The value of the therapeutic relationship in psychotherapy has been studied by seasoned and expert therapists of every therapeutic orientation. Whether the clinicians have been psychodynamic, client-centred, interpersonal or behavioural, a similar conclusion has been reached: A ‘good therapeutic relationship’ is a necessary ingredient in any type of psychotherapy¹ (e.g. Beck, Rush, Shaw, & Emery, 1979; Benjamin & Critchfield, 2010; Goldfried, 1983; Greenson, 1965; Meyer & Gelder, 1963; Rogers, 1957).

Consistent with this, the American Psychological Association (APA) Task Force on Empirically Supported Therapy Relationships recently reviewed the empirical literature on the therapeutic relationship and presented their findings (Norcross, 2001). They concluded, among other things, that “(a) the cumulative research convincingly shows that the therapy relationship is crucial to outcome; (b) the therapy relationship makes substantial … contributions to psychotherapy outcome independent of the specific type of treatment; (c) treatment guidelines should explicitly address therapist behaviors … that promote a facilitative therapy relationship; (d) the therapy relationship acts in concert with discrete interventions … in determining treatment effectiveness and (e) adapting or tailoring the therapy relationship to specific patient needs and characteristics (in addition to diagnosis) enhances the effectiveness of treatment” (Norcross, 2001: pp. 495–497).

The third, fourth and fifth points mentioned above were components of one approach to the therapeutic relationship in cognitive–behavioural therapy (CBT), namely, the case formulation approach to the therapeutic relationship (AuBuchon & Malatesta, 1998). This chapter will provide an update on that approach, as well as what is hoped to be a more sophisticated and evolved view on the therapeutic relationship. It is also hoped that this chapter will offer some suggestions on how to manage the therapeutic relationship according to the case formulation and illustrate ways in which the therapeutic relationship, in and of itself, can be a potent treatment intervention. To start, however, the current chapter will review the literature on the therapeutic relationship in behaviour therapy, highlighting two of the more impressive approaches to this relationship, and briefly review the case formulation approach to behaviour therapy.

Review of the Literature

The importance of the therapeutic relationship has been emphasized by prominent clinicians throughout the history of behaviour therapy (e.g. Beck et al., 1979; Brady, 1980; Goldfried & Davison, 1976; Kohlenberg & Tsai, 1991; Linehan, 1988; Meichenbaum, 2006; Meyer & Gelder, 1963; Wolpe & Lazarus, 1966). In addition, the therapeutic relationship in behaviour therapy has been studied in a variety of ways. First, there have been studies that have compared behaviour therapists with those of different orientations on a variety of characteristics. Behaviour therapists were found to be at least as warm, empathic, genuine and caring as therapists from other orientations (e.g. Brunink & Schroeder, 1979; Fischer, Paveza, Kickertz, Hubbard, & Grayson, 1975; Sloan, Staples, Cristol, Yorkston, & Whipple, 1975). Behaviour therapists were also found to be more active and to demonstrate more initiative, support and direction than therapists from other orientations (e.g. Greenwald, Kornblith, Hersen, Bellack, & Himmelhoch, 1981; Sloan et al., 1975).

A second group of studies have examined how the therapeutic relationship may improve the efficacy of behaviour therapy. For example, the role of the therapist as a nonfearful model, reassuring stimulus, safety signal or ‘reciprocal inhibitor’, has been addressed (e.g. AuBuchon & Calhoun, 1990; Bandura & Menlove, 1968; Meyer, 1957; Rachman, 1983; Wolpe, 1980). In addition, Wright and Davis (1994) have offered strategies for modifying therapist behaviours based upon assessment of the patient’s expectations of the therapy and/or therapist. Taking the concept one step further, Linehan (1988) and Rosenfarb (1992) have written clinically useful analyses of the therapeutic relationship within the practice of behaviour therapy. These authors discuss the therapeutic relationship both as a vehicle for therapy and as a therapeutic agent in itself (e.g. through modelling and social reinforcement). Linehan (1988) also discusses the beneficial effects of being in a therapeutic relationship, for both the patient and the therapist (e.g. ‘The relationship as life enhancing’: p. 286). All in all, it is an insightful and sophisticated article and one recommended for all cognitive–behavioural therapists.

