So I'll just start off. Today we have Dr. Katherine Eubanks. Dr. Eubanks is a PhD in clinical psychology and professor at Adelphi University. She's one of the big researchers in Alliance-focused training. One of the big themes of our podcast is Alliance, especially applied to psychiatric appointments where it's painfully ignored. The reason we have Dr. Eubanks on is I asked Dr. Fu a question and he recommended I read Rupture and Repair, which Dr.
Eubanks was one of the first authors and editors. And I was like, oh, Dr. Eubanks was my supervisor in residency. I did a group supervision that we had on the brief psychotherapy program. And it was probably my favorite experience in residency. And the Oh, place where I learned the most things. And I think I even mentioned it was like the first place I felt like at home in residency.
So we're super excited to have you on here. And hopefully we can learn some of the ideas and things that I learned in the program.
Thank you for having me. I appreciate it.
I'd like to sing some praises, too, while we're at it. You know, I really think it's an amazing and excellent book. It's a must read. Even if this is an area that's mostly published in psychotherapy, I'm going to second this. If you're listening to this, you work in the mental health field, heck, if you work in the medical field at all, these are concepts that you really need to understand, that you need to practice.
And Dr. Eubanks' book is the way to go, I would say, to start.
Thank you. My goal of this podcast is to hear your ideas on alliance and ruptures and repairs, and I hope it's helpful for providers. I shared one of your podcasts with my group of friends just because I think the concept of repair and being open to repair is something that applies to everyone. It's not just a therapist to therapy concept. Maybe in terms of a place to start, if we could just start with what is Therapeutic Alliance?
And then we'll just kind of see where it goes.
Sure. So when defining the alliance, we usually start with Ed Borden's conceptualization. Borden proposed thinking of the alliance as having three parts. So the goals of therapy to the patient and therapist or, you know, healthcare worker and patient or, you know, whatever the therapist. I can say that. Okay. Yeah.
Everyone listen for psychiatrists as well.
Thanks. So patient and therapist, do they agree on the goals of what they're trying to work towards? Then there's tasks. So any kind of treatment involves tasks. Like it could be we're going to do a particular exercise or it could be we're going to talk about a particular topic, but we're doing something together. And so can we collaborate on those tasks? And then do we have a bond?
Do we have a sense of mutual trust and respect? And does the patient feel safe and comfortable opening up? in this space. So those three things comprise the alliance. It's trying to capture our ability to work together. And then if there's difficulties in those areas, we talk about that in terms of ruptures in the alliance. That could be we don't agree on the goals. It could be we're having trouble collaborating on the tasks.
It could be there's a strain in the bond. And we find it helpful to think about ruptures the word rupture sounds like a big dramatic clash between two people but we use it more broadly to include even very subtle signs of not being quite on the same page not being completely comfortable with each other getting a little stuck or having a little difficulty getting going and another piece of this that um jeremy saffron and chris moran have really brought to the discussion is thinking about how Ruptures can tell us something about the needs of the two people in the interaction, what needs are being met and what needs aren't being met.
And everybody, all human beings, have needs both for agency, like I just need to do my thing and feel autonomous and feel empowered, and a need to be connected to other people, to be related to other people, a need for communion. And those needs can be challenging to navigate even within ourselves, right, our own needs in both directions. And then when we're interacting with another person, now there's a whole lot of needs in the mix.
And it's inevitable that at points those needs are going to clash or collide or conflict with each other. So in that sense, some kind of rupture is inevitable. And so as therapists, to be prepared for that, open for that, understand that this is an opportunity to learn more about what's going on between us and what's going on for each of us the kind of rupture we have could tell us something about what needs are being met and aren't being met and exploring that could really not just help us get back on the same page but help us actually move the therapy forward and provide a corrective experience for the patient, a new way of navigating interpersonal conflict that could change how they see themselves in relation to other people.
I definitely want to dive. Several very key and important concepts there. I think simple in terms of the definition, hard to maybe grasp for many. In your experience so far with researching, writing, and teaching, where do you see learners or even colleagues coming into points of disagreement? or difficulty in kind of absorbing or agreeing upon these concepts and how we define them, for example, a therapeutic alliance.
Yeah. I think one thing, and it's sort of on one level, it's just about sort of quibbling over definitions, but then it gets to something maybe different. deeper than that. So the thing I'm sort of alluding to before, like the word rupture, because for some, I mean, understandably, if you look it up in the dictionary, the word rupture in everyday English, you know, sounds like a big thing, right?
