Alliance Brief

8/16/2019 Alliance Brief

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Levels and Pat terns of the Therapeutic

Alliance

in

Brief Psychotherapy

CHRISTOPHER L. STEVENS, Ph.D.*

J. CHRISTOPHER MURAN, Ph.D.*

JEREMY D. SAFRAN, Ph.D.

BERNARD S. GORMAN, Ph.D.f .. •

ARNOLD WINSTON, M.D.*

We examined the relevance of the level and pattern of the therapeutic

alliance in 44 cases of three different manualized 30-session treatments

using patient

r tings

of the Working Alliance Inventory after

e ch

session. It

was hypothesized that bo th high-alliance level and either linear incre se in

alliance rating or a series of hrief rupture-and-repair episodes would be

found

in

successful treatments.

We

also hypothesized that

a

more global

high-low-high pattern predicted

in tbe

literature would

not be

present.

Consistent with the literature higher lli nce levels were found to be related

to improved

outcome. As

predicted,

we

did not find

glohal, high-low-high

pattern. Local rupture-and-repair patterns were found in 30 of the cases;

linear trends were found in 66 of the cases. There was no relationship

between outcome

and

either pattern.

We

found

no

differences among

the

treatments.

LEVEL PATTERN OF THE THER APEUT IC ALLL^NCE IN BRIEF

PSYCHOTHERAPY

Although findings that a strong, positive therapeutic alliance is related

to positive treatment outcome has been quite consistent, (Horvath and

Symonds, 1991; Martin, Garske, & Davis, 2000) the exact nature of this

relationship has remained less clear. As a result, clinical theorists and

researchers have increasingly turned their attention to determining how

the alliance functions to foster change. For example, some (e.g., Raue &

*Beth Israel Medical Center

and

Alben Einstein College

of

Med icine, New School

for

Social


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AMERICAN JOURNAL O F PSYCH OTHER APY

Goldfrie d, 1994; Beck, 1995) believe that the alliance serves prim arily as a

static foundation for the application of curative techniques, while others

(e.g., Bo rdin, 1979, 1994; Safran M ura n, 2000) believe that the alliance

is an active agent of the change process in its own right. Many of these

authors have theorized that the way in which the alliance develops over

time can give important information about how this takes place. More

specifically, they hypothesized that working through conflicts or strains in

the alliance leads to positive change and that the variability in the alliance

ratings, indicating these periods of strain, could be a pre dictor of impro ved

outcome.

Much of this research can be characterized as a search for global shifts

in the alliance over the course of treatme nt. Researchers, influenced in pa rt

by Mann (1973), suggested that alliance developm ent goes throu gh a series

of changes as patients react to the shifting techniques of the therapist, (e.g.

Ge lso Ca rter 1985, 1994; H orv ath Lub orsky, 1993, Kivlighan

Shaughnessy, 1995, 200 0). Specifically, resea rchers posit that th e alliance

will proceed through three distinct phases. According to this model, the

alliance is characterized by an initial period of high hope fostered by

supportive alliance-building activity by the therapist. During the next

phase of treatm ent, the patient realizes that all expectations will not be m et

and increasingly challenges therapist activity, which leads to growing

ambivalence, resistance, and greater strain on the alliance. Finally, in

successful treatment, patients gain a more realistic understanding of the

therapist's role and accept change and the limitations of therapy, which is

brought about (at least in part) by the therapist's focus on working through

and termination. This process may be perceived as following a high-low-

high pattern of alliance development.

A number of studies tried to demonstrate this global high-low-high

pa ttern with mixed results (Bernard, Schw artz, Ocaltis Stiner, 1980;

G olden Rob bins, 1990; H orvath M arx, 1991; Joyce an d P iper 1990;

Kivlighan Shaughnessy, 2000; Pa tton , Kivlighan M ulton , 1997;

Schwartz and B ernard,

1981;

and Tracey, 1989). Th e most com pelling case

for a high-low-high pattern comes from KivHghan and Shaughnessy

(2000). They noted that as a result of the statistical procedures used, both

their 1995 study and the study by Patton, Kivlighan, and Multon (1997)

were unable to detect possible subgroups of alliance development. As a


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Alliance Level and Pattem

come. They used novice counselors and recruited subjects for a 4-session,

short-term dynamic therapy. Analysis of their initial sample of 38 clients

showed three distinct patterns of alliance development, which they iden-

tified as stable alliance, linear alliance growth, and quadratic alliance

growth. A subsequent replication sample of 41 clients identified the same

three p attern s. In add ition, this analysis of the results of the second sample

showed that clients reporting a quadratic pattern of alliance development

had greater improvement on outcome measures compared to other pat-

terns of development.

