The therapeutic alliance is defined as a cooperative working relationship between patient and clinician. The three factors need to establish a successful therapeutic engagement are:
- Agreement on treatment goals
- Agreement on the tasks of treatment
- Formation of a personal bond based on reciprocal positive feelings
The therapeutic alliance best seen as being dynamic, that is, changeable over the course of treatment. For example, the initial alliance may start strong and lead the patient to commit to the goals and tasks of treatment and, as a result, experience progress towards their goals. This positive feedback cycle includes an increase in trust and bonding with the clinician. This initial period is sometimes called the honeymoon period, a period in which the patient receives personal attention, validation, realistic hope of a good outcome, and a sense of security and support. Their relief and trust in the clinician can be high, sometimes unrealistically so. It is then not unusual for the initial glow of the relationship to dissipate and the limits of the treatment and the hard work of psychotherapy to become apparent.
Misunderstandings and disappointments are usually seen as inevitable in any important human relationship. Thus, it is not a surprise that in a relationship as significant and vulnerability-exposing as the one between a clinician and patient, misunderstandings and disappointments occur. However, the patient is unlikely to explicitly bring up the topic of their feeling disappointed (or angry or anxious) because of a perception that to some degree they were misunderstood, invalidated, or disrespected by the clinician.
Given the importance of the therapeutic relationship, the patient will likely experience a range of emotions, and fear or not know how to explicitly raise them in conversation, and is likely to act them out indirectly within the relationship with the clinician. For example, the patient may shut-down and no longer speak about or show their vulnerabilities. Or they can begin missing or coming late to appointments or even drop from treatment. Or, now, with the availability of clinician rating websites, they can leave a scathing online review of the clinician, sometimes even barely concealing their identity. (The patient may be motivated to retain plausible deniability of their identity while at the same time communicating to the clinician that the clinician failed them specifically.) Or the patient can express anger at the clinician by criticizing the clinician for some peripheral issue, such as, that the patient was kept waiting too long for their scheduled appointment, and then state that the clinician doesn’t respect their time. Or the patient can regress in their progress, which can occur directly related to the emotional disturbance caused by the therapeutic rupture or indirectly as a way to “punish” the clinician with their lack of progress which can be accompanied by explicitly blaming the clinician for their incompetence, lack of effort, or simply not caring enough.
Since therapeutic ruptures are so common, the clinician should be prepared to recognize and address them. The two skill sets required to manage these ruptures are, one, perceptual skills, that allow a rupture, real or potential, to be recognized; and, two, behavioral skills, that allow the clinician to manage the rupture, whether to prevent one from occurring, nipping an evolving one in the bud, or cleaning up after one has fully flowered. You can think of this as primary, secondary, and tertiary therapeutic rupture management. Here are a few interventions to consider:
- At the start of treatment, such as when discussing the treatment plan, the clinician can explicitly anticipate that the patient will likely be disappointed by the clinician and/or treatment at some point and react with a range of emotions and behaviors. The clinician can communicate that such therapeutic ruptures are common and normal, and that in a relationship as important as the current therapeutic one, it is important that the patient can speak freely about what is concerning or disappointing them. The clinician can point out that they too, as the clinician, sometimes need to say something that can be hard for them to say and for the patient to hear. But given the alternative of a possibly failed treatment, it is worth it for both individuals to be open and honest, that it is better to nip concerns and disappointment early on rather than to let them build up and fester, and possibly lead to treatment failure or premature dropout.
- Throughout treatment, the clinician can make a habit of asking the patient for feedback about the treatment itself, about the clinician-patient relationship, and even about themselves directly. Sample statements include the following:
- “How well is this treatment meeting your needs?”
- “What is the most useful part of the treatment?” “And what’s the least helpful part?”
- “How are we doing?” “This is an important relationship we have here and I want to make sure we continue to be on the same page. It may be hard for you to say something critical about this treatment or about me, but not saying something that bothers you is likely going to make things worse.” “Don’t worry, you won’t hurt my feelings … and if you do, I’ll get over it. Haha.”
