https://orcid.org/0000-0001-9559-4160
This set of articles represents the concluding component of the tripartite Special Section focusing on therapeutic relationships in cognitive behavioral therapy (CBT). In Part 1, generic therapeutic elements (e.g., alliance) and CBT-specific components (e.g., collaboration, empiricism, and Socratic dialogue) were identified within a nested structure. Studies were presented regarding critical interpersonal and therapist factors facilitating outcomes (Psychotherapy Research, Vol. 32, issue 8). Part 2 featured research related to more specific applications and tailoring the therapeutic alliance in CBT (Psychotherapy Research, Vol. 33, issue 1).
Client-Therapist Agreement in Alliance Ratings
Adaptation and adjustment of each element of the therapeutic relationship are necessary for the client in a dynamically responsive manner, both within and across sessions (Dobson, Citation2022). Therefore, it is crucial to consider the consistency of client and therapist views on the relationship and its components. Attention to the alliance is particularly important if there are divergent views about the treatment and its goals, even within a proportion of a client’s therapy. As one example, Moshe-Cohen et al. (Citation2022) conducted a study on early and late alliance ratings in an 11-session protocol among patients (N = 181) with panic disorder. Disagreement in alliance during later sessions was associated with a worse clinical outcome when therapist ratings of alliance were higher than those of the patient.
Client Factors
Our work on this topic (Kazantzis et al., Citation2017) highlights that client evaluations of the therapy process, including the alliance and other therapeutic relationship elements, likely reflect the case formulation. Highly endorsed negative core beliefs are typically applied to the clinician and, if activated during sessions, can become a source of alliance rupture. Baier et al. (Citation2023) explored the temporal relationship between alliance and change in trauma-related beliefs among a PTSD sample (N = 142) undergoing a 10-week exposure-based intervention. Their results suggested that alliance and change in cognitions were not independent, and that they tend to grow together over the course of treatment.
Barr et al. (Citation2023) also investigated client factors associated with alliance ratings in samples (N = 212) receiving a schema therapy modification of CBT (6 months followed by 6 follow-up sessions delivered monthly) for binge eating or depression. Early alliance was associated with high levels of participation in therapeutic tasks and other alliance-promoting behaviors, moderate distress, and only slight hostility towards and dependence on therapists during the intervention. The paper also raises the important issue of how other in-session processes of CBT, such as the so-called “structuring” processes of agenda setting and integration of homework, are facilitated by the alliance and other aspects of the therapeutic relationship.
Therapist Factors
Hildenbrand-Burke et al. (Citation2021) examined therapist competence in facilitating the design, plan, and review of homework, and client engagement with homework. This study included an assessment of client feedback (appraisals) on the task using the Homework Rating Scale—Revised (HRS-II) in a community-based trial of CBT delivered across 12 weeks for youth depression (N = 80). Significant mediating effects of client appraisals of homework on the competence-engagement relationship were found.
Relationships with CBT Specific Processes
McEvoy, Bendlin et al. (Citation2023) investigated client engagement and feedback on homework using the HRS-II alongside both the alliance and group cohesion in a sample of clients (N = 105) receiving a 12-session group CBT intervention for social anxiety. Although the working alliance was not found to be related to symptom reduction in this particular set of analyses, both group cohesion and homework engagement emerged as significant predictors of outcome. In their subsequent paper, McEvoy, Bendlin, et al. (Citation2023) and McEvoy, Johnson, et al. (Citation2023) present a focused follow-up study on homework beliefs and found that these beliefs served as a negative predictor of future group cohesion in mid- to late-treatment. Furthermore, a significant and positive relationship was observed between client feedback on the consequences of homework and the working alliance. Hildebrand-Burke et al. and both McEvoy et al.'s papers provide support for the comprehensive model of homework (Kazantzis & Miller, Citation2022), emphasizing the role of therapist competence in the delivery of homework and highlighting the crucial role of client feedback (appraisals) on homework in CBT. This model underscores the importance of alliance, collaboration, empiricism, and Socratic dialogue as nested elements within the process of facilitating homework design, planning, and review.
Conclusions
This tripartite Special Section in Psychotherapy Research offers an important set of contemporary research studies dedicated to advancing our understanding of the contributions of therapeutic relationship elements in CBT. Our objective was to showcase significant research from productive teams examining CBT processes, utilizing the latest in research methodology. Without doubt, this collective work propels the field forward both conceptually and methodologically.
