Counselling and Psychotherapy Research, March 2011; 11(1): 43
54

Alliance evolutions over the course of short-term dynamic

psychotherapy: A case study

LUC MICHEL*, UELI KRAMER, & YVES DE ROTEN

Institute of Psychotherapy, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland

Abstract
Background: Alliance evolutions, i.e. ruptures and resolutions over the course of psychotherapy, have been shown to be
important descriptive features in different forms of psychotherapy, and in particular in psychodynamic psychotherapy. This
case study of a client presenting elements of adjustment disorder undergoing short-term dynamic psychotherapy is drawn
from a systematic naturalistic study and aims at illustrating, on a session-by-session-level, the processes of alliance ruptures
and resolutions, by comparing both the client’s and the therapist’s perspectives. Method: Two episodes of alliance evolution
were more fully studied, in relation to the evolution of transference, as well as the client’s defensive functioning and core
conflictual theme. These concepts were measured by means of valid, reliable observer-rater methods, based on session
transcripts: the Defense Mechanisms Rating Scales (DMRS) for defensive functioning and the Core Conflictual
Relationship Theme (CCRT) for the conflicts. Alliance was measured after each session using the Helping Alliance
questionnaire (HAq-II). Results: The results indicated that these episodes of alliance rupture and resolutions may be
understood as key moments of the whole therapeutic process reflecting the client’s main relationship stakes. Illustrations
are provided based on the client’s in-session processes and related to the alliance development over the course of the entire
therapy.

Keywords: case study; alliance; transference; defence mechanisms; psychodynamic psychotherapy

Introduction Both methods are based on the principles of regres-

sion, focusing on the mean evolution and neglecting
Therapeutic alliance has been shown to be related to
the session-by-session momentary fluctuations of
psychotherapy outcome (Martin, Garske, & Davis,
alliance. As suggested by Safran and Muran (2000)
2000). Several authors have suggested that alliance
and shown by Stiles et al. (2004), the shape of
should not merely be measured at one point in time,
alliance evolution may be characterised by local
but rather be understood as it changes over the
(session-by-session) V-shapes, generally interpreted
course of the entire treatment (e.g. Castonguay,
as alliance ruptures and resolutions; the latter may
Constantino, & Grosse Holtforth, 2006). Empiri-
be related to outcome.
cally, recent studies have shown the relevance of
alliance evolution as being related to outcome (de
Roten, Fischer, Drapeau, Beretta, Kramer, Favre, & Alliance ruptures/resolutions and transference
Despland, 2004; Kivlighan, & Shaughnessy, 2000; According to Safran (1993) the moment of alliance
Kramer, de Roten, Beretta, Michel, & Despland, rupture is understood as a ‘window into core themes’
2008; Kramer, de Roten, Beretta, Michel, & Desp- of the client (p. 13). It may be postulated that at the
land, 2009). The afore-mentioned studies used moment of alliance rupture, the clients and thera-
formalising procedures enabling the representation pists enact the vicious circle which corresponds to
of either (1) general growth tendencies of alliance the client’s core conflictual relationship theme
over the course of psychotherapy or (2) alliance (Luborsky & Crits-Christoph, 1990). For instance,
patterns as groupings of clients presenting similar an alliance rupture may be the result of a therapist
alliance evolution over the course of psychotherapy. intervention aiming at pushing a withdrawn client

*Corresponding author. Email: [email protected]

