Abstract:
This
paper aims to understand the processes of rupture of the Therapeutic
Alliance (TA) of a case of interrupted psychoanalytic psychotherapy
(PP) with a patient with Borderline Personality Disorder (BPD). This
is a systematic case study that comprises 15 sessions of PP, one
patient with complaints of impulsiveness and difficulties in
interpersonal relationships, and his female therapist. The sessions
were videotaped and transcribed. The identification of ruptures was
made by the Rupture Resolution Rating System (3R's). There were 100
ruptures of AT, of these 69% were withdrawal ruptures and 31% of
confrontation. We found 30 contributions from therapist to ruptures.
The withdrawal ruptures are more subtle and difficult to identify,
occurring more frequently than those of confrontation in the
treatment. In the case of patients with BPD, therapists should develop
skills to make interventions focused on TA. The need for other studies
that seek to replicate the research in other cases of success and
therapeutic failure is highlighted.
Introduction
Early
psychotherapy dropout is a significant phenomenon, frequently
encountered by therapists in various theoretical approaches, with
rates ranging from 15 to 75% (Arnow et al., 2007; Bados, Balaguer,
& Saldanã, 2007). Among the factors associated with dropout,
factors of the therapist-patient relationship stand out, especially
the therapeutic alliance (TA). The meta-analysis by Sharf, Primavera
and Diener (2010) revealed a relatively strong relationship between TA
and dropout (d:
0.55), indicating that patients with weaker TAs are more likely to
drop out of treatment early. The study of moderators suggests that the
relationship between TA and dropout is stronger in individuals with
less schooling, longer therapies and in the context of hospitalization.
Establishing and maintaining a good alliance is, therefore, decisive
to avoid treatment dropout and to create the conditions for
therapeutic progress to occur (Horvath, Del Re, Flückiger, &
Symonds, 2011; Krause, Altimir & Horvath, 2011).
The
concept of the TA originates from the consideration of Freud (1913) on
the need for the patient to connect positively with the therapist so
that the analytical work can develop. The terms therapeutic alliance
and working alliance were coined, respectively, by Zetzel and Greenson,
who indicated their character of being conscious, non-conflicting and
differentiated from transference (Gomes, 2015). However, the concept
evolved and started to be conceived pantheorically, from the concept
of Bordin (1979), as a relationship of conscious and purposeful mutual
collaboration between patient and therapist in therapy, characterized
by an agreement on aims, an assignment of tasks (agreed in the
therapeutic contract) and the development of emotional
ties.
This pantheoric vision of the TA, with an emphasis on collaboration
and consensus, influenced, although in a different and non-consensual
way, most of the main current measures of the construct (Horvath et
al., 2011; Krause et al., 2011).
The
TA is currently recognized as a dynamic process that varies in
intensity, frequency and duration, depending on the patient's
diagnosis and the type of theoretical approach employed. These
oscillations, called ruptures, can happen during treatment and even
during the same session (Barros, Altimir & Pérez, 2016; Safran,
Muran, & Eubanks, 2011). The ruptures are characterized by a
deterioration in the TA, manifested by a lack of collaboration in
tasks or objectives or a tension in the emotional bond and difficulty
in negotiating aspects of the therapeutic relationship (Eubanks, Muran,
& Safran, 2015; Safran & Muran, 2006; Safran, Muran, &
Proskurov, 2009). The patient can avoid the therapeutic work and/or
the therapist or confront them directly. These movements of rupture of
TA are inevitable in any psychotherapy (Eubanks et al., 2015). However,
when not repaired, ruptures can cause dropout from the treatment (Safran
et al., 2011).
There
is ample evidence that weakened alliances are correlated with the
patient's unilateral termination of the therapy (Doran, 2016; Safran
et al., 2009; Safran, Israel, & Einstein, 2006), while negative
interactions (i.e., hostile and aggressive) between patient and
therapist are associated with unfavorable outcomes (Coady, 1991;
Samstag et al., 2008; Zilcha-Mano, Muran, Eubanks, Safran, &
Winston, 2018). According to the meta-analysis of Safran et al.
(2011), there is empirical evidence that individuals with personality
disorders present greater intensity of ruptures at the start of
therapy than those without personality disorders. Among the former,
patients with Borderline Personality Disorders (BPD) present the
highest rate of ruptures. This may explain the higher rates of
treatment dropout among patients with this disorder (Kroger, Harbeck,
Armbrust, & Kliem, 2013; Koons et al., 2001; Linehan et al., 2007;
McMain et al., 2009).
