When Hurt Remains

Relational Perspectives on Therapeutic Failure

Asaf Rolef Ben-Shahar, Rachel Shalit

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780367329723
• eBook ISBN:
  9780429923913
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book illustrates the myriad of ways in which hurt was created. It presents an integrative picture of relational psychotherapists working analytically, dynamically, and somatically with therapeutic failures.

PART I

BEYOND BINARIES

Introduction to Part I

Relational psychoanalysis hails from contextual thinking. Experiences should be examined under their socio-cultural, gendered, financial, and political contexts (among others). We aspire to move from either/or logic to both/and—to transcend binaries and discover thirds, thus retrieving the connection to previously dissociated aspects of ourselves and the other (Aron & Starr, 2013).

Can psychotherapy be accountable to binary concepts of success and failure? Can psychotherapy avoid it altogether and still remain sensitive to contextual changes? And if we do give up binary thinking of success and failure, how can we still maintain a system of personal and mutual responsibility, quality assurance of sorts?

The first section of this volume, Beyond binaries, examines some of the binaries in thinking of therapeutic success and failure.

Doris Brothers opens the section by challenging the polarity of success and failure, and points to their relativity and limitation. Jessica Benjamin conceptualises therapeutic positioning in case of failure, looking at the polarities of “good” and “bad” and, in particular, the challenge of the therapist to agree and bear “badness”. Elad Hadad concludes the section with an uncertainty about success and failure in light of cultural indoctrination and expectation. He suggests that the perception of failure and success changes according to the perceiver, the angle of perception, and the scope of time.

CHAPTER ONE

Challenging the success–failure polarity in therapeutic practice

Doris Brothers

Who could doubt the wisdom of Rudyard Kipling’s claim that being able to treat triumph and disaster—“those two imposters”—the same is a mark of maturity? Easier said than done, however, if you happen to make your living as a therapist! The siren call of the success-failure polarity seems to sound particularly sweet to our ears. Many published clinical vignettes read as if their authors, after struggling valiantly, had reached unequivocally successful outcomes; failures, if they are mentioned at all, are usually attributed to the patients’ previous therapists. So widely shared is our delight in celebrating our therapeutic coups, and so great is our reluctance to let the world in on relationships that never get off the ground or land with a thud after a promising start (see Goldberg, 2012), that we rarely question the usefulness or validity of viewing our work as either successful or as a failure.

Judging therapeutic relationships as either triumphs or disasters has a long history. As far back as 1891, Sigmund Freud used the terms “success” and “failure” in relation to therapeutic practice. But even when the resolution of the Oedipus complex was the main criterion for judging the merit of an analysis, the determination of a treatment’s success or failure was far from clear-cut. Those looking back with a postmodernist eye might ask by whose standards the criterion was met. The analyst’s? The patient’s? Was a consensus needed?

Aron and Starr (2013, p. 41) contend that psychoanalysis “has been hindered by its preoccupation with binaries …”. The father of psychoanalysis himself modelled this preoccupation for us. I have conjectured that Freud’s tendency to view psychological life in terms of such dualities as conscious-unconscious, primary process-secondary process, life instincts-death instincts, and masculinity-femininity, among many others, had self-restorative meanings for him. Biographies of Freud, as well as his personal correspondence, contain many references to his dissociative post-traumatic symptomatology. A number of likely traumas have been suggested, including the possibility that he was sexually abused by a nursemaid (Masson, 1985; Partridge, 2014). And there seems little doubt that he was deeply affected by the virulent anti-Semitism that pervaded his cultural surroundings (Aron & Starr, 2013).

The tendency to divide reality into dichotomous categories as a restorative effort in the aftermath of trauma is consistent with the theory I have been developing for some time (Brothers, 2008). In my view, trauma has two components:

1. the destruction of the certainties that pattern psychological life that exposes its victims to the unbearable horror of self-annihilation, and

2. attempts to restore a sense of certainty about what Winnicott (1965) calls our “going-on-being”.

Insofar as feelings of uncertainty tend to be heightened by complexity and lessened by simplicity, either-or, dichotomous, thinking, which reduces complexity, is often a feature of restorative efforts in the aftermath of trauma. Thinking in terms of the success-failure binary may not always represent restorative efforts by therapists in the aftermath of trauma (although what therapist has not undergone trauma?), but it does provide a measure of relief as we engage in what must be one of the most complicated and therefore uncertain of professions.

I have little doubt that the way the success-failure binary is regarded depends, to a great extent, on one’s theoretical orientation. Many postmodernists would recommend accepting the polarity’s paradoxical and dialectical meanings; other relationally oriented analysts would suggest moving beyond it by conceptualising “the third”. Still others, using a contextual perspective, would regard success and failure as aspects of experience that assume different shapes depending on their temporal, spatial, and relational contexts; not as opposing categories.