Like an explosion or something. And so people will come in, I see this sometimes, therapists will come in sort of like, well, I don't have ruptures. Or ruptures are big, scary, terrible things that must be avoided at all costs. So how do I avoid ruptures is the question. And we're suggesting, let's try not to think about it that way. Let's think about it more as, you know, they're going to happen.
They can be small. They present opportunities. And I think that attitude helps us approach them with openness, non-defensiveness, curiosity, I mean, really, it's regulating our own emotions as therapists in the moment and kind of bringing that, oh, this is interesting. I'm curious about this. Can you patient and I explore this interesting thing that's happening together and not, neither of us feel like we have to defend ourselves or prove who's right, but like together, let's look at this thing.
I think that kind of having that perspective is really the most important thing.
You know, there's this old saying that crisis and opportunity are the same word in Chinese, which I can't even verify, by the way. I don't know if that's true or not.
It would be great if it worked because it sounds really cool.
Yeah. And it sounds similar to this. And it also sounds that the rupture can be maybe present even at the beginning without there having anything been done. And that really what matters is big or small, we look at the we have attention to it together with patients.
Yeah. Noticing it. Right. Also, like paying attention to the subtle micro moves that we can see or also our own internal reactions. Right. Like your sense, something's a little off or I'm a little uncomfortable or I'm a little bored or whatever. That's an opportunity to be curious, like, OK, that might be telling me something. What what's going on here?
Yeah, I think one of the big things I learned through the supervision was I like so much how much you humanize ruptures. Like it's a part of being human. It's a part of absolutely every single relationship. I don't know if you've ever watched Love is Blind, the television show.
I've heard about it, but I haven't watched it.
I'm somewhat of a savant at knowing which couples are going to stay together. Oh. But the one huge red flag I think you're kind of mentioning is whenever one of the partners says, like, I never fight or like whenever I'm in a big heated fight, I get super rational. Huge red flag. And I think it's, I do want to talk a little bit more about like withdrawal in regards to, because I feel like that's a big blind spot that people have is they think of ruptures as like these very explosive things.
And especially for therapists, withdrawal and receding your own needs is a huge blind spot.
Yeah, I agree. And I guess also the things people disagree with when I talk about withdrawal is where I get the most pushback. Like, that's not a rupture. What are you talking about? I'm like, wait, this is actually really important.
Yeah. And so a big part of your research is coding these things. So I know it's like coded, I think, one to five on something. Can you talk a little bit about like what withdrawal looks like in the small, like, you know, one and then what like a big, strong withdrawal looks like?
Sure. Yeah. So what Greg's alluding to is we developed an observer-based measure that we can use to watch therapy sessions and sort of track rupture and repair processes and assign numbers to them that we can then use in analyses and research studies. And so small, subtle withdrawals could be like someone starts, maybe there's some we call it minimal response so they go silent or just give like a one-word answer um you might do that just very briefly right there might be like a brief pause and it's not the kind of pause of like i'm actively engaged in thinking but it's more of a pulling away retreating kind of pause um but then a five could be somebody goes silent you know for like a long time um or it could be somebody um gets kind of intellectualized and abstract.
So sort of the opposite of going silent, you could be talking a lot, but you're still withdrawing. So I'm not really answering your question and I'm going really abstract and over here and over there. And, you know, you asked me how I felt in an interaction with a loved one and I'm like society, this people, you know, I'm like way, way out. And that's another way of withdrawing.
And that could be a subtle thing where I just do that like a little bit, or I could, you know, I'm just completely gone and the therapist is struggling to sort of where they've gone, what are they talking about now? You could also take the form of sort of masking how I feel. So, oh, no, yeah, the session was great. Oh, this is very helpful. And you kind of have a sense that's not really how they feel.
Or like someone smiling while talking about something very painful. And it's like, I feel like that that smile is a mask. There's something that they don't feel safe or comfortable fully bringing forward. So you could see little glimpses of this, like somebody just a little smile, a little chuckle while they mentioned something sad to something very extreme where it's actually quite striking how they're smiling while relating a tragic story of a loved one who just died or something.
And you're very aware of the discrepancy. So I would say it's that kind of how intense it is or how long it lasts. will sort of be the distinction between a minor withdrawal that you're like, oh, did I just see something? Maybe I'm not sure. And whoa, this person is really moving away from me and from what we're trying to do together.
