The therapeutic alliance is a well-known and reliable predictor of patient outcomes in psychotherapy. The alliance refers to a collaborative agreement between the therapist and the patient regarding the goals of therapy, how therapy proceeds (the tasks), and the emotional/relational bond between the patient and the therapist. Early views on the alliance saw it as static – once achieved, it fades into the background, and the real work of therapy can begin. However, more recent views see that alliance as a dynamic concept that changes across time, and this change affects patients’ mental health outcomes. One way to understand this dynamic is to examine alliance ruptures and their repairs. Ruptures occur when there is disagreement over therapy goals or tasks, or when there is a strain in the emotional bond between patient and therapist. Unresolved ruptures can lead to poorer patient outcomes. Understanding which patients benefit from focusing on rupture-repair may be important to advance a more personalized approach to psychotherapy. In this study, Igra and colleagues were interested in seeing if the level of impaired interpersonal functioning was a patient characteristic that moderated the impact of rupture repairs on outcomes. The researchers studied whether patients with more impaired interpersonal functioning benefited most from rupture repair and whether they had poorer outcomes when ruptures remained unrepaired. Their study included 514 adult patients with various disorders, seen by 52 psychotherapists practicing within different theoretical orientations. The number of sessions ranged from 3 to 91, with an average of 9.8 (SD = 8.44). They assessed the therapeutic alliance and symptom severity via patient self-report after each session, and they measured interpersonal functioning at the start of therapy. Ruptures were characterized by precipitous drops in the alliance from session to session, and repairs were characterized by a return to the pre-rupture level of the alliance. 57.8% of treatments experienced no ruptures, 32.9% had unrepaired ruptures, and 9.3% experienced repaired ruptures. In cases where alliance ruptures were repaired, patients with more impaired interpersonal functioning showed greater benefit in symptom reduction. This effect was most pronounced in longer-term treatments.
Practice Implications
The main finding of the study was that rupture–repair was more strongly associated with symptom improvement over time among clients with higher levels of interpersonal difficulties. This supports the notion that one size does not fit all in psychotherapy. Clinicians should assess the level of interpersonal impairment in their patients at the start of therapy. Treatment plans should incorporate greater emphasis on alliance rupture–repair work for patients who exhibit more severe interpersonal difficulties. Longer treatments may be necessary for these patients to engage in a more meaningful process of negotiating a therapeutic alliance and to develop a deeper, more stable therapeutic relationship.
Igra, L., Jacobsen, C.F., Falkenstrom, F., Lunn, S., Lauritzen, L., & Poulsen, S. (2025). Rupture patterns and outcomes: The moderating role of interpersonal functioning. Clinical Psychology & Psychotherapy, 32: e70181. https://doi.org/10.1002/cpp.70181.