Strengthening Therapeutic Relationships

• A strong therapeutic relationship has long been acknowledged as a critical factor in therapy success, but traditional therapeutic models have sometimes struggled to develop this connection.
• Motivational interviewing can be a valuable tool for uncovering clients’ beliefs and feelings about therapy that drive resistance and stand in the way of strong, productive professional connections.
• Collecting real-time client feedback about the therapist-client relationship can help therapists recognize, respond to, and repair inevitable ruptures in the therapeutic alliance promptly and effectively.
• Collaborative goal-setting sessions allow clients and therapists to align their motivations, expectations, and goals to ensure everyone is on the same page before and during treatment.

The importance of the therapeutic relationship dates back several decades. Historically, early psychoanalysts were some of the first to recognize this—Freud once remarked that “the personal emotional relation between doctor and client was after all stronger than the whole cathartic process.”¹ Modern research has confirmed these insights: a wide body of evidence shows that a strong therapeutic relationship is a reliable predictor of positive therapeutic outcomes and one of the most important indicators that someone will follow the recommendations of healthcare professionals.² Not only that, but these effects remain consistent across various client demographics, treatment approaches, and countries, suggesting that a strong therapeutic relationship is a universal factor in therapy success.¹

Despite its importance, traditional approaches to fostering therapeutic relationships have not always been successful. Some early psychotherapy models advocated for therapist neutrality to ensure objectivity in the relationship—the goal being to give the client space to express themselves freely. However, this approach soon became synonymous with being cold, aloof, or detached, cutting out the emotional connection that is such a vital component of the relationship.³ At the same time, structured therapeutic techniques like cognitive behavioral therapy (CBT), though incredibly beneficial, can sometimes encourage therapists to take an impersonal approach to therapy or follow manualized methods too rigidly to establish strong client connections.⁴ 
Even when therapists strive to forge strong therapeutic relationships, cognitive barriers—on the part of the client and the therapist—can lead to therapeutic resistance, unresolved disagreements, and goal misalignment. By identifying and addressing these barriers, therapists can better navigate resistance, resolve conflicts, and realign goals to foster stronger therapeutic relationships and promote better client outcomes.

Client resistance is a common barrier to building effective therapeutic relationships, especially when clients are referred by medical doctors or pressured to attend by friends or family rather than actively seeking therapy for themselves. This is an issue because hesitant clients may try to avoid certain topics, withdraw from uncomfortable conversations, deny their problems, or outright disagree with the therapist’s overall approach to therapy.⁵ Uncovering the client’s underlying beliefs and feelings is crucial for addressing this kind of resistance.

Using the ABC Model to Understand Therapeutic Resistance

One behavioral framework that can be used to explore therapeutic resistance is Albert Ellis’ ABC model, which suggests that our beliefs play a critical role in our emotions and behaviors. According to this framework, the client’s resistance to therapy is shaped not by the therapy itself but by their underlying beliefs about it. For example, clients who believe therapy is a sign of weakness might be more likely to experience feelings of shame, anxiety, or self-consciousness when asked to open up about their personal struggles. As a behavioral consequence, these individuals might shut down or dismiss the therapist’s suggestions. Unfortunately, a client’s beliefs about therapy are not always easily identifiable, and making incorrect assumptions can lead to ineffective interventions.¹⁹

The Need for Autonomy in Therapeutic Relationships

Additionally, therapeutic resistance can also stem from a lack of autonomy. Research suggests that clients who feel pressured into therapy are more likely to display resistance because they don’t feel in control.⁶ This is a common issue in court-mandated therapy, where perceived coercion can be highly detrimental to treatment outcomes.⁶ Reactance theory suggests that people often deal with this lack of autonomy by doing the opposite of what they feel pressured to do. In the case of therapy, this might mean clients refuse to participate in exercises, deny or minimize their problems, resist meaningful conversion, or skip sessions altogether. 

Whether resistance is rooted in limiting beliefs or a need to maintain personal control, applying rigid therapeutic structures or simply addressing the client’s resistance is likely to backfire, reinforcing their defensiveness.¹⁹ Instead, research suggests that adopting a collaborative, client-focused approach can help lower resistance while building a solid foundation for a fruitful therapeutic relationship.⁷

Motivational interviewing has become a popular counseling style for addressing client resistance and increasing one’s willingness to alter their behavior.⁷ The goal of motivational interviewing is to address the psychological mechanisms behind resistance, such as the client’s underlying beliefs or the feeling that their autonomy is at risk. It’s a collaborative, non-confrontational, and client-centered interview style that uses techniques like open-ended questions and affirmations that subtly help clients challenge their existing cognitive or behavioral barriers and recognize their internal motivations to change.⁷

