The Injury of a Perfect Therapy

A perspective on a rare therapy iatrogenicity

The brightness of a glowing flame is easily extinguished or dimmed when exposed to the vagaries of daylight…

While reading the second case, subtitled Daddy Dearest, in the fantastic narrative psychotherapy text by Eric Cowan - Ariadne's Thread (thanks to Zach Taylor for recommending it on LinkedIn) - I was hit with the sense that in some very rare instances, a therapy operation can be too successful, too beautifully conducted to the point of giving the lucky client a near perfect relational experience. This, as desirable as it’d seem, has one potential danger: that of further sensitizing the client to the messy imperfections of the relational world outside of therapy.

In that other more popular psychotherapy tales book Love’s Executioner by Irving Yalom, here's how he described a client's feeling upon realizing that she'd never be able to replicate the safety, intimacy, freedom, and acceptance she has found in her weekly appointments with her therapist:

"Betty now entered into a depression which was short-lived and had a curious, paradoxical twist. She was enlivened by the closeness and the openness of our interaction; but, rather than allow herself the enjoyment of that feeling, she was saddened by the realization that her life heretofore had been so devoid of intimacy."

I found immense comfort, as a young callow practitioner, in the stories contained within this book, mostly because Yalom, in addition to many other admirable qualities, was such a ridiculously honest Therapist.

Encounters with some select cadre of therapists (and some people in the real world, though rarer) are just simply too transformational to not deposit in the client something akin to the ineradicable grief of an ideal unattainable outside the well-sanitized therapy space. You know, something like an injury of a perfect relationship that can never be permanently retained and whose replication in vivo is a tall order. Perhaps similar to those rare occasions in the real world when you have a brief encounter with an individual who blows you away in every sense but isn't available for something more lasting. In fact, I'd go further to posit that this is exactly what happens in instances when a jilted partner succumbs to depression or, in worst case scenarios, to suicidal impulses.

I argue that people who lose a romantic relationship that is perceived and/or experienced as ‘perfect or near perfect’ are more likely to suffer a more severe post-relationship emotional breakdown or attempt suicide. We are affected by the loss of a relationship only to the degree that it is experienced or perceived as ideal (within the standard of the psychosocial reality we inhabit). Such individuals, premorbidly, are far more likely to exist in a state of relational anxiety; persons for whom self-enhancing intimate relationships are a rarity. Hence, sometimes, the mere promise of such a relationship is seen as a positive threat, often driving them to sabotage it before it can be painfully realized. This is one reason why therapy, a good therapy, is often experientially transformative. Because ‘relationship' is the universal active ingredient in all therapies, that which is a rarity in the real world is often more likely to be encountered in therapy.

For decades, the art and science of the therapeutic enterprise have undergone countless theoretical and practical iterations, so that what we have now is a highly systematic procedure capable of fostering, in the hands of a skillful and perceptive therapist, a relational experience with otherworldly elements. For certain classes of clients, this is a purifying experience as they hold the memory of the encounter as evidence of what is possible in ideal intimate relationships. I think this particular goal - to demonstrate to the client a model of an ideal relationship - is almost always implicit in every therapeutic interaction. And without a doubt, it is this overarching goal that inspired the set of operational guidelines that we've come to accept as the principles common to all therapy models. Hence, a therapist is expected to listen nonjudgmentally, offer unconditional positive regards, show empathy and understanding, collaborative in approach, draw and maintain healthy boundaries, uphold confidentiality, foster autonomy of thought, choices, and actions, etc., all while fulfilling the vital role of offering constructive feedback. When all these relational principles are observed, the relational experience produced is almost invariably addictive within a short period of time.

There is, however, another class of clients, who I suspect may be further driven into a place of positive despair as they ponder their chances of ever replicating this transformative encounter with their therapist (who is necessarily neither a real nor a complete human being within the therapy context) in the real world. We then understand why it's not uncommon for many clients to come up with various artifices to prolong a session (in the short term) or to extend the therapy contract (as a long-term strategy). It's a largely instinctive response to the sharply felt anxiety of separation from an object experienced as safe, soothing, and growth-enhancing. Every psychotherapist, even mediocre ones, is well familiar with this phenomenon. With this class of clients (who are defined more by a history of relational frustration, injuries, and trauma), the approach of the end of a truly transformative therapy is more likely to trigger a more severe acute anxiety similar to that experienced by a child who has to part, against his wish, with a beloved caregiver/attachment object that may never be seen nor heard from again.

So, again I ask: can a relationship be too perfect in its enactment so that it increases vulnerability to relational injury by sensitizing a psychosocially frustrated individual to the hitherto unknown possibilities of what an ideal relationship can feel like? Can therapy be too successful as a model of an ideal relationship such that it errs by engendering and exposing a relationship-weary soul to a sample of an ideal that's unattainable in real life? I think I'm inclined to say an emphatic ‘yes’, especially if the relationship in question is the one baked in the therapy workshop. Relationships of the type facilitated by skillful therapists can never, for reasons inherent in the setting of therapy as well as the person of the therapist, exist in the real world with all its infinite and messy uncontrollables.

