Mary S

The following might be a reason (a good one, in my opinion) for talking about "very bad therapy" rather than just "bad therapy": There are therapists whose definition of "bad therapy" is "therapy where the client doesn't make progress". The last therapist I tried gave this definition when I asked him what his definition of "bad therapy". It surprised me, so I asked explicitly, "Are you saying that you don't make a distinction between therapy that is not helpful and therapy where the client gets worse?" and he said, "Yes". Since then, I have encountered therapist websites (and as I recall, also some books and papers by therapists, although I didn't locate any in a quick web search just now ) giving that definition. So it makes sense to me for Ben and Carrie to use terminology stronger than just "bad therapy".

I just listened to Episode 4. Here are some comments: Some of the things that the client Carol said reflected my own experiences in therapy. For example, she said that she felt shocked or was speechless in response to some things her therapist said or did -- those phrases describe a frequent state I was in in response to things my therapists said or did. She also mentioned something to the effect that things went so fast that she wasn't able to process them in session, but had to spend time afterwords tprocessing them. This was my experience more often than not -- I think in part because "processing" things in real time isn't something I'm good at (I would guess that's an introvert thing), but partly because so much of what therapists do and say was shocking, and out of the ordinary, for me. Another thing that I think Carol said (or perhaps it was Carrie) was that the therapist is supposed to be open and listen to the client in the client's own words. That seemed pretty rare for a therapist to do, in my experience. So often they would tell me that I had said something that to me sounded very different from what I had said. There was also something Carrie said that I appreciated. I don't recall the exact phrase, but it was something like whether or not something "sat well with" the client, rather that how the client felt about it. To me, asking how I feel or felt about something is really intrusive, but asking how it sat with me, or how it was for me, or how it seemed to me is much more user-friendly for me -- not as intrusive, whereas asking me how I feel or felt about something is asking me to stuff myself into a framework that isn't mine -- using someone else's words rather than my own words; really, asking me to be ungenuine, to pretend I'm someone I'm not. I've got some more notes, but am getting too tired. Perhaps I'll post more later.

I'm taking it as a hopeful sign that trainees are concerned with bad therapy. It may be that it takes a new generation to effect some change.

I just listened to Episode 3. It was really good! I tried taking notes -- I'm not sure I can read them all, but I'll try to mention some things that made a good impression on me (although not necessarily in the order in which they occurred in the podcast -- my notes were just scribbled wherever they would fit on a scrap of paper). Quote: "You have to look at things from another person's perspective.'" Yes, this is something a decent therapist needs to do. But so often (in my experience) they don't; they just impose their own perspective on the client -- and that means they create an imaginary client in their mind, losing sight of the real client in the process. Quote: "Every person is different". Duh -- of course a therapist should have this view -- in this case, "Not all black people are the same" -- but it generalizes to "Not all women are the same," "Not all people in this job category are the same," and (very importantly) "Not all people with this diagnosis are the same". But (in my experience) therapists so often treat clients like stereotypes. Quote: "We have the responsibility to educate ourselves -- it is not the client's responsibility to educate us." One of the better therapists I tried said to me, "You need to teach a therapist how to help you, and that must be a burden to you." I appreciated that he realized he was clueless, but still it was pretty discouraging to hear, especially the "must be a burden" part. I really appreciated the discussion of "cultural competence" vs "cultural humility" -- especially the view that "cultural competence" seems to be a pie-in-the-sky (my rephrasing) idea. Quote: "Let us know if we have gotten things wrong" (Ohmygosh-- How my worst therapist would really lash out when I tried to do this!).

I agree that therapy theories just give therapists a fairy tale world to escape to from the complexity and messiness of the real world. But the client has to live in the real world, complexity and messiness included. Sometimes the therapist succeeds in convincing the client to join the theoretical, fairy tale world, and that sometimes helps the client , at least for a while, until the real world intervenes and pulls the rug out from under the client's reliance on the theory.

