Article Text

46 Mental health simulation workshop on therapeutic alliance rupture
  1. G Billon,
  2. C Attoe
  1. Maudsley Simulation, UK


Background Therapeutic Alliance is grounded in the robust concept of Working Alliance (Bordin, 1979). Large meta analyses (Horvath and Dianne, 1991; Martin et al, 2000) have identified it as a consistent predictor of psychotherapy outcome.

Evidence suggests that ruptures in therapeutic alliance are common, under recognised, and not well managed including by experienced clinicians (Binder and Strupp, 1997).

Teaching alliance-fostering techniques has been attempted (Muran and Barber, 2010), and it has been highlighted that it could benefit from the systematic training offered by simulation (Binder and Henry, 2010).

Methods We designed a simulation course with a clear focus on therapeutic alliance processes, particularly on the recognition and management of alliance ruptures. Course impact was assessed by pre and post questionnaires on the intended learning outcomes, all focussing on therapeutic alliance ruptures and their management. The course was also assessed by evaluation forms filled-in at the end of the session by the participants with mixed quantitative and qualitative data. Lastly, a focus group was carried out with participants (n = 30) to gain a qualitative understanding of their experience of the course and areas of improvement.

Findings Qualitative and qualitative data reflected that the course was a useful addition to existing training and a particularly interesting learning experience. A need to increase the challenges of the scenario and additional didactic teaching on alliance ruptures were highlighted as possible improvements.

We concluded that a simulation course focusing on therapeutic alliance was an innovative way to enhance therapists’ skill in managing situations of alliance ruptures. It addresses an identified training need and was generally praised by participants to enhance their skills.


  1. Bordin, ES. The generalizability of the psychoanalytic concept of the working ?alliance. Psychotherapy: Theory, Research and Practice 1979;16:252–260.

  2. Horvath, AO, Dianne B. Relation between working alliance and outcome in ?psychotherapy: A meta-analysis. J Consult Clin Psychol 1991;38:139–149.

  3. Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with ?outcome and other variables: a meta-analytic review. J Consult Clin Psychol 2000;68:438–450.

  4. Binder JL, Strupp HH. 'Negative Process': A Recurrently Discovered and Underestimated Facet of Therapeutic Process and Outcome in the Individual Psychotherapy of Adults. Clinical Psychology: Science and Practice 4 121–139 (1997). The Therapeutic Alliance: An Evidence-Based Guide to Practice. (Guilford Press, 2010).

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