Ruptures and Repairs in Group Psychotherapy: From Theory to Practice

ABSTRACT

The group climate, cohesion, and alliance with the leaders are critical elements of effective group psychotherapy. Although there has been significant attention to these curative mechanisms, there has been less attention to ruptures in the group relationships or the repair of them. The current special issue is devoted to theory, research, training, and practice regarding ruptures and repairs in group treatment. Contemporary and more traditional theorists describe how ruptures facilitate change in group therapy. Researchers apply the empirical findings on ruptures in individual therapy to group therapy and describe how ruptures can be measured. Group therapists also address how group leaders can contribute to ruptures and their subsequent repair. This introduction to the special issue concludes with the implications for practice and a call for future research that will help us fully understand how ruptures affect group process and outcomes in group work.

There has never been a better time in our history to address ruptures and repairs in group work. We are currently coping with a pandemic that has killed over 400,000 people in the United States and over 1,000,000 worldwide, and the exposure of systemic racism, health-care disparities, economic loss, and social isolation are stressors people are enduring and seeking group therapy to cope with. When people come together, face-to-face or in online group treatment, they are bringing with them their interpersonal difficulties along with their struggle to cope with a pandemic, quarantining, political turmoil, loneliness, economic devastation, systemic racism, and complicated grief (Marmarosh et al., 2020). Given all of these complex issues, we should expect groups to be a breeding ground for ruptures, tensions, and conflicts.

Lo Coco et al. (2019) were the first to apply the individual therapy literature on ruptures to group treatment and to identify ways that we can repair them. They describe ruptures as disruptions in cohesion or connection to the leader, members, or group-as-a-whole. Ruptures can be subtle and reflect a minor tension such as a member interrupting another member. They can also be more painful, such as a leader repeatedly using the wrong pronoun when addressing a group member who is transgender. Group members can express ruptures directly through their feelings or reactions in the group. For example, group members can challenge the leaders and express dissatisfaction, frustration, or anger (Yalom & Leszcz, 2020). Sometimes, members express ruptures more subtly by withdrawing. Coming late to sessions, typing while online in a telegroup session, or missing sessions can indicate a rupture in the group.

Given that ruptures are common, how we identify them, address them in the group, and facilitate repairs is important. Researchers studying the individual therapy alliance have demonstrated that unaddressed ruptures relate to worse outcome (Flückiger et al., 2018) and that identifying ruptures and repairing them relates to decreased dropout (Eubanks-Carter et al., 2010) and improved treatment outcomes (Eubanks et al., 2018). In group therapy, we know that not addressing members’ frustrations and disappointments can have a deleterious effect on group therapy; however, when leaders are aware of declines in the group relationships, leaders are able to address them and facilitate repairs (Burlingame et al., 2018). Although group therapists have been advocating for the process of exploring conflict and disruptions in the group for decades (Burlingame et al., 2018; Yalom & Leszcz, 2020), they do not usually rely on the terms “rupture and repair” to describe their interventions, nor do they typically apply findings taken from the empirical literature on rupture and repair in individual therapy.

The current edition of the International Journal of Group Psychotherapy is dedicated to addressing the significance of ruptures in group work and to their repair. This edition begins by linking the process of rupture and repair to theoretical models of group work. Bateman et al. (this issue, 2021) describe how rupture and repair is a critical component in mentalization-based group treatment. Segalla (this issue, 2021) describes how self psychologists understand ruptures and repairs in groups. Gantt (this issue, 2021) reviews systems-centered theory and how ruptures influence group process.

The special edition also focuses on training group leaders to be aware of ruptures and repair. Rutan (this issue, 2021) reviews the different ways that therapists can trigger ruptures in group therapy. Eubanks, Warren, and Muran (this issue, 2021) explore how ruptures occur within supervision groups, and they apply their coding system historically used in individual therapy. Burlingame et al., (this issue, 2021) describe the use of the Group Questionnaire (GQ) after sessions to detect ruptures and address them in group.

