[wonderingmary]

In another thread (Older Clients), I wondered if some of the problems I have had with therapy stem from being an older client (in my forties when I first tried therapy; now in my sixties). I am aware that my problems with therapy in part came from me -- in particular, that my assertiveness and oral communication skills were not very good, and that I was easily intimidated and shamed. But those were in large part what I was seeking help with. It so often seemed as if the therapists tried to do things for me that I could do on my own, yet weren't willing to try to help where I was asking for help.

Has anyone else had this experience, of the therapists trying to do things for you that you can do on your own, yet not addressing what you're asking for help with? This seemed to be a consistent pattern with me. It often seemed as though the therapist and I might as well be from different planets.

I don't want to castigate individual therapists -- I think the problem is largely with the system. For example, training is often inadequate, too much one-size-fits-all and too much "therapist knows it all," with not enough emphasis on listening skills and flexibility. There are also not enough mechanisms for helping the client find a good client-therapist fit, and there are not adequate mechanisms for weeding out the bad eggs.

I do see improvements in the profession since I first tried therapy. In particular, at least some nod toward informed consent has become standard. However, it still seems to be in many cases only a nod, and more aimed at legal considerations rather than as an ongoing part of the process. Another promising sign is that some therapists are using feedback forms, and finding that it helps. Many of these are partly motivated by preventing harm, which I really appreciate. Also another promising sign is that some therapists are realizing that values are relevant in therapy. Still, so much of what I read seems one-size-fits-all, or perhaps is analogous to offering clothes in lots of heights, but for only one body shape.

There is a theoretical orientation called Client Directed Therapy that makes more sense to me than anything else, but it still seems to have some one-size-fits-all aspects. (The best source on this, in my opinion, is Psychotherapy with "Impossible" Cases, by Duncan, Hubble, and Miller. Their other books seem too polemical for my tastes.)

The Evidence Based Practice movement is a mixed bag. Some therapists seem to use it as an excuse to justify one-size-fits-all practices. Others advocate a form of it that makes more sense to me -- a form that emphasizes being careful not to extrapolate from the scientific evidence, and taking client preferences into account. (If anyone is interested in that, the book Clinician's Guide to Evidence Based Practices, by Norcross, Hogan, and Koocher, is a good source.)

[deliquesce]

Originally Posted by wonderingmary

Has anyone else had this experience, of the therapists trying to do things for you that you can do on your own, yet not addressing what you're asking for help with? This seemed to be a consistent pattern with me. It often seemed as though the therapist and I might as well be from different planets.

i have had this experience, but they have been one-off occassions and i've been quite vocal about it the next session! so i can't say that it's ever been a pattern for me. given that you've said your problem areas lie in assertiveness, i wonder if you ever expressed your concern to your therapist? one thing that strikes me is that you are well read and can write well, that could be a possibility for you expressing yourself early in the therapeutic process. certainly it is what i used to do, many years ago .

I don't want to castigate individual therapists -- I think the problem is largely with the system. For example, training is often inadequate, too much one-size-fits-all and too much "therapist knows it all," with not enough emphasis on listening skills and flexibility. There are also not enough mechanisms for helping the client find a good client-therapist fit, and there are not adequate mechanisms for weeding out the bad eggs.

i've found that the "therapist as undeniable expert" attitude is more prevalent in older therapists - those who were trained about 20ish years ago. a lot has changed in training since then, particularly the idea that we know anything much about mental disorders. my first (and thus far, only) course in psychology in which we focussed on counselling skills only gave us exposure to listening and rephrasing. 13 whole weeks of listening to a (mock) client and reflecting what they had said back to them. our textbook was "the skilled helper" by egan, which was pretty atheoretical in its approach as far as textbooks go.

[sunrise]

Originally Posted by wonderingmary

It so often seemed as if the therapists tried to do things for me that I could do on my own, yet weren't willing to try to help where I was asking for help.

