Understanding Alliance Discrepancies in Youth Therapy: A Case Study of Rupture and Repair in CBT

The therapeutic alliance is a complex, relational construct that cannot be fully understood from a single perspective. Few studies have explored alliance dynamics from both therapist and client viewpoints in youth therapy. This case study investigates discrepancies in alliance ratings-alongside rupture and repair processes-in cognitive behavioral therapy for adolescent depression, where the adolescent consistently reported a stronger alliance than the therapist.

A longitudinal mixed-method case study was conducted using data from the IMPACT-ME dataset, including session recordings, alliance ratings, and post-therapy interviews. The Rupture-Resolution-Rating System was applied to identify rupture-repair markers, and thematic analysis of post-therapy interviews with both adolescent and therapist provided additional context.

The adolescent's high alliance ratings reflected a pattern of excessive compliance, concealing subtle withdrawal ruptures. The therapist, aware of this dynamic, rated the alliance lower and actively attempted to address the ruptures. Most ruptures were successfully repaired, and both parties ultimately described the relationship positively.

Discrepancies in alliance ratings can reflect complex relational processes rather than a weak alliance. In this case, they indicated a compliance-driven pseudo-alliance, which the therapist recognized and addressed. These findings underscore the importance of attending to subtle withdrawal behaviors, even in seemingly strong alliances.