Paul Gilbert and Robert L. Leahy
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.
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 empathic activities (Decety & Jackson, 2004; Völlm et al., 2006). Empathy and theory of mind provide opportunities to understand that others do not feel and think exactly as we do. Clearly, the way the therapist and patient relate to each other will be influenced by these processes.
The above touches on some of the psychological competencies that we (innately) have that allow us to engage in complex social interactions. In addition to these there are a host of other processes that clearly bear on the therapeutic relationship (Freeman & McCloskey, 2003; Klein et al., 2003).
Patient characteristics are an important component of the therapeutic relationship. These include expectations of being helped and symptom severity (Constantino, Arnow, Blasey & Agras, 2005), abilities to trust others and the therapist (Berretta, de Roten, Stigler, Drapeau, Fischer & Despland, 2005), history of relationships, especially those related to attachment experiences (Holmes, 2001; Leahy, 2005; Liotti, Chapter 7, this volume), self–other schemata (Leahy, Chapter 11, this volume), motivation to change (Miller & Rollnick, 2002) and homework engagement (Burns & Nolen-Hoeksema, 1992; Burns & Spangler, 2000). Also important are therapist characteristics such as basic microskills (Ivey & Ivey, 2003), abilities to connect emotionally and express empathy and warmth (Kirschenbaum & Jourdan, 2005), the ability to deal with therapeutic ruptures (Safran & Muran, 2000), skill in the therapeutic modality (Burns & Nolen-Hoeksema, 1992), and personality matches and clashes (Leahy, Chapter 11, this volume).
The nature of the therapeutic modality is also important. This includes the focus or tasks of the therapy – for example, specific symptoms vs interpersonal problem-focused issues (Constantino et al., 2005; Klein et al., 2003); activation of specific processing systems (Harvey, Watkins, Mansell & Shafran, 2004) such as specific memory and attentional systems in posttraumatic stress disorder (Dalgleish, 2004; Lee, 2005); use of imagery (Holmes & Hackmann, 2004), and use of homework (Burns & Nolen-Hoeksema, 1992). The interaction of these various factors is increasingly becoming a key focus for research (e.g., see Castonguay & Beutler, 2006). They are all involved in the co-construction of a relationship and thus in the transference/counter-transference process (Miranda & Anderson, Chapter 4, this volume).
There is now general agreement that therapy involves three core elements, bonds, tasks and goals (see Hardy, Cahill & Barkham, Chapter 2, this volume). These are not mutually exclusive, however, because the way therapists form and develop their bonds (therapeutic relationships) will have an impact on task selection, task engagement and goals. As noted above, tasks/activities that bring improvement will aid the therapeutic relationship. The therapeutic relationship can be key during difficult times. Working and confronting painful experiences tends to run counter to traditional Western medicine, which has developed technologies to remove pain and suffering via medications or surgeries. Putting the patient back at the centre of the recovery process, with the therapist as guide, is key to the cognitive behavioural therapies. However, this does not obviate the need for the therapist to be in some measure “expert, knowledgeable and agenda guiding”. The concept of collaboration becomes hazy in the shadow of the power dynamics. The assumption of collaboration does not mean that the skills in being able to contain, guide, and control the pace of therapy, and suggest ideas, are not important, or that in some sense patients have to “heal themselves”.
As noted above, therapists should be competent in a range of microskills and there is empirical support to show that these have a major impact on outcome (Ivey & Ivey, 2003; Feltham & Horton, 2006). The therapeutic relationship will be supported by the recognition that the therapist will be navigating through various stages. Their microskills therefore will be designed to facilitate these various stages and the transition from one stage to another. For example, Gilbert (2000) suggested ten stages:
These stages can be classified into different groups of processes, as Hardy et al. (Chapter 2, this volume) outline as a more macro set of stages. Microskills facilitate each stage and smooth transition between stages. Microskills involve a mixture of (usually open) questions that invite the patient to discuss, explore and narrate their story; non-verbal communications that help the patient feel safe and non-threatened; and explanations of the processes that will unfold.
