The Therapeutic Relationship in Cognitive-Behavioral Therapy

Abstract Cognitive behavioral therapy has often been criticized for ignoring the role of the therapeutic relationship. In this article, I outline several dimensions for case formulation and intervention that suggest that the cognitive-behavioral approach can be a powerful theoretical model for understanding the causes of and the strategies for overcoming impasses in therapy. I review how the clinician and patient can collaborate in understanding the importance of case conceptualization, validation, emotional philosophies, victim resistance, schematic resistance, schematic mismatch, sunk-cost commitment, and self-handicapping. The relevance of these factors for both patient and therapist are discussed. During the last decade there has been increased interest in the nature of the therapeutic relationship in cognitive behavioral therapy (Gilbert, 1992; Safran, 1998; Safran and Muran, 2000; Greenberg, 2002; Leahy, 2001; Gilbert and Irons, 2005; Leahy, 2005; Bennett-Levy and Thwaites, 2007; Gilbert and Leahy, 2007). Cognitive behavioral therapists have proposed that the therapeutic relationship reflects interpersonal schemas, earlier attachment problems, emotional processing, failures in validation and compassion, and a variety of processes underlying non-compliance or resistance. Resolving “ruptures” in the therapeutic relationship provides an often essential opportunity for using the relationship as a means to modify cognitive and emotional problems (Safran, Muran, Samstag and Stevens, 2002; Katzow and Safran 2007). In light of the emphasis on “empirically supported treatments” (such as CBT) there is the risk that the alliance in therapy may be foreshadowed by the techniques and protocols used in CBT, perhaps giving credibility to Mahoney's (1991) earlier claim that therapy can become “technolatry”.