"Therapeutic alliance ruptures": common, very challenging & a key area for increasing therapist (and personal) helpfulness
Last updated on 12th October 2015
We had another of our small peer Emotion-Focused Therapy supervision/practice groups yesterday evening. Half a dozen of us were able to make it. We'd agreed we would look particularly at "therapeutic alliance ruptures" at this meeting. As a doctor, I can't help finding the term "alliance rupture" rather giggle-inducing. I have all kinds of pictures of unwanted extrusions, metaphorical trusses and possibly extreme interpersonal surgical cures.
The subject matter though is actually bloody important. We know that therapists vary a good deal in their effectiveness. As I've written in a whole series of blog posts, this doesn't seem well explained by training, experience, qualifications or therapy school. A key area however that appears to distinguish excellent therapists from good or average therapists is in their ability to deal with difficult, challenging interpersonal issues. The blog post "Emotion-focused therapy workshop series: client processes and therapist-client conflict" goes into all of this in considerable detail.
In that post I highlighted Michael Lambert's finding that "90% of therapists interviewed thought they were in the top 25% of effective therapists when compared with their peers ... and no therapist rated themselves as below average in effectiveness." While Kraus et al's paper "Therapist effectiveness: Implications for accountability and patient care" joins a series of other research publications to quite shockingly demonstrate how untrue these self-assessments are. Their paper's abstract reads "Significant therapist variability has been demonstrated in both psychotherapy outcomes and process (e.g., the working alliance). In an attempt to provide prevalence estimates of "effective" and "harmful" therapists, the outcomes of 6,960 patients seen by 696 therapists in the context of naturalistic treatment were analyzed across multiple symptom and functioning domains. Therapists were defined based on whether their average client reliably improved, worsened, or neither improved nor worsened. Results varied by domain with the widespread pervasiveness of unclassifiable/ineffective and harmful therapists ranging from 33 to 65%. Harmful therapists demonstrated large, negative treatment effect sizes (d = - 0.91 to - 1.49) while effective therapists demonstrated large, positive treatment effect sizes (d = 1.00 to 1.52)." Ow, ow, ow. This is scary.
We know that interpersonal skills are of major importance here - see, for example, Tim Anderson et al's paper "Therapist effects: facilitative interpersonal skills as a predictor of therapist success" with its abstract reading "This study examined sources of therapist effects in a sample of 25 therapists who saw 1,141 clients at a university counseling center. Clients completed the Outcome Questionnaire-45 (OQ-45) at each session. Therapists' facilitative interpersonal skills (FIS) were assessed with a performance task that measures therapists' interpersonal skills by rating therapist responses to video simulations of challenging client-therapist interactions. Therapists completed the Social Skills Inventory (SSI) and therapist demographic data (e.g., age, theoretical orientation) were available. To test for the presence of therapist effects and to examine the source(s) of these effects, data were analyzed with multilevel modeling. Of demographic predictor variables, only age accounted for therapist effects. The analysis with age, FIS, and SSI as predictors indicated that only FIS accounted for variance in outcomes suggesting that a portion of the variance in outcome between therapists is due to their ability to handle interpersonally challenging encounters with clients."
And as Jeremy Safran, a central figure in research on alliance ruptures, points out - these difficulties are common. Yes the florid client encounter where they end up telling me to "F*ck off" certainly occurs, but happily it's a fairly rare experience. Much more frequent are subtle ubiquitous experiences of emotional withdrawal (distancing interpersonally and/or disengaging from important aspects of intrapersonal experience). This seems to lead to loss of confidence in the therapy/therapist, poorer outcomes & increased chance of dropouts. As therapists we're not particularly good at spotting this stuff. Safran's university web page is an excellent resource here with a whole series of important freely downloadable research papers.
Robert Elliott says helpful things too from the EFT tradition - see the web document "Therapist negative reactions: a person-centered-experiential psychotherapy perspective" with (on pages 15 & 16) his interesting remarks about the potential value of group therapy in helping psychotherapists learn to operate better in this area. I've talked about this as well - writing in the post "The jazz trio metaphor: reworking the core conditions, relational depth, compassion, & two kinds of empathy" - "Gut stuff. Authentic gut stuff. As psychotherapists we can be surprisingly poor at navigating these internal emotional waters. This might be no surprise in cognitive-behaviourists, but my experience over the years is that it's not unusual for therapists of all persuasions to be daunted by moving deeply into feelings ... see, for example, "A quiet rant to group facilitators" and various posts discussing catharsis in peer group work. Much of the work on conflict is relevant here too as is "Is interpersonal group work better than sitting meditation for training mindfulness?" To be fair to CBT therapists though (and CBT approaches are a key aspect of my work), Safran found that cognitive therapy may be associated with fewer "ruptures" than more frankly interpersonal/psychodynamic approaches - see "The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders." But if the sh*t does hit the fan ... or if there is alliance dissonance in more minor ways ... then CBT therapists may do well to drop out of a more "technical approach" and attend very humanly to the threatened therapeutic relationship - see "Predicting the effect of cognitive therapy for depression: A study of unique and common factors."
I would also underline the value of regular in-session tracking of our therapeutic practice. Whipple & Lambert have written about this recently in their paper "Outcome measures for practice" and I am a fan of the freely downloadable Outcome & Session Rating Scales. For more on these measures, see my posts "On becoming a better therapist", "Client-directed, outcome-informed therapy" and "Psychotherapists & counsellors who don't monitor their outcomes are at risk of being both incompetent and potentially dangerous". See too the recently published book by Barkham & colleagues "Developing & delivering practice-based evidence".
At these peer supervision/practice groups we usually spend 50% or so of the meeting trying out the methods we have been discussing. It made good sense this evening to look at how we relate to each other in this group. We talked a bit about what interpersonal issues sometimes gets in the way of the group being as helpful as possible for all of us. Then we dipped down a bit deeper. A couple of days before I had had a fall-out with a friend who also comes to this peer group. We offered to work on this real life "rupture" in the group. Happily this somewhat "high wire" exploration worked out really well. So precious to feel into what's going on, listen, voice what's true, move forward. Precious and absolutely relevant to this whole area of working better with interpersonal difficulties. Louis Armstrong's song "Hello Brother" nudged into my mind intermittently as we talked. Very good.
And for more on this topic, see tomorrow's post "Therapeutic alliance ruptures/tensions: description, frequency, effects, causes, identification, responses & importance".