Intervention and impact: An examination of treatment adherence, therapeutic. alliance, and outcome in cognitive therapy. Kelcey Jane Stratton

Transcription

1 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

2 UMI Number: All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent on the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. UMI Copyright 2011 by ProQuest LLC. All rights reserved. This edition of the work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, MI

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4 2011 Kelcey Stratton

5 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.

6 v Table of Contents Acknowledgements... List of Tables..... List of Figures List of Appendices..... iv vii ix x Part I: Literature Review Introduction 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 Part II: Empirical Article Introduction Purpose of the Current Study Research Hypotheses Methods and Procedures 36 Treatment Conditions Participants Data Selection Procedure 42 Instruments

7 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 References Appendices.. 86

8 vii List of Tables Table 1: Mean Differences and Standard Deviations on Measures of Therapeutic Alliance and Session Tension in Treatment Group Conditions 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 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) Table 7: Intercorrelations Between Measures of Treatment Adherence and Therapeutic Alliance, Session Outcome, and Rupture Intensity: Second Case, No Rupture Session (N=21)... 58

9 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

10 ix List of Figures Figure 1: Interaction of Treatment Type Adherence and Time... 53

11 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

12 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.

13 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.

14 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).

15 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 wellestablished/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

16 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 welltrained 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

17 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

18 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

19 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

20 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

21 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

22 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,

23 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

24 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 therapistpatient 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,

25 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

26 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

27 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

28 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

29 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 manualbased 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.

30 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

31 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

32 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 personalitydisordered 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

33 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

34 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.

35 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;

36 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 welltrained therapists can be subject to negative and idiosyncratic interactions with patients. Psychotherapy, despite its rigorous empirical tradition, remains a deeply human practice.

37 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

38 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

39 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

40 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

41 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 manualbased 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

42 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

43 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

44 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 comorbid 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 comorbid 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

45 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.

46 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

47 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

48 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, anticonvulsant, 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

49 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 selfschema. CBT attempts to explore and challenge the negative emotions and dysfunctional

50 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

51 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.

52 41 Therapist Demographics: At the time of their first training case, the therapists were 1 st year Clinical Psychology PhD students (N=18, 85.7%) and 3 rd 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 4 th 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.

53 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 selfreport 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.

54 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

55 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

56 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

57 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

58 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).

59 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

60 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. 1 st 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) (0.85) 5.48 (0. 86) Therapist WAI Patient SEQ Smoothness 3.79 (0.56)** 4.28 (0.94)** (0.53)* 4.48 (1.03)* (1.15)** 5.21 (1.06)** (1.27) 5.04 (1.41) Therapist SEQ Smoothness 4.56 (0.68)** 4.91 (0.62)** (0.72)* 4.71 (0.72)* SEQ=Session Evaluation 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 The ANOVA had three factors: a within-treatment factor and two betweentreatment factors. The within-treatment factor had 4 levels corresponding to the

61 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 No-Rupture Early (N=21) Late (N=21) 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

62 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.

63 52 Table 3: Analysis of Variance for Treatment Condition to Treatment Type Adherence. Source df Mean Square F Between-Subjects Pillai's trace Rupture p Time Rupture X Time Error Within-Subjects Treatment Type Adherence (TT) ** TT X Rupture TT X Time * TT X Rupture X Time Error 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

64 53 significant interaction between treatment type adherence, rupture condition, and time condition. Figure 1: Interaction of Treatment Type Adherence and Time Adherence Score First Case Mean Sessions Early Sessions Second Case Mean Late Sessions Sessions 0 BAP CBT BRT Non Treatment Type 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 productmoment correlations was performed between treatment adherence to each of the four

65 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

66 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 * 0.05 Pt SEQ-Smooth Pt SEQ-Deep Pt Session Helpful 0.52* * 0.16 Pt Problem Resolved * Pt Intensity of Rupture * Th WAI * Th SEQ-Smooth Th SEQ-Deep * * Th Session Helpful Th Problem Resolved Th Intensity of Rupture ** WAI= Working Alliance Inventory; SEQ= Session Evaluation Questionnaire *p<.05 **p<.01

67 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 Pt SEQ-Smooth Pt SEQ-Deep Pt Session Helpful * -0.47* 0.31 Pt Problem Resolved Pt Intensity of Rupture Th WAI * * Th SEQ-Smooth Th SEQ-Deep Th Session Helpful * Th Problem Resolved 0.48* 0.48* Th Intensity of Rupture 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

68 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 Pt SEQ-Smooth * Pt SEQ-Deep Pt Session Helpful Pt Problem Resolved Pt Intensity of Rupture Th WAI Th SEQ-Smooth * Th SEQ-Deep Th Session Helpful Th Problem Resolved * Th Intensity of Rupture WAI= Working Alliance Inventory; SEQ= Session Evaluation Questionnaire *p<.05 **p<.01

69 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 Pt SEQ-Smooth Pt SEQ-Deep Pt Session Helpful Pt Problem Resolved Pt Intensity of Rupture Th WAI Th SEQ-Smooth Th SEQ-Deep Th Session Helpful Th Problem Resolved Th Intensity of Rupture 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

70 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

71 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. N=21 BAP CBT BRT Non First Case Z Z Z Z WAI **.398 SEQ-Smooth SEQ-Deep Session Helpful Problem Resolved * ** * Intensity of Rupture Second Case Z Z Z Z WAI SEQ-Smooth SEQ-Deep Session Helpful Problem Resolved Intensity of Rupture * WAI= Working Alliance Inventory; SEQ= Session Evaluation Questionnaire *p<.05 **p<.01

72 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 1 st Case, No Rupture Session 2 nd Case, Rupture Session 2 nd 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* 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

73 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

74 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

75 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

76 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 norupture 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

77 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

78 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-

79 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.

80 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

81 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 norupture 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

82 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.

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97 86 APPENDIX A

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99 88