Meredith Hwang disseration

Institute for Clinical Social Work

Mistakes in Psychotherapy: What Becomes of Our Errors?

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Meredith SoRelle Hwang

Chicago, Illinois June, 2014

Abstract

This phenomenological research explored the experience of psychodynamic psychotherapists when they make a mistake in treatment. Eleven experienced psychotherapists were each interviewed twice on their experience of making, using, and living with their errors in treatment. The concept of a “mistake” was defined subjectively by participants.

Interpretative phenomenological analysis of the data yielded several key themes and understandings about mistakes, including broad categories of typical mistakes (such as mistakes of avoiding, disconnecting, acting out emotionally, proving worth, incompetence, and over or underestimating a patient), processes that occur for therapists after making a mistake, and several themes, including the vulnerable self of the therapist evoked by mistakes; the gray area, where therapists feel unsure if they have erred; and professional growth, which denotes how therapists tend to feel more self-compassion and less shame about their mistakes with increased professional maturity. Klein’s paranoid schizoid and depressive positions were used to illuminate therapists’ experience of shame in making mistakes. The findings suggest that acknowledging and talking authentically about mistakes can be a powerful tool to mitigate shame and grow as a therapist, allowing for a more compassionate understanding of one’s mistakes and an increased ability to use them to enhance the treatment. ii

Acknowledgements

First, I am tremendously grateful for the brave, introspective participants in this project; their candor allowed this research to come to life. The project’s chair, Michelle Sweet, has challenged me to seek excellence; I am grateful for her ideas and strong commitment to this project. Woody Faigen has provided unwaveringly wise guidance and a constant reminder of the importance of the unconscious. Dennis McCaughan in many ways inspired this project with his unyielding focus on the authentic in the psychotherapeutic endeavor; he has taught me the immense value of sitting with what is uncomfortable but genuine. My readers, Amy Eldridge, and Michael Hoffman have generously shared their insightful perspective on this work. My work with Jennifer Tolleson also greatly influenced this study, as she helped me understand how to look behind and under the seams in everything, and how to wrestle my alligators. Finally, I want to acknowledge my mother, Jane Pendergraft, who paved the way for me to enter this field and offered her perceptive reflections and support throughout, and my husband, Andrew, who has been here from start to finish and splendidly seen me through it all.

MSH

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Table of Contents

Page Abstract.............................................................................................................................. ii Acknowledgements .......................................................................................................... iii Chapter I. Introduction ....................................................................................................... 1 Statement of the Problem Significance for Clinical Social Work Theoretical and Conceptual Framework of the Study II. Literature Review ............................................................................................ 6 Introduction Section I: The Relational Turn and Countertransference Section II: Theoretical Standing and Mistakes Section III: Research and Experience III. Methodology ................................................................................................. 46 Type of Study and Design Scope of Study, Setting, Population and Sampling, Sources and Nature of Data Data Collection Methods and Instruments iv

Table of Contents–Continued

Data Analysis Statement on Protecting the Rights of Human Subjects IV. Findings ......................................................................................................... 55 Introduction Researcher Preconceptions and Implicit Assumptions Categories of Mistakes Processes Unfolding around Mistakes Theme: The Vulnerable Self Theme: The Gray Area Theme: Professional Growth and Shift in Experience of Mistakes V. Discussion...................................................................................................... 118 Introduction Aim of the Study Assessment of the Study Value of the Study Conclusions and Implications for Research Final Conclusions Appendices A. Sample Letter To Potential Participants, Sent Via E-Mail ...................... 153 B. Consent Form ............................................................................................... 155 v

Table of Contents–Continued

C. Interview Guide, First Interview ................................................................ 159 References .......................................................................................................... 162

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Chapter I

Introduction

Statement of the Problem Being human is inextricably tied to making mistakes, and in the practice of psychotherapy, we are well versed that patients come to therapy to explore and remedy their perceived mistakes. Psychotherapists spend a great deal of time helping patients understand their mistakes. But what of our mistakes? For decades, psychotherapists were viewed and many embraced the role of the all-knowing, wise figure (Hoffman, 2002; Casement, 2002). The objective, dispassionate psychoanalyst stood in sharp contrast to the patient, whose every distortion or false step was analyzed in great detail.

In recent years, however, there has been a growing awareness that psychotherapists, like their patients, are subjective, fallible members of the analytic dyad (Hoffman, 2002). As Levenson (1992) observed in his article on mistakes in treatment: It has been a long and bumpy road from Freud’s 1914 statement that “Analysis presupposes the consent of the analysed: the situation of analysis involves a superior and a subordinate” to Racker’s statement in 1968 that, “The first distortion of truth in the ‘myth of the analytic situation’ is that analysis is an interaction between a sick person and a healthy one. The truth is that it is an interaction between two personalities . . . and each of these two personalities–that of the analyst and that of the patient–responds to every event of the analytic situation.” (p. 555)

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The analyst no longer holds a privileged position that allows her mistakes to be disregarded.1 When psychotherapists make clinical mistakes in the course of treatment, how do they manage this both internally and in the treatment? What is the lived experience of making clinical mistakes?

Psychotherapy is a profoundly messy endeavor, yet this aspect of the work is all too often minimized or denied. Friedman (1988) writes incisively about the ways that therapists do not discuss the genuine experience of doing this work: “Therapists function in a sea of trouble and they talk as though they don’t. . . . [T]he identifying truth about psychotherapy is that it is an uncivil, threatening, even brutal struggle instigated by gently reflective intellectuals dedicated to delicate speculations” (p. 6). Therapist mistakes constitute an underexplored area of Friedman’s “sea of trouble.”

This study has investigated psychotherapists’ experience of making clinical mistakes. The problem is that psychotherapist mistakes are discussed in private or not talked about at all; hence, mistakes are not managed in the most helpful way and they also miss their potential to offer therapists growth and learning. The goal of this study has been to glean a rich, in-depth understanding of psychotherapists’ lived experience of mistakes. A richer understanding of this phenomenon will help psychotherapists navigate the process of managing their mistakes. It will also support psychotherapists in talking more openly and authentically about mistakes in consultation, peer groups, and educational settings.

In order to be concise, when a pronoun is needed the therapist or analyst will be referred to using the pronoun “she” and the patient or client will be referred to using the pronoun “he”. Further, the terms “psychoanalyst,” “analyst,” “psychotherapist,” and “therapist” will be used interchangeably.

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Significance for Clinical Social Work This study is significant because it examines how therapists recognize, correct, use, or live with mistakes they have made. The research describes and illuminates this universal experience. Good psychotherapy practice and basic social work values involve striving to attain a high level of reflectivity, honesty, courage, and authenticity in the work. This project is valuable to the fields of psychotherapy and social work because it demonstrates fellow practitioners frankly reflecting on a normative experience that can feel taboo but is in fact commonplace. The shame and secrecy that surround mistakes can make it difficult to be reflective, honest, courageous, and authentic in the practice of psychotherapy. By building knowledge about psychotherapists’ experiences of mistakes, this study provides a contribution to practice knowledge that encourages reflection on these basic social work values.

Theoretical and Conceptual Framework of the Study This study used a general psychodynamic framework. General psychodynamic concepts such as the existence of the unconscious, the ego’s use of defense mechanisms, and notions about the transference and countertransference illuminate therapists’ experiences of making mistakes in treatment. The study leaned heavily on relational, intersubjective psychodynamic theory because the study explores the therapist’s subjectivity and vulnerability in the therapeutic encounter.

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Questions explored in the study.

Primary research question 

What is the lived experience of clinical mistakes?

Sub research questions 

What do psychotherapists perceive as clinical mistakes in a psychodynamic treatment process?



How do psychotherapists experience mistakes internally and interpersonally?



What do they do–or not do–when they have made a clinical mistake?



How do mistakes get used in psychotherapy for the treatment?



How do mistakes get used for the psychotherapist’s development?

Theoretical and operational definitions of major concepts.

For the purposes of this study, the concept of a mistake was personal and subjective to each participant. The term “mistake” was used as a category holder for many similar concepts (e.g., errors, blunders, oversights, misunderstandings, slips, or misjudgments). Any of those concepts that participants considered “mistakes” were considered material for this study.

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Statement of assumptions. 

All psychotherapists make mistakes on a regular basis. Making mistakes is a normative, universal experience in conducting psychotherapy.



Mistakes impact the process of psychotherapy in some way and understanding mistakes is central to the treatment process.



Making and then considering the meaning behind mistakes is critical to growth as a psychotherapist.

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Chapter II

Literature Review

Introduction Mistakes in psychotherapy have not been extensively explored in the literature.

This topic seems to be experienced as “threatening” and to elicit “denial and defensiveness” on the part of therapists (Kottler and Carlson, 2003, p. ix). The review will begin with an examination of the shift from modern to postmodern modes of thinking about psychoanalysis and the resulting shift from a one-person to two-person psychology model of practice. This is relevant because this shift introduced the idea of the analyst’s subjectivity.

Building on the discussion of the shift from classical to relational theory, the next section of the review will examine countertransference, which the literature clearly shows to be a central source of mistakes for therapists.

The review will then look at how mistakes are discussed in the literature. While there is general agreement on the inevitability of mistakes (Greenson, 1972; Kumin, 1989; Chused & Ralphling, 1992; Levenson, 1992), viewpoints on the particulars of what defines a mistake and how it is to be managed depend heavily on theoretical orientation.

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Next, the literature from Freud as well as other theorists on the purpose, use and management of mistakes will be reviewed. Then, the review briefly will touch on the distinction between mistakes and errors noted in the literature. Subsequently, the review will explore common mistakes in treatment. Also informed by the relational turn in psychoanalytic theory, the role of creativity and play in psychotherapy in juxtaposition to mistakes will be examined. Last in this section, the review will look at the shifting myth of the invulnerable therapist present in psychoanalysis.

The final section of the review will survey research on mistakes and selected literature on the experience of making mistakes.

Section I: The Relational Turn and Countertransference

Modernity and one-person psychology.

Freud created psychoanalysis on the backdrop of modernity. A philosophy born of the Enlightenment, modernity emphasizes rational thinking, positivism, and absolute truths (Leary, 1994). In modern thought, the self is conceptualized as “a distinct, stable entity” and private, interior realities are viewed as “accessible, publicly apprehended, and mapped out as invariant structures of knowledge” (Leary, 1994, p. 441). Modernity assumes that there are absolute, finite truths about individuals that can be accessed and interpreted.

Freud’s focus on reason, rationality, and absolute truths led to the development of what has been called a one-person psychology. This “one-person psychology” reflects the

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central idea that it is primarily the patient’s psychology (and psychopathology) that enters the consulting room. The analyst has the capacity to objectively observe the patient, examine the patient’s transference, history, and dreams, and then come to an absolute, fixed interpretation about the patient’s unconscious, intrapsychic conflicts (Kirman, 1998). This model, to varying degrees, supports the blank screen concept, the idea that the analyst is neutral and analyzes the patient’s transference in a primarily objective, unbiased way (Hoffman, 1983).

The postmodern swing and two-person psychology.

The move from modern to postmodern and one-person to two-person models of practice has profoundly influenced the ways therapists might understand their mistakes.

Postmodern notions have deeply challenged modern ideas that truth is a stable, objective reality that is possible to access and interpret. Lyotard (1984) defined the term postmodern as an “incredulity toward metanarratives” (p. 123), highlighting that postmodern thinkers are deeply skeptical of definitive truths in any arena. Elliott and Spezzano (1996) observed that in postmodern modes of thinking: . . . there is no philosophical or ideological position that is able to claim ultimate authority or justification. On the contrary, the justification of knowledge . . . is always a matter of argumentation from different positions and perspectives, such as that our beliefs about the world are necessarily local, provisional, and contingent. (p. 58) With the postmodern assumption that there is no objective truth to discover, the analyst’s role is fundamentally altered. In a two-person model of psychology, there is a

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new assumption that both the patient and the analyst’s subjectivity is present in the treatment, a great shift from the blank screen theory.

In Hoffman’s (2002) social-constructivist model of psychoanalysis, the analyst must consider the impact of her subjectivity on the psychotherapy process: Therefore, what the analyst seems to understand about his or her own experience and behavior as well as the patient’s is always suspect, always susceptible to the vicissitudes of the analyst’s own resistance, and always prone to being superseded by another point of view that may emerge. (Hoffman, 2002, p. 36) The postmodern has been associated with the development of the intersubjective and relational paradigms of psychoanalysis and the two-person model of psychology.

Strean (2001) observed that the two-person psychology model is defined by the sense that “in the therapeutic situation there are always two vulnerable individuals present who are constantly affecting the therapeutic outcome through their interaction” (p. xiii). Kirman (1998) associated the two-person psychology model with “hermeneutic socialconstructivism,” [which] asserts that there are no absolute truths out there waiting to be discovered by discerning human minds, but only meanings to be constructed by minds functioning together in a cultural context. Mind is itself a social product, and the notion of an isolated mind is an outmoded Cartesian myth. (p. 6) In this new, two-person model, the psychoanalyst is not the authority who is able to interpret absolute insights about the patient (Kirman, 1998). The two-person psychology model dramatically shifts the balance of power in the analytic relationship “in an egalitarian direction” and thus, the “analyst cannot be the sole or superior arbiter of reality or truth. And there is no objective truth to discover in any case, no reality independent of human perception and subjectivity” (Kirman, 1998, p. 6).

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Mistakes in the postmodern.

Goldberg’s (2001) discussion of the rules of psychoanalysis has particular relevance for the exploration of mistakes in the treatment process in the postmodern.

Psychoanalysis, with its roots in modernity, is a discipline that tightly clings to specific rules and a “correct” method (Goldberg, 2001). Goldberg invoked postmodern theorists Bion and Lyotard to emphasize that these rigid rules in psychoanalytic practice can be limiting. For Goldberg, strict rules inhibit rather than facilitate the understanding of each patient, and he implores therapists to avoid having a “one size fits all” approach to patients.

If there are few definitive rules in a postmodern analytic landscape of practice, how does a psychotherapist conceptualize if she has made a mistake? In the classical model of psychoanalysis, the psychotherapist need only consult a very specific set of rules that would clearly define particular actions of the therapist as a mistake. In the twoperson psychology emphasizing the analyst’s subjectivity, this is far less clear cut and problematic. The rulebook no longer exists in the same manner in postmodern practice.

Countertransference and mistakes.

This section of the literature review will examine changes in theoretical ideas about countertransference and the ways that this might relate to a therapist’s perceptions of mistakes. It seems useful to begin by surveying Young’s (1995) division of the shifts in countertransference theory into three distinct phases. Young (1995) labeled the first

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segment the “objectivist” phase, which depicts the time (beginning with Freud) when theoretically the analyst was a “blank screen” who objectively offered interpretations on the patient’s transference-driven “mistaken projections” (p. 176). In the objectivist phase, countertransference is viewed as a “relatively infrequent contaminant, a failure of objectivity due to the therapist's insufficiently analysed subjectivity” (Young, 1995, p.

176).

Represented by theorists such as Winnicott, Little, and Heimann, Young (1995) termed the next phase in countertransference thought the “projectivist” phase, in which the “patient projects into the therapist” and thus contributes to the resulting countertransference (p. 176). In this phase, analysts began to realize they must take stock of their real, “inevitable” vulnerability in the treatment situation (Young, 1995, p. 176).

Evident in the writings of many intersubjective and relational psychoanalytic theorists such as Searles, Ehrenberg, Aron, and Hoffman, Young (1995) described the contemporary phase of thinking on countertransference as “dialectical,” by which he meant that “the [therapeutic] relationship is more than interactive; it is mutually constitutive at many levels” (p. 176). At this point in the theory, “projection into the therapist is 'the essence' of analysis, and part-object relations and relentless searching out of the most subjective and damaged parts of the therapist is the rule” (Young, 1995, p.

176).

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Freud.

From the inception of psychoanalysis, countertransference was considered a “mistake.” Freud (1910) first defined the term “countertransference” in his paper “The Future Prospects of Psycho-Analytic Therapy”: We have become aware of the “counter-transference” which arises in [the psychoanalyst] as a result of the patient’s influence on his unconscious feelings and we are almost inclined to insist that he shall recognize this countertransference in himself and overcome it. We have noticed that no psychoanalyst goes further than his own complexes and resistances permit, and we consequently require that he shall begin his activity with a self-analysis and continually carry it deeper while he is making his own observations on his patients. (pp. 144-145) Freud’s position on countertransference from this writing seemed clear: countertransference was an obstacle to treatment that was to be “overcome” and minimized as much as possible lest it interfere with the work of analyzing the patient.

Classical conceptions of countertransference are represented by Freud’s (1912) famous directive: “I cannot advise my colleagues too urgently to model themselves during psycho-analytic treatment on the surgeon, who puts aside all his feelings, even his human sympathy, and concentrates his mental forces on the single aim of performing the operation as skilfully as possible” (p. 115).

Yet, Freud also seemed to contradict this idea of countertransference as an obvious impediment to treatment. In the same influential paper mentioned above, Freud (1912) provided the foundations for a divergent view of countertransference: The analyst must turn his own unconscious like a receptive organ towards the transmitting unconscious of the patient. He must adjust himself to the patient as a telephone receiver is adjusted to the transmitting microphone. Just as the receiver converts back into sound waves the electric oscillations in the telephone line which were set up by sound waves, so the doctor's unconscious is able, from the

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derivatives of the unconscious which are communicated to him, to reconstruct that unconscious, which has determined the patient's free associations. (pp. 115-116) This statement, Jacobs (1999) has argued, opened the way towards an understanding of both the inevitability and the importance of countertransference in analysis. Jacobs also noted that Freud’s “choice of metaphor implicitly conveyed the notion that unconscious transmission in analysis is a two-way street” and that “analysis inevitably involves the interplay of two psychologies” (Jacobs, 1999, p. 576).

Countertransference conceptualizations prior to World War II. Contrary to most of the analysts of his time, Ferenczi (1919) believed that countertransference was potentially valuable. “Radical” at the time he introduced them and perceived as “dangerous,” these ideas are being revisited by contemporary proponents of intersubjectivity and social constructivist theory (Jacobs, 1999, p. 577). He disagreed with Freud that countertransference is always a force to be controlled, arguing instead that trying to control countertransference impacted the analyst’s free associations in a way that could negatively affect empathy and understanding (Jacobs, 1999). In fact, Ferenczi (1932) wrote in his diary: One could almost say the more weaknesses an analyst has, which lead to greater or lessor mistakes or errors but which are then uncovered and treated in the course of mutual analysis, the more likely the analysis is to rest on profound and realistic foundations. (p. 15)

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Ferenczi’s reflections may be seen as a forerunner to the contemporary idea that the therapist’s humanity and resultant mistakes can make a valuable contribution to the healing process for both patient and therapist.

Along with Ferenczi, other analysts (Stern, 1924; Strachey, 1934; Low, 1935) objected to unambiguously viewing countertransference as an obstacle to treatment. In general, however, in the years prior to World War II the notion of countertransference as a damaging phenomenon became more entrenched. Analytic candidates were taught that the dreaded countertransference was to be avoided at all costs. Articulating the position held by classical psychoanalysts in America on countertransference, Reich (1951, 1960) acknowledged the inevitability of countertransference and that it is even “a necessary ingredient if the analyst is to be engaged in the work,” but argued along Freudian lines that it “must be mastered” (Jacobs, 1999, p. 582). For Reich, countertransference is “not a royal road to the unconscious,” but rather a clear hindrance to the analyst’s work (Jacobs, 1999, p. 582).

The shift in thinking on countertransference: Winnicott, Heimann, and Little.

The Second World War began to shift conceptualizations around countertransference as analysts treated disturbed patients that were evoking intense reactions in them (Jacobs, 1999). Winnicott’s (1949) classic paper “Hate in the Countertransference” was on the forward edge of this nascent shift in attitudes. Winnicott (1949) argued for the inevitability of negative countertransference in treating challenging

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patients, and further argued that these feelings were justified in the analyst based on the patient’s behavior.

Winnicott also was the first to contend that an analyst should actually use the countertransference by telling the patient at some point in the treatment about these negative feelings that were engendered in her. Winnicott (1949) believed that unless the analyst was able to share her negative countertransference with the patient at some point, the treatment would be incomplete (i.e., the analyst would be forever infantilizing the patient by never allowing the patient “to understand what he owes his mother”) (p. 74).

Winnicott (1949) maintained that the analyst “must easily be aware of his own fear and hate,” and that, once aware of these negative feelings, the analyst should use this knowledge to further the treatment (p. 72).

Heimann (1950) built on Winnicott’s concept of countertranference in her significant paper “On Counter-Transference,” in which she argued that the countertransference (“the analyst’s emotional response”) is an indispensable “instrument of research into the patient’s unconscious” (p. 81). Heimann enlarged the term “countertransference” to include all feelings an analyst experiences towards her patient (Epstein and Feiner, 1979). Heimann (1950) also posited that the analyst’s countertransference is actually “the patient’s creation, it is a part of the patient’s personality” (p. 83). Here she contended that the countertransference is a purely projective phenomenon and the analyst is not being personally activated, only incited into this reaction by the patient.

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Little (1951) also made a key contribution to the evolving view of countertransference, arguing that just as analysts hold up a mirror to patients, patients likewise hold up a mirror to analysts. For Little, the countertransference is a complex creation that can lead the analyst to consciously wish a patient well while unconsciously wishing to keep the patient “ill and dependent . . . for our own purposes, both libidinal and aggressive” (Little, 1951, p. 34).

Little (1951) also noted that it is “a paranoid or phobic attitude towards the analyst’s own feelings . . . [which] constitutes the greatest danger and difficulty in counter-transference” and that “the very real fear of being flooded with feeling of any kind, rage, anxiety, love, etc., in relation to one’s patient and of being passive to it and at its mercy, leads to an unconscious avoidance or denial” (p. 38). Little’s idea that analysts can become paranoid about experiencing their own feelings plays directly into the discussion on mistakes. When analysts avoid their feelings in the countertransference, Little warns that this leads to a greater risk of making mistakes.

Bion and Racker.

Bion (1967) emphasized that the analytic enterprise involves a powerful relationship between two people with distinct emotional lives, and that the analyst influences the treatment with her personal beliefs and standards (Jacobs, 1999). Bion (1967) famously proscribed that in order to avoid major stumbling blocks to analysis such as the analyst’s fantasies of omnipotence, all analysts should enter into each session

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without memory or desire. Bion’s writing represented an increasing acknowledgment of the analyst’s internal experience and psychology in theories about the analytic dyad, but he still wrote at a time when it was seen as possible for the analyst to be objective.

Argentinean psychoanalyst Racker (1958, 1968) pioneered the idea of the countertransference neurosis, “a complex of [analyst] predispositions and its manifestations” which served as a counterpart to the transference neurosis in psychoanalytic theory and again underscored the burgeoning idea of the analyst as a fully subjective member of the analytic encounter with the patient (Epstein & Feiner, 1979).

In contrast to a classical position demanding neutrality from the analyst, Racker argued that the countertransference neurosis, with its strong attendant emotions, was both inevitable and possible for the analyst to self-analyze (Epstein & Feiner, 1979). For Racker, transference should more accurately be termed “counter-countertransference,” stressing that the patient’s transference is often a reaction to the countertransference of the analyst (Berman, 2000). Racker (1968) also distinguished between direct countertransference (roused by the patient) and indirect countertransference (roused by someone outside the therapy situation who is emotionally important to the analyst) (Epstein & Feiner, 1979). Overall, Racker provided an augmented “appreciation of the fact that countertransference is a highly complex reaction that condenses and expresses wishes, fantasies, memories, defences, and superego prohibitions in a multi-determined way” (Jacobs, 1999, p. 585).

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Self psychology and countertransference.

In his development of self psychology theory, Kohut (1968, 1971) took a more classical stance on the dangers of countertransference in the analyst. Kohut (1971) cautioned analysts to be aware of the countertransference that can appear in response to the idealizing transference, noting that “[i]f the analyst has not come to terms with his own grandiose self, he may respond to the idealization with an intense stimulation of his unconscious grandiose fantasies” (p. 267).

Kohut then emphasized how the analyst’s unconscious grandiose fantasies can cause a reaction of “embarrassment, shame, and self consciousness” in the analyst, which will then defensively cause her to “ward off” the idealization, thus disrupting a central part of the analytic process (Siegel, 1996, p. 80). Wolf (1979), a key collaborator with Kohut, wrote about the importance of countertransference in analysis, and added his own idea about “mini-countertransferences,” which he defined as subtle misattunements on the part of the analyst that cause “mini-fragmentations” in the patient (p. 590). It is the working through of these fragmentations in the patient that leads to cure in self psychology.

American Interpersonalism.

American Interpersonalists further advanced the concept of countertransference.

Sullivan’s (1953) concept of the analyst as participant-observer introduced the “idea of analysts as inherently subjective–always participating unwittingly, and by definition,

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always countertransfering” (Hirsch, 2002, p. 574). The interpersonal model assumes that the analyst is inevitably and subjectively participating in the analytic interaction and experiencing countertransference continually in the process.

Sullivan (1947) famously wrote that “we are all much more simply human than otherwise, be we happy and successful, contented and detached, miserable and mentally disordered, or whatever” (p. 16), and along with Fromm-Reichmann (1950), he helped “humanize” the therapist by underscoring the relevance of the therapist as a “real object” in the room with the patient (Epstein & Feiner, 1979, p. 505). Despite planting the seeds for a quite substantial reimagining of psychoanalytic theory from a one-person to twoperson psychology, Sullivan himself primarily saw the countertransference as useful for getting insight into how patients described relationships in their lives (Hinshelwood, 1999).

Searles (1986) also wrote in the interpersonal school on the countertransference.

Searles emphasized the therapist’s humanity throughout his writing; he wrote with a unique “forthrightness about the madness which we [as therapists] share with the patient” (Young, 1995, p. 192). Searles was very clear that he saw analysts–both others and most intimately himself–as wholly human and that the therapist’s countertransference might be viewed as, in Young’s words, the “royal road to the psychoanalytic process generally” (Young, 1995, p. 190). On countertransference, Searles (1986) wrote: I cannot overemphasize the enormously treatment-facilitating value, as well as the comforting and liberating value for the therapist personally, of his locating where this or that tormenting or otherwise upsetting countertransference reaction links up with the patient's heretofore-unconscious and unclarified transferencereactions to him. In other words, the analyst's "own" personal torment needs to

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become translated into a fuller understanding of the patient's childhood-family events and daily atmosphere. (p. 214) Building on a Winnicottian notion of the usefulness of countertransference in treatment for locating the unconscious of the patient, Searles added a distinct element to the discussion by exploring “the extent to which the therapist is emotionally engaged and at risk in the therapeutic relationship” (Young, 2000, para. 2). Searles shared his vulnerability and essential humanity in his role as an analyst and warned analysts that they must “be aware of these intense and primitive feelings and cope with them. They are our primary means of production of analytic understanding” (Young, 2000, para. 17).

