Decades of research show that the working alliance, or the degree of agreement between a client and therapist on the goals and tasks of therapy and the quality of their affective bond (Bordin, 1979), is positively associated with clinical outcomes (Fluckiger et al., 2018). However, there are sometimes ruptures in the working alliance, or instances when a client and therapist disagree on therapy goals or tasks or experience a relational strain. Past studies indicate that alliance ruptures are relatively common and highlight the importance of repairing ruptures (Safran et al., 2011). In a meta-analysis, Eubanks et al. (2018) found that clients who experienced alliance ruptures that were then repaired had better outcomes than those with unresolved ruptures (i.e., lower rates of premature termination, greater symptom reduction). Additionally, clients with repaired ruptures had more positive outcomes than those who did not experience any ruptures. Thus, the process of repairing alliance ruptures may provide an opportunity for client growth.
There has been extensive writing and empirical work describing researcher perceptions of events that characterize alliance ruptures and repairs, such as confrontation, withdrawal, and renegotiating goals and tasks (Eubanks, Lubitz et al., 2019; Eubanks, Muran et al., 2019; Safran et al., 2011). Studies have also examined clients’ and therapists’ qualitative narratives of the working alliance (Schattner et al., 2017). However, less is known about client and therapist perceptions of moment-to-moment fluctuations in the alliance within single sessions and the degree of convergence in their perceptions of ruptures and repairs.
One way to examine these perceptions is to use a microprocess approach, in which an observer watches a recording of a therapy session while rating aspects of the therapy process (Altenstein et al., 2017; Clemence et al., 2012; Falkenström & Larsson, 2017). For example, Swift et al. (2017) asked clients and therapists to watch their most recent therapy session while using a dial to give moment-to-moment ratings of the helpfulness of session activities. Participants then wrote descriptions of what was occurring during their three highest- and lowest-rated segments and why those segments were especially helpful or hindering. Helpfulness ratings varied significantly throughout sessions, and client-therapist dyads differed considerably in their perceptions of helpful and hindering events (Penix et al., 2021).
At Idaho State University, we are conducting an ongoing microprocess study of client and therapist perceptions of working alliance ruptures and repairs using a similar method to Swift et al. (2017). This study examines agreement in client and therapist perspectives of these events, which may build on current understandings of the rupture-repair process. The following case example illustrates our method and highlights potential directions for future microprocess research on this topic.
The client in this dyad was an Asian-American, cisgender, heterosexual man in his early 20s with an upper-middle class background. He presented to a psychology training clinic at a mid-sized university in the western U.S. for individual psychotherapy for anxiety and adjustment difficulties. He had been working with his current therapist for four sessions at the time of data collection. The therapist identified as a non-Hispanic White woman in her early 20s and was in the second year of her clinical psychology Ph.D. program. She indicated that her theoretical orientation was interpersonal but that she was taking an integrative approach with this client.
The client and therapist came to the lab separately for data collection. After completing a demographic survey, they were presented with Bordin’s (1979) definition of the working alliance and informed that they would be asked to provide ratings of the working alliance while watching a video recording of their most recent session. They both watched the same session and reported their own perceptions of the alliance (i.e., the therapist was not predicting her client’s ratings or vice versa). While watching the recording, they used a dial to rate the working alliance continuously (DialSmith’s Perception Analyzer); one rating was collected each second. The middle position of the dial (0) was labeled as ‘Neutral’, and the extremes of the dial (-50 and +50) were labeled as ‘Weakest Possible’ and ‘Strongest Possible’, respectively.
After the client or therapist finished providing moment-to-moment alliance ratings for their entire session, a researcher graphed the ratings and visually identified the three lowest-rated segments, which constituted the alliance ruptures. Alliance repairs were also visually identified. Repairs were defined as segments in which the alliance began to be rated more positively after a rupture. Afterward, the participants were shown a 2-minute segment of the beginning of each rupture followed by a 2-minute segment of the subsequent repair. After watching each rupture clip, they typed their responses to the following questions in an online survey: (1) “What was happening during this segment?” and (2) “Why was the working alliance weak during this segment?” After watching each repair clip, participants also typed their responses to (1) “What was happening during this segment?” and (2) “Just prior to this segment, you rated the working alliance more negatively. What led to this improvement?” This was repeated for all three identified rupture-repair sequences. Participants answered these questions for ruptures and repairs based on their ratings only (i.e.., the therapist did not respond to client-rated ruptures or vice versa).
Two measures of client-therapist agreement in quantitative alliance ratings were computed (Penix et al., 2021). First, temporal congruence was calculated by conducting a bivariate correlation between client and therapist moment-to-moment ratings. Higher correlations indicate greater agreement on variations in the alliance throughout the session. Second, directional discrepancy was calculated by finding the difference between the client’s and therapist’s alliance ratings during each second of the session and then calculating the mean of these differences. Smaller absolute values indicate greater agreement in perceptions of the strength of the alliance at any given moment. While qualitative descriptions of ruptures and repairs would be typically analyzed with thematic analysis with group data, representative client and therapist descriptions of each rupture and repair are presented and discussed more informally in this case example.
Client and therapist moment-to-moment working alliance ratings are shown in Figure 1. In terms of temporal congruence, the correlation between the two sets of ratings was trivial (r = -.05, p = .007). This indicates that client and therapist perceptions of the alliance did not fluctuate together over the session. Regarding directional discrepancy, the therapist rated the working alliance an average of 18.61 (SD = 13.17) units lower out of 100 than the client. This suggests that the therapist tended to under-estimate working alliance strength relative to the client. Overall, these results indicate substantial client-therapist differences in perceptions of the alliance at a moment-to-moment level.
