Articles
30 March 2025
Vol. 28 No. 1 (2025)
"Maybe you don’t know what answers I want": unresolved alliance ruptures preceding dropout in short-term psychoanalytic psychotherapy with depressed adolescents
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
343
Views
179
Downloads
3
HTML
Authors
The therapeutic alliance is a predictor of therapy outcome across treatments with adolescents, with ruptures and unresolved ruptures in the alliance being associated with treatment dropout. This study investigated the psychotherapeutic process in short-term psychoanalytic psychotherapy (STPP) with five adolescents with moderate/severe depression who had dropped out of STPP in a large randomized controlled trial and reported dissatisfaction with treatment. In each case, sessions were rated as featuring unresolved ruptures with the therapist. This study aimed to explore the processes characterising ruptures preceding dropout using the Adolescent Psychotherapy Q-set (APQ). Data were analysed using descriptive statistics of the APQ coding; a qualitative reading of the transcripts and clinical vignettes was used to illustrate how the APQ findings manifested in practice. Results revealed a weak alliance preceding the adolescent dropping out of therapy, with a mismatch between self-reliant and disengaged adolescents presenting with strong negative affects and therapists seeking to maintain an active exploration of the adolescents’ difficulties. Research and clinical implications are discussed.
Altmetrics
Downloads
Download data is not yet available.
Citations
Acheson, R., Verdenhalven, N., Avdi, E., & Midgley, N. (2020). Exploring silence in short-term psychoanalytic psychotherapy with adolescents with depression. Journal of Child Psychotherapy, 46(2), 224-240. DOI: https://doi.org/10.1080/0075417X.2020.1830297
Ackerman, S. J., & Hilsenroth, M. J. (2001). A review of therapist characteristics and techniques negatively impacting the therapeutic alliance. Psychotherapy, 38, 171–185. doi: 10.1037/0033-3204.38.2.171 DOI: https://doi.org/10.1037//0033-3204.38.2.171
Angold, A., Costello, E. J., Pickles, A., Winder, F., & Silver, D. (1987). The development of a questionnaire for use in epidemiological studies of depression in children and adolescents. Unpublished manuscript, London University.
Binder, P. E., Holgersen, H., & H⊘stmark Nielsen, G. (2008). Re-establishing contact: A qualitative exploration of how therapists work with alliance ruptures in adolescent psychotherapy. Counselling and Psychotherapy Research, 8(4), 239-245. DOI: https://doi.org/10.1080/14733140802363167
Blos, P. (1967). The second individuation process of adolescence. The psychoanalytic study of the child, 22(1), 162-186. DOI: https://doi.org/10.1080/00797308.1967.11822595
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy Theory Research Practice, 16, 252–260. doi: 10.1037/h0085885 DOI: https://doi.org/10.1037/h0085885
Calderon, A., Midgley, N., Schneider, C., & Target, M. (2014). Adolescent Psychotherapy Q-Set Coding Manual. University College London and Anna Freud Centre for Children and Families.
