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Prior research has shown the therapeutic alliance to be positively related to therapeutic outcome in couple therapy (Johnson & Talitman, 2007; Knoblock-Fedders, Pinsoff, & Mann, 2007). It is common for the therapeutic alliance to vary over the course of therapy. Alliance ruptures can be defined as "deteriorations in the relationship between therapist and patient" (Safran & Muran, 1996, p. 447). If managed successfully, these moments of alliance rupture can positively impact therapy (Safran & Muran, 1996; Sprenkle, Davis, & Lebow, 2009). As a result, researchers have begun to develop models of alliance rupture repair to help further our understanding of how this process is achieved in various therapeutic approaches (Aspland, Llewelyn, Hardy, Barkham, & Stiles, 2008; Binder, Holgerse, & Nielsen, 2008; Safran & Muran, 1996). The purpose of this study was to conduct a preliminary, discovery-oriented task analysis (Greenberg, 2007) in order to develop a model of alliance rupture repair in Emotionally Focused Therapy (EFT), a couple therapy approach which encourages emotional reconnection and restructuring of couple interactions developed by Susan Johnson and Les Greenberg (Johnson, 2004). By conducting a thought experiment with four experienced certified EFT therapists, a rational model of alliance rupture repair in EFT was formulated. The rational model was then compared with the analysis of alliance rupture repair sequences during the process of one couple's therapy with a certified EFT therapist to develop a rational-empirical model of alliance rupture repair in EFT. The final model and treatment implications are discussed. / Master of Science

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Studiens syfte var att undersöka leg. psykoterapeuters uppfattningar om och erfarenheter av att identifiera och reparera rupturer i den terapeutiska relationen (alliansen) i kognitiv beteendeterapi (KBT). Datainsamlingen bestod av narrativa intervjuer. Den kvalitativa metoden fenomenologisk hermeneutik (Lindseth & Norberg, 2004), där intresset riktas mot den levda erfarenheten, användes vid analys och tolkning av texten. Resultatet visade att de terapeutiska färdigheterna medveten närvaro och metakommunikation används för att identifiera, förebygga och reparera rupturer i alliansen. Slutsatsen är att psykoterapeuternas berättelser bär på den dolda innebörden att alla slags terapeutiska interventioner i KBT samtidigt utgör relationella handlingar, och att ett språk för detsamma är önskvärt. Meningsfullhet och yrkesstolthet kan dessutom tillägnas, om uppmärksamheten vänds från misslyckanden till mod att ta ansvar för det terapeutiska förloppet och relationen. / The aim of the study was to investigate psychotherapists perceptions about and experiences of identifying ruptures in the therapeutic alliance in cognitive behavioural therapy (CBT). The data collection consisted of narrative interviews. The qualitative method, a phenomenological hermeneutical method for researching lived experience (Lindseth & Norberg, 2004), was used in the analysis and interpretation of the texts. The result showed that the therapeutic skills awareness and metacommunication was used to identify, prevent and resolve ruptures in the alliance. The conclusion is that psychotherapists stories carries a hidden meaning of any therapeutic interventions in CBT at the same time constitutes relational actions, and a language for the same is desirable. Meaningfulness and professional pride can also be adopted, by shifting attention from failures, into courage to take responsibility for the therapeutic process and the relationship.

Background: attachment theory provides an account of human behaviour across the lifespan, has a strong theoretical foundation and is clinical applicable. It is particularly relevant to older adults, who are often exposed to a greater number of losses. Despite a growing awareness of increasing life expectancy worldwide, services for older adults in the NHS remains under-resourced. However, increased exposure to death and loss in the work might result in clinical psychologists being more reluctant to choose this specialism and may raise issues about their own early attachment experiences. Therefore, it is important to understand how clinical psychologists approach the complexities of their work in light of their own early attachment experiences. Qualitative research of the lived experiences of clinical psychologists is sparse and to date there are no studies addressing this specific issue. Aims: this is an exploratory study which addresses a gap in the literature. The aims are to capture the early attachment experiences of clinical psychologists specialising in working with older adults. It is hoped that the outcome of the study will shed some light on the characteristics of this under-researched group and how they manage the challenges of the work. Methodology: a semi-structured interview schedule was developed to explore how clinical psychologists make sense of their work with older adults in light of their early attachment experiences. Interviews were carried out with five clinical psychologists working in specialist older adult services. The transcripts of the interviews were then analysed using Interpretative Phenomenological Analysis (IPA). Results: the analysis of the five interviews yielded five main themes – “Making sense of early attachment relationships”, “Developing identity in childhood and adolescence”, “Understanding of decision to work with older adults”, “Work with older adults as both challenging and rewarding” and “The person within the professional”. Each of the main themes and their subthemes were supported by excerpts from narratives of participants experiences. Implications: this study highlighted several research and clinical implications. First, the role of non-parental childhood attachments in the development of internal working models is currently an under-researched area which may provide important insights into resilience factors in the face of childhood adversity. Second, clinical implications suggest that access to older adult work early on in the career of clinical psychologists may increase desirability of working in specialist services. Third, the study supports attachment theory as a useful approach to understanding the work with older adults and as a valuable area for the professional development of clinical psychologists. Finally, systemic working with older adults remains an important part of the work which would benefit from further research in this area.

