The power of Arnold Goldberg’s approach in The Analysis of Failure: An Analysis of Failed Cases in Psychotherapy and Psychoanalysis (Routledge) is twofold. First, if a practice or method cannot fail, then can it really succeed? If a practice such as psychoanalysis or dynamic therapy can fail and confront and integrate its failures, then it can also succeed and flourish. Such is
the point of Karl Popper’s approach to the philosophy of science in Conjectures and Refutations. For those who have not heard of hermeneutics, narrative, and deconstruction, and who are still suffering from physics envy, the natural science have advanced most dramatically by formulating and disproving hypotheses. Natural science is avowedly finite, fallible, and subject to revision, advancing most spectacularly within the paradigm of hypothesis and refutation by failing and picking itself up and pulling itself forward. The Analysis of failure is inspired by this lesson without engaging in most of the messy details of the history of science. Second, for a discipline such as psychoanalysis (and psychodynamic therapy) that prides itself on the courageous exploration of self-deceptions, blind spots, self-defeating behavior, and the partially analyzed grandiosity of its practitioners (and patients), the well worn but apt saying “physician heal thyself” comes to mind. The professional ambivalence about taking a dose of one’s own medicine upfront is a central focus not only in psychoanalysis (in its many forms) but in related area of psychiatry, psychopharmacology, cognitive behavioral therapy (CBT), social work, clinical psychology, and so on. Goldberg’s openness to alternative conceptions and frameworks along with his exceptional knowledge of and commitment to psychoanalysis (and self psychology) is an obvious strong point.
As a former colleague of the late Heinz Kohut, Goldberg studiously avoids (and indeed fights against) adopting the paranoid position with respect to failed analytic and psychotherapy cases – what’s wrong here? When a therapy case fails (the determination of which is a substantial part of the work) a series of blame-oriented questions arise: What’s wrong with the patient? What’s wrong with the therapist? What’s wrong with the treatment method(s)? What’s wrong!? And, yes, these questions must be engaged; but, Goldberg demonstrates, they must be put in perspective and engaged in the context of a broader question What is missing the presence of which would have made a difference? The answer will often, but not exclusively, turn in the direction of a Kohut-inspired interpretation of sustained empathy.
This leads to the part of Goldberg’s argument that is explicitly humorous. Having announced a case conference on failure and invited all levels of colleagues, Goldberg reports the casual laughter of many colleagues as they announced that they had no failed cases and so could not be helpful. “One person agreed to present but the following day he yelled across a long hall that he could not and quickly walked away (p. 41). The list of excuses goes on and on, producing a humorous narrative that is definitely a defense against just how confronting the whole issue really is. Less humorous and more problematic is what happens when a case comes to grief and the candidate reportedly does exactly what the supervisor recommends. How one would know what is the “exact recommendation” is hard to determine, but relations of power loom large in such a triangular dynamic. Even Isaac Newton acknowledged that the “three body problem” of the (gravitational) relations between any three bodies is theoretically computable but practically intractable. The number of variables changing simultaneously is such that we are dealing with expert judgment rather than algorithmic results.
For my part I cannot help but think of the process for airline pilot reporting of errors in procedures, operations, and maintenance. Yes, pilots are part of a complex system and “pilot error” does occur – pulling back on the stick to get lift rather than pushing down – yet they are usually given more training and rarely blamed or faulted, absent illegal or blatantly unethical conduct (e.g., drinking on the job). Goldberg calls for an ongoing case conference inquiring into failed cases, and thereby implicitly calls for taking our thinking to a new level of professional rigor, encompassing scientific objectivity that is consistent with talk therapy being a hermeneutic discipline. One might call it looking at the entire system, but not in the sense of family therapy –rather in the sense of the total professional-cultural-scientific milieu. However, Goldberg’s approach differs decisively from a Check List Manifesto (a distinction not in Goldberg (he does not need it) but abroad in the land and by a celebrity MD, Atul Gawande) in that individual chemistry looms large between the therapist and the patient. In analysis or therapy, the number of unknown variables in fitting a prospective patient to a prospective treatment (whether analysis, therapy, psychoparm, CBT, etc.) is so large as to be nearly intractable. These are areas where we simply lack the super-shrink who has mastered the basics of all these methods and can make an objective, upfront call of what just might have the best odds of a favorable outcome without the usual trial and error. For the foreseeable future, mental health professionals can be expected to continue to “sell what they got.” If a person knows Talk Therapy, then that is most often what is initially recommended. If that does not work, try CBT or medication – and vice versa. This reviewer does not agree that the crashes in the mental health area are usually not so spectacular – and they do make the papers in the form of suicides and inexplicable violence – though the track record is no where near the five-nines (one error in a million) that characterizes the airline industry. Goldberg’s subtext for mental health professionals is that we are still learning to live with uncertainty even as we organize case conference, postmortems, and the equivalent of crash investigations that strive to look objectively at outcomes without blame and without omniscient rescue fantasies in the service of healing and professional (“scientific”) development.
