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Candidate Number 21415649CRITICALLY EVALUATE THE ROLE OF THE

Candidate Number 21415649 THERAPEUTIC RELATIONSHIP IN COGNITIVE

BEHAVIOURAL THERAPY.

8

Critically Evaluate the role of the Therapeutic Relationship in

Cognitive Behavioural Therapy

Candidate Number 21415649What is the cognitive model? In very simplifiedAbstractThis essay explores published materials, including research papers, journals, on-line texts and information covering the subject of psychotherapy in general and also those specifically focusing on cognitive behavioural therapy (CBT). The resulting information has been used to critically evaluate the role of the therapeutic relationship in CBT, including a definition of what is meant by the terms therapeutic relationship and cognitive behavioural therapy and describes the processes and developments that define CBT as it is currently delivered and the possibility that there has been a change in the importance and focus on the therapeutic relationship. The term therapeutic or working alliance is also discussed as this is sometimes used in place of therapeutic relationship and is a key component of the therapeutic relationship in CBT. It concludes thatand research implications for future research would seem to recommend the continuing trend in CBT to consider the role of the therapeutic relationship, the role of therapeutic skills and techniques, and the interplay of both. I will summarise my findings and offer my conclusions and further thoughts about the possibilities for continued exploration.Introduction

Rogers stated In my early professional years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth? (1961 p.32).When Carl Rogers wrote this he had already made a critical shift in his thinking around psychotherapy, moving forward from the first wave of psychoanalysis, towards an argument that there were defined conditions or characteristics of the therapeutic relationship that were sufficient to bring about therapeutic change. It seems that a similar shift may be identifiable from the early development of Cognitive Behavioural Therapy (CBT) to a current day evidence-based therapy. This seems to have come about through a process of comprehensive empirical research, focusing increasingly on relationship factors and other common or non-specific factors throughout the process of therapy. This appears to have led to a broadening of the range of CBT as predicted by Beck when he suggested that, in the future, psychotherapy will be used to treat very serious disorders in clients whose symptoms are not completely controlled by medication, such as bipolar disorders and schizophrenia (Beck, 1997. p.283).My evaluation will begin with a definition of the terms therapeutic relationship and cognitive behavioural therapy. I will also define the term therapeutic or working alliance as this is sometimes used in place of therapeutic relationship and explain how this could be considered a key component of the therapeutic relationship in CBT. I will explore the historical development of the therapeutic relationship and therapeutic alliance in psychotherapy generally. I will then consider this with a particular focus on Rogers core conditions as they are a factor of the therapeutic relationship in the historical debate around the efficacy of psychotherapy. I will then consider that whilst these core conditions may be present and are often necessary, they may not be sufficient in CBT. I will explore more recent developments arising from research which draw conclusions on what works in psychotherapy in general and in CBT in particular, with a view to understanding what other factors may be present alongside the therapeutic relationship in a CBT approach, the processes involved throughout therapy including managing and working with ruptures in the therapeutic relationship and an understanding of the need to tailor the relationship and techniques to the client. I will focus particularly on the idea of an on-going process in CBT, feedback, collaboration and the subjective measurement of the relationship between client and therapist. This will also include a discussion on the ineffective qualities of the therapeutic relationship identified in research, in order to understand what research tells us does not work in CBT and how this may relate to findings around the importance of the therapeutic relationship in CBT. Therapeutic Relationship