A key reason motivational interviewing is effective is because it aligns with self-determination theory, which emphasizes the importance of autonomy (the ability to make one’s own choices), competence (the feeling of being capable of achieving one’s goals), and relatedness (the feeling of being connected to others) when fostering intrinsic motivation (the type of motivation that comes from internal satisfaction rather than external rewards). Essentially, motivational interviewing counters reactance by allowing clients to explore their own reasons for change rather than feeling pressured to adopt external goals. This stands in stark contrast to an authoritative therapeutic style where the practitioner assumes the patient doesn’t know what’s best for them and must actively persuade the patient to change their behavior.⁸ 

Motivational interviewing is also an excellent tool for addressing resistance that stems from deeply held beliefs about therapy or mental health. Reflective listening, a core component of motivational interviewing that involves mirroring what the speaker has said, allows therapists to uncover these thoughts, validate the client’s feelings, and subtly help them reconsider their beliefs.⁷ This might involve asking clients questions that get them to confront contradictions between their beliefs and their actual experiences. For example, if a hesitant client thinks that therapy doesn't work, the therapist might ask, “Can you think of a time when talking to someone about how you felt made you feel better?” Or, if someone feels that therapy is a sign of weakness, the therapist could ask them if they recall anyone who seemed strong and capable but still benefited from therapy.

Motivational interviewing has been effectively used to reduce psychological resistance in a variety of contexts, including these impactful areas:

• Substance Use Disorders: An analysis of over 200 randomized clinical trials found that motivational interviewing can be highly effective in the treatment of substance use disorders.⁷ Beyond reducing substance use, this intervention also improves client engagement and retention.
• Anxiety Disorders: Motivational interviewing has also been used alongside CBT in the treatment of anxiety disorders, resulting in significantly lower levels of resistance compared to CBT treatment alone.⁹
• Health Behavior Change: Motivational interviewing has been shown to be effective in helping people manage health conditions like diabetes and improving adherence to treatment and medication.⁸

Across the board, motivational interviewing can be a valuable tool for establishing a respectful, collaborative, and empathic therapeutic relationship that puts the client front and center.

Even once a solid therapeutic relationship is established, occasional ruptures are common. These ruptures usually take the form of disagreements or misunderstandings that create tension or disconnect between the therapist and the client.¹⁰ For example, the therapist might fail to be empathetic at a key moment, interpret the client's experience incorrectly, or unintentionally say something that offends them. In one study, ruptures were reported by 56% of therapists over six treatment sessions.¹¹ Not only that, but the same study found that high rupture intensity was associated with poor therapy outcomes—and failure to resolve these conflicts often led to client dropout.

The main issue isn't that these ruptures happen. It’s that recognizing and repairing ruptures isn’t easy. For instance, some clients may be hesitant to tell their therapist that something is wrong, especially if they’re used to living with prolonged interpersonal conflict.¹⁰ While therapists sometimes notice cues that indicate a strain in the relationship—such as the client shutting down or displaying frustration—the therapist's own biases can cloud their perception and cause them to misinterpret these important indicators. Even skilled therapists may struggle to recognize and respond to ruptures due to these biases.

Cognitive biases—which are meant to help us navigate situations that feel ambiguous or uncertain—tend to pop up when therapists are facing pressure, such as moments when a client is exhibiting sudden frustration, anger, or withdrawal.¹² As a result, therapists might be more prone to cognitive biases when there is a disconnect in the therapeutic relationship, making it more difficult to address ruptures effectively. 

Cognitive Biases That Can Cloud Therapist Judgments

One of the biases at play here is the overconfidence bias, where people tend to overestimate the accuracy of their judgments.¹³ For example, a therapist might be overly confident that they understand their client or that their therapeutic approach is effective, making them less likely to address their client’s concerns or acknowledge personal mistakes.

The fundamental attribution error likely also plays a role in unresolved therapeutic ruptures. This bias describes our tendency to overemphasize personality-based explanations for the behaviors of others while overlooking the situational factors that might explain their behavior instead.¹⁴ As a result, a therapist might assume that a client’s negative reaction reflects their personality rather than a justifiable response to, say, an insensitive comment.

Confirmation bias—the tendency to seek evidence that confirms our existing beliefs—can further influence a therapist’s judgments during periods of tension. For example, they might focus on evidence that supports their view that the client is not committed to therapy (such as arriving late, canceling sessions, or failing to do their CBT homework) rather than asking the client whether something made them feel uncomfortable or invalidated.

Addressing ruptures in the therapeutic relationship is crucial for ensuring positive therapy outcomes, but common cognitive biases can prevent therapists from doing so effectively, even if they are well-aware that these biases exist. To tackle these challenges, therapists need practical strategies to help identify ruptures and mitigate bias so they can catch and correct issues early.

