Practice Innovations

© 2019 American Psychological Association 2019, Vol. 4, No. 2, 112–123

2377-889X/19/$12.00 http://dx.doi.org/10.1037/pri0000088

The Therapeutic Relationship in Cognitive–Behavioral Therapy:

Essential Features and Common Challenges

Annika Okamoto Frank M. Dattilio

Alliant International University Harvard Medical School
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Keith S. Dobson Nikolaos Kazantzis

This document is copyrighted by the American Psychological Association or one of its allied publishers.

University of Calgary Monash University

This article discusses the foundational aspects of the therapeutic relationship in cog-
nitive– behavioral therapy (CBT) and ways of utilizing relational tools to overcome
common challenges encountered by CBT therapists. Despite an emphasis on techniques
and quantifying change mechanisms, the therapeutic relationship is the context within
which interventions occur and is itself a critical aspect of treatment. From that basic
understanding, the unique nature of the client–therapist relationship within CBT is
explicated, including the concepts of collaboration, empiricism, and Socratic dialogue.
Each of these concepts is defined and discussed as a facilitator of treatment processes,
including how to use these relational concepts across the various stages of a “typical”
course of therapy. We illustrate with examples of client–therapist interactions and
emphasize facilitative responses from the clinician. The article concludes with a call for
ongoing theory development and research into the therapeutic relationship in CBT.

Clinical Impact Statement

This article provides clinical guidelines for utilizing relationship elements in cog-
nitive– behavioral therapy (CBT) and overcoming common challenges that thera-
pists face. In addition, it highlights the need for nesting any treatment technique
within a relational context and provides guidance for adapting particular CBT-
specific practices to the client’s unique presentation.

Keywords: therapeutic relationship, cognitive– behavioral therapy, Socratic dialogue,

collaboration, empiricism, homework, ruptures

This article was published Online First February 7, ing the past several years have come from the Aiglé
2019. Foundation (Argentina), Australian Psychological Soci-
Annika Okamoto, California School of Professional Psy- ety’s Institute, Australian Association of Cognitive Be-
chology of Los Angeles, Alliant International University; havior Therapies, Cektos (Denmark), Boston University,
Frank M. Dattilio, Department of Psychiatry, Harvard da Associação Juizforana de Estudantes de Psicologia
Medical School; Keith S. Dobson, Department of Psychol- (Brazil), Green Association for Behavioral and Cogni-
ogy, University of Calgary; Nikolaos Kazantzis, Cognitive tive Psychotherapies, the Institute of Behavior Research
Behaviour Therapy Research Unit, School of Psychologi- and Therapies (Greece), the International Congress of
cal Sciences and Monash Institute of Cognitive and Clin- Cognitive Psychotherapy, the New Zealand Psycholog-
ical Neurosciences, Monash University. ical Society, the Turkish Association of Cognitive and
Nikolaos Kazantzis receives royalties from Guilford Behavior Psychotherapy, the University of Melbourne
Publications, Inc, Springer Publishing, and Routledge (Orygen), the World Congress of Behavior and Cogni-
Press (which includes royalties from books on the topic of tive Therapies, the University of Crete, and various
this article). Grant monies for various projects come from other Australian universities.
the U.S. National Institute of Mental Health, U.S. National Correspondence concerning this article should be ad-
Institutes of Health, Helen, Macpherson Smith Trust, and dressed to Annika Okamoto, 170 South Detroit Street, Los
Lottery Health Research. Consulting and honoraria dur- Angeles, CA 90036. E-mail: [email protected]

112
 THERAPEUTIC RELATIONSHIP IN CBT 113

We view the therapeutic relationship as the ing decisions; and (c) seeking client feedback
“heart and soul” of all effective psychothera- about the reactions to the session (Kazantzis et
pies. While the structured nature of cognitive– al., 2017). Over time, collaboration aims to shift
behavioral therapy (CBT) lends itself easily to a the control to the client. This may decrease the
manualized approach, if used rigidly, or with a resistance that people naturally harbor when
central focus on predetermined interventions, facing a life change, making it less likely that
there is a risk of neglecting the dynamic rela- the client will feel patronized and the therapist
tionship that develops between the clinician and will feel solely responsible for the client’s prog-
clients, a necessary condition for effective prac- ress.
tice of CBT (Beck, Rush, Shaw, & Emery, Clients with persistent relational problems
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

