Facilitating Therapeutic Alliance Repairs in Psychotherapy with Dr. Catherine Eubanks

Dr. Catherine Eubanks returns to continue the conversation with Dan on alliance ruptures in psychotherapy. 

Dan and Dr. Eubanks continue to dive deep into the complexities of ruptures and repairs in therapy. They discuss the challenges therapists face in exploring ruptures, the importance of recognizing therapist-initiated ruptures, and the role of anxiety in therapeutic relationships. Dr. Eubanks emphasizes the need for therapists to trust the process and be aware of their own anxieties, while also advocating for a broader understanding of ruptures in various contexts beyond therapy.

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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Chapters

• 0:00 Introduction and Episode Overview
• 2:58 Therapist Anxiety and Its Impact
• 6:11 Applying Rupture-Repair Concepts Beyond Therapy
• 9:00 Therapist-Initiated Ruptures
• 14:14 Training Therapists to Navigate Ruptures
• 21:07 Disseminating Process-Oriented Approaches
• 25:14 Pushback on the Term "Rupture"
• 28:10 Recommended Resources and Final Thoughts

Transcript

0:00

[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 36 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 some fun along the way. If you find this episode useful, it'd be much appreciated if you shared it with someone else who might enjoy it too. Today I could be more excited to welcome back one of the world's authority on Alliance ruptures and repairs. My guest is a professor at the Gordon F. Learner School of Psychology at Delphi University, associate director of 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, recipient of several prestigious awards from the Society of Psychotherapy Research and the Society for the Advancement of Psychotherapy and the Associate Editor of the Journal of Clinical and Consulting Psychology. In this part of our conversation, we discussed several aspects of Alliance ruptures and repairs, including challenges in repairing ruptures, therapist initiated ruptures, therapist anxiety, training and supervision, and much more. This episode begins with my guest answering my question about if there are certain types of repairs that therapists struggle with. So without further ado, it is my absolute pleasure to welcome back my very special guest, Dr. Catherine Ubex. I think exploring the rupture and sticking with the exploration and in particular disclosing your own experience in the exploration can be challenging or scary for therapists. What do they want to do instead of stick with the exploration? Move away from it. So it might be, you could stay with focusing on the task or linking to patterns. So we can link the ruptures happening to another pattern in the patient's life. Right? Like the thing happening between us. Oh, it's like the thing you were talking about with your parent or your boss or your spouse or whomever. That can be a very valuable intervention, but if we jump to it quickly because we're uncomfortable talking about us, then I would say, okay, yet is an attempt to repair, but it's also a therapist withdrawal. That's an example of how the same move could be both, I would argue, a marker of rupture and an attempt to repair. Say that one more time. Okay, so like we're talking, we're talking about us, right? And some rupture we're experiencing. I'm therapist. I'm getting uncomfortable talking about this. This is a weird way of talking. We don't do this necessarily in all of our relationships, like talk so explicitly about what's happening between us. I see a connection to something you're dealing with in another relationship and I'm like, well, it's like this over here. And we move over to talk about that relationship because it's safer and easier. And there could be some fruitful things to come out of making that connection, but we've also like missed the opportunity to fully mine this thing that's happening right now live in vivo. It might be, that might be a missed opportunity. We can always talk about mom, dad, spouse, boss, whatever. But like the thing is happening right now between us. That's like such a rich opportunity. We should take advantage of it. What did jump a little bit? I might jump back, but it's just as you're talking, I like this just seems like is this process, how unique is this process to psychotherapy? Because as you're talking, I'm thinking about having a conversation with, you know, your spouse about something or your friend about something where you're trying to have those conversations and like the conversations that facilitate the two of you feeling closer at the end of the conversation, you having a sense of, you know, whatever that. And then you're stressed that your experience that's sort of being alleviated and then the conversations where it's sort of like you don't feel closer, you might even feel more distant. Yeah, so I guess I'm curious about your thoughts about this in other contexts. And setting up those two examples, were you kind of thinking one of them is like it was repaired and when it wasn't. And I was thinking about your example of the therapist, you know, the therapist moving to, you know, oh, this is like what's your relationship with your brother and right. So taking it off of me and putting it over there is like, you know, trying to have a hard conversation with somebody and then not wanting to have the hard conversation with you or vice versa, you know, whatever. Yeah. And so like that stuff never gets processed, you know, there is no repair. The repair gets sort of like chopped off. I am really interested in this question of taking this