Clinical Wisdom: A Psychoanalyst Learns from his Mistakes

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• My Two Most Difficult Patients
• Benevolent Values Can Interfere with Effective Treatment
• Over-identification with Our Own Therapists
• Collaboration with Other Analysts Treating the Same Patient
• Becoming Wiser
• Dogen and Michelangelo
• Notes

Identifying and trying to learn from one's own clinical mistakes is often a painful experience, but can be an invaluable source of clinical wisdom. Here, I will share with you several significant mistakes that I have made over the 40 years that I have been practicing and teaching psychotherapy and psychoanalysis which have been extremely helpful to me and my supervisees. I hope that my self-disclosures and self-discoveries will evoke in you an active reflection on your own work and provide a source of professional growth.

My Two Most Difficult Patients

John, a single, unemployed college graduate in his late twenties, came to see me upon the insistence of his sister, who was having a good therapeutic experience with a colleague of mine. John had become very isolated, living with his parents to whom he barely spoke, seldom leaving the house, and devoid of relationships except for minimal contact with his sister. He presented himself as depressed, bitter and severely skeptical that any therapy could help him; of eight previous therapies, he reported that only one had slightly helped him. He usually treated me in a hostile contemptuous manner, frequently testing my competence, patience and interest in him. With much inner struggle I hung in there, bolstered by small signs of his progress, such as his initiating friendly contact with others. After about a year and a half, I became very busy in my practice and my teaching, which necessitated my deleting his second weekly therapy hour, using the excuse that I was so busy that I could not "find" a second hour for him.

This was the beginning of the end of our relationship. His demeaning, hostile sarcasm, already intense, increased; there were fewer moments of his working on his real concerns and increased attacks on me. John said, as he had frequently over the two year course of treatment, that the therapy was not helping, that I was totally incompetent and that he was going to quit therapy with me. He responded to my attempts at exploration with depreciation of me and threats to leave therapy. But this time he meant it. He quit. He did not show for his next appointment nor answer my several phone calls. I felt both guilty and much relieved at the same time!

Mary, a single teacher in her mid-forties, was referred to me by a female colleague who had treated her for several years and now believed that Mary needed to work with a male therapist because she had never succeeded in having any long-term relationships with men, despite her longing for this. Though the first few years of our relationship were stormy, with her rages alternating with moderate depression, externalization and fluctuating mistrust of me, Mary made encouraging progress. She and I were both pleased that she developed a relationship with a real boyfriend for the first time, leading her to experience sex for the first time in her life, while at the same time she was becoming less argumentative with her fellow teachers. Sometime later, an event took place that was the beginning of the catastrophic end of our therapy. Her brother and his wife gave birth to a baby, which thrilled her parents. She became furious with her brother for what she experienced as a total loss in the rivalry for her parents' attention and love. Through a friend who knew me, she found out that I also had a young child. Her hostile and at times rageful feelings toward her brother generalized to me. This morphed into a psychotic-like transference in which I not only had a young child like her brother but she said that I started to look like him.

When I questioned her about this, she said that my gestures and sitting posture were just like her "shitty" brother. My efforts at compassionate communication for her parental loss, reality testing and transference interpretation over several months had little effect upon Mary, leaving me frustrated and seriously discouraged. Mary quit therapy within a few months, saying that the therapy was no longer helping and that she would never see another therapist. Again I felt relief, but questioned—What could I have done differently? Could I have helped her continue her previous progress?

So, what did I learn from these two experiences? Obviously with John I needed to find a second hour, but I did not because he would not try to understand his almost constant demeaning of me and therapy, which I could not tolerate. With Mary I learned two lessons. One, psychotic-like transferences, when not resolved, can lead to the destruction of even a moderately successful therapy. Secondly, I needed help with my intense frustration and discouragement. However, the salient lesson with both patients was that when working with extremely difficult patients, careful self-reflection and occasional consultation are often not enough. I really needed continuous consultation or supervision to help both with the challenging technical issues and my uncomfortable countertransference. My false pride that I should not need such regular consultation interfered with the possibility of breaking through the impasse in both therapies. Since I had been supervising therapists and analysts, I felt that I should not need regular consultation. And I believe that, unfortunately, such a position is implicitly supported in some analytic institutes and other post-graduate training centers.

But if I had had a weekly or bi-weekly consultant, what could have been different? For one, the consultant might have helped me understand the dynamic issues and specific approaches that I was not seeing. Secondly, he could have assisted me with my powerful countertransferences through understanding and compassionate support. Would the outcome have been different? I am not sure, but I would have felt more confident that I did all I could for my patient and in my role as a psychotherapist.

