Stephanie Keller, doctoral student in clinical psychology and one of the study’s researchers
The study, “Patterns of Therapeutic Alliance: Rupture-Repair Episodes in Prolonged Exposure for PTSD,” reported in the Journal of Consulting and Clinical Psychology online article, is among the first to examine how rifts in the relationship between the therapist and client can damage a patient’s treatment outcome.
An alliance rupture may occur when there is a break in the therapist-client bond. For example, ruptures in the therapeutic relationship may occur when therapeutic progress stalls, negative feelings arise between the therapist and client or when the work in therapy becomes challenging.
“We want therapists to know that a rupture in the therapeutic relationship isn’t a bad thing, as long as the therapist tends to it,” said Stephanie Keller, one of the study’s researchers and a CWRU doctoral student in clinical psychology. “However, if the rupture is not repaired, then your patient may not do as well in treatment.”
The research study included 116 people who experienced a traumatic event and received a primary diagnosis of PTSD. Participants engaged in a 10-session treatment program called prolonged exposure therapy.
To help therapists chart progress and examine the therapeutic relationship, each client assessed his or her own PTSD symptoms and perception of his/her relationship with the therapist during treatment.
This helped researchers identify the clients who experience no ruptures in the therapeutic relationship (a stable relationship), clients who experienced a rupture that was subsequently repaired and those with ruptures that went unrepaired.
The first prolonged exposure session outlined what would happen over the course of treatment to set specific goals. Exposure-based exercises began in the second session, which included exposure to anxiety-provoking situations that served as trauma-reminders and talking about their traumatic experiences.
In this sample, 28 percent of patients experiences a repaired rupture and 18 percent experienced a rupture, or dip in the therapeutic relationship, that was never repaired. An unresolved rupture in the therapist-client relationship became a predictor for a poorer outcome in treatment, Keller said.
She also said more research is needed to figure out why these alliance ruptures occur and how to best repair them.
The research was funded through a National Institute of Mental Health PTSD research project, directed by Norah Feeny from Case Western Reserve University and Lori A. Zoellner from the University of Washington.
Other researchers contributing to the project were lead investigator and Case Western Reserve alumna AnnaMaria Aguirre McLaughlin and Eric A. Youngstrom of the University of North Carolina at Chapel Hill.
Case Western Reserve University