Can Session-by-Session Changes in Self-Reported Alliance Scores Serve as a Measure of Ruptures in the Therapeutic Alliance?

Objective: During treatment, the therapeutic alliance is characterized by rupture and repair episodes, which in turn are associated with psychotherapy outcome. It would be important to have a parsimonious tool to identify ruptures in psychotherapy sessions to provide therapists with meaningful feedback about when they occur. The present study thus aims to establish whether measuring self-reported alliance dynamics can function as a measure of alliance ruptures. Method: The sample consisted of 58 depressed patients, who received 22 sessions of cognitive therapy for depression in an outpatient setting. The observer-rated Rupture Resolution Rating System (3RS) was applied to 58 sessions where the self-reported Working Alliance Inventory (WAI) completed by patients after each therapy session indicated that alliance ratings declined more than 2 SDs from that patient's individual mean. For comparison purposes, the 3RS was also applied to 58 randomly chosen sessions from the same treatment phase (early, middle, late). Results: Results showed significant differences between sessions where the WAI indicated a drop in the alliance and randomly chosen sessions of the same treatment phase with regard to the frequency and impact of ruptures. Conclusion: This speaks for the construct validity of the 3RS. Session-by-session alliance ruptures may reliably be measured using a case-sensitive approach to identify meaningful drops in alliance self-report (WAI).