Ruptures In Therapeutic Alliance Research Articles

Examining Goal, Task, and Bond in Therapeutic Alliance Ruptures

Examining Goal, Task, and Bond in Therapeutic Alliance Ruptures

The Use of Synchronous Videoconference in Bipolar Patients

Background: A considerable literature has developed around demonstrating the clinical relevance of mentalizing as a construct. However, much of the emphasis has been on patients’ deficits rather than therapist’s abilities. Although it may be the case that therapist’s mentalization capacity can facilitate better outcomes in psychotherapy, there is a dearth of empirical evidence concerning the impact mentalization has on therapist competencies in psychotherapy and the implications of this in clinical practice dyads.
 Methods/Design: A pilot study will use an integrated design. A longitudinal case series alongside a qualitative grounded theory approach will be utilized to develop a context-specific, grounded micro theory model of therapeutic alliance rupture and resolution during online psychotherapy with patients with bipolar disorder. 10 dyads of therapists and patients will be assessed by pre-and post-session outcome ratings, as well as baseline and post-therapy performance ratings during the four-month intervention period. In addition, semi-structured grounded theory interviews will be conducted with participants to gain a deeper understanding of their experiences during the therapeutic process.
 Discussion: New research findings on videoconferencing-enabled clinical interventions have been needed since the COVID-19 pandemic began. According to an assessment of the available evidence, little is known about psychotherapy, and significant gaps remain. This paper describes a protocol of a pilot aimed to capture the explicit and implicit knowledge that emerge from therapists and patients during the therapeutic process in order to investigate the complex process of therapeutic interaction beyond “outcome effects”.

Using Interpersonal Dimensions of Personality and Personality Pathology to Examine Momentary and Idiographic Patterns of Alliance Rupture.

The Alternative Model of Personality Disorders (AMPD) integrates several theoretical models of personality functioning, including interpersonal theory. The interpersonal circumplex dimensions of warmth and dominance can be conceptualized as traits similar to those in AMPD Criterion B, but interpersonal theory also offers dynamic hypotheses about how these variables that change from moment to moment, which help to operationalize some of the processes alluded to in AMPD Criterion A. In the psychotherapy literature, dynamic interpersonal behaviors are thought to be critical for identifying therapeutic alliance ruptures, yet few studies have examined moment-to-moment interpersonal behaviors that are associated with alliance ruptures at an idiographic level. The current study examined the concurrent and cross-lagged relationships between interpersonal behaviors and alliance ruptures within each session in the famous Gloria films (“Three Approaches to Psychotherapy”). Interpersonal behaviors (warmth and dominance) as well as alliance ruptures (i.e., withdrawal and confrontation) were calculated at half minute intervals for each dyad. We identified distinct interpersonal patterns associated with alliance ruptures for each session: Gloria (patient)’s warmth was positively related with withdrawal ruptures concurrently in the session with Carl Rogers; Gloria’s dominance and coldness were related with increased confrontation ruptures in the session with Fritz Perls concurrently, while her coldness was also predicted by confrontation ruptures at previous moments; lastly, both Gloria’s dominance and Albert Ellis’s submissiveness were positively related with withdrawal ruptures. These interpersonal patterns demonstrated the promise of using AMPD dimensions to conceptualize momentary interpersonal processes related to therapy ruptures, as well as the clinical importance of attuning to repetitive, dyad-specific interpersonal cues of ruptures within each session.

Using the DMM–AAI to overcome ruptures in therapeutic alliance

This article discusses a university counselling case in which an Adult Attachment Interview based on the Dynamic-Maturational Model of Attachment and Adaptation (DMM–AAI), was used to overcome ruptures in a therapeutic alliance. A female client in her thirties came to see the counsellor to change her workaholic lifestyle; however, she soon developed erotic transference towards the counsellor. Because of countertransference, the counsellor proposed termination too early which she almost accepted due to her difficulty in reflecting on her past, and the alliance was ruptured. However, the administration of the DMM–AAI allowed the client to gain awareness of the reason for her seeking to terminate her counselling early; that is, a fear of losing her counsellor, which she realised had been a recurring fear in her past relationships. It also allowed the counsellor to renew his empathy towards the client. The present article discusses the effects and features of the DMM–AAI that made it possible to overcome the ruptures in the therapeutic alliance and proposes that it would be interesting to explore how its use during the therapeutic process can facilitate reflective processes in both client and clinician, particularly when the therapeutic alliance is at risk.