rupture repair idea and applying it to other relationships. This is actually something I want to do something with, write something about. My hunch is that it can apply to a lot of other things. But there may be something about. Like I've thought about this when, you know, their interpersonal conflicts are like there's plenty of like rupture happening in the world right now, right? And like how much could the rupture repair stuff be helpful for that? And one thing that might be different is, I mean, I think when rupture repair is happening and like working in therapy, it's like you've got two people who are coming in good faith. You know, there's some sort of like we're both here and I don't know. There may be things about the therapeutic situation that it those qualities aren't true in another relationship. Would this approach work or would you have to approach it differently? This is like on my list of things I want to think more about. So. I think there's something there, but I also wonder if there's a limit to. The application. I guess I have a couple of I you know, a ton more roughness than I do. I mean, I guess one one thought is like. Yeah, in many cases and optimally, both people are there in good faith, but that's not always true in therapy. Yeah, even as I said that I was like, wow, I'm. Wait, I mean, yeah, I guess I was thinking also that like part of the process could be to. Get more like to feel that more right? So like the recognition of. This person's just being honest my cynical perspective is wrong or change it shifts and I would think that that could. I mean, you know, yeah, that like that could be part of the repair is I thought that they were being an asshole, but actually. Although perhaps misguided they were trying to help. I don't know. I mean, I do think and something I have thought I mean, I've definitely had moments outside of therapy where I've been in a situation in like the repair stuff has come to mind to navigate a situation. And and the things that I find really helpful like okay realizing something's going on and. I'm going to be non defensive. I'm going to be curious. I'm going to be as transparent as I can about where I'm at. I have used those things in other contexts for sure. Yeah, yeah, I think it's probably like it's. It's nice. I mean, it's like it's such a because I was sort of you know in preparing for this, you know, you know, I've been familiar with this work for quite a while, but you know, you start to think more about these things. I'm sort of like this is such a nice way of framing the process that's occurring. Yeah, I don't know. It's just so it's nice. Like it kind of holds together in a way. Yeah, and then you can identify the specific aspects of the things that are happening, which is very cool. One of the things that and this is when I saw you speak at SPR, I was like the thing that really jumped out to me was the talking about the therapist initiated. Proptures. So I wonder if you can talk about that a little bit. And then I'm going to bring up something and get your thoughts on it. This is ultimately this is selfish just to influence my own work. So go ahead. Sure. Well, so part of the and something we're hoping to be able to do more research on now is when we revised the Therapis and added so we can now code for therapist rupture markers as well as patient rupture markers. Because I think yeah, it's not always. I think it's a mistake to think ruptures or things patients do or the patients always start like therapists can initiate ruptures. Therapists can come in with criticism or putting pressure on the patient. Those would be confrontations or therapists can be the ones moving away, changing the subject, being avoided and being disconnected. And there's and we can do that unintentionally. There's also times therapists intentionally are kind of pushing like we were talking about earlier. And and and so being mindful of like when is that too much or you know when is that actually in the service of the therapy and when is that I'm just doing it in a way that you know not regulating my annoyance very well. Yeah. So I think so as I was sitting you so one of my areas of research is sort of working with folks who are acutely suicidal sort of into a side crisis. And so one of the big things and this isn't the part about to talk about this isn't my work. It's more of what I've learned from others is that basically that we shouldn't be doing risk assessments because they don't predict. They're obscenely inaccurate. And it's just there. But so like but it's not just that they're obscenely inaccurate. If that were the case. Okay, we shouldn't be making decisions based on their predictive ability since their their prediction sucks. But there are other problems with it and one and so that what we do is we then we take our focus from the client and what's going on with that person. And instead we bring it to oftentimes this assessment right. So we oftentimes sort of stop being therapeutic in order to collect these data and then you know and that there's all these other things that happen to which is oftentimes our anxiety goes up our work goes up. We start to worry about us right. I don't want to get sued. I don't want this person to die. What if I take this person to the hospital. I have to pick up my kids in half an hour. Nobody else can pick them up. The daycare is closing right. Those are real stressors. And that like so anyway so that we often. Yeah, that we often focus less on our. It becomes less client focused right it's less what's the pain that you're going through right now. And I'm assessing that and working with you and all that sort