Relationship and Techniques in Cognitive–Behavioral Therapy

RELATIONSHIP AND TECHNIQUES IN COGNITIVE–BEHAVIORAL THERAPY – A MOTIVATIONAL APPROACH

MARTIN GROSSE HOLTFORTH LOUIS G. CASTONGUAY University of Bern Pennsylvania State University Motivational attunement is presented to a list of empirically supported treatments here as a set of guiding principles that (EST) (Chambless & Ollendick, 2001), which can be used to foster the therapeutic have provided evidence for the efficacy of specific technical interventions. Based on the current alliance in cognitive–behavioral ther- list of ESTs, a number of technically oriented apy (CBT). The overarching goal of principles of change have in fact been delineated motivational attunement is to provide for depression (Follette & Greenberg, in press), the client with need-satisfying experi- anxiety disorders (Woody & Ollendick, in press), ences. In order to do so, the therapist personality disorders (Linehan, Davison, Lynch, must attune his or her interventions to & Sanderson, in press), and substance use disorders (McCrady & Nathan, in press). the client’s motivational goals. The au- Research has also provided substantial support thors attempt to demonstrate how ther- for the role of the therapeutic relationship in apists can assess motivational goals psychotherapy treatment effectiveness. The ther- and use this information to foster the apeutic alliance has been found to be one of the central components of the alliance. The most robust predictors of psychotherapy outcome authors also outline how motivational across client (presenting) problems, treatment ap- attunement can be used to prevent and proaches, outcome measures, and treatment lengths (Horvath & Bedi, 2002; Martin, Garske, resolve alliance ruptures. Finally, em- & Davis, 2000; Wampold, 2001). In fact, empir- pirical support for the effects of motiva- ical findings suggest that the “impact of the alli- tional attunement is briefly described. ance across studies . . . is far in excess of the outcome variance that can be accounted for by Keywords: psychotherapy, relationship, techniques” (Horvath & Bedi, 2002, p. 61). Fur- techniques, motivation, CBT thermore, several elements of the therapeutic relationship in addition to the alliance have been identified as effective or promising processes of Psychotherapy has undoubtedly established it- change in psychotherapy (Castonguay & Beutler, self as an effective form of treatment for several in press; Norcross, 2002). psychological disorders (Lambert & Ogles, Because of the strong emphasis given to tech- 2004). A considerable amount of research has led niques in cognitive–behavioral therapy (CBT), some have questioned whether the therapeutic relationship is as important in this orientation as Martin Grosse Holtforth, Department of Psychology, Uni- it is in other approaches (Gaston, Thompson, versity of Bern, Switzerland; Pennsylvania State University; Gallagher, Cournoyer, & Gagnon, 1998; Roth & Louis G. Castonguay, Department of Psychology, Pennsylva- Fonagy, 1996; Safran & Wallner, 1991). Feeley, nia State University. DeRubeis, and Gelfand (1999), for example, sug- This research was supported by a fellowship to Martin gested that the association of the alliance with Grosse Holtforth from the Swiss National Science Foundation outcome in cognitive therapy (CT) might be an (No. 101415). Correspondence concerning this article should be ad- epiphenomenon of symptom improvement. On dressed to Martin Grosse Holtforth, University of Bern, De- the contrary, Waddington (2002), after reviewing partment of Psychology, Muesmattstrasse 45, 3000 Bern 9, the available empirical evidence with regard to Switzerland. E-mail: [email protected] CT, concluded that “an association between the

443 Grosse Holtforth and Castonguay therapy relationship and outcome has been ob- allows for emotionally immediate, in the here- served more often than not, with the role of and-now, corrective experiences. Within this technical intervention as a possible mediator of context, the relationship is not only a condition this association greatly debated” (p. 184). Fur- that facilitates the implementation of techniques thermore, the effect of the therapeutic alliance but also becomes the object of the therapist’s has been shown to be at least as robust in CBT as techniques. Fostering the quality of the relation- in other approaches (Raue, Castonguay, & Gold- ship can thus be viewed as a legitimate treatment fried, 1993; Raue & Goldfried, 1994; Raue, Gold- goal, even in CBT. fried, & Barham, 1997; Salvio, Beutler, Wood, & A number of recent recommendations have Engle, 1992; Stiles, Agnew-Davies, Hardy, been made for how to foster and/or work with the Barkham, & Shapiro, 1998). These findings add to therapeutic relationship within the context of CT the results showing that clients in CBT consider the (Burns, 1999; Burns & Auerbach, 1996; New- therapeutic relationship to be important (Morris & man, 1998; Safran & Segal, 1990; Waddington, Magrath, 1983; Persons & Burns, 1985). Taken 2002), brief forms of therapy (Safran & Muran, together, the findings support the claim that, in 1998), and psychotherapy in general (Crits- addition to specific techniques, the therapeutic rela- Christoph et al.,in press). While these recommen- tionship deserves a central position in CBT re- dations certainly provide valuable contributions search, training, and practice. to the improvement of the therapeutic process, For cognitive-behavioral therapists (as for they are rather generic, in the sense that they do therapists of any theoretical persuasion), a key not individualize interventions according to spe- question has thus become, “how does the thera- cific client characteristics. In line with Paul’s peutic relationship interact with prescribed tech- (1966) famous statement about where the field of niques to produce treatment outcome?” With re- psychotherapy should go, we believe that the gard to this issue, the predominant view among applicability and effectiveness of therapeutic in- cognitive-behavioral therapists appears