Catherine F. Eubanks

Adelphi University | AU · Gordon F Derner School of Psychology

Manual for the Rupture Resolution Rating System (3RS) version 2022. This measure is a revision of the 2015 version of the 3RS.

The evidence-based treatment (EBT) movement has primarily focused on core intervention content or treatment fidelity and has largely ignored practitioner skills to manage interpersonal process issues that emerge during treatment, especially with difficult-to-treat adolescents (delinquent, substance-using, medical non-adherence) and those of color....

The therapeutic alliance has been consistently found to be a robust predictor of therapeutic outcome across various modalities of psychotherapy. Alliance ruptures are thought to occur commonly within each therapeutic dyad and, if left unresolved, are associated with premature termination and worsened psychotherapy outcome. Research efforts have ide...

Purpose of Review Individuals with personality disorders are frequently seen in mental health settings. Their symptoms typically reflect a high level of suffering and burden of disease, with potentially harmful societal consequences, including costs related to absenteeism at work, high use of health services, ineffective or harmful parenting, subst...

The therapeutic alliance is considered a robust predictor of psychotherapy outcome. Ruptures and resolutions in the alliance have been the focus of recent alliance literature. Most previous studies investigated their between-patient effects. We used hierarchical linear models to disaggregate the between- and within-patient effects of ruptures on th...

Objective: The purpose of this study was to provide some definition of rupture repair in a cognitive-behavioral therapy (CBT) for personality disorders, specifically how treatment tasks or goals are renegotiated. Method: Following a task analysis, a rational model was developed with the support of an expert panel. An empirical analysis was conducte...

Most research on alliance rupture-repair processes in psychotherapy has been carried out with adults and little is known about the alliance dynamics with adolescents, especially in psychodynamic treatments. Objective: This study aimed to better understand the process of alliance rupture–resolution and its role in a good-outcome case of a depressed...

A strong therapeutic relationship provides the optimal context for CBT, and an important component of this relationship is the alliance. An alliance rupture is a difficulty or deterioration in the alliance manifested by a lack of collaboration on therapy tasks or goals or a strain in the bond. The process of rupture repair can facilitate the work o...

Given the many evidence-supported psychotherapy interventions, and the fact that no single approach or therapist can successfully help all patients, in recent years, there has been a surge in studies focused on evidence-based methods of tailoring treatment to patients, providers, and processes. Although the field still has a long way to go in relia...

About one in five clients drops out of treatment prematurely. Premature termination has been found to correlate with patient, therapist, and treatment factors, as well as complex interpersonal processes, including ruptures in the therapeutic alliance. This study examines the therapeutic alliance using a qualitative approach to patient-, therapist-,...

This study aimed to determine how control charts ‐ a form of time‐series line graphs ‐ can be implemented in psychotherapy research to indirectly identify probable rupture‐repair episodes that are associated with psychotherapy outcome. There is no current standard in psychotherapy research with regard to how to use control charts to identify ruptur...

Objective: The aim of the current study is to explore experiences of trainees engaged in alliance-focused training (AFT), a group supervision modality with an explicit focus on awareness of ruptures and implementation of repair strategies. Using Cognitive Behavioral Therapy (CBT) group supervision as a point of comparison, the study examines super...

This commentary highlights common principles shared across the diverse clinical case examples featured in this In Session issue on Rupture Repair in Practice. We discuss the importance of therapists recognizing subtle signs of rupture and responding to ruptures with curiosity and compassion. We also consider how therapists can use repair strategies...

In this introduction to this issue on Rupture–Repair in Practice, we present our understanding of alliance ruptures using common language to appeal to all theoretical orientations. Specifically, we define withdrawal movements away from another or oneself (efforts towards isolation or appeasement) and confrontation movements against another (efforts...

In March of 2020, due to the COVID-19 pandemic, the mental health services at the Brief Psychotherapy Research Program at Mount Sinai Beth Israel were abruptly altered to be delivered exclusively via teletherapy. Many patient-therapist dyads who had begun working together in an on-site setting were asked to transition to remote work. We wondered wh...

