Psychotherapy and Applied Psychology: Conversations with research experts about mental health and psychotherapy for those interested in research, practice, and training
This show delivers engaging discussions with the world's foremost research experts for listeners interested in or practicing psychotherapy or counseling to provide expert insights and practical advice into mental health, psychotherapy practice, and clinical training.
This podcast provides valuable insights whether you are interested in psychotherapy, an applied psychology discipline such as clinical psychology, counseling psychology, or school psychology; or a related discipline such as psychiatry, social work, nursing, or marriage and family therapy.
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Psychotherapy and Applied Psychology: Conversations with research experts about mental health and psychotherapy for those interested in research, practice, and training
Therapeutic Alliance Ruptures in Psychotherapy with Dr. Catherine Eubanks
Dan is joined by Dr. Catherine Eubanks to break down alliance ruptures in psychotherapy. Dr. Eubanks is a Professor of Psychology at Adelphi University.
Dan and Dr. Eubanks discusses the concept of ruptures in therapy, their relationship to the therapeutic alliance, and the importance of understanding and repairing these ruptures. Then, Dr. Eubanks shares her journey into this field, the significance of training therapists in alliance-focused techniques, and how identity and cultural factors can influence ruptures. Their discussion emphasizes the complexity of therapeutic relationships and the need for therapists to be aware of subtle signs of rupture and repair.
Special Guest: Dr. Catherine Eubanks
Center for Alliance-Focused Training
Therapist Performance Under Pressure: Negotiating Emotion, Difference, and Rupture
Book: Rupture and Repair in Psychotherapy: A Critical Process for Change
Training Video: Rupture and Repair in Psychotherapy
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[Music] Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to episode number 35 of Psychotherapy and Applied Psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and hopefully have a little bit of fun along the way. If you find our show helpful or interesting, it'd be much appreciated if you could share it with someone you know who might enjoy it too. It's a great way to spread the word and keep the conversation going. Today I couldn't be more excited to welcome one of the world's authorities on Alliance, ruptures, and repairs. My guest is a professor at the Gordon F. Learner School of Applied Psychology at Adelphi University, associate director at the Psychotherapy Research Program at Mount Sinai Beth Israel, past president of the Society for the Exploration of Psychotherapy Integration, fellow of the Society for the Advancement of Psychotherapy, and recipient of several prestigious awards from the Society of Psychotherapy Research, and the Society for the Advancement of Psychotherapy, as well as associate editor of the journal of Clinical and Consulting Psychology. In our conversation we discuss what's therapeutic about the therapeutic alliance, what are ruptures and repairs, alliance focus training, types of ruptures, and much more. Quick note, after we finished recording, I realized that I was so engaged in the conversation that we never mentioned that there was a large evidence base that repairing alliance ruptures has been associated with all sorts of good clinical outcomes. On a more personal note, after the research that I did before this conversation and then actually having the conversation, I've come to believe that we should be including ruptures and repair training as a part of any training program. This episode begins with my guest responding to my question about how she got into studying alliance ruptures and repairs. So without further ado, it's my pleasure to welcome my very special guest, Dr. Catherine Ubex. So I first encountered the idea of ruptures and Chris Maranagyrami's affronts work on it. When I was in graduate school, my mentor Mark Goldfried had us read it, and I can't remember where we were reading in class or as part of his research lab or both, but I definitely was exposed to the ideas. And actually my classmate, my labmate, Lisa Perquel, focused on it for her dissertation. And we were collecting our data together, so we were collaborating a lot on pieces of the project. So it was definitely aware of it, thinking about it. But what really got me into working on it was I did my internship at what was then called Beth Israel Medical Center. So my year-long training in a hospital setting, like last step before getting the PhD. And Chris was the chief psychologist there. So all the interns had a, saw one case that he supervised in a group supervision doing this what I now know is called Alliance Focus Training. And then I also did an elective research rotation with him. We worked on a project. And during the course of my internship, Chris said, "Oh, I have a position for a postdoc, and I applied." And I became his postdoc and basically just haven't stopped collaborating with him on research on ruptures and repairs. Do you remember what that was like, like that first Alliance Focus Training with that specific client? Like, could you talk a little about that? Yes. So, I mean, a few things definitely, I think there were things about the approach that I, like I actually have a memory. This is making me remember the first time I, I think it was the first time I saw Chris and Jeremy presented a conference. And so this is before internship. I'm pretty sure if I'm getting my dates right. And I remember they presented some clinical material and I couldn't follow what was going on in the example. I don't know why, but it's funny looking back. I remember sort of like, "Okay, so I'm going on here, but I'm not totally sure what they're talking