Attentiveness
There are two types – externally focused and internally focused. External attentiveness involves a variety of attending behaviours, such as appropriate eye contact. This means that the therapist is able to observe the nonverbal behaviour of the patient, such as subtle changes as the story unfolds (for example, shame patients may begin to look down and curl their head into their chest or go blank/shut down when narrating shame-filled experience). Other non-verbal pointers can be clenching the fist or jaw when discussing events. Careful attention to “the person as a whole” (not just verbal content but body postures and voice tones) gives a fuller picture of possible internal processes. Clearly, however, the eye contact of the therapist should not be staring or threatening. Research into non-verbal communication from both the patient and the therapist reveals complex interactions that can affect outcome (e.g., see Dreher, Mengele, Krause & Kämmerer (2001).
Therapist attentive behaviour is also expressed via body posture, which should be relaxed but show clear interest and focus. Another form of attentive behaviour is verbally following the client’s stories with minimal prompts – for example, “hmm . . . I see . . . could you say more on that?” – rather than changing the subject or engaging in closed questions. Greenberg (Chapter 3, this volume) writes in terms of “presence” where the sense of self is suspended and the attention is purely on the patient. The therapist is absorbed in and curious about the patient’s experience. Internal attentiveness involves a form of mindfulness. Katzow & Safran (Chapter 5, this volume) suggest that mindfulness involves learning to direct one’s attention in a nonjudgemental fashion to one’s own internal processes. This enables the therapist to become aware of his/her thoughts, feelings, and actions as they emerge in the present moment. It involves cultivating an attitude of open curiosity about one’s inner experience as it unfolds, with an ability to let go of one’s preconceptions as they arise when sitting with a patient. The therapist should be non-judgemental and certainly non-critical of thoughts and feelings that emerge from within themselves. Equally they should have sufficient internal capacity to “hold onto” and “contain” those thoughts and feelings without acting them out.
Thus, attention can move back and forth. Ideally therapists are able to move easily between external and internal attentiveness and be aware of their own reactions, thereby facilitating their choices of other microskills and questions. Psychodynamic writers have written far more on the importance of noting and understanding our reactions to patients, and their impacts in therapy, than have cognitive therapists (Greenberg & Mitchell, 1983). This may be partly because cognitive behavioural therapists have focused more on psycho-education with supportive warm encouragement to engage in key therapy tasks such as exposure (Schaap et al., 1993). However, this is changing and Katzow & Safran (Chapter 5, this volume) develop this theme in important ways, while Bennett-Levy and Thwaites (Chapter 12, this volume) explore this aspect from a training point of view. As the story unfolds, three further microskills come into play. Content aspects or factual events in the story are paraphrased, aspects of feeling and emotion should be accurately reflected, and summaries build towards joint understanding and eventual formulation.
Reflections and empathic connecting
Accurately reflecting a patient’s feelings is a skill that enables the therapist to keep in touch with, and form an empathic bridge to, the patient. The patients can hear the reflection and know that the therapist is “with him/ her”. It also gives direct feedback on “what is in the mind of the therapist” and thus aids “theory of mind” understanding. Here are some examples from Gilbert (2000):
Patient:
When Jane invited me in for a coffee after the dance I just had to turn her down. At that point I wanted to get home as quickly as possible.
Therapist:
Sounds as if her offer made you pretty anxious.
Client:
Absolutely. I found my stomach turn over in case she wanted me to stay the night and all.
However, the same statement given in a different way, with voice tone and body language, and in a different context may prompt a different reflection of feelings:
Patient:
When Jane invited me in for a coffee after the dance I just had to turn her down. At that point I wanted to get home as quickly as possible.
Therapist:
Sounds as if her offer made you irritated.
Patient:
Absolutely. She knew I had a busy day the next day and that I was really tired and there she was making more demands on me.
Here we are not exploring in depth the nature of, or underlying beliefs of, the anxiety or anger. We are simply reflecting on feelings. Reflecting feelings enables the therapist to convey his/her understanding and awareness of the client’s internal experience and build an empathic bridge. It is a step towards acknowledgement and validation. Of course, the cognitive therapist might also choose to follow this up with Socratic questions of what was underneath that irritation – what was going through their mind? The point is that, if the therapist moves too quickly to help the patient focus on their thoughts and interpretations without reflecting on feelings, this can be felt to be unempathic. Here is an extreme example:
Patient:
I don’t want to live any more. You see, my baby was knocked over by the Number 42 Bus from Derby.
Therapist:
So what goes through your mind when you think of your baby being knocked over by the Number 42 Bus from Derby?