Although the results offer the strongest support to date of a rupture-

and-repair process, there are several significant limitations to this study.

The stated goal of the study was to examine patterns of global alliance

development, but such a brief treatment is a significant shortcoming. First,

it seems unlikely that any of the stages that Mann described had time to

develop. Similarly, Horvath and Luborsky's (1993) model also suggested

that the alliance-building phase of treatment would take place over the

first five sessions, peaking at session three. With only four sessions of

treatment, it is impossible to determine if the changes observed were

related to those that might be seen in longer treatment. Second, with only

four sessions, there are otily 16 potential patterns that could develop,

several of which could be interpreted as high-low-high, stable, or linear

improvement. Since Kivlighan and Shaugnessy found three different pat-

terns, it might be more important to ask which patterns did not emerge.

And finally, it is impossible to distinguish between discrete or transient

changes in alliance and more global dynamics.

Although, taken as a group, these studies seem to provide support for

the notion of a global high-low-high process, all suffered from significant

limitations. Sample sizes were small or not representative of clinical

pop ulation s (Tracy, 1989; G old en Robb ins, 1990). The training and

exp erien ce of the therapis ts involved was limited (Kivlighan Shaugh-

nessy, 1995, 2000 ; Pa tton et al., 1997). Tre atm ent length was inconsistent

(Bernard et al. 1980; Bernard and Schwartz, 1981) or extremely brief

(Kivlighan Shaughnessy, 2000). Add itionally, the statistical m ethod s

used were not appropriate for detecting patterns that might exist among

subg roup s of patien ts (Tracy, 1989; G old en Robb ins, 1990; Kivlighan

Shaughnessy, 1995; Patton et al., 1997). These limitations raise the ques-


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A M E R IC A N J O U R N A L O F P S Y C H O T H E R A P Y

A review of the literature to date suggests that there is moderate

support for the notion that variability increases in the midphase of

treatment (Bernard, Schwartz, Ocaltis and Stiner, 1980; Schwartz and

Bernard, 1981). Similarly, there is some initial support for the notion that

undergoing a rupture and repair process is related to improved outcome

(Form an M arm ar, 1985; Lansford, 1986; G olde n Robb ins, 1990;

H orva th M arx, 1991; Kivlighan Shaughnessy, 2000 ; Pa tton , Kivlighan

M ulton, 1997). How ever, Ge lso and Carter, as well as H orva th and

Luborsky, point out that the strains in the alliance experienced during the

middle phase of treatment often are the result of more focal strains on the

relationship, which are brought about by momentary lapses or empathic

failures on the part of the therapist, disagreements on tasks or goals, or

strains on the bo nd. Both empirical (Forman M armar, 1965; Rho des,

H ill, Th om pson Elliott, 1994; Safran, Cro cker, M cM ain M urray,

1990; M uran , 2002; Safran M uran 1996; Safran, M uran Samstag,

1994; Safran, M uran , Samstag Stevens, 2002 in press) and theoretical

(Bord in, 1994; Safran M ura n, 2000) work suggest that when strains in

the alliance are not addressed, outcome is negatively impacted and drop

out may occur.

If this is true, then the middle phase of treatment might be better

characterized by a series of brief ruptures and repairs in which the

alliance is strained. In successful treatment, the strain is addressed and

the alhance returns to previously high levels, not during the final stage

of treatment, but within a few sessions. Rather than thinking of alliance

development in terms of curves, with global decrease in patient satis-

faction and general weakening of the alliance in the middle phase, it

could be envisioned as a series of dips and spikes representing, not

global shifts in satisfaction, but a kind of session-by-session negotia-

tion proces s (Safran M ura n, 200 0).

The present study attempts to address many of the methodological

problems that limited the conclusions drawn from previous studies and to

test the idea that the rupture-and-repair process is better described as a

local, rather than global, phenomenon. Consistent with the Bordin's

(1994) assertion that different patients work differently in the alliance, two

patterns of alliance development were predicted. The first form is a linear

increase in Working Alliance Inventory (WAI) scores across the course of


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Alliance Level and Pattern

to five sessions. A global high-low-high pattern was not expected to

appear. Additionally, it was predicted that treatments demonstrating a

linear increase or rupture-and-repair episodes would evidence better

outcome than those that did not.

