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The Therapeutic Relationship in Cognitive-Behavioral Therapy

Article in Cognitive and Behavioral Practice · February 2022

DOI: 10.1016/j.cbpra.2022.02.006

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Cognitive and Behavioral Practice 29 (2022) 541–544

www.elsevier.com/locate/cabp

Therapeutic Relationship
Keith S. Dobson, University of Calgary

This article addresses the important role of the therapeutic relationship in cognitive- behavioral therapy (CBT). As has been
noted from the inception of CBT, there are critical features of both the therapist and the relationship that optimize the like-
lihood of therapeutic success, and this article briefly describes these features. It is further argued that a successful thera-
peutic relationship in CBT is not static but is flexible and adaptive both across and within clients, as their needs and
concerns vary. A positive therapeutic relationship is viewed within CBT as a necessary but insufficient condition for
change, as the relationship serves as a foundation upon which interventions are scaffolded, but that the client’s response
to various interventions itself shapes the interactions between therapist and client. Finally, it is argued that the key ther-
apeutic ingredients of CBT are largely teachable, and the article provides several suggestions to promote an effective ther-
apeutic relationship in CBT.

T HIS ARTICLE addresses the important role of the

therapeutic relationship in cognitive-behavioral
therapy (CBT). As has been noted from the inception
Apart from . . . exceptional circumstances, the two
extremes, encounter and technique, seem to be a mat-
ter of theoretical importance only. Live practice hovers
of CBT and the seminal work of Aaron Beck and col- between the extreme poles. Neither should be looked
leagues (Beck et al., 1979), there are critical features upon contemptuously or disparagingly. (Frankl, 1961,
of both the therapist and the relationship between p. 81)
the therapist and client that optimize the likelihood
of therapeutic success. After a brief review of the com- In somewhat of a contrast to the above arguments,
mon features of a positive therapeutic relationship in and in a partial response to the developments of behav-
psychotherapy, this article briefly describes these fea- iorism in the period following the Second World War,
tures as found in CBT and the work of Aaron Beck, Carl Rogers wrote a highly influential article in which
in particular. he argued that the necessary and sufficient conditions
The therapeutic relationship has been a matter of for therapeutic change included a congruent therapist,
discussion since the inception of psychotherapy. As the therapist experiencing unconditional positive
early as the work of Sigmund Freud, there was a recog- regard for the client, the therapist experiencing an
nition that although the successful resolution of psy- empathic understanding of the client, and the commu-
choanalytic therapy related to uncovering nication of these experiences to the client (Rogers,
unconscious processes, this process rested on a 1957). In a further and more direct expression of these
dynamic interplay between the human encounter same ideas, he wrote:
involved in a therapeutic relationship as well as the The warm, subjective encounter of two persons is more
judicious use of techniques such as free association effective in facilitating change than the most precise set
or dream analysis (Balint, 1950). Existential psycho- of techniques growing out of learning therapy or oper-
analysis reflected this same recognition: ant conditioning. (Rogers, 1961, p. 93)

As has been discussed elsewhere, the early develop-

ment of Beck’s cognitive theory and therapy grew pri-
marily from two sources (Dozois et al., 2017). One
Keywords: therapeutic relationship; cognitive-behavioral therapy; early influence was the training of Dr. Aaron Beck in
intervention; collaborative empiricism; socratic dialogue psychoanalysis, and its reliance on both relationship
1077-7229/20/Ó 2022 Association for Behavioral and Cognitive and technique in psychotherapy. The other was the
Therapies. Published by Elsevier Ltd. All rights reserved. use of empiricism and the behavioral tradition, with
542 Dobson