Another comment on the second podcast: Toward the end, the two hosts talked about trying to achieve empathy for the therapist discussed in the podcast. My guess is that they might have tried to have empathy for the therapist in order to have a better chance of getting their point (their criticism of her) across. But at one point, one of the hosts said something like, "Maybe the therapist's theoretical orientation emphasized pressing when the client showed resistance." My take is that when a theory says to push at a client's resistance even when the resistance is based on facts of the situation (as in this case -- where the purported cause occurred after the purported consequence), that sounds like a theory that is too rigid, too out of touch with the complexity of reality.

I just listened to the second podcast. Once I tried a therapist who made so many snap judgments that I quit him after two sessions and thought of him as Mr. My-Mind-Is-Made-Up-Don't-Confuse-Me-With-The-Facts. The therapist in this podcast sounds like Ms. My-Mind-Is-Made-Up-Don't-Confuse-Me-With-The-Facts. She really must have been out of touch with reality to insist so doggedly that the client's sexual identity concerns were caused by the sexual assault, when the former preceded the latter. Duh!

I listened to the first podcast. Two things stand out for me: First, the "bad therapist" came across as not making any effort to establish rapport with the client, nor explain what the process was and how it worked. Second, both of the interviewers and the EMDR "expert" Kurt seemed to be basically considerate people and emphasized that the therapist needed to establish rapport with the client and give the client information so that the client could make an informed choice of whether or not to try the therapy and what was involved in it, and how it might help. What the latter three emphasize was very rare in my therapist experiences -- some therapists I tried didn't seem to do it at all, and only a minority of the therapists I tried seemed to make any effort to do it (but didn't do it very well -- although possibly if I had had one of the later therapists earlier, it might have worked out; my early therapy experiences made my mental state worse and made it harder for me to trust the later therapists. My experience was that finding a good therapist -- for me, at least -- was like looking for a needle in a haystack.)

I realized that I (presumably unintentionally) included one paper in the above list that was not really relevant to the topic. However, since the topic was interesting, I just looked it up and found it online (https://www.psyencelab.com/uploads/5/4/6/5/54658091/cheat_and_hope_for_the_best_the_unspoken_undergraduate_mantra.pdf ). It does end with something interesting: "One possibility for why the cheating rate on this campus is so high is that our method may have made acknowledgement of cheating behavior more likely. A very recent study by Burrus and colleagues (2007), found that students often do not understand what behaviors constitute cheating and report higher rates of cheating if they are first educated about what constitutes cheating. In the present study, we did not ask students whether or not they “cheated”, per se. Rather, we asked participants whether they engaged in specific behaviors that have been considered illustrative of cheating in the established literature. Had we simply asked participants whether or not they had cheated, without operationalizing the cheating construct into clear behaviors, we might have observed a lower prevalence rate of self-reported cheating. However, we consider the findings from the present study to be cleaner as a result of this methodology. By defining cheating in behavioral terms we were able to cleanly identify a homogenous Never Cheated group, as opposed to a more heterogeneous group that would have included these individuals in addition to those that did not consider themselves to be “cheaters,” when in reality they had engaged in cheating behavior. Similarly, the “cheaters” used in analyses for this study were those that not only acknowledged cheating behaviors but also had external validation that they were cheating by having been caught. As such, our two groups of Never Cheated and Caught Cheaters were behaviorally distinct from one another and appropriate for analyses. It should be noted however, that the largest volume of data was associated with neither of these cleanly identified conditions. The overwhelming majority of the recruited individuals (n = 272) acknowledged engaging in cheating behaviors but were not identified as “cheaters” by the institution because they had apparently evaded detection by instructional staff" This actually makes a good impression on me for doing good research (Making sure you have good measures of what you are measuring!), so makes me think that Callahan has high standards (which the other paper by her suggested also, at least compared to other papers on psychotherapy that I've read).