According to Clarkson (1994, p.29) relationship or interconnectedness between two people has been significant in all healing since the time of Hippocrates and Galen. She goes on to point out that it is common knowledge that ordinary human relationships can have therapeutic value. According to Luborsky (as cited in Gilbert & Leahy, 2009, p.25) there are two phases of the therapeutic relationship, initially it is a ..relationship being characterised by the clients belief in the ability of the therapist to help him or her and the therapists requirement to provide a secure environment for the client this then develops into .. a mutual relationship of working on the tasks of therapy.. This latter definition points to the fluctuations that may occur over time in the contribution that different aspects of therapy and in CBT in particular, make to the outcomes of therapy. Therapeutic/Working AllianceConstantino, Ladany, & Borkovec (2010) writing about the influence of Bordin as an innovative thinker and teacher, recorded Bordins definition of the therapeutic or working alliance as the perpetual negotiation of therapeutic goals and tasks between client and therapist as a function of client and therapist characteristics and the related strain of the work. This refers to his theory that the therapeutic alliance incorporates the goals and tasks negotiated between the therapist and client but also infers another aspect relating to the bond between them which supports this collaboration. In this statement, in speaking about the related strain of the work Bordin (as cited in Constantino, Ladany, & Borkovec, 2010, p.8) seems to suggest that working with ruptures and making these explicit in the relationship is a key aspect of the therapeutic alliance. I discuss this aspect further, when exploring the work of resolution and repair of ruptures to the therapeutic relationship. As Castonguay, Constantino and Holtforth (2006) discovered, it is possible to view the working alliance as a component of the therapeutic relationship alongside and in interaction with other important interpersonal skills such as empathy, positive regard and congruence. There are other skills and micro-skills which evidence suggests, form a part of CBT that I will discuss in greater depth later.Cognitive Behavioural TherapyAs its name suggests CBT developed from the merging of two distinct therapeutic approaches; behaviour therapy (Westbrook, Kennerley & Kirk, 2011, pp1-2) as developed by Wolpe and others in the 1950s and 1960s, and cognitive therapy developed by Beck at the beginning of the 1960s. Westbrook (Westbrook, Kennerley & Kirk, 2011, pp1-2) describes CBT as a broad movement, rather than a single therapy, that continues to develop after its early beginnings and is based on several principles that; It is interpretations of events, not events themselves, which are crucial; What we do has a powerful influence on our thoughts and emotions; Mental-health problems are best conceptualised as exaggerations of normal processes; It is usually more fruitful to focus on current processes rather than the past; It is helpful to look at problems as interactions between thoughts, emotions, behaviour and physiology and the environment in which the person operates (physical as well as social, family, cultural and economic); It is important to evaluate both our theories and our therapy empirically.

CBT is a therapy which has been extensively researched and as a result, has a strong evidence-base for its efficacy. It is used to treat many psychological disorders such as Depression and Anxiety and has been extended and adapted to treat a wider range of disorders such as Schizophrenia and Bipolar Disorder as predicted by Beck (1997 p.283). Moorey (1996) points out that CBT involves the therapist and client working collaboratively to identify current problems and find solutions, with the client actively engaged in assignments and work in between sessions (Moorey, 1996, p.17). This supports the idea that a cognitive change or shift is the most important component in treating apsychological disorder (Beck, 2001).

The Historical Development of the Therapeutic Relationship in PsychotherapyThe concept of the therapeutic relationship developed from Freuds early psychoanalytic theories involving attachment, transference and counter-transference and included the possibility of a beneficial client-therapist attachment grounded in reality (as cited in Horvath & Luborsky, 1993, p.561) this was later elaborated on by Greenson (as cited in Horvath & Luborsky, 1993, p.561) who suggested a concept of a reality-based collaboration between therapist and client and coined the term working alliance. Empathy and therapist warmth is strongly indicated as a factor in Behavioural Therapy and Gilbert and Leahy (2009, pp.6-7) cite the conclusions of a review of studies of interactions between therapists and clients which indicate that behaviour therapists are rated higher on relationship variables such as empathy, unconditional positive regard (UPR) and congruence than other modalities. Becks cognitive therapy placed importance on the therapeutic relationship but according to Gilbert & Leahy (2009, p.5) the parallel development of Rogers helping relationship and the assumption that these were core skills for trainees, meant that 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. Rogers Core ConditionsRogers put forward his theory of the Necessary and Sufficient Conditions of Therapeutic Personality Change in the Journal of Consulting Psychiatry in 1957. Rogers described six conditions proposed as being the necessary and sufficient conditions for therapeutic personality change, being that:I. Two persons are in psychological contact

