COGNITIVE PSYCHOTHERAPY: THE THERAPEUTIC ALLIANCE

COGNITIVE PSYCHOTHERAPY: THE THERAPEUTIC ALLIANCE

The therapeutic alliance is the collaboration between the therapist and client in psychotherapy or counselling.  It has been claimed that this alliance is one of the most important aspects of the process, whichever techniques are used from psychodynamic to behavioural (Bordin, 1979).  The techniques are applied after the alliance is initiated, but this alliance must be maintained if the optimum effect of the therapy is to result.  According to Beck (1979), if you get good collaboration, you get good outcome.

Therapists are faced with different challenges at the beginning of the process from those during the middle and ending stages.  This points to the need for flexibility in their approach as therapy progresses.  There is also a need to match their style to that of the client to maximise the effect.  So it could be that the most important skill of the therapist/counsellor is in the interpersonal area, irrespective of their technical knowledge and training.

In this précis the convention of using a masculine therapist and feminine client will be adopted to aid clarity.

Beck (1979) points to the important qualities of the therapist, which he lists in his chapter on the therapeutic relationship, as warmth, accurate empathy and genuineness.

Warmth is seen as caring concern and interest. This helps overcome the negative distortions and expectations of the client about the therapist and therapy, particularly with depressives.  It is not warmth per se, but the client’s interpretation of therapist warmth that matters.  If the therapist was too warm then this could harm the relationship as the client could think that she was not worth it, that the therapist did not really mean it, that the therapist was mistaken and would rumble her in due course, or it could lead to infatuation.  This means that the therapist must have a great awareness of the client and her views.  It is useful to ask the client, how she finds one as a therapist so that one can monitor the relationship as well as getting information on her cognitive distortions to work on.  As it is always a problem to withdraw warmth if it is too much, it is better to start with a middle position of warmth which could then be increased if the therapist thought it advisable.

Accurate empathy is defined as seeing the world from the client’s point of view – being on the same wavelength.  This allows the therapist to see how the client structures her world and to experience her feelings to some extent.  When the client perceives the therapist’s empathy, this facilitates further disclosure.  The accurate perception and sharing leads to a better understanding and lets the client know that the therapist is not being judgmental.  By understanding how the client feels, the therapist can accept the cynicism and negative attitudes and work to overcome them.  However, the therapist must be careful not to project his own attitudes and expectations.  For instance, the fact that a death has occurred in the family could be a release and not a cause of sadness.  Being too empathic is also a fault as progress could be impeded by accepting too much of the client’s feelings.  It could also lead to the therapist accepting too much of the client’s views as being an accurate representation of her life-situation instead of checking out the reality.  There seems to be a risk here of reinforcing some of the dysfunctional thoughts.  It is important that the empathy does not become sympathy so that some detachment is maintained to allow an intellectual appreciation.  This affords a measure of objectivity which allows the therapy to proceed.

Genuineness is displayed when the therapist is honest with himself as well as with the client. However, the honesty with the client must contain a measure of diplomacy as she may not be ready to take certain truths.  The essence is to tell the truth if not the whole truth, certainly not telling lies which, if discovered, would absolutely destroy any therapeutic alliance.  A further reason for using diplomacy is that a client may attend selectively to the negative aspects of the therapist’s output and gain a distorted view.  The client could view too direct an approach as hostility or rejection and this could lead to resistance.  It is a problem for the therapist to let the client feel that he is genuine without over-emphasising it, which might make him seem insincere or not perceptive.

For Beck et al (1979), the therapeutic relationship is based on trust, rapport and collaboration.  The basic trust is belief of the client that the therapist is working with her towards the best possible outcome.  To build this basic trust requires attention to such aspects as balancing client autonomy with in-session structure set by the therapist, and weighing friendliness against objectivity.  The sessions may well be more therapist led at the start with the client being more proactive later on.

