Tear and Repair: The Use of Therapeutic Rupture asa Tool for Rela-tional Healing

The Relational Psychotherapy movement is a relatively new and integrative theoretical framework for psychotherapy. Considered to be a modern psychodynamic approach, it has roots within the British object relations schools [1] and the American movement of Interpersonal psychoanalysis [2]. At its core, Relational Psychotherapy seeks to understand the client through her or his experience of self with other [3]. When a client discloses meaningful events in therapy, the therapist is not viewing in the client in isolation, but is looking for the larger context of the people and relationship patterns that surround her. Through empathic interactions with the therapist, the client’s history of relationship patterns are understood and played out within the therapeutic process itself. Over time, a new way of doing and experiencing connection with others occurs through the therapist-client relationship.


Introduction
The Relational Psychotherapy movement is a relatively new and integrative theoretical framework for psychotherapy.Considered to be a modern psychodynamic approach, it has roots within the British object relations schools [1] and the American movement of Interpersonal psychoanalysis [2].At its core, Relational Psychotherapy seeks to understand the client through her or his experience of self with other [3].When a client discloses meaningful events in therapy, the therapist is not viewing in the client in isolation, but is looking for the larger context of the people and relationship patterns that surround her.Through empathic interactions with the therapist, the client's history of relationship patterns are understood and played out within the therapeutic process itself.Over time, a new way of doing and experiencing connection with others occurs through the therapist-client relationship.
One essential aspect of the Relational style is that the therapist is not simply a passive observer of the client and her relationship patterns.The therapist also allows him or herself to become part of this pattern as an active participant with the client [4].One helpful way to understand this important component of the Relational style is through the language of "one-person" and "two-person" models [5].One-person models (such as traditional Freudian analysis) emphasize the necessity of the therapist as an objective observer.While absolute objectivity might be unattainable, the goal is to be as objective as possible in order to observe the inner workings of the client.The underlying assumption is that the inner workings of the client exist independently of the therapist's influence.The more removed or objective the therapist can be, the more accurate the understanding of the client.
In contrast, the two-person model contends that a client's inner workings cannot be objectively observed; anything that can be observed is occurring within the context of a relationship.Moreover, two-person proponents believe the very nature or essence of what is observed is a co-creation of the client and therapist together, ever changing along with the qualities and behaviors of the patient and the therapist from session to session.Through participation in this co-creation with the client, the therapist can infer clues about other relationship patterns outside of the consulting room.
There are times when the therapist-client relationship is likely to evoke familiar feelings within the client that are reminiscent of some of the painful relationship patterns the client is attempting to shift.For example, a client might feel as if her therapist is acting just like her dismissive mother or absent father.Painful feelings towards the therapist are often referred to as ruptures in the therapeutic alliance.When these moments arise in therapy, a two-person perspective provides a theoretical foundation for the therapist to explore the therapeutic relationship, provide honest and insightful feedback about his or her own experience of the client, and move towards a different outcome for this painful and repetitive pattern.The case study below provides an illustrative example of such an event.

Case Introduction
Amelia is a 58-year-old, married, Caucasian female with one adult son from a previous marriage.She works full-time as a manager for a chain of chiropractic offices and has been employed in this position for over fifteen years.She was originally referred for psychotherapy by her primary care physician after Amelia disclosed increasing difficulty with concentration and short-term memory.Prior to the start of therapy, she underwent a neuropsychological evaluation which suggested her difficulty with focus was due in large part to symptoms of depression rather than other possible organic factors.Amelia originally saw a male therapist for her first appointment, but then requested to work with a female therapist for the remainder of her treatment; a detail that will be explored in more depth throughout this article.

