The Breaking Point

By Lisa R. Rhodes

March 2024

^{Photo Credit: iStockphoto}

Six years ago, Angela Kaloudis, LMHC, had been working with a client for about a year in her private practice in Massachusetts. In one session, the two were revisiting the client’s treatment goals to discuss whether weekly therapy was still necessary.

While reflecting on her experience in therapy, the client’s eyes began to tear up as she shared how helpful and transformative the work had been for her.

In response, Kaloudis said, “One day, I’ll be a blip on your radar.”

The energy in the room quickly shifted. The client averted her eyes, withdrew and changed where she was sitting on the couch to move away from Kaloudis.

When Kaloudis mentioned the shift in energy in the room, the client confronted her: “That comment makes me feel that this relationship is not very mutual,” the client said. What began as an opportunity to review the success of their work together suddenly became a therapeutic alliance rupture between Kaloudis and her client.

Ruptures and Therapy

A therapeutic alliance rupture is “a breakdown or disruption in the relationship between the counselor and client,” explains Ramona Grad, PhD, LPC, assistant professor and assistant chair of psychology and counseling at the University of Texas at Tyler. “It occurs when there’s a significant disagreement, misunderstanding or tension that impacts the trust, collaboration or communication within the therapeutic alliance.”

In Kaloudis’ case, the therapeutic bond was so strong, and the possible change in treatment was so real, that Kaloudis’ comment made her client feel dismissed and invalidated. That ledto a rupture.

Grad stresses that these ruptures can significantly affect the progress of counseling if they are not addressed effectively.

Ruptures are prevalent in about 20% to 75% of therapy sessions, according to Catherine Eubanks, PhD; J. Christopher Muran, PhD; and the late Jeremy Safran, PhD, in their chapter, “Alliance Ruptures and Resolution,” published in The Therapeutic Alliance: An Evidence-Based Guide to Practice. Safran and Muran were among the first to study therapeutic alliance ruptures in the late 1980s.

While ruptures are a part of therapy, some counselors try to ignore or may not even notice them because of the challenges they present, says Elizabeth Heaney, LPC, owner of Heaney Consulting in Asheville, North Carolina.

It can be difficult for counselors to admit that they may have misunderstood a client or responded in a way that was hurtful when they have been trained to work in the service of the client and the therapeutic relationship, Heaney says.

“Because we’re doing our best to support our clients to be open and vulnerable and develop good relational skills, when we ‘drop the ball’ or misunderstand something very important, it’s hard to address it directly,” she explains.

But as challenging as it may be to admit that a rupture has occurred, therapists can take the lead to work with clients to repair it.

When this happens, research has shown that a therapeutic alliance rupture can open the door to a stronger therapeutic relationship and an opportunity for greater self-awareness for both the counselor and the client, Heaney says.

The Bedrock of Treatment

Although therapeutic alliance ruptures do happen, the work counselors do to establish the therapeutic relationship is critical in building a healing space based on trust, nonjudgment and acceptance.

The therapeutic alliance is the bedrock of treatment for mental health conditions and is the main reason clinicians must be attuned to any disruptions in the therapeutic process, counselors say.

“The therapeutic alliance is really the quality of the relationship, of the bond between the therapist and the client,” says April Nguyen, LPC-A, owner of Sage Counseling Services PLLC in Houston, Texas. “It’s so important because, at the end of the day, therapy is a deeply personal relationship between two human beings. For a deep, meaningful and healing connection to happen in a therapeutic relationship, there needs to be a strong foundation of trust, respect, collaboration, safety and warmth.”

A strong supportive therapeutic alliance empowers clients and encourages autonomy, self-reflection and self-expression, Grad says. It also helps clients take an active role in their healing process and personal growth.

“A strong alliance creates a trustworthy environment where clients feel comfortable in discussing their thoughts, feelings and experiences,” Grad explains. “This trust is fundamental for clients to open up and explore their concerns openly.”

Signs of Trouble

Since the effectiveness of therapy is so closely linked to the caliber of the therapeutic alliance, it is important for counselors to be able to determine when a rupture has occurred.

