Theory Research and Practice

KARYN D. RUiz-CoRDELL AND JEREMY D. SAFRAN

More than half a century of psychotherapy research has yielded compelling evidence implicating the quality of the therapeutic alliance as one of the most robust predictors of overall treatment success (Horvath & Symonds, 1991; Martin, Garke, & Davis, 2000). This is a finding replicated multiples times across treatment modalities. Other findings indicate that poor outcome cases demonstrate greater evidence of negative interpersonal process (e.g., hostile interactions between patient and therapist or deterioration in the quality of the alliance) than good outcome cases (e.g., Coady, 1991; Henry, Schacht, & Strupp, 1986; Samstag, 1999). There is also evidence that therapists who are more helpful are better able to facilitate the development of a therapeutic alliance (e.g., Luborsky, McLellan, Diguer, Woody, & Seligman, 1997). Taken together, these findings suggest that recognizing and attending to negative interpersonal process or ruptures in the therapeutic alliance may play a valuable role in successful treatments.

Impasses or ruptures in the therapeutic alliance may be understood as moments of tension or breakdown in communication between patient and therapist (Safran & Muran, 2000). These moments may fluctuate in strength from seemingly trivial tensions, of which the patient or therapist may only be partially conscious, to significant breakdowns in collaboration and communication that if not resolved may result in premature termination or treatment failure. Alliance ruptures manifest in various ways. Sometimes the existing tension between patient and therapist is obvious and is addressed and resolved quickly. In other cases, a pseudoalliance or alliance based on a false self develops between the patient and therapist. In such cases a complete treatment can occur without the patient being impacted in any real or beneficial manner (Balint, 1958; Winnicott, 1965).

A number of studies have demonstrated that resolving ruptures in the therapeutic alliance can play an important role in treatment process and outcome (e.g., Foreman & Marmer, 1985; Lansford, 1986; Rhodes, Hill, Thompson, & Elliot, 1994; Safran & Muran, 1996; Stiles et al., 2004; see Safran, Muran, Samstag, & Stevens, 2002, for a review). A review of the research identifies three common themes in successful resolution processes: (1) therapist recognition of ruptures at the time of enactment, (2) patient verbalization of their concerns or negative feelings regarding the treatment and the therapist, and (3) the therapist's ability to maintain a nondefensive and empathic stance (Safran et al., 2002). At the same time, the research indicates that it is often difficult for therapists to negotiate alliance ruptures in a successful fashion. The data indicate that even skilled therapists may have difficulty recognizing alliance ruptures when they occur (Hill, Nutt-Williams, Heaton, Thompson, & Rhodes, 1996; Hill, Thompson, Cogar, & Denman, 1993; Regan & Hill, 1992; Rennie, 1994; Rhodes et al., 1994). Moreover, when therapists do become aware of alliance ruptures, they are often unable to address them in an effective fashion. A number of studies have found that therapists commonly increase their adherence in a rigid manner to their treatment model, rather responding flexibly, when addressing problems in the alliance (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Piper, Azim, Joyce, & McCullum, 1991; Piper et al., 1999). The Vanderbilt II Study (Henry, Strupp, Butler, Schacht, & Binder, 1993) demonstrated that experienced therapists who participated in a training program designed to help them manage negative interpersonal process became technically adherent, but actually displayed an increase in negative interpersonal process (e.g., hostile or incongruent communications). Thus it seems critical to further refine our understanding of how to help therapists negotiate alliance ruptures in a constructive fashion.

rupture resolution and the therapeutic alliance

The concept of the alliance has an extensive history, beginning with Freud's early statements about the importance of making a "collaborator" of the patient (Breuer & Freud, 1893-1895) and followed by his introduction of the "unobjectionable positive transference," or that aspect of the transference that should not be analyzed because it provides the patient with the motivation to continue in the treatment (Freud, 1921). This conceptualization was later followed by formulations of the alliance advanced by a number of theorists including Richard Sterba (1934), Elizabeth Zetzel (1956), Lawrence Friedman (1969), and Ralph Greenson (1967). Current conceptualizations of the alliance, while differing in various respects, all converge on the notion that the therapeutic alliance involves the capacity of the patient and therapist to work collaboratively in treatment.