Presenting concerns and history
During her initial interview with her female therapist, Amelia noted mildly depressed mood for roughly six months.She disclosed diminished pleasure in previously enjoyable activities, general fatigue, and significant feelings of stress related to her job.She reported more significant feelings of depression over twenty years ago, which she believed were largely related to her first marriage and subsequent divorce.Amelia was the older of two children born to her parents.Amelia described her father as a former alcoholic whose excessive alcohol use eventually led to the divorce of her parents.She described her mother as passive, causing Amelia to often feel as though she needed to be the "adult" for her family.Amelia characterized her relationship with her brother as one of mixed emotion.While she endorsed warm feelings for her brother, Amelia also described experiences in which she felt taken advantage of and betrayed by him.
Amelia's first marriage ended approximately twelve years ago.She described her first husband as angry and controlling, recalling that he would frequently yell at her and appeared to hold very rigid ideas about what others should believe and how Amelia should behave.Amelia, however, expressed a sense of gratitude for her first marriage in that it resulted in the birth of her son who is now an adult.Amelia reported an emotionally close and connected relationship with her son who is presently married and lives out of state.
Regarding her current marriage, Amelia eventually disclosed feelings of unhappiness in this relationship.She described her current husband as having qualities similar to those of her first husband but with lesser After a few sessions of processing her reaction and the meaning this event held for her, Amelia and her therapist decided to invite the original therapist to participate in a session with the three of them together, which took place at Amelia's next scheduled appointment.During this session, Amelia voiced her feelings of hurt to the original therapist and assertively asked for what she needed in order to move forward from this experience.The original therapist graciously owned his part in playing out this familiar relationship pattern with Amelia and was also able to express his genuine feelings of apology and His honest self-disclosure in the moment was helpful in allowing Amelia to see the ways that she might mistakenly misinterpret the actions of others.Amelia was also able to see how her co-dependency in relationships, particularly with men, can rob her of the opportunity to voice her own opinions and unique perspective.

Ethical Considerations
In conceptualizing and treating this case, there are a few important ethical considerations.It should be noted that different clients and different presenting concerns can benefit from different treatment approaches [7].In Amelia's case, her symptoms were mild to moderate, her functioning was high, and there were no indications of suicidality.Within the first few sessions, it became apparent that Amelia's mood symptoms were related to her experiences in relationship, thus Amelia would be a good choice for an insight oriented approach such as Relational Psychotherapy [8].
Furthermore, despite the continued scientific search for the most efficacious treatments, effect differences among treatments remains minuscule [9,10].In Amelia's case, her primary concern included depressive symptoms.Depression in particular appears to have a variety of efficacious treatment options [11], giving the practitioner some freedom to choose an approach that seems like the best fit based on professional judgment and therapist style.
If the professional literature suggests that the differences among treatments are negligible, what then are the considerations that do have a positive influence on therapeutic outcome?The resounding answer to this quandary appears to be the therapist him or herself and the quality of the therapeutic relationship [12].Researchers have shown that some therapists providing a variety of different treatments, consistently achieve better results than other providers [13,14].What these findings suggest then, is that there are particular therapist qualities and actions which lead to effective outcomes [15,16].According to [17], one important quality of an effective therapist, is that she does not avoid addressing difficult material in therapy.Ruptures in the therapeutic alliance are not unique to Amelia's case.An effective therapist should be able to guide the client through such a rupture, as was illustrated in the present case.Wampold described this well, "When the difficulty material involves the relationship between the therapist and the client, the effective therapist addresses the interpersonal process in a therapeutic way (i.e.what is called by some the 'tear and repair' of the alliance).
Secondly, appropriate consent was sought due to the involvement of two therapists in this case.The American Psychological Association's Ethical Principles of Psychologists and Code of Conduct (2002) states in principle 10.4 that psychologists should discuss treatment issues and client welfare with the client when that client is receiving psychological services from another provider.In this case, the decision was made to transfer services to another therapist.While the therapists were employed at the same practice, care was given to ensure that Amelia's sessions remained confidential with her current therapist and a written release was obtained to allow the original therapist permission to participate in an additional session [18].severity.For example, she stated her current husband is similarly rigid in his thinking and will become frustrated with her when she fails to understand things from his perspective.She remarked that she feels disconnected and misunderstood by her husband and longs for renewed emotional intimacy between them.
Lastly, as mentioned briefly above, Amelia also reported significant feelings of work related stress.She disclosed to her therapist that she and her boss had been close friends for several years, yet she was feeling frustrated by their relationship and undervalued by him.When Amelia began therapy, she was contemplating leaving her position due to her growing feelings of stress at work.

