An Introduction to Cognitive Behaviour Therapy, 2 edition
The Therapeutic Relationship
This chapter reviews the importance of the therapeutic relationship in CBT. We will look at:
- the extent to which the therapeutic relationship is an essential foundation for therapy;
- the role of the therapist in CBT and the importance of non-specific therapist factors;
- ways of building collaborative client–therapist relationships – and of repairing ruptures in the therapeutic alliance;
- working with clients from different cultural backgrounds;
- boundary issues.
The therapeutic relationship as an essential foundation of therapy
An effective therapist–client relationship is important for treatment, with good evidence relating quality of relationship to therapeutic outcome (Orlinsky et al., 1994). However, within CBT the therapeutic relationship is seen as necessary but not sufficient for a good treatment result, and in treatment trials there is typically a beneficial effect from CBT over and above that of being in a therapeutic relationship (Roth & Fonagy, 2005).
Moreover, the evidence indicates that it may be the nature of the client’s participation in treatment that is the strongest predictor of outcome. For example, a client is more likely to do well if he is engaged with the therapeutic task, offers suggestions about treatment, warmly interacts with the therapist and is trusting of the therapist; and a client who consistently completes homework will do better than one who does not (Kazantzis, Whittington & Dattilio, 2010). Furthermore, in so far as therapist characteristics are related to outcome, it is the client’s perception of those characteristics, and not the behaviours themselves, that predicts outcome (Wright & Davis, 1994). For example, if a therapist’s empathic skills are assessed by both her client and by an independent observer, the client’s perception of empathy is a better predictor of outcome. This highlights the importance of the client as an active contributor to the therapy process.
The therapeutic relationship can be viewed as a useful laboratory for working on problems, providing an opportunity to acquire new skills that can then be transferred to situations in real life. For example, the client may learn to evaluate a ‘hot’ thought in a therapy session with coaching from the therapist, before generalising the same technique to ‘real life’. The client may also use sessions to review and modify unhelpful beliefs as they are played out with the therapist in the clinical setting. Safran and Muran (1995) suggest that the therapist can act in ways that provide new, constructive interpersonal experiences for the client, with the client and therapist stepping back together from the interaction and examining what is currently going on between them.
A client’s formulation included beliefs about others failing to be there for him when he was in trouble. In a session where difficulties in the relationship seemed to be emerging, the therapist used her own feelings as the cue for a discussion, saying ‘I am feeling quite defensive just now, and I wonder why. Could we explore this together?’ The discussion revealed that the client was uncertain whether or not the therapist could help him. They then went on to look at whether the therapist would be likely to withdraw if things became difficult, or whether she would want to find ways of hanging in there even in the face of difficulty, a discussion that was highly relevant to the client’s fears, and which led to the therapeutic relationship becoming a ‘laboratory’ for testing out those fears.
Within this model, the ways in which the client responds to the therapist may be influenced by beliefs developed early in life (possibly modified by subsequent experience), as well as by characteristics and behaviour of the therapist herself. However, the therapeutic relationship is not construed in terms of ‘transference’, in the psychoanalytic sense that it is a representation of another relationship from early life, but instead is considered as a relationship in its own right, with the potential for providing the client with new evidence about the range of possibilities for relationships – for example, a new belief like ‘People may stay with you even if difficulties emerge between you’ may be strengthened. The extent to which any corrective interpersonal experience in therapy will colour other relationships should be considered empirically. If the issues are being openly discussed, it is easier to check out whether there is indeed any generalisation to everyday life.
Bordin’s (1979) analysis of the therapeutic relationships as a working alliance is useful. He suggested that three components are necessary for a successful working alliance:
- Agreement on the task– what needs to be done in therapy, what the process of change (cognitive? behavioural?) will be, what activities and techniques will be used.
- Agreement on therapy goals– what is being sought from therapy in the short and long term, (for example, ‘to leave the house having checked the cooker only once; to complete tax returns without checking with my accountant’) with client and therapist each contributing personal commitment to the goals.
- A positive therapist–client bond, typified by mutual liking, respect, trust and commitment.
It is clear that a good working alliance is necessary for a good outcome (Krupnick, Sotsky, Elkin, Simmens, Moyer, Watkins & Pulkonis, 1996). At its most basic, you cannot carry out effective therapy with a client who drops out because he finds you cold and unempathic. The alliance needs to be established within the first three or four sessions (Horvarth, 1995), but this is not to say that the quality of the relationship remains fixed. It varies as treatment progresses, and it may be necessary to attend to breakdowns in the alliance in order for therapy to succeed. Thus, the quality of your therapeutic relationship should continue to be a focus of concern throughout the course of treatment.
Although it is not clear whether effective CBT is typified by a particular kind of alliance, it appears from a number of studies (for example, Raue & Goldfried, 1994) that whatever the therapeutic modality, clients consider similar qualities of the working alliance to be important. These include:
- being helped to understand their problems;
- being encouraged to face whatever situations cause them distress;
- being able to talk to an understanding person;
- being at ease with the personality of the therapist.
Some of these features map onto central features of CBT – for example, presenting a formulation of the client’s problems for him to comment on, designing behavioural experiments to test out unhelpful beliefs. Some of the factors relate to the qualities of the therapist, and these will now be considered.
