Objective: To assess the frequency of alliance ruptures and repairs and their impact on treatment outcome in psychotherapy among patients with substance use disorder. The moderating effects of treatment orientation, attachment style and type of substance use were analyzed.

Methods: Eighty-three patients and six therapists reported alliance ratings after every session. The patients rated psychological distress before each session. Outcome was analyzed as change in psychological distress during the three sessions following a rupture and a repair. Ruptures were identified as an alliance drop in one session compared to the average scores of the three preceding sessions and repairs if alliance scores reached the levels before the rupture within the following three sessions.

Results: Fifty-two percent of the patients rated rupture(s) in the alliance, the therapists in 73% of the dyads. Patient-reported alliance ruptures, but not therapist-reported ruptures, contributed negatively to patients' psychological distress the following three sessions. Both patient- and therapist-reported repairs implied decreased psychological distress the following three sessions. A secure and a fearful attachment style moderated the relation between patient-reported alliance ruptures and deteriorated psychological distress.

Conclusion: Alliance ruptures seem to increase patient distress, while reparation is followed by decreased distress. Future studies may explore other moderators.