ISSN 1473-3145 print/1746-1405 online # 2011 British Association for Counselling and Psychotherapy
DOI: 10.1080/14733145.2011.546160
44 L. Michel et al.
to self-disclosure (Safran, 1993). From the perspec- resolutions
as well as psychodynamic character-
tive of psychoanalytic theory, such interactional istics, i.e. defence mechanisms, the core conflictual
dynamics may be paralleled to the transference- relationship theme and transference issues.
countertransference dynamics in psychotherapy.
Negative affect in the therapist is provoked by the
enactment of the core conflictual relationship theme Method
in the therapeutic relationship. Alliance ruptures The client
therefore have an important diagnostic function in
the reconstruction of the client’s conflicts. Alliance Julia was a PhD student who had come to see us
resolution phases follow the moments of ruptures in because she had been suffering from bouts of
positive therapeutic processes (Safran, 1993). They weeping and diffuse anxiety for several weeks, and
are characterised by what Alexander and French this was stopping her from getting on with her work.
(1946) have called the corrective emotional experi- She presented with a depressed way of thinking and
ence. The latter concept describes the therapeutic various somatisations. This symptomatology ap-
attitude facing the alliance rupture. Clinical illustra- peared when Julia was coming to the end of her
tions of these processes may be found in de Roten, doctoral thesis and would have to start thinking
Michel, and Peter (2007). about her professional career. In addition, she was
not very happy about having two thesis supervisors
as she felt that there was a certain tension between
The role of the client’s psychodynamic characteristics them. One was ambitious and a good researcher and
Defence mechanisms, reflecting the person’s struc- the other gave priority to his family. She found this
tural functioning, are key concepts in psychody- situation confusing and it was paralysing her.
namic formulation and treatment. They are Julia was the youngest of three children; both her
postulated to change over the course of dynamic parents went to university. Her parents married
psychotherapy, as shown by Perry (2001). A client’s young while still at university. Her childhood was
defences change throughout psychotherapy along marked by several house moves to different language
the hierarchy of adaptiveness, from immature de- zones, due to her father’s university career. Her
fences to neurotic and mature defences at the end of mother gave up her career to follow her husband.
treatment. A recent study showed a medium effect ‘My mother sacrificed her career for that of her
size for change in the client’s defensive functioning husband’ were her exact words.
over the course of Short-Term Dynamic Psychother- Julia remembers a particularly difficult moment in
apy (STDP; Kramer, Despland, Michel, Drapeau, & her early teenage years when the family moved.
de Roten, 2010). Defensive functioning may also be When she was 18, her parents separated. Julia chose
related to the individual’s intra-psychic conflicts to finish her schooling alone. She returned to her
(Luborsky, & Crits-Christoph, 1990; de Roten, hometown to round off her studies and start on a
Drapeau, Stigler, & Despland, 2004). thesis. The return was not easy in the beginning and
The aim of the current single case study was to Julia went through ‘a period of depression’ because
present a possible articulation between clinical she had trouble in re-adapting.
material and research-informed assessment over An important element was that Julia had been in
time, in particular around the notion of evolution an intimate relationship for five years now and
of the therapeutic alliance. This single case study was beginning to see it as a long-term commitment.
was greatly inspired by the pragmatic paradigm Her boyfriend had agreed to go abroad with her if
(Fishman, 1999) which tends to bridge the gap her professional plans required such a move. The
between opposing movements, i.e. the positivistic question of having children was a cause of distress:
approach versus the hermeneutic approach to the ‘It’s impossible to be a PhD student and pregnant!’
clinical phenomenon. The present single case study Julia was in a crisis when she consulted the
was based on the session-by-session monitoring of psychotherapist
at a crossroads both professionally
alliance as measured by a self-report questionnaire, and existentially. The difficulty she had in making a
in that it aimed at identifying alliance ruptures and choice seemed to relate to her parents’ contrasting
resolutions. These episodes were related to the lifestyle. She realised that she was embarking on the
clinical evolution of the case
the underlying same path as her father and felt a certain rivalry yet
psychological meaning of the alliance ruptures and also sought to please him by following in his
 Alliance evolutions in STDP 45

footsteps. But how can she conciliate her career with Luborsky (1986) at the end of each therapy session.
her life as a woman reflecting the image of her This inventory consists of 11 items rated on a
mother and the sacrifices her mother had to make? six-point Likert-scale (ranging from 3 ‘I strongly
Her internal conflictuality became a reality in her feel that it isn’t true’, to 3 ‘I strongly feel that it is
discomfort regarding her two thesis supervisors on true’). Only the mean score of all the items was used.
whom she projects. The HAq-I has been shown to have a good reliability
We need to note that this client did not present any and validity and it correlated with other well-
psychiatric diagnosis nor had clinically significant validated instruments (.74 to CALPAS and .74 to
symptoms (as reported on SCL-90) at intake, WAI according to Hatcher & Barends, 1996).
discharge and follow-up. Internal consistency of the HAq in the sample
The client explicitly agreed to the use of the data from which the case was extracted ranged from
related to her psychotherapy for research. Cronbach a.79 .89.