The role of the therapist
One of the guiding principles of CBT is that, as therapist, you work empathically and collaboratively to engage the client in therapy (Ackerman & Hilsenruth, 2003). This aspect of therapy is developed further in the chapter on Socratic method (see Chapter 7), but the general approach is that you function as a guide and mentor rather than as an instructor. You are ‘walking alongside’ your client as he explores new options for feeling and behaving, and your role is to open up new opportunities for exploration, by asking questions or giving information that may lead him into previously unexplored areas. You need to have a good understanding of his current bearings in order to do this, so you need to adopt an open-minded curiosity and respect about your client’s beliefs, emotions and behaviours, and not to assume that you know how he feels or thinks.
This demands a lot of active questioning on your part, and the tone of the interaction is crucial: it should not be accusatory (‘You can’t really mean you think that!’), nor persuasive or haranguing (‘Do you think it is possible that most people respond in this way and that you are not picking up the cues?’). You should reflect a genuine, concerned interest in the client’s current perspectives or feelings. This is a fine balance because, while you are trying to get a detailed sense of what it is like to be your client in the current situation, you also need to maintain a measure of scepticism about what he is saying, since it is possible that he is making cognitive errors that will significantly distort the picture he presents.
Although the therapist’s role as guide is paramount, it may be appropriate to adopt an educative, information-giving role from time to time:
A young man was troubled by intrusive ideas about stabbing other people. He was very reassured when he was given the information that the vast majority of people from time to time have unpleasant intrusive thoughts which they find repellent in some way. This was supplemented by appropriate reading. (Rachman & de Silva, 1978)
Another important role for the therapist is practical scientist, providing a model for the client to adopt in relation to both current and future problems. Hypotheses about problems and experiences are set up and tested, and new conclusions are drawn if appropriate. The adoption of an open-minded approach is relevant throughout therapy, and the importance of looking for evidence that contradicts your initial hypotheses is particularly important – and this is as true for the therapist’s initial formulation as it is for the client’s initial beliefs. Evidence inconsistent with your ideas is the royal road to new perspectives!
The collaborative nature of the therapeutic relationship means that you relate to your client in an adult-to-adult way as far as possible. Thus you are open about your ideas concerning his problems and share your formulation in a way that allows him to give feedback on its relevance or accuracy; you may disclose information about yourself if this is in the client’s interest; and you are free to say ‘I don’t know’ or ‘Can I just think that over for a minute’, without needing to appear all-knowing. It is acceptable for you and your client to problem-solve together. The only occasional exceptions to this openness are when it is clearly in the client’s interest not to be open – for example, you might choose not to disclose early in treatment your ideas about a possible final weight for an eating-disordered client.
Within the complex web of interactions between therapist, client and techniques, it is clear that a good cognitive therapist also needs the characteristics identified by Rogers as necessary for other therapies, namely warmth, empathy, genuineness and unconditional regard for the client (Beck et al., 1979). Therapists who act in this way have been shown in many studies to achieve better outcomes (Lambert & Bergin, 1994; Orlinsky et al., 1994).
Furthermore, in a survey by Wright and Davis (1994), they found that clients wanted their therapists to:
- offer a physically safe, private, confidential setting, comfortable and free from distraction;
- be respectful;
- treat client concerns seriously;
- prioritise client interests over their own;
- be competent;
- share practical information about how to make life improvements;
- permit the client to make personal choices when using information and therapist suggestions;
- be flexible in evaluating the client – not assume that the client fits a theory or is now totally understood;
- review how the client gets on if therapist recommendations are followed;
- pace herself well, not rush, or keep changing appointments.
Although none of these qualities are specific to CBT, they nevertheless give a useful checklist of general rules to follow. Many of them are consistent with the general approach of CBT (for example, are implied by a collaborative approach), and many would fall under the general rubric of treating one’s clients in a respectful and empathic way.
Ways of building a positive and collaborative client–therapist relationship
The general principles of the cognitive-behavioural approach provide a sound foundation for building a good client–therapist relationship. For example:
- careful listening to get a real sense of how it is to be the client;
- taking time to set a shared agenda;
- making it clear that feedback is welcome; and
- carefully establishing the client’s goals for treatment
all contribute to an effective alliance.
Clients differ in what they bring to therapy, and consideration of these factors can also ease the development of a good relationship. For example, some clients may be at a relatively early stage in their ‘preparedness to change’ (Prochaska & DiClemente, 1986), and the therapist needs to be aware of this. A client with an eating disorder may be willing to think about extending the range of food she is eating only if she can be assured of no weight gain; or a client with OCD may be unwilling to consider limiting hand-washing. In such cases, collaboration might be better achieved through initial motivational work (Miller & Rollnick, 2002) rather than active CBT.
It seems that inexperienced therapists are able to create a good working relationship with their clients, but that more experienced clinicians are better able to spot potential ruptures in an alliance. We will now consider how to deal with ruptures when they occur, bearing in mind that an experienced supervisor is invaluable in this area (see Chapter 19).
Ruptures in the therapeutic alliance
Do not be surprised that ruptures in the working alliance occur: your client’s problems have often become so well entrenched that he is unable to deal with them independently, and this means that change is likely to be difficult. As a result, he may experience a range of unhelpful emotions and thoughts while struggling to deal with his problems.
Signs of a rupture in the therapeutic alliance
These may be reflected in non-verbal cues from your client related to emotional states such as discomfort, anger or mistrust; or feelings experienced by you as therapist. There may also be outward signs, such as not carrying out homework tasks, expressing scepticism about the approach, or high levels of expressed emotion. The important issue is to be mindful of the quality of the interaction between you and your client, so that you can take early steps to intervene when difficulties arise. Do not ignore it and hope that it will go away.