Benevolent Values Can Interfere with Effective Treatment

Kathy, a 31-year-old inhibited young woman with low self-esteem and fears of intimacy with men, had accomplished a lot in several years of combined individual and group therapy. She grew substantially more confident and assertive, and eventually fell in love with and married a wonderful, loving man. Believing Kathy and her husband would make good parents, over the course of several years I tried to investigate in individual therapy why she had never discussed becoming a mother. Upon my initial questioning she said that she was not interested in exploring this issue, nor was she willing to examine her reluctance—a stance which was not typical for her. Some months later when she was discussing how happy her friend was to give birth to her first baby, I eagerly saw another opening to explore her thoughts about having a child. She adamantly refused to explore this, angrily chiding me—again, behavior which was very unusual for Kathy. Shortly thereafter Kathy stopped both individual and group therapies, although she was still concerned about career and in-law issues. Questioning by the group members about her leaving therapy elicited only rationalizations such as she was too busy.

How do I understand this premature termination? I believe my value of loving parents raising healthy children interfered with my being attuned with Kathy's needs. Later I learned that Kathy was so determined not to have children that she underwent a tubal ligation. Even our so-called benevolent values may be incongruent with our patients' values and can mess up the treatment. In retrospect, I see that in my eagerness to encourage a lovely young woman to carry out my value to become a mother, I responded to my wishes and lost track of Kathy's needs not to become a mother. I certainly should not have pursued this issue the second time around.

Over-identification with Our Own Therapists

I was very fortunate to have meaningful therapeutic experiences with both my individual and group analysts while I was in psychoanalytic training. Although I was gradually able to experience and express angry feelings to both people—an important accomplishment for me—this affect was not paramount. I primarily appreciated and at times felt loving feelings toward both my male individual analyst and female group therapist, for the effective, compassionate and steady ways in which they helped me.

Therefore, it is not surprising that as a neophyte analyst I identified, and in fact over-identified, with both of them. David was a wonderful empathic listener who infrequently questioned and interpreted. I experienced him as a warm compassionate presence, genuinely interested in me. This analysis helped me immeasurably to discover and accept the deeper shadow aspects of myself, as well as resolve some minor symptoms. So, I too became a very good listener who seldom interpreted with my patients. A supervisor pointed out that, unlike me, some of my patients needed a more active use of inquiry and interpretation in addition to careful listening. She was certainly right. While we can learn from our own personal analysis or therapy, we need to be aware that what is good for us is not always best for others.

Becca, my group therapist, by contrast actively intervened and was emotionally very expressive. She also believed in few traditional limits in group therapy, such as the rule against socializing outside the group. This group experience which included extra-group socializing was very beneficial to me and to most of the high-functioning group members. Therefore, with my own therapy groups I used Becca's agreement that it was okay to socialize outside of the group. Within a few years of conducting and supervising groups, I saw that permission to socialize was detrimental for some groups. For example, some socializing leads to major enactments outside the group which are never discussed in the group because of such reasons as shame, wanting to keep a secret relationship or fear of retaliation from group members or therapists. Gradually, I developed my own way of structuring outside group contact, which fit me and my patient populations better.

In more formal psychoanalytic terms, I had initially introjected David and Becca whole, but gradually was able to differentiate from them, keeping the good part objects (that which fit me) and eliminating that which did not fit me or my patients. In everyday terms, I became truer to the way I work best and to the unique needs of my patients and groups. I learned some extremely valuable lessons from my two analysts. However, as I developed more confidence in myself I was able to let go of the idealized internalization of my analysts and start to become the analyst and therapist who fit my character and my patients.

Collaboration with Other Analysts Treating the Same Patient

Early in my practice, two therapists in training referred themselves to me for group therapy. They told me that their individual analysts, whom I did not know, were unenthusiastic, but okayed their joining a psychotherapy group. After patient approval I contacted both analysts to open a collaborative relationship. I will focus mostly on my experiences with Oscar and his individual analysts, and secondarily on my experience with the other patient Sheila and her analyst.

Much to my surprise, Oscar's individual analyst said to me, "You group therapists are strange ducks. . . . you don't understand that such talk between us will interfere with the treatment. Only if there is a suicidal or homicidal emergency should we contact each other." Unfortunately, I agreed to treat Oscar under this restriction. The group, a good composition for Oscar, enabled him to play out a central dynamic underlying his chronic friction with men and his inability to sustain a meaningful relationship with a woman. He frequently attacked me and two of the other three men in the group, while placating and sweet-talking the three women in the group. Then one of those felicitous accidents happened. One session, all three women were absent, leaving Oscar alone with me and the three other male group members. Oscar's behavior changed dramatically in this session. He not only did not attack us but became friendly to me and the other men. All of us, including Oscar, noticed this marked change. The following week when two of the women returned, Oscar reverted to his typical attack on men and his seduction of the women. When this remarkable behavioral change was brought to his attention, he strongly denied it. Group members suggested that Oscar talk to his individual analyst about the discrepancy between the group's and his perception of his behavior when the women were and were not present in the group, but he refused, insisting that there was nothing different to talk about.