Third, studies have demonstrated that certain types of therapist behaviours are more effective with various clinical populations. These behaviours include acceptance, limit setting and validation with borderline personality-disordered patients (e.g. Linehan, 1993; Shearin & Linehan, 1992); focusing, challenge, encouragement and praise with anxiety-disordered patients (e.g. Grayson, Foa, & Steketee, 1982; Gustavson, Jansson, Jerremalm, & Ost, 1985; Rabavilas, Boulougouris, & Perissaki, 1979; Williams & Chambless, 1990); lenient and flexible behaviours with anorexic patients (Touyz, Beumont, & Dunn, 1987); and initiative, support and direction with depressed patients (Greenwald et al., 1981).

In addition to the studies mentioned above, two recent approaches to the therapeutic relationship in CBT merit a more elaborate discussion. The first of these is Meichenbaum’s ‘Core tasks of Psychotherapy: What “Expert” Therapists Do’ (Meichenbaum, 2001). In this approach, seven behavioural tasks are identified, which Meichenbaum proposes are done by expert psychotherapists regardless of therapeutic orientation. These are as follows: (a) developing a collaborative therapeutic alliance with the patient via compassionate listening and helping the patient identify strengths of theirs that can be built upon in treatment; (b) educating the patient about their problem and possible solutions; (c) reconceptualizing the patient’s problems in a more hopeful way; (d) ensuring that the patient has the necessary intrapersonal and interpersonal coping skills; (e) encouraging the patient to perform personal experiments; (f) ensuring that the patient takes credit for positive changes and (g) conducting relapse prevention strategies. Subsequently, Meichenbaum has identified five additional tasks for patients who have been victimized and/or are suffering from post-traumatic stress disorder (PTSD) (Meichenbaum, 2006).

The other notable approach to the therapeutic relationship is Kohlenberg and colleagues’ Functional Analytic Psychotherapy (e.g. Tsai, Kohlenberg, & Kanter, 2010).In this approach, patient difficulties are conceptualized in accordance with behavioural principles and operant learning history. The authors further propose that the patient demonstrates behaviours with the therapist that are reflective of their problems outside of the therapeutic relationship and in their daily lives (i.e. ‘clinically relevant behaviours [CRBs]’). In this way, the approach bears some similarities to psychoanalytic approaches and to the case formulation approach written about by AuBuchon and Malatesta (1998). Kohlenberg and colleagues then outline in behavioural and interpersonally sensitive terms five guidelines that specify therapist behaviours (‘tasks’), which use operant and interpersonal techniques to modify the patient’s behaviour in accordance with their goals. It is notable that when describing these tasks, the authors also address issues such as how to increase therapist awareness of CRBs and how to address problematic behaviours and issues of the therapist, which may have a negative effect on the therapy. Also commendable is that Kohlenberg and colleagues have demonstrated empirical support for their approach through a series of studies (e.g. Kanter, Schildcrout, & Kohlenberg, 2005; Kohlenberg, Kanter, Bolling, Parker, & Tsai, 2002).

The Case Formulation Approach

The preceding section reviewed and described various approaches to the therapeutic relationship in CBT. In a previous edition of this book, AuBuchon and Malatesta (1998) outlined an approach to the therapeutic relationship that was guided by the case formulation. In this approach, various therapist behaviours are ideographically and systematically demonstrated with each patient, as determined by the therapist’s formulation of the patient and their difficulties. The integral role of the case formulation in guiding and influencing the therapeutic relationship will be again described in the following section and in the following chapter. Before those topics are discussed, however, a brief review of the case formulation approach in CBT is offered.