In connection with the above article, I looked at the vita of the second author (Callahan), and found some things that might also be of interest. I haven't had a chance to look at them yet, but here are some that might be of interest -- in particular, it seems that there is a growing interest in taking client preferences into account (Duh!). Tompkins, K. A., Swift, J. K. & Callahan, J. L.(2013). Working with clients by incorporating their preferences. Psychotherapy,50, 279-283. doi: 10.1037/a0032031 Swift, J. K., Callahan, J. L., Ivanovic, M., & Kominiak, N. (2013). Further examination of the psychotherapy preference effect: A meta-regression analysis. Journal of Psychotherapy Integration, 23,134-145. doi: 10.1037/a0031423 Fellers, C., Davidson, C. L., Almstrom, C. M. & Callahan, J. L.(2009). Cheat and hope for the best: The unspoken undergraduate mantra? Journal of Scientific Psychology, 4, 24-29. Borja, S. E., Callahan, J. L.,& *Rambo, P. L. (2009). Understanding negative outcomes following traumatic exposures: The roles of neuroticism and social support. Psychological Trauma: Theory, Research, Practice, and Policy, 1, 118-129. doi: 10.1037/a0016011 Callahan, J. L.,Hogan, L. R., & Connor, D. R. (2011). Becoming competent in the competencies movement [Review of the book Core competencies in counseling and psychotherapy: Becoming a highly competent and effective therapist, by L. Sperry]. PsycCRITIQUES, 56(18). doi:10.1037/a0023203 Swift, J. K.,Callahan, J. L., Cooper, M., & Parkin, S. R. (2018). Preferences. In J. C. Norcross, & B. E. Wampold (Eds.) (2018).Psychotherapy relationships that work (3rded., Vol.2). New York: Oxford University Press. [I think I may have read an earlier edition of the book. ]

One thing that really bothered me in my (mostly counterproductive) attempts at therapy were the value conflicts between me and most of the therapists I tried. In my background in the STEM fields, backing up your statements with reasoning or evidence (or else providing some modifying words to indicate that you are speculating) is an important value. But therapists didn't seem to care about this at all, and I think one even said "You don't have to justify yourself" when I was giving reasons for something. Yesterday I decided to see if I could find anything on the web about therapist-client value conflicts. I found this: https://www.researchgate.net/publication/257958560_A_Model_for_Addressing_Client-Clinician_Value_Conflict , and was even able to get a copy through a library. It is perhaps the best thing I have found so far that addresses this type of conflict. Some quotes and comments: p. 207 “The APA ethics code acknowledges that both practitioners of psychology and their clients come with diverse sets of cultural and individual values and warn against the former imposing their “biases” upon the latter (APA, 2010, p.3), but he code does not clarify what would constitute such an imposition.” “The authors suggest that supervisors and trainees would benefit from practical guidelines to help them navigate value conflicts with clients in a way the prioritizes the clients’ welfare while still balancing respect for the clinician’s personal values, as this need is currently going largely unmet (see Hage, 2006 for a review) … of particular importance for such frameworks is that they address the appropriate conditions for client referral.” p. 210: “As one important function [of?] therapy is to enhance client awareness of viable and safe alternatives, trainees experiencing an operational value conflict may need to make special efforts to present a wide range of alternative to clients, including those outside of their personal preferences. It may be particularly important for the trainee to expand his or her understanding of the client’s cultural, religious, or social context in order to explore alternative that are compatible with the client’s preferences. Exploration should take place in a respectful and open-minded way that communicates appreciation for the client’s background…. Throughout this process, deference to the client’s preferences should remain of central importance whenever ethically possible.” Wow! This sounds great! I don't recall a therapist's ever presenting "a wide range of alternatives" to me -- they typically took an authoritarian attitude of "This is what you should do,'" or "You shouldn't do this". p. 211: "If for some reason, a clear understanding of the trainee's discomfort in session is not forthcoming and the trainee and supervisor have reasonable evidence that the competency of services is at risk, it may be acceptable to refer the client to competent services elsewhere. However, it is important to note that a referral does not remove the obligation from the trainee to understand the nature of the conflict and make efforts to reduce its impact on future clients. Thus, even when making referrals for unarticulated value conflicts, the trainee retains the responsibility to understand why the referral was necessary. If similar feelings of discomfort continue to require the referral of clients, the trainee might also consider receiving focused individual therapy to assist in the process of value examination. " One big concern I have with the article is that it focuses on trainee therapists, whereas I believe that a lot of practicing therapists need to develop awareness of client-therapist value conflicts, and change their practices to take these into account. In particular, trainers need to be aware of such conflicts and of how to deal with them in ways that do not harm clients; but I suspect that many trainers would be resistant to caring about value conflicts. (This is a particularly relevant concern for me, because my worst therapist was a trainer when I was her client. I hate to think of the harmful attitudes she may have passed on to her trainees.)

