Psychology
2012. Vol.3, No.12, 1049-1058
Published Online December 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.312156
Resolution Process of Therapeutic Alliance Ruptures: A Review
of the Literature
Pierre Baillargeon1, Robert Coté2, Lyne Douville1
1Université du Québec à Trois-Rivières, Trois-Rivières, Canada
2Université de Laval, Québec, Canada
Received September 18th, 2012; revised October 20th, 2012; accepted November 17th, 2012
Adolescents living in youth centers often comply with therapeutic treatment against their will. We think
that this forced environment ruptures the therapeutic alliance between adolescents and their therapists and,
as such, influences the therapeutic results. It has been reported, however, that therapies evoking rupture of
the alliance with its later restoration are more effective than therapies without rupture. We review the lit-
erature on models of therapeutic alliance rupture resolution. This review is limited to experimentally-
tested models. Firstly, we define the concepts of therapeutic alliance and its rupture. Then, we explore
experimental models that quantify therapeutic alliance rupture resolution, describing methods of experi-
mental validation, the results of models applied for experimental validation, and analysis of the data thus
obtained.
Keywords: Therapeutic Alliance; Rupture, Resolving; Literature Review; Psychotherapy
Introduction
Adolescents in youth centers often submit to treatment
against their will. Pauzé, Toupin, Déry and Mercier (2000) and
Lessard (2001) report that a large number of adolescents in
youth centers were placed there in accordance with the Young
Offenders Act or the Youth Protection Act. Lessard (2001)
specifies that in 1999-2000, 48.2% of referrals were finalized
by a judge. Le Blanc, Girard, Kaspi, Lanctôt and Langelier
(1995) note that in the Jesness Personality Inventory, adoles-
cents under judicial control have a tendency to be mistrustful
and withdrawn in their interactions with others, particularly
authority figures. This context may influence the quality of the
therapeutic alliance between youths and their caseworkers, and
thus affect the results of the intervention.
Yet, quality therapeutic alliances are associated with a wide
range of positive results. Researchers like Horvath and Sy-
monds (1991), Martin, Garske and Davis (2000) and Orlinsky,
Grawe and Parks (1994), for example, arrive at this conclusion.
These researchers evaluated the short- and long-term effects of
psychodynamic, cognitive and experimental therapies with
clients whose problems varied. Florsheim, Shotorbani, Guest-
Warnick, Barratt and Hwang (2000), on their part, suggest that
young delinquents who develop and maintain a positive thera-
peutic alliance with their caseworkers show considerable im-
provement during treatment and less recidivism in the year
following treatment.
Ruptures in the therapeutic alliance between youths and their
caseworkers seem inevitable in youth center contexts. However,
some authors, for example Safran, Crocker, McMain and
Murray (1990), argue that therapies that include alliance ruptures
appear to be more effective than those without ruptures, on
condition, however, that the alliance is restored.
This article reviews experimental models of the resolution
process of therapeutic alliance ruptures. Experimental models
of the resolution process are interesting because they are likely
to propose ways of resolving alliance ruptures to caseworkers.
Applying one resolution process model would make interven-
tions more specific and thus increase its effectiveness. First, we
want to remind psychosocial workers of the concepts of thera-
peutic alliance and of therapeutic alliance rupture. Next, we
will focus on experimental models of alliance rupture resolution,
describing experimental investigation methods, the results of
experimental investigation of these models, and analysis of the
data.
The Therapeutic Alliance Concept
The therapeutic alliance concept, which has been the subject
of research over the past few decades, specifies the importance
of the relationship in successful therapy. The first theoretical
and experimental studies on the therapeutic alliance originate
primarily from psychodynamic approaches (Luborsky, 1976;
Zetzel, 1956) and are client-centred (Rogers, 1957; Barrett-
Lennard, 1962, 1978, 1986). The more recent investigations
stem from cognitive and systemic approaches (Pinsof, 1995;
Safran & Muran, 2000). In these studies, there is increasing
recognition of the role of the alliance in the effectiveness of
therapy. Furthermore, pharmacotherapy considers the alliance
as a factor that influences collaboration and, consequently, the
results of therapy (Docherty, 1989). Although heterogeneous in
terms of change mechanisms, these studies help conceive the
importance of the alliance in the change process.
Recognition of the importance of the patient therapist alli-
ance dates back to Freud. In his first papers, Freud (1913, 1966)
proposed that therapists establish a bond with their patients at
the outset of the therapeutic relationship. According to Freud,
the patient must be allowed time for this bond to be established.
If the therapist shows great interest in the patient, eliminates
resistances and avoids certain mistakes, the patient will form an

P. BAILLARGEON ET AL.
attachment to him. This attachment will resemble the one that
he has already established with people who have paid attention
to him. Freud adds that an intervention can start off badly if,
during the first sessions, the therapist does not receive the pa-
tient’s point of view with sympathetic understanding.
