Relational factors in CBT facilitate, but do not, themselves, contribute to positive change.

From a cognitive-behavioural perspective, the working alliance or the therapeutic relationship can be defined as being what Aron Beck-  founder of cognitive therapy, named collaborative empiricism (Parpottas, 2012). Beck’s collaborative empiricism refers to an environment of mutual collaboration, a dialog between the therapist and his/her client, where the client provides his/her data (thoughts/ emotions) to be investigated and a genuinely, warm, emphatic therapist guides the client not only to unravel, but also challenge his/her unrealistic and unhelpful thoughts and beliefs (Parpottas, 2012).

In an ample analysis of conceptual underpinnings of what constitutes a therapeutic relationship and what can be termed as technique, Lundh (2017) concludes that relation and technique in psychotherapy represent partly overlapping categories and that the concept of technique in psychotherapy is intrinsically linked to therapeutic skills, therapeutic attitudes, and therapeutic relating. Lundh (2017) distinguishes between self-techniques and relational techniques. The relational techniques that Lundh (2017) conceptualises are further distinguished in two subcategories: a) relational techniques that involve a prescribed form of relating to the client, in that of offering a rationale for a certain treatment - reflecting a form of relational skills; b) a second subcategory of relational techniques that focus on the relation between therapist and client, whereas the therapist makes active interpretations as to what goes on in the therapeutic relationship defined as metarelational techniques.

Lundh’s (2017) theoretical frame is a useful tool when applied to an understanding of the therapeutic relationship in CBT; that being largely accepted as being the foundation on which CBT approach stands (Cockx, Corrie and Townend, 2016). 

The next part of this paper is proposing a historical consideration of the therapeutic relationship. Relevant empirical findings from the last two decades are presented in an attempt to address 

theoretical understandings of the therapeutic relationship as a concept and implications for outcome psychotherapeutic research.

In his seminal paper “The generalizability of the psychoanalytic concept of the working alliance”, Bordin (1979) states that working alliance is key to the process of change between the therapist and her/his client.

Bordin (1979) tripartite model represents a combined view on the significance of a relationship between the therapist and client (Greenson, 1967), an agreed working contract and a psychodynamic alliance between therapist and his client’s rational ego. All such views had their origin in psychoanalytic theory, but in elaborating his three components of the therapeutic working alliance, Bordin (1979) insisted in its universal applicability across different therapies. The three aspects of the working alliance described by Bordin (1979) are: an agreement on goals, an assignment of task or grouped several tasks and the development of bonds.

Bordin (1979) argued that the therapeutic goals are interpreted differently from psychodynamic perspective to that of behaviour therapy. Such distinction had as a starting point a different interpretation of the very scope of a person’s life and that was included in such therapeutic goals. Goal consensus and collaboration are the essence of a psychotherapeutic contract and in CBT are regarded as part of the foundation of the therapeutic process and representative of its principles - where therapy is regarded as a collaborative effort between therapist and client ( Beck & Emery, 2005).

In a meta-analysis of studies published between 2000 and 2009, Tryon and Winograd (2011), report strong links between client-therapist goal consensus and positive therapy outcomes with their results attesting to a significant correlation between client-therapist collaboration and positive therapy outcomes. Based on their findings, Tryon and Winograd (2011) made a number of practice recommendations for practicing psychotherapists to consider. A first such consideration was that of therapists beginning their work on their client difficulties only after an agreement on treatment goals has been established collaboratively and agreed ways to reach such goals together. The second recommended practice involved that therapists need to be weary of their own agenda and formulate interventions with their clients’ input and understanding, offering a rationale for their work. An acknowledgement and encouragement of client’s contribution throughout the therapy being central to their work and reinforced by constant feedback, insights, reflections and elaborations.

