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Intervention and impact: An examination of treatment adherence, therapeutic
alliance, and outcome in cognitive therapy.
by
Kelcey Jane Stratton
May 12, 2011
Submitted to the New School for Social Research of The New School University in partial fulfillment of the requirements for the degree of Doctor of Philosophy.
Dissertation Committee: Jeremy D. Safran, Ph.D. J. Christopher Muran, Ph.D. Xiaochun Jin, Ph.D. Iddo Tavory, Ph.D
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© 2011 Kelcey Stratton
iv
Acknowledgements
I gratefully acknowledge the support I received from my dissertation committee.
Dr. Jeremy Safran and Dr. Chris Muran provided incredible support and wisdom
throughout the years and were available for consultation at every step of the research
process. Thank you to Dr. Bernard Gorman, Laura Kohberger and the Adherence coding
team, and to all of those at the Brief Psychotherapy Research Program who were part of
my intellectual home for the past six years.
Tim Parrott contributed thoughtful comments on drafts of this paper and provided
much enthusiasm. My dear friends and classmates commiserated with me and offered
priceless laughter and encouragement. My parents, Andy and Maggie, provided
unconditional support, love, and belief in me. And finally, my husband, Scott, offered
constant reassurance, humor, and hope, and stood by me at every stage of this project.
I thank you all.
v
Table of Contents
Acknowledgements………………………………………..………….…… iv
List of Tables…………………….……………………………..………..… vii
List of Figures………………………………………………………...….... ix
List of Appendices…………………………………………………..…...… x
Part I: Literature Review
Introduction………………………………………………..……….. 1
Psychotherapy Research: History and Purpose………………......... 3
Common Factors: Understanding Therapeutic Alliance………….... 6
Therapeutic Alliance: Patterns and Development…………….……. 11
The Role of Therapist Adherence on the Therapeutic Alliance…… 14
Resolving Alliance Ruptures: Interpersonal Considerations………. 19
Future Directions………………………………….……………...... 21
Part II: Empirical Article
Introduction…………………………..…………………………….. 24
Purpose of the Current Study.…….……………………………….. 33
Research Hypotheses………………………..……………... 35
Methods and Procedures…………………………………………… 36
Treatment Conditions…………………..….…….…………. 38
Participants………………………………………….…….... 39
Data Selection Procedure………………………………… 42
Instruments…………………………..…………….……..... 43
vi
Table of Contents (Continued)
Assessments………………………………………………… 44
Interrater Reliability………………………………………… 48
Results………………………………………………………………. 48
Additional Findings: Therapeutic Alliance and Session Impact…………………………………………………..… 61
Discussion…………………………………………………………… 61
Limitations and Recommendations for Future Research…… 67
Conclusions……………………….……………………….... 69
References………………………………........................................... 72
Appendices………………………………………………………..… 86
vii
List of Tables
Table 1: Mean Differences and Standard Deviations on Measures of
Therapeutic Alliance and Session Tension in Treatment Group
Conditions……....................................................................... 49
Table 2: Means and Standard Deviations for Adherence Scores by
Treatment Group Conditions……….………………………. 50
Table 3: Analysis of Variance for Treatment Condition to Treatment
Type Adherence…….……………………………………….. 52
Table 4: Intercorrelations Between Measures of Treatment Adherence and
Therapeutic Alliance, Session Outcome, and Rupture Intensity:
First Case, Rupture Session (N=21)…………………………. 55
Table 5: Intercorrelations Between Measures of Treatment Adherence
and Therapeutic Alliance, Session Outcome, and Rupture
Intensity: First Case, No Rupture Session (N=21)………….. 56
Table 6: Intercorrelations Between Measures of Treatment Adherence
and Therapeutic Alliance, Session Outcome, and Rupture Intensity:
Second Case, Rupture Session (N=21).................................... 57
Table 7: Intercorrelations Between Measures of Treatment Adherence
and Therapeutic Alliance, Session Outcome, and Rupture Intensity:
Second Case, No Rupture Session (N=21).............................. 58
viii
List of Tables (Continued)
Table 8: Differences in Correlation Coefficients Between Rupture Sessions and
No-Rupture Sessions on Measures of Treatment Adherence and Patient
Session Evaluations………………………………………….. 60
Table 9: Intercorrelations Between Patient and Therapist WAI Ratings
and Session Impact Questions..………….…..………….…… 61
ix
List of Figures
Figure 1: Interaction of Treatment Type Adherence and Time………... 53
x
List of Appendices
Appendix A. Therapist Post-Session Questionnaire….…………………… 86
Appendix B. Patient Post-Session Questionnaire.………………………… 90
Appendix C. Beth Israel Adherence Scale Rating Form…….……………. 92
Appendix D. Beth Israel Adherence Scale Item Descriptions………….…. 93
1
Part I: Literature Review
Introduction
The field of psychotherapy research has widely diversified over the past several
decades. Varieties of psychotherapy have become both more numerous and more specific
as the field of psychology seeks to discover empirically supported therapies and identify
mechanisms of change. Throughout the history of modern psychotherapy research, one
of the central concerns has been to determine how people change over the course of
therapy and to identify specific elements that contribute to that change. Psychotherapy
researchers have a unique responsibility to not only identify the theories and techniques
that underlie a successful treatment, but also the myriad interpersonal factors that impact
the therapy and, in effect, help or hinder the change process. Psychotherapy research
studies have investigated therapist characteristics (e.g., Crits-Christoph, Baranackie,
Kurcias, & Beck, 1991; Sandell, Lazar, Grant, Carlsson, Schubert, & Broberg, 2007),
patient characteristics (e.g., Horowitz, Rosenberg, & Bartholomew, 1993; Constantino,
Arnow, Blasey, & Agras, 2005), differing theoretical models and techniques (see
Chambless & Ollendick, 2001, for a review), and any and all combinations thereof (e.g.,
Bruck, Winston, Aderholt, & Muran, 2006). Despite strong commitment to study in this
area, inconsistent findings have left fundamental questions about the means by which
psychotherapy succeeds unanswered. Mixed results from psychotherapy outcome studies
illustrate the great complexity inherent to the psychotherapy experience and the need for
more attention to the nuances of treatment.
2
This paper will review previous work in the field of psychotherapy research and
discuss recent areas of interest; namely, the efficacy of manual-based treatments,
therapeutic alliance, and alliance ruptures. The question of how therapy works has been
the subject of rigorous debate, and many studies have attempted to untangle the complex
interaction of technical and interpersonal factors in psychotherapy. Moments of tension
or strain in the treatment have emerged as a point of interest for psychotherapy
researchers, as these events provide a unique window into the therapeutic process.
Within the context of a therapeutic alliance rupture, the therapist must carefully balance
the prescribed treatment interventions with awareness of the interpersonal interaction,
thereby highlighting the interplay of the relational and technical ingredients of a
treatment. Alliance ruptures are of particular interest to clinicians because there is an
opportunity to discover the patient’s underlying difficulties and core relational themes, as
well as any interpersonal meanings that are being co-constructed between the therapist
and patient (Safran & Muran, 2000). Therapists have different abilities in this type of
exploration, and they may draw upon a variety of skills and techniques to negotiate the
therapeutic alliance. Furthermore, a therapist’s ability to skillfully negotiate an alliance
strain will impact the outcome of the session, and ultimately, the entire treatment. This
paper will pay particular attention to studies that have investigated the negotiation and
resolution of therapeutic alliance ruptures, and will discuss future directions and concerns
in the field of psychotherapy research.
3
Psychotherapy Research: History and Purpose
Since its inception, psychotherapy has been subject to the primary question of
whether or not treatment works. This central concern—and indeed, skepticism—about
the workings of psychotherapy as an effective treatment for mental illness has been the
catalyst for decades of empirical inquiry. For the past century, clinicians and researchers
have undertaken serious efforts to evaluate the treatment processes and outcomes of
psychotherapy. While early studies principally focused on treatment results from analytic
institutes and clinics, interest in the therapeutic process quickly broadened to incorporate
a diverse array of theories and techniques (Strupp & Howard, 1992). The focus of
research shifted from “Does psychotherapy work?” to the substantially more complex
issue: “How does psychotherapy work?” With this important question at the fore of
psychological study, consideration for the specific components of psychotherapy
progressed and expanded. The increased focus on mechanisms of change became even
more critical with the emergence of unique theories and approaches to psychotherapy.
As psychotherapy became more widespread and techniques became more clearly
formulated, explicit treatment variations emerged and developed. With the specification
of treatment principles and techniques came a movement toward defining particular
modalities of psychotherapy, which could then be implemented via formal training in a
set of therapeutic skills. Often, psychotherapy training incorporated the use of a
treatment manual designed for the dissemination of these critical theories and techniques,
and ideally, to produce improvements in clinical practice (Luborsky & DeRubeis, 1984).
4
The development of manualized treatments allowed therapeutic training to become
standardized and subject to rigorous study.
Patients face a number of options for treatment, and much attention has been
placed on the comparative benefits of these different treatments. The motivation to
identify unique and effective therapies yielded a number of empirically supported
therapies (ESTs), and also led to current efforts to improve the quality of psychological
treatments for mental disorders (Carroll & Rounsaville, 2007). The Task Force on
Promotion and Dissemination of Psychological Procedures of Division 12 (Clinical
Psychology) of the American Psychological Association described standards for defining
ESTs. Treatments and interventions are classified in terms of their being “well-
established/efficacious and specific,” “probably efficacious,” or “promising” (Chambless
& Ollendick, 2001). Encouraging results with manualized treatments for a number of
psychological symptoms and disorders have spurred enthusiasm and further development
of ESTs. However, the proliferation of ESTs has been rather controversial, and clinicians
and researchers continue to debate about the value, efficacy, and training utility of such
therapies (Chambless & Ollendick, 2001; Carroll & Rounsaville, 2007; Lambert, 1998).
Multiple large-scale randomized trials have identified those treatments that demonstrate
some degree of efficacy, but these studies provide very little guidance regarding the
relative superiority of treatment alternatives (Beutler, 2000). Luborsky and colleagues’
(Luborsky, Rosenthal, Diguer, Andrusyna, Berman, Levitt, Seligman, & Krause, 2002)
meta-analysis of the studies comparing treatment modalities suggested a fairly small
effect size (0.20) between different therapies. While empirically validated therapies have
5
been demonstrated to be efficacious relative to control therapies, research has yet to
identify meaningful outcome differences across various treatments. A number of other
meta-analyses have been unsuccessful in finding significant differences across treatments
(Crits-Christoph, 1992; Luborsky, Diguer, Seligman, Rosenthal, Krause, Johnson,
Halperin, Bishop, Berman, & Schweizer, 1999).
The failure to find significant differences across different therapeutic traditions may
have less to do with the diversity of specific theoretical conclusions and interpretations
and more to do with variations in each therapist-patient dyad. Despite the trend toward
validating theoretically coherent, manual-based therapies, such an approach may not be
sufficient for understanding the complex transactions that occur between patient and
therapist. Regardless of whether or not a particular treatment has been found to “work,”
the actual implementation of the therapy can vary widely from therapist to therapist
(Carroll & Rounsaville, 2007; Luborsky et al., 1986). Moreover, the training of
psychotherapists can be incredibly difficult, as the acquisition of therapeutic skill is
influenced by many complex—and often personal—factors. As Strupp and colleagues
found in the Vanderbilt I and II studies (Strupp, 1980; Henry, Schacht, & Strupp, 1986;
Henry, Schacht, Strupp, Butler, & Binder, 1993), even highly experienced and well-
trained therapists can be subject to negative and idiosyncratic interactions with patients.
Psychotherapy, despite its rigorous empirical tradition, remains a deeply human practice.
Therefore, it is necessary to evaluate psychotherapy through intensive examination of the
interpersonal processes by which the therapy unfolds, and the influence that these
complex processes have on the treatment outcome. Understanding the nature of the
6
interpersonal transactions between patients and therapists will elucidate the emotional
complexities of the psychotherapy experience and augment the technical skills put forth
in treatment manuals.
Common Factors: Understanding Therapeutic Alliance
In 1936, Rosenzweig suggested that potent implicit factors common to most
psychotherapies were more important than the methods purposely employed, and could
explain the uniformity of success of seemingly diverse methods. He summarized these
factors as:
...the operation of implicit, unverbalized factors, such as catharsis, and the yet undefined effect of the personality of the good therapist; the formal consistency of the therapeutic ideology as a basis for reintegration; the alternative formulation of psychological events and the interdependence of personality organization
(p. 415).
Rosenzwieg’s argument for the common factors model of psychotherapy has been
interpreted to mean that all therapies, in some way, involve a helping relationship with
the therapist (Luborsky, Singer, & Luborsky, 1975). This prescient statement has held
true throughout the course of modern psychotherapy research. The most consistent
finding in the psychotherapy research literature has been that the quality of the
therapeutic alliance is one of the strongest predictors of successful outcome and change
across a variety of treatment modalities (Horvath & Symonds, 1991; Martin, Garske, &
Davis, 2000). Therapeutic alliance began to emerge as a significant concept after
repeated findings that therapy nonspecific factors may account for more variance in
7
treatment efficacy studies than any one specific form of psychotherapy (Lambert, 1998;
Luborsky et al., 1975). Nonspecific elements in psychotherapy refer to aspects of
treatment that are shared across virtually all therapeutic interventions, and include a
healing setting, education, treatment rationale, expectations of improvement, and the
therapeutic relationship (DeRubeis, Brotman, & Gibbons, 2005). All psychotherapies
share several nonspecific factors, and these elements are employed alongside a set of
specific factors that are based upon the therapist’s theoretical orientation. The concept of
therapeutic alliance has been used to support the potency of the nonspecific elements
argument, as many believe that the therapist-patient bond plays a major role in
determining treatment success, regardless of theoretical orientation (DeRubeis et al.,
2005). The concept of therapeutic alliance has thus emerged as an important focus of
psychotherapy research, and the therapeutic relationship itself has been invoked as an
instrument of change across a variety of therapies. Given the strength of the empirical
evidence in support of therapeutic alliance, it is important to understand what is meant by
therapeutic alliance and how such a concept can be applied as a measurable skill within
the context of formal psychotherapy.
The concept of the therapeutic alliance has its origins in the psychoanalytic
literature starting with Sigmund Freud, who focused largely upon the transferential
aspects of the patient-analyst relationship. In Freud’s “The Dynamics of Transference”
(1912), he differentiated between the negative transference and the positive
“unobjectionable” transference by which the patient came to consciously view the
therapist as a supportive figure. He argued that the positive transference had great
8
therapeutic potential in its ability to motivate the patient to collaborate effectively with
the therapist and, in turn, function as “a vehicle of success in psychoanalysis” (Freud,
1912, p.105). Ferenczi (1932) expanded on the idea of a collaborative relationship by
highlighting the role of interpersonal factors and the analyst’s personality and experience
in the treatment process. He recognized the analyst as a real person who produces a real
effect on the transference–countertransference relationship.