I find that really interesting, WM. Could you give an example to help me understand better? What is something the therapist might "do" for a person that the person doesn't need help with? (I am not sure I have had experience with a therapist "doing" something for me like this. For example, my therapist gives me unconditional positive regard when listening to me. It's not quite the same to give oneself UPR, although something similar that is self-directed could be valuable too--UPR almost requires the "doer" of this to be "other" and not oneself.)

There are also not enough mechanisms for helping the client find a good client-therapist fit

I do agree with this. I am not sure there are any mechanisms for this (beyond early recognition by the therapist and referral to another practitioner). The client begins with a therapist and often continues for quite some time even if the fit is not good (or even not "good enough"). Often the client will eventually get discouraged and quit, feeling "therapy was not helpful" or realizing some small gains but never the huge life changes that therapy can help bring about.

Here is one idea for how a good fit might be promoted. This comes from a study on counseling for alcoholism. Alcoholic clients were assigned to 3 different types of one-on-one psychotherapy treatment. One of the three was an individual psychotherapy based on "12 step" programs (like AA). The second was a CBT-based therapy, and I can't remember the third approach. The results showed that it was not the type of therapy that was the most efficacious but the therapist-client relationship (no surprise, as other studies outside of the addiction world have also showed the relationship's primacy). What was interesting about this study was that one component was to assess the strength of the therapeutic alliance very early on using standard instruments. As has been shown in other studies, the early strength of the relationship (after only 3-6 sessions), as assessed by these instruments, is an outstanding predictor of the strength of the alliance much later in therapy. As an intervention, spin-offs from this study involved using the instrument early on to assess the relationship and then switching the client to another therapist if the alliance was weak. This allowed the client not to linger in therapy with a therapist who was not a good fit. (I can't remember how the therapist was picked that the client was switched to.)

I thought this was a very interesting intervention and might be applied in all areas of psychotherapy, not just addiction counseling.

I think the client, especially one new to therapy, often does not know how important the therapist relationship is to success of therapy and so doesn't think to change practitioners. I know that with my first therapist, this never occurred to me. She was a nice lady, but I had no idea the relationship with a therapist could be so much more, and no idea that this could be important for the therapy's success. Maybe if would be helpful in therapy to assess the alliance in this way early on and recommend a change if there is not a good fit.

[wonderingmary]

Originally Posted by sunrise

What is something the therapist might "do" for a person that the person doesn't need help with?

All the examples I had in mind fall under the category of trying to make me aware of things I was already aware of. I was seeking help primarily in dealing with the (often painful) awareness and in learning to change my behaviors and attitudes. Having the therapist point out things I was aware of and hadn't been successful in changing was like rubbing salt in a wound. In fact, sometimes there were things that I had been making progress on, and was quite proud of my progress, but the therapists seemed to look at the glass as half empty when I was looking at it as half full. There may have been other things I wasn't aware of, but I had such a backlog of awareness that I was trying to work on that I needed to deal with that backlog before going on to anything else. Slowly I've been making progress on that backlog, but it has been much slower after therapy than it was before, since I also have had to deal with the "therapists in my head" that I developed in therapy. (These are intrusive thoughts of therapists doing things like the "pointing out" that was so unneeded and unhelpful, or "giving me suggestions" that I have just given myself, or asking me questions in a framework that doesn't fit the reality that I experience, or telling me I mean something other than what I mean, etc., etc.)

Originally Posted by sunrise

I think the client, especially one new to therapy, often does not know how important the therapist relationship is to success of therapy and so doesn't think to change practitioners.

In fact, I did change practitioners. I didn't go back to a second session with the first therapist I tried. I decided to quit the second after three sessions, since there just didn't seem to be any rapport, but I went back for a fourth to tell her, because I was trying to practice assertiveness and wanted to tell her face to face rather than avoiding that. She said that I expected too much. My tendency to feel ashamed and guilty kicked in. I vowed not to "give up" on the third so quickly. That was a mistake. After three months of getting worse, I did finally come to my senses and quit her; we were just on different wavelengths from word go. Unfortunately, I still blamed myself too much and tried to stick it out with the next one for six months, which was also a big mistake. I did actually at first think she was going to be helpful, that I could make a go of it with her, but I just was not able to make it work out. When I told her I was going to quit, she said, "You'll never get better if you keep seeking the perfect therapist." I had really been trying hard to be tolerant of our differences and not expect too much.

