Alliance Rupture and Repair in Adolescent Psychotherapy

Adolescence is a crucial stage for growth and development, but also a delicate one, marked by the emergence of various mental health issues (World Health Organization et al., 2021). Research indicates that approximately half of all adult mental health disorders begin during this critical period (Solmi et al., 2022). Therefore, addressing mental health concerns during adolescence is paramount. However, despite their need for support, adolescents frequently encounter challenges in participating in treatment and exhibit high dropout rates from therapy (de Haan et al., 2013^; Stubbing & Gibson, 2022). These issues pose specific obstacles for youth therapists: In the absence of active engagement from adolescents, even well-established evidence-based therapies may fail to attain the desired outcomes.

A primary focus in the endeavor to enhance adolescent engagement is the therapeutic alliance, that is, the collaborative aspect of the relationship between clients and their health care providers (Bordin, 1979). Similar to research findings in adult therapy, studies focused on youth psychotherapy have consistently demonstrated a positive correlation between a strong alliance and both sustained treatment engagement and favorable outcomes across various therapeutic modalities (Bose et al., 2022^; Karver et al., 2018^; McLeod, 2011). This correlation is evident in both in-person and online therapy contexts (Anderson et al., 2016^; Mortimer et al., 2022^; Resnikoff & Nugent, 2021). Despite its recent growth, alliance research in youth psychotherapy remains less developed compared to adult therapy.

In a previous review (Cirasola & Midgley, 2023), we conducted a theoretical and empirical investigation into the definition, measurement, and role of the alliance in the context of child and adolescent psychotherapy. One key insight derived from this review was the crucial role of developmental factors in understanding the therapeutic alliance with young people. Expanding on this work and acknowledging the developmental differences between children and adolescents, our current review is dedicated to exploring the therapeutic alliance, with particular attention to its rupture and resolution, specifically within the context of adolescent psychotherapy. Our aim is to distil practical insights from both theoretical frameworks and empirical evidence on the topic to inform and support clinicians working with young people.

To accomplish this, firstly, we establish clear definitions of the therapeutic alliance and its rupture and repair processes. Second, we explore adolescent development, providing a developmental perspective to better comprehend the unique complexities of engaging adolescents in therapy. Third, based on a comprehensive narrative review, we present the findings derived from various studies concerning alliance ruptures and their repair in youth psychotherapy. Finally, we distill insights from this complex literature, which encompasses neuroscience, developmental theories, and alliance research, into clinical implications. These insights are translated into actionable strategies aimed at assisting therapists in cultivating and sustaining a robust therapeutic alliance while adeptly managing ruptures with adolescent clients.

Defining the Therapeutic Alliance and Its Ruptures and Resolutions

A widely accepted definition describes the alliance as the “mutual understanding and agreement about change goals and the necessary tasks to move toward these goals along with the establishment of bonds to maintain the partners’ work” (Bordin, 1994, p. 13). Over recent decades, the concept of the alliance has undergone revision to account for its dynamic and evolving nature. Consequently, it has been redefined as an ongoing process involving intersubjective negotiation between patient and therapist marked by moments of deterioration in its quality, known as ruptures, and moments in which such tensions are resolved, termed resolutions (Muran & Eubanks, 2020^; Safran & Muran, 2000).

Alliance ruptures are defined as challenges in collaborating on therapeutic tasks or goals, a weakening of the therapeutic bond, and/or difficulties in balancing client and therapist needs (Muran & Eubanks, 2020^; Safran & Muran, 2000). A rupture is deemed resolved or repaired when the client and therapist successfully re-establish a positive emotional bond and return to collaborative therapy.