METHODS

PARTICIPANTS ., . . -

her pists

This study was conducted as part of a psychotherapy research project

at a major medical center in New York City (see Muran, 2002, for an

overview). The therapists were drawn from the department of psychiatry

and included attending psychiatrists, clinical psychologists, social workers,

psychiatry residents, psychology interns and externs. To assure consistency

of treatment, all of the therapists, regardless of their background and

experience, received similar training and evaluation in the therapeutic

model they practice. To assure treatment adherence, trained observers

rated videotapes of a randomly selected session in each treatment third

(beginning, middle and end), using an instrument developed by the

project, which has demonstrated adequate psychometric properties (Pat-

ton, M uran, Safran, W ach tel, W insto n, 1996). Licensed clinicians

participated in one-hour weekly supervision until they met acceptable

standards for treatment adherence (1-2 cases), while unlicensed therapists

continued to receive individual supervision for all of their cases. All

therapists participated in a weekly 90 -m in ut e g roup supervision.

Patients were randomly assigned to one of three manualized, 3 0 -

session, on ce- pe r-w eek treatment conditions designed to treat person ality-

disordered patients. All the therapy sessions were videotaped. The three

different conditions were Brief Relational Therapy ([BRT] Safran, 2002;

Safran M uran , 2000; M uran Safran, 2002 ), Co gnitive-Behavioral

Therapy ([CBT ] Tu rner M uran, 1992) and Brief Ad aptive Psychother-

apy ([B AP]; Pollack, Flegen heirmer Kaufman, 1988). Brief Relational

Therapy is an integrative model that combines the principles of relational

psychoanalysis and humanistic psychotherapy. It focuses on detection and

resolution of alliance ruptures and has an explicit emphasis on process

rather than content. The CBT condition is a fairly traditional, schema-


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AMERICAN JOURNAL OF PSYCHO THERA PY

to the environment in a more adaptive fashion. Of the 128 cases reviewed

for inclusion in this the project, 44 fit the specific inclusion criteria

(presented below). Of the 44 patients, eighteen were seen in CBT, 14 in

BRT and 12 in BAP.

Patients

Patients were recruited using advertisements in local newspapers,

inviting adults suffering from long-standing depression, anxiety, or

interpersonal problems to participate in a program to investigate

short-term psychotherapy. The principal inclusion criterion was that

they met criteria for diagnosis of Personality Disorder (PD) cluster C or

NOS on axis II. Exclusion Criteria was evidence of schizophrenia or

other psychoses, organic brain syndrome or mental retardation, mania

or bipolar disorder, severe obsessive compulsive disorder or serious

eating disorder, serious dissociative disorders, a current substance use

disorder, active para-suicidal or suicidal behavior, a history of violent

behavior or severe impulse control problems, psychotropic medication

use within the past six months.

Patient

demographics.

Th ere were an equal num ber of male and female

patients. They ranged in age from 25 to 63 years (M = 40, SD =10). All

w ere edu cated at or above the high school level, and 7 5 had a college

degree or at least some gradu ate level education. M ore than 7 5 were

employed. Eighty percent were Caucasian.

Patient diagnostic characteristics.

All of the patients in this study m e

the criteria for an Axis II diagnosis, and all but two met criteria for an Axis

I diagnosis in the

DSM IV

(American Psychiatric Association, 1994). All

patients with an Axis I diagnosis were in the mood or anxiety disorder

spectrum. All 44 patients met criteria for an Axis II diagnosis, and 14 also

met criteria for a secondary Axis II diagnosis based on the SCID-II. More

than half (23) had a personality disorder NOS, with the remainder

diagnosed as falling into Cluster C (14 avoidant, 7 obsessive compulsive,

aggressive).

Coders

We had four coders classify alliance development curves and identify


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MEASURES

lliance

Alliance was assessed using the short form of the WAI (Horvath

G reenb erg, 1989, Tracey Kokotovic, 1989).The W AI was adm inistered

at the end of each session as part of a postsession questionnaire (PSQ)

designed to assess the therapeutic relationship (Muran et. al. 1991).

The WAI (Horvath, 1989) was created to assess the working alliance

independent of a therapist's theoretical orientation while simultaneously

providing a clear description of what constitutes a working alliance and

how the alliance functions to promote positive change. Items for the WAI

were generated in a unique multi-step process to insure content validity.

Items were created initially to reflect the three different dimensions (tasks,

goals and bond) of Bordin's model (Bordin 1974, 1979, 1980) and were

rated by psychologists from different theoretical backgrounds. Experts on

the working alliance reviewed each item, rating it for relevance. The

remaining items were reviewed a second time from randomly selected

practicing psychologists and separated into clusters corresponding to each

of the three dimensions (tasks, goals and bo nd ). Th e to p- rat ed 12 items in

each group were chosen to form the WAI. There has been good empirical

support both for the overall scale and the subscales.