to be that terventions are likely to be maximized if the the relationship provides the needed condition to interventions are specifically relevant to particu- implement specific techniques that are ultimately lar individuals. We also believe that efforts to- responsible for change. Thus, according to this ward the individualization of therapeutic pro- view, a good alliance, or rapport, is necessary but cesses should have a theoretical as well as an not sufficient for change to take place in CBT empirical foundation. To address this need, this (see Gelso & Fretz, 1992; Gelso & Hayes, 1998; paper presents a motivational model of the inter- Schulte & Eifert, 2002). action of techniques and the therapeutic relation- Other cognitive-behavioral therapists have as- ship, as well as how this interaction influences cribed a more direct curative role to the relation- therapeutic outcome. Motivational attunement ship in CBT. Goldfried and Padawer (1982), for will be presented as a “metatechnique” designed instance, have argued that the relationship has a to individualize therapeutic interventions to fos- therapeutic value in and of itself due to the fact ter and work with the therapeutic relationship. that many people do not frequently have the The motivational approach—and thus motiva- experience of being listened to in a sympathetic tional attunement—is based on Consistency The- manner. As we have seen in our own clinical ory (Grawe, 2004a/b), a general model of psy- practice, the warmth, support, and acceptance of chological functioning that is derived from a nurturing other may, at different phases of research in psychotherapy, basic disciplines in therapy, go a long way toward reducing distress, psychology (e.g., general and social psychology), a sense of demoralization and isolation, and feel- and the neurosciences. Consistency Theory is de- ings of depression and anxiety. In addition, some scribed in more detail below. cognitive-behavioral therapists have argued that the therapeutic relationship provides a unique setting within which the client’s distorted Need Satisfaction as a Dual Mediator of thoughts about others and maladaptive ways of Successful Psychotherapy relating can manifest and be altered (Arnkoff, Consistency Theory 1981; Goldfried, 1985; Goldfried & Padawer, 1982; Safran & Segal, 1990). Working with what The most fundamental assumption of Consis- emerges in the therapeutic relationship therefore tency Theory (Grawe, 2004a/b) is that human

444 Special Issue: Motivational Attunement beings strive for the satisfaction of their psycho- interventions can have their impact maximized, logical needs. Based on Epstein’s (1990) both in terms of disrupting maladaptive behav- cognitive-experiential self-theory, four basic psy- ioral patterns (e.g., avoidance, seclusion) and es- chological needs are proposed: orientation and tablishing new and more need-satisfying behav- control, pleasure, attachment, and self-enhancement. ioral patterns. To satisfy their psychological needs and prevent their needs from being frustrated, individuals de- Need-Satisfying Experiences velop motivational goals. Motivational goals consist of approach goals and avoidance goals. In the above model, need satisfaction is the Approach goals are geared toward the satisfac- link between the therapeutic relationship and tion of needs. In contrast, avoidance goals are therapeutic techniques: A good therapeutic rela- assumed to develop in response to strong and/or tionship provides the client with need-satisfying prolonged aversive experiences and are geared experiences. These need-satisfying experiences toward protecting the individual from reexperi- can then facilitate the successful application of encing the frustration of his or her needs. To techniques. However, a positive influence might pursue approach and avoidance goals the individ- also work in the opposite direction: Disorder- ual also develops more concrete plans and behav- specific techniques might provide the client with iors. According to Consistency Theory, insuffi- need-satisfying experiences, which in turn im- cient need satisfaction (incongruence) contributes prove the therapeutic relationship. Considering to the development and maintenance of psychopa- both potential causal pathways, a client may ben- thology. Consequently, improved need satisfaction efit most if the therapist provides the client with is proposed as a central mechanism to foster symp- as many need-satisfying experiences as possible. tom reduction and improved well-being. This would likely further improve the relation- Similar to other mechanisms of change in psy- ship and contribute to outcome via direct symp- chotherapy, improved need satisfaction is pro- tom reduction and/or facilitated application of posed to operate via both direct and mediated techniques. In addition to the role of the thera- pathways. Specifically, it is assumed that if need peutic relationship as a resource, however, the incongruence actively contributes to the current relationship can also contribute to the change maintenance of the disorder, a reduction of such process by activating and correcting the client’s incongruence—that is, an increase in need interactional problems and maladaptive interper- satisfaction—can directly lead to symptom re- sonal schemata (Constantino, Castonguay, & duction and increased well-being. Need satisfac- Schut, 2000). In the following sections we will tion can also contribute indirectly to change in focus on motivational attunement as an attempt to therapy. Consistency Theory assumes that the provide need-satisfying experiences. We will fulfillment of some needs during therapy (e.g., by show how to apply this theoretical account in experiencing a good relationship with the thera- therapy practice in order to foster the alliance and pist or by developing a stronger sense of control) provide corrective interpersonal experience (es- triggers the client’s approach system (behavioral pecially via strategies to deal with alliance activation system, BAS; Gray, 1981). As argued ruptures). by Grawe (in press), the approach system is associated with approach-oriented behaviors (e.g., Motivational Attunement active engagement in pleasant and/or anxiety pro- voking activities) and the experience of positive In line with Newman’s (1998) assertion that emotions. In the context of psychotherapy, it is “the therapist’s approach has to be tailored to fit hypothesized that activation of the approach sys- the specific needs of a given patient” (p.101), we tem will lead to a greater openness on the part of propose that alliance fostering in CBT should be the client, which, as demonstrated by Orlinsky, customized to the client’s motivational goals in Grawe, and Parks (1994), is one of the most order to provide the client with need-satisfying important predictors of change in psychotherapy. experiences. Need-satisfying experiences are hy- Accordingly, activation of the approach system is pothesized to improve the therapeutic alliance as assumed to facilitate the reception of and collab- well as outcome. More specifically, the central oration with disorder-specific interventions. Ap- hypothesis is that a better therapeutic relationship plied in such optimal context, disorder-specific and a better outcome can be promoted if the

445 Grosse Holtforth and Castonguay therapist supports the realization of approach factor-analytically developed the IAAM as a goals and does not contribute to the activation of standardized questionnaire for self-report and ob- avoidance goals more than necessary. This moti- server report. Approach-goal scales in the IAAM vational attunement can be considered a “meta- are intimacy, affiliation, altruism, help, recogni- technique,” that is, a technique to individualize tion, status, autonomy, performance, control, ed- other therapeutic techniques. Caspar and col- ucation, spirituality, variety, self-confidence, and leagues (Caspar, 1995; Caspar, Grossmann, Un- self-reward. Avoidance-goal scales are separa- mu¨ssig, & Schramm, 2005) as well as Grawe tion, deprecation, humiliation, accusations, de- (2004a) use the term “Complementary Therapeu- pendency, hostility, vulnerability, helplessness, tic Relationship” (CTR) for custom tailoring the and failure. Plan Analysis and the IAAM, which therapist’s behavior to the client’s motivation. To have both been found to be psychometrically avoid any confusion with the complementarity sound (Caspar et al., 2005; Grosse Holtforth & concept in interpersonal theory and research Grawe, 2000), can be used alone or in conjunc- (Carson, 1969) we use the synonymous term tion. As will be shown below, the approach and “motivational attunement.” It is important to note avoidance goals inferred by these methods can be that motivational attunement is not intended to used as targets for therapist interventions in the replace the more general recommendations for service of fostering and working with the alli- alliance fostering mentioned above. Rather, mo- ance. As such, these methods provide tools for tivational attunement is intended to be an addi- what has been described as a foundation of ef- tion to existing techniques. Before outlining mo- fective treatment: case formulation (Eells, Kend- tivational attunement in CBT, we will first jelic, & Lucas, 1998). However, we need to stress describe two methods for assessing plans and that the type of motivational assessment proposed motivational goals. here is not intended to be an alternative to well- established methods of case formulation in CBT Assessment of Plans and Motivational Goals (e.g., Persons & Tompkins, 1997) or other approaches (Eells, 1997). It should rather be viewed Two methods can be used to assess the client’s as a system of analysis to complement other motivational goals: Plan Analysis (Caspar, 1995), assessment methods that can be used for the and the Inventory of Approach and Avoidance 1 fine-tuning of therapists’ interventions. In addi- Motivation (IAAM , Grosse Holtforth, & Grawe, tion, motivational attunement based on a case 2000). Plan Analysis is an ideographic method formulation is not intended to proscribe thera- for inferring the client’s plan structure from var- pists’ spontaneity. However, we do not attribute ious sources of information (e.g., anamnestic in- superior value to spontaneous over intended information, behavioral observations, the client’s terventions. In fact, because we believe that spon- impact on others). “A person’s plan structure is taneous reactions are unlikely to be totally ran- the total of conscious and unconscious strategies dom, we would argue that such spontaneous this person has developed to satisfy his or her reactions can be, at least to a certain extent, needs” (Caspar et al., 2005, p. 92). The main motivationally attuned. Concretely, this means question guiding the assessment process is: that rather than suggesting that therapists should “What is the explicit or implicit purpose of this restrict their spontaneity, we would suggest that client’s behavior?” The result is a graphic display they can use motivational attunement as a crite- of the structure of the client’s most important rion for monitoring and potentially filtering their approach and avoidance goals, as well as his or spontaneous reactions (see also Bacal & Herzog, her individual means (plans and behaviors) to- 2003). Finally, a case formulation based on mo- ward pursuing these goals. tivational assessment should not be viewed as The Plan Analysis approach requires training, fixed or static. Each case formulation is a set of can be labor-intensive, is focused on the observ- preliminary hypotheses that might be revised er’s perspective, and results in nonstandardized whenever new information becomes available. goal formulations. To overcome these limita- Furthermore, because the client’s goal system tions, Grosse Holtforth and Grawe (2000) identified the most prevalent approach and avoidance goals in case formulations that had been devised 1 The questionnaire is available in German, English, according to plan-analytical principles, and French, Italian, and Turkish from Martin Grosse Holtforth.

