Using the Rupture Resolution Rating System (3RS) for microanalysis of the psychotherapeutic dialogue. This article describes the use and function of this instrument in psychotherapy research.
The psychotherapeutic dialogue is the tangible aspect of the psychotherapeutic alliance. Within this alliance is the healing aspect of psychotherapy. An alliance rupture is defined in this manual as a deterioration in the alliance, in the sense that these occurrences are manifested by ab apparent lack of collaboration between patient and therapist on the task forward. While the concept of rupture may have like a “negative” connotation in other alliances, ruptures are essential parts of the psychotherapeutic alliance.
The absence of rupture and repair in a therapeutic session is a sign of confluence between therapist and client; whereby both parties give in to each other’s requests throughout the session, without question or challenge. These mainly confluent, rupture-less relationships in psychotherapy do not lead to healing at best, and at worst, may lead to the client being dependent on the therapy.
By rupture, the authors Eubanks-Carter et.al (2014) reiterate that it is not about lack of agreement, but lack of collaboration. The authors are also aware that agreement on the surface may actually be withdrawal, which is a kind of rupture.
“Note that a lack of ruptures is not necessarily the same as effective therapy. A patient and therapist could be in agreement and be working together very smoothly, but pursuing goals and tasks that are not the best choice for the patient’s situation. When coding ruptures, the focus is on the quality of the collaboration and bond between the patient and therapist—not the quality of the therapist’s case conceptualization, choice of treatment approach, or adherence or competence.” (p. 4)
Ruptures may be outside the consciousness of the therapist and client. In severe cases, ruptures can lead to dropout or failure of treatment.
2 subtypes of ruptures:
withdrawal ruptures : moving away the therapist (avoiding questions, etc.) or moving towards the therapist in a way as to avoid experiences (being overtly appeasing, etc), avoiding the actual work of the therapy.
confrontation ruptures : moving against the therapist, expressing anger, dissatisfaction by trying to pressure or control the therapist /therapy
Both therapist and client contribute to ruptures.
The coding system looks at the patient’s behaviors as markers of ruptures.
Resolution process is a process by which the rupture is repaired. This is a opportunity for rebinding the alliance, and reinstating new goals.
Resolution strategies are measures taken by the therapist to initiate the resolution process.
Signs of rupture (p. 5):
Patient and therapist are not working together collaboratively and productively. They
are “not on the same page.”
There is strain, tension, or awkwardness between patient and therapist.
Patient and therapist are misaligned or misattuned.
Patient and therapist seem distant from each other.
Patient and therapist are working at cross purposes.
Patient and therapist are acting friendly, but you sense tension or disagreement beneath the surface, such that the friendliness seems to be a pseudo-alliance.
Patient and therapist seem to be caught in a vicious cycle or enactment.
You feel very bored while watching a session. This might be a sign that a withdrawal rupture is occurring
Eubanks-Carter, C. F., Muran, J. C., & Safran, J. D. (2014). Rupture resolution rating system (3RS): Manual.
Treatment Adherence : degree in which the treatment is conducted in accordance with the theoretical model and prescribed technique.
Treatment Differentiation: degree in which different treatments differ in the intended direction with respect to therapeutic interventions (e.g. comparative outcomes).
Trijsburg, R. W., Frederiks, G. C., Gorlee, M., Klouwer, E., den Hollander, A. M., & Duivenvoorden, H. J. (2002). Development of the comprehensive psychotherapeutic interventions rating scale (CPIRS). Psychotherapy Research, 12(3), 287-317.
“The processof psychotherapy represents anything that can be conceptualized as a constituentof the psychotherapeutic treatment; more specifically, it refers to all of the events that, during the course of a treatment, occuras part of the therapy sessions and/or may be related to these sessions (Hill and Lambert 2004 ; Orlinsky et al. 2004 ). These events may refer to any domain (physiological, affective, cognitive, behavioral, etc.) that is ascribable to the client, to the therapist, and/or to their relationship. This definition is highly inclusive and, thus, analogous to the definition of the treatmentprocess that is given by Orlinsky et al (2004 ); therefore, it should be distinguished from the more specific changeprocess, which refers to those specific aspects of the treatment process that represent any clinically meaningful event “through which clients or patients are hypothesized to improve”(p. 312; also see Greenberg 1986 ; Rice and Greenberg 1984 ).”
“The outcomeof psychotherapy represents anything that can be conceptualized as a clinical effect of the psychotherapeutic treatment process; more specifically, it refers to those clinically meaningful changes that, during the course of a treatment and/or after its completion, may be observed as resultsof the therapeutic process, as defined above. These changes refer to the client’s problematic domains (e.g., physiological, affective, cognitive, or behavioral) that represent the treatment’s target, and should be observed outside the treatment situation (Orlinsky et al. 2004 ).”
