some people (Yalom, 1980). More recently attention has focused on the importance of safety behaviours/strategies as short-term efforts to defend self from harm or aversive experiences. These are seen as key in the process of accentuating and maintaining disorders (Mineka & Zinbarg, 2006; Salkovskis, 1996). These strategies may also involve efforts to avoid internal events such as emotions, thoughts or memories, and external events, and problematic aspects of the therapeutic relationship.

Behaviour therapy got something of a bad reputation when it flirted with aversion therapies, particularly for people with homosexual preferences. This was unfortunate because most behaviourists were well aware that punishment was a bad way of trying to change behaviour, not least because people will learn to avoid their punishment rather than the behaviour you are wanting to reinforce. Books and films like Clockwork Orange painted behavioural control in a very frightening way. However, for the most part the research on the therapeutic relationship in behaviour therapy tells a very different story. In fact, behavioural therapists are often rated as the warmest of all the schools of therapy. Schaap, Bennun, Schindler & Hoogduin (1993) reviewed a number of studies including some using videotaped interactions of therapists and patients. Their conclusion was:

behaviour therapy has a characteristic style, which is different from other schools. Somewhat surprisingly studies indicate that behaviour therapists are rated higher on relationship variables such as empathy, unconditional positive regard and congruence than are Gestalt therapists and psychodynamic psychotherapists. These results clearly contradict the traditional stereotype of the ‘cold’ and mechanistic behaviour therapist.

(p. 21)

A scientifically focused therapy

The union of cognitive and behavioural therapies in the 1970s was not originally a happy one, but today most cognitive therapists involve key behavioural aspects such as exposure to “the feared and avoided”. It is also recognised that people’s beliefs about the consequences of their behaviour (e.g., if I don’t act assertively or I don’t get over-aroused when my heart rate goes up, I will stay safe) can be key to maintaining unhelpful behaviours. However, one of the great strengths of cognitive behavioural therapy (CBT), which was certainly fuelled by the evidence-focused and experimental research of the behaviourists, is that its practitioners have always been very concerned to ally themselves strongly to a scientific understanding of psychological and psychopathological process. Behaviour therapy has been informed by animal and human research on learning, while the cognitive model has been continually influenced by research on the complexities and processes underpinning cognition and decision making. These are not without controversies (Haidt, 2001). Salkovskis (2002), among others, has pointed out that evidence-based treatments evolve partly through good linkage between theory, experimental research studies and outcome research. Indeed, CBT has become so wedded to psychological science (and increasingly neuroscience) that there is some argument that it is ceasing to be “a school” and is simply evidence-based psychological therapy.

In terms not only of process but also of efficacy, CBT has been at the forefront of efforts to develop demonstrably effective treatments. This is no easy task, and is not free of the numerous debates over methodologies in psychotherapy research. Concerns with the methods, findings and implications of psychotherapy research were aired in two journals in the late 1990s ( Journal of Consulting and Clinical Psychology, 1998, volume 66; Psychotherapy Research, 1998, volume 8). Persons and Silberschatz (1998) debated the value of randomised controlled trials (RCTs) to clinicians. Persons viewed them as essential and Silberschatz argued that they are potentially artificial and limiting for clinical practice. Elliott (1998) outlined over 13 major concerns with developing guidelines prematurely from RCT evidence, including the concern that the need to standardise treatments via manualisation may introduce unhelpful artificialities to the treatment and affect the therapeutic relationship. Elliott also notes some concern as to how therapies will continue to develop in the future if they become overidentified with manual-based approaches, developed for RCTs. Nonetheless, CBT has now been developed and has proved helpful for many (but by no means all) individuals with a variety of defined disorders; it is often recommended as a treatment of choice (see www.NICE.org.uk).

In addition there has been a focus on trans-diagnostic cognitive processes such as memory, attention and rumination (Harvey, Watkins, Mansell & Shafran, 2004); behavioural process of avoidance (Hayes, Wilson, Gifford, Follette & Strosahl, 1996); safety behaviours (Mineka & Zinbarg, 2006; Salkovskis, 1996), shame (Gilbert, 1998, 2003), and resistance (Leahy, 2001, 2004). This is moving psychological therapy to a much more psychological as opposed to a medical-centred model of human difficulties. Unfortunately, academic journals are very wedded to medical diagnoses. When shame, resistance, safety behaviours and difficulties in articulating thoughts and feelings dominate the clinical picture, this may pose particular challenges to the therapeutic relationship.

Why focus on the therapeutic relationship?

Psychodynamic theories have focused on drive reduction, defence mechanisms, character structure or relationship formation. In these types of approach the therapeutic relationship both is a means for gaining insight and has therapeutic effects itself (Greenberg & Mitchell, 1983; Clarkin, Yeomans & Kernberg, 2006). As noted above, CBT has taken a very different approach to the therapeutic relationship. There is probably some agreement, however, between most therapies that the therapeutic relationship should be a “containing” relationship which enables the patient to feel safe with the therapist (Holmes, 2001). Given the intense interest in the scientific and research-focused approach to CBT it is time to recognise how the therapeutic relationship influences outcomes, and this means a greater awareness of the power of interpersonal relationships to affect a variety of physiological and psychological processes (Cacioppo, Berston, Sheridan, & McClintock, 2000). For example, early relationships, especially neglect and trauma, affect the maturation of the brain and that clearly has implications for therapy (Gerhardt, 2004; Schore, 2001). Interpersonal processing occurs at both conscious and non-conscious levels, and can be rapid and conditioned (Baldwin & Dandeneau, 2005; Hassin, Uleman & Bargh 2005; Miranda & Andersen, Chapter 4, this volume).

Social processing

We can look at this in a different way. Psychotherapy is, of course, an interpersonal relationship where the mind of one person seeks to impact on the mind of the other in an interactive dance. The interactional sequences, co-constructions and interpersonal dances of therapy are choreographed through specific psychological abilities of participants and what they are seeking to achieve. One such ability is “theory of mind”, which relates to the way we make inferences about the internal causes of other people’s behaviours, and assess what ”is going on in their minds” – what they are thinking (Baron-Cohen, 1995; Byrne, 1995; Flavell, 2004). We are aware that we can be an object for other people’s judgements – that is to say, each person is an object of observation and judgement for the other. This ability to “think about thinking” and to think about the relationship has been a focus in earlier work in developmental social cognition (see Selman, 1980, 2004). We cannot assume that these complex evaluative processes can be understood like any other cognitive or evaluative process with single notions of “beliefs” or “schemata”. They are more complex than this – and they are interactive (Decety & Jackson, 2004; Malle & Hodges, 2005). Some people have major difficulties in being able to “read” others’ minds or have empathy for others – as the work of Baron-Cohen, Selman and others demonstrates.

Theory of mind is a specific skill that is open to various forms of distortion (Nickerson, 1999). Theory of mind may well be a key quality in our capacity to create fantasy relationships – for example, with God – and to create and engage with fictions (Bering, 2002). Theory of mind, however, differs from empathy. Empathy is more related to an intuitive sense of what’s going on in the mind – especially the emotions – of the other person. It requires ability not just “to think about” the mind of the other but to resonated emotionally with the feelings of another. New research in neuroscience is beginning to explore how the brain engages in theory of mind and...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Contents
• List of Contributors
• Preface
• Acknowledgements
• Part I Key issues
• PART II The therapeutic relationship in specific therapies
• Index