In line with Freud’s ideas, authors like Greenson (1965,
1967), Sterba (1934) and Zetzel (1956) pursued studies on the
impact of the patient-therapist alliance on the success of an
intervention. Sterba (1934) introduced the ego alliance concept
in which he refers to the need for a positive relationship be-
tween the patient’s reasonable ego and the therapist’s analyzing
ego. The author stresses the importance of the patient’s ability
to work towards the success of the intervention.
Zetzel (1956) introduced the therapeutic alliance concept,
which she believes comprises the patient’s positive relationship
and identification with the therapist. She sees the therapeutic
alliance as a repetition of the parent-child relationship. Zetzel
does not define this concept any further, but sees it as an im-
portant element in the success of an intervention.
Inspired by Sterba and Zetzel, Greenson (1965, 1967) intro-
duced the concept of working alliance, which he uses as a
synonym of the therapeutic alliance. Greenson sees the alliance
as a positive relationship between patient and therapist and as
the patient’s ability to work towards the success of the inter-
vention.
In addition to acknowledging the patient’s contribution to the
alliance, Freud (1913, 1966) advanced that the therapist plays a
major role in the establishment of an alliance. Rogers (1957)
pursued Freud’s idea of a patient-centred approach. One of the
central concepts of the Rogerian approach is formulated as
follows: the relationship offered by the therapist is a necessary
condition that is sufficient to help patients resolve their prob-
lems. Rogers (1957) and Barrett-Lennard (1962, 1978, 1986)
presented the conditions involved in a patient-therapist alliance.
They proposed the following hypothesis: empathy, congruence
and unconditional acceptance from the therapist suffice for the
patient to improve. However, authors like Gelso and Carter
(1985) and Mitchell, Bozart and Krauft (1977) believe that the
conditions described by Rogers and Barrett-Lennard are not
sufficient to ensure the success of an intervention.
Other authors affirm that the concept of the alliance is neither
valid nor useful (Brenner, 1979) or that it can be misleading
(Curtis, 1979). Brenner (1979) argues that there is no alliance
phenomenon. The patient’s relationship with the therapist is a
phenomenon of transference that must be treated as resistance.
The patient’s desire to work within treatment can be viewed as
a desire to win the approval of a parental figure or to compete
with the therapist for his perspicacity. Such transference deter-
minants of the patient’s engagement and collaboration in treat-
ment are considered difficult to distinguish from non-conflict-
ual determinants of the alliance. Curtis (1979) believes that the
alliance concept represents a danger of moving away from the
analytical concepts of unconscious intrapsychic conflicts, of
free association and the interpretation of transfer and resistance.
Another controversy pertains to divergent concepts of the al-
liance. They can be illustrated by the variability in definitions
of the alliance. For example, Luborsky (1976) and Zetzel (1956)
described the alliance as the patient’s bond with the therapist
and the therapist’s helpfulness as perceived by the patient.
However, Frieswyk, Allen, Colson et al. (1986) define the alli-
ance as the patient’s active collaboration in treatment tasks.
Both definitions of the patient’s collaboration in psychotherapy
can be conceived as distinct, but relatively dependent, dimen-
sions. The alliance includes the affective aspects of the patient’s
collaboration in therapy that are aimed at the therapist’s person
and reflect the more skillful aspects of the patient’s collabora-
tion that are directed towards treatment tasks.
Definition of the Therapeutic Alliance
Bordin (1979) proposes the most recognized concept of the
alliance. According to Bordin, the 3 main dimensions of con-
tent of the therapeutic alliance are tasks, goals and the bond.
Pinsof (1995) describes and illustrates each of these dimensions.
The task dimension pertains to the activities or main tasks in
which the patient and therapist engage during the intervention.
Specifically, it refers to the extent to which a patient believes
that the tasks meet his expectations and how comfortable he
finds them. If the patient expects to have a conversation with
the therapist and the therapist rarely speaks, the therapist’s be-
haviour does not live up to the patient’s expectations of the
intervention. The patient expects a dialogue while the therapist
expects the patient to speak with a minimum of feedback on his
part. In this situation, the task components of the alliance will
be relatively weak. Comfort in the task dimension refers to the
degree of well-being or anxiety that the patient experiences
relative to the tasks. For example, the therapist can strongly
encourage Louise, a 17-year-old woman hospitalized after a
suicide attempt, to tell her elder brothers and sisters and her
parents that she was sexually abused by her uncle from the ages
of 10 to 14 years. If Louise is too afraid to perform this task,
she will be in conflict. The therapist’s expectations exceed her
comfort threshold. Even if Louise thinks that confiding in her
brothers, sisters and parents is a good idea, and even if her ex-
pectations for the tasks are congruent with those of the therapist,
emotionally, the task may prove beyond her strength at that
time. If the therapist insists that she perform this task, the task
component of the alliance will be seriously compromised.
The second major dimension of the alliance, the goals, refers
to the extent to which the patient experiences a therapist who
works with him on the problems for which he requests help: “Is
the therapist trying to help him attain his goals?” or “Is the
therapist pursuing goals that do not interest him?” For example,
parents with marital problems seek help for their son’s depres-
sion. Since their goal does not consist in improving their mar-
riage, prematurely targeting their marital problems would
greatly weaken their alliance and compromise the intervention.
