The Therapeutic Relationship

There are some common misconceptions regarding the nature of the therapeutic relationship in behaviour therapy. It is often thought of as distant, one sided and somewhat authoritarian. Arguably, behaviour therapists themselves are partly responsible for this prejudice as they - in contrast to psychodynamic therapists and experientially oriented therapists, for example - pay scarce attention to the therapeutic relationship in their published work. However, most behaviour therapists recognize the importance of a strong treatment alliance and invest time and effort in establishing a cooperative relationship.

There is currently ample literature demonstrating that 'Rogerian' concepts such as warmth and empathy are also characteristic of the therapeutic relationship in behaviour therapy.

However, in contrast to other therapy schools, these variables are not thought of as merely facilitative for the therapeutic process. In behaviour therapy these concepts are thought of as significant situational variables in the promotion of a learning process and changing problem behaviour. This conceptualization implies that not every patient needs equal amounts of warmth, empathy, structuring, support and so forth. Relevant aspects can also differ from one phase of therapy to the next. Diagnosis and functional analysis (microanalyses and macroanalyses) can contribute to an informed decision regarding a productive relational style. The patient's comportment in the therapeutic alliance is another factor for the therapist to consider when choosing a relational style.

As in other therapies, the behaviour therapist may be faced with phenomena such as resistance or transference. Their perceived significance and the way they are dealt with by the behaviour therapist, however, differ from the way in which psychodynamic therapists perceive and act. When a patient displays resistance, for instance by being consistently late, or by avoiding specific subjects, being taciturn or overly talkative, the therapist will examine what factors might elicit such behaviours (Wright & Davis, 1994). The therapeutic stance regarding resistance is thus, in fact, quite similar to how other problem behaviours are regarded and approached. Making use of his observations and, if needed, additional probing, the therapist will attempt to formulate a functional analysis of the resistance behaviour. As a result, the therapist may learn that the behaviours are better understood by other factors than by the initial impression of treatment resistance. Consider the patient who often looks out of the window and is generally taciturn. On closer inspection it may turn out that these behaviours only occur when the therapy session takes place at the end of a gruelling workday.

Sometimes the patient may resist the (initially) agreed upon treatment objective:

Arnold openly discusses a multitude of problems that bother him, cooperatively registers his problem behaviours (panic attacks), but consistently sabotages his homework assignments. The first session he forgot his assignments, the second session the neighbour visited, and the third session he spent five minutes on the scheduled exercise instead of the agreed upon 90 minutes. When something like this happens, the therapist should collaboratively re-examine the problem analysis with the patient. In this case it demonstrated that Arnold thought that the treatment approach was far too simplistic for his problems. How were a couple of homework assignments going to cure him of his anxiety attacks that had been haunting him for more than 10 years?

In other instances, assumed negative effects of treatment may explain the treatment resistance:

A 46 year-old woman suffered from social anxiety and agoraphobia. Initially, treatment (exposure in vivo) appeared to be going smoothly, but as the exercises progressed treatment halted. The patient started cancelling appointments and when she did show up she had not completed the assignments. In view of the initial smooth progress, the therapist hypothesized that the stagnation might have to do with fears associated with definitive improvement of the complaints. Inquiry revealed that the patient dreaded having to go back to work for her father, whom she described as an authoritarian man whom she felt unable to stand up to. As a result of this discussion, the functional analysis and treatment plan were revised and patient and therapist agreed to include assertiveness training as part of the treatment.

The therapeutic style should be markedly different with a dependent patient versus a patient with clear narcissistic or paranoid features (Velzen & Emmelkamp, 1996). When working with a dependent phobic patient at the start of treatment, it may be advisable to enquire by telephone how the homework assignments are coming along. With a narcissistic patient, however, the therapist would be advised to refrain from this as it may reinforce the narcissistic tendency to demand excessive attention. The same applies for the paranoid patient as this patient may interpret the therapist's good intentions as doubts as to whether he or she is completing the homework assignments. Note that later in therapy one should fade out the telephone inquiries with the dependent patient as well, as these calls may end up reinforcing the undesired dependent behaviours.

There are some general features that characterize the therapeutic relationship in behaviour therapy:

• The patient is treated as a competent person who will (learn to) maximally contribute (1) to the examination of factors that may have caused or maintained the problem behaviour and (2) to the design of strategies for therapeutic change.

• The therapist and patient collaboratively determine the objectives of treatment. Patients have usually tried a number of strategies to remedy their problem with various degrees of success. The therapist is advised to pay heed to these previous self-directed efforts.

• In behaviour therapy the therapist spends considerable time and attention to non-technical elements such as increasing motivation, explaining the therapeutic model, and introducing techniques and homework assignments.

Schindler's (1988) research shows that the first sessions are crucial for the subsequent progress in therapy. The most important dimension is 'support' - a collective term for such divergent therapeutic intervention as giving positive feedback, reassurance and encouragement and positive reframing. Research by Ford confirms that these expressions of support are pivotal at the start of treatment (Ford, 1978). During the later stages of therapy the patient attaches less importance to the non-specific support and becomes more involved in events outside of therapy (see also Raue & Goldfried, 1994).

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