Rupture, Repair, and Relational Presence: A Qualitative Study of Therapists' Perspectives on the Therapeutic Alliance

Fixsen, Alison, Tragantzopoulou, P. and Health-Watt, Rianne 2026. Rupture, Repair, and Relational Presence: A Qualitative Study of Therapists' Perspectives on the Therapeutic Alliance. Psychiatry International. 7 (3), p. 93. https://doi.org/10.3390/psychiatryint7030093

TitleRupture, Repair, and Relational Presence: A Qualitative Study of Therapists' Perspectives on the Therapeutic Alliance
TypeJournal article
AuthorsFixsen, Alison, Tragantzopoulou, P. and Health-Watt, Rianne
Abstract

The therapeutic alliance is widely recognized as a central mechanism of change in psychotherapy; however, much existing research risks reifying it as a measurable and static construct, obscuring its fluid, co-constructed nature and the ways it is shaped by power, identity, and social context. This study aimed to explore how psychotherapists understand, construct, and enact the therapeutic alliance in their everyday practice, with particular attention to diversity, anxiety, rupture, and the reciprocal impact of the therapeutic relationship on the therapist. Using a qualitative design, semi-structured interviews were conducted with 14 psychotherapists primarily working in private practice, and the data were analyzed using reflexive thematic analysis. Six interrelated themes were identified: moving from technique to relational presence; diversity as relational negotiation; anxiety as a co-created relational process; rupture as inevitable and generative; therapist transformation through the therapeutic relationship; and navigating professional role and human authenticity. The findings suggest that effective therapeutic work relies less on rigid adherence to technique and more on reflexivity, emotional attunement, and a willingness to engage with discomfort, difference, and relational rupture. The study highlights the need for psychotherapy training to prioritize relational, ethical, and reflexive capacities alongside technical skills, and contributes a more process-oriented understanding of the therapeutic alliance from therapists’ lived perspectives.

Keywordsherapeutic alliance; reflexive practice; rupture; diversity; psychotherapy;qualitative research
JournalPsychiatry International
Journal citation7 (3), p. 93
ISSN2673-5318
Year2026
PublisherMDPI
Publisher's version
License
CC BY 4.0
File Access Level
Open (open metadata and files)
Digital Object Identifier (DOI)https://doi.org/10.3390/psychiatryint7030093
Web address (URL)https://www.mdpi.com/2673-5318/7/3/93
Publication dates
Published01 May 2026

Related outputs

Shaped by the Industry: Female Fashion Models’ Perceptions of Aesthetic Labour, Body Governance and Disordered Eating
Fixsen, Alison, Nagy, Reka and Bailey, Magdalena 2026. Shaped by the Industry: Female Fashion Models’ Perceptions of Aesthetic Labour, Body Governance and Disordered Eating. Behavioral Sciences. 16 (6), p. 959. https://doi.org/10.3390/bs16060959

Mental Illness, The Social Construction of
Fixsen, Alison 2025. Mental Illness, The Social Construction of. in: The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society John Wiley & Sons.

Julia E.H. Brown: The Clozapine Clinic: Health Agency in High-risk Conditions:
Fixsen, Alison 2025. Julia E.H. Brown: The Clozapine Clinic: Health Agency in High-risk Conditions: Culture, Medicine and Psychiatry. 49, pp. 940-944 49. https://doi.org/doi.org/10.1007/s11013-025-09915-6

Dementia Citizenship in Mitigating Global Challenges of Polypharmacy in Long-Term Care
Panagiota Tragantzopoulou, Vaitsa Giannouli and Tragantzopoulou, G. 2025. Dementia Citizenship in Mitigating Global Challenges of Polypharmacy in Long-Term Care. in: Kallol Kumar Bhattacharyya (ed.) Health Promotion in Long-Term Care Facilities: The Present Scenario and Future Demands Springer Nature. pp. 41-48

“Paradoxical bio-citizenship: Examining healthy eating from lay and professional perspectives.”
Alison Fixsen, Damien Ridge, Anna Cheshire and Panagiota Tragantzopoulou 2025. “Paradoxical bio-citizenship: Examining healthy eating from lay and professional perspectives.”. Social Science & Medicine. 381 118187. https://doi.org/10.1016/j.socscimed.2025.118187

