TWELVE-YEAR-OLD BILLY hated needles and hated the clinic. But he had acute lymphocytic leukemia, which meant he had to tolerate both needles and the clinic. He came to see me (SL), accompanied by his mother, for help with his pain and anxiety around medical procedures. At first, he listened attentively as I discussed the situation with his mother; gradually, he became talkative and joined the conversation.
He agreed that he would like the pain and worry to be less but said, glumly, “Nothing will help.” I described how techniques that used one’s imagination had been helpful to other children and offered to help him in the same way. While I spoke with enthusiasm, I had to admit to myself that I had more than the usual doubts in Billy’s case. Yet, he agreed to try whatever I had to offer.
When we met the following day, Billy’s first comment was, “That tie you’re wearing is so ugly! Where did you get it?” He seemed startled and disarmed by my response: I looked down at my tie and told him that it was fun wearing ugly ties and asked him if he would like me to wear an even uglier tie next time. He laughed and said, “Sure. That would be fine.”
I noticed with only a little discomfort how smoothly, yet dishonestly, I had deflected his jab. The truth was, I liked my tie and I didn’t like a child challenging my taste. Even as I moved the conversation to his family, pets, and favorite TV shows, I vacillated between my sympathies for him and my anger at his impudence.
Anyway, I thought to myself, our work together isn’t psychotherapy; however, that’s what he needs—somebody with time and a sympathetic ear to listen to his fears and his anger. I began to feel hypocritical, focusing only on his reaction to procedures, when I imagined he must also be struggling with the larger question of dying. I felt a little embarrassed that my reaction had been so facile, sleek—and false. I began to resent Billy for being a part of my confusion.
Awkward and out of sorts, I brushed aside my jumbled thoughts and pressed on. When I asked him whether he could get a picture in his mind of a model train, which I knew he enjoyed, he told me he could, but that he didn’t want to. Furthermore, he had changed his mind and decided there was nothing that could help, so there was no point to our meeting anymore.
The truth was that he was right. And the truth about myself was that I felt angry and embarrassed at this dismissal. I continued to make “social calls” when Billy was admitted to the hospital. When I came to his room, he was always cordial and polite, but nothing of significance transpired. During the next several weeks his physical and medical status deteriorated very rapidly; about two months after our first meeting Billy died.
I wish that, at the very least, I had stopped to listen to his anger. If only I had said, “I’m sorry you don’t like my tie.” Then, instead of being witty, if only I had sat there with him in the midst of his fear and anger.…
At present, Billy’s needs and my mistakes seem painfully clear to me. But they weren’t then.
This chapter explores the experience of treatment failure. Until this chapter, the book has been primarily devoted to the description and exploration of various treatment approaches that are often successful in the treatment of pain and suffering. In fact, most of the clinical literature concerns apparently successful treatments. It is rare to find a discussion of a treatment that was unsuccessful. All clinicians are familiar with the experience of treatment failure, although most, psychotherapists in particular, rarely have an opportunity to discuss a failure with colleagues. In this chapter we describe some of our own treatment failures, in the hope that this will help you learn from your own experiences of failure.
All clinicians have the experience of treating patients successfully only some of the time. In fact, the same treatment is sometimes successful and at other times unsuccessful, depending upon … well, that is the question that interests us. What factors lead to therapeutic success, and what factors lead to therapeutic failure? And how much control do we have over any of these factors?
We are interested in exploring therapeutic failures, for four reasons:
1. We want to acknowledge that therapeutic failures are a natural part of clinical practice.
2. We hope that exploration of cases of therapeutic failure might help us identify the cause of the failure, so that we can learn from it.
3. We believe that acknowledgment of our therapeutic failures is a necessary step toward growth as effective clinicians, and we want to take that step and, perhaps, help others to take it as well.
4. Awareness and acceptance of our human limitations allow us to create a place of honesty, contact, and comfort for our patients and ourselves.
WHAT UNDERLIES TREATMENT FAILURE?