Gilbert (Chapter 6, this volume) therefore suggests that therapists need to be compassionately engaged with their patients and sensitive to their distress, able to reflect it, and moved by their distress. When used well, reflecting feelings aids guided discovery, and enables people to recognise their safety behaviours and biases and gradually find the courage to confront them. This is a therapist skill that avoids telling the patient that their thinking is distorted or biased – an experience often accompanied by shame and self-criticism.
Paraphrasing and summarising
Paraphrasing, and at some stage tentatively summarising, gives an opportunity for the patient to hear their story placed in context and to correct any misunderstanding, vagueness or lack of emphasis. These are the building blocks to formulation. Done skilfully, the formulation emerges because the therapist has been building the blocks for the formulation via their mini-summaries based on the patient’s narrative. In CBT formulation it is a collaborative building process, not an interpretive one.
Linking
A therapist might help patients link things together in ways they may not have noticed before. For example, the therapist may offer the observation – “Listening to your story, I notice that the fear of upsetting people is something you mention often. I wonder if this is a key theme for you?” or “Given what we have been saying so far, I wonder if it is possible to see how these thoughts (feelings/behaviours/experiences) might be linked to earlier events you told me about in your life?” It is sometimes said that CBT is not interested in the past or in helping people understand the origins of their difficulties as emerging from their personal histories. A lot depends on the case, but for many of the more complex cases (especially where abuse and trauma are involved in the background), it would be inappropriate to ignore history. Indeed, working with traumatic memory is now commonplace in CBT (Dalgleish, 2004; Hackmann, 2005; Lee, 2005).
Socratic questions
Socratic questions can be seen as “advanced” open questions that enable and encourage the patient to discover connections in their meaning-making. Socratic questions are designed to help patients explore in more detail their meanings and the implications of what they are saying. So, for example, they will include questions such as “What did that mean to you? What did you make of that? What do you think will happen next?” or “What is your worst fear in this situation?” Socratic questions are often used to help patients to “ladder” or inference chain their thoughts. For example, patients may discuss the fact that they find it difficult to be assertive. The therapist may then ask “What is it about this difficulty with assertiveness that most distresses you?” or “What do you think will happen if you are assertive?” or “What do you think will happen as a result of your lack of assertiveness?” These explorations are not integrations and thus again nonverbal communication, voice tone and pacing are crucial here. A question such as “What is it about this difficulty with assertiveness that most distresses you?” can be asked in a dismissive or inquisitorial way (like “Why do you get so upset about this – you wimp!”), or in a gentle way (“Let’s explore this fear together”). Like a good joke, it is not what you say but how you say it.
It is important that the therapist show understanding for the patient’s distress and gently acknowledge that, “I can see that thinking like that is very distressing and frightening for you”, or “Those images/intrusions/ thoughts/feelings are terrifying for you”. Here the therapist is connecting not to the source of the problems (which comes later) but with the experience of the problem. When Tom’s son broke his leg the physician held the son’s hand and acknowledged how painful it must be while at the same time straightening the leg and plastering it.
Psychotherapists have long recognised the importance of empathy, validation and unconditional positive regard (Rogers, 1965), with many studies indicating the importance of the perceived therapeutic relationship in predicting outcome, regardless of therapeutic modality (Martin, Garske & Davis, 2000). Although it is commonly believed that validation and empathy contribute to successful outcome, it has also been argued that improvement in symptoms leads the patient to perceive greater empathy or care in the therapist (Feeley, DeRubeis & Gelf, 1999).
Leahy (2005) has offered the following distinction between empathy, validation and compassion:
Validation – finding the truth in what we feel and think – stands as the fulcrum between empathy – where we recognize the feeling that another person has – and compassion – whereby we feel with and for another person and care about the suffering of that person. For example, empathy is recognizing what the other person feels (“It sounds like you are feeling sad”), validation adds on “finding the validity in the other’s feelings” (e.g., “I can understand why you feel sad, since you believe that she was the only person that you might love”), and compassion (assumes empathy and validation) but goes further to assure the individual, “I care very much about how you are feeling and how hard it is for you and I want you to know I am here for you during this difficult time”.
