According to one fairly comprehensive review (Lambert, 2013), approximately 50% of people in psychotherapy can be expected to experience “recovery” within 20 sessions. While I am pleased to see this evidence for the effectiveness of psychotherapy, the data also gives me pause: What about the other 50% of help-seekers? What about the therapies that get stuck before significant benefits are achieved?
This article, as a follow-up to my previous post on “stuck-ness” in therapy, will examine three more factors that can cause a therapy to get stuck, leading to sub-optimal results. It is my hope that my discussion of these potentially therapy-stalling ways of thinking, feeling, and behaving will lead to increased awareness of the factors that can lead a therapy to get stuck, and, ideally, to improved therapy outcomes. Read to the end for more information about my interest in “stuck-ness,” and for some of my thoughts about overcoming it.
Would you give a good thing to someone you hate? Would you work hard on their behalf so they can achieve their goals? If you truly hate them, I’m guessing you would not. This is why self-hate, especially when it goes unaddressed, can keep your therapy stuck. If your self-hate persists, how likely are you to let yourself get a satisfying result from therapy?
Many people enter therapy with some variant of self-hate operating in their lives. A sense of worthlessness, hopelessness, or a certain comfort with suffering often becomes evident in the first moments of treatment through statements like, “I’m not worth trying for,” “Therapy won’t work for a (insert expletive) like me,” or, “I deserve these symptoms.” As a therapist in those moments, I must ask myself, “Can healing occur under such conditions?” And I must ask of the person in therapy, “Are you going to let yourself have a good experience here if you think you’re not worth trying for?”
I have even heard people insist these qualities are not changeable. I think this is where the stuck-ness truly occurs: The person in therapy and the therapist become convinced the self-hate cannot change. They try to achieve a self-loving result to the therapy, but the saboteur of self-hate lingers in the background.
Self-hate can change. I have seen it happen in as little as one therapy session. However, if you are not focusing on your self-hate with your therapist, trying to “do therapy” while a part of you tries to withhold from or devalue you, how likely are you to succeed? If you’re feeling stuck in therapy, and you’re aware self-hate may be keeping you there, please bring that up to your therapist and see if you can do something together to create and sustain some thoughts and feelings about yourself that might allow you more benefit from the therapy.
A sense of disconnectedness and detachment from friends and loved ones often brings people to therapy. They have relationships, but these relationships lack the emotional intensity that makes interpersonal life vital and satisfying. This can lead to a sense of loneliness, even when you’re not alone, and can contribute to depression.
When we detach in our therapy and detach from our therapists, the emotional intensity of the work is all but lost in a haze of thoughts and words. The lyrics are there, but the music is missing. We have insights, but they do not get inside.
Once in therapy, someone with a detachment may have no problem sharing and talking with the therapist. They can clearly describe their problems. They can label emotions. The words of the therapy sessions sound just right. So why do people get stuck in therapy because of detachment?
When we detach in our therapy and detach from our therapists, the emotional intensity of the work is all but lost in a haze of thoughts and words. The lyrics are there, but the music is missing. We have insights, but they do not get inside. Through the veil of detachment, we talk about our feelings, but we do not feel our feelings; this prevents us from learning new ways of managing those feelings in therapy. We end up in the same detached, emotionless pattern with the therapist that keeps us stuck with our friends or partners. If we are detached, we cannot learn new ways to attach, and our growth process may stall.
If it feels like you’re thinking hard and saying all the right words in therapy, but you’re not feeling the emotional impact and benefits of your sharing, detachment may be keeping you stuck. If you are noticing this in yourself and your therapist is not, try to bring it to the therapist’s attention. If they can’t help you with this thorny problem, find someone who will.
3. ‘It’s Just the Way I Am’
Say I came to you and told you my house was on fire. Say you asked me if I wanted help with that and I blandly replied, “Meh, that’s just how my house is.” You’d be worried about my house, and you’d probably wonder why I seem so comfortable with the fire destroying it.
Some people are comfortable with suffering, usually as a result of developmental experiences that required them to accept a certain degree of suffering as normal. Some people even become identified with their suffering: “This is just the way I am. I am a suffering person.” When suffering becomes a piece of a person’s identity, a thread in the fabric of their character they cannot imagine parting with, therapy can get stuck. Why?
To achieve optimal results in therapy, we have to be willing to let go of the thoughts, behaviors, and relationship patterns that hurt us. Liking or even loving the very things that hurt us can make recovery impossible.
To whatever degree we remain married to our destructive thoughts, feelings, and behaviors, we may be unable or unwilling to let them go. If you are aware that a part of you is clinging to your suffering or identified with it, make sure to bring this to your therapist’s awareness. See if they can help you face the complicated feelings that have kept you clinging to a self-defeating pattern. If they can’t, consider finding a therapist who can.
Why I’m Stuck on This ‘Stuck-ness’ Soapbox
All too often, I find myself working with people who belong to the other 50%, who ended up stuck in multiple previous therapies over the course of multiple years. Stuck-ness prolonged their suffering, and I am aware that whatever kept them stuck with their previous therapists could sabotage our therapy, too. As a survivor of sub-optimal therapy in my own past, I am all too familiar with the pain and continued burden this can cause, so I strive to be vigilant, and to assist the people who come to me for therapy to do the same.
In intensive short-term dynamic psychotherapy (ISTDP), the model of psychoanalytic therapy that I practice and teach, we have an elegant, evidence-based system of interventions (Abbass, 2015) that helps us address the self-defeating and treatment-defeating emotional factors that can keep people stuck in life, love, and therapy. Empirical research is beginning to show that ISTDP has unique efficacy for “complex, treatment-resistant conditions” in which the stuck-ness mechanisms are often a factor (Solbakken and Abbass, 2014, 2015; Abbass, 2006). Other psychodynamic approaches are also beginning to demonstrate efficacy for treatment resistance (Fonagy, et al., 2015).
Again, if you’re feeling stuck in therapy, the first person who needs to hear about that is your therapist. However, if you’re finding your therapist is failing to help you get unstuck, consider finding a therapist with training in ISTDP or another psychodynamic approach. We are trained to work effectively with self-hate, detachment, and all the other stuck-ness mechanisms I’ve described. Perhaps you will find it worthwhile to offer yourself a new, different treatment experience that offers the support you need.
- Abbass, A. (2006). Intensive short-term dynamic psychotherapy of treatment-resistant depression. Depression and Anxiety, 23, 449-452.
- Abbass, A. (2015). Reaching through resistance. Kansas City, MO: Seven Leaves Press.
- Fonagy, P., Rost, F., Carlyle, J., McPherson, S., Thomas, R., Fearon, R.M.P., Goldberg, D., & Taylor, D. (2015). Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS). World Psychiatry, 14, 312-321.
- Lambert, M.J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (169-208). Hoboken, NJ: Wiley.
- Solbakken, O.A., & Abbass, A. (2014). Implementation of an intensive short-term dynamic treatment program for patients with treatment-resistant disorders in residential care. BMC Psychiatry, 14, 516-522.
- Solbakken, O.A., & Abbass, A. (2015). Intensive short-term dynamic residential treatment program for patients with treatment-resistant depression. Journal of Affective Disorders, p://dx.doi.org/10.1016/j.jad.2015.04.00
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