Effectiveness of Therapy?

[Mary S]

I just came across this web site:from 2011: Psychotherapy is effective and here’s why

It starts out, "Psychotherapy works, and the science and research are there to back it up, said Bruce E. Wampold, PhD, at the APA 2011 Annual Convention symposium, "Psychotherapy Effectiveness: What Makes it Work?".

Then there is a list of qualities of a good therapist. Here are some of them, together with my comments on how well therapists I have tried displauyed these qualities:

• "Has a sophisticated set of interpersonal skills."" My impression is that the interpersonal skills of therapists I have tried ranged from extremely naive to downright poor."
• "Builds trust, understanding and belief from the client." Very rare in my experience. Therapists I have tried seem to expect the client to see them as some kind of authority, but seem to have such shallow and narrow views that I can't rationally accept them as authorities.
• Has an alliance with client. Oh, I wish! But we seemed to be on different wavelengths so much of the time. Often it seemed as though we were from different planets.
• Has an acceptable and adaptive explanation of the client's condition. Not in my experience! Explanations were few and far between, and typically were either shallow or seemed off in a fairy tale world.
• Has a treatment plan and allows it to be flexible. No therapist I tried ever mentioned having a treatment plan. Some were a little flexible, but some were anything but.
• Is influential, persuasive and convincing. Maybe some tried to persuade me, but their attempts were not persuasive --they typically seemed either shallow or out in left field.
• Monitors patient progress. Not that I was aware of.
• Offers hope and optimism (realistic optimism, not Pollyanna-ish). Nope.
• Is aware of a client's characteristics in context.What therapists "reflected back" to me about my characteristics had little or no relationship with what other people I interacted with "reflected back" to me.
• Is reflective. Some (a minority) were a little reflective; most were all too often like, "My mind is made up; don't confuse me with the facts"

[Eve B]

The problem I see is that many of the above criteria aren't consistently followed by many therapists, so it would be more realistic to list why psychotherapy can be ineffective and why insurances usually won't cover for long-term, slow to no-improvement talk sessions.

[Mary S]

3 hours ago, Eve B said:

The problem I see is that many of the above criteria aren't consistently followed by many therapists

I think something stronger is warranted, namely: Few therapists have these qualities. Many don't even seem to care about cultivating them. But these would be a good list of things to have clients give feedback on.

[Eve B]

I think it's easier for therapists to not care about cultivating better manners towards their clients because there's no third party oversight monitoring their unprofessional behavior in session.  If few therapists have the good qualities listed, then I expect few would offer clients the opportunity to give honest feedback. How many clients would be comfortable criticizing their therapist, though?

[Mary S]

19 hours ago, Eve B said:

I think it's easier for therapists to not care about cultivating better manners towards their clients ...

Yes (sadly), "poor manners" all too often describes how therapists treat clients.

19 hours ago, Eve B said:

...  How many clients would be comfortable criticizing their therapist, though?

There are a lot of things in life I'm not comfortable doing, but still do because I think they're important to do. I did sometimes offer criticisms of therapists. Mostly I got "lashing out"  or defensive (e.g., "You can't expect me to ...!") responses, but a minority of therapists I tried seemed to at least try to respond to criticism professionally.

[disequilibrium1]

That article reinforces what I see in psych writing and what I pulled from my own experience--that a significant number of therapists consider themselves magically superior beings with supreme insights, social skills and mastery over life. That's dangerous for both the therapists and the client. (And then some turn around to claim they're only human.)

[Eve B]

On 9/19/2019 at 4:01 PM, disequilibrium1 said:

That article reinforces what I see in psych writing and what I pulled from my own experience--that a significant number of therapists consider themselves magically superior beings with supreme insights, social skills and mastery over life. 

Would just having a degree in psychology give them that kind of attitude, though? Maybe these know-it-all therapists already have grandiose personalities before they even enter the field? Or does the schooling bring that out in them?

[Eve B]

On 9/19/2019 at 3:23 PM, Mary S said:

Mostly I got "lashing out"  or defensive (e.g., "You can't expect me to ...!") responses, but a minority of therapists I tried seemed to at least try to respond to criticism professionally.

Were their professional responses to the criticism helpful to you? It probably helped them understand your needs better, if nothing else.

[Mary S]

2 hours ago, Eve B said:

Were their professional responses to the criticism helpful to you? It probably helped them understand your needs better, if nothing else.

Hard to say -- partly because I don't recall many instances of this. But an important one I do remember was when a therapist presented me with a lengthy "informed consent" form to read and sign, and after reading it, I said I wasn't willing to sign it because it was essentially asking me to give up my right to informed consent. His initial reaction did seem defensive, saying  "Where does it say that?!",  and I responded that it didn't explicitly say that, but that signing it would be giving blanket consent to his asking me questions, and that would be giving up my right to truly informed consent, because informed consent would require knowing the reason for each question. He accepted that as legitimate, and I think I rewrote or amended the form to read as something I could rationally consent to. I suppose in some sense this was  helpful, because it gave me evidence that he could "listen to reason," rather than give me the type of dismissive response most therapists gave. It was one of the best moments in my therapy experience  -- it seemed professional, rational, and in touch with the real world -- things that were usually missing from what therapists did. It gave me a least a moment of hope.