BACKGROUND In recent years, there has been a push to measure and monitor the quality of health care and the delivery of effective services. Substance use disorders are debilitating and in order to better understand this facet of substance abuse, it is important for organizations and providers to assess the quality of services, client satisfaction, and the relationships that exist between clients and treatment providers. PURPOSE The purpose of the study was to (1) assess the extent of the relationship between measures of client perceptions of satisfaction and treatment outcomes and (2) to assess the relationship between measures of therapeutic alliance and treatment outcomes. METHODS Data was obtained from a larger study assessing organizational factors affecting the implementation of evidence-based practices in the treatment of substance use disorders. This study was focused on the client satisfaction survey data obtained during the months of August and December of 2008, consisting of several five-day periods, during which clients were asked to complete the survey. The study population consisted of 371 clients aged 18 to 64 years. Logistic regression was used to evaluate demographic and other substance use-disorder factors for each of the scales pertaining to client satisfaction (general satisfaction, access, and quality/appropriateness) and therapeutic alliance (bond, goal, and task) in order to obtain odds ratios and 95% confidence intervals. Pearson correlation coefficients were used to assess the strength of the relationship of each of the measures of client satisfaction and therapeutic alliance with client perceived outcomes. Due to the nature of the survey questions being adapted from validated measures, Cronbach's coefficient alphas were used to determine internal consistency and reliability within each of the scales. To further assess client measures of satisfaction, multivariate linear regression was used to examine whether a specific client satisfaction measure or therapeutic alliance measure was a significant predictor of better client perceived outcomes. RESULTS Client perceptions of satisfaction - general satisfaction, access, and quality/appropriateness (worse vs. better) were significantly associated with better client perceived outcomes. Therapeutic alliance measures were also significantly associated with better client perceived outcomes. The strongest predictors from logistic regression analysis were quality/appropriateness (OR = 14.45, 95% CI 1.16-19.01) and general satisfaction (OR = 11.96, 95% CI 7.04-20.33) followed by WAI Goal (OR = 5.56, 95% 3.29-9.39), access (OR = 5.81, 95% CI 3.55-9.50), WAI Task (OR = 4.42, 95% CI 3.29-9.39), and WAI Bond (OR =3.61, 95% CI 2.06-5.22). Cronbach's coefficient alphas were all above the .70 threshold indicating strong internal consistency among the measures of client satisfaction, therapeutic alliance and client perceived outcomes. Pearson correlation coefficients indicated moderate relationships between access, general satisfaction, WAI Bond, Goal and Task with client perceived outcomes. The strongest correlation was that of quality/appropriateness of treatment services and client-perceived outcomes (r = 0.61, p<0.0007) CONCLUSIONS Client perceptions of satisfaction and therapeutic alliance were found to be significantly associated with better client perceived outcomes. Age, time in treatment, and number of times a client moved in the past 6 months was implicated in the association of general satisfaction and better client perceived outcomes. Age and race were implicated in the association of access and better client perceived outcomes. Further research is needed to measure the effectiveness of treatment services to ensure that clients are receiving appropriate evidence-based services that result in better outcomes.

Premature termination is a substantial problem with significant adverse effects for clients, therapists, and treatment organizations. Unfortunately, it is also a relatively common phenomenon within mental healthcare settings. Across varied mental healthcare settings, rates of premature termination have reportedly ranged from 19.7 % to 40 %. Perhaps not surprisingly, the rate of premature termination in training clinics is substantially higher than in community mental health settings and private practice, with 75 to 80 % of clients ending treatment services prematurely. The purpose of this study was to explore the combined effect of intake therapist continuity or discontinuity, and quality of the therapeutic relationship on premature termination. Intake therapist continuity, measures of working alliance, and termination outcome from 524 clients at the University of North Texas Psychology Clinic were utilized for adults receiving individual therapy services between August 2008 and August 2013. Results of the study suggest intake therapist continuity did not predict subjective termination status (X2(2, n = 524) = 1.61, p = 0.45), nor did it predict change in symptomology status (X2(3, n = 453) = 1.14, p = 0.77). Additionally, working alliance predicted subjective termination status (X2(6, n = 212) = 21.17, p < 0.01), but not change in symptomology status (X2(9, n = 208) = 6.27, p = 0.71). The findings of the current study are discussed, as well as suggestions for further research related to client, therapist, treatment, and procedural variables and their impact on premature termination.