Does Pet Attachment Affect Men’s Psychological Well-Being, Loneliness, and Perceived Social Support? A Cross-Sectional Analysis During the COVID-19 Crisis
Zachariadou, Sophia and Tragantzopoulou, P. 2025. Does Pet Attachment Affect Men’s Psychological Well-Being, Loneliness, and Perceived Social Support? A Cross-Sectional Analysis During the COVID-19 Crisis. Psychiatry International. 6 (1) 32. https://doi.org/10.3390/psychiatryint6010032

A Song for the Mind: A Literature Review on Singing and Cognitive Health in Aging Populations
Tragantzopoulou, P. and Giannouli, V. 2025. A Song for the Mind: A Literature Review on Singing and Cognitive Health in Aging Populations. Brain Sciences. 15 (3), p. 227. https://doi.org/10.3390/brainsci15030227

Lingering Shadows and New Horizons: The Complex Legacy of the COVID-19 Lockdown in Greece
Tsimirikas, Christos and Tragantzopoulou, P. 2025. Lingering Shadows and New Horizons: The Complex Legacy of the COVID-19 Lockdown in Greece. COVID. 5 (2), p. 23. https://doi.org/10.3390/covid5020023

Mitigating Burnout: A Qualitative Exploration of Clinical Supervision's Impact on Novice Psychotherapists
Demirtzidou, M. and Tragantzopoulou, P. 2025. Mitigating Burnout: A Qualitative Exploration of Clinical Supervision's Impact on Novice Psychotherapists. European Journal of Psychotherapy & Counselling. Advanced online publication. https://doi.org/10.1080/13642537.2024.2438924

Seeking support and treatment: A thematic analysis of tweets about the experience of endometriosis
Tragantzopoulou, P. and Giannouli, V. 2025. Seeking support and treatment: A thematic analysis of tweets about the experience of endometriosis. Journal of Endometriosis and Pelvic Pain Disorders. 17 (2), pp. 67-72. https://doi.org/10.1177/22840265241312516

Opening Pandora’s Box: Exploring Body Image Perceptions and Influencing Factors in Women—An Interpretative Phenomenological Analysis
Adamidou, Konstantina and Tragantzopoulou, Panagiota 2024. Opening Pandora’s Box: Exploring Body Image Perceptions and Influencing Factors in Women—An Interpretative Phenomenological Analysis. Healthcare. 13 (1) 15. https://doi.org/10.3390/healthcare13010015

The Construction of Eating Disorders Psychiatry, Politics and Cultural Representations of Disordered Eating
Fixsen, Alison 2024. The Construction of Eating Disorders Psychiatry, Politics and Cultural Representations of Disordered Eating. Palgrave Macmillan.

The Battle Within: A Qualitative Meta-Synthesis of the Experience of the Eating Disorder Voice
Tragantzopoulou, Panagiota, Mouratidis, Christos, Paitaridou, Konstantina and Giannouli, Vaitsa 2024. The Battle Within: A Qualitative Meta-Synthesis of the Experience of the Eating Disorder Voice. Healthcare. 12 (22) 2306. https://doi.org/10.3390/healthcare12222306

Burnout and Coping Strategies in Integrative Psychotherapists: Findings from Qualitative Interviews
Tragantzopoulou, Panagiota, Giannouli, Vaitsa, Filippou, Anna and Demirtzidou, Margarita 2024. Burnout and Coping Strategies in Integrative Psychotherapists: Findings from Qualitative Interviews. Healthcare. 12 (18) 1820. https://doi.org/10.3390/healthcare12181820

Understanding the Dynamics of Extreme Healthy Eating Practices: A Qualitative Exploration of the Role of Online Messages, Culture, and Family
Tragantzopoulou, Panagiota 2024. Understanding the Dynamics of Extreme Healthy Eating Practices: A Qualitative Exploration of the Role of Online Messages, Culture, and Family. PhD thesis University of Westminster Social Sciences https://doi.org/10.34737/wwq23

Spatial Orientation Assessment in the Elderly: A Comprehensive Review of Current Tests
Tragantzopoulou, P. and Giannouli, V. 2024. Spatial Orientation Assessment in the Elderly: A Comprehensive Review of Current Tests. Brain Sciences. 14 (9) 898. https://doi.org/10.3390/brainsci14090898

Understanding the Neuropsychological Implications of Klinefelter Syndrome in Pediatric Populations: Current Perspectives
Tragantzopoulou, P. and Giannouli, V. 2024. Understanding the Neuropsychological Implications of Klinefelter Syndrome in Pediatric Populations: Current Perspectives. Pediatric Reports. 16 (2), pp. 420-431. https://doi.org/10.3390/pediatric16020036

