Judith S. Beck, PhD

A lot of research demonstrates that the therapeutic alliance is associated with outcome and dropout

 and that successful repair of therapeutic relationship ruptures is associated with better outcomes.

 The following case example shows how I was able to overcome a rift in the therapeutic relationship with a patient who posed many challenges in treatment.

I had diagnosed “Nancy,” a 55-year-old female patient, with major depressive disorder, recurrent, moderate, and borderline personality disorder. Nancy had received many types of treatment—although not 

 (CBT)—beginning when she was aged 13 years.

At first, Nancy responded well to treatment. We worked on structuring her day—ensuring she got out of bed by 10 AM and followed a morning routine (shower, dress, eat breakfast, take medication, read therapy notes, etc)—and made sure to schedule activities that we predicted could give her a sense of pleasure, achievement, connection, or purpose. We also predicted the thoughts that could interfere with her following her schedule, and I used Socratic questioning to help her develop robust responses to them. Then we wrote the responses down for her to read every morning and on a pro re nata basis. A typical example is:

 It’s true that it is difficult to do this, but it’s not impossible. Jumping to the roof of my house would truly be impossible. It’s worth it to do an experiment and push myself 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 a challenge arose in session 6. The session proceeded in the usual fashion. We did a mood check. I asked Nancy for an update from our previous session, focusing on times when she felt even a little better, and I asked her what it meant to her that she was now able to consistently get out of bed, do her morning routine, do a little cleanup around her house, eat regular meals, and experience some degree of mastery and pleasure. She acknowledged that she was more capable than she had thought, that she was able to take more control of her life than she had expected, and that 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 into her schedule. As a result of our discussion, she created an action plan for herself to implement in the coming week, and she added to her therapy notes. Then I noted we only had a few minutes left and asked Nancy for feedback about the session.

At that point, Nancy wailed, “Oh, no. I need more time! I forgot to tell you that my mother is coming to visit, and I just don’t know what to do!” I told Nancy that I was sorry, but I could not give her extra time right away. I offered to schedule another session or half session in the next few days. When she angrily turned me down, I offered to have at least a brief phone call with her. She became very upset and yelled, “You don’t understand. I need to keep talking to you 

I knew that Nancy was not suicidal, that her depression had started to ease a little, and that she had gotten through many visits from her mother without me. My goal was to make sure she returned next week. So I acknowledged, “Nancy, you must really feel like I’ve let you down.” She readily and heartily agreed. Then I gave her a choice. “Nancy, let me propose 2 things. It’s very important that you let me know just how badly I’ve let you down. So I’d like you to write a letter to me right now, in the reception area.” She grimaced. I continued, “Or, if you don’t want to do that, I’d like to start next week’s session by having you tell me directly, before we check your mood, or set the agenda, or do anything else.” Nancy responded angrily, “Well, I’m not going to take time to write you a letter! But I will come next week and tell you.”

Fast-forward to our session the following week. As promised, I started off by asking, “Nancy, is it OK 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 

 to you that I didn’t give you extra time?” “Well,” she told me, “you obviously don’t care about me.” This statement was Nancy’s distorted automatic thought. Before I addressed it, I provided her with positive reinforcement for the feedback, even though it was incorrect. “It’s good you told me that, Nancy.” Then I followed up with a suggestion. “It seems to me it would be really important for you to find out whether that thought is 100% true, or 0% true, or someplace in the middle.”

Nancy agreed to evaluate her cognition. In the midst of examining the evidence that I cared or did not care about her, she expressed an underlying assumption. “But if you 

 cared, you’d give me 100%.” I questioned her about the corollary of this assumption. “And since I 

 give you 100%, does that mean I don’t care?” She nodded, “Of course.” Then I elicited her agreement to evaluate the idea that I was actually capable of giving her 100%. For example, I asked, “Wouldn’t giving you 100% mean that you could come to my office anytime, and I would have to ask whichever patient I was seeing to take a break and wait until we were finished?” After a few more examples, she sighed deeply and said, “I guess you can’t give me 100%.” I asked another leading question. “So is it possible that I 

that’s really the problem?” She sighed again, but agreed.