Later, Elizabeth Zetzel (1956) became the first to formally articulate this helping
relationship with the terms “therapeutic alliance” and “working alliance.” She argued that
the therapeutic alliance was crucial to the effectiveness of any intervention. The alliance
described the patient’s ability to form a positive and trusting relationship with the analyst,
which would evoke the patient’s earlier developmental experiences through the process
of identification. She argued that it was crucial for the analyst to meet the needs of the
patient in order to provide a trusting relationship that led to an alliance, in much the same
way that a mother needs to fulfill the child’s needs in order to facilitate the emergence of
safety and trust. Ralph Greenson (1967) agreed that the patient’s transference supports
the working alliance, but he emphasized the importance of the “real” relationship
between patient and therapist. This real relationship is comprised of undistorted
perceptions and mutual respect for one another, which enables the therapist and patient to
work together for a common goal. Greenson’s conceptualization moved toward a more
rational and impartial understanding of therapeutic alliance.
The movement toward a consideration of the real relationship between therapist
and patient was important for understanding the interpersonal processes that occur in
9
therapy. Both therapist and patient are participants in the therapy, and as such, both
participants are responsible for constructing the therapeutic relationship. Although many
theorists considered therapeutic alliance as an important aspect of the therapeutic process,
very little empirical attention had been given to how alliance is developed and maintained
within the therapeutic relationship. It was not until the 1970’s that researchers began to
give notice to the therapeutic alliance. This focus was largely due to Edward Bordin’s
(1979) reconceptualization of the therapeutic alliance. He created a model that was not
allied with any one psychological theory or technique, and which viewed a strong
therapeutic alliance as central to the effectiveness of any kind of therapy. Bordin
operationalized the therapeutic alliance as consisting of three interrelated parts: the task,
the goals, and the bond. The tasks of therapy consist of the specific covert or overt
activities that the patient must engage in to benefit from the treatment. The goals of
therapy are the general objectives toward which the treatment is directed. The bond
component of the alliance consists of the affective quality of the relationship between
patient and therapist. These three components of the alliance influence one another in an
ongoing fashion, and Bordin’s central assertion was that the strength of the alliance was
dependent upon agreement of these parts by both therapist and patient. Bordin’s model
of alliance is striking in that “it highlights the interdependence of relational and technical
factors in psychotherapy” (Safran & Muran, 2000, p. 14) by emphasizing the
interpersonal context in which those factors are applied. Within this interpersonal realm,
therapeutic alliance provides a framework for guiding the therapist’s interventions in a
flexible fashion, rather than basing an approach on some inflexible and idealized criterion
10
such as therapeutic neutrality (Safran & Muran, 2000). Furthermore, Safran and Muran
(2000) have built upon Bordin’s conceptualization by arguing that it is the ongoing
negotiation between the patient and therapist over the tasks and goals of treatment that is
central to therapeutic change.
A multitude of psychotherapy research projects have since undertaken the project
of investigating the role of therapeutic alliance (e.g., Samstag, Batchelder, Muran, Safran,
& Winston, 1998; Muran, Safran, Samstag, Winston, 2005; Horvath, Gaston, &
Luborsky, 1993; Horvath & Symonds, 1991; Orlinsky, Grawe, & Parks, 1994).
Therapeutic alliance has gained prominence as a critical component of change in
psychodynamic, cognitive, and cognitive-behavioral traditions (Waddington, 2002). The
introduction of working alliance into the focus of contemporary psychotherapy research
as a pantheoretical concept recognizes of the importance of evaluating therapeutic
methods within the relational context.
Although the effect of therapeutic alliance on outcome has been a consistent and
positive finding, it is clear that alliance alone does not capture the complete picture of
successful or unsuccessful psychotherapy. In a meta-analytic review of 68 studies,
Martin, Garske, and Davis (2000) reported that the overall weighted alliance–outcome
correlation was .22. A comparable .26 correlation was reported in Horvath & Symonds’
(1991) review of 24 studies. Therapeutic alliance appears to make important and reliable
contributions to the psychotherapy process, but the small effect size found across various
studies raises further questions about how this concept contributes to therapy, and
whether it can be understood as a measurable skill. It is necessary to explore in greater
11
detail the development and maintenance of the therapeutic alliance beyond the predictive
value on outcome.
Therapeutic Alliance: Patterns and Development
More recently, therapeutic alliance research has moved beyond validating the
predictive value of alliance on psychotherapy outcome, and has endeavored to better
understand how alliance is formed and maintained. Specific elements or patterns of
therapeutic alliance may be responsible for the effect on treatment outcome. Gelso and
Carter (1994) have suggested that a distinction must be made between the average level
of alliance over time and the specific pattern of the alliance as it unfolds during the
course of treatment. In other words, the therapeutic alliance is a dynamic process that
undergoes fluctuations throughout the treatment, and a static measure of therapeutic
alliance may be unable to capture the important processes through which the alliance is
forged. Hartley and Strupp (1983) examined alliance levels from the initial, first quarter,
midpoint, third quarter, and termination points of brief therapy cases, and they reported
that the level of alliance, averaged across the entire course of treatment, was not
significantly associated with outcome. More successful clients, however, reported an
increase in alliance ratings during the initial quarter of therapy. In contrast, less
successful clients reported a drop in alliance ratings during this same period of treatment
(Hartley & Strupp, 1983). A similar pattern of working alliance development in
successful therapies has been reported in other studies (Luborsky, Crits-Christoph,
Alexander, Margolis, & Cohen, 1983; Klee, Abeles, & Muller, 1990). Conversely, Stiles,
12
Agnew-Davies, Hardy, Barkham, & Shapiro (1998) found a link between treatment
success and alliance late in treatment, while still other studies found that a pattern of a
strong or improving relationship between therapist and patient is associated with positive
treatment outcome (Muran, Gorman, Safran, Twining, Samstag, & Winston, 1995; Safran
& Wallner, 1991; Strupp, 1980).
More recently, support has emerged for a high-low-high alliance pattern that
represents the process of alliance rupture and repair. In this process, previously hidden
negative feelings emerge and then are resolved, or the therapist makes a mistake and then
acknowledges and addresses it (Samstag, Muran, & Safran, 2004; Safran & Muran, 1996,
2000; Agnew, Harper, Shapiro & Barkham, 1994). Gelso and Carter (1994) proposed
that this type of curvilinear pattern of alliance development would be characteristic of a
more effective time-limited therapy episode. They argue that these data are consistent
with Mann's (1973) theory of time-limited therapy in which three phases are predicted: an
initial period of optimism regarding the treatment gives way to a subsequent period of
frustration and negative reactions, which is then followed by a final period of positive
reactions that is more reality based than the initial perceptions.
Intuitively, a linear growth pattern in alliance should be therapeutic because it is a
sign of a positively developing relationship. However, the high-low-high pattern may not
merely represent the bond aspects of the therapist-patient relationship; rather, the pattern
is indicative of the therapeutic process as a whole. Bordin (1979) argued that the rupture
aspect of the rupture-repair process is inevitable because the patient's pathology creates
relationship problems. Further, he believes that the activities involved in repairing the
13
alliance are the essence of the therapy. Stiles, Glick, Osatuke, Hardy, Shapiro, Agnew-
Davies, Rees, & Barkham (2004) found that patients who had demonstrated alliance
rupture profiles averaged significantly better gains in treatment than those patients
without alliance ruptures. Stiles and colleagues (2004) argued that the curvilinear
alliance pattern, in which alliance gradually decreases and later increases across the
treatment, may actually be better represented as a V-pattern than a U-pattern. They found
that alliance ruptures tend to occur haphazardly and are repaired relatively quickly.
Across time, this rupture-repair sequence looks like large downward spikes followed by a
quick return to previous or higher levels of therapeutic alliance (Stiles et al., 2004). This
V-shaped pattern was associated with larger treatment gains, and is consistent with the
hypothesis that alliance ruptures represent opportunities for the patient to learn about
relationship difficulties within the therapeutic context (Safran, Crocker, McMain, &
Murray, 1990; Safran & Muran, 2000).
Despite evidence linking alliance patterns to outcome, several researchers have
cautioned against interpreting a strictly temporal relationship between alliance and
outcome. Correlational findings are subject to the alternative explanation of reverse
causation; in this case, symptom improvement may lead to an increase in the therapist-
patient bond (Crits-Christoph, Connolly-Gibbons, & Hearon, 2006; Feeley, DeRubeis, &
Gelfand, 1999). Indeed, several studies have reported that early change predicts a
subsequent increase in the therapeutic alliance (Barber, Connolly, Crits-Cristoph, Gladis,
& Siqueland, 2000; DeRubeis & Feeley, 1990), and early change is typically associated
with final outcome in psychotherapy (Crits-Christoph, Connolly, Gallop, Barber, Tu,
14
Gladis, et al., 2001; Haas, Hill, Lambert, & Morrell, 2002; Klein, Schwartz, Santiago,
Vivian, Vocisano, Castonguay, et al., 2003). However, Klein and colleagues (2003)
found that alliance remained significantly associated with improvement in depressive
symptoms, even after controlling for patient variables and prior improvement. These
results are promising for establishing therapeutic alliance as a direct contributor to
symptom improvement, but more study is necessary to elucidate this process and rule out
confounding factors.
The Role of Therapist Adherence on the Therapeutic Alliance
The debate over specific versus nonspecific mechanisms of change in
psychotherapy has led some researchers to more closely examine the interplay of these
factors. The quality of the therapeutic alliance may have a strong influence on the
treatment, which includes the tasks of any given session, the short and long-term goals of
the therapy, and the therapist’s choice and application of interventions. The alliance has
been shown to fluctuate—sometimes greatly—over the course of treatment (Stiles et al.,
2004; Kivlighan & Shaughnessy, 1995, 2000; Luborsky et al., 1983). Breakdowns, or
ruptures, in the relationship may pose significant challenges for the therapy. It is within
these moments of strain and tension that the effective use of therapeutic techniques may
be most difficult, and ultimately, the most important.
The therapeutic alliance takes on different roles of significance in various
theoretical traditions. Although it is generally agreed that therapists who are not able to
develop a good working relationship with patients will find it quite challenging to bring
15
about therapeutic change (DeRubeis et al., 2005), some traditions emphasize the role of
the therapeutic relationship more than others. Beck (Beck, Rush, Shaw, & Emery, 1979)
highlights the establishment of the patient-therapist relationship as an important first step
of cognitive therapy. Further negotiation of the alliance, however, is generally addressed
as part of the patient's fundamental beliefs about interpersonal relationships. The work of
cognitive therapy must then reveal the link between modifying these beliefs and resolving
difficulties in the therapeutic alliance (Soygut, 1999). Within interpersonal and relational
thinking, the therapeutic relationship provides a theoretical justification for greater
technical flexibility by asking the therapist to consider how the patient may experience a
particular therapeutic task in a given moment (Safran & Muran, 2000). The therapeutic
alliance is more than simple agreement on the tasks and goals of the session; rather, this
broadened conceptualization of alliance highlights the intrapersonal and interpersonal
aspects of the therapeutic demands.
Because patients may have different and highly personal reactions to the tasks and
goals of psychotherapy, the therapist is rarely faced with a situation in which he or she is
able to practice a “pure” form of therapy. Often, psychotherapy outcome efficacy
studies operate from the “drug metaphor” (Stiles & Shapiro, 1994), in which the
components of verbal psychotherapy are evaluated for strength, integrity, and
effectiveness, similar to the evaluation of ingredients in pharmacological therapies. The
ingredients, or components, of psychotherapy are the verbal and nonverbal utterances and
interventions produced by patient and therapist. This model suggests that if a particular
component is an active ingredient, then patients who receive more of it should tend to
16
improve more (Stiles & Shapiro, 1994). However, this logic overlooks therapist and
patient responsiveness to various techniques and interventions. Any intervention may
have a positive or negative impact on the therapeutic process depending on its
idiosyncratic meaning to the patient (Safran & Muran, 2000), or the therapist’s own
competence and responsiveness to the patient’s experience (Stiles, Shapiro, & Firth-
Cozens, 1989).
Studies on the relationship between therapist adherence to a specific theoretical
model and outcome have yielded inconsistent results. In cognitive-behavioral therapy
(CBT), specific techniques have been shown to be more potent predictors of treatment
outcome than the therapeutic alliance (DeRubeis & Feeley, 1990; Feeley et al., 1999).
However, other studies have found that strong adherence reflects therapist rigidity and
overreliance on technique, which undermines the development of an effective therapeutic
relationship (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Henry et al., 1993).
Strong adherence early in the treatment has been shown to either predict early symptom
improvement (Feeley et al., 1999), or to be predicted by early symptom improvement
(Barber, Crits-Christoph, & Luborsky, 1996). As with therapeutic alliance, it is
conceivable that early symptomatic improvement may result in better therapist
adherence. If a patient is doing well, the treatment may simply be easier to administer
(Loeb, Wilson, Labouvie, Pratt, Hayaki, Walsh, Agras, & Fairburn, 2005).
Barber and colleagues (Barber, Crits-Christoph, & Luborsky, 2006) found a
curvilinear adherence effect, wherein intermediate adherence predicted greater
improvement in drug use and depression symptoms than did high adherence or low
17
adherence. Intermediate adherence represents a balance between treatment protocol and
clinical flexibility, which may be related to the concept of therapist competence. In this
study, however, an explicit measure of competence did not predict outcome directly or
moderate adherence-outcome effects (Barber et al., 2006). Hogue and colleagues
(Hogue, Henderson, Dauber, Barajas, Fried, & Liddle, 2008) had similar results, in which
intermediate adherence to CBT and multidimensional family therapy promoted
therapeutic change better than did high or low adherence. This study also failed to find a
relationship between therapist competence and outcome, which may indicate the
difficulty in measuring such a highly contextual factor (Hogue et al., 2008).
The question of therapist competence is intriguing, because it considers the
effectiveness, responsiveness, and timing of a therapist’s intervention within the context
of a particular patient relationship. Stiles and Shapiro (1994) argue that a therapist’s
selective application of techniques based on the patient’s constantly shifting needs is a
better predictor of outcome than degree of adherence. It is the relatively competent and
appropriate delivery of techniques, rather than frequency of use, that predicts
psychotherapeutic change (Barber et al., 1996). Thus, the therapist’s flexibility and
openness to the interdependence of the relational and technical aspects of the treatment
will allow both participants to proceed in negotiating the therapeutic tasks and goals
(Safran & Muran, 2000). Strict adherence to manual-based interventions may limit the
therapist in some ways and decrease the effectiveness of the therapy. As Beutler (1999)
writes, “Without maintaining therapist interest, the qualities of support, caring, and
18
empathy that are so important to the therapeutic process will detract from whatever
advantages are obtained by standardizing treatments” (p. 404).
