therapist problems

January 16, 2013

How Therapists Fool Themselves

Snowball therapy

The above photo of Kyle Young’s album “Snowball Therapy” is not meant to suggest anything negative about his music. Unfortunately, however, there are probably a few therapists who are using forms of “therapy” that are nearly as preposterous as that name implies.

The fallibilities of therapists could probably fill several books. I will not win much applause from colleagues by telling you how therapists sometimes fool themselves. The list below does not apply to all healers, but the self-deceptions are more common than one would wish. Here are a few of the ways that counselors sometimes lack a realistic appraisal of themselves and their work:

1. “I’m not doing this for the money.” While almost all therapists come to the profession in order to do some “good,” most also have to make a living like everyone else. Quite a few will discount their fees for certain patients, but most set some number as the very bottom-line that is acceptable compensation, meaning that clients without medical insurance coverage or a heavy wallet go without.

Those practitioners who do lots of marketing and employ other therapists clearly are mindful of the potential for profit. All this is fine, but it also means that there is more than one reason that therapists do the work; and that for some, money is of equal or greater importance than the work itself. Keep in mind the old joke about the MD who is asked about his specialty. His answer is: “My specialty is diseases of the rich.”

2. “I can treat almost any diagnosis.” There are too many different ways a life can go wrong and too many areas of skill and knowledge required to help put things right. No one has seen them all and knows them all, but some think they do. If your counselor claims omniscience or anything close, run — run fast!

Watch out for a therapist who thinks of himself as some sort of therapeutic comic book hero.

Watch out for a therapist who thinks of himself as some sort of therapeutic comic book hero.

3. “There is no research supporting what I do, but I know it works.” Some therapists go so far as to write books about their style of treatment despite a lack of research support. They claim that their experience justifies their approach, citing anecdotal evidence which no scientist would take seriously. They ignore the fact that empirically validated treatments exist for conditions like Obsessive Compulsive Disorder (OCD) and Social Anxiety Disorder, to name only two.

In effect, these healers practice the rough equivalent of using an unproven folk-remedy to cure cancer. They tend not to read scientific journals that publish rigorously designed, peer-reviewed articles, dismissing them as too “academic and impractical,” and may not even have the training to adequately understand such research reports. Good luck if you are the patient of one of these people.

4. “We need to continue; you aren’t where you need to be yet.” Several potential problems are found here, even though it might be true that the patient could benefit from something more. First comes the question of why therapy hasn’t already accomplished what it needs to do. The therapist may have taken this person as far as he is now capable of going, regardless of who might treat him; or else lacks the skills needed to take him further. Is the healer’s desire to extend therapy motivated by money? What is the treatment plan to get the person to the finish line and is the patient prepared to make the effort and pay with his time and hard-won dollars?

The truth is that we humans are never perfected in all the things that could make our lives better, yet most of us continue without lifelong therapy. The decision to end must come sometime.

5. “My personal issues haven’t compromised my ability to do therapy.” I have known (or known about) therapists who treated obesity despite their own considerable overweight, who treated addiction despite themselves smoking two or more packs of cigarettes a day, and who were cheating on their spouses (sometimes with patients). I’ve heard of therapists practicing with their own untreated (and perhaps undiagnosed) Attention Deficit Hyperactivity Disorder (ADHD); others with undiagnosed or untreated Bipolar Disorder.

The list of human weaknesses in therapists is not much different from the list you will find in non-therapists. Having problems at home, as therapists sometimes do, can be enormously distracting, to say the least. The more chaotic and disturbed is the healer’s life, the less effectively can he help anyone.

6. “My values don’t influence my ability to do therapy.” I’ve known therapists who were very religious, going so far as to encourage their patients to adopt a similar view; and atheist counselors who were troubled by patients who had strong religious beliefs. I’ve known those who can’t easily talk about death because they are terrified of it, a problem when dealing with someone who has mortality issues. Therapists must either refuse to see certain people, refer them to others, or heal themselves in order to practice honorably and well. Unfortunately, some practitioners deny their own limitations and the extent to which their own beliefs and issues can affect therapy.