Here is a history of informed consent in medicine: https://www.encyclopedia.com/science/encyclopedias-almanacs-transcripts-and-maps/informed-consent-i-history-informed-consent The first therapist I tried who had an informed consent form was a psychiatrist (I had tried two psychologists previously, so thought a psychiatrist might be better -- no such luck). This was in 1987, I believe. Since psychiatrists are M.D.'s, they presumably follow the medical requirements/policies for informed consent. So this suggests that psychologists started using informed consent sometime after 1987. The psychiatrist's form only had policies about appointment lengths, fees, and cancellation policies. However, (if I remember correctly) when she said she thought I was depressed, she did give me a copy of the DSM description of "depression". And, if I remember correctly, when she wanted me to take anti-depressants (which I refused) she gave me a copy of the "package insert". As I recall, it was much later than 1987 when I first encountered a psychologist with an informed consent form. In fact, the only one I remember was in around 1999. And the last one I tried (I think 2006) didn't have one. Ah! Here is Ken Pope's page on informed consent in therapy https://kspope.com/consent/

When I first tried therapy, there was no consent form; the first time there was a consent form, it had no disclaimer -- it was just about fees, appointment lengths, and cancellation policies. And later therapists mostly had no consent form.

When my worst therapist said, "Consider me to be something like a computer: What you say goes in, mixes around with my training and experience, and out comes a response" I suspect she was saying "Just trust my intuition" or "Just trust my unconscious" or something like that -- but I sincerely doubt that she cared about thinking; just her intuition. The theory includes the theories they have been taught, and also their own idiosyncratic theories. The former at least have some transparency, so can be criticized to some extent publicly, and possibly discounted on the basis of that criticism; the latter have no transparency, so are not open to criticism (let alone confirmation by evidence!) -- they are essentially just the therapist's whimsy, virtually completely in the therapist's head. The client might as well not exist except as a point of departure for the therapist's fantasy-making ; the therapist may make it up as they go along.

Over-control (or at least attempts at it, which can be really shocking/crazy-making) can occur without idolization. I never idolized a therapist, but so much of what they did was shocking and left me dumbstruck. These were the types of things that could be "inadvertent gaslighting" -- or perhaps "automatic gaslighting" or "conditioned response gaslighting" rather than deliberate or conscious gaslighting.

It was the Wondery link. I was expecting something like the earlier New York Times link, where I could click on a transcript of the podcast rather than just listen to the podcast. Today I tried going back to the NYTimes link that has the transcripts of the original podcasts, but it didn't have a link to the Update that was on the Wondery site. So I did listen to the oral podcast (although I had difficulty figuring out how to turn down the volume, so listened to most of it while standing out in the hallway so it wasn't so loud). Anyhow, thanks for the link to the update. The part by Jan Wohlberg was good -- discussing "grooming". I think that is important to disseminate, but I think there also needs to be more about other ways a therapist can sabotage the client's experience. The only thing that I experienced in my therapy experience that fit the "grooming" model was with my second-worst therapist. I asked if I could bring my partner to a session. She said no; she would only see him separately (and my insurance would cover it), but she would not see us together until she and I had a "suitable relationship" (not sure if I've got the exact phrase she used). The experience was pretty shocking to me, because she answered questions he asked that she had not answered when I asked them. So it was in some sense like the idea in the podcast of serving to separate the client from sources of support. But it also fit into a more general pattern of belittling me and my concerns -- for example, laughing at me rather than discussing what I thought were important issues.