Endometriosis and stigmatization: A literature review
Tragantzopoulou, P. 2024. Endometriosis and stigmatization: A literature review. Journal of Endometriosis and Pelvic Pain Disorders. 16 (2), pp. 117-122. https://doi.org/10.1177/22840265241248488

‘You Are Not Alone, We’ve Got You’: Power Plays, Devotion, and Punishment on Healthy Eating and Pro-Eating Disorder Websites
Tragantzopoulou, P., Fixsen, Alison, Ridge, Damien T. and Cheshire, A. 2024. ‘You Are Not Alone, We’ve Got You’: Power Plays, Devotion, and Punishment on Healthy Eating and Pro-Eating Disorder Websites. Qualitative Health Research. 34 (12), pp. 1216-1230. https://doi.org/10.1177/10497323241238628

A Review of the Literature on HIV and Neuropsychological Functioning in Older Adults: Is More Research Needed?
Tragantzopoulou, P. and Giannouli, V. 2023. A Review of the Literature on HIV and Neuropsychological Functioning in Older Adults: Is More Research Needed? Problems of Psychology in the 21st Century. 17 (1), pp. 47-56. https://doi.org/10.33225/ppc/23.17.47

“You feel that you are stepping into a different world”: Vulnerability and biases in the treatment of anorexia nervosa
Tragantzopoulou, P. and Giannouli, V. 2023. “You feel that you are stepping into a different world”: Vulnerability and biases in the treatment of anorexia nervosa. European Journal of Psychotherapy & Counselling. 25 (4), pp. 351-368. https://doi.org/10.1080/13642537.2023.2278088

Battles over ‘unruly bodies’: Practitioners’ interpretations of eating disorders and the utility of psychiatric labelling
Fixsen, Alison, Ridge, Damien T., Ponsford, O., Holder, M. and Saran, G. 2023. Battles over ‘unruly bodies’: Practitioners’ interpretations of eating disorders and the utility of psychiatric labelling. Sociology of Health & Illness. 45 (3), pp. 560-579. https://doi.org/10.1111/1467-9566.13601

I’m Skinny, I’m Worth More: Fashion Models’ Experiences of Aesthetic Labor and Its Impact on Body Image and Eating Behaviors
Fixsen, Alison, Kossewska, Magdalena and Bardey, Aurore 2023. I’m Skinny, I’m Worth More: Fashion Models’ Experiences of Aesthetic Labor and Its Impact on Body Image and Eating Behaviors. Qualitative Health Research. 33 (1-2), pp. 81-91. https://doi.org/10.1177/10497323221141629

Is it time to change the approach of mental health stigma campaigns? An experimental investigation of the effect of campaign wording on stigma and help-seeking intentions
Hazell, C.M., Fixsen, Alison and Berry, C. 2022. Is it time to change the approach of mental health stigma campaigns? An experimental investigation of the effect of campaign wording on stigma and help-seeking intentions. PLoS ONE. 17 (8) e0273254. https://doi.org/10.1371/journal.pone.0273254

Arachne, self-care and ‘power-nets’ on women’s self-development programmes
Fixsen, Alison, Ridge, Damien and Porter, Alan 2022. Arachne, self-care and ‘power-nets’ on women’s self-development programmes. Gender and Education. 34 (7), pp. 770-786. https://doi.org/10.1080/09540253.2022.2078793

Challenges and Approaches to Green Social Prescribing During and in the Aftermath of COVID-19: A Qualitative Study
Fixsen, Alison and Barrett, S. 2022. Challenges and Approaches to Green Social Prescribing During and in the Aftermath of COVID-19: A Qualitative Study. Frontiers in Psychology. https://doi.org/10.3389/fpsyg.2022.861107

Orthorexia Nervosa: the Medicalization of Extreme Healthy Eating Practices
Fixsen, Alison and Cheshire, Anna 2022. Orthorexia Nervosa: the Medicalization of Extreme Healthy Eating Practices. in: Harbusch, Martin (ed.) Troubled Persons Industries: The Expansion of Psychiatric Categories beyond Psychiatry, Palgrave Macmillan. pp. 147-170

