The therapeutic alliance includes the collaborative agreement between therapist and patient on the goals of therapy (what outcomes are desired) and the tasks of therapy (how therapy should proceed), as well as the affective bond between patient and therapist (liking, respect, and mutual regard). Rather than being a static thing that remains stable once established, the alliance tends to fluctuate across therapy sessions. This fluctuation may indicate ruptures or tensions in the alliance. Ruptures may also be defined as in-session behaviours that are markers of confrontations (moving against the therapy or therapist [complaints, anger, frustration]) or withdrawals (moving away from the therapy or therapist [silence, denial of feelings, changing topic]). Ruptures are common and occur in all types of therapy, with a range of patients, and they can negatively impact patient outcomes. However, repairing alliance ruptures (renegotiating goals or tasks, or working on the therapeutic bond) can strengthen the alliance and improve outcomes. Studies have demonstrated inconsistent findings regarding the impact of alliance ruptures on outcomes. The inconsistencies may be due to differences in how alliance ruptures are conceptualized and measured across studies. Some studies rely on precipitous drops from session to session in patients' self-reports of the therapeutic alliance itself (an indirect measure of rupture), whereas other studies focus on in-session rupture processes of withdrawal and confrontation, either through self-report or observer ratings of a session (a direct measure of rupture). These approaches tap into different ways of understanding ruptures (as session-to-session fluctuations in the alliance vs rupture behaviours of confrontation or withdrawal). In this meta-analysis, Babl and colleagues document the effect of in-session alliance rupture behaviours (confrontations or withdrawals) on patient outcomes. They found four such studies in the literature that yielded 18 effect sizes of the association between in-session rupture markers and patient outcomes. The studies provided data from 301 adult patients undergoing psychotherapy. Results showed a significant aggregated effect size of z = .0.22, SE = 0.04, 95 CI [.0.303, .0.133]; t(17) = .5.40, p < 0.001, which translates into a correlation of r = 0.21. These findings indicate that in-session alliance rupture behaviours (withdrawals or confrontations) were associated with poorer therapy outcomes.
Practice Implications
The findings of this meta-analysis document a small to moderate association between in-session rupture behaviours and patient outcomes in psychotherapy. Therapists who can recognize when an alliance rupture has occurred (a withdrawal or a confrontation) and who have the skills to engage in repair strategies (renegotiating goals or tasks, or working on the relational bond with the patient) will likely have patients who experience better outcomes.
Babl, A., Gomez Penedo, J.M., Nimphy, C., Kesel, M., Crainic, C., Boendermaker, N., & Eubanks, C.F. (2026). Alliance ruptures and psychotherapy outcomes: A multilevel meta-analysis of their associations. Journal of Clinical Psychology. https://doi.org/10.1002/jclp.70192.