In some thirty cases that were reviewed by Goldberg, using the method of expert evaluation and feedback by the participants in the local case conference, the definition of failure included cases that never get off the ground; cases that are interrupted and so felt to be unfinished by the therapist or analyst; cases that suddenly go bad, characterized by a negative eruption whereas previously therapy was perceived to be going well; cases that go on-and-on without improvement; cases that disappoint whether due to the initial goal not being attained or being modified and not attained or endless pondering of what might have been.
Since this is not a “soft ball” review, one category of failure that is conceivable but missing from The Analysis of Failure is the example where treatment arguably left the person worse off (other than in terms of wasted time and money, which itself is not trivial). What about someone who did not experience impotence, writer’s block, or (say) hysterical sneezing until they tried psychoanalysis (psychotherapy)? What about compliance and placating behavior, reportedly a significant risk in the case of candidates for analytic training? What about regression in service of treatment that was initiated within the empathic context of the therapeutic alliance, but something happened and the regression got out of control and a breakdown or fragmentation occurred? Work was required to contain the fragmentation that was minimally successful, prior to an untimely termination that was a flight from fragmentation, a flight into health or a statement that in effect said “Let me otta here for my own good!” To his credit, Goldberg identifies “a patient who was getting worse off” (p. 162), but leaves the matter unconnected to regression mishandled or any other psychodynamic explanation. It is possible that such a scenario is already encompassed in the category of “cases that go bad,” at least implicitly, but in an otherwise through review of possibilities, this one was conspicuous by its absence.
The book itself is Goldberg’s answer to the question, given that failure occurs, what do we do about it? We inquire, define our terms, organize the rich clinical data, identify candidate variables, take the risk of making judgments about possible, probable, and nearly certain reasons, causes, and learn from our failures, pulling ourselves up by our boot straps in an operation that seems impossible until it succeeds. The role of lack of sustained empathy, counter-transference, rescue fantasies, disappointments, uncontrolled hopes or fears, partially analyzed grandiosity (on the part of the therapist), lack of knowledge of alternative approaches to therapy, are towards the top of a long (and growing) list of issues to be engaged in the classification of causes for failure.
The turning point of Goldberg’s argument occurs in his chapter on “How Does Analysis Fail”? This is an obvious allusion to Kohut’s celebrated work on How Does Analysis Cure? Once again, failure is a deeply ambiguous term, and the ironic edge is that in contrast to an analysis gone bad where the patient leaves in a huff with symptoms unresolved, a successful self psychology analysis proceeds step-by-step by tactical, nontraumatic failures of empathy that are interpreted and used to promote the development of self structure. The short answer is that analysis cures through stepwise, incremental, nontraumatic breakdowns – i.e. failures – of empathy, which are interpreted in the analytic context and result in the restarting of the building and firming of psychic structure of the self. In turn, these transformations of the self promote integration of the self resulting in enhanced character traits such as creativity, humor, and expanded empathy in the analysand.
