Setbacks in Psychotherapy

• Introduction
• The Setback Session
• Takeaways

Introduction

When I was in graduate school learning about psychotherapy, I read a lot about how to do therapy, but I found myself yearning to see clinicians doing the work as models to emulate or reject. Now that I am a university professor training graduate students in clinical psychology, I expose my students to as many clinical video recording demos as I reasonably can. In my first-year interview and psychotherapy courses and in my second-year practicum, my grad students watch hours of clinicians doing psychotherapy. In turn, they seem to really benefit from watching the work and seeing the full range of styles, techniques, and theoretical approaches. We all agree that seeing clinicians in video demonstrations makes our readings on assessment and psychotherapy come to life as we appreciate and critique excerpts from my library of videos. Like me, they find it helpful to see models of how this kind of work is done. Moreover, they also have a yearning—like I had in graduate school—to actually see work that does not go well, in order to discern how clinicians react and recover when there are setbacks in the course of psychotherapy.

To this end, as the creator of the Collaborative Assessment and Management of Suicidality (CAMS), an evidence-based framework for effectively engaging and treating suicidal risk, I can now satisfy and promote my early yearnings to see and understand what to do when faced with a clinical setback. However, this particular article is not about extolling the virtues of CAMS or its extensive supportive evidence base (including nine published clinical trials, five published randomized controlled trials, and a rigorous and convincing meta-analysis of nine CAMS trials). Rather, my emphasis here is focused on an aspect of a training video that has been offered for several years by our training company, CAMS-care, LLC.

The Setback Session

Over the course of my career, I have routinely done live roleplay demonstrations, recruiting someone out of the audience to roleplay a case they know well. Obviously as an unscripted and spontaneous demonstration, it always puts a bit of pressure on me to “perform” with a variety of different roleplay “clients” that I encountered. There have been many times over the years when a volunteer audience member plays an especially difficult or provocative case, and everyone then gets to watch me squirm and struggle—just like what happens in real life! Beyond my early yearnings to see clinical demonstrations, I also wanted to see demonstrations of things not going perfectly as well—just as in real life. Overwhelmingly, most clinicians at my workshops have appreciated these live roleplay demonstrations and my taking the risk to demo techniques even when they do not go perfectly. It follows that when CAMS-care moved to scale up our training of CAMS, we shot a 12-session role play video in a studio with a former grad student—now colleague—named Dr. Kevin Crowley, who played a difficult client he saw during his VA internship.

Over two days in the studio, we shot unscripted segments of the first session of CAMS, portions of the second session, a latter interim session, a rather provocative setback session (where the patient has a major suicidal crisis), and the final outcome disposition session of CAMS. This online course has proven to be quite popular and has held up quite well over the years since we shot it. It has now been viewed by thousands of clinical providers being trained in CAMS around the world. Moreover, we know from an unpublished doctoral dissertation project defended last year that this three-hour online course has a notable and meaningful impact on clinicians learning to use CAMS within our integrated training model.

But, getting to the point of this article, what has been most popular—and contentious—about this online course has been Session 9, the “setback session.” I would say overall that 80-90% of those we train praise, appreciate, and feel quite positively about the setback. In contrast, there is a small minority who emphatically do not like the setback demo and share critical comments, with some even feeling offended by it! In any case, the setback session evokes a lot of strong reactions. I have often reflected on why this might be.

The online course provides overview portions of me talking about the model, but most of the course features various demo excerpts of Sessions 1-12, depicting a successful course of CAMS-guided care. My “client” Kevin plays a tricky case—he behaves peculiarly and is extremely wary of being in therapy at all. What emerges is a significant trauma history and a lifelong preoccupation with suicide. More to the point, he does not generally trust people, as he has experienced extensive interpersonal betrayal, one of his “drivers” of suicide (in CAMS parlance) and thus a major focus of his treatment. After making steady clinical progress, depicted in the video training over the first eight sessions, Kevin comes into the ninth session of CAMS angry and belligerent after a series of disappointments since his previous session that evoked an acute suicidal crisis. Clearly upset, Kevin immediately goes on the attack, accusing me of “lying” to him, “letting him down,” and “not having his back.” At first, I patiently hear his accusations but gently observe that he did not follow his CAMS Stabilization Plan, which involves engaging in predetermined coping strategies and ultimately contacting me on my cell phone. But as he repeatedly accuses me of lying to him and betraying him, I became increasingly angry myself. As my voice raises, I point out that he did not even give me the chance to have his back—a critical therapeutic issue within his suicide-focused treatment.

