Babl, A., Rubel, J., Gómez Penedo, J. M., Berger, T., Grosse Holtforth, M., & Eubanks, C. F. (2023). Can session-by-session changes in self-reported alliance scores serve as a measure of ruptures in the therapeutic alliance? Journal of Consulting and Clinical Psychology. Advance online publication. https://doi.org/10.1037/ccp0000861
The therapeutic alliance is a robust predictor of patient outcomes in psychotherapy. One can define the alliance as the collaborative agreement between patient and therapist on the goals of therapy (what is the desired outcome) and tasks of therapy (how therapy should proceed), and the relational bond between patient and therapist. Ruptures in the therapeutic alliance are breakdowns or tensions in the relationship between therapist and patient in any of the three core components of the alliance (agreement on goals and tasks, and the bond). If ruptures go unaddressed, they can lead to poor outcomes or patient dropout. Despite the practical importance of the alliance and of identifying alliance ruptures, therapists often feel at a loss when it comes to detecting a rupture. Ruptures can be characterized by patient behaviours that indicate withdrawal from the therapist (going silent, abstract, or vague responses) or confrontation with the therapist (complaining or rejecting interventions). However, therapists may not always be aware that a rupture in the alliance has occurred, and so they may need help to identify an alliance rupture. One source of help is to have patients complete a brief self-report measure of the state of the therapeutic alliance at the end of each session. In this study, Babl and colleagues asked 58 patients with depression who received CBT to rate the therapeutic alliance with a short validated scale (i.e., the Working Alliance Inventory [WAI]) after each of 20 sessions. The authors also video-recorded each session and rated alliance ruptures within each session with the 3RS a validated observer rating scale. Although the 3RS is the best way to assess alliance ruptures, 3RS ratings require an intensive process of coding by expert judges. And so, if the WAI, which is a relatively easy procedure, can reliably identify ruptures, then this may give clinicians a way of knowing when a rupture occurred. Rubl and colleagues defined an alliance rupture as a significant drop in the patient’s WAI score from one session to the next (i.e., technically, they used a score 2 standard deviations lower than the patient’s average WAI score in all preceding sessions). They found that sessions for which the WAI indicated a drop in alliance ratings had significantly more rupture markers (as rated by the 3RS) than sessions that did not show a drop in alliance ratings.
Although somewhat preliminary, the results of this study suggest that clinicians can use changes in patient-self-reported WAI scores from session to session to identify if a therapeutic alliance rupture occurred. If there is a precipitous drop in WAI scores after a session, then therapists might enquire with the patient about the state of the therapeutic alliance in the next session. That is, therapists might ask if there is still an agreement on the goals of therapy or if the therapy is proceeding in a way that is congruent with what the patient expects. Alternatively, the therapist may check in on the state of the therapeutic relationship, that is, to assess if the patient may feel some tension, disappointment, or frustration with the therapist. The goal is for therapists to use relatively easy-to-use measures like the WAI to help them make the most of the therapeutic alliance.