William James, the pragmatic philosopher, might have asked about the usefulness or “cash value” of the success-failure polarity. Its appeal seems apparent. Aside from appearing to bring a measure of perceived clarity to our highly uncertain profession, it promises to allow clinicians to learn from their own as well as others’ mistakes and triumphs (Goldberg, 2012). And from the perspective of some psychoanalytic theories, notably self psychology, therapeutic gain hinges on the sequence of rupture (empathic failure) and repair (empathic success).

Why then am I questioning the usefulness of the success-failure polarity? When viewed from the relational systems perspective that I favour, the problems and complexities involved in thinking in terms of the success and failure of any given therapeutic relationship assume staggering proportions. Analysts’ embedment within the interpenetrating systems that structure their relational worlds profoundly affects not only their understanding of what constitutes success and failure but also their experience of it. Adherents of one theoretical system may view as successful a treatment that would be viewed a failure in another. A horror of failure may be perpetuated in one analyst’s cultural surround and family system but well tolerated in another. Just as the analyst’s criteria for success and failure as well as his or her experiences undoubtedly affect a patient in countless ways, so too the patient’s often unformulated criteria and experiences affect the analyst.

Another reason that I question the usefulness of the success-failure polarity involves the ways in which the duration of the treatment has been used as a criterion for judging the success or failure of a therapeutic relationship. I find that this criterion is often highly misleading. Many clinicians seem to believe that a therapeutic relationship should neither be too short nor too long, and that it should end after a suitable “termination” phase; the length of time considered optimal for any given therapy varies widely depending on one’s preferred theoretical orientation. However, I can think of many exceptions to what may seem like sensible guidelines.

For example, a therapeutic relationship that ends quickly, say after only a few sessions, particularly when the patient is very young, may simply mean that a little has gone a long way. For patients who have never before felt that their needs and feelings deserved the full attention of another person, a brief therapeutic encounter that demonstrates that such attention is possible may in itself prove transformative. However, some therapies that last for decades seem to have more to do with a patient’s compliance with the unspoken needs of his or her therapist than with any healing that is taking place. This is certainly an aspect of the clinical example I now present.

My Relationship with Lily

It was only after her analyst, Dr A, held a clock to her ear when the phone rang during a session that Lily reluctantly ended a five-day-a-week analysis that had lasted twenty-five years. In the weeks before this happened, the therapist had frequently phoned Lily at home, often sounding confused and distressed.

Lily phoned me on the recommendation of a relative’s therapist, a colleague of mine. For the better part of the following year, our relationship was dominated by Lily’s account of her complicated feelings about Dr A’s precipitous cognitive decline and subsequent death, which she surmised was caused by Alzheimer’s disease. She celebrated Dr A’s keen intelligence and prestige in the psychoanalytic world as a writer and teacher, railed against her failure to acknowledge her impairment, and chastised herself for having abandoned Dr A in her “darkest hours”. But hard as she tried, Lily seemed unable to reach any conclusion about the value of her long years with Dr A.

We agreed to meet three times a week for what I assumed would be a brief period of time. So urgent was her need to process her relationship with Dr A and its painful and shocking ending that finding out who I was or what a therapeutic relationship with me might offer rarely seemed to enter her mind.

Perhaps I can be forgiven for secretly comparing myself favourably to Dr A when I learned that Lily’s relationship with her had long roiled with conflict. Dr A seems to have engaged Lily in a struggle about her connection to her parents, insisting that her inability to “separate” was the result of their severe pathology—and Lily’s own. “Let them go,” she would implore Lily. “You have me now.” Lily confided that she had no intention of ever letting her parents go because she loved them dearly and they had loved her. Besides, she added, “I really didn’t know what letting them go meant and Dr A never explained it to me in a way that made sense.”

When, in the course of our work together, Lily and I realised that a familial trauma that occurred when she was only four years old had probably precipitated the depression suffered by both her parents, as well as the chaos that marked her growing up years, she was stunned. How was it possible, she asked, that after working with me for so long, Dr A had not recognised the significance of this tragic event? Lily also described her inability to write a novel, which was to have been a fictional rendering of the political scandal that brought shame and dishonour to her father, an official in local government. Dr A’s repeated message had been, “Just do it. Sit down and write. You can take me with you.” However, for Lily, sitting at her desk alone, to try to write was “torture”. She apparently could not or would not take Dr A with her. We came to understand that at such times Lily re-experienced the terror that had so often overtaken her during the long lonely hours of her childhood. As her anger mounted over Dr A’s failure to understand the many devastating effects of her childhood traumas, Lily’s view of her long analysis became darker and darker. Eventually she declared that her analysis had been “a horrible failure”.

It was not long after Dr A fell from the idealised position she had long occupied that Lily seemed to install me in this exalted role. She now made it clear that she regarded me as the embodiment of analytic perfection. She expressed no desire to set a date for ending therapy with me, and said she believed that her real analysis had only just begun. “You understand me so well,” Lily would say reverently in response to what I regarded as fairly mundane utterances. She would ask for my help with simple quotidian decisions such as where and when to go on vacations and about what to serve at dinner parties, as well as more substantive ones including whether she should join a group for writers. She also became increasingly interested in me. Was I married? Did I have children? Where did I go to school? She seemed satisfied when I answered her questions as simply as I could without revealing information that I regarded as too personal.