Object relations.

In the object relations tradition, Sandler’s (1976) concept of role responsiveness in his classic article, “Countertransference and Role-Responsiveness,” was influential in the contemporary development of countertransference theory. Sandler (1976) maintained: In the analyst's overt reactions to the patient as well as in his thoughts and feelings what can be called his 'role-responsiveness' shows itself, not only in his feelings but also in his attitudes and behaviour, as a crucial element in his 'useful' countertransference. (p. 45) He argued that an interaction occurs between the analyst’s unconscious and the patient’s unconscious in which there is a pressure for the analyst to conform to a particular role that the patient is transferring onto him. In the past, there has been a tendency in analytic writing to assume that this pressure is entirely based on internal, personal countertransference reactions on the part of the analyst; however, the crux of

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Sandler’s point is that the analyst’s behavior represents a “compromise between his own tendencies or propensities and the role-relationship which the patient is unconsciously seeking to establish” (Sandler, 1976, p. 47).

Bollas (1987) has posited that countertransference can be a very useful means of helping the analyst deeply understand and then articulate to the patient what has heretofore been an “unthought known” (p. 3). Bollas (1987) described psychoanalysis of the unthought known as “the emergence into thought of early memories of being and relating . . . the reliving through language of that which is known but not yet thought” (pp. 3-4). The dawning awareness of the dynamics inherent in the transference and countertransference allow the analyst to gradually grasp this unthought known and communicate it to the patient, which Bollas (1987) views as curative and deeply relieving to the patient (p. 3). Awareness of the omnipresence of countertransference serves a central function for Bollas in the healing work of psychoanalysis.

Intersubjective and relational.

The relational turn in psychoanalysis has given rise to theories on intersubjectivity. Intersubjectivity refers to the idea inherent in the move to two-person psychology that psychoanalysis involves the commingling of two subjective parties–the analyst and the patient–on both a conscious and unconscious level. Intersubjectivity conceptualizes “the analytic relationship and process as mutually constructed out of the reverberating influence and interaction of the conscious and unconscious wishful and

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defensive needs and desires of the analyst and the analysand, each upon the other” (Levine & Friedman, 2000, p. 66).

Contemporary relational analyst Ehrenberg (2006) emphasized that intersubjective thinking requires a “radical reconceptualization of the data of analysis . . . [and] how we use ourselves as analytic instrument” by seriously taking into account “the centrality of the unconscious in both analyst and patient” (p. 543). She argued that therapists can never “transcend our intersubjectivity” and that “we are as human as our patients and as vulnerable to unconscious influence as they are” (Ehrenberg, 1996, p.

278).

Enactments.

Along with the growth of relational theory and intersubjectivity, ideas about enactment have entered into the theoretical discussion. First introduced into the literature

by Jacobs (1986), and analogous to Sandler’s (1976) idea of role responsiveness, countertransference enactment might be described as “the covert, scarcely visible, yet persistent reactions that pervade [the analyst’s] manner of listening and responding” (Jacobs, 1986, p. 292).

Enactment is now considered by relational theorists to be inevitable, omnipresent, and potentially curative. Though a relatively new term, thinking on enactment has already seen a shift from an original suspicion that enactments were resistances to the analytic

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process to the idea that they are useful and curative when they can be properly analyzed (Friedman & Natterson, 1999).

Following theoretical dividing lines, more classical theorists tend to recommend avoiding enactments to the degree that it is possible (Chused, 1991). Contemporary relational theorists embrace enactment and the potential it has for deepening the understanding of the patient (Ehrenberg, 2006). Renik (1993) argued for the positive, curative potential in enactment: Unconscious personal motivations expressed in action by the analyst are not only unavoidable, but necessary to the analytic process. . . . [I]t is precisely because of the analyst's capacity for self-deception, the analyst's willingness to be selfdeceived, that he or she is able to enter spontaneously and sincerely into corrective emotional experiences with the patient without the presumption and hypocrisy of deliberate role-playing. These interactions provide a crucial series of gratifications and frustrations to the analysand that form the basis for a successful analytic process. (p. 564) Renik contended that enactments are not only inevitable but beneficial. For Renik and many contemporary relational theorists (Hirsch, 1998; Ehrenberg, 2006), analyzing enactments is central to the healing process. The serious consideration of the ubiquitous presence of enactment in the therapeutic process adds another complex layer to the discussion of a therapist’s perceived mistakes.

Countertransference as contributor to mistakes.

Countertransference is frequently cited in the literature as a key contributor to making mistakes (Greenson, 1972; Casement, 2002; Robertiello & Schoenwolf, 1987; Rothenberg, 1988). Greenson (1967) commented that errors based on countertransference

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occur with more frequency than other errors and are “the most difficult to detect” (Greenson, 1967, p. 35). Casement (2002) also considered the dynamics of countertransference that come into play around mistakes. He averred that when therapists “fall into making quite striking mistakes,” there is a need to look closely at the countertransference to understand the therapist’s role in this (p. 32).

Casement reflected on two distinct types of countertransference: personal countertransference, “which has to do with our internal worlds and sensitivities,” and diagnostic countertransference, “which can give us useful clues about the patient and our responses to the patient” (p. 32). He argued that countertransference mistakes tend to originate from unconscious role responsiveness (Sandler, 1976), as well as projective identification (Casement, 2002). Levenson (1992) also noted the degree to which countertransference (in contributing to an error) operates out of conscious awareness, observing that “[r]eal counter-transference–the kind that makes trouble–operates out of awareness. As they used to say about the minnie ball in the Civil War, you never hear the one that gets you!” (p. 560)

Section II: Theoretical Standing and Mistakes

Freud’s thinking on mistakes.

For Freud (1898), all mistakes are unconsciously motivated. Material that is deemed unacceptable by the mistake maker’s unconscious is repressed and thus leads to mistakes in forgetting. In Freudian theory mistakes are consciously viewed as a failure,

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and at the same time unconsciously viewed as a success because they have obscured the threatening thought or feeling. Early in his theoretical development, Freud (1898) linked his theory of repression with mistakes around forgetting. Freud emphasized the defensive function of forgetting and also pointed out that these incidences occur in both healthy and neurotic people.

In The Psychopathology of Everyday Life (1901), Freud argued that mistakes are psychically meaningful rather than simple, uncomplicated slip-ups. He used a term that he coined himself, “fehlleistung,” to refer to a “faulty action,” which Strachey translated into the term “parapraxis” in his translation of The Standard Edition of Freud’s works (Keegan, 2003). The prefix “fehl” in German is translated into “wrong” or “false” and makes up a significant portion of the word “fehlen,” which is the German word for “mistake” (Keegan, 2003). The second portion of Freud’s new term “leisstung” can be translated as “performance,” or “achievement.” Bettelheim (1982) observed that Freud’s “fehleisstung” implies both failure and achievement: When we think of a mistake we feel that something has gone wrong and when we refer to an accomplishment, we approve of it. In Feillistung, the two responses become somehow merged. We both approve and disapprove. Feillistung is much more than an abstract concept. It’s a term that gives German readers an immediate, intuitive feeling of admiration for the cleverness and ingenuity of the unconscious processes, without the reader’s losing sight of the fact that the end result of those processes is a mistake. (p. 85) Freud maintained that forgetting reveals an unconscious process in which some threatening knowledge is obscured. While a person might feel they have lapsed or done something wrong, this “lapse” is actually offering the person protection from knowledge of their own disturbing wish. This wish needs to be disguised by the unconscious because

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it is in opposition to the desires of other aspects of the self. The need to disguise this wish is the mechanism that leads to the mistake of forgetting someone’s name, for example.

In analyzing a seemingly minor mistake in writing out a birthday card to a friend, Freud (1935) observed that these types of mistakes illuminate “how complicated the most unobtrusive and apparently simplest mental processes may be” and marvels at how his apparently minor mistake is “yet based upon this large number of premisses and dynamic determinants” (p. 235). The most central point Freud makes regarding mistakes is that they are a complex phenomenon rooted in the unconscious with the aim of avoiding anxiety stemming from a threatening desire or wish. The attempt to avoid anxiety by keeping unsafe content unconscious is a huge determinant in the making of a mistake such as forgetting in Freudian theory.

The purpose, use, and management of mistakes.

There is a strong undercurrent in the small amount of literature that is available on mistakes regarding the purpose, use, and management of mistakes. Over time, mistakes have shifted from being viewed as undesirable and damaging into a phenomenon that can provide movement forward in the treatment along with growth for the therapist. This shift in thinking on mistakes seems to parallel the shift from classical to relational theories on psychotherapy.

Classical theorists see the purpose of mistakes more in terms of managing the mistake and perhaps in minimizing the negative impact the mistake might have on the

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treatment. In classical treatment, there has been a tendency to heavily favor the therapist’s reality over that of the patient’s reality (Schwaber, 1983). The classical analyst holds definitive authority as the evaluator of “reality”.

While Freud saw mistakes as significant due to their unconscious origins, mistakes and their impact on the treatment process are not discussed at length in the literature on classical treatment and are seemingly not viewed as exceedingly important.

An example of this attitude towards mistakes may be found in Edward Glover’s 1931 paper “The Therapeutic Effect of Inexact Interpretation: A Contribution to the Theory of Suggestion,” in which Glover wrote, “A glaringly inaccurate interpretation is probably without effect unless backed by strong transference authority, but a slightly inexact interpretation may increase our difficulties” (Glover, 1931, p. 401). The idea that a “glaringly” mistaken interpretation can have no impact unless certain conditions are met clearly reflects the classical idea that the analyst is not a part of the process, but rather the impartial observer who is capable of sharing objective interpretations with the patient about the “truth.”

Greenson (1967) and Kumin (1989) both represent classical psychoanalytic theorizing that takes a more moderate tone than Glover (1931). Both Greenson and Kumin acknowledge that errors do impact treatment and emphasize the importance of the analyst privately reflecting on her error. They consider it a further error to encumber the patient with the analyst’s thoughts and feelings about the mistake, with Greenson (1967) putting it succinctly that “the patient should not have to be my therapist” (p. 347). In a notable departure from classical theory, Greenson (1967) emphasized that mistakes can

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provide a great source of growth for therapists, stating that “it has been my experience that one can learn more from . . . errors, particularly one’s own, than from any other single source” (p. 346).

Laying the groundwork for the relational turn in psychoanalytic theory, Little (1951) noted that it is important for analysts not only to admit a mistake (in a “mistimed or wrongly emphasized interpretation”) to the patient but also to disclose the mistake’s origins in “unconscious counter-transference” (p. 33). She noted: Such explanation may be essential for the further progress of the analysis, and it will have only beneficial results, increasing the patient’s confidence in the honesty and good-will of the analyst, showing him to be human enough to make mistakes. (Little, 1951, p. 37) Little (1951) highlighted the importance of acknowledging the therapist’s humanity (indicated by the “existence not only of the analyst’s objective or justified feelings, but also of the analyst’s subjective feelings”) to the patient when this is made evident by way of a mistake (p. 37). This position on mistakes stands in opposition to a classical recommendation to focus on the pathology of the patient and not to consider the therapist’s contribution to the therapeutic milieu through mistakes.

Building on Little’s argument and turning further in the relational direction, Winnicott (1963) began to carve out a larger space for the analyst’s subjectivity and hence for the way that mistakes can be useful–even central–to the treatment. He argued that whether “forced” by the patient, or entirely created by the patient in his mind, the failures of the analyst should be used by the analyst and patient together to understand earlier environmental failures and heal old wounds from these failures. Winnicott (1963) elaborated on this:

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The corrective provision is never enough. What is it that may be enough for some of our patients to get well? In the end, the patient uses the analyst’s failures, often quite small ones, perhaps manoeuvred by the patient, or the patient produces delusional transference elements (Little, 1958) and we have to put up with being in a limited context misunderstood. The operative factor is that the patient now hates the analyst for the failure that originally came as an environmental factor, outside the infant’s area of omnipotent control, but that is now staged in the transference. . . . So in the end we succeed by failing–failing the patient’s way. (p. 344) The analyst’s mistakes can be used by the patient transferentially to recreate disappointments and failures from the patient’s history; this allows the patient to reexperience and work through these original failures. Thus, Winnicott argued that in the service of his healing the patient may make use of the analyst’s mistakes quite beneficially. The idea that therapists might “succeed by failing . . . the patient’s way” was a newer way to approach analyst mistakes (Winnicott, 1963, p. 344).

As the relational turn gained momentum, Yassky (1976) also appealed for the positive use of mistakes in treatment, noting that as a profession therapists “do not show enough interest in making mistakes, accepting them, and correcting them” (p. 43).

Yassky (1976) observed that the literature shows “therapeutic mistakes and accidents [to be] . . . one of the most valuable, if not the most significant factor, in bringing about significant change in the patient” (p. 44).

In the literature, analysts typically do not perceive their mistake as the significant factor in creating change; instead, “objective observers” reading the literature may see the value in the mistake (Yassky, 1976). Yassky (1976) argued that it would be tremendously beneficial for therapists to begin to understand the value of their mistakes. This point is

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essential to this research inquiry because it argues for why it is important to consider therapist mistakes more thoroughly.

Further building on the argument for the use of errors in treatment, Feiner (1991) wrote that “for any kind of error that is a straying there is a potential value,” which he held “resides in its acknowledgment, reception and interpretation by the patient . . . so that it may become part of the binding process between human beings, part of that ‘union’” (p. 626). Along with his former supervisor Fromm, Feiner (1991) believed that intimacy is the most important component of psychotherapy, and that “authentic intimacy could only be experienced via the sharing of the truth” (p. 628), which ultimately leads to “union.” Errors can be seen as an opportunity to create union, a central healing aspect of psychotherapy in both Feiner and Fromm’s view.

Rothenberg (1988) also noted some of the positive aspects of making errors, observing that “[i]n recognizing and focusing on errors, both learning and correcting inevitably occur” and “one should not at all be afraid of making errors and should allow oneself a freedom that incurs errors and mistakes” (Rothenberg, 1988, p. 168). He went on to observe that in the process of making errors and being prepared to articulate them, “one . . . thereby incorporates into the therapy one’s own and the patient’s individuality, and the humanity of both” (Rothenberg, 1988, p. 168).

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Distinctions between mistakes and errors.

Interpersonalist psychoanalytic writers Levenson (1992) and Feiner (1991) established a distinction between mistakes that they view as more clearly detrimental to the treatment and errors that are viewed as potentially useful. Feiner (1991) pointed out the etymology of the word “error,” which comes from the Latin “to wander or stray”.

These wandering types of errors are viewed as being potentially useful in psychoanalytic treatment for moving the treatment forward. Feiner (1991) noted that modern conceptions of mistakes often imply a “Cartesian view of phenomena, a clear subject/object split in which things are right or things are wrong” (p. 625). In Levenson’s (1992) position, “there cannot be a ‘right’ mistake; to mistake is to take the wrong way,” while he maintained that errors can be used creatively to move the treatment forward. Thus, one must try to “avoid mistakes; conversely, we should capitalize on errors–use them” (p.

557).

Both Feiner (1991) and Levenson (1992) argued that the wandering inherent in making “errors” could generate valuable material. The focus on the usefulness of errors reflects the postmodern, relational theoretical stance of these two theorists, though it is also interesting to observe that both Feiner and Levenson each have a category of errors (i.e., “mistakes”) that they consider totally unhelpful to treatment and something to be avoided.

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Theoretical orientation and the analyst’s perception of mistakes.

The literature shows that mistakes can be obscured and rationalized using analytic training and theory, and the process of determining what is a mistake is undoubtedly influenced by this phenomenon. The chosen theory of a therapist heavily influences what is considered to be an error in the treatment (Chused & Ralphling, 1992; Levenson, 1992). Chused and Ralphling (1992) observed that differentiating what might be perceived as a mistake from variations in technique among analysts can be tricky. They pointed out that “[o]ne analyst’s mistake is often another’s correct technique” (Chused & Ralphling, 1992, p. 92). Similarly, Rabin (1995) argued that “each theory brings with it a greater probability of certain kinds of clinical errors, although it is excruciatingly difficult for many of us to appreciate the errors that are more intrinsic to the approach to which we are deeply committed” (p. 476).

Contemporary authors (Chused & Ralphling, 1992; Casement, 2002) have noted a propensity for analysts to skew their perceptions of clinical situations to avoid believing that they have erred. Chused and Ralphling (1992) noted that mistakes can be unconsciously justified as “necessary modifications of technique, with the specifics of the patient’s psychopathology used as justification for unconventional analytic behavior” (p.

93). Arguing along similar lines, Casement (2002) maintained that analysts have honed the ability to “connect almost anything with anything,” and that “when things don’t fit exactly, we can assume the patient is employing whatever forms of defensive thinking best lend themselves to our own way of seeing things” (p. 4).

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Kottler and Karlson (2003) observed how unusual it is to hear a psychotherapist frankly acknowledge “blowing it” (p. 193) with a patient, and that when confronted with a potential mistake, psychotherapists tend to “make up excuses, identify scapegoats and extenuating circumstances, [and] create elaborate explanations for what happened and why” (p. 193) rather than own it. Thus, there is a strong sense in the literature that analysts do not want to believe they have made a mistake and will use theory and the patient’s psychopathology to avoid seeing any error.

Common mistakes.

Mistakes can range from general, overarching attitudes toward the psychotherapeutic endeavor to specific types of mistakes, such as particular kinds of comments. What is considered a mistake is clearly dependent on the eye of the beholder.

Attitudinal mistakes.

Freud (1912, 1915), Levenson (1992), Casement (2002), Yassky (1976), and Feiner (1991) all wrote about common mistakes in the attitude of the therapist. Reflecting his positivist roots, Freud (1912) discussed the mistake that analysts make when they deviate from taking the attitude of a surgeon towards their patients. Freud (1912) noted that an analyst who does not keep this “emotional coldness” towards his patients puts

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himself “into a state of mind which is unfavourable for his work, but will make him helpless against certain resistances of the patient” (p. 115).

Freud (1912) also noted that he strongly disagreed with psychoanalysts who take the attitude that they must be equal to the patient by sharing their “own mental defects and conflicts, and . . . giving him intimate information about his own life, [to] enable him to put himself on equal footing” (p. 117). Freud (1912) clearly stated that “I have no hesitation . . . in condemning this kind of technique as incorrect” (p. 118).

In a different, more relational take on a common mistake in attitude, Levenson (1992) averred that “the cardinal mistake in psychoanalysis is to assume that the patient is sick, distorting, developmentally impaired” (p. 569). Levenson was writing from a perspective that includes and values the analyst’s subjectivity. He pointed out that this attitudinal mistake of pathologizing the patient “has the effect of protecting the therapist against his or her own anxiety, [and] fosters a subtle disdain for the patient” (Levenson, 1992, p. 569).

Casement (2002) argued that a predominant attitudinal mistake that psychotherapists make is being too certain or dogmatic with their views regarding a patient. Yassky (1976) argued that the majority of errors relate to therapists “not showing our humanness enough,” which he asserted happens when therapists do not focus on the actual, non-transference portion of the relationship with patients and “thus help maintain a greater distance than is necessary and appropriate in the therapeutic relationship” (p.

43).

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Technique mistakes.

Theorists have discussed more specific types of “common” mistakes made by psychotherapists. In his papers on technique, Freud (1913) recommended correct ways to perform the method of psychoanalysis. In doing so, he implied that by not following his suggestions, one would be in error. It is well worth noting, however, that while laying out quite specific rules for treatment, Freud (1913) did make an appeal for flexibility in applying these recommendations: The extraordinary diversity of the psychical constellations concerned, the plasticity of all mental processes and the wealth of determining factors oppose any mechanization of technique, and they bring it about that a course of action that is as a rule justified may at times prove ineffective, whilst one that is usually mistaken may once in a while lead to a desired end. (p. 123) While Freud may have stipulated what is “correct” technique (and therefore implied other types of technique are errors), he also suggested flexibility in applying the techniques of psychoanalysis. So determining whether something is a “mistake” may be a far more individual and complex process than it at first might seem.

For more contemporary writers Levenson (1992) and Casement (2002), mistakes around boundary issues are viewed as critical. While both theorists take the stance that certain mistakes are “wanderings” that can be useful to the treatment, they also strongly believe that the frame is what allows the patient and the therapist a feeling of safety in the therapeutic interaction; thus, mistakes in this area are viewed as very problematic.

Levenson (1992) discussed the analyst faltering in preserving the frame as a prime example of a mistake, and summarily argued that “deviations in what I would describe as

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the frame are mistakes, wrong, interfere with the therapy and should be stopped. An authoritarian frame begets an egalitarian treatment” (p. 560).

Empathic failures.

Empathic failures are conceptualized as ruptures in the relationship of analyst and patient. Kohut wrote extensively on empathic failures and recommended that they are “to be treated as the sin qua non of effective analytic intervention” (Goldberg, 1987, p. 411).

In Kohut’s self psychology, empathic failures are viewed as inevitable and are used by the analyst to facilitate cure.

Mordecai (1991) wrote about different types of empathic failures on the part of the psychotherapist and looked at the typical therapist response to these errors. She discussed errors in basic empathy for the situations going on in a patient’s life, errors that stem from a therapist’s preoccupation with personal stress, errors that stem from countertransference, and errors that belie a lack of understanding of the patient’s pathology. Typical therapist responses to these empathic breaks include efforts to gratify or over reassure the patient, shame and grandiosity, discomfort, and even terror.

The capacity for creativity in psychotherapy and mistakes.

Creativity is a vital element to the practice of psychotherapy (Winnicott, 1971; Rothenberg, 1988; Feiner, 1991). Winnicott (1971) argued for the importance of

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creativity in the analytic encounter. In his seminal work Playing and Reality, Winnicott (1971) stated: Psychotherapy is done in the overlap of the two play areas, that of the patient and that of the therapist. If the therapist cannot play, then he is not suitable for the work. If the patient cannot play, then something needs to be done to enable the patient to become able to play, after which psychotherapy may begin. The reason why playing is essential is that it is in playing that the patient is being creative. (p. 54) Winnicott emphasized the key ingredient of “play” in psychotherapy and the value of helping the patient learn how to play and therefore live creatively. His statement that a therapist is actually “not suitable” for work as a therapist if she cannot play speaks to the weight Winnicott placed on play in the analytic encounter. For Winnicott, play in psychotherapy holds such significance that it is worth making errors that can ultimately be used by the patient for growth and change.

Rothenberg (1988) noted that in many fields “error [is] intrinsic to the creative process. Both commission of errors and handling of errors are important and special matters in creative processes” (150). Relevant specifically to psychotherapy, Rothenberg (1988) observed: Like the creative writer or artist, both therapist and patient need to be willing to take chances and commit errors in both the form and substance of their relationship. When errors occur, they need to recognize them and then to clarify them as much as possible. As a “wandering”, an error provides the beginning of a separation which, through constant clarification, yields up some of its unconscious content and intent. (pp. 161-162) Rothenberg (1988) emphasized the importance of creativity to the process of psychotherapy, and the way that being open to making errors can be an asset to a creatively conducted psychotherapy process.

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Yassky (1976) also argued for the creative use of mistakes in treatment, urging therapists to “creatively do with . . . mistakes whatever will be most helpful to our patients” (p. 45). He gave the example of a situation where he laughed uproariously at a critical comment that a patient made towards him that she did not intend to be funny. The patient’s unexpected response was first to become enraged and then to begin laughing in return. In processing this mistake with his patient, he was able to use it creatively by admitting his mistake to his patient, and then they talked about how this interaction made her feel closer to him. Thus, there is a link in the literature between the capacity for creativity in psychotherapy and an openness to making errors and using them in treatment.

The myth of the infallible therapist.

Contemporary authors have discussed the myth of the therapist’s superiority and infallibility in the analytic situation (Casement, 2002; Levenson, 1992; Chused & Ralphling, 1992; Kottler & Carlson, 2003; Pope, Sonne, & Greene, 2006; Kottler & Blau, 1989). Viewpoints on the invulnerable analyst myth have hinged on theoretical stance.

Levenson (1992) explored the ways that the therapist may be viewed as the expert who knows all the answers in the treatment for the patient. He noted that psychoanalysis’ genesis in the crucible of the nineteenth century medical model coupled with its basis in hypnosis, particularly its use of submission and suggestion, has created a “thinly masked disdain for the ‘patient’, defined etymologically as ‘the suffering one’” (Levenson, 1992,

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p. 555). Both patient and analyst, Levenson argued, often believe that the therapist is required to enlighten the patient on the true meaning of his life.

Casement (2002) discussed the ways that psychotherapists can “slip into a position of arrogance, that of thinking they know best” (p. xiii). Casement (2002) argued that historically in psychoanalysis, Freud tended to use his theory to justify his favored position and to “see himself as being right whenever he chose” (p. 3). Casement (2002) further contended that “many analysts (like Freud) seem to regard their own position as protected by the certainty of their own sureness” and that there are analysts who “fall into the trap of being too sure in our (assumed) understanding of others” (p. 4).

Racker (1953), in arguing for analysts to have increased awareness of their countertransference, referred to the “‘myth of the analyst without anxiety or anger’” (p.

135). Fromm (1947) “rejected the idea that anyone, simply by virtue of being an analyst and having undergone a training analysis, is therefore the possessor of superior mental health” (Epstein & Feiner, 1979, p. 505). He wrote about “the fiction of the analyst’s superiority” and warned that buying into this myth could “lead the analyst into the major pitfall of the profession, that is, unconscious despair” (Epstein & Feiner, 1979, p. 505).

Greenson (1967) discouraged patients’ view of him as invulnerable, stating, “I am of the opinion that it is of importance to demonstrate in certain actions and matters that the analyst is truly a human being. This includes permitting some of his human frailties to be visible at times” (p. 223). Greenson’s opinion that analysts should “permit” their vulnerability to show fits a more classical model of psychoanalysis. He wrote as though

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the analyst revealing this vulnerability is a choice rather than an inevitability, which proponents of a two-person psychological theory would challenge.

Hirsch (1997) argued for the therapist’s vulnerability in the analytic encounter in the face of the older myth of an objective, infallible analyst: “the notion of the patient's transference as pure distortion or projection has protected analysts for some time from the power of the patient's perceptions” (p. 253). The notion that the transference was purely a distortion has afforded analysts a shield that has often seemed to leave both patients and analysts themselves with a sense that the analyst is invulnerable or less likely to make the typical mistakes that define being a human being in the world.

Section III–Research and Experience

Research on mistakes.

Kottler and Karlson (2003) did an informal study in which they interviewed prominent psychotherapists from many theoretical orientations about their personal reflections on conducting “bad therapy,” which the authors defined using Robertiello and Schoenewolf (1987)’s definition as the “kind of blunders that take place when personal issues and countertransference processes interfere with sound judgment” (p. 4). These interviews found commonalities in therapists’ responses to making a “mistake,” specifically the affects of shame, humiliation, and a deep sense of regret. Therapists shared that they were haunted by their mistakes in particular treatments. Along with a distressing sense of professional incompetence, powerful feelings of sadness, frustration,

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uneasiness, and vulnerability were frequent experiences associated with having made a mistake that resulted in the “bad therapy.”

