‘Why is psychotherapy so different from talking to a friend?’ the protagonist and young trainee psychotherapist Valery Hazanov asks his own therapist. What follows, through ten interlinked case descriptions, is Hazanov's wrestling with the point of psychotherapy, boundaries, supervision, the evidence base for modalities, therapeutic alliance, eventually arriving at his own model, jokingly dubbed ‘Whatever Works’.
We join Hazanov in his preclinical training in Israel, moving to a PHD in clinical psychology in New York, sharing his struggles with psychology's apparent obsession with testing and validation and his confusion over which type of psychotherapy to ‘give’. The supervision is limited, with often conflicting suggestions: ‘Start working in the countertransference’, ‘Maybe a Rogerian intervention?’, ‘You really need something behavioural’.
What occurs, perhaps understandably, is a chaotic, reactionary eclecticism that neglects the patient's wishes in the construction of a therapeutic contract. Behavioural goals seem to come from Hazanov rather than the patient, the therapy is too short and the frame too unstable for any meaningful psychodynamic work. The patients appear to be having therapy ‘done to’ rather than ‘with’ them.
Context that would have helped the reader to appreciate the surrounding dysfunction comes midway through the book, where Hazanov describes a typical day. He sees 14 patients, many of whom have worked with countless trainee therapists previously, in community clinics insufficiently funded by US government programmes. It makes more sense then that supervision is woefully inadequate and fails to contain the splits within patients and the system. The points of therapeutic connection come into focus as small miracles.
Hazanov has a gift for evocative description, and talent for illustrating empathic portraits. The vignettes also demonstrate some moments of attunement, humour and repair. The book is both an honest, raw account of the uncertainty of the trainee and a cautionary tale of the risks of psychotherapy: the real potential to retraumatise vulnerable people, particularly in the hands of the unsupervised. One example is the boundary crossing that occurs in his therapy with a middle-aged female patient. She had experienced prolonged sexual abuse from a young age and now lives a constrained life, fearful of crowds and public transport. Wanting to ‘give her one good day’, Hazanov waits at her stop one evening and rides the bus with her. Although later reflecting on his ‘saviour syndrome’, there is no apparent consideration of how intrusive this might have been for his patient, a woman who had for much of her life suffered the violation of her body and mind.
The first chapter allows us access to Hazanov's own therapy, but the insights into this important experience end there. Although throughout the book he attempts to understand his own anxieties and mistakes, deeper consideration of his unconscious motivations could have added a richness and authenticity to the reflection and learning.
As Bion said, ‘In every consulting room there ought to be two rather frightened people: the patient and the psycho-analyst’ (p. 5).Reference Bion1 However, it is crucial what we as clinicians do with our fear. As trainees, our fear of doing nothing could lead us to action without thought and to the risk of doing great harm. To acknowledge our anxiety, understand our unconscious needs, to experience and make use of containing supervision are how we might avoid harm and perhaps even help.
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