Stepping off the Throne: It's Easy to Be Too Enamored with Our Own Theories
Duncan, Barry L., Hubble, Mark A., Miller, Scott D., Family Therapy Networker
Ten years ago, when we were on the faculty of the Dayton Institute for Family Therapy, Mark Hubble and I asked almost every therapist we knew to send us their "impossible cases": people labeled borderline or delusional; people at high risk of suicide, abuse or violence; people who shuttled in and out of psychiatric hospitals or were bounced from therapist to therapist for decades without getting appreciably better. We were deeply and narrowly enamored at the time with brief, strategic and family therapies, especially the work of John Weakland and the Mental Research Institute (MRI) of Palo Alto; Steve de Shazer and the Brief Family Therapy Center of Milwaukee; and Milton Erickson. We were adept with miracle questions, paradoxical injunctions, embedded commands and reframes. We wanted to show that these techniques could work not only with transient problems, but in tough cases where psychodynamic therapists, with their pathologizing labels and endless treatments, had failed.
Mainly out of revenge, a psychoanalytically trained psychiatrist at a local psychiatric hospital--who did not hide his contempt for us--referred us Richard and Eileen. We thought we were about to teach that referring psychiatrist quite a lesson. Instead, Richard and Eileen taught us a lesson we, thankfully, never forgot.
Over the next three months, Richard and Eileen rubbed our noses in our blind obeisance to theory, technique and our presumed one-up status as therapeutic experts. Our total failure with them forced us to realize that we were far more dependent on our clients than they were on us. Richard and Eileen taught us what outcome research confirms: positive change is only modestly correlated with technical wizardry and not at all correlated with any particular therapeutic school. It is far more heavily influenced by what clients bring into the room and the relationship that is created there.
Richard and Eileen did not look like "nightmare clients" when they first walked in the door. Eileen was a photographer in her thirties, impeccably groomed and dressed. Richard, a semiretired entrepreneur and philanthropist, was in his fifties, with kindly, worried eyes and a well-trimmed beard flecked with gray. They had come in for marital therapy. Not long after their marriage six years earlier, they told me, Eileen had descended into heavy drinking, self-loathing and repeated attempts at suicide. She had been diagnosed as bipolar, hospitalized, treated with lithium and then rediagnosed with Borderline Personality Disorder, alcoholism and what Richard called "compulsive tendencies." She spent a year in a private psychiatric hospital 100 miles from home, where a therapist told Richard that Eileen's was the worst case of Borderline Personality Disorder she had ever seen. Eileen spent the next year in an apartment near the hospital while attending six group and individual therapy sessions a week.
Now she was home, and she and Richard were trying to get to know each other again in an atmosphere of exhausted caretaking, self-harming, domestic violence and continued therapy. Richard did the laundry, cooked the meals and tried to make sure that Eileen ate enough. Eileen still commuted 100 miles twice a week to individual and group therapy sessions. When she was home and got angry, she would slash at her arms and legs with a kitchen knife. When Richard tried to take the knife away, they often ended up on the kitchen floor hitting each other, and Eileen had twice come close to stabbing him.
In our first meeting, each talked mainly to me, rather than to each other. "She's very suicidal. She's so insecure and there's such anger at times," Richard said. He ran down Eileen's psychiatric history and said he was "burned-out" on therapy, but terrified that Eileen would kill herself. …