Kottler and Karlson (2003) concluded that there seems to be a great deal of denial related to therapist mistakes and noticed that it typically appeared to be easier for participants to discuss past failures rather than to reflect on more recent mistakes (Kottler & Karlson, 2003, p. 191). Participants had difficulty thinking of an example of “bad therapy,” despite having foreknowledge of the interview topic. The authors connected this to the “denial and defensiveness” that therapists use to “provide a convenient means to bury our mistakes, sometimes to help us pretend they never happened in the first place” (Kottler & Karlson, 2003, p. ix). While they do not extensively elaborate on them, Kottler and Karlson (2003) placed participants into two general categories in regards to their internal response to failures: the “dwellers,” who tend to “spend a lot of time thinking what they could do differently,” and the “shruggers, . . . [who] don’t dwell on failure, let it go,” and are “forgiving of their mistakes” (p. 192).

Sprayregen (1993)’s doctoral dissertation explored the topic of mistakes in psychodynamic treatment, focusing on the ways that psychotherapists use their mistakes for positive therapeutic change. Spraygren (1993) found that study participants felt their mistakes encompassed a wide scope of actions, ranging from treatment mistakes that felt harmful to those that were used productively. Participants in her study felt multifaceted relational dynamics contributed to their mistakes, including issues around transference and countertransference, enactments, and subjective differences between therapist and patient.

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Spraygren focused primarily on mistakes that were used positively for change in the treatment, and suggested two hypotheses for how treatment mistakes can become positive and useful. Spraygren’s (1993) first hypothesis put forth the idea that mistakes in treatment can be used in a helpful manner to “negotiate an optimum range of closeness and distance between therapist and patient” (p. 211), which “involves a delicate and continuous balancing of interpersonal dynamics . . . [and] seems to be a precondition for safety and genuine dialog between therapist and patient” (p. 213). Her second hypothesis relates to the intersubjective nature of the therapist-patient relationship. She invoked Winnicott’s (1963) idea that patients use the failures of the therapist, and observed the ways that difficult interpersonal patterns get recreated in the treatment dyad in ways that offer opportunities for healing. Overall, Spraygren (1993) argued that therapists can use treatment mistakes to “solidify the therapeutic relationship and facilitate the working through of significant issues” (p. 216).

The therapist’s experience of erring.

There is minimal literature directly describing the experience therapists have in making a mistake, and much of what is available in this arena is anecdotal. While making a mistake is a very individual process, on the whole reactions to making a mistake range from experiencing anxious or depressive affects to minimizing the mistake to owning the mistake.

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Freud (1905) offered a good example of an analyst reflecting on a perceived error in the footnote he wrote to the Dora case. His response to his error seems to run the gamut from acknowledging the error, reproaching himself, to perhaps even minimizing the error. Freud acknowledged his mistake of missing the burgeoning development of the transference, writing, “I did not succeed in mastering the transference in good time” (p.

118). He reproached himself that when Dora told him her first dream (in which she had warned herself to leave treatment with Freud as she left Herr K’s home): “I ought to have listened to that warning myself,” even going so far as to speculate on what he “ought to have said to her” (p. 118) and what impact that a change in direction might have had on the case. He noted that “the transference took me unawares” and that “I was deaf to this first warning” (p. 119).

While Freud did not mention any responses he had to what he clearly seemed to classify as a mistake in missing the transference, he did appear to have regrets in this case. He also, though, seemed to argue that his mistake did not take away the ultimate worth of the work that he did do with her, noting that “[n]evertheless, I am not inclined to put too low a value on the therapeutic results even of such a fragmentary treatment as Dora's” (p. 120). Freud’s commentary here might illustrate a tendency to rationalize any mistake that an analyst believes might have occurred along with an ability to still see value in his work despite an error.

Greenson’s (1967) reflections on a vignette in which he made a mistake prove worthwhile to examine: “I was technically wrong about something, not guilty; I was sorry I caused undue pain, but these are the hazards of treatment and have to reckoned with” (p.

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347). Greenson’s reflections on his mistake seem to reveal a straightforward attitude of acknowledging his mistake, and a feeling of sorrow for “causing pain” that is modulated with a real world sensibility that this these things happen in life and in psychotherapy and cannot be avoided. Similar to Freud, Greenson does not describe experiencing shame or guilt in relation to his errors.

In contrast, Chused and Ralphling (1992) discussed the uncomfortable feelings that can surface for therapists when they realize they have erred. Emphasizing the importance of the analyst’s unconscious in recognizing and dealing with mistakes, Chused and Ralphling (1992) argued that “[u]neasiness, the suspicion that something nontherapeutic and potentially harmful has just occurred within the analysis, tends to evoke defensive rationalizations and projections” (p. 90). Chused and Ralphling also contended that the experience of making a mistake may involve regression of the superego in the analyst, which can engender shame and guilt, and make it difficult for the analyst to face her mistakes.

These authors also maintained that analysts will respond in their own unique, individual manner to particular types of errors. For example, they argued that “the analyst with a predominance of passive character traits is often more tolerant of his errors of omission than those of commission” (Chused & Ralphling, 1992, p. 112). They further noted that the analyst’s worry over a mistake “will be determined by the specific unconscious significance the mistake has for him” (Chused & Ralphling, 1992, p. 113).

Kottler and Blau (1989) explored therapist reactions to erring and noted that no matter how far advanced in the field therapists are, they “are vulnerable to the depression

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and anxiety that accompany a sense of failure” (p. 14). They linked the powerful affects that accompany a therapist’s mistakes in therapy to the fact that “therapists are notoriously hard on themselves when they do not live up to their unrealistically high standards of success” (Kottler & Blau, 1989, p. 14).

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Chapter III

Methodology

Type of Study and Design This study has examined the psychotherapist’s normative experience of making mistakes in the context of a psychodynamic psychotherapy. I conducted this study using a phenomenological approach to explore the psychotherapist’s lived experience of making mistakes.2 Phenomenology “attempts to discern the psychological essence of the phenomenon” being studied by “investigating and analyzing lived examples of the phenomenon within the context of the participants’ lives” (Giorgi & Giorgi, 2008, p. 28).

This methodology has allowed me to access participants’ subjective experience of the phenomenon and emphasizes the participants as the experts on the experience of making mistakes. Edmund Husserl, a 19th century European mathematician, is considered the founder of phenomenology. Parting company from Descartes, Husserl “did not accept that certitude could be achieved solely through the use of rationality and logic” (McLeod, 2006, p. 37). Rather, he believed:

2 As this is a qualitative research project with a focus on the researcher as an inextricable part of the data, I will be using the first person to refer to myself as the researcher. This choice emphasizes the way I am interpreting and contextualizing the data in an ordered yet inevitably subjective manner.

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It was necessary to examine the bedrock of everyday experience, because it was there, in our emotions, actions and perceptions of things and relationships, that an ultimately true understanding could be derived. Phenomenology strives to describe the essence of everyday experience. (McLeod, 2006, p. 37) All types of phenomenology are concerned with understanding what Husserl termed the “lifeworld,” which is defined as the “world as we immediately experience it pre-reflectively rather than as we conceptualize, categorize or reflect on it” (Van Manen, 1990, p. 9). The lifeworld is the world of the everyday, and this study is concerned with understanding the lifeworld therapists experience everyday with their clinical errors.

This study has used a hermeneutic phenomenological design. In hermeneutic phenomenology, the “focus is toward illuminating details and seemingly trivial aspects within experience that may be taken for granted in our lives, with a goal of creating meaning and achieving a sense of understanding” (Laverty, 2003, para. 12). A primary difference in Husserlian (transcendental) and Heidiggerian (hermeneutic) phenomenology centers on the possibility and desirability of bracketing during the research inquiry. Drawing on Husserl’s concept of the epoche, Moustakas (1994) recommends in transcendental or psychological phenomenology that researchers “bracket” their own perspective or experiences “as much as possible” in order to “take a fresh perspective towards the phenomenon” being examined (Creswell, 2007, pp. 59-60).

In theory, this bracketing process allows the researcher to suspend judgment of the phenomenon being studied and achieve superior, more pure contact with the essence of the phenomenon.

In contrast, hermeneutic phenomenology does not require or recommend such bracketing. The researcher is considered to be an inextricable part of the research process.

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Rather than bracketing, in hermeneutic phenomenology, the researcher’s biases are considered to be “embedded and essential to interpretive process. The researcher is called, on an ongoing basis, to give considerable thought to their own experience and to explicitly claim the ways in which their position or experience relates to the issues being researched” (Laverty, 2003, para. 32). Hermeneutic phenomenology allows the researcher to embrace the intersubjective nature both of the psychotherapeutic endeavor and the research endeavor. Thus, I did not bracket my biases, but rather have acknowledged them as I am aware of them. They are set forth at the beginning of the Discussion Section of this paper.

Scope of Study, Setting, Population and Sampling, Sources and Nature of Data Participants for the study were selected according to the following criteria: psychotherapists who defined themselves as practicing within a psychodynamic modality and were interested in speaking about their experience of making mistakes in the course of treatment. Participants were limited to psychodynamic psychotherapists because I assumed that “mistakes” within a psychodynamic modality had a particular meaning for psychotherapists, which might have shifted if the study were opened to therapists who primarily practice using other modalities. Limiting the research to psychodynamic therapists also allowed me to focus on my own area of interest, which is psychoanalytically informed psychodynamic therapy, and this narrowed center of attention helped elicit a richer, more focused set of data. The study participants are all

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licensed psychotherapists in private practice, and consisted of five social workers, five psychologists, and one licensed clinical professional counselor. One psychologist is also a psychoanalyst. All participants have been licensed for a minimum of five years in order to ensure participants who have ample experience with the phenomenon being studied.

Following Servatius (2010), participants were recruited by asking experienced therapists I know for a list of their possible recommendations for the study. In one case, a study participant referred another study participant that she felt would be a good addition to the study. Any recommended psychotherapist who was known to me was excluded from the study. I asked those who gave study referrals to ask permission of those whose names were shared prior to sharing them with me. In this way, participants were aware in advance that their name had been shared as a possible participant for the study.

I initially contacted potential participants by email. I sent a form letter to each potential participant asking if they were interested in participating in the study. A sample of this letter is located in Appendix A. Most people that I contacted did respond to the email, but a few did not respond and my contact with them ended there.

Participants were pre-screened in a phone interview prior to moving forward with the interview. Participants were told that this is a study that aims to better understand the psychotherapist’s experience of making mistakes. They were asked if they have ever made a clinical mistake they would be willing to discuss. This prescreening was done for three purposes: (1) to make sure that participants understood the research objectives and felt comfortable with participating in this project; (2) to ensure that I interviewed participants who were willing to discuss their mistakes for the purposes of this study; and

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(3) to stimulate participants’ thinking on this topic prior to the interview in order to elicit richer data.

One participant scheduled an interview then cancelled due to illness. I asked her to contact me after she was well enough to reschedule and she never followed up with me. I did not pursue her for an interview because I assumed she would contact me if she was still interested and comfortable with participating.

Following the recommendations of Smith, Flowers, and Larkins (2010) on sample size, the number of participants in the study was 11. This number was kept small in order to develop richness and depth in the data because “IPA studies usually benefit from a concentrated focus on a small number of cases� (Smith, Flowers, & Larkins, 2010, p. 51).

Data Collection Methods and Instruments Data was primarily collected in face-to-face, semi-structured interviews with participants. One participant lives out of state and thus her interviews were conducted over the phone. The aim of the interviews was to get participants talking openly and authentically about their experiences in making and using mistakes. I conducted all of the interviews. The interviews were semi-structured to allow me to focus on particular areas of interest while at the same time preserving the spontaneity and free association that might lead to important emergent material.

In order to prepare for the interviews, I conducted a pilot study in which several participants were interviewed about their perceptions of clinical mistakes. The purpose of

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the pilot study was twofold: the first objective involved helping me refine the interview guide questions. The second objective for the pilot study was to help me gain a more solid understanding of the direction that the interviews in the final project might take and get me more adept at engaging in this type of data collection. Both of these objectives were fulfilled in the pilot study.

I created an interview guide that loosely structured the interview situation. This guide is located in Appendix C. The interviews were conducted at a site mutually convenient for participant and researcher. Almost all the interviews were conducted at participants’ professional offices. One participant preferred that I come to his home. One participant lives out of state so her interviews were conducted on the phone. The site for interviews was private and the interviews were not interrupted.

The interviews were digitally taped and then transcribed. In one interview, the last 15 minutes of the second interview was lost due to the batteries dying on my digital recorder. I took notes on this portion of the interview but was not able to code it because I did not have an exact transcription. The transcription was completed by a third party professional transcription service. The transcription service was asked to sign a confidentiality notice for the protection of the data, and they were also compensated at market rate for their services. Further, I took detailed notes both during and following each interview in a research journal. The journal contains observations, thoughts, analysis, and queries about each interview experience.

Each participant was interviewed twice for one to one and a half hours. The first interview was structured by the interview guide, which is located in Appendix C. The

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second interview guide was created based on my considered opinion of further areas to explore from the first interview. I used the second interview to deepen the discussion of mistakes and to allow the participants time to reflect further on mistakes and their responses to them. The second interview allowed me to address the difficulty seen in other research on mistakes (Spraygren, 1990; Kottler & Blau, 1989) wherein participants were unable to produce mistakes to discuss for the interview. By interviewing a second time, participants were allowed ample time and space to consider the topic and their own experience with it.

Data Analysis I analyzed the data using Smith, Flowers, and Larkin’s (2010) interpretative phenomenological analysis method. The aim of the method of data analysis is to investigate thoroughly how participants are experiencing the phenomenon of making a mistake in treatment. I used the interpretative phenomenological analysis method because it emphasizes both the subjective experience of the participants as well as the “active role of the researcher” in interpreting those subjective experiences to create the final analysis (Smith & Osborn, 2008, p. 53). Acknowledging and embracing the subjectivity of the researcher and the researcher’s interpretations of the data fits with a primary goal of this project, which is to acknowledge and embrace the subjectivity of the psychotherapist in conducting a psychotherapeutic process. Thus, the interpretative phenomenological analysis method reflects the goals and underlying assumptions of this project.

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Specifically, the interpretative phenomenological analysis involved searching for themes in the transcript of the first interview. I repeatedly read the transcript of each interview and took note of relevant, emergent themes. Following this, I read the transcript several more times and took note of more abstract, universal themes that began to capture the essence of the phenomenon. Then I created an opening list of themes, followed by a “clustering of themes” that become evident from the first theme list (Smith & Osborn, 2008, p. 71). Next I developed an outline of dominant themes which references exact places in the transcript where instances of that theme were found. I followed this process for all the transcripts until I created a “master table of themes for the group” (Smith & Osborn, 2008, p. 75). These master themes were developed into a narrative form for the data analysis section of the final project.

Statement on Protecting the Rights of Human Subjects This research plan has been approved by the Institutional Review Board of The Institute for Clinical Social Work. Protecting the rights of the participants in the research has been of utmost importance to me. I read aloud the consent forms aloud and had each participant sign them to participate in the research. I ensured that each participant fully understood the consent form and gave them a chance to ask any questions or share any concerns about the research.

Each participant was debriefed following each interview. In the debriefing, I asked the participant how the interview went for them and whether they had any

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questions or concerns they would like to further explore. If any participants had expressed any concerns or felt they needed to explore a particular mistake further, I planned to refer them to consultation per my IRB proposal. This was not an issue, however; no participants expressed any concern that required referral to consultation.

As a further protection of participants’ rights, participants were reminded at each interview that they could discontinue the interview, not answer any question, or contact the researcher after the interview. No participant ever felt the need to stop the interview, but there was an occasion of a participant not feeling comfortable answering one of my questions. The data has been kept in a secured location and the confidentiality of subjects has been ensured through use of number identifications (P1 = Participant 1, P2= Participant 2, etc.) in the final dissertation and on the raw data.

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Chapter IV

Findings

Introduction Participants described making mistakes and dealing with their aftermath as upsetting and exposing while paradoxically healing and profoundly liberating.3 First, to orient the reader to the types of mistakes discussed through the interviews, I will explore various categories of therapist mistakes. Next, I will address typical processes that participants experience when they have made a mistake. This will be followed be an exploration of the themes of the vulnerable self, the gray area, and the maturing professional self. Prior to discussing the data, I will briefly touch on researcher prejudgments.

Researcher Preconceptions and Implicit Assumptions Heidegger (1927) wrote that “Whenever something is interpreted as something, the interpretation will be founded essentially upon the . . . fore-conception. An

3 In order to avoid redundancy, anytime a participant mistake is mentioned, I am referring to the mistake as subjectively defined by the participant.

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interpretation is never a presuppositionless apprehending of something presented to us” (pp. 191-192). Made of up of my “prior experiences, assumptions, and preconceptions” (Smith, Flowers, and Larkin, p. 25), my fore-conceptions inevitably influence this research. Setting aside my personal prejudgments and assumptions (“bracketing”) is impossible according to the hermeneutic design of this study, so I am putting them forth as I am consciously aware of them. Doing so embraces the fact that this research project is essentially an interpretative endeavor and that my biases unavoidably shade my comprehension of the data. Addressing my assumptions and biases also emphasizes the double hermeneutic that is at play in an interpretative phenomenological analysis; that is, while the participants are speaking about their lived experiences of making mistakes, I am interpreting their experience through my own particular lens.

Researcher preconceptions.

In many ways, this dissertation is a personal exploration. When I became a psychotherapist, I quickly learned that my mistakes evoked powerful emotions such as shame or guilt, leaving me feeling uncomfortable and confused. I also was uncertain how to differentiate what was a mistake on my part, as opposed what represented the inherent nature of psychotherapy as an evocative endeavor for both involved parties. As a novice, I felt vulnerable when first learning this distinction, especially because I did not know quite where to turn for guidance. Supervision was difficult because I was admitting a

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misstep to someone from whom I wanted respect, and sharing with colleagues was also challenging because I worried about their judgment.

Though my reaction to making mistakes remained strong, I gradually began to talk more openly about this experience with consultants and colleagues. I learned that many other therapists have intense feelings around their mistakes. Yet, there surprisingly did not seem to be enough spoken and written about mistakes. I realized that therapists’ reticence to reveal their mistakes has created a significant gap in the literature; therefore, I decided to study this ubiquitous yet not well understood phenomenon.

Implicit assumptions.

I approach this project not only as a researcher, but also as a psychotherapist in private practice. As such, I have particular ideas about what constitutes good psychotherapy. I was trained as a psychodynamic psychotherapist. After completing the coursework in my Masters and Doctoral programs, I believe strongly in a psychodynamically informed treatment process. Psychodynamic treatment as I see it entails an attempt to understand unconscious communication in the patient-therapist dynamic. Due to the depth of the patient-therapist relationship, I value the greater healing potential of more intensive treatments. I also value treatments that focus on “deeper� issues such as family of origin impact on current behavior over those that focus exclusively on the current symptoms.

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Because my work is influenced by psychoanalytic theory (largely intersubjective, relational, and object relations schools of thought), I have particular ideas about what constitutes a mistake in psychotherapy. I attempted to identify my own ideas about mistakes and notice my personal internal reactions if a participant discussed a mistake that violated my own standards as a therapist. It is worth reemphasizing, however, that the mistakes that participants discussed for this study were ones that they subjectively felt were mistakes in their own practices. I was not the arbiter of what a mistake is for them, and in fact, at times I struggled to understand how exactly they felt they had erred.

Yet, as I have analyzed the data, my subjective interpretations of participants’ experience have been present. My awareness of this double hermeneutic is the most critical piece of the analysis because I realize that I am not the evaluator of the “truth” about mistakes, but rather I provide merely one lens through which we can consider this phenomenon of making and living with mistakes. This idea mirrors how I think about psychotherapy−as the therapist I am only one, subjective person who functions to help the patient understand his internal conflicts. I am not the expert who is able to provide the patient his ultimate truth; rather, I facilitate the patient discovering an ever developing narrative about himself, realizing my own fallibility in the process.

Categories of Mistakes Participants discussed many mistakes in the interviews. They talked about mistakes that barely impacted them, and mistakes that still feel exceptionally painful

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years later. As I analyzed this broad spectrum of mistakes, several categories of mistakes emerged in the data, including mistakes of avoiding, disconnecting, acting out emotionally, proving worth, incompetence, and under or overestimating the patient.

These categories will be explored below.

Mistakes of avoiding.

One category of mistakes emerged in which therapists were avoiding something or trying to “be the nice guy” (P8). This avoidance led to evading fee issues, “chitchatting” (P3) with the patient rather than addressing difficult issues, staying surface instead of going deeper, sidestepping the patient’s aggression, and staying passive by not addressing various issues. P8 observed that “I could hide behind [the idea] that I could be nice, but . . . that’s not really what the deal is. I think the deal is more hiding, not wanting to deal with some of the people’s explosions and upsets.” Therapists in this type of mistake attempt to stay in the position of being perceived as “nice” and thus avoid having patients get angry at them and going deeper into the work by exploring that anger.

P7 reflected on a mistake of avoiding. He was seeing a patient who often cancelled at the last minute. The patient struggled financially, and P7 felt badly charging him for his late cancellations. P7 commented: He would call and say, “Oh, I’m so depressed.” He lived kind of far away. He’d say, “I just woke up, I’m never gonna get there.” And we’d talk a little on the phone and he’d say, “No, I’m fine,” you know, as far as being suicidal or anything. . . . And I would think, “Boy, I should tell him what I have to charge you.”

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P7 was never able to charge this patient for late cancelling. He avoided the patient’s anger and “leaned too far in the empathic nurturing side. And that really . . . wasn’t what he needed then.” P7 noted that generally he finds it “easier . . . to be understanding and warm and accommodating,” and that he experiences it as challenging to deviate from this nurturing stance.

Mistakes of disconnecting.

Another mistake category consisted of disconnecting from the patient, or “missing the boat.” These mistakes consisted of things such as not paying attention, losing awareness, forgetting details, and being emotionally distant from the patient. While mistakes of disconnecting often initially appear superficial, upon closer examination there are usually reasons why the therapist erred.

P1 revealed a mistake in which she was seeing a student on academic probation from school. In order to return to school the following semester, the patient was required to get the school’s psychiatrist to fill out paperwork for her. P1 asked the patient several times if she had gotten the paperwork filled out, but when the patient was avoidant about answering, P1 “just kinda let it slide” and “didn’t pay much attention to it.” The deadline passed for submitting the paperwork and the patient missed it without any reminders from P1. This meant the patient would have to wait until the following academic year to re-enter school.

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While this mistake seemed to be about a lack of attention on P1’s part, as P1 dissected the mistake she realized that she was also responding to dynamics in the patient. The patient had a pattern of avoiding important tasks in her life. P1 reflected: On the one hand, I felt really badly, because not she was not going to be able to come back to school. And, on the other hand, I also felt my unconscious had set it up. . . . I had ignored something so obvious, but in a way my unconscious had withdrawn from helping her make this happen. Because, honestly, if it had happened–if I had taken the bull by the horns and I had made it happen–I think she would have failed in coming back, because this pattern is so powerful. And I had no idea how it really functioned until I saw it in play.

P1 can see both sides of her mistake. She feels badly that she “missed the boat” by not confirming that the patient turned in the necessary paperwork. Yet, when P1 examined her mistake, she understands that she had an unconscious motivation for the patient not to return to school because some part of her felt it was in the patient’s best interest not to do so yet. Thus, mistakes of disconnecting often have much deeper roots that illuminate the apparently simple slip.

Mistakes of acting out emotionally.

Yet another category of mistakes centered on therapists acting out emotionally with patients. This category of mistakes, where “my own feelings come up too strongly” (P1), included getting too emotional with patients, which often led to therapists having spontaneous reactions that hurt patients’ feelings. Mistakes where therapists described acting out emotionally tended to have the most emotion around them and be the most difficult to understand.

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P5 discussed a mistake in which she had a strong emotional response to a late adolescent male patient who was the same age as her son. After a period of time where the therapist and patient had been getting closer, this patient made a somewhat “sadistic” comment about how a past therapist was a better listener. P5 stated that the patient’s comment “hurt my feelings,” which led her to respond defensively. P5’s defensive response then created a disconnection between P5 and the patient just as they were terminating.

P5 could not remember her exact actions, only that “I’m usually nicer.” She withdrew from the patient and never addressed her mistake before the patient went away to college. P5’s difficulty remembering her response speaks to the powerful feelings and vulnerabilities that were evoked in the interaction. P5 noted about the situation: I think I did take [the patient’s comment] a little personally. . . . And, for whatever reason, there was something that didn’t quite get repaired. . . . It wasn’t anything anybody would sue anybody over, but I could have done a little better on that subtlety. You know, if he was a little bit of a hurt kid, I could have done a little better on that.

P5 reflected that the patient hurt her feelings more than he would have otherwise due to her own college age son launching at the same time, which caused her to withdraw and avoid dealing with her hurt feelings “because my mother’s heart was on my sleeve.”

Mistakes of proving worth.

Participants described mistakes that fell into the category of proving their worth to the patient. Examples of this sort of mistake included over explaining things to the

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patient, and being forceful with the patient about going deeper, faster, and further in the work. Mistakes in this category tend to happen when the therapist is functioning more as a cheerleader to get the patient “happy” than a psychotherapist who will help them explore their feelings.

P4 stated that these sorts of mistakes relate to “my own need to feel like I’m giving [patients] their money’s worth. I’m providing them with a service; I’m doing my job, and doing a good job.” When therapists make mistakes around proving their worth, they function to allow the therapist to feel useful and important.

P2 erred while working with a new patient. The twenty-something male was talking about a potential girlfriend he was excited about dating. Interwoven with his narrative, he also subtly conveyed many possible problems with the relationship. P2 interpreted these problems and their connection to the patient’s history. When the patient left session, he made a comment seemingly out of nowhere to P2 about feeling like he had been punched in the nose. P2 felt the patient was communicating that he had metaphorically felt punched in the nose by P2’s interpretation. In reflecting on his mistake, P2 noted that he was trying to be helpful by warning the patient of the potential pitfalls in this relationship, but that he felt, at times, [in] trying to establish myself as helpful, useful to people, I go overboard. Here’s what I see, here’s what I know, grandiosely saying, “Look what I can do for you.”. . . And people are, “Well, that’s good for you, but . . . I don’t want those dots connected.”

Mistakes of proving worth can involve connecting dots before the patient is ready to have them connected to satisfy the therapist’s motivations rather than staying closer to where the patient is from moment to moment.

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Mistakes of incompetence.