Given the movement toward standardizing treatments and implementing manual-
based therapies, it is critical that both clinicians and researchers understand the interplay
between the specific and nonspecific ingredients of therapy. Despite the wealth of
interpersonal and psychodynamic conceptualizations of therapeutic alliance, rupture, and
repair, this topic is relatively lacking from the theoretical framework of cognitive
behavioral therapy. Considering the prevalence of cognitive therapy in current practice, a
more comprehensive theory of the unavoidable therapeutic tensions and conflicts seems
warranted. In an often-cited study with cognitive therapists, Castonguay and colleagues
(1996) found that therapeutic alliance and patients’ emotional involvement indeed
predicted improvement, but therapists’ focus on distorted cognitions was negatively
correlated with outcome. While these findings may seem somewhat counterintuitive,
Castonguay et al. found that in poor outcome cases, therapists often attempted to address
alliance ruptures by increasing their adherence to the cognitive model, rather than
responding more flexibly. The therapists in this study appeared to rely heavily upon
standard cognitive interventions (i.e., challenging distorted beliefs, examining evidence)
instead of responding to the interpersonal difficulties that may have been triggered in the
therapy relationship. In this study, as in the Vanderbilt studies (Strupp, 1980; Henry,
Schacht, & Strupp, 1986; Henry, Schacht, Strupp, Butler, & Binder, 1993), strict
adherence to the treatment prevents therapists from effectively addressing the in-session
process.
19
Resolving Alliance Ruptures: Interpersonal Considerations
In the case of alliance ruptures, therapist flexibility relative to treatment fidelity
may play an important role in successful negotiation. The negotiation of alliance ruptures
may take varied forms, and many theories have been devised as to the best strategy for
the recognition and resolution of therapeutic strains. While some traditions may
emphasize specific interventions for managing the alliance, such as outlining the
treatment rational in CBT, or analyzing the transference in psychoanalysis (Safran &
Muran, 2000), other techniques may be less explicit. The interpersonal perspective
maintains that any strain in the therapeutic alliance reflects both patient and therapist
contributions, and the exploration of these interpersonal processes can lead to the
clarification of core organizing principles that shape the meaning of interpersonal events
for the patient (Safran, 1993). Kohut (1984) conceptualizes alliance ruptures as empathic
failures on the part of the therapist, and the process of working through these empathic
failures provides an important corrective emotional experience for the client. Successful
resolution of the alliance may target both surface level concerns about the treatment tasks
or goals, as well as the underlying personal and interpersonal meanings of the rupture.
Interpersonal strains are arguably most salient for patients with personality
disorders. These patients present with longstanding and inflexible patterns of emotional
and interpersonal difficulties, which pose a challenge to the development of an effective
therapeutic alliance (Beck, Davis, & Freeman, 2004; Benjamin & Karpiak, 2002; Muran,
Segal, Samstag, & Crawford, 1994; Benjamin, 1993). Several studies have found that
patients with a co-morbid personality disorder are the most treatment resistant
20
(Chambless, Renneberg, Gracely, Goldstein, & Fydrich, 2000; Persons, Burns, & Perloff,
1988; Shea, Pilkonis, Beckham, & Collins, 1990). Moreover, therapists are more likely
to encounter ruptures in the therapeutic alliance with personality-disordered patients, due
to their emotional lability or constriction, and their restricted range of interpersonal
behavior. These maladaptive interpersonal styles have the effect of making empathy
difficult and eliciting certain behavioral responses from therapists, which in turn confirms
and perpetuates the patient’s pathogenic beliefs (Muran et al., 2005). Thus, it appears
that there is a higher risk for alliance ruptures in the treatment of personality-disordered
patients, and therapeutic interventions must be tailored to this probability.
A strong alliance—and in particular, a strong early alliance—may contribute to
treatment retention and to symptom change in patients with personality disorders
(Strauss, Hayes, Johnson, Newman, Brown, Barber, Laurenceau, & Beck, 2006). Given
the difficulty that these patients have in establishing and maintaining relationships,
treatment dropout is a significant concern (Leichsenring & Leibing, 2003). A strong
early therapeutic alliance may be of particular importance for difficult-to-treat
populations, as the alliance is a vehicle by which to increase treatment engagement, instill
hope, and provide a strong foundation for the course of therapy (Gaston, 1990; Horvath,
Gaston, & Luborsky, 1993; Horvath & Luborsky, 1993). However, there has been less
attention paid to the therapeutic alliance in personality disorder populations than in Axis I
cohorts. Strauss and colleagues (2006) found significant links between early alliance and
personality-related symptom improvement in a study of CBT for Avoidant and
Obsessive-Compulsive Personality Disorder patients. Further, they found that patients
21
who reported rupture-repair episodes also reported pre- to post-treatment symptom
reductions of 50% or greater on all measures (Strauss et al., 2006). These findings
support the use of in-session transactions to reveal patients’ core interpersonal schemas
(Alford & Beck, 1997; Newman, 1998), and using the therapeutic relationship as a
“corrective experience” (Beck et al., 2004; Safran, 2002; Safran & Segal, 1990). Safran,
Muran, and colleagues (reviewed in Muran, 2002; Safran & Muran, 2000; Muran et al.,
2005) have focused on the development of therapeutic alliance and rupture resolution
among patients with co-morbid Axis I and Cluster C personality disorders. They have
found success in using alliance-focused psychotherapy in retaining Cluster C personality-
disordered patients (Muran et al., 2005). The integration of rupture-and-repair focused
techniques in therapy may be of particular importance for patients with whom it is
difficult to establish a therapeutic alliance, and this question merits further study.
Future Directions
Even with strong commitment to the study of psychotherapy, many questions
remain about the roles of technique, alliance, symptom presentation, and patient and
therapist characteristics in producing change in treatment. One important issue deserving
of closer examination is the interaction of technical and interpersonal factors in
psychotherapy. The delivery, timeliness, and responsiveness of any intervention will
have wide-ranging effects on the patient and the therapy. Moreover, there may be
unintended interventions or idiosyncratic interpersonal components of therapy that
produce a strong effect on the treatment. It will be critical to understand the extent to
22
which nonspecific therapeutic elements complement or interact with the specific elements
of a treatment. More research is also needed regarding the temporal relationship
between technical interventions, therapeutic alliance, and therapeutic gains. A number of
studies have suggested that early alliance and early gains may be important for a
successful treatment, but it is unclear whether these early gains promote better alliance
and adherence, or are predicted by positive alliance and effective technique. Further,
particular technical interventions may engender greater change than others, and future
studies may be able to reveal those specific techniques that contribute most to positive
change in treatment.
The question of therapist competence is an important and complex area in which
further knowledge is required. As previous researchers have suggested, competence may
reflect the ideal balance between treatment protocol and clinical flexibility (Barber et al.,
2006; Stiles & Shapiro, 1994). However, the difficulty in measuring competence and the
failure of some studies to find a relationship between therapist competence and treatment
outcome suggests that current theories and measurements may be lacking. The
development of assessments designed to measure competence will be an important next
step in the evaluation of technical interventions. As therapeutic competence is better
understood and operationalized, it will also enhance clinical training by providing a set of
targeted behaviors and techniques that promote good outcome above and beyond simple
adherence to a treatment protocol.
Psychotherapy is a complex and deeply human practice, and research may never
fully illuminate the myriad techniques, relationships, and outcomes that interact within a
23
given treatment. However, by integrating our knowledge of interventions that have been
reliably shown to work, and by maintaining an openness to new techniques and
approaches, researchers will continue to reveal the possibilities of change in
psychotherapy.
24
Part II: Empirical Article
Introduction
The field of psychotherapy research has widely diversified over the past several
decades. Varieties of psychotherapy have become both more numerous and more
specific as clinicians and researchers seek to discover empirically supported therapies
(ESTs) and identify mechanisms of change. While the establishment of ESTs has been
critical in answering the question of which therapies work, a substantially more complex
issue remains: how does therapy work? One of the central concerns of psychotherapy
researchers is to determine how people change over the course of therapy and to identify
specific elements that contribute to that change. Thus, a thorough evaluation must not
only identify the theories and techniques that underlie a successful treatment, but also the
myriad interpersonal and environmental factors that impact the therapy and, in effect,
help or hinder the change process. Mixed results from psychotherapy outcome studies
illustrate the great complexity inherent to the psychotherapy experience and the need for
more attention to the nuances of treatment.
The development of manualized treatments allowed therapeutic training to
become standardized and subject to rigorous study. With the specification of treatment
principles and techniques came a movement toward defining particular modalities of
psychotherapy, which could then be implemented via formal training in a set of
therapeutic skills. Despite encouraging results with manualized treatments for a number
of psychological symptoms and disorders, clinicians and researchers continue to debate
the value, efficacy, and training utility of such therapies (Chambless & Ollendick, 2001;
25
Carroll & Rounsaville, 2007; Lambert, 1998). Multiple large-scale randomized trials
have identified those treatments that demonstrate some degree of efficacy, but these
studies provide very little guidance regarding the relative superiority of treatment
alternatives (Beutler, 2000). For example, Luborsky and colleagues’ (Luborsky,
Rosenthal, Diguer, Andrusyna, Berman, Levitt, Seligman, & Krause, 2002) meta-analysis
of the studies comparing treatment modalities suggested a fairly small effect size (0.20)
between different therapies. While empirically validated therapies have been
demonstrated to be efficacious relative to control therapies, research has yet to identify
meaningful outcome differences across various treatments.
The failure to find significant differences across different therapeutic traditions may
have less to do with the diversity of specific theoretical conclusions and interpretations
and more to do with variations in each therapist-patient dyad. Such an approach may not
be sufficient for understanding the complex transactions that occur between patient and
therapist. Regardless of whether or not a particular treatment has been found to “work,”
the actual implementation of the therapy can vary widely from therapist to therapist
(Carroll & Rounsaville, 2007; Luborsky et al., 1986). Moreover, the training of
psychotherapists can be incredibly difficult, as the acquisition of therapeutic skill is
influenced by many complex—and often personal—factors. As Strupp and colleagues
found in the Vanderbilt I and II studies (Strupp, 1980; Henry, Schacht, & Strupp, 1986;
Henry, Schacht, Strupp, Butler, & Binder, 1993), even highly experienced and well-
trained therapists can be subject to negative and idiosyncratic interactions with patients.
Psychotherapy, despite its rigorous empirical tradition, remains a deeply human practice.
26
Therefore, it is necessary to evaluate psychotherapy through intensive examination of the
interpersonal processes by which the therapy unfolds, and the influence that these
complex processes have on the treatment outcome.
One of the most consistent findings in the psychotherapy research literature has
been that the quality of the therapeutic alliance is one of the strongest predictors of
successful outcome and change across a variety of treatment modalities (Horvath &
Symonds, 1991; Martin, Garske, & Davis, 2000). Therapeutic alliance began to emerge
as a significant concept after repeated findings that factors nonspecific to therapy might
account for more variance in treatment efficacy studies than any one specific form of
psychotherapy (Lambert, 1998; Luborsky et al., 1975). Nonspecific elements in
psychotherapy refer to aspects of treatment that are shared across virtually all therapeutic
interventions, and include a healing setting, education, treatment rationale, expectations
of improvement, and the therapeutic relationship (DeRubeis, Brotman, & Gibbons,
2005). All psychotherapies share several nonspecific factors, and these elements are
employed alongside a set of specific factors that are based upon the therapist’s theoretical
orientation. The concept of therapeutic alliance has been used to support the nonspecific
elements argument, as many believe that the therapist-patient relationship plays a major
role in determining treatment success, regardless of theoretical orientation. However,
despite consistent and positive findings that support the effect of therapeutic alliance on
outcome, it is clear that alliance alone does not capture the complete picture of successful
or unsuccessful psychotherapy. In a meta-analytic review of 68 studies, Martin, Garske,
and Davis (2000) reported that the overall weighted alliance–outcome correlation was
27
.22. A comparable .26 correlation was reported in Horvath & Symonds’ (1991) review of
24 studies. Therapeutic alliance appears to make important and reliable contributions to
the psychotherapy process, but the small effect size found across various studies raises
further questions about how this concept contributes to therapy.
The debate over specific versus nonspecific mechanisms of change in
psychotherapy has led some researchers to more closely examine the interplay of these
factors. The quality of the therapeutic alliance may have a strong influence on the
treatment, which includes the tasks of any given session, the short and long-term goals of
the therapy, and the therapist’s choice and application of interventions. The alliance has
been shown to fluctuate—sometimes greatly—over the course of treatment (Stiles et al.,
2004; Kivlighan & Shaughnessy, 1995, 2000; Luborsky et al., 1983). Breakdowns, or
ruptures, in the relationship may pose significant challenges for the therapy. It is within
these moments of strain and tension that the effective use of therapeutic techniques may
be most difficult, and ultimately, the most important. The process of negotiating and
resolving these ruptures in the alliance takes on different roles of significance in various
theoretical traditions. Although it is generally agreed that therapists who are not able to
develop a good working relationship with patients will find it quite challenging to bring
about therapeutic change (DeRubeis et al., 2005), some traditions emphasize the role of
the therapeutic relationship more than others. Beck (Beck, Rush, Shaw, & Emery, 1979)
highlights the establishment of the patient-therapist relationship as an important first step
of cognitive therapy. Further negotiation of the alliance, however, is generally addressed
as part of the patient's fundamental beliefs about interpersonal relationships. The work of
28
cognitive therapy must then identify the link between modifying these beliefs and
resolving difficulties in the therapeutic alliance (Soygut, 1999). Within interpersonal and
relational thinking, the therapeutic relationship provides a theoretical justification for
greater technical flexibility by asking the therapist to consider how the patient may
experience a particular therapeutic task in a given moment (Safran & Muran, 2000). The
therapeutic alliance is more than simple agreement on the tasks and goals of the session;
rather, this broadened conceptualization of alliance highlights the intrapersonal and
interpersonal aspects of the therapeutic demands.
Given that patients may have different and highly personal reactions to the tasks
and goals of psychotherapy, the therapist is rarely faced with a situation in which he or
she is able to practice a “pure” form of therapy. Often, psychotherapy outcome efficacy
studies operate from the “drug metaphor” (Stiles & Shapiro, 1994), in which the
components of verbal psychotherapy are evaluated for strength, integrity, and
effectiveness, similar to the evaluation of ingredients in pharmacological therapies. The
ingredients, or components, of psychotherapy are the verbal and nonverbal utterances and
interventions produced by patient and therapist. This model suggests that if a particular
component is an active ingredient, then patients who receive more of it should tend to see
greater results (Stiles & Shapiro, 1994). However, this logic overlooks therapist and
patient responsiveness to various techniques and interventions. Any intervention may
have a positive or negative impact on the therapeutic process depending on its
idiosyncratic meaning to the patient (Safran & Muran, 2000), or the therapist’s own
29
competence and responsiveness to the patient’s experience (Stiles, Shapiro, & Firth-
Cozens, 1989).
Studies on the relationship between therapist adherence to a specific theoretical
model and outcome have yielded inconsistent results. In cognitive-behavioral therapy
(CBT), specific techniques have been shown to be more potent predictors of treatment
outcome than the therapeutic alliance (DeRubeis & Feeley, 1990; Feeley et al., 1999).
However, other studies have found that strong adherence reflects therapist rigidity and
overreliance on technique, which undermines the development of an effective therapeutic
relationship (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Henry et al., 1993).
