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DEVELOPING
the THERAPEUTIC
RELATIONSHIP
Developing the Therapeutic Relationship: Integrating Case Studies, Research, and

Practice, edited by O. Tishby and H. Wiseman
Copyright © 2018 American Psychological Association. All rights reserved.
DEVELOPING
the THERAPEUTIC
RELATIONSHIP
Integrating Case Studies,
Research, and Practice
Edited by
Orya Tishby and Hadas Wiseman
Copyright © 2018 by the American Psychological Association. All rights reserved. Except
as permitted under the United States Copyright Act of 1976, no part of this publication may
be reproduced or distributed in any form or by any means, including, but not limited to, the
process of scanning and digitization, or stored in a database or retrieval system, without the
prior written permission of the publisher.
The opinions and statements published are the responsibility of the authors, and such
opinions and statements do not necessarily represent the policies of the American
Psychological Association.
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Library of Congress Cataloging-in-Publication Data
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Psychological Association, issuing body.
Title: Developing the therapeutic relationship : integrating case studies,
research, and practice / [edited by] Orya Tishby, Hadas Wiseman.
Description: First edition. | Washington, DC : American Psychological
Association, [2018] | Includes bibliographical references and index.
Identifiers: LCCN 2018000039| ISBN 9781433829222 | ISBN 1433829223
Subjects: | MESH: Psychotherapy | Professional-Patient Relations |
Case Reports
Classification: LCC RA440.6 | NLM WM 420 | DDC 616.89/14—dc23
LC record available at https://lccn.loc.gov/2018000039
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A CIP record is available from the British Library.
Printed in the United States of America

First Edition
http://dx.doi.org/10.1037/0000093-000
10 9 8 7 6 5 4 3 2 1
To Tali, Avner, Ido, Noa, and Yael

—Orya Tishby
To Itzik, Adi, and Uri

—Hadas Wiseman
Contents
Contributors.................................................................................................. xi
Introduction................................................................................................... 3
Chapter 1. The Psychotherapy Relationship:
Where Does the Alliance Fit?.......................................... 15
Adam O. Horvath
I. The Case Studies: Integrating Research and Practice........................ 29

Chapter 2. You Can’t Cross the Same River Twice:
A Case Study of Alliance Rupture and Repair................ 31
Laura Kohberger, Jeremy D. Safran,
and J. Christopher Muran
Chapter 3. Patient and Therapist Relational Patterns:
Implicit Negotiations....................................................... 61
Emanuel Schattner and Orya Tishby
vii
Chapter 4. Closeness and Distance Dynamics
in the Therapeutic Relationship...................................... 81
Hadas Wiseman and Dana Atzil-Slonim
Chapter 5. Facilitating the Sense of Feeling Understood
in Patients With Maladaptive Relationships................. 105
Sigal Zilcha-Mano and Jacques P. Barber
Chapter 6. Clinical Choice Points and Professional Ethics
in Psychoanalysis............................................................ 133
Gaby Shefler
Chapter 7. The Therapeutic Relationship: A Warm,
Important, and Potentially Mutative Factor
in Cognitive–Behavioral Therapy................................. 157
Louis G. Castonguay, Soo Jeong Youn, Henry Xiao,
and Andrew A. McAleavey
Chapter 8. Negotiating Multiple Roles and Stances
in Cognitive–Behavioral Therapy................................. 181
Yoni Elizur and Jonathan D. Huppert
Chapter 9. Affirming the Case for Positive Regard ......................... 211
Barry A. Farber and Jessica Y. Suzuki
Chapter 10. Empathy and Responsiveness
in Emotion-Focused Therapy..........................................235
Jeanne C. Watson
Chapter 11. Where the Alliance and Systems Theory Meet
in Brief Family Therapy................................................. 257
Laurie Heatherington, Valentín Escudero,
and Myrna L. Friedlander
Chapter 12. The Use of Immediacy in Supervisory Relationships....... 289
Clara E. Hill and Shudarshana Gupta
II. Mapping Models and Conclusions.................................................... 315

Chapter 13. Mapping Models of the Therapeutic Relationship:
Implications for Integrative Practice ............................. 317
Stanley B. Messer and Daniel B. Fishman
viii contents

