Alliance Ruptures Research Articles

Maintaining a Strong Therapeutic Alliance: Initial Experiences with the Alliance-Focused Training (AFT) in Germany

Alliance Focused Training (AFT) 1 aims at enhancing therapists' competences in resolving ruptures in the therapeutic alliance using video recordings and role-plays. This pilot study funded by the Heigl Foundation aimed at presenting initial results and clinical experiences with AFT in Germany, and to prepare a subsequent RCT. 7 trainee therapists participated. Therapies of 15 patients with depressive disorder were analyzed. Trainees experienced AFT as very helpful for their professional development and for dealing with alliance ruptures. The therapeutic competence significantly improved both in self and in observer ratings. The results indicate that AFT is a promising approach to improve psychotherapy training, emphasizing the relevance of the planned proof of concept RCT.

Ruptures and repairs of group therapy alliance. An untold story in psychotherapy research.

Although previous studies investigated the characteristics of therapeutic alliance in group treatments, there is still a dearth of research on group alliance ruptures and repairs. The model by Safran and Muran was originally developed to address therapeutic alliance in individual therapies, and the usefulness of this approach to group intervention needs to be demonstrated. Alliance ruptures are possible at member to therapist, member to member, member to group levels. Moreover, repairs of ruptures in group are quite complex, i.e., because other group members have to process the rupture even if not directly involved. The aim of the current study is to review the empirical research on group alliance, and to examine whether the rupture repair model can be a suitable framework for clinical understanding and research of the complexity of therapeutic alliance in group treatments. We provide clinical vignettes and commentary to illustrate theoretical and research aspects of therapeutic alliance rupture and repair in groups. Our colleague Jeremy Safran made a substantial contribution to research on therapeutic alliance, and the current paper illustrates the enduring legacy of this work and its potential application to the group therapy context.

Detecting alliance ruptures: the effects of the therapist's experience, attachment, empathy and countertransference management skills.

Accurate alliance rupture detection is a prerequisite to any successful repair process. Despite its importance, however, rupture detection remains a struggle for most therapists. Supporting the existence of a therapist effect on therapy outcomes, rupture detection skills may rely on certain therapists’ personal characteristics. The aim of this study was to verify whether alliance rupture detection performance is related to therapists’ personal characteristics. One hundred and eight undergraduates, trainees and mental health professionals participated in an experimental task assessing their alliance rupture detection ability. Participants also completed attachment, empathy and countertransference management self-reported measures. Participants with clinical experience (trainees and professionals) reported more alliance ruptures, accurate or not, than those with no clinical experience (undergraduates). Trainees reported more accurate ruptures and less inaccurate ones than the two other groups. Attachment anxiety was positively associated with accurate ruptures detection for undergraduates, while this association proved negative for trainees and therapists. Perspective-taking, a cognitive dimension of empathy, was negatively associated with accurate rupture detection, whereas personal distress, an affective dimension of empathy, was negatively associated with accurate ruptures detection for trainees, and positively associated for undergraduates. Self-insight, a component of countertransference management, revealed a negative association with accurate rupture detection for trainees. These findings suggest that therapists vary as to their rupture detection ability and that this ability is related to certain personal characteristics. They also highlight the importance of specific training and clinical supervision for both trainees and experienced therapists in order to improve their detection ability.

If you believe that breaking is possible, believe also that fixing is possible: a framework for ruptures and repairs in child psychotherapy.

Safran and Muran’s classic theoretical framework of alliance rupture and repair suggests effective techniques for repairing alliance ruptures. Accumulating empirical evidence suggests that successful processes of rupture and repair result in better therapeutic outcome and reduced dropout rates. Although ruptures in the alliance in child psychotherapy are frequent, little is known about how to repair them. The present paper proposes a model for identifying and repairing ruptures in child psychotherapy based on Safran and Muran. It consists of four phases: i) identifying the rupture and understanding its underlying communication message, ii) indicating the presence of the rupture, iii) accepting responsibility over the therapists’ part in the rupture and emphasizing the children’s active role as communicators of their distress, and iv) resolving the rupture using change strategies and meta-communication by constructing a narrative story. The theoretical rationale of each phase is explained in detail, and practical clinical guidelines are provided. Empirical studies are needed to examine the effectiveness of the proposed framework.