The good news is that repairing ruptures in the therapeutic relationship can go a long way toward improving therapy outcomes. In fact, some research suggests that clients who experience rupture-repair events may do even better in therapy than those who experience consistently strong therapeutic relationships.¹⁰ Part of the reason for this is that repairing ruptures normalizes periods of conflict in healthy relationships while allowing therapists to model productive ways of handling disagreements. This normalization process can be especially important in couples therapy where clients are learning how to navigate interpersonal conflicts.¹⁰ Rupture-repair events also allow the therapist to collect feedback on their technique or approach, which can help them recognize their biases or assumptions and become even more responsive to future ruptures. As such, ruptures are an excellent opportunity to strengthen the therapeutic relationship and improve therapy outcomes. 

So, how can therapists better recognize ruptures and avoid biases that might get in the way of resolutions? One solution is using online tools to collect client feedback after each session. Automating this process removes the potential for the therapist’s personal biases to prevent them from actively seeking feedback or misinterpreting client reactions. The Family Institute at Northwestern University already leverages this approach. This behavioral health organization uses the Systemic Therapy Inventory of Change (STIC) feedback system to track various aspects of the client journey—including how clients feel about the therapeutic relationship—and feed this information back to therapists within minutes.¹⁰ Integrating this feedback can allow therapists to address ruptures promptly before they lead to client disengagement or dropout. 

Debiasing—recognizing and reducing one’s own biases—can further help therapists navigate ruptures and use client feedback to effectively improve their practice. Research suggests that bias mitigation strategies are at least partially successful at reducing the effect of therapist biases on the therapeutic relationship.¹⁴ These debiasing techniques include:

• Providing ongoing education to therapists about cognitive biases and their potential impact.
• Encouraging therapists to reflect on therapy sessions by reviewing notes or recordings with a focus on identifying potential biases in their approach.
• Supervising therapists to identify biases in their therapy.
• Having therapists examine real case studies where potential therapist biases have derailed the therapeutic alliance.
• Teaching therapists to monitor their cognitive load and reflect on pressures that could make them more susceptible to bias.
• Prompting therapists to challenge their existing beliefs and assumptions.

Along with integrating feedback systems into therapy practices, bias education can be integrated into initial therapist training and ongoing professional development programs. Some ways to do this might include incorporating supervision and feedback mechanisms into regular training, making cognitive monitoring routines, and creating tools to help therapists self-assess their performance and recognize biases.¹⁴

Therapists and clients don’t always agree on the goals, tasks, and expectations of therapy. Unsurprisingly, perceived discrepancies between client and provider perspectives are a common barrier to strong therapeutic relationships. For example, in one study on individuals with serious mental illness receiving inpatient treatment, the majority felt that they were not on the same page as their therapists.¹⁵ Many disagreed about the cause of their mental illness, pointing to psychosocial stressors such as past trauma and contextual issues like unemployment while rejecting the therapist’s biological explanations. Beyond this, some patients disagreed with the therapists about their assigned diagnosis—one woman rejected her bipolar diagnosis, asserting she had PTSD instead. As a result of these discrepancies, some patients disagreed with their providers about treatment planning, such as whether or not they needed to take medication.

This isn’t just a problem for inpatient programs. Disagreements between clients and therapists on the motivations of therapy can derail therapeutic relationships—and impact therapy outcomes—in outpatient settings as well.¹⁶ For example, a client might attend therapy to address anxiety, but the therapist decides it’s best to focus on their relationship issues instead. Mismatched expectations are also a problem, such as when clients expect to see results sooner than is realistic or assume their therapist is there to provide direct advice rather than guide them toward their own decisions.

Cognitive Dissonance Exacerbates Misaligned Goals

Once again, addressing this misalignment is important, but doing so inefficiently can sow division and even cause clients to dig their heels in. Cognitive dissonance, the feeling of discomfort we experience when our beliefs or expectations don’t align with reality, often arises when therapists and clients have different perspectives. In therapy, this might occur when the client believes their mental illness is caused by trauma, but the therapist suggests a biological basis. To resolve this internal conflict, the client might reject the therapist’s perspective altogether. 

Expectancy theory also comes into play here. This theory suggests that people tend to engage in behaviors consistent with their expected outcomes. If a patient strongly believes that a certain therapeutic technique will help them, they are more likely to participate, experience positive outcomes, and see the therapeutic relationship as productive.¹⁷ If, on the other hand, a patient is skeptical about the potential benefits of an exercise or approach proposed by the therapist, they will be less likely to engage and enjoy productive therapy sessions. 

Aligning therapy with the motivations and expectations of the client is key to building strong therapeutic relationships and allowing clients to make real progress in therapy. Since goal misalignment can undermine this progress, getting clients involved in goal-setting and establishing realistic expectations can open the door to mutual understanding and actionable, goal-oriented therapy.