Ruptures are identified through indicators of withdrawal or confrontation. Withdrawal ruptures are characterized by “movements away” from the therapist/therapy. This might involve a client distancing themselves from the therapy or therapist, manifested in behaviors like denial, minimal responses, topic shifting, or intellectualization. In some cases, withdrawal can be subtle and may appear as “movements toward” the therapist but in a way that negates the client’s genuine experience, such as superficially disagreeing but avoiding direct confrontation to preserve the therapeutic relationship. Confrontation ruptures, instead, are characterized by “movement against” the therapist/therapy. These are evident when a client actively resists the therapy or challenges the therapist, through behaviors like complaining, criticizing, or attempting to assert control. Ruptures can exhibit elements of both withdrawal and confrontation (Muran & Eubanks, 2020^; Safran & Muran, 2000).

Therapists can employ diverse strategies to address ruptures, often influenced by their theoretical orientation. Drawing from research and clinical experiences in adult psychotherapy, strategies for repairing ruptures can be broadly classified into two categories: immediate and exploratory (Eubanks et al., 2018^; Muran & Eubanks, 2020). Immediate repair strategies focus on quickly addressing ruptures in the therapeutic relationship without extensively probing their causes or meanings. The primary objective is to rapidly reduce emotional intensity, re-establishing a positive connection and collaborative spirit. These strategies may involve the therapist clarifying any misunderstandings, re-negotiating therapy tasks or goals to better align with the client’s preferences, offering explanations for chosen treatment approaches, or assisting the client in refocusing on therapy.

Exploratory repair strategies, on the other hand, aim for a more in-depth understanding of the rupture, exploring its underlying relational themes. This approach includes encouraging clients to express their thoughts and feelings about the impasse, providing interpretations of underlying needs or desires, sharing the therapist’s own reflections, and/or acknowledging any contributions to relationship challenges (Eubanks et al., 2018).

Adolescence and Psychotherapy

Adolescence, the transitional phase from childhood to adulthood, is marked by rapid and extensive developmental changes (Vyas et al., 2015). These changes affect various aspects of an individual’s life, including their physical, cognitive, emotional, and social dimensions. To effectively help young clients navigate emotional challenges and behaviors, therapists must grasp the developmental and neurobiological processes of adolescence.

Puberty, a crucial stage in adolescence, coincides with significant emotional and social changes that shape the development of self-awareness, personality, self-image, and gender identity (Lerner & Steinberg, 2009). Each adolescent experiences these physical changes uniquely, influencing their self-esteem and sense of identity. Cultural norms, rites of passage, and societal expectations contribute to the diversity of adolescent experiences (Laser & Nicotera, 2021). Throughout adolescence, there is a notable shift toward greater independence from caregivers, accompanied by increased emphasis on peer relationships, including their first romantic relationship.

Puberty marks a crucial period for sexual exploration during adolescence. However, alongside this exploration come inherent risks, including unintended pregnancies, sexually transmitted infections, and emotional complexities. Cultural influences play a significant role in shaping adolescents’ perceptions and behaviors regarding sexuality. For example, research has shown that factors such as race and gender can impact how adolescents view sexual relationships and seek support and education about sex (Bleakley et al., 2018). Comprehensive sex education and accessible resources are vital for equipping adolescents with the knowledge and support to navigate these risks and make informed decisions about their sexual well-being and relationships (Laser, & Nicotera, 2021). The widespread use of the internet among adolescents adds complexity to the issue (Laser & Nicotera, 2021). A meta-analytic study conducted by Mori et al. (2019) found significant associations between adolescent sexting and various risky behaviors, such as sexual activity, multiple partners, lack of contraception use, delinquent behavior, internalizing problems, and substance use. Addressing sexual health in therapeutic settings requires a nuanced approach that accounts for the complexities of working with adolescents and cultural factors.

