Ruth C. Brown, Kimberly M. Parker, Bryce D. McLeod, and Michael A. Southam-Gerow
Although there is debate about the relative importance and influence of the therapeutic relationship in psychological treatments for children and adolescents, few assert that the relationship is not important. Evidence-based treatments assume that a strong therapeutic relationship with the child and parent is critical. Further, workgroups and task forces have underscored that the therapeutic relationship is a key component of evidence-based practice (e.g., Castonguay and Beutler 2005; Norcross 2011).
The therapeutic relationship is also believed to play an instrumental role in cognitive behavioral therapy (CBT) for children with anxiety and depressive disorders. For one, a strong therapeutic relationship is believed to promote positive outcomes by increasing child engagement in the skill-building tasks that are a hallmark of CBT. A strong therapeutic relationship is also believed to facilitate child engagement in the emotionally challenging tasks of CBT, such as exposure tasks. Considered a key component of CBT for child anxiety, exposure tasks are challenging and emotionally demanding. Children who feel a strong connection to their therapist may be more willing to engage in exposure tasks and thus experience greater symptom improvement (Chu and Kendall 2004).
The ability to form a strong therapeutic relationship with a child and parent depends in part on a therapist’s ability to tailor treatment to the unique needs of the client. This requires a thorough understanding of the core CBT interventions and of how to adapt the delivery of these interventions to fit the personal, developmental, and cultural needs of particular clients. It also requires an understanding of how to help children and parents agree on the tasks and goals of treatment. Ultimately, treatment success depends on the therapist’s ability to convince the child and parent that the different elements of a CBT program are important and that participating in treatment will lead to symptom reduction.
In this chapter we describe competencies that are relevant for building and maintaining a positive therapeutic relationship with child or adolescent clients and their parent(s). Specifically, we will focus on four aspects of the therapeutic relationship by (i) describing key competencies that contribute to therapists fostering positive therapeutic relationships; (ii) discussing how those competencies are specifically applied in treating anxiety and depression in children/adolescents; (iii) outlining how those competencies are adjusted for clients of different developmental levels (e.g., younger children vs. adolescents) and different cultural background; and (iv) delineating obstacles to building a positive therapeutic relationship and outlining methods for overcoming those obstacles.
Sburlati, Schiering, Lyneham, and Rapee (2011) identified four broad competencies associated with building a positive therapeutic relationship: (i) building alliance with children; (ii) building alliance with parents; (iii) instillation of hope and optimism for change; and (iv) engaging children in developmentally appropriate activities. In this chapter we discuss each of these competencies, beginning with alliance-building behaviors. Before we dive into these issues, it is important to note that cultural and diversity issues must be carefully considered when building a therapeutic relationship. A number of factors relevant to the therapeutic relationship can be influenced by a client’s cultural background. Such factors may be the degree of formality of the therapeutic relationship, expectations for treatment, and treatment goals (e.g., expression of distress). Thus a key part of building a therapeutic relationship with a parent and a child is understanding how their cultural values may impact the process and the outcome of therapy. This information should be used in turn to inform efforts to build and maintain the alliance.
It is important to build a positive alliance early in treatment and to maintain a strong alliance throughout treatment. The alliance is often conceptualized as being comprised of three related but distinct dimensions: bond, tasks, and goals. Bond refers to the affective aspects of the client–therapist relationship. Tasks constitute agreement and participation in the activities of therapy. Goals represent the agreement between the client and the therapist on the desired outcome of treatment. A challenge for child therapists is building and maintaining a strong alliance with both the child and the parent. And, of course, the therapist should carefully consider the client’s cultural background, as this can influence a number of factors relevant to forming the alliance (the therapist’s stance, the target of treatment, and so on).
Children rarely refer themselves for therapy, so their motivation to participate in therapeutic activities can vary. A key task of a therapist is to engage children in treatment and to keep them motivated throughout treatment. With children the alliance-building process often starts with forming a strong affective bond and working to achieve agreement on the goals and tasks of therapy.
