Rupture and Repair: Part 1

Inspiration for This Post

A topic that comes and goes in my practice has been weighing on me recently, as it (in full disclosure) appeared in a harmful way to my client, as well as myself. In fact, it caused enough damage that it led to a premature drop off from the client and to me writing this post. It also, weirdly enough, coincided with my own therapy process, where I experienced it as a client. This concept is an inevitability of therapy but also can hold different meaning based on the therapist’s personality/learned behavior, the client’s personality/learned behavior, therapy strategy, therapy goals, therapy expectations, you name it. And what is this mythical beast I am naming? Rupture and repair.  

After events like this, I usually find it hard to balance the moving pieces above. What was my role? What was the client’s role? Could anything different been done by either party or was it a bad fit? I also ask larger questions around therapy in general. When is a rupture something that is possible to collaborate through? When has it dug deep enough that it is insurmountable? Can anything bring it back on track? I often feel it is my responsibility to parse out, that way, I can improve my technique as a therapist over time and attempt minimize harmful situations. But obviously, these questions all have subjective answers; I can’t create a steadfast template to follow any time rupture and repair takes place. So how do both therapist and client influence the therapy system each time rupture occurs and respond to it in real time on a case by case basis? I thought I would write a post on this, since my approach is generally interpersonal/the topic could benefit both other clinicians and clients alike.  

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Interestingly, looking into this topic, I did not find much from a therapist perspective and plethora of information from client perspectives, which really informed me about therapists’ approach to the idea. I can only assume this is borne of therapist imposter syndrome/shame, where exploring concepts of rupture are too uncomfortable, either to the self or admitting to other therapists. I also found an article detailing how therapists use their position to explain away their role in rupture, so it could also be therapists own coping strategies preventing them accurate analysis (Hook & Devereux, 2018). Either way, it appears as though therapists are trained a great deal about other’s discomfort, but nothing of their own discomfort, which clients are feeling and we as providers are not acknowledging. So, here is me acknowledging and attempting to explore. I’m planning on two parts to this blog: the first part below is my personal exploration and what this says about the current state of graduate school training. The second will be a small literature review on what the research currently says about rupture and repair, something that I think SHOULD be provided in graduate school.  

What is Rupture and Repair?

To begin, what do I mean by rupture and repair?  

As I know it now, the term rupture in therapy refers to, “an impairment or fluctuation in the quality of the alliance between the therapist and client” (Safran, Crocker, McMain, &. Murray, 1990). More broadly, it can be observed when a client and therapist are engaging in a negative process, not a positive one (Horvath & Greenberg, 1994). To put more plainly, rupture is any therapy event that 1) disrupts the therapy process and/or alliance and 2) causes therapist and client to engage in negative or nonconstructive patterns. A repair in therapy then, is defined as, “the therapist’s attempts to address the rupture with their client and restore the working alliance” (Norcross, 2002). Again, this is the process of validating, understanding, and collaborating to undo or build from the rupture positively. It is also important to note that this model is founded on the premise the ruptures are a natural part of the therapy process and are inevitable (Fuertes, 2020). On the upside to the eventuality though, rupture and repair are often thought to significantly help the relationship and are associated with more positive outcomes post therapy (Fuertes, 2020). Note that I specifically used “in the therapy space” for these definitions; there will be a broader exploration later.  

I do also want to clarify what is rupture and what is not; rupture is not necessarily harm or abuse. Though, finding the differences in these definitions was…. also unstandardized (this theme will continue). The best working definition of harm I could find was: “compromising adverse events – significant episodes during or shortly after treatment, clinically significant deterioration following treatment, and lasting bad effects as described by the patient” (Hook & Devereux, 2018). Some causes of harm include therapist misconduct, poor skills, and adverse client reactions. Misconduct in this context refers to a therapist not observing boundaries of the professional relationships, poor skills refers to therapist negligence or incompetence, and adverse reactions refers to incompatibility between the client and the treatment modality (Hook & Devereux, 2018). Essentially, rupture is anything that disrupts the therapy process, harm is a form of rupture that has lasting negative effects. Finally, rupture and harm are not abuse, though finding a standard definition to highlight this was hard. I was unable to find a specific counseling relationship definition for abuse, not even in the American Psychological Association’s (APA) or the American Counseling Association’s (ACA) code of ethics/other publications by these organizations. So, I’ve went with the APA’s 2018 dictionary, which had the following definition of abuse in general: “Interactions in which one person behaves cruel, violent, demeaning, or invasive manner towards another person or an animal”. If we extrapolate that to the counseling relationship then, it could mean either the client or therapist’s intentional actions to cause harm to the other party. One lacking aspect this definition from the APA, in my opinion, is underlying power structures. Yes, abuse is possible in either direction (in fact, there was recently a therapist who was killed by a client in Florida), but most commonly occurs from someone of higher power to lower power as an abuse of that power. That power, in the therapeutic alliance, is held by the therapist, as they are the professional.  

