As psychotherapists, a vital part of our job is connecting with people. The relationships we develop with our clients are more than just a passing consideration: they play an active role in our treatments, providing the kind of trust and support that clients need to respond to them.
It’s no wonder, then, that experiences of disconnection with our clients — what are commonly known as ‘therapeutic ruptures’ — would be particularly hard for us. At first glance, they appear to be fundamental errors in the nature of our work, and in the services that we provide to our clients.
But the literature on this topic says otherwise: that ruptures don’t represent failures on our part, but rather, inevitable realities of the therapeutic situation. In this article, the model of therapeutic ruptures introduced by Safran and Muran (2000) will be described, allowing us not only to properly respond to ruptures, but also to reap the rewards that are inherent to them.
Identifying ruptures
Ruptures are defined as any impairment in the quality of the therapeutic alliance, and we’ve all experienced them at least once before. Maybe you said something that didn’t quite fit the client’s experience, or your intended message didn’t come across — or worse still, it came across the wrong way. Whatever it is, the consequence is the same: a feeling of being disconnected from the client, weakening your alliance with them.
Although the experience of a rupture is poignant, it often resists description. This is because it often happens not in the content of therapeutic exchanges, but in their underlying process. Generally speaking, we know that they are negative movements of the progress of therapy. The rupture-repair model organizes them into two categories.
Confrontation ruptures
Some negative movements occur against the therapist: these are known as confrontation ruptures. These ruptures are usually self-evident, and are often instances in which the client exercises control and aggression. These ruptures may reflect the client’s need for self-determination or autonomy.
A confrontation rupture may be occurring when clients:
- Complain about your techniques, background, or personal qualities
- Express dissatisfaction with the progress of therapy or therapeutic goals
Withdrawal ruptures
Some negative movements occur away from the therapist: these are known as withdrawal ruptures. Unlike confrontation ruptures, these ruptures are often more subtle. These ruptures may reflect the client’s need to relate to others and be accepted, which they can accomplish by limiting their own self-expression or assenting to the therapist’s views.
A withdrawal rupture may be occurring when clients:
- Fall silent, avoid offering material, or responding
- Appease the therapist, refraining from offering their own opinions
- Evades a topic by changing it, speaking tangentially, or intellectualizing
The role of mindfulness
Ruptures can either be confrontations or withdrawals. But how can we know when a confrontation has occurred in the first place? The rupture-repair model provides an answer: mindfulness. Only through mindful attention to the present moment can the therapist detect that a rupture has occurred.
For example, consider a therapist who practices mindfulness during a session, resulting in the following internal narrative:
“My client is telling a story, but I can’t get myself to pay much attention. I feel less engaged than usual today. Their story seems tangential and evasive to me. I wonder if they’re moving away from something I said earlier. I’ll be sure to circle back and ask them about how they felt earlier in our session.”
As we can see, this therapist’s mindfulness allowed her to attend to both the internal and external signals of a rupture. First, she became aware of her own sense of disengagement with the client. Then, keeping a non-judgemental stance, she wondered about whether this disengagement was a result of the client’s tangential speech. Finally, she made a plan to test this hypothesis, in the interest of understanding the client’s withdrawal rupture.
Once we’ve used our mindfulness to recognize a rupture, whether confrontation or withdrawal, we must then know how to respond to it.
Responding to ruptures
The importance of responding effectively to a rupture cannot be overstated. Silence, avoidance, and denial are convenient ways to keep the peace, but they only exacerbate the problems that can occur during therapy. The harms that are done to a therapeutic relationship will make even the most meticulously planned treatment intervention fail.
How many premature terminations have resulted from miscommunications or disagreements which couldn’t be adequately addressed in the therapeutic space? No wonder that the client’s natural response was to end their treatment. How could they expect to grow and learn from a process that didn’t allow them to work through the negative feelings they had towards their own therapist?
The rupture-repair model provides us with guidance about responding to ruptures by organizing our responses into two general strategies.
Immediate strategies
When a rupture needs to be immediately addressed and worked on, then an immediate strategy should be used. These are strategies which address the source of the rupture, aiming for its immediate resolution.
Immediate strategies can be of two types:
- Direct interventions: these involve either (a) explaining the tasks and goals of therapy, or (b) clarifying a misunderstanding
- Indirect interventions: these involve changing the tasks and goals of therapy.
For example, suppose that a client has become silent (withdrawal rupture), and reveals that they’re worried about having their information shared with others. In this case, an immediate strategy would be the best course, with a direct intervention being used to clarify and reaffirm the sanctity of confidentiality.
Now, suppose that a client has become irritated (confrontational rupture), and reveals that they don’t agree with the therapist’s stated task of improving their eye contact. In this case, an immediate strategy would again be the best course, with an indirect intervention being used to collaboratively revise the therapeutic task.
Expressive strategies
When a rupture is best addressed by a depth-oriented process, which assesses both the client’s and therapist’s contribution, then an expressive strategy should be used. These are strategies which explore the relational patterns which have led to the rupture, leading the client to insights about themself.
For example, suppose that a client tends to intellectualize during sessions (withdrawal rupture). The therapist observes that this tendency isn’t in response to any specific event, but reflects a pattern of this client’s interpersonal relating. In this case, they may engage in an expressive strategy, to help identify why the client intellectualizes, what the therapist may have done to elicit this response, and how they can work to avoid it in the future.
The benefits of responding
Clinical experience confirms that the process of experiencing a rupture, then successfully repairing it, strengthens the therapeutic relationship. This experience often gives us further insights about our clients, and also conveys respect for their feelings and beliefs.
Consider the process of building muscles. It wouldn’t be possible without the wear and tear of physical excursion, which causes them to grow when healed by the body. The rupture-repair process of therapy is analogous to this process: communication breakdowns, when healed correctly, lead to a further strengthening of the therapeutic relationship.
Key Takeaways
Ruptures are a natural part of therapeutic progress. Identifying them begins with the therapist’s mindfulness, which will allow them to recognize them as either confrontational or withdrawal. From there, the therapist can choose from either an immediate or expressive strategy.
If therapists are experts in anything, it’s in the development of healing relationships with our clients. Knowledge of how to manage ruptures is a key part of this expertise.