II. The first (the client) is in a state of incongruence, being vulnerable or anxious

III. The second (the therapist) is congruent or integrated in the relationship

IV. The therapist experiences unconditional positive regard for the client

V. The therapist experiences an empathic understanding of the clients internal frame of reference, and endeavours to communicate this experience to the client

VI. The communication to the client of the therapists empathic understanding and unconditional positive regard is to a minimal degree achievedThe first two conditions allow a therapeutic relationship to develop that holds the core conditions of empathy, unconditional positive regard and congruence within itself and encourages and enables the client to come to her own conclusions and reach her full potential, with the therapist taking a non-directive role. Clients are able to provide their own solutions to their problems when the therapist assumes that the client and not the therapist is really the expert on the clients problem.His argument seemed to differ widely from other psychotherapies at the time in that the therapist was the expert, and had the skills or tools to excise or cure the part of the person that was sick or in need of change. Given that these conditions were clearly emphasising a client focus, there seems to be further corroboration in a point stated by Horvath and Luborsky (1993) that the majority of findings indicate that it is the client's perception of the therapist as an empathic individual, rather than the actual therapist behavior, that yielded the most robust correlation with outcome. However, in a meta-analysis of clinical research completed by Norcross and Lambert clear It also seems likely that the core conditions are necessary but not sufficient as The therapy relationship makes substantial and consistentcontributions to patient success in all types of psychotherapy studied (for example, psychodynamic, humanistic, cognitive,behavioral, systemic).The therapy relationship accounts for why clientsimprove (or fail to improve) as much as theparticular treatment method.Practice and treatment guidelines should address therapist qualities and behaviors thatpromote the therapy relationship.Practitioners should routinely monitor patients responses to the therapy relationship and ongoing treatment. Such monitoring leads toincreased opportunities to repair alliance ruptures, improve the relationship, modify technical strategies, and avoid premature termination (Lambert, 2010).Efforts to promulgate best practices or evidence-based practices (EBPs) without including the relationship are incomplete and potentially misleading.The relationship acts in concert with treatment methods,patient characteristics, andpractitioner qualities in determining effectiveness. A comprehensive understanding of 2effective (and ineffective) psychotherapy will consider all these determinants and their optimal combinations. Rimondini (2011, p.4) - the appropriateness in

micro-skill application comes from the theoretical background, clinical experiences,

personal attitudes, and self-awareness of the clinician, which means that

the professionalism relies on the co-presence of all these elements blended togetherAdapting or tailoring the relationship to several patient characteristics (in addition to diagnosis) enhances effectiveness (as summarized in chapter13).Key Factors in the Therapeutic Relationship

