Alliance Ruptures and Resolutions in the Treatment of Personality Disorders: What the Research Tells Us

Navigating therapy when you have a personality disorder can feel like climbing a mountain with no clear path. At Philadelphia Integrative Psychiatry, Dr. Danish and his team understand the emotional challenges patients face—especially when progress is hindered by disruptions in the therapeutic relationship itself. That’s why we place a strong emphasis on the quality of the therapeutic alliance, actively monitoring and addressing alliance ruptures when they arise. We stay up to date with the latest research to ensure our approaches are backed by science and customized to each patient’s unique interpersonal needs.

A recent article titled “Alliance Ruptures and Resolutions in Personality Disorders” offers a comprehensive review of the current science on how therapy can go off-track—and more importantly, how those moments can become powerful opportunities for growth and healing. The article highlights research showing that rupture-resolution processes are not only common in treating personality disorders (PDs) but can also be key drivers of meaningful clinical improvement.

How Alliance Ruptures and Resolutions Shape Progress in Personality Disorders

What Are Alliance Ruptures—and Why Do They Matter?

Alliance ruptures are moments in therapy when the working relationship between patient and therapist breaks down. This can look like emotional withdrawal, resistance, denial, or even direct confrontation. In patients with personality disorders, ruptures occur more frequently due to underlying impairments in self and interpersonal functioning.

There are two main types:

• Withdrawal ruptures: Avoiding the therapist or therapeutic process.

• Confrontation ruptures: Challenging or rejecting the therapist or treatment methods.
  
  These ruptures aren't inherently negative. When addressed effectively through resolution strategies, they provide patients with corrective emotional experiences that can promote long-term growth.

Key Research Findings: What the Numbers Say

1. Ruptures Are Common—Especially in Personality Disorders

• In a study of adolescents with borderline personality disorder (BPD), ruptures were observed in 72% of therapy sessions.

• Patients with PD report higher rupture intensity than non-PD patients (F = 16.6, r = .43, p < .01).

• Withdrawal and confrontation ruptures were significantly more frequent in PDs than in patients with depression or anxiety.

2. Resolution Complexity Matters

• Therapists who used higher-complexity resolution strategies—those that explore deeper meanings, foster mutual understanding, and lead to negotiated change—had better outcomes than those using simpler strategies. One study showed that these more advanced strategies correlated with greater improvement in BPD symptoms (r = –.67, p < .05).

• Another study found that resolution stage complexity predicted whether a patient would be categorized as “recovered” vs. “unrecovered” post-treatment.

3. Resolution Patterns Improve Outcomes

• Meta-analyses show that effective rupture resolution is moderately correlated with improved outcomes:

• One analysis found r = .29 (95% CI [.10, .47], p = .003), which translates to a medium effect size of d = 0.62 across 11 studies (n = 1,314).

• The benefit was stronger when resolution was assessed across the entire course of therapy rather than only in early sessions (r = .38 vs. r = .13).

4. Therapist Behavior Also Shifts in Response

• Therapists working with PD patients were observed to be more hostile and less clear, but also more supportive and expressive, highlighting how challenging yet transformative these therapeutic dynamics can be.

Tools for Measuring and Improving the Alliance

Several validated tools help therapists track ruptures and their resolutions, including:

• Rupture Resolution Rating System (3RS): Tracks 14 rupture markers and 10 resolution strategies using a fine-grained, moment-to-moment coding system.

• Collaborative Interaction Scale-Revised (CIS-R): Allows therapists to code collaborative behaviors and ruptures from both patient and therapist perspectives.

Though these tools are research-intensive, their principles are increasingly being integrated into clinical settings. In our practice, we may use adapted tools or structured feedback to monitor how patients experience their relationship with the therapist.

Training Therapists to Repair the Alliance

Alliance-focused training (AFT) has shown promise in helping therapists improve their responses to ruptures. In one study, AFT led to:

• Increased patient expressiveness

• Reduced therapist blaming

• Higher affirmation and attunement by therapists
  Although AFT improved the quality of therapist-patient interactions, meta-analyses suggest it hasn't yet shown a significant impact on treatment outcomes at a broad scale.
  
  

Getting in Touch with Dr. Danish and His Team

If you’re struggling with emotional regulation, interpersonal challenges, or a diagnosed personality disorder, know that you’re not alone—and help is available. At Philadelphia Integrative Psychiatry, our team uses evidence-based strategies and a compassionate, collaborative approach to help patients heal not just their symptoms but their core relationship patterns. Whether you're seeking a second opinion or ready to start a comprehensive evaluation, we're here to support your journey toward mental wellness.

For More on This Topic and Related Subjects, Check Out These Blogs by Dr. Danish:

https://phillyintegrative.com/blog/personality-and-coping-styles-in-depression
Sources

1. https://pubmed.ncbi.nlm.nih.gov/33305340/