- “Is there something you can we should be doing that we’re not, and things we’re doing that we should stop?”
- Throughout the treatment, the clinician should monitor the patient’s in-session statements and other behaviors, especially ones that convey strong emotion, and gently follow-up on them. Similarly, the clinician should address any change in the patient’s attendance and timeliness for sessions, and any changes in between-session behaviors. If the patient, who has been consistent in keeping appointments, being on time, doing homework assignments, and adhering to their medication regimen, suddenly becomes less adherent, the clinician should investigate and not accept “easy” answers that are unlikely to divulge the main concerns, such as, “Oh, I’ve just been busier than usual.” The clinician can respond with, “Yes, I understand how hectic life can be, but I wonder, Is there perhaps something else involved too, something about this treatment or about the two of us working together?”
- As illustrated above, in cases in which the patient is likely not fully forthcoming but can maintain plausible deniability, the clinician can “wonder” about what’s going on. “Wondering” that more can be said about a topic is not the same as accusing the patient of hiding something or even lying. Here’s an even more explicit example of “wondering:” “I wonder if the reason you missed last week’s appointment with me was because of what went on between us the last time we met. I wonder if I disappointed you in some way. If I did, it is ok to talk about it. In fact, it is more than ok, it is likely the most important thing we have to talk about.”
- Also, at all stages of treatment, the clinician can keep and convey the mindset that ruptures are not fully avoidable and that unforeseen and unfortunate events in treatment will occur. And rather than seeing these events are failures, ruptures can be viewed as an opportunity to learn, and even the MOST important opportunity to learn. Why is this? Because relationship ruptures occur within ALL relationships. Everyone has parents, a significant other, children, friends, colleagues, or coworkers. It seems impossible to move through life and not experience ruptures in these important relationships. So, when a rupture occurs in a therapeutic relationship it is an opportunity for the clinician to model ways of dealing with (and healing) these ruptures rather than allowing them to blow up the relationship. These ruptures also afford the patient the opportunity to practice rupture-healing mindsets and behaviors. And last, the issues that lead to ruptures and the patient’s ways of responding are likely the exact points of pain in the patient’s life. Thus, a rupture is almost something to look forward to. Having said that, this is NOT an invitation for a clinician to act thoughtlessly towards a patient in order to “give them an opportunity to heal.” Rather, the clinician should remain at their best and let the ruptures come as they may. The clinician should be attentive to them and their warning signs and then use them to build the patient’s skill and the clinician’s own skill in managing them. And, btw, this type of focus on the relationship is the core of some therapies, such as prominently, transference-focused therapy and, to some degree, dialectical behavior therapy and schema-focused therapy among others.
- So, get ready to develop these rupture management mindsets and skills. Feel free to share your experiences in dealing with them. And if you need advice, email me. I’ll share your conundrum anonymously.
Until next time,
“In liminal space, one meets the unknown, the marginalized, the synchronistic, the other, the unconscious edge of one’s former narratives. At this point, the possibility to try out new narratives, to reframe one’s story, becomes critical. Through narratives of participation the center of gravity shifts from fear and defensiveness to curiosity, creativity, and celebration. One begins to take a stand to validate one own’s affects and doubts while at the same time interrogating them.” – Helene Shulman
“Someday, somewhere – anywhere, unfailingly, you’ll find yourself, and that, and only that, can be the happiest or bitterest hour of your life.” – Pablo Neruda
“…it’s like the people in the play are living in the same world but separately from each other, like their worlds have somehow become disjointed or broken off each other’s worlds. But if they could just step out of themselves, or just hear and see what’s happening right next to their ears and eyes, they’d see it’s the same play they’re all in, the same world, that they’re all part of the same story.” – Ali Smith
“Reality is not always probable, or likely.” – Jorge Luis Borges