Another category of mistake is simple incompetence, or “I don’t know how to do something” (P1). This mistake was referenced less frequently, which may relate to how vulnerable it feels to acknowledge blundering due to lack of skill. P7 talked about his sense that some of his mistakes stem from a “lack of technique, lack of training.” He finds it particularly difficult if he realizes he does not have training to work in the area of a patient’s particular issue.

P11 related a mistake from her internship in which a patient shared traumatic material. P11 was confused about what to do with this material. She talked about her experience of going over the mistake with her supervisor: [The patient] was giving me puzzle pieces and it’s my job to put the puzzle pieces together and I didn’t know how to. At some point as I was playing the tape for my supervisor . . . I stopped it and said, “I have no idea what I’m doing here,” and he said “Neither do I.” It was very clear that I had no road map.

The metaphor of having no road map captures P11’s experience of having no idea where she is going clinically with this patient and no idea how she will get there because she did not have the clinical experience to put those puzzle pieces together with the patient.

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Mistakes of underestimating or overestimating the patient.

Participants discussed the difficulty of accurately assessing how much a patient can tolerate in the psychotherapy process, and that mistakes of underestimating or overestimating can happen when they miscalculate that in either direction.

P7 erred when he tried to avoid describing a patient’s harsh negative introjects with jargon, interpreting to the patient that she was “ripping on herself.” The patient felt wounded by his comment because she thought P7 was saying she was deliberately harming herself. P7 reflected that he wounded his patient by underestimating that she could understand clinical terminology for a concept. Now, he tends to be more exacting with his language and not fear that a patient is incapable of hearing the clinical term if he chooses to use it.

More commonly, participants overestimated their patients and this led to many different mistakes. P8 talked about his belief that he can work with anyone and reflected: I’m learning, or I’m trying to learn, that therapy isn’t for everybody, and I’ve tried to work with some people who may be too sick or too impulsive and that I think they have some capacity for insight that they don’t. They’ve regressed too much.

Regression in the patient was the most common response to overestimating a patient’s capacities. P4 discussed a case in which she worked with a precocious young man from adolescence through his late twenties. Over time, and through many mistakes on P4’s part, the patient dramatically regressed and was hospitalized after threatening P4’s family. In wondering why the patient regressed, P4 reflected: I may have thought he was more capable than he was. . . . Sometimes I wonder if I thought that his emotional capacities were more intact than they were, that his basic structure was stronger than it was. . . . I wonder, a lot, if I was too

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ambitious in my beliefs that he could benefit from a really dynamic treatment. . . .

Or if my hopefulness for him–my supervisor thinks that my hope was a mistake in a way, in that I was ahead of him. I thought he could be well. I thought he had so much potential and so many strengths.

P4 felt that her overestimation of this patient may have led to mistakes because it made her see the patient and the situation less clearly. She saw in this patient certain positive qualities that gave her hope for him that psychotherapy could heal him. Her hope could be viewed as a mistake because it blinded her to his more pathological qualities, leading her to make judgment calls that were not in her later opinion good for the patient.

Processes Unfolding around Mistakes There are several different processes that arise following making a mistake. These processes may usefully be thought of as part of the overall experience of making a mistake that builds, grows, and continually develops nuanced elements as time passes.

This experience is multi-layered and multi-dimensional. As such, similar to the stages of grief, these processes are not necessarily experienced in a linear fashion by participants.

The order chosen by the researcher to present the processes reflects a common experience shared by many participants; nonetheless, it is important to emphasize that even within the same interview, the same participant shared differing timing on entering these processes and differing experiences of being there.

Following making a mistake, participants described experiencing the following processes: initially registering the mistake, responding to the mistake emotionally and

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clinically, understanding the mistake, repairing the mistake, and living with the aftermath of the mistake. Each process will be addressed below.

Registering a mistake.

Initially registering a mistake is the moment when it hits the therapist that she has erred. This moment can happen during the session right after making the mistake, or it can happen later upon reflection. Several therapists described what might be called the “oh shit” moment when it hits them that they have made a mistake. This moment can be experienced as a “momentary loss of control. . . . and then a certain amount of humility goes along with it” (P5).

There is a loss of control for participants in registering a mistake because it is a moment of the therapist not living up to her own internal standards for herself. It is a moment of the therapist’s humanity being undeniably displayed and the experience of having this registered for the therapist seems to be both surprising and vulnerable in the sense that it is exposing. Many participants described this moment as humbling, shaming, or both.

Therapists also registered they had made a mistake if they sensed something did not feel right in the dynamic, even if the patient did not openly react to what the therapist just did. P8 described this aspect of his experience: It’s probably not very scientific. It’s really a visceral kind of bodily reaction. Like, oh, that didn’t work well, or that wasn’t how I wanted that to come out, or I’m feeling, “There’s more affect [in the patient] than I thought.”

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P8 identifies a gut reaction piece to registering a mistake that is hard to describe yet gets experienced somatically. P8 elaborated on this experience for him, sharing, “Your heart races a bit, or you feel a little heavy. You’re just like ugh, that didn’t go right.”

Other participants also identified a somatic component to registering a mistake.

P9 noted that her cheeks can flush, her heart races, and she gets a physical sensation that she described as a “pit in my stomach” when she thinks she has made a mistake. P11 noted that “there’s a squeeze in the stomach or a constricting of the throat. . . . I notice my breathing is more shallow.” She thinks of it as “my body is telling me something is wrong.”

Sometimes a mistake does not register in the above way and therapists go through a more cerebral process of deciding if their actions were a mistake, using “clues” (P3) to make the determination. Generally, two different factors serve as clues: patient reactions and therapist reactions. Participants noticed certain telltale behavioral signs such as that “[patients] don’t show up, they don’t sign their check, they act ticked off, they show up late” (P5).

Participants also observed patient’s emotional reactions, especially if the patient seems “checked out” (P1), confused, hurt, or visibly angry. If the patient comments that he is hurt, the therapist will often conclude her actions were a mistake. P2 said that he usually concludes his actions were a mistake in those situations because he “never aims to hurt.”

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Responding to a mistake.

Therapists discussed a wide range of emotional responses to making a mistake.

Participants predominantly mentioned shame, guilt, anxiety, feeling humbled, fear (about competence level, of exposure of mistake, that the patient will be hurt or withdraw), surprise, and self-compassion. Each individual mistake elicited a different reaction. The reactions were impacted by therapist mood and confidence level, the particular patient, and the dynamics going on in that treatment, as well as how serious the therapist deemed the mistake to be. Further, these reactions tended to shift in intensity and character over time. P11 summed up this difference in reaction by observing, “There are days when I’m just like, ‘Oh, I shouldn’t have said that.’ And then there are days when I’m like, ‘I suck.’”

Shame.

Shame held a central, powerful place in participants’ responses to mistakes.

Participants tended to feel generally “yucky” as P1 put it. P8 described his inclination to react emotionally to mistakes: “I just kind of beat myself up, or the tendency is at least to beat myself up. I’m bad, I shouldn’t have done that.” P8’s description of his feeling that he is bad as a result of his mistake illustrates the experience of shame that can come with mistakes for many participants–the mistake makes them globally bad as a therapist, and sometimes touches on deeper dynamics of how “bad” they are as a person.

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The internal dialog accompanying shame tended to be negative. P2 described what his internal dialog might be upon making a mistake: “Dumb ass, what did you say that for?” or ‘Well, you sort of earned that one, didn’t you?’” P3 noted she might say to herself, “I really screwed that up.” Upon erring, P6 thought, “That was really inappropriate.” P7 simply shared that he would use “colorful language” with himself and noted that “I could probably get pretty pejorative with myself. I’d say, well . . . I screwed up. . . . I hate to say the times I might say oh, maybe . . . I’m not suited for this work.”

Anxiety and fear.

Participants also described anxiety, fear, and a general feeling of being unsettled as emotions that accompany mistakes. P1 shared that her mistakes can generate “an enormous sense of anxiety,” and punctuated how anxious they can make her at times by noting that “I’ve had nights where I stayed up because of something I’ve said or done.”

P1 feared being publicly exposed for her mistakes; she worried that a colleague or someone in the community would find out and judge her to be a bad therapist. P2 observed that his experience can include a sense of being worried about consequences of his mistake, wondering “how will this come back to bite me?”

P7 noted his feelings of insecurity: “I mean, might as well be honest, like . . . do I have too much pathology to do this work?” and “Am I not smart enough?” P7 highlights the difficulty of sharing such a vulnerable, raw thought with his comment that he “might

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as well be honest.” Many participants shared a sense of insecurity in relation to other therapists. P11’s thoughts might include “Maybe I did something wrong. Maybe somebody else would have been better. That’s not a good feeling, when you feel that someone else could have done a better job.” For P11, part of the response to a mistake included suspecting that another therapist would have handled this in a superior way while she has bungled it.

Sometimes the anxiety veered more towards contemplating the right course of action. P11 revealed that she might ask herself “Should I have known better? Was it not the standard of care? Is that not what normal people, normal therapists, would do or say?”

In this case, P11 ruminated on whether other therapists would have done a better job or not be in this situation at all. She compared herself to other therapists and wondered about her own competency in reaction to a mistake.

P4 described some ruminating questions she pondered with a particularly difficult case: I don’t know how much of it was my fault. . . . . Would this have happened [patient decompensates and is hospitalized] without the treatment? Would this have happened with a better treatment? Would this have happened with a different treatment? Would it have happened sooner with a worse treatment?

P4 tries to understand how to assign blame for a case that ended poorly. Where does the “fault” lie and how can she figure this out? She ruminates over if someone else could have perhaps done this differently or better so the undesirable outcome would not be the same.

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Surprise and curiosity.

Some emotional reactions to mistakes can be more neutral and even positive. One reaction shared by participants included surprise in reaction to making a mistake; participants described experiencing a variant of “I can’t believe I just did that!”

Participants also reacted with curiosity and asking lots of questions of themselves. P6 might ask herself, “I wonder why I did that?” The surprise and curiosity was experienced in a more neutral, less blaming way. They were curious and perhaps taken off guard that they had made a mistake, but not necessarily overwhelmed with shame or anxiety.

Empathy and compassion.

Therapists also experienced understanding and compassion in their response to some mistakes. P5’s reaction to a particular mistake was “complete empathy with myself.

I wasn’t mad at myself.” P5 also felt compassion for herself in another mistake where she was caught on video in a family session by the adolescent daughter in the family rolling her eyes at the end of a difficult session. The adolescent then withdrew and refused to be engaged in the therapy, which was a mystery to P5 until it finally came out that the adolescent had seen her rolling her eyes: “My fantasies would have been far worse than, ‘Oh, dear, I rolled my eyes.’ Of course! I was exhausted. They were a complete handful.

Of course I rolled my eyes! Why wouldn’t I roll my eyes?! [laughter]” P5 initially feared the worst but then came to a place of empathy for herself about this. Years later as she told the story to me, she even heartily laughed.

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P7 also noted a compassionate response that he sometimes has when he makes a mistake: You know, I could have done better today . . . but it’s like, all right, I’m gonna get back on the horse. Maybe today I missed some pitches, but boy, on Monday I was doing great. You know, remind myself . . . this isn’t so global.

Though P7 is aware he isn’t happy with his actions, he is able to use his soothing self-talk to put his mistake in perspective and not conclude that he is incompetent in his role as a therapist.

Understanding the mistake.

Another process involved reflecting on the reasons why the mistake happened.

Therapists wanted to understand why they had erred in order to regain a sense of control after making a mistake. This process of being reflective about the mistake may not ever happen, or may happen much–even years–later. Some mistakes were so traumatic that when participants described them in the interview, they were considering reasons behind them for the first time. Several participants noted they had made mistakes that they never thought about in any depth and avoided facing entirely. Thus, some mistakes were not deeply or even superficially considered if they were particularly painful or evocative.

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Emotional reactions.

The biggest source of mistakes was a therapist’s personal emotional reactions to her clients. P1 observed how this process affects mistakes: “Our personal story affects the areas that . . . catch us off guard again, and again, and again. Even if we’re aware of it” (P1). P1 is mindful that her conscious awareness of personal issues does not stop her from making mistakes that can be traced back to those issues.

P1 highlights how the unconscious impacts mistakes that therapists make in the emotional realm. Being “caught off guard” describes what therapists experience when they once again fall into making a mistake that is based on an old, familiar dynamic from their history. It is an unnerving, anxiety-producing experience to be taken by surprise that an old dynamic in the therapist has impacted their work with a patient and caused them to do something they regret.

Enactments.

Therapists also shared that their mistakes were driven at times by enactments, or the therapist unconsciously hooking into something in the patient’s unconscious. P8 erred when he observed to a female patient struggling with issues around her sexuality that her clothing looked rather androgynous. The patient was upset by his comment. After the session, she left him several angry messages that culminated in her demanding a several week break from therapy. P8 knew that this patient experienced men who apologized as

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weak and capitulating, yet he called to ask her to come back to therapy before the two week break ended in spite of this knowledge. P8 observed: There’s no question that I felt like my defenses were a little down and then I got sucked into something and we were enacting. . . . You know, enactment of her feeling [that] I was not respecting her wishes, or not doing what men are supposed to do.

P8 felt something in his unconscious was activated in the dynamic with this patient. This unconscious activation caused him to act against what he knew consciously would be the more prudent course of action (i.e., to tolerate his own anxiety about the situation and wait for her to come back after two weeks).

Challenging treatments.

Therapists also reflected on how challenging treatments contribute to their mistakes. P2 referred to a patient with whom he had made several mistakes as “unquestionably the most difficult kid–person–I’ve ever worked with,” and connected his ensuing mistakes to how generally challenging he was for P2. P3 discussed a mistake where she shocked herself when she spontaneously told a client contemplating an affair that it was a “chicken shit way to get out of a relationship.” P3 commented that “it was such a messy, complicated case. It was really ugly.” She described the patient as extremely difficult to work with and felt that because she was stretched to the limit emotionally in this case, she was more likely to say something out of character for herself as a therapist.

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Reasons for mistakes multi-determined.

Participants sensed that many, if not most, mistakes have a mixture of contributing factors. This was especially true if participants got beyond their initial selfblame and could also see the relational dynamics at play. P4 described a minor mistake in which she gave a patient an unsolicited referral to a new psychiatrist. The patient had just been diagnosed as bipolar by her psychiatrist and wanted to stop seeing the psychiatrist and take herself off all her medication. When P4 heard this, she spontaneously gave the patient a referral to another psychiatrist for evaluation even though the patient did not request this.

P4 experienced giving the phone number to the patient as a mistake because she felt in doing so she was communicating to the patient that she could not manage her life on her own and needed a psychiatrist to help her. P4 also felt she was managing her own anxiety about the patient going off medication rather than responding to something in the patient. P4’s reflections on this mistake are a good illustration of how mistakes often have many contributing factors: That mistake was much bigger than just the words exchanged. It was about the state of mind I was in, my feelings about being able to . . . manage this patient alone. My feelings of not having a team, my feelings of having somebody go off these heavy duty meds right after being diagnosed bipolar, and feeling like I’m competent enough to just be it–to be the only pair of eyes on this girl.

P4 identifies a number of factors that contributed to even this minor mistake–her personal state of mind, her anxiety of being alone with the patient if the patient suddenly stopped seeing the psychiatrist, her reactions to the patient’s new diagnosis and what it

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would be like to treat her without a consulting psychiatrist or medication, and her feelings about her competence as a therapist.

To further complicate matters, the psychiatrist this patient was planning to leave was a personal friend of P4, and it stirred up anxiety for P4 to think of referring her patient away from him. Additionally, the mistake did not occur in a vacuum: it happened in a dynamic with the patient, who was very depressed and yet thinking of drastically changing her situation by suddenly pulling herself off medication. Thus, mistakes can be experienced as having many different contributing factors, and the realization of how many factors contributed can unfold over time and become clearer as the therapist gets more distance from the mistake.

Repairing the mistake.

Repairing the mistake with the client represents another process therapists experience after making a mistake. Therapists at this stage decided whether to address the mistake with the client directly and how best to repair it. It must be emphasized that if the mistake was more painful or for other reasons was not being directly dealt with by the therapist, then this process was not fully experienced, if at all. Many therapists, however, did explicitly consider the best way to repair their mistake and how to go about implementing this plan. Repairing the mistake was repeatedly emphasized as a critical element for therapists in the experience of making a mistake and reconciling it.

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Apologizing.

One dimension of repair was the consideration of whether to apologize for the mistake to the client. This area was fairly divided among study participants. Many therapists never or almost never apologize to their patients for a variety of reasons, while many other therapists would not consider omitting an apology following a mistake. Many therapists felt that apologizing cut off an opportunity for growth and exploration of the transference, while many other participants believed that it cut off an opportunity for healing if they erred and did not apologize.

The experience of apologizing was described as healing yet uncomfortable. For P1, it feels good because it is liberating to admit the mistake and model that for the patient, but it also feels vulnerable because it is exposing a flaw.

P7 observed that apologizing “can be a risk. You know, like if I say, ‘Oh, I made a mistake’ then are other people gonna think, ‘Oh, my God . . . this guy’s incompetent.’”

P7 believes that apologizing is a good thing clinically but it brings up vulnerability in him: “I might feel like [apologizing is] a healing, truthful thing, but yeah . . . wondering where might they run with this in their minds.” Acknowledging a mistake by putting forth an apology can be a healthy thing for the therapist-patient relationship and the treatment, but the therapist still might feel uncomfortable. P7 ponders what the patient is doing with the knowledge–confirmed through an apology–that his therapist has made an error and is imperfect.

Apologizing also seems to bring up the fear of what the patient might be thinking of the therapist and their competence level. P9 noted that apologizing is “sort of a

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humbling thing to do” (P9) while for P2 apologizing can have the feel of conceding to the patient that “you got me” (P2). This concession of “you got me” underscores how vulnerable making a mistake can be and how there can be resistance to acknowledging it openly through an apology.

Therapists apologized for a myriad of reasons. Therapists apologized for reasons that related to their own motivations, for reasons that had to do with the patient and the treatment, and more commonly a mixture of both.

Therapists apologized to relieve themselves of uncomfortable feelings around the mistake. P2 stated that “I own up to it, maybe to rid myself of it,” reflecting that he sometimes thinks his apologies “may even just be for my own relief.” P2 also apologizes to get reassurance from the patient that “it wasn’t such a big deal.” P2 observed that his apologies may psychically relieve him of carrying the burden of the mistake. During the course of the interviews as he examined his tendency to always apologize for his mistakes immediately, P2 began to consider holding off on his apologies to allow the patient time to react to his mistake.

Participants apologized as a part of their overall effort to be authentic with patients. P10 felt that her apologies for mistakes were an outgrowth of her authenticity as a therapist, and that they were healing in part because they are real: “I’m just extremely authentic. If I feel like I’ve done something wrong, I will say I’m sorry.” P10 felt that her patients were receptive to her apologies and that it typically felt mutually beneficial to her and her patients when she apologized.

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Not Apologizing.

Participants also reflected on many reasons why they might not apologize.

Therapists did not apologize for a mistake if they were not certain that they had erred. P2 observed this, stating, “They might not like what I’ve said, but I feel like, this may not necessarily be a mistake.” Just because a patient has a negative response to one of his comments, P2 will not apologize. He must feel certain that he has erred in order to make an apology.

Some participants did not apologize because they wanted to stay with the patient’s agenda and not their own. P4 sought consultation on her mistake of referring a newly diagnosed bipolar patient to a new psychiatrist for medication out of her own anxiety.4 After talking it over in consultation, she did not bring it back up in the next session, much less apologize for her mistake. P4 described this as a process of “following [the patient’s] lead. . . . Waiting consciously during the next session to see if [patient] was gonna bring it up.” P4 did not apologize because she did not want to interject herself into the session in an unhelpful way: “My agenda, my ideas, my apologies.”

P4 believes that apologizing emphasizes the mistake when the patient may or may not have chosen to actually mention it. In her conception of psychodynamic theory, it would be negative for the treatment and the patient for the therapist to apologize when the patient has not referred to or seemed bothered by the mistake.

This mistake is originally referenced on pages 76-77.

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Avoiding mistakes and apologies.

While some therapists were direct about mistakes with patients, others acknowledged that they tended to avoid the issue of apologizing and acknowledging mistakes altogether. P11 noted: My tendency is to pretend it didn’t happen. I mean, that’s probably what my personality might do. That’s my habit. I try not to do that. I try to address it, be conscious of that, because I know my tendency is to avoid.

P11 is aware that she tends to avoid her mistakes, so her solution is to attempt to stay conscious of that. P11 also tries to use her awareness to avoid making the mistake entirely: I could be deluding myself, but I feel like I’m so hypervigilant about what I’m saying and what I’m doing that I would like to think it lowers my rate of mistakes.

I’m always trying to be present and trying to figure out what’s going on and what I’m doing. And therefore I’m also preempting the mistake. . . . My desire to not make a mistake comes out that way. Saying over and over again, “I’m open to hearing you if I’ve done something wrong.” So, if anything, I feel like I’m a little hyperaware of the moment to moment happenings that I catch them before they do, maybe?

P11 wants to avoid the entire experience of making a mistake and then having to apologize for it, so she carefully tries to control her actions and frequently checks in with the patient about whether she might be making a mistake. Though P11 hopes to lower her rate of mistakes due to her hypervigilance, she also is aware that “I could be deluding myself” (P11). She ends her comment that she hopes to catch mistakes before her patients do with a hopeful and uncertain “maybe?”, also indicating P11’s uncertainty that her system for avoiding mistakes is actually working.

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Despite her increased awareness and attempts to avoid the experience of making and repairing a mistake, P11 knows that she may not be able to pre-empt her mistakes.

However, she does have the notion that using her hyperawareness to meticulously track every happening in the dynamic with the patient will allow her to notice if she has erred before her patients do. P11 hopes to mobilize her hypervigilance to prevent mistakes and if she is not able to preclude them, she will hope to catch the mistake first so she is not caught unawares. P11’s desire to avoid mistakes and apologies speaks to her desire to control this process and the sense of being out of control that making a mistake can bring up for her.

Using the mistake.

Participants wondered whether to use their mistake clinically. This process may not be conscious, or may not ever happen if the mistake is one that a therapist puts out of her mind entirely. P6 observed that “[mistakes] have very different lives,” emphasizing that she uses some mistakes to help further the treatment, and she does not use others depending on the particular treatment. Participants noted that not all mistakes need to be used in the treatment with the patient but rather are the therapist’s responsibility for handling internally.

Participants used their mistakes to deepen their relationship with clients. P2 observed that “if two people can say either ‘I hurt you [or] you hurt me, but, we can understand each other better now,’ that absolutely brings the relationship closer.” P5

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erred when she recommended to a patient that she should attend a 12-step meeting. She suggested it several times and initially did not consider this a mistake. The patient later disclosed that she experienced the therapist as “pushy.” She did not tell P5 this directly, but rather told P5 about how another friend had encouraged her to go to a 12-step meeting in a gentle way.

P5 realized that the patient was subtly contrasting her actions with this friend, and understood from the patient that she felt P5 was being aggressive. P5 was intrigued by the patient’s delivery because she generally experienced the patient as being “pushy” herself, and found it notable that she did not share her criticism with P5 directly. P5 felt in retrospect that her insistence that the patient attend a meeting was a mistake. P5 observed that “in the process of that disclosure [that patient felt pushed by P5], it’s brought us a little closer.”

P5 could diagnostically see the pushiness in the patient and was reminded by the patient of her own tendency towards pushiness, which perhaps made them feel closer because they share this quality in some basic way. Also, P5 caught the patient’s subtle criticism of her and they could talk about it, which led to an increased sense of connection. The mistake and its resolution also caused P5 to be more connected to this patient in terms of how carefully she is paying attention: “Now . . . . I will be much more closely tuned into what’s going on in terms of the relationship with me, and how she is feeling and processing things”.

Participants also used mistakes to yield diagnostic information. P2 described a mistake in which a teenage patient revealed that he played video games at his father’s

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funeral rather than participating. The patient felt guilty that he was emotionally disconnected at the funeral. This patient had disclosed many things about his relationship with his father that sounded to P2 like the patient might be angry with him, so “without a lot of thought,” P2 said to the patient, “Well isn’t that how he treated you? Sort of as if you weren’t there?” The patient reacted to this comment strongly and immediately defended his father. P2 observed: It hurt him that I could think that. I don't know. It's funny. It helped–it was definitely a mistake and was poorly timed, maybe not accurate, but I did gain from it more of a developmental sense of him. Just watching him respond to me, he's sitting on the couch. [laughs] There was just something in his body posture.

All of a sudden, I had a vision of this kid playing a video game. He felt small, and latency age. Kind of like, “My dad was a hero. What are you talking about?” And I was, okay, now I have a better idea of who I'm dealing with. Never mind that his dad had another child, died of [addiction] [laughs]. But this kid needed, at least for now, he needs to in some ways remember his dad as, “No he was there for me.”

Without the mistake, P2 did not feel he could have seen as clearly that the patient still had that latency age child inside him, so the mistake gave him a very different diagnostic sense of the patient. His mistake allowed P2 to evoke a very distinctive picture of this patient that he could use to help him treat the patient.

Many therapists also used their mistakes to help them pay more attention, noting that their mistakes served as “a little wakeup call” (P1). P5 described this as “hav[ing] my antennae out now” (P5), and P6 shared that mistakes would cause her to ask herself lots of questions about what is actually going on in the treatment: [Mistakes] are so telling, often more times than when things are going really well.

It’s a kind of wake-up call, like what’s happening here? Why am I having this empathic breach? Or why am I not present with this? What didn’t I get? Or what is this client trying to tell me by not responding to this? There are just so many things to look at.

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Participants used their mistakes to increase their focus on the patient and understand what is going on in the treatment.

Participants also used mistakes and the repair process to help patients deepen their understanding of themselves and how they relate. P6 shared that she used her mistakes as “an opportunity to deepen people’s understanding of how they relate and hopefully . . . feel safe with talking about things that can feel difficult” (P6). Following a mistake, she asks her patients “what does it feel like when somebody hurts you, or somebody disappoints you?”

P7 erred when he double booked his hour, and he sent one of the patients away with the opportunity to come back later that day. The patient declined to come back because it would have meant she had to disappoint her son by not spending time with him. In her next scheduled session, the patient was pleased with herself for declining P7’s offer to meet later. She told P7 that was a huge moment for her because she took care of herself rather than prioritizing P7’s feelings (i.e., making P7’s mistake of double-booking easier for him by rescheduling the same day). P7 processed his mistake with her and used it to help her deepen her own understanding of how she takes care of herself and what sort of boundaries she has with others. P7 commented: She was sort of a dependent, passive person, so for her to say no, she couldn’t come back at that time . . . that is really wonderful. She grew a lot in that treatment in being more assertive, being able to say no, advocate for her own needs. Yeah. She grew a lot around that.

