The Tlierapctitic Relationship 243

tative teaching role, in helping a child. If the therapeutic relationship has

overemphasized closeness and intimacy, a child may have expectations of
dependence which are counterproductive to the task-oriented demands of
cognitive therapy. Again, a therapist must strive for a sensitive balance in the
therapeutic relationship, and this balance will differ for each therapist and
child.

This was brought home to me when I was supervising one of our graduate
students \vho presented a case of a socially fearful medical student he was
treating with cognitive behavioral techniques. His patient, Mark, had such
severe social anxieties that he had few friends, dated infre quently, and
even had difficulty talking with other students. Class presentations were a
nightmare and as early as five days before. Mark would experience
shortness of breath, a tight chest, hyperventilation, and a pounding
tachycardia. Even answering questions in class or on medical rounds was
frightening. The student therapist had been very successful in alleviating
almost all of these anxiety reactions over the course of fourteen sessions
using Beck and Emery's AWARE model and SPA exercises. These
procedures allowed Mark to expose himself to social situations gradually
and substitute adaptive thoughts for the self- defeating ones. And although
the therapist believed any success was predominantly due to the cognitive
procedures, he utilized the thera peutic relationship in a very beneficial
fashion. When Mark stated dur ing the first session that he did not think
anything would help him, his therapist confessed that he too had suffered
these social anxieties, and that therapy had helped him overcome these
problems. Mark seemed comforted by hearing this.
Analyzing his own feelings, the therapist realized that he felt a special
closeness to his patient because thry were both graduate students, and he
believed his patient shared that feeling. Also, because of his own past
difficulties, he felt he had a unique understanding of the pain Mark was
experienced. He believed Mark understood his empathic feelings and
appreciated this.
There were many advantages to this shared closeness. Certainly, it
increased Mark's trust in the therapist, gave him a firm belief that ther apy
would be successful, and increased his motivation to carry out the cognitive
tasks. Thus, while the closeness of their relationship was bene ficial to
therapy, it did not foster a detrimental therapeutic dependence, nor did it
distract attention from developing a cognitive understanding of the social
anxiety or interfere with carrying out in vivo cognitive tasks. Rather, the
therapist used the closeness to increase the patient's cooperation without
allowing it to change the orientation of the treat ment, and the teaching role
often necessitated by cognitive therapy was