A rupture is a deterioration in the therapeutic alliance, manifested by a disagreement between the patient and therapist on treatment goals, a lack of collaboration on therapeutic tasks, or a strain in their emotional bond. We present the most frequently used measures of alliance ruptures and clinical examples to illustrate their repair. To examine the relation of rupture repairs to outcome, and the impact of rupture resolution training on outcome, we conducted two meta-analyses. In the first meta-analysis, we examined 11 studies (1,314 patients) that examined the relation between rupture repair episodes and patient treatment outcomes. Results yielded an effect size of r ϭ .29, d ϭ .62, 95% confidence interval [.10, .47], p ϭ .003, indicating a moderate relation between rupture resolution and positive patient outcome. Our second meta-analysis examined the impact of rupture resolution training or supervision on patient outcome. We examined 6 studies (276 trainees/supervisees) that compared the outcomes of trainees who received rupture resolution training with a comparison group. Results did not find a significant relation, r ϭ .11, d ϭ .22, 95% confidence interval [Ϫ.09, .30], p ϭ .28. Moderator analyses indicated that the relation between training and outcome was stronger when the sample included fewer patients with personality disorders, when the training was more closely aligned with cognitive behavioral therapy than psychodynamic therapy, and when the treatment was brief. The article concludes with limitations of the research, diversity considerations, and research-informed therapeutic practices for repairing ruptures in ways that contribute to good treatment outcome. Clinical Impact StatementQuestion: How are therapists' abilities to address and repair alliance ruptures, or problems in the patient-therapist working relationship, related to treatment outcome? Findings: The findings suggest that clinicians may achieve better outcomes if they repair alliance ruptures. Meaning: Alliance rupture resolution was related to good treatment outcome, but training in alliance rupture resolution was not significantly related to better outcome. Next Steps: Additional research is needed drawing on multiple methods for assessing alliance ruptures and resolution from patient, therapist, and observer perspectives, as well as more research on the best ways to train therapists to recognize and address alliance ruptures.

Objective: Our aim was to examine the reliability and validity of the Rupture Resolution Rating System (3RS), an observer-based measure of alliance ruptures and resolution processes. Method: We used the 3RS to rate early sessions from 42 cases of cognitive behavior therapy. We compared the 3RS to a simplified version of the Structural Analysis of Social Behavior (SASB), as well as patient and therapist self-reports of ruptures and the alliance. Results: Coders achieved high rates of interrater reliability on the frequency of confrontation and withdrawal ruptures and resolution strategies (ICCs=.85 to .98), as well as ratings of the therapist's contribution to ruptures and the extent to which ruptures were resolved (ICC=.92). Predictive validity analyses found that confrontation markers (d=.74), successful resolution (d=. 67), and ratings of the therapist's contribution to ruptures (d=.61) predicted dropout from therapy. Analyses of convergent validity with the SASB failed to meet predictions; however, we observed theoretically coherent relations between 3RS and SASB variables. Confrontation rupture markers were significantly associated with patient self-report of rupture (d=1.54) and therapist selfreported alliance (r = −.50, p = .002). Conclusions: This study provides evidence that the 3RS is a reliable and useful tool for examining psychotherapy process and predicting dropout.

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Objective Better alliance is known to predict better psychotherapy outcomes, but the interdependent and interactive effects of both therapist- and patient-reported alliance levels have yet to be systematically investigated. Method Using Actor-Partner Interdependence Model analysis we estimated actor, partner, and two types of interactive effects of alliance on session outcome in a sample of 241 patient-therapist dyads across 30 sessions of cognitive-behavioral and alliance-focused therapy. Results Findings suggest that the most robust predictors of session outcome are within-treatment changes in patient reports of the alliance, which predict both patient and therapist report on outcome. Within-treatment changes in therapist reports of the alliance, as well as differences between patients and between therapists in their average ratings of alliance levels across treatment, predict outcome as reported by the specific individual. Although alliance was found to be a significant predictor of outcome in both treatments, for therapist-reported alliance and outcome it had a stronger effect in alliance-focused therapy than in cognitive-behavioral therapy. Additionally, dyads with the highest pooled level of alliance from both partners fared best on session outcome. Conclusions The results are consistent with a two-person perspective on psychotherapy, demonstrating the importance of considering the interdependent and interactive nature of both patient and therapist alliance levels on session outcome.