Case formulation approaches to behaviour therapy can be traced to the pioneering work of Victor Meyer (1957). Emphases on (a) an individualized approach to understanding each patient’s problems via sensitive listening and hypothesis testing and (b) tailoring scientifically backed treatment interventions for each patient were hallmarks of Meyer’s approach. I had the pleasure and honour of working with, and observing, Dr. Meyer during the 1980s and 1990s and will never forget his half-serious complaint that he ‘wished [he] had never invented exposure and response prevention (for treatment of obsessive-compulsive disorder), because nobody thinks about their patients anymore’ (V. Meyer, personal communication, London, 1985). Dr. Meyer worked alongside Dr. Edward Chesser, one of the few behaviourally oriented psychiatrists, for several decades. They co-directed an innovative inpatient psychiatric unit, delivering intensive treatment according to behavioural principles. Furthermore, they worked with complex and treatment-refractory cases, all the while displaying a great deal of sensitivity and dignity towards their patients. In addition, they wrote about behaviour therapy in clinical psychiatry (Meyer & Chesser, 1970). As for the case formulation approach in CBT, it has been elaborated upon by Meyer (1975), Turkat (1985), Persons (1989a) and Bruch and Bond (1998). In addition, interesting and thorough accounts of the development of case formulation approaches to CBT can be found in a previous edition of this book (e.g. Bruch, 1998a, 1998b).

In 1979, Meyer and Turkat defined formulation as ‘an hypothesis which (a) relates all the client’s complaints to one another, (b) explains why the individual developed these difficulties, and (c) provides predictions concerning the client’s behavior given any stimulus conditions’ (pp. 261–262). This definition still serves us well, not only in specifying what a case formulation is but also in guiding and challenging us as clinicians. That is, having to meet the criteria specified in the definition given by Meyer and Turkat helps to ensure that we as clinicians really understand our patient and their difficulties. This case formulation approach has also been demonstrated empirically to be effective with a range of disorders including schizophrenia (Adams, Malatesta, Brantley, & Turkat, 1981), chronic pain (AuBuchon, Haber, & Adams, 1985), complex phobia (AuBuchon, 1993), complex obsessive–compulsive disorder (OCD), personality disorders (AuBuchon & Malatesta, 1994; Malatesta, 1995; Turkat & Carlson, 1984) and tic disorders (Malatesta, 1990). It also has utility for guiding and managing the therapeutic relationship as demonstrated by Turkat and Brantley (1981), Persons (1989b) and AuBuchon and Malatesta (1998).

Beyond Therapist Style: Current Thinking on the Therapeutic Relationship

In the first edition of this book, AuBuchon and Malatesta (1998) described an approach for managing the therapeutic relationship that was based upon and guided by the case formulation. First, they proposed that the behaviour the patient demonstrated towards the therapist could be understood in terms of the case formulation. For example, a patient who experienced severe criticism growing up in her family of origin might misinterpret the therapist’s behaviour as being critical of her and/or might become severely upset or defensive when feeling criticized by her therapist. Second, AuBuchon and Malatesta maintained that the case formulation was valuable in guiding the therapist’s interactions with the patient. For instance, if based upon the case formulation, the therapist hypothesized that the patient would have strong negative reactions to feeling controlled, the therapist would make sure that he did not unnecessarily trigger these feelings in the patient. He would do this by sharing control with the patient during the course of the therapy (e.g. by letting the patient choose the frequency of therapy sessions or other treatment activities).

AuBuchon and Malatesta (1998) also presented two sets of therapist behaviours. The first of these was derived from seminal research on the therapeutic alliance (e.g. Frank, 1984; Strupp, 1984) and would be demonstrated with nearly all patients. The other set of behaviours would be systematically varied, and differentially emphasized, on the basis of the therapist’s formulation of the patient and on their experiences with the patient during the course of therapy. They went on to state that this second set of therapist behaviours were ‘hypothesized to be valuable in (a) strengthening the therapeutic alliance, (b) improving the likelihood that the patient will benefit from implementation of specific therapeutic techniques, and (c) helping patients modify interpersonal anxieties and skill deficits likely to be demonstrated in interactions with the therapist’ (AuBuchon & Malatesta, 1998: p. 145). They also introduced and operationally defined a relationship intervention, the ‘therapist style’. Therapist style was defined as ‘a collection of purposeful interpersonal behaviors exhibited by the therapist when in contact with the patient’ (p. 144). It was emphasized that these behaviours were not only genuine for the therapist but also primarily determined by the therapist’s formulation of the patient’s difficulties. For example, with a patient with fears of revealing difficulties, the therapist may elect to disclose something that the therapist struggled with in his life. Again, this appears consistent with the APA Task Force’s recommendations cited earlier in this chapter. That is, treatment guidelines need to explicitly address therapist behaviours that promote a facilitative therapy relationship, and that tailoring the therapy relationship to specific patient needs and characteristics, in addition to diagnosis, enhances treatment effectiveness (Table 4.1).