The last dimension of the alliance, the bond, refers to the af-
fective quality of the alliance and includes aspects of the pa-
tient-therapist relationship, such as trust, concern and engage-
ment. The bond dimension covers the extent to which the
therapist becomes a significant person and an emotionally-
charged object for the patient and to which the patient feels that
the therapist is committed to and concerned about him. The
bond is, therefore, the patient’s emotional response to the
therapist and his effects.
The 3 work alliance dimensions are interdependent. Conse-
quently, the quality of the relationship mediates the patient’s
and therapist’s ability to negotiate an agreement regarding the
intervention tasks and goals. The patient’s ability to negotiate
such an agreement also mediates the quality of the bond be-
tween them.
Predictive Validity of the Therapeutic Alliance
The capacity of the therapeutic alliance to predict the success
1050

P. BAILLARGEON ET AL.
The Concept of Therapeutic Alliance Rupture
of a therapy seems to be confirmed. The most frequently-cited
meta-analysis of the predictive validity of the alliance is that of
Horvath and Symonds (1991). The question at the outset of the
meta-analysis is the following: What is the strength of the rela-
tionship between the therapeutic alliance and the results of
therapy? The study inclusion criteria were the following: 1) the
relationship construct measured in the study must be identified
by the authors as the working alliance, helping the alliance or
therapeutic alliance; 2) the research must concern a quantifiable
relationship between the alliance and the indices of subse-
quently-measured results; and 3) the studies analyzed must
involve at least 5 subjects. Finally, only investigations involv-
ing an individual treatment (as opposed to group or family
therapies) were included. Twenty-four studies met the above-
mentioned criteria. Effect sizes (ES) for all the data were com-
bined and a weighted ES was calculated (summarizing the rela-
tionship between the therapeutic alliance and the results of the
therapy). The combined ES was .26. The size was moderate but
very significant (p < .001).
According to Pinsof and Catherall (1986), the alliance is a
dynamic phenomenon that differs from one therapeutic system
to another and changes within the same system during the in-
tervention. Usually, as the intervention progresses, the alliance
becomes more intense. Different types of interventions and
different caseworkers form different types of alliances with
similar patients. The alliance varies with the intervention
phases. A rupture in the alliance between patient and therapist
can occur at any time. The rupture is deterioration stemming
either from a disagreement on the goals and tasks or from a
problem related to the bond. Such a rupture fractures the alli-
ance and creates a decisive moment in the relationship between
the patient and therapist.
Alliance ruptures can cause the premature end of interven-
tions. Disruptions in the alliance may be too great and become
irreparable for several reasons. Patients may be too narcissisti-
cally vulnerable to manage their disappointment and may reject
the treatment. The therapist’s response may not be empathetic
enough with the patient’s experience and may thus increase the
fracture and sabotage the treatment. Last, the therapist’s mis-
take may be so evident and disturbing that the patient’s escape
becomes a sound, adaptive response to the therapist’s non-ethi-
cal, non-professional or incompetent behaviour (Figure 1).
Furthermore, the most extensive survey of the predictive
factors of psychotherapy results was carried out by Orlinsky,
Grawe and Parks (1994). These authors focus on the relation-
ship between the psychotherapeutic approach or specific meas-
ures of the therapeutic process and the clinical results. The
study inclusion criteria were the following: 1) the studies must
comprise real treatments administered to real patients; 2) they
must specifically contain therapeutic variables whose changes
are measured quantitatively and concomitantly with variations
of the results; and 3) they must lend themselves to observation
of the relationship between the process and the results. The
authors reported 2354 observations on the relationship between
the therapeutic process and the clinical results. For the bond
and cohesion concepts, 2 concepts of the therapeutic alliance,
Orlinsky, Grawe and Parks (1994) listed 132 findings, showing
a 66% significant correlation with the treatment data.
Types of Ruptures
Safran and Muran (2000) identify 2 types of ruptures: with-
drawal and confrontation. In withdrawal ruptures, the patient
withdraws and partially disengages from the therapist, his own
emotions or certain aspects of the therapeutic process. With-
drawal ruptures can take different forms. In some cases, the
patient has difficulty expressing his concerns or needs in the
relationship. For example, one patient expresses his concerns
indirectly or attenuates them. In other cases, the patient submits
or adapts to the therapist’s desire so subtly that the therapist
may have trouble recognizing the patient’s adaptation.
More recently, Martin, Garske and Davis (2000) performed a
meta-analysis similar to that of Horvath and Symonds (1991). It
comprised 79 studies. The combined ES was .22. The size was
moderate and significant (p < .05).
a P = patient’s behaviour ; b T = therapist’s intervention following the patient’s behaviour
Figure 1.
Illustrates Model 2.

