Alliance Ruptures Research Articles

Biological marker of withdrawal ruptures: Dyadic pattern of incongruence in oxytocin release.

Despite widespread clinical, theoretical, and empirical support for the importance of alliance ruptures, little is known about the underlying biological level at times of rupture. The overarching goal of the present study was to investigate dyadic patterns of in-session oxytocin (OT) change between patients and therapists (e.g., patient's OT increases more than therapist's OT) as markers of withdrawal ruptures. Hypothesis 1 construed that OT incongruence (e.g., larger patient increase in OT in comparison to their therapist OT increase) will mark the occurrence of withdrawal ruptures. Hypothesis 2 construed that this effect of OT incongruence will be more pronounced when anxious attachment orientation is low. Surface analysis was conducted on 628 saliva samples that were gathered before and after therapeutic sessions of 53 patient-therapist dyads enrolled in a randomized control trial treating major depression. Only Hypothesis 2 received empirical support, meaning it was only when anxious attachment orientation was low that there were significantly more withdrawal ruptures when the patient's OT increase was higher than their therapist's OT increase. This is consistent with the literature, suggesting that in times of withdrawal ruptures, the patient and therapist are in an incongruent state. Findings suggest that this incongruence is mirrored at the biological level only when anxious attachment orientation is low. Results shed light on what may be happening between patients and therapists on a biological level during a withdrawal rupture. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Selected contemporary approaches to music therapy in psychiatry


 Abstract 
 
 
 Working with music therapy within a psychotherapeutic understanding in psychiatry has a tradition of over fifty years. An overview of music therapy for adults in a psychiatric context and essential results of effect and process research are presented. Psychodynamic music therapy with its free musical improvisation creates a connection between patient and therapist through which a complex relationship can become audible. Effectiveness studies in the psychiatric context show satisfactory to good results. From the perspective of psychiatric patients on music therapy, the shared musical experience and the positive influence on mood are described as strengths. On the one hand, process research emphasises the potential of improvisation for musical attunement and synchronisation; on the other hand, the careful dosage of closeness and distance in shaping relationships must be observed. The recognition that relationships are characterised by attunement and also by inevitable mismatch has gained central importance in recent years. Difficulties, such as misattunement that arise within the therapeutic relationship are not seen as an obstacle, but on the contrary, as an opportunity for change. The concept of Alliance Rupture and Repair is related to music therapy, including a case study. Finally, future fields of research are described.
 
 
 

Pitfalls and Opportunities of the Therapist’s Metacommunication: A Self-determination Perspective

Psychotherapy research identifies alliance ruptures and their resolutions as significant events in psychotherapy, influencing outcome. However, we know little about the process how such events influence outcomes, only assuming if clients stay in therapy that the rupture was resolved, and the outcome will be positive. The purpose of this paper is to problematize this assumption against the backdrop of self-determination theory, introducing motivation and relational positioning as relevant theoretical concepts for understanding rupture resolution and the effect on outcome. A therapeutic transcript demonstrating best practice for alliance rupture resolution in a brief integrative therapy is critically examined, calling the attention of both clinicians and researchers to the risk of prescribing and blindly following techniques during therapeutic impasses. Our analysis of metacommunication demonstrates how the therapist’s use of a certain technique for resolving threats to the therapeutic alliance can lead to the client’s external motivation and compliance, negatively influencing therapeutic outcome. Focusing on the therapist’s relational positioning we present two alternative courses of therapeutic action, ‘mindfulness in action’ and ‘embracing the patient’s ambivalence’, for supporting the client’s autonomous motivation for the therapy process.

Who are the skilled therapists? Associations between personal characteristics and interpersonal skills of future psychotherapists

ABSTRACT Objective Facilitative interpersonal skills (FIS) are a promising variable to explain the so-called therapist effect. We aimed to investigate associations between observer-rated interpersonal skills and self-reported personal characteristics of future therapists. Method In this cross-sectional observational study, psychology students and trainee therapists completed self-report personality and sociodemographic questionnaires as well as the FIS Performance Task (German version, observer-rated). Mixed multilevel model analysis was conducted with FIS total mean score (mean value of 312 individual ratings [13 video-clips, 8 FIS-items, 3 raters]) as dependent variable, therapist ID and FIS clip ID as random effects and 15 therapist variables as fixed effects. Results In the present sample consisting of 177 participants (age: M = 29.8 years (SD = 7.3), [18,59]; 79.1% female, 20.9% male) greater therapists’ experience level, male gender and lower levels of alexithymia were predictive for higher FIS score when statistically controlling for other therapist variables in the model. Age, self-reported childhood maltreatment, attachment style, emotion regulation and self-concept variables turned out to be unrelated. Conclusion The results can inform psychotherapy training programs. They specifically support the importance of addressing therapists’ potential difficulties in recognizing and verbalizing emotions. This is in line with theoretical literature on alliance ruptures and premises of the Alliance-focused training.