Patients
with BPD have inflexible and long-lasting patterns of emotional and
interpersonal difficulties (Benjamin, 1993; Leichsenring, Leibing,
Kruse, New, & Leweke, 2011a) that require from the therapist to
manage central aspects of their pathology (Barnow et al., 2009;
Kernberg, 2012; Lazarus, Cheavens, Festa, & Zachary Rosenthal,
2014; Skodol et al., 2002). For example, affective instability and
lack of integration of the self and significant others is manifested
through feelings of chronic emptiness, contradictory and impoverished
perceptions of themselves and others, hindering the empathic
experience and the relationship with the therapist. For this reason,
it is recommended that interventions with these patients focus on the
development and maintenance of the TA (Bennett, Parry, & Ryle,
2006; Geremia, Benetti, Esswein, & Bittencourt, 2016).
Because
the alliance is so critical to the outcome, Safran and colleagues (Eubanks,
Muran, & Safran, 2014; Muran et al., 2009; Safran & Muran,
1996, 2000; Safran et al., 2011; Safran et al., 2009; Safran et al.,
2006; Safran, Muran, & Samstag, 1994) created and tested a model
to resolve ruptures in the alliance during therapy. Recently, in order
to systematize the codification of ruptures and resolutions of the TA,
Eubanks et al. (2015) developed the Rupture Resolution Rating System (3R’s).
The system aims to code ruptures in the TA and resolution
interventions, in segments of psychotherapy sessions.
Gersh
et al. (2017) conducted a study of 44 young people with BPD, aiming to
explore the processes of rupture and resolution of the TA, through the
3RS. The study showed that ruptures occurred in 53% of the sessions
and with the passage of treatment they tended to increase, with
confrontations being more frequent. The ruptures that occurred at the
beginning of treatment were associated with worse results. Conversely,
greater resolution of the ruptures was associated with better results
and could be opportunities for therapeutic growth.
Considering
the relevance of the TA process for the adherence of patients with BPD
to psychotherapy, this study aimed to identify the frequency and
variations of the processes of rupture in the TA in an interrupted
case of psychoanalytic psychotherapy, performed with a patient diagnosed
with BPD. A further aim was to describe the characteristics of the
overall therapeutic process.
Method
This
was a systematic, idiographic, longitudinal and intensive case study.
This type of study has similarities with traditional clinical case
studies, however, it differs from these in that, among other aspects,
it presents greater methodological rigor, such as the use of
independent judges, analysis of recorded audio and video sessions and
control over biases of the researcher (Edwards, 2007; Serralta, Nunes,
& Eizirik, 2011).
The
process under study and its participants
The
analyzed case consists of a psychoanalytic psychotherapy process. The
treatment was interrupted by the patient in the 15th session. The
patient (fictionally named Carlos) was 30 years of age. His initial
complaints were a lack of emotional control and difficulty in
interpersonal relationships and with his partner. Carlos was seen in a
private psychology practice. The therapist was female, 32 years of age
and trained in psychoanalytic psychotherapy. The diagnosis of BPD was
made by the therapist, based on her clinical experience and the
application of the Shedler-Westen Assessment Procedure - SWAP-200 (Shedler
& Westen, 1998; Westen & Shedler, 1999), a Q-sort type of
instrument consisting of 200 statements that describe cognitive,
affective and relational aspects of patients with personality problems.
For the interpretation of the profile, standardized scores are used. T
scores >60 are compatible with the categorical diagnosis
of personality disorder, while T
scores >55 indicate the presence of these traits.
According to data obtained through the SWAP-200, Carlos presented
characteristics compatible with the diagnosis of Borderline
Personality Disorder, and histrionic characteristics. The most
prominent pathological traits were emotional dysregulation and
psychopathy. His psychological health index was indicative of a medium
level of personality pathology.
Instruments
Process
monitoring form. This
form was prepared by the researcher to be completed by the therapist.
It is a record of the scheduled sessions, the patient's frequency in
the session, including any lateness, and noteworthy complications (such
as, for example, failure in the recording equipment).