Defence mechanisms. The Defense Mechanism

The therapist
Rating Scales (DMRS) was used to assess defence
The therapist was an expert in psychoanalytic mechanisms (Perry, 1990; Perry et al., 2004). The
psychotherapy and psychoanalysis. In this particular DMRS is an observer-rated method that can be
context, he offered specific short-term dynamic applied to the audio or video recording or the written
psychotherapy for university students (Gilliéron, transcription of various forms of interviews or of
1997; Michel & Despland, 2006), in particular therapy sessions. Many studies have supported the
within the context of a naturalistic study focusing validity and reliability of the method (e.g. Perry,
on psychodynamic psychotherapy of adjustment 2001; Skodol & Perry, 1993). The defences de-
disorder (Kramer et al., 2010). scribed in the DMRS are comparable to those listed
and described in the DSM-IV (American Psychiatric
Association [APA], 1994). The instrument includes
The research team
a total of 30 defence mechanisms assigned to seven
The research team was composed of the therapist hierarchical levels of defensive functioning: high
and two senior researchers in psychotherapy (co- adaptive (mature), obsessional, other neurotic,
authors). All members of the team have expertise in minor image-distorting, disavowal, major image-
methodological issues, two are psychologists (PhD), distorting, and action defences. Each of these levels
and one is an MD. The use of the therapist as a includes 3
8 individual defences. As each level of
member of the research team is described under defensive functioning is weighted according to its
Procedure. level of maturity, an overall defensive functioning
score (ODF) can be computed to reflect the patient’s
overall defensive maturity. This overall score is used
Goals and context of treatment
in this study.
The aim of the psychotherapy was to enable the
client to become aware of and work through this Transference. Transference was assessed by two
crisis hypothesis. This would serve as the focus for methods, one well-validated (CCRT) and the other
the beginning of psychodynamic psychotherapy of a exploratory (Transference Dimensions Monitoring;
limited duration (34 sessions) occurring once a TDM). We used both, in order to provide two
week. The therapy took place within an institutional perspectives on the same concept and to explore the
setting (psychiatric clinic), enabling the client to pre-validity of TDM.
be reimbursed for the treatment according to
Federal Law. (1) The Core Conflictual Relationship Theme
(CCRT; Luborsky & Crits-Christoph, 1990)
is a content-analytic method of the patient’s
Instruments
relationship experience. The CCRT was origin-
Therapeutic alliance. To monitor the therapeutic ally developed to reliably identify interpersonal
alliance, the patient and the therapist were asked to relationship patterns described in narratives
fill out the Helping Alliance questionnaire (HAq-I) told during psychotherapy. These narratives
developed by Luborsky (1976) and Alexander and are the basis for the CCRT method which
46 L. Michel et al.
describes the relationship pattern in terms of identify ‘significant’ episodes over the course of
three components: (a) wishes, needs, or inten- the psychotherapy on these variables. All ratings
tions expressed by the subject (Ws); (b) ex- (alliance and transference) were available to all co-
pected or actual responses of the object (ROs); authors at that time, in order to be able to make
and (c) responses of the self (RSs), i.e. the cogent decisions for further analysis. Several con-
emotional, behavioural, or symptomatic reac- sensus meetings were organised, interwoven with
tions of an individual to the other’s response. personal reflection; thus, the consensus procedure
The most prevalent of each of the three was inspired by the Ward method in qualitative
components is used to formulate the CCRT psychotherapy research (Schielke et al., 2009),
which is the most pervasive relationship pattern yielding an iterative process towards consensus.
across the self-other interactions. Negativity Thus, the team met about 10 times during a
scores of RO and RS, in comparison with the one-year-period. The authors identified two signifi-
W, may be computed. cant episodes: (1) sessions 4, 5 and 6, and (2)
(2) The Transference Dimensions Monitoring sessions 21, 22, and 23. The first sessions of each
(TDM) is a qualitative rating that we devel- significant moment may be described as the ‘alli-
oped for this research. The instrument as- ance rupture process’ (sessions 4 and 21), and at
sessed two independent dimensions: (1) the the subsequent two sessions, the alliance scores
nature of the transference (which refers to the reach the local means, again (sessions 5 and 6;
maternal or paternal quality of the transfer- sessions 22 and 23); thus, they may be called
ence), and (2) the valence of the transference resolution sessions. These sessions were transcribed
(which refers to the positive or negative and analysed using the DMRS and CCRT rating
valence of the transference). For the coding, scales.
the two orthogonal dimensions are placed on
a target graph. After each session, the thera-
pist placed a point in the target graph that Results
best represents his perception of the two
Therapy phases
dimensions of the transference during the
session. Using notes taken during the treatment sessions as a
basis, the therapist sought to describe the evolution
of the psychotherapy in function of the themes and
Procedure
relational movements (alliance and transference)
Alliance and transference evolutions were depicted throughout the psychotherapy. This work resulted
as graphs (Figures 1 and 2) and submitted to all in the description of four successive phases of the
co-authors, including the therapist, in order to treatment. Therefore, the status of what follows is

I II III IV

Figure 1. Evolution of therapeutic alliance (I, II, III and IV are phases of therapy
Establishment; Control; Anxiety; and Toward the End.
Data plotted are smoothed. Each point represents the moving average of three sessions).
 Alliance evolutions in STDP 47
I II III IV

Figure 2. Evolution of transference (I, II, III and IV are phases of therapy
Establishment; Control; Anxiety; and Toward the End. Data
plotted are smoothed. Each point represents the moving average of three sessions).

