Last updated on 12th October 2015
I wrote a blog post yesterday entitled "Therapeutic alliance ruptures: common, very challenging & a key area for increasing therapist (and personal) helpfulness". I think this area is so important that I'd like to spend additional time exploring it more thoroughly.
I want to clarify what we mean by an "alliance rupture", try to quantify how frequent they are, look at what causes them to occur, discuss the effects they produce, consider how we could get better at identifying them, lay out the kinds of therapist responses that may best lead to rupture repair, and highlight why this whole topic looks central to the "holy grail" challenge of making therapy more helpful. OK, this is quite a big ask, so in today's post I'll aim to discuss alliance rupture "description, frequency, causes & effects" and in tomorrow's post "identification, responses & importance."
So firstly, what do we mean by the term "alliance rupture"? In their excellent paper "Repairing alliance ruptures", Safran & colleagues helpfully define ruptures in the following way: "A rupture in the therapeutic alliance can be defined as a tension or breakdown in the collaborative relationship between patient and therapist." They go on to highlight "Although the term rupture may imply, to some, a dramatic breakdown in collaboration, ruptures vary in intensity from relatively minor tensions, which one or both of the participants may be only vaguely aware of, to major breakdowns in collaboration, understanding, or communication." I personally find the label "alliance tension" rather more helpful than the often over-dramatic "alliance rupture". It helps alert me to the fairly hidden nature of probably most of these difficulties.
How frequent are significant "alliance tensions" in the collaborative relationship between patient and therapist? Unsurprisingly, the answer to this question varies a good deal with who you ask. So, in general, clients report fewer significant tensions than therapists do. This may in part be because clients & therapists are using different "scoring systems" when assessing the therapeutic alliance. Therapists may well compare the current therapeutic relationship with some kind of ideal model of what a "perfect" therapist-client relationship "should" look like. An example here would be the well know Rogerian therapeutic "conditions" that counsellors are encouraged to try to provide for their clients involving high levels of authenticity, empathy and "unconditional positive regard". The client, in contrast, may be comparing the therapeutic relationship with what may well be somewhat dysfunctional relationships in other areas of their lives. Quite possibly too, clients may feel concerned that voicing criticisms about the alliance with their therapist may anger, upset or distance the very person they are hoping to get help from. So clients may also swallow their dissatisfaction rather than make it public. Certainly this tendency for clients to give a rather rosy view of the patient-helping professional relationship extends beyond psychotherapy to other fields of health care as well - see, for example, the recent British Medical Journal article "Are measures of patient satisfaction hopelessly flawed?".
Safran et al highlight that alliance ruptures/tensions (of a severity to impact on eventual outcome) are common. Greater intensity of tension predicts poorer eventual client therapeutic outcome, and failure to resolve alliance tension risks subsequent dropout. Note that in a 2013 meta-analysis of 34 nonrandomized effectiveness studies on outpatient individual and group CBT for adult unipolar depressive disorder in routine clinical practice, the authors found a dropout rate of approximately 25% of clients. They commented "The considerable treatment dropout rate, especially in individual CBT, must be improved." And it's important to note that CBT may actually have less problems with alliance tensions than some other forms of psychotherapy - see "The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders."
Saxon, D. and M. Barkham (2012). "Patterns of therapist variability: Therapist effects and the contribution of patient severity and risk." J Consult Clin Psychol 80(4): 535-546. OBJECTIVE: To investigate the size of therapist effects using multilevel modeling (MLM), to compare the outcomes of therapists identified as above and below average, and to consider how key variables--in particular patient severity and risk and therapist caseload--contribute to therapist variability and outcomes. METHOD: We used a large practice-based data set comprising patients referred to the U.K.'s National Health Service primary care counseling and psychological therapy services between 2000 and 2008. Patients were included if they had received >/=2 sessions of 1-to-1 therapy (including an assessment), had a planned ending to treatment, and completed the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM; Barkham et al., 2001; Barkham, Mellor-Clark, Connell, & Cahill, 2006; Evans et al., 2002) at pre- and post-treatment. The study sample comprised 119 therapists and 10,786 patients, whose mean age was 42.1 years (71.5% were female). MLM, including Markov chain Monte Carlo procedures, was used to derive estimates to produce therapist effects and to analyze therapist variability. RESULTS: The model yielded a therapist effect of 6.6% for average patient severity, but it ranged from 1% to 10% as patient non-risk scores increased. Recovery rates for individual therapists ranged from 23.5% to 95.6%, and greater patient severity and greater levels of aggregated patient risk in a therapist's caseload were associated with poorer outcomes. CONCLUSIONS: The size of therapist effect was similar to those found elsewhere, but the effect was greater for more severe patients. Differences in patient outcomes between those therapists identified as above or below average were large, and greater therapist risk caseload, rather than non-risk caseload, was associated with poorer patient outcomes.
More to follow ...