Rapport is seen as a harmonious accord between those involved.  When the rapport is good, the client sees the therapist as more tuned in to her feelings and attitudes, sympathetic, empathic and understanding.  She will also see him as a person who accepts her with all her faults, and with whom she can communicate without spelling out feelings and attitudes and having to qualify what she says.  In good rapport, each party is secure and easy with each other.  The client will not be defensive, too cautious, tentative or inhibited, knowing that the therapist accepts, even if he does not approve.  The rapport will increase if the client thinks the therapist accepts and understands her, and thinks he is someone who wants to help her.  The expression of concern, warmth and encouragement will be very helpful.  Self-disclosure is important in rapport.  How much is disclosed can have considerable effect, so much research is needed here to identify what is the optimum.  It has been traditional for therapists not to disclose at all but to remain as neutral as possible.  It could be that with some clients a little self-disclosure could aid the bonding process, particularly as the therapy progressed if it had some value, perhaps for modelling.  If negative feeling are disclosed, however, then the client may distort and magnify them, so thinking the therapist is of no use or insincere.

Rapport can be developed in different ways with different clients.  Those who are more withdrawn may need a friendlier approach, whereas a more detached approach might be less threatening for others.  Constant monitoring is required here so that the therapist can judge from feedback.  With greater rapport, the subject will identify more with the therapist and some modelling may occur.  It is also more likely to promote the client continuing therapy and doing the required homework.  With better rapport, the negative feelings that might stop her attending can be brought out and dealt with.

In developing rapport, common courtesy is very important.  The therapist should attempt to keep to time and remember what the client has told him in the past.  Warm, sincere greetings, maintaining eye contact and reflecting the client’s feelings are all seen as important in maintaining rapport.  An easy questioning technique is helpful, as is the diplomatic way of making comments.  The non-verbal aspects of communication are of great importance.  In fact, research has shown that they have a greater effect than verbal elements when there is a discrepancy, so once again there would be a focus on the worse aspect by many clients.  The appearance of the therapist, his mannerisms and facial expressions, can have considerable impact.  An attitude of warm neutrality and professionalism is the best solution.  Use of non-verbal cues can be better than verbal as they are more likely to be registered as neutral.  They can be used to avoid the therapist interrupting too much.  However, one must still be careful not to shape the responses by verbal or non-verbal cues.  When speech is used, the voice should be as relaxed as possible to encourage matching.  Simple, clear, unambiguous language will also promote rapport, as will less emotive terms, such as, “unhelpful or unproductive thoughts”, rather than, “neurotic or irrational”.

At the start of therapy it is important to elicit the client’s expectations and to discuss probable length of treatment, the frequency, session length, stages, and that having “bad days” is normal. The client should be aware that reverses will occur at times.  All these measures help to build up the rapport.  It is also useful to reflect back by using summaries as they clarify issues in both parties’ minds, spur further disclosure or elucidation, and increase rapport by showing the therapist is taking great interest and remembering what has been said.

The collaboration is in forming a team where the client and therapist work very much together.  Many aspects of collaboration are linked to those discussed in developing rapport as the collaboration itself is an important aspect of developing rapport.  The collaboration grows from the start as the focus is on the client’s thoughts, feelings, wishes and behaviour.  The therapist and client will work together to determine how and what the client thinks, the bases for those thoughts and the practical benefits or losses from such thinking.  The client gives the raw data and the therapist guides and works out with the client how to manipulate these data therapeutically.  Each step deepens the collaboration as the therapist and client work together.  How the client does the homework gives an indication of how the alliance is working.  If the client is involved in formulating the homework, then the therapeutic collaboration increases.  If the client understands the goal and rationale, then she is more likely to do it and so increase the alliance.

Bordin (1979) says we can speak of the working alliance as including three features:  an agreement on goals, an assignment of task or a series of tasks, and the development of bonds.

