Complex clients and ineffective therapy

I just think it's dishonest to talk about ineffectiveness without even mentioning harm (in the first article). Implies that therapy is either helpful or benign. There are lots of articles that discuss failures and drop-outs in a distant and abstract way, as data to be crunched to give the researchers something to blather on about. Very few articles where they show interest in the failures themselves.

"The wrong therapy, by the wrong therapist or with the wrong timing (or a combination thereof) may be psychonoxious."

Another cunning little deceit in that statement. They can't or won't face that possibility that therapy might be "psychonoxious" (they should be shot for using that word) simply because it's therapy.

I don't want to prolong trying to make my point, maybe we just disagree. But I was in and out of therapy for over 50 years -- yes there have been a lot of improvements, and dis-improvements, along the way. I've been in therapy almost continuously for 20 years -- it didn't prevent me from having a terrible breakdown and may have contributed to it, although I am better now. I've known two people with long-term mental health issues who took their own lives, one in his 50's, one in his 60's. They never got the realizations that could help them live healthier, happier lives.

Based on my long experience, though, the two goals that the authors proposed COULD, I believe, help a lot of other clients with trauma backgrounds and complex issues:

1. The therapist and patient form a shared understanding of what is happening and find a way of working together.

2. This way must be found to be beneficial for the patient and sufficiently tolerable for the therapist so that the therapist does not avoid it.

Because of the issues I entered therapy with, I did not have an understanding of the world of social relationships that matched what others did very well. That's the nature of what I presented with. But the therapist couldn't have known how I experienced the world any more than I could know how they did. So, having the development of a shared understanding as an explicit goal sounds to me like something that could have helped a lot.

Similarly, because I had numbed out my emotional reactions to my mother's anger, I could not understand that anger and angry outbursts felt threatening to the therapist. It was in therapy and I was proud of myself for getting in touch with my feelings and expressing it. I had previously understood that anger was "bad" and I could usually control anger by dissociation or self-shaming it internally. But then I couldn't talk about it either. And I expect there were other characteristics of me that were hard for the therapist to tolerate in me sometimes, and I didn't know it, or why, because she didn't tell me. I knew how to behave politely, at least as I had been taught, but to me that was a matter of being "good" or "bad". There was a lot of social nuance I didn't pick up on (still don't, I find out sometimes the hard way, others not at all). So some intellectual understanding by the therapist that that was the case could help a lot, I believe. She/he could develop a way ahead of time to tell the client if they were having a hard time with some of their behavior, or something, without being shaming, blaming, or belittling, which are things which therapists have definitely done to me.

Because of the numbing, I had no idea what a "good fit" was either. I kinda do now, but after . . .well, again, all those years. That's something that it might help to discuss up front, directly, with clients with complex issues at the beginning, too.

I'm putting this out there, here, because I have no confidence at all that any one in the profession is interested. But who knows? Maybe there are some out there who decide to take a look at the client forums as a lark. And certainly the authors of those articles seem to understand the problems and are trying to make a difference. Who knows how many folks will listen to them. Still, very interesting and thanks again, Skies.

I don't think many therapists are going to sacrifice their own self image, their comfort, their illusions, their belief system, their professional allegiances, etc for any of their clients. Client needs are lowest priority. When there is conflict, usually the client is the first thing to be sacrificed. If a client's anger or neediness or criticism threatens therapist equilibrium or the established order, adios client. Even it's a manifestation of PTSD. Or perhaps the client is "allowed" to continue but will be shamed into submission. Therapy is unfailingly hierarchical.

Yes, it was naive, unrealistic, and "disordered" for me to expect otherwise -- looking for a fantasy care taker, like the fantasy I lived in after the trauma of realizing there was no one (in my family) who cared about me.

It was in processing the "failure" -- or maybe the success? -- of the last therapy that this reality now makes some sense to me. Very sad. Not what I "wanted" from therapy. I "wanted" to be fixed and then everything would be "wonderful" or at least OK.

Still, I would argue, 50 years for that? 50 years of unlived, mislived, non-productive life?

Oh, well. It is what it is.

Actually, I beg your pardon. It's only been the last 30 years that my life has been mostly non-productive, especially the last 20. Still, that seems like a pretty long time to me. And, for the society as a whole, a net drain, too.

I've given it my best efforts. Therapists have given it their (currently available) best efforts. What I've learned from the failure of my best efforts is limited to me and my lifetime. If therapists and the profession as a whole were open to learning from the failure of their best efforts, then that could affect and improve the lives of other individuals in the future.

You are not a net drain!! Trumps golfing weekends - ARE a net drain!! Think bigly-er! kidding/not kidding

Eta - cuz if you are, then so am i, and i refudiate that nomenclosure!

This is an interesting thread. Thanks, Skies, for the articles as well. I think we had a somewhat similar discussion once on another thread, where I also commented. My general view is that pretty much everyone is a "complex case" if we look thoroughly enough. One key factor, I think, is how well we are able to cope with our complexities and issues. If they seriously interfere with functioning in a persistent way, that's when I think one needs some kind of approach that taps into the roots deeply. My issue with the kind of depth therapy that is focused only on analyzing and understanding our patterns though is that knowledge on its own rarely resolves problems. This is one reason why I prefer an eclectic, individualized approach, which can target various clients and areas based on the nature of the issues and what is needed for the client to have a better life, both in terms of emotional challenges and practical implications.