Yeah, I found it super helpful the way you conceptualized like intellectualizing as withdrawal. It made me think of a recent scenario with a friend. I was with a group of friends and his dog had just passed away and he was super intellectualizing of being like talking about like Buddhist philosophy and non-clinging and, you know, very high minded ideas of, you know, uh being okay with the situation and it was a group of three four guys so we were all like uh they were all being like oh you're so brave and in my head it was like i want to be like no you should be sad like like you're there's something missing here like a day after you know something really sad you shouldn't be it's not the time to be uh i don't know abstract buddha eastern philosophy um and i think like thinking about this helped me to be like you know, it's okay to be sad right now.
Like we don't need, like, let's not all collude together and ignore just kind of being with this person. So I feel like I've taken a lot of these concepts into my personal life.
Oh, interesting.
Now, you know, we're on a podcast format, so I'm going to ask for some oversimplified advice. Do you feel like you've described some subtle and more extreme withdrawals, one type of rupture? What advice might you have for clinicians to address it? How do you recommend people address it? I feel like the addressing part is hard. People are afraid. They don't want to jump in. They don't want to look at things that are mismatches.
What do you say to trainees or other people?
so um i mean the the first thing is is is actually just noticing it so i think there's a lot that we can miss so if you've noticed it that's already like half the battle and sometimes it can be as simple as just being curious about it right like i i know she got kind of quiet there what's going on um And we talk about this in terms of metacommunication.
That's the fancy word for, like, let's talk about what's happening. Let's communicate about how we're communicating. So it could be, like, I notice something happening. Or I could... metacommunicate by self-disclosing, like, oh, I'm feeling like, you know, there's a wall between us, or I'm feeling lost and confused what's going on here. Or we could kind of metacommunicate about it, sort of framing it. And I like this approach, framing it as a we and an us.
So it's not that you're doing this thing, or I'm doing this thing, but like we are. So like what's happening between us right now? Are we getting lost? Are we getting off track? Are we avoiding something? Just being curious, what's going on with that? And if we're feeling hesitant to broach it, like I'm afraid they'll misunderstand or I'm afraid they'll feel criticized or something, we could metacommunicate that too.
Like I'm noticing something, I'm thinking about bringing it up, but also part of me, is afraid it might sound like a criticism and that's not my intention like you
could kind of put all of that on the table sort of casting a spotlight on whatever process uh that is being noticed that doesn't seem to be going well seems to be the first step there even before attempt at a repair making sure that it's shared visible between the patient and the clinician um I like, I really like that we aspect, you know, it reminds me of Harry Sacks Sullivan's, you know, sitting together with the patient looking out.
I think that's certainly an area where I can be deficient in med management, often aggressive. You seem irritable today. What do you suppose is going on? The way we're interacting now seems to be kind of bringing up a lot of irritability. We're not really on the same page. What do you suppose is going on? Probably much more effective. Easy to miss, I think, when we're kind of crammed into these fast-paced encounters.
So very good. How about for repair? In a nutshell, preview, I suppose, on a podcast, where do you want people to kind of go? Or what would you advise?
Well, I think if they do those things, shine a spotlight on it, express curiosity about it, then that's what kickstarts the repair process. And the repair process also, both ruptures and repairs, we say they're co-constructed, like both people are part of creating it. So that's also for therapists, we can't say do these five things because that leaves out the patient. So it's more like invite a conversation, invite the patient to be part of the process and then follow that, see where it goes.
It could end up with agreeing to change something you're doing, change an approach. There could be some negotiation involved, but it also could just be Or it could be also taking responsibility for our own contributions to it, right? Oh, no wonder you're confused. I wasn't clear. Or I was pushing you. I was rushing you because I was worried about this or that. I realized that's how I was contributing to this.
So those could be important parts. But really, I think it's almost more about coming with the right attitude and mindset. And then the solution... If there is one, the two of you will find it together. And if there's not one, then it might be a process of sort of respecting each other's differences. Like maybe we're just not going to agree on this. And so, okay, we tried and we discussed it.
And, you know, I respect that. That's your autonomy as an individual to your agency. Like sometimes we have to respect the agency as well as the communion.
if I'm hearing this right, it's, it's less about like thinking about like, which of these six different repair strategies going to use and more of a, a frame of mind of, of being open to negotiating and curious about the other person's experience and, uh, open to hearing criticism and, and, and either clarifying or, or something.
Yeah, exactly. Exactly. And, and, um, That may not be a fully satisfying answer in some ways, but I think that's true. And I think that also respects, you know, the importance of context and the importance of sort of like what's the right answer for one patient and therapist might not be the right answer for another. So I think, yeah, I think you're capturing it really well.