1979). The therapeutic relationship is what gal- and/or personality disorders can experience a
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vanizes techniques and lays a foundation for major difficulty with collaboration. In such
case conceptualization, modeling behaviors,
cases, the clinician would be wise to consider
collaborating with clients, and supporting their
the client’s beliefs in case formulation and
autonomy.
Broadly speaking, the therapeutic relation- establishing collaboration. As early as the
ship may be defined as an exchange between first session, the therapist could inquire about
therapist and client with the goal of sharing the thoughts that a client has about the ther-
intimate thoughts and emotions to facilitate apist, and if dysfunctional thoughts emerge,
change. This exchange differs from the thera- assist the client in testing them or looking for
peutic alliance, which implies overt agreement evidence to support or rebuke them (Ka-
on goals, tasks, and bond (Kazantzis, Dattilio, & zantzis, Beck, et al., 2013). This approach has
Dobson, 2017). In the context of CBT, thera- several justifications. For people who present
pists can utilize “common” relationship ele- with impaired social relationships and/or se-
ments, such as expressed empathy or active vere affect regulation issues, the thoughts and
listening that are similarly understood in a wide feelings triggered by a new therapist may
variety of therapeutic camps, or “specific” ele- become dominant in therapy and impede work
ments such as collaboration, empiricism, and on other problems. Collaborative work on the
Socratic dialogue that acquire a distinct mean- client’s thoughts about the therapist builds
ing within CBT (Kazantzis et al., 2017). The trust and demonstrates the clinician’s ability
current article focuses on the use of these CBT- to connect to the client.
specific elements in addressing common chal- Effective CBT therapists model helpful atti-
lenges in CBT and guiding case conceptualiza- tudes and skills to manage and resolve distress
tion and interventions. and provide the consequences of functional and
dysfunctional client behaviors. While relevant
Establishing Collaboration throughout the treatment, the early sessions are
of particular importance in establishing behav-
According to Beck (1995), collaboration in ioral norms and expectations. Unless a clinician
CBT can be understood as teamwork fostering
takes a proactive approach in supporting func-
active client participation, whereas empiricism
tional interactions, the client might begin to
entails grounding the interventions within the
client’s experience (Kazantzis, Beck, Dattilio, shape the clinician’s behavior. For example, the
Dobson, & Rapee, 2013). The constructs of client may reinforce the therapist in making
collaboration and empiricism are typically con- decisions for him. Table 1 outlines some of the
joined in CBT in the form of “collaborative ways of pairing the client’s interpersonal style
empiricism” (Dattilio & Hanna, 2012; Lam, with respective clinical strategies.
Jones, & Hayward, 2010; Tee & Kazantzis, A therapist should remain mindful of any of
2011), reflecting their integrated use by clini- these behaviors in their context. For example,
cians. Specifically, collaboration in CBT refers while introducing peripheral content may be a
to the following: (a) sourcing of information sign of attention-seeking, it could also refer to a
from the client (i.e., rather than relying on gen- sudden increase in anxiety, concentration is-
eral principle or logic); (b) offering client sues, tangential thought processes, or memory
choice and soliciting client involvement in mak- impairment.
 114 OKAMOTO, DATTILIO, DOBSON, AND KAZANTZIS

Table 1
Pairing the Client’s Interpersonal Style With Therapist Behavioral Strategies (Adapted From Kazantzis,
Dattilio, and Dobson, 2017)
Client’s interpersonal style Client behaviors in session Therapist behavioral strategies
Attention-seeking • Excessive reliance on humor • Refuse to give special attention
• Introducing peripheral or unrelated content • Reinforce useful contributions
• Saying things to prompt an emotional response
• Unusual or inappropriate behavior
Dependent • Constant seeking of reassurance and advice • Avoid giving reassurance
• Avoiding confrontation or giving honest feedback • Let client answer their own questions
• Seeking approval of the therapist • Reinforce independent decisions
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• Difficulty making independent decisions

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Hostile • Persistent disagreement with the therapist • Remain unresponsive to provocation

• Criticism of the therapist • Acknowledge the client’s autonomy
• Hostility or irreverence toward the therapist
• Stubbornness regarding discussion and techniques
Withdrawn • Giving up on techniques prematurely • Avoid critical feedback
• Apathy toward therapy and techniques • Acknowledge slight improvements and progress
• Persistent omission of important information • Remain optimistic
• Sabotaging success of interventions • Avoid dominance to support the client taking charge

