Very Bad Therapy podcast

[Mary S]

3 hours ago, Eve B said:

Yes, I wish this could be made mandatory and implemented! The concern, however, would be those unethical clients who would abuse it to get "revenge" against their therapist. It's easy for both sides to feel personally wronged in therapy because of miscommunication or poor communication. I suppose these evaluations would need to be carefully worded so that only facts are presented and not emotional reactions?

I'm not sure that  evaluations could be worded "so that only facts are presented and not emotional reactions". Probably they would be best with some questions worded to focus on facts, but others worded to allow clients to express emotions. (I recall reading somewhere that this is often done in wording evaluation forms for professions where they are required, to be able to distinguish emotional reactions from  facts). Also, if there are emotional reactions that result from miscommunication or poor  communication, that in itself may indicate that the therapist needs more work on facilitating good communication.

[Mary S]

On 11/20/2019 at 5:21 PM, Eve B said:

"A small percentage of clients experience negative effects from therapy"-- I wonder where they got those statistics when the reality is probably more than a small percentage that aren't reported.

Good question. I tried looking this up on the web, and did find one somewhat interesting article: https://www.madinamerica.com/2018/08/new-study-investigates-negative-side-effects-therapy/

 Another at https://www.sciencedaily.com/releases/2017/02/170207092804.htm

And https://thepsychologist.bps.org.uk/volume-21/edition-1/when-therapy-causes-harm

[zygomaticus]

On 1/5/2020 at 5:51 PM, Eve B said:

What's the most common reason why a therapist wouldn't do what the client tells them? Can we simply narrow it down to a controlling and arrogant personality? If that's the case, the psych schools should be filtering these types of people out of their programs as much as possible because those are obviously dangerous traits to have as professional caregivers.

When it comes to manualised therapy models, like CBT, one major reason is that therapists have 'fidelity to the model' seared into their consciousness, the course of therapy tightly binds to a step-by-step approach and they are taught to deal with deviations by trying to get back on script. Also, anything behavioural - crudely put - is sourced in a 'learning theory' basis that treats the client as having a 'skills deficit', in other words, their ability to know what is 'good' for them is diminished. If the client says no to something, it will likely be punished in some way, probably ignored (negative punishment) or the therapist will circumvent it, for instance, if the client reacts badly to the use of a typical positive punisher like sarcasm, or punishers in general, the therapist may look to find something inconsistent with the 'undesired' complaining behaviour or just the overall target behaviour and reinforce that instead: differential reinforcement (the idea being that the behaviour being lavished with approving rewards will get strengthened whilst the inconsistent 'undesirable' behaviour gets left behind).

The main point, as I see it, is that these models don't really value client insight. In fact, I've had referrals to bypass my insight, with someone I had an assessment with saying it was because I had 'a tendency to intellectualise' before referring me for pure behavioural therapy (she didn't tell me it was behavioural, it was vaguely called 'short-term focused therapy'). It was as if my insight, rather than being a resource, was a hindrance. The therapy itself was something I wasn't suited to in the slightest, it was mostly me being heckled until I showed her something that might alleviate the suffocating pressure. I didn't complete it. In CAT, meanwhile, whenever I deviated from the standard circular diagram to say, 'it's not really like that for me,' the therapist repeated verbatim, with some accusatory intonation and narrowing of the eyes, 'you're disagreeing... in a subtle way.' This was designed to build my self-consciousness to the point at which I abandoned having a voice on the matter and simply became compliant. It was an attritional method to make me feel unreasonable simply for having ideas that differed from the standard formula about *gasp* my own mind and my own life (oh, and incidentally, it turned out that, on a previous placement, my friend had been his supervisor when he was a trainee... figures).