Chapter 14. Conclusions: The Tapestry of the Therapeutic
Relationship and Recommendations
for Clinicians and Researchers........................................341
Index.......................................................................................................... 349
About the Editors ...................................................................................... 361
contents ix
contributors
Dana Atzil-Slonim, PhD, Lecturer, and Director, Clinical Training Pro-

gram, Department of Psychology, Bar-Ilan University, Ramat Gan,
Israel
Jacques P. Barber, PhD, Professor and Dean, Gordon F. Derner School of
Psychology, Adelphi University, Garden City, NY
Louis G. Castonguay, PhD, Professor of Psychology, Department of Psychol-
ogy, Pennsylvania State University, University Park
Yoni Elizur, Doctoral Candidate, Hebrew University of Jerusalem, Israel
Valentín Escudero, PhD, Professor, Department of Psychology, Universidade
da Coruña, Spain
Barry A. Farber, PhD, Professor of Psychology and Education, Clini-
cal Psychology Program, Teachers College, Columbia University,
New York, NY
Daniel B. Fishman, PhD, Professor, Graduate School of Applied and
Professional Psychology, Rutgers University, New Brunswick, NJ
Myrna L. Friedlander, PhD, Professor, Department of Educational and
Counseling Psychology, University at Albany, State University of
New York
xi
Shudarshana Gupta, PhD, Diversity Coordinator and Staff Clinician,
Counseling Center, Towson University, Towson, MD
Laurie Heatherington, PhD, Edward Dorr Griffin Professor of Psychol-
ogy, Department of Psychology, Williams College, Williamstown,
MA
Clara E. Hill, PhD, Professor, Department of Psychology, University of
Maryland, College Park
Adam O. Horvath, EdD, Professor Emeritus, Faculty of Education, Simon
Fraser University, Burnaby, British Columbia, Canada
Jonathan D. Huppert, PhD, Professor, Department of Psychology, Hebrew

University of Jerusalem, Israel
Laura Kohberger, PhD, Supervising Clinical Psychologist, Herald Square
Psychology Group, New York, NY
Andrew A. McAleavey, PhD, Instructor of Psychology in Psychiatry, Weill
Cornell Medicine, New York, NY
Stanley B. Messer, PhD, Distinguished Professor, Graduate School
of Applied and Professional Psychology, Rutgers University, New
Brunswick, NJ
J. Christopher Muran, PhD, Professor and Associate Dean, Gordon
F. Derner School of Psychology, Adelphi University, Garden City,
NY; and Director, Mount Sinai Beth Israel Psychotherapy Research
Program, Mount Sinai School of Medicine, New York, NY
Jeremy D. Safran, PhD, Professor of Psychology, New School for Social
Research, New York, NY
Emanuel Schattner, PhD, Clinical Psychologist, private practice; and
Supervisor of Mental Health Clinics, Herzog Hospital, Jerusalem,
Israel
Gaby Shefler, PhD, Professor and Head, Freud Center for Psychoanalytical
Research, Hebrew University of Jerusalem, Israel
Jessica Y. Suzuki, MPhil, Doctoral Candidate, Teachers College, Columbia
University, New York, NY; and psychology intern, Mount Sinai Beth
Israel Hospital, New York, NY
Orya Tishby, PsyD, Associate Professor in Clinical Psychology and Clinical
Social Work, Hebrew University of Jerusalem, Israel
Jeanne C. Watson, PhD, C Psych, Professor and Program Chair, Coun-
seling and Clinical Psychology Program, Department of Applied
Psychology and Human Development, University of Toronto, Ontario,
Canada
Hadas Wiseman, PhD, Professor, Counseling and Human Development,
University of Haifa, Israel
xii contributors

