Umgang mit Spannungen und Krisen in der therapeutischen Beziehung: Erste Erfahrungen mit einem handlungsorientierten Ausbildungs- und Supervisionskonzept

Zusammenfassung

Ziele Das allianzfokussierte Training (AFT) [1] schult therapeutische Kompetenzen, die für den Umgang mit Spannungen und Krisen in der therapeutischen Beziehung hilfreich sind unter Einsatz von Videoaufzeichnungen und Rollenspielen. Ziel der von der Heigl-Stiftung geförderten Pilotstudie war es, erste klinische Erfahrungen und Ergebnisse mit AFT im deutschsprachigen Raum vorzustellen und eine RCT-Folgestudie vorzubereiten.

Methoden 7 Ausbildungskandidaten nahmen teil. Therapien von 15 Patienten mit depressiver Störung wurden analysiert.

Ergebnisse und Schlussfolgerung AFT wurde als sehr hilfreich für die professionelle Entwicklung und den Umgang mit Spannungen und Krisen erlebt. Die therapeutische Kompetenz verbesserte sich signifikant im Selbsterleben und aus Beobachterperspektive. Die Ergebnisse sprechen dafür, dass AFT eine vielversprechende Möglichkeit zur Verbesserung der Psychotherapieausbildung ist und sich die Durchführung eines RCT zum Nachweis der Wirksamkeit lohnt.

Abstract

Aims Alliance Focused Training (AFT) [1] aims at enhancing therapists’ competences in resolving ruptures in the therapeutic alliance using video recordings and role-plays. This pilot study funded by the Heigl Foundation aimed at presenting initial results and clinical experiences with AFT in Germany, and to prepare a subsequent RCT.

Methods 7 trainee therapists participated. Therapies of 15 patients with depressive disorder were analyzed.

Results and conclusion Trainees experienced AFT as very helpful for their professional development and for dealing with alliance ruptures. The therapeutic competence significantly improved both in self and in observer ratings. The results indicate that AFT is a promising approach to improve psychotherapy training, emphasizing the relevance of the planned proof of concept RCT.

Schlüsselwörter

Therapeutische Allianz - Spannungen und Krisen - Übertragung und Gegenübertragung - Psychotherapeutische Kompetenz - Psychotherapieausbildung

Key words

therapeutic alliance - rupture repair - transference and countertransference - interpersonal skills - psychotherapy training

