Processes of Change: Integrating Relationality with Cognitive-Behavioral and Acceptance Constructs

Abstract

Over recent decades, the clinical psychology field as a whole has increasingly emphasized treatment manuals and distillation of evidence-based practices down to specific, standardized procedures. While this approach has proven successful in reducing symptoms, we argue that it is vital to remain vigilant to the social and relational context that humans exist in, for both clients and therapists. The focus on relationships and connections amongst people must remain a central focus in order for the field to progress. This can be embedded into treatment in the context of existing integrated models, such as process-based therapy. We propose a road map for considering environmental context, relationships, the whole self of the client and therapist, and the focus on treatment targets and outcomes.

In the current era of focusing on symptom reduction and specific protocols for specific symptoms, it is more important than ever to step back and examine what is at the core of therapeutic change. However, traditionally, psychotherapies have had a “weak relationality” focus whereby relationships in the end were all related to individual level aspects of behavior, instead of recognizing that relationships and connection are the foundation of our society (Slife & Wiggins, 2008). Indeed, we are not healthy if our relationships and interactions within our systems are not healthy. Thus, a focus on healthy interpersonal function should be added to the bevy of research on individual processes of change, and it should be done from a process-based focus. We argue for an integration of Slife and Wiggins’ (2009) focus on radical relationality within existing therapeutic contexts.

This paper offers a theoretical roadmap, along with specific future clinical, research, and training directions. See Figure 1 for an outline of the model and integration that we describe in this paper.

Figure 1. Integrated Model of Relationality and Adaptation-Focused Therapy.

Note. This figure details a model of what this paper describes by showing the individual client and their core beliefs about the world and motivations, as well as the therapist’s sense of self as a person and a therapist. Both exist within a larger relational context that includes their relationship with each other, and their other relationships to people and systems. That relational context exists within a larger environmental context which Hayes et al. (2020) addresses. Both the therapist and client exist next to the treatment target of adapting, which includes mindfulness and flexibility and draws from Hayes et al. (2020), and the intended outcomes of reduced mental distress and improved wellbeing. The treatment target of adapting could be addressed according to a process-based therapy conceptualization (Hofmann & Hayes, 2019) and by any of the other numerous techniques detailed in the paper.

Symptom Models

Ciarrochi et al. (2024) describe the current state of the clinical psychology field as the “protocol for syndrome era,” focusing on treatment manuals designed for specific DSM-defined diagnoses. For example, such protocols may have modules for specific sessions which set an agenda of skills to be taught, homework to be assigned, specific worksheets to be completed, and even contain sample language to guide conversations with patients (Farchione et al., 2012; Kendall & Hedtke, 2006). Born from clinical trials in which fidelity to protocol across patients is emphasized (Waltman et al., 2017), these manualized, skills-based treatments have indeed ushered success in reducing symptoms (e.g., sadness, compulsions, avoidance) measured by standardized assessments. For example, recent meta-analyses of hundreds of studies have indicated that cognitive behavioral therapy is effective at reducing symptoms of major depressive disorder (Cuijpers et al., 2013), generalized anxiety disorder (Hanrahan et al., 2013), and obsessive compulsive disorder (Olatunji et al., 2013). While the value of this can not be overstated, nonetheless, these approaches have areas for growth. First, as pointed out by Ciarrochi and colleagues, one of the most common diagnostic categories is “not otherwise specified,” meaning that some aspects of the patient presentation disqualify them from a particular diagnosis, although it is common for people to have complex combinations of co-occurring symptoms. Therefore, the trials that test these symptom-targeted treatments commonly exclude the real-world diagnostic presentations that present in the actual therapy room for the majority of practitioners (Ciarrochi et al., 2024). Secondly, there are often individual and situational factors that influence the effectiveness of these treatment protocols. Therefore, therapeutic frameworks are needed that move beyond a focus exclusively on addressing the symptoms of Diagnostic and Statistical Manual (DSM) disorders and instead focus on the skills and aspects of functioning that are impaired for the person in their whole self.