The second aspect of working alliance described by Bordin (1979) referred to therapeutic tasks required to meet the therapy’s goals that involves a collaboration between the client and therapist. Bordin described such collaboration as an agreed-upon contract that includes some very specific and concrete exchanges that most probably varies and it is depended upon the theoretical framework employed. Elliott et al. (2011) have found that empathy is a medium-sized, significant variable predictor of outcome in psychotherapy with robust evidence to suggest that clients’ perceptions of feeling understood by their therapist are strongly related to outcome. Their findings from a meta-analysis across different psychotherapeutic modalities indicated that their evidence is compatible with a causal model that implicates therapist empathy as a mediating process and leading to positive outcome rather than being seen as a directional relation between empathy and outcome. Such distinction is particularly significant as it integrates such findings within an area of research that recognises a limitation in studying constructs such as empathy - that is itself a stipulating ethical stance and requirement in all professional contacts and it would be found both impractical and unethical to use other means of researching such as through randomised control trial. The researchers further conclude that meta-analyses can provide better means for future analyses of empathy and such research need to account for the difficulty of separating empathy from other relational conditions such as positive regard and genuineness. One of the most significant aspect is that of highlighting the complexity and intricacies of research that attempts to study relational constructs as part of the therapeutic relationships and methodological limitations in research of similar constructs as integral part of therapeutic relationship to the outcome of therapy. It is worth noting that their findings are in contrast with a previous meta-analysis conducted almost a decade earlier (Bohart et al, 2002), where the researchers’ findings suggested strong evidence that empathy might be more significant to outcome in cognitive behavioural therapies than in other psychotherapeutic modalities.

The third and last of Bordin’s (1979) proposed features is that of identifying an interpersonal bond between client and therapist that equally enables and maintains the therapeutic process. Depending on the substrate of its theoretical modality, the types of bonds although may not necessarily be one stronger than the other, could and do differ in kind (Bordin, 1979). In a review of the therapy relationship in cognitive therapy, Waddington (2002) notes that research over the previous decade suggests that client and therapist views of the therapy relationship can differ and that the client’s perspective is more predictive of outcome than that of his/her practitioner. Based on her review of available research, Waddington’s indicates that eliciting client’s view of the therapy, consideration of individual client issues in the therapeutic relationship, the use of cognitive skills to establish a good therapeutic relationship – (i.e. use of clinical formulations and collaborative agenda setting) - and aiming to generate hope in using the therapeutic relationship, may aid cognitive therapists to maximise the therapeutic potential of the therapeutic relationship, hence the outcome of the process. Waddington concludes that further research is needed to clarify the role of the therapeutic relationship as a process variable in cognitive therapy, emphasising that existent research is indicating a need for cognitive therapist to develop skills in establishing and using the therapeutic relationship as means to a positive outcome.

Another aspect of difference between possible therapeutic bonds is that of taking charge or therapy power relations. Edwards (2013) suggests that a position of authority or power imbalance between the therapist and his/her client has been proposed as potential and possibly argued as exacerbated by CBT’s appeal to science. In responding to critical arguments that the CBT open, explicit and structured format of the therapist-client relationship and empirical collaboration can actually hinder and mask the power imbalance, Edwards (2013) concludes that collaboration has a high potential as an agent of change and that can only be achieved with therapist’s self-awareness. Edwards (2013) argued that self-awareness is crucial aspect in avoiding an expert stance and a possible misused power relation endorsed by using science. Such awareness can be cultivated through a transparent process of collaboration, therapist self-reflection, use of supervision and therapist awareness of his own biases. Edwards (2013) further indicates a somehow optimistic stance on power dynamics becoming a more prominent aspect of debate in relation to the concept of collaborative empiricism in CBT, seeing it as aiding CBT therapists to enhance and attend to their practice.

Similarly, it has been argued that in CBT by developing a collaborative, shared understanding through both initial case formulation and recognition or identification of a perceived resistance to the therapeutic process are critical elements to ensuring a good outcome. Such a global understanding that involves not only factors present in client’s resistance but also in those activated as a response in therapist, are important and can inform how resistance to the therapeutic process might be best attended to (Cockx, Corrie and Townend, 2016). Once again, this emphasises the invaluable role that self-reflection, supervision and an awareness of therapist’s own self-practice has on a developing therapeutic relationship in CBT and outcome process.