[disequilibrium1]

8 hours ago, Eve B said:

Would just having a degree in psychology give them that kind of attitude, though? Maybe these know-it-all therapists already have grandiose personalities before they even enter the field? Or does the schooling bring that out in them?

I doubt the question can be answered as I doubt many really know why they wanted to be counselors. All but one counselor I know was absurdly grandiose. I also see this in their writing, in their sweeping, glib exclamations about causality and the human mind.

[Mary S]

22 hours ago, Eve B said:

Would just having a degree in psychology give them that kind of attitude, though? Maybe these know-it-all therapists already have grandiose personalities before they even enter the field? Or does the schooling bring that out in them?

 

13 hours ago, disequilibrium1 said:

I doubt the question can be answered as I doubt many really know why they wanted to be counselors. All but one counselor I know was absurdly grandiose. I also see this in their writing, in their sweeping, glib exclamations about causality and the human mind.

I think that one factor contributing to the problem of at-best-mediocre therapists is found at https://blog.prepscholar.com/easiest-majors-college-degrees, which identifies psychology as the easiest undergraduate major (i.e., having the highest average grade point average). This in itself might contribute to the "Lake Wobegon Effect" that has been noted among therapists by Lilienfeld and others.

[zygomaticus]

Here are my responses to the supposed existence of these traits from my own perspective:

• "Has a sophisticated set of interpersonal skills." They've probably been schooled in rapport-building, meaning that they have a repertoire of contrived techniques. However, a lot of the interpersonal skills will be utilised to establish dominance, authority and impose their ideas and theory.
• "Builds trust, understanding and belief from the client." Uses the aforementioned role-play drills in rapport-building, which may include feigned empathy at apposite moments. Reflects back the client's feelings, which is often little more than an exercise in paraphrasing in a sympathetic tone (but will be absent in certain models). Belief is cultured perhaps from presenting themselves as professional, using their jargon, using interpersonal techniques to demonstrate authority and probably welcoming (and rewarding) clients that defer to the therapist from the outset.
• "Has an alliance with client." Perhaps, so long as the client is compliant, but expect it to be more adversarial so long as the client has the temerity to have their own differing opinions and insights regarding their own processes. Behavioural therapists will reward and reinforce compliance, which might seem like an alliance, but switch to punishers the moment the client strays, including changing the subject and ignoring expressions of the client's pain because to empathise is considered to be reinforcing the problem.
• "Has an acceptable and adaptive explanation of the client's condition." There's an explanation that's acceptable to the theory they work with (fidelity to the model) and acceptable to the therapist's supervisor, and such explanations might not be remotely acceptable to the client. In such cases, it is likely that the client will be subjected to compliance-gaining tactics until they agree or will end up falling foul of the 'difficult client' culture that pervades the therapy industry, meaning they don't have to be accountable for their shortcomings. The explanation of the client's condition will almost certainly be adapted to fit with the theory of the model being used (or the easiest one to fit it with, should it be an integrative approach).
• "Has a treatment plan and allows it to be flexible." The plan is likely to be concealed from the client, with only a vague notion being conveyed. The client is not likely to have  much input, so there is little flexibility from that standpoint. If the model is 'evidence-based' then 'fidelity to the model' means there will be VERY LITTLE flexibility whatsoever. It is the client that will be made to fit the model, largely through operant conditioning and general compliance-gaining tactics.
• "Is influential, persuasive and convincing." Therapy is largely a language game, and therapists, like those working from telesales scripts, are schooled in how to gain the upper hand. Forgive me for being repetitive, but again the influence will be attained through establishing dominance, using compliance-gaining tactics, dismantling objections through punishers, cognitive reframing, Socratic questioning etc - basically a truck-load of sophistry - and being prepared to push as hard and persistently as it takes to impose their views.
• "Offers hope and optimism (realistic optimism, not Pollyanna-ish)." This might be a matter of inflating a comfortable - yet temporary - bubble during the course of therapy that provides a false sense of control, which I believe is prevalent in various models, but I will single out the cognitive model as a particular offender. It ignores external psychosocial factors to an absurd degree and makes symptoms seem like a matter of cognitive errors that can be reliably corrected through following formulas, thus making it seem manageable. Also, doubts concerning the formula are firmly pushed out of the picture as the practitioner repeatedly refocuses upon the principles, diagrams and cognitive drills, a lot of which are generic and contrived within absurdly simplistic circular flow-charts.
• "Is aware of a client's characteristics in context." I'm not sure what this is supposed to mean, but an appropriate context would be rooted in the social circumstances, including factors such as poverty, and would require a level of active listening that few models allow for, because most therapists are conditioned to feed everything a client says through their arbitrary theoretical filters rather than attempt to understand a client's experience from the client's history, perspective, socio-economic status, environment and relationships.
• "Is reflective." In my opinion therapists are far more likely to be reflexive and blinkered by theory, so any reflection will most likely have to fit into those parameters and hence be limited.

