The impact of alliance-focused and facilitative interpersonal relationship training on therapist skills: An RCT of brief training.

Research on standard methods of therapist training has found mixed evidence to as to whether standard training methods are effective. This study investigated the impact of a novel, research-informed training protocol that integrated elements of alliance-focused training (AFT) and facilitative interpersonal skills (FIS). Beyond traditional training techniques of didactics and lecture, the AFT/FIS intervention incorporated empirically supported video simulations of therapy, which were reinforced by role plays and deliberate practice on key therapeutic interpersonal skills. Fifty-eight graduate-level therapy trainees and professional therapists from various helping fields were randomized to one of two brief trainings in a multi-site RCT: (i) the AFT/FIS workshop or (ii) a more traditional demonstration training (DT) workshop. Participants were assessed on critical, relational therapeutic skills before and after the training. After controlling for relevant covariates, participants in the AFT/FIS training saw a marginally higher post-intervention level of overall therapeutic skills. Subsequent exploratory analyses revealed AFT/FIS participants also had significantly higher levels of specifically targeted post-training therapist skills (i.e., empathy, alliance bond capacity, and alliance rupture-repair responsiveness) compared to participants in DT. Implications for future empirical investigations and training initiatives are discussed.

Rupture Resolution Rating System (3RS): Development and validation.

OBJECTIVE: Our aim was to examine the reliability and validity of the Rupture Resolution Rating System (3RS), an observer-based measure of alliance ruptures and resolution processes. METHOD: We used the 3RS to rate early sessions from 42 cases of cognitive behavior therapy. We compared the 3RS to a simplified version of the Structural Analysis of Social Behavior (SASB), as well as patient and therapist self-reports of ruptures and the alliance. RESULTS: Coders achieved high rates of interrater reliability on the frequency of confrontation and withdrawal ruptures and resolution strategies (ICCs = .85 to .98), as well as ratings of the therapist's contribution to ruptures and the extent to which ruptures were resolved (ICC = .92). Predictive validity analyses found that confrontation markers (d = .74), successful resolution (d = .67), and ratings of the therapist's contribution to ruptures (d = .61) predicted dropout from therapy. Analyses of convergent validity with the SASB failed to meet predictions; however, we observed theoretically coherent relations between 3RS and SASB variables. Confrontation rupture markers were significantly associated with patient self-report of rupture (d = 1.54) and therapist self-reported alliance (r = -.50, p = .002). CONCLUSIONS: This study provides evidence that the 3RS is a reliable and useful tool for examining psychotherapy process and predicting dropout. Clinical or methodological significance of this article: This study provides evidence of the reliability and validity of the 3RS, an observer-based measure of alliance ruptures and resolution processes. The 3RS can be used to identify problems in the therapeutic relationship that are associated with premature dropout from therapy.

Mentalizing in the presence of another: Measuring reflective functioning and attachment in the therapy process.

Objective: In this paper, we test the reliability and validity of two novel ways of assessing mentalizing in the therapy context: the Reflective Functioning scale (RF) applied to code psychotherapy transcripts (In-session RF), and the Exploring scale of the Patient Attachment Coding System (PACS), which measures in-session autonomy and is linked with secure attachment in psychotherapy. Method: Before treatment, 160 patients in different types of psychotherapy and from three different countries were administered the Adult Attachment Interview (AAI), which was rated with the RF scale. One early psychotherapy session for each patient was independently rated with the In-session RF scale and with the PACS Exploring scale. Results: Both scales were found to be reliable and to have concurrent validity with the RF scale rated on the AAI, with the PACS Exploring scale found to be a better predictor of RF on the AAI. Conclusions: These results suggest that the PACS Exploring scale might be a practical method for assessing RF in psychotherapy research and a way for researchers and clinicians to track patients' RF on an ongoing basis. These results also provide information regarding the ways in which differences in RF manifest during psychotherapy sessions. Clinical or methodological significance of this article Researchers and clinicians can assess patients' mentalizing based on any single psychotherapy transcript, in many therapeutic modalities The Exploring scale of the Patient Attachment Coding System can yield a reliable measure of reflective functioning based on any single psychotherapy transcript, in many therapeutic modalities Client differences in mentalizing manifest in part independently of the therapist's contributions.

A therapist version of the Alliance Negotiation Scale.

