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

Abstract

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 betweenpatient 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 received25 ± 3 sessions of integrativecognitive 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. Clinical Impact StatementQuestion: This study focused on answering the question how ruptures in therapy sessions are associated with the alliance and symptom severity and if rupture resolutions influence that relationship. Findings: A higher intensity of ruptures across treatment was associated with lower alliance levels during treatment. Alliance scores were lower after sessions with an unusually high intensity of confrontation ruptures. Effective resolution processes bolstered against negative effects of withdrawal ruptures on the alliance in patients who consistently withdrew from the therapist or the work of therapy. Meaning: Ruptures and resolutions may not generally be clinically relevant with regard to symptom severity in integrative CBT, however, with regard to the therapeutic alliance, resolution processes may work as some sort of buffer for the negative effect of withdrawal ruptures on symptom severity. Next Steps: Therapists might benefit from routine outcome monitoring and feedback systems that alert them if a therapy is characterized by low alliance levels, and therapists may benefit from a training to help them recognize subtler withdrawal ruptures when they occur during therapy.

Using Personalized Assessment and Network Model Feedback in Psychotherapy: Proof of Principle for the TheraNet Project

“…In the past few years, person-specific network models have grown popular in clinical psychological research, with a primary area of interest being their potential applications in psychotherapy. Patients can vary greatly, as has been shown repeatedly in comparisons of between-and within-patient effects (Babl et al, 2022;Rubel, Zilcha-Mano, et al, 2018).…”