How to deal with ruptures in the alliance
Watson and Greenberg (1995) point out that ruptures can be related to:
- the goals or tasks of therapy (for example, the client does not understand or agree with the goals or strategies used in treatment);
- the client–therapist bond (for example, the client is not collaborative, or does not trust or respect the therapist).
They argue for dealing with the former problems by approaching them directly, e.g. by clarifying the rationale for treatment, or possibly changing the approach. For example, if the client believes that reducing avoidance is important but does not believe that reducing safety behaviours (see Chapters 4 and 13) would be helpful, it may be best to switch in the short term to reducing avoidance, possibly moving on to a behavioural experiment to investigate the role of safety behaviours once he has exhausted the contribution of avoidance (if there is any remaining problem!).
If the rupture in the alliance seems to be related to your bond with the client, first deal with this within your current therapeutic relationship, without assuming that the problem is a reflection of your client’s characteristic interpersonal relationships.
A woman became very irritated when the therapist had to change an appointment. The therapist commented on this, and sought to clarify what had triggered the angry feelings. It transpired that the client was feeling let down, because it seemed to her that she must be of very low priority to the therapist. When she was asked to consider other possibilities, she asked the therapist to explain why she could not make the original appointment time. At this point, the therapist chose to reveal that she was going to a family funeral, and that it was only in such circumstances that she would change an appointment. They then discussed what the client could take away from this experience, and if it told her any more about how to respond to unpleasant feelings. She said that she would continue to try to check out whether her initial responses were likely to be accurate, or whether other explanations could be relevant.
If such work is unsuccessful, or if the formulation indicates that the client may, for example, find it difficult to trust anyone, then it may be necessary to consider the rupture as a characteristic pattern and to use the therapeutic relationship to provide the client with a corrective emotional experience (Safran & Muran, 1995).
Newman (1994) makes the point that you should consider what contribution you are making to any therapeutic impasse, rather than assume that the problem always resides within the client:
A woman with health anxiety was making little consistent progress, despite a formulation that apparently accounted well for her problem, and her commitment to homework tasks. The therapist was aware that the client frequently had moist eyes, but she always denied that she was upset when the therapist questioned her about it. In supervision, the therapist became aware that she was reluctant to discover that the client had the potential for becoming very upset, because the client was slightly histrionic in style, and the therapist had automatic thoughts about being ‘washed away’ by the woman’s distress. As a result, she always asked the client about her feelings in a neutral voice, and never reflected her own perception of the woman’s sadness. Not surprisingly, the client did not feel able to share her feelings with the therapist, and denied that she was upset.
If it seems that the therapeutic relationship is being affected by your own issues or blind-spots, then you can discuss this with a supervisor; if this is not immediately available, then take the opportunity to do some work yourself: for example, listen to recordings of your treatment sessions, keep a thought record of your NATs in session, do a downward arrow for any hot thoughts. This can be interesting and enlightening; self-supervision is discussed in more detail in Chapter 19.
If it seems that the impasse is related to your client’s issues, then, rather than viewing this as an indication of poor motivation or ambivalence, it is more useful to formulate the issue in the same way as any other problem. For example, you could consider:
- what function the behaviour may have (e.g. if the client is hostile, he may be protecting himself against feared rejection);
- what idiosyncratic beliefs may be fuelling the impasse (e.g. the client may believe that a competent therapist would be able to read his mind);
- what fears the client may have about complying (e.g. if he were to change, he may be faced with challenges he could not tackle);
- what skills he may lack (e.g. he may be unable to reflect on his emotional experience);
- what environmental features may be contributing (e.g. he may be exhausted through caring for an elderly mother).
The problem can then be tackled in CBT in the same way as other problems. This could include:
- revisiting the formulation and rationale;
- using Socratic method to clarify the issues;
- collaborating and providing choices, while providing structure, limits and guidance;
- reviewing the pros and cons of change versus no change;
- communicating with the client’s language, metaphors or images;
- gently persisting when the client subtly avoids – don’t take ‘I don’t know’ for an answer;
- maintaining an empathic attitude, and avoiding blaming or making negative interpretations of your client’s behaviour.
Again, we remind budding CBT therapists that effective clinical supervision (see Chapter 19) will be as invaluable for them in tackling this kind of problem as it would be for the highly experienced. If a supervisor is not available at the time, then reflect on the issue by yourself, as discussed above.
Working with clients from different cultural backgrounds
Another important area to consider is broadly that of cultural differences. Here we shall think about some general aspects of working with clients whose ethnic backgrounds differ from the therapist’s. Many of the same principles can be applied when working with people differing in physical ability or sexual orientation, as well as age and social class, insofar as their cultural experiences are different.
Although approximately 10% of the UK population belongs to an ethnic minority group, there is a marked homogeneity among therapists, who are predominantly from the dominant white culture. As a therapist you need to be mindful that your perspectives and beliefs are probably grounded in that culture. It is therefore important that you try to learn about the alternative beliefs of clients from other groups, so that you do not fail to consider issues and questions potentially important for your clients.
It is worth bearing in mind that the dominance of the white British perspective in CBT is not limited to therapists, but shared with society in general. It is easy to take for granted the emphasis on the autonomy of the individual rather than on the value of collectivism, or on assertiveness rather than on compromise or subjugation of one’s own needs; but if you are working with someone from a different cultural group, then you need to be aware that they may hold different views which would be supported by others in their community. It is especially important that you are aware of your own blind spots and areas of prejudice. For example, is the trouble at work which your client is describing an accurate description of racism, rather than the distorted thinking that you were planning to guide him through? Is this woman’s submissive attitude towards her family a reflection of cultural norms rather than low self-esteem?
