Preface

We have been organizing symposia at Cognitive Behavioural Conferences on the therapeutic relationship for the past few years. What became apparent was that participants in the audience were eager to learn more about “how to relate to patients” so that therapy could work more effectively. Although we both recognize the importance of techniques and “empirically validated treatments”, we also recognize that you won’t get very far with techniques and treatments if patients are dropping out of treatment.

It has been noted in various schools of therapy that some therapists are adept at connecting with patients, reducing premature dropout and being open and explorative at times of difficulty, while other therapists, equally intelligent, conscientious and well-trained in techniques, seem to have a hard time keeping patients engaged or “being in tune” with their patients. In our experience of training therapists we have noticed this too, which has led us to consider whether at times “microskills” and the “wisdom-skills” of therapy are overlooked or assumed, or are touched on only in passing in some treatment manuals. Although we all appreciate that therapy is not simply a matter of “applying techniques” – it involves a human relationship that can either help or hinder the effectiveness of the therapy – we are also aware that clinicians outside the CBT tradition criticize CBT for not giving enough attention to the complexities and the importance of the therapeutic relationship. While we believe these criticisms are exaggerated, there may be a grain of truth in the observation that many of us who utilize CBT could do a better job of understanding and working with the therapeutic relationship to benefit the patient. Since CBT prides itself on its scientific approach, it is important that as we learn more about how our minds are influenced through relationships this will need to be taught during training and influence practice.

With these thoughts in mind, we had communicated on the idea for a book on the therapeutic relationship in CBT for some time and then at the annual British Association of Behavioural and Cognitive Psychotherapy conference at the University of York (UK) in July 2003 we decided to get on with it. Paul had been developing his work on the role of compassion in therapy and Bob had been focusing on validation, and from discussion with other attendees it was clear to us that there was a lot of interest and thinking going on in CBT about the therapeutic relationship. We also recognized that concepts like “transference” and “countertransference” had always been around in CBT but primarily seen through the lens of core beliefs and schemata, open to evidence-testing like any other belief. Recent research, however, was bringing to light new processes and issues important to therapeutic relationships – the importance of non-conscious processing, emotional awareness and socialization, attachment processes, shame and compassion, mindfulness, schematic processes, and interpersonal strategies. Each of these has implications for the therapeutic relationship and how to integrate such insights into practice.

In an effort to help articulate new thinking on the therapeutic relationship in CBT we decided to invite our colleagues to address a series of questions. Some invitations were declined and others did not come through, but the authors of this volume approached the project with great enthusiasm, sharing with us many interesting ideas and insights, and also sharing the view that a focus on the therapeutic relationship, and the diversity of views in CBT, was perhaps overdue. So we thought about some key questions to put to our authors, though we stressed that these were only guides and they might wish to address other issues. The issues we suggested included:

1. The importance of how you relate to your patient in the early stages, such that (for example) the patient feels safe and is motivated to return. We think that the issue of safeness may be crucial to a patient’s preparedness to engage and begin the journey of change. What, for example, do you think of the role of non-verbal communication and cues, voice tone, forms of Socratic questioning, type of ‘conversation’, the difference between an invitation to explore and a formulation process?
2. How does the therapeutic relationship in CBT deal with therapeutic ruptures, sticking points, boundary setting and suchlike?
3. Psychotherapy involves moment-to-moment interactions between two people and we are interested in how you conceptualise this dynamic process of transference/counter-transference. To what extent might you use thoughts and feelings triggered in you by the patient to guide your therapeutic interventions and process?
4. How do you view the ending of therapy and the discussion of ending of the relationship? How might you deal with termination issues, such as dependency or apparent narcissistic indifference?

This collection of chapters provides an opportunity to see how the relationship can be considered in complex ways, reflected on, enriched, and utilized more effectively in CBT. Because of space limitations we were not able to include every important model, but we hope the reader will come away with an experience of the richness and vitality of these issues. We also hope that the scientific foundations for CBT and the active nature of CBT will provide new interventions, strategies and conceptualizations for addressing the core issue of the relationship in therapy.

We would like to thank all the authors of this volume for making our job as editors the enjoyable and educational one it has been.

Paul Gilbert and Robert L. Leahy
March 2006