Finally, the biggest self-deception of them all:

7. “My patients get better — I’m a good therapist.” Maybe not. Remember that most people come to therapy at a low point in their lives, perhaps even a crisis. Time passes, whether in therapy or out. Most of us tend to bounce back. As researchers know, the real question is whether the person you are treating would have done as well or better with a different treatment, without treatment; or with someone like a relative, a friend, or a clergyman who did little more than listening and hand-holding.

A few therapists forget the admonition made to physicians: “First do no harm.” Indeed, there are counselors who believe they are doing just fine, but who have failed to diagnose the difference between Bipolar (Manic-Depressive) Disorder and other varieties of depression; or missed recognizing that a patient has partially compensated for his non-hyperactive problems of attention and concentration by dint of intellect and effort, and thereby effectively disguised his need for medication.

Those diagnostic failures virtually guarantee frustration and discouragement in the patient, who then has one more life disappointment to add to a long list; and who might never return to therapy with a genuinely competent therapist. The “doc,” meanwhile blames the client (or the severity of the patient’s problems) instead of his own incorrect evaluation.

Part of the dilemma for prospective patients is that most don’t investigate therapeutic options years in advance of the decision to seek help, nor can they reasonably be expected to. Indeed, they usually spend much less time researching potential treatments than they do when investigating which car to buy. Rather, clients typically come to therapy at life’s low ebb, review the list of people who accept their insurance, and look upon the therapist as a licensed authority who will surely have all the answers. Yes, we are licensed, but that doesn’t guarantee our competence any more than it does for cosmetologists, physicians, cemetery managers, real-estate agents, or barbers, all of whom need to be licensed in the State of Illinois.

There is nothing better than knowing what you are getting into and with whom, even if you are out of gas; especially if you are out of gas. Get recommendations from your friends or your MD if you can. Early on, find out what your diagnosis is and do research on the web concerning empirically validated treatments for that condition.

Therapists generally mean well and some are really terrific. Literally, life-savers. But, like any other group, we are subject to our own self-deceptions. A few counselors should be placed on a pedestal, a few underneath one.

Advocate for yourself.

—

You may find the following related post of interest: When Helping Hurts: Therapists Who Need Therapy.

—

The top photo is from Kyle Young’s fourth album. The second image is of “Retman,” an actual therapeutic comic book hero. The first three initials, R.E.T., stand for Rational Emotive Therapy. The cartoon is the work of Razvantonescu, International Institute for Advanced Studies of Psychotherapy and Mental Health. Both works are sourced from Wikimedia Commons.

January 20, 2012

The Pain of Counseling: When Therapy Turns South

http://upload.wikimedia.org/wikipedia/commons/8/89/U-turn.png

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

November 5, 2009

When Helping Hurts: Therapists Who Need Therapy

http://upload.wikimedia.org/wikipedia/commons/thumb/b/b5/KKC_2007_Crutches.jpg/500px-KKC_2007_Crutches.jpg

I’ve known therapists who slept with their patients. I’ve known therapists who took “down on their luck” patients into their homes. I’ve known therapists who made friendships with their patients and socialized with them outside of the office. And, I’ve known therapists whose sense of their own value depended on their patients’ approval and improvement.

There are problems here and I hope most of them are obvious. But, just in case, I will explain.

A therapeutic relationship involves unequal power. Authority figures, be they bosses, teachers, parents, clergymen, or therapists, usually have a power advantage. Patients assume a therapist has only the patient’s best interests at heart. The patient might never previously have had someone in his or her life who seemed so interested, who listened so patiently, who seemed so caring. Under these circumstances, the patient is vulnerable if the therapist should pursue his own sexual agenda.

