When Therapy Stalls: Recognizing and Repairing Ruptures in the Therapeutic Alliance

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Narrative Clinical Review. This page provides the verified citation, abstract, and full-text PDF for the journal article.

Clinical boundary: Apparent disengagement may reflect rupture, cultural difference, danger, coercion, or a treatment that does not fit. Repair should not restore therapist authority at the expense of safety or choice; modification, consultation, referral, complaint routes, or an orderly ending may be appropriate.

Publication Details

  • Author: Christian Jonathan Haverkampf
  • Journal: The Journal of Psychiatry Psychotherapy and Communication
  • Publication date: 2023-12-31
  • Volume, issue, pages: 12(4), 111–120
  • Article type: Narrative Clinical Review

Recommended citation: Haverkampf, C. J. (2023). When Therapy Stalls: Recognizing and Repairing Ruptures in the Therapeutic Alliance. The Journal of Psychiatry Psychotherapy and Communication, 12(4), 111–120.

Abstract

Psychotherapy can stall without open disagreement. A patient may become compliant, vague, late, intellectually busy, or quietly absent; another may challenge the therapist, the method, or the premise of treatment. These responses may mark a rupture in collaboration, but they may also express reasonable doubt, cultural difference, danger, or a treatment that does not fit. This narrative clinical review examines evidence available through 30 November 2023 on recognizing and responding to strains in the therapeutic alliance. It distinguishes withdrawal and confrontation markers, relates them to agreement on goals and tasks and to the emotional bond, and considers the limits of alliance questionnaires and observer ratings. Repair begins with curiosity about the patient's experience, a willingness to examine the therapist's contribution, and a concrete renegotiation of the work. Meta-analytic findings associate rupture resolution with better outcomes, while training studies remain relatively small and cannot show that every rupture should be preserved or repaired. Cultural humility, attention to power, and direct safety assessment are integral rather than supplementary. When treatment is ineffective, coercive, or unsafe, a good clinical response may be modification, consultation, referral, or an orderly ending. Repair is therefore not restoration of therapist authority. It is renewed, testable collaboration—or an honest recognition that collaboration cannot responsibly continue.

Keywords

therapeutic alliance; alliance rupture; rupture repair; metacommunication; psychotherapy process; cultural humility

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Website copy first made available on 28 August 2026. The journal citation retains the article’s issue date.

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