Empirically Supported Relationship Elements

The weather vane of clinical wisdom often points us in a direction that may at times be at odds with what our instincts tell us. For example, research has attempted to quantify different aspects of “technique” from “relationship.” This effort has led to a long-standing debate about the

Cognitive case conceptualization with a relational focus. Adapted from Cognitive behavior therapy workshop packet with permission of Judith S. Beck, PhD © 2011. Bala Cynwyd, PA

FIGURE 3.5. Cognitive case conceptualization with a relational focus. Adapted from Cognitive behavior therapy workshop packet with permission of Judith S. Beck, PhD © 2011. Bala Cynwyd, PA: Beck Institute for Cognitive Behavior Therapy.

From The Therapeutic Relationship in Cognitive-Behavioral Therapy by Nikolaos Kazantzis, Frank M. Dattilio, ancl Keith S. Dobson. Copyright © 2017 The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the table of contents).

relative merits of factors that are common across therapies (i.e., relational elements) and the techniques of a specific model of therapy. A technique does not spontaneously appear out of nowhere and apply itself to a client (Kazantzis & Kellis, 2012). Except in rare cases where a client is engaged in entirely self-directed therapy, such as in self-help or in therapy via the Internet, CBT techniques are inextricably linked to the therapeutic relationship. In fact, one may go as far as to say that CBT itself simply constitutes the relationship, by virtue of its emphasis on “collaboration.” Just because we can associate variability in a relationship element and frequency of techniques as indicators of outcome, we cannot assume that this actually translates to how CBT operates in a clinical setting. The relationship between therapist and client is what galvanizes the process. If the theoretical assumptions that guide the application of data analyses have inherent problems, then so do the results they produce (see the discussion in Psychotherapy, volume 51, issue 4, 2014).

The American Psychological Association has published the results of a second Interdivisional (APA Divisions 12 & 29) Task Force on Evidence- Based Therapy Relationships, which included important recognition of the aforementioned point: “The therapy relationship acts in concert with treatment methods, patient characteristics, and practitioner qualities in determining effectiveness; a comprehensive understanding of effective (and ineffective) psychotherapy will consider all of these determinants and their optimal combinations” (Norcross, 2011). This Task Force has advocated new research methodologies that utilize objective evaluations of the complex associations among client qualities, clinician behaviors, and treatment outcome. This call has been addressed through the CBT literature on collaborative empiricism and Socratic dialogue, among other more generic psychotherapy issues (see Chapters 4 and 5).

Table 3.1 summarizes the Task Force’s conclusions regarding research support for specific elements of the therapeutic relationship. Relationship elements are recommended to be adapted for each client based on client reactance/resistance level, preferences, culture, religion and spirituality, stages of change, and coping style, which are all part of the cognitive case conceptualization. (Additional considerations of executive functioning, emotional intelligence, and intellectual functioning were covered in Chapter 2.)

As one research step, we took the Working Alliance Inventory-Short Revised—Observer version (WAI-SR-O), revised its scoring criteria, and put it to the test. This effort was necessary because we wanted to develop a version that could be used by third-party observers of the interaction, yet the reliability of working alliance indices initially failed to reach the levels of those achieved by the initial developers (Hatcher & Gillaspy, 2006; Horvath & Greenberg, 1989; Tracey & Kokotovic, 1989). In our

TABLE 3.1. Summary of the Conclusions of the Interdivisional (APA Divisions 12 and 29) Task Force on Evidence-Based Therapy Relationships

Strength of evidence

Relationship elements

Demonstrably effective

  • • Expressed empathy
  • • Alliance in individual psychotherapy, and therapy for youth, families, and groups
  • • Collecting structured client feedback (e.g., symptom inventories)

Probably effective

  • • Therapist expression of positive regard (e.g., positive affirmations)
  • • Collaboration
  • • Goal consensus


  • • Congruence/genuineness
  • • Repairing alliance ruptures
  • • Managing countertransference
  • • Expectations
  • • Attachment style

Note. A more comprehensive report of the Task Force findings may be found at http://societyfor- psychotherapy.org/evidence-based-therapy-relationships.

study of CBT for depression, we structured the data collection in the WAI-SR-O and revised the Likert rating scale, which lead to adequate inter-rater reliability (Finn’s r = 0.91) and a statistically significant relationship between the midtreatment working alliance and the therapeutic outcome at posttreatment stages through to 6-, 12-, 18-, and 24-month follow-up (with an increase of 1 on the total score of the WAI-SR-O corresponding with a decrease of 1 on the total score of the Beck Depression Inventory II), when holding constant pretreatment depressive symptom severity and therapist competence (Kazantzis, Cronin, Farchione, & Dobson, 2017).

While the relationship between alliance and therapeutic outcome was demonstrated within the APA Task Force’s meta-analytic studies (i.e., Horvath, Del Re, Fluckiger, & Symonds, 2011) and extended in our research, an alternative hypothesis has emerged; namely, that symptom improvement may be facilitated by the formation of the working alliance. Indeed, the temporal relationship between alliance and symptomatic change has been the topic of much discussion and remains equivocal as to whether formation of the alliance is a necessary precursor to symptom change (e.g., Barber et al., 2014; Casey, 2005; Falkenstrom, Granstrom, & Holmqvist, 2013; Fltickiger, Grosse Holtforth, Znoj, Caspar, & Wampold, 2013; Goldsmith, Lewis, Dunn, & Bentall, 2015; McEvoy, Burgess, & Nathan, 2014; Zilcha-Mano, Dinger, McCarthy, & Barber, 2014). We suggest that it is equally possible that CBT-specific elements of the therapeutic relationship (e.g., collaborative empiricism, Socratic dialogue) are more important than generic aspects of the therapeutic alliance for cognitive change in CBT (see Kazantzis et al., 2015). If the research that relates therapeutic relationship elements to CBT outcomes has not measured central features, then it is possible that this work has diluted the contribution of the therapeutic relationship. We present data to support this hypothesis in Chapters 4 and 5.

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