My first therapist was like that. Actually, I just went back to see him for one single session earlier this week after a year of leaving because he kept contacting me and in the end I was curious. We did not part in good terms back but I don't feel the session this week made any difference. He said mostly the same things, most of which had no relevance to my current life and some were gross misinterpretations, I think. He also came up with two new areas where, he thinks, I have problems that I should address in therapy. All quite negative for me and defensive on his end, and patronizing. I really don't consider myself as someone who is not willing too look at myself deeply, and I love to do that... but have no tolerance for all that negativity without a reason or purpose. He made me feel pretty cr@ppy about myself that lasted for a day and then I just decided **** it, I'm done with him for good.

Anyway, I mostly just wanted to say here that I think a mixture of depth therapy and more practical approaches can work quite well for many complex cases. I kinda like the idea of seeing different therapists even in parallel, who can target different issues or different aspects in relevant ways. A complex approach that can also teach the client to not expect solutions and support for everything from one single source but use a variety of resources. Of course this is just my opinion but I would be interested in what others think.

Yes, this rings true for me, and with where I was, my expectations of therapy going in, etc.

I wanted to cite only relevant parts of your post but realised that I cannot do that - everything seemed relevant.

I'm actually not disagreeing with you, I'm not even arguing with you. I think what you have written is very sensible. I have actually personally experienced many of the same things that you describe and reading about your and others unhelpful or harmful experiences stemming from inadequate or bad therapy shows me what could have happened to me if perhaps I hadn't been strangely lucky in choosing the therapist.

I guess that based on my experience of therapy with two different therapist, both chosen quite randomly (but having in common that they are relational psychoanalysts) and both originating from completely different countries I sort of though that those two points---the shared understanding and benefit of the patient---are something that can be assumed. How else could you work on your issues at all?

I have shared my experiences about my therapy in a local online forum in my home country and although there are many people who have visited a psychologist or even being in therapy, their experiences are vastly different from mine. Mostly I've understood that those psychologist visits are useless, unless your problems are really minor that can be solved by analysing your negative thought patterns, which I guess is a CBT-style therapy. I don't understand, why such "therapy" is provided at all. It seems that those psychologists themselves don't believe that they can actually do anything useful to people and so they sort of mimic doing something useful while actually being completely useless. The worst thing there is that this all confuses people. They think that this is all there is and no real help is nowhere to be found. I really have hard time understanding what all these people are thinking who are involved in organising and offering such pseudo-therapy.

Didn't mean to suggest it is naive to expect a therapist to tolerate honest expression of needs or emotion. I too expected this. It's kinda the whole point of therapy.

They talk a lot about unconditional acceptance. The big sales pitch. But clearly it is highly conditional. If their ego is threatened, they will probably go into self-preservation mode like anyone else. My therapist felt cornered and the claws came out.

It's all dubious. Therapy training cannot instill selflessness and equanimity. An MFT or PHD doesn't lead to enlightenment. It's a career. They are not relationship wizards. In fact some appear to be socially retarded. It's such a crazy fallacy... I studied psychology so now I am equipped to carry out a series of contrived relationships with troubled or traumatized human beings.

How about we have More psychologist/therapist that specialize in trauma therapy alone. That is what complex-ptsd needs.

[QUOTE=Skies;


Conversations here about people considering themselves as "disordered" or "defective" or "too needy" or "too much" prompted me to post this. I don't like to think of anyone like that, and I've felt disconcerted after hearing others talk like this even though I've thought of myself like that at times, including recently.

[/QUOTE]

I came across this thread and wanted to thank you for posting it. Thank you too for the other posts here. It has been very timely and validating for me right now.

Needy and noncompliant are heavy and scary. This thread and the responses have really helped me.

Thank you!

What's even more ridiculous about this...

I'm not a complex patient.

I've got multiple psychiatric diagnoses, but I don't have any PDs and my main mood disorder is largely under control with meds. "Studies show" that CBT helps with the remaining issue I want help.

I seem to have a high amount of "psychological mindedness." Some things that are referred to as CBT techniques are naturally part of my personality. I can talk about feelings without too much issue.

I'm not inclined to anything that would inconvenience the therapist. A lot of the conflicts or other issues that people describe in this forum are things that are non-applicable to my situation.

And yet, therapy has been useless for me. From what I can tell, all the ways therapy normally helps are things I was already doing before therapy.

I guess it mainly helps people who are in the middle?

ANYWAY, I was interested in further reading on this, which lead me to this paper on a complex patient referred to as Sonia. They had success with that patient through some "integrated" therapy model. It took eight years of active treatment and at least two more years of "maintenance" treatment. It was planned from the beginning to be long term. The providers also worked with her family members. The treatment was a coordinated effort between a psychologist psychotherapist, a psychiatrist, a therapeutic coach, and an "independent assessment team," with psychotherapy sessions being conducted in a variety of settings including private consultation offices, the patient's home, the patient's parents' home, the patient's son's school, and the patient's workplace. She also used medication. The patient had rich parents, and her mother financially supported her when necessary. I don't think the paper mentioned who paid for all her treatment, but I'm guessing it was her mother. There was an event in the patient's life several years into treatment which the paper's author talks about with, "the situation became very tense and nearly everything we had achieved was put at stake," but fortunately, it worked out.

The patient benefited from this treatment whereas she hadn't benefited from previous treatment, but this is a far cry from anything that ever gets a randomized controlled trial. I don't even think you could do an RTC on this. In fact, this patient wouldn't consent to most standardized assessment methods. I can't really imagine the government ever funding a program to provide people with something like this.