Alliance Rupture and Repair in Group Therapy

A substantial body of research has investigated alliance ruptures and repairs within an individual psychotherapy setting, resulting in theory development and clinical guidance for individual therapists (see Eubanks et al., 2018 for a review). However, there is a paucity of research on the rupture-repair phenomenon in group therapy, limiting group leaders’ knowledge of the importance of rupture-repair sequencing and how to detect and intervene when ruptures occur in therapy groups. Given research on the importance of detecting and repairing alliance ruptures within individual therapy, and the acknowledgement of the lack of research on alliance ruptures in group therapy, two special issues on alliance ruptures in group therapy were recently published in Group Dynamics: Theory, Research, and Practice and the International Journal of Group Psychotherapy. The articles across these special issues provide empirical evidence of the importance of repairing ruptures in group therapy, as well as clinical recommendations for addressing ruptures as they occur in group therapy. Below, we review two articles, one from each special issue, to highlight some of this work.

 Miles, J. R., Anders, C., Kivlighan, D. M. III, & Belcher Platt, A. A. (2021). Cultural ruptures: Addressing microaggressions in group therapy. Group Dynamics: Theory, Research, and Practice, 25(1), 74–88.

Research in multicultural counseling has shown that microaggressions occur in therapy and represent a unique kind of rupture (Davis et al., 2016) by perpetuating external patterns of privilege and marginalization. While individual therapy research has established that microaggressions have a negative impact on the therapy process (e.g., early termination, negative outcomes, weaker therapeutic alliance) and that it is important for clinicians to become aware of them, the unique dynamics of group psychotherapy can make addressing them in group quite challenging. Miles and colleagues reviewed the literature to identify factors that interfere with addressing microaggressions in therapy, as well as factors that help. They then proposed practice recommendations for group therapists to respond to those cultural ruptures.

As microaggressions are subtle (Sue, 2010) and stem from implicit bias, recognizing and addressing them is difficult. In group psychotherapy, microaggressions can occur at the therapist and group levels. Miles and colleagues note that because therapists are socialized in an “inequitable society,” it is essential that they strive to become aware of the ways they might repeat patterns of oppression within the group. The authors of the article emphasize the importance of not only developing multicultural competence, but of also adopting a multicultural orientation to complement it. As highlighted by Sue and colleagues (1992), multicultural competence involves developing awareness of our own and others’ cultural background, knowledge of issues affecting diverse cultural groups, and skills to appropriately serve various populations. Approaching clinical work using a multicultural orientation (Owen et al., 2011b) recognizes that no clinician can really achieve complete multicultural competence. In fact, Owen et al. (2011b) described adopting a multicultural orientation as developing a “way of being.” This process relies on cultural humility, cultural opportunities (addressing cultural issues that arise in group), and cultural comfort (approaching those dialogues with comfort). According to Kivlighan and Chapman (2018), clinicians who adopt this framework can create groups that are culturally affirming and inclusive. 

At the group level, clinicians can help their groups develop a multicultural orientation by reinforcing group norms that encourage members to seek cultural opportunities in the here-and-now with humility and openness. The authors recommend that in the early group sessions, therapists model naming visible and invisible identities and power dynamics in the group, encourage members to talk about and explore their identities, discuss cultural ruptures and how to address them in the group, and model self-awareness. In the case of a rupture caused by a microaggression, Miles and colleagues recommend that clinicians name the microaggression, disarm it and provide support to the target, while also educating the group about the nature of the microaggression and its impact. Therapists can also support the perpetrator by helping manage their emotional reaction to the feedback. When addressing microaggressions, it is important for clinicians to not shame the perpetrator. In fact, adopting a multicultural orientation framework that encourages responding with humility and comfort, while also providing education can help therapists avoid shaming group members. Finally, clinicians can create a “corrective emotional experience” (Miles et al., 2021) for the group as would be done with other types of ruptures. 

References

Davis, D. E., DeBlaere, C., Brubaker, K., Owen, J., Jordan, T. A., II, Hook, J. N., & Van Tongeren, D. R. (2016). Microaggressions and perceptions of cultural humility in counseling. Journal of Counseling and Development, 94(4), 483–493. https://doi.org/10.1002/jcad.12107

Kivlighan, D. M., & Chapman, N. A. (2018). Extending the Multicultural Orientation (MCO) framework to group psychotherapy: A clinical illustration. Psychotherapy: Theory, Research, & Practice, 55(1), 39–44. https://doi.org/10.1037/pst0000142

Owen, J. J., Tao, K., Leach, M. M., & Rodolfa, E. (2011b). Clients’ perceptions of their psychotherapists’ multicultural orientation. Psychotherapy: Theory, Research, & Practice, 48(3), 274–282. https://doi.org/10.1037/a0022065

Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. John Wiley & Sons.

Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling and Development, 20(2), 64–88. https://doi.org/10.1002/j.1556-6676.1992.tb01642.x

Burlingame, G. M., Alldredge, C. T., & Arnold, R. A. (2021). Alliance rupture detection and repair in group therapy: Using the group questionnaire—GQ. International Journal of Group Psychotherapy, 71(2), 338-370.

This article provides an in-depth review of the alliance rupture and repair literature in individual and group therapy and outlines the utility and application of an evidence-based tool, The Group Questionnaire (GQ), for detecting alliance ruptures in group therapy. The authors provide important implications for the utility of the GQ in practice and offer critiques and recommendations for future research on alliance ruptures in group therapy.

A large body of research has documented important ways that the alliance can fluctuate across sessions (i.e., alliance ruptures) and how attending to fluctuations in the alliance and intervening when necessary, can significantly impact treatment outcomes (Eubanks, 2018; Safran et al., 2011). However, as Burlingame and colleagues (2021) note, most of the literature and empirical research on alliance ruptures has focused on individual therapy, resulting in a lack of research examining alliance ruptures in a group therapy context. Burlingame et al. (2021) provide an important overview of the therapeutic relationship in group therapy and note the complexity of studying alliance in group research.  They identify how the alliance, and ruptures, can occur in the relationships between the individual member and therapist, the member and the group as a whole, and member to member. 

The authors expand these ideas by reviewing earlier work (Burlingame et al. 2016) in developing the Group Questionnaire (GQ), an instrument designed to assess positive bond (i.e., adaptive relationships within the group), positive work (i.e., effective working relationships within the group), and negative relationship (i.e., negative relationships within the group). Importantly, they illustrate how the GQ may be used in clinical practice to detect ruptures at various levels (i.e., member-member, member-therapist, member-group) and intervene accordingly. We echo the authors’ sentiment that the GQ is a promising tool to detect the complexity of ruptures as they occur and inform the practice of addressing ruptures in group therapy. We also appreciated the authors clinical and research recommendations. To this we add several additional points of consideration for the use of measurement-based data in the detection and repair of ruptures in group therapy.

As noted earlier, we agree with the importance of Measurement-Based Care (MBC) and the provision of feedback to group therapists on client progress and process, such as the utility of the GQ to monitor alliance ruptures in group therapy. However, as Miller and colleagues (2015) note, “Any clinical tool or technology is only as good as the therapist who uses it” (p. 449). Indeed, much of the MBC literature has focused solely on the measurement tool as the most important element of feedback, while neglecting how therapists utilize the feedback provided. Fortunately, a handful of studies provide insight on important therapist factors in the utilization of MBC. These studies suggest that therapists who are committed to MBC (de Jong et al., 2012), open to feedback (Chow, 2014), and report higher levels of self-doubt (Nissen-Lie et al., 2010) are more effective at providing MBC and developing strong alliances and producing positive treatment outcomes. This research suggests that the therapist is an important factor in the utility and effectiveness of clinical tools to inform clinical practice. 

Together, the use of validated clinical tools to detect important processes in group therapy, such as the GQ to detect ruptures in group therapy, as well as an understanding of important therapist factors in the utility of MBC data will undoubtedly improve the delivery of effective group services. Burlingame et al. (2021) provide insightful recommendations for the utility of the GQ to detect and repair ruptures when they occur in group therapy. It is our hope that group therapists consider these recommendations, while also reflecting on their own use of feedback data to enhance the effectiveness of group services.

References

Burlingame, G., Gleave, R., Beecher, M., Griner, D., Hansen, K., & Jensen, J. (2016). Administration and scoring manual for the Group Questionnaire—GQ. Salt Lake City, UT: OQ Measures.

Chow, D. (2014). The study of supershrinks: Development and deliberate practices of highly effective psychotherapists (Doctoral dissertation, Curtin University). http://hdl.handle.net/20.500.11937/45

de Jong, K., van Sluis, P., Nugter, M. A., Heiser, W. J., & Spinhoven, P. (2012). Understanding the differential impact of outcome monitoring: Therapist variables that moderate feedback effects in a randomized clinical trial. Psychotherapy Research, 22, 464–474. https://doi.org/10.1080/10503307.2012.673023

Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508–519. https://doi.org/10.1037/pst0000185

Miller, S. D., Hubble, M. A., Chow, D., & Seidel, J. (2015). Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy, 52(4), 449-457. https://doi.org/10.1037/pst0000031

Nissen-Lie, H. A., Monsen, J. T., & Rønnestad, M. H. (2010). Therapist predictors of early patient-rated working alliance: A multilevel approach. Psychotherapy Research, 20, 627–646. https://doi.org/10.1080/10503307.2010.497633

Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. In J. C. Norcross, Ed. Psychotherapy relationships that work. 2nd (pp. 224–238). Oxford University Press. https://doi.org/10.1037/a0022140