Alliance ruptures in psychiatric music therapy

Im psychotherapeutischen Diskurs hat sich das Konzept der Alliance rupture für die Wahrnehmung und Anerkennung von Spannungen und Krisen in der therapeutischen Beziehung etabliert. Ausgehend von der freien Improvisation in der psychodynamischen Musiktherapie werden Alliance ruptures auf die musiktherapeutische Beziehung bezogen. Das Potenzial von Musiktherapie wurde in der musiktherapeutischen Prozessforschung v. a. in Bezug auf Abstimmungs- und Synchronisationsvorgänge untersucht, während die Analyse von Fehlabstimmungen und negativen Spannungen bisher kaum beachtet wurde. Alliance ruptures gehören zum therapeutischen Alltag. Obwohl der Umgang mit musikalischen Alliance ruptures eine Herausforderung darstellt, beeinflusst die Behebung von negativen Spannungen den Therapieerfolg entscheidend. Musikalische Alliance ruptures in Form von Rückzug, dominant-lautem Spiel und Fehlabstimmungen werden anhand von 3 Fallvignetten demonstriert. Die Behebung („repair“) der musikalischen Alliance rupture erfolgt in der Improvisation und/oder der verbalen Reflexion. Abschließend wird die Bedeutung des integrativen Konzepts der Alliance rupture für die Ausbildung und für zukünftige Forschungsfelder herausgestellt.

Additional Perspectives on the Case of "Chris"

In this article, I respond to commentaries by Dr. Karen Skean (2023) and by Dr. Lauren Lipner (2023) on my case study of "Chris" (Yunusova, 2023), a 30-year-old man who presented to treatment with presenting problems related to depression and aspects of complex PTSD. First, I discuss the way in which Skean precisely captures the core processes in my therapy with Chris. This includes (a) how my use of Fosha's AEDP, which emphasizes the development of a close, warm, and open moment-to-moment relationship between therapist and client, incorporated the behavioral concept of exposure; (b) how this use of exposure must be tailored to the individual client in line with Vygotsky's "Zone of Proximal Development"; and (c) the role of memory reconsolidation in helping to revise traumatic memories. I also discuss the deep positive impact of the case of Chris, as supervised by Dr. Skean, on my subsequent development as a therapist. Second, I discuss how valuable I found Dr. Lipner's viewing of my description of the clinical process of therapy with Chris through a theoretical lens quite different from the one I used, including (a) Goldfried's "principles of change," and (b) Safran and Muran's model for identifying and repairing "ruptures in the therapeutic alliance." Finally, I also respond to Dr. Lipner's question about the way in which I handled the exchange of letters with Chris at the end of our therapy.

The Case of "Chris" through a Principle-Based and Alliance-Focused Lens

The case of Chris (Yunusova, 2023) details an 8-session Accelerated Experiential-Dynamic Psychotherapy (AEDP) treatment delivered in the context of a university clinic. Chris is a 30-year-old white male who had nearly completed a doctoral program at the time of treatment. He presented to treatment with the goals of addressing loneliness and depressive thought patterns in the context of the expectation that his emotions were overwhelming and noxious to others. The case illustrates the active role that avoidance and exposure can play in AEDP, with emphasis on affective exposure by way of AEDP’s efforts to increase the patient’s tolerance of their own emotions as well as those of others. The following discussion applies the integrative notion of principles of change in psychotherapy to the case of Chris, with an explicit focus on the therapeutic alliance and the emergence of alliance rupture markers in the development of the case.

V-episodes in the alliance: A single-case application of multiple methods to identify rupture repair.