about." And then now full circle, all I do is watch videos and develop measures to identify these things that are happening. So it's sort of funny. But my first case, I remember was very challenging. I remember doing a role play in supervision with Chris where I was playing my patient. And that it was incredibly helpful to try to imagine my patient and see, it's like I could see myself through my patient's eyes. I had this sense of like, "Oh, I can see her coming a mile off." And she thinks she's going to get me to open up. But no, she's not. And it just gave me this like different visceral sense maybe of what my patient was experiencing, which I found really helpful. It's like really intense empathy. Yeah, yeah. I mean, of course, I can't be sure I actually know how she felt, but it was like this kind of paradigm shift in my head of what might have been going on between us. And then we were doing a treatment. It was supposed to be 30 sessions. And my patient dropped out at session 24. And I remember, by that point, I think I either already, I definitely applied, maybe had accepted the postdoc position. And I was like, "Oh, no, it's he kind of want me as a postdoc, if my patient dropped out." But that's part of the process. That's part of the experience. And even with her, it was a complicated dropout because in a way, I felt disappointed that she left, but it was also her sort of asserting herself, which actually was something that would be good for her, given sort of how I was understanding what was going on for her. So it was like, wow, this stuff is so complex and interesting. And yeah, I just, I don't know, once I got into it, I wanted to stick with it. And was at that point, were they looking specifically at the rupture parts of the alliance? Oh, yes. So they were studying ruptures and had developed some, they have this sort of post session questionnaire that includes several different indices, questions of basically, like, was there any tension, difficulty, disagreement between you and your therapist for the patient to fill out, between you and your patient for the therapist to fill out? And actually one of the first things I did as a postdoc was help with pulling together a publication analyzing some big set of data that they got with this, with this self-report questionnaire. So, so they had good, had done well using those, but they also wanted to supplement it with more measures, including observer-based measure. And that's sort of, that's how I ended up working on the rupture resolution rating system, or 3RS, is it was also an early project during my postdoc, Chris and Jeremy, or like, hey, can you work on an observer-based measure here? And sort of gave me some materials, give me started. Right, let's give this to the postdoc, this really difficult, laborious, tedious task. Well, yeah, but maybe it also, I don't know, like, if you had told me then that I would still be working on this measure years later, I might have, that might have been daunting. But yeah, it's, it's really interesting, it's never going to be perfect, so I have to accept that. My own issue with perfectionism is part of why I think I like this rupture work. It's like instead of denying, avoiding, being scared of the messiness and the mistakes, like, let's just lean into it, and this can be helpful, useful opportunity. So I think that's part of why this stuff resonates with me. Before we get too far into it, we should probably spend 90 seconds on what the therapeutic alliance is. So, okay, so the short version, a lot of what a lot of people use in our field is Bordin's conceptualization. So Bordin talked about the patient therapist need to agree on the goals of therapy. They need to be able to collaborate on the tasks of therapy, and there needs to be a bond between them, like mutual respect and empathy. So we can think of the alliances, the working alliance as being those three pieces. Okay, so this is one of the things I've been maybe trying to lean a little more into. I did a few weeks ago, I had Paul Hewitt on here, if you know, Paul, yeah, so he does a lot of perfectionism stuff. These like perfectionism has like some really great, like, particularly like group psychodynamic treatments for perfectionism. But we were sort of one of the things that came up with my conversation with him is what is the, I want to use the phrase healing power. That might not be the perfect phrase of the therapeutic alliance. Above and beyond how I think a lot of times we think about it, like I think like the importance of the alliance has sort of become cliche in the field, particularly in training, and it's sort of like, yeah, yeah, I have to have a good relationship with my client or else they're not going to like me, and this isn't going to work. I think that's sort of the, I think if we did an observational coding of how it's talked about in a lot of context, they'd be like, that would be it, you know, necessary, but not sufficient, blah blah blah, right. But I think that there's a lot more in terms of for folks who are really, you know, thoughtful about this. What how the alliance works, how it's helpful, and I was kind of curious what your thoughts are about that. Yeah, I mean, I think so one thing that I find really helpful, so Chris and Jeremy's seminal book that was published in 2000 is called negotiating with therapeutic alliance, and that word negotiating is such a great word because it really captures how this is not like a box you check off. Okay, Alliance good. Let's go forward. It's a process that's always unfolding and it's two, it's two people. It's not just one person. It's the diet, kind of always figuring out, okay, I can give you this much, not that much, hear my boundaries, hear your boundaries, trying to work together to develop a shared understanding of what's going on and to collaborate. So I think that's a really helpful word. And then I also think about, I