The Therapeutic Relationship in CBT
In a recent online discussion, a colleague wrote “Perhaps psychodynamic therapists have relied too heavily on the relationship at the expense of client skill-building, while the opposite tends to be true for CBT therapists.” This is a common criticism of CBT, but is there reason to believe that CBT therapists emphasize client skill-building at the expense of the therapeutic relationship.
Personally, I’d argue that a therapist who emphasizes skill-building at the expense of the therapeutic relationship is doing CBT badly and is likely to be much less effective than he or she could be. I can think of quite a few CBT texts that emphasize the importance of the therapeutic relationship. For example, in Beck’s venerable Cognitive Therapy of Depression (1979), Chapter 3 is on the therapeutic relationship in Cognitive Therapy. It discusses the importance of warmth, accurate empathy, genuineness, trust, rapport, the importance of a collaborative relationship, and briefly discusses transference and counter-transference. I can’t think of any texts on CBT that say that the therapeutic relationship is unimportant.
In a recent discussion of myths about CBT in the Huffington Post, Judy Beck says “CBT requires a good therapeutic relationship. Therapists do many things to build a strong alliance. For example, they work collaboratively with clients (making joint decisions such as how to spend the therapy hour), ask for feedback (“What did you think of the session? Anything you want to do differently next time?”), and conduct themselves as genuine, warm, empathic, interested, caring human beings. They also work hard to reduce patients’ suffering as quickly as possible. Interestingly, research shows that the alliance becomes significantly strengthened when clients see that their therapist is helpful, that is, when clients see themselves solving their problems and feeling better (http://www.huffingtonpost.com/judith-s-beck-phd/cognitive-behavior-therap_b_638396.html).”
If it is true that CBT emphasizes the importance of the therapeutic relationship, where does the idea that it doesn’t emphasize or value the therapeutic relationship come from? There are several possibilities:
- Sometimes this assertion is made by critics who actually know little about CBT and who are basing this comment on their preconceptions about CBT.
- Some presentations on CBT focus solely on what is different about CBT and spend little or no time on “common factors” such as the therapeutic relationship (often because the presenter assumes that the importance of the therapeutic relationship self-evident). This results in the presenter focusing on techniques and strategies that are unique to CBT and unfortunately the audience may get the impression that these strategies and techniques are all there is to CBT.
- Not everyone who claims to practice CBT actually has learned CBT. There are plenty of therapists who have read a CBT-based self-help book and now claim to do CBT. This is equivalent to someone reading Freud’s Interpretation of Dreams and declaring that they’re now psychoanalysts. Therapists who have simply read a manual or two may do therapy “by the book” with little attention to the therapeutic relationship. However, this isn’t because CBT doesn’t value the therapeutic relationship, it is because those therapists don’t know how to do CBT well.
- Not everyone who teaches CBT teaches CBT well. Arnold Lazarus has suggested in the March 2013 edition to the Behavior Therapist that some grad schools are currently teaching structured treatment protocols without teaching the concepts, theory, and principles that are needed to practice CBT well. Again, this isn’t a shortcoming of CBT, it is poor teaching.
- Many works about CBT focus on how to treat one particular problem and the therapeutic relationship is one small part of the discussion. Unfortunately, some readers overlook the importance of the therapeutic relationship as a foundation for effective intervention.
Quite a bit has been written on this topic but for concise discussions see the summary of an excellent article by Jesse Wright and Denise Davis in the archives of this forum at http://www.behavior.net/forums/cognitive/1996/msg121.html, a quote of Ellis comments on this topic at http://www.behavior.net/forums/cognitive/1996/msg128.html, and a summary of Larry Beutler and Benny Martin’s proposed principles of therapeutic change at http://www.behavior.net/forums/cognitive/1996/msg1034.html.