Strong adherence early in the treatment has been shown to either predict early symptom
improvement (Feeley et al., 1999), or to be predicted by early symptom improvement
(Barber, Crits-Christoph, & Luborsky, 1996). As with therapeutic alliance, it is
conceivable that early symptomatic improvement may result in better therapist
adherence. If a patient is doing well, the treatment may simply be easier to administer
(Loeb, Wilson, Labouvie, Pratt, Hayaki, Walsh, Agras, & Fairburn, 2005).
Barber and colleagues (Barber, Crits-Christoph, & Luborsky, 2006) found a
curvilinear adherence effect, wherein intermediate adherence predicted greater
improvement in drug use and depression symptoms than did high adherence or low
adherence. Intermediate adherence may represent a balance between treatment protocol
and clinical flexibility, which may be related to the concept of therapist competence. In
this study, however, explicit measures of competence did not directly predict outcome or
moderate adherence-outcome effects (Barber et al., 2006). Hogue and colleagues
30
(Hogue, Henderson, Dauber, Barajas, Fried, & Liddle, 2008) had similar results, in which
intermediate adherence to CBT and multidimensional family therapy promoted
therapeutic change better than did high or low adherence. This study also failed to find a
relationship between therapist competence and outcome, which may indicate the
difficulty in measuring such a highly contextual factor (Hogue et al., 2008).
The question of therapist competence is intriguing, because it considers the
effectiveness, responsiveness, and timing of a therapist’s intervention within the context
of a particular patient relationship. Stiles and Shapiro (1994) argue that a therapist’s
selective application of techniques based on the patient’s constantly shifting needs is a
better predictor of outcome than degree of adherence. It is the relatively competent and
appropriate delivery of techniques, rather than frequency of use, that predicts
psychotherapeutic change (Barber et al., 1996). Strict adherence to manual-based
interventions may limit the therapist in some ways and decrease the effectiveness of the
therapy. As Beutler (1999) writes, “Without maintaining therapist interest, the qualities
of support, caring, and empathy that are so important to the therapeutic process will
detract from whatever advantages are obtained by standardizing treatments” (p. 404).
Given the movement toward standardizing treatments and implementing manual-
based therapies, it is critical that both clinicians and researchers understand the interplay
between the specific and nonspecific ingredients of therapy. Despite the wealth of
interpersonal and psychodynamic conceptualizations of therapeutic alliance, rupture, and
repair, this topic is relatively lacking from the theoretical framework of cognitive
behavioral therapy. Considering the prevalence of cognitive therapy in current practice, a
31
more comprehensive theory of the unavoidable therapeutic tensions and conflicts seems
warranted. In an often-cited study with cognitive therapists, Castonguay and colleagues
(1996) found that therapeutic alliance and patients’ emotional involvement indeed
predicted improvement, but therapists’ focus on distorted cognitions was negatively
correlated with outcome. While these findings may seem somewhat counterintuitive,
Castonguay and colleagues found that in poor outcome cases, therapists often attempted
to address alliance ruptures by increasing their adherence to the cognitive model, rather
than responding more flexibly. The therapists in this study appeared to rely heavily upon
standard cognitive interventions (i.e., challenging distorted beliefs, examining evidence)
instead of responding to the interpersonal difficulties that may have been triggered in the
therapy relationship. In this study, as in the Vanderbilt studies (Strupp, 1980; Henry et
al., 1986; Henry et al., 1993), strict adherence to the treatment prevented therapists from
effectively addressing the in-session interpersonal strains.
Although interpersonal strains may be present in any therapy, such tensions are
arguably most salient for patients with personality disorders. These patients present with
longstanding and inflexible patterns of emotional and interpersonal difficulties, which
pose a challenge to the development of an effective therapeutic alliance (Beck, Davis, &
Freeman, 2004; Benjamin & Karpiak, 2002; Muran, Segal, Samstag, & Crawford, 1994;
Benjamin, 1993). Several studies have found that patients with a co-morbid personality
disorder are the most treatment resistant (Chambless, Renneberg, Gracely, Goldstein, &
Fydrich, 2000; Persons, Burns, & Perloff, 1988; Shea, Pilkonis, Beckham, & Collins,
1990). Moreover, therapists are more likely to encounter ruptures in the therapeutic
32
alliance with personality-disordered patients, due to their emotional lability or
constriction and their restricted range of interpersonal behavior. These maladaptive
interpersonal styles have the effect of making empathy difficult and eliciting certain
behavioral responses from therapists, which in turn confirms and perpetuates the patient’s
beliefs (Muran et al., 2005). Thus, it appears that there is a higher risk for alliance
ruptures in the treatment of personality-disordered patients, and therapeutic interventions
must be tailored to this probability.
A strong alliance—and in particular, a strong early alliance—may contribute to
treatment retention and to symptom change in patients with personality disorders
(Strauss, Hayes, Johnson, Newman, Brown, Barber, Laurenceau, & Beck, 2006). Given
the difficulty that these patients have in establishing and maintaining relationships,
treatment dropout is a significant concern (Leichsenring & Leibing, 2003). A strong
early therapeutic alliance may be of particular importance for difficult-to-treat
populations, as the alliance is a vehicle by which to increase treatment engagement, instill
hope, and provide a strong foundation for the course of therapy (Gaston, 1990; Horvath,
Gaston, & Luborsky, 1993; Horvath & Luborsky, 1993). However, there has been less
attention paid to the therapeutic alliance in personality disorder populations than in Axis I
cohorts. Strauss and colleagues (2006) found significant links between early alliance and
personality-related symptom improvement in a study of CBT for patients with Avoidant
and Obsessive-Compulsive Personality Disorders. Further, they found that patients who
reported rupture-repair episodes also reported pre- to post-treatment symptom reductions
of 50% or greater on all measures (Strauss et al., 2006). These findings support the use
33
of in-session transactions to reveal patients’ core interpersonal schemas (Alford & Beck,
1997; Newman, 1998), and using the therapeutic relationship as a “corrective experience”
(Beck et al., 2004; Safran, 2002; Safran & Segal, 1990). Safran, Muran, and colleagues
(reviewed in Muran, 2002; Safran & Muran, 2000; Muran et al., 2005) have focused on
the development of therapeutic alliance and rupture resolution among patients with co-
morbid Axis I and Cluster C personality disorders. They have found success in using
alliance-focused psychotherapy in retaining Cluster C personality-disordered patients
(Muran et al., 2005). The integration of rupture-and-repair focused techniques in therapy
may be of particular importance for patients with whom it is difficult to establish a
therapeutic alliance. This question merits further study.
Purpose of the Current Study
The current study aims to further recent areas of research that have investigated
the roles of therapeutic alliance, therapist adherence to a treatment modality, and therapist
flexibility on treatment outcome. This study is unique in that it examines these factors
specifically in the context of early alliance rupture episodes among patients with co-
morbid Cluster C personality disorders, with whom therapeutic alliance may be difficult
to establish. The current study will examine the modality-specific interventions
employed by therapists, and how the implementation of such strategies early in the
treatment influences patient and therapist evaluations of therapeutic impact and the
patient-therapist relationship. This study will assess training clinicians on two cognitive
therapy cases, and as such, the results will provide insight into the therapists’ familiarity
34
and flexibility with manual-based psychotherapy techniques over time and course of
training. Due to the demonstrated efficacy and prevalence of cognitive therapy,
psychotherapy process research must carefully evaluate the mechanisms by which
cognitive interventions are applied. Cognitive theorists have not often broached the topic
of working alliance ruptures in the therapeutic process, and this study hopes to address
the specific concern of how cognitive therapists are able to successfully or unsuccessfully
navigate such challenges in the treatment.
In psychotherapy research, adherence to the treatment method of interest is
critical for understanding how specific techniques and strategies can produce change.
However, adherence to a prescribed technique within an all-encompassing model does
not ensure improvement across all domains. The manner in which therapists engage
different techniques in response to the fluctuations in the therapeutic process may have
important consequences for the forging of a strong therapeutic alliance and subsequent
treatment outcome. This study hopes to further the discussion of therapeutic alliance and
change with regard to the types of interventions used by cognitive therapists when faced
with a rupture episode. To date, very few studies have examined the role of therapeutic
alliance, rupture, and outcome in the cognitive therapy model.
Finally, this study will contribute to the literature on the treatment of patients with
personality disorders. Cluster C personality disorders are among the most prevalent
personality disorders in outpatient populations (Strauss et al., 2006), and the literature
suggests that therapeutic alliance may be of particular importance for these patients.
35
Research Hypotheses
I. It is expected that the patients and the therapists will evaluate rupture
sessions as being less smooth (i.e., more tense) than sessions without a rupture
event, as measured by the Session Evaluation Questionnaire—Smoothness
subscale (SEQ; Stiles, 1980). Similarly, it is expected that the patients and the
therapists will rate rupture sessions as having lower therapeutic alliance than
sessions without a rupture event, as measured by the Working Alliance Inventory
(WAI; Horvath & Greenberg, 1986; Tracey & Kokotovic, 1989).
II. It is predicted that cognitive therapists will employ different interventions
in rupture sessions than in sessions without a rupture episode, as demonstrated by
differences in the means of adherence scores to the four Beth Israel Adherence
Scale subscales: Brief Adaptive Psychotherapy, Cognitive Behavior Therapy,
Brief Relational Therapy, and Nonspecific Factors. It is expected that therapists
approach tensions, conflicts, or misunderstandings in the therapeutic process
differently than smooth or collaborative therapeutic processes.
III. It is predicted that the therapists will demonstrate differences in the means
of adherence scores to the four Beth Israel Adherence Scale subscales from their
first training case to their second training case. We expect to see a pattern of
increased adherence to the CBT modality in the second case, as a result of greater
experience with CBT techniques.
IV. Evidence suggests that therapist rigidity and over-reliance on technique
may have a detrimental effect on treatment, particularly in the event of in-session
36
tensions or conflicts. Specifically, cognitive behavioral therapy interventions may
be inadequate to successfully resolve rupture events. In the context of rupture
episodes, it is predicted that the therapists’ increased adherence to the CBT
modality will relate to lower ratings of therapeutic alliance and more negative
session evaluations.
V. Evidence suggests that therapist flexibility and responsiveness to
interpersonal rupture events has a positive effect on the treatment. In the context
of rupture episodes, it is predicted that the therapists’ increased use of relational,
psychodynamic, and/or nonspecific therapeutic interventions will relate to higher
ratings of therapeutic alliance and more positive session evaluations.
Methods and Procedures
The present study was based on data collected at the Brief Psychotherapy
Research Program (BPRP) at Beth Israel Medical Center in New York City. The program
began in the 1980’s and has continued to study the therapeutic relationship as related to
psychotherapy process and outcome variables within the short-term (30 session)
treatment of adults with personality disorders. The research focuses primarily on
examining the therapeutic relationship, and specifically, the study of therapeutic alliance
rupture and resolution in the context of short-term manualized psychotherapy. These
treatments include Brief Relational Therapy (BRT; Safran & Muran, 2000), Cognitive
Behavioral Therapy (CBT; Beck et al., 1979), and an integrative treatment in which
37
therapists begin implementing specific alliance-focused techniques at various points in
the treatment.
Patients are recruited through advertisements in local papers and through referrals
from medical and psychiatric providers. Participation is voluntary and includes consent
forms for both therapists and patients. Patients receive 30 sessions of treatment for a
minimal fee determined on a sliding scale based on their annual income. Criteria for
participation in the study include: (1) adults between the ages of 18 and 65, (2) no
evidence of mental retardation, organic brain syndrome, or psychosis, (3) no evidence of
DSM-IV diagnoses of paranoid, schizoid, schizotypal, narcissistic, or borderline
personality disorders, (4) no evidence of current or recent substance abuse or dependence,
(5) no evidence of DSM-IV diagnosis of bipolar disorder, (6) no evidence of current or
recent suicidal or homicidal behavior, (7) no change in use of anti-psychotic, anti-
convulsant, or anti-depressant medications within the past 3 months, and (8) no
concurrent psychotherapy treatment.
Prior to participation, patients are screened for exclusion criteria during a
comprehensive intake procedure that includes an initial phone interview, the completion
of a packet of intake questionnaires, two structured clinical interviews (SCID I & II;
Spitzer, Williams, Gibbon, & First, 1990), and an abbreviated Adult Attachment
Interview (George, Kaplan, & Main, 1985). Phone screenings and interviews were
conducted by MA and PhD level graduate students who participated in training and
supervision by advanced PhD students and licensed psychologists. Patients accepted into
38
the program participated in 30 sessions of once-per-week treatment, and were randomly
assigned to either CBT or the integrative therapy.
Treatment Conditions
All patients in the current study received CBT through session 8. For the patients
assigned to the integrative therapy, the therapist began implementing alliance-focused
techniques following session 8 or 16. All other patients received CBT for the entire 30-
session protocol. For the purposes of this study, only the first 8 sessions of each dyad are
included in the analysis so as to provide a consistent examination of therapist
interventions within the CBT modality. There was no difference in training or
supervision for therapists assigned to the CBT-only or the CBT-integrative condition
through session 8. The therapists assigned to the integrative condition later switched to a
unique CBT-integrative supervision group before introducing alliance-focused
interventions.
Cognitive-behavioral therapy is grounded in cognitive theory and the
conceptualization of the “self-schema” (e.g. Beck et al., 1976; Muran, 1991).
Maladaptive self-schemas, or beliefs about oneself and one’s environment, may become
linked to information processing distortions and subsequent emotional disturbance.
Beck (1976) refers to the products of these cognitive distortions as “automatic thoughts.”
Automatic thoughts are viewed as developing out of rigid belief systems or dysfunctional
attitudes, which in turn reflect emotional knowledge and patterns associated with the self-
schema. CBT attempts to explore and challenge the negative emotions and dysfunctional
39
attitudes contained in the patient’s self-schema, and thus produce more rational
interpretations and less negative emotional reactions. CBT emphasizes a structured,
goal-oriented, and collaborative relationship between therapist and patient.
Participants
Patients: Forty-two patients participated in the present study. Patients were
accepted for treatment in concordance with intake criteria, and were diagnosed with an
Axis II, Cluster C Personality Disorder (avoidant, obsessive-compulsive, dependent) or
Personality Disorder Not Otherwise Specified. Many patients also had co-occurring Axis
I disorders, primarily Mood and Anxiety Disorders.
Patient Demographics: Twenty-four women (57.1%) and 18 men (42.9%)
participated in the study. Participants ranged in age from 23 to 62 (M=43.1, SD=13.0 ).
Thirty-five (83.3%) of the participants identified as White/Caucasian, two (4.8%)
identified as African-American of Hispanic origin, two (4.8%) identified as Asian/Pacific
Islander, two (4.8%) identified as “Other” ethnicity, and one (2.4%) identified as Latino.
Thirty-two (76.2%) of the participants were employed, six (14.3%) were unemployed,
two (4.8%) were retired, and data was missing for two (4.8%) cases. For highest level of
education attained, two (4.8%) achieved a high school diploma, three (7.1%) had some
college, 17 (40.5%) were college graduates, three (7.1%) had some post-graduate
education, 15 (35.7%) had a graduate degree, and data was missing for two (4.8%) cases.