The whole point of therapy is embedded in the goal or goals.  According to Bordin, a good therapeutic outcome is facilitated when the counsellor and client agree what the client’s goals are and agree to work towards the fulfilment of these goals.  Goals may be explicit or implicit, and it is important for both therapist and client to have matching goals or there is a risk to the therapeutic alliance.  If the goals are explicit, then the risk is lessened, but there are still dangers as there could be semantic misunderstandings or pseudo compliance by the client – hopefully not by the therapist.  At least by reflecting and working to ensure that the goals are understood, the bonding should be increased.  It is not always easy for both parties to come to mutual agreement on goals.  Whereas they may agree on the problem, the outcome goals could diverge.  The client could be wanting a solution whereas the therapist may consider that coming to terms with the problem is the best that could be achieved.  If this issue cannot be resolved, then it may be preferable to refer the client on.  Therapists may also want greater change than the client is prepared to allow.  The client may claim to want maximum change, but when she realises she can achieve it, she may then resist as it would threaten the gains she gets from being ill at the moment.

As has previously been stated, goals should be carefully formulated with the client in a collaborative way, whether they be outcome or mediating goals.  Each will have their own preferred styles and the ability to compromise will be crucial in deciding whether the alliance can proceed.  Too great a movement on either’s behalf could be counterproductive.

Goals can, and most usually will, change during therapy.  At the beginning goals will include identification of the problems and formulating a contract.  As therapy proceeds there will be a need to redefine certain goals and perhaps make them more precise.  Evaluation will become more important as will the need to maintain motivation.  Later goals will be concerned with client independence, self-assessment and self-help.

Tasks are the goal directed activities carried out by the therapist and the client.  It is essential for the client to understand the value of the tasks and their rationale, not only to further the alliance, but also to carry them out, particularly between sessions.  Furthermore, the client must be able to carry out the tasks set and they should be within acceptable bounds of difficulty.  The last thing that should happen is for a sense of failure to enter, so the homework should be sufficient to create change, but without risk of being too difficult.  This may involve some in-session rehearsal to build up the required confidence.

The client must also have an understanding of the therapist’s tasks and how they relate to her own, or she may spend time wondering why he is acting in a certain way, or she may doubt his competence.  As cognitive approaches are very task orientated, it is important that tasks are seen to be valid for the alliance to work properly.

Bonds need to be formed before appropriate goals can be set and tasks performed.  Most of the elements of bonding have been considered previously in discussing therapist qualities, basic trust, rapport, and to some extent, collaboration.  Bordin (1979) points out that the bonding process is somewhat similar in psychoanalysis and behaviour therapy, which are often seen at opposite poles of the therapeutic spectrum, as in both the therapist takes much of the responsibility for the tasking.  Dryden (1989) quotes the work of Mearns and Thorne (1988) who, as well as putting forward empathic understanding and genuineness as important factors for psychological growth, also include unconditional acceptance as a third element in the way that Rogers includes unconditional positive regard.

For those who have little trust in others and a low esteem of therapists, there is little hope of bonding being other than weak until, through some successful work, the preconceptions begin to be eroded.  The interpersonal styles of each party must also be relevant, so the therapist’s ability to complement those of the client is important.  Furthermore, the expectations of the client are important in the bonding.  There is some evidence that when the client’s expectations are matched there is better response, at least initially.

Whereas Bordin (1979) and Beck (1979) stress the effectiveness of therapy depends largely on the maintenance of the bonds, Dryden (1989) points out that though it is initially important, resolution of manageable conflict in the bond can produce more productive change than remaining in the comfort zone.  If there were no challenges, then there would be little movement, so it seems the initial bond must be strong enough to withstand these, and then the bond will actually strengthen through resolution of dissonance.

The therapeutic alliance is a very useful integrative framework for considering therapy, and by being aware of the value of bonds, goals and tasks, the therapist can maximise his effect.  This is particularly important for the cognitive psychotherapist.

References

Bordin, E S, The Generalizability of the Psychoanalytic Concept of the Working Alliance.

Psychotherapy:  Theory, Research and Practice, Vol 16 Ch 3, Fall 1979.

Beck, A T, Rush, A J, Shaw, B F, Emery, G, Cognitive Therapy of Depression.  1979. New York, The Guilford Press.

Dryden, W, The Therapeutic Alliance as an Integrating Framework. (1989).  Unpublished.