Is it the patient who fails to be successfully treated, or is it the clinician who fails to successfully treat? Or do these questions each miss the complex interaction between clinicians and patients? We will discuss instances in which perhaps it was the patient’s own limitations that undermined treatment and made failure more likely. It is important to identify, as early in treatment as possible, what a patient’s resources and limitations are. We will also discuss examples of our own limitations, as well as complex clinical circumstances, that determined the failure.
Like all of us, pain patients often have mixed motives when seeking treatment. Whereas the patient suffering acute pain is likely to be unambivalently motivated to seek relief, the patient who has endured pain (and treatment) over time has been changed by that experience, and part of that change is that simple relief from pain is no longer the patient’s goal. The pain patient suffers not only from persistent pain but also from the consequences of that pain over time: loss of work productivity—loss of job, even—and the economic disruption that follows; loss of a sense of worth; disruption of marriage and family; loss of social support from friends and coworkers; side-effects of medications; loss of general physical health from simple inactivity; and the psychological effects of these changes as well, particularly in the form of reactive depression.
The patient is often held in a disabling balance between secondary gains, on the one hand, and loss of function, on the other. Any change in the patient’s life, including reduction in pain, will necessarily upset that balance. Such an upset may be an opportunity for growth and development; however, if that balance serves to substantially satisfy the patient’s deeper psychological needs, the clinician is likely to encounter frustrating obstacles to treatment success.
Essential to the art of effective treatment is the clinician’s sensitivity to the balance we have just described and delicacy in promoting shifts that will upset it. Psychological techniques themselves have no inherent sensitivity; that is up to us. We can help the patient become aware of the balance and work toward shifting it. Since no clinician can be unerring in his or her sensitivity and judgment, we inevitably will encounter patients whom we do not help.
Can we become more prescient? Can we reliably judge, early in the evaluation or treatment process, if a patient is likely to benefit from our treatment? How do we determine when and how to correct our therapeutic aims and techniques, to better satisfy the patient’s needs? These are easy questions to which there can be no standard answers. In the pages that follow, we propose some tentative answers. Now, let us explore the unpleasant experience of therapeutic failure in some examples of patients whose suffering we failed to relieve. Perhaps there are lessons to be learned here.
CASE EXAMPLE: DOLORES, 34, WITH PAIN ON THE TOP OF HER HEAD
Dolores walked somewhat forlornly, I (JB) thought, into my office, dressed entirely in black, from her wide-brimmed cloth hat to her platform sandals. Dolores suffered tremendously from pain at the top of her head. She variously described the pain as “tingly,” “shocky,” “lightning-like,” and “burning.” Having been evaluated and unsuccessfully treated with cognitive-behavioral techniques at a pain clinic, she had been referred to me for hypnotic treatment of her pain.
The pain had begun some months before, when Dolores thought she noticed a loss of hair at the vertex of her scalp. (Examining physicians could find no significant hair loss.) Since she had dyed her hair a few days before noticing the loss of hair, she believed that her hair and scalp had been inadvertently damaged. She believed that surgery was the only solution to her problem, even though she was unable to specify how that might help.
Because Dolores believed that sunlight was particularly injurious to her scalp, she wore a circle of aluminum foil at the top of her head, secured with bobby pins. She always wore a snug-fitting hat over that, to make sure that no sunlight touched the top of her head.
Dolores was very certain that her scalp had been damaged beyond healing, and that no one was going to help her (except, perhaps, a surgeon).
The intake interview revealed that Dolores was happily married, had two children (aged four and one), and was aware of no source of tension or unhappiness in her life aside from the pain. (She always referred to this as “the pain on the top of my head.”) My judgment was that Dolores was entertaining a somatic delusion, which I regarded as a serious problem, but I was unaware of any other psychological symptoms. I did not arrange for psychological testing (as I ordinarily would do), because the pain clinic had already done that, and when I reviewed the evaluation sent from the pain clinic, I found nothing remarkable in this information. The medical evaluation found no cause for Dolores’s pain.
I was not sure what would help Dolores, but I thought that hypnotic treatment might serve either to reduce her symptoms or to offer diagnostic information about an alternative approach. Though she was not confident about my ability to help, Dolores consented to treatment, and we agreed that she would return several days later. As she left, however, she reminded me that surgery to remove the “damaged tissue” was the only sure cure.