The
Rupture Resolution Rating System (3RS)
(Eubanks et al., 2015) is a system for observing ruptures in the TA
during a psychotherapy session, with the aim of obtaining a
classification of the type of rupture (withdrawal or confrontation),
as well as the therapist's resolution strategies. This classification
is made on a 5-point significance scale, from 1 (not significant) to 5
(highly significant). Subsequently, the rater assigns a classification
of which rupture predominated in the session, based on frequency. The
final assessment item refers to the extent to which the therapist
caused or exacerbated the ruptures in the session. The system presents
high inter-rater reliability (Eubanks, Lubitz, Muran, & Safran,
2018a). The Portuguese version of the 3RS manual was developed by the
team.
The
Psychotherapy Process Q-Set (PQS)
(Jones, 2000) is a pantheoric Q-sort type instrument, which presents
100 items that describe the patient's attitudes and experiences, the
therapist's actions and attitudes and the nature of the interaction
between them. When observing a therapeutic session, the evaluator
classifies the items on a 9-point scale, classifying the
characteristics identified as the most prominent in the therapeutic
process (positively salient) and those identified as the least
characteristic (negatively salient). Items placed in the central
categories are considered neutral or irrelevant. Forced distribution
follows the normal curve and avoids the halocentric effect. Ordination
is generally carried out by two or more trained judges. The Brazilian Portuguese
version of the PQS was developed by Serralta et al. (2007) and
presented semantic equivalence with the original instrument in English,
and reliability coefficients between previously trained evaluators
comparable to those obtained with the original instrument (Intraclass
correlations greater than .70).
Procedures
This
study was approved by the Research Ethics Committee of the University
of Vale do Rio dos Sinos (CAAE 39120214.6.0000.5344). The 15
psychotherapy sessions in this case were audio recorded and
transcribed in full for later analysis using the 3RS. The
quantification of the ruptures was performed considering five-minute
segments in all sessions by pairs of judges. There were 6 judges: two
Master’s students, a PhD student, a psychologist with a PhD in
Clinical Psychology (all psychotherapists with psychoanalytic
orientation), and two undergraduate students, without clinical
experience. The judges received 20-hours of training, as instructed in
the 3RS manual (Eubanks et al., 2015). In this study, the judges
obtained a substantial degree of agreement (K=
0.760; z=
8.0001; p>
.0001) in identifying the ruptures.
In
order to identify the ruptures, during the playback of the video the
judge must be attentive to the indicators of decreased collaboration
between the patient and therapist and disagreements about the
treatment objectives and tasks, taking into account the verbal and
non-verbal aspects of the patient. The rupture codification process is
complex and involves many steps and has been described in detail by
Dotta (2019).
Analyses
performed with the 3RS included the frequency of ruptures during the
treatment and the frequency of the therapist's contribution to the
ruptures. Subsequently, the mean occurrence of both withdrawal and
confrontation ruptures was evaluated, the mean of the specific impact
of the rupture subcategories on the TA, in each session, and the
overall impact of the ruptures in the TA in all psychotherapy sessions.
For
the analysis of the process with the PQS, each session was codified by
pairs of previously trained judges, formed by different coders from
those that evaluated the ruptures with the 3RS. The PQS evaluators
were: 1 psychology PhD holder, 2 PhD students with clinical experience
and 1 psychology undergraduate student, who was a Scientific
Initiation scholarship holder, without clinical experience. The judges
were blinded to the number of sessions, the result of the treatment
and the other judges' assessments. The judges presented good
reliability in the judgment of the sessions analyzed, with an
intraclass correlation coefficient between .71 and .86. In order to
obtain the result of the overall description of the therapeutic
process, the mean of the 10 items of the PQS that were most and least
characteristic of the process was calculated and ordered.
Results
Overall
psychotherapy process
The
therapy lasted 27 weeks. However, due to frequent absences between
sessions, the patient attended only 15 of them. The patient was late
for almost half of the sessions (46.7%). The mean duration of the 15
sessions was 34.25 minutes (SD=
11.30). Between the 1st and the 4th session, the mean duration was
29.25 minutes (SD=
6.07). Between the 5th and 11th sessions, the duration of
psychotherapy increased, lasting for a mean of 41.87 minutes (SD=
8.98). The recording failed during session number 7 due to a lack of
battery power in the camera.