Objective Contemporary theories and the empirical literature stress the importance of successful resolution of alliance ruptures for the process and outcome of treatment. Yet, little empirical work has examined what leads to successful resolutions. The aim of the present study was to examine which patients are more likely to achieve successful reso...

Group supervision presents unique opportunities for psychotherapy trainees to deepen their understanding of alliance ruptures and repair strategies. Trainees can explore challenging clinical moments and benefit from diverse perspectives and support. Group supervision also provides trainees with multiple opportunities to experience ruptures and repa...

Individuals high in vindictive interpersonal problems tend to experience and express anger and irritability. In treatment, they have poor prognosis for alliance and outcome. We propose that positive expectation may serve as a moderating factor for these patients. In the current study, we examined the ability of expected alliance to act as a moderat...

Background: To draw clinically meaningful evidence-supported implications about the alliance-outcome association, recent studies have investigated patient-therapist congruence on ruptures in alliance. The present study investigated patient-therapist congruence on ruptures and its consequences on subsequent session outcome in two types of treatments...

Background: To draw clinically meaningful evidence-supported implications about the alliance-outcome association, recent studies have investigated patient-therapist congruence on ruptures in alliance. The present study investigated patient-therapist congruence on ruptures and its consequences on subsequent session outcome in two types of treatments...

The authors discuss the phenomena of “misattunements,” or ruptures, in the working alliance. They present a set of skills and tools that aim to help therapists recognize and identify when ruptures occur, and they introduce a model for managing these moments. Albeit difficult, ruptures in the working alliance are common, and research shows that a th...

People with pathological narcisism, with their conflicted sense of grandiosity and vulnerability, often pose a variety of therapeutic challenges, which may impede these patients’ ability to benefit from psychotherapy. To offer a case illustration and provide insight into the intrinsic difficulties of working with this patient group, we examined the...

Objectives: Literature on outcome assessment suggests that 35–40% of patients in randomized control trials terminate treatment with unchanged or higher levels of symptomatology. The goal of the present study was to shed light on this phenomenon and the factors accounting for it using a single case study design that investigates the process and outc...

A rupture is a deterioration in the therapeutic alliance, manifested by a disagreement between the patient and therapist on treatment goals, a lack of collaboration on therapeutic tasks, or a strain in their emotional bond. This chapter presents the most frequently used measures of alliance ruptures and clinical examples to illustrate their repair....

Psychotherapy Relationships That Work is the definitive, evidence-based book on the topic: Volume 1 contains 16 chapters that address what works in general and Volume 2 consists of 11 chapters that address what works for particular patients. Each chapter presents definitions, clinical examples, landmark studies, comprehensive meta-analyses, diversi...

Ambivalence, resistance, and alliance ruptures are three terms commonly used in psychotherapy, across different theoretical approaches and modalities. However, it is still not clear how those terms are related and how the connection can be used to maintain a therapeutic alliance while addressing clients’ ambivalence. This paper aims to briefly desc...

The current study explored trainee therapists' experiences in alliance-focused training (AFT), a form of group supervision focused on training therapists to recognize and negotiate alliance ruptures. We analyzed interviews with 36 former trainees who received AFT during their predoctoral psychology internships. Findings centered on trainees' views...

Decades of work by Jeremy Safran and his colleagues have established that ruptures in the therapeutic alliance are not necessarily obstacles to the treatment, and that the process of repairing these events has the potential to deepen the therapeutic relationship and promote change. The field of alliance rupture research has largely focused on thera...

This special section will honor Jeremy Safran's vision for psychotherapy research by featuring five empirical studies. In a fitting tribute to Safran's love of collaboration, all of these studies were conducted by close colleagues and/or students of his, some in collaboration with him before his untimely death.

A principle-based approach to integration provides a framework for identifying common change processes that may exist among different theoretical orientations. This chapter identifies five change principles that are common across orientations and are supported by outcome research: fostering the patient’s hope, positive expectations, and motivation;...

Psychotherapy integration has become a well-established and influential movement in mental health. In this chapter, the authors explore where psychotherapy integration may be headed in the areas of theory, practice, research, and training, and as a formal movement. The authors hope to advance discussion about future directions that seem particularl...