The aim of the current study was to design and evaluate a therapist version of the Alliance Negotiation Scale (ANS). The ANS was created in order to operationalize the construct of dyadic negotiation in psychotherapy and to augment existing conceptualizations of the working alliance. The ANS has existed only as a client self-report form since its inception and has demonstrated promise as a psychotherapy process measure. This research intended to develop a complementary therapist self-report version of the measure. The scale creation process is discussed in detail, and the results of a preliminary psychometric investigation are reported. The ANS-Therapist version (ANS-T) was developed using a sample of therapists (n = 114) through a principal components analysis procedure. The ANS-T contains 9 unidimensional items and was moderately correlated with therapist-reported working alliance (r = .468). The results of the study support the composition of the ANS-T and provide initial support for the reliability and validity of the measure.

A comparison of pre-dropout and temporary rupture sessions in psychotherapy.

Although numerous studies have investigated the relationship between the therapeutic alliance and dropout, most have focused on the relationship between alliance quality and psychotherapy outcomes. OBJECTIVE: To compare sessions with therapeutic alliance ruptures and two sessions prior to treatment dropout (pre-dropout) in terms of rupture subtypes, psychotherapists' behavior, attitudes, and session content. METHOD: We implemented quantitative methods to select the sessions and qualitative methods to analyze them. We analyzed 16 temporary rupture sessions from 12 therapist-patient dyads and 16 pre-dropout sessions from 8 different therapist-patient dyads. The sessions originate from clinical psychology Master's or Doctoral students under supervision in either cognitive behavioral or schema therapy. Pre-dropout sessions were considered unrepaired rupture sessions while rupture sessions were subsequently repaired. RESULTS: Results revealed apparent differences and similarities between the session types in positive and negative psychotherapist behaviors, content intensity, and the type and frequency of ruptures. We explored three new rupture subtypes: attributing positive developments to other sources, indirect speech, and sarcastic hostility. CONCLUSIONS: A striking implication is that the frequency of positive and negative psychotherapist behaviors, ruptures, and session content is more likely to decrease in the pre-dropout sessions than in the temporary rupture sessions.

Resolving Alliance Ruptures from an Attachment-Informed Perspective.

In this article, we examine how the different attachment patterns enable or hinder the resolution of ruptures in the therapeutic alliance. We try to show that secure and insecure patients alike may experience ruptures in the therapeutic alliance, but that their ability to participate in resolving such ruptures differ markedly. Recent findings with the Patient Attachment Coding System (PACS) show that attachment classifications manifest in psychotherapy as distinct ways of communicating about present internal experience. Secure patients disclose their present experience openly and invite attunement from the therapist, while insecure patients either minimize their contributions to the dialogue (avoidant) or the contributions of the therapist (preoccupied). Using examples from session transcripts, we demonstrate how secure patients are particularly responsive to resolution strategies that focus on here-and-now experience, while insecure patients' characteristic ways of communicating pose significant challenges to the resolution process.

An Investigation of the Relationship Between the Alliance Negotiation Scale and Psychotherapy Process and Outcome.

OBJECTIVE: This study examines the validity of the Alliance Negotiation Scale (ANS) in a psychotherapy research program. Analyses were designed to evaluate the relationship between the ANS and psychotherapy process and outcome variables. METHOD: Data were collected in a metropolitan psychotherapy research program. Participants completed 30 sessions of therapy, postsession assessments, and a battery of measures at intake and termination. RESULTS: Relationships were found between the ANS and session outcome, working alliance, and the presence of ruptures and their resolution. Relationships emerged between the ANS and treatment outcome on measures of psychiatric distress and interpersonal problems. CONCLUSIONS: The ANS demonstrated relationships with several psychotherapy process and outcome variables. The ANS was the most differentiated from the working alliance on measures of interpersonal functioning and in discriminating personality disorder pathology. These results extend previous findings on the ANS' psychometric integrity, and offer new data on the relationship between negotiation and treatment outcome.

AAI predicts patients' in-session interpersonal behavior and discourse: a "move to the level of the relation" for attachment-informed psychotherapy research.

There is currently little empirical evidence regarding how patients' attachment patterns manifest in individual psychotherapy. This study compared the in-session discourse of patients classified secure, dismissing, and preoccupied on the Adult Attachment Interview (AAI). Rather than focusing on content or form alone, this study analyzed how patients' discourse elicits and maintains emotional proximity with the therapist. The AAI was administered to 56 patients prior to treatment and one session for each patient was rated with the Patient Attachment Coding System (PACS) by four independent raters, blind to patients' AAI classification. Significant differences were found in the discourse of patients with different attachment patterns. Namely, secure and preoccupied patients showed more contact-seeking behavior than dismissing patients, who avoided emotional proximity more, while preoccupied patients resisted therapists' help more than did secure and dismissing patients. These results suggest that the different attachment patterns may have distinctive manifestations in the psychotherapy process that can be tracked by external observers.