• Literatur

• 1 Safran JD, Muran JC. Negotiating the therapeutic alliance: A relational treatment guide. New York: Guilford Press; 2007
• 2 Flückiger C, Del Re, AC Wampold BE et al. The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy 2018 Advance online publication.
• 3 Zilcha-Mano S. Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances. Am Psychol 2017; 72: 311-325
• 4 Gumz A, Rugenstein K, Munder T. Allianz-Fokussiertes Training. Schulenübergreifender Weg zum Umgang mit Krisen in der therapeutischen Beziehung. Psychotherapeut 2018; 63: 55-61
• 5 Safran JD, Muran JC. The resolution of ruptures in the therapeutic alliance. J Consult Clin Psychol 1996; 64: 447-458
• 6 Kohut H. Die Heilung des Selbst. Frankfurt a. M.: Suhrkamp Taschenbuch Wissenschaft; 1979
• 7 Binder JL, Strupp HH. “Negative process”: A recurrently discovered and underestimated facet of therapeutic process and outcome in the individual psychotherapy of adults. Clin Psychol 1997; 4: 121-139
• 8 Freud S. Zur Dynamik der Übertragung. Gesammelte Werke, Bd. VIII. Frankfurt a. M.: Fischer; 1912
• 9 Gumz A. Kritische Momente im Therapieprozess – Chance oder Sackgasse?. Psychotherapeut 2012; 27: 256-262
• 10 Hill CE, Thompson BJ, Cogar MC. et al. Beneath the surface of long-term therapy: therapist and client report of their own and each other’s covert processes. J Couns Psychol 1993; 40: 278-287
• 11 Hill CE, Thompson BJ, Corbett MM. The impact of therapist ability to perceive displayed and hidden client reactions on immediate outcome in first sessions of brief therapy. Psychother Res 1992; 2: 148-160
• 12 Coutinho J, Riberio E, Hill C. et al. Therapists’ and clients’ experiences of alliance ruptures: a qualitative study. Psychother Res 2011; 21: 525-540
• 13 Castonguay LG, Aikins SA, Constantino D. et al. Repairing alliance ruptures in cognitive therapy: A preliminary investigation of an integrative therapy for depression. J Psychother Integr 2004; 14: 4-20
• 14 Piper WE, Odrodnikzcuk JS, Joyce AS. et al. Prediction of dropping out in time-limited, interpretive individual psychotherapy. Psychother Res 1999; 36: 114-122
• 15 Rhodes RH, Hill CE, Thompson BJ. et al. Client retrospective recall of resolved and unresolved misunderstanding events. J Couns Psychol 1994; 41: 473-483
• 16 Aspland H, Llewelyn S, Hardy GE. et al. Alliance ruptures and rupture resolution in cognitive-behavior therapy: A preliminary task analysis. Psychother Res 2008; 18: 699-710
• 17 Owen J, Wampold BW, Kopta M. et al. As good as it gets? Therapy outcomes of trainees over time. J Couns Psychol 2016; 63: 12-19
• 18 Castonguay LG, Boswell JF, Zack SE. et al. Helpful and hindering events in psychotherapy: a practice research network study. Psychotherapy 2010; 47: 327-344
• 19 Safran JD, Muran JC, Eubanks-Carter C. Repairing alliance ruptures. Psychotherapy 2011; 48: 80-87
• 20 Stiles WB, Glick MJ, Osatuke K. et al. Patterns of alliance development and the rupture-repair hypothesis: are productive relationships U-shaped or V-shaped?. J Couns Psychol 2004; 51: 81-91
• 21 Strauss JL, Hayes AM, Johnson SL. et al. Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders. J Consult Clin Psychol 2006; 74: 337-345
• 22 Gumz A, Bauer K, Brähler E. Corresponding instability of patient and therapist process ratings in psychodynamic psychotherapies. Psychother Res 2012; 22: 26-39
• 23 Gumz A, Kästner D, Geyer M. et al. Instability and discontinuous change in the experience of therapeutic interaction: An extended single-case study of psychodynamic therapy processes. Psychother Res 2010; 20: 398-412
• 24 Larsson MH, Falkenström F, Andersson G. et al. Alliance ruptures and repairs in psychotherapy in primary care. Psychother Res 2018; 28: 123-136
• 25 Baldwin SA, Imel ZE. Therapist effects: Findings and methods. In Lambert MJ. ed Bergin and Garfield’s Handbook of psychotherapy and behavior change. Hoboken: Whiley & Sons; 2013: 258-297
• 26 Baldwin SA, Wampold BE, Imel ZE. Untangling the alliance-outcome correlation: exploring the relative importance of therapist and patient variability in the alliance. J Consult Clin Psychol 2007; 75: 842-852
• 27 Del Re AC, Flückiger C, Horvath AO. et al. Therapist effects in the therapeutic alliance-outcome relationship: A restricted-maximum likelihood meta-analysis. Clin Psychol Rev 2012; 32: 642-649
• 28 Anderson T, Crowley ME, Himawan L. et al. Therapist facilitative interpersonal skills and training status: A randomized clinical trial on alliance and outcome. Psychother Res 2016; 26: 511-529
• 29 Anderson T, McClintock AS, Himawan L. et al. A prospective study of therapist facilitative interpersonal skills as a predictor of treatment outcome. J Consult Clin Psychol 2016; 84: 57-66
• 30 Anderson T, Ogles BM, Patterson CL. et al. Therapist effects: facilitative interpersonal skills as a predictor of therapist success. J Clin Psychol 2009; 65: 755-768
• 31 Hilsenroth MJ, Cromer T, Ackerman S. How to make practical use of therapeutic alliance research in your clinical work. In Levy RA. et al. ed Psychodynamic psychotherapy research: Evidence-based practice and practice-based evidence. New York: Springer Press; 2012: 361-380
• 32 Laska KM, Smith TL, Wislocki AP. et al. Uniformity of evidence-based treatments in practice? Therapist effects in the delivery of cognitive processing therapy for PTSD. J Couns Psychol 2013; 60: 31-41
• 33 Beck JG, Castonguay LG, Chronis-Tuscano A. et al. Principles for training in evidence-based psychology: Recommendations for the graduate curricula in clinical psychology. Clin Psychol 2014; 21: 410-424