As Wolfe and Goldfried (1988) maintain, the therapeutic alliance is the "quintessential integrative variable." Recognition by diverse therapeutic traditions of the importance of the therapeutic alliance can be attributed, at least in part, to its centrality in the psychotherapy research community (e.g., Hovarth & Greenberg, 1994; Horvath & Luborsky, 1993), where there has been a proliferation of measures and evidence demonstrating the predictive validity of the concept spanning nearly 20 years (Gaston, 1990; Hartley, 1985; Horvath & Symonds, 1991). Interest in this concept among researchers can be partially attributed to the search for understanding common mechanisms of change, given that no particular treatment has been shown to be consistently more effective than others (Smith, Glass, & Miller, 1980). It was also catalyzed by the early empirical work of Lester Luborsky (1976), demonstrating the predictive validity of the alliance. Another important influence was Edward Bordin (1979), who attracted considerable attention within the psychotherapy research community with his transtheoretical reformulation of the alliance concept. Bordin suggested that a good alliance is a prerequisite for change in all forms of psychotherapy. He conceptualized the alliance as consisting of three interdependent components: tasks, goals, and the bond. According to him, the strength of the alliance is dependent on the degree of agreement between the patient and therapist about the tasks and goals of therapy, and on the quality of the relational bond between them.

The tasks of therapy consist of the specific activities (either explicit or implicit) that the patient must engage in to benefit from the treatment. For example, classical psychoanalysis requires the patient to try to free-associate by attempting to say whatever comes to mind without censoring it. An important task in cognitive therapy may consist of completing a behavioral assignment between sessions. Gestalt therapists may ask their patients to engage in a dialogue between two different parts of the self.

The goals of therapy are the general objectives toward which the treatment is directed. For example, ego psychologists assume that the problems people bring into therapy result from a maladaptive way of negotiating conflict between instincts and defenses, and that the goals concern developing a more adaptive way of negotiating that conflict. A behavior therapist, in contrast, may see the goal of treatment as one of removing a specific behavior or symptom.

The bond component of the alliance consists of the affective quality of the relationship between patient and therapist (e.g., the extent to which the patient feels understood, respected, valued, and so on). Goal, task, and bond dimensions of the alliance influence one another in an ongoing fashion. For example, if therapist and patient agree about the therapeutic tasks and goals from the outset, it will have a positive influence on the bond dimension of the alliance. On the other hand, when there is an initial disagreement about the goals of therapy, the presence of an adequate bond will assist the therapist and patient in negotiating an agreement.

Different therapeutic tasks place different demands on patients and will tend to be experienced by them as more or less helpful depending on their own capacities and characteristic ways of relating to themselves and others. One patient may experience a structured cognitive-behavioral task as reassuring and containing. Another may experience it as domineering and controlling. One may experience the task of free associating as liberating. Another may experience it as a form of pressure.

While the quality of the alliance is critical in all therapeutic approaches, the specific variables mediating this quality will vary as a function of a complex, interdependent, and fluctuating matrix of therapist, patient, and approach-specific features. Bordin's formulation thus highlights the complex and multidimensional nature of the alliance. This conceptualization of the alliance has a number of important implications. First, this formulation highlights the interdependence of technical and relational factors in treatment (Safran, 1993b). Although it may be possible to distinguish between technical and relational factors conceptually, in reality they are indivisible. Second, rather than basing one's therapeutic approach on some inflexible and idealized criterion such as therapeutic neutrality, one can be guided by an understanding of what a particular therapeutic task means to a particular patient in a given moment. Third, as Stolorow and colleagues (Stolorow, Brandchaft, & Atwood, 1994) have highlighted, ruptures in the therapeutic alliance are the royal road to understanding the patient's core organizing principles.

