ADDICTION FOCUSED PSYCHOTHERAPY ALLIANCE RUPTURE AND REPAIR
PRACTICE SUGGESTIONS AND GUIDELINES
1. Addiction therapists need to sustain a vigilant sensitivity and awareness pertaining to
alliance fluctuations and nuances very early in the therapeutic relationship and throughout
the on-going course of therapy. Early stage therapy shapes the alliance, and the use of
therapist unconditional positive regard and patient support during the process of
developing essential tasks, goals, and the structural components of the therapeutic process
are essential to the process of establishing and maintaining a working and productive
therapeutic alliance with addictive disordered persons.
2. Addiction therapists and their clients need to discuss the relatively fixed or changing and
evolving nature of various therapy tasks and goals early in therapy, and this general
procedure needs to again be addressed as goals and tasks change as a part of the
therapeutic process. This on-going process can be viewed as a therapeutically preemptive strategy for reducing current and future alliance rupture and repair interactions
and activities. This procedure also fosters some level of “working flexibility” and healthy
adaption upon the part of the therapist and patient. Some alliance goals need to remain
fixed or relatively unchanged throughout the course of treatment (i.e., drug/alcohol
abstinence related to manifesting chronic and severe alcoholic liver disease, transplant
patients, etc.) but most therapeutic goals, methods, tasks, and therapeutic structural core
interactions change or need to be modified during different stages or junctures in the
course of therapy.
3. Addiction therapists need to acknowledge, clarify, and take responsibility for stresses or
relational tensions related to their behaviors that adversely impact the therapeutic
alliance.
4. Addiction therapists need to generally avoid in-depth transference interpretations,
intensive affective work, and confrontational interventions in the early stages of alliance
building and therapy.
5. In the event of alliance ruptures resulting in premature termination occurring after a
limited number of therapy sessions (3-6), and these ruptures are related to the patient’s
having experienced an acute relapse episode, the therapist may deter the rupture and be
able to repair the alliance by directly contacting the client and exploring the relapse
experience triggers, outcome, and his or her ethical and clinical practice interventions
pertaining to the therapist’s actions related to possibly initiating hospitalization or detox
engagement, health and welfare checks, police intervention, and other actions common to
the therapy and treatment of addictive disordered persons.
6. Due to the various risk dynamics associated with the addictive disordered patient
population in general, addiction therapists need to remain personally vigilant with regard
to their internalized emotional reactions to addictive-disordered patients and alliance
ruptures as well as the emotional demands of alliance repair work. We need to personally
establish and initiate supportive collegial and personal relationships that provide support,
nurturing, and therapeutically constructive resources related to our work and general
well-being.
7. Commonly in addictions-focused alliance rupture and repair work, it is clear that this
work consistently evolves from the patient’s repetitive pattern of dysfunctional and self-
defecting interpersonal relationship dynamics (repetition-compulsion). Effective therapy
with addictive disordered persons involves consistent therapist use of strategic,
supportive, timely, and non-threatening interpretation and an exploration of the various
dynamics related to the patient’s addictive disordered repetitive interpersonal behavior.
This aspect of therapeutic alliance rupture and repair work process eventually involves
therapeutic teaching, education, coaching, and a diversity of therapist cognitivebehavioral tools.
8. Finally, addiction therapists need to remain aware of the ever present patient propensity
for terminating therapy or in other ways precipitating a therapeutic rupture; the
therapeutic alliance, as well as the alliance ruptures and repair work, remain byproducts
of the therapeutic relationships. Therapists, patients, therapeutic settings, and a matrix of
various personal and relational dynamics always contribute to the process of efficacious
psychotherapy outcomes as well as the process of constructive alliance rupture and repair
work.