Safran, J.D., Muran, J.C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48, 80-87.
One of the most consistent findings emerging from psychotherapy research is that the quality of the therapeutic alliance predicts outcome across a range of different treatments, and that a weakened alliance is correlated with dropping out of psychotherapy. Jeremy Safran and his colleagues have characterized a “second generation” of alliance research that attempts to clarify the factors leading to the development of the alliance as well as those processes involved in repairing ruptures in the alliance when they occur. A rupture in the therapeutic alliance is defined as a tension or breakdown in the collaborative relationship between patient and therapist. These could include: disagreement on goals of therapy, disagreements on the tasks of therapy, or strains in the patient - therapist bond. Ruptures may vary in intensity from relatively minor tensions, of which one or both of the participants may be only vaguely aware, to major breakdowns in collaboration, understanding, or communication. Similar concepts include: empathic failure, therapeutic impasse, and misunderstanding event. For example, a therapist returned from holidays to a session with a patient with whom she previously had a good alliance. The patient appeared more sullen, and quieter than usual in this session. The patient rated the alliance lower following the session, and the therapist felt the same. In the next session the therapist asked about the change in the patient and explored reasons for the change. It emerged that the patient’s old feelings of loss and abandonment re-surfaced with the therapist’s absence, and the patient felt resentment when the therapist returned. Examining this pattern resolved the rupture and led to continued gains by the patient especially regarding the relational theme of abandonment. In a small meta analysis by Safran and colleagues, 3 studies representing 148 patients were reviewed. The relationship between rupture-repair episodes and treatment outcomes was significant, though modest. In a subsequent meta analysis of 8 studies representing 376 patients, the relationship between an intervention to repair alliance ruptures and positive outcomes was significant and large.
A therapist’s non-defensive response to a client’s negative feelings about the therapy is critical to repairing a rupture. Safran and colleagues suggest 6 strategies for therapists to deal with alliance ruptures. (1) Repeating the therapeutic rationale can help to repair a strained alliance. (2) Changing tasks or goals can make the therapy and its objectives more meaningful to the patient. (3) Clarifying misunderstandings at a surface level by acknowledging how the patient might feel misunderstood or criticized by the therapist. (4) Exploring relational themes associated with the rupture, could help the therapist and patient understand the patient’s relational themes and reactions. (5) Linking the alliance rupture to common patterns in the patient’s life, as in the example provided above, allows the patient to change the pattern in the therapeutic relationship. (6) Providing a new relational experience such that the therapist’s non-defensive response and willingness to repair the rupture may be a new and positive experience for the patient leading to a better alliance and laying the groundwork for further change.
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