Therapeutic relationship

Therapeutic Alliance Ruptures

What is a rupture?

Ruptures are often described as deteriorations in the relationship between the client and therapist. Unless recognised and managed, ruptures in the therapeutic relationship can result in progress stalling or the premature ending of therapy. Maintaining a good alliance is important in all therapies. Ruptures involve both the therapist and client becoming involved in unhelpful and sometimes negative reactions.

How can a rupture be recognised?

The first thing is to recognise when a rupture may be occurring.

He got extremely irritated with me when I brought up the subject of his relationships with others. - Therapist

This can be done by looking out for markers in the client’s behaviours, which can range from more subtle misunderstandings to a withdrawal of involvement in therapy or disagreement between the client and therapist. The therapist’s own reactions in and outside of a session may also indicate a rupture has occurred. Measures of alliance may also pick up a dip in the therapeutic relationship. (Examples include the ‘Working Alliance Inventory’ and the ‘Helping Alliance Questionnaire’; these kinds of measures often have a therapist and a client version).

Two types of ruptures have been described, called ‘confrontation’ or withdrawalIn desperation I just kept going even though my client was getting quieter and quieter. - Therapist ruptures. A confrontation rupture is when a client expresses anger or frustration, such as questioning the tasks, roles, rationale or outcomes of therapy. A withdrawal rupture occurs when a client disengages from an aspect of therapy. Withdrawal might be observed by a client responding minimally, discounting the therapist’s contribution, rationalising or shifting the topic.

How can ruptures be managed?

There are a number of models of rupture resolution and a synthesis of these is provided below: 

  1. Acknowledgement. It is important that the therapist attends to the rupture marker. Some form of acknowledgement of the client’s feelings by the therapist is needed. The form of this may vary for different therapies. In dynamic therapies this may be raised with the client as ruptures are seen as integral to the change process. In CBT, recognition may be implicit.
  2. Negotiation. The therapist and client discuss their respective understandings of the rupture experience or avoidance to develop a shared knowledge of their roles and responsibilities. Sometimes therapist disclosure of their own feelings may be helpful.
  3. Exploration of parallel situations outside of therapy.
  4. Consensus. The client and therapist come to a shared understanding of the client’s dissatisfaction and re-negotiate how they will work together.
  5. New styles of relating. Alternative ways of managing such situations are discussed.

[1]. Horvath, A.O & Greenberg, L S. (1989). Development and validation of the Working Alliance Inventory

Journal of Counseling Psychology, 36(2), 223-233.

[2] Luborsky, L., Barber J., Siqueland L., Johnson S., Najavits L., Frank A. & Daley D. (1996). The Revised Helping Questionnaire (HAq-II): Psychometric Properties. Journal of Psychotherapy Practice and Research 5 (3): 260-271.