These models also don't value the client's agency, so it's no surprise that they don't welcome input regarding client preferences. When I say they don't value the client's agency, I mean that it is all designed to CIRCUMVENT your agency, with you being led left or right via interventions you aren't supposed to be aware of as being interventions, because they're deliberately embedded in interpersonal communication - verbal and non-verbal. There is a huge scope, therefore, to deviate from the client's original stated goals and implement what the therapist sees as of more benefit. Indeed, in the literature, there is a clear component of adjusting the client to social norms (whether this is relevant to the client's presenting problem and the client's aims or not). Here's a quote from a book I'm reading currently, Behavior Analysis and Treatment, "... as a member of society at large, an individual has a right to services that will assist in the development of behavior beneficial to that society." The section concerns the 'rights' that clients of behaviour analysis have, a discourse that they have no voice in and is determined on their behalf, by the industry, and kept internal to the industry. Clearly, in these instances, therapy has deviated from a transaction concerning a specific problem and a desired outcome to being something, well, ideological. If there is no discourse with the client, then they don't even get a say in what is 'beneficial to society' and are kept in the dark that they are being adjusted on the sly towards some hidden agenda concerning social norms regardless of the nebulous meaning of such matters, which are perhaps best left to philosophers and social commentators to debate, not therapists to dictate, and for clients to use their agency to determine their own political choices. Goodness knows there is enough bias out there already acting to influence any individual, without a covert campaign being waged in the clinic.

With these models, I would say the bulk of the methodologies constitute boundary violations. Clients have no idea what they're being subjected to, there is no transparency, no informed consent and the very pact of trust itself is leveraged to maximise the covert influence the therapist has over the unsuspecting client. Behaviourists like to claim what they do is simply an extension of a law of nature, something that proliferates in society anyway. Skinner said as much, too. My response is that if one is looking for an analogue of the manner by which reinforcement and punishment is used to covertly influence and control someone out in wider society, well, it is what can reasonably be labelled as a controlling, abusive relationship, one characterised by heavy doses of manipulation. These are the people that cause harm.

[zygomaticus]

11 hours ago, Eve B said:

The concern, however, would be those unethical clients who would abuse it to get "revenge" against their therapist. It's easy for both sides to feel personally wronged in therapy because of miscommunication or poor communication. I suppose these evaluations would need to be carefully worded so that only facts are presented and not emotional reactions?

I suppose my response would be that emotional reactions will often be the form of the kinds of harm done in therapy, and therefore there should be scope for their inclusion in any process of reviewing complaints. The trouble is, too often client emotions are dismissed by therapists, like it's an acting-out and if it pertains to the therapist, then it's 'transference'. It's difficult, because there is an intangible component to emotional harm that only the client knows the true extent of and those who care for the client know the harm because they listen and they believe (as well as see the effects more broadly). So, claims of emotional harm could be dismissed altogether depending on the terms of what's considered a valid complaint by the body responsible for processing them.

I've read about clients going through a complaints process and then being told they have no evidence, and this is where the private nature of how therapy is conducted acts as a protective shield against practitioners. What are we, as clients, supposed to do? Bring hidden recording devices into sessions? Record meticulous accounts of each session as soon as we get back home? Even the latter would likely be dismissed, but I personally think it's a good idea (even if it only provides a reference so you can see the cumulative process over time yourself and know that your latest red flag corresponds to a series spanning many sessions).

Many trades these days have ratings and reviews for services and those rendering them, why should therapy be any different? Any such system is open to abuse (positively or negatively), but you should expect some sort of reliable picture to emerge given enough numbers. Let's take it out of the hands of the industry, have an independent body host the reviews and ratings, and let the market say what they feel about practitioners and clinics. Let's at least have the debate. If therapy is a special case, why? Is it because us clients are deemed far too unreliable or unstable to provide trustworthy feedback? There is a caveat, of course, and that is that sometimes therapists can do such a number on you, that you end up saying what they want you to say. Not only are a lot of people eager to be the 'good client', they are rewarded when they say positive things and punished when they don't. This has certainly happened to me. So, any system would need to allow reviewers to return at a later date when they've had a chance to discover whether any gains are long-lasting or not - which is very important anyway - and if, upon reflection, they realise their initial impressions were inaccurate.

[Eve B]

I think there will be more internet reviews on therapists just as ratings for medical doctors also seem to be increasing. Therapy shouldn't be a special case, and a lot of it depends on how comfortable clients are with putting themselves in a publicly vulnerable position by giving up confidentiality to tell their side of the story. The truth matters, but being believed is what makes the difference.

