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! Q2:%2*_!i>!O>_!G!@B%2*_!i>!8>![+,,g^>!H26!(#0!7)*701(!):!(#0!2<<$2*70!)B(<$Y0&!$(6!B60:B<*066n! '(A?-",-%#@:AO& lk _!+bgE+\->!! ! Q2:%2*_!i>!O>_!@B%2*_!i>!8>_!G!'B32*M6E82%(0%_!8>![+,--^>!5012$%$*D!2<<$2*70!%B1(B%06>! '(A?-",-%#@:AO&le&pIm >! b,Ebd>! ! ! Q2:%2*_!i>!O>_!G!@B%2*_!i>!8>_!Q296(2D_!A>!K>_!G!Q(0Y0*6_!8>![+,,+^>!5012$%$*D!2<<$2*70!%B1(B%06>!;*!i>!8>! a)%7%)66!['& CmO&'(A?-",-%#@:A&#%B@,)"+(-):(&,-@,&="#a >!a0Z!e)%M_!ae?!Nc:)%&!R*$Y0%6$(4>!! W(*&,!>-001(3!!! One of the most consistent findings emerging from psychotherapy research is that the quality of the therapeutic alliance is a robust predictor of outcome across a range of different treatments and that, conversely, weakened alliances are correlated with unilateral termination by the patient. In the last two decades, there has emerged what we have characterized as a “second generation” of alliance research that attempts to clarify the factors leading to the development of the alliance as well as those processes involved in repairing ruptures in the alliance when they occur (Safran, Muran, Samstag, & Stevens, 2002). A rupture in the therapeutic alliance can be defined as a tension or breakdown in the collaborative relationship between patient and therapist (Safran & Muran, 2006). In this article, we provide a review of this research and metaanalyses of two different types of relevant studies. The first set of analyses examined the association between the presence of rupture-repair episodes and treatment outcome in three studies including a total of 148 patients. The aggregated correlation was .24, z = 3.06, 95% CI [.09, .39], p = .002, a medium size effect that indicates that the presence of rupture-repair episodes was positively related to good outcome. The second set of analyses examined the impact of rupture resolution training or supervision on patient outcome in eight published studies including a total of 376 patients. Both prepost and group-contrast effect sizes were calculated. The mean weighted prepost r for the rupture resolution training studies was .65, z = 5.56, 95% CI [.46, .78.], p = .001. Given the particularly large effect sizes produced by two studies, the results were recalculated excluding these studies (leaving six studies with 252 patients), yielding an effect size of .52, z = 6.94, 95% CI [.40, .63], p = .001. These results provide evidence that rupture resolution training/supervision led to significant patient improvement; however, with a prepost design, we cannot determine whether this improvement was greater than what patients would experience with treatment from therapists who were not trained in rupture resolution. A meta-analysis of the between-groups effect sizes for the seven studies with control conditions (a total of 343 patients) yielded a mean weighted effect size of .15, z = 2.66, 95% CI [.04, .26], p = .01. When one outlier study was removed, leaving six studies with 321 patients, the mean weighted effect size was reduced to .11, z = 2.24, 95% CI [.01, .21], p = .03. These results indicate that rupture resolution training/supervision leads to small but statistically significant patient improvements relative to treatment by therapists who did not such training. @)15-1.*$#! We have reviewed the growing body of evidence indicating that repairing ruptures in the therapeutic alliance is related to positive outcome. On the basis of this review, researchsupported implications for therapeutic practices are described. G$#.1/.\!
Jeremy D. Safran
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