Building upon Bordin's (1979) model of the alliance, we conceptualize the alliance as a process of negotiation between patient and therapist about the tasks and goals of therapy (Safran & Muran, 2000). In this conceptualization, the alliance is viewed as a bi-directional emergent aspect of the relationship, rather than as a static quality. More traditional conceptualizations of the alliance assume that there is only one therapeutic task (i.e., rational collaboration with the therapist on the task of self-observation), or at least privilege this task over others. Although Sterba, Zetzel, and Greenson emphasized the importance of the therapist acting in a supportive fashion in order to facilitate the development of the alliance, ultimately they assume that the patient will identify with the therapist and adapt to the therapist's conceptualization of the tasks and goals of therapy or accept the therapist's understanding of the value of the tasks and goals. In contrast, Safran and Muran's (2000) conceptualization of the alliance assumes that there will be an ongoing negotiation between therapist and patient at both conscious and unconscious levels about the tasks and goals of therapy and that this process of negotiation both establishes the necessary conditions for change to take place and is an intrinsic part of the change process.

This conceptualization is consistent with an increasingly influential way of conceptualizing therapeutic process in relational psychoanalytic thinking. Jessica Benjamin (1990), for example, argues that the process of negotiation between two different subjectivities is at the heart of the change process. Mitchell (1993) emphasizes that the negotiation between the patient's desires and those of the therapist is a critical therapeutic mechanism. Pizer (1992) also describes the essence of therapeutic action as constituted by the engagement of two persons in a process of negotiation. This line of thought deepens our understanding of the significance of negotiation between therapists and patients about therapeutic tasks and goals. It suggests that this process is not purely about negotiation toward consensus. At a deeper level, it taps into fundamental dilemmas of human existence, such as negotiation of one's desires with those of another, the struggle to experience oneself as a subject while at the same time recognizing the subjectivity of the other (Safran, 1993a), and the tension between the need for agency versus the need for relatedness (Safran & Muran, 2000).

Therapeutic alliance ruptures highlight the tensions that are inherent in negotiating relationships with others and bring into relief the inevitable barriers to authentic relatedness. They highlight for patients their separateness and lack of omnipotence (Safran, 1993a; 1999). Expressing one's disappointment to a therapist who accepts this criticism and survives is an important part of the process of developing a sense of agency. Learning to will or to express one's will, however, is only half the battle. The other half consists of coming to accept that the world and the people in it exist independent of one's will, that the events of the world run according to their own plan, and that other people have wills of their own (Safran, 1999). As Winnicott (1965) pointed out, an important part of the maturational process consists of seeing that the other is not destroyed by one's aggression, since this establishes the other as having a real, independent existence as a subject, rather than as an object. Although this type of disillusionment is a difficult and painful part of the maturational process, it ultimately helps to establish the other as capable of confirming oneself as real (Safran, 1993a, 1999). In this way, the groundwork is laid for relationships in which reciprocal confirmation can take place.

Coming to accept both self and other are thus mutually dependent processes that can be facilitated by working through ruptures in the therapeutic alliance. For the patient, establishing the therapeutic relationship requires negotiation at both the interpersonal and intrapsychic level, necessitating constant negotiation that balances the patient's requirements for agency with their needs for relatedness. The therapist, by empathizing with the patient's experience and reaction to the rupture, demonstrates that potentially divisive feelings (e.g., anger, disappointment) are acceptable and that experiencing nurturance and relatedness are not contingent on disowning part of oneself. He or she demonstrates that relatedness is possible in the very face of separateness and that nurturance is possible even though it can never completely fill that void that is part of the human condition. If the therapist is good enough, the patient will gradually come to accept the therapist with all of his or her imperfections. The exploration and working through of alliance ruptures thus paradoxically entails an exploration and affirmation of both the separateness and togetherness of self and other (Safran, 1993a).

rupture resolution: process and research

Our research program on alliance ruptures began in the late 1980s (e.g., Safran, Crocker, McMain, & Murray, 1990). During that period, the concept of the therapeutic alliance was emerging as an important focus for psychotherapy researchers, and evidence regarding the predictive validity of the therapeutic alliance in various forms of treatment was emerging (Gaston, 1990; Hartley, 1985; Horvath

& Symonds, 1991). Our research program has focused on investigating how strained or ruptured alliances can be re-established or repaired.

