Tony Rousmaniere: The value of recognising clinical failures

Like most therapists, I got into the field with the primary goal of helping people. When I started my clinical training, I was gratified so see that many of my clients quickly improved. However, as the months went on, my gratification soured as I realised that some of my clients were not improving. By the end of my first year of training, I came to the shocking realisation that half of my clients were not improving. Some stalled, many dropped out, and around 10% actually deteriorated during therapy.

My first reaction to this failure was shame and embarrassment. I had never heard a prominent psychologist discuss their clinical failures; I assumed everyone else was succeeding. All I had ever heard about therapy models – CBT, dynamic therapy, EMDR, you name it – was how effective they are. In fact, I had heard some teachers claim that they never had treatment failures.

Learning from mistakes

Over the years, I realized that hiding my failures didn’t serve me or my clients. Instead, I decided to write a book, Deliberate Practice for Psychotherapists, in which I argue that clinical skill improvement works best if we can self-compassionately acknowledge our limits and failures. This allows us to use deliberate practice to gradually improve our skills. All professionals need to acknowledge their limits and failures to learn from their mistakes. Can you imagine an athlete improving without ever discussing their failures with a coach? Or an artist improving without showing their imperfect work to a teacher? Or a chess player never acknowledging losing a match? Therapists are no different.

Talking about failure can help clients and clinicians

Ironically, I’ve found that some of my clients start to make the most progress only after we acknowledge the possibility (or even likelihood) of treatment failure. Some benefits from talking about failure with clients that I have noticed:

1. It lets the client know that we can be honest with each other about the possibility of failure.
2. It signals to the client that we are taking the gravity of their challenges seriously.
3. Talking about failure frankly helps the client see that they don’t need to rescue me – the therapist – from my own insecurities, which they would do by pretending to get better when they are not.
4. It signals to the client that they can’t expect me to rescue or save them, because I am not superman. This encourages some clients to step up more for themselves.
5. It facilitates expression of painful feelings like grief/anger that otherwise are kept buried. When these feels are recognized, more honest hope and optimism can emerge, in contrast to forced or pretend hope and optimism, which is unfortunately common in therapy.

These are just some of the benefits of acknowledging failure with clients. I’ve also noticed a range of benefits for myself and other therapists:

1. Improved self-esteem and self-compassion that comes from a more balanced and realistic view of myself and my work.
2. A shift in my focus from worrying if I am a good or bad therapist, to focusing on gradually getting better through continuous deliberate practice.
3. More enjoyment from my work as I am relieved of the impossible pressure to heroically save all of my clients.
4. More open and close relationships with colleagues. Openly sharing our challenges and failures together helps us bond and support each other.

Why do we avoid talking about failures? One common reason is that we worry about turning clients off from treatment. However, consider this: if you went to a doctor for cancer treatment, would you feel more confident if the doctor said “I succeed with 100% of my patients” or if the doctor acknowledged a realistic chance of failure? By acknowledging failure openly, we can experientially help our clients face their often immense challenges with courage and resolve. Try it!