Using Socratic Questioning zantzis at al., 2018; Kazantzis & Stuckey,

2018).
Therapists can enhance clients’ intrinsic mo- Empiricism and collaboration are the building
tivation by supporting their independent deci- blocks for Socratic dialogue. Research evidence
sion-making and setting self-endorsed goals suggests that collaborative self-questioning—as
(Moller, Deci, & Ryan, 2006; Urbanoski & opposed to didactic instruction—supports client
Wild, 2012). This is fostered through Socratic autonomy, self-efficacy, and self-confidence (Tee
dialogue—a method of asking sequenced dis- & Kazantzis, 2011). Ideally, clients gradually in-
covery-oriented questions to facilitate cognitive ternalize the process of self-questioning and then
change (Beck & Dozois, 2011). Building upon spontaneously consider alternative thoughts and
each other, Socratic questions (Table 2) can be synthesize new meanings. Some readers may rec-
(a) exploratory, (b) perspective-shifting, and (c) ognize Socratic dialogue as one of the methods to
synthesizing (Kazantzis et al., 2017). conduct guided discovery. To respect the client’s
Clark and Egan (2015) point out that the term perspective throughout, a therapist may want to
Socratic dialogue implicitly communicates both stay open to multiple possible results instead of
the collaborative aspect as well as recognition pursuing a specific agenda (Kazantzis et al.,
of the client being in charge in addressing their 2017).
difficulties. In addition, Socratic dialogue pro-
motes the empirical discovery of one’s experi- Opening the Session
ences being inconsistent with dysfunctional
schemas, potentially leading to the synthesis of The opening phase of a CBT session allows
new meaning (Dobson & Dobson, 2017; Ka- the therapist and client to reconnect to each

Table 2
Types of Socratic Questions
Type of question Purpose Example
Exploratory Understand the concern • What are the pros and cons?
• What may be some of the reasons why this is happening now?
Perspective-shifting Explore alternatives • What does your best friend think of your situation?
• Are there any other explanations?
Synthesizing Facilitate discovery • How could you find the middle ground here?
• What can we conclude when considering all perspectives?
 THERAPEUTIC RELATIONSHIP IN CBT 115

other and to treatment. It typically includes a time usage, steer clients back from peripheral
brief mood check and functional assessment, topics, and use time-effective pacing appropri-
bridge to the previous session, review of be- ate for clients’ needs. Because clients may have
tween-session homework, review of current difficulties with remaining focused, therapists
concerns, and decisions about topics for the may want to follow a predictable yet flexible
session. While in the beginning and end of the structure for each session. The pacing can be
treatment it may be more beneficial to use for- adapted to individual needs, guided by case
mal psychometric for outcome evaluation, the formulation (Heyne, Sauter, Ollendick, Van
use of a client-defined mood rating scale is Widenfelt, & Westenberg, 2014; Kazantzis,
helpful for promoting empiricism. Instead of Tee, Dattilio, & Dobson, 2013). Kazantzis, Tee,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

just asking clients to rate their mood, a therapist et al. (2013) point out that the extent to which
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could invite them to build their own scale and structure is adhered to will also depend upon the
define the low, medium, and high anchor points strength of rapport, session content, and the
of ratings, acknowledging that the definition of stage in therapy. To illustrate the interplay of
these is likely to vary over time. these factors, Jungbluth and Shirk (2009) exam-
In some cases, a client may present with ined therapist strategies to build involvement in
crisis during the mood check, and the clinician CBT with adolescent depression and found a
may feel obligated to attend to it immediately. negative association between keeping the first
However, research evidence shows that adher- session highly structured given the client’s de-
ing to the CBT session structure is related to a velopmental needs for self-determination.
positive treatment response (Ginsburg, Becker,
Drazdowski, & Tein, 2012). It is recommended Designing Empirically Grounded
to bookmark the concern as a top priority Interventions
agenda item and finish the opening phase as
planned. This models mood-independent coping Although all CBT interventions produce si-
with the client learning that intense and chal- multaneous behavioral and cognitive changes,
lenging emotions do not have to result in chaos they can be more focused on one or the other.
and loss of control. Either focus may produce a different set of
Initially, clients may need assistance to set an challenges.
agenda and establish priorities. However, over For example, when trying to introduce behav-
the course of therapy, the responsibility for set- ioral interventions, therapists may find the client
ting the agenda ideally transfers from the ther- unwilling to engage. Strategies to enhance col-
apist to the client. The therapist will collaborate laboration in behaviorally focused interventions
with the client in setting an adequate agenda include making collaborative decisions in areas
fitting the time frame, establishing priorities, such as the focus of interventions; gauges to
and following the agenda (Young & Beck, evaluate interventions; data recording pro-
1980). The therapist should reserve sufficient cesses; the timing, frequency, duration, and lo-
time to adequately cover each agenda item by cation of interventions; and predictions about
including no more than one to three topics per the outcomes of planned interventions. To
session. Therapists can use collaborative ques- ground the intervention in the client’s experi-
tions to ask the client to identify salient emo- ence the, therapist can ask the client to make
tions and events for the week, seek suggestions multiple specific predictions about the outcome
for the session, or ask the client to prioritize the of the intervention, design multiple tests to-
session topics. The Socratic dialogue can be gether to evaluate predictions, and provide op-
used throughout the collaborative and empirical portunities to reevaluate predictions with data.
questions to promote the client’s discoveries. Table 3 presents Socratic questions that support
client involvement via collaboration and empir-
Maintaining Session Focus icism.
In cognitively focused interventions, clini-
The Cognitive Therapy Rating Scale (Young cians are venturing close to client’s value sys-
& Beck, 1980)—a measure of therapist compe- tem tied to their identity and core beliefs. Cli-
tence in CBT—reserves higher ratings for ther- ents may hold cultural—for example, familial,
apists that ensure productive session flow and religious, or spiritual— beliefs that a therapist
 116 OKAMOTO, DATTILIO, DOBSON, AND KAZANTZIS