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.

Personality disorder and early therapeutic alliance in two time-limited therapies.

This study examined the relationship of pre-treatment personality disorder diagnosis to the quality of early therapeutic alliance in 145 patients randomly assigned to either cognitive behavioral therapy or brief relational therapy. The pre-treatment diagnosis was established by DSM-IV (SCID) and Wisconsin Personality Inventory. Quality of the alliance was assessed by patient and therapist reports using the 12-item Working Alliance Inventory, Session Evaluation Questionnaire, and direct questions of ruptures. Results indicated that pre-treatment personality disorder as determined by SCID predicted no variables of early psychotherapy process. Factor scores yielded from a PCA of the WISPI indicated that high impulsivity, dysregulation, and lability were associated with lower patient and therapist ratings of session depth of exploration and higher patient ratings of rupture intensity.

Wernicke's encephalopathy in adolescents with anorexia nervosa.

Anorexia Nervosa (AN) has always been prevalent in adolescents. During the COVID-19 pandemic, the eating disorder community across the world has noted a sharp increase in adolescent patients with AN and the severity of medical compromise. Rarely seen sequelae have become increasingly more common. This case report describes two previously healthy female adolescents with severe malnutrition due to AN admitted for nutritional stabilization who exhibited paranoid delusions responsive to thiamine and olanzapine. Though neither exhibit the full triad or all the Caine criteria for Wernicke's Encephalopathy (WE), the triad will not present completely in most patients with WE, especially in the pediatric population. Having one symptom of the triad is indicative of WE. Due to the decreased number of clinical criteria for Wernicke's encephalopathy coupled with the lack of typical brain MRI findings found in these patients, we recommend a high index of suspicion for WE and investigation with thiamine. Thiamine supplementation should be standard care in AN with oral supplementation in stable conditions. In the case of refeeding syndromes, preventative parenteral thiamine 100 mg IV qd, and in the case of thiamine deficiency, thiamine 500 mg IV TID.

Therapist mindfulness, alliance and treatment outcome.

The present study investigated the association between therapist dispositional mindfulness and therapist self-affiliation, the therapeutic alliance, and treatment outcome. Total therapist mindfulness was associated with therapist self-affiliation, r=.413, p<.05. Therapist mindfulness was positively correlated with therapist ratings of the working alliance, r=.456, p<.05, though only the Act with Awareness subscale showed a relationship with patient rated alliance, r=.379. Therapist mindfulness was not associated with patient rated decreases in global symptomatology, but was associated with patient rated improvements in interpersonal functioning, r=.481, p<.05. All correlations correspond to a medium effect size. The results indicate that therapist dispositional mindfulness may be an important pre-treatment variable in psychotherapy outcome.

The alliance negotiation scale: psychometric construction and preliminary reliability and validity analysis.

Current measures of the working alliance tend to emphasize the degree of agreement or collaboration between patient and therapist about therapeutic tasks and goals. There are, however, both theoretical and empirical grounds to suggest that the degree to which patient and therapist are able to constructively negotiate disagreements about tasks and goals is another important dimension of the alliance. The present study outlines the preliminary development and evaluation of a measure to operationalize this dimension. This measure, the alliance negotiation scale (ANS), is a 12-item patient self-report instrument. Exploratory factor analysis and expert ratings informed the development of the scale, which consists of two distinct factors that demonstrate good internal consistency. Correlations between these factors and the working alliance offer preliminary support for its construct validity. A working version of the ANS is presented and the need for further validation is discussed.

Impact of therapist emotional intelligence on psychotherapy.

The concept of emotional intelligence (EI) describes a set of emotional skills that may comprise efficacious therapist variables. The present study is the first to investigate EI among psychotherapists. Based on conceptual overlaps between the EI model and psychotherapy models, as well as a review of empirical evidence from both literatures, we make several predictions of how therapist EI impacts treatment. In a small pilot study, we assessed psychotherapist EI to determine its relation to psychotherapy outcome and process. Therapists with higher ratings of EI achieved better therapist-rated outcome results and lower drop-out rates compared with therapists with lower ratings of EI. Though not hypothesized, higher therapist EI was significantly associated with increased patient assessment compliance. There was no relationship between early working alliance ratings and therapist EI. Findings offer preliminary support for the relevance of therapist EI to psychotherapy.

Therapists' and clients' experiences of alliance ruptures: a qualitative study.