the subjective interpretation of the therapist (and and the two daughters).’ She frequently referred to
first author). We first describe the therapy process her mother during the first sessions. ‘She doesn’t
from the clinical viewpoint
from the therapist’s really listen to me, as if she weren’t really interested
perspective
and then report the results from the in what I do’, she says, ‘but I don’t doubt that she
scales. loves me.’ She sadly recalled her parents’ divorce,
seemingly disillusioned: ‘It came as a complete
Phase I. Initial stage (sessions 1
4). In the first few surprise.’ She realised that it was ‘the world
sessions, Julia appeared rather inhibited: ‘With upside-down’ with the parents leaving the family
women we talk more easily than with men.’ The home and the teenagers staying behind!
therapist told her that she hadn’t made things easier She appeared uneasy in the therapist’s presence,
by choosing a male therapist. For her, men seem who reminded her of her father with whom she had
more knowledgeable, which takes the therapist back trouble talking about her feelings. Was it because she
to her early years marked by a fairly positive paternal thinks the therapist holds a certain knowledge, like
transference. Was she trying to attain this phallic her professors who exclude her from certain deci-
force which women to a certain extent lack? sions against her will? The therapist pointed out the
She bears in mind those women who are not as connection between this distress and such decisions
ambitious as she is. In fact, this is exactly what she as her parents’ divorce, when she also felt excluded.
would like to have at the moment
a female boss; Then other memories came back
her departure for
she says she needs such a female role-model. She another country at the age of 16 and the anger she
compares herself with her mother who never worked felt because she had the impression that nobody took
fulltime. ‘My father did little at home. There was her opinion seriously. The therapist linked this
one bathroom for the men (her father and her moment with where she is right now in the process
brother) and another for the women (her mother of psychotherapy, for she has to take part in deciding

Table I. Psychodynamic characteristics.

Moment (1) Moment (2)

Variable 41 5 6 21 22 23

DMRS
ODF 4.28 4.80 4.87 4.53 5.25 4.92
CCRT
Negativity % 100 100 83 100 100 60

Note. DMRS, Defense Mechanisms Rating Scales; ODF, Overall Defensive Functioning; CCRT, Core Conflictual Relationship Theme.
1
Sessions of the psychotherapy chosen based on the consensus procedure.
48 L. Michel et al.

whether to undertake psychotherapy and in which her father. Her own ambition is put in question. At
environment (session 4). 18 she found herself alone, as she refused to return
Julia also recalled her return two years later when to her parents. In fact, she remembers that it wasn’t
she was 18 and her parents’ separation. Here the first so easy, and that sometimes she drank too much at
signs of sadness become apparent and for the first the weekend. Was this to forget her solitude? She
time she said what she felt like when she was faced found it hard to attend the therapy sessions. Don’t
with a broken home. This led her to become aware we always talk about the same things? The therapist
of the fact that she has been blocking out her tried to work on her resistance to facing up to certain
sadness. The therapist interpreted what she had suppressed affects. She recalls images of this period,
been told so far as if the separations weren’t remembering that her parents’ divorce seemed to be
important and that she had spent all her childhood the end of the world to her; a dramatic separation.
and adolescence feeling sad about other things She is beginning to feel furious with her father for
without really knowing why, just as she doesn’t leaving for another woman.
know why she is now seeking treatment. After a In the following session (10) she said that she
moment of silence she said that some years ago she found that she had been overemotional. She once
read a novel that made her cry floods of tears for no again set up her defensive system. She talked about
real reason. She cannot remember the name of the memories of her departure and her life in Canada,
book. how she feared talking about it at school. Then she
remembered that one evening, with a school friend,
Phase II. Concerning self control (sessions 5
17). In she got into the school and set fire to the board with
the following session (5) she referred to her sister’s all the holidays marked on it, so that time would
various illnesses that upset the whole family. There is stand still. But what she particularly found hard at
a contrast between her sister and herself as she is in that time enabled her to evoke the positive sides of
good health and has no problems. This reminds her this uprooting. She gave a lot of thought to her
of her mother, who, when Julia was thinking of relationship with her father. He suggested that she
seeking treatment, told her that in her opinion Julia could spend her holidays with her stepmother and
did not need to see a psychotherapist. The therapist him but she hesitated. Can she bear his traits of
notes how difficult it must be to accept her sadness character which she knows she has too? Several times
and to talk about it. Will he agree to see her, or will she spoke of the conflictual aspect that frequently
he just minimise the situation, as her mother did? comes to the fore in her relationship with her father.
In the next session (6), she goes back to the From now on, several sessions will focus on this
difficulty she has to admit that she is not well and relationship. A certain inhibition is becoming appar-
needs attention. Then memories come back to the ent, and a symptom comes to light
her phobia of
time when she found it so difficult to find her place driving since she returned to her hometown. She
when for the first time she moved to a foreign town is terrified of running over someone. The therapist
at the age of four. If ever she should return there, she points out the aggressive element. As he sees it,
would like to visit the places of her childhood, she also needs to be driven now whereas she has
including her school. As the latter has been pulled always said that she could manage alone. She
down, she wonders ‘if this is not really like a whole becomes aware of the repetitive aspect of her
part of my life which has disappeared,’ and this journeys, playing an active part in such. This makes
upsets her. She was starting to find it hard to attend her think of material with regard to her own sexuality
these sessions and cries and realises just how much and the passive position in which she feels she is
she has suffered and how much she has kept bottled during sexual relations. Here too there is no medial
up. Shaken by the emotions aroused, she comes back position.
to the choice between sacrificing a career or a family, Is a positive paternal opinion, as in this case the
which she sees as not only inevitable but also therapist’s, so necessary for one to be loved and to
unbearable. Does her professional choice have some- love oneself? She explained how uneasy she feels
thing to do with her father? Will her whole therapy when she weeps during therapy (14). The therapist
consist of settling something with her father? asked her if it was really necessary to do everything
The first break in psychotherapy sessions lasts right to be loved and need she really hold back her
two weeks, which was a relief to her (8). She brings tears here as she does with her father. Identifying
back the subject of her career and comparisons with herself with her father means having few emotions,
 Alliance evolutions in STDP 49