The subject of resistance and its ways in which may affect the alliance in CBT has been an area of in-depth research by Leahy (2008). Leahy (2008) recognises that the therapeutic tasks and the relationship in CBT differ greatly from those in other modalities and specifically from psychodynamic therapy. Leahy (2008) outlines various possible impasses that can affect the alliance and concurrently suggesting how these potential resistances to the therapeutic process can be resolved. Some of the resistances outlined by Leahy (2008) include validation- the perception that the therapist lacks empathy and does not validate the client’s feelings - this being in line with previous research discussed on empathy. Leahy (2008) proposes that through the process of case conceptualisation, the therapist is able to identify client’s rules for validation and its history of invalidation and in acknowledging the difficulties encountered by the client through the treatment process the therapist is aiding the client in overcoming such impasses in therapy. Similar obstacles to therapy highlighted by Leahy (2008) are: emotional philosophies, victim resistance, schematic resistance, sunk-cost commitment, schematic mismatched and self-handicapping. Leahy (2008) argues that through an acknowledgment and awareness on the part of the therapist and the empirical collaborative aspect of the relationship in CBT, particularly through the use of an effective case conceptualisation and in strategies employed that are available, CBT therapists can help the client to overcome such resistances. This paper acknowledges and agrees with Leahy (2008) evaluation, and furthermore proposes that the very empirical stance and use of up to date research and acknowledgement of own schemas, beliefs and values, the CBT therapist can enhance and attend to impasses in therapy such as schematic resistance. In a recent study looking at therapist perfectionism and its association with client outcomes in CBT, Presley et al (2017) conclude that their exploratory study support the idea that the interpersonal dimensions of perfectionism are important and it can be of benefit to the outcome of the therapeutic process with the therapist identifying their own perfectionist schema and reflect and manage it as to how that may interact with client outcomes. Their study offer further support to the benefits of self-reflection, self-CBT and clinical supervision of process issues recently recommended in various CBT forums and literature. The researchers also observe that perhaps such interpersonal dimensions can have different outcomes depended on the primary presenting problem of the client.

Being able to distinguish between various therapeutic tasks depending on the therapeutic model employed it is as essential as distinguishing between stages of creating and maintaining an effective therapeutic relationship. The next part is proposing an examination of more recent understandings of the therapeutic relationship and its impact on process outcome.

Stages of change and the working alliance in psychotherapy

Since Bordin’s proposed model, psychotherapeutic learnings concerned with the process of change and working alliance, have developed a more comprehensive and complete picture as to what is essential for providing not only an effective psychotherapy treatment but also an efficient psychotherapy service. For example, Emmerling and Whelton (2009) investigated whether the working alliance can be seen as main mediator between stages of change and symptom improvement or therapeutic outcome. Emmerling and Whelton (2009) observed that recent clinical research can be seen as strong empirical evidence to the hypothesis that clients’ stage of change has a direct influence on the quality of working alliance. Emmerling and Whelton (2009) further argue that because the working alliance has a significant impact on the overall outcome of the therapy, it appears that one of the keys to increasing therapeutic effectiveness is to better understand the stages of change and link such stages with both the psychotherapeutic process and outcome variables.

Emmerling and Whelton (2009) study suggest that not only the working alliance is a strong mediator of the relationship between the stages of change and outcome, but also progression from one stage to a higher level stage during the course of therapy is positively correlated to an enhancement in both the working alliance and therapeutic outcome. Their findings can be seen as strengthening and offering further support to Hardy et al (2007) model of stages in establishing an effective therapeutic relationship and being highly relevant to a practice of CBT that is in constant awareness as to the stages of therapeutic process in its use of a case formulation approach.