A few minutes later, I helped her generalize what she had learned from this part of the session to 2 important relationships. I asked her, “Have you had this idea about anyone else in recent times? Did you think someone else didn’t care because he or she didn’t give you 100%?” She pondered the question and recognized that she had been operating under the same unhelpful assumption in interactions with a cousin and a fairly close friend. In both cases, she had felt badly let down and interpreted the others’ behaviors as signs they did not care. When we looked for alternative explanations for what they had done (or failed to do), she was able to conclude that it was reasonable for them not to give her 100%—and that they probably did care. A little later in treatment, we discussed how to assess her interpersonal requests to make sure they were reasonable and how to express disappointment in a way that would not alienate others.

This was just 1 example of the challenges that this particular patient posed in treatment. Each time a new challenge arose, I conceptualized the challenging behavior and strong emotional reaction in the context of the cognitive model. I asked Nancy what she was thinking that led to a particular behavior or negative affect, positively reinforced her for the feedback, ascertained the meaning of the thought, and planned a strategy that often involved evaluating cognitions, solving problems, or both. These essential CBT techniques helped me mend this rupture with Nancy, and they have helped me develop and maintain strong therapeutic relationships with many patients who have posed challenges throughout treatment.

Beck Institute for Cognitive Behavior Therapy

, a nonprofit organization that provides state-of-the-art training in cognitive behavior therapy (CBT) and recovery-oriented cognitive therapy (CT-R), certification in CBT, and online courses on a variety of CBT and CT-R topics, in addition to conducting research and serving as a leading global resource in CBT and CT-R. Dr Beck is also a clinical professor of psychology in psychiatry at the University of Pennsylvania Perelman School of Medicine. She has written more than 100 articles and chapters, as well as books, workbooks, and pamphlets for professionals and nonprofessionals, including 

Cognitive Behavior Therapy: Basics and Beyond, 3rd edition

Cognitive Therapy for Challenging Problems: What to Do When the Basics Don’t Work

. She has made hundreds of presentations nationally and internationally on various applications of CBT and is the primary developer of Beck Institute’s online CBT training courses, which have been taken by health and mental health professionals in more than 130 countries. Dr Beck maintains a clinical caseload at Beck Institute’s in-house clinic in suburban Philadelphia, treating patients who experience a wide range of challenges.

Psychotherapy Relationships That Work: Therapist Contributions and Responsiveness to Patients

Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review

Naturalistic evaluation of dialectical behavior therapy-oriented treatment for borderline personality disorder

4. Safran JD, Muran JC, Eubanks-Carter C. 

Articles

When experiencing challenges with a particular patient, how can you repair the rupture in the therapeutic alliance?

Cognitive Behavioral Therapy for a Challenging Patient

is President of the Beck Institute for Cognitive Behavior Therapy in Philadelphia and is a Clinical Professor of Psychology and Psychiatry at the University of Pennsylvania. 

Videos

Judith Beck, PhD, talks Cognitive Behavior Therapy, clinical tips, and the work of her father, Dr Aaron Beck. 

Applying CBT to Psychiatry 

In cognitive behavior therapy (CBT), a good working relationship is essential to achieving the goals of therapy, keeping patients engaged, and inspiring hope. During her talk The Therapeutic Relationship in Cognitive Behavior Therapy at Psych Congress 2019 in San Diego, 

, discussed strategies for establishing and maintaining a strong therapeutic relationship and using the relationship to collaboratively solve problems and accomplish goals.

For over 25 years, Dr Beck has led the nonprofit 

. To fulfill its mission of improving lives worldwide through excellence in CBT, Beck Institute provides world-class training in evidence-based CBT, serving health and mental health practitioners, organizations and universities around the world. To learn more about Beck Institute’s training programs, or its new CBT Certification program, visit 

Judith S. Beck, PhD discusses the importance of the therapeutic relationship in CBT. She discusses strategies for developing and maintaining a strong therapeutic alliance and explains how to overcome challenges and repair ruptures.

The Therapeutic Relationship in Cognitive Behavior Therapy

Dr Judith Beck, Clinical Associate Professor of Psychology in Psychiatry at the University of Pennsylvania and President of the non-profit 

, is a featured presenter at this year's PsychCongress. Her talk is titled “Cognitive Behavior Therapy for Personality Disorders.”

Q: Why should psychiatrists be informed about cognitive behavior therapy (CBT)? 

A: A significant number of patients have some degree of personality pathology that can interfere with treatment, whether they receive medication or some form of psychotherapy.

Q. Why did you select this topic for PsychCongress this year and what aspects of CBT do you plan to cover?

A. I’ve seen that some psychiatrists struggle to understand why their patients with personality disorders behave in self-sabotaging ways and feel frustrated that these patients seem unable to take full advantage of the help the psychiatrist is offering.