P. BAILLARGEON ET AL.
In confrontation ruptures, the patient directly expresses anger
or resentment, as well as his dissatisfaction with regard to the
therapist or certain aspects of the therapy. For example, one
patient has long had a desire for support that has not been filled
or a desire to be cared for and a tendency to see the therapist as
one more person who will disappoint him. He therefore enters
into the therapeutic relationship with a pool of disappointment
and rage, waiting to be aroused by the therapist’s inevitable
mistakes and limitations. When a confrontation rupture occurs,
it may be difficult, if not impossible, for the therapist to avoid
responding defensively to the patient’s demands or criticisms;
he thus receives the expected response from the other. It often
happens that a therapist’s interpretations subtly convey mes-
sages of blame and depreciation to his patients, or that these
interpretations are complex communications that simultane-
ously translate messages of help and of criticism.
Withdrawal and confrontation ruptures reflect the various
ways that a patient can face tension between the dialecti-
cally-opposed needs for individualization and relationships. In
withdrawal ruptures, patients fight for the relationship at the
expense of their need for individualization or self-definition. In
confrontation ruptures, patients negotiate the conflict while
favouring the need for individualization or self-definition to the
detriment of their need for a relationship. Different patients
probably have a predominance for one style of rupture rather
than another; this predominance reflects different styles of ad-
aptation. Both types of ruptures (withdrawal and confrontation)
can emerge during treatment.
Given the importance of the therapeutic alliance in the results
of therapy, it seems imperative to clarify the process involved
in resolving therapeutic alliance ruptures.
Experimental Model of Alliance Rupture
Resolution
The question at the outset of the review is the following:
Which models of the alliance rupture resolution process were
subjected to experimental investigation? To answer this ques-
tion, we performed a computerized search in the following
electronic data banks: PsycINFO, ERIC, PsycLIT and Medline.
These data banks contain publications from the fields of psy-
chology and related sciences. They compile thousands of peri-
odicals in several languages from various countries. They refer
also to books, theses and technical reports as well as book
chapters. The descriptors are: restor* or ruptur* or poor or con-
flict* or resolution or problematic or strain* or weak* or viable
or repair* or reestablish* and therapeutic alliance or working
alliance or helping alliance. Document references are a second
source for locating studies. To be included in the review, stud-
ies had to present experimental investigation of a model of the
alliance rupture resolution process or of the help relationship in
a context of psychotherapeutic intervention or psychosocial
intervention.
The computerized search generated 43 studies. Of this num-
ber, 5 met the inclusion criteria: 2 by Safran and Muran (1996),
1 by Safran, Muran and Samstag (1994) and 2 by Inck (1995).
The particularity of studies that were not retained (n = 38) was
that they did not include experimental investigations of a rup-
ture resolution process. They were mainly theoretical papers on
the therapist-patient relationship or experimental studies on
factors that influence the therapist-patient relationship. This
review did not consider models such as in Aspland et al. (2008)
or Bennett, Parry and Ryle (2006) where they developed only
the first steps of the Task analysis by Greenberg (1984b) and
Rice and Greenberg (1984).
In all studies retained (Safran & Muran, 1996; Safran, Muran,
& Samstag, 1994; Inck, 1995), experimental investigation was
carried out on the same alliance rupture resolution model: Sa-
fran, Muran and Samstag’s Model 2 (1994).
Safran, Muran and Samstag’s (1994) Model 2 comprises 4
components. The first, second and fourth include an interven-
tion by the therapist that follows behaviour by the patient. The
third component includes patient behaviour, an intervention by
the therapist and, once again, patient behaviour.
The first component (C1, pay attention to the withdrawal
rupture indicator) includes P1 (the patient produces a with-
drawal rupture indicator) followed by T1 (the therapist focuses
the patient on his immediate experience). One patient’s behav-
iour suggests that he is avoiding exploration of certain feelings
(P1). The therapist draws attention to what is currently happen-
ing between them (T1). There are several ways the therapist can
conduct this intervention. For example, he may ask questions
about the patient’s current experience, such as: “What are you
feeling now?”
The second component (C2, exploration of the rupture ex-
perience) includes P2 (the patient expresses negative feelings
mixed with the indicator) followed by T2 (the therapist facili-
tates self-affirmation). In response to the therapist’s interven-
tion intended to draw the patient’s attention to their current
relationship (T1), the patient expresses negative feelings but
with some reserve (P2). The therapist intervenes so that the
patient expresses his negative feelings more directly (T2). For
example, the therapist tells the patient that he feels he has been
on the defensive since the beginning of the therapy (T1). The
patient then acknowledges that he is starting to feel a bit of
anger towards the therapist (P2). The therapist responds to the
expression of negative feelings either by showing empathy or
by accepting his responsibility for contributing to the interac-
tion (T2). For example, in 1 session, the patient asks the thera-
pist if he is criticizing him. The therapist admits to having criti-
cized him, which can break the impasse.
The third component (C3, exploration of avoidance) includes,
respectively, P3a (the patient reveals the block), T3 (the thera-
pist asks questions about the patient’s block) and P3b (the pa-
tient explores the fear that prevents him from expressing nega-
tive feelings). In response to the therapist’s intervention in-
tended to draw the patient’s attention to their current relation-
ship (T1), the patient begins to reveal his hesitations about dis-
cussing his negative feelings, either by anticipating this per-
spective or by exploring and expressing his experience (P3a).
