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Importance of Therapeutic Relationship in Cognitive Therapy

Paper Type: Free Essay Subject: Psychology
Wordcount: 1600 words Published: 17th Apr 2018

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Within cognitive therapy, the therapeutic relationship, along with the emotional aspects of therapy in general, has historically been of less importance than for other therapeutic modalities. In the last decade this has changed and in the so-called ‘third wave’ in cognitive therapy there is a much greater interest in the therapeutic relationship (Hayes, Strosahl & Wilson, 2004). This essay evaluates the relevance of the therapeutic relationship in cognitive therapy with reference to the outcome research.

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The term ‘therapeutic relationship’ covers a wide range of factors within therapy, each of which have been examined separately in the research. Hardy, Cahill and Barkham (2007) have suggested that it is useful to break down this research into three areas: establishing the relationship, developing the relationship and, finally, maintaining the relationship. Starting with establishing a relationship, Sexton, Littauer, Sexton and Tømmerås (2005) examined the first two sessions with 34 different clients using anonymous ratings at 20 second intervals. They found that better therapeutic alliances were associated with earlier meaningful connection and emotional involvement.

Empathy is also thought to be a major component in establishing a relationship. The research on the contribution of empathy towards the therapeutic outcome has been subject to meta-analysis by Bohart, Elliott, Greenberg and Watson (2002). This found that between 7% and 10% of psychotherapy outcomes were explained by empathy – indeed this relationship was particularly strong in cognitive therapies. Two further components central to establishing a relationship which have also garnered positive relationship with outcomes in the literature are engagement (e.g. Tryon, 2002) and mutual involvement (e.g. Tryon & Winograd, 2002).

The second research area is developing a relationship; in order to progress clients must have a sense of commitment, trust and openness towards their therapist (Hardy, Cahill & Barkham, 2007). This means the therapist must effectively manage the relationship, including negotiating factors like transference and counter-transference (Ligiero & Gelso, 2002). This area, however, has not been extensively examined within cognitive therapy.

The third research area is maintaining the relationship. Research has examined how therapists deal with the inevitable problems that arise in therapeutic relationships. Better outcomes are generally predicted by successfully dealing with challenges to the therapeutic relationship. Challenges studied have included negative feelings towards clients (Gelso & Carter, 1985), disagreements (Safran, Muran, Samstag & Stevens, 2001) and resistance (Binder & Strupp, 1997). Stiles et al. (2004) looked at the overall pattern of alliance development over the course of both cognitive and psychodynamic therapies. They found that those who had ruptures in the therapeutic alliance, which were subsequently repaired, had the best treatment outcomes. This, along with similar previous research by Kivlighan and Shaughnessy (2000) strongly underlines the importance of relationship maintenance in treatment outcome.

Much of the research on the therapeutic alliance across treatment modalities has been reviewed in two meta-analyses (Horvath & Symonds, 1991; Martin, Garske & Davis, 2000). Both found positive support for its effect on outcome. In addition Norcross (2002) has estimated that 30% of psychotherapeutic outcomes are related to ‘common factors’ – mostly therapeutic alliance. This is compared to only a 15% influence of techniques – a component of cognitive therapy that has traditionally been emphasised. This point, though, has proved controversial and DeRubeis, Brotman and Gibbons (2005) have criticised studies such as those cited above for merely providing correlational evidence. For example, almost without exception the studies analysed by Martin et al. (2000) were correlational. DeRubeis et al. (2005) argue that a good outcome could well be producing a good alliance, rather than the reverse. Further Safran and Muran (2006) criticise the meta-analyses for only explaining 6% of the outcome variance. Despite these criticisms Craighead, Sheets and Bjornsson (2005) point out that a strong therapeutic alliance is still a vital component of positive change and research continues to underline its importance in cognitive therapy (e.g. Krupnick et al., 2006).

In conclusion, the research on the therapeutic alliance in cognitive therapy has generally demonstrated its association with a positive outcome for clients. The importance of establishing and maintaining relationships have both been demonstrated in cognitive therapy. Some have even suggested the supremacy of ‘common factors’ such as the therapeutic alliance over specific techniques of the cognitive modality. These claims are tempered, however, by methodological concerns with correlational data, which mean that the therapeutic alliance could be a result of a good outcome. Despite this, given that current research continues to point to the benefits associated with the therapeutic alliance, it seems likely this factor will continue to emerge as a vital component of cognitive therapy.


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