the importance of the therapy alliance n CBT

1. Lecture 2: Building the Working
Alliance as a foundation for CBT
Skills
Specialist skills in CBT
Kevin Standish

3. Learning Outcomes
1. To place the working Alliance into context historically
2. To place the four core elements of the working Alliance in
context
3. To understand and use the role of the therapist in
establishing the Working Alliance
4. To evaluate research on the therapeutic alliance
5. To deal with ruptures in the therapeutic alliance

4. Historical context
• The Western philosophical underpinnings of CBT associated
with Stoic philosophy.
• "Man is disturbed not buy things, but by the views he takes of
them" Epictetus
• Stoic philosophy believed that reason could overcome our
basic instincts and emotions and help us find equanimity in
the face of life's vicissitudes.
• With the dominance of the principles of learning theory:
classical conditioning and operant conditioning, and
psychoanalysis the role of conscious mental processes was not
a focus
• Bandura (1977) expanded learning theory to encompass the
social realm and introduced the concept of self efficacy: "the
belief in one's capabilities to organise and execute the courses
of action required to manage prospective situations".

5. Historical context
• This established one fundamental principles of CBT: a person
can exert control over their own life and can learn to become
the own therapist.
• The work of Ellis and Beck now became the focus of cognitive
behavioural therapy developing the classic ABC model.
• Ellis's REBT evolved with the fourth factor to rate and evaluate
ourselves and others, thereby reducing the effect of self-
defeating beliefs through a rational approach

6. Historical context:
Joseph Wolpe
• "All that the patient says is accepted but I question or
criticism. He is given the feeling that the therapist is
unreservedly on his side. This happens not because the
therapist is expressly trying to appear sympathetic, but as a
natural outcome of a completely non-moralising approach to
the behaviour...." (Wolpe, 1958:106)
• This is a remarkable up-to-date description of the therapeutic
relationship in CBT for its time.
• He shows Rogers three core conditions in his description and
approach emphasising important ingredients of the
therapeutic relationship from one of the founding fathers of
CBT

7. Historical context:
Albert Ellis
• Ellis critiqued Rogers core conditions as being desirable but
neither necessary nor sufficient for therapeutic change to
occur
• He advocated a highly active directive stance and encourage
clients identify, challenge and change irrational ideas which lie
at the source of their disturbances and then to think and act in
accord with their alternative rational ideas.
• Ellis deemphasised and expressed concerns regarding
therapist warmth.
• He felt that while clients appear to value this condition, it
serves to reinforce the need for approval and lead to them
becoming more rather than less anxious, especially in regard
for approval
• it is for this reason that CBT is often seen as quite "cold"

8. Historical context:
Aaron Beck
• From the beginning, Beck emphasised the role of the therapeutic
relationship in cognitive therapy
• He emphasised Rogers core conditions: warmth, accurate empathy
and genuineness. He sees them as necessary but not sufficient.
• there was an emphasis placed on the development and
maintenance of trust and rapport with the client
• this is described as "a therapeutic alliance of collaboration" (Beck et
al, 1979 :54)
• this links to the basic task of therapeutic dyad to: to investigate the
empirical status of the patients cognitions in relation to the problem
• this collaborative relationship is a cornerstone of cognitive therapy
• this is emphasised as part of the feedback at the end of the session

9. Necessary but not sufficient
• In cognitive therapy the therapeutic relationship on its own
may not contribute to the potency of the treatment
• but it absence means that even accurate CBT
conceptualisation and the use of specific techniques based on
this conceptualisation will not bring about a meaningful
change
• "The collaborative relationship permeates effective cognitive
therapy and it is this that gives the techniques of assessment
and treatment their power" (Dryden, 2012:87)