In sum: rupture vs. harm vs. abuse can be viewed as a series of narrowing  foci, rupture being the most generic, then harm being a form of rupture, then abuse being a form of harm, which is a form of rupture. If I were to use a plane metaphor, rupture is turbulence everyone is experiencing, harm is the pilot or a passenger accidentally causing the plane to start failing, and abuse is the pilot or a passenger actively and purposefully crashing the plane. And more likely, the pilot has more power in any of these situations to do something about it.  

Complexity gets added when we consider level of impact of rupture and context, not just textbook definitions. For example, a rupture around a scheduling confusion may have less of an impact than a rupture around a therapist not remembering a pivotal piece of information. BUT, this depends on the client and therapist too; perhaps the client has a developed a narrative around being forgettable, where either of these concerns, to the client, hold the same weight as they support the narrative of being forgettable. Or maybe the client understands the complexity of their story and thus has more patience for the therapist missing information, but adheres to a rigorous schedule and cannot tolerate variation. The same can happen in reverse; perhaps a client forgetting a session activates the therapist more than if the client had yelled at them for forgetting. Or, maybe the therapist is activated by yelling but is not so concerned with scheduling conflicts. So, not only are there the standard definitions of rupture vs harm vs repair, but there are also personal interpretations of events by both parties in unique ways. This is where things can turn to putty: rupture, harm, and repair can be very subjective based on the eye of the beholder. What I, the pilot, view as turbulence, someone else has viewed as me intentionally crashing the plane due to their past flying experiences/traumatic flight headlines filling their heads. This is where it gets tricky: where does the line of subjectivity and objectivity get balanced? To call on above, if I interpret an event in therapy as rupture, the client viewed it as abuse and reports to the licensing board, who’s perception is viewed as “right’? I don’t have an answer to this, of course, but I wanted to point this out for folx. There is not a correct reality, but an amalgamation of everyone’s perceptions of what they THINK is reality. In the end, only the repair process can really delve into this confusion, tease out for both parties what was reality to them in that moment, and reconcile these differences.

My Quest in Gaining This Knowledge

It’s funny because this brief research for a definition was current fully licensed me. It was not, as I will describe below, in any of my graduate school training. I know this, because my actual first step to define rupture and repair was to consult my graduate textbook on helping skills. For context, in counseling graduate schools in general, most programs will have a “helping skills” class or something similar that teaches therapists the ropes to pose non-judgmental questions, meet the client where they are at, develop active listening skills, etc. I went back to my textbook for this class, because naturally, this would be a topic covered here. The book is titled “Helping Skills: Facilitation, Exploration, Insight, and Action” By Carla E. Hill. And a brief note: it is not a bad book by any means, as its main purpose is to overview and introduce students to the helping process, not cover specific clinical issues. But when this is the only text provided to students?.....I have thoughts.  

To resume my exploration of this text, under the section “Dealing with Difficult Clients and Clinical Situations” there was a single page detailing, “Clients who are Angry” ...woof. First, this signals an issue with language: it is phrased, to me, sort of begrudgingly and within client ownership not therapist provocation. Are clients difficult or are we as therapists bad at meeting clients where they are at? And this doesn’t scrape the surface of the colonialism behind therapy/pathologizing normal reactions to difficult events. So, are clients reacting negatively (angry, pathologized), or are they reacting accurately to something we did (angry, normalized)? Second, the authors did not use the language of rupture and repair, which is not helping therapists actually use common language to help each other navigate the issue. It’s so subjectively labeled in schools that therapists are not recognizing the larger pattern together. And the dates on the research I utilized are absolutely old enough to turn into class material; it’s not cutting edge. On the other hand, as always in a psychology space, there is never just one input. There are truly times when a client’s reaction is strong, uncalled for, or abusive, and while therapists can provoke this by a negative/unhelpful skill used, it could also be a layer of touching a topic too close to a vulnerability the client cannot or will not access at that time, parts of a client being activated, coming from a place of being mentally unwell, etc. The hard part is that at the end of the day, there’s no way to determine if, what, and what percentage of the issue is the therapist’s to own versus the client’s in rupture.