Patient diagnostic characteristics: All but three patients (92.9%) met criteria for
an Axis I disorder. Fourteen (33.3%) of the patients had a diagnosis of Major Depressive
40
Disorder, seven (16.7%) were diagnosed with Dysthymic Disorder, six (14.3%) had
Generalized Anxiety Disorder, four (9.5%) had a Major Depressive Episode, two (4.8%)
had a diagnosis of Adjustment Disorder, and there was one (2.4%) patient diagnosed in
each of the following diagnostic categories: Panic Disorder with Agoraphobia, Panic
Disorder without Agoraphobia, Post-Traumatic Stress Disorder, Bulimia, Social Phobia,
and Obsessive-Compulsive Disorder. All of the patients met criteria for an Axis II
diagnosis of a Cluster C personality disorder or Personality Disorder Not Otherwise
Specified (N=16, 38.1%) with at least one Cluster C trait. Of the Cluster C Disorders, 14
(33.3%) patients were diagnosed with Avoidant Personality Disorder, seven (16.7%) had
Obsessive-Compulsive Personality Disorder, and one (2.4%) had Dependent Personality
Disorder. Additionally, using the SCID-II diagnostic criteria (Spitzer, Williams, &
Gibbon, 1987, 1994), three (7.1%) patients were diagnosed with Depressive Personality
and one (2.4%) had a diagnosis of Negativistic Personality.
Therapists: Twenty-one cognitive therapists were assessed on two patient cases
each, for a total of 42 patient-therapist dyads. The therapists were trainees in cognitive
therapy through the Beth Israel Medical Center Brief Psychotherapy Research Project,
and they consisted of first and second year PhD students in Clinical Psychology and third
and fourth year psychiatry residents. All therapists were trained and supervised in CBT
techniques by two highly experienced PhD-level psychologists. Therapists underwent 16
or more weeks of didactics in cognitive therapy before beginning treatment with their
first patient. Therapists participated in 90-minute weekly group supervision in CBT, and
adherence to the CBT protocol was regularly assessed.
41
Therapist Demographics: At the time of their first training case, the therapists
were 1st year Clinical Psychology PhD students (N=18, 85.7%) and 3rd year Psychiatry
residents (N=3, 14.3%). Thirteen of the therapists were females (61.9%), and 20
identified as White/Caucasian (95.2%) and one (4.8%) identified as Asian/Pacific
Islander. By the time of the second training case, the therapists had moved into their
second year of PhD clinical training or their 4th year of psychiatry residency.
Research Coders: Raters consisted of twelve MA and PhD level graduate
students. Raters were trained for a minimum of 20 hours over 10 weeks and achieved
inter-rater reliability of .80 or above. During the training period, raters attended a
weekly one-hour research coding meeting and completed an additional one-hour practice
assignment. In the coding meeting, the raters met with the study’s author to review the
Beth Israel Adherence Scale items, discuss ratings of sample psychotherapy sessions, and
address discrepancies in the practice assignments. The practice assignments consisted of
ratings of sample psychotherapy sessions. Instruction on the definitions of all of the
items was provided by the study author, who had been previously trained in the Beth
Israel Adherence Scale as part of ongoing research at the Beth Israel Brief Psychotherapy
Research Program. During the data collection period, which occurred over a period of
approximately twelve months, four meetings were held to prevent rater drift. Specific
anchors for each of the items were reviewed and clarified, and sample videotaped
segments were reviewed for the purposes of clarifying aspects of an item. Raters were
blind to treatment condition and the study’s hypotheses.
42
Data Selection Procedure
The present study investigates a cohort of therapists in two training cases. Each
of the 21 therapists saw two patients, for a total of 42 therapy dyads. The dyads were
selected on the basis of having at least one session with a rupture event and at least one
session without a rupture event during the initial phase of treatment. The early stage of
treatment was defined as occurring between sessions 3 and 8. We excluded sessions 1
and 2 from the selection methodology, as the initial sessions of CBT often spend
considerable time with history-gathering, explanation of the treatment approach, and
scheduling. These sessions may not be the most representative of the therapy, and as
such, comparisons may be limited.
The rupture episodes were identified by therapist report on a post-session self-
report questionnaire. This selection procedure was informed by the purpose of the study,
which is to assess therapist behaviors in the context of a perceived rupture event. As this
study examines the therapists’ responsiveness and technical flexibility when faced with a
moment of tension, the therapist first has to be aware of the therapeutic tension. Further,
this selection procedure has several methodological advantages. First, this methodology
increases internal reliability; second, it limits third-party observer bias; and third, it
increases generalizability across research settings (Spektor, 2007). Rupture sessions with
a tension rating of "2" or higher on a 5-point Likert scale were selected for investigation.
In cases where there was more than one session from which to select, one session was
randomly selected. The mean rupture rating was 2.83.
43
For the selection of sessions without a rupture episode, the present study
identified sessions in which neither the patient nor the therapist reported tension or
conflict. This selection method identified those sessions in which both patient and
therapist experienced the therapeutic process as smooth and free of significant tension or
conflict. The non-rupture sessions were also selected on the basis of occurring as far
apart in time as possible from the identified rupture session. This selection method
decreased the possibility that precipitating rupture events or rupture resolution elements
would be present in the non-rupture session.
Instruments
Process Measures: The Post-Session Questionnaire (PSQ; Muran, Safran,
Samstag, & Winston, 2002; see Appendices A and B) is a measure completed
independently by therapist and patient after each session. This self-report questionnaire
consists of several scales that assess both patient and therapist evaluations of working
alliance, presence and degree of rupture episode, and session impact and outcome.
The therapeutic relationship is evaluated using the Working Alliance Inventory
(Horvath & Greenberg, 1986; Tracey & Kokotovic, 1989). This measure assesses the
therapeutic relationship through twelve items that assess the goals and tasks of the
treatment as well as the affective bond between therapist and patient. The scale is rated
on a seven-point Likert scale from one (“never”) to seven (“always”). The measure is
designed to yield both a summary mean score of strength of the alliance as well as three
44
subscale scores that provide information regarding agreement between therapist and
patient on goals, tasks, and the bond. The WAI is a widely used and established measure.
The Rupture Resolution Questionnaire (RRQ; Winkelman, Safran, & Muran,
1998) assesses overall resolution of tensions that occurred within the session. This
measure combines a Likert-rating with two open-ended questions inquiring about rupture
and repair processes in the session.
The Session Evaluation Questionnaire (SEQ; Stiles, 1980) is a Likert rating scale
that assesses patient and therapist perceptions of the usefulness and quality of the session.
Psychotherapy sessions are judged as being (a) powerful and valuable v. weak and
worthless; and (b) relaxed and comfortable v. tense and distressing. On the SEQ, these
evaluations generate two subscales, called Depth and Smoothness, respectively. The
SEQ measures therapeutic processes (Smoothness) as well as patient and therapist
evaluation of the session’s worth and impact (Depth).
PSQ session impact questions. The PSQ includes two items that are designed to
assess session impact and session-to-session outcome and improvement. The first item,
Session Helpfulness, asks: “How helpful or hindering to you (your patient) was this
session?” The second item, Presenting Problem Resolution, asks: “To what extent are
your (your patient’s) presenting problems resolved?”
Assessments
Treatment Adherence: The Beth Israel Adherence Scale (BIAS; Patton, Muran,
Safran, Wachtel, & Winston, 1998; see Appendix C) is a 44-item scale designed to
45
evaluate therapist adherence to behaviors specified by protocol in three brief treatments:
psychodynamic psychotherapy, cognitive-behavioral therapy, and interpersonal/relational
therapy. Adherence ratings reflect observer-based judgments for frequency and clarity of
each technique used by the therapist. Averages are then calculated for each of the three
treatment modalities, with a fourth average that is used to evaluate nonspecific
therapeutic behaviors (i.e., “therapist provides reassurance,” “therapist conveys
competence”). A therapist is considered adherent to a particular model if he or she
receives an averaged score of 2.00 or above for the treatment modality subscale.
The scale provides 12 items to reflect each of the three treatment modalities: Brief
Adaptive Psychotherapy (BAP), Cognitive Behavioral Therapy (CBT), and Brief
Relational Therapy (BRT). In addition to these 36 modality-specific therapist
interventions, there are also eight additional items that reflect those aspects of therapy
considered to cut across distinct theoretical orientations, or nonspecific factors. The
specific modality items are randomly mixed throughout the rating form, and the common
factors items are distributed evenly throughout the rating form.
The BIAS was developed and refined by Santangelo (1996) and Patton (1998).
The eight common factors items were derived directly from the Collaborative Study
Psychotherapy Rating Scale (CSPRS; Hollon et al., 1984; Patton, 1998). Hollon and
colleagues (1984) refer to these particular items (e.g., empathy, warmth, supportive
encouragement, agenda setting) as being “traditionally believed to be important in
describing psychotherapies” (p.7). Given conflicting perspectives on the usefulness of
the specific versus nonspecific factors in psychotherapy, the inclusion of these
46
nonspecific items on the scale was designed to address the continuing research emphasis
in this area (Patton, 1998).
The Brief Relational Therapy (BRT) subscale is composed of 12 items and is
based on the work of Safran & Segal (1990), Greenberg & Goldman (1988), and
Santangelo (1996). Safran & Muran (1995) note that the defining aspects of this model
include: an emphasis on a two-person psychology that focuses on the value of therapist’s
and patient’s joint exploration of their contributions to the relationship; the belief that
patients are arbiters of their own experience; the therapist’s use of self-disclosure and
metacommunication to enhance collaborative exploration; and emotional immediacy
achieved by using phenomenological (“here and now”) therapist interventions to explore
the “particulars of the patient-therapist relationship” (p. 29). A key principle in this
therapy includes the therapist’s use of metacommunication and an emphasis on
mindfulness in the therapeutic relationship. The patient is considered the expert on his or
her own experience, and the therapist tentatively explores the interpersonal interactions
with a focus on the patient’s immediate emotional experiencing (Safran & Segal, 1990).
The Brief Adaptive Psychotherapy (BAP) subscale is composed of 12 items that
are based on a short-term dynamic psychotherapy for the treatment of personality
disorders, developed at Beth Israel Medical Center by Pollack, Flegenheimer, Kaufman,
& Sadow (1990). BAP is a generally active and confrontational brief treatment that is
“based on a psychoanalytic understanding of character, character analysis, and of conflict
and defenses” (Pollack et al., 1990, p.2). Character is defined as reflecting adaptive or
maladaptive patterns of beliefs and behavior, and the BAP therapist identifies the
47
expectations, distortions, and behaviors exemplified by the major maladaptive pattern
(Patton, 1998).
The Cognitive-Behavioral Therapy (CBT) subscale is composed of 12 items that
are based on a short-term, cognitive-behavioral treatment for personality disorders as
described by Turner & Muran (1992). All of the items in this subscale were derived from
the work of Beck and his colleagues (e.g. Beck et al., 1979) and from the Collaborative
Study Psychotherapy Rating Scale (CSPRS, Hollon et al., 1984). The CBT subscale has
its theoretical origins in an integration of cognitive theory and the conceptualization of
the “self-schema” (e.g. Beck, 1976; Muran, 1991).
Criteria for Rating of Items: Raters were instructed to consider any therapist
utterance on two dimensions: frequency and clarity. Frequency was defined as the
number of times an intervention occurred, while clarity was defined as the ease with
which an invention could be understood and recognized as a particular item. An
intervention that was rated high on frequency occurred a number of times in a session,
while an intervention rated high on clarity was a well-formed, easily recognized
intervention occurring in that session (Patton, 1998). A single number on a 6-point,
Likert scale (1= “not at all” to 6= “extensively”) reflected a collapsed frequency and
clarity rating. Rationale for the scoring system and item development is described
elsewhere (Santangelo, 1996; Patton, 1998).
48
Interrater Reliability
Reliability between coders was assessed for significance using the Intraclass
Correlation Coefficient (ICC: Shrout & Fleiss, 1979). The ICC is a measure of reliability
that provides an estimate of the reliability of a rating that might be obtained by an
independent coder and represents the generalizability of the rating. To determine the ICC,
a random sample of coders is selected and each coder independently rates each target.
The reliability coefficient indicates the degree to which any single coder can be used to
represent the score. Reliability was assessed weekly on all coders during the phase of the
study. Once a coder was deemed to be reliable (ICC > .80) for three weeks in a row, he
or she was allowed to code study data. During the data collection period, meetings were
held every 3 months to prevent rater drift. The raters watched and coded an additional
practice session on which reliability was assessed. All coders remained reliable
throughout the data collection and coding period. The 84 sessions were distributed
among the twelve coders.
Results
Means and standard deviations for the therapeutic alliance measures are displayed
in Table 1. As expected, the therapists and patients rated the rupture sessions as having
greater tension and lower levels of therapeutic alliance than in the sessions without a
rupture event. The results are most pronounced in the therapists’ first CBT training case.
There were no significant differences between the ratings of therapeutic alliance from
Case 1 to Case 2, suggesting that the differences in the observed conditions are due to the
49
presence or absence of a rupture event and not due to training effects or particularities of
the dyads.
Table 1: Mean Differences and Standard Deviations on Measures of Therapeutic Alliance and Session Tension in Treatment Group Conditions.
1st Case
Rupture 1
st Case
No Rupture 2
nd Case
Rupture 2
nd Case
No Rupture
Alliance
Measure
M (SD) M (SD) t df M (SD) M (SD) t df
Patient WAI
5.19 (0.66)
5.25 (0.89)
-.25
20
5.53 (0.85)
5 .48 (0.86)
.393 19
Therapist WAI
3.79 (0.56)** 4.28 (0.94)** -3.08 20 3.90 (0.53)* 4 .48 (1.03)* -2.43 20
Patient SEQ Smoothness
4.49 (1.15)** 5.21 (1.06)** -3.84 20 4.95 (1.27) 5 .04 (1.41) -.232 20
Therapist SEQ
Smoothness
4.56 (0.68)** 4.91 (0.62)** -3.85 20 4.35 (0.72)* 4 .71 (0.72)* -2.74 20
SEQ=Session Evalua tion Questionnaire; WAI=Working Alliance Inventory
* p<.05. ** p<.001.
In order to test the hypotheses that the training therapists will respond with
different techniques in rupture versus no-rupture sessions, and will demonstrate
differences in technical adherence from Case 1 to Case 2, an analysis of variance
(ANOVA) was performed, using the General Linear Model program in SPSS version
12.0. The ANOVA had three factors: a within-treatment factor and two between-
treatment factors. The within-treatment factor had 4 levels corresponding to the
50
therapists’ adherence to treatment type interventions (BAP, CBT, BRT, and Nonspecific
techniques). The two between-treatment grouping factors corresponded to the conditions
of a rupture or no-rupture session (Rupture factor), and early training case or late training
case (Time factor).
