Resolving Therapeutic Impasses

Jeremy D. Safran, Ph.D. The New School for Social Research

Leeds, 2015

How effective is psychotherapy? Effect size (treatment vs. control condition) Psychotherapy = .80 Treated patients do better than 80% of patients in

untreated control groups Antidepressants = .31 Average effect size for

antidepressant approved by FDA between 1987-2004

CBT = most well researched psychotherapy But:

Averages mask individual differences 30 % of patients don’t improve or

deteriorate Drop-out rates = 30% Patients with Personality Disorders do less

well on treatment

Predicting outcome Therapeutic alliance = robust predictor of

outcome Negative interpersonal process predicts poor

outcome Some therapists more effective than others

(up to 18% of variance: Lutz et al., 2007)

Effective therapists better at establishing alliance

Effective therapists more self-accepting

Therapeutic Alliance

Edward Bordin (1979)BondTasksGoals

First generation alliance research Quality of alliance is a robust predictor of

treatment outcome across therapeutic modalities

Most recent meta-analysis included 190 studies (Horvath et al., 2011)

Second generation alliance research

What happens when there is a problem in the alliance or a therapeutic impasse?

Many terms have been used: Therapeutic Impasses (Hill, Nutt-Williams, Heaton, Thompson, &

Rhodes, 1996)

Alliance Ruptures (Safran & Segal, 1990; Safran & Muran, 1996; 2000)

Misunderstanding events (Rhodes, Hill, Thompson & Elliott, 1994)

Alliance threats (Bennett, Parry, & Ryle, 2006)

Research Reviews In: J.C. Norcross. Psychotherapy Relationships

that Work. New York: Oxford. APA Division 29 Task force on Empirically Supported Relationships

Safran, Muran, et al. (2002) Safran, Muran, & Eubanks-Carter (2011)

Alliance ruptures or impasses Periods of tension or breakdown in

collaboration or communication between patient & therapist

Vary in duration & intensity Brief moments of tension or

misunderstanding///Extended episodes Subtle shifts///Dramatic ruptures

2 Rupture/Impasse Categories

CONFRONTATION

Complaints about… Therapist as person Therapist’s competence Being in therapy Parameters of tx Progress in therapy

WITHDRAWALDenialMinimal responseShifting topicsIntellectualizationAvoidant storytellingTalking about otherCompliance

Basic Principles of Intervention

Basic Books (1990)

Guilford Press (2000)

Therapists should be aware that patients often have negative feelings about treatment or therapist that they are reluctant to bring up.

Important for therapist to be attuned to subtle indications of ruptures or impasses.

Draw attention to relationship & explore patient’s experience & perceptions in the here-and-now

Important for patient to be able to express negative feelings when they arise or assert difference in perspective.

Important for therapist to respond nondefensively.

Explore patient’s fears & expectations that are interfering with exploration & expression of their needs, or negative feelings or concerns about the therapy or therapist.

Important for therapist to empathize with patient’s concerns and validate feelings & accurate perceptions.

Important for therapists to take responsibility for their own contributions.

Dyadic Systems Perspective Patient and therapist are always influencing

one another at both conscious and implicit levels.

Implicit mutual influence takes place through nonverbal communication.

Therapists are typically only partly aware of the role they are playing in influencing patient.

Withdrawal rupture or impasse

Confrontation rupture or impasse

During alliance ruptures or impasses the therapist’s task is to engage the patient in a collaborative exploration of who is contributing what to the interaction.

Interpersonal Complementarity H. S. Sullivan (1953) T. Leary (1957) J.S. Wiggins (1979) D. J. Kiesler (1982) J.D. Safran (1984)

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Dominance (Control))

FriendlyHostile

Submission

(Control))

(Affiliation) (Affiliation)

Therapist’s emotions as information

Emotions: adaptive evolutionary function Emotions = intuitive appraisal Emotions = action tendency information

Therapist’s emotions provide clue as to what might be going on in the relationship by informing him/her regarding the nature of his/her own reflexive response to patient

If I were with this patient I would feel: Bossed around Want to put him down Annoyed Distant from him/her Like an intruder I should do something

to put him/her at ease Charmed

Superior In charge Frustrated he/she

won’t take a position Admired Appreciated Taken care of Friendly

Therapist mindfulness training Becoming aware of feelings emerging in

present moment. Observe whatever emerges in self, patient

& relationship with nonjudgmental awareness & curiosiy

Mindfulness Track subtle shifts in patient’s responses. Change our relationship to our feelings so

they can be used as a source of information instead of influencing us without our awareness.

Metacommunication Mindfulness in action

Metacommunication: Definition An attempt to step outside of the

relational configuration that is being enacted by treating it as the focus of exploration.

Communication about the transaction or implicit communication that is taking place.

An attempt to bring ongoing awareness to bear on the interactive process as it unfolds.

An attempt to put into words an implicit sense of what is going on.

METACOMMUNICATIONMETACOMMUNICATIONPrinciplesPrinciples

Ground all formulations in awareness of Ground all formulations in awareness of one’s own feelings.one’s own feelings.

Accept responsibility for one’s own Accept responsibility for one’s own contributions.contributions.

Comment on what may be a shared Comment on what may be a shared experience.experience.

METACOMMUNICATIONMETACOMMUNICATIONPrinciplesPrinciples

Focus on the here and now.Focus on the here and now. Gauge intuitive sense of relatedness.Gauge intuitive sense of relatedness. Evaluate patient responsiveness to all Evaluate patient responsiveness to all

interventions.interventions.

METACOMMUNICATIONMETACOMMUNICATIONPrinciplesPrinciples

Judicious disclosure of relevant feelings in Judicious disclosure of relevant feelings in the moment.the moment.

Reflect on one’s own actions Reflect on one’s own actions retrospectively.retrospectively.

Provide feedback regarding subjective Provide feedback regarding subjective experience or perception of patient.experience or perception of patient.

METACOMMUNICATIONMETACOMMUNICATIONPrinciplesPrinciples

Recognize that the situation is constantly in Recognize that the situation is constantly in flux.flux.

Expect resolution attempts to lead to more Expect resolution attempts to lead to more ruptures.ruptures.

Ongoing reflection-in-action.Ongoing reflection-in-action. Formulate one’s own experience while Formulate one’s own experience while

tracking patient’s reactions.tracking patient’s reactions.

Impasse resolution as change mechanism

Mother-infant developmental research Affect coordination & repair (Tronick,1987) Mothers & infants spend 30% of time with

matched affect Interactive repairs occur once every 3-5

seconds Functional vs. dysfunctional dyads

Clinical Example with BPD patient

Therapeutic Impasse Collapse of internal space “doer or done to position”

Therapist’s internal state as an instrument of change

Re-open internal space

Relevant state has something to do with:

Surrender “letting go” Self-acceptance Allowing and accepting one’s internal

experience, rather than fighting against it Accessing and acknowledging dissociated

self-states

Metacommunication works in part by Metacommunication works in part by helping therapist enter into a therapeutic helping therapist enter into a therapeutic state of mind through:state of mind through:

Helping him/her create internal space by Helping him/her create internal space by reflecting out loud about current transactionreflecting out loud about current transaction

Saying Saying ““unsayableunsayable”” An act of freedom (Neville Symington)An act of freedom (Neville Symington)

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Training DVDs

Safran, J.D. (2009). Psychoanalytic Therapy Over Time

http://www.apa.org/videos/4310864.html

Safran, J.D. (2008). Relational Psychotherapy

http://www.apa.org/videos/4310846.html

Safran, J.D. (2006). Resolving therapeutic impasses.

http://www.amazon.com

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