and expressing even fewer. The place where I always to see the therapist again. What is troubling her is
used to cry, she says, was at the gynecologist’s. Is this that she is not unique and that after her, there will be
specific to her female identity (15)? other patients. We talked about her greed and her
A fascinating discussion with experienced collea- desire to be exclusive, drawing a parallel between her
gues strengthened her ambition to continue in mother’s apartment where she sleeps every time she
research (17). The therapist pointed out to her goes to see her and the therapist’s office. She said she
how pleased she was to sit at the same table as her had trouble sleeping in her mother’s flat with her
superiors. She was annoyed with the therapist for boyfriend. This opened a discussion, after the
linking her pleasure in this case to her father. As if, mention of her greediness, focusing on her rivalry
the therapist told her, linking him to something and leading her to question her femininity and her
detracts something from him. The therapist’s re- sexuality. The therapist and the client then talked
marks made her doubt about herself, like those of about the competition between her mother and
her father. She feels she is her father’s daughter herself. Feelings of incest and rivalry are uncovered.
because she is identifying herself with him. The It is she who has kept in touch with her father,
therapist intervened and wondered if she could whereas her mother broke off all relations after the
choose a path because her father chose it before divorce (21).
her or because it is the best for her. She was affected Once this issue comes to light, a certain resistance
by these words. becomes apparent and she starts to complain about
being forced to come for therapy. Now she can
Phase III. Concerning greediness (sessions 18
23). accept that before they divorced, her parents also
Her contacts with her father are improving (18): a had a relationship. This leads to the question of her
‘reconciliation’ which leads her to tell herself that she hopes of the choice of a husband, marriage, a family.
needs to make some compromises regarding her The idea of being together then separating enables
career. Financial problems arise concerning the the therapist to remind her that the end of the
therapy, once again making a link with her father psychotherapy is no longer so far off.
and the question of money. She wanted to assume She came to the following session with her first
her responsibilities but, after a period of (anal) self dream (22): ‘I was having a baby! We were on a walk.
control, she shows far more oral voracity. She talked I forget to feed the baby but he doesn’t cry. After two
about her relationship with food, her craving for days he starts crying; I wrap him up in aluminum foil
sweet things, which she no longer wishes to limit, to keep him warm.’ This dream reminds her of her
this hunger that also makes her remember conflicts desire to be pregnant with images of larvae repre-
with her mother who tried to keep her greediness in senting newborn babies. She thinks of breastfeeding,
check. As the therapist mentions her greediness, her which creates a bond with the baby, this irreplace-
fear of going out, the question of security, money able feature of womanhood. The therapist also
and food, she thinks of an apple which her mother recognises her in this baby, who is left in her charge.
used to put in her school bag, just in case. Her Is this a part of herself which she is dealing with
mother was not necessarily there but her apple was
now? This interpretation made her weep a lot,
the very same security that helps her feel close to the arousing sensations and feelings that she described
little baby in her who ‘is speaking’. She also as coming from afar. It is both a memory of eating
mentioned that on leaving the session, she often anything when she was very small, and other
goes to buy a little bun, across the road, but won’t memories of having to eat when her mother did
today. The therapist told her that she doesn’t need not come home at lunchtime and she had to get her
to go because she has been able to talk about meal herself. This expresses her sadness at certain
her greediness, moreover just before a two-week- times in her life when she felt an emotion without
break (20). associating it with a representation. For instance,
In the next session, she admitted that she did in this week she cried a lot, quite out of proportion,
fact buy a bun when she left, as she was too scared of because a colleague was leaving. This reminds her of
being hungry. Tense, with taut muscles in the nape her loneliness, particularly the fact that her boyfriend
of her neck, she talked again about her worries about lives in another town and that she sees him only at
her future. She feels that she is once again experien- weekends, which until now she has never mentioned.
cing the sensations and emotions of her childhood The therapist comes back to the baby in the dream,
