On The Importance of Treatment Failure

When we hear the word ‘failure’, most of us reflexively conceive of it in negative terms. Yet the reality is that all of us are born and bound to fail – and to fail repeatedly – throughout our lives.

When patients consult with us for therapy, our initial instinct is not to contemplate failure, but to avoid it – to strive for success, to conscientiously attempt to foster growth along the axes on which progress has come to a halt, to stimulate healing and maturation. And on rare occasions, treatment of this sort appears to be a fairly straightforward enterprise. The questions, interpretations, guidance, and direction that we earnestly supply our patients with turn out to quickly and effectively untether them, allowing them to summon their inner strengths, desires and ambitions, to re-experience psychological vitality and recommence growth.  

More commonly, however, we will find ourselves running aground at various junctures during treatment, and become frustrated by our lack of influence. Well-thought-out recommendations are rejected, or not followed through on. Assignments designed to augment insight or trigger improvements are abandoned or repudiated. Patients seem to do everything in their power to thwart us, to render us impotent. As a result, we start to feel like we are failing, that we are not making good on our commitment to help resolve the problems that brought them into treatment, that we are letting them (and ourselves) down by not fulfilling the promise of advancement upon which the therapeutic structure is supposedly built.   

A standard and prevalent rejoinder to these feelings of frustration – and a legitimate one – is to work harder to uncover or discover the strategies that might lead to what we would define as successful treatment. 

This response to our uncomfortable confrontation with clinical futility is, of course, embedded in our desire to help the patient, to do right by him/her. But it is also – and just as significantly – embedded in our desire to quell the feeling of clinical futility. Helplessness is one of the most discomfiting of all emotional states, and we generally, and naturally, do everything we can to offset it.

When I am supervising clinicians who are feeling stymied by their patients, I am always supportive of their dogged efforts to find the right formula that will yield clinical success. But if and when those dogged efforts repeatedly get derailed, the supervisee and I begin to have a conversation about his/her own feelings of powerlessness, and how to simply marinate in those feelings as a way of making sense of them – and making peace with them.

Because the reality is that our most frustrating patients can generally be understood to be titanically successful at one particular endeavor, which is making us feel as frustrated as they are.  From my perspective, it is a tremendous accomplishment on the part of therapist and patient when they reach the threshold at which they both feel like failures. This tells me that each of them is doing their job – the patient is working hard to express and articulate what it is like to feel like a failure, and the therapist is attuned and empathic enough to respond to this (either privately and/or interactionally) with his/her own feelings of being a failure.

In a paradoxical way, clinical success, from my vantage point, hinges on the capacity to acknowledge failure – because when we acknowledge our failure, we acknowledge our humanity, and when we have the patience and courage to experience shared failure, we acknowledge our shared humanity, which leaves us feeling a little less alone in the world.

Psychotherapy is unique amongst clinical enterprises in that failures in treatment, when understood and managed well, can actually serve the needs of the patient as well as the practitioner. Our capacity to fully experience, rather than to fretfully sidestep, feelings of futility, helplessness and despair when we are in therapeutic contact is one of the great gifts that we can offer those who consult with us. 

The reality is that experiencing a sense of wholeness, self-respect and self-assuredness requires us to learn how to handle defeats without becoming self-defeating, and without becoming defeatist. Joining our patients in conjointly experiencing, and sometimes conjointly acknowledging, communal feelings of failure doesn’t guarantee immediate clinical success in the form that the patient and therapist may have initially had in mind when treatment commenced.  But doing so does create a unique and surprisingly habitable soil in which a deeper, warmer sense of self can begin to take root for all participants. Success that is rooted in failure often turns out to be the most enduring success of all.