When Dolores returned for her next visit with me, she was dressed, again, in a striking black outfit, except now she wore bright red boots. This sartorial development seemed significant, although I did not know why. Dolores responded readily to my suggestions for hypnotic induction and demonstrated a variety of hypnotic phenomena, including responses to posthypnotic suggestion. Among the suggestions I offered were those for feeling generally more comfortable and less distressed about the “pain on the top of your head,” and for noticing that the sensations would wax and wane, progressively toward less intensity. Afterward, she seemed alert, clear, and pleased with the hypnotic experience. We arranged to meet two days later.
When I saw Dolores two days later, she was still wearing her black hat, a black blouse, and a black jacket, but now the black pants were replaced by red ones, which matched her red boots. This was very striking, but I still did not know what, if anything, to make of her clothing choice.
Dolores reported that she did not feel substantially different from the way she had felt before treatment. Unfazed, I again offered hypnotic suggestions for feeling less bothered by the pain, for feeling curious about the way sensations on the top of her head would begin to change, and for reductions in the intensity of the pain. Afterward, she indicated that she was feeling better. Although the pain was still present, it seemed a little less intense, and she was “a little” less worried about it.
Four days later, Dolores arrived for her next appointment wearing still more red. Now only her blouse and hat were black. Although I had not thought she was depressed, I did wonder if this change from black to red indicated a shift to a less dark mood. Again, she reported that she was not feeling substantially different, although she certainly sounded less obsessed by, and less bothered by, the pain at the top of her head. Further hypnotic suggestions were offered to add to the hoped-for effects of being less troubled by the pain and experiencing it as less intense. We agreed to meet four days later.
As you might predict (though I did not), when Dolores arrived for this appointment, there was no black to be seen among her clothing. She was dressed entirely, strikingly, stunningly—beautifully—in red. I mentioned that I noticed she was not wearing any black, and she replied with a laugh, “I guess it’s working, isn’t it?” Yet she continued to insist that the pain was precisely the same as when we had begun treatment; she did say, though, that she did not think about the pain as much.
This last report seemed to me to indicate that we were moving in the right direction, therapeutically. For, even if pain sensations are present, if she were less bothered by the pain sensations, she would suffer less, and she could turn her attention more readily and more fully to other things in her life. I offered more suggestions, building on the premise that she could continue to be less bothered by the feelings on the top of her head. And we agreed to meet again, three days later.
However, Dolores must have privately had other plans. The next day, Dolores saw her husband off to work, her son off to daycare, and asked a neighbor who often baby-sat to take care of her one-year-old daughter while she “went shopping.” She then apparently returned home, thoroughly cleaned the house, and then lay back in her bed and shot the top of her head off, using the .38 caliber pistol that she and her husband kept for protection. My first thought, on hearing this news from her husband, was that she had finally performed the surgery she insisted would be the only effective remedy—she had removed the offending sensations on the top of her head. My second thought, though, was a little less deft: Surely, Dolores did remove her pain but at terrible cost to herself and to her family. What might I have done to relieve Dolores’s suffering? Why did her treatment fail?
Subsequently, I learned that the psychologist at the pain clinic who had referred Dolores to me had felt quite hopeless about Dolores’s prospects for treatment. Others on the treatment team in the clinic had felt similarly at a loss. No one had seemed to know how to “get through” to Dolores.
Later, as I thought about Dolores, I wondered if we had all overlooked the implications and possible consequences of her delusional disorder. Why had we not considered the possible benefits of neuroleptic medication? If Dolores’s beliefs about her pain had been affected by such medication, and if the energy she spent in obsessing about the dysesthesia on her scalp could have been focused on other issues, perhaps her pain would have abated and she would have been able to benefit from treatment combining psychotherapy and medication. Unfortunately, we will never know. Her husband characterized Dolores as having died from a “terminal illness.” Perhaps this is so.
CASE EXAMPLE: PROFESSOR ADAMS, 52, WHOSE HEAD HURT
This geologist and well-known member of the faculty at our university was referred to me (JB) by his neurologist, a headache specialist, with a letter indicating that his case was a puzzlement, but that she thought Professor Adams was “tense” and might respond well to “hypnotic treatment to promote relaxation.”