Supporting Vulnerable Populations During the Pandemic: Stakeholders’ Experiences and Perceptions of Social Prescribing in Scotland During Covid-19
Fixsen, Alison, Barrett, Simon and Simonovich, Michal 2022. Supporting Vulnerable Populations During the Pandemic: Stakeholders’ Experiences and Perceptions of Social Prescribing in Scotland During Covid-19. Qualitative Health Research. 32 (4), pp. 670-682. https://doi.org/10.1177/10497323211064229

Capturing the whole effect of social prescribing – meaningful outcomes and theoretical positions
Polley, M. and Fixsen, Alison 2021. Capturing the whole effect of social prescribing – meaningful outcomes and theoretical positions. European Journal of Integrative Medicine. 48 102006. https://doi.org/10.1016/j.eujim.2021.102006

Evaluation of a Social Prescribing Pilot in Shropshire – implementation and impact findings
Polley, Marie, Fixsen, Alison and Seers, H. 2021. Evaluation of a Social Prescribing Pilot in Shropshire – implementation and impact findings. European Journal of Integrative Medicine. 48 101949. https://doi.org/10.1016/j.eujim.2021.101949

Fragile minds, porous selves: Shining a light on autoethnography of mental illness
Fixsen, A. 2021. Fragile minds, porous selves: Shining a light on autoethnography of mental illness. Qualitative Social Work. https://doi.org/10.1177/14733250211046657

Weathering the storm: A qualitative study of social prescribing in urban and rural Scotland during the COVID-19 pandemic
Fixsen, A., Barrett, S. and Shimonovich, M. 2021. Weathering the storm: A qualitative study of social prescribing in urban and rural Scotland during the COVID-19 pandemic. SAGE Open Medicine . 9. https://doi.org/10.1177/20503121211029187

“Communitas in Crisis”: An Autoethnography of Psychosis Under Lockdown
Fixsen, Alison 2021. “Communitas in Crisis”: An Autoethnography of Psychosis Under Lockdown. Qualitative Health Research. 31 (12), pp. 2340-2350. https://doi.org/10.1177/10497323211025247

How men step back – and recover – from suicide attempts: A relational and gendered account
Ridge, Damien T., Hannah Smith, Alison Fixsen, Broom, A. and Oliffe, J. 2020. How men step back – and recover – from suicide attempts: A relational and gendered account. Sociology of Health & Illness. 43 (1), pp. 238-252. https://doi.org/10.1111/1467-9566.13216

What are the key features of Orthorexia Nervosa and influences on its development? A qualitative investigation?
Cheshire, A., Berry, M. and Fixsen, Alison 2020. What are the key features of Orthorexia Nervosa and influences on its development? A qualitative investigation? Appetite. 155 104798. https://doi.org/10.1016/j.appet.2020.104798

Applying critical systems thinking to social prescribing: a relational model of stakeholder “buy-in”
Fixsen, Alison, Seers, H. and Polley, M.J. 2020. Applying critical systems thinking to social prescribing: a relational model of stakeholder “buy-in”. BMC Health Services Research. 20 (80) 580. https://doi.org/10.1186/s12913-020-05443-8

The Social Construction of a Concept- Orthorexia Nervosa: Morality Narratives and Psycho-politics
Fixsen, Alison, Cheshire, A. and Berry, M. 2020. The Social Construction of a Concept- Orthorexia Nervosa: Morality Narratives and Psycho-politics. Qualitative Health Research. 30 (7), pp. 1101-1113. https://doi.org/10.1177/1049732320911364

What does successful social prescribing look like? Mapping meaningful outcomes
Polley, M.J., Whiteside, J., Elnaschie, S. and Fixsen, Alison 2020. What does successful social prescribing look like? Mapping meaningful outcomes. London University of Westminster.

‘Momma bear wants to protect’: Vicarious parenting in practitioners working with disturbed and traumatised children
Alison Fixsen, Damien Ridge and Carys Evans 2020. ‘Momma bear wants to protect’: Vicarious parenting in practitioners working with disturbed and traumatised children. Counselling and Psychotherapy Research. 20 (4), pp. 680-688. https://doi.org/10.1002/capr.12285

Evaluation Report of the Social Prescribing Demonstrator Site in Shropshire – Final Report
Polley, M.J., Seers, H. and Fixsen, Alison 2019. Evaluation Report of the Social Prescribing Demonstrator Site in Shropshire – Final Report.

