Or, Therapy Names as Currency
When my client says “Therapy sucks—I tried it and it didn’t work!” there are a number of things this could mean.
“The therapist I had was of a personality that did not mix with my personality well. I felt invaded and condescended to and it was deeply unpleasant.”
“The therapist tried a specific therapy: psychodynamic or DBT or narrative therapy, and it was [not my cup of tea/definitely making it worse/seriously not feasible for my life or personality]”
“Therapy as a modality is not very compatible with me. We should pursue alternate things like medication or structuring parts of my environment to decrease symptoms or finding me a support group.”
I am uncomfortable with you, New Therapist, and expressing it via saying that therapy sucks.
The thing is, I have none of that information, just that the client is not pleased about interacting we me and has low expectations. Though my next question is almost always going to be “can you tell me more about why it sucked for you?” Even presuming they answer and follow that line of questions (and this is not guaranteed), I won’t have a ton of information.
So this is a plea/suggestion/blog post request for therapists to err on the side of telling their clients what the heck they’re doing.* And a second suggestion for clients to ask their therapists what the plan is.
Consider this situation: you, client-named-Jeff, are going to therapy for the first time. You don’t have any prior interaction with psychotherapy, nor do you read blogs like this. Your therapist focuses on cognitive distortions and sends you home with homework, and you just hate it. It feels like being a kid, and you really wanted to figure out why you’re feeling so anxious all the time (you’ve wondered if it comes from having to move around so much when you were growing up). You never end up with rapport with the therapist, and given that trusting and liking your therapist is an important component of therapeutic success…you decide that the cost of seeing a counselor is ridiculous, and leave.
Two years later, your anxiety is severely impairing your ability to function at work. The company you work for is small, and they offer to pay for therapy instead of asking you to resign, hoping that it will allow them to keep an employee who has a history of loyalty and service. So you end up in my office. “Therapy sucks,” you say. We spend a good deal of time trying to figure out what things you hate and what things I can do that don’t make you feel patronized. Eventually we build some kind of trust, but your opinion remains that most therapists are incompetent. Lots of time is wasted in hit-and-miss appointments.
Or, consider this scenario: you, client-named-Jeff, are going to therapy for the first time. Again, you don’t have prior info about what therapy is like. Your therapist tells you do that they do Cognitive Behavior Therapy. They focus on cognitive distortions and sends you home with homework, and you just hate it. As in the previous story, it feels silly and childish and you’re more interested in discussing how you ended up where you are and building from there. The therapist hears your complaints, but for some reason doesn’t deviate much from the CBT framework.
Now two years later, I see you. In the course of trying to figure out why you think therapy is hell served in fifty minute portions, you mention that your previous therapist did CBT. Now, I have some pretty damn useful information. I can ask you what things you didn’t like about it. If you’re able to give me concrete answers, I can avoid those things.
If I end up believing that some part of CBT really would make an impact, even if it annoys you, I can convey that! “I know you didn’t like getting homework because it felt childish, but I think I could help you much more if I had a sense of what triggers your anxiety at home, and I wouldn’t be surprised if you learned something about yourself too. Would you be willing to do a trial period of documenting your panic day to day?”**
Even better, you’re getting information that lets you self-advocate in future therapy settings. If your first therapist tells you they were CBT-focused, and I tell you that I’m mainly doing narrative therapy, you get to convey what worked and what didn’t to any future mental health professionals. If you end up needing some immediate help, or can’t afford an appointment, you’ve got a starting point for googling. You’ll know that Feeling Good is less likely to work for you than Retelling Our Stories, because you can read the flyleaf and compare it to your experiences.
But perhaps most importantly, giving clients information about a treatment plan or orientation can prevent them from generalizing one therapeutic orientation to the profession at large. A client knows that you’re doing one thing under the umbrella of therapy. It’s much easier to say to a therapist “this specific thing seems to fail” than “I think the thing that is your profession (therapy) doesn’t work for me”
*I recognize that sometimes telling certain clients (for instance) that you’re trying solution-focused brief therapy is going to derail the crisis work you’re doing, or going to paint you as an ivory tower academic who doesn’t understand.
**For the curious, this is the worksheet I was thinking of.