If we resume my graduate school textbook and accept all the problems above for a moment, I dove deeper into the paragraph, “Clients Who Are Angry”. The author of my textbook does a minimal job of explaining the therapist experience, stating, “For most helpers, it is extremely stressful when clients are angry at them and express anger in a direct and hostile way. In fact, in one study, 80% of helpers said they felt afraid or angry when clients were verbally abusive towards them.” They then site a study with the conclusion of, “…client anger often disrupts the therapy process, especially when helpers feel angry, confused, hurt, guilty, anxious, or incompetent, instead of able to remain empathetic and objective and talk about the client’s anger.” (Hill, 2020). Again, hate the phrasing of clients causing the issue, but I do agree that a therapist’s discomfort can impede the therapeutic process. (Also, side note, who tf are the 20% of therapists not getting activated, because that’s bonkers!) The book continues, “To avert the negative consequences associated with inappropriately managing client anger, several authors have suggested that helpers respond to client anger as they would to any other emotion by encouraging clients to talk openly about it.” Full heartedly agree with that, anger, like any other emotion, has important origins. Continuing, “…they suggest that helpers need to listen nonjudgmentally and nondefensively and try to understand the anger when clients are angry. We fully recognize how difficult it is to stay calm…” (Hill 2020). I feel the book is much too simplistic here. My first issue is that the book does nothing to give information to therapists about HOW to regulate and stay calm, just that it needs to be done. You know what they do suggest? Discuss in supervision, and that’s it. Remember the beginning of this post where I pointed out that I couldn’t find any material on therapists struggling with rupture and repair? Yeah, seems like supervision is going really well there (NOT)! And, perhaps a supervisor has more experience in the area over time, but relying solely on learning such basics outside of graduate school and not proactively seems irresponsible to me. Especially when my ethics class specifically covered stupider ideas, such dating a past client (GROSSSS!!!! Can you feel the patriarchy in this or what?)  

As I consider my training and the additional research I did for this blog together, I do recognize nuance that can’t be captured in a single grad program. Mainly because most of what I learned in school isn’t super helpful for interpersonal but is more so structured purely for the clinical requirements (medical model). Further, after learning interpersonal skills post-school, there are almost infinite therapeutic approaches to consider rupture and repair from, each interpreting the meanings behind rupture differently and methods to go about addressing a rupture differently. But as I narrow down my therapeutic choice of an interpersonal approach/use my own feelings and emotions as therapy data, the more I cannot rely on the strictly medical model given. Here’s an example of how this process has played out. My school textbook above feels like it’s saying “hey therapist, make sure you shut down your own feelings because they are not helpful! Stay calm and just ignore them and focus on the client!” Isn’t the point of therapy to teach people to be in tune with their emotions, feel them, regulate with them, and communicate them? So how is it helpful if I pretend I don’t have emotion or don’t model the very skills I’m trying to teach? And don’t my own reactions mean something? Why would I want to ignore that important source of information? TLDR: My feelings help guide my clinical interpretations. This isn’t to say expression to the point of making the room about the therapist, but one of the points of interpersonal therapy is to guide how emotions for both people in the room can be used to gain further insight. I don’t subscribe to the blank slate model that people can ping things off and I’m totally cool. I have biases I bring to the room, I also have responses to events in therapy, and it feels unethical to just pretend I’m not a person or have a client prefer I not be one. The push and pull between the two parties is the whole point in my eyes. Therapy is a symbiotic system that works interpersonally to improve interpersonally.  

