Very Bad Therapy podcast

[Mary S]

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.)

[Starling]

On 10/17/2019 at 5:20 PM, zygomaticus said:

it's more like us clients being dogs and having the pills we'd otherwise refuse mixed in with our food, because we'll also get some scooby snacks when we're good doggies and do as we're told.

I had a therapist who was really enamored with the book "Don't Shoot the Dog" - a treatise on behavior modification written by an animal trainer on how to apply those techniques to dogs, cats, porpoises (her actual livelihood), children, colleagues, clients...  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.  

[Eve B]

What's funny to me is that there seems to be plenty of material for the podcast, and yet, they still claim that very bad therapy is an uncommon experience. Episode 23 highlights very bad graduate school education and ineffective curriculum, so what would that imply about the competency of the students who go on to practice on live clients after completing their programs? They even said in the podcast that they don't know what makes a good therapist? Ben's thesis on the impact of therapist bias on clients looked promising until he wrote "the effectiveness of psychotherapy is undeniable..." (pg 16). 

[Mary S]

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.

[Mary S]

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.)

[Eve B]

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?

[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.

[Eve B]

And there are still some things that can't be trained for therapy to be "undeniably effective."

[Mary S]

The Vary Bad Therapy podcasts have gotten some press: http://www.scottdmiller.com/very-bad-therapy-and-how-it-can-make-you-a-more-effective-therapist/

[Eve B]

I'd be more impressed if their publicity press was from someone they hadn't also plugged in their podcast.

[Mary S]

True -- but a small community is better than no community at all. I hope the community continues to grow.

[Eve B]

I think the true test for the VBT podcast will be whether it's still continued after the hosts have graduated as licensed practitioners and how they apply what they're learning with their own clients. At least they're acknowledging and exposing the reality of bad therapy within their field, but they also say that the harmful experiences are uncommon. 

[Mary S]

2 hours ago, Eve B said:

I think the true test for the VBT podcast will be whether it's still continued after the hosts have graduated as licensed practitioners and how they apply what they're learning with their own clients. At least they're acknowledging and exposing the reality of bad therapy within their field, but they also say that the harmful experiences are uncommon. 

Good points -- although I don't recall their saying explicitly that the harmful experiences are uncommon. And there is also the matter of considering both  "How uncommon" and "how harmful" For example, if it's relatively easy for a client who has had very bad therapy to find a better therapist and relatively easy to get over the harm, that is not as bad as if the harm is serious (e.g., leads to suicide, when there had been no risk  of that before therapy). So there needs to be a more detailed study of types of harm and seriousness of each type of harm. Actually, it is sad that graduate students are left to do this work -- more professors in universities should be doing more of it. (Some of them have -- e.g., Lilienfeld).

I recently had an email discussion with Ben, (in response to his thesis) in which he said, "I believe that our field is constructed in a way that some clients simply won't benefit from what we have to offer" -- but he didn't really seem receptive to suggestions for changing the situation, nor did he offer any suggestions for how to improve the situation. (But he hasn't responded yet to my most recent email, so perhaps that will give some additional information.) Also, since he is hoping to extend this work with collaborators, he might be starting something that others do take up. We will see.

[Eve B]

I suspect that Ben is being careful in his responses because he's under supervision and his schooling likely hasn't prepared him on how to answer these challenging, rock-the-boat types of questions. I think the academic setting is the worst place to expect any kind of changes for the psych profession because of the inherent politics, policies, and hierarchy. The pioneers who will most influence the field will need the greater freedom that comes from private practice.

From Ben's email reply to my question regarding compassion training, he said: "The vast majority of us are committed to becoming better therapists, better versions of ourselves, and better people as a whole.  Some are not, but they are the exception to the rule in my opinion."  This assertion implies to me that he believes bad therapists/therapy are uncommon. Besides, therapists can't afford to be bashing their occupational cash cow, and it increases their chances of a better outcome if they can persuade people to believe that therapy/therapists are, more often than not, helpful.

[Mary S]

On 11/11/2019 at 2:24 PM, Eve B said:

I suspect that Ben is being careful in his responses because he's under supervision and his schooling likely hasn't prepared him on how to answer these challenging, rock-the-boat types of questions.

Sad to say: I think that one of the most important things for a therapist trainee to learn is how to answer challenging, rock-the-boat types of questions. I think a big part of my therapy being harmful was that I asked challenging, rock-the-boat types of questions (innocently not realizing that they would be so challenging and rocking-the-boat for the therapists) and was shocked at the responses I got. The therapists so often seemed authoritarian -- which I think is the opposite of what a good therapist should be Clients are very diverse, and an authoritarian approach assumes that "one size fits all". The therapy models often seem like fundamentalist religious beliefs to me. I guess in that metaphor, I was like an atheist. (I did find a couple of therapists that seemed open to differing opinions; possibly if I had gotten to them first, I would have gotten at least somewhat better rather than worse.)

[Eve B]

Therapists say they want to learn from their clients, but I've often found that they only want to learn if they aren't being criticized for their efforts. Ben admitted that some clients won't benefit from therapy because of how it's constructed, so what else could that basically imply other than clients need to play along with the therapist's game in order to see helpful results? Maybe therapists feel overly threatened by clients who act too smart and aware for their own good? I'd bet trainees who asked challenging, rock-the-boat types of questions to their professors probably wouldn't graduate through their programs either.

Mary, what were those more open-minded therapists lacking that they failed you?

