He dove beneath the deep, clear waves of the sea. Reaching into the mouth of the giant clam, he greedily – and unwisely – grabbed the pearl. But it was stuck. He twisted and pried, only to trigger the clam’s reflex; in defense, the clam closed up around his arm.

A seasoned pearl diver knows to resist his instincts: to stop struggling with the clam, release the pearl, and his hand will slip free. But this young diver wriggled and writhed, the clam defensively clamped down harder – and his fist, wrapped around the pearl, was too large to escape the clam’s jaws. [1]

My Story of Failing a Client

From Cindy’s pressed lips, lined with wrinkles that extended noticeably beyond her years, came exasperated concerns of torturous anxiety.

Deeper than her polite solemnity, there seemed to be a well of sadness. This sadness pervaded her down-turned lips, slow gate, and slumped posture. Cindy’s helpless presentation pulled at my heart-strings; in particular as a young therapist-in-training, I wanted to help. I listened empathically, encouraged her strengths, taught skills such as deep-breathing, and offered advice.

However, like clockwork, every 15 minutes Cindy’s down-turned, sad lips would slowly become pursed with frustration. Pursed like a toddler refusing a big spoonful of syrupy cough medicine. Shutting off, and shutting me out.

Her posture became rigid, her arms straight at the elbow with her hands braced upon her knees. She rejected my advice with the “yes, but…” response that is all too familiar to psychotherapists. Eventually, with every question or statement, Cindy would reply, “I don’t know.”

After a few sessions, the “I don’t knows” turned to complaints that therapy wasn’t helping.

Of course, therapy usually takes more than three sessions, but I was also aware of our impasse. To be certain, this was a challenge to the seedling of my professional confidence.

I responded, and probably accurately, “I believe beneath ‘I don’t know’ is a painful experience. If we want therapy to move more quickly, we have to process those experiences.” However, retrospectively, I recognize I was asking her to spontaneously relinquish her defenses. I had asked her to decide between giving up the comfort of her defenses and firing me. She fired me.

Why Did I Fail?

Yet, this goes beyond asking her to give up her defenses. I’ve come to believe that I inadvertently refused to play an interpersonal role I had unwittingly agreed to play. I had greedily and unwisely grabbed the pearl; my hand was stuck – and more stuck and I wriggled and writhed to get free – and her reflex was to defensively clamp down harder.

By offering advice to fix her life problems, I implied I would take responsibility for her well-being.

However, the problems impacting her well-being were not the life-stressors for which she sought advice, but rather it was ambivalence regarding interpersonal closeness. Cindy was the rope in a game of tug-o-war. She was only comfortable with arms-distance relationships: too close feels overwhelming and controlling, too far elicits feelings of stark loneliness.

Consequently, taking my advice would have been surrendering individuality, resigning to feeling controlled and uncomfortably enmeshed. Further, if she had taken my advice and it miraculously worked [2], therapy would end and she would be alone again.

She would have been alone again.

Like her childhood after the birth of her younger brother, when her parents love and doting eyes turned from her to the newborn. Alone like she was when she, “after nearly a decade of otherwise flawless marriage,” got cold feet and left spontaneously one afternoon. She was lonely and didn’t know how else to get the closeness she both desired and feared.

She was frustrated with this lifelong struggle with relationships – this was the underlying struggle that had shaped her plethora of ongoing life-stressors, such as her arguments with her boss and frustration with her friends who could not offer her the help she needed. Like everyone else in her life, it must have felt to her that I also couldn’t, or wasn’t willing to, give her what she needed.

In three sessions, I couldn’t fix anything. But I could have shared in her frustration; I believe she would have opened up to me if I had the wherewithal to simply say, “you know, I think we are both feeling the same frustration – no matter what we seem to do, it just won’t fix the problems you’re facing.” We were both stuck with our hand in a clam.

My Failure Helps Future Clients

I failed this client.