think a lot about the alliance is having a potential for providing or facilitating a corrective experience. So especially for, I mean, this may vary depending on what patients are coming in with or what they're working on, but especially if something about relationships and your experience of relationships is part of what you want to work on in therapy, like here's a relationship, and it's this rich opportunity to navigate, try navigating a relationship in a slightly different way. What happens? Maybe getting a different response and maybe getting a different or expanded understanding of how you can be in relation to another person. Got it. So I think this leads right then into your work on ruptures and repairs. And how do you just just sort of, again, big picture? Do you gen tent, like does it make sense to just sort of like start out with ruptures or sort of doing both at the same time? What do you think? Oh, for rupture and repair? Yeah, I mean, ruptures. So I can like define it very briefly, but then in another way, like so much of my research is trying to define it. So we can go on as long as you want about that. Like in a brief way, okay, if the alliance is, you know, we're collaborating, we agree, we have some shared sense of where we're going, we have some kind of trust and bond, then we've gotten any problems in any of those areas. We've got any difficulties in any of those areas. We can think of those as ruptures. We can also think about it is, look, everybody's got needs for agency and communion. That's a really helpful one. Like we've all got one of like assert ourselves and do our thing and we want to connect to other people. And if you've got those different needs and then two people with those needs, they're going to inevitably kind of bump into each other. That's just going to happen with two people interacting. So some kind of rupture thing is going to happen at some point. And we found it helpful to talk about these using some terms that Heather Harper first used in her dissertation to talk about ruptures in terms of confrontation and withdrawal. So confrontation might be the first thing that comes to mind when you hear the word rupture. We're kind of, we're budding heads, we're moving against each other or moving against the work of therapy. And then withdrawal, we're moving away, avoiding, trying to change the subject, trying to distance from each other or the work of therapy. In our work, to me, both when I'm trying to identify things from a research perspective or when I'm trying to identify things as a clinician, I want to be aware of not just the big obvious ruptures, but the really tiny little micro moments that could become something potentially. That's where I have more room to intervene. So I'll use the word rupture to talk about the little moments as well as the big moments that sometimes throws people because they might even say like,"Oh, ruptures don't happen to be," because they're thinking of some big conflagration. But I'm like, even those little weird moments or little awkward moments, those are something. And I do think about those in terms of little movements of confrontation withdrawal. Well, that's that was that was exactly what I was going to ask you, which is how big does that confrontation withdrawal have to be in order for it to be classified as a rupture? Yeah, I would I would call all of it that and then, you know, then we can we can rate, you know, it's more or less intense or severe or, you know, we can have some kind of gradient. But I think they're all important. And if we just wait for the really big ones to pay attention or take action, we may have missed our opportunity. Could you give us an example of a confrontation is probably easier to do on this medium because, you know, withdrawals might be more, well, I think I think about the beat, but like what would be like, you know, so on your on the three RS, you have a it's a one to five scale. Right. So it's like one is like nothing up to five, which is a bunch. So like, what would it I'm curious what a like confrontation rupture that's a two would look like and what's a confrontation rupture that a thought that's a five. So, that's a good question. So, let me think like a two might be yeah, I I I'm not sure about the homework versus that homework made no sense. I don't you know, I didn't do it. It just made no sense to do that. Okay, right. And then like, what about if we did the same thing for a withdrawal kind of a rupture and I'm sort of thinking that a lot of times a very like a small withdrawal rupture is going to be, I mean, you know, natural is going to passive thing, right? So it might just be like me not responding much or like, okay. Yes. So there is an active form of withdrawal. So that would be like, you're trying to get somebody to talk about something and it's like, well, yeah, yeah, that it is it is tough what's what's going on at work. But you know, it reminded me of something that happened with my neighbor and then I met them in the hall and they were talking about and blah, blah, blah, blah, and I just changed the subject. So I could be talking a lot, but I'm changing the subject or I'm talking, I'm telling you a random story that doesn't seem to go anywhere or I'm using a lot of jargony intellectualized language. I'm moving away from the work. We see a lot of that. So what would a five look like? Because I'm sort of thinking like as you're saying this, I'm thinking about like I was thinking in my head like a five or four or five or whatever would be like me shutting down or putting up a wall. Then I was also thinking if I really do that in a kind of novert way, that's kind of, is that confrontation? No. So this is, I think this is a part of the challenge is if I think hard enough about it, like I can almost think my way from any withdrawal to seeing as a confrontation and vice versa, right? So like yeah, like I can move away in a