The therapeutic alliance is recognized as a key therapeutic mechanism of change in psychotherapy and a reliable predictor of patient improvement across different therapeutic approaches. The alliance refers to the collaborative agreement on the goals and tasks of therapy and the patient-therapist relational bond. Ruptures are tensions or breakdowns in the alliance, such as disagreement on the goals or tasks of therapy or a deterioration in the relational bond. Repairs of the alliance involves restoring collaboration and strengthening the bond. Research shows that alliance ruptures are associated with poorer patient outcomes, whereas rupture repairs can lead to better outcomes. There are two types of ruptures. Withdrawal ruptures involve patients moving away from the therapist (non-responding, changing the topic, denying, intellectualizing). Confrontation ruptures involve patients moving against the therapist (complaining about the therapist or therapy, trying to control the therapist). Repairs are an opportunity for in-session exploration and for patients to experience a corrective emotional experience. Therapists can engage in metacommunication (talking about the therapeutic relationship and the rupture event) and get feedback from patients to repair alliance ruptures. However, this requires that therapists are responsive, that is, being aware of and bringing to light their own and their patient’s thoughts, feelings, and behaviors that affect the ongoing therapeutic interaction. Therapists can take an attitude of non-defensive curiosity, empathy, and acceptance that encourages theirs and their patients' self-awareness and exploration. In this study, Chajmovic and Tishby looked at 35 patients treated by 22 therapists. The authors examined the association between the rupture-repair process and therapists’ and patients’ perceptions of therapists’ responsiveness. They found that therapists’ contributions to confrontation ruptures were negatively associated with therapists’ responsiveness. In other words, the more responsive a therapist was, the lower the likelihood of a confrontation rupture in a session. However, they did not find an association for withdrawal ruptures. Confrontation ruptures are apparent, easily perceived by patients and therapists, and perhaps more difficult for therapists to respond to. The authors also found a positive association between rupture resolution and therapist responsiveness. In other words, successful resolution of an alliance rupture likely requires therapists to be responsive. Finally, the study found that the association between higher alliance ruptures and lower therapist responsiveness occurred mainly during sessions with lower levels of resolution. That is, resolutions seemed to reduce the negative effect of ruptures and improve patients’ experience of therapists’ responsiveness. This supports the view that ruptures are an opportunity for growth in the therapeutic relationship if successfully resolved.
Practice Implications
Identifying and repairing alliance ruptures is emerging as a key skill of effective therapists. Metacommunication and adopting a stance of non-defensive curiosity and empathy can help therapists repair alliance ruptures. This research highlights the importance of training therapists to identify alliance ruptures and using metacommunication to bring to awareness the factors in the therapeutic relationship that lead to a rupture. Training programs like those offered in a PPRNet study may help therapists increase these essential skills (see www.researchpprnet.ca).
Chajmovic, M.L. & Tishby, O. (2025) Therapists’ responsiveness in the process of ruptures and resolution: Are patients and therapists on the same page? Psychotherapy Research, 35, 42-53. https://doi.org/10.1080/10503307.2024.2303318
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