In this introduction to the special edition, I will first discuss each of the articles in the edition in more depth, then address other types of ruptures that we did not explore, and conclude with implications for clinical work and future research. The goal is to place a spotlight on this important aspect of group work and inspire group therapists and researchers to contribute to our understanding of ruptures and repairs in group therapy.

RUPTURE AND REPAIR: BRIDGES TO OUR THEORIES OF GROUP WORK

Exploring how the process of rupture and repair influences our early development, along with our theories of change, illuminates how important disruptions are to a healthy sense of self and capacity for intimacy. According to attachment researchers (Woodhouse et al., 2020), caregivers who are able to soothe their infants at least 50% of the time have secure children. Instead of aiming for perfection, it is the optimal amount of responsiveness, attunement with moments of disruption, that leads to healthy development. Three theorists have described why moments of disruption and their repairs are critical to development and group psychotherapy. Bateman, Chapmen, and Fonagy (this issue, 2021) describe a contemporary model of change based on mentalization, epistemic trust, and attachment theory. Heinz Kohut (1984), the originator of self psychology, describes the development of self structures that begin to form when children tolerate moments of empathic failures, what he described as transmuting internalizations. Gantt (this issue, 2021) describes the systems we see within group therapy, and how these systemic conflicts can lead to greater cohesion and change.

Mentalization-Based Group Treatment

Mentalization is often described as the ability to take another’s perspective, different from our own; it is an important relationship skill to have. Without it, we may assume we know what others are thinking or feeling based on our own reactions instead of being able to imagine another’s perspective. The truth is, we never know what others are experiencing unless we are able to imagine the world from their viewpoint and ask. Many group members seek group therapy because they struggle in relationships, and many of these struggles come from projecting automatic negative experiences onto others. Group members often automatically assume others are angry with them, do not care about them, or are out to hurt them. Their automatic assumptions, often stemming from lived experiences of abuse, neglect, or trauma, replace an open, curious, and trusting stance. It is as if the enormity of early ruptures, without repair, has led to insecure attachments and mistrust of others. Bateman et al. (this issue, 2021) describe the importance of epistemic trust, the basic sense of benevolent intentions of others. They argue that relational trauma and lack of emotional attunement interfere with this basic trust and ability to take in feedback and compassion from others. Group therapy becomes the perfect environment for members to begin examining their reactions in the group and the projections onto others and to practice mentalization (Fonagy et al., 2017).

In their article, Bateman et al. describe mentalization-based group therapy, an intervention derived from the years of research and clinical experience working with patients with insecure attachments who struggle to regulate emotions, trust others, and mentalize. The treatment often integrates individual and group intervention and focuses on helping members learn to trust others. The ruptures in the group help members work together to empathize with one another, practice mentalization, and regain epistemic trust. The clinical examples presented are outstanding and help the reader understand exactly how to begin repairing ruptures in a group setting.

Self Psychological Theory of Group Therapy

Kohut (1984) is one of the few theorists who described the important shift in development from archaic narcissism to a healthy sense of self-esteem. He described the importance of relationships with early caregivers who could provide both emotion regulation/safety (idealizing self-object needs) and encourage a sense of agency (mirroring self-object needs). Similar to attachment theorists (Bowlby, 1988), self psychologists emphasize the value of early caregivers and their ability to regulate distress and provide the environment needed to tolerate disappointment, frustration, and loss. Just as Fonagy et al. (2017) describe the caregiver’s capacity to reflect the child’s experience to facilitate mentalization, Kohut argued that the caregiver’s empathic attunement and facilitation of ruptures with the caregiver facilitated the child’s capacity to rely on people for support later in life. The basic trust in others, as opposed to projections of malevolence or indifference, comes from ongoing experiences of being valued, heard, and seen. Segalla (this issue, 2021) describes a clinical vignette that highlights how the leader repairs a rupture by allowing members to have conflict. Her case example highlights the value of the leader trusting the group’s ability to tolerate tension and manage the uncomfortableness essential to group development (Yalom & Leszcz, 2020).

System-Centered Theory

Gantt’s (2021) article presents theory and clinical examples that demonstrate how functional subgrouping repairs ruptures. Specifically, it shows how System-Centered Theory guides group leaders to intervene by weakening past survivor roles as they are repeated in the present. This process of repairing ruptures prevents members from repeating past relational experiences. Her clinical vignettes will help group therapists navigate ruptures while helping members engage with one another.