Adolescence also represents a period of substantial neural flexibility (Luyten et al., 2020). Recent advancements in neuroscience highlight profound alterations within the adolescent brain, particularly in regions associated with emotional regulation, decision making, and social understanding. Both the amygdala and prefrontal cortex mature to facilitate improved emotional regulation and executive functions. However, the amygdala matures earlier than the prefrontal cortex, contributing to heightened emotional reactivity during adolescence (Ormhaug et al., 2014^; Steinberg, 2018). Similarly, the ongoing development of the prefrontal cortex, crucial for decision making and impulse control, renders adolescents particularly sensitive to rewards and social influences (Casey, 2015^; Vetter et al., 2013). This sensitivity may clarify why adolescents have a strong yearning for peer acceptance and why peer pressure strongly influences their decisions. Furthermore, the brain reaches full maturity only during early adulthood, which might explain why adolescents often experience strong emotions and engage in more risk-taking decisions and behaviors compared to adults (Ormhaug et al., 2014^; Steinberg, 2018).

These developmental transformations inevitably influence adolescents’ involvement in therapy and the formation of the therapeutic alliance. For instance, adolescents’ inclination toward risky and impulsive behaviors can create tension in the therapeutic relationship, especially concerning safety (Blakemore, 2018^; Foulkes & Blakemore, 2018^; A. S. Morris et al., 2007). Conflicts may arise between what an adolescent considers normal behavior (which may involve significant risk-taking) and a therapist’s duty to ensure safety, especially in situations involving substance use. Impulsivity is also recognized as a risk factor for self-harm, a behavior commonly observed in adolescents (Lockwood et al., 2017). The combination of intense emotions, impulsivity, self-harm, and risk-taking behaviors adds complexity to the work of youth therapists when engaging with adolescents compared to adults.

The pervasive use of the internet among adolescents, especially in Western and some Asian cultures, introduces additional considerations for therapy. Adolescents often navigate complex online environments where they may encounter harmful content, cyberbullying, or develop addictive behaviors related to social media use (Primack et al., 2017^; Twenge & Campbell, 2018). Integrating discussions about internet usage and its potential impact on mental health into therapy sessions can be vital in addressing these modern challenges faced by adolescents.

At this stage of development, adolescents prioritize relationships with peers over those with adults, which can impact their willingness to rely on and trust adult clinicians for support (Midgley et al., 2016^; Oetzel & Scherer, 2003). In addition, unlike adults who often seek therapy voluntarily, adolescents are frequently referred to therapy by external entities such as parents, families, or schools (Gulliver et al., 2010^; Shirk et al., 2011). This referral process can affect their motivation and readiness for therapy. The societal stigma surrounding mental health issues and the fear of judgment or isolation by peers add complexity to adolescent’s motivation to engage in therapy (Gopalan et al., 2010^; Oetzel & Scherer, 2003). However, it is important to note that some adolescents, particularly older ones or those dealing with specific issues such as anxiety or obsessive concerns, actively seek help.

Last but not least, in adolescent therapy, establishing a strong alliance extends beyond the therapist–client relationship to include engagement with parents and, in some cases, other influential figures like school staff. Parents may serve various roles, from referring sources to active participants in assessments or organizers of logistical aspects. Engaging parents can significantly enhance therapy engagement and outcomes by fostering a supportive network around the adolescent. However, it also presents challenges for therapists. For instance, conflicting opinions on therapy goals between parents and adolescents, as well as the delicate balance between maintaining confidentiality and facilitating parental collaboration, add complexity to therapy sessions (A. S. Morris et al., 2007^; E. Morris et al., 2016^; Schnyder et al., 2020). Effectively managing these dynamics requires therapists to navigate interactions with both adolescents and their caregivers skillfully. This often involves adopting a balanced approach that respects the adolescent’s autonomy and right to privacy while recognizing the importance of parental involvement in their child’s therapeutic journey.

Considering the unique changes and challenges of adolescence mentioned above, youth therapists should be mindful of the distinct developmental needs of their clients when establishing and fostering an alliance with them. By carefully navigating these complexities, therapists can cultivate a therapeutic environment that encourages trust, open communication, and ultimately positive outcomes.