The therapist delves deeper into what is blocking the patient
(T3). Typically, in response to the patient’s difficulties ex-
pressing his negative feelings (P3a), the therapist directly ques-
tions the patient’s fears that block him from expressing his
feelings (T3). For example, the patient feels anger towards the
therapist but holds back from saying so (P1). In response to the
therapist’s questions about what is currently happening between
them (T1), the patient indicates that he feels anxiety at the
thought of mentioning it (P3a). The therapist then inquires
about the nature of this anxiety, asking the patient what is wor-
rying him (T3). The therapist’s questioning allows the patient
to explore his fear of expressing his negative feelings (P3b).
For example, the patient explores his fear of being abandoned
by the therapist if he expresses his negative feelings toward
1052

P. BAILLARGEON ET AL.
him.
The fourth component (C4, self-affirmation) includes P4 (the
patient asserts himself) and T4 (the therapist validates the
self-affirmation). The patient is then able to express his feelings
more directly and self-assertively. For example, the patient
expresses, hesitantly, the frustration that he felt during the pre-
vious session (P2). The therapist intervenes so that the patient
expresses his negative feelings more directly (T2). Gradually,
as the patient expresses feelings more directly (P4), the thera-
pist approves (T4). The patient thus manages to assert himself
in his interactions with the therapist.
Safran, Muran and Samstag (1994) developed Model 2 with
adaptation of the task analysis method employed by Greenberg
(1984), Safran, Greenberg and Rice (1988), Rice and Green-
berg (1984) and Rice and Saperia (1984). The analysis method
comprises 3 major steps. The first step of the analysis method
consists in developing a preliminary model of the resolution
process based on psychotherapy theories and the researchers’
intuitions (Safran, Segal, Hill, & Whiffen, 1990). In the pre-
liminary model, an intervention by the therapist follows the
patient’s behaviours. Figure 2 presents the preliminary resolu-
tion process model.
In the second step, the researchers perform an informal
analysis of the preliminary model by comparing it with the
content of the psychotherapy sessions in which resolved rup-
tures are found (the method for selecting resolved rupture ses-
sions will be described in the next section). They identify the
gaps between model components and the content of resolved
rupture sessions and refine the preliminary model accordingly.
They thus obtain Safran, Muran and Samstag’s (1994) Model 1.
The researchers develop operational definitions of the compo-
nents of Model 1 with a battery of process measurements: sub-
scales from the Structural Analysis of Social Behavior (SASB)
(Benjamin, 1974, 1979, 1982), codes from the Patient Experi-
encing Scale (P-EXP) (Klein, Mathieu-Coughlan, & Kiesler,
1986) and from the Therapist Experiencing Scale (T-EXP)
(Klein, Mathieu-Coughlan, & Kiesler, 1986) and, finally, the
tone of voice with the Client Vocal Quality Scale (CVQ) (Rice
& Kerr, 1986). Figure 3 presents Model 1.
Finally, at the third step, the researchers perform a descrip-
tive analysis of Model 1. They analyze 4 resolution sessions
and 3 non-resolution sessions by comparing the frequency of
the components and subcomponents of the model. The analysis
enables them to refine Model 1 and arrive at Model 2. The first
refinement of Model 1 for rupture resolution involves the third
component (C3, Exploration of the avoidance). In its original
design, the component included 2 subcomponents. Analysis
suggests the following sequence: recognition of the patient’s
block, the therapist’s questions, and the patient’s exploration.
The second refinement involves the fourth component (C4,
Exploration of the interpersonal pattern). Since the researchers
did not find 2 occurrences of this component, they did not con-
sider it an essential part of the resolution process. The fourth
component becomes the patient’s affirmation.
Description of the Experimental Investigation
Methods
The researchers subject the sequences proposed by Model 2
to experimental investigation. They adopt 2 processes. The first
consists in verifying the transitional probabilities of the model
only in alliance rupture resolution sessions. Safran, Muran and
Samstag (1994) engage this process. The second process con-
sists of verifying the transitional probabilities of the model in
resolution and non-resolution sessions and comparing the re-
sults. Safran and Muran (1996) and Inck (1995) used this proc-
ess. Table 1 summarizes the methodological elements of the
studies.
The number of resolution and non-resolution sessions used
by the researchers varies between 3 and 4. To evaluate rupture
resolution or non-resolution in the sessions, the researchers
score 6 items from the Working Alliance Inventory (WAI)
(Horvath, 1994; Safran, Muran, & Samstag, 1994). After each
session, patients and therapists fill out the questionnaire for the
beginning, middle and end of the session, for each of the items.
When the patient’s and therapist’s evaluations become weaker
in the middle than at the beginning and the end of the session (+,
−, +), the authors note a deterioration in the relationship and a
resolution of the rupture. When the patient’s and therapist’s
evaluations become weaker in the middle and at the end than at
the beginning of the session (+, −, −), the authors note a dete-
rioration in the relationship and rupture resolution. The re-
searchers consider differences of more than 20%.