Gelo, O. C. G., & Manzo, S. (2015). Quantitative approaches to treatment process, change process, and process-outcome research. In Psychotherapy Research (pp. 247-277). Springer Vienna.
Researchers and psychotherapists alike are concerned about the historical accuracy of the narratives reported. Memories can fail or phantasies can be mistaken for memories. This is not that we disbelief the subject or client. Even as therapists ourselves who have done hundreds of hours of personal therapy, we are aware of the fact that we too are not sure about what we remember and what we forget. Forgetting is after all a very present phenomenon of trauma.
Retrospective reports are driven by current experiences. What is in the foreground today may affect how we perceive the background.
Studies have also shown that childhood exposure to trauma leads to sometime destructive relationship patterns.
“Recent research has shown not only the accuracy of retrospectively obtained abuse histories, but also the stability over time of these reports, even when comparing pre- and post-therapy reports (Maughan & Rutter, 1997; Paivio, 2001). This study also used an interview-based method in which the rater was required to identify vignettes in which the individual trauma types could be identified. This approach may protect against false positives.” (Drapeu & Perry 2004)
What is traumatic?
When is an event traumatic enough to be considered as trauma, to the point of having a significant effect on the person?
This raises two possibilities in regards to the present study. The comparison of adult relationship patterns is made between trauma and non-trauma group.
“In this case, trauma could be seen as a dichotomous variable (present–absent). However, secondly, if the effects of trauma are cumulative, then correlations may reveal positive findings not captured by group comparisons. In this case, a dichotomous approach would not be sufficient, and other aspects of trauma such as duration or severity of the abuse or number of perpetrators should also be considered.”
the Traumatic Antecedents Interview (TAI) Scale.
What are the necessary conditions that have the impact of being traumatic?
“Childhood events can be considered traumatic either as a matter of definition or because a stressful event had certain traumatogenic qualities, such as feeling threatened, unable to protect oneself, fend off, or otherwise master a threat, and feeling responsible for its occurrence. Most research takes the approach of identifying traumas ostensively and focusing on clear-cut events such as physical or sexual abuse that are considered gross psychological traumas by wide consensus (Roy & Perry, 2004).”
Thus, trauma is often divided into two broad categories:
(1) gross psychological trauma and
(2) patterns of experiences or more subjective or “subtle” trauma. e.g. CPTSD
Studies on the first category, that is, with major traumata, as assessed using the TAI (Herman, Perry, & Van der Kolk, 1989), because this type of trauma can be relatively objectively described and quantified according to the number of perpetrators and the duration over which the events leading to trauma took place.
In its original form (Herman et al., 1989), the TAI was a 100-item semi-structured interview designed to elicit the reporting of both intra- and extra-familial interpersonal childhood trauma.
In the research by Drapeau & Perry (2004), three additional variables have been added for the present study to assess 12 areas, 10 of which are considered as possible gross trauma. These include Physical abuse, Sexual abuse, Witnessing violence, Physical neglect, Emo- M. Drapeau, J.C. Perry / Child Abuse & Neglect 28 (2004) 1049–1066 neglect, Significant separations, Losses, Domestic chaos, Verbal abuse, and Parental discord. Two additional positive variables are also included: the presence of Caretakers/confidantes and the display of Mutual affection between the parents.
For scoring purposes, a subject’s childhood is divided into three periods, including an early period (0–6 years), a middle period (7–12 years), and a late period (13–18 years). In this study, however, only the total scores across all three-age periods will be examined.
Physical and Sexual abuse, Witnessing violence, Significant separations, Losses, and Verbal abuse are each given scores from 0 to n, with n being the number of perpetrators (or significant separations or losses) in each of the three developmental periods. Physical and Emotional neglect, Domestic chaos, Parental discord, and Parental mutual affection are given scores of 0 (absence) or 1 (presence) for each developmental period. Caretakers/confidantes are scored from 0 to 2 for each age period, reflecting the common finding of two caretakers in a healthy, western nuclear family. Specific predefined criteria are provided for eight of the variables in the instrument’s rating manual (Perry & Herman, 1992). This manual also contains examples of scored vignettes to which the rater can refer when scoring the TAI. The reliability of the TAI variables ranged from acceptable to excellent (median Intraclass R = .73) (Roy & Perry, 2004), and previous studies have demonstrated robust associations between specific types of trauma and both Axis II disorders and self-destructive phenomena (Herman et al., 1989; Van der Kolk, Perry, & Herman, 1991).