of stuff and it's more me collecting this data freaking out and figuring out what I have to do. And so and so I've been you know writing and thinking about this for a while but when you were talking about the therapist initiated ruptures I was like that's it. That's what a lovely framing for what's happening often in these cases. So I'm curious about your thoughts. The therapist anxiety is a huge one right when we get anxious and that that can just suck up all the oxygen and cloud our view of what's going on. And and I'm thinking I think perhaps the presentation you saw at SPR was where I had the example of the therapist with the client with a lot of guns. Maybe that was. Yeah, there's got all anxious about the guns and then you know like you said was right like was worried about that and assessing that and was missing what was going on in a personally and with the patient. And it was sort of the patient who kind of kept bringing it back to the therapeutic relationship. It was the patient sort of leading the repair process and that example. This is an example from Sasha Rudinstein's group contributed to a book we did. I think therapist anxiety is huge and I think that's something that comes up a lot in in AFT. And then the reality in Alliance focus training is helping therapist realize when they're anxious because sometimes people just get you know they just act on it and don't realize oh I'm anxious right now and then being able to kind of do what they need to do to regulate themselves and and and not have the anxiety sort of take over. And once once we get anxious and like I got to do this thing we can just end up steam rolling over the other person right yeah okay I just sort of as I was like okay great yeah that sort of made that seems to be like a really nice way to frame that and to talk about it is using that great I'm glad that was helpful yeah super helpful. Do you think that there's a time to early in people's training to bring this in and we sort of talked about it a little bit. That's a good question I mean. Yeah maybe not I mean maybe how much you get into like exploring a rupture or something maybe that would be a lot in in one's first day trying to learn about therapy or something but I think it would be important very early on to have this idea that you know things are going to happen things aren't always going to work according to plan you're going to mess up they're going to be moments. You and your patient are on the same page and to be prepared for that to be. Yeah that's going to happen and that's that's not immediately a sign that you fail that is something you want to pay attention to and be curious about but yeah don't think that you're going to somehow magically avoid that and in fact it's an opportunity to learn more and maybe work towards a corrective experience. Yeah I think that that I mean as I'm as I'm saying this I'm realizing like I teach an undergraduate class on concepts in therapy and and we spend a class on ruptures I mean they're not doing therapy but like yeah sure I think that idea is a helpful one and could be there right from the beginning. Yeah I was thinking about it because I teach an undergrad basic helping skills class and I was sort of thinking like what this be worth bringing in. Yeah that's something I was thinking about since you've done so much training is there one or two things that you've learned over your time of doing training that has been like oh yeah I should do like by doing this thing differently it's way more helpful or not doing this thing might be really helpful. Like in the training you mean like doing this thing in the training yeah again I guess one of the things that jumped out was when you were talking about earlier about having people bring in the stuff that they aren't proud of that didn't go well I remember having a supervisor sort of say that once at the beginning it was I don't you know working with them like okay I want you to bring in your tape or you stink like don't bring in the tape or you're good bringing the tape or you stink and I sort of like carried that with me for the rest of my training. Like I was like I'm yeah so it was like I'm all because it was like why like of course I should you know and but anyway I guess that was a small thing and that's something that you all do but I mean you're more explicitly looking at ruptures and that sort of thing but yeah I guess I was thinking are there other things or is there anything else that you've learned as people listening will either be going through supervision getting supervision yeah it could be helpful. I mean definitely trusting the process so I've I've I don't know this AFT thing like it just it kind of works so I don't always know exactly what's going to come next you know it might be like well we'll try this exercise and if this exercise doesn't work we'll change it a little and or if I get stuck you know I'm I'm there with a co-leader I'm there with a group like when I get stuck I turn to the group like I'm going to do this. When I get stuck I turn to the group like oh what do y'all think or where should we go or what should we do and people come up with great stuff so I don't worry about running the show and and figuring out everything I don't have to figure everything out just just stay with it roll with it if we get stuck then well that's interesting why are we stuck like why are we as a group stuck that's meaningful or something's going on so this so it's it's almost like you can't really mess up is only she just kind of stay in it and keep trying to do it. Is only she just kind of stay in it and keep trusting and keep moving with it and and