The therapeutic alliance has been consistently found to be a robust predictor of therapeutic outcome across various modalities of psychotherapy. Alliance ruptures are thought to occur commonly within each therapeutic dyad and, if left unresolved, are associated with premature termination and worsened psychotherapy outcome. Research efforts have identified V-shaped shifts in the alliance, characterized by a high-low-high pattern of postsession alliance scores, as a meaningful method of operationalizing rupture-repair episodes, but these efforts rarely evaluate the within-session process of the identified sessions. As a result, it is often unclear whether these sessions identified by methods based on postsession alliance measures are reflective of clinically meaningful within-session rupture process. This article aims to further explore the V-episode operationalization of rupture-repair episodes by assessing for convergence between rupture process identified by between-session measures and the within-session observer-based Rupture Resolution Rating Scale (3RS) in a single patient-therapist dyad in a 30-session brief relational therapy. V-episodes were operationalized using various previously utilized methods to identify ruptures based on postsession measures of alliance. Results of this case study demonstrate that postsession patient-rated V-episodes in the therapeutic alliance can be indicative of within-session rupture process, demonstrating convergence between within- and between-session measures of alliance process. Implications of these results for methodological approaches for identifying alliance ruptures are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Intersections of gendered racial trauma and childbirth trauma: Clinical interventions for Black women.

Studies suggest that racism affects the type and quality of health care that patients who are Black receive, perhaps in part because poorer patient-provider communication and less provider encouragement of patient involvement have been consistently reported for patients of color. In particular, Black women are 3-4 times more likely to experience dangerous and even life-threatening complications, and more likely to report mistreatment and neglect from medical providers and staff, during childbirth. Experiences with gendered racism during childbirth, which in itself is a vulnerable, intense, and potentially traumatic experience when proper support is absent, may lead to posttraumatic stress reactions. Psychotherapy can help affected clients to process gendered racial and childbirth traumas through: (a) the establishment of a safe, trusting, and collaborative therapeutic relationship, in which careful attention is paid to repairing alliance ruptures caused by cultural misunderstandings or gendered racial microaggressions, and (b) framing experiences and "symptoms" as understandable reactions to gendered race-based traumatic stress during childbirth. In addition to direct therapeutic intervention, therapists should collaborate with doulas and/or medical providers on patient care, and, separately, advocate for systemic-level change, supporting clients' lived experiences outside of the therapy room. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The interplay between therapeutic relationship and therapeutic technique: "It takes two to tango".

The idea that the therapeutic relationship is at the core of psychotherapy is shared by most therapeutic approaches. Also, an increasing variety of therapeutic approaches, consider experiential techniques as central tools to promote effective therapeutic change. Commonly, it is argued that the creation of a positive, empathic, safe, and solid therapeutic alliance should be a prerequisite for administering these techniques. However, recent evidence is beginning to challenge this cautious stance showing that the introduction of experiential work early in therapy can be safe and effective. So, the quality of the therapeutic relationship may either facilitate or hinder the use of experiential techniques, but the use of these techniques may also strengthen or cause ruptures in the therapeutic alliance. So how do we balance the attention to the therapeutic relationship and the use of active, emotionally arousing techniques? In this paper, we present an issue of the Journal of Clinical Psychology: In Session exploring the complex interplay between therapeutic relationship and experiential practices in light of different psychotherapeutic approaches. We do so by first providing an initial overview of the topic. Next, we introduce the five papers of the issue along with some thoughts on how authors from diverse psychotherapeutic orientations contributed to illustrate and reflect on this multifaceted "dance" between therapeutic relationship and techniques.

Withdrawal ruptures in adolescents with borderline personality disorder psychotherapy are marked by increased speech pauses-can minimal responses be automatically detected?

Alliance ruptures of the withdrawal type are prevalent in adolescents with borderline personality disorder (BPD). Longer speech pauses are negatively perceived by these patients. Safran and Muran's rupture model is promising but its application is very work intensive. This workload makes research costly and limits clinical usage. We hypothesised that pauses can be used to automatically detect one of the markers of the rupture model i.e. the minimal response marker. Additionally, the association of withdrawal ruptures with pauses was investigated. A total of 516 ruptures occurring in 242 psychotherapy sessions collected in 22 psychotherapies of adolescent patients with BPD and subthreshold BPD were investigated. Trained observers detected ruptures based on video and audio recordings. In contrast, pauses were automatically marked in the audio-recordings of the psychotherapy sessions and automatic speaker diarisation was used to determine the speaker-switching patterns in which the pauses occur. A random forest classifier detected time frames in which ruptures with the minimal response marker occurred based on the quantity of pauses. Performance was very good with an area under the ROC curve of 0.89. Pauses which were both preceded and followed by therapist speech were the most important predictors for minimal response ruptures. Research costs can be reduced by using machine learning techniques instead of manual rating for rupture detection. In combination with other video and audio derived features like movement analysis or automatic facial emotion detection, more complete rupture detection might be possible in the future. These innovative machine learning techniques help to narrow down the mechanisms of change of psychotherapy, here specifically of the therapeutic alliance. They might also be used to technologically augment psychotherapy training and supervision.

