The Pain of Counseling: When Therapy Turns South

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Turning points in therapy and in life are usually seen only in retrospect.

Sometimes — many times — therapy leads to a better life. But sometimes therapy creates pain in the process of trying to do its work. The patient can experience it as a necessary part of the process; or, as one more disappointment, frustration, failure, or betrayal in a life already filled with them.

It often depends on the type of discomfort that therapy is causing.

I’d like to describe four different categories of such therapeutic problems. Three of these involve failures of the therapist. But one (Item #3) is a frequent development in therapy that has to do with the nature of treatment and how people deal with emotional pain, rather than some shortcoming of the counselor.

1. Countertransference

Therapists can get frustrated or angry with patients, attracted to them or repelled by them, bored by them or fascinated by them. Therapists are human, so they are subject to all the same relationship issues as everyone else.

Of course, we are trained to keep a therapeutic distance and to know ourselves well enough to minimize all of the above. Unfortunately, self-knowledge is always less than complete and training can be an imperfect aid when faced with challenging relationships.

The psychoanalytic concept of countertransference was an early contribution to understanding these sorts of dilemmas within the doctor and patient dyad. It refers to the therapist’s feelings toward the patient, particularly those that may be unconscious and stem from unresolved relationship issues in his own childhood.

For example, does the patient somehow remind him of a mother who was insufficiently loving or too critical? Those are the sorts of feelings that can sneak up on the counselor without him fully realizing what is happening and why.

Therapists who are not aware of the shadow of their own past can be destructive toward the very people they are supposed to help. Similarly, healers who are themselves too needy or too stressed will not be at their best when someone else requires their undivided attention. Simply put, the therapist should be safe and stable — on land if the patient is at sea, so that he will not be sucked into a whirlpool of suffering and make things worse.

In other words, the therapist must be professional. And, if he finds that he is pulling too hard or being too critical, then damage to that person is likely.

How will the counselor react if he discovers that he doesn’t enjoy the patient’s company or thinks that the patient is too demanding or too dependent — too critical or cancels appointments too often — not improving fast enough? Will the therapist lash back, feel hurt, try too hard to win the patient’s approval? Under such circumstances, the patient can be harmed, even if he provoked the relationship complication himself.

Therapists are well-advised to reflect on their own feelings, work on their own unresolved issues, obtain advice or supervision about challenging therapeutic encounters, and sometimes refer the patient elsewhere; not to mention, get their own treatment if their issues are compromising professional responsibilities.

2. Therapists Who Cross Boundaries

There are two categories here. First, those therapists who mean well, but are not aware of their personal vulnerabilities and the necessity of inviolable boundaries between themselves and those they serve. These practitioners therefore fail to set firm limits on responding to the neediness (or attractiveness) of their patients. Second, there are those self-described “healers” who are frankly corrupt.

  • Let us begin with the first of these two categories. In an effort to help, some therapists simply do too much for the patient. A few examples:
  1. Discounting (or deferring) fees to the extent of feeling resentment.
  2. Agreeing to schedule appointments so early or late (or on weekends or holidays) to the point of wanting to help the patient more than the patient wants to help himself.
  3. Seeing patients outside of therapy in some sort of quasi-friendship.
  4. Giving patients a physical contact that they crave which leads to sexual contact.

I’ve known therapists who took too many calls in the middle of the night for their own good or that of their family, counselors who brought patients who were down-on-their-luck into their own homes, and those who did not (I don’t think) intend for a comforting hug to become sexual, but who found that it did.

  • In the second category, some counselors — thankfully not a great number (although one would be too many) — take advantage of the power relationship in treatment. An attractive patient can be used for sexual purposes, or for the ego-boost that such encounters can provide, without conscience; or with some sort of rationalization that it is actually therapeutic. It isn’t, no matter how much the patient provokes it, desires it, or the counselor rationalizes it. More on the problem of “dual roles” and boundary violations can be found on a previous blog post about damaged therapists: When Helping Hurts.

