Repairing Ruptures in the Therapeutic Alliance

:Ruptures (i.e., deteriorations or strains in the therapeutic alliance) are an inevitable part of any psychotherapy. They are not only common but are also clinically meaningful. If not adequately attended to, ruptures are associated with poor therapy outcome and premature termination. Fortunately, a strong research base is available that provides clinically useful guidance for identifying and resolving alliance ruptures. After a brief review of the theoretical and empirical literatures, a list of “markers” used to identify the two subtypes of ruptures (i.e., withdrawal and confrontation) is provided. Proper assessment of the subtype is critical, as they each require slightly different rupture resolution techniques across a four-stage process. Finally, a list of specific rupture resolution techniques is provided.

The Process of Interpretation

Interpretations are efforts by the therapist to connect conscious (or preconscious) feelings, thoughts, and behaviors (e.g., symptoms) to the unconscious materials that gave rise to them. Interpretations may consist of therapist observations or the presentation of a hypothesis that goes beyond what the patient already knows. Interpretations are often considered to be the epitome of the expressive therapy approach and, when done well, have been empirically linked to a positive outcome. Unfortunately, many beginning therapists are reluctant to use interpretations due to their complexity. Therefore, this chapter describes a clear, six-step procedure for generating psychodynamic interpretations and presenting them to patients. It also includes a list of questions for therapists to answer as they organize patient material. The chapter concludes with a lengthy clinical vignette following the six-step process and a discussion of the potential risks and rewards of interpretation.

The Supportive–Expressive Continuum

Psychodynamic therapy can be flexibly applied to a wide range of psychopathology. However, different patient problems imply different techniques. If inappropriate interventions are used, therapy progress could stall or negative patient events could occur. A useful tool for selecting the best mix of psychodynamic techniques is the supportive–expressive continuum. When patients are properly situated on this continuum, it is far easier to choose interventions. After the different intentions of the more purely supportive or expressive therapies are described, the clinical indicators for each approach are listed. Finally, patient transitions along the continuum (i.e., they require a different mix of supportive and expressive techniques) are discussed with suggestions on how to make these changes while minimizing therapy disruptions.

Supportive Therapy Techniques Part II

This chapter concludes the section on supportive therapy and describes four additional sets of techniques with clinical examples. Interventions that are intended to reduce and prevent unhelpful anxiety or other emotions are discussed first. These include techniques such as supportive bypassing, encouraging the use of adaptive defenses, and reframing. Next, supportive approaches meant to enhance patient self-awareness are discussed (e.g., the use of “upward explanations”). A third set of interventions focuses on what have been called, for lack of a better term, “parenting strategies.” Examples include containing affect, setting limits, and providing limited advice. Techniques to create and sustain a positive therapeutic alliance are discussed last. Displaying interest and empathy, sharing agendas, jointly agreeing upon treatment contracts, and many other approaches and interventions serve to foster a therapeutic alliance. The alliance is a critical component of all therapies and may be particularly challenging to achieve with lower-functioning patients. The chapter concludes with a discussion of the process of “working through” in supportive therapies.

Supportive Therapy Techniques Part I

A number of patients seen in contemporary clinical practice are not appropriate for traditional insight-oriented therapy (i.e., expressive approaches). These may include sicker patients or those who are not interested in exploratory work. Supportive therapy refers to a flexible treatment approach that is intended to be responsive to the particular needs of these patients. Supportive therapy also benefits from the integration of techniques from other orientations (e.g., cognitive-behavioral therapy). After discussing supportive therapy more generally and differentiating it from the expressive approaches, this chapter focuses on two sets of supportive techniques. The first focuses on ways to support and enhance realistic patient self-esteem. The second set consists of techniques used to increase patient knowledge and build adaptive skills (e.g., psychoeducation, reality testing).

Foundational Techniques Part II

This second chapter on foundational techniques begins with a discussion of how psychodynamic therapists typically behave. These behaviors often differ markedly from normal social conventions but help maintain professional boundaries and a therapeutic focus on the patient. An example of this is therapist ambiguity, or limiting the patient’s general knowledge about the therapist’s personal history and beliefs (e.g., limiting reciprocal self-disclosure). Another example is psychodynamic abstinence, or not gratifying the patient’s unhealthy wishes or desires. Technical neutrality is also considered in the context of the patient’s level of personality organization but, in general, consists of taking a nonjudgmental stance. Finally, therapists model healthy and adaptive behaviors for their patients (e.g., thoughtfulness, honesty). The second section of this chapter focuses on how to begin a course of psychodynamic psychotherapy. Therapy contracts, the therapeutic alliance, and ways to socialize patients into treatment are all discussed.

Goals of Psychodynamic Therapy

After briefly discussing the process of “translating” a patient’s desire for change into usable psychodynamic targets for change, eight specific therapy goals are described. These include several that have been discussed since the earliest days of psychoanalysis (e.g., the generation of insight, an increased ability to love and work, personality change) as well as the more transtheoretical goals of autonomy from the therapist and symptom reduction. Goals derived from existential versions of dynamic therapy are also considered (e.g., acceptance of that which cannot be changed; an increased sense of meaning and purpose). Specific suggestions for assessing clinical progress (e.g., questionnaires and interviews) and relevant citations are listed in a table and at the end of each section.

Introduction

This introductory chapter discusses the complexity of psychotherapy in general and the difficulty of learning psychodynamic therapy in particular. After discussing historical reasons for the latter (e.g., inconsistent definitions of key terms across authors; significant theoretical developments over the past 120 years), the author details his approach to differentiating the various psychodynamic techniques. Specifically, the individual techniques are distinguished from one another according to their clinical intentions. Next, the book outlines the background knowledge required to make the most use of this work (e.g., experience with psychodynamic case formulation and risk assessment). Finally, the three sections of the book and the appendix are briefly outlined.

The Process of Questioning

Therapist questions are meant to generate patient information that is unknown to the therapist but needed for treatment. They are used to (a) facilitate free association/foster patient exploration and (b) to gain specific information about the patient, their problems, and the unique ways that they think, feel, behave, and respond to the therapy process. Suggestions are provided for the proper wording of questions as well as determining an appropriate frequency for their use. This is because an overuse of questions, or even the inclusion of irrelevant questions, can derail the therapy process and lead to alliance ruptures. However, questions can be used to meet a number of important clinical aims and are a necessary part of any treatment. The chapter ends with a consideration of how therapists can effectively handle patient questions.

The Psychodynamic “Stance”

The psychodynamic stance (as known as the psychodynamic sensibility) is a collection of essential values and theoretical assumptions that support a therapist’s moment-to-moment practice. This chapter describes 13 components of the psychodynamic stance and situates them in historical and theoretical contexts. Several of these components are fairly unique and serve to distinguish psychodynamic therapy from other approaches. It is argued that the process of articulating one’s stance facilitates the selection and use of specific psychodynamic techniques. Further, when unexpected clinical events occur, a therapist’s stance can serve as a useful guide for difficult decisions. Throughout the chapter, the common mistakes of beginning therapists (e.g., intervening too quickly, placing their values on the patient) are explored and suggestions are provided.