Henry Xiao, MS, Graduate Assistant, Castonguay Lab, Pennsylvania State
University, University Park
Soo Jeong Youn, PhD, Clinical Fellow, Department of Psychiatry,
Massachusetts General Hospital, Harvard Medical School, Boston
Sigal Zilcha-Mano, PhD, Associate Professor, Department of Psychology,
University of Haifa, Israel
contributors xiii
DEVELOPING
RELATIONSHIP
the THERAPEUTIC
Introduction
During the last 2 decades, remarkable progress has been made in psycho
therapy research, specifically in the development of evidence-based treat-
ments for a range of disorders (e.g., Barlow, 2014; Lambert, 2013; Nathan
& Gorman, 2002; Norcross & Wampold, 2011; Weisz & Kazdin, 2010).
However, the mechanisms through which these therapies influence outcome
are generally not yet well understood (Barber, Muran, McCarthy, & Keefe,
2013; Barber & Sharpless, 2015; Kazdin, 2011) and, furthermore, the strat-
egy of matching research-based treatments to specific disorders is not always
effective (Wampold & Imel, 2015). Attempts to delineate the active ingre-
dients in the different treatments have pitted treatment methods against
relationship variables, or specific versus common factors, as core mechanisms
of change in the therapy process (Castonguay, 2011; Norcross & Lambert,
2011). However, years of research have shown that studying technique and
relationship variables as separate entities yields inconsistent results, suggesting
http://dx.doi.org/10.1037/0000093-001
Developing the Therapeutic Relationship: Integrating Case Studies, Research, and Practice, O. Tishby
and H. Wiseman (Editors)
Copyright  2018 by the American Psychological Association. All rights reserved.
3
that different change mechanisms play different roles with different clients
(e.g., Webb, DeRubeis, & Barber, 2010; Webb et al., 2012).
In light of this, researchers have shifted the focus to how relationship
variables and techniques interact with one another and affect outcome in
different treatment modalities, and how technique is applied in the con-
text of a particular relationship (Castonguay & Beutler, 2005; Goldfried &
Davila, 2005; Hill, 2005; Horvath, Del Re, Flückiger, & Symonds, 2011).
One of the conclusions of the second APA task force on the therapeutic
relationship (Norcross & Wampold, 2011) was that “the relationship acts
in concert with treatment methods, patient characteristics and practitioner

qualities in determining effectiveness; a comprehensive understanding of
effective (and ineffective) psychotherapy will consider all these determi-
nants and their optimal combination” (p. 423).
In the reality of clinical practice, technique and relationship are inter-
twined and cannot be neatly separated—the therapy process consists of a
synergy between technique and relationship. Applying a specific technique
may strengthen the bond, whereas a strong bond may support the use of
techniques that move clients out of their comfort zone. In our quest to gain
a deeper understanding of what facilitates or hinders therapeutic process,
we need to find new ways of conceptualizing and studying the complexity
inherent in such interrelated processes during the unfolding of therapeutic
relationships in practice.
ORIGINS OF THE BOOK
This book originated from a research workshop held in Jerusalem called

“Multiple Lenses on the Therapeutic Relationship.” As an extension of our
collaboration in the Jerusalem–Haifa psychodynamic psychotherapy study
(see Chapters 3 and 4), we invited leading psychotherapy researchers and
clinicians to take part in the 3-day workshop. The key speakers addressed
theoretical underpinnings, client–therapist relationship processes and expe-
riences, client and therapist variables, techniques versus the relationship and
outcome, and implications for training therapists (Wiseman & Tishby, 2014).
On the last day of the workshop, we gathered for a closed meeting (without an
audience) to watch videos of clinical cases in order to discuss “hands on” how
to translate the presented contributions into practice. The focus on moment-
to-moment process in specific cases treated by leading therapists who took
part as speakers led to challenging “how” questions, including: How does the
relationship work? How does the therapist make decisions on how to inter-
vene? and, How similar or different are therapists of different orientations?
4 tishby and wiseman

For example, in a video that Robert DeRubeis showed of himself conducting
therapy with a patient who was extremely depressed, we were all struck by the
centrality of his empathic reflection and affirming positive regard that went
way beyond cognitive–behavioral therapy (CBT). In fact, if we had to guess
the orientation of this therapist, we would probably not have easily recog-
nized it as CBT. The lively clinical discussions highlighted the usefulness of
intensive study of clinical cases in gaining a deeper understanding of thera-
peutic process and its relation to outcome. The choice to study clinical cases
resonated with Stanley Messer’s presentation to the group of his formulation
with Dan Fishman of the methodology for pragmatic cases studies.

