Wednesday 12 May 2010
Exploring Level 1 - The Therapeutic Relationship in Integrative CBT
Integrative CBT is, amongst other things, an attempt on my part to follow in the tradition of Aaron Beck, who saw Cognitive Therapy as “...the integrative therapy…” (Beck, 1991). When it came to the therapeutic relationship, Beck was very definitely of the ‘necessary but not always sufficient’ camp. He emphasised that “The general characteristics of the therapist that facilitate the application of cognitive therapy… include warmth, accurate empathy and genuineness…” (Beck et al., 1979). However, he also believed that “…these characteristics in themselves are necessary but not sufficient to produce optimum therapeutic effect…” (ibid.)
So Integrative CBT believes in introducing Cognitive-Behavioural models and interventions, as necessary, into a well-grounded therapeutic relationship. But what do I mean by a well-grounded therapeutic relationship in the context of Integrative CBT?
Firstly, I agree that all therapy is conveyed through the medium of relationship - even with a CBT self-help book, the reader must feel that they are meeting the author, and can relate to them, including trusting them to have reliable information. (The online therapeutic relationship is also very interesting in its own right, but as it is an important and growing topic, I’ll address it, in relation to Integrative CBT, in a separate blog at a later date).
As soon as the two roles of helper and helpee exist, we are dealing with basic issues such as expectations, goals, rationale, telling the story, assessment etc. Indeed, many of these issues are looked at further in later levels, but they need to get a good start here. Many of us are familiar with the problems caused later on by false starts in any of these areas.
Secondly, the therapeutic relationship needs, of course, to be a very particular type of relationship. From an Integrative CBT point of view this is captured first of all by the “non-specific” factors described in the Person-Centred approach, Gestalt Therapy etc. These factors are based on the importance of making real psychological contact with the client, and include familiar skills such as Attentiveness, Linking and Validation , as well as broader attitudes such as Empathy, Congruence and Unconditional Positive Regard. Some clients may need no more than this experience of contact with another human (for instance, clients with uncomplicated bereavement), but in many cases I would also see the need for the additional factors of Explicit Collaboration, Psycho-Education, Guided Discovery etc. In situations where we are dealing with problems like Social Anxiety or an Eating Disorder, there is a lot of detailed problem-solving, cognitive restructuring, etc to be done at other levels, and the groundwork needs to be laid at the beginning.
One of my favourite things about this type of therapeutic relationship is its explicitness – clients have a reasonably clear idea of what is happening and why.
Another interesting point to mention here is that there is a very strong cognitive component to good empathy, which is often neglected; Guided Discovery is all about jointly discovering how this particular client sees their world – what could be more empathic?
Of course, the starting point is the client’s feelings/emotions, and Beck amongst others has made it very clear that CBT is no exception. “How do you feel about that?” is always one of the most fundamental questions a therapist can ask (and keep asking!)
Integrative CBT believes that forming and maintaining the relationship is not the end of the job - we need to move on to other levels, into territory which goes beyond just relationship, into practical work towards change. But in moving ahead with problem-solving, case-formulating and intervening at other levels, we mustn’t lose the felt connection with the client. If we do, we need to go back and re-establish it.
References, further reading:
Alford, B.A. & Beck, A.T. (1997) The Integrative Power of Cognitive Therapy. Guilford Press.
Beck, A.T. (1991) Cognitive therapy as the integrative therapy. Journal of Psychotherapy Integration, 1, 191-198.
Beck , A.T. et al. (1979) Cognitive Therapy of Depression. Guilford Press.
Gilbert, P. & Leahy, R.L. (2007) The Therapeutic Relationship in the Cognitive Behavioral Psychotherapies. Routledge.
Sanders, D. & Wills F. (2005) Cognitive Therapy: An Introduction. Sage.