Commentary: Rupture repair as a transtheoretical corrective experience

Therapists' responsiveness in the process of ruptures and resolution: Are patients and therapists on the same page?

OBJECTIVE

This study examined the association between the rupture-repair process and patients' and therapists' perceptions of the therapist's responsiveness.

METHOD

We used the Rupture Resolution Rating System to rate early sessions (3-5) in 35 short-term psychodynamic psychotherapy cases. The patients and therapists rated their perceptions of the therapist's responsiveness after each session using the Patient's Experience of Attunement and Responsiveness (PEAR) Scale.

RESULTS

Therapists' contribution to ruptures was negatively associated with both patients' and therapists' PEAR ratings. Confrontation ruptures were negatively associated with patients' PEAR ratings, whereas there was no significant association with withdrawal ruptures. Resolution was positively associated with both patients' and therapists' PEAR ratings. In addition, resolution moderated the negative association between ruptures and patients' PEAR ratings.

CONCLUSION

The findings emphasize the link between therapists' responsiveness and the rupture-repair process. They also highlight the significance of providing therapists with the necessary training to recognize these dynamics and engage in discussions about them with their patients when appropriate.

The role of interpersonal coordination dynamics in alliance rupture and repair processes in psychotherapy-A systematic review

Introduction

The purpose of this systematic review is to expand our knowledge of the underlying mechanisms of the alliance in psychotherapy. This is done by examining the association between alliance rupture and repair processes and interpersonal coordination dynamics.

Method

A systematic review based on PRISMA guidelines was conducted, aimed at papers investigating the association between alliance rupture and repair episodes and different behavioral modalities (i.e., physiology, movement) in the psychotherapeutic interaction. Seventeen studies were included for full text-analysis.

Results

The results indicate that rupture and repair episodes were associated with interpersonal coordination dynamics. Different modalities (movement, heart rate, and vocalization) were found to serve as markers for alliance rupture and repair events. Facial expressions, physiological arousal, vocalization, and behavior were found to play important roles in the therapeutic interaction in relation to mutual emotion regulation, empathic response, safety, trust, and meaning-making.

Discussion

Limitations of this review are discussed, including the great methodological variation and selection bias observed in the reviewed studies. Recommendations for future research in this area are presented. Overall, interpersonal coordination dynamics was found to have the potential to help identify and manage alliance ruptures and foster repairs in the therapeutic interaction, which has high potential for future clinical work and training.

Moral Injury and Shame Mediate the Relationship Between Childhood Trauma and Borderline Personality Disorder, PTSD, and Complex PTSD Symptoms in Psychiatric Inpatients

Moral injury (MI) has received increased research attention in the past decades. However, despite its detrimental mental health consequences, MI has not been studied in psychiatric patients. We aimed to establish the relationship between childhood trauma, MI, and borderline personality disorder (BPD), posttraumatic stress disorder (PTSD), and disturbances in self-organization symptoms (DSO), a core diagnostic criterion of complex PTSD besides PTSD symptoms, and shame as a moral emotion in an inpatient psychiatric sample (N = 240). We found that the impact of childhood trauma on present BPD, PTSD, and DSO symptoms was mediated by MI and shame; the models accounted for up to 31% of variance in symptomatology. To our knowledge, this study is the first to investigate MI in a psychiatric sample, and our results highlight the importance of considering MI as a critical factor of patient experiences in relation to childhood trauma that potentially contributes to the development of psychiatric symptoms.

Exploring the processes of connection and disconnection in imagery work in a patient with depression and dependent personality disorder

Imagery work is a useful therapeutic tool in the treatment of depression. It is central in different therapeutic approaches, such as cognitive behavioral therapy and compassion-focused therapy. The clinical case of Cynthia is presented. Cynthia started therapy for severe depression associated with social anxiety and dependent personality disorder. At different key moments in the therapy, the proposed change strategies led to ruptures in the therapeutic alliance. For example, difficulties in accepting depression, fears of being judged by the therapist, guided imagery of compassion and work on the termination of therapy were both triggers of ruptures and spaces for working on the issues linked to the therapeutic relationship. The interactions between different factors of the therapeutic relationship from the perspectives of both the patient and therapist and the implementation of imagery practices in session are presented.

