Mary S

17 minutes ago, Eve B said:

So basically, Ben is saying that if it wasn't for the inherent human flaws and biases of therapists, therapy itself is an undeniably effective tool towards helping clients with their emotional issues? Blame the therapist not the therapy?

I don't think that's what he's saying -- I think he's saying that therapy is effective for many clients, but that it can still be improved to be effective for more people -- and that one key element of improving it is to help therapists be aware of and correct the biases that many therapists (and many other people) currently have and that interfere with the therapists being effective for the clients who currently do not have outcomes as positive as most clients have. Another way of saying this is to improve therapy theories and training to include therapist's awareness of common biases, to help them improve their practices.

As I see it, he isn't talking about  "inherent human flaws of therapists," but about fairly common problems in insight and thinking that he thinks can be improved with improved training. So he is blaming the training, not the therapists. He does point to measures some therapists are taking to improve their thinking and their practices -- things such as the "measuring outcomes" (that Scott MIller and others advocate) and "deliberate practice' (as Tony Rousmaniere and others advocate), and possibly even further improvements that may be extensions of these improvements.

On 10/21/2019 at 9:38 PM, Eve B said:

... Ben's thesis on the impact of therapist bias on clients looked promising until he wrote "the effectiveness of psychotherapy is undeniable..." (pg 16). 

I can see how this sounds "unpromising," but I think it's just that he has poorly expressed what he is trying to say. For starters, it helps to look at the entire sentence from which you have quoted part. It says, "The effectiveness of psychotherapy is undeniable, yet it is fair to wonder whether the decades-long plateau in outcome progress is heavily influenced by universal cognitive illusions such as overconfidence bias, base rate neglect, confirmation bias, affect heuristic, and availability bias."

This refers to the following from p. 3: '"Seminal meta-analyses of outcome studies found the overall effect size of psychotherapy and counseling to be in the range of .75 to .85 (Smith & Glass, 1977; Smith, Glass, & Miller, 1980). On average, a person receiving therapy will experience greater benefit than approximately 80% of untreated individuals. This figure has not changed significantly despite forty years of subsequent pioneering (Wampold & Imel, 2015). Hundreds of new empirically supported treatment models have emerged, yet these approaches are nearly equivalent to one another once researcher allegiances are attributed for in the outcome data (Wampold, 2010). Additionally, evidence is inconclusive as to whether specific ingredients of treatment are even necessary for therapeutic progress (Wampold, 2001)." [Note: I think that what he means by "nearly equivalent to one another" is that the overall outcomes (as measured in the research studies" were nearly the same,]

In other words, the overall body of research in  psychotherapy suggests that therapy is effective in the sense that "On average, a person receiving therapy will experience greater benefit than approximately 80% of untreated individuals", but that this overall assessment of therapy effectiveness has not improved noticeably despite forty years of trying to improve it. So Ben is suggesting/promoting other methods that give some hope of improvement.

My own impression is that efforts to increase effectiveness of therapy have for the most part neglected looking at cases where the client actually gets worse. I think that the kinds of things Ben goes on to suggest have potential to turn this around. In particular, I think that his discussion ( pp. 11- 12) of how "System I thinking" on the part of therapists can lead to poor therapy outcomes fits my experience well. My background involves a lot of emphasis on what he calls "System 2 thinking," which I had come to think of as  professional thinking. Yet therapists so often seemed to engage in "System 1 thinking," which I tended to call "snap judgments". And this really threw a monkey wrench in my attempts at therapy. The therapists just shut out so much that was important to me, while making these snap judgments that didn't make sense to me. You might say that I had a "bias" that professionals should be adept at System 2 thinking. At the very least, I think that trying to work with therapists who were not adept at (and perhaps even did not care about, or even scoffed at) System 2 thinking was counterproductive rather than helpful for me -- I got worse rather than improving. (Also, I think the predominance of System 1 thinking by the therapists had a gaslighting effect on me, which was a big part in getting worse rather than better.)

On 10/21/2019 at 5:59 PM, Starling said:

..  I should have taken it as the red flag it was.  Granted, we only had six session, but those six sessions culminated in me having a total psychic breakdown.  

So many red flags,  so easy to get worse in therapy.

