Having studied my copious and countless clinical mistakes as well as the mistakes of others over the years, a few themes stand out, many resulting from what I call clinical myopia.
When I refer to clinical myopia, I mean the act of missing the forest for the trees, of glomming on to one principle and in doctrinaire fashion pursuing this course of action regardless of the bigger picture and the unique specifics of a given client that make up the bigger context.
The bulk of the mistakes and potential mistakes that I will discuss are errors with clients with lower ego-adaptive capacity with highly ego-syntonic character defenses — clients in the repressive and projective systems of resistance. However, I believe myopic mistakes are also relevant to client’s in isolation of affect with higher ego-adaptive capacity.
Most all of the blunders that I will reflect on pertain to not adequately considering the triangle of person and reenacting problematic relational dynamics with our clients as we try to apply a technique. Therefore these issues are relevant to all clients, no matter where they fall on the psychoneurotic spectrum. The actual and potential mistakes that I discuss by no means represent an exhaustive list, they reflect my opinions and my opinions only.
Because the clinical flaws were a feature, not just bugs, in my work for so long, I have developed an eye for them. I am far from ‘over’ them and find myself repeating versions of these mistakes often.
Though certainly not the only source of sub-optimal work, a prevalent theme is that of using the metric of a partial or full unlocking of the unconscious as the only measure of positive and meaningful therapeutic movement, resulting in what I call unlocking blinders.
This is what we do when we are so focused on trying to get a high rise of complex transference feelings and looking for unconscious signals in the form of striated muscular discharge of anxiety and latent content from the unconscious that we do not even listen to and hear what the client is actually saying. The relationship itself takes a backseat to the application of a technique.
With these blinders on, we see therapeutic movement only when there is fulsome experience of emotion and impulse. Communications from the client that involve defensive processes are typically seen as categorically maladaptive, and there is no understanding of how less than completely defense-free communications can represent openings and be used to solidify the conscious therapeutic alliance. These blinders create a myopic form of misguided perfectionism.
Examples (all case vignettes conceal identifying information):
Not seeing Openings, Pushing for More
How many times have I not pushed for more, rather than seeing what is there and capitalizing on it. A client who has never had a voice, had been chronically discounted and marginalized by his parents, and who has remained submissive in relationships throughout his life comes in for his weekly therapy session and, through an act of courage, shared that he had felt discounted by me in the previous session when I had questioned his helpless stance.
His standard chief complaints of brain fog and “not thinking clearly” are not present as he makes the announcement, but I miss the opportunity to help him see that what he did was an act of lowering his wall and being emotionally intimate. It wasn’t an unlocking, so I didn’t see it.
Fortunately I had good supervision and was able to go back and support the opening, which facilitated an emotionally corrective experience for the client who had been discounted by me not once, but twice when I did not support his announcement as the very act I had invited him to do all along — lower his walls.
By failing to see that the patient was actually communicating intimately with me, I stepped into the shoes of his mother who never noticed him and who continuously conveyed to him that who he was and what he did was never enough.
As this client could see that indeed his symptoms were in abeyance when he was clear about how he didn’t like what I had done — and isn’t that what anger essentially is, a felt sense of not liking? — he could see that the negative associations he had with anger and emotional closeness were not the same as the liberating experience in the office. I eventually came back to him and repaired my mistake, resulting in the overall experience being a positive one for him.
This positive experience for the client of having a voice with me became a reference point that helped solidify his understanding of why and how it helps him to be connected to himself and to have his feelings rather than avoid them, and it helped us begin to experientially differentiate feelings from anxiety and defense.
His motivation to engage in the therapeutic task increased. The client’s acknowledgement and announcement of a negative reaction he had with and toward me wasn’t an unlocking. It contained defenses. But it was enough of a passage of honest feeling that we could capitalize on it, strengthen the conscious alliance, help him see intrapsychic causality, and continue to make his defenses more ego-dystonic. Had I continued to discount the client because there were still defenses on board and pressed for more defense-free affect and impulse, I would have solidified the transference neurosis of embodying his mother.
This case illustrates how part of clinical myopia includes being focused on the triangle of conflict to the exclusion of the triangle of person.
Not assuming all Mistrust is a Defense
(and even if it is, don’t treat it as such until the client herself can see that it is a defense)
Another client with horrific trauma history, often taking a compliant role with me, one day lets on that she is fearful of letting me close because, “what if you use something compromising or embarrassing that I reveal to you, against me?”
Some clinicians see mistrust, regardless of context, as always a defense. This client was actually opening up and collaborating when she shared this mistrust with me. From a very early age, she had been betrayed by most all people in her life, and given this life experience, her concern was reasonable. We can call her mistrust a defense, a projection, but the fact is that her act of being forthcoming about this concern that had hitherto been hidden, was very much an act of collaboration.
Had I treated her announcement as a defense, cast doubt on her mistrust or otherwise questioned her position, it’s not hard to imagine that this would reinforce her perception of me as someone who brushes past her concerns and who cannot be trusted.
When I supported her communication and let her know that it was encouraging that she could be honest about this mistrust, and that glossing over it would probably not be a good idea, she told me, “See, I am already starting to trust you more, and that scares the shit out of me.”