Objective: Two decades of empirical research suggest that changes in symptoms are not linear, and many patients gain much of their symptom reduction in one between-sessions interval. Theoretically, such gains are expected to be manifested in the working alliance as well, following a rupture session; however, no study to date has directly examined b...

Objective: Our aim was to examine the reliability and validity of the Rupture Resolution Rating System (3RS), an observer-based measure of alliance ruptures and resolution processes. Method: We used the 3RS to rate early sessions from 42 cases of cognitive behavior therapy. We compared the 3RS to a simplified version of the Structural Analysis o...

A rupture is a deterioration in the therapeutic alliance, manifested by a disagreement between the patient and therapist on treatment goals, a lack of collaboration on therapeutic tasks, or a strain in their emotional bond. We present the most frequently used measures of alliance ruptures and clinical examples to illustrate their repair. To examine...

Aim: One of the most prominent achievements attributable to psychotherapy probably stands in the vast body of literature demonstrating its efficacy for a variety of diagnoses. However, a close look at the literature shows that some foundational questions such as defining and assessing outcomes have not yielded extensive literature. This study inves...

Client ambivalence toward change has been shown to be a central influence on outcomes in psychotherapy, as higher levels of ambivalence can result in limited engagement in therapy. Furthermore, research has consistently demonstrated the importance of the therapeutic alliance, which can be impacted by alliance ruptures, or moments of tension or mis...

The working alliance is one of the most consistent predictors of outcome. Yet, little empirical knowledge exists on how therapists can use this association to maximize the outcome of cognitive behavioral therapy (CBT) for individual clients. The present study aimed to examine pre-treatment client interpersonal characteristics that determine what fu...

The aim of this exploratory study was to investigate alliance rupture and resolution processes in the early sessions of a sample of clients who underwent 1 year of standard dialectical behavior therapy (DBT) for borderline personality disorder (BPD). Participants were three recovered and three unrecovered clients drawn from the DBT arm of a randomi...

Objective: It has been demonstrated that patient perspective on alliance can predict subsequent treatment outcome as reported by the therapist, but not the other way around. This study aimed to investigate the circumstances in which therapists can provide estimations of alliance capable of predicting patient perceptions of subsequent session outcom...

Objective: The alliance been recognized as an essential common factor and robust predictor of outcome. The present study sought to further our knowledge of the alliance and to promote the integration of research and practice by assessing consensus among peer-nominated expert therapists of varying theoretical orientations on the effectiveness of cl...

Objective: In order to improve success rates in psychotherapy, an alliance-focused training (AFT) protocol was developed and evaluated with regard to patient-therapist interpersonal behavior in a 30-session protocol of cognitive-behavioral therapy for outpatients comorbid with Axis I and II conditions conducted in a medical center setting. Method:...

Small, R. B., Muran, J. C., Safran, J. D., & Eubanks, C. (2016, June). The impact of Alliance-Focused Training on therapist self-expression, emotional involvement, and alliance perspective. Poster presented at the 47th International Annual Meeting of the Society for Psychotherapy Research, Jerusalem, Israel.

Objective: Better alliance is known to predict better psychotherapy outcomes, but the interdependent and interactive effects of both therapist- and patient-reported alliance levels have yet to be systematically investigated. Method: Using actor-partner interdependence model analysis the authors estimated actor, partner, and 2 types of interactiv...

Reviews the book, Cradling the Chrysalis: Teaching and Learning Psychotherapy (2nd Ed.) by Mary MacCallum Sullivan and Harriett Goldenberg (see record 2015-21773-000 ). Drawing on philosophy as well as psychotherapy theory, Sullivan and Goldenberg advocate for an understanding of therapy that they feel is being lost in the focus on evidence-based p...

In two National Institute of Mental Health (NIMH)-funded studies, our program has developed alliance-focused treatment and training (AFT) protocols and has demonstrated their beneficial effect on treatment resistance and interpersonal process in psychotherapy. AFT is founded on relational principles derived from research on cognitive, affective, an...

Integration has become an important and influential movement within psychotherapy practice, reflected by the fact that many treatment providers now identify as integrative. However, integration has not had as great an influence on psychotherapy research. The goal of this paper is to highlight the growing body of research on psychotherapy integratio...