Though in the real world, relationships don't have to be perfect to tag along just fine or to be considered 'good enough'. But the problem is that subpar, bad, and outrightly injurious relationships are actually the rule. In the real world, relationship, in general, is the ultimate hedonic currency that's hard to sustainably counterfeit without paying a heavy price. It's the most valuable legal tender in any psychosocial economy and whose distribution, like material wealth and everything else, is grossly unequal. And with such immense power to confer happiness and mediate the experience of subjective pleasure comes the corresponding potential to become weaponized and addictive, causing so much pain, miseries, and injuries. It can permanently fuck up lives and inflict lasting trauma.

However, it's important to note that victims of bad relationships are often not entirely innocent: they're victims twice over - victims of their abuser and then victims of their own personality or interpersonal style. Hence, why the 'curse' of bad relationships seem to follow them everywhere they go. If you wouldn't assign some blame points to the victim, no matter how small, then you'll realize that you won't be able to logically assign any blame to the aggressor/predator either without having to completely strip the victims of their agency. Why? Every predator is another creature's prey! And every prey is someone else's predator! This is the law of the food chain in principle. No victim is a victim in all contexts and no predator is a predator to all creatures across all relational context - of course, exceptions exist in extreme cases of predatory disposition (e.g. the dark personality types, but no one’s relational experiences consisted only of dealings with these dark types). A prey often needs the constant threat of a predator to keep its vitality alive, hence the reflex gravitation towards risky partnerships. It's an eternally symbiotic relational dynamic. The only ones who are safe are those who exist outside this predator-prey existential frame. And stepping outside this frame, after long functioning within it is not an easy task. Victims of relational abuse are like sugar and ants, like nectars and bees, or like rotten food and worms. They attract the bad and the worst types of humans just as positions of immense power attract amoral and corruptible personalities.

Thus, we acknowledge that the open world isn't an ideal place to nurture a relationally wounded and disturbed person in a way that is safe and corrective. That's where therapy, therapists, and the enclosed therapy space come in with all its conditions for idealization which it necessarily seeks to foster in the mind and feelings of the receptive and impressionable client. As a general rule, such repeatedly wounded clients tend to exist in the predator-prey functional frame prior to entering the therapy space, while the proper therapist tends to exist (or at least professionally operate) outside of this frame. This is, in part, the basis of the transference that most clients bring into their novel relationship with their therapists. It's the baggage from their predator-prey operational mode: a prey needs its predator and a predator its prey. Except that a competent and healthy therapist doesn't operate within this framework. Hence, cannot play the role the victim-ed client (being mostly a functionally assumed role rather than an imposed one) expects by force of habit. Two things can happen from this point onwards: either the client gradually learns to disengage from his victim-ed role or the therapist allows herself to be co-opted into the client's frame. In which case the unsuspecting and gullible therapist is drawn into confirming the relational assumptions of this client by unwittingly transforming into a fresh predator, powerfully called into being by the prey in the client in order to continue to unconsciously render his/her experience of the world thematically coherent and consistent: "nobody can be trusted", "everybody is selfish" "everyone is a judgmental prick" “no one really cares about me”, etc. People who hold these kinds of blanket thematic opinions about other people cannot be properly understood by being cast in the victimized light. No, they are people unfortunately fashioned by multiple psychodevelopmental forces, as it were, for the victimized role. It is not their experience, strictly and rigorously considered, that dictates their beliefs, rather their latent belief disposition shapes and selects their experiences which, like an endless circular curse, further confirms and entrenches their dispositional beliefs for which normal experience is not corrective.

The Pseudomatic Nature of the Therapeutic Relationship

There's a sense in which the therapy relationship is pseudomatic (automatically slipping into a false relational mode while actively pretending otherwise) and untrue (in the kind of hopes, ideas it engenders), and, therefore, potentially existentially injurious. To set up an artificial relational space, constrained by many technical (though necessary) restrictions and in which the primary driver of the relational transactions, the therapist, is effectively and permanently shut out of reach beyond that tiny and tidy space; and to expect a client to find in this a model of relationship in the outside infinitely more dynamic and complex world, is an act of professional disingenuousness at best, and professional deception at worst. And the more successful this contrived relational microcosm is, the more benevolent damage it’s capable of doing to the mind of certain types of client as it plants in their mind an idea of something that is neither realistic (though real) nor realizable (though possible). It relentlessly seduces them with an experience that can hardly ever be replicated in the real world because the conditions that made it possible in the therapy space exist nowhere else in the normal world - "This was therapy, and the normal economy that regulates how people stay connected did not apply", says Eric Cowan when narrating another case with a borderline personality organization. Yet, it's precisely this laboratory-like setting of therapy that makes it such a perfect tool for corrective relational experience. Usually, the most competent therapists are highly selected for and optimized to be capable of giving a client an experiential taste of what an ideal relationship should look and feel like. But in truth, not even these therapists' own extra-therapy relationships are remotely like what they channel in therapy - and this is mostly not their fault.