The
overall therapeutic process evaluated with the PQS showed that the
therapy had few silences (item 12) and was permeated by significant
material (item 88). The dyad discussed topics related to the patient's
current life situation (item 69), as well as his aspirations (item
41), generally presenting a specific focus (item 23) on the discussion
of the interpersonal (item 63) and loving relationships (item 64) of
the patient. During the sessions, the patient felt safe and confident
(item 44), was active (item
15) and initiated the subjects (item 25). He generally showed
acceptance of the therapist's comments (item 42) and was able to
understand the therapist's comments (item 5).
The
therapist was self-confident (item 86) and communicated through a
clear and coherent style (item 46). In her relationship with Carlos,
she was responsive, involved (item 9) and showed tact (item 77). Her
interventions were directed toward obtaining more information and
elaboration (item 31) and to facilitating the patient's speech (item
3), giving attention to verbal aspects, without referring to
non-verbal ones.
The
identification of ruptures in figure 4 illustrates the number of
rupture markers identified in each treatment session. Ruptures were
identified in all the psychotherapy sessions. Over the 15 sessions,
100 rupture markers were found (a mean of 6.66 ruptures per session).
Of these, 69% were withdrawal ruptures and 31% confrontation ruptures.
As
shown in Figure 1, the sessions with the highest occurrence of
ruptures were 5, 6 and 9 (with 17, 13 and 17 ruptures, respectively).
The ones with the lowest occurrence were 7, 12 and 14 with 3 ruptures
each, and session 15, with only one. A bimodal frequency distribution
was observed, in which two main peaks of increase in ruptures were
identified (sessions 5 and 9). Regarding the type of rupture, with the
exception of the 1st, 4th and last sessions, there was a predominance
of withdrawal ruptures in all sessions.
The
withdrawal ruptures with a higher mean frequency throughout the
treatment were: avoidant storytelling and/or shifting topic (Fr= 11),
deferential and appeasing (Fr= 9), and abstract communication (Fr= 6).
The predominant confrontation ruptures were: patient rejects therapist
intervention (Fr= 12), defends self against therapist (Fr= 3) and
efforts to control/pressure therapist (Fr= 3). The frequencies of the
ruptures are presented in Table 1.
The
intensity of the impact of the confrontation and withdrawal
ruptures was examined. The intensity of the confrontation
ruptures (M=
3.61; SD=
0.9) was slightly higher when compared to the impact of the
withdrawal ruptures (M=
2.97; SD=
1.1). The most intense confrontation ruptures were: patient
defends self against therapist (M=
3.67; SD=
0.5); efforts to control/pressure therapist (M=
3.67; SD=
1.12) and patient rejects therapist intervention (M=
3.11; SD=
1.0). The rupture of complaints/concerns about the parameters of
therapy (M=
4.00) presented only one occurrence, and therefore, the 4 degree
of impact refers only to this marker. Among the withdrawal
ruptures, the markers with the greatest impact were denial (M=
3.33; SD=
1.4); abstract communication (M=
3.17; SD=
1.0) and deferential and appeasing (M=
3.09; SD=0.9).
The other means of the impacts of the specific subcategories of
the withdrawal and confrontation ruptures are presented in Table
2.
The
ruptures (of confrontation and withdrawal) showed some mean
significance for the TA (M=
3.0; SD=
0.62). In all sessions, the ruptures had at least some impact on the
TA (score of at least 3.0). In sessions 5, 6, 9, 13 and 14 there were
high impact ruptures (score 5.0). The sessions that had the greatest
mean impact on the TA were 12 (M=
3.7; SD=
1.10), 13 (M=
4.2; SD=
1.10) and 14 (M=
4.0; SD=
1.10).
During
the treatment, 30 contributions of the therapist to causing or
exacerbating the ruptures were identified. The sessions in which the
therapist most frequently contributed to the occurrence of ruptures
were 5 (n=
10), 6 (n=
6), 8 and 9 (n=
5 in each), although this conduct was also observed in sessions 7, 10
and 11. In contrast, there were no contributions by the therapist to
the ruptures in sessions 1, 2, 3, 4, 12, 13, 14 and 15.