AIM: We explored therapists' and clients' experiences of alliance rupture events for the first 15 sessions of each of eight cases; therapists were each paired with one client who had a personality disorder. METHOD: All sessions were videotaped and rated with the Rupture Resolution Rating System. Approximately 1 week after a rupture, clients and therapists were individually interviewed about the causes of the rupture, how the rupture evolved, the impact of the rupture on the therapeutic process, and experiences during the event. The interviews were analyzed by five judges using consensual qualitative research (CQR; Hill, 2011). RESULTS: Typically, rupture events involved a repetition of a previous rupture event, the rupture emerged when the client was not prepared to respond to the therapist's intervention, both therapists and clients felt confused and ambivalent, and confrontation events activated intense and negative feelings. We discuss the implications for practice, training, and research.

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).

Subjective and intersubjective analyses of the therapeutic alliance in a brief relational therapy.

The aim of the study described in this paper was to develop a method for measuring the therapeutic alliance from an intersubjective perspective and to evaluate the efficacy of the measure in predicting psychotherapy outcome. We conducted the study using data from 22 patient-therapist dyads engaged in a 30-session protocol of a brief relational therapy. The alliance measure chosen for this purpose was the short form of the Working Alliance Inventory. We used the subjective patient and therapist versions of the measure and created a correlation index representing the intersubjective congruence between patients and therapists on their ratings of the alliance. We examined the relations among the measures, as well as their predictive relation to an outcome measure. The results showed significant intercorrelations among the three alliance measures, suggesting that all captured aspects of the therapeutic alliance. In addition, all three measures were significantly predictive of outcome, with the correlation index appearing more powerful.

Evaluating negative process: a comparison of working alliance, interpersonal behavior, and narrative coherency among three psychotherapy outcome conditions.

The aim of this study was to investigate the interrelationships of three measures of the therapeutic relationship and their validity in predicting treatment outcome, including the early identification of two treatment-failure conditions. Forty-eight patient-therapist dyads, in 30-session therapies for personality-disordered patients, were classified as premature dropout (DO), poor outcome (PO), or good outcome (GO) cases. Poor and Good Outcomes were determined by a reliable change score. Dropout cases were terminated during the first third of treatment, and patients cited dissatisfaction with the therapy or therapist. Assessment of working alliance, interpersonal behavior and a new measure of narrative coherency in the first third of treatment revealed that DO dyads had significantly poorer alliances and less coherent narratives in early sessions, while PO dyads, who ultimately completed the 30-session treatment protocol, unexpectedly demonstrated the highest degree of hostile complementarity. Clinical implications of the results are discussed.

Alliance rupture repair: A meta-analysis.

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. We present the most frequently used measures of alliance ruptures and clinical examples to illustrate their repair. To examine the relation of rupture repairs to outcome, and the impact of rupture resolution training on outcome, we conducted two meta-analyses. In the first meta-analysis, we examined 11 studies (1,314 patients) that examined the relation between rupture repair episodes and patient treatment outcomes. 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. Our second meta-analysis examined the impact of rupture resolution training or supervision on patient outcome. We 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 article concludes with limitations of the research, diversity considerations, and research-informed therapeutic practices for repairing ruptures in ways that contribute to good treatment outcome. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

The effect of alliance-focused training on a cognitive-behavioral therapy for personality disorders.

OBJECTIVE: To improve success rates in psychotherapy, we developed and evaluated an alliance-focused training (AFT) protocol with regard to patient-therapist interpersonal behavior in a 30-session protocol of cognitive-behavioral therapy (CBT) for outpatients comorbid with Axis I and II conditions. METHOD: Participants included 40 patients treated by 40 therapists in a multiple baseline design in which novice therapists trained to fidelity standards in CBT were introduced to AFT at different time intervals (after either 8 or 16 sessions) during a 30-session CBT protocol. Interpersonal behaviors were assessed with a simplified version of the Structural Analysis of Social Behavior (SASB) on videotaped sessions sampled from the early (between Sessions 6 through 8), mid (Sessions 14 through 16), and late (Sessions 22 through 24) phases of therapy. RESULTS: As predicted, several significant interactions were observed between within-subject interpersonal change and between-groups differences in exposure to AFT. Specifically, there were decreases in patient dependence and in therapist control (including criticism), plus increases in patient expressiveness and in therapist affirmation and expressiveness, all of which could be attributed to AFT. The predictive relationship of several of these variables to session-level and overall treatment outcome was also demonstrated. CONCLUSIONS: This study demonstrates that novice CBT therapists can be trained to improve their interpersonal process with patients who present with comorbid diagnoses, including a personality disorder. (PsycINFO Database Record