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A relational approach to supervision: Addressing ruptures in the alliance

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Abstract

In this chapter, we discuss how our supervision model prepares therapists to address ruptures in the therapeutic alliance. We begin by outlining our model of the rupture resolution process. Next we outline general principles of supervision. We then outline some of the basic features of our group supervision model. We conclude with a transcript illustrating the supervisory process.
7
A
RELATIONAL
APPROACH
TO
SUPERVISION:
ADDRESSING
RUPTURES
IN THE
ALLIANCE
JEREMY
D.
SAFRAN,
J.
CHRISTOPHER
MURAN,
CHRISTOPHER
STEVENS,
AND
MICHAEL
ROTHMAN
Establishing, sustaining,
and
repairing ruptures
in the
therapeutic
alliance
are
among
the
most important competencies
in
psychotherapy.
For
the
novice
psychotherapist,
strain
within
the
therapeutic
alliance
usually
arouses
feelings
of
insecurity
and may
undermine
the
trainee's developing,
yet
precarious,
sense
of
confidence. Alliance strains
and
ruptures pose unique
challenges
for the
clinical supervisor
as
well,
who
must
safeguard
client
wel-
fare
while facilitating
the
supervisee's professional
development
(Falender
&
Shafranske,
2004,
p. 6). The
types
of
skills required
for the
therapist
to be
able
to
constructively negotiate alliance ruptures
are
complex, multifaceted inner
and
interpersonal skills. They require
a
basic capacity
for
self-acceptance
(or
at
least
an
ability
to
work toward it),
a
willingness
to
engage
in an
ongoing
process
of
self-exploration,
and a
capacity
to
engage
in a
genuine dialogue
with
the
client.
The
quality
and
style
of the
supervisory process thus play
a
critical role
in the
development
of
these skills.
Portions
of
this chapter
are from
Negotiating
the
Therapeutic
Alliance:
A
Relational
Treatment
Guide,
by
]. D.
Safran
and ]. C.
Muran,
2000,
New
York:
Guilford
Press.
Copyright
2000
by
Guilford
Press.
Adapted
with
permission.
137
In C. A. Falender & E. P. Shafranske (Eds.). Casebook for
clinical supervision: A competency-based approach. 137-157.
Washington, DC, US: American Psychological Association.
2007
In
this chapter,
we
discuss
how our
supervision model prepares thera-
pists
to
address ruptures
in the
therapeutic alliance.
We
begin
by
outlining
our
model
of the
rupture resolution process. Next
we
outline general princi-
ples
of
supervision.
We
then
outline some
of the
basic features
of our
group
supervision model.
We
conclude
with
a
transcript illustrating
the
supervisory
process.
RESOLVING RUPTURES
IN THE
THERAPEUTIC ALLIANCE
The
therapeutic alliance
is one of the key
mutative factors
in
psycho-
therapy (Horvath
&
Symonds, 1991; Martin, Garske,
&
Davis, 2000),
and
learning
how to
explore
and
repair therapeutic alliance ruptures should
be an
important
focus
of
supervision.
For
more than
15
years,
we
have been encour-
aging
therapists
to pay
careful
attention
to the
therapeutic relationship
and
to the
ongoing relational "pushes
and
pulls" that occur between
the
client
and the
therapist.
We
believe that inherent
in all
relationships, including
therapy,
is a
negotiation between
the
subjectivities
of
each person.
Within
the
context
of
psychotherapy, these negotiations
are
often most explicit
in the
form
of
ruptures
or
therapeutic impasses.
We
have identified
and
classified
the
types
of
therapeutic ruptures that
we
believe
are
germane
to the
therapeutic
process
and,
on the
basis
of our
research
findings,
have developed
a
model
of
the
rupture resolution process (Muran, Safran, Samstag,
&
Winston,
2005;
Safran,
1993a, 1993b; Safran, Crocker, McMain,
&
Murray, 1990;
Safran
&
Muran, 1996,2000;
Safran,
Muran, Samstag,
&
Stevens, 2002; Safran, Muran,
Samstag,
&
Winston, 2005; Safran
&
Segal, 1990; Samstag, Muran,
&
Safran,
2004).
Our
goal
in
focusing
on and
working with ruptures
is not
simply
to
repair
them
so
that
work
can
continue with
a
revitalized alliance. Rather,
the
aims
are
to
help clients develop
a
fuller
understanding
of how
they construe events
and how
that
construal impacts their interaction with others,
and to
provide
them with
a new
experience
of
relating.