Relationality

Human beings are relational, including both clients and therapists. We argue that integrating relationality is an important step in the direction towards a more holistic conceptualization of clients’ functioning and their progress in therapy. Based on the work of Slife and Wiggins (2009), we refer to relationality as the degree to which relationships function as a central focus of the existence of the units of analysis. In this particular case, we refer to the degree that relationships are a central focus of understanding people and behavior. Slife and Wiggins (2009) summarize theoretical research from fields as diverse as physics and psychology that examine the inherent degree of connection amongst items, objects, substances, and people. In contrast, psychology has traditionally focused on individualism, independence, and self-reliance; which conveys the impression that such goals and ideas take precedence over connections to family and community. Any connections between people are understood to exist because of an individual’s motivations and driving influences. In contrast, a strong relationality framework would posit that people, things, events, and places are first their relationships and connections with each other, and with context, and then the individuals within them (Slife & Wiggins, 2009).

Positive relationships impact individual and family functioning due to the foundational nature of relationships to human daily life. Social relationships have an essential influence on mental health both in situations that do and do not have adversity. Moreover, quality, content, and one’s subjective interpretations are essential considerations for beneficial relationships (Andersen et al., 2021). For instance, family and parent marital relationship quality impacts the family’s mental health in addition to the individual’s mental health (Cummings et al., 2005; Thomas et al., 2017). Family relationships also impact psychological health and quality of life (Grevenstein et al., 2019).

Within a strong relationality view, the therapist exists within the client’s relational context and neutrality is not possible (Slife & Wiggins, 2009). Thus it is vital that the therapist maintain awareness of their own role, power, and potential in the therapeutic relationship in order to facilitate change (Slife & Wiggins, 2009). This is in step with the consistent finding that the therapeutic alliance is a mediator of change in psychotherapy (Baier et al., 2020). In addition, the therapist’s self in the relational context is vital for therapeutic alliance maintenance. This is important given the influence of therapist attachment style on their ability to engage in therapeutic empathy and maintain the therapeutic alliance (McIntyre & Samstag, 2022). Further, therapeutic empathy is a dyadic process that takes place between both the client and the therapist (McIntyre & Samstag, 2022).

Thus, relationships are a vital focus of therapy and in conceptualization of clients. In order to properly focus on relationships, one must consider both the client and therapist, and their whole life contexts that they bring to the interaction. We are all inherently made up of our relationships and connections amongst each other in the past, present, and future (Slife & Wiggins, 2009). The environmental context is important as well, both socially and in the level of care setting. Each of these levels is addresed in Figure 1.

Integrated Model with Relationality

We argue that case conceptualization and treatment models should address symptoms according to relevant therapeutic processes, not just DSM diagnoses. These sections outline empirical and theoretical research according to how relationships, the therapeutic relationship, and environmental context can be emphasized within an existing integrated model, that of process-based therapy.

Process-Based Therapy

Alongside the manualization, and related “technification” of therapy, there has also been a parallel increased focus on integrated and transdiagnostic approaches in psychotherapy. This transdiagnostic movement has led to recent meta-models that attempt to incorporate many aspects of human functioning in a more nuanced way for case conceptualization, treatment planning, and clinical research. Process-based therapy can be defined as the use of evidence-based processes linked to evidence-based procedures within a context and to promote wellbeing (Hofmann & Hayes, 2019). To provide a nuanced and holistic view of integrating intervention strategies for psychological health, Hayes et al.’s (2020) proposed the extended-evolutionary meta-model (EEMM) , which emphasizes the thoughtful evaluation of information and adapting as foundational to psychological functioning.

Ong et al. (2024) describe how the EEMM can be integrated to describe functioning and wellbeing among many elements of human experience. In their paper about the EEMM, Ciarrochi et al., (2024) indicate that all psychopathology could be considered social in nature, and they focus on interpersonal relationships and culture at one level of their model. However this is only at one phase of treatment, and there is still a strong individualistic focus on behavior and outcome in relationships, versus a strong relationality focus that connection should be an inherent part of conceptualization, definition, and treatment planning from the start to the conclusion of therapy.

