Cognitive Behavioral Therapy for a Challenging Patient

Psychiatric TimesVol 39, Issue 4

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

CBT©DavidCarillet/Adobe Stock

CBT©DavidCarillet/Adobe Stock

A lot of research demonstrates that the therapeutic alliance is associated with outcome and dropout1-3 and that successful repair of therapeutic relationship ruptures is associated with better outcomes.4 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 cognitive behavioral therapy (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:

Automatic thought: I can’t do this.

Response: 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 now!”

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 mean 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 really cared, you’d give me 100%.” I questioned her about the corollary of this assumption. “And since I didn’t 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 do care about you—and maybe it’s your assumption 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.

Dr Beck is president of 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, and 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.


1. Horvath AO, Bedi RP. The alliance. In: Norcross JC, ed. Psychotherapy Relationships That Work: Therapist Contributions and Responsiveness to Patients. Oxford University Press; 2002:37-69.

2. Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. J Consult Clin Psychol. 2000;68(3):438-450.

3. Turner RM. Naturalistic evaluation of dialectical behavior therapy-oriented treatment for borderline personality disorder. Cogn Behav Pract. 2000;7(4):413-419.

4. Safran JD, Muran JC, Eubanks-Carter C. Repairing alliance ruptures. Psychotherapy. 2011;48(1):80-87. ❒

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