446 Special Issue: Motivational Attunement

(his or her motivational goals, plans, behaviors, apy to produce direct effects on depressed symp- as well as their interrelations) change in the toms” (p.320). course of therapy, the clinician is well advised to Of the three components of the alliance, the continually monitor these changes (ideally via task component is affected most by the therapeu- repeated administration of the IAAM), revise his tic orientation. Therefore our discussion of moti- or her case formulation when necessary, and vational attunement related to fostering the task adapt his or her alliance-focused interventions component of the alliance will be most specific to accordingly. CBT. In contrast, motivational attunement for fostering the therapeutic bond will be less depen- dent on particular techniques, so the proposed Motivational Attunement in CBT interventions can be easily applied to approaches other than CBT. In what follows, we will present the application of motivational attunement in CBT. It is important to mention, however, that the applica- Fostering the Bond tion of motivational attunement is not limited to Crits-Christoph and colleagues propose several CBT. Our focus on CBT here is motivated by the strategies to foster the therapeutic bond. Apart facts that motivational attunement has grown out from showing respect, caring, acceptance, of the cognitive–behavioral tradition (Grawe & warmth, and positive regard, the authors propa- Dziewas, 1978), has a theoretical basis that was gate enhancing the client’s change motivation founded in empirical research (Grawe, 2004a), through more specific techniques, establishing a and uses assessment methods that are either be- collaborative and empathic climate, and handling havioral or are derived from behavioral analyses. alliance ruptures in an accepting and nondefen- Additionally, it is tempting to show the applica- sive way. Motivational attunement can be applied tion of this alliance-fostering method within an as part of all of these strategies. (We will discuss approach that historically did not pay particular alliance ruptures separately in a later section.) attention to relational issues. Consistency Theory assumes that excessively As indicated above, motivational attunement is strong avoidance goals and/or excessively weak proposed as a customization of other technical approach goals potentially contribute to a de- interventions to alliance fostering. Crits- crease in the client’s motivation to participate in Christoph and colleagues’ (in press) alliance- the therapeutic work. For example, a depressed fostering therapy appears as the most differenti- client might fear to be humiliated by others when ated set of guidelines for fostering the alliance it becomes known that he or she is in therapy. thus far. The guidelines for this therapy are struc- The therapist can try to enhance the client’s tured by the three components of the alliance as change motivation by cognitively restructuring proposed by Bordin (1979): bond, agreement on this fear. In addition, the therapist can strengthen goals, and agreement on tasks. To ensure com- the client’s approach motivation for change by patibility of our presentation of motivational at- discussing and supporting the wished-for conse- tunement with alliance-fostering therapy—which quences of change. As an example, if the client in turn would ensure compatibility with the most wishes to have an exciting life, the therapist can common theoretical systematization for alliance help the client to imagine how he or she would, concepts—we will structure our presentation of for example, travel to foreign countries again motivational attunement according to the three when he or she has overcome the depression; components of the alliance. This structural deci- inquire about the exciting details of the journey; sion is also supported by Rector, Zuroff, and and show his or her own excitement about the Segal’s (1999) research-based suggestion that the client’s imagination. three components of the therapeutic alliance Motivational attunement can also facilitate (Bordin, 1979) have different roles in CT: “cer- communicating empathy to the client. Empiri- tain aspects of the therapeutic alliance (i.e., goals cally, communicated empathy is related to a good and tasks) may facilitate the implementation of alliance in general and a good bond in particular the technical factors of cognitive therapy, while (Horvath & Bedi, 2002). What a particular client other aspects of the alliance (i.e., bond) act in finds empathetic differs from client to client, so concert with technical factors of cognitive ther- that the therapist is well advised to individualize

447 Grosse Holtforth and Castonguay the expression of this understanding and support. client is irritated by seeing emotion in others, a Newman (1998) distinguishes simple and accu- more distanced, rational, “technical” therapeutic rate empathy in CT. While simple empathy in CT stance might be indicated. If it is very important consists of “listening, reflecting, and offering for the client to be autonomous, the therapist words of kindness, concern, and encouragement” should leave as many decisions as possible (e.g., (p. 104; e.g., “That must have been very difficult about scheduling, location of an exposition, for you. . .”), accurate empathy implies a deeper agenda-setting homework, etc.) in the client’s understanding of the potential reasons for the hands. If the client values education and broad client’s experience. A motivationally attuned ex- interests, the therapist might put in extra effort pression of accurate empathy would be based on toward providing explanations or theoretical a previous assessment of the client’s approach models for the client’s problems. Finally, if the and avoidance goals. Using the above example, client finds religion very important, the therapist this could sound like: “It must have been very might allow the client to frame the therapy in difficult for you to take care of your ill father spiritual terms (see Beutler et al., in press). given that it is also very important for you to It is important to note that according to Con- preserve your own autonomy.” sistency Theory, psychological needs (for attach- Accurate empathy that is based on the assessment, control, self-enhancement, and pleasure) ment of the client’s most important approach and are by definition adaptive. However, a client’s avoidance goals