The understanding of the therapeutic alliance as a component of the therapeutic relationship is common. Using the latter understanding, the American Psychological Association conducted the largest ever review of empirical evidence (Cooper 2008, p.101) in the area of the therapeutic relationship in an attempt to identify the relationship components of effective therapy. The following elements were found to be demonstrably effective: empathy, alliance, goal consensus and collaboration, positive regard and affirmation, congruence/genuineness, collecting client feedback, repair of alliance ruptures, management of counter-transference, and adapting the relationship to the individual client (Norcross, 2011). In this study, the therapeutic alliance is defined as the quality and strength of the collaborative relationship between client and therapist (Norcross 2011, p.120), and it is understood as one of the components of the therapeutic relationship.Processes in the Therapeutic RelationshipIn considering the temporal nature of the therapeutic relationship, Leahy states that It is important to think of the therapeutic relationship or alliance as an on-going process, rather than an achievement that is fixed at one point in time, since the relationship is interactive and iterative, reflecting the patients response to the therapists response to the patient (2008). The accumulated evidence importantly states that the quality and nature of the therapeutic relationship or alliance is predictive of outcome. Fiedler in his research into the nature of the therapeutic relationship in different modalities of therapy concluded that Thesefactors are related to the therapist's abilitytocommunicatewith and understandthe patient, and to his security and his emotional distance to thepatient. Nofactors were found which clearly separate therapists of oneschool from thoseofanother.This supported the hypothesis of his research, that thenature of the therapeuticrelationship isa functionofexpertness rather than school. Norcross concludes that (2011, p.101) psychotherapy is at root a human relationship and evidence suggests that the therapeutic relationship is a common factor in most therapies but research is still not conclusive as to whether therapeutic change is purely driven by the efficacy of the client/therapist relationship or whether this is a factor amongst many. Much recent research has also considered whether the therapeutic relationship is more or less important at different points throughout therapy, with differing outcomes but drawing some important conclusions regarding key factors in offering evidence based therapy.Resolution and Repair of RupturesIn their research, Castonguay, Goldfried, Wiser, Raue, and Hayes (1996) found clear evidence of strains in the alliance (e.g., clients were negative, unresponsive, avoidant) in several cases of cognitive therapy; they noted that therapists addressed the strain by increasing their adherence to the cognitive therapy protocol and emphasizing the impact of the clients distorted thoughts, which unfortunately then led to therapist-client power struggles.Leahy (2008) states that During the last decade there has been increased interest in the nature of the therapeutic relationship in cognitive behavioral therapy and goes on to emphasise the opportunities presented for using this relationship to resolve ruptures in the therapeutic relationship.Safran et al. (1990) concluded that the positive outcome of therapy was more closely associated with the successful resolution of ruptures in the alliance than with a linear growth pattern as the therapy proceeds. Horvath and Marx (1991) describe the course of the alliance in successful therapies as a sequence of developments, breaches, and repairs and Norcross (2011) points out that an ineffective therapist ignores these ruptures with a corresponding reduction in efficacy of therapy.Safran & Muran state that Ruptures in the therapeutic alliance are episodes of tension or breakdown in the collaborative relationship between patient and therapist. Exploring and repairing alliance ruptures when they occur can be an important element contributing to positive treatment outcome. (as cited in Norcross & Lambert, 2011).Summary

ConclusionReferencesBeck, A, T. (1997). The Past and Future of Cognitive Therapy. Cognitive Therapy, 6(4), 276-284.Burgess, M, Andiappan, M, & Chalder, T. (2012). Cognitive Behaviour Therapy for Chronic Fatigue Syndrome in Adults: Face to Face versus Telephone Treatment - A Randomized Controlled Trial.Behavioural and Cognitive Psychotherapy,40 number 2.

Castonguay, L. G., Constantino, M. J., & Holtforth, M. G. (2006). The working alliance: Where are we and where should we go?.Psychotherapy: Theory, Research, Practice, Training,43(3), 271.

Clarkson, P, & Pokorny, M. (1994).The Handbook of Psychotherapy. United Kingdom: London; Routledge.Constantino, M. J., Ladany, N., & Borkovec, T. D. (2010). Edward S. Bordin: Innovative thinker, influential investigator, and inspiring teacher. In L. G. Castonguay, J. C. Muran, L.

Angus, J. A. Hayes, N. Ladany, & T. Anderson (Eds.), Bringing psychotherapy research to life:

Understanding change through the work of leading clinical researchers (pp. 21-57).

Washington, DC: American Psychological Association.Cooper, M. (2008).Essential research findings in counselling and psychotherapy: The facts are friendly. Sage.

Dugas, M J, & Robichaud, M. (2007).Cognitive-Behavioural Treatment for Generalized Anxiety Disorder - From Science to Practice. United Kingdom London: Routledge Taylor & Francis Group, LLC.

Fiedler, F. (1951). Factor Analysis of Psychoanalytic, Non-directive, and Adlerian Therapeutic Relationships. Journal of Consulting Psychology, 15, 32-38.

Gilbert, P.P, & Leahy, R. (2009). The Therapeutic Relationship in the Cognitive Behavioral Psychotherapies (1st Ed.). United Kingdom: Taylor & Francis, Inc.

