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

Most 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

Repairing alliance ruptures in psychodynamic psychotherapy with young people: The development of a rational-empirical model to support youth therapists

Alliance ruptures in youth psychotherapy can have a significant impact on treatment outcomes. However, there is currently limited guidance on how to effectively repair these ruptures with young people. This study aims to address this gap specifically in the context of psychodynamic psychotherapy with adolescents. The objectives of the study are (a) to understand the therapeutic interventions and attitudes that either facilitate or hinder the resolution of alliance ruptures and (b) to develop a model for repairing these ruptures within this particular treatment approach. To accomplish this, a task analysis of a previously developed rational model of resolving alliance ruptures was conducted using 16 sessions from short-term psychodynamic psychotherapy with depressed adolescents. The analysis supported some stages of the hypothesized rational model while revealing the need for revisions. As a result, the study developed a rational-empirical model that includes flexible strategies that therapists can use to repair alliance ruptures. This model emphasizes the significance of a collaborative, open, and empathetic approach to resolving ruptures. In contrast, rigid, defensive, or invalidating therapist attitudes can hinder the resolution process. The evidence-based model developed from the study can provide valuable guidance to psychodynamic psychotherapists working with young people, offering insights on how to approach ruptures and employ effective strategies to promote their resolution. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

Future Challenges in Psychotherapy Research for Personality Disorders

Purpose of Review Individuals with personality disorders are frequently seen in mental health settings. Their symptoms typically reflect a high level of suffering and burden of disease, with potentially harmful societal consequences, including costs related to absenteeism at work, high use of health services, ineffective or harmful parenting, substance use, suicidal and non-suicidal self-harming behavior, and aggressiveness with legal consequences. Psychotherapy is currently the first-line treatment for patients with personality disorders, but the study of psychotherapy in the domain of personality disorders faces specific challenges. Recent Findings Challenges include knowing what works for whom, identifying which putative mechanisms of change explain therapeutic effects, and including the social interaction context of patients with a personality disorder. By following a dimensional approach, psychotherapy research on personality disorders may serve as a model for the development and study of innovative psychotherapeutic interventions. Summary We recommend developing the following: (a) an evidence base to make treatment decisions based on individual features; (b) a data-driven approach to predictors, moderators, and mechanisms of change in psychotherapy; (c) methods for studying the interaction between social context and psychotherapy

Opening the Black Box of Family-Based Treatments: an artificial intelligence Framework to Examine therapeutic alliance and therapist Empathy

The evidence-based treatment (EBT) movement has primarily focused on core intervention content or treatment fidelity and has largely ignored practitioner skills to manage interpersonal process issues that emerge during treatment, especially with difficult-to-treat adolescents (delinquent, substance-using, medical non-adherence) and those of color. A chief complaint of real world practitioners about manualized treatments is the lack of correspondence between following a manual and managing microsocial interpersonal processes (e.g. negative affect) that arise in treating real world clients. Although family-based EBTs share core similarities (e.g. focus on family interactions, emphasis on practitioner engagement, family involvement), most of these treatments do not have an evidence base regarding common implementation and treatment process problems that practitioners experience in delivering particular models, especially in mid-treatment when demands on families to change their behavior is greatest in treatment - a lack that characterizes the field as a whole. Failure to effectively address common interpersonal processes with difficult-to-treat families likely undermines treatment fidelity and sustained use of EBTs, treatment outcome, and contributes to treatment dropout and treatment nonadherence. Recent advancements in wearables, sensing technologies, multivariate time-series analyses, and machine learning allow scientists to make significant advancements in the study of psychotherapy processes by looking under the skin of the provider-client interpersonal interactions that define therapeutic alliance, empathy, and empathic accuracy, along with the predictive validity of these therapy processes (therapeutic alliance, therapist empathy) to treatment outcome. Moreover, assessment of these processes can be extended to develop procedures for training providers to manage difficult interpersonal processes while maintaining a physiological profile that is consistent with astute skills in psychotherapeutic processes. This paper argues for opening the black box of therapy to advance the science of evidence-based psychotherapy by examining the clinical interior of evidence-based treatments to develop the next generation of audit- and feedback- (i.e., systemic review of professional performance) supervision systems

Can session-by-session changes in self-reported alliance scores serve as a measure of ruptures in the therapeutic alliance?