There are many ways of gaining information about different cultures. There are now an enormous number of books about ethnic and cultural minority groups (Hays, 2006, gives an extensive bibliography), but there are many other ways to gain relevant knowledge; for example:
- read newsletters etc from the groups themselves;
- seek supervision from someone from the relevant group;
- attend cultural celebrations and other events organised by different communities (e.g. Gay Pride Marches, or a local Carnival);
- read the historical accounts of the arrival and integration of any ethnic groups, about legal decisions concerning them.
The dominant cultural message will otherwise colour our understanding of the experiences of members of other groups, and we shall maintain our ignorance of how it is for them.
Is it worth the effort? There is disappointingly little research about the efficacy of CBT with groups other than Western white ones, but there is a growing body of evidence about how cross-cultural competence in the therapist may facilitate psychotherapy and improve assessment (Hays, 2006). We will first consider issues of engagement at the assessment stage, and then go on to think about more general ideas about modifying CBT for use in different client groups.
Engaging your client
During an assessment, it is essential that you begin to engage your client. An important bridge in building a good working relationship is demonstrating your respect of his culture. If you bear in mind that the dominant culture will often by implication denigrate alternative views of the world, it will be apparent that you need to pay explicit attention to, and genuinely value, the positive aspects of the different culture; this could be, for example, spirituality, sense of humour, or the involvement of children in family events within the group.
Acknowledgement of the environmental setting in which the client finds himself will contribute to this. Your client’s problems may present in an adverse environmental setting (for example, poor housing or difficulties accessing benefits), but there may also be positive features (for example, an active church/mosque or community facility) which you should overtly note. Interpersonal supports may be very strong, and different from those in the dominant culture; or there may be an important extended family, possibly including aunts and uncles from a broader base than blood relatives, whose views about, and response to, his problem may be more important in its maintenance than would be typical in the dominant culture. Furthermore, if the client has a positive racial or ethnic identity, this is often associated with positive self-esteem, lower levels of loneliness, anxiety and depression, and improved mastery, optimism, and coping, and this may be worth including in the formulation if it is indeed an asset for your client.
On the other hand, distress caused by racism and discrimination figures highly in the reasons that people from minority groups seek help (see for example, Kelly, 2006), and may also contribute to low self-esteem. It is therefore important to acknowledge what the experiences are, and not to assume that the distress is a result of distorted perception or other cognitive error. As far as your working alliance is concerned, your client’s previous experiences may, for example, result in her being reluctant to see a white therapist or a male therapist or in being hostile if she does; acknowledging this as an understandable position may be a necessary step in forming a working alliance.
It is also important to understand how the client’s background will have been crucial in the development and maintenance of assumptions and beliefs; for example, the client’s beliefs about the importance of personal privacy as opposed to the value of openness about one’s feelings may be shared by most people in his community.
Clearly, no ethnic or other minority group is homogeneous, and the idiosyncratic experiences and beliefs of the individual are as important as for people of the dominant culture. For example, skin colour (such as being more or less black) may partly determine the kind of racism suffered by someone, but may also contribute to self-esteem and status within the minority group. More specific experiences of racist behaviour may account for beliefs that have a direct impact on therapy; for example, the client may repeatedly turn up late for sessions because she believes that the therapist would not hesitate to keep her waiting.
An important dimension to consider is acculturation, the extent to which the client has adopted the dominant culture (including beliefs about self and the world), or remains within his indigenous culture. It is as important as ever, throughout the assessment, to listen to the idiosyncratic detail of what the client is reporting, and not to be blinkered by pre-conceived beliefs of your own.
It is helpful to be open about the issues of race/ethnicity/minority status. Questions like ‘Are there aspects of your race and culture that are important for me to know in order for us to work together?’ or ‘Are there any religious or spiritual beliefs that are important for you to tell me about?’ can demonstrate your interest and potential respect.
The client’s understanding of the nature of his problem, and what he expects of the therapeutic relationship therapist may be different from yours, and ways of modifying how you work with this will now be considered.
Ways of modifying CBT for use with people from different cultural groups
Enhancing the therapeutic relationship
Many of the distinctive characteristics of CBT mean that it is easily generalisable to clients from different cultures, and allows a good working relationship to be maintained. For example, CBT aims to adopt a non-judgemental stance; there is an emphasis on tailoring treatment to the individual; it is a collaborative approach where the client’s perspectives on and knowledge about his problems are respected and valued; and it aims to be empowering and to equip the client with transferable skills.
However, in working cross-culturally, it is important that the therapist demonstrate her credibility for the client. This can partly be achieved by showing respect for the client and his culture, but it will also be useful to demonstrate that she has something to offer – which may mean that it is important that she begins to work on a goal where a good outcome could be quickly expected.
Having a therapist who validates their experiences will help clients maintain a good working relationship, and may reduce the high drop-out rate which may otherwise bedevil working with minority groups (Hays & Iwamasa, 2006). It is therefore important, for example, not to discount reports of discrimination as necessarily distorted, whether arising from ethnicity, sexuality, physical disability, or other group difference. By the same token, by developing a genuine curiosity about the value of differences between groups, you will be showing respect for the other culture, and increasing the strength of your relationship.
Dealing with different belief systems
Although CBT is generalisable to other cultural groups, there are no grounds for complacency; there are limitations in the approach. CBT is non-judgemental as long as the therapist is aware of the frames of reference that he is operating in, and is not blind to his own underlying beliefs. For example, the approach is predicated on empiricism and rationality, which implicitly devalues the spirituality that may be central to the world view of other groups. However, as idiosyncratic beliefs about oneself and the world have primacy within CBT, it should be ideally placed for working across cultural boundaries.
