Alliance Rupture Repair in Psychotherapy
By Elisabet Rosén
Life is full of ruptures. Misunderstandings, mis-attunements, break-ups and other interpersonal conflicts. It can feel scary to face these, especially in important relationships. At the same time, ruptures could be great opportunities to initiate change. When we manage to detect and manage ruptures in therapy, we help our clients onto the royal road to a new way of handling relationships.
Repairing ruptures in the therapeutic alliance takes gratitude, interest, care, responsibility and seeing things in light of patients´ relational history (Eubanks, Muran & Safran, 2018). Research tells us that when therapists repair even the smallest ruptures, results are better than rupture-free therapy, and definitely more successful than therapies where ruptures go unnoticed (Holmqvist, 2009). In this skill post, we will briefly discuss rupture repairs and dive into practice.
Ruptures are commonly divided into two types: Confrontation Alliance Ruptures and Withdrawal Alliance Ruptures. We think of confrontation ruptures in therapy as moments where clients express their critique towards the therapist or therapy. Repairing these Confrontation Alliance Ruptures is a work towards increased trust and closeness in relationships (Safran & Muran, 2000). Confrontation ruptures will be addressed in a future blog post.
Withdrawal Alliance Ruptures are a “sneakier” variant of ruptures, and can therefore be harder to detect. They often come in many vague variations. For example:
• Denial
• Giving minimal response
• Changing subject
• Intellectualizing
• Telling stories
• Talking about others´ reactions
• Being over considerate and compliant
• Splitting affect and content of story (telling a sad story with a giggle)
• Self-punishing and hopelessness
• No-shows, cancellations, not paying
• Misunderstandings
• Unintentional ironies or sarcasm
• Irritation, that is not acknowledged by the client or the therapist
The aim of repairing a Withdrawal Rupture is to help the client approach the experience of a rupture, rather than avoiding it. This helps the client move towards increased independence and assertiveness in relationships. Since withdrawal ruptures are harder to detect, we will give you the opportunity to work with a list of them in the following exercise.
Learning objectives: Be capable of detecting and handling withdrawal ruptures.
Level of difficulty:
How to make it easier: Choose to work with stimuli that feel a little easier. You can also focus on one
skill criteria to start with, and then add another when it feels easier.
How to make it harder: you can always use a personal example: something a patient said, where you
had a feeling of some unspoken critique, and use the same skill criteria, to that stimulus.
Instructions for Roleplay of Withdrawal Ruptures (2 participants):
1. STIMULUS (the person playing the client): Read the client statement (see below for different examples)
2. RESPONSE (the person playing the therapist): Improvise an answer based on the skill criteria:
a) Reflect what you notice (rupture marker)
b) Validate the client´s withdrawal
c) Invite the client to further explore the rupture
3. MONITOR: Therapist: How hard was this? Do we have to adjust (make it harder or easier)?
Client: Did the therapist fulfill the skill criteria a), b), and c)?
4. FEEDBACK & ADJUSTMENTS: Give each other feedback, adjust if needed, and give it another try!
NOTE! ONLY when the client statement feels easy to respond to, you may proceed to the next client
statement and keep following these same four steps.
a) Say what you notice (rupture marker)
b) Validate the client´s withdrawal
c) Invite the client to further exploration of the rupture
Example 1:
Client statement: It has to feel pretty hopeless to have a patient like me. I can´t even answer your questions!
Therapist response 1: It seems to me that these thoughts are devaluing and handicapping you, omitting other aspects of you and your experiences that you might have. (Say what you notice – rupture marker)
Therapist response 2: You seem to feel inept, and if I were in your shoes, that would give me an impulse to withdraw. (validation)
Therapist response 3: Would it make sense to you if we together approach you instead, to see if there can be something more of interest here? (invite to exploration)
Example 2:
Client statement: “When my son decided he wanted to learn to become a carpenter, my husband was thrilled! He started play-fighting him and was super encouraging. You could really tell that he was very happy”.
Therapist response 1: I notice that you´re telling me about your husbands’ reactions to your sons’ choice of education.
