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Thursday, November 11, 2010

Psychotherapy: Ruptures and Repairs in Therapy

In the last two blog articles, I discussed transference in psychotherapy in the context of the erotic and the idealized transference( Psychotherapy and the Erotic Transference and Psychotherapy and the Positive Transference). I also mentioned "ruptures" in treatment and discussed this briefly. In this post, I would like to focus on the effect of ruptures in treatment and how they can be repaired so that the therapeutic relationship between therapist and client can be preserved and, in many cases, even thrive after a rupture.

Psychotherapy: Ruptures and Repairs in Therapy

What are Ruptures in Psychotherapy?
In any long-term psychotherapy, there are bound to be treatment ruptures. Usually, these ruptures occur when the therapist unwittingly commits an empathic failure with the client. Even the most empathic psychotherapist will, a times, either misunderstand what a client is saying or give a response that is less than empathic. This is usually not intentional. It's a mistake.

When a client, especially a client who might be emotionally fragile, feels that his or her therapist has been either insensitive or doesn't hear or understand what the client is saying, the client often experiences this as a rupture in treatment. Sometimes these ruptures are small, as when a therapist forgets a particular small detail of a client's history and this becomes obvious to the client. And sometimes, these ruptures can be big, and I'll give an example of this later on.

Whether the rupture is perceived by the client as big or small is determined by many factors, including the strength of the therapeutic relationship at the time of the rupture, how fragile the client is feeling what the therapist actually did or said and so on

If the therapeutic alliance is strong and there haven't been very many ruptures in the past, many clients can overlook a therapist's mistake, especially if the client knows that this was a mistake. However, if the client and therapist have just begun to work together or if there have been frequent ruptures or if the client has a personal family history where he or she was neglected or abused, any kind of empathic failure can lead to a big rupture between client and therapist.

If there are egregious offenses by the therapist, like sexual boundary crossings or other serious offenses, this not just a rupture. This is a serious ethical and legal breach, and that's not what I'm referring to in this article.

How Can Treatment Ruptures Be Repaired?
If we consider that in most long-term psychotherapy treatments there will be inevitable and unintentional empathic failures or mistakes on the part of the therapist, how can these empathic failures be addressed and repaired so that the rupture doesn't lead to the failure of the treatment?

The most important part of repairing a rupture in treatment is for the therapist to be able to acknowledge that he or she made a mistake. Except for the most narcissistic psychotherapists, most therapists can and will do this. Even if it wasn't originally perceived as a "mistake" by the therapist, once the client feels misunderstood or not heard, the therapist needs to acknowledge and take responsibility for it.

Almost any rupture, if it's not egregious, can be repaired in treatment if the therapist acknowledges that he or she either made a mistake or failed the client in some way. For most clients, the acknowledgement on the part of the therapist that there was a mistake or the client was hurt in some way is often enough to repair the treatment.

Ruptures in Therapy Can Often Be Repaired

Many clients have grown up in homes where their parents never owned up to mistakes that they made, so the experience of having the therapist take responsibility for an empathic failure can be reparative in itself, especially if the client feels that the therapist's acknowledgement is heartfelt.

Even Experienced and Talented Psychotherapists Can Commit Unintentional Empathic Failures:
I remember when I was training to be a psychotherapist at a psychoanalytic institute, my peers and I were very concerned about making mistakes in treatment. As therapists in training, most of us feared that our inexperience could lead to irreparable damage to clients.

In the context of a discussion about empathic failures, one of our instructors, who was much admired, told us a story about a rupture in treatment due to an empathic failure that he had committed with a client. Before I discuss what the empathic failure was, I should mention that not only was this instructor much-admired by the psychoanalytic trainees and faculty, but most of the trainees had a strong idealizing transference for him, which relates to my prior blog post.

Most of us, at the time, were very surprised that someone of his talent and skill could make such a mistake. This is another example of the effects of the idealizing transference between students and instructors.

Our instructor was well aware of this and he used the story that he told us not only to show that ruptures can be repaired in treatment but in his humility, to show that even seasoned and skilled therapists can make mistakes in treatment. He didn't want us, as therapists in training, to be so afraid of making a mistake that we'd be too self conscious with clients, which would have, in and of itself, interfered with treatment.

His main point in telling us about a mistake that he made was: While it's not great to make mistakes with clients, in most cases, it's not so much about the mistake that leads to the rupture-- it's more about how the therapist handles the mistake and repairs the rupture.

To that end, he told us about a time when he forgot about a client's appointment and he left the office. The client had been coming to treatment for a few years, and he had a great deal of difficulty trusting people, including his therapist.

