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. Summary 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.

Rupturas da Aliança Terapêutica: um estudo de caso malsucedido em psicoterapia psicanalítica com paciente borderline

Esse trabalho tem como objetivo compreender os processos de ruptura da Aliança Terapêutica (AT) de um caso de psicoterapia psicanalítica (PP) interrompida, realizada com paciente com Transtorno de Personalidade Borderline (TPB). Trata-se de estudo de caso sistemático, que contempla 15 sessões de PP, com um paciente com queixas impulsividade e dificuldades de relacionamento e sua terapeuta. As sessões foram gravadas em vídeo e transcritas. A identificação das rupturas na AT foi feita pelo Rupture Resolution Rating System. Foram encontradas 100 rupturas da AT, destas 69% são rupturas de evitação e 31% de confrontação. Foram verificadas 30 contribuições da terapeuta para as rupturas acontecerem. As rupturas de evitação são mais sutis e de difícil identificação, apresentando-se em maior frequência do que as de confrontação. Diante de pacientes com TPB, os terapeutas devem desenvolver habilidades para fazer intervenções com foco sobre a AT. Destaca-se a necessidade de outros estudos que busquem replicar a pesquisa em outros casos, de sucesso e insucesso terapêutico.

Brüche der Arbeitsbeziehung in Coaching und Supervision

Zusammenfassung In Coaching und Supervision ist die Arbeitsbeziehung zentraler Wirkfaktor. Zwischenmenschliches Geschehen ist aber auch eine Bühne für Störfaktoren, die es zu handhaben gilt. In diesem Beitrag wird das aus der Psychotherapieforschung stammende Konzept der Brüche der Arbeitsbeziehung und ihrer Reparatur vorgestellt. Hierzu gehen wir auf das „Rupture Resolution Rating System“ (3RS) ein, das Spannungsphänomene systematisiert, die Qualität einzelner Brüche veranschaulicht und für die Prozessforschung zugänglich macht. Anschließend wird das Phänomen der Brüche auf den Kontext von Coaching und Supervision übertragen und mit theoretischen und praktischen Implikationen für die Beratung abgerundet.

Alliance challenges in the treatment of a narcissistic patient: the case of Alex

People with pathological narcisism, with their conflicted sense of grandiosity and vulnerability, often pose a variety of therapeutic challenges, which may impede these patients’ ability to benefit from psychotherapy. To offer a case illustration and provide insight into the intrinsic difficulties of working with this patient group, we examined the treatment of a fictional character, Alex, from the TV series In Treatment. Based on the Shedler-Westen Assessment Procedure-200 we diagnosed Alex with pathological narcissism, and evaluated the treatment process (seven sessions) by reporting on measurements of session-by-session change in explicit working alliance, implicit language alliance, and ruptures and repairs. Over the course of treatment, the working alliance (Working Alliance Inventory-Observer scale) fluctuated with a particularly low bond at session five, identified as a rupture (Rupture Resolution Rating System). Language analysis (Linguistic Inquiry and Word Count) showed that the unconscious aspects of the alliance started to deteriorate just before the rupture occurred. The results illustrate how therapists might be pulled to collude with narcissistic patients’ grandiosity, with the risk of neglecting their vulnerability. This fictional portrayal of a treatment with a narcissistic patient may be widely shared with researchers, students and therapists alike, offering a common locus of scholarly attention, and an innovative tool for teaching. Given the lack of empirical treatments for pathological narcissism and the great therapeutic challenges narcissistic patients present, further research and development of clinical guidelines are warranted.

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

Jeremy Safran and his research group suggest that rupture-repair processes are important for the therapeutic change in patients with personality disorders. In this exploratory study, we describe alliance ruptures and resolutions on a session-by-session basis in a clinical sample of adolescents with Borderline Personality Pathology (BPP). Three research questions are addressed: i) Is there a typical trajectory of alliance ruptures over treatment time? ii) Which rupture and resolution markers occur frequently? iii) Which rupture markers are most significant for the therapeutic alliance? Ten patients who presented with identity diffusion and at least three Borderline Personality Disorder criteria were studied and treated with Adolescent Identity Treatment. Alliance ruptures and resolutions were coded in 187 therapy sessions according to the Rupture Resolution Rating System. Mixed-effect models were used for statistical analyses. Findings supported an inverted U-shaped trajectory of alliance ruptures across treatment time. The inspection of individual trajectories displayed that alliance ruptures emerge non-linearly with particular significant alliance ruptures appearing in phases or single peak sessions. Withdrawal rupture markers emerged more often compared to confrontation markers. However, confrontation markers inflicted a higher impact or strain on the immediate collaboration between patient and therapist compared to withdrawal markers. Clinicians should expect alliance ruptures to occur frequently in the treatment of adolescents with BPP. The findings support the theory of a dynamic therapeutic alliance characterised by a continuous negotiation between patients and therapists.

Repairing Alliance Ruptures

A rupture is a deterioration in the therapeutic alliance, manifested by a disagreement between the patient and therapist on treatment goals, a lack of collaboration on therapeutic tasks, or a strain in their emotional bond. This chapter presents the most frequently used measures of alliance ruptures and clinical examples to illustrate their repair. To examine the relation of rupture repairs to outcome, the authors conducted a meta-analysis on 11 studies (1,314 patients) that compared the treatment outcomes of patients with rupture-repair episodes to those of patients with unrepaired ruptures. Results yielded an effect size of r = .29, d =.62, 95% confidence interval [.10, .47], p =.003, indicating a moderate relation between rupture resolution and positive patient outcome. To examine the impact of rupture resolution training or supervision on patient outcome, the authors examined 6 studies (276 trainees/supervisees) that compared the outcomes of trainees who received rupture resolution training with a comparison group. Results did not find a significant relation, r = .11, d = .22, 95% confidence interval [-.09, .30], p = .28. Moderator analyses indicated that the relation between training and outcome was stronger when the sample included fewer patients with personality disorders, when the training was more closely aligned with cognitive behavioral therapy than psychodynamic therapy, and when the treatment was brief. The chapter concludes with limitations of the research, diversity considerations, and research-informed therapeutic practices for repairing ruptures in ways that contribute to good outcome in therapy.

Ruptures, repairs, and reflections: contributions of Jeremy Safran

Jeremy D. Safran’s contributions to our understanding of the complexities of the therapeutic relationship, and its role in the process of patient change in psychotherapy, have been profound. In this paper, we briefly summarize the evolution of his thinking about the alliance and highlight how his ambivalence about this construct contributed to his seminal work delineating rupture resolution models, defined as negotiated intersubjective processes between patient and therapist that are the very essence of the therapeutic process for some patients. Responding to strains in the alliance throughout the rupture resolution process is critical and is an aspect of the treatment model that trainees find most challenging. A clinical example is included to illustrate how Jeremy’s attempts at metacommunicating about his experience with a frustrated patient initiated a productive shift in the process that also contributed to additional ruptures, requiring a simultaneous focus on the strained alliance.