Patterns of therapeutic alliance: rupture-repair episodes in prolonged exposure for posttraumatic stress disorder

To better understand the role of therapeutic alliance in posttraumatic stress disorder (PTSD) treatment, we examined patterns of and shifts in alliance. First, we identified individuals with repaired ruptures, unrepaired ruptures, and no ruptures in alliance. Then, we explored group differences in these alliance events for clients with common clinical correlates (i.e., co-occurring depression and childhood abuse history) and whether or not the presence of these events influenced treatment outcome.

At pretreatment, clients (N = 116)-76.1% female, 66% Caucasian, age M = 36.7 years (SD = 11.3)--completed measures assessing PTSD diagnosis and severity (PTSD Symptom Scale Interview and Self-Report), depression diagnosis and severity (Structured Clinical Interview for DSM-IV and Beck Depression Inventory), and trauma history. During 10 weeks of prolonged exposure therapy, alliance (California Psychotherapy Alliance Scale) measures were completed. At posttreatment, PTSD and depression were reassessed.

Ruptures in alliance were quite common (46%). No significant differences emerged in the frequency of repaired ruptures, unrepaired ruptures, or no ruptures between those with and without co-occurring major depressive disorder, χ²(2, N = 82) = 2.69, p = .26, or those with and without a history of childhood abuse, χ²(2, N = 81) = 0.57, p = .75. Unrepaired ruptures predicted worse treatment outcome (β = .44, p = .001).

The current study underscores the importance of attending to discontinuities in alliance throughout treatment.