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OBJECTIVE: In order to improve success rates in psychotherapy, an alliance-focused training (AFT) protocol was developed and evaluated with regard to patient-therapist interpersonal behavior in a 30-session protocol of cognitive-behavioral therapy for outpatients comorbid with Axis I and II conditions conducted in a medical center setting. METHOD: Participants included 40 patients treated by 40 therapists in a multiple baseline design in which novice therapists trained to fidelity standards in CBT were introduced to AFT at different time intervals (after either 8 or 16 sessions) during a 30-session CBT protocol. Interpersonal behaviors were assessed with a simplified version of the Structural Analysis of Social Behavior (SASB) on videotaped sessions sampled from the early (between sessions 6–8), mid (14–16), and late (22–24) phases of therapy. RESULTS: As predicted, several significant interactions were observed between within-subject interpersonal change and between-group differences in exposure to AFT. Specifically, there were decreases in patient dependence and in therapist control (including criticism), plus increases in patient expressiveness and in therapist affirmation and expressiveness, all of which could be attributed to AFT. The predictive relationship of several of these variables to session-level and overall treatment outcome was also demonstrated. CONCLUSIONS: This study demonstrates that novice CBT therapists can be trained to improve their interpersonal process with patients who present with comorbid diagnoses, including a personality disorder. PUBLIC HEALTH SIGNIFICANCE: Demonstrating the efficacy of a protocol designed to develop novice therapists’ alliance-focused abilities has important implications for professional training, as well as for outcome in psychotherapy.

OBJECTIVE It has been demonstrated that patient perspective on alliance can predict subsequent treatment outcome as reported by the therapist but not the other way around. This study aimed to investigate the circumstances in which therapists can provide estimations of alliance capable of predicting patient perceptions of subsequent session outcome. The study focused on 2 potential indicators: time in treatment and treatment efficacy. METHOD Data of 107 treatment completers assigned to either cognitive-behavioral therapy or alliance focused therapy were analyzed. Data included session-to-session assessments of alliance and the session outcome measure across the 30 weeks of treatment as well as pretreatment to posttreatment assessments of treatment efficacy using the Symptom Checklist-90-Revised. An actor-partner interdependence model of longitudinal hierarchically nested data, disentangled for within- and between-patients effects, was used. The interactive effects of time and treatment efficacy and their combined effect were examined. RESULTS At the sample level, as expected, the therapist perspective of alliance did not significantly predict patient perception of subsequent session outcome, but significant interaction effects were detected. Therapists' perspective on the alliance was a stronger predictor of patients' perception of subsequent session outcome when therapy was more rather than less effective. This effect was evident mainly early in treatment, during which greater variability across dyads was found. CONCLUSIONS Findings suggest that although therapists' ratings of the alliance are not consistently predictive of patients' rating of subsequent session outcome, they are better predictors in more than in less effective treatments. (PsycINFO Database Record

Objective: In this paper, we test the reliability and validity of two novel ways of assessing mentalizing in the therapy context: the Reflective Functioning scale (RF) applied to code psychotherapy transcripts (In-session RF), and the Exploring scale of the Patient Attachment Coding System (PACS), which measures in-session autonomy and is linked with secure attachment in psychotherapy. Method: Before treatment, 160 patients in different types of psychotherapy and from three different countries were administered the Adult Attachment Interview (AAI), which was rated with the RF scale. One early psychotherapy session for each patient was independently rated with the In-session RF scale and with the PACS Exploring scale. Results: Both scales were found to be reliable and to have concurrent validity with the RF scale rated on the AAI, with the PACS Exploring scale found to be a better predictor of RF on the AAI. Conclusions: These results suggest that the PACS Exploring scale might be a practical method for assessing RF in psychotherapy research and a way for researchers and clinicians to track patients' RF on an ongoing basis. These results also provide information regarding the ways in which differences in RF manifest during psychotherapy sessions. Clinical or methodological significance of this article Researchers and clinicians can assess patients' mentalizing based on any single psychotherapy transcript, in many therapeutic modalities The Exploring scale of the Patient Attachment Coding System can yield a reliable measure of reflective functioning based on any single psychotherapy transcript, in many therapeutic modalities Client differences in mentalizing manifest in part independently of the therapist's contributions.