[Eve B]

So is there anything that can help distinguish a genuinely good therapist from a manipulative pretender?

[Mary S]

1 hour ago, Eve B said:

So is there anything that can help distinguish a genuinely good therapist from a manipulative pretender?

I would guess that there are some therapists who consider themselves genuinely good, (or might be considered genuinely good by some clients and/or some other therapist) but might appear to be a manipulative pretender to some other people. And a therapist might be helpful for some clients but not for other clients. It's not a "one-size-fits-all" situation.

[Eve B]

Then a "good" therapist is only about perception--how therapists see themselves and/or how clients see them? If these viewpoints clash, then the therapy fails? 

[Eve B]

"Have We Overestimated the Effectiveness of Psychotherapy?":  "the field of psychotherapy research needs to work harder to ensure that negative results are published as well as good news results, especially given the findings of another recent paper suggesting that the field has a problem with undeclared researcher allegiance to particular therapeutic approaches."  The article also mentions how psychotherapy can negatively change personality along with other related consequences.

[Mary S]

Thanks for the link.

[Eve B]

https://www.verywellmind.com/therapeutic-rapport-2671659

"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?

 

From an article on therapy rapport:

"The two fundamental pillars that rapport is based on are trust and fluid communication. The therapist and client should understand each other’s verbal and non-verbal communication. 

-listening to the patient without interrupting or making value judgments

-important to show warmth towards the client

-see the world through their eyes. You must do this even if you don’t share their feelings or agree with their actions

-appear credible

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

-Consistency between verbal and non-verbal language"

[Mary S]

2 hours ago, Eve B said:

-important to show warmth towards the client

I've often read that therapists should be warm, or show warmth toward the client. But, to be honest, I don't really know what "warm" or "warmth" are in this context. When I've tried looking it up on the web, I've gotten things about body temperature, or once something about charisma. I don't consider charisma to be a good quality in a therapist -- I think of  charisma as something that sucks you in -- a kind of manipulativeness.

My own guess is that what some people call warmth (as a quality of a therapist or other person) I is what I might call cloying, or invasive, or disrespectful of boundaries. Can anyone tell me their definition/interpretation of  "warmth" in the above quote?

[Mary S]

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.

Edited September 26, 2019 by Mary S

[Mary S]

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.)

[zygomaticus]

5 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 remember reading about these psychologists training rapport, mostly via role-plays, and insisting that it had to be 'authentic'. Of course, the true meaning is that it has to seem authentic. The context was training police for interrogations, by the way, with the theory being that suspects open up more readily under such conditions (there was more to it than that, but I'd be delving off-topic). If the rapport seems genuine, but the reason behind it is ulterior; how is that authentic?

The nonverbal stuff is used a lot in therapy, but if it's rehearsed or someone has to think about it mechanically before using it, then it isn't genuine, in my opinion. It's a simulation of what authenticity might look like. Giving feedback in the moment, rather than later is something emphasised in behaviour modification: the stimulus should follow the target behaviour as soon as possible, so that it is linked in the doggie/lab rat/horse's client's mind (even if they're not cognizant of exactly what happened, the idea is that an association will be registered at least unconsciously).

3 hours ago, Mary S said:

-important to show warmth towards the client

Can anyone tell me their definition/interpretation of  "warmth" in the above quote?

For the theory, it's that warmth seems helpful in terms of outcomes for clients because it makes them feel more accepted, at least this is what Rogers and others have concluded. For me, it again comes down to whether the warmth is authentic or the result of someone demonstrating their grasp of method, the results of their training to the point that it's so drilled it almost appears to be natural. I personally would find warmth, acceptance and empathy helpful, but if I felt it was no more than a therapist going through the motions of applying theory, and thus authenticity is questionable, then I'd feel perturbed, frankly, by being dealt a counterfeit.

I suppose there is this idealistic, humanistic notion that these two people are brought together and a natural empathy, warmth and acceptance will flow, but in reality people clash an awful lot and dislike one another, and in such cases where a therapist dislikes a client in client-centred counselling or a similar model, the therapist has to either find it in themselves to have unconditional positive regard for them anyway - like some sort of Buddha-like figure - or they put on a pretence. If they do the latter, then they're not 'congruent', one of the three 'core conditions' for Rogers.

When warmth is faked, and the client knows it, the danger is always that it devalues the therapeutic relationship and possibly undermines their trust in those they encounter in general that superficially appear to display warmth.

[Eve B]

16 hours ago, zygomaticus said:

Of course, the true meaning is that it has to seem authentic.

I think this is the key. The therapist is trained to act in a certain way in order to try to get their clients to respond in a certain way, so the effectiveness of therapy is really based on pretense not authenticity. Therapists can't and won't admit this underlying deception because successful outcomes depend on trusting the process. 

[Mary S]

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.)

[Eve B]

 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. 

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