What are the other like big teaching points or things that you see the research show that are important for outcomes?
So we've talked some about withdrawal and the other broad category of rupture is confrontation. So withdrawal moving away, confrontation moving against. So that would be the stuff you might think of more readily when you hear the word rupture, like somebody criticizing, attacking the other person, complaining about something, trying to sort of control or pressure the other person. And So far in research studies on this, I mean, one question people sometimes ask is sort of like, which one is worse or which one is harder to repair or which one contributes more to outcome?
And so far, I don't think there's a clear finding. And I think that actually what we're going to find as we study this more is that it will depend. And in certain settings or with certain populations, you might see more withdrawal and others you might tend to see more confrontation and which one has a bigger impact on outcome will also depend. And I think we as therapists can pay attention to if we find one or the other more challenging to recognize or more challenging to deal with.
And also being aware that Ruptures by themselves, it's not as simple as like rupture leads to poor outcome because rupture repair predicts good outcome. So it's really that unrepaired ruptures lead to poor outcome. Repaired ruptures have been so associated with good outcome. So in this interesting way, ruptures can be good. They present this interesting opportunity and can facilitate repair. And in some studies, patients with repaired ruptures actually had better outcomes than patients who reported no ruptures at all.
So I think that's an interesting thing to keep in mind about ruptures and sort of shift our maybe initial like, oh, no, these are bad things we need to avoid perspective.
Sounds like it demands a level of bravery from clinicians that we have to be willing to make errors. We have to be willing to not do well in order to do well. It's a paradoxical, I think, but important.
Yeah, I think so. But it's also sort of liberating, right? It's like, look, you're going to make mistakes, right? That's human. And... They present these really amazing opportunities to learn more, better understand, and actually become closer and have a better working relationship on the other side of it.
in terms of the getting closer element
um For you personally, you know, everyone has different theories. It's been published upon. But for you personally, I'm curious, what do you see as the major contributor or the factors that lead to the emotional bond and the thrust between patient and therapist? Because the rest of the two elements of the therapeutic alliance, at least for me, they're pretty cognitive. You know, it's something that you can talk about abstractly.
But what about that fundamental thrust element? And to add on that, if you can comment on whether you think there's a difference in technique or approach for people at lower levels of personality function. It's a big question.
Oh, talk about that. Huh. That's an interesting question. What leads to trust?
So it's funny, and I don't know if this is because I focus on rupture. I'm like in my head wanting to translate that into like, well, what gets in the way of trust or what leads to mistrust? I don't know what that reveals about me. But I think a lot of people... in this line of work part of what drew them to this line of work is is they do have some level of interpersonal skills some empathic abilities you know some interest in building good relationships with other people and so it's it's interesting when they struggle and what i have noticed is people struggling i mean it's it's usually some version of therapist anxiety right something is is getting kicked off in me that's getting in the way of me accessing my empathic abilities um so so i see a lot of our alliance focused training not so much about giving people alliance skills but more helping them realize what's getting in the way of them using their alliance related skills and and um and so seeing that like right if i'm if a patient if i'm feeling that uh uh either the patient sort of i feel like they're coming at me with confrontation and so i'm feeling defensive or anxious or scared or feel like they're running away from me with withdrawal and so now i'm like chasing them down i i'm I'm going to be defensive or I'm going to be missing things.
I'm not going to be attuned. I'm going to be too caught up in my own dysregulated emotions to be fully open and present to the other person. Helping therapists recognize when that's happening, giving them these ideas that might help them reframe some of that away from I'm being a bad therapist or they're being a bad patient to this is just human interaction and we can talk about it and we can work through it i think that helps people kind of be in that sort of centered grounded space where they're able to be attuned and open and genuine i think that's also helpful you build trust more easily i think if you're able to bring some genuine authentic part of yourself to the interaction i don't know if that
No, I think it's very interesting. It's almost it strikes me as Rogerian. It strikes me as a fundamental trust in humanity that we want to be close, that we want to connect and that it's really that we get in our own way. You know, there's this inherent good. I believe in that. I also believe in the opposite at the same time. I think it's very effective, though, to think that way for the majority of therapists and patients.
So I think it's very helpful. So thank you for that.
But you also asked about if a patient has a lower level of personality functioning.
Yes. Severe, moderate to severe personality disorders. Any alteration technique, advice or belief?
