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Skill Building in Alliance Rupture Repair for Psychotherapy Courses

How Theravue targets alliance rupture repair skills and what it means for future patient outcomes

by Bruce Wampold on January 13, 2021

Psychotherapy is a complex endeavor. A therapist meets with a client typically once a week for approximately one hour. This relatively brief interaction produces remarkable benefits. Indeed, there is convincing evidence that psychotherapy is an effective treatment for a variety of mental health disorders and psychological problems.

Despite the evidence for the effectiveness of psychotherapy, how psychotherapy works to produce these benefits has been a mystery. Many very different treatments have been shown to be effective, which suggests that factors common to most treatments are responsible for the benefits of psychotherapy.

The Therapeutic Alliance is a Common Factor of Effective Therapy

The most established common factor is the therapeutic alliance, which is composed of the bond between therapist and client, as well as the mutual agreement about the goals and tasks of therapy. Many studies have examined the correlation of the alliance measured early in therapy with the final outcome. Several meta-analyses (the latest one conducted in 2018 aggregating nearly 300 studies and 30,000 patients) have shown that indeed the alliance formed early in therapy is a robust predictor of how well therapy progresses. Clearly, the alliance is one of the most important, if not the most important, factors in psychotherapy.

Evidence Suggests that Alliance Ruptures Must Be Addressed Directly

Although it is comforting to recognize the importance of the alliance, the situation is much more complex than it first appeared. Here we focus on one aspect of the complexity involving the alliance.

The alliance is not a constant—it varies over the course of therapy. The therapist and the client have their own personalities, attachment history, stressors, and context. Inevitably during the course of therapy, there will be strains on the alliance. Not infrequently, the strain is so great, that it could be described as a “rupture.” There is now strong and convincing evidence that when the therapist addresses strains and ruptures directly, clients stay engaged in therapy and progress. On the other hand, failure to recognize and address alliance ruptures leads to disengagement (e.g., dropout) and poor client outcomes.

How to Ensure Therapists are Prepared to Respond to Alliance Ruptures

How does one recognize and respond to variations in the alliance? There are a number of strategies for responding to alliance ruptures. Choosing and using these strategies in an effective way requires practice. Unfortunately, therapists rarely get to practice alliance repair strategies. In a session, there may be few instances to use the repair strategy, they often fly by quickly, and the therapist laments, “Oh, I wish I had addressed that alliance rupture—I’ll look for it again.” Or even if the therapist recognizes it, they may well have responded in a way that was less than ideal: “Well, I didn’t really address the issue between us directly.” Alliance ruptures present difficult challenges.

What is needed is a platform that provides the therapist the opportunity to deliberately practice repairing the alliance. With Theravue.com, the therapist is presented with video clips of clients expressing material indicative of ruptures. The therapist responds to these clients as if they would with their own client, and is able to review their response, refine it through repetition, and when satisfied with the response, send it to an instructor, supervisor, or peer for feedback. In this way, the therapist can gradually improve their ability to use rupture repair strategies effectively.

About the Author

Bruce Wampold

Dr. Bruce Wampold, PhD

Dr. Bruce Wampold, PhD

Dr. Wampold is the Patricia L. Wolleat Emeritus Professor of Counseling Psychology at the University of Wisconsin—Madison and Director of the Research Institute at Modum Bad Psychiatric Center in Vikersund, Norway. He is a Fellow of the American Psychological Association, Board Certified in Counseling Psychology by the American Board of Professional Psychology, and is the recipient of the 2007 Distinguished Professional Contributions to Applied Research Award. His current work is summarized in The Great Psychotherapy Debate (with Z. Imel, Routledge, 2015).

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