The efficacy of training on resolving therapeutic alliance ruptures

communication P: But I mean, you know, I was thinking that maybe what I would do is just not let that happen, and just say, well, you know, maybe I don’t even have to understand why that happened, maybe if I just don’t let that happen, that I would just be in a better place to work on things. Avoidant storytelling and/or shifting topic T: Are you experiencing me as angry right now? P: No, no. I feel, um, actually, um, very safe talking to you. And it’s not that I don’t worry-I don’t feel-I can say to my boyfriend. Deferential and appeasing T: How was the homework? P: Oh, it was so helpful. You give such wonderful advice. Content/affect split Patient looks tearful. T: It’s hard for you to tell me about those sad feelings. P: (A bright, forced smile). Yes, it is. It’s not easy to talk about. Self-critical/hopelessness T: It’s hard for you to tell me “no.” P: Now you see why it’s impossible for me to get a job. In contrast, confrontation ruptures are moments in which the patient moves against the therapist in a non-collaborative or hostile manner. For example, a patient may express his dissatisfaction with the progress of therapy, criticise the therapist or reject his or her interventions. Eubanks, et al. (2015) have empirically identified seven sub-categories of confrontation ruptures (Table 2). In some cases, confrontation ruptures may arise because of unresolved preceding withdrawal ruptures (Coutinho et al., 2011). Treatment outcome and confrontation ruptures are linked; indeed, a higher number of confrontation markers in a session are associated with dropouts. Conversely, when confrontation ruptures are successfully resolved, the more Efficacy of training on resolving therapeutic alliance ruptures Theoretical background 9 likely the patient will remain in treatment (Coutinho, Ribeiro, Fernandes, Sousa & Safran, 2014). Table 2: Confrontation ruptures sub-categories Sub-category Example Complaints/concerns about the therapist P: I can’t communicate with you. Patient rejects therapist intervention T: It sounds like you are concerned about him. P: (hostile tone) No, that is not it at all. Complaints/concerns about the activities of therapy P: What is this? Why are we doing this exercise? I feel really uncomfortable right now. Complaints/concerns about the parameters of therapy P: Once a week is not enough. It’s not enough time to address all my problems! Complaints/concerns about progress in therapy P: As I told you, I have the feeling we are going in circles. Patient defends self against the therapist P: But I think it’s normal for people to change. I’m going through a transitional period. So I have new ideas about what would help me get through this situation. It doesn’t necessarily mean that I am unstable. Efforts to control/pressure the therapist P: Tell me what my problem is and what I need to do. 2.2 Resolution strategies Throughout the years, Safran and Muran’s team (Safran & Muran, 1996; Safran et al., 2011) have refined their stage-process model of rupture resolution. Resolution begins with the therapist acknowledging the rupture event, whether confrontation or withdrawal, and encouraging a thorough examination of said rupture. The second stage involves the facilitation of “a disembedding from the relational matrix” (Muran & Barber 2011, p. 323) in which metacommunication is crucial. It is at this next stage of the resolution process that the distinction between confrontation and withdrawal becomes pertinent. When addressing a confrontation rupture, the aim is to help the patient progress from hostility to the expression of underlying emotions and needs: “The resolution often involves the therapist’s empathic engagement Efficacy of training on resolving therapeutic alliance ruptures Theoretical background 10 with the patient in order to facilitate the expression of disowned feelings of disappointment, hurt, vulnerability, and the need for nurturance” (Safran & Krauss, 2014, p. 382). In withdrawal ruptures, resolution will focus on moving from avoidance to healthy self-assertiveness and involves the “exploration of interpersonal fears and internalized criticisms that inhibit the expression of negative feelings, as well as providing the patient the latitude to begin to communicate their wishes and needs” (Safran & Krauss, 2014, p. 382). In both cases the therapist must respond in a non-defensive and nonhostile manner, empathise with the patient’s experience and acknowledge his or her own contribution to the rupture where appropriate. In order to attend to ruptures effectively, Safran and Muran (2000) suggest conceptualising them according to Bordin’s definition of the alliance. A rupture can thus either be an expression of a disagreement on the tasks or goals of therapy or reflect a problem in the emotional bond. The therapist can then resolve the rupture directly or indirectly, at surface-level or by exploring the underlying meaning. For example, following a patient’s