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1 Oxford Doctoral Course in Clinical Psychology the THERAPEUTIC Oxford Doctoral Course in Clinical Psychology THE THERAPEUTIC ALLIANCE, RUPTURES, AND SESSION-BY-SESSION FEEDBACK Christopher James Laraway A thesis submitted in partial fulfilment of the requirements of the degree of Doctor of Clinical Psychology, validated by the University of Oxford (Trinity Term) July 2015 Word Count: 19,863 (Paper A: 9684; Paper B: 10,179) 1 The Therapeutic Alliance, Ruptures, and Session-by-Session Feedback Christopher James Laraway Harris Manchester College, University of Oxford, Doctorate in Clinical Psychology (Trinity Term 2015) Abstract The therapeutic alliance has consistently been found to be predictive of good outcome across a number of different therapeutic modalities and in a number of different intervention types. Ruptures in the therapeutic alliance are critical points in therapy for exploration and change. Resolving ruptures in the therapeutic alliance can lead to a stronger therapeutic alliance and improved outcome, and unresolved ruptures in the therapeutic alliance have been linked to poor outcome and drop-out. Session-by-session feedback on the therapeutic alliance is an integral part of the most successful feedback systems known to improve outcome. Little is known regarding how this may be used within the rupture resolution process. The review paper systematically evaluates the link between the therapeutic alliance and outcome in group interventions. Two types of group interventions were reviewed: CBT groups, and psychotherapy groups. A significant relationship between the therapeutic alliance and outcome in group interventions was found, although there were major methodological flaws in the studies reviewed. The empirical paper employed a task analytic design to develop a model for how session-by-session feedback on the therapeutic alliance could be used to inform the rupture resolution process. Experts were interviewed to develop a theoretical model. This was then combined with an empirical model developed through analysis of the in-session performance of a therapist and four of their individual patients. This model shared similarities with 2 existing models of rupture resolution, however noticeable differences were found. These are discussed, alongside limitations of the study and implications for clinical practice and future research. 3 Acknowledgements I would like to thank all five participants who so kindly allowed their therapy to be recorded as part of this project. I would also like to thank Dr Michael Lambert, Dr Scott Miller, Dr Rolf Holmqvist, and Dr David Green, for generously sharing their considerable expertise. In particular, thank you to Dr Jeremy Safran, for his considered thoughts on this study as it progressed. A big thank you to James Macdonald, whose passion for this area has been infectious. His thoughtful advice and continued support have been invaluable throughout. I hope I have taken care of my reader. Thanks also to Anne-Marie Daly for the careful reading of transcripts, methodological advice, and whose words of encouragement have kept me going. Thank you to Carmen Chan, who despite joining after the beginning of this project has been generous with her time, spirit and contributions. To my friends both on and off the course. Your encouragement, support, and ability to make me laugh have helped me through at every stage of this project. Finally, and most importantly, to my family. This would not have been possible without your unwavering support, patience, and belief in me. A special thank you to my mother Janice, and my sister Amy, who have helped me take every step of this journey. 4 Contents Paper A Paper A Abstract ...................................................................................................................... 15 Introduction .............................................................................................................................. 16 Group Psychotherapy ........................................................................................................... 16 Outcome ............................................................................................................................... 17 Therapeutic Alliance ............................................................................................................ 18 Therapeutic Alliance and Outcome ..................................................................................... 19 Individual therapy. ........................................................................................................... 19 Couples and family therapy. ............................................................................................ 19 Group therapy. ................................................................................................................. 19 Therapeutic Alliance and Cohesion ..................................................................................... 21 Rationale for Review ........................................................................................................... 22 Aim of Current Review ........................................................................................................ 22 Method ..................................................................................................................................... 22 Search Strategy .................................................................................................................... 22 Inclusion Criteria ................................................................................................................. 23 Flow Diagram of Screened and Included Studies…………………………………………24 Procedure ........................................................................................................................... 255 Results ...................................................................................................................................... 37 Characteristics of Studies ..................................................................................................... 37 5 Intervention type. ............................................................................................................. 37 Conceptualisation of the alliance. .................................................................................... 37 Alliance measure. ............................................................................................................. 37 Target Problem................................................................................................................. 39 Group CBT Findings............................................................................................................ 40 Alliance as predictive of outcome. ................................................................................... 40 Correlation between alliance and outcome. ..................................................................... 41 No alliance-outcome link. ................................................................................................ 42 Group Psychotherapy Findings ............................................................................................ 42 Alliance as predictive of outcome. ................................................................................... 42 Correlation between alliance and outcome. ..................................................................... 45 No outcome-alliance link. ................................................................................................ 46 Critique .................................................................................................................................... 46 Participant Demographics .................................................................................................... 46 Study Design and Methodology........................................................................................... 47 Sample size. ..................................................................................................................... 47 Alliance measures. ........................................................................................................... 47 Timing of alliance assessment. ........................................................................................ 48 Outcome measures. .......................................................................................................... 48 Follow up………………………………………………………………………..………49 Confounding variables.. ................................................................................................... 49 Ethical issues. ................................................................................................................... 50 6 Discussion ................................................................................................................................ 50 Implications for Clinical Practice and Research .................................................................. 54 Limitations of Review.......................................................................................................... 55 References ................................................................................................................................ 57 7 Contents Paper B Paper B Abstract ...................................................................................................................... 70 Introduction .............................................................................................................................
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