1 Oxford Doctoral Course in Clinical Psychology THE THERAPEUTIC ALLIANCE, RUPTURES ...

225 Pages·2015·2.45 MB·English

by  Christopher Laraway

Oxford Doctoral Course in Clinical Psychology

THE THERAPEUTIC ALLIANCE, RUPTURES, AND SESSION-BY-SESSION
FEEDBACK

Christopher James Laraway

A thesis submitted in partial fulfilment of the requirements of the degree of Doctor of
Clinical Psychology, validated by the University of Oxford

(Trinity Term)

July 2015

Word Count: 19,863
(Paper A: 9684; Paper B: 10,179)
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The Therapeutic Alliance, Ruptures, and Session-by-Session Feedback
Christopher James Laraway
Harris Manchester College, University of Oxford, Doctorate in Clinical Psychology
(Trinity Term 2015)
Abstract
The therapeutic alliance has consistently been found to be predictive of good outcome
across a number of different therapeutic modalities and in a number of different intervention
types. Ruptures in the therapeutic alliance are critical points in therapy for exploration and
change. Resolving ruptures in the therapeutic alliance can lead to a stronger therapeutic
alliance and improved outcome, and unresolved ruptures in the therapeutic alliance have been
linked to poor outcome and drop-out. Session-by-session feedback on the therapeutic alliance
is an integral part of the most successful feedback systems known to improve outcome. Little
is known regarding how this may be used within the rupture resolution process.
The review paper systematically evaluates the link between the therapeutic alliance
and outcome in group interventions. Two types of group interventions were reviewed: CBT
groups, and psychotherapy groups. A significant relationship between the therapeutic alliance
and outcome in group interventions was found, although there were major methodological
flaws in the studies reviewed.
The empirical paper employed a task analytic design to develop a model for how
session-by-session feedback on the therapeutic alliance could be used to inform the rupture
resolution process. Experts were interviewed to develop a theoretical model. This was then
combined with an empirical model developed through analysis of the in-session performance
of a therapist and four of their individual patients. This model shared similarities with
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existing models of rupture resolution, however noticeable differences were found. These are
discussed, alongside limitations of the study and implications for clinical practice and future
research.

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Acknowledgements
I would like to thank all five participants who so kindly allowed their therapy to be
recorded as part of this project. I would also like to thank Dr Michael Lambert, Dr Scott
Miller, Dr Rolf Holmqvist, and Dr David Green, for generously sharing their considerable
expertise. In particular, thank you to Dr Jeremy Safran, for his considered thoughts on this
study as it progressed.
A big thank you to James Macdonald, whose passion for this area has been
infectious. His thoughtful advice and continued support have been invaluable throughout. I
hope I have taken care of my reader. Thanks also to Anne-Marie Daly for the careful reading
of transcripts, methodological advice, and whose words of encouragement have kept me
going. Thank you to Carmen Chan, who despite joining after the beginning of this project has
been generous with her time, spirit and contributions.
To my friends both on and off the course. Your encouragement, support, and ability
to make me laugh have helped me through at every stage of this project.
Finally, and most importantly, to my family. This would not have been possible
without your unwavering support, patience, and belief in me. A special thank you to my
mother Janice, and my sister Amy, who have helped me take every step of this journey.