Originally Posted by sunrise

Maybe if would be helpful in therapy to assess the alliance in this way early on and recommend a change if there is not a good fit.

Yes, I believe that there are therapists who are doing such early assessment, and trying to make changes (either the therapist takes a different approach or refers the client to another therapist) before the poor relationship continues too long. But I think that many therapists, as well as clients, still do not realize how important the therapeutic relationship is to success of therapy. I do believe that the profession is improving in this way, though. I doubt that a therapist today would say, "You expect too much" or "You'll never get better if you keep seeking the perfect therapist." However, (based on my reading), some therapists seem to think the relationship is important, but in a one-size-fits-all way. I believe that different clients may need different relationships with the therapist. This is tied in with the interventions the therapist chooses. To me, a big impediment to forming a therapeutic relationship was that the therapists typically did so much that didn't make sense to me. Some (not all) of the ones I've tried seemed like nice people, but we were just not enough on the same wavelength to be able to communicate meaningfully. It so often seems that therapists have an agenda (which may differ from therapist to therapist). Sometimes it seems like the client is nothing but raw material for the therapist to "do their thing" to.

[crystalrose]

deli thats the text book i learned counselling from. Very basic isn't it. My lecturer thought it was the best book written. Some professors and lecturers teach from the theory that they agree with the most. So one lecturer taught me cbt and another taught me rebt. Another taught me client focussed. This was at the basic level i'm not a counsellor just have some training in it.

[imapatient]

Mary, I don't have time to reply to the substance here--a discussion and topic I like and will get more into later--but I do have to say that with this analogy

Originally Posted by wonderingmary

Still, so much of what I read seems one-size-fits-all, or perhaps is analogous to offering clothes in lots of heights, but for only one body shape.

you have gained me as a fan for life. I love it. I'm sure I'll be using that as analogy and metaphor in various guises for the rest of my days.

[velcro003]

Interesting topic! This is my first go-round with therapy, and I have struggled/still sometimes struggle with the "is it a good fit?" theme. I do agree that there is no way for clients to really understand if they have a good fit with their T, or how important that relationship is.

What I am having trouble with-is how do you REALLY know, when your feelings towards the T fall in the gray area? She has never said or done anything to really upset me, she has left me feeling slightly better on occasion...but its been two years and I still get nervous and its like pulling teeth to get me to open up.

Is this because I don't feel comfortable with her/we don't mesh? Is it because I am afraid to trust, no matter who it would be? Is it neccesarily bad that it is so hard for me? That if I keep working at it, I will (hopefully) be able to open up? I sometimes think if I had a T like my GP who is the sweetest lady in the world--would I open up easier/faster? Not that my T isn't kind, she's just very neutral. Then I think would a T act like my GP? Be so open and sweet and caring? Probably.

See what my brain does?! My T has mentioned that maybe I would be less anxious seeing someone else, but I keep saying "no, I want to keep at it." I don't know why-i hoope it isn't just fear of starting all over. I also hope that its just hard because I just am afraid to be vulnerable, and that would be difficult with anyone...maybe less so with someone more "up front" with their caring. But maybe I will feel a greater sense of satisfactuion and self by keep trying. I don't know.

[pachyderm]

Better the devil you know than the one you don't?