For a time, it might feel good to both parties, but it is a fundamental corruption of the therapist-patient relationship and, in the long run, can do extraordinary damage to the patient and add one more life-injury to the long list of hurts the patient has already suffered. This is true even if it is the client who provokes or initiates the sexual contact, as sometimes happens.

Dual roles are generally a problem. Thus, a therapist is well-advised to avoid the complication of being more than a therapist to his patient. Meaning he shouldn’t be a therapist/lover or therapist/friend. To take on more than one role almost inevitably confuses both the therapist and the patient as to which role takes priority. And, it compounds the potential feeling of rejection, if the therapist should say or do something that seems critical or indifferent.

Expectations of friends, therapists, and lovers depend on which role you believe that person occupies in your life.

Even the anticipation of a possible future friendship or sexual relationship after therapy ends can change the therapeutic relationship for the worst if either the client or counselor harbors such hopes. Imagine a therapist who desires a patient who is considering a possible divorce; if he anticipates the possibility of “dating” the newly divorced woman once treatment is over, might he be more likely to encourage her to end her marriage?

It is for reasons like this that the American Psychological Association’s ethical guidelines rule out any such contact between counselor and patient, during or after therapy, in virtually all cases.

None of this is to say doctors do not, sometimes, have feelings of attraction to clients. We treat the beautiful, the charming, and the handsome, as well as the less than beautiful and less than charming. But all counselors should be trained about and reminded of the boundaries concerning therapeutic relationships, boundaries that must never be violated.

Therapists run other risks, as well. Among them, is the need for approval from their patients. Certainly, it is human to want such approval. But the therapist needs enough confidence to be able to withstand his inevitable inability help everyone; and, that in order to help some people, it will be necessary to tell them painful truths that may cause the patient to end the therapy and reject the therapist.

If the counselor is too invested in the patient’s improvement for his own good, he can be laid-low if the patient does not get better. And, ironically, if the therapist is working too hard to help his client, harder (in fact) than the client is working, he is likely to steal the essential initiative of the client so necessary for his or her improvement.

Anyone in a helping-profession faces a problem with respect to how close he should get to his patient. If he is emotionally distant from this person, his ability to help is compromised. Most people, after all, want a doctor who cares. If you think your healer doesn’t care, or is only in it for the money, you are likely (and correctly) guided to go elsewhere for treatment.

On the other hand, however, is the problem of the health-care-professional who cares too much; who feels your pain almost as much as you do; who suffers the ups and downs of your mood as if he is a passenger on the same roller coaster, sitting right beside you. He is in danger of giving too much of himself, to the point burning out. Moreover, when you reach for him in your sadness or confusion, you are not likely to find a “rock” upon whom you can rely, but instead someone who is just as pained or disoriented as you are over the reverses in your life. From that vantage point, no therapist can be of any use.

Therapists need to be solid, emotionally and physically, to take on the complicated emotional and intellectual lives of the people sitting across from them. They need to be involved, but not to the point their own emotional well-being is compromised by the sadness or turmoil of the people who they are treating. They need to know their own limitations and set limits on the extent they provide care, lest they be sucked-dry by the process and unable to be of any use to anyone, including themselves.

It can be useful for therapists to receive their own therapy. But when the counselor’s world is rocked from the outside, or when he is unable to navigate the white-water of human emotion that he is attempting to traverse, sucked into whirlpools beyond his control, he is well-advised not only to seek supervision and treatment, but sometimes, to refer the patient or patients in question to those who do have the equanimity to be able to do good for those same people.

Nearly all therapists mean well. Nonetheless, as the saying goes, “The road to hell is paved with good intentions.” If you think your therapist is unstable, too involved, or in some way inappropriate, it is time to consider your options: there are lots of good therapists out there, but there is only one of you; one life to live and set on the best possible course you can.

—

You may find the following related post of interest: How Therapists Fool Themselves.

—

The above image is Cropped Photo of 2007 KKC Participant with Self-made Custom-fabricated Crutches by Rich Cosgrove, sourced from Wikimedia Commons.