and is surprised that she wants, maybe even needs, her greediness, her wish to be held in someone’s
50 L. Michel et al.
arms, and the therapist’s and the client’s upcoming At the time of the separation the desire to have a
separation. That makes her think of an umbrella child is intense and urgent. How can she remain a
because she wants to distance herself from the wet woman and have plans for a career, yet still mourn-
tears. Then come the sadness and reproaches that ing self-fulfilment since ‘I thought that I had every-
the therapist will be leaving her, for she likens this to thing but I’m a woman.’ She is working on her ideals,
a mother who used to leave her in a nursery rather on negotiating with her boyfriend, but becoming
than hold her in her arms. As if she could at last somewhat conflictual in her plans.
admit how much she had suffered. Thinking again of She commented in session 32 on the fact that for
the photo album the nursery gave her, she speaks the first time she had come to the session by bike and
about the first separation when she was 4
5 years was proud of herself. The therapist succeeded, she
old, after the family moved home. Shortly after- tells him, signifying by this the end of the therapy.
wards, she heard that her infant school teacher had The therapist reminded her of this image and she
died. The therapist linked this death to the disap- replied that she now knows how to get around and
pearance of her childhood memories that she has that the therapist can now let her manage alone. This
repressed until now, and to a two-week interruption was followed by a series of memories about her
in therapy sessions (23). father to whom she wanted to show that she had
grown up. The bike was in fact her father’s birthday
present. She is now less afraid of following the route
Phase IV. Talking about the end (sessions 24
34).
she has taken and less afraid of driving.
When she returns (24), she says that she feels that
When she turns to the discussions with her
something has changed in the consulting room, boyfriend, she mentions that they have decided to
which led the therapist to relate this to the separation wait a while before having a child. It’s not absolutely
and the changes that she is going through. At this necessary for her to do exactly the same thing her
point she meets a teacher who she finds fascinating parents did. In the final session (33) she comes back
as she is both the mother of several children and very to the image of the bike: the small wheels have been
successful career-wise. In a burst of self-identifica- taken off! Is this a coincidence? She has worked hard
tion, she sees her as a role-model. Time passes. Then on her thesis and carried out the last experiment.
the client spoke about separation and the desire of She has projects and has at last managed to tell her
being pregnant comes up again. The therapist links father about her wedding. He took this well and
this to the baby she dreamt about, to herself. Once things seem to be sorting themselves out for the table
again she misses a session for professional reasons. layout for the wedding meal. ‘It is my parents’
Then she returns and comments on the fact that the problem to decide whether or not to come to the
throw on the sofa has been changed and other wedding together and I do not have to adapt to their
alterations have been made in the therapist’s office own conflictual problems!’
(27). The therapist pointed out that obviously quite
a number of things have happened in her absence!
After criticising all these changes, she thinks of her Therapy process: Results of the scales
father who she realises now also hesitates from time Alliance and transference. Comparing time series
to time in certain situations. She sees changes in her data is often difficult and confusing. We chose to
relationship with her father who seems to be less smooth the data set to create an approximating
idealised. She comes back to all the current trans- function that attempts to capture important patterns
formations in the office, which greatly disconcert in the data, while leaving out noise. The algorithm
her; she realises that she needs a stable place, chosen was the ‘moving average’ of three sessions.
probably because this is the last session before the The results are depicted in Figures 1 (for alliance)
separation of the summer holiday. She understands and 2 (for transference). Two significant episodes of
that this office has its own life; that it exists even alliance ruptures and resolutions are analysed more
when she is not there. She can link this with what fully (based on the raw data of alliance as rated by
happened with her parents when she was away. the patient; see Figure 2): (1) sessions 4, 5 and 6;
Other changes occurred in the family within a very (2) sessions 21, 22 and 23.
short lapse of time. That was when she decided to
take up an academic career thus following in her Psychodynamic characteristics. Overall Defensive
father’s footsteps. Functioning (ODF) tends to increase within each
 Alliance evolutions in STDP 51