The Way is in Training: Martial Arts-informed Compassionate Mind Training to enhance CFT Therapists’ Compassionate Competencies

Traditional Martial Arts practice(s) can be construed as forms of fully embodied Compassionate Mind Training (CMT). Integration of these body-mind systems can be a powerful means to cultivate and entrain important therapist competencies in compassionate engagement and action. Through such training and personal practice, compassion-focused therapists can develop and enhance their abilities to stimulate and access compassionate motivation at a deeply embodied level. Martial arts-informed CMT thus has the potential to afford therapists greater sensitivity, attunement, distress tolerance, courage and compassionate responsiveness, particularly in difficult therapeutic encounters such as alliance ruptures.

Mothers and public health nurses' experiences of sleep problems in children aged 6months to 3 years: A qualitative study.

The aim of this study was to explore mothers' and public health nurses' (PHN) experiences with sleep problems in children aged 6 months to 3 years in Norway. Sleep problems in children are common, affecting their health and development, and their mothers' well-being. It is also the primary reason parents seek help in well-child clinics (WCC). However, there is limited knowledge regarding the experiences of these mothers and the public health nurses who consult them. Qualitative design. Four semi-structured focus group interviews were conducted: two with mothers (n= 14) who had children with sleep problems and two with public health nurses (n= 14) from well-child clinics. The Framework Method was used for analysing the interviews of mothers. Data from public health nurses were charted onto the analytical framework of maternal data to understand how or whether public health nurses addressed the issues raised by mothers. The study is reported according to the COREQ checklist. The analysis resulted in two main themes: 'therapeutic alliance' (categories 'alliance ruptures' and 'demanding negotiation process') and 'reorganisation of identity' (categories 'unfulfilled expectations' and 'internal tension conflicts'). Young children's sleep problems present challenges to new mothers due to failed expectations, negatively affecting their feelings as mothers and towards their children, and consequently the reorganising of maternal identity. Most mothers experienced unsatisfactory therapeutic alliances while seeking help from public health nurses because advice was considered overly general, contradictory and unsafe for their children. Public health nurses were mostly aware of the parental consequences of children's sleep problems, but many appeared unable to help because of limited time and knowledge. Public health nurses need to establish a therapeutic alliance and provide evidence-based knowledge and guidance on sleep problems while also considering women's reorganisation of identity when becoming mothers. Open Science Framework: osf-registrations-6ag38-v1 (https://archive.org/details/osf-registrations-6ag38-v1).

Examining Goal, Task, and Bond in Therapeutic Alliance Ruptures

Examining Goal, Task, and Bond in Therapeutic Alliance Ruptures

Idiographic and nomothetic relationships between momentary interpersonal behaviors, interpersonal complementarity, and alliance ruptures in psychotherapy.

In this study, we aimed to examine how moment-to-moment interpersonal behaviors of warmth and dominance in patients and therapists, as well as interpersonal complementarity, are related to withdrawal and confrontation ruptures as sessions unfold. Sixteen psychotherapy sessions from eight independent therapeutic dyads were sampled for the highest level of alliance ruptures from a naturalistic psychotherapy data set featuring evidence-based psychodynamic psychotherapy for patients with interpersonal problems and personality pathology. Interpersonal behaviors, complementarity, and alliance ruptures were generated every 30 s within each session. Subgrouping within group iterative multiple model estimation (S-GIMME) was used to identify an idiographic network structure for each session and examine generalizability at the nomothetic and subgroup levels. Nomothetically, patients' dominance negatively predicted therapists' dominance concurrently, but positively predicted therapists' dominance with a 30-s lag; additionally, therapists' dominance predicted their own concurrent warmth. At the subgroup level, therapists being less dominant than typical predicted more concurrent withdrawal ruptures. Idiographic modeling revealed a high degree of heterogeneity in how interpersonal behaviors are associated with ruptures. More confrontation ruptures concurrently predicted higher dominance complementarity in one subgroup. This study demonstrated the interconnection between patients' and therapists' in-session behaviors as well as the role of therapists' behaviors in momentary rupture development. This study highlights the importance of attuning and responding to individualized, momentary therapeutic contexts in navigating ruptures, and emphasizes the value of idiographic relational network approaches to aid in psychotherapy research and case conceptualization. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Religious microaggressions in psychotherapy: A mixed methods examination of client perspectives.

