The Good Enough Therapist

Futility, Failure, and Forgiveness in Treatment

Brad E. Sachs

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9781138348806
• eBook ISBN: 9780429771514
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The Good Enough Therapist is a guidebook—not an instruction manual—written for beginning, intermediate, and experienced clinicians. It encourages readers to explore, accept, and embrace their flaws and failings in a way that promotes effective treatment as well as personal growth. It focuses both on craft and process—craft related to the tools, the strategies, and the tactics of treatment, and process related to the session-by-session struggle to implement these tools in ways that speak to and illuminate the experience of living and struggling as a human being. It does not endeavor to transmit a method, but a sensibility, a way of being with patients that results in a deeper recognition of the therapist's, and the patient's, vulnerability, resilience, imagination, and integrity.

1
The Vandal

I have always experienced an unshakeable desire to please people, to keep everyone happy. So you can probably imagine my response when I pulled up to my office one misty summer morning to find that the nameplate next to my front door, and the door itself, had been vandalized. Thick, black paint, still partially wet, almost completely coated the outside of my office. I stared at the glistening darkness, unable to comprehend what it meant and how I felt.

In a daze, I called the police, and a young officer promptly showed up. He took a quick look at the damage, then walked up and down the corridor of the other offices on my floor and the floor above me, all of which had outside entrances as well. He returned, and bluntly commented, “No one else in the building has been vandalized. It appears you’ve been targeted.”

His words perforated me. Targeted? Why…and by whom? I let the officer into my office and he conscientiously filled out a report. My office building is in a racially and economically diverse neighborhood, one that has seen a fair amount of crime, mostly robberies and hold-ups but, on rare occasions, stabbings and gunshots. With these concerns in mind, a small, satellite police station had been set up just across the parking lot from my building several years ago in an effort to build better police-community relations and to more effectively mitigate misconduct. So it was clear to me that black paint on a single nameplate in an office building was not going to be the highest of priorities for an officer of the law in this part of our town.

“Is there any chance that you’ll be able to figure out who did this?” I asked him.

“Highly unlikely. The only possibility is if the vandal was caught on the security cameras. Even then, it’s not as if we would necessarily know who it was or where this individual could be found.”

My heart lifted a bit. The landlord had recently installed cameras in the upper and lower parking lots. I put in a call to the building supervisor, who said that he would contact the company that operates the cameras to see who or what showed up.

In the meantime, it was tremendously difficult to concentrate on my work with patients that day, and for several days afterwards. One complicating factor was that several other clinicians rent space in my office suite, and their names were on the front nameplate, as well. So it was certainly possible that it was not me who was pinpointed but someone else.

I e-mailed all of my colleagues to explain the situation, asking if any of them had clues as to who might be responsible for the defacement. However, everyone drew a blank. Plus, I could not rid myself of the nagging suspicion that I, not anyone else, was the bulls-eye that this malevolent veneer had been aimed at. I was the only full-time clinician who inhabited the suite, my name is at the top of the nameplate in bigger, bolder letters than anyone else’s, and the building directory at the entry to the parking lot lists my name, and my name only, next to the suite number.

For a couple of weeks I ran down my caseload in my head, considering who among my current or former patients might be so angry with me that he or she would be motivated to symbolically injure me. This forced me to consider carefully not only those patients who were clearly dissatisfied with me to the extent that they had terminated treatment with me but also those patients who were not clearly dissatisfied with me but whose dissatisfaction might have been suppressed to the extent that it eventually took the form of this visually menacing violation.

What had I done wrong? Whom had I offended? How had I transgressed? And why was I—so earnest, so hard-working, so sensitive, so caring—being singled out for psychological damage in this way? Or was concluding that I was being singled out by someone my way of establishing my significance? Perhaps this transgression wasn’t directed at me at all. Perhaps it was meant for one of the other clinicians in the suite—perhaps it was meant for another suite altogether, and there had simply been some mistake? Was I that important? And what if I wasn’t?

My agitation, as well as my tendency to scrutinize every one of my current patients carefully even though I imagined that the victimizer was an erstwhile patient, were still at a relatively high level when the owner of the security camera company called to arrange an appointment so that he could show me what had been captured on film.

It was with tremendous eagerness that I watched him open up his laptop and click over to what had been recorded. And what showed up on the recording was, as I feared it might be, disturbingly unhelpful.