I think there... Maybe that's also where the compassion and the openness and the non-defensiveness and the attunement we need to bring to the other person, we also have to bring to ourselves. And that might be particularly important with patients struggling with severe personality disorders, right? So just as I have to respect their boundaries, I have to respect mine. And there may be times and maybe this is also like, you know, it's it's it's communion and agency and the therapist has both, too.
And I think for their own ability to to work well, they have to respect those. And that's also modeling. So we can also argue that that's helpful for the patient, too. But but maybe, you know, just being like genuine and sincere. But like I can't go like this is as far as I can go. I can't go further on this. You know, this is what I can do.
This is what I can't do. OK, we disagree on this and we've tried to negotiate it, but maybe this thing we can't. And like I have to stand here in my two shoes and and you're not going to be happy about that. And I get that and I feel for you. But this is where I have to stand. Maybe that might be the piece that might be even more important in those cases.
giving a sort of stance that isn't rigid but at least is strong yeah Sort of makes me think of, in that first chapter of your book, the concept of the safe and unsafe environment, you know, being consistent, really. And yes, I think many people talk about the frame of treatment when they think about trust and, you know, dealing with difficulties with boundaries, but an internal stance and being able to sense that seems very important too.
So thank you for that.
I feel like I see this part can be very challenging, especially for newer therapists, because the temperament of a therapist typically is open, accepting, non-confrontational. And if you don't have this good conceptualization of the importance of setting boundaries, I see early therapists and psychiatrists really struggle with setting boundaries or when they're feeling under pressure, negotiating those things. I'm curious, what do you see help when you're training or supervising, helping people to learn those skills or feel comfortable learning those skills?
So something this will sound familiar to you, Greg, but we in our supervision approach, we use a lot of role plays. and exercises where you can play out a conversation with your patient. And I think that can be a really helpful space to encourage people to try to do the thing they're afraid to do. The idea being like your patient's not really here. So, you know, if you're worried they're going to explode or crumble, if you say this, they won't because they're not really here, but we can play with it.
And you might be surprised what emerges when you play it out. You might stumble on something that actually would work with your patient. And now you've like practiced it. Or you might just by paying attention to what emotions and thoughts come up for you when you're playing it out, you might better understand that. your hesitation about it or your concerns about it. And when you get to play your patient, that can be really interesting, I think.
And I'm also speaking from having done this myself in this form of training as a trainee, like play trying to play out your patient can help you really. I mean, of course, you can't perfectly understand what they really feel like you're still not them, but it's a really useful exercise in trying to see things from their perspective. And and and so I think These things can help us better understand, like, what are we so afraid of about setting the boundary or being more flexible with the boundary, right?
Like problems on either side could be an issue. But really understanding what's going on for us and the other person can then help us be, yeah, can help us sort of understand. get at what might be behind that, our fears, our grandiose fantasies that we're going to magically cure everybody or whatever it is, we can kind of get at those better by trying to not just stay in our heads, but trying to actually like play out and notice our emotional reactions to imagining these conversations.
Yeah, I used to hate role plays. I remember in med school, I was too cool. I was like, this is stupid. And it wasn't until residency that I really started embracing them. And I think it's probably one of the most helpful tools in learning any sort of clinical skill. I think it's so helpful to... really engage and it's a lot of fun uh and it's like a safe environment and i think it's especially scary when you're in a group environment to like look stupid or uh say something stupid and i don't know how else to put it but you have to put that aside because it's such a good like i i learned so much by trying to take the role of a patient like there's it just opens so much that you can't do just from thinking about a problem
Yeah, and we're asking for a lot in that when we're doing that in the group supervision, right? To do it in front of your peers. But some of it is the idea of performing under pressure. Like if you can do this under the pressure of your peers watching, that's how you prepare yourself to do this in a high pressured situation with a patient right um if we can just do it in a in a completely safe and comfortable space then that's not necessarily preparing us for the high stakes that we might be encountering in a session so some of that we're kind of trying to get that like optimal arousal level where you know you're kind of a little bit anxious, maybe a little bit uncomfortable as you're trying to do it, not overwhelmed.
It's important to keep it manageable, but that we think that is part of what helps it be effective.
Yeah. In med school, I was so afraid of making mistakes so I wouldn't put myself out there. And if I could shake my old self for one thing, it's like the more mistakes you're making, the more you're learning, period. So like in group supervisions, in these things, like ask dumb questions, ask questions that you think like I should know this already and really engage in supervisions and role plays.
I think those are like the most important things for progress and learning. Yeah. Yeah.