Tracey and Kokotovic (1989) used a hierarchical bilevel model to

represent the factor structure of the WAI, and they concluded that the

WAI assesses both the individual aspects of the alliance represented by the

subscales and the overall alliance dimension. Based on their findings, they

selected the four items that best defined each of the unique aspects of the

alliance (i.e. the three subscales) and constructed a 12-item short form of

the WAI. It is this shortened version that is used as a part of the PSQ and

provides the alliance ratings used in this study.

utcome

me sures

Outcome for this study was measured using two factors established by

calculating the standardized residual gains for each of six outcome mea-

sures,

the Global Assessment Scale ([GAS] Endicott, Spitzer, Fleiss,

Cohen 1976), Global Symptom Index (GSI) of the Symptom Checklist

90-Revised ([SCL—90—R] Derogatis, 1983), Inventory of Interpersonal

Problems

([IIP] ,

H oro w itz, Ro senberg, Baer, U reno Villasefior, 1988),


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analysis with Varimax rotation.

Two

factors were ex tracted with eigenval-

ues exceeding

1.00 and

with

5 9 . 1 1 % of the

variance accounted.

Two

outcome composites were calculated

by

averaging

the

standardized scores

of

the

measures that loaded

> .45 on the

respective factors

and by

applying the yielded factor scores as weights. Factor one, which is consid-

ered

a

m easure

of

symptom reduction,

is a

composite that included

GAS

(factor loading

=

-.78, factor score

=

- .36) ,

PTC

(.83, .41),

TRC

(.81,

.40)

and

the GSI {.45, .12).

Factor

two, a

measure

of

patients interpersonal

functioning,

is a

composite that included

the IIP

(.82,), WIPSI

.89, .61)

and

GSI .50, .23).

STATISTICAL METHODOLOGY

ata selection

Since patterns

of

alliance development were

the

focus

of

this study,

gaps

in PSQ

reporting could have been problematic.

As a

result,

we

included only cases

in

which

the

patient

had

completed treatment,

and

returned

a

minimum

of

6 6 %

of the

PSQ s, with

no

gaps

of no

more than

three consecutive sessions.

Of the 128

original cases,

44 met all of

these

criteria

and

were included

in the

analysis.

The

largest

gap in

consecutive

sessions

was

three , w ith

an

average

of

one missed session.

To

allow

for the

consistent analysis

of

patterns across

the

length

of

therapy,

all

gaps

in PSQ

scores were filled

in

with

the

average

of

scores from

the

sessions be fore

and

after

the

skipped session

s). For

example,

if a PSQ

from session

14

were

missing,

the

average

WAI

values

for

sessions

13 and 15

were substituted

for session

14.

As

it

seemed possible that large gaps

in the PSQ

reporting might

be

indicative

of

ruptures,

and

because cases with large numbers

of

missing

PSQ s could

not be

included

in the

analysis,

it is

possible that

the

rem aining

cases might

be

representative

of

only good cases .

To

help control

for

this, the

data

was

analyzed

in

several ways. First,

we

conducted

a

t-test

to

compare the percentage of PSQs returned for clients who completed

treatment with those

who

dropped

out of

treatment.

The

test results were

not statistically significant

/ =

.423,

p

.673). Next,

all

cases

of

patients

who completed treatment were examined

for a

correlation between

the

percentage

of

PSQs returned

and

outcome. Outcom e

for

symptom reduc-

tion and interpersonal functioning both at termination and follow-up was


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Table 1. OVERA LL

W AI

Mean

Standard

Deviation

Ilanjje

Ont-

5.24

0.75

3/>-6.7

WAI MEAN

Phase

Two

5.58

0.72

3.7-7.0

AND STANDARD

Three

5.95

0.69

4 . ^ 7 . 0

Three

5.39

0.86

3.0-7.0

DEVIATION SCORES

Session

Fifteen

5.55

0,85

3.5-7.0

Thirty

6.0

0.75

4.3-7.0

Overall

Treatment

5.59

0.66

4.1-7.0

relationship was found for either symptom reduction or interpersonal

functioning at termination or follow-up. Although the precise meaning of

missing PSQs cannot be determined, the percentage of PSQs returned

does not appear to be predictive either of length of treatment or of

outcome.

Data nalysts

Before analyzing the impact of different patterns of alliance develop-

ment on outcome, we needed to determine first if alliance

level

for this

sample correlated with outcome. The treatment was first divided into

phases, as suggested by the literature (eg., Mann 1973; Gelso and Carter,

1994;

and Horvath and Luborsky, 1993). Using bivariate Pearson corre-

lations with a Spearman two-tailed test of significance, we compared

• aUiance levels at the third , fifteenth, thi rtieth session;

• average alliance levels for p hase on e (sessions on e to five),

• pha se two (sessions six to twen ty-five), and ph ase thre e (twenty six

through thirty); and

• overall W A I mean -.