A major aim of CBT therapists is that of ensuring agreement between himself/herself and client on the client’s outcome goals for change. Such an agreement must be reflective of a shared, common understanding of the client’s relevant issues as defined and recognised by the client herself/ himself and that is achieved at the very beginning of the therapy and throughout the therapy by using a case-formulation or case conceptualisation driven approach. A case-formulation driven approach involves the therapist developing a formulation or a set of hypotheses about the factors that cause and maintain the client’s presenting problem and using such formulation to devise intervention/treatment strategies and guide clinical decision making (Persons, Beckner & Tompkins, 2013). Case conceptualisation is considered the most essential aspect of cognitive behavioural therapy (CBT) because it describes and examines clients’ difficulties in ways that makes possible and informs effective interventions (Kuyken, Padesky & Dudely, 2008). All such process takes place collaboratively with the client, hence collaborative empiricism is at the heart of a case-formulation approach to clinical work (Persons, Beckner & Tompkins, 2013). The therapeutic relationship in this sense can be considered as an essential factor in both guiding and underpinning the therapeutic process.

Hardy et al (2007) proposed three stages to the development of the therapeutic relationship, and their conceptual map (fig.1) is inclusive of more current additions to and understandings of the working alliance. For instance that of contextual factors and therapist factors.

According to Hardy et al (2007), establishing a relationship is the first stage in creating an effective therapeutic relationship where client’s expectancies, intentions, motivations and hope represent the engagement objectives. The engagement processes of establishing a relationship are empathy, warmth and genuineness, negotiation of goals, collaborative framework, and support guidance and affirmation. The role modelling and encouragement of hope in relation to goals is particularly important in CBT (Grant and Townend, 2010).

In a qualitative study exploring therapist conceptualisations of hope within therapy O’Hara and O’Hara (2012) identified a wide range of hope-focused strategies or reflecting hope-in- action and considered as having three dimensions: relationship, task and transcendence. The researchers assert that hope-in-action has both an implicit and explicit focus thus the most fundamental aspect is that of its integration within the therapeutic relationship. Hope-in-action needs the therapeutic relationship as context of development and once such relationship is established, specific hope focused tasks can take place. Such link to both therapeutic goals and therapeutic tasks give relevance to hope designed strategies within the therapeutic process not only as prominent components of working alliance between therapist and client, but overall to its role in the effectiveness of the therapeutic relationship.

The second stage in Hardy et al (2007) model is that of developing a relationship. The objectives of this stage are openness, trust and commitment and the processes involved are exploration, reflection, feedback, relational interpretations and nonverbal communication.

Conceptual Factors

Therapeutic meetings

Processes outcomes

Contextual Factors

Establishing relationship

Developing relationship

Maintaining relationship

Therapist factors

All above forming a Conceptual map of a therapeutic relationship according to Hardy and colleagues (2007).

Clients that seem to be engaged in the therapeutic relationship and the therapy process are more likely to follow through with all therapeutic tasks whereas defensiveness and or hostility was negatively correlated with poor quality of therapeutic relationship and working alliance ( Hardy et al., 2007). Evidence suggests that detailed and descriptive feedback is more useful than inferential feedback and positive feedback is more accepted (Hardy et al. 2007).

The third and last stage in Hardy et al. (2007) model is that of sustainment of a therapeutic relationship and maintaining a high degree, qualitative relationship between client and therapist. At this stage the processes involved are self-reflection, metacommunication, flexibility, responsiveness and repair. This stage includes client’s overall satisfaction with the therapeutic process and reported dissatisfaction has been found as most frequent reason for leaving/ terminating the therapy. Another objectives at this stage are that of enabling the client to explore emotional expression as well as experiencing a changing view of self with others – this latter objective being very similar with what Greenson (1965) defines as the necessary transcendence for a strong and successful therapeutic alliance. The identified threats to maintaining a relationship have been categorised in that of therapist behaviours, client behaviours and relationship challenges including raptures, confrontations, misunderstandings and or withdrawal (Hardy et. al 2007). The last objective stated for this stage is that of a productive and positive working alliance. It has long been argued that both the strength and quality of the alliance are crucial to maintaining and forming an effective collaborative relationship between the client and therapist.