Motivation

Motivation is important to consider in understanding how people can come to engage in therapy. While motivation has been widely discussed as having a major impact on treatment outcome and engagement (e.g., Drieschner, Lammers, & van der Staak, 2004), its definition and operationalization varies widely. Motivation can be broadly defined in a variety of ways, including as an “internal force that moves an organism to engage in a particular behavior” (Drieschner et al., 2004, pg. 1117), or a “willingness and desire for change that comes from within” (as defined by Self-Determination Theory; Ryan, Lynch, Vansteenkists & Deci, 2011, pg. 194). These definitions highlight the role of motivation as a driver of treatment engagement, which represents the behavioral process resulting from an individual’s motivation.

Given the broad nature of these definitions, and variability of how individuals, clinicians, and researchers think about/approach motivation, having an organizing framework for understanding the complexities of an individual’s motivation for treatment can be useful in a treatment context. For example, Self-Determination Theory (Ryan & Deci, 2000) provides a flexible framework for understanding an individual’s motivation for mental health treatment that acknowledges the dynamic nature of motivation. Self-determination theory highlights the role of autonomy/choice, feelings of mastery, and relatedness/social connectedness as driving factors that influence an individual’s motivation for a task at a given time. Thus, relationships and social connection are present here as key drivers of helping people to engage in treatment.

Further, inherent in many of the motivation frameworks, is the importance of understanding that motivation should be viewed as related to a specific behavior or tasks (instead of viewed as a global construct). For example, many may state they are motivated to “get better,” but struggle to access motivation for engaging in the specific behaviors associated with the recovery process ((for example engaging in exposures to particularly distressing feared outcomes or confronting distressing/difficult emotions). Helping individuals understand the complex nature of human motivation, and how it can be influenced by contextual factors can help open the door to more direct and nuanced understanding of why we choose certain behaviors. While this process is highly individualized, research has identified many therapeutic factors that influence motivation in the context of treatment, including level of distress, insight/recognition of the problem being addressed, expectation of success, therapeutic alliance, and perceived costs of the treatment/process (Drieschner, Lammer, van der Staak, 2004).

Context and Environment

Hayes et al. (2020) also detail the role of one’s environment and the importance of considering all levels of influence on any given situation. To this aim, it is important to consider social and structural influences on perceptions of mental health, mental health care, help-seeking, and the origins of psychopathology (Browning et al., 2024; Ahuvia & Schleider, 2023). This should be done by understanding and addressing stigma, and acknowledging when the root of stressors may be systemic or structural in nature, such as systemic racism, threat of sexual assault, or actual negative views towards seeking mental health treatment from important people in one’s life (Browning et al., 2024; Ahuvia & Schleider, 2023). Further, shame is a construct related to treatment outcome that is rooted in a socially adaptive emotion that motivates people to correct taboo behaviors to fit in with a group, but can result in self-criticism and self-judgment (Norder et al., 2021). Shame warrants comprehensive and transdiagnostic treatments (Norder et al., 2021). These socially rooted challenges do not negate the need for psychotherapy, but instead warrant a more thoughtful and respectful approach that acknowledges a clinician’s humility and the client’s expertise on their own experience and positionality, and the specific targeting of the impact of internalized shame, stigma, and discrimination.

Some further examples of specific studies have detailed the impacts of environmental and contextual factors on mental health outcomes. In a large population study in Norway, numerous environmental stressors were related to mental health and wellbeing, including discrimination, unsupportive social environments, perceived problems with crime and violence where one lives, worrying about violence or threats, and problems with noise and contamination at home (Bjorndal et al., 2024). In a longitudinal study of the impact of adverse childhood experiences on later adolescent mental health, history and current exposure to bullying and parent psychological distress as a child were associated with increased anxiety and depression (Sahle et al., 2024). Lastly, health conditions are important to consider in families, as parental chronic illness can impact child psychological and educational functioning, and child chronic illness can impact their own psychosocial functioning (Chen, 2017; Brady et al., 2021)

Therapeutic Relationship

The therapeutic alliance is foundational to facilitating potential chance, regardless of theoretical orientation. It is important to integrate relational strategies by building on the use of transference and the therapeutic relationship, which can fit within process-based conceptualizations like that described by Ong et al. (2024). Even within manualized cognitive behavior therapy approaches, the therapeutic relationship still lies at the core of the work that is done. Central tenets of cognitive behavior therapy, such as collaboration, soliciting feedback, respect, and guided discovery, can all contribute to developing and maintaining a positive therapeutic relationship. In turn, creating a warm and positive relationship results in a solid foundation for the work to occur (Wenzel, 2021).

