I was very pleased to read Robert Langs' letter ("Violence Against Mental Health Professionals," Psychiatric Times, July 2007), in the wake of Dr Fenton's death. Dr Langs discussed violations of the therapeutic frame in relation to risk of violence and voiced concern over our tendency toward a "one-sided thinking and approach to this problem" of patient violence. He is particularly qualified to weigh in on this discussion; his classic paper "Therapeutic Misalliances"1 described the interactional nature of therapeutic failures in general.
In his letter, Dr Langs pointed out psychotherapists' strong resistance to recognizing the possible contribution of a therapist to patient violence. In my experience, analyses within our professions of disastrous or even simply unsuccessful therapy outcomes usually reflect "one-sided thinking." Those involved in the discussion of such cases tend either to identify with the therapist and focus only on aspects of the patient's neurochemistry, psyche, and behavior that contributed to the poor outcome or to identify with the patient and focus only on objectionable aspects of the therapist's behavior, such as gross boundary violations.
A particularly narrow viewpoint I have witnessed involves a rigid employment of the medical model. I have seen colleagues who use this approach object to any analysis of the therapeutic relationship at all. For example, I have witnessed colleagues objecting to a discussion of the therapeutic relationship in the case of a patient's suicide. They argued that since a significant percentage of bipolar patients commit suicide, it is an outcome of the disease. They objected to psychiatrists "wringing our hands" over the consequences of illness, when those in other medical specialties would not. Of course, what is missing in such an assessment is an understanding of the nature of psychotherapy as an interactive therapeutic tool. Probably equally lacking is a tolerance for our uncomfortable existential position in being practitioners ofsuch a tool.
As psychotherapists, after a disastrous outcome we can never honestly say that everything possible was done. We may say that the therapist's behavior was reasonable, but we can never say that everything possible was done. On further reflection, with further consultation, and especially in retrospect, we should always be able to see new angles that could have been pursued in psychotherapy and that may have averted disaster or even led to progress. We cannot know for sure, and this lack of certainty can be uncomfortable, but we have a duty to ourselves, our colleagues, and our patients to reflect on and learn from these cases. Such reflection must use multiple perspectives, including an interactional perspective.