bringing in the group members they become at once everybody sort of gets what we're doing then it's it's not one or two supervisors it's like a whole room full of people with with great ideas and and great things to bring to the conversation. One of the things you just said there that I think is worth pointing out is that supervision is a process so instead of thinking about supervision as I need to know what we're going to do as you know as the supervisor right that I it's going to be structured and they're going to ask me questions and I'm going to have answers for them right or I'm going to ask them questions and they're going to have answers to me like that this is a process that's how I want to see it so I'm like I don't know what's going on we're just going to like figure it out together and and in many ways the therapist is the expert on their case I'm not there to tell them what I'm going to do. I'm there to like accompany them in this journey right and we're like together trying to figure this out and then I guess another thing that's that's actually top of mind because I doing some some training with with like we're sort of training trainers or training supervisors and in a recent meeting. Nobody kind of had material to present and so then I was like well fine I'll present so I presented a case and I had not presented a case in that context you know in a long time and it was so helpful to again be in that seat and remember what it's like to be the one presenting so I really think when there when supervisors have the chance to bring their material or it's it's just helpful. Because it's you can lose touch with what it's like to be the one opening up making yourself vulnerable sharing these things you know taking in what people are saying I don't want to lose sight of what that's like. One of the other things that I think is that we haven't made explicit also is how experiential your training is so lots of it's we're watching stuff in as much as humanly possible and then we're doing a lot of idea generation but then also some practice in the moment and a lot about really what are you experiencing and then met a communicating it right like practicing. So you know what if you told your patient all these things you were feeling. Try it right now out loud in front of the group you know let's see what happens let's see what that. Sturze up or reveals or helps us get in touch with. A question that I had this is just a big picture question and having all these conversations one of the things that sort of constantly struggling with is like how do we do a better job of disseminating. Process work you know I think that it's and I think actually what I'm talking about is disseminating it to the training programs. You know it's an eternal challenge how do you disseminate it to practitioners but even just to the training programs and I think that there's there's a natural appeal and I don't say yeah maybe easyness I don't know it that this treatment for this problem. That makes so much sense if I have a headache I take an aspirin right so like that we are moths to the flame I think when it comes to that sort of thing that just in. But this sort of like the work that you're doing and many of the other people I talked to or doing is it's it's not you know just like it's not this treatment for this problem right is it's meta thing is well so I guess I'm curious about your thoughts or if you have any thoughts about you know how we could do that more effectively. I am part of something that's trying to address this so Hennie Westra road a great piece that was published in the American psychologist talking about you know we we should use we train researchers and research students to do process coding right we teach them these ways like my three RS measure there's other measures for other processes. We train our coders to use them and they often come back and tell us that it's helped make them better therapist because it's it's talk them the ability to like observe these processes and be really attuned to them when they emerge and and so. Hennie invited me and and Tali Boritz to join her in writing a we're doing a book where we invited people different process researchers to write chapters illustrating the use of their measure and and the idea is is for the book and some resources that come with it to be something that you could use for training therapists so like you could kind of get. And enough of the measure to put into training it might not be enough to put in to be a reliable coder but enough to to be useful as like a lens through which to see your own therapy sessions. So I think that and and bringing that kind of training more into how we train therapists I think is is one fruitful way to go. That reminds me of the there's a book I think it's tired and and sick is that it that it's like psychotherapy based on process research or something the version I have is blue that's all I know. That sort of but it's but it's not measure specific which is kind of nice kind of the idea of that way also gives practitioners are trained like here's a tool to use as you move through which can really help to to an extent the stuff that we're talking about it is. A little nebulous right it's a little like where five a treatment manual says you know this is how you do this is that you that. So anyway so yeah I think having those tools can be helpful even if you're not regularly using them in practice just getting a scent which would be great but just getting a sense of okay what does this actually mean what does you know what is this actually look like. And what because once you start looking for these things