of the significant moments. At moment (1), ODF at intake, during therapy, at discharge and at
evolves from 4.28 to 4.87, both in the narcissistic 12-month follow-up; therefore, we do not discuss
range of defensive functioning; at moment (2), the therapeutic outcome. Nevertheless, based on the
similarly, ODF evolves from 4.53 to 4.92 (also process information, we may conclude that the
narcissistic range). Note that these are micro- outcome of the psychotherapy was highly positive,
evolutions on the overall coefficient of defensive from both the therapist’s and the client’s perspec-
functioning; they were not tested statistically, but tives, as well as the research team’s perspective.
they are illustrated using the clinical material. Second, we observe that the alliance assessed by
The Core Conflictual Relationship Theme showed the patient and the nature of the transference, as
a high level of negativity for Julia on the six sessions assessed by the therapist, co-vary with the four main
analysed. We found in particular the rupture sessions phases of the therapeutic process:
(sessions 4 and 21) to be associated with high
negativity scores, from the CCRT perspective . Phase I. The therapeutic alliance (assessed by
(100% of negativity for RO and RS). The CCRT of the patient) lessens and the transference be-
resolution sessions (in particular the last of the comes more and more maternal.
chosen triads, i.e. sessions 6 and 23) present a lower . Phase II. The alliance tends to increase in a
level of negativity, which is associated with positive linear manner and transference changes from
outcome in different psychotherapy studies. the maternal pole to the paternal pole.
In conclusion, over the two episodes chosen, . Phase III. Both measures show more instability:
alliance rupture sessions tend to present lower, i.e. the alliance lessens then increases (rupture-
less adaptive, defensive functioning and higher con- resolution process) whereas the transference
flictuality in Julia, whereas the subsequent sessions varies while remaining in a paternal pole.
of rupture resolution tend to present slightly more . Phase IV. The alliance shows a more marked
adapted ways of defensive functioning and a lower episode of diminishing then returns to the
conflictuality in Julia. average (rupture-resolution) whereas the trans-
ference once again passes from the maternal
pole to the paternal pole and reaches the same
Discussion level as at the beginning of the therapy.
Using session notes as a basis, it was possible to
divide the entire psychotherapy into four main The evolution of the alliance, as assessed by the
phases. The confrontation between this model of therapist, together with the valence of the transfer-
clinical comprehension with the various measures of ence seem less sensitive to the different phases of the
the process suggests the following findings. process described by the therapist. The latter alli-
First, it is important to note that the alliance is ance tends to increase more or less linearly through-
generally positive and follows a positive trend: The out the treatment, but with a decrease that reflects
patient and the therapist evaluate the alliance as that of the patient during the end of treatment phase.
increasing in strength during the process, which As for the transference valence, this remains rela-
reflects the positive atmosphere in which the psy- tively stable throughout the therapy.
chotherapy took place and which no doubt benefited Even if we refer to three separate components
the treatment. This corresponds to the positive of the therapeutic relationship, that are the real
correlation found on the overall sample between relationship, the therapeutic alliance and the
the evolution of the alliance and therapeutic success transference-countertransference (according to the
(Kramer et al., 2009). The alliance rated by the model proposed by Gelso and Carter, 1994), which
therapist is generally slightly below the patient’s occur simultaneously and interact in a complex
rating, as observed in previous studies (Fitzpatrick manner, the nature and the role of each in psycho-
et al., 2005; Kramer et al., 2008), moreover, the dynamic psychotherapy has been a controversial
therapist’s alliance evolution presents fewer fluctua- issue. Our observations on the case of Julia show
tions; therefore, we based our interpretation on the that at least two (out of three) phenomena measured
patient’s evolution of alliance only. We should state co-vary to a certain extent, without overlapping
once again that the patient did not present any completely.
psychiatric diagnoses and global severity index The link between clinical work and psychotherapy
(general symptomatology) was in the normal range research is complex. It remains difficult to establish
52 L. Michel et al.

