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.
Soon after my mother was diagnosed as bipolar my younger brother and myself went to counseling to try and come up with some skills of how to deal with her illness. She’d had a complete nervous breakdown and when she came home had some problems. Some OCD to the point where if anyone put dishes on the counter away she’d rage that she needed to be able to see everything in the kitchen, or a panic attack if someone came home 15 min late from a movie, not to mention copying my hair color every time I dyed it (I was about 19).
I remember we went to Dr. Eric who basically just sat there and listened to us bitch about her behavior. Every once in a while he’d agree her behavior was unacceptable, but that’s about it. I think the most we got out of seeing him was he referred us to a Movie/Videogame exchange where you could trade in used merchandise–which we used for years. But he certainly never told me any good ways to deal with a parent which such serious problems.
Still, I’m smart enough to know it was him that was the problem. Not therapists in general.
I want to punch your supervisor in the nose.
Let me know when there’s an app for that.
I’m a graduate student training to become a therapist. I’m in the middle of my first practicum and if anything I think I’m the opposite. I’m probably too hard on myself and am always going over less successful closed cases in my head wondering what I could have done differently. “Oh, I wasn’t assertive enough with that client…”, “Oh, I pushed that client too hard…”
Do you think different schools of training are more likely to instill the over confident attitude in therapists. From the examples you gave it almost sounds like the traditional analysts are the worst about it.
Also, it’d be interesting to hear your take on diploma mills more. Why are they still running? What are the big ones? How do people with “Ph.D’s” from the Correspondence College of Tampa get away with practicing?
@Kevin: I think most students share your experience, but the majority seem to lose that fear and lack of confidence once they are out of school and practicing for a living.
I do give the analysts a very hard time, mainly because their way of thinking lends itself most easily to the arguments in this post. They are also the most annoying. But that doesn’t mean other orientations aren’t guilty as well.
The diploma mills still run because they make money. It’s not entirely familiar with the accredidation process, but I suppose the schools offer enough supervision and follow the suggested curriculum, which might be enough. I won’t name names here, but a quick google search could tell you the programs with the largest number of students.
I loved this article! I’ve been working for the last several years with a really gifted therapist who has helped me make amazing changes in my life and if I had to pick out one quality to describe him it would be humility. His approach to healing is to be totally open to the patient and just be with them, then see where that takes you. He takes non-defensiveness to a high art, yet apologizes very clearly if he knows he messed up. Even better, he’s more than willing to listen to my feelings about something he did, even when he didn’t mess up. And he doesn’t apologize in those cases, which has modeled boundaries for me in such a way that I now really understand them and how to have healthy ones. The other thing I really appreciate is his willingness to learn no matter where it comes from. I do a lot of reading in order to understand both my issues and how therapy works, and my therapist and I at times have been reading the same books. I’ve NEVER gotten the sense that he felt like he needed to know more than me or that he was threatened by my having knowledge of the process. Actually, he’s been quite complementary about it at times as well as willing to read and incorporate into his practice books I have recommended to him.
Just in case this sounds like I’m doing all the work, I also want to add that his focus and attunement are used to gather the facts about my internal landscape, at which point he applies his considerable knowledge and experience in order to both understand me and help me understand myself. And he’s a master of the timely confrontation (I call it “velvet bulldozer” mode). He brings an absolutely necessary expertise to the process.
I’m on a support forum for people in therapy, and considering the stuff I hear from other people about their therapists, I think what you have written would make excellent reading for a lot of therapists out there.
Thanks so much! I’ve been reading for a while and always enjoy your stuff. And I love your sense of humor!
Not to be a naysayer for a thoughtful and worthwhile article, but doesn’t this create the possibility for dangerous taking of responsibility?
Obviously it’s important to evaluate your own performance, but it will probably always be possible to find problems – like you said, shrinks are human. But did this cause the patient to truly be unable to benefit from therapy is another question entirely.
There’s a fine line between taking responsibility and putting the weight of the world on your shoulders. You will screw up. It will happen. Some people really can’t be helped though.
I think most often, you’ll find the problem somewhere in the middle. The patient was unusually resistant, the doctor made a small error, and that synergy was more devastating than either problem would’ve been on it’s own.