way that there's some kind of like hostile or controlling quality to it. Right, I'm thinking like cross my arms, I move back, I would write or I could like in a way that that is, it's kind of aggressive. I mean, there's nothing, right? Because like passive is like it's sort of like I don't want you to notice me. I want to sort of shrink away and beat, but like if I do have those big gestures that is sort of like, I want you to see this, which does feel more aggressive. Yeah. And and in coding, we might handle those kind of situations. I mean, first, you can code one thing as being multiple things. So you could consider a moment of having both elements of confrontation and withdrawal. Also, it can have elements of both rupture and repair in the same moment. And sometimes just in terms like with coding, we have to reach reliability. So we kind of draw a limit as to how far we'll infer. You know, we'll sort of like, well, maybe it could be this, this, in this, but we kind of have to keep it a little bit more at like not exactly the surf, but pretty close to the surface level. But clinically, I think it's super helpful to be thinking about how these things can all be combined. I mean, really, the withdrawal confrontation distinction, it's like a heuristic that's useful, but it's nothing's that simple in real life, right? Everything is a mix of a lot of things. So what would be an example of like a five withdrawal? It could be, and we're usually coding in like five-minute segments, right? So a five-minute segment, if I started telling a random story and I spent the whole five minutes telling it, I'd give a five or withdrawal for that five-minute segment, right? Like the whole five minutes was dominated by withdrawal. It is clear based on this session and what I've seen of perhaps other sessions that this is a filibuster, very intentionally, but he's trying to get away with it. He's not trying to... I mean, we're not making a judgment about how conscious or deliberate it is. It's just, this is what we see, is movement away that's salient and, you know, intense. Or it could be the person go silent, right? It could be either extreme, but they're both not collaborating with the process. While you were saying that, I realized we probably should say this. So there's the one that I... I had your old one, and I guess maybe your original one, in my files. And then when I was preparing for this, I was like, I found the 2022 one. Is that the most recent one? Yes. Okay. So it's a lovely manual, lots of examples, lots of nuance. So I will link to that in the show notes for anybody who's interested, though it's free, at least as far as I could tell. I don't think I was doing a thing I wasn't expecting. No, that's our intention. We want it to be accessible for people. Great. But it is worth, I think, highlighting that when you all do this coding that you do, you take the session, you divide it into five minute chunks, and then you code each five minute chunk on the various indices. Okay. Okay. So what does it look like when the two happen simultaneously? Oh, well, I guess we haven't gotten to repairs yet. So I guess I should briefly talk about repairs. Well, repairs is, yeah, repairing whatever happened, right? So if they couldn't agree, then maybe they reach an agreement, or if there was a sense of disconnection, now they come back to being more connected and collaborating again. With the coding system, we do have a way of rating sort of how much things were repaired, but we also are rating repair attempts, because it may be somebody's trying to repair something, and we're interested in that, like their efforts to repair, whether they are successful or not, is like a separate determination. So we have descriptions of different strategies. Someone may use to try to repair. Initially, we thought of them as therapist strategies, but in this 2022 revision, one of the things we were focused on is realizing, you know, both patients and therapists rupture and repair. So you can rate both of them on both on ruptures and repairs. So could you, in the manual, there's a bunch of different sort of repair strategies. Could you give us, you know, you don't know, they're all of them, but some examples of those? Yeah. So one set of them, we think of is sort of repairs where you're kind of focusing on the task. So this could be like, there was something unclear about a homework assignment, and so then it would usually probably be the therapist explains the homework assignment, you know, in response to, I didn't understand it or I didn't see the point, and then the therapist is like, oh, well, this is why I asked you to do it. I thought it would be helpful for this reason. So that could be a simple repair strategy. Then there's also repair strategies that are more about saying, hey, someone's going on, let's explore what's happening between us and really getting into exploring the rupture. And what's happening for you, what's happening for me, exploring that, validating that they could include the therapist's self-disclosing their experience of the rupture. So that's, and that's where a lot of like Chris and Jeremy's rupture repair work was really focused on kind of developing a model of that exploration of rupture. So that jumped to this then, so because they did some task analysis, well, you were part of it too, some task analysis work sort of like looking at what this repair process looks like. As well, if you could talk a little bit about that. Yeah. So the first task analysis predated my my joining the team, but the first one was looking at this exploration and this idea, you sort of recognize that a rupture is happening and then kind of invite this exploration of it, really trying to get into the experience, the here and now, don't jump yet to trying to interpret or link it to somebody's, you know, past or anything. But really what's happening between us, really trying to get into