Case Conceptualization
In conceptualizing Amelia's case, the therapist first attempted to understand Amelia within the context of her most important relationships.Given the description of her childhood and relationship with her mother and father, it was unsurprising that she endorsed feelings of depression and anxiety that are common amongst adult children from similar environments [6].More particularly, however, a relational therapist is seeking to understand the repeated relational patterns Amelia appeared to be experiencing.The relationship pattern which will be explored in further detail here is Amelia's historical relationship pattern with important men in her life.
Throughout the course of her therapy, when discussing distressing events or painful memories, it became apparent that many of these experiences held relational similarities.Some examples of these similarities include: feelings of hurt and anger towards her boss after a harsh interaction, feeling misunderstood and unloved by her husband following a disagreement about purchasing decisions, and growing feelings of loneliness paired with a belief that she was personally responsible for taking care of the needs of everyone around her. What became clear overtime was a pattern of Amelia attempting to find safety in her environment and relationships by anticipating the needs of others, taking on unrealistic amounts of responsibility, only to feel hurt by important others who were not able to see or respond to her needs.
In order to collaborate with Amelia to move towards a place of emotional and relational health, a Relational therapist will engage in this pattern of relationship with Amelia.Through continued experiences of empathy and understanding, Amelia will begin to feel heard and valued rather than dismissed and hurt.She will eventually come to realize that she does not need to over-perform in order to win her therapist's approval and can risk more clearly verbalizing her needs to her therapist.Ultimately, the goal of therapy within this context is for Amelia to utilize the experience of a healthier relationship pattern with the therapist as a catalyst for new interactions and new relationship patterns with others outside of the therapy space.

Tear and Repair
Interestingly, Amelia explored similar feelings of hurt towards the male therapist she had seen during her first session, which led to her decision to pursue therapy with a female therapist.She disclosed to her current therapist that she felt unheard during this appointment as the therapist appeared fixated on something that was not important to Amelia and pushed his agenda over her own for the session.This experience disturbed Amelia enough that she processed it several times on different occasions with her current therapist.Through these conversations with her therapist, Amelia realized this encounter was especially painful because it reminded her of feeling dismissed and undervalued by her husband, first husband, and boss.Open Access

Summary of Changes in Relationship Patterns and Symptoms
Amelia participated in weekly sessions for approximately six months, decreased her sessions to twice a month for several more months, and successfully terminated therapy after approximately one year of treatment.
By the end of treatment, Amelia reported positive changes in her relationship patterns with both her husband and her boss.She was able to feel less upset by moments of disagreement or disruption in those relationships because she discovered value in herself beyond the approval of others.She became skilled at assessing her own needs and engaging in self-care activities outside of these two relationships, which subsequently created less pressure in her relationship with her husband and at work.Amelia also became more assertive in her relationships.She was able to establish appropriate boundaries with others so that she was less likely to be taken advantage of or mistreated.Her symptoms of depression were largely alleviated, her focuses and drives improved, and her sense of purpose increased.

Treatment Implications
The results of this case suggest that missteps or moments of dissonance between the therapist and client can be a powerful tool for positive relational change.It should be noted that a therapist does not need to actively seek to create these missteps.They will occur naturally and inevitably due to the imperfect nature of human relationships.No therapist can be perfectly empathic or perfectly understanding all of the time.In this case, the enactment used was not caused by the client's current therapist, however, there were certainly moments of tear and repair in that relationship as well.The results of this case also suggest that making changes in relationship patterns can have a positive impact on mood symptoms such as mild to moderate depression or anxiety.