The Evidence BaseD Practitioner

Cory F. Newman, PhD, ABPP - University of Pennsylvania, Perelman School of Medicine

A common misconception about CBT is that the therapeutic relationship is not given sufficient attention; that it is taken for granted and not addressed as an important factor in therapy. A simple review of the literature in CBT demonstrates otherwise, in which the early, seminal works of A.T. Beck explicitly state that the methods of cognitive therapy (or CBT, as the two have become intertwined over the decades) require a caring, constructive, collaborative therapeutic relationship for the patient to benefit optimally from treatment (e.g., Beck, 1976; Beck, Rush, Shaw, & Emery, 1976). In 1980, Beck, along with Jeffrey Young, developed the Cognitive Therapy Scale (CTS: Young & Beck, 1980), which is perhaps the most widely used measure of competency in conducting generic, Beckian CBT. The CTS includes three scoring categories out of eleven that measure aspects of the therapeutic relationship, demonstrating the high priority that is placed on the relational competencies of the CBT therapist. In the ensuing years, many publications in the field of CBT offered empirical and clinical support for the importance of the therapeutic relationship in CBT, including methods for understanding, managing, and resolving difficulties in the alliance between therapist and patient (e.g., Safran & Segal, 1990; Gilbert & Leahy, 2007).

When patients have significant, perhaps pervasive and chronic problems in their interpersonal lives, it is not uncommon for them to bring these difficulties into the therapeutic relationship (Safran & Segal, 1990). Sometimes this is manifested by a penchant for mistrusting the therapist, having unrealistic expectations for treatment, communicating in ways that are inadequate and/or aversive, and other such problems (see Newman, 1997, for extreme examples). Such scenarios pose special challenges for CBT therapists, who may come to realize that being pleasant, professional, attentive, and competent are necessary but insufficient conditions to earn optimal collaboration from some patients. Additionally, even when the patients do not necessarily manifest serious interpersonal dysfunction, they may have areas of psychological vulnerability (e.g., early maladaptive schemas, see Young, Klosko, & Weishaar, 2003) that can lead to alliance strains or ruptures when well-meaning therapists make a misstep (e.g., saying something that is invalidating). Therapists, as all humans, are fallible, and sometimes their errors can create stress and strain in the therapeutic relationship (e.g., forgetting something very important about a patient, to the patient’s dismay and chagrin). When any of these scenarios occur, it is a vitally important competency for the CBT therapist to be able to recognize the problem, conceptualize what is happening, take ownership of at least part of the process, maintain composure, empathy, and professionalism, and intervene to repair the strain or rupture in the therapeutic relationship (see Eubanks, 2022; Zilcha-Mano, Eubanks, Bloch-Elkouby, & Muran, 2021).

The literature on problems in the therapeutic relationship has described two broad categories – withdrawal ruptures, and confrontation ruptures. Withdrawal ruptures refer to those scenarios in which the patient is disengaging from therapy, either within a session (e.g., giving perfunctory but inauthentic comments just to be polite) or outside a session (e.g., failing to show up for a session and then not returning the therapist’s messages). Withdrawal ruptures that occur in a session can sometimes be difficult to detect, as the patient often is not being explicit about their discomfort or displeasure with what is occurring in therapy. Therapists in this situation may ascertain that the energy in the session is low, and/or that progress in the session is sub-optimal, but they may not want to jump to the conclusion that the patient is silently unhappy with the process. Even when therapists ask their patients for feedback, there is a chance that the patient will simply state that things are fine, avoiding discussing their actual thoughts and feelings. Confrontation ruptures are more overt, in that they characteristically involve patients making comments or otherwise engaging in behaviors that are patently negative. Such comments may be described as complaining about or disagreeing with the methods of treatment, criticizing or blaming the therapist, and sometimes even expressing demands and threats. Here, the therapist’s main challenges are maintaining a professional demeanor, staying empathic, being able to listen, and then having the conceptual understanding and communication acumen to begin a process of trying to do constructive problem-solving with the patient, perhaps under duress.