Empathy, validation and compassion are social–emotional experiences that are grounded in early attachment. As Gilbert (Chapter 6, this volume), Greenberg (Chapter 3, this volume) and Liotti (Chapter 7, this volume) indicate, the attachment bond during infancy and throughout childhood (and later life) is predicated on these experiences. Leahy (2005) has proposed that the willingness of parents to validate and empathise is related to Gottman’s “emotional philosophies” – that is, parents who believe that their child’s painful emotions provide an opportunity to get closer, to know and to help are more likely to validate and show compassion, whereas parents holding the view that the child’s emotions are overwhelming, threatening or self-indulgent are less likely to validate (Gottman et al., 1996; Leahy, 2002). As a result of these different emotional-coaching strategies, the child may come to learn that their emotions are a reason for embarrassment or that their emotions do not “make sense”. Leahy (2002, 2005) has proposed a model of emotional schemata that reflect how individuals respond to their own emotions. Thus, negative emotional schemata are reflected by beliefs that one’s emotions do not make sense, are shameful, are overwhelming, are out of control, will last indefinitely, are dangerous, are different from others and cannot be expressed.
Thus, one’s beliefs about emotion are linked to the reflective empathising, validating, and emotional coaching that have occurred in early and later attachment relationships. Of course, the therapeutic relationship is another relationship that is viewed, from this perspective, as eliciting these earlier experiences of emotional socialisation. Therapy – even within the CBT model - is not simply eliciting and testing problematic thoughts; it also involves the elicitation of emotions, in what cognitive therapists have come to call “hot cognitions”. Emotional experience is an essential part of this model, but therapists need to be attuned to how individual patients may experience the “opportunity” to share their emotions. For some it is a welcome experience, but for others it may resurrect old fears of shame, humiliation, confusion and loss of control.
Indeed, validation may be such a “problem” for some patients that they have developed their own “rules for being validated” (Leahy, 2001). For example, some patients may demand perfect validation – to the point of believing that unless the therapist has suffered exactly the same problems and intensity of despair, the therapist is incapable of validating. Moreover, some patients may engage strategies to elicit validation – such as escalating, catastrophising, creating emergencies, ruminating, and focusing on physical ailments – that may be intended to elicit validation from the therapist or from others, but which usually backfire. Leahy (2001) indicated that these specific rules and strategies for validation in therapy can provide an excellent opportunity to understand and, eventually, modify the patient’s apparently “self-defeating” style of interaction in relationships outside therapy. Thus, “roadblocks” in therapy become opportunities for transforming change outside therapy.
While it is important to provide a warm and supportive emotional environment in therapy, it is also important to recognise that some patients – seeking out personal emotional goals or engaging in old habits – will violate the boundaries of the therapeutic relationship. Once again, these impediments to change, or “therapy interfering behaviours”, can provide an opportunity for growth, if handled skilfully. The therapist can use a “dialectical” strategy of firmly and compassionately setting boundaries, while exploring with the patient the meaning of the boundary. It is often the case that patients who utilise coercive strategies in therapy have found that this may be the only way to be “heard” in earlier relationships.
We can see that there is a range of key therapy skills that advances the therapeutic relationship in creating a safe place where “work” can occur, courage to engage the process of change can be nurtured and new self-knowledge gained. CBT has a range of techniques at its disposal for helping people change and these are increasingly evidence-based, but this in no way means that we become psychological mechanics (Leahy, 2005).
We started this chapter by noting that the importance of the qualities of a relationship have been seen as central to the therapeutic process for a long time and in many different cultures. What occurs within the relationship, however, is linked to cultural meanings on the sources and cures for suffering. We live in a time where we have come to a particular set of views and beliefs on the sources and cures for suffering, and these beliefs texture the construction of the therapeutic relationship. Given the growing awareness of the complexities in developing a therapeutic working alliance or relationship, this book brings together a variety of clinicians representing different CBT orientations to address key issues of the therapeutic relationship. What emerges from these writings is a rich tapestry of thinking, conceptualisation and research focused on the therapeutic relationship and how this can impact on our therapeutic work. We have tried not to offer a single view but to reflect diversity of thinking within CBT.
The book is divided into two parts. The first part, “Key issues”, examines the key elements that are involved in developing and maintaining the therapeutic relationship and bringing it to an end. The second part explores the therapeutic relationship in more specific types of CBT. That section also includes chapters on issues of training and therapist development.