The mistake gave the patient an opportunity to practice taking care of herself by setting healthy boundaries, and thus led to growth for her.

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Aftermath.

Therapists must also live on an ongoing basis with the aftermath of a mistake, which can be experienced as a wide range of emotions that change–or do not markedly change–over time. Therapists described tolerating and living with a range of reactions to a mistake, including worry, guilt, self-blame, shame, fear, empathy, curiosity and understanding.

Dealing with aftermath in personal therapy.

Participants described dealing with feelings around their mistakes in consultation and their own personal therapies. P3 reflected on a mistake where she incorrectly told a teenage girl patient that she might have to report an older male who was acting inappropriately toward the patient to DCFS. P3 experienced it as a big “relief” to talk to her colleagues about this case and get consultation that she did not need to report anything to DCFS, followed by a further relief to talk to her personal therapist about the case and why she felt the need to jump in and protect this patient. She related her mistake back to times she did not feel protected as a child, and realized she feels “this super responsibility to protect someone else.”

The aftermath of the case shifted from immediate worry and fear that she had negatively impacted the patient and the therapy, to relief after discussing her worries with consultants and her therapist. P3 then apologized to the patient, which provided an increased sense of relief and an ability to move on from the mistake. Once P3 had insight

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into how her personal safety issues had played into her mistake, she felt more at peace about it and was able to untangle her own emotional reactions from what she needed to be doing to help this particular patient clinically.

Developing mixed reaction to the mistake.

Internally handling the mistake sometimes meant gradually developing a more mixed reaction to the mistake. A mixed reaction consisted of both seeing the therapist’s own part in the mistake as well as seeing the dynamics at play that may have contributed to the mistake. Several therapists mentioned this process of shifting from a more onesided explanation of the mistake that usually centered on self-blame to a more complex understanding of many components of the mistake.

P5 provides a good example of this process, and also illustrates the way that therapists can go back and forth in their experience of handling the mistake internally.

Here P5 reflects on internally handling a mistake in which she reacted defensively to a patient and then never really repaired it before he left treatment:5 Well, it’s still there on my conscience. So, when you called [for the study], I thought, oh, that wasn’t . . . I don’t feel one hundred percent about that. On the other hand, part of me feels like this is what he does. Part of me doesn’t feel bad. I do think he pushed buttons. But I hold myself to a little higher standard than that.

P5 shows how over time, as she has tried to work through this mistake, she has developed a more mixed reaction to it; she can now see that this patient’s particular dynamics played a part in her defensive reaction that she experienced as a mistake. The

5 This mistake is discussed in more detail on page 62.

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patient made a comment that she experienced as sadistic, and P5 did not respond in a purely nurturing way.

In other words, P5 can see she is not entirely to blame for her mistake. P5 is in a dynamic with this patient and this dynamic contributed to her mistake. Further, this dynamic that the patient has with her is a dynamic he also has with other people in his life. Yet, P5 still ends with saying that she does hold herself to a higher standard, so she is still clearly holding some uncomfortable feelings about the mistake even as she also can appreciate how the patient contributed.

Positive aftermath.

Sometimes mistakes help the therapist learn and grow. P1 held her mistakes as “a blessing in disguise” despite a feeling of vulnerability that she had made them; she felt that her mistakes help her stay awake and alert as a therapist, stating: It makes me pay attention when I make a mistake. So, it's always a little wake up call, like “Oh, [P1], you didn't pay attention to that.” And, I think that's one of the things in therapy that's so challenging is to be really, really present. . . . And we can't ever one hundred percent be aware of what's going on. . . . So, the mistakes, to me, make me think about something and revisit it and pay attention to something I'm not particularly tuned into.

Participants also believed that their mistakes helped them learn not to repeat the same types of errors. In sharing a case where a patient left treatment ostensibly over a mistake he made, P8 observed: I think I’m much better, or try to be much better . . . when people go on the attack of just absorbing it . . . and try[ing] not to get provoked. There are patients

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because of my work with [that patient] and that mistake that I’ve definitely held in treatment.

Making a mistake with one patient helped P8 become more conscious of his global tendency to get provoked and anxious when patients become enraged with him. In several treatments, this increased awareness helped him to step outside his usual way of responding and do something different and more helpful.

Mistakes that “just sit there.”

When a patient has left treatment–sometimes over the mistake–and there is no or very little resolution to the mistake, living with this is challenging for participants. P1 described this as “the kind of mistake that just sits there.” Mistakes that just sit there are those that do not markedly shift over time; they remain disturbing for the therapist even as time passes.

P1 described a mistake in which a patient developed a persistent negative response to any of P1’s interventions. P1 began to feel uncomfortable because the patient started to believe that P1 had “an anti-gay thing." This was on the backdrop of the patient struggling with her sexuality and deciding whether to come out as a lesbian. After some time, the patient decided to leave therapy with P1 to see a gay therapist because she felt that P1 was judging her for her sexual preferences no matter what P1 did to reassure her this was not the case.

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P1 felt her mistake related to not being able to explore the transference because it was too vulnerable for her.6 In reflecting that this mistake left her feeling “yucky,” P1 talked about the torment of having to “simmer with” the notion that this client’s next therapist or others might hear an inaccurate picture of her as a therapist, and especially that the next therapist might hear that she was anti-gay.

This sort of aftermath is hard to tolerate and very painful. P1’s best effort to process it was to leave the patient on the most positive note she could and try to deal with her own feelings of distress about the patient carrying this distorted picture of her: So, I think in the end, I felt like the best I could do was to do something that was going to be corrective, which was not to put it back on her, and to be really supportive of her need to see a gay therapist. Because, in her family, everything was always turned back on her. So, even though this was a real distortion, and it was really hard for me to have her see me that way, I felt like it would be doing potentially more damage if I tried to help her own it. Because, her defenses were so high at that point, which, obviously they were or she wouldn’t be projecting this much onto me, and if I tried to go up against that I was just gonna recreate something.

Despite the fact that P1 clinically decided that the best thing to do in this case was to terminate with the patient in a supportive way and not confront the patient’s defenses, this was a very painful thing for her, because [the patient] was gonna leave with this distortion about who I was. . . .

Like, “Oh, I saw this therapist, and ugh, I had to leave her because she had this anti-gay thing.” I mean, I had to live with that. . . . It was painful. It was really, really, really hard. And to have someone leave on a yucky note that I couldn’t fix, but if I tried to fix it I would risk pushing up against something she’s not ready to get past yet. . . . So in the end I felt like I got left with a little yucky, but I didn’t harm her in the process.

This aspect of P1’s mistake will be explored in more detail in the “Achilles Heel” section.

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P1 felt good that she did not put her distressed response onto the patient in what she felt would have been a damaging way. She did wish that she could have handled the patient’s reaction to her in a way that would have had a better outcome, and even wondered if “someone who knew more would have known what to do with this to have gotten through it.” She felt sure that she would need more psychoanalytic training to “really get into the muck with people with that stuff.” So P1’s aftermath for this case was to be left with some uncomfortable tensions that have not felt better over time despite her having the knowledge that she did the best she could for the patient.

P11 described how her experience of making mistakes can be particularly upsetting and stay alive in a way that does not become easier to tolerate over time: Even now I can look back [on certain mistakes] and go, oh, not my finest moment, and feel badly, and wish I had done something differently. So that there’s a way in which that’s still alive. . . . They’re almost like pictures in my mind, because it’s like time stands still or time freezes in a way. It’s almost like a mini-trauma. I wish I had done something different, so that there’s a way in which that’s still alive.

The feeling of trauma for P11 seems to be related to shame, as she reflected that for her, there’s a little bit of shame in all my mistakes, because ultimately . . . I strive for excellence, probably perfection, to some degree. And so, if I make a mistake, I’m not supposed to make mistakes, you know what I mean? I mean, I know I do, but I’m not supposed to so, yeah, I guess there would be shame in every instance, like I’ve done something wrong.

When P11 makes a mistake, she is violating the standards of perfection that she has for herself and doing something “wrong.” This causes her to feel powerful shame, which leads the mistake to stay stuck in her memory as something unprocessed and traumatic. The mistakes stay alive precisely because they are frozen. The shame does not

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allow P11 to look at the mistakes because it is too painful, therefore they cannot shift into something more compassionate. They stay “frozen” in place just as traumatic events do.

So while the aftermath of many mistakes is that they shift into a more forgiving place in the participant’s mind, in some instances mistakes stay frozen when there is a great deal of shame around them, which prevents them from transforming into a more compassionately held experience.

Another example of a mistake that “just sits there,” P4 shared a case that terminated when the client decompensated and was hospitalized for threatening her family.7 P4 questioned many of her actions as possible mistakes after he left treatment, including seeing him out of her home office for a period of time and doing the depth of psychodynamic work she did with him. P4 was left with feelings of fear for her physical safety, but described that what was even worse for her was “the feeling that I . . . was at fault. That I had done this. That I had messed up.” For P4, the aftermath of blaming herself is more painful even than any threats to her safety or losing this person as her patient. The sense that she had erred somehow was the worst part of this entire nightmarish experience.

P4 described living with a sense of regret that she had ever been this patient’s therapist, which emphasizes the degree to which the case and her potential mistakes left her with feelings of guilt and shame. She described her feelings of regret: [I am] very plagued by all the different things I could have done differently, or should have done differently, discrete mistakes in things I did or said. And just in general, this bucket of . . . general attitudinal problems I had, or the way I theorized the case, or thought about it incorrectly. And the horror of losing a

7 This mistake is discussed in more detail on pages 65-66.

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patient that way is–you’ll never know. This isn’t an exact science. It’s not like you have a laboratory where you go, “Oh, but I didn’t mix this chemical properly and here’s what happened.” I don’t know.

P4 illustrates how in the aftermath of mistakes, therapists can sometimes be left with a sense of being haunted by the way events unfolded and their own actions. P4 reflects how the uncertainty around mistakes can be excruciating, and shares how she perseverates over what went wrong at different junctures and tries to understand it. The fact that no one can verify for P4 what exactly went wrong, when, and why is experienced as extremely anguishing. There is no manual that will tell P4 precisely what she could have done differently to have a different, better outcome with this patient. She ruminates in an effort to understand and make her peace in the aftermath of this case and these mistakes, but is still left with a deep sense of regret and wondering what went wrong.

Some mistakes incite profound feelings of regret and anxiety and are difficult to let go of, even years later. P7 described deeply regretting his work with a patient he had early in his career. He felt bothered when he ran into his old patient recently and strongly desired to have another chance with this patient using the skills he has as a therapist now.

On his sense of regret, P7 commented: I really felt I didn’t do enough for him. I felt I let him down. Yeah, it really bothered me. I looked back and I was like, “Oh, I want another chance with him.” . . . I was . . . so young in my training and in my own development. I made so many mistakes with him. He was my first psychotherapy patient. . . . I was angry with myself. . . . I want another chance… I feel I know him so well and I could help him so much more now.

For P7, the aftermath of the mistakes he made with this patient is a sense of regret and anger that he does not have the opportunity to work with this patient now that he has

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developed as a therapist. He strongly desires “another chance,” as if this might wipe the slate clean. P7’s regret seems to come from wishing he could have helped this patient more, but also a desire to avoid the pain of the aftermath.

Aftermath of mistakes shifts over time.

One of the most fascinating aspects of the aftermath process relates to the way that the conceptualization of mistakes can shift over time. What was initially experienced as self-blame, shame, regret and anxiety can shift over time into compassion, ongoing curiosity about, and learning from the mistake. For example, P6 felt she erred by overreacting to a patient’s disclosure of a past abortion. The patient was disconnected from her emotions and rarely moved out of the position of a flat affect. When the patient told P6 she had an abortion with no emotional connection to the words, P6 put her hand to her heart and gasped. P6 held her response as a serious mistake because it put a judgment on the patient’s abortion that it should have a particular meaning (i.e., heart breaking or upsetting) and also meant that she was not staying with the patient where she was at the time.

P6 attempted to repair the mistake, but she could not remember what she tried to do. P6 primarily remembered that the patient “definitely started pulling away, cancelling sessions, [and became] much more guarded” after that incident and ultimately left therapy. P6 felt that her mistake was a major contributor to the patient terminating. P6’s initial reaction to her mistake was to feel terrible about it, but over time she shifted into a

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more reflective place about why it happened, observing that “now . . . I’m much more curious about [the mistake]. You know, curious about myself, my own response to it. I’ve had other people in the room who tell me about abortions and I didn’t have that same response.”

P6 even shared this mistake with a classroom full of students she was teaching several years later in order to help them know they were not alone in making mistakes.

This felt like “staring my own judgment in the face, seeing these students look at me like, ‘Oh my God, how could you do that?!’” Sharing her mistake was both “scary and . . . hard to feel, but it was also liberating . . . just to be able to say, ‘I did this, and I own it, and I try to be aware of myself as a clinician.’” So the aftermath shifted from P6 experiencing self-blame and shame to curiosity to ultimately using the mistake to help other budding clinicians, despite an ongoing sense of judgment that still lingered for P6.

P8 described a mistake with a patient who left treatment with him seemingly over a single comment he made. In the initial aftermath, he was pained by his mistake and blamed himself. As time passed and he got some distance from the pain of it, he became curious about how the mistake might have played into dynamics with the patient. He even began to wonder if this patient was at the point of launching into the world and she needed to leave him to be independent. His curiosity led him to wonder if the patient leaving was actually a piece of her work, rather than the consequence of something horrible he had done. P8 observed: I felt bad, and then I just felt self-conscious that I had worked with somebody for so long and they would just leave that quickly, and . . . at the time, it felt like a huge mistake. I guess I came to find out that it, it just seems to be part of how things go.

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Over time, P8 has shifted from simply feeling responsible and ashamed to understanding that incidents like this are inevitably part of psychotherapy and potentially even part of something therapeutic for this patient.

Theme: The Vulnerable Self A major theme centered on the vulnerability that surfaced for participants around mistakes. Making and living with mistakes can elicit both vulnerability and shame. As the analysis explored in an earlier section, many participants described experiencing some variant of the “oh shit” moment when they first registered making a mistake.

This “oh shit” seems reflective of something deeper. For mistakes that rouse the experience of vulnerability, participants described being plunged deeply into confusing, emotional aspects of themselves. The “Achilles’ heel” emerged as a sub-theme that represents where a therapist is most likely to make mistakes. Perhaps surprisingly, participants also found they connected on a profound healing level to patients when they were in their Achilles heel. Another sub-theme emerged around the desire to keep mistakes hidden and the experience of having them exposed, which can be either shameful, liberating, or both, depending on context.

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Sub-theme: Achilles’ heel.

Mistakes can reveal what one participant called her “Achilles’ heel” (P1), which is where the therapist is most emotionally raw, and also where she might be most likely to err. P1 observed that working with easily wounded patients who get into entrenched negative transferences activates her Achilles’ heel. These types of patients remind her of her mother, who would frequently emotionally distort things with P1. P1 observed that these situations “always make me feel really confused and horrible. . . . I really don’t like the kind of patients where I have to feel like I’m walking on eggshells” and noted that it is “too triggering” for her.

Patients and dynamics that trigger her Achilles’ heel engender a deep sense of vulnerability in P1, which she described as a feeling that “I am getting into a place of crazy . . . distortion,” and she finds herself feeling “out to sea” and “in territory that I don’t know how to navigate.” P1 reflected how overwhelming the dynamic can be for her, pondering that “it is really disturbing to me, and I almost feel like I can’t–I don’t know how to dig my way out of it.” Despite having a desire to feel in control, P1 becomes at least momentarily mired in her own vulnerabilities and does not have access to the part of her that feels more grounded and stable.

P1 observed that this dynamic is “so powerful” for her that “I no longer trust myself to be in a position where I’m helpful.” P1 does not feel she can be helpful in these situations because she is too emotionally activated. In cases where patients distort her emotional offerings just as her mother did, it tends to make P1 angry, which she fears she might respond to in ways that would be a mistake.

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P1 finds these types of patients so difficult that she would prefer not to work with them and avoid the experience of vulnerability and being out of control of her professional self that it evokes. So when a therapist is feeling exposed and vulnerable, there is a resulting lack of trust in the self and sense of being out of control that can be fertile ground for making mistakes. P1 further reflected on her Achilles’ heel: You can never be in total control anyway, but . . . those things that are really the Achilles’ heel, I just feel like, I have to admit my incompetence in that area.

That’s the one kind of dynamic that really gets to me. You know, I’ve worked with people who’ve murdered people. I’ve worked with all kinds of scary things, but the scariest dynamic to me is when someone projects something onto me that they ascribe all kinds of intentions on my part that aren’t there. I find that just the most difficult thing.

P1 emphasizes just how hard this is for her by noting other dynamics that would at face value be more difficult. For P1, the way to mitigate the vulnerability and ensuing shame and anxiety that can arise when in the territory of the Achilles’ heel is to accept that this is a limitation she has. Acknowledging areas where she feels out of control in an unhelpful way to the treatment is powerful for P1.

P2 reflected on the ways that he can feel vulnerable when he is activated by a difficult patient in his Achilles’ heel: [I] get into a place of trauma in myself that felt helpless, weak, incompetent, overwhelmed. And, instead of being able to process that, I . . . go defensive and identify with the aggressor. So in that respect . . . I think it is a little bit of a loss of [control].

Certain patient dynamics can make P2 feel out of control because they take him back to his own trauma, and this leads to defensive and perhaps even aggressive behavior with the patient.

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P2 discussed a particularly difficult patient that caused him to struggle with his Achilles’ heel. The patient is a little boy who becomes extremely disregulated, and tries to destroy things in P2’s office along with disruptive behaviors such as spitting and yelling. This escalated to the patient attempting to kick P2 in the crotch. P2 reflected that this patient has the capacity to “get to me in that place that isn’t good” because when the patient started to kick him in the crotch “I had a flash of, ‘You do that, I’m gonna hit you back!’” In “that place that isn’t good,” P2 fears that he might angrily lose his professional self and be physical back with this child or have a strong emotional response.

P2 believed that his mistake with this patient was “not stopping him sooner. The mistake I made was not stopping him before I got into my place of trauma. The trouble was, I didn’t really know how.” P2 “didn’t really know how” in that moment because he was immersed in his Achilles’ heel and this can lead to difficulty thinking clearly and rationally. When he got angry with this patient, P2 was aware: [This patient] got the side of me I don’t want you to see. That I don’t want to feel.

And I think part of my fear in seeing him is–when’s he gonna tap that, and how? . . . And what am I gonna do? Last time we . . . recovered from it. . . . But he knows this about me now.

This patient’s dynamics and behavior hit P2 in his most vulnerable place, and made him feel exposed. This sense of exposure along with the patient’s disregulation can lead him to feel out of control, which then causes him to want to retreat from the patient and potentially make more mistakes. He does not want the patient to see this vulnerable side of him, and he does not want to be compelled to feel it either. He is unsure how he will react once his Achilles’ heel is activated. Once that side of him has been exposed, he

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feels vulnerable that it could be elicited again and that the patient is aware at some level that he reached P2 in that vulnerable area.

Sub-theme: hiding and exposing mistakes.

A major theme that emerged around the vulnerability and shame that mistakes can elicit is the desire to keep them hidden, as well as the feelings that surface when they are exposed. As participants discussed their mistakes, the urge to hide them appeared repeatedly. This theme appeared both as participants related to themselves and also in their interactions with others.

Hidden from self.

Participants had the capacity to keep mistakes and their aftermath hidden from their own view. During the interview process, participants commented on not being able to recall many mistakes to discuss. This was in spite of the fact that participants acknowledged that they must have made many more mistakes than they were remembering to share. P11 noted that “it’s hard to think about mistakes” and that “my mind wants to avoid it.” P11 indirectly references the unconscious tendency to hide mistakes as a defense, as though participants were not allowing themselves to remember too many mistakes or too many details about the ones they did remember because it was threatening in some way.

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A good example of participants’ tendencies to hide mistakes from themselves, P8 shared a mistake where he made a comment that angered his patient enough that she left the session.8 As he shared the details of this, they were somewhat convoluted and he kept revising his memory of the narrative and how the mistake unfolded. After the session, the patient called P8, berated him on his voicemail, and declared that she was taking a two week break from therapy. P8 knew that this patient had disdain for men who acted submissive, but he decided to call and ask her to come back to session in spite of this knowledge. When the patient never returned to therapy, P8 held it as his mistake that he had asked her to come back rather than tolerating his anxiety about the situation and respecting her desire to wait two weeks to return.

In the second interview, P8 began by stating that after the first interview he realized that he had forgotten the most significant piece of the story, the piece that made him feel most ashamed. P8 and the patient had one phone conversation after their last session in which the patient was angrily threatening not to return, and P8 heatedly said something along the lines of “Fine, don’t come back then.” P8 was fascinated by his own ability to protect himself through repression of the most agonizing details of his mistake.

P8 kept the most difficult to process portion of the mistake hidden even from himself. P8 marveled, “Wow, It’s amazing how the mind works and how the unconscious lives and how we try to forget things that are painful.”

8 This mistake is originally discussed on pages 74-75.

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Hidden from others.

Participants also reflected on their desire to keep their mistakes hidden from others. Many participants feared their mistakes becoming public and worried what the next therapist might think of them upon hearing of the mistake. P4 stated “I would go so far as to say I sometimes feel paranoid about if [former patient] is in therapy again, what he says about me, and how he spins it. Or what these things sound like.”

P8 worried that his psychiatrist friend still seeing the patient who left treatment with him would think he is an “idiot,” and had anxious fantasies about what the patient would tell another therapist about him. The desire to keep mistakes secret seemed to stem from shame around the mistakes. If the mistake remained hidden, the participant did not have to grapple consciously with the shame they might feel if other people knew about and could possible judge them for it.

Hidden from supervisors and colleagues.

Participants wanted to keep mistakes hidden from supervisors and colleagues. P4 stated, “I am an A student, so if I’m gonna sit in front of a supervisor I’m gonna give him my A work” (P4). As a student supervisee, P4 was less likely to disclose information that could be potentially unflattering, and therefore she was less likely to talk about her mistakes with supervisors. Notably, P4 does talk about mistakes in her paid consultation now that she has graduated from school and has chosen her consultant. This perhaps speaks to the importance of the sense of safety in the supervisory relationship, and the

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way that having a sense of control can impact how vulnerable one chooses to be (i.e., since P4 chose her consultant after school she may feel more free to be vulnerable with her).

Participants had supervisors who made them feel terrible about mistakes, especially while they were students. Participants described feeling like “shit” and “horrible” when they revealed mistakes to supervisors who then were highly critical of them. P8 related his “humiliating, embarrassing” experience with judgmental supervisors: I’ve had some really awful supervisors that made me feel horrible. “How come you’re doing this?” “You need to do that.” And it just never worked, those who said, “You’re making mistakes.” Somehow the supervision just would never work out versus supervisors [who were] like, “Oh, yeah, we all do this.”

P8 has a tendency not to share as much about his cases in situations where he is being told he is wrong rather than working with a supervisor who is less shaming and more supportive. It is notable that what P8 finds soothing is a supervisor who can also own his own mistakes (“Oh, yeah, we all do this”), thereby mitigating the sense that P8 is alone in the experience of making mistakes.

P7 also found it very soothing when his supervisor owned mistakes in his own practice. Getting into a supervisory relationship where the therapist feels judged and criticized creates a sense that mistakes should not be explored but rather should stay shrouded in secrecy, hidden away from anyone who might cause the therapist to feel additional shame.

Participants shared a desire to keep mistakes hidden in a classroom setting or from colleagues. P9 shared her experience of being “dressed down” in front of an entire classroom by her instructor for a mistake she made of seeing an individual out of a family

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she was working with separately, and remembered that the instructor “made me feel completely inept, completely wrong and defensible. Exposed. Some kind of idiot.” P3 also shared an experience of being “sadistically humiliated” in a classroom setting for mistakes she had made in a case she was presenting.

P11 preferred to keep her mistakes hidden in cases where she consults with colleagues informally, and stated that she would not reveal mistakes she had made to colleagues casually because it was too exposing. P11 also wanted to keep her mistakes hidden because if another therapist revealed her mistakes to P11, “I don’t know it if could help but change my idea of how they are as therapists.” When P11 hears about the mistakes of others, it makes her feel critical of them on a global level, which then impacts her decision to hide her mistakes to protect herself from being similarly judged.

P10 also wished to keep mistakes hidden from colleagues due to her fear of judgment: Some of [my colleagues], there are certain things I can say to them, but usually I don’t just because they are closer in age and sometimes I don’t want them to think badly or that I’ve made a judgment call that they may not have.

If P10 feels similar to her colleagues (as measured by age, which presumably indicates experience level to her), then she feels more vulnerable opening herself up to them and their possible criticism. Revealing mistakes publicly, whether in a classroom or to colleagues, brought up intense feelings of vulnerability and shame and contributed to a desire to hide mistakes from the view of others.

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Hidden from interviewer.

The desire to keep mistakes hidden from others also appeared in the dynamic with me. The most striking example of this occurred with P11. Throughout both interviews with P11, she repeatedly commented that she remembered very few mistakes to share with me and that this seemed really strange to her. At almost the end of the second interview, I asked if she had ever made any mistakes that she had not talked about with anyone. At that point, P11 revealed that she had made a mistake that felt so shameful to her that she did not feel comfortable talking about it with me. In talking about why she did not want to get into specifics of her “egregious” mistake, P11 said, It doesn’t feel entirely safe to talk about it again for fear of being misunderstood, . . . and it almost feels too risky to open it up necessarily. . . . It’s not as if there’s an easy answer, I don’t think, so again, it’s very dicey to bring it up with people, if that makes sense.

P11 keeps her mistake hidden because she has a strong fear of being judged about it. Being “misunderstood” seems to relate to be being misjudged as a “bad” therapist because she made this mistake. There is a sense of danger that comes along with unearthing this mistake, the risk of judgment and of being shamed. Her safety is compromised (i.e., it is “dicey,” “risky,” and not “entirely safe”) if she exposes the mistake and therefore herself to my judgment and, perhaps more meaningfully, to her own.

After I asked if she could tell me how the mistake made her feel in lieu of revealing details about the mistake, P11 offered a vague outline of the mistake:

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I felt awful about it, I felt cornered by the client, and then I felt pushed to do something I normally wouldn’t do. And then that ended up, I guess you could say–you could argue it was a mistake, ‘cause it didn’t go well.

P11’s mistake apparently involved acting out of her normal mode of being a therapist. She experiences her mistake when she thinks of it now, ten years later, as “torture.” The level of shame that is tied up with this mistake seems to be compounded immensely by the fact that it stays hidden. The experience of the mistake can never shift or be healed because it stays “frozen” as P11 described her experience of mistakes, likening them to mini-traumas. It is a dangerous enterprise for P11 to share this mistake that makes her “bad” in her own judgment and perhaps mine as well, so she protects herself by keeping it concealed.

Not hiding.

