Ruptures and repairs are processes related to shifts in the collaborative relationship Cthe working allianceJ between patient and therapist in psychotherapy. Ta study ruptures and repairs is one way ta disentangle mechanisms that might underlie the association between the working alliance and psychotherapy outcome. The overarching aim af this thesis was ta analyze the clinical relevance af the rupture and repair concepts at different process levels. The same three alliance patterns were investigated in the three empirical studies: the rupture pattern, the repair pattern, and the no-rupture/stable pattern. The analyses af the alliance patterns moved fromwhole treatments ta session segments. In Study I ruptures were found ta be associated with worse outcomes than treatments without ruptures. Repairs were, in longer therapies, shown ta be related ta better outcomes than norupture treatments. In Study Il it was found that the three alliance patterns could be discerned within sessions. Ruptures and repairs within sessions were found ta be associated with patient-ratings af the working alliance. In Study 111 the alliance patterns were found ta be related ta different  interaction patterns within sessions. In these analyses, importont patient contributions ta repairs af ruptures were found.

Alliansbrott och reparationer är processer relaterade till förändringar i samarbetet och relationen mellan patient och terapeut i psykoterapi. Att studera alliansbrott och reparationer av dem kan utveckla kunskapen om sambandet mellan arbetsallians och psykoterapiutfall. Avhandlingens övergripande syfte var att pröva den kliniska relevansen av begreppen alliansbrott och reparationer på olika processnivåer. Samma tre alliansmönster undersöktes i de tre empiriska studierna: alliansbrottsmönstret, reparationsmönstret och icke-alliansbrott/stabila mönstret. Analyserna av alliansmönstren gick från hela behandlingar till sessionssegment. Studie I visade att alliansbrott hade samband med sämre utfall än behandlingar med mönstret icke-alliansbrott. Reparationer visade sig, för längre terapier, vara relaterade till bättre resultat än mönstret ickealliansbrott I Studie Il befanns de tre alliansmönstren vara urskiljbara inom sessioner. Alliansbrott och reparationer inom sessionerna visade sig vara associerade med patientskattad arbetsallians. I studie 111 befanns alliansmönstren vara relaterade till olika interaktionsmönster inom sessionerna. Det visade sig att patienterna bidrog på viktiga sätt till reparationer av alliansbrott.

Objective: The aim of this study was to test a new observer-rated instrument, the Alliance and Rupture Observation Scale (AROS). It was designed for repeated measurements of the alliance within sessions and to detect alliance ruptures.

Method: Videotaped therapy sessions with depressed adults were analyzed. Reliability was mainly assessed as inter-rater reliability. Convergent, predictive, and discriminant validity of the AROS was assessed by comparing the instrument with both observer-rated and patient-rated measures.

Results: The AROS exhibited excellent inter-rater reliability. Alliance levels measured with the AROS predicted patients’ ratings of the alliance in the same session and were highly correlated with another observer-rated alliance measure. Alliance patterns (rupture; repair; and no-rupture) based on AROS scores were significantly correlated with patients’ ratings of the alliance.

Conclusions: Preliminary support for convergent and predictive validity was found. It is yet to be determined whether AROS scores are related to psychotherapy outcomes.

OBJECTIVE: The association between alliance level and outcome in psychotherapy has been extensively studied. One way to expand this knowledge is to study alliance patterns. The main aims of this study were to examine how frequent alliance patterns with ruptures or rupture-repair episodes were in a naturalistic sample of psychotherapies in primary care, and if three alliance patterns (a Rupture pattern, a Repair pattern, and a No Rupture pattern) were differentially associated with treatment outcome.

METHOD: The psychotherapies (N = 605) included a wide range of different treatment orientations and patient diagnoses. Alliance patterns were studied at session-to-session level, using patient-rated alliance scores. Outcome data were analyzed using longitudinal multilevel modeling with a slopes-as-outcomes model.

RESULTS: The Repair pattern accounted for 14.7% (n = 89) of the treatments, 10.7% (n = 65) exhibited a Rupture pattern, and 74.5% (n = 451) contained no ruptures. The Rupture pattern was associated with inferior treatment outcomes. The Repair pattern was, in longer treatments, associated with better outcomes than the No Rupture pattern.