When a client and therapist have different beliefs about the nature of the problem, it is helpful to acknowledge the differences, and if possible work with the CBT model in parallel with the client’s model, hopefully demonstrating the usefulness of the CBT approach.
An Asian client who was highly educated and had lived in UK for 25 years presented with reduced motivation and enjoyment, social withdrawal, inactivity, neglect of himself and his work, and self-criticism and hopelessness. Although he had been diagnosed as depressed, he did not agree with this diagnosis, and would not take medication. He believed that the problem was that he had fallen out of love with his wife of 20 years, and that without a woman behind him, life had no meaning and he could have no motivation. This understanding of the problem was shared by his uncle and a friend, and so appeared to be culturally acceptable.
It was agreed with the therapist that he would work on increasing his social activity, and on pleasure and enjoyment of everyday activities, in order to improve his chances of finding a new partner. The therapist explained that in CBT terms this approach might lead to improvement in his mood and level of motivation. As his social activity improved, his general level of activity increased. Time was also spent on identifying negative automatic thoughts about being unable to initiate action on his own behalf, and he reported that he was feeling better in himself. It was important for the therapist to give the client’s theory the benefit of the doubt, and to try to test out its usefulness using a well-developed CBT strategy.
Similarly, in clients who present with somatic complaints, it can be helpful to adopt a two-stage approach, where the focus in the first stage is on the presenting physical symptoms. When you have a clear understanding of the nature of the problem, you can move on to stage two, which involves linking the physical complaint to the other three systems familiar in CBT – emotions, cognitions and behaviour. Naeem, Phiri, Rathod and Kingdon (2010) described this approach with a woman who had headaches: once the therapist had made it clear in the first two sessions that he understood the nature of the headache, he then linked it to the emotional and physiological changes that can be associated with headaches, and how they might be tackled, for example using relaxation.
In addition to differences in belief about the nature of the problem, the same can be true of beliefs about the therapeutic process and relationship. For example, be aware that some cognitive errors, such as black and white thinking, or perfectionism, may be unfamiliar to your client. As usual, check out with your client whether you are making sense and whether what you are doing fits with his experience.
Some clients may find the collaborative nature of the therapeutic relationship surprising and unwelcome, and may expect (and prefer) the therapist as expert. Asking questions, or challenging you (as a perceived authority figure), may be unacceptable in some cultural groups, and you may need to take special care when trying to get feedback, or to find out if the formulation or homework makes sense. You can in this instance ask positive questions such as, ‘What did you find helpful about today?’ ‘Are there particular things that you would like to focus on more?’, which do not imply criticism of the therapist. The more general point is that it is important to look out for any ruptures in the therapeutic relationship, and to bear in mind that a belief about the therapeutic process may be implicated.
At a more concrete level, there are a number of practical difficulties that may interfere with psychotherapeutic effectiveness. These include ones relating to language and literacy, and non-verbal social behaviours.
As CBT relies so heavily on unpicking the meaning of experiences, it is crucially important that differences in language between client and therapist, and their relation to experience, do not lead to misunderstanding. The ways in which concepts relate to each other differ from language to language, and the straightforward translation of ideas might not be possible. For example, the Greek language has three different words for love (sexual love, brotherly love, and unconditional love) which are less finely differentiated in English (Iwamasa, Hsia & Hays, 2006). It is particularly important therefore to check out with your client that you seem to have understood what was being said. The preference for using the client’s own words when summarising what she has said is therefore particularly germane in cross-cultural work.
In its most extreme form, it may sometimes be necessary to involve an interpreter in therapy sessions, though this merits careful consideration (Ardenne & Farmer, 2009) in order to ensure the following:
- The interpreter is sufficiently psychologically minded.
- There is opportunity for minimal training in CBT working, for example to clarify that summaries, as opposed to a more detailed translation of what the client has said, are not adequate.
- Protection for the interpreter from vicarious traumatisation/despair.
- Acceptability of the interpreter to the client. This can be an issue if there are few people locally who speak the client’s language, but care should be taken to establish acceptability, particularly if a family member, or other known member of the client’s community is being offered as interpreter.
- The interpreter understands the importance of confidentiality.
Reading and writing skills may not be well-developed in some groups, so be creative. For reading, make as much use as possible of translated material, or audio tapes or CDs. MP3s, mobile phones, or digital recorders can be used to record NATs, and to record sessions. Beads or counters are commonly used in counting in some cultures, and may be more familiar than a knitting or golf counter. You may find that your client is more familiar with new technology than you are, so do not be reluctant to suggest cutting edge strategies, but ask for his help when devising measures or homework aids.
Non-verbal and social behaviours differ between groups, and it would be worthwhile becoming familiar about typical behaviour if you were working frequently with one cultural group. For example, smiling can have very different meanings in different groups.
There are suggestions for reading some more detailed material at the end of the chapter, which gives specific information about different ethnic minority groups. The most important sources of information however probably lie in your local communities.
We will now turn to considering issues about boundaries in CBT.
‘[Keep] far from all intentional ill-doings and all seduction, and especially from the pleasures of love with women and men.’
The Hippocratic Oath
The relationship between therapist and client is different from other social relationships, and boundary issues need careful and serious consideration in CBT, just as they do in other approaches. Treatment boundaries provide a framework for appropriate roles for the therapist and client, and include structural components – such as where, when and at what cost – as well as what happens in the therapy between the therapist and client. The main governing principles are common to all therapeutic encounters:
- The client’s needs must have primacy.