Studying the Process of Psychoanalytic Psychotherapy: Discursive and Embodied Aspects

This paper presents a case study that aims to further our understanding of the relational and embodied aspects of the psychotherapy process. One psychoanalytic session is examined on multiple levels, including talk, participants’ physiological arousal and interactional attunement, ruptures in the therapeutic alliance, postural congruence and facial expression of affect. Implicit processes of non‐verbal attunement seem to play a role in resolving ruptures and in fostering exploration and the creation of new meanings. Embodied attunement was found to be at its highest at points in the session characterized by verbal disjunction and ruptures in the therapeutic alliance. The therapeutic dyad was ‘in sync’ non‐verbally until tension was resolved, at which point, synchrony was relaxed, and therapist and client were able to proceed with their respective ‘tasks’, secure in the knowledge that the other is there for them. It is argued that attempts to describe the complex and nuanced processes of psychotherapeutic change would benefit from attending to both explicit/semantic and implicit/non‐verbal domains of interaction.

Ambivalence, resistance, and alliance ruptures in psychotherapy: It’s complicated.

Ambivalence, resistance, and alliance ruptures in psychotherapy: It’s complicated.

Jeremy David Safran (1952–2018).

Present an obituary for Jeremy David Safran (1952-2018). In 1993, Safran became full professor and director of clinical training at the New School for Social Research. At the New School, he developed the program with an affiliation to Beth Israel Medical Center, where he was a principal consultant on a psychotherapy research program founded by Arnold Winston and directed by me. In 2001, Jeremy completed psychoanalytic training at the New York University Postdoctoral Program. Subsequently, he cofounded (with Lewis Aron and Adrienne Harris) the Sandor Ferenczi Center at the New School, became president of the International Association for Relational Psychoanalysis and Psychotherapy, and served as associate editor for Psychoanalytic Dialogues. Jeremy's efforts and collaborations regarding emotion and interpersonal process laid the foundation for our own collaboration regarding ruptures in the therapeutic alliance. Our aim was to promote a "second generation" of alliance research that went beyond demonstrating its predictive validity and could be applied across treatment orientations to redress failure rates. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Rupture Resolution Rating System (3RS): Development and validation

Objective: Our aim was to examine the reliability and validity of the Rupture Resolution Rating System (3RS), an observer-based measure of alliance ruptures and resolution processes. Method: We used the 3RS to rate early sessions from 42 cases of cognitive behavior therapy. We compared the 3RS to a simplified version of the Structural Analysis of Social Behavior (SASB), as well as patient and therapist self-reports of ruptures and the alliance. Results: Coders achieved high rates of interrater reliability on the frequency of confrontation and withdrawal ruptures and resolution strategies (ICCs = .85 to .98), as well as ratings of the therapist’s contribution to ruptures and the extent to which ruptures were resolved (ICC = .92). Predictive validity analyses found that confrontation markers (d = .74), successful resolution (d = .67), and ratings of the therapist’s contribution to ruptures (d = .61) predicted dropout from therapy. Analyses of convergent validity with the SASB failed to meet predictions; however, we observed theoretically coherent relations between 3RS and SASB variables. Confrontation rupture markers were significantly associated with patient self-report of rupture (d = 1.54) and therapist self-reported alliance (r = −.50, p = .002). Conclusions: This study provides evidence that the 3RS is a reliable and useful tool for examining psychotherapy process and predicting dropout.Clinical or methodological significance of this article: This study provides evidence of the reliability and validity of the 3RS, an observer-based measure of alliance ruptures and resolution processes. The 3RS can be used to identify problems in the therapeutic relationship that are associated with premature dropout from therapy.

Alliance rupture repair: A meta-analysis.

A rupture is a deterioration in the therapeutic alliance, manifested by a disagreement between the patient and therapist on treatment goals, a lack of collaboration on therapeutic tasks, or a strain in their emotional bond. We present the most frequently used measures of alliance ruptures and clinical examples to illustrate their repair. To examine the relation of rupture repairs to outcome, and the impact of rupture resolution training on outcome, we conducted two meta-analyses. In the first meta-analysis, we examined 11 studies (1,314 patients) that examined the relation between rupture repair episodes and patient treatment outcomes. Results yielded an effect size of r = .29, d = .62, 95% confidence interval [.10, .47], p = .003, indicating a moderate relation between rupture resolution and positive patient outcome. Our second meta-analysis examined the impact of rupture resolution training or supervision on patient outcome. We examined 6 studies (276 trainees/supervisees) that compared the outcomes of trainees who received rupture resolution training with a comparison group. Results did not find a significant relation, r = .11, d = .22, 95% confidence interval [-.09, .30], p = .28. Moderator analyses indicated that the relation between training and outcome was stronger when the sample included fewer patients with personality disorders, when the training was more closely aligned with cognitive behavioral therapy than psychodynamic therapy, and when the treatment was brief. The article concludes with limitations of the research, diversity considerations, and research-informed therapeutic practices for repairing ruptures in ways that contribute to good treatment outcome. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

