“We can work it out”: Working through termination ruptures.

Supportive-expressive (SE) psychodynamic treatment is based on the identification of and working through the patient’s signature core conflictual relationship theme. According to the SE framework, when termination is anticipated, separation conflict arises, and the actualization of the patient’s interpersonal wish in the relationship with the therapist is no longer possible. The disactualization of the patient’s wish in the relationship with the therapist may cause patients to regress to their maladaptive prototype responses (Nof, Leibovich, & Zilcha-Mano, 2017), which may manifest as a rupture in the therapeutic alliance. The present work integrates constructs based on the SE framework, specifically the disactualization of the patient’s wish at the end of treatment, with the framework of alliance ruptures and their resolution (Safran & Muran, 2000). We propose a conceptual clinical model to guide therapists in the successful resolution of alliance ruptures, which are the result of the disactualization of the patient’s interpersonal wish. We propose a two-stage process to achieve successful resolution of termination ruptures: (a) identification of termination ruptures and (b) addressing and resolving termination ruptures. For each stage, we propose practice-based guidelines and steps to follow. We demonstrate the proposed guidelines based on the case study of a patient with major depressive disorder. We used three sources of information from the case study: verbal transcripts of the therapy sessions, questionnaires, and semistructured posttreatment interviews.