Research: Rupture Resolution Rating System (3RS)

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:

  1. 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.
  2. confrontation ruptures : moving against the therapist, expressing anger, dissatisfaction by trying to pressure or control the therapist /therapy
  3. Both

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

Bibliography

Eubanks-Carter, C. F., Muran, J. C., & Safran, J. D. (2014). Rupture resolution rating system (3RS): Manual.

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Research: The Psychotherapeutic Alliance in Research

Interdependent factors that make an alliance:

  • *the agreement between patient and therapist on the tasks and goals of treatment and
  • *the affective bond between patient and therapist.

Ruptures

Refer also to the 3RS manual on ruptures here.

Ruptures are understood as: misunderstanding events, impasses, alliance threats and markers of enactments.


A rupture is a deterioration in the alliance, manifested by

  1. a lack of collaboration between patient and therapist on tasks or goals, or
  2. by a strain in the emotional bond.

Although the word “rupture” connotes a major breakdown in the relationship, the term is also used to describe minor tensions of which one or both of the participants may be only vaguely aware. Ruptures can be obstacles to treatment and can contribute to patient dropout.

Resolution of Rupture as Opportunity for Therapeutic Change

Successful resolution of a rupture can serve as a corrective emotional experience (Alexander & French, 1946), providing a powerful opportunity for therapeutic change

Recognizing the negative impact that unresolved ruptures can have on
treatment outcome, and realizing that these ruptures can go unnoticed by the therapists research is done that is centered around the investigation of whether integrating rupture resolution techniques can improve the efficacy of a particular treatment.

The chapter in this reference gives a detailed account of the kind of research that has been done, that works on the alliance rupture and repair, with the goal of improving probability of training therapists to focus on the alliance.

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Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80-87.
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Barber, J. P., Khalsa, S. R., Sharpless, B. A., Muran, J. C., & Barber, J. P. (2010). The validity of the alliance as a predictor of psychotherapy outcome. The therapeutic alliance: An evidence-based guide to practice, 29-43.

Empirical studies that have shown that alliance is correlated to good outcome:

Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 37–70). New York: Oxford University Press.

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450.

Samstag, L. W., Batchelder, S. T., Muran, J. C., Safran, J. D., & Winston, A. (1998). Early identification of treatment failures in short-term psychotherapy: An assessment of therapeutic alliance and interpersonal behavior. Journal of Psychotherapy Practice and Research, 7, 126–143.

Samstag, L. W., Muran, J. C., Wachtel, P. L., Slade, A., Safran, J. D., & Winston, A. (2008). Evaluating negative process: A comparison of working alliance, interpersonal behavior, and narrative coherency among three psychotherapy outcome conditions. American Journal of Psychotherapy, 62, 165–194.

Tryon, G. S., & Kane, A. S. (1990). The helping alliance and premature termination. Counselling Psychology Quarterly, 3, 233–238.

Tryon, G. S., & Kane, A. S. (1993). Relationship of working alliance to mutual and unilateral termination. Journal of Counseling Psychology, 40, 33–36.

Tryon, G. S., & Kane, A. S. (1995). Client involvement, working alliance, and type of therapy termination. Psychotherapy Research, 5, 189–198.

Reference

Eubanks-Carter, C., Muran, J. C., & Safran, J. D. (2010). Alliance ruptures and resolution. The therapeutic alliance: An evidence-based guide to practice, 74-94.

Index of this book:

I. Critical Studies of the Therapeutic Alliance

  1. Alliance Theory and Measurement 7 Robert L. Hatcher

  2. The Validity of the Alliance as a Predictor 29 of Psychotherapy Outcome Jacques P. Barber, Shabad-Ratan Khalsa, and Brian A. Sharpless

  3. The Alliance over Time 44 William B. Stiles and Jacob Z. Goldsmith

  4. Qualitative Studies of Negative Experiences 63 in Psychotherapy Clara E. Hill

  5. Alliance Ruptures and Resolution 74 Catherine Eubanks-Carter, J. Christopher Muran, and Jeremy D. Safran xiv

Contents II. Practice and the Therapeutic Alliance

  1. A Psychodynamic Perspective 97 on the Therapeutic Alliance: Theory, Research, and Practice Stanley B. Messer and David L. Wolitzky 7. An Interpersonal Perspective on Therapy 123 Alliances and Techniques Lorna Smith Benjamin and Kenneth L. Critchfield 8. The Therapeutic Alliance 150 in Cognitive-Behavioral Therapy Louis G. Castonguay, Michael J. Constantino, Andrew A. McAleavey, and Marvin R. Goldfried 9. A Functional Analytic Psychotherapy (FAP) 172 Approach to the Therapeutic Alliance Mavis Tsai, Robert J. Kohlenberg, and Jonathan W. Kanter 10. The Therapeutic Alliance 191 in Humanistic Psychotherapy Jeanne C. Watson and Freda Kalogerakos 11. Therapeutic Alliances in Couple Therapy: 210 The Web of Relationships Adam O. Horvath, Dianne Symonds, and Luis Tapia 12. Therapeutic Alliances and Alliance Building 240 in Family Therapy Valentín Escudero, Laurie Heatherington, and Myrna L. Friedlander 13. The Therapeutic Alliance in Group Therapy 263 William E. Piper and John S. Ogrodniczuk III. Training Programs on the Therapeutic Alliance 14. Developing Skills in Managing 285 Negative Process Jeffrey L. Binder and William P. Henry Contents xv 15. Training in Alliance-Fostering Techniques 304 Paul Crits-Christoph, Katherine Crits-Christoph, and Mary Beth Connolly Gibbons 16. Developing Therapist Abilities to Negotiate 320 Alliance Ruptures J. Christopher Muran, Jeremy D. Safran, and Catherine Eubanks-Carter 17. Coda: Recommendations for Practice 341 and Training Brian A. Sharpless, J. Christopher Muran, and Jacques P. Barber