Ideally,
this
will
help them
to
become
more comfortable with
their
own
emotional states
and
needs,
and to
develop
greater
flexibility
in
expressing those
feelings
and
needs, with
an
improved
expectation
of
maintaining relatedness with important others.
Elsewhere
(Safran
&
Muran, 2000),
we
have
found
it
useful
to
distin-
guish
withdrawal
ruptures
from
confrontation
ruptures,
and we
have developed
specific
resolution models
for
each
type
of
rupture.
For our
purposes here,
however,
we
have abstracted
a
more general model consisting
of five
basic
positions describing
the
therapist-client
dyadic interaction:
(a)
identify-
ing
the
rupture maker,
(b)
recognizing
and
disembedding
from
the
relational
matrix,
(c)
exploring
the
client's construal,
(d)
exploring
the
avoidance
of
aggression-vulnerability,
and (e)
emergence
of the
underlying wish
or
need.
138
SAFRAN
ETAL.
For
heuristic purposes, these
are
presented
as a
consecutive series
of
separate
and
distinct positions.
In
practice, however, work with ruptures often moves
back
and
forth through different stages.
As a
result,
it is
essential
for the
ther-
apist
to be
focused
on the
moment-to-moment dyadic interactions instead
of
relying
on the
theoretical stepwise progression
we
describe here.
Position
1:
Identifying
the
Rupture
Marker
Ruptures
begin when during
the
course
of
therapeutic work,
the
client
notices some action
of the
therapist
that
confirms
his or her
dysfunctional
or
pathogenic expectations about relationships.
The
client reacts
by
either con-
fronting
or
withdrawing
from
the
therapist. This often
triggers
a
defensive
or
angry
reaction
from
the
therapist, which
in
turn, confirms
the
client's
expec-
tations. Whether
the
client's initial perception
was
realistic
or
distorted,
at
this point,
both
the
therapist
and
client
are
engaged
in a
cycle
of
reaction
and
counterreaction
Position
2:
Recognizing
and
Disembedding
From
the
Relational
Matrix
The first
step
in
beginning
the
resolution process
is for the
therapist
to
recognize
that
he or she is
embedded
in a
relational cycle with
the
client.
When
a
client begins
to
openly criticize
or
blame
the
therapist
or
abruptly
withdraws
by
becoming silent
in
sessions, repeatedly missing visits,
or
com-
ing
late
to
sessions,
it can be
easy
to
recognize that
the
normal negotiation
process
has
broken down. Other ruptures, however,
can be
much more subtle
and
difficult
to
detect.
This
is
especially true when clients
try to
conceal
their
anger
or
dissatisfaction.
In
cases
like
this,
it may
only
be by
noting
his or her
own
subjective experience (e.g.,
feeling
frustrated,
spaced out,
confused,
or
angry)
that
the
therapist
is
able
to
recognize
that
the
negotiation process
has
been compromised.
In
this
way, maintaining
an
ongoing sense
of
awareness
of
their
own
emotional reactions allows therapists
to
detect strains
in the
relationship
and
begin
to
identify
client behaviors
that
are
pulling
for a
complementary
response.
Once
the
rupture
has
been detected
and the
therapist
realizes
that
both
he or she and the
client
are
caught
in a
cycle,
the
disembedding process,
in
which
both
the
therapist
and the
client
attempt
to
step back
and
commu-
nicate about what
is
going
on, can
begin. This process involves
the
therapist
metacommunicating
his or her
observations about
the
cycle
to the
client
(communicating about
the
communication process).
No
matter
how the
rup-
ture
began,
the
therapist must recognize,
and be
able
to
talk about,
his or her
own
contribution
to the
cycle.
This
prevents
the
client
from
feeling blamed
and
gives
him or her
important
feedback
about
how he or she is
affecting
others.
It can
also serve
as a
model
for the
idea that expressing
feelings,
even
A
RELATIONAL
APPROACH
TO
SUPERVISION
139
uncomfortable
ones,
can
lead
to
closeness rather
than
increase alienation
and
can
open
up
further
exploration.
Position
3:
Exploring
the
Client's
Construal
The
goal
in
this
stage
is to
unpack
and
explore
the
client's
construal
of
events.
The
focus
here should remain
on the
interaction
in the
moment.
The
goal
is to
provide
the
client with
the
experience
of
working
his or her way out
of
those cycles with another person,
not
simply
to
come
to
greater under-
standing
of
these cycles.