Following a brief but detailed definition of CBT and a review of research on the topic, I will discuss the cognitive formulation for various personality disorders, a method of conceptualizing individual patients; strategies to strengthen and solve problems in the therapeutic alliance; and an information processing model to explain and demonstrate how to modify patients’ core beliefs.

Q: How is this topic relevant to psychiatrists who consider themselves “medication management only” clinicians? 

A: Patients with personality disorders may have beliefs that interfere with medication adherence. One set of beliefs concerns “other people.” They may think, for example, “Others (including the psychiatrist) are likely to diminish me, control me, criticize me.” Another set of beliefs reflects their basic understanding about themselves that they apply to the need for medication. “Taking medication means I’m weak; I’m crazy; I’m a failure.” Or, “Taking medication will harm me.” Identifying and modifying beliefs such as these leads to improved adherence.

A: CBT, as developed by Aaron T. Beck, MD, is a psychotherapy based on the cognitive model: It is not situations (internal or external experiences) that directly impact individuals’ reactions (their emotional, behavioral, and physiological responses), but rather their construal or perception of the situation.

When individuals are in emotional distress, they often display characteristic errors in their thinking. When they evaluate their thinking and appraise situations more realistically, they have an improved response. But 

 is not defined by the use of cognitive techniques. While cognitive and behavioral techniques are used most frequently, a variety of interventions from a range of psychotherapeutic modalities are used within a cognitive framework to bring about enduring changes in individuals’ thinking, moods, behavior (and sometimes physiology).

Q: How is CBT adapted for patients with personality disorders? 

A: Generally we focus initially on helping patients function better in their current lives, reduce symptomatology, solve problems, and learn skills. When the personality disorder itself interferes with patients’ ability to participate fully in recovery, we conceptualize the challenges in cognitive terms.

Often patients have negative beliefs about engaging in treatment, experiencing negative emotion, solving problems, and/or getting better. We put a greater emphasis on helping them modify their negative core beliefs, their basic understanding of themselves, their worlds, and other people. We may use a wider variety of techniques, including strategies from Gestalt therapy, motivational interviewing, interpersonal psychotherapy, dialectical behavior therapy, acceptance and commitment therapy, mindfulness, psychodynamic psychotherapy, compassion therapy, and positive psychology. When patients change their beliefs at an intellectual level, but not at an emotional level, we use emotional-level techniques, such as imagery, psychodrama, and behavioral experiments.

Q: How can clinicians develop a strong therapeutic alliance with patients who have personality disorders? 

A: We use a number of therapeutic relationship techniques with all patients, regardless of the presence or absence of personality pathology. Therapists act as a “team” with patients to help them reach their goals: They jointly make therapeutic decisions such as choosing which problems to focus on, share their conceptualization and treatment plan with the patient, provide rationales for interventions, elicit feedback at the end of sessions, and vary their style to suit the individual. They display solid counseling skills: accurate understanding, acceptance, positive regard, genuineness, and empathy.

While therapists strive to be attuned to the emotional experience of patients during sessions, they need to take special care with patients who have personality disorders. When therapists notice a shift in affect, they elicit patients’ thoughts and feelings. Patients with personality disorders often have overgeneralized, negative beliefs about other people, which they bring with them to the therapy session, and they may misperceive their therapist’s attitudes and intentions.

Providing patients with positive reinforcement for expressing negative feedback, apologizing when the therapist has made a mistake, and helping patients evaluate their negative cognitions and perceive the therapist more accurately-these components help build the alliance. Through the therapeutic relationship, patients can directly learn to correct distortions about themselves and others and to solve interpersonal problems. 

Dr Beck reports no conflicts of interest concerning the subject matter of this article.

Cognitive Therapy for Challenging Problems: What to Do When the Basics Don't Work

Cognitive Therapy of Personality Disorders (2nd Ed). 

Leahy RL, Beck JS, Beck AT. Cognitive therapy for the personality disorders. In: Strack S, Ed.

 Handbook of Personology and Psychpathology

A significant number of patients have some degree of personality pathology that can interfere with treatment, whether they receive medication or some form of psychotherapy. But how can clinicians develop a strong therapeutic alliance with patients who have personality disorders? An expert explains.

Judith S. Beck, PhD

Articles

Cognitive Behavioral Therapy for a Challenging Patient

Applying CBT to Psychiatry

The Therapeutic Relationship in Cognitive Behavior Therapy

What Psychiatrists Need to Know About CBT for Personality Disorders