Collaborative goal-setting is a process where clients and therapists work together to specify areas of focus and treatment objectives.¹⁸ While this can take a little more time than more traditional directive approaches—where the therapist alone establishes treatment paths and objectives—it fosters a shared understanding, builds trust, and ensures that the goals are not only meaningful to the client but also actionable and measurable. For example, if one client expresses that they would like to feel less depressed, the therapist might work with them to define more precise goals like “Be able to interrupt spirals of negative thinking” or “Be able to identify triggers and depressive symptoms.” Therapists could also suggest ancillary goals that could support their main objective and help to address the underlying factors that might indirectly impact the client’s main concern, such as their relationship dynamics, self-esteem, or sleep habits. 

Like many of the solutions suggested above, this approach works because it capitalizes on the client’s need for autonomy. By framing potential therapy goals, exercises, or therapy techniques as targeted solutions to the client’s particular concerns, therapists can ensure clients’ feelings are validated and honored. Establishing goal-setting as a regular practice at the start of each new therapeutic relationship is also an excellent opportunity to engage in expectation management, ensuring clients know what to expect from their therapy sessions and believe that their interactions can lead to positive outcomes. Discussing therapy goals together allows therapists to address misconceptions immediately, such as the idea that therapy could offer a quick-fix solution or that the therapist is there to make difficult decisions for them. This reduces the risk that clients will experience cognitive dissonance: instead of creating conflict between their beliefs and the therapist’s perspective, collaborative goal-setting can help clients align their expectations with the reality of the therapy process. 

Collaborative goal-setting can even extend to using digital tools, like mental health apps, so that clients can track their goals and progress, ensuring they feel a sense of ownership over their treatment path. This is also a great way to ensure working towards goals creates a sense of self-efficacy, where clients attribute their successes to their internal capabilities rather than crediting the therapist alone for their progress.¹⁸ 

While these strategies can go a long way toward strengthening therapeutic relationships, mental health leaders and practitioners must consider a few important caveats before implementation. First, not every solution is guaranteed to work for every client. Clients from varying cultural backgrounds or with different personalities may need different approaches. Fortunately, the flexible nature of these client-focused techniques allows therapists to adjust their approach in real time rather than relying on rigidly structured processes. 

Another important issue to point out is the ethics of using behavior change techniques to enhance client engagement or get people to open up. Clients should never feel coerced or manipulated. Rather, these behavioral strategies should be used as a tool to empower clients to make their own decisions, support their autonomy, and enhance their intrinsic motivation.

Finally, it’s crucial to acknowledge the presence of systemic barriers that cannot be solved at the therapist-client level. High caseloads that make it hard to dedicate time and resources to each client and insurance models that prioritize symptom reduction over enduring therapeutic relationships can create significant challenges, even if therapists are doing everything right.²⁰ To support therapists in their work, health leaders must advocate for policies that allow for person-centered therapeutic approaches that promote better long-term outcomes for clients.

As we’ve seen, therapists face many common challenges when building client relationships. From therapeutic resistance driven by deeply held beliefs and concerns about autonomy to unresolved ruptures in the therapeutic relationship and mismatched client-therapist perspectives, each of these barriers contributes to the overarching problem of client disengagement. Fortunately, a growing body of research suggests that behavioral strategies like motivational interviewing, alliance tracking, debiasing, and collaborative goal-setting can help therapists build stronger connections with clients and improve treatment outcomes.

As therapy increasingly moves into the online space, the importance of forging strong therapeutic relationships is becoming more crucial than ever. The physically distant and potentially impersonal nature of virtual therapy only underscores the need to focus on efforts to address barriers to client engagement. On a global scale, initiatives advocating for supportive policies and professional development opportunities are important for ensuring therapists receive the training, tools, and resources needed to succeed in this area. Some organizations, such as the American Journal of Accountable Care (AJAC), are actively involved in discussions on policy reforms and advocacy to address gaps in behavioral health care, emphasizing the need to address systemic barriers to make therapist-level strategies effective at scale.²¹

At The Decision Lab, we specialize in leveraging behavioral science to foster well-being through targeted behavior change techniques and evidence-based policy design. We’re always excited to collaborate with like-minded mental health professionals and organizations interested in advancing these techniques and improving outcomes for individuals. Contact us today to learn how we can help you build policies and practices that lead to stronger, more productive therapeutic relationships.

Beyond Access: How can we leverage digital solutions to improve mental health interventions?

This article explores the limitations of traditional therapy and the potential for digital solutions to help fill the gaps. Learn how digital tools can be used to measure the efficacy of mental health interventions, provide personalized information to clients, and empower individuals to take an active role in their mental health treatment.

Fostering Stronger Relationships Between Nutritionists and Their Patients

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) plays a crucial role in promoting childhood nutrition in the U.S. To help improve uptake of the program, TDL worked with a design team at IDEO.org to design a behavioral toolkit for nutritionists intended to help practitioners forge stronger relationships with their patients.

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