Ethical guidelines state that psychologists should consider clients' religion in their practice. However, some clients have reported negative experiences regarding clinicians' treatment of religion in psychotherapy. These experiences may constitute microaggressions, which have been negatively associated with the working alliance and treatment outcomes among clients with various identities (e.g., those of marginalized racial groups or sexual orientations). The present study used mixed methods to examine religious microaggressions among current and former psychotherapy clients identifying as religious (N = 396). Approximately 39% of participants indicated that at least one religious microaggression occurred during treatment; the most common was minimization or avoidance of religious issues. Religious microaggressions were negatively associated with the working alliance and outcomes. Additionally, the working alliance fully mediated the association between religious microaggressions and poorer outcomes. Thematic analysis of qualitative descriptions of religious microaggressions yielded seven themes: minimization/avoidance of religious issues, assumptions of religious homogeneity, pathologizing religion, unhelpful/inappropriate interventions, pressure to embrace religion, prioritization of therapist's religious beliefs, and lack of expertise. Limitations include a retrospective, cross-sectional design and a majority White, female, and Christian sample. These results provide initial evidence that a substantial minority of religious clients may experience religious microaggressions in psychotherapy, which could impede treatment progress via negative effects on the working alliance. As such, clinicians may be able to enhance client outcomes by increasing awareness of religious microaggressions in their work and addressing microaggression-related alliance ruptures openly when they do occur. Implications for training are also discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Using ROM in family therapy.

Routine outcome monitoring (ROM) is in this article defined as a tool for feedback-informed therapy where clients' therapy relevant information is applied in real-time therapy. Because family therapy represents a comprehensive clinical setting, ROM is experienced as particularly useful. In a vignette from family therapy practice, the use of ROM is demonstrated on individual, couple, and family levels with reference to integrative systemic therapy. ROM information is shown to play a central role in the different phases of treatment. It is demonstrated how ROM facilitates patient-centered assessment that strengthens the therapeutic collaboration such as the working alliance, identifying treatment targets, and possible constraints. In particular, ROM revealing alliance rupture followed by alliance repair is emphasized as a crucial therapeutic event in this treatment.

The alliance construct in psychotherapies: from evolution to revolution in theory and research

The alliance construct in psychotherapies: from evolution to revolution in theory and research

Alliance ruptures and resolutions in short-term psychoanalytic psychotherapy for adolescent depression: An empirical case study

ABSTRACT Most research on alliance rupture-repair processes in psychotherapy has been carried out with adults and little is known about the alliance dynamics with adolescents, especially in psychodynamic treatments. Objective: This study aimed to better understand the process of alliance rupture–resolution and its role in a good-outcome case of a depressed adolescent treated with short-term psychoanalytic-psychotherapy (STPP). Method: A longitudinal, mixed-methods empirical single-case approach was employed. Multiple sources of information (questionnaires, interviews, sessions recordings) from various perspectives (adolescent, therapist, observer) were assembled and analysed. Results: The different sources of evidence converged and showed that, despite the presence of frequent alliance ruptures, patient and therapist managed to resolve these and develop a good and collaborative relationship. Both patient and therapist regarded the evolution in their relationship as the treatment factor mainly responsible for the positive changes experienced by the adolescent. Based on both theoretical and empirical data, a preliminary model of how to explore and repair alliance ruptures in STPP is presented. Conclusion: This study illustrates one way of applying an empirical, mixed-method approach to a single case. Its finding supports the idea that the process of repairing ruptures is an important mechanism of change. Strengths, limitations, and possible implications are discussed.

Rupture Repair

A strong therapeutic relationship provides the optimal context for CBT, and an important component of this relationship is the alliance. An alliance rupture is a difficulty or deterioration in the alliance manifested by a lack of collaboration on therapy tasks or goals or a strain in the bond. The process of rupture repair can facilitate the work of therapy by renewing collaboration and strengthening the bond. Rupture repair can also provide the opportunity for a corrective experience of successfully navigating interpersonal conflict. A review of research on rupture repair in CBT treatments highlights that ruptures are common, and that failure to repair ruptures is associated with poor outcome and premature dropout. Therapists can reduce the likelihood of contributing to ruptures by adhering to the principle of collaborative empiricism. Therapists can facilitate rupture repair by recognizing ruptures when they occur and employing repair strategies: immediate repair strategies such as modifying the treatment task, or expressive repair strategies such as metacommunicating about the rupture and exploring the interpersonal schemas that underlie it. Training in rupture repair has demonstrated benefits for CBT therapists, particularly trainees.