Resistant Parts given a Voice rather than blindly Enacted can Redefine Intimacy
Another client, when I pointed out how she was being emotionally distant through a vague, noncommittal position, adamantly exclaims, “I am not going to sit here and be vulnerable, I am just not!” There was enough affect in this to reduce symptoms and render previously ego-syntonic defiance more dystonic. Helping her see her terror around emotional closeness and the conflict she was in, rather than jumping to pointing out the consequences of not giving up her resistance (an otherwise often very fine intervention), made her feel understood, her defiance softened, and projections that had made her see me as one more demanding figure in her life were undermined.
Furthermore, compared to her previously vague and noncommittal manner in which she related to me, her announcement of defiance actually consisted of an emotionally intimate communication. A myopic, perfectionistic view might see her announcement as merely the crystallization of resistance and the resistance becoming conscious, and though there is truth to this, it is not only this. Treating this communication from the client as also an intimate interaction, that in announcing her current position in this way, she was letting me know the depth of her dread and pain around previously disastrous experiences with depending on others. Vulnerability and defending on others, indeed had been previously catastrophic.
In conveying to her that she was actually being vulnerable with me in sharing her honest current position — and not allowing the fact that there was still room for far deeper levels of intimacy to get in the way — she could begin to redefine emotional closeness and vulnerability, and find that being open about what she was really thinking and feeling can have positive outcomes.
It’s not hard to imagine that had I simply done a head-on collision at this juncture, it could easily have reinforced projections and the opportunity to redefine emotional intimacy and strengthen the alliance would have been lost.
Collaboratively giving voice to resistant parts is not the same as blindly enacting and acting out resistance, and to stay open to this way of working with clients require giving up myopic adherence to technique.
Just being more Honest is the Breakthrough for Some
Another client with strong narcissistic features and a chronic tendency to lie experienced a lot improvement in our work from the intervention, “But if you are brutally honest now with me?” And he would share things he would normally hide, but without a fulsome experience of emotion and impulses.
A Baseball analogy comes to mind as I think of one of the principles that stand out to me as I reflect on these cases: If the unlocking is the home run, getting a client to first, second, or third base through recognizing and capitalizing on smaller passages of authentic psychic experience paves the way for sustained and eventually deeper work. The idea that we have to have a home run with every client in every session or we are not doing good work is a recipe for misalliances and taking the joy out of what we do.
Assuming that just because a client sighs (his skeletal muscle tissue can contain his anxiety and feelings are near the surface, although a sigh can also be a sigh of relief rather than build-up and discharge of anxiety) we need to ask or press for emotions. If the conscious alliance has not been cemented, and the client has no understanding of the connection between avoided emotions and his presenting complaints, automatically pressing for feelings is not always the most helpful thing to do and can even create a misalliance. In other words, just because a client has the capacity to tolerate added pressure does not mean it’s always the right intervention, the conscious alliance still needs to be in place.
The client is ready for more intensive work, needs unremitting pressure on his defenses, will, and towards the experience of his feelings, but the therapist does not engage in this more intensive work and ends up short-changing the client and slowing down the therapeutic process.
Inaccurate psychodiagnoses — a client with fragility engages in intellectualizing and self-reflection as a way to manage anxiety. This is helping her but we treat her as if she is not fragile and try to get her to turn against this defense, resulting in over-threshold anxiety and a misalliance.
When a client projects as a tactical defense, not brushing past it but bogging down the process with unnecessary exploration of the projections/tactical defenses.
Assuming that we should always ask and never tell, and assuming we need to hide our wish to help the client. It is often advisable to ask rather than tell, and to mitigate against an interpersonal conflict and facilitate an intrapsychic one instead by ensuring that the client’s will, not our own, be the engine of the treatment. There are instances, however, when it makes sense to declare our lack of neutrality, and there are instances when telling rather than asking gets it done.
Inspiration and Conclusion
With all this focus on mistakes, I like to reflect on sources of inspiration. My mind goes to Dr. Davanloo’s first phase of the Central Dynamic Sequence — Inquiry — which involves exploring the nature of the client’s difficulties and assessing the client’s ability to interact, do his or her part, and respond meaningfully to the inquiry.
When I observed Dr. Davanloo’s recorded sessions and when I read his transcript (all stages of therapy but particularly the inquiry part) I see a clinician who first and foremost tries to understand his clients, more-so than only applying a technique. In pouring over these transcripts and recalling his recorded work, part of what strikes me is that all the stages of the Central Dynamic Sequence, executed with incredible technical skill, seem to flow from the connection with and attunement to the client, creating a seamless flow.
In a sense, from the initial phase of inquiry of looking at what the problem is, specific instances that exemplify problem areas, to heavy pressure — all potentially capture the spirit of inquiry — what are the client’s most intimate thoughts and feelings? What is the nature of his or her defenses? In what contexts do they arise? What are we going to do about the obstacles? That does not say how you feel, how do you feel towards me?
When all interventions, even heavy pressure and challenge, come from the earnest wish to understand the client rather than change the client, we begin to turn a corner on the myopic clinical outlook.