Our aim was to examine the reliability and validity of the Rupture Resolution Rating System (3RS), an observer-based measure of alliance ruptures and resolution processes.We used the 3RS to rate early sessions from 42 cases of cognitive behavior therapy. We compared the 3RS to a simplified version of the Structural Analysis of Social Behavior (SASB), as well as patient and therapist self-reports of ruptures and the alliance.Coders achieved high rates of interrater reliability on the frequency of confrontation and withdrawal ruptures and resolution strategies (ICCs = .85 to .98), as well as ratings of the therapist's contribution to ruptures and the extent to which ruptures were resolved (ICC = .92). Predictive validity analyses found that confrontation markers (d = .74), successful resolution (d = .67), and ratings of the therapist's contribution to ruptures (d = .61) predicted dropout from therapy. Analyses of convergent validity with the SASB failed to meet predictions; however, we observed theoretically coherent relations between 3RS and SASB variables. Confrontation rupture markers were significantly associated with patient self-report of rupture (d = 1.54) and therapist self-reported alliance (r = -.50, p = .002).This study provides evidence that the 3RS is a reliable and useful tool for examining psychotherapy process and predicting dropout. Clinical or methodological significance of this article: This study provides evidence of the reliability and validity of the 3RS, an observer-based measure of alliance ruptures and resolution processes. The 3RS can be used to identify problems in the therapeutic relationship that are associated with premature dropout from therapy.

In this article, we examine how the different attachment patterns enable or hinder the resolution of ruptures in the therapeutic alliance. We try to show that secure and insecure patients alike may experience ruptures in the therapeutic alliance, but that their ability to participate in resolving such ruptures differ markedly. Recent findings with the Patient Attachment Coding System (PACS) show that attachment classifications manifest in psychotherapy as distinct ways of communicating about present internal experience. Secure patients disclose their present experience openly and invite attunement from the therapist, while insecure patients either minimize their contributions to the dialogue (avoidant) or the contributions of the therapist (preoccupied). Using examples from session transcripts, we demonstrate how secure patients are particularly responsive to resolution strategies that focus on here-and-now experience, while insecure patients' characteristic ways of communicating pose significant challenges to the resolution process.

There is currently little empirical evidence regarding how patients' attachment patterns manifest in individual psychotherapy. This study compared the in-session discourse of patients classified secure, dismissing, and preoccupied on the Adult Attachment Interview (AAI). Rather than focusing on content or form alone, this study analyzed how patients' discourse elicits and maintains emotional proximity with the therapist. The AAI was administered to 56 patients prior to treatment and one session for each patient was rated with the Patient Attachment Coding System (PACS) by four independent raters, blind to patients' AAI classification. Significant differences were found in the discourse of patients with different attachment patterns. Namely, secure and preoccupied patients showed more contact-seeking behavior than dismissing patients, who avoided emotional proximity more, while preoccupied patients resisted therapists' help more than did secure and dismissing patients. These results suggest that the different attachment patterns may have distinctive manifestations in the psychotherapy process that can be tracked by external observers.

Objective Better alliance is known to predict better psychotherapy outcomes, but the interdependent and interactive effects of both therapist- and patient-reported alliance levels have yet to be systematically investigated. Method Using actor-partner interdependence model analysis the authors estimated actor, partner, and 2 types of interactive effects of alliance on session outcome in a sample of 241 patient-therapist dyads across 30 sessions of cognitive-behavioral and alliance-focused therapy. Results Findings suggest that the most robust predictors of session outcome are within-treatment changes in patient reports of the alliance, which predict both patient and therapist report on outcome. Within-treatment changes in therapist reports of the alliance, as well as differences between patients and between therapists in their average ratings of alliance levels across treatment, predict outcome as reported by the specific individual. Although alliance was found to be a significant predictor of outcome in both treatments, for therapist-reported alliance and outcome it had a stronger effect in alliance-focused therapy than in cognitive-behavioral therapy. Additionally, dyads with the highest pooled level of alliance from both partners fared best on session outcome. Conclusions The results are consistent with a 2-person perspective on psychotherapy, demonstrating the importance of considering the interdependent and interactive nature of both patient and therapist alliance levels on session outcome. (PsycINFO Database Record

