The development of the therapeutic alliance and the emergence of alliance ruptures. [El desarrollo de la alianza terapéutica y la aparición de rupturas en la alianza]

Abstract

Título: El desarrollo de la alianza terapéutica y la aparición de rupturas en la Alianza. Resumen: Objetivos: Este estudio evaluó el desarrollo de la alianza terapéutica y la aparición de rupturas de alianzas, en una muestra de pacientes con diferentes diagnósticos y resultados terapéuticos. Diseño: Se analizaron los datos longitudinales de 38 díadas terapéuticas que recibieran terapia cognitivo-conductual. La muestra incluyó a casos de abandonos, así como casos exitosos y no exitosos. La muestra incluyó a casos con trastornos del Eje I y Eje II. Método: Al final de cada sesión, los pacientes evaluaron la alianza mediante el Inventario de Alianza de Terapéutica (WAI). Seis jueces entrenados en la observación de los marcadores de ruptura de alianza con un sistema de observación de rupturas, codificaran 201 sesiones terapéuti-cas grabadas en vídeo. Se aplicaran modelos estadísticos longitudinales a los datos. Resultados: Se encontró que el patrón de desarrollo de la alianza de los casos de éxito era diferente de la de los casos sin éxito y abandonos. En media, los pacientes con trastornos de la personalidad iniciaran la terapia con una menor puntuación en el WAI que disminuyó con el tiempo, mientras que los pacientes con trastornos del Eje I iniciaran la terapia con una mayor puntuación en el WAI que aumentó con el tiempo. Palabras clave: dDesarrollo de la alianza terapéutica; rupturas en la alianza, trastornos del Eje I; trastornos del Eje II. Abstract: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.

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

“…The study by Gersh et al (2016) showed that the proportion of sessions with a high number of ruptures increased over the treatment course of adolescents with BPD. Coutinho, Ribeiro, Fernandes, Sousa and Safran (2014) found a small increase in the intensity of withdrawal ruptures over the treatment course for all patients, whereas the intensity of confrontation ruptures increased only for dropout patients, not for the completers. Focusing on the early treatment phase (session one to four) in the treatment of Dialectical Behavior Therapy (DBT) for BPD, a study by Boritz, Barnhart, Eubanks, and McMain (2018) reported a higher frequency of withdrawal ruptures in unrecovered compared to recovered patients.…”

“…Empirical evidence from observer-based assessments of alliance ruptures and resolutions over the treatment course is sparse. In general, only two studies were published that assessed alliance ruptures in a limited subset of therapy sessions over the treatment course (Coutinho, Ribeiro, Fernandes, Sousa, & Safran, 2014;Gersh et al, 2016); based on a literature search in the databases PubMed, PsycINFO and Web of Science, accessed 27 November 2018 with the key term alliance rupture. The study by Gersh et al (2016) showed that the proportion of sessions with a high number of ruptures increased over the treatment course of adolescents with BPD.…”

Alliance ruptures in cognitive‐behavioral therapy: A cognitive conceptualization

“…Confrontation ruptures involve the patient directly expressing dissatisfaction with the therapist or aspects of therapy whereas, in withdrawal ruptures, the patient completely or partially disengages from therapy. Withdrawal ruptures may lead to inferior recovery and lack of treatment benefit (Boritz et al, 2018), but unresolved confrontation ruptures are more likely to result in premature termination, preceded by increased confrontation and withdrawal scores immediately before dropout from CBT (Coutinho et al, 2014).…”

Facial-affective communication and verbal relational offers during ruptures and resolution strategies: A single case study

“…The relevance of studying ruptures is based on research that indicates that a poor resolution of these events is associated with the repetition, within the therapeutic relationship, of the patient's dysfunctional interpersonal cycle (Coutinho, Ribeiro, Hill, & Safran, 2011), and of ineffective interventions by the therapist (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996;Piper, Azin, Joyce, & McCallum, 1991). Specifically, an association between the repeated presence of unresolved confrontation ruptures and premature dropout has been observed (Coutinho et al, 2011;Coutinho, Ribeiro, Fernandes, Sousa, & Safran, 2014;Tryon, & Kane, 1995). Meanwhile, an adequate approach and timely resolution of ruptures is associated to therapeutic change, as it allows the patient to explore, challenge, and eventually modify maladaptive interpersonal patterns (Safran, Muran, Samstag, & Winston, 2005).…”

“…As the prior evidence indicates, the study of facial-affective behavior of patient and therapist, which is spontaneous and unconscious (Merten, 2005), allows an empirical access to processes that belong to the implicit domain of affective experience, that are involved in the regulation of the therapeutic relationship (Bänninger-Huber & Widmer, 1999). It becomes therefore relevant to further examine how these facial-affective processes take place during ruptures, insofar as they constitute highly emotional relational contexts for both patient and therapist that challenge the stability of the relationship and the quality and progress of psychotherapy (Coutinho et al, 2011;Coutinho et al, 2014). In an attempt to examine this relationship Barros, Altimir and Pérez (2016) observed that during confrontation ruptures, where patients verbally challenged the therapist, their facial-affective behavior showed, emotional neutrality, thus favoring their sense of agency over their need for affiliation.…”