Introduction
This essay is about the therapeutic relationship as conceptualised by cognitive models of therapy and the challenges it presents. As a practitioner, first and foremost I value the therapeutic relationship as a crucial factor in effective therapy, regardless of the model in which I am working. Indeed, there is a vast body of research that argues that it is the relationship more than any other factor that result in the efficacy of therapy 1.
Traditionally, psychological change in cognitive behavioural therapy was linked to the skill of the practitioner in applying the tools and techniques of the model. For an overview of CBT please see here. However, the cognitive model has been modified to take into account interpersonal processes that exist with the therapy relationship. It has also been reformulated by Beck et al. (1990)2, and this modified theory places more emphasis on the therapeutic relationship.
This essay will begin by outlining the relationship as conceptualised by Becks (1979)3 original model and will go on to discuss how modifications of cognitive theory have placed more significance on the relationship between therapist and client.
The paper will only allude to Beck et al. (1990) reformulated model as it shares similarities with the theory I want to orient the reader toward Schema Theory. The one crucial difference in terms of this essay is how the relationship is used within Schema Theory as a medium for change in itself. For this reason, I chose to devote a significant part of the paper to the therapeutic relationship as it is conceptualised within Schema Theory.
Collaborative empiricism
Cognitive therapy was developed as a structured, short-term, present-oriented psychotherapy for depression, directed toward solving current problems and modifying dysfunctional thinking and behaviour (Beck, 1964)4.
Although Beck (1979) acknowledged the importance of a good working relationship, which included the therapist being empathic, warm and genuine, he stated these qualities were necessary but not sufficient for psychological change. According to Beck (1979) there also needed to exist collaboration, trust and rapport.
Psychological change was facilitated by the skill of the therapist in decreasing the clients belief in their automatic thoughts. Since its development the model has been reformulated to treat a range of psychological difficulties. In his later work (Beck et al. 1990) there was more emphasis on cognition, emotions, coping mechanisms, the influence of culture and the use of the therapeutic relationship. For the purpose of this essay, the original model will be referred to in order to expand on collaborative empiricism.
In Becks (1979) cognitive model, at its simplest level, thoughts, mood and behaviour are related. In an assessment session with a 19-year-old woman who was discussing her relationship with a prospective boyfriend, I used this opportunity to educate her into the basics of the model.
I asked her to imagine that the young man she was attracted to asked her on a date. In this scenario, he was sitting opposite her but often would appear distracted and glance over her shoulder. I asked my client, what would you think?
She replied that she thought he would be looking at another woman. Using standard cognitive behavioural techniques, it emerged that she thought the other woman was more attractive.
When prompted, she said this made her feel angry and jealous and may result in her leaving her date. When I gave her the same scenario and told her that he was looking over her shoulder to check if a taxi he had booked had arrived to take her somewhere special for dinner, her mood changed.
Rapport was established with this young woman easily by explaining the model and techniques we would be using by couching it in her own discourse. Very quickly, this young woman grasped the idea that her negative automatic thoughts (hes looking at another woman) influences how she feels (jealous and angry) and this affects her behaviour (in that she may have missed out on a nice evening) even though the situation had not changed, her beliefs about the situation had.
Beliefs represent the individuals understanding of themselves, their world, and others (Beck, 1967)5. For example, in my own practice when working with a young man who was referred for agoraphobia, it was not being outside per se that was the problem, but rather the clients difficulties where being manifested from his beliefs about being outside.
Underlying his fear of going outside was the negative automatic thought of what if something happens to my wife and kids? which as Beck stated these thoughts are not the result of deliberation or reasoning, but occur without the client necessarily being aware of them.
Using standard techniques we were able to identify this and other similar thoughts and the client became aware of the concomitant emotion of fear and how it stopped him from going out without either his wife or children. Working collaboratively we then modified the belief when discussing the likelihood that something would happen to his family has something happened to them before?
Using a combination of modification of his dysfunctional beliefs and behavioural experiments, the client is now able to go outside without either being accompanied by his wife or children. The outside place has not changed but the clients beliefs about going out alone have. It is not a situation in and of itself that determines what people feel but rather the way in which they construe a situation (Beck 1964).
Using these straightforward examples to outline the model in terms of collaborative empiricism and how change occurs, in its original form it begs the question, is there an objective reality to modify and whose reality is it? Safran and Segal (1996:9)6 have argued that viewing psychological problems as resulting from cognitive distortions encounters the unanswerable question of who ultimately will decide what constitutes a distortion, stating that many cognitive therapist have failed to take a stand on the vital question of who is the final arbiter of the patients reality patient or therapist? In their interpersonal model, they provide an alternative constructivist view that includes the interpersonal processes that exist within the therapy relationship.