How does hostile resistance interfere with the benefits of cognitive-behavioral therapy for panic disorder? The role of therapist adherence and working alliance

Objective Although clients' hostile behavior directed at therapists (hostile resistance) predicts worse outcomes in cognitive-behavioral therapy (CBT) for panic disorder, the process by which this happens remains unknown. This study examines two putative mechanisms: working alliance and therapist adherence. Method: Seventy-one adults with primary panic disorder received CBT in a larger trial. Hostile resistance and adherence in Sessions 2 and 10 were reliably coded using observer-rated measures; client- and therapist-rated questionnaires assessed working alliance. Outcome measures were attrition and symptomatic improvement, assessed at multiple timepoints with the Panic Disorder Severity Scale. Results: Hostile resistance was significantly related to both preexisting (r  = -.36, p  =  .04) and subsequent declines (r  = -.58, p  <  .0001) in the working alliance. Nevertheless, hierarchical linear modeling revealed that neither a declining alliance nor therapist adherence (whether treated as linear or curvilinear) was independently predictive of symptom change, nor did these factors mediate hostile resistance's association with worse symptomatic improvement. Exploratory logistic regressions similarly indicated that neither adherence nor alliance moderated whether hostilely resistant clients dropped out. Conclusion: This is the first study to establish a bidirectional association between hostile resistance and a declining working alliance. Findings also add to a mixed literature on the adherence-outcome relationship.

Within-patient perceptions of alliance and attunement: Associations with progress in psychotherapy

The most frequently examined aspect of the therapeutic relationship is the working alliance, which reflects the conscious collaborative bond, and agreement on task and goal. In addition to the established importance of the working alliance, the therapists' attunement and responsiveness might reflect another important aspect of the therapeutic relationship that can be considered in relation to session-by-session progress over treatments. Emerging research suggests that the quality of the working alliance not only differs between patients but also within patients over time. However, little is known about the quality of the therapeutic relationship between and within patients in relation to progress in psychotherapy. We examined fluctuations of the working alliance measure (WAI) and the newly developed measure of the Patients' Experiences of Attunement and Responsiveness (PEAR) during treatment in a naturalistic sample of patients in an outpatient psychotherapy clinic. Multilevel modelling was used to examine the respective contribution of these measures to subsequent improvement in psychological functioning longitudinally. Results suggest that the within-patient effect, instead of between-patient effect, was significant for WAI (and did not reach significance for PEAR), indicating that the fluctuation of WAI was predictive of psychological functioning in the subsequent month. Based on these findings, therapists and their patients might benefit from regular tracking of the patient-reported working alliance. The findings underscore the importance of the alliance, specifically at the within-patient level. It also highlights the challenge for research to tap into other aspects of the therapeutic relationship that can help explain progress in therapy. Given the breadth and accessibility of the working alliance construct, more work is needed for researchers to examine the construct of attunement and responsiveness.

The beginning of the end: A comparison of treatment completers and early dropouts in trainee-provided time-limited Cognitive Behavioral Therapy

About one in five clients drops out of treatment prematurely. Premature termination has been found to correlate with patient, therapist, and treatment factors, as well as complex interpersonal processes, including ruptures in the therapeutic alliance. This study examines the therapeutic alliance using a qualitative approach to patient-, therapist-, and observer-based data. The sample includes five trainee therapists, each of whom worked with one patient who terminated after the first or second session, and one who completed a cognitive-behavioral therapy protocol. The session(s) preceding premature termination in the drop case and the corresponding session(s) in the completer case were examined. Rupture resolution process was prevalent in both groups, though confrontation ruptures seemed more prevalent with completers and withdrawal ruptures were more clinically impactful with dropouts. Therapist awareness of process and responsiveness or contribution to rupture were identified as potential factors contributing to patient retention.