Professor Adams complained of pain that had been diagnosed by the neurologist as “atypical muscle tension headache.” Atypical—the word covers a lot of unknown territory without yielding much information. I was a young psychology intern and did not yet have the confidence (or the competence) to ask the neurologist for further information. It would have been helpful to have a clearer understanding, at the outset, of the etiology of Professor Adams’s headaches.
This referral reflects a misunderstanding about the nature of hypnotic treatment, namely, that it is a “relaxation technique.” As Banyai (1980) and others have reported, relaxation and the hypnotic experience are independent phenomena. Moreover, the notion that relaxation will effectively treat pain is a notion unsupported by any evidence that I know of. Even if a patient’s pain is the result of muscle tension (which is usually the case, of course, in musculoskeletal syndromes), reducing that tension merely for the duration of a treatment session is of little benefit.
In any event, I accepted the referral of Professor Adams with the hope that I might create at least temporary analgesia. (What truly was “atypical” about his headaches was his characterization of them as “unrelenting, unvarying, and unceasing”—such lack of variation is extremely unusual.) I believed that if he could have even a momentary respite from the pain, such relief might create a psychological space within which to place a therapeutic lever, so to speak, in order to create real and lasting treatment gain.
Professor Adams was cooperative but totally unresponsive to my suggestions. I can still see him looking at me, levelly and cooly, as if he were waiting for the show to begin. He was unceasingly polite, he was affable, he did whatever I asked of him, but nothing happened. For example, I suggested that he imagine being in a pleasant sunlit meadow. When he was sitting quietly, eyes closed, I asked him, what he saw in his mind’s eye. He said he didn’t know about his mind’s eye, but his eyes could see only “the insides of my eyeballs.”
Day after day we met. We went through hypnotic procedures, he endured my probing questions about what psychological issues might be involved in the headaches-with no effect at all, aside from my growing consternation (and perhaps his own frustration, though he did not reveal this).
Finally, on the ninth visit (the eighth treatment visit), Professor Adams said, “I thank you for your attempt to help me. I think, though, that this will be my last visit.” I did not object to his decision; after all, we seemed to be getting nowhere. I would have liked to offer him an alternative, but I really did not know of one. That was the last I saw of him, except in my thoughts, where he has appeared occasionally through the subsequent years, stimulating questions in my mind about how I might have helped him.
Many would argue that the problem was a simple one of hypnotic responsivity. Perhaps they would be correct. What is clear to me is that I never really touched Professor Adams, either physically or psychologically, let alone hypnotically. I do not know what I might have done differently, except perhaps to begin a conversation with him about my sense that I was not touching him. Perhaps that conversation might have been of interest to him.
CASE EXAMPLE: MR. BUTTERWORTH, 79, WHOSE MOUTH HURT
Mr. Butterworth was an exceedingly charming gentleman, a retired art dealer of substantial means, referred by his dentist (a practitioner whose reputation for fitting dentures was exceptional). Unfortunately, Mr. Butterworth’s dentures were very painful to him. He was a very handsome man who dressed in a very elegant, “old-world” style, and it mattered to him a lot that he look his best, which he could not without wearing his dentures, but they hurt too much to wear for more than very brief periods.
My (JB) initial conversation with Mr. Butterworth revealed that he fully expected that I would take out a gold watch and use it as a pendulum, commanding that his eyelids would close and his dentures forever after feel terrific. When I told him that, if I used hypnotic methods, they would probably bear little resemblance to what had passed for “hypnosis” at a night club he had attended, he graciously accepted my explanation and consented, perhaps a little begrudgingly, to cooperate with the remainder of the intake interview.
What was most apparent from the interview was that Mr. Butter-worth had a narcissistic style of relating to me, which fended off any real emotional contact; he was, nonetheless, insistent that we “get on with the hypnosis” so he could wear his teeth. Also, Mr. Butterworth was very forthright (after reminding me that our conversations were confidential) in letting me know that he still lived “an active romantic life” and enjoyed the company of several young men, an important reason for him to look young and handsome. It was really essential to him that he wear his dentures painlessly and, in his words, “discreetly.” In addition, Mr. Butterworth told me that, although he had officially retired over a decade previously, he was involved in several business and charitable ventures, some of which would require 15 to 20 more years of his life for fulfillment. He had no intention of leaving this work unfinished.