The footage revealed a car pulling into the upper parking lot around 2:30 a.m., circling around once, and then disappearing, at which point it was picked up by the camera in the lower parking lot, where my office was. Unfortunately, it was too dark to make out the license plate, which would have been our best chance of identifying the perpetrator. However, there was enough light to allow us to make out a white, adult male parking the car, getting out, somewhat casually pulling a can of paint from the back seat, and strolling—and I do mean strolling, without any apparent urgency—toward the entrance of my office.

At that point he was out of range of the camera, but about 90 seconds later he emerged back in the parking lot, still carrying the can, reentered his car, and drove off.

I shared the video footage with the police, who sympathetically explained that without the license plate number available, the likelihood that they would ever be able to locate and apprehend the vandal was quite slim.

And, from a crime investigation standpoint, that was the end of the story.

But from a personal standpoint, the investigation continues. Particularly when I have a fractious interaction with a patient, I begin to think about what happened. I do have a mental lineup of disgruntled former patients whom I could easily imagine performing, or arranging for, the destruction of my property. I sometimes think about what would happen if I ran into one of them in public. My fantasy is that I would coolly comment, “I know what you did,” leaving him or her in a state that I hope would be as emotionally discomfiting as, if not more so than, my own.

But thus far that hasn’t happened. And so what I have to contend with is that my work as a therapist, with a certain individual, must have violated him or her to such an extent that a vengeful violation needed to be enacted. There is a combination of both scar tissue and fresh hurt for me as I consider this. Whether the vandal experiences both, as well, I do not know, although I would guess that this is the case. Like it or not, we are creatures of reciprocity.

All of us would like to be able to disarm the power of another to hurt us. But disarming the power to hurt would also mean disarming the power to heal. I would like to understand more about how I hurt rather than healed the perpetrator of this crime. I am glad that this individual directed his or her rage at my realty, rather than at my person. Vandalism has always intrigued me precisely because it is indeed intentional and malicious, yet it often lies at the filmy interface between expressiveness and destructiveness, between protest and riot—graffiti art being the best example of this. But, like any act of terrorism, the defiling of my property terrorized me and left me unnerved. I still have to face the fact that a faceless individual defaced a part of me.

The maintenance crew completely removed the paint later that afternoon, but, several years later, there remains a scattering of black specks that noiselessly freckles the window frame. I see them every morning when I unlock the front door to the suite, and I think about forgiveness—forgiving the perpetrator and being forgiven by him or her. I say a little prayer hoping that, today, I don’t recommit whatever wounding mistake I made that led to this Stygian reprisal, knowing that there is always a chance that I will.

Exercise

Rabbi Nachman wrote, “If you believe that you can do damage, then believe that you can repair.”

These are reassuring words, but if we want to imagine that therapy is potentially therapeutic, we do have to believe that it can be hurtful or detrimental as well, even though this may be far from our (conscious, or even subconscious) intent. We are real only insofar as we can be hurt and as we can hurt others.

Think of a time when you know that you damaged or injured a patient, or when you may have damaged or injured a patient:

• What was the nature of the damage or injury that you perpetrated?
• How did you come to find out, or believe, that you caused this damage or injury?
• How did or do you try to talk yourself out of knowing that an injury occurred?
• Did you choose to, or have the opportunity to, address this injury with your patient?
• If so, how did it go?
• If not, why not? What has kept you from doing so? And what do you think would happen if you did?

Interlude 1

What Is the Point of My Writing This Book?

This book, like most books—and certainly like my books—began long before I imagined its conception. And even after it was conceived, it tugged insistently at my sleeve for quite some time, demanding my attention. Why it took so long to get to and to complete, I cannot be sure. Although lack of surety is certainly one of the foundations upon which the scaffolding of this book has been built. But because writing a book is such an ordeal, most authors ask themselves, at some point, “Why am I writing this?”

And, in particular, I have asked myself, “Why go to the trouble of writing an entire book about clinical failure when the unarguable words ‘We will all fail’ essentially sum it up?” The answer is inevasibly selfish—after all, it requires tremendous self-involvement to write a book, and a towering (although often teetering) ego to imagine that one might contribute a meaningful tributary to any literary river.

