Skip to main content

Defining the Role and Function of the Therapeutic Relationship in Cognitive Behavioral Therapy: a Modified Delphi Panel

Abstract

While it is accepted that therapeutic relationship is a necessary condition for cognitive behavior therapy (CBT), the way a therapist adapts to that relationship based on the case formulation has not been clearly articulated. In addition, the direct effects of the therapeutic relationship and its elements require further empirical study. Achieving expert consensus on the roles and function for the therapeutic relationship is important for training, supervision, accreditation, as well as the next generation of research examining whether treatment processes are wholly or partially dependent upon in-session processes. This article summarizes the findings, conclusions, and recommendations of an expert panel on these features of the therapeutic relationship in order to identify potentially fruitful avenues for future research.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

References

  1. American Psychological Association, Task Force on Evidence-Based Therapy Relationships. (2011). Conclusions and recommendations of the interdivisional task force on evidence-based therapy relationships. Retrieved from http://www.divisionofpsychotherapy.org/continuing-education/task-force-on-evidence-based-therapy-relationships/.

  2. Asnaani, A., & Hofmann, S. G. (2012). Collaboration in multicultural therapy: Establishing a strong therapeutic alliance across cultural lines. Journal of Clinical Psychology, 68(2), 187–197.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., Sauer-Zavala, S., Bentley, K. H., Thompson-Hollands, J., Conklin, L. R., Boswell, J. F., Ametaj, A., Carl, J. R., Boettcher, H. T., & Cassiello-Robbins, C. (2017). The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: a randomized clinical trial. JAMA Psychiatry, 74(9), 875–884. https://doi.org/10.1001/jamapsychiatry.2017.2164.

    Article  PubMed  Google Scholar 

  4. Beck, A. T., Rush, A. J., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.

    Google Scholar 

  5. Brady, J. P., Davison, G. C., Dewald, P. A., Egan, G., Fadiman, J., Frank, J. D., et al. (1980). Some views on effective principles of psychotherapy. Cognitive Therapy and Research, 4, 271–306.

    Article  Google Scholar 

  6. Braun, J. D., Strunk, D. R., Sasso, K. E., & Cooper, A. A. (2015). Therapist use of Socratic questioning predicts session-to-session symptom change in cognitive therapy for depression. Behaviour Research and Therapy, 70, 32–37.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Cameron, S. K., Rodgers, J., & Dagnan, D. (2018). The relationship between the therapeutic alliance and clinical outcomes in cognitive behaviour therapy for adults with depression: a meta-analytic review. Clinical Psychology & Psychotherapy. https://doi.org/10.1002/cpp.2180.

  8. Castonguay, L. G. (1993). “Common factors” and “non-specific variables:” clarification of the two concepts and recommendations for future research. Journal of Psychotherapy Integration, 3, 267–286.

    Article  Google Scholar 

  9. Clark, D. A. (2013). Collaborative empiricism: a cognitive response to exposure reluctance and low distress tolerance. Cognitive and Behavioral Practice, 20(4), 445–454.

    Article  Google Scholar 

  10. Clark, D. M., Canvin, L., Green, J., Layard, R., Pilling, S., & Janecka, M. (2017). Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data. Lancet. https://doi.org/10.1016/S0140-6736(17)32133-5.

  11. Dattilio, F. M., & Hanna, M. A. (2012). Collaboration in cognitive-behavioral therapy. Journal of Clinical Psychology, 68(2), 146–158.

    Article  PubMed  Google Scholar 

  12. DeRubeis, R. J., Brotman, M. A., & Gibbons, C. J. (2005). A conceptual and methodological analysis of the nonspecifics argument. Clinical Psychology: Science and Practice, 12, 174–183.

    Google Scholar 

  13. Felder, J. N., Dimidjian, S., & Segal, Z. (2012). Collaboration in mindfulness-based cognitive therapy. Journal of Clinical Psychology, 68(2), 179–186.

    Article  PubMed  Google Scholar 

  14. Friedberg, R. D., & Gorman, A. A. (2007). Integrating psychotherapeutic processes with cognitive behavioral procedures. Journal of Contemporary Psychotherapy, 37, 185–193.

    Article  Google Scholar 

  15. Froján-Parga, M. X., Calero-Elvira, A., & Montaño-Fidalgo, M. (2011). Study of the Socratic method during cognitive restructuring. Clinical Psychology & Psychotherapy, 18, 110–123.

    Article  Google Scholar 

  16. Gilbert, P., & Leahy, R. L. (Eds.). (2007). The therapeutic relationship in the cognitive behavioral psychotherapies. New York: Routledge.

