One more time with less jargon: An introduction to "Rupture Repair in Practice"

Homework assignments in relational psychoanalytic treatment of personality disorders: A case study of a patient with narcissistic personality disorder

Homework assignments, or specific tasks patients are asked to engage in or complete between sessions, are a controversial topic among psychoanalysts. While many argue these interventions contradict psychoanalytic principles, others believe they can help address problems and promote coping skills. We propose that homework can be a legitimate aspect of relational psychoanalysis when used in a way that is attuned to the patient's experience and that homework may be an important component of treating personality disorders (PD). We present the case of a man diagnosed with narcissistic PD. He often felt superior to and reported that he despised others, though the core self-image was of fragile. He embraced the role of the omnipotent caregiver, which came with boredom and anger and lack of satisfaction in his social life. The patient tried to control therapy, asserting that he could psychoanalyze himself. As a result, therapy was stalled and progress was limited. At this point, the therapist asked him to complete homework assignments that encouraged him to refrain from his compulsive caregiving to better understand what motivated this behavior. Through this process, the patient came to realize he acted out of avoidance, as he did not want to disclose his own vulnerabilities and flaws. At that point he was able to experience relationships while adopting different stances and finding new meanings. We argue that homework can be fully integrated into the relational psychoanalytic repertoire to improve self-reflection and foster change in patients with PD.

The ongoing rewriting of the therapeutic contract in Metacognitive Interpersonal Therapy for narcissistic personality disorder: The case of Mark

In order to effectively treat individuals suffering from Narcissistic Personality Disorder (NPD), it is crucial to establish therapeutic goals and identify tasks to achieve them. However, this is a challenging process with NPD patients because they often struggle to find meaningful goals beyond the pursuit of status. Moreover, in order to change Furthermore, to promote change, they must confront painful emotions such as shame, guilt, or fear, which they habitually try to avoid. Additionally, they face difficulties in forming a positive perception of their therapists and cooperating towards mutually agreed-upon goals and tasks. As a consequence, NPD patients ask for change but hardly engage themselves in the work necessary to achieve it. Therapists therefore need to pay the uttermost attention to drafting, negotiating and continuously updating a reasonable and realistic therapeutic contract. In this paper we describe the story of a man in his thirties with NPD who was ridden with depression, guilt, envy and anger and did not find ways to pursue the healthy and adaptive behaviors he would need to pursue in order to leave a richer social life. The therapist overcame ruptures in the therapeutic alliance and then involved the patient in a process where they set the steps to follow, making sure the patient was convinced they made sense. After a contract was reached progress became possible. Implications for the role of the therapeutic contract in NPD treatment are discussed.

Understanding "patient deterioration" in psychotherapy from depressed patients' perspectives: A mixed methods multiple case study

OBJECTIVE

This study scrutinizes the meaning of deterioration in psychotherapy beyond the widely used statistical definition of reliable symptom increase pre-to-post treatment.

METHOD

An explanatory sequential mixed-methods multiple case study was conducted, combining quantitative pre-post outcome evaluation of self-reported depression symptoms and qualitative analysis of patients' interviews. In a Randomized Controlled Study on the treatment of Major Depression, three patients showing reliable increase in symptom severity on the BDI-II pre-to-post therapy were selected. An interpretative phenomenological analysis (IPA) was performed on individual interviews conducted pre-, peri- and post-treatment.

RESULTS

Cross-case outcome experiences were: (1) uncontrollable complaints; (2) remaining questions and uninternalized insights and (3) persisting interpersonal difficulties. Within-case idiosyncratic differences revealed that the statistical classification of "deterioration" not necessarily corresponds to a "deteriorated experience," nor univocally indicates unwanted therapy effects. Our findings point at the influences of the patient's (lack of) agency in the process, a discrepancy between patients' expectations and the therapy offer, the therapeutic relationship, interpersonal difficulties, and contextual influences.

CONCLUSION

The meaning of symptomatic deterioration should be interpreted within a patient's idiosyncratic context. The multi-faceted nature of deterioration requires further research to rely on multiple perspectives and mixed methods.

Therapists' responsiveness in the process of ruptures and resolution: Are patients and therapists on the same page?

OBJECTIVE

This study examined the association between the rupture-repair process and patients' and therapists' perceptions of the therapist's responsiveness.

METHOD

We used the Rupture Resolution Rating System to rate early sessions (3-5) in 35 short-term psychodynamic psychotherapy cases. The patients and therapists rated their perceptions of the therapist's responsiveness after each session using the Patient's Experience of Attunement and Responsiveness (PEAR) Scale.

