Unreliable case studies

By Michael Randolph

There is a case to be made out for reliably unreliable case studies, i.e. ones that are based on far too little information coupled to a somewhat feverish imagination. The case is that all case studies are anyway basically unreliable in that they present a twice or thrice filtered view of a patient/client in psychotherapy: They filter the present, past and future massively in or out by the choice of verbatim reporting, edited reporting or charged description; the patient’s view of things is sometimes, though very rarely, heard, as in Irving Yalom’s Every Day Gets a Little Closer but, although a courageous and welcome innovation, it doesn’t mean we grasp what we might really want to grasp; the therapist’s conceptual references may and do clarify some things whilst systematically obscuring others; the whole idea of conveying the reality of a psychotherapy in a study is a resoundingly dubious one, though there is no better learning material, no more inspirational humus to allow our growth as practitioners.

Below there is an upbeat text about modern psychotherapy I found while ordering a book from Amazon. I agree with almost all of it in the sense that I hope and assume that these things are basically true, basically realisable. From time to time, however, I run across something that, taking these hopes and assumptions as my baseline, gives me pause for thought, sometimes a long pause. I think it could enrich our clinical awareness to exchange these, not so radically uncommon, exceptions or, possibly, surprising therapeutic meanders which end up reconnecting in some way with mainstream expectations. Attached and further below find my pump-priming two-page starter. Lots of my colleagues never write anything because they worry about conveying something as comprehensive as it is comprehensible or they worry about their five-book bibliography.

There’s a lot of thought, feeling and synthesis-provoking experience out there which practitioners occasionally mutter about wanting to share with someone, preferably in the privacy of their own home, and which never gets to illuminate the trade. Pity. Short and sweet, with as few disclaimers as possible and no obligation to conclude with any plausible foresight, it could even form the basis of a one-off review.

Z’s profile

By Michael Randolph

In a 5 day group psychotherapy workshop in the spring, both L. and especially Z. seemed to be in shock at the prospect of self-induced disaster, seemingly mediated, encouraged or accelerated by their experience in psychotherapy. They were apparently mesmerised by the perspective of an unavoidable smash-up. The equally appalling prospect of accepting a posteriori radical impotence in the face of the destructive cunning of wilful neglect, in Z’s case, or the grim fate of the worn-out plaything in L’s did not appear even remotely envisaged as an option by these two relatively young adults (27 and 32 respectively).

Here is a plausible outline of her situation reconstructed from the hints put out by Z: Z.’s mother was an intellectual, a university literature teacher whose husband, Z’s father, humiliated her by rapidly directing all of his emotional intensity back on to his family of origin after their marriage and disgraced her by fulfilling her overbearing parent’s prophecy that hers was a lousy choice of a husband. She revenged herself by being, whenever she didn’t forget herself, ostentatiously uncaring for and uninterested by his offspring, her children. She also strove to label him, an occasional festive over-imbiber, an alcoholic to their children and to the world, thereby consigning him to the slag-heap of the weaving Slovakian working-class drunk.

Z. rapidly, in primary school already, totally appalled by the girls’ baroque world of friendship-negotiation and betrayal, found a durable boy-friend. After four years, presumably aided by the fact that the boy couldn’t really understand what his purpose was, she dumped him and felt intense euphoria at this decision which “resolved everything”. Not long after she started another relationship which also lasted four years and whose demise was the occasion for another ride into euphoria. This happened two more times, the always impending “solution” being a guilty secret she half-hid from herself.

She is now contentedly married with two children and the four year horizon draws near. The compulsive imperative to “go walkabout” is felt in her gut like doom. The mechanism feels unstoppable . What she decided to stop instead is staring at it, i.e. basically to stop therapy.

It is not necessarily a bad solution or the wrong solution for the rabbit looking at the snake or the deer caught in the headlights to turn their back on any overweening fascination with outcome. Many things on their own may be expected to roughly heal through the gentle tidal action of everyday life. The devil can perhaps only collect his due when he is actively and permanently dreaded.

Whilst looking at it intensely, she may find it impossible to forever give up the lure of what she half knows to be the spurious euphoria of a so-called resolutive separation. Amongst other things, these serial monogamies allowed her to cock a snook at her mother who paraded a manifest unwillingness to gratify her husband by smiling at or responding warmly to her children. To be left facing just that unsmiling unresponse, whilst deeply gratifying her therapist of course through her abandonment of the repetition compulsion, may well seem intolerable and who are we adamantly to insist?

Faced with the terrifying boundlessness of her hate-filled rage at the mocking mask of empty motherhood as well as her terror at the prospect of unavoidably destroying what she most holds dear, she has essentially said: Time out! I think it’s time to forego thinking. I want to put my life on automatic pilot, please.
Perhaps she is right that self-generated trauma is too vertiginous for a run-of-the-mill-heart and a run-of-the-mill mind, especially when being run-of-the-mill – one of the undistinguishable herd of contented-enough adults whose lives imply the prior existence of a contented-enough child – is possibly a buoyant-enough fiction to allow life to continue without the urge towards definitive decisions weighing intolerably in the universal balance.

Can the therapist’s tolerant, supportive eyes replace the battlefield glare of a maternal general sending her infantile cannon-fodder in for the slaughter? Maybe. We should not count on it however, and even if we do entertain such a hope, we must expect many situations of recoil and scrambling retreat which effectively test the therapist’s genuine Mit-Gefühl, his capacity to feel-with, a quality which would quite probably require in this case a full sharing of real war-wounds. It’s possible that what doctors used to know and seem recently to have forgotten – most things get better on their own – justifiably appears to be a safer bet.