Mistakes

I recently did a deep dive into the complaints received and adjudicated by BACP and UKCP. Like many therapists, I secretly harbour some anxiety about being complained against, as well as a mixture of horror and fascination with the trials and tribulations of colleagues who have 'sinned' and have been punished accordingly. Nobody (those who make complaints, or are complained against) comes out of a complaints procedure thinking they would ever want to go through it again.

BACP: What complaints tell us

BACP and UKCP acronyms represent organisations which run registers of counsellors and psychotherapists; both publish summaries of the type of situations that cause clients to want to complain against a therapist. I was curious to learn what issues come up and was suprised to find that they seem both ordinary and hard to believe: a client encounters a member of the therapist's family as they leave the house (ordinary); one therapist consistently extended sessions by thirty minutes making the client feel uneasy and offering to pay more (hard to believe), a client complains the sessions were not reviewed regularly (ordinary), the therapist does not present her client with a written contract (ordinary), a therapist abruptly decides to terminate the therapy (therapists can feel they are in over their heads), therapist falls asleep during the session (more common than you think), after seven years of therapy, the therapist declares he has fallen in love with a client (it happens).

In the same masochistic vein, I was reading some interesting and challenging research articles about therapy's negative side effects; around 10% of clients get worse whilst in therapy and this is not sufficiently acknowledged (Berk and Parker, 2009).

berk-parker-2009-the-elephant-on-the-couch-side-effects-of-psychotherapy (2) 2

.pdf

Download PDF • 108KB

Meanwhile, my Metanoia students were writing a report on clinical practice exploring a 'difficult situation', one that might be defined as a mistake, failure, rupture or enactment. We ask them to do this so that they become used to examining difficulty, rather than running away from it. Reading their essays I had to consider these concepts afresh.

Although talking therapy is generally deemed safe and effective, sometimes things do go wrong. Buyer beware.

This must be the disclaimer I wish I could articulate during my first contact with any prospect client:

"Hi. As this is your first session, I would like you to know that things can and will go wrong from time to time. Let me count the ways. In spite of my best efforts, may make the occasional blunder. I may hurt your feelings, misunderstand you, not attend to you perfectly. We may not always agree. We may even dislike each-other from time to time. There might be periods when you will feel everything more intensely: anxiety, sadness, loss. I hope that, when these types of situations arise, you will be willing to tough it out and talk it out."

Blow is my attempt to classify the many specimens of 'wrong', the way a botanist would classify different types of common garden weed.

The 'weed' metaphor is not exactly right. On close examination it becomes apparent that what feels 'wrong' or 'uncomfortable' may not always 'bad' for the client. (What feels right and comfortable is not always good for the client, either). A lot of events that appear in a negative light at first inspection, turn out to be pivotal turning points, moments of profound recognition of blind spots, that is if they are fully explored and understood.

As existential therapist Irvin Yalom would say, everything that happens in therapy - good or bad - is grist to the therapeutic mill. Some of the moments we end up cherishing and remembering most from therapy sessions started out as sticky situations. These events are the proverbial grain of sand in the oyster, around which healing occurs. An oyster's healed wound becomes a pearl, so there is hope that therapy injuries can also become transformed into cherished moments.

It goes without saying that therapists do not set out to hurt their clients - that would be unethical. But they accept that the occasional discomfort or difficult moment is inevitable and maybe even useful. Minor stressors and micro-tears in the fabric of relationships can lead to increased resilience over time.

In a similar vein, physical trainers do not set out to injure their clients, but accept that a vigorous workout might lead to micro-tears in the muscle fibre. The aftermath of a good workout will be experienced as unbearable pain at the time, but soon the muscle fibre will regrow stronger to meet future increased demands posed by exercise.

There is an entire fauna of concepts related to therapeutic mistakes, and I will catalogue them all.

Therapists who work in a relational way - who bring their entire personhood to the therapeutic encounter, including their authentic thoughts and emotions, accept that this will cause more interpersonal friction than if they were to maintain a professional, competent and benevolent 'front' at all times. The question is not how to eliminate imperfections; the question is if the client can be supported to make productive use of the therapist's imperfections.

A mistake in the therapeutic context is an error or blunder. 

Mistakes typically involve absent-mindedness, distraction, over-confidence, clumsiness, or neglect on the part of the therapist. They occur more frequently when the therapist is overwhelmed, overworked, distracted or when there is a change in pattern (going on holiday or coming back from holiday, new frequency of meetings, changed times). 

Mistakes tend to cluster around boundaries. To explain the idea of boundaries, think of those sand-pits sometimes installed for children in city parks. The pit has a frame specifically constructed to contain the play and stop the sand from spilling out. Therapeutic folklore has it that the therapist brings the container and the client brings the chaos. Therapy needs a sturdy frame in order for the client to risk showing her mess. In relational therapy, it is understood that both client and therapist will create a little chaos and mess together. Mess-making does not sit very comfortably within a professional model of therapy which is error-avoid, but is very compatible with the idea that therapy is an experimental laboratory where new ways of being can be found and tried for measure. The container better be strong.

Boundary mistakes on the part of the therapist take many shapes: double-booking, not remembering an appointment, getting the session time wrong, finishing a session early, getting the client's name wrong, sending an e-mail to the wrong recipient.

Mistakes also tend to occur around delivery: clumsy or imprecise wording, vagueness, or using emotionally triggering words, pitched at the wrong intensity.

Lastly and most importantly, mistakes also occur around process. We shall call this type 'technical mistakes', for instance: the therapist not being accurate in their 'reading' of the client's state of mind, failing to note that the client is not ready to disclose or engage with certain material, believing the client is saying 'yes' to a request although the affect is not matching the words, failing to check how an intervention has landed with the client. Timing mistakes (making an interpretation or challenge prematurely), and contract mistakes (not doing enough to clarify the social level contract or to attend to the psychological level), are other varieties.