Several studies support the overall conceptualization of utilizing social support, relational strategies and the therapeutic alliance, as well as more direct skills-focused approaches in an integrated way to increase flexibility and values-based behavior. Fruhbauerova et al. (2024) found in their instrumental analysis of unified protocol data that both the therapeutic alliance and skill use helped facilitate outcomes in therapy. Null et al. (2024) found that social support mediated the effects of childhood unpredictability on anhedonia. Parker et al. (2024) found in a recent network study of psychological flexibility and relationships to well-being that overall psychological inflexibility was associated with distress, and psychological flexibility was associated with well-being. Lynch et al. (2006) detail mechanisms of action in dialectical behavior therapy surrounding reducing ineffective action urges related to strong emotions. Gomez-Penedo et al. (2023) found that changes in symptoms associated with cognitive therapy are preceded by accomplishing tasks in treatment and understanding of insight. Wrede et al. (2023) found that affective experiences within a session predicted coping within the context of a solid emotional bond between a client and therapist. Additionally, for those patient-therapist dyads with high affective experiences, collaboration agreement and therapists mobilizing strengths predicted coping. Macri and Rogge (2024) found in their meta-analytic review of treatment mechanisms that acceptance and commitment therapy techniques led to increased flexibility and decreased psychological inflexibility. Lastly, Oltean and David (2018) found in their meta-analysis that rational beliefs from a rational emotive behavior therapy lens are associated with decreased psychological distress. Together, this body of research suggests that both experiences within the therapeutic relationship, the therapeutic alliance, and specific skills targeted towards various mechanisms of interest all can combine together to create therapeutic change.

Clinical Skills at the Individual Level

There are multiple relevant aspects of schema, cognitive behavioral, dialectical behavioral, rational-emotive, acceptance and emotion regulation-based treatments for an integrated relational and process-focused conceptualization. At the core of this conceptualization is the idea that psychopathology originates from faulty beliefs that are not helpful, then leads to faulty predictive processing, similar to what Rief et al. (2024) and Herzog et al. (2023) describe. Techniques from schema therapy, as well as rational emotive behavior therapy could facilitate taking a holistic, contextual, and personalized view of the development and maintenance of beliefs a client builds on to relate to the world (van Dijk et al., 2023; Masley et al., 2012; David et al., 2017). This, along with techniques from cognitive therapy, would allow for targeting inferential, evaluative, and descriptive beliefs and considering their potential developmental origins. This could help a person adapt to more flexible ways of relating to the world (van Dijk et al., 2023; Masley et al., 2012; David et al., 2017; David et al., 2010). It may be useful to integrate ACT techniques, given their effectiveness for such a wide range of conditions (Ong et al., 2024; Gloster et al., 2020). Additionally, dialectical behavior therapy skills should be integrated into therapy, acknowledging the important lens distinguishing equally important roles of recognizing need for change with balancing acceptance (Linehan & Wilks, 2015). A recent qualitative study found that people who participated in dialectical behavior therapy reported being better able to manage difficult situations and engage in healthier and more rewarding relationships (Gillespie et al., 2022). These aspects should be integrated according to the skills a client needs to improve and make more flexible adaptations in their lives, thus also facilitating improved relational health.

The Clinician in the Relational Context

Part of considering relationality and the client as a whole person, as well as the therapeutic alliance, means also considering the clinician as a whole person. This will mean considering the clinician’s ability to maintain self-care, self-reflection, and distress tolerance skills in order to be able to mindfully engage in this kind of deep, thoughtful, and creative work. For example, Campbell-Lee et al. (2024) found that reflective capacity was a meta-capacity that was present to a greater degree in more experienced clinicians, although it is a skill that can be developed. Cooper et al. (2020) discuss one potential next step to develop reflective capacity, given that mindfulness skills are associated with some aspects of empathy development. Johnson and Walsh (2021) found that some aspects of in-session mindfulness practices were associated with the therapeutic alliance. Therefore reflective capacity is important for therapeutic effectiveness and can be developed through developing mindfulness skills.