Calderon, A., Schneider, C., Target, M., & Midgley, N. (2017). The adolescent psychotherapy Q-Set (APQ): A validation study. Journal of Infant, Child, and Adolescent Psychotherapy, 16(1), 106-120. DOI: https://doi.org/10.1080/15289168.2016.1255499
Colli, A., & Lingiardi, V. (2009). The Collaborative Interactions Scale: A new transcript-based method for the assessment of therapeutic alliance ruptures and resolutions in psychotherapy. Psychotherapy Research, 19(6), 718-734. DOI: https://doi.org/10.1080/10503300903121098
Constantino, M. J., Castonguay, L. G., Zack, S. E., & DeGeorge, J. (2010). Engagement in psychotherapy: Factors contributing to the facilitation, demise, and restoration of the therapeutic alliance In Elusive alliance: Treatment engagement strategies with high-risk adolescents. American Psychological Association, pp. 21-57. DOI: https://doi.org/10.1037/12139-001
Cirasola, A., Martin, P., Fonagy, P., Eubanks, C., Muran, J. C., & Midgley, N. (2022). Alliance ruptures and resolutions in short-term psychoanalytic psychotherapy for adolescent depression: An empirical case study. Psychotherapy Research, 1-18. DOI: https://doi.org/10.1080/10503307.2022.2061314
Cregeen, S., Hughes, C., Midgley, N., Rhode, M., & Rustin, M. (2017). Short-Term Psychoanalytic Psychotherapy for Adolescents with Depression: A Treatment Manual. doi: 10.4324/9780429480164. DOI: https://doi.org/10.4324/9780429480164
De Haan, A. M., Boon, A. E., de Jong, J. T. V. M., Hoeve, M., & Vermeiren, R. R. J. M. (2013). A meta-analytic review on treatment dropout in child and adolescent outpatient mental health care. Clinical Psychology Review, 33, 698–711. doi: 10.1016/j.cpr.2013.04.005 DOI: https://doi.org/10.1016/j.cpr.2013.04.005
Eaton, T., Abeles, N., & Gutfreund, M. (1993). Negative indicators, therapeutic alliance, and therapy outcome. Psychotherapy Research, 3(2), 115-123. DOI: https://doi.org/10.1080/10503309312331333719
Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018a). Alliance rupture repair: A meta-analysis. Psychotherapy, 55, 508–519. doi: 10.1037/pst0000185. DOI: https://doi.org/10.1037/pst0000185
Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Rupture Resolution Rating System (3RS): Development and validation. Psychotherapy Research, 29, 306–319. doi: 10.1080/10503307.2018 .1552034 DOI: https://doi.org/10.1080/10503307.2018.1552034
Falkenström, F., Ekeblad, A., & Holmqvist, R. (2016). Improvement of the working alliance in one treatment session predicts improvement of depressive symptoms by the next session. Journal of Consulting and Clinical Psychology, 84(8), 738. DOI: https://doi.org/10.1037/ccp0000119
Garcia, J. A., & Weisz, J. R. (2002). When youth mental health care stops: Therapeutic relationship problems and other reasons for ending youth outpatient treatment. Journal of Consulting and Clinical Psychology, 70(2), 43. DOI: https://doi.org/10.1037//0022-006X.70.2.439
Gersh, E., Hulbert, C. A., McKechnie, B., Ramadan, R., Worotniuk, T., & Chanen, A. M. (2017). Alliance rupture and repair processes and therapeutic change in youth with borderline personality disorder. Psychology and Psychotherapy, 90, 84–104. doi: 10.1111/papt.12097 DOI: https://doi.org/10.1111/papt.12097
Glasser, M. (1979). Some aspects of the role of aggression in the perversions. Sexual deviation, 2, 278-305.
Goodyer, I. M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., Hill, J., & Senior, R. (2017). Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial. The Lancet Psychiatry, 4(2), 109-119. DOI: https://doi.org/10.1016/S2215-0366(16)30378-9
Goodyer, I. M., Tsancheva, S., Byford, S., Dubicka, B., Hill, J., Kelvin, R., & Wilkinson, P. (2011). Improving mood with psychoanalytic and cognitive therapies (IMPACT): a pragmatic effectiveness superiority trial to investigate whether specialised psychological treatment reduces the risk for relapse in adolescents with moderate to severe unipolar depression: study protocol for a randomised controlled trial. Trials, 12(1), 175 DOI: https://doi.org/10.1186/1745-6215-12-175
Henriksen, A. K. (2017). Helpful aspects at the beginning of successful outpatient treatment: Retrospective views of adolescents and their therapists. Journal of Psychotherapy Integration, 27(4), 508–525. DOI: https://doi.org/10.1037/int0000066
Horn, H., Geiser-Elze, A., Reck, C., Hartmann, M., Stefini, A., Victor, D., Winkelmann, K., & Kronmüller, K. T. (2005). Efficacy of short-term psychotherapy children and adolescents with depression. Praxis Kinderpsychol Kinderpsychiatr, 54, 578–597.