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.

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.

A comparison of pre-dropout and temporary rupture sessions in psychotherapy

Although numerous studies have investigated the relationship between the therapeutic alliance and dropout, most have focused on the relationship between alliance quality and psychotherapy outcomes. Objective: To compare sessions with therapeutic alliance ruptures and two sessions prior to treatment dropout (pre-dropout) in terms of rupture subtypes, psychotherapists’ behavior, attitudes, and session content. Method: We implemented quantitative methods to select the sessions and qualitative methods to analyze them. We analyzed 16 temporary rupture sessions from 12 therapist–patient dyads and 16 pre-dropout sessions from 8 different therapist–patient dyads. The sessions originate from clinical psychology Master’s or Doctoral students under supervision in either cognitive behavioral or schema therapy. Pre-dropout sessions were considered unrepaired rupture sessions while rupture sessions were subsequently repaired. Results: Results revealed apparent differences and similarities between the session types in positive and negative psychotherapist behaviors, content intensity, and the type and frequency of ruptures. We explored three new rupture subtypes: attributing positive developments to other sources, indirect speech, and sarcastic hostility. Conclusions: A striking implication is that the frequency of positive and negative psychotherapist behaviors, ruptures, and session content is more likely to decrease in the pre-dropout sessions than in the temporary rupture sessions.

A thematic analysis of therapists' perspectives on therapeutic alliance rupture moments

This study aimed to qualitatively examine the perspectives of therapists using different theoretical orientations on rupture moments. The study features a qualitative research design. Six different therapy session segments were presented to the participants and questions were asked to gather their perspectives on the segments. The thematic analyses conducted on 20 therapists’ evaluations on the 6 rupture segments of 5 patients were based on two categories: i) the causes of the rupture moments, ii) the recommendations for resolution. Findings revealed that therapists are more likely to report patients’ negative contribution as the main cause of rupture moments. Participants attributed less importance to the negative contribution of the therapist or to the therapist-patient relationship in rupture moments, and therapists tended to suggest mostly technical resolutions to ruptures. This second-generation alliance research draws attention to relational aspects of the rupture resolution processes for a positive outcome. However, our findings yielded that there was a lack in therapists’ evaluations in addressing the contribution of the therapists and/or therapist-patient relationship to rupture moments. This highlights the importance of supervision training to foster therapists’ awareness of rupture moments and develop their skills for resolution in the context of the therapist-patient relationship.

Relational Turn and Psychotherapy Research

Psychoanalytic authors have traditionally been skeptical of nomothetic studies, in which group averages obscure the uniqueness of individual cases. Several relational psychoanalytic authors have expressed more pronounced skepticism, affirming, for example, that given the uniqueness of each therapist-patient dyad, systematic empirical research is particularly problematic. In this article we highlight the potential synergy between relational thinking and today's psychotherapy research, by exploring some of the ways in which the work of relational authors has influenced relational psychotherapy research, shifting the focus of study from validation of the models of treatment to the study of the clinical variables such as: countertransference, therapist empathy, self-disclosure, rupture and resolution in therapeutic alliance, intersubjective negotiation, and the patient-therapist attachment relationship. In conclusion, the aim of this article is to facilitate the dialogue between relational psychoanalysis and the field of psychotherapy research, by exploring ways in which these two different worlds can reciprocally stimulate and enrich one another.

