The “Impossible” Case project
I have always been taken by Emily Dickinson and this is one of my favorites. I included this poem in the book, Psychotherapy with “Impossible” Cases, which described my work with several clients who were part of the “Impossible” Case Project.
The main goal of the “Impossible” Case project was to investigate how impossibility developed—how clients came to suffer “bloated file” syndrome or staying in therapy for extended periods of time without benefit. We learned that the first freeway to failure was “attribution creep.” Whether the experience is borne in simple trait ascriptions or by establishing a formal diagnosis, once set in motion, the expectancy of hard going can be surprisingly resilient. If left unchecked, the expectation becomes the person and we unwittingly select or distort information to conform to our expectations. Attribution creep erodes our ability to confirm and affirm clients' strengths—especially “veterans” of failed therapies. Theory and tradition provide another avenue for the onslaught of attribution creep. Clients eventually take on the characteristics defined by the theoretical premises. They are triangled or dry drunks or parentified—walking, talking embodiments of the helper’s favored theory.
The second highway to hell paved by good intentions arises by persisting in approaches that are not working. The unyielding nature of a problem arises in the very efforts to solve it. The attempted solution has become the problem as the wise folks from the Mental Research Institute preached. Impossibility develops in situations when we repeatedly apply the same or similar strategies
The final road to impossibility is paved by the neglect of the client's motivations and perceptions. There is no such individual as an unmotivated client. Clients may not share our motivations, but they certainly hold strong ones of their own. When their points of view are ignored, dismissed, or trampled by the therapist's theory, “resistance” is a predictable outcome. To us the client begins to look, feel, and act impossible. To the client, we come across as uncaring, disinterested, or patently wrong. At this stage, therapy has changed from a helping relationship to a clash of cultures with no one the winner.
From nearly 500 clients, we learned that most “impossible” clients could be avoided by attention to the alliance and honoring the client’s theory of change.
Of course, the ‘impossible” case project occurred long before the Partners for Change Outcome Management System or PCOMS was developed. But in many ways the goals of both are the same. Identifying the reasons clients became “impossible” shifted blame from both the client and the therapist, suggested that the therapy “do something different” when faced with a lack of change, and encouraged therapists to attend more to client motivations and theories as well as the alliance. PCOMS addresses each of those aspects by monitoring benefit and the alliance, and is specifically designed to prevent “impossible” situations by identifying clients who are not benefitting, enabling a collaborative search for new directions and better outcomes.
But I digress. I liked the Dickinson poem so much because it captured the feeling I got when one of these “veterans” of failed therapy realized success. I felt that my work as a therapist was not in vain. I also resonate with it so much because it represents why I became a therapist in the first place, what I aspired to do as a therapist—to make a meaningful difference in people’s lives, to stop one heart from breaking, ease one life from aching, cool one pain…
Let’s not forget why we chose this profession. Let’s re-remember our first aspirations and celebrate the victories, small as they may be, in the lives of those we serve.