The Alliance and Rupture Observation Scale (AROS): Development and validation of an alliance and rupture measure for repeated observations within psychotherapy sessions.

The aim of this study was to test a new observer-rated instrument, the Alliance and Rupture Observation Scale (AROS). It was designed for repeated measurements of the alliance within sessions and to detect alliance ruptures. Videotaped therapy sessions with depressed adults were analyzed. Reliability was mainly assessed as inter-rater reliability. Convergent, predictive, and discriminant validity of the AROS was assessed by comparing the instrument with both observer-rated and patient-rated measures. The AROS exhibited excellent inter-rater reliability. Alliance levels measured with the AROS predicted patients' ratings of the alliance in the same session and were highly correlated with another observer-rated alliance measure. Alliance patterns (rupture; repair; and no-rupture) based on AROS scores were significantly correlated with patients' ratings of the alliance. Preliminary support for convergent and predictive validity was found. It is yet to be determined whether AROS scores are related to psychotherapy outcomes.

Impact of confrontations by therapists on impairment and utilization of the therapeutic alliance

Objective: Striking the balance between creating challenge through confrontation (drawing attention to discrepancies) to encourage change and offering support through the therapeutic relationship to ensure safety for patients represents a central issue for psychotherapists. The aim of the present study was to assess immediate effects of confrontations by therapists on the therapeutic alliance. Method: We rated video recordings of 77 therapies to measure incidences of alliance ruptures/resolution attempts as well as confrontations by therapists. Change in the therapeutic alliance and therapy outcome were measured through questionnaires filled out by patients. Results: Confrontations were significantly associated with ruptures/resolution attempts on the micro level. Changes in the therapeutic alliance moderated the association between confrontations and alliance ruptures on the macro level: The bigger the fraction of a session containing confrontations, the larger the fraction containing ruptures, given a prior positive change in the therapeutic alliance. Therapists’ use of confrontation during a resolution attempt was associated with significantly better therapy outcomes than no use of confrontation during or no resolution attempt. Conclusions: Confrontations by therapists may temporarily impair the therapeutic alliance, but might also lead to better therapy outcomes when used to make an alliance rupture explicit as part of a resolution attempt.Clinical or methodological significance: This study provides quantitative explorations of therapists’ fears and hopes regarding the use of confrontations (defined as focus on a discrepancy by the therapist). Results point to associations between confrontations and alliance ruptures, especially in the context of a secure alliance. Furthermore, resolution attempts might profit from initial confrontations regarding the relevant alliance rupture.

Resolving Alliance Ruptures from an Attachment-Informed Perspective.

In this article, we examine how the different attachment patterns enable or hinder the resolution of ruptures in the therapeutic alliance. We try to show that secure and insecure patients alike may experience ruptures in the therapeutic alliance, but that their ability to participate in resolving such ruptures differ markedly. Recent findings with the Patient Attachment Coding System (PACS) show that attachment classifications manifest in psychotherapy as distinct ways of communicating about present internal experience. Secure patients disclose their present experience openly and invite attunement from the therapist, while insecure patients either minimize their contributions to the dialogue (avoidant) or the contributions of the therapist (preoccupied). Using examples from session transcripts, we demonstrate how secure patients are particularly responsive to resolution strategies that focus on here-and-now experience, while insecure patients' characteristic ways of communicating pose significant challenges to the resolution process.

Session-to-session effects of alliance ruptures in outpatient CBT: Within- and between-patient associations.