Research on Therapeutic Impasses and Ruptures in the Therapeutic Alliance

In this article, we provide an overview of our research program on therapeutic impasses and alliance ruptures. Beginning in the mid-1980s at the University of Toronto, and continuing in New York at Beth Israel Medical Center since the early 1990s, we have focused our efforts on trying to illuminate the processes associated with resolving ruptures in the alliance and working through therapeutic impasses. Influenced both by the relational turn in psychoanalysis and findings emerging from our own research on the process of change, we have developed and evaluated an approach to short-term treatment that appears promising. We are also developing and evaluating the effectiveness of training methods for enhancing therapists’ capacities to work constructively with negative therapeutic process, regardless of the particular “brand” of treatment they are practicing. Finally, we summarize some preliminary findings regarding the impact of therapists’ capacity for mentalization on both treatment process and outcome.

Dealing with Ruptures in the Therapeutic Alliance in Psychotherapy

The therapeutic alliance, based on mutually shared assumptions, goals, and trust, constitutes a keystone of successful treatment in all

Resolution of ruptures in therapeutic alliance: Its role on change processes according to a relational approach

Este artigo apresenta as premissas básicas de uma abordagem relacional em psicoterapia, nomeadamente no que diz respeito às origens de natureza interpessoal da psicopatologia e consequentemente ao modo como a experiencia relacional que a psicoterapia oferece, pode servir para alterar os esquemas interpessoais disfuncionais do paciente subjacentes aos sintomas. Na 2ª parte do artigo, apresentamos as implicações clínicas do conceito do conceito de Rupturas na Aliança Terapêutica, entendidas como um comprometimento ou quebra na relação colaborativa entre terapeuta e paciente. Seguindo a conceptualização de Aliança de Bordin, as rupturas podem consistir num desacordo ao nível das tarefas ou objectivos do processo ou numa tensão no vínculo. São revistos os resultados mais relevantes que têm sido encontrados sobre o modo como estes ciclos interpessoais entre terapeuta e paciente podem conduzir à mudança quando eficazmente geridos, ou a resultados pobres ou finalizações unilaterais quando não resolvidos. Tendo já acumulado evidência para a importância da aliança terapêutica, uma segunda geração de investigadores na aliança, tem procurado compreender o modo como a aliança é, em si mesma, um mecanismo de mudança. Os resultados que aqui são revistos sugerem que o processo de reparação de alianças enfraquecidas pode oferecer uma resposta a esta questão.

Resolution Process of Therapeutic Alliance Ruptures: A Review of the Literature

Adolescents living in youth centers often comply with therapeutic treatment against their will. We think that this forced environment ruptures the therapeutic alliance between adolescents and their therapists and, as such, influences the therapeutic results. It has been reported, however, that therapies evoking rupture of the alliance with its later restoration are more effective than therapies without rupture. We review the literature on models of therapeutic alliance rupture resolution. This review is limited to experimentally- tested models. Firstly, we define the concepts of therapeutic alliance and its rupture. Then, we explore experimental models that quantify therapeutic alliance rupture resolution, describing methods of experimental validation, the results of models applied for experimental validation, and analysis of the data thus obtained.

Repairing alliance ruptures.

In this article, we review the existing empirical research on the topic of therapeutic alliance ruptures in psychotherapy. Ruptures in the therapeutic alliance are defined as episodes of tension or breakdown in the collaborative relationship between patient and therapist. Two meta-analyses were conducted. The first reviewed studies examining the relation between rupture-repair episodes and treatment outcome (r = .24, z = 3.06, 95% CI [.09, .39], p = .002, k = 3, N = 148). The second meta-analysis reviewed the research examining the impact on treatment outcome of training therapists in the use of alliance rupture intervention principles (prepost r = .65, z = 5.56, 95% CI [.46, .78], p < .001, k = 8, N = 376). Both meta-analyses provided promising evidence regarding the relevance of alliance rupture-repair processes to therapeutic outcome. The limitations of the research reviewed are discussed as well as practice implications for repairing the inevitable alliance ruptures in psychotherapy.

