Learner therapist (34)……Not
good enough therapist
Learner therapist
(34)……Not good enough therapist
Torrey
Orton
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!!