RESULTS

Therapists' contribution to ruptures was negatively associated with both patients' and therapists' PEAR ratings. Confrontation ruptures were negatively associated with patients' PEAR ratings, whereas there was no significant association with withdrawal ruptures. Resolution was positively associated with both patients' and therapists' PEAR ratings. In addition, resolution moderated the negative association between ruptures and patients' PEAR ratings.

CONCLUSION

The findings emphasize the link between therapists' responsiveness and the rupture-repair process. They also highlight the significance of providing therapists with the necessary training to recognize these dynamics and engage in discussions about them with their patients when appropriate.

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.

Never underestimate fears, blocks, and resistances: The interplay between experiential practices, self-conscious emotions, and the therapeutic relationship in compassion focused therapy

Experiential practices are a core component of compassion focused therapy (CFT). Throughout the treatment process, the client's engagement with these practices may become blocked, resulting in a rupture in the therapeutic relationship. In these instances, the interplay between these experiential practices and the therapeutic relationship becomes an essential focus of therapy to repair the rupture, re-engage the client in the therapeutic process, and proceed with the CFT treatment plan. This paper presents the case of a man diagnosed with social anxiety disorder, with the presence of shame-based self-criticism, treated via 12 sessions of CFT. CFT was proceeding well until certain embodiment practices and chair work were introduced, at which point the client refused to continue and became disengaged in the session. The process of repair and re-engagement will be discussed from the perspective of this interplay between experiential exercises and therapeutic relationships. Implications for CFT practice and clinical recommendations will be provided.

Connecting and Healing: The Role of Existential Isolation in Mediating the Impact of the Therapeutic Relationship on Canadian Men's Mental Health Outcomes

The therapeutic relationship has emerged as one of the most important components of successful treatment outcomes, regardless of the specific form of therapy. Research has now turned its attention to better understanding how the therapeutic relationship contributes to patient improvement. Extant literature contends that a strong therapeutic relationship may help reduce a patient's sense of existential isolation (i.e., a sense of not feeling understood by others). Research indicates that existential isolation might be especially problematic for men, potentially increasing their risk for suicidality. This study investigated the association between strength of the therapeutic relationship and psychological distress and suicidality among men who received psychotherapy, and whether existential isolation mediated this association. A total of 204 Canadian men who had previously attended psychotherapy participated in a cross-sectional survey, completing measures of the quality of their most recent therapeutic relationship, existential isolation, depression and anxiety symptoms, and suicidality. Regression with mediation analysis was conducted. Two models were tested; one with depression/anxiety symptoms as the dependent variable and the other with suicidality as the dependent variable. Both mediation models emerged as significant, indicating an indirect effect for quality of the therapeutic relationship on symptoms of anxiety/depression and suicidality through existential isolation. The findings suggest that a positive therapeutic relationship can contribute to men feeling less isolated in their experiences in life (i.e., less existentially isolated), thereby helping mitigate psychological distress and suicidality.

How does hostile resistance interfere with the benefits of cognitive-behavioral therapy for panic disorder? The role of therapist adherence and working alliance

Objective Although clients' hostile behavior directed at therapists (hostile resistance) predicts worse outcomes in cognitive-behavioral therapy (CBT) for panic disorder, the process by which this happens remains unknown. This study examines two putative mechanisms: working alliance and therapist adherence. Method: Seventy-one adults with primary panic disorder received CBT in a larger trial. Hostile resistance and adherence in Sessions 2 and 10 were reliably coded using observer-rated measures; client- and therapist-rated questionnaires assessed working alliance. Outcome measures were attrition and symptomatic improvement, assessed at multiple timepoints with the Panic Disorder Severity Scale. Results: Hostile resistance was significantly related to both preexisting (r  = -.36, p  =  .04) and subsequent declines (r  = -.58, p  <  .0001) in the working alliance. Nevertheless, hierarchical linear modeling revealed that neither a declining alliance nor therapist adherence (whether treated as linear or curvilinear) was independently predictive of symptom change, nor did these factors mediate hostile resistance's association with worse symptomatic improvement. Exploratory logistic regressions similarly indicated that neither adherence nor alliance moderated whether hostilely resistant clients dropped out. Conclusion: This is the first study to establish a bidirectional association between hostile resistance and a declining working alliance. Findings also add to a mixed literature on the adherence-outcome relationship.

Predictors of therapeutic alliance, treatment feedback, and clinical outcomes among African American women in treatment for co-occurring PTSD and SUD

INTRODUCTION

Black women are at heightened risk for trauma exposure, post-traumatic stress disorder (PTSD), and substance use disorders (SUDs), compared to White women and the general population. However, disparities in treatment engagement and retention persist, particularly for Black women with co-occurring PTSD+SUD. Although therapeutic alliance is an important predictor and mediator of treatment retention and outcomes, we know little about predictors of alliance and the mediating role of alliance for PTSD+SUD outcomes among Black women.

