by Rebecca Endres and Bonnie Eissner

Why do patients drop out of psychotherapy or fail to improve? What causes ruptures in the therapeutic relationship? How can these be addressed and resolved?

J. Christopher Muran, Ph.D., associate dean of Adelphi University’s Gordon F. Derner Institute of Psychological Studies and the recently elected general vice president of the International Society for Psychotherapy Research, has been tackling these issues since 1990, when he became the director of the Brief Psychotherapy Research Program at Beth Israel Medical Center. And this fall, the extensive video collection from his research—taped psychotherapy sessions from roughly 1,000 cases over two decades—will come to Adelphi, to be archived and studied by psychology doctoral students.

“Our videotape sessions are precious; they’re not easy to come by,” Dr. Muran said.

The tapes are the raw data of a comprehensive, precedent-setting study of the therapeutic process. The concept is to examine—via videotaped sessions and various measures—time-limited psychotherapy in action and how it affects patient outcomes. As the research program director, Dr. Muran has honed in on ruptures—relational difficulties or impasses—between therapists and their patients, in an effort to understand what causes them and how to resolve them.

“Our thinking is that the ruptures reflect something about the patient’s history, presentation and personality,” Dr. Muran said. “But it also reflects something about the therapist as well.”

Dr. Muran offered an example: “Oftentimes a therapist can be oblivious to the patient’s distress because of their own anxiety. It’s fascinating when you look at the research to see how often therapists miss cues from patients.” He described how anxiety can diminish a therapists’ empathy and literally become contagious.

To address this issue and related ones, Dr. Muran and his colleagues have devised innovative training techniques, including role playing and mindfulness meditation, which improve therapists’ metacognitive capacities. All of the training is conducted in a group format.

“I like to think it’s pretty innovative,” Dr. Muran said. “Typical approaches to training have been more didactic…Our angle is not to tell you you’re anxious but to help you discover your anxiety.” He added: “Mindfulness is something being practiced all over now; at the time [when we started] we were the only ones doing it to train therapists.”

In their book, Negotiating the Therapeutic Alliance (The Guilford Press, 2000), Dr. Muran and his coauthor Jeremy Safran, describe various principles and models of intervention and training from their study of the therapeutic relationship. “This book…belongs in the library of every mental health professional who practices or teaches psychotherapy,” wrote a reviewer in The American Journal of Psychiatry. Dr. Muran and Dr. Safran continue to collaborate and refine their thinking.

“I think the consensus continues to grow that so much comes down to the therapeutic relationship and the therapist’s ability to negotiate that relationship,” Dr. Muran said. “People recognize how important it is and, as much as there is written about it, there are still so many questions to answer.”