Table 3
Examples of Socratic Questions That Support Collaboration and Empiricism
Collaboration Empiricism
What thought or emotion would you like to focus on? Can you discuss the last time you noticed it?
What do you think will happen if you act opposite to How can you measure the intensity of your emotion?
your emotion?
How could we find out if it is an accurate prediction? Is that particular situation a good way to test out your
prediction? How many times will you need to test
it?
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may mistake for dysfunctional core beliefs or cognition by accounting for the effects of expe-
cognitive distortions. These aspects of their be- riencing ongoing loneliness. Martha developed
lief system may constitute a “contraindication” the alternative perspective of the emotional re-
for intervention if they are at odds with the action to rejection being less disturbing than
client’s strongly held worldview and as a result isolation. She synthesized these perspectives as
should be approached delicately. The CBT ther- she realized that she is setting herself up for
apist is encouraged to be tentative when first certain failure when she magnifies the effect of
suggesting an intervention to evaluate assump- a potential rejection.
tions or rules, because it is likely to be emo-
tionally challenging to evaluate a belief system Managing Between-Session Interventions
for the first time. It may disrupt the client’s (Homework)
homeostasis and yield in significant distress.
The therapist should consider the use of So- Between-session interventions constitute an
cratic questions and collaboration by inviting extension of the psychological work accom-
the client to identify triggers for the cognition, plished in the session (Young & Beck, 1980).
asking the client to prioritize the cognition with Relationship elements influence the effective-
the most emotion, inquiring about the helpful- ness of these interventions from the very first
ness of the cognition, inviting the client to con- sessions. For example, clients who perceive
sider an alternative perspective, and developing their therapist to be more empathic in the be-
a tailored thought evaluation. ginning of the treatment may be more likely to
To anchor cognitively focused interventions comply with midtreatment homework assign-
in a client’s experience, CBT therapists can ask ments (Hara, Aviram, Constantino, Westra, &
the client to identify their cognitions, prioritize Antony, 2017). Ideally, a therapist and client
them based on a strength of emotion or belief, collaborate in tailoring a meaningful interven-
gather evidence for and against the prioritized tion that is empirically anchored in the client’s
cognition, obtain a rating of belief in the alter- experience.
native cognition, and rerate the emotion, pro- Several challenges exist in the use of assign-
moting synthesis and conclusions. While doing ments in CBT. Clients may unwilling to com-
so, a therapist can use Socratic questions to help plete activities that involve distressing thoughts
the client refine their thoughts, explore other or emotions (Cronin, Lawrence, Taylor, Norton,
related thoughts, develop alternative perspec- & Kazantzis, 2015). The mere term “home-
tives, synthesize the information, and gain feed- work” carries a burdensome connotation (Ka-
back on the usefulness of their discoveries. zantzis, Arntz, Borkovec, Holmes, & Wade,
Consider the following example: a CBT client, 2010). Clients may subtly draw the therapist
Martha, identified her cognition of avoidance in away from utilizing assignments by providing
asking a fellow whom she admired to have negative feedback or simply failing to complete
lunch with her: “I’d rather avoid asking him, the work. Research evidence shows that clini-
than risk rejection and be devastated.” She de- cians view homework to be less effective than
scribed the feared rejection as “something that I other CBT interventions, potentially because of
couldn’t rebound from.” Socratic questions as- difficulties with implementation (Chu et al.,
sisted Martha in reassessing the priority of her 2015).
 THERAPEUTIC RELATIONSHIP IN CBT 117

