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.

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.

Can we agree we just had a rupture? Patient-therapist congruence on ruptures and its effects on outcome in brief relational therapy versus cognitive-behavioral therapy

To draw clinically meaningful evidence-supported implications about the alliance-outcome association, recent studies have investigated patient-therapist congruence on ruptures in alliance. The present study investigated patient-therapist congruence on ruptures and its consequences on subsequent session outcome in 2 types of treatments that differ in the training therapists receive to identify ruptures: brief relational therapy (BRT), in which therapists receive alliance-focused training, and cognitive-behavioral therapy (CBT), in which no training specifically focused on the alliance is provided. We implemented polynomial regression and response surface analysis, and the truth and bias model on data of 162 dyads reporting weekly on their levels of ruptures, for 30 sessions, during either CBT or BRT. Therapists and patients exhibited substantial temporal congruence in their session-by-session rupture ratings. Therapists showed a tendency to detect more ruptures than did their patients. This tendency correlated with higher levels of congruence and was more evident in BRT than in CBT. Agreement and disagreement between patients and therapists on the question of whether a rupture had occurred was found to have a greater effect on subsequent session outcomes in BRT than in CBT. These findings may suggest that therapists who are more attuned to their patients may demonstrate greater vigilance in identifying ruptures than their patients do. This vigilant stance may be taught. Greater congruence may result in better subsequent session outcome throughout treatment in BRT than in CBT. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Clinical Consensus Strategies to Repair Ruptures in the Therapeutic Alliance

Objective

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.

Method

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.

Results

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.

Conclusions

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.

Resolution of alliance ruptures: The special case of animal-assisted psychotherapy

Many therapists regard alliance ruptures as one of the greatest challenges therapists face in the therapy room. Alliance ruptures has been previously defined as breakdowns in the process of negotiation of treatment tasks and goals and a deterioration in the affective bond between patient and therapist. Alliance ruptures have been found to predict premature termination of treatment and poor treatment outcomes. But ruptures can also present important opportunities for gaining insight and awareness and for facilitating therapeutic change. A process of rupture resolution may lead to beneficial outcomes and serve as a corrective emotional experience. The article describes unique processes of alliance rupture resolution inherent in animal-assisted psychotherapy (AAP). Building on Safran and Muran's model and on clinical examples, the article describes strategies for identifying ruptures in AAP and techniques for repairing them to facilitate a corrective experience in treatment. Implications for clinical practice and future research are discussed.

Alliance ruptures and repairs in psychotherapy in primary care

OBJECTIVE

The association between alliance level and outcome in psychotherapy has been extensively studied. One way to expand this knowledge is to study alliance patterns. The main aims of this study were to examine how frequent alliance patterns with ruptures or rupture-repair episodes were in a naturalistic sample of psychotherapies in primary care, and if three alliance patterns (a Rupture pattern, a Repair pattern, and a No Rupture pattern) were differentially associated with treatment outcome.

METHOD

The psychotherapies (N = 605) included a wide range of different treatment orientations and patient diagnoses. Alliance patterns were studied at session-to-session level, using patient-rated alliance scores. Outcome data were analyzed using longitudinal multilevel modeling with a slopes-as-outcomes model.

RESULTS

The Repair pattern accounted for 14.7% (n = 89) of the treatments, 10.7% (n = 65) exhibited a Rupture pattern, and 74.5% (n = 451) contained no ruptures. The Rupture pattern was associated with inferior treatment outcomes. The Repair pattern was, in longer treatments, associated with better outcomes than the No Rupture pattern.

CONCLUSIONS

The results support theory about the importance of ruptures in the therapeutic alliance and suggest that identification of alliance ruptures is important in alliance-outcome research, for feedback purposes in clinical practice, and in training of therapists.

Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders

Participants were 30 adult outpatients diagnosed with avoidant personality disorder or obsessive-compulsive personality disorder who enrolled in an open trial of cognitive therapy for personality disorders. Treatment consisted of up to 52 weekly sessions. Symptom evaluations were conducted at intake, at Sessions 17 and 34, and at the last session. Alliance variables were patients' first alliance rating and "rupture-repair" episodes, which are disruptions in the therapeutic relationship that can provide corrective experiences and facilitate change. Stronger early alliances and rupture-repair episodes predicted more improvement in symptoms of personality disorder and depression. This work points to potentially important areas to target in treatment development for these personality disorders.