^

-

with outcomes for symptom reduction (factor one) and interpersonal

functioning (factor two) at term ination (see Table 1 for des crip tion of

statistics). As can be seen in Table 2, the mean WAI ratings for both

factors were correlated significantly with outcome. With the exception of

the ratings in phase one for interpersonal functioning, all of the mean

ratings for the phases were correlated significantly to outcome. Ratings

taken from individual sessions showed a weaker relationship with out-

come, with only sessions 15 and 30 being significant. Interestingly, corre-

lations were highest for phase two and session fifteen, indicating the closest


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Table

2 .

WORKING

ALLIANCE

O ne

BY OUTCOME

Phase

Two Three

CORRELATIONS

Session

Three Fifteen Thirty

Treatment

Mean

Factor Pearson

One Correlation

Sig. (2-tailed)

Factor Pearson

Two Correlation

Sig. {2-tailed)

- . 4 4 4 - . 5 1 6 - . 3 6 4 - . 2 7 7 - . 4 7 9 - . 3 2 7 - . 5 2 4

.006 .000 .024 .092 .002 .044 .000

- . 1 6 7 - . 3 2 9 - . 3 2 5 - . 0 6 3 - . 2 8 1 - . 2 5 5 - . 3 2 5

.280 .030 .032 .682 .064 .094 .032

range, while all of the correlations for factor two, interpersonal function-

ing, were somewhat lower. Low scores for either factor indicate improve-

ment, so that a negative correlation indicates that higher WAI scores are

related to decreased patient symptoms or decreased interpersonal prob-

lems.

Identification of urves

To test the hypothesis that both a linear trend and a series of ruptures

and repairs are predictive of improved outcome, we examined each of the

44 cases to determine if either of these two definitions described the

pattern of alliance development, or if they were better described as

high-low-high or other patterns. Testing was done in several ways. First,

we used the mean WAI scores for each of the 44 cases to construct a

Chance-corrected Coefficient of Proportionality Matrix. This correlation

matrix allows cases to be examined for shifts across a series of cases,

regardless of their abso lute value. This m eans that the sha pe of the alliance

development may be examined independently of the level of the alliance

scores. W e used W ard s m ethod to see if the cases wou ld cluster by pa ttern

of developm ent. W ard s m etho d is a fairly conservative m eth od , which

constructs fairly compact (minimum variance) clusters.

Large breaks in similarity occurred to produce two dusters, each

consisting of four highly similar cases. Examination of the two clusters

indicated that both were forms of linear increase, with the first (r

.46 to

.87) cluster characterized by a steady, but gradual, increase across the

length of treatment with little variation, and we called this pattem linear-


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stable scores, and we labeled this late-linear. No other patterns of alliance

development were identified using the cluster analytic technique.

dentific tion

of Alliance Curves

W e then employed a second m ethod to determine if linear or qu adratic

patterns were present. Both linear and quadratic patterns can be detected

using ANOVAs to describe regression curves. ANOVAs generated for

each model were examined to determine if adding a quadratic term better

described the shape of the alliance over time compared to a simple linear

relationship.

Since many potential curves could be associated with a positive finding

for a quadratic relationship, the coders were asked to examine each of the

curves and to determine if the curves were best described by a high-low-

high, linear, or stable pattern. Four coders examined each of the curves

and classified each as being high-low-high, linear increase, or other

{Kappa = .90). To determine if a case could be categorized as having

undergone a local period of rupture and repair as measured by the WAI,

the same four coders were given graphs of each of the 44 cases and asked

to identify rupture and repair cycles.

A total of 29 cases (66%) were identified as having a linear trend by

regression analysis with ANOVA (significant at the .05 level or better),

indicating that WAI scores improved over the course of treatment. After

examining each of the regression curves, coders identified 13 cases (30%)

as being best categorized as having a linear trend. All of the cases identified

by the coders, and all of the cases in each of the two clusters, were

identified as having a linear trend in the ANOVA analysis.

dentific tion

of Rupture and Repair Events

Rupture-and-repair patterns were identified differently from more

global trends (e.g., linear, high-low-high, etc.). Cases that demonstrated

micro rupture-and-repair events are not easily detected by statistical

procedures. Although these patterns have a distinctive shape, consisting of

a dro p in alliance scores with a subsequ ent return , the length, severity, and

timing of these episodes may be different in each case. It was, therefore,

necessary to use coders to identify these rupture-and-repair episodes.

If we define ruptu res in the therapeutic alliance as disagreements abou t

tasks or goals or prob lems with the relational bond (Safran et al., 2002, and


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F i g u r e 1

LINE GRAPH OF WORKING ALLIANCE RATINGS (MEAN) BY SESSION.