In addition, the ANOVA provided a test of interaction of therapist adherence to
treatment type, rupture condition, and time condition. A preliminary analysis for
assumption of sphericity was performed using Mauchly’s test. As Mauchly’s test was
statistically significant, the multivariate analysis of variance test was used. Table 2
displays the mean scores and standard deviations of therapists’ adherence to treatment
type, and Table 3 shows the ANOVA of therapists’ adherence to treatment type.
Table 2: Means and Standard Deviations for Adherence Scores by Treatment Group Conditions. Rupture
Early (N=21)
Late (N=21)
No-Rupture
Early (N=21)
Late (N=21)
Treatment Type M (SD) M (SD) M (SD) M (SD)
BAP
1.30 (.29)
1.47 (.34)
1.47 (.41)
1.39 (.28)
CBT 2.50 (.56) 2.27 (.51) 2.64 (.59) 2.23 (.55)
BRT 1.52 (.33) 1.77 (.44) 1.62 (.45) 1.64 (.38)
Non 4.67 (.87) 4.37 (.87) 4.38 (1.05) 4.53 (.65)
BAP= Brief Adaptive Psychotherapy; CBT=Cognitive Behavior Therapy; BRT=Brief Relational Therapy; Non=Nonspecific interventions
51
As can be seen in Table 3, there were no statistically significant differences in
therapists’ overall combined mean scores of adherence; that is, the therapists
demonstrated similar levels of technical activity across all four adherence subscales.
However, findings demonstrated a statistically significant effect for adherence to the
specific treatment types. There was a statistically significant within-subjects main effect
for adherence to treatment type, as well as a statistically significant interaction between
time and adherence to treatment type. Results did not support the hypothesis that
therapists would demonstrate overall differences in treatment type adherence in rupture
sessions versus no-rupture session. The training therapists did not appear to respond to
tension and conflict in the rupture sessions by altering their choice of interventions.
Contrary to the expected findings, therapists used significantly less CBT in their
second-case sessions than in their first-case sessions, regardless of rupture event.
Additionally, there was a trend toward the therapists using more BRT interventions in the
second-case sessions than in the first-case sessions. The interaction main effect for time
and adherence to treatment type is represented in Figure 1.
52
Table 3: Analysis of Variance for Treatment Condition to Treatment Type Adherence.
Source df Mean Square F Pillai's trace p
Between-Subjects
Rupture 1 .00 .00 .95
Time 1 .27 .52 .47
Rupture X Time 1 .05 .10 .75
Error 80 .51
Within-Subjects
Treatment Type Adherence (TT) 3 220.29‡ 375.84 .94 .00**
TT X Rupture 3 .09‡ .34 .01 .80
TT X Time 3 1.08‡ 2.83 .10 .04*
TT X Rupture X Time 3 .79‡ 1.31 .05 .28
Error 78 0.37‡
‡ Huynh-Feldt correction *p<.05 **p<.01
These findings suggest that the training therapists were becoming more flexible in
their choice of therapeutic interventions in the second case, as demonstrated by a
statistically significant decrease in adherence to CBT techniques and a trend toward
increased use of BRT techniques. There was no significant difference in adherence to
BAP techniques or Nonspecific techniques from Case 1 to Case 2. These training effects
do not appear to be related to the presence or absence of a rupture event, as there was no
53
significant interaction between treatment type adherence, rupture condition, and time
condition.
BAP= Brief Adaptive Psychotherapy; CBT=Cognitive Behavior Therapy; BRT=Brief Relational Therapy; Non=Nonspecific interventions
In order to test the hypothesis that the use of BRT, BAP, or Nonspecific
therapeutic techniques in the context of rupture sessions is associated with higher ratings
of therapeutic alliance and more positive session evaluations, a series of Pearson product-
moment correlations was performed between treatment adherence to each of the four
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
1 2 3 4
Treatment Type
Adh
eren
ce S
core
Mean EarlySessions
Mean LateSessions
BAP Non CBT BRT
First Case Sessions
Second Case Sessions
Figure 1: Interaction of Treatment Type Adherence and Time.
54
treatment modalities and the therapeutic alliance and session impact variables for each
group condition (Tables 4-7). These correlation coefficients were then tested for
differences using an asymptotic variance Z-test computed by the POWCOR program
(Allison & Gorman, 1992) to determine whether the relationships between these variables
were significantly different in rupture sessions than in no-rupture sessions. In this study,
the treatment conditions were matched by therapist and patient, and thus the correlations
are dependent. The Z-test statistic was used to control for the dependency of the
variables and assess whether the relationships between the variables in the early rupture
sessions are significantly different from the relationships between the variables in the
early no-rupture sessions. The analysis also tested differences in the relationships
between the variables in the late rupture sessions and the late no-rupture sessions. The Z-
test statistic has been found to maintain good significance level and power in
comparisons of dependent correlation coefficients (Yu & Dunn, 1982). The comparisons
of differences of the correlations are found in Table 8. For this analysis, we only
included the patient evaluations of session impact and therapist alliance, as we believed
the therapists’ evaluations of the session are inherently biased in the self-report data
methodology. We were most interested in determining the impact of the therapists’
interventions on the patients’ perceptions of the session and therapeutic alliance.
The PSQ items designed to assess session impact and session-to-session outcome
and improvement are represented here as the variables Session Helpfulness (“How
helpful or hindering to you [your patient] was this session?”), and Problem Resolved (“To
what extent are your [your patient’s] presenting problems resolved?”). This study also
55
assessed the patients’ and the therapists’ perceptions of the intensity of the rupture
episode as related to the adherence variables. The previous analysis found that the
training therapists did not appear to respond to rupture events by altering their choice of
therapeutic interventions. By analyzing the differences in correlation coefficients
between the treatment adherence variables and the therapeutic process variables, we were
able to assess the impact of modality-specific treatment interventions in each group
condition.
Table 4: Intercorrelations Between Measures of Treatment Adherence and Therapeutic Alliance, Session Outcome, and Rupture Intensity: First Case, Rupture Session (N=21).
BAP CBT BRT Non
Pt WAI 0.20 -0.08 0.42* 0.05
Pt SEQ-Smooth 0.06 -0.22 0.28 -0.27
Pt SEQ-Deep 0.13 -0.23 0.15 -0.15
Pt Session Helpful 0.52* -0.03 0.53* 0.16
Pt Problem Resolved 0.41 0.29 0.10 0.46*
Pt Intensity of Rupture -0.20 0.41* -0.15 0.02
Th WAI 0.13 0.20 0.08 0.45*
Th SEQ-Smooth 0.17 0.19 0.11 -0.01
Th SEQ-Deep 0.09 0.53* -0.14 0.49*
Th Session Helpful 0.42 0.09 0.33 0.36
Th Problem Resolved 0.31 -0.19 0.20 0.16
Th Intensity of Rupture 0.13 -0.17 0.24 -0.59**
WAI= Working Alliance Inventory; SEQ= Session Evaluation Questionnaire *p<.05 **p<.01
56
Table 5: Intercorrelations Between Measures of Treatment Adherence and Therapeutic Alliance, Session Outcome, and Rupture Intensity: First Case, No Rupture Session (N=21).
BAP CBT BRT Non
Pt WAI -0.20 0.24 -0.13 -0.08
Pt SEQ-Smooth -0.11 -0.01 -0.37 0.19
Pt SEQ-Deep -0.01 0.28 -0.27 0.31
Pt Session Helpful -0.13 0.46* -0.47* 0.31
Pt Problem Resolved 0.19 0.01 0.10 -0.11
Pt Intensity of Rupture 0.34 0.10 0.40 -0.20
Th WAI 0.31 0.47* 0.05 0.48*
Th SEQ-Smooth 0.36 0.07 0.04 0.31
Th SEQ-Deep -0.10 0.05 -0.08 0.15
Th Session Helpful 0.32 0.47* 0.16 0.15
Th Problem Resolved 0.48* 0.48* 0.29 0.07
Th Intensity of Rupture 0.10 -0.01 0.14 -0.10
WAI= Working Alliance Inventory; SEQ= Session Evaluation Questionnaire *p<.05 **p<.01
The results from the First Case sessions support the hypothesis that a more
flexible and varied use of therapeutic techniques is related to more favorable patient and
therapist ratings on the WAI and better evaluations of the session’s helpfulness in the
context of a rupture episode. The results from the no-rupture condition suggest that CBT
techniques are related to more positive evaluations of session helpfulness when the
session is free of tension. Unexpectedly, the results show a negative relationship between
57
BRT techniques and patient evaluations of therapeutic alliance in these no-rupture
sessions. When no rupture event is present, a deviation from the CBT goals and
techniques may lead to increased tensions in the session. However, this same amount of
adherence to BAP, BRT, and Nonspecific techniques appears to be effective in the
context of rupture episodes, as indicated by the positive relationship with patient and
therapist ratings of therapeutic alliance and session impact.
Table 6: Intercorrelations Between Measures of Treatment Adherence and Therapeutic Alliance, Session Outcome, and Rupture Intensity: Second Case, Rupture Session (N=21).
BAP CBT BRT Non
Pt WAI 0.23 -0.07 0.17 -0.06
Pt SEQ-Smooth 0.25 -0.49* -0.07 0.01
Pt SEQ-Deep 0.26 0.07 -0.05 -0.09
Pt Session Helpful 0.15 0.25 -0.14 -0.19
Pt Problem Resolved 0.22 -0.25 0.16 -0.01
Pt Intensity of Rupture -0.07 -0.04 0.00 -0.07
Th WAI 0.20 -0.11 0.13 0.06
Th SEQ-Smooth 0.14 -0.44* -0.02 0.12
Th SEQ-Deep -0.03 -0.14 0.07 0.39
Th Session Helpful -0.20 0.09 -0.26 -0.27
Th Problem Resolved 0.21 0.11 0.29 0.47*
Th Intensity of Rupture -0.24 -0.02 -0.05 -0.31
WAI= Working Alliance Inventory; SEQ= Session Evaluation Questionnaire *p<.05 **p<.01
58
Table 7: Intercorrelations Between Measures of Treatment Adherence and Therapeutic Alliance, Session Outcome, and Rupture Intensity: Second Case, No Rupture Session (N=21).
BAP CBT BRT Non
Pt WAI -0.36 0.08 -0.17 -0.20
Pt SEQ-Smooth -0.27 0.19 0.10 0.41
Pt SEQ-Deep -0.15 0.00 -0.03 -0.17
Pt Session Helpful -0.24 -0.12 -0.11 0.01
Pt Problem Resolved -0.17 0.14 -0.09 0.19
Pt Intensity of Rupture -0.07 0.19 0.13 -0.04
Th WAI -0.27 -0.06 0.24 -0.08
Th SEQ-Smooth 0.08 0.18 0.26 0.20
Th SEQ-Deep 0.02 -0.04 0.09 -0.04
Th Session Helpful 0.01 -0.08 0.19 0.11
Th Problem Resolved -0.31 0.11 0.41 0.12
Th Intensity of Rupture -0.17 -0.04 -0.42 -0.04
WAI= Working Alliance Inventory; SEQ= Session Evaluation Questionnaire *p<.05 **p<.01
The results from the Second Case sessions support the hypothesis that the
therapists’ adherence to the CBT modality is negatively related to the level of tension in a
rupture session, as reported by both patient and therapist. However, among this
observation group, there were no significant findings to suggest that other therapeutic
techniques (e.g., BRT, BAP) had a significant effect on the therapeutic alliance or patient
59
evaluations of session impact. There were no significant correlations among the
variables in the no-rupture condition.
The correlation coefficients from the four treatment group conditions were then
matched by First Case and Second Case and analyzed for differences between the rupture
sessions and the no-rupture sessions. The Z-test statistic was used to determine the
differences in these dependent correlation coefficients. The analysis yielded several
statistically significant results in the First Case sessions. The relationships between the
therapists’ use of BAP, BRT, and Nonspecific interventions and patient evaluations of
working alliance, session helpfulness, and presenting problem resolution are significantly
different in rupture sessions than in no-rupture sessions. Although previous analyses
found that the therapists did not use significantly more or less BAP, BRT, or Nonspecific
techniques in the rupture sessions than in the no-rupture sessions, the presence of these
techniques had very different effects on patient evaluations of the session and therapeutic
alliance. When rupture events were present, the non-CBT techniques had a far greater
influence on alliance and session outcome than did the CBT techniques; in fact, BAP,
BRT, and Nonspecific techniques contributed to more positive session evaluations and
improved therapeutic alliance. Thus, although the therapists did not alter the amount of
BAP, BRT, or Nonspecific interventions, these interventions were more effective and had
a greater impact in rupture sessions than they did in the no-rupture sessions.
In the Second Case sessions, only the relationship between CBT and patient rating
of the SEQ-Smoothness subscale was found to be significantly different from rupture to
no-rupture condition. The impact of the therapists’ use of CBT techniques was
60
significantly greater in rupture sessions, and was related to patient perceptions of greater
tension in the alliance. The presence of BAP, BRT, and Nonspecific interventions did
not have any significant effects on therapeutic alliance or session impact evaluations in
these sessions.
Table 8: Differences in Correlation Coefficients Between Rupture Sessions and No-Rupture Sessions on Measures of Treatment Adherence and Patient Session Evaluations.
WAI= Working Alliance Inventory; SEQ= Session Evaluation Questionnaire *p<.05 **p<.01
N=21 BAP CBT BRT Non
First Case Z Z Z Z
WAI 1.22 .982 1.72** .398
SEQ-Smooth .534 .683 1.90 1.69
SEQ-Deep .442 1.66 1.22 1.72
Session Helpful 2.22* 1.69 3.00** .571
Problem Resolved .761 .903 .029 2.09*
Intensity of Rupture 1.75 1.11 1.61 .828
Second Case Z Z Z Z
WAI 1.84 .450 1.02 .428
SEQ-Smooth 1.59 2.20* .527 1.28
SEQ-Deep 1.24 .214 .067 .246
Session Helpful 1.16 1.16 .109 .615
Problem Resolved 1.15 1.25 1.02 .619
Intensity of Rupture .030 .713 .440 .091
61
Additional Findings: Therapeutic Alliance and Session Impact
In addition to the results related to the main hypotheses, we found evidence that
therapeutic alliance factors are also related to patient and therapist evaluations of the
session. In both cohorts, patient ratings on the WAI were positively related to
evaluations of the session’s helpfulness and degree of presenting problem resolution.
Therapist WAI ratings did not have a relationship with the session impact questions, with
the exception of the Presenting Problem Resolution item in the first case rupture session.
