While it may be unfair to second guess a colleague’s treatment decisions–and it’s always easier to see someone else’s work more clearly than one’s own– I couldn’t help but wonder if Ruth Livingston’s therapy with her patient ‘Steve’ was doomed  even before it began. In her essay, “Poetry Kept My Patient Alive” that appeared on May 24th in the NY Times column, THE COUCH,  she describes her daunting work with seriously disturbed man. As a psychotherapist, I read the piece with an eye for treatment details that lay readers may overlook ( or perhaps my competitive impulses have gotten the better of me, having submitted numerous essays to that column to no avail) that have signaled ‘red flags’.  In all fairness, no one has a crystal ball and the prognosis working with a psychotic patient is quite poor, particularly so in a case like this one of chronic mental illness.  Nevertheless, I was stuck by Livingston’s description of how ‘Steve’ was referred to her, knowing that the manner in which a patient comes to treatment is often a significant variable in its course and outcome. First, she says that he was referred to her by a colleague ‘who no longer took his insurance’. I wondered if the referring therapist had committed an ethical breach known as abandonment of treatment.  How long had they worked together and did the clinician do everything possible to continue seeing the patient even without the insurance? Perhaps Livingston sensed the same thing when she questioned the clinician’s motive for the referral.  She says;” I suspect the colleague had grown tired of Steve”. If these issues were in fact the case, then whatever feelings of rejection and abandonment Steve felt toward the referring clinician would invariably get played out in his treatment with her. This  reaction would not be purely his transference, his distortion, as transference implies;  he was, in fact, dumped!  Did Steve worry that eventually she too would tire of him and dump him as the other one had? Who could blame him for keeping her at a great emotional distance? It was no wonder that he tried to reverse the roles so that he was the teacher and she the student.  He may have been desperately trying to gain control  over the relationship, and its outcome, in the only way he knew.   To my mind, this may account, in part, for his insistence on talking only about his poetry. It may be seen as a resistance to talking about his negative feelings to what was done to him. When a patient has negative feelings toward the referral source, whether that source is professional or personal in nature, those negative feelings will wreak havoc on the treatment unless they are addressed.  Livingston doesn’t mention any of this in the essay, instead she focusses on the dream-like meaning of his poems,  and while quite touching such a focus may have missed a critical resistance to the therapy. One axiom of treatment practice that I strongly adhere to is: “If a therapist doesn’t address the patient’s negative feelings about the treatment, the patient will probably terminate pre-maturely”.  Of course, it is impossible to know just how much this played a part in her patient’s early death but it did make me wonder: was the treatment doomed from the start?