Psychotherapy: Theory, Research, Practice, Training Copyright 2005 by the Educational Publishing Foundation 2005, Vol. 42, No. 4, 443–455 0033-3204/05/$12.00 DOI: 10.1037/0033-3204.42.4.443 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 spe- cific 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 disor- ders (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 re- lationship 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.