The affective bond is one of the most important components of the alliance with children who derive motivation to participate in therapeutic tasks from a positive relationship with the therapist. It is therefore important to establish with a child a relationship marked by warmth and openness, and to do so early in treatment. Interventions traditionally associated with client-centered psychotherapy can facilitate alliance building. Rapport-building behaviors that elicit information, provide emotional understanding and support, and explore the child’s subjective feelings help foster an affective bond (Karver, Handelsman, Fields, and Bickman 2008). Therapists’ use of collaborative language (e.g., we, us, let’s) can also help build the bond by helping to establish therapy as a collaborative effort (Creed and Kendall 2005). Attending to and tracking client affect (e.g., fear, disappointment) and the use of validating statements help clients feel understood and supported. In all, client-centered interventions such as these help form an affective bond and ensure that the child will present him-/herself to treatment ready to engage in the hard work ahead.
As children get older, agreement on the tasks and goals of treatment becomes increasingly important. Young children do not have the cognitive capacity to understand long-term goals, so the affective aspect of the alliance is more important for young children (Shirk and Saiz 1992). However, adolescents have an increased need for autonomy, so it is essential that they have a say in establishing the goals and tasks of treatment. Of course, treatment goals and tasks should be presented in developmentally appropriate terms. Young children may find the simplest explanation suitable (e.g., “Today we are going to learn how to talk back to your anxiety”), whereas adolescents may benefit from a more detailed rationale of the treatment strategies to be used (e.g., “Today we are going to talk about two kinds of thoughts: anxious thoughts and coping thoughts because it is important to understand how our thoughts can influence our feelings”). Collaborative approaches that allow the child to have input into the selection of goals and tasks help to strengthen the alliance. Indeed, children who feel like they have some say in establishing treatment goals and tasks are more motivated and willing to engage in treatment (Meyer et al. 2002). Therapists must be aware that parents and children may have different goals for treatment. Parents often initiate treatment and have treatment goals that the child client may not share. The therapist must therefore work to resolve discrepancies or to identify common goals by following ethical and professional standards.
The therapist must build and maintain a strong alliance with the parents. Parents play a critical role in child psychotherapy. While it is important to establish a strong affective bond with them, it may be more important that both parties – therapist and parents – agree on the tasks and goals ahead. As many parents give consent and provide transportation for their children, failure to agree on the goals and tasks of treatment can result in premature termination. Taking the time to understand the parent’s treatment goals, drawing a clear connection between tasks and goals, and setting realistic treatment expectations can help form a strong alliance with a parent. It is also important to check in with the parents throughout treatment, to ensure that no problems related to tasks and goals arise.
Parents play various roles in treatment. In some cases they may be asked to take responsibility for homework activities that give a child the opportunity to practice skills. In other cases parents may be asked to alter behaviors that contribute to the development and/or maintenance of a child’s symptoms. Parents may not expect to participate in treatment without understanding why their participation will help achieve treatment goals. It is therefore important to clearly explain why a parent is being asked to participate in treatment, and also to detail how his or her participation will help achieve treatment goals.
Parents and children who come to treatment with low expectations about its potential advantages can benefit from a sense of hope. Thus, early in treatment therapists must ascertain what expectations parents and children have for treatment. This work can occur when they discuss the treatment’s tasks and goals. Any sign of unrealistic treatment expectancies indicates the need to instill a sense of hope for change. Providing psycho-education about the therapy process, the typical timeline for treatment, and the expected outcomes can instill hope and generate a set of realistic expectancies. To help maintain hope, therapists should foster the development of client self-efficacy regarding his/her ability to successfully accomplish the tasks and goals of treatment. And, to foster this development, therapists can highlight accomplishments and normalize “set-backs” by reminding clients that change is not a linear process.
Although the competencies described up to this point apply to working with children who suffer from anxiety or depressive disorders (or both), there are some disorder-specific suggestions to consider.
Some children with anxiety are inhibited. A few issues arise from this state of affairs. First, these children may be slow to form an alliance; in fact interacting with the therapist may be an exposure task for inhibited children. Second, with inhibited children, therapists may struggle to gauge the quality and progress of the alliance, which makes it important to regularly assess that alliance from the child’s and the parent’s perspectives.
Exposure tasks are a key ingredient of CBT for anxiety. These tasks are challenging and emotionally demanding for children. A strong alliance may facilitate client involvement in exposure tasks. Existing evidence suggests that exposure tasks do not have a negative impact on the alliance, particularly in the context of an established positive alliance (Kendall et al. 2009). It is therefore important to establish a strong alliance with a child before starting on the exposure tasks, so as to maximize child involvement. Providing encouragement and praise during exposure tasks can help maintain the alliance and build client self-efficacy.