One product of the conference was a special issue of Psychotherapy
Research called The Therapeutic Relationship: Innovative Investigations.
The articles presented an array of empirical studies in which the contributors
offered innovative ways of studying various relationship mechanisms as they
relate to change processes and outcomes (Wiseman & Tishby, 2014). While
the special issue, which was later published as a book (Wiseman & Tishby,
2015), fulfilled our intention of contributing to innovative research, the pres-
ent book integrates theory, research, and practice in the form of case studies
and has the potential to contribute more fully to practitioners, trainees, and
supervisors. In other words, the culmination of our work together is our desire
to build bridges between practitioners and researchers. We also believe that
such bridges will contribute to the professional development of graduate stu-
dents who can be trained as clinical researchers without having to choose one
over the other.
OUR PURPOSE AND RATIONALE
This book examines the development of the therapeutic relationship

through different “lenses” based on theory, research, and practice. Research
on the therapeutic alliance shows that its contribution to outcome cuts
across theoretical orientations (Flückiger, Del Re, Wampold, Symonds, &
Horvath, 2012); however, we believe that this process develops in different
ways in various types of therapies. Our contention is that the methodol-
ogy of case studies (Chapter 13) is highly suited for examining in-depth
links between relationship process and technique that enhance therapy
process, leading to beneficial outcome. The authors of the chapters are
clinicians who are also psychotherapy researchers; they faced the challenge
of integrating their case studies with research and practice. In each chapter,
they present a relationship conceptualization that guided them (involving
both patient and therapist) and demonstrate through the case study how it
introduction 5
contributes, together with technique, to successful outcome. Emphasis is
on the unfolding of the client–therapist interaction and the development
of the therapeutic relationship in their case study, rather than on discrete
relationship variables (e.g., empathy, alliance, self-disclosure) or on schools
of psychotherapy.
In examining the process of change in the case studies, the authors of
each chapter outline their theoretical basis for the case (which may represent
one or more models of psychotherapy) and describe the course of therapy.1 In
addition to the detailed case analysis in each chapter, the authors’ relevant
research supporting these relational concepts and their connections to pro-

cess and outcome are presented. The contribution of their research to their
clinical understanding and practice and to training is highlighted, as well as
the contribution of practice to their research. Thus, we aim to demonstrate
the mutual influence of research and practice, leading to strengthening the
connections and dialogue between these two fields.
OVERVIEW OF THE CHAPTERS: INTEGRATING CASE STUDIES,

THEORY, RESEARCH, AND PRACTICE
The book begins with an overview of the therapeutic relationship,

and its centrality to the therapeutic process (Chapter 1). The chapter pre
sents four main theoretical “threads,” delineating different functions of the
client–therapist relationship and how they facilitate therapy process. The
chapter emphasizes the need to discover which parts of the therapy relation
ship are shared among different kinds of treatments, and which parts are
unique. It also recommends examining specific ways in which the interactive
nature of psychotherapy is differently manifested and utilized in a variety
of contexts.
Eleven clinical case studies (Chapters 2–12) follow, describing a variety
of relationship aspects and how they are manifested in different therapies.
As volume editors, we were faced with a dilemma: to give the contributors
as much freedom as they needed to present their ideas and case studies or to
ask them to adhere to guidelines in order to provide a common framework.
We resolved this by providing them the essential guidelines for the chapters,
while accepting that some chapters would follow them more closely than
others. We presented authors with the following overarching guideline:
Describe an aspect of the client–therapist relationship that you will
be focusing on. The description should clearly depict a relational process
between patient and therapist. This will be the “lens” through which you will
analyze the case. Use the following five areas to discuss the case:
1Note: Case examples have been disguised to protect client confidentiality.