Table 9: Intercorrelations Between Patient and Therapist WAI Ratings and Session Impact Questions. 1st Case,
Rupture Session 1st Case, No Rupture Session
2nd Case, Rupture Session
2nd Case, No Rupture Session
Alliance Measure
Session Helpful
Problem Resolved
Session Helpful
Problem Resolved
Session Helpful
Problem Resolved
Session Helpful
Problem Resolved
Patient WAI .86** .56* .57** .58** .58** .47* .71** .57**
Therapist WAI
.37 .46* .09 .17 .23 .30 .32 .10
N=21; WAI= Working Alliance Inventory *p<.05 **p<.01
Discussion
The overall goal of this study was to investigate the technical behavior of
cognitive behavioral therapists-in-training, and to examine the extent to which the use of
prescribed and proscribed interventions in the context of rupture episodes is associated
62
with patient and therapist evaluations of therapeutic impact and the therapeutic
relationship. Further, this study investigated changes in therapists’ technical behavior
over time, thereby providing insight into the therapists’ familiarity and flexibility with
manual-based psychotherapy techniques over the course of training. Consistent with the
first hypothesis, both patients and therapists acknowledged the presence of a rupture
event, as demonstrated by the expected pattern of lower SEQ-Smoothness and WAI
ratings for sessions identified as having a rupture event. However, despite perceiving
tension, misunderstanding, or conflict in the treatment, the training therapists did not
significantly alter their use of therapeutic interventions. Contrary to the third hypothesis,
the CBT therapists did not demonstrate significant differences in their use of treatment
specific interventions in rupture sessions versus no-rupture sessions. However, the
therapists varied their choices of therapeutic interventions overall in their second training
case.
The manner in which therapists engage different techniques in response to the
fluctuations in the therapeutic process may have important consequences for the forging
of a strong therapeutic alliance and subsequent treatment outcome. Indeed, this study
found an interesting relationship between levels of technical adherence and therapeutic
tensions. When no alliance ruptures were present, adherence to CBT interventions was
associated with positive evaluations of session helpfulness. However, in the context of
rupture episodes, this same level of adherence to CBT was associated with patient ratings
of increased rupture intensity and tension in the session. In the second case sessions, the
relationship between CBT and patient evaluations of session tension was the primary
63
distinguishing factor between the rupture and no-rupture sessions. Thus, a very similar
level of adherence to a particular therapeutic modality can have very different effects on
the patient and on the treatment depending on the interpersonal context.
Among the first case rupture episodes, Nonspecific therapeutic techniques and
proscribed interventions associated with BAP and BRT were associated with favorable
patient and therapist ratings on the WAI and better evaluations of the session’s
helpfulness. Although the therapists did not vary the amount of BAP, BRT, and
Nonspecific interventions from rupture to no-rupture session, these techniques had a
significant impact on the therapy and were more meaningful to the patients’ evaluations
of therapeutic alliance and session impact. Although the therapists were strongly
adherent to CBT, the non-CBT techniques had the greatest influence on treatment in the
context of therapeutic alliance ruptures. The results suggest that CBT techniques are
adequate for addressing the patient’s goals in therapy when the therapeutic process is
smooth and free of tension; in fact, a deviation from the agreed upon CBT goals and tasks
may lead to increased tensions in a no-rupture session. However, when tensions or
conflicts arise, additional therapeutic interventions are needed to effectively address the
interpersonal strain. In this study, the use of techniques that promote a better therapeutic
alliance or a focus on the current tensions had a significant and positive effect on the
session outcome when used in conjunction with the CBT interventions.
Training therapists, and particularly those therapists who are very new to a set of
therapeutic techniques, may be inclined to apply the “one size fits all” mentality to
treatment. In this study, the training therapists demonstrated high adherence to the CBT
64
model in sessions with or without a rupture event. However, this approach to therapy
may not be adequate, particularly when alliance ruptures are present. Despite
identification of rupture sessions by therapist report, the results did not indicate that the
therapists responded to the perceived tension or conflict by intentionally altering their
choice of interventions. Although the CBT model does support the forging of therapeutic
alliance early in treatment, there are few prescribed techniques for addressing or repairing
interpersonal strains. It is likely that these training therapists were less equipped to
address interpersonal tensions, and instead focused on applying CBT interventions in a
consistent, technical manner. While consistent and strong adherence to a manualized
treatment may be advantageous for learning a particular theoretical orientation, it may be
less effective for addressing idiosyncratic and interpersonal factors in treatment. Further,
the lack of rupture-focused techniques in CBT may have limited the therapists’ ability to
respond to therapeutic tensions, and thus they had no choice but to continue applying
CBT interventions. Despite a lack of training in rupture-focused techniques, the
therapists did use a limited number of techniques that are associated with positive
alliance-building or with more relational or psychodynamic approaches. These
intuitive—or perhaps unintended—interventions had a significant impact on the
treatment. This study suggests that non-CBT techniques can have an important role in
the negotiation of alliance ruptures, and different types of alliance-focused techniques
may have an additive effect by increasing the effectiveness of CBT in tense moments.
The finding that therapists became more flexible overall in their use of therapeutic
interventions in their second training case is an unexpected result that can be understood
65
in several different ways. We expected that the therapists would show greater adherence
to CBT in their second case because they would have gained greater experience and
practice with the CBT interventions. However, the therapists used significantly less CBT
in the second case sessions, and used more interventions associated with the relational or
interpersonal model. Although the therapists appeared to become more flexible overall in
these second case sessions, this flexibility did not translate into overall treatment gains. It
is likely that too much flexibility reduces the effectiveness of the intended treatment
interventions. The failure to find robust relationships between the adherence variables
and the therapeutic alliance and session impact ratings in the second case sessions may
reflect a need for increased adherence to CBT. The therapists may have struggled to
strike the correct balance between using enough prescribed CBT interventions in the no-
rupture sessions and being more flexible and interpersonally focused in the rupture
sessions. By diluting the CBT protocol, the therapists became less effective overall at
promoting therapeutic alliance and positive patient evaluations of the session impact.
The use BAP, BRT, and Nonspecific techniques was most meaningful in the first case
sessions when it was used in conjunction with high adherence to CBT.
Another explanation for decreased CBT adherence in the second case is that the
therapists were exposed to different therapeutic techniques throughout their course of
training. An expanded awareness of therapeutic traditions may have impacted their
choice of interventions in the second training case. In this study, the therapists were first
year clinical psychology PhD students and third year psychiatry residents at the time of
the first CBT case. In addition to CBT training provided by this study, these therapists
66
also engaged in outside clinical training and academic learning. By the time of the
second CBT case, the trainees were simply more experienced in clinical techniques and
theoretical orientations, and therefore had a greater range of experiences upon which to
draw. This study suggests that an overly flexible or eclectic approach may not be
effective for promoting treatment gains. Rather, in the case of the CBT sessions analyzed
in this study, an ideal level of responsive and interpersonally-focused interventions may
best support and augment an adherent treatment protocol.
The therapists were not supervised and trained in Brief Relational Therapy or
Brief Adaptive Psychotherapy at the time of the study. Therefore, it is unknown the
quality and clarity of the interventions associated with these two modalities. For the
purpose of this study, we understand the rated frequency of BRT or BAP techniques as
indicating greater flexibility or deviation from the CBT model, rather than the utilization
of a refined psychodynamic or interpersonal technique. Although it is possible that the
therapists had some previous experience or training in psychodynamic or interpersonal
therapies, the majority of the therapists were quite new to clinical training and practically
inexperienced. The frequency of these particular interventions suggests that the therapists
attempted to respond to current emotional experiencing and tensions in the relationship in
a general sense, whether or not the therapists succeeded in the technical application of
these theory-driven techniques. Additionally, the Nonspecific factors of therapist
warmth, supportive encouragement, communication style, and rapport were related to
higher evaluations of therapeutic alliance and session impact. These Nonspecific
elements are common to all therapeutic modalities, and the ability to draw on these
67
alliance-building techniques in times of strain—regardless of treatment type—may have
important consequences for the negotiation of an alliance rupture.
Limitations and Recommendations for Future Research
This study assessed the impact of therapeutic interventions on session impact
ratings and session-specific ratings of therapeutic alliance in the first eight sessions of
treatment. Thus, it is unknown whether these ratings predict treatment outcome.
Although previous research has suggested that early gains in treatment and early positive
therapeutic alliance are related to final treatment outcome (Strauss et al., 2006; Feeley et
al., 1999), this study did not include outcome measures in the analyses. Future studies
that include both initial and final assessments of alliance, treatment interventions, and
outcome will provide a more comprehensive understanding of the relationship between
therapeutic activities early in treatment and subsequent therapeutic gains.
The therapists in this study demonstrated overall high levels of adherence to the
CBT protocol in all treatment group conditions, which may partially explain the failure to
find significant differences in treatment type adherence between groups. Given that the
study found several medium effect sizes in the expected direction, it is also likely that a
larger sample size would reveal more significant relationships between treatment type
adherence, therapeutic alliance, and session impact. Further, the Beth Israel Adherence
Scale aggregates techniques employed across an entire session, and thus it is unknown
how a particular intervention was used in a specific moment or interaction. A moment-
68
by-moment qualitative analysis would allow richer observations and clarify the impact of
specific interventions.
The primary goal of this study was to investigate the relationship between
technical interventions and ratings of session impact and therapeutic alliance. Results
from the study suggest that therapeutic alliance may play an important role in mediating
the effects of technical interventions. This finding is consistent with previous studies that
suggest an important and reliable contribution of therapeutic alliance to treatment
outcome. This study did not explicitly address the role of therapeutic alliance in helping
or hindering therapeutic interventions, and this is a concern that may be corrected in
future research. In particular, more research is needed regarding the temporal
relationship between technical interventions, therapeutic alliance, and therapeutic gains.
Adherence to a therapeutic modality does not equal competence. Therapeutic
competence has emerged as an important construct in the evaluation of manual-based
treatments. Competence is a complex factor that may be related to therapist flexibility,
variability of interventions, and appropriateness of an intervention within a unique
therapeutic interaction. This study suggests that mere flexibility or deviation from the
intended treatment protocol is not equal to competence or effectiveness. The
development of assessments designed to assess competence will be an important next
step in the evaluation of technical interventions.
69
Conclusions
Findings indicated that CBT therapists-in-training did not significantly alter their
use of therapeutic interventions in rupture sessions versus sessions without a rupture
event, despite perceiving tension, misunderstanding, or conflict in the therapeutic
relationship. Although the therapists varied their choices of therapeutic interventions
overall in their second training case, this flexibility did not result in more positive
treatment evaluations.
The limited ability of CBT therapists to respond to therapeutic tensions by
altering their choice of therapeutic interventions had a significant effect on both therapist
and patient evaluations of session impact and the therapeutic relationship. In the context
of rupture sessions, techniques associated with positive alliance-building strategies (i.e.,
rapport, warmth, communication style) were related to better ratings of session impact
and lower ratings of therapeutic tension. In sessions without a rupture event, prescribed
CBT interventions were perceived as being most helpful in treatment. These techniques
were related to positive evaluations of session impact and alliance.
The failure to find significant differences in the therapists’ adherence to treatment
type in rupture sessions versus no-rupture sessions suggests that the CBT therapists were
not sufficiently trained to respond to therapeutic tensions by altering their technique.
Despite this result, the study found that some non-CBT interventions were indeed related
to the interpersonal processes in the treatment. Within any treatment, a therapist may use
a mix of prescribed and proscribed interventions. Although there is not sufficient
evidence that the therapists significantly altered their choice of interventions from rupture
70
to no-rupture sessions, the results are promising in suggesting that some techniques are
more successful than others in addressing interpersonal elements of therapy. Indeed, the
therapists’ use of BAP, BRT, and Nonspecific factors had very different effects on
patient evaluations of session impact and therapeutic alliance in rupture sessions and no-
rupture sessions. In the first case rupture episodes, BAP, BRT, and Nonspecific factors
were most related to positive alliance and session impact, and appeared to be more
effective than the CBT interventions.
This study shows that CBT is related to positive therapist and patient rating of
session helpfulness and therapeutic alliance when no ruptures are present. However,
unwavering adherence to CBT in rupture sessions does not adequately address the
idiosyncratic and interpersonal elements that may be present in an alliance strain. CBT
may be improved by greater attention to the interpersonal processes in treatment, thereby
allowing the patient and therapist to engage in ongoing negotiation of the task, bond, and
goals of therapy so that the CBT elements will be of utmost utility to the patient. Rigid
application of technique may invalidate the patient’s experience and demonstrate the
therapist’s lack of awareness of interpersonal processes. When working with patients
with personality disorders, strategies for strengthening the therapeutic alliance may be of
particular importance for engaging the patient in treatment and addressing long-standing
problems or deficits in interpersonal interactions.
The results of this study suggest that clinical training in techniques that promote
therapeutic flexibility, responsiveness, and awareness of potential interpersonal
difficulties can enhance CBT, and in fact, such strategies do not detract from manualized
71
CBT protocols. Early in treatment, development of positive working alliance and
attunement to patient’s experience of treatment should be a primary focus. Cognitive
therapists-in-training should be encouraged to remain aware of misunderstandings or
disagreements, as the effective resolution of these issues will allow the patient to fully
engage in the prescribed treatment. Responding to tensions with a more rational,
didactic, or confrontational stance may be detrimental to the therapeutic alliance and,
ultimately, treatment outcome.
72
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APPENDIX A
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APPENDIX B
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APPENDIX C
Beth Israel Adherence Scale Rating Form
Rater Name: ____________ Acronym/ID #: ______________ Session #: _______ Rating Date: _____________
Please rate each of the following 44 items on a 1-6 scale based on the frequency and clarity of each technique as it is used by the therapist during the session. Use check marks to denote the frequency and clarity of each item as it appears in the session. Please refer to the item descriptions for more detailed information about the therapeutic techniques listed here.
