The relationship between clinician and patient is vital to a client’s progress. You can use all sorts of strategies and techniques, but if your patients don’t trust you, and doesn’t feel like they can talk to you, you won’t get very far. After all, it’s hard enough sharing your vulnerabilities with a stranger.
So how do you build a strong therapeutic alliance?
We spoke with seasoned clinical psychologist Frank M. Dattilio, Ph.D, ABPP, all about the ins and outs of strengthening your connection with your clients. Dr. Dattilio is the co-author of the new book, “The Therapeutic Relationship in Cognitive-Behavioral Therapy: A Clinician’s Guide.” You’ll find his illuminating insights below.
Q: What is the biggest challenge in creating a connection with patients? How can clinicians navigate this challenge?
A: Actually, there are a series of related challenges in establishing a therapeutic connection with clients. We need to convey our level of expertise as a therapist to enable clients to even seek our services. But once the relationship begins, we need to endear ourselves to our clients, through communicating a clear and honest sense of our personhood, and the message that we are genuinely interested in helping them to achieve their goals in therapy.
Quite simply, clients evaluate the mental health professional as a person, and are unlikely to engage in or benefit from therapy with an individual whom they do not like. The skill in CBT is how to adapt that relationship, to best suit each individual client. Of course, no therapist can be all things to all people, but in our opinion, an effective relationship is central to success in therapy, and we have a duty to develop a solid sense of the client’s struggle in life.
The rest of it has to do with our particular skills as a clinician. Navigating this set of relationship tasks is not easy to address in a few sentences and is partly why my colleagues, Dr. Nikolaos Kazantzis, Dr. Keith Dobson and I dedicated an entire book to the subject (i.e., Kazantzis, Dattilio, & Dobson, 2017).
However, it is important for clinicians to first relate to their patients as human beings, and secondarily implement their knowledge and skills to facilitate the type of change the person desires. These are, in fact, simultaneous and parallel processes – we definitely do not mean to be misunderstood here, we do not believe that therapeutic outcomes are due to “common” factors.
Research shows that previously unstudied aspects of the therapeutic relationship in cognitive-behavioral therapy (CBT) suggest stronger relations with outcome than aspects such as a general “alliance.” Our collaborative research underscores this point, and the book is a communication of “how to” facilitate and develop these relationship factors for the clinician.
Q: What mistakes do clinicians unwittingly make when they try to strengthen their connection with clients, which might actually do the opposite?
A: One of the greatest mistakes that therapists make is to move too rigidly and quickly, to introduce techniques without considering their bond with the client. While we do not have yet data to support this idea, this technical style of interaction may come across disingenuously to clients, and explain why they drop out of therapy prematurely.
A central feature of our book is the CBT case conceptualization – we illustrate how central features of the bond, such as emotion focused empathy from the clinician, really should be tailored for each individual.
For example, some clients may have a vulnerability schema (i.e., core beliefs “I am weak,” “others are strong”, “the future is uncertain” in the context of a pervasive pattern of avoidance and fear). Such clients will benefit from a warm and empathic therapist at the outset of therapy as they develop a shared conceptualization of their panic attacks.
However, that same relational dyad may benefit from a central focus on securing their feedback within a broader process of collaboration, or shared work, as the client moves into introreceptive exposure. A different client with the same therapeutic goals, but with the belief that other people are insincere and untrustworthy, may require an early focus on expressed empathy.
If patients get the sense that they’re just a number, or that they are being judged, they will be less inclined to remain in therapy, as opposed to if they have developed a solid therapeutic relationship and genuinely believe that their therapist is interested and cares for them as a human being.
Even though CBT is often a short-term treatment, CBT therapists must take the time to know their clients and recognize that every technique exists within a relational context.
Q: What are the most important ingredients for clinicians to strengthen their connection with patients?
A: For one, avoid “talking at your client” as opposed to establishing a mutual exchange and dialogue. Clients do not want to be looked down on or diminished in any way, particularly in a therapeutic relationship. Secondly, it is important to acquire the skill of listening with a “third ear.” Do you really understand what they are saying? Clients want to know that [their] therapist truly understands their struggle, as opposed to fitting them into a therapy formula and proceeding with techniques and interventions, but without a true sense of their struggle.
The notion of “understanding the client’s internal reality” has always been part of how we train, assess, and accredit CBT therapists (see Cognitive Therapy Scale [Young & Beck, 1980] used by our accreditation body, the Academy of Cognitive Therapy). In our opinion, this understanding and interpersonal effectiveness represents the crux of developing a good therapeutic relationship. Of course, therapy is complex and we should not detract from the importance of techniques, but the relationship is necessary for therapeutic change in our opinion.
Q: What can clinicians do when working with a client who does not want to be in therapy and/or keeps resisting your interventions?
A: First, it has been long understood that resistance is a part of the treatment process even with the most motivated clients (Leahy, 2001). Understanding the essence of resistance is important before one can successfully address it. In CBT, we do not interpret the “resistance” or “reluctance,” but rather try to hypothesize the beliefs, previous relational experiences, and early childhood events that explain what is happening in the session. Usually clients relate to their therapists in the same way that they relate to others in their lives. Thus, resistance is not necessarily a “bad” thing that needs to be “worked through.”
Our suggestion is to develop a case conceptualization with respect to resistance, and then convey to the client that we understand it and in many ways even accept it, since it can be a sign of defensiveness or fear on the person’s part about making change.
From this perspective, resistance is naturally explained by core beliefs, assumptions, rules, and automatic thoughts, usually about other people, the client themselves, or their beliefs about their problems or how to cope.
We have developed a new case conceptualization worksheet in our book, which places a central emphasis on aspects typically missed in CBT. These aspects include: (a) the client’s attachment style, schema, and values; (b) significant aspects of their relational history, and associated beliefs; as well as (c) specific instances of in-session relational experiences with the clinician (e.g., such as the therapists use of collaboration, and Socratic dialogue), mapping how they are adapted based on these “deeper” cognitions and historical events. (With thanks to our colleague, Dr. Judith Beck, for the permission to adapt her case conceptualization diagram for this purpose.)
The effort to develop a relational case conceptualization helps our clients to appreciate that we understand the genesis and nature of their resistance, so that we can respond with curiosity and patience. This process is key to determine how to harness the same energy, in order to facilitate acceptable change for the client.
It is also important to convey to clients that we accept that being in therapy is a choice and that they don’t have to be there if they do not want to. The communication of respect for the client’s autonomy may help them to make a decision to remain in treatment for some time, so that the therapist and patient can re-evaluate whether or not it is in their best interest to continue.