“The clinical psychologist, the stock picker, and the pundit do have intuitive skills in some of their tasks, but they have not learned to identify the situations and the tasks in which intuition will betray them.” – Daniel Kahneman (2011)
Intuition is a critical tool in therapeutic progress. It is also woefully susceptible to the influences of confirmation bias and overconfidence – just ask the respondents of a study which found that every single mental health professional surveyed rated themselves as above average (1). The therapeutic alliance is widely accepted as the most important aspect of treatment, yet therapists frequently fail to correctly understand their clients’ assumptions and assessments of the working relationship (2).
With that in mind, here are four things we have learned from our guests after twenty episodes of the Very Bad Therapy podcast.
1. Clients experience significant barriers to providing honest feedback about the therapeutic relationship.
We expected to hear a few stories that reflected the inherent power dynamic within the therapeutic relationship. It was astonishing to hear the same themes repeatedly emerge from guests who are themselves therapists (Listen to Episode 17 and Episode 20). Clients often feel unable to voice feelings about elements of therapy that are experienced as bothersome. This is especially concerning in conjunction with the fact that therapists are quite poor at identifying both the subtleties of unspoken feelings and the red flags of client deterioration (3). How do we create a culture of feedback to help our clients share their experience? Dr. Scott Miller shares his ideas in Episode #18.
2. Therapeutic ruptures can be helpful, but only if they are repaired.
No surprise, right? What has been surprising are the amount of guests who share stories about therapist defensiveness. Clinical mistakes are unavoidable, but they seem to be compounded when the gift of client transparency is unable to be received. “Perhaps you might be too racially sensitive” is not a helpful response to a valid client concern, as our guest Carol learned in Episode #4. However, client outcomes are actually better when ruptures take place and the emerging alliance has room for growth (4). Ruptures happen; it is our responsibility to remain humble and open to repair.
3. Bad therapy is often nonverbal.
Prior to starting this podcast – and speaking to guests like Bryan and Allison – we didn’t spend much time thinking about what our clients experience in session beyond the therapeutic conversation. This is decidedly harder for clients to do when dirty plates are on the desk, stacks of papers are strewn about the office, and the therapist pauses to take unimportant phone calls. Being a therapist can be difficult work, but not tending to and creating a therapeutic space can negatively impact a client’s engagement of the session (5).
4. Clients will keep coming back even when therapy has harmful effects.
Our guests have supported the notion that clients want therapy to succeed and implicitly trust that the clinician can help achieve this goal. This makes sense; a person who receives therapy will experience greater benefit than approximately 80% of untreated individuals (that this figure hasn’t changed in forty years is a whole other story)(6). Even in the face of grooming behavior or reinforcement of disordered eating habits, clients trust in the culturally sanctioned expert role of the therapist. Accordingly, our job as practitioners is to remain aware of how this trust is manifesting within the therapeutic relationship.
After hearing twenty weeks of bad therapy stories, our learnings can be distilled down to the simple notion that we must seek to understand our clients’ experiences in session beyond what they offer in words and observed behavior. It is a fair assumption that most of the therapists described in our guests’ narratives remain unaware that their actions were anything but therapeutic. The mission of Very Bad Therapy continues to promote better outcomes through therapist accountability and client empowerment. Thank you for joining us on this journey of learning.
Walfish, S., McAlister, B., O'Donnell, P., & Lambert, M. J. (2012). An investigation of self assessment bias in mental health providers. Psychological Reports, 110(2), 639-644.
Bachelor, A. (2013). Clients’ and therapists’ views of the therapeutic alliance: Similarities, differences and relationship to therapy outcome. Clinical Psychology and Psychotherapy, 20, 118-135; Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75(6), 842-852.
Hill, C. E., Thompson, B. J., Cogar, M. C., & Denman, D. W. (1993). Beneath the surface of long-term therapy: Therapist and client report of their own and each other's covert processes. Journal of Counseling Psychology, 40(3), 278-287; Hatfield, D., McCullough, L., Frantz, S., & Krieger, K. (2009). Do we know when our clients get worse? An investigation of therapists’ ability to detect negative client change. Clinical Psychology & Psychotherapy, 17(1), 25-32.
Miller, S. (2016). I Was Wrong: The Healing Power of Admitting Mistakes in Psychotherapy. Retrieved from https://www.scottdmiller.com/i-was-wrong-the-healing-power-of-admitting-mistakes-in-psychotherapy/
Nissen-Lie, H., Havik, O. E., Høglend, P. A., Monsen, J. T., & Rønnestad, M. H. (2013). The contribution of the quality of therapists’ personal lives to the development of the working alliance. Journal of Counseling Psychology, 60(4), 483-495.
Wampold, B. E., & Imel, Z. E. (2015). Counseling and psychotherapy. The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). New York, NY, US: Routledge/Taylor & Francis Group.