Suggestions for Mental Health Professionals dealing Challenging Cases

In 1986 psychologist Sue Elkind surveyed 330 fellow therapists at the Psychotherapy Institute in Berkeley, California. Of the 100 who responded, 58% reported experiencing harm from an impasse as a therapy patient.

She cites another study that showed 43% of therapists had negative termination experiences as a patient.

In another, 21% of therapists reported that previous therapy had been harmful to them as patients.

Re: the last one, Elkind says: "This study is cited as one of the reasons why experienced psychotherapists do not seek psychotherapy."

I did a search and found she has a 1992 book on resolving impasses in therapy, too. Plus the search "Sue Elkind harm in therapy" had some other potentially interesting links as well.

So, what next?

I hear you-I wouldn't want that either.

This idea was never meant to take away from a client's choices. The idea was to provide clients with more informed choices and cut to the chase to help facilitate a better outcome.

An assessment could show what the issues are, the types of therapy that are known to help, and referrals to therapists who have had good outcomes from working with clients who have similar issues. For example, some therapists could work better with those who are clingy; others with those who are dismissive attachments. Some cannot tolerate self harm. Some cannot tolerate clients who don't talk, etc. Therapists get to know other therapists successes and failures.

It could also screen for your cognitive style and what modality you might prefer. For example, if you are creative or analytically minded, psychoanalytic therapy might be close to the top in choices. If you want to get to the bottom of things and are set on problem solving, another type of therapy would be #1. Or if you want someone to listen and support only, another therapist.

I've been to enough therapists to know something like this would have helped me considerably. Having no methodology was a tremendous waste of time and money and set me back at least a decade. That was the worst part about it-i feel like 10 years was wasted from my life, thinking I was doing what I needed to do. but it was the furthest from that! I personally think therapy works better when you are younger, too. 10 years is a long time to have your wellness delayed. All that time, I thought I was doing what I was supposed to be doing.

In this day and age, with statistics, data analytics, information processing speed, mathematical algorithms, etc., there's no reason something like this couldn't be created. We even have advanced analytics for advertising and marketing, to predict what people will buy, etc.

It would look something like this:

1. Preliminary diagnosis: depression, GAD
2. Trauma effects: self-worth, self-defeating behavior
3. Primary attachment style: anxious/pre-occupied
4. Current social support:
5. Goals:
6. Therapies indicated (1 through 10 ranked by evidence and ways of thinking and relating)
7. Therapists in area (10 names of gender preference or 5 female + 5 male names from database network ); biographies and insurance information and fees would be available

Each section of the assessment results would have educational materials so that a client can be informed.

It would only be a guide. A client can do whatever they want.
Anyway, I like throwing ideas around. This, I think is something that is needed.

Compare that with methodology I used when choosing past therapists:

1. Psychiatrist said I had to see someone in therapy at his practice in order to be treated. Therapist was the worst ever. And-she was CBT (which is horrible for me). Not only that, he made money off of it-he wasn't recommending what was best for me; this was best for him. This was my first experience with psychiatry so I had no idea.

2. Referral by primary care doc/GP - this was someone who didn't even have a license to practice therapy or a graduate degree. She was nice and I liked talking with her, but it was a huge waste of time and was like talking with a friend. Thinking back, I wondered if this was a friend or relative of the person referring me. Again, in someone else's interest, not mine.

3. Referred by a different psychiatrist - this one seemed good for me, but he emphasized hypnosis too much. I liked him a lot, but he passed away.

4. Referred by co-worker - this therapist greatly harmed me

5. Referred by therapist colleague who harmed me - a really decent therapist who I grew to love and who really helped me; it was cut short for logistical reasons. The referring therapist knew this therapist worked well with people with my issues. I would have never found him as he had no advertising anywhere.

6. Googling for hours and days; wasted appointments and money and never found a decent therapist

7. Using my insurance list - call after call and none of them actually took the insurance despite getting the free advertising through the insurance directory.

8. Psychology Today - finally found current therapist who I like a lot despite having some issues; but doesn't take insurance

However, I also found some really shady therapists and with questionable ethics and competence on Psychology Today.

Some psychoanalytic communities already have some elements of this built into their system at the local level. I think it would be a better option than just a shot in the dark. People could still use Psychology Today and Google to find their therapists if that's what works for them.

In addition to harm caused, I do wonder how much productivity is wasted by the fact their are little to no methods. In this day and age, we already have the technology to accomplish something like this.

There really is no excuse to not offer this type of thing to people. Psychiatry is so in the dark ages. Something recent that came out was the genetic testing to guide medication selection. I've heard mixed results for that.

Money would be the issue. It could be rewarding to start a non-profit to create something like this.

Should there could there be an app for that?

If you want to make one, go right ahead.

I know, really, like I don't have a zillion other things I should be doing right now besides fantasizing about creating something. Oh well, it's fun to do in my mind.

I really do need to find a new career.

Skies, I like what you outlined in your second last post (#78). I love systems and when things can be categorized in meaningful and useful ways, especially using data, knowledge and technologies available today. I actually work this way officially, do mental health-related research (with big data, highly interdisciplinary approaches etc). Why I am also aware of some of the limitations...

