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 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. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Repairing alliance ruptures.

Increasingly, research on the therapeutic alliance has shifted its focus to clarifying the factors contributing to alliance development, including the processes involved in resolving alliance ruptures. This article provides a brief review of the empirical literature on ruptures in the alliance and their resolution or repair. In sum, the research is promising, indicating the relevance of ruptures and resolution to psychotherapy outcome. However, much of the research thus far consists of small samples or qualitative studies. In many respects, such research should be considered in the early stages of development. Provisional practice implications are presented, suggesting that therapists be more attentive to ruptures, explore patient negative feelings about therapy, and respond to those feelings in an open and nondefensive fashion. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance in behavior therapy.

It may be argued that behavior therapy has proceeded with minimal regard for the therapeutic alliance (TA) as a key mechanism of change. However, ignoring the role of TA in behavior therapy may not only be problematic on a practical level, but also may be inconsistent with basic principles that underlie behavior therapy. In beginning to address these issues, the authors consider the role of TA in behavior therapy with a focus on relevant basic principles. Keeping a focus on these basic principles, the authors then outline three contemporary behavior therapies that already incorporate a focus on the therapeutic relationship and conclude with a clinical case illustration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of the therapeutic alliance in psychotherapy.

Traces the development of the concept of the therapeutic working alliance from its psychodynamic origins to current pantheoretical formulations. Research on the alliance is reviewed under 4 headings: the relation between a positive alliance and success in therapy, the path of the alliance over time, the examination of variables that predispose individuals to develop a strong alliance, and the exploration of the in-therapy factors that influence the development of a positive alliance. Important areas for further research are also noted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders.

This study examined the relationship of early alliance ruptures and their resolution to process and outcome in a sample of 128 patients randomly assigned to 1 of 3 time-limited psychotherapies for personality disorders: cognitive–behavioral therapy, brief relational therapy, or short-term dynamic psychotherapy. Rupture intensity and resolution were assessed by patient- and therapist-report after each of the first 6 sessions. Results indicated that lower rupture intensity and higher rupture resolution were associated with better ratings of the alliance and session quality. Lower rupture intensity also predicted good outcome on measures of interpersonal functioning, while higher rupture resolution predicted better retention. Patients reported fewer ruptures than did therapists. In addition, fewer ruptures were reported in cognitive–behavioral therapy than in the other treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance in psychodynamic-interpersonal and cognitive-behavioral therapy

This study was performed to determine the fluoride concentration of the various cementum surfaces in different tooth groups to find out the most proper teeth and tooth surfaces for different cementum studies. For this purpose, direct measurements of phosphorus and fluoride were carried out in an acid etch biopsy solution. The findings indicate that incisors with exposed cementum are the most inappropriate teeth in comparison with the other groups. According to the results obtained it may be recommended that the studies related to fluoride uptake for cementum should be performed on teeth with no gingival recession or on the unerupted teeth.     

Conceptualizing the therapeutic alliance from a psychoanalytic perspective.

Defines the therapeutic alliance as the patient's active collaboration in the work of psychotherapy or psychoanalysis. The failure to differentiate alliance from transference has in part led to the skepticism regarding the concept of alliance. The patient's active use of the treatment process as a resource for self-understanding and constructive change constitutes his/her collaboration. The nature of collaboration varies with the type of treatment. The alliance depends significantly upon the patient's ability to maintain an observing ego; the activation of transferences significantly affects this process. The alliance is influenced by a core of object relations capacities that are essential to forming a trusting relationship. Defining alliance as patient collaboration makes a sharp distinction between technique and alliance. It is suggested that a scale devised to assess the degree of collaboration, based on this conceptualization, by the present 3rd author and colleagues (1983) provides an instrument for future research. (25 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictive validity of therapeutic alliance in group marital therapy.