Children with anxiety disorders are likely to have parents who suffer from anxiety too. Anxious parents may inadvertently interfere with treatment by negatively reinforcing escape behaviors or by “rescuing” their children from challenging tasks. Therefore the therapist must help parents understand how their behavior impacts treatment progress. In the context of a supportive parent–therapist alliance, parents may feel more comfortable to express concerns or difficulty in watching their children face distressing situations. Therapists may also find the need to provide the parents with strategies for coping with their own anxiety, or they may recommend that the parents seek their own treatment.
Children with depression tend to be irritable. An irritable client can punish help-giving behaviors and can be a tough challenge for a therapist aiming to form an alliance. Indeed, clients with depression provide lower levels of reinforcement in response to alliance-building behaviors. Therapists thus need to be vigilant and maintain their alliance-building efforts despite the lack of reinforcement from the child.
Children’s irritability can make reinforcement difficult for their parents as well (Dietz et al. 2008). Parents of depressed children may therefore need increased support to appropriately reinforce the tasks and skills the child is acquiring in treatment. Feedback to parents will be easier to give and better received in the context of a supportive parent–therapist alliance.
The therapist should also be aware that parents of depressed children may suffer from depression and other psychiatric disorders themselves. Depressed parents may be difficult to engage in treatment. If parental psychopathology interferes with treatment progress, it may be necessary to refer a parent to treatment. Indeed recent studies have shown that the treatment of parental depression can lead to improvements in the child’s depression (Wickramaratne et al. 2011).
CBT with children and adolescents can be conceptualized as a skill-building therapeutic approach. As such, it relies on children and on their parents to engage in in-session, homework, and out-of-session activities (Chorpita and Daleiden 2009). The alliance is a key mechanism in engaging children in treatment and facilitating their active involvement in skill-building tasks. However, different skills and activities are needed to establish and maintain the alliance with children of different developmental levels.
It is essential that clinicians consider the developmental level of children in the delivery of CBT, in order to foster and maintain a positive alliance. Development can refer to a variety of characteristics, including chronological age, cognitive developmental level, and emotional developmental level. Here we present guidelines to consider when building an alliance with children and adolescents; but therapists should always be aware of the particular developmental needs and preferences of their clients. Flexibility and creativity are valued qualities in designing and delivering developmentally appropriate strategies to strengthen the child–therapist alliance.
With children, encouraging collaboration and engagement can be accomplished through the use of activities. Children often find direct questions uncomfortable, so therapists should consider delivering interventions via play-based activities. For example, the therapist and the child can make up stories about a superhero who uses CBT skills to face and conquer his/her fears. Therapists can use a variety of activities to deliver interventions; such activities may involve children’s books, artwork, puppets, or dolls. It is also important to provide age-appropriate rewards – for example, comics, books, or stickers – for participating in therapeutic tasks. To maintain motivation, therapists can provide rewards for in-session efforts as well as for accomplishing treatment goals (e.g., for achieving a certain mark on the fear ladder).
The focus and delivery of therapy must shift when one works with adolescents. Individuation and autonomy are important for most adolescents, so confidentiality takes on greater importance. Adolescents may prefer that their parents not be privy to any information disclosed to the therapist. Therapists should therefore have an open and frank discussion with parents and adolescents at the outset of therapy about the limits of confidentiality. Alliance formation may be difficult for adolescents if they believe that the therapist will talk to the parents about what transpires in treatment.
It is also important to discuss treatment goals and tasks with adolescents. Adolescents may not believe that they need treatment, or they may have different treatment goals from those of their parents. It may be difficult to motivate them if they do not agree on treatment goals and tasks. Compared to children, adolescents may need the therapist to spend more time discussing treatment goals and explaining the treatment rationale. Collaboration between therapist and adolescent can be enhanced by encouraging the latter to identify treatment goals and to suggest his/her own solutions to therapeutic problems (Diamond, Liddle, Hogue, and Dakof 1999). Sufficient time should be spent working with the parent and the adolescent to set mutually agreed-upon goals.
Just as with younger children, therapists should choose age-appropriate activities and rewards for engaging adolescents. When choosing fun therapeutic tasks, therapists can have adolescents make collages with cutouts from teen-relevant magazines, use workbooks, and provide personal examples from their own life. Therapists should determine if an adolescent is comfortable with talk-based therapy or prefers to participate in other activities (e.g., collages, workbooks). Age-relevant rewards for adolescents may include items such as gift certificates for magazines, music, or clothing stores or social rewards such as spending additional time with friends.