Participants also talked about the experience of not hiding their mistakes in spite of an urge to do so, and how talking about mistakes helped them to grow. P8 noted that processing mistakes with his analyst is “good for me but it doesn’t feel good” because it evokes vulnerability. P7 characterized his experience of sharing his mistakes in supervision as “vulnerable and . . . kind of painful” to be exposed in that way and to fear being judged by the supervisor. Yet, participants felt that their supervision and personal therapy, assuming they were safe and non-judgmental environments, provided an excellent place to analyze mistakes on a deeper level.

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P4 emphasized that it was in the discussing and analyzing of her actions with her consultant that she often decided if something was a mistake. She also stressed that the supervision allowed her to make the best possible use of her mistakes. In talking about a mistake that she felt she handled well, P4 reflected: I don’t know if I would have gotten to the [meaning] and resolution of the mistake on my own, in my own mind. . . . The [mistake] unfolded [into something useful] with intervention. I don’t think it would have unfolded in the same way, or lead to the same beneficial outcome, had it just unfolded in my mind.

For P4, supervision is essential to helping her process and use her mistakes. P4 needs the supervision to make sense of her mistakes, help her decide what to do about them, and provide support as she faces the aftermath of making mistakes.

Even though P7 felt the urge to keep his mistakes hidden, he was struck that he had talked about almost all of them in supervision, saying, “I have . . . pried my mouth open in supervision.” P7 here underscores the difficulty inherent in talking about mistakes when he uses the metaphor that he must pry his mouth open despite an urge to keep it shut, which would make him less vulnerable. P7 has the sense that supervision can be essential but painful at the same time: I know if I’m gonna get better and if I’m gonna be helpful to the people I’m working with, the thing I cannot do is squirrel away my mistakes. I’ve had some very painful supervision sessions [laughing], ‘cause I really feel like I have to bring this stuff up.

P7 also observed that simply connecting with his supervisor after he has erred can be enormously helpful for him, noting that “regardless of any response I got [from his supervisor], I thought the most important [thing] was that I just put it out there, connect with someone about it.”

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P7 also emphasizes the isolation that can come with making a mistake and the way that connecting with someone about it can be healing. Rather than “squirrel away” his mistakes, P7 decides that that “there is nothing to be gained by hiding away . . . my vulnerability.” Here, P7 again highlights that he makes the best use of his mistakes when he has spoken about them and connected with someone over them. This mitigates the shame and isolation that can cluster around the experience of making a mistake for P7.

Participants found it a worthy exercise to spend a few hours considering their mistakes in the interviews. P7 observed that talking about his mistakes made him feel more accepting of them, and that there is “not so much a sting” to them as he might have thought. Talking about the mistakes takes away some of the “stigma and how I might judge myself.” Speaking about his mistakes allowed P8 to feel more compassion and less of his instinctive urge to kick himself for making them: . . . once you talk about [mistakes], like with you and other people, you come to see that there’s something liberating about being able to talk about mistakes and being able to talk about being vulnerable, and to realize, well, I’m being a little bit hard on myself, or . . . stuff happens, and it’s enactments. And you have to try your best to . . . learn from it and not do it again. . . . So there is something that feels less shameful . . . or less self-conscious talking about it.

Talking about his mistakes was relieving for P2 in that it “opens the door to more curiosity and less blame”. In other words, the experience of talking about their mistakes in the research interviews seems to have mitigated shame and allowed participants to reflect more deeply on the dynamics around mistakes in a constructive, healing way that shame can disallow.

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Sub-theme: vulnerability as opportunity.

While participants discussed how their mistakes made them feel exposed in ways that do not appear helpful to treatment, many also identified that they connected with patients on a deeper level after making a mistake. P9 stated that along with her mistakes comes a sense of authenticity that allows a deeper connection between her and her patients. Mistakes that elicit the therapist’s vulnerable self “allow more of a relationship to happen,” because while they can be undermining to a sense of competency, they also bring a refreshing sense of authenticity where “you own up . . . to what you can and can’t do.”

Though therapists described carrying an idealized version of themselves that they feel they should live up to, mistakes bring them face to face with their humanity. P8 observed, “Somehow you’re supposed to be an uber, super human and never have any countertransference and never be reactive . . . and that’s just not possible,” while P7 averred that “I’m not this… perfect… therapy machine.” The authenticity that mistakes put participants in touch with can be a relief which allows them to let go of the sense that they should be perfect and allows them simply to be real.

Making mistakes forces participants to face their limitations and their humanity.

P2, in talking about how he can feel vulnerable and in his own trauma when he makes a mistake, also commented that though the mistakes meant he lost a bit of control, it is also “hard to say [it is] not therapeutic because I also feel that’s a level of empathy that allows me to feel the other person.” Being in his vulnerability and into the sense of losing control can help P2 connect more deeply on an empathic level with what the patient

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might be experiencing. It breaks through the false dichotomy of healer-patient and reveals both participants in the dyad as human for a moment. While this is painful for the therapist when it happens, it can also be fulfilling.

P7 reflected that mistakes are bittersweet for him; they are bitter in that his mistake has perhaps hurt his patient and has probably made him feel vulnerable and perhaps ashamed. Yet, they are sweet in that “it is an opportunity for connection and for me to be real. And I think it’s an opportunity for a patient to really heal.” For P7, acknowledging a mistake to the patient can be healing because many patients never received this sort of validation as children. He uses his vulnerability and uncomfortable feelings to achieve further healing for the patient through validation of what they see (i.e., they see that P7 has made a mistake and he does not pretend otherwise but rather owns it and thereby validates their perceptions).

P9 shared an example of a mistake that made her feel vulnerable but also allowed her to deepen her connection to her patient over time. P9 was working intensively long term with an emotionally fragile, bipolar patient. During the treatment, P9’s mother became ill and P9 travelled to see her regularly. The patient was aware of this due to P9’s cancellations. At some point, P9’s mother died, and she was unsure whether she should reveal this to the patient. She called a colleague for consultation and got advice that she should not reveal this to the patient so she did not. Weeks later, the patient asked about P9’s mother, and directly asked if she had died. P9 said that she had, and when the patient realized that P9 had not told her this, the patient became enraged and made some hurtful

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comments about how she and her mother had been praying for someone who was already dead.

P9 burst into tears at this comment as she was feeling vulnerable and still grieving, describing it as “a dagger to my heart.” P9 revealed some of her upset feelings to the patient about this comment. P9 and the patient still refer to this moment in the treatment more than eight years later; the patient recently brought and played a song for P9 that referenced the time when the patient made this comment. P9 later apologized for her mistake of not revealing her mother’s death to the patient and felt it was healing and helpful.

The vulnerability that P9 experienced and showed the patient was “an opportunity . . . at that time to connect at that authentic place . . . .” She went on to reflect that “those artificial boundaries of . . . therapist-patient can get breached in the way that’s real and authentic and okay.” When the patient hurt P9 with her comment, P9 was authentic with her (at first spontaneously because she burst into tears, and then more out of a conscious choice to talk with the patient about it), and subsequently they could connect at an even deeper level. P9’s mistake of not telling the patient that her mother died led to a closer connection for both of them.

Theme: The Gray Area Another emergent theme in this research, the gray area represents the experience therapists have when they feel unsure if they have made a mistake. They aren’t quite sure

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how to understand what may have happened; it feels unclear. The gray area represents the way that being engaged in a psychotherapeutic process can feel unclear and confusing, and how even if there is no specific action or “mistake,” the therapist can still carry a feeling that she has made a mistake and created this mess.

P11 described the gray area as a time when it is “cloudier as to what the right thing to do would be,” and that there are times when her actions feel “awkward, and if it feels awkward, it often feels like a mistake. It may not necessarily be one . . . .” The experience of being in the gray area is confusing, as illustrated by P11’s description of it: Sometimes, I also know that nonverbally something feels off, and then my mind is scrambling. Like I know that something funny is happening, but I don’t know what it is yet. And so my mind is going in a million different directions, trying to figure out what is the right thing to do here? Do I move on, do I ignore it, do I comment on it . . .?

P11 is “scrambling” because something feels off but she isn’t sure if that uncomfortable feeling relates to her having erred in some way or if this is part of the dynamic.

When therapists are in the gray area around mistakes, it can be an agonizing experience and it is often experienced in a similar way to having made a definitive mistake. When a case ends poorly as in P4’s case where her patient was hospitalized after threatening her family, the therapist can question many steps along the way as possible mistakes and feel uncertain about whether they were mistakes or not. P4 described it as “very torturous because you just never know. I don’t know.”

P11 reflected on a patient she had seen for three years who moved out of state and began to see a new therapist. The patient was not doing well when she moved and had

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progressively regressed through the therapy with P11, prompting her to wonder if she had made mistakes, and what these might be: I mean, you can conjecture, ‘cause there’s millions of choices every step of the way. But, yeah, I don’t really know. So that’s that global feeling of maybe I just suck at this. . . . It’s murky, all I know is she looks worse than she did [before treatment]. Now, is that part of the journey, or is that a mistake?

Because this patient has gone into deeper, darker places in the therapy with P11 and is now doing “worse,” P11 questions her choices as a therapist and simply isn’t sure if she has erred or not. The gray area involves not being certain of what might be a mistake and feeling baffled by this question. It also engenders feelings of incompetence just as unequivocal mistakes can, and is experienced in a very similar way to an unambiguous mistake.

There are many “what-ifs” in the gray area around mistakes, and participants described questioning themselves about if there had been a mistake at all, and if so, what it had been. This feeling can come up around hospitalizations, when therapists feel responsible for the fact that their patient was hospitalized but are unsure what they might have done differently. P7’s patient did not show up for session, and then called him to say she was suicidal. He called an ambulance and the EMTs brought her to the emergency room. When she arrived, she denied being suicidal. The emergency room staff called P7 to ask about hospitalizing his patient, and P7 insisted that they hospitalize her against her will. Even though much of him knew it was the clinically correct decision, he also questioned whether he had made a mistake because he worried that his anger at her played a part in his insistence to the staff to hospitalize her, that he was seeking “revenge” in some way.

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P7 wondered whether he did the right thing: “I totally have different levels. On one level it’s like, ‘Oh, God, I was really aggressive.’ Maybe that was too much–which is not true–but I have that reaction.” P7 is demonstrating the back and forth that can happen in “murky” clinical situations that cause the therapist to experience something as a mistake that upon deeper reflection is not actually a mistake. P7 questioned his motivations for his actions and therefore felt he might have erred, even though in retrospect he did not see how he could ignore a threat of suicide from his patient.

P7 conjectured that his awareness that he did something differently than his normal modus operandi contributed to his sense that he made a mistake, even though he intellectually did not feel he erred: “I think it’s not my usual MO [to be aggressive] so it really goes against that and . . . I think it made it feel like, ‘Oh, this could be a mistake.’

This isn’t how I usually do things.” Stepping outside of his normal way of operating by being more aggressive created anxiety for P7 and made him question if he was making a mistake.

So, the gray area is the experience therapists have when they are in the depths of a difficult case and their interventions don’t go over well with the patient, or the case as a whole is going poorly. This can be experienced as the therapist making mistakes, but upon closer examination, participants could not actually name anything they had done that they would objectively call a mistake.

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Theme: Professional Growth and Shift in Experience of Mistakes Therapists shifted how they experienced making and living with mistakes over the course of their career. Most participants internalized a gradual understanding as they matured professionally that mistakes are an inevitable part of the psychotherapy process and not necessarily an incompetence of the therapist. The internal handling of the mistake shifts such that therapists have “more forgiveness” (P5) and increased compassion for themselves as they begin to hold the tension that they will inevitably make mistakes, and that they can actually be useful to the process.

P5 reflected that as a beginning psychotherapist she believed she must follow rigid rules to do things correctly, and now that she has matured as a therapist and person, she has become more “resilient” to patient’s different emotional states and her own mistakes. She remembers believing that her mistakes were “so important and catastrophic” early in her practice, and reflected that she has “evolved tremendously . . . in my perspective” by being far more compassionate and relaxed.

Most therapists observed that over time they had become gentler with themselves over mistakes and had learned to be curious about them rather than to only feel shame and judgment. When P8 first entered the field, he felt like everything that was difficult in a treatment was his fault, and now he knows that sometimes it is him, but often it is the dynamics of the treatment. He feels far more okay with tolerating this now than he did early in his career. P8 stated that towards the beginning of his career he used to think: I’m doing something wrong. They’re not getting better faster. How come this didn’t change? I used to think I am doing something wrong, or I used to think I’m not getting it right . . . as opposed to saying, “Wait a minute, what’s going on

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here? What’s . . . happening in the transference? . . . What are they reacting to?”

[Now, after] my own analysis . . . a lot of consultation, case conferences, . . . I think, “Wait a minute, I’ve been doing this a while . . . . This isn’t all me, or this isn’t only me.” And that there’s something to be understood here and that I do know what I’m doing. I am competent.

P8 has had a tremendous change in his perspective. While he used to immediately blame himself for things that did not feel right in the dynamic, or when a patient had a strong reaction to something he did, he now has matured to the point that he can realize that this is inherent to the process and not necessarily a mistake on his part. Even when P8 does make what he perceives as a mistake, he now has an increased sense of compassion and curiosity as opposed to a desire to deem himself incompetent.

P9 noted that “I think those first 10 years [of practice] you do a lot of agonizing [about mistakes] . . . It’s a long time to get to the place where you’ve got a little more ability to regulate that.” P2 also noted her own shift in perspective: I used to feel very anxious in sessions, at times, where if I felt like a client was getting angry or agitated, I felt really responsible for that, or I felt like I upset them in some way. That maybe I had made a mistake or done something improperly, and I would try to reconcile it. So, I would feel flustered inside of myself, or worried. I think now I'm able to use the reactions on the part of the client as more evidence for the treatment, rather than it being about me that something has been triggered. That's not necessarily a bad thing.

P2 used to assume he was always at fault. Now he realizes that things sometimes don’t feel good in the interaction with the patient, but that does not automatically mean he has created that. In fact, over time he has learned to use that as “evidence for the treatment,” using the dynamic in the room to understand the patient and their dynamics, rather than personalizing it.

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P7 also feels much more comfortable taking risks that might be mistakes as he grows professionally: You know, I’m much less risk averse now. I’m kind of like, we’re doing psychotherapy, let’s do it . . . ! [laughing] And maybe they won’t like what I say and then we can talk about that. . . . I still feel that reticence . . .I still feel it, but I’m like no, I’m just, I’m gonna do it. . . . And, I think I feel more confident. I feel more confident in therapy in general. I think, especially early on, I didn’t know about–does therapy really work?

P7 has an increased ability to trust in the process of psychotherapy as well as an improved level of confidence in himself to tolerate the gray areas in psychotherapy. He also seems to be saying that he believes the process can handle mistakes. He can take the risk (“let’s do it!”) that what he’s saying is imperfect or might create a reaction in a patient because he trusts now that therapy works; he can process any reactions with the patient rather than fearing it and avoiding that at all costs.

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Chapter V

Discussion

Introduction This study has examined the experience of making and talking about mistakes for psychotherapists. The data from this research supports the idea that making mistakes and dealing with their fallout is challenging because it uncovers something that therapists tend to keep covered; making mistakes puts therapists starkly in touch with their own vulnerability in the clinical interaction. This project’s data indicates that talking about and facing mistakes is critical for therapists. It helps to loosen the sense of isolation and shame about mistakes and increases the sense of compassion therapists have for themselves, which then allows them to think more clearly about treatment and encourages a deeper, more productive treatment process. Further, because mistakes are powerfully evocative and personal, dealing with them might be one of the most profound ways to become a more attuned, aware therapist. These ideas will be discussed in detail in this chapter.

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Aim of the Study This study aimed to understand the felt experience of making mistakes for psychodynamic psychotherapists. It examined the everyday blunders that psychotherapists face in clinical situations in order to produce a deep understanding of the kinds of mistakes therapists make, how they use (or don’t use) mistakes for professional and personal growth, and how mistakes impact the therapeutic process. The overall goal of the project was to provide knowledge on this topic that will help therapists and supervisors to recognize, process, and learn from the inevitable experience of making mistakes.

Assessment of the Study Making a mistake, the data suggests, is evocative on conscious and unconscious levels, and it noticeably impacts the therapist who makes one and the treatment process.

This study fundamentally achieved its aim, producing the following key themes and understandings that illuminate the experience of making a mistake: (1) Participant mistakes fell into the broad categories of avoiding, disconnecting, acting out emotionally, proving worth, incompetence, and under or overestimating patients.

(2) The processes that occur after participants made a mistake including initially registering the mistake, responding to the mistake emotionally and clinically, understanding the mistake, repairing the mistake, and living with the aftermath. These

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processes may or may not happen depending on how ready the therapist is to address the internal experience of having made the mistake.

(3) The vulnerable self of the psychotherapist can get activated in treatment and cause the therapist to make more mistakes. Therapists tend to want to keep their mistakes hidden to avoid experiencing this vulnerability. When therapists are at their most emotionally vulnerable, the “Achilles’ heel,” they make more mistakes and feel more out of control of their actions, leading to more mistakes. Paradoxically, the Achilles Heel can also lead therapists to an increased sense of empathy and connection with the patient.

(4) The gray area describes those times where therapists believe they are erring because something feels challenging or off in the dynamic and it is simply unclear for therapists if they are making a mistake. The gray area captures an inherent uncertainty present in the psychotherapeutic process rather than an explicit mistake on the part of participants.

(5) Participants responded differently to mistakes over the course of their careers. More professional maturity led to increased self-compassion and less shame about mistakes.

While professional maturity led to increased self-compassion, this does not happen if the mistake has not been dealt with in any fashion.

Value of the Study Participants found it worthwhile to consider their mistakes, which points towards the inherent value of this study. Though talking about mistakes evoked “bittersweet” emotions and defenses in a similar way to the experience of making mistakes,

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participants also felt they benefitted greatly from talking about mistakes in the study interviews. Participants found shedding light on their mistakes helpful and even therapeutic, commenting that talking about their mistakes allowed them to reflect on their cases more deeply and also made them feel more comfortable with their mistakes than they anticipated. P7 observed: I did notice I feel more accepting of mistakes. . . . I feel like, eh, big deal, in a way, it’s not so much a sting. . . . I think talking about mistakes was actually helpful for me. . . . Sort of taking away some of the sting, maybe some of the stigma or how I might judge myself. [I] felt more accepting.

For P7, reflecting on these mistakes allowed him to see that the mistakes were not as bad as he remembered them. He knew there was a “sting” when he initially made the mistake, but looking back on it gave him a different perspective that allowed him to be more compassionate towards himself.

Talking about her mistakes made P4 realize how much work she does with them: It gives me reassurance as a clinician knowing that I can readily think about these things and call to mind the positive outcomes, more or less, of how I make use of mistakes. . . . I was thinking afterwards, “Okay, but the mistakes I’ve made, I can say, with confidence, have been considered, utilized. They’ve contributed to growth rather than just been dreadful.”

P4 marveled at how much effort she has put into understanding her mistakes. She felt relieved and confident that her mistakes have “contributed to growth.” Her comments seem to imply that when she doesn’t spend time as she did in the interviews explicitly considering her mistakes, she can lose sight of the fact that she makes use of her mistakes and that they aren’t “just dreadful.”

Participants expressed a sense of relief and catharsis in sharing and exploring their mistakes for the study interviews, which highlights the importance of talking about

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mistakes. Not talking about mistakes and keeping them secret seems to magnify them in the mind. They functioned for participants like monsters in the closet: when the light gets turned on, they realize they aren’t so terrible after all.

Conclusions and Implications for Research

The felt experience of making a mistake.

This study has developed a rich understanding of participants’ experience of making a mistake. In this section, I will explore the felt experience of making a mistake, including mistakes as a personal experience, the shame that mistakes evoke, and my observations of the interviews.

Mistakes as a personal experience.

The experience of making mistakes and understanding them (or not reflecting on them at all) is highly personal. As one participant put it, “who you are is the mistakes you make,” emphasizing that therapist mistakes can be an inroad to one’s character and unresolved anxieties. Mistakes can touch on the most personal areas within therapists, so the experience of making them can be uncomfortably revealing of aspects therapists may prefer to keep private. By the same token, because mistakes are such a personal experience, this suggests that understanding one’s mistakes is a compelling way to grow and become a more attuned, aware therapist.

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Participants cited a range of characterological traits that repeatedly affected their mistakes, such as being direct, being aggressive, being passive, being controlling, being anxious, and being over nurturing. For example, P11 stated that she has a tendency to be tougher on her patients (less empathic) because the relational dynamic feels too intimate to her at times: I am a friendly person, I’m a warm person, I’m an empathic person. I’m not necessarily a vulnerable, intimate person. I probably have a higher guard than other people. So, to make an empathic statement might feel a little bit more intimate than a question, in which it’s all on them, versus an empathic statement, [which] is more, “I see you and this is what I see.” And there are times when I’m comfortable doing that and then there are other times when it gets a little too mushy feely.

P11 feels uncomfortable being too close at times, and notices that she might begin to ask questions rather than making empathic statements. She can experience this as a mistake, and it is something that touches on something highly personal about her. She is aware that this can protect her from her vulnerability in the interaction with patients: “If I can be the therapist asking the question, I’m a lot more protected. It’s easier to hide behind a question than a statement” (P11), yet it still disturbs her that she does this because one of her personal traits is impacting her work as a therapist.

Personality traits and countertransference impact participant mistakes in a way that participants found frustrating: “It bothered me that I know that [personality trait] about myself, and I didn’t –and I still did it. I mean, I could have not done that” (P4). As with countertransference, it seems impossible to avoid one’s personality in a clinical situation. The personality traits and countertransference that fuel mistakes are a good, if

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frustrating, opportunity for therapists to deepen their understanding of themselves in a way that helps them to become better clinicians.

The Achilles heel, or the area of unresolved trauma in the therapist, is a central part of the experience of erring. The Achilles heel is highly idiosyncratic. Each therapist will have her own area that feels particularly difficult and tender. What might be an easy area for one therapist to navigate could be an incredibly fraught one for another, depending on each therapist’s particular history. The data points to the idea that mistakes can feel vulnerable precisely because they are caused by and exacerbated by one’s personal issues. Therapists may have the urge to cover over their mistakes because they reveal more than simply an imperfection; they are evidence that might point towards an area of trauma or a central personal aspect that negatively impacts the therapist not just professionally but personally as well.

Shame and the experience of making a mistake.

Shame is a critical part of the felt experience of making a mistake. Participants described a reflexive, deeply painful sense of feeling incompetent and worthless that followed making some mistakes. Brown (2007) defines shame as “the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging” (p. 5).

Many participants reported that they instinctively think, “Oh shit” upon erring, which seems to be descriptive of the self-state participants enter after realizing they have

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erred. In untangling the emotions and various elements that emerge following a mistake, therapists are “in the shit” so to speak. Making a mistake for many participants meant being plunged into troublesome, uncomfortable aspects of their own internal experience, including feelings of shame and unworthiness.

One of the most important implications of this study is that the vulnerability and shame evoked by many mistakes is both difficult to describe and confusing to experience.

It is in some ways unspeakable due to how painful it is. Zaslav (1998) conveys this point well: The experience of shame includes states that have been described as “wordless.” . . . Shame is generally not experienced in well-modulated states of mind in which phenomena are clearly understood, experienced, or conveyed. Instead, shameful states are often characterized by subtle or co-vert discordances between verbal and nonverbal behavior. Attempts by the clinician to direct attention to such processes may be anxiously thwarted. Furthermore, object relations and ego integrity frequently suffer decompensation in acute shame. Along with this regression in defensive functioning comes a transient inability to think, upon entry into shameful states, that has been referred to as “cognitive shock.” (para. 11) The shame evoked by some mistakes shuts down one’s ability to think clearly.

P11 illustrates this when she describes her mistakes as “almost like pictures in my mind, because it’s like time stands still or time freezes in a way. It’s almost like a mini-trauma.”

Time freezing serves as an apt metaphor for the “mini-trauma” that participants describe experiencing upon realizing they have erred. The experience is traumatic because it can expose highly uncomfortable and painful internal self states, even if only momentarily.

This is the experience of being in the “Achilles heel.” Participants describe feeling exposed and vulnerable at the moment of a mistake, and shame can take away their ability to process it and decide how to address it.

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When shame floods a therapist after a mistake, admitting to that mistake can be unbearable. Karen (1992) observes: Pathogenic shame belief seems to block creative avenues. It is crippling, because it contains not just the derisive accusation that one is a wimp, a bully, a runt or a fag but the further implication that one is at core a deformed being, fundamentally unlovable and unworthy of membership in the human community. It is the self regarding the self with the withering and unforgiving eye of contempt. And most people are unable to face it. It is too annihilating. (pp. 3-4) When a mistake evokes intense shame, an exceedingly painful part of that experience can be for the therapist to deem herself “at core a deformed human being” and to regard herself with “the withering and unforgiving eye of contempt” (Karen, 1992, pp.

3-4). This is a highly vulnerable, excruciating thing to bear, and as Karen points out, most people do not bear it but rather make it unconscious. When this process happens and the feeling around the mistake stay largely unconscious, there can be no healing or growth that can result from the mistake. It stays frozen to use P11’s metaphor, just as trauma does.

While P11 did come forward with a frozen mistake that had apparently not shifted in terms of how terrible it felt to her, it is worth pondering how many other mistakes might have stayed out of the consciousness of participants to even mention as they spoke with me. P11’s admission of this frozen mistake gives a fleeting glimpse of many other types of mistakes that are much harder to explore because they are deemed too dangerous to be revealed.

The gray area theme further highlights the power of shame. If a therapist’s action has the slightest hint of shame about it–even something that is not a clear error but rather a “murky” (P11), uncomfortable situation–the evoked shame can still be powerfully held.

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It was only when I began questioning participants on their current understanding about these “gray” mistakes that they seemed to gain the perspective that they had in fact done nothing they considered a mistake. The shame they initially felt when they were in the gray situations made it difficult to think clearly about their own role in them. Shame shut down their ability to deeply understand all the factors at play. This also speaks to the power and importance of talking about experiences that are experienced by therapists as mistakes in order to help shift the therapist’s perspective from shame and self-blame to a fuller understanding of all the clinical dynamics that are contributing to a gray, challenging situation.

Researcher observations of interviews.

My observations of the participant interviews illuminate the felt experience of making and talking about mistakes. While most participants stated that reflecting on their mistakes in the interviews was valuable for them, participants conveyed in words and action that the experience of reflecting on mistakes was also somehow difficult for them.

I sensed we were treading on potentially dangerous ground in talking about mistakes and that, if we wandered into the wrong area, the interview material might provoke shameful and therefore painful affects that participants unconsciously wanted to avoid.

