How can we visualize the evolving psychotherapeutic alliance in dialogue? The psychotherapeutic dialogue is an important source of data for psychotherapy outcome and process research. Micro-analyses of dialogical turns within the therapeutic session support the understanding of the therapeutic method. This paper introduces the Helbig Method of Dialogue Analysis. This method is founded upon 4 pillars: 1) that dialogue is implicit action between persons that is supported by explicit verbally uttered content, 2) that the individual’s mode of inter-action within the dialogical dyad reflects the person’s relationship theme or pattern which plays out in the here-and-now, 3) that dialogue is an intersubjective process that leads to the development of new intersubjective configurations, and 4) that the observer-researcher’s phenomenological involvement plays a part in the analytical process. In this study, a 28-minute video-recorded gestalt therapy session is selected. The transcription of the session is coded using the instrument, the Core Conflictual Relationship Theme Leipzig/Ulm. Results obtained from this study are quantified graphical representations of the developing relationship between therapist and client. Simple to operate, scalable and practical, this method is designed for use by therapists and researchers who are interested in tracking, comparing and/or contrasting the developing psychotherapeutic alliance in a single or in multiple psychotherapy sessions.
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.
“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.
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.
These are summarized findings obtained from this 2008 study by Jennings et. al. entitled Psychotherapy expertise in Singapore: A qualitative investigation. The researcher cited Singapore as a good place for studying psychotherapy due to it cultural diversity relative to its geographical size.
In this study, a group of 9 therapists and/or counselors were selected from a pool based on being seconded by colleagues as “master therapists”. The interviews were conducted with structured questions, and video-taped. These were later analyzed using grounded theory.
Results of the Study
Here are the viewpoints of the master therapists.
Needed personal characteristics that therapists should have:
Empathic : Master therapists spoke of possessing a great empathy for their clients. As one master therapist explained, once the client felt genuinely understood and accepted in whatever circumstances, true change and healing began.
Non-judgmental: This trait can produce a sense of safety for clients.
Respectful: The master therapists were mindful of their impact on clients and the importance of working with clients in a respectful manner. Respect for clients, whoever they are and whatever their issues may be, was a pervasive theme among these master therapists.
Needed developmental influences that therapists should have are:
Experience: The interviewees described a journey, explaining the many elements that created and influenced their path to expertise. When exploring elements of expertise, experience was mentioned frequently as an important factor. One master therapist made the point that there were no quick developmental influences and no guarantee that experience alone leads to expertise.
Self-awareness: The master therapists spoke of how their self-awareness has served them well when conducting therapy. One master described it as recognizing your internal processes when working with clients and being able to be a participant/ observer of interactions with clients.
Humility. The master therapists recognized humility as another important component in the development of expertise. Recognizing one’s limits may serve as a source of motivation and growth. One master therapist described the importance of the humbling process of recognizing and learning from one’s mistakes.
Self-doubt: Despite their experience and reputation, some of the master therapists addressed another issue related to the development of expertise* periodic self-doubt*and how this feeling motivated them to keep growing their clinical skills.
Therapists’ approach to practice:
Balance between support and challenge: Many of the master therapists spoke of the importance of maintaining a balance between support and challenge when working with clients.
Flexible therapeutic stance. The master therapists described a flexible approach in their work with Psychotherapy clients. If client variables required them to adapt their style, they did. One theory does not fit all.
Empowerment/strength-based approach: A number of master therapists spoke about their clients’ internal resources and how the therapist’s task was to reinforce these strengths and bring them to bear in dealing with the problem at hand.
Primacy of the therapeutic alliance: Many of the master therapists acknowledged the importance of the therapeutic relationship. The impact of the relationship varied from a necessary condition in the therapeutic process to the relationship being the actual source of healing.
Comfortable addressing spirituality: Beyond observance of any particular religion, many master therapists spoke of a broad personal spiritual mind-set, which primarily functioned as a backdrop when working with clients but also included some therapists privately praying for clients.
Embraces working within a multicultural context: A number of master therapists spoke of the importance of cultural awareness in their work and the challenges of adapting Western therapeutic approaches to Eastern values and systems.
On on-going professional growth:
Professional development practices: Professional development, a key factor in developing and maintaining expertise, was not limited to conferences, literature, or textbooks. One master therapist believed that therapists should extend beyond their areas of practice to broaden development.
Benefits of teaching/training others: Now highly regarded and seasoned, the master therapists have much to offer other therapists. Many of the master therapists viewed teaching and training as an opportunity to hone their own skills and to reflect upon their practice.