Where do you see yourself going in the future with research? What are you hoping to cast more light on? You've done some great stuff already. I'm curious, what do you see in the next few years?
So one thing is... continuing to try to improve our ability to measure ruptures and repair processes because we can't do research on them if we can't measure them and so you know a lot of my time went into developing this observer-based coding measure and then revising the observer-based coding measure and we still have more work to do validating it and trying to apply it to different types of therapy in different settings and contexts um For example, I'm working with some folks.
We're trying to adapt it for family therapy, which is more complicated. There's a whole lot going on.
Ruptures galore.
Yeah, ruptures galore between the family members and the family members and the therapists. So how can we capture all of this richness, but in a way where the coder is not overwhelmed trying to apply the system? And we've also got projects in different countries and different cultural contexts, which I think is also really interesting, like cultural differences and how ruptures might be expressed or experienced. So that's an exciting avenue.
trying to, also trying to work on some better self-report measures to better capture these constructs. Most alliance-based measures have a problem with most people saying the alliance is good most of the time. And that sounds funny to say that's a problem, but we end up with not enough variation in scores to then look at relationships between things. The big thing that is getting a lot of attention these days is how can ai help us so there are multiple research groups trying to see could could ai code for ruptures so we don't have to put all this time and effort into human beings watching sessions to identify them could ai identify them and we'll see where that goes that's maybe the
best use of ai in therapy that i can think of pattern recognition right You could even cast it across sessions outside the research setting, theoretically, to spit out something that the therapist and the patient can work on to talk about. I'm curious about the self-report, either on the therapist side or the patient side. Has there been any evidence or a signal that you've seen that completing that helps the insight process for either party, or is it really more research tool?
That's a great question. I don't think anybody's looked at that specifically. There are some studies where alliance measures have been part of a routine outcome monitoring system. But there's a lot of things going on, like you're completing the measure and then you're talking about the measure or getting feedback from the measure. So I don't think anybody, to my knowledge, nobody's just isolated completing the measure and the impact of that.
But I am interested in that question. And I do wonder about about that. And that could be an interesting, relatively simple intervention if it had a positive impact.
Yeah. Because I'm always wondering what simple interventions can be done across the community to improve quality of delivery therapy. We can't do much in terms of standardization of training. We just can't. We can't do much in terms of getting people to self-reflect and to do certain things right but then you know working in the community health center i wonder what if we just did one thing just like the other uh silly forms that we require but add something like this has to be discussed between two people and of course uh needs more research but a very
interesting area yeah definitely it it's um And my hope is, and this is something I was aiming for with the self-report measure I've been trying to work on, is also kind of bringing in some of these, like the way we've been framing rupture here. So kind of presenting it as like, look, this stuff happens and it's normal. And, you know, sort of encouraging being open and curious about it, not like I'm asking you to report what went wrong.
Like that's not exactly it.
yeah thinking about therapeutic alliance i think that's the kind of thing like so many we pay lip service to it but very few people are are constructively thinking about it um and i think there's a bunch of things you mentioned but what things would you recommend people explicitly bring to therapy or their appointments um or or things that they talk about or do to improve therapeutic alliance
Think about it.
And I guess, and maybe being able to like reflect on both the content of what you're doing and the process of what you're doing. So I think there's something about being able to like bring in that process lens. And I feel like looking back for myself, like I remember in my training when it sort of clicked for me, like, oh, process and content can be different. and sometimes when people are struggling it's like they're going on and on and on in a kind of a vicious cycle repetitive process all around like we're arguing about the content arguing about the content we're arguing about the content we're arguing about what your problem really is or are you going to take this medication or not or like whatever we're arguing about something and it's that ability to go wait a minute process-wise what's happening here you know and and can we recognize that and go and pause for a second and talk about it or try to talk about it, or at least the therapist can think about it.
Because I think that's where I see people getting really stuck, frustrated or lost is, is sort of not being or having a hard time sort of seeing things from a process lens. Does that make sense?
Mm hmm.
Hard to do that, I think, alone. Hard to do any of this alone. And I suppose this is one of the main things. It's an unfortunate thing, but it doesn't seem like you can learn and progress very well with any kind of thing alone. We need peers, we need supervision, we need groups. And unfortunately, in society, it seems like things are increasingly atomized. You're sent through a training program, and then you get stuck in your little hole, and you have go on so for trainees you know you get out of training try to stay in contact with people and continue your progress now therapists since at least freud tried to extrapolate their ideas their work to broader society and trends within treatment i'd like to know if you are inclined to do so even if you're not how do you see your work as uh impacting or at least reflective of broader society or at least the field that large.