D 2 3 4 S 8 7 3 9 t O I 1 1 2 1 3 1 4 1 5 1 8 1 7 1 8 1 8 2 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 D 3 1

S E S S IO N N U M B E R

and-repair event as a downward shift in WAI ratings from stable (consistent

or dropping no more than 5 point, or an increase in the previous session),

with a drop of one WAI point in one session (moderate) or more than one

point (serious) in one or more consecutive sessions (starting with an initial

drop of or more points), with a subsequent return to within .25 point of the

predrop level or higher within 3 to 5 sessions.

The same four coders who classified regression curves also identified

rupture events. They were able to reliably identify cases as being rupture

free, having only m ode rate rup ture s, or serious rup ture s (K appa ^ .91). A

total of 22 cases (50 ) were cod ed as having rup ture s. Th irteen (3 0 ) of

these were classified as having serious events. See Figure

for an example

of a case with a single rupture-repair episode, which starts in session 16


13/22


for which a linear trend was detected by the initial ANOVAs were

categorized as significant lin ear . Tho se for which a linear trend was

identified by the coders were categorized as co de r-r ate d linear . Because

coders agreed about only two cases as being best described by a global

high-low-high pattern, this category was not included in the final analysis.

Cases identified as having local ru ptu re patte rns were categorized as any

ruptu res . Tho se with only m odera te ruptures were categorized as only

mo derate ruptu res and those with patterns of only serious ruptures were

classified as only serious ru ptures .

We ran ANOVAs, using the General Linear Model of SPSS (9.0), for

each category to test the degree to which they related to outcome for factor

one or factor two. Treatments categorized as linear by ANOVA and coders

were not found to be related significantly to outcome on factor one.

However, cluster 1 (the stable linear group) showed a relationship to

improved outcome on factor one (symptom reduction) with a modest

effect size

{F

(2, 44) ^ 4.497,

p

.045,

r

.31). Similarly, there was no

significant relationship between linear development patterns as defined by

ANOVA, coder or cluster analysis and factor two (interpersonal function-

ing). There also was no relationship between the presence of rupture-and-

repair episodes and outcome on factor two.

Since rupture-and-repair cycles, as operationalized here, were not

significantly related to outcome, a secondary analysis was run to determine

if variability in the alliance was predictive of outcome. To do this, the

standard deviation for each patient's WAI scores was correlated with

outc om e for each factor. A m oderately strong relationship was found

between the standard deviation of the WAI scores and factor one

ir

.345,

p —

.042), indicating that a patie nt's im prove m ent on factor o ne

(symptom reduction) is negatively correlated with variability on alliance.

Factor two (interpersonal functioning) was not found to be significantly

correlated with variability in WAI scores

[r

.028). Additionally, to

explore the different findings between this study and Kivlighan and

Shaugnessy (2000), an additional analysis was conducted. The Kivlighan

and Shaughnessy (2000) study found that treatments with brief high-low-

high patterns were positively correlated with outcome. This study found

no such relationship. We conjectured that this discrepancy might be


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AMERICAN JOURNA L OF PSYCH OTHERA PY

and Shaughnessy study. To determine if this difference in treatment length

had an effect on the relationship between pattern development and

outcome, the WAI scores for session 3 were subtracted from those of

session 30. Eighteen of the 22 cases containing rupture-and-repair events

had higher scores at session thirty than at session three, indicating that a

majority of cases (81 ) with ru pt ur e- an d- re pa ir episodes ended w ith

alliance scores as high or higher than hose with which they began.

Treattnent Conditions

In addition to looking for an overall relationship among alliance level,

pattern of alliance development, and outcome, the data was also analyzed

for relationships among the three treatment conditions and patterns of

alliance development. No significant relationship was found between

alliance levels and treatment group. A series of Chi-Square tests were run

to test for relationships between type of alliance pattern developed with

treatment group. The percentage of cases with ruptures was higher in the

BRT gro up (a total of 10 rup tures in a total of 6 6 of the cases) than in

either CB T or BAP condition (with nine rup ture s in 5 3 of the cases and

3 ruptures in 3 3 of the cases respectively). Th e relationship app roach ed

significance

x^ -

4.725,

p =

.094).

There also was no significant relationship found between linear in-

crease and treatment condition

{)^ —

.625,

p =

.732). There was a

moderately significant relationship

{r

(2, 44) = .38,

p =

.042) between

treatment condition and variability. The BRT condition was found to have

significantly greater variability (M = .66) than BAP (M

=

.51) and CBT

(M = .49). One additional finding is that the linear stable cluster of four

cases found to be related to improved outco m e was m ade u p of three C BT

and one BAP case.