10. Historical context:
Gilbert & Leahy
• This book emphasises the central importance of the therapeutic
relationship in CBT
• it places emphasis on the following:
• emotion in the therapeutic relationship
• transference
• dealing with ruptures in the therapeutic relationship
• internal working models of attachment in the therapeutic
relationship
• using the therapeutic relationship with difficult to engage clients
• schematic mismatch in the therapeutic relationship
• self and self reflection in the therapeutic relationship
• Some of these themes will follow in the next few slides
• to be an effective CBT therapist two conditions are required:
• 1. To be technically proficient in the CBT skills
• 2. To be proficient in developing and maintaining the collaborative
nature of the relationship

11. Working Alliance Theory ( Bordin
1979)
• Bordin’s article emphasised the importance of the working
Alliance
• Broader than the concept of the therapeutic relationship, the
Working Alliance is comprised of the following components:
• Bonds: the interpersonal connectedness between therapist and
client
• Goals: the purpose of the therapeutic meetings
• Tasks: the procedures carried out by therapist and client to
achieve the goals
• a fourth one added by Dryden (2008): views: the
understandings that both participants have on the salient issues

12. Four components of Working
Alliance
• There are four broad elements that need to be considered in
the therapeutic relationship over all
1. Bonds
2. The views of the therapist and client
3. Goals
4. Tasks

13. 1. Bonds
• Three elements:
• 1. core conditions;
• 2. interpersonal style;
• 3. transference and counter transference

14. 1.1.The core conditions
• Unconditional positive regard
• Congruence
• Empathy
• Small group work:
• In pairs please describe your understanding of the three
concepts involved in the core conditions
• highlight the difficulties you have in applying these
conditions
• Three minutes

15. 1.1.The core conditions
• : Necessary but not sufficient.
• Recent research (Beutler, et al, 2004)
shows that core conditions are often
important for most but not all clients.
• "As CBT therapists you need to
emphasise certain conditions with some
clients and deemphasised other
conditions with other clients in order to
establish the most productive and
idiosyncratic therapeutic bond with each
individual client" (Dryden, 2012:89) Case
study 5.1

16. 1.2. Interpersonal style
• This refers to the "fit" between the interpersonal styles of
counsellor and client
• when the fit is good the therapeutic alliance is enhanced
• when the fit is poor the therapeutic alliance is threatened
• In CBT the preferred style is active collaboration, working with
the cognitive behavioural elements of the client’s problems
• not all clients can collaborate with the therapist e.g. the more
passive client wants be told what to do. Case study 5.2
• Socratic questioning is preferred style in CBT, but this also has
some limits with particular clients
• what kind of clients would struggle with Socratic questioning?

17. 1.2. Interpersonal style
• 4 alternatives to Socratic questioning:
• 1. A didactically style: points are made directly matter of factly to
the client and the therapist checks the client's understanding of and
response to the point made
• 2. a metaphorical style: a metaphor, story or parable is used often
linking to the client's own life to bring across the point.
Understanding of the meta-fur needs to be checked out with the
client
• 3. A humorous style: human can facilitate the Working Alliance and
encourages clients to put their life situation into healthier
perspective. You may may also increase the tendency to defend
themselves by minimisation or leave them with a sense that they
are being ridiculed. Getting client feedback on the use of humour is
critical
• 4. A self disclosing style: self disclosure may be a powerful way of
encouraging clients to re-evaluate dysfunctional beliefs. Using an
example of a coping model of the therapist self disclosure helps
clients and re-evaluate their own dysfunctional beliefs.

18. 1.2. Interpersonal style
• It is important that the therapist demonstrate interpersonal
flexibility in CBT.
• This needs to be done genuinely, with sensitivity to the
client's responses, whilst at the same time remaining
authentic in the here and now of the therapeutic relationship

19. 1.3. Transference and counter-
transference
• What is your understanding of these concepts of transfer in's
and countertransference?
• Small-group work:
• define the two concepts and give an example
• two minutes