    Google Scholar 

  17. Goldfried, M. R., & Davison, G. C. (1976). Clinical behavior therapy. New York: Holt, Rinehart, & Winston.

    Google Scholar 

  18. Greenberg, L. S., & Warwar, S. H. (2006). Homework in an emotion-focused approach to experiential therapy. Journal of Psychotherapy Integration, 16(2), 178–200.

    Article  Google Scholar 

  19. Hayes, S. C., & Hofmann, S. G. (2017). The third wave of CBT and the rise of process-based care. World Psychiatry, 16, 245–246. https://doi.org/10.1002/wps.20442.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Hayes, S. C., & Hofmann, S. G. (2018). Process-based CBT: the science and core clinical competencies of cognitive behavioral therapy. New Harbinger: Oakland CA.

    Google Scholar 

  21. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: an experiential approach to behavior change. New York: Guilford.

    Google Scholar 

  22. Heiniger, L. E., Clark, G. I., & Egan, S. J. (2018). Perceptions of Socratic and non-Socratic presentation of information in cognitive behaviour therapy. Journal of Behavior Therapy and Experimental Psychiatry, 58, 106–113. https://doi.org/10.1016/j.jbtep.2017.09.004.

    Article  PubMed  Google Scholar 

  23. Heyes, M. E., Schnitzen, L., et al. (2018). Recertification and reentry to practice for nurse anesthetists: determining core competencies and evaluating performance via high-fidelity simulation technology. Journal of Nursing Regulation, 8(4), 43–55. https://doi.org/10.1016/S2155-8256(17)30181-3.

    Article  Google Scholar 

  24. Hofmann, S. G., & Barlow, D. H. (2014). Evidence-based psychological interventions and the common factors approach: the beginnings of a rapprochement? Psychotherapy, 51(4), 510–513. https://doi.org/10.1037/a0037045.

    Article  PubMed  Google Scholar 

  25. Holmes, E. A., Ghaderi, A., Harmer, C. J., Ramchandani, P. G., Cuijpers, P., Morrison, A. P., Roiser, J. P., Bockting, C. L. J., O'Connor, R. C., Shafran, R., Moulds, M. L., & Craske, M. G. (2018). The lancet psychiatry commission on psychological treatments research in tomorrow’s science. The Lancet Psychiatry, 5(3).

  26. Horvath, A., Del Re, A., Fluckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9–16. https://doi.org/10.1037/a0022186.

    Article  PubMed  Google Scholar 

  27. Huppert, J. D., Roth Ledley, D., & Foa, E. B. (2006). The use of homework in behavior therapy for anxiety disorders. Journal of Psychotherapy Integration, 16(2), 128–139.

    Article  Google Scholar 

  28. Hutton, P., & Morrison, A. P. (2013). Collaborative empiricism in cognitive therapy for psychosis: a practical guide. Cognitive and Behavioral Practice, 20(4), 429–444.

    Article  Google Scholar 

  29. 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.

    Article  Google Scholar 

  30. Kazantzis, N., & Kellis, E. (2012). A special feature on collaboration in psychotherapy. Journal of Psychotherapy Integration, 68(2), 133–135.

    Google Scholar 

  31. Kazantzis, N., & Ronan, K. R. (2006). Can between-session (homework) activities be considered a common factor in psychotherapy? Journal of Psychotherapy Integration, 16(2), 115–127.

    Article  Google Scholar 

  32. Kazantzis, N., Cronin, T. J., Dattilio, F. M., & Dobson, K. S. (2013). Introduction: using techniques via the therapeutic relationship. Cognitive and Behavioral Practice, 20(4), 385–389.

    Article  Google Scholar 

  33. Kazantzis, N., Cronin, T. J., Norton, P. J., Lai, J., & Hofmann, S. G. (2015). Reservations about the conclusions of the interdivisional (APA divisions 12 & 29) task force on evidence-based therapy relationships: what do we know, what don’t we know? Journal of Clinical Psychology, 71, 423–427. https://doi.org/10.1002/jclp.22178.

    Article  PubMed  Google Scholar 

  34. Kazantzis, N., Dattilio, F. M., & Dobson, K. S. (2017). The therapeutic relationship in cognitive behavior therapy: a clinician’s guide. New York: Guilford.

    Google Scholar 

  35. Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic psychotherapy: a guide for creating intense and curative therapeutic relationships. New York: Plenum.

    Book  Google Scholar 

  36. Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence-based practice in psychotherapy: a common factors perspective. Psychotherapy, 51, 467–481. https://doi.org/10.1037/a0034332.

    Article  PubMed  Google Scholar 

  37. Lorenzo-Luaces, L., & DeRubeis, R. J. (2018). Miles to go before we sleep: advancing the understanding of psychotherapy by modeling complex processes. Cognitive Therapy and Research, 42(2), 212–217.