the details of that, recognizing that doing that can be hard. So be on the lookout for movements away, kind of withdrawals within that exploration, try to come back to it. And the idea being that with withdrawal, you would probably be identifying some kind of underlying need that the patient needs to assert. Something they've been holding back or moving away from, you want to kind of help them come forward with it and assert it more directly. And for confrontation, the idea being there may be some underlying like herter vulnerability that underlies the attack or the hostility or whatever you're seeing on the surface. And you want to help somebody sort of access that. And the hope is that that then all of this is facilitating a corrective experience. So that's kind of the the model for exploring a rupture. More recently, we did a task analysis looking at the the strategies that are more about focusing on the task. And we basically in the data we were looking at, we found that the therapist used all kinds of different things. There wasn't sort of a clear do this than this than this. It was just like a lot of strategies and they would employ different ones sort of depending on the patient and the situation. But things like explaining the task or if you got to move it away from the task is sort of like, well, let's come back to the task and focus on it again, giving a good rationale for it, things like that. Okay, so there wasn't and that was something that the the process wasn't as consistently sequential. Right. And and and something that Chris and I are interested in doing is seeing. So we've done this work on though, this is how you might explore and here's ways you could kind of focus on the task. But what about that decision point like which set of strategies to go towards? Do I explore or do I not? Do I focus on the task or do I not? And so we something we're planning to do and thinking about is could we have one big model that like sort of brought it all together and kind of helped somebody in thinking about? I think the question of when to explore and when not is a really interesting one because you can't explore every little ruptured thing you see or you'll never do anything else. So how like I'd love us to have guidance for like when when should you go away? Now I really need to explore this versus that. Maybe I let it go for a minute or I wait and see or that kind of thing. So that the exploration is going to be typically a more a bigger lift in the therapeutic context. Yeah I guess I guess that's fair. I mean it may also depend on the kind of therapy you're doing or sort of what your typical session looks like. Like how much it will differ from what you're normally doing. Yeah. So because I think we're talking this language and I think I feel like I'm following you but I sort of feel like in podcast land if I was listening to this while I was doing the dishes I might get a little bit lost. Sure. So I'm curious if we could sort of so like if I was a client and I said to you you know Dr. U banks I didn't do the homework this week. I really I don't I kind of didn't feel like it fit what I needed. Like what would that look like like what would your look your response look like if you were going to do more exploration versus more you know task focused. Does that a reasonable question? Yeah that is. The first I mean I think the first move either way would probably be you know oh keep telling me more about that. And then if I'm going the exploration route I would just I would be seeing that is like this is something I really want to dig into and I really want to really focus on. Whereas the other route might be if there's some kind of you know I didn't think it fit my experience and then I'm like oh well this was like I gave a rationale well this is what made me think of this assignment and then if you were like oh okay that makes sense and I'd be like okay fine and we'd move on versus the exploration might be even if you said okay fine I might be like but wait I think we need to talk about this some more. This this like maybe if it was a pattern that had happened a few times so I felt like there's something more going on here than just this particular assignment didn't make sense or if something about sort of how I'm understanding you and what we're working on like we need to we need to dig in here for a minute. So in that moment as the therapist you're sort of using your clinical judgment to say okay is this is this something that well yeah I probably just didn't do so it's such a hot job explaining it at the outset and I just need to explain it a little better and get their reaction and assuming their reaction is somewhat agreeable and you know considering their larger sort of presentation and whatever great budget this will be a 30 second 60 second sort of an interaction to get for that repair to happen but then there could be other situations where okay I've we've done this homework this is this is the third week in a row with this homework thing he he came in here asking for this sort of work and he's not doing it and this is consistent with other things he's doing or not doing so we we this might be the whole session but we're going in yeah now that I mean the way you lay that out was beautiful yes and add to and I might make the wrong call right like I might decide to we need to explore this and then we kind of don't get anywhere and I realize I should let that go or I may think oh we're fine and then it you know I mean the imported stuff often comes back right so so then it's like oh that was the third time oh now here we're the fourth time okay Catherine come on we need to talk about this right yeah yeah that that's exactly what I was thinking about which was like you know that the first time you do the if you're if you do homework like the first time you do it that it's not it's very common for it to be a little bit of a dud you know