Discussion
Carlos'
psychotherapy was understood as an unsuccessful therapy, as the
patient unilaterally abandoned the treatment without the intended
therapeutic gains having been achieved. The treatment lasted for 27
weeks. However, despite the weekly frequency contracted, it totaled
only 15 sessions. Furthermore, the low number of sessions in relation
to the treatment time was mainly due to the absences between sessions
(there were 9 absences; of these, only one previously agreed with the
therapist). The absences started in the 4th session, just when,
according to the literature, it is expected that the TA starts to
develop more effectively (Gersh et al., 2017).
When
examining the sequence of attendance and absences in the sessions, it
can be seen that, with the exception of the initial sessions, the
process is practically all interspersed with absences. This possibly
reflects the pair's difficulty in developing a sufficiently good TA at
the beginning of the treatment (Horvath et al., 2011). As the patient
spontaneously sought psychotherapy, expressing a need for help and
apparently agreed with the initial contractual arrangements, there is
a clear indication of disagreement over the therapy tasks (Bordin,
1979; Krause, Altimir & Horvath, 2011) that manifested itself in
frequent absences and lateness.
Effective treatment models
for BPD share, among other aspects, a focus on emotional experience,
greater activity by the therapist and a focus on the therapeutic
relationship (Weinberg, Ronningstam, Goldblatt, Schechter, &
Maltsberger, 2011). The overall description of the process with the
PQS does not capture any of these elements, although there are items
in the instrument that describe these characteristics. Furthermore,
this description shows an "apparent collaboration" in the
exploration of significant material in the sessions, related to the
problems that led the patient to treatment. There was also a
significant lack of discussion of non-verbal behaviors that could have
been due to resistance and difficulties in the interaction.
The
fact that the overall analysis with the PQS takes into account the
macroprocess in psychotherapy and focuses on the broad observation of
how the patient and therapist experience the therapeutic process
should be considered. Just like a photograph, a scene is captured as a
whole and a panoramic view of the process is obtained, with a low
degree of resolution (Bucci, 2007; Cordioli & Grevet, 2018).
Therefore, in order to better understand the TA process, through the
3RS the aim was to address specific, detailed and immediate issues
related to how the patient and therapist organized themselves during
the psychotherapy session (the microprocess), observing the
therapeutic scene with greater resolution to identify possible
problems with the TA (Barcellos, Cardon, & Kieling, 2018; Bucci,
2007).
The
evaluation of the TA throughout the treatment, analyzed at a
microscopic level, identified problems in the collaboration between
the patient and therapist in the present case, already verified at the
macro level due to the absences and lateness mentioned. Ruptures were
identified in all the sessions, a high number of ruptures (n=100),
compared to other studies conducted using the 3RS with patients with
BPD (Gersh et al., 2017). The ruptures were predominantly of avoidance,
more frequent in the intermediate sessions (with the contribution of
the therapist) and had some impact on the TA. Furthermore, it was
observed that after the ruptures increased, in the intermediate
sessions, there was a decrease in frequency. However, there was an
increase in their impact on the TA in the sessions just before the
end, in which the therapist contributed to the ruptures.
The
difference between the frequencies of ruptures in the present study,
when compared with some reports in the literature, is an interesting
and unexpected finding. However, the pattern is consistent with the
other indicators evidenced (absences and lateness). The fact that this
was an interrupted (unsuccessful) psychotherapy with a BPD patient,
supposedly more likely to demonstrate difficulties in establishing and
maintaining the TA, cannot be disregarded (Boritz, Barnhart, Eubanks,
& McMain, 2018; Safran et al., 2009). The study by Doran, Safran
and Muran (2017), which examined the relationship between the
therapeutic process and the negotiation of the TA in 47 patients with
different clinical psychopathologies (anxiety and depression) and with
personality disorders (48.9%), also highlighted fluctuation in the
occurrence of ruptures (confrontation and withdrawal) over time.
Bennett
et al. (2006) point out that a greater occurrence of ruptures of the
TA and treatment dropout are common in patients with BPD. These
patients have flaws in the process of representing the self and others
(Caligor, Kernberg, & Clarkin, 2008) and under emotional
activation, they tend toward concrete, non-mentalized thinking (Bateman,
Campbell, Luyten, & Fonagy, 2018), showing impulsive behaviors
related to flaws in emotional regulation, which lead to a rapid
distortion of themselves and of the relationship with their therapists
(Caligor et al., 2008; Leichsenring et al., 2011b). This distortion in
the relationship with the therapist favors the occurrence and impact
of ruptures in the TA (Spinhoven, Giesen-Bloo, van Dyck, Kooiman,
& Arntz, 2007).