I just got around to finishing listening to Very Bad Therapy podcast 21 (on Very Bad Supervision). In case you don't have time to listen to the whole thing:What I think is the best part starts from around minute 42.

(I can easily believe that therapy supervision can often be pretty awful -- my worst therapist was working mostly as a trainer/supervisor at the time that I was her client.)

5 hours ago, zygomaticus said:

I remember reading something about manipulative and controlling types being drawn to the 'caring professions', with the rationale being both the vulnerable nature of the clients/patients and the almost military like hierarchical culture in a profession like medicine (so when you rise up, you can domineer those underneath you). When it comes to institutions, it can be highly competitive to even become a trainee. I can certainly see narcissists finding the idea of status combined with the potential to have power over patients and subordinates very appealing, all whilst getting the extra kudos from the reputation of being someone that supposedly helps or cares for others.

 

See here for some discussion of narcissistic therapists.

12 hours ago, Eve B said:

Do you think it could be changing somewhat with the newer generation of therapist graduates, though? The trainees hosting the very bad therapy podcast seem to show more open-mindedness and humility than many already practicing in the profession.

I agree with your last sentence. Whether or not that reflects some change beyond their particular circumstances/training/whatever remains to be seen. I hope it augurs a change for the better -- but my impression is that the majority of therapists still stick to the "old ways".

5 hours ago, Eve B said:

Because they're paid to be the "experts," and many therapists assume that clients want them to take the lead?

This might be part of the picture, but I don't think it's all. I think there are some other contributing factors, including:

A lot of therapists have pretty big egos and think they know it all and/or are "special".

A lot of therapists enter the profession precisely because they like to "mold" people (a power thing, I guess). 

Therapist training is often like a religious indoctrination.

11 hours ago, zygomaticus said:

I agree with Mary, therapists often act as if there is a high degree of certainty. In fact, the so-called 'evidence-based' models operate in a highly categorical manner, formalising symptoms into causal diagrammatic cycles and pushing this at clients as if it's the only option. This is so inflexible that client expression falling outside of these limited statements is treated as a matter of getting sidetracked. I've tried saying it doesn't work like X for me only to be told, authoritatively, that yes, it does.

Proponents of most models seem to reify their theories, judging from what I've read over the years, like various faiths all claiming to revere the one true god. Therapists make sweeping statements about clients as if they are statements of fact rather than conjecture. I've been corrected many times by therapists, who claim to know my mind or situation better than I do, even on matters they didn't know existed five minutes previously. Therapy needs certainty to be a part of how it operates, because without it the house of cards collapses. It's predicated on faith, not fact, and often those with the least evidence will act as if they have the most certainty.

In theory, there are supposed to be systems in place to prevent negative consequences for clients, but I think the reality is that they're ineffective because a) they rely upon the honesty of the therapist when discussing cases with supervisors, and b) the client has no access to the supervision system to put across their side of the story. Yes, there are complaints procedures with professional bodies, but as has been pointed out above, the private nature of the therapy room means the client is empty-handed when it comes to proof. Plus, from what I can gather from the professionals I've spoken to, as well as the accounts of those that have tried complaining through official channels, there is a culture of stigmatising the client with a reputation as a trouble-maker.

This climate amounts to little more than lip-service when it comes to professional standards, codes of ethics and any notion of accountability. Yes, sometimes there is disciplinary action from what I've been told, but only when there are repeated complaints from multiple clients over time that can't be ignored.

This pretty much describes my experience as well.

On 10/13/2019 at 10:22 PM, Mary S said:

  I suppose the not-too-encouraging answer is that as professionals, we do our best in the face of circumstances which have lots of gray areas and uncertainty, but there are no systems in place to ensure the absence of negative consequences on clients.  Nearly all therapists are working out of a sense of wanting to help others (in my opinion), but that often is not good enough.  And so, we continue to do our best in an imperfect system."

The above are quotes from Ben Fineman's email response to me. Two  points in them that I would like to address:

1. "we do our best in the face of circumstances which have lots of gray areas and uncertainty"

Uncertainty is just  a normal, inevitable  part of life. One thing that often disturbs me in what therapists say is that they so often act as if things are (or at least should be) certain. Therapists need to learn to deal more realistically with uncertainty, rather than to go off in the fairy tale world where they believe things are (or should be) certain.