Therapist response 2: I do understand it can feel odd to speak up about your own reactions in different situations, since that has been forbidden in your history.
Therapist response 3: Since we are here you and me, I wonder if you are willing to take a look at your own feelings in this moment?
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an example client to respond to - good luck!
Stimuli:
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(looks and sounds upset) “I´ve been frustrated at my friend for failing to be there for me even when she knew I was doing really terribly, but I feel like I´m done processing and don´t feel angry anymore”.
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“From a meta-perspective one could argue that what I´ve been going through also has a flavor of justice to it. I know that people devoted to some religions are actually convinced of stuff like that.”
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(Context to Client Statement 3: The client just let you know that his father could be “a bit heavy- handed and sometimes get physical”.)
“But yeah that reminds me of a brilliant movie where that happens to the antagonist. I think movies and even books can be super for illuminating stuff. As I´m getting old and lazy I get out to the cinema less, but thank God I have HBO and Netflix. What about you, do you prefer the theatre or what?”
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“I´m not sure what to talk about today. I´m sorry”
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(Context to Client Statement 5: First session with a 17-year old client who sits with a sunken posture and is avoiding your (the therapist´s gaze). You have read about the client´s father´s untimely death and the client´s following escalating symptoms in the referral. You have tried inviting the client to sharing, among other things by stating that “I´ve heard about what happened and I´m sorry about your loss. It must be hard to take it in.”)
Client Statement: (Shrugs shoulders) “I guess”
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“When my son decided he wanted to learn to become a carpenter, my husband was thrilled! He started play-fighting him and was super encouraging. You could really tell that he was very happy”.
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(Context to Client Statement 8: You therapist are very tired but manage to be somewhat present, until you yawn loudly and then apologize)
“Let´s just say that he crossed my boundaries a lot from I was 8 to I was 13. I´ll spare you the details, no one should have to even imagine these things”
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(Context to Client Statement 8: You therapist are very tired but manage to be somewhat present, until you yawn loudly and then apologize)
“I appreciate you saying you´re sorry you yawned, but it´s OK really, don´t worry about that. You must be very tired after listening to four more like me today”
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“I have such a profound respect for you guys that are working as therapists. To me, it´s really saving the world one person at a time. I would never be able to do it. How do you manage to always be there and never let your clients down?”
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(Context to Client “Statement” 10: This clinical challenge is purely non-verbal)
(Checks his/her cellphone for messages and gets distracted for 10-15 seconds).
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(Context to Client Statement 11: You therapist have just asked if the client wants to focus on how he/she experienced what was just described, visiting his/her father at the hospital)
“Yeah sure we can focus on that if you want to”
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“Those pants look really good on you… Does it happen often that your clients are attracted to you?”
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“I´m a f#”&*%ing idiot that´s unable to even benefit from therapy. You must feel ike giving up as a therapist and I wouldn´t blame you if you did. I can´t even answer your questions”
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“It must have done you good to have five weeks off work! I can imagine it´s a bliss not having to see all your miserable clients. After all, it´s just a job and all that has a job need to have some time off!”
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(Context to Client Statement 15: You therapist accidentally missed last week´s session. The client is back in your office and you said you´re sorry for what happened)
“Yeah but let me tell you about something that happened! Do you remember that job interview I was to? On my way home from your office, I saw the guy who conducted the interview. I happened to overhear what he was saying as he spoke on the phone with someone, and you know what: He was talking about me!
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“I´m totally hopeless. I´m not able to do therapy. There is nothing more to do.”
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“When I came home, my partner asked me how therapy was. I said that you´re very good looking”
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”My mother was trying to remind me to ”check in” on my own thoughts and breathing yesterday. So annoying! People are always trying to solve my problems without possibly being able to understand what I´m going through.”
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”I thought we said 10AM….?, but I´m sure it is just me who have misunderstood the time….”
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(Context to Client Statement 20: You therapist cancelled the therapy session last week, and now the client is back in your office for a new session. You´ve just asked the client: “Before we begin, I want to ask you. I cancelled last week. I wounder how was that for you?”)
Client Statement: “…….OK…..I guess….” (very little and vague response)