During
the treatment, Carlos used withdrawal ruptures more frequently:
avoidant storytelling and/or shifting topic, deference and appeasement
and abstract communication. This finding suggests that the patient had
difficulty expressing his dissatisfaction or anguish directly.
According to the literature, the frequency of withdrawal ruptures is
significantly higher in patients that
dropout from treatment (Boritz et al., 2018). These ruptures, in
comparison to those of confrontation, are more difficult to identify,
since the behavior of the patient, in avoiding the therapeutic work or
the therapist, is subtle, unclear or even obscured (Safran et al.,
2011). Withdrawal ruptures may be disguised as superficial compliance
or engagement, for example (Boritz et al., 2018).
Withdrawal
behavior can therefore be seen as a strategy to regulate the intense
and overwhelming emotion that is activated in the context of the
therapeutic relationship (Bernecker, Levy, & Ellison, 2014). The
study by Cash, Hardy, Kellett and Parry (2014) highlighted that the
resolution of the rupture did not occur when therapists discussed or
explored the ruptures directly, but when they approached the rupture
indirectly by changing their approach to exploring issues that were
more important to the patient. In the present study, however, rupture
resolution strategies were not specifically analyzed. Nevertheless,
the results suggest that in the absence of explicit clues for the
withdrawal ruptures, the therapist may have positioned herself more
passively when faced with them, having difficulty identifying and/or
resolving them. The therapist's contributions to the occurrence of the
ruptures suggest that she seemed to ignore the rupture markers and was
not aware of what was happening at the relationship level,
underestimating the impact these ruptures in the therapeutic
collaboration had on the process. One study indicates that the
therapist's contribution to ruptures is predictive of treatment
dropout (Eubanks et al., 2018b). In addition, the literature
highlights an apparent paradox in the work of resolving ruptures with
BPD patients, as dealing with the rupture directly can be considered
excessive and threatening for some individuals, although not
addressing it directly can further exacerbate the rupture (Boritz et
al., 2018).Despite the predominance of withdrawal ruptures, the
confrontation ruptures also deserve attention. In these, the patient
mostly rejected the therapist's interventions, defended himself from
her and attempted to control the therapeutic process or the therapist.
Confrontation ruptures occurred in 13 of the 15 treatment sessions.
The judges also noted that, in rejecting the interventions of the
therapist, the patient demonstrated a debauched tone, used sarcastic
comments and described aggressive behaviors. A study by Gülüm,
Soygüt and Safran, (2018) identified sarcastic humor as a third
category of rupture. Sarcasm is a subtle form of aggressive
communication, which expresses the difficulty in verbalizing feelings
about the therapy or therapist, leading to treatment dropout in later
sessions. In the final phase of psychotherapy, the decrease in
ruptures is associated with their resolution (Eubanks et al., 2018b).
In contrast, in the present case, the last sessions did not constitute
a final phase, since in a supposedly long-term therapy the process
would ideally have reached an intermediate stage (Luz, 2015).
Therefore, the decrease in the occurrence of ruptures observed in the
last sessions (sessions 12, 13 and 14), associated with the increase
in their significance in terms of the impact on the TA, seems to
indicate a deterioration in the TA that may have led to the patient’s
dropout from the therapy.
It
should be highlighted that the sessions in which the ruptures had the
greatest impact on the TA were those that preceded the last session,
when the patient talked about his decision to interrupt the treatment.
These sessions were also the ones with the least ruptures, and in them
there were no ruptures that showed expressions of self-criticism
and/or hopelessness, complaints/concerns about the therapist, about
the therapy activities or the treatment progress. It appears,
therefore, that numerous minor ruptures may precede major ruptures.
The hypothesis to be verified is that the non-resolution of less
significant ruptures leads to an increase in the worsening of the TA,
culminating in dropout. The ruptures can be comprehended as enactments,,
a concept that highlights the role of the unconscious in the
relationship between patient and therapist (Safran & Kraus, 2014;
Safran & Muran, 2000). For Safran and Kraus (2014), ruptures in
the TA are essentially unconscious movements between the pair. The
therapist is involuntarily involved in the patient's functioning, thus
re-enacting a form of dysfunctional relationship that is
characteristic of the patient. These processes, when they do not
become conscious and the targets of the therapeutic work, obstruct the
development of a good therapeutic process. On the other hand, the
therapist's awareness of the continuous fluctuations in the quality of
the TA can present valuable opportunities to mobilize the process of
change in the patient.
