Jeremy D. Safran

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.

Integrating affect and cognition: A perspective on the process of therapeutic change

There is a growing recognition among clinicians of the need for a comprehensive model of emotion, which illuminates the role of affective processes in psychotherapy. In the present article, we employ a constructive model in which emotion is viewed as resulting from a synthesis of components. This emotional synthesis model is used to explore some of the ways in which “feeling” and “thinking” interact, both in clinical problems and in therapeutic change. It is suggested that many clinical problems involve a breakdown in the emotional synthesis process and that an important focus of therapy should be the integration of the different levels of processing involved in the construction of emotional experience. It is also argued that affect does not play a simple, uniform role in therapeutic change but instead should be viewed as operating in different ways in different change events. For this reason, it is important to begin delineating different mechanisms through which changes in emotional processing can bring about therapeutic change. To this end, three such mechanisms are proposed: the synthesis of adaptive emotional experience, de-automating dysfunctional emotional habits, and modifying state-dependent learning.

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

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.

Linking in-session change to overall outcome in short-term cognitive therapy.

To better understand the mechanisms of change in psychotherapy, it is important to validate suboutcome measures that represent intermediate links between more molecular in-session changes and ultimate outcome. The present study involved the collection of pre- and postsession ratings from 53 patients in a 20-session protocol of cognitive therapy, which yielded 5 suboutcome measures: Anxiety Shift, Depression Shift, Cognitive Shift, Optimism Shift, and Therapeutic Alliance. From a series of regression analyses of repeated measures with a generalized estimating equations approach, results regarding the predictive relationship of these variables to a number of patient and therapist-rated outcome criterion variables indicated that change in cognition and quality of the therapeutic alliance were the strongest predictors.

Assessing the cognitive-interpersonal cycle

This article argues that Harry Stack Sullivans conceptions of interpersonal psychotherapy have a number of important implications for both the theory and practice of cognitive behavior therapy. Sullivans formulations, while compatible with cognitive behavioral theory in many respects, add both motivational and interpersonal contexts that are missing from cognitive behavior therapy. With regard to the first theme, it is argued that Sullivans theory on the role of anxiety in the development and maintenance of dysfunctional cognitive structures has important implications for both cognitive assessment and modification. With regard to the second theme, it is argued that the therapists role as a participant-observer in the therapeutic relationship provides him with a valuable opportunity for identifying maladaptive interpersonal patterns and assessing dysfunctional cognitive activities that are linked to these patterns.

Widening the Scope of Cognitive Therapy: The Therapeutic Relationship, Emotion, and the Process of Change

Jeremy D. Safran, whose work has systematically broadened the scope of cognitive therapy by integrating principles from other therapeutic traditions, probes critical clinical and theoretical issues in this volume of seminal papers. He begins by outlining the implications of interpersonal theory for cognitive therapy, and proceeds to examine emotion and attachment theory, revolutionizing thinking about the role of emotion in the process of change. Chapters on ruptures in the therapeutic alliance provide a sophisticated approach to working with difficult patients. The concluding section on psychotherapy integration highlights the importance of dialogue among diverse therapeutic traditions as a way for clinicians to see and advance beyond their own preconceptions.

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.

The Relational Turn, the Therapeutic Alliance, and Psychotherapy Research

I AM GRATEFUL to Jay Greenberg for asking me to write about the influence of the relational turn on my work, and extremely pleased to have an opportunity to honor Stephen Mitchells memory in this fashion. I had the good fortune of being in clinical supervision with Steve and of collaborating on a project with him shortly before he died. I had been deeply influenced by his writing for many years, and the experience of beginning to develop a relationship with him is one that I will always cherish. One of the qualities I most admired in Steve was his openness to different perspectives and his ability to play with seemingly irreconcilable visions of reality in a way that pointed toward a larger whole. My central focus in this article is on the way in which relational psychoanalysis has influenced my thinking as a psychotherapy researcher and as a clinical theorist who writes both for analysts and for clinicians of other orientations. The divide that separates the world of psychoanalysis from the worlds of both mainstream psychotherapy research and other therapeutic traditions is, in many respects, a large one. At the same time, there is a critical need for psychoanalysts to become more actively involved in a dialogue with these different cultures. While the rumors of Freuds death may be exaggerated, the declining fortunes of psychoanalysis in recent years make this type of dialogue increasingly important. As I have argued elsewhere, the type of insularity that has been characteristic of the psychoanalytic tradition does not, to put it mildly, serve it well these days (Safran, 2001; Safran & Aron, 2001). The growing demand by the health care system and by the public in general for some form of accountability, and associated developments such as the American Psychological Association Task Force on Psychological Intervention Guidelines (1995) or the American Psychiatric Association Steering Committee

A relational approach to supervision: Addressing ruptures in the alliance.

Establishing, sustaining, and repairing ruptures in the therapeutic alliance are among the most important competencies in psychotherapy. For the novice psychotherapist, strain within the therapeutic alliance usually arouses feelings of insecurity and may undermine the trainees developing, yet precarious, sense of confidence. Alliance strains and ruptures pose unique challenges for the clinical supervisor as well, who must safeguard client welfare while facilitating the supervisees professional development (Falender & Shafranske, 2004, p. 6). The types of skills required for the therapist to be able to constructively negotiate alliance ruptures are complex, multifaceted inner and interpersonal skills. They require a basic capacity for self-acceptance (or at least an ability to work toward it), a willingness to engage in an ongoing process of self-exploration, and a capacity to engage in a genuine dialogue with the client. The quality and style of the supervisory process thus play a critical role in the development of these skills.