Please note that Global/Nonspecific therapy items should be coded after the entire session is viewed. These items may be better coded by quality or effectiveness of intervention, rather than frequency and clarity. These items are highlighted below. Please code ALL items. Not at all Extensively √-, √, √+
1. Homework* .………………………………………. 1 2 3 4 5 6 2. General Interpretation …………………………… 1 2 3 4 5 6 3. Explores “how” of defense ……………………..... 1 2 3 4 5 6 4. Reflects Content …………………………………. 1 2 3 4 5 6 5. Th.’s communication style ………………………. 1 2 3 4 5 6 6. Non-verbal ……………………………………….. 1 2 3 4 5 6 7. Distance ………………………………………….. 1 2 3 4 5 6 8. Individuation ……………………………………... 1 2 3 4 5 6 9. Frames symptoms ………………………………... 1 2 3 4 5 6 10. Th. conveys competence ……………………….. 1 2 3 4 5 6 11. Probes meaning ………………………………… 1 2 3 4 5 6 12. Links resist./maladaptive pattern ……………….. 1 2 3 4 5 6 13. Advantages/disadvantages ……………………… 1 2 3 4 5 6 14. Here and now …………………………………… 1 2 3 4 5 6 15. Therapist involvement ………………………….. 1 2 3 4 5 6 16. Confronts ………………………………………. 1 2 3 4 5 6 17. Cognitive distortion ……………………………. 1 2 3 4 5 6 18. Tentative ……………………………………….. 1 2 3 4 5 6 19. Alternative explanation ………………………… 1 2 3 4 5 6 20. Links sig. past w/present ……………………….. 1 2 3 4 5 6 21. Interprets defenses/resistance …………………… 1 2 3 4 5 6 22. Therapist warmth ……………………………….. 1 2 3 4 5 6 23. Tracks …………………………………………… 1 2 3 4 5 6 24. Specific thoughts ……………………………….. 1 2 3 4 5 6 25. Empathic conjecture ……………………………. 1 2 3 4 5 6 26. Unconscious aspects ……………………………. 1 2 3 4 5 6 27. Socratic questioning ……………………………. 1 2 3 4 5 6 28. Rapport ………………………………………….. 1 2 3 4 5 6 29. Probe feeling/experience ……..…………………. 1 2 3 4 5 6 30. Symptoms as coping ……………………………. 1 2 3 4 5 6 31. Didactic …………………………………………. 1 2 3 4 5 6 32. Maladaptive pattern …………………………….. 1 2 3 4 5 6 33. Th.’s receptive silence ………………………….. 1 2 3 4 5 6 34. Examine evidence ……………………………… 1 2 3 4 5 6 35. Arbiter of experience …………………………… 1 2 3 4 5 6 36. Links sig. past w/therapist ……………………… 1 2 3 4 5 6
37. Awareness exercise* …………………………….. 1 2 3 4 5 6 38. Rational responses ……………………………… 1 2 3 4 5 6 39. Th.’s supportive encouragement ……………….. 1 2 3 4 5 6 40. Evocative reflection …………………………….. 1 2 3 4 5 6 41. Plan/practice alternative behaviors ……………… 1 2 3 4 5 6 42. Links parts of conflict ………………………….. 1 2 3 4 5 6 43. Metacommunication …………………………… 1 2 3 4 5 6 44. Set and follow agenda ………………………….. 1 2 3 4 5 6
Rating Notes: Underlined items* should be weighted heavily (liberal rating on Likert scale) Italicized items should be weighted lightly (conservative rating on Likert scale)
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APPENDIX D
BETH ISRAEL ADHERENCE SCALE
1. Assigns and reviews homework. The therapist goes over with the client the previous assignment from the week before. The therapist discusses with the client the assignment for the coming week. (Rate on freq/clarity - "not at all" to "extensively.")
2. Interprets other aspects of client's behavior or experience. (Not captured in other items - General interpretation). "It sounds like you have trouble figuring out who you are and what you want out of your life, separate from what your parents want." (Rate on freq/clarity - "not at all" to "extensively.")
3. Explores the HOW, or mechanism of a client's defense, not the WHY. Therapist focuses on the feelings underlying the client's defense and NOT the reasons for them. The goal is not to establish causal links but to identify and experience the feelings which elicit certain defenses. "Are you aware of controlling your feelings in any way?" "What are you avoiding?" "Are you aware of stopping your feelings right now?" "How do you stop your feelings?" (Rate on freq/clarity.)
4. Reflects the content of client's statement. Therapist attempts to understand the meaning of the content of what client has said and reflects this back to the client. It is often a summary or precis of what the client has just said rather than a reflection of feeling. Therapist conveys that client's meaning has been understood. (Rate on freq/clarity.)
5. Therapist's communication style. How interesting is the therapist's style of communication? Consider the vividness of his/her language, the originality of the ideas, the liveliness of the manner of speaking. Rating: "1"=dull, uninteresting; "3"=less interesting than average; "6"=very interesting. Adapted from CSPRS, Hollon, 1984.
6. Directs client's attention in non-confrontational manner to specific client behaviors, subtle non-verbal communications or paralinguistics, to increase client's awareness. This can be an observation of facial expression, body movement or posture, or voice inflection, etc. Therapist does this in a supportive and nonjudgmental manner. "I'm aware of a particular tone in your voice." "When you say this, you have a very angry expression on your face." (Rate on freq/clarity.)
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7. Encourages client to distance him/herself from his/her thoughts, viewing them as beliefs rather than facts. Therapist urges or challenges the client to consider the thoughts as beliefs which may or may not be true. Therapist urges the client to consider his/her thoughts as testable hypotheses rather than given facts. This item can be coded if the therapist makes direct statements to this effect OR if the therapist less directly encourages this, as well. "What's that belief about?," "What is that thought?," NOT "What do you think?" or "What do you believe?" BUT more, "this or that thought," "this or that belief," "do you see how thinking of it in this way allows you to see it as a hypothesis that you have, rather than a carved-in-stone fact?" (Rate on freq/clarity.)
8. Facilitates individuation and/or self-assertion. Therapist encourages the client either to ask for what s/he wants or to express his/her feelings directly to therapist. "Do you have a sense of what you want from me right now?" "I wonder if you could tell me how disappointed you are in me now?" (Rate on freq/clarity.)
9. Frames symptoms in a relationship context. Therapist shows client that particular symptoms are associated with aspects/events in client's relationships. Symptoms are believed to be a result of previously dysfunctional relationships. Forgetting is a "symptom" of memory dysfunction; anxiety and depression are also examples of symptoms. E.g., Therapist notices that every time a client's attractiveness is mentioned, she feels very sad. Father would show little interest when client would get recognition for an achievement or attribute, etc. Therapist says, "You felt depressed in response to your father's losing interest in you. And now you feel sad with me because you perceive that I, too, have lost interest in you." (Rate on freq/clarity.)
10. Therapist conveys competence. Did the therapist convey that s/he has understood the client's problems and is able to help the client? (ref. Hollon, 1984.)
11. Probes for client's beliefs or personal meaning behind client's thoughts. "What does that mean to you?," "What does that thought mean to you?," "If you think that he doesn't want to talk to you, what does that mean to you?," "It sounds like you believe that in order to feel good about yourself, you must be liked by everybody." (Rate on freq/clarity.)
12. Links resistance (to the therapeutic process) to the maladaptive pattern E.g., "You're tuning out here just like you do when things get tough". Links behavior in
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session with behavior elsewhere. "You're shutting down with me now just like you do at home with your family when you get angry." (Rate on freq/clarity.)
13. Explores the disadvantages and advantages of dysfunctional attitudes. "What's the advantage to believing that?," "How useful is the belief that you will never get ahead?," "Is there a disadvantage to that thinking style?" (Rate on freq/clarity.)
14. Directs or redirects the focus to the "here and now" either with regard to the client's experience or with regard to the relationship between the client and therapist. "What's happening for you right now?," "What would satisfy you with me right now?," "What's your fear of exploring those feelings with me right now?" (Rate on freq/clarity.)
15. Therapist involvement. How involved is the therapist with the process? Consider the range from detached to involved. (Hollon, 1984)
16. Confronts client, suggesting that he/she is saying, feeling, or thinking something different than what the client claims. "You say that you are not angry and yet your expression looks very angry," "You say that you are not anxious and yet you've been twisting your hands back and forth in a way that you told me you do when you're nervous." (Rate on freq/clarity.)
17. Helps client identify cognitive distortions, errors that were present in his/her thinking. Magnifying, maximizing, catastrophizing, personalizing, generalizing. "Do you see how this all-or-none thinking actually decreases your options?," "It sounds like you believe that the only possible result of your effort is going to be failure. Is there a more accurate way of looking at this problem? Do you see how you are singling out the worst possible case scenario?" (Rate on freq/clarity.)
18. Intervenes with skillful tentativeness. Refers to quality of therapist attitude of exploration and subjectivity; therapist uses words like "perhaps," "it seems," "possibly." (Rate on freq/clarity.)
19. Facilitates client's consideration of alternative explanations for events. Did the therapist help the client consider alternative explanations for events besides the client's initial explanation? "What would be another way to explain why Bill reacted in this way?," "What about considering another perspective on the situation?," "Are there other
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factors which could have played a role in your not getting the position?" (Rate on freq/clarity.)
20. Interprets/Explores maladaptive patterns by linking dynamics with parental/significant figures in the past to others in the present, NOT including therapist (i.e. carrying past parental relationship dynamics into the present in a way that is not productive). "One of the things we've learned from looking at your relationship with your mother is that you tried to do the accommodating thing in order to get her approval. It seems that you do a similar thing with Bob, never crossing him, so that he won't be angry with you." (Rate on freq/clarity.)
21. Interprets and/or explores client's resistance or defenses. An interpretation provides a new understanding or offers a label of an inner state; it presumes knowledge by the speaker of the client's experience and places it in the speaker's frame of reference. "You try to avoid situations which make you feel confused," "When you feel anxious, you tend to withdraw." (Rate on freq/clarity.)
22. Therapist warmth. Did the therapist convey warmth?
23. Tracks client's experience in a moment-to-moment fashion. The act of following client's perceptions, thoughts, and feelings as they emerge in the moment. Therapist does not make reference to client processing that is not currently being experienced. (Rate on freq/clarity.) (GLOBAL BRT item.)
24. Asks client to report specific thoughts. Asks client to report specific thoughts as verbatim as possible. In order to code this item, it must be specific and verbatim. "What specific thoughts do you have about that?," "Let's get to the thought that you're having about this feeling." (Rate on freq/clarity.)
25. Engages in empathic conjecture: Hypothesizing, exploring the nature of the client's experience AND then "checking in" after making the conjecture (often, but not always, interrogative). The conjecture is about inner experience, not about psychogenetic causes or patterns in behavior or experience. Therapist takes a "guessing" or "hypothesizing" stance with client and asks client to "check" therapist's hunch with client's experience. "and so this is when I guess the hopelessness sets in... Is that true for you?" "Powerful, right? It's like the only power you have, right?" (Rate on freq/clarity.)
26. Explores and elucidates the unconscious aspects of major maladaptive patterns, thoughts, and behaviors. "What's that need you have to feel frustrated?" "Why do you think you do that?" "What's that about when you act that way?" "Why do you think you're
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so frightened of competition?" "When you feel scared, you act hostile. Why do you think that is?" Here, the therapist is probing for the unconscious aspects of the client's behavior/feelings. (Rate on freq/clarity.)
27. Engages in Socratic questioning aimed at guiding client's reasoning process. This is guided questioning which may involve disputing or challenging the client's beliefs or ideas. "And what do you think would happen if you did that?," "How likely is that to happen?," "Where's the evidence for that?" "Where is that kind of thinking going to take you?" (Rate on freq/clarity.)
28. Rapport. How much rapport was there between the therapist and client? How well did they get along? "1"=total absence of rapport; "6=excellent rapport. (Hollon, 1984)
29. Asks exploratory questions which probe for the feeling/experience underlying the client's utterance including feelings about the feeling/experience or utterance itself - feeling ashamed about feeling this way, etc. Therapist makes inquiries into what the client is or has experienced. "What does that feel like?," "What was it like for you when he went away?," "What was that like for you?," "What's your feeling about feeling so anxious?" (Rate on freq/clarity.)
30. Frames symptoms as coping attempts. The therapist recognizes and points out that particular symptoms can be understood as faulty and costly attempts at problem solving. "You really want someone to soothe you but nobody is there so you eat as a way of feeling better." (Rate on freq/clarity.)
31. Engages in didactic persuasion. The stance is teaching, guiding, persuading. It is a goal-directed stance that is meant to, through examining evidence, convince the client that his/her way of thinking is erroneous. "This plan we were talking about allowed you to test out the predictions you had. Do you see how you were able to disprove those predictions and thus get more accurate information?" (Rate on freq/clarity.)
32. Defines/Identifies/Specifies the maladaptive pattern. "You have a tendency when you're feeling scared to pull back. We've seen how this happens in your friendships and with people at work," "When you get angry with people you are close to, you have a tendency to react impulsively. This has been going on for a long time, and we need to understand what this pattern is about."
33. Receptive silence. (a/k/a receptive listening) Did the therapist appear to allow silence to continue, using minimal encouragements such as "uh-huh," "mm-hmm," and
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"okay" as a means of encouraging the patient to talk? Allows pt space to communicate. (Hollon, 1984)
34. Helps client examine currently available evidence or information to test the validity and realistic consequences of the client's beliefs. Therapist helps the client use evidence from 1) client's past experience, 2) his/her knowledge of the way the world works, to test his/her beliefs for validity. This can also be applied when the therapist looks at the realistic consequences of an event with the client. "Let's look at what actually happened and see if your belief still holds," "What's the evidence for the belief that your friends can't stand you?" (Rate on freq/clarity.)
35. Respects client as arbiter of experience. Therapist maintains a humble, subjective, exploratory stance. Therapist is not the expert on the client's feelings; s/he is facilitating their unfolding. (Rate on freq/clarity - GLOBAL item.)
36. Interprets/Explores maladaptive patterns by linking dynamics with others (past and present) to current dynamics with the therapist. Therapist tries to show the client that patterns that existed in relationships with significant others are similar to patterns in the relationship with the therapist. "So you used to rely on John on a daily basis, and now you can't do that because he's gone, so you feel like you are starting to rely on me for those things." (Rate on freq/clarity.)
37. Deepens client's awareness/experience through in- or out-of-session awareness exercise. Often, when the client has expressed an emotion, the therapist will say: "Try saying that to me directly," "Try saying, 'I'm angry at you'" or "Over the week, be aware of when you get sad or close off and withdraw." (includes 2-chair exercise.) (Rate on freq/clarity.)
38. Therapist and client practice rational responses to client's negative thoughts and beliefs. Rational responses represent more accurate or reasonable ways of thinking about an event or issue than the client's original thought or belief. "Let's try to generate some thoughts that may be more reasonable than concluding that you are a loser." "I'll come up with the negative thoughts and you try to counter them with more reasonable thoughts. What would you say if I said that I can't make a decent meal?" (Rate on freq/clarity.)
39. Supportive encouragement. Was the therapist supportive of the client by acknowledging the gains during therapy or by reassuring the client that gains will be forthcoming? Must be concrete. "1"=not at all; "6"=extremely. (Hollon, 1984)
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40. Deepens client's experience through evocative reflection. Therapist takes the client's either implicitly or explicitly expressed feelings and empathizes with these feelings to amplify/elaborate the client's felt experience of them. "So, you're feeling a bit shut down and angry," or "So you're feeling like no one really understands how hard it is for you." (Rate on freq/clarity.)
41. Works with client to plan or practice alternative overt behaviors for the client to use both inside and outside of therapy. Overt behaviors refer to "observable" behaviors rather than covert or cognitive behaviors. The therapist may help the client develop a plan for getting a new job. This may involve role playing, etc. (Rate on freq/clarity.)
42. Interprets/explores maladaptive patterns by linking components of a conflict. Therapist provides a construction that links different components of an internal conflict. For example, drives or wishes can be linked with anxiety, which can be linked with defensive processes, which can be linked with affect. "You felt anxious and that made you pick a fight with your wife;" "You want to leave but you are afraid to so you stay." (Rate on freq/clarity.)
43. Metacommunicates by conveying own feelings to help client become aware of his/her role in the interaction or to probe for client's internal experience (general metacommunication item). Includes acknowledging own role in the interaction. "I think I've been acting hostile towards you," "I feel shut out right now," "I'm feeling put down right now," "I feel like I'm playing a game of chess. Does that make any sense to you?" (Rate on freq/clarity.)
44. Set and follow agenda. Did the therapist work collaboratively with the client to formulate and follow a specific agenda for the session? (Rate on freq/clarity.)