Abstract
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If that decision already sounds a little precarious to you, then you're on the right track, but if opening and reading from the DSM-5 in session sounds like a perfectly sensible idea, then hopefully my candid experience can provide you with a useful insight or two. After two sessions, my patient decided that she would be better off working with someone else. Of course it is not uncommon for patients to wait to commit to long-term therapy until after a trial session or two gives them the chance to feel they have a strong personality fit. Thus, on a rational level it was easy for me to accept that I had simply overestimated our chemistry. However, she made her decision without informing me and it stung when I became aware of her decision indirectly. I might not have ever known why she stopped scheduling sessions, but she had asked to work with my supervisor instead.
“Really?! Things were going so well, I thought.”
“I mean, I've been dumped before… but this? This came as a total surprise.”
“Did she want me to be an expert? I wasn't going to fake it.”
“This is just what I get for heeding that age-old advice: ‘Just be yourself’.”
“What had I done to undermine her confidence in me? Was it something I couldn't change like my race, my gender, my age, or my lack of hair? Or, perhaps more frightening, was it my willingness to be vulnerable?”
I suppose reading down lists of symptoms in the DSM-5 didn't exactly inspire confidence in my ability to be helpful. The way I saw it, reading each item so literally was a way to illustrate the rigidity of the diagnoses labels, while giving her an opportunity to accept or reject each container as she attempted to fit her experience within them. I read each item with a playful and gently sarcastic tone, attempting to lighten what could have otherwise felt like a threatening process. This felt like the safest way to operate considering I had no previous experience making official diagnoses.
Despite my best intentions, I faltered in part because I had not fully appreciated the context to my patient's desperate state. She had lost her mother to cancer and was now facing a potentially lethal cancer of her own. A woman in her early 20s, she was facing a cancer of unknown etiology and was experiencing poor symptom control. She was used to tackling life head on and identified herself as driven and structured. Her cancer and pain experiences were robbing her of the ability to experience achievement, a sense of control, or even basic social participation. Death was chasing her down and had just laced up a new pair of sneakers. On top of all this, she had described an unsatisfactory experience with psychotherapy in the past, which required more patience of her than she was willing to give. She was experiencing a lack of certainty in her health and I was experiencing a lack of certainty in finding an honest and personalized way to be helpful. To her, my relatively unstructured, transparent, and inquisitive style did not help her to trust that I could be helpful.
From my perspective as a young therapist, enriching psychotherapy is not performed with hermetically sealed protocol. Therapy is practiced in a space created by the patient and therapist together. This space is constantly evolving, growing, and requires that a patient and a therapist be willing to navigate a great deal of uncertainty and discomfort together. Just as the patient is provided with an opportunity to develop an expanded repertoire of perspectives and behaviors, the therapist grows just the same. Just as the therapeutic relationship can serve as a model for the patient to draw from, the therapist too evolves in her practice and this is one reason why extensive training has been so vital to my professional development. In this example, however, I learned that being transparent about my learning process blurred the lines of professional boundaries and prevented me from being effective. Inviting my patient into my professional process, though genuine and well intentioned, wasn't appropriate given what uncertainty she was experiencing at the time. This approach might be effective for some client experiences, but the combination of our uncertainties did not allow us to develop a space of mutual trust.
One of the primary lessons I drew from this experience was that not every patient finds comfort in a completely transparent version of this mutual development. Some patients find more comfort in consulting with an expert and might prefer a therapeutic relationship with a less equal power dynamic. Discovering to what exactly the patient is well suited is often subtle and complex. Many patients may have never explicitly considered such power dynamics, let alone be asked for their preference in the matter. Thanks to experiences like this, with equal measures of success and failure, I continue to adopt clearer boundaries and find that within more well-defined spaces, there are even greater opportunities for vulnerability.