Interpersonal process
Safran and Segal (1996:39) highlighted the importance that in undertaking therapeutic work, it is not a straightforward task of modifying dysfunctional thinking, but that the therapist needs to be aware that during this process, there are interpersonal factors at play that may cause difficulties in the alliance.
For example, in my own practice, a client did not attend for two sessions after the initial assessment session. I wrote her a standard letter asking her to confirm if she wished to attend for psychological therapy. If she confirmed, an appointment would be re-arranged for her. The letter stated that if I did not hear from her within a pre-defined time, I would assume that she did not wish to attend for therapy and I would therefore discharge her from my caseload.
The client did not confirm that she wished to attend for therapy and I was therefore surprised when reception called to say my client had arrived. I agreed to see her and explained to her the importance of attending sessions and the implications of non-attendance.
I was aware of a change in affect and I enquired as to how she experienced me, in order to ascertain any beliefs she may have about my intervention. A constructivist interpersonal approach allows for this, emphasising using the therapeutic relationship as a laboratory for exploring cognitive/affective processes and challenging interpersonal schemas (Safran & Segal, 1996:240). She stated that she thought alright alright, I got it the first time. Furthermore she stated that she thought I was angry with her.
The exploration of the relationship rupture that followed from this facilitated us in exploring her interpersonal beliefs about herself and others and avoid what has been succinctly captured in Safran and Murans (1996)7 paper as the therapist unwittingly participating in a maladaptive interpersonal cycle, that resemble those characteristic of patients other interactions, thus confirming their patients dysfunctional interpersonal schemas.
This use of the interpersonal processes involved in the difficulties that were going on between us meant that the client could communicate that she felt that she was being told off which normally would result in non-engagement.
It allowed an opportunity to work with her underlying beliefs about me as therapist, which we could modify in order for her to progress in the process. In this sense the therapeutic alliance is not a static, unchanging entity but a fluctuating, dynamic aspect of the therapeutic relationship, mediated in an ongoing fashion by the patients perception of the meaning of the therapists action (Safran & Segal, 1996:37).
As therapist, my thinking was to maintain boundaries and the contract agreed in the assessment. My clients perception of this intervention was the feeling that I was scolding her bad behaviour, which could have resulted in an impasse if the interpersonal aspects of the intervention were not explored. As such, difficulties that arise in the relationship are seen as an active ingredient in the change process.
The modification of the cognitive model to include the interpersonal processes that may result in relationship ruptures allow the relationship to play a more significant role than that of collaborative empiricism in Becks (1979) original model.
I would like to devote the rest of the essay to a theory that expanded on traditional cognitive techniques. Schema Theory, an integrative philosophy, places the therapeutic relationship as a vital component in psychological change and, in my opinion, is more in keeping with the philosophy of counselling psychology.
Schema Therapy
Blends elements from cognitive-behavioural, attachment, Gestalt, object relations, constructivist, and psychoanalytic schools into a rich, unifying conceptual and treatment model.
(Young, Klosko & Weishaar, 20038)
Where a schema is pervasive theme comprising of emotions, memories, regarding ones self and relations with others and are dysfunctional to a significant degree (Young, Klosko & Weishaar, 2003). I would like to point out, that in my reading, schemas appear to be used often within the cognitive literature and may not always be referring to the same thing.
Although also referred to in his early work, Beck et als (1990) reformulated model, which is similar in many respects to Schema Theory, also includes schemas. However, in the theory presented below, schemas as conceptualised by Schema Theory are a vital component of the relationship.
Schema Therapy uses the therapeutic relationship as a vital component of schema assessment and change (Young, Klosko & Weishaar, 2003:177). This sets it apart from the reformulated cognitive model of Beck et al (1990) and Alford and Beck (1997). Both Schema Therapy and the recent reformulated models of cognitive therapy acknowledge the significance of the therapeutic relationship, but as Young,
Klosko and Weishaar (2003) note, the relationship within the cognitive model is primarily used as a medium to motivate the individual to comply with treatment. The therapeutic relationship as conceptualised within Schema Theory however, is one of the vital components to facilitate psychological change. The remainder of this essay will focus on the therapeutic relationship as conceptualised within Schema Theory, how schemas are modified within the therapeutic relationship and the notion of limited reparenting (Young, Klosko & Weishaar, 2003). In order to fully expand on this, an example from my own practice will be employed.
The assessment stage as used to identify schemas
During the assessment phase, the therapist utilises cognitive, experiential, and behavioural measures and observes the therapist-patient relationship (Young, Klosko & Weishaar, 2003:64). Core schemas and how the client copes with their schemas are identified. In my illustrative example, the client was referred for a chronic psychosomatic complaint and has an emotional deprivation and subjugation of emotion schema.
