Trajectories of alliance ruptures in the psychotherapy of adolescents with borderline personality pathology: timing, typology and significance

"You can't really have a relationship with them because they just ask you questions": understanding adolescent dropout - an empirical single case study

Introduction

High dropout rates are common in youth psychotherapy, including psychoanalytic psychotherapy, yet the reasons behind this trend remain obscure. A critical focus to enhance adolescent engagement could be the therapeutic alliance, particularly in resolving alliance ruptures. This study sought to clarify the complex relationships between the therapeutic alliance, encompassing alliance ruptures and resolutions, and dropout within the context of poor outcome. It investigated a single case of an adolescent with depression who dropped-out of Short-Term Psychoanalytic Psychotherapy, without showing clinical improvement.

Method

Data was garnered from diverse sources, including questionnaires, interviews, and session recordings, and analyzed through a mixed-method longitudinal framework. This encompassed views from the adolescent, therapist, parents, and external evaluators.

Results

The study identifies several factors impacting the decision to drop out, including initial profound distrust toward the therapist, a complex and difficult therapeutic relationship characterized by unresolved alliance ruptures, and sporadic attendance. External factors including minimal parental engagement with therapy were also seen as detrimental to the adolescent's involvement and progress.

Discussion

The research underscores the challenges in engaging adolescents, especially when there may be distrust of professionals, and in the absence of parental involvement with treatment.

Difficulties in interpersonal regulation of emotions (DIRE) questionnaire: Psychometric Properties of the Italian Version and Associations with psychopathological symptoms

The goal of this research was to validate an Italian adaptation of the questionnaire Difficulties in Interpersonal Regulation of Emotions (DIRE) and to investigate its associations with psychopathology. An Italian sample (N = 630) completed the DIRE and the Symptom Checklist-90 (SCL-90). We tested the factorial structure of the DIRE using explorative and confirmatory factorial analyses; we analysed the convergent validity in terms of zero-order correlations with SCL-90 dimensions; and, we conducted multiple regressions to test the predictivity of DIRE factors on specific SCL-90 dimensions. The Italian DIRE replicated the four-factor structure of the original measure, with two interpersonal (Vent and Reassurance-seek) and two intrapersonal (Accept and Avoid) factors. Interpersonal factors resulted correlated with SCL-90 global indexes of psychopathology. Moreover, specific association between DIRE factors and SCL-90 dimensions were found. The Italian DIRE is a reliable and valid measure to evaluate clinically-relevant forms of emotion dysregulation.

Facilitative interpersonal skills are relevant in child therapy too, so why don’t we measure them?

One of the consistent findings from psychotherapy process research has been the impact of therapist effects on patient change and the therapeutic alliance. The Facilitative Interpersonal Skills (FIS) paradigm is a task in which participants respond to standardized videos of actors playing patients in interpersonally challenging moments as if they were the therapist, which was designed to assess therapist effects. Participants’ video recorded responses are coded for eight skills: verbal fluency, emotional expressiveness, warmth/acceptance/understanding, empathy, persuasiveness, hope/positive expectations, alliance-bond capacity, and rupture-repair responsiveness. Performance-based procedures like the FIS minimize self-report bias and systematically control for client-related variability while maintaining strong clinical relevance. Research has shown that therapist FIS predicts the quality of the therapeutic alliance and outcome in adult psychotherapy. This paper describes the development and first adaptation of the FIS task using child and adolescent patients as the stimuli, and reports findings from a pilot study testing the reliability. The FIS-Child (FIS-C) task was administered to 10 therapists with a range of clinical backgrounds. Participants also completed the original FIS task and self-report measures of their empathy, social skills, and playfulness. Adequate interrater reliability was achieved on the FIS-C. There were no significant differences between participants’ ratings on the FIS-C compared to the original FIS, although there were minor differences in the correlations between the FISC and self-report measures compared to the original FIS. Findings support moving forward with utilizing the FIS-C to empirically study therapist effects that may be common factors across treatment models.

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

ABSTRACTMost 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.

Alliance rupture profiles by personality disorder pathology in psychotherapy for depression: Tendencies, development, and timing

OBJECTIVE

Clinical and theoretical considerations presume that patients with different personality disorder (PD) clusters will be associated with distinct alliance rupture profiles; however, there is scarce empirical literature examining this. The present study adopted a systematic framework for investigating profiles of alliance ruptures for individuals belonging to each of the three PD clusters.

METHOD

The sample consisted of 94 patients from a randomized controlled trial for treatment of depression. PD cluster features were assessed at intake and ruptures were assessed across treatment. Three sets of multilevel analyses were conducted to test differences between the PD clusters in the general tendency to show a rupture profile, rupture development throughout the treatment, and timing of predicting ruptures by PD within sessions.