OBJECTIVE During treatment, the therapeutic alliance is characterized by rupture and repair episodes, which in turn are associated with psychotherapy outcome. It would be important to have a parsimonious tool to identify ruptures in psychotherapy sessions to provide therapists with meaningful feedback about when they occur. The present study thus aims to establish whether measuring self-reported alliance dynamics can function as a measure of alliance ruptures. METHOD The sample consisted of 58 depressed patients, who received 22 sessions of cognitive therapy for depression in an outpatient setting. The observer-rated Rupture Resolution Rating System (3RS) was applied to 58 sessions where the self-reported Working Alliance Inventory (WAI) completed by patients after each therapy session indicated that alliance ratings declined more than 2 SDs from that patient's individual mean. For comparison purposes, the 3RS was also applied to 58 randomly chosen sessions from the same treatment phase (early, middle, late). RESULTS Results showed significant differences between sessions where the WAI indicated a drop in the alliance and randomly chosen sessions of the same treatment phase with regard to the frequency and impact of ruptures. CONCLUSION This speaks for the construct validity of the 3RS. Session-by-session alliance ruptures may reliably be measured using a case-sensitive approach to identify meaningful drops in alliance self-report (WAI). (PsycInfo Database Record (c) 2023 APA, all rights reserved)

Disaggregating between- and within-patient effects of ruptures and resolutions on the therapeutic alliance and symptom severity.

The therapeutic alliance is considered a robust predictor of psychotherapy outcome. Ruptures and resolutions in the alliance have been the focus of recent alliance literature. Most previous studies investigated their between-patient effects. We used hierarchical linear models to disaggregate the between- and within-patient effects of ruptures on the alliance from patient- and therapist perspective and symptom severity. Further, the moderating effects of rupture resolutions were analyzed. The sample consisted of 56 patients diagnosed with depressive or anxiety disorders who received 25 ± 3 sessions of integrative cognitive behavioral therapy in the outpatient setting. The observer-rated rupture resolution rating system was applied to all 1st, 8th, 16th and 24th therapy sessions. The alliance quality and symptom severity were assessed using self-report questionnaires after these four sessions. Results showed that a higher intensity of ruptures across treatment was associated with lower alliance ratings from both patient- and therapist perspectives during treatment. After sessions with more intense confrontation ruptures, both reported a weaker alliance. Rupture resolutions significantly moderated the withdrawal rupture effect on the alliance. The results provide meaningful practical implications for therapist feedback and training. They further underline the importance of using appropriate statistical analyses to the data structure and nature of psychotherapy to better understand the role of the alliance, rupture, and repair during therapy. (PsycInfo Database Record (c) 2022 APA, all rights reserved

Addressing interpersonal patterns in patients with personality disorders partially explains psychotherapy outcome via changes in interaction patterns: A mediation analysis.

OBJECTIVE Many patients with personality disorders (PDs) present with problematic interaction patterns. These may also manifest in the therapeutic relationship. For successful treatment, therapists must therefore find effective ways to address such problematic interaction patterns. METHODS A total of 382 patients with PDs were recruited within a naturalistic setting and received integrative cognitive-behavioral therapy (CBT). Two subscales of the observer-rated Process-Content-Relationship Scale were applied to sessions 15, 20, and 25 of treatment: one on patient interaction patterns and the other on therapist addressing these. Symptom severity was assessed at intake and discharge. Mediation analysis was applied. RESULTS We found significant main effects of (1) therapists' addressing problematic interaction patterns in session 15 on patients' changes in such patterns from session 15 to 25 and (2) patients' changes in problematic interaction patterns on symptom severity at treatment termination. Further, the effect of therapists' addressing problematic interaction patterns on outcome was mediated by changes in patients' interaction patterns. CONCLUSION The results indicate that therapists' addressing of PD patients' problematic interaction patterns may be particularly important to improve such patterns and thereby treatment outcome. Future research should identify in which patients the mechanism of addressing interaction patterns works best

Ambivalence, resistance, and alliance ruptures in psychotherapy: it's complicated

Ambivalence, resistance, and alliance ruptures are three terms commonly used in psychotherapy, across different theoretical approaches and modalities. However, it is still not clear how those terms are related and how the connection can be used to maintain a therapeutic alliance while addressing clients' ambivalence. This paper aims to briefly describe ambivalence and resistance, describing their impact on psychotherapy process; reintroduce the theory of resistance as a manifestation of ambivalence (Engle & Arkowitz, 2006); and relate it to the concept of alliance ruptures. An original study is presented to further demonstrate this interaction between process and content in psychotherapy sessions. Moreover, this paper will discuss the implications of this relationship, offering directions for psychotherapists in addressing both ambivalence and ruptures in their work.- (undefined