Learner therapist (34)……Not good enough therapist
Learner therapist (34)……Not good enough therapist
April 21, 2013
Another of my therapeutic errors…
A year ago I wrote:
I am somewhat obsessively tuned to my mistakes, a commitment moderated by a fairly balanced level of professional self-regard. However, it seems that mistakes continue to occur in sufficient numbers and powers to guarantee the balance falls slightly towards the obsessive side. From my point of view, my reputation is always in danger from my next performance.
And a striking case has arisen, as they do, totally predictable as sessions went on, but avoided by me out of my self-imposed belief that I should always be able to work with anyone and that I am infinitely flexible. Yes, I see the universalising and that I am in the grip of moderate catastrophising, but that’s the price of standards in practice (another argument this, but not now). I pay this price a few times a year in the currency of disturbed sleep and therapeutic relationship crises (in my mind often). Here’s this one:
In brief, he’s a 33 year old in a growingly committed relationship with a woman he characterises as anxious like himself. They are on the verge of cohabiting. But he doesn’t share with her the vitality of his anxiety – that it is persistent, permanent, paralysing – which he deploys like a shield from his deep sense of being notgoodenough. This sense has been unavoidably present to him for 10 years post a major car accident recovery, which took a year of physio and some subsequent therapies through a parade of therapists and psychiatrists of which I am the last, so far, in line.
We’ve been one session a week for three months on an insurance funded therapeutic journey. It was limited to 5 in the first instance and then only after review which I did not do at the time. I had never clearly monitored the conditions of the insurance. So, I was working for free.
He knows his notgoodenough comes from somewhere further back in his past, and has recently acknowledged that father is the obvious source. Father has never been accessible to him nor outreaching for him, though always present… an active, unconscious (?) denial of the son’s existence. Mother appears as the good parent, though almost acknowledgeable as a collusive partner in father’s absent presence. She is also in late stages of thrice recurrent cancers, so seriously compromised as a pathway to the father, or even a discussant of son’s needs.
He can do anger at two things: his parents, but especially his father, and me if I suggest he “out” his admittedly socially phobic obsessions and compulsions to anyone, but especially his girlfriend. When angry he presents clearly as powerful – language strong (f bombing) and posture strike ready. Outing is part of a process of exposure which is a widely accepted ingredient of anxiety and addictive therapies, and one I’ve used in a wide variety of situations with workable effectiveness for patients of many sorts. I said as much to him in roughly the following words:
The principle reason for encouraging self-outing of any kind is to reduce the burden of the un-outed secret(s) which, for lack of psycho-spiritual-relational air, fester in the paranoid richness of the dark holding bay of the self. At this point it was a crucial move because we were going around in circles and the only talking place for this was therapy.
There exists alongside the phobic persona a competent, though self-doubting, one with a wide range of social and potentially professional skills, and with better than average verbal skills, both spoken and written. He is supposed (psychiatric report) to have done CBT for self-doubt, but shows little retention. He’s devoted to the latest manual driven self-improvement thingy about social phobia – very CBTish in style. He hasn’t been able to stick with any such processes or related tracking of moods over the three months, though getting started a couple of times. He’s swamped by the daily flux of his fears, and amplifies them at each session by arriving late and leaving early, starting to notice the approaching self-imposed departure time 30 minutes into the session.
Because of his intense resistance to raising his phobia with his girlfriend or selected workmates and his increasingly reported despair about the phobia (expressed in spontaneously written emails capturing the daily experience), I felt trapped and ineffective and looking to reduce it by stopping our work and handing him on to someone appropriate.
I had not confronted him with this thought, but he could have been aware of my doubt from my unwillingness to add another session to the present once a week. He has history for losing therapists because they cannot / will not fit into his workplace secrecy regime which requires him to do nothing in work time (even if lunch) which might invite a question from colleagues or management about what he’s doing.
I did not feel that I had the time or mood flexibility to respond usefully to his needs. At the same time, progressively over the preceding two weeks, I found myself under a rapidly increasing load of high need patients. It takes a while for me to notice I’m close to not coping, but I’m getting better at it. This is a significant straw in this story, and this camel’s back was bending. With this case I was feeling like death and actually surrounded by long term patients considering themselves as candidates for death. My decision to discontinue our work came off a base of having done similar things at very high pressure times of near overwhelm over the decades of my organisational development practice, both here and in China.
A few days ago we had our first session since my coming to the conclusions above about my needs and his. He walked in and started immediately with his doubts about how we were going, beating me to the task. Within 20 minutes we had agreed that I would find him an alternative therapist within the day and pass that option back to him, which I did. He was a bit angry that he had once again lost a start on therapy which happened partly because he did not demand at intake that the proposed therapist (in this case, me) work outside normal hours. Some of the other lost therapists had parted for similar reasons, he said.
I think from the backside of my failed effort that it is principally a result of insufficient checking with the patient about how things were going for him. Checking is about the only antidote to letting things amble along when they really aren’t ambling much at all. And it is not as if I don’t check regularly. But maybe it is that I check somewhat less regularly than I think and that rigorous attention to checking (putting it explicitly on every session’s agenda) would reveal a pattern that somewhat more diffident checking occurs with more diffident patient experiences – and it’s my diffidence I’m talking about here. My failure to check the insurance requirements for continued payment are party to my self-deception or avoidance.
As I said at the start: “my self-imposed belief that I should always be able to work with anyone and that I am infinitely flexible” may facilitate my not taking seriously some recurrent but slight evidence that things are not getting very far or very well, though they continue! As so often in development matters, awareness is all except when it isn’t enough, as in this case. I know exactly what that self-monitoring awareness feels like from my commitment over the last 6 weeks to raising my performance in aikido weapons practice to both a higher intensity and greater regularity. The subject is always close to the front of mind, including when I choose to not make the required effort.
For the moment it is clear that my reputation to myself as an aikido practitioner is more important than my professional one!!