1. A theoretical/conceptual basis for this relational process. The con-
ceptual basis can be drawn from any theoretical model of therapy,
an integration of theories, or it can be transtheoretical.
2. The clinical case study:
77 Presenting problem and patient description.
77 Formal assessment and any quantitative measures that mea-
sure level of patient distress and outcome (e.g., standardized
self-report questionnaires, clinician-rated instruments like
the Structured Clinical Interview for DSM–IV).
77 Provide measures of relationship (e.g., alliance or Early

Experience of Close Relationships or transference) and
measures of technique (e.g., Multitheoretical List of Inter-
ventions, Comparative Psychotherapy Process Scale) if they
were used in this case.
77 Initial interviews and case formulation.
77 Course of treatment: Focus on relationship concepts and how
they interact with technique, clinical choice points, and rele-
vant feedback leading to adaptations or changes in process and
significant moments in therapy that moved the process along.
77 Outcome and prognosis: Include results from relevant quan-
titative measures.
All identifying data should be changed, so that the patients
cannot be recognized.
3. Summary of the mechanisms of change involving both relation-
ship and/or technique factors and their interaction described in
both qualitative and, when possible, quantitative terms.
4. Research to practice and back: Quantitative and qualitative mea-
sures used in research that are relevant to your concept and can
be applied to practice and training.
5. Practice implications and recommendations for clinicians and
supervisors.
It may come as no surprise that there is a built-in tension between these
specific guidelines and the variations required to keep the clinical richness of
the cases and to capitalize on the clinically and empirically informed insights
and visions of our contributors.
ORGANIZATION OF THE BOOK
As indicated above, our goal was to present the development of the

therapeutic relationship through different “lenses” based on theory, practice,
and research. Although our emphasis is on microtheories of change (Cunha
et al., 2012; Stiles, Hill, & Elliott, 2015) rather than on broad-based schools
introduction 7
of psychotherapy, the contributors of the clinical cases formulated their con-
ceptual lenses in the broader context of specific schools. Some adhere more
closely to a specific school than others, but what is common to all is going
beyond the boundaries of a specific major school of psychotherapy and break-
ing new ground for understanding what takes place between the client and
therapist.
Schools of Psychotherapy
The chapters herein are organized under four broad schools of

psychotherapy.
Psychodynamic and Psychoanalytic

Five chapters represent various modes of psychodynamic therapy and
psychoanalysis, in which the therapeutic relationship is a key mechanism
of change. These therapies examine the relationship on both conscious and
unconscious levels, and from both the therapist’s and the client’s perspec-
tive. In psychodynamic therapy, the relationship as a means serves not only
of creating a safe environment but also of reflecting various aspects of the
client’s inner world and interpersonal patterns that are a focus for change.
Each of the five chapters thus focuses on a different relational aspect.
Kohberger, Safran, and Muran (Chapter 2) examine ruptures and repairs
in the alliance in two successive courses of brief relational therapy with the
same client. The process of identifying ruptures and attempting repairs helps
clients gain a deeper understanding of their relationship patterns and creates
an opportunity to experience new relationship patterns with the therapist.
In this chapter, the authors examine how ruptures were addressed by each of
the two therapists, and the relation of rupture and repair work to the outcome
of the two treatments. Schattner and Tishby (Chapter 3) look at patterns of
transference and countertransference in a successful case of psychodynamic
therapy. Using the core conflictual relationship theme method, they iden-
tify core relational patterns of therapist and patient, and how these patterns
play out in the therapy relationship. Wiseman and Atzil-Slonim (Chapter 4)
rely on a conceptual combination of attachment theory and contemporary
relational thinking about the mutual impact client and therapist have on
each other in the process of change as the lens for the development of the
therapeutic relationship. They address the issue of the subjective sense of
closeness and distance in the relationship during the course of therapy as
depicted in relational narratives and how it relates to therapist’s and patient’s
attachment styles. Zilcha-Mano and Barber (Chapter 5) focus on patients’
experience of feeling understood in treatment. They present two case studies
to examine how patients’ interpersonal patterns influence their ability to