Treating intimate partner violence with metacognitive interpersonal therapy: The case of Aaron

Intimate partner violence (IPV) is responsible for loss of lives and significant psychological, financial, and social costs. Research into therapeutic effectiveness show inconsistent results irrespective of therapeutic orientation. The capacity to understand one's own mental states as subjective and distinct from others is an important factor in the regulation of mental states and physiological arousal associated with the perpetration of IPV. Metacognitive Interpersonal Therapy (MIT) offers an innovative approach in working with male perpetrators of IPV. The current paper outlines 14 sessions of MIT with a 45-year-old male perpetrator. A core aspect was helping the client resolve how his view of self and others were subjective experiences that were distinct from relational objectivity. The emergence of healthy self-narratives was fostered through experiential processes, involving guided imagery, rescripting and body focused interventions. Qualitative outcomes are summarized and implications for the use of MIT in treatment of perpetrators of IPV is discussed.

Challenging rigidity in Anorexia (treatment, training and supervision): questioning manual adherence in the face of complexity

BACKGROUND

Anorexia Nervosa is a debilitating illness. While there have been many advancements to treatment protocols and outcomes for people with eating disorders, the field acknowledges there remains considerable room for improvement. This timely Special Edition of the Journal of Eating Disorders has invited those of us in the field to consider a range of topics in aid of this task, including potential modifications and implementation of evidence-based practice, specific and common psychotherapy factors, treatment manuals, adherence and individualising treatment approaches for individuals and families. BODY: In this paper, we briefly outline the key manualised treatments currently available to treat children, adolescents and adults with Anorexia Nervosa, considering the benefits, potential reasons for adaptations and limitations. We then review the current evidence for training strict adherence to treatment manuals which is often a key focus in training and supervision, questioning the association of increased treatment adherence with improved therapeutic outcome. We then summarise some key evidence behind other therapeutic factors which have been demonstrated to affect outcome regardless of which manual is implemented, such as readiness to change and therapeutic alliance.

CONCLUSION

The paper concludes with implications and considerations for future research, clinical guidelines, training and supervision, highlighting the need to consider the therapeutic relationship and processes alongside manual content to conduct best evidence-informed practice.

Metacognitive reflection and insight therapy in an inpatient setting: Transforming messianism to a coherent mission

Metacognitive reflection and insight therapy (MERIT) is an integrative form of psychotherapy which seeks to help adults with serious mental illness make sense of the psychosocial challenges and possibilities they face and decide how to respond to them and direct their own recovery. In this article, we present an adaptation of MERIT to the context of an inpatient ward with an accompanied case illustration. Specifically, we describe how this approach is supported by a broad intersubjective framework, followed by a presentation of processes and contents of the treatment. Special attention is given to the concurrent improvements in reflective abilities and overall well-being of the patient. The unique role that psychotherapy in general, and approaches that emphasize reflective processes in particular, play during acute crises in an inpatient setting is discussed.

Incorporating narrative repair in the treatment of avoidant personality disorders: A case in point

Avoidant personality disorder (AvPD) is characterized by multiple struggles, including shyness, feelings of inadequacy, and hypersensitivity to interpersonal judgments. Research indicates that people with AvPD also show disturbances in narrative identity, which is an internal and evolving story created about the personal past, present, and presumed future. Here, the novel Guide for Narrative Repair (GNaR) recently developed by (Thomsen et al., 2020) is introduced as a potentially useful tool to help people with AvPD in crafting more adaptive narrative identities. The guide is brought to life via a case study analysis of Adam, a male outpatient suffering from AvPD. Consistent with the GNaR, disturbances in Adam's storied self are brought to light and ways to facilitate his narrative repair are proposed. We conclude with implications related to the case as well as the potential narrative turn in AvPD treatment.

Working with social withdrawal, or hikikomori, in Japan: From shame to pride

The term hikikomori, or social withdrawal, was first coined in the late 1980s in Japan to describe adolescents and young adults who isolated themselves at home, withdrew from most social engagement, such as work or school, and had almost no relationships with others (except family members and online contacts) for longer than 6 months. Hikikomori often results from emotional injuries such as rejection, or failures that have not been addressed or even noticed. In the current case illustration, the problem of hikikomori is depicted through a client named Ken, a 40-year-old single man who, following graduation from university, became lodged in a 15-year cycle of repeatedly finding employment, quitting within the first year, and going into reclusive isolation. Ken underwent affect-oriented integrative psychotherapy for 4 years. The importance of processing emotional pain and highlighting positive emotional experiences to build a positive sense of self in working with hikikomori will also be discussed.