Mistakes may be weathered well, or may lead to ruptures and the failure of the therapeutic relationship.

Rupture: This is a fallout; the whole relationship is being shaken to its core, power dynamics have to be examined and re-considered, trust has to be re-earned and clarification needs to occur. Too much pressure is put on the relationship, and there is a temporary break in communication, which can be restored (repair) or not (breakdown).

A rupture usually occurs when too much strain has been put on the goodwill of either party, when they can no longer deny or ignore things about the relationship that have been niggling them. Ruptures can reveal that the client and the therapist are not aligned in terms of tasks, bonds and goals (to reference Bordin, a researcher in this field).

Ruptures also occur when the therapist does something new and bold, when they begin to take risks in truthtelling and authentic relating, or experiment with a new technique. The client hears something that is unwelcome or potentially shaming (truth hurts).

Ruptures are common outcomes when the therapist makes a mistake AND fails to realise they have made it, OR attempts to blame the client for the mistake through inappropriate interpretation (I wonder what it is about you that made me forget our appointment). 

Typically ruptures allow the partners to see each other in a new and usually unflattering light. The therapist falls off the pedestal. The client is no longer the GOOD client. Hurt is involved; shame is triggered. Ruptures are uncomfortable, but not necessarily catastrophic.

It may take the therapist a while to suss out that a rupture has occurred. They may find out only indirectly by observing subtle changes in the client’s demeanour and attendance, or they may be confronted by the client.

Failure: Failure is a little more serious than a mistake because the consequences are more permanent and irreversible. They are exceptionally rare events (black swans) but with disproportionately negative consequences: a client commits suicide; therapy is abruptly curtailed and later a malpractice complaint is made. We are talking about dramatic situations that are played out in the morgue or in the court/complaints tribunal, as Eric Berne would say. Failures can be seen as a culmination of a series of unexamined mistakes over time leading to a catastrophic outcome. Therapists tend to be inconsolable and mull over their failures for a long time (the overwhelming majority therapists do have a conscience).

Breakdown: is similar to failure but the only casualty may be the relationship; no actual tissue damage occurs. Breakdown follows a serious violation of trust when either party fails to live up to the ethical principle of trustworthiness (doing as you say), or realises they had not examined their starting assumptions. Breaking confidentiality outside the parameters established in the contract, making sexual advances towards a client, and intruding into the other’s space (clients stalking the therapist, public take-downs on social media) – these are the types of situations that lead to breakdown.

Enactment: Is literally playing out a crucial scene from the client's early life. Enactments are uncannily similar to actual situations that the client experienced when they were growing up, but this awareness is always revealed only after the fact. Therapists can also enact their own key scenes with clients. Enactments can be small/subtle or big. Therapists have learned to appreciate the potentially transformative power of enactments.

Acting out: Is the client not being able to express feelings through language (rage, envy, disappointment, resistance) and expressing them in harmful ways outside the therapy room (self harm is an example).

Acting in: doing the same but, INSIDE the therapy, targeting the therapist and the therapeutic frame (payments, attendance). 

It is the therapist's job to notice that acting in and acting out is happening and to interpret what the client is trying to communicate.

Interpersonal games: 

A game - this is a transactional analysis term first used by Berne in 1964 - is a series of ‘secret’ (ulterior BUT NOT unconscious) messages, leading to an emotional payoff that reconfirms a person's position in life and their decisions. A game involves being conned (provoked, challenged, come-on, tested), having an irresistible urge to respond to the con (this is the hook), a psychological itch that we just have to scratch, a need to prove a point. There is a decision to ‘play along’ (response), to accept the challenge, to supply what is asked for at a social level. However, this leads to frustration, players eventually refuse to continue in the same vein, someone turns the table, power positions are switched, and each person ends up feeling familiar hopelessness, rage, confusion or triumphant self-righteousness.

There are different degrees of games, depending on the consequences. The rarest and most serious games end up in failure and a total breakdown in the therapeutic relationship .

A drama is a series of mini-games in which players can swiftly change power positions from helpless Victim to triumphant Persecutor, from busy Rescuer to defeated Victim. Karpman (2019), who invented the Drama Triangle, says that originally, he had a fourth position in mind, that of the Trickster, but abandoned it for the sake of simplicity. The Trickster however is still in the model; it is the dynamic shift in positions. Dramas also require an audience (Bystanders), and rely on a mismatch/incongruity between content and location (boardroom talk in the bedroom; bedroom talk in the boardroom). There are options to stay out of the drama triangles as 'players' find vulnerability, compassion and assertiveness.

Karpman's 2019 review of drama triangle

So here we are. This is my exhaustive catalogue of terminology for 'sticky' therapeutic moments. Now that I have released most of the common 'curses' of the therapy world's own Pandora's box, fortunately there is hope left, hope that with goodwill on both sides, what has been broken can also be mended, what has been out of awareness can become known and owned.

Repair in therapy vernacular is the attempt to make amends, to account for oneself and to attend to hurt that has been caused. It usually involves vulnerability AND compassion for self/other, plus a willingness to forgive. Repair may mean acknowledging hurt, saying sorry, being honest about how we have been impacted, making a new commitment or even or even financial reparation.

Rupture and repair cycles are very common in the therapeutic relationship particularly when the therapist is risking more of herself; they are the means through which the individual gains mastery in interpersonal situations, and develops emotional resilience. I will finish with this image of a kintsugi vase a technique of pottery repair where precious metal is incorporated preserving the history of the object but also elevating it aesthetically. It is not an attempt to plaster over cracks; it is making the cracks the main feature. This kind of sums up relational therapy.

*The images on this post were generated by artificial neural networks based on my prompts