When you experience challenges with a particular patient, how do you mend the breach in the therapeutic alliance?
Much research shows that the therapeutic alliance is associated with outcome and dropout1-3 and that successful repair of fractures in therapeutic relationships is associated with better outcomes.4 The following case study shows how I was able to overcome a rift in the therapeutic relationship with a patient who presented many treatment challenges.
I had diagnosed “Nancy”, a 55 year old patient, with Major Depressive Disorder, Relapsing, Moderate and Borderline Personality Disorder. Nancy had received many types of treatment since she was 13 – though no cognitive behavioral therapy (CBT).
Initially, Nancy responded well to treatment. We worked to structure her day – making sure she got out of bed by 10am and followed a morning routine (shower, dress, eat breakfast, take medication, read therapy notes, etc.) – and made sure activities were planned, that we predicted would give her a sense of joy, accomplishment, connection, or purpose. We also predicted the thoughts that might prevent her from keeping to her schedule, and I used Socratic questions to help her develop robust responses to them. Then we wrote down the answers for her to read each morning and pro re nata. A typical example is:
Automatic Thought: I can not do this.
Answer: It’s difficult, but not impossible. Jumping onto the roof of my house would be really impossible. It’s worth doing an experiment and urging me to try it for just 5 minutes because I really want to get better and reconnect with my family and friends and just feel normal. These things are really important to me.
By the end of our fifth session together, Nancy was feeling a little better, a little more in control, and a little more hopeful. But in Session 6 a challenge arose. The session proceeded in the usual manner. We did a mood check. I asked Nancy for an update from our previous session, focusing on times when she was still feeling a little better and I asked her what it meant to her to be consistently getting out of bed now, her morning routine doing a little tidying up around their house, eating regular meals, and experiencing a measure of mastery and enjoyment. She acknowledged that she was more capable than she thought, able to take more control of her life than she expected, and this boded well for the future.
Then I set the agenda. I asked her what problems or goals she wanted to work on during the session. We agreed to focus on adding interpersonal activities to their schedule. As a result of our conversation, she created an action plan for herself to implement over the coming week and attached her therapy notes. Then I realized we only had a few minutes left and asked Nancy for feedback on the session.
At this point, Nancy whined, “Oh, no. I need more time! I forgot to tell you my mom is coming to visit and I just don’t know what to do!” I told Nancy I was sorry but I couldn’t give her extra time right away. I offered to arrange another session or a half session in the next few days. When she angrily rejected me, I offered her at least a quick phone call. She became very upset and yelled, “You don’t understand. I need to keep talking to you now!”
I knew that Nancy wasn’t suicidal, that her depression had eased a bit, and that she’d gotten through many of her mother’s visits without me. My goal was to make sure she comes back next week. So I admitted, “Nancy, you must really feel like I’ve let you down.” She readily and heartily agreed. Then I gave her the choice. “Nancy, let me suggest two things. It’s very important that you let me know how badly I let you down. That’s why I want you to write me a letter in the reception area now.” She made a face. I continued, “Or, if you don’t want that, I’d like to start next week’s session by you telling me directly before we check your mood, set the agenda, or do anything else.” Nancy angrily replied, “Well , I will not take the time to write you a letter! But I’ll come and tell you next week.”
Fast forward to our session the following week. As promised, I started by asking, “Nancy, is it okay if we start with how badly I let you down last session?” She said, “You really did. I really needed help, and you wouldn’t give it to me.” To conceptualize her reaction, I asked, “What did it do? mean “Well,” she said to me, “obviously you don’t care about me.” That statement was Nancy’s warped automatic thought. Before addressing it, I positively confirmed her feedback even though it was wrong. “Glad you told me that, Nancy.” Then I followed up with a suggestion. “It seems to me that it would be really important for you to find out if that thought is 100% true or 0% true or somewhere in between.”
Nancy agreed to rate her cognition. In the midst of examining the evidence that I cared for her or not, she voiced an underlying assumption. “But if you Yes, really interested, you would give me 100%.” I asked her about the consequence of that assumption. “And since me not give you 100%, does that mean I don’t care?” She nodded. “Of course.” I then elicited her agreement to evaluate the idea that I might actually be able to give her 100%. For example, I asked, “Wouldn’t 100% mean that you could come into my office anytime and I would have to ask the patient I was treating to take a break and wait until we were done?” After a few After another example, she sighed deeply and said, “I guess you can’t give me 100%.” I asked another leading question. “So is it possible that I to do take care of you – and maybe it’s yours adoption Is that really the problem?” She sighed again, but agreed.
A few minutes later, I helped her generalize what she had learned from that part of the session to two important relationships. I asked her, “Have you had this idea of someone else lately? Did you think someone else wouldn’t care because he or she didn’t give you 100%?” She considered the question and realized that she’d been operating under the same unhelpful assumption in interactions with a cousin and a fairly close friend . In both cases she had felt very let down and interpreted the behavior of the others as a sign of indifference. When we looked for alternative explanations for what they had done (or failed to do), she concluded that not giving her 100% was reasonable – and that they probably cared. Later in treatment, we discussed how to evaluate her interpersonal requests to ensure they were reasonable and how to express her disappointment in a way that would not offend others.
This was just one example of the challenges this particular patient presented in the treatment. Each time a new challenge arose, I conceptualized the challenging behavior and strong emotional response in the context of the cognitive model. I asked Nancy what she thought led to a particular behavior or negative affect, affirmed positively for the feedback, identified the meaning of the thought, and planned a strategy that often involved evaluating findings, solving problems, or both. These essential CBT techniques have helped me heal this break with Nancy, and they have helped me build and maintain strong therapeutic relationships with many patients who have presented challenges throughout treatment.
Dr Beck is President of Beck Institute for Cognitive Behavioral Therapy, a non-profit organization that offers state-of-the-art CBT and Recreational Cognitive Therapy (CT-R) training, certification in CBT, and online courses on a variety of CBT and CT-R topics, in addition to conducting research and as the leading global resource for CBT and CT-R. dr Beck is also clinical professor of psychology in psychiatry at the University of Pennsylvania’s Perelman School of Medicine. She has written more than 100 articles and chapters, as well as books, workbooks, and pamphlets for professionals and laypeople, including Cognitive Behavioral Therapy: Fundamentals and Beyond, 3rd Editionand Cognitive Therapy for Challenging Problems: What to Do When the Basics Don’t Work. She has given hundreds of presentations nationally and internationally on various uses of CBT and is the lead developer of the Beck Institute’s online CBT training courses, which have been attended by health and mental health professionals in more than 130 countries. dr Beck oversees a clinical case group at the Beck Institute’s on-site clinic in suburban Philadelphia, treating patients who face a variety of challenges.
1. Horvath AO, Bedi RP. The Alliance. In: Norcross JC, ed. Psychotherapeutic relationships that work: Therapists’ contributions and responsiveness to patients. Oxford University Press; 2002:37-69.
2. Martin DJ, Garske JP, Davis MK. Relationship of therapeutic alliance with outcome and other variables: a meta-analytic review. J Contact the Psychol Clinic. 2000;68(3):438-450.
3. Turner RM. Naturalistic evaluation of dialectical behavioral therapy-oriented treatment of borderline personality disorder. Cogn Behavior Practice. 2000;7(4):413-419.
4. Safran JD, Muran JC, Eubanks-Carter C. Repair breaches of alliance. psychotherapy. 2011;48(1):80-87. ❒