Drapeau, M., & Perry, J. C. (2004). Childhood trauma and adult interpersonal functioning: A study using the Core Conflictual Relationship Theme Method (CCRT). Child abuse & neglect, 28(10), 1049-1066.
Herman, J. L., Perry, J. C., & Van der Kolk, B. A. (1989). Childhood trauma in borderline personality disorder. American Journal of Psychiatry, 146, 490–495.
Van der Kolk, B. A., Perry, J. C., & Herman, J. L. (1991). Childhood origins of self-destructive behavior. American Journal of Psychiatry, 148, 1665–1671.
The Core Conflictual Relationship Theme Method (CCRT) is an instrument used in researching process of psychotherapy. In this article, a research work is cited in which this instrument is used in psychotherapy research.
The CCRT method is a measure of central relationship schemas of a person that are revealed through his/her narratives.
The CCRT (Luborsky, 1998) is one of the most employed methods of assessing relationship patterns. Over the last decade, it has been used to study numerous forms of psychopathology and symptom impairment, as well as the process of psychotherapy.
There is also evidence that the CCRT shares many characteristics with Freud’s transference theory. The CCRT assesses interpersonal narratives in three components:
(1) the wishes, needs, motivations or intentions of a subject (W);
(2) the response of others to the subject’s wishes (RO); and
(3) the response of the subject to others’ response (RS).
These three components are rated using the standard categories provided by the method, which includes 35 Wishes, 30 ROs, and 31 RSs. The manual gives detailed descriptions for each Wish, RO, and RS.
The CCRT components are identified in a series of Relationship Episodes (RE) told by the subject during an interview designed to collect such narratives (Relationship Anecdotes Paradigm [RAP]). An RE is a brief story or vignette of an interaction the subject had with another person.
The client’s relationship pattern is studied by analyzing the recorded transcripts of the therapeutic session.
Example from Drapeau & Perry (2004) research:
Title of this research paper is: Childhood trauma and adult interpersonal functioning: A study using the Core Conflictual Relationship Theme Method (CCRT).
The interview starts with the interviewer saying: “I am going to ask you to tell me stories of interactions you have had with others that struck you as particularly important, interesting or troublesome or a combination of those. These interactions must have happened within these last 6 months.” During the interview, the interviewer inquires about the wishes or desires the subject had during the interaction, how the other person involved in the interaction felt or reacted, and how the subject felt or reacted as a result of the other person’s response. The subjects in this study freely chose which stories to report, although the direction specified three general types, specifically occupation, close relationships and any therapy or professional relationship, all within a time-frame of the past 6 months.
The narratives or relationship episodes from 119 subjects were recorded, transcribed then scored using the CCRT method, with each subject giving approximately 10 or 11 recent relationship episodes. The interviews were scored using CCRT coding procedures and the data considered quantitatively.
For any given relationship episode, the rater is required to identify :
which segments represent a W, a RO, and a RS and
use the definitions provided in the manual to attribute a standard category to this specific segment.
This standard category, or score, is descriptive and reflects a specific type of motive or behavior.
Considering the data quantitatively allows us to examine the proportion of each CCRT category across the entire interview in comparison with the proportions in the other categories.
Two experienced raters were used. They rated a total of 8000 relationship episodes. Consensus rating and reliability assessment were don on randomly selected cases (20% of total).
Defining Trauma: Traumatic Antecedents Interview (TAI) Scale is used to determine which of the subject have what kind of traumatic experience. These factors, together with the results of the CCRT scores were tabulated as such.
Here is an example of how the results were interpreted
Example: “Verbal abuse (see table 1). The verbally abused group reported more of the wish to be distant from others (W10; trend only). The verbally abused group experienced others as less strong (RO24) and in interpersonal interactions, they themselves more often reacted by being not open (RS8). However, none of these differences remained significant following the Bonferroni corrections.”
The CCRT instrument seems to give a clear quantified overview of and individual’s relationship patterns. The purpose of reading this research article was to learn about how the CCRT is applied. In addition we are also offered an insight into childhood trauma.
Bond, J. A., Hansell, J., & Shevrin, H. (1987). Locating transference paradigms in psychotherapy transcripts: Reliability of relationship episode location in the core conflictual relationship theme (CCRT) method. Psychotherapy: Theory, Research, Practice, Training, 24(4), 736.
Luborsky, L. (1998). The Core Conflictual Relationship Theme: A basic case formulation method. In T. D. Eells (Ed.), Handbook of psychotherapy case formulation (pp. 53–83). New York: The Guilford Press.
Luborsky, L., & Crits-Christoph, P. (1998). Understanding transference: The Core Conflictual Relationship Theme method (2nd ed.). Washington, DC: American Psychological Association.