Understanding Alliance Ruptures in Youth Therapy: Research Insights

Compared to the extensive research on alliance ruptures and resolutions in adult psychotherapy, studies within the context of youth psychotherapy have been relatively limited. Nonetheless, in line with adult literature, existing research on the topic demonstrates a correlation between effectively resolving alliance ruptures and positive treatment outcomes (Cirasola et al., 2022^; Daly et al., 2010^; Eubanks et al., 2018^; Gersh et al., 2017^; Schenk et al., 2019). Conversely, unresolved ruptures have been identified as a factor contributing to poorer outcomes and the premature termination of therapy by young clients (Cirasola, Szegedi, et al., 2024^; O’Keeffe et al., 2020). This highlights the significance of understanding what factors can lead to ruptures and how to effectively resolve them with adolescents. Doing so can improve their engagement, enhance outcomes, and mitigate the risk of therapy ending prematurely among this demographic.

Repairing Alliance Ruptures in Youth Psychotherapy

Extensive guidance exists for cultivating a robust therapeutic alliance and managing ruptures in adult psychotherapy, often supported by specialized training programs like the alliance-focused training (Safran & Kraus, 2014). These training methods have demonstrated effectiveness in improving therapeutic outcomes in adult therapy (Eubanks et al., 2018^; Safran et al., 2011). However, comparable resources explicitly tailored to adolescent therapy are lacking. While some of the adult guidance may be relevant to adolescents, as discussed earlier, working with this population presents unique challenges and developmental considerations that may require a nuanced approach.

The absence of tailored guidance for cultivating a strong therapeutic alliance and managing ruptures with adolescents can leave therapists working with youth feeling unprepared and unsupported. Qualitative research has shown that youth therapists often experience vulnerability and caution in their work with young people (Binder et al., 2008a^; Morán et al., 2019). Addressing this gap is crucial to ensure that youth therapists receive adequate training and that adolescents receive high-quality care.

In recent years, there has been a deliberate push to develop strategies for resolving ruptures specifically tailored for youth therapy. However, many therapeutic models used with adolescents are adaptations of approaches originally designed for adults. For example, Daly et al. (2010) validated Bennett et al.’s (2006) model for repairing ruptures in cognitive analytic therapy for use with young people. Similarly, Nof et al. (2019) modified Safran and Muran’s (2000) rupture–repair model for child psychotherapy, resulting in the “child alliance-focused approach”. In addition, for adolescents aged 12–16 and older, Safran and Muran’s original rupture model is recommended (Nof et al., 2019). In contrast, Cirasola et al. (2022^; Cirasola, Midgley, et al., 2024) specifically developed a model for resolving ruptures in short-term psychoanalytic psychotherapy, integrating research, and theory through task analysis. This represents a strategic effort to enhance therapeutic practices to better meet the unique needs of adolescents. However, further research is needed to assess the effectiveness of these guidelines.

Instead of focusing on individual models, this review highlights common effective strategies that have emerged across various therapeutic approaches. By adopting this approach, therapists from diverse backgrounds can become acquainted with a spectrum of effective techniques for fostering therapeutic alliances and repairing ruptures with adolescents. This stance is supported by recent research, which emphasizes that there is no singular “magic” solution or prescribed sequence of interventions for addressing ruptures. Instead, therapists are encouraged to actively engage in repeated “movements toward” the client to effectively manage ruptures, recognizing that these may present as “movements away or against” the therapist or therapy (Cirasola, Midgley, et al., 2024^; Muran et al., 2023^; Muran & Eubanks, 2020).