CONCLUSIONS: The results support theory about the importance of ruptures in the therapeutic alliance and suggest that identification of alliance ruptures is important in alliance-outcome research, for feedback purposes in clinical practice, and in training of therapists.

Recently, researchers have started to measure the working alliance repeatedly across sessions of psychotherapy, relating the working alliance to symptom change session by session. Responding to questionnaires after each session can become tedious, leading to careless responses and/or increasing levels of missing data. Therefore, assessment with the briefest possible instrument is desirable. Because previous research on the Working Alliance Inventory has found the separation of the Goal and Task factors problematic, the present study examined the psychometric properties of a 2-factor, 6-item working alliance measure, adapted from the Working Alliance Inventory, in 3 patient samples (ns = 1,095, 235, and 234). Results showed that a bifactor model fit the data well across the 3 samples, and the factor structure was stable across 10 sessions of primary care counseling/psychotherapy. Although the bifactor model with 1 general and 2 specific factors outperformed the 1-factor model in terms of model fit, dimensionality analyses based on the bifactor model results indicated that in practice the instrument is best treated as unidimensional. Results support the use of composite scores of all 6 items. The instrument was validated by replicating previous findings of session-by-session prediction of symptom reduction using the Autoregressive Latent Trajectory model. The 6-item working alliance scale, called the Session Alliance Inventory, is a promising alternative for researchers in search for a brief alliance measure to administer after every session.

The aim of this study was to assess whether a modified version of the Emotional Availability Scales (EAS), created to assess interaction quality between parents and children, could be applied to psychotherapy sessions and whether emotional availability (EA), as assessed by the modified EAS-T, was associated with client- and therapist-rated working alliance. EAS-T was used to assess 42 sessions from 16 therapies. The therapies came from the LURIPP project, comparing IPT with BRT for depressed clients. The results showed that sessions could be reliably rated with EAS-T. Most rating scales had acceptable variance. The clients perception of task alliance was associated with several of the EA subscales (sensitivity, nonhostility, responsiveness) assessed over therapies, whereas the perception of bond was associated with Structure on EAS.

In order to prevent relapse into criminality, it is important to understand what precedes criminal behavior. Two earlier studies found deficits in mentalizing ability to be related to violent and criminal actions. Mentalizing refers to the ability to make human behavior predictable and meaningful by inferring mental states (thoughts, feelings, etc.) as explaining behavior. In this study, mentalizing ability was assessed by rating 42 Adult Attachment Interviews with young male offenders with the Reflective Functioning (RF) scale. In addition, specific mentalizing ability about their crimes was assessed, as well as psychopathy traits (Psychopathy Checklist, Screening Version [PCL: SV]) and alexithymia (Toronto Alexithymia Scale [TAS]). Results suggest impaired mentalizing in criminal offenders. Examples of anti- and prementalizing reasoning about crimes are presented. RF scores were not correlated with the PCL:SV or TAS.

Background and aims

Psychodynamic psychotherapy (PDT) is an effective treatment for major depressive disorder (MDD), but not all clients with MDD can receive psychotherapy. Using the Internet to provide psychodynamic treatments is one way of improving access to psychological treatments for MDD. The aim of this randomised controlled trial was to investigate the efficacy of an Internet-based psychodynamic guided self-help treatment for MDD.

Methods

Ninety-two participants who were diagnosed with MDD according to the Mini-International Neuropsychiatric Interview were randomised to treatment or an active control. The treatment consisted of nine treatment modules based on psychodynamic principles with online therapist contact. The active control condition was a structured support intervention and contained psychoeducation and scheduled weekly contacts online. Both interventions lasted for 10 weeks. The primary outcome measure was the Beck Depression Inventory-II (BDI-II).

Results

Mixed-effects model analyses of all randomised participants showed that participants receiving Internet-based PDT made large and superior improvements compared with the active control group on the BDI-II (between-group Cohen's d = 1.11). Treatment effects were maintained at a 10-month follow-up.

Conclusions

Internet-based psychodynamic guided self-help is an efficacious treatment for MDD that has the potential to increase accessibility and availability of PDT for MDD.