Rupturas da aliança terapêutica: ilustração clínica de um sistema de avaliação e análise de um caso de abandono em psicoterapia

Abstract

The therapeutic alliance (TA) is a common factor of psychotherapies and a predictor of positive outcome of treatments. Through investigation of processes (along the treatment) and of microprocesses (detailed analysis of the sessions) one can understand which elements strengthen and / or weaken TA. The alliance ruptures are characterized by a lack of collaboration, and situations of tension or collapse in the therapeutic relationship. This dissertation introduces in Brazil the evaluation and identification of alliance ruptures, which takes into account the specific, detailed, and microprocessional dynamic nature of alliance oscillations during treatment and / or a session through the Rupture Resolution Rating system System - 3R's. The 3R's identifies the occurrence of ruptures, in session segments, and offers a global categorization of session ruptures, and of each rupture marker. The system allows the evaluation of the degree of global impact of ruptures throughout the treatment, in each session, and the strategies for the resolution of these ruptures. The dissertation is organized in two papers, one being theoretical and the other empirical. The first paper describes how this coding system works and discusses its clinical and research implications, illustrating its application with vignettes of a case of dropout in psychoanalytic psychotherapy (PP), which is the subject of the empirical study. The contributions of this instrument to clinical research and practice are discussed. The empirical paper applies the 3R's for identifying ruptures and their impact on TA in conjunction with the Psychotherapy Process Q-Set (PQS), an instrument that describes the overall therapeutic process. The aim of the study was to explore the processes of TA rupture in an interrupted case of PP of a patient with a diagnosis of Borderline Personality Disorder. The process was characterized by multiple missed sessions and delays. In general, a predominance of withdrawal ruptures was observed, characterized by an increase in frequency from the 5th session and subsequent decrease in the final sessions (11th and 15th). The sessions that preceded treatment dropout (11th, 12th and 13th) were marked by the lower frequency of ruptures and had a moderate impact on TA. The therapist contributed to the occurrence of ruptures, especially in the 5th, 6th and 9th sessions, which presented a greater number of treatment ruptures. Taken together, these factors seem to be related to dropout. To better understand the case it is necessary to evaluate the resolution strategies used by the therapist. I future, the 3R's system should be used to examine the microprocess of TA in other similar cases and in comparative case studies with different diagnoses, approaches and outcomes.