• 34 Laska KM, Gurman AS, Wampold BE. Expanding the lens of evidence-based practice in psychotherapy: a common factors perspective. Psychotherapy 2014; 51: 467-481
• 35 Strauß B, Barnow S, Brähler E et al. Forschungsgutachten zur Ausbildung von Psychologischen Psychotherapeutinnen und Kinderund Jugendlichenpsychotherapeutinnen. Bundesministerium für Gesundheit. 2009
• 36 Hill CE, Knox S. Training and supervision in psychotherapy. In: Lambert MJ. ed. Bergin and Garfield’s handbook of psychotherapy and behavior change. Hoboken: Wiley & Sons; 2013: 775-811
• 37 Eubanks-Carter C, Muran JC, Safran JD. Alliance-focused training. Psychotherapy 2015; 52: 169-173
• 38 Muran JC, Safran JD, Gorman BS. et al. The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders. Psychother Theor Res Pract Train 2009; 46: 233-248
• 39 Gumz A, Marx C, Rugenstein K. et al. Krisen in der therapeutischen Beziehung. In: Gumz A, Hörz-Sagstetter S. (Hrsg.). Lehrbuch der Psychodynamischen Psychotherapie. Weinheim: Beltz; 2018: 623-635
• 40 Safran JD, Muran C, Shaker A. Research on therapeutic impasses and ruptures in the therapeutic alliance. Contemp Psychoanal 2014; 50: 211-232
• 41 Muran JC, Safran JD, Eubanks CF. et al. The effect of Alliance-Focused Training on a Cognitive-Behavioral Therapy for personality disorders. J Consult Clin Psychol 2018; 86: 384-397
• 42 Safran J, Muran JC, Demaria A. et al. Investigating the impact of alliance-focused training on interpersonal process and therapists’ capacity for experiential reflection. Psychother Res 2014; 24: 269-285
• 43 Craig P, Dieppe P, Mcintyre S. et al. Developing and evaluating complex interventions: The new Medical Research Council guidance. BMJ 2008; 337: a1655
• 44 Grosse-Holtforth M, Krieger T, Zimmermann J. et al. A randomized-controlled trial of cognitive-behavioral therapy for depression with integrated techniques from emotion-focused and exposure therapies. Epub Psychother Res 2017; 12: 1-15
• 45 Teo AR, Choi H, Valenstein M. Social relationships and depression: ten-year follow-up from a nationally representative study. PLoS One 2013; 8: e62396
• 46 Weightman MJ, Air TM, Baune BT. A review of the role of social cognition in major depressive disorder. Front Psychiatry 2014; 5: 179
• 47 McCullough JP, Schramm E, Penberthy JK. CBASP as a Distinctive Treatment for Persistent Depressive Disorder. New York: Routledge; 2015
• 48 Fernandez E, Salem D, Swift JK. et al. Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators. J Consult Clin Psychol 2015; 83: 1108-1122
• 49 Wittchen HU, Zaudig M, Fydrich T. Strukturiertes Klinisches Interview für DSM-IV. Achse I und II. Göttingen: Hogrefe; 1997
• 50 Orlinsky DE, Rønnestad MH. How psychotherapists develop: A study of therapeutic work and professional growth. Washington DC: American Psychological Association; 2005
• 51 Uhlin BD. Therapist In-session Rated Facilitative Interpersonal Skills (FIS-IS) in the Psychotherapy. Process. [Dissertation]. Athens, Ohio, University of Ohio. 2011
• 52 Fleiss JL, Levin B, Paik MC. Statistical methods for rates and proportions. Hoboken: Wiley & Sons; 2013
• 53 Patton MJ, Muran JC, Safran JD. et al. Treatment fidelity measure for three brief psychotherapies. New York: Beth Israel Medical Center; 1998
• 54 Muran JC, Safran JD, Samsta LW. et al. Evaluating an alliance-focused treatment for personality disorders. Psychother Theor Res Pract Train 2005; 42: 532-545
• 55 Schmidt J, Lamprecht F, Wittmann WW. Zufriedenheit mit der stationären Versorgung. Entwicklung eines Fragebogens und erste Validitätsuntersuchungen. Psychother Psychosom Med Psychol 1989; 39: 248-255
• 56 Zarbock G, Drews M, Bodansky A. et al. The evaluation of supervision: Construction of brief questionnaires for the supervisor and the supervisee. Psychother Res 2009; 19: 194-204
• 57 Falkenström F, Hatcher RL, Skjulsvik T. et al. Development and validation of a 6-item working alliance questionnaire for repeated administrations during psychotherapy. Psychol Assess 2015; 27: 169-183
• 58 Hatcher RL, Gillaspy JA. Development and validation of a revised short version of the Working Alliance Inventory. Psychother Res 2006; 16: 12-25
• 59 Munder T, Wilmers F, Leonhart R. et al. Working Alliance Inventory Short Revised (WAI-SR): psychometric properties in outpatients and inpatients. Clin Psychol Psychother. 17: 231-239
• 60 Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clin Psychol Rev 1988; 8: 77-100
• 61 Hautzinger M, Keller F, Kühner C. BDI-II. Beck Depressions Inventar Revision -Manual. Frankfurt: Harcourt Test Services. 2006
• 62 Steinmeyer EM. Zur klinischen Validität des Beck-Depressionsinventars: Eine facettentheoretische Reanalyse multizentrischer klinischer Beobachtungsdaten. Nervenarzt 1993; 64: 717-726
• 63 Löwe B, Spitzer RL, Zipfel S. et al. Gesundheitsfragebogen für Patienten (PHQ D). Komplettversion und Kurzform. Testmappe mit Manual, Fragebögen, Schablonen. 2. Aufl Karlsruhe: Pfizer; 2002
• 64 Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 1999; 282: 1737-1744
• 65 Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol 1991; 59: 12-19
• 66 Muran JC. A relational approach to understanding change: multiplicity and contextualism in a psychotherapy research program. Psychother Res 2002; 12: 113-138
• 67 Swift JK, Greenberg RP. Premature discontinuation in adult psychotherapy: A meta-analysis. J Consult Clin Psychol 2012; 80: 547-559