can be seen as a refinement of goal system (motivational goals, plans, and be- the two kinds of empathy that Burns and Auer- haviors) might be maladaptive, that is, it might be bach (1996) target in their “empathy training too extensively geared toward the satisfaction of program” for CBT, that is, thought and feeling one need, or might involve maladaptive strategies empathy. While thought empathy is a mere rep- and behaviors aimed at fulfilling adaptive needs. etition of the client’s words, and feeling empathy As a consequence, while a person’s goal system is the formulation of likely feelings “behind” a may enable him or her to satisfy some of his or client’s utterance, motivationally attuned empa- her needs in the short run, it may compromise thy adds the expression of likely wishes and fears other needs in the long run. For example, a nar- associated to the utterance. Information about the cissistic client who frequently brags about gran- client’s motivational goals can also support the diose achievements may well foster his self- application of the disarming technique that has esteem by perceiving himself to be better than the been developed by Burns (1999; Burns & Auer- others. The same behavior, however, is likely to bach, 1996) to deal with problems in the thera- compromise his need for attachment by alienat- peutic relationship. A central intervention within ing and distancing others. From a motivational the disarming technique is that the therapist finds attunement perspective, the presence of such mal- “truth in what the patient is saying” (p.153). adaptive goals, plans and behaviors has important Having understood the client’s wishes and fears implications with regard to the therapeutic bond is likely to help the therapist better capture the and, as such, requires different types of interven- subjective background of the client’s responses. tions at different phases of treatment. In order to Furthermore, we assume that showing motiva- foster an initial bond, an early task of a therapist tionally attuned empathy will prevent the thera- working with such a client will be to understand pist from appearing insincere by simply para- the function of his arrogant behavior. It might be phrasing the client’s statements or labeling likely that the client has learned that being better than emotions in a general way (Gelso & Hayes, others was the most reliable way to gain his 1998). father’s approval. Consequentially, bragging Because human communication involves both about grandiose achievements may have become issues of content and process (Watzlawick, Bea- a reinforced (at least early on in his development) vin, & Jackson, 1969), motivational attunement means for connecting to others, that is, to fulfill for fostering the therapeutic bond also includes his (profoundly and intrinsically) adaptive need the nonverbal and paraverbal aspects of the com- for attachment. In therapy, it might be necessary munication. For example, if close relationships for the therapist to initially conform to the cli- are important for a client, he or she is likely to ent’s wish to have his grandiosity confirmed by prefer warm, close, and caring nonverbal behav- expressing admiration for the client’s achieve- ior from the therapist. If, on the other hand, a ments. Once an initial bond is formed, however,

448 Special Issue: Motivational Attunement the therapist is likely to facilitate therapeutic (al- ple very important, for example, could be: “I will beit difficult) change by shifting his or her focus be able to drive to my disabled niece and help her to satisfying the underlying need (attachment) as with the groceries.” Even the process of finding opposed to immediately and directly responding goals itself can be need-satisfying for the client to (reinforcing) the client’s maladaptive motiva- because mental representations of approach goals tional goals, strategies, and behaviors. The ther- will be activated. apist might, for example, express accurate empa- Generally, it is preferable if the treatment goal thy by emphasizing with the client’s legitimate is formulated in terms of approach instead of wish for approval or the frustration he experi- avoidance. Naturally the removal of symptoms is ences when other people distance themselves one of the main motivations to seek treatment from him. Attuning to what is assumed to be an (e.g., “get rid of my anxiety”), but treatment underlying need is not only likely to stabilize the goals will be even more attractive for the client if bond but also might additionally provide a cor- the removal of a problem is paired with an indi- rective emotional experiences (Alexander & vidually attractive approach goal (e.g., “be able to French, 1946), that is, allowing the client the help my niece again”). Additionally, an approach opportunity of interacting with another person in formulation of treatment goals might contribute an adaptive way without having to experience a to the activation of the approach-oriented mode feared outcome (e.g., being dismissed, attacked, of functioning (see above), which is thought to or ignored). As can be seen from the example, the have a beneficial effect on therapy process and more complex a client’s motivation appears, the outcome. Furthermore, by regularly reviewing more helpful a detailed analysis of the client’s treatment goals, the therapist can keep refreshing goal system by Plan Analysis, in addition to a the beneficial effects of motivational attunement. standardized assessment of motivational goals, If client and therapist have to revise their treat- will be. ment goals, the therapist should make sure that the new goals match the client’s approach goals. Fostering Goal Agreement Fostering Task Agreement In general, the formulation of treatment goals has been shown to have beneficial effects on Task agreement has a special relevance to our treatment process and outcome (Tryon & Wino- discussion about the interaction of relationships grad, 2002). The fostering of goal agreement in and techniques in CBT. If we equate tasks with Alliance Fostering Therapy (Crits-Christoph et therapeutic techniques, task agreement translates al., in press) mainly consists of establishing ex- into agreement on the techniques to be applied to plicit treatment goals and regularly reviewing reach the treatment goals. Consistency Theory them. Goal formulation should be a joint effort by assumes that interventions have beneficial effects client and therapist