Challenges to professional development in Singapore. During the interviews, master therapists identified several ‘‘professional growth edges’’ in the Singapore psychotherapy profession. For instance, a training need recognized by several therapists was that of basic counseling skills. One master therapist explained that basic counseling skills are not natural for many Singaporean trainees.
Comments on the Study and it’s Results
As a Singaporean therapist with training in Austria, it appears that what the master therapists highlight regarding personal characteristics, development and education of therapists are not so different in Singapore than in Europe.
There is one difference that stands out for me, and that is of the need of the Singapore-based therapist to address spirituality. Although it is also important in Europe, the emphasis in this article gives me the impression that is more important and challenging in Singapore.
What is somewhat disappointing about the results is that (and it was articulate also in the article) is that the Master therapists shared very little of their own emotional experiences. The researchers attributed it to the cultural background of the therapist. As someone doing qualitative research myself, I am of the opinion the it is the job of the researchers to lead the subjects to provide this information.
It could be that the shortfall in this study is the interviewers own discomfort in checking with the interviewees on more personal levels.
As a whole, I do agree that Singapore is good ground for psychotherapy research.
Jennings, L., D’Rozario, V., Goh, M., Sovereign, A., Brogger, M., & Skovholt, T. (2008). Psychotherapy expertise in Singapore: A qualitative investigation. Psychotherapy research, 18(5), 508-522.
CCRT is employed in this research paper to study Gestalt and Emotive Behavioral Therapy sessions with adolescence.
With a standard treatment CCRT, 4 sessions are analyzed, 2 early
and 2 late with around 20 RE’s in all.
“In this study, only one therapy session for each of two clients was available and, therefore, only single session CCRT’s were formulated. A session CCRT is said to be “a special version of the CCRT and may differ slightly from the treatment CCRT” (Luborsky, 1990b, p. 32). “
“Relationship episodes (RE’s) were demarcated on the written transcripts and judged as to their completeness. When the RE’s judged complete enough for the study were isolated, they were then examined for the three major components: wishes, responses from others and responses from self. A set of standard categories is available for describing the three components of the CCRT (Barber, Crits Christoph & Luborsky, 1990).”
“The standard category system is recommended for use with research while a tailor-made system seems to be more useful for clinical work. The second edition of the standard category system was used in this study. After each component was categorized, those occurring with the greatest frequency across RE’s were drawn together and the clients’ CCRT’s were formulated. A comparison was then made between the two treatment orientations.”
Agin, S., & Fodor, I. E. (1996). The use of the Core Conflictual Relationship Theme method in describing and comparing gestalt and rational emotive behavior therapy with adolescents. Journal of rational-emotive and cognitive-behavior therapy, 14(3), 173-186.
This short note features the work of Stirn et.al. (2005) entitled, An analysis of two novels written by authors suffering from anorexia nervosa.
The methodology was to analyze 2 novels written by 2 different authors who are known to have survived anorexia nervosa.
Objective: Two literary works of authors suffering from anorexia nervosa were analyzed with the method of the core conflictual relationship theme (CCRT) to prove that novels and/or personal accounts may reveal the same maladaptive relationship patterns typically revealed in psychotherapy sessions with this nosologic group.
Method: Two novels, Valerie Valere’s The House of the Crazy Kids and Andrea Graf’s Die Suppenkasperin, were selected which promised applicability of the CCRT method due to the completeness of the described relationship episodes.
Results: After several methodologic adjustments, the application of the CCRT method revealed the different courses and developments of the novels. Both the positive and negative as well as the conscious and unconscious relationship patterns were clearly expressed.
Discussion: The results indicate that after certain adjustments, the CCRT method may be successfully applied to data obtained from sources other than psychotherapy sessions.
More examples of tables:
Stirn, A., Overbeck, G., & Pokorny, D. (2005). The core conflictual relationship theme (CCRT) applied to literary works: An analysis of two novels written by authors suffering from anorexia nervosa. International Journal of Eating Disorders, 38(2), 147-156.
Client Centered, psychodynamic, behavioral, cognitive, group psychodynamic, and systemic orientations are included in the CPIRS.
Apart from these orientations, interventions and attitudes derived from common factors are included. The scale is also useful in determining how far the treatment is eclectic/integrative or pure form.
Items of the Interventions Rating Scale
3 Studies were carried out, that are also presented in this article to validate this scale.
The first 2 studies indicated unconvincing differentiation between psychodynamic therapies and experiential therapies studied. The differentiation was clearer in the third study.
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.