One solution to these challenges is to rethink decrease the client’s agency and reduce their
the purpose of between-session assignments. In- role to recipient of information. Research sug-
complete, unattempted, or “unhelpful” home- gests that didactic presentation of information
work opens the opportunity to discuss what got (as contrasted to Socratic questions) is per-
in the way, and whether or not the homework ceived as less helpful and less supportive of
assignment was too distressing, difficult, vague, autonomy and engagement (Heiniger, Clark, &
or poorly matched with client goals. Incomplete Egan, 2018).
homework assignments may reflect work ethic, The client can be encouraged to actively sum-
commitment, or skill deficits, but can also indi- marize the session and provide highlights. So-
cate the activation of a dysfunctional schema cratic questions can help the client synthesize
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such as unrelenting standards, defectiveness, or the session discoveries and link the work done
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worthlessness (“I can never do anything right”; with the overarching treatment plan. When
“I am not worth helping”; “What I do makes no planning between-session interventions, the
difference”) and provide data for other work. It therapist can inquire how these connect to client
may be helpful to ask for the client’s thoughts goals and make predictions of how they could
and emotions when planning, starting, and ex- help. The therapist can ask the client to evaluate
ecuting a task (Kazantzis et al., 2017). For ex- the session, have the client rate their readiness
ample, someone who maintains a schema that to complete the between-session interventions,
“What I do makes no difference” may have no and seek out their responses about the therapy
interest in attempting the assignment. If there is process in general. Throughout the ending
evidence that a client’s beliefs interfered with phase of the session, therapists can seek clients’
the completion of the task, the therapist can ask feedback on any issues or concerns and help to
how these beliefs are present in and affect other problem solve any obstacle (Kazantzis et al.,
aspects of their life (Cronin et al., 2015). 2017).
Effective between-session interventions re-
sult from collaborative discussion that includes Addressing Relationship Ruptures
the details (when, where, how often, how long)
and provides the client with a cohesive under- Safran, Muran, and Eubanks-Carter (2011)
standing of the purpose and steps of the plan define ruptures as deterioration of the collabor-
(Cronin et al., 2015). It is helpful to seek client ative relationship between client and therapist.
feedback on the perceived importance of the Ruptures can vary from minor tensions to major
intervention as well as their readiness and con- breakdowns. Safran and Muran (2000) differen-
fidence to follow through. In-session practice tiate between confrontation and withdrawal rup-
can also be useful as it allows clarification and tures, wherein the former involve the client’s
guidance and enables the client to experience expression of irritation or dissatisfaction with
some of the benefits. In the long term, being the therapist or aspects of therapy, while the
thorough and taking time is likely to pay off: latter includes the client’s partial or complete
quality ratings of homework completion appear withdrawal or disengagement. Ruptures often
to be a stronger predictor of treatment outcome combine both elements. Withdrawal ruptures
than quantity ratings (Cammin-Nowak et al., have been associated with inferior recovery and
2013). lack of treatment benefit (Boritz, Barnhart, Eu-
banks, & McMain, 2018), but confrontation
Ending the Session ruptures are more likely to lead to treatment
dropout if not navigated effectively by the ther-
The closing part of the session serves three apist (Coutinho, Ribeiro, Fernandes, Sousa, &
main tasks—summarizing the session, finaliz- Safran, 2014), possibly because the client’s di-
ing the plan for between-session interventions, rect expression of dissatisfaction makes it more
and seeking client feedback to the session and challenging to retain empathy and respond
planned interventions (Kazantzis et al., 2017). adaptively (Coutinho, Ribeiro, Hill, & Safran,
Clinicians may feel tempted to take control of 2011). Button, Westra, Hara, and Aviram
and/or speed up these processes— especially if (2015) suggest differentiating between clients’
they are running out of time. However, domi- resistance to the therapist and ambivalence to-
nant behaviors from the therapist are likely to ward change—they suggest that disharmony in
 118 OKAMOTO, DATTILIO, DOBSON, AND KAZANTZIS