The concept of alliance ruptures has had a large impact on contemporary studies of the alliance. Although this debate mainly focuses on the effect of ruptures and repairs on subsequent alliance and outcome levels within patients, to date no study has actually examined these within-patient effects. The present study fills this lacuna by examining the effect of alliance ruptures and in-session repairs on alliance ratings and symptom impairment in the subsequent session, accounting for the temporal sequence of ruptures and symptom impairment. Ruptures and in-session repairs were rated by 1,210 patients and 147 therapists using a postsession questionnaire (PSQ-P/-T). Alliance was assessed with the Bern postsession reports and symptomatic impairment with the Hopkins symptom checklist, short form. Patient- and therapist-reported ruptures were significant predictors of subsequent alliance and symptom impairment. While sessions in which both patient and therapist perceived a rupture were especially detrimental for next session symptom distress, they were less damaging to next session alliance levels than sessions in which either only the patient or the therapist experienced the rupture. Neither the intensity of the rupture nor the perceived level of in-session repair were associated with next-session fluctuations in symptom or alliance levels within-patient. The findings demonstrate the importance of disentangling between- and within-patient rupture and in-session repair processes to better understand the roles of rupture and repair in treatment. (PsycINFO Database Record

Extending the context-responsive psychotherapy integration framework to cultural processes in psychotherapy.

Psychotherapist competence in attending to cultural processes has long been considered an ingredient of successful treatment. Although some research findings support a positive association between clinician multicultural competence (MCC) and client improvement, others suggest that MCC may not be a skill that therapists uniformly acquire and then stably maintain. Rather, MCC is likely more fluid and contextualized, potentially rendering within-therapist variability across their patients and within-dyad variability across different moments in a given case. With such variability in perceptions and actual behavioral manifestations of therapist MCC, it may be important for clinicians to heed contextual markers that call for flexibility and evidence-informed responsivity. To this end, we extend Constantino, Boswell, Bernecker, and Castonguay's (2013) context-responsive psychotherapy integration framework, a pantheoretical, if-then approach to responding to common clinical process markers with modular, evidence-based therapeutic strategies. Specifically, we present a therapy case supporting that clients' social and cultural identities can serve as both specific-client contexts in themselves and unique factors that may influence other important therapeutic contexts (e.g., lowered client outcome expectation and alliance ruptures, client change ambivalence/resistance to treatment) that require context-relevant therapist responsivity. With this case, we provide examples both of successful responsivity and missed opportunities. (PsycINFO Database Record

Clinical Consensus Strategies to Repair Ruptures in the Therapeutic Alliance.

The alliance been recognized as an essential common factor and robust predictor of outcome. The present study sought to further our knowledge of the alliance and to promote the integration of research and practice by assessing consensus among peer-nominated expert therapists of varying theoretical orientations on the effectiveness of clinical strategies to repair alliance ruptures. This study drew on the behavioral-analytic model (Goldfried & D'Zurilla, 1969) and the methodology of the Expert Consensus Guideline Series (Frances, Docherty, & Kahn 1997). In Phase I, 69 therapists submitted clinical situations describing alliance ruptures. In Phase II, 177 therapists generated responses to the situations, and clinical strategies underlying the responses were identified. In Phase III, 134 peer-nominated experts (a mean of 22.3 therapists per situation) rated the effectiveness of these clinical strategies. The experts reached consensus on the use of strategies that validated the client's experience and explored the rupture during the rupture session. Change-oriented interventions (e.g., changing interpersonal interactions; highlighting patterns of behavior, thought, or emotions) were generally rated as less effective to use during the rupture, but effective for use in future sessions. The findings are consistent with the growing literature on the value of using certain alliance-focused interventions during a rupture. The findings point to the importance of therapists' awareness of the state of the alliance so that they can identify when ruptures are occurring.

Alliance Rupture and Resolution in Dialectical Behavior Therapy for Borderline Personality Disorder.

The aim of this exploratory study was to investigate alliance rupture and resolution processes in the early sessions of a sample of clients who underwent 1 year of standard dialectical behavior therapy (DBT) for borderline personality disorder (BPD). Participants were three recovered and three unrecovered clients drawn from the DBT arm of a randomized controlled trial that compared the clinical and cost-effectiveness of DBT and general psychiatric management. Alliance rupture and resolution processes were coded using the observer-based Rupture Resolution Rating Scale. Unrecovered clients evidenced a higher frequency of withdrawal ruptures than recovered clients. Withdrawal ruptures tended to persist for unrecovered clients despite the degree of resolution in the prior session, unlike for recovered clients, for whom the probability of withdrawal ruptures decreased as the degree of resolution increased. This study suggests that alliance rupture and resolution processes in early treatment differ between recovered and unrecovered clients in DBT for BPD.