Studies by Safran, Muran and Samstag (1994) and Inck
(1995) involved 3 therapists who held a Ph.D., a master’s de-
gree or a clinical psychology license. Safran and Muran (1996)
give no information about the therapists. The number of pa-
tients varied from 3 to 5 adults. The diagnoses were the fol-
lowing: depressive symptoms, major depression, anxiety, dyst-
hymia, agoraphobia, cannabis addiction and various personality
disorders. Safran and Muran’s (1996) studies do not describe
the patients’ diagnoses. Some sessions involve the same thera-
pist or patient.
Safran, Muran and Samstag (1994), Safran and Muran (1996)
and Inck (1995) in their first study employed the same instru-
ments to measure the process as those used for Model 1: SASB,
P-EXP, T-EXP, CVQ. Inck’s (1995) second study examined an
instrument developed by the author: direct identification of the
resolution components (DIRC). Weighted coefficients for the
resolution and non-resolution sessions vary from .61 to .84 for
SASB, from .70 to .95 for P-EXP, from .66 to .80 for T-EXP,
from .36 to .55 for CVQ and from .46 to .75 for DIRC. Safran,
Muran and Samstag (1994), Safran and Muran (1996) and Inck
(1995) for their first study give no indication of the validity of
their instruments. In his second study, Inck evaluated the valid-
ity of his system of categories by comparing the DIRC codes
with the SASB, P-EXP, T-EXP and SVQ codes. Inck gives a
validity coefficient varying from .76 to .90 for the DIRC.
Results of Transitional Probabilities of the
Model
Safran and Muran (1996), Safran, Muran and Samstag (1994)
and Inck (1995) performed sequential analyses to evaluate the
transitional probabilities suggested by the model, both within
components (P1-T1; P2-T2; P3a-T3-P3b; P4-T4) and between
components (C1-C2; C1-C3; C2-C4). Table 2 presents the
results of transitional probabilities of the resolution model.
The results of Safran, Muran and Samstag’s (1994) sequen-
tial analyses do not appear in Table 1 because the authors as-
sign z scores rather than probabilities, as in the 4 other studies.
Safran, Muran and Samstag (1994) performed sequential
analyses only on alliance rupture sessions. All sequences within

P. BAILLARGEON ET AL.
1054
Figure 2.
The preliminary resolution process model.
Component 1
Attending to the rupture marker
Component 2
Exploration of the rupture experienceComponent 3 Exploration of the avoidance
Component 4
Exploration of interpersonal schema
T1
b
Therapist focuses patient
on immediate experience
P1
a
Patient rupture
withdrawal marker
T3
Therapist probes for fears
P3
Patient explores avoidance
P4
Patient explores
interpersonal schema
T2
Therapist empathizes and/or
accepts responsibility
P2
Patient expresses
negative feelings
aP = patient’s behaviour b T = therapist’s intervention following the patient’s behaviour.
Figure 3.
Model 1.

P. BAILLARGEON ET AL.
Table 1.
Methodological elements of the studies.
Session Dyads Process measurement instruments2
Studies Processes
R1 NRTherapist (T) Patient (P) Reliability Validity
Safran &
Muran’s
(1996) study 1
Compare alliance rupture
resolution sessions to
non-resolution sessions
4 3
Number and training not
available
Experiential and
cognitive approach
Not available
SASB .69 - .84
P-EXP .89 - .70
T-EXP .66 - .79
VQC .43 - .55
Not available
Safran &
Muran’s
(1996) study 2
Compare alliance rupture
resolution sessions to
non-resolution sessions
4 4
Number and training not
available
Experiential and
cognitive approach
Not available
SASB .61 - .67
P-EXP .89 - .82
T-EXP .70 - .80
VQC .36 - .41
Not available
Safran, Muran,
& Samstag
(1994)
Verify the transitional
probabilities of Model 2 in
alliance rupture resolution
sessions
4
T1 Ph.D. and cognitive
approach
T2 Master’s and
cognitive approach
T3 Master’s and
cognitive approach
P1 depression symptoms
P2 depression symptoms
and anxiety
P3 interpersonal problems
SASB .69
P-EXP .83 - .95
T-EXP .72 - .79
VQC .55
Not available
Inck’s (1995)
study 1
Compare alliance rupture
resolution sessions to
non-resolution sessions
3 3
T1 Ph.D. and cognitive
approach
T2 Ph.D. and cognitive
approach
T3 license and cognitive
approach
P1 depressive disorder,
obsessive compulsive and
dependent personality.
P2 dysthymia, cannabis
addiction and personality
disorder.
P3 major depression, ago-
raphobia, obsessive com-
pulsive and passive aggres-
sive personality.
