Therapeutic alliance and patients’ reflective functioning: preliminary results of a micro-analytic investigation of session transcripts

This study aims at investigating the relationship between therapeutic alliance ruptures and resolutions and patient’s reflective functioning (RF). The relationship between these two variables is yet unclear and complex: several authors have noted that mentalization to some extent may be a prerequisite for effective use of psychotherapy but from another point of view intersubjective negotiation and the resolution of alliance ruptures could promote the creation of an in session secure base effect and improvements in patient’s reflective functioning. Although empirical literature on this topic, especially at in session level, rarely examined together these constructs, investigating fluctuations in reflective functioning and in the alliance within sessions may be an interesting level of research for clinicians because it may inform psychotherapeutic technique and practice. Our objectives are to: (1) evaluate whether low levels of RF will be related to rupture processes; (2) verify whether high levels of RF will be related to collaborative processes; (3) verify if a direct/confrontation ruptures are associated with lower RF scores with respect to indirect/withdrawal ruptures. In doing so we hypothesize that: (1) patient’s ruptures would be associated with lower scores of RF, while patient’s collaborative processes would be associated with higher RF scores; (2) different ruptures would be associated with different RF scores, specifically direct/ confrontation ruptures would be characterized by lower RF scores than indirect/withdrawal ruptures. Methods: We evaluated 50 session transcripts (1,032 narrative units) from 10 Caucasians patients (2 men, 8 women; mean age=29.91 years, SD=10.12) in psychotherapy. Before entering psychotherapy, all patients received a DSM–5 diagnosis (APA, 2013). A total of 4 patients had at least one PD diagnosis. Psychotherapies were administered by 8 psychologists and 2 psychiatrists (mean age=44 years, SD=8.5). Therapists practiced in a private setting and in a mental health institutions. Eight therapists reported a psychodynamic theoretical and clinical approach while 2 reported a cognitive-behavioral approach. Measures. (a) Collaborative Interactions Scale Revised (Colli, Gentile,Condino, & Lingiardi, 2017), for the assessment of alliance’s rupturesand resolution processes on the basis of Safran and Muran’s (2000) model. The CIS-R is divided into two sub-sales: CIS-R Patientand CIS-R Therapist, each focused on the specific contribution of each member of the therapeutic dyad at the communication process. The CIS-R Patient is composed of four scales: Direct Rupture Markers (DRS; 3 items); Indirect Rupture Makers (IRM; 4 items); Direct Collaborative Processes (DCP; 3 items); Indirect Collaborative Processes (ICP; 3 items). The CIS-R Therapist is comcomposed of four scales: Direct Collaborative Interventions (DCI; 4 items); Indirect Collaborative Interventions (ICI; 3 items); Rupture Interventions (RI; 5 items); Therapist Interventions (TI; 4 items); (b) Reflective Functioning Scale (Fonagy et al., 1998) for the assessment of patient’s RF on a Likert scale from -1 (negative RF) to +9 (marked RF). The RFS has been developed for the assessment of the verbatim transcripts of the Adult Attachment Interview, but can also be applied to psychotherapy session transcript. The RFS assesses the presence of mentalization on the basis of four different subscales: Awareness of the nature of mental states (4.1); Explicit effort to tease out mental states underlying behavior (4.2); Recognizing developmental aspects of mental states (4.3); Mental states in relation to the interviewer (4.4). In the present study, raters assessed the presence or absence of each marker of the CIS-R and the RFS in each verbal unit. Each transcript was rated by two independent and trained raters for each measure (CIS–R and RFS). In the present study the mean overall inter-rater reliability for CIS– R ranged from .67 to .81 (Cohen’s Kappa) while for the RFS ranged from .60 to .85 (ICC; single measure, absolute agreement). Results: Our results enlighten the presence of lower scores of RF in psychotherapy session fragments characterized by therapeutic alliance ruptures. More specifically, partial correlations indicated that patient’s direct rupture markers (DRM) were significantly negatively correlated with RF [r=-.086, p=.002]. Moreover, we found a significant negative correlation between indirect rupture processes (IRM) and RF [r=-.155, p=.000]. We didn’t find a significant correlation between direct collaborative processes (DCP) and RF, but our results showed a strong positive correlation between indirect collaborative processes (ICP) and RF [r=.127, p=.000]. Our results didn’t enlighten the presence of a correlation between therapists collaborative interventions and patients’s RF. We did find a strong negative correlation between therapists rupture interventions and patients’ RF [r=-.106, p=.000]. Conclusions: Results confirm our hypothesis about the relationship between alliance ruptures and resolutions and patient’s reflective functioning and show how patients alliance ruptures are characterized by lower FR level than patient collaborative processes. Contrary to our hypothesis patent’s indirect ruptures are characterized by lower RF scores than direct ruptures. We may hypothesize that direct rupture markers, even though with a non-collaborative modality, are characterized by an expression by the patient of the affect mental state, which does not happen in other rupture processes. In future will be important to investigate if different rupture markers are associated with different kind of prementalizing modes such as psychic equivalence and pretend mode. We did not find a correlation between therapists’ collaborative interventions and RF. This may be due to the specific analysis adopted in this study, which does not allow for us to see the effect of therapists interventions on the subsequents verbal units. For the future, further analyses will be necessary in order to address this issue. This study represents an attempt to micro-analytically investigate the fluctuations in patient’s RF in response to therapeutic alliance’s ruptures and collaborative processes. Clinical implications will be discussed.