Hurry, A., & Sandler, J. (1971). Coping with reality: The child's defences against the external world. British Journal of Medical Psychology. DOI: https://doi.org/10.1111/j.2044-8341.1971.tb02183.x
Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. Bergin and Garfield’s handbook of psychotherapy and behavior change, 5, 139-193.
Lingiardi, V., & Colli, A. (2015). Therapeutic alliance and alliance ruptures and resolutions: Theoretical definitions, assessment issues, and research findings. In Psychotherapy research (pp. 311-329). Springer, Vienna. DOI: https://doi.org/10.1007/978-3-7091-1382-0_16
Leider, R. J. (1983). Analytic neutrality – a historical review. Psychoanalytic Inquiry, 3(4), 665–674. doi: 10.1080/07351698309533520 DOI: https://doi.org/10.1080/07351698309533520
Mars, B., Heron, J., Klonsky, E. D., Moran, P., O'Connor, R. C., Tilling, K., & Gunnell, D. (2019). Predictors of future suicide attempt among adolescents with suicidal thoughts or non-suicidal self-harm: a population-based birth cohort study. The Lancet Psychiatry, 6(4), 327-337. DOI: https://doi.org/10.1016/S2215-0366(19)30030-6
McManus, S., Hassiotis, A., Jenkins, R., Dennis, M., Aznar, C., Appleby, L., & Brugha, T. (2014). Suicidal thoughts, suicide attempts and self-harm. Mental Health and Wellbeing in England: Adult Psychiatric Morbidity Survey.
Midgley, N., Mortimer, R., Cirasola, A., Batra, P., & Kennedy, E. (2021). The Evidence-Base for Psychodynamic Psychotherapy With Children and Adolescents: A Narrative Synthesis. Frontiers in Psychology, 12, 1188. DOI: https://doi.org/10.3389/fpsyg.2021.662671
Muran, J. C., Safran, J. D., Gorman, B. S., Samstag, L. W., Eubanks-Carter, C., & Winston, A. (2009). The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders. Psychotherapy: Theory, Research, Practice, Training, 46(2), 233. DOI: https://doi.org/10.1037/a0016085
National Institute for Health and Care Excellence (2019). Depression in children and young people: identification and management. NICE guideline [NG134]. Available from: https://www.nice.org.uk/guidance/NG134.
Nof, A., Dolev, T., Leibovich, L., Harel, J., & Zilcha-Mano, S. (2019). If you believe that breaking is possible, believe also that fixing is possible: a framework for ruptures and repairs in child psychotherapy. Research in Psychotherapy: Psychopathology, Process, and Outcome, 22(1). DOI: https://doi.org/10.4081/ripppo.2019.364
Norcross, J. C. (2011). Psychotherapy relationships that work. Oxford University Press. doi: 10.1093/acprof:oso/9780199737208.001.0001 DOI: https://doi.org/10.1093/acprof:oso/9780199737208.001.0001
O’Keeffe, S., Martin, P., & Midgley, N. (2020). When adolescents stop psychological therapy: Rupture–repair in the therapeutic alliance and association with therapy ending. Psychotherapy, 57(4), 471. DOI: https://doi.org/10.1037/pst0000279
O’Keeffe, S., Martin, P., Goodyer, I. M., Wilkinson, P., Consortium, I., & Midgley, N. (2018). Predicting dropout in adolescents receiving therapy for depression. Psychotherapy Research, 28(5), 708-721. DOI: https://doi.org/10.1080/10503307.2017.1393576
O’Keeffe, S., Martin, P., Target, M., & Midgley, N. (2019). ‘I Just Stopped Going’: a mixed methods investigation into types of therapy dropout in adolescents with depression. Frontiers in Psychology, 10, 75. DOI: https://doi.org/10.3389/fpsyg.2019.00075
Odhammar, F., Goodman, G., & Carlberg, G. (2019). Different perspectives in measuring processes in psychodynamic child psychotherapy. Journal of Child Psychotherapy, 45(1), 18-35. DOI: https://doi.org/10.1080/0075417X.2018.1539864