It was clear that Mr. Butterworth was denying his age a bit and that the denture problem was an obstacle to that denial. Here is a clear example of how the meaning of pain determines how one copes with it. The denture pain reminded Mr. Butterworth of his advancing age, and such a reminder was itself painful. It is worth noting that, while hypnotic analgesia might well reduce the physical discomfort of dentures, it cannot affect the emotional discomfort of unwanted aging.
Mr. Butterworth was very responsive to hypnotic suggestions; moreover, he was amused at his responsiveness and enjoyed the experiences of arm catalepsy, anesthesia of his mouth and jaw, response to posthypnotic suggestion, and reversible amnesia. (While it is rarely appropriate to demonstrate these phenomena in a clinical setting, I believed the experience would lend him confidence in me and the treatment we were undertaking. Perhaps this demonstration lent me confidence, as well.)
Curiously, Mr. Butterworth was responsive to relevant suggestions, over several treatment appointments, for experiencing comfort in his mouth when wearing his dentures—but only while he was hypnotized in my office. Afterward, he began to feel increasing discomfort from his dentures, so that, after only five minutes, they were as painful as they had been prior to the treatment. He said that the use, at home, of a tape recording of his successful hypnotic experience in the office was “hopeless.” As he elaborated on this, it became clear that the prospect of actually listening to the tape recording at home made him agitated, and so he avoided doing so.
Finally, after the sixth treatment appointment, I received a letter from Mr. Butterworth, in elegant handwriting, on beautiful stationery, thanking me for my kind efforts and indicating that he would be traveling out of the country and would “unfortunately be unavailable for further visits with you.” Telephoning him at home, I thanked him for the note and expressed my disappointment that we had not been more successful. He was his usual gracious self, expressing (somewhat exaggeratedly, I thought) gratitude for my patience, my kindness, my thoughtfulness (not my effectiveness, unhappily), and wished me luck in my future ventures.
I thought then, and I think now, that if I could have helped Mr. Butterworth to feel more accepting of his aging, I would have stood a better chance of helping him with his dentures. But somehow I was not able to initiate an exploration of that important issue.
Although Professor Adams and Mr. Butterworth had different underlying psychological issues, in retrospect I noticed a similarity. In both cases, these men seemed to be cooperative, and in both I had the impression that they were motivated for pain relief. Unfortunately, it seemed that nothing I said or did really made an impact upon either of them. I am now aware that something about the way I related to each man created an inhibition in me around discussing what may have been a key issue. (In Mr. Butterworth’s case, for instance, his aging was a relevant issue, but I felt inhibited to discuss it by his seamless denial of it.) I choose to take this lesson from the experiences: When the pain symptom is not responding well to treatment, this may suggest exploration of the meaning of the pain, or of other, perhaps less obvious psychological issues about the pain, or about the relationship between the patient and myself.
CASE EXAMPLE: MS. WILMINGTON, 46, AND HER PAIN IN THE NECK
Ms. Wilmington was a CPA, divorced, without children, who lived by herself. She came to see me (SL) because of recurring pain in her neck, shoulders, and face. She had already been evaluated by three internists, two neurologists, an ENT specialist, and an orthodontist. She had been given a variety of diagnoses, including trigeminal neuralgia, atypical facial pain, cervical neck strain, and psychogenic pain syndrome.
An MRI of her neck had demonstrated some deterioration of the cervical spine, which could have accounted for some of her symptoms (though not all). She was also noted to have a mild to moderate kyphosis of her spine, which could have contributed somewhat to the symptoms. She noted that these symptoms were worse in times of stress and fatigue and seemed to improve when she was well rested; however, they never went completely away. In fact, even when she was at rest, without any obvious signs of great stress, she continued to have the pain. She described it as a mixture of severe aching with an overlying sharp, stabbing quality that was recurrent and unpredictable. This pain would sometimes attack her shoulders and neck; at other times, it would stab upwards into her jaw and even radiate into her face. Sometimes it seemed to almost explode into her cheekbone on the left side, the explosion sometimes lasting for two to three seconds. On occasion, this pain had been so severe that it caused her to drop to her knees and burst into tears.