In sum, regardless of technique a therapist subscribes to, I think a more realistic model for graduate programs would be giving therapists-to-be the skills to actually regulate through those moments like we teach clients to do. Because while I do use my emotions to give therapy, it has to be done so in a therapeutic way. Teaching us to teach the skills versus teaching us to use those skills ourselves have a very different framing. Because no matter what technique is used, our own emotional regulation plays a large role in our ability to show up effectively. Also, teaching more on rupture and repair too; my textbook was the one and only time I was exposed to anything remotely similar. Pretending we all know how to do this because we teach the skills is lying to ourselves and our clients, benefiting no one.  

Applications to Context Outside the Therapy Room

Shifting to a broader perspective outside of therapy, there is an uncomfortable truth I think can be difficult for therapists to communicate without getting flack and clients to receive without feeling burden: authentic repair with any person, therapist or otherwise, requires accountability and reflection and effort from all parties. Not all fault all the time lies with the professional. There is nuance to this, of course, but in a situation where a therapist may blow past a signal and a client reacts poorly, a therapist can own missing a cue, and the client can own reacting poorly. However, I think where I have personally been a stickler is, “If the client has an issue, I cannot do anything about it unless they tell me”. And yes, some of that is true, but it’s also pretty black and white. If I’m a passenger on a plane and it’s crashing, the pilot is not going to be like, “Hey Natalie, land this plane for me.” It is expected that the more experienced person guides the interaction. Then, when I am used to being in an aircraft, I can start guiding the plane on my own. To match, us as clinicians similarly must attend in a way that identifies cues that a rupture has occurred and do the groundwork for clients so they may fly the plane later. Clients do not have the know-how at the beginning to be able to broach the subject, even in the most secure of dynamics. Thus, at the end of therapy, rupture and repair operates inside the dynamic just as it would on the outside in client’s lived lives.  

And because I can’t help but be blunt about the role of the internet, this is a small call out to clients. The internet is a polarizing place. People 1) get locked into black and white thinking about therapy and 2) gain unrealistic expectations of therapy. Specifically, something I have noticed in online spaces is a demonizing of any real OR perceived mistake from a therapist. Like I have heard the spectrum from genuine ethical concerns to “she ended on time and that upset me.” Do I know the latter concern comes from a deep attachment wound that is highlighted by the therapist being human? Yup. Does it still peeve me off that clients do not discuss this with us and instead turn to the internet for wind tunnel validation? YES! This is why I earlier prefaced with rupture vs. harm. vs. abuse; I see a lot of convoluting online. Put bluntly: just because your therapist pissed you off or made you sad does not mean they abused you and does not mean they harmed you. It means you are in an interpersonal dynamic where there is vulnerability. Turbulence on the aircraft and the plane crashing are not the same event. If a therapist has ever harmed or abused you, then absolutely that therapist did a poor job, escape the crash. But if the complaints are more, “this isn’t working for me” or “why can’t the therapist just see that…” or “I think I’m just going to switch therapists because they don’t get it” with no communication to the therapist about these concerns (weathering the turbulence), that is avoidance of rupture and repair on client’s end, not anything the therapist is doing. Nor is there any collaboration to find any possible misinterpretations/co-building reality, leading to incorrect assumptions based purely in your own head. And with that, there is not much a therapist can do for you; this pattern will continue with any therapist, and you will feel stuck. You will feel therapy does not work for you, or that all the therapists you have had are incompetent. But are they incompetent, or are you holding out on vulnerability that would move you two closer? You not disclosing, at some level, prevents the therapist from doing their job well.  

Rupture, Repair, and the Secret Third Component: Reconciliation

As a final point, rupture happens, and repair can only happen if both parties consent. Two parties must own up to their role AND want to move forward together. If one or the other does not wish to repair, then there is nothing to be done. Or even if they want to repair, that does not entitle you to reconciliation (you can repair hurt but still decide it is better to not interact anymore. (The Instagram @christabelmintahgalloway has beautiful content on this if you would like to read more). Spoiler: I struggle with this most because I know the value of seeing it through so much. I know that rupture is inevitable and getting through it mostly leads to fostering better understanding and a closer therapeutic alliance. But jumping into that process with that agenda was my shortcoming in the situation that provoked my blog post. I tried to initiate repair when I did not have consent to do so. My agenda was to get this client to see that rupture can happen and that there is relief on the other side! To show them that there can be disagreement in a safe way. And, whether or not they wanted to keep working with me, to interrupt a possible cycle they would have with any therapist, because avoiding conflict with me is only going to perpetuate feeling dissatisfied when it happens with other therapists too. But forcing that onto someone who is unable or unwilling to do that sort of work at that time obviously flopped. No amount of my trying to tell a client that this is turbulence is going to change their perception of the plane crashing if they cannot or do not want to change their perception. Or at least, not even asking permission first to see if they can or want to. Because me having an agenda my client does not also subscribe to means I am no longer doing the work for them but for myself. Through not respecting a client boundary to insert my own values, I did harm.  