feel understood in treatment, whether the therapist actively deploys strate-
gies to make the patient feel understood, and whether the patient indeed
feels understood as a result of these efforts, which is the result not only of the
patient’s traitlike tendencies but also of the actual interactions between the
therapist and the patient in the therapy room. The final chapter among
the psychodynamic chapters is by Shefler (Chapter 6), who describes the
dilemma of adhering to the classical psychoanalytic setting even when there
is a risk of straining the alliance. He presents two clinical vignettes that show
that maintaining professional boundaries can at times turn against the therapy
process, and that the therapist has to make difficult choices regarding whether
to break those boundaries in order to maintain the alliance.
The supervisory relationship provides the template for developing the
therapy relationship. Thus, by focusing on the processing of the relation-
ship in supervision, supervisees can incorporate these supervisor–supervisee
experiences into their clinical work. Hill and Gupta (Chapter 12) apply the
concept of “immediacy” (talking about the here and now in the relationship),
which they have studied in the therapeutic relationship to the supervisory
process. They present several vignettes that show how the use of immediacy
helped resolve problems or tensions in supervision, which in turn helped
supervisees in their work with clients.
Cognitive and Cognitive–Behavioral Therapy

Traditionally, the relationship in cognitive and CBT is a necessary
but not a sufficient condition for successful therapy. In the two chapters
in this section, the authors demonstrate the ways in which the therapeu-
tic relationship becomes part of the process, although in ways that differ
from psychodynamic therapy. Castonguay, Youn, Xiao, and McAleavey
(Chapter 7) integrate relational concepts from other therapy models,
such as addressing ruptures and repairs, in order to improve the efficacy of
CBT. In their case example, they describe how the client missed several
sessions, saying that he had felt judged in therapy. The therapist, instead
of working on cognitive biases, focused on the rupture and even used some
self-disclosure in order to repair the rupture and set the therapy back on
track. Elizur and Huppert (Chapter 8) describe the different roles that the
CBT therapist plays in the relationship, including that of expert, sales-
person, ally against avoidance, and coach. These roles are described in
detail in the treatment of a woman with social anxiety disorder.
Humanistic Psychotherapy, Emotion-Focused Therapy, and Experiential Therapy

Farber and Suzuki (Chapter 9) present the case for positive regard, dem-
onstrating the impact of positive regard in the therapy of a young woman who
introduction 9
had been abused as a child. The authors describe positive regard as “most
effectively conveyed through multiple and ever-changing expressions of both
verbal and nonverbal communication” (p. 212). Watson (Chapter 10) focuses
on the central role of therapist empathy and responsiveness in emotion-
focused therapy. She focuses on listening to clients closely and responding
to their emotional needs in the moment and emphasizes attunement, accep-
tance, congruence, and warmth, and how these qualities contribute to changes
in clients’ self-structures.
Family Systems Therapy

Heatherington, Escudero, and Friedlander (Chapter 11) demonstrate
the importance of engaging with each family member and with the family
as a whole, in order to foster a sense of safety to facilitate family work. The
relationship is not processed, and it is not in itself a mechanism of change.
However, different creative interventions, attuned to each family member,
are employed in order to build strong alliances.
Understanding the Therapeutic Relationship Framework
Chapter 13, by Messer and Fishman, offers a general framework for orga-
nizing these chapters (2–12) according to the different foci and lenses on the
therapeutic relationship. This framework maps each chapter along two major
dimensions: (a) The therapist’s goal in establishing a relationship vis-à-vis
therapeutic change: Is the relationship a necessary but insufficient compo-
nent, or is it the central focus of therapy? (b) How directly does the technique
address the therapeutic relationship versus techniques that impact the rela-
tionship, although they do not address it directly? These two dimensions form
a two-by-two grid with four cells, and the cases are placed in their respective
cells. Thus, readers can get an overall grasp of the similarities and differences
between the different therapies in terms of the centrality of the relationship
and its function in each treatment.
WHAT CAN TRAINERS AND SUPERVISORS

GAIN FROM THE CASES?
This book can be used in a number of ways for training and super
vision for both beginning and advanced trainees. The debate on how to teach
psychotherapy (e.g., Castonguay, Eubanks, Goldfried, Muran, & Lutz, 2015;

