Strengthening the Therapeutic Alliance

The alliance is widely understood as comprised of purposeful collaboration (the extent patient and therapist agree on the tasks and goals in treatment) and affective bond (the extent there is mutual respect and trust between patient and therapist). Tasks and goals can vary by treatment orientation: For example, cognitive-behavioral tasks can include homework assignments such as activity scheduling to increase behavioral activation and decrease depressive symptoms as goals. Emotion-focused and some analytically informed tasks can include the exploration of emotion expression to increase insight in emotional experience. And agreement on these tasks and goals are always facilitated by the quality of the bond (and vice versa).

The alliance should also be understood as implicitly shaped by the ongoing negotiation of patient and therapist respective needs or desires, referred to as intersubjective negotiation. In other words, any of the tasks described above involves patient and therapist underlying wishes. Every interpersonal encounter can be interpreted as an expression of “I can or will do this (for you), but not that” by either the patient or therapist. For example, a patient may want to discuss feelings about a partner (and maybe only certain feelings at that), but not those about a parent. Or a patient may just want to be heard about a problem and not necessarily act on it. Likewise, a therapist may wish to direct a particular task, exploring a specific question or assigning a specific exercise – a choice based on clinical judgement or personal comfort.

Following what I described before, some signs can include to what extent a patient is appears to agree and adhere to a task suggested by the therapist -a behavioral sign. Are they responding to exploratory questions or completing exercises or experiments, especially those of a challenging nature? These are behavioral signs. There are also emotional signs, what some might described as emotional attunement, namely to what extent does the therapist feel empathy and compassion for a patient. Here it is important for therapist to guard against pseudo-alliance (alliances built on false pretenses or unwitting collusions to avoid true, difficult feelings in order to play nice or smooth things over) and misempathy (believing one understands when in fact one doesn’t, which includes overidentifying or attributing one’s own feelings to the patient).

We have defined problems in the alliance (that is, disagreements on or resistances to tasks or goals, deteriorations in the bond, breakdowns in negotiation) as ruptures. In this regard, we have found it useful to make a distinction between confrontation and withdrawal rupture markers (though often there are mixed expressions of these). These are interpersonal behaviors or communications by patient or therapist. The former includes movements against the other: that is, movements towards control or aggression (such as objectifications and coercions of the other to conform, criticisms and complaints, and microaggressions). The latter includes movements away from other (behavioral avoidance) or from self (experiential avoidance): that is, movements towards isolation (such as silences, minimal responses, excessive or abstract talk, and topic shifts) or appeasement (such as begrudging compliances, capitulations, and deferential behavior). We have also defined ruptures by intrapersonal markers (especially to facilitate therapist awareness): that is, an internal or emotional experience that is felt in interaction with another and indicates some kind of negative process (such as anxiety and panic, anger and disgust, hopelessness and despair, embarrassment and shame, guilt and self-doubt, boredom and neglect). Ruptures marked as therapist internal experience can be likened to such clinical concepts as countertransferential reactions, role-responsiveness or interpersonal pulls, and empathic failures or affective misattunements.

Although defining ruptures by such markers (whether expressed by patients or therapists) can useful for recognition purposes, it remains important to appreciate that they emerge in a context, in the field of the therapeutic relationship. Ruptures are co-constructions that can be understood as markers of relational matrices, enactments or vicious circles, which consist of patient and therapist belief systems and action patterns. They are essentially the result of patients and therapists struggles to negotiate a fundamental dialectic in human motivation: namely their respective needs for agency or self-definition (to feel effective and worthwhile) and communion or relatedness (to feel connected or recognized by another). There is an inherent tension in the pursuit of these motivations. Accordingly, a confrontation rupture can be understood as the pursuit of agency at the expense of communion, and withdrawal rupture as the pursuit communion at the expense of agency (even moves to isolate can serve to maintain an attachment). Another important and related dialectic to consider here is one noted by existentialists, developmentalists and feminists: namely how human relations typically begin with objectification (putting others in categories according to implicit biases or heuristics based on personal past experiences and social constructions) before subjectification (seeing the other as having their own unique experience). The latter recognition is very important to recognizing one’s own subjectivity or experience. Ruptures invariably involve some form of objectification of the other.

Rarely does one see this both in research and practice. Given the definition I provided, a purposeful collaboration and affective bond between therapist and patient of some kind is required for treatment success. An alliance is necessary, but one can question whether it is sufficient for change, which I’ll address later with regard to another question.

Without going out too much on a limb, I would think this is probably due to difficulties in assertion and negotiating the need for agency. This would be consistent with the limited research in this respect, as well as our definition of withdrawal rupture.

Not particularly according to the research. They can be quite oblivious to subtle negative communications or quite defensive in response to more conspicuous or confrontative expressions. This is what makes our efforts to study and train so interesting and challenging!

I’m hesitant to endorse this straight up, but I do believe a therapist’s relationship to their internal experience is integral to their abilities to recognize and repair ruptures. And the nature of this relationship probably depends on personal variables, as well as developmental experiences like personal therapy and meditation practices etc.

Don’t know why? There should be training in this regard. Payment is a part of the parameters that therapist must negotiate in their relationships with their patients. It has clinical significance and much to do with how the patient construes and uses the therapist: Very much a part of the intersubjective negotiation described above (see also my answer to the relevance of ethical codes).