We have identified two major forms of ruptures: withdrawal and confrontation ruptures (Safran & Muran, 2000). In a withdrawal rupture the patient responds to tension in the therapeutic relationship by disconnecting or withdrawing from the therapist, or from some aspect of his or her experience. Various processes are employed by the patient including: denial, minimal responsiveness, random alternating of presented topics, and intellectualization. For example, a patient may deny feeling anger that he or she expressed indirectly toward the therapist. Or a patient may comply or defer to the therapist.

In a confrontation rupture, anger is expressed in a blaming, aggressive, or entitled fashion. This anger is directed at the therapist, the therapeutic process, or a blend of both. For example, the patient may complain about the therapist as a person, criticizing his or her interested manner as meddlesome, or the patient may find the therapist's comments of no use and question the therapist's ability. Patients who present primarily with withdrawal ruptures tend to favor the needs for relatedness over the needs for agency. Patients who present primarily with confrontation ruptures often have difficulty expressing their needs for relatedness. The resolution of an alliance rupture thus not only facilitates the implementation of a particular therapeutic task, it also provides an opportunity for patients to learn to constructively negotiate their needs for both agency and relatedness.

Over the years we have used the task analysis research paradigm (Greenberg, 1986; Rice & Greenberg, 1984), to develop and refine a stage-process model explicating the rupture resolution process (Safran et al., 1990; Safran & Muran, 1996; Safran, Muran & Samstag, 1994). Task analysis involves a combination of intensive analysis of single cases, and hypothesis testing studies that use group comparison designs. The model that has emerged is comprised of four stages: (1) Attending to the Rupture Marker, (2) Exploring the Rupture Experience, (3) Exploring the Avoidance, and (4) the Emergence of the Wish/Need. Although resolution begins with the process of Attending to the Rupture Marker, and usually ends with the Emergence of the Wish/Need, repetition and cycling between the states in an ongoing fashion typically occurs throughout.

When Attending to the Rupture Marker, the first stage in the resolution process, the therapist becomes aware of and draws the patient's attention to an interactional cycle that is taking place between them. At this point, both therapist and patient are embedded in the relational configuration, and the therapist may possess only limited recognition of the nature of his or her own contribution to the impasse. Therapists begin by drawing the patient's attention to the rupture and initiating a collaborative exploration of both partner's contribution to the impasse. Through reflecting and explicitly owning his or her own contribution, the therapist is able to initiate the disembedding process and begin the movement toward the resolution. At this point, the use of metacommunication is often helpful. Metacommunication is an attempt to bring ongoing awareness to bear on the interactive process as it unfolds. It facilitates the process of stepping outside of the relational cycle being enacted by treating it as the focus of collaborative exploration and communicating about the transaction or implicit communication that is taking place. For example, a therapist who finds his or her attention wandering could metacommunicate by explicitly disclosing this experience to the patient and then inquiring about the patient's experience. For example, the therapist may remark: "I'm aware of losing my ability to focus on what you're saying as you speak. It's not clear to me as to why, yet I'm wondering if it's connected at all to a distance that I hear in your voice, a disconnectedness. Any sense of what's going on for you right now?" In reaction to this intervention, the patient is able to recognize this withdrawal as directly connected to feeling wounded by something the therapist said previously. Metacommunication may also be useful in the context of a confrontation rupture. In this context, the therapist might remark: "I feel very uncomfortable saying anything to you, because I feel criticized when I attempt address your questions and concerns." A comment such as this provides the patient with feedback that might, for example, ultimately help him or her to explore dissociated feelings of anger toward the therapist.

