Written by: Alexandra Poole, LCSW
Team Lead and Primary Therapist with Renfrew@Home, Renfrew’s Virtual Treatment Program
With the rise of ChatGPT therapy, I find myself thinking a lot about which parts of the therapeutic alliance are exclusively human and won’t be replicated or made obsolete. AI is affordable, accessible, and consistently offers up useful advice. As therapists, we are limited by systemic constraints, and sometimes, we get it wrong. But what if our imperfections were actually the most human thing we can offer our clients?
In the age of quiet quitting, ghosting, and severing ties with all that does not serve you, it can be hard to imagine conflict in a relationship as a gift, something productive, or an invitation for more intimacy. I’ll admit, this is something I only started to integrate later in life. I grew up in a family where ruptures were not met with repair. Disconnections were dealt with through the silent treatment, triangulation which is when we confide in another family member who is not directly involved in the conflict to form an alliance, and years of estrangement until one family member finally “got over it” and could be in the same room again. The original conflict remained unaddressed. There was no blueprint for moving through disconnection. As clinicians it is essential we know our own blind spots. Relationships, like peanut butter, require stirring to stay smooth. Let me implore you on the importance of rupture and repair in the therapeutic relationship:
The Peanut Butter Metaphor
If you’ve ever picked up a jar of natural peanut butter, you may have noticed the following message: “Separation is natural, stir.” Reading this has always felt like opening a fortune cookie. There is wisdom to be found in peanut butter. Like a jar of peanut butter that has been left too long on the shelf, two people in a relationship can drift away from each other. Unaddressed ruptures can separate people like oil and peanut butter, but in the same way peanut butter needs to be stirred, we can repair disconnection in relationships. And perhaps reach an even smoother consistency than before! You just have to work for it and allow for a little messiness along the way.
What is a disconnection?
According to Relational Cultural Theory, a disconnection in a relationship occurs when the positive qualities of a mutual, growth fostering relationship are ruptured by an experience of separation, misunderstanding, perceived abandonment, or judgement. A disconnection can refer to a specific moment or series of moments that lead to a state of disconnection in a relationship.
We know what the research shows. Eating disorders thrive in isolation. Our clients with eating disorders experience higher than average levels of relational disconnection. And chronic disconnection is a driving force for Emotion-Driven Behaviors (EDBs): behaviors that are often maladaptive and come about as a way to manage strong, unwanted emotional experiences. EDBs may look like restriction, bingeing, body checking, self-harm, etc. They serve a short-term function to dull, or completely avoid, the underlying feeling but fail to meet the original emotional need. Reliance on EDBs often causes shame and the person living with the eating disorder may avoid close relationships and push away opportunities for support. The therapist-client relationship can serve as a mirror of other relationships in the client’s world. It is therefore an opportunity for a corrective emotional experience when new ways of responding to disconnections are modeled.
READ MORE: Trauma & Eating Disorders: Which Should Be Treated First?
Disconnections Between Clinicians and Clients
We don’t heal individually. We heal relationally and in community. It is widely known that the quality of the therapeutic alliance is the greatest predictor of positive outcomes in therapy. Traditional psychotherapy often encouraged clinicians to interpret a current rupture by linking it to broader relational patterns in the client’s life. For example, suggesting the client is avoiding vulnerability as they did in their marriage, or that they’re reenacting an unconscious family role. However, making these interpretations can leave clients feeling patronized or disconnected. As a clinician, it’s often enough to simply recognize that there is likely a connection, without needing to name the pattern explicitly in the moment.
In the therapeutic relationship, a disconnection may look like getting a name wrong, forgetting a pertinent part of a client’s story, missing a need, a microaggression, or enforcing your own goals in lieu of the client’s, among many other examples. The source of the disconnection may not be immediately obvious to the clinician, but may result in a change of tone, posture, lack of engagement, tardiness, rescheduling, missed sessions, or requests for termination.
The way a disconnection is felt and understood can be magnified if the client also carries their own trauma history, systematically oppressed identities, and negative core beliefs. Individuals with trauma histories may have a harder time tolerating a disconnection and rebuilding trust with providers. The power imbalance of the Clinician-Client dyad along with a potential lack of shared identities may cause feelings of hopelessness around being heard/understood or in one’s ability to influence the relationship. Negative core beliefs such as inherent worthlessness, otherness, and aloneness can be triggered when disconnections occur within the therapeutic relationship. Based on these factors, the amount of effort and time it takes to rebuild and reach repair will vary, and will depend on the distress tolerance level of both the client and clinician and their willingness to lean in.
Steps to Move Through a Disconnection
- Affirm the importance of the connection
- Clinician: I value the connection we’ve built over the last few months and take my role of creating a safe, welcoming and warm space seriously. I care about your feelings and the ways in which my words and actions impact you.
- Name or clarify the disconnection
- Clinician: I’ve noticed that you cancelled our session last week and arrived a little later today. It made me reflect on what might’ve gone wrong in our last session. I remember noticing a shift in your posture when I asked about getting bloodwork done and I wonder if I hit a nerve?
- Make space for the other’s understanding of disconnection and engage the differences with non-judgmental curiosity
- By being curious about the nature of the disconnection with a regulated, non-judgmental demeanor, the client has an opportunity to clarify whether this was in fact the disconnecting moment or cite another reason. Let’s imagine the client was activated by the request for bloodwork. Maybe they’ve received ultimatums with providers in the past like a forced step-up to a higher level of care or treatment abandonment. Maybe they’ve experienced medical trauma.
- Take accountability if/when you’ve caused harm
- Clinician: I’m sorry I wasn’t attuned to your needs and really appreciate you sharing your feelings transparently with me now and giving us the opportunity to talk through it together. It makes sense you felt afraid – you’ve experienced ultimatums in the past. Although medical data like bloodwork can help tell us how your body is doing, I also recognize that for you and many others, accessing medical care comes with historical antecedents.
- Offer time and space for the client to process
- Clinician: We can keep talking about this next week after you’ve had some time to reflect. I will reach out to you before our next session to check in and see if you are still open to meeting at that time. I would love to hear a little more about some of your past experiences with providers if you are open to sharing and we can also set aside time to discuss more aligned ways to access care for some of the physical health symptoms you are experiencing.
Conclusion
Clinicians should be skilled at noticing the ruptures and be able to tolerate the distress of the disconnection. When we name disconnections and address them with empathy, emotional regulation, and curiosity about the mistake, we model accountability and show that disconnections are a natural part of the messiness of human relationships. The ripple effect can lead clients to access more compassion for themselves and others, more comfort getting and receiving feedback, and greater confidence asking for their needs to be met in relationships. In this way, a therapeutic alliance that repairs itself may have even greater value and application to the client’s life than an alliance where no ruptures occurred.
Struggling with disordered eating or body image? The Renfrew Center provides compassionate care for all bodies. Contact us today to get started.
References
- Eubanks-Carter, Catherine F.; Burckell, Lisa A.; Goldfried, Marvin R. (2018) “Clinical Consensus Strategies to Repair Ruptures in the Therapeutic Alliance”
- Jordan, Judith V. (2017) “Relational Cultural Therapy” Second ed.
- Marmarosh, Cheri L. (2021) “Ruptures and Repairs in Group Psychotherapy_ Introduction to the Special Issue”
- Safran, Jeremy D.; Muran, Christopher; Eubanks-Carter, Catherine F. (2011) “Repairing Alliance Ruptures”
If you, a loved one, or a patient is experiencing an eating disorder, help is available. Contact The Renfrew Center’s team by phone at 1-(800) 736-3739 or complete our online form.
