Therapeutic alliance ruptures occur in approximately 30% to 100% of sessions. Research indicates that when left unresolved, alliance ruptures can lead to poor outcomes for patients or patients dropping out of therapy. Withdrawal ruptures occur when a patient moves away from a therapist by becoming silent, changing the topic, or engaging in abstract conversation. They may want to maintain relatedness with the therapist and so do so at the expense of not expressing their feelings of displeasure with the therapy or therapist. Therapists may not always identify when a withdrawal rupture is occurring, so they may experience fewer negative emotions. Confrontation ruptures occur when a patient moves against a therapist by becoming aggressive, critical, or controlling. They want to express their anger, perhaps at the expense of their relationship with the therapist. Therapists can more easily identify when a confrontation rupture has occurred, and they may feel negative emotions more intensely during these events. Much of the research on alliance ruptures relies on retrospective self-reporting of the event and feelings by patients and therapists, which may obscure responses that occur at the physiological level. In this intensive case study, Tchizick and colleagues used heart rate variability (HRV) as a marker of autonomic nervous system arousal in a therapist and a patient. HRV reflects interval fluctuations between heartbeats across time, intricately linked to emotional states and arousal levels. The patient and therapist wore smartwatches to measure HRV in real-time during sessions, and independent raters coded successive therapy sessions for alliance ruptures and repairs. The authors found that the patient demonstrated higher physiological regulation during withdrawal than confrontation ruptures. That is, the patient made an effort to maintain a good relationship with the therapist during withdrawal ruptures and engaged in autonomic nervous system self-regulation to achieve this. The therapist did not show a clear parasympathetic reaction during withdrawal ruptures, suggesting that they were not aware, even at a physiological level, that a rupture had occurred. The opposite happened for confrontation ruptures. While the patient was confrontational, their level of physiological self-regulation was low; that is, they did not regulate their emotional arousal. The therapist, who was likely more sensitive to confrontation ruptures, attempted higher self-regulation as a means of controlling their arousal and remaining in a calmer state.
Practice Implications
Withdrawal ruptures are more difficult for therapists to identify partly because patients do not express their dissatisfaction directly, and they control their physiological arousal. Therapists much more easily identify confrontation ruptures partly because of the emotional arousal that they cause. Therapists may benefit from training that raises their awareness of internal processes within themselves and their patients for both types of ruptures. Therapists can explore their feelings or their absence through metacommunication (talking to patients about their interpersonal impact on the therapist), which can help to resolve a rupture.
Tchizick, A., Kleinbub, J. R., Bittan, S., Bitton, T., & Zilcha-Mano, S. (2024). Physiological regulation processes differentiate the experience of ruptures between patient and therapist. Psychotherapy. Advance online publication. https://dx.doi.org/10.1037/pst0000543
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