- Gratification of the therapist’s needs (beyond professional satisfaction) is excluded from consideration in the therapeutic setting.
Therapeutic boundaries are set in such a way that the client can:
- feel safe;
- trust the therapist to act in his interest;
- feel free to disclose material of deep personal significance;
- be confident that he understands the therapist.
In addition, the therapist must also feel safe, by ensuring that there are sensible policies about the kinds of referral accepted; assessments include a consideration of risk; and the physical location and arrangement of the clinic/sessions takes account of safety.
The following guidelines for appropriate boundaries within CBT may be useful:
- Refrain from self-seeking or personal gratification.
- Maintain confidentiality unless it involves a significant risk to the safety of the client or others.
- Evaluate the effect of a boundary violation on the client. Rather than adopting an absolute rule like ‘never accept a gift’, consider the impact of such behaviour on the client and the therapeutic relationship.
A gift of a jar of home-made chutney from one client could mean that a further attempt was being made to identify the therapist as a family friend; while for another it may mean that the client was at last beginning to see himself as an independent adult, equal in the relationship.
- Make choices about boundaries that minimise the risk of harm to the client. This means only departing from ordinary clinical practice when it will clearly benefit the client.
A behavioural experiment with a socially anxious man took place in a coffee shop. Part of the experiment involved complaining that the coffee was too cold. The therapist did the task initially, and as part of this, he had to disclose to the client how self-conscious and anxious he felt. Although that was crossing the more usual boundary re disclosure of feelings, it was definitely in the interests of the client.
- Do not express opinions about, or otherwise interfere in, aspects of the client’s life other than those relevant to the formulation and goals of therapy. If your client sought help for his panic attacks, bear that in mind when he begins to tell you about the way his child’s school is dealing with the child’s frequent absences – unless it relates to his panic attacks, do not give your advice or opinion, or share similar experiences.
- Seek to increase the client’s independence and autonomy, hence increasing his freedom to explore and the choices available to him.
Maintaining treatment boundaries
The therapeutic relationship is non-reciprocal in a number of ways, putting the therapist in a powerful role, even in the relatively collaborative mode of CBT. This non-reciprocity includes:
- extensive self-disclosure by the client, with almost total non-disclosure of significant material by the therapist;
- the emotional neediness of the client, compared with the exclusion of any of the therapist’s emotional needs;
- the power attributed to healers in many societies in order for them to reduce suffering and restore health.
Crucially, maintaining appropriate boundaries is the responsibility of the therapist: it is never reasonable to blame the client for infringements. The maintenance of boundaries is unequivocally your responsibility, whatever the behaviour of the client, so it is incumbent on you to seek sufficient supervision and support if you are concerned about boundaries. In rare cases (such as clients with sociopathy) it may be necessary to terminate therapy if the client cannot maintain reasonable boundaries even with coaching and encouragement.
Although the power differential between therapist and client is generally acknowledged, some therapists have felt exploited by their clients. For example, Smith and Fitzpatrick (1995) described reports of clients with severe or borderline personality disorders forming ‘special’ relationships with their therapists, where contact outside the therapy became established. Some therapists have blamed clients for ‘leading’ them into flagrant boundary violations. You might find yourself potentially over-involved with, and feeling manipulated by, your client; but you must be alert to this and be prepared to discuss the situation with both the client and other professionals.
It is sometimes argued that the nature of the transference relationship means that the client may seek the fulfilment of needs arising from unresolved conflicts, and that boundaries must therefore be very strictly enforced and contained by the therapist. Transference in this psychoanalytic sense is not part of CBT theory, so although some boundaries are important (as discussed in this section and below), such strict adherence to inflexible boundaries is not necessary in all aspects of therapy. For example, if a client has to postpone a session for some reason, this would usually be accepted by the therapist and would only be considered to be resistance if it happened repeatedly, with no other explanation.
Effective CBT may mean that you need to visit your client at home, possibly at unusual times of the day. For example, a client with obsessional rituals that are preventing him from starting the day may need visiting first thing in the morning. Do not undertake this lightly. Consider whether you should put safeguards in place to reduce the possibility of misinterpretations of your behaviour by the client: for example, an assistant could be taken along for a home visit or a relative included in the setting-up of the session.
You might need to accompany clients into a range of everyday situations, for example in order to do behavioural experiments. Personal feelings may even be disclosed, if this is appropriate to the on-going task.
A socially anxious man had fears about sweating heavily, particularly in cafes and bars with bright lights. The therapist arranged to have a couple of treatment sessions in a bright cafe. The therapist wet his face, his back, and arm-pits to look as though he was sweating heavily, and the client sat nearby, and observed the responses of the waitress and other people to the therapist. The client then asked the therapist what thoughts were going through his head, and how he felt in the situation.
It is helpful to make the aims of such sessions very explicit, by spending time agreeing what predictions are being tested out, how the experiment will be carried out, and so on (see Chapter 9). This makes good technical sense and it also sets boundaries for the session, making it clear that this is a treatment session with a specific purpose, and not a social event. This can be difficult for some needy clients to understand, especially if the therapist contact is the only social event of the week.
A woman with obsessional problems was finding it difficult to test out the effects of exposure and response prevention on her fears of pushing people off the pavement into the path of cars. The therapist and client therefore spent two lengthy sessions walking in crowded streets, busy with cars. Although they planned what specific ‘tasks’ she should do as they walked along, and discussed changes in her distress level as she walked past people near the edge of the pavement, they nevertheless had quite long periods of time when they were not specifically addressing the problem. The therapist then discussed general topics of a non-emotional and relatively non-personal nature, like annual holidays, but continued to be mindful of the nature of any disclosure and its possible impact on the client.