TRAINING THERAPISTS TO UNDERSTAND RUPTURES AND REPAIRS

The focus of most of training in group therapy is often on fostering group cohesion (Yalom & Leszcz, 2020) and identifying risks to cohesion that include screening members, preparing members, and understanding group dynamics (Burlingame et al., 2006). The same is true in individual psychotherapy where the focus is on building the alliance. Researchers studying the individual therapy alliance have demonstrated that it significantly relates to outcome (Flückiger et al., 2018) and that identifying ruptures and repairing them is linked to less dropout (Eubanks-Carter et al., 2010) and successful treatment (Eubanks et al., 2018). Group researchers have studied the alliance (Alldredge et al., in press) and cohesion (Burlingame et al., 2018) as they relate to positive outcome in group therapy. Though there has been little to no empirical research on ruptures and repairs in group therapy, we can presume based on related literature that training group leaders to identify ruptures and to facilitate repairs should be prioritized.

Taking Responsibility: When the Leaders Cause the Rupture

We know that ruptures are inevitable in any group session, and they occur most often between members of the group (Garceau et al., in press). Sometimes ruptures occur when the leader makes a mistake or intervenes in a way that lacks empathy. Rutan (this issue, 2021) describes a variety of different types of ruptures that are a result of the group leader. They include ruptures related to insensitivity to cultural diversity equity and inclusion, forgetting important information relevant to members, timing of interventions, countertransference, and poor boundary maintenance. Rutan explores how leader privilege or lack of awareness of microaggressions can cause ruptures within the group and negatively impact group cohesion and the effectiveness of group treatment. All of these ruptures can occur without the leader being aware. The rich clinical examples highlight what leaders need to be looking for and how they can intervene when ruptures occur.

Therapists in Group Supervision: Coding Ruptures

Eubanks-Carter et al. (2015) developed a model of supervision that is focused on helping therapists repair the alliance, what they call alliance-focused training. This training emphasizes the relationship between the therapist and the patient in individual therapy and includes both individual and group supervision. Because the model focuses on teaching therapists how to identify ruptures and facilitate repairs, they incorporate this process in the group supervision component. Therapists learn to identify ruptures within the group and learn how to repair them. In this edition, Eubanks et al. (this issue, 2021) apply their Rupture Resolution Rating Scale (3RS; Eubanks et al., 2019) coding process to examine the different types of ruptures they see occurring within the supervision groups.

In their study, seven sessions of group supervision that focused on improving therapists’ abilities to recognize and negotiate ruptures were coded for alliance ruptures and repair strategies using a modified version of the 3RS. Coded sessions revealed ruptures between the supervisor and therapists, between therapists in the group, and between a therapist and the group-as-a-whole. The findings of this pilot study suggest that the 3RS can be useful for measuring process in group supervision. It also encourages group therapists to consider using the 3RS to assess behavioral indicators of ruptures. Garceau et al. (in press) applied the 3RS to group therapy sessions, and they found similar types of ruptures between leaders and members, members and members, and members and the group-as-a-whole.

Feedback Monitoring in Groups: Identifying Ruptures

Another way to identify ruptures in groups is to ask group members how they feel after a session. Janis et al. (2018) were some of the first to develop a relational feedback system in group therapy. They found that when leaders had critical information about ruptures, they could address them quickly compared to leaders who did not have this feedback (Chapman et al., 2012). In this edition, Burlingame et al. (this issue, 2021) describe the value of measurement-based care (MBC) and systems that rely on self-report assessment of both outcome and relationship measures. In their clinical work, they rely on the Group Questionnaire (GQ; G. Burlingame et al., 2017) and demonstrate both with research and clinical examples how the GQ can identify members who are struggling in the group via group climate deteriorations. In essence, the significant decrease in a member’s self-report notifies the leaders that a member is struggling and there has been a rupture. They demonstrate how useful it is for leaders to have this type of information about group members and how it can influence group treatment.