Discussion

The exploration of alliance ruptures and their resolutions in adolescent therapy, though a relatively new research area, has seen significant growth in recent years. This expanding research offers valuable insights for clinical practice in working with adolescents. Understanding alliance ruptures and resolutions in youth therapy begins with recognizing the unique developmental challenges and opportunities of this life stage. The adolescent phase is characterized by profound physiological and neurobiological changes, demanding therapists to navigate these complexities with skill and sensitivity. The interplay of emotional fluctuations with maturation processes adds layers to the therapeutic context. Advances in neuroscience have deepened our understanding of adolescent behavior in relation to brain development. Awareness of increased impulsivity, decision-making challenges, and the balance between stressors and developmental opportunities is vital for creating targeted interventions. Such knowledge is fundamental for developing and implementing therapeutic strategies that meet the unique challenges and opportunities presented by adolescents in therapy.

The prevalence of withdrawal ruptures among adolescents, characterized by subtle behaviors and minimal responses, underscores the importance of therapists’ attentiveness in identifying these nuanced challenges. Adolescents, in the midst of identity formation and seeking autonomy, may not overtly express their true feelings, necessitating therapists to adeptly recognize and address even minor strains in the therapeutic relationship. Additionally, adolescents’ inclination toward risk-taking and impulsive decision making can lead to conflicts within therapy, especially regarding safety and well-being. Therapists must navigate these issues with a comprehensive understanding of adolescents’ developmental context, thereby enhancing their ability to effectively address ruptures and foster positive therapeutic outcomes.

Alliance research underscores the critical role of trust in the therapeutic relationship, particularly in adolescent therapy (Cirasola et al., 2022^; Cirasola, Szegedi, et al., 2024^; Li et al., 2022^; Morán et al., 2019^; O’Keeffe et al., 2020). While initial mistrust is common, adolescents greatly benefit from feeling acknowledged, heard, and understood by their therapists, fostering the development of epistemic trust crucial for therapeutic progress. Therefore, therapists should be attuned to this dynamic and actively work to build trust from the onset of therapy. Therapists’ genuine use of self and avoidance of a rigid, distant, nondisclosing approach have been found effective in this regard (Cirasola, Szegedi, et al., 2024). Addressing inevitable misunderstandings and tensions in therapy becomes a reparative journey, which, we argue, can catalyze for further trust-building.

Based on existing evidence, we also advocate for therapists to cultivate a diverse range of strategies and apply them flexibly, guided by clinical judgment, rather than rigidly adhering to a single approach or model. This approach allows therapists to tailor their interventions to the unique needs of each adolescent client. Drawing from existing evidence and clinical expertise, this review identifies several therapeutic strategies and attitudes that have consistently proven effective in fostering a strong therapeutic alliance and repairing ruptures with adolescents. These include: (a) validating the feelings and experiences of young people, (b) actively nurturing trust, (c) demonstrating genuine interest and curiosity in adolescent clients, (d) respecting their autonomy and identity, and (e) acknowledging and praising their efforts and engagement in therapy, (f) maintaining flexibility and authenticity in their interactions (Cirasola, Midgley, et al., 2024^; Marquardt, 2021^; Nof et al., 2019). By embracing this diverse repertoire of strategies, therapists can create a supportive and empowering therapeutic environment that encourages adolescents to actively participate in their therapeutic journey and facilitates meaningful change.

While we acknowledge that these strategies may not cover every aspect and may occasionally overlap with approaches for adult clients, they provide a solid groundwork for further exploration and application in clinical practice with young people across various therapeutic modalities. These approaches are well-suited for integration into training and supervision programs, supported by evidence suggesting that deliberate practice of these techniques can effectively incorporate them into routine therapeutic practice (Bate et al., 2022).

As we hope this review makes clear, even in the “best” therapy, alliance ruptures will occur, and youth therapists should not expect that they can always prevent or repair these ruptures. However, it is crucial to support therapists and provide them with adequate training to view these ruptures as opportunities for growth and improvement. Indeed, it may well be that the process of experiencing alliance ruptures, then recognizing them and going through a process of repair is part of what makes therapy effective. When ruptures are successfully addressed, this can lead to a strengthening of the therapeutic bond and provide the adolescent with an experience of feeling understood and recognized as a person with their own mind and feelings, which in turn may contribute to better outcomes.