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Introduction and Literature Review
Therapists' Adherence to Manualized Treatments in the Context of Ruptures
Researchers investigating the process of change in psychotherapy have
demonstrated what clinicians have intuited for many centuries: the therapeutic
relationship, or the therapeutic alliance, is the strongest predictor of change in
psychotherapy outcome research (Horvath & Symonds, 1991; Martin, Garske, & Davis,
2000). In response to these findings, a generation of research has emerged investigating
the factors that aid in the development and maintenance of a strong therapeutic alliance.
Findings have shown that the therapeutic alliance is vulnerable to change and that
deteriorations in the alliance can be detrimental to the process and outcome of therapy
(e.g., Safran, Crocker, McMain, & Murray, 1990). These findings inspired a number of
researchers to investigate ruptures, or strains, in the therapeutic alliance in order to
clarify the factors involved in effectively repairing ruptures in therapy.
Research findings on therapists' technical behavior during ruptures have indicated
that the process of recognizing and attending to ruptures is not an easy task for even
experienced clinicians. For one, many therapists are not aware of some of the problems in
the alliance (Regan & Hill, 1992; Hill, Thompson, Cogar, & Denman, 1993) and even if
they do become aware of their patients' negative feelings, the ways in which they
respond to these feelings are not always helpful.
On the other hand, interpersonal and relational theories have informed clinicians
and researchers on the ways in which therapists can address ruptures in beneficial ways.
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