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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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.)