To do
this,
the
therapist needs
to
help
the
client
to
unpack
his or her
understanding
of
what happened
to
precipitate
the
rupture.
Position
4:
Avoidance
of
Vulnerability-Aggression
Although exploring
the
client's experience
of the
rupture
may
lead
to a
resolution, talking about these
feelings
can
often generate considerable anxiety
and may
trigger avoidance
of
underlying feelings.
As a
result,
an
ongoing aware-
ness
of the
emotional
shifts
in
both client
and
therapist
is
critical,
and the
focus
needs
to be
kept
on
what
is
happening
in the
moment.
As
clients become anx-
ious,
the
focus
needs
to
shift
to the
current anxiety,
and the
exploration needs
to
shift
between both
the
feelings
and the
avoidance. This
can
help clients
to
better understand,
and
more comfortably express,
a
wider range
of
feeling
states.
It
is not
uncommon
for
ruptures
to be
partially resolved
and
then
to
reappear
in
slightly
different
form
as the
underlying schema
is
reactivated later
in
therapy.
Position
5:
Expressing
the
Underlying
Wish
or
Need
Clients
often believe
that
their
underlying wishes
or
needs
are un-
acceptable
or
will
go
unmet, leading them
to
express them
in a
qualified
or
indi-
rect
way,
which
may
pull
for
complementary
feelings
of
frustration,
confusion,
or
irritation
from
the
therapist.
If the
therapist
is not
aware
of his or her own
feelings
and
responses, this
may
perpetuate
a new
enactment
of the
cycle. Pro-
viding
the
therapist
can
continue
to be
mindful
of his or her own
responses,
continued work
can
lead
to the
examination
of the
underlying wish
or
need.
As
the
exploration continues,
and the
therapist continues
to
validate
the
client's
emotional
responses,
the
client
can
gradually become more comfort-
able
with
his or her
underlying feelings
and
needs,
and
more capable
of
expressing
them directly without feeling
that
doing
so
will endanger
his or
her
ability
to
relate
to
others.
At the
same time,
the
client begins
to
under-
stand
that
all of his or her
wants
and
needs cannot
be met and
that
the
feel-
ings
of
sadness
and
disappointment
that
result
can be
tolerated
and
accepted.
Learning
to
facilitate such
a
process, which
in our
view
is an
essential clini-
cal
competency,
is
initially learned
and
practiced within clinical supervision.
140
SAFRANETAL.
THE
SUPERVISORY PROCESS
Supervision
is
directed
at
helping therapists develop
a
particular stance,
including
an
awareness
of, and
ability
to
work with, their
own
feelings
and
reactions.
To do
this,
we
believe
that
training needs
to go
beyond
a
didactic
presentation
of the
model
and a set of
techniques.
To
help therapists develop
the
ability
to
integrate procedural knowledge
and
self-awareness (which
is
necessary
to
respond
to
clients
in a
flexible
and
creative way),
it is
essential
that
training have
a
substantial experiential component
and
emphasize
the
process
of
personal growth
for
therapists. Below
are a
number
of
principles
that
facilitate
the
development
of
this
type
of
focus
and
awareness. First,
we
talk about general principles,
and
then
we
describe
the
specific
structure
and
exercises
of a
typical group supervision session.
General
Principles
There
are
some basic principles
that
guide
our
approach
to
supervision
and
that
help
define
the
stance taken
by the
supervisors
and are
encouraged
in
trainees. They include
a
strong emphasis
on an
experiential
focus
and the
relational context
of
supervision,
the use of
supervisors
as
models,
and
open-
ness
to
diversity issues.
Explicitly
Establishing
an
Experiential
Focus
The
process
of
establishing
an
experiential
focus
often involves
a
partial
shift
away
from
many traditional
ways
of
thinking about doing therapy
that
emphasize
the
development
of a
case formulation
and the
implementation
of
interpretations guided
by
this formulation. Although case formulations
can be
extremely
helpful,
they
can
also lead
to
premature formulations that foreclose
experience.
It
can be
useful
to
begin
the
supervision process
by
explicitly presenting
a
rationale
for an
experiential emphasis
to
training. Typically,
we
begin
by
discussing
the
dangers
of
assimilating
new
experience
to
preconceptions
and
emphasizing
the
value
of
striving
to
develop what
the Zen
master Shunru
Suzuki
(1970) referred
t