Counselors can spot a rupture — which can take on many forms and intensities — by paying close attention to the therapeutic alliance and being highly attuned to the state of the relationship, says Nguyen, who co-presented “Ruptures in the Therapeutic Relationship: Effect on Outcomes and Methods of Repairing” with Jungeun “Jay” Lee, PhD, at the 2023 annual conference of the Texas Counseling Association.

“I always end my sessions with a temperature check, where I ask my client, ‘How are you feeling after today?’” Nguyen says. “If you’re communicating to the client that you care about how therapy feels for them, they may be more open to letting you know when a rupture has occurred.”

Kaloudis, a clinical training specialist at the Renfrew Center for Eating Disorders who presented on therapeutic ruptures in the webinar “From Rupture to Repair: Navigating Disconnection in the Therapeutic Relationship,” says anything can cause an alliance rupture and leave clients feeling betrayed or hurt. For example, a rupture can result from a joke that the client didn’t take as a joke or a counselor’s decision to move to a virtual platform when treatment has primarily been in person.

Muran, dean and professor at the Gordon F. Derner School of Psychology at Adelphi University in Garden City, New York, says counselors can determine if a rupture has occurred if they are on the lookout for interpersonal markers. These markers are specific communications or behaviors that indicate a rupture, he explains.

There are two different types of markers. A withdrawal marker is a movement away from the other person or from an aspect of the self, Muran says. For example, a client may become silent or try to change the subject.

If a client is angry about something the counselor has said or done, they may not want to express the anger, so they move away from the emotion to avoid conflict. A withdrawal marker can be understood as the maintenance of “connection to the other at the expense of self-definition,” Muran says.

A confrontation marker is a movement against the other and is “the promotion of self-definition at the expense of relatedness,” he says. For example, a client may become critical of the therapist or try to gain control of the therapy session.

When ruptures occur, counselors will typically notice abrupt changes in a client’s behavior, such as missed appointments and sudden cancellations, says Grad, whose primary area of research is the therapeutic relationship and diversity. Clients may also show avoidance behaviors or seem less engaged in sessions.

Nguyen advises counselors not only to check the pulse of the therapeutic relationship with clients but to also be aware of their own inner responses.

“Check in with yourself during and after every session,” she says. “Ask yourself, ‘How do I feel it went?’ ‘What could I tell about the client’s verbal responses and body language?’ ‘Did we talk about anything this session that I know is a particularly sensitive topic for the client, and if so, how did that go?’”

Because therapy is a collaborative process, counselors need to know how they and their clients feel about the therapy sessions to properly identify and respond to a rupture.

Responsibility and Repair

It is important for therapists to also recognize that ruptures — misunderstandings, disagreements and tensions that affect the trust between people — are an integral part of all relationships.

Because they happen so frequently, there is always the possibility to repair a rupture. However, the task of easing the tension begins with the counselor, not the client, Heaney says.

“As the therapist, I would want to take responsibility for the therapeutic relationship, for the quality of it, the steadiness of it, the ‘bond’ that gets created,” she explains. “And a rupture is a break in the bond. I want to work to reestablish, repair or rebuild the bond.”

Grad suggests counselors consider three key responses once they become aware of an alliance rupture:

• Acknowledge and reflect on the rupture without judgment. “Understanding the underlying cause, whether it’s a misunderstanding, disagreement or any other factor is vital,” she explains. “I encourage counselors to reflect on their role in the rupture and how it might have affected the client.”
• Initiate an open and honest dialogue with the client about the rupture. “Create a safe space where the client feels comfortable discussing their feelings and perspectives,” Grad says. “First, counselors need to be open and recognize their contribution and share that with clients and encourage clients to express any thoughts, concerns and dissatisfaction they might have regarding the therapeutic relationship.”
• Collaboratively work on repairing the rupture. “This involves validating the client’s experience, offering empathy and exploring potential solutions or adjustments that can rebuild trust and strengthen the therapeutic alliance,” Grad advises. “[Being flexible] in adapting therapeutic approaches or methods might also be necessary to address the rupture effectively.” Most importantly, counselors should approach this entire process with a sense of humility, Grad says.