2. "Nearly all therapists are working out of a sense of wanting to help others (in my opinion), but that often is not good enough. "

I"m willing to assume that almost all therapists genuinely want to help others, but a big part of the problem is that they want to help others in ways and toward ends that they (the therapists) choose. That is treating the client as an object, unless the client freely  (without pressure) consents to both the ends and the means. However, many therapists seem to be very good at the art of persuasion, which can push the client to consent to things that they would not have consented to without the pressure of the persuasion. For example, one thing I hoped to get out of therapy was to be less vulnerable to persuasion, but I never got help toward that goal -- it was just swept under the rug by therapists. In other words, the problems I went to therapy for help with were bigger problems in therapy than in real life.

On 10/12/2019 at 4:40 PM, Eve B said:

... There problem with enforcing regulations for this profession is that it will depend on the client to report the violations because there are no other witnesses in the session room. Therapists know the general rules that they're supposed to follow, but with confidentiality comes the power to bend or break those rules however and whatever they believe it's for their client's good.

Yes, good point. This is something the professional societies and regulatory agencies really need to think about.

I got this reply from Ben Fineman:

"You make a lot of very valid points.  While I can't speak to what was happening with that therapist, it certainly fits with your idea.  I hadn't considered that possibility, and as you suggest, it brings up an important subject of therapist impairment and who is responsible for deciding when a therapist is no longer able to provide effective and ethical services.  I suppose the not-too-encouraging answer is that as professionals, we do our best in the face of circumstances which have lots of gray areas and uncertainty, but there are no systems in place to ensure the absence of negative consequences on clients.  Nearly all therapists are working out of a sense of wanting to help others (in my opinion), but that often is not good enough.  And so, we continue to do our best in an imperfect system."

I just sent this message to the VBT website in response to Episode 20:

Last night I read the VBT Podcast 20, and was appalled at the therapist’s behavior.

 

But this morning, it dawned on me that there might be a reason for the therapist’s impairment - namely, that she might have been undergoing chemotherapy that caused the impairment. In particular, I recall from a friend’s experience that chemotherapy can produce extreme nasal discharge. (Indeed, after his chemotherapy treatments, my friend carried plastic baggies in his pocket, since tissues were inadequate for the post-therapy nasal discharge). Chemotherapy side effects (particularly if the client's appointment is later on the day of a therapist's chemotherapy) could also account for some of the therapist’s other inappropriate behaviors (being late; having dirty dishes around; taking off her shoes, and generally seeming out of it).

 

This, of course, does not negate the negative effects for the client. But it does bring up the general question of therapist impairment (for whatever reason) and its effects on clients. When the impairment is the result of medical conditions or treatments, this is a societal problem. In particular regarding therapy, there need to be mechanisms to help ensure that a therapist’s medical condition and/or its treatment do not affect client’s treatment. I can well believe that a therapist impaired by medical conditions or treatments may be caught in a bind -- perhaps needing to work in order to pay for medical treatment, or to continue being qualified to receive medical insurance benefits. This is a societal problem that professional societies, agencies hiring therapists, and governmental bodies responsible for making and carrying out policies and regulations all need to play a part in addressing.   

4 hours ago, Eve B said:

Unless the APA makes it mandatory, I doubt many therapists would want to request regular feedback, especially if it's in a written format that could be used to question their professional competence. The problem I see is that many therapists just have too much pride to be able to take honest criticism from their clients without overreacting in a defensive manner. Maybe there needs to be a better filtering of the types of personalities who enter the field, but that's not going to happen either.

There is the possibility that clients may start to "vote with their feet", if the benefits of feedback informed therapy become more widely known (either by word of mouth or just searching on the web).

Also, I don't think that APA has any official capacity to make anything mandatory in therapist practice -- it is the individual state (etc.) boards that license therapists.

Also, insurance programs probably have some clout, since they can restrict insurance for therapy to therapists who meet their own requirements. So, for example, research that shows that feedback informed therapy is more effective than "treatment as usual" might convince insurance programs to only cover treatment by therapists  who use feedback informed therapy.