I suppose my response to that question is basically twofold: I write because finding the right words to describe my clinical work is pleasurable and helps me to better understand my patients and myself, and I write because writing keeps me feeling like I am alive and that my presence on this earth remains intact—somehow, it prevents me (at least temporarily) from vanishing.

Nevertheless, during my most benighted moments at the computer, yoked to this particular project, here are some of the concerns and questions that have come to mind in response to that most fundamental question:

• Is writing about being good enough a form of self-protective self-criticism, akin to vaccinating myself (administering a small and harmless dose of “the disease”) in order to inoculate myself against the full onslaught of “the disease” (which, in this case, would not be self-criticism but self-loathing)?
• Is it to use the publication of a book to bolster my self-regard, to declare my sufficiency, my belief that I am, indeed, good enough?
• Is it a way to transcend the possibility that I am not good enough by trying to do something that distinguishes me from others, that is “great”?
• Is it a way to humbly aggrandize myself? To elevate myself above its readers, and those who don’t write, by cleverly going “one down” and thus remaining “on top”?

With this last possibility in mind, here is another brief Jewish tale. During the High Holydays, the temple’s Rabbi runs up to the ark, falls to his knees, and pleads, “Lord, Lord, I am nothing!” Seeing this, the assistant Rabbi also runs up to the ark, falls to her knees, and pleads, “Lord, Lord, I am nothing!” Seeing this, the custodian runs up to the ark, falls to his knees, and pleads, “Lord, Lord, I am nothing!” At which point, the Rabbi leans over to the assistant Rabbi and whispers, “Look who thinks he’s nothing.” Grandly ratifying our humility may be nothing more than grandiosity in another form.

In any case, I continue to struggle with these questions. But despite all the doubts that come to mind as I write, I want to emphasize that The Good Enough Therapist is essentially nothing more than an undertaking designed to convey the pain of failing, as well as the importance of failing, and the ways in which failing changes us in unexpected and revealing ways. Failure, paradoxically, never fails—we have no choice but to become experts at it, but how we can learn and grow from that expertise is the inquiry that lies in the sediment beneath this book. I am seeking to encompass in these pages the entire human vocabulary of resignation, diminishment, and defeat. I have, of course, inelegantly failed at completing this preternaturally Sisyphean task, but I have also discovered that trying to do so brings me not only emptiness but also a sustaining sense of fullness, and of wholeness, as well.

Exercise

Now It Is Your Turn…

I was telling a trusted colleague about my frustration with this book midway through and at one point asked him, “I mean, who would want to read a book that is nothing more than a dispiriting account of a therapist’s failures and defeats?” He smiled kindly and said, “I would.”

You could have chosen to read countless clinical publications. Think about why you chose this one to read.

• What are the reasons behind this decision?
• What are you looking for or hoping to find or discover?
• What are you afraid will result from reading this book?

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Previous Books
• Acknowledgments
• Introduction: Socioeco-Location
• 1 The Vandal
• 2 On Writing About the Clinical Without Being Too Clinical
• 3 Good Enough or Good-for-Nothing?
• 4 A Place to Start: On the Importance of Treatment Failure When Treating a “Failure-to-Launch”
• 5 Two Powerful Lessons in Powerlessness
• 6 Three Births…
• 7…and a Fourth Birth, the Birth of Forgiveness
• 8 The Joy of Thwarting…and of Being Thwarted
• 9 Reduced Sentences
• 10 Cash in the Cup
• 11 Here and Not Here, There and Not There
• 12 Tough Love—And Why It’s so Tough
• 13 The Ambivalent Tango of Hope
• 14 Narcissism and Its (Occasional) Nobility
• 15 Nowhere but the Dark
• 16 Punishing the Punitive Therapist
• 17 On Hating a Patient
• 18 What Do We Want When We Want Out?
• 19 Defeated by Success
• 20 The Diagnostic Dragnet
• 21 We Hold These Truths to Be Self-Evident…but Without Any Real Evidence
• 22 “I Am Beside Myself”
• 23 What We Give Our Patients When We Give Up—and When We Don’t
• 24 “Why Am I Doing This?”
• 25 The Good Enough Supervisor
• 26 Giving What You Never Got
• 27 Loops
• Conclusion: “Going Grandfather”: The Good Enough Therapist in Twilight
• Epilogue: In Praise of Defeat
• Index