A Focus on the Therapeutic Relationship

Cognitive therapists believe that a positive therapeutic relationship is necessary but not a sufficient criterion for effective psychotherapy. They are mindful of Rogerian principles and practices, or the so-called nonspecific variables of psychotherapy (Craighead, Sheets, Bjornsson, & Amarson, 2005). They also attend to the literature on therapist characteristics and styles that promote therapeutic change (Castonguay & Beutler, 2006), as well as to methods to promote an effective therapeutic alliance (Safran, 1998; Safran & Muran, 2000). Cognitive therapists also recognize and attend to “therapy ruptures” (J. S. Beck, 1995), problems in the therapeutic alliance, and resistance in cognitive therapy (Leahy, 2001). They also attend to both the patient’s negative affective experiences with and toward the therapist, and the therapist’s negative thoughts and feelings toward the patient. Such processes and reactions can inhibit treatment, and although they ideally do not become the focus of the therapy, they need to be monitored and, if necessary, overcome so that the focus of therapy can remain on the patient’s problems.

Several aspects of the therapeutic relationship are promoted in cognitive therapy. The therapist and patient hopefully begin therapy with a general attitude of respect toward each other. Patients typically come to therapy with the idea that they are interacting with an expert and are often deferential toward the therapist. Hopefully, the therapist reciprocates this attitude and respects patients’ efforts to struggle with life’s problems and their willingness to seek assistance. The cognitive therapist tries to evaluate the patient’s own coping skills and competencies and will work with existing skills while trying to strengthen these aptitudes during course of therapy. The patient is considered the expert in his or her own life, and cognitive therapists respect this unique position.

Cognitive therapists are encouraged to care about their patients and to demonstrate empathy. In this regard, cognitive therapists do not differ from therapists in other schools of psychotherapy, since these characteristics are viewed as facilitating a positive relationship (Castonguay & Beutler, 2006). They try to have open and direct communication with their patients to maximize the effective and reciprocal transmission of ideas, feelings, and concerns. As is true of other schools of therapy, cognitive therapists are expected to behave in an ethical manner toward their patients and not to exploit them for financial or personal gain.

Collaborative Empiricism

One idea that cognitive therapy has contributed to the area of positive therapeutic relationships is collaborative empiricism. This term reflects two intersecting notions. The first is that the therapist and patient work together as a team to identify problems, areas of needed change, and the optimal ways to effect change in the patient’s life. As noted earlier, the therapist recognizes and respects the patient’s competencies and skills, even while the patient comes to the therapist for expert advice and guidance in solving problems. The idea of a partnership evolves during the course of therapy. Often, in the early stages, the therapist is dominant and will provide ideas to the patient about new ways to think about or approach his or her problems. These proposals are always provided as suggestions and are discussed and approved by the patient before being considered as homework. As problems are overcome and the patient learns the methods of cognitive therapy, increasing control is given to him or her. Thus, the patient may suggest topics for discussion in a given session and will be encouraged by the therapist to set the homework himself or herself, with the therapist’s responses, questions, and support. Cognitive therapy is not provided to patients but is conducted with patients as active partners.

The second aspect of the concept of collaborative empiricism relates to the notions of evidence and objectivism. The cognitive model recognizes that all humans misperceive events in the world, as our schemas to some extent color or shade what we see and how we view events. Cognitive therapists recognize that if therapy is limited to talking about events or experience, any discussion might be predicated on erroneous perceptions or ideas. Thus, the therapist encourages the patient through discussion and homework to evaluate the facts of the matter and to separate perception from evidence as much as possible. If the evidence related to a particular key cognition is insufficient, the homework assignment may be no more than to ascertain the objective “truth” as much as possible. Once the evidence is clear, it can be evaluated independently of the meaning attached to it or of the emotional responses engendered by that meaning.

A challenging situation in cognitive therapy arises when the patient asks for the advice or opinion of the therapist. In general, cognitive therapists work with patients to generate strategies that will work in the patient’s life, and the patient is the best judge of outcomes. Cognitive therapists are reluctant to give the patient the “correct” or “best” answer, since such an answer rarely exists. Furthermore, because the therapist does not have to live out the consequences of decisions that are made in treatment, it is more ethical for the patient to determine the course of his or her own life. Thus, the cognitive therapist often asks the patient what he or she thinks (which also is an assessment of the patient’s coping abilities and thoughts about the situation). In some instances, the answer to this question reveals a skills deficit, which might be addressed through reading or instruction and practice. In other cases, the answer reveals a negative thought, which can become the focus of an intervention. If the patient persists with appeals for the therapist’s ideas, the therapist might inquire what others would do in a similar situation. Sometimes this question can lead to homework in which the patient canvasses other people to get some ideas. If pushed further, the therapist might offer one or more suggestions, and the therapist and patient can discuss the various options and select one that would work for the patient.

The patient may persist in asking the therapist’s opinion or advice. The cognitive therapist will want to assess the meaning that the patient attaches to this advice. If the patient’s belief is that “the therapist always knows best,” this assumption would likely be addressed as absolutistic and erroneous, and the therapist might offer examples of how he or she does not always know best before giving a suggestion. When the belief is that “if the therapist cares about me, he will tell me what he would do,” the therapist can offer other evidence that supports his or her caring and concern and then choose whether to provide the suggestion. If the patient’s motive is to tell the therapist how his or her idea won’t work or to challenge the therapist, providing an answer is likely to be unhelpful to the patient and possibly destructive to the therapy relationship. In such cases, the therapist might refuse to provide a suggestion.