Study finds mending ruptures in client-therapist relationship has positive benefits

November 6, 2013

In order for prolonged exposure therapy, an evidence-based psychotherapy for post traumatic stress disorder (PTSD), to reach its full potential, any misperceptions or ruptures in trust and communication between therapist and client need fixing, according to a new Case Western Reserve University study.

The study, reported in the Journal of Consulting and Clinical Psychology online article, "Patterns of Therapeutic Alliance: Rupture-Repair Episodes in Prolonged Exposure for PTSD," is among the first to examine how ruptures in the between the therapist and client can damage a patient's treatment outcome.

An alliance rupture may occur when there is a break in the therapist-client bond. For example, ruptures in the therapeutic relationship may occur when therapeutic progress stalls, negative feelings arise between the therapist and client, or when the work in therapy becomes challenging.

"We want therapists to know that a rupture in the therapeutic relationship isn't a bad thing, as long as the therapist tends to it," said Stephanie Keller, one of the study's researchers and a Case Western Reserve doctoral student in . "However, if the rupture is not repaired, then your patient may not do as well in treatment."

The research study included 116 people who experienced a traumatic event such as childhood sexual or physical abuse, physical assault, or combat exposure, and had a primary diagnosis of PTSD. Participants engaged in a 10-session treatment program called prolonged exposure (PE) therapy.

To help therapists chart progress and examine the therapeutic relationship, each client assessed his or her own PTSD symptoms and perception of their relationship with the therapist during treatment.

This helped researchers to identify those clients who experience no ruptures in the therapeutic relationship (a stable relationship), clients who experienced a rupture that was subsequently repaired, and those with ruptures that went unrepaired.

The first PE session outlined what would happen over the course of treatment to set specific goals. Exposure-based exercises began in the second session, which included exposure to anxiety-provoking situations that served as trauma-reminders and talking about their traumatic experiences.

In this sample, 28 percent of patients experiences a repaired rupture and 18 percent experienced a rupture, or dip in the therapeutic relationship, that was never repaired. An unresolved rupture in the therapist-client relationship became a predictor for a poorer outcome in treatment, Keller said.

She also said more research is needed to figure out why these alliance ruptures occur and how to best repair them.

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