Shades of communitas: a study of soft skills programs
Fixsen, Alison and Ridge, Damien T. 2019. Shades of communitas: a study of soft skills programs. Journal of Contemporary Ethnography. 48 (4), pp. 510-537. https://doi.org/10.1177/0891241618792075

HRI Malta 2017—Cutting Edge Research in Homeopathy: HRI’s Third International Research Conference in Malta
Mosley, A.J., Roberts, E.R., Partington, H., Gaertner, K., Fisher, P., Lex Rutten, A.L.B., Mathie, R.T., Cartwright, S.J., Fixsen, Alison, Kokornaczyk, M.O., Sokol, A.M. and Tournier, A.L. 2018. HRI Malta 2017—Cutting Edge Research in Homeopathy: HRI’s Third International Research Conference in Malta. Homeopathy. 107 (1), pp. 50-54 107. https://doi.org/10.1055/s-0037-1609018

Homeopathy in the age of antimicrobial resistance: Is it a viable treatment for upper respiratory tract infections?
Fixsen, Alison 2018. Homeopathy in the age of antimicrobial resistance: Is it a viable treatment for upper respiratory tract infections? Homeopathy. 107 (2), pp. 99-114. https://doi.org/10.1055/s-0037-1621745

Self-care and entrepreneurism: An ethnography of soft skills development for higher education staff
Fixsen, Alison, Cranfield, S. and Ridge, Damien T. 2018. Self-care and entrepreneurism: An ethnography of soft skills development for higher education staff. Studies in Continuing Education. 40 (2), pp. 181-197. https://doi.org/10.1080/0158037X.2017.1418308

Mixing work with therapy: a work based autoethnography
Fixsen, Alison 2017. Mixing work with therapy: a work based autoethnography. Work Based Learning e-Journal International. 7 (1), pp. 40-63.

Stories of Hell and Healing: Internet Users’ Construction of Benzodiazepine Distress and Withdrawal
Fixsen, Alison and Ridge, Damien T. 2017. Stories of Hell and Healing: Internet Users’ Construction of Benzodiazepine Distress and Withdrawal. Qualitative Health Research. 27 (13), pp. 2030-2041. https://doi.org/10.1177/1049732317728053

Feeling Our Way: An ethnographic exploration of university staff experiences of ‘soft skills’ learning and development programmes
Fixsen, Alison 2017. Feeling Our Way: An ethnographic exploration of university staff experiences of ‘soft skills’ learning and development programmes. Prof Doc Thesis University of Westminster Leadership and Professional Development

Interaction Rituals and Jumbled Emotions Among “Relative Strangers”: Simulated Patient Work on a Trainee Complementary Therapy Practitioner Program
Fixsen, Alison, Ridge, Damien T., Kirkpatrick, S. and Foot, D. 2015. Interaction Rituals and Jumbled Emotions Among “Relative Strangers”: Simulated Patient Work on a Trainee Complementary Therapy Practitioner Program . Sage Open. pp. 1-12. https://doi.org/10.1177/2158244015595090

“I’m Not Waving, I’m Drowning”: An Autoethnographical Exploration of Biographical Disruption and Reconstruction During Recovery From Prescribed Benzodiazepine Use
Fixsen, Alison 2015. “I’m Not Waving, I’m Drowning”: An Autoethnographical Exploration of Biographical Disruption and Reconstruction During Recovery From Prescribed Benzodiazepine Use . Qualitative Health Research. 26 (4), pp. 466-481. https://doi.org/10.1177/1049732315576496

Should homeopathy be considered as part of a treatment strategy for otitis media with effusion in children?
Fixsen, Alison 2013. Should homeopathy be considered as part of a treatment strategy for otitis media with effusion in children? Homeopathy. 102 (2), pp. 145-50. https://doi.org/10.1016/j.homp.2013.01.004.004.

Performance, emotion work, and transition: challenging experiences of complementary therapy student practitioners commencing clinical practice
Fixsen, Alison and Ridge, Damien T. 2012. Performance, emotion work, and transition: challenging experiences of complementary therapy student practitioners commencing clinical practice. Qualitative Health Research. 22 (9), pp. 1163-1175. https://doi.org/10.1177/1049732312449213

Permalink - https://westminsterresearch.westminster.ac.uk/item/x781q/rupture-repair-and-relational-presence-a-qualitative-study-of-therapists-perspectives-on-the-therapeutic-alliance


Share this

Usage statistics

1 total views
0 total downloads
These values cover views and downloads from WestminsterResearch and are for the period from September 2nd 2018, when this repository was created.