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Contents
Paper A
Paper A Abstract ...................................................................................................................... 15
Introduction .............................................................................................................................. 16
Group Psychotherapy ........................................................................................................... 16
Outcome ............................................................................................................................... 17
Therapeutic Alliance ............................................................................................................ 18
Therapeutic Alliance and Outcome ..................................................................................... 19
Individual therapy. ........................................................................................................... 19
Couples and family therapy. ............................................................................................ 19
Group therapy. ................................................................................................................. 19
Therapeutic Alliance and Cohesion ..................................................................................... 21
Rationale for Review ........................................................................................................... 22
Aim of Current Review ........................................................................................................ 22
Method ..................................................................................................................................... 22
Search Strategy .................................................................................................................... 22
Inclusion Criteria ................................................................................................................. 23
Flow Diagram of Screened and Included Studies…………………………………………24
Procedure ........................................................................................................................... 255
Results ...................................................................................................................................... 37
Characteristics of Studies ..................................................................................................... 37
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Intervention type. ............................................................................................................. 37
Conceptualisation of the alliance. .................................................................................... 37
Alliance measure. ............................................................................................................. 37
Target Problem................................................................................................................. 39
Group CBT Findings............................................................................................................ 40
Alliance as predictive of outcome. ................................................................................... 40
Correlation between alliance and outcome. ..................................................................... 41
No alliance-outcome link. ................................................................................................ 42
Group Psychotherapy Findings ............................................................................................ 42
Alliance as predictive of outcome. ................................................................................... 42
Correlation between alliance and outcome. ..................................................................... 45
No outcome-alliance link. ................................................................................................ 46
Critique .................................................................................................................................... 46
Participant Demographics .................................................................................................... 46
Study Design and Methodology........................................................................................... 47
Sample size. ..................................................................................................................... 47
Alliance measures. ........................................................................................................... 47
Timing of alliance assessment. ........................................................................................ 48
Outcome measures. .......................................................................................................... 48
Follow up………………………………………………………………………..………49
Confounding variables.. ................................................................................................... 49
Ethical issues. ................................................................................................................... 50
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Discussion ................................................................................................................................ 50
Implications for Clinical Practice and Research .................................................................. 54
Limitations of Review.......................................................................................................... 55
References ................................................................................................................................ 57

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Contents
Paper B
Paper B Abstract ...................................................................................................................... 70
Introduction .............................................................................................................................. 71
The Therapeutic Alliance ..................................................................................................... 71
Ruptures in the Therapeutic Alliance .................................................................................. 71
Repairing Ruptures in the Therapeutic Alliance .................................................................. 72
Session-by-Session Feedback on the Therapeutic Alliance................................................. 73
Aims of the Present Study.................................................................................................... 75
Research Questions .............................................................................................................. 75
Method ..................................................................................................................................... 75
Design .................................................................................................................................. 75
Participants ........................................................................................................................... 76
Inclusion Criteria. ............................................................................................................ 77
Exclusion Criteria. ........................................................................................................... 77
Measures .............................................................................................................................. 77
Session Rating Scale. ....................................................................................................... 77
Post Session Questionnaire. ............................................................................................. 78
Rupture Marker Coding Form. ........................................................................................ 78
Interview Schedule........................................................................................................... 78
Procedure ............................................................................................................................. 78
Rational Model................................................................................................................. 78
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Empirical Model. ............................................................................................................. 79
Selection of Sessions for Analysis. .................................................................................. 79
Data Analysis ....................................................................................................................... 80
Research Question One. ................................................................................................... 80
Research Question Two. .................................................................................................. 80
Research Question Three. ................................................................................................ 81
Quality Checks ..................................................................................................................... 82
Credibility. ....................................................................................................................... 82
Triangulation. ................................................................................................................... 82
Coherence and Transparency. .......................................................................................... 82
Reflexivity........................................................................................................................ 82
Transferability. ................................................................................................................. 83
Ethical Considerations ......................................................................................................... 83
Results ...................................................................................................................................... 83
The Rational Model ............................................................................................................. 83
Creating a Culture of Feedback ........................................................................................... 86
Triangulation ........................................................................................................................ 86
Therapist Internal Work & Sensitivity to Feedback ............................................................ 87
Deciding Whether to Pursue ................................................................................................ 87
Enabling/Empowering Negative Feedback.......................................................................... 88
Clarification/Elaboration...................................................................................................... 88
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Bond ..................................................................................................................................... 89
Task/Goals ........................................................................................................................... 90
Re-Engagement .................................................................................................................... 90
Successful Failure ................................................................................................................ 90
The Empirical Model ........................................................................................................... 91
Session Selection. ............................................................................................................ 91
Creating a Culture of Feedback ........................................................................................... 94
Attentiveness to Feedback ................................................................................................... 95
Emphasising Importance of Feedback ................................................................................. 95
Clarification/Elaboration...................................................................................................... 96
Therapist Contribution ......................................................................................................... 96
Client Contribution .............................................................................................................. 97
Making Links ....................................................................................................................... 98
Re-negotiation ...................................................................................................................... 98
The Rational-Empirical Synthesis ....................................................................................... 99
Discussion .............................................................................................................................. 103
The Findings in Relation to Clinical and Empirical Literature .......................................... 103
Session-by-Session Feedback. ....................................................................................... 103
Ruptures in the Therapeutic Alliance. ........................................................................... 103
Existing Models of Rupture-Resolution. ....................................................................... 104
Covert Client Processes. ................................................................................................ 104
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