The relation between marital distress, therapeutic alliance formation, and treatment outcome was investigated in a group marital skills training program in which 63 couples met for 9 weekly 3-hr sessions. Treatment outcome was assessed before and after completion of treatment through a series of self-report measures. The quality of the therapeutic alliance as viewed by the couples and the therapists was monitored at the 3rd session. Results indicate that levels of marital distress neither impaired nor facilitated alliance formation. In addition, it was demonstrated that patients' and therapists' ratings of the strength of the therapeutic alliance constitute a determinant of successful treatment. It appears, however, that the strength of the alliance is a more powerful predictor of therapeutic success among men than among women. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance in psychodynamic psychotherapy: Theoretical conceptualizations and research findings.

The construct of the therapeutic alliance is approached from the psychoanalytic tradition by reference to the ideas of Freud, R. Sterba, E. R. Zetzel, R. R. Greenson, and L. Luborsky. The transtheoretical approaches posited by E. S. Bordin and L. Gaston are also presented and the relation of alliance to the transference is discussed. The empirical evidence as to the role of the alliance in psychodynamically oriented psychotherapy is presented, and the construct is operationally defined by means of the major psychometric instruments. Factors that foster the development of strong alliances (patient and therapist factors), as well as those that hinder or result in its rupture are discussed in detail. The differential association of alliance to outcome depending on who measures the alliance (patient, therapist, or independent observer) and the timing of the measurement of the alliance (first, third, fifth, or later session) are considered. Last, there is a discussion of the criticisms of how research in this area is conducted, and suggestions for future researchers are made. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient collaboration as a criterion for the therapeutic alliance.

In this article we show that a focus on patient collaboration, as a marker for the therapeutic alliance, is advantageous not only for theory and research but also for clinical practice. This point of view in no way minimizes the importance of the therapist's activity or the clinical significance of the interaction between patient and therapist. Rather, it focuses attention on how the therapist's personality, skill, and technique interact with the problems the patient brings to psychotherapy. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The therapeutic alliance in adolescent substance abuse treatment: A one-with-many analysis.

Studies of the therapeutic alliance typically use a one-with-many (OWM) design in which each therapist (the one) treats multiple clients (the many). This study used Kenny, Kashy, and Cook's (2006) OWM method to examine the composition of the therapeutic alliance and to analyze the association between alliance and outcome in a sample of 398 adolescents treated for substance abuse by 14 therapists. Both the client and therapist alliance ratings yielded large relationship variances, with limited consensus among clients treated by the same therapist about the quality of the alliance. If a client reported an especially strong alliance with his or her therapist, the therapist was likely to also report an especially strong alliance with that client (dyadic reciprocity). The association between the components of the alliance and treatment outcome was complicated, with different levels of measurement and different components of the alliance (perceiver, partner, or relationship) derived from different informants (therapist or client) relating to different outcomes. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

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. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The prisoner's dilemma: game theory and the therapeutic alliance

My aim in this paper is to describe how the therapeutic alliance evolves during psychoanalytic treatment. Lindgren has shown that a coevolutionary process can optimize the level of cooperation by the players in the game of prisoner's dilemma. This level is reached when strategies for recognizing reliable patterns in the sequence of moves by the other player have evolved. These are multiple memory strategies. Lindgren's work suggests that the analytic process must have sufficient time for multiple memory strategies to emerge if it is to achieve the necessary level of trust for an effective therapeutic alliance to develop.     

Studying psychotherapy using the one-with-many design: The therapeutic alliance as an exemplar.

Most psychotherapy research uses a one-with-many design, in which each therapist (the one) treats multiple clients (the many), which raises the challenge of nonindependent data. We present a statistical model for analyzing data from studies that use a one-with-many design. This model addresses the problems associated with nonindependence and can address theoretically relevant questions. To illustrate this model, we analyzed data in which 65 therapists and their 227 clients rated their therapeutic alliance. The primary finding was that both therapist and client alliance ratings were largely relational (i.e., specific to the unique therapist–client combination). There was little consensus among clients treated by the same therapist about the quality of the therapeutic alliance, although some therapists reported forming stronger alliances than other therapists. There was substantial dyadic reciprocity, indicating that if a therapist reported an especially good alliance with a particular client (better than with his or her other clients), then that client was also likely to report an especially good alliance (better than those reported by the therapist’s other clients). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The alliance.