the relationship impacts outcomes more nega- egies to manage emotions associated with the
tively. Coutinho et al. (2014) observed that cli- rupture experience. Ideally, therapists acknowl-
ents’ confrontation and withdrawal scores edge their own contributions to the rupture and
tended to increase immediately before dropping focus on the client’s thoughts and feelings re-
out, illustrating the need to address and resolve lated to the rupture. A therapist may also invite
ruptures to prevent premature termination. It is the client to make specific predictions of how
interesting that many clients dropped out before the therapist will react if the client expresses
the fifth session, suggesting a typical duration certain feelings or needs and empower the client
for alliance formation. to test these ideas (Safran & Muran, 2000).
Ruptures of the therapeutic alliance fre- Aspland, Llewelyn, Hardy, Barkham, and
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quently involve activation of a client’s beliefs Stiles (2008), who researched how therapists
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about self and others, including the therapist handle ruptures in the therapeutic relationship
(Safran & Muran, 2000). For example, clients in the CBT context, also recommend nondefen-
who expect abandonment may avoid disclosing sive exploration, validation, and client empow-
their needs or strike preemptively with anger. It erment. However, they note discrepancies be-
makes it difficult for the therapist to support tween what CBT therapists think they need to
them, and in turn, confirms the client’s negative do and actually do to attend to relationship
expectations. Thus, therapeutic ruptures neces- ruptures, because the therapists in their study
sitate exploration of the client’s beliefs and per- had difficulties acknowledging the ruptures to
ception of the therapist or interventions. For the client.
instance, a client who perceives the therapist as Clinicians may find that using collaboration,
too dominant may see themselves as inadequate focusing on the client’s experience and Socratic
and powerless. Exploring relationship ruptures questioning enhances the resolution process.
may provide the client with an opportunity for For example, consistent usage of motivational
corrective learning about themselves and others.
interviewing that employs Socratic questions
Haugen, Werth, Foster, and Owen (2017) stud-
and emphasizes collaboration during disagree-
ied different rupture patterns in psychotherapy
ments has been found to relate to better treat-
longitudinally, differentiating between ruptures
ment outcomes (Aviram, Westra, Constantino,
without repair (10.7%), ruptures with repair
(14.7%), and no-rupture patterns (74.5%). They & Antony, 2016).
found that the ruptures without repair were as- Self-disclosure can also help to address rela-
sociated with inferior treatment outcomes. Rup- tionship ruptures. A study by Miller and Mc-
tures with repair were associated with better Naught (2018) suggested that self-disclosure is
long-term treatment outcomes than the no- used in CBT as a tool for change and managing
rupture pattern. These findings support the im- the therapeutic relationship. The use of disclo-
portance of attending to ruptures as well as sure is especially pertinent for clients with per-
utilizing the therapeutic potential of the resolu- sonality disorders, for whom the relationship
tion process. may become central to therapy (Linehan, 1993)
Safran and Muran (2000) note that therapists and for whom the ruptures may involve a rep-
often engage in the client’s maladaptive inter- etition of earlier ruptures, activating intense and
personal pattern before realizing that they have negative feelings (Coutinho et al., 2011). Many
become a participant in that process. Safran and protocols have been developed especially for
Muran suggest shifting the interaction focus to treating people with personality disorders
the metalevel as soon as the therapist becomes (Beck, Davis, & Freeman, 2015; Leahy, 2001;
aware of problematic communication patterns. Linehan, 1993), and CBT therapists may want
Therapists can ask the client to discuss what is to incorporate these treatments or refer clients to
going on in the session or reflect their experi- a therapist who can provide the respective treat-
ence that the client is confronting or withdraw- ment (Kazantzis et al., 2017). Tufekcioglu, Mu-
ing. Clients frequently respond in a nonadaptive ran, Safran, and Winston (2013) found that re-
manner. For example, they may minimize their gardless of the formal diagnosis, certain client
own feelings, blame the therapist, change the traits such as impulsivity and poor emotion reg-
topic, or make general complaints. These ac- ulation correlate with higher rupture intensity
tions should be conceptualized as coping strat- ratings by clients.
 THERAPEUTIC RELATIONSHIP IN CBT 119