Romano, Orlinsky, Wiseman, & Rønnestad, 2010), whether through sepa-
rate courses on each major school of therapy or through common principles
(e.g., insight, corrective experience) is also relevant to the way trainers can
use the cases in this book. For beginning therapists, it would be helpful to
focus on several individual chapters, defining and illustrating the relational
concept that is at the heart of the chapter and how it plays out in the clinical
case. It would probably be helpful to start with some didactic knowledge of
basic concepts in a given model so that beginners could follow more closely
the unfolding therapy process. For instance, to learn from the chapter on
how family systems and alliance meet, some basic understanding of systems
theory needs to be acquired and then be followed by reading and reflecting
on the alliance as it plays out with different family members. More advanced
trainees would be better equipped to compare and contrast the relation-
ship themes presented in each chapter and think about how they could be
used in therapy in different ways. For those, the Messer and Fishman grid
(Chapter 13) would serve as a fruitful and broader prism to appreciate the
breadth and complexity of the relationship. We propose that the chapters
in this book can actually constitute an outline for a course syllabus on the
therapeutic relationship. In addition to reading chapters, course instructors
could accompany the chapters with demonstration video recordings to iden-
tify and observe these relationship processes, as well as to generate exercises
to practice them.
One central theme that emerges from these clinical cases is the impor-
tance of monitoring the relationship throughout treatment. The supervisor
can pick which process in the relationship he or she views the trainee as ready
to apply, and can focus on guiding the trainee to attend to it and choose the
relevant techniques to facilitate the process. As trainees gain experience and
confidence, the supervisor can broaden their relational perspective by focus-
ing on additional concepts the trainees can learn to recognize and monitor.
A case in point is the use of types of immediacy, which requires some level
of confidence before the supervisee can implement it with their clients. As
Hill and Gupta suggest, the use of immediacy in supervision is a good way to
experientially teach supervisees its application in the therapies they conduct.
Such extensions for creative applications in supervision could be used with
other relational themes and layers that are described in the chapters.
We hope that by integrating relationship and technique in innovative
ways our book will appeal to clinicians from diverse orientations who will be
able to draw on the relational concepts presented in the cases. In present-
ing research linked to clinical practice, we also hope to pique the interest of
clinicians to conduct research, with the goal of improving the therapy we
offer our clients.
introduction 11
REFERENCES
Barber, J. P., Muran, C. J., McCarthy, K. S., & Keefe, J. R. (2013). Research on
dynamic therapies. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of
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introduction 13
Introduction
During the last 2 decades, remarkable progress has been made in psycho
therapy research, specifically in the development of evidence-based treat-
ments for a range of disorders (e.g., Barlow, 2014; Lambert, 2013; Nathan
& Gorman, 2002; Norcross & Wampold, 2011; Weisz & Kazdin, 2010).
However, the mechanisms through which these therapies influence outcome
are generally not yet well understood (Barber, Muran, McCarthy, & Keefe,
2013; Barber & Sharpless, 2015; Kazdin, 2011) and, furthermore, the strat-
egy of matching research-based treatments to specific disorders is not always
effective (Wampold & Imel, 2015). Attempts to delineate the active ingre-
dients in the different treatments have pitted treatment methods against
relationship variables, or specific versus common factors, as core mechanisms
of change in the therapy process (Castonguay, 2011; Norcross & Lambert,
2011). However, years of research have shown that studying technique and
relationship variables as separate entities yields inconsistent results, suggesting
http://dx.doi.org/10.1037/0000093-001
Developing the Therapeutic Relationship: Integrating Case Studies, Research, and Practice, O. Tishby
and H. Wiseman (Editors)
Copyright  2018 by the American Psychological Association. All rights reserved.
3
that different change mechanisms play different roles with different clients
(e.g., Webb, DeRubeis, & Barber, 2010; Webb et al., 2012).
In light of this, researchers have shifted the focus to how relationship
variables and techniques interact with one another and affect outcome in
different treatment modalities, and how technique is applied in the con-
text of a particular relationship (Castonguay & Beutler, 2005; Goldfried &
Davila, 2005; Hill, 2005; Horvath, Del Re, Flückiger, & Symonds, 2011).
One of the conclusions of the second APA task force on the therapeutic
relationship (Norcross & Wampold, 2011) was that “the relationship acts
in concert with treatment methods, patient characteristics and practitioner

qualities in determining effectiveness; a comprehensive understanding of
effective (and ineffective) psychotherapy will consider all these determi-
nants and their optimal combination” (p. 423).
In the reality of clinical practice, technique and relationship are inter-
twined and cannot be neatly separated—the therapy process consists of a
synergy between technique and relationship. Applying a specific technique
may strengthen the bond, whereas a strong bond may support the use of
techniques that move clients out of their comfort zone. In our quest to gain
a deeper understanding of what facilitates or hinders therapeutic process,
we need to find new ways of conceptualizing and studying the complexity
inherent in such interrelated processes during the unfolding of therapeutic
relationships in practice.
ORIGINS OF THE BOOK
This book originated from a research workshop held in Jerusalem called