Drapeau, M., & Perry, J. C. (2004). Childhood trauma and adult interpersonal functioning: A study using the Core Conflictual Relationship Theme Method (CCRT). Child abuse & neglect, 28(10), 1049-1066.
Conversation analysis is a research method used to study the phenomena that arises within the psychotherapeutic session. Analysis of the conversation is fundamental to change processes psychotherapeutic sessions, since most psychotherapy work is centered around patient-therapist dialogue, as founded on the words, “talking cure” coined by Anna O. the first patient whose therapy sessions were written in-depth by Freud.
“Conversation analysis has a unique place in the cluster of methods generally considered qualitative (Madill and Gough 2008 ). It is avowedly empirical and has a claim to being relatively atheoretical…“
The argument is that conversation analysis
avoids use of pre-conceived theories,
is primarily inductive and data driven.
foundational (assumes that objective principles can be established)
progressive (builds a corpus of knowledge)
no attempt is made to categorize the content of the data with a view to theorizing how social processes or individual experiences are to be understood.
is not concerned with how sociocultural meanings
uses rigorous empirical observations
applies method that will reveal the (normative) rules of conversational exchange
Conversational analysis of psychotherapeutic dialogue begins with transcription of actual recordings of the therapeutic session. Jeffersonian transcription conventions have been designed for this (see http://www.sscnet.ucla.edu/soc/faculty/schegloff/ ) and are under constant development.
Since the work is intensively micro-analytically focused, small areas (phenomena) of interest are identified and studied.
Typically, the sequence of analysis would entail:
identification of a conversation phenomenon of interest,
the collection of a series of instances of that phenomenon from available conversational data,
cross-comparison of these instances in order to determine the common practices through which the phenomenon is regulated (informed by current knowledge regarding interactional exchange),
the presentation of a carefully evidenced and argued case for the pattern discovered using detailed analysis of examples of real conversational data.
Aspects of conversation that are of Interest
There are five main features of talk-in-interaction of interest in conversation analysis:
word selection, and
Madill, A. (2015). Conversation analysis and psychotherapy process research. In Psychotherapy Research (pp. 501-515). Springer Vienna.
There are as many styles of psychotherapy as there are therapists. Within modalities of psychotherapy, one would learn that the art snd style of the therapist’s work are unique to the person of the therapist in relation to the personality of the client.
In this article, I would like to highlight the concept of common factors among all psychotherapeutic work. The significance of the common factors are well established in psychotherapy research (Budge & Wampold 2015).
Verhaeghe, a critic of the mental health profession in general, mentions this:
“It has recently become increasingly clear that the effective factors in therapeutic practice are very much the same, beyond and above the various different paradigms. Every theoretically based clinical practice (psychoanalytic, cognitive behavioral, systemic, experiential . . . ) has its good and bad therapists, and this evidently has less to do with the particular theory than with the way these therapists are (un-)able to handle these common factors (Verhaeghe, 2008. p.72)”
What are the common factors? A meta-study
The meta-study by Grencavage & Norcross (1990) on the common factors that are attributed to psychotherapeutic change process are as follows:
Positive expectation/hope or faith
Distressed or incongruent client
Patient actively seeks help
General positive descriptors
Cultivates hope/enhances expectancies
Socially sanctioned healer
Opportunity for catharsis/ventilation
Acquisition and practice of new behaviors
Provision of rationale
Emotional and interpersonal learning
Success and mastery experiences
Identification with the therapist
Use of techniques/rituals
Focus on “inner world7exploration of
Adherence to theory
A healing setting
There are participants/an interaction
Communication (verbal and nonverbal)
Explanation of therapy and participants’ roles
Development of alliance/relationship (general)
The therapeutic alliance, described as “the quintessential integrative variable” (Wolfe & Goldfried, 1988) and probably the most often cited “common factor” in psychotherapy (Wampold, 2001).
What does this tell us?
The process of change in psychotherapy is a client-therapist dynamic. It is however, the job of the therapist to be effective. In return the client can be trusted to want to go through with the work for his/her own benefit.
That the psychotherapeutic theory alone is not listed explicitly as a common factor, tells us that it is the relationship and the contract to work is important. Education and continued self-awareness of the therapist determines how well the therapist can work with the client, and provide the necessary qualities that the client needs in the therapeutic sessions.
Budge, S. L., & Wampold, B. E. (2015). The relationship: How it works. In Psychotherapy research (pp. 213-228). Springer Vienna.
Grencavage, L. M., & Norcross, J. C. (1990). Where are the commonalities among the therapeutic common factors?. Professional Psychology: Research and Practice, 21(5), 372.