RESULTS

The three clusters were associated with distinct profiles of alliance ruptures. Clusters A and B were characterized by a general tendency to show more withdrawal and confrontation ruptures. Cluster A had a greater decrease in confrontation ruptures over the course of treatment, while cluster B had a greater decrease in withdrawal ruptures. Cluster C was characterized by a general tendency to show fewer withdrawal and confrontation ruptures, with a greater increase in both ruptures over the course of treatment. For withdrawal ruptures, the differences between clusters were evident from the beginning of sessions, whereas for confrontation ruptures, there was less of a difference between beginning and end of sessions.

CONCLUSION

The distinct profiles of alliance ruptures for each PD cluster may contribute to progress towards tailoring treatment to individuals with PDs.

Movement Synchrony in the Psychotherapy of Adolescents With Borderline Personality Pathology - A Dyadic Trait Marker for Resilience?

Movement synchrony describes the coordination of body movements. In psychotherapy, higher movement synchrony between therapist and patient has been associated with higher levels of empathy, therapeutic alliance, better therapy outcome, and fewer drop-outs. The current study investigated movement synchrony during the psychotherapeutic treatment of female adolescents with borderline personality disorder. It was hypothesized that there are higher levels of movement synchrony in the analyzed therapy sessions compared to pseudo-interactions. Further, we tested whether higher levels of movement synchrony correlate with stronger patients' symptom reduction and whether higher movement synchrony predicts higher post-session ratings. A total of 356 sessions from 16 completed psychotherapies of adolescent patients with BPD were analyzed. Movement synchrony was assessed with motion energy analysis and an index of synchrony was calculated by lagged cross-correlation analysis. As hypothesized, the findings support higher levels of movement synchrony in therapy sessions compared to pseudo-interactions (Cohen's d = 0.85). Additionally, a correlation of movement synchrony with better therapy outcome was found (standardized beta = -0.43 indicating stronger personality functioning impairment reduction). The post-session ratings were negatively associated with higher levels of movement synchrony (standardized beta = -0.1). The relevance of movement synchrony and potential implications for clinical practice are discussed.

The Evidence-Base for Psychodynamic Psychotherapy With Children and Adolescents: A Narrative Synthesis

Despite a rich theoretical and clinical history, psychodynamic child and adolescent psychotherapy has been slow to engage in the empirical assessment of its effectiveness. This systematic review aims to provide a narrative synthesis of the evidence base for psychodynamic therapy with children and adolescents. Building on two earlier systematic reviews, which covered the period up to 2017, the current study involved two stages: an updated literature search, covering the period between January 2017 and May 2020, and a narrative synthesis of these new studies with those identified in the earlier reviews. The updated search identified 37 papers (28 distinct studies). When combined with papers identified in the earlier systematic reviews, this resulted in a combined total of 123 papers (82 distinct studies). The narrative synthesis of findings indicates that there is evidence of effectiveness for psychodynamic therapy in treating a wide range of mental health difficulties in children and adolescents. The evidence suggests this approach may be especially effective for internalizing disorders such as depression and anxiety, as well as in the treatment of emerging personality disorders and in the treatment of children who have experience of adversity. Both the quality and quantity of empirical papers in this field has increased over time. However, much of the research demonstrates a range of methodological limitations (small sample sizes, lack of control groups etc.), and only 22 studies were Randomized Controlled Trials. Further high-quality research is needed in order to better understand the effectiveness of psychodynamic psychotherapy for children and young people.

Alliance Ruptures and Resolutions in Personality Disorders

PURPOSE OF REVIEW

This review provides an overview of the state of research on alliance ruptures and resolutions in the treatment of personality disorders (PDs). We discuss frequently used instruments to measure alliance ruptures and resolutions. We discuss the effectiveness of rupture resolution processes and highlight possible avenues for research to explore. Innovative assessments with the potential to reveal the link of ruptures and resolutions and mechanisms of psychotherapeutic change are discussed.

RECENT FINDINGS

The assessment of alliance rupture and resolutions is heterogeneous. Instruments vary largely with respect to a direct or indirect assessment, the time resolution of assessment (integral therapy, phase, session, event), session sampling strategy and perspectives (patient, therapist, observer). The heterogeneity in the instruments and study designs impedes comparability and interpretation of the findings. Results support the hypothesis that ruptures are more frequent in PD. Results also point towards beneficial effects of rupture resolution patterns, early alliance quality, and resolution complexity. Few studies control findings for pretreatment factors. Evidence points to the direction that rupture resolution processes can be considered a general principle of change in the treatment of PD. The concept of alliance ruptures and resolutions provides a useful tool for the management of the therapeutic alliance and its moments of deteriorations throughout the treatment course. Dimensional pretreatment personality functioning is considered a key variable in future studies to highlight what works for whom.