and like oftentimes it's like oh shit we only have three minutes left I better do it now and so but then if you know it's repeated or whatever that's when you might dig deeper into it exactly yeah so that yeah okay so that that totally makes sense yeah as I was reading the the task analysis that you did like what we did a task analysis and it was like but it was like solely focusing on the client and I was like in reading I was like man doing with both the client and the therapist in this process unfolding over time I was like man it's doing a task analysis on hard mode like I was like that's really hard because it's hard I mean it's hard yeah but we did was hard it's hard but it's I love I've always been really interested in the experience of the therapist and the person of the therapist and and I get I find it really exciting because there's so much I guess training implications right when we identify the therapist role and and what about the therapist how can we maybe train or support therapists to navigate situations more effectively I just think that's really interesting and I know you do a lot of training so why don't we just jump right in there so could you give sort of a broader review of the the training that you've been doing so Alliance focus training and the way we've primarily done it as it is as a form of group supervision or group consultation so a group of you know maybe four or five trainees and we've been doing it with two co-leaders we found it's a really nice way to to do it and how big are the groups so like so if we've got like four or five trainees plus two co-leaders so four okay yeah so ideally everybody's video taping their therapy sessions and can bring session video but sometimes people are in places where that's not possible so if you can't bring video then we might ask you to you know tell us as in as rich a way as you can and we use a lot of role plays so what so the way a meeting might look is we will start with a mindfulness exercise because we think mindfulness really fosters the right kind of headspace for doing this work where you're really open and curious and non-judgmental and self-compassionate so we'll start with that and then you know figure out who's going to present they'll show video or you know describe a challenging moment so it's not a place to come and show off about you know it's not your highlight reel time it's it's bring the place where you felt stuck place it was really hard and so this is where it's really important that the the space feels like a safe place to bring these moments so it's really important that the co-leaders foster a safe environment with good group cohesion so bring that difficult moment and we'll try to kind of so what's hard for you like what's the place you're getting stuck what's your struggle for the therapist to identify that and then we'll look for an opportunity to do some kind of experiential work with that it might be just helping you like a focusing exercise to help the therapist really understand what was going on for them in that moment might be a role play where they play out a conversation with their patient and they could play their patient like I did in my training experience it was so helpful playing my patient or you could play yourself and somebody else in the group could play the patient or you could play both parts and move back and forth between the chairs sometimes in the process of exploring that will will realize there's some kind of inner struggle for the therapist like do I do this or do I do that or I'm trying to do this but I feel like I'm so ineffective and you hear their kind of inner critical voice coming out and we might shift the role play to being two parts of the therapist kind of having a conversation like your internal dialogue and what we're trying to do here is just increase awareness of what's going on and as you become more aware of what's happening places where you felt stuck you start to get unstuck you start to see possibilities you didn't see before you might come up you might come across something that you're like oh yeah I'm going to say that to my patient in the next session that could happen but that's not necessarily the aim like we're not having them rehearse what they're going to do it's more like helping them see it differently so they're now ready to go in in their next session and roll with whatever happens right they're they're like feeling more capable and and seeing more avenues that they could take the next time they meet do you think that the in going through this process that the therapists are better able to in the moment in their in session the following week or month or whatever able to identify the ruptures as they're happening I that is a hope and we're always like with our research trying to get better and closer to actually being able to like say that that's definitely happening right to use the right measures to get at that but yes I think with with recognizing ruptures there's both people turn developing the skills to kind of see it and and this is where things like oh there's a withdrawal there's a confrontation those concepts can be helpful so recognizing those markers but then also the big thing in AFT is your own sort of internal sense that something's going on so the more I'm able to realize what I'm feeling then I can pick up on oh some things off like that might be the earliest warning signal of a ruptures I feel a little uncomfortable or anxious or disconnected or you know whatever it is so yeah that's that's definitely a goal of the training that's this what I was sort of preparing for this and thinking about this that's exactly what came to my mind is that it's that feeling right and that like and you know of course this is just based on what was happening in my head so I could be terrible at it but the it's like that feeling is the trigger of like there's something going on here to pay attention to