I say this only because I’ve met so darn many people who just weren’t willing to get better. I’m not a shrink, nor a shrink in training, but it doesn’t take a shrink to meet someone who clearly has a problem that they aren’t interested in fixing, even when they ask for your help or your sympathy. I’ve seen too many people trying to help others start to go crazy because they can’t help these incorrigible idiots who want sympathy and advice, but refuse to take any actual action.
None of this, of course, invalidates anything you’ve said above. I just feel that there has to be really careful balance in that their fault/my fault dichotomy, because tipping the scales either way ends poorly.
GregC: I definitely agree with what you’re saying in the first bit of your post – the combination of small things on both sides meets in the middle to form the big issues.
Having never had therapy but always having had a listening ear to my friend’s problems, I definitely have the lack of confidence Kevin talks about. “Oh, I should have pressed this issue.” “I should have ratcheted it back a notch here.” “We should have talked about this instead.”
It’s all about balance, I suppose. The most difficult part of anything.
My old therapist (MD with psychoanalytic training) once suggested that I might not ever benefit from that kind of talk therapy. When I asked her what, then, she might suggest, she had no suggestions. The following week, I suggested to her that laying the full responsibility at making a treatment work at the feet of the patient was arrogant at best, and overall, just wrong. I said that without doubt the majority of the responsibility was mine, the client, but that it wasn’t 100% up to me, because therapy happens between two people, and one person can’t be solely responsible for what happens a relationship, even of the therapeutic kind. I pointed out most of the reasons you suggested. She more or less rolled her eyes.
I’d like to hope she heard some truth is what I was saying. Not at all sure that is the case, unfortunately.
I liked reading the comments so far as much as I liked reading the article. Get it published. Hurry up. Snap to it Rob you’re not getting any younger… And so on and so forth until you do it. Haha. This was great man. I’ve got about 2 months left of massage therapy school and then I’ll be getting ready to enter the Athletic Training Ed. Program in the Fall…sweet.
Awesome post. I think that a therapist’s humility is what makes the whole interaction between therapist and patient a more human kind of exchange. I know that I can’t deal with people that I have friendships or relationships with that refuse to acknowledge any mistakes they have made; why should I have to deal with that from my therapist? It seems like that should be the one place where acknowledging mistakes is one of the primary criteria. And if it’s a mistake to acknowledge a mistake, then you can look at why it was an incorrect decision. I wholeheartedly agree with everything in this article.
I’ve only been in therapy a bit, and I was fortunate to have a fairly modest therapist. A lot of our sessions were brainstorming for what could make things better (was in a difficult situation), so we didn’t exactly do all that much therapy. It was really very helpful at the end when my own therapist admitted that some of the things we did helped (life-changing, really), and some of the things we did really didn’t (irritating, overanalyzed, overly assertive in wrong directions and occasionally mildly insulting).
It also helped that I read your blog beforehand, so I expected only a human and not a dispense-o-matic of advice. Mostly though, reading your blog helped humanise the profession for me, which made it easier for me to be less distrusting of therapists in general by seeing them as one of our species instead of as, well, creepy people with odd social skills who stare at you a bit too intensely and talk too much about Freudian analytics. Made it easier to understand why a person would go into the profession and do the things they do, I guess, which felt as if I’d have common ground with whomever I was seeing before going in.
Perhaps you could give this glowing recommendation to your publishers, or maybe a psychologists’ association as good press for the profession and have them foot the bill for publishing? Your blog does seem like something that would make for good reading in the waiting room before an appointment – better than the glossy family-friendly home-related magazines, children’s picture books, and scientific article-focused psychology magazines, at any rate.
I don’t know how I feel about this. Using an analogy, I’m sucking wind right now to keep up as it’s finals time and I just got my 2 hours of sleep for the night.
Maybe I do suck more then I considered.
Cross Posted as Usual, Dr. Rob
I think maybe the issue is that people are too focused on results. With therapy (and a zillion other things), the results are not entirely in your control.
Instead, the focus should be on the process. Did you show up on time? Did you pay attention and take notes? Did you really try to understand what the patient was telling you? Did you secretly have a sudoku puzzle on your note pad?