The therapist during this stage also decides which style of reparenting is needed. From its use of attachment theory, the idea of the mother as a secure base was incorporated into the notion of limited reparenting, where the therapist becomes the secure emotional base the patient never had. In anticipating questions that may arise from other cognitive theorists, I would like to include some recent research that has explored the significance of early attachment relationships and the implications this has for the individuals adult life, and what the therapy relationship can offer.
This is based on the work of LeDoux (1996)9 the main tenet of which is that during a traumatic experience, conscious memories are stored by the hippocampul system and unconscious memories are stored by an amygdala-based system. Both these systems operate in parallel and I believe the important point for psychologists is that when triggered (for example by a schema) the unconscious body responses are activated via the amygdala system without having the benefit of being cognitively appraised by the hippocampul system. Or put more simply, because the amygdala system is faster, the individual experiences the uncomfortable feelings relating to the original event, without necessarily understanding why. This also has, I believe important implications for cognitive behavioural models.
Furthermore, it was proposed that
The quality of the relationship between parent and child influences both the biochemistry and the structure of the brain. The most frequent behaviours of the parental figures, both mother and father, will be etched in the babys neural pathways as guides to relating. These repeated experiences turn into learning, and in terms of the pathways involved in emotion, this consists primarily of learning what to expect from others in close relationships. Are other people responsive to feelings and needs, or do they need to be hidden? Will they help to regulate them and make me feel better or will they hurt me or disappoint me? Our basic psychological organisation is learnt from our generalised experiences in the earliest months and years.
(Gerhardt, 2004:211)10
The recent research of the effect of the amygdala system (Gerhardt, 2004) highlights the importance of the early attachments (Bowlby, 1988)11 we make with caregivers and the implications that this can have on our relational life. This research, when applied to the integrative philosophy of Schema Theory has produced positive implications for my practice. The concept of Young, Klosko and Weishaars (2003) limited reparenting offered in the therapy resonates with
Relationship is the therapywhat clients needs from therapists and what infants needs from their carers is strikingly similar (OBrien & Houston, 2000:133)12.
when consideration is given to what occurs between the infant and the caregiver and the impact this has on the amygdala system. Returning to the case example, in working with her emotional deprivation and subjugation schema, the theory details how the therapeutic relationship can be used to heal the schema. Although the effect of the amygdala system cannot be undone, the effect of it can be lessened, through what has been termed in Schema Therapy as limited reparenting, which will now be discussed.
According to Schema Theory, limited reparenting offers a partial antidote to the clients unmet core emotional needs. In returning to the client in my own practice, Young, Klosko and Weishaar (2003) suggest that the therapist, when working with an individual with an emotional deprivation schema, provides a nurturing atmosphere where the client can ask for their emotional needs to be met. As my client also has a subjugation of emotions schema, which Young, Klosko and Weishaar (2003) suggest needs the therapist to provide a non-directive reparenting atmosphere, both schemas when triggered could cause difficulties in the relationship. For example, if her schemas were triggered, the client would not be able to express her anger or ask for her emotional needs to be met.
The therapeutic relationship was used to explore the impact of her schemas as they arose in the relationship. For example her subjugation of emotions schema, when triggered in therapy may affect how she experienced me as a therapist as someone who she could not express her needs to, or explore the anger that she had learnt to control since a child. Because of the inclusion of object relations and attachment theory, we were able to explore her early relationships where we discovered that it was necessary for her not to experience anger as a child in order to protect herself from volatile relationships within her family. This gave us insight into how she was inadvertently perpetuating her schema in her adult life, which was maintaining her somatic difficulties. That is, in anger provoking situations, which trigger her subjugation of emotions schema, she copes with this by surrendering to the schema and experiences a psychosomatic presentation of her anger.
Working within this model, we began to address the impact of schemas as they arose in the therapeutic relationship. How her coping strategy of surrendering to the schema made it difficult for her to express her emotions in therapy. The therapeutic work could then progress in providing her with a safe relationship in which she could experience her emotions that were previously being manifested through somatic presentations.
The therapeutic relationship is then said to provide a corrective emotional experience (Alexander, 195613).
Conclusion
My intention in writing this essay was to provide an account of the therapeutic relationship as it has been conceptualised within traditional models of cognitive therapy and the models that have been modified. Although I appreciate the principles of cognitive therapy, in my opinion, the original model was left wanting in light of current research that shows the significance of the therapeutic relationship in affecting change. New reformulated models of cognitive therapy by Beck et al (1990) have addressed this limitation, but were only alluded to in this paper, as I wished to explore a model, which placed the therapeutic relationship at the heart of psychological change. Schema Therapy, although sharing many similarities with Beck et als (1990) reformulated model uses the relationship in a way that not only is in keeping with current research but also with the philosophy of Counselling Psychology.
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