[chaotic13]

Wonderingmary, you seem to have a good vision of what you want in a T. Maybe you could continue to work on your assertiveness in asking and molding your therapy into what best meets your needs. I have only had one T so I don't know what the system is like. However my T does not seem to be a one-size-fits-all kind of T. Our relationship was very rocky in the beginning. In hindsight I think that was because my T had few expectations and waited for me to figure out what I wanted/needed her to do and provide. Although my T has been practicing a long time...I think she has learned a lot from working with me and seeing if she could accomidate and to therapy using the chaotic13 approach. LOL

Maybe... Part of your therapy is teaching your T about a better way to "do" your therapy.

[velcro003]

Originally Posted by pachyderm

Better the devil you know than the one you don't?

What do you mean? *confused*

[pachyderm]

Originally Posted by velcro003

What do you mean? *confused*

My T has mentioned that maybe I would be less anxious seeing someone else, but I keep saying "no, I want to keep at it." I don't know why-i hoope it isn't just fear of starting all over. I also hope that its just hard because I just am afraid to be vulnerable, and that would be difficult with anyone...

"Better the devil you know than the one you don't? "

[velcro003]

Originally Posted by pachyderm

"Better the devil you know than the one you don't? "

I don't think I'm staying purely on the fear of the ubknown, though I'm sure it contributes. I guess I was writing that out to see if anyone else struggled with a sense of feeling "open" and comfortable with their T.

[pachyderm]

Originally Posted by wonderingmary

I also have had to deal with the "therapists in my head" that I developed in therapy. (These are intrusive thoughts of therapists doing things like the "pointing out" that was so unneeded and unhelpful, or "giving me suggestions" that I have just given myself, or asking me questions in a framework that doesn't fit the reality that I experience, or telling me I mean something other than what I mean, etc., etc.)

Very similar to what happens with me. It completely stalls any progress that I can make on my own. If not sending me (once again) into a death spiral...

[pachyderm]

Originally Posted by wonderingmary

Psychotherapy with "Impossible" Cases, by Duncan, Hubble, and Miller.

On Amazon this has six reader reviews; five give it five stars and one gives it one star. The one-star review is full of praise for the book, so it seems that the rating is in error!

[wonderingmary]

[quote=deliquesce;1206160][/font]

given that you've said your problem areas lie in assertiveness, i wonder if you ever expressed your concern to your therapist?

I've tried, but not with much success.

one thing that strikes me is that you are well read and can write well, that could be a possibility for you expressing yourself early in the therapeutic process. certainly it is what i used to do, many years ago .

I've tried this with at least three therapists. The first ("therapist #3) just seemed to sit there patiently listening and smiling, but I don't recall any evidence of what I said making any difference. When I gave the second something I'd written that I wanted to go over, he just briefly glanced at it, tossed it aside, and proceeded to ignore it. I remember his interrupting me a couple of times to argue with what I hadn't said and didn't intend to say. I'm glad to say that I did not go back to him. (He also never did send me a receipt, so I couldn't get insurance reimbursement.)

The third time was with the last therapist I tried. The fact that I was over sixty gave me a little more confidence in asserting myself. I very carefully wrote out a list of "Things that are more likely to be part of the problem than part of the solution," with "better alternatives" whenever I could think of any. I told him I would like to use that as a "crutch" to give me an outline of what I wanted to talk about. He had some hesitation, saying that it wasn't what he usually did, but did agree. It was actually very helpful. I also got some assertiveness practice in (for example, once I mentioned some sexist things that friends of mine had encountered, and he said, "That's fascinating," which I though was very inappropriate -- and I told him so.) But then when I got through the list and associated commentary (which took several sessions), he started intervening more, and it was almost as if what I had said had gone in one ear and out the other. Much of what he said just didn't make sense -- it essentially said, "Don't talk about what's important to you," so the experience was overall like two steps forward and one backward, which was actually better than most of my therapy experiences.

i've found that the "therapist as undeniable expert" attitude is more prevalent in older therapists - those who were trained about 20ish years ago. a lot has changed in training since then, particularly the idea that we know anything much about mental disorders.