Safran: What do you think that psychoanalysis will look like 10 or even 20 years from now? Aron: In some ways it depends on what you mean by psychoanalysis, because I think one of the ways that we’ve gotten ourselves into so much trouble is by defining psychoanalysis in contrast to psychotherapy. So, if we’re defining psychoanalysis in this very limited or narrow way, as opposed to psychoanalytic therapy or other analytic therapies, then the question of what the discipline of psychoanalysis will look like would lead you to one answer, which I do not think would be a very optimistic one. But I tend to think that it’s a mistake to define it that way, and that we need to think of psychoanalysis as a broad continuum of treatments with different frequencies and differences in variables of other types, all based on psychoanalytic ideas. And if we define psychoanalysis more broadly in this way, then I have a much more optimistic perspective on the future of psychoanalysis. Not everyone would agree with me on this. Kernberg, for example, defines psychoanalysis in the more narrow sense, and takes the position that psychoanalysis is for the very few and that most people are either too ill or too healthy for psychoanalysis. Thus, from his perspective, and from the perspective of many others, many people need some other treatment, an analytically modified kind of treatment. From his perspective, psychoanalysis is an appropriate treatment for very few people, and he believes that the most important contribution we can make as psychoanalysts is to develop a broad range of analytic treatments or therapies. Safran: I didn’t realize that was Kernberg’s position. Aron: Yes, I did a panel with him last year where he took that position . . . . And I think this position is based on a choice he makes to keep the definition of psychoanalysis rather narrow and very specific. But I think that’s a mistake. Merton Gill, for example, in his final book before he died, took the position that he didn’t differentiate between psychoanalysis and psychodynamic therapy. He spoke of all forms of psychoanalysis as consisting of a range of different forms of therapies, varying with respect to variables such as frequency, intensity, and so on. And I think there are many advantages to this type of perspective. For one thing, I think that it really is very troubling for analysts who spend most of their working lives doing what would have to be called modified analytic therapy (from Kernberg’s perspective) and then end up having a tremendous identity problem about what it means to be a psychoanalyst, since they’re not really doing “psychoanalysis.” And the statistics in the field are very clear. A number of surveys have shown that the great bulk of psychoanalysts are doing something other than psychoanalysis, as it was

The aim of the study described in this paper was to develop a method for measuring the therapeutic alliance from an intersubjective perspective and to evaluate the efficacy of the measure in predicting psychotherapy outcome. We conducted the study using data from 22 patient-therapist dyads engaged in a 30-session protocol of a brief relational therapy. The alliance measure chosen for this purpose was the short form of the Working Alliance Inventory. We used the subjective patient and therapist versions of the measure and created a correlation index representing the intersubjective congruence between patients and therapists on their ratings of the alliance. We examined the relations among the measures, as well as their predictive relation to an outcome measure. The results showed significant intercorrelations among the three alliance measures, suggesting that all captured aspects of the therapeutic alliance. In addition, all three measures were significantly predictive of outcome, with the correlation index appearing more powerful.

Objectives: This study evaluated the development of the therapeutic alliance and the emergence of alliance ruptures, in a sample of patients with different diagnosis and different therapeutic outcome. Design: We examined the longitudinal data of 38 therapeutic dyads receiving cognitive-behavioural therapy, including dropouts as well as successful and unsuccessful cases. The sample included cases with Axis I and Axis II disorders. Method: At the end of each session, patients evaluated the alliance using the Working Alliance Inventory (WAI). Six judges trained in the observation of alliance rupture markers with an observational system of ruptures, rated 201 videotaped sessions. Longitudinal statistical models were applied to the data. Results: We found that the pattern of alliance development of successful cases was different from the unsuccessful and dropouts cases. In addition on average, patients with personality disorders began therapy with a lower WAI score that decreased over time, whereas patients with Axis-I disorders began therapy with a higher WAI score that increased over time