Grant, A, Mills, J, Mulhern, R, & Short, N. (2004).Cognitive Behavioural Therapy in Mental Health Care. United Kingdom: SAGE Publications Ltd.

Grant, A, Mills, J, & Townend, M. (2008).Assessment and Case Formulation in Cognitive Behavioural Therapy. United Kingdom: SAGE Publications Ltd.

Greenberg, L, S, & Horvath, A, O. (1994) The Working Alliance: Theory, Research, and Practice. New York: John Wiley & Sons, Inc.

Horvath, A, O, & Luborsky, L. (1993) The Role of the Therapeutic Alliance in Psychotherapy. Journal of Consulting and Clinical Psychology, 61(4) 561-573.

Hubble, M. A., Duncan, B. L., & Miller, S. D. (1999).Introduction. American Psychological Association.Langdridge, D. (2010).Understanding Counselling and Psychotherapy. Milton Keynes [England]: In association with The Open University.

Leahy, R, L. (2008). The Therapeutic Relationship in Cognitive-Behavioral Therapy. Behavioural and Cognitive Psychotherapy, 36(6), 769-777.

May, R.

McLeod, S, A. (2010). Behavioral Therapy. Retrieved from http://www.simplypsychology.org/behavioral-therapy.html

Mearns, D, & Cooper, M. (2005).Working at relational depth in counselling and psychotherapy. Sage Publications Ltd.Moorey, S. (1996). Cognitive behaviour therapy for whom?Advances in Psychiatric Treatment,2(1), 17-23.Nolan, P. (2012). Therapist and Client: A Relational Approach to Psychotherapy. Wiley-Blackwell.

Norcross, J. C., & Lambert, M. J. (2011). Evidence-based therapy relationships.Psychotherapy relationships that work, 3-21.Persons, J. B., & Burns, D. D. (1985). Mechanisms of action of cognitive therapy: The relative contributions of technical and interpersonal interventions. Cognitive therapy and Research,9(5), 539-551.

Pitchford, D. B. (2009). The Existentialism of Rollo May: An Influence on Trauma Treatment.Journal of Humanistic Psychology,49(4), 441461.

Rimondini, M. (2011). Communication in Cognitive Behavioral Therapy. New York Dordrecht Heidelberg London: Springer.Rogers, C. (1957) The Necessary and Sufficient Conditions of Therapeutic Personality Change. Journal of Consulting Psychiatry, 21, 95203.

Rosenfarb, I, S.(1992). A behavior analytic interpretation of the therapeutic relationship. Psychological Record, Vol 42(3), 341-354.Safran, J. D., & Muran, J. C. (1996). The resolution of ruptures in the therapeutic alliance.Journal of consulting and clinical psychology,64(3), 447.Safran, J. D., Muran, J. C., Samstag, L. W., & Stevens, C. (2001). Repairing alliance ruptures.Psychotherapy: Theory, Research, Practice, Training,38(4), 406.Schaap, C., Bennun, I., Schindler, L., & Hoogduin, K. (1993).The therapeutic relationship in behavioural psychotherapy. John Wiley & Sons.

Stiles-Shields, C, Kwasny, M. J, Cai, X, & Mohr, D. C. (2014). Comorbid Anxiety as a Differential Treatment Predictor for Telephone versus Face-to-Face Administered Cognitive Behavioural Therapy for Depression.Depression and Anxiety,31, 934-940.

Wellings, N, & McCormick, E. W. (2003).Transpersonal Psychotherapy. United Kingdom: SAGE Publications Ltd.Westbrook, D., Kennerley, H., & Kirk, J. (2011).An introduction to cognitive behaviour therapy: Skills and applications. United Kingdom: SAGE Publications Ltd.

Specific therapeutic strategies such

as debating or cognitive restructuring are effective insofar as the clinician shows

proficiency in illustrating and applying them through a proper patient centered

language. Rimondini (2011, p.V)

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