V-episodes in the alliance: A single-case application of multiple methods to identify rupture repair.

The therapeutic alliance has been consistently found to be a robust predictor of therapeutic outcome across various modalities of psychotherapy. Alliance ruptures are thought to occur commonly within each therapeutic dyad and, if left unresolved, are associated with premature termination and worsened psychotherapy outcome. Research efforts have identified V-shaped shifts in the alliance, characterized by a high-low-high pattern of postsession alliance scores, as a meaningful method of operationalizing rupture-repair episodes, but these efforts rarely evaluate the within-session process of the identified sessions. As a result, it is often unclear whether these sessions identified by methods based on postsession alliance measures are reflective of clinically meaningful within-session rupture process. This article aims to further explore the V-episode operationalization of rupture-repair episodes by assessing for convergence between rupture process identified by between-session measures and the within-session observer-based Rupture Resolution Rating Scale (3RS) in a single patient-therapist dyad in a 30-session brief relational therapy. V-episodes were operationalized using various previously utilized methods to identify ruptures based on postsession measures of alliance. Results of this case study demonstrate that postsession patient-rated V-episodes in the therapeutic alliance can be indicative of within-session rupture process, demonstrating convergence between within- and between-session measures of alliance process. Implications of these results for methodological approaches for identifying alliance ruptures are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Renegotiating tasks or goals as rupture repair: A task analysis in a cognitive-behavioral therapy for personality disorder.

OBJECTIVE: The purpose of this study was to provide some definition of rupture repair in a cognitive-behavioral therapy (CBT) for personality disorders, specifically how treatment tasks or goals are renegotiated. METHOD: Following a task analysis, a rational model was developed with the support of an expert panel. An empirical analysis was conducted on six CBT cases sampled from a clinical trial that included personality disordered patients and treatment adherent therapists. Two sessions from each case indicating rupture repair were selected, based on patient and therapist ratings of the Working Alliance Inventory-12 item version (WAI-12) and rupture presence. A qualitative analysis of the sessions was conducted with the support of the observer-based Rupture Resolution Rating System (3RS-2022). RESULTS: The empirical analysis provided some support for many of the stages defined in the rational model, but less support for the hypothesized sequences of stages. A rational-empirical synthesis yielded a revised model that suggested therapists combine various strategies in rupture repair in a variety of ways, not necessarily in consistent sequences. CONCLUSIONS: The renegotiation of tasks and goals in this CBT sample was variable. The importance of responsiveness and the need to validate the rational-empirical model were highlighted.

Operationalizing alliance rupture-repair events using control chart methods.

This study aimed to determine how control charts-a form of time-series line graphs-can be implemented in psychotherapy research to indirectly identify probable rupture-repair episodes that are associated with psychotherapy outcome. There is no current standard in psychotherapy research with regard to how to use control charts to identify rupture-repair events. Control charts were generated for each patient (N = 73) using patient-rated Working Alliance Inventory (WAI) scores obtained at the end of every session in a 30-session therapy protocol of either brief relational therapy (BRT) or cognitive behavioural therapy (CBT). Empirically derived cut-off points were used to identify rupture and repair based on each dyad's control chart. Coded rupture-repair episodes were correlated with outcome measures to assess for their relationships. The results of these analyses provide preliminary support for the utility of control charts in psychotherapy research for the indirect identification of probable rupture repair events that are associated with psychotherapy outcome.

The beginning of the end: A comparison of treatment completers and early dropouts in trainee-provided time-limited Cognitive Behavioral Therapy.

About one in five clients drops out of treatment prematurely. Premature termination has been found to correlate with patient, therapist, and treatment factors, as well as complex interpersonal processes, including ruptures in the therapeutic alliance. This study examines the therapeutic alliance using a qualitative approach to patient-, therapist-, and observer-based data. The sample includes five trainee therapists, each of whom worked with one patient who terminated after the first or second session, and one who completed a cognitive-behavioral therapy protocol. The session(s) preceding premature termination in the drop case and the corresponding session(s) in the completer case were examined. Rupture resolution process was prevalent in both groups, though confrontation ruptures seemed more prevalent with completers and withdrawal ruptures were more clinically impactful with dropouts. Therapist awareness of process and responsiveness or contribution to rupture were identified as potential factors contributing to patient retention.

Panic-Focused Reflective Functioning and Comorbid Borderline Traits as Predictors of Change in Quality of Object Relations in Panic Disorder Treatments.

OBJECTIVE: To investigate whether (a) baseline levels of panic-specific reflection function (PSRF; i.e. patients' capacity to reflect on their panic symptoms) and improvement in this capacity over treatment; (b) baseline borderline personality disorder (BPD) traits and pre-post treatment improvement in BPD traits predict change in patients' quality of object relations. METHOD: A subsample of 102 patients diagnosed with panic disorder from a larger randomized controlled trial received either Cognitive-Behavioral Therapy or Panic-Focused Psychodynamic Psychotherapy. We investigated whether baseline levels and change in both PSRF and BPD traits (as measured by the SCID-II) predicted pre-post change in quality of object relations (QOR), while controlling for pre-post treatment change in panic symptoms assessed by the Panic Disorder Severity Scale. RESULTS: In both treatments, higher baseline levels of PSRF and lower levels of BPD traits, as well as pre-post decrease in BPD traits, predicted improvement in QOR when controlling for symptomatic change. CONCLUSIONS: The findings suggest that reduction in comorbid BPD traits can facilitate improvement in patients' quality of object relations even in brief symptom-focused psychotherapies. Additionally, patients with higher baseline levels of symptom-focused reflective function and lower BPD traits are more likely to demonstrate interpersonal change over the course of psychotherapy for panic disorder. Finally, our study highlights the importance of examining therapeutic change beyond reduction in symptoms, particularly in domains of interpersonal functioning.