[Eve B]

21 hours ago, Mary S said:

Good question. I tried looking this up on the web, and did find one somewhat interesting article: https://www.madinamerica.com/2018/08/new-study-investigates-negative-side-effects-therapy/

"results were published in Cognitive Therapy and Research, found that 43% of CBT patients in their sample experienced side effects, which they define as 'negative reactions to an appropriately delivered treatment.'"

"One such side effect — deterioration of symptoms due to therapy — has been found to occur in 3 to 10% of patients.

"The study has several limitations. As psychotherapists reported side effects, reports may have been influenced by therapist bias; the authors suggest that future studies use a blend of stories from patients, therapists, and outside interviewers. The study’s sample was composed of patients with various diagnoses, and as such, results would likely be different in a more homogenous sample, or with a different form of therapy. Additionally, as approximately half of the patients whose cases were reported on in the study were taking psychotropic drugs, and it is thus impossible to rule out the effect of medication on the observed side effects."

-Therapy harm is real, but there just aren't enough studies because of the difficult nature of collecting accurate data. 

[Eve B]

Episode 37: What does it imply (or confirm) about the psych profession if anyone can call themselves a therapist for just $16?

[Eve B]

Episodes 56 and 57 discuss the cultural biases of therapists. Should it be unsurprising that therapists are predominantly white?

[Mary S]

I haven't been following the Very Bad Therapy podcasts lately, but I just listened to a recent one which is very interesting/good: : https://www.verybadtherapy.com/episodes/episode-60-vbt-in-history

It discusses recent developments in evaluating research quality, which shows that a lot of research in psychotherapy makes claims that are not sound. (A heads up: The podcast is close to an hour -- I think earlier ones were around 1/2 hour)

[Mary S]

I looked at the Very Bad Therapy website again today. Episode 65 (When Treatment Fails (with Henk Spierings, who has written a book, Becoming Compliant ) is really good -- I recommend it highly. An overarching theme is that therapists need to ask clients questions like, "Is this working for you?". I remember that in my therapy experience, therapists never seemed to ask, "Does this make sense to me?" And, more often that not, what they did didn't make sense to me. They just seemed to be off in a fairly tale world, disconnected from the real world that I live in.

[Eve B]

Looks like the VBT website's home page has changed, and one of them is no longer a trainee? Episode 65 also mentions that "about 50-60% of the time, therapy works really well, and then, there's 5-10% of the time, where it actually harms clients..." (00:52:47).  I think the real harm percentage is higher because it's probably under-reported.

[zygomaticus]

8 hours ago, Eve B said:

Episode 65 also mentions that "about 50-60% of the time, therapy works really well, and then, there's 5-10% of the time, where it actually harms clients..." (00:52:47).  I think the real harm percentage is higher because it's probably under-reported.

I agree that it's under-reported. Also, the 50-60% claim is very dubious. When negative studies are included (which typically go unpublished due to institutional and journal bias) the percentage of positive outcomes gets reduced by about a third. My friend has said a number of times 'psychotherapy only works 30% of the time', but I didn't ask whether this figure was adjusted to account for the negative studies. Presumably, there are more unpublished negative studies in file drawers out there.

Then, what is the percentage of clients whose symptoms improve and stay improved? I think it's claimed to be somewhere around 15%, but as Shedler points out, the screening out of large percentages of real-world clients presenting for participation in these studies casts doubt on the applicability of data to actual clinical reality.

Ben talks towards the end of this episode about the placebo effect and how the busy clinic and lack of parking spaces Henk mentioned enhanced his expectations. I think he referenced Caroline considering marketing of services to virtually be a clinical intervention, even! It seems they see placebo as a significant element of therapy. A Cambridge University meta-analysis states this:

Quote

A qualitative analysis of the studies in terms of the type of patient involved indicates that those using psychiatric outpatients had essentially zero effect sizes and that none using psychiatric inpatients provide convincing evidence for psychotherapeutic effectiveness. The only studies clearly demonstrating significant effects of psychotherapy were the ones that did not use real patients. For the most part, these studies involved small samples of subjects and brief treatments, occasionally described in quasibehavioristic language. It was concluded that for real patients there is no evidence that the benefits of psychotherapy are greater than those of placebo treatment.

