I am not what happened to me, I am what I choose to become - Carl Jung
Early in training, we are introduced to the idea of a psychotherapeutic rupture. We learn that they occur and how to overcome and get past them with our patients. The emphasis is on the latter because that is what we are supposed to do: overcome and move on to bigger and better things.
When I first started therapy with patients, I was quite afraid of ruptures. I did my best to avoid them by changing my demeanor and approach with different patients. Patients who were more sensitive, for example, drew me to a more passive stance, where as those who were more quiet and thoughtful pulled me to be more engaged and active. I was a different type of therapist for each. This is also true for patients with a variety of presenting concerns, including narcissistic, borderline, and more depressive personalities. I would act differently with each patient.
As I reflect back, I wondered why ruptures were so uncomfortable. For one, I don't like ruptures in relationships outside of therapy, so why would we like them in the therapy room? Ruptures take a lot of work to repair and a whole lot of patience, effort, and empathy. Also, for many trainees, we want to keep our patients for as long as possible (in others words, more than the a handful of sessions, or perhaps even working beyond the intake session). Ruptures lead many patients to terminate, leaving the training therapist with a lot of doubt, insecurity, and fear that not enough hours will be accumulated for internship.
Ruptures can be very uncomfortable, and something that we want to get through as quickly as possible. But isn't it the rupture itself where some of the greatest changes occur? I have seen so many therapist avoid working through a rupture. And this is quite a tragedy. Though each patient needs to be approached differently (e.g., depending on several factors, like ego strength, frustration tolerance, length of treatment), ruptures are a great opportunity to strengthen the therapeutic relationship, work through deeply-entrenched interpersonal issues and enactments with the therapist, as well as bring attention to what just happened?
This is no easy task. When I first exploring what just happened with patients, I felt like I was going to implode. Some patients make it very difficult by utilizing every defense mechanism in their tool belt; denial, projection, isolation of affect, humor...the list goes on. Despite only working with patients for about 3-4 years as a doctoral student, I have seen most of the colors on the paint pallet when working in the here-and-now with a rupture.
One thing that I have noticed, however, is that by talking about what just happened, patients begin to understand how much the therapist cares about them. Working within a rupture brings about an incredible amount of shame, guilt, anger, frustration, fear, hate, love, and just about every other feeling (and not just in the patient). If the therapist is able to sit with those feelings, empathize, and begin to try to understand, something changes in the relationship. Something new is created and though it is hard to articulate exactly what that something is, you know it's there. There is a mutual understanding, a strengthening of bonds, and an unlocking of possibilities for what is yet to come.
- cg