My Personal, Non-Clinical Experience

I want to take a moment to share my own process and what was activated for me in this moment to show that therapists also have work they are working on, and my hope is to highlight how my own self-awareness influences my work (and me continuing to pursue a healthier relationship with myself). Read this only you are interested in my process. If not, feel free to skip the next paragraph! I understand it can feel weird or hard hearing your therapist’s mental state, and it is in no way an attempt for pity or make you regard me in any different light. And it’s OK if it’s something you don’t want to know about me too. :)

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My underlying emotion for myself was that if I don’t get clients to see rupture and repair through, they won’t ever improve handling conflict, then I wouldn’t have done my job or the best job I could have done, which makes me a bad therapist and that I am horrible at guiding conflict. The irony is that listening to that narrative instead of my client really did make me a bad therapist at that moment. And then being called out for that made me spiral because it confirmed those fears! The call out activated a part of me who is often frustrated for not being viewed as a person when I am a therapist, which has happened before when I was experiencing intense grief at the loss of my cats and uncle in the same 2 month span (links to prior negative experiences with clients from my own seat.) Another part was my child self who was frequently criticized for any mistake and ready to be hit/ignored for a week for said mistake (links to childhood traumatic experiences.) Other smaller parts include Rejection Sensitivity with my neurodiversity, core fears about being inherently unlikable, sadness/powerlessness/shame that I caused harm, and my own personal values of “do no harm but take no shit” being violated by my own hand. Considering all of this, I can validate that it makes sense this was such an uncomfortable experience for me!

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Final Reflections

Essentially, even if I can’t understand not wanting to see rupture and repair through, I have to respect it, no matter how frustrating. And I also have my own work of finding better ways to communicate and regulate when something said activates very strong parts of me. While I will do that with continued supervision, research, and my own therapy, I would like to see more formalization in training programs to assist this process in future generations. At the end of it, a colleague of mine said, “The clients you can help will do that [rupture and repair] with you”, and I just have to trust in that.  

I doubt the client that inspired this post will have read this, but if they do, I hope this post can be viewed open apology and affirm that I am dedicated to constantly pursuing being the best version of myself that I can be in my profession. And to the other clinicians reading this, hopefully provide a more raw experience of rupture and repair from our perspective and create more open dialogue surrounding this issue.  

With that full introduction, I decided to look into the research and actually pull together a realistic guide on rupture and repair that I wished existed when I was looking. More on that in the next post!  

Citations

American Psychological Association. (2018, April 19). APA Dictionary of Psychology. https://dictionary.apa.org/abuse‍ ‍

Fuertes, J. N. (Ed.). (2020). Working Alliance Skills for Mental Health Professionals (pp. 159-179). Oxford University Press.

Hill, C. E. (2020). Helping Skills: Facilitation, Exploration, Insight, and Action (5th ed., pp. 416-417). : American Psychological Association.

Hook, J., & Devereux, D. (2018). Boundary violations in therapy: the patient’s experience of harm. BJPsych Advances, 24(6), 366–373. doi:10.1192/bja.2018.26

Horvath, A.O., & Greenberg, L.S., (Eds.). (1994). The Working Alliance: Theory, Research, and Practice (pp. 225-255). New York: Wiley.

Norcross, J.C. (Ed.). (2002). Psychotherapy Relationships that Work (pp. 235-254). New York: Oxford University

Safran, J.D., Crocker, P., McMain, S. & Murray, P. (1990). Therapeutic alliance rupture as a therapy event for empirical investigation. Psychotherapy: Theory, Research, Practice, Training, 27(2), 154-165.