Adherence to elements of metacognition-based therapy for schizophrenia moderates the negative association between therapist-perceived rupture intensity and the client's session evaluation

Objective: Alliance ruptures are common in psychotherapy, and their clinical impact depends on how they are recognized and responded to. Little empirical work has examined rupture processes in psychotherapy for schizophrenia-spectrum disorders. The present study investigated whether therapists’ adherence to Metacognition Insight Reflection Therapy (MERIT) elements is associated with clients’ session-quality evaluations and whether adherence moderates the association between therapist-perceived alliance ruptures and client-perceived session quality. Method: Data included 610 therapy sessions from a randomized controlled trial, including 37 clients diagnosed with schizophrenia or schizoaffective disorder. Following each session, therapists rated their adherence to MERIT elements and their perceived intensity of alliance ruptures, while clients independently rated session quality. Multilevel models were used to examine within-client associations across sessions. Results: Therapists’ adherence to MERIT elements was positively associated with clients’ perceptions of session quality. Higher therapist-perceived rupture intensity was negatively associated with clients’ session evaluations. Adherence to MERIT content elements moderated this association: when content adherence was high, therapist-perceived rupture intensity was no longer associated with poorer client-rated session quality, whereas under low adherence conditions, greater rupture intensity predicted worse session evaluations. Conclusion: Therapists experienced rupture was negatively related to clients’ satisfaction, in sessions characterized by weaker therapist-rated adherence to content elements.