title: Alliance ruptures and repairs in psychotherapy in primary care.
abstract: The association between alliance level and outcome in psychotherapy has been extensively studied. One way to expand this knowledge is to study alliance patterns. The main aims of this study were to examine how frequent alliance patterns with ruptures or rupture-repair episodes were in a naturalistic sample of psychotherapies in primary care, and if three alliance patterns (a Rupture pattern, a Repair pattern, and a No Rupture pattern) were differentially associated with treatment outcome.
  
  
  
  The psychotherapies (N = 605) included a wide range of different treatment orientations and patient diagnoses. Alliance patterns were studied at session-to-session level, using patient-rated alliance scores. Outcome data were analyzed using longitudinal multilevel modeling with a slopes-as-outcomes model.
  
  
  
  The Repair pattern accounted for 14.7% (n = 89) of the treatments, 10.7% (n = 65) exhibited a Rupture pattern, and 74.5% (n = 451) contained no ruptures. The Rupture pattern was associated with inferior treatment outcomes. The Repair pattern was, in longer treatments, associated with better outcomes than the No Rupture pattern.
  
  
  
  The results support theory about the importance of ruptures in the therapeutic alliance and suggest that identification of alliance ruptures is important in alliance-outcome research, for feedback purposes in clinical practice, and in training of therapists.
authors.affiliation: a Department of Psychiatry , Linköping University , Linköping , Sweden.|b Department of Behavioral Sciences and Learning , Linköping University , Linköping , Sweden.
authors.forename: Mattias Holmqvist
authors.initials: MH
authors.lastname: Larsson
authors.affiliation: b Department of Behavioral Sciences and Learning , Linköping University , Linköping , Sweden.|c Center for Clinical Research Sörmland , Uppsala University , Uppsala , Sweden.
authors.forename: Fredrik
authors.initials: F
authors.lastname: Falkenström
authors.affiliation: b Department of Behavioral Sciences and Learning , Linköping University , Linköping , Sweden.|d Department of Clinical Neuroscience , Karolinska Institute , Stockholm , Sweden.
authors.forename: Gerhard
authors.initials: G
authors.lastname: Andersson
authors.affiliation: b Department of Behavioral Sciences and Learning , Linköping University , Linköping , Sweden.
authors.forename: Rolf
authors.initials: R
authors.lastname: Holmqvist
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000628:therapy*; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000379:methods*; D011369:Professional-Patient Relations; D011613:Psychotherapy / Q000379:methods*; D055815:Young Adult
keywords: alliance; alliance patterns; alliance ruptures; longitudinal multilevel modeling; naturalistic process and outcome research