you start me you can't see them so you look for them and then it gives you like a framework. For identifying subtle shifts and things that maybe happen right so just a couple more that I'll let you go so and we talked a little bit about this in terms of pushback that you've gotten in terms of like intellectualizing and people sort of pushing back on that is there any other pushback that you've gotten from from your work I sort of like to ask this question about everybody. The main thing is is is is people the definition of rupture so so I mean people saying like the word rupture should mean big stuff and you're including all these little things and I always I always open like early in every presentation I'll say explicitly like look the word rupture is not the perfect word for what I'm describing. I understand that the dictionary definition of rupture you know it makes sense you would think big configurations we're kind of this work is there's been enough of this work for stuck with the word right like we can't it's too late to change it so I'm just trying to I'll define I'll tell you how I'm defining it and how I'm understanding it but sometimes I find people keep coming back to that's not a rupture or you know like okay we just use a different word. I'm not it's not that's not important what's important is like paying attention to these processes so if you had a magic wand and you could go back and choose a different word or use a different word would you that's a really good question. By the way you're not the first person who's brought this up on the podcast of people who have theories that are sort of very you know what that they're like yeah I might change this word so just let you know you're in the company inevitably right because we're always nothing's perfect and so any word you're trying to take a bunch of stuff and capture it with one term that terms never going to be perfect and they try to translate into different languages and I mean it just gets so complicated. I know there in a number of publications my colleagues and I have kind of said oh you know there's ruptures and it could be related to all these other things like a bunch of other words that have been used in the literature to describe similar things so I guess if I could go back in time I might go back to that list and just see what I want to go with any of the other ones I don't know it's it's it's been rupture since I got into this work so I just accepted long ago like it's too late to change it is what it is. It is funny though I was thinking about the other day I don't remember what it was but just how like how you know terms often do because I mean it makes sense right if you're coming to something and they use a word and you're like oh well that means this right and that's and I'm not talking about your work specifically but just generally and then you so then it does become sort of a I haven't sort of had that experience personally but it must become like a constant just a constant drum beat of like oh my god this is and it's just it has to feel like it is just like a little bit of it is just gets in a way. Yeah I mean all I can do is say this is how I'm using it and actually something that's been helpful is right I'll talk about rupture markers because really when we're coding a session we're looking for these markers so we don't have to say it's necessarily a rupture or whatever it's a marker that we should pay to it's a marker something's going on whatever you want to call it so so let's let's look at these markers. Yeah that matches it's a good that is nice. So I'm sorry. So the other thing the last thing I wanted to ask is if there were one or two resources like we would ever that you want me to you want to sort of bring out for people who want to learn more so I'll link for to the measure. I think there be is there a particular place where folks can go if they want to learn more about the training. Yes we have a website. Oh great what is it. Therapeutic hyphen alliance dot org. Great and I will link to that and then is there is there and then the the book negotiating the therapeutic alliance I sort of mark that to link to that is there anything else that you think would be particularly. Yeah we have a couple more recent books that might be helpful so so Chris and I did therapist performance under pressure in 2020 and then in 2023 we did an edited book with Lisa Walner Samstag rupture and repair and psychotherapy a critical process for change and what's nice about that book is we invited people from different therapy approaches to write chapters about ruptures and repairs in their approach. So if you work in a particular approach and you want to read about this in kind of your context. We've got a bunch of great chapters in there and we're in the finishing stages of a book about alliance focused training that is designed for supervisors who want to do this form of training so that will be coming out hopefully next year and we'll have a video and APA video to go with it. And Chris and I also did an APA video on rupture repair that you can get through psych therapy if you have access to that like psychnet psych therapy library. Maybe that's something I could think about because I do. Oh yes that's something I could psych therapy is like a great resource for it for teaching. And so we've got some us working clients repairing doctors. Ladies and gentlemen, Dr. Catherine UBanks. That's a wrap on our conversation about alliance ruptures and repairs. As I noted at the top of the show it'd be much appreciated if you spread the word to anyone else who you think might enjoy the show. Until next time.(upbeat music)