DISCUSSION

The hypothesis that alliance development would be characterized by a

linear increasing pattern and treatments demonstrating localized (three to

five session) rup tu re -an d- re pa ir episodes was sup por ted. As predicted ,

there was no evidence of a global high-low-high pattern of alliance

development and decay. Rather, alliance development was characterized in


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seen in BRT than in BAP or CBT, indicating that rupture-and-repair

events may occur differently in different types of treatment.

The hypothesis that treatments demonstrating a linear trend or rup-

ture-and-repair episodes would be related to improved outcome, received

limited support. No relationship between the presence of rupture-and-

repair episodes and outcome was found. There also was no relationship

found between a statistically significant linear trend or coder-rated linear

trend and outcome, but one cluster of four cases classified as stable-linear

was found to have a significant relationship to improved ou tcom e on factor

one (symptomatology). Finally, variance in WAI ratings was found to be

negatively correlated with outcome on factor one (symptomatology).

There are a number of possible explanations for the failure to find any

significant relationship between the presence of rupture-and-repair epi-

sodes and outcome. First, the way in which ruptures in the alliance were

operationalized in this study may not accurately reflect actual rupture

events. Working from a definition that ruptures in the aUiance are char-

acterized by disagreements about tasks or goals, or problems with the

relational bond, we hypothesized the WAI scores, which dropped and

then returned to pr e -d ro p levels, wo uld reflect this process. Although the

classifications of moderate and serious rupture events were made to

discriminate levels of disagreement, we did not consider the number or

severity of rupture events in this analysis. Currently, there has been no

theoretical prediction about the pattern alliance ruptures make. Safran and

M uran (2000) state that the process of resolving rup ture s m ay, in fact, lead

to further rup ture s. In describing the BRT m odel, Safran w rote, In this

approach, the treatment process is conceptualized as ongoing cycles of

therapeutic enactment, disembedding and understanding, enactment and

disem bed ding (Safran, 2002, p. 171).

Nevertheless, there is no clear notion of how many (or few) rupture

events lead to imp rovem ent. It is possible to imagine cases in which patient

and therapist encounter, and work through, a significant rupture around a

core maladaptive interpersonal issue and then move on to other topics.

Pe rha ps b eing able to survive this one conflict, o r feel understood, just this

once, is enough to lead to significant improvement. It is just as easy to

imagine, however, that a patient may need to work through a particular

conflict several times with a therapist before being able to experience it in


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A M E RICA N J O U R N A L O F P S Y C H O T H E R A P Y

timing, and number of these events, based on a more detailed model,

might yield a better understanding of how the pattern of ruptures may be

related to outcome.

The additional findings, variance in WAI ratings was negatively corre-

lated with outcome, and only the most stable cluster of cases displaying a

linear pattern was correlated with improved outcome, make interpretation

more difficult. Regardless of the specific pattern that alliance development

had been expected to take, be it the global high-low-high pattern or the

more local, rupture-and-repair events predicted here, there is broad

consensus among theorists that fluctuations in the therapeutic relationship

are both unavoidable and form an important component of the change

process. These theorists (e.g. Bordin, 1994; Forman & Marmar, 1965;

H orvath and Luborsky, 1993; M uran 2002; Rhod es, Hill, Th om pson &

Elliott, 1994; Safran, Crocker, McMain & Murray, 1990; Safran & Muran

1994, 1998, 2000; Tracey, 1989) suggest that it is through these disagree-

ments, misunderstandings, and conflicts, that patients learn critical lessons

about how to balance the needs of the self and the needs of others. Tracey

(1989),

and Horvath and Luborsky (1993) suggest that when therapists do

t

notice periods of tension or disagreement, they should begin to

question if the treatment needs to be changed, noting that it is important

to be aware that during periods when therapy goes too sm oothly might

represent a problem in the therapeutic work.

The belief that having the experience of working through conflicts with

an empathic and responsive listener is an essential part of therapeutic

change, reflects years of clinical theory and experience backed by compel-

ling anecdotal evidence. This has lead researchers to attempt to discover

the way therapeutic technique interacts with the alliance and shapes its

development. Finding patterns of alliance development consistent with the

belief that a degree of conflict is an essential element of change has proven

however, to be a difficult task. Studies that have found these patterns (e.g.

Berna rd et al., 1980; Berna rd & Schw artz, 1981; Pa tton et al., 1997;

Kivlighan & Shaughnessy, 2000) have been hampered by methodological

prob lem s. Conversely, the finding that a strong, stable alliance is related to

improved outcome (Joyce & Piper, 1990; Kivlighan & Shaughnessy, 1995;


17/22


little between-session variation is more conducive to improvement than a

more dramatically fluctuating alliance.

