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Mistakes in Therapy

Are mistakes so humiliating that everyone should be spared the experience?

When I was a second-year graduate student, my practicum site was hiring a new staff member, and I sat in on interviews with candidates, paired with Sue, a young psychologist. She told each candidate that the culture at the site was unusual: if you say something in a case conference that others disagree with, they will say so. I expected her to continue with what was unusual, but that was apparently enough. The first two candidates expressed surprise and said they would not want to work in a place “like that.” (Eventually, we found one who did.)

It had never occurred to me that you could learn a complicated skill like therapy or assessment without making mistakes. It had never occurred to me that there was a culture of psychology like T-ball, which was just getting invented, a game that sort of resembled baseball but with a tee holding the ball instead of a pitcher, with hitters staying at bat until they connected, and no one keeping score. When I played baseball as a kid, every at bat meant a win for the pitcher and the defense or a win for the batter. We learned how to win (graciously, and asking what we could learn from it) and we learned how to lose (graciously, and asking what we could learn from it). The whole idea of T-ball communicates that losing is so humiliating that everyone should be spared the experience.

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When I ran a small outpatient clinic, some of the staff and students complained that I distinguished “mistakes” from “good technique.” They felt that the word, mistake, was too aggressive, too hostile. They either disputed the possibility that one way of doing therapy could be superior to another, or else they felt there should be a kinder, gentler way of improving. When I started my teaching career, I was shocked that graduate students asked me to use green ink instead of red ink to correct their grammatical errors. I tried to make it a psychology lesson, pointing out that their emotional reaction to green ink would soon be what it now was to red ink if green ink were used to correct errors. This is why I don’t “sandwich” corrective feedback between compliments; I don’t want compliments to become conditioned aversive stimuli (when you hear one, you’ll get anxious because you know something bad is coming). Instead, I want corrective feedback itself to become a desired result, because you know when you hear it that you can get better at what you’re doing.

So Smokey Robinson is my hero: “Mistakes, I know I’ve made a few. But I’m only human; you’ve made mistakes too.” My motto in therapy is to make messes and clean them up. If you don’t make messes, you are avoiding and not engaging problematic patterns. If you don’t clean them up, you are using your privilege to determine that everything you do is just fine. I don’t want to be tortured by my mistakes; I just want to acknowledge them, fix them, and learn from them.

Some of the disagreements I hear about my therapy ideas have to do with specific questions. I think it’s a mistake to hug a patient; some think it’s not. (In my view, the best way to handle any frame deviation that would communicate kindness is to comment on how you are in a lose-lose situation; if you breach the frame, you are condoning an enactment where therapy is about discussion; if you don’t, you seem to be rejecting the client. This sort of comment goes beyond suggesting a third way called metacommunication: it implements it.) How to resolve these differences—how to tell whether you made a mistake—will be a subject of future posts. But many of the disagreements I hear about my therapy ideas imply that one cannot make mistakes at all. If true, that would make therapy not a skill (can you think of another skill that doesn’t involve mistakes?) but something else. Why pay someone to do something that takes no skill?

It’s obvious why unskilled therapists would have us believe that whatever they do is okay. What’s less obvious is how they get away with it. Would you go back to a dentist, a mechanic, or a vacuum repairperson who told you that there’s something about dental or garage or repair visits that makes your teeth or car or vacuum better regardless of the ability of the practitioner to identify and avoid mistakes? Even parents try to parent well. Only therapists claim their work is T-ball.

Of course, one of the drawbacks of orienting myself to mistakes is that I sometimes look only at what could be better and forget that so many clinicians are open to mistakes, want to learn from them, and want to become outstanding practitioners. One of my favorite moments in academia so far happened during a period when I was constantly discussing the communicative context before offering corrective feedback. (I’d usually start by asking whether the student was experiencing me at that moment as an educator or judge, that kind of thing.) A trainee told me about a case, and as I was thinking of how to prepare her for feedback, she said, “Michael, skip the speech and just tell me what you think.”

Michael Karson, Ph.D., is a professor of psychology at the University of Denver.

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