Therapeutic alliance ruptures do not only involve confrontation events.
What does an alliance rupture mean to you? A client who is affronted by something you’ve said, and storms out of a session? A raised voice or intense distress in response to discussion of a break? A complaint made to your service? All these may indeed signal a rupture in need of addressing. However more subtle markers may present themselves more regularly yet could feel more difficult to address.
Research suggests that in a fair number of cases therapists do not notice tension or difficulties in the therapeutic relationship which arise from problems in the therapy alliance. This might be because therapists more readily associate ruptures with confrontations or the expression of critical or angry feelings towards the therapist. Withdrawal ruptures may be as important in terms of impact upon therapy outcome. However, a withdrawing rupture may be enacted in a multitude of ways which can be easier to overlook. Recent research by Kyle et al. (2018) seems to support this possibility. They found that therapists were less aware of withdrawal ruptures than confrontation ruptures and so intervened less often in these cases.
Harper (1989) developed a framework for identifying markers of confrontation and withdrawal ruptures. Muran & Barber (2010) discussed the need for therapists to be alert to subtle markers of withdrawal as they argued that they were more likely to be missed or accepted at face value. Arriving late for a session or forgetting homework are two examples where therapists might interpret these markers as simply being human or be tempted to accept explanations at face value.
Two things come to mind. First, understanding interventions as relational acts can be helpful to aid decisions about when to explore further. For example, a perfectionistic client may avoid a task to avoid missing an internally imposed standard, or risking the therapist judging them negatively in some way. Not exploring this together might mean missing an opportunity to understand this pattern within a compassionate relationship.
Second, in my experience it is always worthwhile enquiring about the experience of the previous session. Any hint of tension or difficulty might relate to the withdrawal marker in question. For instance, a client who feels embarrassed or ashamed in a session might come late to the next one as a way of managing this. If not addressed the client could prematurely end the therapy.
More broadly, in my experience therapists can understandably feel reticent to address withdrawal ruptures because they can feel they have less to go on and worry that exploration could lead to confrontation! Sometimes as therapists we may be aware that something we said has triggered the client but feel awkward about acknowledging this or that we made a mistake. In my experience acknowledging our fallibility and vulnerability to our clients can strengthen the alliance. This can also reduce the pressure they may feel to get things right all the time and help them accept their own vulnerable sides more.
What can help? I believe that feeling confident in the skill of therapeutic metacommunication can be useful. By this I mean being able to create an open, honest and respectful dialogue between you and your client that fosters awareness and understanding of such relational patterns, so they can be explored safely and resolved collaboratively. Cognitive analytic therapy offers us many useful approaches to this end, many of which can be integrated usefully into other therapeutic models to help inform and strengthen a relational perspective. Want to learn more about all the above? Then read more about this ACAT CPD event which promises to be a rich day of learning new ways of negotiating the therapeutic alliance.
Dr Robert Watson, Clinical Psychologist and Accredited Cognitive Analytic Therapist Supervisor and Therapist.
Harper, H. (1989). Coding Guide II: Identification of withdrawal challenges in exploratory therapy. University of Sheffield, Sheffield, England.
Kathryn V. Kline, Clara E. Hill, Taylor Morris, Seini O’Connor, Ryan Sappington, Collin Vernay, Gabriela Arrazola, Michelle Dagne & Hide Okuno (2018). Psychotherapy Research, Vol. 10.
Murran, C. & Barber, J. (eds.) (2010). The therapeutic alliance: an evidence-based guide to practice. Guilford Press.