This study compared two methods of detecting ruptures in therapy sessions, a procedure based on a self-report measure, the Working Alliance Inventory (WAI), and an observational Rupture Resolution Rating System (3RS). We anticipated that the 3RS would detect more ruptures than the WAI. We examined the longitudinal data of 38 patient-therapist dyads in a cognitive-behavioral therapy condition. The sample included cases that did not complete treatment (dropped cases) as well as good-outcome and poor-outcome cases. At the end of each session, patients completed the WAI self-report questionnaire. Six judges were trained to observe and detect the occurrence of ruptures, and then rated 201 videotaped sessions. Longitudinal statistical models were applied to the data retrieved from the WAI questionnaires completed by patients. We found discrepancies in the ability of the two methods to detect rupture events with the observational 3RS detecting more ruptures than the WAI. Thus, the use of observational systems for the detection of alliance ruptures is crucial for effectively assessing the quality of the therapeutic alliance over the course of treatment. Furthermore, observational systems proven to detect ruptures can be used to improve clinical practice and training of new clinicians., (undefined)

Aim: We explored therapists’ and clients’ experiences of alliance rupture events for the first 15 sessions of each of eight cases; therapists were each paired with one client who had a personality disorder. Method: All sessions were videotaped and rated with the Rupture Resolution Rating System. Approximately 1 week after a rupture, clients and therapists were individually interviewed about the causes of the rupture, how the rupture evolved, the impact of the rupture on the therapeutic process, and experiences during the event. The interviews were analyzed by five judges using consensual qualitative research (CQR; Hill, 2011). Results: Typically, rupture events involved a repetition of a previous rupture event, the rupture emerged when the client was not prepared to respond to the therapist’s intervention, both therapists and clients felt confused and ambivalent, and confrontation events activated intense and negative feelings. We discuss the implications for practice, training, and research., Fundação para a Ciência e a Tecnologia

This article presents the basic theoretical assumptions of a Relational Approach to Psychotherapy, particularly in what concerns the interpersonal roots of psychopathology and consequently the way the relational experience therapy provides, may serve to change the client’s dysfunctional interpersonal schema subjacent to symptoms. In the second part of the article we present the clinical implications of the concept of Ruptures in Therapeutic Alliance, seen as a tension or breakdown in the collaborative relationship between therapist and patient. Following Bordin’s conceptualization of the alliance, ruptures may consist of a disagreement about the tasks or the goals of treatment or a strain in the bond. The most important findings that have been collected about the way these interpersonal cycles between therapist and patient can lead to change when efficiently addressed, or to poor outcome or unilateral termination when unresolved, are reviewed. Having already accumulated enough evidence about the importance of the therapeutic alliance, a second generation of alliance researchers is now trying to understand the way the alliance is a mechanism of change. The findings we review suggest that the process of repairing weakened alliances may offer an answer to that question., Este artigo apresenta as premissas básicas de uma abordagem relacional em psicoterapia, nomeadamente no que diz respeito às origens de natureza interpessoal da psicopatologia e consequentemente ao modo como a experiencia relacional que a psicoterapia oferece, pode servir para alterar os esquemas interpessoais disfuncionais do paciente subjacentes aos sintomas. Na 2ª parte do artigo, apresentamos as implicações clínicas do conceito do conceito de Rupturas na Aliança Terapêutica, entendidas como um comprometimento ou quebra na relação colaborativa entre terapeuta e paciente. Seguindo a conceptualização de Aliança de Bordin, as rupturas podem consistir num desacordo ao nível das tarefas ou objectivos do processo ou numa tensão no vínculo. São revistos os resultados mais relevantes que têm sido encontrados sobre o modo como estes ciclos interpessoais entre terapeuta e paciente podem conduzir à mudança quando eficazmente geridos, ou a resultados pobres ou finalizações unilaterais quando não resolvidos. Tendo já acumulado evidência para a importância da aliança terapêutica, uma segunda geração de investigadores na aliança, tem procurado compreender o modo como a aliança é, em si mesma, um mecanismo de mudança. Os resultados que aqui são revistos sugerem que o processo de reparação de alianças enfraquecidas pode oferecer uma resposta a esta questão., Fundação para a Ciência e a Tecnologia (FCT)