The second stage, Exploring the Rupture Experience, develops as the patient begins the process of self-exploration and the expression of feelings associated with the alliance rupture. The therapist's task at this point is to assist the patient in unpacking his or her experience of the interaction through working to illuminate the subtle nuances of the patient's construal, and to help the patient begin to articulate that which is not yet fully explicit. For example, in a withdrawal rupture, patients typically begin to become aware of and express negative feelings in a qualified or indirect manner; whereas in a confrontation rupture, the patient's mode of expression will be primarily critical or accusatory in nature. Thus, in the case of a withdrawal rupture, the therapist may ask the patient to explore the direct articulation of any unacceptable feelings that the therapist believes may have been pushed away or rejected, a task then followed by asking the patient to be present for any feelings that may have emerged during the exercise. Importantly, when exploring confrontation ruptures, it is essential that patients experience any feelings of anger, pain, or rapprochement that present as real, allowable, and endurable, even prior to the process of exploring existing longings that are more vulnerable in nature. The acknowledgement of these existing underlying needs must surface in an organic manner from the therapeutic relationship through the negotiation and working through of the particular hostile interaction. This process is facilitated through empathic holding on the part of the therapist.

In the third stage, Exploring the Avoidance, the therapist and patient explore the defensive mechanisms blocking the acceptance and articulation of feelings about the therapist or underlying wishes that are being avoided. The avoidance is indicated by the patient engaging in defensive strategies such as switching topics, monotone speech, and presenting overly general topics rather than remaining in the here-and-now. These mechanisms function to avoid or manage the emotions associated with the rupture experience. There is often an alternation between Exploring the Avoidance and Exploring the Rupture Experience. Exploring the

Avoidance acts to free up and facilitate further Exploration of the Experience when it becomes blocked and Exploring the Experience creates an increased anxiety state and defensive process, thus requiring more extensive Exploring of the Avoidance. There are two common defensive processes in this context. The first consists of expectations, hopes, and fears the patient has regarding the therapist's potential reaction to his or her feelings or underlying needs. The second common defensive process in this context is the patient's internalized criticism of his or her own needs or wishes. These introjected criticisms impede the exploration of feelings the patient has about the therapeutic impasse. Overall, it is helpful for the therapist to assist the patient in distinguishing and exploring these various emotion states in context. Therapists can help to refocus the patient's awareness to the ways in which she or he moves to a self-critical stance when self-assertive feelings are triggered and thus facilitate an understanding of this experience as a conflict between two variant aspects of the self. The therapist can then ask the patient to begin a dialogue between these conflicting parts of the self, explicitly articulating and alternating between the self that desires to directly assert and the part that criticizes that wish (Safran & Muran, 2000). This process enables the patient to develop an experientially grounded appreciation of the way in which feelings associated with the rupture are blocked by intrapsychic conflict.

In the fourth state, the Emergence of the Wish/Need, the patient articulates wishes or needs that develop in the context of the therapeutic relationship and that are blocked by defensive processes. In withdrawal ruptures, this typically takes place in the form of self-assertion and often involves the overt expression of negative feelings (e.g., expressed resentment toward the therapist due to perceived failings). In confrontation ruptures, the expression of the underlying wish or need is typically linked to an experience of vulnerability (e.g., the desire for support or nurturance from the therapist).

Once the patient has begun to accept and then express an underlying wish, it is important for the therapist to respond in an empathic and nonjudgmental way. This kind of response plays an important role in challenging the expectations (both conscious and unconscious) that have made it difficult for the patient to self-assert or express a wish in the first place. A common pattern is for patients to initially assert themselves in a manner that is structured by their characteristic relational schema—for example, a patient whose father was tyrannical and critical, asks the therapist to be more confrontative. When the patient asserts in this manner, the therapist should try to empathize with the patient's desire, rather than to immediately interpret it as a reflection of an old relational schema. The latter response risks discouraging patients from asserting themselves more and can lead to them to further submerge their underlying wishes. In contrast, when therapists empathize with their patient's desires, it helps them to assert themselves in a fashion that is less likely to be structured by their old schema. Thus, the patient in the above example may ultimately be able to ask the therapist to be more supportive.