Misalignment as a Therapeutic Resource

The article reports conversation analysis of a single cognitive psychotherapy session in which an interactional misalignment between the therapist and the patient emerges, culminates, and is mitigated. Through this case study, the interactional practices leading to a rupture in therapeutic alliance and the practices leading to its mending are explored. In the session the therapist pursues investigative orientation in relation to the patient's experience under discussion, whereas the patient maintains orientation to “troubles-telling.” The diverging projects of the participants amount to overt misalignment. Eventually, the therapist brings the relationship of the patient and herself as a topic of conversation in ways which turn the misalignment into a resource of therapeutic work. The microanalysis of actual interactional patterns in this single case is linked to discussions of therapeutic alliance in psychotherapeutic literature.

The Collaborative Interactions Scale: A new transcript-based method for the assessment of therapeutic alliance ruptures and resolutions in psychotherapy

The authors present a new transcript-based method for the assessment of therapeutic alliance ruptures and resolutions in psychotherapy—the Collaborative Interaction Scale (CIS)—and discuss the structure and theoretical background of the scale and the rating procedure. To assess interrater reliability, three raters independently evaluated 32 psychotherapy sessions (2,984 patient utterances and 2,984 therapist utterances) using the CIS, which demonstrated good interrater reliability (average κ=.66–.81). In evaluating the relationship between therapist interventions and patient alliance rupture and collaborative processes, the authors found significant correlations between therapist negative interventions and patient alliance ruptures and among therapist positive interventions, patient collaborative processes, and indirect rupture markers. Results indicate that the CIS is a reliable rating system, useful in both empirical research and clinical assessments.

The Relationship Between Critical Thinking and Interpersonal Skills

Research suggests that clinicians who think critically use more effective interpersonal skills. This paper offers clinical supervisors specific guidelines on how to utilize this connection to strengthen supervisees' skills in both areas with an emphasis on how helping supervisees develop greater skill in critical thinking can improve their interpersonal skills of empathy and addressing therapeutic alliance ruptures. Some specific strategies discussed include: modeling, facilitating a supervisory environment that supports exploring different points of view, asking questions that require critical thinking skills, and facilitating supervisees' skills in conceptualizing client communications in thematic terms.

A Relational Approach to Understanding Change: Plurality and Contextualism in a Psychotherapy Research Program

This paper presents a relational approach to understanding the self and change that represents a convergence of theoretical perspectives and developments in the literature regarding, for example, emotion, communication, attachment, child development, intersubjectivity, and social constructionism. It introduces the Beth Israel Brief Psychotherapy Research Program as a center for the study of the therapeutic relationship, specifically alliance ruptures and impasses. The program is designed to assess change on multiple dimensions by multiple measures from multiple perspectives and on three levels of analysis: ultimate, intermediate, and immediate outcome. The paper then presents a sampling of studies illustrating the work accomplished at each level. In addition, it outlines current and future investigatory endeavors and, in the process, suggests increased efforts to study the therapist subjective experience in the context of the therapeutic relationship, especially in the resolution of therapeutic alliance ruptures.

Therapist Empathy and Depth of Interpretation in Response to Potential Alliance Ruptures: The Role of Therapist and Patient Attachment Styles

This analogue study examined the relationship between therapists' resolution of therapeutic alliance ruptures and their attachment styles. Seventy-seven clinical psychology graduate student therapists responded to videotaped statements made by role-played patients displaying four different attachment styles (preoccupied, dismissing, fearful, and secure). Therapist responses were rated on empathy and depth of interpretation. Therapist differences in attachment style were assessed on the two dimensions of anxiety and avoidance, derived from a factor analysis of the Relationship Scales Questionnaire. Overall, more anxious therapists tended to respond less empathically, particularly with the fearful and secure patients. There were no therapist differences in depth of interpretation. As a whole, responses to the fearful and preoccupied patients tended to be deeper and more empathic than those to the dismissing and secure patients.

Resolving therapeutic alliance ruptures: diversity and integration.

This article reviews and synthesizes the diverse contributions of the authors in this issue of In Session: Psychotherapy in Practice. It presents a schematization of direct and indirect interventions that therapists typically implement to address problems related to the tasks and goals of treatment, or the affective bond between therapist and client. We then present an additional perspective on the resolution of therapeutic alliance ruptures, emerging out of our own research program.