The entertaining and even heartwarming reflections on Goldberg’s relationships with his teachers Max Gitelson and Charles Kligerman, betrayed (at least to this reader) a significant critique of the “old guard,” resolutely defended against the possibility of any failure, thanks to a position that avoided any risk – analysis is about improving self-understanding. According to this position, the reduction of suffering and symptoms relief is a “nice to have” but not essential component. Analysis is a rite of passage into an exclusive club, where you are just plain different than the untransformed masses. Though Goldberg does not emphasize the debunking approach, the reduction to absurdity of the description of the old guard makes psychoanalysis sound a tad like the est training from the late 1970s. You just “get it” or you don’t – in which case here is your money back and now go be miserable and unenlightened (only analysis does not give you your money back). In both cases failure is not an option, though not in the sense initially intended by the slogan, namely, that risk is analyzed and mitigated through interpretation. Failure is not an option because it is excluded by definition from the system of variables at the onset, thus, also excluding many meaningful forms of success. In short, many things are missing including sustained empathy, which, in turn, becomes the target of the analysis of failure in the remainder of the book
The net result of the compelling chapters on Empathy and Failure, Rethinking Empathy, and Self Psychology and Failure, is to challenge the analyst and psychotherapist to deploy sustained empathy in the service of structural transformation. While I personally believe that agreement and disagreement are over-valued in terms of creating authentic understanding, the section on Empathy and Agreement raises a significant distinction between the two terms. It is insufficiently appreciated by many clinicians how agreement becomes a smoke screen – and defense against – basic inquiry and exposure to the other’s affects in all their messiness and ambivalence. It remains unclear how sustained empathy undercuts agreement (or disagreement).For example, Dr. E. wants his analyst to agree with him that it is okay to sleep with his patient(s). For the sake of discussion, the analyst mouths the form of words, “Okay, given your marriage, okay, I agree.” But Dr. E. then asserts that he can tell the analyst does not really mean it (an accurate observation). So why not raise the question what is agreement doing here other than disguising Dr. E.’s own unacknowledged commitment to “being righteous and justified”. There is nothing wrong with being righteous, everyone does it. However, is it workable? The resistance has to be engaged and interpreted at some point in order to make a difference in treatment. Agreement (or disagreement) remains a conversation with the superego, even in the mode of denying there is amoral issue. It may stop a tad short of moral justification, but it is on the slippery slope to it. There are many cases along a spectrum of engagements but the really tough one is empathizing with behaviors that are ethically and legally suspect such as doctors sleeping with their patients and other relations of power where one individual uses his or her position to dominate the other as a mere means not an end in him- or herself. This is a high bar in the case of empathizing with the child molester or Nazi who have used a form of empathy (arguably a deviant one) to increase his domination of the victim. This remains a challenge to our empathy as well as to our commitment to treating a spectrum of behavior disorders (where Goldberg has made a life-long contribution) that are significantly upsetting to large parts of the mental healthcare market. Keeping in mind the scriptures and the sayings of Jesus(the rabbi), which Goldberg does not mention but arguably is the subtext, we are still challenged to love the sinner but hate the sin.
In a concluding rhetorical flourish, Goldberg claims that the book is a failure. The prospective reader – a very wide audience as I am any judge of the matter – may see the many complimentary remarks that properly disagree with this rhetoric printed on the back cover (which this review endorses and agrees). In a further ironic and richly semantic double reverse in the title of the final chapter, failure has a great future. This is especially so when failure is scaled down from a global narcissistic blind-spot on the psyche of the therapist (where failure remains a valid research commitment) to an expanded tactical approach in the form of “optimal frustration … disappointment being real, tolerable, and structure building” (p. 200). The concluding message is an admirably nuanced clarion cry for further study rather than condemnation, finger pointing, or blame of some particular therapeutic modality such as Talk Therapy versus CBT. The concluding message is a sustained reflection on de-idealization, the difficult process of taking responsibility for the inevitability of one’s parents’ lack of omnipotence. Failure is part of the development process in analysis and psychotherapy, and, by implication (and taken up a level), the study of failure in broad terms will be part of the development of the profession going forward. The analyst and therapist must give up the rescue fantasy, give up being right and justified, give up misplaced ambition, but also give up guilt, self-blame, disappointment, and embrace an approach that interpretation of the pathogenic situation of early childhood in which traumatic deidealization of the parent occurred, becomes inherently transformative. It reactivates the process of structure-building internalization. Learning to live within one’s limitations invites a process of risk taking that sometimes results in failure and sometimes results in – redefining one’s limitations outwards towards an endless horizon of progress in satisfaction and meaning making. Our thanks to Arnold Goldberg both for the journey and the end result.
Categories: Empathy, Psychoanalysis, psychotherapy, talk therapy