and the resulting treatment in psychotherapy if they help to better satisfy goals should be representative of what the client psychological needs. As with goal agreement, we wants and what the therapist thinks he can help assume that the beneficial effects of task agree- the client with (Grosse Holtforth & Grawe, ment vary with the attractiveness of the tech- 2002). We propose that the beneficial effect of niques for the client. Part of the attractiveness of goal agreement on the therapeutic relationship the techniques is their promise to help reach the can be enhanced when the formulation of the therapeutic goals. Therefore, when presenting the treatment goals closely matches important ap- treatment rationale, the therapist has to plausibly proach goals of the client. Treatment goals that explain that the techniques will lead to goal match the client’s approach goals are more at- attainment. tractive for the client because they promise to Consistency Theory also assumes, however, satisfy the client’s needs. As the match between that in addition to this cognitive plausibility, there treatment goals and approach goals increases, the is a motivational component to the subjective therapist’s “value” for the client will also in- attractiveness of techniques. The techniques can crease because his or her role is to facilitate, be more or less attuned to the client’s motiva- support, or enable the attainment of these goals. tional goals, and thereby have a stronger or A motivationally attuned treatment goal for an weaker potential to satisfy the client’s psycholog- agoraphobic client who finds helping other peo- ical needs. The subjective prospect to satisfy

449 Grosse Holtforth and Castonguay needs, on the one hand increases the client’s is whether, or to what extent, a therapist should motivation to engage in the application of tech- prevent alliance ruptures. If the alliance is viewed niques, and, on the other hand increases the ther- as a facilitator of techniques, alliance ruptures apist’s “stimulus value” as the “provider” of should be avoided as much as possible because these techniques. This means that the therapeutic such ruptures can only hinder the application of relationship will be better if the techniques are techniques. If the alliance is viewed as a curative attuned to the client’s motivational goals. Ad- factor in its own right, however, alliance ruptures ditionally, if a technique activates an avoidance may have contrasting types of impacts on the goal, the likelihood of task disagreement, alli- process of change. On the one hand, alliance ance ruptures, noncompliance, and/or resis- ruptures might (temporarily) hinder need satis- tance increases. faction in the therapeutic interaction. On the other To motivationally attune the choice of tech- hand, if one assumes that alliance ruptures occur niques, the therapist can compare a list of empir- because the therapist activates and engages in ically supported techniques for a given problem maladaptive interpersonal cycles that resemble with the list of the most important approach and the client’s relationships outside of therapy, they avoidance goals of the client and try to match can also be considered an opportunity to facilitate approach goals with techniques. For example, a corrective interpersonal experiences (Con- client who especially values close relationships stantino, et al., 2000). We neither demonize nor might particularly enjoy direct reassurance, self- naı¨vely favor triggering alliance ruptures. Fol- disclosures, or modeling of behavior by the ther- lowing the assumption of Consistency Theory apist. Clients who ﬁnd it particularly important to that satisfaction of psychological needs is crucial be independent might particularly favor explor- for a good therapeutic relationship, we propose ing new activities, exploring new meanings of that the CBT therapist should try to foster the thought, examining available evidence, testing alliance and try to prevent alliance ruptures as beliefs, or searching for alternative explanations. much as he or she can. However, if alliance Clients who favor being in control of their situ- ruptures occur, they should be addressed with the ations might particularly enjoy explanations of appropriate techniques. In the following, we will the treatment rationale, agenda setting, frequent show how alliance ruptures can be understood in summarizing, recording behaviors and cogni- motivational terms, which alliance ruptures are tions, or training skills. (We will discuss the typical for CBT, which approach and avoidance relationship of avoidance goals and techniques in goals are likely involved, and how motivational a later section on alliance ruptures). attunement can support the resolution of alliance We are not arguing that motivational attun- ruptures. ement should be the only criterion for selection of Based on empirical studies, Ackerman and techniques. Instead we argue that the therapist Hilsenroth (2001) categorized potential precipi- should be aware of the attractiveness of the ap- tants of alliance ruptures either in terms of the plicable techniques for his or her client. If com- “therapist does something that the patient does parably effective techniques are available, the not want or need” or “the therapist fails to do therapist can choose the one that is more attuned something that the patient wants or needs” (p. to the client’s goals. If the therapist has to choose 183). These two categories of precipitants sug- a technique that is motivationally “unattractive” gest a motivational basis of alliance ruptures. for the client, however, the therapist will have to Failing to do something that the patient wants or put in extra effort toward activating the client’s needs can be translated as “failing to satisfy the approach goals by means other than techniques. patient’s approach goals,” and doing something that the client does not want as “activating the Alliance Ruptures patient’s avoidance goals.” Newman (1998) and Safran and Muran (1998) The recommendations for fostering the thera- give examples of typical alliance ruptures in peutic relationship cited above (Crits-Christoph CBT: clients might feel overwhelmed with activ- et al., in press; Safran & Muran, 1998; Wadding- ity and optimism by the therapist, feel rushed into ton, 2002) all agree that the therapist should tasks before they are ready, perceive a competi- attend, and respond appropriately, to alliance rup- tion with the therapist for control, perceive the tures. However, an interesting question for CBT therapist as patronizing, and react to the antici-