Two decades of empirical research have consistently linked the quality of the alliance between therapist and client with therapy outcome. The magnitude of this relation appears to be independent of the type of therapy and whether the outcome is assessed from the perspective of the therapist, client, or observer. Although the strength of the connection between alliance and therapy outcome appears to be relatively uniform throughout therapy, the client's report of the early alliance may be the most clinically useful indicator. In successful treatments, the therapist's and client's assessments of the alliance tend to converge over time. Recent research suggests that the therapist's skills and personal factors both influence the likelihood of developing a good therapeutic alliance with the client. Though the relation between the therapist's level of training and the quality of the alliance is inconsistent, it is likely that the more trained therapists are able to form better alliances with severely impaired clients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder.

This study investigated the quality and development of the therapeutic alliance as a mediator of change in schema-focused therapy (SFT) and transference-focused psychotherapy (TFP) for borderline personality disorder. Seventy-eight patients were randomly allocated to 3 years of biweekly SFT or TFP. Scores of both therapists and patients for the therapeutic alliance were higher in SFT than in TFP. Negative ratings of therapists and patients at early treatment were predictive of dropout, whereas increasingly positive ratings of patients in the 1st half of treatment predicted subsequent clinical improvement. Dissimilarity between therapist and patients in pathological personality characteristics had a direct effect on growth of the therapeutic alliance but showed no relationship with clinical improvement. The authors conclude that the therapeutic alliance and specific techniques interact with and influence one another and may serve to facilitate change processes underlying clinical improvement in patients with borderline personality disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relation of patient pretreatment characteristics to the therapeutic alliance in diverse psychotherapies.

The prediction of the therapeutic alliance from patient pretreatment characteristics was investigated with a sample of elderly depressed outpatients treated in behavioral, cognitive, and brief dynamic psychotherapy (N?=?60). For the sample as a whole, a higher degree of patient defensiveness was related to a lower patient contribution to the alliance as reflected in patient commitment and working capacity. Also, the availability of environmental support was positively associated with greater patient commitment across treatment conditions. The association of patient pretreatment characteristics with alliance was similar across behavioral and cognitive therapy and less similar across brief dynamic and behavioral or cognitive therapy. The nature of the therapeutic alliance in diverse treatment modalities is discussed, and implications for selection criteria and technical strategies for engaging the difficult patient are explored. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contribution of the therapeutic alliance to outcome in active versus control psychotherapies.

Few studies have examined the role of the therapeutic alliance scores in active versus control psychotherapies. Using data from a randomized clinical trial of psychotherapy and pharmacotherapy for cocaine dependence, it was found that therapeutic alliance scores were rated as significantly more positive in cognitive-behavioral treatment than clinical management, a psychotherapy control condition. However, level of the therapeutic alliance was associated with outcome for the control but not the active psychotherapy. These data suggest that control conditions, which are intended to control for common factors of psychotherapies such as the therapeutic alliance, may exert their effect on outcomes primarily through the level of those common factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cultural difference and the therapeutic alliance: An evidence-based analysis.

The research on positive psychotherapy outcome consistently indicates that the quality of the alliance is important across different models of psychotherapy (D. E. Orlinsky, M. H. Ronnestad, & U. Willutzki, 2004; B. E. Wampold, 2000). Social psychological research has documented how "unintentional bias" can produce barriers to university admissions, employment, and advancement of well-qualified members of ethnic minority groups (J. F. Dovidio, S. L. Gaertner, K. Kawakami, & G. Hodson, 2002). Neuroscience is further confirming social psychological responses associated with race (J. L. Eberhard, 2005). Unintentional bias identified in social psychological research may be part of the psychotherapist/client interaction, interfere with the therapeutic alliance, and partly account for the high dropout rates and underutilization of psychotherapeutic services by people of color. The purpose of this article is to provide an evidence-based analysis of how psychologists in practice may unintentionally interfere with development of quality alliances with culturally different clients or patients and thus contribute to the barriers to effective multicultural counseling and psychotherapy. Principles from the American Psychological Association's (2003) multicultural guidelines and a review of relevant research are applied in suggesting strategies to reduce bias and to develop culturally appropriate skills in psychological practices. (PsycINFO Database Record (c) 2010 APA, all rights reserved)