The therapist's capacity to genuinely empathize with the patient's pain and despair can represent an important new experience—one that helps the patient begin to emerge from his or her feelings of isolation and alienation, and to develop more self-compassion. By responding to the patient's despair in a compassionate and understanding fashion, the therapist provides the patient with the experience of being cared for and connected to another in his or her pain.

rupture resolution and practice: metacommunication

An important part of the therapist's task when utilizing this kind of exploration with the patient is to discover and reflect on his or her own feelings and use them as a point of departure for collaborative exploration. Different forms of exploration and discovery are possible. The therapist may give the patient feedback regarding the ways in which he or she impacts others. For example: "I feel cautious with you ... as if I'm walking on eggshells." Or, "I feel like it's difficult to really make contact with you. On the one hand, the things you're talking about really seem important. But on the other, there's a level at which it is difficult for me to really feel you." Or, "I feel judged by you." Comments such as these provide an opening for the exploration of the patient's dissociated actions and self-states. For example, the therapist can add, "Does this feedback make any sense to you? Do you have any awareness of judging me?" It is often useful for therapists to pinpoint specific instances of patients' eliciting actions. For example, "I feel dismissed or shut out by you, and I think it's connected to your tendency not to pause and reflect in a way that suggests that you are actually considering what I'm saying."

Below are described a number of general principles underlying the skillful use of therapeutic metacommunication:

1. Explore with skillful tentativeness and emphasize one's own subjectivity.

Therapists should communicate observations in a tentative and exploratory manner. The message at both explicit and implicit levels should be one of inviting patients to participate in a collaborative effort to understand what is taking place, rather than one of conveying information with objective status. It is also essential to highlight the subjectivity of one's perceptions since this encourages patients to use the therapist's observations as a stimulus for self-exploration rather than to react to them either as authoritative statements in a positive or negative fashion.

2. Do not assume a parallel with other relationships.

Therapists should be wary of prematurely attempting to establish a link between the interpersonal cycle that is being enacted in the therapeutic relationship and other relationships in the patient's life. Attempts to draw parallels of this type (while useful in some contexts) can be experienced by patients as blaming (especially in the context of an alliance rupture) and may serve a defensive function for therapists. Instead the focus should be one exploring patient's internal experience and actions in a nuanced fashion, as they present in the here-and-now.

3. Ground all formulations in awareness of one's own feelings and accept responsibility for one's own contributions.

All observations and formulation should be grounded in the therapist's feelings. Failure to do so increases the risk of distorted understanding that is influenced by unconscious factors. It is crucial to accept responsibility for one's own contributions to the interaction. We are always unwittingly contributing to the interaction and a central aspect to this undertaking consists of exploring the nature of this contribution in an ongoing fashion. In some situations, the process of explicitly accepting responsibility for one's contributions to patients can be a particularly potent intervention. First, this process can help patients become aware of unconscious or semiconscious feelings that they have difficulty articulating. For example, conceding that one has been critical enables patients to articulate their feelings of hurt and resentment. Second, by validating the patient's perceptions of the therapist's actions, the therapist can reduce his or her need for defensiveness.

4. Start where you are.

Collaborative exploration of the therapeutic relationship should integrate feelings, intuitions, and observations that are emerging for the therapist in the moment. What was true one session may not be true the next and what was true one moment may change the next. Two therapists will react differently to the same patient, and each therapist must begin by making use of his or her own unique experience. For example, although a third observer may be able to adopt an empathic response toward an aggressive patient, therapists cannot conceptually manipulate themselves into an empathic response they do not feel. They must begin by fully accepting and working with their own feelings and subjective reactions.