Thank you for this observation. It is a little demoralizing, but believable, since my therapist #3 was a trainer when I tried her, around 1986. It's also demoralizing since I would be most comfortable with a therapist who is my age or older. But acknowledging reality has its merits.

my first (and thus far, only) course in psychology in which we focussed on counselling skills only gave us exposure to listening and rephrasing. 13 whole weeks of listening to a (mock) client and reflecting what they had said back to them.

I have a hard time with the rephrasing/reflecting approach -- just too much personal attention, which I have a problem with. I generally don't find it helpful, and in fact it makes for a difficult relationship for me -- I have for a long time (way before trying therapy) considered it a difficult behavior to cope with. I need a therapist who gives me space and lets me proceed at my own pace, particularly with personal attention.

[wonderingmary]

Originally Posted by imapatient

Mary, I don't have time to reply to the substance here--a discussion and topic I like and will get more into later--but I do have to say that with this analogy ...

you have gained me as a fan for life. I love it. I'm sure I'll be using that as analogy and metaphor in various guises for the rest of my days.

Thanks. I appreciate your appreciation. Actually, the analogy that usually comes to mind is that therapy is like a shoe store that has lots of different styles of shoes -- but they are all the same size, and that size doesn't fit me. But while writing the post, the new one popped into my mind. They both pretty much get the idea across. Well, not entirely. The shoe store analogy has an extension: That when I tell the shoe salesman that I don't wear that size, he says with a look of indignation, "But most people wear this size!"

[wonderingmary]

Originally Posted by velcro003

Interesting topic! This is my first go-round with therapy, and I have struggled/still sometimes struggle with the "is it a good fit?" theme. I do agree that there is no way for clients to really understand if they have a good fit with their T, or how important that relationship is.

What I am having trouble with-is how do you REALLY know, when your feelings towards the T fall in the gray area? She has never said or done anything to really upset me, she has left me feeling slightly better on occasion...but its been two years and I still get nervous and its like pulling teeth to get me to open up.

Is this because I don't feel comfortable with her/we don't mesh? Is it because I am afraid to trust, no matter who it would be? Is it neccesarily bad that it is so hard for me? That if I keep working at it, I will (hopefully) be able to open up? I sometimes think if I had a T like my GP who is the sweetest lady in the world--would I open up easier/faster? Not that my T isn't kind, she's just very neutral. Then I think would a T act like my GP? Be so open and sweet and caring? Probably.

See what my brain does?! My T has mentioned that maybe I would be less anxious seeing someone else, but I keep saying "no, I want to keep at it." I don't know why-i hoope it isn't just fear of starting all over. I also hope that its just hard because I just am afraid to be vulnerable, and that would be difficult with anyone...maybe less so with someone more "up front" with their caring. But maybe I will feel a greater sense of satisfactuion and self by keep trying. I don't know.

I think fear of starting all over (or perhaps not so much fear but a sense of the enormity of the task) was part of what kept me from trying a different therapist when therapist #3 clearly was more counterproductive than helpful, and that I made a big mistake by staying with her for as long as I did (and repeated the same mistake with #4). But everyone is different. It is a decision we each have to make for ourselves. Regrettably, we can't know in advance if we're making the right decision, and we have to live with the consequences if we make the wrong decision. I wonder if your therapist could make some suggestions of therapists she thinks might be better for you, and you could try them, but come back to your current T if they don't work out? Although, that might not work out financially if you are using insurance.
Another possibility is to see if your T would be willing to try alliance and outcome evaluations. I think there are some available on the web at links from http://www.talkingcure.com/.

[wonderingmary]

Originally Posted by velcro003

I don't think I'm staying purely on the fear of the ubknown, though I'm sure it contributes. I guess I was writing that out to see if anyone else struggled with a sense of feeling "open" and comfortable with their T.

I don't think I've ever felt comfortable with a therapist. I went into therapy assuming I wouldn't feel comfortable, since I couldn't imagine feeling comfortable with one. But the problems I encountered were more than just feeling comfortable.

[wonderingmary]

Originally Posted by pachyderm

Very similar to what happens with me. It completely stalls any progress that I can make on my own. If not sending me (once again) into a death spiral...