FUTURE DIRECTIONS

Although we have heard about many types of ruptures in groups, we have not focused on microaggressions in group as a specific type of rupture (J. J. Owen et al., 2011). There also has been little attention on ruptures between coleaders and between leaders and group supervisors. To date, most of the ruptures written about are between members, between the member and leader, and between the member and the group-as-a-whole. However, problems between coleaders can influence the group, and ruptures with supervisors can hinder group treatment. We also need to address how group factors (cohesion, group climate, stage of development) and individual differences (age, culture, ethnicity, attachment) affect how members experience ruptures, how members and leaders respond to ruptures, and what repairs are most useful. Lastly, there is a need for group therapy research that addresses how ruptures influence treatment and how repairs can facilitate positive outcomes.

Measuring Ruptures in Groups

There are many ways to identify, measure, and code ruptures in groups. Burlingame et al. (this issue, 2021) focus on using the GQ and collecting member feedback about the group after each session. Lo Coco et al. (in press) use the GQ as well, but they emphasize the importance of not only observing shifts in each member’s attitudes about the group but to also examine how each member compares to the average scores for the entire group over time. They argue that it is always important to include group-level analyses when doing group work. Garceau et al. (in press) rely on the 3RS to code sessions for behavioral markers of ruptures in a group. Like Eubanks et al. (this issue, 2021), they found that ruptures between members were the most common type of rupture and that the leaders relied on empathy, curiosity, and open exploration to address them in the group. Each of these group researchers describes ways that we can further study ruptures in group treatment and develop clearer training for leaders to facilitate repairs.

Microaggressions in Group

One of the more common types of ruptures that we see are related to microaggressions in group therapy. These are described as subtle forms of discrimination that may not be intentional or even conscious (Sue, 2010). Despite the often lack of overt malevolent intentions, these insults or devaluing comments send negative and denigrating messages that are often related to gender, race, ethnicity, sexual orientation/identity, religion, or disability. Unfortunately, they occur frequently, especially during social interactions in groups (Sue, 2010). They can be toxic to peoples’ adjustment (Lui & Quezada, 2019) and can affect their trust in and sense of safety with their therapists, which can negatively influence the alliance and prevent clients from engaging in therapy (Constantine, 2007; Horvath & Bedi, 2002; J. J. Owen et al., 2011). Despite many books (Williams, 2020) and articles (J. Owen et al., 2019) addressing microaggressions in individual treatment, few have examined microaggressions in group therapy (Bemak & Chung, 2018; Kivlighan & Chapman, 2018). Lefforge et al. (2020) were the first to develop a training model to help leaders address microaggressions in group treatment. They describe the fears group members and leaders have when discussing these ruptures, and they provide helpful tips for leaders. One of the most helpful recommendations is to not avoid ruptures when they occur and to try and avoid shaming, and othering, members who perpetrate ruptures. Rather than saying something said is “bad” and finger-pointing, they recommend describing personal negative reactions to microaggressive comments. They argue that sharing personal reactions to comments in the group can help members be more curious and thoughtful and prevent members from shutting down and withdrawing. Calling members “in” versus “out” is more empathic and compassionate because almost all of us may perpetuate a microaggression in groups (Thurber & DiAngelo, 2018). We need researchers to study the effects of these types of ruptures on members and to link interventions to treatment outcomes.

Coleader Ruptures

Coleading groups is a common practice and can be very effective (D. M. Kivlighan et al., 2012). Despite the effectiveness, we know that differences in orientation and not selecting your coleader can impact the satisfaction of leading a group (Bridbord & DeLucia-Waack, 2011). It is surprising that there has been little, if any, attention to addressing ruptures between coleaders. It is safe to assume that conflict between the two group therapists leading the same group is inevitable and will affect the group (Freedman & Diederich, 2018). It is common for coleaders with different orientations to struggle with what direction to take the group. Differences in gender or race can influence members’ projections onto the leaders, and this can lead to conflict between coleaders. Power differences when one leader is a student clinician and the other is a licensed practitioner can lead to tensions or disruptions in the group. Competition between coleaders can lead to ruptures in sessions where leaders talk over one another or challenge their colleague in the group. Some of the tensions may be unconscious, but many are within awareness but avoided due to the difficulty talking openly about anger, hurt, and disappointment. It is important for leaders to be aware that the relationship between them does affect the group (Freedman & Diederich, 2018). We need more research, more attention to coleader dynamics, and more training on interventions so the next generation of group therapists is more effective at addressing these ruptures (Bridbord & DeLucia-Waack, 2011).

