The Therapeutic Alliance

Cognitive Behavioural Therapy (Source : Gilbert and Leahy, 2007)

Aims

• Discuss the significance and nature of the ‘working alliance’ for the CBT practitioner.

• Show an awareness of how the CBT relationship differs from other therapeutic approaches.

• Reflect on the implicit (unspoken, implied) and explicit (clearly evident) aspects of the therapeutic relationship

The Therapeutic Alliance

• Research has indicated that the relationship between client and counsellor is paramount in the effectiveness of therapy and overrides any one approach or theory (BACP, 2013, Corey 2012, Nelson-Jones 2012).

• Beck was very definitely of the ‘necessary but

not always sufficient’ camp. Beck described ‘a therapeutic alliance of collaboration’ (Beck et al 1979).

The Relationship

• Bordin (1979:253) argues that the relationship is an alliance between counsellor and client and is broader than a therapeutic relationship as it has three strands which he names as bonds, goals and tasks.

• He identifies these as “an agreement on goals, an assignment of task, and the development of bonds (p253).

Stages of the relationship

• Gilbert and Leahy (2007) identify three stages in the development and maintenance of the therapeutic relationship which are the :

• Establishment• Development • Maintenance stages in therapeutic relationship, all of which have mini outcomes or objectives.

Establishment (The therapist)

• Rapport

• Core conditions

• Negotiation of goals the Collaborative

framework

• support and guidance and affirmations

Client Engagement Objectives

• Expectancies

• Intentions

• Motivations

• Hope

Development

Counsellor (demonstrates)• Honesty and transparency establish

a trusting relationship • Encourage a commitment from the

client

Maintain

• To help maintain the relationship clients need to feel satisfied with the quality of the relationship and that they feel that the alliance is productive and positive (Reis and Brown ,1999)

• As soon as the two roles of therapist and client

exist, interpersonal factors come into play e.g. dealing with basic issues such as expectations, goals, rationale, telling the story, assessment etc.

• Therapists need to be aware of these factors and in articular the role they play in client resistances

It a two way process

Ruptures

• Establish a stage of ‘we-ness’ frame the impasse as a shared experience ( Leahy 2007)

• The collaboration is an ongoing negation • Ruptures can be seen as ‘windows 'into a clients

interpersonal belief system and have the potential for real growth if worked through

• Counsellors need to be aware of their own responses and be willing to take responsibility for the part they play in the rupture.

(Gilbert and Leahy, 2007)

Threats to the relationship therapists factors

If the therapist is:

• Intrusive

• Defensive

• Demonstrates negativity

• Inappropriate self-disclosure

Threats to the relationship client factors

• Resistance• hostility • Challenge• withdrawal • Misunderstanding

It is essential that the therapist possesses the skills to be able to deal with these impasses in

the process

Therapist need to be aware of

Client’s reactions towards them especially negative feelings of:• Frustration• Annoyance• Disappointment • Positive feelings of admiration• Adoration

Skills for dealing with interpersonal issues in CBT

RELATIONSHIP BREAKDOWNS DURING SESSIONS (Safran & Segal, 1990)

1. The client is skeptical.2. The client is sarcastic.3. The client makes indirect allusions to relationship

problems via a third relationship – e.g., ‘I can’t stand women who tell me what to do.’

4. Client and therapist disagree on goals or tasks.5. Client is over-compliant.6. The client does not respond to an intervention.7. The client activates ‘therapy safety behaviours’: e.g.,

avoids going near painful areas.

How therapists can unhook from negative interpersonal patterns

• First, be aware enough of own reaction to ‘catch’ oneself reacting.

• Second, be aware enough to step back from the reaction to avoid ‘over-reaction’ or ‘retaliation’ (some client behaviours can be quite provocative).

• Third, decide when to comment – may be best to discuss in supervision first.

• Fourth, consider and own one’s part in the interaction (sometimes the main problem can be a therapist schema reaction – e.g., the therapist’s need to be helpful or right, etc.).

IMMEDIACY: a key interpersonal skill

• Immediacy is the skill to use reflections on the nature of what is going on between you and the client in ways that are helpful to the client.

• Often useful to ‘slow things down’ and invite the client to reflect with you – ‘Can we just stop and think what happened there? It seemed to me that … How did it seem to you?’

• Need to think how emotionally open I can be with this client. It can be a priceless opportunity for them to learn how they come over to others. Most social situations are not safe enough for this – therapy can be.

References

Gilbert, P., Leahy, L. (eds)(2007) The Therapeutic Relationship in the Cognitive Behavioral Psychotherapies, London: Routledge.