J. Christopher Muran

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.

Has the concept of the therapeutic alliance outlived its usefulness

In this article, we provide a brief summary of our current thinking about the constructs of the therapeutic alliance and ruptures in the therapeutic alliance. We speculate about some of the factors that have led to sustained interest in these constructs by psychotherapy researchers and discuss some of the conceptual problems associated with them. We also consider the question of whether the therapeutic alliance continues to be a meaningful construct, and we delineate more and less promising avenues of research for the future. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Resolving therapeutic alliance ruptures: Diversity and integration

This article reviews and synthesizes the diverse contributions of the authors in this issue of In Session: Psychotherapy in Practice. It presents a schematization of direct and indirect interventions that therapists typically implement to address problems related to the tasks and goals of treatment, or the affective bond between therapist and client. We then present an additional perspective on the resolution of therapeutic alliance ruptures, emerging out of our own research program.

Evaluating an alliance-focused treatment for personality disorders.

This paper presents a study with theaim of evaluating the relative efÞcacyof an alliance-focused treatment, briefrelational therapy, in comparison to ashort-term dynamic therapy and acognitiveÐbehavioral therapy on a sam-ple of highly comorbid personality dis-ordered patients. Results indicated thatthe three treatments were equally effec-tive on standard statistical analyses ofchange, including those conducted onrepeated measures and residual gainscores. Some signiÞcant differenceswere indicated regarding clinically sig-niÞcant change and reliable change,favoring the brief relational andcognitiveÐbehavioral models. Therewas also a signiÞcant difference re-garding dropout rates, favoring briefrelational therapy.Keywords: therapeutic alliance, person-ality disorders, brief psychotherapies,treatment outcome, clinical signiÞcance,reliable change, dropout status

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).

Evaluating alliance-focused intervention for potential treatment failures: A feasibility study and descriptive analysis.

This article describes a pilot study evaluating the feasibility of an approach developed to test the efficacy of a therapeutic intervention (brief relational therapy) for patients with whom it is difficult to establish a therapeutic alliance. In the first phase of the study, 60 patients were randomly assigned to either short-term dynamic therapy (STDP) or short-term cognitive therapy (CBT), and their progress in the first eight sessions of treatment was monitored. On the basis of a number of empirically derived criteria, 18 potential treatment failures were identified. In the second phase of the study, these identified patients were offered the option of being reassigned to another treatment. The 10 patients who agreed to switch treatments were reassigned either to the alliance-focused treatment, referred to as brief relational therapy (BRT), or a control condition. For patients coming from CBT, the control condition was STDP. For patients coming from STDP, the control condition was CBT. The results provide preliminary evidence supporting the potential value of BRT as an intervention that is useful in the context of alliance ruptures.

Patient defense/therapist interventions.

LISA WALLNER SAMSTAGBeth Israel Medical CenterCity University of New YorkPatient defensive behavior and therapistaddressing defense (TAD) was studiedover the course of two brief dynamicpsychotherapies in twenty-eight patientswith personality disorders, primarily ofthe Axis II Cluster C variety. Three levelsof patient defense were coded: immature,intermediate, and mature. Resultsindicate a significant decrease in thefrequency of intermediate defensivebehavior across psychotherapy which isnot related to patient outcome. However,there is a positive relationship betweenthe frequency of immature defenses in thefirst quartile of treatment and outcome attermination. Further, there is a significantcorrelation between patient defensivebehavior and the therapist addressingthis behavior, as well as a decrease inimmature and intermediate defenseswhich correlates with the frequency ofthe therapist addressing these behaviorsearlier in treatment. Finally, thefrequency of TAD is significantlycorrelated with patient outcome.

Self-relations in the psychotherapy process

In this groundbreaking volume, prominent scholars examine the major tenets of post-modernism and apply them to the process of psychotherapy practice. Clinicians from a variety of orientations, including psychoanalytic, humanistic, and cognitive -- behavioral, scrutinize such concepts as social constructionism, intersubjectivity, deconstruction, and contextualism in light of the day-to-day challenges that must be resolved by therapists.

Therapist mindfulness, alliance and treatment outcome

Abstract 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.

Research on psychotherapy integration: Building on the past, looking to the future

Abstract Integration has become an important and influential movement within psychotherapy practice, reflected by the fact that many treatment providers now identify as integrative. However, integration has not had as great an influence on psychotherapy research. The goal of this paper is to highlight the growing body of research on psychotherapy integration, and to identify future directions for research that may strengthen the integration movement as well as the field of psychotherapy as a whole. We first summarize the past 25 years of research on integration, with a focus on four approaches to integration: theoretical integration, technical eclectic, common factors, and assimilative integration. Next, we identify directions of research within these four areas that could strengthen and support integrative practice. We then propose ways in which the perspective of integrationists could contribute to psychotherapy research in the critical areas of harmful effects, therapist effects, practice-oriented research, and training. We end this paper by suggesting that a greater collaboration between integrationists and psychotherapy researchers will help to create a unified landscape of knowledge and action that will benefit all participants and advance the field.