Following this introductory chapter, Hardy, Cahill & Barkham (Chapter 2) give an overview of research on patient–therapist interactions. From their systematic review of the literature they develop a process model of the therapeutic relationship as it unfolds over time. Greenberg (Chapter 3) uses an emotion-focused approach to reflect on key microskills, such as empathy and “presence” within the therapeutic context – that is, how therapists listen, attend and respond to the emotional textures of patient communication and how these behaviours affect the process and outcome. Miranda and Andersen (Chapter 4) address the important issue of transference and counter-transference from a social-cognitive approach. They review a wealth of data on the importance of recognising relationships as co-constructions such that what the therapist brings and what the patient brings are important to the relationship pattern. In Chapter 5 Katzow & Safran discuss the therapeutic relationship in the light of major developments in the use of mindfulness within cognitive therapy. Mindfulness points to a specific set of microskills, which is the ability to attune to one’s own inner processes “mindfully”. They explore how this can be essential for understanding and resolving therapeutic ruptures. In Chapter 6, Gilbert contextualises the therapeutic relationship against the background of humans as evolved social beings with important social needs. Recent research suggests that we have special processing systems that are sensitive to social safeness and threat. Thus the way a therapist is able to create experiences of safeness, often with the use of compassion, can be key to therapy progress, especially with high shame and self-critical people. Liotti, in Chapter 7, develops the evolutionary theme with the importance of attachment theory as a model for understanding the therapeutic relationship. As he notes, if therapists can understand and recognise different patterns of attachment, particularly disorganised attachment, and how these can emerge in therapy, this can be highly beneficial to therapeutic understanding and the therapeutic relationship.
Newman, in Chapter 8, begins the second part of the book, which focuses on the therapeutic relationship in specific CBT-focused approaches. Newman outlines the traditional cognitive therapy approach and discusses how the relationship is important not only for developing collaboration but at times when therapists are required to be more challenging and confrontative. Chapter 9, by Swales & Heard, offers a dialectical behavioural therapy (DBT) approach to the therapeutic relationship. DBT was designed to help people with suicidal behaviour and with borderline personality difficulties. These patients can be especially difficult to engage, set boundaries for and develop a therapeutic programme with. As DBT recognises, the therapeutic relationship is crucial here. Pierson & Hayes, in Chapter 10, explore the therapeutic relationship from the point of view of acceptance and commitment therapy (ACT). ACT sees the therapeutic relationship as playing a key role in the ability of patients to be accepting of their difficulties. However, as they point out, it is also essential that the therapist has the same competencies and capacities.
In Chapter 11, by Leahy, the therapeutic relationship is understood as an interactive game whereby the participants (“players”) are the therapist and the patient – each following his or her own set of rules and anticipating “moves” by the other. Of specific interest in this chapter are the individual “schemas” about emotion, relationship and engagement. Thus, the therapist with demanding standards and negative schemas about emotions may inadvertently confirm negative beliefs about relationships and emotions endorsed by the avoidant or dependent patient. Viewing the transference and counter-transference in this manner provides the therapist with a conceptualisation and a strategy to avoid unnecessary pitfalls in the therapeutic relationship, and to utilise these roadblocks to better understand how the patient’s interpersonal world outside of therapy may be reflected in the current relationship in the therapy.
Training is a major issue for all therapies, especially training people in microskills that new therapists coming into CBT may lack. In Chapter 12, Bennett-Levy & Thwaites explore training issues but with particular attention to how therapists can become more self-aware and insightful using the very techniques and approaches that they will apply in their work. Early psychodynamic therapists were very keen that therapists should have personal therapy to ensure they do not bring their own agendas and unresolved conflicts into the therapy. However, this was before the days of video and audio tape recordings that allow supervisors to hear and see what is going on between therapist and patient in supervision. It is important therefore to consider how supervisors work with and help trainee therapists who may be bringing personal issues, who may be easily threatened and become defensive, or who may be anxious about challenging patients. Since CBT is not an interpretive therapy, the problems encountered in psychodynamic therapy are less likely here.
Although there are of course various CBT approaches that are not reflected here, we hope this book stimulates interest in the therapeutic relationship within the CBT approach, and puts to rest the view that CBT does not regard the therapeutic relationship as important or worthy of research and focus. Because cognitive therapy is a non-interpretive therapy but focuses on guided discovery, opportunities to expose self to various fears and desensitise to feared outcomes, re-attend, re-evaluate, and in some cases mature new ways of experiencing self and others, this does not mean that the therapeutic relationship is unimportant or a side issue. Research consistently shows the therapeutic relationship to be a key ingredient of many forms of successful therapy. We hope that the contributors to this book have shown how and why CBT is also very keen to establish scientific ways of understanding the therapeutic relationship and bringing the best qualities to the teaching of therapy and the provision of therapy to our patients.
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