5. Focus on the concrete and specific and the here-and-now of the therapeutic relationship.

Whenever possible, questions, observations, and comments should focus on concrete instances in the here and now rather than generalizations. This promotes experiential awareness rather than abstract, intellectualized speculation.

6. Collaborative exploration of the therapeutic relationship and dis-embedding take place at the same time.

It is not necessary for therapists to have a clear formulation prior to metacommunicating. In fact, the process of thinking out loud about the interaction often helps the therapist to unhook from the cycle that is being enacted by putting into words the subtle perceptions that might otherwise remain implicit. Moreover, the process of telling patients about an aspect of one's experience that one is in conflict over, can free the therapist up to see the situation more clearly.

7. Remember that attempts to explore what is taking place in the therapeutic relationship can function as new versions of an ongoing unconscious interpersonal cycle.

For example, the therapist articulates a growing intuition that the patient is withdrawing and says: "It feels to me like I'm trying to pull teeth." In response, the patient withdraws further and an intensification of the interpersonal cycle ensues in which the therapist escalates his attempts to break through and the patient becomes more defended. It is critical to track the quality of patients' responsiveness to all interventions and to explore their experience of interventions that have not been facilitative. Does the intervention deepen the patient's self-exploration or lead to defensiveness or compliance? The process of exploring the ways in which patients experience interventions that are not facilitative helps to refine the understanding of the unconscious interpersonal cycle that is taking place.

rupture resolution and therapist internal processes

In recent years we have become increasingly interested in investigating the type of internal processes that help therapists to negotiate alliance ruptures (Safran, 2003). Since therapeutic impasses often evoke difficult, painful, and conflictual feelings in therapists, it is important for them to develop the capacity to reflect on these feelings (e.g., rage, impotence, self-loathing, and despair) without defining themselves by these reactions and without dissociating them. This involves engaging in a process of "letting go" and yielding to one's experience, while simultaneously holding and reflecting on it in a nonjudgmental manner. In fact, one important function of metacommunication is to facilitate the development of this state of mind, through articulating feelings, which seem unacceptable or unsayable (Safran, 2003; Safran & Muran, 2000).

This state of mind can be cultivated through the use of mindfulness training. Mindfulness involves the ongoing observation of experience as it emerges in the here-and-now. It is comprised of three essential elements or skills: (1) the direction of attention, (2) remembering or reconstructing, and (3) nonjudgmental awareness (Safran & Muran, 2000). An important byproduct of mindfulness practice is the discovery of internal space (Safran & Muran, 2000). This consists of the loosening of attachments to one's cognitive-affective processes, with the objective of viewing them as constructions of the mind. This, in turn, reduces the experience of constriction resulting from an over-identification with these processes, and allows one to reflect on them and to use them therapeutically. Mindfulness involves radical self-acceptance of thoughts, feelings, and behaviors. It is vital in this practice that therapists work to develop true acceptance through awareness of the subtle and not so subtle aspects of what they deem unacceptable in their attitudes and actions. True compassion develops through struggling and finally accepting one's own pain, limitations, failures, and internal conflicts (Safran, 1999). Of course, personal therapy can contribute to the development of this type of self-acceptance, but mindfulness practice constitutes a valuable additional tool. During moments of conflict, it is only through radical acceptance of their own disavowed and undesirable feelings that therapists can begin to become more accepting of their patients. Just as patients cannot change by forcing themselves to be one way rather than another, therapists cannot will themselves into a more empathic stance. Self-acceptance plays a critical role in allowing therapists to free themselves up to recognize their own contributions to the impasse and to see new possibilities for resolving it.

brief relational psychotherapy (brt)

