Therapeutic Alliance: Why It Is Critical to Treatment Success

Therapeutic alliance refers to the quality of the relationship between a patient and a therapist. At its core, the alliance is a combination of both obvious and less-obvious factors. There is purposeful collaboration between patient and therapist, where both work together on shared tasks and goals. Less-obvious factors include the bond or relationship between a patient and therapist, including mutual respect, trust, and understanding of each other.

The therapeutic alliance is dynamic; it can change from session to session or even over the course of a single session. It is a relationship that is constantly evolving and negotiated between patient and therapist. It’s also one of the most robust predictors of treatment success in all forms of psychotherapy.

Research has shown that developing and maintaining an optimal therapeutic alliance can be a challenge for therapists. It can be difficult for therapists to recognize if there is a problem in the alliance, and if so, how to address and resolve problems in a constructive way. If problematic shifts in the alliance occur without any resolution, they can result in poor outcomes, premature termination, or patient deterioration over the course of treatment.

What is a rupture?

Difficulties in the alliance are referred to as "alliance ruptures." Successful therapy is highly dependent on the ability of the patient 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 patients' symptoms, or premature treatment drop-out. Alliance ruptures can be organized into two general categories: confrontation ruptures and withdrawal ruptures. Many ruptures combine features of both types.

Confrontation ruptures are easy to identify

Sometimes when patients are not making progress in therapy it becomes obvious that there is a problem in the therapeutic alliance. For example, patients may express concerns about not making progress or complain about the treatment approach. They may also criticize or attack the therapist. We refer to these types of ruptures as confrontation ruptures because the patient is directly expressing his or her concern.

Withdrawal ruptures are harder to spot

Other types of alliance ruptures may be more subtle and difficult to detect. It's not unusual in this type of situation for therapists to feel stuck, confused and unable to pinpoint what is going on. Subtle impasses of this type may indicate a withdrawal rupture is taking place. In a withdrawal rupture, patients may have difficulty fully recognizing their own sense of frustration or disappointment. Or they may be aware of their concerns but have difficulty expressing them to the therapist due to concerns about disapproval, retaliation, or abandonment. Clients may also have concerns about hurting the therapist and feel they need to protect him or her.

How to resolve an alliance rupture

Rupture repair, or resolution strategies, fall into two major categories: immediate and exploratory.

Immediate repair strategies are common interventions therapists employ to immediately correct and re-establish client collaboration. 

They include:

• Providing the client with an explanation or rationale for a specific treatment task or goal
• Changing a task or goal to something more agreeable to the client
• Clarifying a misunderstanding with the client

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Exploratory resolution strategies involve exploring core relational themes that underlie a rupture. These typically lead to clarifications of client 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 non-defensive to patients’ negative sentiments, and to take responsibility for their part.

Two specific resolution models for confrontation and withdrawal ruptures 

Confrontation ruptures are resolved through a progression of phases: the patient moves through feelings of anger, to disappointment and hurt over the therapists' perceived failure to understand. After this, the patients' feelings can change to vulnerability and the wish to be nurtured.

Withdrawal ruptures are commonly resolved by patients as they move through increasingly clearer articulations of discontent to self-assertion, in which the need for their own agency is realized. 

Throughout these progressions, there are often shifts, regardless of rupture type. These shifts can be described as avoidant movements that reflect patient anxieties, resulting from the fear of being too aggressive or too vulnerable. These anxieties are associated with the expectation of retaliation or rejection by the therapist. Clients benefit greatly from a therapist that is open to exploring these shifts through thoughtful questioning as the shifts occur.