“Multiple Lenses on the Therapeutic Relationship.” As an extension of our
collaboration in the Jerusalem–Haifa psychodynamic psychotherapy study
(see Chapters 3 and 4), we invited leading psychotherapy researchers and
clinicians to take part in the 3-day workshop. The key speakers addressed
theoretical underpinnings, client–therapist relationship processes and expe-
riences, client and therapist variables, techniques versus the relationship and
outcome, and implications for training therapists (Wiseman & Tishby, 2014).
On the last day of the workshop, we gathered for a closed meeting (without an
audience) to watch videos of clinical cases in order to discuss “hands on” how
to translate the presented contributions into practice. The focus on moment-
to-moment process in specific cases treated by leading therapists who took
part as speakers led to challenging “how” questions, including: How does the
relationship work? How does the therapist make decisions on how to inter-
vene? and, How similar or different are therapists of different orientations?

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Developing the Therapeutic

Relationship Integrating Case Studies

Publication Manual of the American Psychological

Publication Manual of the American Psychological

Publication Manual of the American Psychological

Cognitive-Behavioral Therapy Second Edition American

The Therapeutic Relationship in Analytical Psychology

Engaging Archaeology 25 Case Studies in Research

Integrating Research and Practice in Software

Developing Global Leaders: Insights from African Case

Developing the Therapeutic Relationship: Integrating Case Studies, Research, and

Published by APA Order Department

American Psychological Association P.O. Box 92984

Typeset in Goudy by Circle Graphics, Inc., Columbia, MD

Printer: Sheridan Books, Chelsea, MI

Library of Congress Cataloging-in-Publication Data

Names: Tishby, Orya, editor. | Wiseman, Hadas, 1956- editor. | American

British Library Cataloguing-in-Publication Data

Printed in the United States of America

To Tali, Avner, Ido, Noa, and Yael

To Itzik, Adi, and Uri

I. The Case Studies: Integrating Research and Practice........................ 29

II. Mapping Models and Conclusions.................................................... 315

viii contents

Dana Atzil-Slonim, PhD, Lecturer, and Director, Clinical Training Pro-

Jonathan D. Huppert, PhD, Professor, Department of Psychology, Hebrew

xii contributors

in concert with treatment methods, patient characteristics and practitioner

ORIGINS OF THE BOOK

This book originated from a research workshop held in Jerusalem called

4 tishby and wiseman

with Dan Fishman of the methodology for pragmatic cases studies.

OUR PURPOSE AND RATIONALE

This book examines the development of the therapeutic relationship

research supporting these relational concepts and their connections to pro-

OVERVIEW OF THE CHAPTERS: INTEGRATING CASE STUDIES,

The book begins with an overview of the therapeutic relationship,

1Note: Case examples have been disguised to protect client confidentiality.

6 tishby and wiseman

77 Provide measures of relationship (e.g., alliance or Early

ORGANIZATION OF THE BOOK

As indicated above, our goal was to present the development of the

The chapters herein are organized under four broad schools of

Psychodynamic and Psychoanalytic

8 tishby and wiseman

Cognitive and Cognitive–Behavioral Therapy

Humanistic Psychotherapy, Emotion-Focused Therapy, and Experiential Therapy

Family Systems Therapy

Understanding the Therapeutic Relationship Framework

WHAT CAN TRAINERS AND SUPERVISORS

10 tishby and wiseman

York, NY: Guilford Press.

12 tishby and wiseman

sented in the international meeting of the Society for Psychotherapy Research.

in concert with treatment methods, patient characteristics and practitioner

ORIGINS OF THE BOOK

This book originated from a research workshop held in Jerusalem called

4 tishby and wiseman

To protect the Project Gutenberg™ mission of promoting the free