One of the most consistent factor predictive of therapeutic outcome is the quality of the therapeutic alliance and within the psychotherapy research weakened alliances are correlated with unilateral termination by the patient (Safran et al., 2011). In a meta-analysis of the association between presence of rupture-repair episodes and treatment outcomes, Safran et al. (2011) contend that therapists need to become attuned to subtle indications of ruptures in the therapeutic relationship and explore causes of such conflicts as there is a growing evidence that indicates repairing alliance ruptures in the therapeutic relationship is positively associated with successful outcome of therapy.

Hardy et al (2007) argued that perhaps more important than goal consensus in client engagement as a process is an actual mutual involvement in the helping relationship, with the therapist aiding such involvement by adopting several behaviours. Examples of such behaviours including the therapist actively and verbally participating in session thus verbal engagement on the part of the therapist and role modelling for client, avoiding silences and possible conflict within sessions (Grant & Townend, 2010).

Concluding remarks

For the last two decades, numerous literature reviews have become increasingly concerned with a thorough and careful examination of the therapeutic relationship and its impact in outcome process and some of such research has been presented in this paper. Waddington’s (2002) review of the therapy relationship in cognitive therapy is one illustrative attempt of bringing to the forefront of enquiry the therapeutic potential of the therapy relationship and the implications for the practice of cognitive therapy. Leahy (2008) producing a convincing account as to how CBT is uniquely qualified to attend to the subtleties and intricacies of a therapeutic relationship and its impact on the outcome process. Issues of diversity and difference are one of many examples that can be incorporated within such subtleties of therapist and client relationship and attended to by the therapist from the beginning of the developing therapeutic process and its relationship.

In presenting theoretical conceptions of therapeutic relationship and outcome research the aim of this essay was that of emphasising the difficulties in separating various components of the therapeutic relationship and seeking a directional causal relationships to outcome as a process rather than integrating such relational components within the therapeutic process and be seen as a mediator. Similarly, it has been recognised and universally accepted that some microskills underlying the therapeutic relationship - such as active listening, regulating, differentiating and attending - are present regardless of the therapeutic modality employed (Leahy, 2008), hence enhancing the complexity of separating skills and/or techniques from what is deemed to be a therapist mediating factor and an integral part of the therapeutic relationship as it has been defined as a collaborative empiricism in CBT that infers such therapist factors in its very conceptualisation and principles approach.

Lundh (2017) conceptualisation argument of relation and technique being two partly overlapping concepts was found a useful tool in integrating and attending to the statement proposed by this paper title. It has been recognised, at both theoretical and empirical evidence level that in considering a critical analysis of the therapeutic relationship in CBT, client’s factors and how such factors can be empirically accounted for in outcome research is a complex process that requires further consideration at both clinical level and research level.

The origin of such clarification rests on adopting a universally accepted statement on the process of change or the therapy in all its entirety and whether it can be interpreted as a continuous process developed from the start of the therapy and/or a highly dynamic relationship.

The empirical evidence and theoretical understandings of a therapeutic relationship as conceptualised in CBT presented in this paper have attempted to respond to the two part statement in the tile, concluding that research in the therapeutic relationship in CBT is in continuing development and both clinical and research implications are continuously evaluated. Devising a new Collaborative Case Conceptualisation Scale for assessing competence in collaborative case conceptualisation is one example of many as to how both researchers and practitioners of CBT are relentlessly dedicated to CBT training and research that can enhance and aid not only the therapist competence but also a collaborative, empirical stance to practice and effective outcomes for clients (Kuyken et al, 2015).

As a concluding remark, in the very choices of empirical research used to critically examine proposed title, perhaps some bias and own theoretical preference can be identified. Such a bias can be acknowledged through a careful consideration and selection of specific research and theoretical stance proposed.

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