Yeah, I have thought about this a lot because I feel like there's definitely a lot of rupture happening in the world right now. Like that part seems very, very clear, the relevance of the rupture. And what I think I've tried to think about some, and I feel like I need to wrestle with more. It's like, well, do I have anything helpful to say beyond, oh, gee, we have a lot of rupture.
How do these repair ideas help? And I think, and I guess this is also, it's not like we can say, okay, people of goodwill bring these repair strategies to society and we'll fix it all. Because, yeah, it's co-constructed. And so I think it's challenging. It feels like there's a lot of mistrust and a lot of people on all sides of any issue who feel fed up or frustrated or like, I can't, maybe not even interested in repair anymore, right?
I've just sort of concluded these ruptures are too deep. That's it. So I don't know. I think I struggle with that too. I wish everybody in the world, we could all be open and non-defensive and aspire to better understand each other. But I understand that that seems, people may feel like they tried that and it failed, or that's too naive, or that's not going to work.
maybe it's an issue with that we aren't really talking or trusting one another you know these days maybe whatever medium we're used to doing that in has collapsed or gone away maybe we were in person more and yeah you know we're speaking here over zoom uh that's one thing but i don't think most people even contact each other with the full experience data set of human interaction right it's all text and not only that it's text and images that have been filtered and present in a very specific way so maybe we just have to start talking at first have any kind of contact with another person that's to their inner world rather than just the content process over content, I suppose, as you were earlier referencing.
Yeah, I think that's a good point. Right. And kind of going back to the idea of, you know, most human beings have some empathic abilities.
You hedged a little there.
I guess I can't claim that it's universal. I'm not casting aspersions on anybody. I'm just trying to be, yeah, I haven't met everybody, right? So I don't know. There's a lot of different things out there, but I think most people, certainly a majority have it. And so, yeah, how are things set up now that are instead of facilitating and encouraging those things or kind of blocking them, like you were saying, right?
Like, yeah, when I don't have to really interact with you, then it's easy for me to not see you as a real person. And then I can do all kinds of terrible things. But when I'm actually interacting with you, and most people I think have this experience, you have people you know in your family or friends or neighbors who you don't agree with, but you also see them as a full person.
And it's easier to have some grace there.
Also, technology makes it so that for me, there's less opportunity for repair. Like to me, a strong repair process is much easier in person when I can kind of get a feeling for the person and a connection. And I mean, I've had so many fights get prolonged because we're not texting or texting not enough. And like the ability to stay far apart and not interact through means that aren't conducive to repair prolong this thing.
Yeah. That makes a lot of sense.
I'm actually curious if you see a difference, I mean, sort of connecting to that in terms of research that you've done on this stuff in person versus like on Zoom.
Yeah. This is a tough one because my instinct is to agree with you that this stuff makes sense to... work on ruptures and repair in person, and I bet it's more powerful. So far, research comparing online therapy and in-person therapy are finding little to no difference.
Good enough.
yeah um how much of that is we just don't have we don't know what to measure or are the best ways to measure it but like using our existing measures there's there's often little to no difference and um yeah and maybe this is actually getting back to that point of like technology so we're about to uh start some new waves of data collection um chris moran and i and our colleagues And our plan is to do it all over teletherapy because the technology makes the research easier, right?
It's easier to record. It's easier to transcribe. It's easier. So, yeah, we're going along with further, you know, studying this stuff over this somewhat disconnected medium because technology pulls us in that direction. And then what is getting missed?
Yeah, the tele... teletreatment teletherapy fan uh i'll have to admit my bias i i'm a fan of it but i personally draw a very distinct difference between video based and non-video based you know i had an experience practicing during the pandemic that the quality and content and process changed considerably when moving to telephone only there's something about that almost like making someone face away on the couch and just based on that i've been very insistent about getting that data of the visual i suppose you know we think about how Humans tend to perceive others.
The face is probably the most important part, though obviously, you know, we can miss a lot if you don't look under the shoulders in the mental status exam. But I suspect that's probably the main dividing line. And we can say dependatively that most people are not interacting with others in broader society, not in the clinical setting with any facial expression.
Yeah, that's a real loss. We've evolved to be so attuned to facial expressions. Yeah.
