What is the Alliance?

The therapeutic alliance refers to the quality of the relationship between patient and therapist. It is comprised of a purposeful collaboration (the extent to which the therapist and patient work together on agreed upon tasks and goals) and affective bond (the degree of mutual respect and trust and understanding). In our work, we have elaborated on the alliance concept to take into the account the fact that the alliance is not a static variable but rather a fluctuating, emergent property of the therapeutic relationship that is negotiated between patients and therapists at both explicit and implicit levels throughout the course of treatment. 

A number of measures have been developed based on these dimensions, and a great deal of research has been conducted demonstrating that the therapeutic alliance is one of the most robust predictors of treatment success in all forms of psychotherapy. Research has also demonstrated that therapists often struggle to develop or maintain an adequate alliance and fail to recognize problems in the alliance when they occur.  In addition, even when therapists recognize problems in the alliance, they often fail to address them in a constructive way. Failures of this type often lead to poor outcome, premature termination, or patient deterioration over the course of treatment.  

What is a Rupture?

Difficulties in the alliance are referred to as "alliance ruptures," with successful therapy being highly dependent on the ability of the client and therapist to resolve ruptures and strains in the alliance. Alliance ruptures are periods of tension or breakdown in collaboration or communication between patients and therapists. They vary in intensity and duration, from brief moments of tension or misunderstanding to more enduring periods of difficulties or breakdown in collaboration between patient and therapist. Unresolved ruptures can lead to poor treatment outcome, deterioration in clients' symptoms, or premature treatment drop-out. Alliance ruptures can be organized into two general categories: 1) Confrontation Ruptures, and 2) Withdrawal Ruptures.  Many ruptures combine features of both types.


What is Rupture Repair?

Rupture repair or resolution strategies fall into two major categories: 1) Immediate and 2) Exploratory. 

Immediate repair strategies, such as providing the patient with an explanation or rationale for a specific treatment task or goal, changing a task or goal to something more agreeable to the patient, and clarifying a misunderstanding with patient: These are common interventions that clinicians frequently employ to immediately correct and re-establish collaboration.  
​
Exploratory resolution strategies, which involve exploring core relational themes that underlie a rupture: These typically lead to clarifications of patient beliefs and action patterns around the rupture. They also require significant attention to the therapist experience and behavior. The essential technical principle for such explorations is therapeutic metacommunication, which involves any form of communication about the communication process. The critical tasks for therapists are to recognize and invite a collaborative inquiry about the rupture event, to empathize and remain nondefensive with regard to patients’ negative sentiments, and to take responsibility for their part.

Various models of this exploratory process have been proposed.  Our research group has proposed two specific resolution models for withdrawal and confrontation ruptures: In the former, the common progression consists of moving through increasingly clearer articulations of discontent to self-assertion, in which the need for agency is realized. The progression in the resolution of confrontation ruptures consists of moving through feelings of anger, to feelings of disappointment and hurt over having been failed by the therapist, to contacting vulnerability and the wish to be nurtured. Throughout such progressions, there are often shifts, regardless of rupture type, avoidant movements that reflect anxieties resulting from the fear of being too aggressive or too vulnerable associated with the expectation of retaliation or rejection by the therapist. The therapist should explore these shifts when they emerge.