What was happening during ruptures?
The client indicated that ruptures were often characterized by his therapist asking him to do something in a way that was confusing or ambiguous. For example, he shared, “My therapist asked me to demonstrate something I was unsure of how to do, so it took me a while just sitting in silence, then I did it wrong.” For a later rupture, he reported, “My therapist was asking me specifically how I could do something, and I was struggling to put the words together.”
The therapist typically reported that she was introducing new concepts or activities to the client during ruptures: “We were doing a mindfulness exercise where he was instructed to let himself ruminate about distress and think about where he felt that in his mind and body.” She later shared, “We were going to build new skills surrounding willingness, and I was introducing the concept of willingness and acceptance to the client.”
Why was the alliance weak during those segments?
The client generally said that ruptures were due to disagreement or lack of clarity in the goals and tasks dimensions of the alliance rather than problems with the bond:
“I think this is because our thoughts on how to meet my goals weren't aligned at that time, although it wasn't weaker because our bond was still strong because I knew that she was trying to explain it as best as she could, I just wasn't getting it.”
Similarly, he later expressed that “the exercise my therapist gave me confused me and I didn't feel like our goals were aligned.”
The therapist shared that ruptures based on her ratings were due to her being too directive, being distracted by note-taking, or failing to address the client’s confusion about the rationale for certain activities or concepts:
This segment didn't seem as collaborative to me, as I was more telling him concepts than also having him tell me why these might be important/what that might look like for him. I was also using notes which inhibited eye contact, so I couldn't gauge as much if he was resonating with these skills and concepts or if these were aligned with his treatment goals.
She also referenced a lack of directly addressing a potential rupture:
We didn't conceptualize the activity similarly, and the client was confused multiple times in this segment. Subsequently, I didn't process this confusion or dissect in, but instead moved on to different forms of application. In this context, our bond and goals seemed to be inconsistent. I feel like I missed an opportunity to explain the utility of the activity in relation to treatment goals.
What was happening during repairs?
The client reported greater clarity on what his therapist wanted him to do during alliance repairs. For instance, he stated, “My therapist helped me understand what she wanted me to practice, and I did it right. The therapist then asked me how it felt, and I was able to answer confidently after being prompted to elaborate.” He also alluded to greater collaboration on goals and tasks: “I was finishing telling my therapist about something that happened that frustrated me, and she related it to my values, which have been a main topic that we have been discussing.”
The therapist shared that during repairs, they discussed how the client believed certain concepts applied to him personally: “We continued to talk about willingness and how that applied to the client’s perception of his presenting concerns.” She also described focusing more on the client’s emotions: “We tied cognitive diffusion concepts to emotions and feelings, and how acknowledging thoughts impacted his emotions.”
What lead to improvements in the alliance during those segments?
The client indicated that a greater mutual understanding and sense of productivity were responsible for alliance repairs. He shared, “I was finally able to answer the difficult question and I felt as though my therapist finally understood what I was trying to say.” For another repair, he stated, “The improvement came when my therapist related what we were talking about to my goals that we have been discussing, so I felt like it was more than me just complaining, and it was more productive.”
The therapist reported that increased collaboration and empathy and processing the personal meaning of concepts she introduced led to improvements in her perceptions of the alliance. She reported:
We became more collaborative, and the client offered his insight as to whether these concepts would help and in which ways they might work. We also began to process what acceptance of his primary concerns means to him and what that would look like, so the focus was brought back to his goals and tasks he could do, of which we were on the same page about.
In addition, she later shared:
The client realized that these thoughts influence his emotions and actions… and the client indicated increased confidence in understanding and applying these skills. In addition, I empathized with him more than I had in previous parts of the session, and it seemed like he responded well to that and expressed more motivation in applying these skills.
There are a variety of ways that microprocess paradigms could be used to study working alliance ruptures and repairs in the future. For example, research could test convergence of client and therapist ratings of ruptures and repairs with observer rating systems, such as the Rupture Resolution Rating System (Eubanks, Lubitz et al., 2019). Quantitative studies might also examine whether session outcomes differ between clients with resolved and unresolved within-session ruptures. Additionally, future research could test whether client- or therapist-rated within-session ruptures and repairs are most predictive of outcomes.
Qualitative client and therapist accounts of events that facilitate within-session rupture repairs could also highlight effective ways to resolve various types of ruptures, such as those stemming from therapist microaggressions, disagreement on goals or tasks (such as those in the case example above), or clients’ interpersonal difficulties. Additionally, integrating qualitative perceptions with quantitative ratings could clarify whether different types of ruptures and repairs have different impacts on process and outcome. For instance, do within-session ruptures resulting from therapist microaggressions have a different impact on the alliance than ruptures based on disagreement on goals or tasks, and are the client’s or therapist’s alliance ratings impacted most?
Finally, microprocess methods could have training and clinical applications. For example, clinical supervisors could assist trainees in using free or low-cost moment-to-moment rating systems to reflect on processes such as the working alliance, collaboration, or empathy in their session recordings (e.g., Software for Continuous Affect Rating and Media Annotation [CARMA]; Girard, 2014). Clinicians could also have more informal discussions with clients at the end of sessions about moments when clients felt the working alliance was particularly strong or weak. This may assist in identifying potential ruptures and capitalizing on interventions that clients believe are particularly helpful.
Cite This Article
Trusty, W. (2023). Using microprocess methods to study client and therapist perceptions of working alliance ruptures and repairs. Psychotherapy Bulletin, 58(2,3), 44-49. Retrieved from http://www.societyforpsychotherapy.org/using-microprocess-methods-to-study-client-and-therapist-perceptions-of-working-alliance-ruptures-and-repairs
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