The therapeutic alliance is the agreement between the psychotherapist and the patient on the tasks of therapy (what is done during treatment), the goals of therapy (the desired outcomes), and the relational bond (mutual liking and respect). Much research shows that a good alliance is related to better patient outcomes. More recently, researchers have shown that therapeutic alliance ruptures (disagreement on tasks and goals or tensions in the therapeutic relationship) can lead to poor patient outcomes. On the other hand, repairing alliance ruptures through a collaborative exploration of what occurred between patient and therapist can lead to better patient outcomes. However, therapists and patients do not always agree if a rupture occurred or if there was a resolution to the alliance rupture. Most studies on therapeutic alliance ruptures and repairs have only looked at the phenomenon from the patient or therapist’s perspective, not from a dyadic perspective. A dyadic perspective would consider whether the patient and therapist had a similar (congruent) or differing experience of the alliance and its impact on psychotherapy processes and outcomes. In this study, Shir and Tishby examined whether patient-therapist congruence or agreement in their perception of alliance ruptures, the intensity of the ruptures, and the resolution of the rupture impacted patient outcomes. They looked at 45 therapists who treated 61 patients receiving 16 sessions of short-term dynamic therapy for depression or anxiety. After each session, they asked both patient and therapist if an alliance rupture occurred, to rate the intensity of the rupture, and the degree to which it was repaired. Asking both therapist and patient to rate alliance ruptures and repairs allowed the researcher to assess the level of congruence or agreement between therapist and patient. Shir and Tishby also asked patients how helpful the session was in addressing their therapy goals after each session (a measure of patient outcomes). They found that the therapist’s recognition that a rupture occurred was insufficient to facilitate a repair, especially for ruptures that patients rated as more intense. In other words, the therapist’s perspective alone, independent of the patient’s perspective of a rupture, was not useful. However, the congruence or agreement between therapists and patients in their perceptions of the rupture’s intensity was related to how much they discussed it in a session (presumably as an attempt to repair it). Congruence or agreement between the therapist and the patient's perceptions of rupture repair was associated with the patient’s ratings of a session’s helpfulness (outcomes). This was especially true for ruptures that were more intense, as rated by both patient and therapist.
Practice Implications
The findings suggest that if therapists and patients have similar perceptions of the quality of their therapeutic relationship and of repairing any tensions, they are more likely to resolve ruptures, and patients will have better outcomes. Therapists must remain attuned to their patients’ experiences, but therapists may misperceive patients’ experiences of the alliance. Therapists should regularly engage patients in a discussion of the therapeutic relationship, especially of any tensions in their interactions. The PPRNet is currently conducting a study to train therapists to identify and repair therapeutic alliance ruptures. For more information, go to https://researchpprnet.ca/.
Shir, R., & Tishby, O. (2024). Should we feel the same? Mutual recognition and congruence between therapist and client regarding ruptures and repairs. Psychotherapy. Advance online publication. https://doi.org/10.1037/pst0000532
To learn more about the Psychotherapy Practice Research Network, visit www.pprnet.ca.
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