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This exploratory single session-study presents a multimodal, mixed-method description of a session of psychoanalytic psychotherapy and illustrates an in-session “failure”, defined in terms of rupture in the therapeutic alliance and the process of its repair. It aims to enhance our understanding of the mechanisms implicated in therapeutic change. The research materialcomprises session’s video-recording, transcript, and measurements of participants’physiological arousal, as reflected in their heart rate in the session. The analysis consisted of an iterative, multi-layered process that combines observations from verbal and nonverbal modalities of interaction for the identification of significant in-session moments. We applied quantitative descriptive analysis on participants’ physiological arousal and synchronization, qualitative analysis of the clinical dialogue, and coded the in-session fluctuations in the therapeutic alliance,using the Rupture Resolution Rating System. The detailed analysis of specific interactive events in the session illustrates the shift from a “failure” in therapeutic collaboration to gradual repair; this shift entailed increased relatedness and physiological synchronization, and on a semantic level, co-created, reflective meanings in the here-and-now of the therapeutic interaction. The findings highlight ruptures as important in-session events and suggest that the therapist’s empathic oscillation between interpretative and metacommunication strategies can be mutative during moments of relational rupture. Practical ImplicationsNegotiation and resolution of in-session therapeutic ruptures may provide opportunities for therapeutic growth in terms of increased relatedness and reflectiveness.The therapist’s flexible shifts between using interpretative interventions and immediate collaborative explorations in the here-and-now, in the form of metacommunication, seem to facilitate the repair of alliance rupture.Multimodal methodologies and multi-layered analyses, integrating verbal and nonverbal, physiological data in the study of therapeutic interaction can shed light on significant in-session events and mechanisms of the change process. Negotiation and resolution of in-session therapeutic ruptures may provide opportunities for therapeutic growth in terms of increased relatedness and reflectiveness. The therapist’s flexible shifts between using interpretative interventions and immediate collaborative explorations in the here-and-now, in the form of metacommunication, seem to facilitate the repair of alliance rupture. Multimodal methodologies and multi-layered analyses, integrating verbal and nonverbal, physiological data in the study of therapeutic interaction can shed light on significant in-session events and mechanisms of the change process.

Alliance rupture and repair processes in psychoanalytic psychotherapy: multimodal in-session shifts from momentary failure to repair