Ruptures with Supervisors

Another type of rupture that has not received enough attention in group therapy is the impact of ruptures with group supervisors. When the group supervisor is in conflict with the group leader/s, it is bound to affect the treatment. For example, there was a case in our clinic where the group supervisor, one who did not practice group therapy but agreed to help out in the Clinic, failed to help the group leaders navigate group process and member dropout. The leaders felt that the supervisor avoided the group process, did not understand their frustration, and was unable to help them recruit more members. After months of losing members, the group ended up having only one group member left. The supervisor required the two leaders to continue meeting weekly with the one group member for a semester without searching for group referrals. Over time, the leaders became furious, hopeless about group treatment, and dreaded the sessions with the lone member. The ruptures with the supervisor trickled into the group, leading to dropout. The group eventually turned into individual therapy, the treatment of choice for this supervisor.

The individual therapy literature has a significant amount of research devoted to understanding the impact of supervision on therapist development and treatment; however, there is very little theory, practice, or research on the supervision of group treatment and how it can have a significant impact on group process and outcome. Understanding ruptures in supervision is an important area for both group therapists and researchers.

Ruptures With Referring Therapists: Colluding With Patients

Marmarosh et al. (2013) describe a challenging interaction between a group leader and the referring individual therapist that negatively impacted the group. The referring therapist was providing individual therapy with a patient who was experiencing conflict with many people, a history of interpersonal difficulties, and was on probation in school for verbally attacking an administrator. According to the individual therapist, who did not experience any issues with the patient, the referral was offered because interpersonal difficulties were increasing and group might help address them. After a few group sessions, the member was triggered by a comment made in the group and proceeded to verbally shame and insult individual members and the group-as-a-whole. Similar to her outbursts in other settings, she became aggressive and attacked the members. She also dropped out of the group. When the group therapist consulted with the individual therapist, the therapist refused to talk about what happened. He said he would not even invite his patient to talk about her experience in the group unless she brought it up first. He appeared to avoid anything that would possibly upset her in their relationship.

Neither clinician was able to work through the disagreement about how to help the referred member. In this case, the rupture between the referring individual therapist and the group therapist hindered the group member working on the very issue she struggled with—her anger and conflict in relationships. The rupture in the group was disruptive to the entire group, and the leader had to help repair the injuries the referred member left behind. Group leaders have much to offer individual therapists since relationship issues emerge quickly in groups and may lie dormant in individual treatment. However, it requires both clinicians be able to collaborate when painful issues emerge to help the patient.

Group Factors

We all know that ruptures in groups do not occur in a vacuum. There are many group factors influencing how well members navigate tensions, struggles, or misattunements. The factor that is most likely going to influence rupture and repair is the climate of the group. If the group is cohesive and the climate is safe, there is more likelihood that a rupture can be discussed, explored, and forgiven. If the group climate is tense and the leader is less empathic, there is less likelihood that members will share their honest reactions in the group.

In addition to the climate, the stage of group development influences rupture and repair. If the group is just forming, members tend to be more focused on safety and are more cautious (Yalom & Leszcz, 2020). When the group begins to have more conflict and tolerate disagreements and ruptures (storming), the group shifts to norming and genuine cohesion where members feel safe to express themselves and challenge one another. The stage of group development is likely going to impact the interventions leaders try and the ones that are successful. Kivlighan et al. (1984) found that when leaders focused on conflict and the group was just beginning, it was less helpful than when the group was in the storming stage. Helping members engage in discussions of conflict is not as useful when members are getting to know one another. However, group members do benefit from those types of interventions when the group is ready to engage in conflict. Addressing ruptures successfully in group is likely going to be influenced by the comfort members have with conflict and the safety they experience over time. Successfully addressing ruptures will also lead to great cohesion and greater capacity for the group to endure future ruptures.