As mentioned above, therapists sometimes make mistakes that play a role in the alliance rupture, and this needs to be acknowledged. Nonetheless, there is evidence that alliance ruptures have been found to be more common in working with patients diagnosed with personality disorders than when treating patients without such diagnoses (Coutinho, Ribeiro, Sousa, & Safran, 2014). Interestingly, there is evidence that alliance ruptures with patients who have diagnosed personality disorders may present a positive opportunity for therapists to present the patients with a meaningful, corrective experience (in repairing the rupture) that allows their work to continue, perhaps with more of a sense of collaboration and optimism than was evident prior to the rupture, and with improved outcomes (Strauss et al., 2006; Cummings, Hayes, Newman, & Beck, 2011). With this in mind, therapists who are confronted with significant difficulties in their interactions with patients can rally themselves with the understanding that if they bring a high level of conceptual, relational, and technical skills to the situation they may be catalysts for significant therapeutic change. Recent studies of the phenomena and skills pertinent to repairing alliance ruptures suggest that the requisite competencies to manage these challenging situations can be taught (Eubanks, 2022; Muran, Safran, Eubanks, & Gorman, 2018), thus adding impetus to inclusion of this topic in supervised clinical practica and continuing education training.

Clinical Examples

The following are two, brief, representative examples of therapists recognizing and addressing alliance ruptures – a withdrawal rupture, followed by an example of a confrontation rupture. Each example is comprised of four parts: (1) situation, (2), patient’s responses, (3) therapist’s conceptualization of the patient’s responses, and (4) therapist’s responses.

Withdrawal Rupture

1. Situation: The patient, a young cisgender female diagnosed with a severe mood disorder, also shows signs of excessive eating restriction and a possible trauma history, neither of which she acknowledged at intake (or since). I (the therapist) delicately state that I would like to ask more about her eating habits as part of today’s session agenda, expressing worry about her gaunt appearance.
2. Patient’s Responses: The patient looks downward, keeps her glance fixated there, and goes silent for a long period of time. She does not interact with me, even when I express concern and empathy, and even when I apologize for bringing up such a sensitive topic without advance notice.
3. Therapist’s Conceptualization: The patient has stated earlier that she often feels that she has “no control” over her personal space and time in the face of demands and intrusions from her parents and her employer. It is also possible that she has experienced traumatic intrusions into her personal space that she has not yet discussed. She tries to maintain some semblance of control by circumscribing what she is willing (and not willing) to discuss in therapy. Apparently, I have just breached her boundary, and she is experiencing a negative affect shift, manifested by going mute and not making eye contact. This behavior may also reflect a self-protecting trauma response of trying to hide, though this is a topic we have not previously discussed. Now I have to facilitate giving her back a sense of control and safety.
4. Therapist’s Responses: (At first remaining quiet, hoping that the patient will look up and see my sympathetic demeanor, but she does not, so I quietly, caringly state the following). “I can see you’re in some distress, and I’m concerned that my comments may have triggered you (long pause). I gather that asking about your eating is a very sensitive topic for you, and I probably should have realized that (long pause). If my comments and questions came across as a jarring invasion of your privacy, or maybe sounded like an accusation I sincerely apologize (long pause). You have a right to set the agenda for your own therapy, and I owe it to you to respect your agenda (short pause). I also think I owe it you to share with you my best clinical observations so you can have the most effective treatment plan, and that’s why I asked about your eating (short pause). I hope you will talk to me to let me know how you’re doing right now. I get bored listening to myself talk. I would much rather have a collaborative dialogue with you. I promise that I will be very respectful of what you have to say on this matter.”