Two collective conclusions can be drawn from the articles in this Special Section. Firstly, research on alliance-outcome relations is evolving and becoming more intricate and nuanced. Future studies will need to grapple not only with the mutual influence of client, therapist, and changes over time, but also the distinction from other processes based on the subjective experience of the client, such as changes in cognitions, and feedback on the process of therapy (see the discussion in Kazantzis, Citation2018).
Secondly, there is a pressing need for psychotherapy researchers to examine foundational elements of the therapeutic relationship in CBT, such as collaborative empiricism and Socratic dialogue. While these concepts permeate the articles in the tripartite Special Issue, reliable and valid measures of these CBT therapeutic relationship elements have yet to be produced. Our hope is that future research will examine these CBT-specific elements of the therapeutic relationship and their influence on the mechanisms of therapeutic change.
Disclosure statement
Kazantzis disclosed his royalties from Guilford Press (Therapeutic Relationship in Cognitive Behavior Therapy: Cognitive and Behavior Theories in Clinical Practice), Oxford University Press; Routledge (Using Homework Assignments in Cognitive Behavior Therapy); Springer Nature publishers (CBT: Science into Practice Book Series), and the Association for Behavioral and Cognitive Therapies (Editor stipend for Cognitive and Behavioral Practice). Dobson has no conflict of interest to disclose.
References
- Baier, A. L., Feeny, N. C., Coyne, A. E., & Zoellner, L. A. (2023). Temporal sequencing of change in trauma-related beliefs and therapeutic alliance during prolonged exposure and sertraline for chronic PTSD. Psychotherapy Research. . https://doi.org/10.1080/10503307.2023.2184733
- Barr, B. L., McIntosh, V. V. W., Britt, E. F., Jordan, J., & Carter, J. D. (2023). Clinical factors and early life experiences associated with therapeutic alliance development in treatment for depression or binge eating. Psychotherapy Research. https://doi.org/10.1080/10503307.2023.2191800
- Dobson, K. S. (2022). Therapeutic relationship. Cognitive and Behavioral Practice, 29(3), 541–544. https://doi.org/10.1016/j.cbpra.2022.02.006
- Hildenbrand-Burke, C., Davey, C., Gwini, S., & Kazantzis, N. (2021). Therapist competence as a determinant of engagement with homework in CBT for depression in young people: Results from a community-based trial. Psychotherapy Research.
- Kazantzis, N. (2018). Introduction to the special issue on processes of cognitive behavioral therapy: Does “necessary, but not sufficient” still capture it? Cognitive Therapy and Research, 42(2), 115–120. https://doi.org/10.1007/s10608-018-9891-z
- Kazantzis, N., Dattilio, F. M., & Dobson, K. S. (2017). The therapeutic relationship in cognitive behavior therapy: A clinician’s guide. New York: Guilford.
- Kazantzis, N., & Miller, A. R. (2022). A comprehensive model of homework in cognitive behavior therapy. Cognitive Therapy and Research, 46(1), 247–257. https://doi.org/10.1007/s10608-021-10247-z
- McEvoy, P. M., Bendlin, M., Johnson, A. R., Kazantzis, N., Campbell, B. N. C., Bank, S. R., & Egan, S. J. (2023). The relationships among working alliance, group cohesion and homework engagement in group cognitive behaviour therapy for social anxiety disorder. Psychotherapy Research. . https://doi.org/10.1080/10503307.2022.2161966
- McEvoy, P. M., Johnson, A. R., Kazantzis, N., & Egan, S. J. (2023). Predictors of homework engagement in group CBT for social anxiety: Client beliefs about homework, its consequences, group cohesion, and working alliance. Psychotherapy Research. https://pubmed.ncbi.nlm.nih.gov/36630684/.
- Moshe-Cohen, R., Kivity, Y., Huppert, J. D., Barlow, D. H., Gorman, J. M., Shear, K., & Woods, S. W. (2022). Agreement in patient-therapist alliance ratings and its relation to dropout and outcome in a large sample of cognitive behavioral therapy for panic disorder. Psychotherapy Research. https://doi.org/10.1080/10503307.2022.2124131