Leader Factors

One factor that influences the group is the leader. We know that there are therapist effects in psychotherapy (Barkham et al., 2017), and the same is true of group psychotherapy. Not all leaders are the same. Some leaders are very good at noticing ruptures, empathizing with members, and being able to cope with their own reactions when others are distressed. Some leaders have more experience leading groups and are less anxious about intervening when they detect a rupture. Some leaders also have more multicultural competency and may notice microaggressions more readily and feel more prepared to address them. In addition to experience, training, and personality, we have leaders with different attachment styles (Marmarosh et al., 2013). Davidovitz et al. (2007) found that leaders with more insecure attachments were less attuned to the group members and less able to help group members cope with stress. According to Marmarosh (2014), the leader’s attachment style has one of the biggest effects on the group, but it is one of the least studied factors.

Member Factors

Similar to group leaders, members come to group with their own interpersonal histories, stressors, and capacity to mentalize. Fonagy et al. (2017) described members who had the capacity to understand how others feel or think, have a basic sense of trust in people, and can cope with their feelings. These individuals will have an easier time addressing ruptures, regardless if they receive them or perpetrate them. Individuals with a history of trauma, betrayal, insecure attachments, on the other hand, will have a more difficult time tolerating a rupture and forgiving (Mikulincer and Shaver, 2017).

In individual psychotherapy, more insecure patients have fewer working alliances (Bernecker et al., 2014), and in group therapy, more avoidant group members report less cohesion (Marmarosh, 2014). Insecure attachments influence how well patients can attach to their therapists (Mallinckrodt, 2010) and how well they can trust them in treatment. Fonagy and colleagues (Bateman et al., this issue, 2021; Fonagy et al., 2017) argue that this is exactly why group therapy may be the most helpful to these patients. Ruptures can provide here-and-now experiences where projections of malevolence can be understood and members can practice being more authentic, empathic, and vulnerable. Leszcz (2017) describes how leaders can benefit from understanding member attachment and how attachments can influence group dynamics.

In addition to attachment and interpersonal history, group members come to the group with different intersecting identities (Ribeiro, 2020). These identities, related to race, sexual orientation, gender, age, class, ethnicity, religion, or disability, influence how likely one will be a victim of a rupture and how one may respond to a rupture. For example, some group members may have learned that their social identities are linked to aggressiveness or hostility, so they avoid conflict and sharing their negative reactions in the group. Societal or cultural expectations based on a group member’s race/ethnicity and/or gender (along with other intersecting social identities) may lead some group members to want to be perceived as “nice” at all costs, and therefore work hard to avoid causing or identifying a rupture in the group. For others, their experience of oppression and discrimination leads them to challenge authority and to mistrust leaders with privilege. These group members may mistrust the leader—less because of epistemic trust and more because of systemic racism and a history of marginalization. These group members may feel overwhelmed in the group, have less support, and avoid addressing ruptures due to the need to prevent burnout. In today’s climate, they may be overwhelmed with ruptures they experience every day and need a break from the stress in the group. In addition, some members come from non-Western cultures and are uncomfortable challenging the leader or the group. They prefer deferring their own personal needs for the welfare of the group and are uncomfortable with members challenging one another. Raising the rupture may feel like they are being selfish and not prioritizing the needs of the others in the group. We need much more research to understand how these member factors influence the experience of ruptures and the process of repair.

CONCLUSIONS

It is time for us to devote much more theory, research, and practice to understanding ruptures and repairs in group treatment. As these articles demonstrate, ruptures can occur in complex ways in group as they can occur between members, between leaders, between members and leaders, and between a member and the group-as-a-whole. They also range from subtle tensions between members to microaggressions that can impact the safety of an entire group. Repairing ruptures is a critical component to all therapies and is now getting more attention in group therapy. These articles set the stage for further research to understand the measurement of ruptures and repairs in groups, how leader and member differences influence ruptures and repairs, and what types of interventions facilitate positive change. We are definitely moving in the right direction.