Piper, W. E., McCallum, M., Azim, H. F., & Joyce, A. S. (1993). Understanding the relationship between transference interpretation and outcome in the context of other variables. American Journal of Psychotherapy, 47(4), 479–493. doi: 10.1176/appi.psychotherapy.1993.47.4.479 DOI: https://doi.org/10.1176/appi.psychotherapy.1993.47.4.479
Safran, J. D., & Muran, J. C. (1996). The resolution of ruptures in the therapeutic alliance. Journal of Consulting and Clinical Psychology, 64, 447–458. doi:10.1037/0022-006x.64.3.447 DOI: https://doi.org/10.1037//0022-006X.64.3.447
Safran, J. D., & Muran, J. C. (2000). Resolving therapeutic alliance ruptures: Diversity and integration. Journal of clinical psychology, 56(2), 233-243. DOI: https://doi.org/10.1002/(SICI)1097-4679(200002)56:2<233::AID-JCLP9>3.0.CO;2-3
Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80–87. doi: 10.1037/a0022140 DOI: https://doi.org/10.1037/a0022140
Samstag, L. W., & Norlander, K. (2019). Characteristics of trainees’ early sessions: A naturalistic process-outcome study tribute to Jeremy D. Safran. Psychoanalytic Psychology, 36(2), 148. DOI: https://doi.org/10.1037/pap0000239
Sandler, J., Kennedy, H., & Tyson, R. L. (1980). The technique of child psychoanalysis: Discussions with Anna Freud. Harvard University Press.
Target, M., & Fonagy, P. (1994). Efficacy of psychoanalysis for children with emotional disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 33(3), 361-371. DOI: https://doi.org/10.1097/00004583-199403000-00010
Tatarsky, A., & Kellogg, S. (2010). Integrative harm reduction psychotherapy: A case of substance use, multiple trauma, and suicidality. Journal of Clinical Psychology, 66(2), 123-135. DOI: https://doi.org/10.1002/jclp.20666
Von Below, C., & Werbart, A. (2012). Dissatisfied psychotherapy patients: A tentative conceptual model grounded in the participants’ view. Psychoanalytic Psychotherapy, 26(3), 211-229. DOI: https://doi.org/10.1080/02668734.2012.709536
Warnick, E. M., Gonzalez, A., Weersing, V. R., Scahill, L., & Woolston, J. (2012). Defining dropout from youth psychotherapy: how definitions shape the prevalence and predictors of attrition. Child and Adolescent Mental Health, 17(2), 76–85. DOI: https://doi.org/10.1111/j.1475-3588.2011.00606.x
World Health Organization. (2017). Depression and other common mental disorders: global health estimates (No. WHO/MSD/MER/2017.2). World Health Organization.
Yadlin, Y., Edginton, E., Lepper, G., & Midgley, N. (2022). How to do things with questions: the role of patients’ questions in Short-Term Psychoanalytic Psychotherapy (STPP) with depressed adolescents. Journal of Child Psychotherapy, 1-18. DOI: https://doi.org/10.1080/0075417X.2022.2042584
Zack, S. E., Castonguay, L. G., & Boswell, J. F. (2007). Youth working alliance: A core clinical construct in need of empirical maturity. Harvard review of psychiatry, 15(6), 278-288. DOI: https://doi.org/10.1080/10673220701803867
Electronic sources
An introduction to the Rupture and Resolution Rating System (Eubanks, 2015). Society for Psychotherapy Research. Publicly available from: https://youtu.be/BiAZP9VOdUY?feature=shared.
APQ rating procedure (online platform for rating procedure – restricted access: Accessible at https://psychprocessqsets.com/login, the website is available only upon obtaining explicit consent from Dr. Calderon: ana.Calderon@uss.cl).
How to Cite
"Maybe you don’t know what answers I want": unresolved alliance ruptures preceding dropout in short-term psychoanalytic psychotherapy with depressed adolescents. (2025). Research in Psychotherapy: Psychopathology, Process and Outcome, 28(1). https://doi.org/10.4081/ripppo.2025.841
Copyright (c) 2025 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.