On 8/27/2019 at 3:37 PM, zygomaticus said:

... Gaslighting is PURE MANIPULATION. I don't think it's ever justified therapeutically, no way. The fact that, as Theo Dorpat suggests, it can happen unwittingly by therapists, suggests to me that there can't be enough checks, balances and safeguards (including supervision) to prevent therapy from descending into a dynamic of sheer uncontrolled influence from one with greater power over someone with significantly less, all with no immutable guiding force behind it because a therapist (or their supervisor) isn't bloody omniscient!

Here's a website I just came across that discusses gaslighting, including a somewhat sarcastic but somewhat amusing  video, and in some sense seems consistent with my suspicion that people who put a high priority on "winning" arguments tend to engage in gaslighting (in a possibly not deliberate, but more behavioral "positive reinforcement" learned way -- because it often leads to "winning" or at least getting the last word, or shutting the other person up): https://www.psychologytoday.com/gb/blog/ambigamy/201910/new-tool-getting-better-spotting-gaslighters

 

1 hour ago, Eve B said:

... The only way to know if the therapist learned to correct their mistakes would be for the client to risk continuing with the sessions. Should clients give their therapist the benefit of the doubt, and how many chances should a therapist deserve?

I don't think it's (in practice)  a matter of "Should clients give their therapist the benefit of the doubt", but rather, "Do clients give their therapists the benefit of the doubt?" I know I did until the side-effects of a therapist got really bad, and I suspect many clients do as well. However, this may have changed since I last tried  therapy, because now internet discussion and searching gives more possibilities of finding out information about therapists and therapy.

However, my understanding is that what Miller is talking about is therapists who do measure outcomes and client ratings routinely, and I think his statements are based on such therapists -- so the real question is how to get more therapists doing this routine requesting of feedback. I think that he is trying to get more therapists to practice routinely asking for feedback and adjusting what they do accordingly -- and he is talking about what such therapists (and their clients) have found the results of this practice to be, in order to persuade more therapists to follow these practices which seem to give better results.

On 10/1/2019 at 12:32 PM, Eve B said:

... Therapists claim to learn from their failed outcomes, but I think they tend to forget or negate those mistakes if their treatment techniques are successful with other clients.  

I think this may be confusing what "many" do with what "some" do. In other words, I think that there are some therapists who really do learn from their failed outcomes (part of this learning being that they need to treat each client as an individual)  -- but they are not the majority of therapists.

27 minutes ago, Eve B said:

Focus on their mistakes? Divert from and/or deny their mistakes is more like it. How are results accurately measured other than by outcome, though?

"Divert from and/or deny their mistakes" is what (in your and my experience) therapists all too often do. What I understand Miller to be saying by "focus on your mistakes" is the opposite of "divert from and/or deny" them -- instead, focus on doing better, on not repeating the same mistakes (and maybe even focusing on undoing any harm that the therapist's mistakes may have caused).

I assume that what he means by "measure results" is indeed by looking at outcomes -- and, in my experience at least, just as therapists typically divert from and/or deny their mistakes, they typically also don't pay attention to outcomes -- or at least, not the outcomes that the client is seeking, or that have been agreed on by therapist and client as what they're working to achieve. Instead, the therapist all too often has "goals" for the client that the client hasn't agreed upon and often isn't even told until the therapist scolds the client for not making progress toward the therapist's (previously unstated) goals for the client.

I just noticed that the Very Bad Therapy website has posted their first blog entry. It's at https://www.verybadtherapy.com/blog .

Following some links from one of the websites listed with Episode 19, I got to this one https://www.scottdmiller.com/three-free-evidence-based-resources-for-improving-individual-therapist-effectiveness/ , that says that the only factors that have been documented as influencing development of individual therapist effectiveness are "(1) measure your results; and (2) focus on your mistakes." This sure makes sense to me! Yet so few therapists seem to do these things-- especially (2)!  But intuitively (to me at least), (2) seems really important, if for no other reason than setting a good example for clients to learn to help themselves.

 

4 minutes ago, Eve B said:

I still don't understand why the APA doesn't require therapists to use mandatory feedback forms as part of the therapy, especially if outcome depends more on the cooperation of the client.

The APA is an organization for therapists, not for clients. Remember "Professional Ethics vs Guild Ethics"? 

52 minutes ago, Eve B said:

 I usually know what "warmth" is when I feel it. A "warm" person is inviting and welcoming, and you feel safe, relaxed, and comfortable in their company.  Warm people are approachable and can more easily gain trust from strangers. Kindness, friendliness, and affection are part of behaving warmly. Warmth attracts closeness, but there can also be sincere warmth and fake warmth. People can pretend to be "warm" just as therapists can act like they care.