If this is the case, then for genuine clients out in the real world, outcomes are likely to be nothing other than placebo effects. The technical aspects, irrespective of the model, only matter insofar as they lend credence to the expectations of expertise clients have with regard to the services and their providers.

Since outcomes are the name of the game, does this matter? Well, with the significant expense of sessions, when the level of training, accreditation, experience etc of the service-provider is essentially meaningless (a volunteer counsellor can be just as effective if they seem credible), and an academic estimation of a 15% chance of long-term benefits - itself a dubious figure likely to be far lower - I think there are probably other placebos out there that could be just as effective (or just as ineffective) that cost far less in terms of money, time and emotional upheaval. Plus, the placebo effect is usually short-lived.

It also matters when there is also a risk attached that the therapy could cause harm. In a way, therapists are claiming placebo effects as due to their skills and clinical theory, which makes it all the more irksome when they also claim that failures in therapy are broadly due to client attitudes.

[Mary S]

18 hours ago, Eve B said:

 Episode 65 also mentions that "about 50-60% of the time, therapy works really well, and then, there's 5-10% of the time, where it actually harms clients..." (00:52:47).  I think the real harm percentage is higher because it's probably under-reported.

Good point. Telling it to the therapist is usually like talking into a black hole. Trying to file a complain can (in my experience) result in just getting a run-around -- this agency says you need to report it to that agency, etc.

[Mary S]

9 hours ago, zygomaticus said:

I agree that it's under-reported. Also, ...

Thanks! Lots of good points here. So sad that they have gotten little if any attention by those who practice the "profession".

Some of the most harmful things in therapy were comments like the following from therapists: "You'll never get better if you keep seeking the perfect therapist", "You expect too much; that's your problem", "I can't help you if you take everything I say as criticism". It was so rare for a therapist to acknowledge their part in a problem. (I do remember a therapist once saying, "I take responsibility for that distortion" when I called him on his claim that I said something I hadn't said). I naively expected that therapists would set good examples. They sure didn't -- just the opposite. I would feel ashamed if I treated other  people the way they often treated me.

[Big_girl_now]

Also what does it mean for therapy to 'work'.

Sometimes it can seem like it's working but in the big picture it is not.

Slapping a bandaid on a wound only makes things worse if it's festering unseen below the surface.

[disequilibrium1]

Late to the party, I only listened to a couple of episodes out of the many. I applaud anyone who raises this topic, but what I hear falls far short of my discussions with consumers. The practitioners tend believe only damaging clinicians as bad apples, yet I see damage as far more nuanced.
I doubt there's a therapist on the planet who'd consider my syrupy maternal therapist "bad"-- she's been hospital affiliated for decades. Yet she was the opposite of what I needed. If I'd given feedback while I had the therapy, I'd think the woman a saint. It's only in retrospect I realize the injuries. Yet reasons for the damage are basic and obvious--to those outside the throes of theory.

[Eve B]

Episode 103- The Therapists' Side of the Story:

(15:45-16:00)- "It doesn't really matter what the therapist specifically said in any given moment. All that really matters is how the client received it."

[Mary S]

This is so depressing -- the client sounds like she has her head on straight, but the therapist sounds like she's off in some fairy tale world -- and perhaps pretty narcissistic (e.g., "Know it all").

[disequilibrium1]

On 5/17/2022 at 12:31 AM, Eve B said:

Episode 103- The Therapists' Side of the Story:

(15:45-16:00)- "It doesn't really matter what the therapist specifically said in any given moment. All that really matters is how the client received it."

While I agree with that statement, the devil's advocate guy on that episode absolutely roiled me. He favored questioning the abused clients' perceptions and/or getting the therapist's side of the story. My therapist claimed all the interpretations and knowing all the thoughts in my head. That's the problem with the therapist's side of the story. I was amazed that the woman admitted no mechanism for hearing client viewpoint, therapy existing for the client after all.

Edited May 18, 2022 by disequilibrium1