Confrontation Rupture

1. Situation: The patient, a middle-aged cisgender male with a range of anxiety disorders and related IBS, notes that he succeeded in going hiking with some friends, overcoming his fear of heights and possibly not being able to find a bathroom when he might need it. I (the therapist) congratulate him, showing genuine enthusiasm for the patient’s accomplishment, and I wonder aloud how the patient might be able to generalize this success experience to attempt to face other previously avoided situations.
2. Patient’s Responses: (Voice grows progressively more irritated in tone). So, you’re saying that what I did wasn’t enough? I should just do more, right? All this anxiety I’ve had my whole life, I should just fix it, right? That’s what you’re saying? You think it’s easy? Do I get a chance to just enjoy one small respite from my humiliation, or do I have to do more, and more, and more in this therapy? (Looking very tense in facial expression and sitting posture).
3. Therapist’s Conceptualization: This patient has a long history of being humiliated for decades by his father for having anxiety and “not being a man.” Consequently, the patient – though he has friends and a successful career – has felt a deep sense of shame, often experiencing great anticipatory anxiety that his peers will discover his vulnerabilities and reject him. Currently, the patient does not hear my comments as supportive, respectful, and hopeful, but perhaps as patronizing, dismissive of the significance of what he has just done, and/or demanding more from him because he is not yet “good enough.” The patient’s fight-or-flight responses become heightened, as he experiences both anxiety and anger at this perceived insult and invalidation.
4. Therapist’s Responses: (First, gathering myself in response to the patient’s unexpectedly angry comments, then proceeding in a manner that was meant to run totally counter-schematically to what the patient would have expected from his father, as Safran & Segal’s text would recommend). “I am genuinely happy for you. I also recognize that going hiking required a great deal of fortitude and belief in yourself. It’s a major deal, and I respect you for making this important step forward – probably at least 30,000 steps if we look at your Apple Watch. I would never, ever make light of anyone’s therapeutic achievements, and I never take for granted how difficult it can be to keep pushing beyond one’s comfort zone, again and again. You are way beyond “good enough.” And I am committed to supporting you.  

Concluding Comment

The clinical examples above are but “snippets” of what happens when a therapist identifies, conceptualizes, and responds therapeutically to an alliance rupture. It is not typically a quick or easy process, nor can it be expected to be linear (Lipner et al., 2023). The pathway forward can be dramatically positive, or less so, depending in part on how the patients perceive and respond to the therapist’s attempts to repair their rift. Regardless, the examples above provide a flavor of what is involved, how it fits very well within a CBT model, and how important it can be in preventing treatment drop-out and in promoting more positive therapeutic outcomes.

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Beck, A. T., Rush, A. J., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press.

Coutinho, J., Ribeiro, E., Sousa, I., & Safran, J. D. (2014). Comparing two methods of identifying alliance rupture events. Psychotherapy, 51, 434-442. https://doi.org/10.1037/a0033171.

Cummings, J. A., Hayes, A. M., Newman, C. F., & Beck, A. T. (2011). Navigating therapeutic alliance ruptures in cognitive therapy for avoidant and obsessive-compulsive personality disorders and comorbid Axis-I disorders. International Journal of Cognitive Therapy, 4, 397-414. DOI:10.1521/ijct.2011.4.4.397

Eubanks, C. F. (2022). Rupture repair. Cognitive and Behavioral Practice, 29(3), 554-559. https://doi.org/10.1016/j.cbpra.2022.02.012

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Lipner, L. M., Liu, D., Cassel, S., Hunter, E., Eubanks, C. F., & Muran, J. C. (2023). V-episodes in the alliance: A single-case application of multiple methods to identify rupture repair. Psychotherapy, 60(1), 119-129. https://doi.org/10.1037/pst0000469.

Muran, J. C., Safran, J. D., Eubanks, C. F., & Gorman, B. S. (2018). The effect of alliance-focused training on a cognitive-behavioral therapy for personality disorders. Journal of Consulting and Clinical Psychology, 86(4), 384-397. DOI:10.1037/ccp0000284

Newman, C. F. (1997). Maintaining professionalism in the face of emotional abuse from clients. Cognitive and Behavioral Practice, 4(1), 1-29. DOI:10.1016/S1077-7229(97)80010-7

Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. Jason Aronson.

Strauss, J.L., Hayes, A.M., Johnson, S.L., Newman, C.F., Barber, J.P., Brown, G.K., Laurenceau, J.P., & Beck, A.T. (2006). Early alliance, alliance ruptures, and symptom change in cognitive therapy for avoidant and obsessive-compulsive personality disorders. Journal of Consulting and Clinical Psychology, 74(2), 337-345. https://doi.org/10.1037/0022-006x.74.2.337 

Young, J. E., & Beck, A. T. (1980). The Cognitive Therapy Rating Scale. Unpublished manual. University of Pennsylvania, Philadelphia, PA.

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. Guilford Press.

Zilcha-Mano, S., Eubanks, C. F., Bloch-Elkouby, S., & Muran, C. J. (2021). Can we agree we just had a rupture? Patient-therapist congruence on ruptures and its effects on outcome in brief relational therapy vs. cognitive behavioral therapy. Journal of Counseling Psychology, 67(3), 315-325. Doi:10.1037/cou0000400.