20. 1.3. Transference and
counter-transference
• Derived from psychoanalytic approaches to psychotherapy
• the phenomena that the terms point are more crucial than the terms
themselves.
• the terms point to the fact that both clients and therapist bring to the
counselling relationship tendencies to perceive, feel and act towards another
person influenced by the prior interaction with significant others.
• These tendencies have a profound influence on the development and
maintenance of the therapeutic alliance
• Miranda & Andersen ( 2007) suggest the following social cognitive model of
transference:
• 1. Ask the client to name and describe significant others with special reference
to facets of interpersonal relating
• 2. Once identified the therapist can see when these are activated in the
therapeutic relationship
• 3. Help identify the link between present response to the therapist and the
representations of significant others
• 4. Self acceptance, compassion and humility are important if the therapist is to
acknowledge anti-therapeutic reactions to clients and their own dysfunctional
schemas

21. 2. The views of the therapist and
client
• Views refers to the
understanding that both
participants have on
salient issues
• 2.1 Views of the
therapist
• 2.2. Views of the client
• 2.3. Similar views:
effective therapy

22. 2.1 Views of the therapist
• What are you most effected by when it comes to
understanding the nature of the client's problems?
• Answer: CBT theory
• CBT therapists differ concerning their views on how to help
clients with their problems depending upon the theoretical
formulation of a problem
• the conceptualisation of the problems becomes salient when
it comes to helping the client with the dysfunctional
cognitions.

23. 2.2. Views of the client
• Clients will come with views of their problems and how they
can best be helped.
• Clients may have read self-help books or gone online and will
come with accurate ideas.
• Whilst others will have misconceptions about what CBT is and
may have been referred by their GP for therapy without any
clear understanding of the process.
• Misconceptions and myths client's carry about CBT need to be
clarified

24. 2.3. Similar views: effective
therapy
• Working Alliance theory holds that when clients' views are
similar to their therapist' on issues, then therapy is likely to be
effective than when such views are different.
• When there are different these differences need to be
acknowledged and openly discussed
• Helping clients to see that they have used principles of CBT in
their lives encourages them to see the relevance of CBT and
encourages the engagement with the process
• If clients do not fit with the CBT approach and cannot take on
board a common view then they need to be referred to a
more appropriate therapeutic approach

25. 3.Goals
• This pertains to objectives both client and councillor have for
coming together.
• CBT therapists are more goal focused and deal explicitly with
clients goalsetting than other therapy.
• Goals in CBT are reformulated into specific elements which fall
within the client's power to address
• Good therapeutic outcome is facilitated when the therapist
client agree what the client goals are, and agreed to work
towards the fulfilment of these goals
• the Working Alliance is threatened when therapist and client
have different outcome goals in mind, these are often implicit
and not expressed clearly.

26. 4. Tasks
• Tasks are activities carried out by therapist and client in a goal
directed manner.
• While CBT is rich in its use of techniques it is important from
the Working Alliance perspective to consider the following for
effective CBT to occur:
• does the client understand the nature of the therapeutic task
he needs to undertake?
• Does he see the value of carrying out these tasks?
• Does the client have the ability to carry out the therapeutic
tasks required?
• Does the client have confidence to carry out the task?
• Will the task help achieve the goal?

27. What if your client does not "buy
in" to the model
• There are times when clients will not agree with specific goals will
even be interested in the CBT model of change.
• It is important to consider reasons behind this lack of buy in.
Possible reasons include:
• 1. Lack of understanding of the model
• 2. Lack of credibility of the model
• 3. Disagreement about case formulation
• 4. Lack of suitability of the model
• 5. Persistence in asking "why?" questions
• Dobson, D. and Dobson, K.S 9 (2009) Evidence-based Practice of
Cognitive Behavioural Therapy, London. Guildford press. Chapter 4
Beginning Treatment: Planning for Therapy and Building Alliance

28. The role of the therapist
Clients looking to their therapists to be experts in the provision of treatment ,
which include having good professional boundaries and interpersonal skills.
You must balance the number of interpersonal demands while remaining
sensitive to the needs of clients
the following demands need awareness
expertise versus equality
coping versus mastery
use of self disclosure
use of affect
encouraging courage