3. When the Patient Has Improved Somewhat and Now Has Less Motivation to Continue the Hard Work of Treatment

Naturally, when therapy is working the person who came to treatment starts to feel better. Sometimes, in fact, he feels better even when therapy isn’t doing very much. Many if not most individuals come to therapy in a crisis. Eventually such a crisis will pass or at least begin to be more tolerable, even if the treatment isn’t the reason.

Once the patient is experiencing less pain, he now has less reason to stay in therapy. The pain is what brought him in and the desire to reduce pain was the motivation to do the hard work involved in treatment. Now that there is less motivation, there just might be less cause to suffer the unsettling thoughts and feelings that therapy stirs up, not to mention its financial cost and the amount of time that it takes.

Take a look at the graph below. The red line (AB) is the pain of “life,” the distress that the patient finds outside of the doctor’s office — the upset, unhappiness, and disappointment that brought him to consult the psychologist in the first place.

The blue line (PQ) in the graph is the pain or effort required by the therapy process itself. Therapy is hard work. It is often also intense and wrenching, since it asks people to change, stop avoiding frightening situations, and face the demons that might have been covered over until the therapist worked to address them: those incompletely healed psychic wounds that are still excruciating to touch.

intersecting lines

On the left side of the graph you will note that the red line (AB) is above the blue line (PQ). That is, when the person enters treatment, the pain of the person’s life is greater than the pain caused by therapy’s effort to make life better. But, as I indicated, at some point it is likely that the pain of life is reduced, while the discomfort (effort or difficulty) of therapy remains constant or might even increase. Why increase? Usually because the most tenacious problems are the hardest for the therapist to successfully address and might include taking the patient deeper into traumatic memories that he has tried to look past.

Once the patient has improved sufficiently (where the two lines intersect at point C), he now begins to find that staying in therapy causes more discomfort than getting out of it, as indicated on the graph by the fact that the blue line is higher than the red line (on the right side of the image). When the point of intersection of these lines is passed, the patient often wants to terminate treatment. Only those with sufficient “therapeutic integrity” or courage will stay long enough to resolve the most intractable of the issues that brought them to the doctor’s office in the first place. Or, they will wait until another life crisis brings them back to finish the job.

4. Therapists Who Haven’t Done Their Homework

It has only been in the last couple of decades that research has begun to point clearly to those treatments that are most helpful for some of the conditions therapists treat. Broadly defined, for example, Cognitive Behavior Therapy (CBT) has been demonstrated to be the “treatment of choice” for most people who suffer from Social Anxiety Disorder and Post Traumatic Stress Disorder.

Despite this, many therapists who claim to treat such conditions do not avail themselves of these treatment approaches or don’t familiarize themselves with the research upon which they are based.

Why?

Some weren’t trained in how to evaluate research or in how to engage in this form of therapy. Some stopped reading about progress in working with these conditions or “don’t believe” in the conceptual grounding of CBT. Some are too busy (or think they are too busy) making a living to afford the time and effort required to be up to date. Some trust their intuition to the point of rejecting anything that doesn’t match what they have come to believe is most important about how to deliver service to the people who seek them out.

The difficulty here is that therapeutic models should not be like religious beliefs, based on faith rather than evidence.

While a failure to follow “best practices” for which there is empirical evidence is not as egregious a violation of trust as sexual contact with a patient, counselors must keep learning and growing in their field of alleged expertise, just as much as they encourage their patients to grow personally.

In summary, therapists are not unique in having the capacity to do injury, but their position of authority gives them a vantage point somewhat like that which parents have with their children, making it easier to accomplish quite inadvertently.

The remedy? Obtain recommendations about counselors from those you trust. Read up on the treatment of your condition. Collaborate in your treatment, don’t just count on the therapist to do exactly what you need at every moment. Let him know about any concerns that arise. If necessary, get a second opinion. And keep your eyes open for the things I’ve described.

Not least, have the courage to stay in therapy even when the process touches on important issues that are sensitive.

As the old saying tells us, “when the going gets tough, the tough get going.”

And, no, I don’t mean “…going out the door.”

The above photo is called U-Turn by Zipley is sourced from Wikimedia Commons. Intersecting Lines is sourced from onlinemathlearning.com

What To Do When Therapy Doesn’t Help

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Therapy doesn’t always help. That doesn’t mean that it can’t help and that a second chance isn’t indicated. But, it does mean that you will need to ask yourself a few questions about what is going wrong.