Thanks!

 

52 minutes ago, Eve B said:

 I'm not sure why this thought was stuck in my head all day, but the therapy relationship reminds me of Cheez Whiz-- it's an imitation product that tries to mimic the real thing. I didn't know that Cheez Whiz wasn't even real cheese!  https://www.thedailymeal.com/eat/what-cheez-whiz

Nice (at least, amusing) metaphor.

One thing I found interesting that Miller said in the podcast with him was that his experience was that most therapists who were trained/taught that their job was to provide a "healing relationship" tended to get burned out easily -- that trying to maintain that "healing relationship" was extremely demanding. But when these therapists tried what he promotes (feedback informed and measuring outcomes), they didn't get burned out: the feedback gave them a means to adjust the relationship to fit the client, and that lead to progress toward the desired outcomes, and that was "positive reinforcement"/rewarding  for the therapist. It does seem to make sense to me.

I guess I didn't make myself clear in my comment above., so let me try again: Can anyone give me a  definition of '"warmth" -- for example, what does a "warm" person do that a "non-warm" person does not do? Or what does a "warm" person not do that a "non-worm" person does? Put another way: How can I tell whether a person is acting in a warm way or a non-warm way? (I'm not asking about "genuinely warm" vs "not genuinely warm" -- I just don't know what "warm" is.)

Maybe this might help: Here are a couple of definitions of "warmth" I found in a dictionary (American Heritage Dictionary, 1985) -- does either of these agree with what you [whoever cares to answer] would give as a definition of warmth? If not, are you able to state your definition of the word?.

1. "Kindness and affection; love: human warmth"

2. "Excitement or intensity, as of love or passion; ardor."

(Sorry to be difficult, but this is something I've just never understood.)

18 hours ago, zygomaticus said:

Or they just deny that your criticism is even about them by using theory evasively. Typically, across a whole range of models, this will be the classic 'it's not about me, it's transference' denial of responsibility. They then get to evade being accountable, deny the validity of your feelings by positing a more 'viable' alternative explanation (without the therapist being so wise, you'd have no idea that what you thought was your opinion of him or her as an individual was actually some sort of playing out of a pivotal dynamic with your absent parent), and can hence divert you into delving into this other dynamic.

I call it gaslighting.

This makes sense to me

18 hours ago, zygomaticus said:

It attempts to inject doubt into the client's assertions, especially when done authoritatively, so that the client then loses trust in their grasp on reality in the matter. I think it's popular across models - even amongst those who don't seem to care for any other element of psychodynamic theory - precisely because it supposedly is a theoretically valid way to puncture criticism coming from the client by interpreting it as something else entirely, a phenomenon that turns the tables and places the lens of scrutiny back upon the client.

I'm not convinced that it necessarily attempts  to inject doubt into the client's assertions. It may be in some cases, but I think that in many cases, therapists  do it just because it's what they've been taught, and in some sense gets them results that seem positive to them -- so I'd classify it (in many cases) as inadvertent rather than deliberate gaslighting.

2 hours ago, Eve B said:

"Some of the ways the therapist can demonstrate genuineness is to:

-Provide supportive nonverbal cues, including eye contact and nodding in agreement.
-Give feedback in the moment, rather than in a later session.
-Encourage you to be active and feel empowered in regards to your treatment plan."

Does the above really qualify as genuineness?

I don't see these things as demonstrating genuineness; I do see them as things that might be supportive, at least for some clients. (For example, "feeling empowered" is one of those many therapist things that seem like the therapist is in a strange culture that I don't belong to, and don't really care to belong to.)

2 hours ago, Eve B said:

-try to focus on things you have in common that will help you move towards the client’s therapeutic goal

So often therapists have very little (if anything) in common with me -- and sometimes they seem to believe that we have things in common that aren't things that apply to me.

For example, my last therapist told me that I was harming myself by focusing so much on our differences. From my perspective, we had very little in common, especially things that were important to me. Also, therapists seemed  to care very little about what I considered goals of therapy -- they may have had their own goals for me, but didn't bother to tell my what they were, or why they thought these should be goals for me.