The formulation-guided approach to the therapeutic relationship described by AuBuchon and Malatesta represented a step forward within CBT. It remains a highly effective way to manage the therapeutic relationship, and one with many benefits. First, it emphasizes the value of a thoughtful and systematic approach to the therapeutic relationship (i.e. one guided by the case formulation). This means a very individualized relationship with each patient, based on their learning history and interpersonal presentation. In effect, no two therapeutic relationships are the same. This differs from traditional psychoanalytic approaches with a heavy reliance on technical neutrality and from client-centred approaches relying primarily on unconditional positive regard. The formulation-guided approach also differs from cognitive–behavioural approaches, which often focused too much on treatment techniques for specific disorders, thereby ignoring the interpersonal context in which these disorders developed, or were maintained (e.g. interpersonal dependency with an agoraphobic patient). In addition, this individualized approach appears to be a more natural approach to the therapeutic relationship. One could argue, for instance, that no two interpersonal relationships in nature are the same: that is, no two parent–child relationships, no two husband–wife relationships, no two friendships or no two relationships between colleagues.

Second, the strengthened therapeutic alliance that results from the formulation-guided approach yields several additional benefits for patients. One such benefit is the increased effectiveness of specific (‘nonrelationship’) treatment techniques (e.g. exposure and response prevention; assertiveness training). This increased effectiveness seems to occur for various reasons. First, patients seemed to like or trust their therapist more. Second, patients report feeling well understood by their therapists. Third, in the context of a strong therapeutic alliance, patients have expressed feeling strongly affirmed and supported by their therapists. It is easy to see that if a patient is experiencing these positive emotional states they would be more willing to experiment with therapeutic suggestions, expose themselves to challenging situations or emotions or comply with therapeutic homework. Additionally, the strong therapeutic alliance that can result from the formulation-guided relationship helps clinicians avoid therapeutic ruptures and roadblocks. Finally, the formulation-guided approach helps therapists conceptualize, understand and treat various maladaptive cognitive, autonomic and behavioural responses demonstrated within the therapeutic relationship (e.g. automatic thoughts about the therapist’s motives, overwhelming emotional reactions like fear or anger and behaviours such as withdrawal or criticism).

Since the publication of the ‘Therapist Style’ chapter, my primary concern with it has been that the ‘therapist-style intervention’ would be implemented in a ‘cookbook’ fashion (i.e. akin to matching treatment techniques to diagnoses). This would not be consistent with a formulation-based approach. I was also concerned that therapists would choose behaviours from ‘column A’ or ‘column B’ and apply them in a contrived manner instead of relating to their patients in a genuine, sensitive and caring fashion. In addition, the therapeutic relationship skills of listening intently to the patient and trusting one’s intuition and then responding sensitively and accurately to ‘where the patient is’, in a moment-by-moment fashion, need to demonstrated as well.² The goal, therefore, is to do both: Demonstrate sensitive and attentive clinical skills while having the therapist’s way of interacting with the patient be informed and guided by the case formulation.

In the 14 years since the ‘Therapist Style’ chapter was written, clinical experience with hundreds of patients has deepened my appreciation of the richness of therapeutic relationships. These experiences have also demonstrated to me the power and potential of this component of therapy to bring about meaningful and lasting changes for the individuals we treat. ‘Good’ therapeutic relationships enhance the effectiveness of treatment techniques, are an intervention in and of themselves, provide for corrective emotional experiences for patients (e.g. patients can feel valued, likable, worthy and even lovable), can turn therapeutic ruptures into unique learning experiences that result in lasting changes in core problems (e.g. feelings of being unwanted and expectations of abandonment) and can minimize treatment dropout rates.

Therapeutic relationships improving specific treatment interventions

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