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When Adolescents Stop Psychological Therapy

Rupture-Repair in the Therapeutic Alliance and Association With Therapy Ending


The therapeutic alliance predicts dropout from psychological therapy, and ruptures in the therapeutic alliance may also predict dropout, yet there is a dearth of research with adolescents. This study investigated whether markers of rupture–repair in the alliance were indicative of different types of treatment ending in adolescents receiving psychological treatment for depression. Data were from the IMPACT study, a trial investigating the effectiveness of therapies for adolescent depression. Participantswere randomly allocated to receive a brief psychosocial intervention, cognitive– behavioral therapy, or short-term psychoanalytic psychotherapy. The sample (N 35) comprised adolescents who had either completed their treatment (n 14) or dropped out (n 21) according to their therapist. Dropout cases were further classified as dissatisfied (n 14) or got-what-they-needed (n 7) based on posttherapy interviews with the adolescent and therapist. Selected recordings of therapy sessions were rated using the Rupture Resolution Rating System and Working Alliance Inventory (observer version). Therapeutic alliance and rupture–repair during therapy were similar for completers and got-what-they-needed dropouts, whereas dissatisfied dropouts had poorer therapeutic alliance, more ruptures, ruptures that were frequently unresolved, and greater therapist contribution to ruptures. Qualitative analysis of sessions led to the construction of three categories of therapist contribution to ruptures: therapist minimal response, persisting with a therapeutic activity, and focus on risk. Results suggest that ruptures, especially when unresolved, could be warning signs of disengagement and dropout from therapy. Future research shou

Sally O’Keeffe is a Research Fellow in the School of Health Sciences at City, University of London. Sally has worked on clinical trials investigating the effectiveness of psychological interventions, including treatments for depression and self-harm. Sally is particularly interested in the use of mixed methods to explore how interventions work and what works for whom. Sally completed her PhD at University College London (UCL) and the Anna Freud National Centre for Children and Families. She is currently working on a research programme to develop a brief psychological intervention for people presenting to Emergency Departments having self-harmed.

Cite This Article

O’Keeffe, O., Martin, P., & Midgley, N. (2020, January). When adolescents stop psychological therapy: Rupture-repair in the therapeutic alliance and association with therapy ending. Psychotherapy, 57(4), 471-490.



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