These results align with Garrote-Caparros et al.’s (2023) finding that mindfulness and compassion-based intervention improved psychotherapy outcomes. There were improved patient symptoms, improved patient and therapist perceived psychotherapeutic mindfulness skills, and improved therapeutic bond. Relatedly, Clarke et al. (2024) found a protective role of self-compassion and psychological flexibility against emotional exhaustion for psychologists. These results align within McIntyre and Samstag’s (2022) conceptualization of therapeutic empathy as an empathic dialectic of which the therapist’s attachment security and mentalizing skills are a vital component. These things can be honed through developing reflective practice through mindfulness skills which can be conceptualized as foundational to mentalizing (Swenson & Choi-Kain, 2015; Allen, 2013). We would add that targeting clinician distress tolerance would be important in this process along with flexibility, and mentalizing skills, similar to the clinical procedure we outline, in order to facilitate their own flexible use of clinical strategies in response to their patients’ needs and the therapeutic alliance.

Discussion

In conclusion, flexibility is central for improving relationships and psychological health. Flexible ways of relating to one’s beliefs about the world and oneself and operating from a mindful, curious, and unattached stance can help someone adapt continuously to their external and internal experiences. Relationships are an essential part of this process, providing avenues for both barriers and resources to adapting, as well as contexts for functioning and values-based goals and actions. Overall, this integrated conceptualization would allow for a respectful, person-centered, and action-oriented theory of cure.

Clinical Considerations

An important future direction will be for clinicians to implement aspects of these meta-models in practice and to continuously refine and improve them based on how they are used in practice. It is essential for clinicians to be involved in conversations with theorists and researchers regarding implementation of these meta-models in practice and subsequent refinements. Additionally, there are models that detail a process for ensuring that a clinician is appropriately matching treatment kernels to necessary processes for their client, and it is vital that those are considered.

The nature of time, money, and access to treatment are vital, especially with the ever-changing landscape of behavioral health. This work with integrating relationships is deeper and more challenging as one is intervening at multiple levels of a system. However, one would hypothesize that it would create more robust and lasting health for a person, especially considering the numerous health benefits of positive social support and relationships (Cohen, 2004). Therefore, it is important to balance these ideas with the reality that some people may have limited time, money, and access to therapy, and therefore treatment should always be an ongoing and honest collaboration between patient and provider.

Reconceptualizing Recovery and the Role of the Patient

Further consideration and centering of the patient’s experience during treatment should be front of mind. Schleider et al. (2023) and Crane et al. (2023) detail similar ideas in discussing involving consumers in clinical research and involving those with lived experience, or “experts by experience.” Indeed, we all have some sort of intersection with the mental health care system whether it is as a consumer or relative of a consumer, as this can create a more open and empowering environment for delivering and seeking care. Moreover, this all fits under the concept of shared decision-making which aims to foster informed, meaningful, and collaborative discussions and relationships between patients and providers receiving healthcare services (SAMHSA, 2024).

An illustrative example comes from changing conceptualizations of recovery, and what it means to be “recovered”. The Recovery Science Research Collaborative offered the following consensus definition of recovery, “Recovery is an individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness” (Ashford et al., 2019). Many clinicians already conceptualize recovery from a restorative perspective (e.g., Rubenstein et al., 2024). However, when it comes to many risk behaviors, full cessation remains a common therapeutic goal, even if unstated. This may or may not be at odds with client goals (full cessation may not be a short or even long-term goal), and necessitates collaboration between client and therapist in setting realistic and achievable therapeutic goals (Whitlock, Lloyd-Richardson, & Woolsen, 2024).

Conclusion

Lastly, it will be important that the ideas considered in this paper be carried out within the therapy room, and then that they can be translated to other settings where clinical interventions are delivered (Dodge et al., 2024). This might involve integrated care settings, consultation programs, group therapy, stepped care approaches, in schools, at higher levels of care, or with the use of technology. It is important that the field balances the dialectics of acceptance and change, similar to dialectical behavior therapy (Linehan & Wilks, 2015), and does not neglect its roots of helping humans through relationships, but also changing with the ever-evolving nature of mental healthcare.