I couldn’t have met her needs with the skills I had at the time. I didn’t have the knowledge base to conceptualize her personality. But I had to experience this failure in order to help so many others. I feel bad I couldn’t do more for her, but appreciative for the inspiration I gained from this difficult experience. I was motivated to seek supervision and read many books that have allowed me to work more effectively with numerous clients since then.

Since working with this client, I have had the opportunity to experience my personal and professional uncertainties and many imperfections as strengths rather than weaknesses in psychotherapy.

This is something I am always working on: recognizing weakness of which I had not been aware, and attempting to grow from that awareness.

At times, using my shortcomings for the benefit of therapy might entail joining with a client on our feelings of being stuck and frustrated with a challenge we are facing together. At other moments, working with clients who have a brittle sense of self-esteem that hinges upon perfectionistic, grandiose ideals, accepting my imperfections and failures has given clients the space to face their own mere humanity.

Conclusion

And finally I’d like to share a memory from my work with a client who suffered for years with pervasive suicidal urges. Around eight months into therapy, we made a particularly notable leap forward in treatment. However, she responded, “but what now?” I knew she meant “but how do I stay alive?”

As if from deep inside me, from my emotion and gut rather than my head, my reaction was, “I don’t know.” At the time, we processed the uncertainty for a while. However, in reflection upon therapy, she found this single moment – the single statement that “I don’t know” – the most helpful experience in therapy. Her suicidality hinged upon not only her pessimistic uncertainty of the future, but also her sense she did not have the strength to overcome this uncertainty.

Yet, I could sit with her, and share with her, in this discomfort – this uncertainty.

More specifically, I could sit with this uncertainty, the fact that she would face real and immense hurdles, and I could be okay; to reflect simply in my affective expression I believed she could face these hurdles without the escape of suicide. Maybe she could believe in herself too?

At our final session, she referred back to an analogy of life being an open book: “I have pages to turn, and no matter what those pages hold, I’m going to finish this book.” We are all lucky to have an, albeit uncertain, future.

 

Thank you for reading the second installment in my three-part series on uncertainty and imperfection in psychotherapy (read Part I here, or Part III here). I hope this case report was thought-provoking and that you return to read the third and final article in my series – a discussion of uncertainty and imperfection based upon psychological theories.

Of note, the preceding case material was de-identified to protect the confidentiality of any individuals who influenced the writing of the report. Confidentiality has been ensured by changing names, any specific details that could possibly identify a client, and by combining case material from multiple clients that related to the topic being presented. However, it’s worth noting that this case report involves common human experiences with which many individuals can relate. If this case feels familiar to yourself or anyone you know, this is purely by coincidence.

 

Other Articles in this Series

Attention Psychotherapists…You’re Going to Fail. [Part I]

Uncertainty, Transference, & Other Reasons Therapists Might Fail. [Part III]

 


 

[1] I owe thanks to a supervisor of mine for suggesting the analogy of a pearl diver who got his hand stuck in a clam’s jaws.

[2] Offering advice didn’t help because it overlooked the underlying problem, which was ultimately relational.

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Jon Weingarden, PsyD

Jon Weingarden, PsyD

As the program director of the Integrative Health and Aging Program at Western Psychiatric Institute and Clinic of UPMC and Kane Glen Hazel's behavioral health residential nursing facility, I function as a clinician, an administrator and a manager. Prior to this, I completed an Internship at Carnegie Mellon University's Counseling and Psychology Services to finish my PsyD (Psychology Doctorate) program in Counseling Psychology at Chatham University.

Prior work experience includes community mental health at Staunton Clinic, UPMC's trauma and borderline personality disorders inpatient unit, multiple bipolar disorder treatment studies including light therapy and interpersonal social rhythm therapy, and at Chatham University as a doctoral student practicum site supervisor and TA for master's level statistics.

I practice from an integrated theoretical orientation informed primarily by Sullivanian Interpersonal Psychotherapy. This includes, but is not limited to, various psychodynamic therapies, Cognitive and dialectical Behavior Therapies, and Gestalt / Experiential approaches.
Jon Weingarden, PsyD