METHODS

This study utilized data previously collected for the National Drug Abuse Treatment Clinical Trials Network (CTN) Women and Trauma Study. Participants were 88 Black/African American women (Mage = 41.90, SD = 7.72) participating in a clinical trial comparing Seeking Safety (a cognitive-behavioral intervention for PTSD+SUD) to Women's Health Education (control). This study includes participants from both arms. Measures included the Helping Alliance Questionnaire, Addiction Severity Index-Lite, and Clinician Administered PTSD Scale. Women in the intervention arm also completed the Seeking Safety Feedback Questionnaire.

RESULTS

Stepwise, hierarchical linear regressions indicated that years of education and previous alcohol/drug treatment attempts significantly predicted early alliance in the second week of therapy (β = 0.411, p = .021 and β = 0.383, p = .011, respectively), but not late alliance in the last week of therapy (ps > .794). Greater education and more treatment attempts were associated with higher early alliance. Alliance did not mediate relationships between these significant predictors and treatment outcomes (e.g., attendance, post-treatment PTSD and SUD symptoms) or treatment feedback in the Seeking Safety group.

CONCLUSIONS

Education and prior treatment attempts predicted early alliance among Black/African American women in PTSD+SUD group treatment, and higher education level was associated with poorer Seeking Safety feedback topic ratings. Educational level and treatment history should be considered during alliance building in therapeutic interventions with Black women. Clinicians may consider the integration of pre-treatment alliance-building strategies with Black female patients who have lower levels of education. This study provides insight into the relative impact of several important factors that influence early alliance among Black women with co-occurring PTSD+SUD.

Perfectionism unbound: An integrated individual and group intervention for those hiding imperfections

The tendency to hide and mask suffering and one's perceived imperfections is one of the biggest obstacles in treating those with prominent perfectionistic traits. In this single case, we present an integrative form of psychotherapy for patients with recurrent strategies aimed at neither displaying nor disclosing their perfectionism. Emily was a 26-year-old woman diagnosed with Major Depressive Disorder and reported a personality pathology as diagnosed through the Alternative Model of Personality Disorders. The intervention comprised of a 4-month individual therapy and 2-month group therapy. The former is based on Metacognitive Interpersonal Therapy protocol for personality disorders. The latter is a protocol that integrates the Dynamic Relational Treatment for Perfectionism and Compassion Focused Therapy. At the end of this integrative treatment, Emily remitted from Major Depressive Disorder and personality pathology. Further studies should confirm our promising results in larger samples.

Treating Avoidant Personality Disorder With Combined Individual Metacognitive Interpersonal Therapy and Group Mentalization-Based Treatment: A Pilot Study

ABSTRACT

Avoidant personality disorder (AvPD) is a severe but understudied condition. The current pilot project reports data on acceptability and outcomes of a novel treatment combining biweekly individual metacognitive interpersonal therapy (MIT) and weekly mentalization-based therapy (MBT) group therapy. A total of 30 patients with AvPD were consecutively included in the program. The primary outcome was AvPD-specific personality functioning measured by self-report after treatment. Secondary outcomes were symptom distress, interpersonal problems, quality of life, and psychosocial functioning. Twenty-two patients completed treatment, with a mean duration of 13 months. On the primary outcome, effect sizes were generally moderate to large (effect size range: 0.59-1.10). On secondary outcomes, effect sizes were large (effect size range: 0.77-2.3). Both in terms of acceptability and outcomes, results are promising for the combination of MIT and MBT for AvPD. The approach is a strong candidate for further investigation in future large-scale randomized controlled trial.

Treating intimate partner violence with metacognitive interpersonal therapy: The case of Aaron

Intimate partner violence (IPV) is responsible for loss of lives and significant psychological, financial, and social costs. Research into therapeutic effectiveness show inconsistent results irrespective of therapeutic orientation. The capacity to understand one's own mental states as subjective and distinct from others is an important factor in the regulation of mental states and physiological arousal associated with the perpetration of IPV. Metacognitive Interpersonal Therapy (MIT) offers an innovative approach in working with male perpetrators of IPV. The current paper outlines 14 sessions of MIT with a 45-year-old male perpetrator. A core aspect was helping the client resolve how his view of self and others were subjective experiences that were distinct from relational objectivity. The emergence of healthy self-narratives was fostered through experiential processes, involving guided imagery, rescripting and body focused interventions. Qualitative outcomes are summarized and implications for the use of MIT in treatment of perpetrators of IPV is discussed.