Building an alliance with children and their parents is not always a simple task. Several factors can present hurdles to developing and maintaining a positive alliance. Here we describe some common obstacles to forming an alliance and methods for overcoming them: (i) discrepancies between children and parents; (ii) low motivation; (iii) poor treatment expectations; (iv) lack of treatment credibility or acceptability; and (v) alliance ruptures.
Children and parents can have different perspectives on the problems that brought them to treatment, and thus on the goals and methods of treatment (Yeh and Weisz 2001). Parents may conceptualize the cause of the presenting problem as lying solely within the child, and they may anticipate limited involvement in treatment. In contrast, youth may view their parents (or teachers, peers, etc.) as the problem and may resent being the focus of treatment. When discrepancies exist, the therapist must work with the child and the parent to identify them and to work toward consensus.
Difficulties may also arise when there is a discrepancy between the problem the parent and/or the child has identified and the therapist’s conceptualization of the problem. For example, a parent may bring a child into treatment on account of disruptive behavior problems, but the therapist may identify anxiety as the treatment target. When such a discrepancy exists, the therapist must attempt to build consensus about the treatment goals and tasks. This collaborative work can be made easier by establishing from the outset a strong affective bond with both child and parent, along with developing an understanding of the client’s cultural values. Sometimes this requires working with the child and the parent separately before bringing them together to discuss the treatment’s tasks and goals.
Signs of low motivation may include poor engagement in session, frequent cancellations, or resistant behavior. Low motivation to participate in treatment can contribute to premature dropout. Anxious or depressed children may also fear or expect failure, or rejection from the therapist, and this would reduce their motivation to engage in treatment tasks. Alliance ruptures may occur if the therapist charges ahead in treatment rather than addressing the cause of the low motivation. Therapists should assess motivational levels early in treatment and quickly address any motivational issues as they arise, even if this means a delay in getting to the core content of treatment. As discussed above, establishing agreed-upon goals and building the child’s sense of self-efficacy and positive expectations both play a vital role in enhancing motivation and engagement. Youth may have low motivation for treatment when they believe that others are the source of the problem. This is a common issue in therapy, as youth rarely refer themselves for treatment. For youth ambivalent about change, motivational interviewing and enhancement strategies have been shown to increase the motivation to engage in behaviors that bring about change, for instance by attending treatment sessions, engaging in in-session tasks, and completing therapeutic homework (Miller and Rollnick 2002).
Parents, too, may exhibit low motivation for treatment. Since parents may be involved in the maintenance of the target problem or may be responsible for ensuring that children attend sessions, addressing low motivation in parents may be necessary. If a parent is not motivated for treatment, then it is important to identify the reason. For example, when a youth has been referred by the school or child welfare system, the parent may not perceive a problem and may thus have low motivation for treatment. Or again, if parents have limited resources or experience a number of barriers to participating in treatment (Nock and Photos 2006), they may have less motivation to attend treatment. Finally, parents who believe that treatment should be child-focused may not be motivated to participate personally in it. Alliance ruptures may occur if a therapist does not recognize and address the source of low motivation for treatment. If a parent feels that a therapist is not aware of or concerned about practical or financial barriers, then an alliance rupture may occur. To the extent that such barriers are contributing to low motivation, therapists may need to engage in problem solving with the parent (McKay and Bannon 2004). Helping parents overcome these barriers may enhance both the motivation and the alliance, by demonstrating that the therapist is a concerned and capable ally. To the extent that low motivation is due to ambivalence, therapists may need to engage in motivational enhancement strategies to get parents to participate in their child’s treatment. Fortunately, motivational interventions have been demonstrated to enhance treatment retention and outcomes in treatments with parents with low motivation as well (Chaffin et al. 2009; Erickson, Gerstle, and Feldstein 2005).
Clients come to therapy with expectations about what will happen during sessions, how long treatment will take, and what benefits they will gain. In some cases, clients have expectations that are unrealistic. For example, a parent might expect complete recovery of his or her child within just a few weeks. These clients are at risk of becoming frustrated with any lack progress in treatment, and also at increased risk of dropping out of it. On the other hand, some clients might have very low expectations concerning the benefit of treatment, and hence they may be difficult to engage in it. As discussed earlier, collaborative discussions with clients, conducted at an early stage, about what they do expect and what they should expect from treatment can establish positive expectations and facilitate a positive alliance.
