Bennett Dawn, Parry Glenys, Ryle Anthony
Lancashire Care NHS Trust, Clinical Psychology, Blackburn, UK.
Psychol Psychother. 2006 Sep;79(Pt 3):395-418. doi: 10.1348/147608305X58355.
Alliance ruptures and premature drop out from psychotherapy are very common with patients who have a diagnosis of borderline personality disorder, limiting the clinical effectiveness of treatment.
To test and refine a model of how therapists successfully resolve threats to the therapeutic alliance involving enactment of problematic relationship patterns in the cognitive analytic therapy of borderline personality disorder.
Task analysis (Greenberg, 1984a) of 107 enactments from 66 sessions in four good outcome cases, compared with 35 enactments from 16 sessions in two poor outcome cases. This systematically compares a rational model of process with empirically coded transcripts of therapy sessions where independent raters have identified an alliance threat event.
The process stages of the rational model were observed, and 20 refinements were made, including a new process stage, heuristic principles and 'when-then' steps. Therapists were found to cycle between stages. Therapists in good outcome cases recognized the majority of these enactments and focused attention to them in contrast to poor outcome cases where therapists usually failed to notice or draw attention to the alliance threat and did not adhere to the model.
Competent resolution of alliance-threatening events is crucially dependent on therapists' ability to recognize them, and secondarily on their adherence to the principles in the refined model. The model is consistent with prior research and can be used in supervision and quality improvement strategies.
对于被诊断为边缘性人格障碍的患者而言，治疗联盟破裂以及过早退出心理治疗的情况非常普遍，这限制了治疗的临床效果。
检验并完善一个模型，该模型阐述了治疗师如何在边缘性人格障碍的认知分析治疗中成功解决对治疗联盟构成威胁的问题，这些威胁涉及到有问题的关系模式的再现。
对四个治疗效果良好案例中66次治疗环节的107次关系模式再现进行任务分析（格林伯格，1984a），并与两个治疗效果不佳案例中16次治疗环节的35次关系模式再现进行比较。这系统地将一个合理的过程模型与治疗环节的经验编码记录进行了对比，在这些记录中，独立评估者已经识别出了联盟威胁事件。
观察到了合理模型的各个过程阶段，并进行了20处细化，包括一个新的过程阶段、启发式原则以及“如果-那么”步骤。发现治疗师会在各阶段之间循环。治疗效果良好案例中的治疗师识别出了这些关系模式再现中的大部分，并对其予以关注，而治疗效果不佳案例中的治疗师通常未能注意到或提请注意联盟威胁，并且没有遵循该模型。
能否妥善解决对联盟构成威胁的事件，关键取决于治疗师识别这些事件的能力，其次取决于他们对细化模型中各项原则的遵循情况。该模型与先前的研究一致，可用于督导及质量改进策略。