complaint about a homework assignment, the therapist may respond directly at surface level and explain the rationale behind the task and implications for treatment, or he could invite the patient to explore the core relational schema underlying the patient’s frustration. On the other hand, addressing a disagreement on tasks or goals indirectly would involve reframing the meaning of or changing said tasks or goals. The selection of resolution strategies to deal with ruptures will thus be based on how the rupture is conceptualised and at what level the therapist wishes to target his response. As a key ingredient to a strong alliance, agreement on tasks and goals should be addressed at the outset and the therapist should frequently check that the patient is still on board as the therapy progresses and adjust as necessary. In cases where the rupture originates from a misunderstanding or a need for clarification, a direct, surface level intervention following a complaint about tasks or goals may suffice. Some ruptures could indicate an enactment of a vicious relational cycle within the patient-therapist relationship. The key focus for the Efficacy of training on resolving therapeutic alliance ruptures Theoretical background 11 therapist here would be an in-depth exploration of the patient’s underlying schemas. In the same way, when dealing with strains in the relational bond, a direct, surface-level intervention aims to clarify a misunderstanding whilst an exploration of a core relational theme occurs at a deeper level. The latter could become a therapeutic task in itself when a sufficient degree of trust and self-awareness has been achieved. Otherwise, an indirect resolution would be more fruitful (Safran & Muran, 2000). Another technique, allying with the resistance, comprises a validation of the patient’s defensive posture and emphasising the adaptive role avoidance of negative emotions can play. This would entail, for example, reframing the need for distance in relation to a particular painful memory as a necessary step towards acceptance. In this way, instead of denying a part of the patient’s experience by directly confronting the suffering, the therapist allies with it and creates a more trustful and close bond. Finally, the therapist can indirectly address a rupture by creating a new, and hopefully corrective, relational experience. In this case, it is crucial to avoid reenacting an unhealthy and traumatising schema to instead replace it with a new type of interpersonal experience. This type of intervention involves a set of non-verbal communications or actions the therapist can adopt rather than intervening verbally (Safran & Muran, 2000). This model of resolution echoes therapist personal characteristics and therapeutic techniques fostering a solid therapeutic alliance, such as being honest, warm and open as well as facilitating the expression of affect, exploration and depth (Ackerman & Hilsenroth, 2003). In contrast, those contributing to the deterioration of the alliance are discouraged (Ackerman & Hilsenroth, 2001), thus providing support to the above potential interventions as beneficial to the therapeutic relationship. A key principle behind the resolution process is metacommunication in the here and now, a kind of “mindfulness in action”, especially when resolution entails exploring core relational themes. Metacommunication facilitates the “disembedding” from the relational cycle the patient is perpetuating with his/her therapist and promotes communication about both Efficacy of training on resolving therapeutic alliance ruptures Theoretical background 12 patient and therapist’s immediate experiences of the relationship. As such, the degree of inferences the therapist needs to make is limited to a minimum since communication is based on concrete descriptions. It is the therapist’s role to initiate metacommunication, for which he may use his intuition before moving towards an overt discussion. There are three dimensions the therapist can metacommunicate about: his/her own experience (“How do you think I am feeling right now? ”), the patient’s experience (“I sense a lot of anger coming from you, is that correct? ”), and their interpersonal interaction (“I feel like we’re stuck in a rut, how do you feel about what’s going on between us? ”) (Muran & Barber, 2011). For the purposes of the present research and to illustrate the types of resolution strategies that can be used, the ten sub-categories are presented in Table 3. As discussed above, these can be either targeted at the surface-level (i.e. clarifying a misunderstanding) or they may explore the deeper, underlying meaning of the rupture (i.e. linking the rupture to patterns in the patient’s other relationships). 2.3 General hypotheses The main research question of this paper, as mentioned in the introduction, is to investigate whether the brief rupture and resolution training develops and improves therapist’s skills to detect and deal with rupture events. In particular and foll