    Article  Google Scholar 

  38. Muran, J. C., Safran, J. D., Eubanks, C. F., & Gorman, B. S. (2017). The effect of alliance-focused training on a cognitive-behavioral therapy for personality disorders. Journal of Consulting and Clinical Psychology.

  39. Newman, C. F. (2012). Core competencies in cognitive-behavioral therapy: becoming a highly effective and competent cognitive-behavioral therapist. New York: Routledge.

    Google Scholar 

  40. Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. New York: Guilford.

    Google Scholar 

  41. Persons, J. B., Beckner, V. L., & Tompkins, M. A. (2013). Testing case formulation hypotheses in psychotherapy: two case examples. Cognitive and Behavioral Practice, 20(4), 399–409.

    Article  Google Scholar 

  42. Petersen, R. C., Lopez, O., et al. (2018). Practice guideline update summary: mild cognitive impairment. Report of the guideline development, dissemination, and implementation Subcommittee of the American Academy of neurology. Neurology, 90(3), 126–135. https://doi.org/10.1212/WNL.0000000000004826.

    Article  PubMed  Google Scholar 

  43. Rogers, C. (1951). Client-centered therapy: its current practice, implications, and theory. Boston: Houghton Mifflin.

    Google Scholar 

  44. Rogers, C. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting and Clinical Psychology, 22, 95–103.

    Article  Google Scholar 

  45. Sauer-Zavala, S., Boswell, J. F., Bentley, K. H., Thompson-Hollands, J., Farchione, T. J., & Barlowa, D. H. (2018). Expectancies, working alliance, and outcome in transdiagnostic and single diagnosis treatment for anxiety disorders: an investigation of mediation. Cognitive Therapy and Research, 42(2), 135–145. https://doi.org/10.1007/s10608-017-9855-8.

    Article  PubMed  Google Scholar 

  46. Simos, G. (2012). Collaboration in psychopharmacotherapy. Journal of Clinical Psychology, 68(2), 198–208.

    Article  PubMed  Google Scholar 

  47. Sloane, R. B., Staples, F. R., Cristol, A. H., Yorkston, N. J., & Whipple, K. (1975). Psychotherapy versus behavior therapy. Cambridge: Harvard University.

    Book  Google Scholar 

  48. Stricker, G. (2006). Using homework in psychodynamic psychotherapy. Journal of Psychotherapy Integration, 16(2), 219–237.

    Article  Google Scholar 

  49. Tee, J., & Kazantzis, N. (2011). Collaborative empiricism in cognitive therapy: a definition and theory for the relationship construct. Clinical Psychology: Science and Practice, 18, 48–62.

    Google Scholar 

  50. Thase, M. E., & Callan, J. A. (2006). The role of homework in cognitive behavior therapy of depression. Journal of Psychotherapy Integration, 16(2), 162–177.

    Article  Google Scholar 

  51. Wiseman, H., Tishby, O., & Barber, J. P. (2012). Collaboration in psychodynamic psychotherapy. Journal of Clinical Psychology, 68(2), 136–145.

    Article  PubMed  Google Scholar 

  52. Wolpe, J. (1958). Reciprocal inhibition therapy. Stanford: Stanford University.

    Google Scholar 

  53. Wolpe, J., & Lazarus, A. (1966). Behavior therapy techniques. New York: Pergamon.

    Google Scholar 

  54. Young, J. E. (1999). Cognitive therapy for personality disorders: a schema-focused approach (3rd ed.). Sarasota: Professional Resource.

    Google Scholar 

  55. Zilcha-Mano, S., Muran, J. C., Eubanks, C. F., Safran, J. D., & Winston, A. (2018). Not just a non-specific factor: moderators of the effect of within- and between-clients alliance on outcome in CBT. Cognitive Therapy and Research, 42(2), 146–158. https://doi.org/10.1007/s10608-017-9866-5.

    Article  Google Scholar 

Download references

Acknowledgments

Mathew E. Stuckey is acknowledged for comments on a previous version of this manuscript.

Funding

The authors acknowledge the scientific committee of the 8th International Congress of Cognitive Psychotherapy held in Hong Kong, 24–27 June 2014, who supported this expert panel

Author information

Affiliations

Authors

Corresponding author

Correspondence to Nikolaos Kazantzis.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kazantzis, N., Dattilio, F.M., McGinn, L.K. et al. Defining the Role and Function of the Therapeutic Relationship in Cognitive Behavioral Therapy: a Modified Delphi Panel. J Cogn Ther 11, 158–183 (2018). https://doi.org/10.1007/s41811-018-0014-0

Download citation

Keywords

  • Cognitive behavioral therapy
  • Therapeutic relationship
  • Delphi Panel