A systematic review and thematic synthesis of qualitative literature on the experiences of alliance ruptures within psychotherapy

OBJECTIVE: The therapeutic alliance is an important part of psychotherapy, with a breakdown in the alliance negatively impacting therapy outcomes. This review aimed to synthesize qualitative studies exploring both therapist and client lived experiences of alliance ruptures in therapy. METHODS: Four databases (MEDLINE, CINAHL, APA PsycInfo, Web of Science) were systematically searched for relevant studies. Qualitative, peer-reviewed studies written in English were included. Findings of the included studies were synthesized using Thematic Synthesis. GRADE-CERQual was used to assess confidence in the findings. RESULTS: Ten studies were included in the synthesis and assessed using the Critical Appraisal Skills Programme. Thematic Synthesis resulted in three themes: (1) Experiencing ruptures as threats to relational safety, trust and hope; (2) Making sense of ruptures; and (3) Rupture repair as strengthening the alliance and developing a shared understanding. CONCLUSION: Findings highlighted that ruptures are experienced by both therapists' and clients' as embodied, emotionally charged threats to relational safety, trust and hope for therapy. It was also seen as important for therapists to regulate their own emotions and maintain reflexive capacity. Overall, it was found that rupture and repair can result in therapeutic change.