Here's the tragic reflection of Eric Cowan’s female client involved in the case cited at the beginning of this essay:

"I was just thinking that so much of life has passed me by, and my marriage turned to shit, and my relationships with my father and men have been problematic for a long time. And in here is the only place where I have had a really good relationship with a man, or at least the most important place. And here is the one place where it can’t be sexual, but it’s the one place where, because there is so much understanding and communication, it should be sexual .. . you know. Not that I want it to be in reality, but that I wish I had a relationship like this on the outside where affection and sexuality and spirituality were all part of the same relationship. That seems to be the feeling in the dream. I guess that’s it; I want what I’ve experienced in here with someone else out there. Wow. I can’t believe I just said that. I mean,” she said, rare tears springing into her eyes, “that I really want that. I can’t remember having, or even wanting, that feeling for a very long time. It’s a sense of passage into something new.” p. 68

Some might argue: but the goal of therapy isn't to lead a client to expect an ideal or flawless relationship. The goal is to present a model of what a healthy nurturing human relationship looks like so that they may see more clearly the unhealthy outlines in their own past and present relationships as well as their own contributions to it. And having experienced such comparatively more liberating model in their therapy work, it's hoped that the client may come to exercise their power of agency and the universal preference for what is personally nurturing to remake their relational universe in the real world. This will be a very good argument indeed except that it still manages to miss my point which is this: in trying to achieve the above-stated therapy goal, a very good therapist can be too successful so much that this success inevitably as well as unwittingly creates in the client a sense of despair as to the attainability of what they've experienced in therapy rather than a release of agentic and optimistic energy for goal-oriented actions. And the more exceptional and penetrative the therapist is, the more likely this paralysis of healing. It is comparable to the experience of floating in a gravity chamber and then being told that you can do the same outside it if you apply the principle you learned while inside. Somebody please get me a parachute!!!

As a rule, outstanding therapists are deeply attuned, skilled in communicating feelings, skilled in coaxing others to bare their souls, long-suffering, sagacious, delicately penetrative, affectionate, and able to make the most insecure adult feel safe. You'll be lucky to come across one or two of this kind of person in your normal world in a lifetime. Our parents, teachers, spouses, partners, mentors, role models, friends, bosses are, in 99% of cases, nothing like this. And even if you do come across such a person in the real world, you quickly find that they're often not much available for the deep kind of connection and sharing that the therapy space routinely engenders (I mean that’s why people pay for therapy - as normalized as it has become, it is still a very rare experience). And indeed a deeply relationally injured patient may begin to adjust appropriately in the reflective and nurturing presence of an effective therapist. But the important question is: what then happens in other, indeed most, multiple relational contexts that's nothing resembling the one in therapy?

In the Betty's story from Love's Executioner, Yalom wrote:

“I attempted to address Betty’s despair, and her belief that once she left me all our work would come to naught, by reminding her that her growth resided neither in me nor in any outside object, but was a part of her, a part she would take with her. If, for example, she was able to trust and to reveal herself to me more than to anyone previously, then she contained within herself that experience as well as the ability to do it again.”

This was as the very successful therapy was nearing its termination and separation anxiety was at its peak. Yalom's admonition to Betty is a very powerful and, perhaps, even reassuring one. But the bit about she containing “within herself that experience as well as the ability to do it again” is only one half of a truth; and though it's the more potent half, it doesn't make it less a half-truth. And what makes it so is the fact that while Betty could easily, if she wanted, re-enact in her real life her own part of the therapeutic interactions, she has no control over who's going to play the other half. And the odds are extremely low that whoever chance and fate is going to place before her will be as exquisite in self-presentation, precise in communication, gentle in manners, discerning of feelings, sagacious of speech, and infinitely long-suffering as her therapist. ‘Extremely low’ because this is something that the client, for manifold reasons, was never able to achieve prior to therapy.

Conclusion

Therapy, if successful, in fact, to be successful, has to present a model close to an ideal as possible. It's the purity of this model itself that is, in turn, purifying as well as inspiring for the client to first discover within themselves the stirrings of a long-abandoned possibility. But as their contact with the source of this ideal - in therapy - becomes discontinued due to necessary termination, the contrived artificiality of this ideal experience is rendered more prominent in their mind. And a crippling and despairing doubt is what naturally ensues!

What's the way out of this blinding enlightenment, this paralyzing freedom, this mortifying exhilaration, this depressing ecstasy, this forever-possible and never-impossible ideal-experienced? Well, like Yalom hinted, it's the ineradicable knowledge that it did happen. It's like witnessing the eclipse of the moon when everyone else was asleep. It's a rare occurrence but if it happened once it can and indeed will happen again if the conditions are right. It doesn't matter if there are other witnesses to it. Second, the client who has experienced firsthand what ‘heaven’ feels like would eventually have to learn to settle for a less sparkling paradise. And to achieve this vital calibration of expectation to reality, she must never allow the memory of the ‘hell’ she once lived in to dim.