29. Expertise vs equality
• This element involves a powerplay between being an expert in
your skills and knowledge but allowing the client the space to
make decisions that suit them best.
• You need to not know in your role as expert.
• It is important to see the client as the expert on their own
history, functioning and current concerns
• it is important to acknowledge the expertise the client may
have in other areas that could contribute towards the
therapeutic work.
• The relationship can never be one of complete equality as
clients will view you as powerful and as the expert
• as the "expert" you are also an educator but you need to do
this with humility and respect

30. Coping versus mastery
• You're not expected to be an expert in all areas.
• You will appear as unauthentic if you show mastery in all areas
to your client
• Clients learn more from a coping model than a mastery model
• It is reassuring for clients to see the therapist makes mistakes,
acknowledge them and work to improve their own behaviour.
Being real and authentic.

31. Use of self disclosure
• Self disclosure can be broken into the disclosure of content versus process.
• Content disclosure includes your response to questions asked by the client.
• Do not answer questions with which you do not shall comfortable by simply
stating that.
• Consider the intention of the client when they ask those sorts of questions.
• It is your responsibility to answer questions regarding your training
background and experience
• Process disclosure involves occasionally disclosing problems you have
encountered in your life and how you have dealt with them. The purpose is
to facilitate the client to disclose more. It is in the interests of the client that
the self disclosure is made. They should be kept a minimum and allow the
client to build upon your self disclosure. It is the process of disclosure that
keeps the therapeutic process going
• A second type of process disclosure include sharing your automatic
thoughts or emotional responses with clients who have particular
interpersonal problems. This allows them to receive honest feedback that
they do not normally receive from people in their life.
• It also allows the modelling of a skill of reflection

32. Use of an affect
• Whilst CBT is focused on thoughts and behaviours, the affect
of clients needs to be acknowledged and dealt with.
• Affect is triggered by many interventions and is required for
them to be effective
• Being genuine in affect when touch by client's experiences is
important. You do not need to be stoical in the face of
distressing stories. It is important for clients to see that you
have been touched by their distress but not overwhelmed

33. Encouraging courage
• When we ask clients to undertake difficult tasks it is important
to understand that they have often avoided the very things we
are asking them to do.
• We asked them not only to become more aware of their
problems but also to face them head on.
• It is crucial to encourage clients to be courageous in their
quest for change.
• You support change through encouragement, support and
reinforcement of small changes that you see.

34. The therapeutic relationship that
promotes client change
• There are three broad phases in the therapeutic relationship
that require different aspects and attention in their
development
• 1. Establishing a relationship
• 2. Developing a relationship
• 3. Maintaining a relationship
• Awareness of Contextual factors
Hardy et al ( 2007) Chap 2: Active ingredients if the therapeutic
relationship that promote client change: a research
perspective. Found in Gilbert & Leahy The Therapeutic
relationship in the cognitive behavioural psychotherapies.
this is also a Dawson Book

35. 1. Establishing a relationship
Engagement processes Engagement objectives
Empathy, warmth and genuineness Expectancies
Negotiation of goals Intentions
Collaborative framework Motivation
Support Hope
Guidance
Affirmation

36. 2. Developing a relationship
Processes Objectives
Exploration Openness
Reflection Trust
Feedback Commitment
Relational interpretations
Non-verbal communications

37. 3.Maintaining a relationship
Threats Processes Objectives
Therapist behaviour Self reflection
Intrusive Meta-communication
Defensive
Negative feelings
Self disclosure
Client behaviour Flexibility Satisfaction
Resistance Responsiveness Alliance
Hostility Emotional expression
Negative feelings Changing view of self
Relationship challenges Repair
Ruptures/confrontations
/withdrawal
Misunderstandings

38. 4. Contextual factors
• The broader client, therapist and contextual factors that impact on the
quality of the therapeutic relationship.
• Two main client characteristics that moderate treatment outcome are
functional impairment and coping style.
• Functional impairment includes problems in work, social and intimate
relationships. The more difficulties clients have in these areas are less
likely there are to benefit from therapy. For such clients treatment often
need to be more than six months in length to give time for the
therapeutic relationship to develop.
• Paying attention to therapeutic ruptures is important than sticking
rigidly to therapeutic techniques.
• Clients who have insecure attachment styles less able to form
satisfactory alliances.
• Some cultural and demographic variables may impact on the therapy
relationship. In cultures with therapy is not encouraged the chances of
success are decreased.
• What other contextual factors do you think play a role in effecting
positively or negatively the therapeutic relationship?