Some participants observed openly that talking about mistakes left them feeling uncomfortable and vulnerable to judgment. However, it was primarily participants’ behavior that underscored my sense that talking about mistakes was stirring. The first

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interview tended to feel lighter, and it was easier for participants to stay with the topic of mistakes. Therapists could laugh at the mistakes they brought to the interview; participants appeared more alert. There was a sense of ease in exploring the mistakes that participants shared, and even that reflecting on mistakes was perhaps enjoyable.

Almost without exception, there was a tendency for the second interview to have a darker tone. Participants were more serious, and sadder in tone as they shared more painful mistakes. Sometimes participants became more reflective and sad, while other times participants tended to act more defensively, seeming to want to get off this bothersome topic as though we had spent enough (or too much) time on it. In this interview, many participants seemed a bit impatient, more tired and less alert. Several participants even directly commented on being tired in the second interview or slumped somewhat in their chairs. Some participants also made less time for this interview than they had for the first, a manifestation of the level of discomfort the topic was evoking.

It became increasingly difficult as the interviews progressed to get some participants to stay on the topic of mistakes. Repeatedly, the conversation drifted into vignettes where the participant did not make a mistake, or into stories about mistakes that other therapists had made. Sometimes, the topic would veer so far off course that participants began to talk about things like office politics. Many participants even wondered out loud about how they started to tell such an off-topic story, as if they were baffled that their own associations could have led us so far away from the stated topic.

There was also a dynamic in which participants were willing to talk about a mistake they shared for a certain length of time, and then seemed to get impatient or irritated that I

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kept going back to explore it further. It felt as though they were internally saying “enough is enough,” and it spoke to how we were treading on vulnerable, anxiety-producing ground in dwelling on their mistakes.

Overall, it felt as though in the first interview participants were able to stay emotionally in control of the experience. It seemed that they had thought in advance about what they wanted to share (and some participants were clear with me that they had shared exactly what they felt comfortable sharing, begging the question of how guarded they were being). By the second interview, the amount of time we were probing at deeper levels into this difficult topic seemed to impact the defensive processes of participants.

The fact that participants became so tired, disengaged and irritable in the second interview underscores the idea that evoked shame can bring people into “wordless” states. Defensive aspects of experience felt as though they were dominating the second interviews in ways that were not present in the first interviews. An example of this occurred in the second interview with P3. She was describing a mistake in which she missed that a patient had a bipolar diagnosis, and said it was overall “a mess, a mess of a case” (P3). She seemed distant and distracted as she talked about this, and when I asked her questions she was short on details. As she was sharing her feelings about the case and cases like it, she stated: P3: Sometimes I do feel like, “Man, I’m really screwing up here.” Sometimes I’m like, “What in the world is going on? What am I missing?” Which, I guess is a police–it’s a self-criticism, or a question I guess. . .

MSH: Is there anything that comes to mind for that?

P3: For?

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MSH: [pause] For thinking about mistakes. . . . I’m sorry, I lost my train of thought. . . . It just totally left me, the question we were talking about.

P3: Me too.

We both completely lost the thread as we were talking about something painful that may have also been stirring shame for her, which can be seen as both of us unconsciously trying to protect her by avoiding shame. I also began to feel awkward that I sensed P3 was ready to be done talking about mistakes altogether, which made it harder to stay with questioning her about it.

The seesaw dynamic.

Shame also became a theme that I observed in the dynamic between me and the participants that I have labeled the “seesaw dynamic.” In analyzing the data, it became clear to me that I repeatedly seesawed back and forth with participants about “blame” for mistakes. When participants were hard on themselves about a mistake, I made comments that asked them to look at the whole picture of what was going on, or that even called into question whether what they were describing was actually a mistake. On the other side, after a mistake had been discussed for a while and I had been “convinced” that it was in fact a mistake and started to treat it as such with my questions, participants often began to get defensive by underplaying the mistake, treating it as though there was nothing more to say about it. I felt as though I was prodding them about something uncomfortable and should stop talking about it.

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An example of one side of the seesaw happened with P2, as he was describing his mistake of commenting that his patient’s emotional disengagement at his father’s funeral was similar to the way his father treated him.9 P2 describes the mistake and I repeatedly make comments to soften his stance with himself about it.

P2: He [the patient] was pretty defensive. And, he wasn't just defensive, he was sort of confused by my comment, like, “How could you say that?” He didn't say that, but the tone felt like, “No, my dad was there for me!”

MSH: Like it kind of hurt a little bit, almost like– P2: Yeah. It hurt, maybe, it hurt him that I could think that. I don't know. Yeah.

It's funny. It helped–it was definitely a mistake and was poorly timed, maybe not accurate, but I did gain from it a more of a developmental sense of him. Just watching him respond to me, sort of–he's sitting on the couch. [laughs] There was just something in his body posture. All of a sudden, I had a vision of this kid playing a video game. He felt small, and latency age. Kind of like, ‘My dad was a hero. What are you talking about?’ And I was, okay. Now I have a better idea of who I'm dealing with. Never mind that his dad had another child, died of [addiction], like [laughs]. But this kid needed to, at least for now, he needs to in some ways remember his dad as, “No he was there for me.” When he had another family, worked all the time, and died of [addiction]. Like, probably not too available. [laughs] MSH: Yeah. That's right. I mean, it's–from what you said, it doesn't really sound like the comment wasn't accurate. I mean, you don't know.

P2: I guess I still feel a little defensive about it. [laughs] MSH: You feel defensive . . .

P2: I just realized I'm defending myself, but . . . [laughs] MSH: Well, it's a vulnerable thing, and it seems like, as I listen to you, I'm thinking, "Wow." I mean, to me it sounds like that comment very well could have been absolutely accurate. But, it's just, you were feeling like you said it at a time when he wasn't in that same space, and his reaction made you feel then that it wasn't the right time to say it?

9 This mistake is discussed in more detail on pages 83-84.

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P2: Yeah. Just, I mean, in some ways, he's still the [age] year old boy at the funeral. I don't think he's had much time to resolve a lot of his feelings about his dad. . . . Yeah, so it was poorly timed. Another few years maybe. [laughs] Without being fully aware of it, I picked up that P2 felt defensive and perhaps some shame about his mistake as he described it to me. I made comments (see italics) about the mistake that justified the mistake, questioned whether it in fact had been a mistake, and even later suggested possible reasons why he may have made the mistake (“Do you think you may have been feeling protective of [the patient] when you asked that?”).

In suggesting other reasons why he might have made the comment he experienced as a mistake, I was consciously trying to widen the understanding of why this mistake happened and help us see the whole picture. Intuitively, I had a sense that P2’s defensiveness and shame was shutting down a fuller understanding of why this mistake may have actually occurred.

Unconsciously, however, I believe I was trying to minimize P2’s shame. I did not want him to feel badly, so I tried to take his reaction away from him. My unconscious communication to P2 was that fully owning his mistake in an unvarnished way was too painful to handle. He needed to be protected from the shame that he might be feeling in admitting and owning his mistake. Together, we had to somehow make this enterprise more bearable by looking for other understandings of what happened beyond that he made a mistake, plain and simple.

It is complicated, however, because it is certainly part of this research endeavor to look more deeply into mistakes, and understand more about their origins. Further, as P2

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and I explored his mistake, he reflected that his own father had died recently, which he felt impacted his comment to his patient. P2 even noted at the end of the interview that our discussion around this mistake widened his thinking about this patient and his mistake: I hadn’t thought so much about what I was responding to. I don’t know why, but I hadn’t thought so much about what I was responding to in him, and what was he eliciting, and certainly I hadn’t gone that deep, so that’s really helpful.

So while it is useful to explore mistakes on a deeper level, the seesaw dynamic that I got into with P2 in this interview is representative of an unconscious and conscious sense in me that I should mitigate or even erase shame if I sense it. The message is that shame is something that no one should have to feel; it is unbearable.

The flip side of the seesaw dynamic happened when participants minimized mistakes after we had talked about them for a while. At first, participants would often be somewhat defensive or hard on themselves as they described a mistake. After I attempted to soften that harshness with the process I discussed above and was finally “convinced” that they had made a mistake, I would start to ask questions about the mistake. This would sometimes occasion participants to act as though the mistake was not a big deal and we should not keep exploring it.

Examples of this dynamic occurred with P5. In discussing the case where she did not repair things with the young man going off to college, I asked lots of questions. At first she did talk about feeling bad, but eventually there was a sense that we were not going to talk about this anymore: And I guess the maternal side of me feels kind of bad about [her mistake]. I let him hurt my feelings, But I can–again, I’ll do what I can, and in the big picture, I

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think I did a 90 percent good job. Or in the big picture, I think I did fine but that wasn’t perfect. . . . But again, not the end of the world. I mean, I can think of end of the world, but this was not that.

In many ways, P5 seems to be displaying how she internally handles her mistakes.

She may feel bad for a period of time, but then she forgives herself. Something else might be operating here, however. It feels as though P5 has had enough of talking about this mistake and now wants to move on from it. She does not want to stay too long in the shame or other uncomfortable emotions talking about this mistake may have evoked for her.

When I asked about another, more wide-ranging mistake she mentioned of making lots of errors in working with borderline personality structures, P5 said, “I give myself complete grace. . . . I’m in complete grace that I did it. I didn’t do any worse than anybody else and I gave it my best shot.” When I inquired further into her process of giving herself complete grace, P5 laughed and said, “I try not to think about it,” which effectively shut down any further inquiry on my part into her process. The overall sense I had was that we were not to stay on this topic and now that I wanted to probe into this mistake, P5 was ready to move out of it.

Researcher’s internal seesaw dynamic as parallel process in writing paper.

Shame is not only evocative of painful experience in the participants and in the interviews; it has appeared for me as I have analyzed the data and written this paper. I

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experienced my own, internal seesaw dynamic. Karen (1992) makes the following on point observation: Even writing about shame is difficult, especially in social-science prose. Shame is melodramatic. It strikes at our sense of humanness. . . . And it has a contagious quality, not only because it is considered shameful to look upon another's shame, but because it makes our own shame demons restive. To the extent that professionals have avoided discussing shame, this may help account for it, as would certain shame-aversive trends in the culture. "People are ashamed of being ashamed," Thomas Scheff says. "So we don't talk about it, we don't express it, and we don't acknowledge it.” (pp. 9-10) It is well worth noting that in sharing the above dialog from the interviews, I find myself feeling a bit exposed. Similar to P2 feeling defensive in revealing his mistake, I feel critical of my interviewing skills and wonder why I didn’t stay in a “better,” more neutral position. I notice myself feeling defensive about sharing this part of the interviews, my own “shame demons [are] restive” (Karen, p. 9).

As condemnatory, harsh thoughts fill my mind, it is hard to appreciate that this dynamic from the interviews is informative, relevant, and in fact a fundamental outgrowth of the qualitative research process itself. My defenses and shame shut down exploration and understanding of my actions and instead cause me to judge myself. The shame I feel about not being a “perfect” interviewer who would have avoided this seesaw dynamic floods me and makes me want to remove this section of the paper. This would prevent me from actually using the seesaw dynamic as data for this paper because I am too fearful and defensive to reveal it Yet, I am aware that interpretative phenomenological analysis allows for my subjectivity and the ways that my interpretations are interwoven into the data. I can see that the way that the seesaw dynamic emerged is reflective of what happens with

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mistakes in general and is likely reflective of an internal dynamic that occurs within therapists about their mistakes. I experience blame, which shuts down further exploration, and it shifts into understanding and empathy, which allows me to reflect on my role in the seesaw dynamic and use it as data.

I share my above process in order to emphasize that even as participants were going through their defensive processes, I as the researcher was going through my own as well. As Karen (1992) noted, “shame is contagious.” The fact that I also felt shame so powerfully even as I tried to write about other people’s shame is important because it speaks to why research on shame and talking about shame is both so easy to avoid and enormously important.

In Zaslov’s quotation about shame, he is referring to patients and the way that shame can push them into a defensive mode of operating and interfere with their ability to think. It is important for clinicians to begin to think more about the ways that shame can do the same for them as evidenced by this study. Karen references this when he talks about the impact shame can have clinically: “If the therapist has not come to terms with his shame, the treatment may go awry. The therapist may be defeated and proceed on the patient's terms, or he may regain control by using the power of his position to shove the patient back into his own shame” (p. 24). If therapists are unaware that they could go into their Achilles Heel when they have erred, they may be more likely to let their shame or other defensive manifestations take over with patients.

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The seesaw dynamic and shame.

Both sides of the seesaw dynamic, as well as my own parallel process in writing this paper, vividly illustrate the power of shame. In the interviews, if I softened the mistake by suggesting alternative reasons it may have happened, participants were often able to stay unambiguously in the position of acknowledging the mistake. If I moved out of the position of softening the mistake, as with P5, participants often seemed to want to soften the mistake themselves. Likewise, I could feel myself shifting back and forth on wanting to accept “blame� for participating in the seesaw dynamic. I felt defensive and ashamed of it, and had the strong urge to hide the seesaw dynamic that I discovered in the data analysis. I wanted to cover my tracks, and hence protect myself from potentially feeling judged, flawed, and exposed. I ultimately shifted into a position of being able to share this important finding, but not without some pain and lingering discomfort.

During the interviews with participants and also internally within me, the seesaw dynamic suggests that shame can only be borne for so long. On my end, I unconsciously seemed to want to protect participants from experiencing shame that I felt might be unbearable. Likewise, when participants were confronted with the full weight of my questions on their mistakes after I stopped padding them, they would often want to stop discussing them as well. It felt as though staying too long in the shame was too painful – for me, the participant, or both of us.

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The seesaw dynamic and the felt experience of making a mistake.

The seesaw dynamic is a useful way to conceptualize the felt experience of making a mistake. Participants described a good deal of internal back and forth that occurred in their experience of making mistakes. This seems reflective of an internal dance of sorts; when making a mistake, participants can only experience the most painful part of it for so long. Therapists experience the initial sting when it hits them they have erred. Then there are moments of blame, and moments of forgiveness; moments of internal self-punishment, and moments of compassion. It is a fluid, ever shifting experience. The seesaw dynamic emphasizes that mistakes frequently fluctuate in the way that they are carried by participants. Even years later, the aftermath of mistakes can shift and new understandings (or judgments) can be present in relation to an old mistake.

Mistakes (at least the ones that are meaningful to participants) in some sense, then, are alive. They live within participants and can always “seesaw� into a newly held experience, whether that be a positively held experience, a negatively held experience, or a more mixed experience.

Part of the underlying reason for this shifting, as illustrated by the seesaw dynamic present in the interviews and within me, is a difficulty tolerating too much shame around mistakes. When a mistake hits a particularly vulnerable, painful area of the therapist and she experiences the initial shame, she can eventually shift into being more reflective and consider making reparations, or she can stay in the shame the mistake initially evoked, which does not allow for healing and growth. The discussion of Kleinian

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theory in the next section will further expand ideas around the shift from the experience of shame into the experience of owning the mistake and trying to repair it.

Theoretical implications.

Klein’s paranoid schizoid and depressive positions.

Klein’s theory of the paranoid schizoid and depressive positions provides a helpful lens to examine this data. According to Klein (1946), the paranoid schizoid position occurs developmentally in young infants as a way of managing intense anxieties brought on by their absolute vulnerability and neediness. The infant splits the mother into a good object (breast) that nurtures and gratifies the infant’s needs, and a bad object (breast) that the infant experiences as frustrating and persecuting. The infant wishes to “rob the mother’s body of its good contents” “by all sadistic means” (Klein, 1946, p. 99); this desire is projected into the mother, who is then experienced as attacking the infant.

The primary defenses at play in this position are splitting, projection, idealization, and the infant’s feeling of omnipotence. This psychical position can reemerge at any time in later development, and some people remain in this position for much of their lives, feeling persecuted by the other into whom they have projected their badness. To be in a paranoid schizoid mode of operating means to experience the world as a frightening place where one feels all powerful but ultimately very emotionally fragile.

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The depressive position is set out by Klein as a developmental achievement in which the infant can now see that the good and bad breast are one and the same. Klein (1946) describes the development of the depressive position as such: With the introjection of the complete object in about the second quarter of the first year marked steps in integration are made. This implies important changes in the relation to objects. The loved and hated aspects of the mother are no longer felt to be so widely separated, and the result is an increased fear of loss, a strong feeling of guilt and states akin to mourning, because the aggressive impulses are felt to be directed against the loved object. (p. 105) In other words, the infant can now feel aware of his aggressive impulses; he is not projecting them outward into others and then feeling afraid of being destroyed from the outside. He becomes aware that these impulses come from within him, and along with that realization he becomes afraid of losing his loved object due to his aggression.

This is a remarkable achievement because the infant no longer feels persecuted but rather feels grief, and the desire to make reparations for his aggressive impulses emerges. Klein describes this process in Envy and Gratitude (1957): When the infant reaches the depressive position, and becomes more able to face his psychic reality, he also feels that the object’s badness, is largely due to his own aggressiveness and the ensuring projection. This insight . . . gives rise to great mental pain and guilt when the depressive position is at its height. But it also brings about feelings of relief and hope, which in turn make it less difficult to reunite the two aspects of the object and of the self and to work through the depressive position. (p. 195) Thus, the depressive position is a place of “fac[ing] psychic reality,� which can be extraordinarily painful. However, if one is able to tolerate this pain and the ensuing guilt, there is a possibility of working through the depressive position by offering reparations.

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The paranoid schizoid position and mistakes.

Carveth (2001) describes how “the archaic, sadistic superego reigns” in the paranoid schizoid position, which means that The subject, caught up in paranoid-schizoid splitting or polarization, feels it cannot admit of any wrongdoing or badness without being revealed as a poisonously all-bad object. In other words, at the root of the problem is a difficulty in self and object constancy in holding both good and bad simultaneously, in being able to acknowledge the badness without forgetting the goodness and so achieving ambivalence. In the pre-ambivalent, paranoid schizoid position to admit of any imperfection is to reveal oneself as hopelessly defective. (para. 20) Whether internally, or to the patient, or in an interview with me, owning a mistake can be an excruciating admission if the therapist is in the paranoid schizoid position. If a mistake makes a therapist “hopelessly defective”, then bringing it to light and talking about it is akin to torture. This sheds light on the idea of a “frozen” mistake. Mistakes can become frozen if there is a great deal of shame around them that leads the therapist to believe that she is a “poisonously all-bad object” (Carveth, 2001).

The depressive position and mistakes.

Moving into the depressive position with mistakes is painful and difficult, but participants described this process as ultimately worthwhile because they could own the mistake and decide what to do about it from a more reflective, clear place. An example of moving into the depressive position occurred during the interviews. As she reflected on how she has areas that are her Achilles heel and very difficult for her, P1 seemed to

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become more tired, and her tone became more serious and perhaps even sad. Later in the interview, P1 let me know that she felt “self-conscious” and vulnerable in revealing her trouble working with these patients to me. P1 noted that she felt “worried that you might think, ‘Oh, see. She’s not really a good therapist.’”

P1 felt vulnerable that areas where she had made mistakes and where she is not perfect had been exposed, which seemed to bring up some shame as well as sadness. By revealing a mistake to me that made her feel vulnerable, P1 fears that I might make the judgment that she is actually not a good therapist based on this one disclosure. This admission seems consistent with momentarily being in the paranoid schizoid position because P1 is worried that I am splitting and deeming her all bad, as she likely is doing to herself internally.

Interestingly, by admitting this concern, P1 can shift into the depressive position.

Though she acknowledges that she worries I will judge her to not be a good therapist, she can talk about it. In other words, the sharing of her concerns with me allows P1 to shift into the depressive position. In the depressive position, participants are able to deal with whole objects and they are capable of ambivalence. In the paranoid position, splitting is the major defense and there are no gray areas, no room for intersubjective dynamics that contribute to what happened. The therapist becomes all bad when a mistake occurs, even if this state only lasts for a brief time. The depressive position allows for a recognition that both parties are whole, flawed objects. In the depressive position, a therapist can own her mistake and not be annihilated by it as P1 is doing in this exchange.

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Shame as a defense against depressive guilt.

Carveth (1999) argues persuasively that the persecutory guilt characteristic of the paranoid schizoid position (which could also be thought of as shame) is a defense against experiencing and bearing depressive guilt. Depressive guilt comes as a result of facing a mistake and owning it. He states: because the need for punishment substitutes for and defends against genuine guilt, learning in analysis how to face and bear one’s guilt (i.e., working through the depressive position) is the road to freedom from the unconscious need for punishment and for the soothing of the pain arising from the self-torment. For, however effective on the surface, such soothing (whether derived from substances, “selfobjects” or other sources) cannot eradicate the savage god, the unconscious superego and its punitive operations. (Carveth, 2001, para. 21) When therapists are harsh with themselves over a mistake, Carveth might argue that this sort of self-persecution serves the defensive function of taking them out of actually dealing with the mistake. The vulnerability and shame that can powerfully emerge following a mistake helps therapists avoid authentically bearing their guilt about the mistake they made. The shame that can pervade the therapist’s self experience leaves no room for a real reckoning with the aftermath of the mistake for the client and the treatment.

Carveth (2001) points out how difficult it can actually be to enter into the depressive position and achieve Winnicott’s “capacity for concern” for the other: It requires a certain level of self-esteem and a certain cohesion or constancy of self to be able to acknowledge guilt without feeling totally annihilated–that is, without regressing from the depressive position of guilt and concern to the paranoid schizoid sense of the self as all-bad. (para. 31)

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Participants illustrated this point. When they were feeling more secure, they were more able to achieve the depressive position following a mistake. If a mistake happened when they were in their Achilles heel and feeling more vulnerable, they were more likely to regress into the paranoid schizoid position and find it difficult to navigate the mistake.

When participants were able to achieve the depressive position and bear their guilt over a mistake, they were also able to make reparations in a healthy way. Carveth (2001) observes that “facing and bearing guilt opens the path toward restoration of a sense of inner goodness through reparative processes” (para. 35).

Clinical implications.

The value of holding onto a constant awareness of the ways that therapists’ personal defensive processes are impacting treatment is a central implication of this project’s findings. Power dynamics inherent to the therapist-patient relationship make it easy to focus on the patient’s pathology and ignore how the therapist is impacting the process. As the literature review explored, the shift to relational and intersubjective modalities in psychoanalytic theory has allowed for a real consideration of the therapist’s subjectivity and vulnerability in the therapeutic encounter. Yet, the lack of a substantive discussion in the literature around mistakes speaks to an avoidance of them and even a denial that they happen.

While all participants stated that mistakes are inevitable, the actual experience of talking about them and making them evokes defenses that as a field we would do well to

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be aware of and understand. In other words, it is not challenging to consider and take responsibility for one’s mistakes when they are an intellectual concept. What this research suggests is that actually making a mistake and even trying to talk about the experience of making a mistake can evoke uncomfortable aspects of therapists. These defenses shut down reflectivity and the ability to learn from and use a mistake.

Ultimately, this is what therapists ask of their patients: psychotherapists try to help patients embrace what they would like to push away, and make conscious aspects that they defensively would like to keep unconscious. How are therapists to ask patients to go through this process if they are unable to do so themselves when making inevitable mistakes? Also, how can psychotherapists expect themselves to be apt guides to patients in the process of shifting into the depressive position if so much is getting disavowed in the relationship around their own mistakes?

As the discussion of this research has shown, not only are mistakes inevitable, but so is the appearance of a therapist’s defenses when the mistake hits a certain, vulnerable area. Even in the position of researcher and writer of this paper, I have seen these defenses emerge and hold sway at times. It is in the awareness of these defenses and how they manifest that therapists will gain more power and clarity to do a better job managing and using their mistakes.

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Education and supervision implications.

Talking openly and frequently about mistakes and the experience of making them is vital to therapists not only as they train, but over the course of their careers. The research has shown that much about the experience of mistakes is kept hidden, either consciously or unconsciously. Karen’s (1992) remarks on the benefit of people talking about shame in therapy are relevant here: The experience of therapy suggests that being able to come out of hiding and speak of one's shame to another person can be a healing process. The patient who is able to face the shameful fact that she is a shrew to her husband and children is free to stop the endless litany of blame and to feel again. . . . Once she speaks about it, to someone who is able to listen and absorb without becoming anxious, something changes. She is able to view herself from a freer, less tyrannical perspective, able, perhaps for the first time, to feel some sympathy for herself and her predicament. (pp. 24-25) While Karen is referring to a patient in therapy, I can easily make the comparison based on this research of the similar benefit a therapist might get from talking in a classroom setting or with a supervisor about her shame around a mistake.

When a therapist can speak openly about her reaction to a mistake, it actually allows the feelings of shame and defensiveness to shift so that she may acknowledge the mistake, handle it with the client, and learn from it. This shift allows the therapist to more deeply reflect on the mistake and the best ways to handle it within herself and within the treatment for the patient’s greatest benefit.

Overall, the study data suggests that mistakes should be a regular part of the conversation throughout training program classes and clinical supervisions. Many participants had shaming, even traumatic, experiences in supervisions and classrooms

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when they shared a mistake. Part of the source of the trauma seems to have been the sense that the student should not have made a mistake in the first place.

It is my hope that this study and future studies in the same area develop a culture in which it is understood and embraced that therapists regularly make mistakes. It has been said that one is not truly a psychotherapist until one has made their first one thousand mistakes. The results of this study argue for making education and supervision programs for therapists that support this understanding of the ubiquity of therapist errors and the ways they can be used to improve both the therapist’s work and the treatment.

Based on the study data, I recommend requiring a class on mistakes in all training programs for therapists. By devoting a class specifically to mistakes in psychotherapy, educational programs would help normalize making mistakes and perhaps loosen some of young therapists’ reticence to admitting mistakes. This research into therapists’ experience of making mistakes might also be used in the course to help therapists reflect on what happens for them when they make a mistake and what sorts of mistakes they are prone to making. Most importantly, it would allow for any shame that mistakes have brought up to be spoken, and therefore have the potential to shift participants from being more defended to acknowledging and understanding their mistakes more clearly. This would also allow more room for reflection on how to use mistakes to grow as a therapist and help the treatment and patients as well.

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Limitations of the study.

The primary two limitations of this research center on sampling and method.

Servatius’ (2010) sampling method limited study participants to professional connections of colleagues of the researcher, therefore this study is not a representative sample of all psychodynamic psychotherapists’ perceptions of mistakes. The sample size (n=11) is also small, which also limits the generalizability of the research. However, phenomenology calls for the researcher to interview a small sample in great depth in order to elicit a rich, nuanced description of mistake making.

The data collection method constitutes the second primary limitation of the research. The semi-structured interviews allowed for exploring mistakes in great depth, but they limit the data collected to concepts and thoughts that the participants were able to perceive and verbalize. This is inherently a limitation to participants talking about their own experience.

Directions for further research.

More research focused on vulnerability in the therapist and ways that gets shut down or opened up would be helpful to the field. How exactly do therapists use their vulnerability about a mistake to feel more compassion for patients? What are the ways that vulnerability can shut the process down for therapists–what is the “tipping point” that causes therapists to move into their own trauma? How do therapists handle this vulnerability when they make a mistake? What happens when they shut down with their

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patient as a result of being in the Achilles heel after making a mistake? A closer look at vulnerability and mistakes would be an important addition to the literature.