Some therapists are more likely than others to a one-time task targeting only client’s culture.
experience ruptures or early treatment termina- As the importance of multicultural issues in
tion. Presley, Jones, and Newton (2017) re- psychology has become more acknowledged,
ported negative associations between therapist the notion of cultural competence has been re-
perfectionism, treatment efficacy, and client re- fined by concepts that emphasize it as a process
tention. They recommended that therapists and not expertise, such as cultural inclusion and
manage their own cognitive schemas as part of cultural humility (Hook, Davis, Owen, Wor-
their clinical practice. Therapists need to be thington, & Utsey, 2013).
mindful of the impact that their personality, Knowing that the therapist’s attitudes and
personal history, cultural background, and value feelings about the client play a significant role
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system have on their clients to respond appro- in the success of the relationship, it is important
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priately when issues arise (Kazantzis et al., to note that various difficulties that clinicians
2017). attribute to clients may be rooted in cultural
differences. For instance, Owen et al. (2017)
Incorporating a Cultural Lens suggest that therapists’ level of cultural comfort
with ethnically and racially diverse clients (but
Respect for and responsiveness to the client’s not with their overall comfort in doing therapy)
cultural beliefs and preferences is inherent in plays a role in unilateral termination decisions
collaborative empiricism, because it uses the of their racial/ethnic minority clients. The rela-
client’s experience as a basis for therapeutic tionship-based approach calls for therapist’s cu-
work (Kazantzis, Tee, et al., 2013). The appli- riosity and openness to different vantage points
cation of any relationship-based strategies re- of clients and willingness to self-reflect.
quires consideration of cultural aspects and a Naeem et al. (2015) suggest that the cultural
mindful effort to maintain cultural sensitivity adaptation of CBT should extend beyond trans-
and curiosity (Wong, 2013). For instance, build- lation of therapy manuals to assessment of cul-
ing collaboration in collective cultures may be tural identity (including religion, spirituality,
very different than in individualistic cultures and family involvement) and acculturation lev-
(Kazantzis, Tee, et al., 2013; Wong, 2013). As el. They stress the necessity of culturally sensi-
another example, culture impacts the case con- tive engagement strategies and adaption of in-
ceptualization. Husain and Hodge (2016) illus- terventions. Chu and Leino (2017) describe
trate how the biomedical basis of making clin- multiple levels of potential cultural modifica-
ical decisions in Western psychotherapy may tions. Peripheral modifications involve changes
conflict with a person’s cultural or spiritual un- in client engagement (e.g., outreach efforts) and
derstanding of their problems: Being cursed by in treatment delivery (e.g., modifications to ma-
the evil eye can be overlooked as a cultural terial and semantics). In contrast, core modifi-
expression of distress or misdiagnosed as psy- cations involve structural adaptations to treat-
chosis. ment delivery, maintaining interpersonal styles
However, cultural considerations extend be- congruent with the client’s culture, and allow-
yond a client’s association with a particular ing for person/place modification (e.g., adding
ethnic population. Many therapists utilize the spiritual healers into treatment). Therapists can
“ADDRESSING framework” developed by Pa- assess the client’s cultural needs and collabora-
mela Hays (2008) to recognize overlapping cul- tively decide with the client whether they can
tural influences of age, disabilities, religion, eth- meet these needs, at least to the extent it that
nicity, socioeconomic status, sexual orientation, allows both parties to reasonably assume that
indigenous heritage, national origin, and gen- the treatment will succeed.
der. Therapeutic relationship emerges at the
crossroads of various intersecting social identi- Concluding the Therapy Relationship
ties of both the client and clinician, in the con-
text of a particular place and time, and as such, The literature on concluding therapeutic rela-
is comprised of complex, unique, and dynamic tionships in CBT is limited and existing studies
social elements. This sanctions an ongoing cul- focus more on premature termination (Dobson
tural reflection of the therapy encounter as op- & Dobson, 2017). Termination may be less
posed to approaching the cultural assessment as researched in CBT when compared with other
 120 OKAMOTO, DATTILIO, DOBSON, AND KAZANTZIS

modalities as CBT is a time-limited and goal- another. If they conclude that ending the ther-
oriented treatment and primes clients for the end apy is the most honorable course of action, they
of treatment from the first session (Vidair, Feyi- need to be honest with themselves and the client
jinmi, & Feindler, 2017). In any event, the end and initiate the discussion about whether the
of therapy may be associated with multiple out- client may be better served by another therapist
comes, as clients may have achieved the in- or treatment modality. Dattilio (2013, 2015)
tended goals, may not be benefitting from ther- points out that therapists risk burn-out if they
apy, or may have logistical or financial reasons continue to work with clients who do not benefit
to discontinue. from treatment or have reached their potential
Whenever possible, it is helpful to construct a within the particular treatment settings. Clini-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

relapse prevention plan, link the client to out- cians may also have a negative reaction to a
This document is copyrighted by the American Psychological Association or one of its allied publishers.

