The impact of alliance-focused and facilitative interpersonal relationship training on therapist skills: An RCT of brief training.

Research on standard methods of therapist training has found mixed evidence to as to whether standard training methods are effective. This study investigated the impact of a novel, research-informed training protocol that integrated elements of alliance-focused training (AFT) and facilitative interpersonal skills (FIS). Beyond traditional training techniques of didactics and lecture, the AFT/FIS intervention incorporated empirically supported video simulations of therapy, which were reinforced by role plays and deliberate practice on key therapeutic interpersonal skills.

Rupture Resolution Rating System (3RS): Development and validation.

Objective: Our aim was to examine the reliability and validity of the Rupture Resolution Rating System (3RS), an observer-based measure of alliance ruptures and resolution processes.

Method: We used the 3RS to rate early sessions from 42 cases of cognitive behavior therapy. We compared the 3RS to a simplified version of the Structural Analysis of Social Behavior (SASB), as well as patient and therapist self-reports of ruptures and the alliance.

Alliance rupture repair: A meta-analysis.

A rupture is a deterioration in the therapeutic alliance, manifested by a disagreement between the patient and therapist on treatment goals, a lack of collaboration on therapeutic tasks, or a strain in their emotional bond. We present the most frequently used measures of alliance ruptures and clinical examples to illustrate their repair. To examine the relation of rupture repairs to outcome, and the impact of rupture resolution training on outcome, we conducted two meta-analyses.

A therapist version of the Alliance Negotiation Scale.

The aim of the current study was to design and evaluate a therapist version of the Alliance Negotiation Scale (ANS). The ANS was created in order to operationalize the construct of dyadic negotiation in psychotherapy and to augment existing conceptualizations of the working alliance. The ANS has existed only as a client self-report form since its inception and has demonstrated promise as a psychotherapy process measure.

Resolving Alliance Ruptures from an Attachment-Informed Perspective.

In this article, we examine how the different attachment patterns enable or hinder the resolution of ruptures in the therapeutic alliance. We try to show that secure and insecure patients alike may experience ruptures in the therapeutic alliance, but that their ability to participate in such ruptures differ markedly. Recent findings with the Patient Attachment Coding System (PACS) show that attachment classifications manifest in psychotherapy as distinct ways of communicating about present internal experience.

When therapist estimations of the process of treatment can predict patients rating on outcome: The case of the working alliance.

Objective: It has been demonstrated that patient perspective on alliance can predict subsequent treatment outcome as reported by the therapist but not the other way around. This study aimed to investigate the circumstances in which therapists can provide estimations of alliance capable of predicting patient perceptions of subsequent session outcome. The study focused on 2 potential indicators: time in treatment and treatment efficacy.

The effect of alliance-focused training on a cognitive-behavioral therapy for personality disorders.

Objective: To improve success rates in psychotherapy, we developed and evaluated an alliance-focused training (AFT) protocol with regard to patient-therapist interpersonal behavior in a 30-session protocol of cognitive-behavioral therapy (CBT) for outpatients comorbid with Axis I and II conditions.

Method: Participants included 40 patients treated by 40 therapists in a multiple baseline design in which novice therapists trained to fidelity standards in CBT were introduced to AFT at different time intervals (after either 8 or 16 sessions) during a 30-session CBT protocol. Interpersonal behaviors were assessed with a simplified version of the Structural Analysis of Social Behavior (SASB) on videotaped sessions sampled from the early (between Sessions 6 through 8), mid (Sessions 14 through 16), and late (Sessions 22 through 24) phases of therapy.

Mentalizing in the presence of another: Measuring reflective functioning and attachment in the therapy process.

In this paper, we test the reliability and validity of two novel ways of assessing mentalizing in the therapy context: the Reflective Functioning scale (RF) applied to code psychotherapy transcripts (In-session RF), and the Exploring scale of the Patient Attachment Coding System (PACS), which measures in-session autonomy and is linked with secure attachment in psychotherapy. Before treatment, 160 patients in different types of psychotherapy and from three different countries were administered the Adult Attachment Interview (AAI), which was rated with the RF scale. One early psychotherapy session for each patient was independently rated with the In-session RF scale and with the PACS Exploring scale.

A comparison of pre-dropout and temporary rupture sessions in psychotherapy.

Unlabelled: Although numerous studies have investigated the relationship between the therapeutic alliance and dropout, most have focused on the relationship between alliance quality and psychotherapy outcomes.

Objective: To compare sessions with therapeutic alliance ruptures and two sessions prior to treatment dropout (pre-dropout) in terms of rupture subtypes, psychotherapists' behavior, attitudes, and session content.

Method: We implemented quantitative methods to select the sessions and qualitative methods to analyze them.

An Investigation of the Relationship Between the Alliance Negotiation Scale and Psychotherapy Process and Outcome.

Objective: This study examines the validity of the Alliance Negotiation Scale (ANS) in a psychotherapy research program. Analyses were designed to evaluate the relationship between the ANS and psychotherapy process and outcome variables.

Method: Data were collected in a metropolitan psychotherapy research program.

The relationship between alliance and outcome: Analysis of a two-person perspective on alliance and session outcome.

Objective: Better alliance is known to predict better psychotherapy outcomes, but the interdependent and interactive effects of both therapist- and patient-reported alliance levels have yet to be systematically investigated.

Method: Using actor-partner interdependence model analysis the authors estimated actor, partner, and 2 types of interactive effects of alliance on session outcome in a sample of 241 patient-therapist dyads across 30 sessions of cognitive-behavioral and alliance-focused therapy.

Results: Findings suggest that the most robust predictors of session outcome are within-treatment changes in patient reports of the alliance, which predict both patient and therapist report on outcome.