There are several possible explanations for this contradiction between

the theory and the findings. First, the shape of the alliance may mean

different things for different pa tien ts. As Bordin 1994) suggests, for som e

patien ts, good outc om e will be associated with a stable alliance. Fo r oth ers,

as Tracey 1989) suggests, an overly stable alliance repres ents collusion

between patient and therapist to avoid difficult topics or over compliance

by the patient. Similarly, the presence of rupture-and-repair events may

mean different things in different treatments. For some patients, these

events may represent the uncovering and working through of maladaptive

interpersonal cycles, for others it may be more indicative of an inability to

form or maintain a consistent relationship or engage in therapeutic work.

If this is true, than rather than looking for globally generalizable patterns,

investigators need to focus on factors that might cause particular dyads to

work in the alliance in a particular way.

Just as alliance patterns vary depending on the particular treatment

dyad, there is some evidence in this study that the shape the alliance takes

relates to treatment condition. There were marginally more cases with

rupture events in the BRT than in BAP and CBT conditions. There was

greater variability in BRT than CBT or BAP cases, and three of the four

members of the stable, high-alliance cluster, which was found to be

significantly related to im proved ou tcom e on factor on e symptom redu c-

tion), were seen in the CBT condition. While these findings are certainly

suggestive, the effect sizes were small and the relationships marginal.

Cau tion should be taken in interpre ting these results. Bo rdin 1994)

contends that different treatments will produce different forms of alliance,

and presumably, different pattems of alliance development. It may be that

BRT therapists are taught to focus on rupture events while CBT therapists

are more likely to smooth over misunderstandings that may alter the

pattern of alliance development. While the fmdings of this study indicate

an area that should be investigated in further detail, there is not currently

enough information to draw any real conclusions.

It is possible that the way alliance and outcome were measured in this

study was not sensitive to the kind of changes that come from working


18/22

AMERICAN JOURNA L O F PSYCH OTHER APY

within the session. Since the WAI can only look at shifts between sessions,

rather than within them, it is possible that it is missing a critical part of the

negotiation and change process. Researchers, such as Form an and M armar

(1985), Lansford (1986), and Safran, Muran and Samstag (1994), who

found that directly addressing strains, misunderstandings, and ruptures led

to improvement in alliance scores and predicted improved outcome,

looked at events that took place and we re address ed w ithin a given session.

The WAI may not measure the kinds of relational factors central to the

negotiating process. The WAI focuses on

greement

between patient and

therapist. It is clearly vital for patient and therapist to agree on what they

are trying to accomplish and how. This basic agreement on the central

goals of a treatment—and the methods used to achieve them—maybe a

fairly stable core of the therapeutic relationship. Shifts in this basic

agreem ent may reflect an inability to establish a firm foun dation for

treatment. What may be more important for some patients, however, is to

learn that they can dis gree with their therap ists without disrup ting the

relationship. The elements of the therapeutic relationship that may be

central to change may have much more to do with patients feeling their

therapist is willing to listen, understand and respect them, even when

expressing ang er, anxiety, disa ppo intm ent, hopelessness, etc. It may, there-

fore, be less important that the patient and therapist work through

conflicts about a particular task, than it is that the patient feel free to

express his or her doubt, discomfort, or skepticism and believe that the

therapist is taking him or her seriously. In these instances, a therapist's

willingness to explain a task, or change it, may be the curative factor.

Negotiations can take place in very brief moments, and may never be

explicitly stated, and thus, could not be reflected by an instrument that

measures problems lasting more than one session.

Similarly, the outcome measures, which reflect standard measures of

symptomatology and interpersonal functioning, may not reflect the kind of

changes that would be brought about by working through alliance rup-

tures. Safran and Muran (2000) suggest that working through ruptures,

w hethe r explicitly or implicitly, . . . can have an impact on the fundamen-

tal way in which patients con strue self-o the r intera ctions (p. 16). M uran


19/22


treatment, but provides opportunities for a unique kind of growth that is

not reflected by standard measures.

Results from this study seem to suggest that the level of the alliance, as

measured by the WAI, rather than the shape of its development, is

predictive of outcome. Given the limitations of the WAI in tracking

interpersonal process, however, it may be more a function of the way in

which alliance is defined. The WAI has clearly demonstrated that the

alliance, defined by agreement on tasks, goals and bond, is a powerful

component of change in therapy. It may be necessary to develop other

tools to determine, with greater precision, how that change takes place.

Acknowledgments: The research presented in this article was supported in pan by Grsuit

MH50246 from the National Institute of Mental Health.

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Alliance Brief

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