meaningful bridges between what happens clinically talk, seemingly untouched by this comment
in the therapeutic process and the empirical data then, suddenly, wonders why she never weeps in
stemming from questionnaires or rating scales. Two the psychotherapy sessions, whereas elsewhere, for
visions, which, by analogy with the human’s sight, no reason whatsoever, she does. The psychothera-
need a chiasm to allow them to benefit one another pist suggests that here she retains her tears, just as
and to lead to the beginnings of binocular vision. she used to retain them when she was with her
The comparison of the alliance and transference father, for fear of disappointing him and not
measures with the clinical material of the sessions in being loved. Deeply moved, she recalls memories
this case study show that more regressive material involving her ‘nordic, cold’ father, memories in
and the use of more regressive defence mechanisms which she prevented herself from expressing her
are associated to a maternal polarisation of the emotions.
transference. We hypothesise that the clinician does
not examine the details of the defence mechanisms Bringing the patient’s infantile conflictuality into the
during the session, as done by the Defense Mechan- hic et nunc and into the transference is interpreted. In
isms Rating Scales (based on the session transcript), some ways, this is a deconstruction followed by a
but intuitively builds up a Gestalt of the individual’s reconstruction of the link between the affect repre-
whole ‘defensive organisation.’ It is this Gestalt the sentation and the word representation. Such mo-
therapist is working with and reacting to in terms of ments of insight are to be paralleled to what the
his counter-transference. We hypothesise that the Boston group describes as ‘moments of meeting’
rupture sessions, the patient’s most regressed posi- which, in its view, is the crux of the change process
tion in terms of defences and conflicts, may be (Stern, 2004). According to this group of authors,
described as a ‘transference crisis’ within the ther- however, these moments of meeting would not seem
apy, which, at the same time, opens up to the core directly linked to the verbal material but rather part
interpersonal problem in the patient (Safran, 1993). of the wider context of the interpersonal encounter
Finally, the resolution sessions may represent the between the patient and the therapist, including
resolution of this transference crisis, if done in a affective and non-verbal markers.
constructive manner, by enabling the patient to How can these changes be objectively looked at?
make a corrective emotional experience. The posi- A metaphor may be used: a seismograph records an
tive outcome of the entire psychotherapy with Julia earthquake as the earth’s crust feels it. Such a shock
makes us suppose that this corrective emotional is also perceived by a human observer if it is
experience took place at least twice, during sessions sufficiently strong. However, if it is only slight or
6 and 23, during the therapeutic process. the movement extends over a long lapse of time, it is
When and how did the clinical change take place? usually ignored. The use of a seismograph allows the
In the case of Julia, the psychotherapist describes in movement to be measured objectively and examined
his clinical narration what he observed throughout in more detail. By analogy, we can query whether
the sessions. In particular, he noted certain moments what the psychotherapist calls a ‘change’ can be seen
he found to be crucial. These are the sessions where objectively when measures such as ours are applied.
the psychotherapist thinks that his patient is under- So, are the movements described by the clinician in
going a psychic change which corresponds to what is his narration, truly objective with the help of
commonly called insight in psychotherapy research. repeated measures? They definitely produce evi-
The following conversation from the 15th session is a dence of a process underway. Certain connections
good example: could thus be made between the process and insight.
To continue with our analogy: It is certain that
Julia talks a lot about the activities she shares with advances made in seismography have allowed us not
her father, then about her boss’s publications, in only to witness what is happening but also to forecast
which she collaborates. She talks about her fear of future events.
being judged, her fear of other’s regard and the Several research implications ensue from the
effort she makes to satisfy him by remaining present case study. The use of self-reported and
amenable, even if sometimes her true feelings are observer-rated process information over the course
very different. The psychotherapist points out that of psychotherapy in order to inform about the
it seems that she has to behave well to make the client’s process may be used in different treatment
men in her life love her. The patient continues to modalities and therapeutic approaches. We think it is
 Alliance evolutions in STDP 53
particularly useful to monitor the alliance evolution, dynamic psychotherapy: The shape of productive relationships.
Psychotherapy Research, 19 (6), 699
706.
session by session, and link this information to the
Kramer, U., Despland, J.-N., Michel, L., Drapeau, M., &
clinical evolution of the case. More studies in this de Roten, Y. (2010). Change in defense mechanisms and
field might enhance the collaboration between psy- coping over the course of short-term dynamic psychotherapy
chotherapy researchers and clinicians and inform for adjustment disorder. Journal of Clinical Psychology, 64(12),
about the ‘how’ of specific psychotherapy processes. 1232
1241.
Luborsky, L. (1976). Helping alliances in psychotherapy: The
It would also be interesting to apply such a metho-
grounded work for a study of their relationship to its outcome.
dology to bad outcome cases where process informa- In J.L. Claghorn (Ed.), Successful psychotherapy (pp. 92
116).
tion would be particularly helpful. New York: Brunner/Mazel.
Luborsky, L., & Crits-Christoph, P. (1990). Understanding trans-
ference: The CCRT method. New York: Basic Books.
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Hatcher, R.L., & Barends, A.W. (1996). Patient’s view of the
alliance in psychotherapy: Exploratory factor analysis of three Luc Michel is a psychiatrist and psychoanalyst
alliance measures. Journal of Consulting and Clinical Psychology, member of the IPA. He is head of the Student
64 (6), 1326
1336. Counselling Service of the University of Lausanne
Kivlighan, D.M., & Shaughnessy, P. (2000). Patterns of working
and responsible for the teaching of psychoanalytic
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ratings. Journal of Counseling Psychology, 47 (3), 362
371. psychotherapy at the Institute of Psychotherapy.
Kramer, U., de Roten, Y., Beretta, V., Michel, L., & Despland, Ueli Kramer, Ph.D., psychotherapist FSP, is
J.-N. (2008). Patient’s and therapist’s views of early alliance
senior researcher and clinical supervisor at the
building: Patterns and relation to outcome. Journal of Counsel-
ing Psychology, 55 (1), 89
95. Center for Psychotherapy Research (CPR) at the
Kramer, U., de Roten, Y., Beretta, V., Michel, L., & Despland, Institute of Psychotherapy, Department of Psychia-
J.-N. (2009). Alliance patterns over the course of short-term try-CHUV, University of Lausanne. He is specialized
54 L. Michel et al.
in the treatment of personality disorders at the Yves de Roten is head of research at the Institute
Outpatient Personality Disorder Program of the Karl for Psychotherapy, lecturer and researcher at the
Jaspers Clinical Unit at the Department of Psychiatry- University of Lausanne and adjunct professor at
CHUV, University of Lausanne. His research inter- McGill University, Montreal. His research interests
ests include adaptational processes (defence mechan- include therapeutic alliance, therapeutic process,
isms and coping) in affective and personality communication and emotions, and therapist inter-
disorders, case formulation, single case studies, and ventions. De Roten can be contacted at: yves.
therapeutic change models. [email protected]
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