This is not unusual. Often initial efforts to discuss a rupture can lead to a furthering of the rupture. See my responses below for more on rupture repair principles and considerations.

I think in this regard it is important to highlight 1) the execution of any treatment task requires some agreement and trust between patient and therapist (see above alliance definition) and 2) the outcomes of manualised treatments from trials are still sobering: We still need to redress nonresponse, deterioration and drop rates -and developing therapists’ abilities to build and repair alliances is an important path to improve adherence to and outcome in these treatment options.

We have defined three pathways or strategies to rupture repair. The first can be described as alliance-building and involves efforts to establish agreement on tasks and goals (purposeful collaboration) and to promote the affective bond between patient and therapist (trust and respect). These include providing a rationale for the work (that is, the tasks to be undertaken) and its relation to the goal (for example, to reduce a symptom, to change a behavior, to develop a skill, to increase insight or awareness), clarifying any misunderstanding, validating patient feelings (especially anxieties about therapy), and inviting feedback periodically during the psychotherapy process. The second pathway can be described as immediate repair strategies and involves any renegotiation of a task or goal: that is, changing the work, such as providing different direction, developing a new skill, exploring another subject, adjusting a homework assignment. The third pathway involves expressive repair strategies aimed at using a rupture marker to explore a relational theme currently being enacted by the patient and therapist (e.g., “What is happening between us?”). We have identified a number of fundamental attitudes to guide therapists in these expressive efforts to repair ruptures, such as humility, compassion, curiosity, and patience. We have suggested the principle of metacommunication to facilitate expressive efforts: that is, communications about the communication process (e.g., questions and observations, including self-disclosures by the therapist, from “What are you feeling now?” and “I notice your hand trembling” to “I’m aware we’re in some kind of dance” and “I’m feeling a bit defensive right now”). Here we recommend trying to establish a collaborative inquiry, a conversation about what is transpiring between patient and therapist in the here-and-now, a dialogue that aims to clarify patient and therapist respective experiences and contributions to the interpersonal field. The emphasis is on recognizing shared contribution and responsibility, focusing on details and granularity, understanding the fluidity of experience, and tracking responsiveness and relatedness.

Hard to answer this in the abstract, but here is a couple of thoughts that might help. First, there has to be a mutual readiness to explore (yes, an agreement that such a task is worthwhile). The patient (or therapist) might not be ready (or able for a variety of reasons) for the time-being. Second, it is reasonable to expect that initial efforts to metacommunicate will lead to further rupture before resolution. Metacommunication is more a process that an intervention and requires patience and resilience (see my definition above for more on basic principles).

Here I’d like to start with the recognition that ruptures are quite prevalent and ubiquitous based on the research. So I think therapist’s attention and efforts should be directed toward rupture repair and not rupture avoidance. I’m not suggesting, however, to create ruptures; rather they are fairly inevitable, so pay attention for them –not only because they represent risk factors for treatment failure, but also because they also pose opportunities for change. Let me describe how rupture repair strategies as I previously presented (including what I called alliance-building) can be understood as change processes or events. They can all provide new relational experiences or corrective emotional experiences (to use an oft-cited concept). For example, to be helped and understood by another (to experience another make an effort to clarify a misunderstanding), to have another adjust to try to accommodate an expressed wish (e.g., for some kind of advice or for another appointment time), these can be new experiences with corrective consequences, such as challenging negative expectations of others (such as “others are fundamentally withholding or self-interested”). Immediate repair strategies can provide patients the opportunity to negotiate their needs more effectively, to see the world as more negotiable. Expressive or exploratory strategies can bring the implicit intersubjective negotiation between patient and therapist into relief –and by doing so, promote emotion regulation (via putting unformulated feelings into words) and mutual recognition (seeing respective subjectivities more clearly). By mutual recognition, I am suggesting a momentary meeting of the minds, something akin to an I-Thou encounter.

One could use routine measurement or ask your patient about agreement, but one could also carefully track patient responsiveness to any intervention (to any question or observation), patient adherence to treatment directions or parameters as markers of alliance or rupture. In addition, therapists could and should pay attention to their own internal experience, as an emotional to compass to what is happening in the relationship, to gauge connection or attunement. For example, therapist anxiety or frustration, despair or boredom (etc), can be important indicators that something is amiss and worth addressing.

Every relationship has its limits: There things you can and cannot do (be or not be) for your patient (as I suggested in my definition above). Ethical codes dictate some of these things. They are part of the ongoing negotiation in the alliance and can be important part of a rupture repair process.

The answer to this question depends on definition. The definition of alliance I provided, which emphasizes collaboration and bond, highlights the inherent interaction between technique and the relationship (that is, every treatment task requires agreement and trust). So ultimately, it is not a matter of either/or. The alliance is arguably involved in all change processes in psychotherapy. And rupture repair should be understood as one change process among others where alliance remains relevant.

I think you probably need to need some level of trust to explore a rupture in depth (in other words, it takes two to tango, two to construct a rupture and two to repair it – thus some mutual readiness to resolve the problem), but such an exploration can facilitate a greater awareness of the respective subjectivities in play (a mutual recognition) that should result in a more intimate and intense level of trust.