There is an awkward pause in a kind of “gotcha” moment, and his head drops in shame as he sees that we are experiencing a re-creation of a dynamic that he has experienced repeatedly. Seeing this clear shame response, I immediately drop and soften my voice, regroup, and apologize and endeavor to clarify the therapeutic moment: that we can do this differently and it could be a corrective experience! The session quickly settles down, eye contact is regained, and we both discuss and learn about what did and did not happen. I also quote my research mentor, Marsha Linehan, who famously would say in such situations, “The patient never fails the treatment, only the treatment fails the patient!” I have to work hard to move Kevin from a position of embarrassment and shame following this contentious exchange. By the end of the session, we clearly do come back together with smiles and an obviously increased bond for having weathered the intensity of our intense exchange. In our final outcome-disposition session (Session 12), when asked what made the difference, without hesitation Kevin notes the breakthrough in Session 9 and the insights gained in that setback session.

Takeaways

So what exactly are viewers reacting to when they see our setback demo? Many say they like how real it is and that my anger shows how much I care. Others are relieved to see an expert lose their cool because it has happened to them, and still others appreciate my recovery and reasserting of the model in a therapeutic manner. Detractors of the setback are not happy with my getting angry at the patient and raising my voice and shaming the client. There are sometimes comments about my being a privileged white male who is asserting my power in a paternalistic way. There are some native cultures in Australia and the United States who find my approach offensive towards a vulnerable client. My UK colleague and friend Dr. Zaffer Iqbal reviewed the setback in isolation (not having seen the previous sessions) and noted, “Oh, the Brits will never go for that!” Incidentally, while we have heard some negative feedback from our UK colleagues, the overall take has been quite positive (also, seeing the setback within the context of a demo of a full course of care is very important). Still others object to my personalizing the crisis and focusing on Kevin’s not calling me on my cell—and notably many clinicians are not comfortable sharing their personal cell phone number. And some say it is never okay to let the client see the clinician get upset.

Recently for suicide prevention month (September 2020), our training company posted a new video on our website of the same setback session, with Dr. Crowley reprising his role of Kevin. But this time the clinician is Dr. Blaire Ehret, who is a VA Staff Psychologist (Dr. Ehret got her Ph.D. at Catholic U and worked in my lab and is now a CAMS-care consultant). The goal was to show that within this same provocative session, a different clinician could handle the same situation quite differently and still adhere to the CAMS model. Dr. Ehret did an outstanding job; she never once lost her cool. She was empathic to Kevin’s anger and validated his feelings of betrayal with no particular pushback. Kevin the client eventually comes around and responds to her earnest appeals to look more closely at what has happened. I watched it and marveled at how reactive I still felt towards Kevin’s pointed attacks of the clinician, and I appreciated her composure and patience. We have received very positive feedback about this redo of the setback session, and it shows there is more than one way to do this kind of work and the model still prevails in both versions. And unlike my version, it is hard to imagine anyone being offended by the way Dr. Ehret does the same session!

So what is the point? The setback clearly evokes a lot in those who see it. Do I regret having reacted so strongly in the original rendition? Yeah, a bit; I wish I had not raised my voice quite as much as I did. But then again, no, because it is me—warts and all—and who among us is perfect at doing this? I certainly know that I am not perfect! How about you? What is plain to me is that being real, earnest, honest, and responsible matters a lot. My reaction was real, my attempts to apologize were earnest and honest, and I calmed down and recovered. I gently pushed to achieve a therapeutic breakthrough, and, in the end, I think I was quite responsible, owning my imperfection but still endeavoring to achieve a “teachable moment” which my client ultimately appreciated as the turning point within this demo of using CAMS.

*****

Who among us is perfect at doing something as complex as psychotherapy? Is it better to train by showing relative perfection, or is it better to be real in showing a setback and then recovering? Clearly, I favor the latter. But I respect those who disagree and have strong opinions otherwise. Perhaps it is useful to reflect on the evolution of psychoanalysis during the 20th century. Early analysts saw clinicians’ reactions (like becoming emotional) as countertransference and evidence of poor training (i.e., time to go back into analysis to rid oneself of such reactions). Then there was a notable shift as drive theory psychoanalysis split off into various relational models (e.g., the British School of Object Relations and Self Psychology).

I am a fan of these relational models, particularly as they relate to the evolving notion of countertransference, as increasingly such reactions have been seen as data about the client. What the client evokes in the therapist can be helpfully used to directly inform and shape interventions. Rather than being admonished as an imperfect clinician in need of further psychoanalysis, the relational models emphasize using the clinician’s own reactions as a valuable part of the therapeutic exchange. Perhaps not surprisingly, I love Kohut’s argument that invariably there will always be empathic failures; the key is how one handles such failures in order to create a therapeutic moment. Believe me, such a view is music to the ears of beginning clinicians. And for my part, I want the people I train to see that while all of us are imperfect, there are appropriate ways to work within our imperfections for therapeutic good. Should beginning clinicians and even seasoned clinicians actually see a setback and consider the range of ways of responding? There is no doubt in my mind. And until I finally master being perfect, I will continue to show struggles in my trainings and how such struggles can ultimately be made into therapeutic gold!


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