Alliance ruptures in cognitive‐behavioral therapy: A cognitive conceptualization

Abstract

The therapeutic relationship is crucial to the ethical and effective practice of any psychotherapy. In Cognitive Behavior Therapy (CBT) as formulated by Aaron T. Beck, the generic elements of the relationship including expressed empathy, expressions of positive regard, agreement on goals, and agreement on tasks within a therapeutic bond were considered a necessary condition for change. Alliance ruptures can therefore have a detrimental effect on therapy if left unrepaired. This article contributes to the In‐Session issue on rupture repairs by outlining the role of the alliance as a component of the therapeutic relationship in CBT and illustrates how ruptures can be identified and effectively resolved through detailed case examples. Given the central importance of using collaborative empiricism and Socratic dialogue for the therapeutic relationship in CBT, we demonstrate the distinctive role of these elements in repairing ruptures.

Alliance rupture and repair in cognitive behavior therapy.

“…Alliance ruptures occur when the collaborative relationship between client and therapist deteriorates as a result of minor or major tensions (Okamoto & Kazantzis, 2021;Safran et al, 2011) that lead to either a confrontation or withdrawal ruptures or a combination of the two (Safran & Muran, 2000). As discussed in other chapters of this book, confrontation ruptures include overt expressions of dissatisfaction or irritation with the therapist or therapy course, whereas withdrawal ruptures consist of the client's complete or partial disengagement from therapy and/or themselves (Muran & Safran, 2017).…”

“…Evidence supports the notion that the process of resolving alliance ruptures itself may foster psychological improvements (Muran et al, 2018) and that resolved alliance ruptures in client-therapist dyads lead to improved outcomes (see the meta-analysis by . Specific practice guides have also been published for using case formulations to integrate stressors and prepare for stressors in the relationship (Kazantzis et al, 2017;Okamoto & Kazantzis, 2021).…”

“…In addition to inquiring about the consequences of certain client experiences to identify potentially reinforcing consequences of a rupture, therapists can ask about the sequence of events that contributed to the rupture. If a therapist begins to feel hesitant about putting themselves in an exposed position and/or possibly triggering the client in some way, a useful reminder is that the rupture itself has already occurred and the client is likely to benefit from an open, collaborative resolution process (Okamoto & Kazantzis, 2021).…”

“…It is important to note that the relational elements particular to CBT, such as outcome relations for homework adherence being mistaken as evidence for collaboration outcome relations, have been poorly defined and measured in empirical studies (see the discussion in Kazantzis et al, 2015). When responding to ruptures in CBT, the therapist will (a) elicit the client's perspective, (b) share in the decision-making process with the client, (c) solicit feedback from the client, and (d) actively attend to the client's responses (Okamoto & Kazantzis, 2021). Confidentiality of all client cases presented in this chapter has been maintained, and personal identifiers have been removed or altered.…”

“…There are eight main steps in identifying and processing ruptures to the therapeutic alliance: (a) identify and acknowledge the rupture; (b) validate the client's experience; (c) explore the rupture in collaboration with the client; (d) share decision making on how to proceed with the resolution process; (e) seek and use information from the client's experience; (f) use Socratic questions to explore the situation, shift perspectives, or synthesize different viewpoints; (g) invite feedback from the client and exercise responsiveness to it; and (h) engage in self-reflection, self-practice, and mindfulness. In the following sections, we outline these eight steps from the perspective of CBT (Okamoto & Kazantzis, 2021). We then provide a case study to illustrate the steps in practice.…”