Assessing alliance ruptures and resolutions: Reliability and validity of the Collaborative Interactions Scale-revised version

Objective: This study presents the revised version of the Collaborative Interactions Scale (CIS) [Colli, A., & Lingiardi, V. (2009). The Collaborative Interactions Scale: A new transcript-based method for the assessment of therapeutic alliance ruptures and resolutions in psychotherapy. Psychotherapy Research, 19(6), 718–734.], an observer-rated measure for the assessment of therapeutic-alliance ruptures and resolutions. Intensive use of the previous scale resulted in three criticisms: (i) excessive time required to perform evaluations, (ii) the low occurrence of some items, and (iii) the scale’s low capacity to capture some patient–therapist interactions in fine detail. In this study, we aimed to describe the scale revision process and evaluate interrater reliability and scale validity by comparing sessions of patients with and without personality disorders (PDs). Method: Three raters conducted a blind evaluation of a sample of 60 sessions (180 segments; 3607 narrative units) with 30 patients (15 had a PD diagnosis and 15 had a DSM-5 clinical syndrome diagnosis without a PD). Results: Interrater reliability results ranged from acceptable to excellent and were comparable to those of the former version. Patients with PDs showed a greater number of alliance ruptures and a smaller number of collaborative processes than patients without PDs. Moreover, therapists presented more negative interventions with the PD sample than with the non-PD sample. Conclusions: The results indicate that the revised CIS is a reliable rating system that is useful for both empirical research and clinical assessments.Clinical or methodological significance of this article: The CIS-R is a reliable rating system that is suitable for both empirical research and clinical assessment. It is useful for recognizing rupture and resolution processes, both in clinical everyday practice and in psychotherapists’ training. Application of the CIS-R promotes clinical reflection on the therapeutic action used to manage ruptures in a session.

Confessions of a New York rupture researcher: An insider’s guide and critique

Objective: The study of alliance rupture has become quite prevalent since 1990 and especially in the past 10 years where we have seen a noticeable surge in empirical publications on the subject. This honorary paper attempts to provide a critical review of this literature from the perspective of someone who has contributed to it in his collaborative work on a research program designed to investigate ruptures and to develop intervention and training models to resolve them. Method: This paper is organized into three topics or sections: (1) alliance rupture, (2) rupture resolution, and (3) alliance training; and it addresses definitions, findings, questions, and lessons with regard to each topic. Results/Conclusions: It suggests some clinical conceptualizations (concerning agency and communion as well as mutual recognition), training implications (regarding emotion regulation and deliberate practice), and methodological considerations (promoting pluralism and contextualism), along with future directions.Clinical or methodological significance of this article: The paper provides a critical review of research on a possible risk factor and potential change process in psychotherapy, including related training strategies, that has important implications for treatment outcome and professional development.

Al Qaeda and the Islamic State's Break: Strategic Strife or Lackluster Leadership?

ABSTRACTEmploying counterfactuals to assess individual and systemic explanations for the split between Al Qaeda and the Islamic State of Iraq and al-Sham (ISIS), this article concludes that individual leaders factor greatly into terrorist alliance outcomes. Osama bin Laden was instrumental in keeping Al Qaeda and ISIS allied as he prioritized unity and handled internal disputes more deftly than his successor, Dr. Ayman al-Zawahiri. Although a troubled alliance, strategic differences between Al Qaeda and ISIS were not sufficient to cause the split. Rather, the capabilities of Al Qaeda's leader determined the group's ability to prevent alliance ruptures.

Former les futurs psychothérapeutes à la relation : la réflexion-en-action dans l’alliance thérapeutique

In the Anglo-Saxon world, many higher education programs in psychology have been designed and developed on the mode of reflection-in-action. Practice quickly supports the development of reflective abilities of future professionals. Work on common factors in psychotherapy have highlighted the importance of the relational dimension between patient and psychotherapist, including therapeutic alliance as a major ingredient in the change process. Reflection-in-action is here considered to allow psychotherapists to develop their capacity to identify ruptures of the therapeutic alliance, and to help the patient make sense with them. These alliance ruptures can precipitate abandonment or therapeutic impasse. However, identified and used in a relevant way, they are likely to promote insight and change in the patient. What training model should be then considered to support psychotherapists’ reflexivity, and to promote the development of relevant postures and relational interventions in psychotherapy?