The therapeutic alliance comprises the collaborative agreement between the patient and therapist on the goals of therapy and how therapy should proceed (tasks), as well as the relational bond between them. The alliance is one of the most well-studied concepts in psychotherapy, and it is reliably associated with patient outcomes. Second-generation research on the therapeutic alliance has focused on alliance ruptures and their repairs. A rupture in the therapeutic alliance refers to tensions or breakdowns in the collaborative relationship, manifested by disagreement between therapist and patient over goals or tasks, or by a strain in the relationship. Repairs of ruptures involve negotiating a resolution of the rupture. These alliance negotiations are an important change process that helps patients work on their needs and those of others, leading to a new, internalized, constructive interpersonal experience for the patient. Despite the size and importance of this research, no previous study has examined alliance rupture and repairs and their effects on outcomes for patients with substance use disorder. In this study, Gidhagen and colleagues assessed the alliance and outcomes after each session by asking both patients and therapists to rate the alliance and psychological distress. The authors then examined whether a rupture (a decline in alliance ratings) and a repair (a subsequent increase in alliance ratings) were associated with a change in distress in the following sessions. Patients were 119 men and women with substance use disorder treated by six experienced therapists in a substance use treatment setting. Treatments included individual CBT, psychodynamic, or supportive psychotherapy and lasted 16 sessions on average. The therapeutic alliance increased significantly across sessions of treatment for substance use disorder. 52% of patients and 73% of therapists reported a rupture in the therapeutic alliance. It appears that therapists are more vigilant to alliance ruptures than patients are, or that patients may be more reluctant to report ruptures. Patient-reported ruptures, but not therapist-reported ruptures, contributed negatively to patient psychological distress in the following sessions. Both patient- and therapist-reported repairs of ruptures in one session were associated with decreases in patient distress in a subsequent session.
Practice Implications
These findings indicate that the therapeutic alliance and its ruptures and repairs play a key role in the outcomes of treatment of substance use disorder. Therapists should keep track of alliance ruptures and outcomes by monitoring them session to session. Therapists who are sensitive to signals of alliance ruptures and make efforts to resolve them are likely to have patients who experience better outcomes. Training and supervision to detect and repair alliance ruptures can also improve patient outcomes.
Gidhagen, Y., Holmqvist, R., & Falkenström, F. (2025): Rupture and repair in the working alliance among patients with substance use disorder. Psychotherapy Research, https://doi.org/10.1080/10503307.2025.2569043