It’s like playing blackjack. The right move has nothing to with whether you actually won or lost, but rather whether you gave yourself the best chance at winning. If you’re dealt a pair of kings and split, and the next two cards are aces, you still made the wrong play, even though it worked out. Contrariwise, you can make the right play and still lose.
This is what irritates me about your supervisor. He’s basically saying that since you never see what cards the dealer had, you might as well assume you always played right. That’s bullshit. Even if you never see the outcome, you still have to take the actions that make a good outcome as likely as possible. Then, at the end of the day, even if you end up losing, you can still rest easy knowing you did the best you could.
I was suffering from what was later dx’d as BPD which blew through the roof during my first pregnancy which began our honeymoon night. The first therapist we saw was a nightmare. But what did we know; we had been raised to trust doctors.
After talking to us for fifteen minutes he declared we should forget therapy and get divorced. We had a strong relationship. That wasn’t going to cut it. He then wanted to meet with us separately. This led to bigger problems. We were always open and honest with each other, however, what we were told never matched up. Finally as things began to reach a head we started wondering “what if neither one of us is the problem and he is.” We confronted him.
He admitted to using an “unorthodox” form of therapy; separately blaming the other for all our troubles and demanding we keep it secret. When we explained how angry this made us because we never would lie to each other he became extremely angry, blamed both of us of being uncooperative and difficult and “fired” us as patients.
He was divorced six months later. We are celebrating our 28th anniversary. I am fully recovered. And believe it ort not – he is still in practice. We call him Dr. Divorce. Heaven forbid anyone not follow his example.
*stands and applauds* How wonderful to see a shrink accepting accountability! I went through a roughly decade-long cycle of hospitalizations, meds, and sporadic therapy before finding someone I was compatible with. In that period, I was accused of:
Not being willing to change
Not wanting to get better
Being too stubborn
Being lazy/not doing my homework
Not being “committed enough” to the program
Showing up physically but not really engaging the therapist
There’s probably more, but those are the ones I heard most. Thing is, I could easily turn those same accusations back on those who said them. (Discounting C, with whom I found great success and still adore) most of the mental health workers I encountered…
Were not willing to change, even when something was patently not working
Insisted that I should be “fixed” within a certain time frame (which, oddly enough, almost always was the same as how long my insurance would pay)
Just showed up and were not fully engaged in my sessions.
I quit working with a few because I couldn’t afford them, a few decided that I did not want to improve and quit seeing me. The vast majority of them, though, I left because for whatever reason, it just wasn’t working out. We didn’t gel.
There really was no fault in those cases. Not every therapist is a good match for every patient. I’m sure that harsh and demanding Dr. L.’s style was exactly right for some folks. I’m sure that some patients C is assigned ask to be transferred to someone else ’cause they don’t mesh well. At the end of the day, you’ve got two people talking to each other, and neither one will benefit if the whole time is spent butting heads.
I applaud you, Dr. D., for acknowledging your humanity and being willing to admit to mistakes. Every long-term psych patient has a few not-gels with therapists; it’s nice to know that the feeling can be mutual!
1. I am a huge supporter of peer groups/consultation groups because it provides a space for discussion and also some reflection.
2. It seems much more common for therapists in training to be harder on themselves than not hard enough. I think as experience is gained, some bad habits can form around “expertise”.
The other day I was talking to my supervisor and she came right out and admitted fault about a clinical decision. It was really helpful to see a seasoned clinician (20+ yrs) own up to not only being human, but also being willing to solicit feedback from a much less experienced clinician (6 years). I later had to own up to a flaw in my logic about another case, and it was easier knowing that judgment wasn’t waiting for me from across the room.
is there any scientific evidence that alleged “therapy” has any merit at all?
@ misanthrope: of course. You think managed care would pay for something without a track record?
Thanks Rob – I enjoyed this article.
I am a Counsellor from the UK and find I can become complacent about my decisions and tend to be harder on myself regarding not taking the time to reflect upon sessions and given directions, than upon those actual directions.
As keeping a business alive and well also takes a significant amount of time, it seems to be the time due to reflection that is sacrificed. I wondered if others shared my view and if anyone had a system that put reflection into their working day.