Addressing treatment expectations at the beginning of treatment is important; but it is also essential to monitor these expectations throughout treatment. As treatment unfolds, expectations may change. New complexities may emerge (e.g., identification of comorbid disorders) or crises may occur (e.g., job loss, illness, marital discord, child abuse) that alter the treatment’s trajectory or focus. When changes occur, the therapist should discuss how the events may influence that trajectory, together with the expected outcomes and duration of treatment. Aside from such changes, therapists should check in periodically with the clients by discussing their expectations – positive and negative. Finally, as the end of treatment draws near, it is important to talk about the client’s expectations and address any concerns that (s)he may have about his/her ability to maintain treatment gains on his/her own.
Treatment acceptability is another factor that can influence the alliance. A mismatch between the types of treatment a client expects and the treatment being offered can weaken the alliance. For example, some clients may expect the therapist to simply listen empathetically, and they become frustrated when the therapist challenges their maladaptive beliefs or pushes them to face their fears. Or some clients may expect that a therapist will be directive and not open to a collaborative approach. As discussed before, socializing clients into therapy is an important part of the treatment process – one that helps establish a collaborative therapeutic relationship. This socializing process includes providing clients with a clear, developmentally appropriate treatment rationale. Children and adolescents who are familiar with coaches in schools and with recreational sports may easily understand the metaphor of the therapist as a coach. This metaphor triggers other relevant concepts and images applicable to treatment, such as the concepts of active involvement and frequent practice, both of which are much needed, or the metaphor of “cheerleading” from the therapist and parents, which brings many benefits.
Although offering a treatment rationale at the beginning of treatment is valuable, it is also important to discuss that rationale when a new task is introduced, or when the client exhibits resistance. The therapist might be met with resistance if the child does not understand the purpose of an in-session activity. Very young children do not require a complex treatment rationale, they simply need to understand that a given task will help them feel better or fight back against anxiety. Adolescents do, however, benefit from a credible treatment rationale. Of course, when they provide a treatment rationale, therapists need to adjust their language and activities to the developmental level of their clients.
Some clients may not find CBT acceptable or feasible, even after a clear treatment rationale has been provided. For example, certain parenting skills featured in CBT programs may not be consistent with the cultural values of certain parents. Therapists who forge ahead with therapeutic interventions that are not acceptable to clients may be faced with resistance or dropout. Therapists may therefore need to shift to methods that are acceptable to clients in order to maintain the alliance or to enhance their motivation to participate in treatment. Therapists may also have to address more practical barriers to treatment, such as issues of costs, transportation, or time (McKay and Bannon 2004).
An alliance rupture is defined as tension on, or dissolution of, the collaborative aspects of the therapeutic relationship (Safran, Muran, and Eubanks-Carter 2011). An alliance rupture can occur at any point in therapy and therapists can take a number of steps to guard against ruptures. Failure to track affect, being pushy, appearing overly formal, and failing to recall relevant information may hinder alliance formation or lead to an alliance rupture (Creed and Kendall 2005; Karver et al. 2008). Accurate, well-timed therapeutic interpretations can enhance the therapeutic relationship by helping a child feel understood. However, excessive questioning or inaccurate interpretations can cause problems with the alliance (Karver et al. 2006). If a rupture occurs, encouraging clients to talk openly about the negative feelings they have about treatment or the therapist may help repair alliance ruptures (Safran, Muran, and Samstag 1994; Safran, Muran, Samstag, and Stevens 2001). In therapy, it is therefore important to strike the right balance between asking questions and reflecting emotions, so that the client may share relevant information without being pushed past his/her comfort zone.
Failed exposures run the risk of creating an alliance rupture, especially in the early phases of exposure treatment. Starting with exposures that guarantee success can help build a client’s confidence and trust in the therapist. Should an exposure fail, the therapist must assess for an alliance rupture and re-evaluate the fear hierarchy. Using a sports metaphor may be helpful: even the best teams do not win every game, or the best players do not make every shot. Effort should be praised and reinforced even if the desired outcome was not achieved.