its emphasis on measurable change, and its consequent 2021; Dobson & Dobson, 2017) is a respectful style of
focus on the methods or techniques that optimize (ob- interaction, in which the therapist does not assume
servable) change. From its inception, cognitive therapy that they “know best,” but rather that they can learn
therefore highlighted the synergistic role of the thera- to understand the client based on inductive questions
peutic relationship and the therapy techniques and and reflective dialogue, so that the client and therapist
methods to optimize treatment outcomes. Indeed, together gain an optimal understanding of the issues
the first complete treatment manual based on cogni- that have brought the client to therapy, and that can
tive therapy (Beck et al., 1979) devoted an entire chap- then suggest roads for improvement. Although there
ter to the nature of the therapeutic relationship in are times and circumstances in CBT when the therapist
treating depression. This chapter highlights such key may need to be more confrontive (Linehan, 2014;
features of a successful cognitive therapist as warmth, Young, et al, 2003), this interactive and dialogical style
accurate empathy, and genuineness, and also eluci- is typically provided, based on the case conceptualiza-
dates critical aspects of the therapeutic relationship, tion and awareness of what may help the client best
including trust, rapport, and therapeutic collabora- reach their treatment goals.
tion. Elsewhere in this same volume it is suggested that Second, the literature has converged on the impor-
the therapist can encourage the client to reflect on the tance of the optimal therapy relationship as one that is
issues raised in the therapy sessions, in what can be dynamic and flexible (Castonguay et al., 2018). For
considered a precursor to what is now referred to as example, effective therapists are responsive to different
Socratic dialogue (Beck, 2005; Dobson & Dobson, interpersonal aspects and needs of the client across dif-
2017; Kazantzis et al., 2017). ferent clients, problems, and diagnoses (see Norcross
Discussion of the nature of the therapeutic relation- & Wampold, 2011), remaining adaptable to change
ship also features in many other books related to cogni- over the course of the treatment for a given client or
tive therapy for various disorders, including works by in response to issues such as “therapeutic ruptures.”
Beck (1988, 1999; Beck & Emery, 1985; Beck et al., As an example, when working with a more depressed
1993; Beck et al., 2008; Beck et al., 2015) and many client the CBT therapist may need to provide more
other books related to CBT more generally (cf. Arntz structure and encouragement for the client to try ideas
& Jacob, 2012; Beck, 2021; Dattilio & Freeman, 1994; in the early stages of treatment, but as the client hope-
Dobson & Dobson, 2017; Dugas & Robichaud, 2007; fully responds and becomes less depressed, the effec-
Fairburn, 2008; Segal et al., 2012). tive therapist will invite the client to take more of a
Most of the discussions of the therapeutic relation- coleadership role, and to perhaps design their own
ship in cognitive and cognitive-behavioral therapies homework assignments (Beck et al., 1979). As another
converge on three primary themes. The first is that a example, clients may have had difficult relationships in
constructive and successful relationship is integral to their past; if so, it would be unrealistic to think that
positive results with CBT (Okamoto et al., 2019). In they will not bring relationship concerns or issues into
this regard, the research literature in the general field the therapy situation. Thus, effective therapists need to
of psychotherapy (Norcross & Wampold, 2011) has gauge the expectations, social skills, interpersonal
been highly informative, as it has demonstrated that styles, and relationship affects that the client brings
such features as congruence, authenticity, empathy, to the treatment room, and to adjust their style of inter-
positive regard, and a positive alliance/working rela- action accordingly.
tionship are important features of successful therapeu- Third, and perhaps somewhat controversially, I sug-
tic relationships across therapeutic modalities. Within gest that the data strongly supports the conclusion that
the field of CBT these constructs are often reflected a positive therapeutic relationship is a necessary but
in two primary features of the therapy relationship: col- insufficient condition of therapeutic change in CBT.
laborative empiricism and the Socratic process Indeed, the field of CBT has underscored the critical
(Kazantzis, et al, 2017). The first essential aspect of role of many therapeutic techniques, including but cer-
the therapeutic relationship in CBT is collaborative tainly not limited to activity scheduling, exposure to
empiricism; the therapist and client are encouraged avoided situations and stimuli, skills training, cognitive
to work together as a team to understand and then restructuring, mindfulness training, and the examina-
modify problems through an iterative process of tion of core beliefs in relationship to presenting prob-
designing assignments that take place in the time lems. It is also to my mind incontrovertible that the
between therapy appointments, and to then adjust success of cognitive therapy and CBT relies in part on
these assignments and tasks, as the evidence emerges what happens in the therapy room, but even more so
as to what changes are most adaptive in the client’s life. on what happens between sessions, when the client
The process of Socratic dialogue (see also J. Beck, takes the homework assignments and implements
 Therapeutic Relationship 543

them in their life (Kazantzis et al., 2005, 2016; & Dobson, 2017; Kazantzis et al., 2017). Indeed, any-
Kazantzis & Miller, 2021). The precise value of a given one who had the privilege of seeing Aaron Beck in per-
technique or homework assignment will depend on a son engaged in cognitive therapy with a client, or who
variety of factors, including the presenting problem has viewed any of his training films, can witness his
(s) of the client, the stage of therapy, the skill of the remarkable interpersonal skills, and the ability he
therapist to effectively deploy the technique, the will- had to adapt to the client’s current state and clinical
ingness of the client to attempt the method, and of needs. The field of psychotherapy has been enriched
course the outcome of the use of the technique. Suc- by this awareness of the critical role of the interper-
cessful CBT therapists have a large “toolkit” of tech- sonal process, and through both the clinical demon-
niques that they can go to, to select, adapt, and stration of these issues as well as their formalization
deploy those interventions that have the highest likeli- in theory and research.
hood to lead to successful client outcomes.
One of the encouraging aspects of CBT is that many
aspects of an effective therapeutic relationship can be
taught. Psychopathology courses are one strategy to
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