and I need to I need to quickly make some sense of it I don't mean literally not fully interpret it but like bring it into the room is this my is it my own anxiety about something that you know some sort of you know kind of counter-transferancy kind of a thing that I don't need to verbalize it but I need to think about you know that intuition to like not talk about this thing is probably wrong you know like that that sort of stuff so I was thinking about that in terms of those like that feeling is what you know gets you going you know in your head very quickly of like what's going on here what should I do about it well and maybe what's going on here I think we can linger there for a long time actually because the what do I do about it might bring with it a sense of pressure right so yeah so I'm thinking it's more like okay let's just lean I'm really curious let's lean into that and and and and kind of follow that curiosity right say say say more about that what I think part of what I think happened what we hope to do in AFT one of my colleagues referred to it as sort of destigmatizing ruptures so therapists may come in thinking okay ruptures are bad and scary I should avoid them at all costs and if they happen it's like a fire I've got to put out immediately and we're trying to say these are part of the process it's inevitable that ruptures will occur I'm not saying that every single rupture that occurs is inevitable because I think there's some things we like shouldn't do there's some mistakes that we shouldn't make and and but something of some sort is going to happen and and to like lean into it with curiosity and if we're coming from a you know a position of humility like I contributed to this somehow I'm part of whatever process is unfolding and I'm curious about what's happening and I think understanding this will help if my patient and I can work together to understand this this will help both of us and help the process so kind of thinking about that and like as we lean in like that then what to do will come more easily I think more organically total so okay so in your in the training that you do what where are folks in professionally great question so typically I guess yeah so for many years we were working with advanced but I'd say advanced trainees so like psychology interns psychiatry residents so people who we weren't teaching them how to do therapy right we were like bringing additional skills to people who already had some way of doing therapy and we've recently done some more trainings with people who are already licensed so definitely already know how to do therapy I think if we were going to do this work with somebody who's like literally it's their very first case we would need to add things to it because we're really I it's important to me that it's not presented as a type of therapy it's it's an approach to training that my hope is useful for anybody doing any kind of therapy I'm not coming in here saying you can't do whatever kind of therapy you're doing I'm not interested in being part of the therapy wars it's more like here's some tools and ideas that anybody could incorporate that I hope would be helpful when the idea of rupture shouldn't happen that sort of unhelpful belief do you see that a lot I see that I mean it's often it's often tied to also defining rupture I mean it gets tangled up and help people define ruptures so somebody could probably define ruptures in a way where we'd all be like yeah that shouldn't write like a blatant argument with your client we're just like going back and forth yeah like that we're like we're I don't know beating each other up physically or something like yeah yeah that shouldn't happen agreed but I think I think maybe there there's some people who might I have heard some people say like oh in this approach or whatever like we don't see ruptures are we very rarely see ruptures because we're so good at this and the other and I guess I mean the way I define ruptures I do see ruptures I mean I see ruptures everywhere but that's because I am looking at these little more subtle things too and then I think there are beginning trainees like who feel like I'm supposed to be perfectly understanding and empathic 100% of the time and I'm supposed to always know what to do and so every little this step is terrible and and you know if I just work a little harder than I won't make any of those ever I'm thinking about as we're talking I'm thinking about I just talked to Dennis Kifley-Khan who's a big group researcher right and so we talked about like group conflict and that the value in having sort of that like increased group conflict during the you know the the middle stage if you will of group therapy right and that I'm also thinking about some of the work on like interpersonal complementarity and that sort of this model of again sort of as you get into the real work of therapy you have increased anti-complementarity right so like that that tension is necessary and part of the process of change because you're bringing you're bringing things that are going to push the client or pull the client and they're going to do the same things back to you like that is regardless of orientation and this stuff's been observed across orientations and so that like just that and I don't know I'm curious you're thoughts about this but like that that is sort of this is a way of thinking about that that ruptures are in some cases a indication of working of doing hard work yes I think that that is true and I think one example that springs to mind is especially like when somebody who's been very withdrawn finally starts coming out of their shell and maybe they come out in a slightly aggressive way like I might code that as confrontation but I'd be thinking hey that's good that's progress for that person my only hesitation is I want to be careful about going too far in the oh ruptures are good that means I'm doing the right