Investigating the impact of alliance-focused training on interpersonal process and therapists' capacity for experiential reflection.

OBJECTIVE: In this article we present preliminary findings from a research program designed to investigate the value of alliance-focused training (AFT), a supervision approach designed to enhance therapists' ability to work constructively with negative therapeutic process. METHOD: In the context of a multiple baseline design, all therapists began treating their patients using cognitive therapy and then joined AFT supervision groups at either session 8 or 16 of a 30 session protocol. Study I investigated the impact of AFT on patient and therapist interpersonal process as assessed through the Structural Analysis of Social Behavior (SASB). Study 2 investigated the impact of AFT on therapists' tendency to reflect on their relationships with their patients in an experientially grounded fashion, as assessed via the Experiencing Scale (EXP). Since one of the goals of AFT is to train therapists to use their own emerging feelings as important clues regarding what may be taking place in the therapeutic relationship, we hypothesized that they would show increased levels of EXP after undergoing AFT. RESULTS AND CONCLUSION: The results of both studies 1 and 2 were for the most part consistent with hypotheses. Implications and future research directions are discussed.

Quantitative naturalistic methods for detecting change points in psychotherapy research: an illustration with alliance ruptures.

Analysis of change points in psychotherapy process could increase our understanding of mechanisms of change. In particular, naturalistic change point detection methods that identify turning points or breakpoints in time series data could enhance our ability to identify and study alliance ruptures and resolutions. This paper presents four categories of statistical methods for detecting change points in psychotherapy process: criterion-based methods, control chart methods, partitioning methods, and regression methods. Each method's utility for identifying shifts in the alliance is illustrated using a case example from the Beth Israel Psychotherapy Research program. Advantages and disadvantages of the various methods are discussed.

The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders.

This study examined the relationship of early alliance ruptures and their resolution to process and outcome in a sample of 128 patients randomly assigned to 1 of 3 time-limited psychotherapies for personality disorders: cognitive-behavioral therapy, brief relational therapy, or short-term dynamic psychotherapy. Rupture intensity and resolution were assessed by patient- and therapist-report after each of the first 6 sessions. Results indicated that lower rupture intensity and higher rupture resolution were associated with better ratings of the alliance and session quality. Lower rupture intensity also predicted good outcome on measures of interpersonal functioning, while higher rupture resolution predicted better retention. Patients reported fewer ruptures than did therapists. In addition, fewer ruptures were reported in cognitive-behavioral therapy than in the other treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Alliance-focused training.

Alliance-focused training (AFT) aims to increase therapists' ability to recognize, tolerate, and negotiate alliance ruptures by increasing the therapeutic skills of self-awareness, affect regulation, and interpersonal sensitivity. In AFT, therapists are encouraged to draw on these skills when metacommunicating about ruptures with patients. In this article, we present the 3 main supervisory tasks of AFT: videotape analysis of rupture moments, awareness-oriented role-plays, and mindfulness training. We describe the theoretical and empirical support for each supervisory task, provide examples based on actual supervision sessions, and present feedback about the usefulness of the techniques from trainees in our program. We also note some of the challenges involved in conducting AFT and the importance of maintaining a strong supervisory alliance when using this training approach.

On the need for a new psychotherapy research paradigm: comment on Westen, Novotny, and Thompson-Brenner (2004).

Basic, process, and outcome research have the potential to inform clinical practice. However, as D. Westen, C. M. Novotny, and H. Thompson-Brenner observed in their timely analysis, the current dominant paradigm for psychotherapy outcome research--the randomized clinical trial--is not fulfilling this potential. The field's reliance on the medical model and manual-based interventions has contributed to the gap between research and clinical practice. Greater collaboration between practitioners and researchers, a focus on therapeutic principles rather than treatment packages, and systemic changes in how scholarly efforts are reinforced are needed to shift the current research paradigm.

Appraisals of daily romantic relationship experiences in individuals with borderline personality disorder features.

The current study examined the relationship between borderline personality disorder (BPD) features and appraisals of daily romantic relationship experiences. The sample included 114 ethnically diverse, young adult dating couples (total N = 228). Participants completed a 14-day daily diary study and reported negative impact and emotional loss to their romantic partner in response to daily positive and negative self-initiated and partner-initiated romantic experiences. Results indicated that BPD features, even when controlling for relationship satisfaction, total number of relationship experiences, and depressive symptoms, were associated with reporting greater negative impact and greater emotional loss to both partner-initiated negative and positive experiences. BPD features were generally not associated with reporting greater negative impact and emotional loss in response to self-initiated negative and positive experiences. The results suggest that individuals with BPD features have a negative interpretation bias to both negative and positive experiences and the effect is generally specific to partner-initiated experiences. Negative appraisals may be one mechanism underlying interpersonal dysfunction in those with BPD features and interventions that directly assess and target these cognitive biases may help improve individual well-being and overall couple functioning.

