Key moments, in order
The alliance is not just whether the patient likes you. It has three necessary parts: an emotional bond, including trust in the treatment process; a shared understanding of the problem and the goal; and a shared understanding of how to get there, meaning the treatment target and modality.
"Rupture" sounds like a big dramatic clash, but it includes very subtle signs of not being quite on the same page or not being completely comfortable with each other.
Some rupture is inevitable: both people have needs, and at points those needs will clash.
Do not treat ruptures as big, scary events. They are going to happen, they can be small, and they present opportunities; that attitude lets you approach them with openness, non-defensiveness and curiosity.
Pay attention to subtle micro moves and to your own internal reactions. A sense that something is a little off, or that you are uncomfortable or bored, is an opportunity to be curious.
People picture ruptures as explosive, but withdrawal, and receding your own needs, is a huge blind spot for therapists.
Withdrawal can happen while the patient talks a lot: not answering the question, going abstract, intellectualizing, like high-minded talk of Buddhist non-clinging and being okay with a painful situation.
How intense it is and how long it lasts separate a minor withdrawal ("did I just see something?") from a major one.
Use metacommunication: talk about what is happening, communicate about how you are communicating.
Frame it as we and us: what is happening between us right now? Are we getting lost, getting off track, avoiding something?
Name the process instead of reacting: you seem irritable today, the way we are interacting seems to be bringing up a lot of irritability, we're not on the same page, what do you suppose is going on?
Ruptures and repairs are co-constructed, so there is no five-step recipe that leaves out the patient.
Take responsibility for your contribution: "No wonder you're confused, I wasn't clear." Or: "I was rushing you because I was worried about this."
There are two broad kinds: withdrawal, moving away, and confrontation, moving against.
Unrepaired ruptures lead to poor outcome. Repaired ruptures are strongly associated with good outcome.
You are going to make mistakes; that is human. Then you repair it or the patient leaves and finds somebody else, and a repair is a chance to understand more and end up with a closer working relationship.
When trust or empathy is struggling, it is usually some version of therapist anxiety blocking empathic abilities you already have.
Reframe the moment away from I am a bad therapist or they are a bad patient, toward this is just human interaction and we can talk about it.
Just as you respect the patient's boundaries, respect your own.
Therapists tend to be open, accepting and non-confrontational. Without a good understanding of why boundaries matter, early therapists and psychiatrists really struggle to set them.
Role plays let you try the conversation you fear: the patient is not really there, so they will not explode or crumble, and you can play with it.
Doing it under the pressure of peers watching is how you prepare to do it in a high-pressure moment with a patient.
The more mistakes you make, the more you learn. In group supervision, ask the dumb questions, the ones you think you should already know.
When you are stuck arguing about content, step back and ask what is happening process-wise, and pause to talk about it.
So far, research comparing online and in-person therapy finds little to no difference.
We draw a sharp line between video and phone visits. The quality, content and process of care changed considerably when moving to telephone only.
When a patient is describing something painful, it is not the time to connect it to the past or intellectualize. Be there and sit with the emotion.
When something comes up live in the session, that is gold. Explore it while you are both feeling the feelings and thinking the thoughts.
Stay close to what the patient brings in. If you are focused on a med change or a billable diagnosis, you can miss a lot.
Therapy is a little laboratory for a new experience. It is something you do, not something you think.
Rupture and repair training is among the most practical training there is, and its skills get used constantly in medication management, not just therapy.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.