[Mary S]

3 hours ago, Eve B said:

Mary, what were those more open-minded therapists lacking that they failed you?

Eve,

I'm not clear on what you're asking.

[Eve B]

What didn't those more open-minded therapists say or do that could've helped you better? What qualities were they lacking that you really needed?

[Mary S]

1 hour ago, Eve B said:

What didn't those more open-minded therapists say or do that could've helped you better? What qualities were they lacking that you really needed?

I'm still not clear on what you're asking.

By "those more open-minded therapists" are you referring to the couple of therapists in this quote: "I did find a couple of therapists that seemed open to differing opinions; possibly if I had gotten to them first, I would have gotten at least somewhat better rather than worse."?

If so, I really don't know how to answer your questions about them.

[Eve B]

Yes, the therapists who seemed open to differing opinions.  Should those therapists have asked more questions or try to really understand your point of view? Were they unhelpful because they only appeared to be listening to your concerns, but they didn't know how to communicate effectively with you? A therapist can be open-minded, but they lack good communication skills, so therapy fails.

[Mary S]

On 11/14/2019 at 10:46 PM, Eve B said:

Yes, the therapists who seemed open to differing opinions.  Should those therapists have asked more questions or try to really understand your point of view? Were they unhelpful because they only appeared to be listening to your concerns, but they didn't know how to communicate effectively with you? A therapist can be open-minded, but they lack good communication skills, so therapy fails.

My point in the original post was that the later therapists might have been able to help me if they had been the first ones I had tried  -- but that after my experiences with the ones that I did try before them, I was in far worse condition than when I first tried therapy, so my experiences with the earlier therapists made me a more difficult client to help than I was when I first tried therapy -- for example, I wasn't as trusting, and went to the later therapists with a greater fear of therapists -- and had all this extra baggage (from the counterproductive therapy experiences) on top of the original stuff I went to therapy for -- in fact, I think the "extra baggage" was a bigger problem than the original problems I went to therapy with. I don't have any criticisms of them for not listening to me or not knowing how to communicate effectively with me. But I think that most therapy training doesn't help therapists deal with clients with the "extra baggage" from extremely bad previous therapy. Possibly the therapists trained in "feedback informed therapy" might have had a better chance of helping me.

[Eve B]

9 hours ago, Mary S said:

 "my experiences with the earlier therapists made me a more difficult client to help than I was when I first tried therapy -- "

 I felt the same way by the time I reached a therapist who wasn't as bad as my first one. I gave the first one all of my trust and benefit of the doubt because I didn't really understand what therapy was at the time or the effects he was having on me. He didn't explain his treatment or ask my permission. The most he said during that session was, "I'm going to try something different on you today," and he just went ahead and did it.  The dissatisfaction and frustration I felt as I tried different therapists only increased my suspicion, disrespect, and animosity towards them. I need them to be able to effectively communicate with me because I don't speak well. I have a hard time syncing my complex thoughts to speech, and it's worse when complex emotions also jumble themselves into the mix. I was more angry than afraid, and I kept thinking that most of them are just overpaid (oxy-)morons. I would feel somewhat sorry (and maybe some admiration) for any therapist with the guts to try working with me at this point because of my heightened emotional sensitivities and accumulated psychological baggage. I don't believe it's too late to be helped by a "good enough" therapist, but I'd have to really weigh the risk versus the possible worst/best case results. 

[Mary S]

12 hours ago, Eve B said:

 I gave the first one all of my trust and benefit of the doubt because I didn't really understand what therapy was at the time or the effects he was having on me. He didn't explain his treatment or ask my permission. The most he said during that session was, "I'm going to try something different on you today," and he just went ahead and did it. 

Yes, I gave the therapists too much benefit of the doubt. I had read a book on therapy and naively thought it was an accurate description of what therapy was. (It described therapy as "a nurturing experience" -- but there wasn't anything in my therapy experiences that I could call "nurturing".

Yes, my experience was also that therapists didn't explain what they were doing or why, or ask permission.  Saying "I'm going to try something different on you today" really sounds like he sees you as an object or a toy to play with. That attitude was very common in my therapy experience.

[Mary S]

12 hours ago, Eve B said:

...  I need them to be able to effectively communicate with me because I don't speak well. I have a hard time syncing my complex thoughts to speech, and it's worse when complex emotions also jumble themselves into the mix.

Yes, communication was a real problem in my attempts at therapy. I had trouble putting my (often complicated) thoughts (let alone emotions) into words orally on the spur of the moment. (With writing, I can look at what I've "said",  think about whether or not it is what I am trying to (or need to) say, and revise.)  But the therapists sure didn't set a good example of good communication, nor did they do anything to help me communicate. They were so quick to criticize -- but not constructive criticism, just "lashing out" type criticism. Or maybe it wasn't criticism so much as a knee-jerk "wanting to win" response. Whichever it was, it sure wasn't helpful. (Actually, that's an understatement; it essentially sabotaged any possibility of helping me.) Therapy was harder to cope with than the situations that I came to therapy for help in coping with.

[Eve B]

On 11/17/2019 at 9:38 PM, Mary S said:

Yes, I gave the therapists too much benefit of the doubt. I had read a book on therapy and naively thought it was an accurate description of what therapy was. (It described therapy as "a nurturing experience" -- but there wasn't anything in my therapy experiences that I could call "nurturing".

Therapists upsell their product (therapy) because it's also a business.  If it sounds too good to be true, though, then it probably is.