V-episodes in the alliance: A single-case application of multiple methods to identify rupture repair.

Abstract

The therapeutic alliance has been consistently found to be a robust predictor of therapeutic outcome across various modalities of psychotherapy. Alliance ruptures are thought to occur commonly within each therapeutic dyad and, if left unresolved, are associated with premature termination and worsened psychotherapy outcome. Research efforts have identified V-shaped shifts in the alliance, characterized by a high-low-high pattern of postsession alliance scores, as a meaningful method of operationalizing rupture-repair episodes, but these efforts rarely evaluate the within-session process of the identified sessions. As a result, it is often unclear whether these sessions identified by methods based on postsession alliance measures are reflective of clinically meaningful within-session rupture process. This article aims to further explore the V-episode operationalization of rupture-repair episodes by assessing for convergence between rupture process identified by between-session measures and the within-session observer-based Rupture Resolution Rating Scale (3RS) in a single patient-therapist dyad in a 30-session brief relational therapy. V-episodes were operationalized using various previously utilized methods to identify ruptures based on postsession measures of alliance. Results of this case study demonstrate that postsession patientrated V-episodes in the therapeutic alliance can be indicative of within-session rupture process, demonstrating convergence between within-and between-session measures of alliance process. Implications of these results for methodological approaches for identifying alliance ruptures are discussed. Clinical Impact StatementQuestion: Given that ruptures in the therapeutic alliance can weaken the strength of the alliance, and if unrepaired, can lead to treatment failure, this article seeks to address whether alliance measures are capable of accurately identifying clinically meaningful rupture process. Findings: When used to track the course of psychotherapy, commonly used alliance measures may capture clinically significant shifts in alliance development, including rupture and rupture repair processes. Meaning: Using V-episodes to operationalize alliance rupture repair process based on postsession alliance measures may help researchers and clinicians to identify and intervene on clinically meaningful psychotherapy process. Next Steps: Future studies might examine whether therapist ratings, rather than patient ratings, of alliance produce similar results.

Can session-by-session changes in self-reported alliance scores serve as a measure of ruptures in the therapeutic alliance?

“…The goal of the present study was to assess whether session-by-session changes in self-reported alliance scores can serve as a measure of ruptures in the therapeutic alliance. In line with our hypothesis and Lipner et al (2023), sessions with a drop in the alliance rating based on a case-sensitive method differed from randomly selected sessions of the same treatment phase by presenting more rupture markers and a higher impact of ruptures. Case-sensitive methods take reporter variability in alliance ratings into account when assessing the presence of ruptures and may actually represent a parsimonious tool to identify ruptures in psychotherapy sessions to provide therapists with meaningful feedback about when they occur.…”

“…Alliance ruptures can be measured in various ways: (a) by means of observer-based ratings of what happens in the therapy sessions (e.g., Rupture Resolution Rating System [3RS]; Eubanks et al, 2015), (b) by directly asking the patient and/or the therapist questions about the occurrence of a rupture in the session, or (c) by identifying declines in self-reported alliance ratings based on some criterion and interpreting these drops as indirect measures of ruptures (Eubanks et al, 2018). A review of rupture identification methodologies based on alliance self-report measures indicated a wide range in the frequency of ruptures across studies (Lipner et al, 2023), likely reflecting the lack of consistency between various methods. Eubanks-Carter et al (2012) differentiated between two methods to identify rupture sessions using indirect assessment: the criterion-based and the case-sensitive method.…”

“…Conversely, case-sensitive methods of rupture identification apply a unique formula or algorithm to each individual dyad within a given sample, for example, a drop in the alliance rating by 1, 1.5, or 2 SDs below the individual mean alliance Working Alliance Inventory (WAI) score across treatment (e.g., Lipner et al, 2022). Case-sensitive methods take reporter variability in alliance ratings into account when assessing the presence of ruptures and, as a result, may be a more conservative estimate of rupture occurrence than criterion-based methods (Lipner et al, 2023). Further, more conservative approaches to coding rupture within the case-sensitive methods (i.e., at least 2 SDs below the individual mean alliance score) identified potential rupture events that were more strongly associated with treatment outcome (Lipner et al, 2022).…”

“…Eubanks et al (2019) found evidence of some divergence between patient-rated WAI and observer-rated 3RS: Using a sample of early CBT sessions of a CBT treatment, they conducted correlations between 3RS ratings and postsession patient-rated WAI and found moderate but nonsignificant associations between rupture and alliance ratings. However, Lipner et al (2023) explored various methods to identify ruptures based on changes in the WAI and assessed for convergence with the 3RS in a single patient–therapist dyad in a 30-session brief relational therapy. Results of this case study demonstrated preliminary evidence that (case-sensitive) postsession patient-rated alliance drops corresponded with within-session rupture process as measured with the 3RS.…”

Therapist and client perceptions of the working alliance: Codevelopment, linear growth, variability, and client functioning.

“…Moderator analyses found that this association between rupture and repair and outcome was not related to how rupture and repair were operationalized (e.g., direct vs. indirect assessment). In addition, recent research shows that these V-shaped patterns are associated with observer-rated within-session rupture processes (Lipner et al, 2023). Therefore, V-shaped patterns of alliance ratings are indicators of a rupture-and-repair process, which is associated with client improvement.…”