On Failure

“This is a personal question, Jon. Through your book and your facebook page, I get to read about succesful interventions and the path forward. But do you still get patients whose resistance is too strong for you to help them? Or who, for some reason or other, just won’t benefit from ISTDP? How do you learn from and carry your failed therapies, if you can call them that, gracefully?” Thanks to Arvid for this important question.

According to psychotherapy research, no therapist succeeds with all patients all the time. Not me, not you, no one succeeds all the time. No therapy succeeds 100% of the time with all patients. Anyone who claims differently is just lying.

Sure I fail at times, even after practicing for thirty years! I can console myself that I sometimes get patients who failed with many other therapists. But still, I fail. Everybody does. So the question becomes, how can we learn from our failures?

When I fail, I study my videotapes to see what I can learn. I show my videotapes to colleagues to see if they can help me see what I don’t see. I read more widely. I think about the case. I write out transcripts of the session to see if my analysis of it helps me see a pattern I didn’t see before.

I make a note of the specific problems the patient has that are are not resolving and I consider what other approaches I could use. Sometimes a stalemate resolves after I have tried four or five different approaches until something works. And sometimes, I never figure out how to help the patient get better. Sometimes I send a patient to colleague to get a second opinion.

You mention “failed therapies, if you can call them that.” We must call them that. We fail. We have failed therapies. We do our best, and sometimes our best is not enough. If you read psychotherapy research studies carefully, you will notice that EVERY single psychotherapy research study involves patients who did not respond to treatment. Psychotherapy research shows that about 50% of patients improve in therapy and 10-15% of them get worse! Fortunately, ISTDP is getting better results than that in our studies. But, ISTDP is still a therapy model, not magic. We do not and cannot claim perfection without failures.

Forgive my repetition about this, but I do it for a reason. All of us have a deep longing to heal those who suffer. Sometimes we even harbor a longing to save others. But therapy requires two people. Results in therapy are a form of addition: what I can do plus what the patient can do. Sometimes we can do a lot, sometimes a little, sometimes nothing at all.

Sometimes people will make magical claims for a therapy model, but we do not practice magic, we do not save people, we do not achieve the impossible. We do what we can in the time we have with the abilities we have with the abilities the patient can bring to the task. That means sometimes we succeed and sometimes we fail. And when we fail, we have the chance to learn from our failures so that future patients may be able to have results that we couldn’t have before.

That’s why the path of the therapist involves humility, the acknowledgement of our strengths and weaknesses, and guilt. When we fail, we feel guilt over not being able to do more. But the productive bearing of our guilt can mobilize us to study our work, analyze our videos, get some supervision and consultation, and then do better with our future patients. Admitting failure and bearing our guilt is part of the path for all therapists who love their patients enough to face the truth and the feelings it provokes. Sometimes, the truth is, we fail……like everybody else.

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