The JTA article is really depressing. So sad that people do these things to other people. ( I couldn't figure out how to get anything from the second link).

Interactions with therapist can definitely affect interactions and other things outside of therapy. Therapy (in my experience) is pretty abnormal, freaky. Being subjected to crazy stuff once a week makes it harder to function the rest of the week (especially when you have intrusive thoughts of the therapist interaction, which make it hard to focus on everyday things.) Therapy hinders being able to cope with normal stresses and demands ; but I thought it was supposed to be something that helped you cope -- why would I have tried it if I didn't expect that?

Weird, really weird.

Also: I think one of the better therapists I had was religious. I know someone who had him as a therapist and decided to adopt his religion. But he never did anything that explicitly brought up religion in my experience with him. He was just a very nice, kind person who treated his clients with respect -- whereas most therapists I have tried were noticeably weak in the treating-others-respectfully department.

Also some interesting (and some disturbing) discussion here .

Just for the heck of it, I did a web search on "therapy like religion" and came up with this: https://qz.com/796630/millennials-are-finding-spirituality-on-the-therapists-couch-instead-of-the-church-pew/. It's somewhat interesting, but doesn't fit my therapy experience. First, I'm not a millennial. Second, I'd already worked through the "church doesn't fit my needs" thing long before trying therapy. Third, I went to therapy initially to work on specific problems (but that never happened). Then there's this quote: "Pushing back against your own beliefs or those of the therapist is not only allowed, but encouraged. The freedom to think critically and be honest about major doubts has been transformative for me." Wow! In my therapy, things like pushing back against the therapist's beliefs, thinking critically, and being honest about major doubts brought a lot of criticism (typically of the "lashing out" rather than respectful variety) from the therapist.

Amen! So why in heaven's name do they believe that it will help the client in their real world life?? It's like a religious belief. Maybe if the client shares in the belief it might be helpful. But if it doesn't make sense to the client, it's not likely to be helpful.

My experience was that even therapy within office confines created a "therapist-in-my-mind" that interfered with my normal life. Getting rid of that "therapist-in-my-mind" has been very difficult; I"m not entirely rid of it yet.

Today I looked up Kenneth Pope's web page on informed consent in therapy . The page includes several references, with excerpts from each. Here are a couple having excerpts that I think are particularly worthwhile (in large part because they bring up points that are important but infrequently discussed): Medical Choices, Medical Chances by Harold J. Bursztajn, Richard I. Feinbloom, Robert M. Hamm, and Archie Brodsky. San Jose, CA: iUniversity Press, 2000. Excerpt: "The term informed consent is used to describe the requirement that a doctor inform the patient (within reason) of the available options and the risks of each. The weakness of this concept lies in the word consent, which implies a passive consumer accepting options that the doctor (like a car dealer) presents, rather than participating in creating the options. The words informed choice better describe the scientific gambling that patients and doctors...must do together." "Managing Uncertainty: The Therapeutic Alliance, Informed Consent, and Liability" by Thomas G. Gutheil, Harold J. Bursztajn, Archie Brodsky, and Victoria Alexandra, in Decision-Making in Psychiatry and the Law edited by Thomas G. Gutheil, Harold J. Bursztajn, Archie Brodsky, and Victoria Alexandra. Baltimore, MD: Williams & Wilkins, 1991. Excerpt: "The most serious problem with the consent form, however, is not its language, the response it elicits from the patient, or the circumstances in which it is proffered and signed. The overriding danger of the form is that it tempts the clinician to treat the transaction as a discrete task that is accomplished, and thus terminated, once the patient has signed the form. This unfortunate misuse of the form defeats the very purpose of informed consent, which is to foster and sustain an ongoing dialogue between patient and physician, as part of the process of joint decision making. Ideally, informed consent is never over. At any point along the way, the patient should feel free to ask questions about the impact of the treatment...."