Finally, the open, collaborative style of CBT can sometimes be compromised if the therapist is involved in a compulsory admission to an institution. The repercussions can be minimised if you discuss it openly with the client, including what it meant to him, and any associated misperceptions, either beforehand or after the crisis has resolved.
Kinds of boundary violation
Although there is a continuum of boundary violations, any straying over boundaries should be done in awareness of the principles sketched out earlier in this chapter. There are particular kinds of violation that are worth specific consideration.
Dual relationships, where the therapist and client are in a second relationship in addition to the therapeutic one: for example, being school governors together. Although therapists are usually advised against such dual relationships, it is sometimes difficult to avoid them. If a therapist lives in a small community, for example a rural setting or an academic group, then barring her from treating all those with whom she had an existing relationship might mean that they have no access to treatment at all. Similarly, if you are involved in groups related to your political, religious, ethnic or sexual identity, then dual relationships may be inevitable as people tend to seek out a therapist with similar values to themselves. In addition, despite ethical guidelines prohibiting dual relationships for therapists, it is not uncommon for therapists to accept invitations to, for example, a client’s special event.
It may be possible to differentiate those dual relationships that are harmful to the client or therapy from those that are innocuous. Gottlieb (1993) suggested that the therapist should consider the other (non-therapeutic) relationship along three dimensions – power, duration and whether the other relationship had a planned finite end – with risk to the client increasing with increasing values on any of the three dimensions. You should be mindful of such factors before entering into a dual relationship.
A therapist decided to join the only choir in her small local town, even though she knew that a current client was in the choir. This meant that the client would see her with her friends, possibly being picked up by her husband, and with opportunities for casual interactions in the ten weeks that the choir was planned to rehearse. This was deemed to be acceptable, given there was no other choir available, and the therapist was a musical enthusiast. It would probably not have been acceptable had the client been the conductor, for example, where role reversal could have become an issue.
Self-disclosure would almost always be seen as inappropriate in psychodynamic therapy or counselling, but there is a less rigidly drawn line within CBT. Self-disclosure can be useful if it is done with the client’s interests in mind. For example, a therapist could disclose information about a past problem of her own that she had overcome, in order to increase the client’s hope for improvement and confidence in the proposed method. Beck et al. (1979) suggested that it is may be appropriate to use self-disclosure with more severely depressed clients, as this may facilitate their engagement in treatment. It would probably never be helpful to describe current problems, whether psychological or financial, social or sexual, to a client: he can reasonably expect that the focus should be on his own problems.
It may sometimes be necessary to disclose personal details to a client – for example, illness in the therapist or her family, or pregnancy – if the circumstances are likely to have an impact on the delivery of treatment. But judgements of this kind may be less clear-cut than they seem, and you should make use of supervision if you have concerns about sharing such information.
A young client in her twenties was discussing whether to try to forgive her emotionally abusive mother. Her therapist had been recently bereaved, and was grieving for the close supportive relationship that she had had with her own mother. In the course of the session, the client said to the therapist, ‘I feel that you really want me to make moves towards my mother’, and the therapist became aware that she had too much emotional involvement in the client achieving that closeness for herself. Supervision confirmed that disclosure would not be in the client’s interest, as the therapist’s own issues were not resolved.
Non-sexual physical contact may feel comfortable to some therapists, who would give a distressed or frightened client a reassuring pat, but they may still confine this to clients of the same gender as themselves. However, never underestimate the potential for clients to misinterpret such actions. Departures from normal practice should not be made casually – always be aware and mindful of your client’s formulation. For example, a touch on the arm could be alarming to someone with a history of abuse, who has rules about maintaining her distance from people; while a pat on the leg could be misinterpreted as sexual by a client longing for physical closeness to another person, especially someone showing unconditional warmth and empathy. A useful way to deal with this is to find a time when your client is calm and to ask him how he would like you to react when he is highly distressed. For example, you could say:
You were obviously very distressed when we were talking earlier. I wonder how I could be most help at times like that. Some people like to simply express the feelings, and to deal with it themselves; others may find a little pat on the arm comforting. Is there any particular way you would like me to react?
Obviously such discussion must be constrained by what you feel is right for your own therapeutic boundaries.
Pope, Tabachnick and Keith-Spiegel (1987) reviewed three kinds of physical contact between therapists and clients and found that a sizeable minority of therapists had experience of each kind of touching. According to a survey of therapists, the least unacceptable was shaking hands with the client; that was practised often by 76% of therapists and was generally seen as ethically acceptable. Hugging was considered acceptable in some circumstances by 44%, but was only practised regularly by 12%. Kissing was seen as unacceptable or rarely acceptable by 85% of therapists, and was practised only infrequently by 24% and never at all by 71%.
The distinction between erotic and non-erotic physical contact falls along a continuum: it is not ‘all or nothing’. Cultural influences are relevant here: in many European and South American cultures, kissing on both cheeks is a customary form of greeting and may be only rarely interpreted as erotic, even in a therapy situation. Holding back from kissing could be seen by some clients as distant and aloof. In other words, the therapist has to draw boundaries flexibly and sensitively and cannot simply use rules about proscribed behaviour.