450 Special Issue: Motivational Attunement pation of abandonment. From this list, we can tionally attuning interventions to the client’s ap- infer motivational goals that might be activated in proach goals, the therapist ends up decreasing the these situations. For example, both overwhelm- client’s motivation to use disruptive behaviors ing the client with activity and urging the client to because his or her needs get satisfied without the engage in a task for which he or she does not feel use of maladaptive strategies. In addition to mo- ready might trigger fears of failure, criticism (by tivational attunement to approach goals, the ther- the therapist), or helplessness in the client if he or apist can prepare to avoid possible triggers of she does not live up to the therapist’s expecta- alliance ruptures by assessing the client’s avoid- tions. The client might also fear disappointing the ance goals and noting in the case formulation therapist if the therapist expresses a lot of opti- which potential therapist behaviors might be par- mism. Expression of optimism might further dis- ticularly aversive for the client. If these behaviors appoint the client’s wish for understanding and are not part of necessary interventions, the ther- care because the therapist does not acknowledge apist should try to avoid them. If necessary inter- the client’s suffering or the difficulty of the cur- ventions will likely trigger avoidance goals, “. . . rent task. The aforementioned therapist behaviors therapists must tune into the patient’s fears . . .” might also be particularly aversive for clients (Newman, 1998, p. 114). In addition, the thera- who strongly value autonomy and being in con- pist should activate as many of the client’s re- trol. These clients might engage in power strug- sources as possible (e.g., praising client strengths gles with the therapist when they feel that they and previous successes, engaging a supportive cannot influence the therapy process enough. partner, etc.) in order to bolster the implementa- Power struggles can also occur with clients who tion of these aversive tasks (Gassmann & Grawe, have motivational goals other than autonomy and 2002; Grawe, 2004a/b). control. Clients who strongly value status and Techniques to resolve alliance ruptures have respect, for example, may see it as an expression been described in detail by Safran and Muran of disrespect when the therapist assumes a dom- (2000), as well as by Burns (1999; Burns & inant or directive role. Similarly, directive behav- Auerbach, 1996). According to Safran and Muran ior on the therapist’s part might be perceived as (2000), the therapeutic alliance is the result of an being patronizing for clients who value status ongoing process of negotiation between client and/or autonomy. Finally, clients who react with and therapist. These authors outline a taxonomy disruptive behaviors to the therapist’s suggestion of interventions for addressing (directly or indi- to reduce the session frequency obviously fear rectly) alliance ruptures that is based on the three- being abandoned by the therapist. component model by Bordin (1979). Alliance Constantino et al. (2000) noted that “some ruptures are conceptualized as either problems in technical interventions, at least when applied in the therapeutic bond or as disagreements on task specific contexts, may play a role in maintaining and goals. In addition to these specific interven- and potentially increasing alliance ruptures” tions, the authors also outline general heuristics (p.115). The “specific context” could be therapy for renegotiating the alliance after a rupture has relationships in which strong motivational goals occurred depending on how the rupture is ex- exist in the client. Clients who fear criticism, for pressed in the client’s behavior (confrontation or example, might be particularly reluctant when withdrawal markers). In an experimental study, asked to recognize their cognitive errors. Simi- an innovative treatment that focused on the ap- larly, clients who are very fearful of failure might plication of these rupture resolution principles perceive the trying out of new behaviors as (Brief Relational Therapy, BRT ) was shown to be threatening. Clients who, on the other hand, equally effective as CBT but yielded a lower strongly value autonomy might experience tight frequency of dropouts (Safran, Muran, Samstag, self-observation as a violation of personal space. & Stevens, 2002). We believe that the therapist’s Finally, clients who either fear deprecation or attunement with the client’s motivational goals strongly value status might be especially averse could be complementary to Safran and Muran’s to psychoeducational interventions. interventions. Knowing the client’s motivational Continually providing the client with need- goals might prevent, or alert the therapist to, satisfying experiences via motivational attune- potential alliance ruptures. Furthermore, resolu- ment to approach goals (see above) is the primary tion of such ruptures may lead to a better under- strategy to prevent alliance ruptures. By motiva- standing and thus attunement to the client’s mo-

451 Grosse Holtforth and Castonguay tivational goals. In fact, as noted by Safran and from the clients’ perspective. Further support can Muran (1998), one of the outcomes of a success- be found in research conducted by Stucki (2004), ful resolution of alliance ruptures is that the client in which the relationship behavior of therapists becomes able to express his or her wishes that during the first three sessions of psychotherapy were not met by the therapist and/or identify the was analyzed using a sample of 30 outpatients fears that the therapist confirmed. It remains to be with heterogeneous diagnoses. The therapists shown, however, whether the combination of mo- practiced an integrative form of psychotherapy, tivational attunement with the principles of rup- in which the therapists differentially combined ture resolution outlined by Safran and Muran cognitive–behavioral, process-experiential, and (2000) leads to better outcomes and fewer interpersonal interventions following a case for- dropouts. mulation based on Consistency Theory and ap- In sum, the issue of alliance ruptures shows plied motivational attunement as defined by how techniques and the