The association between the therapeutic alliance and outcome is now well-established and widely known (Flückiger et al., 2018), highlighting a need to better understand the factors that influence the quality of the alliance. Thinking around therapists’ capacities to establish and maintain the alliance has grown increasingly sophisticated, as researchers have long-investigated ruptures and repairs in the therapeutic process (Muran & Eubanks, 2020; Safran, 1993; Safran & Muran, 2000). This work increasingly emphasizes the therapist’s awareness of subtle changes in their internal state, proposing that such intrapersonal awareness is critical to therapeutic change (Muran et al., 2021). In the current paper, I describe this shift and discuss its implications for training. I point readers toward cost-effective strategies likely to enhance therapist trainees’ awareness of the blind spots and emotional vulnerabilities that contribute to alliance ruptures.

Rupture Repair Theory

Safran and Muran’s (2000) seminal research on the therapeutic alliance focuses on rupture and repair processes. The authors cite interpersonal theory and the idea that we all have needs for agency and communion, which we must negotiate within the significant relationships we seek to develop and maintain (Wiggins, 1991). Since negotiating these needs is complicated, alliance ruptures – i.e., disagreements, breakdowns, and strains – are the rule in psychotherapy rather than the exception (Muran, 2019). As the theory goes, therapists best detect ruptures by attending to specific interpersonal markers. For example, a confrontation rupture is defined as a patient’s angry expressions or attempts to move against the therapist. In contrast, a withdrawal rupture is characterized by a patient’s false compliance or efforts to move away from the therapist (e.g., by terminating; Safran & Muran, 2000).

While the word “rupture” often brings to mind breakups in our significant relationships, an interesting element of Safran et al.’s (1993) original theory is that alliance ruptures are often subtle. It follows that the therapist’s mindfulness is required to detect them (Safran & Muran, 2000). Similarly, the rupture repair literature emphasizes therapists’ awareness of internal reactions to patients during ruptures, or intrapersonal markers (Muran et al., 2021). This paradigm shift follows research suggesting that the therapist’s attachment patterns influence their capacity to detect ruptures (e.g., Marmarosh et al., 2015; McIntyre et al., 2019; McIntyre & Samstag, 2022; Talbot et al., 2019), and it includes the conclusion that therapists’ blind spots both precipitate and exacerbate rupture events. These ideas are foundational; a recent book demonstrates that thought leaders from multiple therapeutic orientations have applied rupture repair principles to their models of therapeutic change (Eubanks et al., 2023).

Implications for Training and Relationships

Rupture repair theory implies that trainees can learn to detect and negotiate alliance ruptures by becoming aware of their unconscious relational patterns and the blind spots left in their wake (Muran & Eubanks, 2020). Therefore, rupture and repair researchers have developed Alliance-Focused Training (AFT) to facilitate trainee’s awareness, and, thus, capacity for rupture resolution. Through AFT, trainers analyze trainees’ ruptures, engage in awareness-oriented role plays, and provide mindfulness instruction (Eubanks et al., 2015). There is evidence that this guidance sensitizes trainees to ruptures and bolsters their affect regulation and awareness; this, in turn, enhances trainees’ capacity to identify and negotiate ruptures.

Given the clear and transtheoretical significance of rupture repair dynamics, it seems vital to explore other cost-effective methods that trainees might use to hone their awareness. Personal therapy, relational supervision, and intimate relationships are examples of contexts where ruptures are likely to emerge, because they all require some degree of emotional acknowledgment. Indeed, given that emotional acknowledgment is related to interpersonal trust (Yu et al., 2021), something stands to be lost or ruptured within these interactions. Another option for honing one’s awareness of alliance ruptures is to practice acknowledging others’ emotional states within environments that call for it. The success of this hypothetical activity would be measured by the extent of insight one gleans from ruptures that occur despite their best efforts to acknowledge another’s emotional state.

Empathic Listening within Empathy Circles

Empathic listening is closely related to the emotional acknowledgment required to build and maintain trust within relationships. It involves reflecting upon what someone expresses verbally while focusing primarily on their affect (Rogers, 1975). Despite the obvious benefits of empathic listening on one’s significant relationships, beginners may benefit from practicing this skill with strangers where the stakes and emotions tend not to run as high. Empathy Circles, co-created by Edwin Rutsch and colleagues (Niezink, 2016) and advertised as online training to the general public over the last several years, provide a format where one might learn and practice empathic listening.

An empathy circle is a structured dialogue between three to five participants. It involves engaging in a live conversation with strangers in person or over a video-conferencing platform. Participants’ roles alternate between the speaker, active listener, and silent listener. To begin an empathy circle, the first speaker selects an active listener in the group who either shares their thoughts and feelings about a weekly topic, or states whatever is alive for them. Then, for three to five minutes, the active listener’s role is to reflect the speaker’s utterances until they feel heard. The silent listener’s role is to listen without responding. Following this initial round, the active listener switches to the role of the speaker, and chooses an active listener from the group. The process continues this way for a predetermined amount of time.

Empathy circles are thought to generate mutual empathy and understanding among all participants. At the end of each empathy circle, participants participate in a debriefing session to reflect on their experiences. Conceivably, this debriefing period could also allow participants to reflect on any ruptures which interfered with their participation in the empathy circle. Speaking with trained professionals to review these ruptures in-depth would likely offer participants further clarity into their unique blind spots and emotional vulnerabilities. Such awareness could help participants better understand the internal states that typically precede their motivations to withdraw from, or confront, others in their life. In this way, trainees who participate in empathy circles may prepare themselves to better anticipate, identify, and respond to ruptures with patients.

Conclusion

Within the literature on the therapeutic alliance, rupture repair theory provides helpful guidance about how therapists may best navigate the therapeutic process (Muran & Eubanks, 2020; Safran & Muran, 2000). Increasingly, rupture repair literature emphasizes therapists’ abilities to detect and utilize subtle changes in their internal states to address ruptures with their patients (Muran et al., 2021). Alliance-focused training is an in-depth program that teaches trainees to identify ruptures and work toward resolutions (Eubanks et al., 2015). Given the growing popularity of rupture repair theory (Eubanks et al., 2023), exploring other accessible and cost-effective ways to train students to recognize and resolve alliance ruptures seems vital.

The purpose of this paper was to suggest cost-effective strategies that may help trainees identify and resolve alliance ruptures, including intensive reflection on ruptures that emerge within relationships that require emotional acknowledgement. In addition, this paper highlighted the empathy circle as a promising format where trainees may learn to listen empathically and identify the intrapersonal markers associated with rupture events.

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Shannon L. McIntyre, Ph.D.