SASB .69 - .78
P-EXP .81 - .92
T-EXP .73 - .78
VQC .38 - .43
Not available
Inck (1995)
study 2
Compare alliance-rupture
resolution sessions 3 3 Same therapists as in Inck’s (1995) study 1
Same subjects as in Inck’s
(1995) study 1 DIRC .46 - .75 DIRC .76 - .90
Note: 1R = alliance rupture resolution session; NR = alliance rupture non-resolution session, 2SASB = Structural Analysis of Social Behavior (Benjamin, 1974, 1979, 1982);
P-EXP = Patient Experiencing Scale (Klein, Mathieu-Coughlan & Kiesler, 1986); T-EXP = Therapist Experiencing Scale (Klein, Mathieu-Coughlan, & Kiesler, 1986);
CVQ = Client Vocal Quality Scale (Rice & Kerr, 1986)
Table 2.
Results of transitional probabilities of the resolution model.
Sequences Safran & Muran (1996) Inck (1995)
Study 1 Study 2 Study 1 Study 2
Resolution Non-resolution Resolution Non-resolution Resolution Non-resolution Resolution Non-resolution
P1  T1a
P2  T2
P3a  T3
T3  P3b
P4  T4
1.00***
.87***
.58***
.52***
1.00***
.92**
.67***
.10
.00
.00
1.00***
.96***
.83***
.48***
1.00***
1.00***
.67***
.27*
.19*
.00
1.00***
.96***
.83***
.48***
1.00***
1.00***
.67***
.27*
.19*
.00
1.00***
.97***
1.00***
.84***
1.00***
1.00***
.47***
.56**
.60***
.00
C1  C2 b
C1  C3
C2  C4
.50*
.50***
.44**
.24
.13
.00
.89*
.11
.34**
.76
.14
.00
.89*
.11
.34*
.76
.14
.00
.83*
.17
.33*
.22
.33*
.00
Note: The results of sequential analyses by Safran, Muran and Samstag (1994) do not appear in Table 1. aP1 = the patient produces a withdrawal rupture indicator; T1 = the
therapist focuses the patient on his immediate experience; P2 = the patient expresses negative feelings mixed with the indicator; T2 = the therapist facilitates the
self-affirmation; P3a = the patient reveals the block; T3 = the therapist asks questions about the patient’s block; P3b = the patient explores the fear that blocks him from
expressing negative feelings; P4 = the patient asserts himself; T4 = the therapist validates the self-affirmation. C1 = pay attention to the rupture indicator; C2 = explore the
rupture experience; C3 = explore the avoidance; C4 = self-affirmation. ***p < .001 **p < .01 *p < .05.
components proved to be significant below .01. z scores varied
from 3.01 to 10.06. The significance levels for all sequences
between components were below .05. z scores varied from 2.28
to 4.24.
Safran and Muran (1996) and Inck (1995) performed sequen-
tial analyses of alliance rupture resolution and non-resolution
sessions. The first results of sequential analyses by Safran and
Muran (1996) and Inck (1995) pertain to sequences within
components. Transitional probability for the sequence between
P1 (the patient produces a withdrawal rupture indicator) and T1

P. BAILLARGEON ET AL.
(the therapist focuses the patient on his immediate experience)
was 1.00 (p < .001) in the 4 studies for resolution sessions. For
non-resolution sessions, transitional probability was .92 (p
< .001) in Safran and Muran’s (1996) first study and 1.00 (p
< .001) in the 3 other studies. Transitional probabilities for the
sequence between P2 (the patient expresses negative feelings
mixed with the indicator) and T2 (the therapist facilitates the
self-affirmation) varied from .87 (p < .001) to .97 (p < .001) for
resolution sessions and from .42 (p < .001) to .47 (p < .001) for
non-resolution sessions. Transitional probability for the se-
quence between P3a (the patient reveals the block) and T3 (the
therapist asks questions about the patient’s block) varied
from .58 (p < .001) to 1.00 (p < .001) for resolution sessions
and from .10 to 0.56 (p < .01) for non-resolution sessions.
Transitional probability for the sequence between T3 (the
therapist asks questions about the patient’s block) and P3b (the
patient explores the fear that blocks him from expressing nega-
tive feelings) varied from .48 to .84 (p < .001) for resolution
sessions and from .00 to .60 (p < .001) for non-resolution ses-
sions. Transitional probability for the sequence between P4 (the
patient asserts himself) and T4 (the therapist validates the
self-affirmation) in the 4 studies was 1.00 (p < .001) for resolu-
tion sessions and .00 for non-resolution sessions. The second
results of sequential analyses concern sequences between com-
ponents. For resolution sessions, transitional probability for the
sequence between C1 (pay attention to the rupture indicator)
and C2 (explore the rupture experience) varied from .50 (p
< .05) to .89 (p < .05) for resolution sessions and from .22
to .76 for non-resolution sessions. Transitional probabilities for
the sequence between C1 (pay attention to the rupture indicator)
and C3 (explore the avoidance) varied from .11 to .50 (p < .001)
for resolution sessions and from .13 to .33 (p < .05) for
non-resolution sessions. Transitional probability for the se-
quence between C2 (explore the rupture experience) and C4
(self-affirmation) varied from .33 (p < .05) to .44 (p < .01) for
resolution sessions. For non-resolution sessions, transitional
probabilities were .00 in the 4 studies. The researchers per-
formed the sequential analyses with Bakeman’s (1983) Lag 1
software.