relationship inseparably Grawe (2004a). Results indicated that the thera- interact with each other. Techniques might trig- pists in dyads with a better client-rated relation- ger alliance ruptures because they fail to satisfy ship are more attuned to the clients’ motivational approach goals or confirm avoidance goals. Ad- goals as assessed by the IAAM. These results ditionally, the therapist uses specific techniques support the notion that motivationally attuned to not only prevent alliance ruptures, but also to therapist behavior is associated with a better re- try to resolve them. Having a clear picture of the lationship and a more favorable outcome. client’s approach and avoidance goals early in the therapeutic process can support both of these Discussion therapeutic tasks. Empirical research has shown that both tech- Empirical Support for Beneficial Effect of nical interventions and the therapeutic relation- Motivational Attunement ship are important contributors to the outcome of psychotherapy, both in general and specifically in There is initial evidence that motivational at- CBT. Based on the theoretical work of leading tunement has a beneficial impact on CBT and figures in CBT (as well as in other orientations), other forms of psychotherapy. The Berne Com- it can also be argued that the therapeutic relation- parative Treatment Study (BCTS, Grawe, Caspar, ship is in continuous interaction with technique, & Ambu¨hl, 1990) compared broad-spectrum be- either as a facilitator of the application of tech- havior therapy (BSBT), interactional behavior niques or as the object of techniques when it therapy (IBT), and client-centered therapy for comes to fostering the alliance or dealing with outpatients with heterogeneous diagnoses. Both alliance ruptures. We presented Consistency The- BSBT and IBT are based on Lazarus’ (1973) ory as a model that explains the interaction of multimodal therapy. In IBT, however, the choice relationship and techniques and its impact on of interventions used by the therapist is guided by outcome via the mediational influence of need principles of Plan Analysis (see assessment sec- satisfaction. Motivational attunement is presented tion) and a Complementary Therapy Relationship as a method that can be used to tailor therapeutic (CTR; motivational attunement). Results indi- interventions to the clients’ motivations in order cated that IBT was superior in some outcome to provide clients with need-satisfying experi- measures, especially from the client’s perspec- ences. We have attempted to demonstrate how tive. Additionally, in IBT, success depended less motivational attunement can be used to foster the on client characteristics, and there were also bond, goal, and task components of the alliance fewer dropouts. Further empirical support for the and to handle alliance ruptures. We have also beneficial effect of motivational attunement can described studies that begin to provide evidence be found in a study conducted by Caspar et al. to support the effectiveness of this model in psy- (2005) analyzing the impact of spontaneous CTR chotherapy. However, much more empirical on outcome with respect to Interpersonal Therapy work needs to be done. for 22 depressed inpatients. In this study, spon- Future research should further test the associ- taneous relationship behavior (displayed by the ations between motivationally attuned therapist therapist) that matched the client’s most impor- behaviors, the therapeutic relationship, and ther- tant goals was associated with better outcome, apy outcome. Given the small number of clients

452 Special Issue: Motivational Attunement in Caspar and colleagues’ (2005) study, natural- (Eds.), New directions in cognitive therapy: A casebook istic studies should try to replicate these findings (pp. 203–223). New York: Guilford Press. BACAL,H.A.,&HERZOG, B. (2003). Specificity theory on spontaneous motivational attunement and out- and optimal responsiveness: An outline. Psychoanalytic come in CBT. Future studies should also involve Psychology, 20(4), 635–648. experimental designs to assess the causal impact BEUTLER, L. E., BLATT, S. J., ALAMOHAMED, S., LEVY, of motivational attunement on therapeutic K. N., & ANGTUACO, L. A. (in press). Participants change. For example, a CBT condition without factors in treating dysphoric disorders. In L. G. Caston- guay & L. E. Beutler (Eds.), Principles of therapeutic specific alliance-fostering efforts could be com- change that work. New York: Oxford University Press. pared to a CBT condition with alliance-fostering BORDIN, E. (1979). The generalizability of the psychoan- interventions according to Crits-Christoph et al. alytic concept of the working alliance. Psychotherapy: (in press), and to a CBT condition with alliance Theory, Research and Practice, 16, 252–260. fostering via motivational attunement. Our hy- BURNS, D. (1999). The Feeling Good Handbook (Rev. ed.). New York: Plume Books. pothesis is that alliance fostering via motivational BURNS,D.D.,&AUERBACH, A. (1996). Therapeutic attunement will be associated with the best alli- empathy in cognitive-behavioral therapy: Does it really ance ratings from the client perspective, fewer make a difference. In P. M. Salkovskis (Ed.), Frontiers dropouts, and better outcomes. of cognitive therapy (pp. 135–164). New York: Guilford Finally, it should be noted that this article Press. CARSON, R. C. (1969). Interaction concepts of personality. addresses the task of fostering the therapeutic Chicago: Aldine. alliance by focusing mainly on client individual CASPAR, F. (1995). Plan Analysis. Toward optimizing differences. However, the therapeutic alliance psychotherapy. Seattle: Hogrefe-Huber. should be understood as the product of an ongo- CASPAR, F., GROSSMANN, C., UNMU¨ SSIG,C.,&SCHRAMM, E. (2005). Complementary therapeutic relationship: ing negotiation between client and therapist, in Therapist behavior, interpersonal patterns, and thera- which the needs of both participants are at play. It peutic effects. Psychotherapy Research, 15(1–2), 91– is therefore important to recognize the role of the 102. therapist (as a unique person) in the successful CASTONGUAY,L.C.,&BEUTLER, L. E. (in press). Prin- application of the therapeutic guidelines de- ciples of therapeutic change that work. New York: Ox- scribed in this paper. Research findings have in- ford University Press. CHAMBLESS,D.L.,&OLLENDICK, T. H. (2001). 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