Clinical Consensus Strategies to Repair Ruptures in the Therapeutic Alliance

The alliance been recognized as an essential common factor and robust predictor of outcome. The present study sought to further our knowledge of the alliance and to promote the integration of research and practice by assessing consensus among peer-nominated expert therapists of varying theoretical orientations on the effectiveness of clinical strategies to repair alliance ruptures. This study drew on the behavioral-analytic model (Goldfried & D'Zurilla, 1969) and the methodology of the Expert Consensus Guideline Series (Frances, Docherty, & Kahn, 1997). In Phase 1, 69 therapists submitted clinical situations describing alliance ruptures. In Phase 2, 177 therapists generated responses to the situations, and clinical strategies underlying the responses were identified. In Phase 3, 134 peer-nominated experts (a mean of 22.3 therapists per situation) rated the effectiveness of these clinical strategies. The experts reached consensus on the use of strategies that validated the client's experience and explored the rupture during the rupture session. Change-oriented interventions (e.g., changing interpersonal interactions; highlighting patterns of behavior, thought, or emotions) were generally rated as less effective to use during the rupture, but effective for use in future sessions. The findings are consistent with the growing literature on the value of using certain alliance-focused interventions during a rupture. The findings point to the importance of therapists' awareness of the state of the alliance so that they can identify when ruptures are occurring.