Various medical regimens had been tried with little or no success. The side-effects of some of these seemed to her to outweigh any possible benefits. Ms. Wilmington was a pleasant, intelligent woman with a witty sense of humor. For the past three years, she had carried the burden of an older sister who was suffering from multiple sclerosis, and who was also divorced; the two sisters had depended on each other for emotional support and companionship through their difficulties and now, as the sister’s condition worsened significantly, she had moved in with Ms. Wilmington. With the help of a live-in housekeeper, she took care of her disabled sister.
When I suggested the possibility of using therapeutic techniques based on the power of her imagination, she was willing to give it a try. She listened intently and complied with all of the requests and suggestions I made; however, none of the suggestions or images seemed to relieve her pain. She reported that it was very pleasant to be so relaxed, and that she enjoyed the beautiful images; on the other hand, she was disappointed that such a pleasant intervention, which had apparently been helpful to other people, did not result relieve her pain.
We continued to try a variety of different suggestions, relaxation techniques and images, both in the office and at home, including many of the suggestions found on standardized scales of hypnotic responsiveness. She accomplished most of these items easily, reflecting her considerable hypnotic talent. She appeared to be very dedicated to trying new techniques and, in spite of repeated failure to achieve a reduction in her pain, continued to express considerable optimism that a different approach might be helpful, even if only a little bit. Yet, while she was able to sleep better at night and she found that she was more relaxed in the day, she continued to suffer from pain.
I was puzzled that Ms. Wilmington was not more disappointed that her pain was not diminished. On the one hand, she was obviously suffering and sincerely hoping for relief; on the other, she appeared to react to this therapeutic failure with unsettling equanimity—as if failure were the only expected outcome.
How curious it seems to me, in retrospect, that I did not explore her wishes and feelings more. (Perhaps her burden of caring for her sister was not accepted unambivalently; perhaps it was an unacceptable burden, but one she did not know how to put down.) At the time, I experienced her as rather stiff and awkward; ironically, however, as I look back on our interaction, I see the same awkward reserve in myself, which inhibited me from addressing the potentially problematic issue of her apparent lack of concern about the failure of therapy. I can only presume, then, that Ms. Wilmington and I contributed jointly to this failure.
CASE EXAMPLE: MR. JACKSON, 42, ALSO SUFFERED FROM PAIN IN THE NECK
Mr. Jackson came to see me (SL) for chronic neck pain. He had received multiple medical evaluations, as well as various types of treatment, for this neck pain, which had been variously described as cervical neck strain, myositis, and fascitis. Treatment modalities had included various medications, massage, physical therapy, and acupuncture; the workup had included evaluations by neurologists, x-rays, and an MRI.
Mr. Jackson was a very pleasant, mild-mannered man, who smiled readily. He struck me as a man who seldom had strong feelings about anything. He did not even seem particularly frustrated by the long and so far futile attempt to treat the pain in his neck. His work was described as satisfactory, varied, and quite rewarding. He had married in the last 12 months and described his relationship with his wife in the same somewhat bland terms that he used to describe everything else, so it was difficult to know whether or not there were strains in their relationship. He did not appear depressed and there were no indications of depression in his history.
Like other complicated pain patients, Mr. Jackson was referred to our pain clinic. Several sessions ensued during which a variety of treatment modalities, including relaxation, exercises, biofeedback, and again, various medical modalities, were attempted without success. After he was seen by a psychotherapist for several sessions, neither he nor the psychotherapist felt that there was any need to continue.
When Mr. Jackson raised the possibility of hypnotic treatment, I agreed to try this with him. At the end of one session, he reported that it was very pleasant and that he had felt considerable reduction in the discomfort for a few seconds at a time. Though it was a minimal change for him, he was eager to try further treatment.
During the second session, he brought his tape recorder and recorded our meeting. At the third meeting, he reported that he became very relaxed while listening to the tape. He seemed enthusiastic about this—in spite of the fact that it did not relieve any of his pain. After a fourth session, he stated that he did not feel any more sessions would be helpful to him, so he discontinued treatment.