The
initial or opening phase of treatment may be longer in therapy with
patients with BPD, in view of the need to explore the ruptures that
may interfere with the establishment and maintenance of the TA.
Furthermore, the need to cultivate the TA with the main aim of the
treatment becomes important, with the adaptation of psychotherapy to
the patient's characteristics and constant monitoring of the
fluctuations in the TA. The therapist's flexible and empathetic
attitude is essential to deal with the ruptures, both those of
withdrawal and confrontation.
The
need to be cautious in the interpretation of the data presented is
highlighted, in view of the limitations of this exploratory study. The
coding of the ruptures in the TA was performed through the 3RS manual,
which does not have categories for the assessment and codification of
ruptures caused by the therapist. The evaluation of the microprocess
measure involved only the patient's perspective. Although the judges
received training and obtained substantial agreement, it is not known
to what extent the coding is consistent with the coding of the gold
standard 3RS.In the item "the therapist's contribution to the
ruptures", only the frequency at which the therapist exacerbated
or contributed to them was identified. The assessment of the TA
resolutions, which was not the target of this study, could better
clarify the oscillatory behavior of the TA throughout treatment.
In
future studies, it is suggested to include the coding of strategies
that therapists can use to effectively identify and resolve TA
ruptures. In addition, the ruptures and resolutions in the TA could be
examined in multiple cases, with different psychopathologies and
outcomes, with the performance of studies that assess the differences
in the nature and predictive value of early and subsequent ruptures.
Conclusion
This
study puts forward empirically supported hypotheses regarding the
early dropout from therapy by a borderline patient. It reveals a
process permeated by many ruptures from the beginning, which increased,
first in number and then, in intensity, culminating in the session in
which the patient communicated that he would dropout. The therapist
contributed to the occurrence or increase in the ruptures. Her actions
and interventions focused on the patient's problems, but not on the
therapeutic relationship. Taken together, these factors seem to have
been related to the dropout. However, considering the limitations of
the purely descriptive design and the absence of specific analysis at
the microprocessual level of the rupture resolution strategies, this
hypothesis was not tested.
It
should be emphasized that in Brazil, to date, there are no empirical
assessments of ruptures in the TA. The 3RS system was recently
translated into Brazilian Portuguese by the team of the Research
Laboratory in Psychotherapy and Psychopathology (LAEPSI). Therefore,
this is a pioneering study in the national context for the
microprocessual examination of the TA, constituting an exploratory
study that secondarily aims to introduce studies on the subject.
Nevertheless,
the study presents contributions for the clinical practice by
highlighting for discussion and analysis the role of the therapeutic
relationship in the process of change and in the outcome of
psychotherapy. Contemporary psychoanalytic theory emphasizes the
mutual influence between therapist and patient and values the
therapist's authenticity, flexibility and spontaneity. In this context,
the TA acquires a central role, not only being a support for the
initial stage of the treatment. With patients with personality
disorders, such as borderline patients, who typically have
difficulties in developing the alliance, the focus on this difficulty
seems to be fundamental to the process. Working through ruptures in
the alliance (that is, anticipating, identifying and resolving them)
can provide patients with opportunities to learn to negotiate the
tension between their own difficulties
and the need for help versus the difficulties and needs of the
therapeutic relationship, in a new and more constructive way.
Considering
the empirical evidence indicating that the TA is a critical ingredient
for change in various forms of therapy, it seems important to develop
a well-articulated body of research with relevant knowledge about TA
microprocessual measures. This study is the first developed in the
country to use an approach based on external observers to microprocess
the assessment of ruptures in the TA, and to explore how these
processes unfold over time in therapy. Further studies should
contribute to the expansion of this type of investigation in the
country. National and international investigations of other individual
cases, as well as multiple and comparative case studies on these
microprocesses, developed with patients with different diagnoses,
outcomes and therapeutic approaches may, in the future, shed more
light on the complex issue of the contribution of the therapeutic
relationship and alliance for adherence, dropout, success and/or
failure of the psychotherapy.
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