I'm looking at the time. There's one topic I did want to touch on before we end. So this is a bit of a combo change. I think focusing on rupture and repair was the first time I... You know, the concept of like here and now in therapy. I feel like it was the first time I got a real grasp on the here and now. And I think what I...
in one of the, I think videos we had watched, it was like, um, you know, a patient described some very painful thing going on. And the therapist goes like, that reminds me, that reminds me of your relationship with your mother, or that reminds me of your relationship with your, you know, whatever. Um, and yeah, kind of the timeout that stopped, it was like that the therapist really missed something because this wasn't a time to make a connection to the past or, you know, like intellectualize and think of all the way that connections in this person's life.
This is a time to be there and sit there with that emotion. And that it was a rupture. It was the therapist was withdrawing from the emotion in the room by thinking about what we think of as like, you know, psychoanalyzing. So that concept is, was really helpful for me to understand the importance of the here and now.
Yeah, it's when something comes up like live, in the session i mean that's gold right we want to mine that it's happening right now it's like this amazing opportunity to explore something live to explore something while you're feeling the feelings and thinking the thoughts not having to report what you remember about feeling or thinking and and and like connecting to other stuff you can we can do that anytime we can do that next week we can do that whenever but yeah i think there's something really um It's such an amazing opportunity when it's happening right then and there and in vivo and we can explore that.
So staying attuned and trying to capitalize on those moments is so important.
Either way, I think it's being close to the patient's material, you know, staying in the moment. It's paradoxical, but I think that even translates to diagnostic interviewing, assessment and medication treatment. You know, if you're so focused on making a med change or getting a billable diagnosis, you can miss a lot by not paying very close attention to what somebody is bringing in and acting.
And I was going to say like the corrective emotional experience, I think it's more like riding a bike than it is like learning a reading a book. Like it's an experiential thing that occurs. It's not some thinking thing you do. Like anyone can go and think outside of therapy. But in therapy, it's like it's a little laboratory for a new experience, which is something it's something you do, not something you think.
I don't know if that made any sense. Yeah.
Yeah. Yeah. Yeah. And then hopefully we'll think about it and reflect on it afterward. Like the thinking, well, the thinking will come, but we don't want to miss the chance to have that experience because they, I mean, I'm sure we've all worked with patients that are like, okay, I know this or that is my problem. And I know I need to do this or that, but I still like, that's it.
Just having that intellectual awareness is not sufficient.
Mm-hmm.
All right, we have five minutes before we wrap things up. Any other big, big things we want to touch on?
It's a podcast we don't have a lot of listeners, but anything like pitch, sell, any vitamins maybe. Supplements.
Well, one other thing that I'm excited about in our work going forward is not just the research on ruptures and repairs, but the research on the training, so like on the kind of supervision, Greg, that you were a part of, we've been doing increasingly more research on that. And there is very, there's compared to how much we depend on training and supervision in our profession, when you look at how much research there is on training and supervision, it's woefully inadequate, we need way, way more.
So I am excited that we're really trying to bring all our research tools to the supervision process itself. We're recording supervision meetings. We're filling out questionnaires about supervision. We're trying to apply coding measures to supervision meetings as well. And really thinking about also, how did you train people to be supervisors? So I'm really excited about all of that. I think that has a lot of potential to help support and train therapists.
Very neglected area. And, you know, I can remember from a talk at the training director's conference about, you know, you can see so many patients, but if you supervise, teach, train, that's a multiplying, you know, exponential on the number of patients that you can have. And so I'm glad that's an area that you folks are working on.
You know, I did want to bring up, there's a training event that the Alliance Rupture Repair on November 13th, virtually $60. We'll put a link in the podcast for my mom and sister to see because that's most of our viewers on the podcast. Okay.
um we're signing up for folks uh you know anything like this and especially straight from the horse's mouth uh if you can do it i would do it yeah like i said
this was i learned the most in this supervision just in terms i feel like it's the most practical uh To me, it's the most practical training. And I feel like I approach, I use the skills so much in medication management in not just therapy. So I think I recommend, yeah, people really engage with this stuff.
Oh, great. Thank you. You should think about like writing something about that or something. I think that'd be great to get more of that out there, how it's relevant for medication management. Absolutely. I think that's a good idea.
All right. Any closing remarks?
I mean, thank you both. I feel like for most of the questions, I would give an answer and then you would summarize it way better than I said it. So I feel like you both have a really good nuanced understanding of these ideas. It was really cool.
Well, it's a shame we didn't have any ruptures to repair today. seem to go too well but you know there's always the future all right thanks so much
for coming on no thank you