Future research could also focus specifically on mistakes and supervision.

Participant experiences of discussing mistakes in supervision ranged from tremendously helpful to traumatic. What are the factors that make talking about mistakes in supervision possible and useful? How does supervision on a mistake ultimately impact the treatment at hand?

In future research on this topic, I would recommend spending more time with each participant by adding a third or even fourth interview. P11 alluded to a mistake that was traumatic for her, but she did not feel comfortable giving me the specific details of it.

It brings up the question of how many other participants had “frozen� mistakes that they either protected themselves from remembering or chose not to discuss with me. Perhaps if we had more time together it would have felt safer to discuss this. This would elicit an even richer, more nuanced understanding of the experience of making mistakes for therapists.

More interview time would have also allowed me to go more into the dynamics at play clinically around the mistakes that were described. This study did not deeply examine the ways that mistakes impacted treatments because I decided to focus heavily on the participants’ experiences with mistakes rather than the dynamics with the patient.

It would be interesting in future research to focus more specifically on the ways that mistakes unfold in particular treatments. It would undoubtedly pose an ethical issue, but

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it would be fascinating to interview both therapists and clients about the same mistake and understand each one’s experience of the mistake.

P8 agonized over a mistake that he felt caused a patient to end treatment with him.

He spent many years berating himself about this mistake and being worried about what the patient’s next psychoanalyst might think of him for making this mistake. It was an uncomfortable aftermath that over time finally shifted into an uneasy yet more tolerable perspective that perhaps the patient needed to leave treatment in that manner. Overall, P8 believed that the client carried a negative view of him based on this ending and he felt unsettled about it.

After my second interview with P8, he left me a voice message as a postscript to his final interview. P8’s client had just contacted him and asked to come in to see him just prior to moving out of state. P8 was intrigued to notice that his client did not carry the negative memories of him that he had imagined she did. In fact, her reflections on their earlier treatment were overwhelmingly positive. P8 found it interesting that his fantasy about her reaction to his mistake was so different than her actual experience. His vignette drives home the point that therapists’ viewpoints and reactions to their mistakes may potentially be quite different from that of patients.

So . . . what becomes of our errors?

Overall, this study suggests that it is difficult, if not impossible, to get a complete resolution to our mistakes–no one can definitively tell the therapist how to hold the

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aftermath of her mistakes. There is a perpetual back and forth inherent in the experience of erring. Therapists shift in their capacity to experience shame and to experience depressive guilt around mistakes. Most mistakes seem to land on one side or the other in the aftermath (shame or understanding), but there always seems to be elements of both shame and guilt in any meaningful mistake, no matter how well analyzed it may have been. There is no final resolution and no final resting place for most mistakes.

One of the goals of this project was to talk about what psychotherapists authentically do in this work, so I want to point out that the experience of making mistakes may be seen as a reflection of the experience of conducting psychodynamic psychotherapy. Therapists never solve the puzzle or have the final answer. Despite an urge therapists sometimes have to “wrap it up pretty� (P4), it rarely works out that way.

There are always loose ends and hanging threads and the work is never done. There is a constant back and forth that exists for psychotherapists doing the work of psychotherapy.

Therapists are continuously questioning, wondering, reflecting, and struggling with their work. To be a psychotherapist is to be in a constant dialectic, and it is striking that the experience of making mistakes seems to follow this pattern as well.

Final Conclusions Guntrip (1962) theorized that people often unconsciously prefer to stay in the experience of the paranoid schizoid position to the experience of the depressive position because humans “have a universal preference for feeling bad but strong rather than

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feeling weak and afraid” (p. 99). Facing and bearing the guilt that comes with making a mistake can bring up feelings of weakness and fear. There are ways that it may seem easier to avoid this topic of mistakes altogether. However, this research implies that owning mistakes by reflecting on them and accepting the feelings they bring up can be a powerful tool to grow as a therapist, allowing for a more compassionate understanding of one’s mistakes and an increased ability to use them to enhance the treatment.

And still, it is a challenging, painful process to move from the shame evoked after making a mistake to the guilt involved in facing it and repairing it. P1 made an insightful observation about mistakes: P1: It's like that balance between knowing what you're doing and not knowing what you're doing. I feel like as a therapist, the minute I think I know everything, I better hang up my shingle and just say I'm done. Put down my shingle and say I'm done, because then you move into passivity and arrogance, and thinking you know something more, and thinking you're the expert on somebody else's life and experience. So, I try to see myself as always in a learning position, but, you know, it's painful too.

MSH: Absolutely. It's both.

P1: It's both. It's both wonderful, and painful, and–so, I'm grateful for the mistakes as much as I'm also sometimes deeply embarrassed and ashamed. And, I have to kind of balance that.

P1 is here beautifully reflecting on the ways that mistakes inevitably bring out therapists’ most vulnerable selves while also serving as some of their greatest teachers.

They are “both wonderful and painful” (P1). It is psychically demanding but enormously important to “balance” the ways that mistakes can provoke therapists’ most uncomfortable aspects at the same time as understanding that they can help increase selfawareness and ultimately make therapists better at their craft.

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Appendix A Sample Letter to Potential Participants, Sent Via E-Mail

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Dear [Potential Participant]: I am a doctoral student at The Institute for Clinical Social Work. [Referral source] shared your name and email address as a possible participant for my dissertation study, entitled “Making and Using Mistakes in Psychodynamic Psychotherapy: What Becomes of our Errors?” This is a phenomenological study that aims to understand how therapists experience making mistakes in a psychodynamic treatment process. As the principal researcher on this project, I hold that making and facing mistakes is a normative, universal experience that is understudied and underexplored. For the purposes of this study, the term mistake encompasses any personal conception of error one might hold, including mistake, error, blunder, oversight, misunderstanding, slip, and misjudgment.

I am interested in interviewing licensed psychotherapists who have been practicing at least five years. Participants must consider their treatment framework to be primarily psychodynamic. Clinical material and your personal experience with making what you consider to be mistakes will be discussed in the interviews.

Participating in the study involves two interviews lasting from 1- 1 ½ hours each, held at participant’s convenience. You may reach me at the following email address (meredithhwanglcsw@gmail.com) or phone number (773-398-9150) if you are interested in participating in the study.

Sincerely, Meredith Hwang

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Appendix B Consent Form

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Individual Consent for Participation in Research INSTITUTE FOR CLINICAL SOCIAL WORK I, ______________________________________, acting for myself, agree to take part in the research for the dissertation research project entitled “Making and Using Mistakes in Psychodynamic Psychotherapy: What Becomes of Our Errors?”.

This work will be carried out by Meredith Hwang, LCSW (Principal Researcher) under the supervision of Michelle Sweet, PhD (Dissertation Chair). This work is conducted under the auspices of the Institute for Clinical Social Work; Robert Morris Center; 401 S. State Street, Ste. 822; Chicago, IL 60605; (312) 935-4232.

Purpose The purpose of this study is to examine the psychotherapist’s normative experience of making mistakes during the course of conducting a psychodynamic treatment. The study aims to gain a better understanding of the internal and interpersonal processes that therapists go through when feel they have made a mistake, error, or blunder in psychotherapy.

PROCEDURES USED IN THE STUDY AND THE DURATION The method of investigation for this study involves semi-structured interviews with a sample of psychotherapists who are interested in reflecting on their experience of mistakes. Study participants will be interviewed two times. Each interview will last approximately 1-1 1/2 hours.

Benefits There are no known benefits to participation in this study, but participants may find this experience helpful and reflective. Participants may also experience a sense of satisfaction at contributing to research in the field.

Costs The costs of participating in this research are the time that participants must take out of their schedule to participate in the interviews. The interviewer will meet the participants at a location of their choosing in order to minimize inconvenience to participants.

Possible Risks and/or Side Effects One possible risk in this research is that the interviewee will experience emotions such as guilt, regret, shame, or vulnerability in thinking about issues around mistakes in their practice.

A second possible risk is that the interviewee will describe a mistake that constitutes a violation of the NASW Code of Ethics or a mistake that constitutes a potential legal violation on the part of the participant or his or her client.

This is a study about normative mistakes; it is not a study about ethical or legal violations. It is important to note that this study does not view ethical or legal transgressions as mistakes but rather as serious violations. In the event that a participant discusses ethical or legal transgressions, the researcher will take the following specific courses of action.

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In the case of the disclosure of an ethical violation, the researcher is required by the NASW Code of Ethics to refer the participant to consultation and possibly report that violation to the appropriate formal agencies.

In the event that a participant discloses a potential legal violation on the part of the participant or his or her client, the researcher has no obligation to report this information (with the exception of disclosures of child or elder abuse or immediate threat of harm to self or others). However, in the unlikely event that someone reads the dissertation and reports the details around a murder or suicide to law enforcement, the researcher is not legally able to keep that participant’s identity confidential from law enforcement.

Privacy and Confidentiality The transcriptions of the interviews and the final product will disguise any identifying information about participants. There will only be one computer that the data will be stored and analyzed on. This computer will be password protected. The computer will also have data encryption software and proper virus protection to protect from computer viruses. Finally, the data will be regularly backed up and stored in a locked box on disks.

The only exception to confidentiality of participants is discussed in detail above. If a participant discusses an ethical or legal violation, the researcher will follow this protocol. In the case of an ethical violation, the researcher will follow the NASW Code of Ethics and/or the state and federal laws and report the violation to the NASW or proper authorities (e.g., DCFS). Legal violations do not require reporting, but it is important to note that the researcher is not legally able to keep the identity of a participant confidential if they discuss details of a murder or suicide in some manner and law enforcement wants details on that participant’s identity in order to further an open investigation of suicide or murder.

Subject Assurances By signing this consent form, I agree to take part in this study. I have not given up any of my rights or released this institution from responsibility for carelessness.

I may cancel my consent and refuse to continue in this study at any time without penalty or loss of benefits. My relationship with the staff of the ICSW will not be affected in any way, now or in the future, if I refuse to take part, or if I begin the study and then withdraw.

If I have any questions about the research methods, I can contact Meredith Hwang (Principal Researcher) or Michelle Sweet, PhD (Dissertation Chair/Sponsoring Faculty), at this phone number 773-398-9150 (day and evening).

If I have any questions about my rights as a research subject, I may contact Daniel Rosenfeld, Chair of Institutional Review Board; ICSW; Robert Morris Center; 401 S. State Street, Ste. 822; Chicago, IL 60605; (312) 935-4232.

Signatures [All consent forms must be signed and dated. They must be explained to the participants and witnessed by the person who is explaining the procedure.]

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I have read this consent form and I agree to take part in this study as it is explained in this consent form. _________________________________ Signature of Participant

_____________ Date

I certify that I have explained the research to _____________________ (Name of subject) and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward. ________________________________ Signature of Researcher

______________ Date

Revised 6 Sep 2006

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Appendix C Interview Guide, First Interview

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Sample interview guide, first interview

1. What do you call mistakes to yourself and in consultation? Do you use the word mistake or some other term?

2. What do you think of as clinical mistakes in your treatments?

3. What different kinds of mistakes have you dealt with in your practice?

4. I’d like to ask you to think of a particular recent mistake and tell me about it.

5. How do you know when you’ve made a mistake? What happens for you?

6. What internal reactions do you have when you perceive you have made a clinical mistake? What happens?

7. What have you done in the session or with the patient after a mistake, if anything?

8. Is there a mistake that feels particularly important to you that you think of?

9. Are there some mistakes that have bothered you more than others?

10. Are there mistakes that you have never talked about with anyone?

11. Are there mistakes that have ended up being positive in your work with someone? Are there mistakes that have been particularly negative or hard to repair? What were those like for you?

12. How have you handled mistakes–with whom have you talked about these mistakes?

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13. Has anyone ever talked to you about their mistakes?

14. How did you learn about mistakes?

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References

Berman, E. (2005). Psychoanalytic supervision: The intersubjective development. In L. Aron & A. Harris (Eds.), Relational psychoanalysis volume 2: Innovation and expansion (pp. 147-170). Hillsdale, NJ: The Analytic Press.

Bernstein, J. (1999). Countertransference: Our new royal road to the unconscious?

Psychoanalytic Dialogues, 9(3), 275-300.

Bettelheim, B. (1982). Freud and man’s soul. New York, NY: Random House.

Bion, W.R. (1967). Notes on memory and desire. Psychoanalytic Forum, 2, 271- 286.

Bollas, C. (1987). The shadow of the object: Psychoanalysis of the unthought known.

New York, NY: Columbia University Press.

Brown, B. (2007). I thought it was just me: Women reclaiming power and courage in a culture of shame. New York, NY: Gotham Books.

Carveth, D.L. (2001). The unconscious need for punishment: Expression or evasion of the sense of guilt? Psychoanalytic Studies, 3(1), 9-21. Retrieved from http://www.yorku.ca/dcarveth Casement, P. (2002). Learning from our mistakes: Beyond dogma in psychoanalysis and psychotherapy. New York, NY: The Guilford Press.

Chused, J.F. (1991). The evocative power of enactments. Journal of the American Psychoanalytic Association, 39, 615-639.

Chused, J.F., & Ralphling, D. L. (1992). The analyst's mistakes. Journal of the American Psychoanalytic Association, 40, 89-117.

Creswell, J.W. (2007). Qualitative inquiry & research design: Choosing among five approaches. Thousand Oaks, CA: Sage Publications.

Ehrenberg, D. B. (1974). The intimate edge in therapeutic relatedness. Contemporary Psychoanalysis, 10, 423-437.

Ehrenberg, D. B. (1992). The intimate edge: Extending the reach of psychoanalytic interaction. New York, NY: W.W. Norton and Company.

163

Ehrenberg, D. B. (1996). On the analyst's emotional availability and vulnerability.

Contemporary Psychoanalysis, 32, 275-286.

Ehrenberg, D.B. (2006). The interpersonal/relational interface: History, context, and personal reflections. Contemporary Psychoanalysis, 42(4), 535-550.

Elliott, A., & Spezzano, C. (1996). Psychoanalysis at its limits: Navigating the postmodern turn. Psychoanalytic Quarterly, 65, 52-84.

Epstein, L., & Feiner, A.H. (1979). Countertransference: The therapist’s contribution to treatment – An overview. Contemporary Psychoanalysis, 15, 489-513.

Feiner, A.H. (1991). The thrill of error – Image and appearance, articulation, union.

Contemporary Psychoanalysis, 27, 624-653.

Ferenczi, S. (1932). The Clinical Diary of Sandor Ferenczi (J. Dupont, Trans.).

Cambridge, MA: Harvard University Press, 1988.

Ferenczi, S. (1952). On the technique of psychoanalysis. In Further contributions to the theory and technique of psychoanalysis (pp. 177-189). New York, NY: Basic Books. (Original work published 1919).

Freud, S. (1898). The psychical mechanism of forgetfulness. In J. Strachey (Ed. & Trans.). The standard edition of the complete psychological works of Sigmund Freud (Vol. 3, pp. 287-297). London: Hogarth Press.

Freud, S. (1905). Fragment of an analysis of a case of hysteria. In J. Strachey (Ed. & Trans.). The standard edition of the complete psychological works of Sigmund Freud (Vol. 7, pp. 1-122). London: Hogarth Press.

Freud, S. (1901). Psychopathology of everyday life (A.A. Brill, Trans.). London, UK: T. Fisher.

Freud, S. (1913). On beginning the treatment (Further recommendations on the technique of psycho-analysis). In J. Strachey (Ed. & Trans.). The standard edition of the complete psychological works of Sigmund Freud (Vol. 12, pp. 121-144). London: Hogarth Press Freud, S. (1918). From the history of an infantile neurosis. In J. Strachey (Ed. & Trans.).

The standard edition of the complete psychological works of Sigmund Freud (Vol. 17, pp. 1-124). London: Hogarth Press.

164

Freud, S. (1923). The ego and the id. In J. Strachey (Ed. & Trans.). The standard edition of the complete psychological works of Sigmund Freud (Vol. 19, pp. 1-66).

London: Hogarth Press.

Freud, S. (1933). New introductory lectures on psycho-analysis. In J. Strachey (Ed. & Trans.). The standard edition of the complete psychological works of Sigmund Freud (Vol.22, pp. 1-182). London: Hogarth Press.

Freud, S. (1935). The subtleties of a faulty action. In J. Strachey (Ed. & Trans.). The standard edition of the complete psychological works of Sigmund Freud (Vol.22, pp. 231-236). London: Hogarth Press.

Friedman, L. (1988). The anatomy of psychotherapy. Hillsdale, NJ: Analytic Press.

Friedman, R. J., & Natterson, J. M. (1999). Enactments: An intersubjective perspective.

Psychoanalytic Quarterly, 68(2), 220-247.

Fromm-Reichmann, F. (1950). Principles of intensive psychotherapy. Chicago, IL: University of Chicago Press.

Gabbard, G.O. (Ed.) (1999). Countertransference issues in psychiatric treatment.

Washington, DC: American Psychiatric Press.

Giorgi, A., & Giorgi, B. (2008). Phenomenology. In J.A. Smith (Ed.), Qualitative psychology: A practical guide to methods (2nd ed.). London: Sage.

Glover, E. (1931). The therapeutic effect on inexact interpretation: A contribution to the theory of suggestion. International Journal of Psycho-Analysis, 12, 397-411.

Goldberg, A. I. (1987). The place of apology in psychoanalysis and psychotherapy.

International Review of Psycho-Analysis, 14, 409-417.

Goldberg, A.I. (2001). Postmodern psychoanalysis. International Review of PsychoAnalysis, 82(1), 123-129.

Greenson, R.R. (1967). The technique and practice of psychoanalysis (Vol. 1). New York, NY: International University Press.

Greenson, R.R. (1972). Beyond transference and interpretation. International Journal of Psycho-Analysis, 53, 213-217.

Guntrip, H. (1961). Personality structure and human interaction. London, UK: Hogarth Press.

165

Guntrip, H. (1962). The manic-depressive problem in light of the schizoid process.

International Journal of Psycho-Analysis, 43, 98-112.

Heidegger, M. (1962/1927). Being and time. Oxford: Blackwell.

Heimann, P. (1950). On counter-transference. International Journal of Psycho-Analysis, 31, 81-84.

Hinshelwood, R., D., (1999). Countertransference. International Journal of PsychoAnalysis, 80(4), 797-818.

Hirsch, I. (1997). Analytic intimacy, analysability and the vulnerable analyst. Free Associations, 7(2), 250-259.

Hirsch, I. (2002). Beyond interpretation: Analytic interaction in the interpersonal tradition. Contemporary Psychoanalysis, 38(4), 573-587.

Hoffman, I.Z. (1983). The patient as interpreter of the analyst’s experience.

Contemporary Psychoanalysis, 19, 389-423.

Hoffman, I.Z. (2002). Toward a social-constructivist view of the psychoanalytic situation. In S. Fairfield, L. Layton, & C. Stack (Eds.), Bringing the plague: Toward a postmodern psychoanalysis (pp. 33-68). New York, NY: Other Press.

Jacobs, T.J. (1986). On countertransference enactments. Journal of the American Psychoanalytic Association, 34, 289-307.

Jacobs, T.J. (1999). Countertransference past and present: A review of the concept.

International Journal of Psycho-Analysis, 80(3), 575-595.

Karen, R. (1992). Shame: The rediscovery of what some psychologists regard as the primary cause of emotional distress. Atlantic Monthly, 269(2), 40-70.

Keegan, P. (2003). Introduction. In S. Freud, The psychopathology of everyday life (pp. vii-xlii). New York, NY: The Penguin Group.

Kirman, J. (1998). One-person or two-person psychology? Modern Psychoanalysis, 23(1), 3-23.

Klein, M. (1946). Notes on some schizoid mechanisms. International Journal of PsychoAnalysis, 27, 99-110.

Kohut, H. (1968). The psychoanalytic treatment of narcissistic personality disorders: Outline of a systematic approach. Psychoanalytic Study of the Child, 23, 86-113.

166

Kohut, H. (1971). Analysis of the self. New York, NY: International Universities Press.

Kottler, J.A., & Blau, D.A. (1989). The imperfect therapist: Learning from failure in therapeutic practice. San Francisco, CA: Jossey-Bass Inc. Kottler, J.A., & Carlson, J. (2003). Bad therapy: Master therapists share their worst failures. New York, NY: Brunner-Routledge.

Kramer, P.D. (1989). Moments of engagement: Intimate psychotherapy in a technological age. New York, NY: W.W. Norton and Company.

Kumin, I. (1989). The incorrect interpretation. International Journal of Psycho-Analysis, 70, 141-152.

Laverty, S. M. (2003). Hermeneutic phenomenology and phenomenology: A comparison of historical and methodological considerations. International Journal of Qualitative Methods, 2(3). Article 3. Retrieved from http://www.ualberta.ca/~iiqm/backissues/2_3final/html/laverty.html Leary, K. (1994). Psychoanalytic “problems” and postmodern “solutions.”

Psychoanalytic Quarterly, 63, 433-465.

Levenson, E.A. (1992). Mistakes, errors, and oversights. Contemporary Psychoanalysis, 28, 555-571.

Levine, H. B., & Friedman, R. J. (2000). Intersubjectivity and interaction in the analytic relationship: A mainstream view. Psychoanalytic Quarterly, 69(1), 63-92.

Little, M. (1951). Counter-transference and the patient’s response to it. International Journal of Psycho-Analysis, 32, 32-40.

Low, B. (1935). The psychological compensations of the analyst. International Journal of Psycho-Analysis, 16, 1-8.

Lyotard, J. (2003). The postmodern condition: A report on knowledge. In M. Drolet (Ed.). The Postmodern Reader (pp. 123-146). London, UK: Routledge. (Original work published in 1984).

McLeod, J. (2001). Qualitative research in counselling and psychotherapy. London, UK: Sage Publications.

Mordecai, E.M. (1991). A classification of empathic failures for psychotherapists and supervisors. Psychoanalytic Psychology, 8, 251-262.

167

Moustakas, C. (1994). Phenomenological research methods. Thousand Oaks, CA: Sage Publications.

Pope, K.S., Sonne, J.L., & Greene, B. (2006). What therapists don’t talk about and why: Understanding taboos that hurt us and our clients. Washington, DC: American Psychological Association.

Rabin, H. M. (1995). The liberating effect on the analyst of the paradigm shift in psychoanalysis. Psychoanalytic Psychology, 12(4), 467-481.

Racker, H. (1953). The countertransference neurosis. International Journal of PsychoAnalysis, 34, 313-324. Reprinted in H. Racker (1968). Transference and countertransference. New York, NY: International Universities Press.

Reich, A. (1951). On counter-transference. International Journal of Psycho-Analysis, 32, 25-31.

Reich, A. (1960). Further remarks on counter-transference. International Journal of Psycho-Analysis, 41, 389-395.

Renik, O. (1993). Analytic interaction: Conceptualizing technique in light of the analyst's irreducible subjectivity. Psychoanalytic Quarterly, 62, 553-571.

Robertiello, R.C., & Schoenewolf, G. (1987). 101 common therapeutic blunders: Countertransference and counterresistance in psychotherapy. Northvale, NJ: Jason Aronson.

Rothenberg, A. (1988). The creative process of psychotherapy. Scranton, PA: W.W. Norton & Company.

Sandler, J. (1976). Countertransference and role-responsiveness. International Review of Psycho-Analysis, 3, 43-47.

Schwaber, E. (1983). Psychoanalytic listening and psychic reality. International Review of Psycho-Analysis, 10, 379-392.

Searles, H. (1986) My work with borderline patients. London, UK: Jason Aronson.

Servatius, J. (2010). Clinical social workers, psychoanalytic theory, & deepening the treatment (Doctoral dissertation). Retrieved from http://www.icsw.edu/information/students-and-faculty/dissertation-archive/P100.

Siegel, A.M. (1996). Heinz Kohut and the psychology of the self. London, UK: BrunnerRoutledge.

168

Smith, J.A., & Osborn, M. (2008). Interpretative phenomenological analysis. In J.A. Smith (Ed.), Qualitative psychology: A practical guide to research methods (pp.

53-80). London, UK: Sage.

Smith, J.A., Flowers, P., & Larkin, M. (2010). Interpretative phenomenological analysis: Theory, method and research. Los Angeles, CA: Sage Publications.

Sprayregen, B. (1993). Mistakes that transform: Psychotherapists’ perceptions of treatment mistakes that lead to therapeutic change. (Doctoral dissertation).

Retrieved from ProQuest Dissertations and Theses database. (Order Number 9319417).

Stern, A. (1924). On the counter-transference in psychoanalysis. Psychoanalytic Review, 11(2), 166-174.

Stern, D. (2002). What you know first: Construction and deconstruction in relational psychoanalysis. In S. Fairfield, L. Layton, & C. Stack (Eds.), Bringing the plague: Toward a postmodern psychoanalysis (pp. 167-194). New York, NY: Other Press.

Strachey, J. (1934). The nature of the therapeutic action of psycho-analysis. International Journal of Psycho-Analysis, 15, 127-159.

Strean, H. (2001). Countertransference: An introduction. In H. Strean (Ed.).

Controversies on countertransference (pp.1-24). Northvale, NJ: Jason Aronson.

Sullivan, H. S. (1947). Conceptions of modern psychiatry. New York, NY: W.W. Norton and Company. van Manen, M. (1990). Researching lived experience: Human science for an action sensitive pedagogy. Albany, NY: State University of New York Press.

White, R. S. (2001). The interpersonal and Freudian traditions: Convergences and divergences. Journal of the American Psychoanalytic Association, 49(2), 427454.

Winnicott, D.W. (1949). Hate in the counter-transference. International Journal of Psycho-Analysis, 30, 69-74.

Winnicott, D.W. (1963). Dependence in infant care, in child care, and in the psychoanalytic setting. International Journal of Psycho-Analysis 44, 339-344.

Winnicott, D.W. (1971). Playing and reality. New York, NY: Routledge.

169

Wolf, E.S. (1979). Transferences and countertransferences in the analysis of disorders of the self. Contemporary Psychoanalysis, 15, 577-594.

Yassky, A.D. (1976). On making therapeutic mistakes. Journal of Contemporary Psychotherapy, 8(1), 43-46.

Young, R.M. (1995). The vicissitudes of transference and countertransference: The work of Harold Searles. Free Associations, 5(2), 171-195.

Young, R.M. (2000, March). Harold Searles. Lecture conducted at the Tavistock Clinic, in the series ‘Psychoanalytic Pioneers.’ Retrieved from http://humannature.com/rmyoung/papers/pap129h.html Zaslav, M.R. (1998). Shame-related states of mind in psychotherapy. Journal of Psychotherapy Practice and Research, 7(2), 154-166. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3330497