The 3RS is an observer-based measure of alliance ruptures and resolution strategies. The 3RS yields ratings for the frequency and significance of withdrawal and confrontation ruptures, as well as the therapist’s use of strategies to resolve these ruptures.

Alliance-focused training (AFT) aims to increase therapists' ability to recognize, tolerate, and negotiate alliance ruptures by increasing the therapeutic skills of self-awareness, affect regulation, and interpersonal sensitivity. In AFT, therapists are encouraged to draw on these skills when metacommunicating about ruptures with patients. In this...

Literature on psychotherapy outcome suggests that 35% to 40% of patients in randomized control trials do not improve over the course of therapy, and 5% to 10% actually deteriorate. This phenomenon is not bound to a specific approach to treatment, but rather seems to occur across all types of evidence-based therapies. So far, literature on deteriora...

Objective: In this article we present preliminary findings from a research program designed to investigate the value of alliance-focused training (AFT), a supervision approach designed to enhance therapists' ability to work constructively with negative therapeutic process. Method: In the context of a multiple baseline design, all therapists bega...

The current study examined the relationship between borderline personality disorder (BPD) features and appraisals of daily romantic relationship experiences. The sample included 114 ethnically diverse, young adult dating couples (total N = 228). Participants completed a 14-day daily diary study and reported negative impact and emotional loss to the...

Analysis of change points in psychotherapy process could increase our understanding of mechanisms of change. In particular, naturalistic change point detection methods that identify turning points or breakpoints in time series data could enhance our ability to identify and study alliance ruptures and resolutions. This paper presents four categories...

First published in 2002, the landmark Psychotherapy Relationships That Work broke new ground by focusing renewed and corrective attention on the substantial research behind the crucial (but often overlooked) client-therapist relationship. This thoroughly revised edition brings a decade of additional research to the same task. In addition to updatin...

In this article, we review the existing empirical research on the topic of therapeutic alliance ruptures in psychotherapy. Ruptures in the therapeutic alliance are defined as episodes of tension or breakdown in the collaborative relationship between patient and therapist. Two meta-analyses were conducted. The first reviewed studies examining the re...

The goal of this study was to develop a method for examining children's expectations about the short-term consequences of defensive interpersonal behaviour. We employed the theory of interpersonal defence (Dahmen & Westerman, in press; Westerman, 1998, 2005; Westerman & Prieto, 2006), an interpersonal reconceptualization of defence processes, as th...

Modern interpersonal psychology is now at a point where recent advances need to be organized so that researchers, practitioners, and students can understand what is new, different, and state-of-the art. This field-defining volume examines the history of interpersonal psychology and explores influential theories of normal-abnormal behaviors, widely-...

This state-of-the-art book presents research-based practice guidelines that clinicians of any orientation can use to optimize the therapeutic alliance. Leading proponents of the major psychotherapeutic approaches explain just what a good alliance is, how to create it, and how to recognize and repair alliance ruptures. Applications in individual, gr...

This state-of-the-art book presents research-based practice guidelines that clinicians of any orientation can use to optimize the therapeutic alliance. Leading proponents of the major psychotherapeutic approaches explain just what a good alliance is, how to create it, and how to recognize and repair alliance ruptures. Applications in individual, gr...

The treatment of personality disorders is a rapidly evolving focus of contemporary mental health practice. Personality dysfunction is often further complicated by the comorbidity of an Axis I disorder, such as anxiety, bipolar disorder, depression, substance abuse, and others. Because personality dysfunction cuts across many clinical domains, pract...

Research that identifies areas of agreement among expert therapists can complement findings from clinical trials by highlighting common practices as well as innovations. The present study accessed consensus among expert therapists on the effectiveness of clinical strategies for treating young adults experiencing interpersonal problems with their pa...

This study examined the relationship of early alliance ruptures and their resolution to process and outcome in a sample of 128 patients randomly assigned to 1 of 3 time-limited psychotherapies for personality disorders: cognitive-behavioral therapy, brief relational therapy, or short-term dynamic psychotherapy. Rupture intensity and resolution were...