Accepting and Growing from “Bad Therapy” as a Young Clinician

In my third year as a graduate student at the University of Arizona in the clinical psychology doctorate program, I took a seminar course on supervision. As part of the course, the professor leading the seminar asked the class to read Bad Therapy: Master Therapists Share Their Worst Failures. ¹ The book is a collection of stories and lessons learned from some of the most prominent and well-respected psychologists in the field including Susan M. Johnson, the creator of emotionally focused couples therapy, Peggy Papp, a seminal figure in systemic family therapy, and Arnold A. Lazarus, one of the grandfathers of cognitive-behavioral therapy just to name a few. The table of contents reads like a who's who list of the most important clinical psychologists in the history of the field. As a young psychology trainee, it was truly humbling to read about some of the “failures” of these world-renowned clinicians and clinical scientists in their writings about cases that stuck with them for decades. After completing the book, I found myself wondering not if, but when I would have a case stick with me and haunt me; what case would be my “worst failure.”

During the second month of my clinical internship, I received a consult for a patient in his late 50s diagnosed with acute myeloid leukemia, experiencing depression and anxiety secondary to his cancer diagnosis. After receiving the consult, I completed a brief chart review and spoke with the referring provider to get a better sense of the presenting problem. I learned that this patient had no medical history, felt fatigued one day, went to an urgent care walk-in clinic, and ended up being hospitalized for three months, receiving aggressive chemotherapy. I also learned this patient suffered from severe anxiety around being in the hospital and was frequently seen by the inpatient consultation/liaison service to help manage his anxiety. In addition, this patient had an extensive history of substance abuse up through the day he was admitted to the hospital. During our intake session, the patient's poor eye contact, frequent fidgeting in his chair, and limited responses made his level of discomfort and anxiety palpable. The patient described himself as living “on the fringe” of society for the majority of his adult life and was now being forced into a world where he felt “less than” and “inferior” to those around him. Having experienced these feelings in my personal life, I truly felt empathy for this patient's situation and how difficult it was for him to be inserted into a world completely different than the world he had been living in the majority of his adult life. I imagined how scary it must have been to go from “the fringe” to the high-stress environment of a major hospital system.

The patient needed an allogeneic bone marrow transplant. However, given the patient's extensive history of substance abuse, he would not be eligible for a transplant until he had provided evidence of his ability to abstain from substance use. The patient's need for a transplant increased my sense of urgency as his therapist. I thought his physical well-being hinged on my ability to help him maintain sobriety. Using a motivational interviewing approach, ² I began our first session of psychotherapy exploring the patient's values and weighing the pros and cons of abstaining from substances. The patient seemed to be in the preparation stage of change ³ and I highlighted the patient's change talk along with his values. I became hopeful about the patient's motivation to abstain from substances and my ability as his clinician to guide him through the stages of change on way to his bone marrow transplant. Our next session was in the hospital because of an acute bacterial infection. The patient continued to use change talk and I was confident our work would continue to be fruitful. Unfortunately, this session would prove to be our last.

After multiple missed appointments and failed attempts to reach the patient, I had to terminate the case. I was able to speak with the patient over the phone on two occasions after termination and learned during these conversations that the patient had relapsed and was not actively seeking substance abuse treatment: a requirement set forth by the bone marrow transplant team to be eligible for listing. I also learned that the patient had left two infusion visits against medical advice and was shifted to a less aggressive form of chemotherapy because of his poor reliability, putting him at increased risk for poor prognostic effects. The patient apologized for relapsing and for “disappointing” me and the medical team. I found myself pleading with the patient, almost begging him to come back into therapy. I thought if I could just get him in the therapy room, I would be able to convince him to continue on with our treatment and work toward sobriety. My “righting reflex” and social pressure from knowing the gravity of the patient's medical situation clouded my ability to remain nonjudgmental and client centered. Despite the patient's extreme social anxiety and the chaos around his care, I had developed a bond with this patient. I connected with him on his feeling of being “on the fringe” and the experience of what it felt like being a stranger in a strange world.

Substance use disorders are difficult to treat and data on the effectiveness of psychosocial treatments for substance use disorders are equivocal at best. ⁴ In addition, there is a body of literature suggesting that depression and anxiety are risk factors for noncompliance. ⁵ My patient's history of substance abuse combined with co-occurring depression and anxiety, along with the psychological stress of cancer diagnosis, made him an extremely high-risk case. From a statistical standpoint, the odds of him completing treatment were low from the start regardless of my level of expertise as a therapist. However, I continue to ask myself to this day where I went wrong and how I failed this patient.

One thing I have learned during my clinical training is the importance of self-reflection in therapy. I find myself frequently reflecting back on therapy sessions and exploring what went well and what could have gone better. Usually, I am able to move on from the “what could have gone better” part of self-reflection by incorporating these changes into my next therapy session; however, I never had the opportunity to implement changes with this patient. I have had unsuccessful cases in the past, but this case seemed different than previous cases. Maybe it was the fact that the patient had a clear course of treatment paved for him with the potential of a positive prognosis on the other side if he were able to adhere to treatment recommendations or the lack of closure as his therapist. Maybe it was my personal connection with the patient's sense of being “an outsider.” Maybe it was the sense that I failed both the patient and medical team.

I understand from a logical, objective perspective I did just about all I could to help guide this patient toward treatment. Nonetheless, I still continue to find myself asking the question: what could I have done differently? Will this be the case that will come up 30 years from now when reflecting back on my career as my “worst failure”? I end this piece with a quote from the famous child clinical psychologist Dr. Violet Oaklander, “I think that if I can say I learned some things that I can apply to other…situations, then I can forgive myself. I don't become too hard on myself for those things. I have regrets, and I feel bad, but then I can learn. I don't beat myself up.” ¹ I believe we have to be kind to ourselves as clinicians and understand we will have difficult cases. The important part of these cases is to learn and grow from them rather than get stuck or fused with the thought that we delivered “bad therapy.” In that way, we honor the time and effort put forth by both ourselves and the patient.