Depending on where you get your numbers, roughly 1/3 of all patients will not benefit from psychotherapy. Why this is so isn’t entirely clear and could be due to multiple factors: intractable diagnoses, poor compliance/follow-through, an inadequate match between client and therapist, negative changes in the patient’s life circumstances, etc. Any and all of these can easily make therapy a failed endeavor.
When clients leave an unsuccessful therapeutic experience, shrinks often provide explanations couched in jargon, usually pointing to the patient’s “pathology” as a reason for the lack of follow-through:
“Clearly, the transference issues were far too intense for the patient to tolerate.”
“The Jungian archetype that emerged in session created a too startling response in the client’s collective subconscious.”
“Without question the patient’s defense mechanisms wouldn’t allow for the necessary vulnerability to facilitate the required psychological mindedness that makes the analysis flourish in its decided glory. How do I know this, you ask? I’m the expert, that’s how.”
However, what you will rarely hear, if ever, is a therapist assume actual responsibility for the failed treatment. Although it’s important that clients feel confident in their providers’ abilities, to see your therapist as without fault is naive. Most readers of this site don’t spend a lot of personal time with shrinks, but if they did they would hardly ever hear the professionals lament their mistakes or short-comings:
“I wasn’t empathic enough and left him feeling misunderstood.”
“I should have challenged the patient more, gotten her to think more about one particular issue.”
“I jumped in too quickly, I should have given him more space to get comfortable.”
“I was too cocksure and that made me appear cold and uncaring.”
“I just wasn’t good enough to help him.”
In short, it’s never the therapist’s fault. We always do our jobs correctly, so if therapy doesn’t work, it’s either due to the psychological problem or the patient. Why would we think this way? Part of it is our required role as promoting confidence in the therapeutic process. Patients need to believe that we know what we’re doing in order to invest the time, energy and finances into treatment. We are also greatly rewarded for our successes; the rush of pleasure and pride we feel when clients say “Oh, Dr. So and So, you’ve changed my life!” is like a drug. To think that your words and actions altered the landscape of a person’s life is something you hold onto forever. Add in a human being’s natural urge and ability to avoid blame and suddenly you’ve got a recipe for an overly confident shrink. But there’s another piece as well.
Consider a shrink’s training. During my graduate studies, I had a supervisor tell me that because therapy is an inexact science, one can never say that what you’ve done was wrong. “Anything you say might actually be correct, accurate and helpful, so don’t let anyone tell you that you might have erred.” He actually extended this line of thinking to never apologize for “mistakes,” such as being late for a session or forgetting an important piece of information about the patient’s history.
But ineptitude is, in fact, a viable factor for consideration. While gaining acceptance into a doctoral program for practicing Psychology is quite difficult, once you’re there, it’s not all that hard to navigate through the program*. Others will tell you differently, but as long as you are capable of reasonably structuring your time to read the textbooks and attend class, graduating is very easy (read about the real difficulties of being a Psychologist here). Those who do not finish their program rarely leave due to academic demands; rather, they realize that this line of work is not for them or they simply don’t complete their dissertations and thus can’t have their degree conferred upon them.
That said, graduation does not translate to success in real world psychology. While a licensing exam is required, there is simply no adequate way to predict what students will excel as practicing psychologists. And while many programs will point to intensive supervision and feedback about a student’s clinical work throughout graduate training, the reality is that unless you engage in some grave ethical violation or consistently drool on yourself in session, your odds of passing are quite high.
But even the well-qualified practitioners are going to make their share of mistakes. This site is constantly dissecting the “human” element of shrinks, which includes our foibles, idiosyncrasies and professional limitations. Shrinks need to work on what I’m calling Humble Skills (HS) and recognize our errors and failures (just peruse the archives to see the countless blunders I’ve made and, make no mistake, my clients have often correctly pointed out when I’ve fumbled the ball). Psychology is often an inexact science and thus mistakes will be made. We need to own up to that, acknowledging that we have said things to our patients that have not been beneficial or perhaps even hurtful. In graduate school I worked with a severely mentally ill man who told me that a former doctor of his admonished him about his lack of progress. “If you don’t get your act together you’ll be walking the floors of an insane asylum for the rest of your life.” Of course selective memory could easily have been in play here, and perhaps the doctor was using warning as a possible motivator, but the reality is that the patient’s interpretation of what was said created a deep psychological scar.
Let’s end with this: if you’re a shrink, sit back and really reflect on your own “psychological mindedness,” wonder if you’ve simply dropped the ball at times in the therapy room. Really consider viable mistakes you’ve made and instances where you were simply not equipped to do the best work possible, especially those times when it was easy to point the finger at the client or the disorder. I mean this not for the purposes of punishing yourself, but to be more humble, open and simply better at the job. And if you are a client, don’t use this post as a mechanism to abdicate all responsibility for your treatment. Rather, view it as an invitation to consider your shrink as someone who might have said or done things that didn’t benefit you and, therefore, what might have been more helpful.
* An exception to this would be a small number of “diploma mills,” or programs that accept a colossal number of students (in exchange for very high tuition rates). A small number of these programs alone actually produce more than 50% of the United States’ Psychologists each year.