Results Analysis
Generally, the results of sequential analyses confirm both
sequence types (within and between components) for resolution
sessions more than for non-resolution sessions. However, the
results of sequential analyses confirm the hypotheses of se-
quences within components more than they do for those be-
tween components. In fact, the results of sequential analyses
confirm all sequences within the components for resolution and
non-resolution sessions alike. Only for resolution sessions do
the results confirm sequences between components.
The cognitive model of the therapeutic relationship explains
these results. Several academics (Horowitz, 1988; Mahoney,
1982; Safran, Vallis, Segal, & Shaw, 1986) suggest that central
cognitive structures or patterns organize a patient’s perception
of the meaning of other people’s actions. According to Safran
(1990) and Safran, Segal, Hill and Whiffen (1990), central cog-
nitive structures are conceptualized into generalized expecta-
tions regarding a person’s interactions with others or his inter-
personal patterns based on past experiences. When these central
cognitive structures are dysfunctional, they activate malad-
justed interpersonal cognitive cycles where the patient’s expec-
tations lead to a behaviour that triggers interpersonal conse-
quences, confirming their dysfunctional expectations. For ex-
ample, further to numerous abandonments, a person expects to
be abandoned by others when beginning new relationships.
Consequently, the person acts clingy and dependent, which
eventually alienates others and confirms his expectations. An-
other person, who lived in a very critical environment, expects
others to be critical of him and will therefore act in an ex-
tremely self-justifying manner, which irritates others and even-
tually provokes the type of criticism that he expects.
According to Safran (1990), when the therapist’s actions are
consistent with the patient’s dysfunctional interpersonal pattern,
he perpetuates a dysfunctional cognitive interpersonal cycle.
For example, a therapist who responds to a patient’s hostility
with counter-hostility may confirm the patient’s belief that the
universe is a hostile place that must be treated with hostility.
Furthermore, if the therapist can avoid participating in the pa-
tient’s interpersonal cognitive cycle, the patient faces a major
experiential challenge to his dysfunctional beliefs.
The central mechanism consists of challenging the client’s
pathological beliefs. The client interprets the questioning of his
dysfunctional beliefs in a way that allows him to collaborate
with the therapist. Furthermore, interventions that confirm the
client’s dysfunctional beliefs make it difficult to collaborate
with the therapist. For example, a client who thinks others will
try to dominate him will have difficulty establishing an alliance
with a dominant therapist. A client who sees others as being
emotionally unavailable will have trouble establishing an alli-
ance with a therapist who is withdrawn.
Generally, alliance ruptures occur when the therapist’s ac-
tions confirm the client’s dysfunctional cognitive structure. A
rupture creates a unique situation that allows exploration of the
expectations, beliefs, emotions and evaluation processes that
play a central role in the client’s dysfunctional interpersonal
relationships. For example, a therapist realizes that a client
responds to the intervention by withdrawing. Exploring this
experience allows the therapist to discover that the client feels
he is being treated with condescension, but does not mention it
for fear of angering the therapist.
Exploring the interpersonal pattern fits in with the entire
resolution process proposed by Safran, Muran and Samstag’s
(1994) Model 2. The model thus allows the therapeutic alliance
to be restored.
Conclusion
Adolescents in youth centers often undergo treatment against
their will. This context seems to make ruptures in the therapeu-
tic alliance between youths and their caseworkers inevitable.
According to some authors, therapies that include alliance rup-
tures appear to be more effective than those without ruptures,
on condition, however, that the alliance is restored.
The question at the origin of the article is the following:
Which models of the alliance rupture resolution process were
subjected to experimental investigation? It turns out that very
few experimental studies concern models of the resolution
process of therapeutic alliance ruptures. Only Safran and Mu-
ran’s team conducted a heuristic study on a rupture resolution
model that they subjected to experimental investigation. Fur-
thermore, the method had limitations. First, in all the studies,
the treatment included a very limited number of sessions. The
studies involved 6 therapists and the number of patients proved
1056

P. BAILLARGEON ET AL.
to be very low, varying from 3 to 5. All these aspects of the
method limited generalization of the alliance rupture resolution
model.
The researchers used a very heavy process analysis method
that did not allow a larger sampling. Is replicating studies a way
to resolve the problem? Is it possible to simplify the process
analysis method? Inck (1995) attempted to remedy this defi-
ciency by developing the direct identification of resolution
components (DIRC). The idea of directly identifying the com-
ponents seems to be an interesting technique.
According to Safran (personal communication), the team at-
tempts to improve the experimental value of its models by pur-
suing its work with other patients and therapists. Safran and
Muran (1996, 2000) also turned towards another technique to
identify model components: the Core Conflictual Relationship
Theme (CCRT) (Luborsky & Crits-Christoph, 1990).
The authors of this article also proposed to conduct research
that would continue the work by Safran and his colleagues in a
psychosocial intervention context among youths with adjust-
ment difficulties. They also proposed to rework certain ele-
ments of the method, such as the way to select rupture sessions
and operationalize model components.
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