Oscar had enacted a salient dynamic—a dynamic that was hidden from his awareness because it was too threatening to be known. Yet this enactment was ripe with wonderful therapeutic possibilities. With Oscar unwilling to discuss this with his individual analyst, I told him that I would alert his analyst that something crucial was happening with Oscar in the group making it vital for us to talk. Oscar said, "Go ahead. My analyst will never believe this group bullshit anyway!" However, since Oscar was neither suicidal nor homicidal, his analyst refused to talk with me. Not surprisingly Oscar dropped out of the group within a short time. I believe that had his individual analyst been willing to talk with me, we would have had a good opportunity to cooperatively work with Oscar in depth on this crucial dynamic.

Sheila, a psychiatric resident in individual analysis, wanted group treatment because she was starting to recognize that she was rejecting decent eligible men as lovers and potential mates. Within a couple of months the group and I realized that Sheila was looking down upon the group members, especially the men, from an "I-am-superior-to-you" position. Believing this was salient to her reason for group treatment and being concerned that she might flee from this group of "inferiors," I told Sheila that with her permission, I was going to talk to her individual analyst. After her analyst did not return several of my calls, I informed Sheila, and she responded that her analyst must have had a good reason, but she refused to elaborate. Shortly thereafter Sheila dropped out of the group.

What lessons did I learn from the two frustrating experiences cited above? Over the last decades I have made it my practice not to accept any referral for group or individual therapy when there is another therapist treating the same patient, unless there is agreement from the other therapist that we can collaborate if and when needed. In my experience our collaborative contacts are usually few and far between, but occasionally crucial. It is the trust between the two professionals that is vital. I have found almost all patients agreeable to therapist collaboration, and in fact are often pleased with this arrangement. Many patients experience this as genuine interest in them. In the rare case when the patient is reluctant for me to speak with their other therapist, I try to understand what this means for the patient. Typically our work on understanding the patient's reluctance has led to a solution that benefits the therapy and the patient. In one situation with a suspicious patient who protested, I told him I would be willing to talk with his therapist on the phone while the patent was present—thus allowing him to hear every word and tone that I expressed. Hearing this willingness on my part, the patient said that he did not need to be present, but he wanted me to tell him what I said and what was said to me, which I was quite willing to do. In another unusual situation where the other therapist said communication between us would damage therapy, the patient insisted that we two therapists cooperate. She said that she would never go to a second physician if he would not collaborate with her present doctor.

Becoming Wiser

I need to state one salient caveat to all that I have written above. These are my mistakes. In the oral presentation that this paper was based on, which I gave at the Postgraduate Center (cited below), there was some vigorous disagreement as to what I considered mistakes. Indeed, some analysts argued that my mistakes were not true mistakes, whereas a few participants were critical of some of my solutions. For example, some analysts said that they would never talk with the other therapist treating their patient unless there was an extreme emergency such as a probable suicide danger.

What does this mean to me? I believe that mistakes and solutions are unique to each practitioner and interact uniquely with each particular patient.

Over the years I have come to know myself better both as a human being and as a therapist, and what works better for my patients with our intersubjective uniqueness. With experience, analysts and therapists are ideally true to our own uniqueness and our particular interersubjective fit with individuals, couples or groups that we are trying to help. This to me is a vital component of clinical wisdom. I know of a few analysts of varying theoretical perspectives who adhere so closely to their cherished theoretical and technical ideas that they miss what I would consider crucial aspects of their relationships with their patients. These analysts may need such adherence to theory and practice for them to feel coherent, secure and competent. Another type of wisdom would be for those therapists and analysts to understand how this view affects their practice and work.

Dogen and Michelangelo

Dogen, considered one of the greatest Buddhist teachers, stated in the thirteenth century, "My life has been a continuous series of mistakes." After decades of experience, I continue to make mistakes and try to learn from them. As Michelangelo said at the age 87, "I am still learning." I certainly am too.

Notes

¹ A briefer version of this paper was originally presented by Dr. Rabin at the Annual Colloquium of the Group Department of the Postgraduate Center for Mental Health, New York City on December 7, 2006.


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