The Alliance Negotiation Scale: A psychometric investigation.

This study investigates the utility and psychometric properties of a new measure of psychotherapy process, the Alliance Negotiation Scale (ANS; Doran, Safran, Waizmann, Bolger, & Muran, 2012). The ANS was designed to operationalize the theoretical construct of negotiation (Safran & Muran, 2000), and to extend our current understanding of the working alliance concept (Bordin, 1979). The ANS was also intended to improve upon existing measures such as the Working Alliance Inventory (WAI; Horvath & Greenberg, 1986, 1989) and its short form (WAI-S; Tracey & Kokotovic, 1989) by expanding the emphasis on negative therapy process.

Alliance-focused training.

Alliance-focused training (AFT) aims to increase therapists' ability to recognize, tolerate, and negotiate alliance ruptures by increasing the therapeutic skills of self-awareness, affect regulation, and interpersonal sensitivity. In AFT, therapists are encouraged to draw on these skills when metacommunicating about ruptures with patients. In this article, we present the 3 main supervisory tasks of AFT: videotape analysis of rupture moments, awareness-oriented role-plays, and mindfulness training.

Alliance ruptures, impasses, and enactments: a relational perspective.

Alliance ruptures, impasses, and transference-countertransference enactments are inevitable in therapy. A growing body of evidence suggests that repairing ruptures in the alliance is related to positive outcome (Safran, Muran, & Eubanks-Carter, 2011). Our research program has led to the development of training methods to enhance therapists' abilities to detect and work constructively with alliance ruptures and negative therapeutic process (Safran et al.

AAI predicts patients' in-session interpersonal behavior and discourse: a "move to the level of the relation" for attachment-informed psychotherapy research.

There is currently little empirical evidence regarding how patients' attachment patterns manifest in individual psychotherapy. This study compared the in-session discourse of patients classified secure, dismissing, and preoccupied on the Adult Attachment Interview (AAI). Rather than focusing on content or form alone, this study analyzed how patients' discourse elicits and maintains emotional proximity with the therapist.

Windows into clients' perspectives on psychotherapy.

In this brief discussion I highlight some dimensions of Angus and Kagan's (2013); Olivera, Braun, Gomez Penedo, and Roussos (2013); and Jock, Bolger, Olivera, and Roussos (2013) articles that are of particular interest to me. Reading their articles has served as a catalyst for me to reflect at a more general level on the state of the art of qualitative methods in psychotherapy research, and to articulate some informal reflections about qualitative research.

Personality disorder and early therapeutic alliance in two time-limited therapies.

This study examined the relationship of pre-treatment personality disorder diagnosis to the quality of early therapeutic alliance in 145 patients randomly assigned to either cognitive behavioral therapy or brief relational therapy. The pre-treatment diagnosis was established by DSM-IV (SCID) and Wisconsin Personality Inventory. Quality of the alliance was assessed by patient and therapist reports using the 12-item Working Alliance Inventory, Session Evaluation Questionnaire, and direct questions of ruptures.

Comparing two methods of identifying alliance rupture events.

This study compared two methods of detecting ruptures in therapy sessions, a procedure based on a self-report measure, the Working Alliance Inventory (WAI), and an observational Rupture Resolution Rating System (3RS). We anticipated that the 3RS would detect more ruptures than the WAI. We examined the longitudinal data of 38 patient-therapist dyads in a cognitive-behavioral therapy condition.

The alliance negotiation scale: psychometric construction and preliminary reliability and validity analysis.

Current measures of the working alliance tend to emphasize the degree of agreement or collaboration between patient and therapist about therapeutic tasks and goals. There are, however, both theoretical and empirical grounds to suggest that the degree to which patient and therapist are able to constructively negotiate disagreements about tasks and goals is another important dimension of the alliance. The present study outlines the preliminary development and evaluation of a measure to operationalize this dimension.

Therapist mindfulness, alliance and treatment outcome.

The present study investigated the association between therapist dispositional mindfulness and therapist self-affiliation, the therapeutic alliance, and treatment outcome. Total therapist mindfulness was associated with therapist self-affiliation, r=.413, p<.

Repairing alliance ruptures.

In this article, we review the existing empirical research on the topic of therapeutic alliance ruptures in psychotherapy. Ruptures in the therapeutic alliance are defined as episodes of tension or breakdown in the collaborative relationship between patient and therapist. Two meta-analyses were conducted.

Impact of therapist emotional intelligence on psychotherapy.

The concept of emotional intelligence (EI) describes a set of emotional skills that may comprise efficacious therapist variables. The present study is the first to investigate EI among psychotherapists. Based on conceptual overlaps between the EI model and psychotherapy models, as well as a review of empirical evidence from both literatures, we make several predictions of how therapist EI impacts treatment.

The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders.

This study examined the relationship of early alliance ruptures and their resolution to process and outcome in a sample of 128 patients randomly assigned to 1 of 3 time-limited psychotherapies for personality disorders: cognitive-behavioral therapy, brief relational therapy, or short-term dynamic psychotherapy. Rupture intensity and resolution were assessed by patient- and therapist-report after each of the first 6 sessions. Results indicated that lower rupture intensity and higher rupture resolution were associated with better ratings of the alliance and session quality.

Evaluating negative process: a comparison of working alliance, interpersonal behavior, and narrative coherency among three psychotherapy outcome conditions.

The aim of this study was to investigate the interrelationships of three measures of the therapeutic relationship and their validity in predicting treatment outcome, including the early identification of two treatment-failure conditions. Forty-eight patient-therapist dyads, in 30-session therapies for personality-disordered patients, were classified as premature dropout (DO), poor outcome (PO), or good outcome (GO) cases. Poor and Good Outcomes were determined by a reliable change score.