Thanks for your comment. It's nice to know that someone else has problems with therapists in their head. I had a few people-in-my-head before therapy, but nowhere as bad as the therapists. I do seem to be improving with the therapists-in-my-head a little lately: They are mostly verbal now, not so much visual. That may be because I haven't actually worked with a therapist for about four years. The sense of being watched is really hard to deal with. I'm also getting a little better at saying "I am alone" and having it have an effect.

[velcro003]

Originally Posted by wonderingmary

I think fear of starting all over (or perhaps not so much fear but a sense of the enormity of the task) was part of what kept me from trying a different therapist when therapist #3 clearly was more counterproductive than helpful, and that I made a big mistake by staying with her for as long as I did (and repeated the same mistake with #4). But everyone is different. It is a decision we each have to make for ourselves. Regrettably, we can't know in advance if we're making the right decision, and we have to live with the consequences if we make the wrong decision. I wonder if your therapist could make some suggestions of therapists she thinks might be better for you, and you could try them, but come back to your current T if they don't work out? Although, that might not work out financially if you are using insurance.
Another possibility is to see if your T would be willing to try alliance and outcome evaluations. I think there are some available on the web at links from http://www.talkingcure.com/.

Originally Posted by wonderingmary

I don't think I've ever felt comfortable with a therapist. I went into therapy assuming I wouldn't feel comfortable, since I couldn't imagine feeling comfortable with one. But the problems I encountered were more than just feeling comfortable.

I think this says it all for me. I don't think my sessions are counter-productive, I just sometimes wonder if they ARE productive at all. Sometimes they are. But, besides being anxious before each session and just having a hard time opening up, there hasn't been anything she's necessarily said or done that has made me second guess this. I think I just need to put myself on the line more and see how it goes from there. It just is REALLY hard. I am so afraid she doesn't care.

[wonderingmary]

Originally Posted by sunrise

What is something the therapist might "do" for a person that the person doesn't need help with?

In my original reply to this, I said that all the examples I had in mind fell into the category of trying to make me aware of things I was already aware of. It dawned on me later that there was another category: Suggesting ideas. To me ideas are cheap; I can think of ideas on my own, and can find them easily in books (and now on the web, which didn't exist when I first tried therapy). Where I tend to need help is in implementing ideas. A variation on this: One therapist said he helps people find solutions. It is the same problem: implementing the solutions/ideas is where I could use help. For example, just giving me a somewhat sheltered place where I can practice "speaking my voice" is one of the most helpful things a therapist can do to help me. (I call this "two ears are better than none." Some other kinds of help might be considered as "four hands are better than two.") But therapists seem to believe that their job is to engage in interventions of their own choosing. It wouldn't be so bad if they worked on an informed consent basis, explaining what sort of interventions they proposed, and what they were intendeded to accomplish. Then I could say yes or no; or that I thought the purpose was OK, but the means weren't; or that the purpose was not something I consented to; or propose something that I thought would be more helpful to me. But they just seem to decide on their own, and then I am faced with the task of saying after the fact, "no, that was not helpful," or asking why they did it. And in addition, I may need to deal with counterproductive consequences of an inappropriate intervention. I think it would be much more efficient as well as user-friendly (just all-round more helpful) if they operated on more of an informed consent basis.
I related beef of mine is that some things I have read aimed at therapists say that "engage the client" is the most important thing for a therapist to remember. I disagree. Not disengaging is much more important. Yes, some clients sometimes need to be engaged. But I find that interventions often interfere with engagement. Perhaps a better perspective would be "foster the client's engagement," encompassing three things:
1. Provide conditions that are user friendly for the client to take the initiative.(e.g., saying at the very beginning, "Please let me know if I do anything that doesn't make sense to you or if I am interfering with your helping yourself.")
2. Be careful not to do anything to interfere with the client's engagement.
3. Only if the above don't work should you try to engage the client.