During these sessions, the client often talked about wanting more from the therapist in terms of being more like friends rather than client and therapist. Since this would be an ethical breach of the treatment frame, the therapist explained, as gently and tactfully as possible, that this wasn't possible and explained the reasons why.

Most clients would understand that the client-therapist relationship, albeit caring and, at times, intense, is still a professional relationship. However, some clients, for a variety of reasons (sometimes, due to a history of neglect or abuse), want more from the therapist and it's up to the therapist to preserve the safety of the therapeutic relationship and the treatment to maintain the treatment frame.

All of this is to say that, even after a few years of treatment where the client came multiple times per week and kept his appointments, the therapy sessions were often rocky because the client wanted a more personal relationship with the therapist and, in some ways, he felt deprived that the therapist would not give in to his wishes.

So, in a nutshell, that's the background of the case, and you can picture many sessions where the client attempted to get the therapist to break the treatment frame and the therapist was holding the line for the sake of the client's emotional safety, although the client didn't realize it at the time.

One day, the therapist received a call from his young daughter's school that his daughter was sick and he needed to pick her up from school. At the time, the therapist had a very busy schedule that included a full-time private practice; being an instructor and supervisor at the psychoanalytic institute; involvement in various professional committees, and so on.

Tired, distracted and focused on his concerns about his daughter, he left the office completely forgetting about the client's appointment. He picked up his daughter, brought her home, and called the pediatrician. Fortunately, it turned out to be only a cold, and his daughter went right to sleep.

Relieved that his daughter didn't have a major illness, the therapist began to relax after a busy, stressful day. It was only then that he realized that he had forgotten about his client, something that had never happened to him before in his many years of practice.

Being very concerned, he called the client to apologize, but the client was too upset to accept the apology. He didn't tell the client that he had to pick up his daughter. It would have been too hurt for a client, who wanted more of a personal relationship from his therapist, to feel that the therapist's daughter took precedence over him. He simply apologized and told the client that he was called away from the office, he forgot about his appointment, and he was deeply sorry.

As an aside, one could speculate as to whether there was an unconscious wish on the part of the therapist to avoid dealing with this client on this particular day. While this might have been a factor, if and when that occurs, it's up to the therapist in this situation to do some self-analysis to explore this question.

In any case, the client was unable to accept the therapist's apology immediately. In fact, he focused on this empathic failure and the rupture in the treatment for about two months in every session. They were unable to move beyond this problem and it consumed the client's thoughts. Not only was the client very angry, but he was very deeply hurt that the therapist forgot about him.

This empathic failure fed right into his worst fear that the therapist really didn't care about him and he wasn't important to the therapist which, of course, was not the case at all. However, for a client who grew up with emotional neglect, he was very sensitive to any kind of empathic breach. In many ways, he was always vigilant and suspecting that this would happen because he found it difficult to trust people. So, in terms of empathic failures, this couldn't have happened to a more emotionally fragile client.

The therapist knew that, in many ways, the client was "testing" him on an unconscious level. The therapist needed to withstand the client's anger and hurt to show the client that he cared about him. After a few months of the client venting his anger and hurt and, together with the therapist, making connections to how this empathic failure triggered his history of emotional neglect, over time, the client and therapist were able to repair their relationship.

What's more, the relationship was more than just repaired to its former state, it was actually enhanced. Over time, the client was able to see that his therapist actually did care about him a great deal and that the empathic failure was an unintentional mistake. He realized that his therapist was human and let go of some of his idealization (much as I and the other psychoanalytic trainees did on the day when our instructor told us this story).

Feeling cared about, over time, the client stopped demanding that the therapist be his friend. He realized that it was enough that the therapist was compassionate and cared about him.

As psychotherapists in training back then, we were much relieved to hear that, even a therapist who was known to be highly skilled, could make such a mistake. It served to take a lot of pressure off of us, and I've always remembered this story.

For most clients, a sincere and caring apology can go a long way to repairing a rupture in treatment. And, in many cases, the reparative experience is more important than the rupture.

I'm a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist

To set up a consultation, call me at (212) 726-1006 or email me: josephineolivia@aol.com.












2 comments:

Ron Friesen said...

Ms. Ferraro, Thank you for this article. I refer my students to this article to help them understand rupture and repair in therapy.

Ron

Josephine Ferraro, LCSW said...

Dear Ron, thanks so much for your comment. I'm glad that you found this article to be helpful and I hope that my other articles about the psychotherapy process will also be helpful.
All the Best,
Josephine Ferraro, LCSW