Sexual relationships between therapist and client are the most harmful kind of boundary violation, with possible negative impacts on vulnerable individuals, as well as damage to the therapeutic relationship. It is difficult to get data on the frequency of such behaviour, and estimates of the number of therapists who have had sexual intercourse with at least one client range from 1% to 12%, but these are likely to be underestimates because of the compelling reasons for therapists to conceal the behaviour. There is an extensive literature on the harmful effects on clients of such boundary transgressions (Pope & Bouhoutsos, 1986), and some authors have suggested that in such cases the therapist should be charged with rape, since the client could not be capable of informed consent within that relationship.
Therapists who engage in sexual behaviour with clients tend to gradually blur boundaries rather than suddenly descend into inappropriate behaviour. Inappropriate self-disclosure, rather than other boundary violations, tends to precede sexual transgressions (Simon, 1991). Sexual violation of boundaries appears to be more common among middle-aged male therapists who are professionally isolated and currently experiencing personal problems, often including marital problems. They typically begin to cross appropriate boundaries by discussing their own problems with younger, female clients (Gabbard, 1991).
It is therefore incumbent on you as therapist to be aware of any gradual change in boundaries with any particular client, and to raise this with your supervisor if it seems that your relationship may be subtly changing. It may seem that your client’s needs may be best met via a relationship different from a typical clinical one, but in that case, discuss it openly with your supervisor, to protect both yourself from allegations by a client who may possibly misinterpret your motivation, and your client from possible abuse. Another sensible rule of thumb is that in situations where there is a grey area, it is probably in the interests of both client and therapist to err on the side of caution.
A good working alliance between you and your client is an essential component of successful CBT, without which the sophisticated models of CBT would be irrelevant. The following principles are useful:
- Establish a good relationship early in therapy, then be aware of the quality of the relationship throughout treatment, and attend to any developing problems between you and your client.
- The therapeutic relationship can be seen as a laboratory where problems can be worked on.
- Many of the cardinal features of CBT, such as collaboration, active participation, use of guided discovery and so on, contribute to the development of a good working relationship.
- The therapist’s role in CBT is to be a guide, who is genuinely curious and respectful about the client’s perspectives, aiming to broaden the range of possibilities open to him.
- The Rogerian characteristics that typify good therapy in other approaches are equally important in CBT.
- If there are disruptions in the therapeutic relationship, these are construed in cognitive behavioural terms, and dealt with in the here and now, in terms of the immediate situation; only if this is unsuccessful is the disruption dealt with as a more enduring characteristic.
- Consider your own possible contribution to a breakdown in the relationship with our client.
When working with clients from different cultural backgrounds:
- Remember that your perspectives on events are likely to be grounded in the dominant culture, and different from those of other groups.
- Find out about the different groups with whom you work.
- Be aware of your blind spots as far as your beliefs are concerned.
- Focus on engagement and developing a good therapeutic alliance with an emphasis on:
o showing respect for your client’s culture
o acknowledging the difficulties he may face through discrimination
o being open about issues to do with race/minority status.
In order to work cognitive behaviourally with different groups:
- Remember that CBT translates well to different belief systems.
- Demonstrate your credibility early on.
- Acknowledge if there are differences in belief about the nature of the client’s problems.
- Be aware that there may be differences in beliefs about the therapeutic relationship; and also about cognitive processes.
There may be practical difficulties, for example in language and literacy, which may need to be creatively tackled.
Boundary issues need careful consideration in CBT, particularly as clinical contact may be in unusual places, at unusual times. The major principle is that the client’s needs are of prime importance.
- Three specific boundary issues were considered. These were:
o dual relationships
o physical contact.
Make use of supervision if you are concerned about a boundary issue.
Review and reflection:
- What are your reactions to reading about the therapeutic relationship in CBT? Are you surprised or reassured by anything you have read?
- If you have worked in other ways, in what ways do you behave differently in CBT therapy compared with your work in other modalities? In what ways are there similarities? In what ways would it be helpful to change?
- If you notice a disruption in your relationship with a client, what physiological or cognitive cues in yourself alerted you to it?
Taking it forward:
- Find a client who is not very actively engaged in the session, for example, frequently responding ‘I don’t know’. Think about the pros and cons of commenting directly on this, as opposed to trying to encourage him to be more active, without explicitly addressing the issue. Try to explicitly follow up the issue of inactivity, in order to test out whether the pros and cons that you listed were relevant.
- Find a client with whom you feel that boundaries are an issue. Reflect on the ways in which they are being stretched, and on what has contributed to the difficulties in maintaining more typical boundaries.
- If this chapter has raised issues for you, discuss them with your supervisor.
Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.
This classic text describes clearly a style of therapeutic relationship which, as they say, facilitates effective treatment.
Gilbert, P., & Leahy, R. (Eds.). (2007). The therapeutic relationship in the cognitive behavioural psychotherapies. Hove: Routledge.
The most comprehensive collection of CBT views on the therapeutic relationship.
Hays, P.A., & Iwamasa, G.Y. (Eds.). (2006). Culturally responsive cognitive behaviour therapy. Assessment, practice and supervision. Washington, DC: American Psychological Association.
This book has detailed advice about working with different cultural groups. All of the examples are American, but they give a good feel for the dimensions of difference.
Safran, J.D., & Segal, Z.V. (1990). Interpersonal process in cognitive therapy. New York: Basic Books.
An interesting book with interesting ideas about tackling difficulties in the therapeutic relationship.
Padesky, C.A., & Greenberger, D. (1995). Clinician’s guide to mind over mood. New York: Guilford Press.
This book has some specific ideas on working with minority groups of different kinds.