I continue to be puzzled by Mr. Jackson. I imagine that there was another, perhaps more important problem waiting to be discovered, attention to which may have helped to resolve his suffering. But he didn’t tell, and I didn’t ask.
What causes our reluctance as clinicians to ask certain questions? Probably many of the same factors that are a discomfort to us outside our professional roles: fear of hearing an answer that may be too embarrassing, fear of upsetting someone, and fear of setting in motion interactions that are otherwise too challenging for us. We take an easier path, one that is, unfortunately, less helpful to many patients, focusing almost solely on symptomatic relief and excluding more troubling and difficult aspects of the therapeutic relationship.
WHY DO WE FAIL?
What can we learn from reviewing these cases of failed treatment? Let us first face what we find most difficult to acknowledge: As imperfect humans, we sometimes fail and will continue to do so, no matter how hard we try to succeed. Even if both patient and clinician do the best they can, the treatment will sometimes fail. We must acknowledge our fallible humanity, not with dismay or shame, but with benevolent acceptance—just as we encourage our patients to do.
In each of the cases we have described, we failed to “reach” the patient. (Perhaps the patient felt that he or she failed to “reach” the clinician.) Even though the contact was friendly, even though the patient seemed genuinely motivated to be free of pain, even when the patient apparently cooperated with treatment, we felt as if we were being politely, sometimes even graciously, kept at a psychological distance. In each case, we must have contributed to that psychological distance as well, even if we cannot identify our contribution. This distance prevented the therapeutic contact needed for change; somehow we were not able to breach the distance.
Which raises the question: What is necessary therapeutic contact? What qualities are required of this contact to make it therapeutically effective? The cliché that the patient must trust the clinician is obviously true, but what, in the contact, establishes such trust? And what prevents its natural development? What is it about our contact with some patients that even raises this question, when with other patients there is no question? What does it take for us to raise an issue that may be very uncomfortable for both patient and clinician?
We know, of course, that some patients are very easy for us to treat. The ease is not a function of their clinical syndrome (though, obviously, some syndromes are easier to treat than others). Upon close inspection, it appears that the ease is dependent, in part, upon our own easiness. We feel comfortable, self-confident, and competent with some patients. The feeling is not about our ability to treat a particular syndrome; rather, some quality of the clinical interaction that develops, quite soon in most cases, establishes this feeling within us.
When we feel comfortable, self-confident, and competent with a patient, we are more likely to say what we think needs to be said and to do what we think needs to be done. In the opposite case, unfortunately, we do not. We may not even be aware, except in retrospect, of what we need to say and do. Perhaps this hesitancy is key to understanding the subsequent treatment failure.
This feeling of being comfortable with a patient is difficult to describe fully and accurately. It is opposed to anxiety, intimidation, and powerlessness, which we often experience with difficult-to-treat patients. It is freedom to fully be ourselves with a patient. As such, it may be impossible for a young intern to achieve in the presence of an older patient who conveys a lack of confidence in the clinician.
And yet, this is not the full answer, for, with some patients whom we fail to treat, we may feel comfortable and confident yet have the sense that we are alone in the room, as if the patient is not present with us or does not experience us as present. It seems that the patient does not apprehend us, does not appreciate what we have to offer. The patient may have trouble feeling confident in us, for reasons both real and transferential, and experiencing the safe refuge of our consulting room. Although we wish the patient to feel free to fully be him- or herself, relieved of the ordinary pressures and burdens of the outside world, this freedom is not successfully created or conveyed by us or experienced by the patient (or by us).
We intend to continue to gather material and to one day write a more detailed commentary on issues of failure. Meanwhile, we hope that our discussion here will inspire you to explore what you know, and what you do not know, about the patients with whom you have experienced failure. More, we hope that you will be encouraged to seek consultation with colleagues as a routine part of your professional life. Such opportunities for greater self-awareness are a primary means for personal growth, professional development, and clinical competence. As you think creatively about this issue, perhaps you will have ideas that will lead to more satisfactory future contacts with patients—difficult patients and easy patients both. And, of course, all those patients in between.