Ideally, all therapists would continue to develop and improve their craft throughout their years of practice. But it’s not uncommon for therapists to put in the minimum time necessary in order to meet continuing education and other regulatory requirements. It’s also not uncommon for people who have sought help from therapists to have stories about one unhelpful therapy experience after another.
Research into therapeutic outcomes often points to the finding that there have been no improvements in psychotherapy outcome studies in 30 years (Caldwell).
Therapists tend to struggle or make mistakes when they:
- Lack technical knowledge rooted in a clear framework and metapsychology around what helps people heal and change.
- Have unresolved issues that get in the way of working optimally with people seeking help. This is known as countertransference.
I have spent hundreds of hours reviewing my own video-recorded work, the work of peers, and the work of interns I have trained. From this review, and the feedback I have received from senior consultants, I have developed the following ideas about common areas where therapists often fall short.
An inaccurate view of the situation
Before we can know how to intervene and best offer help to people seeking therapy, we must first be able to understand what is happening, or where and why they are stuck. Seeing clearly and accurately in this way is not easy. It is unlikely there is any therapist who is so tuned in to those they are helping that they always know what response or technique will be most useful.
Therapists who become too focused on individual aspects of treatment may become unable to see larger themes and dynamics at work as a result. They miss the forest for the trees, so to speak. At times they may also not be able to recognize or assess signs of fragility or lack thereof. They may also see obstruction and resistance where there is health and therapeutic movement, or the opposite, therapeutic movement where there is obstruction and resistance.
Many therapists, myself included, can fall into a trap of becoming formulaic with the people they work with. In other words, they use a one-size-fits-all approach. This might happen when therapists aren’t sure what to do, fear they won’t be helpful, or have anxiety around not having their bearings. As a result, people seeking help may feel put off or as if they are not understood. They may feel they are merely being “handled” or talked at, instead of related with.
Skimming the surface
Skimming the surface can take different forms, such as:
- Saying nice things about the person they’re working with
- Talking about patterns in an abstract way without moving to actually discontinue painful patterns
- Giving advice in the face of significant emotional conflicts
In some circumstances, it may be perfectly fine for a therapist to encourage the person (or couple) they are working with to plan another date night or practice I-statements. But when helping people work through issues such as chronic infidelity, this approach may not help resolve trust concerns or other underlying dynamics.
Checking in with people in therapy about the meaning they attribute to an event and asking them to confirm or disconfirm our observations can go a long way toward correcting these assumptions.
Some therapists may make assumptions about a person’s motivation to change. For example, I have often made the mistake of working harder than the person seeking my help. It was more important to me for the person to change than it was to them. Some other common assumptions have to do with thinking the person we’re working with shares our perceptions or finds the same meaning in an event or experience. A closer look may reveal that the person has not bought into our idea of the therapeutic task but is instead dutifully going along with us.
We might also assume a person who cries during a session is experiencing sadness and grief, when a closer look reveals the tears are covering up anger or expressing unregulated anxiety. Checking in with people in therapy about the meaning they attribute to an event and asking them to confirm or disconfirm our observations can go a long way toward correcting these assumptions. The people we work with can also give us feedback on how they experience our attempts to help, and this input can help inform our practice.
Timing of interventions
The pace of treatment needs to account for what works for the person we are treating. This might include their capacity, their readiness, and their level of insight.
Timing-related mistakes typically involve one of two situations:
- The therapist pushes a person too hard before there is sufficient trust or development of the therapeutic relationship.
- The therapist stays in a relationship-building phase when the person in therapy is already prepared to address their difficulties in a more head-on way.
One example of this involves therapists trying to help people gain access to feelings by repeatedly asking “What are you feeling?” without first having sufficiently addressed internal barriers to feeling.
Failing to address complex feelings in the here-and-now
At some point in the process, in-depth psychotherapeutic work tends to involve looking at things that are painful. Much like an animal who has been abused will growl at anyone approaching, friend and foe alike, many of the people we work with will experience complex feelings toward us when we try to form an emotionally intimate relationship with them.
If we do not notice the signs that a person in therapy is experiencing complex feelings toward us, these emotions can then go underground, and walls often begin to form. We as therapists become part of the problem in the person’s life. This has been called the “transference neurosis.” It begins when the therapist does not pick up on and address the mixed and complex feelings the person in therapy develops in the here-and-now towards the therapist. At that point, the therapist becomes lumped in the person’s (often unconscious) mind with all of the past disappointing relationships in their lives where they felt similarly unseen.
By not frequently inviting and eliciting real-time feedback on how the person in therapy experiences and reacts to the way we approach them, we miss opportunities to differentiate ourselves from others in their life. As a result, stifling walls may form. These walls may keep us from receiving valuable input from the people we work with on how they are experiencing our attempts to help them.
As a therapist, I find it important to review my recorded work, over and over, with professional consultants. I believe this is important for all therapists. By doing so, we can improve our ability to accurately see what’s in front of us, what the people we work with are experiencing, and the types of interventions they may need. We can also acquire the needed skills to address other common areas of concern.
The two most impactful ways for therapists to succeed in gaining these skills and addressing these areas of concern are:
- Working through our own unfinished emotional business with a skilled psychotherapist
- Seeking out advanced psychotherapy training and continuing education opportunities where we receive professional feedback on our work, much like that described in the literature on deliberate practice (Rousmaniere)
- Caldwell, B. (2015). Saving psychotherapy: How therapists can bring the talking cure back from the brink. Los Angeles: Benjamin E. Caldwell.
- Rousmaniere, T. (2017). Deliberate practice for psychotherapists: A guide to improving clinical effectiveness. New York, NY: Taylor & Francis.
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