One key issue (out of many) with assessments in the mental health field is the perception and self-assessment ability of many people who go for treatment. Many people (and usually the most serious, most complicated cases) find it hard to describe their experience, symptoms, even themselves (here come those issues with self concept and identity) in simple and straightforward enough ways to be used accurately in a relatively short (even 2-3 appointments) interview to reveal realistic and clinically useful patterns...more useful than what clinicians (therapists, psychiatrists) typically do anyway. And even, say, if categories emerge based on the test, for example what someone's most dominant psychological challenge is, as most people who have been in therapy or know about "modern" psychiatry are aware, they are never stable, distinct categories like many medical health problems but are fluid and are usually on a spectrum. And cognitive styles and abilities can be heavily influenced by momentary mental challenges, especially in an unstable person. Then there is the other end: the possible treatment categories. I think that in reality, most therapists actually do use a more eclectic approach than some claim, also influenced by their own perceptions, ideas, abilities... unlike medical science, it's all highly subjective and individualistic.

There is an ongoing initiative from the National Institute of Mental Health called Research Domain Criteria (RDoc) that was proposed as sort of an alternative to the DSM for complex assessment of mental health (disorders) using modern knowledge and technology. Don't know if people here are familiar, I have not seen it mentioned on PC. Not going into it because it would be an endless post, but obviously it's not being used in clinical practice yet.

Another challenge around therapy specifically is that many of the modalities and their theoretical frameworks are quite old, subjective, obscure and hard to integrate with other areas of modern science (even just neuroscience, which is probably most relevant). But I also definitely see this as the future of the mental health industry, if it'll have a positive, constructive future.

Skies... You could actually take your interests and what you guys are proposing here seriously if you wanted. There are so many opportunities easily available nowadays and a lot of room for improvement in the mental health area, inside out

I read the book. It's quite good. One of the few honest examinations of therapy harm i've read.

I mentioned the studies because I suspect many of the alleged predictors of a "good" therapist have little or no factual basis, including the idea that there is a correlation between extent of personal therapy done and effectiveness as a clinician. If therapy is damaging or ends in impasse, perhaps little or nothing was resolved and more baggage was added. Might make the therapist-in-training more empathic about therapy harm, but could also make them more wounded and more needy and less stable.

In terms of screening, I'd rather know what sort of mental problems a therapist has, their biography, their psychological complexes... than what they studied or how much therapy they've had. Ironically this is the sort of stuff they rarely reveal. I'd also like to know their outcomes.

I think the reality is that what happens in therapy is almost entirely unpredictable. Too many variables, not much science, poor controls, methods that are not replicable, often unacknowledged power dynamics, ambiguous relationship.

Can psychological problems can be "treated" like bodily disease, and can you match diagnosis to practitioner speciality? I don't buy it. I think this is the sort of wishful thinking MH pro's like to engage in. Makes them feel like doctors.

No reason there couldn't be a place for clients requirements like that on the website we're discussing. ;-0 Let's call it "ClientMatch". Prospective clients can be anonymous, like here, but the professionals have to register and use their real names.

If things don't work out "ClientMatch" assumes no responsibility but might have a rating system.

I've been considering using a website to get some bids on my next home repair effort. I've had people my neighbors recommended not work out for me at all. And I hate to call people over to make a bid, knowing that somebody else might beat them out, and then they call back and I have to tell them that. But I haven't tried any so I don't know how well the home repair websites work out, either. Has anybody else tried them?

OK so "ClientMatch" might already be trademarked and we don't have the non-profit organized and chartered yet to trademark it if it's not taken, so it will probably have to be some other name, but it's an idea.

ETA: yes, that domain name is already taken.

I like "wackipedia"

Thanks for your thoughtful response X.

It would be a semi-structured interview, but yes, still a challenge. It's not well known, I think, but in psychodynamic assessments, much can be gleaned from the absence of information because defensive patterns are revealed. So the manner in which someone talks about trauma, not the actual information revealed by the client, is the actual data measured.

I can't find the information on what I am thinking of, and it's been years since I read about this, but here's one example of an assessment that doesn't look at the story told, but instead, looks at how the story his told. (I don't know much about this one-just using it for an example)

I never heard of Research Domain Criteria (RDoc), I would love to be involved in creating a new DSM and have (embarassingly) actually fantasized about working on a project like that too. I never thought it would be done because of the problems with aligning a new system with insurance reimbursements, so this it's cool to see something new being done out there. I will read more about it.

I'm interested and love systems and categorization too. I also tend to have a knack for finding creative ways to quantify concepts. I think of it is some type of engineering, not sure if/what the discipline would be called, but if it doesn't exist, maybe we can create that too...

Thanks for the encouragement. I was serious to some extent, as I really dislike my job and career field and want to branch out to something else in the near future.

I cannot imagine therapists ever disclosing info on their own mental health. The whole enterprise is sustained by secrecy and asymmetry. Genuine transparency would likely kill or seriously injure it.

Sometimes clients who don't have any huge, apparent, surface level crises can be difficult in their own way too.