side resources (Antony, Ledley, & Heimberg, client for personal reasons. If it persists, despite
2005; McKay, Abramowitz, & Taylor, 2010), seeking supervision and/or consultation, it may
and phase out the last sessions to allow for be necessary to discuss the need to end treat-
practice of skills as well as adjustment to losing ment openly with the client while taking per-
the support. It is also important to consider the sonal responsibility. The therapist should sum-
surrounding context of ending the treatment, marize the work done together and plan ending
such as waiting until a stressful time period has therapy as one would do with a successful case.
passed (Kazantzis et al., 2017). Vidair et al. If appropriate, it is the therapist’s responsibility
(2017) suggest that in the case of therapy com- to offer referrals or resources and ensure that the
ing to a natural closure, the therapist should client has access to these resources before the
initiate the discussion of termination, process collaboration ends (Kazantzis et al., 2017). Ta-
the related experiences, cover practical aspects ble 4 provides strategies to respond to common
such as relapse prevention or booster sessions, emotions evoked by the end of therapy.
and make space to say goodbye during the final
session.
To support a collaborative and experience- Summary
grounded end to therapy, therapists can ask cli-
ents Socratic questions that invite clients to This article is predicated on the clear under-
consider their degree of progress, evaluate their standing that the therapeutic relationship is an
achievement of treatment goals, rate their cur- integral aspect of CBT. The article describes the
rent satisfaction and quality of life, or discuss unique nature of the relationship within CBT,
their observations about their own change and including the concepts of collaboration, empir-
sense of agency. Other common activities in- icism and Socratic dialogue and their use across
clude reviewing and synthesizing highlights the various stages of therapy. We also provide a
from therapy, discussion of remaining concerns, number of examples of circumstances in which
and exploration of feelings related to the con- the therapeutic relationship can be fostered, and
clusion of therapy. Regardless of the success provide examples of therapist-client interac-
level of the treatment, therapists can express a tions and facilitative responses that the therapist
fitting degree of confidence in clients, acknowl- can provide.
edge the effort invested from both therapist and We are highly mindful that much of the dis-
client and offer the option to return if circum- cussion in this article reflects shared clinical
stances warrant it. Adherence to collaboration wisdom about how to optimize the practice of
and empiricism will affect how clients perceive CBT, as opposed to evidence-based or validated
the end of therapy. Clients’ higher ratings of concepts and practices. Much of the literature
productivity during the termination sessions are related to the therapeutic relationship in CBT
related to their engagement and participation has evolved from clinical practice and reflects
level in those sessions (Weil, Katz, & Hilsen- the shared experiences of many clinicians (cf.,
roth, 2017). In successful treatments, patients Kazantzis et al., 2013). There is relatively
viewed themselves as more engaged in the ter- sparse research in these areas, so we hope that
mination process (Knox et al., 2011). as with other aspects of CBT, the therapeutic
Therapists may feel that the relationship with relationship itself will become the object of
a client is not productive, for one reason or study and will ultimately remain integrated with
 THERAPEUTIC RELATIONSHIP IN CBT 121

Table 4
Strategies to Address Clients’ Common Emotional Responses to the End of Therapy
Client’s emotions Clinical strategies
Client expresses anger and/or rage • Validate client’s experience
• Acknowledge one’s own role in triggering client’s frustration
• Establish boundaries for acceptable behaviors or ways of expressing
emotions
• Protect one’s own safety and well-being if need be
Client expresses fear and articulates feeling • Use Socratic questions to facilitate an increased sense of self-
dependent on therapist autonomy and self-reliance, as well as internal attributions for
achieved change
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

• Reduce frequency or length of sessions as you move towards the

This document is copyrighted by the American Psychological Association or one of its allied publishers.

end of treatment or schedule a holiday from therapy

• Normalize anxiety and express realistic confidence in client’s ability
to manage, but avoid active attempts to soothe client
• Target dependency as the last treatment goal
Client expresses sadness or denies any • Validate and normalize sadness or feelings of loss
sadness • If client denies feeling any sadness at all, consider disclosing your
own feelings of sadness
• Stay present (as opposed to minimizing the loss or cheerleading the
client)
• Facilitate processing of the loss

an overall evidence-based practice of CBT Boritz, T., Barnhart, R., Eubanks, C. F., & McMain,
(Dobson & Dobson, 2017). S. (2018). Alliance rupture and resolution in dia-
lectical behavior therapy for borderline personality
disorder. Journal of Personality Disorders,
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