If, during this period, I had been asked to bet on the outcome of our work together, I might have wagered that substantial healing was well within our reach, although, as you might imagine, I also anticipated that I would eventually fall in her estimation. Much self-psychological literature describes how a patient’s disappointments in a therapist once seen as almost god-like in perfection contribute to the working through of “idealising transferences”. I have found that when I am able to non-defensively acknowledge my “failures in empathic responsiveness”, as they recommend, ruptures are usually quickly repaired. So I was not terribly surprised at Lily’s initial bursts of irritation when flaws in my “perfect understanding” became evident. But I did not expect the intense rages with which she came to react to seemingly innocuous lapses in my attunement. For example, I once wished her a happy holiday after a session in which she had recalled painful scenes from her childhood. “Happy holiday?” she had howled, “how can you expect me to have a happy holiday after a session like this!”

As my attempts to acknowledge my errors in understanding fell on increasingly deaf ears, the happy ending I had hoped for now seemed all but unreachable. I worried that perhaps I was not the right therapist for Lily, that perhaps someone more like Dr A was who she needed. Yet I also felt it was important for me to stay the course. Then, one day, as Lily expressed intense outrage over some comment of mine that missed the mark for her, I was overcome with a feeling of deep sadness. Thinking about the poignancy of the feeling after the session, I recalled the sorrow I felt when my own analyst abruptly ended our twelve-year-long analytic relationship to relocate in a far away place. After my initial feelings of anger had subsided, I had been overcome with profound grief over my loss of a truly transformative therapeutic relationship.

Struck by the parallel between Lily’s loss of Dr A and my loss of my own analyst, I suddenly understood why my previous interpretations had fallen flat. I had suggested that my lapses in empathic responsiveness recreated the world of her childhood in which none of her carers could be trusted to respond in reliably protective and guiding ways. However, I had not realised that my lapses in attunement reminded Lily of the devastating signs that Dr A was losing her mind. When I suggested that this might be true, Lily burst into tears. Her anguished cries filled several sessions. At last she was able to grieve her loss.

Just as I could recall how responsive and insightful my analyst had been once my anger at her had cooled, Lily’s harsh condemnations of Dr A gradually gave way to more positive recollections of the long years they spent together. Dr A, Lily now acknowledged, had helped her to gain confidence in her ability to think analytically, and had encouraged her interest in the classics and history; she had been very helpful when problems arose in her relationships with her children. But even more importantly, unlike her preoccupied parents, Dr A had demonstrated unwavering interest in Lily’s life and had been reliably present in good times and bad.

Along with the growing integration of her perception of Dr A’s unique strengths and weaknesses as an analyst was Lily’s willingness to forgive my lapses in attuned responsiveness. After we had accomplished a great deal together, such as better understanding her tendency to take on the role of trustworthy carer for others as a way to compensate for deprivations in her own life, and after celebrating the progress she now was making on her novel, I had suggested that perhaps we could think about ending our therapeutic relationship. We had just begun to consider what this might mean for Lily when her husband was diagnosed with a life-threatening disease. We are now meeting once a week as Lily grapples with this tragic development. It is clearly not the time for us to end our work together.

I have long believed when a therapeutic relationship is truly healing, it enhances the therapist’s development and well-being as well as the patient’s (e.g., Brothers & Lewinberg, 1999). George Atwood (2011) uses the evocative term “radical engagement”, to describe a psychotherapeutic dialogue by means of which the worlds of both partners are transformed. I would say that working with Lily has been transformative for me precisely because it has allowed me to confront my own struggles over success and failure. My early life, much like Lily’s, was largely organised around the systemically emergent certainty, or SEC (Brothers, 2008), that my psychological survival depended upon meeting the emotional needs of my carers. Since I was convinced that my parents’ well-being depended upon my excelling at all I attempted, I felt compelled to triumph in each activity I undertook.

Traumatic disappointments in my parents had transformed what might have been a context-sensitive certainty into a rigid, inflexible, certitude that gained new strength when I became a psychologist/psychoanalyst. If only I tried hard enough, I believed, I would enable my patients to achieve their therapeutic goals. This belief represented a restorative effort in the aftermath of my childhood traumas insofar as it enabled me to gain a measure of certainty that my “going-on-being” (Winnicott, 1965) was assured.

Although intellectually I understood that a patient’s motivation to heal plays an important role in the unfolding of a therapeutic process, and that both the patient’s and my participation in the relationship were greatly influenced by the multiple systems in which our lives were embedded, I nevertheless experienced each of my therapeutic relationships as if the outcome were entirely in my own hands. I would often sacrifice my own need for rest and restoration for what I imagined to be the good of my patients by working very long hours, taking calls at night and on we...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Dedication
• About the Editor and Contributors
• Foreword
• Introduction
• Part I Beyond Binaries
• Part II Techniques: Holding on and Letting Go
• Part III Enactments: When Biographies and Self-States Converge
• Part IV Affects on the Edge
• Part V Broader Perspectives
• References
• Index