39. Ruptures in the
therapeutic alliance
Signs of a rupture
Dealing with ruptures
Boundary issues

40. Ruptures in the therapeutic
alliance
• CBT anticipate ruptures in the alliance as problems are well
entrenched and change is likely to be difficult
• Signs of a rupture in the therapeutic alliance: non-verbal cues
such as the discomfort, anger or mistrust. Behavioural science
such is not carrying out homework, expressing scepticism, or
high levels of expressed emotion.
• When ruptures identified it is important to intervene early in
the difficulties arise

41. Dealing with ruptures in the
alliance
• Ruptures can be related to:
1. the goals and tasks of therapy: deal with directly by clarifying
the rationale for treatment or changing the approach.
2. The client - therapist bond: first deal with this within the
current therapeutic relationship without assuming it is a
reflection of your client’s characteristic interpersonal
relationship style. If this is unsuccessful then consider the
rupture as a characteristic pattern of the client interpersonal
style and use the therapeutic relationship to provide the client
with a corrective emotional experience.
• Consider what contribution you as the therapist are making
to any therapeutic impasse rather than assume all problems
reside within the client.

42. Boundary issues
• Therapeutic boundaries are set in such a way that the client
can:
• Feel safe
• Trust the therapist to act in his interest
• Feel free to disclose material of a deep personal significance
• Be confident that they understand the therapist and understood
by the therapist

43. Boundary issues
• The therapeutic relationship is non-reciprocal:
• Extensive self disclosure by client was total nondisclosure by the
therapist
• Emotional neediness of the client is expressed compared with the
exclusion of the therapist emotional needs
• To be aware of the power imbalance attributed to people in
“healing positions”

44. conclusion
• An effective alliance between therapist and client is an
essential condition for implementation of specific methods of
CBT
• As therapist engage clients in the process of CBT they need to
show understanding, empathy and warmth, and flexibility in
their responses.
• A good therapeutic relationship in CBT is characterised by high
degree of collaboration, empirical style of questioning, and a
range of client learning through jointly defining problems and
searching for solutions

45. Readings for this lecture
• 1. Gilbert, P. & Leahy, R. (2009) The Therapeutic Relationship
in the Cognitive Behavioral Psychotherapies, London,
Routledge. Chapters 1-4 are all very useful.
• 2. Wright, J.H; Basco, M.R; & Thase, M.E (2006) Learning
Cognitive Behaviour therapy: An illustrated guide, Chapter 2
• Westbrook D, Kennerley H & Kirk J (2008) An Introduction to
Cognitive Behavioural Therapy: Skills and Applications. chap 3
• Dryden & Branch (2012) chapter 5 the therapeutic relationship
in CBT
• Dryden & Branch (2012) chapter 13 challenges in the CBT
client – therapist relationship
• Castonguay et al (2010) The therapeutic alliance in cognitive
behavioural therapy on NL

46. Journal article for this lecture
• Hayes et al (2007) Working Alliance for Clients the Social
Anxiety Disorder: Relationship with Session Helpfulness and
with in the Session Habituation. Cognitive Behaviour Therapy
volume 36, no 1, pp 34 – 42

47. Readings for next week
• Westbrook et al (2007) chapter 4: assessment and formulation
• Dryden & Branch (2012) chapter 6: assessment and
formulation in CBT

48. http://www.psychotherapy.net/article/therapeutic-
alliance#section-the-therapeutic-alliance