9, ALLIANCE RUPTURES: ait
SUMMARY AND CONCLUSIONS
In general, an alliance rupture is a particular conceptualization of a treat
ment impasse or misalliance involving both patient and therapist contribu-
tions in a complex interpersonal process. It includes features that are out-
side of subjective awareness but visible to observers, and features that are
exclusively the internal experiences of the patients and therapists in the
room and only accessible by their self-descriptions. A rupture is also a pat-
tern of relating and disengaging within the ebb and flow of the therapeutic
relationship that captures the ways in which the participants negotiate the
dialectically opposing, essential human needs they both have for related-
ness and individuation.
More specifically, ruptures are experienced as a kind of tension in the
therapeutic relationship and are described by patients as a sense of feeling
misunderstood, alone, and demoralized: They range in intensity from subtle
to severe, in duration from isolated to protracted, and in frequency from few
to several; they take on qualitatively different forms with different clusters of
patient interpersonal behaviors marking different internal conflicts and expe-
riences of distress; and they can occur within the context of an ongoing treat-
ment and strong alliance or at the beginning of a therapy when the patient
and therapist meet for the first time. Clinically, ruptures provide a unique op-
portunity to explore and reconfigure a patient's relational schemas and
maladaptive interpersonal experiences. A rupture is all of these things and as
such, it is a challenge to define comprehensively yet succinctly.
Our conceptualization of this important change event has been en-
hanced by assessment methods that incorporate patient and therapist de-
scriptions of their own rupture experiences and observer ratings of video-
taped recordings: Patient and therapist subjective experiences provide
information that cannot be witnessed by objective observers, but observ-
ers pick up on behavior that is outside of the participants’ subjective aware-
ness. Videotaped sessions are a critical part of the assessment process be-
cause many of the rupture marker behaviors are nonverbal and could not
be rated by audiotape or transcript alone. Increasing specificity regarding
the components of a rupture episode—the misunderstanding event and rup-
ture marker behaviors—have helped to further distinguish the breakdown
in the alliance from stages of the resolution process. Additional features of
withdrawal ruptures and two types of control ruptures (attacking and blam-
ing and manipulative) have been identified through intensive observation
and analysis of rupture episodes, deepening our understanding of these dis-
tinct clinical phenomena.
‘The observer-rated Rupture Resolution Scale (Samstag et al., 2000)
emerged out of our observational analyses and is in an early stage of devel-
opment. Future research efforts will focus on the reliable assessment of cy-