Stepping Stones and Creating Futures: A group-based approach to addressing violence against women through working with men

In low‐ and middle‐income countries, group‐based interventions to address intimate partner violence (IPV) working with men, whether or not they are violent themselves, are increasingly common. Stepping Stones and Creating Futures (SSCF) is one intervention demonstrating reductions in men's perpetration of IPV through working with men around gender inequalities and livelihoods. Using a case study of Thembani, a young man living in an urban informal settlement in South Africa who was a participant within a large randomized controlled trial evaluating SSCF, we discuss how his use of violence changed. This reduction occurred through recognition that his situation was not a personal failing, but similar to others, thus reducing the shame he felt, learning to control his anger, and starting to understand how others felt when he used his power over others. This case study provides some initial evidence about how group‐based interventions working with men may start to transform men's practices.

The Clinical Relevance of Interdisciplinary Research on Affect Regulation in the Analytic Relationship

After more than a century of existence, theoretical development, research, and clinical practice within the psychoanalytic movement have consistently demonstrated that psychoanalysis is not a unitary and autonomous discipline. This has been evidenced by the various ways in which psychoanalytic thought and practice have been informed by and have established a dialogue-more or less fruitful-with related disciplines (neurosciences, developmental psychology, psychotherapy research, attachment theory and research, feminism, philosophy). This dialogue has contributed to a better understanding of the functioning of the human psyche, and therefore of the analytic process, informing clinical interventions. In turn, it has enriched research on psychoanalytic practice and process, underlining the fact that research in psychoanalysis is fundamentally about clinical practice. Since its origins, psychoanalysis has made explicit the work on the patient-analyst relationship as the terrain in which the analytic process unfolds. For its part, research in psychotherapy has demonstrated the relevance of the therapeutic relationship for the good development and outcome of any psychotherapeutic process. This supports the argument that research in clinical psychoanalysis should be research on the impact of the analyst interventions on the analyst-patient relationship. In this context, a central element of what happens in the analytic relationship refers to affect communication and therefore, affect regulation, which is manifested in the transferential and counter-transferential processes, as well as in the therapeutic bond. On the other hand, affective regulation is found at the crossroads of etiopathogenesis, complex personality models and psychopathology, allowing the understanding of human functioning and the staging of these configurations in the patient-analyst relationship. In this way, research on affective regulation in the analytic process is proposed as a path that exemplifies interdisciplinary research and scientific pluralism from which psychoanalysis enriches and progresses as a discipline. The case of a line of research on affective regulation in psychoanalytic psychotherapy is illustrated. The need to resort to other disciplines, as well as the translational value of our research and its clinical usefulness, is discussed.

Metacognitive reflection and insight therapy in an inpatient setting: Transforming messianism to a coherent mission

Metacognitive reflection and insight therapy (MERIT) is an integrative form of psychotherapy which seeks to help adults with serious mental illness make sense of the psychosocial challenges and possibilities they face and decide how to respond to them and direct their own recovery. In this article, we present an adaptation of MERIT to the context of an inpatient ward with an accompanied case illustration. Specifically, we describe how this approach is supported by a broad intersubjective framework, followed by a presentation of processes and contents of the treatment. Special attention is given to the concurrent improvements in reflective abilities and overall well-being of the patient. The unique role that psychotherapy in general, and approaches that emphasize reflective processes in particular, play during acute crises in an inpatient setting is discussed.

Incorporating narrative repair in the treatment of avoidant personality disorders: A case in point

Avoidant personality disorder (AvPD) is characterized by multiple struggles, including shyness, feelings of inadequacy, and hypersensitivity to interpersonal judgments. Research indicates that people with AvPD also show disturbances in narrative identity, which is an internal and evolving story created about the personal past, present, and presumed future. Here, the novel Guide for Narrative Repair (GNaR) recently developed by (Thomsen et al., 2020) is introduced as a potentially useful tool to help people with AvPD in crafting more adaptive narrative identities. The guide is brought to life via a case study analysis of Adam, a male outpatient suffering from AvPD. Consistent with the GNaR, disturbances in Adam's storied self are brought to light and ways to facilitate his narrative repair are proposed. We conclude with implications related to the case as well as the potential narrative turn in AvPD treatment.

Commentary: Rupture repair as a transtheoretical corrective experience

This commentary highlights common principles shared across the diverse clinical case examples featured in this In Session issue on Rupture Repair in Practice. We discuss the importance of therapists recognizing subtle signs of rupture and responding to ruptures with curiosity and compassion. We also consider how therapists can use repair strategies responsively to facilitate a corrective experience for the patient. We explore the ways in which the specific resolution strategy of linking a rupture to larger interpersonal patterns can benefit the therapeutic process, and the ways in which it can constitute a form of avoidance. We conclude by noting promising future directions and celebrating the generosity evidenced by these insightful authors' willingness to share and explore challenging moments in therapy.