There are several possibilities:

1. Misdiagnosis. If, for example, you have an alcohol or drug problem, but the therapist wasn’t told about it or didn’t realize its significance, treatment is almost certain to fail. Similarly, if you have a Bipolar (manic-depressive) Disorder that goes untreated (these can be difficult to diagnose), it will be hard to profit from therapy. I have seen many adults, for example, who have the inattentive form of ADHD and have never been diagnosed and treated for the condition, even though they have seen more than one therapist.

2. Insufficient motivation. Have you been giving therapy your best effort? Do you go to sessions religiously? Do you follow through on any “homework” assignments that you and the therapist discuss? If you are not adequately open and dedicated to getting better, then treatment is likely to fail. Defensiveness in the treatment process and inconsistent attendance are major problems. With respect to lack of effort, the old joke goes: “How many therapists does it take to change a light bulb?” Answer: “One, but the light bulb has to want to be changed.”

3. The therapist/patient match. Do you feel comfortable with the counselor? That doesn’t mean that therapy will never make you uncomfortable (change isn’t easy and it is often painful), but it does mean that the therapist is someone you can trust, who is sincere, and who is competent. Does the therapist have sufficient understanding of your life circumstances? This doesn’t necessarily mean that he has lived through a similar situation or has an identical background, gender, age, or religion; but he will need to understand where you are coming from.

4. The tempo of therapy. Does the therapist push too hard? Do you find yourself too often overwhelmed by the issues and feelings being stirred up in your sessions? Or perhaps, do things seem to go too slow? Are the sessions becoming boring and unproductive?

5. Activity level of the therapist. Is the counselor too active and probing for you? Does he seem to have a plan and a direction for your treatment (he should)? Is he too controlling, seeming to follow an agenda that is inflexible and ignores what you need? Or, alternatively, is he too passive, simply waiting for you to talk about whatever you want, regardless of how far afield this might lead the treatment?

6. Is the therapist too friendly? Does he want (or is he open to) a friendship or anything other than a therapeutic relationship (he shouldn’t be). Or, is he too distant and uninvolved?

7. Type of therapy. Therapists are not all equally comfortable and competent at the multiple types of treatment available. Some problems have been subjected to well-documented and researched treatments (Obsessive Compulsive Disorder, for example). If your therapist is using the wrong treatment approach, you are not likely to benefit as much as you could.

8. Medication. Would you do better if you were on medication? If you are on medication, might you improve more with a different medication?

9. The therapist’s problems. Does the therapist seem stable? Does he act in an inappropriate way in the sessions? Does he become angry and critical? Is he judgmental rather than supportive? Does he talk about his own current problems?

If you are still in therapy and you have concerns about its effectiveness or any of the issues mentioned above, it is usually best to voice those issues to your counselor. He should not only be open to hearing what you have to say, but want to be responsive.

Therapists are not mind readers and won’t always figure out what you are thinking or worried about unless you say it. Do your homework and try to find out what therapeutic approaches might be more appropriate for you (your therapist should be able to describe at least some alternatives).

If he cannot provide you with the kind of treatment you are asking for, he should be able to come up with some very good reasons for what he is doing. Should those reasons be unconvincing, perhaps a second opinion is indicated and he should be open to this idea, as well. If you remain sure that this therapist is not the right one for you, getting a referral from him to someone else is entirely appropriate.

If, on the other hand, you have had unsatisfying experiences in therapy before and are not now in treatment, but are thinking of trying again, make sure that you have attempted to investigate your potential new therapist’s background and experience. Also, when you talk to him on the phone, ask about his therapeutic approach. If you do decide to see him, talk about the things that didn’t work in previous therapy attempts, as well as those that did.

Be as informed as you can be. Unlike brain surgery, you aren’t going to be passive and unconscious during treatment. You are going to participate and interact with someone who, you hope, is well-trained and dedicated and compassionate. Evaluate what is going on in treatment in an open and thoughtful way; collaborate with the therapist.

You will be glad you did.

The Red Woman by Neuthaler is the name of the above image, sourced from Wikimedia Commons.