thing because sometimes we can use that to be licensed to to push too hard or to be too aggressive ourselves right or to kind of like write off dismiss things that might be warning signs for like oh this just means good things are happening so so I think I guess I like to be sort of like we just have to be really curious whatever's happening it could be good it could be bad we just have to we can't like assume we know what it means right yeah and I think maybe the amendment would be that ruptures and repairs are an indication of working like the two happening together right that if I totally disregard that's overstating it but if I become brazen right because I you know so I just like push super hard like then that sort of indicates I don't care that much so like repairs plan not gonna happen because I just think it's okay and ruptures are fine and we're just gonna keep going but if I you know and be able to find that you know the zone of proximal development or whatever like to push some but then also to like work through that with my client that that's that's an indication of working yes I think that that's well put okay okay so what what where do you think that and so this is I'm sort of curious about your own sort of experience and training and working with lots of folks like where do practitioners tend to miss ruptures like where do they there are certain types of ruptures that they you sort of see like oh yeah this is frequently missed I think um generally withdrawal is more subtle and more challenging to recognize the confrontation and actually when I when I present on this that's also where I would get more pushback like some of the withdrawal examples people will be like oh that's not a rupture and to be like like um let's say you keep going but well no like the the very intellectualized patient people will say well that's just how that patient is and I'm like well you could say the same of the very hostile patient but you're okay with me calling that confrontation I still think that's withdrawal then to be fair as we you know do more research with this we may find that some of the ways we're operationalizing this you know okay maybe we're over coding some things or maybe we need to adjust some of that but I think movements a way can be harder to detect and they can also include somebody being kind of deferential and appeasing and that can be tricky because you made they're saying everything's great and you're like okay great everything's great but everything's not really great that that can be challenging to to pick up on yeah that's one of the things I talked to in my uh the class I just finished teaching is like I always say that like if everything you say your client completely agrees with you then there's something going on there like because just because that just is not normal like they have to amend some things and say like yeah mostly but a little bit if it's everything is if you're perfect there's a problem because you're not perfect yeah what kind of ruptures do so like that's in the identification are there types of ruptures that you think that therapists have the hardest time sort of responding to therapeutically? That's a good question um hmm and I have a related question so they might be the same answer okay which is the types of ruptures that therapists tend to have the strongest emotional reactions to I was I was struggling to think like what's the answer to that and I think it depends it always does it always does but but what I'm thinking is I think the answer may be a little bit different for every therapist right because it's it's also tied into to us and our interpersonal styles and and you know some people like some people um I've heard uh people say that you know the withdrawals really hard for them they prefer a good confrontation where everything's out in the open and they know the patients have said and it's clear but then for other people confrontation would freak them out and or you know be really uncomfortable and they would rather deal with withdrawal um and then there's there's uh subtypes within that um and I think also you know ruptures that are tied to um differences in identity and culture I think those can be really tricky or people can get very uncomfortable um around um but I think it's it the answer may be different for every therapist and we also maybe just need more research to answer that question when you say rupture related to identity blue was that look like so I think I I see um you could you could have a rupture that like I think you could conceptualize microaggressions as falling within rupture if a microaggression happened in therapy either the patient saying something against the therapist identity or the therapist saying something against the patient's identity um I think there can be misunderstandings that arise due to cultural differences um and and actually in in um like Chris has written about how you you can understand all ruptures as being part of like two people with all their different identities and experiences kind of you know um clashing or having difficulty connecting so you could sort of see all of ruptures being having a cultural being embedded within culture and cultural identities but sometimes there are certain ruptures where it's more explicit that that bias misunderstanding prejudice is something like that is is a salient piece of the rupture when it comes to repairs are there certain types of repairs that you think folks have more difficulty I want to say learning doing I'm not exactly sure yeah I think exploring the rupture and sticking with the exploration and in particular that's a wrap on the first part of our conversation about alliance ruptures join us in our next episode when we dive deep into rupture repairs as I noted at the top it'd be much appreciated if you could spread the word to anyone else who you think might enjoy the show until next time Bye.[Music]