Monitoring for signs of resistance is important. Resistance can emerge due to a number of factors, for instance an alliance rupture, skill deficits, goal discrepancies, or avoidance patterns (Turkat and Meyer 1982). Identifying the factors that contribute to the resistance is critical. For example, to deal with resistance that results from a skill deficit (e.g., poor conversation skills), skill-building interventions would be introduced. On the other hand, resistance arising from goal discrepancies would require a return to treatment planning (Turkat and Meyer 1982). Therefore it is important to identify the underlying cause of the resistance. Regular assessment of the alliance can be a powerful tool for monitoring progress, eliciting feedback, and opening dialogue on the therapeutic process.
In teaching therapists how to deliver CBT for child anxiety and depression, attention must focus on the technical and relational elements of treatment. Training materials focus the appropriate amount of attention on the technical aspects of CBT. However, it is important to place equal emphasis on the skills needed to develop and maintain a strong therapeutic relationship with children and parents over the course of a treatment. Therapists should have exposure to graduate courses in developmental psychopathology, developmental processes, minority mental health, and CBT theory. The knowledge gleaned from these courses will help them understand how to adapt the technical elements of CBT to fit the unique developmental and cultural needs of each client. It is also important that therapists learn early on in their training how to deliver client-centered interventions, engage in collaborative goal setting, and explain therapeutic tasks. Supervision can then help therapists understand how best to modify the delivery of therapeutic interventions to meet the developmental and cultural needs of children and parents.
A number of assessment tools focused upon the therapeutic relationship can be used to inform training and treatment. A growing body of evidence indicates that providing feedback to therapists about the therapeutic relationship can improve client outcomes (Lambert and Shimokawa 2011). We believe that the systematic collection of data on the therapeutic relationship can also play a role in therapist training. During treatment, therapists can collect data that can be used to inform both treatment and training. For example, collecting data on the child alliance in each session can help identify potential ruptures in the alliance. Supervisors can use observational measures to generate data from taped sessions about the therapeutic relationship that can be used to inform the training. For example, an observational alliance measure can be used to characterize the quality of the child–therapist alliance during supervision. Below we present some measures that can be used at pre-treatment and during treatment to quantify processes related to the therapeutic relationship.
Collecting data at the intake about treatment expectations, motivation for treatment, and about barriers to treatment can be used to inform treatment planning and training. It is important to address problems with motivation and expectations directly and early on, as well as to identify potential barriers to subsequent treatment participation. Collecting data on these processes early on in treatment can help therapists determine whether they need to spend more time engaging the family during the intake in order to retain its members in treatment. Therapists can also review the data with their supervisor. Of course, these measures can be administered during treatment as well. The following measures have demonstrated reliability and validity:
Two processes related to the therapeutic relationship can be assessed during treatment: alliance and client involvement. As noted before, feedback systems are increasingly including therapeutic relationship measures designed to help therapists identify ruptures in the alliance. These measures can therefore be administered on a weekly or monthly basis. A number of child-, parent-, therapist-, and observer-rated alliance measures exist for child psychotherapy. Observer-rated alliance measures can be used by supervisors to rate the quality of the child–therapist and/or parent–therapist alliance during supervision. A good option for this purpose is the Therapy Process Observational Scale for Child Psychotherapy – Alliance scale (McLeod and Weisz 2005). Self-report alliance measures can be used to identify potential problems in the alliance. The Therapeutic Alliance Scale for Children (Shirk and Saiz 1992) is a good option for collecting self-report alliance data, as it has child, parent, and therapist versions. Supervisors can also use the Child Involvement Rating Scale (Chu and Kendall 2004) to rate child behavioral involvement in therapeutic tasks. These measures can be used as part of a feedback system designed to identify potential problems with the therapeutic relationship that can be used to inform treatment and to guide training.
The therapeutic relationship plays an important role in CBT for child anxiety and depressive disorders. A strong therapeutic relationship is an important ingredient in successful treatment because it helps to maximize client involvement in treatment activities. To form a strong therapeutic relationship, therapists must understand how developmental and cultural factors influence the different facets of the therapeutic relationship and tailor CBT interventions to fit each unique client. It is important that training and supervision focus upon the skills needed to form a strong therapeutic relationship. Therapists need to be exposed to the right combination of coursework, training, and supervision in order to learn how to flexibly deliver the core components of CBT in a way that maximizes client motivation and engagement.