Roadblocks in Therapy

Even though most systems of treatment build on what has gone before and honor the history of our field, each school of therapy maintains that it offers advantages unavailable through any other method developed to promote emotional growth and remediate whatever it sees as dysfunction. All of us who serve as faculty or correspondents here on Behavior OnLine have been trained in at least one well-known such system, and most of us have gone from our training to devise a method of practice that suits our personality and cognitive style. Nevertheless, I don't think there is any one best method of treatment or any one best therapist. Furthermore, I know that a significant fraction of those who come to me for assistance would be better off working with someone else, and try whenever possible to facilitate their ability to find the therapist who might be best for them. People are different over a wide range of attributes, and the dysphorias or discomforts that bring them to us arise from a wide range of possible glitches.

Two extreme positions illustrate a point that has become of increasing interest to me, and, I hope, of equal interest to those of us to browse and contribute to BOL. Some classically trained psychoanalysts, many of whom taught during my residency some 30-odd years ago, maintained that a training analyst could be assigned to an analytic candidate—that it was not necessary for analyst and potential analysand to interview each other to assess what we now describe as "goodness of fit." The technique itself was thought to be pure, the analytic technician pure and skillful enough to analyze anybody. At the other end of the therapeutic spectrum lie some proponents of neurobiology who look forward to the day when we can "plug the patient into the lab and find out what's wrong." In neither of these extreme (and actually quite rarely espoused) positions is there the slightest doubt that human, personal factors might interfere with the scientific beauty of the treatment process. Proper passage through the psychosexual phases of infantile development and normalization of neurotransmitter metabolism are seen as independent of all other factors that might influence personality and adaptation to life. Again, lest I arouse unwanted controversy by appearing as an enemy or a proponent of either of these two hypothetical, antithetical, and certainly mythic positions, I have stated them to raise a point unassociated with the practice of either. In actuality, the well trained psychoanalyst has gotten pretty good at figuring out when a patient needs medication, just as the experienced psychopharmacologist often refers people for couples therapy, cognitive-behavioral therapy, or one of the uncovering therapies.

I am fascinated by impasse or outright case failure that the therapist comes to recognize as due to some sort of missed connection between patient and therapist. Since the revolution brought by Kohut and made understandable by Basch, we have come to think of this realm of case problem as involving empathic failure. Most of us have become sensitive to those moments during which we feel out of synch with our patients no matter how hard we and they work at therapy.

Starting as a straight, unmarried, upper middle class, Jewish man from a large Eastern city I felt thoroughly out of tune with patients who came from backgrounds significantly different from mine. For example, early in my career as a psychiatrist I felt inadequate to deal with adults who were involved in extramarital affairs. Not until I hit a patch in which six or seven of the people with whom I was working at the same time were involved in affairs was I able to learn enough about that particular world to become a competent counselor to it. At other times, I was forced to ask the women in my practice to explain what it was like to be a woman so I could help them better. Homosexual men and women, Asian- or African-American adults, WASPS from fabulously wealthy families, grifters, con-men, prostitutes, a long string of Episcopal priests—whenever I realized I was out of synch I was forced to look for the most likely cause and ask the patient for help. True, this approach did prevent or interfere with the development of a certain type of transference, but it was a transference I have never found useful in any aspect of treatment.

After a few years as a beginner, I learned to tell my patient that "This is not my native planet. Actually, I came here from another star system far, far away, and if I'm going to be useful to you, you are going to have to tell me everything I need to know about your world so I will know how to be your therapist." Done with tongue thrust deeply in cheek and a half-smile, this statement alerts the patient to the real gulfs between us, to my willingness to learn from the patient, and to my belief that after the chasms have been crossed, real therapeutic work may be accomplished. I recognize the sort of empathic failure that triggers such an approach by a peculiar form of discomfort in which both the patient and I feel awkward, and in which identification of this awkwardness does not seem to produce useful forward motion. From my position as a student of innate affect, I believe that the affect in question is some form of shame stemming from an impediment to the mutualization of positive affect and from the sense of failure permeating the interpersonal field, but each of you may have quite another way of looking at the problem.

Whatever your realm of interest or approach, I invite my colleagues to join me in the forum I host here on BOL, the Shame and Affect Theory Forum, so that we may begin a discussion of empathy and its failures, as well as the concept of case failure. I hope that you, too, may share some of your stories about your own "stupidity" and inability to work with a particular patient, and may let us in on some of the personal misconceptions you've undone in yourselves in order to reach your current level of competence. This message will be duplicated on the Shame and Affect Theory Forum as the beginning of a new thread so that all of us will be able to contribute. I'd welcome participation from the other BOL Forum hosts, as well as our remarkable Editor, Gil Levin, and our super-host, John Grohol. Thanks to all of you who work and lurk on BOL for the opportunity to share this material.

Don Nathanson

• Duh in a Group by Gil Levin, 7/28/97
• Impasses, Roadblocks and Other Opportunities for Learning by Ellen Dornelas, 7/30/97
  • Impasses as Learning Opportunities by Sue Deppe, MD, Burlington, VT, 7/31/97