Drawing upon the concepts and research described above, we have developed and manualized a treatment approach specifically designed to be used for the purposes of negotiating or resolving ruptures in the therapeutic alliance (Safran, 2002; Safran & Muran, 2000). The approach is referred to as Brief Relational Therapy (BRT). At the level of overall outcome, we have conducted research evaluating the efficacy this treatment approach that has been influenced by our process research as well as current developments in contemporary psychoanalysis (e.g., relational theory). BRT is a manualized treatment designed to be conducted in a time limited manner (although it can be administered as a long-term treatment as well). The approach is based both upon findings emerging from our own research program and principles from relational psychoanalysis. We have found that adherence to the principles of BRT can be reliably assessed and that therapists conducting BRT can be distinguished from therapists administering either short-term cognitive therapy or short-term dynamic therapy of a more traditional nature (Muran, Safran, Samstag, & Winston, 2005; Safran, Muran, Samstag, & Winston, 2005).

The central principles of BRT are as follows: (1) it assumes a two-person psychology (i.e., it assumes that both the patient and therapist contribute to the interpersonal cycle that is being enacted; (2) there is an intensive focus on the here-and-now of the therapeutic relationship; (3) there is an ongoing collaborative exploration of the patients' as well as the therapists' contributions to the interaction; (4) it emphasizes in-depth exploration of the nuances of patients' experience in the context of unfolding therapeutic enactments and is cautious about making transference interpretations that speculate about generalized relational patterns; (5) it makes intensive use of countertransference disclosure; (6) it emphasizes the subjectivity of the therapist's perceptions; and (7) It assumes that the relational meaning of interventions is critical (Safran, 2002).

Training in BRT and rupture resolution includes an important emphasis on experiential learning and self-exploration. Therapists are trained to attend to and explore their own feelings as important sources of information about what is going on in the therapeutic relationship. We often use role-playing exercises in order to provide therapists with the opportunity to simulate working with difficult patients and experimenting with metacommunication. The purpose of these exercises is not just to provide them with the opportunity to practice technical skills, but also to develop the skill of exploring their own feelings and internal conflicts as they emerge during alliance ruptures. These are referred to as "awareness-oriented role plays" (Safran & Muran, 2000). Supervision employs mindfulness training for the purposes of helping therapists refine their capacity to observe their own inner experience as well as the nature of their own contributions to alliance ruptures. Through this training, therapists learn to refine their capacity to investigate their own experience and observe their own actions in a nonjudgmental fashion. In fact, we conceptualize metacommunication as a type of "mindfulness in action" (Safran & Muran, 2000).

We have evaluated the efficacy of BRT relative to two more traditional models of short-term treatment: short-term dynamic psychotherapy (STDP) and short-term cognitive-behavior therapy (CBT) (Muran, Safran, Samstag, & Winston, 2005). Although the three treatments were found to be equally effective, there were fewer dropouts in the BRT condition than in the other treatment conditions. A related small sample pilot study was conducted to explicitly assess the effectiveness of BRT as a treatment strategy for treating patients with whom it is difficult to establish a therapeutic alliance. Patients receiving STDP and CBT were monitored over the first few sessions of treatment, and poor alliance patient/therapist dyads were identified using a set of empirically established criteria. These patients were offered the option of transferring to another therapist in another treatment condition. Those who accepted were randomly assigned to either to BRT or to a control condition depending on the type of treatment in which they began (CBT for those patients beginning in STDP and STDP for those patients beginning in CBT). The results indicated that patients who had been transferred to BRT showed more improvement than patients in the other two treatments (Safran, Muran, Samstag and Winston, 2005). Taken together, these findings suggest that BRT may have some advantage over the other two treatments in addressing strained alliances.

conclusion

Although our research program began a number of years ago, in many ways it is still in its early stages. An overarching principle guiding us has been an attempt to achieve a meaningful integration between the art and science of psychotherapy. We attempt to respect and acknowledge the complexity of the therapeutic process while at the same time identifying generalizable principles of change and testing them where possible. This is daunting challenge, and sometimes gains in knowledge can be slow. Nevertheless we remain convinced of the importance of pursuing this type of integration.

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