Repairing alliance ruptures.

In this article, we review the existing empirical research on the topic of therapeutic alliance ruptures in psychotherapy. Ruptures in the therapeutic alliance are defined as episodes of tension or breakdown in the collaborative relationship between patient and therapist. Two meta-analyses were conducted. The first reviewed studies examining the relation between rupture-repair episodes and treatment outcome (r = .24, z = 3.06, 95% CI [.09, .39], p = .002, k = 3, N = 148). The second meta-analysis reviewed the research examining the impact on treatment outcome of training therapists in the use of alliance rupture intervention principles (prepost r = .65, z = 5.56, 95% CI [.46, .78], p < .001, k = 8, N = 376). Both meta-analyses provided promising evidence regarding the relevance of alliance rupture-repair processes to therapeutic outcome. The limitations of the research reviewed are discussed as well as practice implications for repairing the inevitable alliance ruptures in psychotherapy.

Clinical consensus strategies for interpersonal problems between young adults and their parents.

OBJECTIVE: Research that identifies areas of agreement among expert therapists can complement findings from clinical trials by highlighting common practices as well as innovations. The present study accessed consensus among expert therapists on the effectiveness of clinical strategies for treating young adults experiencing interpersonal problems with their parents. METHOD: This study drew on the behavioral-analytic model (Goldfried & D'Zurilla, 1969) and the methodology of the Expert Consensus Guideline Series (Frances, Kahn, Carpenter, Ross, & Docherty, 1996). In Phase I, 54 therapists (mean age = 60.32 years; 55.6% women, 44.4% men; 96.3% White/European American) provided clinical situations involving young adult clients and their parents. In Phase II, 171 therapists (mean age = 59.45 years; 47.4% women, 52.0% men; 91.8% White/European American) proposed responses to the situations, and more general clinical strategies underlying the responses were identified. In Phase III, 134 peer-nominated expert therapists (a mean of 22.33 therapists per situation; mean age = 55.46 years; 61.2% women, 34.3% men; 91.0% White/European American) rated the effectiveness of these clinical strategies. RESULTS: Results indicated that the experts reached consensus on strategies rated as highly effective; in particular, they agreed on the value of exploring clients' emotional experience and providing validation. Participants reached greater agreement on strategies for use in future sessions than strategies for immediate use. Exploratory analyses revealed correlations between experts' theoretical orientations and their ratings. CONCLUSIONS: The findings provide converging evidence of the value of exploring emotions and validating clients and, further, demonstrate the feasibility of this method for accessing clinicians' experience.

The impact of client sexual orientation and gender on clinical judgments and diagnosis of borderline personality disorder.

Concerns have been raised that individuals who are having difficulty coming out as gay or bisexual may be misdiagnosed with borderline personality disorder. In this analogue study, 141 psychologists evaluated a hypothetical client with problems that resembled borderline symptoms but were also consistent with a sexual identity crisis. Client descriptions varied by sexual orientation and gender. Results revealed an effect of sexual orientation for male clients, but not female clients. Male clients whom therapists perceived likely to be gay or bisexual, and male clients with partners of unspecified gender, were more likely to be diagnosed with borderline personality disorder. Therapists were more confident and willing to work with female clients and gave them a better prognosis. Therapists' responses are discussed in light of gender role bias and social desirability.

Therapist self-disclosure in cognitive-behavior therapy.

Although cognitive-behavior therapy emphasizes between-session change, therapist self-disclosure within the session can be an effective tool for strengthening the therapeutic bond and facilitating client change. After noting the use of self-disclosure in other theoretical orientations, we place self-disclosure in the context of cognitive-behavioral theories of reinforcement and modeling. Clinical vignettes illustrate the use of therapist self-disclosure to provide feedback on the interpersonal impact made by the client, enhance positive expectations and motivation, strengthen the therapeutic bond, normalize the client's reaction, reduce the client's fears, and model an effective way of functioning. Therapists need to observe appropriate boundaries when self-disclosing, and in particular, should consider their own motivations for self-disclosing. Although more research is needed on the effects of self-disclosure, cognitive-behavior therapists have found that self-disclosure can be a powerful intervention.